Journal of Clinical Nutrition & Dietetics

Keywords

Nutrition; Undernutrition; Human rights; Cancun declaration; Cartagena declaration

Introduction

Having reviewed publications made in the last four decades, we believe that hospital malnutrition remains a social stigma that shames us, and it is caused by different factors that blocks its prevention and treatment due to the lack of government policies, such as the regulation and control of nutritional therapy in hospitals by experts in multidisciplinary teamworks.

In 2003, the ELAN study Latin American nutrition survey reported a prevalence of 50.2% of malnutrition among hospitalized patients in the region. It further revealed that less than 23% of audited medical records contained information on the nutritional status of the patient [1]. Only 8.8% of the cases used a formal nutritional therapy scheme and only Costa Rica and Brazil regulate the practice of nutritional therapy through government policies.

In the following years, the nutritional status of hospitalized patients would continue to be a concern for academics and health professionals in Latin America. As an expression of this commitment, on May 20, 2008, in the city of Cancun, Quintana Roo, Mexico, within the framework of the XI congress of clinical nutrition and nutritional therapy of Latin America and the Caribbean FELANPE and XV Congreso de la Asociacion Mexicana de Alimentacion Enteraly Endovenosa-AMAEE, the Presidents of the societies and associations convened by Dr. Juan Carlos Castillo (in turn President pro tempore of FELANPE and AMAEE) promulgated the now-recognized "Cancun declaration" which called for "the human right of the patients to receive timely and optimal nutritional therapy wherever they are".

Literature Review

The ENHOLA study of Malnutrition in Hospitals in Latin America, published in 2016, revealed the prevalence of malnutrition in patients, 10.9% with severe malnutrition and 34% with moderate malnutrition.

Thus, the magnitude of the problem regarding hospital malnutrition is such, because of its many ramifications and repercussions that go beyond the efforts of a teamwork, a trade association, or even a country [2]. The readings made and the invariance of the events observed necessarily led to the design of a new declaration. This project began during the Presidency of FELANPE pro tempore (2017-2018) of Dr. Humberto Arenas MArquez. Its purposes were realized on May 3, 2019 in the Colombian city of Cartagena de Indias, within the framework of the 33 Colombian congress of metabolism and clinical nutrition and IV Andean regional congress of the FELANPE, with Dr. Dolores Rodriguez-Veintimilla occupying the Presidency pro tempore (2019-2021) of the FELANPE. Dr. Charles Bermudez and Dr. Diana Cardenas, members of the Colombian Association of Clinical Nutrition (ACNC) presented to the Presidents of the associations, societies and college that make up the federation the now titled "Cartagena declaration: International declaration on the right to nutritional care and the fight against malnutrition" during the extraordinary assembly convened for this purpose The declaration of Cartagena was unanimously accepted by the countries that make up the FELANPE and promulgated through the signature of the Presidents of the associations, societies and college gathered. During the signing of the letter of the declaration of Cartagena the representatives of the North American Association of Enteral and Parenteral Nutrition (ASPEN), the European Society of Clinical Nutrition and Metabolism (ESPEN), The Latin American Society of Nutrition (SLAN), the European Society of Gastroenterology, Paediatric Hepatology and Nutrition (ESPGHAN), The Latin American Society of Gastroenterology, Paediatric Hepatology and Nutrition, (LAPSPGHAN) officiated as witnesses of honour.

Following the proclamation, dissemination and implementation of the 13 principles of the Cartagena Declaration, FELANPE has received numerous expressions of support from several correspondent organizations that provide nutritional care to pati ents [3]. This recognition led FELANPE to plan an international alliance among all these organizations, namely FELANPE itself, the aforementioned ASPEN and ESPEN and the Asian Society of Enteral and Parenteral Nutrition (PENSA) and the West African Society of Enteral and Parenteral Nutrition (WASPEN), an alliance that seeks to recognize and promote the human right inherent in every patient to nutritional care [4]. The coordination of this international alliance is in charge of Dr. Diana Cardenas and held her first meeting in virtual mode on October 19, 2020, forming the "International working group for patients' right to nutritional care", who presented a programme document with his position on nutritional care as a human right intrinsically linked to the right to food and the right to health.

After 13 years of the Cancun declaration and 2 years of the Cartagena declaration, we consider it opportune to examine the role of these proclamation instruments in the reaffirmation of the nutritional rights of patients, the actions required for their full implementation and the achievement of the purposes contained.

Discussion

Starting in the 1970’s, it was recognized that the biological causes of malnutrition were superimposed on the attitudes and practices of the teamworks that care for patients in different health scenarios, including the hospital [5]. Butterworth, in its publication in JAMA revealed that diagnostic fasting, unjustified suspension of the oral route, postp onement (and even abandonment) of the supportive/ replenishing nutritional therapies were recognized as some of hospital practices that perpetuate and aggravate the malnutrition that accompanies the disease in almost every hospital in the world.

Some authors have equated hospital malnutrition with a form of iatrogenic malnutrition: That is originated from painful medical actions that can be traced back to the lack of training in the medical science students in topics, basic food and nutrition and the impossibility of instituting a multi-disciplinary working culture in the hospital, leading to therapeutic failures, extended stay, complications, increased costs, dissatisfaction of the patient and family members with the treatment received and increase in mortality [6]. Hospital malnutrition could also be seen as the failure of the Osler approach to medical care, the pyramidized training system for medical residences, and the central (if not monopolistic) role of the task force leader in patient care.

In the universal declaration of human rights made in December 1948, signed by the country members of the United Nations general assembly in its resolution 217 A (III), article 25, states that "everyone has the right to an adequate standard of living to ensure for himself and his family health and well-being, in particular food, clothing, housing, medical care and necessary social service. The Cancun and Cartagena declarations, as expressed in their articles, would constitute important efforts to guarantee three of the components of the aforementioned human right: Food (timely and quality), medical care (accompanied by nutrition professionals), and patient health. The reference to food security as a component of a human right in article 25 of the universal declaration is consistent with the rights derived from the international covenant on economic, social and cultural rights [7]. The Sustainable Development Goal (SDG) number two "Zero hunger", signed by 193 UN member states, also stipulates the importance of initiatives that seek to end hunger, achieve food security and improve nutrition. The declarations of Cancun and Cartagena, based on descriptive statistics that reflect the conditions of malnutrition of patients over the years, contribute with these agendas, seeking, as mentioned one of their approaches: "That the patients receive without discrimination an optimal and timely diet [8].

The Cancun and Cartagena declarations would help to ensure full and quality medical care. Nutrition, to this day, has become an area of knowledge of its own, which, in many universities around the world, it is studied independently of medical training [9]. Bermudez observed that Nutritional education offered to medical students might not necessarily translate into adequate nutritional care for patient needs (as long as there is no universally accepted benchmark on the nutritional skills of physicians), highlighting the importance of adequate nutrition/ dietary training as part of the implementation of a programme to improve medical care. The importance of this preparation is also evident in the study by Cardenas. Nutrition competencies for undergraduate medical education: Results of an international interdisciplinary consensus. To establish the goals of secondary education in undergraduate nutrition, basic nutrition skills and strategies for curriculum development in nutrition education [10]. In their research, the experts recommended the inclusion of health promotion, prevention and treatment of nutritionrelated diseases in the curriculum of general practitioners.

On the other hand, the practice of nutrition professionals is present in the comprehensive medical care of health centers around the world, in specific departments of nutrition and/or dietetics. The "need" for dietitians in modern hospitals it is established in the 1969 PAHO text on "Hospital planning and management. This professional is described there as someone with a training "more scientific than commercial" and notes among his own tasks the supervision of the food and the diets of the patients, educate them in the ways and means to prepare food in their own homes, provide advice on the nutritional value of the hospital regular diets and educate groups of people in nutrition as part of the hospital health education program [11]. Nutritionists and/or dieticians, with specific training and functions, both in operational aspects of the hospital and in outpatient areas, would constitute a fundamental part in the quality of medical care in health homes [12]. The proposal of the declarations of Cancun and Cartagena, in this point, is that "in cases where enteral and/or parenteral nutritional therapy is required, this is done by professionals with expertise". This phrase would make sense because of the possible gaps in the training of general practitioners outlined by Bermudez and because of the specificity of the work of nutrition professionals [13]. Thus, the incorporation and training of nutrition professionals, respect for their activities and the provision of adequate infrastructure and tools for the fulfilment of their tasks, as suggested by the Cancun and Cartagena declarations, would help public and private health service providers to ensure an improvement in the quality of the human right to medical care.

The Cancun and Cartagena declarations are also an effort to guarantee the human right of health. As PAHO (f.o.) states, healthy nutrition is critical to the prevention of diet-related risk factors (such as overweight and obesity) and associated noncommunicable diseases; it may also contribute to an improvement in the quality of survival of patients with serious diseases, such as cancer (ACS, 2019) or cystic fibrosis [14]. WHO, in a transcript of a 2019 press release (citing world bank researchers), stated that a greater emphasis on nutrition in health services could save 3.7 million lives by 2025. In the same statement, Dr. Naoko Yamamoto, WHO deputy director-general, said health services "should focus more on ensuring optimal nutrition at every stage of a person’s life", seeking to "provide quality health services and achieve universal health coverage", where "nutrition must be one of the cornerstones of essential health services" (2019). Thus, the Cancun and Cartagena declarations would also contribute to the preservation of the human right to health, through their international pronouncement to support nutrition as a fundamental aspect in the preservation of health and the recovery of patients [15].

Conclusion

The evolution of what was written in the declarations of Cancun and Cartagena, has gone beyond the framework of updating the letter to offer a new approach in the implementation of actions that lead to the achievement of the purposes of the same being led by the international working group for patient rights to nutritional care which aims to study the link between clinical nutrition and human rights, promoting the defense of access for all patients to nutritional care through the human rights-based approach through interdisciplinary collaboration between medicine, life sciences, human and social sciences, pharmaceutical sciences, nutrition and dietetics which has set a clear goal in the fight against hospital malnutrition. Health is a universal right. By implementing timely nutritional diagnosis and appropriate therapy, constitutes a major global effort fundamental in the dec larations of Cancun and Cartagena to defeat malnutrition that afflicts hospitalized patients.

Acknowledgment

To Asociacion Colombiana de Nutricion Clinica (ACNC), for its initiative and generosity in leading the fight against malnutrition. The international declaration on the right to nutritional care and the fight against malnutrition was signed on Friday, May 3, 2019, in the city of Cartagena, Colombia. The presidents of the different associations, colleges and societies of FELANPE signed the declaration of Cartagena. The representatives of ASPEN, ESPEN, SLAN, ESPGHAN and LASPGHAN were witnesses of honor.

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