project was extensive, and the experiences could be used for fur-
ther developing simpler and more targeted tools in Portugal and
other countries, for monitoring and for multi-country compari-
sons. The interdisciplinary approach involving geography, nutri-
tion and bio-statistics proved to be most useful and could be ap-
plied also in other settings.

**Keywords:** Elderly, nutritional status, geographic information system, holistic approach

**Further collaborators:** Ana Monteiro, Cláudia Afonso, Anzhela Sorokina, Rui Poinhos. Bruno Oliveira, Luís Fonseca, Miguel Sousa, Flora Correia, Bela Franchini, Bárbara Pereira, Ada Rocha, Margarida Liz and Inga Thorsdottir

RESULTS FROM A RESISTANT TRAINING INTER-
VENTION IN ELDERLY PEOPLE AND HOW TO
STIMULATE PARTICIPATION

(1)Thorsdottir, Inga; (2)Geirsdottir, Ólöf Guðný.; (3)Briem, K.; (4)Jonsson, P.; (2)Ramel, A.

(1)School of Health Sciences. University of Iceland Reykjavik.
Iceland; (2)School of Health Sciences (SHS). Universitی of Iceland (UI). The Icelandic Gerontological Research Center. SHS. UI and Landspitali University Hospital. Faculty of Food Science and Nutrition. SHS. Iceland; (3)School of Health Sciences. Universitی of Iceland. Department of Physiotherapy. School of Health Sciences. University of Iceland. Iceland; (4)School of Health Sciences (SHS). UI.The Icelandic Gerontological Research Center. SHS. UI & Landspitali University Hospital. Faculty of Medicine. Department of Geriatrics. National University Hospital of Iceland. Iceland.

**Background and objectives:** The aim of the present work was to identify baseline predictors of drop out with particular focus on physical function; and to compare changes in physical outcomes after a resistance exercise program between elderly men and women.

**Methods:** Subjects (N=236, 73.7 ± 5.7yrs, 58.2% female) participated in a supervised 12-week resistance exercise program (REP) designed to increase muscle mass and -strength. Body composition (DXA), quadriceps- and grip strength, physical function as 6-minutes-walk-for-distance (6MWD) and timed-up-and-go (TUG) were measured before and after the REP. Quality of life (QoL) was assessed.

**Results:** Neither drop-out (11.9%) nor the attendance rate (91%) were different between genders. Although absolute gains in lean body mass (LBM) (1.10 ± 1.30 vs 0.61 ± 1.21kg, P<0.001) and appendicular skeletal mass (ASM) (0.67 ± 0.81 vs 0.42 ± 0.62kg, P<0.001) were higher in men than in women, relative gains were similar (LBM: 1.9 ± 2.2 vs 1.6 ± 2.9%; ASM: 2.3 ± 2.8 vs 2.1 ± 3.0%). Both men and women improved similarly in quadriceps strength (55 ± 57 vs. 52 ± 49), grip strength (3.2 ± 6.2 vs. 3.0 ± 5.4lb), 6MWD (31 ± 38 vs. 35 ± 32m), and TUG (-0.55 ± 0.98 vs. -0.72 ± 1.22sec). In comparison to completers, participants who dropped out were older and had poorer physical function at baseline than the completers. They also exercised less at baseline,

however, neither body composition, QoL nor MMSE were related
to drop out.

**Keywords:** Resistant training. Physical function. Elderly. Intervention.

NUTRITIONAL STATUS OF HEART FAILURE OUT-
PATIENTS IN ICELAND – FOOD, FUNCTION AND
FEELINGS

(1)Vilborgardottir, Vilborg Kolbrún; (2)Geirsdottir, Ólöf Guðný;

(3)Gudlaugsdottir, Gudbjorg J; (4)Thrainsdottir, Inga; (5)Tryggvadottir, Ellen A.

(1)PhD student. Iceland.; (2)PhD. Nutritionist. Faculty of Food Science and Nutrition. University of Iceland. Iceland.; (3)MSc. RD. Department 14E. Clinic for Heart Failure Outpatients. Landspitali. The National University Hospital. Reykjavik. Iceland; (4)MSc. MD. Department 14E. Clinic for Heart Failure Outpatients. Landspitali. The National University Hospital. Reykjavik. Iceland; (5)MSc. Nutritionist. Faculty of Food Science and Nutrition. University of Iceland. Iceland.

Introduction: Malnutrition is associated with increased length of stay in hospital and further complications, consequentially increasing the cost of care. Heart failure is a disease prevalent in older adults, characterized by chronic symptoms, such as fluid retention, dyspnea and fatigue. Therefore patients suffering from heart failure are a delicate group that can be susceptible to malnutrition. Evaluation of nutritional status has never been performed for this group in Iceland.

Aim: To assess the risk of malnutrition in heart failure outpatients using the Simple Screening tool for Malnutrition (SSM) as well as assessing the nutritional status of a smaller sample of the same population using estimations of: appetite and dietary intake; body mass index, reported weight loss and fluid retention; biochemical measurements; grip strength and quality of life.

**Methods:** This was a cross-sectional study. All patients with an appointment at the outpatient clinic of heart failure at Landspitali University Hospital were screened for malnutrition (n=84). A total of 60 patients were invited to participate, whereof 33 signed an informed consent (55%). Participation consisted of answering three questionnaires, as well as undergoing blood sampling and measurement of grip strength. Information on the results of SSM, ICD-10 diagnoses, medication, height, weight, blood pressure and edema were collected from electronic medical records.

**Results:** Screening for all patients (n=84) showed that around 30% were at medium or severe risk of malnutrition. Participants in the current study (n=33) were of both sexes, thereof 27% (n=9) women and medium age was 76 (25th, 75th; 70, 80) years. The participants' diet turned out to be rather rich in protein, with majority reporting to eat at least one warm meal per day. A total of 23% of participants reported loss of appetite and 27% reached reference values for grip strength. Mean T-score for quality of life was 43.8 (±10.4), with the norm being 50±10. Using diagnostic criteria from ASPEN, in tota, 19% (n=6) of participants were diagnosed
with malnutrition and are in need of nutritional intervention, whilst 16% were defined at risk and need supervision.

Conclusion: One third of all patients were at risk of malnutri-
tion and grip strength of participants proved to be impaired. Health
related quality of life was significantly lower than among healthy
older adults. It is of importance to routinely monitor nutritional
status of all patients for timely interventions. Such interventions
are valuable to improve both nutritional status and quality of life,
as well as to preclude further events and complications. The out-
patient clinic of heart failure provides high level of services, which
likely plays a big role in maintaining the quality of life of patients.

**Keywords:** Nutrition, malnutrition, heart failure, food, quality of life

**Further collaborators:** Birgisdottir BE1, Faculty of Food Science and Nutrition, University of Iceland

SS_144/1038

‘FILL THE NUTRIENT GAP’ WITH ‘COST OF THE DIET’ TO INFORM NUTRITION POLICY AND PROGRAMMING

‘FILL THE NUTRIENT GAP’ APPROACH TO SITU-
ATION ANALYSIS AND DECISION-MAKING FOR
IMPROVING NUTRITION

(1)de Pee, Saskia; (2)Baldi, Giulia; (3)Bose, Indira; (4)Kiess, Lynnda.

(1)Technical Advisor. Nutrition Division. World Food Programme. Rome, Italy.; (2)Nutritionist. Nutrition Division. World Food Programme. Rome. Italy.; (3)Economist. Nutrition Division. World Food Programme. Rome. Italy.; (4)Nutritionist. World Food Programme. New York. USA.

Advancing national multi-sectoral nutrition policies and pro-
gramming can greatly benefit from an assessment of opportuni-
ties and challenges to meeting nutrient requirements of key target
groups, because meeting nutrient intake requirements is a key pre-
requisite for preventing malnutrition. The Fill the Nutrient Gap
(FNG) tool for situation analysis and decision making analyses
context-specific secondary sources of information on factors that
directly or indirectly impact on whether people can access and
consume nutritious foods and whether they meet recommended
nutrient intakes. The aim of the FNG is to formulate recommenda-
tions for policies and programming in agriculture, food systems,
health, social protection, education and other sectors that can
contribute to improving nutrition. The tool has been developed by
WFP, with inputs from UNICEF, IFPRI, University of California
Davis, Harvard University Boston, Epicentre Paris and Mahidol
University Bangkok.

The FNG analysis focuses on different target groups, such as
young children, pregnant and lactating women and adolescent
girls, in different situations, by distinguishing for example wheth-
er they live in urban or rural areas, in food-secure or -insecure
areas, belong to higher or lower socio-economic groups etc. The

analysis seeks information (and identifies gaps) on food system re-
lated information, such as access to markets, availability of nutri-
tious foods, affordability of nutritious foods based on price relative
to income (using Cost of the Diet analysis, CotD) and (public-)
private sector initiatives to improve availability and affordability
of nutritious foods; social protection system related information
such as coverage, targeting and design of social safety nets pro-
grams; health system related information, such as coverage of sup-
plements, home-fortification and nutrition education; education
system related information; and also information on food choice
and preparation practices, intra-household food distribution, and
infant and young child feeding practices, from surveys as well as
qualitative enquiries. The CotD analysis is also used for modeling
the impact on affordability of a nutritious diet of approaches that
increase availability and affordability of nutrients from affordable
nutritious foods, fortified foods and supplements and/or improve
purchasing power.

The analysis is designed and conducted together with in-country stakeholders from different constituency groups (government, UN, academia, private sector, civil society) that work in the food system, health system and/or social protection system, and concludes with recommendations for improvements to be made to policies and programs across these sectors that are most needed, relevant and feasible in the country's context. Since its development in 2015, the FNG and CotD has been used in 10 countries and several more are planned for 2017 and 2018.

**Keywords:** Fill the Nutrient Gap; Nutrition situation analysis; Multi-stakeholder decision making; Cost of the Diet; Nutritious foods

IMPLEMENTING THE FILL THE NUTRIENT GAP – IN
COUNTRY PROCESS AND DATA SOURCING

(1)Baldi, Giulia; (1)Bose, Indira; (1)Knight, Frances; (2)Kiess, Lynnda;

(3)Badham, Jane; (1)de Pee, Saskia.

(1)World Food Programme. Nutrition Division. Rome. Italy.;

(2)World Food Programme. Nutrition Division. New York. USA.;

(3)JB Consultancy. Johannesburg. South Africa.

The Fill the Nutrient Gap (FNG) has been developed to gain greater insights into and develop strategies to address one of the two prerequisites to prevent the immediate causes of malnutrition - adequate nutrient intake. It includes a framework for analysis, based on secondary data and linear programming (Cost of the Diet), and a process for multi-stakeholder engagement at country level.

Secondary sources used for FNG analysis include data and other relevant information (reports, grey literature, peer reviewed papers, socio-ethnographic studies and formative research) on nutrition indicators, food access and availability, dietary intake, preferences and practices, food security, household food expenditure and socio-economic conditions, together with analysis of affordability of nutritious diets and intervention modelling using the Cost of Diet (CotD) tool. The secondary data review is extensive, for example, in Pakistan 190 and in Lao PDR 112 sources were reviewed.
Analysis and triangulation of different data sources is used to cross-check findings. National stakeholders contribute to identify and validate data and information sources, and to provide insights on the interpretation of finding inconsistencies. Where available, information from market and consumer surveys on complementary and fortified foods (e.g. Ghana, Indonesia), purchasing patterns of different food commodities by various population segments and, on local supply chains for nutritious foods provide useful insights as to opportunities to be leveraged, on both the demand and supply sides of the food system.

Through this iterative process, the ‘nutrient gap’ within a country can be better defined in terms of who (vulnerable population groups), where (regions, urban/rural), when (seasonality), why (compounding factors) and how (quantity and/or quality of nutrient intake). Secondary data also contributes to an analysis of the enabling environment, including national legal and regulatory framework, policy, programmes and partnerships relevant to nutrition, to inform entry points for sustainable action. The analysis then identifies and models the potential economic and nutritional impact of possible interventions to address the defined gaps, across the identified sectors and entry points, using CotD (see Deptford et al. and Bose et al.).

The multi-stakeholder engagement process at country level, starts with the identification of key target groups (e.g. children under two, pregnant and lactating women, adolescent girls) and determines the level of analysis (e.g. national, sub-national). Consultation continues throughout the data consolidation and analysis of secondary data and CotD phases, ending with the joint identification of a prioritized set of recommended interventions and policy measures across the food system to improve intake and access to a nutritious diet engaging multiple sectors. Where possible (e.g. Pakistan, Madagascar, Lao PDR, Tanzania), SUN country platforms are used to leverage the multi-sectoral, multi-stakeholder process, involving health, agriculture, social protection, education and the private sector.

**Keywords:** Fill the Nutrient Gap, Nutrition Situation Analysis, secondary sources and linear programming, multi-stakeholder, affordability of nutritious diets

## WHAT CAN COTD ANALYSES TELL US?

(1)Roschnik, Natalie; (2)Schofield, Lilly.

(1)MSc. Senior Nutrition Advisor. Save the Children UK; (2)MSc. Nutrition Advisor. Save the Children UK.

The Cost of the Diet is a method and software developed by Save the Children in 2004 to estimate the cost of a nutritious diet in different contexts. The software uses linear programming to calculate the amount, combination and overall cost of local foods that are needed to provide individuals or typical families with their average needs for energy and their recommended intakes of protein, fat and micronutrients. The software was developed in response to research which showed that the poorest households could not afford the diets being promoted and to better understand the extent to which poverty affects nutrition.

The software uses three streams of information: nutrients from foods (from food composition tables); human requirements for nutrients (from WHO/FAO dietary recommendations) and the local cost of food (collected via market surveys). The software pulls these three streams of information together to find the cheapest combination of foods that meet human nutrient requirements. The software generates four standard low cost diets: 1) an Energy-only diet, which only meets the family's energy requirements; 2) a Macronutrients diet which meets the family's energy, protein and fat requirements; 3) a Minimum-cost nutritious diet, which meets the family's energy, macro and micronutrient requirements and 4) the Food habits diet, which meets the family's energy and macro- and micronutrient requirements, while also reflecting people's typical dietary habits e.g. main staple food and food taboos. The software tells us whether poor households can afford a nutritious diet, what the gap is between the cost of a nutritious diet and what they can afford (their income minus essential non food items). It also allows modelling to be done to identify interventions that would reduce the affordability gap e.g cash transfers, supplementary food, food fortification, and the most cost nutrient efficient diets to promote in different contexts.

A review of Cost of the Diet assessments in Asia found that the affordability gap was 48% and 22% for very poor and poor households respectively. This means that on average very poor households would need to increase their annual income by almost 1.5 times to be able to afford a nutritious diet in addition to other essential non-food expenditures (Save the Children, 2017). In Malawi and Nigeria, national recipes were tested and adjusted to increase their nutrient content at a lower cost using local foods.

In 2016, Save the Children released the Cost of the Diet software Version 2 (rewritten in Delphi XE4©) which is more stable, reliable, and adaptable and the method was published and endorsed in BMC Nutrition (Deptford A, 2017). The software is freely available for use on request, but can only be used by trained practitioners. http://www.heawebsite.org/countries/reports/cotd-software-version-2-2016

**Keywords:** Cost, Diet, poverty, software

## HOW ARE COST OF THE DIET ANALYSES CONDUCTED?

(1)Deptford, Amy; (2)Hall, Andrew; (1)de Pee, Saskia; (1)Kiess, Lynnda;

(1)Baldi, Giulia; (1)Bose, Indira.

(1)World Food Programme. Italy; (2)University of Greenwich. England.

A Cost of the Diet (CotD) analyses requires the following information: a list of all foods available in the assessment area; the average cost per 100g of these foods during a season(s) or given time point; the energy and nutrient composition and typical dietary habits of these foods; the typical size of households in the assessment area; and the estimated average requirements for energy and recommended nutrient intakes for the individuals included within the typical household. If the affordability of the diet is to be estimated, data on household or per capita income or expenditure is required.
For the list, cost and typical dietary habits of locally available
foods, primary data collection using the CotD standardised meth-
ods should be used. Alternatively, secondary data sources such as
market price monitoring surveys and household consumption and
expenditure surveys could be used. In order to determine house-
hold size, income or expenditure, household consumption and
expenditure surveys could be used. Secondary data can save time
and resources and has been previously validated by stakeholders
in-country. However, it is important that this data is reviewed for
its quality, access rights and appropriateness. Although a more
costly and resource intensive option, primary data is current and
purposefully collected based upon the objectives of the CotD as-
assessment and the local context.

The CotD software contains numerous databases: the energy and nutrient content for 3,500 foods, their portion sizes and the energy and nutrient specifications for 237 individuals. The CotD software applies these parameters to the data collected through primary or secondary sources and the linear programming solver calculates the least expensive combination of foods to meet the nutrient specifications for the selected household.

The software summarises the results for each diet in terms of
the costs, quantity and proportion of nutrient specifications pro-
vided by all the foods selected for a given individual/target group
or household by day, week, season and year. A study conducted in
Ntchisi district in Malawi found that the cost of a nutritious diet
that was adjusted to include staple preferences for a household of 5
people was 44,212 MWK a month, for which an adolescent girl was
the most expensive individual. Only 59% of the population could
afford this diet. The software selected maize, cowpea, green leafy
vegetables, liver and dried fish as inexpensive sources of essential
nutrients but found calcium, iron and zinc the most difficult nutri-
ents to meet specifications for, using foods available in the market.

Depending on the scope of the assessment and the type of data
used, a CotD analysis can take between 3-6 weeks. The process
should begin with a consensus on the objectives and scope of the
assessment. If primary data collection is to be undertaken, enu-
merators will need to be hired and trained. CotD analyses should
be conducted by certified practitioners. These are nutrition or
food security personnel who have attended the 5 day practitioners
training and completed an assessment for which the data and re-
port has been reviewed by an independent, certified practitioner.

Keywords: Data, cost, diet, linear programming

HOW IS A COST OF THE DIET ASSESSMENT CON-
DUCTED?

The Cost of the Diet (CotD) is a method and software devel-
oped by Save the Children to calculate the lowest cost of meeting
specifications for energy, protein, fat and micronutrients from lo-
cal foods. A CotD assessment requires the following information:
a list of all local foods; the average cost per 100g of the foods in a
season(s); the energy and nutrient composition of the foods; the

typical dietary habits of people in the area; the size and composi-
tion of a typical household; and the estimated average requirement
for energy and the recommended nutrient intakes for the individ-
uals included within the typical household. If the affordability of
the diet is to be estimated, data on household or per capita income
or expenditure will be required.

Standard methods are used to create the list of foods, record
their cost, assess the typical dietary habits of local people, and es-
timate the typical household size. Alternatively, secondary data
from market price monitoring surveys or household consumption
and expenditure surveys could be used. This is less costly and la-
bour intensive than collecting primary data but it is important that
these data are reviewed in terms of their quality, validity, access
rights and appropriateness.

The CotD software contains two main databases: the energy and nutrient content of 3,500 foods with their edible portion sizes, and the energy and nutrient specifications for 237 individuals. The CotD software applies these values with the cost of local foods to a linear programming solver which calculates the least expensive combination of foods to meet the energy and nutrient specifications of the individuals in the household selected. The software presents the results for four standard diets in terms of their costs, quantity and proportion of nutrient specifications provided by the foods selected by the software for all individuals in the household separately and collectively by day, week, season and year.

An assessment done in Ntchisi district in Malawi found that the cost of a nutritious diet that was adjusted to include a preferred staple for a household of 5 people was 44,212 MWK a month, and was most costly for an adolescent girl. The software selected maize, cowpeas, green leafy vegetables, liver and dried fish as inexpensive sources of essential nutrients but found calcium, iron and zinc the most difficult specifications to meet. Only about 60% of the population were estimated to be able to afford this diet.

Depending on the scope of the assessment and the type of data
used, a CotD analysis can take between 3-6 weeks. The process
should begin by defining the objectives and scope of the assess-
ment. If primary data are to be collected, enumerators need to be
hired and trained. A CotD assessment should be conducted by a
certified practitioner. This is a nutritionist or food security expert
who has attended a 5-day practitioners' training course and has
completed an independent assessment for which the data and re-
port has been reviewed by a certified practitioner.

Keywords: Data, cost, diet, linear programming

<footnote>(1)Deptford, Amy; (1)de Pee, Saskia; (1)Baldi, Giulia; (1)Bose, Indira;</footnote>

<footnote>(2)Hall, Andrew.</footnote>

<footnote>(1)World Food Programme. Italy; (2)Save the Children. UK.</footnote>
## MODELLING WITH COST OF THE DIET AND INFORMING FILL THE NUTRIENT GAP (FNG) ANALYSIS

(1)Bose, Indira; (2)Baldi, Giulia; (3)Kiess, Lynnda; (4)Deptford, Amy; (5)de Pee, Saskia.

(1)Nutrition Division. World Food Programme.; (2)Programme and Policy Officer. Nutrition Division. World Food Programme. Rome. Italy.; (3)Programme Advisor. Nutrition Division. World Food Programme. Rome. Italy.; (4)Nutritionist. Nutrition Division. World Food Programme. Rome. Italy.; (5)PhD Nutritionist. Nutrition Division. World Food Programme. Rome. Italy.

Many households cannot afford to meet the nutrient needs of all its members, which has been shown by Fill the Nutrient Gap (FNG) analyses and Cost of the Diet (CotD) studies in numerous different countries across the world. In particular household members with high nutrient needs relative to their energy needs such as children aged 6-23 months, pregnant and lactating women (PLW) and adolescent girls, are often the most expensive household members and/or require specific foods in addition to those consumed by the rest of the family so it is especially difficult to meet their nutrient needs. In order to address this issue solutions are required that reduce the cost of nutritious foods, make nutritious foods more available (e.g. in cases where certain foods do not exist or the availability of foods meeting nutrient needs are highly seasonal), and/or increase purchasing power. Using the Cost of the Diet tool different solutions to improve affordability can be modelled to help inform the FNG analysis on possible feasible solutions within the specific context and guide the formulation of sector specific recommendations.

Throughout the FNG process stakeholders from agriculture, food systems, health, social protection, education and other sectors are engaged to provide their input and interpretation into the analysis. One key area in which stakeholders provide input is the identification of appropriate interventions to be modelled. For example, stakeholders working in agriculture might be interested to see the potential impact of home-gardening interventions such as vegetable production; bio-fortification of crops; or large scale agricultural interventions aimed at reducing the overall cost of certain foods or making certain foods more available. Those involved in social protection might be interested in modelling cash transfers or vouchers for nutritious foods (e.g. leafy greens or animal source foods) or fortified Specialised Nutritious Foods (SNFs). Stakeholders within the health sector might be interested in seeing the impact of interventions such as the provision of iron folic acid tablets for PLWs; micronutrient powders or fortified complementary foods for children under 2; or staple food fortification. These interventions can be targeted at specific individuals of interest in the household, such as a child under 2, a PLW and an adolescent girl, or to the household as whole. Interventions aimed at specific target groups can also be combined to form a potential 'optimal' package of interventions targeting different household members. Different types of transfer modalities can also be modelled such as the provision of these foods through market channels or via voucher/ in-kind.

The results of the modelling are then used to inform stakeholders of the different potential intervention options that could be effective within their context. These results are intended to stimulate discussion and sensitise sectors on the contribution they could provide to improve access to nutritious diets, rather than prescribe specific actions. The results of the modelling combined with the wider FNG analysis then provide a basis upon which sector-specific recommendations to directly or indirectly improve nutrient intake can be formulated and implemented.

**Keywords:** Fill the Nutrient Gap, Cost of the Diet, linear programming, nutrition situation analysis, affordable diets

SS_144/1032

## APPLICATION OF WHO GUIDELINES ON OPTIMAL BLOOD FOLATE CONCENTRATIONS TO PREVENT NTDS IN COUNTRIES

### OPTIMAL SERUM AND RED BLOOD CELL FOLATE CONCENTRATIONS IN WOMEN OF REPRODUCTIVE AGE FOR PREVENTION OF NEURAL TUBE DEFECTS

Rogers, Lisa Marie.

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

Increasing awareness of the public health significance of insufficient folate intake due to its association with neural tube defects has emphasized the need for guidance on use of appropriate biomarkers for the assessment of folate status and cut-offs to define folate deficiency and insufficiency at the population level. In the early 1970's, the World Health Organization (WHO) endorsed serum and red blood cell folate cut-off values for defining folate deficiency based on risk of occurrence of macrocytic anaemia. In 2005, WHO updated the cut-off values to reflect folate deficiency based on metabolic indicators, primarily homocysteine concentrations. In recognizing the important role of folate in the prevention of neural tube defects, WHO has recently released guidance on the assessment of optimal folate status among women of reproduction age for the prevention of these birth defects. WHO recommends that red blood cell folate concentrations should be above 906 nmol/L (400 ng/mL) at the population level to achieve the greatest reduction in neural tube defects. This same threshold can also be used as an indicator of folate insufficiency in women of reproductive age at the population level. However, this should not be used at the individual level, as it cannot explain all cases of neural tube defects and therefore cannot predict an individual's risk of having a neural tube defect-affected pregnancy. The use of microbiological assay is recommended for the assessment of red blood cell folate concentrations with appropriate quality control measures. The current recommendations are based on results of microbiological assay with chloramphenicol-resistant strain and folic acid calibrator. The use of different folate calibrators or dif-
ferent microorganisms may lead to different results among mi-
crobiological assays and laboratories and may need to adjust the
threshold value for optimal red blood cell folate. Due to insuffi-
cient evidence, a threshold for serum folate could not be made at
this time for defining folate insufficiency.

**Keywords:** Folate, folic acid, indicators, status, neural tube defects

USING THE WHO OPTIMAL BLOOD FOLATE CON-
CENTRATIONS FOR THE U.S. TO EVALUATE THE
IMPACT OF FORTIFICATION AND SUPPLEMENT
USE POST-MANDATORY FOLIC ACID FORTIFICA-
TION (NHANES 2007-2012)

(1)Crider, Krista; (2)Qi, Yan Ping; (2)Tinker, Sarah.

(1)PhD National Center on Birth Defects and Developmental Disabilities, CDC Atlanta GA USA; (2)National Center on Birth Defects and Developmental Disabilities (NCBDDD). Centers for Disease Control and Prevention (CDC). Atlanta GA USA.

Intake of 400µg folic acid per day before and during early
pregnancy prevents many neural tube defects (NTDs). Since 1998
there have been three sources of folic acid in the U.S.: enriched ce-
real grain products (ECGP) mandatorily fortified with 140µg folic
acid per 100g; ready-to-eat (RTE) cereals, which are allowed but
not required to contain up to 400µg per serving; and dietary sup-
plements, generally 400-800µg. In 2015 the World Health Organi-
zation established a threshold for the population level optimal red
blood cell (RBC) folate concentration [> 906nmol/L (>400ng/L)]
for prevention of NTDs. We found previously that 22.8% of the
U.S. population is below the threshold. To evaluate the impact of
the current folic acid fortification policy and consumption patterns
on NTD risk, we used 2007-2012 data from the National Health
and Nutrition Examination Survey (NHANES), a cross-section-
al survey representative of the non-institutionalized U.S. civilian
population, to examine usual daily intake of synthetic folic acid
and naturally-occurring food folate and RBC folate concentra-
tions among U.S. women of reproductive age (12-49 years). RBC
folate concentration distributions were then used in simulations
to predict NTD risk based on published dose-response relation-
ships in the population overall and among those consuming folic
acid from difference sources. The predicted NTD risk among U.S.
women of reproductive age was 7.1 NTDs per 10,000 live births
(95% uncertainty interval [UI] 5.3-9.2). Among those with ECGP
as their only source of folic acid had lower median usual daily in-
take of folic acid (115 µg interquartile range 79-156) and higher
predicted NTD risk (8.5/10,000 live births; 95% UI 6.4-10.8) com-
pared to those consuming folic acid from additional sources. We
estimate that if reproductive-aged women with ECGP as their only
source of folic acid (48% of population) increased their folic acid
intake through RTE cereal and/or supplements, it could be pos-
sible to prevent up to an additional 640 NTD-affected pregnan-
cies (95% UI 143-114) per year. Although folic acid fortification
has prevented many NTDs, under current consumption patterns

some U.S. women of reproductive age remain at risk for having an
NTD-affected pregnancy.

**Keywords:** Folic acid, neural tube defects

RED BLOOD CELL FOLATE INSUFFICIENCY
AMONG NON-PREGNANT WOMEN OF CHILD-
BEARING AGE IN BELIZE: PREVALENCE AND PRE-
DICTED RISK OF NEURAL TUBE DEFECTS

(1)Rosenthal, Jorge; (2)Cannon, Michael; (3)Alverson, CJ; (4)Sniezek, Joe;

(5)Crider, Krista; (6)Largaespada, Natalia.

(1)Ph.D., Epidemiologist. National Center on Birth Defects and Developmental Disabilities. National Center on Birth Defects and Developmental Disabilities, Atlanta, USA; (2)Epidemiologist. National Center on Birth Defects and Developmental Disabilities. Centers for Disease Control and Prevention, Atlanta, GA, USA;

(3)Mathematical Statistician. National Center on Birth Defects and Developmental Disabilities. Centers for Disease Control and Prevention, Atlanta, GA, USA; (4)Acting Director. Division of Congenital and Developmental Disorders. National Center on Birth Defects and Developmental Disabilities.Centers for Disease Control and Prevention, Atlanta, GA, USA; (5)Geneticist. National Center on Birth Defects and Developmental Disabilities. Centers for Disease Control and Prevention, Atlanta, GA, USA; (6)Chief. Maternal and Child Health. Ministry of Health, Belmopan, Belize.

**Background and objectives:** Studies have shown that increased consumption of folic acid by women during the periconceptional period can significantly reduce the occurrence of neural tube defects (NTDs), which has led to current recommendations for women to consume 400 µg (0.4 mg) of folic acid daily. Based on these studies the World Health Organization recently released recommendations stating that red blood cell (RBC) folate concentrations should be above 400 ng/L (906 nmol/L) for optimal prevention of folate-sensitive NTDs. The objective of this study was to determine the distribution of RBC folate insufficiency (<906 nmol/L) and potential risk of NTDs based on RBC folate concentrations among non-pregnant women of childbearing age (WCBA) in Belize.

**Methods:** A national and regional multistage cluster probability survey was completed during 2011 among Belizean WCBA, aged 15-49 years. Demographic and health information, and blood samples for RBC folate analyses were collected from 973 women. Prevalence rate ratios of folate insufficiency and predicted NTD prevalence were estimated based on RBC folate concentrations.

**Results:** The national geometric mean of RBC folate was 719 nmol/L (95% confidence interval (CI) 689, 750). National prevalence of RBC folate insufficiency was 48.9% [95% CI 44.8, 53.1]. RBC folate insufficiency showed wide variation by ethnicity: Mavan 70.5% (60.1% - 79.2%); Mestizo 46.2% (40.2%-52.3%); Creole/ Garifuna 54.3% (46.3%-62.1%) and Other 33.5% (21.0%-48.8%). There was also wide variation by geographic region (40.2%-60.4%). Based on the population distribution of RBC folate con-
centrations, the national predicted NTD risk was 15.4 per 10,000 live births (95% CI 11.8, 19.9). The predicted NTD risk was more than 12 times higher among women with RBC folate concentrations at the 5th percentile compared to women with RBC folate concentrations at the 95th percentile (49.5 vs. < 4 per 10,000 live births, respectively).

**Conclusions:** Folate insufficiency is very high and remains a public health concern in Belize. Folate insufficiency was more prevalent among Mayans, Creole/Garifunas and in regions with a large proportion of indigenous populations. These results suggest that there is a need to ensure that WCBA in all ethnic groups in Belize receive at least 400 µg of folic acid daily to reduce the risk of folate-sensitive NTDs.

**Keywords:** Red blood cell folate insufficiency, Prevalence of Neural Tube Defects, Predicted risk of Neural Tube Defects, Non-pregnant women of childbearing-age, National and regional representative household survey in Belize

**Further collaborators:** Krista Crider, PhD

Geneticist, Centers for Disease Control and Prevention

National Center on Birth Defects and Developmental Disabilities

Division of Congenital and Developmental Disorders

Prevention Research and Translation Branch

## FOLATE AND VITAMIN B12 STATUS AMONG NON-PREGNANT WOMEN OF REPRODUCTIVE AGE IN MALAWI, 2015-2016

Nyirenda, Eunice.

MNS coordinator. Nutrition Technical Assistant. Malawi Ministry of Health. Dept of Nutrition HIV and AIDS. Malawi.

consumption of 400 mcg of folic acid prevents the majority of NTDs. Folate insufficiency or deficiency is thought to be a public health problem in Malawi among women of reproductive age (WRA), but data on folate and vitamin B12 micronutrient status are lacking.

**Objective:** To determine baseline prevalence of folate deficiency and insufficiency and vitamin B12 deficiency among non-pregnant women aged 15-49 years in Malawi.

**Methods:** A cross-sectional two-stage cluster sampling design was used to conduct a national nutrition and biomarker survey from December 2015 to February 2016. Demographic and health information were obtained through in-person interviews. Blood samples were collected and analyzed for serum and RBC folate and vitamin B12 from 35 clusters (8 urban, 27 rural) in the country's three regions (North, Central, South). Serum folate deficiency, RBC folate deficiency, and RBC folate insufficiency were defined as <7 nmol/L, <305 nmol/L, and <748 nmol/L, respectively. Vitamin B12 deficiency was defined as <148 pmol/L.

**Results:** Preliminary data show the prevalence of serum folate deficiency, 8.5% (95% CI 5.8-11.2); RBC folate deficiency, 13.3% (95% CI 9.6-17.0); RBC folate insufficiency, 81.4% (95% CI 75.7-87.0) and vitamin B12 deficiency, 11.8% (95% CI 8.1-15.4).

Characteristics of Malawian women by micronutrient status will be presented.

**Conclusions:** Establishing baseline folate and vitamin B12 status among non-pregnant women of reproductive age will help to define folate and vitamin B12 micronutrient insufficiencies and deficiencies in Malawi.

**Keywords:** Malawi, women of reproductive age, red blood cell folate insufficiency, red blood cell folate deficiency

## PERICONCEPTIONAL SURVEILLANCE FOR PREVENTION OF ANEMIA AND BIRTH DEFECTS IN SOUTHERN INDIA

(1)Finkelstein, Julia; (2)Fothergill, Amy; (3)Bose, Beena; (4)Guetterman, Heather; (5)Johnson, Christina; (6)Bonam, Wesley.

(1)MPH SM ScD. Assistant Professor. Division of Nutritional Sciences. Cornell University.; (2)MPH. Doctoral Student. Division of Nutritional Sciences. Cornell University.; (3)Research Fellow. St. John's Research Institute. Bangalore. India.; (4)Graduate Student. Division of Nutritional Sciences. Cornell University.; (5)MS. Study Coordinator. Arogyavaram Medical Centre. Andhra Pradesh. India.; (6)MBBS. Director. Arogyavaram Medical Centre. Andhra Pradesh. India.

Neural tube closure defects (NTDs) are among the most common and debilitating adverse pregnancy outcomes globally. The association between maternal folate status and NTD risk was first observed over 40 years ago. However, there is little representative population-level data, particularly in South Asia, where the burden and consequences of micronutrient deficiencies are unacceptably high.

We are establishing a periconceptional surveillance program as part of our collaborative community-based research program in Southern India. As part of this project, we are establishing the gold standard microbiological assay for folate in our laboratory in India, with expert guidance from the Centers for Disease Control and Prevention, and conducting a biomarker survey to elucidate the burden of anemia and micronutrient deficiencies in women of reproductive age. This living laboratory will also serve as the foundation for future intervention trials and public health programs in this well-characterized population, for the prevention of anemia and birth defects.

In this presentation, we describe the establishment of this periconceptional surveillance program in Southern India, and discuss preliminary findings from the pre-intervention biomarker survey.

**Keywords:** Folate, neural tube defects, biomarker, surveillance, India
# Track 4: Nutrition and Management of Diseases

SS_144/1007

ICAN SYMPOSIUM

## OBESITY AND EPIGENETICS

Raman, Rita.

University of Oklahoma Health Sciences Center. Oklahoma City.
Oklahoma. USA.

Epigenetics involves the study of heritable changes in gene expression that are not due to changes in the nucleotide sequence, but involve for example other mechanisms such as histone modifications or changes in DNA resulting from alterations in the methylation patterns. Such modifications can be impacted by diet, nutrients, and environmental factors such as chemical, psychological, and behavioral influences. While the role of dietary factors is more readily understood in the context of obesity, the epigenetic phenomena associated with obesity risks provides the linkage between factors such as stress, sleep deprivation, and obesity.

The specific genetic alterations that result in diseases and complex syndromes continue to be identified. Genome-wide association studies have identified concepts such as the rare variant-common disease hypothesis and the common variant-common disease hypothesis. Through association studies, unique gene-environment interactions, which may occur with or without specific periods of permissiveness or vulnerabilities, have also been identified. Major conditions where the role of exposomes and epigenetics are rapidly evolving are obesity, neurological disorders, immune disorders and cancers. These concepts are particularly intriguing in the context of obesity. Search for the origins of disease have led to investigations into the roles of dietary and environmental factors as potential triggers or modifiers of risk. In reproduction, certain genes are turned on while others are turned off in the process of imprinting. In the case of imprinting, even though there are two copies of the gene, only one copy is expressed and there is no substitute functional allele. For this reason, imprinting makes the imprinted genes more vulnerable to the negative effects of mutations.

Nutritional epigenetics is seen as a means for the prevention of developmental diseases and cancer, and to delay processes associated with aging. Studies with rodent models suggest that during both early development and in adult life, environmental signals can activate intracellular pathways that directly remodel the epigenome, leading to changes in gene expression and function. These studies define a biological basis for the interplay between environmental signals and the genome in the regulation of individual differences in behavior, cognition, and physiology. Diseases in which epigenetic factors are considered significant include type 2 diabetes mellitus, obesity, inflammation, cardiovascular diseases, neurocognitive disorders, and immune diseases, with function

influenced by environmental factors including early experience. In conclusion, epigenetics can be defined as heritable traits resulting from changes in DNA or chromatin structure without alterations in the DNA sequence and is considered an important phenomenon in understanding the environmental influences that modify disease risk profiles.

**Keywords:** Epigenetics, Obesity, Nutrition, Environment, Diet

## OBESITY AND SLEEP DISORDERS

(1)Giorelli, Paulo; (2)Giorelli, Guilherme; (3)Sartoretto, Silvia.

(1)International Colleges for the Advancements of Nutrology. Brasil; (2)Md. MS. International Colleges for the Advancements of Nutrology. Brasil.; (3)MD. International Colleges for the Advancements of Nutrology. Brasil.

We will discuss about the link between obesity and sleep disorders.

The sleep deprivation leading to a continuous organic stress syndrome with disbalance in body homeostasis and the release of hunger and satiation's neurotransmitters.

We'll show the sleep patterns identified like epigenetic factors that could pull the trigger of obesity.

We show an easier way to identify the presence of sleep disorders in obesity patients.

Finally we call the attention about the role of treat those sleep disorders because if we don't treat them we are making the treatment obesity worse than already is.

**Keywords:** Obesity, Sleep disorders

## NUTRITIONAL FOODS OR SUPPLEMENTS IN OBEsITY: CLINICAL APPROACH

(1)Giorelli, Guilherme; (2)sartoretto, Silvia.

(1)MSc. MD. Associação Brasileira de Nutrologia. International College for Advancement of Nutrology. Brasil; (2)MD, Associação Brasileira de Nutrologia. Brasil.

The incidence of obesity, diabetes and insulin resistance are associated with high glycemic load diets. Identifying food or food groups that can help patients to achieve their glycemic, cholesterol or weight goals could be an preventive strategie with high impact on the cost of the treatment and in public health funds.

Our aim was to analyze the insulin secretion in subjects free of diabetes in response to different food groups with high glycemic index.

We evaluate 24 volunteers free of diabetes, 11(45,8%) female, with 24±3,7years old that underwent laboratory and anthropometric during three days with a seven day distance between each day. Were exclude from the study subjects with diabetes and hypertension. After a 10 hour fasting subjects received a meal with
50 grams (g) of carbohydrate (CHO) with high glycemic index from different foods.

The 3 meals had 240 milliliters (ml) of whole milk (12g of CHO). For the first day (1D) we added 65g of wheat flour bread (38g de CHO). In the second day (2D) we added 43g of wheat flour bread (25g de CHO) and 50g of chunky bananas (13g de CHO). In the third day (3D) we added 43g of wheat flour bread and 86g of apple (13g de CHO). Subjects were asked to consume the meal in 10 minutes and blood samples were performed in -15, 0, 30, 60, 90 and 120 minutes. Were determined: BMI, abdominal circumference, glycemia and insulin in all of the samples, glycemia peak value (VPG), insulin peak value (VPI), glycemia time peak value (VTPG), insulin time peak value (VTPI), absolute insulin increase (deltai), absolute glycemia increase, area under de glycemia curve (AUCG) e area under de insulin curve (AUCI).

There were no statistical difference between glycemic values in all the samples and between the curves at VPG, VTPI, deltai and deltag. The VTPG at the 1D were 67,5 ±36,7, at 2D 50,6 ±34,2, at 3D 99,9 ±13,9 (p < 0,008). The AUCI was higher at 1D 2867,2 (809,2-6947,2) than in 2D 1771,5 (689,2 – 4194,0). The 3D was 2345,2 (416,2-9605,2), equal to 1D.

There is no glycemic index for meals, only for food. High Glycemic index foods are determined with 70 or above. In this study the 1D had 85 of IG, the 2D had 81 and the 3D had 73. The major responsible for this high IG in all meals were the wheat flour bread that induced an higher insulin secretion in order to maintain the same glycemic value. The VTPG had smaller values in 1D and 2D than in 3D because of its higher IG.

Our study suggests that healthy individuals in order to maintain the same glycemic response after a meal with food from different carbohydrate sources is necessary to have a bigger insulin secretion when the meal has high glycemic index foods

**Keywords:** Nutrition, Supplement, Exercise, Performance, Obesity

## COLLAGEN SUPPLEMENTATION FOR HEALTH OF THE SKIN, CARTILAGE AND MUSCLES - CURRENT MYTHS AND TRUTHS

Garcez Duarte, Marcella.

Brazilian Association of Nutrology (ABRAN) / ICAN. Brasil.

Collagen is the most abundant protein in the animal body, it is present from the most primitive invertebrates to man, in at least 27 protein isoforms found in connective tissue throughout the body, such as bones, tendons, cartilage, veins, skin, teeth and muscles.

The commercially important types are Type I, the most common, found in skin, tendons and bones, Type II found in cartilage, and Type III, which forms the reticular fibers of the lungs, intestines, blood vessels, liver, uterus.

Permanent collagen exchange processes in body takes place during the whole human life, the old fibrils are replaced by new ones all the time. In young organism, the collagen production and degradation is balanced dynamically, but with aging the degrada-

tion becomes more intensive and UV radiation, smoking, stress and unhealthy diet can speed up the process.

After protein intake, the most important nutritional factor for proper biosynthesis of collagen is the level of circulating vitamin C. There are at least three vitamin C-depended enzymes, prolyl 3-hydroxylase, prolyl 4-hydroxylase and lysyl-hydroxylase, essential for the biosynthesis of collagen fibers.

Hydrolysate collagen has been generally regarded as having low biological value, because it does not contain all the essential amino acids, it's a reputable nutritional component often used to supplement other proteins because of its superb digestibility and high user tolerance. Hydrolysate collagen have been reported to have beneficial biological functions and designated as Generally Recognized as Safe (GRAS) by the Food and Drug Administration (FDA).

Many researches reported the beneficial effects of oral collagen hydrolysates administration, which crosses the intestinal barrier by dietary bio actives peptides, which reaches the blood circulation and becomes available for metabolic processes. Collagen hydrolysate can be used in several medical applications, such as high energy supplements, geriatric and enteric products, therapeutic or weight control diets for specific digestive disorders, amino acid absorption and metabolism. Papers also included cases of patients with malnutrition attached with trauma, burns, cancer and hepatic encephalopathies. Hydrolysate collagen can be a good source of amino acids for people suffering from anorexia, anemia and for vegetarians. The main scientific evidences show that collagen after absorption can reach and accumulate in the cartilage, stimulating a significant increase in extracellular matrix synthesis by chondrocytes that can prevent or reduce pain in patients suffering from osteoarthritis and osteoporosis. Clinical studies suggest that dietary hydrolyzed collagen supplements are protective agents of tendons, muscle structures and act on joint regeneration in athletes with pain related to joint activity. Important beneficial effects have also been observed in the maintenance of tonus and hydration of skin structures and the quality of hair and nails.

**Keywords:** Collagen, supplement, skin, cartilage, muscle
# Track 5: Nutrients and Nutritional Assessment

SS_144/1025

## PERSPECTIVES ON NUTRIENT DENSITY: TOO HIGH AND TOO LOW

### NUTRIENT-ENERGY DENSITY: ORIGINS OF THE CONCEPT

Drewnowski, Adam.

University of Washington. United States.

The question of what makes a food “healthy” continues to puzzle both regulatory agencies and expert panels. A literature review conducted in 1977 showed that the concept of a nutritious food was not fully defined. General statements that such a food should provide “significant amounts of essential nutrients” were not backed by any firm standards or criteria. The concept of nutrient density was defined three decades later (Drewnowski 2005), along with some of the first attempts to devise a composite nutrient density score. Later attempts to quantify nutrient density of foods, now collectively known under the name of nutrient profiling, have been based on a variety of calories-to-nutrient scores, nutrients-per-calorie indexes, and nutrient-to-nutrient ratios. One problem was that healthy foods were often defined by the absence of problematic ingredients—fat, sugar, and sodium—rather than by the presence of any beneficial nutrients they might actually contain. By contrast, the naturally nutrient rich (NNR) score was based on mean percentages of daily values (%DVs) for 14 nutrients contained in 2000 kcal of food. The subsequent Nutrient Rich family of scores included nutrients to encourage, notably protein, fiber, and a range of vitamins and minerals, as well as the so-called disqualifying nutrients, saturated fat, added sugars and sodium. The US Food and Drug Administration had been disqualifying foods from carrying nutrition or health claims if they contained excessive amounts of fat, saturated fat, sodium, and cholesterol. Later scores of composite nutrient quality assessed amounts of index nutrients per reference amount: 100g, 100 kcal, or serving size. In addition to nutrients, some models also included food groups to encourage (vegetables, fruits, nuts). The goal of nutrient profiling models was to separate empty calories from more nutrient-dense or nutrient-rich food. Nutrient profiling models were also extended to create novel metrics of affordability or environmental impact. Whereas nutrient density was measured in terms of nutrients per calorie, affordability of foods was measured in terms of calories or nutrients per penny. Environmental impact has been measured in terms of energy or nutrient cost in greenhouse gas emissions associated with food production, processing, consumption, and waste. Initially intended to support of nutrition and health claims, nutrient profiles have found a role in consumer education, regulation of marketing to children, and in

food taxation. Industry has used nutrient profiling to assess and reformulate product portfolios.

Adapting nutrient profile models to the needs of low and middle income countries (LMIC), many undergoing nutrition transition, raises additional questions about diet composition, animal versus plant foods, nutrient bioavailability, and amino acid composition of protein. Any nutrient standards need to be based on dietary shortfalls for a given country. Not all nutrient composition and dietary intake data may be readily available. A nutrient profiling manual to evaluate the LMIC food supply would be a valuable addition to the nutrition literature.

**Keywords:** Nutrient profiling, Nutrient Rich Food (NRF) score, affordability, environment

**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

## APPLICATION OF THE CONCEPT IN A PUBLIC HEALTH CONTEXT

Solomons, Noel W.

Center for Studies of Sensory Impairment, Aging and Metabolism (CeSSIAM). Guatemala City. Guatemala.

There are practical and applied aspects for employing “nutrient-density” (ND) as a perspective, beyond total daily intake, as an expression of public health nutrition interest. One can think of ND as a ratio, with a numerator and denominator. The numerator is a quantity of a macro- or micronutrient. The denominator is any expression that can contain (or constrain) the intake of food; it is generally a standard amount of dietary energy, e.g. per 1000 kcal, but it can also be a weight (grams), specific meal or standard portion-size, or even cost/price or environmental footprint (carbon-emission, water-consumption, etc.).

We recognize Brown, Dewey and Allen and their “Complementary feeding of young children in developing countries” (WHO,1998) for insights stimulating the use of ND both in the evaluation and planning of diets, specifically through the infant and toddler years, when human milk forms a variable component of the early-life diet. Both the “critical nutrient-density” concept and the “problem nutrient” term derive from this monograph.

Whereas the nutrient-intake recommendations from the US-Canadian (DRI) and UN (WHO/FAO) sources are based on a fixed daily quantity for each age/sex-group, a novel experience (and experiment) for Latin America was inspired by the Cavendes Foundation of Venezuela, under the leadership of the late Dr. Jose Maria Bengoa in the 1980s. The insightful principle was based on the assumption of a common, communal household-diet (rather than individualized rations); they proposed a prescribed density for each essential nutrient in the family fare, one that would satisfy the needs of each member when consuming the proportion of the foods and beverages meeting their specific daily energy needs. It failed to gain traction in the Region, however, which remained
with the more-established international guidance. With increasing
consumption outside of the home in the intervening three decades,
however, the assumption of a pooled fare has become obsolete.

Although the future trajectory of the human food supply can-
not be predicted with certainty, there are reasonable bases for ex-
pecting constraints on caloric intake around the world. Urbani-
zation, and its concomitant sedentary lifestyle imperative, will
advance the restriction in effective energy needs, whereas food
scarcity may ensue in other settings. In the face of the shrink-
ing energy as the denominator factor, public health tolerance for
“empty calories” is reduced, while an imperative to construct die-
tary fares from micronutrient-enhanced calories will become evi-
dent. To the extent that unprocessed foods are to contribute, their
biofortification – even in the fruit and vegetable sector – must be
considered. The residual processed component of the diet will also
need to offer more micronutrients per calorie, but the fortification
logistics represent a challenge. Dietary diversity confounds any
given staple food’s being the conveyor of key nutrients across the
whole population. A strategy of “total fortifiable foods,” in which a
thin – but broad – “veneer” of balanced micronutrient fortification
is distributed among all commercially-processed foods, has been
proposed by Omar Dary. This, however, presents challenges for
micronutrient-safety in any setting with broad extremes of indi-
vidual energy requirements.

**Keywords:** Nutrient density, caloric requirement, biofortification, nutrient excess

**Conflict of Interest disclosure:** Travel was sponsored by Nestle Research Center

GUATEMALAN CASE-STUDY: SITUATIONAL LOW-ENERGY INTAKE

Vossenaar, Marieke.

PHD. Center for Studies of Sensory Impairment, Aging and Metabolism (CeSSIAM). Guatemala.

Guatemala has a unique history for contribution to the under-
standing of nutritional problems. It has been a pioneer for public
policies in micronutrient fortification and supplementation. In the
1950s potassium iodate was found to be as nutritionally efficacious
and much more resistant than potassium iodide for fortification of
salt. In the 1970s, Guatemala pioneered the fortification of table
sugar with vitamin A. Despite these measures, micronutrient mal-
nutrition has not been completely controlled in Guatemala.

At any age, from fetal life to older age, Guatemalans have small
body size, with the corresponding implications for daily energy
requirements. The combination of the basic dietary pattern in
Guatemala and its undersized population allows for a rich basis
for understanding the utility of a nutrient-density in analyzing nu-
trient intake and devising remedial solutions.

The initial issue in the convergence is that recommended in-
takes for micronutrients are common for any given age, sex or
physiological group independent of the weight of the individuals.
A population reference value of energy is also created as a standard

reference, but it is widely understood that each individual has a
unique energy requirement based on body size, lean-body tissue
and exertional efforts.

In our work with Guatemalan women we used reference 'criti-
cal nutrient densities' - i.e., nutrient amount per 1000 kcal which
would provide the nutrient requirements when the energy require-
ment is satisfied - to assess the nutrient adequacy of the diet and
pregnant and lactating women from rural and urban communities
of the Western Highlands. For women who are either pregnant
or lactating, the required daily energy and nutrients are higher -
sometimes substantially higher - than for women in the non-re-
productive state. Although women reported eating more during
pregnancy and lactation, estimated energy intakes were below the
status-specific requirements. Without the additional foods to meet
the greater energy and nutrient needs, intake gaps with respect to
the 2004 FAO/WHO Recommended Nutrient Intakes (RNI) were
observed for 9 of 17 index micronutrients in pregnant women and
6 of 17 micronutrients in lactating women across the studied com-
munities. If these women were to consume more calories of the
same diet, requirements of some - but not all - nutrients would be
met. Nutrient which would remain inadequate across the studied
communities - i.e., which have a critical nutrient density above
the observed nutrient density - include vitamin C, pantothenic
acid, vitamin D, E, and K, calcium and iron in pregnant women
and vitamin C, pantothenic acid, vitamin D, E, and K in lactating
women. Nutrients with an adequate estimated nutrient density -
i.e., for which intakes would meet requirements if the women were
to eat 100% of their energy assignment - include vitamin B6, B12
and iron in pregnant women and calcium in lactating women.

The realities in Guatemala are such that normative amounts
of micronutrients are not consumed both because energy-intakes
are below the group reference, and because nutrient-density is in-
trinsically low. Both situations, however, justify increasing nutri-
ent density as a solution to achieve recommended daily intakes of
micronutrients.

**Keywords:** Pregnant and lactating women, nutrient adequacy, nutrient density, Guatemala

BIOFORTIFICATION: INCREASING MICRONUTRI-
ENT DENSITY OF STAPLE CROPS

Boy-Gallego, Erick.

PhD. HarvestPlus. International Food Policy Research Institute.
Washington DC. USA.

Nutrition interventions to alleviate vitamin and mineral defi-
ciencies (hidden hunger) have made significant contributions to
the health and wellbeing of entire generations in low and medi-
um income countries. Universal and targeted supplementation and
food fortification schemes with multiple or single micronutrients,
however, carry recurring costs that donors and/or consumers must
bear because the existing food system does not provide sufficient
nourishment for one or more vulnerable stages of the life cycle. The
poor have very limited or no access to commercial food or pharma-
ceutical products to eliminate the micronutrient intake gap asso-
ciated with monotonous plant-based diets. In societies that derive
over 50% of the daily energy requirements from a single staple crop
such as maize, wheat, rice or cassava, it makes sense to add varieties
of the same staples with higher micronutrient densities, especially
if the target populations can grow a significant proportion of the
food they consume. Biofortification targets the poor, which makes
it a supply-driven initiative; but these crops must also be in demand
by the food sector to keep the plant breeding and bioengineering
pipelines generating high yielding, pest resistant, climate resilient
varieties continuously. Biofortified crop varieties are intrinsically
loaded with higher concentrations of iron, zinc or provitamin A
carotenoids; therefore, their adoption does not bring additional re-
curring costs to farming households. The plants do the work; and
because the crops developed by international agricultural research
network centers and national agriculture agencies are public goods,
sustainability is not an issue. HarvestPlus and collaborators from
multiple disciplines and sectors have developed provitamin A-rich
maize, cassava and sweet potato; high iron beans and pearl mil-
let; and high zinc wheat and rice varieties during the past 15 years.
While plant-breeding programs continue to feed a responsive pipe-
line of crop cultivars, 140+ varieties of 10 staple crops are already
publicly available and contribute to crop varietal diversity in over
30 countries across continents. The provitamin A, iron and zinc
density of the targeted crops have increased up to 15-fold for pro-
vitamin A maize and cassava, doubled the iron in several common
bean varieties and pearl millet varieties, and increased zinc concen-
tration by 30% in whole wheat and 75% in milled rice. Randomized
controlled efficacy trials have demonstrated that at the currently
available micronutrient density levels, biofortified crops improve
micronutrient status and important nutrient-dependent functions
in different vulnerable population groups. Economic analysis indi-
cates that biofortification is cost-effective due to large reductions in
inadequate intake and resulting DALYs saved. The potential addi-
tive effects of the adoption of multiple biofortified crops can have
an important impact on dietary nutrient density and therefore the
vitamin A, iron and zinc status of entire populations. The way for-
ward for biofortification follows a 2030 vision of global availability
and consumption of micronutrient-rich crops by 1 billion people.
Achieving the goals associated with this vision will require scaling
up delivery systems in 30+ countries, mainstreaming breeding for
higher micronutrient density, and expanding markets and adop-
tion of biofortified crops with multiple partners.

**Keywords:** Biofortification, micronutrients, staple, crops, diversity

FOOD FORTIFICATION ADDRESSING DIETARY NEEDS

Klassen, Petra.

PhD. Scientific Advisor. Corporate Nutrition, Health and Wellness Unit. Nestlé. Switzerland.

Inadequate intakes and absorption of vitamins and minerals to sustain good health and development lead to micronutrient deficiencies.

With two billion people suffering from deficiencies in Iron, Iodine, Vitamin A and Zinc, this remains one of the world's biggest public health issues.

While ideally, essential micronutrients should be obtained
from a balanced and varied diet, this is not always possible. For-
tified foods that are both affordable and accessible have been rec-
ognized as a cost-effective way to improve nutrition and health of
vulnerable populations alongside efforts to diversify diets. Infants,
young children and women of childbearing age are disproportion-
ately affected, because of their greater need for these nutrients.

The path to provide relevant and impactful fortified offers
should entail:

* understanding the local nutritional needs and gaps to identify most relevant fortificants

* select vectors that are widely and regularly consumed by the target population

* educate and communicate on the benefits of fortified foods

• ensure accessibility of the fortified products

• partner with stakeholders to leverage efforts

* study the impact of our actions for continuous improvements

Quality, safety and sensorial aspects have to be taken into ac-
count and it is recommended that food manufacturers develop
mandatory internal fortification policies clearly defining fortifica-
tion levels and appropriate quality management and monitoring
procedures.

Eliminating malnutrition is a top priority in the global devel-
opment agenda and is the second of the United Nation's Sustaina-
ble Development Goals. The private sector can work together with
governments and civil society to develop new models to make
tasty, nutritious and affordable foods accessible to the people who
need them.

**Keywords:** Micronutrient, Fortification, Food, Voluntary fortification

**Conflict of Interest disclosure:** The author is employed by Nestlé, Switzerland

NOVEL HOME-FORTIFICATION FOR LACTATING WOMEN

(1)Bonorden, Melissa; (2)Hirst, Daniel.

(1)M.S. Nutritionist. Research & Development. Hormel Foods Corporation. Austin. Minnesota. USA; (2)B.S. Packaging Scientist. Research & Development. Hormel Foods Corporation. Austin. Minnesota. USA.

Thoughtful design of a food supplement will consider both di-
etary needs and cultural behaviors as a way to improve nutritional
impact and compliance. This talk will focus on the model we used
to develop a novel food supplement for use at home among lactat-
ing women in Guatemala. It is well documented that the first 1000
days of a child's life provide a critical window of opportunity to in-
fluence cognitive and physical development. Examination of cul-
tural practices during the early postpartum period in the Western
Highlands of Guatemala identified the role of atole, or thin gruels,
as a beverage perceived to improve both quality and quantity of breastmilk and an important vehicle to deliver additional nutrients through home fortification. Gruels are consumed in Guatemala several times per day and make an important contribution to total daily water intake, which frequently falls below the Adequate Intake recommendations among lactating women. Initial work quantifying the characteristics of how atole is prepared, served and consumed in markets and at home identified a wide variety in temperature at which atole is served and standard volume consumed. Nutrient gaps were identified by comparing intakes from 24 hour dietary recall to recommended values for women in urban, semi-rural and rural locations. Gaps were found for protein and several micronutrients and were more pronounced in rural women. Based on these data, a goal was developed to deliver an additional 15 grams of high quality whey protein dispersed three times throughout the day. The supplement was initially tested at benchtop for impact on solubility in atole and changes in organoleptic quality. Acceptability and use was further tested through in-country consumer testing in rural and urban dwelling women using both commercially-available and home-prepared gruels. In these panels, women were able to identify a difference between atole with and without whey protein supplementation; however, the supplemented atole was reported as the more preferred beverage. Future work will encompass identifying novel forms of vitamins, minerals and long chain fatty acids that will have little to no impact on color and flavor. Packaging options will focus on materials that protect integrity and prolong shelf life as well as graphic designs that clearly convey serving size and clear, appropriate directions for use. Successful integration of this novel home fortificant into the diet of lactating women will provide a culturally-relevant approach to improve hydration, intake of high quality protein and micronutrient status.

**Keywords:** Hydration, protein, micronutrients, fortification, lactation

**Conflict of Interest disclosure:** Melissa Bonorden is employed by Hormel Foods Corporation.

# Track 6: Functional Foods and Bioactive Compounds

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## POLYPHENOLS IN HUMAN NUTRITION

### POLYPHENOL ADME: HOW FOOD AND PHYSIOLOGICAL FACTORS IMPACT DELIVERY OF THESE BIOACTIVE PHYTOCHEMICALS

Ferruzzi, Mario.

Professor. Plants for Human Health Institute. North Carolina State University. Kannapolis NC. USA.

With evidence suggestive of a health-protective role for dietary polyphenols, interest in factors that can influence their bioavailability from foods has increased. Both food matrix and physiological factors are important modifiers of digestive behavior, absorption and metabolism of polyphenols. Using tea, cocoa, grape and berries as models, the role of food formulation on bioaccessibility and bioavailability of key dietary flavonoids (flavan-3-ols, flavonols and anthocyanins) were investigated. Macro and micronutrient interactions in foods and through the GIT were found to alter digestive stability and intestinal transport of flavan-3-ols from these foods. Specifically, formulation with ascorbic acid, minerals and carbohydrate improved flavan-3-ol digestive stability and bioavailability in vivo. In contrast, protein has only a modest negative impact to overall absorption, despite the ability to enhance stability of flavan-3-ols to normal digestion. These factors suggest that flavonoid interactions with macro and micronutrients in foods and through normal digestion may lead to differences in acute bioavailability.

Flavonoid bioavailability and metabolism may also be impacted by dietary and physiological factors including repeated exposure typical of dietary patterns high in fruits and vegetables and the presence of underlying conditions. To study these factors, the impact of background diet (high fat versus low fat), repeated exposure and presence of risk factors (obesity and diabetes) were investigated in animals and clinical settings. 10 day repeated dosing studies with grape polyphenols were conducted with Sprague Dawley (SD) and Zucker diabetic fatty rats. Background diet did not significantly impact anthocyanin or flavonol acute absorption or metabolism in SD rats. However, flavan-3-ol and flavonol bioavailability and metabolism were reduced in diabetic Zucker diabetic fatty rats relative to lean controls suggesting that obesity and diabetes might impact flavonoid bioavailability and metabolism. Similar results were observed in a pilot clinical with lean (BMI 23.5) and obese (BMI 30.5) participants. Following 11 day repeated dosing of grape polyphenols from Concord grape juice (20 oz/d), grape seed extract (900 mg/d) and resveratrol (250 mg/d) to grape polyphenols an increase in acute pharmacokinetic response was observed for catechin, epicatechin and quercetin in lean in-
individuals but not obese suggesting the potential for differential adaptation in the gut to flavonoid absorption in obese individuals.

Mechanisms of adaptation were explored using the Caco-2 human intestinal cell model. Findings suggest that repeated exposure to 1-10µM of flavonoids during differentiation of intestinal cells results in an enhancement of trans-epithelial transport over time despite a tightening of tight junctions. Changes in xenobiotic and metabolizing systems (COMT, ABCC2 and ABCB1) were observed from exposure to flavonoids and extracts which suggest that repeated exposure to flavonoid rich foods may alter gut function and response to flavonoids. Overall, it is apparent that both food and physiological factors can alter bioavailability and metabolism of flavonoids and that adaptation to flavonoid dietary exposure must be considered as a factor in the study of association to disease risk and outcomes.

**Keywords:** Flavonoids; Bioavailability; Metabolism; Food Matrix; Adaptation

**Conflict of Interest disclosure:** Corporate Advising/Board Service: Coca Cola Company. Sensient Technologies. Welch's Foods

Research Funding: Alliance for Potato Research and Education. Welch's Foods. General Mills. McCain Foods. Pepsico Global. USDA. USAID. NIH

Travel Support: Tate & Lyle

**Further collaborators:** Dr. Elsa Janle. Department of Nutrition Science. Purdue University. Dr. Janet Novotny. Research Physiologist. USDA-ARS Beltsville Human Nutrition Research Center

## POLYPHENOLS AND INTESTINAL FUNCTION: LOCAL AND SYSTEMIC EFFECTS

Oteiza, Patricia.

Ph.D. Professor. Department of Nutrition. University of California. Davis. USA.

The intestinal epithelium is not only the place of nutrient absorption, but it is also the first barrier against the systemic entrance of microbiota-derived and food toxins, The gastrointestinal tract (GIT) also exerts major immunomodulatory actions, regulates energy metabolism, and hosts the microbiota, which plays a central role in gut physiology. The GIT is exposed to large amount of flavonoids present in foods, which can exert local effects as parent compounds, or can be transformed by the microbiota to bioactive metabolites. Current evidence supports the concept that flavonoids and their metabolites may have significant health effects at the GIT by: i) preserving the functionality of the intestinal barrier, ii) regulating fat absorption, iii) regulating energy metabolism (e.g. by modulating the release of incretins and GIT hormones), iv) shaping the gut microbiota, and v) exerting anti-colorectal cancer (CRC) actions. Among the multiple types of existing flavonoids, the flavanol (-)-epicatechin (EC) and its polymers, the procyanidins (PACs), and anthocyanins (AC) are among the most abundant in human diets. These polyphenols protect the intestinal epithelium from different aggressors, including pro-inflammatory cytokines, bile acids and high fat diets. The capacity of AC and EC to prevent intestinal

permeabilization and the associated increased transfer of luminal bacterial endotoxins into the circulation (endotoxemia), underlies in part their capacity to prevent steatosis and insulin resistance in high fat diet-fed mice. AC and EC also increase the circulating levels of glucagon-like peptide-1 (GLP-1) and 2 (GLP-2), which improve glucose homeostasis and have trophic effects on the GIT. AC and PAC also modulate the GIT physiology by positively modulating the microbiota ecology and exerting anti-inflammatory and anti-CRC actions. In this regard, PAC interacts with select areas of the epithelial cell membranes, inhibiting inflammatory, proliferative and anti-apoptotic cell signals. In summary, flavonoids can have significant beneficial effects at the GIT that may be relevant not only locally, but can also extend to systemic health benefits, including an improvement of Western style diets-induced insulin resistance and steatosis.

**Keywords:** Flavonoids, polyphenols, intestine, bioactives, microbiota

## POLYPHENOLS AND GUT MICROBIOME FOR A HEALTHY AGING. EVIDENCE FROM CLINICAL STUDIES

Polyphenol-rich foods and polyphenol-rich diet may affect the development of age-related diseases, and therefore lifespan. There are, however, a number of limitations related to epidemiological studies concerning the associations between diet and healthy aging. One of the causes of these limitations is the multi-factorial complexity of accurately assessing dietary exposure. Therefore, nutritional biomarkers are increasingly used in current research.

Our findings in InCHIANTI study increasing evidence on the protective effects of total polyphenols, and indirectly, diets with polyphenols rich foods like fruit and vegetables and some beverages such as red wine, against cognitive decline and overall mortality.

Our results also demonstrate the importance of assessing the intake of polyphenols, whenever possible, using nutritional biomarkers and not only by dietary questionnaires.

**Keywords:** Polyphenol, microbiota, mortality, InChianti study, Metabolomics, frailty, microbiota, mediterranean diet

<footnote>(1)Andres-Lacueva, Maria Crisitina; (2)Rabassa, Montserrat;</footnote>

<footnote>(3)Zamora-Ros, Raul; (4)Urpi-Sarda, Mireia; (5)Bandinelli, Stefania;</footnote>

<footnote>(6)Ferrucci, Luigi; (7)Cherubini, Antonio.</footnote>

<footnote>(1)University of Barcelona. Barcelona. Spain.; (2)Biomarkers and Nutrimetabolomics Laboratory. Department of Nutrition, Food Sciences and Gastronomy. Faculty of Pharmacy and Food Sciences. University of Barcelona. Spain.; (3)Unit of Nutrition and Cancer. Cancer Epidemiology Research Programme. Catalan Institute of Oncology. Bellvitge Biomedical Research Institute (IDIBELL). Barcelona. Spain.; (4)Biomarkers and Nutrimetabolomics Laboratory. Department of Nutrition, Food Sciences and Gastronomy. Faculty of Pharmacy and Food Sciences. University of Barcelona. Spain. CIBERFES.; (5)Geriatric Unit. Azienda Sanitaria Firenze. Florence. Italy.; (6)Clinical Research Branch. National Institute on Aging. NIH. Baltimore. Maryland. United States.; (7)Geriatrics and Emergency Care. Italian National Research Centre on Aging (INRCA). Ancona. Italy.</footnote>
**Further collaborators:** Patricia Casas, Nicole Hidalgo, Raul González, Alex Sánchez, Antonio Miñarro, Biomarkers and Nutrimentabolomics Laboratory, Department of Nutrition, Food Sciences and Gastronomy, Faculty of Pharmacy and Food Sciences, University of Barcelona, Spain. CIBERFES

## FLAVANOLS AND VASCULAR FUNCTION: FROM HYPERTENSION TO KIDNEY FILTRATION

Flavanols are under active research as responsible for the beneficial effects on human health associated to the consumption of certain fruits and vegetables. Particularly, the effects on vascular function constitute a relevant topic and are being thoroughly studied because on their potential impact decreasing the prevalence and incidence of hypertension and its related diseases, including kidney dysfunction.

We have extensively studied the vascular protection by (-)-epicatechin (EC) in rodents subjected to dietary overload with both fructose and fats. In both conditions the main effects of dietary EC were associated with decreasing oxidative stress, inflammation, and maintaining functional levels of nitric oxide (NO).

In rats overloaded with fructose (condition that mimics most of the features of the metabolic syndrome in humans) was observed increase in the blood pressure in association with a compromised NO bioavailability at vascular level. Concomitantly, there was a development of kidney functional alterations, evaluated as the presence of mild proteinuria, as well as renal cortex fibrosis, decreases in nephrin, synaptopodin, and WT1 (all indicators of podocyte dysfunction), increased markers of oxidative stress, and development of pro-inflammatory conditions, manifested as NF-κB activation, and higher expression of TNFα, iNOS, and IL-6. Dietary supplementation with EC prevented or ameliorated most of these adverse effects of high fructose consumption.

When analyzed in terms of biochemical mechanisms, it is possible to hypothesize that all these effects are consequence of the regulation of the tissue production of NO and superoxide anion by EC: i) NO generation through NO synthases, ii) superoxide anion, essentially produced by NADPH-oxidases, and iii) the resultant balance considering the high rate of reaction between NO and superoxide anion.

In summary, our results suggest that EC ingested through the many fruits and vegetables that contains it, would protect the vascular and kidney function of patients with metabolic diseases. This information can be valuable to design nutritional approaches with scientific bases to modify the development of silent conditions that when chronically established develop in disease and pathological conditions.

**Keywords:** Epicatechin; nitric oxide; NADPH-oxidase, inflammation.

## SHOULD WE EAT MORE POLYPHENOLS?

Fraga, Cesar G.

Professor. Universidad de Buenos Aires. Facultad de Farmacia y Bioquímica. Fisicoquímica. IBIMO. UBA-CONICET. Buenos Aires. Argentina.

Major research efforts are currently aimed to identify healthy foods and healthy food components. The overall purpose is to design appropriate dietary strategies that positively influence the quality of life. Plants are substantial sources of compounds that once in our body can interact with the biological machinery. One of the most robust recommendations for improving health is to increase the intake of fruits and vegetables. Based on the premise that different plants contain different bioactives, it is crucial to identify the substances that can better act against pathological conditions. Our research is focused on characterizing select polyphenols, e.g. (-)-epicatechin (EC), as bioactives. That is, to find biochemical mechanism(s) that could explain EC physiological effects considering its actual presence in human tissues (ADME). These mechanistic data together with epidemiological and clinical studies would finally define evidence based recommendation for populations. In this road to define the need for establishing recommendations for EC consumption, it is today accepted: a) the consumption of EC-containing foods has no known undesirable effects; b) the consumption of EC has been epidemiologically and clinically ascribed to lower risk of disease or decreased markers of disease; c) there are several biochemical mechanisms in which the actions of EC are well characterized; and d) there is a consistency between clinical data, in which EC is mostly treated as a drug, and the dietary consumption of EC by human populations. Overall, the consumption of EC as well as of other polyphenols could help to prevent, delay, or ameliorate diseases, especially those that progress silently during life. Establishing the amounts of these polyphenols needed to exert such health effects is conditioned by the absence of formal evaluative processes that quantitatively establishes the importance of these bioactives.

Supported by PICT 2012-0765 (ANPCyT) and UBACYT 20020160100132BA, Argentina; Packer-Weiss Endowment (USA).

**Keywords:** Flavanols. Flavonoids. Antioxidants. Inflammation. Chronic diseases.

<footnote>(1) Galleano, Monica; (2) Prince, Paula Denise; (2) Litterio, Maria Corina;</footnote>

<footnote>(2) Fischerman, Laura; (2) Piotrkowski, Barbara.</footnote>

<footnote>(1) Universidad de Buenos Aires. Facultad de Farmacia y Bioquímica. Fisicoquímica. IBIMOL. CONICET. Buenos Aires. Argentina;</footnote>

<footnote>(2) Universidad de Buenos Aires. Facultad de Farmacia y Bioquímica. Fisicoquímica. IBIMOL. CONICET. Buenos Aires. Argentina.</footnote>
EGGS IN EARLY COMPLEMENTARY FEEDING AND CHILD GROWTH: A RANDOMIZED CONTROLLED TRIAL

(1)Iannotti, Lora; (2)Lutter, Chessa; (3)Stewart, Christine; (4)Gallegos, Carlos Andres; (5)Malo, Carla; (6)Reinhart, Gregory; (6)Palacios, Ana; (5)Karp, Celia; (1)Chapnick, Melissa; (1)Cox, Katherine; (5)Waters, William.

(1)Washington University in St. Louis. United States; (2)University of Maryland. United States.; (3)University of CA. Davis. United States.; (4)Washington University in St. Louis. Universidad San Francisco de Quito. Ecuador; (5)Universidad San Francisco de Quito. Ecuador.; (6)The Mathile Institute. Ohio. United States.

**Background:** Eggs are a comprehensive source of nutrients for growth and development. We hypothesized that introducing eggs early during complementary feeding would improve child nutrition.

**Methods:** A randomized, controlled trial was conducted in Cotopaxi Province, Ecuador from March-December 2015. Children ages 6-9 months were randomly assigned to treatment, one egg per day for 6 months (n = 83), and control, no intervention (n = 80) groups. Both arms received social marketing messages to encourage participation in the Lulun Project ("egg" in Kichwa). All households were visited once per week to monitor morbidity symptoms, distribute eggs and monitor egg intakes (for egg group only). Baseline and endpoint outcome measures included anthropometry, dietary intake frequencies, and morbidity symptoms.

**Results:** Mothers or other caregivers reported no allergic reactions to the eggs. Generalized linear regression modeling showed the egg intervention increased length-for-age z score by 0.63 (95% confidence interval [CI], 0.38-0.88) and weight-for-age z score by 0.61 (95% CI, 0.45-0.77). Log-binomial models with robust Poisson indicated a reduced prevalence of stunting by 47% (prevalence ratio [PR], 0.53; 95% CI, 0.37-0.77) and underweight by 74% (PR, 0.26; 95% CI, 0.10-0.70). Children in the treatment group had higher dietary intakes of eggs (PR, 1.57; 95% CI, 1.28-1.92) and reduced intake of sugar-sweetened foods (PR, 0.71; 95% CI, 0.51-0.97) compared to control.

**Conclusions:** The findings supported our hypothesis that early introduction of eggs significantly improved growth in young children. Generally accessible to vulnerable groups, eggs have the potential to contribute to global targets to reduce stunting.

**Keywords:** Eggs, complementary feeding, growth, stunting

**Conflict of Interest disclosure:** At the time of the study, Gregory Reinhart and Ana Palacios worked for The Mathile Institute, which funded the study. The Mathile Institute has no vested interest in the outcome(s) of the study. The Mathile Institute is a not-for-profit organization that financially supports basic research in the global nutrition sector pertaining to infant and young children nutrition. The other authors have no conflicts of interests.

BIOLOGICAL PATHWAYS THROUGH WHICH EGGS MAY INFLUENCE CHILD GROWTH AND DEVELOPMENT

Stewart, Christine.

PhD. Associate Professor. Dept of Nutrition. University of California, Davis. USA.

**Background:** Child stunting is a problem of public health significance in many low and middle-income countries. Animal source foods may be particularly important for child nutrition, particularly early during the complementary feeding period when nutrient requirements are high. Recent evidence has suggested that eggs may improve child growth in populations at high risk of stunting.

**Methods:** 163 infants aged 6-9 months were recruited into a randomized controlled trial with two groups: 1) Egg intervention: one egg per day for 6 months or 2) Control: usual diet. Blood samples were collected at baseline and after 6 months of intervention to measure choline and related metabolic pathways, essential fatty acids, long-chain polyunsaturated fatty acids, vitamin B12, and retinol concentrations.

**Results:** Infants in the egg intervention group had higher concentrations of choline, betaine, trimethylamine N-oxide (TMAO), and dimethylamine (DMA); docosahexaenoic acid (DHA), and some amino acids, notably aspartic acid (all p<0.05). Phosphatidylcholine concentrations were lower in the egg group compared to controls. Choline, DHA, and histidine concentrations were all significantly associated with lower odds of stunting and were potential mediating factors of the egg intervention on improved growth.

**Implications:** Eggs are a rich source of choline, essential amino acids, essential fatty acids, and micronutrients all of which may be associated with improved growth. Effects may be mediated through insulin-like growth factor-1 (IGF-1) stimulation, the one-carbon metabolic cycle, or through anti-inflammatory pathways.

**Keywords:** Eggs, growth, choline, amino acids, docosahexaenoic acid

PUTTING OUR EGGS IN MORE THAN ONE BASKET – LESSONS LEARNED FROM WORKING WITH MULTIPLE SECTORS IN RURAL GHANA

(1)Marquis, Grace; (2)Colecraft, Esi; (3)Aryeetey, Richmond; (4)Aidam, Bridget; (5)Kanlisi, Roland.

(1)PhD. Associate Professor. School of Human Nutrition. McGill University. Canada.; (2)PhD. Lecturer. Department of Nutrition and Food Science. University of Ghana. Ghana.; (3)PhD. Senior Lecturer. School of Public Health. University of Ghana. Ghana.; (4)PhD. Senior Research & Evaluation Advisor. Evidence & Learning Unit. World Vision International. USA; (5)Country Representative. Heifer. Ghana.

**Background:** The diet of infants and young children (IYC) is influenced by policies and programs of multiple sectors, includ-
ing health, agriculture, and finance. Collaborative and complementary initiatives are needed to develop effective approaches to improve child nutrition in rural Ghana where families face challenges linked to endemic poverty, erratic weather, and limited and uncoordinated district resources.

**Methods:** Nutrition Links is a 5-y project to improve the well-being of vulnerable rural populations, including IYC, in the Upper Manya Krobo district of Ghana. Three of six sub-districts were selected for a cluster randomized trial to test the effect of a 12-month integrated intervention on child nutrition. Forty-three communities were randomly assigned to the intervention or control arm. Enrollment occurred in two phases, one year apart, using the Heifer 'pass-on-the-gift' model (participants pay back inputs to fund others). The study included 316 (phase-1) and 185 (phase-2) households.

The intervention used a multi-level, multi-sector approach. District-level training to build capacity of frontline workers and harmonize knowledge on nutrition, disease control, gender, and data analysis was provided for staff from agriculture, health, education, finance, and local governance institutions. At the community level, nutrition/health, agriculture, and gender education was provided for residents of intervention communities. At the household level, the intervention included income-generating activities (IGA), promotion of gardens, and related education. The central IGA was poultry farming for egg production. Caregivers received 30-40 hens, initial inputs, weekly technical assistance, and facilitated market access. A second IGA, beekeeping, was primarily taken up by men in phase-1 intervention households. Home gardens were supported with planting materials and training to increase access to micronutrient-rich vegetables. Weekly group education sessions on nutrition, health, and child stimulation promoted optimal caregiving behaviors. Caregivers were encouraged to feed children eggs and diversify the diet. Children's diet on the previous day and anthropometric measurements were documented at baseline and endline; data from both phases will be presented.

**Results:** Less than one-fifth of infants in phase-1 consumed eggs the previous day at baseline (14% intervention, 20% control; $p=0.16$). The poultry IGA rapidly increased the percent of children consuming eggs (61% intervention, 27% control; $p<0.001$). For children who already consumed eggs at baseline, the prevalence at endline of phase-1 was similar for both study arms (52-54%). However, for children with no egg consumption at baseline, 60% more children were reported to consume eggs in the intervention than control group (27% vs. 17%; Mantel-Haenszel $p<0.01$). In-take of eggs was associated with higher BMI (difference = +0.25; $p<0.05$).

Conclusions. Finding the winning mix of interventions that addresses the multiplicity of contributors to childhood malnutrition is challenging. The benefit associated with egg consumption corroborates the value of increasing accessibility to eggs as one of a mix of interventions that can be supported through the presence of multiple sectors in rural communities. Nutrition Links is registered at Clinical Trials (NCT01985243); partially funded by Government of Canada.

**Keywords:** Eggs, diet, children, rural, Ghana,

# SOCIAL MARKETING TO BUILD COMMUNITY ENGAGEMENT IN NUTRITION-SENSITIVE AND NUTRITION-SPECIFIC INTERVENTIONS

(1)Gallegos, Carlos Andres; (2)Waters, William F.; (3)Lutter, Chessa;

(4)Stewart, Christine.; (5)Iannotti, Lora.

(1)PhD Student. Brown School of Social Work. Washington University in St. Louis. Research Associate. Institute for Research in Health and Nutrition. Universidad San Francisco de Quito. Ecuador; (2)PhD. Professor. Institute for Research in Health and Nutrition. Universidad San Francisco de Quito. Ecuador; (3)PhD. Visiting Research Professor. School of Public Health. University of Maryland. Maryland. United States.; (4)PhD. Associate Professor. Department of Nutrition. University of California. United States; (5)PhD. Associate Professor. International Nutrition. Brown School of Social Work. Institute of Public Health. Washington University in St. Louis. United States.

**Background:** Social marketing (SocMkt), a sub-discipline of social psychology, applies a multidisciplinary approach that integrates commercial marketing techniques with other bodies of knowledge in order to promote voluntary prosocial behavior in targeted audiences. In the Lulun project, we developed a SocMkt strategy that accompanied a randomized controlled trial (RCT) to test an egg-based intervention in five rural indigenous parishes in the Ecuadorian highlands. This campaign drew from our previous SocMkt experience in a comparable sociodemographic context, which showed that nutrition interventions are effective when participants become project owners. Effective SocMkt should respond to social realities that recognize cultural norms and values as well as opportunities and barriers that participants face. Our strategy aimed to empower participants and generate solutions for methodological RCT challenges, fieldwork complexity, and potential difficulties.

**Methods:** Our targeted audiences included caregivers of eligible children and other stakeholders such as community leaders. The design and implementation of the strategy was shaped by a creative process developed from market research, which accounted for culture, worldviews, sense of aesthetics, and local expectations. Key outcomes included a communication plan and the "Lulun Project" brand. In tandem with the implementation of the RCT, the SocMkt strategy contained four campaigns: outreach; recruitment; intervention promotion; and project closing. Each campaign was based on specific messages, promotional materials, and activities, which were designed to systematically stimulate behavior change from an isolated event ("giving one full egg to a 6 to 9 months' child"), to the establishment of a habit ("a full egg a day every day"), and ultimately as practice ("a full egg a day should be given to children 6-9 mo. to improve their nutrition").

**Results:** SocMkt implementation was instrumental for overcoming factors beyond our control (e.g. the eruption of the nearby Cotopaxi volcano), protecting the integrity of the RCT, and responding to concerns in the community around methods applied (e.g. blood collection, perceptions of inequity among caregivers with control group children, and negative rumors). Our strategy was directly linked to four interconnected effects. First, the Lulun Project received targeted audiences' loyalty, giving us a compet-
itive advantage in the project's market, where other agents who also seek the loyalty of the target group interact. Second, participants were empowered, as reflected in their narratives, low attrition levels (7%,) and attendance in activities. Third, the strategy influenced behavioral change, as demonstrated by high treatment compliance and low contamination in the control group (n= 80). This was monitored through weekly household visits, health outcomes attained, and attitudes and practices analyzed in qualitative research. Fourth, based on the results of the Lulun project and its SocMkt strategy, Ecuador's Ministry of Health policy changed guidelines regarding the introduction of eggs in complementary diets.

**Conclusions:** Our SocMkt experience offers theoretical and methodological value to the SocMkt sub-discipline as a whole. The strategy was central to the success of this highly effective nutrition intervention. Furthermore, the SocMkt strategy allows for the possibility for scaling up the egg intervention in the region and beyond.

**Keywords:**

Social marketing; behavior change; randomized controlled trial (RCT); rural Ecuador; child nutrition

**Conflict of Interest disclosure:** The study was funded by the Mathile Institute, which has no vested interest in the outcomes of the study. The authors have no conflicts of interests.

## ONE ACRE FUND: SCALING UP SMALLHOLDER FARMERS' ACCESS TO POULTRY IN EAST AFRICA

(1)Youn, Andrew; (2)Lloyd, Emily.

(1)Co-Founder. One Acre Fund. Rwanda.; (2)MSPH. Global Nutrition and Health Lead. One Acre Fund. Rwanda.

Poultry and eggs are unrivaled sources of micro- and macronutrients for undernourished populations, yet how to make poultry accessible and affordable to remote communities remains unknown. Smallholder farmers face difficulties buying, feeding, housing, and vaccinating non-indigenous poultry breeds that are healthier and more productive than indigenous breeds. One Acre Fund aims to offer improved poultry species for purchase on credit to over 500,000 East African farmers. These efforts revolve around ongoing poultry trials in western Kenya.

Phase 1 Trials compare chicken breeds and feeding regimens. We are evaluating growth, egg laying, morbidity, and mortality between breeds Rainbow Rooster, Kruoiler, KALRO and local. Chickens at research stations and on farmers' properties were divided into three groups and fed three different diets: commercial feed, scavenging, and commercial feed plus scavenging. Early results reveal best weight gain in Rainbow Rooster and Kruolier. Group 1 (commercial feed) chickens were heaviest and little difference was seen between Group 2 (scavenge only) and 3 (scavenge plus feed). Data is also being collected on poultry mortality, disease resistance, egg laying, farmer taste preference, and price valuation.

Phase 2 Trials gave farmers in Kakamega District, Kenya, the opportunity to purchase four Rainbow Rooster hens and one

rooster for 25 USD. 250 enrolled farmers received the chickens and 250 will serve as a control and not receive chickens. Poultry weight, mortality, health and expense of health items, and egg laying will be monitored until July 2018.

Scale-up will continue with the Phase 3 Trial in which 1500 Kenyan farmers purchase five chickens on credit. The aim of this trial is verifying Rainbow Rooster's performance in the field and our ability to operate this program on a large scale. We aim to distribute poultry at scale in Kenya by 2020, offering five chickens and a small amount of feed on credit to all farmers in all districts with an expected 10-15% adoption rate. Additionally, in 2017 we began trialing fortified chicken feed to enhance egg nutrition, laying, condition and size. We are considering establishing our own hatching and brooding center to reduce costs and ensure adequate supply and timely delivery of healthy birds. Finally, we may create a buy-back program for farmer's chickens and eggs, an idea that has received interest from businesses seeking chicken suppliers.

Several challenges were faced during these trials. Before we located a large poultry supplier 2-3 hours from farmers, long transport times from supplier to farmers made chickens stressed and tired on arrival. We also had to adapt logistic and delivery system to handle live poultry distribution, new protocols, tracking methods, and reconciliations and returns of dead birds.

Successful scale-up of the poultry trials would result in healthy, productive, and vaccinated poultry being accessible to smallholder farmers across Kenya. These farmers would also receive financing and trainings on poultry housing and cost-effective feeding. One Acre Fund is establishing a model for scaling up poultry access to vulnerable and undernourished populations across sub-Saharan Africa that we hope will be widely replicated.

**Keywords:** Poultry, eggs, Kenya, micronutrients

**Conflict of Interest disclosure:** Supported by Children's Investment Fund Foundation (CIFF)
# Track 7: Food Culture Practices and Nutritional Education

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## NUTRITIONAL EDUCATION IN SPAIN & FESNAD PROJECTS

### ANALYSIS OF NUTRITIONAL PATTERNS FOR A PRECISION NUTRITION

(1)San-Cristobal, Rodrigo; (2)Navas-Carretero, Santiago; (2)Martínez, J. Alfredo.

(1)PhD student. Nutritionist. Department of Nutrition, Food Science and Physiology. Center for Nutrition Research. University of Navarra. Pamplona. Spain.; (2)PhD. Nutrition. Department of Nutrition, Food Science and Physiology. Center for Nutrition Research. University of Navarra. Pamplona. Spain.

Chronic diseases such as obesity, diabetes, dyslipidemia, and hypertension are characterized by nutritional imbalances or by the need to adjust and manage nutrient intake to specific requirements to counteract the associated metabolic dysfunctions. Dietary intake assessments have conventionally been more orientated on macronutrient/micronutrient supply and seldom on food dietary patterns. Currently, there are some epidemiological and statistical approaches enabling to screen the dietary quality and variety on a population, in order to provide nutritional guidelines for healthy nutrition and safe nutritional intervention programs. Actually, observational and association studies considering dietary patterns and the prevalence/incidence of different metabolic diseases are allowing to identify and define metabolic derangements accompanying chronic unhealthy dietary habits. Potential suitable tools to be applied for the characterization of dietary patterns are diverse, but health professionals and policy makers must distinguish those that are appropriate for each occasion. The design of scores or nutritional indices allow finding out the role of the adherence to a specific dietary pattern on health outcomes, whereas bio-statistical strategies based on cluster, principal component, factor analysis or reduced rank reduction tests allows to determine the onset of dietary patterns within a specific population or nutritional exposures that contribute to prevent obesity and metabolic syndrome associated manifestations. A factor analysis concerning food intake to feature those patterns in a Spanish population interested in an online Personalised Nutrition program (Food4Me) was performed. Food items were branded according to nutritional value to carry out the nutritional profile analysis. After the food patterns were defined, results based on the differences in macronutrient distribution between these dietary patterns were re-appraised. Thereafter, association studies between such dietary patterns and reliable anthropometric determinations were implemented to find out potential relationships. The factor analysis statistical strategy produced two quite different regimes; the first one was mainly consti-

tuted by high energy yielding foods, and the second one, featured a higher consumption of vegetables or fruits and seafood products. When the patterns were independently assessed, contrasting trends between both analyses and body adiposity (BMI) were found, although they followed the expected tendency, respectively. Nevertheless, those studies considering with both patterns showed interesting interactions with specific nutrients. Quantitative and qualitative analyses concerning food consumption may assist not only to understand the relationships between nutrition and health issues, but also to prevent the onset and development of chronic diseases as well as to detect specific nutrients that may be metabolically protective for a given population. The assessment of the dietary adherence could be helpful for the design of screening tools and algorithms in Personalised Nutrition evaluation, in order to identify nutritional targets to be precisely approached in every person.

San-Cristobal R, et al. Analysis of Dietary Pattern Impact on Weight Status for Personalised Nutrition through On-Line Advice: The Food4Me Spanish Cohort. Nutrients 2015;7:9523-37.

Celis-Morales C, et al; Food4Me Study. Effect of personalized nutrition on health-related behaviour change: evidence from the Food4Me European randomized controlled trial. Int J Epidemiol. 2016 Aug 14. pii: dyw186.

**Keywords:** Obesity, Diabetes, Dyslipidemia, Macronutrient distribution, Diet

## HEALTHY FOOD FOR PREGNANT AND LACTATING WOMEN. ACTIVITIES RELATED TO THE NATIONAL NUTRITION DAY

Arija, Victoria.

Professor of Preventive medicine and public health. Faculty of Medicine and Health Sciences. Rovira i Virgili University. Tarragona. Spain.

Given the importance of food and nutrition for the health of the population, the Federation of Societies of Nutrition, Food and Dietetics (FESNAD) has developed one of its objectives over nutritional education for the population, celebrating every year the National Nutrition Day (NND), since the year 2003.

Among the different campaigns, FESNAD recently focused its campaign on healthy eating for pregnant and lactating women, given the importance it has for their health and the health of their baby. The growth and development of the baby from the embryonic and fetal stage and during the first year of life is a critical period of extreme vulnerability, especially dependent on the environmental factors that surround the mother, with nutritional intake being one of the most important.

To carry out of the NND campaign, FESNAD conducted a survey on eating and healthy lifestyles in a national sample of women of childbearing age, in order to know their knowledge, habits and attitudes regarding feeding during gestation and lactation, at the same time what was done an update of the scientific evidence on the subject.
The scientific evidence and guidelines of the main international organizations were reviewed on the following sections: energy recommendations and weight control during gestation, as well as nutritional recommendations during gestation and lactation, focusing on the iron and folate status, and their patterns of supplementation during gestation. Evidence on dietary patterns and habits, as well as other lifestyles strongly related to maternal and child health, was reviewed.

Subsequently, all the information obtained in the survey of pregnant and lactating women, as well as the proximity of their knowledge, habits and attitudes to the most appropriate, according to scientific evidence, were evaluated.

From the understanding of all the information, the key points of education were formulated, while the most adequate messages were defined for the realization of the campaign of health promotion adapted to the reality of our environment.

Different materials were made with this information: posters, triptychs, slides of a presentation. The dissemination of the NND was carried out among professional groups of education, health, business, etc ...; Who are invited to perform a nutritional education activity on the subject of DNN-15 in their professional or personal environment. For this they were provided, printed and online, the material designed for the campaign.

In the NND on Healthy Foods for pregnant and lactating women, different materials were distributed throughout the Spanish territory, with more than 300 activities being carried out in different centers and institutions. The activities were directed to small and large groups of the population in general, school or university students, members of associations, workers of companies, users of primary care, etc.

**Keywords:** FESNAD, nutritional education, pregnant, lactating

**Further collaborators:** Director of FESNAD in 2015: President: J Salas-Salvadó (SENPE), Vice-president: MD Romero de Ávila (ALCYTA), Treasurer: A Villarino (SEDCA), Secretary: V Arija (SENC), Members: I Bretón (SEEN), JJ Díaz (SEGHNP), R Farré (SEÑ), M López-Pardo (ADENYD), S Monereo (SEEDO).

Director of FESNAD in 2017: President: A Marcos (SEÑ), Vice-president: I Bretón (SEEN), Treasurer: I Polanco (SEGHNP), Secretary: V Arija (SENC), Members: A Villarino (SEDCA), M López-Pardo (ADENYD), Sánchez I (ALCYTA), Ashbaugh R (SENPE).

• Asociación de Enfermeras en Nutrición y Dietética (ADE-NYD)

• Asociación Española de Licenciados, Doctores y Graduados en Ciencia y Tecnología de Alimentos. (ALCYTA)

• Sociedad Española de Dietética y Ciencias de la Alimentación (SEDCA)

• Sociedad Española de Endocrinología y Nutrición (SEEN)

• Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediátrica (SEGHNP)

• Sociedad Española de Nutrición (SEÑ)

• Sociedad Española de Nutrición Comunitaria (SENC)

• Sociedad Española de Nutrición Parenteral y Enteral (SENPE)

## NUTRITIONAL EDUCATION AT SCHOOL

Polanco, Isabel.

Full Professor of Pediatrics. School of Medicine. Autonomous University. Madrid. Spain.

Scientific evidence supports that prevailing food patterns and physical activity during infancy and childhood influence growth and development; have an impact on health not only during this period of life, but also on the potential development of risk and protective factors related to the onset of chronic diseases later in adulthood. Programs on nutritional education have been widely used for teaching or reinforcing knowledge on food habits or healthy life styles in children and are considered a useful strategy to prevent the appearance of nontransmissible chronic diseases at early ages. The implementation of nutritional education programs in schools may help to inculcate in children the ability of identifying a healthy food choice for themselves.

It has been established that the triangulation of information amongst the teacher, the children, and the family is a useful strategy for modifying negative feeding behaviors that are contributing to the recent increase in the prevalence of overweight, obesity, hypertension, diabetes, and metabolic syndrome in children, while in the opposite extreme of the spectrum, nutritional deficits persist as important nutritional problems, especially regarding micronutrient, and vitamin deficiencies such as iron, calcium, folic acid, and vitamin A, among others.

The inclusion of nutritional education into formal education programs is one of the most used and recommended strategies, mainly because the children obtain and fix the information in a easy, fun, and permanent way, but also because they act as multipliers of the information, bringing the new information to their homes to achieve, in the best case scenario, the transmission of the information to the whole family group.

Some studies indicate that to obtain a better impact on changing habits on the long term, nutritional education programs must include the whole community, to assure the permanence of changes.

**Keywords:** Nutritional education; schools; healthy eating practices; educational strategies

## HOSPITAL DIETOTHERAPY AND UNDERNUTRITION. EDUCATING PROFESSIONALS

Ashbaugh Enguídanos, Rosa Ana.

Nurse. Nutrition and dietetics service. Hospital Príncipe de Asturias University. Alcalá de Henares. Madrid.Spain.

The hospital food presents characteristics that make it unique in the context of collective catering. It is not just about offering a catering service. It has to translate the science of nutrition into medical therapy. On the other hand, hospital feeding must provide all its technique to get the patients admitted to the hospital receive that nutritional therapy with quality to achieve an adequate food
intake. This is not an easy job because of the patient's own pathological process.

It should always be taken into account that in developed countries there is a significant percentage of patients admitted to hospital with malnutrition, which is not diagnosed as such, and which, in addition to its acute pathology, causes the patient's clinical situation to worsen.

To this must be added the appearance of new cases of malnutrition among the population admitted. All these situations constitute a worrying scenario of great clinical significance.

We must know that hospital feeding is a complex process where the science of nutrition, dietetics, bromatology and hotel techniques are united. This food service should contribute to the recovery of patients and to provide a level of well-being (everyone knows that food is a factor that influences the concept of patients in the hospital).

Nutrition occupies an important place in health and throughout the history of medicine the prescription of adequate food has been part of the treatment of patients.

The diary code: is the document where all diets available in each center are recorded

The philosophy that governs the preparation of a therapeutic diet responds to two general lines. The first one focuses on the patient's education regarding the principles of proper nutrition, while the other is about providing foods that the patient can eat and enjoy. There is usually a compromise between the two trends, taking into account that:

Energy and nutrient needs must be met according to the clinical situation.

It must provide a sufficiently broad and varied diet

It will represent a rewarding action.

Must have an appropriate and attractive presentation

The habits of the patient, their tastes, religious beliefs and any other factors that may influence the acceptance or rejection of the diet

**Keywords:** Dietotherapy, undernutrition, educating

## CONSENSUS ON FATS AND OILS IN THE DIET OF SPANISH ADULTS. POSITION PAPER OF THE SPANISH FEDERATION OF FOOD, NUTRITION AND DIETETICS SOCIETIES

In this consensus document the scientific evidence relating effects of dietary fat quantity and quality on cardiovascular risk is reviewed and recommendations for the Spanish adult population

are issued. As a novelty in nutrition guidelines, emphasis is made more on parent foods than on fatty acids per se. In summary, replacing saturated fatty acids (SFA) for monounsaturated fatty acids (MUFA) and polyunsaturated fatty acids (PUFA) reduces cardiovascular risk. Recent data suggest that SFA proper may be harmful or not depending on the parent food, a reason why an intake threshold is not established, but consumption of butter, processed meats, and commercial confectionery and fried foods is discouraged. The established threshold of <1% of energy intake as trans FA, well known to be harmful for cardiovascular risk, is fulfilled in Spain due in part to its present low levels in margarines. MUFA are beneficial or neutral for cardiovascular risk depending on their dietary sources (virgen olive oil versus other fats), and no intake limitations are established. n-6 PUFA are cardioprotective and recommended intakes (5-10% of energy) are not always fulfilled in the Spanish population, thus increased consumption of their vegetable food sources (seeds, derived oils, and margarines) is encouraged. Marine n-3 PUFA are also cardioprotective and the recommendation stands to eat fatty fish ≥2 servings/weeks to reach intake levels up to 1% of energy. Increasing evidence suggests that alpha-linolenic acid (ALA), the vegetable n-3 PUFA, is also cardioprotective, but the parent foods (walnuts, soy products, green-leaf vegetables) may provide benefits beyond ALA itself. Finally, low-fat (high carbohydrate) diets appear to lack cardiovascular preventive effects, while high-fat, high-vegetable fat dietary patterns such as the Mediterranean diet, are protective, a reason why a fat intake limit of up to 40% of energy is suitable for the Spanish population. This position statement targets dietitian, nutritionists and other health professionals involved in dietary counsel so they can deliver it rightly and according to the last scientific evidence

**Keywords:** Fats, consensus, Fesnad

## DAIRY PRODUCT CONSUMPTION AND RISK OF CARDIOVASCULAR DISEASES

Salas-Salvadó, Jordi.

Director of Human Nutrition Unit. Department of Biochemistry & Biotechnology. School of Medicine. Rovira i Virgili University. Reus. Spain.

Cardiovascular disease (CVD) is the responsible for 17.3 million deaths each year being the leading cause of mortality in the world. Dairy products has been suggested as a marker of diet quality and has been related with cardiometabolic health outcomes (1).

During the last years, consuming dairy products has been criticized by several nutritional and non-nutritional reasons without consistent scientific evidence. However, the consumption of dairy, including milk, cheese and yogurt has been associated with a reduced risk of several cardiovascular risk factors. The purpose of this presentation is to review the recent literature examining the relationship between dairy product consumption and the risk of type two diabetes (T2D), obesity, metabolic syndrome (MetS), hypertension (HT) and CDV.

High-quality evidence supports favorable associations between the consumption of milk, regular high-fat, low-fat and fermented

<footnote>(1)Riobó, Pilar; (2)Bretón, Irene; (3)Rubio, Miguel Ángel; (4)Gil, Ángel;</footnote>

<footnote>(5)Salas-Salvadó, Jordi.</footnote>

<footnote>(1)MD, PhD. Endocrinology and Nutrition Department. Jimenez Díaz Foundation. Spain.; (2)MD PhD. Endocrinology and Nutrition Department. Hospital Gregorio Marañón. Spain.; (3)MD PhD. Endocrinology and Nutrition Department. Clinical Hospital of San Carlos. Spain.; (4)PhD. Biochemistry Department. University of Granada. Spain.; (5)MD PhD. Nutrition Department. University of Reus. Spain.</footnote>
dairy such as cheese and yogurt and a reduced risk of T2D. The
most consistent inverse association has been reported for yogurt
consumption. In case of obesity, studies reflect that dairy con-
sumption is not positively related with changes in body weight.
Yogurt was the only dairy food that showed some evidence for a
beneficial effect, where higher intakes were inversely associated a
reduced risk of obesity, changes in body weight or waist circum-
ference (2).

Additionally, the last systematic review performed in seven prospective cohorts showed inverse associations between dairy products consumption and MetS incidence, especially in relation to yogurt intake (3). Moreover a favorable association between the consumption of dairy products, low-fat dairy, fermented dairy and cheese and the risk of HT. No association with of high-fat dairy, milk and yogurt and HT was found (4).

The newest systematic review indicates with moderate ev-
idence, neutral associations between the consumption of total
dairy, cheese, yogurt and CVD risk. Furthermore, with higher evi-
dence total dairy and milk consumption were positively associated
with lower risk of CVD.

In conclusion, intake of some type of dairy products seems to
be related with a lower risk of CVD and other cardiovascular risk
factors such as T2D, obesity, MetS and HT (10). Further research
in different populations are required to replicate and confirm
strongly all the published literature in reference to this issue.

References:

1. Cormier H, Thifault É, Garneau V, Tremblay A, Drapeau V, Pérusse L, Vohl MC. Association between yogurt consumption, dietary patterns, and cardio-metabolic risk factors. Eur J Nutr. 2016; 55(2): 577-87.

2. Schwingshackl L, Hoffmann G, Schwedhelm C, Kalle-Uhl-
mann T, Missbach B, Knüppel S, Boeing H. Consumption of Dairy
Products in Relation to Changes in Anthropometric Variables in
Adult Populations: A Systematic Review and Meta-Analysis of Co-
hort Studies. PLoS One. 2016; 11(6): e0157461.

3. Chen GC, Szeto IM, Chen LH, Han SF, Li YJ, van Hekezen R, Qin LQ. Dairy products consumption and metabolic syndrome in adults: systematic review and meta-analysis of observational studies. Sci Rep. 2015; 5: 14606.

4. Drouin-Chartier JP, Brassard D, Tessier-Grenier M, Côté JA, Labonté MÈ, Desroches S, et al. Systematic Review of the Association between Dairy Product Consumption and Risk of Cardiovascular-Related Clinical Outcomes. Adv Nutr. 2016; 15;7(6): 1026-1040.

**Keywords:** Dairy products, cardiovascular disease, cardiovas-
cular risk factors

**Conflict of Interest disclosure:** Professor Jordi Salas-Salvadó declares that he is a member of Danone S.A.'s Advisory Board, a member of the Danone Institute, and that he received payments from Danone S.A. for the purposes of scientific and technical consulting, but not for the preparation of this presentation.

STATEMENT ON OBESITY

Marcos, Ascensión.

Research Professor at the Spanish National Research Council (CSIC). President of the Spanish Federation of Nutrition, Food and Dietetics Societies (FESNAD). Spain.

The epidemics of obesity across the world is a big concern of public health associated to diverse disorders at a metabolic, social and mental levels. Over the last decades, the increase in obesity prevalence has been attributed to excessive intakes of calories within diets including low-density nutrients. Generally, obesity, as the excess of adipose tissue in the organism, is the consequence of the high consumption of macronutrients but with a suboptimal intake of micronutrients, together with distorted lifestyle habits. Weight management treatments for obese children and adolescents should aim to ensure adequate growth and development, by reducing excessive fat mass accumulation, avoiding loss of lean body mass, improving well-being and self-esteem and preventing cyclical weight regain. Nevertheless, there are also genetic and environmental factors that should be taken into account in efforts to tackle obesity. In the case there are no appropriate actions on time, this global crisis has been predicted to develop obesity in 2050 in 60% of male adults, 50% of female adults and 25% of children. The World Health Organization has defined childhood obesity as one of the most important health challenges for this century. One of each five European children is estimated to suffer from overweight and every year around half million children achieve more weight than they should for their age and height. Albeit the actual damage on the metabolism does not show up immediately at an early stage of life, the harm provoked by overweight has to be beard in mind from the beginning since "a posteriori" in the adulthood, the reactions can arrive too late. However, it is important to highlight that not everybody has the same predisposition to lose weight at the same level due to genetic agents. Therefore, with the aim to prevent obesity and maintain an adequate weight during the whole life, the main strategy to manage obesity at any age is to deliver an appropriate nutritional education among the general population, but taking into account the bases of personalized and precision nutrition.

**Keywords:** Nutritional education, obesity, strategies

REMARKS ON FESNAD FUTURE PROJECTS

Sanchez-Gonzalez, Ignacio.

PhD Food Science and Tech. Spanish Society of Food Science
and Tech. ALCYTA. Spain.

FESNAD arose with the spirit to gather all the organisations devoted to the Nutrition, Feeding and Dietary Sciences (NFDS). The general aim is to create a voice in order to have healthy life habits to improve and expand the hope and life quality (www.fes-nad.org).

The federation future projects are:
# 1. SCIENTIFIC ACTIVITIES

A) The National Nutrition Day (DNN). The line developed in DNN works with the food groups properly said. The 2018 DNN will be about legumes. Source of vegetal protein with equiparable quality to the meats and fishes, have an important percentage of soluble and insoluble fibre, (15-20 g/100 g). Have a low contribution of fats (2-5%). Consumption is associated, to a satiating effect and suggests that help in the weight loss, contribute to the colorectal cancer prevention, and have a reverse relation with the high levels of total cholesterol making a LDL-cholesterol decrease and a HDL-cholesterol increase. In summary, taking into account their properties, the important proteinaceous source regarding to the low content of fats, the high content in fibre (Fibre consumptions in Spain (18g/person/current day vs. 30 g/pers/day recommended) and a decrease in the recommended consumptions in Spanish people (1,5 weekly rations: vs 3-4 weekly rations recommended). FESNAD will develop this campaign to inform of the nutritional properties, culinary properties and good relation between nutritional quality and price.

B) NAOS Strategy: The obesity in the spanish chilhood is about (18-23 %) (10). Although all FESNAD projects include activities to eradicate it, we will develop collaborations with the AE-COSAN* to propose and establish new models of work to decrease the obesity percentage.

C) FESNAD Congress 2020: There are demands to organise an event that gathered to all the NFDS professionals. With this premise FESNAD develops a congress every five years, with more than 1000 participants. The next announcement will be in Zaragoza 2020. Our challenge is the creation of new research groups to improve the efficiency of resources and the scientific results.

D) Recommended rations (RR) for spanish people document. It exists a professionals needed to establish RR for menus (patients, commensals... or to the development of epidemoiology studies). There are some guides (SENC) but is complex to establish RR in function of physical activity, age, health, or even the culinary process... The changes in the habits and the diversity of opinions regarding the RR demand of a project with all professionals involved.

# 2. ACTIVITIES OF SCIENTIFIC MANAGEMENT

A) FESNAD has a system of accreditation and standardisation of external training activities. It realises an evaluation to the contents to obtain the greater scientific quality. www.fesnad.org.

B) To the achievement of point 1.D, FESNAD realise agreements for the adhesion of affine organisations involved in the NFDS. In this process will participate Professional Colleges, consumers organisations and professional Societies...

C) FESNAD participates like a scientific membership in the National Food Safety Day (DNSA). This proyect is a informative approach on the process involved in food chain (including consumer) in order to have a better food safety.

**Keywords:** NAOS, Zaragoza 2020, legumes, DNN

# Track 8: Agriculture, Food Science and Safety

SS_144/1020

## INNOVATIVE METHODS AND METRICS FOR AGRICULTURE AND NUTRITION ACTIONS

### DIAGNOSTICS TO SUPPORT THE IDENTIFICATION, DESIGN, AND EVALUATION OF INTERVENTIONS IN VALUE CHAINS TO IMPROVE DIETS OF LOW-INCOME POPULATIONS

(1)Gelli, Aulo; (2)Aberman, Noora-Lisa; (3)Donovan, Jason; (4)Margolies, Amy; (5)Santacroce, Marco.

(1)PhD. Nutrition. Poverty Health and Nutrition Division. IFPRI.
DC. USA.; (2)PhD. Malawi Country Programme Manager. IFPRI.
DC. USA.; (3)PhD. Agriculture Economics. ICRAF. DC. USA.; (4)PhD
candidate. Johns Hopkins University. USA; (5)MA. Economics.
IFPRI. USA.

Emerging evidence on the nutrition double burden suggests income growth alone cannot solve the problem of malnutrition and may in fact create problems linked to overweight and obesity. The challenge from the nutrition perspective is how to sustainably improve diets, as well as other health-related behaviors, across different low-income populations. In recent years, the nutrition community has explored value chain approaches to address malnutrition. The value chain framework focuses on the actors involved in the production, processing, trade, and consumption of a given product, and the opportunities to achieve beneficial economic outcomes for some or all of the actors through changes in the structures, systems, and relationships. Because value chains play a key role in determining food availability, affordability, and quality, they have a role in shaping diets and can contribute to improving nutrition. Most applications, however, have focused on a single chain and its implications for nutrition, which from a diet quality perspective implies a partial solution at best. The challenge lies in better understanding the options for leveraging a set of value chains (a multi-chain focus) to address the various constraints to improving the diets of a given target group. This case study from the Zomba District of southern Malawi applies data from household surveys, in-depth individual interviews, and market surveys to examine opportunities for improved diets through leveraging demand and supply of nutritious foods, and enhancing value chain performance with a nutrition lens. Preliminary results on bottle-necks and opportunities provide insights for policy and programs.

**Keywords:** Diagnostics, food policy, diets, markets.
# DEVELOPING AN INNOVATIVE APPROACH TO MEASURING THE LIVELIHOODS OF SMALLHOLDER FARMERS AND TESTING CRITICAL LINKAGES FROM FARMER LIVELIHOODS TO NUTRITION

(1)Jones, Andrew; (2)Somé, Jérôme; (3)Mensah, Edouard; (4)Blesh, Jennifer; (5)Dillon, Andrew.

(1)PhD. Assistant Professor. Department of Nutritional Sciences. University of Michigan. USA.; (2)PhD. In-Country Researcher. International Dietary Data Expansion (INDDEX) Project. Burkina Faso.; (3)MSc. PhD Student. Department of Agricultural, Food, and Resource Economics. Michigan State University. USA.; (4)PhD. Assistant Professor. School of Natural Resources and Environment. University of Michigan. USA.; (5)PhD. Assistant Professor. Department of Agricultural, Food, and Resource Economics. Michigan State University. USA.

**Background:** Analyses of agriculture and nutrition relationships often rely on data collected using different survey design methods. Assessing the magnitude of bias of estimates of agricultural production characteristics resulting from the design of such surveys could inform the development of surveys that make efficient use of limited resources for collecting data on those agricultural characteristics most relevant for predicting nutrition outcomes. This study aims to assess the effect of agricultural survey design on estimates of agricultural production characteristics, and on the association of these characteristics with dietary quality and diversity as well as anthropometric outcomes among pre-school-aged children in Burkina Faso.

**Methods:** A methodological cluster-randomized controlled trial was carried out between January and February 2017 in seven provinces of Burkina Faso testing three different approaches to collecting data on agricultural production characteristics by varying respondents and agricultural units of analysis. Provinces were randomly selected within each of the country's three agroecological zones. Five communities per province, and 30 households per community were randomly selected, with 10 households per community randomly assigned to one of three study arms (n=1,050 households). Respondents in the control arm received a comprehensive questionnaire that collected plot-level data on land area, crops raised and harvested, earnings from agriculture and non-agricultural activities, and control of management decisions and agricultural income. These data were collected from each plot manager separately. Households assigned to treatment arm one of the trial were administered a diagnostic version of the control arm survey that collected aggregate data from the household head only. Households in treatment arm two were administered the same survey version as treatment arm one, but a randomly selected household member, excluding the household head, was chosen as the respondent. We use multi-level regression analysis adjusting for intra-village clustering to estimate the average treatment effect of the three alternative survey designs.

**Results:** We will examine the extent to which sociodemographic characteristics of surveyed households are well balanced across the three treatment arms of the trial. Mean child height-for-age Z-score (HAZ) (SD) for children aged 24-59 months among the entire sample was -1.2 (1.2). Mean child weight-for-age

Z-score (WAZ) and weight-for-height Z-score (WHZ), respectively, were -0.98 (-0.96) and -0.41 (0.96). The area of cultivated land, overall crop yields (by weight), and the species diversity of crop production were all significantly lower among treatment arms 1 and 2 as compared to the control arm of the trial (P<0.05). We will present findings from separate adjusted regression analyses examining associations of land area, crop yield and crop species diversity with child diet and anthropometric outcomes, and including the interaction of agricultural production characteristics with dummy variables representing the randomized treatment assignment.

**Conclusions:** Survey design choices have a clear influence on estimates of agricultural production characteristics based on data collected from household surveys in Burkina Faso. Estimating the extent to which survey design may bias the assessment of key agriculture-nutrition relationships can allow for the estimation of confidence intervals for interpreting results across studies that apply different survey designs to examine similar relationships.

**Keywords:** Agriculture, dietary diversity, child anthropometry, crop diversity, Burkina Faso

# SCHOOL FEEDING PROGRAM IMPLEMENTATION AND CHILD NUTRITION IN GHANA: IMPROVED METHODS AND TOOLS

Laar, Matilda Essandoh.

PhD. Lecturer/Nutritionist. Department of Family and Consumer Sciences. Sch of Agriculture. University of Ghana. Ghana.

School feeding is among the most universal form of nutrition intervention, aiming to improve nutrition, health and educational outcomes of children. In Ghana, school feeding follows a “home grown” approach to promote agricultural development through local food procurement from smallholder farmers. The program uses a decentralized procurement model which involves caterers who pre-finance procurement and serve as the potential link between small-scale farmers and program beneficiaries. The lack of simple and effective monitoring and evaluation (M&E) tools hinder process and impact assessments of the Ghana School Feeding Program (GSFP) that are needed to inform decisions to improve program effectiveness. Furthermore, existing M&E efforts have emphasized on assessment of educational (e.g., enrollment and attendance) and qualitative outputs (e.g., farmer-reported cultivated land size), while outcomes and outputs that assess nutritional quality of meals and the link between school feeding and local agriculture have been ignored. This study aimed to assess the feasibility of using the GSFP’s new M&E tools in measuring nutritional quality of the meals and the link of the program to local agriculture. The new tools combined measurement of program impacts on school children with effects on local agriculture, using meal quality from school-level data on beneficiary children combined with procurement and meal planning data from GSFP caterers. The study was conducted in a total of 18 beneficiary schools from the Northern, Ashanti and Greater-Accra regions of Ghana over a school term. Data on type and portions of meals served were collected by school headteachers or their representative, and procure-
ment information collected from caterers. The findings showed that, in 16 out of the 18 schools observed, meals were provided for pupils every school day in the school term. However, the quality of meals served were low. Generally, no fruits were provided in 99.8% of the observed school meals. The school meals consistently met less than a third of the recommended nutrient intakes of protein (animal source protein offered was mostly milled smoked fish) and micronutrients (Iron, Calcium, Vitamin A & Vitamin B) for school-age children. From the procurement data, the link between caterers and small-scale farmers is either weak or non-existent. Caterers used both imported foods (e.g., rice, tinned tomatoes) and produce from other districts or regions in meal preparations. There was a heavy reliance on wholesale retailers who had more flexible payment terms and sourced food from both local and foreign producers. Caterers attributed their choice to the irregular financial reimbursement by the GSFP management, which often made it impossible to buy from local small-scale farmers who required immediate payment. In conclusion, the new M&E tools were successfully used to access meal quality and procurement from local farmers. However, there is a need to develop or adopt a user-friendly menu-planning tool and standardize handy measures used by caterers to reduce the burden involved in monitoring meal quality and training staff. In addition, efforts to improve local procurement, including timely payment of caterers and formation of farmer-based groups, should be promoted.

**Keywords:** School feeding, monitoring and evaluation, nutrition, agriculture, tools

## INDICATORS OF AFFORDABILITY OF NUTRITIOUS DIETS IN AFRICA (IANDA)

(1)Herforth, Anna; (2)Coates, Jennifer; (3)Masters, Will; (4)Sarpong, Daniel; (5)Mishili, Fulgence; (6)Bai, Yan; (7)Kinabo, Joyce; (8)Heidkamp, Rebecca; (9)Gersten, Zachary.

(1)PhD. Nutritionist. Friedman School of Nutrition Science and Policy. USA.; (2)PhD. Nutritionist. Friedman School of Nutrition Science and Policy. Tufts University. USA.; (3)PhD. Economist. Friedman School of Nutrition Science and Policy. Tufts University. USA.; (4)PhD. Economist. University of Ghana. Ghana.; (5)PhD. Economist. Sokoine University of Agriculture. Tanzania.; (6)MSc. Friedman School of Nutrition Science and Policy. Tufts University. USA.; (7)PhD. Nutritionist. Sokoine University of Agriculture. Tanzania.; (8)PhD. Nutritionist. Johns Hopkins Bloomberg School of Public Health. USA.; (9)MPH. Friedman School of Nutrition Science and Policy. Tufts University. USA.

**Background and Objectives:** A primary way that agriculture can influence food security and nutrition is by increasing year-round availability and affordability of diverse, nutritious foods. Food prices are tracked by national governments and international agencies but typically encompass basic commodities, or a food basket not closely related to nutritional needs. The IANDA Project (Indicators of Affordability of Nutritious Diets in Africa) develops indicators that reflect nutritious food, using existing food price monitoring systems. Additionally, IANDA partners with national

data collectors and end users, toward mainstreaming the use of new indicators that reflect the affordability of nutritious diets.

**Methods:** In Ghana and Tanzania, IANDA worked with stakeholders to identify the most important sources of food price data and to understand their scope in geographic coverage, foods covered, frequency and methods of data collection. The food lists covered by each organization were analyzed for comprehensiveness from a nutritional perspective, in partnership with stakeholders from national agencies. Using both historical data and new pi-lot data, three types of indicators were constructed. To construct the Cost of Dietary Diversity (CoDD) indicator, food items were grouped into the 10 food groups of the Minimum Dietary Diversity for Women indicator (MDD-W), and the lowest cost items for each group were used to establish the cost of minimum dietary di-versity. To construct the Cost of Nutrient Adequacy (CoNA) indi-cator, food price data were used in conjunction with the West Afri-can Food Composition table, and linear programming determined the lowest cost way to achieve adequacy of essential nutrients. To construct the Cost of Recommended Diets (CoRD) indicator, the average price of foods in each food group were summed to deter-mine the cost of meeting food-based dietary guidelines.

**Results:** In each country, there were two primary sources of food price data: in Ghana, the Ministry of Food and Agriculture (MoFA) and the Ghana Statistical Service, and in Tanzania, the Ministry of Industry and Trade and the National Bureau of Statistics. In Ghana, a total of 22 food items were added to the existing food price monitoring list used by MoFA; this expanded list was piloted in four geographically distinct districts. MoFA determined that the expanded list would be useful for monitoring the price of nutritious foods and not overly burdensome, and therefore is now institutionalizing the expanded list nationwide. These data, as well as data from the national statistics organizations in both countries, were adequate to construct the three indicators (CoDD, CoNA and CoRD).

**Conclusions:** Resulting from partnership between the Ghana MoFA and IANDA, in our knowledge Ghana is the first country to institutionalize monitoring of the price of nutritious diets. The indicators developed can be incorporated into food price monitor-ing systems in other countries as well, to track costs of nutritious food across seasons and geographies. They can also be used as in-dicators of nutrition-sensitive agriculture within programmes or national evaluation platforms. The accuracy and feasibility of the indicators in representing a nutritious diet depends on the com-prehensiveness of food lists within food price monitoring systems, and strong partnerships with stakeholders.

**Keywords:** Food prices, food environments, food access, affordability, monitoring systems.
# FARM TO FORK - PATHWAYS TO NUTRITION OUTCOMES AND IMPLEMENTATION CHALLENGES OF INTEGRATED AGRICULTURE-PROGRAMS

## WHY ARE INTEGRATED NUTRITION SENSITIVE AGRICULTURE PROGRAMS NECESSARY AND WHAT ARE THE IMPLEMENTATION CHALLENGES?

Nordhagen, Stella.

PhD. Africa Regional Monitoring and Evaluation Advisor. Helen Keller International.

There is great potential for mutual influence between agriculture and nutrition. Seventy-five percent of the world's poor work in agriculture in rural areas and are dependent on agriculture as their main source of income and at least some of their food. Agriculture thus plays a direct role in determining nutrition through food production and consumption, providing access to diets rich in diverse nutritious foods. The crops and livestock chosen and the methods used for production, harvest, processing, and storage can all influence nutrition. Agriculture also plays an indirect role in nutrition by generating income that can be spent on market-purchased food as well as healthcare, water, education, and other living essentials; all of these play a key role in influencing nutrition. Agriculture also impacts women's empowerment, including decision-making over income and time use, assets, and knowledge. When women control a larger share of income and production, this generally strengthens the pathways from income to nutrition and production to nutrition, respectively. Agriculture also plays a role in women's time use and workload, which can have impacts on their own nutrition as well as that of their families. Agriculture can also negatively influence health and nutrition through zoonosis and environmental enteropathy from livestock production, exposure to agricultural chemicals, and food-based diseases and toxins, such as aflatoxins.

Given these complex linkages, there is now widespread recognition that agriculture has a role to play in addressing malnutrition and increasing human health and wellbeing. However, a wide range of past experiences and micro- and macro-level data have borne out the fact that, without specific planning and design, agriculture will not have a large impact on nutrition or health. There is thus a need to develop interventions that aim to explicitly influence nutrition through agriculture. Interest in such nutrition-sensitive agricultural programs and policies is growing, but there remain a number of challenges to their implementation. These include adapting global best practices to resource-constrained local contexts, targeting to reach the most vulnerable while also creating conditions for successful uptake, demonstrating impact, managing diverse multi-sectoral collaborations, empowering women, avoiding adverse impacts on women's time use, mitigating potential increases in environmental enteropathy and zoonosis, balancing diverse demands on water use, avoiding adverse environmental impacts, balancing income-earning with consumption, and delivering integrated agriculture-nutrition behavior change communication.

Moreover, interventions must increasingly strive to have impacts at numerous levels of agricultural systems, including across large-scale market zones. Finally, all of this must be done at sufficiently large scales and in a sustainable and cost-effective way.

This talk will give an overview of these motivations for nutrition-sensitive agriculture programs and constraints on their successful implementation, thereby laying the foundation for a rich discussion among experts who are involved with a diverse set of projects currently making advances in this sector.

**Keywords:** Agriculture, livestock, women's empowerment, implementation
**Track 1: Advances in Nutrition Research**

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SELENIUM IN COMMONLY CONSUMED FOODS
OF BANGLADESH

(1)Shaheen, Nazma; (2)Akhter, Kazi Turjaun; (2)Khan, Ishrat Nourin;

(2)Md. Irfan, Nafis; (3)Rahim, Abu Torab Md. Abdur.

(1)PhD. Professor and Director. Institute of Nutrition and Food Science. University of Dhaka. Dhaka. Bangladesh; (2)Lecturer. Institute of Nutrition and Food Science. University of Dhaka;

(3)PhD. Professor. Institute of Nutrition and Food Science.
University of Dhaka.

**Background and objectives:** As an essential trace mineral Selenium has a pivotal role in maintaining human health. The beneficial role of Selenium includes antioxidant activities, proper functioning of the immune system, DNA synthesis and conservation of reproductive health. In spite of such beneficial roles of Selenium, there was a lack of data on the Selenium content of foods in Bangladesh. This study is the very first approach of incorporating analytical data of Selenium of commonly consumed foods.

**Methods:** Sample selection and prioritization were done according to the key food approach throughout the year. A total of twenty foods of predominant varieties were collected for analysis. Fresh samples of cereals (Rice, Wheat flour), pulses (Lentils), vegetables (Brinjal, Bean, Carrot, Green chili, Onion, Potato, Tomato) fruits (Banana, Mango, Jackfruit), freshwater fish (Rohu, Tilapia, Pangas), meat (chicken leg and breast), egg (chicken), and milk (cow) were collected for analysis of Selenium. The samples were analyzed by inductively coupled plasma mass spectrometry (ICP-MS) followed by microwave digestion.

**Results:** The result shows that highest and lowest content of Selenium (fresh weight basis) was found in tilapia fish (1.18 µg/g) and in rice (0.13 µg/g) respectively. Among the different food groups the estimated average Se content (µg/g) was found in the decreasing order of egg (1.06) > fish (1.03) > meat (0.75) > milk (0.42) > fruits (0.27) > Cereals (0.13) > Pulse (0.07) > Vegetables (0.06). Again among the individual food categories, the food sample which showed the highest concentrations of Se are cereals- Wheat flour (0.24), pulse-lentil (0.07), Vegetables-bean (0.1), fruits-mango (0.43), meat-chicken breast (0.79), fish-Tilapia (1.18), milk (0.42) and egg (1.06) respectively.

**Conclusions:** Accurate food compositional database for Se is immensely important to find out the rich source of Selenium. Findings of the present study from nationally representative com-

monly consumed foods of Bangladesh revealed that animal foods contain more selenium than foods from plant origin.

**Keywords:** Selenium, Commonly consumed foods, Bangladesh

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DIETARY PATTERNS IN ADOLESCENTS AGED
18 YEARS: RESULTS FROM THE 1993 PELOTAS
(BRAZIL) BIRTH COHORT

(1)Buffarini, Romina; (2)dos Santos Vaz, Juliana; (3)Baptista Menezes, Ana Maria; (4)Formoso Assunção, Maria Cecília.

(1)PhD. Nutritionist. Post-Graduate Program in Epidemiology. Federal University of Pelotas. Brazil; (2)PhD. MSc. Nutritionist. Post-Graduate Program in Epidemiology. Federal University of Pelotas. Brazil; (3)MD. PhD. Post-Graduate Program in Epidemiology. Federal University of Pelotas. Brazil; (4)Nutritionist. MSc. PhD. Post-Graduate Program in Epidemiology. Federal University of Pelotas. Brazil.

**Background and objectives:** The employment of dietary patterns (DP) to assess dietary has increased rapidly over recent years as an alternative to studying the intake of individual food items or a nutrient-specific approach. In this study we aimed to obtain dietary patterns in adolescents aged 18 years using principal components analysis (PCA), a multivariate method which may allow a meaningful approach to assessing dietary intake.

**Methods:** Cross-sectional analysis of 4052 adolescents belonged to the 1993 Pelotas (Brazil) Birth Cohort. A food frequency questionnaire (FFQ), composed by 88 items with eight frequency options (from zero to five or more times a day), was administered. The food items were combined into 44 food groups based on nutrient composition similarities and frequency of consumption. Varimax rotation was applied to obtain orthogonal factors. The food groups that showed factor loading >0.25 were considered to have a strong association with this factor. The number of factors that best represent the data were chosen primarily on the basis of the screeplot.

**Results:** Four DP were identified: "meat and fast foods", "fruit and vegetables", "candies, sodas, and dairies" and "common Brazilian". They explained 40% of the total variance. The first component had a high loading on all types of meat, including processed meats (canned tuna/sardine, salt-cured meat, bacon) and fast foods (hamburger, hot dog). The second component loaded highly on all types of fruits, vegetables and other legumes (except black beans). The third component was characterized by high loads of chocolate powder, regular sodas, dairies products (milk, yogurt, cheese, soft cheese), sweets and chocolates, candies and caramels. Lastly,
the fourth component loaded highly on black beans, white sugar, margarine/butter, white rice and white bread, and was labeled as "common Brazilian" in line with the usual Brazilian lunch "rice and beans" and "coffee and bread" breakfast.

**Conclusions:** This study identified four DP through a useful method that overcome the inherent problem of intercorrelations between food items when examining individual food associations. These patterns describe 18 years old adolescents' food habits and may be useful for future epidemiological research on health risk in the 1993 Pelotas Birth Cohort.

**Keywords:** Food consumption; Dietary patterns; PCA; Adolescents; 1993 Pelotas Birth Cohort

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PROGNOSTIC VALUE OF METABOLITES FOR PREDICTING RESPONSIVENESS TO NUTRITION-AL INTERVENTION AGAINST OXIDATIVE STRESS AND INFLAMMATION

(1)Kim, You Jin; (2)Kwon, Oran.

(1)PhD. Department of Nutritional Science and Food Management, Ewha Womans University, Republic of Korea;

(2)Professor, PhD. Department of Nutritional Science and Food Management, Ewha Womans University.

**Background and objectives:** Integrating traditional biomarkers and omics biomarkers might allow the discovery of prognostic markers for distinguishing responders from non-responders to nutritional interventions. We aimed to identify prognostic metabolites that predict responses to an intervention against oxidative stress and inflammation, using a data set from a randomized controlled trial evaluating Korean black raspberry (KBR).

**Methods:** We performed a case study to evaluate the prognostic use of 1H NMR metabolite profiling, using a data set from a four-week, randomized controlled study evaluating Korean black raspberry (KBR) in sedentary overweight/obese adults. To achieve this, we applied several statistical analyses to integrate biochemical and metabolite markers.

**Results:** Compared with the placebo group, KBR supplementation significantly changed erythrocytes oxidized glutathione (GSSG), the ratio of reduced glutathione (GSH) to GSSG, plasma malondialdehyde (MDA) and interleukin-6 levels, and seventeen urinary metabolites. Seven urinary metabolites were associated with clinical biomarkers. A two-metabolite set (glycine and N-phenylacetylglycine) had the strongest prognostic power for oxidative stress and probably inflammation (AUC-ROC=0.778, AUC for the leave-one-out cross-validation ROC= 0.683).

**Conclusions:** The integration of 1H NMR metabolomics data and biochemical markers may provide a novel prognostic marker that can be used to screen for responders to an intervention against oxidative stress in sedentary overweight/obese adults.

This study was supported by the Ministry of Science, ICT & Future Planning through the National Research Foundation (Bio-synergy Research Project NRF2012M3A9C4048761).

**Keywords:** oxidative stress, nutritional intervention, prognostic marker, metabolomics.

**Conflict of Interest Disclosure:** The authors declare no conflict of interest. The founding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, and in the decision to publish the results.

**Further collaborators:** Department of Statistics, Seoul National University, Seoul 08826, Korea (Iksoo Huh and Taesung Park). Department of Food Science and Technology, Seoul National University of Science and Technology, Seoul 01811, Korea (Ji Yeon Kim). Department of Sport Science, Korea Institute of Sport Science, Seoul 01794, Korea (Saejong Park). College of Pharmacy, Dankook University, Chungnam 31116, Korea (Sung Ha Ryu and Kyu-Bong Kim).

Department of Chemistry and Chemistry Institute for Functional Materials, Pusan National University, Busan 46241, Korea (Suhk-mann Kim)

144/541

INTAKE OF MARINE DERIVED OMEGA 3 POLY-UNSATURATED FATTY ACCIDS AND MORTALITY IN RENAL TRANSPLANT RECIPIENTS

(1)Sotomayor, Camilo G.; (2)Gomes Neto, António; (2)Pranger, Ilse G.; (3)van den Berg, Else; (4)Gans, Rijk O. B.; (5)S. Soedamah-Muthu, Sabitha; (4)Navis, Gerjan; (4)Bakker, Stephan J.L.

(1)Medical Intern. University Medical Center Groningen. University of Groningen. The Netherlands; (2)MD, PhD candidate. Internal Medicine, Nephrology. University Medical Center Groningen. University of Gronigen. The Netherlands; (3)MD, PhD. Internal Medicine, Nephrology. University Medical Center Groningen. University of Gronigen. The Netherlands; (4)MD, PhD. Internal Medicine. University Medical Center Groningen. University of Gronigen. The Netherlands; (5)PhD. Human Nutrition. University of Wageningen. The Netherlands.

**Background and objectives:** Marine-derived omega-3 polyunsaturated fatty acids (n-3 PUFA) have been shown to exert protective effects on all-cause and cardiovascular (CV) mortality in the general population. In renal transplant recipients (RTR) all-cause and CV mortality is high but the effect of n-3 PUFA intake on long-term outcome is unclear. We investigated whether marine-derived n-3 PUFA intake is associated with risk of all-cause and CV mortality in a large cohort of RTR.

**Methods:** Intake of Eicosapentaenoic acid plus Docosahexaenoic acid (EPA-DHA) was assessed using a validated Food Frequency Questionnaire. Cox-Proportional Hazards Regression analyses were performed to evaluate the associations of EPA-DHA intake with all-cause and CV mortality.

**Results:** We included 627 RTR (age 53 ± 13 years, 56% male). EPA-DHA intake was 102 [interquartile range: 42-216] mg/day. During median follow-up of 5.4 years, 130 (21.0%) RTR died, with 52 (8.3%) due to CV causes. EPA-DHA intake was associated with lower risk of all-cause mortality (Hazard Ratio (HR) 0.85; 95%
confidence interval (95%CI) 0.75-0.97, P = 0.02), independent of potential confounders. The HR for the association of EPA-DHA intake with CV mortality was of similar magnitude, but did not reach significance (HR 0.83, 95%CI 0.68-1.02, P = 0.08). The association of EPA-DHA intake with mortality was significantly modified by age (P = 0.03) and smoking status (P = 0.01), with lower risk for all-cause and CV mortality particularly in the older (≥ 63 years old) (HR 0.75; 95%CI 0.61-0.92, P = 0.01; and 0.68; 95%CI 0.48-0.95, P = 0.02 respectively) and non-smokers (HR 0.80; 95%CI 0.68-0.93, P = 0.01; and 0.74; 95%CI 0.56-0.98, P = 0.04, respectively) subgroups of RTR.

**Conclusions:** Higher marine-derived n-3 PUFA intake was associated with lower risk of all-cause and CV mortality in RTR. Strongest associations were present in elderly and non-smoking RTR. Our study adds further evidence to the plea for EPA-DHA supplementation in RTR, particularly in subgroups of this population.

**Keywords:** Renal transplant recipients; Omega-3 polyunsaturated fatty acids; Cardiovascular mortality; All-cause mortality.

acids to fatty acids in whole-blood (FA%) were lower, while most monounsaturated fatty acids were higher in children with SAM compared to controls. All n-6 PUFAs including linoleic (LA) and arachidonic acid (AA), as well as total n-3 PUFA and docosahexaenoic acid (DHA) were lower in children with SAM. Whole-blood n-6 PUFA proportions increased until follow-up, except for AA, which decreased by 0.79 (95%CI 0.46, 1.12) FA% from admission to transition and additional 0.10 (95%CI 0.23, 0.44) FA% to discharge. Compared to admission levels, total n-3 long-chain (LC) PUFA decreased by 0.21 (95%CI 0.03, 0.40) FA% at discharge and 0.22 (95%CI 0.01, 0.42) FA% at follow-up. This decrease was greater in children from families with recent fish intake before admission and those with nasogastric tube feeding.

**Conclusions:** Children with SAM had low whole-blood LCP-UFA. Current therapeutic feeds do not correct whole-blood levels of LCPUFA, particularly n-3 LCPUFA.

**Keywords:** Essential fatty acids, malnutrition, treatment, children

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## CHANGES IN WHOLE-BLOOD POLYUNSATURATED FATTY ACIDS AND THEIR PREDICTORS DURING RECOVERY FROM SEVERE ACUTE MALNUTRITION

(1)Babirekere-Iriso, Esther; (2)Mortensen, Charlotte; (3)Mupere, Ezekiel;

(4)Rytter, Maren; (5)Namusoke, Hanifa; (6)Michelsen, Kim F.; (7)Briend, André; (8)Stark, Ken; (9)Friis, Henrik; (9)Lauritzen, Lotte.

(1)MD. PhD. MwanamugimuNutrition Unit. Department of Paediatrics. Mulago Hospital. Uganda.; (2)MSc. Department of Nutrition, Exercise and Sports. University of Copenhagen. Denmark.; (3)MD. PhD. Department of Paediatrics. Makerere College of Health Sciences. Uganda; (4)MD. PhD. Department of Nutrition, Exercise and Sports. University of Copenhagen. Denmark.; (5)PhD. MwanamugimuNutrition Unit. Department of Paediatrics. Mulago Hospital. Uganda.; (6)Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Denmark.; (7)Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Denmark. Department of International Health, University of Tampere Medical School, Tampere, Finland.; (8)PhD. Department of Kinesiology. University of Waterloo. Canada.; (9)PhD. Department of Nutrition, Exercise and Sports. University of Copenhagen. Denmark.

**Background and objectives:** Severe acute malnutrition (SAM) is common in children in low-income countries and may be associated with low polyunsaturated fatty acids (PUFA) status.

The objective was to describe changes in PUFA-status during SAM treatment.

**Methods:** A prospective study among children treated for SAM in Uganda. Whole-blood fatty acid composition was assessed at admission, transition, discharge and follow-up, and among healthy children. ANCOVA was used to identify predictors of change.

**Results:** The study included 120 children with SAM and 29 controls. At baseline, the relative contribution of saturated fatty

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## HEMOGLOBIN CONCENTRATIONS AND ANEMIA PREVALENCE AMONG CONGOLESE CHILDREN 6-59 MONTHS WITH SICKLE CELL AND A-THALASSEMIA HEMOGLOBINOPATHIES

(1)Barker, Mikaela; (2)Henderson, Amanda M.; (3)Whitfield, Kyly

C; (4)Devlin, Angela M.; (5)Bahizire, Esto; (6)Akilimali, Pierre

Z.; (7)Tugirimana, Pierrot L.; (8)Boy, Erick; (9)Green, Timothy J.;

(10)Karakochuk, Crystal.

(1)MSc. Food, Nutrition and Health. British Columbia Children's Hospital Research Institute. University of British Columbia.

Canada.; (2)BS. Department of Pediatrics and Pathology and Laboratory Medicine. British Columbia Children's Hospital Research Institute. University of British Columbia. Canada.;

(3)PhD. Applied Human Nutrition. Mount Saint Vincent University.

Canada.; (4)PhD. Department of Pediatrics and Pathology and Laboratory Medicine. British Columbia Children's Hospital Research Institute. University of British Columbia. Canada.;

(5)MD. Faculty of Medicine. Catholic University of Bukavu.

Democratic Republic of Congo.; (6)MD. Department of Nutrition.

Kinshasa School of Public Health. University of Kinshasa.

Democratic Republic of the Congo.; (7)MD. Faculty of Medicine.

University of Goma. Democratic Republic of the Congo.; (8)PhD.

International Food Policy Research Institute. USA.; (9)PhD. South Australian Health and Medical Research Institute. Adelaide.

Australia.; (10)PhD. Food, Nutrition and Health. British Columbia Children's Hospital Research Institute. University of British Columbia. Canada.

**Background and objectives:** Genetic hemoglobin (Hb) disorders are autosomal inherited conditions caused by mutations and/or deletions in the genes encoding the α- and β-globin chains of Hb. The Glu6Val variant in HBB causes sickle cell trait in the heterozygous form and sickle cell disease in the homozygous form. Deletions in HBA1 and HBA2 cause α-thalassemia; the most com-
mon variant is the α3.7 deletion. Our aim was to determine the prevalence of these gene variants in children in the Democratic Republic of the Congo, and to assess the association with Hb concentrations and anemia.

**Methods:** Venous blood was collected from n=709 children 6-59 months in South Kivu (SK) and Kongo Centrale (KC) provinces. Genomic DNA was extracted from buffy coat. Pyrosequencing was used to detect the Glu6Val variant in HBB and PCR was used to detect α3.7-thalassemia deletions. Capillary Hb concentration (g/L) was determined using a Hemocue*. One-way ANOVA (Bonferroni-adjusted for multiple comparisons) was used to detect significant differences in Hb concentration across genotypes.

**Results:** Prevalence of sickle cell trait was 6% (n=26/426) in SK and 16% (n=47/283) in KC, and sickle cell disease was <1% (n=1/426) in SK and <1% (n=1/283) in KC. Prevalence of α3.7-thalassemia heterozygous was 10% (n=39/372) in SK and 6% (n=2/31) in KC, and α3.7-thalassemia homozygous was 2% (n=6/372) in SK and 6% (n=2/31) in KC. Overall, Hb concentrations were not significantly different among children with no sickle cell variants (111±16 g/L) compared to children with sickle cell trait (111±17 g/L) and sickle cell disease (94±30 g/L) (P>0.05); anemia prevalence (Hb <110 g/L) was 43%, 48%, and 50%, respectively. Hb concentrations were not significantly different among children with no α3.7-thalassemia deletions (111±14 g/L) as compared to both α3.7-thalassemia heterozygous (108±12 g/L) and α3.7-thalassemia homozygous (107±8 g/L) (P>0.05); anemia prevalence was 41%, 54%, and 50%, respectively.

**Conclusions:** These disorders were not significantly associated with Hb concentrations. Sickle cell disease and thalassemia are associated with ineffective erythropoiesis that may result in increased iron absorption and higher concentrations of ferritin and/or sTfR. Further work is warranted to investigate the associations with iron status.

**Keywords:** hemoglobin, anemia, sickle cell, α-thalassemia

**Conflict of Interest Disclosure:** HarvestPlus contributed to the study design, but did not have a role in the analysis of samples or data, or the final interpretation of findings. All authors declare no conflict of interest.

## ASSOCIATION OF PPAR GAMMA GENE EXPRESSION WITH DIETARY INTAKE OF FAT AND OIL AMONG NON-DIABETIC SUBJECTS

**Background and objectives:** Several animal studies showed the expression of peroxisome proliferator activated receptor-gamma (PPAR gamma) in adipocytes among rats fed with high-fat diet was higher than those fed with normal diet. However, there are no human studies to support this. The objective of the present study was to investigate the association between the PPAR gamma expression in visceral and subcutaneous human adipose tissues and intake of hydrogenated and non-hydrogenated vegetable oils and butter.

**Methods:** Visceral and subcutaneous adipose tissues were obtained from 97 subjects (41 non-obese, 18 obese, and 38 morbid obese), who underwent open abdominal surgery with minimal impact on dietary intake. Intake of hydrogenated and non-hydrogenated vegetable oils and butter were collected using a valid and reliable food frequency questionnaire. The gene expressions of PPAR-gamma in visceral and subcutaneous adipose tissue were assessed by Real-Time PCR.

**Results:** after adjustment for total energy intake and age, visceral adipose tissue PPAR-gamma gene expression was correlated with total fat and oil intake (β=-0.531, P=0.014) in the total population. Among non-obese subjects, visceral adipose tissue PPAR-gamma gene expression was correlated with non-hydrogenated oil (β=0.621, p=0.017). PPAR-gamma gene expression in subcutaneous adipose tissue was correlated with non-hydrogenated oil (β=0.481, P=0.026) among obese subjects. Moreover, among morbidly obese subjects, we found significant correlations between visceral adipose tissue PPAR-gamma expression and total fat and oil intake (β=0.417, P=0.020).

**Conclusions:** Expression of adipose tissue PPAR-gamma mRNA negatively correlates with total fat and oil intake mostly in

<footnote>(1)Yuzbashian, Emad; (2)Zarkesh, Maryam; (3)Asghari, Golaleh;</footnote>

<footnote>(4)Mahmoodi, Behnaz; (2)Hedayati, Mehdi; (2)Zadeh-Vakili, Azitah;</footnote>

<footnote>(3)Mirmiran, Parvin; (5)Khalaj, Alireza; (6)Daneshafrooz, Afsoon;</footnote>

<footnote>(7)Safarian, Mohammad.</footnote>

<footnote>(1)MSc. Nutrition and Endocrine Research Center. Research Institute for Endocrine Sciences. Shahid Beheshti University of Medical Sciences. Tehran. Iran; (2)PhD. Cellular and Molecular Endocrine Research Center. Research Institute for Endocrine Sciences. Shahid Beheshti University of Medical Sciences. Tehran. Iran; (3)PhD. Nutrition and Endocrine Research Center. Research Institute for Endocrine Sciences. Shahid Beheshti University of Medical Sciences. Tehran. Iran; (4)Department of Exercise Physiology. Faculty of Physical Education and Sports Sciences. Alzahra University. Tehran. Iran.; (5)MD. Obesity Treatment Center. Department of Surgery. Shahed University. Tehran. Iran; (6)MSc. Cellular and Molecular Endocrine Research Center. Research Institute for Endocrine Sciences. Shahid Beheshti University of Medical Sciences. Tehran. Iran; (7)PhD. Biochemistry and Nutrition Research Center, Department of Biochemistry and Nutrition Sciences. School of Medicine. Mashhad University of Medical Sciences. Mashhad. Iran.</footnote>
visceral fat. In addition, non-hydrogenated oil positively correlates with PPAR-gamma expression.

**Keywords:** PPAR-gamma, adipose tissue gene expression, oil and fat

**Further collaborators:** The authors would like to thank Dr Mohammad-Reza Ebrahimi for surgical procedures.

## CARBOHYDRATE INTAKE IS ASSOCIATED WITH HIGHER APELIN GENE EXPRESSION IN VISCERAL AND SUBCUTANEOUS ADIPOSE TISSUES

(1)Yuzbashian, Emad; (2)Zarkesh, Maryam; (3)Asghari, Golaleh;

(4)Mahmoodi, Behnaz; (5)Daneshafrooz, Afsoon; (2)Hedayati, Mehdi;

(2)Zadeh-Vakili, Azitah; (3)Mirmiran, Parvin; (5)Tabaei, Kimia; (6)Khalaj, Alireza.

(1)MSc. Nutrition and Endocrine Research Center. Research Institute for Endocrine Sciences. Shahid Beheshti University of Medical Sciences. Tehran. Iran; (2)PhD. Cellular and Molecular Endocrine Research Center. Research Institute for Endocrine Sciences. Shahid Beheshti University of Medical Sciences. Tehran. Iran; (3)PhD.Nutrition and Endocrine Research Center. Research Institute for Endocrine Sciences. Shahid Beheshti University of Medical Sciences. Tehran. Iran; (4)Department of Exercise Physiology. Faculty of Physical Education and Sports Sciences. Alzahra University. Tehran. Iran.; (5)MSc. Cellular and Molecular Endocrine Research Center. Research Institute for Endocrine Sciences. Shahid Beheshti University of Medical Sciences. Tehran. Iran; (6)MD. Obesity Treatment Center. Department of Surgery. Shahed University. Tehran. Iran.

**Background and objectives:** The evidence showed that the insulin level concentrations have an important role in apelin gene regulation and circulation. Diet may affect the level of insulin. The aim of the current study was to investigate the association of the apelin gene expression and concentration with habitual carbohydrate intake.

**Methods:** Visceral and subcutaneous adipose tissues were obtained from 32 morbidly obese and 32 age- and sex-matched non-obese subjects, who underwent open abdominal surgery. Dietary intake was collected using a valid and reliable food frequency questionnaire, and daily intake of carbohydrates, fiber, glucose, fructose, and total sugar were calculated. The mRNA expressions of apelin gene in visceral and subcutaneous adipose tissues were analyzed by Real-Time PCR.

**Results:** The mean age was 39.6 years for both groups and body mass index for morbid obese and non-obese subjects were 45.3 and 25.6kg/m2, respectively. Apelin gene expression was more increased in morbid obese than non-obese subjects in both subcutaneous (3.42 vs 0.49, P<0.05) and visceral adipose (3.65 vs 0.19, P<0.05) tissues. Apelin expression in visceral adipose tissue among non-obese subjects was marginally correlated with fructose (r=0.314, P=0.061); however, among morbid obese subjects, carbohydrate (r=0.429, P=0.014), fiber (r=-0.360, P=0.034), glu-

cose (r=0.341, P=0.048), and fructose (r=0.310, P=0.057) was correlated with apelin gene expression in visceral adipose tissue. Moreover, among obese subjects we found significant correlations between apelin expression in subcutaneous adipose tissue and carbohydrate (r=0.447, P=0.010), fiber (r=-0.443, P=0.013), total sugar (r=0.369, P=0.038), and among non-obese subjects we found significant correlations with glucose (r=0.481, P=0.006), fructose (r=0.467, P=0.008), and total sugar (r=0.435, P=0.014). Apelin concentration was correlated with percentage of energy from carbohydrate (r=0.379, P=0.046), fiber (r=-0.501, P=0.001) only in non-obese subjects.

**Conclusions:** The results of the current study showed that apelin among morbid obese had a positive correlation between carbohydrate and simple sugar intakes and a negative correlation with fiber intake.

**Keywords:** Fiber; Carbohydrate; apelin gene expressions; visceral and subcutaneous adipose tissues

**Further collaborators:** The authors would like to thank Dr Mohammad-Reza Ebrahimi for surgical procedures

## COMPARISON BETWEEN ENERGY INTAKE AND EXPENDITURE USING ACCELEROMETERS IN LARGE SCALE DISASTER SCENARIOS

(1)Koizumi, Nao; (2)Ogata, Hitomi; (3)Omi, Naomi.

(1)Master. Graduate School of Comprehensive Human Sciences. University of Tsukuba. Japan.; (2)PhD. Graduate school of integrated Art & Sciences. Hiroshima University. Japan; (3)PhD. Faculty of Health and Sport Sciences. University of Tsukuba. Japan.

**Background and objectives:** When large-scale disasters occur, firefighters are expected to engage in high-intensity and long-term disaster response activities under harsh environments. Total energy consumption at the time of disaster activity is presumed to be about 3,000 to 4,000 kcal from literature review research, etc. However, the necessary amount (energy) is wide and there is no sufficient basis yet for these values.

In a report issued by the Fire and Disaster Management Agency of the Ministry of Public Management, Home Affairs, Posts and Telecommunications in 2012, each fire department headquarters has been shown to make efforts to prepare foods, drinking water, personal equipment, etc. that can function for 72 hours or more.

"Eating" or food plays an important role in maintaining the condition of firefighters even in case of emergencies and continuing to demonstrate their strength. Therefore, food (reserve) stocking needs to be considered in advance. However, the energy requirements of firefighters engaged in disaster response activities are not known, and it is the current situation that is left to the judgment of each municipality.

When large-scale disasters occur in the future, there is a need to clarify energy consumption and energy requirement at the time of disaster response activity in order to prevent the condition maintenance and performance deterioration of firefighters.
Therefore, in this research, we aimed to investigate the amount of activity in training close to the actual disaster activity and clarify the current state of energy consumption.

**Methods:** We targeted firefighters consisting of 62persons in 11 departments of three prefectures participating in a two-day blind firefighting training dedicated to large-scale disasters (hereinafter referred to as brand training). For the activity level survey, a clinical triaxial acceleration sensor activity meter was mounted from before the start of the blind training until after the end. Food content survey was recorded by photographing and filling in the survey form.

**Results:** In the blind training assuming large-scale disasters, the obtained result supported the past literature in terms of energy consumption.

**Conclusions:** In comparison, it became clear that there is a deficiency in the amount of energy of the meals currently being ingested by firefighters or disaster rescue personnel.

**Keywords:** Fire-Fighters. energy-intake. energy-expenditure. accelerometers.

(1)Zhu, Zhonghai; (2)Zeng, Lingxia; (1)Elhoumed, Mohamed; (3)He, Guobin; (3)Li, Wenhao; (3)Zhang, Min; (3)Li, Wenjing; (3)Li, Danyang; (3)Tsegaye, Sintayehu; (2)Cheng, Yue.

(1)MSc. PhD candidate. Department of Epidemiology and Biostatistics. School of Public Health. Xi'an Jiaotong University Health Science Center. P.R. China.; (2)PHD. Nutritional epidemiology. Department of Epidemiology and Biostatistics. School of Public Health. Xi'an Jiaotong University Health Science Center. P.R. China.; (3)BSc. Master student. Department of Epidemiology and Biostatistics. School of Public Health. Xi'an Jiaotong University Health Science Center. P.R. China.

**Background and objectives:** The benefits of maternal micronutrient supplementation in pregnancy on their offspring's mental development in early childhood have been evaluated from the randomized controlled trials. The aim of this study is to further examine the long-term effect of perinatal micronutrient supplementation on the adolescent intellectual development.

**Methods:** Eligible adolescents whose mother received one of three kinds of daily antenatal micronutrient supplementation (folic acid, iron/folic acid, and multiple micronutrients [MMNs]) in a community-based, double-blind, randomized controlled trial in rural western China, were recruited to a follow-up evaluation. Intellectual development of adolescents was assessed by the Fourth Version of Wechsler intelligence scale for children (WISC-IV). 5 composite scores were derived from WISC-IV to indicate the full-scale intelligence quotient (FSIQ), verbal comprehension index (VCI), working memory index (WMI), perceptual reasoning in

dex (PRI), and processing speed index (PSI). Mean differences and 95% confidence intervals (CI) of 5 composite scores among three treatment group were estimated by generalized estimated equation linear models, and adjusted for the potential confounders.

**Results:** 2119 adolescents aged 9-15 years old were interviewed. There were non-significant differences among three treatment group in scores of FSIQ, WMI, PRI, and PSI. The score of VCI in MMNs group was significant higher than those in folic acid group (adjusted mean difference: 1.71; 95% CI: 0.11-3.32). In adolescents, whose mother initiated micronutrient supplementation before 12 gestational weeks, MMNs supplements significantly increased FSIQ by 2.05 (95% CI: 0.20-3.90) compared with folic acid group. For adolescent from poorest one-third household both in pregnancy and in current, maternal MMNs supplements was significantly associated with increased PRI scores (adjusted mean difference: 4.31; 95% CI: 0.77-7.86) compared with folic acid only. Compared with iron/folic acid group, MMNs supplementation significantly increased FSIQ (adjusted mean difference: 1.94; 95% CI: 0.18-3.70) in adolescent with their maternal total consumption number of antenatal supplementation less than 180.

**Conclusions:** In rural China, maternal MMNs supplementation was positively associated with the intellectual development of their offspring in adolescent compared with iron/folic acid or folic acid alone with the largest benefits in initiating supplementation in first trimester and in poor household subgroup.

**Keywords:** Maternal micronutrient supplementation, adolescent, intellectual development, longitudinal study, rural western China.

(1)Mahmoodi, Behnaz; (1)Shemshaki, Afsaneh; (2)Yuzbashian, Emad; (3)Zarkesh, Maryam; (4)Asghari, Golaleh; (4)Mirmiran, Parvin; (3)Hedayati, Mehdi; (5)Safarian, Mohammad.

(1)Department of Exercise Physiology. Faculty of Physical Education and Sports Sciences. Alzahra University. Tehran. Iran.; (2)MSc. Nutrition and Endocrine Research Center. Research Institute for Endocrine Sciences. Shahid Beheshti University of Medical Sciences. Tehran. Iran; (3)PhD. Cellular and Molecular Endocrine Research Center. Research Institute for Endocrine Sciences. Shahid Beheshti University of Medical Sciences. Tehran. Iran; (4)PhD. Nutrition and Endocrine Research Center. Research Institute for Endocrine Sciences. Shahid Beheshti University of Medical Sciences. Tehran. Iran; (5)PhD. Biochemistry and Nutrition Research Center, Department of Biochemistry and Nutrition Sciences. School of Medicine, Mashhad University of Medical Sciences. Mashhad. Iran.

**Background and objectives:** adipose tissue is an expanded endocrine organ affects body hemostasis by secreting protein named adipokine. Plasma level of apelin (a new adipokine) decreased after exercise; however, the evidence on gene regulation in
adipocyte is rare. The objective of the present study was to investigate the association between the apelin gene expression and habitual physical activity among morbid obese and non-obese subjects.

**Methods:** Visceral and subcutaneous adipose tissues were obtained from 32 morbidly obese and 32 non-obese age- and sex-matched subjects, who underwent open abdominal surgery. Physical activity was collected using a valid and reliable International Physical Activity Questionnaire (IPAQ)-long form, and the metabolic equivalent of task (MET) was calculated. The mRNA expressions of apelin gene in visceral and subcutaneous adipose tissues were analyzed by Real-Time PCR.

**Results:** The mean age was 39.6 years for both groups and body mass index for morbidly obese and non-obese subjects was 45.3 and 25.6 kg/m2, respectively. Apelin gene expression was more increased in morbid obese than non-obese subjects in both subcutaneous (3.42 vs 0.49, P<0.05) and visceral adipose (3.65 vs 0.19, P<0.05) tissues. Apelin expression in visceral adipose tissue among morbidly obese subjects was correlated with total MET (r=-0.345, P=0.045); however, apelin gene expression in subcutaneous adipose tissue was not significantly correlated with total MET. Among morbid obese subjects, total home MET (r=-0.412, P=0.019) was correlated with visceral adipose tissue.

**Conclusions:** Decreased apelin gene expression in visceral adipose tissue is linked to total MET in morbidly obese subjects, suggesting an important role of physical activity pathways in the causal relationship between consequences of higher physical activity and the development of obesity.

**Keywords:** Exercise, Adipokine, Apelin, Physical Activity.

**Further collaborators:** The authors would like to thank Dr Mohammad-Reza Ebrahimi for surgical procedures

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ANTI-STEATOTIC EFFECTS OF DOCOSAEXAENOIC ACID AND HYDROXYTYROSOL IN THE LIVER OF MICE FED A HIGH-FAT DIET: PPAR-Α AND NRF2 UP-REGULATION, AND OF SRBP-1C AND NF-ΚΒ DOWN-REGULATION

(1)Valenzuela Baez, Rodrigo Wladimir; (2)Echeverria, Francisca; (2)Soto Alarcón, Sandra Anakaren; (2)Orellana, Paula; (3)Rincón-Cervera, Miguel Ángel; (4)Vargas, Romina; (5)Valenzuela, Alfonso; (6)Videla, Luis A.

(1)Nutritionist. PhD. Nutrition Department, Faculty of Medicine, University of Chile; (2)Nutritionist. MSc. Nutrition Department, Faculty of Medicine, University of Chile; (3)Chemical. PhD. Lipid Center, Institute of Nutrition and Food Technology (INTA), University of Chile; (4)Biology. MSc. Molecular and Clinical Pharmacology Program, Institute of Biomedical Science, Faculty of Medicine, University of Chile; (5)Biochemistry, PhD. Lipid Center, Institute of Nutrition and Food Technology (INTA), University of Chile; (6)Biochemistry, MSc. Molecular and Clinical Pharmacology Program, Institute of Biomedical Science, Faculty of Medicine, University of Chile.

**Background and objectives:** Background: Non-alcoholic fatty liver disease (NAFLD) is characterized by abnormal ac-

cumulation of lipids, being insulin resistance, oxidative stress, inflammation and a drastic depletion of n-3 LCPUFA the main expressions of the disease. Docosahexaenoic acid (DHA, 22:6, n-3) controls liver lipid metabolism by stimulation of lipolysis and inhibition of lipogenesis and Hydroxytyrosol (HT) exhibits strong tissue cytoprotective effects. Objetive: To evaluate the molecular mechanisms involved in the protective effects of a mixture of DHA and HT (DHA /HT), to prevent the development of NAFLD induced by high-fat diet (HFD) in mice.

**Methods:** Male C57BL/6J mice received control diet (CD) (10% fat) or high fat diet (HFD - 60% fat), non-supplemented/supplemented of DHA (50 mg per kg per day)/ HT (5 mg per kg per day) for 12 weeks. Parameters studied included liver histology (optical microscopy), activity of hepatic antioxidant enzymes (catalase, superoxide dismutase, glutathione peroxidase, and glutathione reductase (by spectrophotometry), oxidative stress indicators (glutathione, thiobarbituric acid reactants, and the antioxidant capacity of plasma), gene expression assays for PPAR-α, Nrf2, SREBP-1c and NF-κB (qPCR and ELISA), and LCPUFA profiles in liver (gas-liquid chromatography).

**Results:** Results: HFD induced (i) liver steatosis (increasing total fat, triacylglycerols and free fatty acid content), (ii) higher fasting serum glucose, insulin levels and HOMA index, total cholesterol, triacylglycerols, TNF-α and IL-6, (iii) liver and plasma oxidative stress enhancement, (iv) depletion of n-3 LCPUFA content of liver phospholipids, increasing lipogenic and reducing lipolytic enzyme activities (v) down-regulation of PPAR-α and Nrf2, and (vi) up-regulation of SREBP-1c and NF-κB (gene expression and DNA binding activity). These changes were either reduced (p < 0.05) or normalized (compared to CD) in animals feed HFD supplemented with DHA/HT.

**Conclusions:** DHA/HT intervention exerts anti-steatotic effects underling antioxidants and anti-inflammatory responses by improving insulin sensitivity and recovering the lipolytic/lipogenic status of the liver altered by HFD, being PPAR-α and Nrf2 up-regulation, together with SREBP-1c and NF-κB down-regulation important molecular mechanisms involved in the protective action of DHA/HT. These effects may support the potential therapeutic use of DHA/HT supplementation in the treatment of liver steatosis induced by nutritional factors and/or other etiologies.

**Keywords:** Anti-steatotic effects; docosahexaenoic acid; hydroxytyrosol; antioxidant effects; antiinflammatory effects

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THE FADS GENETIC VARIANTS, FISH INTAKE AND LONG TERM WEIGHT CHANGE: RESULTS FROM THE SINGAPORE CHINESE HEALTH STUDY

Huang, Tao; Koh, Woon Puay.

National University of Singapore.

**Background and objectives:** A recent study in Greenlandic Inuit identified genetic signatures for adaption to diets rich in fish and n-3 polyunsaturated fatty acids (PUFAs), such as variants in
FADS cluster, which also affect adiposity feature. We therefore hypothesized that the genetic signatures might interact with fish/ PUFA intakes on body weight.

**Methods:** The interactions between FADS variant and the fish, long chain polyunsaturated fatty acids intakes in relation to long term changes in body-mass index (BMI) were prospectively tested in 6,592 Chinese women and men from the Singapore Chinese Health Study (SCHS).

**Results:** We found that total EPA+DHA intake consistently accentuated the genetic influences of signatures FADS rs174570 (C/T, with T is rich in Inuit) on long term changes in BMI in the SCHS cohort. Differences in long term changes in BMI were -0.105 (SE 0.067), 0.027 (SE 0.064), and 0.120 (SE 0.067) kg/m2 across three tertiles of total EPA+DHA intake. Similarly, fish intake significantly accentuated the genetic influences on long term changes in BMI (p for interaction=0.006). Differences in long term changes in BMI were -0.096 (SE 0.071), 0.041 (SE 0.052), and 0.251 (SE 0.151) kg/m2 across three categories (≤1 serving/week, 1~6 servings/week, and ≥ 1 serving/day) of fish intake. In addition, the T carriers had much stronger associations of fish and long chain n-3 PUFAs intakes with long term changes in BMI than did the non-T carriers.

**Conclusions:** Our data supports that fish and long chain n-3 PUFAs intakes might modify the genetic effects of FADS variant on weight change in Chinese.

**Keywords:** Fish, fatty acids, FADS gene, gene diet interaction

**Results:** The dietary surveys, anthropometric, biochemical and hematological determinations are methodological aspects defended by specialists of nutrition and the handbook suggest, it have to take into account in the investigative practice with this type of natural product, that's why that proposal suggest necessary the participation of the accredited specialist in nutrition and propose their functions. The handbook contains issues to be taken into account during the planning and execution of the clinical trial. The specialists who valued the proposal agree with more than 75% of the indicators and 76.92% with all the indicators to evaluate the guide.

**Conclusions:** The handbook provides the necessary theoretical and methodological aspects while performing clinical trials with dietary supplements of natural origin.

**Keywords:** The handbook provides the necessary theoretical and methodological aspects while performing clinical trials with dietary supplements of natural origin.

**Background and objectives:** Introduction: The clinical development of natural products, especially dietary supplements, is a field of research currently under development around the world and in Cuba. The clinical trials with dietary supplements used different methodologies which are sometimes inadequate, with inconclusive results. There is no methodology for clinical trials with these products, the scientific evidences, supporting health benefits, are insufficient and limited for their generalization.

**Objective:** To prepare a handbook for conducting clinical trials with dietary supplements of natural origin.

**Methods:** A study that classified as applied research was carried out. The current situation of clinical trials with dietary supplements, the theoretical and the methodological foundations and the methodology used in clinical trials with these natural products, were identified in the scientific literature; and was designed a handbook to conducting clinical trials with natural dietary-supplements.

**Background and objectives:** Calcium is the only dietary factor that affects both non-heme and heme iron absorption in humans. Mechanisms behind this effect are not elucidated. Our hypothesis is that calcium could modify the expression of gene and proteins involved in iron absorption. An interesting experimental model for evaluating this effect in small intestine is the human cell line Caco-2, which is easy to use and produces results that strongly correlate with the absorption of iron in humans.

**Objective:** To evaluate the effect of calcium on the expression of gene and proteins involved non-heme iron absorption by Caco-2 cells

<footnote>(1)Casamayor Laime, Zuleika; (2)Castanedo Valdés, Raquel;</footnote>

<footnote>(3)Adalberto, Adalberto.</footnote>

<footnote>(1)MSc. Clinical trials department. Entrepreneurial Group LABIOFAM. Cuba.; (2)MSc. Clinic department. National Institute of Hygiene Epidemiology and Microbiology. Cuba.; (3)MSc National Coordinating Center for Clinical Trials (CENCEC). Cuba.</footnote>

<footnote>(1)Herrera Mejía, Julián; (2)Herrera Mejía, Julián; (3)Zapata, Wildeman;</footnote>

<footnote>(4)Corrales-Agudelo, Vanessa; (5)Olivares Grohnert, Manuel; (6)Gaitan-Charry, Diego.</footnote>

<footnote>(1)Candidate Msc Biomedical Sciences. Nutritionist. Research Group on Human Food and Nutrition (GIANH is its acronym in Spanish), Universidad de Antioquia UdeA. Medellin-Colombia.;</footnote>

<footnote>(2)Msc. Candidate. Nutritionist and dietician. Research Group on Human Food and Nutrition (GIANH is its acronym in Spanish), Universidad de Antioquia UdeA. Medellin-Colombia.; (3)PhD. bacteriologist. Immunovirology Group, University of Antioquia, Medellin, Colombia.; (4)Msc. Nutritionist and dietician. Vidarium, Nutrition, Health and Wellness Research Center, Grupo Nutresa, Medellin, Colombia; (5)PhD. Medical. Micronutrient Laboratory, Institute of Nutrition and Food Technology (INTA is its acronym in Spanish), University of Chile. Santiago de Chile-Chile; (6)PhD. Medical. Research Group on Human Food and Nutrition (GIANH is its acronym in Spanish), Universidad de Antioquia UdeA. Medellin-Colombia.</footnote>
**Methods:** Caco-2 cells were exposed by 1h with 2µM iron solution (ferrous sulfate) and calcium (chloride) using different calcium:iron molar ratios (MR) 0:1 to 1000:1. Intracellular iron concentration was determined by ECLIA method, mRNA expression by qRT-PCR and protein expression by Flow-Cytometry. Changes in ferritin, mRNA and protein expression were compared between non calcium-stimulated cells (calcium: iron molar ratio=0:1) and cells stimulated with calcium at different concentrations.

**Results:** Calcium does not affect intracellular iron concentration. However, calcium increased mRNA DcytB expression (p=0.007) but an opposite effect was found in DcytB protein expression in membrane (p=0.001). No effect was found on both, mRNA and protein expression in membrane of DMT1 (p=0.42 and p=0.55 respectively). Otherwise, mRNA levels and protein expression of FPN (Ferroportin) were decreased by calcium (p=0.002 and p=0.03, respectively).

**Conclusions:** Calcium decreased the protein expression of DcytB and FPN in membrane. Because FPN is the only protein involved in efflux of all dietary iron forms from diet, this effect may explain the negative effect of calcium on iron absorption previously described in humans. However, our results as well as previous data warrant further investigation into the effect of calcium on iron absorption.

**Keywords:** Non-heme iron, Calcium, Iron absorption, Caco-2 cells

IDENTIFICATION OF BLOOD CELL TRANSCRIPT LEVELS OF POMC AND AGRP IN THE OFFSPRING OF GESTATIONAL CALORIE RESTRICTED RATS AS POTENTIAL BIOMARKERS OF PREDISPOSITION TO IMPAIRED ENERGY HOMEOSTASIS CONTROL

**Background and objectives:** Undernutrition during gestation is associated to perturbations in neuropeptides regulation and impaired leptin sensitivity, setting the stage for further obesity development. In turn, leptin supplementation during lactation reverses most of these detrimental effects. We used the animal model of gestational calorie restriction to determine potential transcript-based biomarkers in peripheral blood mononuclear cells (PBMCs) in adulthood indicative of a deficient energy homeostasis control and hence predictive of increased risk to develop obesity.

**Methods:** Adult male Wistar rats belonging to three experimental groups were studied: the offspring of control dams fed ad libitum with standard diet during gestation (controls); the offspring of 20% calorie-restricted dams from days 1-12 of gestation (CR); and CR rats supplemented with a daily oral dose of leptin throughout lactation (CR-Leptin). All offspring were fed standard diet thereafter. Body weight was followed. Body fat content and plasma leptin levels were determined at 3 and 6 months. Results of a microarray analysis performed in PBMCs at 4 months were used to identify genes related to feeding control being differentially expressed between controls and CR animals. RT-qPCR analysis was performed to confirm gene expression results.

**Results:** No significant differences were found between the three groups of animals concerning body weight, although CR an-

<footnote>(1)Szostaczuk, Nara; (2)van Schothorst, Evert; (3)Sánchez, Juana;</footnote>

<footnote>(4)Priego, Teresa; (5)Bekkenkamp-Grovenstein, Melissa; (6)Keijer, Jaap;</footnote>

<footnote>(7)Palou, Andreu; (7)Picó, Catalina.</footnote>

<footnote>(1)PhD. Student. Laboratory of Molecular Biology Nutrition and Biotechnology Nutrigenomics. University of the Balearic Islands and CIBER de Fisiopatología de la Obesidad y Nutrición CIBEROBN. Palma de Mallorca. Balearic Islands. Spain; (2)PhD. Associate Proffessor. Human and Animal Physiology. Wageningen University. Wageningen. The Netherlands; (3)PhD. Postdoc</footnote>

<footnote>Possition Ramon y Cajal. Laboratory of Molecular Biology Nutrition and Biotechnology Nutrigenomics. University of the Balearic Islands and CIBER de Fisiopatología de la Obesidad y Nutrición CIBEROBN. Palma de Mallorca. Balearic Islands. Spain;</footnote>

<footnote>(4)PhD. Postdoc Possition. Laboratory of Molecular Biology Nutrition and Biotechnology Nutrigenomics. University of the Balearic Islands and CIBER de Fisiopatología de la Obesidad y Nutrición CIBEROBN. Palma de Mallorca. Balearic Islands. Spain;</footnote>

<footnote>(5)Research Assistant. Human and Animal Physiology. Wageningen University. Wageningen. The Netherlands; (6)Prof. Human and Animal Physiology. Wageningen University. Wageningen. The Netherlands; (7)Prof. Laboratory of Molecular Biology Nutrition and Biotechnology Nutrigenomics. University of the Balearic Islands and CIBER de Fisiopatología de la Obesidad y Nutrición CIBEROBN. Palma de Mallorca. Balearic Islands. Spain.</footnote>