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Health nutrition practice in Italy

Hellas Cena, Carla Roggi, Lucio Lucchin, and Giovanna Turconinure_315 556..563
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 needto be enhanced, as do the educationandtraining 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 19
th
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 Association
4
as
the integration and application of principles derived from
the disciplines of food, nutrition, management, commu-
nication, 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 discipline-
specific and provide more detailed insight into core com-
petencies, 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 compe-
tencies 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 sur-
veillance 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: hcena@unipv.it, Phone: +39-0382-987542, Fax: + 39-0382-987570.
Key words: clinical nutrition, nutrition education, nutrition practice, public health nutrition
Nutrition↔Science Policy
doi:10.1111/j.1753-4887.2010.00315.x
Nutrition Reviews® Vol. 68(9):556–563 556
status of different groups, communities, and populations;
nutrition communication; food program and policy plan-
ning and evaluation; leadership and management; nutri-
tional science and health promotion; skills training;
individual-level approaches, such as counseling and
nutrition education for general and high-risk popula-
tions; clinical intervention and treatment; interdiscipli-
nary collaboration; and professionalism, ethics, and
culture as part of the environmental, behavioral, social,
and economic sciences.
7–20
It is also important to recog-
nize that competencies evolve to reflect changes in public
health nutrition that occur in response to new require-
ments. Given current trends, nutrition is facing techno-
logical, social, political, global, and environmental forces
that are significantly reshaping the world food system.
Nutritional science must be considered a multidisci-
plinary 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 methodologi-
cal approaches or techniques in biochemistry, immunol-
ogy, 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 nutri-
ents or non-nutrient food components; choosing animal
and in vitro models relevant for human nutrition; exam-
ining the nutritional effects of food components and pro-
cessing and the scientific substantiation of health claims
on foods; epidemiologic studies on nutrient and xenobi-
otic intakes in human populations and development of
analytical techniques for food components); 2) Epidemi-
ology 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 Nutri-
tion (e.g., nutrient metabolism in humans; body compo-
sition 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 market-
ing; 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.
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 individu-
als, chronic diseases, infectious diseases, eating disorders,
and the elderly population, together with the rising ethnic
and cultural diversity of Italian society and income dis-
parities, 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 2005
22
high-
lights seven risk factors for the majority of non-
communicable 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 prevent-
able risk factors in most countries. Overweight status
alone is responsible for about 7.8% of total disability-
adjusted 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 Euro-
pean 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
physicians
24
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 mel-
litus in the elderly (14.5%)
23
are key areas of focus for
Nutrition Reviews® Vol. 68(9):556–563 557
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, men-
toring, 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 knowl-
edge at all levels) recommends an increase in the number
of post-graduate education and training courses in clini-
cal nutrition.
36
Gaining nutritional competence is recognized
worldwide as an important component in the develop-
ment 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 dis-
eases, medical nutrition therapy (MNT) continues to be
an essential component for their management. As knowl-
edge expands, the list of nutrition-related disorders
increases. The treatment of such established diseases
through adequate changes in dietary practices, nourish-
ment procedures, and sophisticated feeding place a great
deal of responsibility on nutrition care. There is also a
growing demand for prevention while the WesternWorld
continues to search for cures. Despite consensus about
the need for improved nutrition education, there has
been considerable neglect of and even opposition to inte-
grating 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 com-
pleting 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, stu-
dents 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 architec-
ture 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 univer-
sity 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 hos-
pitals, which carry out research and operate within the
health service. Under this scheme, nutritional interven-
tion is organized under two categories: 1) preventative,
which is managed principally by 186 food and nutrition
hygiene services (SIAN) in which many professional dis-
ciplines 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):556–563 558
2006) and the dietetic service, which is made up of quali-
fied 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
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 malnutri-
tion and obesity (21% and 30.7%, respectively).
39
Other
Table 1 Human nutrition and dietetics courses in Italian universities.
University courses Duration
(years)
No. of
schools/no.
of students
Objectives
Medical/health area
Level 1 degree course in dietetics.
Class 111 medical/health degree
3 27/522* Train health workers to be competent in all the
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
nutrition and food science – medical
(new rearrangement)
5 23/28* Enable students to acquire competence in the
evaluation of nutritional status, in the
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
human nutrition and food science
(new rearrangement)
5 10/60* Acquire competence in evaluating nutritional status,
and in the definition of energy and nutrient
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
– Quality and Safety of Human Nutrition
(Classes 69/S)
2 3 Acquire a good understanding of the correct
application of diet and nutrition, and of the laws
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.
Nutrition Reviews® Vol. 68(9):556–563 559
indicators relevant to the present inadequacy of nutri-
tional services include the following: 1) Insufficient pres-
ence 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. Regard-
ing 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 2000
40
study revealed a drastic 25% increase in
obesity in this period. The most alarming finding that
emerged from the study concerns children; 4% of chil-
dren were found to be obese and 20%overweight. Regard-
ing future trends, it was predicted that the situation will
worsen, leading to increasing damage to health and cor-
responding 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 study
41
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 aware-
ness 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
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 communica-
tion 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 behav-
iors. 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 ser-
vices, community services, and obesity centers. Among
the various aims of the project, the following are men-
tioned: raise public awareness regarding the risks associ-
ated 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 associa-
tion centers that deal with obesity and overweight. The
project is carried out through two primary mediums: the
Web site www.obesityday.org
43
; and the organization of
“a patient day” during which 200 Italian dietetic centers
supply, free of charge, information and education regard-
ing 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 diet-
related 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):556–563 560
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 nutri-
tional problems. Although professionals in the private
sector may have inadequate qualifications and insufficient
specialist training, many of them have become nutrition-
ists 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 uni-
versities identify professional roles and emphasizes the
gap between the amount of university training being pro-
vided and the need for nutrition expertise.
Media
Typically, the media covers a range of different nutri-
tional topics. Many radio and TV shows dedicate special
seasonal editions to diet and well-being and present tech-
nical 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 regu-
larly published articles on nutrition.
Recent market research
41
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.
SUMMARY OF CURRENT NEEDS IN
NUTRITION SERVICES
The Public Health Nutrition infrastructure in Italy needs
to be enhanced, as does the education and training
system. The roles and functions of professionals operat-
ing in health nutrition practice need to be more clearly
defined and discipline-specific competencies need to be
integrated. The health nutrition workforce is continu-
ously evolving and adjusting to environmental factors,
funding sources, and political goals. These changes neces-
sitate 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 com-
munication and means by which the consumer obtains
nutritional information; and increasing social multicul-
turalism, which diversifies the public’s attitudes, lan-
guages, 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 com-
munity care. In Italy, efforts to include more nutrition
education in medical schools are needed; although nutri-
tion training for medical students is currently recom-
mended, it is not required and is not being fulfilled. More
grants should also be made available to support special-
ization courses in Human Nutrition and Food Science;
the development of a specialist workforce to lead and
support public health nutrition activities at the popula-
tion 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.
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