The Recovery and Resilience Plan (PRR) is a strategic document that identifies fundamental structural reforms to ensure a successful exit from the pandemic crisis and guarantee a resilient future for Portugal. The Plan has now been submitted to public consultation, aiming to gather new contributions to improve it and ensure the broadest possible consensus around the document.
With this text in “Thinking Nutrition” we present our opinion on the subject, which will be submitted to the managers of the public consultation as another contribution to the discussion of this important plan. But beyond the exercise of citizenship, we also present ourselves as nutritionists and academics working in the area of public policy, with the interest that the work of nutritionists be recognized. And that public policies increasingly incorporate the need to intervene in favor of promoting healthy eating. The voice of nutritionists and nutritional issues, as a central determinant of the health of the Portuguese population, is not very explicit in this document, unlike other equally important areas such as dental health or mental health.
We would reinforce these needs by emphasizing that inadequate nutrition is the main determinant of years of healthy life lost by the Portuguese population, and that the main diseases affecting the Portuguese have a dietary basis at their origin . Obesity, hypertension, diabetes, and cancer affect disadvantaged populations with lower education and income levels more. An increasingly aging population needs nutritional support. And we must prepare ourselves to live more healthy and productive years. It should also be emphasized that these diseases are more evident in less educated and lower-income populations.
The Recovery and Resilience Plan (PRR) has as one of its central objectives, and within the integrated set of major investments it intends to carry out, to strengthen the capacity of the National Health Service (SNS) to respond to the country's demographic and epidemiological changes, therapeutic and technological innovation, the trend of increasing healthcare costs, and the expectations of a more informed and demanding society. This document identifies challenges facing the SNS and potential solutions.
Main challenges of the National Health Service identified in the Recovery and Resilience Plan
The document identified the main challenges facing the National Health Service (SNS), namely (Page 38):
a) The demographic transition, characterized by the accelerated increase in the elderly population and the reduction in the young population;
b) Changes in disease patterns, with an increasing burden of chronic and degenerative diseases (Portugal is the 3rd OECD country with the highest percentage of people over 65 living with two or more chronic diseases, according to the Health at a Glance report (2019)) , and a gradual increase in multimorbidity, which already affects more than a third of the Portuguese population, according to the 1st National Health Survey with Physical Examination prepared by INSA (2016) ; We add that in this report (Health at a Glance, 2019) inadequate nutrition has appeared in recent years as the main cause of years of healthy life lost by the national population.
c) High preventable mortality, particularly that which occurs before the age of 70;
d) Low levels of well-being and quality of life, primarily in the population over 65 years of age;
(e) Weak investment in health promotion and disease prevention, two crucial aspects for proactively responding to the evolving health needs of the population and for ensuring the sustainability of health and social protection systems;
f) Fragmentation of care provided, with a high predominance of episodic, discontinuous, reactive interventions focused on disease treatment. Several studies have concluded that such characteristics lead to delays in diagnoses, particularly in the most prevalent chronic diseases (diabetes, cardiovascular, oncological, respiratory), duplication of care, avoidable hospital admissions, poorer quality of life, and higher costs;
g) High weight of direct payments in healthcare (out of pocket), which represent 29.5% of total healthcare expenditure in Portugal (OECD, 2020) .
Given these challenges and needs, identified in the document, the need for a reform in the national health service to improve interventions promoting healthy eating habits, which is currently extremely weak in many sectors, becomes clear.
Promoting healthy lifestyles and eating habits is crucial to European political strategy
Recently, the European Commission received a proposal from the European Parliament and Council concerning the creation of a Union action programme in the field of health for the period 2021-2027, which underlines the fact that “keeping people healthy and active for longer and empowering them to take an active role in managing their health will have positive effects on health, reducing health inequalities, quality of life, productivity, competitiveness and inclusiveness, while reducing pressures on national budgets. In the context of the analysis of this proposal, the Commission committed to helping Member States achieve the sustainable development goals set out in the UN 2030 Agenda for Sustainable Development , in particular Sustainable Development Goal No. 3, “Ensure healthy lives and promote well-being for all at all ages.”
The proposal from the European Parliament and Council also emphasized that “non-communicable diseases result from a combination of genetic, physiological, environmental and behavioural factors. These non-communicable diseases, such as cardiovascular diseases, cancer, chronic respiratory diseases and diabetes, are major causes of disability, poor health, sick leave and premature death in the Union, with significant social and economic impacts. To reduce the impact of non-communicable diseases on individuals and society in the Union and to achieve target 3.4 of Sustainable Development Goal 3, which aims to reduce premature mortality from non-communicable diseases by one third by 2030, it is essential to provide an integrated response focused on prevention in all sectors and areas of intervention, combined with efforts to strengthen health systems.”
In the context of the European Union, it is also worth noting the recently published Europe's Beating Cancer Plan, which highlights the need for a set of measures to improve health promotion through access to healthy food, with the aim of saving lives through a strong commitment to cancer prevention.
Concrete proposals for the Recovery and Resilience Plan in the area of food and nutrition
To address these needs, we present two concrete proposals to make nutrition and the promotion of healthy eating a central area for the necessary reorientation of the National Health Service (SNS) towards health promotion and prevention. These are our contributions to the heated debate currently taking place within the framework of the Recovery and Resilience Plan (PRR).
Measure 1. Equip primary healthcare with more resources in the area of promoting healthy lifestyles, and in particular in the prevention and treatment of diet-related diseases, with overweight being a central issue as it affects more than half of the Portuguese population. Increasing the capacity to assess nutritional status in all health centers and early intervention for overweight patients should be a key priority.
This measure falls under the Resilience and Recovery Plan (PRR)
Contextualizing the relevance of the measure:
Alongside the previously described epidemiological context, in which inadequate nutrition and poor nutritional status have a very significant impact on the disease burden in Portugal, the context of this measure within the ongoing reform of the Primary Health Care area is described below.
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. “Eating behaviors” is one of the five specific areas of intervention identified in this document as an undervalued area where change is needed, a topic we have already discussed here . The document also acknowledges that “Primary Health Care is the ideal place to encourage behavioral changes and 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 lifestyle and aspects related to their diet.” This document stated that by 2016, all Primary Health Care Units 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. According to official data from the Ministry of Health, there are currently 97 nutritionists in Primary Health Care, a number that is still insufficient.
Along the same lines, the relaunch of the primary healthcare reform, under Order No. 200/2016 of January 7 and Order No. 695/2019 of January 15 , foresaw the strengthening of primary healthcare intervention capacities in several areas beyond oral health, namely the area of nutrition.
More recently, the Primary Health Care Reform, which is being implemented under the Basic Health Law, foresees action in 6 major areas of intervention, one of which is the promotion of health and healthy lifestyles.
Concrete Measures
1. Strengthen the capacity of Primary Health Care at the level of specialized nutrition care, guaranteeing an initial goal that we consider achievable: at least 1 nutritionist per health center / 1 nutritionist for every 50,000 registered users.
2. Define and promote the effective implementation of the organizational and operational model of Nutrition Centers/Units/Services in Primary Health Care.
Expected Results:
With this increased responsiveness of primary healthcare in the area of nutrition, we aim to achieve significant improvements in the responsiveness of Primary Healthcare in the areas of health promotion, healthy lifestyles, and disease prevention in three key areas:
1) the creation of a pre-obesity consultation service focused on lifestyle modification, promoting early intervention for chronic diseases associated with excess weight;
2) increased integration of nutritionists into school health teams; and
3) implementation of nutritional risk screening in Primary Healthcare.
Measure 2. Inclusion of nutritionists in local authorities. The promotion of health and healthy lifestyles and the prevention of disease largely takes place outside of health services and in the context of the territories where people live and work, through intersectoral, decentralized and community-based interventions that are only possible via local government.
Context of this measure within the Recovery and Resilience Plan (PRR):
The Recovery and Resilience Plan is an essential response component for the implementation of the Portugal 2030 Strategy . This strategy, approved by Resolution of the Council of Ministers No. 98/2020, of November 13, integrates a thematic agenda based on strengthening territorial cohesion, contributing to the harmonious development of the entire national territory and, in particular, to reducing the disparity between the development levels of the various regions, especially the most disadvantaged regions.
Context of the relevance of the measure:
The ongoing decentralization of powers in the areas of health and education, namely under Decree-Law No. 23/2019 of January 30 and Decree-Law No. 21/2019 of January 30 , assigns municipalities a set of responsibilities relevant to the area of promoting healthy eating.
Specifically, Decree-Law No. 23/2019 of January 30 , which implements the framework for the transfer of powers to municipal bodies and intermunicipal entities in the field of health, transfers to municipalities the establishment of strategic partnerships with the National Health Service (SNS) regarding disease prevention programs, with a special focus on promoting healthy lifestyles and active aging. In this context, local authorities will be able to develop or participate in activities related to disease prevention, namely in the promotion of healthy eating, regular physical activity, and active and healthy aging, in partnership with the ACES (Local Health Unit) and the Regional Health Administration, within the framework of their respective action plans and the Municipal Health Plan.
This decentralization of powers and consequently greater involvement of municipalities in programs in the area of health promotion and disease prevention is necessary, since intervention in this area is much more extensive outside than within the National Health Service (SNS).
Decree -Law No. 21/2019, of January 30 , implements the framework for the transfer of powers to municipal bodies and intermunicipal entities in the field of education. Through this decree, the provision of meals in school canteens in the 2nd and 3rd cycles of basic education and secondary education will be managed by the municipalities. Management includes, among other factors, defining the nutritional criteria for menus in the tender specifications, actions taken to verify and monitor what is offered, and measures to promote adequate food and nutritional consumption within the school environment. Thus, very soon the management of school canteens at all levels of education will become the responsibility of the municipalities, as will the management of school social action. This will allow for a more detailed understanding of the social reality at all levels of education and more effective intervention in addressing social inequalities where food/nutritional issues are highly relevant.
COVID-19 has exposed the weaknesses of municipalities in the area of health, due to the fact that, in many cases, there are still no solidly constituted health intervention departments with human resources in the health field capable of an integrated intervention in the promotion of healthy lifestyles and balanced eating habits. Investing in the promotion of healthy eating at the local level is crucial for improving public health, but it can also help combat social inequalities through social action departments and protect and make local economies more competitive and cohesive by boosting healthy and local food production and its incorporation into the food networks of local structures.
Therefore, it is anticipated that measures will be needed to strengthen the capacity of municipalities to respond to these new/future responsibilities in the area of health.
Concrete measure
– Guarantee the presence of at least one nutritionist in all Portuguese municipalities.
Expected Results:
With the presence of nutritionists in municipalities, it is expected to achieve results in 3 main areas:
1) increasing the capacity and scope of community intervention programs for health promotion and disease prevention;
2) improving the quality of school meals;
3) increasing the capacity to respond to nutrition needs in community institutions, particularly those in the social sector.
Other areas to consider
Given that the Recovery and Resilience Plan is more comprehensive, particularly in the area of resilience, which identifies the components of Housing, Social Responses, the Elimination of Pockets of Poverty, and where food issues are important, much more could be proposed. In this context, combating food insecurity and promoting healthy eating is also an important factor in reducing social vulnerabilities, improving health, and thus productive capacity. Or, considering global food production as the greatest threat to climate stability and ecosystem resilience , constituting the single largest driver of environmental degradation, where urgent intervention by nutritionists is necessary.
Many other proposals could therefore be put forward, but we have decided to focus our contribution on two major proposals that may, in the future, allow us to leverage many other areas of intervention. We hope that other colleagues and entities have been able to contribute so that the essential issues of promoting healthy eating can have the central role they deserve in this Plan.
Final Acknowledgments – This reflection was initiated within the scope of the Food and Nutrition Policy course of the Master's program in Community Nutrition and Public Health at FCNAUP. We thank our students who initially contributed to the discussion, namely: Andreia da Conceição Vieira Borges; Cátia Filipa Coelho Ramalho; Clara Moreira Novais; Filipa de Melo Pinto Correia; Ivo Paulo Gomes dos Reis Pinto de Sousa; Joana Cláudia Melo Ribeiro; Joana Margarida Marques Ferreira; Patrícia Andreia Barbosa Leão; Pedro Daniel das Neves Ferreira; Raquel Rodrigues Luís; Ricardo Jorge Coelho de Castro; Rita da Costa Rodrigues; Sara Maria Da Fonseca Damas Gonçalves; Sílvia Raquel Taveira Vaz and Teresa Cláudia Mendes Ferreira. We also thank Professor Teresa Sofia Sancho for her contribution to an important part of this discussion.
Written by
Pedro Graça, Director of the Faculty of Nutrition and Food Sciences at the University of Porto
