The presence of nutritionists in Primary Health Care (PHC) can represent significant health gains, but the organization of this care delivery model, the integration of nutritionists into its different functional units, and the reduced number of nutritionists performing these functions are factors that can compromise this assumption. In this article, we highlight the obstacles, challenges, and opportunities for a more efficient intervention by nutritionists in this area, which we consider central.
In recent decades, many things have changed in Portuguese society, particularly in how we view the role of food in our health. Today we can quantify the decisive role of inadequate nutrition in the loss of healthy years for the Portuguese population, identify the foods to consume to achieve a dietary pattern in accordance with the recommendations of the Food Wheel, and even define a medium- and long-term national food strategy that distinguishes us at the European level. Furthermore, Portugal has a long tradition of high-quality higher education for nutritionists, which can make a difference compared to other European countries that began this journey later and in a more rudimentary way.
Currently, most pathologies with severe impacts on the State Budget and public accounts have a dietary basis. These include obesity, diabetes, cardiovascular and cerebrovascular disease (where hypertension is a central determinant), oncological disease (where various cancers are related to excessive body weight and a deficiency in the intake of plant-based products), osteoarticular diseases, and malnutrition, which causes thousands of additional days of hospitalization in our health services, particularly among the elderly population. Despite these conditions suggesting the need for intensive intervention by nutritionists in the health system, where changes in eating habits can be promoted and effectively implemented, this intervention is still incipient and, above all, ineffective. This is due to deficient organization of health services and the inability of these professionals to demonstrate their added value, particularly in primary care centers where they could make all the difference, considering the current profile of chronic diseases in our country.
It is generally agreed that the existence of a good response at the primary healthcare level is a sine qua non for more cost-effective health systems that contribute to greater equity in access and are geared towards providing greater health gains ( Biscaia et al, 2008 ). Interestingly, or perhaps not, the emergence of primary healthcare in Portugal was driven by Francisco Gonçalves Ferreira, along with Arnaldo Sampaio and Baltazar Rebelo de Sousa, in 1971, even before the establishment of the National Health Service, which took place in Portugal in 1979. We recall that we also owe to Gonçalves Ferreira a completely innovative idea, at the time, of how to implement public health measures to improve the nutrition of the Portuguese population, which we have presented here previously .
How is Primary Healthcare currently organized in Portugal?
To understand the current situation of nutritionists in the National Health Service (SNS), particularly in primary care centers, it is worth knowing the current organizational model of this level of care provision, which is described below.
Following the 2005 Primary Health Care Reform , the provision of this level of care in Portugal is organized into Groups of Health Centers (ACES) , which have different functional structures: Family Health Units (USF), Personalized Health Care Units (UCSP), Public Health Units (USP), Community Care Units (UCC), and Shared Care Resources Units (URAP).
Health Center Groups are management units, composed of one or more health centers, integrated into the Regional Health Administrations IP or Local Health Units, EPE, and are "responsible for the organization and integration of the various levels of primary health care provision, as well as coordination and liaison with the various community partners."
The creation of Family Health Units was the most important achievement of the 2005 Primary Health Care Reform. Implemented in 2006, the Family Health Units have the mission of providing personalized health care to the registered population of a specific geographic area, guaranteeing accessibility, continuity, and comprehensiveness of the care provided… and are structures comprised of a multidisciplinary team (models A, B, and C).
Personalized Healthcare Units are also personalized healthcare units, composed of doctors, nurses and administrative staff not integrated into Family Health Units (Article 10 of Decree-Law No. 28/2008).
Community Care Units provide healthcare and psychological and social support at home and in the community, particularly to the most vulnerable individuals and groups, those at higher risk or with physical and functional dependence, or those with illnesses requiring close monitoring. They also work in health education, integration into family support networks, and the implementation of mobile intervention units. The UCC team may consist of nurses, social workers, doctors, psychologists, nutritionists, physiotherapists, speech therapists, and other professionals (Article 11 of Decree-Law No. 28/2008).
Public Health Units function as the health observatory for the geodemographic area of the ACES (Local Health Unit Group), being responsible for preparing information and plans in the field of public health, carrying out epidemiological surveillance, managing intervention programs in the areas of prevention, promotion and protection of the health of the population or specific groups, and collaborating, in accordance with the respective legislation, in the exercise of the functions of the health authority (Article 12 of Decree-Law No. 28/2008). The USPs are composed of public health physicians, public health or community health nurses, and environmental health technicians, also including, permanently or on a temporary basis, other professionals deemed necessary in the area of public health.
Shared Healthcare Resource Units are units that provide consulting and healthcare services to all other functional units of the ACES (Local Health Units) and organize functional links to hospital services. They are composed of different professionals, including, for example, social workers and psychologists, physiotherapists, occupational therapists, oral health technicians, nutritionists, among others (Article 13 of Decree-Law No. 28/2008).
How is the area of food and nutrition currently viewed within the context of primary health care?
The document “Primary Health Care in 2011-2016: strengthening, expanding”, published in 2010, lists a set of measures that should be implemented to continue the necessary reform to strengthen primary health care. This document identifies some specific areas of intervention that are considered undervalued and justify a differentiated intervention by primary health care providers. “Eating behaviors” is one of the five specific areas of intervention identified in this document as an undervalued area where change is needed. The document also recognizes that “primary health care is the ideal place to encourage behavioral changes and to provide nutritional advice not only to overweight individuals but, especially, to those responsible for feeding children and young people. In fact, studies indicate that users view primary health care providers as an important source of advice on both lifestyles and aspects related to their diet.” This document stated that by 2016, all Primary Care Units (URAP) should have at least one nutritionist, and that indicators to evaluate the provision of care should also be included in the Performance Plan of the Health Center Groups.
Later, in 2016, through Order No. 200/2016, of January 7 , the Deputy Secretary of State for Health recognized the importance of increasing the intervention capacity of Primary Health Care Centers (PHCs) in the area of nutrition: “strengthening the intervention capacities of PHCs through increased own resources and complementary support, whether in the direct provision of care or in consultancy activities, in areas such as psychology, nutrition, oral health, ophthalmology, obstetrics, pediatrics, physiotherapy and physical medicine and rehabilitation”.
Later, in 2018, another official document reinforced a new organizational and operational model in the area, through the creation of Nutrition Centers/Units/Services (Order No. 6556/2018, of July 4th ), one of the aspects considered important for improving and increasing the problem-solving capacity of Primary Health Care Centers in the area of nutrition, as described in the “Final Report December 2015-October 2019” of the National Coordination for the Reform of the National Health Service for the Area of Primary Health Care.
In which Primary Health Care structures are nutritionists integrated?
The history of nutritionists in the National Health Service begins in the 1990s with the integration of graduates in Nutrition Sciences from FCNAUP (Faculty of Nutrition, Food and Nutrition of the University of Porto) into the Senior Health Technicians career track, in the Nutrition branch. In 1991, with the publication of Decree-Law No. 414/91 of October 22 , the professional profile and functional content of each category were defined. The Northern Regional Health Administration has always been the public entity that has welcomed the most nutritionists and where their intervention in favor of the health of users of the National Health Service has been the greatest, most diverse and most productive.
The solid scientific and humanistic training, based on evidence and pursuing the public interest in each of their interventions, has led the nutritionists at the Primary Health Care Centers to very diverse interventions – outpatient consultations, intervention in school health, community intervention with the most vulnerable populations, namely in food support programs, in training for more balanced and economical eating practices among the elderly, pregnant women, low-income families (where food insecurity is present), epidemiological research in the field of public health, clinical intervention with integrated continuing care teams – trying to make the most of all weekly working time.
We can discuss the effectiveness of these multiple interventions in such diverse situations. Between the extremes of trying to serve all the stated scenarios, a few hours a week, or working full-time in only one area, there are multiple solutions to create an approach that best serves the organization's interests. However, these solutions are scattered across the field, are not homogeneous, or result from local planning to respond to local problems or organizational formats, which makes it difficult to verify the real effectiveness of the nutritionists' work as a whole, depriving them of the ability to make demands and have a voice at the national level.
But what prevents the National Health Service (SNS) from having a more effective role in improving the dietary patterns of the Portuguese population?
One of the first barriers is the insufficient number of nutritionists in primary care centers.
Analysis of official data from the Ministry of Health shows that, at the time, there were only 97 nutritionists working in Primary Health Care Centers (CSP) across the different Regional Health Administrations, from north to south of the country. Many were not integrated into the Primary Health Care Units (URAP) as recommended by law. Some professionals are scattered across Community Care Units (UCC) (12), Primary Health Care Units (UCSP) (4), and Primary Health Care Units (USP) (2), revealing various uncertainties about the nutritionist's role in the current configuration of Primary Health Care Centers. Another important issue is that 30 of these nutritionists are integrated into careers other than the Senior Health Technicians (TSS) career path, generating inequalities in remuneration and career progression. Another 60 have not participated in a career progression competition since at least 2007, representing a long period of stagnation, salary devaluation, effective loss of purchasing power, and demotivation associated with successive performance evaluations (SIADAP) without career consequences.
The insufficient number of nutritionists in primary care centers (CSP) stems from a lack of strategic vision in recent decades, failing to steer the National Health Service (SNS) towards a preventative mindset and to create truly multidisciplinary teams in this area. This discussion could also include the inability of primary care nutritionists themselves, professional associations such as the Order of Nutritionists, and universities and research institutions to regularly demonstrate the impact of their interventions and their capacity to do more and better than other healthcare professionals in the same field. This inability (to evaluate what is done) is further compounded by the incomplete functioning of an information system that would allow for the use of data collected from nutritionists' interventions, although there has been enormous progress in this area recently compared to the past, and this situation could change soon. Furthermore, at the level of management of primary care centers (ACES), it is increasingly necessary to replace simple process evaluation with a culture of impact assessment, focusing on the results achieved for the patient. The dialectic of effectiveness versus efficiency always slips into a reductionist view of the nutritionist's work regarding access to consultations, reporting on the performance of actions instead of results.
The second barrier is the organizational model of primary health care.
The need to ensure the presence of nutritionists in Family Health Units
The second barrier is the organizational model of primary healthcare centers (CSP), namely family health units (USF), which are essentially considered units for the provision of medical and nursing care. These functional units can certainly play a relevant role in promoting and protecting health, thus maximizing the financial resources that the State has invested in them. In this context, the integration of nutritional care should be considered. The centrality of care provision to the user is only truly possible when USFs acquire technical skills, such as nutritional assessment and dietary counseling, to manage health throughout the life cycle and within the family context, in a coordinated manner by the multidisciplinary healthcare team. The effective implementation of Integrated Care Plans requires that the current configuration of Primary Care Centers transcends the dimension of "access" and complements it with respect for the needs, values, and preferences of users, guarantees continuity of care and a facilitated transition between different health units, provides care in coordination with the family and other informal caregivers, and is based on a coordinated effort to design and implement a personalized care plan for each user, always within a logic of proximity, ideally carried out in the user's own home.
The role of nutritionists in the different functional units of primary healthcare centers deserves in-depth discussion. This discussion should consider the need to ensure the presence of nutritionists in Family Health Units (USF). The integration of nutritionists into USF would raise the level of care in all the dimensions mentioned, throughout the life cycle, in interventions in maternal and child health, in the prevention of childhood obesity, in the prevention of excessive gestational weight gain, in adult health, in preventive interventions against chronic non-communicable diseases, in the elderly in the prevention of functional decline leading to frailty, in the training of caregivers for food support and nutritional support for users with limitations in their food intake, to mention only the most frequent.
The unclear definition of the role and articulation model of the URAPs
Currently, nutritionists are mostly integrated into the URAP (Shared Healthcare Resource Units), as foreseen in the aforementioned document "Primary Healthcare in 2011-2016: strengthening, expanding". Initially, the proposal for the integration of nutritionists into all URAPs seemed logical; however, 11 years have passed since the creation of the ACES (Local Health Units), and these units, no matter how much effort is made, still fail to have their purpose clearly defined and their articulation within the ACES clarified, as is evident in the Final Report of the Coordination of the Primary Healthcare Reform : "...Shared Healthcare Resource Units – Organization, in 2017, of a multi-professional Working Group of the URAPs that developed a proposal for the implementation of Contractualization for these UFs (Family Units), based on the review and consensus of their basic service portfolio." “… In a process that has been far too prolonged, all contributions were analyzed and aggregated, and in February 2019, with a smaller multidisciplinary team, a proposal was drawn up for a set of indicators that could be contracted according to the resources available in each URAP.” It is clear from reading the previous paragraphs that, with regard to URAP, years go by and it is not possible to make these units truly functional and contribute to the effective provision of nutritional care to the majority of NHS users.
The need for the integration of Nutritionists in Community Health Units
Beyond the necessary integration of nutritionists into Family Health Units (USF), we believe that nutritional intervention should be present in the daily work of Community Care Units (UCC), in order to develop and operationalize local and regional strategies of national programs on Healthy Eating, in conjunction with schools and municipalities, integrated into the School Health program, as can be read in the program of the recently inaugurated XXII Constitutional Government: “To make health center groups responsible for coordination with schools in promoting healthy eating and physical activity, in preventing substance use and risky behaviors, in health education and mental well-being, empowering children and young people to make informed choices and manage their health with quality.” Occupying this role, nutritionists would have the space to respond to intervention in a community context.
Within the context of the UCCs (Continuing Care Units), there is crucial work to be done with the Integrated Continuing Care Teams in assessing the nutritional status and defining nutritional support measures for users of the National Continuing Care Network. Quality nutritional intervention is necessary in the ECCI (Integrated Continuing Care Teams). Complementarily, it is necessary to support the families of users by allowing them access to artificial nutrition products, with state co-payment, to reduce inequalities in access to therapeutic food alternatives that play an important role in combating malnutrition, frailty, and dysphagia, to name just a few of the most frequent situations. However, since this is not yet a common reality in Portugal, the presence of a nutritionist to work with the caregiver in implementing changes to the patient's diet becomes all the more important.
Their contribution is still valuable in the new Palliative Care Teams, in supporting caregivers of people at the end of life. After all, eating is an act of dignifying the human being and is present even in the final moments of life.
The importance of nutritionists at USP (University of São Paulo)
Decree -Law No. 28/2008 of February 22 , which regulates the creation and organization of Primary Health Care Units (PHCUs) in Groups of Health Centers, defines the competences of Public Health Units: “The PHCU is responsible, in the geo-demographic area of the Group of Health Centers in which it is integrated, specifically for preparing information and plans in the areas of public health, carrying out epidemiological surveillance, and managing intervention programs in the context of prevention, promotion and protection of the health of the general population or specific groups.” This regulation highlights the need to utilize the skills of nutritionists to achieve these objectives. The production of knowledge in this area is not exclusive to academia; it must be increasingly articulated with academia and evaluated within the context of professional activity. Health interventions should use well-defined and continuously functioning evaluation mechanisms, as quality clinical governance demands. Given that many interventions in this area are related to nutrition and its consequences, the full-time presence of nutritionists in PHCUs would be of paramount importance for the quality of the intervention.
Public health interventions should allow for the development of research on specific phenomena related to childhood obesity and its dietary, social, and economic determinants in the surrounding community, or, more broadly, for example, on the space and networks of food production, distribution, and aid in the geographical area of intervention of the Public Health Units (USP). Furthermore, it should involve conducting epidemiological research to help Primary Health Care Units (ACES) identify obesity early and develop community interventions to improve the dietary patterns of elderly patients and coordinate available resources, particularly with local authorities. In this way, nutritionists could effectively contribute to the definition, implementation, and evaluation of Local Health Plans.
In the context of public health, a nutritionist is much more than a professional invited to lead lectures and workshops on food education. We need them to contribute to defining food strategies for schools in their area of influence, to be consulted when defining food offerings, and to be involved in the educational approach to nutrition, in coordination with the School Health Teams and the Health Education Program Coordinators of each School Cluster.
It is important to highlight that decision-making regarding the food offered in schools (specifically what to buy) and how to monitor the quality of the food provided is currently the responsibility of local authorities and the nutritionists working within them, making this collaborative work crucial. The current decentralization of responsibilities to local authorities in the areas of education and health can be an opportunity to align the intervention of local authorities in the development and implementation of the Local Health Plans of their respective Health Center Groups, promoting close collaboration in monitoring the population's health status through the systematic collection of information on health determinants.
Final reflections for improving the quality of nutritional services
Using incentives to strengthen the role of primary health care in the areas of primary, secondary and tertiary prevention
Funding is an issue that deserves in-depth reflection. Family Health Units (USF) should contract with the Primary Care Groups (ACES) and receive financial incentives for carrying out primary, secondary, and tertiary prevention interventions, with an objective evaluation of health outcomes. Furthermore, it is interesting to read the Follow-up Audit of Recommendations Formulated in the Audit Report on the Performance of Functional Primary Health Care Units of the Court of Auditors: “Ten years after the implementation of the Primary Health Care reform triggered by the XVII Government, with the creation of the first Family Health Units (USF), the Ministry of Health has still not carried out any ex-post evaluation whose results reveal the gains in economy, efficiency and effectiveness associated with each type of functional unit, nor the health gains for the populations.” Conversely, some impact assessments of nutritionists' interventions in primary care centers, such as a study with patients with type 2 diabetes mellitus , reveal that each consultation with a nutritionist in primary care centers was associated with a decrease of 4.7 hospital admissions per 100 person-years.
However, it must be acknowledged that in Portugal there is still a huge lack of cost-effectiveness studies evaluating the activity of nutritionists in primary care, and much of this work should already have been done. In particular, studies that could value models of nutritional care delivery based on results achieved, based on the concept of "value-based healthcare ," that is, care delivery models in which providers, including health units and professionals, are paid based on the health outcomes achieved for the individual. In these models, professionals are differentially rewarded for helping patients improve their health, reduce the effects and incidence of chronic diseases, and adopt healthier lifestyles, based on the latest scientific evidence. Even so, the technical and professional capacity to carry out this type of evaluation exists; what is lacking is the participation of the professionals themselves who are in the field, entangled in their intense daily routines, and the interest of professional associations and academia to initiate this process.
Conclusion
The European Commission published reports , outlining the profile of healthcare systems in 30 countries. The transition to prevention and primary care is the most important trend across all countries. In our understanding, this is the type of positioning that could contribute to directing the National Health Service (NHS) towards effective prevention in the area of food and nutrition, and to enabling higher quality nutritional care within our healthcare system. A system that uses the majority of its budget to treat chronic food-related diseases.
And so that Portugal can establish itself as a country that is adapting its existing qualified workforce in the field of nutrition (mostly trained in public universities and interested in working and serving in the National Health Service) to face future challenges and to make our National Health Service increasingly efficient and capable of fulfilling its mission.
This analysis reveals the need for in-depth reflection on the model for integrating nutritional and dietary interventions in primary health care. Although the most recent documents on primary health care reform timidly acknowledge the importance of increasing the capacity of these services in the area of nutritional care, the steps taken towards its implementation are still very incipient.
The approach advocated here defends a clear and distinct vision for the intervention of nutritionists in primary healthcare settings and implies an ambitious and disruptive strategy for their organizational model. The integration of nutritionists into the different functional units of the National Health Service (SNS) must be done with the ambition of modernizing and technically empowering multidisciplinary teams, evaluating the efficiency of nutritional interventions at the individual and population level by nutritionists compared to other health professionals, and having the courage to break the straitjacket of the excessively biomedical view of healthcare, counteracting the blocking forces arising from corporatism and the fear of sharing knowledge and skills in the health field.
Miguel Ângelo Rego and Pedro Graça
Written by
Pedro Graça, Director of the Faculty of Nutrition and Food Sciences at the University of Porto