Orthobunyavirus, family Peribunyaviridae, was first isolated from a snowshoe hare (Lepus americanus) in Montana, United States, in 1959. The virus, closely related to LaCrosse virus (LACV) and Chatanga virus (CHATV), occurs across Canada and the northern latitudes of the United States, primarily in the northern tier of states bordering Canada. Reports of SSHV in northern Europe and Asia are probably the closely related to CHATV, or the less closely related Tahyna virus. Vertebrate associations include snowshoe hares and ground squirrels, demonstrated by field isolation of virus from wild-caught animals, seroconversion of snowshoe hares, seroconversion of sentinel rabbits, isolation of virus from sentinel rabbits, and experimental infections demonstrating viremia. Isolations of virus from field populations of mosquitoes include primarily univoltine and boreal mosquitoes of the genus Aedes, Culiseta impatiens and Culiseta inornata; and, rarely, certain multivoltine floodwater Aedes species. Experimental transmission studies in mosquitoes show infection in and transmission by boreal Aedes and Culiseta inornata. Isolation of SSHV from larval Aedes on three occasions, and experimentation in Culiseta inornata, reveal transovarial transmission of the virus in mosquitoes. Serosurveys reveal exposure to SSHV in human and domestic animals, with rates of seropositivity commonly high in some settings in Alaska and Canada, but disease in humans or horses has rarely been reported, only in Canada.Snowshoe hare virus (SSHV), within the California serogroup of the genus  Lepus americanus Erxleben), heavily parasitized with Dermacentor andersoni Stiles ticks, in the Bitterroot Valley of western Montana in 1959 by Willy Burgdorfer and colleagues  from Aedes trivittatus in 1948 in North Dakota, and San Angelo virus from Anopheles punctipennis (Say) in 1958 in Texas (Aedes scapularis (Rondani) in Trinidad, Tahyna virus from Aedes caspius  in Czechoslovakia in 1958, and Lumbo virus from Aedes pembaensis Theobald in Mozambique in 1959 (Aedes aegypti [L.]) to suckling mice (Oryctolagus cuniculus [L.]) in Richmond, Ontario, in the summers of 1962–1963, the first isolation of any California serogroup virus in Canada and the second time SSHV was isolated from vertebrates in nature, but inadvertently reported by Dicrostonyx groenlandicus [Traill])  and from brain of northern red-backed vole, Clethrionomys rutilis . The latter event was a mixed infection of SSHV and Northway virus (a Bunyamwera virus). SSHV was not isolated from sentinel rabbits in Alaska (Snowshoe hare virus (SSHV) was first isolated from the blood of an emaciated snowshoe hare  , and 1 isolate was obtained from 188 pools of 4,763 Culiseta impatiens  . The latter isolate was obtained from a pool of three blood-fed individuals aspirated from a trap baited with a domestic goat. Subsequently in 1965, SSHV was isolated from mosquitoes in four different locations  group and one pool of Aedes stimulans  group mosquitoes, near Rochester, Alberta, Canada  in Massachusetts in 1968 ; and once from a pool of Simulium spp. (Diptera: Simuliidae), all in east-central Alaska in 1970–1971  removed from mammalian hosts were attributed to acquisition of virus from infected hosts; infections waned within 48 hours, leading to the conclusion that ticks do not become infected and are not vectors  and mosquitoes, and the quite widespread geographic distribution of the virus. It is important to note that SSHV as an entity distinct from CEV was recognized gradually as other viruses such as LaCrosse (LAC) virus were discovered and as immunological reagents and procedures became available. Aedes trivittatus Coquillett; Aedes triseriatus around a focus on human disease there. There is no record of isolation of SSHV from Manitoba, a province that borders on the provinces of Ontario and Saskatchewan and the Nunavut Territory, from where SSHV has been isolated from both mosquitoes and mammals  in western Siberia documented high seropositivity rates to SSHV ; however, only a single putative isolate of SSHV was obtained in the same study from a single Aedes euedes Howard, Dyar, and Knab mosquito. This isolation, which occurred at a different location than where the mammals were sampled and also resulted in isolation of a Bunyamwera group virus, prompted the investigators to note: “it is uncertain whether the test we used is specific for antibody to SSH …. It is clear from the results, however, that SSH virus or a closely related virus is present in the area”   of the Aedes communis group including the Aedes punctor subgroup; and the “stripe-legged” species such as Aedes stimulans and related species in a species complex sometimes called the Aedes stimulans group, as well as Aedes canadensis which does not belong to this group of species. However, isolations outside of these groups include Aedes cinereus  . Isolaticinereus . Second,ribution . That Tumpatiens , the facAedes vexans in Wisconsin  were varied (see °C), and transmission of virus to uninfected mice by bite, after which the suckling mice became infected. These findings support criteria #1, #3, and #4 for SSHV in relationship to Culiseta inornata and Aedes communis. Additionally, they suggest that SSHV could persist in overwintering populations of Culiseta inornata females. Aedes provocans  and Aedes abserratus-punctor with SSHV via membrane feeding, and after holding the mosquitoes at 19 °C for > 12 days demonstrated transmission of virus to suckling mice by mosquito bite of 4/20 Aedes provocans and 2/20 Aedes abserratus-punctor. Aedes triseriatus by bite-to-suckling mice. Aedes triseriatus; they attributed this variation to reduced viral dissemination from the midgut in the presence of LAC viral reassortants containing the SSHV middle-sized segment of the SSHV genome.Addressing criterion #4 and criterion #1, ried see . MosquitAedes mosquito larvae at endemic sites and indeed used an isolate in some of their adult mosquito infection experiments. SSHV was also isolated from adult Aedes implicatus Vockeroth raised from larvae collected in Saskatchewan province of Canada , and as a maintenance species with efficient transovarial transmission of SSHV to progeny, while univoltine Aedes spp. such as Aedes communis could serve as vectors and overwintering reservoirs via transovarial and transstadial transmission. Transovarial transmission was not studied in the above experiments, but f Canada  and fromf Canada , suggestCallospermophilus lateralis Merriam, yellow pine chipmunk Tamius amenous Allen, or meadow vole Microtus pennsylvanicus Ord (Citellus undulatus) was the main natural reservoir host in the summer of 1974” . Nonetheless, mosquitoes associated with transmission of other CAL serogroup viruses such as CEV, KEYV, and TVTV have regularly been demonstrated via blood meal analysis to feed upon wild rabbits  and California serogroup viruses by considering Aedes phylogeny and species groupings and the history of isolation of various viruses from different species of mosquitoes. Aedes communis group including the Aedes punctor subgroup, the Aedes stimulans group, and the Aedes canadensis group. He further noted that these associations were similar to those of Jamestown Canyon virus. Of interest is that these two viruses are rarely found in the same pools of mosquitoes, but there are examples of co-occurrence of JCv and SSHV in sympatric mosquito populations , and 9 of the 227 (4%) red squirrels (Tamiasciurus hudsonicus Erxleben) were positive. In Nova Scotia, 6%–14% of snowshoe hares had antibodies to SSHV, with variations among sampling sites  in Nova Scotia (0docoileus hemionus hemionus), black-tailed deer (O. hemionus columbianus), and Roosevelt elk (Cervus elaphus roosevelti) in Oregon (Rangifer tarandus [L.]), Arctic fox (Vulpes lagopus [L.]), red fox (Vulpes vulpes [L.]), and polar bear (Ursus maritimus Phipps), and attributed rising seroprevalence from 1986 to 2017 to increasing temperatures in the arctic regions of Canada where the samples were acquired. Forty of 100 (40%) snowshoe hare sera were positive for antibodies to SSHV in studies conducted from 2009 to 2012 in the northern Greater Yellowstone area of Wyoming, USA. Of the six animals that were captured twice with at least one year between captures, four had developed antibodies to SSHV at the second capture , indicating active transmission of the virus . Sera collected at 8 and 28 days after onset of clinical symptoms were tested in parallel using plaque reduction neutralization (PRNT). The titer of SSHV-specific neutralizing antibody by PRNT was 4-fold greater than that of JCV; SSHV was identified as the etiological agent involved with this case.Despite the close relationship of SSHV to LACV, and the significance of the latter as a causative agent of human infection and neurologic disease, there have been very few cases of illness in humans with documented infection with SSHV, and none reported from the United States. A total of 10 human cases of meningoencephalitis likely due to infection with SSHV were reported between 1978 and 1981 in Quebec, Ontario, and Nova Scotia, Canada . Meier-SBased upon the above findings and widespread seropositivity to both SSHV and JC virus  in the Canadian human population and in the population of human diagnostic samples associated with meningoencephalitis , Mincer


Racism is “a system [of power and oppression] of structuring opportunity and assigning value based on the social interpretation of how one looks  that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources” . At a syPreventing Chronic Disease solicited manuscripts to elucidate research, training, practice, and public health policy–based efforts that address topics ranging from the effects of racism and racial discrimination on psychological, mental, and emotional health and disease risk to institutional, organizational, or community policies and changes implemented to address institutional racism. Articles in this collection 1) link exposures to racial discrimination with morbidity among diverse populations; 2) detail implementation of multicomponent antiracist initiatives enacted in schools of public health, schools of medicine, and other university-affiliated units; and 3) elevate attention to underlying drivers of structural inequities in housing and to domains through which meaningful community engagement in health initiatives is achievable.The work in this collection, “Combating Racism Through Research, Training, Practice, and Public Health Policies,” captures insights on roles and actions taken in public health, medicine, and policy to eliminate racism as a public health threat. The creation of racially and ethnically patterned differences in morbidity and mortality is well documented — covering many populations and health dimensions ,22–26. HExperiencing rejection, unfair treatment, or discrimination because of the meanings assigned to race, ethnicity, and skin color affects the odds of experiencing 2 or more chronic conditions concurrently in older adulthood among Colombians . Such exAcademic organizations play an important role in perpetuating racism and its effects on health through institutional norms, pedagogy, and research practices –36. SeveBoth Allen et al  and PolsThe approach to pedagogy in institutions of health-related higher learning also represents an important focus for antiracism efforts ,34,40. SAcademic organizations also promote and support research that has promulgated well-earned distrust of medical research ,43. LeboHealth-based efforts to dismantle racism must eliminate racial and ethnic inequities in social determinants of health such as housing while maximizing community agency in health promotion and disease prevention ,19,26,45Although Wonderly’s discussion of housing calls for addressing features of social structure, her treatment of meaningful community engagement urges committed investment in enhancing community agency. At base, she asserts that meaningful advancement of health equity and systems transformation can result from strengthening partnerships and alliances, expanding co-created community knowledge, designing community-relevant health and health care programs and policies, and cultivating thriving communities . CenteriThe articles in this PCD collection provide inspiration for future efforts to dismantle racism in public health and medicine, and they also help identify gaps in the field for future progress. First, these articles demonstrate the need for continued efforts to link exposures to racial discrimination with morbidity experiences among minoritized individuals and communities. Studies could include efforts that elucidate interactions between racialized contexts in shaping health, such as specific life stages and settings for experiences of discrimination for discrete populations. Research could also include more sophisticated analyses of policies, such as redlining and resultant differences in built environments and health-promoting environments, which are associated with inequitable health outcomes. Regarding the former set of studies, examinations of how distinctive combinations of institutional policies of specific places reinforce social marginalization could help devise more robust tactics for pursuing equity with populations whose social positions are reinforced by particular racialization and multiple, overlapping minoritization processes. New discoveries here are key to overcome limitations of strategies for addressing racism through universal remediation — which ignore important within-population and between-population differences in structural positioning that can vary exposures to chronic stress and the availability of protective social and socioeconomic capital. In addition, actively considering intersections of multiple interlocking systems of privilege and oppression, such as racism, heterosexism, and cisgenderism, in shaping health allows health care and public health to be in a better position to address the compounded effects of these systems on physical and mental health ,31,47–50The articles in this collection also highlight the need for educational institutions in medicine and public health to look within themselves to identify and dismantle fundamentally racist norms, pedagogies, and processes that perpetuate racist practices in clinical and public health practice and research. Efforts should examine and reform admissions and hiring practices, curricula, teaching and mentor training and hiring practices, approaches to retain and promote minoritized individuals and staff, and institutional partnerships and contracting practices. Strategies for effectively synergizing organizational change efforts of individual institutions to eliminate systemic racism require additional attention. Strides here are key to transforming racism initiatives within institutions into movements capable of tackling racism in health care and public health systems.Increased attention is also needed to codify and actualize the imperative of meaningfully engaging community partners in focused efforts to address inequities in housing, food insecurity and poverty, and other “nonhealth” domains that affect health. We must find ways to make community-centered strategies that incorporate multisystemic, intersectional approaches our norm and mandate. Doing so may more effectively blend and leverage community and institutional assets, evidence, and know-how to address racism in all systems affecting health opportunity.Additional gaps in ongoing work, not highlighted in this collection, should also be addressed. For example, the public health sector should become more actively engaged in efforts to dismantle policy-mediated causes of racial health inequities. Novel strategies, including partnerships with grassroots action efforts  that inform system changes could be pursued to stimulate action to develop or support implementation of antiracist policies. Similar strategic partnerships with other nonhealth sectors  for maximum effectiveness could create powerful alliances with the potential to influence social change in and across systems linked to racial and ethnic differences in health. Within the public health sector itself, work to synchronize and achieve strategic alignments of antiracist interventions in the areas of education, research, and public health practice will amplify and accelerate progress toward inseparable racial and health equity goals.Lastly, further examination of the role of the COVID-19 pandemic in reinforcing the very systemic racism responsible for observed disproportionate burden of COVID-19 among some racial and ethnic minority populations should be contemplated as directions for future effort are considered. New longitudinal efforts here could describe and address the long-term consequences of systemic racism not only for the patterning of COVID-19 health disparities by race and ethnicity but also for the persistence and patterning of chronic disease disparities and inequities in the social determinants of health. These efforts could cover potential additional increases in morbidity and mortality that may occur among some racial and ethnic populations as COVID-19 becomes endemic. But they might also cover possible enduring functional limitations and chronic conditions that could be associated with complications of COVID-19, such as the development of 1) multisystem inflammatory syndrome in children, 2) multisystem inflammatory syndrome in adults, and 3) post-COVID-19 conditions . Additional variations in subsequent disproportionate effects by race and ethnicity on well-being for different age cohorts should also be explored. This exploration is suggested because the consequences of the COVID-19 pandemic for social development, social participation, social network density, and psychosocial resource availability likely also vary by chronological age and social placement during the life course within race and ethnicity. Lastly, the disparate systemic implications of COVID-19 for the socioeconomic positions, collective efficacy, and access of vital conditions for health and well-being  of racially and ethnically diverse communities should be continuously documented and addressed. Doing so may ensure that the increased attention to systemic linkages between racism, health, and well-being stimulated by COVID-19 and social injustices occurring during the past 3 years will be sustained and leveraged toward societal transformation.At a health systems level, pandemic-associated racial and ethnic inequities in access to prevention and treatment should be further dissected and prospectively monitored. First, health systems research could continue to identify circumstances where access inequities existing before the onset of the COVID-19 pandemic may have been exacerbated  . CharactUltimately, work to dismantle racist systems present in health will require multipronged efforts that draw on numerous strengths from within and outside health care and public health institutions. As this work moves forward, our fields are called to consider bold and innovative actions that have the potential to produce lasting change.


The COVID-19 pandemic posed significant risk to the health of cancer patients, compromised standard cancer care and interrupted clinical cancer trials, prompting dramatic streamlining of services. From this health crisis has emerged the opportunity to carry forward an unexpected legacy of positive reforms to clinical cancer research, where conventionally convoluted approvals processes, inefficient trial design, procedures and data gathering could benefit from the lessons in rationalisation learned during the pandemic. Cancer is a leading contributor to health and economic burdens , 2, highThe coronavirus disease 2019 (COVID-19) pandemic triggered a brisk contraction of clinical research in the UK and globally . Cancer The European Union Clinical Trials Directive 2001/20/EC (CTD), whose implementation in 2004 was intended to harmonise trials processes across EU member states by stipulating minimum standards for approval, conduct and monitoring, instead delivered layers of misinterpretation and inconsistency within and between jurisdictions . SubsequApproval of a proposed trial can be a convoluted process of submissions to one or more regulatory agencies, Research Ethics Committees (REC), and institutional research and development (R&D) approval boards generating duplication of duties, conflicting feedback, repeated clarification and redrafting. Since the implementation of the EU CTD, the European Organisation for Research and Treatment of Cancer noted a slowing in initiation of its trials by 5 months, mainly through increased workload for RECs . AcknowlTrials are beset by protocol-driven administrative demands on both patients and staff, often disproportionate to the risk posed by the investigational medicinal product (IMP). Rigid trial design and protocols obligate extensive paperwork and reappraisal for sensible and potentially foreseeable alterations. Complexity is most immediately apparent to patients in lengthy trial information sheets and consent forms, potentially disadvantaging those from culturally diverse backgrounds . In earlManagement of trial databases has come to take up an inordinate amount of time and resources. Detailed clinical information, investigation results and adverse events—many of which will be irrelevant to final publication—are manually transcribed, updated, and clarified in the trial’s data entry system . While tGiven the association of cancer with ageing, comorbidities and immunosuppressive treatment, it is unsurprising that oncology patients are overrepresented in morbidity and mortality statistics for COVID-19 , 28. DivWhile the pandemic exposed the vulnerability of the cancer care and research sectors, it also highlighted their adaptability. The cancer community quickly adopted infection risk-mitigation strategies, with rapidly disseminated consensus guidance on balancing therapeutic de-escalation against the potential loss of disease control –36. AlgoRestrictions were placed on outpatient escorts and visitors for inpatients at times of high coronavirus prevalence, with attendant implications for communication and psychological support. These safeguards also precluded trial monitoring visits which, together with pressures on site staff capacity, rendered 100% on-site SDV unfeasible in real time. It was replaced instead by rationalised, remote monitoring of essential data. Though trial recruitment was slowed or halted in anticipation of the expected decline in site capacity, mitigation strategies stabilised and even partially recovered numbers in the face of subsequent waves , 43, allThe COVID-19 pandemic launched an unplanned testbed for strategies to streamline clinical trials. The resulting simplification of key research components—the approvals process, site set-up, recruitment and consent, delivery of trial procedures and data handling—together with innovative study design, have proven feasible. They could be preserved beyond the pandemic to optimise the time, resource and financial cost of many trials  has been gaining traction in an era of increasingly expedited approvals of targeted therapies based on early-phase trials, as a means to supplant small interventional or control groups, elongate safety follow-up and evaluate generalisability. COVID-19 has accelerated awareness and adoption of RWE to inform clinical practice, although the scientific rigour of this strategy must be scrutinised given the potential for heterogeneity across populations and time . ClinicaWhile trials conduct has returned to pre-pandemic practice in the immediate aftermath of lockdowns, there is an opportunity to capitalise on adaptive strategies developed during the COVID-19 pandemic to optimise the delivery of cancer care and clinical trials in future. Rationalised and decentralised procedures, including telemedicine, can improve accessibility of trials, fostering inclusivity of underserved groups reflective of real-world populations, and potentiating research into rare cancer subtypes. Optimised data monitoring can significantly reduce trials costs and workload, and expedite the research process without compromising safety or data integrity. Many of the bolder reforms depend upon explicit clarity and reassurance from regulatory bodies regarding acceptable de-escalation in trial procedural and data requirements, and a culture of mutual trust between authorities, investigating sites and sponsors. Cancer inflicts a devastating global healthcare burden in need of innovative, efficient and safe trials capable of yielding meaningful results in a timely fashion. A competing global healthcare emergency may have given us a glimpse of the way forward.


The aim of this review is to evaluate the relationship between weight status and taste perception and preference of sweet, salt, fat, bitter, and sour through reviewing observational and interventional studies with objective methods.A comprehensive literature search was performed in 6 online databases of PubMed, Scopus, Web of Science, Cochrane, Embase, and Google Scholar up to October 2021. The following keywords were used in the search strategy: (Taste OR "Taste Perception" OR "Taste Threshold" OR "Taste preference" OR "Taste sensitivity" OR "Taste changes") AND (weight OR "Weight gain" OR "weight loss" OR "weight change").Most observational studies indicate that four taste sensitivities or perceptions  are lower in subjects with overweight and obesity. The longitudinal studies reported that sweet and fat preference is increased along with weight gain in adults. It is concluded that taste perceptions are decreased in individuals with overweight and obesity, especially in men. Also, taste perception and preference change after weight loss but not significantly.It is suggested that the results of the interventional studies are not conclusive and need further studies with the same and standard design adjusting cofounding variables including genetic, gender, age and food condition of subjects.The online version contains supplementary material available at 10.1186/s12937-023-00850-z. Obesity, with severe complications including hypertension, cardiovascular disease, type 2 diabetes and certain types of cancer, is an increasing global health threat in children and adults resulting to economic and social consequences. According to a predictive model, the prevalence of obesity will reach 48.9% by the year 2030 among US adults . There aTaste sensation, one of the five main senses, helps humans to determine five basic tastes of sweet, salty, bitter, sour, and umami- and recognize nutritious and harmful substances .The tastOverall, a systematic review is needed to summarize all available findings in this issue. Therefore, the current review was done to evaluate the relationship between taste and weight changes and discuss the evidence on the effects of weight changes on sense of taste  in children, adolescence and adults. It is suggested that a better understanding of the relationship between weight change and taste can provide an opinion in terms of a food choice and eating habits.This study was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol. A comprehensive literature search was performed in 6 online databases of PubMed, Scopus, Web of Science, Cochrane, Embase, and Google Scholar up to February 2023. The following keywords were used in the search strategy: (Taste OR "Taste Perception" OR "Taste Threshold" OR "Taste preference" OR "Taste sensitivity" OR "Taste changes") AND (weight OR "Weight gain" OR "weight loss" OR "weight change"). In addition, the reference list of the relevant papers was checked to avoid missing any publication. All searched studies were included in the Endnote software for screening. Duplicate citations were removed afterward. The human studies which evaluate the effect of weight changes on taste  in children, adolescence and adults were included. No restriction was made at the time of publications and language and type of study. All observational studies with cross-sectional, case–control, or cohort design and trial studies conducted on weight and taste status were included. All studies that were used a direct measurement scale such as using filter paper for assessment of taste perception and special foods assessment for assessment of taste preference were included. The exclusion criteria involved: studies in which the subjects suffered from any disease and used any prescription; studies with the interventions of weight loss using any drug; studies in which an overall food questionnaire was included in taste scale; unpublished studies, review articles, papers with abstract only, and presentations. The number of articles included and excluded in the study selection process is shown in the flowchart below , duration of the intervention , and method of taste assessment.The Cochrane quality assessment tool was used to assess the bias risk for the interventional eligible studies by two reviewers independently . This ton = 1053), Web of Science (n = 59), Scopus (n = 767), Cochrane (n = 244), Embase (n = 45) and the reference lists of all relevant articles (n = 15). Considering title and abstracts of articles, 185 duplicate articles and 1935 unrelated articles were excluded. The full text of 45 publications were studied for further evaluation. Finally, 26 eligible studies  were selected in the current systematic review  or quinine hydrochloride or caffeine) dissolved in tap water were used to measure taste sensitivity and threshold in all studies except two studies in which strawberry milk, salad dressing, sweetness and creaminess of milk were used to assess the sweet and fat taste status –22, 40 aSeventeen cross-sectional studies were included. Eight studies indicated that the perception and sensitivity of sweet taste was lower and threshold of sweet taste was higher in subjects with overweight/ obese than in normal-weight , 36, 39.Fourteen cross-sectional studies were included. Nine studies indicated that the sensitivity of salt taste was lower and threshold of salt taste was higher in subjects with overweight/ obese than in normal-weight subjects , 34, 36.Twelve cross-sectional studies were included. Seven studies showed a significant difference in sensitivity and threshold of sour taste between non- obese and obese individuals , 36, 39.Fourteen cross-sectional studies were included. Seven studies showed the sensitivity of bitter taste was lower and the threshold of bitter taste was higher in overweight/obese individuals , 38, 39.There were six studies investigating the sweet sensitivity and threshold , 30, 35.The Fat threshold or sweet and fat preference were decreased in three weight loss interventional studies , 17, 19.The sensitivity and threshold of salt taste did not change after weight loss interventions in three studies , 30, 35 There were two studies investigated the sensitivity and threshold of sour and bitter , 35. OneFood choice can be affected by various factors including social factors such as family and cultural norms; smoking, physical factors such as access, availability, and time; economic factors such as cost and income; individual psychological factors such as stress, mood and attitudes; and biological factors such as appetite and taste as well as some medications , 43. It Furthermore, there are few longitudinal studies reported a linear correlation between taste preference of sweet or fat and weight gain , 40. SomAlthough several observational and longitudinal studies reported an inverse correlation between taste sensitivity and preference in overweight or obese subjects, there is still unclear that weight loss may reverse taste perception and decrease taste preference in overweight or obese subjects. Recent studies indicated the effects of weight loss surgery on decreasing the preference of sweet and fat taste in obese subjects –50. As iIt is suggested that having various study designs such as duration of intervention, may be a reason that the results of studies were not consistent. Moreover, in some studies the variables like single nucleotide polymorphisms (SNP) were not considered. In Burgess et al. study, the preference of sweet and fat taste was decreased after six months of a weight loss diet, while did not reduce after 3 months . It was Recently, several studies suggested a link between hormone leptin and the perception and preference of taste , 51, 52.As several factors can impact on food choice, we did not include studies in which a food questionnaire was used to assess the perception and preference of taste. However, most studies in which these scales were used showed that the subjects with obesity had higher preference of sweet and fat taste –57. LanfOverall, as the results of all included articles in this review can be inferred the sensitivities or perceptions of four main tastes specifically sweet and saltary taste are lower in overweight and obese than normal weight subjects. Additionally, according to longitudinal studies, the preference of sweet and fat is increased along with weight gain in adults. Although the number of studies in this issue is insufficient, it seems that weight gain and obesity can lead to reduction of taste perception and increase the preference of sweet and fat. In addition, many both observational and interventional studies demonstrate taste function is more affected in men than women. It is suggested that the results of the available interventional studies are not conclusive and need further studies with the same and standard design adjusting cofounding variables including genetic, gender, age and food condition of subjects.Additional file 1: Table S1. Quality score of case-control studies. Table S2. Quality score of cohort studies. Table S3. Quality score of interventional studies.


Data science health research promises tremendous benefits for African populations, but its implementation is fraught with substantial ethical governance risks that could thwart the delivery of these anticipated benefits. We discuss emerging efforts to build ethical governance frameworks for data science health research in Africa and the opportunities to advance these through investments by African governments and institutions, international funding organizations and collaborations for research and capacity development. In this Review article, the authors discuss emerging efforts to build ethical governance frameworks for data science health research in Africa and the opportunities to advance these through investments by African governments and institutions, international funding organizations and collaborations for research and capacity development. Other examples include the use of Geographical Information System (GIS) data to map spatial variations in the determinants, incidence, prevalence, and outcomes of disease, and the response of healthcare systems3. Several countries also utilize data science to monitor and evaluate multi-sectoral progress towards meeting the UN Sustainable Development Goals (SDG), reduce fraud and corruption, identify fake pharmaceutical products, and improve supply chain management to prevent stock-outs11. More recently, Large Language Models (LLM) have captured public imagination with the release of tools like GPT-4. LLMs are rapidly being used to transform multiple industries and disciplines17. With these capabilities, data science is rapidly transforming the landscape and touching vast areas of human endeavors.Data science is poised to revolutionize healthcare and research by enabling the development of novel interventions and groundbreaking strategies derived from high-quality and efficient analyses of the huge datasets derived from the activities of our multifaceted lives. Data science applications use high-performance computational infrastructure to process massive datasets from personal, public, and commercial sources including healthcare systems, smartphones, shopping records, social media postings, and wearable devices. Using novel, complex, and occasionally opaque algorithms, data scientists generate new insights and generalizable knowledge. Examples of data science applications include combination of diverse data streams to develop bio-preparedness, monitoring, and response strategies for infectious diseases outbreaks in human health and in agriculture18. Other examples include mining electronic health records for precision medicine19 and analysis of medical images for computational histopathology and radiology to improve diagnoses, among other uses21. In public health, data scientists are transforming practice through the application of high-level computational methods to population-level datasets typically used in public health to advance precision public health practice and research22. Examples of public health data science research include mining social media data for early detection, analyses of trends, education, planning and implementation of health systems responses to infectious and non-communicable diseases23, and application of myriad novel technologies and algorithms for precision public health22. Data science health research therefore presents huge opportunities for the application of novel methods and transformative technologies that would solve many healthcare challenges facing African people today and enable wider availability of high quality and cost-efficient health services.Data science health research is the novel application of data science methods and technologies for systematic generation, collection, processing, storage, management, analyses, visualization, interpretation, and communication of health-related data to develop generalizable knowledge and generate actionable insights. Examples of data science health research include integration of data from multiple omics technologies to generate insights about biological mechanisms and diseases’ pathways, and identify novel therapeutic and preventive opportunities25. Even though Africa currently constitutes 17% of the world’s population, it bears 25% of the world’s disease burden, has only 3% of the world’s healthcare workers, and 2% of global health research output26. This is due to limited infrastructure, lack of trained personnel, poor funding, economic and social instability which hinder access to clinical and preventive services26. Global public health emergencies such as emerging and re-emerging infectious diseases epidemics and climate change pose more challenges to African countries than the rest of the world. African countries would therefore require innovative data science tools and strategies to overcome these challenges.Africa, potentially, has the most to gain from implementation of data science for health care and research. With a population expected to reach 2.5 billion people or ~25% of the world’s population by 2050, data science technologies would enable African countries to leapfrog legacy healthcare systems and technologies, and dramatically transform lives on the continent27. This underrepresentation renders data science models and algorithms unstable and potentially inaccurate in African populations27. Without dedicated and focused efforts at remediation, persistence of this data science equity gap would worsen and this portends dire consequences for data science health research in African populations.Substantial gaps exist in the representation of people from Africa in the datasets currently used to build data science models and applications29. Most of these uses involve novel applications or extensions of current healthcare expertise and technologies. Examples of data science applications already in use in Africa include teleradiology and telepathology, patients’ navigation and clinical decision support (CDS) tools, integration of genomics data into public health and clinical care, and cancer screening33. However, most of these applications were designed, developed, tested, and validated outside Africa. They may not have been adequately evaluated in African populations and may be insensitive to local contexts and health priorities35. They may therefore primarily benefit people outside the continent. Given the novel opportunities being created by data science applications, it is critical to develop and implement technologies that are relevant and adapted to the contexts in which they would be used in Africa.African researchers, institutions, governments, and the private sector are already using data science for research, discoveries, and preventive and clinical care36.Several initiatives are being implemented in Africa to develop data science health research capacity, build infrastructure, implement training programs, organize scientific conferences, and engage in international collaborations that would empower African institutions to generate datasets, develop and apply data science models, and close the data science gap between Africa and high-income countries (HIC). In 2022, the NIH Common Fund awarded 20 grants worth $74.5 million in the “Harnessing Data Science for Health Discovery and Innovation in Africa (DS-I Africa)” program to accelerate data science health research in Africa. The projects being implemented by the DS-I Africa program include a Coordinating Center, an Open Data Science platform, seven training programs, four ethical, legal, and social implications (ELSI) projects, and seven research projects. Table 36.Table 37. H3Africa built new collaborations among scientists, developed genomics research infrastructure, and created publicly available governance and ethics policies for the African genomics research ecosystem40. Data science conferences and training programs are also proliferating in Africa including the Data Science Africa—an AI and Data Science Research Group at Makerere University, Uganda, the multi-country African ML and AI organization— Deep Learning Indaba, the School for Data Science and Computational Thinking at Stellenbosch University in South Africa, the African Institute for Mathematical Sciences Centre of Excellence in Cameroon and the African Center of Excellence in Data Science in the University of Rwanda. These programs are critical to generating data that will close the data science gap in Africa and enrich global resources for data science health research.The DS-I Africa initiative builds on the infrastructure previously developed by programs such as the $176 million Wellcome Trust and NIH-funded Human Heredity & Health in Africa (H3Africa) program45. Despite these investments, there remain many unresolved challenges including concerns about quality of informed consent, data ownership, data sharing, benefit-sharing, privacy, autonomy, exploitation, and weak governance49. Recent examples of these challenges include controversies about community benefit and data sharing during COVID-19 pandemic research and unauthorized use of DNA samples from African populations to develop a DNA genotyping microarray chip50. Given the methods and technologies used in data science health research, its potential to exacerbate preexisting health research ethics problems and generate new ones are quite substantial.In contrast with other disciplines where data science is also rapidly advancing, health research already has established frameworks and infrastructure for ethical governance. Substantial investments by the US National Institutes of Health (NIH), UK Wellcome Trust, the European Union through the European-Developing Countries Clinical Trials Partnership (EDCTP), African governments and institutions have significantly expanded African health research ethics infrastructure in the past few decades38. They also provided training for researchers and ethics committees. For example, H3Africa’s publication policy gives African researchers protected time to analyze and publish before their data becomes publicly available. This protection, which is designed to accommodate the infrastructural and personnel challenges faced by African researchers, enables them to frame the narrative about their research and advance their research priorities. Other policies require that the funded studies should focus on African health priorities, be led by African researchers, and that African institutions should be the primary recipients of the research grants, even when they collaborate with international institutions. These are meaningful practices that the emerging data science health research programs should emulate and further develop.Research consortia like H3Africa developed policies on samples and data sharing, biorepositories, publications, collaborations, and commercialization52. When data science health research projects are conducted within single institutions, e.g., computational histopathology of diagnostic biopsies, sufficient ethical oversight can be provided by the institution’s health research ethics committee. However, even in these situations, institutional health research ethics committees may lack sufficient knowledge, expertise, and experience in evaluating the ethical dilemmas that may accompany these studies and struggle to provide adequate ethical review and oversight53. In addition, the methods and technologies of data science often run counter to the established principles and practices of ethics review of health research thereby creating situations that may be beyond the capacity of individual ethics committees to resolve56. In such cases and in others where data science health research is being conducted in multiple institutions within the same country, collaborations between the ethics committees or centralization of ethics review, for example, by national health research ethics committees may be required to provide ethical oversight57. National health research ethics committees can constitute standing review committees that, in addition to chartered members, may also include local and international experts as ad-hoc members who can provide ethical oversight for complex data science health research within national boundaries57. This centralization of ethical review enables efficient utilization of scarce data science health research ethics expertise and improves the efficiency of ethical review58. Despite these innovations, even national health research ethics committees are susceptible to some of the problems affecting institutional health research ethics committees including lack of resources, lack of independence, poor funding and lack of efficacy, albeit to a lesser degree53.The rapid evolution of data science methods, utilization of complex algorithms, and huge datasets obtained from a variety of sources under uncertain consenting procedures particularly challenges the current model of ethical review of health research59. This would be highly impactful and motivate significant institutional response.Despite the tremendous investments in recent decades, the capacity, resources, and infrastructure for ethical oversight of health research in Africa remains weak and poorly resourced. A surge of data science health research projects would significantly strain and may overwhelm the system. The major responsibility for building and maintaining national and institutional health research ethics infrastructure rests with African governments and local institutions. Information showing how research significantly boosts the intellectual and economic capital of institutions and countries, and are engines for growing local and national economies may encourage more investment in research infrastructure, including ethical review in Africa. Many African institutions built their current health research ethics programs to support local investigators involved in collaborative international research projects. Research sponsors should incentivize development of local data science health research ethics capacity by linking progress in this domain with new research funding42. These would improve the knowledge of research ethicists about data science health research and that of data scientists about health research ethics, build local capacity that would enable local ownership and sustainment of training programs, and support the conduct of research into contextual data science health research ethics in Africa while contributing to the global health research ethics discourse.Research ethicists should engage with their local research and data science communities to better understand data science health research methods and projects, and jointly develop ethical governance frameworks that build on existing research ethics oversight infrastructure. Well-funded, well-designed, and sufficiently long training programs that have enabled African countries to avoid widespread egregious harm to research participants despite recent growth in the volume and sophistication of health research on the continent, are also needed for data science health research ethics61. The major challenges with GDPR and similar data protection laws include lack of sufficiently explicit frameworks for enforcement, complexity of certain provisions, a focus that is often insufficient for the nuances of data science health research63. Other suggestions for ethical governance of data science include giving participants ownership of their digital selves or using blockchain technologies to protect digital privacy and securely share data65. These approaches are highly technological, expensive and are not resource-level appropriate in the African health research setting66.Many African governments are rushing to enact laws similar to the European Union’s General Data Protection Regulation (GDPR) and modifying them for their environments68. These consortia must engage frontline stakeholders in different research environments and serve as petri-dishes for experiments into ethical regulation of data science health research. Governments and their agencies also have major roles to play in engendering and maintaining public trust, accountability, and support that are required to sustain public engagement in and support for data science health research.Research and training consortia are developing novel policies, ideas, and implementation strategies for ethical regulation of data science health researchExisting health research ethics regulations already have the essential elements for the ethical oversight of all types of health research. While data science health research includes novel methods and technologies, these do not abrogate the foundations, principles, and practices of modern health research ethics. African countries can quickly introduce sufficient oversight of data science health research by adding to or modifying existing regulations.58. This poses significant problems for oversight and accountability. Multilateral agencies including the United Nations and its organs, governments, advocates, bioethicists, and researchers have conducted multiple consultations and stakeholders’ meetings leading to issuance of guidelines on the use of data science in healthcare, research, and policy70. These guidelines call for development of multinational frameworks for data science health research to prevent egregious harm and maximize data science’s benefits to global populations52. To ensure relevance and implementation, these multinational agencies should work with African institutions to develop the mechanisms for enforcement of these principles, model laws, guidelines, and regulations for ethical oversight of data science health research across national borders. They should rigorously engage a broad range of stakeholders including those whose voices are typically drowned out in global discourse. Innovations in virtual meeting technologies should enable cost-effective, frequent, and sustained global engagement of stakeholders.Most data science health research sponsors, principal investigators, and scientists belong to international or commercial organizations that may not have local offices in Africa and may not be subject to national laws, guidelines, and regulations71. Healthcare data may derive from electronic health records, surveillance data, diseases’ registries, etc., while other datasets may be derived from wearable devices and other digital footprints. Large-scale genomic, transcriptomic, proteomic, and other omics research projects are also generating huge amounts of data for data science health research. Despite interventions like H3Africa and DS-I Africa, more of these data are still being generated in HIC compared to LMIC72. The resulting digital data inequity is pervasive and growing worse73. Digital health innovations also contribute to the widening inequities because of the “inverse care law” which postulates that well-resourced individuals are more likely to be aware of and utilize digital health interventions74. Unaddressed, these inequities will lead to severe and adverse health outcomes for majority of the world’s population75. Urgent, sustained, large-scale efforts are required to reverse this trend for the sake of equity and justice.Data science relies on large repositories of data generated by individuals as they engage with the healthcare system, during activities of daily living, and participation in research73. General investments in healthcare systems, implementation of electronic health records, improvements in diseases’ registries, and broader utilization of digital systems will increase the amount of digital data generated by African populations. Additional systematic interventions that are similar to but substantially larger than programs like H3Africa and DS-I Africa are needed to ensure that African countries, at a minimum, keep up with the high volume of omics and other data types being generated in HIC for data science.Multi-level interventions guided by frameworks for digital health equity such as the digital determinants of health (DDOH) would be useful for identifying the barriers and facilitators, and guide meaningful interventions to increase the volume of digital health data generated in Africa76. These algorithmic biases  coupled with the lack of equity and diversity in the foundational datasets used to develop, train, and validate data science algorithms lead to algorithmic deprivation, discrimination, and distortion81. Other concerns, particularly with respect to data science in Africa, are data colonization and extractive research82. Biased and inequitable algorithms lead to ethically, socially, politically, and economically undesirable outcomes in health research and health care, and can negatively affect perceptions of fairness, acceptability, and trust in applications derived from data science health research. These have the potential of denying populations that are most in need, the benefits of data science health research76. These harms are unpredictable and may not be remediable post hoc, they therefore require vigorous and robust attention a priori76.Data science technologies produce algorithmic bias by replicating and reinforcing societal biases that benefit or disadvantage certain individuals or groups. This results in structural, racial and ethnic biases in the HIC where most data science technologies are developed85. These include improving the diversity of data scientists through targeted capacity building programs, creation and implementation of guidelines and policies, implementation of programs to detect and rectify algorithmic bias, training data scientists on health research ethics87. These interventions require long-term commitments that go beyond the typical duration of many HIC research grant award mechanisms. They also require strong commitment by national governments, local institutions, and research sponsors. Novel strategies for supporting the development of personnel, resources, and infrastructure for data science health research in Africa that are aligned with clear goals and objectives, rather than just utilizing frameworks developed and used in the substantially different health research ecosystems of HIC are desperately needed.Many approaches have been recommended to reduce or eliminate algorithmic bias in data science health researchGiven the scope of data science health research, its potential to improve health outcomes, engender more equitable research participation, reduce marginalization, and utilize heterogeneous data types, all stakeholders must be urgently engaged in development of the most efficacious governance frameworks for it.


Dear Editor,Multiple cutaneous and uterine leiomyomatosis (OMIM 150800) is a rare, dominant autosomal hereditary disease in which patients develop multiple cutaneous and uterine leiomyomas. Around 14%‒30% of patients also develop unilateral, solitary, and aggressive renal cell carcinomas . Consequently, some authors refer to this disease as Hereditary Leiomyomatosis and Renal Cell Carcinoma syndrome (HLRCC).The authors recently examined a 35-year-old woman (with a history of eating disorder (anorexia nervosa) since she was 13, suicide attempts, convulsive crises, irritable bowel syndrome, pollen allergy, and bronchial asthma) who presented with over 20 subcutaneous nodules around her body, some of which were painful, which she had had from adolescence with gradual onset.Exploration revealed the presence of small, elastic nodules and papules with poorly defined borders, covered by slightly hyperpigmented skin and fibroelastic in consistency . Some weExcisional biopsy revealed lesions with a poorly defined border, composed of fascicles of entwined fusiform cells irregularly distributed within the dermis, sparing the superficial dermis . HLRCC wThe patient was referred for gynecological examination, and multiple uterine leiomyomas were detected. A hysterectomy was performed (despite the patient's age and her having no children), and she was referred for nephrological monitoring, which she continues with no important findings.Examination of her family members revealed her mother and maternal uncle both have multiple cutaneous leiomyomas as well. Her mother had undergone a hysterectomy for bleeding leiomyomas as a young adult after having two children. Genetic analysis of these relatives revealed the same genetic mutation as the patient; to date neither has developed renal cancer.HLRCC is characterized by the development of up to three types of tumors: cutaneous piloleiomyomas, which are seen in nearly all patients by the age of 40 years; uterine leiomyomas, which are seen in 70%‒98% of female patientsUterine leiomyomas affect 76%‒100% of women with a mutated gene for FH.Around 20% of patients with HLRCC may also develop type 2 papillary renal cell carcinoma10https://databases.lovd.nl/shared/genes/FH) and has been associated with a 47% loss in FH enzyme activity. Not all patients show the same phenotype, however, which suggests the involvement of additional genetic modifiers or environmental factors in the development of HLRCC.The FH enzyme takes part in the Krebs cycle, promoting the transformation of fumarate into L-malate. It has been proposed that the inactivation of FH causes the accumulation of fumarate in cells to about 200 times its normal concentration.Given the range of conditions associated with HLRCC, a set of diagnostic criteria has been established ,2 with tNone declared.Elena González-Guerra: Approval of the final version of the manuscript; critical literature review; data collection, analysis and interpretation; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic; management of studied cases; manuscript critical review; preparation and writing of the manuscript; statistical analysis; study conception and planning.Alberto Conde-Taboada: Approval of the final version of the manuscript; critical literature review; data collection, analysis and interpretation; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic; management of studied cases; manuscript critical review; preparation and writing of the manuscript; statistical analysis; study conception and planning.José Antonio Cortés Toro: Approval of the final version of the manuscript; critical literature review; data collection, analysis and interpretation; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic; management of studied cases; manuscript critical review; preparation and writing of the manuscript; statistical analysis; study conception and planning.Eduardo López-Bran: Approval of the final version of the manuscript; critical literature review; data collection, analysis and interpretation; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic; management of studied cases; manuscript critical review; preparation and writing of the manuscript; statistical analysis; study conception and planning.Pedro Pérez-Segura: Approval of the final version of the manuscript; critical literature review; data collection, analysis, and interpretation; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic; management of studied cases; manuscript critical review; preparation and writing of the manuscript; statistical analysis; study conception and planning.None declared.


Investing in preparedness is essential to healthcare resiliency, yet the COVID-19 pandemic exposed the inefficiencies in many healthcare systems and processes. Defined as the ability to resist, tolerate, recover from, prepare for or adapt to an adverse event that causes harm, destruction or loss, healthcare resiliency reflects the ways in which healthcare can face unexpected overloading without degradation of healthcare delivery [Health system resiliency has been previously defined as “the capacity of health actors, institutions and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits, and; be informed by lessons learnt during the crisis and reorganize if conditions require it” ,3. To prInfection prevention and control (IPC) is defined as a “practical, evidence-based approach which prevents patients and health workers from being harmed by avoidable infection and as a result of antimicrobial resistance” . A scopiWhile poor IPC is linked to infectious disease transmission among patients and healthcare workers, a lack of national IPC strategies or dedicated leaders at facility or national levels is associated with inconsistent messaging and coordination, leading to poor response coordination and the spread of misinformation in communities . InvestiThe following case studies discuss how two international grantee programmes supported by the National Foundation for the Centers for Disease Control and Prevention (CDC Foundation) used designated flexible funding to improve and strengthen the grantee countries’ IPC systems.In March 2020, Ethiopia reported its first COVID-19 case [Through the project, designed to strengthen IPC programmes at different health systems levels, 16 Ethiopian healthcare facilities were chosen to receive IPC guidance and assistance, receiving technical assistance and financial support for baseline capacity assessments to understand their COVID-19 prevention, containment and management readiness. The project led to the design and development of IPC standardised operating procedures, including screening and identifying healthcare workers suspected of COVID-19 exposure. ICAP developed guidance documents to enable healthcare workers to establish effective and quality IPC practices, and all 16 facilities now have IPC operational plans and standardised procedures in place, including source control screening, triage for patients, visitors, and healthcare workers, and inpatient isolation.Through the project, all 16 facilities helped develop national IPC indicators and dashboards to share across various levels of health care and strengthen cross-system collaboration; they now regularly report IPC indicators to the Ministry of Health. By identifying and addressing IPC programme gaps and improving capacity, this project also helped with the development and dissemination of a standardised programme that is now informing public health decisions via streamlined collection and reporting to the Ministry of Health.The burden of COVID-19 in Indonesia significantly exceeded the capacity of the country’s healthcare workers and contact tracers. While safe IPC was already a criterion to accredit Indonesia’s healthcare facilities, an intra-action review conducted by the Ministry of Health during the COVID-19 pandemic recommended improving IPC strategies throughout the country . To reduAn initial assessment of surveillance and IPC activities at 12 hospitals evaluated IPC implementation and training of healthcare workers during the COVID-19 pandemic, including epidemiology education and qualifications, types of training and site status of contact tracing. At the start of the project, only 12 out of the 48 total assessment respondents (25%) were trained in IPC (PAEI conducted training and held regular monitoring and evaluation meetings to improve surveillance and IPC activities in all the districts within the four provinces, training surveillance staff on reporting daily COVID-19 cases and field investigation results. During the project period, seven IPC training sessions were held, hosting 498 participants from 38 hospitals across the four provinces.At provincial and district health offices, the number of staff trained in surveillance activities increased from 41% to 98% after the project; at community health centres, the number of staff trained in surveillance, contact tracing, and epidemiological investigation rose from 15% to 80%. The number of healthcare workers trained in IPC increased from 25% to 86% by the end of this five-month project (COVID-19 transmission rates exceeded healthcare capacity limitations and disproportionately impacted international healthcare systems. The Ethiopia and Indonesia case studies enhanced COVID-19 surveillance and detection by creating local, regional, and national systems and tools, improving testing capacity, providing IPC training for healthcare professionals, and bolstering COVID-19 mitigation efforts.Going forward, countries should consider establishing national IPC guidelines and engaging local health facilities to create more sustainable responses, as collaboration between local facilities, implementing partners, and health authorities led to national IPC policies that were, in turn, adopted locally. Each programme case study also used flexible funding to meet the community’s needs and focused on embedding IPC programmes into both the local and national healthcare systems. Multi-sector collaboration between local and national experts around IPC programming created more resilient health systems through holistic and integrated approaches. By increasing capacity and training healthcare workers in IPC, countries can be better equipped to provide surveillance of future healthcare needs.


Public health organizations, including the Academy of Nutrition and Dietetics and the American Hospital Association, recognize the importance of achieving food and nutrition security to improve health outcomes, reduce healthcare costs, and advance health equity. In response, federal, state, and private agencies are increasingly seeking to fund healthcare-based interventions to address food insecurity among patients. Simultaneously, nutrition-based interventions targeting chronic diseases have grown across the United States as part of the broader “Food is Medicine” movement. Few studies have examined the successes, challenges, and limitations of such efforts. As Food is Medicine programs continue to expand, identifying common approaches, metrics, and outcomes will be imperative for ensuring program success, replicability, and sustainability. Beginning in 2020, the Food as Medicine (FAM) program, a multipronged, collaborative intervention at Grady Health System has sought to combat food insecurity and improve patient health by leveraging community resources, expertise, and existing partnerships. Using this program as a case study, we (1) outline the collaborative development of the FAM program; (2) describe and characterize patient engagement in the initial 2 years; and (3) summarize strengths and lessons learned for future hospital-based food and nutrition programming. As this case study illustrates, the Food as Medicine program provides a novel model for building health equity through food within healthcare organizations. Food insecurity, a state in which an individual or household lacks social, economic, or physical access to nutritious foods to support a healthy and active life, impacts approximately 11% of all individuals in the United States , unstablAs a public health concern and a prevalent social determinant of health, food insecurity is a primary target of interventions to alleviate diet-related chronic diseases. Though intervention approaches vary widely, many apply principles of the “Food is Medicine” movement . “Food iTo our knowledge, this is one of few manuscripts to detail the real-world implementation of a Food is Medicine program, and to describe the characteristics and engagement of patients who enroll. The partnerships of this program enable rigorous evaluation in real-world settings to assess program outcomes. By describing program characteristics and initial outcomes, this manuscript aims to address gaps in the current literature to enhance the sustainability, scalability, and transferability of these interventions to other hospital and clinical settings. The Food as Medicine (FAM) partnership, which began in 2020, operates as a collaboration between a large hospital system in the Southeast US and local nonprofit organizations. Akin to similar interventions across the nation, the FAM program targets patients living with or at-risk for food insecurity and hypertension or diabetes mellitus.Over 11% of individuals living in the Southeast experience food insecurity—the highest prevalence of any region in the US . The AtlThe Grady Health System is the busiest level 1 trauma center in Georgia and has over 158,000 Emergency Department visits annually. Comprised of a hospital with 853 licensed beds and six neighborhood health centers across two counties in the Atlanta MSA, Grady serves over 2,300 patients per day. The Population Health team at Grady seeks to design, deliver and coordinate care to address the critical needs of the community in accordance with overall health status. A key priority for the Population Health team is to contribute to a coordinated system of care delivery within and outside the clinical setting the team does so by working at the nexus of three key social determinants of health: housing, transportation, and food. Previous needs assessments estimated that the prevalence of food insecurity among patients attending Grady Health System is nearly four times higher than in Atlanta overall. Based on these assessments, approximately 50% of the patient population may experience food insecurity at some point in the year; moreover, since these assessments were conducted before the COVID-19 pandemic, current patient needs are likely even greater. Recognizing this need, the aims of the Food as Medicine partnership are threefold: 1. Increase access to healthy, affordable food for patients and their families, employees, visitors, and the wider community; 2. Leverage community resources and expertise to address food insecurity and chronic disease; and 3. Improve the health and overall quality of life of patients.In 2016, Grady announced the examination and alleviation of diabetes, hypertension, and social determinants of health as community health needs priorities. At this time, the early inceptions of Food as Medicine began with a pilot Fruit and Vegetable Rx Program, discussed and evaluated at length in . By 2017Grady formed the Food as Medicine (FAM) program as a collaboration between Grady Health System, Atlanta Community Food Bank, and Open Hand Atlanta. Constructing a shared vision and goals across partners proved critical to the program’s success in its inception and initial stages. A Feeding America affiliate, the Atlanta Community Food Bank has a long history of working to provide access to nutritious meals for those in need within their 29-county service area. Open Hand Atlanta, a non-profit agency, seeks to eliminate disability and untimely death due to nutrition-sensitive chronic disease and medically-tailored meals and nutrition education. By working in coordination with the Atlanta Community Food Bank and Open Hand Atlanta, the FAM program leveraged the experience and resources of existing community-based food and nutrition security resources in the development, design, and implementation of programming. Finally, partnerships with Emory University researchers enable evaluation of this program. These non-governmental, private, and research sector partnerships have proven vital to the implementation and maintenance of the FAM program over its initial 3 years. This case-study focuses on one of the integral prongs of the FAM program: The Food Prescription Program. Given the increase in food prescription programs across the U.S., Grady prioritized disseminating evaluation findings from the Food Prescription Program prong, with other aspects of the program to be evaluated and shared more widely in the future.The Food Prescription Program, a service line within the larger Grady FAM program, is a multi-pronged intervention that provides eligible patients with nutrition counseling, cooking classes, and fresh food (purchased from the Atlanta Community Food Bank). The Food Prescription Program operates within the Jesse Hill market space to serve as a hub for nutrition and well-being for Grady patients, employees, and the greater community. The Jesse Hill market also houses a teaching kitchen that focuses on plant-based cooking and nutrition and chronic disease education.Food security is often conceptualized as being comprised of four pillars: availability, accessibility, utilization, and stability. Scholarly examination of these pillars is varied, with an arguable over-representation of dimensions of availability and access in commonly used measurement tools and studies of insecurity and health. The Food Prescription Program attempts to address multiple pathways proposed to underlie food insecurity and adverse health outcomes, including nutritional, compensatory, and psychological pathways, as outlined by Te Vazquez and colleagues in a recent systematic review . The nutor diastolic blood pressure greater than 90 mmHg during the last measure taken) or uncontrolled diabetes Type 1 or 2 (last hemoglobin A1c reading greater than 9.0). Notably, the HVS™ identifies risk for food insecurity; therefore, individuals who are living with marginal food security may screen as “at-risk” for food insecurity using the HVS™. Studies in clinical settings show that the HVS shows high sensitivity and specificity with the Household Food Security Survey Module  screen positive for food insecurity using the validated two-item Hunger Vital Sign™ (HVS) and (2) are identified as having uncontrolled hypertension  within Epic  which prompts providers to sign a referral  to the Food Prescription Program. As a feature of the electronic medical record, referral to the Food Prescription Program is a staff-led intervention, offering nurses and certified medical assistants the ability to respond to the BPA. In the period between August 2020 and August 2022, each month an average of 236 BPAs were prompted, 122 referrals were made, and 42 enrollments occurred. Once enrolled, food prescriptions provide patients access to the Food Prescription Program for a 3-month “episode” of care which can be renewed up to 3 times . During each episode, patients are invited to pick up fresh produce boxes biweekly, attend cooking classes in Jesse Hill Market’s on-site Teaching Kitchen, participate in nutrition education sessions  with a registered dietitian, and continue to follow-up with their primary healthcare provider. The food prescription process is documented within the electronic medical record (EMR) system, including the referral and enrollment for eligible and participating patients, documentation of visits to the Food Prescription Program, Teaching Kitchen and nutrition education sessions, and health records. At their first Food Prescription Program visit, patients complete a standardized survey that further assesses social determinants of health using validated instruments. Specifically, patients complete the 6-item Household Food Security Survey Module (HFSSM), the Center for Disease Control Healthy Days Core Module , a one-iBetween August 2020 and August 2022, 1,012 patients visited the Food Prescription Program at least once. Of those, 863 were eligible to renew their prescription by August 2022 based on their initial start date. During this period, the Food Prescription Program distributed over 142,000 pounds of food to patients enrolled in FAM. Overall, approximately 42.6% of patients renewed their prescription. Reflecting the demographics of the hospital, the majority of enrolled these patients identify as Black or African American (93%) and female (60%). Notably, 20% of these patients experienced housing insecurity in the previous 12 months, illustrating the influence of multiple social determinants on the health of this community. Similarly, using the Household Food Security Survey Module, nearly 70% of all enrollees experienced low or very low food security in the past month. Enrollees ranged in age from 19 to 90 years, with an average age of 56 years. Approximately one-third of all enrollees reported living in a household with at least one child, while almost half reported living in a household with at least one adult over age 60. Most enrollees reported preparing their own meals at home, which indicates capacity to implement lessons from the cooking and nutrition education components of the Food Prescription Program.As shown in or diastolic blood pressure greater than 90 mmHg), and 48% had a baseline HbA1c greater than or equal to 9.0%. Approximately 58% of patients had hypertensive blood pressure readings and HbA1c values of greater than or equal to nine, suggestive of a high prevalence of comorbidity relative to the general population. Those lost to follow-up had significantly smaller baseline waist circumference, but significantly greater diastolic blood pressure and A1C levels compared to than those who renewed prescriptions. There were no other differences in baseline physical or perceived health measures between the groups, suggesting that program retention may not be affected by differences in morbidity status or baseline health condition. As shown in Of the 863 individuals who attended the Food Prescription Program at least once were eligible to renew their prescription, 495 (57.4%) did not renew their prescription to re-enroll in the Food Prescription Program. Noting that many participants enrolled had not met the participation requirements to re-enroll in an additional episode, a qualitative phone-based survey was conducted to query barriers to program engagement in April 2022. We identified 62 participants who would have been eligible for re-enrollment at this point had they met requirements and were able survey 25 (40% response rate). Barriers to engagement identified were highly individual but were often related to competing priorities and overlapping social determinants of health such as lack of transportation, caregiver responsibilities, work hours, and physical health challenges. Some responses were not able to be categorized but generally discussed the time commitment involved in meeting program requirements within the 3-month episode window (24% of responses discussed the time commitment as a barrier) .Following principles of the Food is Medicine movement, this study of the Grady Food as Medicine program development and delivery is shared here for the purposes of transparency, replicability and transferability, and the enhancement of public health impact by integrating resources to alleviate social determinants of health directly within a health system. During the first 2 years of a Food Prescription program, Grady Health System engaged 1,012 patients living with diabetes or hypertension and at-risk for food insecurity, retaining approximately 42.6% of those eligible for future iterations of the program. The significantly greater loss to follow-up among individuals who identified as male warrants further investigation. In a recent study, Sauder and colleagues report similar findings from the Diabetes Prevention Program, in which older men and younger men were significantly less likely to complete one or more sessions than older women and younger women . AnalyseThe intervention development process strived to build upon effective research-community partnerships, incorporating community organizations working in the local food system sector for several decades and leveraging research expertise through academic partnerships with local universities. These organizations afforded the FAM partnership access to valuable networks and funding, without which this program would not be possible. The BPA alerts within the electronic medical record and nurse-led protocols facilitate easy identification of eligible participants, timely referral, and clinical integration of this program within the health system. Integrating referral in the electronic medical record also enables data sharing across clinical and intervention spaces. Moreover, the Food as Medicine program attempts to address the four major pillars of food insecurity: availability, access, stability, and utilization. While concerted efforts to address issues of availability and access are evident in intervention approaches, the cooking classes work to also improve utilization and patients’ ability to re-enroll for up to 1 year aims to improve stability. Furthermore, the Food as Medicine program acts as a vital “one-stop-shop,” for healthcare and food. The physical infrastructure and proximity of the Food Prescription Program in relation to the hospital alleviates some barriers to enrollment. FAM also enables patients to visit the Food Prescription Program on the same day as their initial referral, enabling patients to access food immediately. Nevertheless, as is evident in the proportion of people who do not return for a second visit, there remains space for growth regarding engagement and retention.In the future, Grady aims to further develop the Food Prescription Program and the overarching FAM program, with a particular emphasis on improving referrals and alleviating barriers to program participation. Based on our preliminary evaluation, engagement with the program appears to be representative of the patient population at Grady, though a fraction of those eligible enroll in the FAM program. Further research is needed to understand barriers to engagement across each level of programmatic implementation. In this regard, more work should focus on barriers within the referral system, including variability across healthcare provider and clinical referral practices. Similarly, challenges or resistance to program enrollment among those referred warrants further attention. Among those who enroll in FAM, re-enrollment for additional three-month increments remains low. This begs the critical question: Why do people not remain engaged? And What additional supports can health systems implement to reduce barriers to engagement? Preliminary findings from brief interviews with enrollees suggest that transportation assistance may improve engagement and retention. Critically, program design anticipated that lack of access to transportation would pose a barrier for patients, particularly for bi-weekly food pick-ups. To address this barrier, Grady has piloted two transportation support programs in conjunction with the FAM program: home delivered boxes directly from the Atlanta Community Food Bank and car share rides for FAM participants funded by a health plan partner. In that regard, ongoing research with academic partners seeks to understand the added value of transportation assistance and incentives.Other healthcare systems interested in developing Food is Medicine partnerships should prioritize the early establishment of cross-sector partnerships spanning nongovernmental and academic organizations with vested interest in the community. Additionally, programs should consider funding sources and funding sustainability. Program costs will vary depending on established partnerships and target patient engagement; at present, funding for Food is Medicine programs may incorporate governmental and private funds. As noted in our limitations section, patient engagement may present unique and contextually dependent challenges to program success. The pre-existence of social determinants of health screening facilitated recruitment for FAM at Grady and may provide a useful scaffold for enrollment in food and nutrition security programming within other healthcare systems. Finally, health systems and advocates alike must work toward a paradigm shift in how food and nutrition are treated and covered. More specifically, by viewing healthy foods, including fruits and vegetables, as fundamental to well-being and preventative care, health systems may promote increased coverage of these programs by insurance payors.Though Food is Medicine programs are most prominent in North America, the lessons learned have global relevance. A Food is Medicine program offers insight into how a more holistic approach to food and eating can sustainably improve well-being. The program emphasizes dietary quality in addition to quantity in a manner that seeks to address each of the pillars of food insecurity, including those often unaddressed in other programs, such as utilization and stability. One of the future directions of this program—increasing emphasis on culturally preferred and culturally relevant foods derives from the premise that celebrating foodways is essential for combatting the often-racialized stigmatization of certain foodways and for generating more sustainable dietary change. From the standpoint of sustainability and resilience, it is also important to reference and incorporate produce and cultural foods grown locally, sustainably. Relatedly, programs that adopt more multifaceted approaches, including access to community gardens and arable land, which can foster physical activity and social connection—both shown to reduce rates of mood disorders , 40—can In response to the disproportionate burden of food insecurity affecting the patient population at a large safety-net health system in the Atlanta MSA, Grady collaboratively developed a healthcare-integrated Food as Medicine program to improve food access and patient well-being. This case study details the development, refinement, and initial findings regarding patient engagement. In so doing, it aims to facilitate the replication or transferability of Food as Medicine interventions toward improving food security and human well-being for patients nationwide.lhmarshburn@gmh.edu.The datasets presented in this article are not readily available because they include public health information. Requests to access the datasets should be directed to The studies involving humans were approved by the Emory University Institutional Review Board; Grady Health Research Oversight Committee. The studies were conducted in accordance with the local legislation and institutional requirements. The ethics committee/institutional review board waived the requirement of written informed consent for participation from the participants or the participants’ legal guardians/next of kin because this study was deemed quality improvement and program evaluation.CO: conceptualization, writing-original draft, and analysis. MC: analysis. JG: implementation. LM and KT: project administration. SS and JB-J: resources and supervision. RC: conceptualization, resources, and supervision. All authors contributed to review and editing of the manuscript.