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When Joana Sousa learned that she was going to enter the Dietetics course at the Lisbon Higher School of Technology (ESTeSL), she was greatly disappointed. She had just got to the Rectory when she saw a paper affixed to her 6th course option. Her biggest goal was Pharmaceutical Sciences and she missed getting in by 4 tenths. Obstinate and with the fixed idea about her ideal future, at the end of the first year of her course where she got excellent grades, she tried to request a transfer to the Faculty of Pharmacy of the University of Lisbon. Fifteen students got in, but Joana wasn't one of them, she was 16th. That was when she made a truce with fate and understood that if she was so upset, then there is some message to be decoded. She is thrilled when she remembers her father's words, when she considered not joining the Dietetics course and was improving her grades to try for Pharmaceutical Sciences the following year, "if you came in it was for a reason. You have to be good at something, move forward!" Joana Sousa went on, without ever wanting to take on Pharmaceutical Sciences, a project greatly influenced by a childhood friend who wanted to follow this area, and whose mother had a pharmacy.

In her second year at ESTeSL she met Catarina Sousa Guerreiro, who had just arrived. They had actually followed similar paths throughout the study programme and the fact is that, as soon as she finished her role as a student, Joanna was invited to attend classes in Dietetics and join the teaching staff. The following year Catherine would follow the same steps.. "We have always been side-by-side throughout the journey of this study programme."

At that time, the course was a two-year degree, but Bologna would change the framework of it in 2006, making it an undergraduate degree from the start. In 2009, Joana and Catarina entered the two positions as assistant professor in dietetics and nutrition which had opened at ESTeSL. Little did they know that they would follow a joint path, with increasing responsibilities.

Accepting that Nutrition was part of her life, she planned that what made sense to her was Paediatrics, very much linked to the fact that she had always loved children, and it was even a career objective when she was a child educator. Her dreams had now found the right course, because she got to where she wanted, and her first position as a Dietician at the time was at the Dona Estefânia Hospital, where she was put into the dietetics and nutrition where she supported inpatients as well as external consultation. Later, she followed her path in the hospital area, but this time with the greats at the Militar de Bélem Hospital, she says that leaving Paediatrics was her toughest decision ever. At that point she was starting her Master's in Public Health, and doing her PhD, also in Public Health, following a line of interest in the area of Childhood Obesity. She was the first person to portray the prevalence of childhood and adolescent obesity in mainland Portugal, with almost 6,000 children between 10 and 18 years of age.

Martim and Constança, 11 and nearly 10 years of age, respectively, are her two children and her most diligent followers; they don't particularly like sweets and their preferred drink is water. When Constança is missing salad as a side dish with her meal, she complains. Just like the goals she set for her professional future, she also made them in her family life, but the fact is that having a third child hasn't happened yet. At least not yet!

She always thinks that she is too strict, especially with her own: she argues that no child is born with the permanent will for sweets and that giving diversity to the palate is a way of educating; you just need to not give up.

It was always with this sense of health care that Joana Sousa became aware of her interest in community and public health issues, always in a field closely linked to children. It's not in vain that she has always dedicated herself to the Portuguese Dieticians Association and that she became so involved in the Order of Nutritionists, in favour of the nutritional health of the Portuguese. Even today Joana is part of the Management of the Order.

Teaching, research and support to the community are the pillars on which they base their actions and all their concern.

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How did you get to the Faculty of Medicine?

Joana Sousa: My connection to FMUL existed only in the fact that I joined the teaching staff of the Master's in Clinical Nutrition of the partnership between FMUL and ESTeSL. When Professor Catarina Sousa Guerreiro was proposed a challenge and then proposed it directly to me, this closer link with the Faculty sprang forth. It was a large project, of enormous scope, that involved a lot of intense thought. Then, I confess that at the time, I was a little apprehensive because my connection to ESTeSL was vast and long-lasting (since 1997). I always said ESTeSL was my 2nd home! Whether I wanted to or not, I felt that there could be direct competition to my school from the past. She knows that they are phases of life and that she doesn't invalidate the whole journey prior. We left ESTeSL in 2017, both of us, and we joined here by application, me as Assistant Professor and Professor Catarina as Associate. Whereas Professor Catarina has a practical and clinical aspect, I am more connected to the academic and organisational aspects. In recent years at ESTeSL I have been involved in management bodies and in more practical issues related to the organisation of the degree and we ended up developing work and complementing experiences and knowledge.

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From the academic experience you bring from the past, this will probably allow you to know what is in store for you.

Joana Sousa: It's going to be a big challenge above all else. Things have been thought out and structured for success, but of course the question mark is always there. This course has a major asset: the fact of having the face of the Faculty of Medicine, with a connection to two other organic units of the University of Lisbon, the Faculty of Human Motricity and Pharmacy. It brings us a know-how of differentiation in the area of nutrition that is unique. I can't even identify current difficulties with Nutrition. It has been in a different reality for 5 or 10 years, nowadays it is a fad, which entails the existence of much demand for training in this area. The only point I highlight as less positive and that we identified when we did a SWOT analysis (Strengths, Weaknesses, Opportunities, Threats) of the course was the possibility that we were inside the "hat" of the Medical School. Being in this faculty is a bonus, but we have quite a vast history of Medicine that it may not be easy to create the identity of the nutritional sciences. That's a lot, which is what we want to strive for. A few years ago this could be a way for those who, eventually and for reasons relating to the academic average, did not join Medicine could join the Faculty through Nutritional Sciences and try to transition between courses at the end of first year, being able to create a parallel path; however, today the reality is different and the student will always have to finish their study cycle. Of course, they may be less motivated, but then it's up to us to change their motivations.

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What changed in the last few years that made you say that students are also different now?

Joana Sousa: Nutrition has been increasingly talked about as a strategy, from a health point of view. Food is the modifiable risk factor that contributed most to preventing the leading causes of death. There is a growing concern within people. And unfortunately, nowadays, most people think that they increasingly understand food. This created myths and some problems in terms of public health. All of this makes us more willing to clearly mark the difference because we want to affirm that it is the Nutritionist who has enough know-how to understand, based on scientific evidence, and according to the individual and/or popular characteristics, what food and/or nutritional needs they have. Nutrition has grown a lot in terms of interest and impact among the general population and we want precision to exist in this area. The search for general well-being and the practice of physical activity has fostered the interest and growth of knowledge in the Nutritional area. This connection between nutrition and physical activity and the fact that we have the Faculty of Human Motricity as a partner entity to this project differentiates the training offer and eventually boosts demand for this course, given the specialised knowledge in the area that it can offer.

We have been hearing talk of Dietitians and Nutritionists over time and the struggle to have equal roles. But then what are the differences?

Joana Sousa: This situation has ceased to exist since 2015. The Order of Nutritionists has made it so that any graduate in nutrition, dietetics or dietetics and nutritional sciences, provided this training was recognised by the order, has access to the Nutritionist profession. Of the professionals who work as dieticians, there is the possibility (until October 2018) of requiring convergence for nutritionists. This was possible because in reality, the differences don't exist. Portugal was one of the only countries in Europe to have two professionals who, from a nomenclature point of view, were different, but their professional skills were identical. At the European and global level, we are talking about the Dietician, as in Portugal the profession that corresponds to this is the Nutritionist.

These professionals develop their professional activity in three major areas of performance, or even areas of expertise: Collective Feeding and Restoration, Clinical Nutrition and Community Nutrition and Public Health. These are the three areas with the highest growth at national level and with a European and global environment.

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So when they complete the study programme, will our students be Nutritionists?

Joana Sousa: Correct and with access to the Order of Nutritionists. They are graduates in Nutrition Sciences, with 240 ECTS (credits), 4 years and 8 semester curricula and academic internship of 30 ECTS.

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And what can they aim for in the future?

Joana Sousa: Our Undergraduate Degree took into account the articulation of the different organic units, but it was also developed with base reference for the academic training of the Nutritionist, of the Order of Nutritionists. This reference emanates the guidelines for what should be the 1st cycle of training for access to the Nutritionist profession. We clearly have a syllabus that works out competencies for the three main areas of intervention: Clinical nutrition, with the pathological and nutritional intervention aspects; then the community and public health aspects, looking more at the epidemiological perspective and with the aim of promoting collective or individual health; and then the collective feeding and catering aspect, that is, through the control of food quality and food supply for specific groups. Then within these three large areas, we can think of more specific sub-areas and that is where we will gain a lot from our partnership with other Faculties (Human Motricity and Pharmacy). Nutrition in sport is one of the areas that is growing the most and has had a huge demand and clearly the Faculty of Human Motricity will be a great asset.

The other very interesting area is food technology and innovation: nowadays, there is a huge growth in food supply that tries to respond to the growing demand for foods with specific characteristics. There is increasing professional development and commitment in this technical-scientific aspect of elaboration of products that may correspond to certain nutritional characteristics.

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What kind of products are we talking about?

Joana Sousa: They are products developed so that they can respond to specific needs. For example, nowadays we have many products that are sugar-free, gluten-free, lactose-free, supplemented with specific micronutrients, amongst others. They all try to respond to specific nutritional characteristics.

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But will we have more and more food intolerances, or have we always had them but we didn't know about them?

Joana Sousa: That is a topic, from the public health point of view; it's very interesting and I fear that it may become a problem 10 years from now. Food intolerances have always existed and have always been diagnosed. It's true that we may have individuals with greater susceptibility, but the truth is that this subject is also becoming very fashionable and a big myth, causing people to have certain convictions and fears, taking very extreme actions, completely withdrawing this kind of nutrient from their diet. This can further enhance what may come to be food intolerance. That is, if I'm going to deprive my body of the intake of that nutrient, for a long time, physiologically we can react, inhibiting the physiological mechanisms necessary to metabolise this type of nutrient, being able to stunt its production and activity. Will we eventually be able to develop a secondary intolerance, due to deprivation of intake? I fear that in 10 years there will be a greater prevalence of this type of food intolerance, due to the change in peoples' eating habits, which is highly centred on the possible media attention and radicalism of certain food options. There is a lack of balance and common sense, as opposed to increasingly extreme and abrupt positions for the body, which usually come from individual decisions and without clinical and nutritional monitoring. Sometimes it's only by us reading an article and because what we read seems to make sense that we decide to make food changes, then the reality is that it has implications.

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We are at a time when we were recently eliminated from the World Cup, but we all followed, in some way, the performance of the country and essentially Ronaldo. He is a phenomenon that we can affirm that is not only from motivation, or training, because his performance is evolving, even as he gets older. And it seems that one of his greatest assets is a super calculated diet.

Joana Sousa: He loses weight, but the percentage of muscle mass, lean mass, increases in what is his total weight and this is what also allows him to have a better sporting ability. Increasingly sporting and physical performance sees diet as a key role. And this is studied, as scientific evidence has grown a lot in this area, although we are still gaining in this sphere, because studies are still conducted on the basis of relatively small samples. However, the truth is that there is also only one Ronaldo! It's also a specific area that, given its characteristics, does not allow us to develop and work with much larger samples. But in different ways it's possible to perceive the importance of diet and its impact on pre-competition, competition and post-competition, and all these elements become central to improving performance at a decisive moment. In this context, I give the example of excess protein consumption. Nowadays it is common sense that to increase muscle mass, I must increase protein consumption. In the context of individual physical leisure activity, when there is no evaluation and nutritional intervention, it's really common for the individual to change his or her dietary pattern with an increase, in most cases an unregulated increase, of foods that increase the total intake of protein or other nutrients that are disseminated in the media as boosters of this effect. This has a worrying public health impact because continuing behaviour of this kind has no immediate negative effects, but in the long run it may have very negative health implications. All nutrients are vital, but watch out for balance and the physical and sporting characteristics and goals of each one. Specialised nutritional monitoring is essential.

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This is an important message not only for those who come to do the study programme, but also for public use. Warn about the consequences of personalised food plans without the knowledge to make them.

Joana Sousa: That for me is the big problem when we talk about food and nutrition. Hence my fascination for community nutrition and public health. Clinical Nutrition intervenes in the presence of disease, in which clinical diagnosis exists, when the problem is already in place. In my view, diet is much more important in the health promotion phase and when we are just acquiring healthy lifestyles. The commitment continues to be much more in treatment than in prevention, because in treatment the results are more immediate and measurable in the short or medium term, but this should not be the case. Scientific evidence shows that gains in promoting diet and nutritional health are a gain in the medium/long term, but the gain it brings in the long run is vastly greater from the overall health standpoint, that is, from the point of view of health economics. It is the area where the largest intervention continues to fail.

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How are these issues of public welfare and social responsibility communicated?
Joana Sousa: In recent years the reality in this area has been changing. Since 2012 we have had the National Program for the Promotion of Healthy Eating. Clearly in terms of national strategy, concern, interest and knowledge of the importance of food and nutrition intervention are beginning to appear. Do you believe that we have not known the true standard of food for our population since the 1980s? Only last year was it possible to have this national picture through the hard work of the National Food Survey and Physical Activity.

There was some scientific evidence, at local or regional level, but from a global and national point of view, the true eating habits of the population were not known throughout all phases of the life cycle. Without a proper diagnosis, it becomes more difficult to delineate a good intervention strategy. Now, it is possible to identify populations at higher risk, who are more vulnerable and to delineate a better intervention along with food and nutritional monitoring. Today we can already know the most critical age groups and in what context they find themselves. At this stage, the diagnosis is already made and this now allows us to start growing. I think this should be the future path of Nutrition. Because this will mean that we have already begun to be more careful in continuous dietary and nutritional terms, minimising nutritional intervention when the clinical problem is already installed. Obviously, it also has to exist and the growth of scientific evidence makes it even more effective in this area.

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Do you want to tell me what the main focuses for dietary concerns are?

Joana Sousa: Nowadays I would say that there are several focal points, but we can highlight two more vulnerable groups for different reasons. We are one of the European countries with the highest prevalence of childhood obesity. We have managed to stabilise these indicators in recent years, but the reality is still very worrisome and at very early ages. On average, one in three children is overweight. These are worrying numbers, even by the evident connection of the obese child with the obese adult, with obesity being one of the main risk factors for all chronic non-communicable diseases. From the point of view of public health, it is undoubtedly a priority, which calls for a concerted intervention strategy. The nutritionist's connection with the community, in the health centres, the autarchy, in school, with charitable institutions, is vital. We are beginning to believe that this may be the future.

The elderly should also be another focus of concern. It's true that we have the population with greater longevity, living longer is not enough. We want quality of life in the coming years. The elderly population is increasingly malnourished with all the clinical implications that scientific evidence shows us this entails.

We have recently made it public that they will open 40 places for nutritionists in primary health care. There are still only a few, but it's a big gain for citizens' dietary and nutritional health. The truth is that Portugal, in recent months, has been pointed out by the World Health Organisation as an example of good measures to be implemented in the area of diet. But what do I think is missing? That there aren't only measures that are a little "loose" and that there is a commitment and compromise for developing a dietary and nutrition policy in Portugal.

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Naturally insisting at least 15 times to give a new food is the number that Joana Sousa says is reasonable to teach a child to like a new flavour.

Methodical and well-established, she knows that she cannot predict the success of this new study programme in Nutritional Science, but she knows that everything has been done to create a strong identity for the soon-to-be-born embryo.

And this cherished baby will be born in September, will soon take its first steps, and in practically no time we will have a promising teenager before us.

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Joana Sousa

Editorial Team