The Norwegian Association of Clinical Dietitians affiliated with The Norwegian Association of Researchers (KEFF) celebrated its 34th anniversary in 2018. The association has grown from just 25 members to more than 500 members in this time. This article will try to capture chronologically the KEFF story, with special attention to the foundation of the association, the development of a clinical dietetic education in Norway, the recognition of clinical dietitians as health personnel, reimbursement for our services as clinical dietitians and future goals of the association.
The foundation of KEFF
In 1984, approximately twenty-five clinical dietitians came together and founded the Norwegian Association of Clinical Dietitians (Norsk forening for kliniske ernæringsfysiologer - NFKE). In the years prior to 1984 clinical dietitians were organised in a subgroup of the Norwegian Association of Nutritionist (Norsk forening for ernæringsfysiologer). Our goals and work differed from the association of Nutritionists. To set a new agenda for an educational path and professional practice, there was a need to start an own association.In 1989 NFKE became affiliated with The Norwegian Association of Researchers and changed its name to Klinisk ernæringsfysiologers forening tilsluttet forskerforbundet (KEFF – Eng: Norwegian Association of Clinical Dietitians affiliated with The Norwegian Association of Researchers).
A small country with very few clinical dietitians
Clinical dietitians in Norway today need to honour the founders of KEFF and their members, who worked extremely hard and had a very ambitious plan for the profession. The Norwegian national health care services had less than 50 clinical dietitians in the whole country. To achieve the association’s goal of nutrition becoming an integrated part of medical treatment it was necessary to increase dietetic staffing in Norway. To achieve this, the KEFF board and its members identified very early the need for an education in clinical dietetics in Norway, the need for clinical dietitians to be an authorized health personnel, and the need for financial reimbursement of dietetic services provided.
Education - The Norwegian model for clinical dietetics: a 5-year master program
Before 1997, education could only be obtained abroad, or through the Nordic Ministry Cooperation Education Program for Clinical Dietetics. This education program was divided between the University of Oslo, and the University of Gothenburg, Sweden, for a total of 4 years of study.
In 1997 the master’s program in clinical dietetics was started at the Medical Faculty at the University of Oslo. The thinking was that if clinical dietetics, dentistry and medical students attended classes together (in total 105 ETSC credit point hours), it would enhance communication between the groups; Medical doctors and dentists would have better knowledge of nutrition and dietetic care plan and dietitians would have a better knowledge of medicine. The education in Norway had always had a strong base in medical science, biochemistry, nutrition and research.
The decision to make the education a master’s degree was thoroughly discussed and not all agreed on this model. However, given the complexity of modern day medical care, medical nutrition therapy and the need for a good understanding of research of nutrition and dietetic science, the educational ministry agreed to fund a 5-year professional master’s degree in clinical dietetics for 15 students at the University of Oslo, Faculty of Medicine in the fall of 1997.
The 5 year master degree in clinical dietetics is today offered at three Universities in Norway; Oslo, Bergen and Tromsø for a total of ca 70 placements. The programs vary slightly, but to become a clinical dietitian you must attend the full 5 years of study. A fourth university, in Trondheim, is planning a master degree program in clinical dietetics. With this program all universities educating medical doctors in Norway will educate clinical dietitians. Since 1997 there has been an increasing number of graduates in clinical dietetics, and many students also obtain a PhD.
Due to many years of dedicated work from the members, Norwegian clinical dietitians became authorized and licensed health personnel in 2001. In order for this event to occur, a change in the laws governing health personnel was needed, and this law was passed in 1999. The lobbying effort was typically done on member’s free time, answering and commenting on white papers, attending government hearings and making sure that the voice of the clinical dietitian was heard at every instance possible. To obtain an authorization, candidates need to apply through the Norwegian Directorate of Health.
Reimbursement - Activity based financing (ABF) financing for clinical dietitians’ services
Norway has a national health care system and most hospitals are government funded and owned. Most clinical dietitians working in the health care sector are employed in hospitals, however, not all hospitals have clinical dietitians. There are very few clinical dietitians in the primary health care system, in public health care or in food services in Norway.
Norwegian health services are financed by the government. Allocation of funds are done by using the Diagnose Related groups (DRG). Clinical dietitians working with inpatients will typically be financed through the allocated overhead which represents 50% of hospital financing.
In 2016 clinical dietitians were ABF for outpatient care. This meant that hospitals were reimbursed for services provided by clinical dietitians in the same way nurses and medical doctors were reimbursed. The following diagnose groups were included: Tumor in GI tract; Inflammatory bowel disease; gastrointestinal diseases; diabetes mellitus; thyroid diseases; obesity and overweight (2017); endocrine, nutritional and metabolic diseases, non-malignant liver disease, gallbladder diseases, other diseases in liver and gallbladder. Table 1 shows the DRG’s and the funding per consultation (2016). After the change in financing in 2016 there has been an increase in positions in outpatient clinics for clinical dietitians and an increase in providing much needed nutrition care services for patients.
Table 1: ISF Reimbursement in Norway
KEFF is today a healthy and solvent organization and growing in member size each year. The number of members of KEFF has increased from 50 in the early 1990’s to more than 500 in 2018.
Figure 1: Clinical Dietitians in Norway and KEFF Members
The last years KEFF has worked especially towards the goal to get prescription rights and to increase its organizational staffing. Most of the members continue to work for the association on a volunteer basis. KEFF has only one paid employee, an organization secretary who works in a 35% position.
In the years to come, with an aging population and with patients spending less time in the hospital KEFF is working for improved dietetic care in the primary health care sector, where dietetic care especially has been neglected.
ICDA membership 2016
KEFF was very pleased that the ICDA decided to change its statutory to accept two member organizations from each country in 2016. To keep improving dietetic care and to be innovative, international cooperation and exchange of knowledge between sister organization is very important. KEFF certainly supports and believes the main aspiration of ICDA that a strong dietetic- nutritionist workforce will contribute to health improvements through food and nutrition knowledge and care.
A special thanks to the following dietitians who have contributed to this article with facts and have been a part of KEFF from the very start:
- Ingunn Bergstad, clinical dietitian. Ingunn has been a lead clinical dietitian at Oslo University Hospital, Oslo. She retired in 2017. Ingunn received the King's Medal of Merit for outstanding work in clinical dietetics in 2017.
- Lene Thoresen, clinical dietitian, PhD, Trondheim University Hospital. Lene has been a member of EFAD’s Professional practice committee for many years and is currently chairing the clinical dietetics educational board at Ministry of Education and Research
Sissi Stove Lorentzen
Clinical Dietitian,MS Lovisenberg Diakonale Hospital, Oslo
EFAD delegate and Executive committee member
Sissel Urke Olsen
Lead Clinical dietitian, RD, PhD student Diakonhjemmet Hospital, Oslo
EFAD and ICDA delegate