Academic literature on the topic 'National Institute of Child Health and Human Development (U.S.). Section on Nutrition and Growth'

ABSTRACT: Asia is the second region after Africa to have the tallest prevalence of stunting in the world. Indonesia is one of the countries in Southeast Asia with the fifth highest prevalence of stunting in the world at 37%, or nearly 9 million children who experience stunting. This study aims to examine the factors that influence and risk the occurrence of stunting in children in Indonesia. The research method uses a type of qualitative research with a traditional literature review. This study found that stunting is influenced by several complex factors not only at the individual level but also at the family and community levels. A comprehensive synthesis of the available evidence on the determinants of stunting in children in Indonesia outlines who is most vulnerable to stunting, which interventions are successful, and what new research is needed to fill knowledge gaps. Keywords: Indonesian toddlers, stunting factors References: Adair, L. S., & Guilkey, D. K. (1997). Age-specific Determinants of Stunting in Filipino Children. The Journal of Nutrition, 127(2), 314–320. https://doi.org/10.1093/jn/127.2.314 Akombi, B. J., Agho, K. E., Hall, J. J., Merom, D., Astell-Burt, T., & Renzaho, A. M. N. (2017). Stunting and Severe Stunting Among Children Under-5 Years in Nigeria: A Multilevel Analysis. BMC Pediatrics, 17(1), 1–16. https://doi.org/10.1186/s12887-016-0770-z Asfaw, M., Wondaferash, M., Taha, M., & Dube, L. (2015). Prevalence of Undernutrition and Associated Factors Among Children Aged Between Six to Fifty Nine Months in Bule Hora District, South Ethiopia. BMC Public Health,15(1), 41. https://doi.org/10.1186/s12889-015-1370-9 Badan Penelitian dan Pengembangan Kesehatan. (2018). Hasil Utama RISKESDAS 2018. Bardosono, S., Sastroamidjojo, S., & Lukito, W. (2007). Determinants of Child Malnutrition During the 1999 Economic Crisis in Selected Poor Areas of Indonesia. Asia Pacific Journal of Clinical Nutrition, 16(3), 512–526. Best, C. M., Sun, K., De Pee, S., Sari, M., Bloem, M. W., & Semba, R. D. (2008). Paternal Smoking and Increased Risk of Child Malnutrition Among Families in Rural Indonesia. Tobacco Control, 17(1), 38–45. https://doi.org/10.1136/tc.2007.020875 Biadgilign, S., Shumetie, A., & Yesigat, H. (2016). Does Economic Growth Reduce Childhood Undernutrition in Ethiopia? PLoS ONE, 11(8), 1–14. https://doi.org/10.1371/journal.pone.0160050 Black, R. E., Victoria, C. G., Walker, S. P., Bhutta, Z. A., Christian, P., Onis, M. de, Ezzati, M., McGregor, S. G., Katz, J., Martorell, R., Uauy, R., & The Maternal and Child Nutrition Study Group. (2013). Maternal and Child Undernutrition and Overweight in Low-income and Middle-income Countries. The Lancet, 382, 396. Budge, S., Parker, A. H., Hutchings, P. T., & Garbutt, C. (2019). Environmental Enteric Dysfunction and Child Stunting. Nutrition Reviews, 77(4), 240–253. https://doi.org/10.1093/nutrit/nuy068 Burchi, F. (2010). Child Nutrition in Mozambique in 2003: The Role of Mother’s Schooling and Nutrition Knowledge. Economics and Human Biology, 8(3), 331–345. https://doi.org/10.1016/j.ehb.2010.05.010 Casale, D., Espi, G., & Norris, S. A. (2018). Estimating the pathways through which maternal education affects stunting: Evidence from an urban cohort in South Africa. 21(10), 1810–1818. https://doi.org/10.1017/S1368980018000125 Casanovas, M. del C., Lutter, C. K., Mangasaryan, N., Mwadime, R., Hajeebhoy, N., Aguilar, A. M., Kopp, C., Rico, L., Ibiett, G., Andia, D., & Onyango, A. W. (2013). Multi-sectoral Intervensions for Healthy Growth. Matern Child Nutrition, 2, 46–57. https://doi.org/10.1111/mcn.12082 Chirande, L., Charwe, D., Mbwana, H., Victor, R., Kimboka, S., Issaka, A. I., Baines, S. K., Dibley, M. J., & Agho, K. E. (2015). Determinants of Stunting and Severe Stunting Among Under-Fives in Tanzania: Evidence from The 2010 Cross-sectional Household Survey. BMC Pediatrics, 15(1), 1–13. https://doi.org/10.1186/s12887-015-0482-9 Creswell, J. W. (2014). A Concise Introduction to Mixed Methods Research. SAGE Publications Inc. Dao, D., Thang, V. Van, & Hoa, D. T. (2010). Malnutrition Status and Related Factors Within Ethnic Minority Children Under 5 Years Old in North Tra My District, Quang Nam Province in 2010. Journal of Science, 61. Fantay Gebru, K., Mekonnen Haileselassie, W., Haftom Temesgen, A., Oumer Seid, A., & Afework Mulugeta, B. (2019). Determinants of Stunting Among Under-Five Children in Ethiopia: A Multilevel Mixed-Effects Analysis of 2016 Ethiopian Demographic and Health Survey Data. BMC Pediatrics, 19(1), 1–13. https://doi.org/10.1186/s12887-019-1545-0 Fitri, L. (2018). Hubungan BBLR dan ASI Eksklusif Dengan Kejadian Stunting di Puskesmas Lima Puluh Pekanbaru. Jurnal Endurance, 3(1), 131–137. Goldstein, H. (2010). Multilevel Statistical Models, 4th Edition. Wiley. Handayani, F., Siagian, A., & Aritonang, E. (2017). Mother’s Education as A Determinant of Stunting among Children of Age 24 to 59 Months in North Sumatera Province of Indonesia. IOSR Journal of Humanities and Social Science, 22, 58–64. https://doi.org/10.9790/0837-2206095864 Hendraswari, C. A., Purnamaningrum, Y. E., Maryani, T., Widyastuti, Y., & Harith, S. (2021). The Determinants of Stunting for Children Aged 24-59 Months in Kulon Progo District 2019. Kesmas: Jurnal Kesehatan Masyarakat Nasional, 16(2), 71–77. https://doi.org/10.21109/kesmas.v16i2.3305 Hoddinott, J., Alderman, H., Behrman, J. R., Haddad, L., & Horton, S. (2013). The Economic Rationale For Investing In Stunting Reduction. Maternal & Child Nutrition, 9, 69–82. https://doi.org/10.1111/mcn.12080 Horrell, S., Humphries, J., & Voth, H.-J. (2001). Destined for Deprivation: Human Capital Formation and Intergenerational Poverty in Nineteenth-Century England. Explorations in Economic History, 38(3), 339–365. https://doi.org/10.1006/exeh.2000.0765 International Food Policy Research Institute. (2016). Global Nutrition Report 2016: From Premise to Impact: Ending Malnutrition by 2030. Kementerian Kesehatan Republik Indonesia. (2016). InfoDATIN: Situasi Balita Pendek. Kementerian Kesehatan Republik Indonesia. (2018). Warta KESMAS: Cegah Stunting itu Penting. Kimani-Murage, E. W., Muthuri, S. K., Oti, S. O., Mutua, M. K., Van De Vijver, S., & Kyobutungi, C. (2015). Evidence of A Double Burden of Malnutrition in Urban Poor Settings in Nairobi, Kenya. PLoS ONE, 10(6), 1–17. https://doi.org/10.1371/journal.pone.0129943 Kusumawati, E., Rahardjo, S., & Sari, H. P. (2015). Model Pengendalian Faktor Risiko Stunting pada Anak Usia di Bawah Tiga Tahun Model of Stunting Risk Factor Control among Children under Three Years. Kesmas: Jurnal Kesehatan Masyarakat Nasional, 9, 249–256. Madan, E. M., Haas, J. D., Menon, Purnima., & Gillespie, Stuart. (2018). Seasonal Variation In The Proximal Determinants Of Undernutrition During The First 1000 Days Of Life In Rural South Asia: A Comprehensive Review.Global Food Security, 19, 11–23. https://doi.org/10.1016/j.gfs.2018.08.008 McGregor, S. G., Cheung, Y. B., Cueto, S., Glewwe, P., Ritcher, L., Strupp, B., & International Child Development Steering Group. (2007). Developmental Potential in The First 5 Years for Children in Developing Countries. The Lancet, 369, 60–70. https://doi.org/10.1016/S0140-6736(07)60032-4 Mugianti, S., Mulyadi, A., Anam, A. K., & Najah, Z. L. (2018). Faktor Penyebab Anak Stunting Usia 25-60 Bulan di Kecamatan Sukorejo Kota Blitar. Jurnal Ners Dan Kebidanan (Journal of Ners and Midwifery), 5(3), 268–278. https://doi.org/10.26699/jnk.v5i3.art.p268-278 Ntenda, P. A. M., & Chuang, Y.-C. (2018). Analysis of Individual-level and Community-level Effects on Childhood Undernutrition in Malawi. Pediatr Neonatol, 59(4), 380–389. https://doi.org/10.1016/j.pedneo.2017.11.019 Oddo, V. M., Rah, J. H., Semba, R. D., Sun, K., Akhter, N., Sari, M., De Pee, S., Moench-Pfanner, R., Bloem, M., & Kraemer, K. (2012). Predictors of Maternal and Child Double Burden of Malnutrition in Rural Indonesia and Bangladesh. American Journal of Clinical Nutrition, 95(4), 951–958. https://doi.org/10.3945/ajcn.111.026070 Prado, E. L., & Dewey, K. G. (2014). Nutrition and brain development in early life. Nutrition Reviews, 72(4), 267–284. https://doi.org/10.1111/nure.12102 Prakhasita, R. C. (2019). Hubungan Pola Pemberian Makan Dengan Kejadian Stunting Pada Balita Usia 12-59 Bulan di Wilayah Kerja Puskesmas Wedi Surabaya. Universitas Airlangga. Reynaldo, Martorell., & Young, M. F. (2012). Patterns of Stunting and Wasting: Potential Explanatory Factors. Advances in Nutrition, 3(2), 227–233. https://doi.org/10.3945/an.111.001107 Rosiyati, E., Pratiwi, E. A. D., Poristinawati, I., Rahmawati, E., Nurbayani, R., Lestari, S., Wardani, P. S., & Nugroho, M. R. (2019). Determinants of Stunting Children (0-59 Months) in Some Countries in Southeast Asia. Jurnal Kesehatan Komunitas, 4(3), 88–94. https://doi.org/10.25311/keskom.vol4.iss3.262 Sari, M., De Pee, S., Bloem, M. W., Sun, K., Thorne-Lyman, A. L., Moench-Pfanner, R., Akhter, N., Kraemer, K., & Semba, R. D. (2010). Higher Household Expenditure on Animal-Source and Nongrain Foods Lowers the Risk of Stunting Among Children 0-59 Months Old in Indonesia: Implications of Rising Food Prices. Journal of Nutrition, 140(1), 195–200. https://doi.org/10.3945/jn.109.110858 Satriawan, E. (2018). Strategi Nasional Percepatan Pencegahan Stunting 2018-2024. [National Strategy for the Acceleration of Stunting Prevention] Semba, R. D., Kalm, L. M., De Pee, S., Ricks, M. O., Sari, M., & Bloem, M. W. (2007). Paternal Smoking is Associated with Increased Risk of Child Malnutrition Among Poor Urban Families in Indonesia. Public Health Nutrition, 10(1), 7–15. https://doi.org/10.1017/S136898000722292X Semba, R. D., Moench-Pfanner, R., Sun, K., De Pee, S., Akhter, N., Rah, J. H., Campbell, A. A., Badham, J., Bloem, M. W., & Kraemer, K. (2011). Consumption of Micronutrient-fortified Milk and Noodles is Associated with Lower Risk of Stunting in Preschool-Aged Children in Indonesia. Food and Nutrition Bulletin, 32(4), 347–353. https://doi.org/10.1177/156482651103200406 Shieh, S. J., Chen, H. L., Liu, F. C., Liou, C. C., Lin, Y. in H., Tseng, H. I., & Wang, R. H. (2010). The Effectiveness of Structured Discharge Education on Maternal Confidence, Caring Knowledge, and Growth of Premature Newborns. Journal of Clinical Nursing, 19(23–24), 3307–3313. https://doi.org/10.1111/j.1365-2702.2010.03382.x Stewart, C. P., Iannotti, L., Dewey, K. G., Michaelsen, K. F., & Onyango, A. W. (2013). 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Eating habits develop during the first years of a child's life, children learn what, when, and how much to eat through direct experience with food and by observing the eating habits of others. The aim of this study is to get a clear picture of the Eating program Healthy, starting from the planning, implementation, supervision, and evaluation as a case study of nutrition education; to get information about the advantages, disadvantages and effects of implementing a healthy eating program for children. This research was conducted through a case study with qualitative data analysed using Miles and Huberman techniques. Sample of children in Ananda Islāmic School Kindergarten. The results showed the Healthy Eating program could be implemented well, the diet was quite varied and could be considered a healthy and nutritious food. The visible impact is the emotion of pleasure experienced by children, children become fond of eating vegetables, and make children disciplined and responsible. Inadequate results were found due to the limitations of an adequate kitchen for cooking healthy food, such as cooking activities still carried out by the cook himself at the Foundation's house which is located not far from the school place; use of melamine and plastic cutlery for food; the spoon and fork used already uses aluminium material but still does not match its size; does not involve nutritionists. Keywords: Early Childhood, Eating Healthy Program References: Bandura, A. (1977). Social learning theory. Englewood Cliffs: Prentice-Hall. Bandura, Albert. (2004). Health promotion by social cognitive means. Health Education and Behavior, 31(2), 143–164. https://doi.org/10.1177/1090198104263660 Battjes-Fries, M. C. E., Haveman-Nies, A., Renes, R. J., Meester, H. J., & Van’T Veer, P. (2015). Effect of the Dutch school-based education programme “Taste Lessons” on behavioural determinants of taste acceptance and healthy eating: A quasi-experimental study. Public Health Nutrition, 18(12), 2231–2241. https://doi.org/10.1017/S1368980014003012 Birch, L., Savage, J. S., & Ventura, A. (2007). Influences on the Development of Children’s Eating Behaviours: From Infancy to Adolescence. Canadian Journal of Dietetic Practice and Research : A Publication of Dietitians of Canada = Revue Canadienne de La Pratique et de La Recherche En Dietetique : Une Publication Des Dietetistes Du Canada, 68(1), s1– s56. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19430591%0Ahttp://www.pubmedcentral.nih.gov/a rticlerender.fcgi?artid=PMC2678872 Coulthard, H., Williamson, I., Palfreyman, Z., & Lyttle, S. (2018). Evaluation of a pilot sensory play intervention to increase fruit acceptance in preschool children. Appetite, 120, 609–615. https://doi.org/10.1016/j.appet.2017.10.011 Coulthard, Helen, & Sealy, A. (2017). Play with your food! Sensory play is associated with tasting of fruits and vegetables in preschool children. Appetite, 113, 84–90. https://doi.org/10.1016/j.appet.2017.02.003 Crain, W. C. (2005). Theories of development: Concepts and applications. Upper Saddle River: Pearson Prentice Hall. Dazeley, P., Houston-Price, C., & Hill, C. (2012). Should healthy eating programmes incorporate interaction with foods in different sensory modalities? A review of the evidence. British Journal of Nutrition, 108(5), 769–777. https://doi.org/10.1017/S0007114511007343 Derscheid, L. E., Umoren, J., Kim, S. Y., Henry, B. W., & Zittel, L. L. (2010). Early childhood teachers’ and staff members’ perceptions of nutrition and physical activity practices for preschoolers. Journal of Research in Childhood Education, 24(3), 248–265. https://doi.org/10.1080/02568543.2010.487405 Eliassen, E. K. (2011). The impact of teachers and families on young children’s eating behaviors. YC Young Children, 66(2), 84–89. Elliott, E., Isaacs, M., & Chugani, C. (2010). Promoting Self-Efficacy in Early Career Teachers: A Principal’s Guide for Differentiated Mentoring and Supervision. Florida Journal of Educational Administration & Policy, 4(1), 131–146. Emm, S., Harris, J., Halterman, J., Chvilicek, S., & Bishop, C. (2019). Increasing Fruit and Vegetable Intake with Reservation and Off-reservation Kindergarten Students in Nevada. Journal of Agriculture, Food Systems, and Community Development, 9, 1–10. https://doi.org/10.5304/jafscd.2019.09b.014 Flynn, M. A. T. (2015). Empowering people to be healthier: Public health nutrition through the Ottawa Charter. Proceedings of the Nutrition Society, 74(3), 303–312. https://doi.org/10.1017/S002966511400161X Franciscato, S. J., Janson, G., Machado, R., Lauris, J. R. P., de Andrade, S. M. J., & Fisberg, M. (2019). Impact of the nutrition education Program Nutriamigos® on levels of awareness on healthy eating habits in school-aged children. Journal of Human Growth and Development, 29(3), 390–402. https://doi.org/10.7322/jhgd.v29.9538 Froehlich Chow, A., & Humbert, M. L. (2014). Perceptions of early childhood educators: Factors influencing the promotion of physical activity opportunities in Canadian rural care centers. Child Indicators Research, 7(1), 57–73. https://doi.org/10.1007/s12187-013-9202-x Graham, H., Feenstra, G., Evans, A. M., & Zidenberg-Cherr, S. (2002). Healthy Eating Habits in Children. California Agriculture, 58(4), 200–205. Gucciardi, E., Nagel, R., Szwiega, S., Chow, B. Y. Y., Barker, C., Nezon, J., ... Butler, A. (2019). Evaluation of a Sensory-Based Food Education Program on Fruit and V egetable Consumption among Kindergarten Children. Journal of Child Nutrition & Management, 43(1). Holley, C. E., Farrow, C., & Haycraft, E. (2017). A Systematic Review of Methods for Increasing Vegetable Consumption in Early Childhood. Current Nutrition Reports, 6(2), 157–170. https://doi.org/10.1007/s13668-017-0202-1 Hoppu, U., Prinz, M., Ojansivu, P., Laaksonen, O., & Sandell, M. A. (2015). Impact of sensory- based food education in kindergarten on willingness to eat vegetables and berries. Food and Nutrition Research, 59, 1–8. https://doi.org/10.3402/fnr.v59.28795 Jarpe-Ratner, E., Folkens, S., Sharma, S., Daro, D., & Edens, N. K. (2016). An Experiential Cooking and Nutrition Education Program Increases Cooking Self-Efficacy and Vegetable Consumption in Children in Grades 3–8. Journal of Nutrition Education and Behavior, 48(10), 697-705.e1. https://doi.org/10.1016/j.jneb.2016.07.021 Jones, A. M., & Zidenberg-Cherr, S. (2015). Exploring Nutrition Education Resources and Barriers, and Nutrition Knowledge in Teachers in California. Journal of Nutrition Education and Behavior, 47(2), 162–169. https://doi.org/10.1016/j.jneb.2014.06.011 Jung, T., Huang, J., Eagan, L., & Oldenburg, D. (2019). Influence of school-based nutrition education program on healthy eating literacy and healthy food choice among primary school children. International Journal of Health Promotion and Education, 57(2), 67–81. https://doi.org/10.1080/14635240.2018.1552177 Lwin, M. O., Malik, S., Ridwan, H., & Sum Au, C. S. (2017). Media exposure and parental mediation on fast-food consumption among children in metropolitan and suburban Indonesian. Asia Pacific Journal of Clinical Nutrition, 26(5), 899–905. https://doi.org/10.6133/apjcn.122016.04 Mc Kenna, & L, M. (2010). Policy Options to Support Healthy Eating in Schools. Canadian Journal of Public Health, 101(2), S14–S18. https://doi.org/10.1007/BF03405619 Menkes, R. PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA NOMOR 41 TAHUN 2014. , Menteri Kesehatan Republik Indonesia § (2014). Mitsopoulou, A. V., Magriplis, E., Dimakopoulos, I., Karageorgou, D., Bakogianni, I., Micha, R., ... Zampelas, A. (2019). Association of meal and snack patterns with micronutrient intakes among Greek children and adolescents: data from the Hellenic National Nutrition and Health Survey. Journal of Human Nutrition and Dietetics, 32(4), 455–467. https://doi.org/10.1111/jhn.12639 Moffitt, A. (2019). Early Childhood Educators and the Development of Family Literacy Programs: A Qualitative Case Study. ProQuest Dissertations and Theses, 96. Retrieved from http://proxy.mul.missouri.edu/login?url=https://search.proquest.com/docview/2242479347 ?accountid=14576%0Ahttps://library.missouri.edu/findit?genre=dissertations+%26+theses &title=Early+Childhood+Educators+and+the+Development+of+Family+Literacy+Progra ms%3A+ Mustonen, S., & Tuorila, H. (2010). Sensory education decreases food neophobia score and encourages trying unfamiliar foods in 8-12-year-old children. Food Quality and Preference, 21(4), 353–360. https://doi.org/10.1016/j.foodqual.2009.09.001 Myszkowska-Ryciak, J., & Harton, A. (2019). Eating healthy, growing healthy: Outcome evaluation of the nutrition education program optimizing the nutritional value of preschool menus, Poland. Nutrients, 11(10), 1–17. https://doi.org/10.3390/nu11102438 Nekitsing, C., Hetherington, M. M., & Blundell-Birtill, P. (2018). Developing Healthy Food Preferences in Preschool Children Through Taste Exposure, Sensory Learning, and Nutrition Education. Current Obesity Reports, 7(1), 60–67. https://doi.org/10.1007/s13679- 018-0297-8 Noura, M. S. pd. (2018). Child nutrition programs in kindergarten schools implemented by the governmental sector and global nutrition consulting companies: A systematic review. Current Research in Nutrition and Food Science, 6(3), 656–663. https://doi.org/10.12944/CRNFSJ.6.3.07 Oh, S. M., Yu, Y. L., Choi, H. I., & Kim, K. W. (2012). Implementation and Evaluation of Nutrition Education Programs Focusing on Increasing Vegetables, Fruits and Dairy Foods Consumption for Preschool Children. Korean Journal of Community Nutrition, 17(5), 517. https://doi.org/10.5720/kjcn.2012.17.5.517 Osera, T., Tsutie, S., & Kobayashi, M. (2016). Using Soybean Products in School Lunch for Health Education may improve Children’s Attitude and Guardians’ Knowledge in Kindergarten. Journal of Child and Adolescent Behaviour, 04(05). https://doi.org/10.4172/2375-4494.1000310 Park, B. K., & Cho, M. S. (2016). Taste education reduces food neophobia and increases willingness to try novel foods in school children. Nutrition Research and Practice, 10(2), 221–228. https://doi.org/10.4162/nrp.2016.10.2.221 Pendidikan, K., & Kebudayaan, D. A. N. Menteri Pendidikan Dan Kebudayaan Republik Indonesia Nomor 137 Tahun 2013 Tentang Standar Nasional Pendidikan Anak Usia Dini. , (2015). Prima, E., Yuliantina, I., Nurfadillah, Handayani, I., Riana, & Ganesa, R. eni. (2017). Layanan Kesehatan,Gizi dan Perawatan. Jakarta: Direktorat Pembinaan Pendidikan Anak Usia Dini Direktorat Jenderal Pendidikan Anak Usia Dini dan Pendidikan Masyarakat Kementerian Pendidikan dan Kebudayaan. Resor, J., Hegde, A. V., & Stage, V. C. (2020). Pre-service early childhood educators’ perceived barriers and supports to nutrition education. Journal of Early Childhood Teacher Education, 00(00), 1–17. https://doi.org/10.1080/10901027.2020.1740841 Rizqie Aulianaca5804p200-169314. (2011). Gizi Seimbang Dan Makanan Sehat Untuk Anak Usia Dini. Journal of Nutrition and Food Research, 2(1), 1–12. Retrieved from http://staff.uny.ac.id/sites/default/files/pengabdian/rizqie-auliana-dra-mkes/gizi-seimbang- dan-makanan-sehat-untuk-anak-usia-dini.pdf Sandell, M., Mikkelsen, B. E., Lyytikäinen, A., Ojansivu, P., Hoppu, U., Hillgrén, A., & Lagström, H. (2016). Future for food education of children. Futures, 83, 15–23. https://doi.org/10.1016/j.futures.2016.04.006 Schanzenbach, D. W., & Thorn, B. (2019). Food Support Programs and Their Impacts on Young Children. Health Affairs, (march). Retrieved from https://www.healthaffairs.org/briefs Schmitt, S. A., Bryant, L. M., Korucu, I., Kirkham, L., Katare, B., & Benjamin, T. (2019). The effects of a nutrition education curriculum on improving young children’s fruit and vegetable preferences and nutrition and health knowledge. Public Health Nutrition, 22(1), 28–34. https://doi.org/10.1017/S1368980018002586 Sekiyama, M., Roosita, K., & Ohtsuka, R. (2012). Snack foods consumption contributes to poor nutrition of rural children in West Java, Indonesia. Asia Pacific Journal of Clinical Nutrition, 21(4), 558–567. https://doi.org/10.6133/apjcn.2012.21.4.11 Sepp, H., & Ho, K. (2016). Food as a tool for learning in everyday activities at preschool exploratory study from Sweden. Food & Nurtition Research, 1, 1–7. Shor, R., & Friedman, A. (2009). Integration of nutrition-related components by early childhood education professionals into their individual work with children at risk. Early Child Development and Care, 179(4), 477–486. https://doi.org/10.1080/03004430701269218 Taylor, C. M., & Emmett, P. M. (2019). Picky eating in children: Causes and consequences. Proceedings of the Nutrition Society, 78(2), 161–169. https://doi.org/10.1017/S0029665118002586 Taylor, C. M., Steer, C. D., Hays, N. P., & Emmett, P. M. (2019). Growth and body composition in children who are picky eaters: a longitudinal view. European Journal of Clinical Nutrition, 73(6), 869–878. https://doi.org/10.1038/s41430-018-0250-7 Unusan, N. (2007). Effects of a food and nutrition course on the self-reported knowledge and behavior of preschool teacher candidates. Early Childhood Education Journal, 34(5), 323– 327. https://doi.org/10.1007/s10643-006-0116-9 Usfar, A. A., Iswarawanti, D. N., Davelyna, D., & Dillon, D. (2010). Food and Personal Hygiene Perceptions and Practices among Caregivers Whose Children Have Diarrhea: A Qualitative Study of Urban Mothers in Tangerang, Indonesia. Journal of Nutrition Education and Behavior, 42(1), 33–40. https://doi.org/10.1016/j.jneb.2009.03.003 Witt, K. E., & Dunn, C. (2012). Increasing Fruit and V egetable Consumption among Preschoolers: Evaluation of Color Me Healthy. Journal of Nutrition Education and Behavior, 44(2), 107–113. https://doi.org/10.1016/j.jneb.2011.01.002

The aim of the present study was to evaluate the protective effects of linseed oil on lipid peroxidation, antioxidative capacity, as well as serum glucose, total cholesterol (TC), LDL-C and TG levels, in cafeteria-diet-fed dams during gestation and lactation, and in their offspring throughout adulthood. Food and energy intakes were also evaluated. The cafeteria diet led to higher energy intake, body weight, hyperglycemia and hyperlipidemia (higher TC, LDL-C and TG) in dams’ rats and their pups. Plasma vitamin C, Erythrocyte GSH levels and catalase activity were lower, whereas plasma diene conjugates (DC), Malondialdehyde and protein carbonyl levels (PC) in plasma and erythrocytes were higher in cafeteria-diet-fed mothers and their pups compared to controls. Supplement of linseed oil significantly enhanced plasma antioxidant defense capacities, as evaluated by the marked increase in the levels of plasma vitamin C and erythrocyte GSH as well as the activities of CAT and the significant reduction in lipid peroxidation (lower DC and MDA) and PC in CAFL-diet-fed mothers and their offspring. Simultaneous intake of linseed oil also reduced body weight, plasma TG, TC and LDL-C contents in obese pregnant and lactating dams and their pups at day 30 and day 90. The flaxseed oil supplementation may prevent lipid peroxidation and metabolic disorders which might be helpful in preventing obesity complications in mothers during pregnancy and lactation and in their offspring. REFERENCES:Adeoye, O., Olawumi, J., Opeyemi, A., & Christiania, O. (2016). Review on the role ofglutathione on oxidative stress and infertility. JBRA Assisted Reproduction, 22(1), 61-66.Aebi, H. (1974). Catalase. 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ABSTRACT Finger millet (Eleusine coracana (L) commonly known as ragi is an important crop used for food, forage and industrial products. Finger millet has a wide ecological and geographical adaptability and resilience to various agro-climatic adversities hence, it is highly suited to drought condition and marginal land and requires low external input in cultivation.. Farmers participatory field demonstrations of ragi variety Arjun and Bhairabi were conducted at two villages ie Pedawada of Malkangiri block and MPV -1 of Kalimela block of Malkangiri district, comprising 40 farmers in cluster approach in Kharif 2018 and 2019 , by Krishi Vigyan Kendra, Malkangiri , in South Eastern Ghat Zone of Odisha . Conducting front line demonstrations on farmer’s field help to identify the constraints and potential of the finger millet in the specific area as well as it helps in improving the economic and social status of the farmers. Observation on growth and yield parameters were taken and economic analysis was done. The final seed yield was recorded at the time of harvest and the gross return in (Rs ha -1) was calculated based on prevailing market prices. The results from the demonstration conclusively proved that finger millet variety Arjun (OEB-526) recorded the higher yield ( 18.8 q ha-1) , followed by Bhairabi ( 15.3 q ha-1) and farmer’s traditional variety Nali Mandia ( Dasaraberi) recorded an average yield of (8.6 q ha-1 ) . HYV Finger millet variety Arjun with proper nutrient management and plant protection measures gave 118 % higher over farmer’s practices. The technological and extension gap was 1.9 q ha-1 and 12.07 q ha-1 respectively. Similarly, technological index was 8.2 percent. The benefit cost ratio was 2.4 and 1.9 in case of Arjun and Bhairabi respectively and in case of farmer’s variety Nali Mandia it was 1.4. Hence the existing local finger millet variety can be replaced by HYV Arjun ans Bhairabi , since it fits good to the existing rainfed farming situation for higher productivity. By conducting front line demonstrations on millet on large scale in farmer’s field, yield potential of finger millet can be enhanced largely which will increase in the income level of farmers and improve the livelihood condition of the farming community. Introduction Among small millets, finger millet (Elusine coracana L,) locally known as Ragi/Mandia is the most important crop grown in tribal districts of Odisha and it is the staple food of the tribals. It was originated about 5000 years ago in east Africa (possibly Ethiopia) and was introduced into India, 3000 years ago (Upadhyaya et al., 2006) and it is highly suited to drought condition and marginal land and requires low external input in cultivation. Millet is a collective term referring to a number of small seeded annual grasses that are cultivated as grain crops, primarily on marginal lands in dry areas in temperate, subtropical and tropical regions (Baker, 1996). Nutritionally finger millet is superior to major cereal crops and rich source of micronutrients such as calcium, phosphorous, magnesium and iron. And it has several health benefits. Finger millet grains contain higher amount of proteins, oils and minerals than the grains of rice, maize or sorghum (Reed et al., 1976). Vadivoo and Joseph (1998) mentioned finger millet grains contain 13.24% moisture, 7.6% protein, 74.36% carbohydrate, 74.36% carbon, 1.52% dietary fiber, 2.35% minerals, 1.35% fat and energy 341.6 cal/100g. (Joshi and Katoch, 1990; Ravindran, 1991). It is a rich source of micronutrients such as calcium, phosphorus, magnesium and iron. Cysteine, tyrosine, tryptophan and methionine are the right spectrum of amino acids found in finger millet protein (Rachie, 1975). The increase in global temperature leads to climate changes that directly affect crop production and increase people's hunger and malnutrition around the world.. With regard to protein (6-8%) and fat (1-2%) it is comparable to rice and with respect to mineral and micronutrient contents it is superior to rice and wheat (Babu et al., 1987). It is also known for several health benefits such as anti-diabetic, anti-tumerogenic, atherosclerogenic effects, antioxidant, which are mainly attributed due to its polyphenol and dietary fiber contents. Being indigenous minor millet it is used in the preparation of various foods both in natural and malted forms. Grains of this millet are converted into flours for preparation of products like porridge, puddings, pancakes, biscuits, roti, bread, noodles, and other snacks. Besides this, it is also used as a nourishing food for infants when malted and is regarded as wholesome food for diabetic's patients. Diversification of food production must be encouraged both at national and household level in tandem with increasing yields. Growing of traditional food crops suitable for the area is one of the possible potential successful approaches for improving household food security. Malkangiri is one of the seven districts where a flagship programme called “Special Programme for Promotion of Millets in Tribal Areas of Odisha (hereafter, Odisha Millets Mission, (OMM)” has been launched by Department of Agriculture and Farmers Empowerment, Odisha in order to revive millets in rainfed farming systems and household consumption. It was started in kharif 2017 in four blocks of the district, namely Chitrakonda, Korkunda, Mathili and Khairiput. The Government of Odisha launched Odisha Millets Mission (OMM) also known as the Special Programme for Promotion of Millets in Tribal Areas of Odisha in 2017 to revive millets in farms and on plates. The aim was to tackle malnutrition by introducing millets in the public distribution system (PDS) and other state nutrition schemes. The focus is on reviving millets in farms and putting it on plates.” Millet, a nutritious and climate-resilient crop, has traditionally been cultivated and consumed by tribal communities in the rainfed regions of southern Odisha. Technology gap, i.e. poor knowledge about newly released crop production and protection technologies and their management practices in the farmers’ fields is a major constraint in Ragi production. So far, no systematic approach was implemented to study the technological gap existing in various components of Ragi cultivation. Awareness of scientific production technology like HYV of ragi, seed treatment with fungicide, use of insecticide and bio-fertilizers, is lacking in Malkangiri district which were a key reason for low productivity. The production potential could be increased by adopting recommended scientific and sustainable management production practices with improved high yielding varieties and timely use of other critical inputs. Objective The field experiment was undertaken to study the performance of three finger millet varieties Local Mandia (Nali Mandia), Bhairabi and Arjun in rainfed upland situation in kharif season. The present investigation was undertaken to evaluate the field performance of newly released finger millet varieties Arjun and Bhairabi under rainfed condition. The demonstrations were carried out in Malkangiri district covering two villages like Pedawada and MPV-6 to find out the existing technological and extension gap along with technology index with an objective to popularize the ragi varieties having higher yield potential. Material and methods The study was carried out in operational area of Krishi Vigyan Kendra (KVK), Malkangiri during Kharif season in the year 2018 and 2019. The study was under taken in Malkangiri and Kalimela blocks of Malkangiri district of Odisha and the blocks were selected purposefully as Finger millet is the major cereals crop grown in large area in Kharif season. The demonstrations were conducted in two different adopted villages Pedawada and MPV-6 in cluster approach. The Front Line Demonstration (FLD) is an applied approach to accelerate the dissemination of proven technologies at farmer’s fields in a participatory mode with an objective to explore the maximum available resources of crop production and also to bridge the productivity gaps by enhancing the production in national basket.The necessary steps for selection of site and farmers and layout of demonstrations etc were followed as suggested by Choudhary (1999). Forty numbers front line demonstrations on HYV Ragi were conducted in two clusters comprising 40 numbers of farmers. All the participating farmers were trained on various aspects of Ragi production technologies and recommended agronomic practices and certified seeds of Ragi variety Arjun and Bhairabi were used for demonstration. The soil of demonstration site was slightly acidic in reaction (pH-5.0 to 5.25) with sandy loam in texture and EC was 0.134 (dS m −1). The available nitrogen, phosphorus and potassium was between 214 .00, 22 .00, 142 .00 (Kg ha−1) respectively with 0.48 (%) Organic Carbon. The crop was sown in under rainfed condition in the first to second week of July. The crop was raised with recommended agronomic practices and harvested within 4th week of November up to 2nd week of December. Krishi Vigyan Kendra ( KVK), Malkangiri conducted front line demonstration with HYV varieties like Bhiarabi and Arjun and farmer’ local var Dasaraberi as check Finger millet Variety Arjun (OEB-526) is having Maturity duration 110 days and average yield 20.7q/ha with moderate resistance to leaf, neck and finger blast and brown seed and Bhairabi is a HYV of Ragi with Maturity duration 110 days and average yield 17.6 q/ha. Moderate resistance to leaf, neck blast and brown seeded and protein content 81%. Local variety Dsaraberi or Nali Mandia is having 105 days duration and drought tolerant variety used as farmers variety as local check . The technologies demonstrated were as follows: Popularization of high yielding Ragi variety, Seed treatment with Trichoderma viride @ 4g kg-1 seed , Line sowing with, soil test based fertilizer application along with need based plant protection measures. The field was ploughed two times and planking was done after each plugging, Need based plant protection measures were taken; along with soil test based fertilizer application was done with fertilizer dose 40:30:60 kg. N: P2O5: K2O kg ha -1. In case of local checks existing practices being used by farmers were followed. The observations were recorded for various parameters of the crop. The farmers’ practices were maintained in case of local checks. The field observations were taken from demonstration plot and farmer’s plot as well. Parameters like Plant height, number of fingers per plant, length of finger , no of fingers per year, 1000 seed weight and seed yield were recorded at maturity stage and the gross returns (Rs ha -1 ) were calculated on the basis of prevailing market price of the produce. The extension gap, technology gap, technology index along with B: C ratio was calculated and the data were statistically analyzed applying the statistical techniques. Statistical tools such as percentage, mean score, Standard deviation, co-efficient of variation, Fisher‘s “F” test, were employed for analysis of data. The farmer’s practices (FP) plots were maintained as local check for comparison study. The data obtained from intervention practices (IP) and famers practices (FP) were analyzed for extension gap, technological gap, technological index and benefit cost ratio study as per (Samui et al., 2000) as given below. Technology gap = Pi (Potential yield) - Di (Demonstration yield) Extension gap = Di (Demonstration Yield) - Fi (Farmers yield) Technology index = X 100 Result and Discussion The results obtained from the present investigation are summarized below. The Table 1 depicts the major differences observed between demonstration package and farmer’s practices in ragi production in the study area. The major differences were observed between demonstration package and farmer’s practices were regarding recommended varieties, seed treatment, soil test based fertilizer application, keeping optimum plant population by thinning, weed management and plant protection measures. The data of Table 1 shows that under the demonstrated plot only recommended high yielding variety, proper weeding and optimum plant population maintaining by thinning and the farmers used herbicides and the farmers timely performed all the other package and practices. It was also observed that farmers were unaware about balanced fertilizer application, seed treatment, and use of fertilizers application and maintenance of plant population for enhancing the yield. Majority of the farmers in the study area were unaware about use of weed management practices. The findings are in corroborated with the findings of (Katar et al., 2011) From the Table 2 it was revealed that in the district Malkangiri the productivity of finger millet was 6.38 (q ha-1) as compare to state average productivity 8.67 (q ha-1), but there exists a gap between potential yield and farmers yield, which can be minimized by adoption High yielding varieties with improved management practices. The productivity of finger millet was very low in the district as the crop is mostly grown along the hillsides on sloppy land on light textured soil. It was also coupled with negligence in adoption of improved varieties no input like fertilizers use and no plant protection measures and improper method and time of sowing. However, there is a wide gap between the Potential and the actual production realized by the farmers due to partial adoption of recommended package of practices by the growers. Several constraints contributed to yield fluctuation on Ragi production, including: unreliable rainfall; lack of high yielding variety ,disease tolerant varieties; pests and diseases incidence; low producer prices; poor agronomic practices; and lack of institutional support (Bucheyeki et al., 2008; Okoko et al., 1998). One of the central problems of ragi production and processing in this district is due to an uncertain production environment owing to rain fed cultivation, the low resource base of smallholder farmers and processors, and no scope for post harvest management and value addition facilities and poor marketing facility. The results clearly indicated from the Table 3 that the positive effects of FLDs over the existing practices. HYV Ragi Arjun recorded higher yield 18.8(q ha-1) followed by Bhairabi 15.53 (q ha-1) which was 21 % more and the yield performance of these two HYV varieties was higher than the farmer’s variety. This is due to higher of panicle length, more number of tillers and more number of fingers per panicle in HYV of ragi as compared to local variety. The results are in conformity with the findings of (Tomar et al. , 2003). The results clearly indicated the positive effects of FLDs over the existing practices towards enhancing the productivity. It is revealed form table 4 that, as the calculated ‘F’ value at α=0.05 level was found to be larger than table value, indicating significant difference in yield between farmer’s variety and recommended varieties. There was significant difference between average yield of ragi under Farmers practice (FP) and Recommended practice (RP) in variety Arjun under this demonstration. It was concluded that the yield of these HYV ragi varieties was significantly higher as compared to farmer’s variety. The economics and B:C ratio of farmers practice and Demonstration practice has been presented in Table 6. From the table it was revealed that Benefit: Cost ratio (B:C) was recorded to be higher under demonstrations against control treatments during all the years of experimentation. The cost of cultivation in HYV variety was higher due to more labour cost involved in transplanting and also it included cost of fertilizers and plant protection chemicals and also net returns was higher as compared to farmer’s practice. The B: C ratio was found to be 2.4 in case of variety Arjun as compared to 1.9 in case of variety Bhairabi. The results on economic analysis indicated that HYV ragi Arjun and Bhairabi performed better than local variety Ragi. The HYV variety Arjun recorded higher gross return upto Rs 54,332 and followed by Bhairabi Rs 44,289 per ha which was significantly higher than farmers practice and it was due to higher productivity of varieties under demonstration. Conclusion The results revealed that in Malkangiri district finger millet variety Arjun rerecorded highest yield followed by Variety Bhirabi with proper package and practices under rainfed upland condition. From the above study it was concluded that use of finger millet varieties like Arjun or Bhairabi with scientific methods and technological practices of can reduce the technological gap and enhance the productivity in the district. Yield improvement in Finger Millet in the demonstration was due to use of HYV seed and scientific management practices adopted by the farmers. Yield of Finger Millet can be increased to a great extent by conducting effective front line demonstrations in larger area with proven technologies. Finger millet is one of future smart food crop of India and can be grown in the drought condition. This crop is rich in nutrient for food insecurity and within few years because of increase in population of world and depletion of area of production.. The principal reasons of lower productivity of finger millet in the district Malkangiri were lack of knowledge among the farmers about cultivation of HYV finger millet varieties and improper fertilization, late season sowing and severe weed infestation in crop at critical stages. From the above findings, it can be concluded that use of scientific methods of Finger millet cultivation can reduce the technology gap to a considerable extent thus leading to increased productivity of millets in the district. 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Morphological diversity in finger millet germplasm introduced from Southern and Eastern. African Journal of SAT Agriculture Research. 2007, 3(1). ejournal.icrisat.org. Vadivoo, A.S.; Joseph, R. Genetic variability and diversity for protein and calcium contents in finger millet (Elusine coracona (L.) Gaertn) in relation to grain color. Plant Foods for Human Nutrition Dordrecht. 1998, 52, 353-364. Department of Botany, Avinashilingam Institute for Home Science and Higher Education for Women, Deemed University, Coimbatore, TN, 641 043, India.

The purpose of this article is to clarify the policy and legal provisions in the development of high-quality human resources (H-Q HR) in the field of education. A number of studies have shown that policies and laws play an important role in developing H-Q HR, but it is also a barrier if the policies and laws are not suitable for the actual development of the country. This research focuses on analyzing the real situation of H-Q HR in the field of education and training, pointing out the major successes and limitations in this field; at the same time, systematizing some practical and theoretical issues, analyzing the current situation of laws, and policies and on the development of H-Q HR in the field of education and training. From there, provide basic views and solutions to improve policies and laws on develop Cisco and Oxford Economics. (2018). Technology and the future of ASEAN jobs: the impacts of AI on workers in ASEAN’s six largest economies. https://www.cisco. com/c/dam/global/en_sg/assets/csr/pdf/technology-andthe-future-of-asean-jobs.pdf Communist Party of Vietnam. (2011). Document of the XIth NPC. Hanoi: National Politics Truth. Communist Party of Vietnam. (2016). Document of the XIIth NPC. Hanoi: National Politics Truth. Communist Party of Vietnam. (2021a). Document of the XIIIth NPC, vol 1. Hanoi: National Politics Truth. Communist Party of Vietnam. (2021b). Document of the XIIIth NPC, vol 2. Hanoi: National Politics Truth. Frederick Harbison and Charles A. Myers. (1964). Education, manpower, and economic growth: Strategies of human resource development. New York: McGraw - Hill. FAO/WHO. (1992). The Role of Nutrition in Social and Economic Development. Retrieved from https://www.fao.org/3/y5343e/y5343e04.htm (2020). Decree No. 112/2020/ND-CP on disciplining cadres, civil servants, and public employees. General Statistics Office. (2021). Press release on the employment situation in the fourth quarter of 2021 and Vietnam Human Development Index 2016 – 2020. Retrieved from https://www.gso.gov.vn/du-lieu-va-so-lieu%20-thong-ke/2022/01/thong-cao-bao-chi-tinh-hinh-lao-dong-viec-lam-quy-iv-nam-2021-va-chi-so-phat-trien-child-people%20-viet-nam-2016-2020/,%20January%206,%202022 Hai, T. N. (2021). Policy on development of Vietnamese intellectuals - viewed from Resolution 27, term X. Journal of Propaganda. Retrieved from http://tapchimattran.vn/nghien-cuu/chinh-sach-phat-trien-doi-ngu-tri-thuc-viet-nam-nhin-tu-nghi-quyet-27-khoa-x-42283.html V. Van. (2022). Management of educational activities in schools towards the approach of learners’ competency: a case study of a high school. Nuances: Estudos Sobre Educação, 32(00), e021005. https://doi.org/10.32930/nuances.v32i00.9118. V. Van., & Hiep, H. D. (2019). Innovating teaching and learning methods to improve the quality of human resource training in Vietnam today. International Journal of Science and Research 8 (8), 1853-1861. DOI: 10.21275/ART2020713 V. Van. (2022). The State's Legal Policy and Management on Civil Servants: The Current Situation and Issues Raised. International Journal of Early Childhood Special Education, 14(3). DOI: 10.9756/INT-JECSE/V14I3.688 Hang, L. T., & Van, V. H. (2020). Building Strong Teaching and Learning Strategies through Teaching Innovations and Learners’ Creativity: A Study of Vietnam Universities. International Journal of Education and Practice, 8(3), 498–510. https://doi.org/10.18488/journal.61.2020.83.498.510 Hieu, N. (2022). Building a team of intellectuals in the current era. State Organization Magazine. Retrieved from https://tcnn.vn/news/detail/40902/Xay_dung_doi_ngu_tri_thuc_trong_thoi_dai_hien_nayall.html Hoduc, H., Vothanh, H., &Vuhong, V. (2022). The changes in education policy in the context of educational innovation in Vietnam. Revista on Line De Política E GestãoEducacional, 26(esp.1), e022043. https://doi.org/10.22633/rpge.v26iesp.1.16772 HongVan, V (2020). Identify Methods of Teaching and Learning to Create Interest, Self-Study, And Creativity of Students. Humanities & Social Sciences Reviews, 8(3), 646-656. https://doi.org/10.18510/hssr.2020.8369. International Labor Organization. (2022). The open economy changes the form, distribution and quality of Vietnamese jobs. Retrieved from https://www.ilo.org/hanoi/Informationresources/Publicinformation/comments-and-analysis/WCMS_736066/lang--en/index.htm,%2011-2-2022 Schwab. (2016). The Fourth Industrial Revolution: what it means, how to respond https://www.weforum.org/agenda/2016/01/the-fourth-industrial-revolution-what-it-means-and-how-to-respond/ Luongngoc, V., & Vuhong, V. (2022). Research and teaching of marxism-leninism at the universities: The requirements, difficulties and recommended solutions. Nuances: Estudos Sobre Educação, 33(00), e022011. https://doi.org/10.32930/nuances.v33i00.9489 Mai, V.T.P. (2012). Renovate the remuneration policy for H-Q HR, creating a driving force to promote the cause of industrialization and modernization in the spirit of the XIth Party Congress. Communist Journale (online). Minh, H. C. (2011): Complete Volume, Volume 5. Hanoi: National Politics Truth. National Assembly of the Socialist Republic of Vietnam. (2008). Law on cadres and civil servants (Law No. 22/2008/QH12). Hanoi. National Assembly of the Socialist Republic of Vietnam. (2010). Law on Public Officials (Law No. 58/2010/QH12). Hanoi. National Assembly of the Socialist Republic of Vietnam. (2014). Law on Organization of the National Assembly (Law No. 57/2014/QH13). Hanoi. National Assembly of the Socialist Republic of Vietnam. (2015). Law on Organization of Local Government (Law No. 77/2015/QH13). Hanoi. National Assembly of the Socialist Republic of Vietnam. (2012). Labor Code (Law No. 10/2012/QH13). Hanoi. National Assembly of the Socialist Republic of Vietnam. (2019a). Amending and supplementing a number of articles of the Law on cadres and civil servants and the Law on public employees (Law No. 52/2019/QH14). Hanoi. National Assembly of the Socialist Republic of Vietnam. (2019b). Law on Education (Law No. 43/2019/QH14). Hanoi. National Assembly of the Socialist Republic of Vietnam. (2019c). Labor Code (Law No. 45/2019/QH14). Hanoi. Party Central Committee. (2021). Conclusion No. 21-KL/TW on accelerating the rectification of the Party and political system, strictly handling cadres who have degraded in ideology, morality, and lifestyle, and exhibiting “self-evolution” and “self-transformation”. Hanoi. OECD/ERIA (2018). SME Policy Index: ASEAN 2018: Boosting Competitiveness and Inclusive Growth. OECD Publishing, Paris/Economic Research Institute for ASEAN and East Asia, Jakarta. https://doi. org/10.1787/9789264305328-en The National Council directs the compilation of the Vietnam Encyclopedia. (2005). Encyclopedic dictionary. Hanoi: Encyclopedia Dictionary. The Politburo. (2011). Resolution No. 08-NQ/TW, issued on December 1, 2011, on “Strengthening the leadership of the Party, creating a strong change in physical training and sports until 2020”. Hanoi. Theodore W.Schultz (1961). Investment in human capital. USA: The American Economic Review. Trung, N. S., & Van, V. H. (2020). Educating Traditional Cultural Values in Vietnam Universities. South Asian Research Journal of Humanities and Social Sciences 2(3), pp. 210-214. Trung, N. S., & Van, V. H. (2020). Vietnamese Cultural Identity in the Process of International Integration. Journal of Advances in Education and Philosophy 4(6), pp. 220- 225. Truong P. X. Anh, T. T. (2019). National human resource development strategy in the world and lessons learned for Vietnam. VNU Journal of Science: Policy and Management Studies, 35(3), pp. 12-20. Vuhong. (2021). Managing traffic safety education activities in primary and y schools: status, necessity, and influencing factors. Revista on Line De Política E GestãoEducacional, 25(3), 2535–2551. https://doi.org/10.22633/rpge.v25i3.15840 Van, V. H. (2022a). The State's Legal Policy and Management on Civil Servants: The Current Situation and Issues Raised. International Journal of Early Childhood Special Education, 14(3). DOI: 10.9756/INT-JECSE/V14I3.688 Van, V. H. (2022b). Education policy in the context of Vietnam’s international integration: Problems raised and proposed solutions. International Journal of Health Sciences, 6(S4), 3562–3571. https://doi.org/10.53730/ijhs.v6nS4.9019 VNIES. (2018). 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The UP Manila Health Policy Development Hub recognizes the invaluable contribution of the participants in theseries of roundtable discussions listed below: RTD: Beyond Hospital Beds: Equity,quality, and service1. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, UP Manila2. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, UP Manila3. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, UP Manila4. Hilton Y. Lam, MHA, PhD, Chair, UP Manila HealthPolicy Development Hub; Director, Institute of HealthPolicy and Development Studies, University of thePhilippines Manila5. Irma L. Asuncion, MHA, CESO III, Director IV,Bureau of Local Health Systems Development,Department of Health6. Renely Pangilinan-Tungol, MD, CFP, MPM-HSD,Municipal Health Officer, San Fernando, Pampanga7. Salome F. Arinduque, MD, Galing-Pook AwardeeRepresentative, Municipal Health Officer, San Felipe,Zambales8. Carmelita C. Canila, MD, MPH, Faculty, College ofPublic Health, University of the Philippines Manila9. Lester M. Tan, MD, MPH, Division Chief, Bureau ofLocal Health System Development, Department ofHealth10. Anthony Rosendo G. Faraon, MD, Vice President,Zuellig Family Foundation (ZFF)11. Albert Francis E. Domingo, MD, Consultant, HealthSystem strengthening through Public Policy andRegulation, World Health Organization12. Jesus Randy O. Cañal, MD, FPSO-HNS, AssociateDirector, Medical and Regulatory Affairs, AsianHospital and Medical Center13. Christian Edward L. Nuevo, Health Policy and SystemsResearch Fellow, Health Policy Development andPlanning Bureau, Department of Health14. Paolo Victor N. Medina, MD, Assistant Professor 4,College of Medicine, University of the PhilippinesManila15. Jose Rafael A. Marfori, MD, Special Assistant to theDirector, Philippine General Hospital16. Maria Teresa U. Bagaman, Committee Chair, PhilippineSociety for Quality, Inc.17. Maria Theresa G. Vera, MSc, MHA, CESO III, DirectorIV, Health Facility Development Bureau, Departmentof Health18. Ana Melissa F. Hilvano-Cabungcal, MD, AssistantAssociate Dean for Planning & Development, Collegeof Medicine, University of the Philippines Manila19. Fevi Rose C. Paro, Faculty, Department of Communityand Environmental Resource Planning, University ofthe Philippines Los Baños20. Maria Rosa C. Abad, MD, Medical Specialist III,Standard Development Division, Health Facilities andServices Regulation21. Yolanda R. Robles, RPh, PhD, Faculty, College ofPharmacy, University of the Philippines Manila22. Jaya P. Ebuen, RN, Development Manager Officer,CHDMM, Department of Health23. Josephine E. Cariaso, MA, RN, Assistant Professor,College of Nursing, University of the Philippines Manila24. Diana Van Daele, Programme Manager, CooperationSection, European Union25. Maria Paz de Sagun, Project Management Specialist,USAID26. Christopher Muñoz, Member, Yellow Warriors SocietyPhilippinesRTD: Health services and financingroles: Population based- andindividual-based1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, University of thePhilippines Manila3. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, University of thePhilippines Manila4. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, University of the PhilippinesManila5. Mario C. Villaverde, Undersecretary, Health Policyand Development Systems and Development Team,Department of Health6. Jaime Z. Galvez Tan, MD, Former Secretary, Department of Health7. Marvin C. Galvez, MD, OIC Division Chief, BenefitsDevelopment and Research Department, PhilippineHealth Insurance Corporation8. Alvin B. Caballes, MD, MPE, MPP, Faculty, Collegeof Medicine, University of the Philippines Manila9. Carlos D. Da Silva, Executive Director, Association ofMunicipal Health Maintenance Organization of thePhilippines, Inc.10. Anthony Rosendo G. Faraon, MD, Vice President,Zuellig Family Foundation (ZFF) 11. Albert Francis E. Domingo, MD, Consultant, HealthSystem strengthening through Public Policy andRegulation, World Health Organization12. Salome F. Arinduque, MD, Galing-Pook AwardeeRepresentative, Municipal Health Officer, San Felipe,Zambales13. Michael Ralph M. Abrigo, PhD, Research Fellow,Philippine Institute for Developmental Studies14. Oscar D. Tinio, MD, Committee Chair, Legislation,Philippine Medical Association15. Rogelio V. Dazo, Jr., MD, FPCOM, Legislation,Philippine Medical Association16. Ligaya V. Catadman, MM, Officer-in-charge, HealthPolicy Development and Planning Bureau, Department of Health17. Maria Fatima Garcia-Lorenzo, President, PhilippineAlliance of Patients Organization18. Tomasito P. Javate, Jr, Supervising Economic DevelopmentSpecialist, Health Nutrition and Population Division,National Economic and Development Authority19. Josefina Isidro-Lapena, MD, National Board ofDirector, Philippine Academy of Family Physicians20. Maria Eliza Ruiz-Aguila, MPhty, PhD, Dean, Collegeof Allied Medical Professions, University of thePhilippines Manila21. Ana Melissa F. Hilvano-Cabungcal, MD, AssistantAssociate Dean for Planning & Development, College ofMedicine, University of the Philippines Manila22. Maria Paz P. Corrales, MD, MHA, MPA, Director III,Department of Health-National Capital Region23. Karin Estepa Garcia, MD, Executive Secretary, PhilippineAcademy of Family Physicians24. Adeline A. Mesina, MD, Medical Specialist III,Philippine Health Insurance Corporation25. Glorey Ann P. Alde, RN, MPH, Research Fellow,Department of HealthRTD: Moving towards provincelevel integration throughUniversal Health Care Act1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, University of thePhilippines Manila3. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, University of thePhilippines Manila4. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, University of the PhilippinesManila5. Mario C. Villaverde, Undersecretary of Health, HealthPolicy and Development Systems and DevelopmentTeam, Department of Health6. Ferdinand A. Pecson, Undersecretary and ExecutiveDirector, Public Private Partnership Center7. Rosanna M. Buccahan, MD, Provincial Health Officer,Bataan Provincial Office8. Lester M. Tan, MD, Division Chief, Bureau of LocalHealth System Development, Department of Health9. Ernesto O. Domingo, MD, FPCP, FPSF, FormerChancellor, University of the Philippines Manila10. Albert Francis E. Domingo, MD, Consultant, HealthSystem strengthening through Public Policy andRegulation, World Health Organization11. Leslie Ann L. Luces, MD, Provincial Health Officer,Aklan12. Rene C. Catan, MD, Provincial Health Officer, Cebu13. Anthony Rosendo G. Faraon, MD, Vice President,Zuellig Family Foundation14. Jose Rafael A. Marfori, MD, Special Assistant to theDirector, Philippine General Hospital15. Jesus Randy O. Cañal, MD, FPSO-HNS, Consultant,Asian Hospital and Medical Center16. Ramon Paterno, MD, Member, Universal Health CareStudy Group, University of the Philippines Manila17. Mayor Eunice U. Babalcon, Mayor, Paranas, Samar18. Zorayda E. Leopando, MD, Former President,Philippine Academy of Family Physicians19. Madeleine de Rosas-Valera, MD, MScIH, SeniorTechnical Consultant, World Bank20. Arlene C. Sebastian, MD, Municipal Health Officer,Sta. Monica, Siargao Island, Mindanao21. Rizza Majella L. Herrera, MD, Acting Senior Manager,Accreditation Department, Philippine Health InsuranceCorporation22. Alvin B. Caballes, MD, MPE, MPP, Faculty, Collegeof Medicine, University of the Philippines Manila23. Pres. Policarpio B. Joves, MD, MPH, MOH, FPAFP,President, Philippine Academy of Family Physicians24. Leilanie A. Nicodemus, MD, Board of Director,Philippine Academy of Family Physicians25. Maria Paz P. Corrales, MD, MHA, MPA, Director III,National Capital Region Office, Department of Health26. Dir. Irma L. Asuncion, MD, MHA, CESO III, DirectorIV, Bureau of Local Health Systems Development,Department of Health27. Bernard B. Argamosa, MD, Mental Health Representative, National Center for Mental Health28. Flerida Chan, Chief, Poverty Reduction Section, JapanInternational Cooperation Agency29. Raul R. Alamis, Chief Health Program Officer, ServiceDelivery Network, Department of Health30. Mary Anne Milliscent B. Castro, Supervising HealthProgram Officer, Department of Health 31. Marikris Florenz N. Garcia, Project Manager, PublicPrivate Partnership Center32. Mary Grace G. Darunday, Supervising Budget andManagement Specialist, Budget and Management Bureaufor the Human Development Sector, Department ofBudget and Management33. Belinda Cater, Senior Budget and Management Specialist,Department of Budget and Management34. Sheryl N. Macalipay, LGU Officer IV, Bureau of LocalGovernment and Development, Department of Interiorand Local Government35. Kristel Faye M. Roderos, OTRP, Representative,College of Allied Medical Professions, University ofthe Philippines Manila36. Jeffrey I. Manalo, Director III, Policy Formulation,Project Evaluation and Monitoring Service, PublicPrivate Partnership Center37. Atty. Phebean Belle A. Ramos-Lacuna, Division Chief,Policy Formulation Division, Public Private PartnershipCenter38. Ricardo Benjamin D. Osorio, Planning Officer, PolicyFormulation, Project Evaluation and MonitoringService, Public Private Partnership Center39. Gladys Rabacal, Program Officer, Japan InternationalCooperation Agency40. Michael Angelo Baluyot, Nurse, Bataan Provincial Office41. Jonna Jane Javier Austria, Nurse, Bataan Provincial Office42. Heidee Buenaventura, MD, Associate Director, ZuelligFamily Foundation43. Dominique L. Monido, Policy Associate, Zuellig FamilyFoundation44. Rosa Nene De Lima-Estellana, RN, MD, Medical OfficerIII, Department of Interior and Local Government45. Ma Lourdes Sangalang-Yap, MD, FPCR, Medical OfficerIV, Department of Interior and Local Government46. Ana Melissa F. Hilvano-Cabungcal, MD, AssistantAssociate Dean for Planning & Development, College ofMedicine, University of the Philippines Manila47. Colleen T. Francisco, Representative, Department ofBudget and Management48. Kristine Galamgam, Representative, Department ofHealth49. Fides S. Basco, Officer-in-charge, Chief Budget andManagement Specialist, Development of Budget andManagementRTD: Health financing: Co-paymentsand Personnel1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, University of thePhilippines Manila3. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, University of thePhilippines Manila4. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, University of the Philippines Manila5. Ernesto O. Domingo, MD, Professor Emeritus,University of the Philippines Manila6. Irma L. Asuncion, MHA, CESO III, Director IV,Bureau of Local Health Systems Development,Department of Health7. Lester M. Tan, MD, MPH, Division Chief, Bureau ofLocal Health System Development, Department ofHealth8. Marvin C. Galvez, MD, OIC Division Chief, BenefitsDevelopment and Research Department, PhilippineHealth Insurance Corporation9. Adeline A. Mesina, MD, Medical Specialist III, BenefitsDepartment and Research Department, PhilippineHealth Insurance Corporation10. Carlos D. Da Silva, Executive Director, Association ofHealth Maintenance Organization of the Philippines,Inc.11. Ma. Margarita Lat-Luna, MD, Deputy Director, FiscalServices, Philippine General Hospital12. Waldemar V. Galindo, MD, Chief of Clinics, Ospital ngMaynila13. Albert Francis E. Domingo, MD, Consultant, HealthSystem strengthening through Public Policy andRegulation, World Health Organization14. Rogelio V. Dazo, Jr., MD, Member, Commission onLegislation, Philippine Medical Association15. Aileen R. Espina, MD, Board Member, PhilippineAcademy of Family Physicians16. Anthony R. Faraon, MD, Vice President, Zuellig FamilyFoundation17. Jesus Randy O. Cañal, Associate Director, Medical andRegulatory Affairs, Asian Hospital and Medical Center18. Jared Martin Clarianes, Technical Officer, Union of LocalAuthorities of the Philippines19. Leslie Ann L. Luces, MD, Provincial Health Officer,Aklan20. Rosa Nene De Lima-Estellana, MD, Medical OfficerIII, Department of the Interior and Local Government21. Ma. Lourdes Sangalang-Yap, MD, Medical Officer V,Department of the Interior and Local Government 22. Dominique L. Monido, Policy Associate, Zuellig FamilyFoundation23. Krisch Trine D. Ramos, MD, Medical Officer, PhilippineCharity Sweepstakes Office24. Larry R. Cedro, MD, Assistant General Manager, CharitySector, Philippine Charity Sweepstakes Office25. Margarita V. Hing, Officer in Charge, ManagementDivision, Financial Management Service Sector,Department of Health26. Dr. Carlo Irwin Panelo, Associate Professor, College ofMedicine, University of the Philippines Manila27. Dr. Angelita V. Larin, Faculty, College of Public Health,University of the Philippines Manila28. Dr. Abdel Jeffri A. Abdulla, Chair, RegionalizationProgram, University of the Philippines Manila29. Christopher S. Muñoz, Member, Philippine Alliance ofPatients Organization30. Gemma R. Macatangay, LGOO V, Department ofInterior and Local Government – Bureau of LocalGovernment Development31. Dr. Narisa Portia J. Sugay, Acting Vice President, QualityAssurance Group, Philippine Health InsuranceCorporation32. Maria Eliza R. Aguila, Dean, College of Allied MedicalProfessions, University of the Philippines Manila33. Angeli A. Comia, Manager, Zuellig Family Foundation34. Leo Alcantara, Union of Local Authorities of thePhilippines35. Dr. Zorayda E. Leopando, Former President, PhilippineAcademy of Family Physicians36. Dr. Emerito Jose Faraon, Faculty, College of PublicHealth, University of the Philippines Manila37. Dr. Carmelita C. Canila, Faculty, College of PublicHealth, University of the Philippines ManilaRTD: Moving towards third partyaccreditation for health facilities1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, University of thePhilippines Manila3. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, University of thePhilippines Manila4. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, University of the PhilippinesManila5. Rizza Majella L. Herrera, MD, Acting SeniorManager, Accreditation Department, Philippine HealthInsurance Corporation6. Bernadette C. Hogar-Manlapat, MD, FPBA, FPSA,FPSQua, MMPA, President and Board of Trustee,Philippine Society for Quality in Healthcare, Inc.7. Waldemar V. Galindo, MD, Chief of Clinics, Ospital ngMaynila8. Amor. F. Lahoz, Division Chief, Promotion andDocumentation Division, Department of Trade andIndustry – Philippine Accreditation Bureau9. Jenebert P. Opinion, Development Specialist, Department of Trade and Industry – Philippine AccreditationBureau10. Maria Linda G. Buhat, President, Association ofNursing Service Administrators of the Philippines, Inc.11. Bernardino A. Vicente, MD, FPPA, MHA, CESOIV, President, Philippine Tripartite Accreditation forHealth Facilities, Inc.12. Atty. Bu C. Castro, MD, Board Member, PhilippineHospital Association13. Cristina Lagao-Caalim, RN, MAN, MHA, ImmediatePast President and Board of Trustee, Philippine Societyfor Quality in Healthcare, Inc.14. Manuel E. Villegas Jr., MD, Vice Treasurer and Board ofTrustee, Philippine Society for Quality in Healthcare,Inc.15. Michelle A. Arban, Treasurer and Board of Trustee,Philippine Society for Quality in Healthcare, Inc.16. Joselito R. Chavez, MD, FPCP, FPCCP, FACCP,CESE, Deputy Executive Director, Medical Services,National Kidney and Transplant Institute17. Blesilda A. Gutierrez, CPA, MBA, Deputy ExecutiveDirector, Administrative Services, National Kidney andTransplant Institute18. Eulalia C. Magpusao, MD, Associate Director, Qualityand Patient Safety, St. Luke’s Medical Centre GlobalCity19. Clemencia D. Bondoc, MD, Auditor, Association ofMunicipal Health Officers of the Philippines20. Jesus Randy O. Cañal, MD, FPSO-HNS, AssociateDirector, Medical and Regulatory Affairs, Asian Hospitaland Medical Center21. Maria Fatima Garcia-Lorenzo, President, PhilippineAlliance of Patient Organizations22. Leilanie A. Nicodemus, MD, Board of Directors,Philippine Academy of Family Physicians23. Policarpio B. Joves Jr., MD, President, PhilippineAcademy of Family Physicians24. Kristel Faye Roderos, Faculty, College of Allied MedicalProfessions, University of the Philippines Manila25. Ana Melissa Hilvano-Cabungcal, MD, AssistantAssociate Dean, College of Medicine, University of thePhilippines Manila26. Christopher Malorre Calaquian, MD, Faculty, Collegeof Medicine, University of the Philippines Manila27. Emerito Jose C. Faraon, MD, Faculty, College ofPublic Health, University of the Philippines Manila 28. Carmelita Canila, Faculty, College of Public Health,University of the Philippines Manila29. Oscar D. Tinio, MD, Representative, Philippine MedicalAssociation30. Farrah Rocamora, Member, Philippine Society forQuality in Healthcare, IncRTD: RA 11036 (Mental Health Act):Addressing Mental Health Needs ofOverseas Filipino Workers1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Leonardo R. Estacio, Jr., MCD, MPH, PhD, UPManila Health Policy Development Hub; College ofArts and Sciences, UP Manila3. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD, UPManila Health Policy Development Hub; College ofPublic Health, UP Manila4. Michael Antonio F. Mendoza, DDM, UP ManilaHealth Policy Development Hub; College of Dentistry,UP Manila5. Frances Prescilla L. Cuevas, RN, MAN, Director,Essential Non-Communicable Diseases Division,Department of Health6. Maria Teresa D. De los Santos, Workers Education andMonitoring Division, Philippine Overseas EmploymentAdministration7. Andrelyn R. Gregorio, Policy Program and Development Office,Overseas Workers Welfare Administration8. Sally D. Bongalonta, MA, Institute of Family Life &Children Studies, Philippine Women’s University9. Consul Ferdinand P. Flores, Department of ForeignAffairs10. Jerome Alcantara, BLAS OPLE Policy Center andTraining Institute11. Andrea Luisa C. Anolin, Commission on FilipinoOverseas12. Bernard B. Argamosa, MD, DSBPP, National Centerfor Mental Health13. Agnes Joy L. Casino, MD, DSBPP, National Centerfor Mental Health14. Ryan Roberto E. Delos Reyes, Employment Promotionand Workers Welfare Division, Department of Laborand Employment15. Sheralee Bondad, Legal and International AffairsCluster, Department of Labor and Employment16. Rhodora A. Abano, Center for Migrant Advocacy17. Nina Evita Q. Guzman, Ugnayan at Tulong para saMaralitang Pamilya (UGAT) Foundation, Inc.18. Katrina S. Ching, Ugnayan at Tulong para sa MaralitangPamilya (UGAT) Foundation, Inc.RTD: (Bitter) Sweet Smile of Filipinos1. Dr. Hilton Y. Lam, Institute of Health Policy andDevelopment Studies, NIH2. Dr. Leonardo R. Estacio, Jr., College of Arts andSciences, UP Manila3. Dr. Ma. Esmeralda C. Silva, College of Public Health,UP Manila4. Dr. Michael Antonio F. Mendoza, College of Dentistry,UP Manila5. Dr. Ma. Susan T. Yanga-Mabunga, Department ofHealth Policy & Administration, UP Manila6. Dr. Danilo L. Magtanong, College of Dentistry, UPManila7. Dr. Alvin Munoz Laxamana, Philippine DentalAssociation8. Dr. Fina Lopez, Philippine Pediatric Dental Society, Inc9. Dr. Artemio Licos, Jr.,Department of Health NationalAssociation of Dentists10. Dr. Maria Jona D. Godoy, Professional RegulationCommission11. Ms. Anna Liza De Leon, Philippine Health InsuranceCorporation12. Ms. Nicole Sigmuend, GIZ Fit for School13. Ms. Lita Orbillo, Disease Prevention and Control Bureau14. Mr. Raymond Oxcena Akap sa Bata Philippines15. Dr. Jessica Rebueno-Santos, Department of CommunityDentistry, UP Manila16. Ms. Maria Olivine M. Contreras, Bureau of LocalGovernment Supervision, DILG17. Ms. Janel Christine Mendoza, Philippine DentalStudents Association18. Mr. Eric Raymund Yu, UP College of DentistryStudent Council19. Dr. Joy Memorando, Philippine Pediatric Society20. Dr. Sharon Alvarez, Philippine Association of DentalColleges

Background “The sense of taste,” write Nelson and colleagues in a 2002 issue of Nature, “provides animals with valuable information about the nature and quality of food. Mammals can recognize and respond to a diverse repertoire of chemical entities, including sugars, salts, acids and a wide range of toxic substances” (199). The authors go on to argue that several amino acids—the building blocks of proteins—taste delicious to humans and that “having a taste pathway dedicated to their detection probably had significant evolutionary implications”. They imply, but do not specify, that the evolutionary implications are positive. This may be the case with some amino acids, but contemporary tastes, and changes in them, are far from universally beneficial. Indeed, this article argues that modern food production shapes and distorts human taste with significant implications for health and wellbeing. Take the western taste for fried chipped potatoes, for example. According to Schlosser in Fast Food Nation, “In 1960, the typical American ate eighty-one pounds of fresh potatoes and about four pounds of frozen french fries. Today [2002] the typical American eats about forty-nine pounds of fresh potatoes every year—and more than thirty pounds of frozen french fries” (115). Nine-tenths of these chips are consumed in fast food restaurants which use mass-manufactured potato-based frozen products to provide this major “foodservice item” more quickly and cheaply than the equivalent dish prepared from raw ingredients. These choices, informed by human taste buds, have negative evolutionary implications, as does the apparently long-lasting consumer preference for fried goods cooked in trans-fats. “Numerous foods acquire their elastic properties (i.e., snap, mouth-feel, and hardness) from the colloidal fat crystal network comprised primarily of trans- and saturated fats. These hardstock fats contribute, along with numerous other factors, to the global epidemics related to metabolic syndrome and cardiovascular disease,” argues Michael A. Rogers (747). Policy makers and public health organisations continue to compare notes internationally about the best ways in which to persuade manufacturers and fast food purveyors to reduce the use of these trans-fats in their products (L’Abbé et al.), however, most manufacturers resist. Hank Cardello, a former fast food executive, argues that “many products are designed for ‘high hedonic value’, with carefully balanced combinations of salt, sugar and fat that, experience has shown, induce people to eat more” (quoted, Trivedi 41). Fortunately for the manufactured food industry, salt and sugar also help to preserve food, effectively prolonging the shelf life of pre-prepared and packaged goods. Physiological Factors As Glanz et al. discovered when surveying 2,967 adult Americans, “taste is the most important influence on their food choices, followed by cost” (1118). A person’s taste is to some extent an individual response to food stimuli, but the tongue’s taste buds respond to five basic categories of food: salty, sweet, sour, bitter, and umami. ‘Umami’ is a Japanese word indicating “delicious savoury taste” (Coughlan 11) and it is triggered by the amino acid glutamate. Japanese professor Kikunae Ikeda identified glutamate while investigating the taste of a particular seaweed which he believed was neither sweet, sour, bitter, or salty. When Ikeda combined the glutamate taste essence with sodium he formed the food additive sodium glutamate, which was patented in 1908 and subsequently went into commercial production (Japan Patent Office). Although individual, a person’s taste preferences are by no means fixed. There is ample evidence that people’s tastes are being distorted by modern food marketing practices that process foods to make them increasingly appealing to the average palate. In particular, this industrialisation of food promotes the growth of a snack market driven by salty and sugary foods, popularly constructed as posing a threat to health and wellbeing. “[E]xpanding waistlines [are] fuelled by a boom in fast food and a decline in physical activity” writes Stark, who reports upon the 2008 launch of a study into Australia’s future ‘fat bomb’. As Deborah Lupton notes, such reports were a particular feature of the mid 2000s when: intense concern about the ‘obesity epidemic’ intensified and peaked. Time magazine named 2004 ‘The Year of Obesity’. That year the World Health Organization’s Global Strategy on Diet, Physical Activity and Health was released and the [US] Centers for Disease Control predicted that a poor diet and lack of exercise would soon claim more lives than tobacco-related disease in the United States. (4) The American Heart Association recommends eating no more than 1500mg of salt per day (Hamzelou 11) but salt consumption in the USA averages more than twice this quantity, at 3500mg per day (Bernstein and Willett 1178). In the UK, a sustained campaign and public health-driven engagement with food manufacturers by CASH—Consensus Action on Salt and Health—resulted in a reduction of between 30 and 40 percent of added salt in processed foods between 2001 and 2011, with a knock-on 15 percent decline in the UK population’s salt intake overall. This is the largest reduction achieved by any developed nation (Brinsden et al.). “According to the [UK’s] National Institute for Health and Care Excellence (NICE), this will have reduced [UK] stroke and heart attack deaths by a minimum of 9,000 per year, with a saving in health care costs of at least £1.5bn a year” (MacGregor and Pombo). Whereas there has been some success over the past decade in reducing the amount of salt consumed, in the Western world the consumption of sugar continues to rise, as a graph cited in the New Scientist indicates (O’Callaghan). Regular warnings that sugar is associated with a range of health threats and delivers empty calories devoid of nutrition have failed to halt the increase in sugar consumption. Further, although some sugar is a natural product, processed foods tend to use a form invented in 1957: high-fructose corn syrup (HFCS). “HFCS is a gloopy solution of glucose and fructose” writes O’Callaghan, adding that it is “as sweet as table sugar but has typically been about 30% cheaper”. She cites Serge Ahmed, a French neuroscientist, as arguing that in a world of food sufficiency people do not need to consume more, so they need to be enticed to overeat by making food more pleasurable. Ahmed was part of a team that ran an experiment with cocaine-addicted rats, offering them a mutually exclusive choice between highly-sweetened water and cocaine: Our findings clearly indicate that intense sweetness can surpass cocaine reward, even in drug-sensitized and -addicted individuals. We speculate that the addictive potential of intense sweetness results from an inborn hypersensitivity to sweet tastants. In most mammals, including rats and humans, sweet receptors evolved in ancestral environments poor in sugars and are thus not adapted to high concentrations of sweet tastants. The supranormal stimulation of these receptors by sugar-rich diets, such as those now widely available in modern societies, would generate a supranormal reward signal in the brain, with the potential to override self-control mechanisms and thus lead to addiction. (Lenoir et al.) The Tongue and the Brain One of the implications of this research about the mammalian desire for sugar is that our taste for food is about more than how these foods actually taste in the mouth on our tongues. It is also about the neural response to the food we eat. The taste of French fries thus also includes that “snap, mouth-feel, and hardness” and the “colloidal fat crystal network” (Rogers, “Novel Structuring” 747). While there is no taste receptor for fats, these nutrients have important effects upon the brain. Wang et al. offered rats a highly fatty, but palatable, diet and allowed them to eat freely. 33 percent of the calories in the food were delivered via fat, compared with 21 percent in a normal diet. The animals almost doubled their usual calorific intake, both because the food had a 37 percent increased calorific content and also because the rats ate 47 percent more than was standard (2786). The research team discovered that in as little as three days the rats “had already lost almost all of their ability to respond to leptin” (Martindale 27). Leptin is a hormone that acts on the brain to communicate feelings of fullness, and is thus important in assisting animals to maintain a healthy body weight. The rats had also become insulin resistant. “Severe resistance to the metabolic effects of both leptin and insulin ensued after just 3 days of overfeeding” (Wang et al. 2786). Fast food restaurants typically offer highly palatable, high fat, high sugar, high salt, calorific foods which can deliver 130 percent of a day’s recommended fat intake, and almost a day’s worth of an adult man’s calories, in one meal. The impacts of maintaining such a diet over a comparatively short time-frame have been recorded in documentaries such as Super Size Me (Spurlock). The after effects of what we widely call “junk food” are also evident in rat studies. Neuroscientist Paul Kenny, who like Ahmed was investigating possible similarities between food- and cocaine-addicted rats, allowed his animals unlimited access to both rat ‘junk food’ and healthy food for rats. He then changed their diets. “The rats with unlimited access to junk food essentially went on a hunger strike. ‘It was as if they had become averse to healthy food’, says Kenny. It took two weeks before the animals began eating as much [healthy food] as those in the control group” (quoted, Trivedi 40). Developing a taste for certain food is consequently about much more than how they taste in the mouth; it constitutes an individual’s response to a mixture of taste, hormonal reactions and physiological changes. Choosing Health Glanz et al. conclude their study by commenting that “campaigns attempting to change people’s perception of the importance of nutrition will be interpreted in terms of existing values and beliefs. A more promising strategy might be to stress the good taste of healthful foods” (1126). Interestingly, this is the strategy already adopted by some health-focused cookbooks. I have 66 cookery books in my kitchen. None of ten books sampled from the five spaces in which these books are kept had ‘taste’ as an index entry, but three books had ‘taste’ in their titles: The Higher Taste, Taste of Life, and The Taste of Health. All three books seek to promote healthy eating, and they all date from the mid-1980s. It might be that taste is not mentioned in cookbook indexes because it is a sine qua non: a focus upon taste is so necessary and fundamental to a cookbook that it goes without saying. Yet, as the physiological evidence makes clear, what we find palatable is highly mutable, varying between people, and capable of changing significantly in comparatively short periods of time. The good news from the research studies is that the changes wrought by high salt, high sugar, high fat diets need not be permanent. Luciano Rossetti, one of the authors on Wang et al’s paper, told Martindale that the physiological changes are reversible, but added a note of caution: “the fatter a person becomes the more resistant they will be to the effects of leptin and the harder it is to reverse those effects” (27). Morgan Spurlock’s experience also indicates this. In his case it took the actor/director 14 months to lose the 11.1 kg (13 percent of his body mass) that he gained in the 30 days of his fast-food-only experiment. Trivedi was more fortunate, stating that, “After two weeks of going cold turkey, I can report I have successfully kicked my ice cream habit” (41). A reader’s letter in response to Trivedi’s article echoes this observation. She writes that “the best way to stop the craving was to switch to a diet of vegetables, seeds, nuts and fruits with a small amount of fish”, adding that “cravings stopped in just a week or two, and the diet was so effective that I no longer crave junk food even when it is in front of me” (Mackeown). Popular culture indicates a range of alternative ways to resist food manufacturers. In the West, there is a growing emphasis on organic farming methods and produce (Guthman), on sl called Urban Agriculture in the inner cities (Mason and Knowd), on farmers’ markets, where consumers can meet the producers of the food they eat (Guthrie et al.), and on the work of advocates of ‘real’ food, such as Jamie Oliver (Warrin). Food and wine festivals promote gourmet tourism along with an emphasis upon the quality of the food consumed, and consumption as a peak experience (Hall and Sharples), while environmental perspectives prompt awareness of ‘food miles’ (Weber and Matthews), fair trade (Getz and Shreck) and of land degradation, animal suffering, and the inequitable use of resources in the creation of the everyday Western diet (Dare, Costello and Green). The burgeoning of these different approaches has helped to stimulate a commensurate growth in relevant disciplinary fields such as Food Studies (Wessell and Brien). One thing that all these new ways of looking at food and taste have in common is that they are options for people who feel they have the right to choose what and when to eat; and to consume the tastes they prefer. This is not true of all groups of people in all countries. Hiding behind the public health campaigns that encourage people to exercise and eat fresh fruit and vegetables are the hidden “social determinants of health: The conditions in which people are born, grow, live, work and age, including the health system” (WHO 45). As the definitions explain, it is the “social determinants of health [that] are mostly responsible for health iniquities” with evidence from all countries around the world demonstrating that “in general, the lower an individual’s socioeconomic position, the worse his or her health” (WHO 45). For the comparatively disadvantaged, it may not be the taste of fast food that attracts them but the combination of price and convenience. If there is no ready access to cooking facilities, or safe food storage, or if a caregiver is simply too time-poor to plan and prepare meals for a family, junk food becomes a sensible choice and its palatability an added bonus. For those with the education, desire, and opportunity to break free of the taste for salty and sugary fats, however, there are a range of strategies to achieve this. There is a persuasive array of evidence that embracing a plant-based diet confers a multitude of health benefits for the individual, for the planet and for the animals whose lives and welfare would otherwise be sacrificed to feed us (Green, Costello and Dare). Such a choice does involve losing the taste for foods which make up the lion’s share of the Western diet, but any sense of deprivation only lasts for a short time. The fact is that our sense of taste responds to the stimuli offered. It may be that, notwithstanding the desires of Jamie Oliver and the like, a particular child never will never get to like broccoli, but it is also the case that broccoli tastes differently to me, seven years after becoming a vegan, than it ever did in the years in which I was omnivorous. When people tell me that they would love to adopt a plant-based diet but could not possibly give up cheese, it is difficult to reassure them that the pleasure they get now from that specific cocktail of salty fats will be more than compensated for by the sheer exhilaration of eating crisp, fresh fruits and vegetables in the future. Conclusion For decades, the mass market food industry has tweaked their products to make them hyper-palatable and difficult to resist. They do this through marketing experiments and consumer behaviour research, schooling taste buds and brains to anticipate and relish specific cocktails of sweet fats (cakes, biscuits, chocolate, ice cream) and salty fats (chips, hamburgers, cheese, salted nuts). They add ingredients to make these products stimulate taste buds more effectively, while also producing cheaper items with longer life on the shelves, reducing spoilage and the complexity of storage for retailers. Consumers are trained to like the tastes of these foods. Bitter, sour, and umami receptors are comparatively under-stimulated, with sweet, salty, and fat-based tastes favoured in their place. Western societies pay the price for this learned preference in high blood pressure, high cholesterol, diabetes, and obesity. Public health advocate Bruce Neal and colleagues, working to reduce added salt in processed foods, note that the food and manufacturing industries can now provide most of the calories that the world needs to survive. “The challenge now”, they argue, “is to have these same industries provide foods that support long and healthy adult lives. And in this regard there remains a very considerable way to go”. If the public were to believe that their sense of taste is mutable and has been distorted for corporate and industrial gain, and if they were to demand greater access to natural foods in their unprocessed state, then that journey towards a healthier future might be far less protracted than these and many other researchers seem to believe. References Bernstein, Adam, and Walter Willett. “Trends in 24-Hr Sodium Excretion in the United States, 1957–2003: A Systematic Review.” American Journal of Clinical Nutrition 92 (2010): 1172–1180. Bhaktivedanta Book Trust. The Higher Taste: A Guide to Gourmet Vegetarian Cooking and a Karma-Free Diet, over 60 Famous Hare Krishna Recipes. Botany, NSW: Bhaktivedanta Book Trust, 1987. Brinsden, Hannah C., Feng J. He, Katharine H. Jenner, & Graham A. MacGregor. “Surveys of the Salt Content in UK Bread: Progress Made and Further Reductions Possible.” British Medical Journal Open 3.6 (2013). 2 Feb. 2014 ‹http://bmjopen.bmj.com/content/3/6/e002936.full›. Coughlan, Andy. “In Good Taste.” New Scientist 2223 (2000): 11. Dare, Julie, Leesa Costello, and Lelia Green. “Nutritional Narratives: Examining Perspectives on Plant Based Diets in the Context of Dominant Western Discourse”. Proceedings of the 2013 Australian and New Zealand Communication Association Conference. Ed. In Terence Lee, Kathryn Trees, and Renae Desai. Fremantle, Western Australia, 3-5 Jul. 2013. 2 Feb. 2014 ‹http://www.anzca.net/conferences/past-conferences/159.html›. Getz, Christy, and Aimee Shreck. “What Organic and Fair Trade Labels Do Not Tell Us: Towards a Place‐Based Understanding of Certification.” International Journal of Consumer Studies 30.5 (2006): 490–501. Glanz, Karen, Michael Basil, Edward Maibach, Jeanne Goldberg, & Dan Snyder. “Why Americans Eat What They Do: Taste, Nutrition, Cost, Convenience, and Weight Control Concerns as Influences on Food Consumption.” Journal of the American Dietetic Association 98.10 (1988): 1118–1126. Green, Lelia, Leesa Costello, and Julie Dare. “Veganism, Health Expectancy, and the Communication of Sustainability.” Australian Journal of Communication 37.3 (2010): 87–102 Guthman, Julie. Agrarian Dreams: the Paradox of Organic Farming in California. Berkley and Los Angeles, CA: U of California P, 2004 Guthrie, John, Anna Guthrie, Rob Lawson, & Alan Cameron. “Farmers’ Markets: The Small Business Counter-Revolution in Food Production and Retailing.” British Food Journal 108.7 (2006): 560–573. Hall, Colin Michael, and Liz Sharples. Eds. Food and Wine Festivals and Events Around the World: Development, Management and Markets. Oxford, UK: Routledge, 2008. Hamzelou, Jessica. “Taste Bud Trickery Needed to Cut Salt Intake.” New Scientist 2799 (2011): 11. Japan Patent Office. History of Industrial Property Rights, Ten Japanese Great Inventors: Kikunae Ikeda: Sodium Glutamate. Tokyo: Japan Patent Office, 2002. L’Abbé, Mary R., S. Stender, C. M. Skeaff, Ghafoorunissa, & M. Tavella. “Approaches to Removing Trans Fats from the Food Supply in Industrialized and Developing Countries.” European Journal of Clinical Nutrition 63 (2009): S50–S67. Lenoir, Magalie, Fuschia Serre, Lauriane Cantin, & Serge H. Ahmed. “Intense Sweetness Surpasses Cocaine Reward.” PLOS One (2007). 2 Feb. 2014 ‹http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0000698›. Lupton, Deborah. Fat. Oxford, UK: Routledge, 2013. MacGregor, Graham, and Sonia Pombo. “The Amount of Hidden Sugar in Your Diet Might Shock You.” The Conversation 9 January (2014). 2 Feb. 2014 ‹http://theconversation.com/the-amount-of-hidden-sugar-in-your-diet-might-shock-you-21867›. Mackeown, Elizabeth. “Cold Turkey?” [Letter]. New Scientist 2787 (2010): 31. Martindale, Diane. “Burgers on the Brain.” New Scientist 2380 (2003): 26–29. Mason, David, and Ian Knowd. “The Emergence of Urban Agriculture: Sydney, Australia.” The International Journal of Agricultural Sustainability 8.1–2 (2010): 62–71. Neal, Bruce, Jacqui Webster, and Sebastien Czernichow. “Sanguine About Salt Reduction.” European Journal of Preventative Cardiology 19.6 (2011): 1324–1325. Nelson, Greg, Jayaram Chandrashekar, Mark A. Hoon, Luxin Feng, Grace Zhao, Nicholas J. P. Ryba, & Charles S. Zuker. “An Amino-Acid Taste Receptor.” Nature 416 (2002): 199–202. O’Callaghan, Tiffany. “Sugar on Trial: What You Really Need to Know.” New Scientist 2954 (2011): 34–39. 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Wang, Jiali, Silvana Obici, Kimyata Morgan, Nir Barzilai, Zhaohui Feng, & Luciano Rossetti. “Overfeeding Rapidly Increases Leptin and Insulin Resistance.” Diabetes 50.12 (2001): 2786–2791. Warin, Megan. “Foucault’s Progeny: Jamie Oliver and the Art of Governing Obesity.” Social Theory & Health 9.1 (2011): 24–40. Weber, Christopher L., and H. Scott Matthews. “Food-miles and the Relative Climate Impacts of Food Choices in the United States.” Environmental Science & Technology 42.10 (2008): 3508–3513. Wessell, Adele, and Donna Lee Brien. Eds. Rewriting the Menu: the Cultural Dynamics of Contemporary Food Choices. Special Issue 9, TEXT: Journal of Writing and Writing Programs October 2010. World Health Organisation. Closing the Gap: Policy into Practice on Social Determinants of Health [Discussion Paper]. Rio de Janeiro, Brazil: World Conference on Social Determinants of Health, World Health Organisation, 19–21 October 2011.

Dear Colleagues, In the previous editorial paper published by Balat et al. [1] as an Early View Article a few months ago, it was reported that there were changes in the Editorial Team of the European Journal of Therapeutics (Eur J Ther). During these few months, while the preparations for the new issue (June 2023, volume 29, Issue 2) continued, the editorial board also was revised. We would like to inform you that the Editorial Board has been strengthened by academics who are competent in their fields from many countries of the world and will continue to be strengthened in the future. As it is known, Eur J Ther started broadcasting in 1990 as a Journal of the Faculty of Medicine University of Gaziantep (In Turkish: Gaziantep Üniversitesi Tıp Fakültesi Dergisi). In the first paper titled “While Starting” (In Turkish: Başlarken) of the first issue, Prof. Sabri Güngör, who was the first Editor-in-Chief, stated that the aim of the journal is to have an influential place in the field of science [2]. Over the past three decades, the journal has continued to advance. At the present time, it is inevitable to reorganise the editorial board of the journal and enrich it with leading international editors in order to move the journal to better places. This editorial will explain essential developments in the journal in the last few months, and the new Editorial Board Members of the Eur J Ther will be introduced. Changes are inevitable, and we are delighted to announce that this issue marks several significant improvements. Specifically, we bolstered our editorial team with esteemed international academics and expanded our pool of referees. Consequently, the evaluation period for the submitted articles was significantly reduced. In the last two months, the journal metrics are as follows: Acceptance rate: %29 Average time until the final decision: 24.4 days Average time to publish as Accepted/Early View Article, after acceptance: 4.8 days. Thanks to these improvements, as you will notice, there are 25 articles in this issue. In this way, this issue has been the issue in which most articles have been published so far. In addition, applications were made to DOAJ (Directory of Open Access Journals) and BASE (Bielefeld Academic Search Engine), among the most essential open-access databases in the world, in May 2023. Moreover, cited references to the previous and/or alternative names of the journal (Gaziantep Medical Journal, Gaziantep Med J, Gaziantep Tıp Dergisi and Gaziantep Üniversitesi Tıp Fakültesi Dergisi) in Web of Science that were not reflected in the journal metrics were identified and reported to the Web of Science. Some of these correction requests have been finalized and corrected, and thus the total number of citations and the H-index of the journal increased [3]. After all these data are updated, it will be seen that the citation values of the Eur J Ther will increase even more. We will also update the guidelines for the authors and reviewers with respect to the ICMJE [4] and EQUATOR Network [5], which will enhance the quality of research in the medical fraternity. Additionally, the use of DOI for articles published in the journal started in 2011 (2011, volume 17, Issue 2). In order to facilitate the recognition and access of the articles, DOIs have also been defined for all articles published in previous issues. Editors Ayşe Balat, MD, became the new Editor-in-Chief of Eur J Ther for the second time, the first between 2007-2010. She is a Professor in Pediatrics and a specialist in Pediatric Nephrology and Rheumatology. She has been working as Vice President of Gaziantep University since October 2020. She was the Dean of Gaziantep University Medical Faculty (2007-2010), President of the Mediterranean Kidney Society (MKS) between 2015 to 2018, and Secretary beginning in 2018. She is also President of the International Association for the History of Nephrology (IAHN) since 2022. In Gaziantep, she first established Pediatric Nephrology and Pediatric Rheumatology Units, and the first peritoneal dialysis was performed by her. She has several studies published in international and national peer-reviewed scientific journals (H-Index: 26, i10-index: 59 and approximately 2500 citations). She was the Guest Editor of the International Journal of Nephrology in 2012 (special issue titled “Devil’s Triangle in Kidney Diseases: Oxidative Stress, Mediators, and Inflammation”). She is a member of many national and international associations related to her field, including membership in the Turkish Pediatric Nephrology Association board in the past. She has several scientific presentation awards at national and international congresses. She has been joined as an “invited speaker” at 20 International Meetings. As of 2007, she organizes World Kidney Day activities within the scope of the “Survival is not Enough” program (in the first rank among European pediatric nephrologists as an organizer of those activities). Recently, she was elected as a “lifelong member of the Academy of Medicine and Surgical Sciences” of the University of Naples, which is one of the four important academies in Naples. Şevki Hakan Eren, MD, is the new Deputy Editor-in-Chief of the Eur J Ther. Dr Eren graduated from the Medical School, University of Gaziantep, Turkey and completed Emergency training at Cumhuriyet University. He has been working as a Professor at Gaziantep University, Department of Emergency Medicine, Gaziantep, Turkey. He is interested in traumatology, and toxicology. Mehmet Sait Menzilcioğlu, MD, is the new Deputy Editor-in-Chief of the Eur J Ther. Dr. Menzilcioğlu graduated from the Medical School, University of Gaziantep, Turkey and completed Radiology training at the same University. He has been working as an Associate Professor at Gaziantep University, Department of Radiology, Gaziantep, Turkey. He is interested in neuroradiology, ultrasonography, doppler Ultrasonography, Computerized Tomography, Magnetic Resonance Imaging, interventional radiology, and obstetric sonography. İlhan Bahşi, MD, PhD, is the new Deputy Editor-in-Chief of the Eur J Ther. Dr Bahşi is also on the Editorial Board of the Journal of Craniofacial Surgery, Frontiers in Neuroanatomy, and Mersin University School of Medicine Lokman Hekim Journal of History of Medicine and Folk Medicine. In addition, he has published more than 80 articles (H-index: 12 and i10-index: 15) and has been a referee for more than 600 academic papers in many internationally indexed journals. Dr Bahşi, who has been working in the Department of Anatomy at the Gaziantep University Faculty of Medicine since 2012, completed his doctorate education in 2017 and obtained the title of PhD. Besides anatomy, he is particularly interested in the history of medicine, medical ethics, and education. İlkay Doğan, PhD, is the new Editorial Board member of the Eur J Ther for Statistics and Methodology. He is in the Department of Biostatistics at the Gaziantep University Faculty of Medicine. His professional focus lies in research about Structural Equation Modeling, Multivariate Analysis. With a wealth of experience spanning over 15 years across multiple disciplines, including veterinary, nursing, sport and medicine, Dr Doğan has held various notable articles. He is a member of the Turkish Biostatistics Association. Ahmet Acıduman, MD, PhD, graduated from Ege University Faculty of Medicine in 1987 and later specialized in Neurosurgery in 1997. Dr Acıduman further expanded his academic credentials by completing a PhD in the History of Medicine and Ethics in 2005. Currently, he is a Professor in the Department of History of Medicine and Ethics at Ankara University Faculty of Medicine. With a notable record of over 200 academic publications, Dr Acıduman’s contributions to the field continue. Bilal Çiğ, PhD, is a new Editorial board member of the Eur J Ther. Associate Prof Bilal Çiğ is a Postdoctoral researcher at King's College London Wolfson Card. He has been investigating the roles of ion channels in neurological diseases using the patch clamp technique for nearly 15 years. For the past few years, he has focused on the interactions of TRPA1 and Kir 4.1 channels in demyelination. He has 40 SCI-E and international publications, with about 1300 citations. Tsvetoslav Georgiev, MD, PhD, holds an esteemed position as an associate professor at the First Department of Internal Medicine in Varna, Bulgaria, while also working as a clinician at the University Hospital St. Marina. He has successfully defended his doctoral dissertation in 2018 at the Medical University in Sofia. Having obtained a specialization in rheumatology that same year, Dr Georgiev has extensive expertise in this intricate field of medicine. He further expanded his knowledge and skills by attending comprehensive courses on imaging diagnostics and musculoskeletal ultrasound in rheumatology held in various locations. Dr Georgiev has been involved in formulating the Bulgarian consensus on osteoarthritis and EULAR recommendations for the non-pharmacological core management of osteoarthritis. Notably, Dr Georgiev has received recognition for his outstanding contributions as a reviewer, earning awards in 2019 and 2021 from the Korean Academy of Medical Sciences. Davut Sinan Kaplan, PhD, is a new Editorial Board Member of the Eur J Ther. Dr Kaplan is an Associate Professor in the Department of Physiology at Gaziantep University Faculty of Medicine. He is also the Graduate School of Health Sciences’ Director. He has taken involved in a wide variety of research with animal models. His research generally focuses on Endocrinology, Metabolism, Physical Activity, and Breast Milk. He has mentored a large group of master’s and PhD students. He has served for many years as a member of the local animal experiments ethics committee. Mehmet Karadağ, MD, is a new Editorial Board Member of the Eur J Ther for Psychiatry. Dr. Karadag is an Associate Professor of Child and Adolescent Psychiatry. He is in the Department of Child and Adolescent Psychiatry at the Gaziantep University School of Medicine. He has experience on Posttraumatic Stress, Attention Deficit Hyperactivity, Autism Spectrum, Anxiety, Depressive Disorders and EMDR Therapy. He is also EMDRIA accredited EMDR Consultant. Murat Karaoglan, MD, is a new Editorial Board Member of the Eur J Ther for Endocrinology. Dr. Karaoglan is an Associate Professor of Pediatric Endocrinology. He is in the Department of Pediatric Endocrinology at the Gaziantep University School of Medicine. He has experience on growth disorder, diabetology and disorder of sexual development. Waqar M. Naqvi, PhD, is a faculty in the Department of Physiotherapy at the College of Health Sciences, Gulf Medical University, Ajman, UAE. His professional focus lies in the development of the research ecosystem within healthcare education, with a particular interest in AI, AR, VR, Sensors, and innovation in health sciences. With a wealth of experience spanning over 14 years across multiple countries, including India, Canada, Cameroon, Hong Kong, and Saudi Arabia, Dr Naqvi has held various notable positions. These include his roles as the Associate Director of Research at the NKP Salve Institute of Medical Sciences, Acting Dean and Vice Dean of the Physiotherapy College, Convener for the International Admission Office, International Accreditation and Quality Assurance Wing, Staff Selection Committee, and Coordinator for a Staff-Student Exchange Program. In recognition of his outstanding contributions, Dr Naqvi was honored with the Distinguished Service Award and Young Achiever Award from the Indian Association of Physiotherapy. Dr Naqvi is widely recognized for his expertise in conducting seminars and workshops on research, publications, and intellectual property rights. Specializing as a research trainer in the fields of medicine, dentistry, physiotherapy, and health sciences, Dr Naqvi's unwavering commitment to research excellence and his genuine passion for mentoring aspiring researchers are instrumental in shaping the future of healthcare. He firmly believes in the power of evidence-based practice and actively advocates for its implementation. Ali Nasimi is a neuroscientist in the field of central regulation of the cardiovascular system. Victor Nedzvetsky, PhD, DrSc is a full professor of Physiology, Biochemistry and Lab Diagnostics, where coordinates courses on Neurochemistry, Molecular and Cell Biology. Additionally, he is a vice-director of “The Biosafety Center” research and development company (Ukraine). He obtained PhD in biochemistry at Dnipropetrovsk University, Ukraine (1990). After postdoctoral training, he received a degree of Doctor Science at Kyiv National University (2006). Since 2015 he was involved as an invited professor of Bingol University, Turkey as a supervisor of PhD projects on genetic and molecular biology. He has participated in both the education and research work of the Dept. Art and Science of Bingol University from 2015 to 2021. His current research interests are focused on intestinal barrier function, brain blood barrier, astrocytes, cognitive deficits, bioactive compounds as anticancer agents, nanomaterials, and neuroprotection. He is the author of over 230 research publications and ten patents. He is a member of the editorial board of the journal “Regulatory Mechanisms of Biosystems”. Raphael Olszewski, DDS, MD, PhD, DrSc is a full professor of oral surgery and dentomaxillofacial radiology at the Université Catholique de Louvain (UCLouvain), Brussels, Belgium. Professor Olszewski is an oral surgeon and member of the Department of Oral and Maxillofacial Surgery at Cliniques Universitaires Saint Luc, UCLouvan, Brussels, Belgium. Prof Olszewski is the Editor-in-Chief of NEMESIS: Negative effects in medical sciences: oral and maxillofacial surgery. Janusz Ostrowski, MD, PhD. Internal medicine, nephrology, and public health specialist. Former Head of the Department of Internal Medicine and Nephrology at the Provincial Hospital in Wloclawek, Poland. Director for Peritoneal Dialysis in Diaverum Company Poland. Secretary of the Historical Section of the Polish Society of Nephrology. Former President of the International Association for the History of Nephrology. Professor, Vice Dean of the School of Public Health and Head of the Department of the History of Medicine in the Centre of Postgraduate Medical Education in Warsaw, Poland. Ayşe Aysima Özçelik, MD, is a new Editorial Board member of Eur J Ther for Neurology. She is the head of the pediatric neurology department and works at Gaziantep University Faculty of Medicine. She is the regional manager for the treatment of spinal muscular atrophy disease. She is an experienced physician in the treatment and follow-up of genetic neurological disorders, epilepsy, and neuromuscular diseases. Maria Piagkou, DDS, MD, MSc, PhD is a new Editorial Board member of Eur J Ther for Neurology. She is an associate professor at the Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens. She is a Deputy Vice-President of the Hellenic Association of Public Health in Greece and a President of the printed material handling committee of the National Organization for Medicines. She has twenty-one years of teaching activity in the field of anatomy, focused on head and neck, oral and maxillofacial area, as well as on skull base anatomy and anatomical variants. Her main areas of interest are head and neck anatomy and surgery, skull base anatomy, oral surgery, maxillofacial and dental trauma, rehabilitation, intraoral fixation after condylar fractures, and teeth replantation. She is an associate editor in 2 journals of Anatomy and acts as Editorial Board Member in six other journals. She authored six chapters in neuroanatomy and oral and maxillofacial surgery and thoracic surgery books, two monographs, and edited the translation of 9 books. She is a reviewer in 30 international scientific journals. She authored 156 publications in PubMed, 91 abstracts in 26 international congresses, and 318 abstracts in Greek scientific meetings. She is General Secretary of the Sports Medicine Association of Greece and treasurer of the Hellenic Association of Anatomy. Halima Resić, MD, PhD is a Professor of Internal medicine – nephrology in Sarajevo. Professor Resić studied medicine at the University of Belgrade where she also undertook a clinical fellowship in nephrology. She finished her postgraduate studies also at the University of Belgrade in 1987. Professor Resić worked at the Clinical Centre of Belgrade from 1972. to 1992. In 1993. She worked at the Marmara University of Istanbul. Also, in the period from 1994. to 1996. she took part in projects for refugees in Munich with the support of the Ministry of Health of the city of Munich. From 1996. till 2019. professor Resić worked at the Clinical Center University of Sarajevo, where she was head of the Clinic of Hemodialysis. In 2001. She obtained her PhD degree in Nephrology. She became a professor at the Medical Faculty of the University of Sarajevo in 2013. Professor Resić published about 180 professional and scientific papers in relevant journals. She has been a president of organizations of a few national congress and nephrology schools, and also an active participant of ERA congress and WCN congress. She has also been invited lecturer in over 60 different international and national congresses. Professor Resić was President of the BANTAO Society (2017-2019), and President of the Mediterian Kidney Society. She has been President of the Society of Nephrology, Dialysis and Kidney Transplantation in Bosnia and Herzegovina (2010-2020) and also, she is President of Donor’s network of Bosnia and Herzegovina. She is a member of ERA EDTA and ISN, and also a member of the Committee of SRC by ISN. She is a member of the Council of EAPE (European Association of Professor Emerita). She is also vice president of IANUBIH (International Academy of Science and Arts in Bosnia and Herzegovina) and a member of the board of South Eastern Europe by ISN. In her carrier, she obtains many international awards for her work in the field of Nephrology. Aldo Rogelis Aquiles Rodrigues is a new Editorial Board member of Eur J Ther for Neurology. Currently, he is an associate professor in physiology at the Federal University of Triângulo Mineiro, MG, Brazil since 2006. Before that, he worked as a research associate at the Department of Neurophysiology, Madison, USA from 2002 to 2005. He has experience in auditory neurons electrophysiology, enteric neurons and ion channels in general. Domenico Santoro is a Full Professor of Nephrology, Director of the Division of Nephrology and Coordinator of the Nephrology Fellowship Program University of Messina, AOU G. Martino – Messina. He is s a clinical expert in glomerular disorders with a scientific formation at the section of renal Pathology of the CSMC UCLA Los Angeles. He collaborated in genetic studies in glomerular disease. He coordinates as principal investigators several studies in glomerular disease both in clinical/therapeutical as well genetic aspects. He is the Associate Editor of the Journal of Nephrology and MBC Nephrology. Author of more than 270 scientific publications indexed on Scopus, H-index in Scopus: 38; H-index in Google Scholar: 46. Onur Taydaş, MD, is a new Editorial Board Member of the Eur J Ther for Radiology. Dr Taydas is an Associate Professor in the Department of Radiology at the Sakarya University School of Medicine. He has a Turkish Society of Radiology Proficiency Certificate, a European Diploma in Radiology, and a Turkish Interventional Radiology Diploma. He has experience in neuroradiology, musculoskeletal radiology, and interventional radiology. Gregory Tsoucalas (or Tsoukalas), born in 1974 and originated from the Island of Skopelos in the center of the Aegean Sea, he had studied Medicine in the University of Saint Kliment Ohridski in Sofia Bulgaria. He had then continued his studies in Lyon France and Athens Greece. He had been a Nuclear Medicine-Oncology-End stage physician in Saint Savvas Anticancer Hospital of Athens. He had after that moved to the city of Volos where he had been a physician in the Saint George Clinic for Alzheimer and Related Dementia Syndromes-End stage. He had finally moved to the General Clinic Anassa of Volos in the Internal Pathology Department. He currently holds the position of the Assistant professor of the History of Medicine, and head of the Department of History of Medicine and Medical Deontology, Medical School, University of Crete, Heraklion, Greece. Specialized in Nuclear Medicine, MSc in Palliative Medicine and PhD in the History of Medicine from National and Kapodistrian University of Athens, History of Medicine Diploma from Claude Bernard Lyon 1 University, post-doc in Anatomy from Democritus University of Thrace, Anthropology Course Diploma from Leiden University. He holds diplomas in Mastology and Clinical Nutrition for the related European Societies. He is the General Secretary of the Hellenic Branch of the Balkan Medical Union. Interested in the fields of History of Medicine, Deontology, Bioethics, Anatomy and Humanities, he is the writer of more than 200 articles in the PubMed database and more than 200 in other bases. He loves books and had published 10, while he had participated with chapters in various publications. Member of the International Society of the History of Medicine he had presented more than 130 speeches and 50 lectures in international level. Member of DELTOS (Hellenic Society) he had presented more than 400 speeches in local level. He enjoys more than 2500 citations, H-index: 17, and i10-index: 41. Hamit Yıldız, MD, PhD, is the new editorial Board member for Internal Medicine. Dr Yildiz is an internal medicine specialist and practices in Gaziantep University Hospital. He is Board Certified in Internal Medicine. He completed his internship at Gaziantep University in Gaziantep and also graduated with a PhD in molecular biology. He has more than ten years of experience as a specialist who focuses on patients with diabetes, hypertension and thyroid diseases. His special interest is recombinant DNA technologies and the development of biotechnological drugs. Betül Yılmaz Furtun, MD, FASE, FAAP, is a new Editorial Board Member for the Eur J Ther. She is an Associate Professor of Pediatrics at the Texas Children's Hospital, Baylor College of Medicine and Associate Medical Director of the Fetal Cardiology/Fetal Cardiac Intervention Program at Texas Children's Hospital. Dr Yilmaz Furtun is also a Course Director of Fetal Cardiology Education/Curriculum Development for advanced and categorical cardiology fellows and an Associate Director of the Fetal Care Center Steering Committee for fetal cardiology at Texas Children's Hospital. Dr Yilmaz Furtun is a pediatric cardiologist with expertise in advanced imaging modalities including fetal echocardiography, transthoracic and transesophageal echocardiography. Dr Yilmaz Furtun completed her pediatrics training at Washington University in St. Louis, pediatric cardiology training at Columbia University Medical Center, New York Presbyterian Hospital, and fetal cardiology/advanced imaging training at Cincinnati Children's Hospital. Dr Yilmaz Furtun actively participates in fetal and pediatric echocardiography laboratory protocol development and fetal and echocardiography lab and Fetal Care Center quality and improvement initiatives. Dr Yilmaz Furtun has been a member of the American Society of Echocardiography, the International Society of Ultrasound in Obstetrics and Gynecology, the Fetal Heart Society as well as American College of Cardiology. Dr Yilmaz Furtun’s clinical and research focus relates to cardiac imaging by echocardiography and fetal echocardiography. She utilizes her experience in these areas to study how we can use non-invasive imaging modalities for investigating normal and abnormal cardiac function in patients with congenital heart disease and in fetuses with cardiac compromise. Her primary research interests focus on fetal cardiovascular assessment and cardiac dysfunction in patients with congenital heart disease, in fetuses with congenital abnormalities, and in multiple gestation pregnancies complicated by twin-twin transfusion syndrome. Matthew Zdilla, DC, is a new Editorial Board Member for the Eur J Ther. Dr Zdilla was educated at the University of Pittsburgh and Northeast College of Health Sciences. He serves as an Associate Professor at the West Virginia University School of Medicine in the United States of America. He is an award-winning, internationally recognized clinical anatomist who has published scores of high-impact research papers regarding human diversity and the impact of anatomical variation on clinical procedures. In addition to his experience as an accomplished researcher, Zdilla brings his experience as an ad hoc reviewer for nearly 40 journals to the European Journal of Therapeutics. Joseph Schmidt, MFA has taught academic writing for the University of Louisville and various campuses of The City University of New York (CUNY). An accomplished poet, he has contributed content to, and edited a number of small literary journals. At Gaziantep University, he has lent his editorial and native English language talents to some of his Turkish colleagues in the sciences. He teaches in the university’s School of Foreign Languages (YDO).

Photo by 14825144 © Alita Xander | Dreamstime.com ABSTRACT The US government's approach to the War on Drugs has created laws to deter people from using illicit drugs through negative punishment. These laws have not controlled illicit drug use, nor has it stopped the opioid pandemic from growing. Instead, these laws have created a negative bias surrounding addiction and have negatively affected particularly vulnerable patient populations, including pregnant women with substance use disorder and newborns with neonatal abstinence syndrome. This article highlights some misconceptions and underscores the challenges they face as they navigate the justice and healthcare systems while also providing possible solutions to address their underlying addiction. INTRODUCTION Pregnant women with substance use disorder require treatment that is arguably for the benefit of both the mother and the fetus. Some suggest that addiction is a choice; therefore, those who misuse substances should not receive treatment. Proponents of this argument emphasize social and environmental factors that lead to addiction but fail to appreciate how chronic substance use alters the brain’s chemistry and changes how it responds to stress, reward, self-control, and pain. The medical community has long recognized that substance use disorder is not simply a character flaw or social deviance, but a complex condition that requires adequate medical attention. Unfortunately, the lasting consequences of the War on Drugs have created a stigma around addiction medicine, leading to significant treatment barriers. There is still a pervasive societal bias toward punitive rather than rehabilitative approaches to addiction. For example, many women with substance use disorder lose custody of their baby or face criminal penalties, including fines and jail time.[1] These punitive measures may cause patients to lose trust in their physicians, ultimately leading to high-risk pregnancies without prenatal care, untreated substance misuse, and potential lifelong disabilities for their newborns.[2] As a medical student, I have observed the importance of a rehabilitative approach to addiction medicine. Incentivizing pregnant women with substance use disorder to safely address their chronic health issues is essential for minimizing negative short-term and long-term outcomes for women and their newborns. This approach requires an open mind and supportive perspective, recognizing that substance use disorder is truly a medical condition that requires just as much attention as any other medical diagnosis.[3] BACKGROUND The War on Drugs was a government-led initiative launched in 1970 by President Richard M. Nixon with the aim of curtailing illegal drug use, distribution, and trade by imposing harsher prison sentences and punishments.[4] However, it is worth noting that one can trace the roots of this initiative back further. In 1914, Congress enacted the Harrison Narcotics Tax Act to target the recreational use of drugs such as morphine and opium.[5] Despite being in effect for over four decades, the War on Drugs failed to achieve its intended goals. In 2011, the Global Commission on Drug Policy released a report that concluded that the initiative had been futile, as “arresting and incarcerating tens of millions of these people in recent decades has filled prisons and destroyed lives and families without reducing the availability of illicit drugs or the power of criminal organizations.”[6] One study published in the International Journal of Drug Policy in the same year found that funding drug law enforcement paradoxically contributed to increasing gun violence and homicide rates.[7] The Commission recommended that drug policies focus on reducing harm caused by drug use rather than solely on reducing drug markets. Recognizing that many drug policies were of political opinion, it called for drug policies that were grounded in scientific evidence, health, security, and human rights.[8] Unfortunately, policy makers did not heed these recommendations. In 2014, Tennessee’s legislature passed a “Fetal Assault Law,” which made it possible to prosecute pregnant women for drug use during pregnancy. If found guilty, pregnant women could face up to 15 years in prison and lose custody of their child. Instead of deterring drug use, the law discouraged pregnant women with substance use disorder from seeking prenatal care. This law required medical professionals to report drug use to authorities, thereby compromising the confidentiality of the patient-physician relationship. Some avoided arrest by delivering their babies in other states or at home, while others opted for abortions or attempted to go through an unsafe withdrawal prior to receiving medical care, sacrificing the mother's and fetus's wellbeing. The law had a sunset provision and expired in 2016. During the two years this law was in effect, officials arrested 124 women.[9] The fear that this law instilled in pregnant women with substance use disorder can still be seen across the US today. Many pregnant women with substance use disorders stated that they feared testing positive for drugs. Due to mandatory reporting, they were not confident that physicians would protect them from the law.[10] And if a woman tried to stop using drugs before seeking care to avoid detection, she often ended up delaying or avoiding care.[11] The American College of Obstetricians and Gynecologists (ACOG) recognizes the fear those with substance use disorders face when seeking appropriate medical care and emphasizes that “obstetric–gynecologic care should not expose a woman to criminal or civil penalties, such as incarceration, involuntary commitment, loss of custody of her children, or loss of housing.”[12] Mandatory reporting strains the patient-physician relationship, driving a wedge between the doctor and patient. Thus, laws intended to deter people from using substances through various punishments and incarceration may be doing more harm than good. County hospitals that mainly serve lower socioeconomic patients encounter more patients without consistent health care access and those with substance use disorders.[13] These hospitals are facing the consequences of the worsening opioid pandemic. At one county hospital where I recently worked, there has been a dramatic increase in newborns with neonatal abstinence syndrome born to mothers with untreated substance use disorders during pregnancy. Infants exposed to drugs prenatally have an increased risk of complications, stillbirth, and life-altering developmental disabilities. At the hospital, I witnessed Child Protective Services removing two newborns with neonatal abstinence syndrome from their mother’s custody. Four similar cases had occurred in the preceding month. In the days leading up to their placement with a foster family, I saw both newborns go through an uncomfortable drug withdrawal. No baby should be welcomed into this world by suffering like that. Yet I felt for the new mothers and realized that heart-wrenching custody loss is not the best approach. During this period, I saw a teenager brought to the pediatric floor due to worsening psychiatric symptoms. He was born with neonatal abstinence syndrome that neither the residential program nor his foster family could manage. His past psychiatric disorders included attention deficit disorder, conduct disorder, major depressive disorder, anxiety disorder, disruptive mood dysregulation disorder, intellectual developmental disorder, and more. During his hospitalization, he was so violent towards healthcare providers that security had to intervene. And his attitude toward his foster parents was so volatile that we were never sure if having them visit was comforting or agitating. Throughout his hospital course, it was difficult for me to converse with him, and I left every interview with him feeling lost in terms of providing an adequate short- and long-term assessment of his psychological and medical requirements. What was clear, however, was that his intellectual and emotional levels did not match his age and that he was born into a society that was ill-equipped to accommodate his needs. Just a few feet away from his room, behind the nurses’ station, were the two newborns feeling the same withdrawal symptoms that this teenager likely experienced in the first few hours of his life. I wondered how similar their paths would be and if they would exhibit similar developmental delays in a few years or if their circumstance may follow the cases hyped about in the media of the 1980s and 1990s regarding “crack babies.” Many of these infants who experienced withdrawal symptoms eventually led normal lives.[14] Nonetheless, many studies have demonstrated that drug use during pregnancy can adversely impact fetal development. Excessive alcohol consumption can result in fetal alcohol syndrome, characterized by growth deficiency, facial structure abnormalities, and a wide range of neurological deficiencies.[15] Smoking can impede the development of the lungs and brain and lead to preterm deliveries or sudden infant death syndrome.[16] Stimulants like methamphetamine can also cause preterm delivery, delayed motor development, attention impairments, and a wide range of cognitive and behavioral issues.[17] Opioid use, such as oxycodone, morphine, fentanyl, and heroin, may result in neonatal opioid withdrawal syndrome, in which a newborn may exhibit tremors, irritability, sleeping problems, poor feeding, loose stools, and increased sweating within 72 hours of life.[18] In 2014, the American Association of Pediatrics (AAP) reported that one newborn was diagnosed with neonatal abstinence syndrome every 15 minutes, equating to approximately 32,000 newborns annually, a five-fold increase from 2004.[19] The AAP found that the cost of neonatal abstinence syndrome covered by Medicaid increased from $65.4 million to $462 million from 2004 to 2014.[20] In 2020, the CDC published a paper that showed an increase in hospital costs from $316 million in 2012 to $572.7 million in 2016.[21] Currently, the impact of the COVID-19 pandemic on the prevalence of newborns with neonatal abstinence syndrome is unknown. I predict that the increase in opioid and polysubstance use during the pandemic will increase the number of newborns with neonatal abstinence syndrome, thereby significantly increasing the public burden and cost.[22] In the 1990s, concerns arose about the potentially irreparable damage caused by intrauterine exposure to cocaine on the development of infants, which led to the popularization of the term “crack babies.”[23] Although no strong longitudinal studies supported this claim at the time, it was not without merit. The Maternal Lifestyle Study (NCT00059540) was a prospective longitudinal observational study that compared the outcomes of newborns exposed to cocaine in-utero to those without.[24] One of its studies revealed one month old newborns with cocaine exposure had “lower arousal, poorer quality of movements and self-regulation, higher excitability, more hypertonia, and more nonoptimal reflexes.”[25] Another study showed that at one month old, heavy cocaine exposure affected neural transmission from the ear to the brain.[26] Long-term follow up from the study showed that at seven years old, children with high intrauterine cocaine exposure were more likely to have externalizing behavior problems such as aggressive behavior, temper tantrums, and destructive acts.[27] While I have witnessed this behavior in the teenage patient during my pediatrics rotation, not all newborns with intrauterine drug exposure are inevitably bound to have psychiatric and behavioral issues later in life. NPR recorded a podcast in 2010 highlighting a mother who used substances during pregnancy and, with early intervention, had positive outcomes. After being arrested 50 times within five years, she went through STEP: Self-Taught Empowerment and Pride, a public program that allowed her to complete her GED and provided guidance and encouragement for a more meaningful life during her time in jail. Her daughter, who was exposed to cocaine before birth, had a normal childhood and ended up going to college.[28] From a public health standpoint, more needs to be done to prevent the complications of substance misuse during pregnancy. Some states consider substance misuse (and even prescribed use) during pregnancy child abuse. Officials have prosecuted countless women across 45 states for exposing their unborn children to drugs.[29] With opioid and polysubstance use on the rise, the efficacy of laws that result in punitive measures seems questionable.[30] So far, laws are not associated with a decrease in the misuse of drugs during pregnancy. Millions of dollars are being poured into managing neonatal abstinence syndrome, including prosecuting women and taking their children away. Rather than policing and criminalizing substance use, pregnant women should get the appropriate care they need and deserve. I. Misconception One: Mothers with Substance Use Disorder Can Get an Abortion If an unplanned pregnancy occurs, one course of action could be to terminate the pregnancy. On the surface, this solution seems like a quick fix. However, the reality is that obtaining an abortion can be challenging due to two significant barriers: accessibility and mandated reporting. Abortion laws vary by state, and in Tennessee, for instance, abortions are banned after six weeks of gestation, typically when fetal heart rhythms are detected. An exception to this is in cases where the mother's life is at risk.[31] Unfortunately, many women with substance use disorders are from lower socioeconomic backgrounds and cannot access pregnancy tests, which could indicate they are pregnant before the six-week cutoff. If a Tennessee woman with substance use disorder decides to seek an abortion after six weeks, she may need to travel to a neighboring state. However, this is not always a feasible option, as the surrounding states (WV, MO, AR, MI, AL, and GA) also have restrictive laws that either prohibit abortions entirely or ban them after six weeks. Moreover, she may be hesitant to visit an obstetrician for an abortion, as some states require physicians by law to report their patients' substance use during pregnancy. For example, Virginia considers substance use during pregnancy child abuse and mandates that healthcare providers report it. This would ultimately limit her to North Carolina if she wants to remain in a nearby state, but she must go before 20 weeks gestation.[32] For someone who may or may not have access to reliable transportation, traveling to another state might be impossible. Without resources or means, these restrictive laws have made it incredibly difficult to obtain the medical care they need. II. Misconception Two: Mothers with SUD are Not Fit to Care for Children If a woman cannot take care of herself, one might wonder how she can take care of another human being. Mothers with substance use disorders often face many adversities, including lack of economic opportunity, trauma from abuse, history of poverty, and mental illness.[33] Fortunately, studies suggest keeping mother and baby together has many benefits. Breastfeeding, for example, helps the baby develop a strong immune system while reducing the mother’s risk of cancer and high blood pressure.[34] Additionally, newborns with neonatal abstinence syndrome who are breastfed by mothers receiving methadone or buprenorphine require less pharmacological treatment, have lower withdrawal scores, and experience shorter hospital stays.[35] Opioid concentration in breastmilk is minimal and does not pose a risk to newborns.[36] Moreover, oxytocin, the hormone responsible for mother-baby bonding, is increased in breastfeeding mothers, reducing withdrawal symptoms and stress-induced reactivity and cravings while also increasing protective maternal instincts.[37] Removing an infant from their mother’s care immediately after birth would result in the loss of all these positive benefits for both the mother and her newborn. The newborns I observed during my pediatrics rotation probably could have benefited from breastfeeding rather than bottle feeding and being passed around from one nurse to the next. They probably would have cried less and suffered fewer withdrawal symptoms had they been given the opportunity to breastfeed. And even if the mothers were lethargic and unresponsive while going through withdrawal, it would still have been possible to breastfeed with proper support. Unfortunately, many believe mothers with substance use disorder cannot adequately care for their children. This pervasive societal bias sets them up for failure from the beginning and greatly inhibits their willingness to change and mend their relationship with their providers. It is a healthcare provider’s duty to provide non-judgmental care that prioritizes the patient’s well-being. They must treat these mothers with the same empathy and respect as any other patient, even if they are experiencing withdrawal. III. Safe Harbor and Medication-Assisted Treatment Addiction is like any other disease and society should regard treatment without stigma. There is no simple fix to this problem, given that it involves the political, legal, and healthcare systems. Punitive policies push pregnant women away from receiving healthcare and prevent them from receiving beneficial interventions. States need to enact laws that protect these women from being reported to authorities. Montana, for example, passed a law in 2019 that provides women with substance use disorders safe harbor from prosecution if they seek treatment for their condition.[38] Medication-assisted treatment with methadone or buprenorphine is the first line treatment option and should be available to all pregnant women regardless of their ability to pay for medical care.[39] To promote continuity of care, health officials could include financial incentives to motivate new mothers to go to follow-up appointments. For example, vouchers for groceries or enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) may offset financial burdens and allow a mother to focus on taking care of her child and her recovery. IV. Mandated Substance Abuse Programs Although the number of people sentenced to state prisons for drug related crimes has been declining, it is still alarming that there were 171,300 sentencings in 2019.[40] Only 11 percent of the 65 percent of our nation’s inmates with substance use disorder receive treatment, implying that the other 89 percent were left without much-needed support to overcome their addiction.[41] It is erroneous to assume that their substance use disorder would disappear after a period without substance use while behind bars. After withdrawal, those struggling with substance use disorder may still have cravings and the likelihood of relapsing remains high without proper medical intervention. Even if they are abstinent for some time during incarceration, the underlying problem persists, and the cycle inevitably continues upon release from custody. In line with the recommendations by Global Commission on Drug Policy and the lessons learned from the failed War on Drugs, one proposed change in our criminal justice system would be to require enrollment and participation in assisted alcohol cessation programs before legal punishment. Policy makers must place emphasis on the safety of the patient and baby rather than the cessation of substance use. This would incentivize people to actively seek medical care, restore the patient-physician relationship, and ensure that they take rehabilitation programs seriously. If the patient or baby is unsafe, a caregiver could intervene while the patient re-enrolls in the program. Those currently serving sentences in prisons and jails can treat their substance use disorder through medication assisted treatment, cognitive behavioral therapy, and programs like Self Taught Empowerment and Pride (STEP). Medication assisted treatment under the supervision of medical professionals can help inmates achieve and maintain sobriety in a healthy and safe way. Furthermore, cognitive behavioral therapy can help to identify triggers and teach healthier coping mechanisms to prepare for stressors outside of jail. Finally, multimodal empowerment programs can connect people to jobs, education, and support upon release. People often leave prisons and jail without a sense of purpose, which can lead to relapse and reincarceration. Structured programs have been shown to decrease drug use and criminal behavior by helping reintegrate productive individuals into society.[42] V. Medical Education: Narcotic Treatment Programs and Suboxone Clinics Another proactive approach could be to have medical residency programs register with the Drug Enforcement Administration (DEA) as Narcotic Treatment Programs and incorporate suboxone clinics into their education and rotations. Rather than family medicine, OB/GYN, or emergency medicine healthcare workers having to refer their patients to an addiction specialist, they could treat patients with methadone for maintenance or detoxification where they would deliver their baby. Not only would this educate and prepare the future generation of physicians to handle the opioid crisis, but it would allow pregnant women to develop strong patient-physician relationships. CONCLUSION Society needs to change from the mindset of tackling a problem after it occurs to taking a proactive approach by addressing upstream factors, thereby preventing those problems from occurring in the first place. Emphasizing public health measures and adequate medical care can prevent complications and developmental issues in newborns and pregnant women with substance use disorders. Decriminalizing drug use and encouraging good health habits during pregnancy is essential, as is access to prenatal care, especially for lower socioeconomic patients. Many of the current laws and regulations that policy makers initially created due to naïve political opinion and unfounded bias to serve the War on Drugs need to be changed to provide these opportunities. To progress as a society, physicians and interprofessional teams must work together to truly understand the needs of patients with substance use disorders and provide support from prenatal to postnatal care. There should be advocation for legislative change, not by providing an opinion but by highlighting the facts and conclusions of scientific studies grounded in scientific evidence, health, security, and human rights. There can be no significant change if society continues to view those with substance use disorders as underserving of care. Only when the perspective shifts to compassion can these mothers and children receive adequate care that rehabilitates and supports their future and empowers them to raise their children. - [1] NIDA. 2023, February 15. Pregnant People with Substance Use Disorders Need Treatment, Not Criminalization. https://nida.nih.gov/about-nida/noras-blog/2023/02/pregnant-people-substance-use-disorders-need-treatment-not-criminalization [2] Substance Use Disorder Hurts Moms and Babies. National Partnership for Women and Families. June 2021 [3] All stories have been fictionalized and anonymized. [4] A History of the Drug War. Drug Policy Alliance. https://drugpolicy.org/issues/brief-history-drug-war [5] The Harrison Narcotic Act (1914) https://www.druglibrary.org/Schaffer/library/studies/cu/cu8.html [6] The War on Drugs. The Global Commission on Drug Policy. Published June 2011. https://www.globalcommissionondrugs.org/reports/the-war-on-drugs [7] Werb D, Rowell G, Guyatt G, Kerr T, Montaner J, Wood E. Effect of drug law enforcement on drug market violence: A systematic review. Int J Drug Policy. 2011;22(2):87-94. doi:10.1016/j.drugpo.2011.02.002 [8] Global Commission on Drug Policy, 2011 [9] Women NA for P. Tennessee’s Fetal Assault Law: Understanding its impact on marginalized women - New York. Pregnancy Justice. Published December 14, 2020. https://www.pregnancyjusticeus.org/tennessees-fetal-assault-law-understanding-its-impact-on-marginalized-women/ [10] Roberts SCM, Nuru-Jeter A. Women’s perspectives on screening for alcohol and drug use in prenatal care. Womens Health Issues Off Publ Jacobs Inst Womens Health. 2010;20(3):193-200. doi:10.1016/j.whi.2010.02.003 [11] Klaman SL, Isaacs K, Leopold A, et al. Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance. J Addict Med. 2017;11(3):178-190. doi:10.1097/ADM.0000000000000308 [12] Substance Abuse Reporting and Pregnancy: The Role of the Obstetrician–Gynecologist. https://www.acog.org/en/clinical/clinical-guidance/committee-opinion/articles/2011/01/substance-abuse-reporting-and-pregnancy-the-role-of-the-obstetrician-gynecologist [13] R. Ghertner, G Lincoln The Opioid Crisis and Economic Opportunity: Geographic and Economic Trends. ASPE. Office of Assistant Secretary for Planning and Evaluation. DHHS Revised September 11, 2018 https://aspe.hhs.gov/reports/economic-opportunity-opioid-crisis-geographic-economic-trends [14] Midon, M. Z., Gerzon, L. R., & de Almeida, C. S. (2021). Crack and motor development of babies living in an assistance shelter. ABCS Health Sciences, 46, e021215-e021215. And for example, see Crack Babies: Twenty Years Later : NPR https://www.npr.org/templates/story/story.php?storyId=126478643 [15] Williams JF, Smith VC, the Committee on Substance Abuse. Fetal Alcohol Spectrum Disorders. Pediatrics. 2015;136(5):e20153113. doi:10.1542/peds.2015-3113 [16] CDC Tobacco Free. Smoking During Pregnancy. Centers for Disease Control and Prevention. Published April 11, 2022. https://www.cdc.gov/tobacco/basic_information/health_effects/pregnancy/index.htm [17] Abuse NI on D. What are the risks of methamphetamine misuse during pregnancy? National Institute on Drug Abuse. https://nida.nih.gov/publications/research-reports/methamphetamine/what-are-risks-methamphetamine-misuse-during-pregnancy [18] CDC. Basics About Opioid Use During Pregnancy | CDC. Centers for Disease Control and Prevention. Published July 21, 2021. https://www.cdc.gov/pregnancy/opioids/basics.html [19] Honein MA, Boyle C, Redfield RR. Public Health Surveillance of Prenatal Opioid Exposure in Mothers and Infants. Pediatrics. 2019;143(3):e20183801. doi:10.1542/peds.2018-3801 [20] Winkelman TNA, Villapiano N, Kozhimannil KB, Davis MM, Patrick SW. Incidence and Costs of Neonatal Abstinence Syndrome Among Infants with Medicaid: 2004–2014. Pediatrics. 2018;141(4):e20173520. doi:10.1542/peds.2017-3520 [21] Strahan AE, Guy GP Jr, Bohm M, Frey M, Ko JY. Neonatal Abstinence Syndrome Incidence and Health Care Costs in the United States, 2016. JAMA Pediatr. 2020;174(2):200-202. doi:10.1001/jamapediatrics.2019.4791 [22] Ghose R, Forati AM, Mantsch JR. Impact of the COVID-19 Pandemic on Opioid Overdose Deaths: a Spatiotemporal Analysis. J Urban Health Bull N Y Acad Med. 2022;99(2):316-327. doi:10.1007/s11524-022-00610-0 [23] Mayes LC, Granger RH, Bornstein MH, Zuckerman B. The Problem of Prenatal Cocaine Exposure: A Rush to Judgment. JAMA. 1992;267(3):406-408. doi:10.1001/jama.1992.03480030084043 [24] NICHD Neonatal Research Network. The Maternal Lifestyle Study. clinicaltrials.gov; 2016. https://clinicaltrials.gov/ct2/show/study/NCT00059540 [25] Lester BM, Tronick EZ, LaGasse L, et al. The maternal lifestyle study: effects of substance exposure during pregnancy on neurodevelopmental outcome in 1-month-old infants. Pediatrics. 2002;110(6):1182-1192. doi:10.1542/peds.110.6.1182 [26] Lester BM, Lagasse L, Seifer R, et al. The Maternal Lifestyle Study (MLS): effects of prenatal cocaine and/or opiate exposure on auditory brain response at one month. J Pediatr. 2003;142(3):279-285. doi:10.1067/mpd.2003.112 [27] Bada HS, Bann CM, Bauer CR, et al. Preadolescent behavior problems after prenatal cocaine exposure: Relationship between teacher and caretaker ratings (Maternal Lifestyle Study). Neurotoxicol Teratol. 2011;33(1):78-87. doi:10.1016/j.ntt.2010.06.005 [28] N, P, R. Crack Babies: Twenty Years Later. NPR. Published May 3, 2010. https://www.npr.org/templates/story/story.php?storyId=126478643 [29] Miranda L, Dixon V, September CRP on, 30, 2015. How States Handle Drug Use During Pregnancy http://projects.propublica.org/graphics/maternity-drug-policies-by-state [30] NCDAS: Substance Abuse and Addiction Statistics [2023]. NCDAS. https://drugabusestatistics.org/ [31] (Tenn. Code Ann. § 39-15-216). [32] Institute G. Interactive Map: US Abortion Policies and Access After Roe. https://states.guttmacher.org/policies/ [33] Whitesell M, Bachand A, Peel J, Brown M. Familial, Social, and Individual Factors Contributing to Risk for Adolescent Substance Use. J Addict. 2013;2013:579310. doi:10.1155/2013/579310 [34] CDC. Five Great Benefits of Breastfeeding. Centers for Disease Control and Prevention. Published July 27, 2021. https://www.cdc.gov/nccdphp/dnpao/features/breastfeeding-benefits/index.html [35] Welle-Strand GK, Skurtveit S, Jansson LM, Bakstad B, Bjarkø L, Ravndal E. Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants. Acta Paediatr. 2013;102(11):1060-1066. doi:10.1111/apa.12378 [36] Ilett KF, Hackett LP, Gower S, Doherty DA, Hamilton D, Bartu AE. Estimated dose exposure of the neonate to buprenorphine and its metabolite norbuprenorphine via breastmilk during maternal buprenorphine substitution treatment. Breastfeed Med Off J Acad Breastfeed Med. 2012;7:269-274. doi:10.1089/bfm.2011.0096 [37] Pedersen CA, Smedley KL, Leserman J, et al. Intranasal Oxytocin Blocks Alcohol Withdrawal in Human Subjects. Alcohol Clin Exp Res. 2013;37(3):484-489. doi:10.1111/j.1530-0277.2012.01958.x [38] Montana SB0289. https://leg.mt.gov/bills/2019/billhtml/SB0289.htm [39] Mullins N, Galvin SL, Ramage M, Gannon M, Lorenz K, Sager B, Coulson CC. Buprenorphine and Naloxone Versus Buprenorphine for Opioid Use Disorder in Pregnancy: A Cohort Study. J Addict Med. 2020 May/Jun;14(3):185-192. doi: 10.1097/ADM.0000000000000562. PMID: 31567599. [40] Drug Related Crime Statistics [2023]: Offenses Involving Drug Use. NCDAS. https://drugabusestatistics.org/drug-related-crime-statistics/ [41] Association APH. Online only: Report finds most U.S. inmates suffer from substance abuse or addiction. Nations Health. 2010;40(3):E11-E11. [42] Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) | NIDA Archives. Published January 17, 2018. http://archives.nida.nih.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition

According to The Betoota Advocate (Parker), a CSIRO (Commonwealth Scientific and Industrial Research Organisation) paper has recently established that “it takes roughly seven minutes on average for a vegan to tell you that they’re vegan” (qtd. in Harrington et al. 135). For such a statement to have currency as a joke means that it is grounded in a shared experience of being vegan on the one hand, and of encountering vegans on the other. Why should vegans feel such a need to justify themselves? I recognise the observation as being true of me, and this article is one way to explore this perspective: writing to find out what I currently only intuit. As Richardson notes (516), writing is “a way of ‘knowing’—a method of discovery and analysis. By writing in different ways, we discover new aspects of our topic and our relationship to it. Form and content are inseparable” (qtd. in Wall 151).Autoethnography, the qualitative research methodology used for this article, is etymologically derived from Greek to indicate a process for exploring the self (autos) and the cultural (“ethno” from ethnos—nation, tribe, people, class) using a shared, understood, approach (“graphy” from graphia, writing). It relies upon critical engagement with and synthesising of the personal. In Wall’s words, this methodological analysis of human experience “says that what I know matters” (148). The autoethnographic investigation (Riggins; Sparkes) reported here interrogates the experience of “being judged” as a vegan: firstly, by myself; secondly, by other vegans; and ultimately by the wider society. As Ellis notes, autoethnography is “research, writing, story and method that connect the autobiographical and personal to the cultural, social and political. Autoethnographic forms feature concrete action, emotion, embodiment, self-consciousness, and introspection” (xix).Introspection is important because researchers’ stories of their observations are interwoven with self-reflexive critique and analysis: “illustrative materials are meant to give a sense of what the observed world is really like, while the researcher’s interpretations are meant to represent a more detached conceptualization of that reality” (Strauss and Corbin 22). Leaving aside Gans’s view that this form of enquiry represents the “climax of the preoccupation with self […] an autobiography written by sociologists” (542), an autoethnography generally has the added advantage of protecting against Glendon and Stanton’s concern that interpretive studies “are often of too short a duration to be able to provide sufficiently large samples of behaviour” (209). In my case, I have twelve years of experience of identifying as a vegan to draw upon.My experience is that being vegan is a contested activity with a significant range of variation that partly reflects the different initial motivations for adopting this increasingly mainstream identity. Greenebaum notes that “ethical vegans differentiate between those who ‘eat’ vegan (health vegans) and those who ‘live’ vegan (ethical vegans)”, going on to suggest that these differences create “hierarchies and boundaries between vegans” (131). As Greenebaum acknowledges, there is sometimes a need to balance competing priorities: “an environmental vegan […] may purchase leather products over polyvinyl chloride (PVC), thinking that leather is a better choice for the environment” (130). Harrington et al. similarly critique vegan motivations as encompassing “a selfless pursuit for those who cared for other beings (animals)” to “a concern about impacts that affect all humans (environment), and an interest mostly in the self (individual health …)” (144). Wright identifies a fourth group of vegans: those searching for a means of dietary inclusivity (2). I have known Orthodox Jewish households that have adopted veganism because it is compatible with keeping Kosher, while many strict Hindus are vegan and some observant Muslims may also follow suit, to avoid meat that is not Halal certified.The Challenge of the EverydayAlthough my initial vegan promptings were firmly at the selfish end of an altruism spectrum, my experience is that motivation is not static. Being a vegan for any reason increasingly primes awareness of more altruistic motivations “at the intersection of a diversity of concerns [… promoting] a spread and expansion of meaning to view food choices holistically” (Harrington et al. 144). Even so, everyday life offers a range of temptations and challenges that require constant juggling and, sometimes, a string of justifications: to oneself, and to others. I identify as a bit of a bad vegan, and not simply because I embrace the possibility that “honey is a gray area” (Greenebaum, quoting her participant Jason, 139). I’m also flexible around wine, for example, and don’t ask too many questions about whether the wine I drink is refined using milk, or egg-shells or even (yuk!) fish bladders. The point is, there are an infinite number of acid tests as to what constitutes “a real vegan”, encouraging inter-vegan judgmentality. Some slight definitional slippage aligns with Singer and Mason’s argument, however, that vegans should avoid worrying about “trivial infractions of the ethical guidelines […] Personal purity isn’t really the issue. Not supporting animal abuse – and persuading others not to support it – is. Giving people the impression that it is virtually impossible to be vegan doesn’t help animals at all” (Singer and Mason 258–9).If I were to accept a definition of non-vegan, possibly because I have a leather handbag among other infractions, that would feel inauthentic. The term “vegan” helpfully labels my approach to food and drink. Others also find it useful as a shorthand for dietary preferences (except for the small but significant minority who muddle veganism with being gluten free). From the point of view of dietary prohibitions I’m a particularly strict vegan, apart from honey. I know people who make exceptions for line-caught fish, or the eggs from garden-roaming happy chooks, but I don’t. I increasingly understand the perspectives of those who have a more radical conception of veganism than I do, however: whose vision and understanding is that “behind every meal of meat is an absence: the death of the animal whose place the meat takes. The ‘absent referent’ is that which separates the meat eater from the animal and the animal from the end product [… keeping] something from being seen as having been someone” (Adams 14). The concept of the global suffering of animals inherent in the figures: “31.1 billion each year, 85.2 million each day, 3.5 million each hour, 59,170 each minute” (Adams dedication) is appalling; as well as being an under-representation of the current situation since the globe has had almost two further decades of population growth and rising “living standards”.Whatever the motivations, it’s easy to imagine that the different branches of veganism have more in common than divides them. Being a vegan of any kind helps someone identify with other variations upon the theme. For example, even though my views on animal rights did not motivate my choice to become vegan, once I stopped seeing other sentient creatures as a handy food source I began to construct them differently. I gradually realised that, as a species, we were committing the most extraordinary atrocities on a global scale in treating animals as disposable commodities without rights or feelings. The large-scale production of what we like to term “meat and poultry” is almost unadulterated animal suffering, whereas the by-catch (“waste products”) of commercial fishing represents an extraordinary disregard of the rights to life of other creatures and, as Cole and Morgan note, “The number of aquatic animals slaughtered is not recorded, their individual deaths being subsumed by aggregate weight statistics” (135). Even if we did accept that humans have the right to consume some animals some of the time, should the netting of a given weight of edible fish really entail the death of many, many time more weight of living creatures that will be “wasted”: the so-called by-catch? Such wanton destruction has increasingly visible impacts upon complex food chains, and the ecosystems that sustain us all.The Vegan Threat to the Status QuoExamining the evidence for the broader community being biased against vegetarians and vegans, MacInnis and Hodson identify that these groups are “clear targets of relatively more negative attitudes” (727) towards them than other minority groups. Indeed, “only drug addicts were evaluated more negatively than vegetarians and vegans” (726). While “vegans were evaluated more negatively than vegetarians” (732), there was a hierarchy in negative evaluations according to the underlying motivation for someone adopting veganism or vegetarianism. People motivated by personal health received the least negative evaluations from the general population followed by those who were motivated by the environment. The greatest opprobrium was reserved for vegans who were motivated by animal rights (732). MacInnis and Hodson reason that this antipathy is because “vegetarians and vegans represent strong threats to the status quo, given that prevailing cultural norms favour meat-eating” (722). Also implied here is that fact that eating meat is itself a cultural norm associated with masculinity (Rothgerber).Adams’s work links the unthinking, normative exploitation of animals to the unthinking, normative exploitation of women, a situation so aligned that it is often expressed through the use of a common metaphor: “‘meat’ becomes a term to express women’s oppression, used equally by patriarchy and feminists, who say that women are ‘pieces of meat’” (2002, 59). Rothberger further interrogates the relationship between masculinity and meat by exploring gender in relation to strategies for “meat eating justification”, reflecting a 1992 United States study that showed, of all people reporting that they were vegetarian, 68% were women and 32% men (Smart, 1995). Rothberger’s argument is that:Following a vegetarian diet or deliberately reducing meat intake violates the spirit of Western hegemonic masculinity, with its socially prescribed norms of stoicism, practicality, seeking dominance, and being powerful, strong, tough, robust and invulnerable […] Such individuals have basically cast aside a relatively hidden male privilege—the freedom and ability to eat without criticism and scrutiny, something that studies have shown women lack. (371)Noting that “to raise concerns about the injustices of factory farming and to feel compelled by them would seem emotional, weak and sensitive—feminine characteristics” (366), Rothberger sets the scene for me to note two items of popular culture which achieved cut-through in my personal life. The evidence for this is, in terms of all the pro-vegan materials I encounter, these were two of a small number that I shared on social media. In line with Rothberger’s observations, both are oppositional to hegemonic masculinity:one represents a feminised, mother and child exchange that captures the moment when a child realises the “absent referent” of the dead animal in the octopus on his plate—https://www.youtube.com/watch?v=SrU03da2arE;while the other is a sentimentalised and sympathetic recording of cattle luxuriating in their first taste of pastureland after a long period of confinement—https://www.youtube.com/watch?v=huT5__BqY_U.Seeing cows behaving like pets does call attention to the artificial distinction between “companion animals” and other animals. As Cole and Stewart note, “the naming of other animals is useful for human beings, while it is dangerous, and frequently lethal, for other animals. This is because the words we use to name other animals are saturated with common sense knowledge claims about those animals that legitimate their habitual use for humans” (13). Thus a cat, in Western culture, has a very different life trajectory to a cow. Adams notes the contrary case where the companion animal is used as a referent for a threatened human:Child sexual abusers often use threats and/or violence against companion animals to achieve compliance from their victims. Batterers harm or kill a companion animal as a warning to their partner that she could be next; as a way of further separating her from meaningful relationships; to demonstrate his power and her powerlessness. (Adams 57)For children who are still at a stage where animals are creatures of fascination and potential friends, who may be growing up with Charlotte’s Web (White) or Peter Rabbit (Potter), the mental gymnastics of suspending identification with these fellow creatures are harder because empathy and imagination are more active and the ingrained habit of eating without thinking has not had so long to develop. Indeed, children often understand domestic animals as “members of the family”, as illustrated by an interview with Kani, a 10-year old participant in one of my research projects. “In the absence of her extended family overseas, Kani adds her pets to [the list of] those with whom she shares her family life: ‘And my mum and my uncle and then our cat Dobby. I named it [for Harry Potter’s house elf] ...and the goldfish. The goldfish are Twinkle, Glitter, Glow and Bobby’” (Green and Stevenson). Such perceptions may well filter through to children having a different understanding of animals-as-food, even though Cole and Stewart note that “children enter into an adult culture habituated to [the] banal conceptualization of other animals according to their (dis)utilities” (21).Evidence-Based VeganismThose M/C Journal readers who know me personally will understand that one reason why I embrace the “bad vegan” label, is that I’m no more obviously a pin-up for healthy veganism than I am for ethical or environmental veganism. In particular, my BMI (Body Mass Index) is significantly outside the “healthy” range. Even so, I attribute a dramatic change in my capacity for stamina-based activity to my embrace of veganism. A high-speed recap of the evidence would include: in 2009 I embarked on a week-long 500km Great Vic bike ride; in 2012 I successfully completed a Machu Picchu trek at high altitude; by 2013 I was ready for my first half marathon (reprised in 2014, and 2017); in 2014 I cycled from Surfers’ Paradise to Noosa—somewhat less successfully than in my 2009 venture, but even so; in 2016 I completed the Oxfam 50km in 24 hours (plus a half hour, if I’m honest); and in 2017 I completed the 227km Portuguese Camino; in 2018 I jogged an average of over 3km per day, every day, up until 20 September... Apart from indicating that I live an extremely fortunate life, these activities seem to me to demonstrate that becoming vegan in 2007 has conferred a huge health benefit. In particular, I cannot identify similar metamorphoses in the lives of my 50-to-60-something year-old empty-nester friends. My most notable physical feat pre-veganism was the irregular completion of Perth’s annual 12km City-to-Surf fun run.Although I’m a vegan for health reasons, I didn’t suddenly wake up one day and decide that this was now my future: I had to be coaxed and cajoled into looking at my food preferences very differently. This process entailed my enrolling in a night school-type evening course, the Coronary Health Improvement Program: 16 x 3 hour sessions over eight weeks. Its sibling course is now available online as the Complete Health Improvement Program. The first lesson of the eight weeks convincingly demonstrated that what is good for coronary health is also good for health in general, which I found persuasive and reassuring given the propensity to cancer evident in my family tree. In the generation above me, my parents each had three siblings so I have a sample of eight immediate family to draw upon. Six of these either have cancer at the moment, or have died from cancer, with the cancers concerned including breast (1), prostate (2), lung (1), pancreas (1) and brain (1). A seventh close relative passed away before her health service could deliver a diagnosis for her extraordinarily elevated eosinophil levels (100x normal rates of that particular kind of white blood cell: potentially a blood cancer, I think). The eighth relative in that generation is my “bad vegan” uncle who has been mainly plant-based in his dietary choices since 2004. At 73, he is still working three days per week as a dentist and planning a 240 km trek in Italy as his main 2019 holiday. That’s the kind of future I’m hoping for too, when I grow up.And yet, one can read volumes of health literature without stumbling upon Professor T. Colin Campbell’s early research findings via his work on rodents and rodent cells that: “nutrition [was] far more important in controlling cancer promotion than the dose of the initiating carcinogen” and that “nutrients from animal-based foods increased tumor development while nutrients from plant-based foods decreased tumor development” (66, italics in original). Plant was already an eminent scientist at the point where she developed breast cancer, but she noted her amazement at learning “precisely how much has been discovered already [that] has not filtered through to the public” (18). The reason for the lack of visible research in this area is not so much its absence, but more likely its political sensitivity in an era of Big Food. As Harrington et al.’s respondent Samantha noted, “I think the meat lobby’s much bigger than the vegetable lobby” (147). These arguments are addressed in greater depth in Green et al.My initiating research question—Why do I feel the need to justify being vegan?—can clearly be answered in a wide variety of ways. Veganism disrupts the status quo: it questions both the appropriateness of humanity’s systematic torturing of other species for food, and the risks that those animal-based foods pose for the long-term health of human populations. It offends many vested interests from Big Food to accepted notions of animal welfare to the conventional teachings of the health industry. Identifying as a vegan represents an outcome of one or more of a wide range of motivations, some of which are more clearly self-serving (read “bad”); while others are more easily identified as altruistic (read “good”). After a decade or more of personal experimentation in this space, I’m proud to identify as a “bad vegan”. It’s been a great choice personally and, I hope, for some other creatures whose planet I share.ReferencesAdams, Carol. The Sexual Politics of Meat: A Feminist-Vegetarian Critical Theory. New York: Continuum, 1990.Campbell, T. Colin, and Thomas M. Cambell. The China Study: Startling Implications for Diet, Weight Loss and Long-Term Health. Dallas: BenBella Books, 2005.Cole, Matthew, and Karen Morgan. “Vegaphobia: Derogatory Discourses of Veganism and the Reproduction of Speciesism in UK National Newspaper.” British Journal of Sociology 62 (2011): 134–53.———, and Kate Stewart. Our Children and Other Animals: The Cultural Construction of Human-Animal Relations in Childhood. Farnham: Ashgate, 2014.Ellis, Carolyn. The Ethnographic I: A Methodological Novel about Autoethnography. Oxford: Altamira Press, 2004.Gans, Herbert J. “Participant Observation in the Era of ‘Ethnography’.” Journal of Contemporary Ethnography 28.5 (1999): 540–48.Glendon, A. 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