Clinical Nutrition xxx (xxxx) xxx

Contents lists available at ScienceDirect

Clinical Nutrition
journal homepage: http://www.elsevier.com/locate/clnu

Original article

Clinical nutrition and human rights. An international position paper

Diana Cardenas a, *, Maria Isabel Toulson Davisson Correia b, Juan B. Ochoa c, Gil Hardy d,
Dolores Rodriguez-Ventimilla e, Charles E. Bermúdez f, Karin Papapietro g,

gis Hankard h, Andre
Re
Briend i, Winai Ungpinitpong j, Katerina Mary Zakka k,
Teresa Pounds , Cristina Cuerda m, Rocco Barazzoni n
l

a
Faculty of Medicine, Research Institute on Nutrition, Genetics and Metabolism, El Bosque University, Bogota
, Colombia
b
Surgical Department, Medical School, Universidade Federal de Medicina, Belo Horizonte, Brazil
c
Department of Surgery, Ochsner Medical CentereNew Orleans, New Orleans, LA, USA
d
Ipanema Research Trust, Auckland, New Zealand
e
gico Nacional- SOLCA, Guayaquil, Ecuador
Clinical Nutrition and Dietetics Service, Instituto Oncolo
f
Surgery and Nutrition Department, Clínica La Colina and Clínica Del Country, Bogota, Colombia
g
Nutrition Unit, Hospital Clínico de La Universidad de Chile, Santiago, Chile
h
Nutrition Mobile Unit, CHU Tours, Universit
e de Tours, European Institute for History and Culture of Food, University of Tours, France
i
Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Frederiksberg, Denmark and Center for Child Health Research,
Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
j
Surgery Department, Surin Hospital, Thailand
k
Department of Internal Medicine, Wellstar Atlanta Medical Center, Atlanta, GA, USA
l
Department of Pharmacy, Wellstar Atlanta Medical Center, Atlanta, GA, USA
m
Nutrition Unit, Hospital General Universitario Gregorio Maran ~o

n, Madrid, Spain
n
Department of Medical, Technological and Translational Sciences, University of Trieste, Ospedale di Cattinara, Trieste, Italy

a r t i c l e i n f o s u m m a r y

Article history: The International Working Group for Patients' Right to Nutritional Care presents its position paper
Received 25 January 2021 regarding nutritional care as a human right intrinsically linked to the right to food and the right to health.
Accepted 23 February 2021 All people should have access to food and evidence-based medical nutrition therapy including artificial
nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access
Keywords: to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to
Human rights
overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related
Food
malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life
Health
Disease
and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision
Disease-related malnutrition for the patient must be taken and this may include, under certain circumstances, the decision not to feed.
Artificial nutrition therapy Application of the human rights-based approach to the field of clinical nutrition will contribute to the
construction of a moral, political and legal focus to the concept of nutritional care. Moreover, it will be
the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.
© 2021 European Society for Clinical Nutrition and Metabolism and American Society for Parenteral and
Enteral Nutrition. Published by Elsevier Ltd. All rights reserved.

Abbreviations: AIDS, Acquired immunodeficiency syndrome; AANH, Artificially administered nutrition and hydration; ASPEN, American Society for Enteral and Parenteral
Nutrition; CESCR, Committee on Economic, Social and Cultural Rights; DOHaD, Developmental origins of health and disease; DRM, Disease-related malnutrition; ESPEN,
European Society for Clinical Nutrition and Metabolism; FELANPE, Latin American Federation of Nutritional Therapy, Clinical Nutrition and Metabolism; HIV, Human im-
munodeficiency virus; HRBA, The human rights-based approach; ICESCR, International Covenant on Economic, Social and Cultural Rights; PENSA, Parenteral and Enteral
Nutrition Society of Asia; UN, United Nations; WASPEN, West African Society of Parenteral and Enteral Nutrition.
* Corresponding author. Universidad El Bosque, Carrera 7 No. 117 e 15, Bogota, Colombia.
E-mail addresses: [email protected] (D. Cardenas), [email protected] (M.I.T.D. Correia), [email protected] (J.B. Ochoa), gil.hardy50@
gmail.com (G. Hardy), [email protected] (D. Rodriguez-Ventimilla), [email protected] (C.E. Bermúdez), [email protected] (K. Papapietro), regis.
[email protected] (R. Hankard), [email protected] (A. Briend), [email protected] (K.M. Zakka), [email protected] (T. Pounds), cuerda.cristina@
gmail.com (C. Cuerda), [email protected] (R. Barazzoni).

https://doi.org/10.1016/j.clnu.2021.02.039
0261-5614/© 2021 European Society for Clinical Nutrition and Metabolism and American Society for Parenteral and Enteral Nutrition. Published by Elsevier Ltd. All rights
reserved.

Please cite this article as: D. Cardenas, M.I.T.D. Correia, J.B. Ochoa et al., Clinical nutrition and human rights. An international position paper,
Clinical Nutrition, https://doi.org/10.1016/j.clnu.2021.02.039
D. Cardenas, M.I.T.D. Correia, J.B. Ochoa et al. Clinical Nutrition xxx (xxxx) xxx

1. Introduction ASPEN, ESPEN, FELANPE, PENSA and WASPEN. Therefore, the aim of
this position paper is to provide the link between clinical nutrition
Malnutrition (i.e. undernutrition, inadequate vitamins or min- and human rights, in an attempt to characterize nutritional care as
erals, overweight and obesity) is a major contributor to disease a human right, and thus highlight the need to early diagnosis and
burden and thus, the delivery of optimal nutritional care should be treatment of DRM as a holistic process of patient care.
an effective strategy to reduce its global burden [1,2]. The situation
is even more acute in children, not only because neglecting 2. The human rights-based approach
malnutrition makes health professionals accountable for an actual
threat to the child, but also for the future adult she/he will become. The human rights-based approach (HRBA) is a conceptual
In childbearing women and children, malnutrition is a strong framework that can be applied to clinical nutrition. According to
determinant of health in adulthood. This is the concept of the “early the United Nations (UN), this approach is “normatively based on
origin of adult” or “developmental origins of health and disease” international human rights standards and operationally directed
(DOHaD) or “fetal programming/developmental programming”. In to promoting and protecting human rights” [27]. Applied to the
these situations, malnutrition has long lasting effects with poten- healthcare context, this approach focuses “on the underlying
tial impacts on the health of future generations [3,4]. The positive social determinants of health and on emphasizing the principles
impact of nutritional care is related to its capacity to influence of accountability, meaningful participation, transparency, equality
disease outcomes, particularly the vulnerable malnourished pop- and non-discrimination” [28]. Priorities and objectives in the field
ulation [5e8]. Indeed, nutritional care contributes to reduced of clinical nutrition can be identified and program outcomes can be
morbidity, mortality, length of hospital stay as well as fewer formulated, through this approach. It is an interesting approach in
readmissions. Therefore, it is considered cost effective, and may the current analysis as it reinforces a situation evaluation on three
influence the financial sustainability of health care systems [9e13]. levels: 1 e the causality analysis: to focus attention on root causes,
Nutritional care is “an overarching term to describe the form of in our case, analysis of the origin of DRM; 2 e the role or obligation
nutrition, nutrient delivery and the system of education that is analysis: to help define who owes which obligations to whom,
required for meal service or to treat any nutrition-related condition in our case, identification of the root causes of DRM; and 3 - the
in both preventative nutrition and clinical nutrition” [14]. In the identification of the required interventions to improve duty-
clinical context, nutritional care should be understood as a process, bearers’ performance and build rights-holders’ capacities. Thus,
which is carried out by interrelated steps including screening, according to the UN, a HRBA seeks “to deepen understanding of the
diagnosis, assessment, nutritional therapy and monitoring [14,15]. relationships between rights-holders and duty-bearers, contrib-
It aims to early assess, prevent and treat malnutrition by imple- uting to bridge the gaps between them” [27].
menting an optimal nutritional therapy strategy.
The efficacy of nutritional care has been extensively docu- 3. Health and human rights
mented, however, high levels of disease-related malnutrition (DRM)
have persisted in all health care settings over the past five decades The relationship between health and human rights is bidirec-
despite marked advances in medical sciences over this same period tional. This means that health is a human rights issue, and
[11,16e21]. Moreover, public policies and legislation to address this conversely human rights are a health issue [29,30]. Both have been
issue are scarce and the human rights approach has never been developed in the last seven decades under international law,
assessed. mainly as a basis for public health. What is central to this rela-
Academic, practical, social and economic factors have been tionship is that it offers a universal framework “to promote justice
recognized as barriers to the improvement of nutritional care in in public health, elaborating the necessary freedoms and rights to
clinical nutrition, and they must be addressed [22]. In the last de- achieve dignity for all” [31].
cades, different strategies have emerged to address these issues and Human rights are norms that aim to protect people from social
overcome these barriers. In Europe, the Resolution ResAP (2003) on and political abuse. They can be considered as moral, philosophical,
food and nutritional care in hospitals addressed this problem and judicial and political concepts which posit that “every human being
was approved by the Council of Europe in 2003 [23]. In the US, The possesses inalienable, universal rights, regardless of the statutory
Alliance to Advance Patient Nutrition gathered key US scientific legal framework in force and independent of other factors such
nutrition companies, in 2013, to advocate for effective nutrition as ethnicity or nationality” [32]. Fundamental human rights are
care, including optimal food intake [24]. In Latin America, this defined as a variety of an individual's personal prerogatives, which
problem was addressed by the International Declaration on the democratic societies generally enshrine into law. Human rights
Right to Nutritional Care and the Fight Against Malnutrition, named are grounded in the political constitutions as a consequence of
the Cartagena Declaration, signed in May 2019 [25]. Among these adhering to international conventions, and thereby ensure primacy
initiatives, human rights can be identified as a common basic is respected by governments and largely by all actors. It is note-
foundation. worthy that in childbearing women and children, human rights
Indeed, it is well known that there is an inextricable link be- address not only the actual person, fetus and child, but also the
tween human rights and health. According to Dr. Jonathan Mann, future adult.
“Health and human rights are complementary approaches for The centrality of human rights concerning key health issues
defining and advancing human well-being. The goal of linking throughout the history of medicine can be found in historical public
health and human rights is to contribute to advancing human well- health policies, programs, and practices. There is well accepted
being beyond what could be achieved through an isolated health or evidence demonstrating that norms consecrated to the respect,
human rights-based approach” [26]. Despite the evident rapport, protection, and fulfillment of human rights can translate into
clinical nutrition has never been examined under such perspective. improved public health in several important health issues [33].
This is why an international working group was launched in 2020 A prime example of previous use of HRBA to health issues is
to explore how the human rights-based approach can contribute to the campaign against the human immunodeficiency virus (HIV)
the challenges faced by the practice of clinical nutrition in and acquired immunodeficiency syndrome (AIDS). In fact, policy
increasingly demanding health care systems. The working group is makers were forced to ensure basic human rights protections in
composed of experts in clinical nutrition and representatives of order to guarantee the access to care of HIV stigmatized and
2
D. Cardenas, M.I.T.D. Correia, J.B. Ochoa et al. Clinical Nutrition xxx (xxxx) xxx

marginalized populations [31,34]. By advocating for human rights, 4.2. The right to food in the clinical context
these population had improved access to health services and
medications, as well as guaranteed availability of preventative The Universal Declaration of Human Rights, adopted by the UN
measures and reduced discriminatory practices [35]. The HRBA in in December 1948, is the first document to recognize the right to
this context positively impacted HIV patients by reducing food as a human right. It is therein considered as a constituent part
morbidity, mortality and disease transmission. of an overarching Right to Adequate Living Standards (Article 25):
It is necessary to recognize that the existence, validity, and exact “Everyone has the right to a standard of living adequate for the
nature of human rights have been perennial topics of heated de- health and well-being of himself and of his family, including (access
bates in regard to contentious rights or in controversial contexts. to) food …” [42]. The mandatory nature of this right (i.e. legally
Nutritional care as a human right and the right to food, considering binding), was enshrined in the International Covenant on Eco-
that without the latter life is unsustainable, can turn into such a nomic, Social and Cultural Rights (ICESCR) in 1976. For the last four
disputed right in the context of clinical practice. decades, international agreements have reasserted the right to
food. For example, the Convention on the Elimination of All Forms
4. Nutritional care as a human right of Discrimination against Women (1979) and the Convention on the
Rights of the Child (1989). To date, 160 States have ratified the
4.1. The emergence of the right to nutritional care ICESCR and, thus, are legally bound to enact its provisions. Article
11 of the ICESCR establishes that “the States Parties to the present
Clinical nutrition has not yet been explored in the context of Covenant recognize the right of everyone to an adequate standard
HRBA. Until now, it has been limited to promoting and claiming the of living for himself and his family, including adequate food” and
right to food in the clinical context [36,37]. The Declaration of the Committee on Economic, Social and Cultural Rights (CESCR)
Cancun, signed in 2008 by FELANPE members, was based on the general comment number 12 asserts the existence of every person's
right to food and nutrition in hospitals [38]. Another example, the right to be free from “hunger and malnutrition” [43,44]. Hence, this
Resolution ResAP (2003) (22) on Food and Nutritional Care in right encompasses two distinct ancillary rights: the first is the right
Hospitals, adopted by the Committee of Ministers of the Council of to “adequate food” while the second is “the fundamental right to
Europe, was based on the right to food, as stated in the introduc- freedom from hunger and malnutrition”. Then, how should the
tion: “access to a safe and healthy variety of food is a fundamental right to food be understood within the clinical context?
human right.“. By invoking the right to food and nutrition in hos- In order to answer this question, it is necessary to address it at
pitals, the right to be protected against hunger and the right to the political level. The beneficiary of the right to adequate food is an
adequate food would be promoted. However, it is well known that active individual to whom the State is obliged to provide an envi-
although food is available in hospitals, it does not necessarily mean ronment that permits them to “feed themselves”, but, failing this
the patients will be able to ingest it as a consequence of their dis- basic tenet, they, are to be provided with assisted feeding without
ease status. In this regard, acknowledging that the lack of food compromising their dignity. Conversely, in the clinical context the
along with the disease will further deteriorate the patient's nutri- right to adequate food should be conceived differently. In this
tional status, and thus negatively impact on outcomes, nutrition context, the participation of a third person is a key element in
care becomes a human right. Thus, we should ask: Why is the right understanding this right. This is explained by the fact that the act of
to food neglected in the clinical field? feeding someone sick, who cannot reach his/her basic nutritional
Surprising as it may seem, in hospitals (an essential institution requirements, must be done by an expert, who can act within an
for the care of persons seeking health improvement), this right is interdisciplinary team of caregivers. This means that the patient
too often disrespected. Our hypothesis is that DRM does not fall has the right “to receive” nutritional therapy in the best possible
within the scope of the concept or normative content of the right manner that is to say, the right to “be fed” and to be treated and not
to food. Moreover, the right to food is within the scope of com- the right to “feed themselves”. This also means that the right to
munity malnutrition, a distinct form of malnutrition, the origin of health is linked to the right to nutritional care. Therefore, nutri-
which lies in food insecurity. Fig. 1 shows the different pathways tional care must be considered an emerging human right. It is
of community malnutrition and disease-related malnutrition. It motivated by the need to move forward on key issues such as the
must be noted that according to the particularities of each form promotion of better outcomes and cost-effectiveness. Clinical
of malnutrition, a different approach is needed. nutrition research and education as well as patient empowerment
Therefore, we advocate that it is necessary to recognize nutri- should also be integrated into fighting the disease burden along
tional care as a human right, taking into account the latter gua- with malnutrition. To make progress in this matter, public policies
rantees that all people should have access to food and evidence- and legislation on clinical nutrition are needed, and the promotion
based medical nutrition therapy including artificially adminis- of the right to nutritional care is a way to achieve it. Furthermore, it
tered nutrition and hydration (AANH). In this regard, the is necessary to define nutritional care as a human right.
malnourished ill should mandatorily have access to nutritional
care. In particular, screening, diagnosis, nutritional assessment and, 4.3. The definition of nutrition care as a fundamental right
with optimal and timely nutritional therapy in order to reduce the
high rates of hospital malnutrition and the associated morbidity The human right approach carries considerable rhetorical po-
and mortality. This right does not imply that there is an obligation wer and can help mobilize the force of public opinion in bringing
to feed all patients at any stage of life and at any cost. On the about a change. It is thus essential to have clarity and precision
contrary, this right implies, from an ethical point of view, that the about the real nature of human rights, and the role they can play. It
best decision for the patient must be made and this may include the is important to preserve their normative power and enable effec-
decision not to feed, when terminality has been defined and the tive policy guidelines. In this regard, nutritional care as a human
patients, families and/or caregiver together with the clinical team right must be well defined. According to different authors [45,46],
decide against it. an emergent human right can be defined in accordance to its
The Cartagena Declaration signed in 2019 for the first time foundation, its duty-bearers and its content or scope.
proposes that nutritional care, understood as a holistic process of Dignity is the universally endorsed candidate for the core value
patient care, should be recognized as a human right [25,41]. of human rights [42]. It has been previously described as the link
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D. Cardenas, M.I.T.D. Correia, J.B. Ochoa et al. Clinical Nutrition xxx (xxxx) xxx

Fig. 1. A: Pathways from inadequate food access to multiple forms of malnutrition (Except disease-related malnutrition) According to the FAO, 2018 [39]; B: Pathways from disease
to malnutrition. Figure according to the classifications and definitions of ESPEN [14]. Reprinted with permission and adapted from [40].

between human dignity and nutrition [41,42]. In fact, the absence of environments are considered cardinal to nutritional therapy [42].
nutritional care and AANH can constitute an offence against human While caring for the patients in need of nutrition care (i.e.
dignity (Table 1). malnourished patients), all these factors must be considered. Thus,
Through nutritional therapy, it is possible to respect human respect for human dignity is the foundation of the right to nutri-
dignity (i.e. a person's right to be treated ethically and to be tional care.
valued and respected for their own sake) [48]. This is achieved The second aspect concerning the definition of the right to
when individual autonomy, religious beliefs, and socio-cultural nutritional care is the imposition of human rights on duty-bearers.
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D. Cardenas, M.I.T.D. Correia, J.B. Ochoa et al. Clinical Nutrition xxx (xxxx) xxx

Table 1
The definition of nutritional care as a human right.

The foundation of the right to nutritional care

Human dignity

Ethical principles
The duty-bearers

The state, policymakers, institutional managers and caregivers
The content or scope

The human right to benefit from the whole process of nutritional care. This means that the patient has the right to beneficiate from the right to be screened and
diagnosed for disease related malnutrition, to receive regular hospital diet, therapeutic diet (i.e. food modification and supplements) and evidence-based medical
nutrition therapy (i.e. AANH) administrated by an interdisciplinary team of experts, and the government has the duty to guarantee it.

Table reprinted with permission and adapted from [47].

This means that human rights must be respected by all of the attainable standard of health is one of the fundamental rights of
different stakeholders, not only the States, who are capable of ful- every human being without distinction of race, religion, political
filling them. Beyond policy makers and other political stakeholders, belief, economic or social condition.” Numerous international
scientists, and healthcare givers are also concerned with the right agreements protect this human right, for example, the 1948 Uni-
to nutritional care. The main issue at stake is the capacity of versal Declaration of Human Rights (Article 25), the ICESCR (Article
healthcare systems to provide optimal nutritional care. 12), of the Convention on the Rights of the Child (Article 24), the
Finally, the content or scope of human rights refers to the in- Convention on the Elimination of All Forms of Racial Discrimination
terests that define and ground them (e.g. health, autonomy and (Article 5), the Convention on the Elimination of All Forms of
knowledge) and to the duties generated by these underlying in- Discrimination Against Women (Articles 12 and 14), the American
terests. Thus, nutritional care is part of the holistic approach for the Declaration on Rights and Duties of Man (Article 11), and of the
patient, and encompasses a process beginning with the identifi- Convention on the Rights of Persons with Disabilities (Article 25)
cation of nutritional risk, assessment, and diagnosis, which aims to [51].
prevent and treat DRM by early provision of nutrition, ranging from The right to health is closely related to and dependent upon the
normal food to evidence-based medical nutrition therapy realization of other human rights, such as the right to food. The
(including AANH). The latter is considered as a medical interven- CESCR general comment number 14 (Article 14) emphasizes that
tion requiring a medical indication that aims to achieve a treatment “The right to health embraces a wide range of socio-economic
goal, which in turn needs the informed consent of the patient. In factors that promote conditions in which people can lead a
summary, nutrition care encompasses the duty to feed ill patients healthy life, and extends to the underlying determinants of health,
by natural or artificial means in order to prevent DRM, contribute to such as food and nutrition …” Thus, the right to health, the right to
better health and improve outcomes. Consequently, the content of a food and the right to nutritional care should be considered in a
proposed nutritional care human right must be conceived in a close close relationship. Nutritional care is at the intersection of the right
relationship to other human rights. From our perspective, it is to food and the right to health. This approach and the indivisibility
possible to frame this duty in the scope of two well recognized of these human rights can create opportunities for the imple-
rights: the right to food and the right to health. So, what does it mentation of rights-based legislation, policies, and programs for
mean to say that nutritional care is a human right? the realization of the right to nutritional care (Fig. 2).
States and duty-bearers, from a legal and political point of view,
are bound by certain obligations. People can legitimately claim the 5. The ethical approach
effective implementation of these obligations. Consequently, duty-
bearers are bound “to respect, to protect and to fulfill” the right to Human rights and health care ethics are closely linked as
benefit from the entire process of nutritional care. The patient has they support and complement each other when applied together
the right to be screened for nutritional risk and diagnosed for [52]. Human rights norms are meant to guide the actions of gov-
malnutrition, and to receive a regular hospital diet or a therapeutic ernments, whereas ethics in health care much more broadly
diet (i.e. food modification and supplements) or evidence-based “encompass concern for the specific actions, inspirations, and re-
medical nutrition therapy including AANH therapy under the care lationships of individual health workers, researchers, and organi-
of an expert interdisciplinary team, and the government has the zations” [52]. Human rights concepts, according to E. Hirsch,
duty to guarantee said rights (Table 2). The question that arises is, “characterize and illuminate the issues of an ethical requirement in
how must nutritional care be related to the recognized human the fields of care and research.” Thus, in the context of nutritional
rights? care, respect for human rights and dignity are not abstract values,
but take on a practical dimension “which define a social order and
4.4. The right to health and nutritional care place us in mutual obligations towards each other.” [53].
We believe that human rights and ethics provide unique and
Health is a fundamental human right that should be considered valuable guidance for the actions of parenteral and enteral (PEN)
indispensable for the exercise of other human rights, in particular societies and other international organizations focused on clinical
the right to food, and is, according to our proposed approach, the nutrition. The human rights norms and ethical values and princi-
right to nutritional care [49]. ples can contribute to moving forward in fighting malnutrition in
The right to “the enjoyment of the highest attainable standard the clinical context. Recognizing the right to nutritional care as a
of physical and mental health” was first found in the 1946 Consti- human right establishes a commitment to a very important ethical
tution of the World Health Organization (WHO). The preamble responsibility that must be based on the respect of the four ethical
defines health as “a state of complete physical, mental and social principles (autonomy, beneficence, nonmaleficence, and justice)
well-being and not merely the absence of disease or infirmity” [50]. [54] as well as other principles such as vulnerability, equality, jus-
The preamble further states that “the enjoyment of the highest tice and equity [55,56].
5
D. Cardenas, M.I.T.D. Correia, J.B. Ochoa et al. Clinical Nutrition xxx (xxxx) xxx

Table 2
Fulfillment of the right to nutritional care requires the following mandatory actions.

Nutrition screening at hospital admission and during the first clinical contact in primary care.
Diagnosis and assessment of malnutrition in all at risk patients;
Provision of a regularly monitored nutrition care plan, by
a) Maintaining a regular oral diet, or, if precluded by the patients' clinical condition,
b) Implementing evidence-based medical nutrition therapy/AANH.

Fig. 2. Nutritional care is at the intersection of the right to food and the right to health, therefore creating opportunities for the implementation of rights-based legislations, policies,
and programs for its realization. DRM: Disease-related malnutrition; AANH: Artificial Nutrition and Hydration.

In 2016, ESPEN published a guideline on ethical aspects of of future generations is at stake. Among the priorities and objec-
artificial nutrition and hydration focused on the adult patient that tives in the field of clinical nutrition, it is possible to identify the
provided a critical summary for physicians and caregivers [57]. The need to increase research and improve nutrition education for all
four principles of the Bioethics are presented in the context of health professionals [60], to emphasize the economic aspects
artificial nutrition and hydration covering different sceneries from thereof [61], to create an institutional culture that values nutri-
the patient with dementia and their care in the intensive care unit tional care, and to promote patient empowerment as a necessary
to palliative care and the terminal patient. action to improve nutritional care [62]. Consequently, such prior-
The updated 2021 ASPEN position paper on ethics of AANH ities enable recognizing specific duties for the duty-bearers (poli-
focusses on applying these ethical principles. Recommendations for cymakers, institutional managers and caregivers) and the rights-
preventing and resolving ethical dilemmas are addressed with an holders (the patients). It is our aspiration to create interventions
emphasis on a collaborative interdisciplinary approach following that improve the rights-holders’ capacities and the duty-bearers’
the twenty proposed ethics position statements. The laws of indi- achievements, in order to bridge the gaps between them. From an
vidual states and national governments have to be considered, but ethical approach, recognizing nutritional care as a human right
overall the international perspective on the ethics of AANH are implies the ethical duty of feeding the ill person in conditions of
essentially similar [58]. dignity, while ensuring justice and equality.
Moreover, the realization of the right to nutritional care needs a
5.1. Developing a human rights-based approach to clinical multi-stakeholder approach. For example, the right to nutritional
nutrition: perspectives for clinical nutrition care could be at the core of the programs and the strategy of the
ESPEN Optimal Nutrition Care for all campaign in Europe [63]. This
Clinical Nutrition is a basic interdisciplinary and applied science, initiative has been promoting and supporting the development of
concerned with the caring of those in need of nutrition care (i.e. public health policy in clinical nutrition. Basing health policy on
undernutrition, inadequate diet intake, overweight and obese pa- human rights can give the program additional strength. The pa-
tients). Its aim is to apply the principles of nutritional care in order tients' associations or support groups should be mobilized and be
to ensure a balance in nutritional status, and modulate other bio- aware of the recognition of the right to nutritional care.
logical functions to positively influence the individual's homeo- Finally, the realization of the right to nutritional care must be a
stasis, any healthcare treatment and outcomes [59]. We are goal of state policies and programs regardless of their economic,
convinced that recognizing that people have the right to nutritional social, cultural, religious or political background. To achieve this,
care is a major advance in the field of clinical nutrition. The main the international working group recommends the following 10
importance of the HRBA approach is that it should help to identify principles:
major priorities and objectives in order to fight against malnutri-
tion and to implement optimal nutritional care for all. In child- 1. Public health policy must make fulfillment of the right to
bearing women and children, not only current health but also that nutritional care a fundamental axis in the fight against DRM;

6
D. Cardenas, M.I.T.D. Correia, J.B. Ochoa et al. Clinical Nutrition xxx (xxxx) xxx

2. Clinical nutrition must be integrated into public health policy none; Cristina Cuerda: Lecturer for Abbott, Baxter, Fresenius,
based on human rights, equity and economic values; Nestle, Nutricia, Persan, Takeda;; Rocco Barazzoni: none.
3. Clinical nutrition education and research is a fundamental
axis of the respect and the fulfillment of the right to nutri- Acknowledgements
tional care;
4. Ethical principles and values in clinical nutrition including We thank Pr Isabella Hannequard and Pr Loïc Bienassis for their
justice and equity in nutritional care access is the basis for contribution to the discussion on human rights and clinical nutri-
the right to nutritional care; tion in this article.
5. Clinicians, researchers and policy makers should work
together to translate evidence-based medical nutrition
therapy into policy; References
6. To be effectively implemented, public health policy on clin-
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including childbearing women and children, as the target Burden of Disease Study 2019. Lancet 2020;396(10258):1204e22.
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