Cardenas D, et al. Rev. Nutr. Clin. Metab. 2019;2(Supl.1):14-23.





The International Declaration on the Right to Nutritional Care and the fight against Malnutrition, “Declaration of Cartagena”


DECLARACIÓN DE CARTAGENA
Declaración Internacional sobre el Derecho al Cuidado Nutricional y la Lucha contra la Malnutrición

Declaração Internacional sobre o Direito ao Cuidado Nutricional e a Luta contra a Desnutrição


Diana Cardenas1, Charles Bermúdez2, Sonia Echeverri3, Angélica Pérez4, Milena Puentes5, Lina López6,
Isabel Correia7, Juan Bernardo Ochoa8, Ana Maria Ferreira9, María Alexandra Texeira10, Diego Arenas Moya11,
Humberto Arenas Márquez12, Miguel Leon-Sanz13, Dolores Rodríguez-Veintimilla14.


Received: May 4, 2019. Accepted: October 1, 2019

Published Online: May 4, 2019

https://doi.org/10.35454/rncm.v2supl1.015



1. Research Institute in Nutrition, Genetics and Metabolism, Faculty of Medicine, Universidad El Bosque, Bogotá, D.C., Colombia.

2. Department of Surgery, Clinica la Colina and Clinica del Country, Bogotá, D.C., Colombia. ACNC President 2017-2021.

3. Hospital Ethics and Humanism Committee, Fundación Santa Fe de Bogotá, Bogotá, D.C., Colombia. Vice-president FELANPE Central Region 2019 - 2020.

4. Department of Nutrition and Biochemistry, Pontificia Universidad Javeriana, Bogotá, D.C., Colombia. Executive Secretary ACNC 2017 - 2021.

5. League against cancer, section Bogotá, Bogotá, D.C., Colombia. Treasurer ACNC 2017 - 2021.

6. Nutrition support team, Clinica Universitaria Colombia, Bogotá, D.C., Colombia. Vice-president ACNC 2017 - 2021.

7. Federal University of Minas Gerais, Belo Horizonte, Brazil. President of FELANPE 2015 - 2016.

8. University of Pittsburg, PA, USA. Medical Director Surgical Critical Care, Ochsner Medical Center, Jefferson Campus, USA.

9. Paraguayan Nutrition Society. Asunción,Paraguay. President of FELANPE 2021 - 2022.

10. The Human Milk Bank of Hospital Regional Salto, Salto, Uruguay. Director of the Nutrition Committee of FELANPE 2019 - 2020.

11. Clinical Nutrition and Functional Medicine, SANVITE, Guadalajara, Mexico. Director of the FELANPE Education Committee.

12. Integrated Intestinal Failure Unit, Hospital San Javier, Guadalajara, Jalisco, Mexico. President of FELANPE 2017 - 2018.

13. Department of Endocrinology and Nutrition, Hospital Doce de Octubre & University Complutense Madrid, Spain. President of SENPE.

14. Clinical Nutrition and Dietetics Service of the Ecuadorian Society to Fight Cancer, Guayaquil, Ecuador. President of FELANPE 2019 - 2020.

* Corresponding author: Diana Cárdenas,

Dianacardenasbraz@gmail.com


Summary

Faced with the need to promote the right to nutritional care, to fight against malnutrition and to advance in education and research in clinical nutrition, all the FELANPE’s societies signed on May 3 during an extraordinary assembly in the city of Cartagena, the International Declaration on the Right to Nutritional Care and the fight against Malnutrition, “Declaration of Cartagena”.

The Declaration provides a coherent framework of thirteen principles which can serve as a guide for societies, schools and associations affiliated to FELANPE in the development of action plans. In addition, it will serve as an instrument to promote, through governments, the formulation of policies and legislation in the field of clinical nutrition. We believe that the general framework of principles proposed by the Declaration can contribute to raise awareness about the magnitude of this problem and to forge cooperation networks among Latin-American countries. Although this Declaration does not have a binding legal effect, it has undeniable moral force and can provide practical guidance to States. We will then be contributing to achieving the United Nations Sustainable Development Goals which aim to put an end to all forms of malnutrition by 2030.

Keywords: Malnutrition, Right to Health, Right to Food, Right to Nutritional Care.


Resumen

Frente a la necesidad de promover el derecho al cuidado nutricional, de luchar contra la malnutrición y de avanzar en temas de educación e investigación en nutrición clínica, las sociedades que constituyen la FELANPE firmaron la Declaración Internacional sobre el Derecho al Cuidado Nutricional y la lucha contra la Malnutrición, “Declaración de Cartagena”, en la asamblea extraordinaria que tuvo lugar el 3 de mayo del presente año en la ciudad de Cartagena.

La Declaración proporciona un marco coherente de trece principios los cuales podrán servir de guía a las sociedades, los colegios y las asociaciones afiliadas a la FELANPE en el desarrollo de los planes de acción. Además, servirá como un instrumento para que promuevan, a través de los gobiernos, la formulación de políticas y legislaciones en el campo de la nutrición clínica. Consideramos que el marco general de principios propuesto por la Declaración puede contribuir a crear conciencia acerca de la magnitud de este problema y a forjar redes de cooperación entre los países de la región. Aunque esta Declaración no tiene un efecto jurídico vinculante (obligatorio), tiene una fuerza moral innegable y puede proporcionar orientación práctica a los Estados. Estaremos entonces contribuyendo a alcanzar los Objetivos de Desarrollo Sostenible de Naciones Unidas que buscan, para 2030, poner fin a todas las formas de malnutrición.

Palabras clave: malnutrición, cuidado nutricional, derecho a la alimentación, derecho a la salud.


Resumo

Confrontados com a necessidade de promover o direito à assistência nutricional, para combater a desnutrição e favorecer o progresso na educação e na pesquisa em nutrição clínica, todas as companhias membros da FELANPE em data do 3 de maio 2019 numa reunião extraordinária, na cidade de Cartagena, reconhecem e suscrivem à Declaração Internacional sobre o Direito à Nutrição e o combate à desnutrição, “Declaração de Cartagena”.

A Declaração fornece uma estrutura coerente de treze princípios que podem servir como um guia para sociedades, escolas e associações afiliadas à FELANPE no desenvolvimento de planos de ação. Além disso, servirá como instrumento para promover, através dos governos, a formulação de políticas e legislação no campo da nutrição clínica. Acreditamos que a estrutura geral de princípios proposta pela Declaração pode contribuir para aumentar a conscientização sobre a magnitude desse problema e forjar redes de cooperação entre os países da região. Embora esta Declaração não tenha um efeito legal vinculante, tem força moral inegável e pode fornecer orientação prática aos Estados. Vamos então contribuir para alcançar os Objetivos de Desenvolvimento Sustentável das Nações Unidas que visam, até 2030, pôr fim a todas as formas de desnutrição.

Palavras-chave: Desnutrição, direito à saúde, direito à alimentação, direito ao cuidado nutricional.


INTRODUCTION

On the occasion of the tenth anniversary of the Cancún Declaration, which refers for the first time in Latin America to the right to nutrition, the Colombian Association of Clinical Nutrition (ACNC) proposes to the Latin American Federation of Nutritional Therapy, Clinical Nutrition and Metabolism (FELANPE) to revise and update the above-mentioned declaration(1). This proposal is based on three fundamental aspects.

First, the need to recognize nutritional care as a human right(2). We consider nutritional care as an emerging human right, which implies that governments and health systems must respect, protect and fulfill the right to regular hospital diet, therapeutic diet (i.e food modification and supplements) and medical nutrition therapy (i.e. enteral and parenteral nutrition). This could mean that the patient has the right to benefit from food or medical nutrition therapy administered by a team of experts, and the government has the duty to guarantee it. We are convinced that promoting this right in all care settings and from the level of primary care to highly complex hospital institutions is a mechanism that will allow us to fight against the problem of malnutrition and promote nutritional therapy ensuring respect for dignity of all patients(3).

Secondly, the need to go forward in clinical nutrition education and research. The lack of education and training of health professionals (doctors, dieticians, nurses and pharmacists, among others) in the field of clinical nutrition is worrying(4,5). Added to this is the lack of awareness of these professionals about the importance of adequately addressing nutritional problems with patients(6). The integration of content and a sufficient number of hours of nutrition education into undergraduate curricula is a priority(5). In addition, the recognition of clinical nutrition as a specialty is essential in order to promote its teaching in postgraduate and continuing education programs. Providing high quality nutrition education to physicians and other caregivers is a mechanism that contributes to building healthier populations. Hand in hand with education, research will promote and ensure the development of the discipline. The development of lines of research on the most frequent problems in this field is a priority. In particular, efforts to understand the pathophysiology of malnutrition and nutritional alterations through innovative technology (e.g. metabolomics) should be guided, which will be important to improve treatment and to develop new strategies in order to obtain better results.

Third, the need for tools to address bioethical questions and dilemmas. The possibility of feeding all sick people thanks to advances in science and technology leads to bioethical questions and dilemmas. We believe that the exercise of clinical nutrition must be carried out within the framework of a set of ethical principles and values which must be based on respect for human dignity. The UNESCO Declaration on Bioethics and Human Rights, promulgated on 19 October 2005, served as a reference for the development of these principles(7).

Therefore, the declaration seeks through its XIII principles to provide a frame of reference to promote the development of nutritional care in the clinical setting that allows all sick people to receive nutritional therapy in conditions of dignity. The definition of these principles was consolidated after the presentation of the review, from different approaches, carried out by Latin American experts during the FELANPE congress in Guadalajara in 2018. These principles were defined by a committee of experts defined by the ACNC and submitted for discussion and validated by the presidents of the societies, colleges and associations of the member countries of FELANPE.

The Cartagena Declaration, adopted on May 3 at the extraordinary assembly of FELANPE in the city of Cartagena, provides a coherent framework of principles that can serve as a guide to the societies, schools and associations affiliated to FELANPE in the development of action plans. It will also serve as an instrument for governments to promote the formulation of policies and legislation in the field of clinical nutrition. The general framework of principles proposed by the Declaration can contribute to raising awareness of the magnitude of this problem and to forging cooperation networks among the countries of the region. We will then be contributing to achieving one of the goals of the United Nations Sustainable Development Goals(8), which seeks by 2030 to “put an end to all forms of malnutrition”.


References

  1. Castillo Pineda JC, Figueredo Grijalva R, Dugloszewski C, Ruy Díaz Reynoso JAS, Spolidoro Noroña JV, Matos A, et al. Declaración de Cancún: Declaración Internacional de Cancún sobre el Derecho a la Nutrición en los Hospitales. Nutr Hosp. 2008;23(5):413-7.
  2. Cardenas D. Is the right to food in hospitals a human right? Rev. Nutr. Clin. Metab. 2018;1(2):9-12.
  3. Correia MITD, Perman MI, Waitzberg DL. Hospital malnutrition in Latin America: A systematic review. Clin Nutr 2016;36:958-67.
  4. Cuerda C, Shneider SM, Van Gossum A. Clinical nutrition education in medical schools: Results of an ESPEN survey. Clin. Nutr. 2017; 36:915-6.
  5. Arenas Márquez H. Clinical Nutrition Education. Rev. Nutr. Clin. Metab. 2018;1(2):13-16.
  6. Perlstein R, McCoombe S, Shaw C, Nowson C. Medical student perceptions regarding the importance of nutritional knowledge and their confidence in providing competent nutrition practice. Public Health. 2016;140:27-34.
  7. Organización de las Naciones Unidas para la Educación, la Ciencia y la Cultura. La Declaración de Bioética y Derechos Humanos. [Internet]. Paris: Unesco; 2005 [consultado el 8 de abril 2019]. Disponible en: http://portal.unesco.org/es/ev.php-URL_ID=31058&URL_DO=DO_TOPIC&URL_SECTION=201.html.
  8. Organización de las Naciones Unidas. Objetivos de Desarrollo Sostenible. https://www.un.org/sustainabledevelopment/es/energy/ [Internet]. New York: ONU; 2015 [consultado el 8 de abril 2019].


International Declaration on the Right to Nutritional Care and the Fight against Malnutrition

CARTAGENA DECLARATION


Approved on May 3, 2019 within the framework of the 33rd Colombian Congress of Metabolism and Clinical Nutrition, IV Andean Regional Congress-Center Region of the Latin American Federation of Nutritional Therapy, Clinical Nutrition and Metabolism (FELANPE) 2019, during the extraordinary assembly.


The Assembly,

Recognizing that the societies, colleges and associations affiliated to FELANPE have joined efforts since its creation to promote research, education and training of professionals in Clinical Nutrition, and to collaborate, if required, with the public authorities in the evaluation and solution of problems related to clinical nutrition,

Recalling the International Declaration of Cancun, 2008, on the right to nutrition in hospitals, where for the first time the Presidents of the societies, schools and associations of FELANPE declared their will to raise nutrition in hospitals to the level of basic human right,

Noting article 25 of the Universal Declaration of Human Rights of December 10th, 1948 which states that “ everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food,...” and article 11 of the International Covenant on Economic Rights, The International Covenant on Economic, Social and Cultural Rights (ICESCR) stipulates that States parties “recognize the right of everyone to an adequate standard of living for himself and his family, including adequate food” and affirms the existence of the “fundamental right of everyone to be free from hunger”,

Invoking article 12 of the International Covenant on Economic, Social and Cultural Rights, in particular general comment No. 14 on the right to the highest attainable standard of health, which recognizes that “the right to health encompasses a wide range of socio-economic factors that promote the conditions under which individuals can lead healthy lives, and extends this right to underlying determinants of health, such as food and nutrition”,

Recognizing nutritional care as a human right inseparable from the right to health and the right to food,

Considering that the right to food must be respected in all spheres, including the clinical one, the sick person must be fed in conditions of dignity and has the fundamental right to be free from hunger,

Bearing in mind that the right to food is often disrespected in the clinical setting resulting in an unacceptable number of people suffering from disease-related malnutrition,

Recognizing that inpatient malnutrition is associated with prolonged hospital stays, reduced quality of life, increased comorbidity, and unnecessary health costs,

Stressing that advances in science and technology today make it possible to feed naturally or artificially any sick person and to actively combat malnutrition,

Aware that adequate nutritional therapy can correct malnutrition, improve disease prognosis and quality of life, reduce co-morbidities, mortality and health costs,

Aware of the need to seek, through the application of basic, clinical and public health sciences, increasingly effective nutritional solutions,

Aware that nutritional therapy may have side effects and low effectiveness in some patients such as those in a hypercatabolic state, or if not administered properly,

Convinced of the need to call upon researchers, the pharmaceutical industry and academic entities on the importance of promoting research in clinical nutrition under a new paradigm that considers nutritional therapy beyond the administration of micro and macronutrients,

Convinced of the need to appeal to public authorities and various national and international bodies on the importance of nutritional care and the fight against malnutrition,

Bearing in mind that the scientific and technological advances that have enabled the development of artificial nutrition therapy pose dilemmas and ethical problems, which should be addressed from a bioethical perspective, and respecting the principles set out in the UNESCO Declaration on Bioethics and Human Rights promulgated on 19 October 2005,

The FELANPE urges the States and the Human Rights Council of the United Nations to recognize this Declaration and therefore the Right to Nutritional Care as a human right, as it guarantees to all people, especially the malnourished ill people, access to nutritional care and, in particular, optimal and timely nutritional therapy in order to reduce the high rates of hospital malnutrition and the associated morbidity and mortality among other things.


It is proclaimed,


I. Scope

The Declaration deals with the right to nutritional care, independent of the level of health care, and the fight against various kinds of malnutrition in particular that one associated with disease, thus limited to the field of clinical nutrition. Clinical nutrition is an interdisciplinary and applied discipline and science concerned with malnutrition. The aim is to apply the principles of nutritional therapy (artificial nutrients administered through supplements, enteral and parenteral nutrition) within the framework of nutritional care in order to ensure nutritional status and to modulate other biological functions to positively influence the treatment, quality of life and outcome of patients;

This declaration is addressed to the societies, schools and associations affiliated to FELANPE and to any organization or institution that defends the right to food, the right to health and promotes the fight against malnutrition. The Cartagena Declaration should be considered to be a framework document whose principles constitute the basis for promoting the development of nutritional care in the clinical field, and raising awareness among public authorities, academic bodies, and the pharmaceutical industry.


II. Objectives

1. To promote respect for human dignity and protect the right to nutritional care, ensuring respect for human life and fundamental freedoms, in accordance with international law on human rights and bioethics;

2. To provide a frame of reference whose principles constitute the foundation for promoting the development of nutritional care in the clinical setting that allows all sick persons to receive nutritional therapy under dignified conditions;

3. Promote awareness of the magnitude of the problem of malnutrition associated with disease and the need to develop a model of nutritional care in health institutions;

4. Promote the development of research and education in clinical nutrition under a new paradigm.


III. Principles


1. Feed the ill person in conditions of dignity

The right to food must be understood as an International Human Right that allows all human beings to be fed in conditions of dignity. It is recognized that this right encompasses two distinct norms: the first is the right to adequate food; the second is that everyone be protected against hunger. In the clinical field, the fulfillment of this right also implies the respect of these two norms and it becomes concrete when the sick person receives complete nutritional care under the intervention of an interdisciplinary group of professionals specialized in clinical nutrition. The right to nutritional care is recognized as an emerging right that relates to the right to health and the right to food;

It is emphasized that the sick person must be fed in conditions of dignity, which implies recognizing during the process of nutritional care the intrinsic value of each human being, as well as respect for integrity, the diversity of moral, social and cultural values. The right to nutritional care includes quantitative, qualitative and cultural acceptability aspects;

Therefore, sick people, without distinction of any kind, should enjoy the same quality of nutritional therapy under conditions of dignity, and a comprehensive approach to the malnutrition associated with the disease. The right to nutritional care is considered to be exercised when every man, woman and child, after appropriate diagnosis, receives adequate nutrition (oral, enteral or parenteral nutritional therapy) taking into account all dimensions (biological, symbolic, affective and cultural) and does not suffer from hunger. Essential elements are safety, timeliness, efficiency, efficacy, effectiveness of nutritional care and respect for bioethical principles. This is considered the minimum that must be guaranteed independent of the level of health care;

It must be considered that nutritional therapy is a medical therapy, sick persons have the right and autonomy to refuse it and health personnel have the obligation to accept this decision and not to perform futile actions.

The right to nutritional care should not be limited or restricted to energy sources, protein and other specific nutritional elements, but should guarantee the human, physical and economic mechanisms for access to nutritional therapy.


2. Nutritional care is a process

Nutritional care is part of the patient’s overall care, and should therefore be an inherent component of their care. It is conceived as a continuous process consisting of several stages which can be summarized as follows: 1. Screening, 2. Nourish and 3. Watch.

Screening

The identification of nutritional risk by means of screening is the first stage, which leads, in the next stage, if the patient is at risk, to the completion of a complete diagnosis of nutritional status, allowing the medical indication of nutritional therapy to be established and the nutritional plan to be carried out. Screening should be systematic for sick people at any level of health care. Any patient at nutritional risk should benefit from the full nutritional diagnosis.

The nutritional diagnosis allows the identification of nutritional alterations, which can be: a. Malnutrition (synonym of undernutrition), b. Overweight and obesity, c. Micronutrient abnormalities. Malnutrition is defined as the condition resulting from lack of intake, nutritional absorption, increased nutrient losses leading to alteration of body composition (decrease in fat-free mass) and body cell mass leading to decreased mental and physical functions and deterioration of clinical outcome. Malnutrition may be the result of fasting, disease or old age (i.e. > 80 years). Each can be presented in isolation or in combination.

Malnutrition may present as: a. Malnutrition without disease, b. Malnutrition associated with inflammatory disease (acute or chronic), c. Malnutrition associated with disease without inflammation.

It is emphasized that the diagnostic criteria for malnutrition established by consensus should be evaluated in the Latin American context, taking into account the phenotypic characteristics of the population and the socio-economic situation, among others.

The detection of nutritional risk should be a priority at all levels of health care.

Nourish

The nutrition plan includes nutrition therapy (or medical nutrition therapy), i.e., oral nutrition therapy, artificial nutrients administered through supplements, enteral and parenteral nutrition. Nutritional therapy is considered to be a medical intervention, requiring a medical nutritional indication, which has the objective of specific treatment and requires the informed consent of the patient. Like any therapy, nutrition also has side effects, risks and benefits. The biological dimension (quantitative and qualitative), the symbolic, affective and cultural dimension associated with food are taken into account even if it is artificial nutritional therapy.

Watch

Nutrition therapy should be monitored and documented. Monitoring seeks to verify that the different dimensions of nutrition therapy are met and to prevent side effects. Documentation serves to track and evaluate the continuity of therapy for each patient and to ensure quality.

The three stages seek safety, timeliness, efficiency, efficacy and effectiveness of nutritional care. Health institutions should promote the development of the nutritional care model based on detecting, nourishing and monitoring.


3. Patient empowerment as a necessary action to improve nutritional care

Empowerment is defined as a process and an outcome. The first is based on the principle that increasing education improves the ability to think critically and act autonomously, while the second (outcome) is achieved through the sense of self-efficacy, the outcome of the process.

Empowerment is achieved through education, and education implies freedom. Therefore, in nutritional care, empowering patients is offering them the opportunity to be part of the nutritional process and treatment. Empowering the patient not only seeks to obtain a voice, but also to share knowledge and responsibilities with them and with the family.

Empowerment seeks to increase the freedom and autonomy of the patient (the ability to make informed decisions) about the role of malnutrition and nutritional therapy in the different phases of treatment.

Empowering patients and their families in the fight against malnutrition implies empowering them to think critically about this syndrome and its respective negative consequences, while allowing them to make autonomous and informed decisions, such as demanding nutritional care and complying with the suggested nutritional treatment.


4. The interdisciplinary approach to nutritional care

Nutritional care should be performed by interdisciplinary teams which should include, at a minimum, nutrition professionals, nurses, physicians, pharmacists, and encourage the integration of phonoaudiology, occupational therapy, physical therapy, rehabilitation, social work, and psychology, among other disciplines that can increase the effectiveness of nutritional therapy. This approach involves the equitable integration of the various disciplines related to nutritional activity. Scientific evidence shows the advantages of this approach in terms of cost-effectiveness, safety, efficiency and efficacy.

The creation of nutrition therapy teams and the result based accreditation of functioning teams should be promoted.


5. Ethical principles and values in clinical nutrition

It is important to emphasize that nutritional therapy (oral, enteral and parenteral nutrition) is considered a great scientific and technological advance that has allowed any sick person to be fed and and to improve clinical outcomes, quality of life and impact on health costs. It is recognized that with these advances bioethical issues arise that may have repercussions on individuals, families and groups or communities. These issues should be analysed within the framework of the principles set out in UNESCO’s DUBDH, in particular the universal principles of equality, justice and equity, non-discrimination and non-stigmatization, nonmaleficence, autonomy, beneficence and respect for human vulnerability and personal integrity. Respect for cultural diversity and pluralism is fundamental to the realization of nutritional care and the debate around ethical questions.

It is recognized that patients at risk or in a state of malnutrition are a group considered ethically vulnerable. Vulnerability is an inescapable dimension of human beings and the configuration of social relations. Considering the vulnerability of the malnourished patient implies recognizing that individuals may at some point lack the capacity and means to feed themselves and, therefore, it is necessary for this need to be met by professionals in clinical nutrition. Malnutrition implies physical, psychological and social deterioration (with the risk of losing one’s life and the possibility of losing one’s autonomy).

Professionalism, honesty, integrity and transparency in decision-making should be promoted, in particular the declaration of all conflicts of interest and the sharing of knowledge in accordance with article 18 of the DUBDH.


6. The integration of healthcare based on value (economic aspects)

Economic aspects should be integrated into clinical nutrition exercise, assessment and research. It is proposed to integrate value-based health care into nutritional care. Under this approach, the aim is to reorient health services to improve the satisfaction of people’s health needs, particularly nutritional care, while maintaining an optimal relationship with costs and outcomes. Generating value implies an emphasis on achieving health outcomes for both patients and organizations and society while maintaining an optimal relationship with costs. In this context, value in health is defined by an efficient relationship between results and costs. It is the patient, society and the health service provider who capture the value.

The sick person has the right to receive safe and high-quality nutritional care, with qualified personnel and seeking cost-effectiveness, based on scientific evidence. Resources should be allocated according to public policies focused on promotion, prevention and nutritional intervention that result in improving the quality of life of patients. For this it is fundamental that quality programs are implemented which integrate elements of the health economy: cost minimization, cost effectiveness, cost benefit, cost effectiveness and cost utility.


7. Clinical nutrition research is a pillar for the realization of the right to food in the clinical field and the fight against malnutrition

The development of clinical nutrition research should be promoted under a new paradigm, which consists of a vision of clinical nutrition that considers that the sick person needs, beyond food and nutrients, an approach to metabolism in the particular context of the disease and a better understanding of its metabolic and nutritional state. For this, it is necessary to develop research to understand the biological-molecular mechanisms associated with the metabolic states of sick people.

Authorities, health organizations (insurers, hospitals), pharmaceutical and food companies should be required to invest more and support research in clinical nutrition.

Interdisciplinary research groups should be created, promoted and supported at the appropriate level for the purpose of:

a) research on relevant clinical nutrition issues under scientific standards of quality, evidence-based medicine and respecting the principles of bioethics;

b) developing relevant lines of research in the regional (Latin American) context;

c) evaluating the advances in science and technology that arise in the field of clinical nutrition;

d) supporting the formulation of recommendations, guidelines and consensus of clinical practices based on scientific evidence;

e) promoting debate, education and public awareness on clinical nutrition and the problem of malnutrition, as well as participation in respect of the right to food in this field.

It is recognized that the interests and welfare of the individual should have priority over the sole interest of science or society (pharmaceutical industry, companies, etc.).


8. Clinical nutrition education is a fundamental axis for the fulfillment of the right to nutritional care and the fight against malnutrition

Clinical nutrition education should be created, promoted and supported at the appropriate level and under the new paradigm:

a) at the undergraduate level: promote the teaching of clinical nutrition in health careers (medicine, nutrition, nursing, pharmacy, etc.);

b) at postgraduate level: recognize clinical nutrition as a clinical specialty and not as a subspecialty or complementary training;

c) appropriate institutions: accredit specialised training and promote continuing education in the field of clinical nutrition.


9. Strengthening of networks

Activities, programs and projects shall be created, promoted and supported at the appropriate level for the purpose of:

a) promoting in health institutions the development of the nutritional care model based on detecting, nourishing and monitoring;

b) strengthening clinical nutrition education programs;

c) developing and strengthening lines of research in clinical nutrition;

d) promote solidarity and cooperation in the development of programs to promote nutritional care and the fight against malnutrition.


10. Creating an institutional culture that values nutritional care

Activities, programs and projects shall be created, promoted and supported at the appropriate level for the purpose of:

a) sensitizing physicians and other health professionals to the importance of clinical nutrition;

b) sensitizing the public and institutions to the problems of malnutrition and the right to nutritional care;

c) showing the scientific evidence that will make it possible to advance in the institutionalization of the nutritional care model based on detecting, nourishing and monitoring;

d) promoting the participation of the public, patients and institutions in the realization of the right to nutritional care;

e) promoting fair and equitable nutritional care.


11. Justice and equity in nutritional care

A fair and equitable public health agenda should be created, promoted and supported for the purpose of:

a) developing mechanisms so that every sick person has availability, and stable, continuous and timely access to nutritional therapy, as well as the correct use of nutritional therapy;

b) promoting the integration into health systems of the nutritional care model capable of providing nutritional therapy under dignified conditions;

c) promoting the interdisciplinary approach and the creation of nutritional therapy teams;

d) valuing the reimbursement and payment of nutritional care services;

e) contributing to achieving the goals of United Nations sustainable development goals 2 and 3 (DSO 2 and 3) in particular goals 2.2: “By 2030, end all forms of malnutrition”, and 3.4: “By 2030, reduce by one third premature mortality from non-transmissible diseases through prevention and treatment and promote mental health and well-being”.


12. Ethical, deontological and transparency principles of the pharmaceutical and nutritional industry

Relationships should be promoted between societies, schools and associations that defend the right to clinical nutrition with the the pharmaceutical and nutritional industry (Ph&NI), based on the ethical and transparency policies they demand:

a) Clarity and accountability in the roles of the Ph&NI so that they can:


To this end, each society, college and association must establish policies of ethics, integrity and transparency.


13. Call to International Action

FELANPE calls on societies and international organizations to unite in the fight against malnutrition and the respect of the right to nutritional care. The principles set out in this document will serve as a basis for common action.

The FELANPE urges the States and the Human Rights Council of the United Nations to recognize this Declaration and therefore the Right to Nutritional Care as a human right as it guarantees all people, especially the malnourished ill, access to nutritional care and, in particular, optimal and timely nutritional therapy in order to reduce the high rates of hospital malnutrition and the associated morbidity and mortality among other consequences.

Cartagena, 3 May 2019,

Signed by FELANPE Presidents.

Dr. Dolores Rodríguez-Ventimilla

Federación Latinoamericana de Terapia Nutricional, Nutrición Clínica y Metabolismo – FELANPE 2019-2020

Dr. Ana Ferreira

FELANPE 2021 – 2022

Dr. Ma. Virginia Desantadina

Asociación Argentina de Nutrición Enteral y Parenteral – AANEP

Dr. Dan Waitzberg

Sociedad Brasileña de Nutrición Parenteral y Enteral – BRASPEN

Ms. Janett K. Rodriguez

Asociación Boliviana de Nutrición Clínica y Terapia Nutricional

Dr. Paula Sánchez

Asociación Costarricense de Nutrición Enteral y Parenteral – ACONEP

Dr. Charles Bermúdez

Asociación Colombiana de Nutrición Clínica – ACNC

Dr. Lázaro Alfonso Novo

Sociedad Cubana de Nutrición Clínica y Metabolismo – SCNCM

Dr. Karin Papaprieto

Asociación Chilena de Nutrición Clínica, Obesidad y Metabolismo – ACHINUMET

Dr. Mery Guerrero

Asociación Ecuatoriana de Nutrición Parenteral y Enteral – ASENPE

Dr. Miguel León-Sanz

Sociedad Española de Nutrición Parenteral y Enteral – SENPE

Dr. Juan Carlos Hernández

Colegio Mexicano de Nutrición Clínica y Terapia Nutricional – CMNCTN

Dr. Rosa Larreategui

Asociación Panameña de Nutrición Clínica y Metabolismo – APNCM

Dr. María Cristina Jiménez

Sociedad Paraguaya de Nutrición – SPN

MSg. Luisa Angélica Guerrero

Asociación Peruana de Terapia Nutricional – ASPETEN

Dr. Anayanet Jáquez

Sociedad Dominicana de Nutrición Enteral y Parenteral – SODONEP

Ms. Mabel Pellejero

Sociedad Uruguaya de Nutrición – SUNUT

Dr. José Guillermo Gutiérrez

Asociación Salvadoreña de Nutrición Parenteral y Enteral – ASANPEN,


Witnesses

Dr. Roberto Berni Canani

The European Society for Paediatric Gastroenterology, Hepatology and Nutrition – SPEGHAN

Dr. Liliana Ladino

Latinamerican Society for Paediatric Gastroenterology, Hepatology and Nutrition – LASPEGHAN

Dr. Rafael Figueredo

Sociedad latinoamericana de Nutrición – SLAN

Pr. Rocco Barazzoni

European Society for Clinical Nutrition and Metabolism – ESPEN

Dr. Juan Bernardo Ochoa

American Society for Parenteral and Enteral Nutrition – ASPEN.