Search

TIGR2ESS-FP6: The Mobile Teaching Kitchen (MTK) in India Series March 2023 Authors: Harmanpreet Kaur, Wanja Nyaga, Sarah Armes Editors: Sumantra (Shumone) Ray, Sucheta Mitra, Ramya Rajaram Acknowledgements: We would like to acknowledge and thank key individuals particularly - Lord Diljit Rana, and Urmil Verma; organisations - Cordia Group of Institutes, Sanghol; Lord Rana Foundation Charitable Trust, and NNEdPro, for their time and resources towards this project. With the success of the Mobile Teaching Kitchen (MTK) project in Kolkata, the innovative initiative has since been adapted in different forms, throughout the country and all over the globe. One such adaptation was made in the land of five rivers – PUNJAB. MTK was inaugurated in Sanghol, Punjab at Cordia Group of Institutes and surrounding rural areas, in 2017. Sanghol is a place of great archaeological importance and also happens to be the birthplace of the NNEdPro Global Patron, Lord Diljit Rana (OBE). The project has been the rural replication of the MTK project in Kolkata, with further scope for cross-sectional study between two groups that include: 1. Mothers working in the educational institute of Cordia 2. Mothers residing in the villages around the Institute In 2019, 12 student volunteers, were trained in imparting Nutritional Education. Under their supervision, 10 mothers from the institute and 7 mothers from the nearby village ‘Pallo Majra’ were trained for dissemination of the skills and education in the surrounding areas to empower women and upgrade the health status of their children. But the first wave of COVID-19 led to a loss in connection with most of the student trainees due to various reasons such as academic progression. This also impacted the enthusiasm and interest of the community in the project, which translated to decreased involvement Post Covid. This brought the project to a plateau, that warranted completed rebuilding and retraining of the team for further phases. In the year 2021, new volunteers (students & teachers) were selected and the trained women from both the sub-sets were reapproached, leading us to relocate 5 of the in-house mothers. Village mothers could not be mobilised, as after the first wave, community women got involved in various programs initiated by both the State and Central government. Hence, the first, See One session for the newly inducted volunteers and Do One session for the old in-house mothers had been successfully conducted in November. A session with the team - pre and post-COVID-19. Due to a lack of involvement from the latter subset of women, a plan was devised to move into phase III of MTK directly from Phase-I, in March 2022 with consent from the college authorities and women keen to be attached to the project, mainly the smaller group of the former subset. The plan was to initiate a tiffin service or alternatively open a canteen serving healthy and nutritious snacks while disseminating knowledge to the consumers by in-house women with assistance from a few small entrepreneurs in the villages, who served homemade food to students/employees residing in their respective villages. This plan was made with the intention of fully realising the idea behind MTK and proving an opportunity for the women to follow through with their training and create a much larger impact through the dissemination of nutrition education to the wider communities attached to the villages. Due to several unavoidable factors, the plan couldn’t be executed and hence in September 2022, NNEdPro handed over participation certificates to people who were involved in the project since the beginning, along with a series of probable next steps, that they can follow to move forward with the MTK microenterprise in Punjab at Sanghol. Although our rural replication has come to an end this year, we hope to keep providing strategic support to women for being an entrepreneur or change agents for the community. Taruna Narang, the project facilitator from Cordia institute on behalf of all volunteer teachers mentioned that- “this project helped most of them to reconnect with the community influencer part of their self, which motivated them to be more connected with the students and learn new things about the community around them”. One of the hospitality departments when reflecting on the program said that - “they never realised while putting together ingredients for a dish that they form such an important part of a healthy life”. Certificate Distribution on 10th September 2022 It was a newer and enriching experience for both teams as we were able to understand the social and cultural setup in a rural area of Punjab and how it differs from urban areas in Kolkata. We look forward to incorporating the acquired experience into areas of new development for better outcomes in the future.

TIGR2ESS-FP6: The Mobile Teaching Kitchen (MTK) in India Series March 2023 Authors: Suveera Gill, Harmanpreet Kaur, Wanja Nyaga, Sarah Armes Editors: Sumantra (Shumone) Ray, Ramya Rajaram Acknowledgements: We would like to acknowledge and thank key individuals from Panjab University and NNEdPro, for their time and resources towards this project. ‘Economics’ is a factor that could affect the nutrition status and health of an individual. In developing countries like India, economic statuses such as purchasing power and affordability influence people's food choices, which in turn affects Nutritional Health. Health, Nutrition, and Spending Power form a TRIAD which is mainly neglected by both “Economists and Health Professionals.” The project, Transforming India's Green Revolution by Research and Empowerment for Sustainable food Supplies (TIGR2ESS) brought together a team that thinks out of the box and is dedicated to bringing about positive changes in and around them with innovative ideas of research and action plans. One such distinctive study design was put forward by Suveera Gill (Business Management Professor from Panjab University) and the team to connect the dots between the two most related and untouched topics of Nutrition and Costing. In this context, the cost of two North Indian vegetarian Thalis (platter), both for lunch and dinner for moderately active females and males, was planned and calculated, keeping in mind the sustainability of the ingredients (organic vis-a-vis conventional) used in the meal preparation. The quantities and nutritional value of dishes for preparing Thalis were based on the ICMR (Indian Council of Medical Research-National Institute of Nutrition, 2020) Dietary Guidelines. DietCal - an Indian professional dietary assessment and planning software based on the ICMR-NIN and Nutritics - software developed in London, was used for nutritional calculations. The study aimed to quantify what it costs a representative four-member household to prepare two full, balanced meals daily as agriculture can address nutritional and health problems by providing good quality harvests at affordable prices (Welch and Graham, 1999). Various studies (Magkos et al., 2003; Rosen, 2010 & Vigar et al., 2019) prove that organic food is tastier, more nutritious, and healthier as the bioavailability of nutrients is more than conventional food. But consumer awareness about this is scarce and is a definitive need of the hour. In India, organic farming is being practised by small and marginal farmers using biological fertilisers, derived from animal and plant wastes. However, organic food often has low yields with high production costs, making it more expensive for the general population. Thus, the trade-off between sustainability and affordability challenges the food system. Due to the lack of awareness in this field, both acceptance and practice are insufficient. With changes in the climate and its adverse effect on health, food choices, and livelihoods, we should consider changing our farming practices so that everyone can afford a healthy and nutritious diet. For sustainable development of the environment, health, and livelihood, providing support for organic farming by making favourable policies is an urgent requirement. We need to develop markets and facilitate linkages of production to consumption that benefits producers, consumers, and the environment. This value chain across the food system has been lacking in India, and added insight through further research can facilitate a planning strategy to move forward. This baseline study has contributed to unravelling the relationship between the healthfulness and cost of food nudging exploration in alternate contexts. To support the study further with evidence, NNEdPro has planned to include the concept of sustainability and costing in the new version of our Mobile Teaching Kitchens (MTK) cookbook 2.0, which will be launched by next year.

Author(s): Mayara de Paula and Sarah Armes Reviewer(s): Shane McAuliffe and Professor Sumantra (Shumone) Ray Diet has long been recognised as an important factor influencing our health. Today, fruits and vegetables, protein and healthy fats are at the top of everyone’s mind. One food group often overlooked are spices, those wonderfully colourful powders, seeds, bulbs, and roots that are used to add flavour and colour to the foods we cook and consume all around the world. Spices come from different parts of plants and shouldn’t be confused with herbs which only come from the leaves of the plant (Institute 2022). Despite spices being used in relatively small quantities in food, spices contain some of the highest concentrations of antioxidants, bioactive compounds, and polyphenols. These compounds have been shown to be protective against inflammation, oxidative stress, cancer, high blood pressure, diabetes, and cardiovascular disease (affecting the heart or blood vessels) to name a few. We’ve reviewed the research and highlighted the health benefits of some of the most consumed spices: Black Pepper Black pepper (Piper nigrum L.) is one of the most widely consumed spices worldwide, known for its pungent flavour when added to dishes, but also its ability to enhance the taste of other ingredients (Srinivasan 2007). The main active component of pepper is piperine which has been shown to reduce the time it takes to digest food, act as an antioxidant, enhance the bioavailability of drugs in the body, and possess anti-mutagenic and anti-tumour effects (Takooree et al. 2019). Garlic Belonging to the plant family of lilies, garlic is a type of bulbous plant that originated in central Asia. There are more than 450 varieties, first cultivated over 4000 years ago it is believed to be one of the oldest food flavourings discovered. Today, garlic is as popular as it was millions of years ago. Garlic has a long history of medicinal use with broad health benefits largely due to the presence of sulphur and various compounds including allicin, alliin, and methyl allyl trisulfide (MATS). These compounds have been shown to have anti-inflammatory effects even down to modulating inflammatory genes. As well as the active compounds, garlic is also high in B vitamins and vitamin C, making it an ideal nutrient-rich food to add to meals (Mirzavandi et al. 2020). Ginger Ginger is well-known throughout the world and is used extensively in Asian cuisines. Coming from the Zingiber officinale plant, ginger has been used as a traditional remedy for nausea, vomiting and pain. Like most spices, ginger has several compounds with the major ones being gingerol, shogaols, zingiberene, and zingerone (Zhang et al. 2021). In a large comprehensive review of 109 randomised controlled studies, ginger was found to improve chemotherapy-induced nausea and vomiting (CINV), nausea and vomiting in pregnancy, digestive function, osteoarthritis, pain, cancer risk factor, and metabolic markers including lipid levels, blood pressure and cholesterol levels (Anh et al. 2020). Cinnamon Cinnamon (Cinnamomum Zeylancium) has been used as a spice and as traditional herbal medicine for centuries, commonly added to beverages, desserts, liqueurs, teas, chicken and lamb dishes, bread, and pastries. Cinnamon exhibits varying levels of cinnamaldehyde, cinnamic acid, coumarin, linalool, eugenol, caryophyllene, and polyphenol polymers. Suggested beneficial health effects include anti-microbial activity, lowering of blood glucose, blood pressure and serum cholesterol, antioxidant properties, anti-inflammatory, wound healing properties and hepato-protective effects (Ranasinghe et al. 2013). Most of the human research on cinnamon has been undertaken to determine its effectiveness for the treatment of type 1 and/or type 2 diabetes mellitus. These findings are contradictory, yet there is some evidence to support this theory. Multiple clinical trials revealed that cinnamon improved glycaemic indicators (Khan, et al. 2003; Zare, et al. 2019; Lira Neto et al. 2022). Despite this, some studies have demonstrated no effect on glycaemic control and no preventive effect on metabolic diseases (Altschuler, et al. 2007; Talaei, et al. 2017). Turmeric Turmeric is a spice that is widely used throughout the Middle East and Asia not only to add flavour and colour to dishes, but also to provide health benefits as a component of traditional medicines. Turmeric is likely the most studied of the spices commonly combined with other spices in Asian cuisines and contains key bioactive curcuminoids, including curcumin. Curcumin, responsible for the vibrant yellow pigmentation, makes up approximately 3.14% of turmeric’s weight and is its main active phytochemical. Curcumin has interested researchers for its medicinal values and variety of biological functions, such as antibacterial, anti-inflammatory, antimicrobial, and anti-cancer effects (Kunnumakkara et al. 2017). Preliminary evidence from human trials, curcuminoid extracts and other novel formulations may have the potential to help manage symptoms of type 2 diabetes, metabolic syndrome, and arthritis. Despite its proposed beneficial properties, several studies have shown that curcumin is poorly absorbed, rapidly metabolized, and rapidly excreted; therefore, it has limited bioavailability (Singletary 2020). Food for thought Despite the growing interest in spices and health, most of the evidence available to date stems from animal studies. Another factor to consider is dosage. It is also worth noting that many spices, including those highlighted above, are poorly absorbed. As such, the dosage provided by research studies is usually much higher than the usual quantities of spices used in everyday cooking. Therefore, care should be taken when extrapolating the benefits to humans. By similar logic, while the proposed benefits of spices include the potential to positively impact on aspects of conditions such as cancer, cardiovascular disease, and diabetes, it is important to state that these compounds should not be considered as a replacement for evidence-based medical therapies. There is also a consideration of drug nutrient interactions with certain spice compounds and their influence on the bioavailability of different drug classes (for example curcumin and the chemotherapy drug acalabrutinib). While many interactions are likely to be dependent on dosage and probably be less likely to provide clinically relevant when consumed as part of a habitual diet, caution is advised if considering supplementation with higher doses (Pilla Reddy, Jo, and Neuhoff 2021). Despite some of the caveats within the research space, there is no doubt that spices have promising benefits which can be highly relevant in the nutrition space. Aside from the potential health benefits, adding spices to your daily cooking is a sure way to add more colour and flavour! Our pioneering Mobile Teaching Kitchen programme aiming to empower and educate marginalised communities through nutrition education has released its very own cookbook full of healthy recipes incorporating many wonderful spices. You can grab yours here! References: Altschuler, J.A., Casella, S.J., MacKenzie, T.A. and Curtis, K.M., 2007. The effect of cinnamon on A1C among adolescents with type 1 diabetes. Diabetes care, 30(4), pp.813-816. Anh, Nguyen Hoang, Sun Jo Kim, Nguyen Phuoc Long, Jung Eun Min, Young Cheol Yoon, Eun Goo Lee, Mina Kim, Tae Joon Kim, Yoon Young Yang, Eui Young Son, Sang Jun Yoon, Nguyen Co Diem, Hyung Min Kim, and Sung Won Kwon. 2020. 'Ginger on Human Health: A Comprehensive Systematic Review of 109 Randomized Controlled Trials', Nutrients, 12: 157. Institute, McCormick Science. 2022. 'CULINARY SPICES'. https://www.mccormickscienceinstitute.com/resources/culinary-spices. Khan, A., Safdar, M., Ali Khan, M.M., Khattak, K.N. and Anderson, R.A., 2003. Cinnamon improves the glucose and lipids of people with type 2 diabetes. Diabetes care, 26(12), pp.3215-3218. Kunnumakkara, A. B., D. Bordoloi, G. Padmavathi, J. Monisha, N. K. Roy, S. Prasad, and B. B. Aggarwal. 2017. 'Curcumin, the golden nutraceutical: multitargeting for multiple chronic diseases, Br J Pharmacol, 174: 1325-48. Lira Neto, J.C.G., Damasceno, M.M.C., Ciol, M.A., de Freitas, R.W.J.F., de Araújo, M.F.M., Teixeira, C.R.D.S., Carvalho, G.C.N., Lisboa, K.W.S.C., Marques, R.L.L., Alencar, A.M.P.G. and Zanetti, M.L., 2022. Efficacy of Cinnamon as an Adjuvant in Reducing the Glycemic Biomarkers of Type 2 Diabetes Mellitus: A Three-Month, Randomized, Triple-Blind, Placebo-Controlled Clinical Trial. Journal of the American Nutrition Association, 41(3), pp.266-274. Mirzavandi, Farhang, Mehdi Mollahosseini, Amin Salehi-Abargouei, Elham makiabadi, and Hassan Mozaffari-Khosravi. 2020. 'Effects of garlic supplementation on serum inflammatory markers: A systematic review and meta-analysis of randomized controlled trials', Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 14: 1153-61. Pilla Reddy, Venkatesh, Heeseung Jo, and Sibylle Neuhoff. 2021. 'Food constituent– and herb-drug interactions in oncology: Influence of quantitative modelling on Drug labelling', British Journal of Clinical Pharmacology, 87: 3988-4000. Ranasinghe, Priyanga, Shehani Pigera, G. A. Sirimal Premakumara, Priyadarshani Galappaththy, Godwin R. Constantine, and Prasad Katulanda. 2013. 'Medicinal properties of ‘true’ cinnamon (Cinnamomum zeylanicum): a systematic review', BMC Complementary and Alternative Medicine, 13: 275. Singletary, Keith. 2020. 'Turmeric: Potential Health Benefits', Nutrition Today, 55. Srinivasan, K. 2007. 'Black Pepper and its Pungent Principle-Piperine: A Review of Diverse Physiological Effects', Critical Reviews in Food Science and Nutrition, 47: 735-48. Talaei, B., Amouzegar, A., Sahranavard, S., Hedayati, M., Mirmiran, P. and Azizi, F., 2017. Effects of cinnamon consumption on glycemic indicators, advanced glycation end products, and antioxidant status in type 2 diabetic patients. Nutrients, 9(9), p.991. Takooree, Heerasing, Muhammad Z. Aumeeruddy, Kannan R. R. Rengasamy, Katharigatta N. Venugopala, Rajesh Jeewon, Gokhan Zengin, and Mohamad F. Mahomoodally. 2019. 'A systematic review on black pepper (Piper nigrum L.): from folk uses to pharmacological applications', Critical Reviews in Food Science and Nutrition, 59: S210-S43. Zare, R., Nadjarzadeh, A., Zarshenas, M.M., Shams, M. and Heydari, M., 2019. Efficacy of cinnamon in patients with type II diabetes mellitus: A randomized controlled clinical trial. Clinical nutrition, 38(2), pp.549-556. Zhang, Mengmeng, Rong Zhao, Dan Wang, Li Wang, Qing Zhang, Shujun Wei, Feng Lu, Wei Peng, and Chunjie Wu. 2021. 'Ginger (Zingiber officinale Rosc.) and its bioactive components are potential resources for health beneficial agents', Phytotherapy Research, 35: 711-42. Photo: Christina Rumpf

Seven decades of Queen Elizabeth II as the beloved monarch of hearts and minds We at NNEdPro were deeply saddened by the passing of Her Majesty The Queen on 8th September 2022. Our thoughts and condolences go out to The Royal family and all her loved ones. Ahead of the state funeral on 19th September 2022 we are sharing this humble tribute. Our Honorary Joint Presidents, The Lord Rana OBE and The Lord Balfe, both members of the House of Lords, and NNEdPro Associate Director Dr Rajna Golubic (University of Oxford), have had the pleasure of meeting Queen Elizabeth II on various occasions and reminisce on their encounters with affection. Lord Diljeet Singh Rana OBE, in his role as a member of the House of Lords and leading on many aspects of UK-India business relations, has had the privilege of seeing Her Majesty in person at innumerable gatherings, as well as meeting personally. On one particular occasion, Lord Rana was invited to join a small group to dine with The Queen and fondly remembers how amazed he was by how the she put all her guests at ease and the remarkable attention to detail she had when making everyone feel so comfortable and valued. Lord Rana speaks of her incredible knowledge, quality of conversation, as well as her interest and dedication to service as being exemplary and unique. He feels truly honoured to have had the acquaintance of Her Late Majesty Queen Elizabeth II and conveys that her kindness will forever be remembered by one and all. Lord Balfe also had the pleasure of meeting Her Majesty on various occasions in his role as a member of the House of Lords. According to him, Her Majesty realised the importance of international solidarity. Her devotion was not just to the Commonwealth but to its peoples of many different races, religions and levels of affluence. Like NNEdPro, she supported the developing world and its people. We can take strength from her example in developing our International cooperation and desire to build a more just and equitable world. NNEdPro Associate Director, Dr Rajna Golubic, had the pleasure of meeting Her Majesty during the quincentenary celebration of St John's College in April 2011. Dr Golubic, being a representative of the graduate student committee, was one of the few invited to attend the celebratory lunch with Her Majesty The Queen and speaks fondly of this once-in-a-lifetime opportunity. She will cherish the memory of The Queen's genuine interest in the research taking place, her warm and kind manner, and her dedication and service to the nation which was evident not only in her life's work but also when meeting in person. Dr Golubic is deeply saddened by Her Majesty's passing and will remember her for her elegance, clarity of communication and the role model she became for many female leaders. As a global organisation headquartered in the UK but working across continents, many of us have taken inspiration from the life and work of Queen Elizabeth II, who was loved and respected by millions all over the globe. Through seven decades of selfless service, she gave the UK a unique place in the modern world. May Her Majesty rest in peace, and may her unparalleled legacy live forever more! Compiled by Professor Sumantra Ray, Sarah Anderson and Matheus Abrantes on behalf of the NNEdPro Global Institute for Food, Nutrition and Health (Cambridge, UK) Images from https://www.royal.uk

Written by: Wanja Nyaga Reviewed by: Dr Luke Buckner, Sally Ayyad, Ebiambu Agwara, and Prof Sumantra Ray Nutrition Implementation Coalition The Nutrition Implementation Coalition was formed in 2019 as a collaborative group convened by NNEdPro and including Nutritank, ERimNN and Culinary Medicine UK. Together, these organisations bring a variety of educational, professional and research experiences, sharing the same vision to advocate for a greater focus on nutrition education for healthcare professionals. This coalition fully supports the implementation of the newly launched national nutrition curriculum in the UK but recognises that the most challenging step is still to come in implementing this into medical school training. AfN Curriculum October 2021 marked the launch of the new Association for Nutrition (AfN) convened Curriculum in Nutrition for medical graduates (co-created with a nationally representative Inter-Professional Group in the UK). NNEdPro colleagues took part in the process of formulating and launching the curriculum. This nutrition curriculum provides undergraduate students with the knowledge, understanding and skills required to support them in being safe practitioners before they move on to the next stage of their medical training. The Undergraduate Curriculum in Nutrition for Medical Doctors supports the development of 13 core nutritional competencies for all undergraduate medical students at the point of graduation, assessed through the achievement of 11 graduation fundamentals. The curriculum supports the understanding and skill development of the core competencies and has 8 key curriculum statements. The curriculum statements are supported by teaching points which can be integrated across foundation courses (or introductory learning) where the principles of basic nutrition underpinning good health across the life course can be incorporated alongside basic biochemical and physiological principles, within public health teaching, and within clinical teaching by speciality. Thus, ensuring students understand the importance of nutrition in the prevention and both the progression and management of disease and conversely how disease can exert an effect on the nutritional state. Roundtable In February 2022, the Nutrition Implementation Coalition coordinated and chaired a roundtable with approximately 29 representatives from 14 medical schools. The aim of the Roundtable was to bring together medical schools and interested nutrition educators in the UK, providing a ground for discussion on how different curriculum developers can envision accommodating greater focus on nutrition for medical students. What did we learn from the roundtable? Below is our capture of key points shared by various members during the roundtable highlighting where they felt it is important medical students are competent and confident on graduation. Medical Attitudes in Nutrition Care Acting as role models to doctors and other health professionals Recognising how all members of the Multidisciplinary team (MDT) have a role in developing and supporting good nutritional care Nutrition knowledge Understanding the role of food and nutrition in the management of NCD, and other disease states/health issues Nutrition Practice Understanding nutrition science and recognise how they contribute to: - Identifying those at risk of malnutrition/or are malnourished through history taking, screening, routine blood tests Thinking about drug-nutrient interactions when prescribing/reviewing It was agreed that doctors are an important part of the MDT and should act as role models in ensuring the identification, first-line treatment and monitoring of nutrition status. It is also important they are confident to use all the resources available to them, including clinical and social prescribing and referring to registered dietitians and nutritionists where appropriate. Further feedback highlighted how this may be incorporated into medical curricula: Integrating nutrition where relevant rather than a standalone subject may help to demonstrate relevance to students and can be added in short regular additions to current teaching. Medical students would value more practical consultation skills and a chance to practice in simulated patient consultations. Clear signposting where nutrition teaching is placed ensures teaching is explicit via learning outcomes and linked to examination. Linking knowledge directly to patient care- A case-based approach seems to be easier for students to identify with. Doctors are not nutritionists but can benefit from learning more detail on nutrition interventions where relevant. Collaborating with nutrition faculty and dietetic colleagues helps to provide teaching expertise and can assist medical schools in lecture delivery and course development. In summary, there is recognition that nutrition training for doctors needs improvement, but is unlikely to get large amounts of extra time. Hence, there was a focus on greater emphasis on existing content, signposting to further reading, and practical training with clear translation to clinical care. It is also highlighted that doctors should not be expected to be nutritionists and so will need to recognise the capabilities of their training and use experts such as dietitians and trained nutritionists. Link to the AfN curriculum. Survey Responses In a few words, share ideas on how to improve the implementation of nutrition education. Do you perceive barriers to implementing more nutrition at your medical school, and if possible, please share in the text below. Yes. No. Why? Give two examples of where you have already changed (or plan to change) your medical school nutrition training.

Since its inception, NNEdPro’s COVID-19 Taskforce has worked to improve health during the COVID-19 pandemic, by focusing on nutrition research, clinical practice and public health. As a global organisation, our dedicated microsites contain a repository of generic and region specific public health resources to highlight up-to-date policy and practice across our regional networks(1). Additionally, the taskforce has identified areas for research and evidence synthesis relating to the nutritional aspects of COVID-19 prevention and treatment, including issues of food and nutrition security (2). Our aim has been to coordinate and share resources with NNEdPro’s global and regional networks, and the public, to highlight key challenges, policy updates and best guidance on good nutrition and health practices in the context of COVID-19. Each month the NNEdPro COVID-19 microsites are updated with new resources related to both public health and nutrition in the context of the COVID-19 pandemic. These evidence collections are linked closely with our research focussed ‘Evidence Tracker’ as well as the International Knowledge Application Network Hub in Nutrition (iKANN). Alongside this, we will endeavour to produce a monthly statement reflecting on these updates to the evidence base as well as inviting thoughts from taskforce members involved in these areas of work. Public Health Updates There has been a focus on COVID-19 vaccines during July and August, with a particular focus on three population groups. Two studies have investigated COVID-19 vaccination in pregnancy (3,4). Pregnancy is an independent risk factor for severe COVID- 19, and vaccination is the best way to reduce the risk of infection. However, there have been some opposing opinions from professionals and the public regarding the safety of using vaccines before, during and post pregnancy. The World Health Organisation (WHO) and Centers for Disease Control (CDC) considered the potential effects of vaccination on foetal development, placental transfer of antibodies and maternal safety and have decided to recommend pregnant, postpartum and lactating women to receive the COVID-19 vaccine. In this review, the authors examined the evidence supporting the effectiveness, immunogenicity, placental transfer, side effects, and perinatal outcomes of maternal covid-19 vaccination, as well as describing the vaccine hesitancy in pregnancy (3). A Canadian population based retrospective cohort study assessed the risk of preterm birth, small for gestational age at birth, and stillbirth after covid-19 vaccination during pregnancy (4). The authors concluded that COVID-19 vaccination during pregnancy was not associated with a higher risk of preterm birth, small for gestational age at birth, or stillbirth. There is still little evidence into the pregnancy specific effects of COVID-19 vaccines. Therefore, vaccination during pregnancy must be prioritized in vaccine research. A BMJ feature looked into what is known about COVID-19 vaccines in children under 5 years (5). The US authorised the vaccination of under 5s in June 2022, joining Argentina, Bahrain, Chile, China, Cuba, Hong Kong, the United Arab Emirates, and Venezuela in offering covid-19 vaccines to the youngest age category. The UK is currently only offering vaccines to those over the age of 5. This feature reported on the evidence of the vaccines’ effectiveness in this age group. A multicentre prospective cohort study described the incidence of, risk factors for, and impact of vaccines on primary SARS-CoV-2 infection during the second wave of the covid-19 pandemic in susceptible hospital healthcare workers in England (6). The study investigated NHS clinical, support and administrative staff between September 2020 – April 2021 and recorded their COVID-19 infection and vaccination status. Being under 25 years, living in large household, having frequent exposure to COVID-19 patients, working in an emergency department and being a healthcare assistant were the factors increasing the likelihood of infection in the second wave. Time to first vaccination was strongly associated with infection (P<0.001), with each additional day multiplying a participant’s adjusted odds ratio by 1.02. The authors concluded that without the rapid COVID-19 vaccine rollout to healthcare workers in England from December 2020, the second wave infections could have been 69% higher. Equitable delivery of booster vaccines to healthcare workers is therefore essential. ​ Nutrition Updates A number of further papers have been added to the nutrition resources site across the months of July and August. The BMJ-NPH Nutrition Interactions with COVID-19 special collection has seen 3 new publications in the last number of weeks (7). Two publications from July examine the impact of dietary interventions (periodic fasting and ketogenic diet therapy) on metabolic health (8,9), a widely considered risk factor for COVID-19 susceptibility and severity. The most recent August submission comes from a collaboration between members of the NNEdPro Nutrition and Covid-19 Taskforce and Diabetes Digital Media (DDM), providing interesting insights into changes in diet, physical activity and sleeping behaviours in adults with type 1 and type 2 diabetes during the COVID-19 pandemic in the UK (10). Additional factors considered in new papers added include the impact of ultra-processed food intake on the risk of COVID-19, with data taken from the UK Biobank suggesting a higher risk associated with higher UPF consumption (11). Further to this, a Finnish epidemiological study examines the effects of the pandemic on incident cases of chronic disease, suggesting reduced access to healthcare services as an important factor in their findings (12). On the subject of food security, two studies examine the implications for food access during pandemic times. One study from the Academy of Nutrition and Dietetics in the USA describes changes in practice, challenges and areas of need for registered dietitians working in the area (13). A further systematic review examines global trends in food security and dietary habits of University students (14), noting some concerning trends posing a high risk of weight gain and food insecurity. The final additions to the microsite collections consider the role of micronutrients in cardiovascular disease and potential implications for COVID-19 infection (15), a clinical case report on the complexities of long-term care With Gastro-Jejunal (GJ) feeding tubes and enteral migration (16) and lastly, qualitative exploration of the clinical presentation, trajectory, management and recovery of COVID-19 in older people (17). References ​ COVID-19: Useful Resources: https://www.nnedpro.org.uk/coronavirus COVID-19: Nutrition Resources: https://www.nnedpro.org.uk/covid-19nutrition-resources Covid-19 vaccination in pregnancy: https://www.bmj.com/content/378/bmj-2021-069741 Risk of preterm birth, small for gestational age at birth, and stillbirth after covid-19 vaccination during pregnancy: population based retrospective cohort study: https://www.bmj.com/content/378/bmj-2022-071416 What do we know about covid-19 vaccines in under 5s? https://www.bmj.com/content/378/bmj.o1892 Burden of SARS-CoV-2 infection in healthcare workers during second wave in England and impact of vaccines: prospective multicentre cohort study (SIREN) and mathematical model: https://www.bmj.com/content/378/bmj-2022-070379 BMJ NPH Nutrition Interactions with COVID-19: https://nutrition.bmj.com/pages/collections/nph_nutrition_interactions_with_covid-19/ Association of periodic fasting with lower severity of COVID-19 outcomes in the SARS-CoV-2 prevaccine era: an observational cohort from the INSPIRE registry https://nutrition.bmj.com/content/early/2022/06/30/bmjnph-2022-000462 Reduced COVID-19 severity elicited by weight loss from a medically supervised ketogenic diet in a geographically diverse ambulatory population with type 2 diabetes and obesity https://nutrition.bmj.com/content/early/2022/07/01/bmjnph-2022-000444 A web-based survey assessing perceived changes in diet, physical activity and sleeping behaviours in adults with type 1 and type 2 diabetes during the COVID-19 pandemic in the UK https://nutrition.bmj.com/content/early/2022/07/19/bmjnph-2021-000391 Impact of ultra-processed food intake on the risk of COVID-19: a prospective cohort study - https://pubmed.ncbi.nlm.nih.gov/35972529/ The impact of the COVID-19 pandemic on incident cases of chronic diseases in Finland https://pubmed.ncbi.nlm.nih.gov/35972418/ Repeated Cross-Sectional Surveys of Registered Dietitian Nutritionists Demonstrate Rapid Practice Changes to Address Food Insecurity During the COVID-19 Pandemic https://pubmed.ncbi.nlm.nih.gov/35963532/ Effect of COVID-19 Outbreak on the Diet, Body Weight, and Food Security Status of Students of Higher Education; A Systematic Review https://pubmed.ncbi.nlm.nih.gov/35946073/  https://pubmed.ncbi.nlm.nih.gov/35946073/ The Mutual Relationship among Cardiovascular Diseases and COVID-19: Focus on Micronutrients Imbalance https://www.mdpi.com/2072-6643/14/16/3439 Complexities of Long-Term Care With Gastro-Jejunal (GJ) Feeding Tubes and Enteral Migration During COVID-19 Pandemic Times: A Case Report https://pubmed.ncbi.nlm.nih.gov/35968246/ A qualitative exploration of the clinical presentation, trajectory, management and recovery of COVID-19 in older people: Learning from frontline staff experiences https://pubmed.ncbi.nlm.nih.gov/35962626/ ​ Previous monthly statements ​ April 2022 May 2022 June 2022 July 2022 ​

Authors: Nikitah Ray (NNEdPro Junior Ambassador Co-Lead & Founder of the ‘Nikitah’s Little Library’ project) & Sucheta Mitra (NNEdPro India & MTK Co-Lead) Reviewer/Editor: Prof Sumantra (Shumone) Ray Special Acknowledgements: NNEdPro India/MTK Team (Debashis Chakraborty, Harmanpreet Kaur, Asim Manna, Sabyasachi Ray); NNEdPro India/MTK Educational Supervisors (Mitali Gupta, Chitra Ray, Elizabeth Richards); NNEdPro/MTK Kolkata Champions; Minha Rajput-Ray, Luke Buckner & MTK Researchers (NNEdPro Virtual Core) Note: These images have been shared with the consent of the families and communities involved In 2016 NNEdPro decided to start working on improving the nutritional status in urban slums of India; we had detected some barriers so during the summer of 2017 we held a workshop in Cambridge to give ideas for the first and foremost design of the kitchen as a previous physical facility had been demolished as it was built in an unregistered slum territory so the council did not like this slum having ‘privileges’ of their own; I (Nikitah) had been in that meeting and had decided to sketch one of my own, and being 8 years old at the time I had decided to base it off a mobile ice-cream van! Ironically, this caught the attention of many NNEdPro core members who chose to look at the opportunities it would bring and weighing out the pros and cons it was considered something with serious potential. From there professional blueprints were being made, collaborators were getting on board and soon 5 members of NNEdPro, Luke, Lanthi, Riya, Minha and Sumantra were bringing in ~£40K in funding which would help for a physical van to be designed especially for a teaching kitchen. The concept became an enterprise officially named the NNEdPro Mobile Teaching Kitchen (MTK) where the central motto is ‘see one, do one, teach one‘ which encourages MTK champions to teach others, meaning that the knowledge is wider spread than just the MTK. From starting out by giving food for free to seeing customers' experience to being able to charge for the nutritionally enhanced vegetarian menus in several parts of Kolkata and India, here are the mothers are learning to cook the kitchen food in preparation for the MTK. And here the champions are in the kitchen itself serving food to the public. Following the success of the MTK, the mobile library is a separate entity we created attached to the slums where the main MTK champions live and these are attached to the schools in these slums. Nikitah’s Little Library The word ‘library’ is derived from the Latin liber, “book”.The first systematically organised library in the ancient Middle East was established in the 7th century BCE by Assyrian ruler Ashurbanipal in Nineveh, in contemporary Iraq. It contained approximately 30,000 cuneiform tablets assembled by topics. Shiyali Ramamrita Ranganathan, (born August 9, 1892, Shiyali, Madras, India—died September 27, 1972, Bangalore, Mysore), an Indian librarian and educator, was known as the father of library science in India and her contributions worldwide influence. The idea of a Mobile Library for the children of the marginalised communities in Kolkata, India was outlined (by Nikitah) as early as 2018 when the MTK entered operations. However, this came to fruition when in Autumn 2021 funds were raised (by Nikitah from her school) via a children’s workshop on ‘Diwali and spreading kindness’ organised by the parents’ association and primary section at St Leonard’s School in St Andrews Scotland. At the end of March 2022 and early April 2022, the mobile library idea was executed in two slums at Kolkatanamely Chetla Lock Gate and RG Kar, where NNEdPro is working to create Nutritional Knowledge awareness amongst women and families since 2017. On 30th March 2022, Nikitah’s little library was inaugurated and set up at the Integrated Child Development Services (ICDS) school in the Chetla slum community, where 3 college students from the slums were assigned the duty of Librarians to distributing books among interested children from the slum and nearby areas to read and learn, keeping track of borrowing, monitor attendance of children in Library, and gathering more books for the library. This library was inaugurated by members of the NNEdPro Global delegation present at the time. Similarly, on 14th April 2022, Nikitah’s little library was set up in the RG Kar slum at a registered club named “Milan Saathi”. A named ICDS teacher has been given the responsibility of taking care of books and making sure that education reaches every child residing in that/nearby area. This library was inaugurated by local Councilor Dr Meenakshi Ganguly, a renowned Gynecologist in Kolkata. Both Libraries have started taking up considerable pace in line with the mission of EDUCATION FOR ALL and provide hubs for bilingual literacy and educational materials in English, Bengali and translations between the two languages particularly for ages 5-15. We hope to see these libraries flourish and develop further in long run to help ignite the untapped potential of the next generation as we bring together linguistic aspects of literacy together with learning in food, nutrition, health, and life skills. Please donate NOW by clicking THIS LINK.

Chefs as Agents of Change to Accelerate Transformation of Food Systems through solutions-driven advocacy for culinary and food professionals Author: Jaroslav Guzanic (Executive Chef; Culinary Instructor/Educator; Project Director and Founder of the Swiss Association for Cooperation on Food Education; Chefs' Manifesto Switzerland; Co-Lead of the NNEdPro Swiss and Non-Mediterranean Europe Regional Network) Acknowledgements for consultation: Keren Allen (Project and Partnership Lead – SDG2 Advocacy Hub Secretariat | www.sdg2advocacyhub.org); Wanja Nyaga, Sucheta Mitra and Matheus Abrantes (NNEdPro) Reviewer/Editor: Professor Sumantra (Shumone) Ray The Chefs’ Manifesto, together with the support of multiple partner networks (also with the support of the Swiss Association for Cooperation on Food Education as a research promoter) compiled a survey between February-May 2021 to learn what chefs perceive to be the top practical actions they can take to help accelerate food systems transformation in the Decade of Action. The UN Food Systems Summit (UNFSS) was convened by UN Secretary-General António Guterres and held in September 2021. The purpose was to shape global commitments and to raise global awareness of food systems, and how they might be transformed to reduce diet-related diseases, resolve hunger, and restore planetary health. The Secretary-General was calling all citizens to collective action, to “radically change the way we produce, process, transport, market and consume food”1. Building on global platforms and events, the UNFSS aimed to generate agreements and highlight collaborative actions. Initiatives locally, regionally, nationally, and globally that support food systems transformation had been explored prior to the Summit occurring. Knowledge sourced from these initiatives informed future recommendations from the Summit. The UNFSS followed 5 Action Tracks 1. Ensuring access to safe and nutritious food 2. Shifting to sustainable consumption patterns 3. Boosting nature-positive production 4. Advancing equitable livelihoods 5. Building resilience to vulnerabilities, shocks and stress2 2021 was a critical year with events such as the UNFSS, Nutrition for Growth (N4G) and COP 26 all being convened throughout 2021, truly was a superb year of opportunities for collective action whereby chefs created a global manifesto identifying a framework of actionable steps. It was critical that advocacy actions were at the forefront of these events, driving forward change by bringing in as many diverse voices as possible, to ensure that 2021 actively heralds in the remainder of the Decade of Action to achieve the SDGs. As Agents of Change, and to drive action, chefs need to come together in one collective, connected voice. Chefs’ Pledge The Chefs’ Manifesto network took a leading role to further focus and narrow the SDG roadmap for chefs, as well as bridging and connecting across chef networks worldwide. This was motivated by the UN Food Systems Summit, and the urgent need to generate actions to be able to achieve the SDGs by 2030. Through conducting a survey, the aim was to learn from participants, what the top priorities were for 2021, the results of which informed the creation of a ‘Chefs’ Pledge’. This Pledge was a commitment to key practical priorities that can have the greatest impact to enact change in and across food systems. It aimed to create collective momentum to rally greater attention and engagement of chef food systems champions, mobilising them even further as agents of change, at key global events, especially the past UN Food Systems Summit. Participants and Stakeholders 1. Chefs and cooks and other partner networks who had wished to join 2. External certified, as well as non-certified chefs 3. Scientific group of the UNFSS 4. Chairs and Vice Chairs of the Action Tracks 5. Other scientists and food professionals 6. Food science and culinary students Objectives This international survey aimed to narrow the already existing Chefs’ Manifesto Action Plan[1], formed from the UN SDGs to a much more succinct, 8-point practical action pledge, which could begin to be immediately implemented by existing and future chefs, cooks, and food professionals. Through statistically prioritising which actions would be deemed to have the most impact from the wider Action Plan, the objective was to uncover the 8 key actionable solutions chefs globally would like to prioritise to tackle food systems challenges and accelerate transformation. The research was conducted from late February through to May 2021. Study Design The aim was to conduct analytical surveys, questionnaires and multiple global, inclusive dialogues across the culinary sector (the reports of which were submitted to the UN Food Systems Summit 2021) interviews to learn from participants what the top priorities for chefs in 2021 and beyond were and what actions and impactful ideas they have enforced, the results of which informed the creation of a Chefs’ Pledge - a potential SDGs roadmap for other chefs and culinary students to improve food systems in their specific region or community. The survey was translated into several languages, including Mandarin/Chinese, Arabic and Spanish. This allowed for a greater diversity of voices and participation. The preliminary results were published in June 2021 as part of the preparations for the 2021 UN Food Systems Pre-Summit Event, which was held in Rome, Italy. Other key information and data were also collected during the Swiss Independent Dialogue on May 14 2021 organised by the Swiss Association for Cooperation on Food Education. Timeline Methods Chefs’ Manifesto and partnering organisations invited participants via social media, direct email, through partner networks and various campaigns. Effective until the 1st of June 2021, several hundred respondents have participated from more than 50 countries, with a wide variety of skills and expertise, yet all with a common goal: to make the positive transformation to our food systems, share existing examples of practice and accelerate good food for all. Survey participants identified as being engaged as one of the following: trained chefs and scientists (represented by 62%), cooks (7%), culinary students (3%) and other food-related non-culinary professionals (24%). Over 50 countries were represented including, but not limited to India, the Philippines, Ghana, Slovakia, South Africa, Colombia, China, Brazil, Mexico, Ireland Australia, Austria, New Zealand, Kenya and Switzerland. The survey questions were categorized into 8 Thematic Areas as introduced above. At the end of the survey, participants were asked to share practical and innovative actions (based on the thematic areas) they have been implementing or measures and efforts they had implemented in support of the transformation of food systems. A summary of the responses is as follows and has been prioritized based on the statistical prevalence of all, so far received replies to the survey questions (to each thematic area) and subsequent dialogues. Each question was headlined with one of the 8 Thematic Areas. Participants were asked to rank using a number system, with 1 = most important = the action they believe would have the greatest impact when implemented. The Chefs’ Manifesto created the survey, engaged, co-ordinated and briefed partner networks to support partner networks to promote and conduct the survey. Secondly, they collected and analysed the data, and hosted several dialogues to discuss findings and the Chefs’ Pledge commitment and curated Chefs’ Pledge commitment. Moreover, they shared an official logo and asked all participants to place the designed materials on all Chefs’ Pledge graphics and curated social media tiles for wider dissemination. Furthermore, the Chefs’ Pledge was disseminated throughout the Chefs’ Manifesto and partner networks to promote, share, and seek commitments globally and also shared the Chefs’ Pledge commitment with the UNFSS. Finally, they committed themselves to organising several chefs to participate and be the public face of the actions at different global key events hosted by the UN and its partnering networks. Partner networks and individual participants promoted the survey within their networks, and shared links via email and social media. They participated in dialogues hosted by the Chefs’ Manifesto. Additionally, they put forward specific chefs and/or delegates to endorse the Chefs’ Pledge and suggested chefs and/or delegates participate in FSS dialogues focused on this throughout 2021 and suggest chefs endorse the Chefs’ Pledge alongside global events such as the FSS, COP 26 and N4G. The Chefs’ Manifesto will act as the convenor of the Chefs’ Pledge and the pledge was being taken from the Action Plan in the Chefs’ Manifesto aligned to the SDGs. Any network that signed onto the pledge had its logo represented on the document as a partner network. In exchange, they promoted the survey to their members and hosted a discussion or dialogue to help shape the final pledge. Results Thematic Area 1: Ingredients are grown with respect for the earth & its oceans Action 1: Choosing ingredients with the lowest impact on the environment (38%). Action 2: Use purchasing power by choosing producers or suppliers who work sustainably and only buy from the sources who share your values (28%). Action 3: Sustainable ingredients and producers through your menus in restaurants, public catering venues and community kitchens (34%). Thematic Area 2: Protection of biodiversity and improved animal welfare Action 1: Use different varieties of plants, grains, and proteins and champion “wild” variants and avoid monoculture (31.8%). Action 2: Raising awareness about the importance of free-range eggs, sustainably sourced fish and animal welfare on daily menus in households and restaurants (21.8%). Action 3: Choosing producers who commit to higher animal welfare standards (19.4%). Action 4: Using purchasing power to choose only fish and seafood that is abundant and sourced sustainably (27%). Thematic Area 3: Investment in Livelihoods Action 1: Knowing your ingredients and investigating the journey from farm to fork and reducing the number of intermediaries between you and the farmer (23.4%). Action 2: Use your purchasing power to choose products that are priced fairly, to enable a viable livelihood for farmers and suppliers (13.5%). Action 3: Supporting more farmers to access marketplaces by choosing to buy from small-scale producers (13%). Action 4: Promoting equal opportunities and providing training within your restaurants (15.8%). Action 5: Providing training and mentoring to chefs (15.8%). Action 6: Further support for female farmers, female producers and female chefs (18.5%). Thematic Area 4: Natural resources and reduction of food waste Action 1: Monitoring and setting targets to reduce and prevent food waste. It is also about managing food safety processes and use by dates to avoid wastage (15%). Action 2: Planning food orders and menus to minimise food waste by offering smaller portion sizes (11.9%). Action 3: Being creative through pickling, preserving, dehydrating and freezing (11%). Action 4: Using purchasing power to engage with suppliers and producers to help incorporate surplus produce into menus (10.6%). Action 5: Become a community food champion and re-distribute surplus food through community sharing and food bank programmes or apps (11%). Action 6: Being resource efficient and managing water usage to cut costs and protect the environment (13%). Action 7: Diverting waste from landfill and investigating turning food waste into compost or bio-gas. It is about considering offsetting the carbon used in your restaurant or switching to renewable energy sources (14%). Action 8: Using purchasing power through working with producers and suppliers to avoid excess packaging and to use recycled, recyclable and biodegradable packaging (13.5%). Thematic Area 5: Celebration and local foods Action 1: Use your purchasing power by buying locally produced foods in season and avoiding air-freighted foods (27%). Action 2: Showcasing local producers and traditional techniques on restaurant menus (17%). Action 3: Become a community food champion through engaging with your local community and working with schools and teaching kids about nutritious food and how to cook it (17%). Action 4: Becoming the connection between producers and consumers. Helping to show people where their food comes from. Inviting farmers and connecting them to diners. Organise events to bring people - young and old - together around good food. (16%) Action 5: Promoting kitchen gardens and urban farming. Encouraging people to start growing their own food. (24%). Thematic Area 6: A focus on plant-based ingredients Action 1: Make vegetables, beans and pulses the centre of your dishes (32.5%). Action 2: Using less, and better, meat (20.6%). Action 3: Incorporating plant-based proteins on menus and in restaurants and other public catering venues (20.6%). Action 4: Avoid using words like “vegan” and “vegetarian” which may be off-putting (26.3%). Thematic Area 7: Education on food safety and healthy diets Action 1: Showcasing best practise on food safety, allergens and nutrition in your kitchens and through your menus. (24%) Action 2: Be a community food champion and support good nutrition education for all young and old. Volunteer to teach a nutritious cooking class in a school, community centre or care home. (18%) Action 3: Educating diners about the importance of eating a colourful plate. (20%) Action 4: Use annual events like International Chefs Day (20 October), World Food Day (16 October) and local holidays to get creative and engage people in nutritious cooking. (18%) Action 5: Using technology as a tool for teaching others. Make videos, and run webcasts and online sessions. Thematic Area 8: Nutritious food that is accessible and affordable for all Action 1: Support initiatives that provide access to nutritious meals in communities (43%) Action 2: Helping raise awareness about what a nutritious meal looks like and how to cook well on a budget. (30%) Action 3: Creating more Chef's communities across the world to share stories, best practices and learnings on how to help ensure good food is accessible and affordable for all. (18%) Action 4: Spreading the word and using social media to raise awareness about food issues and how to be part of the solution (9%).4 Conclusion The conclusion resulted in 8 practical actions that were deemed the most likely to accelerate food systems transformation. These were as follows: 1. I will get to know my ingredients: How are they grown, reared or sourced? I will choose ingredients with the lowest impact on the environment. 2. I will lead by example: To maintain the rich diversity of the world’s natural larder by using different varieties of plants, grains and proteins. I will champion ‘wild’ variants and avoid monoculture. 3. I will get to know my ingredients: Who grows, harvests, sources and packages them? How do they get to you? I will investigate the journey from farm to fork. I will choose ingredients with as few intermediaries as possible between myself and the farmer. 4. I will lead by example: by separating, monitoring and setting targets to reduce food waste. 5. I will use my purchasing power: Buying locally produced foods in season and avoiding air-freighted foods. 6. I will lead by example: Making vegetables, beans and pulses the centre of my dishes. 7. I will be a community food champion: Showcasing best practices on food safety, allergens and nutrition in my kitchen and through my menus. 8. I will be a community food champion: Supporting initiatives that provide access to nutritious meals. Chefs were then asked to sign a pledge, committing to one or more of these actions, to help ensure good food for all. Continuity of the research, as well as satellite activities and events, followed until December 2021. In 2022 following the NNEdPro International Summit on Nutrition and Health, there is momentum and opportunity to develop as well as implement several of these practical actions, especially in the wake of the globalisation of the Mobile Teaching Kitchen initiative: www.nnedpro.org.uk/mtk References 1https://www.unccd.int/actions/food-systems-summit-2021 2https://www.unccd.int/actions/food-systems-summit-2021 3 https://sdg2advocacyhub.org/chefs-manifesto/chefsagents 4https://sdg2advocacyhub.org/chefs-manifesto/actions/chefs-pledge-results-are Attachment 1: Global Dialogues Summary https://www.un.org/sites/un2.un.org/files/global-dialogues-compiled-summary_final.pdf Websites www.foodplatform2030.org www.nnedpro.co.uk/switzerland Research Design and Implementation The Chefs’ Manifesto Other Researchers The Chefs’ Manifesto, World Association of Chef's Societies, Social Gastronomy Movement, Chef Ann Foundation, Le Cordon Bleu London, Good Food Fund China, James Beard Foundation, Chefs 4 the Planet and other external networks – the full list of researchers and other details regarding the survey can be requested by sending an inquiry to info@foodplatform2030.org

Since its inception, NNEdPro’s COVID-19 Taskforce has worked to improve health during the COVID-19 pandemic, by focusing on nutrition research, clinical practice and public health. As a global organisation, our dedicated microsites contain a repository of generic and region specific public health resources to highlight up-to-date policy and practice across our regional networks(1). Additionally, the taskforce has identified areas for research and evidence synthesis relating to the nutritional aspects of COVID-19 prevention and treatment, including issues of food and nutrition security (2). Our aim has been to coordinate and share resources with NNEdPro’s global and regional networks, and the public, to highlight key challenges, policy updates and best guidance on good nutrition and health practices in the context of COVID-19. Each month the NNEdPro COVID-19 microsites are updated with new resources related to both public health and nutrition in the context of the COVID-19 pandemic. These evidence collections are linked closely with our research focussed ‘Evidence Tracker’ as well as the International Knowledge Application Network Hub in Nutrition (iKANN). Alongside this, we will endeavour to produce a monthly statement reflecting on these updates to the evidence base as well as inviting thoughts from taskforce members involved in these areas of work. Public Health Updates There has once again been a strong focus on the long-term effects of COVID-19, including recovery from and long-term management of the disease. In the UK, the NHS have created a new hub ‘Your COVID recovery’ to host useful and accessible resources for patients and recovering from the disease and their families (3). Examples of the resources include information on the disease itself, patient's wellbeing and their road to recovery. The Suth African and Indian governments have both released further guidance on the long-term management of patients recovering from COVID-19 (4,5). The European Respiratory Society has published a statement on the follow up of patients suffering from long covid (6). The ERS taskforce agreed on eight clinical questions which would be used to search the existing literature and identify the optimal strategies for follow-up care that may positively impact the patient's quality-of-life. Overall, they found that the evidence available for follow-up care for patients with long COVID-19 was limited. There have been two more additions to the BMJ COVID-19 journal exploring long-covid. Researchers from King’s College London analysed self-reported data from the UK ZOE covid app and found that the risk of developing long covid was lower among people with the omicron variant of SARS-CoV-2 compared to those with the delta variant (7). Another test negative case control study estimated the change in odds of covid-19 over time following primary series completion of the inactivated whole virus vaccine CoronaVac in São Paulo State, Brazil (8). The authors found a significant increases in the risk of moderate and severe covid-19 outcomes three months after primary vaccination in adults >65 years. Despite the recent attention, there is still a lot unknown about the recovery from COVID-19 and long-covid should be made a priority research area across the globe. A final addition this month is an interesting perspective on the difficulties of science communications during the pandemic, emphasising the importance of educating both the public and policymakers about the scientific process and its constant evolution (9). Nutrition Updates A number of further papers have been added to the nutrition resources site during the month of June. In the clinical nutrition space, we have a literature review on the challenges of providing enteral nutrition in the prone position, a commonly used technique in critically ill patients during the pandemic, with a case study from practice also included (10). Further to this, a large US review examines the impact of malnutrition on clinical outcomes from COVID-19, emphasising the importance of a focus on nutrition in primary prevention (11). We have added an RCT from Pakistan, examining the effectiveness of micronutrient supplementation (Curcumin, Quercetin, and Vitamin D3) as an adjuvant therapy for mild to moderate symptoms of COVID-19 (12). The authors highlight some promising findings and highlight the need for an expansion of this research, particularly in developing countries, in the search for safe, cheap, accessible, and effective treatments for early-stage COVID-19 infection. A further paper from India examines the impact of COVID-19 infection on treatment adherence and outcomes in patients with diabetes mellitus (13). Lastly, on the subject of Long COVID and COVID recovery, a new paper documents the effectiveness of intensive, multidisciplinary rehabilitation on nutritional and functional outcomes in patients recovering from COVID-19 (14), strengthening the evidence of the importance of multi-modal care in this patient group. In addition, a study from the Netherlands discusses some of the challenges faced by COVID patients receiving dietetic treatment in primary care (15). References ​ COVID-19: Useful Resources: https://www.nnedpro.org.uk/coronavirus COVID-19: Nutrition Resources: https://www.nnedpro.org.uk/covid-19nutrition-resources NHS: Your COVID recovery: https://www.yourcovidrecovery.nhs.uk SA National Institute for Communicable Diseases- Lond covid: https://www.nicd.ac.za/diseases-a-z-index/disease-index-covid-19/long-covid/ Ministry of Health and Family Welfare Government of India - NATIONAL COMPREHENSIVE GUIDELINES FOR MANAGEMENT OF POST- COVID SEQUELAE - https://www.mohfw.gov.in/pdf/NationalComprehensiveGuidelinesforManagementofPostCovidSequelae.pdf European Respiratory Society Statement on Long COVID-19 Follow-Up: https://erj.ersjournals.com/content/early/2022/02/03/13993003.02174-2021 Covid-19: Long covid risk is lower with omicron than delta, researchers find: https://www.bmj.com/content/377/bmj.o1500 Change in covid-19 risk over time following vaccination with CoronaVac: test negative case-control study: https://www.bmj.com/content/377/bmj-2022-070102 In Layman's Terms: The Power and Problem of Science Communication https://pubmed.ncbi.nlm.nih.gov/35757894/ Challenges to Provision of Adequate Medical Nutrition Therapy in a Critically Ill COVID-19 Patient Fed in the Prone Position https://pubmed.ncbi.nlm.nih.gov/35761886/ Impact of malnutrition on clinical outcomes in patients diagnosed with COVID-19 https://aspenjournals.onlinelibrary.wiley.com/doi/10.1002/jpen.2418 Oral Co-Supplementation of Curcumin, Quercetin, and Vitamin D3 as an Adjuvant Therapy for Mild to Moderate Symptoms of COVID-19 —Results From a Pilot Open-Label, Randomized Controlled Trial https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9211374/pdf/fphar-13-898062.pdf Impact of SARS-CoV-2 Pandemic on Glycaemic Control, Metabolic Status, Treatment Adherence, Quality of Life in Diabetes Mellitus Patients in Tertiary Care Hospital of Eastern India https://pubmed.ncbi.nlm.nih.gov/35733731/ The Effects of an Intensive Rehabilitation Program on the Nutritional and Functional Status of Post-COVID-19 Pneumonia Patients https://pubmed.ncbi.nlm.nih.gov/35745230/ Nutritional problems of patients with COVID-19 receiving dietetic treatment in primary care https://pubmed.ncbi.nlm.nih.gov/35732588/ ​ ​ Previous monthly statements ​ April 2022 May 2022 June 2022

Author: Timothy McAuliffe Editor/Reviewer: Professor Sumantra (Shumone) Ray Acknowledgements: Thank you to the NNEdPro 2022 Summer School Team (Breanna Lepre, Sarah Armes, Pauline Douglas, Eleanor Beck and Matheus Abrantes) for the opportunity to share this reflection based on the winning essay for 2022. I am grateful to Rima Al-Nimr, Dr Auden McClure, Dr Larry Myers, and Dr Steve Bensen at the Geisel School of Medicine at Dartmouth College (New Hampshire, USA) for introducing me to teaching kitchens during my medical education. Further acknowledgement to Tecla Coleman (NNEdPro US Regional Network Co-Lead) for facilitating the Dartmouth-NNEdPro Summer School scholarship scheme 2022. Barriers to Nutritious Eating A healthy eating pattern is a central part of nutrition and overall well-being. However, many individuals encounter challenges maintaining a nutritious diet. Fifty-eight percent of US adults indicated that they should probably be eating healthier.(1) Providing foundational information about healthy foods is a core component, and lack of information is a frequently cited challenge for patients (2) (3) (4). A more nuanced mix of personal circumstances and structural barriers highlights a consistent set of challenges encountered across many populations. A lack of time or motivation to cook healthy foods poses a frequently cited barrier (4) (5) (6) (7). Furthermore, higher relative costs of nutritious foods and equipment necessary for food preparation generate challenges in preparing healthy meals (3) (4) (7). Many note that special dietary needs, preferences, and cultural eating traditions may generate barriers in making dietary changes (3) (4) (7). Finally, factors related to social or community eating habits contribute as well (2) (4) (6). Teaching Kitchen Model In the face of barriers to healthy eating and personal meal preparation among community members, teaching kitchens have emerged to address these challenges. Teaching kitchens leverage nutrition and culinary education to improve patient culinary skills to strengthen healthy eating patterns. These sessions, which can occur in a community or health centre kitchen, generally include interactive cooking instruction to teach culinary skills, improve confidence in cooking, and build knowledge on healthy meal preparation and eating (8) (9) (10). The central aim of the teaching kitchen model is to educate and engage a diverse audience (including patients with obesity or managing chronic disease) in eating and cooking in thoughtful ways to improve their health and cooking capabilities. Specific objectives include [1] improving familiarity with different eating patterns (e.g., plant-based diet, Mediterranean diet), [2] promoting cooking skill capabilities and confidence, [3] providing recipes that can be applied to at-home cooking, [4] encouraging mindful eating habits, and finally [5] promoting an environment where individuals can engage in their food preparation. Teaching Kitchen Impacts on Health In addition to improving general eating habits and cooking skills, teaching kitchens have tangible benefits for patient health. First, they can act as primary prevention strategies for diseases. Surveys from a teaching kitchen programme showed participants increased the frequency of eating fruits and vegetables and reduced the likelihood of eating fast food (10). Families participating in a kitchen-based nutrition programme were about three times as likely to follow a Mediterranean dietary pattern and saved approximately $20 per week on food costs due to home-prepared meals (11). Another teaching kitchen programme, combined with lifestyle and exercise guidance, was associated with reduced participant weight, BMI, waist circumference, blood pressure, and total cholesterol (8). A diet rich in fruits and vegetables and the Mediterranean diet have shown reductions in risks of cardiovascular disease, gestational diabetes, and breast cancer (12) (13) (14). Once patients are managing a chronic condition, nutrition-focused teaching kitchens can further improve outcomes. A Mediterranean diet-focused cooking and nutrition programme for patients with type 2 diabetes was associated with reductions in diastolic blood pressure and total cholesterol (15). A culinary education programme for individuals with cancer resulted in increased knowledge and confidence in preparation skills for plant-based diets and reduction in processed meat intake (16). Overall, evidence highlights that teaching kitchens can generate meaningful improvements for patients in primary and tertiary disease prevention. Implementation and Evaluation of Teaching Kitchens Implementation of teaching kitchens has already started gaining meaningful traction. The Teaching Kitchen Collaborative, founded in 2016, has a network of 45 teaching kitchens worldwide (17). Furthermore, culinary teaching has been incorporated into medical education, such as implementation in curricula at medical schools at Geisel (Dartmouth), Stanford, and Tulane (18). This mirrors culinary medicine programmes available through broader academic medical centers across the United States (9) (19). Nutrition professionals, instructors, and medical students have highlighted the meaningful impact of teaching kitchens on patient health and training: "With poor nutrition consistently cited as a major cause of morbidity and mortality, hands-on culinary medicine training in a teaching kitchen as a formal part of medical education has been shown to improve future physician confidence in comprehensive patient lifestyle counseling, as well as their own self-care. Evidence-based, technique-driven culinary training is an innovative and effective way to both teach and cement nutrition in medical education." – Rima Itani Al-Nimr, MS, RDN, LD, Lecturer in Medical Education & Medicine, Nutrition in Medicine Curriculum Director; The Geisel School of Medicine at Dartmouth “Our session in the teaching kitchen was a truly valuable opportunity for students to gain first-hand knowledge surrounding nutritious choices, food accessibility, and technical culinary skills. This experience will allow us to better provide informed care and resources to our patients.” – Adriana Radosavljevic, Medical Student at The Geisel School of Medicine at Dartmouth The core resources required to establish new teaching kitchens include a kitchen location, cooking equipment and food, and a course instructor and/or clinician to lead the programme. Furthermore, connections with community organisations or healthcare settings will enable more community members to be engaged with teaching kitchen programmes. The primary measurement is how many individuals are able to access teaching kitchen culinary education programmes. Beyond this, secondary evaluations should focus on impact and outcomes. These include patient-reported confidence in cooking skills, comfort and readiness in preparing meals, and interest in eating healthy foods and avoiding processed food. Outcome evaluation of major health measurements – such as weight, HbA1c, blood pressure, and cholesterol – can connect teaching kitchen instruction with concrete health outcomes. Conclusion and Call to Action Teaching kitchens provide an engaging and supportive environment for patients to learn fundamental culinary skills, new recipes, and healthy habits and offer an innovative new pedagogy for impactful nutrition education. In addition to improving general eating habits, studies have found culinary education significantly improves patient health outcomes. Academic and community organisations have shown how successful models can be developed and integrated into the community. With appropriate funding, stakeholder engagement, community involvement, and focused measurement, teaching kitchens can personalize healthy eating and equip patients with the skills and tools necessary to improve their well-being. Medical providers and researchers in patient care and nutrition should advocate local medical organisations to establish and sponsor the development of community-based teaching kitchens. Providing tailored and hands-on nutrition-based culinary training for all patients can improve population health, reduce medical care costs, and build robust community connections. By investing in teaching kitchens, professionals focused on improving nutrition can provide more comprehensive health support for patients. NOTE: Please refer to the award-winning NNEdPro Mobile Teaching Kitchens initiative as well as its successful adaptation in Mexico. In July 2022, the MTK initiative has won the Society for Nutrition Education and Behavior Program Impact Award and is poised and really for adaptation to the US context in collaboration with prime movers in the field across US partner organisations. References 1. Public views about Americans' eating habits [Internet]. Pew Research Center Science & Society. Pew Research Center; 2020 [cited 2022May31]. Available from: https://www.pewresearch.org/science/2016/12/01/public-views-about-americans-eating-habits/ 2. Beck AL, Iturralde E, Haya-Fisher J, Kim S, Keeton V, Fernandez A. Barriers and facilitators to healthy eating among low-income Latino adolescents. Appetite. 2019Apr4;138:215–22. 3. Oliver TL, McKeever A, Shenkman R, Diewald L. Barriers to healthy eating in a community that relies on an emergency food pantry. Journal of Nutrition Education and Behavior. 2020Nov8;52(3):299–306. 4. Munt AE, Partridge SR, Allman-Farinelli M. The barriers and enablers of healthy eating among young adults: A missing piece of the Obesity Puzzle: A Scoping Review. Obesity Reviews. 2016Oct20;18(1):1–17. 5. Ashton LM, Hutchesson MJ, Rollo ME, Morgan PJ, Collins CE. Motivators and barriers to engaging in healthy eating and physical activity. American Journal of Men's Health. 2016Dec5;11(2):330–43. 6. Nicholls R, Perry L, Duffield C, Gallagher R, Pierce H. Barriers and facilitators to healthy eating for nurses in the workplace: An integrative review. Journal of Advanced Nursing. 2016Nov9;73(5):1051–65. 7. de Mestral C, Stringhini S, Marques-Vidal P. Barriers to healthy eating in Switzerland: A nationwide study. Clinical Nutrition. 2016Apr7;35(6):1490–8. 8. Eisenberg DM, Righter AC, Matthews B, Zhang W, Willett WC, Massa J. Feasibility pilot study of a teaching kitchen and self-care curriculum in a workplace setting. American Journal of Lifestyle Medicine. 2017May23;13(3):319–30. 9. Polak R, Phillips EM, Nordgren J, La Puma J, La Barba J, Cucuzzella M, et al. Health-related culinary education: A summary of representative emerging programmes for health professionals and patients. Global Advances in Health and Medicine. 2016Jan1;5(1):61–8. 10. Black M, LaCroix R, Hoerster K, Chen S, Ritchey K, Souza M, et al. Healthy Teaching Kitchen Programmes: Experiential Nutrition Education Across Veterans Health Administration, 2018. American Journal of Public Health. 2019Oct17;109(12):1718–21. 11. Razavi AC, Sapin A, Monlezun DJ, McCormack IG, Latoff A, Pedroza K, et al. Effect of culinary education curriculum on Mediterranean diet adherence and food cost savings in families: A randomised controlled trial. Public Health Nutrition. 2020Aug3;:1–7. 12. Estruch R, Ros E, Salas-Salvadó J, Covas M-I, Corella D, Arós F, et al. Primary prevention of cardiovascular disease with a Mediterranean diet supplemented with extra-virgin olive oil or nuts. New England Journal of Medicine. 2018Jun21;378(25). 13. Assaf-Balut C, García de la Torre N, Durán A, Fuentes M, Bordiú E, del Valle L, et al. A Mediterranean diet with additional extra virgin olive oil and pistachios reduces the incidence of gestational diabetes mellitus (GDM): A randomized controlled trial: The St. Carlos GDM Prevention Study. PLOS ONE. 2017Oct19;12(10). 14. Toledo E, Salas-Salvadó J, Donat-Vargas C, Buil-Cosiales P, Estruch R, Ros E, et al. Mediterranean diet and invasive breast cancer risk among women at high cardiovascular risk in the predimed trial. JAMA Internal Medicine. 2015Nov1;175(11):1752. 15. Monlezun DJ, Kasprowicz E, Tosh KW, Nix J, Urday P, Tice D, et al. Medical School-based teaching kitchen improves hba1c, blood pressure, and cholesterol for patients with type 2 diabetes: Results from a novel randomized controlled trial. Diabetes Research and Clinical Practice. 2015Aug;109(2):420–6. 16. Miller MF, Li Z, Habedank M. A randomized controlled trial testing the effectiveness of coping with cancer in the kitchen, a nutrition education programme for cancer survivors. Nutrients. 2020Oct15;12(10):3144. 17. History & leadership [Internet]. Teaching Kitchen Collaborative. Teaching Kitchen Collaborative, Inc.; 2022 [cited 2022Jun1]. Available from: https://teachingkitchens.org/history-leadership/ 18. Green S. Food as medicine: Integrating Nutrition Education into the Medical Education Curriculum [Internet]. Geisel News. Trustees of Dartmouth College; 2018 [cited 2022Jun1]. Available from: https://geiselmed.dartmouth.edu/news/2018/food-as-medicine-integrating-nutrition-education-into-the-medical-education-curriculum/ 19. Culinary Medicine Programme [Internet]. DHMC and Clinics. Dartmouth Hitchcock Medical Center and Clinics; [cited 2022Jun1]. Available from: https://www.dartmouth-hitchcock.org/weight-welln

Author: Joshua Clamp / Editors: Shane McAuliffe and Sumantra Ray A recent announcement from the US Congress has set in motion a move towards improved nutrition education for health care professionals. Representatives James McGovern and Michael Burgess have secured a bipartisan resolution calling for this long-awaited and well-needed transformation. With momentum building, the potential for nutrition-trained healthcare professionals to mitigate the health and economic implications of unhealthy diets is growing, mirrored by an increased prominence of nutrition among the public and professionals. NNEdPro firmly aligns with this mission and supports these bold policy changes and calls to action. Nutrition plays a central role in maintaining good health. Unhealthy diets can increase the risk of obesity, type II diabetes, cardiovascular disease and cancer, bearing physical, emotional and financial costs for individuals and those around them. Furthermore, with public health spending related to diabetes exceeding $200 billion each year, and $90 billion in reduced productivity, there are significant economic and societal costs [1]. All the while, inequities in the food and healthcare systems result in more extreme food insecurity and health complications for individuals from minority ethnic and low-income backgrounds. Overcoming the health and economic challenges of unhealthy diets demands changes to the policy landscape, a reimagining of the food environment, and an array of strategies to support individual behaviour change. Whilst this process of change requires a complex, systems-level, and multidimensional approach, key strategies with the potential to have potent, positive impacts have been identified. Health care professionals are perfectly positioned to provide education and counselling on nutrition to patients, facilitate behavioural change in nutrition and lifestyle, and in turn drive positive health outcomes. Providing such staff with the knowledge, skills, tools, and capacity to include nutrition in their practice is therefore essential. Despite this, a well-recognised evidence-practice gap exists between the knowledge required for effective nutrition care and the nutrition education provided to medical students and other health professionals during training [2]. Medical staff receive little to no education on the relationships between diet, food and health, and are not provided with the skills necessary to counsel patients. One systematic review found that nutrition was insufficiently incorporated into medical education, regardless of country, setting, or year of medical education. Some reports have identified that medical students receive less than two hours of nutrition training throughout their time studying [3]. Consequently, much medical staff lack the capacity, and in many cases confidence, to deliver quality nutritional advice. The historical lack of nutrition education in medical training is a double-edged sword. Not only does a lack of training limit one’s ability to learn, understand, and share nutrition advice, but its very absence is suggestive of insignificance in health and health outcomes. Health professionals may therefore be left not only without the tools to deliver effective nutrition counselling but without the motivation to do so. Growing awareness of this evidence-practice gap has spurred research into how nutrition training may be effectively implemented into medical curricula. This issue has been a focus of NNEdPro, and its international network of nutrition professionals has contributed to numerous publications in this space across a 13-year journey advocating for the important role of nutrition education across the globe [4]. In the USA in particular, over the years NNEdPro has highlighted the need to advance nutrition education in the training of health care professionals [5,6,7]. Further NNEdPro publications: Global architecture for the nutrition training of health professionals: a scoping review and blueprint for next steps Reports, interviews, and surveys were analysed and used to generate recommendations for building global nutrition capacity. Read the full publication here. Read our blog on this review here. Reference to nutrition in medical accreditation and curriculum guidance: a comparative analysis A review of directories found that nutrition content or instruction on nutrition education is missing from important accreditation and formal curriculum guidance for medical education internationally, with only 45% including nutrition. Read the full publication here. Hidden curriculum within nutrition education in medical schools Interviews with medical students highlight the important context in effective nutrition education and the limitations of merely mapping nutrition content. Read the full publication here. Time for nutrition in medical education Analyses of surveys of medical students and doctors confirm the desire and necessity for more nutrition within medical education in the UK, as well as a need for greater clarity of a doctor’s role in nutrition care. Read the full publication here. A 13-year journey towards implementing improved medical nutrition education in the UK and beyond Read the full publication here. The combined efforts of organisations and institutions have built momentum, bridging the historical evidence-practice gap. The growing body of peer-reviewed research now provides a strong enough foundation on which policy changes can be brought about. The US Congress's announcement to support nutrition education within medical schools, residency, and fellowship programmes represents a huge step forward in this movement. The resolution encourages action in several key areas: Physician and health professional training programmes to provide meaningful nutrition education. It urges federal agencies to provide oversight, to ensure federal funding goes to the programmes that prioritise nutrition education. Asks agencies to find research and support the development and dissemination of curricular resources. Calls upon government and private institutions to raise awareness of the critical role of diet and nutrition in health, and the responsibility of health care practitioners to promote healthy diets. Importantly, this announcement raises the importance of nutrition education in medical training to a level of national concern, and will likely be a key topic at the long-awaited relaunch of the White House Conference on Nutrition, Hunger, and Health happening in late 2022. Thanks to the hard work and collaboration of individuals, organisations and institutions, nutrition education is being implemented in medical curricula. As a result, the health workforce is becoming better equipped with the knowledge and skills to help patients with diet and behaviour change, leading to improved health outcomes and a reduced economic burden of diet-related diseases. NNEdPro will continue to support this transformation and is excited to learn about future developments in this exciting space. NOTE: NNEdPro will contribute to a conference on malnutrition in September 2022, organised by the National Institutes of Health (NIH) in the USA. On this occasion, we will draw from this body of knowledge. Key references 1. American Diabetes Association (2018) Economic Costs of Diabetes in the U.S. in 2017. Diabetes Care, 41 (5): 917–928, doi.org/10.2337/dci18-0007 2. Bassin S, Al-Nimr R, Allen K, Ogrinc G (2020) The state of nutrition in medical education in the United States, Nutrition Reviews, 78(9): 764–780, doi.org/10.1093/nutrit/nuz100 3. Crowley J, Ball L, Hiddink GJ (2019) Nutrition in medical education: a systematic review, The Lancet Planetary Health, 3(9): E379-E389, doi.org/10.1016/S2542-5196(19)30171-8 4. Elaine MacAninach and Prof Sumantra Ray. A 13-year journey towards implementing improved medical nutrition education in the UK and beyond. https://www.nnedpro.org.uk/post/a-13-year-journey-towards-implementing-improved-medical-nutrition-education-in-the-uk-and-beyond 5. Kris-Etherton PM, Akabas SR, Bales CW, et al. (2014) The need to advance nutrition education in the training of health care professionals and recommended research to evaluate implementation and effectiveness. Am J Clin Nutr, 99(5 Suppl):1153S-66S, doi:10.3945/ajcn.113.073502 6. Kris-Etherton PM, Akabas SR, Douglas P, et al. (2015) Nutrition competencies in health professionals' education and training: a new paradigm. Adv Nutr, 6(1):83-87, doi:10.3945/an.114.006734 7. Van Horn L, Lenders CM, Pratt CA, et al. (2019) Advancing Nutrition Education, Training, and Research for Medical Students, Residents, Fellows, Attending Physicians, and Other Clinicians: Building Competencies and Interdisciplinary Coordination. Adv Nutr, 10(6):1181-1200, doi:10.1093/advances/nmz083 NNEdPro publications Lepre B, Trigueiro H, Johnsen JT, et al. (2022) Global architecture for the nutrition training of health professionals: a scoping review and blueprint for next steps. BMJ Nutrition, Prevention & Health, e000354, doi: 10.1136/bmjnph-2021-000354 Lepre B, Mansfield KJ, Ray S, et al. (2021) Reference to nutrition in medical accreditation and curriculum guidance: a comparative analysis. BMJ Nutrition, Prevention & Health, 4, doi: 10.1136/bmjnph-2021-000234 Martin S, Sturgiss E, Douglas K, et al. (2020) Hidden curriculum within nutrition education in medical schools. BMJ Nutrition, Prevention & Health, 3, doi: 10.1136/bmjnph-2019-000059 Macaninch E, Buckner L, Amin P, et al. (2020) Time for nutrition in medical education. BMJ Nutrition, Prevention & Health, 3, doi: 10.1136/bmjnph

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