At a time of global interconnectedness, the internationalization of medical education has become important. Anatomy as an academic discipline, with its close connections to the basic sciences and to medical education, can easily be connected with global health and internationalization of medical education. Here the authors present an international program based on a partnership between twelve anatomy departments in ten countries, on four continents. Details of a proposed plan for the future direction of the program are also discussed.The aim is to improve global healthcare by preparing future global healthcare leaders via early international networking, international collaboration and exchange, intercultural experience, and connecting two seemingly distant academic disciplines – anatomy and global health – via internationalization of medical education.Based in the anatomy course, the program involved early international collaboration between preclinical medical and dental students. The program provided a stepwise progression for learning about healthcare and intercultural topics beyond pure anatomy education – starting with virtual small groups of international students, who subsequently presented their work to a larger international audience during group videoconferences. The above progressed to in-person visits for research internships in the basic sciences within industrialized countries.Students appreciated the international and intercultural interaction, learned about areas outside the scope of anatomy , and valued the exchange travel for basic sciences research internships and cultural experience.This unique collaboration of international anatomy departments can represent a new role for the medical anatomy course beyond pure anatomy teaching – involving areas of global health and internationalization of medical education – and could mark a new era of international collaboration among anatomists. At a time of global interconnectedness, internationalization of medical education (IoME) has become an important part of medical education.Internationalization in higher education is “the intentional process of integrating an international, intercultural, or global dimension into the purpose, functions, and delivery of post-secondary education, in order to enhance the quality of education and research for all students and staff and to make a meaningful contribution to society .”Internationalization of medical education (IoME) is a term used in studies of the education literature 3456, and345There are several models that have been described as the rationale for pursuing IoME. Hanson (2015) describes a market model, a liberal model, and a social transformation model 9. In theIt is important for healthcare practitioners and leaders to practice medicine with a global mindset, and internationalization can enhance learning about key issues that are specific to health education worldwide . BecauseIoME can have different formats involving various stakeholders and dimensions of medical education. It can address student issues and experiences, faculty related topics, and/or the curriculum itself . FurtherAt the student level, IoME can involve didactic lectures in the classroom, peer-to-peer connections, outbound mobility activities for international student travel , and inbIn the US, it appears that the social transformation model is the predominant reason for IoME. Often, reports on IoME are part of a GH initiative and as such most reports revolve around placements of clinical students and students’ clinical or research experiences in low- and middle-income countries (LMIC) .In Europe, international exposure has a long tradition  and institutional or governmentally supported programs are common 1516. The1518Internationalization in medicine as an educational field does not seem to have standardized curricula or agreed-upon learning objectives 1221222324,212223Anatomy is present in all health sciences curricula. Although international collaborations among anatomy departments can be advantageous, the existing cases have not been extensively reported recently, with even fewer reports involving international anatomy collaboration in the LMIC 262728.2627Anatomy as an academic discipline, with its close connections to the basic sciences and to student education, can easily be connected with GH and IoME. In his keynote address at the meeting of the American Association for Anatomy (AAA) in San Diego (2018), Dr. Jeffrey Murray, Deputy Director of the Bill and Melinda Gates Foundation, encouraged the involvement of anatomists in international work and GH .This article describes the efforts of twelve anatomy departments in ten countries, on four continents, who collaborated in a unique program to promote IoME, with the ultimate goal of improving global healthcare. While the program was purposefully anchored in the anatomy courses, the content for student experiences expanded beyond anatomy and involved areas of public and GH. The authors have previously reported on a limited pilot study regarding this novel approach and are now presenting the full program along with updated results of student questionnaires .The goal of the program was not to internationalize anatomy teaching or the anatomy course content. The anatomy courses rather served as a vehicle and binding element to help improve global healthcare by preparing future medical and dental leaders via early international networking, international collaboration and exchange, and intercultural experience.Anatomy was chosen as a commonality for student networking because this subject field is generally taught at an early stage and is represented in all medical and dental school curricula around the world. In addition, the topic of body donation and associated concerns about the topic of death are areas that are shared by young students in this phase of learning.The program provided a structure for students to exchange knowledge and learn about other medical education and healthcare systems, differences in health law and ethics, public health challenges, and to be introduced to basic sciences research, along with immersion in an academic life abroad and intercultural exchange. To the authors, these elements seemed important to include in the preparation of future global healthcare leaders, and to help them to approach their future practice with a global frame of mind. By preparing global healthcare leaders, the program hopes to improve global healthcare.The results of this publication focused on short-term outcomes regarding the learning of relevant competencies via the program. Although global competencies in medical education are not clearly agreed upon in the literature 23, compeLed by Columbia University, this program was a collaboration of twelve universities in ten countries, on four continents Table . In the Partner schools in phase 1 were carefully evaluated for a number of inclusion criteria . The vetting process, while subjective, included an initial online search for leading schools with strong scientific research opportunities, as well as recommendations from professional scientific colleagues. In addition, pre-selected partners that were already collaborating with Columbia University were included. Initial connections were made via their respective anatomy departments, and through anatomical professional societies. Twelve universities participated.The second phase includes experience with LMIC, is in the pilot stage, and not part of this report; its format is addressed at the end of the program structure .The program was a voluntary program and accessible to all preclinical medical and dental students. The focus was on very junior students. Therefore, a stepwise progression was provided, starting with bonding in small and subsequently larger video groups, proceeding to in-person visits to industrialized countries in phase 1, before moving on to in-person visits to LMIC in phase 2 (pilot stage). All participating students were encouraged to remain in contact with their international peers for future life-long professional networking.The preclinical program in phase 1 currently enrolls approximately 200 students per year  who led the student cohort from their respective schools and represented their school and country at the videoconferences (see program details below). The NSL formed their own sub-leadership groups and worked closely with the coordinating entities at Columbia, thus representing a second level of communication in this multi-member collaborative partnership.The purpose of the small group work was to give students a framework to practice international teamwork, develop an understanding of others’ customs, and to familiarize themselves with differences in culture and work ethics.Small groups typically consisted of three to five students from three countries . Beginning in the fall, students met online for one semester to work in small groups during several structured sessions. Session topics covered the differences in the anatomy courses, body donation policies, healthcare education and delivery systems, health law and ethics, and public health.The program content goal deliberately went beyond anatomy and its related topics. Only one of the small group sessions was dedicated to discussions related to anatomy and the practice of body donation. The purpose of this first session/exercise was to serve as an “ice-breaker” and to reflect on subjects that were familiar to all participants . In this first session, the students were asked to compare the format of their anatomy courses, followed by reflection on the topic of body donation in self-reflection and as an international group. Body donation processes can vary between countries, even between schools in one country . Because body donation is handled so differently, it serves as a tool to raise awareness about cultural differences. A list of suggested discussion topics for the remaining sessions was initially developed by faculty and further expanded upon over the years per students’ requests Table .Toward the end of the small group sessions, the students worked with their peers on a short collaborative small group paper covering one topic from the aforementioned list, creating a video and slide presentation together. The reasons for producing the paper and presentation were to strengthen their collaborative efforts, to communicate efficiently, to work across different time zones, to exercise professionalism and tolerance of others in an international setting, and to practice international public speaking at the videoconferences.At the end of the semester the students presented their collaborative small group work to the entire cohort at two large international virtual conferences, with all students and faculty participating Figure .The groups of students from each country met in their respective lecture halls, libraries, or AV rooms, and connected via an online videoconferencing program (Zoom)©. NSL from each country served as moderators for the conferences, with minimal faculty involvement – although faculty was present with their groups online.The conferences were divided into three blocks. Block 1 included a cultural presentation by the respective NSL. The presentation covered various characteristics  of each country and region. The purpose of the cultural exchange was to introduce different cultures and customs to these junior students and to inspire them to learn about a different country beyond the perspective of healthcare.Block 2 included selected international group presentations on the topics the students had previously chosen for their collaborative papers. This exercise was practice for international public speaking and listening, developing an appreciation of non-English speaking students, and for non-native speakers to practice their fluency in English.Block 3 included an introduction of the students that had expressed an interest in international exchange. Students introduced each other and paired up as “buddies”. This portion was meant for virtual international networking and was the only time when all students met together online.The two international online conferences ended in early spring, completing the semester of virtual exchanges.Subsequently, in the summer following the conferences the students travelled to the partner countries in order to perform short-term research in basic science laboratories (from 1–2 months up to 12 months). In addition, they socialized with their peers in the host country. This portion of the program was introduced to deepen collegial friendships, help students to immerse themselves in an academic life in another country, and for them to acquire research skills in the basic sciences.Research laboratories were selected based on the students’ preferences for an area of research  and institution, subject to availability in the host laboratories of the partner countries Table .The anatomy faculty in each country assisted with laboratory placement, and supported grant applications. Funding sources varied , and students also self-funded their trips. Peers helped each other with travel logistics, accommodations, leisure activities, and facilitated immersion into academic life in the host countries.Student visits were divided (by countries) into several travel groups, to ensure that not all students travelled at the same time and that participating students were available for hosting the incoming students in each country. Incoming students experienced a rich social program hosted by peers and faculty . This allowed for mingling with their peers during their stay abroad, outside of their time involved in a research project. A constant flow of new incoming international short-term students internationalized the host campuses.Program evaluation can be separated into short-term and long-term results. Short-term evaluations had two purposes – evaluate the program itself , and assess student learning . In this program, qualitative data included students’ perceptions of what they had learned.Questionnaires © were sent to the students, after both the virtual and the travel portions of the program, to evaluate the success of the endeavor. Questions included closed and open questions and Likert scales. Success was measured using students’ perceptions of their satisfaction with the above experiences, their knowledge about covered topics and basic sciences research, and their fundamental understanding about other cultures and healthcare systems. Questionnaires in Qualtrics were developed in collaboration with the Center for Education Research and Evaluation (CERE) at Columbia University and were approved by the IRB at Columbia University (#AAA0003715) and at McGill University (#A07-E54-17B).Long-term evaluation to measure what effect the program had on the students’ careers and lives, and subsequently on global healthcare, could not be evaluated at this stage.Questionnaires were collected using Qualtrics. Analysis of data was performed using NVivo12© and Excel©. Online software used for the small group discussions included Facetime and Skype. The large group conferences were conducted via a university-licensed Zoom account.Since the students only worked with peers from two other countries, they connected and socialized with the larger group via closed social media sites .A recently initiated, second phase of the program, is in the planning stage and represents a progression from industrialized to LMIC. It involves a scholarly project conducted during the senior clinical years, available to prior program participants. Students who participated in part 1 are offered online international small group projects addressing global and public health issues in the LMIC, which culminate in clinical observership placements in the LMIC Table . ComponeResults represent the academic year of 2018/19.Of 194 participating students, 40% were male and 60% were female. Twenty-eight percent of the students were under the age of 20, and 72% were under 25 years old.Ninety-two students responded to the program questionnaires (46%), and 99 (49%) replied to a separate questionnaire on the topic of body donation. Of those responding to the latter questionnaire, 19% were under the age of 20, and 63% were under 25 years old.The low return rate was expected because the program was a voluntary program.Small group sessions. The majority of students enjoyed the small group interaction. On a Likert scale of from 1 to 10, the mean ranking reported was 8.46 (data not shown). The appropriateness of the interactions based in the anatomy course, the selection of discussion topics, and the desire to keep in contact with their peers were positively rated and consistent with previous years .Conferences. 80% of the students liked the conferences (data not shown). When asked to rate their prior experience in international speaking engagements on a scale of from 1 to 10 the mean rating was 4.23, indicating that students did not feel that they had much experience .Student mobility. In 2018/2019 about 80 students travelled Table . StudentBeyond anatomy topics. Overall, students felt that they had learned about healthcare education, healthcare delivery, public health, and health ethics in the partner countries during the small group sessions and large group conferences Figure . In addiNetworking. After their travel Figure , more st“The hidden curriculum”. To measure skills that are not linked to the immediate program goals, some questions covered what additional skills the students thought that they gained. Students felt that they gained experience/knowledge in a variety of areas of “hidden” learning objectives – i.e., tolerance, appreciation, self- confidence, change in world-view, and influence on lifestyle changes Figure . StudentIn summary, this program offered students insight into other international healthcare education systems and healthcare delivery systems and sensitized the students to intercultural differences. Also, they learned about international public health challenges, other countries’ health ethics and health laws, international ethics on body donation, and obtained a global picture of healthcare. In addition, the program taught the students about differences in body donation processes in different countries, and helped them to reflect on this sensitive topic.This report adds to the body of available literature on IoME with the format, content, and results of a new international student exchange program that was built upon a unique partnership of multiple international anatomy departments. Anatomy as an educational discipline was utilized as a binding element for the international work.The program included formal elements of IoME such as university partnerships, student education, and student mobility. Program content encompassed elements of the liberal, social justice, and competitive models to promote future international collaborative problem solving in healthcare, with the ultimate goal of improving GH.Very few published programs build on a trajectory of international experiences and involve both industrialized and LMIC countries . Unlike International experiences, particularly in the US, frequently aim to support the social justice notion of IoME, and historically often involved humanitarian work in the LMIC as part of GH programs 23. The aOften, there is little introduction to acquaint young students with international differences, although pre-departure training is considered important and offered in recent years 32. The sReports on early internationalization efforts for junior medical students are limited 63334. In633Limited reports are available on programs that connect students from different countries to each other 36. While37230There is undeniable value to student-run programs via large organizations . Direct involvement in peer connection via medical schools and senior medical teaching faculty can be of value for quality control and integration into medical school curricula. As globalization will play a larger role in medical education, medical schools should take on an active role in student interactions.Student outbound mobility has long been regarded as synonymous with internationalization in medical education . Eight-s13641Programs with multidirectional student exchanges are limited 43. This International collaborations in medical education have been presented in various forms and directions 183545464748.4546474950The majority of students in this program supported the idea of having anatomy as an anchor for the international exchanges. Due to the limited amount of time the students could spend with their peers, a significant number of groups decided not to focus on learning anatomy related topics from each other during their small group sessions. This demonstrates that students appreciated the networking opportunity initiated via the anatomy course. With the exception of reports generated by this group of authors there are no reports that link the discipline of anatomy to internationalization of medical education 30.There are several advantages to choosing anatomy as an anchor for international activities. First, anatomy is a subject field that is taught universally in all medical and dental schools. Secondly, anatomy is typically taught very early in the preclinical phase of medical education. Many US medical schools offer GH experiences between years 1 and 2 of medical school . TherefoThe content of this program differed from many international programs 2223 beca22Cultural awareness is important for global leaders and should be part of the medical curriculum . The culThis program is primarily meant as an educational program. This paper presents qualitative research data . Long-term effects of these early international experiences on the student’s lives and careers will not be immediately available, and the authors are aware that there will be a lag time between the start of the program and potential longitudinal data, along with the challenges of keeping in contact with the participating students .In the available literature there are not agreed upon learning objectives for GH programs, which will pose another challenge should one attempt to study learning objectives and outcomes for this program 2023.20Lastly, as with any new emerging field in medicine, funding is limited until an official acknowledgement of the field is achieved. While some funds for students’ activities via institutional GH programs were secured, self-funding and the voluntary dedication of participating faculty are the norm.Nevertheless, the program represented a substantial international student networking and exchange program, and reflected a new and additional role that the anatomist and the anatomy course can play in GH and the IoME.The current report about an international partnership of anatomists in a new area of medical education – seemingly distant from pure anatomy teaching – can inspire future opportunities for collaboration in this regard.International collaboration among anatomy departments can lead to enhancement of student education by facilitating international experiences. This unique collaboration represented a new role for anatomy departments in GH and IoME – beyond the classic educational role of anatomy – and introduced a new purpose for international collaboration among anatomists.The additional file for this article can be found as follows:10.5334/aogh.2665.s1Additional File.International Exchange Program Questionnaire 2018/19.


The Nordic Nutrition Recommendations (NNRs) constitute the scientific basis for national dietary reference values (DRVs) and food-based dietary guidelines (FBDGs) in the Nordic and Baltic countries.To define principles and methodologies for the sixth edition of NNR to be published in 2022 (NNR2022).The principles and methodologies of the previous edition of NNR were used as a starting point. Recent nutrition recommendations commissioned by other national food and health authorities or international food and health organizations were examined and dissected. Updated principles and methodologies were agreed by the NNR2022 Committee in a consensus-driven process.de novo SRs on prioritized topics. To avoid duplication and optimize the use of resources, qualified SRs commissioned by other national and international organizations and health authorities will also inform DRVs and FBDGs in NNR2022.An organizational model with ‘checks and balances’ was developed to minimize the influence of subjective biases of the committee members and experts. Individual chapters on all included nutrients and food groups will be updated as scoping reviews. Systematic reviews (SRs), which are the main basis for evaluating causal effects of nutrients or food groups on health outcomes, will be embedded in each chapter. A NNR SR Centre will be established for performing The evidence-based methods defined in the NNR2022 project are compatible with most contemporary methods used by leading national food and health authorities. Global harmonization of methodological approaches to nutrition recommendations is strongly encouraged.Evidence-informed principles and methodologies underpinned by SRs will ensure that DRVs and FBDGs defined in the NNR2022 project are based on the best available evidence and as far as possible free from overt bias. The Nordic and Baltic countries are developing a common scientific basis for national nutrition recommendations.The project is commissioned by the Nordic Council of Ministers.A comprehensive organizational model with ‘checks and balances’ was developed.Contemporary evidence-based principles and methodologies based on the best available evidence were defined.The Nordic Nutrition Recommendations (NNR) constitute the scientific basis for national dietary reference values (DRVs) and food-based dietary guidelines (FBDGs) in Denmark, Finland, Iceland, Norway, and Sweden, as well as Estonia, Latvia, and Lithuania. The international collaboration has resulted in the previous five editions of the NNR . The recThis article is the first of a three-part series for the sixth edition of the NNR (NNR2022):Principles and methodologies (this article),Structure and rationale of qualified systematic reviews . Herein, we define  reviews , is a guThe main objective of NNR2022 is to use the best available scientific evidence to ensure a diet that provides energy, food, and nutrients for optimal growth, development, function, and health throughout life. It should be noted that certain DRVs and FBDGs are only applicable if the supply of other foods and nutrients are adequate.Historically, the NNR has included the following DRVs for nutrients: 1) average requirement (AR); 2) recommended intake (RI); 3) upper intake level (UL); 4) lower intake level (LI); and 5) reference values for energy. Recently, NNR has also included FBDGs.The principles and methodologies for developing DRVs and FBDGs have evolved considerably over the last few years. For example, during the last decade, SRs have been established as the preferred method for evaluating causality between diet and health outcomes –9. The mDue to possible further development of the principles and methodology for developing DRVs and FBDGs, some aspects defined in the present paper may be changed at later stages of the project. Any potential deviation will be clearly stated in the final report.The following sponsors have supported the work with NNR2022:Nordic Council of MinistersNordisk arbeidsgruppe for kosthold, mat og toksikologi (NKMT), The Nordic CouncilSamarbeidsministrene(MR-SAM), TheNordic CouncilNordisk ministerråd for fiskeri og havbruk, jordbruk, næringsmidler og skogbruk (MR-FJLS), The Nordic CouncilNordisk embetsmannskomite for fiskeri og havbruk, jordbruk, nærinmgsmidler og skogbruk (EK-FJLS), The Nordic CouncilFood and health authorities in Denmark, Finland, Sweden, and NorwayAffiliations). The Steering Committee (see below) also consists of members from national food and health authorities. Otherwise, the sponsors will have no direct role in the NNR2022 project.The mandate from the sponsors was to update the fifth edition of the NNR (published in 2014) based on new scientific evidence. The only specific request was that sustainability needed to be implemented in NNR2022. The main position/affiliation for HE, EWL, and HMM were their respective national food and health authorities , are the main drivers of the project, we have designed an organizational system of ‘checks and balances’ that tries to minimize the influence of The NNR2022 Committee is responsible for organizing and implementing the NNR2022 project and publishing the final NNR2022 report. The NNR2022 Committee is appointed by the national food and health authorities in Denmark , Finland , Iceland , Norway , and Sweden . Representatives appointed by food and health authorities in Estonia, Latvia, Lithuania, as well as the autonomous areas of the Faroe Islands, Greenland, and the Åland Islands have been welcomed to contribute to the NNR2022 Committee as observers. The committee has 11 members , five observers, and one project secretary (AH).The NNR2022 Committee is responsible for appointing the Scientific Advisory Group, the NNR Systematic Review Centre, chapter authors, and referees, and for approving any conflict of interest for the Scientific Advisory Group, chapter authors, and peer reviewers. If there are any conflicts of concern, the NNR2022 Committee will consult the Steering Committee.The NNR2022 Committee is responsible for project progress and coordination, communication with the Steering Committee, organization of relevant workshops, public hearings, and the NNR2022 websites.Based on initial scoping reviews (ScRs) and public consultations, the NNR2022 Committee will select chapter topics for SRs and decide how to update each individual chapter. The committee is also responsible for the final editing of all chapters and the setting of DRVs and FBDGs.The NNR2022 Committee will arrange several public hearings, call for experts and topics for SR, and strive to be as transparent as possible in all considerations related to the project.The Steering Committee consists of five representatives from the food and health authorities in the Nordic countries , and is chaired by the representative from Norway. The responsibilities of the Steering Committee are to approve the budget, set the criteria for conflict of interest, and evaluate the declaration of conflict of interest for the NNR2022 Committee. The Steering Committee will also regularly approve progress reports from the NNR2022 Committee.The Scientific Advisory Group is appointed by the NNR2022 Committee after consultation with the Steering Committee. The group should consist of international scientists with experience in developing DRVs and FBDGs for national authorities or health organizations, as well as to have competence in the field of sustainability. As such, they will advise on the principles and methodologies for developing the sixth edition of the NNR, including the methodology used to perform SRs as part of the NNR2022 project. They will also give advice on general scientific issues related to the NNR2022 project.The NNR2022 project will fund a NNR Systematic Review Centre (NNR SR Centre), which will be responsible for performing all SRs on topics prioritized by the NNR2022 Committee.The NNR SR Centre will consist of a team of at least six scientists from different disciplines. At least two of the members will be senior scientists and one should be a statistician, all three with experience in conducting SRs. The other members may be PhD students or postdocs. In addition, the NNR SR Centre will be facilitated by two librarians. The NNR SR Centre team will be selected by the NNR2022 Committee based on invitations by the NNR2022 Committee and a public call. Representatives from all the Nordic countries will be included in the NNR SR Centre, if possible.The NNR2022 project will engage scientific experts across the Nordic and Baltic countries to update the chapters. Experts outside these countries may also be engaged. All experts and referees will be listed in the relevant chapter. At least two experts will be assigned to a chapter, one of which will serve as a leading author. The experts will be appointed by the NNR2022 Committee based on invitations by the NNR2022 Committee and a public call, after careful evaluation of each expert´s skills and experience related to the chapters. The NNR2022 Committee members should avoid being authors on the nutrient and food chapters.In addition to the main organization, at least two experts will be appointed to peer-review individual chapters and SRs. These experts will be appointed by the NNR2022 Committee based on direct invitation by the NNR2022 Committee and a public call. Personal skills and competence related to the individual chapters or SR will guide the choice of peer reviewers.Almost all scientists have some sort of direct or indirect conflict of interest. Conflict of interest may arise due to the institution where the scientist is employed; many state institutions receive external funding directly or indirectly from commercial interests or interest organizations. Many private or commercial institutions may also have specific interests related to their purpose or ideology.Conflict of interest may also arise due to funding to the scientist of concern. All scientists must compete for internal and external resources for scientific activities. The external sources that fund most research span from national research funds that distribute resources from governmental budgets, to patient or interest organizations  and commercial entities . Furthermore, governmental funds, including those resources distributed through European Union and national research councils, most often demand collaboration with commercial companies. Industry-sponsored research is therefore a large part of modern medical science. Otherwise, the development of newer drugs, and medical technologies for the detection and treatment of disease would not have been possible.The objective of the NNR project is to develop updated DRVs and FBDGs, as objectively as possible, without the influence or bias of the scientists involved. That is why we have designed an organizational system of ‘checks and balances’ that minimizes the influence of the innate biases of the scientists involved. Some important features of this system are that:the project is split into discrete parts that will be done by separate experts,the project involves a large number of experts from a large number of nutrition and non-nutrition subdisciplines,we avoid the likelihood of experts influencing multiple parts of the process,peer-review will ensure scientific quality and integrity of the final output, andwe strive to be as open and transparent as possible in all matters related to the project.Due to sponsorship for research from commercial entities and ideological organizations, concerns have been raised about bias in the results of such research. For example, evidence for substantial bias has been identified in conclusions of industry-sponsored systematic reviews. It is suggested that industry-sponsored research will result in approximately 30% higher likelihood off a favorable conclusion, compared to nationally sponsored research , 5. WhilFurthermore, to reduce the risk of such bias, NNR2022 does not consider SRs commissioned or sponsored by industry or organizations with a business or ideological interest as qualified SR. Only SR commissioned by national food or health authorities, or international food and health organization, may be identified as qualified SR .Due to the impact of the NNR2022 project, a number of industry and ideological organizations are expected to contact the NNR 2022 Committee during the project period. In order to prevent any influence of such contacts on scientific conclusions, the NNR2022 project only accepts inputs from such sources through the official website of the NNR project. All inputs through this website will be fully open and available for everybody. General contact with industry and ideological organizations is expected in open symposia or workshops.The central goal of the conflict of interest policies is to protect the integrity of professional judgment and to preserve public trust. The disclosure of individual and institutional financial relationships is a critical step in the process of identifying and responding to conflict of interest. NNR2022 experts and committee members will declare, on a specific form, all relationships from which they (and their spouse or dependent children) received either assets or supplemental income of greater than 10.000 DKK in the last 5 years outside of compensation related to their full-time, permanent employment.Experts with strong ties to industry or ideological organizations are also excluded from serving as chapter authors, peer reviewers, NNR SR Centre members, or other committee members. Thus, relevant industry or ideological ties will also be declared.Instruction to authors guide. The main chapter subsections are listed in Chapters in NNR2022 will follow a standardized format, outlined in an a priori defined procedure and conclude with a grading of the evidence for a causal association . The EQUATOR network has formulated requirements that must be met in reporting SRs . In addition, for a limited selection of other associations, the NNR Systematic Review Centre will perform de novo SRs (see ‘Process for selecting topics for systematic reviews’ section).NNR should ideally build on updated SRs of highest quality for de novo SRs or other qualified SRs, the text will follow the procedures of the PRISMA Extension for Scoping Reviews (PRISMA-ScR) defined by the EQUATOR Network (For subsections of the NNR chapters not covered by  Network  7). A S. A Sde n Network .de novo SR by the NNR2022 project, but the qualified SR will instead be used. If no previous relevant qualified SR exists, the PI/ECOTSS statement will be considered for prioritization. The final list of prioritized topics is then ranked by the NNR2022 Committee and consulted by the Scientific Advisory Group. If prioritized above a certain threshold , the topic is commissioned to the NNR SR Centre.The process starts with the formulation of an initial draft ScR for each chapter by the NNR2022 Committee. The drafts and inputs from a public call is then discussed by the NNR2022 Committee; the discussion concludes with a decision on whether each topic should be shortlisted or not . If shortlisted, the NNR2022 Committee formulates a formal research question (PI/ECOTSS statement). The NNR2022 Committee then examines whether a recent qualified SR exists on the same topic. If a qualified SR exists, the topic is not prioritized for Box 1Scoping reviewsA scoping review (ScR) is a relatively new type of review. Like in a systemic review (SR), subjective choices made during the review process are clearly described, making it more transparent than a narrative review. In ScRs, the specific methods by which the included studies are identified, selected, and evaluated are always reported. Thus, although not as comprehensive as in an SR, the conclusions of a ScR are likely to be less colored by bias than those of a narrative review.SRs are often used for a limited number of and narrowly defined questions, while ScRs are used for broader questions . ScRs are also useful when the literature has not recently been comprehensively reviewed by an SR.Shortlisting and prioritization is done according to the following criteria:Relevance: The topic is within the scope of NNR2022.Importance: The topic has new, relevant data in an area of substantial public health concern.Potential national impact: The SR may inform national food and health policies and programs.Avoiding duplication: The topic is not currently addressed through other qualified SRs .When a topic is selected for NNR2022 SR, the scientific research question will be formulated as a formal PI/ECOTSS statement. The PI/ECOTSS statements will consist of the following elements: population; intervention, intake or exposure; comparators; outcomes; timing; setting; and study design.All NNR2022 SRs will strictly follow The Nordic Nutrition Recommendations 2022 – Structure and rationale of qualified systematic reviews . For an Many SRs have been published on the effect of nutrients or foods on health outcomes. Some SRs are of very high quality and may be used as part of the evidence base in NNR2022. Inclusion and exclusion criteria for qualified SRs in the NNR2022 project are summarized below. To qualify, all criteria must be met.Commissioned by national food or health authorities, or international food and health organizationAuthored by a multidisciplinary group of expertsConsists of an original SR of the evidence for a nutrient/food–health relationshipIncludes at least one nutrient/food topic, and its relationship to at least one outcome related to a chronic disease or condition that is of public health interest in Nordic or Baltic countriesIncludes a clear description of SR methodology, which should be similar to the methodology used NNR2022 (companion paper)Includes an assessment of the quality of primary studiesProvides an evidence grade for the overall quality of the evidenceEnglish languageSR should not be commissioned or sponsored by industry or an organization with a business or ideological interestSR should not be updated later in another qualified SR on the same topicSR should not focus on an outcome outside the scope of the NNR (e.g. disease management or food safety).Qualified SRs will be included in the evidence base of each chapter together with the SRs developed as part of the NNR2022 project. A limited number of qualified SRs from national or international authorities and organizations have been publised . The folNational Academy of Scienes, Engeneering and Medicine, the United StatesDietary Guidelines Advisory Committee, the United StatesWorld Health Organization (WHO)World Cancer Research Fund (WCRF)European Food Safety Agency (EFSA)Scientific Advisory Committee on Nutrition (SACN), the United KingdomGerman Nutrition Society, GermanyHealth Council, The NetherlandsNational Health and Medical Research Council, AustraliaMinistry of Health, New ZealandHealth Canada, Canadaother subsections of the NNR2022 chapters  clinical trials (preferably RCTs); 2) observational studies (preferable prospective cohort studies or Mendelian randomization [MR] studies); and 3) mechanistic studies   and 3. SWell-designed and well-implemented RCTs can demonstrate causality, while observational studies, in the absence of huge effect sizes, do not. RCTs are not, however, always available (see below).The methodology for SRs normally used within the field of clinical medicine is based on the methods described by The Cochrane Collaboration  and the will not – be available. When considering nutrient deficiency, adequacy, or toxicity, other types of studies are more often used: mechanistic studies, studies in animals or humans on nutrition status and metabolism, and balance studies. Prospective cohort studies may also be useful.For ethical reasons, long-term RCTs on deficiency or toxicity are not – and RCTs are not realistic for many chronic diseases that develop slowly over a long period, often several decades. It is not ethical, practical, or economically feasible to conduct RCTs with decades long lifestyle interventions. Clinical trials that randomize healthy people to a presumably unhealthy lifestyle, such as a poor diet, smoking, or physical inactivity, and then wait for decades to test whether the intervention arm dies prematurely has not, and should not, be performed. Evaluation of the evidence for causal associations between lifestyle factors, such as diet, smoking, physical activity, stress, sleep, and other lifestyle habits, must therefore apply a more holistic and sophisticated strategy, which indeed differs in important aspects from the methods used by, for example, Cochrane  and GRADThere are some important exceptions where RCTs are also available and useful when considering DRVs and FBDGs , epidemiological studies (particularly prospective observation and MR studies), and physiological and mechanistic studies . The sum of this literature forms a basis for assessments of causality in accordance with the methodology described by the WCRF , 15, therelevance of the causal associations for the Nordic countries. This stage takes into account the characteristics of the Nordic and Baltic populations, including the current patterns of dietary consumption, and diet-related health challenges in the Nordic and Baltic countries. The NNR will also have a special emphasis on integration of aspects related to physical activity, obesity, and sustainability. The implications of the boundaries defined by the 1) Nordic and Baltic diet pattern, 2) Nordic and Baltic health challenges, 3) physical activity, 4) obesity, and 5) sustainability will be described in separate chapters.The third stage involves the evaluation of the Box 2Various types of scientific study are necessary in order to assess causalityEach individual study type, all with strengths and weaknesses, cannot alone form the basis for drawing causal conclusions and setting dietary reference values and food-based dietary guidelines. Collectively, they can however provide an adequate basis for dietary advice. Some of the strengths and weaknesses of each study type are described below.Intervention studiesAmong intervention studies, randomized controlled trials (RCTs) give the best evidence of causal associations, since this type of study can provide the best control for confounding factors , 11.The For a few diseases, surrogate disease markers can be used as substitutes for chronic disease outcomes. Examples of such qualified surrogate markers are low-density lipoprotein -cholesterol, serum total cholesterol, and blood pressure for cardiovascular diseases; bone mineral density for osteoporosis; adenomatous polyps for colorectal cancer; and increased blood glucose and insulin resistance for type 2-diabetes. In such cases, RCTs may be more feasible in evaluating causality.Observational epidemiological studiesStrengths of longitudinal epidemiological studies include a long observation period and that morbidity and mortality can be included as endpoints. Effects of foods in free-living people without any restrictions can thus be studied. It is however difficult to control for all confounding factors. In addition, adequate methods for assessing diet in sufficient detail in epidemiological studies are generally not available. Epidemiological studies also require differences in exposure levels between individuals in the population groups being studied, which is often not the case within a population. External validity of observational studies is largely related to representativeness of the cohort .Prospective cohort studies have the fewest sources of error, and the results of such studies therefore provide the highest level of evidence among epidemiological types of study –12. ObseMechanistic in vitro studies, studies involving cell cultures and experimental animalsin vitro and cell tests to a physiological context, and it is challenging to transfer results from controlled animal experiments to free-living people. Tests using ‘knockout’ mice and other transgenic mice are particularly important for establishing biological mechanisms in a physiological context. The revolution in molecular biology and the sequencing of the human genome have provided ground-breaking new insights into mechanisms and our biological understanding of nutrients, other bioactive substances in diet, and the development of diseases. In addition, the long-term regulation of genes in connection with epigenetic mechanisms can be an important factor in explaining how lifestyle habits can affect the risk of disease, a risk which can also be passed on to the next generation . However, it can be difficult to transfer results from neration .Various types of scientific study are necessary in order to assess causalityTogether, these three types of study will form the basis for assessments of causality in accordance with the methodology described by the World Cancer Research Fund (WCRF) , 15, theThe fourth stage involves the final development and formulation of DRVs and FBDGs. While the scientific evidence for causal associations and the Nordic and Baltic context are the main bases for the specific DRVs and FBDGs, several other aspects will also be taken into account.The evidence base for DRVs and FBDGs may be different. For example, the level of certainty of a causal relation between exposure and outcome may often be quite different when assessing nutrient deficiency, nutrient adequacy, upper limits of nutrients, and optimal intake of food groups. In spite of these differences, we aim at, whenever possible, applying similar principles and methodologies when setting the two kinds of recommendations.SRs will likely find that certain aspects within each chapter  are unknown or uncertain. There may be lack of data, the studies may be very old, studies may have a high risk of bias, or there may be uncertainties related to biomarkers or methods for extrapolation to certain age groups. Still, for many nutrients, we will formulate DRVs in spite of uncertainties in these assessments. In the final NNR report, we will describe transparently all the relevant uncertainties for each nutrient, food group. Thus, a holistic assessment will lie behind the decisions to formulate FBDGs.Box 3Mendelian randomization studiesEpidemiological studies cannot infer causality due to two major limitations: confounding and reverse causality .Mendelian randomization (MR) studies, on the other hand, combine the strengths from both epidemiological studies and randomized controlled trials (RCTs). Similar to an epidemiological study, a MR study is observational – it aims to quantify the association between an exposure (a biomarker) and a disease outcome. In addition, similar to an RCT, an MR study is also interventional. The basis for these unique features of the MR methodology is the random segregation of gene variants, or alleles , during meiosis. Consequently, confounding factors should be equally distributed between subjects with different alleles. In addition, since the segregation of alleles precedes the development of disease outcomes, MR studies should be free from reverse causation .MR studies can be particularly relevant for situations where specific alleles directly affect the level or function of gene product. If the underlying molecular relationships between gene variants, protein level and function, and physiology are thoroughly described, the allele can constitute a so-called instrumental variable for a specific exposure or biomarker. The three fundamental assumptions underlying this MR concept is that 1) genes are randomly assigned among people, 2) some genes influence the exposure of interest, and 3) the genes that influence the exposure do not influence the outcome via any other path than via the exposure  Fig. 4aFig. 4a.Documentation of causality for certain risk factors  and non-causality for others (high-density lipoprotein cholesterol), have implications for the strength of evidence of nutrition recommendations. Importantly, in light of MR studies, dietary interventions that report sufficiently large changes in causal risk factors can be considered highly clinically relevant: although they show changes in intermediate endpoints, we may now more precisely extrapolate to hard endpoints, such as coronary heart disease (CHD) morbidity and mortality . In thisIn some MR studies, instrumental variables may be used to objectively assess intake or exposure to certain nutrients . For exaIn recent years, gene-exposure-outcome associations examined using MR studies have become more and more complex, including those within nutrition research, which makes it harder to robustly conduct and interpret the findings . BecauseIn summary, MR studies can be considered observational experiments of nature, and well-conducted MR studies can determine causality of associations between exposures and disease outcomes . Some MRFood-based scientific studies will be used as a starting point for setting FBDGs; however, if food groups are of particular importance for certain nutrients, nutrient-based research will also be included. Formulating FBDGs must also take into consideration the entirety of the diet, Nordic and Baltic food traditions, and developments in the Nordic and Baltic diets. The FBDGs set in the NNR will be general, mainly on food group level, allowing each country to develop more specific national FBDGs, if required.For FBDGs, we will consider to include nutrient considerations for each food category if 15% of a nutrient originates from that food category. This is in line with the European regulations on the declaration of nutrients in foods (No 1169/2011): a quantity or source is defined as being ‘significant’ if the food contains 15% or more of the DRVs.For chapters in NNR that concern nutrients, qualified SRs will inform the NNR2022 Committee on the scientific evidence that is relevant for setting DRVs. In the following, we give a general description of the considerations and the principles for setting DRVs.The DRVs are intended for healthy individuals. Generally, the DRVs cover increased requirements such as during short-term mild infections or certain medical treatments. The DRVs are usually not suited for long-term infections, malabsorption, and various metabolic disturbances or for treatment of persons with a suboptimal nutritional status. They are meant to be used for prevention purposes. The NNR, however, does cover dietary approaches for sustainable weight maintenance after significant, intentional weight reduction. For individuals with disease and for other groups with special needs, the dietary composition might have to be adjusted accordingly.Where original data are lacking or insufficient, extrapolation from one group to another is often necessary. The most common method is to extrapolate values from adults to children using a weight or metabolic factor and adjusting for growth. This approach will also be applied in the current NNR.For most nutrients, a hierarchy of criteria for nutrient adequacy can be established ranging from prevention of clinical deficiency to optimal levels of body stores and functionality . A higheIn NNR, the AR is defined as the value to meet the requirement for half of a defined group of healthy individuals provided that there is a normal distribution of the requirement .In general, the selected criteria for establishing the AR apply to micronutrients and are usually based on data on biochemical markers of adequate nutritional status. However, the AR can also be derived for some macronutrients such as protein and essential fatty acids.Deficiency of a nutrient would imply that the supply is so small that specific symptoms of disturbances in body functions emerge. During serious, manifest deficiency, overt clinical symptoms or signs such as bleeding of the gums during scurvy or neurological symptoms due to vitamin B12 deficiency would arise. Data on biochemical markers can include the activity of certain enzymatic systems in which nutrients have a role as cofactors or concentrations of a nutrient in cells or fluids as a measure of tissue stores. Low activities or concentrations might be associated with deficiency symptoms or impaired function. Moreover, it is possible to define an interval between manifest deficiency and optimal intake level in which clinical symptoms are more diffuse or do not exist at all. This level is sometimes called latently insufficient . Such inAR corresponds to the term ‘Estimated Average Requirement’ (EAR) used in the UK and US recommendations .RI refers to the amount of a nutrient that meets the known requirement and maintains good nutritional status among practically all healthy individuals in a particular life stage or gender group. When the distribution of a requirement among individuals in a group can be assumed to be approximately normally distributed  and a standard deviation (SD) can be determined, the  follows : RI = ARAR, an approximate coefficient of variation (CV) of 10–15% can be used  while the stores of water-soluble vitamins (with the exception of vitamin B12) are usually lower.The Where sufficient scientific evidence is available on interactions with other dietary factors, these are accounted for. Examples are the enhancing effect of ascorbic acid on non-heme iron absorption and the effect of folate on homocysteine levels in the blood. When establishing the RI values, these aspects have been taken into consideration.High doses of certain vitamins and minerals can have pharmacological effects different from their primary nutritional effects. Generally, this concerns amounts that the target group could not normally obtain from the diet. The effect of high doses of nicotinic acid as a lipid-lowering agent and the effect of fluoride on dental caries can be considered pharmacological rather than nutritional effects. Such effects have not been taken into consideration in the establishment of the RI .The RI is intended for healthy individuals and is not necessarily appropriate for those with different needs due to diseases such as infections. In general, the RIs are only applicable when the supply of other nutrients and energy is adequate.The definition of RI corresponds to the term ‘Recommended Intake’ used in the United Kingdom and ‘Recommended Dietary Allowance’ (RDA) used in the United States , 26. TheIn some cases, data are not available to establish AR or RI. In such cases, we will consider establishing Adequate Intake. This will be discussed in forthcoming publications.For most nutrients, high intakes might cause adverse effects or even toxic symptoms. The UL is defined as the maximum level of long-term (months or years) daily nutrient intake that is unlikely to pose a risk of adverse health effects in humans. The threshold for any given adverse effect varies depending on life-stage, sex, and other individual characteristics just as it does for any nutrient requirement. However, there are insufficient human data to establish distributions of thresholds for each adverse effect. The different steps in setting the UL include the identification of the critical endpoint, which is the lowest dose at which an adverse effect occurs, and using a surrogate measure for the threshold .Box 4Setting recommended intake for micronutrientsIn setting recommendations for micronutrients, the Nordic Nutrition Recommendations use the classical approach with the following steps:The first step includes an evaluation of the average physiological and dietary requirement for the population group in question as judged by criteria that have to be set specifically for every individual nutrient. The establishment of these criteria includes considerations of clinical and biochemical deficiency symptoms, body stores, body pool turnover, and tissue levels. The nutritional requirements are influenced mainly by different biological factors such as age, sex, growth, height, weight, pregnancy, and lactation.The second step includes an estimation of a safety margin to ensure that all individual variations are considered and added to the requirement to obtain a level of recommended intake. The size of this safety margin depends on several factors, among others the variation in the requirements between individuals and potential adverse effects of high intakes. Furthermore, the precision of the estimation of the requirement should be taken into consideration .The thresholds are the following:No observed adverse effect level (NOAEL): the highest intake of a nutrient with no observed adverse effectsLowest observed adverse effect level (LOAEL): the lowest intake level with an observed adverse effect.Based on these evaluations, a UL is derived by taking into account the scientific uncertainties in the data by dividing the NOAEL by an uncertainty factor (UF) . This factor should account for uncertainties in human inter-variability or, in the case of insufficient human data, an extrapolation from animals to humans as well as other uncertainties or deficiencies in the data. The definition of UL corresponds to the term ‘Tolerable upper intake level’ used in the United States  and by tThe LI is defined as a cutoff intake value below which an intake could lead to clinical deficiency symptoms in most individuals. Establishment of an LI is thus based on observations of individuals and is in many cases based on criteria other than the AR.LI differs from the term ‘Lower reference nutrient intake’ (LRNI) used in the United Kingdom, which is defined as EAR minus 2 SD . Thus, the reference value for energy intake should be considered a theoretical value intended to be used as a reference for the entire population group.The term RI range of macronutrients (i.e. percentage of energy from macronutrients) is used to emphasize the importance of the distribution of energy between energy-providing nutrients. The current major lifestyle diseases mainly result from overnutrition and nutritional imbalances rather than from under-nutrition and deficiency symptoms. The intention of setting the RI range of macronutrients is, therefore, to derive a dietary macronutrient composition that will provide an adequate intake of essential nutrients for optimal health and a reduced risk of major lifestyle diseases . In these cases, the RI range of macronutrients is based on an overall assessment of the scientific evidence and includes specific considerations about known patterns of intake of nutrients and foods, and the actual composition of available foods in the Nordic countries. On this basis, the RI range of macronutrients should be considered ‘optimal’ for the Nordic and Baltic conditions.upper and lower thresholds are defined. These thresholds refer to maximum and minimum levels of dietary intake for which a population is recommended to adhere; for example, for saturated fat and added sugar (upper thresholds), and dietary fiber (lower threshold).The RI range of macronutrients refers to appropriate ranges of the usual intake in the majority of individuals in the population . For plaa priori all methodology and data handling for clarity and transparency. This paper is the first of three and should be viewed in concert with its two companion papers, namely, Structure and rationale of qualified systematic reviews (Handbook for qualified systematic reviews (In this paper, we have described the organization, principles, methods, and the systematic approach that will be used in the development of NNR2022. The paper has defined  reviews , which dWe believe and hope that these principles and methods also can serve as a state-of-the-art basis for other national food and health authorities that plan to develop DRVs and FBDGs. See section on “Conflicts of interest” and “Sponsors of the NNR2022 project”


The majority of people with intellectual disabilities (ID) and psychiatric disorders access mainstream mental health services across Europe. However, only 56% of countries provide postgraduate psychiatric training in ID according to a survey across 42 European countries. We explore the challenges of ID training and make recommendations for education and health policymakers. Intellectual disability (ID) is a neurodevelopmental disorder affecting 1–2% of the population [It is well established that people with intellectual disabilities have significantly higher rates of mental  and physHowever, the provision of services is often poorly planned and does not necessarily match the needs of people with ID . This isWithout qualified and skilled clinicians to look after people with ID, the care and support of people with ID cannot be further improved. Given mental health problems are highly prevalent in people with ID , there iQualified clinicians are an essential pillar to improved care. The content and methods of postgraduate psychiatric training profoundly shape future psychiatrists and the quality of psychiatric care and expertise .In Europe, the international frameworks for training standards, including ID, are issued by the Union Européenne des Médecins Spécialistes (UEMS). Despite these harmonized evidence-based policies, for example “Training Requirements for the specialty of Psychiatry” (uemspsychiatry.org), and the automatic mutual recognition of qualification in EU, the practice differs vastly .Each person, regardless of the country they live in, has the right to health, to have the best care possible, and to have it delivered by skilled professionals.www.efpt.eu), an umbrella organization for trainee associations, conducted the most comprehensive study so far of postgraduate psychiatric training and provision of ID training across Europe.The European Federation of Psychiatric Trainees  answered the questions on the availability of ID training see . Twenty-The design of this study, where the respondents have the responsibility of being national representatives, ensured an extremely high response rate (98%) and assures us of the accuracy of the data. Furthermore, the information provided reflects the actual experiences of trainees about the provision of training. In countries where training is not nationally standardized there may be bigger variation within different regions of the same country that could not be captured, although these respondents would be the best placed to have such intelligence. The authors are not aware of significant changes to psychiatric training programs since the time of data collection.To our knowledge, this is the most recent and comprehensive study on this topic. The only other survey done so far that covered postgraduate psychiatry ID training was done in 2004 and was much smaller . It showThe biggest question is whether we need specialists in ID psychiatry.In many countries, less time available for training and constraints of service provision during training limit the exposure to ID. Limited exposure to people with ID and their problems contributes to increase the stigma these people already face. Previous exposure, either in personal or working life, has shown to influence choice of ID subspecialty training. Different modalities of training operate in Europe with a debate about the need for a subspecialty in ID versus the need for all psychiatrists to have ID training. The former has been criticized alongside other subspecialties as it can lead to fragmentation of care. The latter, despite great efforts, has yet to be implemented within and between countries.The cost of ignorance on the subject matter due to lack of training can be far-reaching. Firstly, diagnosing mental disorders in people with ID can be challenging for many reasons. There is the risk of under-diagnosing or mis-diagnosing mental disorders in people with ID. The presence of multiple physical, neurodevelopmental, and psychiatric co-morbidities can change the way mental illnesses present in people with ID. Diagnostic overshadowing is very commonly reported. Lower intellectual functioning along with communication difficulties can affect how psychiatric symptoms are manifested. Failing to identify and treat early can have an adverse outcome in health leading to premature death and social disintegration. Secondly, lack of skills to identify the real issues and lack of knowledge or availability of specialist multidisciplinary centers lead to unwarranted and off-label prescription of medication, for example, antipsychotics with the deleterious consequences associated with those, or to over-use of physical restraint. Thirdly, the lack of skilled adult psychiatrists leads on many occasions to child and adolescent psychiatrists being approached by parents of people with ID already in their 20s because they are desperate and have no-one to turn to with sufficient expertise.•Given the above, the authors believe ID psychiatry should be a mandatory part of training curricula and exams (assessment drives learning) in all European countries.•We acknowledge the different challenges faced by different countries, related to economic power, organization of services, organization of training, provision of social care, and general societal expectations. Nonetheless, we suggest that through harmonized training—between and within countries—we can promote harmonized care despite all the existing contextual differences .•Professional exchange programs, like those provided by EFPT and EPA offer a means to complement the training curricula where opportunities are not available locally.•Importantly, even after the completion of postgraduate training, the provision of quality Continuous Medical Education (CME) on the topic, especially through new technologies, can increase the reach of ID training, overcoming location and economic barriers.•We recommend that ID training should not be limited to CAP training, but should work on facilitating the transition between CAP, when the disorders are normally identified, adult psychiatry, as well as old age psychiatry—as the life-expectancy of people with ID continues to increase.•Last but not least, it is important to remember that improvements in the field will come from good cooperation with other professionals and including people with ID, their families, and carers as stakeholders.National and international policy is an important lever for directing and effecting change. Without improvements in postgraduate psychiatric training in ID, psychiatric care for people with ID will not fundamentally improve. Looking at the survey results, not much has happened in the past decade. For the benefit of people with ID, we need to come together to make a more active push for curriculum reform across Europe.


Supplemental Digital Content is available in the text People with autism spectrum disorder (ASD) have an increased susceptibility for many chronic health conditions compared with their peers. An increasing number of adolescents are transitioning from pediatric to adult healthcare services. Thus, being able to access appropriate healthcare services that can not only address specific needs of the person but enable them to better manage healthcare conditions and decrease the development of preventable disease is necessary. A systematic review was conducted to identify barriers and enablers of healthcare access for autistic adults.The studies included in the review were quantitative and qualitative and were published between 2003 and 2019. The participants for the review are considered to be adults (over 18 years of age) with a primary diagnosis of ASD.In total, 1290 studies were initially identified and 13 studies were included based on the inclusion and exclusion criteria outlined in a previous protocol paper. The analysis of these studies identified areas of concern to access appropriate healthcare, such as clinician knowledge, the environment, and life events.Identifying the barriers to healthcare, highlights ways healthcare services can regulate scope of practice, the physical environment, and the process of managing health conditions, thus, autistic adults can strive for optimal health. This review contributes to peer-reviewed evidence for future research and up-to-date information when developing and piloting health interventions for autistic adults.There are no human participants, data, or tissue being directly studied for the purposes of the review; therefore, ethics approval and consent to participate is not applicable.PROSPERO 2018 CRD42018116093 Autistic people have an increased susceptibility to physical, mental, and social health issues.,6,7 The prevalence of ASD is estimated to be 1 in 160 children worldwide. The implications of this increase in diagnosis is that there will be a substantial number of autistic adults transitioning from the pediatric healthcare system to the adult healthcare system. At the same time, people with ASD have been shown to experience health disparity compared with their peers.Autism spectrum disorder (ASD) is a neurodevelopmental condition where people may experience difficulties in social communication and social interaction skills, restricted interests, and repetitive behaviors. Mental health difficulties are also common, such as anxiety, bipolar disorder, dementia, depression, and schizophrenic disorder.,6,10–12 Autistic people have also been reported to frequently demonstrate behaviors of concern such as aggression, property destruction, disruptive, and self-injurious behavior,–16 which may further interrupt their ability to access appropriate healthcare. Most notably, numerous studies have indicated that many common chronic health conditions, were significantly more common in autistic adults than their non-autistic peers.,7 Multiple life factors can impact the overall health of an autistic person,18 and consequently create barriers to access appropriate healthcare. These multiple factors can include, the ASD diagnosis, the age of diagnosis, living situation, level of education, employment opportunities, or family and friend support.,18Autistic people are frequently reported to experience more common chronic health conditions than their peers, such as seizure disorders (11.9% compared with 0.73%), hypertension (25.6% vs 15.6%), and allergies.,19,20 and there are several reviews on disparities in healthcare for pediatrics, barriers for vaccinations, and autism intervention.–24 The health disparities experienced by autistic adults, including barriers and enablers to healthcare remains unexplored, not quantified, and remains a question. That is why we are undertaking this project and the systematic review.Most of ASD research concentrates on children and adolescents, considered disparities in healthcare, in a pediatric population. More recently, a systematic review by Mason et al explored physical healthcare services for autistic adults, which only included 6 studies. One of the reasons for this was the included studies focused on the views of autistic people. To date, there is no systematic review evidence on overall healthcare access for autistic adults from multiple perspectives and the level of healthcare where barriers and enablers are present. Given the increased prevalence of chronic health conditions and the incidence of preventable health problems experienced by autistic adults, ensuring this population has access to appropriate healthcare is vital, and a review that aims to identify known barriers and enablers may assist when developing and implementing appropriate health interventions in the future.A review conducted by Tregnago and Cheak-Zamora and the results will provide peer-reviewed evidence for future research directions when developing and piloting health interventions for autistic adults. The primary question is what are the barriers and enablers of healthcare access for adults with ASD; and how can healthcare access for adults living with ASD be enhanced? Our hypothesis was that poor communication plus a lack of understanding of autistic needs are the main barriers to access appropriate healthcare in primary settings and the literature exploring this topic is sparse.Reviewing the evidence for healthcare access for autistic adults will identify ways healthcare clinicians can regulate scope of practice, the environment and appropriate management of health conditions, thus, autistic adults attain optimal health. This systematic review will explore healthcare access, and appropriate services for autistic adults. An up-to-date systematic review is imperative for clinical practice22.1 A university librarian with experience in systematic reviews assisted with the database search strategies. Databases searched were EBSCOhost, Scopus, PubMed, The Cochrane Library, and Web of Science applying this search strategy and the journal Autism was manually searched. A sample of a search strategy used to extract relevant articles was  AND  AND  AND (Enable∗ OR Facilitat∗)). The full search strategy is included in the supplementary material . Searches were conducted between November 2018 and July 2019 for any eligible recent published articles.This review is registered on the PROSPERO database (CRD42018116093) and the protocol is published.2.2 was employed as a database and utilized for the screening of articles. The inclusion criteria were as follows: a primary diagnosis of ASD although intellectual disability is a co-occurring condition and was included as a co-condition. Study types included were original peer-review research articles with a date from 2003 to 2019—a 16-year range. The participants for our review were considered to be adults (over 18 years of age) with a primary diagnosis of ASD. The search was limited to English and limited to adults living with ASD. No unpublished data were included. Our exclusion criteria were pediatric studies—children under the age of 18, ASD not the primary diagnosis, studies of parents of children under the age of 18, review papers (systematic or narrative), book chapters, commentary articles, opinions, letters, and editorials. The primary outcome was to identify barriers and enablers of healthcare access for autistic adults. A further level of analysis was conducted to identify the level of healthcare that needs further support to better access healthcare services for autistic adults.One reviewer (SC) independently screened data from eligible articles and resolved any differences by discussion. All authors reviewed the titles and the results and compared with the eligibility criteria, to increase validity . The EndNote program2.3 The data were extracted using a data extraction form which included the studies for assessment of quality and evidence synthesis .The quality of studies were assessed using the Mixed Methods Appraisal Tool (MMAT).Extracted information included quantitative studies: number of participants; source of participants ; participant demographics ; geographic location; type of study; other co-conditions included; reported outcomes and statistical significance, and level of healthcare identified that may need further support.Qualitative studies: number of participants; source of participants ; participant demographics ; geographic location; type of study; other co-conditions included; category- or theme-level evidence from the findings or results section of the included papers, and level of healthcare identified that may need further support. Narrative synthesis is an approach that will enable the investigation of similarities and differences and highlight the quality of published evidence to inform practice or policy. We organized the studies inductively into broad categories of study design and summarized each study using the data extraction form for the study characteristics. Calleja et al proposed to use the Risk of Bias tool (RoB 2.0) although during the analysis, it was not applicable for the included studies.All quality assessment and data extraction were carried out by 1 reviewer and checked in detail by all reviewers. We completed a narrative synthesis of the results. A narrative synthesis is a systematic approach for undertaking a review where statistical methods or pooling of the data cannot be performed.3A total of 1290 articles were identified through the original search process, of which 93 were duplicates. Based upon title and abstract screening, 1129 articles were excluded as they did not meet inclusion criteria. Sixty eight articles were determined to be eligible and a full-text review was completed. The remaining 13 studies were included in the review. The screening process is detailed in Fig. Table There was a variance in opinions for the type of studies, the outcomes and the quality of evidence, however, all authors came to a consensus using the MMAT . The studies were divided into the following 2 categories of identified barriers to healthcare: Barriers to healthcare included: health conditions, communication, and life changes. Barriers to organizational healthcare provision included: support from health practitioners, lack of knowledge about ASD, care coordination, and environmental factors. A total of 8 studies evaluated autistic adults and the experiences of healthcare, a total of 2 studies evaluated the health needs of autistic adults, and 3 studies evaluated other outcomes regarding healthcare and autistic adults.3.13.1.1 which also impacts family caregivers. Health problems vary from chronic and physical health conditions to mental health conditions.–39 Nicolaidis et al identified that autistic adults had higher physical health needs  compared with non-autistic people and higher mental healthcare needs  compared with non-autistic people.One of the barriers to accessing appropriate healthcare could be due to the type of health problems autistic adults are likely to experience,3.1.2 is focused on the language used from the practitioner and inexperienced experts. This suggests that the communication mode may have to be addressed for transparency and to build strong provider–patient relationships to adequately address healthcare issues and concerns.Poor miscommunication may be due to multiple factors, some factors identified by Tint and Weiss3.1.3,40,41 Hare et al and Weiss et al focused on family carers and crisis from acute demands, such as caregiving, multiple stressors, and lack of support from healthcare providers. Hare et al and Havlicek et al identified a significant importance in the transition period for people with ASD from the pediatric to adult healthcare system. There is limited coordination, the transition is usually fast which can be distressing and there is a lack of attention to personal needs.While all people experience life changes, for people with ASD families and caregivers may be the focus of healthcare intervention rather than the person themselves. Further, most people transitioning from childhood to adulthood do not require a handover of services; yet for this population, going from a well-supported pediatric system to a fragmented system with an emphasis on self-management is difficult. A total of 3 studies highlighted that life changes may impact the lives of people living with ASD.3.23.2.1 and Weiss et al identified that there is a lack of support from service providers, particularly, from general practitioners and the hospital system. Moreover, dishonesty and lack of information from healthcare providers were also reported as barriers in the healthcare system. The participants in this study were fathers of autistic people and they expressed that the best information would come from people that have similar experiences.Frye3.2.2 identified a number of factors impacting the personal level, provider, and system level. Healthcare interactions are important, they can be affected if verbal communication is unclear. The outcomes for the provider level barriers were incorrect assumptions, lack of knowledge, and providers unwillingness to communicate in writing. Four studies addressed communication, between the provider and patient.,37,43,45 The system level barriers were highlighted around the supports for autistic people, the complexity of the healthcare system, accessibility and stigma. This suggests that many levels of support can impact healthcare access for autistic adults.Nicolaidis et al3.2.3 Three studies highlighted the lack of knowledge from health service providers.,46,47 One study highlighted that incorrect assumptions led to stigma about ASD and in turn suggests that these system level factors that impact healthcare can impact an individual's wellbeing.Healthcare providers play a vital role in access and delivery of healthcare for autistic adults. One study noted that general practitioners are fundamental in the coordination of health as they are the gatekeepers to services.3.2.4 There may be difficulties making phone calls, the physical environment of the waiting area may make a person feel anxious, the stress of the uncertainty (time), physical closeness to other people, sensory overstimulation, and disturbing sounds. The sensory sensitivity may also be a barrier to accessing health as the environment may make a person feel safe or unsafe, for example, the lights may be too bright.One study focused on the environment playing a role in the access to healthcare for autistic adults.4 Secondly, examining healthcare access barriers and enablers assists in identifying pathways for future pilot interventions that contribute to healthcare for autistic adults in providing opportunities to better improve healthcare access by developing appropriate resources/tools. Finally, clarifying the current literature focusing on autistic adults and healthcare access is important for streamlining and directing further research efforts for future interventions. The level of healthcare that needs further support is important to identify as future research efforts can develop interventions to support practice.Accessing appropriate healthcare to reduce health problems is part of the international health agenda for autism, however, autistic people have poorer health compared with non-autistic people. This systematic literature review examined the known healthcare access barriers faced by autistic adults. The study included quantitative and qualitative study designs. Firstly, it is imperative to identify and understand the different barriers and enablers autistic people experience as ASD is a complex lifelong condition, which can have a potentially detrimental impact on adult functioning. The evidence on barriers and enablers for autistic adults is limited, and the available evidence suffers from reliability. Most studies have a small sample size that impacts in drawing any appropriate conclusions. Moreover, most of the studies have primarily been conducted in the United States and the United Kingdom, and no studies measured the same variables. One study focused on the outcomes of the barriers for autistic adults and the delivery of healthcare, but the authors combined 2 studies in 1, the discussion was based on the validation of a tool, but identified the population and used 2 designs, the title implies comparisons of healthcare for autistic and non-autistic people, but the discussion of the study was specifically about validating a tool. One of the barriers is specifically due to miscommunication between autistic adults and healthcare providers. Appropriate communication between the provider and the patient is essential, although, some clinicians may not describe the health result or future referrals in a way that the autistic adult may understand.,43 Many autistic adults receive healthcare for their mental health, and this is well supported.,35,37–39 Regarding overall wellbeing, health clinicians need further support around the types of services autistic adults can access, health services that are local, and health services that are relevant to individual needs.Autistic adults are more likely to have multiple health conditions compared with the general population and the type of healthcare accessed can have detrimental impacts on adult functioning. Transitioning from the pediatric to the adult healthcare system can be overwhelming and difficult to locate relevant and appropriate services for autistic people. This study focused on foster youth transitioning to the adult healthcare system, however, the change of clinicians can also be of concern, where the history of the patient will have to be understood. These changes are important and vital for wellbeing and care of all autistic adults, from our review, interventions for autistic adults around the transition period from the pediatric to adult healthcare system is limited and this can be problematic in the future. An existing study by Nicolaidis et al identified recommendations specifically for online toolkits that clinicians can access to increase knowledge and confidence for their patients with autism. This toolkit enables clinicians to better support autistic patients, however, clinicians need to be informed of such toolkits that are available for use. The toolkit provides an understanding of autism, the diagnosis process, and relevant referrals to specific disciplines. A synthesis of the studies reveals that the level of healthcare that needs further support is primary healthcare. This finding has various implications to the access and delivery of healthcare. Since, general practitioners are the first point of referral, clinicians need to understand what is autism and what support an individual and their family may need.,43,45–47 Likewise, with the understanding of what services an individual will need to access, the physical environment needs to be considered for each practice. The lighting, sound, and activities need to be reviewed and considered.The evidence for life changes such as the confusion of accessibility of future services for autistic people is very limited compared with healthcare in general.,43,45–47 Future interventions could be focused on the importance of interdisciplinary care approaches for autistic adult healthcare, the access and delivery of healthcare from a general practitioner level, and the physical environment could be altered to better support patients with autism. General practice clinicians, hospital services including the emergency department, allied health, and specialist services play a vital role in an autistic person's life and, patient-provider level and service level factors can impact appropriate healthcare access.The findings highlight the need for future interventions to focus on general practitioners and their practice. They are the key stakeholders in the care of autistic adults and managing the health services autistic adults access and receive.Concentrating on the transition age of autistic adults is vital, this is an important time in their life and their families lives that need to be considered. The services they stop accessing and the services they commence accessing, need to be well considered. Future interventions can focus on this area to support general practitioners’ resources and development of access to adult healthcare to better support autistic adult's health needs. The support coordination is vital and needs to be addressed.A strength of this review is inclusion of autistic adult studies incorporating their views of the barriers of healthcare. The review considered multiple levels of healthcare that need further support to develop future interventions to better support this cohort. By establishing strict inclusion and exclusion criteria, a potential weakness of the study highlights that only 13 studies were eligible and accepted. Of these, none were Randomized Control Trials. found that acknowledging family's needs are important when addressing healthcare for autistic adults, as families may be involved in the health support coordination of their children. The research team were expecting to find literature related to how to enable participation in health services, however, we did not find any articles that were eligible for this systematic review. This is an important area of research, however, there is a paucity of evidence relating to the enablers of healthcare access and it is limited (Supplementary File 4- PRISMA-2009-Checklist-MS-Word).Consistent communication, sharing information, and building relationships is vital. Supporting the transition is important to build opportunities across agencies, which develops the reciprocal relationship required for successful transitions. In addition, Frye,5A weakness of the review was associated with the inclusion of both quantitative and qualitative research, which limited our ability to conduct a meta-analysis due to inconsistent results. Identifying specific enablers of healthcare was difficult to review because the included studies were diverse in participant numbers and demographics, measurement and analysis tools, quality and length of data collection. Such a range of studies led to limitations around a lack of consistency within the literature, the evidence-base was not coherent and there was no single variable measured amongst all articles, hence, it was not robust enough to perform a numeric meta-analysis or a sensitivity analysis.6 Our systematic review has strengthened previous knowledge and supports the need for future interventions to focus on primary healthcare and effective communication for autistic adults. The implications for clinical practice remain part of the scope of practice for primary healthcare clinicians, however, future research can aim to create and implement evidence-based practices to better support access for this population. In conclusion, clinical guidelines on autistic healthcare access should be considered by all primary healthcare practices. Further empiric evidence is required to explore and understand the healthcare access barriers and enablers for autistic adults. This should include an analysis of various views and perceptions of people involved in the healthcare access of services for autistic adults.Autistic adults report many barriers specific to the delivery of healthcare but not particularly about the access to healthcare services. This systematic review highlights a global paucity of evidence for autistic adults’ access to healthcare. It is vital to support primary healthcare services to better enhance support for autistic adults as this is the first point of call for many individuals. A substantial number of autistic people are transitioning to adult healthcare and will need to access various services for overall wellbeing. Effective communication is the greatest barrier when accessing appropriate services and primary healthcare requires further support as general practitioners play a central role in liaising with services and finding appropriate support for autistic adults. This supports our initial hypothesis that poor communication and a lack of understanding about autistic needs are identified barriers. Therefore, interdisciplinary care approaches support transition and provides assistance when managing multiple chronic health conditions. Sharing medical information between clinicians and consistent communication between the patient, carers (if involved), and clinicians is vital in building relationships and transparency to provide better support for appropriate healthcare services and needs for the individual. This systematic review found that the transition from pediatric services to adult services requires a substantial number of clinicians and supports to support overall wellbeing. Similarly, past systematic reviews have focused on communication and found that communication was also a major barrier.Data curation: Shenae Calleja.Analysis: Shenae Calleja.Appraisal: Shenae Calleja, Rachael McDonald, Amirul Islam and Jonathan Kingsley.Writing – original draft: Shenae Calleja.Writing – review & editing: Shenae Calleja, Rachael McDonald, Amirul Islam and Jonathan Kingsley.