Real assessments of a year of COVID-19

On April 19th, we reopened our doors to in-person teaching at our school. A year has passed under the shadow of Covid. A year that felt like an eternity. A long, painful year that allowed us to learn a great deal. From a personal, family, and professional perspective.

Although the pandemic began insidiously in a distant country, and Portugal was one of the last European countries to be affected, following an east-west path already taken by other European epidemics over the last few centuries, this unknown infection initially seemed benign and had little to do with the nutritional status of the populations.

This initial perception was short-lived. Not only did the disease spread rapidly throughout the country and grow exponentially, but evidence also accumulated that nutritional status could be a determining factor in the course of the disease. In the first text written about the pandemic on Pensar Nutrição on March 16, 2020, we wrote: “After contact with the virus, most people develop mild illness, with the likelihood of serious complications being more common in older age groups, in the presence of other chronic diseases (e.g., diabetes), or in cases of reduced immunity.” And we added: “The role of nutritionists is therefore to communicate simple messages. And to help preserve the supply chain, informing about the need to avoid buying poorly and in excess. To promote a balanced diet in the many children who will reduce their physical activity, so that childhood obesity does not increase in these weeks. And to help those who are debilitated and hospitalized recover, contributing to adequate nutritional support, case by case. We hope that common sense will prevail in the area of food. And that nutritionists will contribute with their scientific knowledge to informed decisions by citizens in these moments of concern and anxiety.” It was March 2020 and we still thought that the epidemic would only last a few weeks and we had many uncertainties. On April 10, 2020, Professor Alejandro Santos wrote a text , now a reference, where he relates in a well-founded and unequivocal way the relationship between diet, obesity and COVID-19. He concluded the article by saying: “In addition to all the measures proposed for mitigating COVID-19, adopting a healthy lifestyle with a balanced diet and physical activity, promoting weight loss when necessary, can be the difference between suffering a manageable or fatal case of COVID-19. There is still much to learn about this new relationship between obesity and COVID-19, but one thing is certain: the way we will view obesity in the future, now that new and successive infectious waves are expected, whether by SARS-CoV-2 or another variant, will transform the work of healthcare professionals, and in particular nutritionists.” Other texts from the scientific community on this subject followed. In “Thinking Nutrition,” we reflected extensively on the impact of the disease on professional practice and, in particular, on the need for nutritionists not to stay at home during the pandemic and to assume the role of active, not passive, agents in the healthcare system in the face of the disease. In the essay “The Post-COVID World and the New Role of Nutritionists,” published exactly one year ago, on April 19, 2020, we concluded the text as follows: “The solution is once again in our hands. And our professional action will now be more decisive than ever. In fact, nutritionists cannot “stay at home” in these times, at the risk of becoming irrelevant.”

However, a year has passed. In our profession, we are left with the feeling of a missed opportunity for our class. In the midst of this enormous public health crisis, where those most affected were clearly the most "nutritionally unregulated" citizens, to put it simply. The gains we could have had by placing nutritionists on the front line, or the gains of those who were actually there, were not visible. For example, improving energy regulation, salt control, or glycemic regulation—achievable goals, mostly through dietary intervention—could have been an essential contribution from nutritionists to mitigate this crisis, especially since this would have allowed for a reduction in hospital stays and better prognoses for patients hospitalized with COVID-19. Nutritional intervention in intensive care or post-hospital discharge care also deserves much reflection . And we could have done much more if we had been more present or more visible.

colleagues who had the opportunity to demonstrate this relevance in their workplaces, from Minho to Algarve, were spared; DGS (Directorate by the technical quality of the materials it released from the very beginning, but what remained and what became visible to society throughout 2020 was very little. There is no public perception in Portugal today of the importance of nutritionists in this crisis that has shaken us. This perception did not exist among citizens during 2020. And even less so in the political community that makes decisions.

However, unemployment or low-quality employment seems to have skyrocketed, especially among younger people, as revealed by data collected by the Order of Nutritionists in the report "COVID-19 | Impacts on the Professional Activity of Nutritionists", from September 2020, which indicates worrying data about our profession and the current professional trajectory of many of our graduates, particularly the younger ones, to whom it is impossible to remain indifferent. This is not only a result of COVID-19, but also, and mainly, stems from the pre-COVID situation of multiple jobs, job insecurity, financial fragility, inability to negotiate, and even lack of leadership skills at work, which became more pronounced during the COVID period.

Source: Order of Nutritionists

We believe that the diagnosis presented reflects the state of our profession, the current precarious employment model (which extends to other professions), and the career paths of nutritionists well before COVID-19. This is in addition to the oversupply of professionals in certain areas and even the poor quality of training, which we cannot exclude from discussing as stakeholders in the higher education system.

The severe economic crisis that has taken hold and will soon worsen will particularly affect the youngest members of the profession. These younger members are the most qualified generation, the most capable and best-prepared nutritionists ever, and well above the European average in terms of training quality. I believe we have a duty to support them in this struggle. FCNAUP, as a leading institution in nutrition education in Portugal, will certainly do so. At a time when the Ministry of Health has hired more than 5,000 healthcare professionals since the beginning of the pandemic, it seems justifiable that many of these could be nutritionists.

Despite the current situation, we have great faith in the future. There is enormous potential for the continued growth of the profession.

In disease prevention, combating inadequate nutrition, which is the central determinant of the days spent with chronic illness among Portuguese adults, and investing in improved care delivery, which can mean many fewer days of hospitalization in health services, are crucial. It is estimated that excess weight is responsible for 70% of the expenditure on diabetes treatment; 23% of the expenditure on cardiovascular disease treatments; and 9% of the expenditure on oncological disease treatment . In Portugal, pre-obesity and obesity affect more than 6.1 million Portuguese adults. Moreover, this disease tends to be more frequent in the most disadvantaged population groups. And now that infectious disease will persist in our societies, mainly affecting these population groups, the presence of a nutritionist in prevention, support for home treatment, hospital intervention, and post-discharge follow-up of infected patients will make even more sense. Economically, the presence of nutritionists in these services is profitable in a purely cost-benefit logic that is very appealing to health economists and also helps to counteract health inequalities, which are one of the main threats to our democracy.

The presence of a nutritionist can contribute to combating health inequalities, but they can also be a key professional in reducing regional asymmetries in healthcare. This includes increasing the capacity of our communities, both coastal and inland, to better utilize their food resources to promote the health and well-being of the population and to improve the environmental conditions of their communities, thus contributing to the territorial cohesion of our country. This was, in fact, our contribution to the Recovery and Resilience Plan (PRR ), where we proposed the inclusion of nutritionists in all Portuguese municipalities—that is, in all 308 municipalities: 278 on the mainland, 11 in Madeira, and 19 in the Azores. Promoting health and healthy lifestyles, as well as preventing disease, largely takes place outside of health services (although in conjunction with them) and within the context of the territories where people live and work, through intersectoral, decentralized, and community-based interventions that are only possible via local government.

We could also talk about our role in environmental and other issues, now that we know that the food system is responsible for more than 34% of greenhouse gas emissions and the need to distribute food equitably and fairly so as not to create social imbalances that could destroy our entire social fabric. This is an area where nutritionists should be able to contribute. Something that other health professions are not equipped for, and which gives us broad and bright optimism.

Unfortunately, optimism does not generate employment or address the need for higher-quality jobs for young people. Creating value associated with the profession is achieved by demonstrating the specific know-how practiced by nutritionists. This includes differentiating them from other health professions in addressing the same pathologies, and through the quantitative and qualitative evaluation of our interventions, essentially focusing on health outcomes. In other words, it involves producing high-quality technical documentation, creating consensual clinical practice guidelines in the various areas where nutritionists work, and regularly evaluating the quality and quantity of interventions in the field, particularly regarding economic aspects and health results. Finally, it means valuing, within the health system, the quality work of nutritionists in the field (so often forgotten and poorly supported) from the Algarve to the Azores.

This inside-out model of the healthcare system needs to be valued more instead of the inside-out model that has been predominant in recent years. Our profession easily builds bridges. With the environment, with agriculture, and even with tourism. These are attributes of our profession, for which we have fought for many years. Knowing these areas and working with them seems central to us, but we believe that defending the employment and dignity of this healthcare profession goes beyond simply looking at border areas. In academia, we will be here to present study plans , training nutritionists for collaboration and, if necessary, even leadership in border areas. But investing excessively in promoting these pivotal areas, without first strengthening, improving the quality of, and valuing the nutritionist's intervention in the core area of the profession, which is healthcare, seems strategically inadequate for the creation of qualified jobs.

Moreover, outside of Portugal, the demand for nutritionists is growing, and the perception of their importance in healthcare teams is becoming increasingly evident . In the United States, it is estimated that in the next decade the demand for nutritionists could grow 8% above the average compared to other professions . The same is happening in other countries such as Australia and Canada .

Source: Bureau of Labor Statistics, US Department of Labor, Occupational Outlook Handbook, Dietitians and Nutritionists (Visited on 03/14/2021).

These are reasons for hope for nutritionists in the midst of a pandemic, justifying the need for our services and demonstrating our technical quality to other healthcare professionals every day. With a lot of hard work and study. As has always been the case in the past of our profession and will continue to be in the future.

PS For all those who may be feeling down these days, it's always worth remembering that we are the only profession in the health field that works with, or acts as a bridge to, one of the human gestures that gives us the most pleasure and around which part of Western culture has developed – the act of eating and the culture that has grown up around it. As George Steiner aptly said: “Europe is made of cafes, of coffeehouses. These range from Pessoa's favorite cafe in Lisbon to the cafes of Odessa, frequented by Isaac Babel's gangsters. They range from the cafes of Copenhagen, where Kierkegaard spent his focused walks, to the counters of Palermo. There are no old or defining cafes in Moscow, which is already a suburb of Asia. Few in England, after a brief period when they were fashionable in the 18th century. None in North America, beyond the Gallican outpost of New Orleans. Draw a map of cafes and you will obtain one of the essential markers of the idea of Europe.” This vision of European culture and its relationship with its food spaces and territories, more or less real (see the case of the Mediterranean Diet), makes this profession a permanent utopia that only nutritionists experience.

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