The further development of research capacity in low- and middle-income countries is critical to the delivery of evidence-based healthcare, the design of sound health policy and effective resource allocation. Research capacity is also critical for the retention of highly skilled faculty and staff and for institutional internationalization.We summarize the accomplishments, challenges and legacy of a five-year program to train biomedical researchers entitled “Enhanced Advanced Biomedical Research Training for Mozambique (EABRTM)”.A program conducted from 2015–2021 built upon the Medical Education Partnership Initiative to develop research capacity at Eduardo Mondlane University (UEM) and allied institutions. The project included design and implementation of postgraduate training programs and bolstered physical and human research infrastructure.The program supported development and implementation of UEM’s first doctoral  and master (Biosciences) programs with 31 and 23 students enrolled to date, respectively. Three master programs were established at Lúrio University from which 176/202 (87.1%) and 107/202 (53.0%) students obtained a Postgraduate Diploma or master’s degree, respectively. Scholarships were awarded to 39 biomedical researchers; 13 completed master degrees, one completed a PhD and five remain in doctoral studies. Thirteen administrative staff and four biomedical researchers were trained in research administration and in biostatistics, respectively. A total of 119 courses and seminars benefited 2,142 participants. Thirty-five manuscripts have been published to date in peer-reviewed international journals of which 77% are first-authored by Mozambicans and 44% last-authored by Africans. Sustainability was achieved through 59 research projects awarded by international agencies, totaling $16,363,656.42 and funds  secured through 2025.The EABRTM program substantially increased research and mentorship capacity and trained a new generation of biostatisticians and research administrators. These programmatic outcomes significantly increased the confidence of early stage Mozambican researchers in their ability to successfully pursue their career goals. Mozambique’s population of 30,06 million includes 62.9% living below the income poverty line and 66% in rural areas. Life expectancy 61 years) is below the African average and the adult literacy rate is 60.7% [ years is234Mozambique also has among the fewest health professionals per capita , despite a national disease profile that is dominated by infectious diseases such as HIV/AIDS 13%), malaria (40%), diarrheal and respiratory infections (29%), tuberculosis  and neglected tropical diseases such as intestinal parasites (53%), lymphatic filariasis (13%), and schistosomiasis 47%). There are also substantial rates of chronic malnutrition (43%) and mortality from non-communicable diseases 28%) [2%, malari6%. There % [2%, maAfter gaining independence in 1975, a 16-year-long civil war challenged Mozambique’s economy and slowed development of its only public university ) 9. UEM ev223111312131411121516318Centro de Investigação em Saúde de Manhiça – CISM), the main UEM teaching hospital ) and a handful of non-governmental organizations conduct biomedical research in Mozambique and topics of investigation are generally dictated by donor priorities [1415The Instituto Nacional de Saúde (INS) under the Ministry of Health (established in 2004), the Manhiça Health Research Centre , initially to train professors for the education system. Later, in 2006 and 2009, in the north and central part of Mozambique (located in Nampula and Tete province), the most populated but underserved regions in the country, two more universities were formed to train physicians and other professionals in Health Sciences: the Lúrio University (UniLúrio) and the Zambeze University (UniZambeze) .In 2010, an existing collaboration between UEM and the University of California San Diego (UCSD) was leveraged by the Medical Education Partnership Initiative (MEPI), funded by the US Department of State under the President’s Emergency plan for AIDS Relief (PEPFAR) and the US National Institutes of Health (NIH) to accelerate research infrastructure development 222. As anThis manuscript summarizes the impact of the EABRTM program and reflects on how the program contributed to a strengthening of biomedical research in Mozambique and north-south and south-south collaboration, and enumerates the challenges, lessons learned and the steps forward.This is a longitudinal case study conducted between 2015–2022. The data sources were annual progress reports, minutes from meetings and proceedings from international and national conference calls.The trainees were recruited amongst faculty members and researchers from UEM, UniLúrio, INS, MCH and the Ministry of Health.As outlined above, the EABRTM sought to build upon MEPI’s goals and achievements to train a new generation of leaders in biomedical research in Mozambique.Under MEPI, guided by a needs assessment led by a team of senior faculty from UEM, UCSD, and other participating Brazilian and Portuguese universities, we identified obstacles hampering Mozambique’s biomedical research productivity. Our initial steps were to implement master’s programs at UniLúrio, and to develop short courses in research methods, manuscript and grant writing, submission and management. The curriculum included bioethics, good clinical practices, biostatistics, Responsible Conduct of Research (RCR), and bioinformatics. Wet laboratories were enhanced and UEM laboratory staff received advanced training. A mentorship system was established 1223. We 12We defined 6 main targets and outcomes as follows:Designing new Postgraduate programs and supporting the implementation of existing ones1. At UniLúrio, we supported the consolidation and expansion of three master’s programs , Health Professional Education (MHPE), and Nutrition and Food Security (MNFS)) that were initially developed with MEPI support . At UEM,Each master’s program included a first year of didactic content (preparatory modules (15 credits), basic modules (45 credits) and advanced modules (60 credits)), a second year of seminar discussions on potential dissertations, and the research itself, culminating in a final examination. The general structure of our masters’ programs specified two years of activity with a total of 120 credits according to the National Credit Transfer and Accumulation System, in which each academic credit corresponds to 30 hours of interaction with the lecturer/mentor/supervisor [Upon completion of preparatory and basic modules, a postgraduate diploma is awarded. This is followed by the advanced modules in the second year, which include seminars to elucidate dissertation topics under at least one mid-experienced supervisor. On completion of the research project, the student undergoes an examination by a jury of three scientists in the area; those passing the examination are awarded a master’s degree .For the postgraduate programs, we enrolled candidates wishing to pursue postgraduate degrees, regardless of whether they were working in public, private or nongovernmental institutions. These candidates were selected according to the criteria defined by the Ministry of Higher Education for pursuing postgraduate studies. Those holding faculty positions and researchers at participating institutions were given priority for selection .Development and implementation of short courses (core modules) on research methods and didactic topics2. Senior mentors developed short courses  on research methods, some of them developed under MEPI  for partTraining of biomedical researchers (faculty members and researchers at master’s and PhD degrees) and establishment of a mentorship system3. Biomedical researchers receiving advanced training included graduate and postgraduate faculty members, early career researchers and physicians working concurrently as research staff or faculty in participating institutions. The program was initially designed for ten junior mentors interested in strengthening their research and mentorship skills and willing to mentor other emerging researchers. Eligible candidates submitted applications outlining proposed research projects. Those selected by a dedicated jury conducted mentored research and participated in relevant short courses. During years 2 to 4, we planned to recruit 8 faculty members or researchers to enroll in the master’s or PhD programs. Scholarship support included stipends, payment of tuition and fees, funding for research work and continuous mentoring.Research administration development via training of research administrators4. Junior and senior research administrators were trained in Mozambique and at UCSD through courses on grants management and administration, and through participation in the annual conferences of the Society of Research Administrators and related workshops. These courses included fundamentals of research administration, development and submission of research proposals, administration and monitoring of grant awards, compliance with sponsor requirements, and maintenance of electronic platforms.Development of a Biostatistics Unit to support biomedical researchers5. This was done by further training of our trainees in biostatistics under the supervision of two midcareer faculty members.Fostering North-South and South-South collaboration6. These efforts included joint manuscript and grant writing, and networking meetings at international scientific meetings, including the African Forum for Research and Education in Health , the D43 MEPI junior faculty meetings and the Consortium of Universities for Global Health (CUGH).individual level was based on accomplishments of trainees provided with either full or partial scholarships. These included the number of conference presentations and manuscripts published. Trainee publications were confirmed by PubMed author field searches. The baseline scientific output of our trainees (defined as the number of publications attributed to them before their participation in the program) was compared to the number of publications resulting from support from this training grant. The assessment considered papers published between September 2010 and July 2022. We also quantified the number of publications and new research grants written and awarded to senior researchers and trainees involved in the EABRTM program, as well as the number of research administrators and trainees who received complementary training in biostatistics.Program evaluation at an institutional capacity were assessed as the number of postgraduate training programs designed or supported (master’s and PhD programs), the number of students who obtained a postgraduate diploma or degree, and the number of workshops, courses, and seminars delivered to trainees and the broader academic community. Research administration capacity development and north-south and south-south collaboration were evaluated according to the number of joint research and training projects written and implemented, and by the number of joint manuscripts published and abstracts presented in international meetings. Primary outcomes were also evaluated by using descriptive statistics.Improvements in Concerning postgraduate programs designed and supported, at UniLúrio, three master’s programs designed during the MEPI period received support for their implementation, MTMGH, MHPE, and MNFS. Between 2015 and 2018, 202 students entered these master’s programs. Of these, 152 (75.2%) obtained a postgraduate diploma on the basis of their first year of academic studies. A total of 89 (44.0%) completed the master’s degree . SubsequAt UEM, the EABRTM program provided support for the design and initiation of the master’s program in Biosciences with three tracks: Parasitology, Microbiology and Neurosciences. Twenty-three students have been selected and enrolled in this program, with two of them supported by a scholarship through this grant. As for the other master’s programs, the available slots have first prioritized researchers and faculty members (11) from the institutions involved in this consortium .The DPBPH was initiated in 2017 at the Faculty of Medicine, in 2018 at the Faculty of Sciences and in 2019 at the Faculty of Veterinary Science and was supported by this program through a number of above-mentioned short courses and seminars provided to students, mentors and the overall academic community See . As of JWith regard to the design, development and implementation of postgraduate short courses, during the study period, we organized 119 courses and seminars that benefitted 2,142 participants from over 14 institutions located in seven of Mozambique’s 11 provinces . In addiThe program exceeded its goal of 18 trainees  and instead supported 39 trainees (17 junior mentors and 22 postgraduate students) at the master and PhD level. Thirteen of 22 trainees completed a master’s degree, as follows: UEM master’s in Public Health (n = 3), Masters in Biotechnology (1), UniLúrio MTMGH (5), and MHPE (4). One UniLúrio faculty member completed a PhD in Education Sciences at the Catholic University of Mozambique. Two trainees dropped-out and six are still in the program. Of those completing master’s degrees, four are now pursuing doctoral studies at UEM and one is doing so abroad. As of July, 2022, 35 manuscripts were published in peer-reviewed international journals, including articles from Mozambican trainees  and from senior faculty as a result of networking with international partners . Articles published in a national scientific journal (1) or by an open access publisher (1) and one book from the AFREhealth Governing Committee were not included in this tabulation.Seventy-seven percent (27/35) of publications were first-authored by Mozambicans .Concerning development of research administrative infrastructure, the EABRTM program trained 13 junior research administrators from MIHER (5), UEM (4), UniLúrio (2) and the INS (2) in research administration. Furthermore, five senior and junior MIHER research administrators participated in a total of 15 international courses and conferences organized by the International Society of Research Administrators (Supplementary file 2).From 2015 until June 2021, MIHER supported the joint writing and submission of 72 proposals by senior faculty members and trainees. Of these, 59 (82%) were approved for funding by international agencies. These agencies were from the US , Europe  and Oceania  totaling $16,363,656.42, including the training grant discussed here . Thirteen of our grant applications were either not awarded or are still awaiting a funding decision.Information technology enhancements enabled file sharing amongst grant management officials within MIHER and partnering institutions, and launched the Asana application. This grant management software package allows MIHER grant management staff to manage projects, assign work to teammates, specify deadlines, and communicate about tasks directly in one tool. Additionally, as part of institutional networking, one of our senior researchers is part of the Training Advisory Committee for a research grant from the University of Nigeria.A Biostatistics Unit led by two mid-career UEM faculty members with support from four trainees was established to provide support in basic data analysis using qualitative and quantitative methods.North-south and south-south collaboration activities developed in this EABRTM program involved participation of 103 institutions from 28 countries. The majority of institutions involved in this research capacity building initiative were from Africa  followed by the American continent  mostly represented by USA  . AdditioThis manuscript summarizes activities and discusses the achievements and legacy resulting from the five-year funding period of the EABRTM program to train a new generation of Mozambican leaders in biomedical and behavioral research, develop and strengthen a research infrastructure, and foster north-south and south-south collaboration initiated during MEPI . The EABThe EABRTM program positioned Mozambican scientists as first authors in 77% of published manuscripts, reversing prior experiences where most publications from Mozambique were first-authored by researchers from high income countries 12141520.1214151231215212425262728293031323334Contrary to traditional models of mentorship, and taking into account the scarcity of experienced role models, through the diverse courses, workshops and seminars we were able to create an environment in which trainees themselves could provide reciprocal mentorship 3637. Thi36315The EABRTM program had additional indirect outcomes as some trainees’ research work involved the recruitment of patients in the hospitals, which in turn required the involvement of additional research team members, such as doctors, nurses and psychologists. Thus, new potential scientists were exposed to, initiated in, and motivated towards scientific research activities.This Fogarty training grant fostered north-south and south-south collaboration among MEPI schools and their US counterparts through the AFREhealth forum and MEPI D43 networking meetings, CUGH conferences, and the European and Developing Countries Clinical Trials Partnership (EDCTP) forum meetings and allowed joint research and publications on the most pressing health issues related to the African continent, and Mozambique in particular [262127282930313234Retention of trainees was excellent. All trainees, including mid-career and senior researchers involved in this research capacity building program, have remained at their home institutions, and are now supporting more junior colleagues seeking to initiate investigative careers. This can, in part, be attributed to scholarship support provided to trainees and monetary incentives given to mentors to buy-out their time for research. Otherwise, they would have been unable to withdraw from other activities required to support basic income needs. Indeed, most brain drain in Mozambique is internal, with individuals moving from the public sector to NGOs. Other factors contributing to retention were the improvement of working conditions and the contributions to career development offered by the program 12. It is121525The administrative research infrastructure initiated by MEPI through MIHER has been consolidated , as demoBiomedical courses in Mozambique and sub-Saharan Africa, more broadly, offer biostatistics as an elementary discipline, and fail to provide students with comprehensive knowledge in research study design and statistical analyses. Few universities in Africa provide advanced training in statistics and even fewer are linked to programs that emphasize biomedical research applications 414243, f414215Taken together, our Mozambican-led program supports direct engagement with major funding agencies, and shifts from traditional models of north-south collaboration to one led by Africans who are better positioned to identify the most compelling local research needs. This approach creates a greater sense of ownership and leadership and thus supports future sustainability 121525. S12153Despite our progress and achievements, we are still challenged by a shortage of skilled mentors, as the few existing ones are overwhelmed. However, our mentorship experience in using students to mentor their counterparts (peer mentoring) has proven to be effective, similar to initiatives in other countries sharing the same human resource limitations 3637. Lim363More recently, the unexpected and unprecedented coronavirus 2019 (COVID-19) pandemic had a negative impact on our productivity secondary to lockdowns and several other imposed restrictions that affected or slowed down our progress. The situation significantly affected the importation of supplies and reagents for the work of our trainees and prevented travel to and from US to participate in various training courses and laboratory work. Physical distancing imposed for mitigation of the spread of SARS-CoV-2 also affected recruitment of patients for studies. Although distance learning and zoom meetings kept activities from grinding to a halt, they are not effective substitutes for in person activities. Quarantines, isolations and psychological consequences faced by our trainees as they were infected or had to deal with infected or ill family members were also highly disruptive. The initiation of the master’s program in Biosciences was delayed, but with increasing use of remote communication technologies we ultimately were able to initiate the program despite being in the midst of a third wave of the COVID-19 pandemic. Indeed, in order to address the unexpected pandemic, many senior African academicians and scholars were forced to shift their routine research focus to COVID-related topics.Experiences gained from this program extend well beyond biomedical research to other areas of scholarship in sub-Saharan countries and to the world in general 29303244.293032Although Mozambique has been exposed to many capacity-building collaborations that have taken different approaches, the EABRTM program was conducted in a systematic way with focus on country priorities, as well as the empowerment of local scientists and institutions, and has made a considerable contribution to north-south and south-south collaboration. We have trained a new generation of biomedical researchers equipped with key didactic and research skills that ultimately will improve the working environment, increase career satisfaction, and build institutional capacity with retention of those trained within public sector universities and institutions. Sustainability of our strategy has been demonstrated by the number of proposals written and awarded and by the fact that it is embedded in multiple critical interconnected programs and resources. Collaborations established between our trainees and faculty members with counterparts at UCSD and African peer institutions will enable EARBTM’s reach to extend well beyond the funding period. The programs described here fostered learning, collaboration and resource-sharing among national and international institutions, and contributed to an increase in scientific output as reflected by publications and grants awarded.The additional files for this article can be found as follows:10.5334/aogh.3684.s1Supplementary File 1.Articles published through the EABRTM and statistics regarding the authorship, institutions and countries.10.5334/aogh.3684.s2Supplementary File 2.Description of the participation of trainees, mentors and research administrators in international scientific meetings and courses.10.5334/aogh.3684.s3Supplementary File 3.Funding agencies of the 59 grants administered by MIHER from 2015 to 2021.


The effectiveness of public-private partnerships (PPPs) to address malnutrition will depend on the issue, engagement purpose, policy context and actors’ interactions. This commentary offers advice for governments, United Nations (UN) and civil society organizations to decide whether and how to engage with industry actors to improve diets for populations. First, food systems governance actors must acknowledge and reconcile competing visions, harmonize numerous corporate-engagement principles, and support a shared narrative to motivate collective actions toward healthy sustainable diets. Second, food systems governance actors have tools to guide engagement through many alliances, networks, coalitions and multi-stakeholder platforms with different levels of risk and trust. Third, food systems governance actors must prioritize accountability by setting corporate-performance threshold scores to justify private-sector engagement; evaluating engagement processes, outcomes and consequences; using incentives, financial penalties and social media advocacy to accelerate time-bound changes; and revoking UN consultative status for corporate actors who undermine healthy people and planet. There is currently no agreement among food systems actors—United Nations (UN) agencies, government and civil society organizations, and transnational agri-food and beverage firms—about how to achieve resilient food systems that provide safe, affordable, healthy, equitable and sustainable diets within the context of the Global Syndemic  and coronavirus disease 2019 (COVID-19) pandemic. Many organizations use cross-sectoral partnerships legitimized and institutionalized over decades to achieve the UN Sustainable Development Goals (SDGs) Agenda. Business engagement may be pursued to address governance gaps, conduct research or implement programs to test bundled innovations, advocate for systems-level policy changes and improve corporate reputations.The effectiveness of voluntary public-private partnerships (PPPs) to address malnutrition will depend on the issue, purpose of engagement, policy context and use of risk-assessment and decision-making tools to guide actors’ interactions for the partnership process .1 Ther conducted an evidence review as part of an independent evaluation funded by the Global Alliance for Improved Nutrition (GAIN), and analyzed 30 key informant interviews to understand the challenges associated with using PPPs to promote healthy diets within food systems to address malnutrition  worldwide. They did not examine partnerships for agriculture and sustainable diets within the context of climate change. Their three major conclusions were that: (1) government and civil society organizations that engage with private-sector entities must address potential, perceived or actual conflicts of interest (COI); (2) substantial trust deficits exist between public- and private-sector actors that must be overcome; and (3) compelling evaluations are lacking to justify using partnerships over legislative or legal policy approaches to achieve diet, food system and health outcomes.Fanzo et al were examined by Ralston et al and eight commentaries; therefore, COI is not addressed in this paper.This commentary offers advice for food systems governance actors to decide whether and how to engage with private-sector firms to address malnutrition within the context of healthy sustainable food systems. Strategies to identify, manage and mitigate nutrition-related COIs using the World Health Organization (WHO) risk-assessment tool Or will people experience a market-driven dystopian future where food systems are governed by surveillance capitalism; and controlled by transnational technology, media, food and beverage, and chain restaurant firms with complicit governments that allow digital currency, precision agriculture, grocery deliveries via drones, and artificial intelligence-powered algorithmic nudging to collect and use people’s personal biometric information to influence what, when, where and how we eat?Diverse stakeholders have competing visions, paradigms and narratives for establishing future sustainable food systems. By 2050, will local, regional, national and global food systems be healthy, green, equitable and sustainable for all people and the planet based on an optimistic, principled, inclusive and actionable vision? The UN’s Committee on World Food Security’s Voluntary Guidelines on Food Systems has developed a vision, roadmap and recommendations supported by 138 FAO member states that prioritize a human-rights approach, and identify partnerships as one of many potential forms of engagement with private-sector actors through multi-stakeholder deliberation platforms that will require transparency, democratic and strong accountable governance to produce desirable outcomes.Myriad expert Lancet Commission reports and UN bodies, including the Food and Agriculture Organization (FAO) and WHO, have published guiding principles for state and non-state actors  to support healthy sustainable diets. highlighted the need for prospective partners to differentiate between constructive versus rogue private-sector food and beverage industry actors, and identify effective policy approaches to reduce power asymmetries and hold firms accountable for practices that undermine healthy diets. Among the 30 informants interviewed were representatives of GAIN (the study funder) and the Scaling Up Nutrition (SUN) Business Network, co-convened by GAIN and the World Food Programme (WFP). But only two UN agencies—WHO and the United Nations Children’s Fund were interviewed and no representatives were included from the FAO, WFP, The World Bank or World Economic Forum to understand their position on partnerships used to address malnutrition.Fanzo et al Civil society concerns have been raised about the 2021 UN Food Systems Summit that allege a “powerful alliance of corporations, philanthropies are subverting the multilateral UN institutions’ food governance to capture the global narrative of food systems transformation…and lack of transparency and accountability for how Summit participants are recruited and engaged to shape the agenda and outcomes to maintain corporate control of food systems.” One must acknowledge that that UN agencies had already deeply committed decades ago to use cross-sectoral partnerships to address many issues that impact malnutrition, diets and food systems.Controversy has simmered for decades about whether private funding and corporate philanthropy should be allowed to influence and erode the multilateral nature of UN agencies with dire implications for democracy within global governance. The WFP engages with Unilever and Yum Brands! (parent firm for KFC and Pizza Hut), without which this UN agency states it could not provide humanitarian support for vulnerable populations. The FAO also endorses a market-driven paradigm to justify partnerships to achieve the SDG 2030 agenda and has articulated engagement principles to justify corporate engagement for innovation, data sharing for dissemination, and support for financing and investment.The WFP supports PPPs to provide private-sector knowledge, resources and expertise to improve its impact, fundraising and innovation to achieve Zero Hunger by 2030.GAIN, the SUN Movement’s Secretariat, and the SUN Global Business Network each have their own private-sector engagement principles to help build and sustain consumer demand for safe and healthy diets through several initiatives including the Making Markets Work program. The SUN Global Business Network’s 25 members have a combined revenue of over US$560 billion and Cargill, DSM, Kellogg, Mars, PepsiCo and Unilever provide technical assistance to countries through the network to design and implement food fortification, product development and reformulation, food safety and product marketing to populations in 63 low-income SUN countries. Four of these firms also participate in the International Food & Beverage Alliance (IFBA) that has adopted GAIN’s multi-stakeholder engagement principles, which do not mention protecting human rights from business impacts. The market-driven paradigm embraced by the FAO, WFP, GAIN and the SUN Network reveal the inherent preference for a shared-governance approach as the most viable strategy to address hunger precipitated by humanitarian emergencies, undernutrition and micronutrient deficiencies for vulnerable populations especially in low-income countries. In response to COVID-19, many food and beverage firms donated funding to UN agencies, and products to charitable food providers to feed families who lost their income and livelihoods. These realities require critics of partnerships to identify viable alternatives and the trade-offs if UN agencies and national governments do not engage with businesses. A contrasting view describes transnational firms as having cultivated a neoliberal corporate paradigm that has favored corporate interests over public interests, and fostered policy inertia that has perpetuated a culture of overconsumption of unhealthy commodities and unsustainable systems that have driven the Global Syndemic. Yet the government regulation paradigm urged by civil society coalitions is inadequate to address the policy inertia. Systems change occurs at levels structural, relational and transformative. To achieve food systems transformation, governance actors must acknowledge and reconcile competing paradigms, harmonize corporate-engagement principles, and develop a shared vision and narrative with collective actions to motivate people to work together to promote health for all people and the planet given the major anthropogenic challenges that impede planetary health. to clarify the purpose and guide a spectrum of engagement activities including networking, cooperation, coordination and collaboration that have different levels of risk and trust.The type of engagement requires understanding the issue and examining all available options and potential trade-offs, and preparing for anticipated and unintended outcomes, impacts and consequences. Research suggests that power-sharing and trust-building strategies built into engagement from the outset are important predictors of trust, and that power asymmetries and weak leadership are predictors of mistrust.Food system actors should use existing decision-making tools have only scratched the surface of a complex topic that requires greater scrutiny to evaluate numerous global and national partnerships, alliances, networks, coalitions and multi-stakeholder platforms to facilitate food systems transformation within an institutional context. Real-world public- and private-sector engagement must be evaluated to assess whether these strategies are effective to achieve the SDGs in various country contexts.  illustrates five dimensions of sustainability applicable to private-sector commitments, engagement and activities that align with the UN Food Systems Summit’s five action tracks. Fanzo et al suggest that many food, beverage and restaurant firms are setting less ambitious performance standards and time-bound targets recommended by expert bodies and UN agencies without consequences when they do not meet expected outcomes.Evaluations of partnerships in Australia, the United Kingdom and United States and the IFBA alliance of 12 global manufacturers Certain multi-stakeholder platforms and industry-funded networks have lost public trust and legitimacy, which are difficult to re-establish. Fifteen years after the European Union (EU) Platform on Diet, Physical Activity and Health was established to address obesity in 27 countries (2004-2019), the European Public Health Alliance and six civil society organizations jointly resigned, citing that the EU Platform was not fit for purpose and voluntary pledges were ineffective to reverse obesity and diet-related NCDs. The Multi-Stakeholder Initiative Integrity reached a similar conclusion in 2020 after evaluating 40 international standard bodies that were ineffective at restricting corporate power and holding businesses accountable for violating human rights. The Coca-Cola Company singularly funded the Global Energy Balance Network that advised physical activity researchers to minimize the contribution of sugary beverages to obesity and NCD risks. This industry front group was dissolved after investigative reporting and public outrage but has re-emerged. This example of corporate mis-behavior jeopardizes trust and legitimacy for future engagement, such as Coca-Cola’s support for Project Last Mile, a global partnership to strengthen health systems in three African countries.; using incentives and financial penalties to accelerate time-bound changes; and revoking UN consultative status for non-compliant industry actors who undermine human and planetary health. Civil society coalitions could use social media advocacy and activism to expose corporate public relations campaigns used to oppose government legislation to protect health; conduct external evaluations to ensure that corporate actors’ environmental sustainability pledges do not divert attention away from their human health commitments; expose greenwashing and bluewashing used to enhance corporate reputations; and use boycotts and shareholder advocacy to change corporate policies and practices.These examples underscore the need for food system actors to build trusted relationships that will facilitate food system transformation, and ensure independent evaluations to document processes  and corporate-engagement outcomes and impacts. Governments must legislate and regulate industry practices to protect health, and also foster collaborative learning among actors to transform food systems. UN agencies and governments could more effectively hold industry accountable by setting corporate-performance thresholds to justify engagement such as an Access to Nutrition Index (ATNI) score of 8.0 or higher or requiring certified B Corporation membership To enhance the capacity of industry partnerships to promote healthy and sustainable diets and food systems to address malnutrition, there is a need for governance actors to clarify the policy context, purpose and rules of engagement, and assess the quality of actors’ interactions and outcomes. Food systems governance actors must acknowledge and reconcile competing visions and paradigms, harmonize numerous corporate-engagement principles, and develop a shared vision and narrative to motivate collective actions that create healthy sustainable diets within resilient food systems. Diverse actors should use existing decision-making tools to clarify goals and a spectrum of engagement activities with business actors, and use various accountability strategies including evaluations of engagement processes, outcomes and consequences that undermine healthy people and planet.I thank Juan Quirarte for creating  Not applicable. Author declares that she has no competing interests. VIK is the single author of the paper.VIK participated in the study published by Fanzo et al.https://www.un.org/en/food-systems-summit/action-tracks) that include (1) ensure access to safe and nutritious food for all; (2) shift to sustainable consumption patterns; (3) boost nature-positive production; (4) advance equitable livelihoods; and (5) build resilience to vulnerabilities, shocks and stress.[1] The UN Food Systems Summit 2021 has five action tracks (The Access to Nutrition Index (ATNI) Initiativehttps://accesstonutrition.org/ and BIA-Obesity Tool https://www.informas.org/bia-obesity/ rate food and beverage manufacturers firms on a scale of zero (no evidence) to 10 (best practice) based on their nutrition‐related commitments, performance, and disclosure across seven weighted categories including governance (12.5%), product formulation (25%), product accessibility (20%), responsible marketing (20%), healthy lifestyles (2.5%), food labeling (15%), and stakeholder engagement (5%). In 2018, the total ATNI score for the 12 IFBA firms ranged from 2.3  to 6.8 (Nestle) and no firm had achieved a score of 8 or higher out of 10. An updated ATNI report will be released in 2021. In 2020, ATNI Foundation released Investor Expectations for Nutrition, Diets and Health: https://accesstonutrition.org/investor-signatories/. Certified B corporations meet specific standards of verified social and environmental performance, public transparency, and legal accountability to balance profits and purpose. https://bcorporation.net/about-b-corps.[2]


Early Childhood Caries (ECC) remains a global issue despite numerous advancements in research and interventional approaches. Nearly, 530 million children suffer from untreated dental caries of primary teeth. The consequences of such untreated dental caries not only limit the child's chewing and eating abilities but also, significantly impact the child's overall growth. Research has demonstrated that ECC is associated with nearly 123 risk factors. ECC has also been associated with local pain, infections, abscesses, and sleep pattern. Furthermore, it can affect the child's emotional status and decrease their ability to learn or perform their usual activities. In high-income countries, dental care continues to endorse a “current treatment-based approach” that involves high-technology, interventionist, and specialized approaches. While such approaches provide immediate benefit at an individual level, it fails to intercept the underlying causes of the disease at large. In low-income and middle-income countries (LMICs), the “current treatment approach” often remains limited, unaffordable, and unsuitable for the majority of the population. Rather, dentistry needs to focus on “sustainable goals” and integrate dental care with the mainstream healthcare system and primary care services. Dental care systems should promote “early first dental visits,” when the child is 1 year of age or when the first tooth arrives. The serious shortages of appropriately trained oral healthcare personnel in certain regions of the world, lack of appropriate technologies and isolation of oral health services from the health system, and limited adoption of prevention and oral health promotion can pose as critical barriers. The oral health care systems must focus on three major keystones to combat the burden of ECC−1. Essential oral health services are integrated into healthcare in every country ensuring the availability of appropriate healthcare accessible and available globally, 2. Integrating oral and general healthcare to effectively prevent and manage oral disease and improve oral health, 3. Collaborating with a wide range of health workers to deliver sustainable oral health care tailored to cater to the oral health care needs of local communities. The Sustainable Development Goals (SDGs) framework, first launched in 2015 during the UN General Assembly, includes 17 universal goals and 169 targets, while the sustainable development agendas are envisioned to be accomplished by 2030 , nor menEarly Childhood Caries (ECC) is a common chronic disease of childhood , and itsDespite ECC being largely preventable, its increasing prevalence continues to raise concern. The coinciding inequalities in oral health, both within and between countries, high cost of dental treatment and competing health priorities with available resources to address are policy makers' concerns . MoreoveA PubMed and google scholar search was conducted using the following keywords: ECC, Sustainable Developmental Goals, SDG, Oral Health and Policy, fields: all; without limits on the year of publication. Additionally, websites of the World Health Organization (WHO), FDI and National Immunization Schedules (NIS) were reviewed.Primary Health Care (PHC) is an all-inclusive society approach toward health and well-being. It focuses on people's needs along with continued health promotion, disease prevention, treatment, rehabilitation and palliative care in concordance with people's day-to-day environment , 21. TheIn order to achieve the SDG target of early diagnosis, it is imperative to work in concordance with medical personnel and integrate oral health monitoring at each stage of primary tooth eruption with immunization schedule. Most governing bodies of children such as AAPD, the American Academy of Pediatrics (AAP), American Dental Association (ADA) recommend the children to have their first dental visit within 1 year of their life . UnfortuOne of the primary ways to achieve the SDG3 on health indirectly relies on early diagnosis of the disease entities. Hence efforts to diagnose ECC early becomes a priority. Enamel hypoplasia or Enamel defects (EH/ED) emerging as the primary risk factor for ECC, permits a window of opportunity to diagnose them as soon as the tooth erupts into the oral cavity. Early diagnosis or identification of these changes on the enamel surface and timely interventions plays a significant role in successful management of ECC . With eaDissemination of the recent evidence on EH/ED being the primary risk factor for ECC needs to be disseminated widely to the dental, medical and primary health care workers. Simple screening and drying the tooth surface soon after its eruption will help the health care workers to identify the earliest changes of ECC. This also raises a need to create self-reporting tools useful for the parents/caretakers to identify these early changes on the enamel.The MAAAC charts are a series of charts developed at the “Center for Early Childhood Caries Research (CECCRe)” to educate primary health care providers, parents, and caretakers. These charts illustrate the various early patterns of enamel defects (demarcated and diffuse opacities on various maxillary teeth) as a collage of pictures organized as incisors and canines. Thus, these charts can be practical, accessible tools for primary healthcare workers to match and report the early signs of ECC . The preliminary results have been very encouraging as the parents could identify, the earliest changes on the enamel and report to the dental team soon after the tooth erupts into the oral cavity. Following either self-reports or early diagnosis by the health care team, there is a need for further guidance on handling these early changes.via telephone calls, SMS or follow-up visits, continuous monitoring and evaluation with application of fluoride varnish wherever necessary (effect of sustained interventions). This type of sustained interventions with periodic follow up and reinforcement could therefore be highly effective in early diagnosis and prevention of ECC  . SAG cann of ECC .Management of ECC involves prevention, remineralization and arrest of carious lesions . These cEarly intervention protocols for ECC can allow precise, easy instructions for parents and caretakers. These protocols could be followed in early infancy with few erupted teeth showing signs of non cavitated lesions (in the forms of a line or a patch on one or more tooth surfaces) and minimal or early-stage cavitation of one or more surfaces. During the first consultation, the clinical appearance of the white spot lesions and the role of plaque in the demineralization of tooth surfaces are explained to the parents. If appropriate preventive measures are not taken, the possibility of developing a full-blown ECC is also put forward to them. The consequences of severe ECC are described to them with the possibility of an intervention in the hospital under general anesthesia. Counseling regarding diet, oral hygiene measures, fluoride adequacy and the need for frequent recall to monitor the progress of the ECC is also elucidated.Regarding diet, the importance of frequency of refined carbohydrates intake is enumerated, and the need to clean the infant's teeth after every meal or intake is stressed. The need for assistance in performing oral hygiene measures (mother or father brushing the child's teeth) is emphasized. In the presence of EH/ED, fluoride varnish applications (fluorprotector) are recommended 2–4 times in 2 months interval. If the parents take appropriate care and the professional advice is followed meticulously, ECC can be arrested at an early stage. Periodic application of fluoride varnish has been proven to aid in preventing the development of new lesions and in remineralization of white spot lesions , 29, 31 It is crucial to analyze the reasons for unfavorable behaviors, such as poor oral hygiene and intake of free sugars, which are deemed primary risk factors of ECC . SociallIn 2011, the UN Political Declaration on Prevention and Control of NCDs first recognized oral diseases as a significant health burden , 46. ThiThe next question to consider is, “How do we bridge this gap between oral and general health?” There may be an implicit number of theories and visions from various experts on how oral and general health can be integrated, but the translation of theories to practice is critical. Furthermore, this translation requires a deeper understanding of healthcare professionals of how oral health is a part of general health. This is also essential for advocacy purposes. Therefore, the next logical question is whether it is possible to deliver a clear, precise explanation of oral health that will foster communication and support broader advocacy efforts between general health and oral health key personnel. A group of 22 experts, including the FDI-International Consortium for Health Outcomes Measurement (ICHOM) team, focused on producing a tool for measuring oral health. The team identified the key domains that fit under the physiological and psychosocial dimensions of oral health based on a series of Delphi-type consultations . This toIn 2016, FDI World Dental Congress in Poznan, Poland, proposed a definition of oral health as “multi-faceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through facial expressions with confidence and without pain, discomfort and disease of the craniofacial complex”, 49. LatChildren aged under five or six years are more often seen by primary care teams and less often by oral health professionals in most countries for the purpose of for vaccinations or consultation for systemic health problems. Such primary care teams who are already trained to deliver a wide range of services  and to treat minor conditions and injuries, have the educational background and clinical skills needed to learn about oral health promotion and control of ECC. WHO's guidelines on health policy and system support optimize community health worker programmes . The WHOXiao et al. in  reportedCavity Free at Three (CF3) is a state-wide Oral Health Promotion (OHP) training program of Colorado  that wasIn addition, Smile Train Oral Health Project or STOP was developed using the SAG principles. This was piloted and tested at the Center for Early Childhood Caries Research (CECCRe). Through this program, infants with cleft lip and/palate are recruited during their early visits for lip repair to the Smile Train unit. These babies with a cleft are then provided SAG to help them grow cavity-free [Smile Train Oral Heath Project (Ongoing project)]. The phase 1 of the project achieved 69.7% caries reduction . The phaAdopting such programs to educate obstetricians, pediatricians, physicians, physician assistants, nurses, and medical assistants can be an effective method of preventing and early intervention of ECC. Thus, the PHC team should comprise medical and dental health care providers comprising obstetricians, pediatricians and physicians, cleft care teams, nurses, midwives, kindergarten and preschool teachers, and anganwadi (in India) and social workers .Oral health coverage is the goal that all people receive essential oral health services effectively and is central to the oral health-related targets of SDGs . The broThe WHO proposed, STEPwise approaches such as “WHO Oral Health Surveys Basic Methods” for oral health surveillance that could be adapted to local and national settings.Step 1—involves assessment of oral conditions and risk factors by one's self, which in turn facilitates effective surveillance of ECC programs. The WHO Oral Health Surveys tool also facilitates the collection of information by self-reporting of dental caries, painful teeth, modifiable risk factors such as consumption of sugars and dietary patterns, oral hygiene, quality of life, and socioeconomic and environmental conditions. This tool reflects suitable core components of a questionnaire and allows self-interview. Similarly, the clarity of questionnaires has been designed for primary school teachers engaged in oral health education of young children .Step 2—Clinical oral health data is collected in step 2. ECC Lesions are recorded using a WHO oral health assessment form. involves the collection of clinical oral health data. Step 2 also allows using photographs for caries assessment in countries with a shortage of oral health professionals. However, WHO insists on well-trained examiners to make reliable clinical judgements , 14.Thus, it is peremptory that existing oral health promotional programs exclusive to ECC prevention are evaluated periodically. Furthermore, the involvement of preschool children in oral health surveillance programs globally and the use of mHealth applications such as “Smart Systems of Disease Management (SSDM)” can allow easy and systematic monitoring of SDGs .National-level health missions, infant immunization programs, and pregnant women's health programs carried out on a large scale in most countries, if integrated with Oral health/ECC and SDGs targets, can help achieve a more holistic coverage.Childsmile is a national program for the children of Scotland, developed to improve their oral health. This also targets to reduce the disparities in dental health and increase the access to dental services. As a result of this program, it has been reported that 60% children upto the age of 7 years have no noticeable decay. It has three main elements:A tailored oral health advice and preventive services is provided to infants and children through Health Visitors / Public Health Nurses and Oral Health Support Workers after the child is registered.All children under this scheme receives 6 dental packs which includes toothbrush, toothpaste and fluoride toothpaste until 5 years.Children from poor communities are being offered additional fluoride varnish applications. This is provided by trained staff under NHS Highland's Salaried General Dental Service .“Mission Indradhanush (MI) 4.0,” a flagship scheme, intensified in 2022 and aims to achieve 95% of immunization coverage in children. This program conducts head count survey in all districts across the country for identifying children and pregnant mothers who may have been missed out in earlier surveys. This program also allows “Flexible session timings” and “On demand vaccination timings” to ensure better turn-out of community . AnotherAn important initiative called Rashtriya Bal Swasthya Karyakram (RBSK) was introduced under Nation Rural Health Mission (NHM) which aims at early identification and intervention for children from birth through 18 years of age, who will be managed at the District Early Intervention Centers (DIEC). Although, dental conditions are included under the RBSK scheme, the availability of pediatric dentists at DIECs remain sparse. Specific guidelines on early diagnosis and prevention of caries need to addressed in this scheme in future. The principle of Sustained Anticipatory Guidance developed by the Center for Early Childhood Caries Research (CECCRe) has shown promising results in prevention of caries in cleft children (SAG) , 60, 61.The concept of a government run insurer with a single-payer insurance system was first established in Taiwan in 1995, to ensure health coverage to all citizens. This health insurance system provides topical fluoride application for all children under 6. In addition, pit and fissure sealant are used to seal first permeant molars along with oral prophylaxis and oral mucosal screening for children above 12 years. Thus, universal national health insurance facilitates nation-wide oral care .The National Oral Health Plan 2014–2024 is a blueprint that ensures healthy teeth and mouths among Australian children and adults across different sectors and jurisdictions .The Smiling Brazil National Oral Health Program (NOHP) was launched in Brazil with the vision to prevent ECC. The model developed to achieve this involved collective and individual educational-preventive actions among pregnant women. This created an opportunity for the establishment of early dental homes for infants. This program also utilized vaccination campaigns to introduce good oral health habits for pregnant mother and newborn infants. Group activities and home visits for early identification and referral of high risk children was also another crucial element of this program , 65.The National Program for Chronic Disease Control and Prevention (2017–2025) launched agendas and action plan for the Healthy China 2030. This program included the following strategies for oral health promotion (1) promoting oral health education in kindergarten, primary and middle schools. (2) developing oral health-related techniques and instruments. (3) promoting early intervention in community health service centers and township hospitals. (4) integrating oral examination into the regular physical examination. (5) developing a personalized interventions for children and the elderly, which focus on dental caries and periodontal disease management; and (6) providing topical fluoride, pit and fissure sealing and other oral health-care measures to reduce the caries prevalence rate to below 30% by 2025 , 67.In 2019, the Faculty of Dentistry at the University of Hong Kong started a “Jockey Club Children Oral Health Project” (JCCOHP), supported by The Hong Kong Jockey Club Charities Trust. This large-scale school-based oral health project aims to screen all preschool children for ECC . FurtherIn Thailand, the Bureau of Dental Health focuses on the primary prevention of dental caries, and promotes reduction of sugar consumption through the “Sweet Enough Network.” This program, started in 2002 which was later adapted as a national policy to stop added sugar in infant formulas in 2006. This policy played a pivotal role in the reduction of ECC prevalence. Another program was launched by the Ministry of Public Health called “Tooth-brushing on the first tooth eruption with appropriate fluoride toothpaste.” This campaign aims to enhance community participation along with providing hands-on training for the mothers or caregivers on how to brush the baby's first tooth , 70.The National Health Service (NHS) provides free oral care in England and other devolved nations such as Scotland, Wales, and Northern Ireland .Although the work on integrating oral health into general health is underway, the introduction of robust SDGs and their targets for ending ECC will pave the way for using oral health outcome measurements as the basis for remuneration schemes. The monitoring and evaluation (M&E) frameworks for measuring the progress of national health policies, strategies, SDGs and core health indicators have been established across nations. How well “oral health” M&E fits into this framework solely depends on four critical steps:1. Inclusion of oral health under SDG3 or health goal,2. Establishment of childhood caries under non-communicable disease (NCD),3. Amalgamation of oral health with UHC,4. Embedding oral health into all health policies.Furthermore, linking potential SDGs to the health linkage with 17 SDGs could accelerate the process across the globe . Nationavia mobile services to parents of young children in rural regions. Oral Health promotion and awareness of ECC among parents, caregivers and preschool teachers could be provided through mHealth. Reminders on reducing sugar intake can act as a reinforcement measure. Automated daily SMS in regional languages has proven to be an effective strategy to sustain health education among parents. Such approaches have revealed significant results in ECC prevention among children with a cleft.The term digital health is rooted in e-health and allows the employment of consistent and effective forms of healthcare delivery for underserved populations. In 2018, the World Health Assembly Resolution on Digital Health recognized the value of digital technologies in contributing to the advancement of Universal Health Coverage . The AmeThe importance of consolidating oral health within primary health care systems and universal health coverage programmes has been described in the Lancet Issue on Oral Health (2019) . CoveragThe year 2022 has faced the sharpest economic slowdown in past eight decades with rising inflation, food insecurity, war and the continued negative impact of Covid−2019 . Such inAn increase in the number of dental schools has led to an increase in the number of dentists. But sadly, the availability of dentists in rural areas is still sparse. Also, in LICs, very few dental schools exist and hence the availability of dental personnel is extremely low .Dental Insurance schemes could play a major role in treating patients with low socio-economic status, who would otherwise ignore dental services. In the United States of America, Medicaid provides health insurance to most population including the low-income groups. It also provides dental insurance for children to relieve pain and infection, restoration of teeth and maintenance of dental health [Medicaid.Gov]. In United Kingdom (UK), insurance is provided by the National Health Service (NHS). However, these are High—Income countries. In India, Arogya Finance provides medical and dental loans. However, presence of dental insurance in low and middle income countries still remain a far-fetched reality.Despite vital initiatives and the development of strategic frameworks for ending ECC , the success of these frameworks is possible only if they are in practice. Once launched, monitoring and sustaining these goals are the biggest challenge. Factors such as politics, governance, national health schemes, education, regional oral health leaders, trained personnel, socio-demographic index etc., can constrain the implementation of these solution-based frameworks. Nonetheless, oral health leaders must demonstrate and prove the impact of oral health on general health in a child. Overcoming these fundamental challenges can be elusive if not proven.With the current knowledge of ECC and its effects on the child's general health, it is imperative to set up long-term sustainable goals, which could be beneficial for the pediatric population. Shifting the focus from treatment minimally invasive, preventive and to patient-driven is critical to achieve an exponential outcome from such strategies. The culmination of oral health with NCD, UHC and SDG3 are the key steps. Raising awareness at the global, national and regional levels through benchmark research will mitigate the ECC burden in societies. Early Interventional Protocol and principles of SAG need to be widely disseminated. Political mandate, proper governance, using the common risk factor approaches and the alignment of ECC SDG targets with emerging political opportunities can further aid to remove regional disparity. Surveillance and monitoring of demographics and health-related indicators in the SDGs era will aid in attaining sustainability. Tailored cutting-edge mHealth services need to be curated to achieve these sustainable targets across nations.AS, AJ, and MS contributed to design, acquisition, analysis, interpretation, drafted manuscript, critically revised the manuscript, gave final approval, and agrees to be accountable for all aspects of work ensuring integrity and accuracy. RA contributed to design, drafted manuscript, contributed to interpretation, critically revised the manuscript, gave final approval, and agrees to be accountable for all aspect of work ensuring integrity and accuracy. AS and AJ drafted manuscript, critically revised manuscript, gave final approval, and agrees to be accountable for all aspects of work ensuring integrity and accuracy. SP, TW, and MS critically revised manuscript for important intellectual content, gave final approval, and agrees to be accountable for all aspects of work ensuring integrity and accuracy. MS contributed to conception and design, contributed to acquisition, contributed to analysis, contributed to interpretation, drafted the manuscript, critically revised the manuscript, gave final approval, and agrees to be accountable for all aspect of work ensuring integrity and accuracy. PM and MD contributed to acquisition, critically critically revised the manuscript, gave final approval, and agrees to be accountable for all aspects of work ensuring integrity and accuracy. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Meirelles et al.; Barany et al.). In addition, two review papers  summarize our current understanding of membrane transporters localized in the digestive system of fish and other aquatic animals as they transport nutrients and xenobiotics.This Research Topic covers integrative molecular and physiological approaches focusing on intestinal alterations (caused by hormones or food contaminants) that induce or impair fish growth conditions  together with physiological, morphometric, and molecular effects caused by the expected increase in GH secretion. Effectively, GH overexpression increases zebrafish growth variables and feed intake (hyperphagia). Furthermore, these effects are associated with morphometric changes in the intestine including: increased intestinal length and mass, enterocyte height, and longer microvilli; which result in an enlargement of the intestinal surface area for absorption. In addition, they report the induction of the mRNA expression of the crucial dietary peptide transporter PEPT1 (slc15a1). Finally, the authors also show the involvement of GH in the observed changes through the induction of the GH receptor ghrb and the insulin-like growth factor 1a (igf1a) in the intestine. The authors conclude that GH overexpression increases the expression of its receptor, with the consequent induction of igf1a, leading to increased intestinal absorption area through morphometric changes along with an increase in the expression of membrane transporters needed to efficiently uptake nutrients and thus support increased body growth.Specifically, Barany et al. explored the effects of the mycotoxin aflatoxin B1 (AFB1) on the gastrointestinal tract of the seabream (Sparus aurata). The authors theorized that this toxin was the cause of the growth impairment that was previously observed and sought to determine the mechanism of action. The study used both in vitro and in vivo exposure to realistic AFB1 concentrations (8 µM and 16 µM) to evaluate the integrity and function of the intestinal mucosa. Electrophysiological measurements of transepithelial resistance (TER) and short-circuit currents (Isc), histopathological analysis, and mRNA expression of tight junction-related proteins (claudins and occludins) were conducted to provide an integrative picture of intestinal function in response to this toxin. The authors found no short-term effects of AFB1on the intestinal barrier function. In contrast, long-term exposure to AFB1 caused TER changes with histopathological damage and changes in the mRNA expression of both claudins and occludins. They concluded that these changes to intestinal function likely contributed to growth impairment, as described in previous studies.Secondly, Romersi and Nicklisch; Bieczynski et al., present an overview of the current knowledge on the gastrointestinal ATP Binding Cassette and Solute Carrier proteins (ABC and SLC) of aquatic species. These proteins are involved in the transport of ions, physiologic metabolites and xenobiotics, and nutrient absorption. Members of both protein groups play an essential role in a highly conserved defense mechanism known as multidrug resistance (MDR), also described for aquatic species as multixenobiotic resistance (MXR).Finally, two review papers, Romersi and Nicklisch review the under-researched SLC proteins that include numerous nutrient, ion, and xenobiotic transporters. They summarize the interaction of xenobiotics and physiological compounds with these proteins at gene expression and functional levels and review the knowledge on the regulation of these proteins by diet and environmental stressors. Finally, they call attention to the presence of environmental chemicals acting as competitive substrates or inhibitors of MXR and nutrient uptake transporters  in the prey species of commercial fish and in the components of aquafeeds to produce healthy fishery and aquaculture products.Especially, Bieczynski et al. review the current information on all ABC subfamilies’ identification and characterization and focus on their localization and physiological and toxicological role in the fish intestine. The authors highlight the intestine’s barrier functions and its epithelium polarity, paying particular attention to the most extensively studied fish ABC proteins , their apical or basolateral location, distribution along the intestine, and regulatory mechanisms. The authors conclude that fish intestinal ABCB, ABCC, and ABCG proteins are essential in transporting physiological substrates and aquatic pollutants, such as pesticides, cyanotoxins, metals, hydrocarbons, and pharmaceutical products. Still, much work is needed to obtain a complete picture of fish ABC proteins’ physiological and toxicological functions.Further,


Despite substantial efforts to counter sexual assault and harassment in the military, both remain persistent in the Armed Services. In February 2021, President Biden directed the U.S. Department of Defense to establish a 90-day Independent Review Commission on Sexual Assault in the Military (IRC) to assess the department’s efforts and make actionable recommendations. As servicemembers discharge from the military, effects of military sexual trauma (MST) are often seen in the Veterans Health Administration (VA). In response to an IRC inquiry about VA MST research, we organized an overview on prevalence, adverse consequences, and evidence-based treatments targeting the sequelae of MST. Women are significantly more likely to experience MST than their male counterparts. Other groups with low societal and institutional power  are also at increased risk. Although not all MST survivors experience long-term adverse consequences, for many, they can be significant, chronic, and enduring and span mental and physical health outcomes, as well as cumulative impairments in functioning. Adverse consequences of MST come with commonalities shared with sexual trauma in other settings  as well as unique aspects of the military context, where experiences of interpersonal betrayal may be compounded by perceptions of institutional betrayal . MST’s most common mental health impact is posttraumatic stress disorder, which rarely occurs in isolation, and may coincide with major depression, anxiety, eating disorders, substance use disorders, and increased suicidality. Physical health impacts include greater chronic disease burden , and impaired reproductive health and sexual functioning. Advances in treatment include evidence-based psychotherapies and novel approaches relying on mind-body interventions and peer support. Nonetheless, much work is needed to enhance detection, access, care, and support or even the best interventions will not be effective. Despite substantial efforts to counter sexual assault and harassment in the military, both remain persistent in the Armed Services. In February 2021, President Biden directed the U.S. Department of Defense to establish a 90-day Independent Review Commission on Sexual Assault in the Military (IRC) to assess the department’s efforts and make actionable recommendations. The IRC work was organized around four lines of effort: accountability, prevention, climate and culture, and victim care and support. Given VA’s research infrastructure, leaders of the fourth line (care and support) requested a briefing on VA military sexual trauma (MST) research. This paper provides the resulting overview on the definition and prevalence of MST, then broadly describes the range of adverse consequences associated with MST, including mental and physical health outcomes, functioning, and well-being. We then describe the research on evidence-based care targeting negative outcomes, with a focus on posttraumatic stress disorder (PTSD). This paper is not intended to be an exhaustive review of all studies conducted in the VA on MST; instead, it is a broad overview of the state of the knowledge on this important topic. The preponderance of included studies was conducted by VA researchers. We also included several non-VA studies to enhance knowledge throughout.MST is the term used by the VA to refer to experiences of sexual assault or sexual harassment during a period of military service. The specific definition of MST, from U.S. Code 1720D, is “physical assault of a sexual nature, battery of a sexual nature, or sexual harassment  which occurred while the former member of the Armed Forces was serving on duty, regardless of duty status or line of duty determination.” As such, any experience of sexual assault or harassment while serving in the U.S. Armed Forces regardless of the reason for the assault, whether the assault occurred on or off base, or whether the assault was perpetrated by another member of the military, is included in the VA’s definition of MST. The VA definition of MST is distinct from other definitions of sexual trauma in its inclusion of sexual harassment, defined as “unsolicited verbal or physical contact of a sexual nature which is threatening in character.”1 Estimations of MST in VA recruited samples tend to be higher than in non-VA and mixed samples.2 The prevalence of MST among men has been understudied relative to women and, as a result, is particularly difficult to estimate.3 A recent meta-analysis conducted with studies of military personnel and Veterans suggested that approximately 16% report MST with marked gender differences, such that proportionally more women (38%) than men (4%) reported experiences of MST.2 When sexual assault and harassment were considered individually, experiences of harassment were more common, with 31% of military personnel and Veterans experiencing harassment (52% of women and 9% of men) and 14% sexual assault (24% of women and 2% of men).It is difficult to determine the exact prevalence of MST as methodological differences across studies contribute to a range of estimates. Data from self-report surveys and interviews typically result in higher prevalence compared to estimates derived from VA medical records.4 When compared to non-LGBT servicemembers who reported MST (14%), servicemembers who identified as sexual minorities (26%) and as transgender (30%) were more likely to report MST.5Beyond women’s elevated risk for MST, administrative data suggest that other groups with low societal and institutional power  are also at increased risk of experiencing MST.Notably, not all MST survivors experience long-term adverse consequences or require clinical care. However, for a substantial number of MST survivors, the adverse consequences of MST can be significant, chronic, and enduring. Research conducted in VA has focused primarily on VA users and has revealed that the complexity of the aftermath of MST is apparent across a host of co-occurring mental and physical health outcomes as well as in the cumulative impairments in functioning across major life domains. The impact of MST varies widely across survivors, and the cumulative effect of MST can be significantly influenced by known social determinants of health. Given the universe of potential adverse outcomes of MST, there is no clear formula for assessing the impact of MST and no single solution for intervening in its effects.6 which, when related to suppressing emotionality in male military personnel, was associated with more severe PTSD symptoms.7 To try to make sense of the event, survivors may attempt to identify why this happened and may come to faulty conclusions about their responsibility for the assault , resulting in significant experiences of guilt and shame.Sexual trauma that takes place within military settings shares many commonalities with sexual trauma that occurs elsewhere. Sexual victimization often represents significant interpersonal betrayal that can disrupt existing views of the world, self, and others. Survivors of sexual trauma may encounter “rape myths” that blame the victim for the assault or justify the perpetrator’s actions . For male survivors of sexual trauma, gender-specific rape myths may increase male gender role stress10 Many MST survivors report fear of reprisal if they speak openly of their experiences, including the possibility of additional violence, demotions, and unwanted job reassignments.12 Other feared consequences include ostracism by colleagues, isolation from peers, loss of support, and disruptions in unit cohesion.13 Concerns about disruptions in unit cohesion and fears for the implications of MST on military careers may be more salient for male Veterans.3 Survivors of MST may experience subsequent distrust of both comrades and command.10 The disintegration of the support structure in the military is uniquely egregious not only because the nature of the job requires trusting one another with one’s very life, but also because military service includes working with and living with one’s fellow soldiers.14 Having to continue to work and live side by side with one’s perpetrator, and potentially rely on one’s perpetrator for safety in life-threatening situations, presents an environment from which escaping the effects of MST may be impossible. This context compounds distress and complicates later help-seeking.17To fully understand the adverse consequences of MST, the unique personal, social, political, and occupational context of this type of trauma must also be acknowledged. Institutional betrayal can compound interpersonal betrayal. Those who experience MST frequently report that the military institution contributed to an environment in which MST was common, likely to occur, and difficult to report.18 The risk for developing PTSD for women Veterans who experienced MST is well documented. When compared to women Veterans without a history of MST, women Veterans who experienced MST were 9 times more likely to develop PTSD.19 Moreover, MST is more strongly associated with PTSD among women Veterans relative to their male counterparts.20 While the risk for PTSD may be higher for women who experience MST, research has also shown that PTSD symptoms may be more severe for men who have experienced MST than for women.21 Taken together, studies demonstrating elevated risk for developing PTSD secondary to MST suggest that the unique aspects of military exposure  may amplify distress and increase the likelihood of diagnosable mental illness.22PTSD is the most common psychiatric condition to develop secondary to MST.24 Indeed, MST is associated with increased odds of receiving any mental health diagnoses.18 Experiences of MST also exacerbate pre-existing mental health conditions and increase the severity of mental health disorders including PTSD, depression, substance use disorders, eating disorders, and insomnia.29Notably, PTSD rarely occurs in isolation. Women Veterans who report MST and have PTSD are more likely to receive a host of comorbid mental health diagnoses, including major depression, anxiety, eating disorders, and substance use disorders.16 Notably, the majority of Veterans who reported post-MST suicidality experienced the onset of suicidal ideation (68%) and attempted suicide for the first time (75%) after MST.16 MST is an independent risk factor for suicide mortality among Veterans using VA services, including MST services.30 The integration of cross-cutting prevention initiatives within MST care and suicide prevention at VA is critical to identifying risk and intervening to prevent suicides.The scope and severity of mental health sequelae following MST include the ultimate negative outcome—suicide. Even after controlling for other risk factors, MST independently predicts suicidal ideation and attempts.31 In a sample of women Veterans who served in the Gulf War, MST was linked to gastrointestinal, genitourinary, musculoskeletal, and neurological symptoms.32 In a study of women Veterans seeking treatment in the VA for PTSD related to MST, two-thirds reported chronic pain.33 Physical health consequences of MST can be further complicated by the negative mental health consequences described earlier. Comorbid mental health disorders can complicate receipt of medical care, furthering amplifying the negative effects on physical health.34Similar to mental health outcomes associated with MST, physical health consequences are broad and variable across individuals. MST history in women is associated with a host of chronic medical illnesses including increased risk for diabetes mellitus, hypertension, obesity, and cardiovascular risk factors.38 Difficulties in sexual functioning secondary to MST were significantly more severe in women Veterans than that which was associated with childhood sexual abuse alone.36 In a recent study, women Veterans who reported MST were less likely to have a full-term birth infant, more likely to have a lower birthweight infant, and more likely to report experiencing postpartum depression and/or anxiety above and beyond age at pregnancy, racial/ethnic minority status, childhood violence exposure, and warfare exposure.39The impact of MST on reproductive health and sexual functioning in women Veterans is well-established including a higher likelihood of having a sexual dysfunction disorder, sexually transmitted infections, infertility, perinatal depression, sexual pain, and reporting low sexual satisfaction.40 Military sexual harassment specifically was linked with impairment in post-military functioning across major life domains including satisfaction with employment for women and satisfaction with romantic relationships and parenting for both women and men.41 Post-deployment homelessness has also been associated with MST, particularly in male Veterans.42 Impairments in functioning can persist over time and have significant implications for long-term quality of life. For example, in a recent study of Vietnam-era women Veterans, military sexual harassment and discrimination conferred significant risk for continued impairment for over 40 years in later life functioning and increased rates of disability, even after accounting for psychological and psychiatric distress.43 Military sexual harassment was also associated with decreased physical functioning, also an important indicator of quality of life and successful aging.43The impact of the experience of MST on survivors’ functioning can be immediate, and the sequelae can be enduring. In a study of women Veterans deployed to post 9/11 wars, the experience of MST negatively impacted reintegration efforts including relationships with family, and occupational and educational functioning.44 most experiences of MST go undetected by formal helping systems.46 Many MST survivors may be reluctant to disclose their trauma history to healthcare providers, either due to expectations of or prior experiences with negative, invalidating and blaming reactions to disclosure47 or, perhaps, due to fear of posttraumatic stress responses that describing traumatic events can elicit.48 The Veterans Health Administration (VHA) implemented a universal MST screening program49 designed to aid providers in identifying Veterans who have experienced MST and to facilitate their access to no-cost treatment for MST–related health conditions. Analysis of medical record data demonstrates that VHA’s MST screening program is feasible and yields clinically meaningful information, and that identification of a history of MST through screening increases the likelihood of mental health treatment.50 Importantly, VA patients have described their experiences with disclosures to VA providers to be generally positive, although a subset of male Veterans, regardless of MST history status, reported lower satisfaction.51 That said, male Veterans are less likely to access psychiatric care for MST–related distress than women Veterans or may delay care longer.52 In summary, despite the barriers to care for all MST survivors noted in qualitative studies, quantitative research revealed that Veterans with a positive MST screen were more likely to engage in healthcare in VA.While primary prevention of MST research falls largely outside of the domain of the VA, screening, detection, and secondary prevention efforts are critical parts of the VA response to MST. Like sexual trauma that occurs outside of military settings,Diagnostic and Statistical Manual of Mental Disorders, 5th edition, as an example of a Criterion A traumatic event, a necessary but not sufficient condition for a diagnosis of PTSD.53 Some MST experiences that involved sexual harassment victimization in the absence of sexual assault victimization will reach the threshold for a Criterion A traumatic event, while others will not.54 While harassment-only MST may result in PTSD and other mental health conditions, sexual assault MST shows a stronger association with a host of negative outcomes including more severe PTSD, depression, sexual functioning, and suicidal ideation.55 The results of a comprehensive assessment of the MST event and associated symptoms will best inform the potential diagnoses and personalized intervention. As noted, the heterogeneity of potential adverse consequences of MST is substantial and interventions for each outcome are beyond the scope of this paper. We focus on an overview of VA’s evidence-based care for PTSD given that this is the most common mental health condition associated with MST.Once a patient reports the experience of MST, the next step is to assess the extent and scope of the sequelae of this experience with respect to mental and physical health outcomes and impacts on functioning. Sexual violence is explicitly noted in the 56 Overall, trauma-focused treatments are more effective than non-trauma-focused treatments.57 Based on these studies and independent reviews of randomized, clinical trials, clinical practice guidelines (CPGs) have been independently developed by workgroups from internationally recognized professional organizations and healthcare systems, including a VA/DoD workgroup . Decisions about the strength of the evidence for an existing intervention are based on the empirical evidence for that intervention. The quality of the evidence for effectiveness of Prolonged Exposure58 (PE) and Cognitive Processing Therapy59 (CPT) has been given the highest ratings across CPGs.Systematic reviews and meta-analyses, summarizing the efficacy of interventions by evaluating multiple studies, reveal that psychotherapy for PTSD yields larger effects in treating PTSD than pharmacotherapy.63 In addition to RCTs, effectiveness studies testing these therapies in real-world clinical settings have demonstrated the effectiveness of these evidence-based practices (EBPs) in both non-residential and residential VA services.66 Given the effectiveness of these interventions, the VA has dedicated substantial resources to the historic, large-scale dissemination effort of these therapies via the Mental Health Dissemination Initiative. As a result, PE and CPT have been widely disseminated across VA resulting in access to the gold standards of care for PTSD for Veterans enrolled in the healthcare system.68Both PE and CPT were originally developed in the civilian population and initially tested with female survivors of sexual trauma. The VA has been a leader in continuing to develop, evaluate, and implement PE and CPT within the Veteran population, including randomized clinical trials (RCTs) including patients with PTSD secondary to MST. Indeed, because these interventions were originally developed for PTSD due to sexual trauma, the translation to target the sequelae of MST was not a leap.d = 0.78 to 1.02 and 35–40% of participants fail to experience clinically meaningful improvement.70 Premature attrition from treatment for all trauma survivors suffering from PTSD is also problematic. For example, at least 35% of all Veterans who initiate a course of CPT in VA clinics fail to complete therapy, resulting in suboptimal doses of treatment which contributes to poor outcomes.71 Initiating treatment and continued engagement in treatment are difficult, and MST survivors may be faced with various barriers to care including grappling with institutional betrayal, experiencing stigma about mental health needs, and not recognizing symptoms as PTSD72 as well as gender-related barriers.52 Despite these barriers to engaging in care for PTSD that may be unique to MST, post 9/11 Veterans were more likely to initiate73 and complete treatment74 for PTSD as compared to Veterans who did not experience MST. Likewise, attrition rates from residential VA care for PTSD did not differ between those who experienced MST and those patients who did not.75 In the same study, those who reported MST experienced larger treatment gains but did not maintain those gains to the extent that non-MST patients did after discharge. PE and CPT are examples of trauma-focused interventions which, by definition, ask the patients to engage with the trauma memory that they have been working very hard to avoid—in other words, to break through the avoidance that has been keeping them trapped in PTSD and preventing recovery. Thus, the very avoidance of the trauma memory  may be prohibitive for engaging in the treatment for the disorder.76Despite the evidence base supporting the effectiveness of PE and CPT, there is room for improvement. Among RCTs in active duty and Veteran populations, PTSD symptom effect sizes from pre- to posttreatment range from 60; however, fewer studies on nTFTs have been conducted specifically focusing on treating PTSD secondary to MST, with some exceptions. Examples of nTFTs include Present-Centered Therapy63 (PCT), which is currently recommended by several CPGs, and Interpersonal Therapy78 (IPT) and Stress Inoculation Therapy79 (SIT), which are recommended only by the VA/DoD CPG. Given that the evidence is not as strong for nTFTs as it is for trauma-focused treatments, these interventions are recommended for patients who are not able to engage in trauma-focused treatments for any number of reasons.80 Skills Training in Affective and Interpersonal Regulation81 (STAIR) is a preparatory treatment designed to target affective dysregulation and interpersonal difficulties that may prevent patients from engaging in trauma-focused therapy, and one CPG issued a standard recommendation for its use.There is emerging evidence that non-trauma-focused therapies (nTFT) may also be effective in reducing PTSD symptoms82 Kelly and colleagues83 recently published interim results from an ongoing trial comparing trauma-sensitive yoga to group CPT for women who were diagnosed with PTSD secondary to MST. The results indicated that both interventions were effective in achieving sustained, clinically meaningful improvements and that retention rates were higher in the yoga therapy condition.Finally, there is emerging evidence to support complementary, integrative, and alternative treatments in VA. A systematic review of mind-body interventions, such as mindfulness, yoga, and relaxation techniques, indicated promise in reducing PTSD symptoms.84 peer support may mitigate these effects independently as well as offer a conduit to clinical care and support during an MST survivor’s journey through recovery.85 The Women Veterans Network (WoVeN) is an example of a national peer support network with a developed 8-week core curriculum designed to increase connection and support for women Veterans.86Strategies designed to support and supplement evidence-based care are emerging. Peer support is one such strategy. Designed to target major risk factors for poor outcomes after trauma including loneliness, thwarted belongingness, institutional betrayal, and isolation,87 Some survivors of MST may not need or want mental health treatment or may prefer to receive care in a different setting. Alternative strategies might provide educational and interventional resources for those who are not engaged in services within or outside of VA. Mobile and web-based mental health strategies may serve the function of reducing barriers to care, increasing access, and increasing choice for Veterans at all stages of recovery. Delivery of Self Training and Education to Stressful Situations-Women Veterans (DESTRESS-WV) is an example of an online, coach-assisted intervention that was specifically tailored for women Veterans with PTSD and with demonstrable efficacy in reducing PTSD.88 Beyond MST is a free, secure, and private self-help mobile app developed by VA specifically to support the health and well-being of MST survivors. The app has specialized psychoeducation, assessments, and skills-based tools to help Veterans who experienced MST cope with challenges, manage symptoms, improve their quality of life, and find hope.90Certainly, many MST survivors do not access VA care and/or do not have access to evidence-based community care. While the experience of MST is associated with VA healthcare utilization, this association may be mediated by mental health needs .91 The recommendations for victim care and support were informed by the type of VA studies highlighted in this overview and include suggestions for optimizing the victim services workforce within the Department of Defense, expanding victim service options to meet the needs of all sexual harassment and assault survivors, centering survivors to facilitate healing and restorative justice, and re-envisioning training and research to improve victim care and support.The VA has funded MST research for over 25 years, resulting in significant gains in our knowledge base through efforts from groups such as the National Center for PTSD, Women’s Mental Health, the national MST Support Team, and the VA Women’s Health Research Network. In July 2021, the IRC released their final report with 82 recommendations for their four priority areas: accountability, prevention, climate and culture, and victim care and support.Despite great strides, this work is far from complete. Areas for further research include continued inquiry into MST survivors’ service needs and continued improvement in screening and detection of those needs; the impact of MST on health behaviors and overall physical health consequences including gynecologic care, and fertility; and the risk for subsequent trauma. There is also a need for research documenting the intergenerational impact of MST on Veteran family functioning including parenting, parent-infant bonding, and risk for adverse outcomes among dependents. Continued study with Veterans who experienced MST but do not use the VA is necessary, as their health status is largely unknown. Research should continue to explicate the role of social determinants of health on both access to care and effectiveness of care, particularly for racial, ethnic, and sexual minority Veterans, with consideration of important intersections between systemic racism, sexism and heterosexism with trauma, healthcare, and military service.The adverse consequences of MST are complex and include mental and physical negative outcomes as well as significant impairment in functioning across major life domains. The patterns of outcomes are variable across survivors of this type of trauma, and no single intervention can be universally applied for recovery. The complexity of clinical presentations requires personalized approaches to care that leverage recent advances in health technology. Flexible interventions that may vary significantly across survivors will best accommodate the wide range of psychiatric disorders and physical health complications, and address the impact on functioning. Finally, barriers to reporting MST and receiving care must be removed or even the best of interventions will not be effective. In conclusion, further research in organizational, secondary prevention, and intervention science will continue to guide important policy decisions in preventing and effectively responding to sexual trauma during military service.


International Classification of Sleep Disorders  [Parasomnias are sleep disorders that involve abnormal behaviors, emotional experiences, perceptions, and dream activity, occurring during specific sleep stages or sleep–wake transitions. The third edition of the 3rd ed.)  categoriRecent research introducing the concept of local sleep regulation  has offeConcerning REM sleep parasomnias, local sleep may represent an interesting perspective on REM sleep behavior disorder (RBD). This parasomnia is characterized by vivid dream activity and dream enactment provoked by the loss of physiological REM atonia  , and it Another potential application of the assessment of local sleep in parasomnias concerns the field of dream research. By definition, dream content is not directly accessible. Therefore, researchers obtain information on oneiric activity by retrospective recall: spontaneous or provoked awakenings are the gold standard for dreaming investigation . HoweverOverall, local sleep represents an interesting perspective to increase our understanding of parasomnias. Beyond such a psychophysiological view, the complexity of these phenomena, their frequent underdiagnosis, and poor understanding (particularly concerning DOAs) lead to the need for further efforts and the integration of different clinical and scientific perspectives to promote new knowledge in this field.The present Special Issue aims to provide updates on different facets of parasomnia and parasomnia-like events. Original articles and reviews focused on local electrophysiological patterns of parasomnias are encouraged. Moreover, the submission of articles focused on different aspects of parasomnias and disruptive sleep-related disorders is welcome, including: brain mechanisms; pathogenesis; nocturnal and diurnal behavioral, emotional, and physiological features; cognitive functioning; dreaming; neuropsychological patterns; relationships with psychiatric disorders; and pharmacological and non-pharmacological treatments.