Identifying emerging and complex challenges in food and health systems

Promoting good nutrition is essential to tackle current and emergent health crisis. For instance, non-communicable diseases (NCDs) are responsible for about 70% of deaths globally, with high intake of sodium, red meat, refined sugars and/or ultra-processed foods and low intake of whole grains, legumes and fruits raking among the top dietary risks for NCDs related deaths. Diet also play an important role in emergent health crises, as illustrated during the Covid-19 pandemic, where those who are malnourished and/or present underlying NCDs have more severe and deadly outcomes. Despite that, limited progress is being made toward the United Nations Sustainable Development Goals (SDGs) on malnutrition and NCDs.Nutrition is linked with other modifiable risk factors for chronic diseases such as physical activity, sleep, mental well-being, substance abuse (e.g., alcohol and smoking) and environmental factors. The complexity of foods and their constituents and the multitude of factors involved in the aetiology of NCDs make dissecting the relative contribution of risk factors and interventions on disease onset and progression a challenging task. Understanding the interrelation between traditional risk factors that are established already and lifestyle risk factors will allow us to offer a more holistic approach to human well-being. Rigorous and innovative research that harnesses the power of large datasets and multiple research methods is needed to support the development of coherent theories in nutrition and risk identification and management. It is also necessary to connect this innovative research with the complex needs of individuals and systems. For example, the Covid-19 pandemic has exacerbated food insecurity (i.e., not being able to access foods that are safe and nutritionally appropriate for one’s health) in multiple ways, including disruptions at the system level, such as interruptions and delays across food chains and increased food prices or individual level, including job losses and lack of access to food. In the UK, research has shown that ethnic minorities groups, those limited by health problems/disabilities, food sector workers and households with children were at increased risk of experiencing food insecurity. In some parts of Africa, conflicts, displacements, and droughts are additional factors contributing to the high prevalence of food insecurity, further exacerbated during the Covid-19 pandemic. The idea that ‘Nobody ever just needs food’ highlights that addressing food insecurity and malnutrition requires multisectoral solutions to resolve underlying causes of the problem.Public and private sectors play an important role in addressing the burden of malnutrition but goals and responsibilities must be transparent, focused on public benefit, and collaborative. Systems-based approaches where nutrition and health are prioritized should be also employed. While changes in systems, policies and services can be triggered by community demand and advocacy, education and training are necessary to promote capacity for change and sustained impact. Quality data on food, nutrition and health can support this behavioural shift through the identification of problems and gaps. There is a need to establish a data foundation which enables the development of a science-based approach upon which statistically backed actions can be derived. This is particularly difficult with nutrition where much is dependent on observational data and longitudinal cohorts are scarce. Advancing our knowledge through research partnerships and data sharing will allow us to provide convincing evidence to policy makers as well as the public. Ultimately, improving data literacy among relevant stakeholders is also needed to enable accurate interpretation and relevant action. Advancing our knowledge through research partnerships and data sharing will allow us to provide convincing evidence to policymakers as well as patients. Programs such as the NNEdPro’s International Knowledge Application Network Hub in Nutrition (iKANN), can facilitate this collaboration, while also curating nutrition data, evidence and training resources.

NNEdPro global centre response to the UK government obesity strategy

BackgroundFollowing considerable interest in the relationship between obesity and COVID-19, the UK Government have released a policy paper: ‘Tackling obesity: empowering adults and children to live healthier lives’.1 This response may be focused on a limited and potentially historical view of overweight and obesity. We consider the complexity of the condition, its determinants, and co-existing conditions.2ObjectivesWe sought to gain consensus iteratively, using implementation framework thinking, to advocate for the appreciation of a wider, more complete understanding of the existing science behind obesity and the appropriate strategies needed to address it.ResultsWe identified four strategic points and provided recommendations for more comprehensive coverage and greater impact: 1. Improving focus and messaging 2. Understanding drivers of food choice and nutritional status 3. Promoting healthy eating from early years 4. Addressing the complexity of obesityDiscussion1. Effective messaging should be inclusive, collaborative and non-judgemental, promoting co-participation in the development of messages used in public national campaigns.3 2. Higher rates of obesity are observed in socioeconomically deprived groups who rely on food assistance programmes, in which nutritional quality could be improved through involvement of nutrition professionals.4 In order to influence behaviour, basic food literacy and financial management skills could be developed, while subsidies for healthier alternatives may complement taxes on less healthy foods.5 3. Advocating for better education on food science and nutrition from early learning sectors will promote increased awareness early in life.6 This could be augmented by reinstatement of initiatives like the healthy start programme. 4. Human health is multi-dimensional, therefore focussing on a single-metric risks oversimplifying this complexity and undervaluing the importance of healthy behaviours, even those not directly associated with weight.7 Instead, we should consider positive lifestyle habits, rather than a narrow focus on weight or BMI alone for the individual, informed by existing and accepted scientific findings.ConclusionAn integrated systems approach ought to be developed with a multipronged intervention strategy, targeting food production, supply and environments as well as marketing to improve availability of as well as accessibility to more nutrient-rich but less energy-dense foods. These combined with appropriate food education for consumers would enable more consistently healthy food choices.AcknowledgementsNNEdPro Virtual Core and Global Innovation Panel;Nutrition and COVID19 TaskforceReferencesUK Government - Tackling obesity: empowering adults and children to live healthier lives. July 2020.Foresight, Obesity Systems Map. 2007.Language Matters: Language and diabetes. 2018.Fallaize R, Newlove J, White A, Lovegrove JA. Nutritional adequacy and content of food bank parcels in Oxfordshire, UK: a comparative analysis of independent and organisational provision. J Hum Nutr Diet 2020;33:477–486. https://doi.org/10.1111/jhn.12740Garcia A, Reardon R, Hammond E, Parrett A, Gebbie-Diben A. Evaluation of the ‘eat better feel better’ cooking programme to tackle barriers to healthy eating. International Journal of Environmental Research and Public Health 2017;14(4):380. doi:10.3390/ijerph14040380Oostindjer M, Aschemann-Witzel J, Wang Q, Skuland S, Egelandsdal B, Amdam G, et al. Are school meals a viable and sustainable tool to improve the healthiness and sustainability of children´s diet and food consumption? A cross-national comparative perspective. Critical Reviews In Food 2016.Salas-Salvado J, Bullo M, Babio N, Martinez-Gonzalez M, Ibarrola-Jurado N, Basora J, et al. Reduction in the incidence of type 2 diabetes with the mediterranean diet: results of the PREDIMED-Reus nutrition intervention randomized trial. Diabetes Care 2010;34(1):14–19. doi:10.2337/dc10-1288

Disseminating evidence during the COVID-19 pandemic

Knowledge networks, such as the NNEdPro Nutrition and COVID-19 Taskforce, are central to the rapid creation and dissemination of evidence, as highlighted at the NNEdPro Sixth International Summit on Nutrition and Health. During the COVID-19 pandemic, the Taskforce rapidly collated evidence and widely shared clear and accessible resources globally, via NNEdPro Regional Networks. The impact of the Taskforce on disseminating evidence and encouraging collaboration was made evident, and thus demonstrates the importance of this approach for addressing regional and global nutrition challenges. Scientific journals, such as BMJ Nutrition, Prevention & Health, as discussed by Editor-in-Chief, Professor Kohlmeier, also play a significant role in the dissemination of evidence. Once published, research is open access, disseminated widely online, and is encouraged to be used to inform practice. During the COVID-19 pandemic, any article with research findings relevant to the Coronavirus outbreak, were also shared widely with policymakers to increase global uptake. Knowledge networks, and scientific journals such as BMJ Nutrition Prevention and Health, are critical to the generation and dissemination of evidence, which is key to its uptake and implementation in policy and practice.

Lessons learned from the NNEdPro Nutrition and COVID-19 taskforce

Acknowledgements:NNEdPro Nutrition and COVID-19 Taskforce (Named authors plus James Bradfield, Luke Buckner, Harrison Carter, Elaine Macaninch, Suzana Almoosawi, Timothy Eden, Emily Fallon, Claudia Mitrofan, Niky Raja, Sucheta Mitra, Matheus Abrantes, Lynn Haynes) and BMJ Nutrition, Prevention and Health.BackgroundNutritional issues relating to the COVID-19 pandemic span clinical nutrition in acute patients to impacts on global dietary patterns and food security. In March 2020, the NNEdPro Global Centre for Nutrition and Health established a rapid-response Nutrition and COVID-19 Taskforce to help the organisation navigate the initial phases of the pandemic and make a constructive contribution to the scientific landscape.1–3ObjectivesTo highlight lessons learned over 6 months (March-September 2020) of the COVID-19 pandemic in understanding the role(s) of nutrition.MethodsCritical and constructive reflections from Taskforce co-chairs and lead scientific members based on a 6-month summative webinar and journal club examining the strength of evidence and key gaps.ResultsSuccesses in Taskforce operations include pooling a broad range of expertise including clinical medicine, nutrition and dietetics, research, public health, and communications. Pre-existing NNEdPro operations were predominantly online and dedicated virtual meetings supported the proactive collation of key resources relating to nutrition and COVID-19 with production of public-facing information summaries. Academic collaboration with partner organisations, including BMJ Nutrition, Prevention & Health, has focused research priorities and produced contributions to the scientific landscape.4Challenges included managing the sense of urgency, particularly earlier in the pandemic and driven by an unease of the unknown, both at organisational level and in the need to translate nutrition knowledge to COVID-19 sensitive practice. A collaborative, scientific and politically neutral approach was intended to ensure the quality of outputs and the avoidance of hasty conclusions. Other challenges have been maintaining relevance to all geographic regions given the global variation of COVID-19 and maximising the reach of outputs to stakeholders who would benefit most from them. More recently the Taskforce has provided key inputs to consensus in a national guideline agency and global advisory bodies. Further progress will require involvement of researchers and innovators, policymakers, practitioners, patients and the public.Discussion/ConclusionThis Taskforce has already made a significant contribution to the scientific conversation about food and nutrition in the prevention and management of COVID-19. Future work should focus on multiple-stakeholder collaboration to transform research into positive action at all levels (from patient to policy) for the benefit of public health.ReferencesNNEdPro Global Centre for Nutrition and Health. COVID19: Useful resources. nnedpro.org.uk. [Online] [Cited: September 7, 2020.] https://www.nnedpro.org.uk/coronavirus.NNEdPro Global Centre for Nutrition and Health. COVID19: Nutrition Resources. nnedpro.org.uk. [Online] [Cited: September 7, 2020.] https://www.nnedpro.org.uk/covid-19nutrition-resources.NNEdPro Global Centre for Nutrition and Health. Combatting COVID-19: A 10-point summary on diet, nutrition and the role of micronutrients. nnedpro.org.uk. [Online] [Cited: September 7, 2020.] https://www.nnedpro.org.uk/post/combatting-covid-19.Dietary micronutrients in the wake of COVID-19: an appraisal of evidence with a focus on high-risk groups and preventative healthcare. McAuliffe, Shane, et al. s.l. : BMJ Nutrition, Prevention & Health, 2020, Vols. bmjnph-2020-000100. doi: 10.1136/bmjnph-2020-000100.

Dietary micronutrients in the wake of COVID-19: an appraisal of evidence with a focus on high-risk groups and preventative healthcare.

Existing micronutrient deficiencies, even if only a single micronutrient, can impair immune function and increase susceptibility to infectious disease. Certain population groups are more likely to have micronutrient deficiencies, while certain disease pathologies and treatment practices also exacerbate risk, meaning these groups tend to suffer increased morbidity and mortality from infectious diseases. Optimisation of overall nutritional status, including micronutrients, can be effective in reducing incidence of infectious disease. Micronutrient deficiencies are rarely recognised but are prevalent in the UK, as well as much more widely, particularly in high-risk groups susceptible to COVID-19. Practitioners should be aware of this fact and should make it a consideration for the screening process in COVID-19, or when screening may be difficult or impractical, to ensure blanket treatment as per the best practice guidelines. Correction of established micronutrient deficiencies, or in some cases assumed suboptimal status, has the potential to help support immune function and mitigate risk of infection. The effects of and immune response to COVID-19 share common characteristics with more well-characterised severe acute respiratory infections. Correction of micronutrient deficiencies has proven effective in several infectious diseases and has been shown to promote favourable clinical outcomes. Micronutrients appear to play key roles in mediating the inflammatory response and such effects may be enhanced through correction of deficiencies. Many of those at highest risk during the COVID-19 pandemic are also populations at highest risk of micronutrient deficiencies and poorer overall nutrition. Correction of micronutrient deficiencies in established COVID-19 infection may contribute to supporting immune response to infection in those at highest risk. There is a need for further research to establish optimal public health practice and clinical intervention regimens.

Avoidance of vitamin D deficiency to slow the COVID-19 pandemic.

Vitamin D deficiency, which impedes good immune function, is common during winter and spring in regions of high latitude. There is good evidence that vitamin D deficiency contributes to the seasonal increase of virus infections of the respiratory tract, from the common cold to influenza, and now possibly also COVID-19. This communication explores key factors that make it more likely, particularly in combination, that individuals are vitamin D deficient. These factors include old age, obesity, dark skin tone and common genetic variants that impede vitamin D status. Precision nutrition is an approach that aims to consider known personal risk factors and health circumstances to provide more effective nutrition guidance in health and disease. In regard to avoiding vitamin D deficiency, people with excess body fat, a dark skin tone or older age usually need to use a moderately dosed daily vitamin D supplement, particularly those living in a high-latitude region, getting little ultraviolet B exposure due to air pollution or staying mostly indoors. Carriers of the GC (group-specific component) rs4588 AA genotype also are more likely to become deficient. Very high-dosed supplements with more than 4000 IU vitamin D are rarely needed or justified. A state-by-state Mendelian randomisation analysis of excess COVID-19 mortality of African-Americans in the USA shows a greater disparity in northern states than in southern states. It is conceivable that vitamin D adequacy denies the virus easy footholds and thereby slows spreading of the contagion. This finding should drive home the message that vitamin D supplementation is particularly important for individuals with dark skin tones. Vitamin D deficiency, even for a few months during the winter and spring season, must be rigorously remedied because of its many adverse health impacts that include decreased life expectancy and increased mortality. Slowing the spread of COVID-19 would be an added bonus.