available. Few studies in nutrition have comprehensively examined the steps of implementation and utilization in pilot interventions, thus limiting the interpretation of impacts of interventions. In this analysis we have mapped pathways of how a novel intervention to promote breast milk feeding was implemented and utilized to enable contextually grounded interpretation of results, differentiate poor design from poor implementation, and identify factors that might influence the utilization of interventions. Objective: We used program impact pathway (PIP) analysis to understand study an intervention that installed breast milk supportive technology such as breast pumps and breast milk pasteurization device in a garment factory setting to promote expressed breast milk feeding among low income working women in Bangladesh. Methods: The study was conducted among 70 mothers working in a readymade garment factory with <1 year old infants in Gazipur, Bangladesh from August 2015-March 2016. The PIP was developed through an iterative process with the program implementation team; the PIP then guided the choice of methods and tools. Using mixed methods, we reviewed the content of training materials for implementation staff, measured their IYCF knowledge (n = 2), observed their communication with mothers (n = 10), and examined factors influencing promotion of IYCF practices and their trial and adoption by mothers (n = 62). Results: Implementation staff demonstrated good knowledge and maintained fidelity to the intervention to a large extent. Mothers identified them as their primary sources of information, and a majority of mothers tried recommended breast-feeding practices. Key facilitators included family support, positive attitude towards breast milk feeding and perception of cost reduction whereas lack of time, lack of care givers and perceived negative health outcome of the infant were salient barriers to adopting recommended practices. Conclusion: Using a PIP analysis identified critical issues pertaining to implementation (e.g., the role of work breaks and supervisor support) and utilization such as supportive care givers at home, supplementary food for lactating women that need further research and programmatic attention. These conclusions will help address the needs of women in the workforce.

**Keywords:** Breastfeeding, pasteurization, urban, Bangladesh, working mother

COMBATING MALNUTRITION IN MAHARASHTRA

Krishna, Vandana.

MA (Economics). M.Phil (Economic Planning). IAS. Principal Secretary. Finance and Director General. Rajmata Jijau Maternal Child Health and Nutrition Mission. Government of Maharashtra. India.

**Background:** In Maharashtra, 39% of children below the age of two years were stunted in 2005-06 and 19.9% were wasted. Maharashtra was the first state in the country to take a decision to tackle malnutrition in 'Mission - mode' with the purpose of reducing child malnutrition by focusing on the first 1000 days from conception. The Rajmata Jijau Mother - Child Health & Nutrition Mission was thus launched in its first phase in 2005 and the second phase in 2011.

**Objective:** To describe the goals of the mission, its activities, and its impact and future policies for sustaining the impact of the mission.

**Methods:** This is a description of policies that enabled the development of the mission and its goals to significantly reduce rates of child malnutrition by targeting mother and child nutrition for the first 1000 days of from conception.

**Results:** The mission was funded by the state and received technical support from UNICEF. It had the highest political commitment of the Chief Minister and a cabinet approval. There was a phase wise expansion of the mission over five years to cover all 0-6 year old children leveraging on the existing tracking systems used by the public health department and the Integrated Child Development Scheme (ICDS) for service delivery. The mission specially focused on high burden districts, blocks and tribal areas. The three pillars were i) capacity building and skill development, ii) inter-sectoral collaborations between government, non-government organizations, UN bodies like UNICEF and the corporate sector, iii) community ownership and participation. The phase wise activities were as follows: a) establishment of Nutrition Rehabilitation Centres (NRCs) at District Hospitals for management of SAM (Severe Acute Malnutrition) and MAM (Moderate Acute Malnutrition) cases b) training of Anganwadi workers in the new WHO growth standards, taking height and MUAC measurements, identifying wasting i.e. SAM and MAM, c) establishment of Village Child Development Center (VCDC) and day care centres in tribal areas for under 3 children in phase I. In phase II, partnerships were established with the government bodies like the ICDS, National Rural Health Mission (NRHM), public Health department, NGOs, civil society and corporate sector to help achieve the mission goals.

The impact of the mission is evident from the improved rates of stunting and wasting from 39.0% to 23.3% and from 19.9% to 16.3% respectively and the fact that other states are also considering its adoption for malnutrition alleviation. The mission provides a holistic approach for addressing malnutrition through inter-sectoral collaboration in the areas of health, nutrition, agriculture, WASH (water, sanitation and hygiene), education, food security, agriculture, tribal and rural livelihoods. The public health department has taken over ownership of the nutrition mission and has proposed a comprehensive MIYCN (Maternal, Infant and Young Child Nutrition) policy which covers adolescent health, maternal health during pregnancy and lactation, breast feeding and complementary feeding.

**Conclusion:** The mission demonstrates that high level political commitment and inter-sectoral collaborations help to reduce malnutrition and provide sustainability for mainstreaming comprehensive nutritional interventions.

**Keywords:** Malnutrition, Nutrition Mission, Stunting, Severe Acute Malnutrition and Moderate Acute Malnutrition
# OVERVIEW OF THE PAKISTAN IYCF POLICY ENVIRONMENT

(1)Hazie, Tabish; (2)Mahmood, Hana.

(1)Principal Investigator. Maternal, Neonatal and Child Health Research Network (MNCHRN) and SAIFRN-Pakistan. Pakistan;

(2)Project Director. Maternal, Neonatal and Child Health Research Network (MNCHRN). International Research Force (IRF). Pakistan.

High levels of malnutrition have serious consequences on the health and survival of infants and young children. Almost 44% of children in Pakistan are stunted, 30% are underweight and 15 % are severely wasted according to the National Nutrition Survey of 2011. One of the major reasons for such high rates of malnutrition is inappropriate Infant and Young Child Feeding (IYCF) practices which includes breastfeeding and complementary feeding. Association of inappropriate feeding practices with malnutrition has been shown by various studies. The World Health Organization (WHO) and United Nations International Children's Emergency Fund (UNICEF), with the broad participation of many stakeholders, developed the Global Strategy for IYCF to revitalize global commitment for improving infant and young child nutrition by promoting, protecting and supporting appropriate IYCF. Effective interventions for IYCF are well established, including but not limited to interventions for skilled support by the health system, interventions for community based counseling/support and IYCF in emergency circumstances. Additionally, training and capacity building of community health workers to deliver IYCF support and intervention is also imperative. But for the best outcomes at national level, such interventions need to be supported by appropriate policies. And the development of these policies is influenced by the major stakeholders of the policy environment including the ministry, nutrition officers, academicians, researchers, development partners, etc.

The health policy environment of Pakistan has been markedly influenced by its unsteady political environment especially, after the devolution of the Ministry of Health in 2011, whereby a number of federal health responsibilities were placed under the jurisdiction of other government ministries/divisions. However, within the past couple of years an improvement has been observed at the policy level showing commitment of the major stakeholders to the cause. This paper outlines the progress made so far in the IYCF policy environment in terms of implementation, especially of the provinces of Punjab and Sindh, two of the most populous provinces in Pakistan with the most rapid pace towards development.

**Keywords:** Malnutrition, IYCF, policy, Pakistan

# OPPORTUNITIES TO STRENGTHEN THE POLICY ENVIRONMENT TO BETTER SUPPORT APPROPRIATE IYCF AND REDUCE CHILDHOOD MALNUTRITION: SRI LANKAN EXPERIENCE

(1)Jayawickrama, Hiranya; (2)Senarath, Upul; (3)Godakandage, Sanjeeva.

(1)MBBS. MSc. MD.Consultant Community Physician. National Programme Manager Child Nutrition. Family Health Bureau. Ministry of Health, Nutrition & Indigenous Medicine. Sri Lanka;

(2)Professor in Community Medicine. Faculty of Medicine. University of Colombo. Sri Lanka.; (3)Consultant Community Physician. Family Health Bureau. Ministry of Health, Nutrition and Indigenous Medicine. Sri Lanka.

Sri Lanka provides free health for all through a well established preventive and curative government health service island wide. Family Health Bureau of the Ministry of Health is assigned with the responsibility for the implementation of MCH programme where maternal and child nutrition services are delivered as an integrated package. All relevant evidence based interventions are implemented throughout life cycle at all levels of health system.

National Nutrition Policy (2010), MCH Policy (2012), MNH strategic plan (2012-2016), National Strategy for IYCF 2015-2020, Code to regulate marketing of designated products provide guidance for implementation. Formal training packages on IYCF for capacity building of health personnel ingrained in the MCH programme.

A well established mechanism is in place to strengthen policy implementation at various levels. At the Presidential Secretariat National Nutrition Secretariat has been established to facilitate multi-sector collaboration to improve nutrition; National Nutrition Council comprises of senior ministers and chaired by HE the President, National Nutrition Steering Committee consists of secretaries of relevant ministries and Technical Advisory Committee provides technical guidance for policy formulation. At Ministry of Health, Nutrition Steering Committee (NSC) chaired by the secretary health functions as a multi-sector platform to address nutrition issues in health sector. Two subcommittees of this NSC, Maternal and Child Nutrition subcommittee and Nutrition Communication subcommittee chaired by the Deputy Director General Public Health Services function as technical advisory bodies to make recommendations to the NSC which includes advice on policy formulation, planning, financial allocation, resource management and other relevant issues pertaining to MCN and guidance in the development, review/revision of policies, strategies, guidelines and other relevant documents in relation to maternal and child nutrition.

**Keywords:** Child malnutrition. IYCF. Policy.
# TOWARD A NEW PARADIGM FOR ASSESSING CHILD GROWTH: A CAPABILITY APPROACH

## HOW SHOULD WE DEFINE HEALTHY CHILD GROWTH?

(1)Haisma, Hinke; (2)Yousefzadeh Faal Dhagati, Sepideh; (3)Boele, Pieter.

(1)PhD. Nutritionist. Population Research Centre. Faculty of Spatial Sciences. University of Groningen. Netherlands.; (2)PhD. Political Scientist. Population Research Centre. Faculty of Spatial Sciences. University of Groningen. Netherlands; (3)PhD. Philosopher. Globalisation Studies Groningen. Faculty of Arts. University of Groningen. Netherlands.

Measuring a child's weight and height has been central to the assessment of child growth. This has had implications not only on how we identify poorly or healthily growing children but also on how we assess the achievements of the targets for the Millennium Development Goals, and more recently the Sustainable Development Goals. Over the past decades, the focus has shifted from a mere biomedical approach to a social epidemiological approach, and several multi-sectoral frameworks have been developed in the recent years. Although, these frameworks have allowed an increased insight into the social determinants of child growth, they still fail to address how people's capabilities are central to healthy growth. We argue that there is a need for advancing current frameworks and monitoring practices toward a capability approach to child growth to allow better targeting of inequity and inequalities. In such an approach child growth is considered as a plural space, including but not restricted to the physical dimension. Other dimensions could be derived from the broader clusters love and care, mental well-being, bodily integrity and safety, social relations, participation, education, freedom from economic and non-economic exploitation, shelter and environment, leisure activities, respect, religion and identity, time autonomy, and mobility as derived from the Rights of the Children. Dimensions and indicators could be identified using theories from other disciplines, such as demography and evolutionary biology. The nutrition transition theory helps to understand that we may want to deal with low birth weight differently depending on a countries stage in the nutrition transition: in countries where low birth weight is highly prevalent, rapid growth may result in adverse later health outcomes and the advice to parents should be accordingly. Theories from evolutionary biology, such as life offspring theory, or parent offspring conflict theory are indicative of the importance of including for example, birth order or maternal body composition as indicators of child growth. By conceptualising child growth as a multi-dimensional outcome, we fundamentally change our perspective to child growth, and open up new ways for policies and interventions. In such a capability approach societal and parental context will be embedded into the growth measurements. This will have consequences not just on how children are being measured, but also on how health professionals will be trained, how care-givers will be counselled and how policies and interventions will be

developed. Eventually, this could contribute to improved morbidity and mortality rates.

**Keywords:** Child growth, Capability approach, Inequalities, Sustainable Development Goals.

**Further collaborators**

IUNS Task Force "Towards Multi-dimensional indicators of Child Growth and Development"

## CHILD HEALTH: JUSTICE AND CAPABILITIES

Venkatapuram, Sridhar.

Senior Lecturer. Global Health & Philosophy. Dept Global Health & Social Medicine. King's College London. London. United Kingdom.

The initial, modern idea for the theory of human capabilities can be traced back to the 1979 Tanner Lecture on Human Values entitled "Equality of what?" given by the Nobel Prize laureate Amartya Sen. In the lecture he identified the weaknesses of measuring inequality, poverty and well-being purely in terms of income or resources, negative liberties, basic needs, or utility (happiness) and suggested human "capabilities" and capabilities equality/equity as a more coherent alternative. Over the three decades since the lecture, and following from many publications by Sen and others on the subject, an extensive interdisciplinary school of thought has developed around the initial idea of human capabilities. Scholars, researchers, and practitioners have developed and used the approach as an analytical and normative framework in which to ground theoretical, evaluative, and prospective analyses as well as concrete applications in a broad range of fields. These have included the analysis and measurement of national wellbeing, poverty and inequality, the prescription and design of welfare policies, the modelling and evaluation of development projects, and the assessment of living standards. The papers in the present task force symposium are applying the capabilities approach to child growth and wellbeing.

This paper will present the basic conceptual components of the capabilities approach such as resources, capabilities, conversion factors, functionings and how these concepts can be applied in measurements of child growth. The discussion will then explain how capabilities are seen to be both constitutive of human wellbeing as well as instrumental to human wellbeing; both the means and ends of policy. If the argument that human wellbeing should be seen in terms of capabilities is convincing, then the argument is that measuring wellbeing is in the space of capabilities, and the causes of the contraction or expansion of capabilities encompass biological and social factors. This has important implications when applied in child growth. This conceptual framework of human wellbeing in general, and in child growth in particular in terms of capabilities will then be situated in discussions about equity and justice.

**Keywords:** Capabilities approach, Amartya Sen, wellbeing, equity, justice.
## ALL ELSE EQUAL – A CAPABILITY FRAMEWORK TO CHILD GROWTH MEASUREMENT

(1)Yousefzadeh Faal Dhagati, Sepideh

(1)Population Research Center, Faculty of Spatial Sciences, University of Groningen, Groningen, The Netherlands.

In the past few decades, scholars of child nutrition and healthy growth have increasingly become interested in scrutinizing the social determinants of growth faltering. Those efforts were crucial to argue that child growth is not only about nutritional inputs, but also about the economic arrangements and resource allocations, societal settings and individual differences. Nevertheless, when it comes to the monitoring and measurement of child growth, anthropometric outcomes remain to be the sole output to be evaluated. In this paper, we claim that, by measuring the anthropometric indicators as the key output, we do not pay due attention to the plurality of elements that interact together to make healthy growth.

The paper applies the Capability Framework to Child Growth (CFCG) as the conceptual framework. The CFCG helps bringing a multidimensional paradigm to the measurement level. This paper defines child healthy growth as the process of continuous physical, psychological and social change that builds a child's capacities to maximize life chances at the individual and societal level. The paper aims to examine how a CFCG gives insights into multiple attributes of healthy growth as a set of capabilities. I use Demographic Health Survey data on India (2005-2006) as the case study. Capabilities of healthy growth are defined under eight core dimensions: life and physical health; love and care; bodily integrity; education; shelter and environment; respect and personal autonomy; social relations and mobility

Some of the findings of this paper include:

Of all dimensions of child healthy growth, the mean achieved functionings are lowest under the “utilization of childcare services,” “information”, and “sanitation”. Children with higher and lower functionings for healthy growth are not equal in their parental education and in using prenatal and breastfeeding services. Furthermore, our analysis suggest that improving utilization of prenatal services, information, sanitation and birth registration improves height for age (fertile functionings). This is while disadvantage under physical integrity (domestic violence) and service dignity has negative impacts on height for age (corrosive effect).

At the first glance, our results may sound similar to studies that apply Social Epidemiology (SE). The paper elaborates in detail on differences between CFCG and

SE at the conceptual and empirical level. However, one key difference is about distinguishing social and individual characteristics (conversion factors) from capabilities. In SE, 'predictors' include factors such as age, sex or religion (individual or social characteristics), as well as capabilities (education or employment). The CFCG distinguishes between the two concepts. Focusing on capabilities helps us acknowledging the 'agency' of caregivers.

**Keywords:** Child growth, Capability Approach, Fuzzy analysis

**Further collaborators:** Hinke Haisma, University of Groningen, Faculty of Spatial Sciences, Population Research Centre, the Netherlands

## Track 3: Public Health Nutrition and Environment

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### HISTORY AND LEGAL CHALLENGES OF CREATING AND PROTECTING A SUGAR-SWEETENED BEVERAGE TAX IN MEXICO: LESSONS FOR THE GLOBE

#### CAMPAIGN STRATEGY FOR A TAX ON SUGAR-SWEETENED BEVERAGES IN MEXICO

(1)Calvillo, Alejandro; (2)Espinosa, Fiorella.

(1)BS. Sociology. Executive Director. El Poder del Consumidor. Mexico; (2)Nutritional Health Researcher. El Poder del Consumidor. Mexico.

**Background and objectives:** Mexican civil society organizations together with academics and public interest lobbyists played a fundamental role in securing the approval of a 1-peso-per-liter tax ($0.05 U.S. dollars [USD]) on sugar-sweetened beverages, and subsequently have succeeded in defending this fiscal measure against attempts of the industry to reduce and eliminate it.

**Methods:** The tax on sugary beverages in Mexico was achieved through a three-pronged effort, that included academics, a large network of civil society organizations, and lobbyists working in the public interest. The civil society campaign strategy was composed of three stages: a) exposing the human drama of obesity and diabetes, including its catastrophic future consequences, in order to generate the urgency to act; B) highlighting one of the main causes of this tragedy, which is the consumption of sugary drinks and, c) presenting a proposal for the first action necessary to confront this situation, a tax on sugary drinks. The campaign focused on transmitting these three campaign stages through both traditional media and social networks using a variety of tools: academic forums, public demonstrations, public campaigns (in traditional media), formal and ironic videos (in social networks). The campaign also ensured the maintenance of a strong and consistent presence in the media and the capacity to react quickly to the strategies of the beverage industry to stop this measure.

**Results:** The tax was presented by the executive branch as part of the 2013 fiscal reform package and was approved by Congress despite strong lobbying of the beverage industry, which experienced its highest sales per capita in Mexico, the country that is also home to the largest Coca Cola bottling plant in the world. In 2015, civil society, academia and public interest lobbyists were able to curb the industry's attempt to reduce the tax levied on sugary drinks that contained under a certain threshold of sugar.

**Conclusions:** The experience of the struggle for a sugary-sweetened beverage tax in Mexico demonstrates three important lessons. First, the importance of collaboration among academia, civil society organizations, and the work of public interest lobbyists with decision-makers. These three axes are essential to
provide evidence and build consensus for the need for a tax on these products. Secondly, the Mexican experience demonstrates the need to make the dimension of the health problem resulting from the consumption of these drinks, visible, in order to create awareness across the population for the need to act, and consistently relying on scientific evidence to support such action. Thirdly, the importance of rigorous activism to maintain the topic in the public eye and to constantly explore diverse and attractive ways of communicating and engaging the public on the issue.

**Keywords:** Sugar-sweetened beverage tax. campaign strategy. coalition building

## LOBBYING AND LEGAL STRATEGY

**Background and objectives:** The lobbying and legal activities for the promotion and approval of the excise tax on Sugar Sweetened Beverages (SSBs) in Mexico started in early 2012, as part of a broad advocacy strategy on obesity prevention that included the participation of different stakeholders, including the National Institute of Public Health (research purposes), the non-governmental organization El Poder del Consumidor (communications and awareness purposes, as well as strategic litigation) and the advocacy firm Polithink (design and carrying out of the advocacy and the legislative strategy).

The tax is conceived as part of a comprehensive policy agenda on obesity prevention in Mexico, which includes the regulations on child-targeted marketing, front-of-package labeling and school food policy and nutrition, as well as the access to potable water in schools and public spaces. The decision to choose the tax as the first policy to be promoted was based on an analysis of adequate timing, political scenarios, implementation processes, short-term effects in consumption and awareness, and the possibility of creating a strong social and political debate.

**Methods:** The main objective of the lobbying strategy was to position the tax in the political and legislative agendas, by taking into consideration several key elements for the promotion of the tax with the Federal Government, and for the introduction and approval of the tax in Congress. The six key elements of the lobbying strategy were: problem identification; context analysis; stakeholder mapping and engagement; definition of policy needs; communication strategy; and political outreach. The strategy considered a combination of direct lobbying activities performed by Polithink, and advocacy activities performed by civil society organizations and coalitions (such as the ContraPESO Coalition).

**Results:** The lobbying strategy was developed in four stages: (1) The drafting of the bill; (2) The introduction of the bill in Congress; (3) The winning of the debate; (4) and the Voting of the bill

in Congress. It is important to highlight that the lobbying activities carried out through these stages were not isolated to the research and communication activities done by the other partners. Hence, it is not coincidence that the launch of some awareness campaigns, or the release of research studies, matched key congressional timings, which supported advocacy strategies.

**Conclusion:** The tax was approved on October 2013 and implemented on January 2014 as a $1 peso per liter on all SSBs. Following this win, the lobbying strategy was shaped to defend the tax from industry proposals to discard it or reduce it after its first year of implementation, and to increase it to an optimal level of a $2 pesos per liter (a 20% rate based on international recommendations).

**Keywords:** Advocacy. lobbying. legal strategy. civil society coalitions. political timing

**Conflict of Interest disclosure:** Funding came primarily from Bloomberg Philanthropies as part of the Global Obesity Prevention Program. Polithink and the authors do not have financial relationships or conflict of interests to disclose.

## RESEARCH TO PROMOTE POLICY CHANGE AND MEASURE IMPACT OF POLICIES

Rivera, Juan.

Professor. Health and Nutrition Research Center. National Institute of Public Health. Mexico.

**Background and objectives:** México is facing an obesity epidemic (overweight and obesity) of 70% in adults and about 33% in school-age children and adolescents. The National Public Health Institute in Mexico (INSP) has generated scientific evidence supporting the design of obesity prevention policy. Monitoring though periodic National Health and Nutrition Surveys since 1988 has provided information about the magnitude, distribution and trends of excess BMI during the last three decades. From 1988 to 2012, obesity in adult women increased from 9.5% to 35.2%. This dramatic rise alerted the government about the urgent need for interventions.

**Methods:** INSP has conducted the following set of studies aimed at generating information to inform policymaking: a) Monitoring changes in key drivers of obesity have been useful to identify shifts in the diet that may be responsible for the increase of obesity. b) Formative research allowed recognition of obesity promoting elements in different environments and barriers for the adoption of healthy eating and physical activity. c) Randomized efficacy trials have tested effects of specific interventions. d) The evaluation of policy actions has provided feedback for redesign or improvements.

**Results:** The research conducted by INSP to justify the SSB's tax implemented in Mexico since 2014 is an example of the use of evidence to support the design of policies. The study of the dietary intake of the Mexican population, using 24-hour recall methodology, showed that about 25% of total energy intake in the diet was provided by sugar-sweetened beverages and non-basic energy-dense processed-foods (referred to by the population as “junk food”). One of the known dietary risk factors for obesity is the

<footnote>(1)Rocha Camarena, Adriana; (2)Arango Perez, José Alonso;</footnote>

<footnote>(3)Encarnación Cruz, Luis Manuel.</footnote>

<footnote>(1)BS. Economics. Civil Society and Legislative Affairs Director at Polithink. Mexico; (2)BS. Political Science. Founder and General Director at Polithink. Mexico; (3)BS. International Affairs. Director at Salud Critica and Coordinator of the ContrPESO Coalition. Mexico.</footnote>
high intake of added sugars and particularly of sugar-sweetened beverages. It also showed that the average intake of added sugars is 12.5% of total energy intake, well above the WHO recommendations. Moreover, SSB's contribute with 70% of all added sugars. Estimations of own and cross price elasticity of the demand for SSB showed that the demand of these products was elastic and that substitutes were healthy beverages. These findings indicated that taxes would result in a reduction in the intake of SSB's. Modeling effects of different tax levels on weight loss and diabetes prevention provided evidence about potential impacts of the tax on health. This scientific evidence produced by INSP, along with the information about the negative effects of SSB intake on health, was instrumental for approval of the SSB's tax by the congress in 2013.

**Conclusion:** INSP along with the University of North Carolina (UNC) have evaluated the effects of the tax on prices and on the intake of SSBs. Results indicate that tax passed along to consumers for SSBs in general and that the purchases of taxed products have decreased while those of untaxed substitutes have increased. In addition, the tax has generated revenue that should be used to fund obesity prevention actions and for partially correcting high negative externalities. The Mexican experience has demonstrated that taxing SSB and other unhealthy foods are successful components of a multifaceted prevention strategy.

**Keywords:** Evidence based public health. tax sugar-sweetened beverages. Mexico

ened beverages, processed meat and also red meat are predictors of worse health outcomes. Theoretical measures of a healthy diet (e.g. the Mediterranean Diet Score, the Health Eating Index and the Baltic Sea Diet Score) are also quite consistent predictors of positive health outcomes. The number of randomized, food-based clinical trials is lower, but positive results have been found for, e.g., adding olive oil or nuts to the diet.

The European food-based dietary guidelines are at first glance rather similar, but some important differences exist. The main differences are apparently related to how much the above mentioned scientific basis for food vs. health associations are applied. Several guidelines still include butter and oils/margarine in the same “box”, they do not separate whole-grain cereals from refined grains and meat is recommended to the same extent as fish. Others are now using a more detailed classification of foods and these food-based dietary guidelines can be regarded as more science-based.

Some researchers have suggested that since the food-based dietary guidelines pay attention also to non-nutrients in the foods (e.g. flavonoids), they could even replace the nutrient-based guidelines. I don't totally agree with this suggestion, since surveillance and food-policies are still partly dependent also on information related to nutrient intakes and distributions. However, the role of food-based dietary guidelines is clearly emerging.

**Keywords:** Food, diet, recommendations, guidelines, health

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# DIETARY GUIDELINES IN EUROPE: RECENT DEVELOPMENTS

## FOOD BASED DIETARY GUIDELINES IN EUROPE AND THEIR SCIENTIFIC BASIS

Fogelholm, Mikael.

University of Helsinki, Department of Food and Environmental Sciences.

Nutrition recommendations can be divided into nutrient-based recommendation and food-based dietary guidelines. Traditionally, the food-based guidelines were merely a graphical example of how individuals and populations could reach the nutrient-based recommendations. Hence, these guidelines could be regarded more as communication, not as something based on solid science. The situation is different at present. This is mainly due to a great number of recent population-based cohort studies linking foods, food groups and entire diets to health outcomes.

Studying the relationships between foods and health is difficult and therefore conclusions must be based on a considerable number of studies. Some patterns are, fortunately, quite consistent: higher consumption of whole-grain cereals, fruit, vegetables, legumes, fish and oil (particularly olive oil) are predictors of, e.g., lower mortality lower incidence of type 2 diabetes and cardiovascular diseases. In contrast, higher consumption of sugar-sweet-

## THE ROLE OF FOOD BASED DIETARY GUIDELINES IN TRANSLATING NUTRITIONAL RECOMMENDATIONS FOR PUBLIC USE

MacDonald, Ian A.

University of Nottingham.

The basic principle underlying nutritional recommendations is that the essential nutrients need to be identified and the amounts needed to prevent deficiency disease arising need to be determined. For most essential nutrients (except for energy) for which there are such recommendations, the latter exceed the minimum requirement to achieve maximum population protection. In order to derive these recommendations, it is necessary to have quantitative information about the role of the nutrient, and the values then derived (whether RDA, DRV, DRI) are based on a statistical analysis of the data available such that the recommendation is normally 2 SDs above the mean intake, as this will prevent deficiency in the majority of the population. Clearly attitudes towards nutrition and health have moved on substantially from the 'prevention of nutritional deficiencies' which dominated nutritional science and public health in the early to mid parts of the 20th Century, but this is not reflected in the principles underlying dietary recommendations. Thus, achieving optimum health is the goal of good nutrition but we do not have any evidence based dietary recommendations which are designed to achieve this.

The UK Scientific Advisory Committee on Nutrition released a report on Carbohydrates and Health in 2015, which recommended a change in one of the Carbohydrate DRVs (namely for dietary
fibre) and also recommended that there should not be a reference value for Free sugars as these were not essential components of the diet. The report did recommend limiting Free Sugars intake to no more than 5% of total energy in order to minimise disease risk and promote good oral and cardiometabolic health.

The challenge for Public Health professionals and the general public itself, is how to translate the quantitative nutrient recommendations into food based guidelines. Different countries use different approaches - plates, wheels, pyramids etc - and some are simply qualitative whereas others are more prescriptive about how often certain foods should be eaten and how others should be limited. This presentation will compare some of the major national food based dietary guidelines and show how easy, or otherwise, it is to turn these guidelines into actual meals and diets. The other challenge about food based dietary guidelines is of course that individual foods are usually sources of more than one nutrient and so whilst the guidelines may be phrased in simple language, the actual contributions to achieving a good nutritional status are much more complex.

**Keywords:** Dietary Reference Values, Food based dietary guidelines, optimum health

**Conflict of Interest disclosure:** The Author has Advisory Board roles with Mars Inc and Mars Europe, Nestle and IKEA. All honoraria are paid to the University of Nottingham and used for research purposes.

The Author is a member of the UK Government Scientific Advisory Committee on Nutrition and Chaired its Carbohydrates Working Group

## FOOD BASED DIETARY GUIDELINES: OPTIONS FOR REGIONAL INITIATIVES

(1)Sobajic, Sladjana; (2)Boeing, Heiner.

(1)PhD. Pharmacist. Department of Bromatology. Faculty of Pharmacy-University of Belgrade. Serbia; (2)PhD. Nutritionist. Department of Epidemiology. German Institute of Human Nutrition. Potsdam-Rehbruecke. Germany.

Food-based dietary guidelines (FBDGs) are recognized as modern, simple, and practical tools in public nutritional education, as well as in process of forming national strategies for dietary improvement. Their overall goal is to recommend the intake of certain foods and food groups and their combinations in order to provide the adequate intake of all necessary nutrients. Since different countries have different nutrition situation, different food culture, specific nutrition-related health problems, development of specific national FBDGs are of vital importance. In last two decades the process of developing and implementing national FBDGs has received increased attention from national and international scientific bodies. Food and Agricultural Organization (FAO) has published guidelines for FDBG development and has formed The Nutrition Education and Consumer Awareness Group with a task to help developing FBDG in different countries based on scientific principles. The European International Life Sciences Institute

(ILSI Europe) has also organized workshops and published document on experiences in FBDG development in 2004. European Food Safety Authority (EFSA) gave scientific opinion on FBDG in 2009 intended for the whole European region.

The process of scientifically-based national FBDG development consists of several steps and requires existence of reliable data on country specific nutrition-related health problems and dietary deficits, as well as data on national specific food consumption patterns and food composition tables. Unfortunately, for many low-income countries those data are either unavailable or not collected in standardized way, and adequate expertise in data interpretation is often lacking. One solution for mentioned problems could be development of FBDG on regional level that could be used in countries with similar geographic characteristics and dietary cultural heritage.

Federation of European Nutritional Societies (FENS) in order to assist South-East European countries in the process of FBDG development organized at the end of 2016 a workshop to discuss the status and potential developments of dietary recommendations and guidelines in this region. The representatives from public health institutions from Slovenia, Croatia, Serbia, Montenegro, Macedonia, Bosnia and Herzegovina, Romania and Bulgaria, participated at the workshop. The workshop intention was to establish a nucleus of scientists from nutrition and public health that could work conceptually and practically at improving and aligning such guidelines in this region. It was recognized that there is a high potential for capacity building in this area which could best be addressed by collaboration among the local stakeholders and input from those who already went through phases of establishing such guidelines. The following conclusions were drawn: (1) The Belgium food-based dietary guidelines, currently under development, could be a good show case for the South-Eastern countries; and (2) for those countries which are candidates to become a member of the European Union, a common initiative might be worthwhile to ask for expertise and funds for meetings and capacity building within the region. It was the common conviction that the countries of South Eastern Europe share similar backgrounds in scientific infrastructure and culinary practices and that some of the recommendations and guidelines should been issued not nationally but for the region.

**Keywords:** FBDG development, South-Eastern Europe region

## NOVEL DEVELOPMENTS IN FOOD BASED DIETARY GUIDELINES

Boeing, Heiner.

German institute of Human Nutrition.

There is a worldwide interest to establish Food Based Dietary Guidelines (FBDGs) for each country or region as a tool to counsel the population and to formulate health/nutritional policy aims. An excellent overview of the situation is currently being available at the website of FAO. This international organization together with WHO can also refer to a number of documents – some of
them from the 1990ies – that describe the background of the FB-DG-concept. In modern terms, FBDGs are a translational tool of nutritional scientific knowledge into a practical food guide. FB-DGs should consider the dietary practice and understanding of the population by giving guidance regarding the intake of food and food groups. In contrast to nutrients, there is a high common understanding what a specific food or food group include. Thus, in the WHO/FAO documents, the communication of FBDGs is an important aspect. FBDGs are often communicated as simple and understandable graphics such as plates, cycles, and pyramids. The documents also highlight that the process of developing FB-DGs for a country/region should involve as many stakeholder as possible.

EFSA, the European Food Standard Agency, also contributed to the concept of FBDGs in 2009 by an own panel-document, available as article in the EFSA-Journal. This document gave guidance how to establish regional/national FBDGs in the European Union.

We should realize that some of the basic documents on FBDG are reflecting thoughts that had been partly developed two decades ago. This might not be bad but it is the question whether these documents still provide a suitable frame that helps to issue a FBDG for each region/country. In particular, with more FBDGs, the need is increasing to harmonize the scientific concepts underlying a FBDG. We already learned from the previous lectures that different criteria are addressed in the European FBDGs such as risk reduction or meeting the nutrient recommendations. In addition, new areas of concerns recently became obvious in relation to food use such as sustainability and energy overflow. It is therefore the question, on which basis new initiatives such as the South-Eastern-Europe FENS initiative should work.

In the upcoming time, therefore, the development of FBDGs should been given an updated concept. This regards several aspects ranging from the scientific basis to the graphical display. One aspect is the scientific basis and the way evidence is generated and used. It is obvious that only solid evidence can be used to guide the population regarding a healthy diet. This principle of solid evidence regards all criteria underlying a FBDG such as recommended nutrient intakes, food -disease relationships and potentially climate impact. Thus, it would be a useful to establish public data bases that collect the single study results and make them accessible to all groups working on FBDGs. It should also been agreement on how to weight the many findings and which of them give priority and why. Similar discussions and harmonizing the thoughts including presenting suitable alternatives could be done regarding other aspects of FBDGs.

**Keywords:** Food based dietary guidelines, disease risk, recommendations, harmonization

OVERVIEW OF GLOBAL REGULATORY EFFORTS

Popkin, Barry M.

Phd. Nutrition. Department of Nutrition. University of North Carolina. United States.

**Background and objectives:** The major focus for preventing obesity, diabetes and all nutrition-related noncommunicable diseases lies with shifting our populations toward a much healthier eating pattern and ultimately creating a culture of healthy eating.

**Methods:** I review the main set of large-scale regulatory tools and taxes considered.

**Results:** First, to date we have focused on attempting to create a price structure where we tax unhealthy foods and sugary beverages with a great focus on sugary beverages as a prime example, but there are other economic tools affecting subsidies and trade being considered. Second, is the area of marketing controls that are based on some nutrient profiling system. Third, is front-of-the-package (FOP) logos. It is ideal if these are based on the same nutrient profiling systems as the marketing controls. The major nutrient profiling systems that are increasingly being deployed in all regions of the world include a negative or positive FOP logos. It is strongly recommended that one not allow claims on food packaging not allowed under each FOP system. And as the Chilean law has shown, removal of characters from nonapproved products is also very important. In all cases the goal is to minimize added sugars, unhealthy saturated fats, sodium and promote fruit and vegetable, legume and whole grain-based diets. This is the big three we expect will have the largest impact. A fourth area is food in public institutions, especially schools and hospitals. To date much less work and few studies show major impact on shifting school and other public facilities (e.g., hospitals) meals, marketing, and availability of junk food and beverages; however, we see this also as critical to changing the entire culture of eating and our overall food system in a healthier direction. The short-term and long-term impact of these changes needs to be better understood, but we do also deem them important to achieve any long-term shift in eating patterns.

We have completely neglected globally systematic regulations related to the away-from-home fast food and restaurant sector (e.g., calorie pricing where each calorie charged for a burger or drink must cost the same). Similar with the massive transition of our farm to fork food system we have not figured out how and what impact shifts in government policies toward farmers can make. We do know that until we eliminate major marketing efforts of unhealthy eating, it will be imposible for public education to make a major impact.

**Conclusion:** As we will show with this set of presentations there are several countries that have or will provide strong evidence on the impact of various regulatory and tax efforts.

**Keywords:** Taxation. marketing bans. front-of-the-package labeling. nutrient profiling
IMPACT OF MEXICO'S SUGAR-SWEETENED BEVERAGE TAX: OVERALL AND ACROSS SUBPOPULATIONS

(1)Colchero, Arantxa; (2)Ng, Shu Wen; (3)Guerrero-López, Carlos;

(3)Molina, Mariana; (4)Popkin, Barry M.; (5)Rivera, Juan.

(1)PhD. Cener for Health Systems Research. National Institute of Public Health. Mexico; (2)PhD. Research Professor. Nutrition Department. University of North Carolina at Chapel Hill. USA;

(3)MS. Research Assistant. Center for Health Systems Research. National Institute of Public Health. Mexico; (4)Phd. Nutrition. Department of Nutrition. University of North Carolina. United States.; (5)PhD. Health and Nutrition Research Center. National Institute of Public Health. Mexico.

**Background and objectives:** Mexico implemented a 1-peso per liter excise tax on sugar-sweetened beverages (SSB) on January 1, 2014. We present evidence on changes in taxed and untaxed beverages sales and purchases overall, and by subgroups of the population, before and after the SSB tax was implemented.

**Methods:** Three different data sets have been used for evaluating how Mexico's SSB tax relates to beverage purchases and sales: 1) Household purchases by a longitudinal panel of urban households (2012-2015) to estimate changes in overall purchases of taxed and untaxed beverages and by socioeconomic status, adjusting for pre-tax trends, household sociodemographic characteristics, seasonality and macroeconomic variables. 2) National Income and Expenditure Surveys (ENIGH) rounds 2008, 2010, 2012 and 2014 to estimate changes in overall purchases and by income level, place of residence and type of household, adjusting for household sociodemographic characteristics and economic. 3) Aggregated monthly data on national sales of SSB and bottled water (2007-2015) to estimate changes in per capita sales adjusting for economic activity and seasonality activity.

**Results:** Among the panel of urban households, we found an average 7.6% reduction in purchases of taxed beverages two year after implementation of the tax (5.5% reduction in 2014 and a 9.7% reduction in 2015). The reduction was higher among household at the lowest socioeconomic status. We also found a 2.1% increase in untaxed beverages. Meanwhile, estimates from the ENIGH show a 6.3% reduction in SSB purchases in 2014, higher among lower income households, residents living in urban areas and households with children; and a 16% increase in bottled water. Finally, Mexico's national sales showed that there was a 7.3% average reduction in sales of sugary beverages and a 5.2% increase in bottled water compared to 2007-2013.

**Conclusions:** Results across the different studies using various data sets show that the SSB tax was associated with a reduction in purchases/sales of SSB and increases in untaxed beverages. Reductions in SSB purchases were larger among key populations: low income groups and households with children, but there were lower reductions in rural areas. Findings from the second year suggest a sustained and increasing response from the population. Results from Mexico provide important evidence for other countries considering the use of fiscal policies to lower the consumption of SSB along with other interventions.

**Keywords:** Sugar-sweetened beverages. tax. Mexico

MEXICO: IMPACT OF THE NONESSENTIAL ENERGY-DENSE FOODS TAX

(1)Batis, Carolina; (2) Smith Tallie, Lindsey; (3) Rivera Dommarco, Juan Ángel; (4) Popkin, Barry M.

(1)CONACYT- Nutrition and Health Research Center. National Institute of Public Health of Mexico. Mexico.; (2)Department of Nutrition, Gillings School of Global Public Health, Carolina Population Center, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina, United States of America; (3)National Institute of Public Health. Mexico.; (4)Phd. Nutrition. Department of Nutrition. University of North Carolina. United States.

**Background:** In an effort to prevent continued increases in obesity and diabetes, in January 2014, the Mexican government implemented an 8% tax on nonessential foods with energy density ≥275 kcal/100 g and a peso-per-liter tax on sugar-sweetened beverages. Limited rigorous evaluations of food taxes exist worldwide.

**Aim:** examine changes from 2012-2013 (pre-tax) and 2014-2015 (post-tax) in volume of taxed and untaxed packaged food purchases and in the proportion of taxed purchases from total purchases. We examined the effects in the entire sample and stratified by socioeconomic status and by pre-tax purchasing pattern.

**Methods:** This study uses longitudinal data on household packaged food purchases representative of the Mexican urban population from The Nielsen Company's Mexico Consumer Panel Services. We included 6,248 households for the 2014 evaluation and 6,089 households for the 2015 evaluation. We used a longitudinal, fixed-effects model that adjusted for preexisting trends to test whether the observed post-tax trend was significantly different from the one expected based on the pre-tax trend. We controlled for household characteristics and contextual factors like minimum salary and unemployment rate.

**Results:** The mean volume of purchases of taxed foods in 2014 changed by -5.1% beyond what would have been expected based on pre-tax (2012-2013) trends, with no corresponding change in purchases of untaxed foods. Low SES households purchased on average 10.2% less taxed foods than expected; medium SES households purchased 5.8% less taxed foods than expected; whereas high SES households' purchases did not change. In 2015 there was a decrease in both taxed and untaxed purchases, therefore we focused instead in the change in percentage of taxed purchases from total purchases. Post-tax declines in the % taxed food purchases were -4.8% in 2014 and -7.4% in 2015 (-6.0% in 2014-2015), beyond the counterfactual. Households were classified based on median pre-tax purchases: low untaxed/low taxed ("low"), low untaxed/high taxed ("unhealthy"), high untaxed/low taxed ("healthy"), and high untaxed/high taxed ("high") purchasers. In 2014-2015 Healthy purchasers showed no post-tax change in % taxed food purchases beyond the counterfactual, while unhealthy, low and high purchasers decreased (-12.3%, -5.3% and -4.4%, respectively).

**Conclusions:** Household purchases of nonessential energy-dense foods declined in the first and second year after the implementation of Mexico's nonessential foods taxes. Households with low SES and greater preferences for taxed foods before the tax showed a larger decline in taxed food purchases. Future studies
should evaluate the impact of the taxes on overall energy intake and dietary quality.

**Keywords:** Food taxes, Mexico, evaluation

## CHILE: IMPACT OF THE SSB TAX

(1)Smith Tallie, Lindsey; (2)Corvalan, Camila; (3)Reyes, Marcela; (4)Silva, Andres; (5)Caro, Carlos; (6)Popkin, Barry M.

(1)PhD. Nutrition. Department of Nutrition. University of North Carolina. United States; (2)PhD. Assistant Professor. Institute of Nutrition and Food Technology. University of Chile. Chile; (3)PhD. Associate Professor. Institute of Nutrition and Food Technology. University of Chile. Chile; (4)Ph.D. Assistant Professor. Central University of Chile. Chile; (5)MSc. Nutrition. University of North Carolina at Chapel Hill. USA; (6)Phd. Nutrition. Department of Nutrition. University of North Carolina. United States.

**Background and Objectives:** In October 2014, Chile, a middle-high income country, implemented an 18% excise tax (representing a 5% increase over previous levels) on sugar-sweetened beverages (SSBs) ≥15g sugar/240mL, while SSBs <15 g sugar/240 mL were reduced 3% to a 10% tax rate, and beverages including milk, juice, and water remained untaxed. To our knowledge, there has been no evidence to date about the impact of an SSB tax on household food purchases in a middle-high income country. The objective is to examine the change in price and change in household beverage purchases after Chile's SSB tax.

**Methods:** Using longitudinal data on 2,000 households from Jan 2013- Dec 2015, we used a fixed-effect model to explain change in unit values of 0%, 10% and 18% taxed beverages (Chilean pesos/liter). We utilized fixed effects models to examine post-tax changes in the volume and kcal of household 0%, 10% taxed, and 18% taxed beverages and compared these to the counterfactual (the expected post-tax purchases based on projected pre-tax trends), controlling for household characteristics and macroeconomic conditions. We examined whether there was a difference in response for high vs. low socio-economic status households.

**Results:** Preliminary results show that the price increase from the tax was not passed on to consumers for the 18% tax, and that households did not change their purchases of 18% taxed, 10% taxed, or untaxed beverage purchases. There were no differences by socio-economic status.

**Conclusions:** Despite a higher overall tax rate, the relative increase in price of SSBs was small and not passed through to the consumers. Governments considering the use of an SSB tax to change SSB purchasing behavior should consider greater than a 5% relative price increase.

**Keywords:** Soda tax. sugar-sweetened beverages. Latin America. global nutrition. food policy

## CHILE: THE CHILEAN MARKETING LAWS: INITIAL STUDIES

(1)Corvalan, Camila; (1)Reyes, Marcela; (2)Correa, Teresa; (3)Dillman Carpentier, Francesca; (4)Mediano, Fernanda; (5)Popkin, Barry M.; (6)Smith Tallie, Lindsey.

(1)PhD. Assistant Professor. Institute of Nutrition and Food Technology. University of Chile. Chile; (2)PhD. Associate Professor. Institute of Nutrition and Food Technology. University of Chile. Chile; (3)PhD. School of Media and Journalism. University of North Carolina at Chapel Hill. USA; (4)MA. Health Psychology. University of North Carolina at Chapel Hill. USA; (5)Phd. Nutrition. Department of Nutrition. University of North Carolina. United States.; (6)PhD. Research Assistant Professor. University of North Carolina at Chapel Hill. USA.

**Introduction:** To prevent the continued increase of obesity and obesity-related non-communicable diseases in children and adults, the Chilean government recently passed the most comprehensive set of food environment regulations in any country to date. In July 2016 the National Law of Food Labeling and Advertising was implemented with 3 major components: (i) improving consumer information by using front-of-package warning labels on unhealthy packaged foods, (ii) restrictions on marketing (i.e. prohibitions of using any licensed character, toy or give-away or child-targeted imager) and advertising (on TV or websites) of unhealthy foods to children under age 14y, and (iii) limiting the availability of unhealthy foods at preschool and school settings by restricting sales of any product with a warning label. Methods: This comprehensive evaluation includes before and after analyses of: i) Nutrient content of 5,000+ packaged foods and beverages, ii) Marketing on packages (e.g. characters, health claims) of the 5,000+ products photographed, iii) Marketing on TV using a representative sample of two months of TV programming from the four main broadcast channels and four cable networks with the highest children's audience, iv) Food/beverages purchases at home using the Kantar World Panel, which follows a representative sample of 2,000 households from urban areas, and v) food knowledge and perceptions, diet, and anthropometry (body mass index and waist circumference) collected through face-to-face surveys of 700 +low-middle adolescents and 900+ low-middle preschoolers.

**Results:** Baseline analyses show that 63% of the packaged foods studied would be classified as unhealthy based on the policy's initial nutrition standards (this number will increase to about 83% as standards become more stringent, based on the policy's incremental rollout). Preliminary analysis on beverages reveals that products with a child-friendly character had higher sugar and calorie content than beverages without a character. Baseline evaluation of the marketing restrictions indicate that children see a lot of food ads for sweet and savory snacks (22%) and sugary drinks (12%), and about 2 out of 3 food ads include strategies attractive to children. Post-implementation data will allow us to assess the impact of the different actions implemented.

**Conclusion:** There is an unique opportunity of understanding how the package of regulatory actions implemented in Chile will
impact the food environment, people's behaviors and ultimately, people's diet and obesity rates.

**Keywords:** Obesity regulatory actions. Chilean law of labeling and marketing restrictions. food environment

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# MONITORING AND ENFORCEMENT OF THE INTERNATIONAL CODE OF MARKETING OF BREAST-MILK SUBSTITUTES: EXPERIENCES WITH A NEW WHO/UNICEF PROTOCOL

## NATIONAL IMPLEMENTATION OF THE INTERNATIONAL CODE OF MARKETING OF BREAST-MILK SUBSTITUTES: CURRENT STATUS

Clark, David.

Legal Specialist, Nutrition Section, UNICEF, New York, USA.

The international Code of Marketing of Breast-milk Substitutes was adopted by the World Health Assembly (WHA) in 1981, in an attempt to halt the aggressive and unethical promotion of breastmilk substitutes that undermines breastfeeding practices and places infant and young child health, development and survival at risk. In adopting the Code, the WHA called on all Member States to translate the Code into national legislation, regulations or other suitable measures. In spite of some progress, the World Health Assembly has expressed concern over persistent reports of Code violations and the ineffectiveness of some national measures, particularly voluntary measures, to ensure compliance. In 2016, WHO, UNICEF and the International baby Food Action Network (IBFAN) collaborated on the realization of a comprehensive report on the status of Code implementation around the world, utilizing all data and information sources available to the three organizations, and using agreed criteria to categorize national measures. This talk will present the status of implementation of the Code in accordance with the findings of the joint Report, describing briefly the methodology, findings in terms of legislative status of the Code, as well as a discussion of the challenges faced by Governments in implementation, monitoring and enforcement of the Code, as well as recommendations for action.

**Keywords:** International Code of Marketing of Breast-milk Substitutes; implementation; legal status; challenges

**Further collaborators (N/A if not applicable)**

WHO and IBFAN

## A NEW PROTOCOL FOR MONITORING AND ENFORCEMENT OF CODE VIOLATIONS

Grummer-Strawn, Laurence.

PhD. Department of Nutrition for Health and Development.
World Health Organization. Switzerland.

As of March 2016, 135 countries had enacted legislation implementing at least some of the provisions in the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions (the Code). However, very few of these countries have operational monitoring systems to assess compliance with either the full Code or with national laws. WHO and UNICEF have formed a Global Network for Monitoring and Support for Adherence to the Code (NetCode) to assist countries and civil society in strengthening their capacity to monitor the Code. NetCode has developed a monitoring protocol with practical tools and guidance to help countries establish effective monitoring systems. The protocol is composed of two main components. The first focuses on ongoing monitoring to detect, investigate and act on alleged violations of existing national measures and the Code. The second component is a standard for periodic assessment of the state of marketing of breast-milk substitutes.

For ongoing monitoring, national systems need to include systems for detection of violations, reporting, validation, and activation of an enforcement mechanism. While NGOs and consumer organizations could feasibly assist with detection and reporting of violations, validation and enforcement are inherently governmental functions. Therefore, it is critical that governments, including nutrition, health services, food and drug control, and trade departments, are actively engaged in the monitoring and enforcement process. Monitoring should cover media advertisements (TV, radio, online, print materials), promotion in shops and pharmacies, interactions with health professionals, health facility activities, and community promotions. The NetCode protocol includes a standard monitoring and reporting form with electronic tools for easy data collection and management.

The periodic assessment component of the monitoring protocol covers four main groups or settings for assessment of how breast-milk substitutes are being promoted: mothers of children under 24 months, health workers in primary health care facilities, retail outlets, and media including television and the internet. The protocol includes detailed instructions for conducting a survey of mothers of children under 24 months of age that are attending primary health care centers. The survey asks about exposure to advertising through multiple channels, receipt of gifts, feeding advice received, and interactions on social media. Health workers in the same primary health care centers are to be asked about their interactions with representatives of manufacturers and distributors of breast-milk substances. In addition, visual inspection of the centers is to be conducted along with analysis of any educational materials on infant feeding. Retail outlets similarly are to be inspected for promotion and products purchased for analysis of the labels on all infant feeding products. An analysis of television and internet advertising is also included.

Countries that utilize this new protocol can protect mothers from the marketing pressure that interferes with breastfeeding and thus create a more supportive environment for optimal feeding.
**Keywords:** Breastfeeding, breast-milk substitutes, monitoring, legal enforcement

MARKETING OF BREAST-MILK SUBSTITUTES
IN MEXICO: RESULTS FROM MATERNAL AND
HEALTH PROVIDER SURVEYS

Background: Breast-milk substitutes marketing has been iden-
tified as a barrier to improving breastfeeding practices. The inter-
national code of marketing of breast milk substitutes (The Code)
was adopted by the World Health Assembly in 1981 to encourage
breast feeding and to protect mothers from pressure to use substi-
tutes for breast milk. It is of paramount importance to ensure the
compliance to The Code.

Objective: To estimate the prevalence of violations of the in-
ternational code of marketing breast milk substitutes (BMS) and
its subsequent resolutions in health facilities, point of sales and
labelling on BMS in Mexico.

**Methods:** Sampling was based on the Network for Monitor-
ing and Support of the International Code of Marketing of Breast-
milk Substitutes (NetCode) protocol. The sample included 10 mu-
nicipalities (5 per state), selected according to their birth rate, of
two States of Mexico, Puebla, located in East-Central Mexico, and
Chihuahua, located in Northwestern Mexico. For each munici-
pality between 4 to 5 health care facilities were randomly selected,
according to the number of prenatal consults provided the previ-
ous year of the study. At health care facility level 16 to 17 mothers
of infants under 24 months of age were selected and 1 health care
provider (total in two states: 693 mothers and 48 health providers
). In addition, 10 points of sale were selected. In both settings it
was explored BMS promotions, free-samples, and marketing. Fi-
nally, and inventory of BMS available was done from the points
of sale visited and labelling and inserts were evaluated according
to The Code. Data analysis considered the cluster sampling, using
Stata V. 14.1

**Results:** Almost 50% of the interviewed mothers reported they were recommended to use BMS to feed their infant and more than 80% mentioned they had seen publicity of BMS in the media in the previous 6 months. More than 10% of them reported receiving BMS sampling and 8.5% of them had received baby bottles as gifts. The recommendations, coupons and gifts were mainly from health providers. On the other hand, 15 % of health providers interviewed reported that BMS manufactures had contacted them at least once

in the last 6 months. More than 50% of health providers report-
ed not knowing The Code or strategies for its implementation in
Mexico, and less than 30% reported had received any training on
the Code. Promotions of BMS were identified in all point sales
visited, being price promotions the most common. Finally, more
than 90% of BMS labels used an image or text idealizing its use.

**Conclusions:** Violations of The Code were detected in two states of Mexico using the NetCode protocol. There is BMS samples distribution in the health facilities as well as distribution of gifts and coupons. BMS manufactures had contact with health providers in the previous six months and BMS products do not comply with The Code. Important to design and implement a monitoring system to identify violations of the Code.

**Keywords:** Breast-milk substitutes, The Code, NetCode, Mexico

MONITORING FOR CODE VIOLATION THROUGH
ROUTINE SERVICES IN CAMBODIA

In 2005, the Royal Government of Cambodia enacted the Sub-Decree on Marketing of Products for Infant and Young Child Feeding (SD133) which includes many provisions of the International Code of Marketing of Breast-milk Substitutes. However, a decade after SD133 was passed, research found low awareness and enforcement of SD133 by the four line ministries tasked with upholding the law and aggressive promotion of breastmilk substitutes. In response, the government established a multi-sectoral Oversight Board led by the Ministry of Health, which included Ministries of Commerce, Information, and Industry and Handicraft. With support from WHO's Netcode initiative and Helen Keller International, the board developed terms of reference and implementation guidelines for monitoring, and monitoring checklists for all relevant institutions at the national and sub-national level.

Municipalities in four provinces were chosen to pilot the rou-
tine monitoring, and officials from the Ministries of Health, Com-
merce, Information, and Industry and Handicraft were trained on
their respective responsibilities between October 2016 and Janu-
ary 2017. SD133 monitoring began in early 2017, including super-
vision visits to health facilities and inspections of retail locations.
The monitoring checklists were used to identify potential viola-
tions, which were then reported to the Oversight Board for action.

<footnote>(1)Hernandez-Cordero, Sonia; (2)Lozada-Tequeanes, Ana Lilia;</footnote>

<footnote>(2)Shamah-Levy, Teresa; (3)Gonzalez-Cosio, Teresita; (4)Saturno, Pedro;</footnote>

<footnote>(5)Herrera-Maldonado, Nazarea; (6)Grummer-Strawn, Laurence.</footnote>

<footnote>(1) 1 Nutrition and Health Research Center, National Institute of Public Health. México; (2) Researcher. Nutrition and Health Research Center, National Institute of Public Health. México; (3) Director of Health Department, Universidad Iberomericana, Mexico;</footnote>

<footnote>(4)Evaluation Surveys Center, National Institute of Public Health. México; (5)Director of the Maternal and Perinatal health Ministry of Health, Mexico; (6)World Health Organization, Geneva, Switzerland.</footnote>

<footnote>(1)Green, Mackenzie; (2)Hou, Kroeun; (3)Prak, Sophonneary; (4)Aing, Hoksrun; (5)Chum, Seneasna; (6)Rarick, James; (7)Phal, Sano; (8)Khou, Bunsor.</footnote>

<footnote>(1)MHS. ARCH Project. Helen Keller International. Cambodia;</footnote>

<footnote>(2)MPH. Deputy Country Director. Helen Keller International. Cambodia.; (3)MD MPH. National Maternal and Child Health Center. Ministry of Health. Cambodia.; (4)Ph. Department of Drug and Food. Ministry of Health. Cambodia.; (5)MA. ARCH Project. Helen Keller International. Cambodia.; (6)MPH. NCDs and Health Throughout the Life Course. World Health Organization. Cambodia.; (7)MD MPH. Maternal and Child Health Program. World Health Organization. Cambodia.; (8)MPH. Maternal and Child Health Program. World Health Organization. Cambodia.</footnote>
Early observations suggest monitoring responsibilities have been undertaken with greater ease the more closely they align with existing routine responsibilities. Ease of implementation is also dependent on whether the underlying system is well-functioning. Officials with existing inspection protocols and schedules have been more successful in integrating their new SD133 responsibilities, while others, particularly at the subnational level, have been challenged by limited or siloed human and financial resources. There have also been challenges transferring the strong commitment and political will from the Oversight Board and national level down to the subnational officers responsible for the routine monitoring for violations.

Integrating monitoring into routine services and inspections capitalizes on existing capacity, infrastructure, and resources; however, additional attention may be required to reinforce the underlying systems.

**Keywords:** Breastmilk substitute, policy, monitoring, integration, Cambodia

PS_144/1051

# THE SCALING-UP NUTRITION (SUN) MOVEMENT STUNTING PREVENTION PROGRAM 'RIGHT FOODS AT THE RIGHT TIME: TARGETING NUTRITION OF CHILDREN UNDER TWO' IN MALAWI

## IMPACT EVALUATION OF A COMPREHENSIVE NUTRITION PROGRAM TO PREVENT STUNTING AMONG CHILDREN 6-23 MONTHS OF AGE IN RURAL MALAWI

(1)Hurley, Kristen; (2)Hurley, Kristen; (3)Kang, Yunhee; (4)Ruel-Bergeron, Julie; (5)Oemcke, Rachel; (5)Fune Wu, Lee; (6)Mitra, Maithilee; (7)Phuka, John; (8)Klemm, Rolf; (9)West, Jr., Keith.

(1)PhD, Assistant Professor, Center for Human Nutrition, The Johns Hopkins Bloomberg School of Public Health; (2)PhD, Assistant Professor, Center for Human Nutrition, The Johns Hopkins Bloomberg School of Public Health, USA; (3)PhD, Postdoctoral Fellow, Center for Human Nutrition, The Johns Hopkins Bloomberg School of Public Health, USA; (4)PhD, Center for Human Nutrition, The Johns Hopkins Bloomberg School of Public Health, USA; (5)MSPH, Center for Human Nutrition, The Johns Hopkins Bloomberg School of Public Health, USA; (6)Center for Human Nutrition, The Johns Hopkins Bloomberg School of Public Health, USA; (7)MD, College of Medicine, University of Malawi, Blantyre, Malawi; (8)PhD, Center for Human Nutrition, The Johns Hopkins Bloomberg School of Public Health, USA; Nutrition, Helen Keller International, NY; (9)DrPH, Professor, Center for Human Nutrition, The Johns Hopkins Bloomberg School of Public Health, USA.

**Background:** The Malawian Government launched a comprehensive stunting prevention program with technical and financial support from the World Food Program (WFP) and the Children's Investment Fund Foundation (CIFF), respectively. The program

provides a daily lipid-based nutrient supplement (LNS) and social behavior change communication (SBCC) package to improve infant and young child feeding practices (IYCF), targeting children 6-23 months.

Objective. To evaluate the impact of the comprehensive program on child nutritional status.

**Method:** A quasi-experimental study design was used to measure nutrition outcomes in one program and comparison district. The impact evaluation included three cross-sectional surveys (baseline, midline, endline) and an imbedded longitudinal cohort of children. Results for the endline survey are being examined and will also be shared during the symposium.

Midline evaluation: The one-year (interim) program impact was measured using cross-sectional baseline (January-March, 2014; n=2,404) and midline (January-March, 2015; n=2,378) survey data. Estimates of impact were generated using Kernel Density Score Matching Difference-in-Difference (PSM-DID) analyses using both baseline and midline data.

Longitudinal evaluation: Two cohorts of infants (n=367), aged 6-7 months, were enrolled in either the program (n=176) or comparison (n=191) district, and followed-up after 6, 12, and 18-months, or at 12, 18, and 24-months of age, respectively. Program impact was estimated using a difference-in-differences (DID) method at 6, 12, and 18-months follow-up, adjusting for confounding variables and study design.

**Results:** Midline evaluation: While the burden of undernutrition remained high at midline (after one-year program exposure) with half of children stunted across both districts, improvements in nutritional status between midline and baseline in child weight, MUAC, WAZ, and WLZ favored the program over comparison district by 0.20kg, 0.29cm, 0.23 Z-score and 0.30 Z-score, respectively (p<0.05). In the same way, the percent children underweight, wasted, or experiencing MAM were 7.5, 3.8%, and 2.8% lower, respectively (p<0.05). No significant differences were seen for indicators of LAZ or stunting.

Longitudinal evaluation: Early and full (18 months from 6 to 23 months) program exposure improved LAZ and WLZ by 0.34z(p=0.01) and 0.22z(p=0.07) respectively, with increasing (but non-significant) impact between 6 to 12-months of program exposure. Similarly, the program impact on WAZ was significant at 0.16z(p<0.05) from 6-month follow-up and maximized at 18-month follow-up (0.41z, p<0.01). Further, relative to the comparison district, at 12 and 18-month follow-up, the percentages of children stunted was marginally reduced by 10.4%(p=0.08). In the same way, the percentages of children underweight were significantly reduced by 8.2%(p<0.05) and 11%(p<0.01) at 12 and 18-months follow-up, respectively. After 6-month of program exposure MUAC was significantly improved (0.25cm, p<0.01) relative to the comparison district, but there was no program impact in reducing wasting or moderate acute malnutrition (MAM), at any follow-up.

**Conclusion:** The more gradual impact on linear growth is consistent with a biologically plausible explanation that 18-month program exposure (starting at 6-months) may be required to detect improved linear growth, whereas weight gain is more responsive and, thus, evident within months of program exposure.

**Keywords:** Stunting, LNS, Infant and Young Child Feeding

**Further collaborators:** World Vision, Malawi; Wadonda Consult Limited
GROWING THE EVIDENCE FOR NUTRITION PROGRAMMING: PERCEPTIONS AND IMPLEMENTATION OF A STUNTING PREVENTION PROGRAM RURAL IN MALAWI

(1)Ruel-Bergeron, Julie; (2)Hurley, Kristen; (3)Oemcke, Rachel;

(4)Buckland, Audrey; (5)Kapadia-Kundu, Nandita; (6)Kang, Yunhee;

(7)Shu Fune Wu, Lee; (8)Mitra, Maithilee; (9)Phuka, John; (10)Klemm, Rolf; (11)West, Jr., Keith; (12)Christian, Parul.

(1)Johns Hopkins University; (2)Assistant Professor. Department of International Health. Johns Hopkins University. Baltimore, MD. USA.; (3)Research Assistant. Department of International Health. Johns Hopkins University. Baltimore, MD. USA.;

(4)Research Associate. Department of International Health. Johns Hopkins University. Baltimore, MD. USA.; (5)Center for Communication Programs. Johns Hopkins University. Baltimore, MD. USA.; (6)Assistant Scientist. Department of International Health. Johns Hopkins University. Baltimore, MD. USA.; (7)Senior Research Associate. Department of International Health. Johns Hopkins University. Baltimore, MD. USA.; (8)Senior Programmer. Department of International Health. Johns Hopkins University. Baltimore, MD. USA.; (9)Senior Lecturer. College of Medicine. University of Malawi. Lilongwe. Malawi; (10)Associate Scientist. Department of International Health. Johns Hopkins University. Baltimore, MD. USA.; (11)Professor. Department of International Health. Johns Hopkins University. Baltimore, MD. USA.; (12)Senior Program Officer. Women's Nutrition. The Bill & Melinda Gates Foundation. Seattle, WA. United States.

The delivery of efficacious nutrition interventions in a programmatic context can hamper the achievement of nutrition impact due to logistical and sociocultural challenges associated with their implementation. Understanding how programs work to improve child nutrition and feeding behaviors is critical for scaling up nutrition interventions globally.

To study how a nutrition program in rural Malawi was perceived, accepted, and implemented.

Methods: The nutrition program in Malawi includes the monthly distribution of lipid-based nutrient supplements, Nutributter, to all children 6-23 months, and a social behavior change communication campaign to promote optimal infant and young child feeding (IYCF) practices. An independent impact evaluation was led by Johns Hopkins University to measure child nutrition outcomes after 3 years of implementation. This study falls under the impact evaluation, which included a qualitative and a process evaluation study. The qualitative study employed in-depth interviews (IDI) with mothers (n=34) and household members (fathers, n=11; and grandmothers, n=4), focus group discussions (FGD) with village leaders (1 with n=11) and program staff (3 FGD with n=12, n=10, and n=11), to elicit beneficiary and community perceptions of the facilitators and barriers to the uptake of the program's intervention components. Grounded theory guided all study processes, wherein emerging themes were incorporated into continuing data collection, coding, and analysis. The process evaluation study measured the program's conformity to its original design (program fidelity) through direct observations of program activities (n=28), knowledge questionnaires with program staff

(n=84), and use of existing data from program monitoring mechanisms (pooled n=2,901). Process indicators were categorized as "working well" (>75%), "needing improvement" (25%-75%), and "not working" (<25%).

Findings from the qualitative study demonstrated that Nutributter was viewed positively by all members of the household and community, who ascribed perceived changes in child health and growth to the consumption of Nutributter. Barriers to the monthly collection of Nutributter were competing household obligations, such as caring for ill family members. When asked to discuss program messages, mothers demonstrated limited and superficial knowledge of IYCF messages. This, in combination with the lack of financial and physical access to nutritious foods promoted by program messages were perceived as significant barriers to enacting desired IYCF behaviors among mothers.

Direct observations of Nutributter distributions conducted under the process evaluation demonstrated that most procedures were functioning at 85% or higher, with some areas needing improvement, such as the conduct of multiple counseling sessions throughout distributions to account for latecomers. Despite the relatively high implementation of training activities as planned (73.3%), the completion of training modules for breastfeeding (22.9%) and complementary feeding (18.6%) was low, which may have contributed to the limited focus of observed one-on-one counseling on these same topics. Nevertheless, knowledge level of key IYCF messages among program staff was high (85.3-85.7%), with the exception of being able to list the 6 food groups (22.9%).

The documentation of the perceptions, facilitators and barriers to, and implementation of the Malawi program generates important lessons for current and future policy, programming, and scale-up of nutrition interventions in this setting.

**Keywords:** Process evaluation, LNS, SBCC, qualitative

**Further collaborators:**

World Food Programme, World Vision Malawi, Wadonda, Inc.
COMPREHENSIVE PROGRAMING LEADS TO IMPROVEMENTS IN OUTPUTS AND OUTCOMES ACROSS THE PROGRAM IMPACT PATHWAY

The Government of Malawi initiated the Scaling-up Nutrition (SUN) 1000 special days initiative in 2011. In Ntchisi District, World Food Programme and World Vision provided technical and operational support to this initiative. Programming included comprehensive social and behaviour change communication (SBCC) for improved infant and young child feeding (IYCF) and improved water, sanitation and hygiene (WASH). Nutrition-sensitive activities included small animal husbandry and homestead gardening promotion for diet diversification. Nutrition-sensitive activities and SBCC messages were delivered through peer-to-peer support (caregroups). The programme also strengthened community management of acute malnutrition and provided small-quantity Lipid-based Nutrient Supplement (LNS) to all children 6–23 months.

document changes along the programme impact pathway that are associated with nutritional status including formation and activity of caregroups, SBCC message delivery, nutrition-sensitive activity completion, as well as WASH and IYCF changes.

Output indicators were monitored monthly through programme performance reporting. Outcome indicators were measured using statistically-representative surveys conducted three times per year applied to mothers of children 6-23 months. Output indicators analysed for this report were caregroup formation, activity and coverage; activities to reinforce SBCC messages; and small animal husbandry and home gardening activities. Outcome indicators were MAD, MDD and handwashing facility ownership.

MDD and MAD were measured following the WHO/UNICEF methodology and calculated twice. LNS consumption was first included in a composite category of ‘fortified and flesh foods’ and, second, not included. The former analysis was performed to measure impact of LNS on dietary adequacy (i.e. dietary micronutrient profile) and latter to measure dietary diversity based on common home-foods. A Z-test for two population proportions comparing the same indicator annually (January 2015 and January 2017) was used to test for significance at an alpha value of 0.05.

The number of caregroups formed increased steadily: 2014 (268), 2015 (479), 2016 (513) and 2017 (610), which led to continuous increase in caregroup volunteer home visits from 2014 to 2017. By 2016, the coverage of caregroups was 100% in the district. There was an increase in SBCC activities from 2016 to 2017 such as number of billboards (14 to 21) and theatre performances (14 to 32), promoting nutrition and WASH. In 2016, small livestock were distributed to 3000 households. Another 3000 households

received vegetable seeds. There was a continual improvement in children's MDD and MAD, and household handwashing facility ownership from 2015 to 2017. MAD and MDD including provision of LNS increased from 32% to 43% and 36% to 50%, respectively (p<0.05). Without LNS, MDD increased from 10% to 25% (p<0.05) and MAD increased from 12% to 29% (p <0.05). There was a significant increase in handwashing facility ownership from 45% to 17.4% (p < 0.05).

LNS significantly increased the number of children with adequate micronutrient intake, as indicated by MAD. The increase in MAD without consideration of LNS consumption indicated a benefit of SBCC and nutrition-sensitive activities. The quantified increase in SBCC and nutrition-sensitive activities is likely responsible for the positive impact on MDD, MAD, and WASH outcomes over the course of the stunting prevention programme.

**Keywords:** Scaling Up Nutrition, Stunting Prevention, Infant & Young Child Feeding (IYCF), Water, Sanitation and Hygiene (WASH), Malawi

SUPPORTING SCALING UP NUTRITION – FROM POLICY TO ACTION AT THE LOCAL LEVEL

A multi-year stunting prevention programme was launched in Ntchisi District as a part of the roll-out of the ‘Scaling-up Nutrition (SUN) 1000 special days’ initiative’ in Malawi in 2014. Ntchisi district was targeted due to its high stunting prevalence (above 50%) in children 6-23 months of age. The stunting prevention programme is a comprehensive approach to tackling stunting, including complementary feeding (distribution of a small quantity lipid-based-nutrient supplement) to children 6-23 months of age, as well as rigorous social behaviour change communication (SBCC) components, engaging the local community through various mechanisms, including peer to peer counselling through care groups. Additionally, community management of acute malnutrition (CMAM) treatment and Water Sanitation and Hygiene (WASH) activities were scaled up to include all health facilities in the district. To date, the programme has reached over 44,000 children between 6-23 months of age, with attendance rates being over 90% in the last seven months.

to demonstrate how the SUN movement, combined with other international and national initiatives and policies, was translated into local action to address stunting for improved nutrition in one district in Malawi.

a well-structured National SUN framework, reliable coordination platforms related to nutrition and health, and district owner-

<footnote>(1) Mlambo, Trust; (2) Farhikhtah, Arghanoon; (3) Nyirenda, Jason;</footnote>

<footnote>(4) Aburto, Nancy.</footnote>

<footnote>(1)MPH. Nutritionist. Nutrition Unit. UN World Food Programme (WFP). Lilongwe. Malawi.; (2)MSc. RD. Nutritionist. Nutrition Division. UN World Food Programme. Rome. Italy.; (3)MSc. Nutrition Unit. UN World Food Programme. Lilongwe. Malawi;</footnote>

<footnote>(4)PhD. MSc. Nutritionist. Nutrition Division. World Food Programme. Headquarters. Rome. Italy.</footnote>

<footnote>(1) Botomani, Malango; (2) Mlambo, Trust; (3) Farhikhtah, Arghanoon;</footnote>

<footnote>(4) Aburto, Nancy.</footnote>

<footnote>(1)District Commissioner. Ntchisi District. Malawi. Government of Malawi.; (2)MPH. Nutritionist. Nutrition Unit. World Food Programme. Country Office Malawi. Lilongwe. Malawi.; (3)MSc. Nutritionist. Nutrition Division. World Food Programme. Headquarters. Rome. Italy.; (4)PhD. MSc. Nutritionist. Nutrition Division. World Food Programme. Headquarters. Rome. Italy.</footnote>
publications and opinions. In this systematic review the scientific
evidence for the primary prevention of diseases like obesity, type
2 diabetes mellitus, dyslipoproteinaemia, metabolic syndrome,
hypertension, coronary heart disease (CHD), stroke and cancer
through the intake of various fat and fatty acids (SFA, MUFA,
PUFA, TFA), carbohydrates (mono-, di-, polysaccharides) and
proteins was evaluated. The evaluation was conducted by expert
groups of the German Nutrition Society.

Method: Systematic literature searches were conducted with the primary focus on meta-analyses, systematic reviews and monographs. If these were not available, original intervention and cohort studies were considered.

Results: There is convincing evidence that a reduced intake of total fat and SFA as well as a larger intake of PUFA at the expense of SFA reduces the concentration of total and LDL-cholesterol in plasma. Furthermore, there is convincing evidence that a high intake of TFA increases risk of dyslipoproteinaemia and that a high intake of long-chain PUFA reduces plasma TGC concentrations. Additionally, a high fat intake increases the risk of obesity with probable evidence in an ad libitum diet. A larger intake of PUFA at the expense of SFA reduces the risk of CHD with probable evidence and a high intake of long-chain n3-PUFA reduces the risk of hypertension and CHD, whereas a high TFA intake increases the risk of CHD. A high carbohydrate intake at the expense of total fat and SFA reduces the concentration of total, LDL and HDL cholesterol. Conversely, a high carbohydrate intake at the expense of PUFA increases total and LDL cholesterol, but reduces HDL cholesterol. Furthermore, a high consumption of sugar sweetened beverages increases the risk of obesity and type 2 diabetes, whereas a high dietary fibre intake, mainly from whole-grain products, reduces the risk for obesity, type 2 diabetes, CHD and colon-cancer.

Conclusion: The evaluation shows that both the total amount of fat and the pattern of fatty acids as well as carbohydrate quality must be carefully considered in dietary recommendations. The findings suggest that a modification of the fatty acid pattern in favour of unsaturated fatty acids at the expense of SFA and TFA and of carbohydrates in favour of polysaccharides at the expense of mono- and disaccharides is desirable.

**Keywords:** Carbohydrate, fat, intake, chronic diseases

HEALTH EFFECTS OF PLANT-BASED DIETS:
FROM WHOLESOME-MIXED DIETS TO EXTREME
VEGETARIAN DIETS

Boeing, Heiner.

German Institute of Human Nutrition.

There is a high interest in a diet that based primarily on plant
foods. The German Nutrition Society is favoring a diet which is
composed of 75% of foods that originate from plants. The remain-
ing 25% include mainly milk and milk products, fish, and to a
comparable lesser extend meat and processed meat. The intake of
meat including processed meat should be restricted to 600g a week
at maximum. This recommendation in amount for a food group

that had been highly debated due to its relation to disease risk and
environmental impacts consists of about half of the amount of
current intake. Milk and milk products among the food groups of
animal origin are particularly favored due to its content of calcium
and also fish due to its content of long chain polyunsaturated fatty
acids.

A diet characterized in such a way with some further specifications is been labelled as a wholesome mixed diet by the German Nutrition Society. It is obvious that compared to the current dietary practice particularly the reduction of meat and processed meat and the increase of fish will have impact on disease occurrence due to the many relationships with chronic disease endpoints in meta-analyses and also due to the discussed mechanisms. A further reduction of disease occurrence is expected by an increase of intake of fruit and vegetables. The German Nutrition Society is clearly in favor of 5 portions of fruit and vegetables which is equivalent to 650g/d according to German portions.

The German Nutrition Society discussed recently the impact of increasing the proportion of plant foods beyond the wholesome mixed diet approach in respect to nutrient intake and nutrient related health consequences in a specific working group. This working group also published a statement regarding the implication of a vegetarian and vegan diet in respect to nutrient recommendations. The working group concluded that the provision with some critical nutrients such as specific amino acids, vitamin b12, riboflavin, calcium, iron, iodine, zinc, selenium, and ω3 fatty acids is getting more and more difficult as more sources of animal food need to be replaced by plant food. The omission of meat and processed meat in the diet as prime aspect of a vegetarian diet does not seem problematic if replaced by proper plant foods. However, a diet without any animal food sources should include a consultation with diet expert and also a medical a surveillance of clinical markers reflecting the critical nutrient particularly vitamin B12. The German Nutrition Society does not favor a vegan diet for young children and pregnant women due to its high risk of nutrient deficiencies.

In terms of reduction of disease risk it is not expected that a further reduction of animal foods beyond a mixed wholesome diet will have a large impact. Rather, it is to be expected that a lack of fish and milk and milk products will result in small increased risks compared to a diet with some portions of animal foods.

**Keywords:** Disease risk, vegetarian diet, plant foods, animal foods, Food based dietary guidelines

QUALITY STANDARDS FOR CATERING IN DIF-
FERENT SETTINGS

Arens-Azevedo, Ulrike.

Hamburg University of Applied Sciences, Faculty of Life Sciences.

**Background:** The nutritional situation in Germany is characterized by high prevalence of overweight and obesity in both: children and adolescents as well as adults. With increasing age also malnutrition, especially in the elderly and hospitals occur frequently. Against this background the Ministry on Health and the
Ministry on Food and Agriculture adopted the National Initiative on physical activity and healthy nutrition in 2008. Based on this publication the German Nutrition Society developed after intensive discussion within large expert groups quality standards for diverse settings like nurseries, schools, workplace canteens, geriatric care centers, meals on wheels and hospitals. Actually in these settings round about 2.49 billions of lunch per year are consumed.

Objectives: The quality standards make part of the primary prevention. They aim to support the persons responsible in mass catering for implementing adequate and nutritionally balanced meals and allow the guests a healthy choice. In schools and nurseries a link to nutritional education has to be established, so that nutritional behavior can be sustainably shaped. In other settings like workplace canteens or hospitals nutritional information is focused so that adults might learn what is good for them.

The content of the standards: The focus is on the nutritional quality of meals and drinks. For this purpose, the food quality of each group is clearly defined and the frequencies in which they should be offered in one week or during four weeks. The recommendations are derived from the German food-based dietary guidelines. At the same time, the D-A-CH reference values are important, but only some nutrients such as carbohydrates, fat and protein, fibre, vitamin C, vitamin E, folate, iron, magnesium and calcium as well as energy are checked. In addition, requirements to the preparation of food are established, as for instance a maximum warming time of 3 hours or frying with a minimum of fat, preferring rapeseed or olive oil.

Since the standards adopt Donabedian's quality management systematic approach looking to the quality of structure, processes and results, other aspects beside the nutrition-relevant ones are also important. Therefore the standards describe requirements to the framework conditions such as the dining atmosphere, the quality of hygienic processes, the sustainability of food and production or the qualification of the staff.

**Conclusion:** The quality standards were harmonized and continuously updated in the last years. Within the scope of the 13th nutritional report of the German Nutrition Society research in nursing homes and nurseries has shown to what extent and in which way the implementation of the quality standards has changed the meal offer. However, up to this point of time, studies are missing that could reveal an alteration in the nutritional situation or the nutritional behavior of the guests. Such studies should be carried out in the future in order to demonstrate the effects of quality standards as primary prevention in different settings.

**Keywords:** Mass catering, primary prevention, healthy meals

**Further collaborators:**

German Nutrition Society

MAJOR FOOD SOURCES OF SUGAR AND ITS ASSOCIATION WITH OBESITY AMONG COUNTRIES OF ELANS

Overweight and obesity not only represent significant risk factors for developing non communicable diseases, the leading cause of deaths worldwide, but also imply high healthcare costs for governments. Nowadays, Latin American countries are facing not only the challenge of trying to overcome malnutrition due to deficiencies but also to stop the rapidly rising prevalence of overweight and obesity. The projection is that Latin America will be one of the regions with the highest increment during the next decade. Due to the high impact of overweight and obesity on human well-being, the world Health Organization has developed guidelines in relation to sugars intake, as this is one of the most important contributors to high energy intake.

The Latin American Health and Nutrition Study (ELANS), a multicenter study conducted in urban areas of 8 Latin American countries was developed with the objective to describe dietary intake and anthropometric nutritional status on this population. Two 24 hour detailed dietary recalls and anthropometric measurements (height and weight; neck, hip and waist circumferences) were collected in 9218 Latin Americans (15 to 65 years old). Food consumption was processed using the Nutritional Data System for Research (NDS-R) software. Multiple Source Method was applied to estimate the individual usual intake.

<footnote>(1)Pareja, Rossina Pareja; (2)Kovalskys, Irina; (3)Fisberg, Mauro;</footnote>

<footnote>(4)Gómez Salas, Georgina; (5)Rigotti, Attilio; (6)Cortes, Lilia Yadira;</footnote>

<footnote>(7)Yepez Garcia, Martha Cecilia; (8)Herrera-Cuenca, Marianella;</footnote>

<footnote>(9)Nogueira Previdelli, Agatha.</footnote>

<footnote>(1)MSc. Nutritionist. Instituto de Investigación Nutricional;</footnote>

<footnote>(2)MD. Nutrition and Health Area. International Life Science Institute (ILSI). Buenos Aires. Argentina; (3)PhD. MD. Instituto Pensi. Fundação Jose Luiz Egydio Setubal. Hospital Infantil Sabara. São Paulo. Brazil PhD. Professor. Departamento de Pediatria. Universidade Federal de São Paulo. São Paulo. Brazil;</footnote>

<footnote>(4)MSc. Nutritionist. Departamento de Bioquímica. Escuela de Medicina. Universidad de Costa Rica. Costa Rica; (5)PhD. MD. Centro de Nutrición Molecular y Enfermedades Crónicas, Departamento de Nutrición, Diabetes y Metabolismo, Escuela de Medicina, Pontificia Universidad Católica, Santiago, Chile; (6)PhD. Nuticionist. Departamento de Nutrición y Bioquímica, Pontificia Universidad Javeriana, Bogotá, Colombia; (7)MSc. Bch. Med. Tech. Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Ecuador; (8)PhD. MSc. MD. Centro de Estudios del Desarrollo, Universidad Central de Venezuela (CENDES-UCV)/Fundación Bengoa, Caracas, Venezuela; (9)PhD. Professor. Faculdade de Ciências Biológicas e da Saúde. Universidade São Judas Tadeu São Paulo. Brazil.</footnote>
Around 14% of total energy intake came from added sugars. Argentina reported the highest percentage of energy intake from added sugars, in contrast to Ecuador with the lowest.

Beverages accounted for the highest percentage of energy intake from added sugars. All countries reported soft drinks/regular sodas, infusions and natural or ready to drink juices as the main dietary sources of sugar.

Dietary consumption analysis found that more than 25% of the participants are under or over reporters. After adjusting for plausible subjects, no association between added sugar consumption and body mass index was observed. Only Argentina and Chile seems to have a higher consumption reported by underweight people, but still not significant difference was observed.

This study contributes to improve our knowledge about added sugars consumption in the region and its main dietary sources. This can help to focus region and country health policies in order to decrease added sugar consumption and reduce excess calorie intake.

**Keywords:** Added sugar, beverage, energy, obesity, Latin America.

**Conflict of Interest disclosure:** The ELANS is supported by a scientific grant from the Coca Cola Company and support from the Instituto Pensi/Hospital Infantil Sabara, International Life Science Institute of Argentina, Universidad de Costa Rica, Pontificia Universidad Católica de Chile, Pontificia Universidad Javeriana, Universidad Central de Venezuela (CENDES-UCV)/Fundación Bengoa, Universidad San Francisco de Quito, and Instituto de Investigación Nutricional de Perú. The funders had no role in study design, data collection and analysis, the decision to publish, or the preparation of this symposium.

**Further collaborators:** On behalf of the ELANS Study Group

## MAJOR FOOD SOURCES FOR ENERGY AMONG COUNTRIES OF ELANS: ARE WE ALIKE?

It is well known that during the last 4 to 5 decades Latin America (LA) has undergone a process of nutritional transition, resulting in an increase of total energy intake that may be raising the overweight and obesity prevalence.

International comparisons of dietary intake are important to understand food habits and to contribute to the development of public health policies. However, comparisons of dietary intake across nations are not frequently reported due to the difficulty in collecting comparable data among different countries. Besides that, most of the scientific evidence has limited information on Latin American countries that have their own individuality as a region.

In order to correct this weakness, the ELANS group decided to evaluate the energy intake of 9218 subject, 15 to 65 years of age in 8 LA countries using two 24-hours dietary recall (24HR), following the multiple pass method. A total of 3351 types of food and beverages, reported in both 24HR, were grouped into 93 food types and 19 food groups. The percentage contribution of each food item to energy intake was calculated using weighted-proportions formula developed by Block et al (1985).

Ecuador had the highest intake of energy among the eight countries, followed by Argentina, Colombia and Peru. Conversely, Chile had the lowest intake, followed by Brazil, Costa Rica and Venezuela (data to be verified excluding miss reporters). The main source of energy in all countries was grains, pasta and bread followed by meat (not processed) and eggs and oils, fats and dressings. On the other hand, food groups such as vegetables, beans, legumes and soybeans and fruits have a low contribution to the total energy intake. Comparison between countries, reported that Peru is the one that get the highest energy from grains, pasta and bread and Colombia the lowest. Sugars and sweets are an important source of energy in the Argentinean diet, while oils, fats and dressings are the sources for the diet of Ecuadorians.

The distribution of energy throughout the day in the different meal times does not have a homogeneous distribution among the eight countries. For example, Venezuela gets the majority of the energy intake from breakfast and lunch, while Argentina does it from lunch and dinner. Finally, Brazil has an important intake of energy during the snacks along the day.

In conclusion, independent of the gender, in all countries, the main source of energy was grains, pasta and bread, followed by meat. The results reflected a dietary pattern that has been identified in LA population: high protein intake and low fiber, as fruits and vegetables are not consumed in the quantity recommended by the WHO. Regarding the mealtime pattern, none of the countries followed the pattern recommended by the FAO regarding the distribution of energy throughout the day (breakfast 20-25%, lunch 35-40%, dinner 15-25% and snacks 10-20%).

**Keywords:** Energy intake. Main source of energy. Energy distribution.

**Conflict of Interest disclosure:** The ELANS is supported by a scientific grant from the Coca Cola Company and support from the Instituto Pensi/Hospital Infantil Sabara, International Life Science Institute of Argentina, Universidad de Costa Rica, Pontificia Universidad Católica de Chile, Pontificia Universidad Javeriana, Universidad Central de Venezuela (CENDES-UCV)/Fundación Bengoa, Universidad San Francisco de Quito, and Instituto de Investigación Nutricional de Perú. The funders had no role in study

<footnote>(1)Cortes, Lilia Yadira; (2)Kovalskys, Irina; (3)Gómez Salas, Georgina;</footnote>

<footnote>(4)Fisberg, Mauro; (5)Yepez Garcia, Martha Cecilia; (6)Pareja, Rossina Pareja; (7)Herrera-Cuenca, Marianella; (8)Rigotti, Attilio; (9)Nogueira Previdelli, Agatha.</footnote>

<footnote>(1)PhD. Nutritionist. Department of Nutrition and Biochemistry. Pontificia Universidad Javeriana. Bogotá. Colombia.; (2)MD. International Life Science Institute. Buenos Aires. Argentina;</footnote>

<footnote>(3)MSc. Nutritionist. Departamento de Bioquímica. Escuela de Medicina. Universidad de Costa Rica. San José. Costa Rica;</footnote>

<footnote>(4)MD. Instituto Pensi. Hospital Infantil Sabara. São Paulo. Brazil; (5)MSc. Colegio de Ciencias de la Salud. Universidad San Francisco de Quito. Quito. Ecuador; (6)MSc. Nutritionist. Instituto de Investigación Nutricional. Lima. Perú; (7)PhD. MD. Centro de Estudios del Desarrollo. Universidad Central de Venezuela (CENDES-UCV)/Fundación Bengoa. Caracas. Venezuela; (8)PhD. MD. Centro de Nutrición Molecular y Enfermedades Crónicas. Departamento de Nutrición. Diabetes y Metabolismo. Escuela de Medicina. Pontificia Universidad Católica. Santiago. Chile;</footnote>

<footnote>(9)Nutritionist. Faculdade de Ciências Biológicas e da Saúde - Universidade São Judas Tadeu - São Paulo. Brazil.</footnote>
design, data collection and analysis, the decision to publish, or the preparation of this symposium.

**Further collaborators:** On behalf of ELANS group

## HYDRATION PROFILE OF POPULATION OF COUNTRIES OF ELANS

(1)Yepez Garcia, Martha Cecilia; (2)Kovalskys, Irina; (3)Fisberg, Mauro;

(4)Gómez Salas, Georgina; (5)Rigotti, Attilio; (6)Cortes, Lilia Yadira;

(7)Pareja, Rossina Pareja; (8)Herrera Cuenca, Marianella; (9)Nogueira Previdelli, Agatha.

(1)MSc. Bch. Med. Tech. Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Ecuador; (2)MD. Nutrition and Health Area. International Life Science Institute (ILSI). Buenos Aires. Argentina; (3)PhD. MD. Instituto Pensi. Fundação Jose Luiz Egydio Setubal. Hospital Infantil Sabara. São Paulo. Brazil PhD. Professor. Departamento de Pediatria. Universidade Federal de São Paulo. São Paulo. Brazil; (4)MSc. Nutritionist. Departamento de Bioquímica. Escuela de Medicina. Universidad de Costa Rica. Costa Rica; (5)PhD. MD. Centro de Nutrición Molecular y Enfermedades Crónicas, Departamento de Nutrición, Diabetes y Metabolismo, Escuela de Medicina, Pontificia Universidad Católica, Santiago, Chile; (6)PhD. Nuticionist. Departamento de Nutrición y Bioquímica, Pontificia Universidad Javeriana, Bogotá, Colombia; (7)MSc. Nutritionist. Instituto de Investigación Nutricional, Lima, Perú; (8)PhD. MSc. MD. Centro de Estudios del Desarrollo, Universidad Central de Venezuela (CENDES-UCV)/Fundación Bengoa, Caracas, Venezuela; (9)PhD. Professor. Faculdade de Ciências Biológicas e da Saúde. Universidade São Judas Tadeu São Paulo. Brazil.

Water has been considered as the most important drink in relation to a healthy and adequate hydration. Therefore, its daily intake should be sufficient to compensate for metabolic needs such as body composition, physical activity level or fever. In a healthy adult, with normal physiological conditions and without exposure to extreme environmental conditions, the intake recommended by the EFSA (European Food Safety Authority, 2010) for daily fluid consumption is 2.0 liters for women and 2.5 for men. These values are lower than those previously proposed by The Institute of Medicine of the National Academies in 2005. According to these recommendations, water should be the most important drink and in great abundance among the population; however it does not specify the average amount that should represent the consumption of pure water in relation to the liquids ingested daily.

The Latin-American Study of Nutrition and Health (Estudio Latinoamericano de Nutrición y Salud - ELANS) evaluated the intake of pure water in relation to the total of fluids consumed in the population taking into account variations according to gender, age, socio-economic status, and region of residence. The results of two 24-hours (24HR) dietary recalls were used, following the multiple-step method in three Latin American countries (Argentina, Ecuador and Peru).

From the total sample of participants included in the study, 88.9% consumed pure water and the remaining 11.1%, were participants that consumed liquids from others liquids than water. Argentina had the highest total fluid consumption among the three countries studied, followed by Ecuador and finally Peru with significant statistical differences between them. The contribution of pure water in relation to the total of liquids consumed was superior in Ecuador representing 18%, unlike Argentina and Peru where 16% corresponds to pure water, with a significant differences between gender.

Water consumption of the studied population followed the recommendations established by the EFSA for total liquids daily consumption (2.5 for men and 2.0 liters for women). The percentage of pure water consumed by the population of the Latin American countries included in the present study represents a low percentage of the total fluids consumed.

Pure water is recommended as the main source to cover the daily needs of liquids.

In conclusion, the implementation of proposals must be directed to motivate and to improve the different ways to hydrate, prioritizing the consumption of water over other drinks that provide energy. This could contribute to prevention of overweight, obesity and their comorbidities.

**Keywords:** Hydration; consumption habits; water; population.

**Conflict of Interest disclosure:** The ELANS is supported by a scientific grant from the Coca Cola Company and support from the Instituto Pensi/Hospital Infantil Sabara, International Life Science Institute of Argentina, Universidad de Costa Rica, Pontificia Universidad Católica de Chile, Pontificia Universidad Javeriana, Universidad Central de Venezuela (CENDES-UCV)/Fundación Bengoa, Universidad San Francisco de Quito, and Instituto de Investigación Nutricional de Peru. The funders had no role in study design, data collection and analysis, the decision to publish, or the preparation of this symposium.

**Further collaborators:**

On behalf of the ELANS Study Group
LIFESTYLE PROFILE OF FERTILE AGE WOMEN IN LATIN AMERICA: RISKS AND CONSEQUENCES FOR THE NEXT GENERATION

(1)Herrera-Cuenca, Marianella; (2)Nogueira Previdelli, Agatha;

(3)Kovalskys, Irina; (4)Pareja, Rossina Pareja; (5)Fisberg, Mauro;

(6)Gómez Salas, Georgina; (7)Rigotti, Attilio; (8)Cortes, Lilia Yadira;

(9)Yepez Garcia, Martha Cecilia.

(1)PhD, MSc, MD Centro de Estudios del Desarrollo, CENDES/Fundación Bengoa, Caracas, Venezuela; (2)PhD Professor Faculdade de Ciências Biológicas e da Saúde Universidade São Judas Tadeu São Paulo Brazil; (3)MD International Life Science Institute Buenos Aires Argentina; (4)MSc Nutritionist Instituto de Investigación Nutricional Lima Perú; (5)PhD MD Fundação José Luiz Egydio Setubal Hospital Infantil Sabara, Instituto Pensi. São Paulo 01239-040. Brazil;; (6)MSc, Nutritionist Departamento de Bioquímica, Escuela de Medicina. Universidad de Costa Rica. San José 11501 Costa Rica; (7)PhD. Centro de Nutrición Molecular y Enfermedades Crónicas, Departamento de Nutrición. Diabetes y Metabolismo, Escuela de Medicina, Pontificia Universidad Católica, Santiago 833-0024, Chile; (8)PhD Nutritionist Departamento de Nutrición y Bioquímica, Pontificia Universidad Javeriana Bogotá Colombia; (9)MSc, Bch, Med Tech Colegio de Ciencias de la Salud. Universidad San Francisco de Quito. Quito 17-1200-841. Ecuador.

Women of child bearing age should achieve and maintain good nutritional status and lifestyle prior to conception in order to minimize health risks to both: themselves and their babies. Evidence supports that at the time of conception maternal nutritional status is an important determinant of embryonic and fetal growth. The characteristics of Latin American women of fertile age in terms of nutrition status, physical activity level and the socio-economic elements that define their environment are key to understand if they are well prepared to face pregnancies in adequate conditions.

Latin America (LA) has been deep into the nutrition transition process and showed the double burden of malnutrition, including “hidden hunger”, as reported in the literature. How this process has influenced wellbeing in women of fertile age at regional level is a big concern for the scientific community in LA, and the question on the implementation of public policies is: how early should prevention start?

The Latin American Study of Nutrition and Health (Estudio Latinoamericano de Nutrición y Salud -ELANS), is a cross-sectional study conducted in eight Latin American countries with the aim to study: food consumption, physical activity level and socio-demographic and anthropometric characteristics. The study included 4,809 women, divided in four groups: adolescents; women between ages 19-34, women 35-44; and 45 -65 years old.

In general ELANS data reported a prevalence of overweight or obesity in 27% of adolescents, 50.77% of women between 19-34 years and 66.52% of women 35-44 years old. Chilean female adolescents showed the highest prevalence of overweight and obesity, whereas Costa Rican adolescents reported the lowest prevalence of excess. Waist circumference shows a trend for increasing with age in all countries.

Institute of Medicine estimated average requirements were taken as reference. Mean energy intake among all groups of ages are inadequate except for Costa Rica, where caloric intake reached 2000 Kcal/day or above in all age groups. All countries showed a trend to diminish caloric intake with age., Interestingly, 99.3% of women of all ages had adequate intakes of protein. Micronutrients intake outcomes showed: calcium intake to be inadequate in all countries, and adolescents and women over 45 years were the most inadequate. Regarding vitamin A, the most inadequate intakes were in Brazil and Venezuela in all groups of age, vitamin C reported a general prevalence of inadequacy of 35.95% and most concerning: vitamin D reached 98.52% of inadequate intake.

According to IPAQ results, 61.93% of women have low physical activity (PA) levels, adolescents were the group with largest prevalence of inactivity or low levels of PA. Venezuelan adolescents were the most inactive, and the exception of Peruvian women who showed the highest prevalence of activity at all ages, particularly adolescents.

In conclusion, women of fertile age in LA showed a vulnerable nutritional status with inadequate intakes of key nutrients, that combined with high prevalence of inactivity constitute a profile of risk for embracing pregnancies in good condition; thus compromising a good start to life of the future generations.

**Keywords:** ELANS, Women, fertile age, lifestyle

**Conflict of Interest disclosure:** The ELANS is supported by a scientific grant from the Coca Cola Company and support from the Instituto Pensi / Hospital Infantil Sabara, International Life Science Institute of Argentina, Universidad de Costa Rica, Pontificia Universidad Católica de Chile, Pontificia Universidad Javeriana, Universidad Central de Venezuela (CENDES-UCV)/ Fundación Bengoa, Universidad San Francisco de Quito, and Instituto de Investigación Nutricional de Peru. The funders had no role in study design, data collection and analysis, the decision to publish, or the preparation of this manuscript.

**Further collaborators:**

On behalf of the ELANS Study Group

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CLIMATE CHANGE AND NUTRITION: CHALLENGES AND OPPORTUNITIES

CLIMATE CHANGE, AGRICULTURE AND HUMAN HEALTH

Springmann, Marco.

University of Oxford. United Kingdom.

Climate change and human health are related to each other by changes in agriculture. In this talk, I provide an overview of our group's work that analyses three such pathways.

First, I detail how climate change affects agriculture through changes in yields, which affects food consumption by changes in supply, which finally affects health by changes in food composition. Based on a coupled modelling framework, I present quantitative estimates of these climate-related health impacts.
Second, I detail how changes in food demand could impact both climate change and human health. I explore the climate change and health co-benefits of multiple dietary scenarios as estimated by a global comparative risk assessment paired with greenhouse-gas emissions.

Third, I detail how economic incentives could influence food consumption, as well as the health and climate change co-benefits associated with that. Using an agriculture-economic model coupled to a global health model, I present region-specific estimates of the impacts of levying emissions taxes on food commodities, with a special focus on designing tax designs that would result in both health and environmental co-benefits.

**Keywords:** Human health, climate change, agriculture, dietary change, global modelling

**Further collaborators:**

Peter Scarborough (University of Oxford), Mike Rayner (University of Oxford), Charles Godfray (University of Oxford), Daniel Mason-D'Croz (IFPRI), Sherman Robinson (IFPRI), Keith Wiebe (IFPRI)

PS_144/1040

# SHAPING GLOBAL FOOD SYSTEMS FOR BETTER NUTRITION

## ENHANCING MICRONUTRIENT DENSITY OF STAPLE CROPS OF FOOD SYSTEMS IN DEVELOPING COUNTRY

Boy, Erick.

PhD, Head of Nutrition/HarvestPlus, International Food Policy Research Institute, Washington, DC, USA.

In general terms, biofortification comprises the application of genetic engineering, agronomic and plant breeding technologies to enhance the contents of nutrients and phytochemicals in the edible tissues of living organisms. More specifically, biofortification via selective plant breeding for higher iron, zinc and provitamin-A (pVA) carotenoids in staple crops has made most progress insofar as crop development, varietal releases in middle and low income countries with high burden of these micronutrient deficiencies, and deployment of the biofortified varieties through a variety of demand push and pull strategies. Today, biofortified crops, including pVA-rich orange sweet potato, iron beans, iron pearl millet, pVA yellow cassava, pVA orange maize, zinc rice, and zinc wheat, have been released in more than 30 countries and are being tested and grown in more than 40 countries. More than 160 varieties of 10 major and minor staples have been released. Crop improvement continues to develop varieties with higher levels of vitamins and minerals that are adapted to a wide range of agro-ecological conditions. Ensuring that the best germplasm for climate-adaptive and consumer-preferred traits remains a basic criterion in breeding biofortified crops. To make significant headway in contributing to solve the global public health problem

of hidden hunger, biofortified crops must become the norm rather than the exception in staple food markets. To reach a billion people effectively in developing countries by 2030 will require 1) enhancing the knowledge base to develop and deliver more efficient technologies to accelerate plant breeding and hit the highest micronutrient levels possible successfully without sacrificing preferred agronomic and culinary traits; 2) mainstreaming plant breeding for nutritional traits at regional and national agricultural research centers; 3) improving the stability of provitamin A carotenoids post-harvest in maize, cassava, and sweet potato; 4) improve the bioavailability of iron and zinc when the increase in mineral density is insufficient to improve nutritional status; and 5) partnering with implementing agents in agriculture and nutrition in high burden countries. Certainly, serious consideration must be given to assessing the cost-benefit of crop genome editing and other genetic engineering technologies, and to working within the regulatory environment and with consumer education long before any GM product reaches an advanced development stage. But more importantly, each national and regional government must address micronutrient malnutrition disorders holistically and in responding to context-specific requirements and opportunities. There are no magic bullets but there are many interventions, including biofortification, that are already available and waiting to be deployed in an integrated fashion.

**Keywords:** Biofortification, crops, food, micronutrients, mainstreaming

## SHAPING MARKETS FOR BETTER NUTRITION: INSIGHTS FROM THE ASSESSMENT OF THE MARKETPLACE FOR NUTRITIOUS FOODS

(1) Toure, Djeinam; (2) McClafferty, Bonnie; (3) Neufeld, Lynnette M.

(1) PhD. Senior Associate. Global Alliance for Improved Nutrition. United States of America.; (2) Director of Agriculture and Nutrition Programs; (3) Director of Monitoring, Learning, and Research.

Today, poor quality diets are the leading contributor to the global burden of disease and are in large part the result of the failure of the food system to support the accessibility (i.e., availability and affordability) of nutritious foods to all segments of the population. The world's poor are net buyers of food, yet there have been few efforts to leverage markets as an entry point to improving diets. Private-sector actors involved in processing, distributing, and retailing foods influence the availability, affordability, safety, and nutritional content of foods in the marketplace and hence in part govern access to nutritious diets.

In sub-Saharan Africa, the vast majority of businesses are small and medium enterprises (SME) and these entities provide a sizable share of foods purchased by low-income populations. These businesses face many challenges in establishing sustainable, profitable operations and it is recognized that support is necessary to foster their establishment. Supporting SMEs to improve the nutritional quality and safety of their products in ways that are inclusive of low-income communities and to overcome barriers to growth has
about best activities to achieve 5 minute bouts. Examples of these
advancements in physical activity assessment and its associated
outcomes will be shared. For dietary intake, subjective or cultural
terms (e.g., supper) for eating occasions have had mixed results
with regard to overall diet quality. The use of objective time meas-
ures have revealed distinct temporal dietary patterns with signifi-
cant differences in diet quality. Examples will be shared to demon-
strate the improvement in dietary assessment that can accrue from
objectively documenting time of eating, the environment of eat-
ing, and other contextual data. The new methods available to im-
plement these data collection activities will be summarized.

**Keywords:** Physical activity, bouts, dietary assessment, temporal dietary patterns.

THE EXERCISE IS MEDICINE (EIM) IN CHINA

(1)Zhao, Wenhua; (2)Yang, Zhengxiong; (3)Chen, Junshi.

(1)PhD. Professor. National Institute for Nutrition and Health.
Chinese Center for Disease Control and Prevention; (2)Associate
Professor. International Life Sciences Institute Focal Point in
China; (3)PhD. Professor. International Life Sciences Institute
Focal Point in China.

Background and objectives: A third of the world's population does not meet the recommended levels of physical activity, which lead to substantial health and economic burdens. Over the past several decades, along with the changes of lifestyle in Chinese pop- ulation, the physical activity and fitness of Chinese has decreased, where as physical inactivity becomes a major causal risk factor for the rapid increase of overweight and obesity and many of their associated co-morbidities have increased. In China, 86% of deaths due to non-communicable diseases and 8.3% of deaths related to physical inactivity already occur, but where a large gap in research and implementation of PA strategies exists.

Methods and Results: 'Exercise Is Medicine' (EIM) is a global health initiative managed by the American College of Sports Med- icine (ACSM) that is focused on encouraging primary care physi- cians and other health care providers to include physical activity when designing treatment plans for patients and referring their patients to EIM Credentialed Exercise Professionals.

ILSI Focal Point in China signed the Memorandum with ACSM for the Cooperation in Exercise is Medicine (EIM) in China in 2012. The main objective is working on promoting the EIM solution and physical activity in China by holding EIM training courses, setting up EIM website and other projects.

To provide advices for clinicians to offer patients with exercise
prescription, and to provide guidelines on scientific exercises and
non-communicable diseases prevention, ILSI Focal Point in China
has organized more than 10 training courses on EIM in collaborat-
ing with relevant organizations, and totally 1500 of clinicians have
been trained by the end of May 31 2017.

Conclusions: To train the trainers and increase public aware is
the key to the success of EIM in China. In this presentation, we de-
scribe the evolution and Chinese expansion of the EIM initiative,
the implementation and future directions.

**Keywords:** Keywords: Physical Activity, Training, EIM, China

MINI SALTEN: A CASE STUDY ON LEARNINGS
FROM ARGENTINA ON OUTCOMES AND CHAL-
LENGES

(1)Kovalskys, Irina; (2)Indart Rougier, Paula; (2)Luciana, Luciana;

(3)Rauch Herscovici, Cecile; (4)De Gregorio, Maria Jose.

(1)MD. ILSI Argentina; (2)BSc. Nutritionist. Nutrition and Health Area. International Life Science Institute. ILSI Argentina; (3)PHD. Psychologist. Nutrition and Health Area. International Life Science Institute. ILSI Argentina; (4)BCS. Sociologist. University of Buenos Aires.

Global Recommendations on Physical Activity for 5-17 years old, of the World Health Organization (WHO), are to invest at least 60 minutes a day in moderate to vigorous physical activity (MVPA).

Mini SALTEN is a program developed to improve eating hab-
its and increase moderate to vigorous physical activity at home
and school in first grade children. It aims to assess the effects of a
technology family-based and physical activity (PA) school-based
intervention.

The design of the protocol was based in a cluster-randomized
controlled trial designed to run from July 2015 to November 2016
in twelve public schools of the city of Buenos Aires, matched for
socio-demographic characteristics. The intervention was based on
two main components: a) virtual (V): web-based presentations de-
livered to the mothers via a multiplatform application; b) active
breaks (AB): implemented during school breaks by a PA instruc-
tor. V: Especially designed web-based contents, targeting families
and children aimed at encouraging the improvement of eating
habits of the whole family both at home and at school, and increas-
ing mothers' knowledge of the benefits of PA and consequences of
sedentary behaviour, and proposing pleasurable movement entail-
ing activities for the children. AB: included activities comprising
movement during school breaks that were promoted with motiva-
tion as a backbone and devoid of a competitive strive; active play
in which fun, pleasure, and sharing were emphasized. PA instruc-
tor guided activities with the goal of promoting active play for a
minimum of 20-30 min/day, depending on each school. Using a
computer generated random sequence participants were allocated
to one of four intervention conditions resulting in 4 clusters: (AB),
(V), (AB) + (V), and control (C). Outcomes are measured at base-
line and 12 months post intervention, and included data collected
from the dyad (child and her/his mother).. The levels of PA were
measured using ActiGraph wGT3X-BT accelerometers for 7 con-
secutive days (24 hours). Outcomes were: time in light, moderate
and vigorous PA and sedentary time (minutes/day). Family so-
cio-economic level, home environment, and school environment
were also assessed. This study provides objective information re-
garding dietary and PA patterns of first grade children of public
schools of Buenos Aires. It is a pioneer assessment of the impact
of a technology-based virtual intervention, involving the parents,
designed to prevent obesity. planning public health policies.

**Keywords:** Physical Activity. childhood Obesity prevention.
Technology. PA measures.

**Conflict of Interest disclosure:** Disclosure: MiniSalten was supported by a scientific grant from the Coca Cola Foundation
and ILSI Argentina. The founders had no role in study design, data collection and analysis, or preparation of this symposium. The authors declare no conflict of interest.

# NEW COMBINATION METHODS FOR ADVANCING PHYSICAL ACTIVITY AND FOOD INTAKE ASSESSMENT FOR BETTER ADHERENCE TO PUBLIC HEALTH RECOMMENDATIONS

Pratt, Michael.

Professor and Director. Institute for Public Health.University of California San Diego.

Measurement of dietary intake and physical activity has become increasingly important for health monitoring, and providing interventions that optimize population health. Advances in technology have been useful for reducing survey or study participant burden and have increased objectivity and accuracy for some measures. A plethora of tools, applications and systems have been developed and although significant advances have been made, several limitations at the level of the individual measure limit the ability to capture information that is accurate. In November 2016 a group of experts on diet, physical activity, and the use of technology for health purposes gathered at the University of California, San Diego to examine current experience with the use of technology for research on physical activity and diet. This unique forum investigated current and emerging challenges related to improving energy balance behavior assessment and intervention via technology, and focused on how the research community might embrace and apply innovative new tools. The assembled experts made a number of recommendations that will be summarized in this presentation. To be able to fully take advantage of recent technological advancements for the measure of diet and physical activity:

1. A consensus is needed regarding current methodology and needs with regards to each area of assessment. This will foster inter-disciplinary collaborations among experts from technology, nutrition, public health, epidemiology, and medicine to address the gaps in this direction.

2. Additionally, a focus on assessing the validity and reliability of the available methods for dietary intake and physical activity assessment in adult, youth, and older adult populations ratified by expert researchers in the field will help guide investigators to obtain high quality measures.

3. Increasing efforts that are directed to facilitate a plug-and-play open architecture systems that allows for modular systems to be assembled for specific assessments. Success would include smartphone links with various software applications.

4. Establishing a committee or international working group to evaluate, manage or channel the huge influx of new apps and emerging technologies to measure dietary intake and physical activity, so that there is a focused and effective effort in this direction.

5. Development of novel biomarkers using the technological capabilities to increase objectivity of the measures.

6. Bridging between technology developed for research and consumer wearable technology will be important if research on diet and physical activity is to be optimized at the population level.

While there are still many limitations and challenges in the measurement of dietary intake and physical activity, there is much progress and even more promise for using technology to improve measuring diet, physical activity, and sedentary time. Managing the current knowledge base and facilitating a resource center for sharing measurement technology and analytic approaches are keys for success in obtaining accurate dietary intake and physical activity measures and contributing to higher quality research that can turn improve population health.

**Keywords:** Physical activity, nutrition, technology, measurement, public health recommendations

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# DIET, NUTRITION, PHYSICAL ACTIVITY AND CANCER: TOWARDS THE 2017 WCRF CONTINUOUS UPDATE PROJECT UPDATE

## EVIDENCE FROM THE LAST DECADE: WHAT HAS CHANGED?

Wiseman, Martin.

World Cancer Research Fund International, UK and University of Southampton, UK.

This talk will focus on new findings and substantive changes compared to the CUP Panel's conclusions of 2007 report arisen from recent evidence. Although there are changes in the specific conclusions relating nutritional exposures to risk of cancer, the most important changes are changes in emphasis across the overall relation between diet and activity, and cancer. There is a greater emphasis on nutritional state marked by body composition, and markers of growth and maturation, than of specific dietary factors. In particular the combination of adiposity and physical inactivity seems a key determinant of cancers common in high income countries. Within diet, there is greater emphasis on foods than on specific nutrients, and to a greater extent, on patterns of diet as opposed to single foods. In general, the strength of existing conclusions has been strengthened, but in some cases has reduced, while there are also new findings. Selected examples include that both vigorous physical activity and body fatness in young adulthood decrease risk of breast cancer. Possible reasons for these changes will be discussed, as well as possible mechanisms underpinning the changed or new findings. The updated CUP findings will be used to inform a review of WCRF International's Cancer Prevention Recommendations, expected in early 2018.

**Keywords:** Diet, Nutrition, Cancer, WCRF, CUP

**Further collaborators:**

World Cancer Research Fund International
## NUTRITION STATUS DURING CHILDHOOD IN LATIN AMERICA

(1)Corvalan, Camila; (2)Garmendia, María Luisa; (3)Jones-Smith, Jessica; (4)Lutter, Chessa; (5)Miranda, Jaime; (6)Pedraza, Lilia; (7)Popkin, Barry M; (8)Ramirez, Manuel; (9)Salvo, Deborah; (10)Stein, Aryeh.

(1)PhD, MD, MPH. Institute of Nutrition an Food Technology. University of Chile. Chile.; (2)PHD. MD. MPH. Institute of Nutrition and Food Technology; (3)PhD. Department of Health Services. School of Public Health. University of Washington. Seattle. WA. USA.; (4)PhD. Pan American Health Organization. USA.; (5)PhD. CRONICAS Center of Excellence in Chronic Diseases. Universidad Peruana Cayetano Heredia. Lima. Perú.; (6)PhD. Center for Nutrition and Health Research. National Institute of Public Health. Cuernavaca. Mexico.; (7)PhD. Carolina Population Center. The University of North Carolina at Chapel Hill. Chapel Hill. NC. USA.; (8)PhD. INCAP. Research Center for the Prevention of Chronic Diseases (CIIPEC).Institute of Nutrition of Central America and Panama.Guatemala.; (9)PhD. Michael and Susan Dell Center for Healthy Living. The University of Texas Health Science Center at Houston. School of Public Health. Austin.TX.USA.; (10)PhD. Hubert Department of Global Health of the Rollins School of Public Health. Emory University. Atlanta, GA. USA.

**Introduction:** Over the last decades, Latin American (LA) has observed marked improvements in the control of under-nutrition but at the same time, the prevalence of overweight and obesity is increasing among LA children. Childhood obesity epidemic is a matter of concern given its association with earlier development of chronic diseases such as diabetes, cardiovascular disease, and some forms of cancers; it also increases economic and health-care burden.

**Objective:** to describe the current nutrition, dietary, and physical activity situation of LA children, the disparities between and within countries, and the potential challenges for ensuring adequate nutrition and physical activity in the region.

**Methods:** non-systematic review of articles, reports, and demographic surveys.

**Results:** across the region, children face a dual burden of under-nutrition and excess weight with important heterogeneity between and within countries. Nonetheless, in almost all groups overweight is rapidly increasing because of important changes taking place in the food and the physical environments. Rapid urbanization combined with greater penetration of the retail food and food service sector has promoted diets that rely on energy-dense, nutrient-poor foods and away-from-home foods. At the same time, sedentary behaviors have become the norm among children.

**Conclusions:** overweight and obesity are rapidly increasing in LA children because of recent changes in socioeconomic conditions, increase urbanization, growth of the retail food sector, and decrease in public transportation. If no action is taken, the rates of

overweight and obese children will continue to rise in the region. Additional research and research capacity is needed to address this growing epidemic, particularly with respect to design, implementation, and impact evaluation of evidence-based obesity prevention interventions.

**Keywords:** Childhood obesity, nutrition transition, Latin-America, nutrition and physical activity status children.

## PREVENTION OF CHILDHOOD OBESITY AND FOOD POLICIES IN LATIN AMERICA: FROM RESEARCH TO PRACTICE

Perez-Escamilla, Rafael.

PhD. Professor. Yale School of Public Health. New Haven CT. USA.

Evidence-based policies are needed to enable environments to prevent childhood obesity through lifestyle modification including diet and physical activity. The objective of this study was to document the process of translating research into obesity prevention policies in Latin America. Policies examined were selected based on their progress with implementation, awareness, and potential impact in the region. As a first step the following four case studies were developed excise taxes on sugar sweetened beverages (SSBs) and ultra processed foods (Mexico), front-of-package food label (FOP) legislation (Chile and Ecuador), industrial trans fatty acids (TFAs) removal from processed foods (Argentina) - even though not an anti-obesity policy per se, it represents a case study on product reformulation with important lessons to offer to the obesity prevention arena, and Ciclovas recreativas or "open streets" (Latin America). Each case was developed by a team formed by at least two individuals who collectively had strong experience involvement with the specific policy or program. The second step involved coding the case studies to identify implementation as well as sustainability theme and sub-themes. The conceptual framework used was the complex adaptive systems (CAS) developed by the health care system sector and a consensus iterative process was followed to agree on the final coding and interpretation scheme. Findings showed that a series of negative and corresponding positive feedback loops led to the emergence, implementation, and sustainability of for effective anti-obesity policies. The following enabling factors were identified as being common across case study for successful policy implementation: strong evidence supporting policy; evidence-based advocacy driven by civil society; political will; legislation and strategic coordination across key sectors including government, private sector, and civil society. Scientific evidence and adequate program monitoring and evaluation played a key role in reaching the tuning points triggering the successful implementation of the policies examined. Prospective CAS policy research is needed to better understand how the complex web of negative and positive feedback loops detected in this analysis develop and interact across key sectors and stakeholders. This research is crucial to enable the successful emergence, implementation an sustainability of effective anti-obesity prevention policies in Latin America and beyond.
**Keywords:** Food and nutrition policy, physical activity, Ciclovías, childhood obesity, food product reformulation, complex adaptive systems

**Conflict of Interest disclosure:** No conflicts of interest to declare

**Further collaborators:**

Chessa K Lutter, Cristina Rabadan-Diehl, Adolfo Rubinstein, Alejandro Calvillo, Camila Corvalan, Carolina Batis, Enrique Jacoby, Lydia Kline, Ella Ewart-Pierce, Juan A. Rivera

## RESEARCH CAPACITY FOR CHILDHOOD OBESITY PREVENTION IN LATIN AMERICA

Pratt, Michael.

Professor and Director. Institute for Public Health.University of California San Diego.

As Latin America passed through the epidemiologic and lifestyle transitions in recent decades, obesity prevalence among children and adolescents increased markedly. However, in many countries the evolution of obesity is poorly documented and understood, in part, because of a lack of research support and training. Public health effort to build research capacity in the region over the past decades have focused largely on child survival and communicable disease prevention and the capacity for research and translation of that research related to chronic diseases, obesity, and physical activity promotion seems to be much less developed. In this presentation, we report on current research capacity in Latin America related to childhood obesity, nutrition, and physical activity. In addition, we identify key gaps and suggest priorities to further develop research capacity and apply it to public health policies and programs that can address obesity prevention in the region. We conducted a search of peer-reviewed articles on childhood obesity in Latin America with at least one Latin American author from 2010 to 2015. We coded 484 published articles for author affiliation, study subjects nationality, research topic, and study design and extracted a series of networks for each research topic, study design, and collaborating country. Obesity was the most frequently studied topic. Nutrition and obesity were somewhat better developed compared to physical activity and sedentary behavior. There were numerous observational and cross-sectional studies, indicating either a lack of capacity required for more complex research or that the extent of the problem and associated factors remain relatively unexplored. The low number of intervention studies and the near absence of policy articles suggest a void in research capacity in these areas and/or limited funding to support these types of studies. Given the growing concern for the increasing prevalence of childhood obesity in Latin America and the need to document the current state of the problem and design successful prevention and intervention efforts, there is a clear demand for increasing research capacity and extending studies from the merely observational to intervention and policy analyses. While adequate research funding and generating well-trained investigators are fundamental conditions for capacity building, our data show that there is still limited interaction among existing groups with-

in and across countries. Efforts to foster data sharing and scholar exchange can be started immediately and should be a component of any strategic capacity building plan. This interaction is also essential to permit smaller countries, with limited resources, to participate in multi-country studies and develop their own team of qualified scientists.

**Keywords:** Childhood obesity, Latin America, research capacity, physical activity, nutrition

**Further collaborators:**

Diana C. Parra1, Susan Vorkoper2, Harold W. Kohl, III3, Benjamin Caballero4, Carolina Batis5, Alejandra Jauregui6, Jessica Mason7

1. Program in Physical Therapy, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA

2. Fogarty International Center, National Institutes of Health, Bethesda, MD, USA

3. University of Texas Health Science Center – Houston and University of Texas at Austin, TX, USA

4. Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

5. National Council for Science and Technology – Center for Nutrition and Health Research, National Institute of Public Health, Cuernavaca, Mexico

6. National Institute of Public Health, Cuernavaca, Mexico

7. University of Texas Health Science Center at Houston: School of Public Health - Austin Regional Campus, Austin, TX, USA

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## FRONT OF THE PACKAGE PROFILING EMERGES AS A MAJOR REGULATORY TOOL GLOBALLY: NEW IMPACT RESEARCH

### BRIEF OVERVIEW OF FRONT-OF-PACK LABELLING SYSTEMS

(1)Uauy, Ricardo; (2)Popkin, Barry M.

(1)PhD. Professor. INTA. University of Chile. Chile; (2)Phd. Nutrition. Department of Nutrition. University of North Carolina. United States.

**Background and objectives:** Across Europe, the Americas, Asia and Africa countries are increasingly using Front of the Package (FOP) food labelling systems to identify either healthy or unhealthy food products. This presentation introduces the topic and provides background context for the other presentations.

**Methods:** A review of front-of-the-package profiling purposes and approaches.

**Results:** Detailed on-pack nutrition information is necessary, but not suitable for daily shopping decisions by consumers. These front-of-pack labelling systems are organized and implemented at the national level. They are based on different nutrient profiling methods, that all adhere to the basic idea of reducing sodium, added sugar, unhealthy saturated fats, encouraging whole grains,
fruits, vegetables and legumes/pulses. Some like the PAHO system focus on removing the least healthful foods and do not encourage a focus on the healthiest foods. While all FOP systems share the goal of helping consumers in facilitating healthier choices in relation to non-communicable diseases, they differ in many aspects. WHO and many others demand regional and global coherence.

The four FOP labelling systems with strongest international presence are:

1. Voluntary positive logos, to indicate the best in class in each food category. The role of governments is strong in most cases and is complemented with cooperation by the food industry.

2. Mixed positive and negative indications, based on colour coding. The underlying nutrient profiling systems do not differentiate between product categories.

3. Health Star ratings on a scale from 1 to 5, on a voluntary basis

4. Warning labels to indicate products that are high in fat, sug-
ar, salt and energy

The different labelling systems show a clear geographical differ-
ence. While positive logos have a strong presence in Asia, Africa
and Northern Europe, the color coding is present in several West-
ern European countries. The star system is in use in Australia, New
Zealand and Canada, while Latin American countries tend to opt
for warning labels. A regional coherence across these lines might
be an intermediate goal to achieve. International food companies
are not univocal in their preference and implement different sys-
tems in practice. When it comes to guidance for product refor-
mulation, the product group specific nutrient profiling systems
appear to be most suitable.

**Conclusions:** Research has now moved beyond consumer knowledge and attitude studies to explore the impact of the systems on food purchasing patterns. Many studies are on-going but preliminary results will be presented in this session.

**Keywords:** Front-of-the-package labelling. nutrient profiling. geographical difference

THE IMPACT ON FOOD PURCHASES OF THE
DUTCH CHOICES AND THE DANISH KEYHOLE
FOP SYSTEMS

(1)Smed, Sinne; (2) Jansen, Leon; (3)Edenbrandt, Anna.

(1)PhD. Associate Professor. Department of Food and Resource Economics. University of Copenhagen. Denmark; (2)PhD. Schuttelaar & Partners. Denmark; (3)PhD Student. Department of Food and Resource Economics. University of Copenhagen. Denmark.

**Background/Objective:** The costs associated with diet-related health problems are increasing. Information provision in terms of mandatory nutrition facts sheets placed at (the back of) pre-packaged food is one of the strategies that public authorities use to counteract this development. However the level of understanding and use of the information has been proved to be inadequate as consumers have limited information processing capability, and it

requires time, effort and knowledge to understand such detailed
information. The use of FOP nutrition symbols aims to make
the information provided easier for consumers to access, howev-
er the overall effect of FOP nutrition symbols is still questioned.
In a range of studies we aim at accessing how these symbols are
valued by consumers, and whether they contribute to healthier
food choices at the point of purchase, taking into account both
individual differences in needs and wants, and country-specific
differences.

**Subjects/methods:** Contrary to most previous research, these studies are based on real market data in the form of household scanner data from the Netherlands and Denmark. The data spans the period from one year before the introduction of the Dutch Choices and the Danish keyhole respectively to three years after. The data includes a range of different products, enabling comparison across product categories as well as across countries. Because of the unique characteristics of these data (large scale, brand level, longitudinal and with socio demographic characteristics of panel members), the sophisticated econometric models used allow us to control for a range of for confounding factors affecting the valuation and use of nutrition symbols.

**Results:** We find that consumers value products with the symbol higher than products without, hence the provision of the nutrition symbol constitutes additional value to the consumers for the majority of the products we have analyzed. The consumer's valuation of the Choices symbol is larger three months after the product obtained the symbol than immediately after which indicates that there may be a delay before the consumers notice the label, recognize it and potentially take it into account when making decisions on which product to purchase. Furthermore we find that the FOP labels increase purchases for most of products analyzed, hence displaying the label on the package lead to an increased market-share for the products doing so. There seem not to be any complementing behavior as overall healthiness of the households' food purchases, covering all food categories, is for most product categories positively correlated with the share of Keyhole products.

**Conclusion:** Credible nutrition symbols have value for the consumer and increase market shares for products that display the label. We therefore conclude that nutrition symbols are relevant tools to combat diet-related diseases by guiding consumers towards healthier diets.

**Keywords:** FOP labelling. value of information. longitudinal home-scan. point of purchase
# IMPACT OF THE NEW ZEALAND HEALTH STAR RATING SYSTEM: RCT RESULTS AND EVALUATION OF ROLL-OUT

(¹)Ni Mhurchu, Cliona; (²)Eyles, Helen; (³)Volkova, Ekaterina; (⁴)Jiang, Yannan; (⁵)Neal, Bruce; (⁶)Blakely, Tony; (⁷)Swinburn, Boyd; (⁸)Rayner, Michael; (⁹)Choi, Yeun-Hyang.

(¹)PhD. National Institute for Health Innovation. University of Auckland. New Zealand; (²)PhD. Senior Lecturer. University of Auckland. New Zealand; (³)PhD. Research Fellow. University of Auckland. New Zealand; (⁴)PhD. Biostatistician. University of Auckland. New Zealand; (⁵)PhD. Professor. The George Institute for Global Health. Australia; (⁶)PhD. Professor. University of Otago. New Zealand; (⁷)PhD. Professor. University of Auckland. New Zealand; (⁸)PhD. Professor. University of Oxford. UK; (⁹)MSc. Data Analyst. University of Auckland. New Zealand.

**Background:** Interpretive, front-of-pack (FOP) nutrition labels may encourage healthier food choices by consumers and healthier reformulation of foods by industry.

**Objective:** We aimed to evaluate the effects of the Health Star Rating (HSR), a voluntary interpretive FOP labelling system on (1) consumer food choices, and (2) industry food reformulation.

**Design:** Study 1. In a parallel-group randomized controlled trial, we enrolled household shoppers across New Zealand who owned smartphones and were aged >18 y. Participants were randomly assigned to receive either Traffic Light Labels (TLL), HSR, or a control [Nutrition Information Panel (NIP)]. Smartphone technology allowed participants to scan barcodes of packaged foods and receive allocated labels on their smartphone screens. The primary outcome was the mean healthiness of all packaged food purchases, measured using the Food Standards Australia New Zealand Nutrient Profiling Scoring Criterion (NPSC). Study 2. Annual surveys of packaged food labelling and composition were undertaken in supermarkets before and after adoption of HSR in New Zealand i.e. 2014 to 2016. Product data were linked with nationally representative household food purchasing data to obtain estimates of effects weighted by annual purchasing volumes. Outcomes assessed were uptake HSR by food group; composition of products displaying HSR compared with unlabelled products; and composition of products displaying HSR labels in 2016 compared with their composition prior to the introduction of HSR.

**Results:** Study 1. 1357 eligible shoppers were randomly assigned to TLL (n = 459), HSR (n = 443), or NIP (n = 455) labels. There was no significant difference in the mean transformed NPSC scores (healthiness) for the TLL group compared with the NIP group (P = 0.60), or for HSR group compared with NIP (P = 0.12). However, in a per-protocol analysis of participants who used the labelling intervention more often than average (n = 423, 31%), those assigned to TLL and HSR had significantly better NPSC scores than those assigned to NIP (P = 0.04 and 0.01 respectively). Study 2. Two years after adoption of the voluntary system, 5.3% of packaged foods surveyed displayed HSR labels (7.2% weighted by annual purchase volumes). Food groups with highest rates of uptake were cereals, convenience foods, packaged fruit and vegetables, sauces and spreads, and 'other' products (predominantly breakfast beverages). Products displaying HSR labels had significantly lower mean saturated fat, total sugar and sodium contents, and higher fibre contents than unlabelled products (all p-values <0.001). Small but statistically significant changes were observed between 2014 and 2016 in the mean energy (-29 KJ/100g, p=0.002), sodium (-49 mg/100g, p=0.03) and fibre (+0.3 g/100g, p=0.02) contents of products displaying an HSR label in 2016. Reformulation was greater for products carrying an HSR label than for unlabelled products.

**Conclusions:** In a randomised controlled trial, interpretive nutrition labels had no significant effect on consumer food purchases, though regular use of interpretive FOP labels may result in healthier food purchases. Roll-out of the voluntary HSR labelling system is driving healthier reformulation of some products. Greater uptake of the HSR system across the full food supply should improve population diets.

**Keywords:** Labelling. diet. behaviour. reformulation. randomized controlled trial

**Conflict of Interest disclosure:** Cliona Ni Mhurchu is a member of the New Zealand Health Star Rating Advisory Group. The New Zealand Health Star Rating Advisory Group had no role in study design, data collection and analysis, decision to publish, or preparation of study manuscripts or abstracts.

# THE IMPACT OF THE UK TRAFFIC-LIGHT LABELLING SYSTEM ON DIETS

Rayner, Michael; (²)Harrington, Richie; (³)Scarborough, Peter.

(¹)DPhil. Professor. Nuffield Department of Population Health. University of Oxford. UK; (²)PhD. Researcher. Nuffield Department of Population Health. University of Oxford. UK; (³)DPhil. Associate Professor. Nuffield Department of Population Health, University of Oxford, UK.

**Background:** Front-of-pack nutrition labelling involving traffic-light color coding to indicate levels of fat, saturated fat, sugar and salt was first recommended by the UK Government in 2006 and is now found on an estimated 60% of packaged foods and non-alcoholic beverages sold in the UK. A considerable amount of research was carried out to inform the choice of nutrient criteria and format for the system but considerably less research has been carried out into the impact of traffic-light labelling on consumer and producer behavior. Such research that has been carried out is generally of low-methodological quality (e.g. very little is experimental and/or ecologically valid). It is difficult to draw conclusions about the impact of traffic-light labelling from such studies.

This presentation reports the preliminary, and as yet mostly unpublished, findings of the Front of pack food Labelling: Impact on Consumer Choice (FLICC) project. The main FLICC project study was of a web-based intervention designed to increase consumer use of traffic-light labelling to encourage healthier purchase decisions.

**Methods:** The main FLICC project study was a pilot two-arm randomized controlled trial of an intervention that incorporated a number of behavior change techniques and used super-market loyalty cared data to recruit participants (n=496), provide tailored
feedback as part of the intervention and to measure outcomes. The
primary outcome measure was the healthiness of ready meals and
pizzas that had traffic-light labelling purchased before (T1) and
after (T2) the intervention.

**Results:** There was no difference in the main outcome measure between intervention group and control group during period T1 (p=0.315) and T2 (p=0.594).

Conclusions: This study is the only example, known to us, of a trial of a behavior change intervention that utilized supermarket loyalty care data for recruitment, the intervention itself and outcome measurement. The trial did not provide evidence to suggest the specific intervention tested would be effective at changing purchasing behavior, but the process of conducting the trial has provided much information about using supermarket loyalty card data for future trials and delivery of public health interventions. It adds to the literature on the impact of interventions involving traffic-light labelling. It demonstrates some of the difficulties of finding effects on health-related outcomes of interventions involving front-of-pack labelling.

**Keywords:** Front-of-pack nutrition labelling

THE CHILEAN EXPERIENCE OF FOP DEVELOP-
MENT, IMPLEMENTATION AND IMPACT

(1)Reyes, Marcela; (2)Corvalan, Camila; (3)Correa, Teresa; (4)Dillman, Francesca; (4)Mediano, Fernanda; (5)Popkin, Barry M.; (4)Smith-Taillie, Lindsey.

(1)PhD. Assistant Professor Institute of Nutrition and Food Technology, University of Chile; Santiago, Chile.; (2)INTA, University of Chile, Chile.; (3)University Diego Portales, Chile; (4)University of North Carolina, USA.; (5)Phd. Nutrition. Department of Nutrition. University of North Carolina. United States.

Applies to foods and beverages with high density of energy,
sugars, saturated fats, and sodium. Such food must include a front-
of-package (FOP) warning label (if packaged), cannot be market-
ed to children under 14y, and cannot be sold/offered to children
at preschools and schools. This work discusses the process of de-
velopment, implementation and initial impact of the Chilean FOP.

**Methods:** The FOP development was based on different steps: i) literature review on food labeling and warning labels, ii) qualitative study to assess the consumers and experts' opinions regarding food warning labels, iii) a 2-phase quantitative study in which low-middle income women (n=700) and adolescents (n=350) pre-select 2 FOP alternatives out of 15 options (first phase) and then selected a final FOP (second phase) in terms of visibility, comprehension, and intention-to-buy. The initial impact evaluation is part of a larger study evaluating the Chilean regulation (2016-2020) and includes a survey on food knowledge and perceptions collected in 700+ adolescents and 900+ preschoolers' mothers from low-middle income background.

**Results:** The literature review revealed scarce information on
the use of warning labels on foods, but helped defining the word-

ing, design (use of symbols, position, size, colors) and the need
of a neutral (without conflict of interest) and trusted source (i.e.
Ministry of Health). The qualitative studies on consumers provid-
ed general information on the understanding on topics associat-
ed with foods/nutrients, on the wording preferred and most un-
derstood by Chileans, preferred colors (black & white, and red &
yellow), and preferred symbols (triangles and stop signs), among
other aspects; experts' opinions helped narrowing the designs op-
tions developed to that point. In the first phase of the quantitative
study, 2 designs were selected by the interviewee: (i) a hand stating
'excess of sugars, it can cause diabetes', and (ii) a stop sign only
stating 'excess of sugars'; both designs in black & white. In the sec-
ond phase the stop sign had significant best performance in terms
of visibility, comprehension, and intention-to-buy in women, and
visibility among adolescents (with no differences in the other 2
items). Finally, the government decided to use a black & white stop
sign with the phrase "High in...". Baseline data showed that prior
to the law implementation 83% of adolescents and 94% of pre-
schoolers' mothers belonging to the study understood correctly
the FOP warning label and over 90% of both groups approved that
the Ministry of Health helps identifying foods that are less healthy.

**Conclusion:** The Chilean FOP warning label was defined based on literature review and visibility, comprehension and behavior of a sample of Chilean mothers and adolescents. Baseline data indicates that the FOP implemented is well understood and received by the consumers. Post-implementation data will allow evaluating the impact of the FOP warning label and other aspects of the Chilean Law of Labeling and Marketing.

**Keywords:** FOP; Warning Labels; Obesity Regulatory Actions; Chilean Law of Labelling and Marketing Restrictions
# SEVEN-COUNTRY STUDY ON ULTRA-PROCESSED FOOD INTAKE AND OVERALL DIETARY NUTRIENT PROFILE: FINDINGS AND GLOBAL POLICY IMPLICATIONS

## ULTRA-PROCESSED FOODS AND NUTRIENT PROFILE OF DIETS CONSUMED IN CHILE AND COLOMBIA

(1)Uauy, Ricardo; (2)Cediel, Gustavo; (3)Parra, Diana C.; (2)Khandpur, Neha; (4)da Costa Louzada, Maria Laura; (5)Moubarac, Jean-Claude;

(6)Bertazzi Levy, Renata; (7)Reyes, Marcela; (7)Corvalan, Camila;

(8)Monteiro, Carlos.

(1)Professor. Institute of Nutrition and Food Technology. University of Chile. Chile; (2)Post-doctoral fellow. Center for Epidemiological Studies in Health and Nutrition. University of São Paulo. Brazil; (3)Assitant Professor. Program in Physical Therapy. Washington University in St. Louis, US; (4)Associate Professor. UNIFESP. Campus Baixada Santista. Brazil; (5)Associate Professor. Department of Nutrition. University of Montreal. Canada; (6)Researcher, Department of Preventive Medicine. University of São Paulo. Brazil; (7)Assistant Professor. Institute of Nutrition and Food Technology. University of Chile. Chile; (8)Professor. Department of Nutrition. University of São Paulo. Brazil.

**Background and Objective:** A rapid simultaneous increase in sales of ultra-processed foods and prevalence of obesity and other diet-related non-communicable chronic diseases (NCDs) has been observed in Latin America over the past decades. Our study describes the consumption of ultra-processed foods and its association with the nutrient profile of diets in Chile and Colombia.

**Methods:** Data from probabilistic samples studied by cross-sectional dietary studies carried out in Chile (Chi) in 2010 (n=4920 individuals >2y) and Colombia (Col) in 2005 (n= 38643 individuals 2-64 y) were analyzed. Food consumption data were obtained by 24-hour diet recalls and food items were classified into the four NOVA food groups (unprocessed or minimal processed foods/ processed culinary ingredients/ processed foods/ and ultra-processed foods). In each country, the mean dietary nutrient content of total fat, saturated fat, trans fat and free sugars (as % of total energy intake), and the mean diet energy density (kcal/g) and fiber density (g/1000 kcal) were calculated across quintiles of the dietary share of ultra-processed foods (as % of total energy intake). Gaussian regression analyses and regression coefficients (β) adjusted for potential confounding factors (sex, age, location (urban/rural), region, socioeconomic status and years of education) were used to estimate the association between quintiles of the dietary share of ultra-processed foods and dietary nutrient content.

**Results:** In Chile and Colombia, 28.6% and 15.9% of total daily energy intake came from ultra-processed foods, respectively. In both countries, after adjustment for sociodemographic variables, a positive and statistically significant linear trend was found between

quintiles of the dietary share of ultra-processed foods and the dietary content in total fat [β (95%CI): Chi: 1.2 (0.9, 1.5); Col: 0.7 (0.5, 0.9)], saturated fat [β: Chi: 0.5 (0.4, 0.6); Col: 0.5 (0.4, 0.6)], trans fat [β: Chi: 0.02 (0.005, 0.03)], free sugars [β: Chi: 2.8 (2.5, 3.1); Col: 1.1 (0.8, 1.3)], and the diet energy density [β: Chi: 0.09 (0.07, 0.1); Col: 0.07 (0.06, 0.07)]. In contrast, a negative and statistically significant linear trend was observed for protein content [β: Chi: -1.1 (-1.2, -0.9); Col: -0.2 (-0.3, -0.1)] and fiber density [β: Chi: -0.9 (-1.0, -0.7); Col: -0.9 (-1.0, -0.8)].

**Conclusions:** Almost 30% of total calories consumed by the Chilean population were derived from ultra-processed foods while those foods represented less than 20% of energy intake in Colombia. However, in both countries, the consumption of ultra-processed foods was strongly associated with dietary nutrient profiles predictive of increased incidence of obesity and other diet-related NCDs. Actions aimed at reducing the intake of ultra-processed foods and increasing the consumption of unprocessed or minimally processed foods and freshly prepared home-cooked dishes made with these foods plus processed culinary ingredients and appropriately processed foods emerge as potentially effective to achieve a healthy diet.

**Keywords:** Chile, Colombia, ultra-processed foods, nutrients.

**Further collaborators:**

The Ministry of Health of Chile supplied the Database (Chilean National Dietary Survey, 2010). The "Instituto Colombiano de Bienestar Familiar" (ICBF) and PROFAMILIA, provided support and allowing the use of the ENDS/ENSIN data sets to complete this study. Funding: FAPESP n° 2015/14900-9 (Thematic project). GC and NK are beneficiaries of postdoctoral fellowships FAPESP n° 2016/13522-3 and FAPESP n° 2016/13669-4, respectively.

## ULTRA-PROCESSED FOODS AND NUTRIENT PROFILE OF DIETS IN UK AND AUSTRALIA

(1)Scrinis, Gyorgy Scrinis; (2)Machado, Priscila Pereira; (3)Rauber, Fernanda; (4)Levy, Renata; (5)Steele, Euridice Martínez; (6)Millett, Christopher; (7)Monteiro, Carlos.

(1)School of Agriculture and Food. University of Melbourne;

(2)PhD student. Department of Nutrition. University of São Paulo. Brazil; (3)Post-doctoral fellow. Center for Epidemiological Studies in Health and Nutrition. University of São Paulo. Brazil;

(4)Researcher. Department of Preventive Medicine. University of São Paulo. Brazil; (5)Reseracher. Department of Nutrition. University of São Paulo. Brazil; (6)Public Health Policy Evaluation Unit. School of Public Health. Imperial College London. United Kingdom; (7)Professor. Department of Nutrition. University of São Paulo. Brazil.

**Background and Objective:** A rapid simultaneous worldwide increase in sales of ultra-processed foods and obesity prevalence has been observed in the last decade. This study describes the consumption of ultra-processed foods and its association with the nutrient profile of diets in UK and Australia.

**Methods:** Data from national probabilistic samples studied by cross-sectional dietary studies carried out in UK in 2008-2012
(n=4,125 individuals ≥1.5y) and Australia (Aus) in 2011-2012 (n= 12,153 individuals ≥2 y) were analyzed. Food consumption data were obtained through 24-hour recall/unweighted food diary. Food items were classified into the four NOVA food groups. In each country, the mean dietary nutrient content in total fat, saturated fat, trans fat and free sugars (% of total energy intake), and the mean fiber density (g/1000 kcal), sodium density (mg/1000kcal) and potassium density (mg/1000kcal) were calculated across quintiles of the dietary share of ultra-processed foods (% of total energy intake). Gaussian regression analyses and regression coefficients (β) adjusted for potential confounding factors (sex, age, location, region, and socioeconomic status) were used to estimate the association between quintiles of the dietary share of ultra-processed foods and dietary nutrient content.

**Results:** In UK and Australia, 56.8% and 36.6% of total daily energy intake came from ultra-processed foods, respectively. In both countries, after adjustment for sociodemographic variables, a positive and statistically significant linear trend was found between quintiles of the dietary share of ultra-processed foods and the dietary content in total fat [β (95%CI: UK: 0.5 (0.3, 0.7); Aus: 0.6 (0.4, 0.7)], free sugars [UK: 1.0 (0.7, 1.2); Aus: 2.6 (2.5, 2.8)], and the sodium density [UK: 55 (46, 65); Aus: 70 (50, 71)]. Positive and statistically significant linear trend was observed only in Australia for saturated fat [β: 0.7 (0.6, 0.8)] and trans fat [0.03 (0.02, 0.35)]. In both countries, negative and statistically significant linear trend was observed for the dietary content in protein [β: UK: -0.8 (-0.9, -0.7); Aus: -1.2 (-1.3, -1.1)], fiber density [β: UK: -0.3 (-0.4, -0.2); Aus: -0.8 (-0.9, -0.7)], and potassium density [β: UK: -93 (-104, -83); Aus: -102 (-114, -88)].

**Conclusions:** Almost 60% of total calories consumed by the UK population came from ultra-processed foods while in Australia they represented about 40%. However, in both countries, the consumption of ultra-processed foods was strongly associated with dietary nutrient profiles predictive of increased incidence of epidemiologically relevant non-communicable diseases. Actions aimed at lowering the dietary share of ultra-processed foods and raising consumption of unprocessed or minimally processed foods and hand-made dishes made with these foods plus processed culinary ingredients and processed foods emerge as useful tools for achieving a healthy diet.

**Keywords:** UK, Australia, ultra-processed foods, nutrients

## ULTRA-PROCESSED FOODS AND NUTRIENT PROFILE OF DIETS IN SEVEN COUNTRIES

**Background and Objective:** Ultra-processed food and drink products, such as sugared beverages, sweet or savory packaged snacks, confectionery, reconstituted meat products, and pre-prepared frozen or shelf-stable dishes, are industrial formulations of refined sources of dietary energy and nutrients, additives and little if any intact food, using a series of processes (hence 'ultra-processed'). A rapid simultaneous increase in the sales of these products and in obesity prevalence has been observed in lower-middle, upper-middle, and high income countries. This study describes the consumption of ultra-processed food and drink products and its association with the overall nutrient profile of diets in Australia, Brazil, Canada, Chile, Colombia, UK and US.

**Methods:** Data from probabilistic samples studied by cross-sectional dietary studies carried out in Australia in 2011-2012 (n= 12,153 ≥2 y), Brazil in 2008/9 (n= 34003; ≥10 y), Canada in 2004 (n= 33694; ≥2 y), Chile in 2010 (n=38643; 2-64 y), Colombia in 2005 (n= 38643; 2-64 y), UK in 2008-2012 (n= 4,125; ≥1.5 y), and US in 2009-2010 (n= 9317; ≥1 y) were analyzed. Food consumption data were obtained through 24-hour recalls/food diaries and food items were classified into the four NOVA food groups (unprocessed or minimal processed foods, processed culinary ingredients, processed foods and ultra-processed foods). In each country, the mean dietary nutrient content in total fat, saturated fat, trans fat and free sugars (% of total energy intake), and the mean diet energy density (kcal/g) and fiber density (g/1000 kcal) were calculated across quintiles of the dietary share of ultra-processed foods (% of total energy intake). Gaussian regression analyses and standardized regression coefficients (β) adjusted for sociodemographic variables were used to estimate the association between quintiles of the dietary share of ultra-processed foods and dietary nutrient content.

**Results:** The dietary share of ultra-processed foods ranged from 15.9% of total daily energy intake in Colombia to 57.9% in the US. In Brazil, after adjustment for sociodemographic variables, a positive and statistically significant linear trend was found between quintiles of the dietary share of ultra-processed foods and the dietary content in total fat (β: 0.30), saturated fat (β: 0.31),

<footnote>(1)Monteiro, Carlos; (2)Moubarac, Jean-Claude; (3)Uauy, Ricardo;</footnote>

<footnote>(4)Parra, Diana C.; (5)Scrinis, Gyorgy Scrinis; (6)Miller, Christopher;</footnote>

<footnote>(7)Louzada, Maria Laura da Costa; (8)Martines-Steele, Euridice;</footnote>

<footnote>(8)Rauber, Fernanda; (9)Machado, Priscila Pereira.</footnote>

<footnote>(1)Professor. Department of Nutrition. University of São Paulo.
Brazil; (2)Associate Professor. Department of Nutrition. University
of Montreal. Canada; (3)Professor. Institute of Nutrition and Food
Technology. University of Chile. Chile; (4)Assistant professor.</footnote>

<footnote>Program in Physical Therapy. Washington University in St. Louis.</footnote>

<footnote>US; (5)Senior Lecturer. Faculty of Veterinary and Agricultural
Sciences. University of Melbourne; (6)Professor, Imperial College.</footnote>

<footnote>London. UK; (7)Associate Professor. UNIFESP. Campus Baixada
Santista. Brazil; (8)Post-doctoral fellow. Center for Epidemiological
Studies in Health and Nutrition. University of São Paulo. Brazil;</footnote>

<footnote>(9)PhD student. Department of Nutrition. University of Sao Paulo.
Brazil.</footnote>
trans fat (β: 0.29), free sugars (β: 0.28), and the diet energy density (β: 0.39). Negative and statistically significant linear trend was observed for the dietary content in protein (β: -0.32) and the diet fiber density (β: -0.28). Similar findings were observed in each of the other six countries.

**Conclusions:** In the seven countries, the consumption of ultra-processed foods was strongly associated with dietary nutrient profiles predictive of increased incidence of obesity and other epidemiologically relevant non-communicable diseases. In these countries, actions aimed at reducing the intake of ultra-processed foods and raising the consumption of unprocessed or minimally processed foods and freshly-prepared dishes made with these foods plus processed culinary ingredients and processed foods emerge as useful tools for achieving a healthy diet.

**Keywords:** Food processing, ultra-processed foods, diet, nutrient profile, NOVA food classification

**Further collaborators:**

This abstract presents preliminary findings from the Multi-country study on intake of ultra-processed foods, nutrient profile of diets and obesity. Funding: FAPESP n° 2015/14900-9 (thematic project). FR is beneficiary of postdoctoral fellowship FAPESP n° 2016/14302-7. PM is beneficiary of doctoral scholarship FAPESP n° 2016/13168-5.

of a survey from planning through dissemination. Each module contains a chapter of the e-Manual providing step-by-step instructions and key considerations, as well as useful tools, country examples and resources. The Toolkit provides a compilation of tools such as sample size calculators, lists of equipment and supplies, budget templates, specimen collection procedures, training materials, form templates, and report outlines.

The e-Manual and Toolkit provide practical information on how to plan and implement a cross-sectional micronutrient status and coverage survey. The updated tools, resources and e-manual chapters are revised and expanded to include new sections on topics such as the assessment of zinc and folate status and considerations for electronic data collection.

The e-Manual and Toolkit are based on practical field experience in a range of settings, expert group discussions and documents from a variety of organizations. Together, they can help survey managers improve the quality, validity and efficiency of micronutrient surveys.

**Keywords:** Survey, Micronutrients, Toolkit, e-manual

PS_144/164

WHO/CDC SYMPOSIUM ON NEW TOOLS AND RESOURCES FOR MONITORING AND EVALUATING MICRONUTRIENT PUBLIC HEALTH PROGRAMS

THE MICRONUTRIENT SURVEY ELECTRONIC MANUAL AND THE MICRONUTRIENT SURVEY TOOLKIT – NEW TOOLS TO IMPROVE THE DESIGN AND QUALITY OF MICRONUTRIENT SURVEYS

High quality, representative data are needed to manage nutrition programs effectively and to make evidence based nutrition policies. Population-based cross-sectional surveys of micronutrient status and coverage of interventions within populations are important for designing and managing nutrition programs. Updated tools are available to support survey planning, implementation, analysis and dissemination.

The Micronutrient Survey Electronic Manual and Micronutrient Survey Toolkit are integrated tools that provide users with a set of resources to design and carry out micronutrient surveys. They are available for download at http://surveytoolkit.micronutrient.org/. The Toolkit includes 15 modules following the main phases

NEW RESOURCES FOR THE MONITORING AND EVALUATION OF PUBLIC HEALTH PROGRAMMES TO IMPROVE MICRONUTRIENT STATUS

Rogers, Lisa Marie.

PhD. Technical Officer. Department of Nutrition for Health and Development. World Health Organization. Geneva, Switzerland.

The World Health Organization Vitamin and Mineral Nutrition Information System (VMNIS), previously known as the Micronutrient Deficiency Information System, is a collection of tools aimed at assisting WHO Member States and their partners in the assessment of micronutrient status and in the monitoring and evaluation of micronutrient intervention programmes in public health. This system has been in the process of undergoing expansion in the last several years. The main components of VMNIS include: 1) Micronutrients database; 2) summary documents of key clinical and biochemical indicators for assessing micronutrient status; 3) Global laboratory directory for the assessment of micronutrient status; and 4) eCatalogue of indicators for micronutrient programmes. The WHO Micronutrients database tracks the micronutrient status of populations at the national, regional or first administrative level. This database has expanded from collecting data on five key indicators of micronutrient status to over 40. Periodically, some of this data is used to develop global estimates of the prevalence of deficiency for key micronutrients. Summaries of WHO recommendations on the use of eight indicators of micronutrient status and one indicator of inflammation are currently available. These documents summarize the currently recognized cut-offs for defining deficiencies and severity of deficiencies at the population level, and the chronology of their establishment. The WHO Global laboratory directory for the assessment of micronutrient status has recently been developed to collect information on laboratories that are capable of assessing biomarkers of micronutrient status for health and nutrition surveys. The ultimate goal of

<footnote>(¹)Tripp, Katherine; (¹)Whitehead, Jr., Ralph D.; (¹)Mapango, Carine;</footnote>

<footnote>(¹)Anne, Williams; (¹)Ruth, Laird; (²)Knowles, Jacky; (³)De Regil Velez, Luz Maria; (⁴)Kupka, Roland; (⁵)Roger, Lisa; (¹)Jefferds, Maria.</footnote>

<footnote>(¹)Centers for Disease Control and Prevention. USA.; (²)Consultant;</footnote>

<footnote>(³)Nutrition International. Canada.; (⁴)UNICEF; (⁵)WHO.</footnote>
this directory is to help Member States and their partners identify
laboratories measuring biomarkers of vitamin and mineral status
at the population level so that they may be able to further eval-
uate the laboratory for possible participation in their nutrition
surveys. Finally, the eCatalogue of indicators for micronutrient
programmes contains a non-comprehensive register of standard
process and impact indicators for tracking the performance of
public health programmes implementing micronutrient interven-
tions.

**Keywords:** Micronutrients, indicators, status, laboratories, monitoring and evaluation

PS_144/107

INTEGRATING PREVENTIVE STRATEGIES INTO
COMMUNITY-BASED MANAGEMENT OF ACUTE
MALNUTRITION: WHAT WORKS?

THE IMPACT OF ADDING A HOUSEHOLD WASH PACKAGE TO CMAM PROGRAM: A CLUSTER-RANDOMIZED CONTROLLED TRIAL IN CHAD

Water, Sanitation and Hygiene (WASH) interventions have
been reported to have a small but measurable benefit on stunt-
ing, but not on wasting. In order to increase synergies in the fight
against acute malnutrition, WASH and nutrition actors agreed
in 2012 upon a “WASH in Nut” strategy for the Sahel region that
includes the provision of a household WASH package (provision
of chlorine, soap, water storage container and sensitisation on its
use), designed to protect children against new episodes of diar-
rhoea and aiming at improving nutritional outcomes. The aim of
our study was to assess the effectiveness of this household WASH
package on the performance of an Outpatient Therapeutic feed-
ing Programme (OTP) for severe acute malnutrition in Mao and
Mondo health districts in Chad.

We conducted a cluster randomized controlled trial embed-
ded in a routine OTP. The study population included 20 health
centres (clusters). Both arms received the routine nutritional pro-
gramme. The intervention arm received the additional household
WASH package, delivered to the child's caretaker upon admission
in the OTP. Primary outcomes were recovery and relapse rates.

Secondary outcome included time-to-recovery, daily weight gain and morbidity longitudinal prevalence. The trial is registered with
ClinicalTrials.gov, number NCT02486523.

The recruitment phase lasted from April to December 2015 and the follow-up phase ended in May 2016. Among the 1603 recruited children, 845 were in the intervention group and 758 in the control group. The WASH package was well accepted and used. The intervention decreased infectious diseases longitudinal prevalence (-1.6%; 95% CI [-3.2; -0.05]; p=0.043), decreased the time-to-recovery (-4.4 days; 95% CI [-8.6; -0.2]; p=0.038), improved the recovery rate (10.5%; 95% CI [6.7; 19.8]; p=0.034) and decreased the non-responder rate (-9.7%; 95% CI [-16.9; -2.4]; p=0.009). No statistical difference was noticed between the groups in term of relapse rates, both at 2 and 6 months after discharge.

In the Sahel context, the provision of a household WASH package increased the recovery rate among children treated for non-complicated SAM and decreased their time-to-recovery. This study shows that the integrated wash-in-nut approach has the potential to increase programme performance. We recommend this strategy for the wider Sahel context.

**Keywords:** Severe Acute Malnutrition, Water and Hygiene

PS_144/137

NUTRITIONAL PROFILING – SCIENTIFIC BASIS, USES AND IMPACT ON PUBLIC HEALTH

RECENT DEVELOPMENTS IN NUTRIENT PROFILING

Rayner, Michael.

DPhil. Director. Centre on Population Approaches for Non-
Communicable Disease Prevention. Nuffield Department of
Population Health. University of Oxford. United Kingdom.

In this presentation I first provide definitions of nutrient profil-
ing and of a nutrient profile model. I set out the purposes of nutri-
ent profiling: both general and specific. I give two examples of nu-
trient profile models that have been developed for the regulation
of marketing of foods to children: by the Food Standards Agency
in the United Kingdom and the World Health Organisation for its
European Region – the UK FSA/Ofcom and the WHO-Euro mod-
els. I compare the way the models are constructed and function,
how they have been developed and adapted for different regulato-
ry uses. I examine the extent to which the models have been tested
and validated. Finally I draw some conclusions about the future
use of nutrient profiling. I argue that its full potential has yet to be
realised and give some reasons why. I pose some urgent research
questions with respect to nutrient profiling.

**Keywords:** Nutrient profiling, regulation, food marketing, food labelling

**Conflict of Interest disclosure:** The author was closely in-
volved in the development of the UK FSA/Ofcom and WHO-Euro
nutrient profile models and his research centre received funding
from the UK Food Standards Agency to carry out analyses in con-
nection with the development of the UK FSA/Ofcom model.

<footnote>(1)Altmann, Mathias; (2)Altare, Chiara; (3)van der Spek, Nanette;</footnote>

<footnote>(4)Barbiche, Jean-Christophe; (5)Dodos, Jovana; (6)Bechir, Mahamat;</footnote>

<footnote>(7)Ait Aissa, Myriam; (8)Kolsteren, Patrick.</footnote>

<footnote>(1)PharmDr, MPH, Operational Research Advisor, Action Contre la Faim; (2)PhD. Impact assessment advisor. Action Contre la Faim.</footnote>

<footnote>France; (3)MPH. Nutritionist. The Institute of Tropical Medicine in Antwerp; (4)Msc. WASH Technical Advisor. Action Contre la Faim.</footnote>

<footnote>France; (5)Msc. WASH & Nutrition consultant; (6)PhD. Nutritionist.</footnote>

<footnote>ASRADD; (7)MSc. Research Senior Advisor. Action Contre la Faim.</footnote>

<footnote>France; (8)MD. scientific staff / director MSc. NuRuDe programme.
Department of Food Safety and Food Quality. Ghent University.</footnote>
# THE DEVELOPMENT OF THE NUTRIENT RICH FOODS (NRF) FAMILY OF NUTRIENT PROFILE MODELS AND THEIR APPLICATIONS

Drewnowski, Adam.

Center for Public Health Nutrition, University of Washington, USA.

The goal of nutrient profiling (NP) models is to distinguish foods that are energy-dense from those that are nutrient-rich. Typically, NP methods calculate the amount of nutrients per reference amount of food: 100 kcal, 100g, or serving size. Some NP models merely calculate energy density of foods: kcal/100g.

Originally intended as the scientific basis for nutrition and health claims, NP has been used for a variety of food taxation purposes. For example, Mexico has imposed a tax on nonessential snacks with energy density >275 kcal/100g. NP models have also been used to create front-of-pack (FOP) logos to convey nutrition information to the consumer at point of sale. Here, Chile has developed food warning labels based on excessive energy, sugar, or fat content. The food industry has also used NP tools to assess and (re)formulate product portfolios.

NP models can be based on nutrients to limit only (generally fat, sugar and salt) or they can also include some nutrients to encourage, usually protein, fiber, and selected vitamins and minerals. One methodological challenge is to ensure that NP models do not merely track energy density and do not favor the more expensive foods. The Nutrient Rich Foods (NRF 9.3) index used 9 positive or qualifying nutrients (protein, fiber, vitamins A, C, and E, calcium, iron, potassium and magnesium) and 3 nutrients to limit: saturated fat, added sugar, and sodium. The NRF algorithm was the sum of percentage daily values (DVs) for the 9 qualifying nutrients, minus the sum of %DVs for 3 disqualifying nutrients, each calculated per 100 kcal and capped at 100% DV. The NRF score was validated in regression models against the Healthy Eating Index, an independent measure of a healthy diet.

The French SAIN/LIM nutrient density score, was the mean of %DVs for five qualifying nutrients (protein, fiber, vitamin C, calcium and iron) minus the mean of percent daily values for the three disqualifying nutrients (saturated fat, added sugar, sodium). Unlike the continuous NRF score, SAIN/LIM has assigned foods into one of four categories [3]. A continuous version – Le SENS score was developed only recently. The SAIN/LIM score was validated using sophisticated linear programming. One advance in NP modeling has been at apply NP methods to complex meals, menus, or the total diet.

NP models can be adapted to assess nutrient cost, as obtained from different food groups. On a per calorie basis, vegetables, fruit and meat poultry and fish cost more, whereas grains and fats cost less. NP models can show that some food groups are very low cost sources of a particular nutrient: Milk and milk products were the lowest cost calcium source, whereas potatoes and beans delivered most fiber per penny. Analogous calculations have addressed the environmental cost of different nutrients as measured through lifecycle analysis and greenhouse gas emissions (GHGE). Although animal products did have a higher carbon footprint, their environmental cost had to be balanced against their higher nutritional value.

**Keywords:** Nutrient profiling, healthy foods, regulation, food reformulation, taxation, public health

**Conflict of Interest disclosure:** AD has received grants, contracts, and honoraria from public agencies, private industry, private foundations, and commodity groups for projects involving nutrient profiling, diet quality assessments, and health outcomes.

# NUTRIENT PROFILING: SCIENTIFIC AIMS VS. ACTUAL IMPACT ON PUBLIC HEALTH

(1)Gil, Ángel; (2)Soto-Méndez, María José.

(1)PhD. Prof. Department of Biochemistry and Molecular Biology. Institute of Nutrition and Food Technology. Centre of Biomedical Research. University of Granada. CIBERobn. Spain.; (2)Ph.D. Scientific Coordinator. Fundacion Iberoamericana de Nutrición, Granada, Spain.

Populations are constantly modifying their diet due to globalization, the access to food undergoing several technological processes, and the modification of our lifestyles. The Global Strategy on Diet, Physical Activity, and Health, published by WHO in 2004, included as a strategy the action of generating comprehensible, suitable, accurate and standardized information on the content of food products. In order to allow the consumer to make healthier choices, Nutrient Profiling was the response to this action request.

Nutrient Profiling has been described as a scientific method to classify foods and drinks based on their nutritional quality by national authorities of different countries to promote public health and to achieve the nutritional goals proposed for the population. The WHO has proposed, as recently as 2015, the definition of Nutrient Profiling as "the science of classifying or ranking foods according to their nutritional composition for reasons related to preventing disease and promoting health".

Nutrient Profiling Models using the threshold or scoring approaches, and based on food groups or for food in general, have been developed during the last 20 years; sometimes, with no clear conscience of that. The models have been used in regulation for nutritional claims, front-of-package food labeling, policies on subsidies or taxation to different food groups, reformulation of processed foods, regulations for school cafeterias, etc. These models have been developed by more than 16 countries and more than 4 regions, with specific aims and according to the local or regional public health situation.

The nutrient profiling models represent useful tools for taking measures and making decisions, such as the regulation of marketing, front-of-package food labeling and policies on subsidies or taxation to different food groups based on their role, positive or negative, in public health.

For the particular case of processed food, the main target of nutrient profiling, the continuous review of the nutrient profiling is justified by the emergence of new foods, new formulations and new processing techniques that affect their nutrients composition and bioavailability.