Quo vadis nutrition in Romania?

Introduction

Today, the burden of disease due to inadequate nutrition has reached staggering levels. Poor nutrition practices, such as high sodium consumption, low whole grains intake and low fruits intake, are responsible for more than 11 million deaths per year across the globe and for probably more than 255 million disability-adjusted life-years (DALYs)⁽¹⁾. According to the Institute for Health Metrics and Evaluation (IHME), 22% of adult deaths were attributable worldwide to poor nutrition⁽²⁾, with the last decade seeing little improvement⁽³⁾. Only in the United States of America, the economic consequences of the nutrition-related burden of disease are overwhelming, with healthcare costs higher than 20,000 USD per person and 28% of lost income (wages)⁽⁴⁾. Therefore, the World Health Organization (WHO) declared nutrition as a key element in healthcare⁽⁵⁾.

Since it emerged from communism in 1989, Romania has done little in the field of nutrition, although progress has been made. The profession of dietitian has been recognized by the state and regulated by the Romanian College of Dietetics (CDR). Several professional associations are active and most of them are in partnership with European and international associations, such as the Romanian Association of Dietitians (ADR), the Romanian Society of Parenteral Nutrition (ROSPEN), the Romanian Society of Diabetes, Nutrition and Metabolic Diseases, the Romanian Federation for Diabetes, Nutrition and Metabolic Diseases (FRDNBM) and, most recently, the Society for Nutritional Sciences (SSN). However, the practical impact of these organizations on national health indicators is difficult to assess because, although some nutrition-related indicators are available, there is a paucity of peer-reviewed data and information that can be relied upon. The few studies published in the field of nutrition are relatively small, while data regarding obesity have been obtained using sporadic studies, where participants’ recruitment was subjected to recruitment bias^(6,7).

At present, no long-term, continuous and systematic research program has been designed, nor funded appropriately, with the aim of either assessing the nutrition-related burden of disease in Romania, or identifying and addressing nutrition issues in the population. While nutrition-related actions exist, these are not sustained by appropriate funds (long-term sustainability), nor are planned over long periods. At the state level, when present, nutrition-related interventions are decided without peer-reviewed preliminary data and without pilot projects that should assess the efficacy of such interventions.

This editorial will present the author’s opinion on why the state of nutrition in Romania is not at par with efforts present in other European countries, what are the causes, and how nutrition-oriented public health poli­cies, assessments and interventions should benefit from a systematic approach, well thought and implemented.

How much do we know?

Before even thinking about what interventions should be implemented, it is necessary to assess the present state of nutrition in Romania. Continuous and long-term assessment of the nutrition status of a population is a prerequisite that has been implemented in countries with well-defined nutrition policies. Such continuous surveys that exist in the U.S. (e.g., National Health and Nutrition Examination Survey – NHANES; https://www.cdc.gov/nchs/nhanes/index.htm), in some European countries (e.g., the European Prospective Investigation into Cancer and Nutrition – EPIC Europe; https://epic.iarc.fr/about/) or UK (e.g., the National Diet and Nutrition Survey; https://www.gov.uk/government/collections/national-diet-and-nutrition-survey) are just a few examples of continuous assessment of the association between nutrition status and disease. Such studies allow health policymakers to understand which are the problems, their amplitude, and the possible causes. They also allow us to hypothesize the mechanisms linking poor nutrition to the burden of disease.

In Romania, no such studies exist. Some nutrition assessments at the population level are present, performed by government agencies such as the National Institute for Public Health (INSP), but the methodology and the results are not independently peer-reviewed, and the data, when made public, are presented without the required state-of-the-art statistical processing, nor in easily accessible and understandable ways. As such, data are of limited value for third parties, including the Romanian Government and its other agencies. Data are accessible to academic researchers, but there is no satisfactory information on the methodology employed or data representativity at the national level. The potential for selection bias is not convincingly minimized.

As a consequence, today we lack an adequate understanding of the nutrition-related issues in Romania. We do not know (with any degree of precision):

• the nutrition status of the Romanian population;

• the true prevalence of obesity and overweight;

• the adequately estimated nutrient intakes associated with the burden of disease;

• the roadblocks that prevent adequate nutrition (economic, societal and cultural);

• the economic impact of nutrition-related health outcomes (e.g., DALYs, lost wages, healthcare direct costs, indirect costs, etc.);

• the degree of positive impact that the implemented nutrition-related initiatives may have on the overall health status of the nation;

• the impact of any nutrition-related, actual implemented programs.

As such, the nutrition-related health issues in Romania remain to be guessed, as well as the potential solutions and their efficacy.

Why do we know so little?

After more than 10 years of collaborative work with Romanian professionals in the field of nutrition (research, teaching, and other various interactions), one expression comes to my mind: “fractured expertise”. What does it mean? To understand this, we must go back to the role that nutrition had in the overall picture of healthcare in Romania, decades ago. Until 2015, when the profession of dietitian was legally recognized and defined⁽⁸⁾, the only professionals who were practicing nutrition were the physicians who were specialized in diabetes, nutrition and metabolic diseases. Their proficiency was achieved through postgraduate residency programs. However, the de facto expertise in nutrition was limited mostly to only diabetes-related nutrition.

As such, until academic nutrition programs in Romania started being offered (outside a medical track), the pool of specialists qualified in other nutrition-related fields was extremely limited. On top of it, decades of neglect regarding nutrition research and teaching made the available pool of professionals able to either do research or teach in nutrition extremely limited. Therefore, the expertise in nutrition (practice, research, teaching, public health policy, population assessment, economic management, communication to the public, and public education) was insufficiently developed in Romania.

It is important to realize that, when we refer to “nutrition expertise”, this is an umbrella term that may mean different things, in different contexts.

A dietitian is a nutrition expert who implements nutrition interventions in a clinical context. But there are other many levels of expertise in nutrition. Nutrition research requires a partially different set of skills than practicing nutrition. Thinking about national policies in nutrition requires a different set of skills. Teaching about nutrition has its own set of skills, and so on. It is worth mentioning that, even today, Romania does not have any organizational setup dedicated to nutrition, with the role of obtaining, analyzing and making recommendations to stakeholders in nutrition matters.

When various stakeholders need to decide on nutrition-related matters (e.g., the Ministry of Health, the Romanian Parliament, etc.), ad hoc groups are hastily put together, while basic data that should guide these processes are lacking. The selection of members for such groups remains opaque, and no systematic and unbiased efforts for building such groups are revealed. In more than three decades, no nutrition-related program has survived the time, no public health-related mission has been stated and structured, and no peer-reviewed and continuous nutrition surveillance programs have been announced. When implemented, nutrition-related policies lack any efficacy assessment and reevaluation based on their effectiveness.

Today, the various sets of expertise in nutrition are “fractured”. Too few doctors collaborate with dietitians. No nutrition follow-up is mandated or encouraged for patients after exiting the hospital. No state health insurance covers outpatient nutrition.

At the academic level, no departments of nutrition are present to optimize and incentivize nutrition research. At the stakeholders’ level, no permanent panels on nutrition exist to have the time and the means to design, propose and advocate for specific nutrition interventions and policies.

It is not surprising that, lacking the building blocks for evidence-based decision-making (evidence, impact evaluation, reassessing, innovation, and testing new approaches)⁽⁹⁾, meaningful policies cannot be developed.

Professional education

Very important progress has been made in this field during the last decade when various schools of medicine started offering nutrition programs. This allowed the emergence of a pool of dietitians who, today, fill the roles of clinical nutrition assistants. Unfortunately, there are still issues that hamper this process:

• The small number of graduates is not adequate to fill the gaps.

• Most faculty teachers are physicians, with little expertise in nutrition (a legacy problem due to previous lack of expertise in the field). While some courses would benefit from being taught by physicians, many other courses require a different range of expertise.

• Important courses are not offered when compared to programs offered abroad.

• While, after graduation, dietitians are required to fulfill their clinical practice to obtain certification, being mentored by a certified dietitian (or graduate a master’s program), there are not enough certified professionals to accept such internship programs. Moreover, unfavorable legislation mandates such interns to be paid wages by the mentor, which reduces the incentives to accept interns from the start. No unbiased network of mentors is widely available, and CDR, at this moment, does not offer any publicly accessible information on this issue. SSN has made publicly available such a network, but the list is limited to its members and, as such, biased and truncated.

• While rigorous nutrition-based courses and scientific events are present, these are too few. The inflation of public events organized by anyone who can do it is staggering, as nutrition presentations and conferences can be organized and structured without any supervision, even when the topics refer to clinical nutrition (regulated by law).

• The financial hardship for dietitians (due to outpatient assistance not being covered by health insurance) makes participation in time-honored and well-established international conferences very problematic, as it is the access to primary sources of published peer-reviewed scientific articles.

Not surprisingly, these complex issues add to the burden of establishing expertise, when compared to other countries. The ability of academic institutions to rapidly adapt to the very dynamic changes in nutrition education is also hampered by cumbersome and rigid legislation and, sometimes, by academic internal rules that are not well adapted to this rapidly changing field.

“The Center is missing”

Throughout this editorial, I have identified the factors that, in my opinion, contribute decisively to the inadequate state of developing and implementing nutrition in Romania. However, these factors are as such due to the lack of vision by the center. “The Center is missing” means that, at a conceptual level, the stakeholders who ultimately decide national policies do not consider that nutrition is a priority in Romania.

This statement is supported by the following facts, among others:

• Universities are not incentivized to expand nutrition education; for instance, to increase the number of students admitted to the programs.

• Within the research topics offered for funding, the Executive Unit for Funding Academic Teaching, Research, Development and Innovation (UEFISCDI) does not offer research calls focused on nutrition. When awarded, nutrition research proposals must be submitted on various medical topics. No funding channel is dedicated to nutrition.

• CDR’s budget (provided by the Romanian state) is small and woefully inadequate for its mission stated by the law.

• Overall, at both legislation and execution levels (Parliament and Government, respectively), there is a little preoccupation for nutrition topics, demonstrated by the small number of initiatives throughout the time. When implemented, these programs do not survive for long periods, nor are they assessed for their effectiveness.

• No meaningful nutrition education programs are offered to the public in the long term and updated accordingly, except for some nutrition education in schools, but the assessment of the effectiveness of such programs is missing. Often, nutrition programs in schools are taught by personnel without real expertise in nutrition.

Quo vadis nutrition in Romania?

At the end of the day, we must ask ourselves: is nutri­tion in Romania directed towards a meaningful purpose? As so many bottlenecks hamper this field, from so many directions, the question remains open.

Without establishing an articulated purpose, then establishing the nutrition-related statuses in the nation, then providing the means (expertise, logistics, education, financials, and sustainability across the time), nutrition cannot play its deserved role in reducing disease burden and increasing the quality of life in Romania, as well as in reducing the costs associated with disease. Well-established programs are needed to assess, decide, design and implement long-lasting and meaningful nutrition programs in education, clinical practice, research and policymaking.  

Acknowledgments. No financial support was available for writing this manuscript.

Corresponding author: Mihai Niculescu E-mail: mihai.niculescu@gmail.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.