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to improve nutrition security and combat risk of malnutrition The NNEdPro Global Centre for Nutrition and Health in Cambridge led by Professor Sumantra Ray along with the NNEdPro India team have been investigating the diets of ‘Santhal’ tribe communities in rural India to identify key nutritional gaps. This consultancy work is providing a nutritional science basis to the Global Research Translation Award (GRTA) activities led by Professor Nitya Rao (UEA) in collaboration with Indian partner PRADAN. The project is seeking to encourage diet diversification in rural communities to improve nutrition and health. By suggesting subtle changes to traditional recipes which complement existing dietary and lifestyle patterns, the partners hope to achieve nutritional adequacy for these indigenous communities. The Nutritional Analysis Process With support from PRADAN, young Santhali people collected over 100 traditional recipes from their communities. The dietary assessment team at NNEdPro selected 32 individual recipes and 26 consumed menu templates for analysis. Some food ingredients specific to the Santhal tribe were not available through software such as Nutritics e.g. Red ants, Mahua flower, and certain green leafy vegetables (GLVs), therefore advice was provided from the NNEdPro India team based on Nutritive values of Indian foods (National Institute of Nutrition, India). Caption: Red Ants collected for a traditional recipe Each recipe was screened for deficiencies in total energy (kcal), macronutrients (protein, carbohydrates and fat) and micronutrients (sodium, potassium, calcium, iron, zinc, selenium, iodine, vitamin A, vitamin D, vitamin E, Thiamine, Riboflavin, Pantothenic acid, folates, vitamin B6, Vitamin B12, and vitamin C). Dietary values for which the National Institute of Nutrition in Hyderabad lacked reference to, like starch, fibre, sugars, saturated fat, mono-unsaturated fat, polyunsaturated fat, omega 3 and trans fatty acids, were obtained from the World Health Organisation (WHO) guidelines. Creation of New Menu Templates First, the NNEdPro UK team identified potential deficiencies through a nutritional analysis of the consumed menu templates. Next, the NNEdPro India team suggested new menu templates which could provide individuals in the Santhal tribe with all their nutritional needs, making a conscious effort to honour the Santhali indigenous recipes as much as possible. The result is 18 menu templates and 4 supplementary templates which fulfil the following criteria: ▪ Providing nutrients as per Dietary Reference Values (DRV), known as Recommended Dietary Allowances (RDA) in India ▪ Allowing sufficient micronutrients ▪ Making very small changes to consumption patterns ▪ Keeping all indigenous recipes in menu ▪ Not introducing new recipes ▪ Ensuring the method and time of cooking is reasonable ▪ Considering affordability, availability, acceptability ▪ Promoting egg consumption ▪ Adding snacks in between meals Each meal template represented 40% of daily individual needs, and individuals were assumed to consume 2 meal templates per day in addition to a snack which covered the remaining 20% of their intake. Nutritional Analysis Findings After analysing the traditional recipes and consumed menus, the NNEdPro team discovered that the main nutrients of concern were energy, fat (particularly saturated fat), fibre, potassium, calcium, zinc, iron, iodine, vitamin E and the B vitamins, including B1, B2, B6, B9 and B12. After the first round of improving the menu templates, the team saw significant improvements in the percentage of new menu templates meeting the DRVs: • Fat increased from 5.8% to 72% of DRV • Calcium increased by 30% • Iron increased by 38% • Zinc increased by 56% • Vitamin E increased by 57% • Vitamin B1, B9 and B12 increased by 34%, 47% and 55% respectively. For example, the Santhal tribe would typically consume Sakarkand/alu saag with rice. However, based on the nutritional analysis this meal was not meeting the requirements for energy (for males), fibre, potassium, calcium, iron, zinc, thiamine and folate. Adding 40g of Ghanghra Daal, a dish made up of blackeye beans, cumin, red and green chilli peppers and salt, showed an increase in energy, protein, fibre, potassium, calcium, iron, zinc, thiamine and folate (by 7%, 26%, 25%, 32%, 15%, 42%, 21%, 47% and 340%, respectively). This new menu template now meets all the nutritional requirements. Understanding the science in a cultural context PRADAN conducted Dietary Diversity Questionnaires (DDQ) to understand the dietary patterns and cultural behaviours of the Santhal communities. A total of 100 DDQs were conducted between November to December 2020, covering demographic information of household members and various food groups. Ages of household members ranged between 6 months to 80 years of age; and food preparation was mainly carried out by women, with the average age being 36 years old. The different food groups included cereals, white roots and tubers, green leafy vegetables, other vegetables, vitamin A rich vegetables, vitamin A rich fruit, other fruit, animal organs, meat, eggs, fish or other aquatic foods, pulses and seeds, milk and dairy, oils and fats, sweets and snacks. The questionnaires also collected information about food preferences, source of food (subsistence from own land, purchased from a market or other), frequency of consumption, and food availability throughout the year. For example; Rice was the preferred type of cereal, with 79% of individuals consuming rice in the last 24 hours. Additionally, 64% of respondents reported that cereals are sourced on their own land and 19% reporting that they are sourced from the market. We found that the majority of individuals (66%) consume cereals on a daily basis, and all respondents reported that cereals are available throughout the year. Producing a Recipe Book for the local communities The NNEdPro team are going to present the improved menu templates in the form of a recipe book, which has been informed by a good understanding of the local context. The DDQs have provided rich information about availability of local produce, accessibility to wider markets, traditional eating and lifestyle habits, type of labour, and cooking/preparation facilities. By connecting the nutritional science with the community context, the partners can be confident that the suggested improved recipes in the recipe book will meet the dietary needs and will be adopted by the local people because they are culturally relevant and appropriate. This blog was published on 09 December 2021 and was written by the team at NNEdPro Global Centre for Nutrition and Health (Sarah Armes, Project Officer/Research Assistant, Sally Ayyad, Project Officer/Research Assistant, Professor Sumantra (Shumone) Ray, NNEdPro Chair & Executive Director, Sanchita Banerjee, Deputy Network Lead (India) & Project Officer). Edited by Professor Nitya Rao and Hannah Gray, University of East Anglia. Acknowledgements to: Wanja Nyaga, Xunhan Li, Luke Buckner, Aseem Manna, Shuvojit Chakraborty, Nivedita Narain, Arundhita Bhanjdeo and Ayesha Pattnaik.

From Agricultural Nutrition and Social Empowerment to Human Nutrition and Health in India – 24th July workshop. Organised by the NNEdPro Global Centre for Nutrition and Health, in partnership with the University of Cambridge TIGR2ESS GCRF Programme and the University of Surrey Maharashtra GCRF. Written by Wanja Nyaga and Jorgen Johnsen Edited by Sento Kai Kargbo, Sarah Anderson and Professor Sumantra Ray Life-course evolution of diabetes – learnings from the Pune Maternal Nutrition Study by Prof Chittaranjan Yajnik, Director, Diabetes Unit, King Edward Memorial Hospital and Research Centre, Pune, India. The Pune Maternal Nutrition Study started in 1993 in six villages near Pune, India, to determine the cause of low birthweight (LBW) in India and how we can study the life course evolution of diabetes and other health outcomes. Key indicators such as maternal size, nutrition, paternal size, metabolic variables and fetal growth were measured. The mothers (study participants) were followed over 24 years, with a follow-up rate of 96%. This has resulted in an impressive biobank of DNA, plasma, urine, buccal swabs, and microbiota samples. In his presentation, Prof Yajnik provided a brief overview of type 2 diabetes (T2DM), including the natural history of the disease and associated risk factors (e.g., genetics, age, obesity, diet, and physical inactivity). He further discussed the association between LBW, T2DM and other metabolic conditions. LBW was shown to be associated with T2DM and other metabolic conditions (Hales et al. 1991) owing to undernutrition in the early stages of the life-course, which can cause epigenetic changes and, in turn, increase susceptibility to metabolic disease (also known as the ‘thrifty gene hypothesis’). Anaemia in adolescent females and pregnant women: findings from the MAS Phase 1 and 2 studies by Dr Anand Ahankari, Surrey University, UK. Iron deficiency anaemia is highly prevalent in India, especially among pregnant women. Approximately 55% of girls and women of reproductive age have nutrition-related iron deficiency anaemia, and some Indian states have as high as >70% prevalence. In adolescent females, anaemia prevalence was extremely high (87%), and the likelihood of being anaemic increased significantly with age. Factors associated with lower anaemia risk were mid-upper arm circumference, MUAC (> 22 cm) and >3 days/week consumption of fruits and rice. In the case of pregnant women, about 77% were affected by anaemia, and this increased risk of anaemia was more notable in women with consanguineous marriages. Consanguineous marriages were also a major risk factor for low birth weight (LBW). Post-delivery data from full-term singleton live births showed a 7% prevalence of LBW. Lastly, haemoglobin levels in the population were associated with environmental exposures. Understanding this observation may help design better public health interventions to improve the health and wellbeing of adolescent females in rural India. Nutrition, wellbeing and empowerment: the thread that connects by Prof Ramanjit K. Johal, Punjab University, India. Prof Johal presented the work Punjab University has done relating to nutrition. Punjab University comprises a leading multidisciplinary team and is working to inspire change in health behaviours in marginalised communities. She described the TIGR2ESS flagship programmes across education, food, nutrition, empowerment, employment, and entrepreneurship and its expected outputs to improve the wellbeing and nutrition of farmers and rural communities in India. Prof Johal and colleagues conducted a 24-hour dietary recall study in two villages; however, the data is yet to be analysed. Meanwhile, their work is moving towards sustainable agricultural solutions with their organic kitchen gardens and sewing training projects to improve awareness about food sources and develop culinary and entrepreneurship capacities with their stakeholders, despite challenges with COVID-19. Their work continues to show promise in improving knowledge about basic nutrition, food groups, increasing awareness of healthy eating, increasing confidence among stakeholders to discuss their health problems, as well as facilitating knowledge dissemination with peer groups and family members. Opportunities and challenges – Nutritional knowledge and rural livelihoods by Prof Shailaja Fennell, University of Cambridge, UK. Prof Fennell discussed lessons learned from the previous green revolution for sustainable agriculture, which focused on well-irrigated agricultural zones and semi-arid zones. However, marginal communities and the role of women as millet producers in the community were largely overlooked. Due to this neglect, there was a failure to recognise the importance of millet production in these marginalised communities. Prof Fennell also shared experiences with awareness building around millet production and consumption, in partnership with the International Crops Research Institute for the Semi-Arid Tropics (ICRISAT) and Odisha Millet Mission. There have been various attempts to bring millets to the front of food discussions in both urban and rural areas. The issue is not a lack of knowledge, but that the knowledge on millet and its value chain is not internationally recognised. Building on the year of millets (2023) in cooperation with the Millet Mission, more advocacy for millet production and consumption is underway through institutional architecture, drawing on experiences, local biodiversity and combining tradition and science. However, the value chain from production to plate needs to be improved to scale up millets. Current studies are tracing crop production from the rural household level to urban/rural household consumption. Phase one will focus on nutrition and livelihood activities at the household level to identify patterns. While phase two traces the journey of innovative products from the household farms to markets and then to the plate. NNEdPro/Bhavishya Shakti Mobile Teaching Kitchen (MTK) project by Professor Sumantra (Shumone) Ray, NNEdPro. Prof Ray presented on the NNEdPro/Bhavishya Shakti Mobile Teaching Kitchen (MTK) initiative in India. The MTK was first launched in 2017 in two slums in Kolkata, India, and since then has been adapted to other parts of India (Sanghol and Punjab). The MTK initiative aims to tackle food insecurity and malnutrition among underserved and vulnerable populations by engaging with local communities to deliver health and malnutrition screening sessions and effective nutrition education while distributing nutritionally balanced, locally sourced, and affordable meals. It also seeks to disrupt the vicious cycle of intergenerational poverty by introducing communities to sustainable development initiatives and a skill-building platform that links them with dignified livelihood alternatives. You can learn more about the NNEdPro/Bhavishya Shakti MTK initiative in Kolkata here. Impacts of COVID-19 on India’s food system and food environment by Jørgen T. Johnsen, Dr Marjorie Lima Do Vale, NNEdPro and Dr Rekha Bhangaonkar, Cambridge University, UK. Jørgen Johnsen presented the objective of the survey: to gather the TIGR2ESS flagship project teams’ perspectives on the impact of COVID-19 on different aspects of India’s food systems and environments. This included food supply, the food environment, consumer behaviour and diet quality. Currently, the findings from the qualitative interviews are being coded and summarised for a paper. Dr Lima Do Vale described the analytical framework (see image below) used to summarise the data based on the UN Nutrition framework of COVID-19’s impact on food systems. Lastly, Dr Bhangaonkar described the ‘Miro’ tool used and the process of implementing codes to summarise each identified theme. The codes were then adapted to NVivo for qualitative data analysis. Food, nutrition and education interface – A comprehensive nutrition curriculum by Dr Padmaja and team, ICRISAT, India. Dr Padmaja introduced the objective of the health and nutrition literacy programme developed by ICRISAT. Using comprehensive nutrition messaging, this programme aims to improve the wellbeing of poor rural tribal communities in Telangana, India. The study included adolescent girls, pregnant and lactating women (n=921), and the research questions were broadly categorised into assessing current nutrition knowledge, attitude and practice (KAP); how to improve these factors using nutrition messaging; and evaluating the efficacy of the intervention, in terms of improvements in KAP. The KAP focused on food safety, hygiene, nutrition and health. According to the results at baseline, the nutrition knowledge of pregnant and lactating mothers was inadequate, with an average score of less than 50% on the assessment. The pregnant women scored low on attitudes regarding healthy diets compared to lactating mothers and frontline workers, and although attitudes translate into practice, the baseline data revealed that all categories of respondents were not adopting appropriate dietary and nutrition practices. The awareness of iron, vitamin A and iodine was also generally low. Further research activities to be completed. This text was originally published at https://tigr2ess.globalfood.cam.ac.uk/news/uk-global-challenges-research-fund-cross-gcrf-uk-india-workshop-and-satellite-event-7th

Author: Joshua Clamp / Editor: Shane McAuliffe A recent article published in BMJ Nutrition, Prevention & Health tested the efficacy of a remotely delivered weight management service in a primary care setting. Reference: Walker L, Smith N, Delon C. Weight loss, hypertension and mental well-being improvements during COVID-19 with a multicomponent health promotion programme on Zoom: a service evaluation in primary care. BMJ Nutrition, Prevention & Health 2021;bmjnph-2020-000219. Doi: 10.1136/bmjnph-2020-000219 Background Obesity and related metabolic diseases, including Type 2 Diabetes and cardiovascular disease, remain a major public health challenge in the UK. Some 63% of adults in England are overweight or obese, which has been associated with increased risk of Covid-19 complications (PHE, 2020). Not only this, but national lockdowns as a result of Covid-19 have themselves contributed to weight gain (ZOE Covid Study, 2020). In the UK, weight management services have traditionally involved community-based, group lifestyle programmes delivered in a face-to-face format. However, the arrival of national lockdowns in England meant that service providers had no choice but to rapidly shift to virtual delivery and say goodbye to the traditional setting. With lockdowns now lifted in the UK, some weight management services are once again being delivered face-to-face. However, many services in primary care settings remain remote due to the increased vulnerability of primary care patients. Limited research exists on the efficacy of remotely delivered weight management services in such contexts. Developing an understanding of how these services can be optimised for maximum efficacy in these patients is therefore important. The intervention This study explored the efficacy of a remotely-delivered, community-based group weight loss intervention in a primary care setting. The intervention involved a weight loss and health promotion programme delivered as part of an initiative from the registered UK charity Public Health Collaboration. This programme, officially titled the ‘Low Carb Real Food Lifestyle Programme’, involved six 90-minute sessions conducted across ten weeks and was delivered via Zoom. Participants also had access to optional extra support through private social media groups. The patients were recruited from a four-practice, 32000-patient primary care network in Hampshire, UK. Participants were adults with T2D, pre-diabetes or who had been advised to lose weight, plus those living with or caring for someone in one of these categories. Evidence points towards the use of multiple healthy lifestyle behaviours in reducing risk of mortality (Loef & Walach, 2012). As such, this programme included education on several important lifestyle factors, including diet, physical activity, sleep, stress management, gut health and behaviour change. The programme was designed to provide a foundational understanding nutrition, physiology, and behaviour change to help participants understand, engage in and feel some control over their health. Traditional weight loss programmes often involve a focus on caloric restriction and/or may utilise structured meal plans. This intervention, however, did not adopt a calorie-focused approach. Instead, it included an element of carbohydrate restriction, which has reported benefits of reduced blood pressure and weight loss in primary care patients and anecdotal improvements in wellbeing (Unwin et al., 2020). Participants of this programme were encouraged to restrict sugar, processed foods and starchy carbohydrates such as bread, pasta, rice and potatoes and to focus on eating minimally processed foods to satiety. An individualised approach was encouraged to ensure that preferences and demands associated with each participant’s lifestyle were met, and to make changes at their own pace. This advice was provided alongside resources including a one-page guide to low-carbohydrate eating and lists of foods to enjoy and avoid, as well as recipe suggestions. Measurements A range of measures were used to assess the efficacy of this intervention. The primary outcome measures were weight loss, changes in body mass index, waist circumference, and mental wellbeing, measured using the Warwick Edinburgh Mental Wellbeing Scale. Secondary outcomes were changes in blood pressure and blood glucose control. Subjective outcomes regarding participant experience were also recorded, collected via a questionnaire. Most data were collected prior to the first session and after the last session, however participants were encouraged to monitor and record their weight and waist circumference at regular intervals. The design of this study meant there was no control group, and instead authors chose to use a pre-post comparison. Results 30 people attended the information session, however only 20 completed the programme and had data valid for analysis. Of these 20, 17 (85%) were female and the majority (60%) were classified as having obesity. All participants were over 40 years old. All primary outcome measures improved significantly, with participants achieving a mean weight loss of 5.8kg, representing a mean weight loss of 6.5%. Mean BMI reduced by 2 kg/m2, and mean waist circumference reduced by 5.2 cm, whilst mental wellbeing scores also increased. Blood pressure and blood glucose levels also improved, and participants on insulin reduced their dosage. Feedback from participants also reflected the positive objective outcomes, and described improved confidence, increased positive feelings about health, and better energy overall. Furthermore, majority (78%) of participants were confident in their ability to maintain their changes, and over 80% said that that the experience via Zoom worked well. Finally two-thirds of feedback survey respondents reported losing weight without hunger and with reduced food cravings. Strengths, limitations and points for consideration The study had a small sample size, and no control group was used. Additionally, the sample was not randomised, increasing risk of selection bias. Furthermore, much of the data were self-reported, which introduces reporting bias. Long-term follow up was not possible, thus it cannot be said whether such an intervention had a lasting impact on the measured outcomes. The ability of this paper to provide evidence or the efficacy of carbohydrate restriction as an independent driver of weight loss and health improvement is limited. The study did not have the capacity to reliably measure carbohydrate intake of participants, and so exact compliance was unknown. Furthermore, as the intervention used multiple approaches, the positive results cannot be pinned directly to the carbohydrate restriction. Authors also highlighted possible confounding factors that could have affected outcomes, such as the COVID-19 pandemic itself and the drastic changes it imposed on our daily lives. This may have had a positive confounding effect due to there being more time to cook, make meals from scratch, and exercise, as well as fewer social opportunities that may challenge compliance. On the other hand, increased stress, as well as reduced access to food retailers and exercise venues may have had a negative influence. Despite these limitations, the results observed were very positive, and in line with those from similar interventions. This intervention clearly demonstrated the potential for remotely delivered weight management services in primary care patients. One final factor for consideration is the different demands of remote vs face-to-face delivery, and how these demands translate to differing accessibility for different individuals. For example, whilst it is clear that remote delivery can offer logistic, financial and time benefits, it also requires access to and understanding of certain technologies. Patients from different socioeconomic backgrounds may therefore have greater access to and preference of different delivery formats. This is an issue that should be considered when developing and delivering future remote weight management services. Key takeaways This study represents one of the first evaluations of a remotely delivered group-based weight loss or health promotion programme in primary care patients. Results support the notion that an effective health promotion programme can be delivered to a range of participants without the need for premises or meeting in person. This provides promise for addressing obesity and related metabolic conditions in novel ways. It also supports evidence that the provision of information and guidance on a range of dietary factors, including a focus on carbohydrate restriction, can lead to significant changes in weight and other chronic disease risk factors. However, as discussed due to the nature of the study and measuring capacity of the researchers, exact carbohydrate intake could not be measured. So whilst carbohydrates were estimated to have decreased, authors suggest that the advice to eliminate sugar and restrict starches and ultra-processed foods was effective in contributing to the observed benefits. Thus, this guidance could provide a realistic, acceptable alternative to strict carbohydrate restriction or carbohydrate counting. It is worth noting that this advice is also common across a number of dietary approaches for weight loss and overall health improvement. Moreover, this supports the evidence that the use of a holistic approach, targeting both the education and application of multiple features of healthy lifestyles, including nutrition, physical activity, stress management, sleep, and behaviour change, can be efficacious in achieving weight loss. References & further reading Covid Symptom Study. Has lockdown influenced our eating habits? the silent pandemic: how lockdown is affecting our future health. 2020. Available: https://covid.joinzoe.com/post/lockdown-weight-gain#:~:text=The%20factors%20that%20may%20have,less%20healthy%20diet%20(19%25) Loef M, Walach H. The combined effects of healthy lifestyle behaviors on all cause mortality: a systematic review and meta-analysis. Prev Med. 2012;55(3):163-70. Doi: 10.1016/j.ypmed.2012.06.017. Epub 2012 Jun 24. PMID: 22735042. Public Health England. Excess weight and COVID-19. insights from new evidence 2020. Available: https://www.gov.uk/government/publications/excess-weight-and-covid-19-insights-from-new-evidence Unwin D, Khalid AA, Unwin J, Crocombe D, Delon C, Martyn K, Golubic R, Ray S. Insights from a general practice service evaluation supporting a lower carbohydrate diet in patients with type 2 diabetes mellitus and prediabetes: a secondary analysis of routine clinic data including HbA1c, weight and prescribing over 6 years. BMJ Nutrition, Prevention & Health 2020;3(2):285-294. Doi: 10.1136/bmjnph-2020-000072. PMID: 33521540; PMCID: PMC7841829. Walker L, Smith N, Delon C. Weight loss, hypertension and mental well-being improvements during COVID-19 with a multicomponent health promotion programme on Zoom: a service evaluation in primary care. BMJ Nutrition, Prevention & Health 2021;bmjnph-2020-000219. Doi: 10.1136/bmjnph-2020-000219.

Authors: Elaine MacAninach RD and Prof Sumantra Ray RNutr | Editors: Dr Kathy Martyn RN, RNutr and Dr Minha Rajput-Ray | Reviewers: Sally Ayyad ANutr, James Bradfield RD and Dr Luke Buckner Digital Design: Matheus Abrantes | With special thanks: The AIM Foundation for current support to the Nutrition Education Policy for Healthcare Practice (NEPHELP) initiative and the NEPHELP Project Team As we mark the launch of the new Association for Nutrition (AfN) convened Curriculum in Nutrition for medical graduates (co-created with a nationally representative Inter-Professional Group in the UK), we reflect on the NNEdPro journey bringing together a selection of 18 key publications we have been involved in producing over the past 13 years. During this time, we have witnessed truly collaborative and progressive efforts that have led to this landmark moment. Following a formal call to action in the 2007 Department of Health Nutrition Action Plan, the Need for Nutrition Education Project (NNEdPro), as it was then termed, was born back in 2008 to improve medical and healthcare nutrition training as well as practice and associated research. The first NNEdPro output took the form of a policy paper on the potential impact a medical doctor can have on individual and population nutrition, especially in UK healthcare: Ray S, Gandy J, Landman J (2008) The Doctor as a Nutritionist, A Discussion Paper on Nutrition in Medical Careers. Westminster Forum Projects. Having identified nutrition as a gap in medical training, a series of nutrition education interventions were piloted across UK medical students (in over 15 medical schools) as well as UK junior doctors (Foundation Years). NNEdPro training programmes were well received and have continued to evolve to date, demonstrating an ongoing need for training and evaluation data to understand how nutrition knowledge is translated to clinical practice through action, advocacy, and leadership. The following papers provide a snapshot of insights: Gandy, J; Douglas, P; Thompson, B; Rajput-Ray, M; Sharma, P; Lodge, K; Broughton, R; Smart, S; Wilson, R; Ray, S; The impact of a nutritional education intervention on undergraduate medical students (2010). Journal of Human Nutrition and Dietetics. Ray, S., Laur, C., Rajput-Ray, M., Gandy, J., & Schofield, S. (2012). Planning Nutrition Education Interventions for the Medical Workforce: ‘Nutrition Education Workshop for Tayside Doctors’(NEWTayDoc) - A pilot project to inform development of the Need for Nutrition Education Programme (NNEdPro). Laur, C., Thompson, B., & Ray, S. (2012). Short but effective educational interventions in medicine and healthcare–lessons learnt from the ‘Need for Nutrition Education Programme’. In MedEdWorld (pp. 1-15). Ray S, Udumyan R, Rajput-Ray M, Thompson B, Lodge KM, Douglas P, Sharma P, Broughton R, Smart S, Wilson R, Gillam S. Evaluation of a novel nutrition education intervention for medical students from across England. BMJ open. 2012 Jan 1;2(1): e000417 Ball, L., Crowley, J., Laur, C., Rajput-Ray, M., Gillam, S., & Ray, S. (2014). Nutrition in medical education: reflections from an initiative at the University of Cambridge. Journal of multidisciplinary healthcare, 7, 209. Ray S, Laur C, Douglas P, Rajput-Ray M, van der Es M, Redmond J, Eden T, Sayegh M, Minns L, Griffin K, McMillan C. Nutrition education and leadership for improved clinical outcomes: training and supporting junior doctors to run ‘Nutrition Awareness Weeks’ in three NHS hospitals across England. BMC medical education. 2014 May 29;14(1):1. The early-stage ‘on the ground’ efforts of NNEdPro were contemporaneous with national curriculum recommendations at that time by the Intercollegiate Group on Human Nutrition of the Academy of Medical Royal Colleges (UK and Ireland). As the work of NNEdPro progressed, it became clear that the lack of nutrition education for medical doctors was not just a UK problem. Linking with collaborators across the globe, NNEdPro shifted focus internationally to become a Global Centre and began to consider the most important nutrition competencies for good medical and healthcare practice as well as how to implement effective training. Following on from case studies in the USA, India, and Australia, in a 2015 six-country comparison of the UK, Canada, USA, Australia, New Zealand and the Republic of Ireland, all countries were noted to have a visible curriculum on what must be taught to medical students. However, the UK was identified as the only country to mandate that all doctors should be able to complete a basic nutrition assessment. This requirement was unfortunately removed in the 2018 update of the UK Learning Outcomes for Medical Graduates. Common themes emerging over 2014-17 included the importance of multi- and inter-disciplinary approaches with a unified voice across borders as well as the role of clinical leadership in effective implementation. The following papers highlight some of the key points in support of international and interprofessional approaches: Kris-Etherton PM, Akabas SR, Bales CW, Bistrian B, Braun L, Edwards MS, Laur C, Lenders CM, Levy MD, Palmer CA, Pratt CA. The need to advance nutrition education in the training of health care professionals and recommended research to evaluate implementation and effectiveness. The American journal of clinical nutrition. 2014 May 1;99(5):1153S-66S. Ray S, Rajput-Ray M, Ball L, Crowley J, Laur C, Roy S, Agarwal S, Ray S. (2015). Confidence and Attitudes of Doctors and Dietitians towards Nutrition Care and Nutrition Advocacy for Hospital Patients in Kolkata, India. Journal of Biomedical Education. Kris-Etherton PM, Akabas SR, Douglas P, Kohlmeier M, Laur C, Lenders CM, Levy MD, Nowson C, Ray S, Pratt CA, Seidner DL. (2015). Nutrition competencies in health professionals’ education and training: a new paradigm. Advances in Nutrition: An International Review Journal. Crowley, J., Ball, L., Laur, C., Wall, C., Arroll, B., Poole, P., & Ray, S. (2015). Nutrition guidelines for undergraduate medical curricula: a six-country comparison. Advances in medical education and practice, 6, 127. Ball, L., Barnes, K., Laur, C., Crowley, J., Ray, S. (2016) Setting Priorities for Research in Medical Nutrition Education: A Global Approach. BMJ Open. Burch, E., Crowley, J., Laur, C., Ray, S., Ball, L. Dietitians' Perspectives on Teaching Nutrition to Medical Students. Journal of the American College of Nutrition. 2017. Bhat, S., Kohlmeier, M., Ray, S. (2017). Bridging Research, Education and Practice Across Disciplines: Need for Nutrition Education/Innovation Programme (NNEdPro). Journal of Nutrition Education and Behaviour. Penny M Kris-Etherton, Lynne Braun, Marilyn S Edwards, Celia Laur, Charlotte A Pratt, Sumantra Ray et al (2019). The need to advance nutrition education in the training of health care professionals and recommended research to evaluate implementation and effectiveness. The American Journal of Clinical Nutrition. S Ray. The NNEdPro Global Centre for Nutrition and Health: A Consolidated Review of Global Efforts Towards Medical and Healthcare-Related Nutrition Education (2019). Nestlé Nutr Inst Workshop Ser. Nestlé Nutrition Institute, Switzerland/S. Karger AG., Basel, © 2020, vol 92, pp 143–150. THE ‘NEPHELP’ INITIATIVE Following a decade of developing a wide lens across medical and healthcare nutrition education internationally, the NNEdPro Global Centre refocussed UK efforts in evidence-based medical nutrition education, through the creation of the Nutrition Education Policy in Healthcare Practice (NEPHELP) initiative over 2017/18. The core aim of NEPHELP is to develop, test, improve, implement, and evaluate nutrition education resources for doctors and associated health professionals in hospitals as well as community settings. This supports the development of learning resources and toolkits for practitioners. Dr Minha Rajput-Ray and Dr Harrison Carter receiving the MNI-ESPEN award in the Hague (2017) enabling the establishment of NEPHELP The first phase of NEPHELP focussed on junior doctors whilst the second phase looks deeper into both primary and secondary care. Through this initiative, doctors can be empowered with greater nutrition training to become champions for nutrition within local teams, coordinating the key roles that nurses and other healthcare professionals make in nutrition care. Ultimately the goal is to improve nutritional care utilising a whole team approach to improve screening, early detection, and integration into care pathways; examples include reducing cardiovascular risk, managing type 2 diabetes, gastrointestinal problems, undernutrition, or signposting patients to nutrition resources with consideration of age, medical conditions, cultural preferences, financial and environmental circumstances. This supports the implementation of rapid first-line nutrition advice as well as appropriate referrals to dietitians and nutritionists. Alongside this, we continue to advocate for adequate nutrition training for medical and healthcare students as well as professionals, with those we have taught then providing guidance in future to their trainees. The NEPHELP Team (Dr Luke Buckner, Elaine MacAninch RD, Emily Fallon ANutr and Prof Sumantra Ray RNutr, launching the second phase of NEPHELP at the BMJ Safety and Quality in Healthcare Conference in Glasgow (2019) Our vision is to facilitate the development of a nutrition-trained healthcare workforce, to work seamlessly between hospitals and the community in the prevention and treatment of disease, improving the lives of those we care for and protecting scarce NHS and social care resources. Whilst several papers from NEPHELP are currently under development and review, a key publication from the first phase of the initiative led to a collaboration with the medical student-led group ‘Nutritank’ resulting in the ‘Time for Nutrition’ survey: Macaninch, E., Buckner, L., Amin, P., Broadley, I., Crocombe, D., Ray, S. Herath, D., Jaffee, A., et al. (2020). Time for nutrition in medical education. https://doi.org/10.1136/bmjnph-2019-000049 NEPHELP GLOBAL Since 2019, building on the bedrock of the NEPHELP initiative, doctoral research at the University of Wollongong Australia undertaken in collaboration with NNEdPro, has added further global insights through detailed analyses and syntheses around curricula as well as competencies, providing a sound basis for the development of guidance for medical nutrition educators. Furthermore, the development of 12 Regional Networks spanning over 35 countries across six continents provides opportunities for the adaptation and scaling of medical nutrition education efforts which can be supported by a centrally curated evidence collection hosted by the ‘International Knowledge Application Network Hub in Nutrition’ (iKANN). Collaborative work undertaken recently with the World Health Organization has also resulted in a blueprint (Lepre et al 2021; in press) for nutrition training and capacity building amongst health professionals in the wake of Universal Health Coverage. Lepre B, Mansfield KJ, Ray S, et al. (2021) Reference to nutrition in medical accreditation and curriculum guidance: a comparative analysis. BMJ Nutrition, Prevention & Health 2021; bmjnph-2021-000234. doi: 10.1136/bmjnph-2021-000234 Lepre B, Mansfield KJ, Ray S, et al (2021). Nutrition competencies for medicine: an integrative review and critical synthesis. BMJ Open 2021;11: e043066. doi: 10.1136/bmjopen-2020-043066. THE NUTRITION IMPLEMENTATION COALITION Furthermore, based on mutually productive collaborations with Nutritank and the Brighton-based ‘Education and Research in medical Nutrition Network’ (ERimNN) over 2017/18, the UK Nutrition Implementation Coalition was formed in 2019 as a collaborative group convened by NNEdPro and including Nutritank, ERimNN and additionally, Culinary Medicine UK, as core members. The coalition brings together a variety of educational, professional and research experiences, who share the same vision regarding the need to advocate for nutrition education for healthcare professionals and bridge the gap between knowledge and practice to improve the ability of doctors, nurses, health, and social care professionals to deliver effective nutrition care. This coalition fully supports the implementation of the newly launched national nutrition curriculum in the UK. “We believe better nutrition educated health and social care workforce improves patient outcomes and holds benefit for population health.” THE NUTRITION CURRICULUM AND NEXT STEPS Central to the implementation of improved nutrition training and practice is the need for consensus and commitment across different organisations. Alongside other members of the UK Nutrition Implementation Coalition, NNEdPro was honoured to have been involved in the consultative Inter-Professional Group convened by the AfN and leading to the 2021 launch of the new national nutrition curriculum for medical students and graduates. This is a truly critical and very timely blueprint to develop sound conceptual foundations underpinning the relationships between nutrition, health, and disease and to help equip medical professionals and the healthcare workforce with the skills to deliver nutrition care within the multi-professional team. EMERGING OPPORTUNITIES TO PIOT IMPLEMENTATION Over the Autumn term of 2021 the NNEdPro Chair, Professor Sumantra Ray, as a member of faculty at both the Nutrition Innovation Centre for Food and Health (NICHE) and the newly established Medical School at Ulster University, will have the opportunity to deliver a series of five medical nutrition education lectures to the first intake of graduate medical students in Northern Ireland. Furthermore, ERimNN, working with Brighton and Sussex Medical School (BSMS) are developing a strategy for mapping the new AfN Curriculum against existing curricula that highlights gaps and opportunities for continued curriculum development. These timely opportunities to begin implementation of the newly launched nutrition curriculum in real-time can provide potentially useful insights for medical nutrition educators at large. You can learn more and download the AfN Nutrition Curriculum here. Read more: In support of the US Congress’s call to introduce nutrition into medical curricula

An innovative model training marginalised women to become culinary health educators Written by Sento Kai Kargbo, MTK Project Officer at NNEdPro Edited by Luke Buckner, MTK Project Lead at NNEdPro Reference: Buckner, L., Carter, H., Crocombe, D., Kargbo, S.K., Korre, M., Bhar, S.B., Chakraborty, D., Douglas, P., Gupta, M., Maitra-Nag, S., Muhkerjee, S., Saha, A., Rajput-Ray, M., Tsimpli, I., and Ray, S. (2021). ‘Bhavishya Shakti’: Empowering the Future’: establishing and evaluating a pilot community mobile teaching kitchen as an innovative model, training marginalised women to become nutrition champions and culinary health educators in Kolkata, India. BMJ Nutrition Prevention & Health; 0. Doi: i:10.1136/bmjnph-2020-00018 A recent article published in BMJ Nutrition (BMJ NPH) demonstrates the feasibility of a novel Mobile Teaching Kitchen (MTK) as a nutrition education and upskilling platform for marginalised women in Kolkata, India, and the potential for upscaling to similar people worldwide. The MTK as a public health intervention showed promising results in educating and empowering a group of lay disadvantaged women into culinary health educators, otherwise referred to as ‘MTK Champions’. This blog aims to summarise key findings, limitations, and opportunities for future research. Background. Malnutrition – undernutrition, micronutrient deficiencies, and overweight/obesity, and other diet-related non-communicable diseases – affects nearly 2 billion people worldwide and is a leading cause of death and disability worldwide (WHO 2019). The simultaneous existence of underweight and overweight/obesity (“double burden of malnutrition”) persists as a public health emergency in India across the socioeconomic gradient (NFHS-4 2017). According to the Global Nutrition Report (2016), although there has been overall progress in rates of exclusive breastfeeding and prevalence of overweight among children under 5 years old in the region, there is still much work to be done as the overall state of malnutrition remains a cause for concern. The NNEdPro Global Centre, in partnership with local charities, launched the “Bhavishya Shakti” MTK intervention in two slums (Chetla, RG Kar) in Kolkata, India, where the project team including health professionals trained local community volunteers in basic nutritional concepts who then transferred this knowledge to a group of women via a teaching kitchen. The MTK intervention was delivered over the course of 6 months, from baseline assessment to post-intervention data collection. This paper aimed to assess the feasibility of a mobile teaching kitchen as an upskilling platform and nutrition education tool to train marginalised women to become culinary health educators. Figure 1. Timeline of data collection and nutrition education delivery. Baseline assessment. With the help of volunteers, licensed dietitians and physicians collected demographic data (age, gender, education level, occupation, no. of siblings) and performed physical exams (anthropometry and clinical assessments) to evaluate the nutrition status of MTK Champions. KAP (knowledge, attitudes, and practices) surveys were also administered to assess awareness of dietary practices. SODOTO Workshops. The ‘See One, Do One, Teach One’ ("SODOTO") workshops were comprehensive nutrition education and hygiene workshops delivered via cooking demonstrations following a pre-set template menu comprising locally sourced ingredients. In the See One session, MTK champions observed the preparation of nutritionally balanced, affordable meals. In the next session, ‘Do One’, the Champions performed the meal preparations themselves, and in the final session, Teach One, they taught a group of community members who opportunistically assembled. Additionally, following each consecutive session of the SODOTO workshops, the cognitive flexibility and mentalising skills of the MTK Champions were assessed using standard theory of mind (ToM) tasks, the Wisconsin Card Sorting Task, and the Unexpected Transfer task – a novel aspect of the proposed intervention. Mentalising refers to the mothers’ ability to predict, understand, and cater to their children’s psychological needs. Insights into mentalising skills may highlight which candidates are flexible to adapt behaviour to the understanding of others. Figure 2. Overview of the process of knowledge transmission from trained professionals through to the community. In the post-intervention data collection step, clinical assessments and anthropometric measurements were repeated to allow for longitudinal analysis of nutrition and health status. KAP surveys were also re-administered. At the end of the workshops, MTK Champions formed a microenterprise where they prepare and sell meals whilst transferring knowledge onto members of their community. Summary of key findings All Champions were domestic helpers (n=8) or housewives (n=6). Although, the majority of the champions were educated to primary level (up to class IV) (n=6). The maximum level was up to UK college standard (XII standard) or above (n=1), and the lowest level was no formal education (n=4). As anticipated in this timeframe, there was no statistically significant difference in weight, height, or MUAC at baseline or post-intervention in both mothers and children across the 2 slums. Of the 11 signs of micronutrient deficiencies observed at baseline, only 3 were seen post-intervention. The most common clinical sign observed was pallor. At baseline, the combined KAP subsections were as follows (mean (SD)): knowledge 11.7 (1.05), attitude 40.6 (0.74) and practice 23.4 (1.24). Following the intervention, the scores were found to have changed by +4.8 (knowledge), −3.8 (attitude), and +0.8 (practice). Figure 3. Breakdown of KAP scores of Chetla and RG Kar slums Findings from the MTK pilot intervention in Kolkata should be interpreted with caution given the small sample size (n=12) which limits internal and external validity. Furthermore, many of the clinical assessments, especially the examination of the physical signs are subjective, therefore prone to the effects of chance, bias, and confounding. Anthropometric measurements are also prone to subjective inconsistencies or errors. Conclusion. Malnutrition poses serious health and economic consequences for individuals and communities. Nutrition and health interventions, like the MTK, provide an opportunity for cost-effective, innovative, and adaptable action toward addressing nutrition and health inequities among underserved populations, which has been further exacerbated by the ongoing COVID-19 pandemic. The main outcomes of the success of the MTK were improvements in nutrition knowledge and practice among the Champions post-intervention. Further, the MTK also serves as a microenterprise opportunity to generate novel sources of household income and new leadership and educator roles within the community. There is also the potential to adapt and upscale this kind of intervention to other settings globally, across the socioeconomic gradient. References World Health Organization. Malnutrition is a world health crisis, 2019. Available: https://www.who.int/nutrition/topics/world-food-day-2019-malnutrition-world-health-crisis/en/2 Ministry of health and family welfare. National family health survey (NFHS-4) 2015-16 India, 2017. Available: http://www.rchiips.org/nfhs5 Global Nutrition Report. Country Nutrition Profiles – India. Available: https://globalnutritionreport.org/resources/nutrition-profiles/asia/southern-asia/india/ Buckner, L., Carter, H., Crocombe, D., Kargbo, S.K., Korre, M., Bhar, S.B., Chakraborty, D., Douglas, P., Gupta, M., Maitra-Nag, S., Muhkerjee, S., Saha, A., Rajput-Ray, M., Tsimpli, I., and Ray, S. (2021). ‘Bhavishya Shakti’: Empowering the Future’: establishing and evaluating a pilot community mobile teaching kitchen as an innovative model, training marginalised women to become nutrition champions and culinary health educators in Kolkata, India. BMJ Nutrition Prevention & Health; 0. Doi: i:10.1136/bmjnph-2020-00018 NNEdPro. Mobile Teaching Kitchen (MTK) [Internet]. 2021 [cited Aug 12]. Available: https://www.nnedpro.org.uk/mtk

Why are the Culinary Arts and Nutrition Education Important Levers of Sustainability and Healthy Lifestyles? Potential Solutions from the Perspective of Hospitality Author: Jaroslav Guzanic Acknowledgements: This article was reviewed and contributed to by Luke Buckner, Jørgen Torgerstuen Johnsen and Wanja Nyaga. Our thanks go out to those involved in the MTK cookbook launch event at Cambridge festival, as well as the design of the cookbook which can be purchased here. In general, culinary arts are related to the design, preparation, cooking and presentation of food. Culinary art is part of a gastronomy and hospitality industry, and is heavily linked with the development of culture and society. Nowadays, expert chefs are required to have a knowledge of food science, nutrition and diet, and are responsible for preparing meals by performing culinary procedures alongside food and beverage management at restaurants, hotels, schools or other public catering facilities. In my opinion, this is something we are aware of and have heard before, but how does this all relate to sustainability and a lifestyle? Or better said, how much do chefs really know about sustainability? Having worked as a hospitality professional (in different roles and positions within the hospitality sector) for the past 18 years, I have developed a lot of knowledge of the fundamentals of sustainability. More recently this has been added to my position as a Research Chef where I now communicate with customers, learning more about their demands, dietary requirements, and sharing stories about their lifestyles, perceptions and philosophies of cooking. The development of a society Progress in technology, growing cultural diversities and political changes have caused significant gaps and inequalities which are reflected in our social and consumer behaviours and eating habits. This trend has brought confusion, even in gastronomy. For example, using terms like “sustainable, green, eco-friendly, and ethical” have meaning that everyone understands differently and often people (customers and consumers) cannot fully explain what sustainability is, or how to get themselves involved. In addition to this, hospitality workforces, for instance chefs, have the capacity and potential not only to develop recipes, but also help create dialogue with stakeholders, educate communities on healthy diets and work with healthcare professionals. Below are a few key areas we will be working on within our recently established, collaborative, open knowledge platform designed for creating a conversation and sharing educational interactions with hospitality and healthcare professionals, teachers and key organizations based in Geneva and elsewhere in Switzerland. “Working with Jaroslav, in running our first live cook-along to recipes from our Mobile Teaching Kitchen (MTK) in Kolkata, was such a fun and useful experience. He provided a great complimentary perspective to the experience we gave as healthcare professionals and researchers, highlighting simple food swaps and culinary techniques. I truly feel that given the important role food plays in society and socialising, chefs and healthcare professionals working with researchers can form impactful, enjoyable nutrition interventions. Dr Luke Buckner - NNEdPro Assistant Director and MTK Project lead. Leadership: Promoting healthy behaviours through healthcare, school-based education, hospitality training, gastro diplomacy and community-minded projects. Experience from past decades shows the need for mobilizing the capacities of different stakeholders as agents of change and incorporating new strategies of awareness-raising, communication and education for food and nutrition. Gastronomy has become a domain that, in addition to its economic importance, has positioned itself as an area of interest for a large part of the population, the media and governments. Knowledge: Innovating a “Learn and Share” collaboration model between chefs and healthcare professionals to strengthen patients outreach programs in terms of social prescription. Chefs today are among the actors who shape public opinion and influence the general population. They aim to build broad alliances and a global platform to mobilize the capacities of different actors, such as chefs, to strengthen policy dialogue around culture, food and healthy diets. Assessment and Management Skills: A global call to involving chefs in the research methods of creating an idea and obtaining results. In both science and cooking, known ingredients and a common set of techniques are used to produce results. In cooking, it is the synthesis of a meal or dining experience from a set of ingredients expressed through a recipe.Improving collaboration and communication. Assessment of social, psychological and biological predispositions of patients’ behaviours and the resulting health outcomes. Community Support: Delivery of more nutrition and food education to schools. Collaborating with families and community-based projects. Supporting and creating a dialogue between science and regular people (all of us are part of a worldwide community). Having the ability to establish and practice in an interdisciplinary team. Chefs have become increasingly involved in the global movement to reduce food waste, championing food waste reduction efforts in their own restaurants, as well as empowering local heroes. Coming from hospitality industry, this an area that will always exist and it is one of the biggest global cultural and social platforms and tools to incorporate and implement knowledge and create synergies between sustainability and lifestyle. This is a very special area, which needs further research and support. NNEdPro is completely following this mission and provides a very important knowledge foundation on a global level. To support this point of view and add to what has been written above, we strongly believe in creating a productive collaboration, by following this movement, promoting it and connecting with Swiss-based collaborators, as well as Think-Tank hubs. References: 1. Chefs as Agents of Change [Internet]. Food and Agriculture Organization of United Nations. 2021 [cited 22 April 2021]. Available from http://www.fao.org/3/ca3715en/ca3715en.pdf

Melissa Adamski, MND, BSc., APD For many of us, 2020 was a challenging year – both professionally and personally as we all adapted to new routines and ways of working. Online learning and teaching became the norm and for IANE it was no different. 2020 saw a number of firsts for IANE as we not only navigated new ways of working and collaboration but also launched a number of new services and opportunities for members. I was delighted to see: The Summer School and International Summit delivered completely online throughout the month of September through a series of webinars and events. More than 40 participants in the Summer School from around the world. Launch of new IANE member benefits including journal club and webinars. I am really proud of what IANE accomplished during 2020. I am excited and optimistic that we will continue growing and delivering high-quality nutrition education to our members in 2021. We are currently working on launching the IANE awards and fellowships, which will recognise the outstanding contributions to nutrition education by our faculty, student, and professional members. In fact, in this edition of the newsletter, we are announcing our inaugural IANE fellows 2021, selected from our Faculty and IANE steering committee members. We congratulate them on their fellowships and look forward to having them help guide the IANE. We are also working towards the 2021 International Summit which will be held in July, with registrations opening soon - I hope to see many of you attend!

Our hearty congratulations to NNEdPro Global Patron, Lord Diljit Singh Rana, who has been made an OBE (Officer of the Order of the British Empire), in the Queen's New Year Honours 2021, for his services to business and to the economy in Northern Ireland! The Lord Rana was born in Sanghol, a small village in the rural region of Punjab, India, but has been a resident of Northern Ireland since 1966. He was appointed to the House of Lords in 2004 by Prime Minister, Tony Blair, in recognition of his contributions to the economic regeneration of the city of Belfast. He became the first ethnic businessman to be elected President of the Northern Ireland Chamber of Commerce and Industry. Presently, the Lord Rana serves as India's Honorary Consul in Ireland, where he continues to establish economic and collaborative relationships between India and Ireland, most notably, the establishment of the Lord Rana Charitable Foundation Trust and Cordia College in Sanghol. Image 1. Cordia College in Sanghol, India Cordia College benefits from local support of Punjab University, as well as links to Ulster University in Ireland and NNEdPro Global Centre for Nutrition and Health, in the UK. On several occasions, the Lord Rana and his team have graciously hosted NNEdPro members on visits to the college and this has been a source of tremendous support for the NNEdPro Mobile Teaching Kitchen (MTK) initiative in Kolkata, India. The NNEdPro Executive Director, Sumantra Ray, serves as Honorary International Dean to the Lord Rana Charitable Foundation Trust, and the NNEdPro Education Director, Pauline Douglas, and Medical Director, Minha Rajput-Ray, serve as Honorary Associate Deans. Additionally, NNEdPro Assistant Director (Medical, Luke Buckner, serves as Lead Project Officer to the Trust. On one of his visits to Cordia College in 2018, Luke Buckner, recounts his experiences at the college, "I was met by a member of Lord Rana's team who accompanied me to the college, whilst accommodating my needs along the way. When we reached our journey's end, I met the Lord Rana, one of the humblest, funny and most welcoming person, who made me feel instantly at home on his campus." "Nothing is too much to ask of Lord Rana or his team. It is this attitude of the staff and students of Cordia College, that I believe reflects so kindly on the Lord Rana. I am very grateful to have stayed a number of times since then with each having an equally positive experience, and look forward to meeting them all again in the future." The Lord Rana's continued support in fostering international collaboration, hosting and supporting NNEdPro's MTK and through this empowering and enhancing the health of individuals in marginalised sectors of Sanghol is truly admirable. A huge thank you to Lord Rana for his continued support of the MTK project in particular, and to each member of his team who helped us implement this initiative in Punjab. Yet again, well done Lord Rana, OBE and well deserved. Quick Links https://www.nnedpro.org.uk/president https://www.cordiacollege.com/

Learnings from the 5th NNEdPro Summer School in Applied Human Nutrition Key Contributors: Breanna Lepre, Mayara De Paula, and Diptimayee Jena Acknowledgement: 2020 Summer School cohort Poor diet is associated with an increased risk of morbidity and mortality, with 11 million deaths in 2017 attributable to diet-related risk factors [1]. The double burden of malnutrition, characterised by the coexistence of undernutrition along with overweight and obesity, or diet-related noncommunicable diseases, has global implications for health, the environment and the economy. In 2015, 17 Sustainable Development Goals (SDGs) were adopted by United Nations (UN) member states as a universal call to end poverty, protect the planet and ensure peace and prosperity by 2030 [2]. One key goal was to achieve “Zero Hunger”[2] and alongside the UN Decade of Action on Nutrition 2016-2025 report [3], this represents a significant commitment to eliminate all forms of malnutrition by 2030. The UN Decade of Family Farming, 2019-2028 (UNDFF) is aimed at strengthening family farming practices to achieve sustainable food systems that meet SDGs in an inclusive, collaborative and coherent way [4]. Despite some progress made towards achieving SDGs, the prevalence of malnutrition is increasing [5]. Globally, almost 1 in 9 people are undernourished [5], while 1 in 3 people are overweight or obese [6]. Food security provides an important link between diet quality and health. Food insecurity is defined by the Food and Agriculture Organisation of the United Nations (FAO) as “when people lack secure access to sufficient amounts of safe and nutritious food for normal growth and development and an active, healthy life”[7]. Food insecurity is on the rise, with over 2 billion people estimated to have gone without regular access to sufficient, safe and nutritious food in 2019 [5]. The COVID-19 pandemic increased the risk of food insecurity, placing additional strain on existing food systems. In fact, the FAO predicts that the COVID-19 pandemic will increase the number of people who are undernourished from 83 to 132 million people [5]. This is particularly concerning considering the importance of maintaining a healthy diet to support a well-functioning immune system [8]. There are many national and international agencies with a nutrition and health agenda, such as the World Health Organisation (WHO) and the FAO, mentioned above. The NNEdPro Global Centre for Nutrition and Health, is an award-winning, innovative think tank aligned with the United Nations Sustainable Development Goals, the UN Decade of Action on Nutrition (2016-2025) and the UN Decade of Family Farming (2019-2028). NNEdPro is committed to addressing all forms of malnutrition through education, research, and advocacy in nutrition-related aspects of health and healthcare systems. The 5th NNEdPro Summer School in Applied Human Nutrition took place in September 2020 as a virtual event and was co-organised with the School of Advanced Studies on Food and Nutrition of the University of Parma, Italy. The Summer School is accredited by the Royal College of Physicians and Royal Society of Biology and recognised by the International Union of Nutritional Sciences, through the provision of scholarships. The 2020 Summer School cohort brought together delegates from across the globe, spanning 24 countries in Asia, North America, South America, Europe and Africa. As part of course assessment, participants were asked to answer a timely and relevant essay question: “How far do we have to go towards ending malnutrition in all its forms by 2030?” The essay responses were insightful and provided interesting and varied solutions to ending malnutrition in all its forms by 2030. Some of the essay responses were related to the use of digital technologies to transform food systems to deliver affordable, healthy diets for all. “agricultural development programmes that encourage diversification and consumption of home-produced foods and also increase food affordability could be carried out using mobile apps, workshops, and data dissemination using digital networking.” Sneha Deshpande “The Covid-19 pandemic has ushered in a new era where innovative strategies must be employed to overcome the challenges traditional methods of intervention contend within what is now described as the ‘new normal’… Artificial intelligence (A.I.) can increase learning capacity and provide decision-making support systems to help healthcare providers identify and better manage patients who are more at risk for malnutrition.” Maureen Maduagwu “Technology is constantly advancing, and telemedicine systems could not only be used to provide specialist nutritional care to remote areas but also to aid in distance learning and the training of healthcare professionals further afield. Using telemedicine would improve access to care and could have epidemiological benefits via tracking the spread of disease burden and different forms of malnutrition. This, in turn would increase accountability and highlight areas where further work needs to be done.” Karuna Tandon Taking a sustainable approach, using resources readily available within the local region also proved popular as a strategy for tackling malnutrition. “Millets are aligned to the principles of sustainable agriculture in strengthening local economies, providing nutritional security and giving recognition of the role of women in agriculture through a programme called ‘Odisha Millets Mission’ operating in one of the states of Odisha in India. ” Diptimayee Jena Other essays focused on nutrition research and data that underpins decision making, evidence-based policy and practice for sustained change. “focus should be on funding precision nutrition initiatives in which the community is equipped with precise data based on nutrition surveillance of their diet-related health status and economics” Tecla Coleman “Creating effective and evidence-based interventions that include governance body, coordinating agencies, an institutional framework, and a data-sharing and communication system, taking advantage of the unprecedented opportunity that is the Nutrition Decade, is a viable strategy to achieve our title goal: eliminate malnutrition in all its forms by 2030” Pedro Alvez Soares Vaz de Castro Whereas some suggested education as a way to improve workforce capacity and to empower individuals to make healthy and informed dietary choices. Healthcare professionals are particularly well-placed to provide dietary advice, due in part to the large number of individuals they come into contact with. “There are strong links between nutrition, education achievement and economic development: early life and childhood nutrition interventions may play a key role in achieving education for all and contributing to a dynamic, productive and skilful workforce” Nicole Tosi “Training in medical schools focusses on disease, but is overlooking the basics of nutrition, holistic care and preventing illness. Physicians need to have the ability to firstly recognise and then address...malnutrition for their patients” Claudia Mitrofan A reoccurring theme seen from the essay responses was a focus on working collaboratively across multiple sectors, from the technology sector to farming and agriculture. This type of cross-collaboration provides opportunity to exchange knowledge and form networks to meet the goal of eliminating all forms of malnutrition by 2030. Ending malnutrition will have significant benefit for the health of the population and for social and economic development. The COVID-19 pandemic has revealed the need to transform our food system, providing an unprecedented opportunity to implement scalable nutrition interventions for change. The NNEdPro Summer School in Applied Human Nutrition is one example of the potential for nutrition education to inspire change. One key factor to ensure the success of any new intervention is the commitment and investment from local government and policy makers, alongside consistent monitoring and evaluation. We cannot afford to wait any longer to make change – The time to act is now. References: 1. GBD Diet Collaborators, Health effects of dietary risks in 195 countries, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet, 2019. 393(10184): p. 1958-1972. 2. United Nations Development Programme (UNDP). Sustainable Development Goals. 2020; Available from: https://www.undp.org/content/undp/en/home/sustainable-development-goals.html. 3. Food and Agriculture Organisation (FAO). United Nations Decade of Action in Nutrition 2016-2025. 2016; Available from: http://www.fao.org/3/a-i6130e.pdf. 4. Food and Agriculture Organisation of the United Nations (FAO) and The International Fund for Agricultural Development (IFAD), United Nations Decade of Family Farming 2019-2028. Global Action Plan. 2019: Rome. 5. Food and Agriculture Organisation (FAO)., et al., The State of Food Security and Nutrition in the World 2020. Transforming food systems for affordable healthy diets. 2020: Rome, Italy. 6. World Health Organisation (WHO). Obesity and overweight. 2020. 7. Food and Agriculture Organisation of the United Nations (FAO). The State of Food Insecurity in the World 2001. 2001: Italy. 8. Fallon, E., S. McAuliffe, and S. Ray. Combatting COVID-19: A 10-point summary on diet, nutrition and the role of micronutrients 2020; Available from: https://www.nnedpro.org.uk/post/combatting-covid-19.

Children’s right to safe, nutritious, and culturally appropriate food during the COVID-19 pandemic in the UK By Marjorie Lima Do Vale, Helena Trigueiro, Kathy Martin, Shobhana Nagraj, Elaine Macaninch, Dominic Crocombe, Sumantra Ray Last year, in the context of COVID-19, the UK Government published a policy paper entitled “Tackling obesity: empowering adults and children to live healthier lives”, which described several actions being considered by the Government to help people become healthier (1). The NNEdPro Global Centre, as an international and interdisciplinary global think-thank focussed on addressing inequalities and implementing effective solutions in nutrition and health, welcomed many of the actions proposed but advocated for more comprehensive language and actions that do not corroborate a reductionist view of nutrition that is centred on calories and weight (2). This time, in face of several reports of inadequate and inefficient meal provision to school-aged children during the pandemic in the UK, particularly in England, NNEdPro responds to the UK Government actions in the school meal domain. In this advocacy paper, we outline current actions across the UK and make recommendations to improve the adequacy and efficiency of programmes being delivered with the overall goal to urgently protect children from rising food poverty and inequality. Background Information: The COVID-19 pandemic has posed several challenges to food, social and welfare systems, resulting in heightened vulnerability for many families, which are now facing an increased risk of food insecurity and malnutrition (3). Although the long-term impact of the pandemic on children’s nutrition and health is unknown, good nutrition is essential for children’s growth and development (4). Childhood is an essential period for developing healthy eating behaviours that might be carried into adolescence and adulthood (5,6) and therefore provides a window of opportunity to promote growth and development while also reducing the risk of non-communicable diseases later in life. Understanding the early impact of the COVID-19 pandemic on environments where children live, learn and play, and implementing timely and effective actions that promote food security and good nutrition in such unprecedented times is essential to minimise unnecessary risks and burden to individuals, society and future healthcare and social pressures. Advocacy Goals: The first motivating factor for this advocacy piece was the delayed response of the Government in England to secure access to food vouchers over summer and winter holidays by families entitled to receive free school meals. Despite this situation being “resolved” after pressure from third sector organisations along with celebrities in the UK, the food insecurity of children continues. More recently, the media has been inundated with pictures of inadequate food parcels being provided to families with third sector organisations and celebrities, now demanding a comprehensive review of free school meal systems across the UK. We are concerned that taking such a reactive approach, where actions are taken only when access to food is already disrupted, cannot continue any further. As such, we agree with others that free school meals systems must be reviewed and reinstated to prevent food insecurity from happening and not only mitigate its effects. In line with our response to the UK Obesity Strategy (2), we want to prevent short-sighted approaches. Feeding children is not a simple task. Thinking otherwise can result in overlooking essential aspects of children’s food environments that have been disrupted and further wasting of public resources in actions that are inadequate and ineffective. Allocating necessary resources to support families in providing adequately nutritious foods for children needs immediate action and must be prioritised. Poor quality diets can manifest as undernutrition, obesity, or nutritional deficiencies with potentially lifelong consequences (7). We call for immediate commitment of UK Government leaders. Our recommendations are in line with and further build on those made in the National Food Strategy published in the summer of 2020 (8). Recommended Actions: Support local districts in developing capacity and systems to comprehensively identify and monitor children and families eligible to expanded free school meals scheme or at increased risk of food insecurity and malnutrition. Ensure access to safe and nutritionally balanced foods for all children who are normally in receipt of free school meals or otherwise identified as food insecure. This includes access to appropriate foods as well as cooking facilities for preparing and storing foods which can be accomplished via direct cash transfers or vouchers. Cash transfer and vouchers can be preferred options, considering that delivering food parcels that meet nutritional and cultural needs and potential food intolerances/allergies can be complex. However, the delivery of food parcels should not be excluded considering other factors that might prevent families from physically accessing foods. In addition to the expansion of Holiday activities and Food programmes, we call for continued access to information on what and how to feed children from different age groups and for provision of support from nutrition/dietetics and healthcare professionals to parents and caregivers struggling to feed their children. Support the collation of examples of innovation and good practice that are effective in improving equitable and sustainable access to adequate food (e.g., food banks, community kitchens, nutrition education programmes) across the UK and allocate funding to support replication of what works. Importance of good nutrition during childhood Undernutrition (when children have low weight and/or height for their age or gender), overweight or obesity (when children have high weight or body mass index for their age or gender) and micronutrient deficiencies are all part of the concept of malnutrition. In all its forms, malnutrition negatively influences child health in the short and long term (9). Undernutrition and nutrient deficiencies are associated with children’s poor growth, cognition, school readiness and performance along with increased risk of infections and increased mortality. The other face of malnutrition, related to overweight and obesity, also pose risks to child health and have been associated with low self-esteem and increased risk of metabolic disorders (10). Addressing childhood malnutrition by targeting and promoting healthy food environments in places where children live, learn and play, might be effective strategies to set the correct trajectory in the UK. Several studies have found associations between childhood environmental influences within children’s households (11,12,13,14), nurseries and schools (15,16, 17), and children’s eating behaviours, diets and nutrition outcomes. Promotion of healthy food environments includes not only the provision of healthy foods but also, the provision of opportunities for children to interact with food in a positive way and to learn healthy eating behaviours that can potentially be carried into adolescent and adult life (5,6). Background of childhood food insecurity and malnutrition in the UK Food security is a concept closely related to malnutrition. Food security exists when individuals have stable access to foods that are safe, nutritious and culturally adequate—as such, being food secure can be considered a pre-requisite for a healthy dietary intake and nutritional status. The global food security report, 2020, highlighted that about 60k people in the UK could not afford an energy sufficient diet, about 130k could not afford a nutrient adequate diet and 200k could not afford a healthy diet, highlighting the alarmingly vast scale of those already food insecure and at risk of malnutrition. Furthermore, UNICEF reported that in 2014/15 about one in five children below the age of 15 in the UK lived in a food insecure household, which is the highest rate observed in Western Europe (19). Even more pertinent as UK has now exited the European Union and is navigating a number of economic uncertainties that lie ahead. In terms of malnutrition, data from the Global Nutrition Report, including children aged 5 to 19 years, show that despite a small and steady decline in the prevalence of those underweight from 2000 to 2015, around 6.3% of girls and 9.8% boys are still underweight in the UK. In contrast, rates of overweight and obesity spiked within the same 15 years reference period, particularly in terms of obesity among boys (8.3 to 10.9%) (18). More recent data from the National Child Measurement Programme (NCMP) published in 2018/2019 show that the prevalence of children aged 4 years who were underweight was relatively low (1%). Significant variations existed across regions in England, Leicester has five times more undernourished children than Lincolnshire, for example. Rates of overweight, obesity and severe obesity among 4-year-olds reached 12.9%, 7.3% and 2.4% respectively, with important differences across regions. Among 10-11 year-olds, a higher prevalence of overweight (13.9%), obesity (15.4%) and severe obesity (4.3%) is observed (20). It is important to highlight that prevalence of obesity was consistently higher in the most deprived groups, suggesting an important role of socioeconomic deprivation in children's nutritional status (20). For micronutrient adequacy, data from the Diet and Nutrition Survey of Infants and Young Children published in 2013 showed that 11 to 28% of children aged 12 to 18 months living in the UK, had intakes of iron below the lower reference nutrient intake (LRNI). Higher inadequacy was observed for South Asian children (28%) and children from parents that occupied routine and manual labour. Consumption of fruits and vegetables was also lower among South Asian children, and those from parents engaged in routine and manual labour. Intake of sodium was another area of concern, reaching a mean daily intake of 181% adequacy. For older children, aged 11 to 18 years, data from the NDNS show that mean intake of vitamin A, D, calcium, magnesium, potassium, selenium were below reference nutrient intake (RNI) in both sex groups. For girls, folate, iron and zinc were also below RNI. It was noted that for some micronutrients, such as vitamin A, folate and iodine, higher intake was associated with higher income levels. Similarly, consumption of fruits and vegetables and “5 A Day” also increased with income (21). Altogether, this data suggests that childhood malnutrition in all its forms is a serious problem in the UK. Tackling childhood malnutrition is an important area for action to prevent growth and developmental delay, as well as the increased risk of metabolic diseases and non-communicable diseases later in life, particularly for children in lower sociodemographic groups (20). Government role in addressing childhood food security and malnutrition The right to food is a legal obligation anchored in international law proposed by the Committee on Economic, Social and Cultural Rights in 1999, and ratified by 170 State Parties, including the UK (22). It has been advocated that the UK Agriculture Bill 2017-2019 is amended to explicitly recognise the right to food, thus setting an appropriate legal and regulatory structure to guarantee its protection, respect and fulfilment. Also, the Parliament should publish a Right to Food Bill to ensure a comprehensive approach to the right to food, with the identification of principles, finalities, rights holders and duty bearers (23). In 2004, the FAO provided a set of guidelines to support state parties in promoting the right to food in the context of national food security. In the nutrition domain, examples of such actions included: taking measures to maintain or strengthen healthy eating habits and ensure that changes in availability and access to food supply do not negatively affect dietary composition and intake and disseminating information on the feeding of infants and young children that is consistent and in line with current scientific knowledge and internationally accepted practices (24). Government actions in addressing childhood food security and malnutrition Maintain and strengthen healthy eating habits and preventing disruptions During the early stages of the pandemic, about 5.1 million people in households with children had already experienced one or more forms of food insecurity – with more than 200,000 children skipping meals because their family couldn’t financially or physically access sufficient food. The majority of households with children were unable to access food due to lack of food in shops (almost 3 million people) followed economic reasons (almost 1.5 million people) (25). More recent reports from the Food Standards Agency show that concerns about food availability and access across households in the UK peaked during the first lockdown in April. After that, concerns with food availability and access fell steadily until September when it increased again, particularly among households with a child (26). A briefing paper produced on the use of food banks in the UK presented data showing that the Trussell Trust supplied 18% more “three-day emergency food parcels” in 2019-2020 than in the previous year, with one-third of these - more than half a million – being provided to children. Altogether, the available data indicates that households with children are particularly exposed to food insecurity in the context of the COVID-19 pandemic (27). Governments across the UK have opted for different solutions to support school-aged children in accessing healthy food options, including cash transfers, food vouchers and delivery of food parcels, for example. In England, the continued provision of free school meals to eligible children was implemented via the adapted provision of meals by school canteens, delivery of food parcels or issuing of food vouchers. Since June, almost three months after the first lockdown, additional children were also made eligible to free school meals vouchers, and by August 2020, around 94% of state schools in England had registered for the voucher scheme (28). In Northern Ireland, direct payments were made to families of children entitled to free school meals. The “Eat Well, Live well” programme was also extended. Under this programme, anyone aged 4 to 25 years could access a five-day food box containing breakfast and lunch. In Scotland, replacement of school meals was mostly done through the provision of foods to families with only one-third of local authorities using direct cash transfers. In Wales, both vouchers and food delivery options were used. Local authorities were in charge of purchasing gift cards from retailers that operated in their local area. Food deliveries were used as an option for families that were shielding, and in collaboration with charities, aimed to address allergies and special diets, and contain recipe cards (29). Also, in the UK, two Government actions were taken to support food aid charities: the announcement of a £16 million package to support food charities and the opening of a Food Charities Grant Fund (27). Despite increased support provided to food charities which might have enabled food banks to address the need of the emerging demand of families during the pandemic, food parcels provided by food banks do not necessarily meet individual’s nutritional requirements as they are often composed of tinned, long shelf-life products. For instance, one recent study with two food banks in Oxfordshire showed that food parcels distributed were high in sugar and carbohydrate. They also lacked vitamin A and vitamin D compared to the UK guidelines (30). Despite Government efforts, implementation issues might have prohibited many children from getting access to proper foods. In England, schools and parents have reported difficulties in registering for the voucher scheme and obtaining support by telephone or email. Also, many vouchers were not effectively delivered due to wrong email addresses. There was also reported concerns regarding the limited number of grocery stores accepting vouchers and whether families, particularly those in rural areas, could physically access participating stores (28). Also, it has been reported that 45% of pregnant women and/or parents with children aged 0-3 years old were not aware of the Government’s Healthy Start scheme, yet 32% of them reported having a limited budget for food and struggling to afford fruits, vegetables, and milk (27). Also, issues related to the stigma associated with accessing Government benefits have been reported as a contributing factor to food insecurity during the pandemic in the UK (31). Food aid organisations, including food banks, have reported difficulties in supporting the emerging number of families in need, due to a limited number of donations, and facing staff shortages (32). Some of these constraints have been addressed by the Government following pressure from media, non-government organisations and civil society. For example, optimising the free school meals scheme processes and systems, and extending its coverage and duration in England and the announcement of the COVID-19 winter grant scheme focussed on vulnerable households with children. However, many opportunities were still missed, and families are still experiencing different levels of food insecurity. For instance, a recent report from the Food Foundation has shown that although food insecurity has improved since April, about 11% of families with children still experienced moderate to severe food insecurity in August, with 4% of children spending a whole day without eating any food (33,34). Recommendations from the World Food Programme, FAO and UNICEF suggest when cash transfers and food vouchers are used, they should be of similar or enhanced value of the provided school meals, and also be accompanied by nutrition messages and education to better enable beneficiaries to maintain or strengthen diet diversity (35). Another review also conducted by UNICEF on the effectiveness of cash transfers in Africa further recommended that the value of cash transfer should consider inflation, spike in food prices, food availability and also be used as an entry point for other complementary healthy interventions, such as the provision of food supplements and information sessions that could enhance children’s nutritional outcomes (36). When food parcels are the preferred option, parcels' content should provide fresh fruits and vegetables purchased from local food producers where possible. Also, food parcels must cater to children’s nutritional needs, allergies and cultural preferences. Irrespective of options provided, it is important to keep in mind whether parents or caregiver are equipped with the necessary knowledge, skills, time and resources to opt for nutritious meal options instead of relying on processed food that has high energy, low nutrient content. Disseminating information on feeding infants and young children Alongside providing nutritious food for families, advice on selecting and preparing foods to feed children can be crucial. The UK has published the UK Eatwell guide in 2016 following revisions of the previous Eatwell plate. However, these recommendations are only applicable to children aged 2 years and older. Guidance for pregnant women and parents on various aspects of infant’s health, including food and nutrition, is provided under the Start 4 Life information services, which was established in 2012 as a joint initiative by the NHS, Department of Health and Department of Education (37). Also, local councils in the UK have further compiled nutrition guidelines targeting children aged 2 to 5 years (38,39). The Start 4 Life webpage has published specific guidance during the COVID-19 pandemic and UNICEF UK has released a guide for local authorities in terms of infant feeding during the coronavirus crisis in partnership with First Steps Nutrition trust (40). No specific guidance for feeding toddlers and preschoolers during the coronavirus outbreak has been released. Private initiatives led by large food retailers and third sector organisations have been launched with the overall goal to support parents on how to create healthy meals with £15 vouchers provided by the Government (41,42). Providing guidance and support to parents is relevant, considering how the pandemic can disrupt children's food behaviours. Mothers’ increased anxiety and depression can translate in the mothers using more control over their child’s intake and less role modelling of healthy behaviours (43), which can contribute to less healthy eating behaviours in children during the pandemic. Parents have experienced challenges to feed their children during the lockdown, including uncertainties regarding what food to provide (44). A recent survey conducted by Public Health Scotland reported that 5 in 10 children had worse mood and behaviours during the pandemic, with every 3 in 10 also showing worse eating behaviours (45). A recent effort in the UK towards the promotion of healthy eating habits in children included the release of the Child Feeding Guide, which aims to provide credible and freely accessible online support for parents, caregivers and healthcare workers in the form of advice and recommendations. A recent evaluation of the use and impact of this tool showed that it helped mothers to better understand their child’s eating behaviours and it has also influenced the way that mothers fed their children, yet more explorations of the impact of such tool on mothers and families from more diverse socioeconomic and educational background are still needed (46). Also, interventions in the food environments where children live can help promote the healthy choice as the easiest choice. For example, making the healthy choice more visible, affordable and convenient. The recent UK Government Obesity Strategy proposed different actions to support a healthier food environment. This includes actions such as mandatory legislation to end promotions of high fat, sugar and salt options at the point of purchase, and the soon to be released ban on advertisement of high fat, sugar and salt products before 9 pm on TV and online (1). Although we acknowledge the importance of such actions, as we have previously described in our response to the UK Government Obesity Strategy (2), reducing promotions of unhealthy food options can effectively reduce intake of unhealthy food options, particularly among those from a low socioeconomic background (47), but might have an adverse impact on families’ food expenditure if healthy alternatives are not within families’ purchasing power. Promoting a common understanding and aligning efforts between the public and private sector towards healthy food options can optimise outcomes for children, their families and the environment (48). Closing remarks This piece highlighted the importance of supporting parents and caregivers in accessing the resources they need to feed their children in such unprecedented times. Many gaps have been identified, which might have prevented vulnerable children in properly eating nutritious foods required for healthy growth and development. While we understand that the pandemic poses exceptional challenges for individuals, families, Government, non-government and private organisations, those who are hungry cannot wait. As such, timely action is needed. The UK is now in its third lockdown. The right to food places a legal obligation on Governments to protect children from all forms of hunger (49). Many have called for an urgent and long-term fix in current free school meals policy and schemes (50). Multisectoral actions are needed to end children’s hunger in the UK once and for all. Considering that children should not eat just ‘any type of food’ provided in ‘any given way’, actions must also ensure that foods accessed are safe, nutritious and adequate and that feeding practices with accompanying education and enabling environments are supportive of long-term healthy food behaviours. References 1. Department oh Health and Social Care (2020). Tackling obesity: empowering adults and children to live healthier lives. 2. McAuliffe, S., Lima do Vale, M., Macaninch, E., Bradfield, J., Crocombe, D., Kargbo, S., et al. (2020). NNEdPro Global Centre Response to the UK Government Obesity Strategy. 3. Loopstra, R. (2020). Vulnerability to food insecurity since the COVID-19 lockdown 4. NICE. (2014). Maternal and child nutrition. Public health guideline. 5. Movassagh, EZ., Baxter-Jones, ADG., Kontulainen, S., Whiting, SJ., Vatanparast, H.. (2017) Tracking dietary patterns over 20 years from childhood through adolescence into young adulthood: The saskatchewan pediatric bone mineral accrual study. Nutrients. 9(9):1-14. 6. Mikkilä, V., Räsänen, L., Raitakari, OT., Pietinen, P., Viikari, J.. (2005). Consistent dietary patterns identified from childhood to adulthood: The Cardiovascular Risk in Young Finns Study. Br J Nutr. 93(6):923-931. 7. Popkin, BM., Corvalan, C., Grummer-Strawn, LM. (2020). Dynamics of the double burden of malnutrition and the changing nutrition reality. The Lancet. 4;395(10217):65-74. 8. The National Food Strategy. (2020). National Food Strategy: Part One. Recommendations in full. 9. Wells, JC., Sawaya, AL., Wibaek, R., Mwangome, M., Poullas, MS., Yajnik, CS., Demaio, A. (2020). The double burden of malnutrition: aetiological pathways and consequences for health. The Lancet. 395(10217):75-88. 10. UNICEF. (2019). The State Of The World's Children 2019. Children, Food And Nutrition. Growing Well in a Changing World. 11. Scaglioni, S., De Cosmi, V., Ciappolino, V., Parazzini, F., Brambilla, P., & Agostoni, C. (2018). Factors Influencing Children's Eating Behaviours. Nutrients, 10(6), 706. 12. De Cosmi, V., Scaglioni, S., & Agostoni, C. (2017). Early Taste Experiences and Later Food Choices. Nutrients, 9(2), 107. 13. DeCosta, P., Møller, P., Frøst, M. B., & Olsen, A. (2017). Changing children's eating behaviour - A review of experimental research. Appetite, 113, 327–357. 14. Paes, VM., Ong, KK., Lakshman R. (2014). Factors influencing obesogenic dietary intake in young children (0-6 years): Systematic review of qualitative evidence. BMJ Open. 5(9). 15. Yoong, S. L., Grady, A., Seward, K., Finch, M., Wiggers, J., Lecathelinais, C., Wedesweiler, T., & Wolfenden, L. (2019). The Impact of a Childcare Food Service Intervention on Child Dietary Intake in Care: An Exploratory Cluster Randomized Controlled Tria 16. Ward, S., Belanger, M., Donovan, D., Carrier, N. (2015) Childcare educators’ influence on physical activity and eating behaviours of preschool children: A systematic review. Can J DiabetesConference 4th Natl Obes SummitToronto, CanadaConference Publ; 39:S 17. Mikkelsen MV, Husby S, Skov LR, Perez-Cueto FJ. A systematic review of types of healthy eating interventions in preschools. Nutr J. 2014 Jun 6;13:56. 18. Global Nutrition Report (2020). Country Nutrition Profiles: UK of Great Britain and Northern Ireland. 19. UNICEF. (2017). Building the Future Children and the Sustainable Development Goals in Rich Countries 20. Public Health England. (2020). Obesity profile. NCMO prevalece data. 21. Public Health England (2019). National Diet and Nutrition Survey. Years 1 to 9 of the Rolling Programme (2008/2009 to 2017/2017): Time trend and income analysis. 22. Just fair Consortium. (2014). Going Hungry? The Human Right to Food in the UK. 23. Ferrando, T., Dalmeny, K. (2018). A UK right to food law could tackle food poverty and environmental degradation. 24. FAO. (2005). Voluntary Guidelines to support the progressive realization of the right to food in the context of national food security. 25. Food foundation. (2020). Third survey – five weeks into lockdown 26. Food Standards Agency. (2021). COVID-19 Consumer Tracker waves 5 – 8. 27. Tyler, G. (2020). Food banks in UK. Briefing paper. Number 8585. 28. National Audit Office (2020). Investigation into the free school meals voucher scheme. 29. Lambie-Mumford, H., Loopstra, R., Gordon K. (2020). Mapping responses to risk of rising food insecurity during the COVID-19 crisis across the UK. 30. Fallaize, R., Newlove, J., White, A. and Lovegrove, J. A. (2020) Nutritional adequacy and content of food bank parcels in Oxfordshire, UK: a comparative analysis of independent and organisational provision. Journal of Human Nutrition and Diabetics, 33 (4) 31. Connors, C., Malan, L., Canavan, S., Sissoko, F., Carmo, M., Sheppard, C., (2020). The lived experience of food insecurity under COVID-19. 32. Macaninch, E., Martyn, K., Lima do Vale, M. (2020) Exploring the implications of COVID-19 on widening health inequalities and the emergence of nutrition insecurity through the lens of organisations involved with the emergency food response. BMJ Nutrition, 33. Food Foundation. (2020). Demand for free school meals rises sharply as the economic impact of COVID-19 on families bites. 34. Food Foundation (2020). The impact of coronavirus on children’s food. 35. Neitzel, J.,Vargas, M. (2020). Mitigating the effects of the COVID-19 pandemic on food and nutrition of schoolchildren. 36. UNICEF-ESARO/Transfer Project. (2015). Social Cash Transfer and Children’s Outcomes: A Review of Evidence from Africa. 37. NHS. (2020). Start 4 Life. 38. Bath & North East Someret Council. (2013). Feeding Toddlers and Preschool Children 1-5 Year Olds 39. Bradford working in partnership (2013) Bbay matters. Guidelines for good nutrition in Bradford and Airedale Nutrition and 1-5 year olds. 40. UNICEF, First Steps Nutrition Trust and National Infant Feeding Network (2020). Infant feeding during the coronavirus (COVID-19) pandemic. 41. Marks and Spencer. (2020). Lovely lunches for Kids. 42. Cook with Jack. (2020). 43. Haycraft, Emma (2019): Mental health symptoms are related to mothers’ use of controlling and responsive child feeding practices: A replication and extension study. Appetite. 147(1). 44. Clarke, JL & Kipping, R & Chambers, S & Willis, K & Taylor, H & Brophy, R & Hannam, K & Simpson, SA & Langford, R. (2020). Impact of COVID-19 restrictions on pre-school children’s eating, activity and sleep behaviours: a qualitative study. 45. Public Health Scotland. How did COVID-19 affect children in Scotland? Report 1. Key behaviours. 46. Haycraft, E., Witcomb, G.L. and Farrow, C. (2020), The Child Feeding Guide: A digital health intervention for reducing controlling child feeding practices and maternal anxiety over time. Nutr Bull, 45: 474-482. 47. European Comission. (2018). Policies and interventions to improve the nutritional intake and physical activity levels of Europeans. 48. White, M., Aguirre, E,.Finegood, DT., Holmes, C., Sacks, G., Smith, R. (2020). What role should the commercial food system play in promoting health through better diet? Bmj. 368. 49. The Universal Declaration of Human Rights, UN GA Res. 217 (A). 50. Letter to Prime Minister and State `secretary of Education (2020).

NNEdPro Chair's Summary We had an exceedingly successful Summer School (n=46) with a completion rate of ~90% followed by an equally successful International Summit (n>100) with high uptake of the e-poster/video competition as well as the official launch of International Knowledge Application Network Hub in Nutrition 2025 (I-KANN-25). The proceedings of the last two summits were published in BMJ Nutrition, Prevention and Health (NPH) in time for the event and the proceedings as well as individual abstracts of the 2020 Summit will also be published similarly. These events (all held online and remarkably smoothly following investment in digital platforms) were capped off by excellent discussions in our Global Strategy Day (n~40) leading to the finalisation of our fully refreshed 2021-2025 Strategic Plan which has now been released internally in December 2020. Figure 1. The NNEdPro Nine The International Academy of Nutrition Educators (IANE) has experienced growth of about ~2/3rd following the summer events and now has over 130 members connected through the dedicated membership portal. Further, we successfully held 5 webinars and 5 linked journal clubs covering a range of current topics. The IANE awards and fellowship have been announced at the Summit and preparations have taken place to operationalise these features in the New Year. Our flagship journal, BMJ NPH has met its 3-year financial and strategic targets at 2-years and is now indexed in PubMed, Scopus and DOAJ with a promising trajectory for its first impact factor in 2021/22. Development of our Regional Networks reaches completion with the online launch of the 12th network in December 2020 and this provides strategic regional coverage across six continents in a manner that is expected to synergise with I-KANN-25, IANE and our 2021 Summer School and Summit which are now scheduled for May and July, respectively. The UK and Ireland Regional Network is also linked with the Nutrition Implementation Coalition (NNEdPro, Nutritank, Culinary Medicine UK and ERImNN) which held its annual ‘Brighton Showcase’ (n>100) fully online in November 2020 focussing on region-specific case studies. Figure 2. Map of NNEdPro Regional Networks Our flagship projects, the Mobile Teaching Kitchen (MTK) model in India as well as our Nutrition Education Policy for Healthcare Practice (NEPHELP) model in the UK have been written up for peer review to share transferrable elements from both across all networks. Our science communications are now strengthened by two associated strands of activity in digital marketing and advocacy for impact and we have placed greater resource as well as focus in this domain given the digital transformation of 2020. Figure 3. Strategy for Digital Marketing, Science Communications, and Advocacy for Impact The Nutrition and COVID19 Taskforce has gone from strength to strength working in close partnership with BMJ NPH and this has led to over 20 key outputs adding pandemic-specific insights as well as dissemination pieces including a webinar in December 2020 along with colleagues from ESPEN and DSM reaching ~27K recipients. The work of the Taskforce has led to considerable impact including policy influence within the region. Figure 4. Nutrition & COVID-19 Infographic The Nutrition Research and Innovation Consortium (NRIC) incorporates multiple substantively funded research projects all of which are progressing steadily including those with the Swiss Re Institute in Data Science (Causal Inference Analyses in Cardiometabolic Risk, Health Risk Transition in India and Emerging Risks with COVID19), University of Cambridge (Global Challenges in India and South East Asia), Ulster University (Biomedical/Vascular Studies and Educational Innovation) and Imperial College London (Ethnic Inclusivity in the South London Cohort). In all these areas significant further funding has now been applied for. Additionally, further funding has been applied for in relation to regional networks, I-KANN-25 and the work of the COVID19 Taskforce. Figure 5. iKANN Infographic As a global think-tank, our wider membership by invitation to one or more networks stands between 400-500. Within this, the Virtual Core (n~40 comprising about half SLA-holders, half volunteers and multiple external contractors also providing services over and above the Virtual Core) has been galvanised through listening exercises and regular engagement including a recent survey with high returns as well as a series of individual reviews. As a result, in December 2020, the Virtual Core appears to be on board for 2021 activities which have now been planned and timelines as well as roles and responsibilities have been agreed in principle. This includes the addition of new internal leadership positions: Non-Exec Associate Director (International Knowledge Exchange, Scientific & Strategic Development), Assistant Director (Digital Operations, Admin, Finance & Enterprise) and Assistant Director (Nutrition in Medicine, Flagship Projects & Organisational Development) as well as new leads for the Summer School and Summit for 2021. All successful applicants to these roles are from within the existing Operations and Strategy Team and are already familiar with NNEdPro. Over the 2020 calendar year we have been fortunate to have maintained a favourable ratio of income and expenditure along with a limited amount of cost savings pertaining mainly to travel. The extraordinary commitment of our members during this incredibly challenging year was therefore deserving of reward and recognition. We therefore provided internal recognition awards to 46 different people, with a total of 58 awards including career development training awards, Amazon Vouchers for Faculty & Mentors Panel as well as Summer School Faculty and achievement awards announced on the Global Strategy Day. List of Award Recipients Outstanding Contributions to Strategic Operations and Key Projects Matheus Abrantes, Breanna Lepre APD, Sucheta Mitra, Dr. Marjorie Lima Do Vale RD Excellence in Education, Training & Science Communications James Bradfield RD, Shane McAuliffe RD International Impact Dr. Luke Buckner, Jorgen Johnsen, Helena Trigueiro RD GIP Volunteer Awards: Rising Star Dr. Dominic Crocombe, Melissa Adamski APD GIP Volunteer Awards: Sustained Excellence Dr. Kathy Martyn RN RNutr, Professor Eleanor Beck APD, Emeritus Professor Caryl Nowson Extraordinary Achievement Awards (2011-2020) Dr. Celia Laur All in all, this has been a surprisingly productive and successful year despite the pandemic and several systems and processes as well as projects and outputs have been greatly strengthened through considerable innovation. With secured funding for the coming calendar year we are now planning ahead for very promising new horizons in 2021 as well as an array of future possibilities in line with our 2021-2025 Strategic Plan. By Professor Sumantra Ray Founding Chair and Executive Director NNEdPro Global Center for Nutrition and Health St. John's Innovation Center Crowley Road, Cambridge, CB4 0WS, UK Edited by Shane McAuliffe Science Communications Lead NNEdPro Global Center for Nutrition and Health St. John's Innovation Center Crowley Road, Cambridge, CB4 0WS, UK Kai Sento Kargbo Assistant Project & Communications Officer NNEdPro Global Center for Nutrition and Health St. John's Innovation Center Crowley Road, Cambridge, CB4 0WS, UK

Looking Back on the Pandemic Year What an indescribably challenging year this has been, With a vicious pandemic like the world has never seen, For many years before this point in history, The year 2020 was shrouded in mystery, Would it be the year that humankind gained 2020 vision? Or the year that the world marks another major space mission? One wondered whether we would have attained global peace by this time, With artificial intelligence running the world at its very prime, But instead, this year was sobering for us all. As we realise that we are still really very small, In the face of nature with all its force and invisible fury, And as we attempt to live through the COVID story, Paying tribute to those who have lost their lives this year, As well as those who fight at the frontline without fear, We know that advanced science is doing its very best, To prevent and treat the disease that has put us all to test, But aside from this we have also seen evolution, As society has gone through a digital revolution, And human beings have shown overflowing compassion and care, Even as the odds have seemed to smirk and stare, And we are minded to take much better care of our mother earth, To preserve the planet for future generations to take birth, And at a time that we are all physically apart from one another, We have never been so connected or united together, As we battle together all on the same side, With faith that the pandemic will soon subside, So perhaps, we have attained some 2020 vision after all said and done, Reflecting on the year gone by and lighting candles of hope for the year that is now to come, 2020 we see you and hear you for we have humbly heeded your call, And we ask 2021 to bring new and healthy horizons, for absolutely one and all! By Professor Sumantra Ray Founding Chair and Executive Director NNEdPro Global Center for Nutrition and Health St. John's Innovation Center Crowley Road, Cambridge, CB4 0WS, UK