Council of Europe Resolution ResAP(2003)3

Adopted on 12 November 2003 at the 860th meeting of the Ministers’ Deputies. The prefix ResAP designates a resolution taken under the Partial Agreement in the Social and Public Health Field, an instrument created on 16 November 1959 and revised by Resolution (96)35, which binds a self-selected subset of Council of Europe member states (eighteen in 2003) to specific commitments in health and social policy.

Official title: Resolution ResAP(2003)3 on food and nutritional care in hospitals.

Where to find the text

• English: rm.coe.int/16805de855 (behind a CAPTCHA on the Council of Europe document server).
• French, official: Ministère de la Santé, France.
• Full-text mirror (English, 12 pages): nutritionDay.org.
• British synthesis with core dispositive text: BAPEN Alliance leaflet.

The document is published in both official languages of the Council of Europe.

Structure

A short one-page resolution followed by a substantial appendix. The resolution itself contains three operative recommendations to the governments of the states party to the Partial Agreement. The appendix, of roughly twelve pages, is organized into five broad areas and contains, according to the BAPEN Alliance synthesis, more than one hundred detailed recommendations:

1. Nutritional assessment and treatment in hospitals
2. Nutritional care providers
3. Food service practices
4. Hospital food (the food itself)
5. Health economics

There is no separate explanatory memorandum. The preparatory report is published as: Beck A.M., Balknäs U.N., Camilo M.E., Fürst P., Gentile M.G., Hasunen K., Jones L., Jonkers-Schuitema C., Keller U., Melchior J.C., Mikkelsen B.E., Pavcic M., Schauder P., Sivonen L., Zinck O., Øien H., Ovesen L., Food and nutritional care in hospitals: how to prevent undernutrition. Report and guidelines from the Council of Europe, Clinical Nutrition 2001;20(5):455-460. DOI 10.1054/clnu.2001.0494, PMID 11534942. Full-length version as a Council of Europe book: Food and Nutritional Care in Hospitals: How to Prevent Undernutrition (Council of Europe Publishing, Strasbourg, 2002).

Verbatim key passages

The central rights formulation, which the Vienna Declaration of 2022 will cite verbatim:

access to a safe and healthy variety of food is a fundamental human right

In the official French: « l’accès à une variété d’aliments sains et sûrs constitue un droit fondamental de la personne humaine ».

From the preamble, on the epidemiological ground of the resolution:

the unacceptable number of undernourished hospital patients in Europe

undernutrition among hospital patients leads to extended hospital stays, prolonged rehabilitation, diminished quality of life and unnecessary costs to health care

The three operative recommendations to governments:

to draw up and implement national recommendations on food and nutritional care in hospitals based on the principles and measures set out in the appendix to this resolution

to promote the implementation of these recommendations in the public and private sectors that provide food services in hospitals

to ensure the widest possible dissemination of these recommendations among all the parties concerned

From the appendix, on the identification-to-treatment cycle:

Identification of a patient at nutritional risk should be followed by a thorough nutritional assessment, a treatment plan including dietary goals, monitoring of food intake and body weight, and adjustment of treatment plan.

On institutional culture:

A food service policy should be adopted and implemented at hospital or regional level.

On patient information:

Patients must be informed of the importance of good nutrition for the success of their treatment upon hospital admission or before.

On patient autonomy within the institution:

All patients should have the possibility to choose their eating environment.

Genesis

• 1999: the Committee of Experts on Nutrition, Food Safety and Consumer Health, operating under the Partial Agreement in the Social and Public Health Field, decides to survey nutritional programmes in European hospitals.
• 1999-2001: an Ad Hoc Group on Nutrition Programmes in Hospitals is formed, drawing twelve national experts.
• 2001: publication of the intermediate report in Clinical Nutrition (Beck et al., cited above).
• 2002: publication of the full Council of Europe book.
• 12 November 2003: formal adoption by the Committee of Ministers.

The eighteen states party to the Partial Agreement in 2003 were: Austria, Belgium, Cyprus, Denmark, Finland, France, Germany, Ireland, Italy, Luxembourg, the Netherlands, Norway, Portugal, Slovenia, Spain, Sweden, Switzerland and the United Kingdom.

The working group

The authors of the preparatory report (and effectively of the appendix to the resolution): Anne Marie Beck (first author, Danish Veterinary and Food Administration, Søborg), Ulla Nilsson Balknäs (Sweden), Maria Ermelinda Camilo (Portugal), Peter Fürst (Germany, one of the founding figures of European clinical nutrition, deceased 2005), Maria Gabriella Gentile (Italy), Kaija Hasunen (Finland), Liz Jones (UK), Cora Jonkers-Schuitema (Netherlands), Ulrich Keller (Switzerland), Jean-Claude Melchior (France, one of the founding French figures of clinical nutrition), Bent Egberg Mikkelsen (Denmark), Marusa Pavcic (Slovenia), Peter Schauder (Germany), Lauri Sivonen (Finland, also serving as Council of Europe staff), Orla Zinck (Denmark), Henriette Øien (Norway), and Lars Ovesen (Denmark, senior author). The Danish weight of the group (Beck, Mikkelsen, Zinck, Ovesen) is not accidental; Denmark had run the earliest national institutional-nutrition programmes in Europe and had accumulated the first coherent implementation data by the late 1990s.

Fürst and Melchior are the ESPEN figures. Ovesen and Beck are the Danish operational core. The president of the Committee of Experts and the formal rapporteur to the Committee of Ministers are not identifiable from public records and would require access to the Council of Europe archives in Strasbourg.

The epidemiological ground

The resolution was not written in response to a scandal. It was written in response to two decades of accumulating data on the prevalence of undernutrition in European hospitals, at rates of 20 to 50 percent depending on the institution and the definition. The genealogy of that finding runs from Butterworth’s The Skeleton in the Hospital Closet (1974) and Bistrian’s late-1970s work in the United States, through the BAPEN UK 1994 report Organisation of Nutritional Support Within Hospitals, through Naber’s 1997 data from the Netherlands, McWhirter and Pennington’s 1994 UK data, Kondrup’s 2002 development of the Nutritional Risk Screening 2002 (NRS-2002), and the national European surveys of the late 1990s. The Council of Europe working group identified five recurrent institutional causes: absence of clearly defined responsibilities, insufficient training, no patient influence on their own food, poor cooperation between staff categories, and no involvement of hospital administration.

Impact and implementation

• United Kingdom: the Council of Europe Alliance was formed to translate the resolution into the 10 Key Characteristics of good nutritional care in hospitals, formally adopted by NHS England in 2015 and taken up by the Hospital Food Standards Panel Report (2014) and the National Standards for Healthcare Food and Drink (2022). The BAPEN leaflet is the archive of the Alliance.
• Denmark: documented follow-up by Mikkelsen and Beck, European Journal of Clinical Nutrition 2006, tracking national compliance 1995-2003.
• Spain: basis for the consenso multidisciplinar sobre el abordaje de la desnutrición hospitalaria, García de Lorenzo et al., Nutrición Hospitalaria 26(4), 2011.
• France: referenced in the GEMRCN (Groupe d’étude des marchés de restauration collective et nutrition) and in the SFNCM 2019 recommendations.
• Belgium: basis of the Belgian National Food and Health Plan, which in turn produced the Brussels Forum of November 2007 as the follow-up to the resolution.

The Brussels Forum of 22-23 November 2007, organized by the Belgian Federal Public Service of Health, Food Chain Safety and Environment, produced the sub-committee report of December 2008 and, ultimately, the Council of Europe book Nutrition in Care Homes and Home Care, From Recommendations to Action (Strasbourg, 2009). That is the explicit extension of ResAP(2003)3 from the hospital to the care home and to home care.

No formal Council of Europe implementation report at five, ten, fifteen or twenty years exists. The follow-up is carried by ESPEN and by the nutritionDay project directed by Michael Hiesmayr at the Medical University of Vienna, which since 2006 has acted as the de facto international audit of the resolution’s implementation.

Institutional afterlife

The activities of the Partial Agreement in the Social and Public Health Field were transferred in 2007 to the EDQM (European Directorate for the Quality of Medicines), which added & HealthCare to its name at that moment. In practice, the Committee of Experts on Nutrition was dissolved and the nutritional mandate of the Council of Europe atrophied. No subsequent ResAP or CM/Rec has updated ResAP(2003)3 in the hospital nutrition field. The 2009 Nutrition in Care Homes and Home Care book is the last Council of Europe normative text on nutrition. The pivot after 2010 shifted to ESPEN, to FELANPE, and to WHO Europe.

The Council of Europe Committee of Bioethics (CDBIO, formerly DH-BIO) has not taken up the nutritional question. Its mandate remains centred on biomedicine, research and genetics.

Legal weight

The resolution is non-binding soft law. It is distinct from:

• A convention such as the Oviedo Convention (1997), which has the legal weight of an international treaty for states that ratify it.
• A CM/Rec, a recommendation of the Committee of Ministers to all forty-six member states of the Council of Europe.

The ResAP format is a form of self-limitation: it binds only the states that have committed to and finance the Partial Agreement, and it lies between the general recommendation and the treaty commitment in normative weight. The vocation, in the words of the British Dietetic Association, is to inspire political action at a national level. There is no supervisory court or complaint mechanism. States report through the Partial Agreement’s own procedures.

No European Court of Human Rights judgment cites ResAP(2003)3. The resolution has not been invoked in Strasbourg case-law. It has remained an instrument of policy, not of litigation.

Related Council of Europe instruments

• European Convention on Human Rights (1950): health protection is indirect, via Article 2 (life), Article 3 (inhuman or degrading treatment, relevant to institutional captivity where nutritional neglect in care homes, prisons or psychiatric institutions can rise to Article 3), Article 8 (private life).
• Revised European Social Charter (1996): Article 11 (right to protection of health), Article 13 (right to social and medical assistance), Article 23 (right of the elderly to social protection). Monitored by the European Committee of Social Rights (ECSR) with a collective-complaints procedure.
• Oviedo Convention on Human Rights and Biomedicine (1997): Article 3 (equitable access to health care of appropriate quality). The doctrinal route through which nutritional care can be argued as a component of appropriate-quality care.
• Parliamentary Assembly Recommendation 1244 (1994) on food and health, cited in the ResAP(2003)3 preamble.
• Council of Europe book, 2009, Nutrition in Care Homes and Home Care, extension to residential and home care.

The reception in the Vienna Declaration chain

Diana Cárdenas and her working group treat ResAP(2003)3 as the first of three key international non-legally-binding documents that introduced the human-rights-based approach to clinical nutrition. From the 2021 position paper (Clinical Nutrition 40(6):4029-4036):

Since 2003, the human rights-based approach has been introduced in the field of clinical nutrition through three key international non-legally binding documents.

The three are ResAP(2003)3, the Cartagena Declaration (FELANPE, 2019) and the Vienna Declaration (2022). The Vienna Declaration cites the resolution by number in its preamble, placing it fourth in a cascade of fifteen instruments, immediately after the UDHR, the ICESCR and General Comment 14 and before all the clinical-nutrition-society texts. (The Vienna text contains a typographical error, ResAP(2003)2, that is nevertheless universally understood to refer to ResAP(2003)3, a small symptom of how rarely the underlying instrument is re-read.)

Why this matters here

Three points.

First, on precedent. The formulation access to a safe and healthy variety of food is a fundamental human right was adopted by an intergovernmental body in 2003 and applied to the hospital setting. The physiological-rights argument developed in this resource does not invent that formulation; it extends its scope from the hospital to the general population and from variety of food to specificity of physiological requirement.

Second, on the missing implementation report. The Council of Europe has produced no formal review of the implementation of ResAP(2003)3 at any anniversary, and the mandate itself was quietly dissolved in 2007. This is a specific instance of the general pattern this resource documents: a right is proclaimed, a mechanism is created, the mechanism is de-funded, and no institution reads back the record. A twenty-year audit of ResAP(2003)3 implementation is a piece of work that no European body has done and that the physiological-rights community could commission.

Third, on the captive-populations angle. The one clear route through which ResAP(2003)3 could be made justiciable is Article 3 of the European Convention on Human Rights read together with Article 11 of the Revised European Social Charter, applied to institutional settings where the subject cannot self-provision: care homes, prisons, closed psychiatric wards. That is the same juridical vein this resource has flagged as its next editorial priority. ResAP(2003)3 is the soft-law text that the hard-law arguments on captive populations can lean on.