Health Nutrition Italy

8/12/2019 Health Nutrition Italy

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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 need to be enhanced, as do the education andtraining systems. Rolesand 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 (460348

BC), and Galen (130200 AD).2,3 Dietetics as a profession

has been defined by the American DieteticAssociation4 as

the integration and application of principles derived from

the disciplines of food, nutrition, management, commu-

nication, biological, physiological, behavioral, and socialsciences 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.

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The common areas of competencyinclude 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 Turconiare with the Department of Applied Health Sciences, Section of Human Nutrition and Dietetics ,

Faculty of Medicine, at the University of Pavia, Italy. Lucio Lucchinis with the Dietetic and Clinical Nutrition Unit, Health Department of theAutonomous Province of Bolzano, I taly.

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

NutritionScience Policy

doi:10.1111/j.1753-4887.2010.00315.x

Nutrition Reviews Vol. 68(9):556563556


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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.720 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 onanimal 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 ofanalytical 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 evidenceand 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 200522 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 2030% 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 mel-

litus in the elderly (14.5%)23 are key areas of focus for

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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 sufficientcapacity at many levels to respond to national population

needs in the areas of food and nutrition.2530 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.3134 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 MinistersResolution 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 Western World

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 students 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 doesnt 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 healthnutrition 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 20092010. 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 foodscience 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



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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. ofschools/no.of students

Objectives

Medical/health areaLevel 1 degree course in dietetics.Class 111 medical/health degree

3 27/522* Train health workers to be competent in all theactivities related to the correct application ofhuman nutrition and feeding in the physiologicaland pathological setting, designing dietsprescribed by the medical doctor and checkingtheir suitability/acceptability.

Enable health workers to acquire competence in theplanning and organisation of services in thecommunity for both healthy and sick individuals,studying and designing menus and food portionsappropriate to satisfy the nutritional needs ofpopulation groups.

Promote health using nutrition educationinterventions as well as collaborating innutritional 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 theprogramming of nutritional surveillance, and inprimary prevention initiatives.

Develop the capacity to diagnose and applymedical nutritional therapy in pathologies thatcould benefit from dietetic intervention orartificial nutrition in all the different age groups.

Non-medical specialization course inhuman nutrition and food science(new rearrangement)

5 10/60* Acquire competence in evaluating nutritional status,and in the definition of energy and nutrientrequirements for different age groups andphysiological conditions.

Develop the ability to program interventions fornutritional surveillance, as well as for theorganization of catering services.

Non-medical/health areaLevel II degree course in human nutrition

Quality and Safety of Human Nutrition(Classes 69/S)

2 3 Acquire a good understanding of the correctapplication of diet and nutrition, and of the lawsin force, using up-to-date technology andinterpreting the data in order to evaluate thenutritional quality, food safety, suitability of thefood for human consumption, and for evaluatingmalnutrition in the individual and in thepopulation.

Medical and non-medical health area mastersMasters 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 20092010.



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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 thedegree 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 AltoAdige, Umbria, and Val dAosta, 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 effectiveenergy 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 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 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 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 demonstratedpopulation-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 theADI (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: theWeb site www.obesityday.org43; and the organization of

a patient day during which 200 Italian dietetic centers

supply, free of charge, information and education regard-

ing the projects 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

organizations Web site offers popular and informative

publications/papers, as well as press communication and

promotional videos.



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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 womens

magazines, and 4 weekly cooking magazines that regu-

larly published articles on nutrition.

Recent market research41 showed a 30% increase inthe 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

Alzheimers disease; the prevalence of obesity as a publicand 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 publics 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 thechallenges 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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