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What is clinical nutrition? Understanding the epistemological foundations of

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Article in Clinical Nutrition · October 2015

DOI: 10.1016/j.clnesp.2015.10.001

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 Clinical Nutrition ESPEN xxx (2015) 1e4

Contents lists available at ScienceDirect

Clinical Nutrition ESPEN

journal homepage: http://www.clinicalnutritionespen.com

Opinion paper

What is clinical nutrition? Understanding the epistemological

foundations of a new discipline
Diana Cardenas a, b, *
a
Laboratoire Logiques de l'Agir, Philosophy Department, University of Franche Comt!e, Besançon, France
b
Research Institute on Nutrition, Genetics and Metabolism, University El Bosque, Bogota!, Colombia

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

Article history: Background: Although the therapeutic and economic efficacy of nutrition has been proven, optimal
Received 29 May 2015 nutritional care is still scarce among hospital and ambulatory patients. Thus malnutrition is still highly
Accepted 1 October 2015 prevalent. We identify as an underlying cause the absence of a common understanding of clinical
nutrition as a discipline. The aim of this paper is to establish the epistemological foundations of clinical
Keywords: nutrition and to characterize it as a science.
Epistemology
Methods and results: From the standpoint of historical epistemology, we examine the historical condi-
History of medicine
tions that determine i) the main object of knowledge, ii) the nature and iii) domain of this science. Our
Nutritional sciences
Diseases-related malnutrition
hypothesis is that clinical nutrition as a science was formed in the second half of the twentieth century as
Nutritional support an outcome of the integration of medicine and nutrition and underpinned by a primary transformation of
the “nutrient” concept. We identify malnutrition as the primary practical and research domain of
knowledge.
Conclusion: Clinical nutrition is an autonomous empirical science that can be characterized as a basic and
applied science. Its wide multi-disciplinarity guarantees its future.
© 2015 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights
reserved.

1. Introduction malnutrition. Academic arguments range from of the absence of full

The link between humans and food has been studied since
Antiquity. In fact, human beings have learnt that their environment,
especially food, can interfere with their health. Nutrition is now
recognized as a determinant in chronic and acute diseases. The
efficacy of nutritional care has been extensively documented, and
has enabled improvement in nutritional and biochemical markers,
quality of life and reduction in mortality, morbidity, as well as in the
length of hospitalization and rehospitalizations. Moreover, there is
growing evidence that nutrition may contribute to the cost-
effectiveness and financial sustainability of health care systems
[1]. Nevertheless, malnutrition is still highly prevalent in hospitals
but also in ambulatory care clinics, among children, adults, and
geriatric patients [2].
Researchers have proposed reasons to account for the persis-
tence of inadequate nutritional care and the prevalence of high
* Laboratoire Logiques de l'Agir, Philosophy Department, University of Franche
Comte
!, 1 rue Goudimel, 25030 Besançon Cedex, France.
E-mail address: cardenasdiana@unbosque.edu.co.
recognition of clinical nutrition specialists, difficulties in imple-
menting national educational programs in medical and other
health care professionals, to lack of faculty expertise in nutrition in
medical schools and training. Other practical factors include the
lack of consistent criteria for diagnosing malnutrition, a lack of
confidence when addressing nutrition issues as well as inadequate
attention to the nutrition support of hospitalized patients [3].
Economic factors have also been reported, such as the heteroge-
neous nature of coverage or reimbursement of nutritional care
products and services across countries [1].
Given that the impact of malnutrition is well-known and that
the efficacy of nutritional care has been proven, one may wonder
why it is still so difficult to overcome those difficulties. Our hy-
pothesis is that there is a widespread and deeply rooted problem:
the lack of a common understanding of clinical nutrition as a sci-
ence. In fact, “clinical nutrition” is not a new phrase: it has been
used in scientific research publications for the last 60 years at least.
The phrase was first used to refer to the application of nutrition
principles to the specific field of “clinics” [4]. The concept of “clinic”
(klinein, lying down) is originally related to the physician's practice
at the patient's bedside (i.e. all medical activities in connection with

http://dx.doi.org/10.1016/j.clnesp.2015.10.001
2405-4577/© 2015 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Cardenas D, What is clinical nutrition? Understanding the epistemological foundations of a new discipline,
Clinical Nutrition ESPEN (2015), http://dx.doi.org/10.1016/j.clnesp.2015.10.001
2 D. Cardenas / Clinical Nutrition ESPEN xxx (2015) 1e4
patients). Thus we may raise the following question: is clinical
nutrition to be considered only as the application of the science of
nutrition to “clinics”? If so, this implies that we consider clinical
nutrition to be a sub-discipline of nutrition. On the contrary, we
think that clinical nutrition is an autonomous discipline: an
outcome of the integration of medicine and nutrition, underpinned
by a primary transformation of the “nutrient” concept. In this paper,
we will therefore attempt to characterize clinical nutrition as a
science and to define its epistemological foundations.
2. Method
Epistemology is the area of philosophy that investigates the
foundations and the limits of human knowledge. It aims to char-
acterize existing sciences in order to assess their value e in
particular to decide whether they are entitled to approach the ideal
of a ascertainable and genuinely justified knowledge [5]. To achieve
this objective, epistemology describes how a given scientific
discipline provides and develops its theories and gauges the logic
and cognitive value of such theories. In our study, we draw on the
French approach, especially the methodology of “historical episte-
mology”, with a view to answering three fundamental questions: i)
How was clinical nutrition established ii) What are the object and
the domain of this science? iii) What is clinical nutrition?
3. The origins of clinical nutrition
In order to understand what we consider as clinical nutrition
today it is necessary to look for its epistemological foundations. For
this purpose, we have searched the history of sciences for the
events that favoured the emergence of this discipline. We identified
as the main key fact the primary transformation of the “nutrient”
concept achieved as the result of the progress and expansion of
medical and human nutrition knowledge. In fact, the concept of the
nutrient evolved in the second half of the 20th century to the point
of being understood as a medical or artificial nutrient capable of
feeding the sick patient while facing new challenges and adapting
to evolving medical practices (i.e., new medicines, surgical tech-
niques, technology and facilities). Hence, the clue to understanding
the origins of clinical nutrition is to examine the causes of its
transformation in the last decades of the 20th century.
3.1. The nutrient from pre-scientific to scientific era
The first conceptual idea of the word “nutrient” can be found in
Aristotle's biology [6]. Indeed, for Aristotle there was a substance
extracted from food that after becoming blood could turn into any
part of the body. This notion evolved in the XVIII century after the
chemical revolution brought about by the works of Antoine-
Laurent Lavoisier, Joseph Priestley and Carl Scheale, which
demonstrated the true nature of oxygen and the process of oxida-
tion [7]. However, throughout the 18th century as in Ancient times,
food was seen as being constituted of a single universal substance
called the “nutrient”. Indeed, the word nutrient, from the Latin
nutrimentum (any food substance which serves as nutrition), was
defined in 1854 by the doctor Lucien Corvisart as a “food substance
that can be assimilated directly.” [8] The role of a nutrient was then
to be assimilated. This transformation, which involved biochemical
pathways, allowed the nutrient to maintain its nutritional status,
and therefore to contribute to health. The work of the English
chemist William Prout in the 1830s brought about the notion that
there was not just a single nutrient but a variety of nutrients (fat,
carbohydrates and proteins) in food. For the next hundred years,
the history of the science of nutrition was then marked by the
discovery of most of the nutrients and their specific physiological
Please cite this article in press as: Cardenas D, What is clinical nutrition? Understanding the epistemological foundations of a new discipline,
Clinical Nutrition ESPEN (2015), http://dx.doi.org/10.1016/j.clnesp.2015.10.001
functions. As a consequence in the first decade of the 20th century,
“dietetics” was established as a separated paramedical profession
in America, to help the government make optimal use of Armerica's
food resources in wartime. In Europe, dietetics was later developed
also as an instrument of state policies. Thus, nutrition became a
political concern rather than a scientific priority [9]. This is illus-
trated by the lag in the progress of nutrition in the clinical setting.
The way of feeding the sick changed with the emergence of
modern hospitals in Europe [10]. The new design of the hospitals,
introduced by the political and social changes that occurred after
the French Revolution in the nineteenth century, went beyond the
notion of a hospice for the poor. The architecture of the hospital was
now based on therapeutic and hygienic principles. Hospitals
became a privileged spaces for medical education. In fact, the
hospital setting favoured the advances of clinical sciences because a
significant number of patients could be observed, studied (and
compared), and because the hospital made it possible to conduct
autopsies and thus develop anatomopathology. In that context, the
religious meaning of feeding (as an act of charity) that had pre-
vailed until then was replaced by medical feeding based on Hip-
pocratic dietetic principles. However, doctors rapidly lost interest in
diet and abandoned the feeding care and research on nutrition,
leaving it in the hands of hospital administrators. And indeed, ad-
ministrators in the nineteenth century did recognize nutrition in
the clinical setting to be important: nutrition could reduce the
length of patients' stay at the hospital, speed up convalescence,
prevent rehospitalisation and diminish the cost of care [11].
3.2. The nutrient from the 20th century
In the first half of the 20th century, nutrition was defined as “the
science of food (and the ingredients of food known as nutrients),
and its relation to health” [12]. The aim of this science was to
contribute to the well-being and public health conditions. Nutri-
tional care in the hospital and other medical settings was scarce.
For decades, dietary practices in clinical settings relied on outdated
principles. For example, while human nutrition science had already
determined the principal nutrients and the notion of daily ratio and
calorie needs, patients were still being fed according the ancient
principles of an “absolute diet”, ignoring all notions of quantity and
quality. Thus, there was a gap in the advancement of knowledge
between public health research and the clinical field.
In the post-war decades, doctors slowly developed a new in-
terest in and expressed concerns about the feeding of hospitalized
patients. Feeding patients in various situations while coping with
the progress of surgical techniques and other medical interventions
became a real challenge. In fact, such situations, leading to under-
nutrition, had an impact on morbidity and mortality. In 1932,
Cuthbertson had described in detail the metabolic responses of four
patients with lower limb injuries [13]. In 1936, the surgeon HO
Studley had published a statistical analysis that quantified the
relationship between weight loss and mortality. He demonstrated
that a reduction of more than 20% of body weight resulted in a
postoperative mortality rate of 33%, while a group of patients with a
weight loss of less than 20% had a postoperative mortality rate
within 3% [14]. In 1947, it was recognized that the quantity and
quality of food could distinctly influence the outcome of infectious
diseases, surgical or traumatically wounds, burns and blood loss
[15].
Thus, the challenge was to feed the patients by any possible
route (i.e., oral, enteral or parenteral) to prevent malnutrition and
modulate the metabolic response to injury. However, technically
the parenteral route was impossible to perform, which triggered
extensive research on the subject. In the 1960s, the prevailing
dogma was still that ‘‘feeding entirely by vein is impossible; even if
 D. Cardenas / Clinical Nutrition ESPEN xxx (2015) 1e4 3

it were possible, it would be impractical; and even if it were Table 1

practical, it would be unaffordable.’’ [16] Such a difficulty was not Criteria for disciplinary autonomy of clinical nutrition.

new: since the description of circulation by William Harvey in the
seventeenth century, veins had been imagined as a route of
administration for nutrients. Thanks to some significant technical
progress, in 1966, Beagle puppies, could be totally fed by the
parenteral route for the first time, ensuring the sole nutritional
support for growth, development and metabolic support. Two
years after that experiment, it became possible for human beings to
be fed in the same way. Furthermore, enteral nutrition was devel-
oped simultaneously, as risks of hyper-nutrition by the parenteral
route and the role of the intestine were being acknowledged (For a
complete history of parenteral nutrition see Ref. [16]).
Thus, during the 1970s nutrients were no longer only associated
with an oral diet, but with artificial means. First, this means that an
invasive procedure, either the placement of a catheter for paren-
teral administration or a tube for enteral nutrition. These tech-
niques are known today as “parenteral/enteral artificial nutrition”
and their application as “nutritional support”. Thus, the word
“artificial” no longer refers to some food property (the result of a
culinary preparation, for instance) as in Hippocratic medicine, but
to the particular method of administration and production of nu-
trients. The second meaning of “artificial” is that nutrients are not
the outcome of agronomical production and that their availability
does not depend on agricultural policies: nutrients are now the
outcome of pharmacological industrial productions. Thus, we may
find a wide range of products for nutritional support (i.e., “food for
medical purpose”, “nutrition supplement” or “medical foods”). As a
result, in both Europe and the United States, products for nutrition
support are required to have specific bill regulation with specific
legislations and guidelines. Those products are meant for patients
with special nutritional needs and health care professionals must
deliver indications for nutritional support under medical pre-
scription and supervision. This implies a major change in medical
practice since the products of nutrition support are now compa-
rable to the practice in pharmaceuticals [1].
Beside these two meanings, the new concept of the nutrient has
undergone another essential transformation, as its function is to
reach beyond its nutritional objective. So key nutrients called
“immunonutrients” (i.e., glutamine, arginine, citrulline, omega-3)
can modulate inflammatory response and help restore immuno-
logical and other biological functions. Consequently, nutrients are
administered not only for feeding, but to improve host defences
and outcomes [17]. The novelty is that we attribute a
pharmacological-type action to nutrients, and that they are inves-
tigated as such [18]. This aims to guarantee security to the patient,
as nutrients must now be assessed under adequate and well-
controlled clinical investigations, as any new drugs require.
4. Defining clinical nutrition as a science
Epistemological characteristics
! A separable research object: The artificial nutrient
! Separate methods for empirical investigations: pharmaconutrient approach;
tracer methodology, etc.
! An independent theory development or invention of a new theory: Artificial
nutrient concept, parenteral and enteral nutrition principles, etc.
! A common conceptual apparatus: Malnutrition, disease-related malnutrition,
immunonutrients, etc.
Sociological features
! A core group of researchers: ESPEN Special interest groups, etc.
! Common communication channels: Clinical Nutrition Journal, American
Journal of Clinical Nutrition, etc.
! Separate conferences, meetings, etc: ESPEN congress, ASPEN congress, etc.
! Associations or institutions at a national and/or international level: SFNEP
France, SBNC Belgium, DGEM Germany etc.
! The existence of teaching and training curricula, in addition to courses which
are provided at universities or colleges, or offered as commercial courses to
trade and industry: LLL ESPEN course, Adriatic Club of Clinical Nutrition
(ACCN), etc.
screening, diagnostics, treatments, monitoring and audit in all
types of care facilities (hospital, nursing homes and community)
[2]. This leads to considering clinical nutrition in the scope of the
patient-health care provider interaction in opposite to the organ-
ismeenvironment interaction characteristic of human nutritional
science (Fig. 1). This has biological, sociological and ethical
implications.
5. The domain of clinical nutrition: malnutrition
In this context, the domain (a field or scope of knowledge and
activity in science) of clinical nutrition can be defined by a series of
areas: malnutrition, feeding, metabolism, health and disease.
Indeed, clinical nutrition is concerned with all these aspects but
there is one that defines it precisely. The main problem addressed
by clinical nutrition is malnutrition [20]. This means that clinical
nutrition e basic knowledge and practice through nutritional care
e is supposed to help fight against malnutrition. Thus, malnutrition
is what best defines the domain of knowledge and practice of
clinical nutrition.
Even if there is some general agreement about the need to fight
malnutrition, this concept raises semantic, epistemological and
biological controversies. Are malnutrition and undernutrition
synonymous? Are malnutrition/undernutrition/obesity to be un-
derstood as risk factors or as diseases? How can they be defined
biologically, what criteria can be used? There is no consensus. We
consider that the term “malnutrition” must not be considered as
synonymous with “undernutrition” but as a general term encom-
passing a wide variety of nutritional statuses: pure starvation,
disease-related malnutrition (cachexia), sarcopenia and frailty, as
well as overweight, obesity and micronutrient abnormalities. In

Clinical nutrition can be defined as both an autonomous

empirical science and as an art. As an empirical science (i.e.
knowledge derived from or guided by experiment), it interacts with
other biological science like biochemistry, pharmacology and
physiology. Autonomy (i.e. process of a science differentiating itself
from other disciplines) can be defined as “a relative independence
from other related disciplines, including both ‘sociological’ char-
acteristics, such as the existence of research groups and associa-
tions, and ‘epistemological’ characteristics, such as separate
methods and theory development” [19]. Table 1 summarizes the
epistemological and sociological criteria of clinical nutrition.
As an art (i.e. techne, practice), the scientific principles and
theories of clinical nutrition are applied through the practice of
nutritional care. Nutritional care is a global process that includes Fig. 1. The interdisciplinarity of clinical nutrition.

Please cite this article in press as: Cardenas D, What is clinical nutrition? Understanding the epistemological foundations of a new discipline,
Clinical Nutrition ESPEN (2015), http://dx.doi.org/10.1016/j.clnesp.2015.10.001
4 D. Cardenas / Clinical Nutrition ESPEN xxx (2015) 1e4
that sense, the scope of clinical nutrition must include obesity-
related nutritional and metabolic challenges [21]. The consensus
criteria to unify the international terminology published recently
by Cederholm T et al. proposes the term “nutritional disorders” as a
general term encompassing malnutrition, overnutrition and
micronutrient abnormalities and introduce a hierarchical arrange-
ment of the conditions [22]. In our opinion, based on the
complexity of those nutritional syndromes, there is no place for this
kind of organization. Moreover, “nutritional disorder” (i.e. the
absence of order or the state of not being arranged in an orderly
manner) and “malnutrition” (i.e. malus bad, badly) can be synon-
ymous in the clinical field, both giving an axiological meaning to
the term. Thus there is no place for introducing an extra term that
doesn't clarify the nosology of malnutrition. The semantic ambi-
guities, and the normative and axiological status of concept of
malnutrition must be further studied. Efforts should be made to
modify the International Classification of Diseases (ICD) coding and
the recognition of diverse malnutrition conditions.
6. Perspectives for clinical nutrition
Understanding the epistemological foundation of clinical
nutrition may lead to ethical, and academic challenges. First, per-
forming and organizing clinical nutritional care may lead to ethical
issues that should be taken into account. This particularly concerns
the rationalization and standardization of nutritional care that may
question justice and equality in health care. Second, nutritional
support involves a multidisciplinary team in care implying the
provision of food and drink by mouth econsidered as basic care e
but also artificial nutrition legally considered as a treatment. This
puts in a constant tension the ethics of care and cure. In that sense,
the four ethical elements of care, attentiveness, responsibility,
competence and responsiveness, must be placed at the heart of the
matter. The bioethical principles of respect of autonomy, non-ma-
leficence, beneficence and justice can be questioned in the practise
of nutritional support [23]. The ethics of clinical nutrition must be
studied in depth.
The recognition of clinical nutrition as an autonomous discipline
is a new phenomenon and will inevitably lead to some re-
adjustment of existing professional boundaries. Clinical nutrition
is usually subsumed under medical or nutritional-dietetic sciences.
Medical students need to attend more courses and training on
clinical nutrition, particularly courses on the basics of nutrition, and
dieticians need to have more courses and training on clinical
nutrition, particularly courses on the basics of medicine. An inter-
disciplinary speciality must be recognized. This must be a veritable
speciality not a subspeciality of gastroenterology or surgery,
endocrinology. More research and efforts must be combined to
determine consensual core competencies and contents for clinical
nutrition.
We have proposed a definition of clinical nutrition based on its
epistemological status, object and specific domain of knowledge.
Clinical nutrition is a basic interdisciplinary and applied science,
concerned with malnutrition (under/overnutrition/micronutrient
abnormalities). Its aim is to apply the principles of nutritional
support (i.e. artificial nutrients) within the framework of nutri-
tional care in order to ensure the nutritional status and modulate
other biological functions to positively influence patient treatment
and outcome.
7. Conclusion
Clinical nutrition is the outcome of a new vision, typical of the
twentieth century school of thought: a vision defining the way the
patient must be fed, establishing a close relationship between
Please cite this article in press as: Cardenas D, What is clinical nutrition? Understanding the epistemological foundations of a new discipline,
Clinical Nutrition ESPEN (2015), http://dx.doi.org/10.1016/j.clnesp.2015.10.001
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malnutrition and disease and relying on a new concept of nutrient.
It cannot be subsumed under nutritional science, as it is not to be
considered as an organismeenvironment interaction but as an
autonomous science, with a proper core of knowledge, domain, and
mode of intervention, under the patientehealth care provider
interaction. Determining the epistemological status of clinical
nutrition may help to consolidate the discipline, face and integrate
the ongoing production of knowledge and address the accelerating
social, technological, environmental and ethical challenges raised
by this science.
Statement of authorship
Diana Cardenas carried out the study and the whole writing of
the manuscript.
Conflict of interest
There is no conflict of interest to declare.
Statement and funding sources
No funding sources.
Acknowledgements
The author wishes to thank Dr Carole Birkan-Berz of the Uni-
versite
! Paris 3 e Sorbonne Nouvelle who assisted in the editing of
the manuscript.
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