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Key Contributors: Shane McAuliffe, Marjorie Lima do Vale, Elaine Macaninch, James Bradfield, Dominic Crocombe, Sento Kargbo, Daniele Del Rio, Emily Fallon, Kathy Martyn, Martin Kohlmeier, Eleanor Beck, Suzana Almoosawi, Sumantra Ray Acknowledgements: NNEdPro Virtual Core and Global Innovation Panel; Nutrition and COVID19 Taskforce Introduction In late July, following considerable interest and reporting on the relationship between obesity and COVID-19, the UK Government released a policy paper: ‘Tackling obesity: empowering adults and children to live healthier lives’ We commend and celebrate with optimism any commitment to encourage positive lifestyle change and improve population health. However, along with other members of the nutrition and health community, we fear that this response may be overly focused on a limited view of overweight and obesity, considering the enormous complexity of the condition, its determinants, and co-existing conditions. As a group of nutrition researchers, educators and clinicians, we recognise the complexity which spans diet, nutrition and health interfacing with diverse domains such as the social sciences, economics and politics on one hand as well as genetics and biomedical sciences on the other. We also recognise the complexities associated with obesity and weight loss. Therefore, we advocate for the appreciation and adoption of a wider, complete understanding of the science behind obesity and the strategies which are needed to address it. In this blog post, we will discuss four points of the proposed obesity strategy and provide recommendations for a more comprehensive and impactful response. As an organization whose mission is to improve knowledge, skills and capacity in Nutrition and Health, we will also continue to educate medical students, doctors, and the nutrition leaders of tomorrow so that the maximum number of patients and members of the public can learn from this collective, organisational knowledge. First, improve the focus and messaging through valuing lived experiences and co-participation In this policy paper, much of the narrative appears to suggest that the development and maintenance of overweight and obesity is often due to poor decision-making and that stronger willpower and individual commitment to change might be the key to success. While these factors are not without merit, our knowledge of the complexity of overweight and obesity and its root causes are now much further than the seasoned narrative of “eat less, move more” (Foresight-Obesity System Map, 2020). Nevertheless, it seems as though obesity is still widely considered as a self-inflicted condition, which is often reflected in the public’s perception, wider messaging and consequently, public policies employed by both health and social systems (CMAJ, 2020). Much of the actions proposed by the UK Obesity Strategy, for instance, are focused on individual action, such as engagement in app-based weight management interventions, changes in (un)healthy food labels, advertisement and promotion. Through this lens, we risk stigmatising and increasing the psychological difficulty of those individuals affected by overweight and obesity, which is counterproductive, given that research tells us weight bias and stigma contribute to morbidity and mortality independent of weight or Body Mass Index (BMI) (CMAJ, 2020). Placing responsibilities on individuals for their own health and well-being might also contribute to mental distress already caused by the COVID-19 pandemic. Tackling excess weight and related metabolic health outcomes should not be disentangled from the context of the pandemic and its subsequent burden on individual’s socioeconomic and health domains. “We owe it to the NHS to move towards a healthier weight. Obesity puts pressure on our health service. It is estimated that overweight and obesity related conditions across the UK are costing the NHS £6.1 billion each year” This quote further amplifies the idea that as a public, it is our duty to comply to help relieve the pressure that the COVID-19 pandemic has brought on the NHS. While patients are often encouraged to only avail of services when required, for instance, avoiding unnecessary A&E visits, they should not be stigmatised for making use of public services that are crucial to their health and well-being. Further, this adds to the emphasis on personal responsibility to lose weight, while suggesting that not doing so will increase the burden on our already stretched healthcare system. It would appear that this designation of responsibility is both unfounded and unfair, when considering the structural factors driving food choices and consumption, and along with overweight and obesity and the multitude of other factors that have put the NHS under such strain during this pandemic such as cut-backs and the recognised staff-shortages nationally (BMA, 2020). Recommendations Whereas negative messaging can be stigmatising and hurtful, meaning those on the receiving end may ultimately be less likely to engage. On the other hand, use of inclusive, positive and supportive language is understood to be an important facet of effective patient care. Effective messaging, to help inspire change, should be inclusive, collaborative and non-judgemental (NHS England – Language Matters, 2018). Beyond avoiding messages that reinforce victim-blaming, valuing individual’s lived experiences during the pandemic and promoting co-participation in the development of messages used in public national campaigns could be one important strategy to be used. Second, understand, monitor and address the drivers of food choices and nutritional status “Obesity prevalence is highest amongst the most deprived groups in society” The mortality rates from COVID-19 in the most deprived areas of the UK have been more than double that of the least deprived areas (Deaths involving COVID-19 by local area and socioeconomic deprivation - Office for National Statistics, 2020). ICNARC data reflects that a larger proportion of patients admitted to intensive care units (ICU) with COVID-19 were from the most deprived quintile of areas (25.0%) versus the least deprived (14.7%) (ICNARC, 2020). COVID-19 is seen to be more prevalent among ethnic minorities and highly deprived communities, mirroring the national obesity trends and figures. This could be partially attributable to workers from Black, Asian and minority ethnic communities being more likely to live in densely populated urban areas and be disproportionately represented in high-risk, key worker jobs. “it’s hard to eat healthily, especially if we are busy or tired or stressed” “Food isn’t the answer to people needing food banks” (Trussell Trust). Research has shown that households referred to food banks are on average, left with just £50 per week after housing costs, which includes rent, electricity and other utility bills. Financial strain is likely to increase for more socioeconomically deprived households as we emerge from lockdown, with furlough schemes and additional social support subsiding. With additional pressure from housing and other bills, food often becomes less of a priority for struggling families, many of whom have lost jobs and livelihoods. Lack of time, income and resources are often far bigger contributors to poor health choices than lack of knowledge. Unless we equip individuals with the means to implement advice, provision of this information is less likely to be successful. While reducing volume and promotion of foods high in fat, sugar and sodium might be effective in reducing consumers purchase in some contexts, this might not be the case in scenarios where resources allocated to food purchase or food preparation are already scarce. For instance, a report published in 2018 showed that the cost of the minimum essential food basket can range to one-fourth to almost a half of take-home pay among those dependent solely on state benefits in Northern Ireland (Food Standards Agency, 2018). Moreover, processed, convenience foods may seem more expensive than fresh produce at face value, but when measured as cost per calorie they provide high value for money. In a state of food insecurity, many are likely to make decisions based on these factors as well as how long the food will last and the resources required to prepare and store foods. Consequently, the choice of food by individuals in this position is often calorie dense, high in fat, salt, and sugar but remarkably nutrient poor. While these food choices most likely contribute to the development of overweight and obesity, they may also potentially contribute to underlying micronutrient deficiencies, which we know to be prevalent in the UK, particularly among young adults (Derbyshire, 2018). The Trussell Trust reports a soaring 81% increase for emergency food parcels from food banks in its network during the last two weeks of March 2020, compared to the same period in 2019 (Trussell Trust, 2020). Food parcel provision is generally based around the foods described above which are lower in cost and non-perishable as opposed to fresher options. Food bank parcels have been shown to exceed energy requirements and provide disproportionately high sugar and carbohydrate and inadequate vitamin A and D compared to the UK guidelines (Fallaize et al, 2020). A common theme throughout the obesity strategy is that of “Giving everyone a fair deal”. The reality, however, is that structural inequality renders some groups more vulnerable than others, meaning the consequences of the pandemic will be felt unevenly across our society – which is also reflected in our food system. Unless we tackle the root cause of social inequality and inequity, there will be many individuals who are fighting an uphill battle, due to poorer access to quality food or lack thereof, and as a result, poorer health (Health Foundation, 2020). It is crucial to address reports of increasing rates of food poverty during the pandemic response if the government’s strategy to improve the overall health of vulnerable populations is to be effective (Baranuik, 2020). Recommendations Coordinated efforts to support food assistance programmes in providing emergency food parcels and baskets along with the involvement of nutrition professionals will be a crucial factor in ensuring that the nutritional quality of food provision is maximised, particularly when resources are scarce. This has already been demonstrated during the pandemic, through the involvement of specialist dietitians in the formation of an Oncology tailored food bank. This repurposing of food destined for the Macmillan Cafe enabled patients to access foods that were appropriate for their health conditions (Macaninch et al., 2020). In fact, tailored community nutrition support programmes have been gaining significant attention in recent times, with a multitude of examples in the United States of their effectiveness to date (Downer et al., 2020). While improving the quality of food parcels delivered to those most in need will be an important step, it will likely be insufficient. We must consider ways in which to facilitate those living with limited means to make the most of what is available to them. First, in order to maximize success and effect, a combination of food taxes on unhealthy food options in tandem with subsidies for healthy alternatives might be preferable (Niebylski, Redburn, Duhaney & Campbell, 2015). Implementing monitoring and surveillance systems are required to monitor impact for adverse effects. Data must be collected from vulnerable groups of society, who might be under-represented in convenience sampling strategies. Second, food literacy is an important piece of this puzzle. Providing cooking skills to those with limited resources, including ways to minimise waste and how to manage food purchases on a budget will add value (Garcia et al., 2017). Further, we must also provide individuals with the opportunity to implement this knowledge - something as basic as provision of cooking equipment alongside food parcels and nutrition education, in a way that is both practical and accessible. Such food skills programmes can be a highly effective means of improving self-efficacy, psychological capability, and healthy behaviours (Garcia et al., 2017). Further steps to improve abilities related to financial management, tailored to help those on limited income to live within their means, will go a long way in addressing issues of food security (Trussell Trust – Eat Well Spend Less Programme). Third, promote healthy eating habits from early years “Children in the most deprived parts of the country are more than twice as likely to be obese as their peers living in the richest areas” National Childhood Measurement Programme data shows increased widening of childhood obesity prevalence between higher and lower socioeconomic groups. These patterns reflect the inequalities seen throughout the life course which need to be addressed early in life as part of an effective obesity prevention and management strategy. Rising prices and reduced access to fresh food exacerbates the difficulties some families already face in putting a healthy meal on the table. This poverty loop exacerbates nutrition insecurity where all 3 forms of poor nutrition co-exist throughout the life course. For instance, the diet of pregnant women directly affects their babies growth, and in turn influence genetic development. Poorer foundations have been shown to increase the risk of metabolic disorders (obesity, cardiovascular, type 2 diabetes) later in life, with evidence that these changes can have an influence across generations (Edwards, 2017). This means that there is an opportunity to influence genetic potential in early stages of life, in order to provide the best chance of healthy growth and development. Recommendations It may not be enough to simply focus on those who are already living with obesity. We must address the root cause of the problem to ensure fair and equitable access to healthy food for all, from the earliest stages of life. This can be achieved through reinstating initiatives such as the healthy start programme and providing pre-natal vitamins for all pregnant women. Early years nutrition interventions are also possible and potentially effective, which includes educating nurses, midwives, and health workers. Furthermore, the food environment can be influenced effectively in the early learning sector and schools. More investment in early learning and school food environments is a good starting point, which has been highlighted more than ever during the COVID-19 pandemic (Baraniuk, 2020). Alongside this, the role of nutrition and food literacy cannot be overlooked. Health professionals are a part of the picture in improving nutrition literacy among early learning providers, school teachers and school-going children. In Japan, for example, there are a multitude of dietitians, employed at schools to teach children. A nudge towards nutrition as part of school curriculum would be helpful. Advocating for a better education on food science and nutrition from early learning sectors might represent a big leap towards increased awareness from the beginning of life, even before a person starts making these decisions. Early learning sector and schools provide a perfect platform for health promotion - a ready-made opportunity to instil healthy eating habits as well as the opportunity for engagement with both peers and parents (Oostindjer et al., 2016). Fourth, address the Complexity of Obesity – Nutrition and Health “These risks increase progressively as an individual’s body mass index (BMI) increases” “You can start by weighing and measuring yourself and checking your BMI through the NHS BMI tool. If you are overweight, you can start your weight loss journey with the free NHS 12-week weight loss plan app” We fear that the focus on weight as the primary marker of health is erroneous and potentially stigmatising. While BMI is a useful surveillance mechanism for tracking population health, we must acknowledge its flaws as a marker of health on an individual level. BMI alone is not an accurate measure of adiposity-related complications, especially when we consider its lack of generalisability across cultures and ethnicities, through underestimating adiposity in South Asian populations and overestimating it in Black Caribbean populations. “working to expand weight management services available through the NHS, so more people get the support they need to lose weight “We need to make sure that across the nation we don’t take in more calories than we need “That is why we want to make sure that our labelling of products in store and in cafes and coffee shops helps us to make healthier choices” “It is fundamental that we all have access to the information we need to support a healthier weight, and this starts with knowing how calorific our food is” In a similar vein, we must acknowledge the complexity of foods beyond a single metric or marker of quality. Calories, like BMI, provide a very crude marker of the ‘healthiness’ of food. The focus on calories as the marker of a healthy diet runs the risk of being misinterpreted and oversimplified. We are delighted to see such a positive commitment through increasing the funding for NHS weight management services, who do such amazing work for their patients. Although, it seems that the role of dietitians and other nutrition professionals has not been acknowledged in the policy paper, which is concerning. The provision of nutrition & dietetic professionals has been chronically inadequate within the health system at primary and secondary care, as well as public health levels. Needless to say, developing successful effective initiatives requires a diverse, multi-disciplinary workforce. We must ensure funding & training is adequate for those healthcare professionals best equipped to deliver these services most effectively. It will be important to ensure that the complexities of nutrition and health science are understood and acknowledged, to reduce the risk of judgements being made on oversimplified or misguided perceptions of the relationship of food and weight with health. In addition to that, evidence on the effectiveness of app-based interventions to improve diet and physical activity while promoting weight loss must be interpreted with caution. From an implementation perspective, there are several barriers related to access to and literacy in using such technologies that could limit their reach, use and impact. In addition to that, groups included in trials of app-based interventions fail to represent groups with socio-economic restrictions (Ghelani et al., 2020), thus widening inequality. Recommendations Human health is complex and multi-dimensional, meaning that focussing on a single metric runs the risk of oversimplifying this complexity and undervaluing the importance of healthy behaviours, even if they are not directly associated with weight. Better language could and should be chosen to encourage positive lifestyle habits, rather than a narrow focus on weight or BMI on an individual level, especially when we consider how difficult long-term weight loss maintenance is to achieve. Individuals should be encouraged to adopt healthy behaviours that are not captured by BMI and therefore important regardless of this measurement, for example; eating 5 portions of fruit and vegetables per day, adequate hydration, the eat well guide, aiming for 30 mins physical activity, resistance training and adequate sleep - to name but a few. For example, those following a Mediterranean diet high in fruit, vegetables, fibre, fish, nuts and olive oil have been shown to reduce their risk of heart disease and type 2 diabetes by a third - without losing weight (Salas-Salvado et al., 2010). This suggests the potential for effectiveness with nutrition-based goals, where success is measured by additional factors beyond just weight, such as blood pressure, lipids, and mental health. In terms of information and food labelling focused on calories, the public could be better served through education on food-based guidelines and an emphasis on healthy dietary patterns and lifestyle behaviours, in a way that is practical, measurable, and easily understood. The source of calories should be a more important focus than the calories themselves. Perhaps further development of the traffic light system could be used to assess the nutritional quality of foods, beyond just a focus on calories. We might also focus on health-promoting aspects of individual foods. Additional markers of quality might include a tick for foods high in whole grains, or highlighting a good source of certain vitamins or omega-3. The most effective initiatives should be engaging but not overwhelming or complex - simple messaging is key. Conclusion All in all, an integrated systems approach ought to be developed with a multipronged intervention strategy equipped with data systems for surveillance and monitoring of targets at population level using routine data, as well as at individual level, from health-related encounters. On one hand we need to target food production, food supply and food environments as well as food marketing to firstly improve the availability of as well as accessibility to more nutrient-rich but less energy-dense foods. These combined with appropriate food education for consumers would enable more consistently healthy food choices. A systemic shift in such food choices towards dietary patterns with proven impact on nutritional status and health outcomes can improve health outcomes particularly. When considering an at-risk obese/overweight population with concurrent micronutrient deficiencies can be an effective form of primary disease prevention or indeed secondary prevention of disease complications and adverse health outcomes particularly in the wake of the COVID19 pandemic. List of References Baraniuk, C. (2020). Fears grow of nutritional crisis in lockdown UK. BMJ, 370; m3193. doi: 10.1136/bmj.m3193 British Medical Association (2020). Pressure Points in the NHS. https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressure-points-in-the-nhs CMAJ 2020 August 4;192:E875-91. doi: 10.1503/cmaj.191707 Deaths involving COVID-19 by local area and socioeconomic deprivation - Office for National Statistics. (2020). Retrieved 31 August 2020, from https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsinvolvingcovid19bylocalareasanddeprivation/deathsoccurringbetween1marchand31may2020 Derbeyshire, E (2020). Micronutrient Intakes of British Adults Across Mid-Life: A Secondary Analysis of the UK National Diet and Nutrition Survey. doi: 10.3389/fnut.2018.00055 Downer S., Berkowitz, S.A., Harlan, T.S., Olstad, D.L., and Mozaffarian, D. Food is medicine: actions to integrate food and nutrition into healthcare, BMJ 2020; 369:M2482. Edwards M. (2017) The Barker Hypothesis. In: Preedy V., Patel V. (eds) Handbook of Famine, Starvation, and Nutrient Deprivation. Springer, Cham. https://doi.org/10.1007/978-3-319-40007-5_71-1 Fallaize, R., Newlove, J., White, A. & Lovegrove, J.A. (2020) Nutritional adequacy and content of food bank parcels in Oxfordshire, UK: a comparative analysis of independent and organisational provision. J Hum Nutr Diet. 33, 477– 486. https://doi.org/10.1111/jhn.12740 Food Standard Agency (2018). The cost of a healthy food basket in Northern Ireland in 2018. Retrieved from https://www.food.gov.uk/research/research-projects/the-cost-of-a-healthy-food-basket-in-northern-ireland-in-2018 Foresight – Obesity System Map. (2020). Retrieved 31 August 2020, from https://debategraph.org/Stream.aspx?nid=365986&vt=outline&dc=all Garcia, A., Reardon, R., Hammond, E., Parrett, A., & Gebbie-Diben, A. (2017). Evaluation of the “Eat Better Feel Better” Cooking Programme to Tackle Barriers to Healthy Eating. International Journal Of Environmental Research And Public Health, 14(4), 380. doi: 10.3390/ijerph14040380 ICNARC report on COVID-19 in critical care (2020). Retrieved from https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports Language Matters: Language and diabetes. (2018). Retrieved 31 August 2020, from https://www.england.nhs.uk/publication/language-matters-language-and-diabetes/ Niebylski, M., Redburn, K., Duhaney, T., & Campbell, N. (2015). Healthy food subsidies and unhealthy food taxation: A systematic review of the evidence. Nutrition, 31(6), 787-795. doi: 10.1016/j.nut.2014.12.010 Oostindjer, M., Aschemann-Witzel, J., Wang, Q., Skuland, S., Egelandsdal, B., & Amdam, G. et al. (2016). Are school meals a viable and sustainable tool to improve the healthiness and sustainability of children´s diet and food consumption? A cross-national comparative perspective. Critical Reviews In Food Rutter H, Savona N, Glonti K, et al. The need for a complex systems model of evidence for public health. Lancet (London, England) 2017; 390: 2602–4. Salas-Salvado, J., Bullo, M., Babio, N., Martinez-Gonzalez, M., Ibarrola-Jurado, N., & Basora, J. et al. (2010). Reduction in the Incidence of Type 2 Diabetes With the Mediterranean Diet: Results of the PREDIMED-Reus nutrition intervention randomized trial. Diabetes Care, 34(1), 14-19. doi: 10.2337/dc10-1288 The Health Foundation (2020). Will COVID-19 be a watershed moment for health inequalities? Retrieved from https://www.health.org.uk/publications/long-reads/will-covid-19-be-a-watershed-moment-for-health-inequalities Trussell Trust. Eat Well Spend Less. https://www.eatwellspendless.org/ Trussell Trust (2020). Food banks report record spike in need as coalition of anti-poverty charities call for strong lifeline to be thrown to anyone who needs it. Retrieved from: https://www.trusselltrust.org/2020/05/01/coalition-call/

August has been a month juxtaposing the final embers of the summer holidays with the exponential efforts in preparing for our very first ever FULLY VIRTUAL online Summer School and International Summit along with our Global Strategy Day this September! These events are expected to digitally bring together over a hundred potential changemakers at a moment when the pandemic has highlighted the need for nutrition to be brought centre stage more than ever before. August also marked the end of the first six months of learning around Nutrition and COVID-19 brought together by our dedicated Taskforce as we shared our findings with the world in 2.5 hours of live content. This is however just a beginning as we still have much to learn over the next 6 months whilst everyone prepares for secondary impacts of the pandemic as we cross the calendar year. I would also like to welcome a number of new members who have joined this month and thank those who are moving on as our Think tank continues to move forward as a diverse global community. This month we have also had regional network steering meetings in Australia and New Zealand, Brazil, Mexico, Switzerland and the USA whilst planning for India, Italy, and UK and Ireland over the coming month. Once again, in this brave new digital world it has become possible for us to take deep dives into multiple continents without leaving our homes or incurring added carbon footprint, certainly something to consider retaining well into the future! Finally, as we head into the action-packed month of September and come out at the other end with added insights as well as a refreshed organisational strategy, as ever I would like to express huge thanks especially to members of our Virtual Core and particularly our Operations and Strategy Team who have been akin to a galaxy of stars in preparing the stage as we gear up to say ‘lights, camera, and action’ this September for what promises to be another bumper edition of our flagship events… hope to see you very soon (online)!

It is with deep concern that we follow the recent events in the United States – the murder of George Floyd, the protests that occurred in response to it, and the manner in which the crisis has been addressed by certain holders of the highest public offices – all of these have sent shockwaves across a world already reeling under the burden of an already unprecedented pandemic. We express our deepest condolences to Mr Floyd’s family, and we share the public outrage regarding the discrimination and brutality that led to his death as well as the wider debate and protest about policing culture. We also stand behind the undeniable right of citizens to engage in peaceful protest as we fully support their demands for justice and overall societal change that will ensure that cases like this are eradicated. As a public health organisation that researches and promotes one of the most fundamental human rights - the right to food and adequate nutrition - we are well aware of the issues of structural racism and discrimination, as well as the fragile situation of minority groups in many corners of the world, including in developed and industrialised nations. This is not only an infringement on basic human rights and dignity but also erodes the democratic values that ought to form the very fabric of our societies. Black Lives Matter! We will continue to celebrate diversity within our core values as progress in science and health can only be achieved when inequity is eliminated.  We hope that in this turbulent time, while we mourn the tragic loss of life, we also grow with wisdom and strength to push for meaningful societal change ensuring equal rights and opportunities for every human being regardless of the groups to which they belong. Given our extensive regional networks in both developing and developed countries, we will continue to demonstrate our commitment to the principles of social justice by prioritising work with marginalised communities and minority groups, particularly to address food and health-related insecurity in pursuit of the Sustainable Development Goals. Through our work, we will seek to uphold the equal value of all lives and envision a world free from health inequalities owing to discrimination in all its forms. Message from Nikitah Rajput Ray, NNEdPro Junior Ambassador: H Carter, C Laur, S Mitra, M Rajput-Ray, S Ray, B Stankovski, H Trigueiro NNEdPro Equality and Diversity Response Team

It is mid-2020 already! Whilst the world has changed unimaginably in the past six months, the one thing that never changes is the ever marching passage of time. Half of the year has gone by and swept us off our course completely with the combined impacts of the pandemic, increasing climate change effects in the background and a peak into the visibility of struggles against minority oppression in the foreground. Whilst we didn’t anticipate facing such challenges this year, we probably also could not have predicted just how many opportunities there would be to advance our learning and insights in just a few months! On the technical front by being at the helm of our Nutrition and COVID-19 Taskforce, comprising some amazing colleagues from NNEdPro and BMJ Nutrition, I have certainly had to challenge previously held knowledge in the quest for new insights into tackling the pandemic from a food and nutrition perspective. Over 15 weeks there has been an average of an output each week marshalled by this Taskforce to add to national and global efforts including providing advice to guideline agencies. However, what this has taught us is that knowledge can never stand still on its laurels and with the greatest humility we need open mindedness, being ready to potentially discard the truths of yesteryears to embrace novel ways forward in the pursuit of science to serve society! Alongside accruing new knowledge we have also learned new ways of coping with a global crisis and how despite being apart we can be more connected than ever before. This month our colleagues from across the Mediterranean, as well as those under down, will provide a view on how Australia and New Zealand have been combatting COVID-19 from locking down on social contact to unlocking online learning! At NNEdPro we are also delighted with the success to date of our online learning as we enter the third month of conducting linked webinars and online journal clubs for the members of the International Academy of Nutrition Educators as well as external subscribers. This has geared us up to deliver over 60 hours of world class educational content in the form of our Online Summer School and Virtual International Summit this September – I hope to e-meet many of you there – and in the meantime please do spread the word! Another piece of learning in recent weeks has been the insights arising from the Black Lives Matter movement and its corollaries the world over. On one hand, as an organisation we strongly support the abolition of oppression in all its forms. However, on the other hand as an individual, it has made me even more cognisant of the walls of structural discrimination that we have almost come to accept as ‘normal’ due to its pervasive nature and wide prevalence. However, just as the incidence and prevalence of COVID-19 is a phenomenon that we are joining forces to tackle, the momentum from the BLM movement provides us with a similar opportunity to learn, evolve and stand united against the hidden pandemic of inequalities. With this learning, I feel both privileged and humbled as I look back on the past 20 years of my own career and when I first began the journey of attempting to unite the worlds of Nutrition, Public Health and Medicine. Whilst the destination is still a work in progress, the path has been the greatest teacher. Together with colleagues and friends, I have had the opportunity to navigate barriers on rocky and uneven terrain at times against the headwinds of scientific or social ignorance. But this has never dampened our velocity or tenacity as NNEdPro has been spurred on at every stage by the much stronger tailwinds that come from the energy, enthusiasm and collective brilliance of the members at our very core. Aside from the technical aspects of the work we do I realise we also have a responsibility to share our learning around the experience of how best to tackle inequity and turn challenges into opportunities. And in doing so we can hope to be true to our strapline of advancing and implementing nutrition (as well as generic) knowledge to improve health, wellbeing and society! Professor Sumantra Ray RNutr Founding Chair and Executive Director

This blog offers insights from members of our Italy Regional Network, who provide an account of some of their personal and professional experiences during the COVID-19 pandemic. Edited by S McAuliffe & M McGirr Four months ago, the first time I heard about the “new type of coronavirus”, I was thinking “ok, it’s just a flu! Everything is so overstated. The virus is here but far from us, it’s dangerous but not if you are a normal weight, healthy adult. Life goes on and in a few weeks we’ll be back to normal”. Since then, my life has totally changed. Millions of people have been infected or died and this time people were our neighbours, our relatives and friends. The lockdown has frozen our life and we have understood that this frightening situation would have become our new normality. I was coming back to work in January after 8 months of maternity leave and, just some weeks after, I was at home again trying to manage my personal and professional life, more time suspended and things at a standstill. Without time limits, 24/7 I was doing my best to be a good mum, wife and also be an accurate and timely worker. I’m spending a lot of time with my baby, the best of these months of lockdown, but I’ve never stopped working. A lot of data to be processed, papers to be written, online meetings, and projects ongoing. We have many irons in the fire and we can keep working hard without being affected for now. The stay-at-home claim, the rainbow drawings outside the houses, social distancing, masks, friends and relatives on the phone screen will be the memories of this period of my life. I feel very blessed, we are all safe. We have also learned a few things that I hope we will remember in the future. [Alice Rosi] Significantly. Both work and personal activities have changed quite a lot. Research activities have suffered too and most of the ongoing projects have been redefined, postponed, or delayed. This is particularly relevant for a few human studies that have been completely blocked. The good point is that we are processing data and producing deliverables at a fast pace, giving value to some projects that were somehow blocked. Priorities changed, but hard work never stopped. Teaching activities have turned into less reciprocal exchanges with students. We had to adapt teaching activities and exams to suit the new situation. Definitely not an easy task, although I have to say that all involved (students, teachers, and university services) did a great job to make this situation work and get things done. I'm quite happy with the commitment demonstrated by the students, despite the difficulties they may have with working remotely. Working from home has been a challenge. An agreement between family and job responsibilities, trying to make the most of this situation and enjoy both things: discovering new angles of family life and improving my capabilities to work efficiently. I think it has been a very productive period in every way. The perfect storm to review some aspects and grow both as a person and as a professional. [Pedro Mena] It was Wednesday, the 4th of March, the last day I spent in a laboratory, in my usual work space. On that morning, some technicians suddenly switched the useless laboratory in front of our office into a daily operative centre for Covid-19 swab extraction. In the afternoon, I greeted my colleagues, as always, and the day after, we all unexpectedly started a new working reality: smart working. I think our work could partially carried out in every place more generally, and the pandemic has demonstrated this. We had megabytes of data to elaborate, and megabytes of data already elaborated, but not yet critically analysed and scientifically written. Hence, this unreal situation gave us the opportunity to slow down the experimental part of our work and to clean up some old notebook folders, publishing interesting scientific papers. We learned all possible platforms for online meetings, we recorded university lessons, we undertook exams… Finally, I think we made the situation work and “nutrition science has gone on”. Today is the 4th of June and I really miss my laboratory and my normality. During these 3 months, I have merged work with family, with a 1 year old and a 3 year old, drastically modifying my job schedule. I have worked as a researcher early in the morning, late in the night and when the children slept. The rest of the day I was a distracted mom and wife, without any break, without any time, without any routine, with my laptop always switched on up above the kitchen table when I was preparing the lunch or the dinner. Or in the garden, where with one hand I pushed the kids on the swing and with the other I answered e-mails. I love my family and I love my work, and the pandemic taught me the need to separate these two realities to give my best to both my family and to science. [Letizia Bresciani] In December 2019 I was appointed as Assistant Professor at the University of Teramo and so I moved from my place in Parma – where I was Post-Doc – to Teramo, a totally new town for me. For this reason I only spent few months enjoying my new position before the COVID-19 lockdown. At the beginning of this period I felt alone and a bit sad for this restriction, at a time just when I was starting my new life. However I took advantage being closed home by improving my relationship with friends and colleagues. Particularly with the latter – most of them were in the same situation – we enjoyed having on-line meetings and thinking about new projects and ideas which could have been done in the lockdown period and also after COVID-19 ending. Finally I had the chance to meet also some faculty colleagues on line in order to introduce myself and share our skills. [Donato Angelino] When the lockdown started, I had only worked at my new workplace in the University of Milan for a couple of months. So at the very beginning it was quite hard to understand what to do and how to re-organize my smart-work at home. This was particularly important, but difficult also from a personal and emotional point of view, considering that Lombardy was hit harder than Italy's other regions. “Luckily” I had some backlog and during these months I had the opportunity to catch up, by writing several manuscripts as well as by implementing and planning some of the projects that have been kept in storage for a long period in the near future. Moreover, I had my first course as Assistant Professor, and doing the course by Microsoft Teams instead of in a real room was a real challenge - quite stressful to be honest because of my usual “fear of failure”. One of the “positive” points of this very tough time was that I could attend several meetings and seminars. For all these things technology was very useful and gave me the possibility to bridge the gap between me and my colleagues that the lockdown had imposed on us. Now it’s time for a new normality, despite with the belief that “nothing will be the same as before” [Daniela Martini] I work in one of the cities hit worst by COVID-19 pandemic in Italy. I clearly remember the day in which the lockdown in Codogno (the city where the first Italian COVID-19 patient had been diagnosed), was declared. I was having lunch with my boss, who is from Codogno. After lunch, I had my last meeting with a student before the lockdown, to discuss about her graduation thesis, and I clearly remember her face: she was scared. At the University the panic quickly started to spread. In a very short time, my world has changed. I packed all my stuff and transferred my office at my "home safe home". However, a few days later I had to pack all my stuff again to move to another house with my son, since my husband works at the hospital, in the intensive care unit, therefore at high risk of being infected. Initially, I obviously did not really know how big this emergency would be and how long it would last, but I had the feeling this was only the “tip of the iceberg”. However, I always tried to be positive, and I remember thinking: “Well, I am a mom and I am a scientist. I’ll do my best to be resilient, adapting myself to this new situation, and find the best way to keep my work going”. I changed all my plans for the following months, while always trying to remember that I had to find the positive things in this period, even if my routine was completely turned upside down. For instance, I had to interrupt several projects due to be carried out in the lab, but I immediately thought I would use this time to write papers and to finalize backlogs from my new home office. During these months, supporting my students, doing online exams and trying to plan the activities with my colleagues from home has been hard. However, creativity has been the essential ingredient to find constantly new ways to keep my networks alive, to take care and foster relationships with my colleagues and to progress with all projects and activities. In the end, unexpectedly, it has also been "the time for taking time" for new ideas and projects. In conclusion, this pandemic certainly left a mark in my life: it forced me to change my point of view and it has changed the way I used to work - but at the same time, it has also opened the door to new opportunities and new alternative ways of working. I have been forced to rethink my working priorities and to contemplate new ideas for nutrition science. [Margherita Dall’ Asta] I had to introduce profound changes in my work and private life routine. I was responsible for starting a communication project targeted at parents, regarding health nutrition for families with kids. The idea was to organize several events in the area of Milan, and contribute to science festivals in other italian regions. Because the COVID19 pandemic, I decided with the institution where I work, to switch my communication plan and start a social media project. I founded the instagram and Facebook profile of the "Buono al Cubo" project. This enables me to partially work from home, because I have a 2-year old child. [Francesca Ghelfi]

Message from Lord Richard Balfe of Dulwich NNEdPro & IANE Honorary President The NNEdPro Global Centre for Nutrition and Health has a proven track record, built over the past decade of training individuals in the field of nutrition and human health. This has been achieved through many initiatives over the years such as workshops, conferences and online activities. Given their expertise and experiences working with trainers and trainees from across the world, it gives me great pleasure to see them continue their work by bringing training and mentoring online through their International Academy of Nutrition Educators (IANE). IANE was brought about via a need to not only up skill people in the discipline of nutrition, but to give them the skills to go and train others. Using the wide network that has been developed and cultivated over the last number of years, the opportunities for mentorship are vast and varied. The mentors range from clinicians, lab scientists, those involved in policy and public engagement. I believe that this is a great place for anyone interested in learning more about nutrition and how to implement it more in their practice to learn. I would encourage anyone who is curious to engage with and benefit from such a great opportunity for further training as well as professional networking. Message from Lord Rana MBE of Malone NNEdPro and IANE Honorary Patron NNEdPro as a global think tank has over the years been developing its training academy, and creating a strong knowledge network of meaningful exchanges for adaptable and scalable models of medical nutrition education for the healthcare professionals worldwide. To further this goal, NNEdPro in collaboration with SNEB (United States) and Monash University (Australia) created an avenue/platform to mentor our future trainers, particularly in evidence based nutrition and medical/healthcare nutrition. Through its wide range of global networks, NNEdPro has been connecting with current and future healthcare practitioners, nutrition educators, recent graduates and various organizations in delivering high-quality nutrition education and improving heath practices, attitudes, and outcomes of larger communities. I would highly recommend everyone, interested in promoting nutrition education and envisioning healthy communities through research, policy, and practice, to avail the value-added opportunities provided by IANE. Message from Suzanne Piscopo Past President Society of Nutrition Educators and Behaviour (SNEB) As a nutrition educator I have mainly worked in schools, academia, the mass media and in community adult and lifelong education. During my 26 years (and counting) as a SNEB member, this organisation and its various activities, meetings and fellow-members have all enriched my professional delivery and research capacity in myriad ways, contributing to my evolving formation and to the quality of my outputs. However, with Nutrition education being such a dynamic and diverse field, I feel that the quest for learning is never really satiated. Somehow there is always another area which you are enticed to explore; another sector where perhaps you feel you could, or should, be more active. This is where IANE can play a role. I was very excited when SNEB and NNEdPro initiated discussions to collaborate on the IANE. It was evident that IANE could offer interested SNEB members an opportunity to be mentored in an area they wished to strengthen their skills in, or an area they were just starting to pursue, particularly with respect to developing, delivering and evaluating nutrition education in healthcare settings and practices. Indeed, this was one of the reasons I was attracted to IANE membership. This year I took advantage of the SNEB-IANE discount to be able to have access to the expertise and guidance of potential mentors from the IANE. I am particularly keen on honing my skills in development, management and impact evaluation of transdisciplinary training in nutrition for healthcare professionals. Thus, I look forward to being matched with my mentors for multiple personalised sessions. I also look forward to tapping into the IANE faculty’s wealth of experience, in-person or through webinars, gaining from their knowledge and insights and thus adding to my confidence and potential as a nutrition educator with deeper understanding, a broader perspective and, hopefully, a more meaningful impact. I augur that SNEB members will also consider the IANE as a possible route for professional development in nutrition and public health, benefiting from the experts from all over the globe. Suzanne Piscoppo, Malta Message from Melissa Adamski Monash University & IANE Steering Comittee Hello from Australia – I am one of the NNEdPro Global Innovation Panel members from one of the NNEdPro ANZ collaborators. I am an Accredited Practising Dietitian from the Department of Nutrition, Dietetics and Food at Monash University in Australia (also known as Monash Nutrition), and have a keen interest in nutrition education, especially in assisting healthcare professionals and doctors advocate for good nutrition with their patients. I love my role in the Department, leading Monash Nutrition’s suite of Food as Medicine online courses for healthcare professionals. Our Food as Medicine courses are designed to provide doctors and healthcare professionals with practical, relevant and evidenced based nutrition education so they can upskill in nutrition and provide helpful nutrition advice to their patients. At Monash Nutrition we have developed these courses because we believe doctors and healthcare professionals have a role to play, alongside nutrition professionals such as dietitians, in providing nutrition education and advice to people. Monash Nutrition is delighted the Food as Medicine courses are recognised as a pathway for doctors and healthcare professionals to apply for IANE membership. These courses are also offered at a discount to IANE members as a benefit of membership – this is for IANE members who haven’t competed them or wanted to complete additional courses. We believe our collaboration with NNEdPro will provide increased access to nutrition education for doctors and healthcare professionals and continue to raise awareness about the critical role of nutrition in health. There are many benefits of IANE membership, including the bespoke 1-1 mentoring scheme. This scheme provides members with access to experienced nutrition educators from around the world, as a chance to integrate their knowledge into practice. We look forward to seeing the IANE membership grow – and I might even see some of you in mentoring! Melissa Adamski MND, BSc, APD Accredited Practising Dietitian and PhD candidate Monash University Message from Sucheta Mitra IANE Membership Officer After a successful launch of the IANE pilot in February 2019, and the successive few months of the regular sessions being conducted, I am pleased to witness the growing interest in IANE amongst relevant professionals worldwide. Thank you to all our existing members for being part of the IANE scheme and bringing your rich expertise and experience from your respective fields. We hope to keep strengthening our engagement in the coming weeks and months through various innovative and interactive training tools and membership benefits. A few updates going forward: We currently have 68 IANE Subscribing members (38 from IANE and 30 from Faculty and Mentors Panel) The 38 IANE members represent SNEB, Monash University, NNEdPro Summer School Alumni and NNEdPro internal and external members. I would request all our members to please create your members profile on the website if you have not done so; All IANE members registered in 2019 or 2020 will receive complimentary membership until 31st May 2020. Your new membership renewal date will therefore be 1st June 2020; We are soon migrating to a new system ‘Wild Apricot’ replacing the current WIX platform that we have. An email will be sent to all of you in the coming week(s) with instructions on how to transfer to this new platform as well as to smoothly navigate this space; For the new/prospective members, the start date of your new membership will be 1st June and clear instructions regarding the new application system via ‘ Wild Apricot’ will be provided on the IANE page on our website; and All Professional members are entitled to Post Nominal MIANE Certificates which you will soon receive from us. Lastly as the IANE Membership Officer and your membership focal point, on behalf of my team (NNEdPro, SNEB and Monash colleagues), I am looking forward to further engage with all of you to enable a continuous enriching and valuable experience during your entire IANE Membership. Message from Nikitah Ray NNEdPro & IANE Junior Ambassador As our junior ambassador and champion on action for climate change and the environment Nikitah rapidly penned down the following message to ask that we do not forget to address sustainability issues as we go about our business as nutrition educators: One December day it was fine but something tragic happened in China. Some blamed it on one of the earth’s creatures and some blamed it on our mobile phone networks. It was not the point that COVID-19 had happened but rather the fact that we now have two crises but one of them has squished the other out of sight. I’m talking about climate change with polar bears drifting on blocks of ice and Bengal tigers being killed. We were thriving and ‘living life’ but now the tables have turned. Now we know how the animal kingdom felt when we were living the lives of our dreams! Yes we work hard but they were putting in double the energy to live and protect their young. Now we all know what it feels like when they were shrinking in numbers. We need to understand that this planet is shared between the animal kingdom and humans. Some believe that we come first and some believe that animals come before us and you can believe what you want but as long as we understand that it is shared and sharing is caring. Please remember this in your work as nutrition educators!

ICU Nutritional Management – Insights from the frontline By Dr Timothy Eden, RD with contributions from Shane McAuliffe, RD and edited by Professor Sumantra Ray, RNutr Insights from the frontline as NNEdPro Global Innovation Panel (GIP) member Dr Tim Eden RD shares his own experience of the challenges faced in the nutritional management of COVID-19 patients in ICU: https://twitter.com/TimothyEdenRD/status/1245634083012505602 With a high rate of COVID-19 patients in the overweight/obese category as well as those with Type-2 Diabetes, this can present a significant challenge when estimating and fulfilling these individualised nutritional requirements. Looking specifically at obese patients, there has historically been an attitude of underfeeding in intensive care, but this cohort is equally at risk of becoming malnourished (rapid, significant and unplanned weight loss) when nutritional requirements are not met for prolonged periods, and this can be a predictor of poorer clinical course and outcomes (1). The following narrative is not intended to replace clinical guidelines but is designed to highlight some key aspects relevant to nutritional assessment in ICU when treating patients with COVID-19. Estimating Nutritional Requirements: Anthropometry: - Obtaining accurate/actual weight can be difficult when patients are often haemodynamically unstable and susceptible to acute desaturation on repositioning early in the COVID-19 clinical course. - It is advisable to obtain weight when utilising time spent with physiotherapy and/or at times of hoisting. - Equally height is often estimated and remains very variable due to individual bias and limitations on movement/measurements; accurate heights are useful two-fold to help better estimate BMI/weight but also for ventilator settings (manipulating tidal volumes) therefore ulnar measures may be acceptable (2). - From anecdotal experience a significant proportion of patient’s requiring level 3 care have BMI >25 or are in the obese category defined as BMI >30.0kg/m2. - If BMI>30kg/m2 then opt for Adjusted Ideal Bodyweight or Ideal Body Weight (IBW) - Ideal body weight can be calculated based on the patient’s height calculated to BMI = 25kg/m2 (2) – this is more realistic and time efficient. - Limited ideal energy equations in obesity whereby current evidence opts for hypocaloric high protein feeding (so factor this in when implementing feeding regimes). Energy Requirements: - There are a number of suitable predictive equations used on ICU (3,5,6). - PENN State & Mifflin St Jeor: These equations account for temperature and ventilation settings (3,5,6) – although it should be appreciated these fluctuate daily and therefore the additional effort spent may not provide significant clinical gain. - A more practical and time efficient approach to adopt can be the ESPEN/ASPEN equations using kcal/kg. o ASPEN recommend 11-14kcal/kg/actual bodyweight in the BMI range of 30-50kg/m2 or 22-25kcal/IBW when BMI >50kg/m2 (7). o ESPEN recommending 20-25kcal/kg or 25-30kcal/kg in the Ebb and Flow phase respectively for ABW in the non-obese (3). - It is important to note many patients in ICU are ventilated (requiring respiratory support) and having an awareness of the type of ventilation can help gauge the level of support and severity of their respiratory needs e.g. mandatory through to spontaneous modes. - Assessing ongoing temperatures and extremes of febrile states will influence your estimates of insensible losses. - We have seen many patients receive a maximum of approx. 70% of feed in a 24h period due to issues such as proning, aspiration risk, tube placement delays which has been reported elsewhere (8,9,11). - It is therefore important to prioritise tolerance and build up energy/protein provision as able – protocol for nursing staff enable ongoing increments without the need of ongoing dietetic review (3,7). Protein Requirements: - ASPEN recommend 2g/kg IBW in patients with BMI 30-40kg/m2 and 2-2.5g/kg/IBW if BMI>40 kg/m2 (7). - Reaching these high targets may require additional protein supplementation (e.g. Prosource TF), particularly in the presence of tolerance issues or when feed volume is restricted (5,6). - An important consideration is for patients on temporary renal replacement therapy (RRT) whereby the timeframe of continuous filtration will vary greatly - For patients ‘on-filter’ or receiving RRT, aim for 1.5-2g/kg (10). - For patients ‘off-filter’, although potentially still with signs of kidney damage (AKI/ CKD/ low eGFR), aim for 1-1.2g/kg (10). - Fluid balance is closely controlled in COVID-19 patients, along with increased use of diuretics (e.g Furosemide) to aid respiratory function. This can increases the risk of renal dysfunction and electrolyte abnormalities (10). Low volume/electrolyte feeds may be most suitable in these circumstances (5). Factors affecting feed choice: Sedation: - It has been observed that the younger cohort of patients require higher levels of sedation (e.g. Fentanyl/Propofol) and these are also a source of calories, approx. 1kcal/ml should be factored in when using propofol doses of ≥200mg/h. Fluid Balance: - Due to close fluid balance control targets could well be negative 500ml to 1L, meaning high energy, concentrated feeds to help meet energy requirements (1.5-2kcal/ml) (5,11). - Close attention should be paid to time on and off filtration (RRT) as fluid restrictions will be influenced by medical interventions available i.e. be aware of the term ‘filter holiday’ as when off filter, a tighter restriction may be implemented. GI Issues: - This in itself can be a symptom of COVID-19, but is also contributed by high levels of medication (analgesia/sedatives/noradrenaline), which can result in delayed gastric emptying. - Early prokinetics (e.g. Metoclopramide/Erythromycin) can be effective in counteracting this issue and close monitoring instigated to help remove the burden of polypharmacy (5,6). - Hydrolysed (or partially broken down) feeds can also improve digestibility and GI tolerance. - Proning is often associated with poorer feed tolerance – be aware of local guidance for pre-proning advice and set protocols when patient is in prone positon(described below). Proning: - This refers to the adjustment of a patient from a supine (lying back down) into the prone (lying face/chest down), as a means of improving ventilation in patients with acute respiratory distress syndrome (ARDS) (12). - This technique is commonly employed in (up to 70% of) ventilated COVID patients (5). - This generally occurs in cycles, 16 hours on (prone) and 8 hours off (supine) which can contribute to interruptions in feeding (5). - This will require adjusting feeding rate, based on GI tolerance. Starting with a concentrated feed at approx. 20ml/hr and increasing in slow increments is generally good practice. - It is important to monitor gastric residual volumes (GRV’s) or ‘aspirates’ to assess tolerance, and consider reducing rate as these approach 300ml (max). These should be checked every 4-8 hours if possible (5,11). - Persistent intolerance of feed may require post-pyloric feeding although in practice there has been limited clinical need for this so far (5,11). Novel Therapies: - High does Vitamin C has been suggested as an adjunctive therapy to support the immune system during ARDS, however this has not been demonstrated in a recent trial (13) and may warrant further investigation in COVID specific patients. - Low carbohydrate feeds are rarely used in UK practice and few enteral feeds have been shown to exceed glucose oxidation rate (GOR) and therefore this is not likely to impact ventilation settings, but low CHO feeds could impact negatively on energy provision. - Fish oils rich in omega-3 fatty acids possess anti-inflammatory properties (14). This has led to suggestions that they may play a role in mediating the severe inflammatory response observed in critically ill patients with COVID-19, having previously been associated with favourable outcomes in ARDS (15). This may warrant further investigation in COVID-19 patients. - The potential antioxidant effect of specific micronutrients remain contentious and unsubstantiated. There is a high risk of suboptimal micronutrient status in COVID-19 patients based on demographic (16), disease pathology (17) and also certain treatment practices (10). Certain micronutrients have been suggested to play a role in mediating the inflammatory process in critically ill patients (18,19,20), particularly when used to correct suboptimal status. - Suboptimal vitamin D status associates with poorer outcomes in ARDS, and a number of viral infections and may warrant assessment/replacement in high risk patients appreciating the timing of year of this pandemic (post winter) and low risk intervention (21). - Consideration of the role of micronutrient status in COVID-19 risk and recovery may also warrant further investigation. Summary: The nutritional management of patients presenting with COVID-19 in the critical care setting remains complex and evolving. However, we have a wealth of resources to aid our nutritional assessment and to help implement feeding plans. As with all management plans, we must be able to adapt and adjust our clinical management accordingly in line with standard clinical and dietetic review processes. Simplistic equations and utilising feed protocols for varying scenarios may be a pragmatic method to ensure consistency across departments whilst aiding AHPs to manage increased caseloads. Excellent communication with nursing, medical and other healthcare staff who form part of the care process is key to help implement and monitor interventions and identify any acute issues impacting management. Those with doubts or questions, are not alone. Voicing questions within a department as collective thinking will ultimately serve in the best interest of patients whilst recognising we are all navigating uncharted territory. That said each day is a learning curve! Future work As the role of nutritional management in COVID-19 is being elucidated, further research in this field will help to shape specific nutrition guidelines. A key point of interest is the baseline nutritional status for patients presenting with COVID-19 and how this may impact the clinical course. For example measures of anthropometry e.g. weight/BMI have drawn much attention associating with poorer outcomes but also direct nutritional measures such as vitamin D status and other micronutrient panels may be of significant interest. It is well documented in other respiratory viruses that vitamin D plays a role at mediating viral inflammation of the respiratory tract whilst having other roles in immune function. This at present has attracted wide research interest noting that coming out of a winter whereby across the general population vitamin D levels are likely to be suboptimal. It could also be linked to the disproportionate impact to the BAME (Black, Asian and Minority Ethnic) community which has been evident in London but is reflective across the UK and more widely (22). Research groups and clinicians continue to work quickly to help further identify patterns which may lead to therapeutic interventions to combat COVID-19. As a junior doctor in a West London Intensive Care Unit, together with colleagues, we are seeking to address early unanswered questions by assessing nutritional status on admission and tracking morbidity and mortality. The principal aim is to identify a clinical panel of nutritional markers and assess outcomes to begin identifying those groups of patients who may in turn benefit from more targeted nutritional care as we progress through this pandemic. Notes: TE is both a Licensed Medical Doctor as well as a Registered Dietitian working in NHS Intensive Care; SM is a Registered Dietitian working in the NHS; SR is both a Licensed Medical Doctor as well as a Registered Nutritionist (Public Health) working as a Medical Academic. Recently Tim Eden spoke to James Bradfield about his experiences during the COVID-19 pandemic. Links to the podcast below: https://podcasts.apple.com/gb/podcast/nnedpro-global-centre/id1496856424#episodeGuid=tag%3Asoundcloud%2C2010%3Atracks%2F799911673 https://open.spotify.com/episode/3p06Q0TmbMofkgdDiyrIDG?si=YuO3P39aQMSPFC1vcSxP9g TE, Minha Rajput-Ray and SR are co-authors of the chapter on Micronutrient and vitamin physiology and requirements in critically ill patients. Textbook of Nutrition in Critical Care. Cambridge University Press (2014). References: 1. Secombe P, Harley S, Chapman M, Aromataris E. Feeding the critically ill obese patient: a systematic review protocol. JBI Database of Systematic Reviews and Implementation Reports. 2015;13(10):95-109. 2. Sasko B, Thiem U, Christ M, Trappe HJ, Ritter O, Pagonas N. Size matters: An observational study investigating estimated height as a reference size for calculating tidal volumes if low tidal volume ventilation is required. PLoS One. 2018;13(6):e0199917 3. Singer P, Blaser A, Berger M, Alhazzani W, Calder P, Casaer M et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clinical Nutrition. 2019;38(1):48-79. 4. Peterson C, Thomas D, Blackburn G, Heymsfield S. Universal equation for estimating ideal body weight and body weight at any BMI. The American Journal of Clinical Nutrition. 2016;103(5):1197-1203. 5. BDA Clinical Care Specialist Group (CCSG). Guidance on management of nutrition and dietetic services during the COVID-19 pandemic. (2020). 6. Todorovic V, Mafrici B. A pocket guide to clinical nutrition. 5th ed. Birmingham: The Parenteral and Enteral Nutrition Group (PENG) of the British Dietetic Association; 2018. 7. McClave S, Taylor B, Martindale R, Warren M, Johnson D, Braunschweig C et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. Journal of Parenteral and Enteral Nutrition. 2016;40(2):159-211. 8. Passier R, Davies A, Ridley E, McClure J, Murphy D, Scheinkestel C. Periprocedural cessation of nutrition in the intensive care unit: opportunities for improvement. Intensive Care Medicine. 2013;39(7):1221-1226. 9. Cahill N, Dhaliwal R, Day A, Jiang X, Heyland D. Nutrition therapy in the critical care setting: What is “best achievable” practice? An international multicenter observational study*. Critical Care Medicine. 2010;38(2):395-401. 10. Brochard L, Abroug F, Brenner M, Broccard A, Danner R, Ferrer M et al. An Official ATS/ERS/ESICM/SCCM/SRLF Statement: Prevention and Management of Acute Renal Failure in the ICU Patient. American Journal of Respiratory and Critical Care Medicine. 2010;181(10):1128-1155. 11. Australian Society of Parenteral and Enteral Nutrition (AuSPEN). Nutrition Management for Critically and Acutely Unwell Hospitalised Patients with COVID-19 in Australia and New Zealand (2020). 12. Intensive Care Society & Faculty of Intensive Care Medicine: Guidance for Prone Positioning in Adult Critical Care (2019). 13. Fowler A, Truwit J, Hite R, Morris P, DeWilde C, Priday A et al. Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients With Sepsis and Severe Acute Respiratory Failure. JAMA. 2019;322(13):1261. 14. Calder PC (2015) Marine omega-3 fatty acids and inflammatory processes: Effects, mechanisms and clinical relevance. Biochim. Biophys. Acta Mol. Cell Biol. Lipids 1851:469-484. 15. Dushianthan A, Cusack R, Burgess VA, Grocott MPW, Calder PC (2019) Immunonutrition for acute respiratory distress syndrome (ARDS) in adults. Cochrane Database Syst. Rev. CD012041. 16. Maggini S, Pierre A, Calder P. Immune Function and Micronutrient Requirements Change over the Life Course. Nutrients. 2018;10(10):1531. 17. Kilby K, Mathias H, Boisvenue L, Heisler C, Jones J. Micronutrient Absorption and Related Outcomes in People with Inflammatory Bowel Disease: A Review. Nutrients. 2019;11(6):1388. 18. Forceville X. Effects of high doses of selenium, as sodium selenite, in septic shock patients a placebo-controlled, randomized, double-blind, multi-center phase II study – Selenium and sepsis. Journal of Trace Elements in Medicine and Biology. 2007;21:62-65 19. Besecker B, Exline M, Hollyfield J, Phillips G, DiSilvestro R, Wewers M et al. A comparison of zinc metabolism, inflammation, and disease severity in critically ill infected and noninfected adults early after intensive care unit admission. The American Journal of Clinical Nutrition. 2011;93(6):1356-1364. 20. Amrein K, Papinutti A, Mathew E, Vila G, Parekh D. Vitamin D and critical illness: what endocrinology can learn from intensive care and vice versa. Endocrine Connections. 2018;:R304-R315. 21. Teymoori-Rad M et al. The interplay between vitamin D and viral infections. Reviews in Medical Virology (2019). DOI: 10.1002/rmv.2032. 22. Khunti Kamlesh, Singh Awadhesh Kumar, Pareek Manish, Hanif Wasim. Is ethnicity linked to incidence or outcomes of covid-19? BMJ 2020; 369 :m1548

By Jimena De Martino and Mercedes Zorilla Tejeda Acknowledgements to Matheus Abrantes and Sarah Rade We are delighted to share with you great news: NNEdPro has arrived in Mexico! This February, the Network Soft Launch of activities in Mexico called “Nutrition Education Paradigm Applications in Mexico” was hosted by the Monterrey Institute of Technology and Higher Education (Tecnológico de Monterey) in Mexico City. Twenty-five people including academics, nutrition students and independent consultants attended this amazing event. Rebeca Leyva Rico shared with us her experience of the impact of daily professional practice in nutrition education, working with people’s behaviours that are influenced by their own beliefs, perceptions, values, emotions and cultural patterns. Nutrition education is key to promote health and prevent diseases and complications. In patients with diabetes mellitus, the aim of nutrition education is to empower them to achieve metabolic control of the disease by providing them with the required knowledge, skills, confidence and competences for diabetes care, for example the skills to count carbs, monitor their glucose, keep a food diary, choose healthy meals away from home and adopt a healthier lifestyle. Yareni Gutiérrez Gómez spoke about the new way of learning nutrition education in the University. She mentioned that Tec de Monterrey has a new education model called Tec21 and explained how it is being implemented in the BSc in Nutrition and Integral Wellness. Tec21 allows students to develop solid and integral competences that will help them solve present and future challenges in a strategic and creative way. The new educational model, exclusive worldwide, activates and boosts students’ innovation capacity and allows them not only to stay qualified through time but also to be agents of change. This model is unique and has its foundations in three components: challenge based learning, inspiring faculty and memorable experience. Nutrition students have the opportunity to practice what they learn at school from their very first semester with the help of academic partners (companies, institutions, professionals). They present real problems that require our future nutritionists’ knowledge in order to be solved giving them professional experience throughout their career. Teachers are experts in nutrition and health inside and outside the classroom, they work in prestigious institutions and most of them are certified researchers. Professor Sumantra (Shumone) Ray introduced the NNEdPro Global Centre, which is anchored in Cambridge but working without borders both in the UK and globally! Currently there are networks in six continents, which are part of the International Knowledge Application Network Hub in Nutrition-2025. NNEdPro main goal is to develop a critical mass of self-sustaining knowledge, skills and capacity in Nutrition and Health, within the global healthcare and public health workforce, resulting in significantly improved health practices and outcomes. He highlighted the 4 pillars of the centre: training professionals, strengthening research, implementing solutions and addressing inequalities. One of the key aims of the Mexico Network is to pilot the NNEdPro Mobile Teaching Kitchen Project in underserved areas. Professor Ray shared the experience of this ambitious project in India with the main objective being to improve awareness of diet diversity and disease prevention by using cooking skills as a medium for education, providing resources and signposting for food security and promoting social empowerment and impact preventative health. The outcome of this project was the development of a microenterprise model to selling not only food but education to other communities in Kolkata. The model developed addresses WHO Double Duty Actions 5, 6 and 10. Professor Ray shared with the attendees information about the SAFEWATER project, led by Ulster University and Fundación Cántaro Azul in San Cristobal de las Casas, Chiapas. The main goal of SAFEWATER is to ensure access to safe water for all. In Mexico this project aims to measure nutrition and child growth. The key contact for the nutrition and health component of this project is Dr Santosh Gaihre. Prior to the launch event in Mexico City, Professor Ray spent several days in Chiapas as an Advisory Board Member of SAFEWATER, gaining insights into the health needs of rural Mexico and providing advice to the teams involved in field research. In the later stages of the event, participants were asked to form three teams and provide key ideas on what can be done in Mexico. Below are some of the ideas that the participants brainstormed: Raising funds Develop strategies locally with a multidisciplinary team including academia, local government, independent consultants, community leaders, food banks, sustainability companies, food care and technology industries Collaborate with Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán to validate programmes Target rural communities with some activities for children Use a mindful eating focus to address topics - for example, how is agriculture linked to what we eat? Enhance local economy by creating affordable menus with nutritious dishes that people can afford with a minimum salary Use messages to empower women and fight against “Machismo” through food Focus on reducing sugar consumption Be aware of sustainability (preserve Mexican culture, use local food, include indigenous communities) Promote the use in recipes of the kitchen lab food grown locally, regionally: Sonora produces egg plant, so menus can use this vegetables Promote the use of local foods by enhancing their benefits Hoping to launch successful projects in México and searching for a better nutrition to all, if you want to be part of the NNEdPro Regional Network or to learn more about our activities please contact us so we can follow up any request. Spanish version / versión en español Felices de compartirte una gran noticia: ¡NNEdPro ha llegado a México! El pasado mes de febrero, se llevó a cabo el lanzamiento de actividades de NNEdPro en México con la organización de una Mesa Redonda bajo el título “Paradigmas de Educación en Nutrición: aplicaciones en México” que tuvo lugar en el Tecnológico de Monterrey en la Ciudad de México. Veinticinco personas, incluyendo académicos, estudiantes de nutrición y consultores independientes asistieron a este gran evento. Rebeca Leyva Rica, educadora en diabetes, compartió su experiencia sobre la Educación en Nutrición durante la práctica profesional diaria, promoviendo trabajar con los comportamientos de las personas, los cuales son influenciados por creencias, percepciones, valores, emociones y patrones culturales.. Nos mencionó que en pacientes con diabetes mellitus, el objetivo principal de la Educación en Nutrición es empoderarlos para alcanzar los objetivos metabólicos de la enfermedad. Esto se logra al brindarles el conocimiento, habilidades, confianza y competencias necesarias para el autocuidado de la diabetes, por ejemplo; conteo de hidratos de carbono, monitoreo de glucosa, llevar un diario de alimentos, elegir opciones saludables fuera de casa y adoptar un estilo de vida saludable. Yareni Gutiérrez Gómez habló sobre la nueva forma de aprender Educación en Nutrición en la universidad que labora. Mencionó que el Tecnológico de Monterrey tiene un nuevo modelo educativo llamado Tec21 y explicó cómo está siendo implementado en la Licenciatura de Nutrición y Bienestar Integral. El modelo Tec21 permite a los estudiantes desarrollar competencias sólidas e integrales que los ayudarán a resolver retos presentes y futuros de una manera estratégica y creativa. El nuevo modelo educativo, exclusivo en el mundo, activa y aumenta la capacidad de innovación de los estudiantes y les permite no solo mantenerse calificados y actualizados en el tiempo sino también ser agentes de cambio. Este modelo es único y se basa en tres componentes: aprendizaje basado en retos, profesores inspiradores y vivencias memorables. Los estudiantes de nutrición tienen la gran oportunidad de poner en práctica lo que aprenden en clase desde el primer semestre con la ayuda de socios académicos (compañías, instituciones, profesionales). A los estudiantes se les presentan casos reales que requieren el conocimiento de futuros nutriólogos para poder resolverlos, dándoles así experiencia profesional a lo largo de su carrera. Los profesores de la licenciatura son expertos en nutrición y salud dentro y fuera del salón de clases ya que trabajan en instituciones de prestigio y la mayoría de ellos son investigadores certificados. También contamos con la presentación del Profesor Sumantra (Shumone) Ray que explicó qué es el Centro Global de NNEdPro, con su oficina central en Cambridge, Inglaterra, el cual trabaja sin fronteras tanto en el Reino Unido como a nivel mundial, con redes de contactos profesionales en seis continentes. El principal objetivo de NNEdPro es desarrollar acciones a favor del conocimiento y habilidades en nutrición y salud entre los profesionales de la salud a nivel mundial, promoviendo así mejores resultados y prácticas más eficientes en la promoción de la salud. El Profesor Ray destacó la importancia de los cuatro pilares del centro: entrenar profesionales de la salud, fortalecer la investigación, implementar soluciones de nutrición y abordar desigualdades entre las comunidades. Una de las metas clave de NNEdPro en México es poner a prueba el proyecto de la Cocina NNEdPro Enseñanza Móvil en zonas marginadas del país. El Profesor Ray compartió la experiencia de este ambicioso proyecto en la India, el cual tuvo como objetivo crear conciencia sobre la diversidad de la dieta y la prevención de enfermedades utilizando las habilidades culinarias como medio de educación, proporcionando así recursos y herramientas para la seguridad alimentaria y promoviendo el empoderamiento social y las medidas de prevención para el cuidado de la salud. El resultado de este proyecto consistió en el desarrollo de un modelo de microempresa para vender alimentos y brindar educación entre las comunidades en Calcuta. El modelo desarrollado aborda las Medidas con Doble Finalidad para acabar la malnutrición en un decenio de la Organización Mundial de la Salud 5, 6 y 10. El Profesor Ray nos compartió detalles sobre acciones que ya se llevan a cabo en México como el Proyecto SAFEWATER, dirigido por la Universidad de Ulster y la Fundación Cántaro Azul en San Cristóbal de las Casas, Chiapas. El objetivo principal de SAFEWATER es garantizar el acceso a agua potable para todos. En México, este proyecto tiene como objetivo medir el estado nutricio y el crecimiento infantil, dirigido por el Dr. Santosh Gaihre. Antes del evento de lanzamiento en la Ciudad de México, el Profesor Ray pasó varios días en Chiapas como miembro de la Junta Asesora de SAFEWATER, obteniendo información sobre las necesidades de salud de las zonas rurales de México y brindando asesoramiento a los equipos involucrados en la investigación de campo. Ya para finalizar el evento, se pidió a los participantes que formaran tres equipos y proporcionaran ideas clave sobre cómo contribuir en México, dentro de sus propuestas está: · Recaudar fondos · Desarrollar de manera multidisciplinaria estrategias locales que involucre académicos, gobierno, consultores independientes, líderes de la comunidad, bancos de alimentos ,empresas de sustentabilidad, cuidado de alimentos e industrias tecnológicas. · Colaborar con el Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán para validar los programas · Realizar actividades para niños en comunidades rurales · Utilizar un enfoque de alimentación consciente para abordar los temas, por ejemplo, ¿cómo se vincula la agricultura con lo que comemos? · Mejorar la economía local creando menús accesibles con platillos nutritivos que las personas puedan pagar con un salario mínimo. · Utilizar mensajes que empoderen a la mujer y combatan el machismo a través del control de los alimentos · Usar mensajes con enfoque en la reducción del consumo de azúcar · Tener en cuenta la sostenibilidad (preservar la cultura mexicana, usar comida local, incluir comunidades indígenas) · Promover el consumo de alimentos locales Esperando lanzar proyectos exitosos en México y en búsqueda de una mejor nutrición para todos. Si deseas formar parte de la red de contactos profesionales en México de NNEdPro y obtener más información sobre nuestras actividades, ¡contáctanos! para que podamos dar seguimiento a tu solicitud.

By James Bradfield, Dr Luke Buckner Shane McAuliffe, Dr Minha Rajput-Ray and Prof Sumantra Ray With Acknowledgements to Dr Dominic Crocombe, Prof Martin Kohlmeier and Lord Richard Balfe The United Kingdom is soon coming up to a month in lock-down to try and slow the rate of spread of COVID-19. Whilst majority of the public adapt to the enforced social distancing and isolation measures, designated key workers continue working in uncharted environments, often being required to work longer hours and busier shifts. Key workers include those employed in educational services, food and essential goods production, distribution and sales, logistics, utilities, communications, provision of infrastructure and financial services, public safety and security staff, local and national government as well as those facing COVID-19 head on in health and social care services. Whilst it is vital at home people utilise this opportunity to keep themselves physically and mentally healthy given the imminent risk of infection, it is pertinent to support our key workers in staying healthy during this time. This is being done in a variety of forms – with displays of appreciation through weekly applause, signs in windows or on buses, whilst many companies provide discounts or freebies. It is important that key workers are given these privileges, yet also essential for them to maintain their health and overall functionality. At the NNEdPro Global Centre for Nutrition and Health, a collaborative think tank headquartered in Cambridge, a number of core members, and indeed some of the contributors to this article, are frontline healthcare workers, including Doctors, Nurses and Dietitians. Key workers often find that they do not have time to ‘eat well’ amidst a crisis such as this, which is understandable as many frontline staff are being asked to cover more frequent and longer shifts than before. This often results in erratic eating patterns, increased snacking on foods higher in calories, sugar and salt or generally not having time to prepare proper meals or indeed being over reliant on catering services are running on the bare necessities. We believe that the points below will be beneficial in keeping Key Workers in as best a health state as possible. Preparation is key The adage goes that if you fail to prepare, you prepare to fail. Cooking a healthy, nutritious meal is much easier when you have good ingredients. It may be difficult to access fresh, seasonal produce; however, with a few adjustments it may be possible to maximise the nutritional content of meals. Most of the major supermarkets now taking special effort to make accessing food easier for key workers. This ranges from staggered opening times, opportunities for ‘click and collect,’ delivery schemes and home delivery. Examples of simple tips include using tinned tomatoes as the basis of many varied dishes, good quality stock cubes tend to be lower in salt and still pack dishes like curries with flavour while frozen vegetables tend to be every bit as nutritious as those freshly picked. Foods with long shelf lives are important as they provide food security in a time when you may find it difficult to visit a market or supermarket. Food such as rice and pasta can form the basis of a healthy meal. However, in order to reduce the possibility of ‘taste fatigue,’ try to include other foods too such as noodles, cous cous and potatoes. These are widely available and last longer than you might expect. When it comes to meat and fish, remember that most is suitable for freezing so rather than having to pick up something each evening on the way home, you can bulk buy, freeze and de-frost as required. You are made up of 50 – 60% water…make sure to replace it This might seem impossible with factors such as a busy shift, the wearing of different forms of PPE (personal protective equipment) and lack of storage space. Try where possible to bring a drink of water with you to work. Although you may not be able to carry water with you at all times, try to keep it somewhere accessible. Anecdotally, chilling the water beforehand may help to keep it refreshing over the course of a long shift. Make a habit of drinking water regularly whenever you can. Studies show that even dehydration of 2% of body mass may lead to reduced attention and memory, meaning that hydrating throughout the day can quite literally help ensure that you can perform best and help care for your patients, customers or clients. As an extension, make sure to not become reliant on caffeine. While you may feel it helps you to stay alert on shift, this effect is short-lived and in the long run will likely interfere with your sleep. This creates a negative cycle of poor sleep and tiredness which ultimately impacts your energy levels and ability to focus. Healthy snacks to keep you going Once again, preparation is the order of the day however consider that it may be now time to prepare for unusual or demanding working conditions, especially when there are limited options to take breaks. Bringing healthy snacks to work can reduce the likelihood of relying on sweet treats that provide little nutritional benefit. Again, the short term ’boost’ a sugary snack can provide may be satisfying at the time; however, is unlikely to improve concentration and overall energy levels for a sustained period. Instead consider snacks with slow release carbohydrates, quality protein and healthy fats. Good options include fruit, nuts, yogurts, cheese, humous and vegetables or even a small sandwich, ideally made with wholegrain bread. These are the types of foods that are likely to help you keep going for longer while giving your body the nutrients that it needs to maintain your health. Tiredness often contributes to cravings for calorie dense foods. This is normal and is contributed to by alterations in hormone production and metabolism, both of which are caused by shifts in your body’s natural circadian (sleep-wake) rhythm as a result of a lack of sleep and irregular routine. This is not your fault - you are fighting against natural or physiological processes here but keep that in the front of your mind and try fight it to keep yourself focused and healthy. Get enough restful sleep Another tip that seems obvious but is important to emphasise wherever possible. In these unprecedented times, this is easier said than done. Aiming for the best possible recuperation under the circumstances can help your body re-charge, maintain immunity, and enable overall better functioning. This goes together with being physically active in that a healthy mix of the two is likely to set you up for your next shift as best possible. For more information on what to eat on a night shift which is largely applicable to anyone working within the COVID-19 space please follow this link for an article which two NNEdPro members contributed to: https://www.bmj.com/content/365/bmj.l2143 For more information about COVID-19 including useful nutrition resources and a 10-point summary on diet, nutrition and the role of micronutrients, please visit the dedicated NNEdPro microsite at: https://www.nnedpro.org.uk/coronavirus

Commemorating International Women’s Day by Helena Trigueiro The notable increase in the number of human nutrition studies in the early twentieth century can be linked to the entry of women into academia. This is mainly because food and nutrition were considered to be a ‘woman’s issue’. Even until the late 1950s, there were few professional opportunities for the few women who were fortunate enough to study. These scientists, visionary researchers, and leaders in nutrition policy founded a resilient legacy for other nutrition scientists (men and women) to follow and honour. In this article we aim to remember some of these women and their outstanding contributions to nutrition. One such woman was Dame Harriette Chick, born in 1875 in Victorian England. At a time when women and did not even have the right to vote, Harriette was the first to take an assistant position at the Lister Institute of Preventive Medicine. During the First World War she focused on studying soldiers’ rations in order to prevent vitamin C and thiamine deficiency, and ultimately scurvy and beriberi. At the end of the war, Harriette travelled to Vienna to share her knowledge on vitamins, in a country where there was a serious public health problem. The results of her intervention were notable, and it was considered by some as the peak of her career. Harriette was then director of the nutrition division at the Lister Institute, and continued to study vitamin deficiency until close to her death, at the age of 101. Another remarkable scientist, whose contribution was vital during wartime, is Elsie Widdowson. As a result, she is considered to be one of the most relevant British scientists of the 20th century. Her basic training was in chemistry, which allowed her to study the chemical composition of food during her PhD at her Imperial College, London. Somewhat controversially, she questioned the value ​​of carbohydrates in fruit, previously presented by Robert McCance. This audacity paid off, and he later became her mentor. Elsie realised that nutrient composition tables were an essential tool and that there was a lack of information and clarity in those that existed at the time. Widdowson and McCance published the acclaimed publication, ‘The Composition of Foods’, in 1940. During World War II, Elsie's work was essential to study and predict the effects of food rationing on the nutritional status of the English population. Harriette and Elsie’s scientific contributions in Nutrition are an example of innovation born out of adversity during such dark times. Another example of a career full of exceptional research, alongside multiple conflicts and difficulties is that of Agnes Fay Morgan, born in 1884. After completing her PhD, Agnes agreed to teach nutrition at Berkeley, for an annual salary $600 lower than what was paid to her equivalent male colleagues. She experienced first-hand the difficulty of finding people who were willing to finance projects that were conducted and thought of by women. In her personal notes, she describes her purpose as establishing a solid scientific basis for the practices in nutrition taught at the time. This purpose was realised, as her studies allowed us to gain a better understanding about the effect of micronutrients on health, such as the role of calcium, phosphorus and vitamin D in bone health, and Vitamin B5 in skin and hair pigmentation. Further related to the study of micronutrients, other important contributions were made by women involved in nutrition science, specifically in the establishment of recommended daily intake (RDA) values. We remember the work of Doris Howes Calloway, who always defended RDA’s based on the amount needed to guarantee the optimal health for the individual. Doris was born in 1923 and became the Director of the Department of Nutrition Sciences, Berkeley, as well as the president of numerous professional associations, where she always fought for equal opportunities for women and minority groups. Another scientist who fought for women was Icie Hoobler, a biochemist born in Missouri in 1982. She prioritised maternal care and showed the impact of nutrition on infant development, establishing a correlation between access to pre-natal care and the subsequent growth and health status of children. She faced already established sexism and reported in her notes: “This was traumatic at times, until I regained my self-respect and gathered courage and determination to demonstrate to the class that a woman chemistry teacher was capable of teaching, even grown men just back from war.” More names could be added to this list: Ellen Swallow, Isabella Leitch, Hazel Stiebeling, Dr Lydia Roberts, and many more. These pioneering women scientists opened the door for the women leading nutrition sciences today, and they should be remembered and cherished for this.

By Lyn Haynes, Jorgen Johnsen, Luke Buckner and Sumantra Ray With acknowledgements to Sanchita Banerjee, Debashis Chakraborty and collaborators in Kolkata, Sanghol, Bhubaneshwar, Hyderabad and Delhi Over a week straddling late January and the beginning of February 2020 NNEdPro viewed its Mobile Teaching Kitchen (MTK) microenterprise in full action in Kolkata as well as finalising the ‘see one, teach one, do one’ interventions in Sanghol, Punjab. In addition, MTK adaptation exercises were undertaken in Hyderabad in Telangana with the International Crop Research Institute for The Semi-Arid Tropics (ICRISAT) and Bhubaneshwar in Odisha with the Nabakrishna Centre for Development Studies (NCDS) working closely with the Odisha Millets Mission (OMM). Meetings and discussions also took place with Vertiver and the All India Institute of Medical Sciences in New Delhi to plan for near future interventions based on our learning in India to date. This blog focuses on MTK activity in both Kolkata and Sanghol. The visit included NNEdPro Virtual Core Members: Professor Sumantra Ray, Dr Luke Buckner and Jørgen Torgerstuen Johnsen, as well as a first visit for Dr Lyn Haynes. The MTKs are also a key component of the University of Cambridge-led Global Challenges Research Fund (GCRF) supported Programme: Transforming India’s Green Revolution-II with Empowerment, Research and Sustainable Food Supplies (TIGR2ESS). Highlights from Kolkata The first days of our trip started in Kolkata, the City of Joy, and on our very first day we had a press conference discussing the Mobile Teaching Kitchen, this was a success in sharing the new developments with local media making it into some of the local papers and news channels. The second day we met up with the Kolkata team and assembled for a field visit to see the MTK microenterprise in action. We attended a selling session close to the IT district where many works in tech. After a successful selling session, we had a debrief of our observations before heading off to our workshop. The workshop focused on the next steps in our microenterprise phase which included the outfit of the van, stand, data gathering and analysing, marketing, and further strategies on how to make the model sustainable and adaptable. To further help them think of strategies, the United Nations Decade of Action on Nutrition 2016-2025 and the Decade of Family Farming 2019-2028 were presented in addition to the recent proposed 10 double-duty actions to tackle the double burden of malnutrition. The delegates were divided into groups by key topics and synthesise ideas. The MTK champions participated across all discussion groups. The next day Shumone and Jørgen travelled to Bhubaneshwar, along with representatives from the Inner Wheel Club of Greater Calcutta and the Remedy Clinic Study Group, for a workshop with the Odisha Millet Mission (OMM). Here the Kolkata team demonstrated a cooking session of one of our MTK templates which use millets. We shared knowledge, experience and ideas with the existing OMM microenterprise efforts supporting women including those from marginalised communities. Highlights from Sanghol, Punjab The team continued to Sanghol, where we proudly co-operate with the team at the Lord Rana Edu City, founded and funded by the Lord Rana Foundation Charitable Trust, UK, and the Cordia Colleges where the rural adaptation of the MTK initiative has been taking place over a 12 month period. Here we were presented with the data and progress of the rural MTK project and were impressed how far efforts have reached and how much data has already been collected and is ready for analysis. The next day we had a field visit to the cluster of villages where the mothers who are a part of the MTK initiative live. After showing us around, seeing their kitchen gardens and talking to other villagers we conducted a focus group with the mothers to see and hear what they had to say about the initiative. Thus, we could pinpoint logical issues that may arise when we scale up the work and move from stationary learning to an operative mobile unit. The field visit ended with a trip to a local sugarcane factory where we where invited to watch the process of refining the sugar from the sugarcane. These factories are run by families and are makeshift in nature. Dr Lyn Haynes’ notes on the Mobile Teaching Kitchen initiative. In Kolkata two of over 3,500 slums were selected for participation in the NNEdPro Mobile Teaching Kitchen project. The central goal was to educate mothers in each slum about nutrition and healthy eating, originally involving 12 mothers. After training to prepare and serve several different, carefully designed (by dietitians) menu templates, the remaining eight trained mothers, or MTK Champions, have now entered the microenterprise phase of the project. The NNEdPro mobile kitchen is taken to a site close to many office blocks. Here the team of the day will prepare, serve and sell plates of the Menu of the Day. There are ten templates in total: the champions continue to be taught new menus by volunteers from Kolkata Inner Wheel Circle, and oversight by Sanchita and Debashis. One slum is registered; the difference in confidence between the men and women in that and the unregistered slum, is tangible. The reality of the latter is that their proudly constructed [temporary] home could be bulldozed any day. Imagine living with such tension. Not surprising that reported substance abuse is high. In the focus group the women shared their dream to educate their children. Luke shared his observation that the women looked and held themselves differently now, more positive and confident. They admitted to feeling empowered since engaging in the project. Urban Slum life differs remarkably from the rural setting in the Punjab village of Sanghol. The two dimensions of the project here pertain to 10 mothers who work at Cordia College (hailing from a cluster of surrounding villages) and 10 homemakers from the adjacent village, Polomaja. All these women are more confident: could it be because they have homes, security of tenure and are supported by the husbands and/or families in the project. Although these mothers have only been involved in the project since August 2019, and only been taught two menus. It is anticipated that the Mobile Kitchen will be launched after August 2020. The rural mothers were ahead of the urban mothers in sharing their knowledge about healthy eating with families and friends although they have only learned a few of the templates. TIGR2ESS Co-Investigator Prof Ramanjit Johal in discussion with rural mothers at the Teach One day. Cordia College student volunteers with the working Cordia mothers at the Teach One day. Even the plate of food differs in looks from that sold in Kolkata, but offer just the same nutritional value and tastes equally good! As the Kolkata project provides evidence of moving forward effectively, it is now time to introduce new value-added adjuncts. One line of thinking is to involve the men folk to make solar cookers to reduce reliance on expensive bottled gas, and hopefully also limit fire-accident risks. While the idea was taken on board in RG Kar slum in Kolkata, there is a limitation on where one could put a solar cooker as there are many large trees casting shadows. However, in Chetla the area along the railway lines would work best of the possible sites inspected. In Punjab, where there is ample space to position a solar cooker, the members of the project were less enthralled by the concept. Gas cookers are not anywhere near as much a fire hazard as in the Kolkata sites. In Punjabi homes five of the seven Cordia mothers-in-training informed us in the focus group that they also used chula (cow manure and straw pats) for slow cooking recipes. The idea of the Kitchen Garden (KG) project was well received in the Punjab, where such horticulture is already in action in their homes. KG for supplying the Mobile Kitchen might best suit the Cordia mothers who will not be able to go out in the Mobile Kitchen. There is plenty of space for a garden to be operated in the grounds of Cordia College and they could earn their MTK income through tending the garden and supplying the menu ingredients, while the village mothers undertake the client-facing component of MTK. In Kolkata the KG idea raised several issues: children, rats and other people might interfere with and/or destroy the mini gardens that would necessarily need to be grown in pots/tubs. A few spots above the school building in Chetla might provide safe (except from rats) sites. In RG Kar no obvious places for the tub-gardens were obvious. The Mobile Teaching Kitchen is an interesting and innovative initiative and experiment. The most effective evidence as to the impact of engagement, by the 28 women in the two areas, has been being with and talking to the women: narrative is much stronger than raw data, this is after all a human-facing project. Unfortunately, shortly after our visit, they amongst many other vulnerable people in India and indeed the world face the pandemic consequences of COVID-19. Whilst many globally complain of the social isolation, loss of employment and risk to health this disease is causing through measures to slow its spread, the champions in Kolkata face this perhaps more acutely. Due to the cramped conditions of their living situation, minimal access to healthcare and lack of savings the impact could be dramatic. To date the feedback is that they are following government guidance well, we have no reports of ill health, and through NNEdPro’s crowdfunding campaign we have managed to provide some finance to compensate for what they have been making previously during MTK selling sessions. But this has only been one month’s salary and now they need your help once again. The champions and their families are not worried about not seeing friends, going to the cinema or being stuck at home, they face a real-life struggle for both themselves and their family to provide food, water and a roof over their head. If you are able to, please donate on the link below, even small amounts can go a long way to supporting them and their families. MTK Crowdfunding Campaign – aiding our urban slum champions in the wake of COVID-19 https://www.justgiving.com/crowdfunding/mobileteachingkitchens An Overview of the MTK model https://www.nnedpro.org.uk/mtk An Overview of our India network https://www.nnedpro.org.uk/india An Overview of our work with TIGR2ESS https://tigr2ess.globalfood.cam.ac.uk/fps/FP6

By Ananya Ria Roy The theme for International Women’s Day 2020 is #EachforEqual and the belief that an equal world is an enabled world. The NNEdPro Global Centre for Nutrition and Health is proud to be an organisation that can be a platform to give all our members a voice and strive to create equal opportunities throughout the organisation’s networks and projects. It would not be an understatement to say that women are a key driving force at NNEdPro in helping to achieve our mission. In-fact over 60% of NNEdPro’s Governors and Advisors, Board of Directors, Global Innovation Panel and Virtual Core is comprised of women (Read more about our members here: https://www.nnedpro.org.uk/members) Creating opportunities for all are at the heart of our organisation - from supporting anyone with a passion for nutrition throughout their careers starting from the International Academy of Nutrition Education e.g. through mentoring (see membership benefits: https://www.nnedpro.org.uk/iane ), or their research careers, or to supporting projects completely run by and for the empowerment of women such as the Mobile Teaching Kitchens in India. The Mobile Teaching Kitchen in India - Bhavishya Shakti - is one such programme helping to create more opportunities for the empowerment of women and their families. The project is now a microenterprise where women from urban slums in Kolkata are confidently creating nutritionally balanced meals developed by dieticians and tailored towards the needs of the local market to tackle the triple burden of malnutrition in India and transferring knowledge amongst the general public about healthy affordable meals. Img1: A busy afternoon at the Bhavishya Shakti Mobile Teaching Kitchen in March 2020 📷 Img2: How to ’Eat right in one bite’ at a local MTK: An example of a nutritionally balanced meal comprised of a Besan Chila, a vegetable tick, egg curry and green chutney. All for the affordable price of INR 50. 📷 We’re proud to see the Bhavishya Shakti champions have inspired those beyond Kolkata and women are inspiring those across India (e.g. in Punjab as well as Odisha. In the latter the Odisha Millets Mission (OMM) is negotiating with women collectives of the state to replicate mobile teaching kitchen model to impart nutrition education, read more here: https://www.outlookindia.com/website/story/poshan-news-orissa-sees-potential-in-nutrition-education-on-wheel-model/348244 ). NNEdPro are proud to be an international and diverse organisation made up of Health care professionals, Professors, Doctors, Dietitians, Nutritionists, Educators and Students working with tenacity to ensure that we can provide nutrition education for all because we believe that an equal world is an enabled world. Nutrition Education has a fundamental role in societies globally, malnutrition in hospitals costs Billions each year and more importantly lives there are also ever-increasing links between disease and diet. NNEdPro are committed to closing the gap this is a vital part of the process to bring some of the most vulnerable and often heavily exploited members of our societies up to speed. The award-winning mobile teaching kitchen is an example, by enabling these women the tools, platform and education they are now able to very successfully provide an education for their children, an income for their families and healthy affordable meals into Indian cities. NNEdPro throughout our regional networks will continue to enable nutrition education for all, to improve health and wellbeing globally