The nutrition and gut microbiome phase of EATWELL got finally started!

On Sunday 23 March, we finally left to Laya, one of the highest and most remote settlements in the Bhutanese Himalayas. The people from Laya are highly mobile as a semi-nomadic people engaged in yak herding, horse transport and trading.

We left with 11 Bhutanese research assistants (RA’s), Dr Neyzang Wangmo who is representing KGUMSB in the project, and myself. The packing of the bolero pick-up truck and the bus was already quite a challenge as we needed to pack all the materials for the stool sample collection, including -80 portable freezer, generator, and 220 liters of petrol for the likely power cuts, as well as all the luggage for each person.

This new phase will include collecting stool samples for analysis of the gut microbiome, simultaneously conducting 24 hours dietary recalls and an integrated nutrition/food system/microbiome survey to ascertain the influence of food and nutrient intake as well as other activities on the composition and functional potentials of the gut microbiota.

This new phase is designed, based on initial findings in the anthropological phase, which is still ongoing, where we have studied the socio-cultural, political-economic and environmental aspects affecting the different processes from seed to stool (cultivation, animal husbandry, collection, processing, preparation, and consumption of food), which are likely to affect nutrient intake and the gut microbiome. These observations have informed us about relevant seasonal variations in food and nutrient intake as well as in rituals, migratory patterns, and various activities that are hypothesized as being of influence on the gut microbiome. On this basis, we have developed our longitudinal design besides the cross-sectional design.

The latter entails that we collect stool samples and conduct the integrated surveys during maximum one month in Laya. This sounds simple, but given the microbiome protocols, this requires both rigorous planning and a great dose flexibility within this unique context. As we collect the stool samples and conduct surveys at the homes of the participants, and as the stool sample per protocol should be in the freezer within two hours after exiting the body, one can understand that this requires considerable coordination between the RA’s and the participants who have a particularly flexible temporal disposition, which complicates the coordination with a rigid scientific timing. The participant is required to call immediately after having collected their stool in a sample kit, and then the RA will go there and conduct the 24-hour recall and integrated survey, and bring the sample to the freezer located in the health center, which can be up to a few hours away. So, we have devised some protocols to prolong the conservation of the stool sample underway. Key challenges that we foresee is that participants may call simultaneously or may call and then have an urgent errand that will take their focus (e.g. horses running away) and shift their availability. An added component of unpredictability is that it is impossible to fully control when the stool comes out. Being located around 3900 meters above sea level it is challenging to go here and there to first collect the special bags with cooling elements for prolonging the conservation from the health center, then going to the home of the participant and finally getting it back to the health center. Repeat this by 250 times within one month and it is easy to imagine that this is a real tour de force.

When we will soon follow 50 people at 10 timepoints during one year in the longitudinal part to cover seasonal variation and the variation in food, nutrition and microbiome, compounded by associated migration between dwelling places, such as the herder camps and winter camps, and various food-related activities, one can easily imagine that the challenges will multiply in matching the timing between the respondent and RA will.

But these are not the only (anticipated) challenges in this second phase of the EATWELL project. We already had our share. First, we spent around 3,5 years to devise and adjust the protocols and obtain the ethical approvals, which was complicated owing to the radical interdisciplinary character of the overall EATWELL project, and the clash between cultural values engrained in these ethical regulations. Another challenge has been the considerable administration; it has been very difficult to align the kind of bills collected in Bhutan with the requirements of the Norwegian administration. Hence it has literally been taking hundreds of hours per year to get these refunded and with the result of ongoing personal financial losses as many expenses and bills are not accepted. Additionally, it is time-consuming for both us and the receivers to make the bills as acceptable as possible.

We also value highly the inputs from the selected communities and have also taken time to conduct initial community consultations about this phase.

As the ethical approvals, microbiome protocols, and data management and security procedures got finalized, it was soon clear that the logistics of getting all the materials would prove to be quite an undertaking. When Dr Raul from the Raes Lab in Belgium visited Laya last summer, it was clear from the first day that the devised protocol would not work in Laya and consequently the protocol and paperwork had to be adjusted. In addition, when Dr Marianne from OsloMet and Kanchan, my PhD student from UiA conducted an initial training on the nutritional aspects of the integrated survey, followed by a reduced piloting, it became clear we had to modify the survey to render it more manageable for the RA’s and make it resonate more closely to the local cultural understandings and realities. Interestingly, the so-called validated tools, probably validated in other context, seemed to create most challenges in the relevance and understanding by our respondents.

Especially the protocol for stool sample collection in the longitudinal part had to undergo considerable adjustments, as it may take days take stool samples from the herder camps back to the health centre. As a consequence, several tests had to be conducted to compare the new protocol with the one devised for the cross-sectional part to determine similarities and possible differences between protocols.

Due to the development of two different protocols, the logistics thereby became even more complicated, as different kits had to be ordered to the lab in Belgium alongside all other materials, including the portable freezers. Thereafter they were sent to our partner in Bhutan, Royal Centres for Disease Control (RCDC), after which the 13 boxes were transported to my place.

All the material had to be counted, controlled, and repacked according to the locations where we conduct this phase of the research: Laya, Buli and Thimphu and surroundings. This required the division of many materials, additional buying of materials for gifts for the respondents, and materials to pack all the stuff to pack it all safely for transport. For Laya it also had to be packed in such a way that it could be carried on horseback, which means that the boxes and bags should not weigh more than 25 kg per side of the horse. Also, everything had to be packed such that it would not get wet in the event of rainfall. It was good to get the help from a horseman and an experienced friend from Laya to make this work.

We also had to carefully plan the amount of food supplies required for 1 month and for 13 people during our stay in Laya. We bought these supplies before we left as well as underway, which increased the amount of luggage after the horseman had a look at it.

All this was organized while the monthlong training of the newly hired RA’s, organized through our partner RTC, was ongoing so as to prepare them for conducting the EATWELL cover story, informed consent forms, 24-hour recall, integrated questionnaire and the microbiome protocols.

After an additional delay of three weeks due to a severe roadblock due to heavy snowfall, we thus finally left to Laya with a heavy load of materials and bags, where we were greeted by Prof Francoise Pommaret, who is an advisor on our project, and Prof Jelle Wouters from the Himalayan Centre for Environmental Humanities at RTC.

The first stop on the way was Gasa town, where we emptied the bus because it could not drive on the road stretch between Gasa and the army point at Taksti makang, and thus returned to Thimphu.

The next day we had some further training and had a meeting in the afternoon with the Dasho Dzongdag (district governor) and assistant district health officer of the Gasa District in the Dzong.

Meanwhile, our host in Laya was preparing the places of stay as well as two additional pick-up trucks and an estimated 30 horses to carry everything up to Laya from Taksti makang.

Tuesday morning, at 8.30, the two additional pick-up trucks arrived, and everybody helped with the packing, which took an hour. Happily, these drivers are used to packing lots of things and driving this dangerous road.

After a 2-hours drive, we arrived at Taksti makang. The place was full of horses and tents, some bolero pick-up trucks, and lots of hay to feed the horses. Currently, many people from Laya are returning from their winter stay in Punakha and Gasa and are migrating back with many food and other items to be carried up to Laya. Amidst the bustling atmosphere, we could see the horsemen preparing the horses to carry our stuff up to nearly 3900 meters. Our host had organized these, but as we had bought additional food supplies, we soon noticed that we required more horses than reserved. Instead of 30 horses, we needed 36 to carry everything, and this in addition to the 5 porters who would carry the 44 kg generator and the -80 freezer on their backs. These were dropped at the health centre alongside the 220 liters of petrol. It was a challenging hike, at least when not yet adapted to the altitude.

The rest was deposited at the place where we would stay and where all the goods were divided, and the sleeping places were allocated. The 8 male RA’s share one small house and the Anthro RA, Dr Neyzang, female RA’s and I were allocated rooms in the main house.

Next morning we discussed the division of tasks in terms of food preparation and dishwashing, and later we started assembling the first stool sample kits.

But, before we could start the work for full, it would be in line with the local culture to have a puja and some offerings to the regional deity Ap Goma and the local tsen (or spirit) Ap Mayep for the success of the project and the health and wellbeing of the hosts and the project collaborators, and so we did. This happened on an auspicious day and time as calculated by the local astrologer.

Thereafter, we returned to working on the logistics of the project, such as the assembling of the other kits, holding of community meetings, installing the generator and freezer, which proved to more complicated, and conducting community meetings for recruitment of participants.

Logistics continue to take all our time indeed, but we are hopeful that we can start with the research soon. We at least made it to Laya with everything!