Health nutrition practice in Italy

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aggravated by the growing prevalence of nutrition-related diseases as well as by the lack of adequate academic nutrition training. The public health nutrition.

Nutrition↔Science Policy

Health nutrition practice in Italy Hellas Cena, Carla Roggi, Lucio Lucchin, and Giovanna Turconi



The increasing need for nutrition professionals is driven by growing public interest in nutrition and the potential of nutrition to prevent and treat a variety of diet-related conditions. Health promotion units and health services face great challenges in trying to address current and future population health issues. This review describes the present state of health nutrition practice in Italy, exploring the nature, role, and utility of training for nutrition professionals to meet the increasing burden of nutrition-related diseases. Evidence suggests that the public health nutrition workforce and infrastructures lack the necessary capacity to respond to national population needs regarding food and nutrition at many levels. This situation is aggravated by the growing prevalence of nutrition-related diseases as well as by the lack of adequate academic nutrition training. The public health nutrition infrastructures need to be enhanced, as do the education and training systems. Roles and functions in health nutrition practice need to be defined and discipline-specific competencies should be integrated. © 2010 International Life Sciences Institute

INTRODUCTION The history of dietetics can be traced as far back as the writings of Homer, Plato, and Hippocrates in ancient Greece. Although diet and nutrition continued to be judged important for health, dietetics did not progress much until the 19th century, along with advances in chemistry.1 The word diet is derived from the ancient Greek diaita, meaning mode of life, a word that up until the last century was often used in a much broader sense than its current meaning. The word dietetics was noted in the early writings of Hippocrates (460 BC), Plato (460–348 BC), and Galen (130–200 AD).2,3 Dietetics as a profession has been defined by the American Dietetic Association4 as the integration and application of principles derived from the disciplines of food, nutrition, management, communication, biological, physiological, behavioral, and social sciences to achieve and maintain human health. In Italy, since the 1970s, post-graduate courses in the medical specialization of Human Nutrition and Food

Science have focused on the interface between food science and human nutrition in health and disease in order to enable future professionals to acquire specific competencies. Competencies are the areas of knowledge, skill, and ability for specific professional groups.5,6 For nutrition professionals, competencies are disciplinespecific and provide more detailed insight into core competencies, reflecting the exclusive or technical skills, knowledge, and abilities required to define the unique and effective practice of public health nutrition. The literature related to discipline-specific competencies for health nutrition professionals, which were searched for this review, are remarkably similar in intent. Communities and populations, as well as individuals, are the “target” of interest for which nutritional programs, policies, and services are designed to prevent diet-related diseases and conditions and to promote optimal nutrition and overall health.7 The common areas of competency include the following: core public health and health systems knowledge; analysis and research; nutrition surveillance and monitoring; assessment of the nutritional

Affiliations: H Cena, C Roggi, and G Turconi are with the Department of Applied Health Sciences, Section of Human Nutrition and Dietetics , Faculty of Medicine, at the University of Pavia, Italy. Lucio Lucchin is with the Dietetic and Clinical Nutrition Unit, Health Department of the Autonomous Province of Bolzano, Italy. Correspondence: Hellas Cena, Department of Applied Health Sciences, Section of Human Nutrition and Dietetics, Faculty of Medicine, University of Pavia, Via Bassi 21, I-27100 Pavia, Italy. E-mail: [email protected], Phone: +39-0382-987542, Fax: + 39-0382-987570. Key words: clinical nutrition, nutrition education, nutrition practice, public health nutrition 556

doi:10.1111/j.1753-4887.2010.00315.x Nutrition Reviews® Vol. 68(9):556–563

status of different groups, communities, and populations; nutrition communication; food program and policy planning and evaluation; leadership and management; nutritional science and health promotion; skills training; individual-level approaches, such as counseling and nutrition education for general and high-risk populations; clinical intervention and treatment; interdisciplinary collaboration; and professionalism, ethics, and culture as part of the environmental, behavioral, social, and economic sciences.7–20 It is also important to recognize that competencies evolve to reflect changes in public health nutrition that occur in response to new requirements. Given current trends, nutrition is facing technological, social, political, global, and environmental forces that are significantly reshaping the world food system. Nutritional science must be considered a multidisciplinary specialty that integrates knowledge of nutrition science and understanding of the determinants of health and disease. The main research areas are as follows: 1) Applied Nutrition – pertaining to the life sciences and research on food and health (e.g., investigations on animal models and cell cultures that utilize methodological approaches or techniques in biochemistry, immunology, molecular biology, toxicology, and physiology; nutrition genomics/genetics, or the relationship between individual genetic susceptibility, nutrition, and disease, as well as the regulation of gene expression through nutrients or non-nutrient food components; choosing animal and in vitro models relevant for human nutrition; examining the nutritional effects of food components and processing and the scientific substantiation of health claims on foods; epidemiologic studies on nutrient and xenobiotic intakes in human populations and development of analytical techniques for food components); 2) Epidemiology and Public Health Nutrition (e.g., research on nutrition in developing countries; public health nutrition and nutritional epidemiology with emphasis on the use of biomarkers; health promotion and intervention studies and their effectiveness); 3) Dietetics and Clinical Nutrition (e.g., nutrient metabolism in humans; body composition assessment; relation of food intake and nutritional status and lifestyle; nutritional causes of disease and the effects of disease on food intake and nutritional status; the practice of therapeutic dietetics in diseased patients; enteral and parenteral nutrition); 4) Behavioral Nutrition (e.g., sociology of food intake; food attitudes and marketing; food choice and the psychology of eating behavior; eating disorders). The purpose of this report is to synthesize existing published and non-peer-reviewed evidence focusing on health nutrition practice, key needs, and issues and opportunities to be used as the basis for developing a public health nutrition workforce in order to enhance public health in Italy. Nutrition Reviews® Vol. 68(9):556–563

INCREASED NEED FOR NUTRITION SERVICES The increasing need for nutrition professionals is driven by growing public interest in nutrition and the potential of nutrition to prevent and treat a variety of diet-related conditions. Rapid advances in nutritional knowledge and science have led to the development of evidence-based medical nutrition therapy, a practice that has evolved from the judicious use of published scientific evidence and best practices.1 Health promotion units and health services face great challenges in trying to address current and future population health issues.21 Increases in the percentage of overweight individuals, chronic diseases, infectious diseases, eating disorders, and the elderly population, together with the rising ethnic and cultural diversity of Italian society and income disparities, emphasize the need for greater focus on the public health nutrition workforce.

PUBLIC HEALTH NUTRITION ASSESSMENT Good health is fundamental for social and economic development. The European Health Report 200522 highlights seven risk factors for the majority of noncommunicable diseases in the European region, as defined by the World Health Organization. These risk factors are as follows: high blood pressure, tobacco use, harmful and hazardous alcohol use, high cholesterol, being overweight, low fruit and vegetable intake, and physical inactivity. These are also the top seven preventable risk factors in most countries. Overweight status alone is responsible for about 7.8% of total disabilityadjusted life-years in the WHO-defined European region. It is a risk factor for a number of conditions, including diabetes, cardiovascular disease, joint diseases, and cancer. Moreover, it has a strong negative impact on the quality of life and it costs some countries up to 7% of their total healthcare budget. In many countries in the European region, over half the adult population has crossed the threshold of overweight, and 20–30% of adults are categorized as clinically obese. In Italy, high BMI is responsible for 10% of total deaths,22 as confirmed by data collected by the Italian National Institute of Statistics in 2005.23 Recent data from the National Survey on general physicians24 show obesity rates of 29% and 18.8% for females and males in Italy, respectively. The global epidemic of obesity and overweight is a major challenge for public health nutrition prevention programs, but it is not the only one. Prevalence rates for hypertension (13.6%), arthritis (18.3%), allergies (10.7%), underweight (3.4%), osteoporosis in women (9%), ischemic heart disease in men (2.5%), and diabetes mellitus in the elderly (14.5%)23 are key areas of focus for 557

decision-makers, which require priority attention in the agendas of health and education ministries, and national public health organizations. RESPONDING TO INCREASED NEED FOR NUTRITION SERVICES Worldwide, evidence suggests that the public health nutrition workforce and infrastructures lack sufficient capacity at many levels to respond to national population needs in the areas of food and nutrition.25–30 Given the emergence of community-level nutrition programs and interventions, training of para-professionals and allied health professionals in nutrition is needed. Analysis of required competencies reinforces the argument that public health nutrition is a specialty practice that requires advanced-level competencies that are partially developed during the training process via university courses and through practical experience via apprenticeships, mentoring, and clinical supervision.31–34 In addition, they can be partly achieved in real-world practice situations. Public health nutrition research and strategy should be shared between academia and those working in the practical setting in order to enhance the effectiveness of the workforce and improve public health nutrition.35 Today, professional dietetic associations can be found in every continent, and registered dietitians are involved in health promotion and treatment, working alongside physicians. More nutrition training in medical schools At the Council of Europe, the Committee of Ministers Resolution ResAP(2003)3 on food and nutritional care in hospitals (paragraph 2.3: Education and nutrition knowledge at all levels) recommends an increase in the number of post-graduate education and training courses in clinical nutrition.36 Gaining nutritional competence is recognized worldwide as an important component in the development of the health nutrition workforce. A continuous dialogue between universities and health services is strongly advised in order to develop and increase the efficacy of the workforce and improve public health. Even though there have been many advances in the pharmacological treatment of chronic degenerative diseases, medical nutrition therapy (MNT) continues to be an essential component for their management. As knowledge expands, the list of nutrition-related disorders increases. The treatment of such established diseases through adequate changes in dietary practices, nourishment procedures, and sophisticated feeding place a great deal of responsibility on nutrition care. There is also a growing demand for prevention while the Western World 558

continues to search for cures. Despite consensus about the need for improved nutrition education, there has been considerable neglect of and even opposition to integrating nutrition education in medical curricula.37 Although some medical schools report that they offer elective nutrition courses, this does not guarantee that the course is offered routinely, that students are actually completing it, and that nutrition information is entering the graduating student’s knowledge base. Many medical schools integrate nutrition concepts into basic medical courses such as biochemistry and physiology. When taught in this manner, however, students recognize the processes involved in converting myriad complex foodstuff into individual nutrients ready to be used in metabolism, but this doesn’t mean they acknowledge the significance of nutrition throughout the life cycle, during specific times of growth, development, and aging, the role of diet in disease prevention, nor its role in the nutrition care process.38 There is a growing consensus about the importance of required competencies for effective public health nutrition practice. These advanced-level abilities are developed both in academic settings and in real-world practice. Update training as well as mid-career training and specialization are thus important, as is the architecture of competencies required for the development of experts in response to new challenges.35 Table 1 shows the level of nutrition courses offered in all Italian accredited medical schools and other faculties during the academic year 2009–2010. It documents the growing gap in university training compared to the need for nutrition expertise. The significant reduction (about 22%) in the number of specialization courses in human nutrition and food science is also shown. Decisions about the allocation of medical grants provided to all Italian universities for the academic year are presently made by the Italian Ministry of National Education. Italian national health care system The health care system in Italy is covered by 184 health boards (hospitals, territorial, and a combination of both). There are 871 public hospitals, including university hospitals, which carry out research and operate within the health service. Under this scheme, nutritional intervention is organized under two categories: 1) preventative, which is managed principally by 186 food and nutrition hygiene services (SIAN) in which many professional disciplines are represented (e.g., medical doctors, hygienists, dietitians, biologists, and veterinarians); and 2) clinical, which is managed by a mixed group of operative units that are both hospital-based and territorial. The principal body is the Dietetic and Clinical Nutrition Service (SDNC), which includes medical doctors (around 150 in Nutrition Reviews® Vol. 68(9):556–563

Table 1 Human nutrition and dietetics courses in Italian universities. University courses Duration No. of Objectives (years) schools/no. of students Medical/health area Level 1 degree course in dietetics. 3 27/522* Train health workers to be competent in all the Class 111 medical/health degree activities related to the correct application of human nutrition and feeding in the physiological and pathological setting, designing diets prescribed by the medical doctor and checking their suitability/acceptability. Enable health workers to acquire competence in the planning and organisation of services in the community for both healthy and sick individuals, studying and designing menus and food portions appropriate to satisfy the nutritional needs of population groups. Promote health using nutrition education interventions as well as collaborating in nutritional surveillance programs, in food safety, and in the implementation of food policies. Medical specialization course in human 5 23/28* Enable students to acquire competence in the nutrition and food science – medical evaluation of nutritional status, in the (new rearrangement) programming of nutritional surveillance, and in primary prevention initiatives. Develop the capacity to diagnose and apply medical nutritional therapy in pathologies that could benefit from dietetic intervention or artificial nutrition in all the different age groups. Non-medical specialization course in 5 10/60* Acquire competence in evaluating nutritional status, human nutrition and food science and in the definition of energy and nutrient (new rearrangement) requirements for different age groups and physiological conditions. Develop the ability to program interventions for nutritional surveillance, as well as for the organization of catering services. Non-medical/health area Level II degree course in human nutrition 2 3 Acquire a good understanding of the correct – Quality and Safety of Human Nutrition application of diet and nutrition, and of the laws (Classes 69/S) in force, using up-to-date technology and interpreting the data in order to evaluate the nutritional quality, food safety, suitability of the food for human consumption, and for evaluating malnutrition in the individual and in the population. Medical and non-medical health area masters Masters level 1 and 2 1/2 22 Acquire professional competence in the diverse areas of food science, human nutrition, dietetics, and clinical nutrition. * Academic year 2009–2010.

2006) and the dietetic service, which is made up of qualified dietitians (approximately 300). This means around 49% of hospital structures are totally devoid of nutritional professionals. The ratio of SDNC professionals to members of the population is around 1/133,000, but the heterogeneity per macro area is Nutrition Reviews® Vol. 68(9):556–563

higher.39 In addition, a recent nationwide survey (the PIMAI study – Project: Iatrogenic MAlnutrition in Italy) of nutritional risk at hospital admission, revealed that 51.7% of inpatients needed medical nutrition treatment at the time of hospital admission, primarily for malnutrition and obesity (21% and 30.7%, respectively).39 Other 559

indicators relevant to the present inadequacy of nutritional services include the following: 1) Insufficient presence of dietetic services. The number of medical directors for these services is less than 30, and 76% of services employ only one or two medical doctors. 2) Absence of coordination between hospital and territorial services, and between the services of SIAN and the dietetic and clinical nutrition service. 3) Abnormal organization in hospitals with the presence of professionals with only the degree qualification in dietetics. 4) Lack of interest in the dietetic profession among health service management executives. From 1996 to 2006 the average number of dietitians per hospital bed has fallen from 1 per 100 to 1 per 300. There are only six regions in Italy that have policies regarding dietetic and nutritional services: Piemonte, Trentino Alto Adige, Puglia, Calabria, and Lazio. Regarding home-based enteral and parenteral nutrition, a regional policy exists only in Piemonte, Veneto, and Molise. In Campania, Emilia Romagna, Friuli, Marche, Lazio, Liguria, Lombardia, Puglia, Toscana, Trentino Alto Adige, Umbria, and Val d’Aosta, regional and provincial resolutions exist, and in Abruzzo, Basilicata, Calabria, Sardegna, and Sicilia (25% of the country) there are no policies whatsoever. Food education campaigns Minister for Health/Department of Health. Between 1994 and 1999 growth was registered in Italy in the number of people who are overweight; this increase is thought to be a result of increasing consumption of hyper-caloric diets (that are not always balanced in relation to their effective energy content) and decreasing physical activity. The ISTAT 200040 study revealed a drastic 25% increase in obesity in this period. The most alarming finding that emerged from the study concerns children; 4% of children were found to be obese and 20% overweight. Regarding future trends, it was predicted that the situation will worsen, leading to increasing damage to health and corresponding increases, both directly and indirectly, in Department of Health spending. Increasing amounts of money are also being spent in pharmacies for dietetic products, complements, or supplements for slimming. A recent market research study41 shows that proceeds from the sale of these items in pharmacies in 2008 equaled 69.1 million euros, which represents 59.6% of the market share for these goods. In supermarkets, proceeds were 14.2 million euros, representing 31.4% of market share, and other stores accounted for 9%. Combating obesity means promoting public awareness of the damage to health caused by bad dietary habits, and by incorrect lifestyle choices. From this emerges the need for institutions like the Italian Department of 560

Health,42 to organize large-scale educational initiatives and health promotion campaigns for the prevention of obesity. These should be aimed at the whole population, using in the most effective manner different communication channels for the various population groups, i.e., national and private television broadcasting, public and private radio, and new media including internet and various satellite channels, that are able to influence behaviors. Although there is currently no demonstrated population-wide obesity prevention approach that has been shown to be effective, evaluation of diverse beliefs and attitudes as well as differences in age, gender, race, ethnicity, culture, and food practices is the first step towards healthcare delivery for targeted communities. The Obesity Day Project. The Obesity Day Project began in 2001 with the specific purpose of increasing awareness of obesity and overweight prevention and treatment. It is promoted by the ADI (The Italian Dietetic Association) in association with the dietetic and clinical nutrition services, community services, and obesity centers. Among the various aims of the project, the following are mentioned: raise public awareness regarding the risks associated with obesity and overweight; shift the emphasis from obesity as an aesthetic problem to obesity as an important health problem, creating awareness amongst the hospital and community dietetic and clinical nutritional services, both inside and outside of the professional structures in which they operate; create stable relations among the various dietetic services and the Italian dietetic association centers that deal with obesity and overweight. The project is carried out through two primary mediums: the Web site www.obesityday.org43; and the organization of “a patient day” during which 200 Italian dietetic centers supply, free of charge, information and education regarding the project’s theme. Obesity day takes place every year on October 10. INRAN (National Food and Nutrition Research Center). Promotion of correct dietary and lifestyle habits is one of the primary objectives of INRAN.44 In 1986, a committee of experts drafted the first dietary guidelines for a healthy Italian diet. These have since been modified and now contain various updated revisions and specific targeted advice. By offering definite advice and suggestions as to the correct choices in relation to good dietary practices, the dietary guidelines aim to prevent the risk of dietrelated chronic degenerative pathologies, and to promote health status, physical well-being, and an active and dynamic lifestyle. In addition to the dietary guidelines, the organization’s Web site offers popular and informative publications/papers, as well as press communication and promotional videos. Nutrition Reviews® Vol. 68(9):556–563

Private sector response to public health nutrition needs Since the response of the national public health nutrition service to public requirements is inadequate, there are increasing numbers of private centers dealing with nutritional problems. Although professionals in the private sector may have inadequate qualifications and insufficient specialist training, many of them have become nutritionists in practice. A review of the 2009 yellow pages of Italy on web revealed 355 subjects listed as specialists in dietetics and/or human nutrition and food science in Italy. It is noteworthy that some of those subjects have a graduate degree in medicine and a post-graduate degree in human nutrition and food science while others do not; this finding confirms the inconsistent manner in which universities identify professional roles and emphasizes the gap between the amount of university training being provided and the need for nutrition expertise. Media Typically, the media covers a range of different nutritional topics. Many radio and TV shows dedicate special seasonal editions to diet and well-being and present technical reports on different nutritional issues. The print media also devotes attention to the subject of nutrition. An analysis of nutrition coverage in the Italian press in 2009 revealed 10 weekly newspapers, 15 women’s magazines, and 4 weekly cooking magazines that regularly published articles on nutrition. Recent market research41 showed a 30% increase in the use of nutrition and well-being Web sites over the last 3 years, with the sites being accessed from home- and work-based computers. Moreover, thousands of Internet Web sites offer open access to nutrition data; it should be noted, however, that many of these sites lack quality control. As an example, when the keywords “dieta,” “nutrizione,” “centri di dietetica e nutrizione” were entered into the search engine Google in November 2009, 29,500,000, 1,090,000, and 22,000 results, respectively, were returned.

funding sources, and political goals. These changes necessitate the development of skills that will prepare the workforce for future challenges that will change the nature of dietetic practice not just for the dietitian but for all health and medical professionals. Current trends that are expected to have the greatest impact on the future of dietetics include the following: aging of the population and the associated rise in chronic diseases as well as Alzheimer’s disease; the prevalence of obesity as a public and global health issue; growing economic gaps among the different social classes; the global explosion in communication and means by which the consumer obtains nutritional information; and increasing social multiculturalism, which diversifies the public’s attitudes, languages, and food habits. CONCLUSION As outlined in this review, changes are required within the health nutrition system in Italy. However, many of the challenges outlined face other countries as well. In essence, public health nutrition research and strategies should support public health innovation and global community care. In Italy, efforts to include more nutrition education in medical schools are needed; although nutrition training for medical students is currently recommended, it is not required and is not being fulfilled. More grants should also be made available to support specialization courses in Human Nutrition and Food Science; the development of a specialist workforce to lead and support public health nutrition activities at the population level is a global priority. Acknowledgments The authors acknowledge Professor Giuseppe Fatati, president of the Italian Dietetic and Clinical Nutrition Association (ADI), for his contribution in providing data on the Italian national health care system. Declaration of interest. The authors have no relevant interests to declare.



The Public Health Nutrition infrastructure in Italy needs to be enhanced, as does the education and training system. The roles and functions of professionals operating in health nutrition practice need to be more clearly defined and discipline-specific competencies need to be integrated. The health nutrition workforce is continuously evolving and adjusting to environmental factors,

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