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

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.

Nutritional parameters and outcomes in patients admitted to intensive care with COVID-19: a retrospective single-centre service evaluation.

COVID-19 is an inflammatory syndrome caused by novel coronavirus SARS-CoV-2. Symptoms range from mild infection to severe acute respiratory distress syndrome (ARDS) requiring ventilation and intensive care. At the time of data collection, UK cases were around 300 000 with a fatality rate of 13% necessitating over 10 000 critical care admissions; now there have been over 4 million cases. Nutrition is important to immune function and influences metabolic risk factors such as obesity and glycaemic control, as well as recovery from acute illnesses. Poor nutritional status is associated with worse outcomes in ARDS and viral infections, yet limited research has assessed pre-morbid nutritional status and outcomes in patients critically unwell with COVID-19. OBJECTIVES: Investigate the effect of body mass index (BMI), glycaemic control and vitamin D status on outcomes in adult patients with COVID-19 admitted to an intensive care unit (ICU). METHODS: Retrospective review of all patients admitted to a central London ICU between March and May 2020 with confirmed COVID-19. Electronic patient records data were analysed for patient demographics; comorbidities; admission BMI; and serum vitamin D, zinc, selenium and haemoglobin A1c (HbA1c) concentrations. Serum vitamin D and HbA1c were measured on admission, or within 1 month of admission to ICU. Primary outcome of interest was mortality. Secondary outcomes included time intubated, ICU stay duration and ICU-related morbidity. RESULTS: Seventy-two patients; 54 (75%) men, mean age 57.1 (±9.8) years, were included. Overall, mortality was 24 (33%). No significant association with mortality was observed across BMI categories. In the survival arm admission, HbA1c (mmol/mol) was lower, 50.2 vs 60.8, but this was not statistically significant. Vitamin D status did not significantly associate with mortality (p=0.131). However, 32% of patients with low vitamin D (<25 IU/L) died, compared with 13% of patients with vitamin D levels >26 IU/L. Serum zinc and selenium, and vitamin B12 and folate levels were measured in 46% and 26% of patients, respectively. DISCUSSION/CONCLUSION: Increased adiposity and deranged glucose homeostasis may potentially increase risk of COVID-19 infection and severity, possibly relating to impaired lung and metabolic function, increased proinflammatory and prothrombotic mechanisms. Vitamin D deficiency may also associate with poorer outcomes and mortality, supporting a possible role of vitamin D in immune function specific to pulmonary inflammation and COVID-19 pathophysiology. There are plausible associations between raised BMI, glycaemic control, vitamin D status and poor prognosis, as seen in wider studies; however, in this service evaluation audit during the first wave of the pandemic in the UK, with a limited data set available for this analysis, the associations did not reach statistical significance. Further research is needed into specific nutritional markers influencing critical care admissions with COVID-19.

Critical care nutrition and COVID-19: a cause of malnutrition not to be underestimated.

Malnutrition in critical care is highly prevalent and well documented to have adverse implications on morbidity and mortality. During the current COVID-19 pandemic, the evolving literature has been able to identify high risk groups in whom unfavourable outcomes are more common, for example, obesity, premorbid status, male sex, members from the Black, Asian and Minority Ethnic (BAME) community and others. Nutritional status and provision precritical and pericritical phase of COVID-19 illness is gaining traction in the literature assessing how this can influence the clinical course. It is therefore of importance to understand and address the challenges present in critical care nutrition and to identify and mitigate factors contributing to malnutrition specific to this patient group. We report a case of significant disease burden and the associated cachexia and evidence of malnutrition in a young 36-year-old male with Somalian heritage with no pre-existing medical conditions but presenting with severe COVID-19 during the first wave of the pandemic (March 2020). We highlight some key nutritional challenges during the critical phase of illness signposting to some of the management instigated to counter this. These considerations are hoped to provide further insight to help continue to evolve nutritional management when treating patients with COVID-19.

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.