breakfast cereals (20%), canned vegetables/legumes (19%), plain chips (19%), hot cereals (15%), canned condensed soup (14%), and sausages and wieners (11%), (all p<0.01), although significant reductions were not yet seen in many food categories.

In 2015, PAHO in collaboration with representatives of the LatinFoods network in Argentina, Brazil, Barbados, Chile, Costa Rica, Cuba, Ecuador, Guatemala, Jamaica, Mexico, Paraguay, Panama, Peru and Trinidad and Tobago, conducted a baseline survey of packaged foods in 14 countries in the region in order to be able to assess progress in meeting the PAHO regional targets during the upcoming years for: 1) breads; 2) soups, wet and dry, noodles in broth; 3) mayonnaise; 4) cookies and biscuits; 5) cakes; 6) meat; 7) breakfast cereals; 8) dairy (cheese and processed cheese products); 9) butter/dairy spreads; 10) snacks; 11) pasta; 12) seasonings and condiments. These baseline results will be presented per food category and by country.

Together these results can help with monitoring progress to reduce sodium levels in packaged foods in the Americas and will also provide information for development of enhanced sodium reduction targets and in a broader range of foods in the upcoming years. Monitoring progress in sodium reduction is an important component of national and regional efforts to reach the sodium reduction goals set by the WHO.

**Keywords:** Sodium, levels, foods, reformulation

**Conflict of Interest disclosure:** Funding: Canadian Institutes of Health Research; University of Toronto, McHenry Research Chair (MRL)

## SODIUM AND POTASSIUM INTAKE AND THEIR RATIO IN THE U.S. DIET

The dietary ratio of sodium to potassium (Na:K) has been more strongly associated with increased risk of cardiovascular (CVD) disease and CVD-mortality than either sodium or potassium alone.

**Objective:** To estimate the usual sodium and potassium intakes, the dietary Na:K ratio, energy-adjusted sodium and potassium intakes (per 1,000 kcal), and the percentage of individuals with a dietary Na:K ratio of <1.0 by age, sex, and race/ethnicity among non-pregnant, non-lactating U.S. adults (³20 y; 2,393 men and 2,337 women) from What We Eat In America, NHANES 2011-2012.

NHANES is a nationally representative, cross-sectional survey that samples noninstitutionalized, civilian U.S. residents using a complex, stratified, multistage probability cluster sampling design. Two 24-hour dietary recalls are collected, weighted for day of the

week of collection to assure equal distribution across each day of the week, using the USDA's Automated Multiple-Pass Method. The National Cancer Institute method was used to estimate usual dietary intakes. Multiple pairwise t-tests were used for all comparisons between population groups, statistical significance was set at $P \le 0.01$.

U.S. adults consumed approximately 2000 kcal/d, 3600 mg/d sodium, and 2800 mg/d potassium. Most adults (90% ± 0.8%) had sodium intakes of >2300 mg/d, whereas <3% had potassium intakes of >4700 mg/d. Asians had the highest sodium intakes (per 1,000kcal) when compared to all other race/ethnic groups. Women had a significantly lower dietary Na:K ratio than men (1.32 ± 0.0 versus 1.45 ± 0.02). Non-Hispanic whites had a significantly lower Na:K ratio than non-Hispanic blacks and non-Hispanic Asians (1.34±0.02 compared with 1.54 ± 0.03 and 1.49 ± 0.04, respectively). Only 12.2% ± 1.5% of U.S. adults had an Na:K ratio of <1.0. More women (18%) than men (7%) met the recommended Na:K ratio. A significantly higher proportion of whites had an Na:K ratio of <1.0 than did all other racial/ethnic groups. Among men and women, the dietary Na:K ratio decreased linearly as age increased. Mixed dishes (e.g., combinations of foods consumed together) contributed the most sodium (34 ±1%) and potassium (19% ± 1%) to the American diet. However, grains and vegetables were among the highest contributors to sodium intakes of individuals with Na:K ratios of <1.0, compared with protein foods and grains for those with Na:K ratios of ≥1.0. Vegetables as well as milk and dairy products constituted the primary dietary sources of potassium for individuals with dietary Na:K ratios of <1.0, whereas mixed dishes and protein foods contributed the most potassium for individuals with dietary ratios of ≥1.0. Individuals with an Na:K <1.0 were less likely to consume mixed dishes and condiments and were more likely to consume vegetables, milk and dairy products, and fruit compared to those with a Na:K ≥ 1.0.

Only about one-tenth of U.S. adults have a dietary Na:K ratio consistent with the World Health Organization guidelines for reduced risk of mortality. Our data suggest that blacks and Asians have the most unfavorable dietary Na:K ratio in the U.S. Continued efforts to reduce sodium intake in tandem with novel strategies to increase potassium intake are warranted.

**Keywords:** Sodium, potassium, ratio, NHANES

**Conflict of Interest disclosure:** This work was supported in part by resources from the Agricultural Research Service, U.S. Department of Agriculture under agreement no. 58-1950-7-707 and the Office of Dietary Supplements at the National Institutes of Health. Data generation for this work was funded by the Sodium Committee of the North American Branch of the International Life Sciences Institute. The findings and conclusions in this report are those of the author(s) and do not necessarily represent the views of the National Institutes of Health, the U.S. Department of Agriculture, or any other entity of the U.S. Government.

<footnote>(1)Bailey, Regan; (2)Parker, Elizabeth A.; (3)Rhodes, Donna G.;</footnote>

<footnote>(3)Goldman, Joseph D.; (3)Clemens, John C.; (3)Moshfegh, Alanna J.;</footnote>

<footnote>(1)Thuppal, Sowmyanarayanan V.; (1)Weaver, Connie.</footnote>

<footnote>(1)Department of Nutrition Science, Purdue University, United States; (2)University of Maryland, School of Medicine, United State; (3)Agricultural Research Service, United States Department of Agriculture, United States.</footnote>
MODELING THE RELATIONSHIP OF SODIUM, PO-
TASSIUM, CALCIUM, AND MAGNESIUM INTAKES
AND RATIOS TO BLOOD PRESSURE

(1)Weaver, Connie; (2)Weaver, Connie; (3)McCabe, George; (4)McCabe, Linda; (5)Bailey, Regan.

(1)PhD. Distinguished Professor. Dept of Nutrition Science. Purdue University. West Lafayette. IN.; (2)PhD. Distinguished Professor. Dept Nutrition Science. Purdue University. West Lafayette. IN. USA.; (3)PhD. Statistician. Dept Statistics. Purdue University. West Lafayette. IN. USA.; (4)MS. Statistician. Dept Nutrition Science. Purdue University. West Lafayette. IN. USA.; (5)PhD. Nutritionist. Dept Nutrition Science. Purdue University. West Lafayette. IN. USA.

Background: Intakes of sodium, potassium, and their ratios have been associated with modifying systolic and diastolic blood pressure (SBP and DBP). Dietary patterns associated with blood pressure reduction are high in calcium and magnesium as well as potassium.

Methods: We estimated sodium, potassium, calcium, and mag-
nesium intakes from food and dietary supplements including their
ratios and evaluated the role of these nutrients in predicting blood
pressure in U.S. adults from 2011-2014 NHANES (n=2266 men
and n= 2454 women after excluding 5404 who were pregnant or
lactating, taking hypertension medications, smoked, had GFR <30
mL/min, or had missing or implausible data). Non-normal data
were transformed prior to analysis. Models were stratified by sex.

Results: The target mineral ratios for most adults based on recommended intakes of the single nutrients according to the NAM and (% adults achieving those) were less than 0.49 for Na:K (0.54%), less than 2.3 for Na:Ca (15.63%), less than 5.75 for wom- en (7.23%) and 7.42 for men (13.63%) for Na:Mg, and 2.5 for women (31.02%) and 3.22 for men (53.69%) for Ca:Mg. Among women, age and race/ethnicity explained 20% of the variation in SBP. When added to this model, statistically significant positive relationships were found with Na, Na:K, Na:Mg, Ca:Mg, Na:Ca and statistically significant negative relationships were found with K and Mg. For each of these, the increase in the percent of varia- tion explained was ≤ 2%. Addition of BMI and the Poverty-to-In- come-Ratio explained an additional 5%. Among females, age and race/ethnicity explained 8% of the variation in DBP. When added to this model, statistically significant positive relationships were found with Na:K, Na:Mg, and Ca:Mg and statistically significant negative relationships were found with K and Mg. For each of these, the increase in the percent of variation explained was 1% or less. Addition of BMI explained an additional 2%. For males, age, and race/ethnicity explained 10% of the variation in SBP. When added to this model statistically significant negative relationships were found with Ca and Mg. For each of these, the increase in the percent of variation explained was less than 1%. Addition of BMI explained an additional 8%. Among men, age , and race/ethnici- ty explained 11% of the variation in DBP with an additional 4% variance explained by BMI %. No statistically significant effects of minerals or their ratios were found in men for DBP.

Conclusions: Our findings suggest that dietary patterns, which favor lower intakes of sodium, higher intakes of K, and Mg, and

lower Na:K, Na:Mg, Ca:Mg, Na:Ca should be encouraged for pro-
tection against hypertension, especially among women

**Keywords:** Blood pressure, sodium, potassium, calcium, magnesium

Conflict of Interest disclosure: This project was supported by ILSI NA. C Weaver is on the ILSI Board.

PS_144/1050

ADDRESSING THE CHILDHOOD OBESITY CHAL-
LENGE: WHERE ARE WE?

ADDRESSING SOCIAL AND ECONOMIC CONSEQUENCES OF CHILDHOOD OBESITY

Sassi, Franco.

Imperial College London.

Childhood obesity is a key dimension of the global obesity epidemic, linked with a significant rise in metabolic disorders and detrimental long-term health and social outcomes. Tackling childhood obesity means addressing the complexity of behaviour change within an “obesogenic” environment (including the built environment and modes of transportation, the availability, prices and nutritional content of foods, the exposure to commercial advertising, the technology supporting children’s study and play, as well as adults’ work and leisure). This obesogenic environment, combined with a host of cognitive and behavioural biases, provides a powerful drive towards unhealthy behaviours with significant health and economic consequences.

Established links between child and adult obesity, and be-
tween these and non-communicable diseases, are such that det-
rimental health impacts and an increased demand for health care
must be expected as new generations age. However, obesity can
also have major consequences on children's psychology, social life,
and school performance. Obesity is a hindrance to social capital
formation through lower educational attainment, translating into
reduced employment opportunities.

The presentation will explore the social and economic dimen-
sions of childhood obesity and how governments can prevent and
address these consequences through appropriate intersectoral
policies. The presentation will also discuss the key outcomes of
those policies In a range of settings at different levels of income
and development.

**Keywords:** Childhood obesity; economics; social impacts; government policies
# CHILDHOOD OBESITY IN MEXICO: PREVENTION PROGRAMS FOR SCHOOL AGE CHILDREN

(1)Solís-Pérez, Elizabeth; (2)Villarreal-Pérez, Jesús Zacarías; (3)López-Cabanillas Lomelí, Manuel; (4)González-Garza, Raquel; (5)Lavalle-González, Fernando J.

(1)PhD. Public Health and Nutrition School. Autonomous University of Nuevo Leon. Mexico. ICDA; (2)MD. Endocrinology Service.University Hospital. Autonomous University of Nuevo Leon. México; (3)MSc. Public Health and Nutrition School. Autonomous University of Nuevo León. México; (4)BSc in Nutrition. Public Health and Nutrition School. Graduate Program of Master of Science in Nutrition. UANL; (5)MD.Endocrinology Service.University Hospital. Autonomous University of Nuevo Leon. México.

Childhood obesity is a public health problem in México. A 33.2% combined prevalence of obesity in school age children (5-11 years) was reported in the last national survey. The government of Nuevo León implemented a primary prevention obesity program for school age children through multiple components and adapted to the local context.

The aim of this lecture is to present the impact and strategies of an obesity prevention program for elementary school children in the state of Nuevo León México.

The primary intervention consisted in a structured public policy and a program based in evidence, with three components: nutrition education and health promotion; integrated resources from the ministries of health and education; assurance of safe and healthy environments. For the nutrition education and health promotion was elaborated a state catalog with food, beverages and snacks guidance. In addition, an intense training for teachers, parents and educational community was performed. Physical activity routines during the time in the schools (6000 elementary schools) were implemented (to assure 30 minutes during the school time). Weight and height were measured and body mass index (BMI) was interpreted by the WHO 2007 reference. During three consecutive years was recorded the measurements of three different cohorts of school children (year 1= 197, 586 children; year 2= 257,576 children; year 3 = 286, 238 children. Legal and standard measures that meet healthy nutrition guidelines for school stores (2100 establishments) were included.

The combined prevalence of obesity during the three consecutive school years was 32.5%, 30.1% (p value ≤ 0.02) and third year 30.9% (p value ≤ 0.01). More than 30,000 teachers were trained, and one million of food catalogs were distributed to the parents. A didactic collection for health promotion was delivered to school age children. The program was recognized as a successful practice in México because the significant decrease or containment of the obesity prevalence, the high level strategic leadership of the government authorities, the inclusion of health in education policies, the monitoring system (evolutionary chart of health), the coordination, the alliances with the food and beverages industry, and the implementation of a social marketing campaign.

Monitoring, evaluation and surveillance are key strategies related to obesity prevention. It is necessary to assure the sustainability of the childhood obesity programs in Mexico.

**Keywords:** Childhood obesity, prevention programs, school age children, food guidance, health promotion.

**Further collaborators:**

Mario Alberto González Medina. PhD. Public Health and Nutrition School. Autonomous University of Nuevo León. Mexico

PS_144/1046

# AN INVESTMENT FRAMEWORK IN NUTRITION: CURRENT PROGRESS IN COSTING AND FINANCING THE SCALE-UP OF EVIDENCE-BASED NUTRITION INTERVENTIONS

## AN INVESTMENT FRAMEWORK FOR NUTRITION

Shekar, Meera; Dayton Eberwein, Julia; Kakietek, Jakub.

World Bank.

The analytical framework established in Scaling Up Nutrition: What will it Cost? provided the foundation for the World Bank, with support from the Bill & Melinda Gates Foundation (BMGF), to undertake a series of country-level analyses to determine resources needed to scale up high-impact interventions to improve early childhood nutrition. These studies use country-level costs and other data to provide country-tailored guidance on resources needed to scale up cost-effective scenarios which depend on cost-effectiveness considerations, financing constraints and country-specific priorities. In 2016, the World Bank, Results for Development Institute, and 1,000 Days, with support from BMGF and the Children's Investment Fund Foundation (CIFF) released innovative, in-depth costing analyses and developed a global investment framework for achieving four of the six global nutrition targets. While the global and country-based findings are extremely useful in setting nutrition agendas, they are limited by the inability to identify the optimal allocation across intervention of a given 'purse' of resources. To address this constraint, a new optimization tool, Optima Nutrition, has been developed and piloted through a partnership between the World Bank and the Burnett Institute, with financing from BMGF. The tool allows the user to determine allocative efficiency across nutrition interventions within a given country and to better understand existing costing structures of nutrition interventions. These advances will help to catalyze domestic and external investments for nutrition results. This session will present analytical innovations, as described above, to determine the costing and financing needs for scaling up evidence-based nutrition interventions. The panel discussion will address issues of feasibility, smart scale-up and ways to leverage the additional financing needed.

**Keywords:** Maternal and child nutrition; health economics; health financing; benefit-cost analysis

**Further collaborators:**

Ellen Piwoz, the Bill and Melinda Gates Foundation; Susan Horton, University of Waterloo; Martin Short, Power of Nutrition;
LESSONS FROM INVESTMENT FRAMEWORKS FOR NUTRITION IN SELECTED COUNTRIES

Dayton Eberwein, Julia.

PhD. Health Economist. World Bank, Washington, DC. USA.

The World Bank, in the partnership with the Bill and Melinda Gates Foundation, has undertaken a series of country-level analyses to determine resources needed to scale up high-impact nutrition-specific interventions in countries with high burden of malnutrition in Sub-Saharan Africa and South Asia. These studies offer an analysis of the common trends as well as factors explaining the variation in estimated cost-effectiveness and economic benefits of different interventions and intervention packages. Estimates of the costs and benefits of scaling up a package of nutrition-specific interventions to improve nutrition outcomes during the critical 1,000 day window take into account country-specific factors such as the current coverage of interventions, the available delivery platforms, and the local costs for commodities, monitoring and evaluation, and capacity building. In addition, the studies provide policymakers with several context-specific scale-up scenarios, designed to maximize allocative efficiency in situations where available resources for investments in nutrition are limited. The proposed scale up scenarios are evaluated based on their cost-effectiveness (in terms of cost per DALY averted, life saved, and case of stunting averted), as well as their potential contribution to future economic productivity (estimated based on increases in adult wages resulting from childhood stunting averted and/or on improved IQ scores and consequent increases in wages resulting from reductions in other forms of malnutrition [e.g. iodine deficiency]). This presentation provides a synthesis of country studies and their potential to drive political commitment and action to enhance allocative efficiency of nutrition resources.

**Keywords:** Stunting; cost-effectiveness; nutrition interventions; economic productivity

A TOOL FOR OPTIMIZING EFFICIENCY: OPTIMA FOR NUTRITION OPTIMA TOOL

Kakietek, Jakub.

PhD. Economist. World Bank Group. Washington DC USA.

The recent increase in the attention given to issues related to nutrition has been precipitated partially by the growing body of knowledge related to the economic impact of malnutrition as well as the cost and benefits of scaling up key nutrition actions. One key and persistent question asked by policy makers and nutrition and health program managers which has not been addressed to-date is: what allocation of funding across different interventions would allow us to maximize nutrition and health impact while minimizing costs? The existing analytic tools do not address this critical question. A few existing ones, including LiST, OneHealth, Profiles, the World Breastfeeding Costing Initiative tool, and the

FANTA CMAM costing tool, estimate either costs or impacts of different nutrition interventions. Each has its strengths but none offers the analytical capability to integrate all of the following features: (i) combine the estimates of cost, health impacts, and economic impacts of scaling up nutrition interventions; (ii) compare cost-effectiveness of different intervention and scale-up options; (iii) systematically assess allocative efficiency of different scale-up options (iv) use a formal mathematical optimization model to identify the optimal allocation of a given level of resources to reach specific nutrition and/or health outcomes. This session introduces Optima nutrition, a mathematical model that uses an integrated analysis of nutrition status, program, and cost data to determine an optimal distribution of investment at different funding levels to better serve the needs of decision-makers and planners. An initial pilot application for Optima nutrition has been developed through a partnership between the World Bank, the Bill and Melinda Gates Foundation, and the Burnett Institute. Currently, the application is focusing on child stunting and the plan is to incorporate other outcomes such as anemia and wasting over time. The application allows the user to 1) estimate the impact an intervention scale-up will have on stunting prevalence and child mortality; 2) calculate the cost of scale up under different cost function assumptions; 3) for a given budget, calculate the optimal allocation of resources among the seven interventions (that is, identify an allocation that will produce maximum reductions in stunting or/and mortality); 4) for a given budget, calculate the optimal allocation of resources among different geographic regions in a given country. This session presents the structure of the model, and illustrates how the model can be used with preliminary application in two countries.

**Keywords:** Allocative efficiency, Nutrition, Stunting, Cost-effectiveness, Optimization.

**Further collaborators:**

Bill & Melinda Gates Foundation

PS_144/1055

EVIDENCE-BASED INTEGRATION OF NUTRITION ACROSS MULTIPLE SECTOR PROGRAMS: HOW CAN THIS BE DONE?

EFFECTIVE INTEGRATION OF NUTRITION INTO OTHER SECTORS – OPPORTUNITIES AND CHALLENGES

Menon, Purmina.

PhD. Senior Research Fellow. International Food Policy Research Institute. Washington DC, USA.

Since the Lancet Series on Maternal and Child Nutrition was published in 2013, and the launch of the global Scaling Up Nutrition (SUN) movement, there has been a strong resurgence of multisectoral programming to improve nutrition outcomes. Multisectoral plans are being launched globally to address the multiple determinants of poor nutrition and across the globe, poli-
LINKING AGRICULTURE, GENDER, NUTRITION AND MICROCREDIT INTERVENTIONS IN BANGLADESH: WHAT ARE WE LEARNING ABOUT CONVERGING AND INTEGRATING TO REACH HOUSEHOLDS WITH MULTIPLE INTERVENTION STREAMS

It is recognized that leveraging agriculture to address nutrition must also address gender-related challenges. However, program experiences and the literature are limited on the types of integrated intervention models that can do this most effectively and efficiently. IFPRI, in collaboration with BRAC, launched the TRAIN (Targeting and Realigning Agriculture for Improved Nutrition) study in Bangladesh to test different combinations of interventions for strengthening agriculture-nutrition linkages. The four components combined in an additive manner across the intervention arms are (1) credit offered to women, (2) behaviour change communication related to health and nutrition, (3) nutrition-sensitive agriculture extension services and (4) gender sensitization and community mobilization.

In the context of designing the interventions to be tested, we identified several opportunities and challenges within existing platforms or specific programs implemented by BRAC.

**Opportunities:**

BRAC's existing microcredit platform 'Dabi' works through a unique 'credit plus' approach, addressing the special needs of poor populations. Dabi provides loan only to women for investment in any productive sector, thus bringing a gender-lens to the credit program by design

BRAC's Gender Quality Action Learning (GQAL) program has developed and implemented an established a set of interventions to target specific social issues, and was open to exploring opportunities to integrate nutrition-related gender concerns.

BRAC's vast experience in implementing intensive behaviour change counselling programs for infant feeding and maternal nu-

trition through their health worker network BRAC's experience in implementing large scale programs on crop cultivation, fisheries, and poultry & livestock for horizontal & vertical production

**Challenges:**

Different sector-specific BRAC programs deliver their interventions at scale and with focused intensity to deliver impact. While aiming to reach households with each stream in an integrated manner, it is unclear whether it will still be possible to ensure integration at the same intensity as is possible with more vertical programs. Identifying ways in which the delivery of the integrated package will be as effective as the individual streams is a key challenge, therefore.

The initial vision for the TRAIN interventions was that specific services would be offered free of cost to beneficiaries. At the same time, as BRAC moves towards a broader institutional entrepreneurship/business model, there are likely to be challenges to this initial vision.

The GQAL gender platform has not yet been used specifically to address issues of intrahousehold allocation of work, food and resources in relation to agriculture and nutrition. Although there are natural linkages between gender issues and nutrition, the integration of new specific topics into a gender platform that is focused on broader social issues may pose challenges.

Overall, however, our experience to date suggests that the vision for improving nutrition has high-level support in BRAC, as does the understanding that improving nutrition will take multiple streams of programming to come together on the same vulnerable households. Our study will examine the potential for integrating three significant streams – agriculture, gender and nutrition behaviour change communications, while other efforts at BRAC will also examine the integration of additional sectors.

**Keywords:** Agriculture, gender, nutrition, microcredit, integration

INTEGRATION AND SCALING UP NUTRITION WITHIN NGO PROGRAMS – CHALLENGES AND OPPORTUNITIES IN BANGLADESH

BRAC, the largest non-governmental organization (NGO) in the world born in Bangladesh has been implementing interventions through multidimensional approach. Nutrition is one prime focus of BRAC along with micro-finance, agriculture, education, health care services, water, sanitation & hygiene, social protection, climate change, human rights, community empowerment and so on. Nutrition programme addresses improved infant and young child feeding (IYCF) practices of under-two children, enhances food diversity of pregnant and lactating women (PLW) and promotes healthy diets of adolescent girls including micro-nutrient

<footnote>(¹)Siraj, Saiqa; (²)Kumar, Neha; (³)Ruel, Marie; (⁴)Menon, Purmina;</footnote>

<footnote>(⁵)Avula, Rasmi; (²)Quisumbing, Agnes; (⁶)Afsana, Kaosar; (⁷)Miah, Mohammad Mamun; (⁸)Haque, Raisul; (⁹)Hossan, Belayet; (¹⁰)Begum, Anjuman Ara; (¹¹)Hoddinott, John.</footnote>

<footnote>(¹)Sr. Project Manager. TRAIN Project. International Food Policy Research Institute (IFPRI). Bangladesh; (²)PhD, Senior Research Fellow, International Food Policy Research Institute (IFPRI), USA; (³)PhD, Division Director, Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), USA; (⁴)PhD, Senior Research Fellow, International Food Policy Research Institute (IFPRI), India; (⁵)PhD, Research Fellow, International Food Policy Research Institute (IFPRI), India; (⁶)PhD, Director Health Nutrition and Population Program, BRAC, Bangladesh; (⁷)Senior Sector Specialist, Health Nutrition and Population Program, BRAC, Bangladesh; (⁸)PhD, Program Head, Health Nutrition and Population Program, BRAC, Bangladesh; (⁹)Sr. Manager, Dabi Operation, Microfinance Program, BRAC, Bangladesh; (¹⁰)Manager, Gender Justice & Diversity Division, BRAC, Bangladesh; (¹¹)D. Phil, Babcock Professor of Food & Nutrition Economics and Policy, Division of Nutritional Sciences, Cornell University, USA.</footnote>

<footnote>(¹)Afsana, Kaosar; (²)Rifat, Mahfuza; (³)Ara, Riffat.</footnote>

<footnote>(¹)PhD. Director. Health Nutrition & Population. BRAC. Dhaka. Bangladesh.; (²)PhD. Programme Head. Health Nutrition & Population. BRAC. Dhaka. Bangladesh; (³)Msc. Nutritionist. Health Nutrition & Population. BRAC. Dhaka. Bangladesh.</footnote>
intake of under-five children, PLW and adolescents. Currently, nutrition interventions are being implemented in 233 rural sub-districts and 11 city corporations (nearly half of the country) reaching 7.2 million under two children, 3 million PLW and 9 million adolescent girls, and in 61 districts reaching 10 million under five children for micro-nutrient powder. The trained front-line community health workers demonstrate and counsel mothers of children and PLW, render health education to adolescents and sell micro-nutrients sachets for under-five children. Over the years, there has been significant improvement of behavior and practices in IYCF and maternal nutrition, and reduction of anemia among under-five children. Despite recognizing the importance of multi-sectoral approaches, BRAC is facing challenges of integrating all development programmes. Nutrition is integrated with health and population interventions with WASH being promoted. While designing all those development programmes (quite large in population and geographic coverage), integration is not considered due to different donors' requirements, and tendency to make direct and specific impact of individual programmes. With the support of Nutrition International (based in Canada) formerly Micro-Nutrient Initiative, BRAC is exploring pathways for integration in Bangladesh. The knowledge and evidence generated through this method will have wider impact not only on nutrition and health status but also on major socio-economic indicators if integration factored into design which will be easily usable.

**Keywords:** BRAC, Bangladesh, nutrition, integration, challenges

**Further collaborators:**
Nutrition International

## EVIDENCE-INFORMED DESIGNING OF INTEGRATION OF NUTRITION INTO MULTIPLE-SECTOR BRAC PROGRAMS (INBP) – OVERVIEW OF THE RESEARCH DESIGN

(1) Jalal, Chowdhury Jalal; (2) Pelto, Gretel; (3) Lee, Jamie; (4) Bhuiyan, Muhammad Mahbub; (2) Habicht, Jean-Pierre.

(1)Senior Technical Advisor. Nutrition International; (2)Professor, Cornell University; (3)Independent Consultant; (4)Consultant, Nutrition International.

Establishing multi-sector, nutrition-specific and nutrition-sensitive interventions is critically important as a strategy to ensure sustainable interventions to improve nutrition of women, adolescents and children. Designing such strategies presents many challenges and, to date, there is insufficient evidence to provide guidance to the systematic design and integration of nutrition into multiple sectors. The Nutrition International has applied a series of interdependent research methods to identify these barriers particularly related to adolescent nutrition; understand in-depth the individual, household, and community factors affecting nutrition; and explore existing and potential service delivery options to inform the designing of integration of actionable nutrition packages (ANP) into multi-sector BRAC programs. BRAC is a Bang

ladesh-based NGO known globally for its largest national-level programs. This presentation provides an example of systematic guidance on HOW nutrition can be integrated into at-scale multi-sector programs and HOW its application can further inform policy makers on their efforts directed to sustainably improve nutritional status of the vulnerable populations.

**Keywords:** Multi-sector, Integration, Program, Adolescent

## STRATEGY FOR INTEGRATED LINKAGES BETWEEN SERVICE DELIVERY AND HOUSEHOLD UTILIZATION ACROSS PROGRAMS

(1) Lee, James; (2) Jalal, Chowdhury Jalal; (3) Bhuiyan, Muhammad Mahbub; (4) Habicht, Jean-Pierre; (4) Pelto, Gretel.

(1)independent consultant; (2)Senior Technical Advisor, Nutrition International; (3)Consultant, Nutrition International; (4)Professor, Cornell University, USA.

Large multi-sectoral service delivery platforms offer an opportunity to integrate nutrition across a broader range of activities than the Health sector alone. Yet identifying the optimum points for intervention in complex programmes presents a challenge. Using the example of rural Bangladesh, this presentation describes a sequence of project design research steps to map the contact points and interventions that could address anaemia in adolescent girls. Steps discussed include the mapping of Project Impact Pathways (PIPs) for existing services; formative research to describe the operational issues affecting household utilization of these same services; systematic data collection to identify nodes and networks through which health and nutrition information is routinely passed; and focused ethnographic investigation of adolescent consumption and common food proscriptions and prescriptions with a bearing on consumption of iron-rich foods. The presentation concludes by demonstrating the contribution of these steps to the identification of both a set of service “offerings” that can impact adolescent nutrition and the optimum means to deliver them.

**Keywords:** Adolescent, iron, integration, qualitative, Bangladesh.

**Further collaborators:**

Chowdhury Jalal, Muhammad Mahbub Bhuiyan, Jean-Pierre Habicht, Gretel Pelto
## THE CASE OF PASTORALISM IN NORTHERN KENYA: FOOD, WATER, LAND AND LIVELIHOODS

(1)Fox, Elizabeth; (2)Fanzo, Jessica.

(1)PhD. Hecht-Levi Postdoctoral Fellow. Berman Institute of Bioethics. Johns Hopkins University. USA.; (2)PhD. Bloomberg Distinguished Associate Professor of Global Food and Agriculture Policy and Ethics. Director, Global Food Ethics and Policy Program. Johns Hopkins University. USA.

Pastoralists in northeastern Kenya are experiencing significant difficulties in preserving their traditional livelihoods due to various factors including population pressures and environmental stresses induced by climate change. These challenges affect their ability to access key resources, such as food and water. Government policies promoting alternative livelihoods for pastoralists, including sedentarization and modernization, often diverge from traditional pastoralists' culture, values and practices. There are questions as to whether such policies should be embraced in the long-term. In this study, we identified the dilemmas and challenges faced by pastoralists in the context of sedentarisation, modernization, and traditional practices of transhumance. We also explored coping mechanisms pastoralists use to adapt to those challenges. We completed semi-structured interviews and a Photovoice project with nomadic and sedentarized pastoralists from the Borana Oromo and Turkana ethnic groups in Isiolo, Kenya. The interviews were coded for key themes using grounded theory. Both sedentarized and nomadic pastoralists lacked access to key resources essential for survival; lack of water and sanitation were highly salient themes. There was a disconnect between development plans and priorities of pastoralist communities, and sedentarization programs and policies often did not improve pastoralists' access to food or water. Additionally, sedentarized pastoralists indicated high levels of unemployment, and identified a number of microbusinesses that could be used as alternative livelihoods, such as charcoal burning, and fruit and vegetable stands. Nomadic pastoralists expressed concern of the reliability of these alternative livelihoods. Both nomadic and sedentarized pastoralists recognized the tradeoffs of alternative livelihoods to environmental degradation and deforestation. Traditional coping mechanisms were mentioned by both pastoralist groups, but were exceedingly hard to implement in the wake of more severe climate change and of increased conflict between ethnic groups (as a result of competition for scarce resources). As opposed to top-down strategies that assume modernization as an appropriate transition for pastoralist communities, integration of the traditional and cultural needs, knowledge and practices of pastoralist communities could be essential to informing how pastoralists transition their livelihoods in the future.

**Keywords:** Pastoralism, tradition, ethnography, Photovoice, development

**Further collaborators:**

FATUMA ABDI, ADAN KABELO AND THE KENYA SWACEDA TEAM

## FROM MILITARY REGIME TO MARKET LIBERALIZATION: EXPLORING FOOD ENVIRONMENT TRANSFORMATIONS IN MYANMAR

(1)Downs, Shauna; (2)Fanzo, Jessica.

(1)PhD. Department of Health Systems and Policy. Rutgers University. USA.; (2)PhD. Berman Institute of Bioethics. Johns Hopkins University. USA.

After decades of military rule, in 2011 Myanmar made significant reforms towards a demographic government. While the military still has a strong presence in the country, the reforms have led to the removal of sanctions and market liberalization including increased trade and foreign investment. These economic reforms have undoubtedly led to significant changes within Myanmar, including to the local food environment. This has implications for the burden of malnutrition in the country. Undernutrition continues to persist in the country with 8% of Burmese children acutely malnourished and 40% stunted. At the same time, overweight/obesity levels are increasing in the country – 30.8% of women are overweight/obese and 11.8% have been diagnosed with Type 2 Diabetes. The Burmese are experiencing both nutritional and epidemiological transitions. However, there are gaps in knowledge about how those transitions are related to the local food environment. To address this gap, this study uses food environment mapping, market and consumer surveys, as well as focus group discussions to describe the changing food environment in both urban and rural townships in Myanmar. The food environments in the study settings examined were dynamic and largely dominated by the informal food sector, particularly in rural settings. Urban food environments had greater diversity in the types of food outlets (e.g., supermarkets, street foods, etc.), as well as the types of foods sold, as compared to rural food environments. Although rural settings still have access to packaged processed foods, these foods are much more accessible in urban settings. By characterizing the food environment in rural and urban settings in Myanmar, this study will help inform the identification of potential points for intervening to simultaneously tackle the multiple burdens of malnutrition within the context of different food environment typologies. It is likely that different policy and programmatic approaches will be needed in rural and urban settings in the country.

**Keywords:** Nutrition transition, food environment, trade liberalization
# HEALTH IMPACTS OF FOOD SYSTEMS: IDENTIFYING LEVERAGE POINTS FOR CHANGE

Rocha, Cecilia.

PhD. Economist. Centre for Studies in Food Security. Ryerson University. Canada.

The presentation discusses a recent report prepared by the International Panel of Experts on Sustainable Food Systems (IPES-Food). The report is primarily concerned with the political economy of evidence, where food systems intersect with health. It looks at how underlying dynamics and power relations shape the health impacts of those systems, and shape our understandings of those impacts. The report takes a public health perspective, which entails a focus on primary disease prevention, management of chronic conditions, and the general promotion of health, aiming to identify how the root causes of harm could be addressed. It therefore emphasizes the need for detecting social, structural, and environmental determinants of health associated with food systems, and interventions that can potentially benefit many people at a time, ensuring and enhancing conditions for population health. Furthermore, it is hoped that this report can contribute towards a better valuation of the health impacts of food systems and their consideration in policy making.

The discussion of health impacts in food systems is grouped into five channels of impact -- Occupational Hazards; Environmental Contamination, Compromised & Contaminated Foods; Unhealthy Dietary Patterns; and Insufficient Diets. The analysis is focused on health impacts which: a) appear to be most serious; b) have an impact on large numbers of people; and c) have the strongest associations with the food system. Compounding factors in the analysis include: i) systemic blind spots in the evidence base; ii) the ability of powerful actors (e.g., the food industry) to shape the evidence and frame the discussion; and iii) the complexity created by interconnected and mutually reinforcing problems. The report concludes with suggestions on systemic leverage points for change.

**Keywords:** Health impacts; food systems; food policy; food industry; public health.

**Further collaborators:**

All members of IPES-Food.

PS_144/1057

# WHY SHOULD GOVERNMENTS FOCUS ON THE LINKAGES BETWEEN NUTRITION EDUCATION AND FOOD POLICIES?

## IMPLEMENTING FOOD-BASED DIETARY GUIDELINES TO GUIDE POLICIES, PROGRAMMES AND CONSUMER FOOD AND NUTRITION EDUCATION

(1)Wijesinha Bettoni, Ramani; (2)Khosravi, Ashraf; (3)Hernandez-Garbanzo, Yenory; (4)Sherman, Jane; (5)Vargas, Melissa; (6)Islas Ramos, Ana.

(1)PhD. Nutrition Officer. Food and Agriculture Organization of the United Nations; (2)Metropolitan University College, Copenhagen, Denmark; (3)PhD. International Consultant. Food and Agriculture Organization of the United Nations, Rome, Italy; (4)MSc. Nutrition education consultant; (5)MSc. International Consultant. Food and Agriculture Organization of the United Nations, Rome, Italy; (6)Ed.D. Nutrition Officer. Food and Agriculture Organization of the United Nations, Rome, Italy.

The need for food-based dietary guidelines (FBDGs) to guide national food-related policies and programmes including food and nutrition education programmes is increasingly recognized. However, there has been a lack of information on how FBDGs are implemented by national entities, and a lack of guidance on carrying out implementation beyond dissemination. This presentation will describe the findings of a study conducted to obtain a snapshot of country actions of FBDGs implementation. A literature review and key informant interviews with staff and researchers in government ministries, national nutrition organizations and academia in 27 countries were used. The inquiry was based on the social-ecological model. Results obtained will be presented; and some preliminary recommendations on how to maximize the impact of FBDGs are given, which include the need for a consumer-centred approach; an implementation plan with built-in monitoring, evaluation, and funding; the need to target all policies/programmes that influence food, and the need to target policymakers as well as educators and the general public.

**Keywords:** Food-based dietary guidelines; implementation; food.

**Further collaborators:**

We are very grateful to all those who participated in the key informant survey. We would also like to thank the working group made up of FAO staff and external experts (Jeanette Andrade, Minna Huttunen, Sarah Levesque, Ellen Meuhlhoff, Veronica Molina-Barrera, Celeste Naude, Sonia Olivares, Aileen Robertson and Fernanda Villamarin), who have been reviewing the resource documents FAO is preparing, on FBDGs implementation possibilities for various sectors and settings. We would also like to acknowledge useful review comments provided by others who were not part of the working group, in particular Karen Fukofuka, Ann Hayman and Sirpa Sarlio-Lähteenkorva, and other colleagues from FAO. Following review by a wider group of experts, these materials will be made available free to countries. For FAO work on FBDGs, see: http://www.fao.org/nutrition/education/food-dietary-guidelines/home/en/
SUPPORTING POLICIES, PROGRAMS, AND ENA-
BLING ACTION THROUGH RESEARCH: THE WAY
FORWARD

Gillespie, Stuart.

International Food Policy Research Institute (IFPRI). United Kingdom.

Strengthening cross-sectoral country capacity for evidence-in-
formed decision-making to scale-up nutrition

Over the last decade, nutrition has moved from a neglected de-
velopment challenge to one that is centre stage in many high-level
speeches and country plans. This rise in political commitment has
to be matched by large-scale and effective action on the ground
that accelerates positive change. If not, the bubble will burst....or
deflate slowly....as other development challenges come to the fore-
front. Within the nutrition community, the focus is now squarely
on implementation and impact. Decision-makers, wherever they
are, have to make judgements based on knowledge. Knowledge of
the problem and potential solutions -- and the way it's framed and
communicated -- is one of the fundamental drivers and pre-req-
uisites of an "enabling environment" for nutrition. Knowledge de-
rives from evidence and from experience. Evidence of what works,
in different contexts, is growing and there's an increasing focus on
why certain programs work or don't work; more and more evalu-
ations are opening up the black box of implementation to shine a
light on the pathways of impact. And increasing attention is being
paid to "stories of change" which capture real-world experiences
of decision-makers as they come to terms with the complex mul-
ti-sectorality of nutrition. This short presentation seeks to bring
together lessons learnt in the management and development of
large research programs or consortia which attempt to strengthen
and expand the knowledge base on nutrition. Transform Nutri-
tion, LANSA, Stories of Change and now the SPEAR (Supporting
Policies, Programs and Enabling Actions through Research) flag-
ship of the Agriculture for Nutrition and Health (A4NH) program
have all operated in this knowledge arena in recent years. What
has been learnt about the way in which evidential and experiential
knowledge can be effectively brought to bear in different contexts.
What types of evidence can turn keys, open doors, and change
minds? Why is it so important to properly document experienc-
es of nutrition champions and decision-makers in navigating re-
al-world roadblocks and hurdles to drive an agenda forward? How
do we learn from success, or from failure?

**Keywords:** Decision-makers, nutrition, research

THE STATE OF EVIDENCE GENERATION TO SUP-
PORT NUTRITION PROGRESS IN THE COMPRE-
HENSIVE AFRICA AGRICULTURE DEVELOPMENT
PROGRAMME (CAADP)

Covic, Namukolo.

PhD. Senior Research Coordinator. Poverty health and Nutrition Division and Agriculture for Nutrition and health Programme. International Food Policy Research Institute. Ethiopia.

The African Union's Comprehensive Africa Agriculture Devel-
opment Programme (CAADP) seeks to accelerate economic de-
velopment through agriculture in recognition of agriculture being
a key economic livelihood for the continent. Over 75% of Africa's
population depend on agriculture for their source of income and
livelihoods. From inception of CAADP, through the Maputo Dec-
laration in 2003, African Heads of State committed to spending at
least 10% of national GDP on Agriculture and aim for at least 6%
annual growth in the sector. Although addressing hunger was one
of the goals there were no specific nutrition targets stated. In 2011
NEPAD and FAO commenced a capacity strengthening programme
towards mainstreaming nutrition in national agriculture invest-
ment plans. In 2014 under the Malabo Declarations African Heads
of State reaffirmed the 2003 commitments but in addition includ-
ed specific nutrition targets within the broader objective of ending
hunger and malnutrition. The Malabo targets are to reduce stunting
to 10% and wasting to 5% by 2025. As a result, the CAADP results
framework now has some nutrition related indicators: undernour-
ishment, underweight, stunting, wasting, minimum acceptable diet
for children 6-23 months, and Minimum Diet Diversity for women.
There is now an agreed biennial review of CAADP starting in 2017.
There is, therefore, an opportunity to address diet quality and nutri-
tion within CAADP calling for greater attention to related evidence
generation and the challenges this presents.

The CAADP monitoring platform is the Regional Strategic
Analysis and Knowledge Support System (ReSAKSS) led by IFPRI
for the NEPAD Coordination Agency of the African Union. It is
structured to take place through Joint Sector Reviews at country
level with reporting at country, regional and continental levels
through ReSAKSS structures. Like SUN, the country level process
encourages multisectorality presenting opportunities for synergy
if greater alignment takes place. There are significant challenges
relating to generation of the needed data/evidence. For nutrition,
most African countries have relied heavily on DHS and UNICEF
MICS data but these are only collected every 3-5 years and limited
resources and capacity may lead to some surveys not being admin-
istered timeously. Some countries are now implementing annual
SMART surveys but these too have depended on external resourc-
es from development partners. An advantage of DHS data is that
it is collected in collaboration with National Statistics Offices who
also collect agriculture data but this needs to be better leveraged
for nutrition. It is important to take cognisance that effective-
ly monitoring nutrition to inform progress and policy decisions
goes beyond tracking trends. It also requires continued generation
of programme implementation data and evidence both quantita-
tive and qualitative to improve programme contextualization and
quality for subnational situations given the diverse contexts. It
further requires that evaluators and researchers can be candid in reporting and that decision makers become receptive to such reporting to develop genuine synergy among all relevant processes. The state of evidence, challenges and opportunities for evidence generation within CAADP will be presented.

**Keywords:** CAADP, nutrition evidence, agriculture and nutrition, Africa

## STRENGTHENING CAPACITY FOR EVIDENCE-INFORMED DECISION-MAKING IN AFRICA: EVIDENT LESSONS AND OPPORTUNITIES

(1)Aryeetey, Richmond; (2)Colecraft, Esi; (3)Hailu, Tesfaye; (4)Kolsteren, Patrick; (4)Lachat, Carl; (5)Taljaard, Christine; (6)Verstraeten, Roosmarijn.

PhD. Senior Lecturer. University of Ghana School of Public Health. Legon. Ghana; (2)DrPH. Nutritionist. Nutrition and Food Science Department. University of Ghana, Legon, Ghana; (3)MSc. Nutritionist. Ethiopian Public Health Institute (EPHI). Addis Ababa. Ethiopia; (4)Department of food safety and food quality. Ghent University. Belgium; (5)PhD. Nutritionist. Centre of Excellence for Nutrition, North-West University, Potchefstroom Campus, South Africa; (6)PhD. Nutritionist, Independent Researcher, Belgium.

**Background and objectives:** Unacceptably high rates of malnutrition in Africa persists, despite considerable knowledge and technology to address its determinants. A missing link is the access to and use of quality evidence. In the African context, there is disconnect between evidence generators and users, effectively limiting uptake of knowledge for better policies and programs. The EVIDENT (Evidence-informed Decision-making in Nutrition and Health) partnership was established in 2014 to address this gap. EVIDENT aims to enhance Evidence-informed Decision-making (EIDM) by bridging linking researchers and decision-makers and strengthening their capacity to co-create solutions to address local needs. EVIDENT's EIDM framework proposes to identify and prioritize information needs, systematically appraise existing evidence, and translate it into concrete recommendations actionable by responsible bodies. We present the findings of a project evaluation, conducted in 2016 to determine stakeholders' perception of the added value and quality of EVIDENT, and lessons learned regarding drivers, barriers, and opportunities for EIDM in Africa.

**Methodology:** The evaluation used mixed methods including in-depth interviews of EVIDENT partners and stakeholders; project documentation including partner meeting minutes, protocols, and annual reports; and an online survey administered to partners and stakeholders. The evaluation focused on i) the implementation of activities with regard to EVIDENT's goal, expected outputs, and milestones; ii) barriers, challenges and opportunities for a future EVIDENT; and iii) lessons learnt for EIDM.

**Results:** EVIDENT achieved the goals of championing EIDM in Africa through: capacity strengthening (delivering courses in evidence synthesis and contextualisation; n=70 persons), tool development (Evidence synthesis guidance and process tools devel-

oped), understanding EIDM landscape in different contexts (four country case-studies explored current country-specific EIDM procedures), and responded to local priorities (5 systematic reviews on various topics currently being conducted). EVIDENT has also recognized the need to ensure good Africa-based leadership and coordination; Ghana and South Africa are currently sharing coordination role in EVIDENT. EVIDENT's challenges included insufficient funding arrangements, leading to inadequate time commitment by partners, feeling of disconnectedness while working virtually, and initial lack of experience in EIDM. Despite these, EVIDENT was well received, globally. Lessons learnt from implementing EVIDENT includes: existence of high demand for EIDM at both regional and country levels, need to establish partnerships with existing regional/global platforms (e.g. SUN, CAADP, etc.) for sustainability, EIDM needs to adapt processes to individual settings rather than a one-size-fits-all approach, and realization that evidence synthesis (e.g. systematic reviews) takes more time to achieve results than often expected.

**Conclusion and recommendations:** EVIDENT has become a champion of EIDM in nutrition in Africa. Continued efforts focusing on leadership, creation of demand for evidence in nutrition policy and programming in Africa, are needed to capitalize on the investment made in capacity throughout EVIDENT's lifetime. The lessons from the evaluation can contribute to future perspectives on EIDM in Africa and elsewhere.

**Keywords:** Decision-making, lessons learnt, evaluation, Africa, evidence

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# THE CHANGING NUTRITION LANDSCAPE: IMPLICATIONS FOR RESEARCH

## UNSCN TRACKING EMERGING ISSUES AND BROKERING KNOWLEDGE

Oenema, Christine Hendrika.

Coordinator. United Systems Standing Committee on Nutrition.

The United Nations Standing Committee on Nutrition was renewed in 2016, resulting in a new Strategic Plan for the period 2016-2020. Its main task is to maximize coherence of nutrition policy and advocacy in the UN system as well as to support the consistent and accountable delivery by the UN system at country level. The achievement of these objectives is supported by among others, the exploration of new and emerging nutrition related issues and the active brokerage of new knowledge and insights

Since early 2016 UNSCN has participated in several academic fora and conferences. It has inquired among its members about emerging issues that are related to their work or impacting on it. Also in 2016, the UN General Assembly launched the UN Decade of Action on Nutrition. The Decade is organized around 6 action areas:

* Sustainable and resilient food systems for healthy diets;

* Aligned health systems providing universal coverage of essential nutrition actions;
* Social protection and nutrition education;

* Trade and investment for improved nutrition;

* Safe and supportive environments for nutrition at all ages and;

* Strengthened governance and accountability for nutrition

Since the finalization of the work program for the Decade, gov-
ernments have started to make SMART commitments to support
the success of the Decade. In addition action networks are being
formed and shaped in an organic way to support the delivery of
results in the 6 action areas.

The current challenge is if we know enough to deliver sustain-
able results? Are the current areas of interest that are covered by
knowledge platforms and current research by academia sufficient
to support the intensification of sustainable actions and results,
ultimately leading to the elimination of all forms of malnutrition
in 2030? In addition: do we know enough about the large range of
actors and their respective contributions? How do we ensure good
governance for nutrition?

During this seminar UNSCN will present some emerging issues
related to nutrition and explore how well they are being covered by
current research as well as where questions remain to be answered.

Keywords: Emerging issues, research

SUSTAINABLE FOOD SYSTEMS? EXPLORING
THE CROSS ROAD BETWEEN POLICIES AND RE-
SEARCH IN THE COMMITTEE ON WORLD FOOD
SECURITY

Caron, Patrick.

PhD. HDR. in Geography. CIRAD, Montpellier, France. Chairperson of the High Level Panel of Experts on Food Security and Nutrition of the CFS.

The Committee on World Food Security (CFS) is the foremost inclusive and evidence-based international and intergovernmen- tal platform for food security and nutrition (FSN), where policies can be designed, interventions can be coordinated, options can be shared and decisions at different levels can be prepared.

The High Level Panel of Experts on FSN (HLPE), science-policy interface of the CFS, was created in October 2009, as an essential element of the reform of the CFS, with three key functions: (i) as- sess and analyze the current state of FSN and its underlying causes; (ii) provide scientific analysis on specific policy-relevant issues; and (iii) identify critical and emerging issues for FSN. All the HLPE reports are available online: http://www.fao.org/cfs/cfs-hlpe/en/.

The HLPE organizes an inclusive scientific dialogue, building upon the diversity of disciplines, backgrounds and knowledge systems. It thrives to propose a common language, clarify contra- dictory information and knowledge, elicit the backgrounds and rationales of controversies: “One of the key roles of the HLPE re- ports is to help members and participants in CFS to understand why they disagree” (MS Swaminathan, 1st HLPE Chairperson).

In 2014, in its first note on critical and emerging issues for
FSN, the HLPE highlighted the importance of healthy nutrition
in changing food systems. Globally, one person in three today is
malnourished. If current trends continue, this figure will reach one

in two by 2030. The human health, environmental, economic and
social consequences of malnutrition are crippling and the burdens
created by malnutrition are transmitted across generations. Un-
derstanding the causes of this situation is key to any action to im-
prove nutrition. It requires considering recent evolutions of diets
and food systems and their drivers: how and why do diets change?
What are the links between diets, consumption and consumer
habits and food systems? How do changes in food systems affect
changes of diets, and therefore health and nutritional outcomes?

Building on the momentum of the International Conference
on Nutrition (ICN2) in 2014, the UN Decade of Action for Nu-
trition and the SDGs, the CFS requested the HLPE to produce a
report on Nutrition and food systems. The purpose of this report
is two-fold: (i) to analyse the ways in which food systems and di-
etary patterns interact and result in nutritional outcomes for in-
dividuals; and (ii) to highlight effective policies and programmes
that shape food systems in order to contribute more effectively to
improved nutrition and ensure the right to healthy food for all in
a sustainable way.

The report identifies three main elements of food systems (food value chain, food environment, and consumer behaviour) on which policies can act to improve diets and nutrition outcomes. It provides examples of successful policies and programmes and concrete recommendations to different stakeholders on how to progress towards this objective. It also points out to the need for further interdisciplinary and inter-sectorial research covering all the aspects of food systems, from production to consumption, to help design more effective nutrition-sensitive policies and programmes adapted to different contexts.

Keywords: CFS, HLPE, nutrition, food systems

WHY AREN'T WE DOING MORE RESEARCH INTO
THE ROLE OF BUSINESS IN NUTRITION?

Haddad, Lawrence.

Executive Director, GAIN.

There is precious little research into the impacts of public pri-
vate partnerships in nutrition. Is this due to the lack of such PPPs
in nutrition or is it due to systemic factors in the research infra-
structure? If the latter, what are they and how can they be trans-
formed? The presentation addresses these questions.

Keywords: Business research
# NUTRITION, RESEARCH AND THE SDGS: LESSONS GARNERED FROM THE GLOBAL NUTRITION REPORT ON CATALYZING PROGRESS TOWARDS 2030

In 2015, UN Member States adopted 17 ambitious Sustainable Development Goals, with the aim of transforming our world. Countries are currently working out how to make progress on these goals a reality on the ground.

Two specific targets are directly relevant to nutrition: SDG Target 2.2. is to end malnutrition in all its forms; target 3.4 is to reduce by 30% premature mortality from NCDs, which includes obesity as an indicator. Decades of evidence show that ending malnutrition will take much more than just specific actions designed to prevent or treat it; it will take actions that address its underlying causes, such as poverty reduction, education, gender equality, and water and sanitation. At the same time, investing in nutrition can deliver dividends for these sectors. The potential exists for an integrated approach to deliver not just nutrition but other targets as well.

If we are to fully realise the ambition of the nutrition SDGs, research will play a critical role. The 2017 Global Nutrition Report (GNR) shows that all 189 countries for which data are available are off course to meet obesity targets if current trends in continue unabated. For the diabetes indicator, 8 countries had a probability of ≥0.50 of meeting the 2025 target among men, and 26 countries are likely to meet the target for women. 19 countries are on course to meet the stunting target, 30 for wasting, 31 for overweight, and 20 for exclusive breastfeeding. The figures highlight the lack of frequent data to make robust assessments of progress, and a lack of evidence on how interventions can integrate and work best to tackle multiple burdens of malnutrition.

The 2017 GNR will highlight a number of key research gaps which need to be filled, from adolescent nutrition to 'double duty' actions which tackle malnutrition and other development challenges simultaneously. In this symposium, Professor Jessica Fanzo will give a preview of some of the findings of the 2017 GNR, and how research can help countries accelerate progress and ensure accountability towards the SDGs – and improved nutrition outcomes.

**Keywords:** SDGs, double duty, burdens of malnutrition, accountability

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# SCALING UP, SUSTAINING, AND SPINNING OFF: ALIVE & THRIVE'S LESSONS ON INFANT AND YOUNG CHILD FEEDING IN THREE COUNTRIES, AND IMPLICATIONS FOR BEYOND

## IMPACT: INTERVENTION RESULTS FROM ALIVE & THRIVE

An evidence-based package of maternal, infant and young child nutrition (MIYCN) interventions can contribute to optimal maternal and child nutrition and long-term human capital benefits. Several MIYCN interventions recommended for global scale-up are dependent on successful behavior change to strengthen dietary practices and support the use of supplements. Although evidence exists that behavior change interventions (BCI) using interpersonal communications (IPC) work, lessons on effectiveness at large-scale are limited. In a set of impact and process evaluations of large-scale BCI that included IPC, mass media (MM) and policy advocacy (PA) in Bangladesh, Viet Nam, and Ethiopia, we examined impact on breastfeeding and complementary feeding practices (in all three countries) and maternal nutrition behaviors (in Bangladesh).

We used cluster-randomized impact evaluations in Bangladesh and Viet Nam, and a before-after adequacy evaluation design in Ethiopia. All evaluations used repeated cross-sectional surveys of women with children in the appropriate age-group for the results examined (0-6 months, 6-23 months). Statistical analyses examined differences in change over time between intervention and comparison areas, adjusting for clustering and confounders (as needed).

Intervention impacts on infant feeding were predominantly positive in all three countries. In Bangladesh, impacts were seen on breastfeeding and complementary feeding practices (exclusive breastfeeding, dietary diversity and minimum acceptable diet). In Vietnam, impacts were seen on breastfeeding practices (exclusive breastfeeding). In Ethiopia, although the adequacy evaluation design limits attribution, positive change was seen in several behaviors. The maternal nutrition study in Bangladesh found significant impacts on a range of maternal nutrition behaviors, including uptake of supplements and dietary diversity.

The type of delivery platform used for the IPC was related to the achieved exposure to interventions among client populations. Exposure was high in Bangladesh for the IYCF support interventions and the maternal nutrition interventions; both used a large-scale non-governmental outreach platform that included nutrition-focused workers. In Vietnam, where the delivery plat-

<footnote>(1)Fanzo, Jessica; (2)Hawkes, Corinna; (3)Udomkesmalee, Emorn.</footnote>

<footnote>(1)Johns Hopkins University and the Global Nutrition Report;</footnote>

<footnote>(2)City University of London and Centre for Food Policy; (3)Institute of Nutrition of the Mahidol University in Thailand.</footnote>

<footnote>(1)Menon, Purmina; (2)Nguyen, Phuong; (2)Kim, Sunny; (3)Saha, Kuntal K; (4)Frongillo, Edward; (5)Ruel, Marie.; (6)Rawat, Rahul.</footnote>

<footnote>(1)International Food Policy Research Institute; (2)PhD. Research Fellow. International Food Policy Research Institute; (3)World Health Organization; (4)Professor. University of South Carolina;</footnote>

<footnote>(5)Division Director. Poverty Health and Nutrition Division. International Food Policy Research Institute.; (6)Program Officer. Bill & Melinda Gates Foundation.</footnote>
form was through government health facilities that clients had to access, exposure was moderate. In Ethiopia, exposure was lower given delivery through a government health system platform and multipurpose health workers.

Analyses of behaviour uptake in intervention areas in Bangladesh and Vietnam showed that Caesarian-section births, lack of breastfeeding support at birth, and poor knowledge were associated with lower early initiation of breastfeeding. Return to work before the child was 6 months old and maternal stress were associated with lower EBF in Vietnam; in both countries, low maternal knowledge made EBF less likely. In Bangladesh, babies of mothers in the lowest tertile of SES were less likely to achieve minimum dietary diversity.

In conclusion, we demonstrate the feasibility and impact of delivering a set of MIYCN behaviour change interventions in multiple contexts. Our results highlight the range of opportunities and challenges offered by diverse intervention delivery platforms and the contexts for intervention uptake. Looking forward, coupling high quality and large scale BCI interventions with policies and programs that address contextual behaviour-specific constraints can deliver further substantial impact.

**Keywords:** Program evaluation, behavior change, scaling up, breastfeeding, complementary feeding

## ALIVE & THRIVE GENERATION 2: EXPANDING OUR LEARNINGS TO NEW GEOGRAPHIES; NEXT STEPS AND SUSTAINABILITY

(1)Lapping, Karin; (2)Hajeebhoy, Nemat; (3)Alayon, Silvia; (4)Sanghvi, Tina.

(1)Project Director, Alive & Thrive, FHI 360; (2)Bill and Melinda Gates Foundation; (3)Alive&Thrive, FHI 360 & Save the Children; (4)Alive & Thrive, FHI360.

Delivering Maternal, Infant and Young Child (MIYCN) solutions sustainably and on a large scale remains a challenge. High intensity, short duration programs result in fewer lives saved than efforts that build MIYCN capacity and strengthen systems. Embedding programs and critical services within government policy and regulatory guidelines has been effective across development sectors, including MIYCN. Phase 1 (2009-2014) of A&T was designed as a proof of concept to illustrate whether infant feeding practices could be changed at scale, with sustainability incorporated to varying degrees. In phase 2, one of the key learning objectives was to gain a better understanding of the extent to which programs and behaviors are sustained after grant funding ends. A sustainability assessment is examining the determinants of phase 1 program sustainability in Bangladesh and Viet Nam. These determinants may be related to program activities or approaches A&T used during phase 1 operations, or the result of organizational or contextual factors. We will share preliminary results from these assessments. We will share implications on our current and future efforts.

**Keywords:** Sustainability, behavior change, replication, breastfeeding, complementary feeding

# Track 4: Nutrition and Management of Diseases

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PREVENTION OF TYPE-2 DIABETES IN OVERWEIGHT AND OBESE SUBJECTS. ACHIEVEMENTS AND RESULTS FROM THE LARGE EU-PROJECT, PREVIEW

## THE PREVIEW INTERVENTION STUDY-PRELIMINARY RESULTS FROM > 2,000 SUBJECTS ON BODY WEIGHT AND RISK FACTORS FOR TYPE-2 DIABETES

Raben, Anne.

Professor. Dep Nutrition, Exercise and Sports. University of Copenhagen.

Type-2 diabetes (T2D) is one of the fastest growing chronic diseases worldwide. The relative risk of T2D rises exponentially with increasing body mass index (BMI) and people with diabetes have a 2-4 times higher risk of dying from heart disease compared to non-diabetics. Previous diabetes prevention studies have mainly used the officially recommend diet. However, the FP6 EU project "DiOGenes" showed that participants assigned to an ad libitum diet with higher protein and lower glycemic index (GI) had a significantly better weight maintenance and completion rate after an 8 weeks weight loss diet compared with the official dietary guidelines. Whether such a diet is also efficient in diabetes prevention has not yet been investigated.

The main objective of PREVIEW (PREvention of diabetes through lifestyle Intervention and population studies in Europe and around the World) is to determine if a high-protein, low-glycaemic index (GI) diet in combination with moderate or high intensity physical activity can prevent the development of type-2 diabetes in pre-diabetic, overweight individuals, compared with a moderate protein and GI diet. Furthermore, the interaction with the lifestyle factors, habitual stress and sleeping pattern as well as behavioural, environmental, cultural, and socioeconomic variables is also investigated.

The objectives are achieved from two lines of evidence: 1) A worldwide, multicentre, 3-y randomised controlled trial (RCT) in 2,500 overweight and obese pre-diabetic participants from 9 intervention centres and

2) Longitudinal population studies using data from 5 different cohorts (about 130,000 subjects). The RCT in adults starts with an 8-wk weight loss phase (Cambridge Weight Plan®) followed by a 4-arm weight maintenance phase.

In the randomized controlled trial 2,326 adults (2/3 women) were eligible after pre-screening > 15,600 and screening > 5,400 volunteers over a period of 1.5 years. A total of 1,856 (80%) participants completed the weight loss phase successfully (≥ 8% weight loss). Mean (+/-SE) body weight decreased by 10.7 ± 0.4 kg (~11%), fasting glucose by 0.4 ± 0.1 mmol/L, HbA1c by 2.1 ± 0.2 mmol/
mol, and insulin by 4.5 ± 0.4 mU/L (p< 0.001). Based on fasting glucose >1/3 were no longer pre-diabetic after the weight loss phase. After 1.5 years of ad libitum diet and exercise programs, preliminary data analyses showed that weight loss was still ~10% of initial body weight (completer analyses, n ≈ 1,200).

The project is still in its active phase. In the RCT, large decreases in body weight, glucose and insulin were seen after the initial 8 wk weight loss. In those still participating after 1.5 y, weight loss was well maintained. The effect of changing protein, GI and exercise in the RCT will be disclosed when the 3 year intervention has been completed. The first results on sleep and stress from the RCT, as well as main analyses from the population studies are presented in the other PREVIEW conference abstracts.

PREVIEW (wwwerbewerkung.com) (2013-2018) is funded by EU FP7 grant # 312057 and national funds in NZ, AUS, and CAN. The Cambridge Weight Plan® generously donated the formula diets for all centres.

**Keywords:** Weight loss, diabetes prevention, diet, exercise

**Conflict of Interest disclosure:** JBM is President of the not-for-profit Glycemic Index Foundation, director of a GI testing service and author of books about the GI.

**Further collaborators:** Mikael Fogelholm, Thomas M. Larsen, Margriet Westerterp-Plantenga, Ian Macdonald, Pia Christensen, Gareth Stratton, J. Alfredo Martinez, Mathijs Drummens, Santiago N Carretero, Tanja Adams, Roslyn Muirhead, Marta Silvestre, Teodora Handjieva-Darlenska, Sally Poppitt, Wolfgang Schlicht, Jennie Brand-Miller, and all members of the PREVIEW consortium.

## THE PREVIEW POPULATION STUDIES: ROLE OF LIFESTYLE FACTORS (EG PROTEIN, GLYCEMIC INDEX) IN RELATION TO PRE-DIABETES AND DIABETES RISK

Diabetes mellitus is one of the most common emerging diseases of the 21st century. A healthy lifestyle, including diet, physical activity and sleep, is a factor in a type 2-diabetes (T2D) preven-

tion strategy. Within the PREVention of diabetes through lifestyle Intervention and population studies in Europe and around the World (PREVIEW) project, we studied cross-sectional and prospective associations between lifestyle factors and diabetes in five population studies.

From the Lifelines Cohort study (Netherlands), NQplus study (Netherlands), Cardiovascular Risk in Young Finns Study (YFS; Finland), New Zealand Adult Nutrition Survey 2008/09 (NZANS), and the Quebec Family Study (QFS; Canada), data of about 130,000 subjects were included. Follow-up information was available for almost 71,000 subjects. Diabetes at baseline and follow-up was ascertained using fasting glucose, HbA1c, and self-reported diagnosis or medication use. Dietary intake was assessed with food frequency questionnaires, 24-hour dietary recall, or a 3-day dietary record. Physical activity and sleep duration were assessed with a self-reported questionnaire or a 3-day activity record. Prevalence and Incidence Ratios (PR and IR) were estimated for abnormal glucose tolerance (AGT; pre-diabetes and diabetes combined) and diabetes by Cox regression. Risk estimates were pooled using random-effects meta-analysis. Multiple adjustments were made for energy, age, sex, education, medical history, and other lifestyle factors.

A higher energy-adjusted total protein intake (g/day) was associated with a higher prevalence of diabetes: pooled PR of 1-STD increase 1.39 (95%CI 1.15, 1.67). Total protein was also prospectively related to a higher risk of diabetes: pooled IR from four population studies for 1-STD increase was 1.13 (95%CI 1.05, 1.21). Total protein was not associated with AGT. Additional adjustment for BMI and waist attenuated the associations. A 1-STD higher GI was not related to diabetes prevalence, but to a higher diabetes incidence; pooled IR was 1.06 (95% CI 1.02-1.10). A 1-STD higher GL was associated with a lower diabetes prevalence, pooled PR was 0.53 (95% CI 0.35, 0.81), but not with AGT prevalence. Also, the protective association between GL and diabetes did not persist in the prospective analyses. Furthermore, higher levels of moderate and intense physical activity and a longer sleep duration were associated with a lower risk of diabetes.

These analyses of five global population studies, comprising >125,000 participants, showed that a higher protein intake was weakly related to a higher diabetes prevalence and incidence. High GI was related to diabetes incidence. Higher levels of physical activity as well as a longer sleep duration were related to a lower diabetes risk, independent of energy intake.

**Keywords:** Diet, protein, glycemic index, physical activity, sleep, pre-diabetes, diabetes

**Conflict of Interest disclosure:** JBM is President of the Glycemic Index Foundation, a not-for-profit food endorsement program, manager of a GI testing service at the University of Sydney, and the co-author of books about the glycaemic index of foods. All other authors declare no conflicts of interest.

<footnote>(1)Feskens, Edith; (2)Sluik, Diewertje; (3)Mikkilä, Vera; (4)Poppitt, Sally;</footnote>

<footnote>(5)Silvestre, Marta; (6)Tremblay, Angelo; (7)Bouchard, Claude; (8)Brand-Miller, Jennie; (9)Raben, Anne.</footnote>

<footnote>(1)Division of Human Nutrition and Health. Wageningen University. The Netherlands; (2)PhD. Epidemiologist. Division of Human Nutrition and Health. Wageningen University. The Netherlands;</footnote>

<footnote>(3)PhD. Epidemiologist. Division of Nutrition. Department of Food and Environmental Sciences. University of Helsinki. Finland;</footnote>

<footnote>(4)PhD. Professor. Human Nutrition Unit. Department of Medicine and School of Biological Sciences. University of Auckland. New Zealand; (5)PhD. Human Nutrition Unit. Department of Medicine and School of Biological Sciences. University of Auckland. New Zealand; (6)PhD. Professor. Department of Kinesiology. Université Laval. Québec City. Canada; (7)PhD. Human Genomics Laboratory. Pennington Biomedical Research Center. Baton Rouge. USA;</footnote>

<footnote>(8)PhD. Professor. School of Life and Environmental Biosciences and Charles Perkins Centre. The University of Sydney. Australia;</footnote>

<footnote>(9)PhD. Department of Nutrition, Exercise and Sports. Faculty of Science. University of Copenhagen. Denmark.</footnote>
# THE ROLE OF SLEEP AND FOOD REWARD IN PRE-VENTION OF INSULIN RESISTANCE IN PRE-DIABETIC OVERWEIGHT SUBJECTS – RESULTS FROM THE PRE-VIEW INTERVENTION STUDY

(1)Westerterp-Plantenga, Margriet; (2)Drummen, Mathijs; (3)Adam, Tanja; (4)Vreugdenhil, Anita; (5)Dorenbos, Elke; (6)Fogelholm, Mikael; (7)Larssen, Thomas Meinert; (8)MacDonald, Ian A.; (9)Martínez, J. Alfredo; (10)Handjiev, Svetoslav; (11)Poppitt, Sally; (12)Brand-Miller, Jennie; (7)Raben, Anne.

(1)PhD. Department of Human Biology, Faculty of Health, Medicine, Life Sciences. School for Nutrition and Translational Metabolism. Maastricht University. Maastricht. The Netherlands.; (2)MSc. Department of Human Biology, School for Nutrition and Translational Metabolism. Maastricht University. Maastricht. The Netherlands.; (3)PhD. Department of Human Biology, School for Nutrition and Translational Metabolism. Maastricht University. Maastricht. The Netherlands.; (4)PhD, MD. Department of Paediatrics, School for Nutrition and Translational Metabolism. Maastricht University. Maastricht. The Netherlands.; (5)MSc. Department of Paediatrics, School for Nutrition and Translational Metabolism. Maastricht University. Maastricht. The Netherlands.; (6)PhD. Department of Nutrition, Exercise and Sports, University of Helsinki, Helsinki, Finland; (7)PhD. Department of Nutrition, Exercise and Sports, SCIENCE, University of Copenhagen; (8)PhD. MD. University of Nottingham, Nottingham, United Kingdom; (9)PhD. University of Navarra, Pamplona, Spain; (10)PhD. University of Sophia, Sophia, Bulgaria; (11)PhD. University of Auckland, Auckland, New Zealand; (12)PhD. University of Sydney, Sydney, Australia.

Lifestyle factors such as sleep, stress, diet and its rewarding value, and physical activity have been shown to be associated with insulin sensitivity. Within PREVIEW, the role of these factors in prevention of insulin resistance is being assessed. At baseline, i.e. Clinical Investigation Day 1 (CID1) the number of adult subjects was 2,224; mean (±SD) age was 51.6±11.6 years, BMI 35.3±6.5 kg/m. After weight loss, at CID2, their number was 1,856; BMI 31.40 ± 6.0 kg/m, and at CID3, six months after the start, their number was 1,571 BMI 30,67 ± 5,52 kg/m. Insulin resistance assessed by HOMA-IR (HMeostasis Model Assessment; estimated Insulin Resistance) was determined as 3,75±2,43 at CID1, 2,27±1,61 at CID2, and 2,28±1,32 at CID3. At baseline, no associations with sleep assessment (Epworth Sleepiness Scale (ESS) and the Pittsburgh Sleep Quality Index (PSQI)), or with chronic stress perception (Perceived Stress Scale (PSS) were observed. Insulin resistance was related to perception of fatigue in women and vigour in men (Profile of Mood Status), possibly representing limited substrate availability, thus limiting glucose availability in the cells. The impact of insulin resistance, weight status, and lifestyle factors to brain reward activation in response to visual food cues was investigated in a sub-population of the PREVIEW study, at baseline. In 39 obese, pre-diabetic subjects (m22/f17; BMI: 32.3±0.6 kg/m2; fasting glucose: 6.3±0.1 mmol/l; fasting insulin: 13.6±1.0 mU/l; HOMA-IR: 3.9± 0.3) brain reward activity was assessed by functional magnetic resonance imaging while viewing randomized blocks of food and non-food images. Brain activation (food vs non-food) was extracted in a priori defined food reward regions-of-interest (ROIs). Contribution of eating behavior (TFEQ), habitual

physical activity (Baecke), HOMA-IR, BMI or body fat percentage were determined utilizing multiple regression analysis. In the nucleus accumbens (R2=0.3; p=0.003), insula (R2=0.3; p=0.010), prefrontal cortex (R2=0.3; p=0.015) and putamen (R2=0.2; p=0.034), brain activation was predicted by HOMA-IR, independent of BMI and body fat percentage (P<0.05). Brain activation was inversely related to restraint scores and habitual physical activity in multiple food reward ROIs, after adjusting for HOMA-IR, BMI and body fat percentage (P<0.05). Six months after the start, in the complete group of subjects, at CID3, the increased magnitude of the behavioural factor cognitive restraint TFEQ (F1) contributed significantly to the reduction in insulin resistance, controlled for loss of body weight and body fat, and no further associations between changes in insulin resistance and in sleep, stress, or physical activity scores were observed. In conclusion, individuals with prediabetes showed at baseline, independently of BMI and body fat percentage more activity to food cues in brain reward regions. In addition, independently of insulin resistance, both dietary restraint and habitual physical activity appeared to be associated with decreased reactivity to food cues in brain reward regions. The intervention induced change in insulin resistance after six months was related to the behavioural factor cognitive restraint, independently of loss of body weight and body fat. No further associations between changes in insulin resistance and in sleep, stress, or physical activity scores were observed.

**Keywords:** Dietary restraint, physical activity, stress, brain signaling.

**Conflict of Interest disclosure:** JBM is President of the Glycemic Index Foundation, a not-for-profit food endorsement program, manager of a GI testing service at the University of Sydney, and the co-author of books about the glycemic index of foods. We have no further conflict of interest to disclose

# HOW STARCH CHANGED OUR GENES: AMY1 COPY NUMBER VARIATION AMONG PEOPLE AT RISK OF DIABETES. A PREVIEW SUB-STUDY

(1)Brand-Miller, Jennie; (2)Atkinson, Fiona.

(1)PhD. Nutrition Scientist. Charles Perkins Centre. University of Sydney. Australia.; (2)PhD. Nutrition Scientist. Charles Perkins Centre, University of Sydney. Sydney. Australia.

In humans, but not other primates, the salivary amylase gene (AMY1) shows remarkable variation in copy number. Like lactase enzyme persistence, it represents one of the best examples of gene expression adaptation due to diet during human evolution. Populations with traditionally low starch diets show lower average AMY1 CN compared to populations consuming starch-rich diets, independent of geographical region or shared ancestry. AMY1 copy number correlates with the amount of salivary alpha-amylase, but beyond this, the phenotypic and physiological significance is uncertain.

To test the hypothesis that AMY1 copy number increases the rate and extent of starch digestion in healthy subjects and influences risk factors for obesity and diabetes.

We used real-time quantitative PCR with AMY1-specific primers to estimate AMY1 copy number in 201 healthy individuals and
160 overweight and obese participants with pre-diabetes in the Sydney-based cohort of the PREVIEW intervention study.

Copy number (CN) varied from 1 – 16 copies (mean ± SD = 6.5 ± 2.6) in the healthy cohort, correlating positively with salivary amylase activity (r = 0.62, p < 0.0001) but not with BMI, glucose tolerance or insulin sensitivity. In individuals with pre-diabetes, mean CN was higher (7.4 ± 2.9, p = 0.005) and weakly related to measures of body fat. In a pool of 114 healthy individuals with the full range of variation, CN was a strong predictor of normalized glycemic responses to potato (n = 45, r = 0.78, p = 0.0001), white bread (n = 98, r = 0.67, p = 0.0001), rice (n = 56, r = 0.66, p = 0.0001), rolled oats (n = 42, r = 0.63, p = 0.0001), pasta (n = 95, r = 0.51, p = 0.0001) and a mixed meal (n = 24, r = 0.60, p = 0.0021), explaining 26-61% of the inter-individual variation in glycaemia. In contrast, CN was not significantly related to normalized glycemic responses to sucrose (table sugar, n = 60, r = 0.08, p = 0.54) or fruit (n = 29, r = 0.20, p = 0.30). Using genotype-based recall, healthy individuals in the highest vs lowest decile of CN produced modestly higher glycaemia (+15%) and substantially higher peak insulin responses (+38%) to starchy foods, suggesting earlier first phase insulin secretion. In the fasting state and in response to meals of white rice, with and without resistant starch, low CN individuals with and without pre-diabetes displayed 6-fold higher breath methane levels than high CN individuals (n = 30, p = 0.001) but similar levels of hydrogen.

Taken together, the findings imply that the ability to digest starch faster and more completely was a strong selective force during human evolution, with relevance to the risk of diabetes and obesity today. The distinct differences in breath methane in those with low vs high CN imply not only differences in the amount of carbohydrate reaching the large bowel, but also in the microbiome itself.

**Keywords:** AMY1 gene, starch digestion, diabetes, obesity.

**Conflict of Interest disclosure:** JBM and FA are directors of not-for-profit Glycemic Index Foundation, a GI testing service at the University of Sydney, and co-authors of books about the GI.

**Further collaborators:** Dale Hancock (University of Sydney AU), Anne Raben (University of Copenhagen, DK).

## EXPLOITING PREVIEW FINDINGS: A FOOD INDUSTRY PERSPECTIVE

Brand-Miller, Jennie.

PhD. Nutrition Scientist. Charles Perkins Centre. University of Sydney. Australia.

Dissemination and exploitation of the findings of PREVIEW is the focus of a specific work package within the EU-funded PREVIEW project. Previous diabetes prevention studies have proven that type 2 diabetes can be prevented or delayed by lifestyle interventions that focus on diet, exercise and weight loss. However, the composition of the optimal diet for maintenance of weight loss is still debated. The PREVIEW project will determine whether a modestly higher protein-lower glycemic index (GI) improves weight maintenance compared with official dietary guidelines. The findings will have important implications for the food industry.

To communicate and exploit the findings of PREVIEW in order to convert new knowledge into socio-economic benefits, including more effective strategies in public health, products and services that reduce the risk of obesity and type 2 diabetes. A sub-objective is to secure and manage the transfer of exploitable knowledge and intellectual property generated by PREVIEW to the food industry and service providers in the area of health and diet.

PREVIEW's research programme is highly likely to produce outcomes which have the potential for commercial exploitation. This is especially true for the food industry and manufacturers, but also for other sectors delivering services and policies which can aim to treat and prevent overweight and obesity, and type-2 diabetes in people at risk. We have established a pro-active approach to identifying exploitable outputs, including training in basic IPR principles and creation of a patent advisory group. License agreements will be managed by the Consortium when the findings of the intervention study become available in the middle of 2018.

Potential agreements based on the work and findings of PREVIEW include 1) professional software incorporating an international glycaemic index and glycaemic load database, 2) lifestyle change manuals for health professionals with new tools to reduce weight re-gain, 3) online weight loss and diabetes prevention programs, 4) identification of novel biomarkers (genomic/proteomic/metabolomics) to predict weight loss and improved insulin sensitivity taking into account the genetic and environmental background 5) identification of novel food ingredient systems to induce satiety without adverse sensory effects, 6) tools to randomise study participants into 2 or more study groups and 7) cookbooks based on different diet compositions.

Commercial slimming companies, weight loss providers, diabetes-suitable home delivery meal providers, members of the food industry, including food and health ingredient companies, food retailers, supermarkets, food and agriculture organisations, policy makers and obesity-related non-government organisations, individual scientists and their IPR advisors, are encouraged to investigate exploitable outcomes of the PREVIEW project.

PREVIEW (www企业的study.com) (2013-2018) is funded by EU FP7 grant # 312057 and national funds in NZ, AUS, and CAN. The Cambridge Weight Plan® generously donated the formula diets for all centres.

**Keywords:** Weight loss, diabetes prevention, obesity, diet, exercise

**Conflict of Interest disclosure:** JBM is President of not-for-profit Glycemic Index Foundation, director of a GI testing service at the University of Sydney, and co-author of books about the GI.

**Further collaborators:**

PROJECT PARTNERS IN PREVIEW: University of Copenhagen, DK (Anne Raben); University of Helsinki, FI (Mikael Fogelholm); Wageningen University, NL (Edith Feskens); Maastricht University, NL (Margriet Westerterp-Plantenga); University of Nottingham, UK (Ian Macdonald); University of Navarra, ES (J. Alfredo Martinez); Medical University Sofia, BG (Svetoslav Handjiev); Swansea University, UK (Gareth Stratton); University of Stuttgart, DE (Wolfgang Schlicht); Meyers Madhus, Copenhagen, DK (Claus Meyer); NetUnion, Lausanne, CH (Tony Lam); National Institute for Health And Welfare, Helsinki, FI (Jouko Sundvall); University of Auckland, NZ (Sally Poppitt); Laval University, CA (Angelo Tremblay).
INFLAMMATORY DIETARY PATTERNS AND
DEPRESSIVE SYMPTOMS IN ITALIAN OLDER
ADULTS

(1)Vermeulen, Esther; (2)Brouwer, Ingeborg; (3)Stronks, Karien; (4)Bandinelli, Stefania; (5)Ferrucci, Luigi; (6)Visser, Marjolein; (7)Nicolaou, Mary.

(1)PhD. Nutritional epidemiologist. Department of Public Health. Academic Medical Centre. University of Amsterdam. Amsterdam Public Health Research Institute. Amsterdam. The Netherlands.; (2)Prof. Department of Health Sciences. Faculty of Earth & Life sciences. Vrije Universiteit Amsterdam. Amsterdam Public Health Research Institute. Amsterdam. The Netherlands;
(3)Prof. Department of Public Health. Academic Medical Centre. University of Amsterdam. Amsterdam Public Health research institute. Amsterdam. The Netherlands; (4)Prof. InCHIANTI study group. Azienda Sanitaria Toscana Centro. Florence. Italy; (5)Prof. Longitudinal Studies Section. National Institute on Aging. Baltimore. United States; (6)Prof. Department of Health Sciences. Faculty of Earth & Life sciences. Vrije Universiteit Amsterdam. Amsterdam Public Health Research Institute. Amsterdam. The Netherlands.; (7)Dr. Department of Public Health. Academic Medical Centre. University of Amsterdam. Amsterdam Public Health research institute. Amsterdam. The Netherlands.

**Background:** Older adults are more susceptible to higher inflammatory levels and depression. Moreover, diet may influence inflammation as well as depression but no previous study examined whether inflammatory dietary patterns are related to depression in an older population. Objective: To investigate the longitudinal association between inflammatory dietary patterns (using reduced rank regression (RRR)) and depressive symptoms in Italian older adults. Methods: We included 827 participants (aged ≥65 years) at baseline in 1998. Follow-up measurements were collected after 3, 6 and 9 years. We used RRR to identify inflammatory dietary patterns at baseline. The Centre for Epidemiologic Studies Depression (CES-D) scale was used to assess depressive symptoms by using continuous scores and depression by using a cut-off point (CES-D ≥20). Results: We identified two inflammatory dietary patterns using different sets of response variables. Dietary pattern I was related to inflammatory markers C-reactive protein (CRP), interleukin (IL)-6, tumor necrosis factor α and was characterized by high intakes of refined grains, sweet snacks, pasta and rice. After full adjustment for confounders, no longitudinal association was found when comparing extreme quartiles of this dietary pattern and depressive symptoms (Q1 vs Q4, model 4: B=0.01, 95% CI: -0.06, 0.08) or depression (Q1 vs Q4, model 4: OR= 0.89, 95% CI: 0.59, 1.36). Dietary pattern II was related to inflammatory markers CRP, IL-18, IL-1β, IL-1 receptor antagonist and was characterized by high intakes of pasta, sugar-sweetened beverages, processed meat and chocolate and sweets. When comparing extreme quartiles, this dietary pattern was not longitudinally associated

with depressive symptoms (Q1 vs Q4, model 4: B= -0.04, 95% CI: -0.10, 0.03) but an inverse association was found for depression (Q1 vs Q4, model 4: OR= 0.63, 95% CI: 0.40, 0.98). Conclusion: Our study does not support the hypothesis that dietary patterns linked to inflammatory markers are associated with higher depressive symptoms and higher depression incidence. However, dietary intake in our population of older adults was quite homogeneous which makes it difficult to show clear associations.

**Keywords:** Inflammatory dietary patterns, inflammation, reduced rank regression, depressive symptoms, older adults

**Conflict of Interest disclosure:** The analyses of the present study were entirely independent, with no industry association. None of the authors had a conflict of interest.

ROLE OF SUGAR INTAKE IN THE PREVENTION OF
DEPRESSION: PROSPECTIVE FINDINGS FROM
THE WHITEHALL II COHORT STUDY

(1)Knüppel, Anika; (1)Shipley, Martin J.; (2)Llewellyn, Clare; (2)Brunner, Eric J.

(1)MSc. Department of Epidemiology and Public Health. Institute of Epidemiology and Health Care. University College London. UK; (2)PhD. Department of Epidemiology and Public Health. Institute of Epidemiology and Health Care. University College London. UK.

Reduction of sugar intake has become a key target in public health action across the world. Overconsumption of sweet food, sugar-sweetened drinks and added sugars has been linked with depressive symptoms in several populations. It remains unclear whether this association is causal. Such evidence is needed to support interventions to prevent disease.

The aim of this study is to investigate cross-sectional and prospective associations of sugar intake from sweet food/beverages with common mental disorder (CMD) and depression, and to examine the role of the reverse effect, of CMD on sugar intake, for the observed association.

We analysed repeated measures (23,245 person-observations) from the Whitehall II cohort study. Prospective analysis included 2-, 5- and 10-year follow-up periods. CMD was measured with the 30-item General Health Questionnaire and depression with the Center for Epidemiologic Studies Depression scale. Clinical depression was assessed once with the Revised Clinical Interview Schedule. Dietary assessment was based on food frequency questionnaires. We modelled associations using random effects regression.

Direct cross-sectional associations were confirmed. Prospective analyses revealed a direct association of sugar intake from sweet food/beverages with incident CMD in men and with recurrent depression for both sexes. Men in the highest tertile of sugar intake had increased odds of incident CMD after 5 years (OR=1.24; 95% CI: 1.02, 1.48) after multiple adjustment including adiposity. Odds of recurrent depression were increased when sugar intake from sweet food/beverages was modelled continuously (per 30g per day
increment, OR 1.18; 95% CI 1.01, 1.37) but not when analysed in
thirds of intake. Notably, neither CMD nor depression predicted
changes in sugar intake from sweet food/beverages.

An adverse effect of sugar intake from sweet food/beverages on long-term psychological health was confirmed in repeated measures follow-up data over 22 years in men and women. Our findings suggest public health interventions which promote reduced sugar intake could support primary and secondary prevention of mood disorders.

**Keywords:** Mood disorder; Depression; sugar; diet; cohort studies

**Further collaborators**

This research is part of the Multi-country collaborative project on the role of Diet, Food-related behaviour, and Obesity in the prevention of Depression (MooDFOOD, FP7 project reference: 613598).

LONGITUDINAL ASSOCIATIONS BETWEEN VI-
TAMIN D STATUS AND DEPRESSIVE SYMPTOMS
IN OLDER ADULTS

(1)Elstgeest, Liset; (2)de Koning, E.J.; (3)Brouwer, Ingeborg; (2)van Schoor, N.M.; (4)Comijs, H.C.; (5)Lips, P.; (6)van Marwijk, H.W.J.; (4)Beekman, A.T.F.; (4)Penninx, Brenda; (7)Visser, Marjolein.

(1)PhD candidate. Nutritionist. Department of Health Sciences. Faculty of Earth & Life Sciences. Vrije Universiteit Amsterdam. Amsterdam Public Health research institute; (2)Department of Epidemiology and Biostatistics, Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, the Netherlands; (3)Department of Health Sciences, Faculty of Earth & Life Sciences, Vrije Universiteit Amsterdam, Amsterdam Public Health research institute, the Netherlands; (4)Department of Psychiatry, Amsterdam Public Health research institute, VU University Medical Center / GGZ inGeest, Amsterdam, the Netherlands; (5)Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands; (6)Department of General Practice and Elderly Care Medicine, VU University Medical Center, Amsterdam, the Netherlands; and Primary Care Research Centre, Institute of Population Health, University of Manchester, Manchester, United Kingdom; (7)Department of Health Sciences, Faculty of Earth & Life Sciences, Vrije Universiteit Amsterdam, Amsterdam Public Health research institute, the Netherlands; and Department of Internal Medicine, Nutrition and Dietetics, VU University Medical Center, Amster.

Depressive symptoms and low vitamin D status are common in older persons and may be associated, but findings are inconsistent. More prospective studies on the association between vitamin D status and depression are needed, as well as studies that use multiple intra-individual 25-hydroxyvitamin D (25(OH)D) measurements.

We investigated associations of serum 25(OH)D concentra-
tions with the severity (cross-sectionally) and course (prospective-
ly) of depressive symptoms in Dutch older adults. Furthermore,

we investigated whether changes in 25(OH)D over time are asso-
ciated with parallel changes in depressive symptoms.

In the Longitudinal Aging Study Amsterdam, serum 25(OH) D concentrations were determined at baseline in an older cohort in 1995/1996 (≥65 years, n=1282) and in a younger cohort in 2002/2003 (55-65 years, n=737). Depressive symptoms were meas- ured at baseline, after three and after six years with the Center of Epidemiological Studies Depression scale (CES-D). Linear regres- sion and linear mixed models analyses were used to examine the cross-sectional and prospective associations, respectively, between baseline 25(OH)D and depressive symptoms. Serum 25(OH)D and depressive symptoms were also measured 13 years after base- line in the older cohort (n=173) and 6 years after baseline in the younger cohort (n=450). Associations between change in 25(OH) D and change in CES-D score were analysed by linear regression analyses. All analyses were adjusted for relevant confounders, and effect modification by sex and baseline 25(OH)D was examined.

Cross-sectionally, associations between 25(OH)D and depres-
sive symptoms were not statistically significant. Prospectively,
women in the older cohort with baseline 25(OH)D concentrations
up to 75 nmol/l experienced 17-26% more depressive symptoms in
the following six years, compared to women with 25(OH)D con-
centrations >75 nmol/l (P=0.01 to 0.06). In older men and in the
younger cohort, no significant associations were observed. In par-
ticipants with two 25(OH)D measurements, serum 25(OH)D in-
creased during follow-up in 32.4% of the older cohort and in 69.8%
of the younger cohort. Change in 25(OH)D was not significantly
associated with change in CES-D score in the older cohort or in
participants of the younger cohort with higher baseline 25(OH)
D concentrations (>58.6 nmol/l). However, in persons with lower
baseline 25(OH)D concentrations, an increase in 25(OH)D was
associated with a decrease in CES-D score (adjusted B: -0.62, 95%
CI: -1.17, -0.07, P=0.028).

Older women showed an inverse relationship between serum 25(OH)D and depressive symptoms over time. In addition, an increase in serum 25(OH)D over six years was associated with a small decrease in depressive symptoms in young older adults with lower baseline 25(OH)D.

**Keywords:** Serum 25-hydroxyvitamin D, depression, intra-in-
dividual change, elderly, cohort study

**Conflict of Interest disclosure:** The analyses of the present study were entirely independent, with no industry association. None of the authors had a conflict of interest.
# THE LINK BETWEEN MINDFUL EATING AND DE-PRESSIVE SYMPTOMS AND POSSIBLE UNDERLY-ING MECHANISMS

(1)Winkens, Laura; (2)Van Strien, Tatjana; (3)Brouwer, Ingeborg; (4)Penninx, Brenda; (5)Visser, Marjolein; (6)Lähteenmäki, Liisa.

(1)MSc. Department of Health Sciences. Faculty of Earth & Life Sciences. Vrije Universiteit Amsterdam. Public Health research institute. The Netherlands.; (2)Professor. Faculty of Earth & Life Sciences. Vrije Universiteit Amsterdam. Public Health research institute. The Netherlands. Behavioural Science Institute. Radboud University Nijmegen. The Netherlands. Department of Health Sciences.; (3)Professor. Department of Health Sciences. Faculty of Earth & Life Sciences. Vrije Universiteit Amsterdam. Public Health research institute. The Netherlands.; (4)Professor. Department of Psychiatry. VU University Medical Center / GGZ inGeest Amsterdam. Amsterdam Public Health research institute. The Netherlands.; (5)Professor. Department of Health Sciences. Faculty of Earth & Life Sciences. Vrije Universiteit Amsterdam. Public Health research institute. Department of Internal Medicine. Nutrition and Dietetics. VU University Medical Center Amsterdam. The Netherlands.; (6)Professor. MAPP Centre. Department of Management. Aarhus BSS. Aarhus University. Denmark.

Mindful eating is eating with attention and awareness. Mindful eating might be related to depression, both directly and indirectly. Possible underlying mechanisms are obesity-related eating styles.

**Objective.** To examine associations of mindful eating domains with depressive symptoms and depression cross-sectionally, and to examine whether eating styles (emotional, external and restrained eating) are mediating variables in these associations.

Data were collected in Denmark (n=1522), Spain (n=1512) and the Netherlands (n=1439) as part of the MooDFOOD project. The four mindful eating domains were measured by the Mindful Eating Behaviour Scale. Depressive symptoms was defined as the continuous score on the Center for Epidemiological Studies Depression Scale (CES-D) and depression as scoring above the clinically relevant cut-off score on the CES-D and/or current use of antidepressants and/or current psychological treatment. Eating styles were measured using the Dutch Eating Behaviour Questionnaire (DEBQ). Multiple linear and logistic regression analyses were used to test the associations of the mindful eating domains with depressive symptoms and depression for the three countries separately. Furthermore, in the Dutch sample, multiple mediation of the eating styles was tested with bias-corrected bootstrap confidence intervals using the Process macro of Hayes. All analyses were adjusted for socio-demographic characteristics and lifestyle factors.

The domains Focused Eating, Eating with Awareness and Eating without Distraction were all significantly negatively associated with depressive symptoms and depression in all three countries (e.g. Focused Eating Denmark: B=-0.71, 95%CI: -0.87, -0.54 and OR=0.89, 95%CI: 0.86, 0.93). Hunger and Satiety Cues (only measured in the Netherlands) was significantly positively associated with depressive symptoms (B=0.09, 95%CI: 0.02, 0.16), but not with depression (OR=1.01, 95%CI: 0.98, 1.05). No mediation

by the eating styles was found for Hunger and Satiety Cues. Emotional eating was a mediator in the associations of Focused Eating, Eating with Awareness and Eating without Distraction with depression (e.g. Eating with Awareness: B=-0.03 (SE=0.01), 95%CI: -0.06, -0.008).

The results indicate that higher scores on three mindful eating domains are consistently associated with lower levels of depressive symptoms and a lower likelihood of having depression in three European countries. Emotional eating was found to be a mediator in the associations between these three mindful eating domains and depression. Mindful eating may benefit people's mental well-being both directly and indirectly through emotional eating.

**Keywords:** Mindful eating; depression; eating styles; emotional eating; European countries.

**Conflict of Interest disclosure:** Tatjana van Strien has a copyright and royalty interest in the Dutch Eating Behavior Questionnaire (DEBQ) and manual. There are no other conflicts of interest.

PS_144/1053

## BARIATRIC AND METABOLIC SURGERY. STRATEGIES FOR SUCCESS: AN INTEGRATED APPROACH TO OBESITY AND T2DM PATIENT MANAGEMENT

### BARIATRIC AND METABOLIC SURGERY. STRATEGIES FOR SUCCESS: AN INTEGRATED APPROACH TO OBESITY AND T2DM PATIENT MANAGEMENT

Aguirre Ackermann, Marianela.

Phd. Nutrition and Diabetes. Center for Obesity and Diabetes CIEN (Corrientes-Misiones-Buenos Aires, Argentina).

The alarming escalation in the incidence of obesity and diabetes presents significant challenges for healthcare practitioners, health systems, payer groups, and the government, not to mention the impact on the health of the individual. The epidemic increases in both of these chronic conditions requires the replacement of reactive management strategies that employ extreme diets, diets that do not work, minimalist pharmacologic support, and delayed or lack of implementation of bariatric surgery in patients who require it, with more proactive and assertive efforts that focus on the achievement of a new lifestyle to obtein weight management and in this way achieve glycemic targets, blood pressure and lipids control, cardiovascular risk reduction, and the multiple proven benefits of weight loss on health, including of course improvement in quality of life.

As healthcare practitioners, we should provide individualized and integrated medical care, assess therapeutic effectiveness, and provide the best options for each patient. We are challenged to stay current with the escalating volume of new therapies, devices, and lifestyle recommendations and to understand the nuances of treatment strategies while balancing the realities of the world within which we practice.
The approaches in which it is performed only recommendations result in very limited weight loss, which may frustrate both patients and their physicians. Healthcare practices must become more assertive, replacing generic directives to patients such as “eat less” and “exercise more” with more progressive interventions that combine lifestyle modifications, risk evaluation, risk reduction, and disease prevention, while attending to disease management. The morbidity associated with obesity, and the close association of obesity with diabetes and cardiovascular disease, necessitates the development and implementation of integrated treatment strategies.

The cornerstone for the treatment of an obese patient is an intervention with interdisciplinary strategies that involve multiple components, to achieve a better integral lifestyle. Within the treatment options available for obesity and type 2 diabetes, with the evidence currently available, bariatric surgery should be present.

Today we know that it is not about medical treatment versus surgery: the evidence shows that it is about medical treatment plus surgical treatment. Even in the field of metabolic surgery, today we talk about surgery more drugs for diabetes and not surgery to stop taking drugs for diabetes.

In patients with moderate obesity associated with comorbidities or morbid obesity, bariatric surgery is the only available therapeutic modality associated with clinically significant and relatively sustained weight loss. Well-performed bariatric surgery, in carefully selected patients and with a good multidisciplinary support team, substantially ameliorates the morbidities associated with obesity.

The use of bariatric surgery in the clinical management of type 2 diabetes in obese subjects has been included in the clinical practice recommendations released by the most influential diabetologic associations. However, the timing during the diabetic course in which this use may have the better benefit/risk ratio remains debated. Today we know that is better to use surgery very early in the course of the disease in order to anticipate clinical deterioration.

**Keywords:** Obesity; type 2 Diabetes; Medical management; Bariatric Surgery; Metabolic surgery

## FROM BARIATRIC TO METABOLIC SURGERY. DEFINITION OF A NEW DISCIPLINE

Serra, Edgardo.

Center for Obesity and Diabetes CIEN (Corrientes-Misiones-Buenos Aires, Argentina).

It is well known the impact of bariatric surgery as the best treatment in morbid obese patients. These results and the increase of the epidemic did this procedure as one of the most common surgery worldwide. The obesity surgery beyond its effect on weight loss has entailed a change in the way of regarding it. But, success was defined only by excess weight loss. In spite of were reported others markers of resolutions of metabolic comorbidities, they were relegated to a secondary place. Meanwhile, type 2 Diabetes is accepted as a global world health crisis. Diabetes is one of the most common major diseases that impact the health, quality of life, costs, and survival of obese persons. Besides, several commu-

nications have reported that regardless of body mass index (BMI), complete or partial remission of type 2 diabetes mellitus (T2DM) is possible. Because of this, The American Diabetes Association's (ADA) Standards of Medical Care in Diabetes 2009 states, "Bariatric surgery should be considered for adults with BMI 35 kg/m2 and type 2 diabetes, especially whether the diabetes is difficult to control with lifestyle and pharmacologic therapy." This was the first time the ADA declared bariatric surgery as a treatment option that should be considered for a population of diabetic patients. The metabolic surgery effect over metabolic syndrome, mostly occur before weight loss, positioning metabolic surgery as a good tool for controlling the current T2DM epidemic. The term "metabolic surgery" has become more popular to designate those interventions focused mainly at resolving diseases as diabetes and not specifically weight loss. Metabolic surgery has been proven to be safe and effective. And, it is unquestionable that a new discipline has been founded. Metabolic surgery can effectively treat T2DM in individuals with any BMI, including that below 35 kg/m2. In patients with type 2 diabetes and obesity, metabolic surgery has a greater role in metabolic improvement, beyond the weight loss obtained. It is necessary to understand the objectives of each Surgery to indicate in each patient the best Surgery available.

**Keywords:** Obesity; Type 2 diabetes; Bariatric surgery; Metabolic Surgery

## WHICH IS THE BEST TECHNIQUE FOR YOUR PATIENT?

Cohen, Ricardo.

MD. Director of The Center for Obesity and Diabetes, Oswaldo Cruz German Hospital, Sao Paulo-Brazil.

Metabolic surgery is a very efficient option to treat uncontrolled T2D patients in spite of the best medical treatment. The Diabetes Surgery Summitt 2, held in 2015, with the support from over 50 medical Societies worldwide did put gastrointestinal surgery in the algorithm for the treatment of T2D in patients with BMI from 30 kg/m2 and over. Among the surgical options, the Roux-en-Y gastric bypass (RYGB) has the best risk profile, with better-known mechanisms of action and good long term outcomes regarding weight loss and T2D control. The sleeve gastrectomy may be an option, but it carries a non-optimal weight and glycemic control in long term (10 years) prospective and randomized controlled trials with up to 5 years, besides the ongoing risk of gastroesophageal reflux and even Barret's esophagus. In uncontrolled T2D, it may be indicated when there is any RYGB contraindication. The malabsorptive operations have unquestionably better outcomes, glycemic and weight loss, but carry ongoing risks of malnutrition and its undesirable consequences. Currently, RYGB offers a safe, better known and powerful tool for obese patients with uncontrolled T2D.

**Keywords:** Roux-en-Y gastric bypass; metabolic surgery; type 2 diabetes
EXPERIENCE OF THE NEEP PROJECT IN GUATEMALA
AND EL SALVADOR

(1)Monroy Valle, Michele; (2)Velasquez, Carmen; (3)Portillo, Carmen;

(4)Choi, Sunhea.

(1)MEd, MPH. Nutritionist. Nutrition Degree. Faculty of Health Sciences. Universidad Rafael Landívar. Guatemala; (2)MA.

Nutritionist. Nutrition Degree. Faculty of Health Sciences.

Universidad Rafael Landívar. Guatemala.; (3)Nutritionist. Nutrition Department. Hospital Nacional Zacamil. El Salvador.; (4)PhD.

Global eHealth Education Lead. Faculty of Medicine. University of Southampton.

Severe Acute Malnutrition has a low prevalence among un-
der 5 population in Central America; Guatemala has 0.7% and El
Salvador 2%. Important nutrition-health politics have been im-
plemented in the past years. Guatemala, the growth child survey
system implemented in 2009 is capable of screening, assessing and
treat, in the community, moderate acute malnourished children
reducing inpatient treatment needs. El Salvador´s Health System
improved overall health access decreasing stunting rate 13 percen-
tal points.

In this scenario, SAM treatment has dropped its importance,
building skills in health personnel is out of sight; but for those
that work with the poorest population is a necessity missed by
the in-service and pre-service trainers. The aim of the project was
to identify if the Malnutrition eLearning course could cover this
training gap among health professionals and improve the quality
of treatment of SAM children.

Nutrition Embedding Evaluation Program (NEEP), PATH supported a Malnutrition eLearning course evaluation in Guatemala, El Salvador, Ghana and online from overall world. We will describe Central America´s results. Using a mixed methods, evaluation was conducted for existing users and for new users and trainers. Online Malnutrition eLearning course is in English, contents include 3 units about screening, assessing, managing malnutrition

Phase 1

Participants were former users in Guatemala students and pro-
fessionals. Online questionnaires, interviews and Focus groups
were conducted.

Phase 2 new users

We enrolled 143 participants from 6 institutions: Rafael Landi-
var University, Nutrition Degree in Guatemala and Quetzaltenan-
go; Juan Pablo II Hospital (paediatricians); Guatemala´s Health
Ministry Nutritionist; University Evangelica de El Salvador (nutri-
tionist); Hospital Nacional Zacamil (paediatricians). In June 2015
pre-test, questionnaires, focus groups, medical records (one year
before) and hospital observations. eLearning was done in Septem-
ber to comply with the programme contents, post intervention
evaluation was in October. 21 trainers were selected from institu-
tional survey for a workshop where they made an action plan to
implement the course.

A post-6-months test was conducted to verify knowledge gain in longer term. 6 and 12 months' interviews, focus groups and questionnaires were conducted for individuals and for the hospital's medical records and observations.

We had 47 participants, pre-test scores average percentage was 16.83 and post-test were 28.62. Despite the significant change, scores were low, but all the sample reported Language barrier as main reason they were not able to answer properly. Participants that reported skills gain compare course contents to national SAM managing guidelines while eLearning. Implementing the course with credit gains was more successful than the ones that didn´t, learning in English resulted a double burden. For Guatemala, course represented the technical background, that few had, for implementing the national SAM treating guidelines. At the 6 and 12 months' follow-up participants reported they use course contents in their daily work, particularly the assessment and 10 steps.

We generated two needs in SAM control: a tool to support sci-
ence and technical background in managing SAM children avail-
able online for all health workers, and the need of Malnutrition
eLearning course in Spanish.

**Keywords:** Malnutrition, eLearning, prevention, control,
training

**Further collaborators:** As part of the International Malnu-
trition Task Force we will continue efforts for capacity building
in malnutrition assessment, screening, managing, promotion and
prevention. The next step is to translate course to Spanish.

LOW-CALORIE SWEETENERS AND WEIGHT - A
SYSTEMATIC REVIEW OF HUMAN AND ANIMAL
STUDIES

Rogers, Peter.

PhD. Psychologist. School of Experimental Psychology.

University of Bristol. United Kingdom.

The major potential benefits for public health of low-calorie sweeteners (LCS) are a reduction in sugar intake and consequent reduction in overweight and obesity. However, the usefulness of LCS for weight management has been challenged on several grounds. First, there is the possibility that food intake increases to compensate for the energy dilution achieved with LCS, second is the suggestion that LCS weaken the relationship between sweet taste and food energy content and thereby disrupt the learned control of appetite, and third is the argument that exposure to sweetness increases desire for sweetness which escalates sweet food intake. There is partial but, importantly, not full energy intake compensation after consumption of LCS versus sugar. Separately, results of animal studies used to support the disruption of dietary learning by LCS hypothesis have been demonstrated to be explained by a procedural artefact. In any case, this hypoth-
esis is irrelevant to the human diet because sweetness and sugar content do not reliably predict energy density, even within and across categories of minimally processed foods. In relation to the 'sweet tooth' hypothesis, consumption of LCS versus water has not been found to increase energy intake in the short-term, with other evidence showing a decrease in sweet food intake when a LCS drink is consumed with a meal. The latter is consistent with the phenomenon of 'sensory-specific satiety.' There is rather little evidence on the effects of longer-term exposure to sweetness. In one recent study, consumption of a diet low in sweetness for 3 months increased perceived sweetness intensity of sucrose in a pudding and a drink, but it did not affect rated pleasantness of the same test products. Together, these various results largely refute claims about counterproductive effects of LCS and predict that consumption of LCS in place of (some) sugar in the diet should help reduce overall energy intake and body weight. Recent meta-analyses of intervention studies in adults and children, fully support this prediction. The duration of these studies ranged from 1-40 months. Furthermore, if anything, body weight was lower for LCS drinks compared with water, perhaps because, as suggested above, consumption of LCS may help satisfy the desire for sweetness within a meal. Overall, LCS appear to be helpful for weight management. There are nonetheless obviously limits to the extent to which dietary energy content can be reduced (diluted) by replacing sugar with LCS. These include consumers' current level of free sugars intake and their willingness to consume LCS, and technical constraints on how much sugar can be substituted, especially in foods.

**Keywords:** Low-calorie sweeteners, sugars, appetite, obesity, weight management.

**Conflict of Interest disclosure:** Peter Rogers has received funding for research from Sugar Nutrition UK, provided consultancy services for Coca-Cola Great Britain and received speaker's fees from the International Sweeteners Association and the Global Stevia Institute.

## NON-CALORIC SWEETENERS AND GLYCEMIC RESPONSE

Pi-Sunyer, Xavier.

Columbia University. New York, USA.

Non-caloric artificial sweeteners (NAS) are widely used globally. Since they came on the market, they have generally been considered metabolically inactive and safe with regard to glucose homeostasis by the FDA and other regulatory agencies. Numerous safety trials with the various products in the market have been done through the years and most have shown little impact on glucose levels during both short-term and longer-term trials. However, there have been a few that have reported small alterations in glucose and insulin levels.

Recently, three new important issues have emerged: taste receptors in the gut, the impact of microbiota, and interference with learned ingestive responses.

It is evident now that taste receptors, once thought to reside only in the mouth, are also present in the intestinal lumen. NAS

can therefore bind to these receptors and can initiate signals that may be relayed to the blood, brain, pancreas, liver, etc and could modify glucose homeostasis.

The importance of the gut microbiota in modifying the glucose homeostasis of an organism is unclear and is being explored. Most studies to date have been done in rodents generally utilizing high doses of NAS. With these models, perturbations in the microbiota have been shown and an impact on glucose has been reported.

It has been hypothesized that NAS can alter the ability to predict the energy ingested and evoke a learned response that is faulty, leading to metabolic changes in the organism.

The strength of the available evidence base regarding these three potential mechanisms for altering glucose homeostasis will be reviewed and evaluated.

**Keywords:** Non-caloric sweeteners, glucose homeostasis, microbiota, taste receptors, learner responses

## SWEET TASTE AND IMPLICATIONS WITH LOW-CALORIE SWEETENER USE

Bellisle, France.

PhD. Psychologist. Nutritional Epidemiology. Université Paris 13. France.

The World Health Organisation (WHO) recommends that adults and children reduce their intake of free sugars to less than 10% of the daily energy intake. This recommendation is based on the potential adverse effect of a high intake of sugar on body weight control and metabolic health. If dental health is taken into consideration, then the WHO recommends a further reduction of free sugar intake below 5% of the daily energy intake. Such recommendations are challenging for many individuals and more so in certain parts of the world where the culturally accepted levels of sweetness in the diet are high.

Sweetness is a potent psychobiological stimulus in many animal species, including humans of all ages. Human newborns display an innate attraction to sweet substances, manifested by eager acceptance and a stereotyped gusto-facial reflex of relaxation and smile. Such innate responses present a survival advantage in the context of Natural Selection, facilitating the acceptance of energy and nutrient sources by the young organism. Indeed, the appetite for sweetness is high in infants and children. As it does in other species, the human appetite for sweetness spontaneously decreases during growth. Adults vary largely in their preferred intensity of sweetness in a broad range of beverages and foods. Genetic influences and personal experiences with sweetness shape the adult responses. Cultures as well as individuals show large differences in the consumption of sweet tasting products.

Sugar brings 4 kc calories per gram and it is easy to see how its pleasant taste could stimulate overeating and weight gain, as suggested by the WHO. Observational studies in many countries, however, show little correlation between the body adiposity status and individual liking or consumption of sweet tasting products. Overweight and obese individuals often display an enhanced appetite for dietary fats (that bring 9 kc calories per gram) rather than sugar.
How can a reduction of sugar intake be achieved? Should all sweet tasting substances be limited or can low-calorie sweeteners (LCS) contribute to a decrease in sugar intake (and the associated energy load) while retaining the palatable sweet taste of many favorite foods and drinks? Numerous scientific studies have addressed this issue. Experimental reports confirm that the use of LCS is associated with lower energy and sugar intake in the context of weight loss programs. LCS also facilitate the maintenance of the reduced weight after the end of a diet. Disproving early suggestions that LCS may enhance the natural appetite for sweetness and paradoxically stimulate the consumption of other sweet (sugar-containing) products, experimental trials show that LCS satiate rather than enhance the appetite for sweet tasting products and facilitate the reduction of sugar intake. More research is needed to assess the role of LCS in the management of sweetness appetite over the life span, in the prevention of weight gain, particularly in individuals at risk of overweight and in cultures where the traditional level of sweetness in the diet is high.

**Keywords:** Sweetness, sugar, low-calorie sweeteners, appetite, satiety

**Conflict of Interest disclosure:** The author is a member of scientific advisory councils for Cereal Partners Worldwide, European Food Information Council, General Mills, Nomad Foods, CreaBio, International Sweeteners Association, and European Fruit Juice Association. Over the last 5 years, she has received honoraria and travel grants from: American Beverage Association, International Life Science Institute, Mondelez, Tate & Lyle.

Unfortunately starting in the second half of the 1990s, carbohydrates became “bad”. A strong carbophobia was born after a long stage of lipo phobia. Various theories halfway between science and ideology

led this phenomenon. In the first place, there was the high prevalence of dieting caused by the presence of a disease o a simple cultural obsession. Second, it was the insulin theory. Although science has tear down the apparent efficacy in the long term to produce sustainable weight loss, has pointed the hazards inherent to its use and there is strong evidence that de novo lipogenesis under normal conditions is not very relevant in humans, low carb/high protein diets became very popular to lose weight.

Simultaneously, to facilitate the process, it began a demonization process of carbohydrates based erroneously in part, by the confusion generated by dissemination of knowledge about celiac disease.

Fortunately, in the last years, the medical view of carbohydrates is becoming more balanced. The nature of dietary carbohydrates appears to be a more important determinant of health outcomes than the proportion of total energy intake. It began to be emphasized that a high content of dietary fiber is associated with low energy density, promotion of satiety and beneficial influences on the microbiota.

Finally an important pending debt of nutrition science is to redefine what constitutes a healthy diet. We propose it might be sufficient, complete, varied, balanced, adequate, shared, tasty and pleasant, suitable to be adopted as a lifestyle and sustainable for the planet and carbohydrates should be at least, half of it.

**Keywords:** Carbohydrates, carbophobia, healthy diet, nutrition, low carb/high protein diets

PS_144/1018

# STRATEGIES FOR INCORPORATION OF SUITABLE CARBOHYDRATES IN THE PREVENTION OF CHRONIC DISEASES

## CARBOHYDRATES AND HEALTH

Katz, Mónica.

Nutrition. Favaloro University. Buenos Aires Argentina.

Dr. Mónica Katz

Favaloro University. Buenos Aires. Argentina.

Carbohydrates are ubiquitous in nature and fundamental to life. They include grains, legumes, vegetables and fruits; have diverse structures with different functions. This group of macronutrients contributes not only to the nutritional status but also to the pleasure and enjoyment of food. The percentage of carbohydrates established by important nutrition and health institutions varies. It is between 55-75% in the last document published by WHO in 2007. In the case of the Scientific Advisory Committee on Nutrition (UK), it proposed a lower limit of 50%. Finally the Dietary Guidelines for Americans (2015-2030) recommended the same amount as WHO but recommended that half of all carbohydrates be whole grains.

## THE COLON MATTERS IN BLOOD SUGAR MANAGEMENT: HOW PREBIOTIC FIBERS CAN WORK IN GUT MICROBIOTA, GLUCOSE METABOLISM AND METABOLIC DISORDERS

Cani, Patrice D.

RD. MBSc. MHS. PhD. Professor. Research Associate FRS-FNRS.

Université catholique de Louvain. Louvain Drug Research Institute. WELBIO (Walloon Excellence in Life sciences and

BIOtechnology). Metabolism and Nutrition research group. 1200 Brussels. Belgium.

Obesity is characterized by a cluster of metabolic disorders involved in the development of cardiometabolic disorders such as insulin resistance, diabetes, hepatic steatosis and inflammation.

We and others have shown that gut microbes are dialoguing with the host cells via several mechanisms and thereby contribute to the regulation of energy, glucose and lipid homeostasis. Changes in the gut microbiota composition and/or the activity of specific microbes may be obtained by using specific dietary compounds such as prebiotics.
Over the last 20 years, we have contributed to the demonstra-
tion that prebiotics such as oligofructose and/or inulin modulate
host metabolism in both pre-clinical and clinical studies. Their
potential relevance in the management of obesity and related met-
abolic disturbances will be discussed.

Among the key mechanisms, it has been shown that the pro-
duction of bioactive compounds (including short-chain fatty acids
or lipid metabolites) directly interact with host cellular targets to
control energy metabolism and immunity.

For example, prebiotic fibers increase satiety, reduce food in-
take, fat mass development and improve glucose metabolism. The
prebiotic-induced microbiota modulation changes gut peptides
involved in appetite regulation, glucose metabolism, energy ho-
meostasis and gut barrier function (e.g., GLP-1, PYY, or GLP-2).
Other mechanisms such as metabolic endotoxemia, changes in gut
barrier function (e.g., antimicrobial peptides production, mucus
layer thickness, immune system) or altered endocannabinoid sys-
tem tone contribute to reduce inflammation.

Finally, the role of prebiotics on Akkermansia muciniphila, a
key bacteria playing a major role upon obesity, diabetes and in-
flammation, will be discussed.

In conclusion, prebiotic fibers are useful tools with accumu-
lating scientific evidence further supporting their use for human
health.

**Keywords:** Prebiotics, gut microbiota, blood sugar manage-
ment, obesity management

**Conflict of Interest disclosure:** Inventors on patent applica-
tions dealing with the use of A. muciniphila and its components in
the treatment of obesity and related disorders. Consulting/confer-
ence fees: Tate & Lyle, Biocodex, Beneo, PileJe Group

CARBOHYDRATE QUALITY MATTERS: THE
MEANING OF SLOWLY DIGESTIBLE CARBOHY-
DRATES FOR BLOOD SUGAR MANAGEMENT
AND BEYOND

Henry, Jeyakumar.

PhD, Director, Clinical Nutrition Research Centre, Singapore Institutes for Clinical Sciences, Singapore.

Asia and the Middle East are in the grip of a pandemic in type 2 diabetes and metabolic syndrome. They are also the unenviable epicenters of type 2 diabetes. Of the 450 million type 2 diabetics diagnosed worldwide, approximately 50% live in this region. The prevalence of type 2 diabetes has been partly ascribed to the high carbohydrate (CHO) content of the diet that people in this region consume. Recent evidence also suggests that they are susceptible to type 2 diabetes due to their phenotype. The concept of the glycaemia index (GI) of food has emerged as an important nutritional concept. The GI is a classification of the blood glucose-raising potential of carbohydrates in foods. High GI foods are characterized by fast-release carbohydrates and higher blood glucose levels. Low GI foods are absorbed at slower rates which in turn results in a lower rise in blood glucose. Paradoxically, most CHO-rich foods

we consume notably bread, rice and noodles are high GI foods. Diet based interventions have been promoted as a complimentary strategy to manage, prevent and treat diabetes. One of the earliest food based ingredients used to reduce glycaemia was beta-glucan. Since then a series of natural ingredients have been identified and used to reduce the glycaemic impact of carbohydrates. This presentation will highlight the important role that isomaltulose may play in reducing and modulating the glycaemic excursion of carbohydrate rich foods. Using a series of studies the presentation will display how the addition of isomaltulose to a high GI meal can also reduce the glycaemic response over a 24hr period. Finally, the simultaneous measurement of 24hrs blood glucose using a continuous glucose monitor and measurement of energy expenditure demonstrated conclusively that the inclusion of isomaltulose can not only reduce glycaemia but also increase fat oxidation. In our "war on diabetes" the use of isomaltulose may be a useful weapon to combat this worldwide threat. The study also endorses the claim that food is the new medicine.

**Keywords:** Glycaemic index, glycaemic response, continuous glucose monitoring, substrate oxidation and whole body calorimeter

PS_144/133

COMPREHENSIVE MANAGEMENT OF OBESE PATIENTS

RELATIONS BETWEEN THE UNDERWEIGHT OF
CHILDREN FROM 6 TO 59 MONTHS AND THE
FEEDING OF THEIR MOTHER, BAMAKO

Abstract

Malnutrition is a public health problem in Mali. It is within this
framework that the present study on the relationship between the
nutritional status of children aged 6 to 59 months and the feeding
of their mothers was carried out in a first level health facility in the
Bamako district of Mali.

A cross-sectional study involving 151 children aged 6 to 59 months and 149 mothers using the Expanded Program on Immunization and the Consultation of Healthy Children was conducted at the Niamakoro Community Health Center (ANIASCO) in the District of Bamako, Mali from 28 September 2015 to 28 January 2016. Socio-demographic data, feeding patterns and anthropometric measurements of mothers and children were collected. Pearson's Chi2 was used for comparison of means with a significance level of 95%. The bi and multi varied logistic regression was used to calculate the OR.

<footnote>(1)Djeneba, Coulibaly; (2)Djeneba, Coulibaly; (3)Ag Iknane, Akory;</footnote>

<footnote>(4)Fatou, Diawara.</footnote>

<footnote>(1)Médecin, MPH Nutrition, Faculté de Pharmacie; (2)Médecin Nutritionniste, Faculté de Pharmacie; (3)Maître de conférences, Santé Publique Nutrition, faculté de Pharmacie; (4)Médecin Epidemiologiste, Faculté de Pharmacie.</footnote>
The mean age of the children was 7.89 months [7.57 - 8.20] and that of the mothers of 24.79 years [23.87-25.56]. Among the children, the female sex predominated with 55%. Only 2.6% of the children were exclusively breastfed. The prevalence of underweight was 15.2%, and the chronic energy deficit rate for mothers was 6.7%. The dietary diversity score (SDA) was 27.5% for mothers and 86.1% for children.

Multivariate analysis revealed that underweight was signif-
icantly associated with mothers' dietary diversity (SDA) score
(p-value = 0.03). The nutritional status of mothers, on the other
hand, had no influence on that of children. A statistically signif-
icant relationship was observed between maternal nutrition and
underweight children.

Adequate feeding of mothers would improve their nutritional status, which could reduce the prevalence of underweight.

Keywords: Underweight, feeding, mothers, children, Bamako

PS_144/77

MEDICAL MANAGEMENT OF OBESITY

MEDICAL MANAGEMENT OF OBESITY

(1)Ribas-Filho, Durval; (2)Ribas-Filho, Durval; (3)Suen, Vivian; (4)Ferreira, Any; (5)Alonso, Maria del Rosario Zariategui; (6)Almeida, Carlos Alberto Nogueira; (6)Yucif, Nelson.

(1)MD PhD - Brazilian Association of Nutrology - ABRAN; (2)MD PhD. Brazilian Association of Nutrology. Brazil; (3)MD. Phd. University of São Paulo. Brazil; (4)MD. International Colleges of Advancements of Nutrology. Paraguay; (5)MD. International Colleges of Advancements of Nutrology. Brazil; (6)MD. PhD. University of Ribeirão Preto.Brazil.

Obesity is a chronic disease, most chronic illnesses require
treatment based on the pyramid of treatment of chronic diseases:
balanced diet based on guidelines, physical activity, cognitive and
behavioral changes, medications and at the apex of the pyramid
is surgery or other procedure more intensive. Chronic diseases
are almost always treated with diet, physical activity and behavior
modification, drugs and drug combinations and bariatric surgery.
Obesity drugs are generally safe. Average weight loss with current
obesity drugs is modest (5%-10% of initial weight). Some people
respond to drugs with great weight loss. If a drug doesn't work,
stop it! Drugs must be used long term – if you stop an effective
treatment, it stops working. Drugs are generally a lot cheaper than
behavior modification programs. Drugs are the future of obesity
treatment. Combinations of treatments are generally more suc-
cessful in producing weight loss and maintaining weight loss than
single treatments. Drug combinations are the future of obesity
treatment. Obesity surgery is the most effective single treatment,
but weight regain may be treated with obestiy drugs. Thus the fo-
cus of my presentation will be based on antiobesity pharmacolo-
gy therapy showing the different antiobesity medications and the

challenges in their use in function of popular and scientific myths
related to the medical prescription of antiobesity drugs.

**Keywords:** Obesity. Drugs. Mith. Treatment. Weight loss

UPGRADE IN DIETS FOR OBESITY

(1)Suen, Vivian; (2)Ribas-Filho, Durval.

(1)MD. PhD. Ribeirao Preto Medical School University of Sao Paulo. Brazilian Association of Nutrology. Brazil.; (2)MD. PhD. Brazilian Association of Nutrology. School of Medicine of Catanduva. Brazil.

Obesity is a significant medical and social problem due to its
severity and high and growing worldwide prevalence. The medi-
cal management of obesity includes lifestyle modification, with/
without support from medications. A variety of dietary approach-
es that can produce weight loss are described, such as limiting the
daily calorie intake to 800-1500 kcal/day or reducing the daily
caloric intake by 500-750 kcal/day. With respect to pharmaco-
therapy, it is indicated as an adjunct to a reduced-calorie diet and
increased activity for long-term weight management. Results from
a meta-analysis showed that the weight loss with orlistat, lorcaser-
in, and liraglutide used as monotherapy ranged from 5.8 to 8.8 kg
(5.8 to 8.8%) of initial body weight. The weight loss with placebo
ranged from 2.6 to 5.3 kg. It is important to note that a moder-
ate weight loss can result in improved health and quality of life.
Besides, a high-intensity behavioral counseling during the med-
ical treatment with regular recording of food intake and physical
activity is of utmost importance to increase patient's adherence
to treatment. However, the greatest challenge of obesity treatment
is the long-term maintenance of the reduced weight. There is an
urgent need to develop new strategies for weight loss maintenance
in the long-term.

**Keywords:** Obesity, diet therapy, pharmacotherapy, weight loss maintenance

PHARMACOTHERAPY ANTI OBESITY: PRESENT
AND FUTURE

(1)Giorelli, Paulo; (2)Giorelli, Paulo; (3)Giorelli, Guilherme; (4)sartoretto, Silvia.

(1)Medical Doctor. Master Science. Associação Brasileira de Nutrologia; (2)Medical Doctor. Master Science. Director of Obesity Department of Associação Brasileira de Nutrologia. Brasil; (3)Medical Doctor, Master Science, Affiliated Professor of Associação Brasileira de Nutrologia, Brasil; (4)Medical Doctor. Specialist in Endocrinolgy. IEDE Brasil.

The authors will show the Brazil's experience with the anti obe-
sity drugs like Diethylpropion, Fenproporex and Mazindol and
they will present their research with the Diethylpropion's use in
3800 obesity patients. They will discuss about the impact of the
banishment of these medicine drugs in Brazil's public health, with the increase of the obesity's patients in Brazil.

At the same time, we will show the aggravation of the comorbidities of obesity in Brazil's population after the banishment of these anti obesity drugs.

They will show the current Brazil's scenario of anti obesity drugs with Orlistate, Sibutramine, Liraglutide and Lorcaserin.

Finally we will discuss about the use of off-label medicine drugs in the obesity's treatment in Brazil

**Keywords:** Pharmacotherapy of Obesity, Diethylpropion, Liraglutide, Lorcaserin.

## HEALTH CONSEQUENCES OF OBESITY IN CHILDHOOD

Nogueira-de-Almeida, Carlos Alberto.

PhD. Medical Professor. University of Ribeirão Preto. Associação Brasileira de Nutrologia.

In Brazil, nowadays, almost 50% of boys and girls with ages between 5 and 9 years old are overweight or obese. And these children frequently have one or more comorbidities. We have been studying some of these comorbidities from the last 5 years. First of all, we studied dyslipidemia and insulin resistance. We found that 69.4% of the children had high cholesterol, 45.2% high LDL, 54.8% low HDL and 53.2% high triglycerides. It is consensual that we have a vicious circle including obesity and insulin resistance and we evaluated 383 children with ages between 7 and 10 years using fasting insulinemia and Homa as indicators of insulin resistance. The prevalence was very high, independently of the method: 33.1% using fasting insulin > 15 and 37.8% using HOMA > 3.5. We also looked at blood pressure and we showed high blood pressure values among obese children, when compared to eutrophic children. Regarding the heart, we investigated if obese children, with ages between 6 and 9 years, has detectable modifications of the heart anatomy, specially regarding to the left ventricle, and we found that, among 5 index evaluated, two of then (the LV mass and the LV3 index) showed differences, with greater thickness of the ventricle among obese children. The intima-media complex of common carotid artery can be accessed using ultrasonography. This is a very safe and accurate method to evaluate the onset appearance of atherosclerosis. We evaluated 59 children of both genders, between 7 and 10 years old. The average thickness of the intima-media complex in the group overweight / obese was 0.49mm; in the non-obese group, the measurement was 0.41mm. There was a significant difference between groups (p <0.01). And, also, we showed a correlation between the increase of the z-score of BMI and the increase of the intima-media complex. We evaluated the abdominal adiposity distribution. Results from 59 children of both genders, between 7 and 10 years old showed high correlation of fat deposits between each other and the two compartments of abdominal fat deposition increased together. And, even more important, both subcutaneous fat and visceral fat showed almost the same correlation with abdominal circumference. This means

that, at this age, when we measure the abdomen, we are measuring both visceral and subcutaneous fat and this two measurements increase together with the increase of the abdominal circumference. At this same study, we evaluated the liver and an hiperechoic image is an indicator of the presence of Non Alcoholic fat Liver Disease (NAFLD). Children with normal liver tend to have less subcutaneous fat then children with more echoic liver. And, similarly, children with normal liver tend to have less visceral fat then children with more echoic liver. In conclusion, even among school children, we could find a lot of obesity comorbidities, as: dyslipidemia, insulin resistance, high blood pressure, left ventricle hypertrophy, carotid intima hypertrophy, visceral fat accumulation and NAFLD.

**Keywords:** Obesity, Children, Insulin Resistance.

## EATING BEHAVIORS DISORDERS OF OBESE PATIENTS

Zariategui de Alonso, Maria del Rosário.

MD. Physician. Department of Eating Disorders. Associação Brasileira de Nutrologia. ABRAN.Brazil.

Eating behavior disorders appeared more often in patients with overweight and obesity than patients with normal weight. Binge eating and other disordered eating patterns are also more common in overweight youth.

Binge eating disorder (BED) recognized as a formal diagnosis in Feeding and Eating Disorders in the last version of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and Night eating syndrome (NES) are associate with obesity.

Research has shown eating pathology is commonly seen in bariatric surgery patients before surgery, and may persist or emerge after surgery. BED and other eating disorders that NES have been fairly consistently linked to greater weight regain post-surgery

Behavioral modification, nutritional education and cognitive behavioral therapy (CBT) are necessary in eating behaviors disorders of obese patients. Binge eating and other disordered eating patterns are important to asses because they may directly contribute to overweight and addressing these behaviors will directly affect weight management goals. CBT is effective in reducing eating episodes in patients with BED but is not sufficiently effective for reduction of excess body weight. Nutritional deficiences, therapies and drugs are also discussed

**Keywords:** Eating Behavior Disorder Obesity Patients

## SARCOPENIC OBESITY

Lucif Jr., Nelson.

PhD.MD. University of Ribeirão Preto. Brazil.

The world's population is aging. One of the most dramatic body changes with aging is the loss of muscle mass. Although the peak of muscle mass and the beginning and the intensity of the loss all
varies among people, this loss may reach a state called sarcopenia, which compromises the function, quality of life and life itself. Although there is no agreement on the definition of sarcopenia, its concept is well established. In addition, the world increase incidence of obesity also has reached the elderly people, with aggravating factors pertinent to this age group like metabolic disorders and other. The confluence of these two phenomena, called sarcopenic obesity, results in individuals with fragility, greater vulnerability and increased mortality from all causes. Efforts should be concentrated to prevent and treat individuals of these conditions. Adequate food intake, with the provision of energy and protein for weight adjustment and optimize muscle synthesis, in addition to the micronutrientes, is essential. This, along with the regular practice of exercises are the basis of this approach. Some supplementation may be necessary.

**Keywords:** Aging. Sarcopenia. Sarcopenic obesity. Prevention. Treatment.

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# NEW STRATEGIES IN THE CONTROL OF ENERGY BALANCE

## GENOMICS OF BODY COMPOSITION, FROM SEVERE OBESITY TO EXTREME THINNESS: LEPTIN-MELANOCORTIN SYSTEM

Santos, José Luis.

Department of Nutrition, Diabetes and Metabolism. School of Medicine. Pontificia Universidad Católica de Chile. Santiago, Chile.

Although near to eighty obesity genetic syndromes have been described, most cases diagnosed with monogenic obesity are caused by disruption of genes belonging to the leptin-melanocortin pathway such as LEP (encoding leptin), LEPR (leptin receptor), MC4R (melanocortin-4 receptor), POMC (proopiomelanocortin) and PCSK1 (proprotein convertase subtilisin/kexin type 1), among others. Mutations of MC4R are considered as the most frequent cause of rare monogenic forms of human obesity, which may be responsible of up to 5% of severe childhood obesity and approximately to 1% of adult cases of severe obesity. Apart from the roles of MC4R in the regulation of food intake, this receptor also regulates blood pressure, lipolysis and insulin secretion through its reciprocal action on the two divisions of the autonomic nervous system (sympathetic and parasympathetic). The use of MC4R agonists has been proposed as a therapeutic strategy for treating obesity. However, most of the reported MC4R agonists show the undesirable property of increasing blood pressure, although a new MC4R agonist lacking such side-effects (setmelanotide) leads to reduction in body weight and energy intake in patients with mutations in POMC gene. After the identification of the genetic leptin deficiency in mice and humans, it was reported that subcutaneous leptin ad-

ministration to obese patients carrying mutations in the leptin gene reduced dramatically their energy intake and body weight. However, administration of human recombinant leptin as a monotherapy to patients with common obesity (with high circulating leptin and insulin levels) does not seem to reduce energy intake or body fat, indicating a resistance to leptin action in multifactorial obesity. Recently, it has been shown that the administration of leptin-sensitizers such as celastrol to mice with diet-induce obesity generated a reduction in body weight and energy intake, leading also to improved indexes of glucose homeostasis. On the other hand, the study of human leanness represents a complementary approach for ascertaining genes related to body weight regulation. Obesity/leanness are not only opposite phenotypes but also may behave as mirror traits. An interesting example of this phenomenon is provided by structural variations of chromosome 16p11.2, in which large deletions in this region containing SH2B1 gene (involved in leptin and insulin signalling) are strongly associated with obesity, while duplications are associated with leanness. Another example is Type 1 Generalised Congenital Lipodystrophy which is caused by mutations in AGPAT2 gene. Affected patients are characterised by extreme leanness, very low leptin and adiponectin plasma levels, as well as severe insulin resistance. In patients affected with this disease, administration of human recombinant leptin results in a remarkable improvement of glycaemic control, indicating the insulin-sensitizing effects of this hormone. The evaluation of obesity/leanness as opposite phenotypes remarks the usefulness of assessing the role of leptin in different pathophysiological contexts, revealing new aspects of adipose tissue biology.

**Keywords:** Obesity, thinness, leptin, melanocortin, lipodystrophy.

## BROWN ADIPOSE TISSUE AND BROWNING OF WHITE ADIPOSE TISSUE

Gil, Ángel.

PhD. Prof. Department of Biochemistry and Molecular Biology. Institute of Nutrition and Food Technology. Centre of Biomedical Research. University of Granada. CIBERobn. Spain.

Adipose tissue is composed of various cell types, which include adipocytes and other cells of the stromal vascular fraction such as preadipocytes, blood cells, endothelial cells and macrophages. Mammals have two main types of adipose tissue: white adipose tissue (WAT), and brown adipose tissue (BAT), each of which possesses unique cell autonomous properties. WAT and BAT differ at the functional, as well as the morphological and molecular levels. Brown adipocytes have a primary function in heat generation as they uniquely express the uncoupling protein 1 (UCP1) and were considered to be at most a minor component of human adipose tissue. However, the presence of BAT close to the neck and supraclavicular areas in adult humans was discovered in 2007, and later there has been an explosion of knowledge about BAT, both at the molecular, cell and clinical levels.
While the function of BAT located in discrete depots in the thorax is well-established, recent findings suggests that brown adipocyte progenitor cells, and possibly differentiated brown adipocytes, exist as scattered individual cells and small cell clusters distributed diffusely within WAT and possibly skeletal muscle tissue. Indeed, a new kind of adipocytes called BRITE (Brown-like adipocytes in white adipose tissue) or beige adipocytes has been identified within WAT; these cells arise from the same origin as white adipocytes, but they also share characteristics with those of brown adipocytes as the expression of UCP-1. Overexpression of the PRDM16 in white fat depots induces the formation of brown adipocytes, a process called "browning". The presence of brown adipocyte progenitor cells in WAT and the ability to induce brown adipocyte differentiation both in vitro and in vivo, suggest the possibility of a therapeutic approach for obesity based on brown adipocyte-mediated energy expenditure.

As BAT dissipates energy, due to its ability to oxidize glucose and lipids, recruitment and activation of BAT i.e. browning might be a therapeutic target for treating metabolic disorders such as obesity and type 2 diabetes. BAT is stimulated by the sympathetic nervous system (SNS); however, there are some novel BAT activators, some of them myokines, which act independently of the SNS, such as cardiac natriuretic peptides, irisin, interleukin-6, β-aminoisobutyric acid and fibroblast growth factor 21, that could influence BAT metabolism. Recently, we have postulated that exercise might activate and recruit human BAT through activation of SNS, heart and skeletal muscle. Thus, exercise could induce browning of the WAT and activate BAT, which in turn would results in increased thermogenesis and energy expenditure with concomitant loss of fat mass. We are currently carrying out a study (ACTIBATE) to evaluate the effect of long-term exercise training (24 weeks) on BAT activity and quantity in young overweight and obese adults.

**Keywords:** Adipose tissue. Brown adipose tissue. White adipose tissue. UCP-1

## MICROBIOTA AND OBESITY

Marcos, Ascensión.

Research Professor at the Spanish National Research Council (CSIC). Treasurer of the Spanish Nutrition Society (SEÑ).

Both the microbiota and the human host maintain a symbiotic association. Nowadays, metagenomic analyses are providing valuable knowledge on the diversity and functionality of the gut microbiota. However, with regard to the definition of a "healthy microbiota" and the characterization of the dysbiosis linked to obesity or other metabolism and inflammation-related disorders, there is still not a clear answer. Obviously, genes have an important role on the microbiota characteristics of an individual, but also lifestyle habits, such as diet, eating behaviour, body composition, physical activity, stress, as well as sleep profile, have been shown to be responsible of the type and diversity of bacteria in the gut. In addition, a new association has been recently discovered, such as the gut microbiota-brain axis that opens the perception that microbiota can act not only at an intestinal level, but also at several

sites of the organism, no matter how far they are from. Therefore, attempts have been made to counteract obesity through including different foods to be consumed into the diet. To this end, prebiotic and probiotic supplementation have been the former compounds used with the purpose to ameliorate and achieve a healthy microbiota. In the scientific literature, there are several experimental studies in animal models relevant to this topic. So far, evidence of an anti-obesity effect of different lactobacilli and bifidobacteria has been mainly obtained from animal models submitted to dietary-induced obesity. Using these experimental models, a substantial number of studies have reported reductions in weight gain and, particularly, in fat tissue mass at different locations following administration of beneficial bacteria, as compared with controls. Antiatherogenic and anti-inflammatory effects—including regulation of expression of lipogenic and lipolytic genes in the liver, reduction in liver steatosis, improvement of blood lipid profile and glucose tolerance, decreased endotoxemia, and regulation of inflammatory pathways—are also reported in many studies. The number of human studies focused on prebiotic or probiotic administration for obesity management is still very scarce, and it is too soon to judge their potential efficacy, especially when considering the fact that the actions of prebiotics and probiotics depend on the doses, the time and the period of administration, as well as the metabolism of the subject. In addition, the efficacy of probiotics is always strain-specific and the individual response varies according to intrinsic factors, the overall composition of the diet, and the interactions with the rest of lifestyle-related factors.

**Keywords:** Microbiota, obesity, lifestyle factors

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## INTEGRATION TO IMPLEMENTATION (I TO I) ON VITAMIN A INTERVENTIONS

## RELATIVE STRENGTHS AND WEAKNESSES OF AVAILABLE INTERVENTIONS/PROGRAM STRATEGIES TO PREVENT DEFICIENCY OR IMPROVE VITAMIN A STATUS IN INDIVIDUALS OR POPULATIONS

Udomkesmalee, Emorn.

PhD. Senior Advisor. Institute of Nutrition Mahidol University.
Thailand.

Addressing vitamin A deficiency (VAD) as a public health problem in developing countries requires a mix of interventions. The most widely-implemented program is the universal vitamin A supplementation (VAS) among children 6-59 months of age which began in 1990s in response to the evidence of risk reduction of childhood mortality, primarily due to

infectious diseases. The program can be scaled nationwide and achieved desirable coverage cost-effectively through joint implementation with existing child health services. However, VAS is not able to sustain improvement of VA status beyond 3 months
and, therefore, requires complementary interventions to effectively control VAD. Over the past decade, large-scale fortification of VA in sugar (success story in Central America), vegetable oil and staple grains expanded across Africa and Asia. While the approach is efficacious and cost-effective, monitoring quality production to consumption as well as evaluating public health impact remains a challenge in many settings. For dietary diversification to promote consumption of VA foods, data are scarce on efficacy and effectiveness of such interventions. Of interest, provitamin A carotenoids in foods offer a double opportunity to fill the gap of VA intake as well as enhance functional benefits within the healthy diet scheme. Recently, studies on bio-fortified crops especially orange-fleshed sweet potato and maize showed improvement on VA intake and status. Further efforts are required to scale up bio-fortification in target areas. Other VA containing programs include home-fortification micronutrient powder and lipid-based multi-nutrient supplements. In countries where VAS is implemented together with one or more other VA interventions, data gap exists regarding assessment of intakes for inadequate or excess levels as well as program impact on VAD control. For the past two decades, the global progress of nearly 50% reduction in the under-5 mortality, marked decline in undernutrition and burden of infection coupled with emerging data on no effect of VAS on child mortality, raises questions on the relevance and proper scaling of VAS to fit the country profile. Recent reviews identified the need to update magnitude and severity of VAD at national and sub-national levels to guide policy decision. With a co-existence of undernutrition, obesity and non-communicable diseases in low- and middle-income countries, the time is right to redesign the next generation of interventions that address VAD together with other nutritional targets.

**Keywords:** Vitamin A deficiency, supplementation, food fortification, dietary diversity, program impact

Guatemala is the first country in the world to implement and maintain sugar fortification with vitamin A as a successful public health intervention for decades, with monitoring and surveillance systems in place. Monitoring activities have provided information on the quality and coverage of the program and epidemiological surveillance confirms that universal sugar fortification with vitamin A has been a sustainable cost-effective strategy to drastically reduce vitamin A deficiency. Other strategies implemented in Guatemala include mega dose supplements for children and micronutrient powder provision, but with variable coverage. Efforts to adjust supplementation program according to a sufficient amount of VA provided by sugar have resulted in reducing the age group targeted by supplementation, from 6-59 months-old children to the 6-23 months-old.

Recent national health and nutritional surveys and local nutritional surveillance systems have evidenced that in Guatemala there is also availability of additional dietary sources of VA that can be provided by focal nutritional interventions, bought, as well as voluntarily fortified foods such as cereals, milk and juices. This suggests that a potential excess of VA intake is possible in the Guatemalan context. The lessons learned through has been useful to guide public policies and establish inter-sectoral alliances as in the National Commission of Food Fortification.

This presentation will present data available on national level and how those have influenced national policies. Discussion will be issued on how national food fortification programs can achieve sustainable adequate levels of Vitamin A without carrying out excessive intakes in vulnerable groups.

**Keywords:** Vitamin A status, National Fortification Programs, Guatemala

**Further collaborators:**

Manolo Mazariegos, María Claudia Santizo, Humberto Mendez

## COUNTRY PERSPECTIVE. WHAT ARE THE IMPLICATIONS OF THE CURRENT CONCERN/DEBATE ON NATIONAL EFFORTS TO PREVENT VITAMIN A DEFICIENCY IN GUATEMALA

(1)Mazariegos, Dora Inés; (2)Martinez, Carolina; (3)Melgar, Paul.

(1)MsSc Biochemist Human Nutrition. Nutrition and Micronutrient Unit. Institute of Nutrition of Central America and Panama. INCAP. Guatemala; (2)Chemical Biologist. Nutrition and Micronutrient Unit. Institute of Nutrition of Central America and Panama. INCAP. Guatemala.; (3)MD. Planification Unit. Institute of Nutrition of Central America and Panama. INCAP. Guatemala.

During the 1960s the vitamin A deficiency (VAD) in Guatemala was consequence of a cereal-based diet poor in both animal and vegetable sources of vitamin A. After designing and implementing a program to fortify sugar with cold-water soluble retinyl palmitate, a longitudinal evaluation demonstrated the effectiveness of the strategy. Follow-up biochemical assessments based on national health and micronutrient surveys showed a decline of VAD from 26.0% to 15.8% during 1965—1995 in children aged 0-59 months, and in 2008, the prevalence of low serum retinol values was 0.3%.

## WHAT DOES IT ALL MEAN AND HOW MIGHT WE MOVE AN AGENDA FORWARD TO ADDRESS THESE CHALLENGES? C. ENABLING AGENCIES

Kraemer, Klaus.

Managing Director. Sight and Life. Switzerland. Adjunct Associate Professor. International Health Johns Hopkins Bloomberg School of Public Health. USA.

At the World Summit for Children in 1990, it was agreed to 'virtually eliminate vitamin A deficiency (VAD) and its consequences.' However, VAD indicated by serum retinol levels <0.70 µmol/L still affects approximately 190 million preschool-age children. VAD is the most prominent cause of preventable childhood blindness, and increases the risk of childhood death from diseases such as diarrhea and measles. Biannual high-dose vitamin A supplementation (VAS) has been the most successful child survival intervention, which can reduce all-cause mortality rate by 12-24%, and is implemented by 84 countries. In 2014, 17 sub-Saharan countries reached effective coverage >80%. The integration of VAS in national polio campaigns allowed countries to reach high coverage rates. With progress towards the eradication of polio and im-
proved access to vitamin A-rich food, there has been considerable discussion about phasing out VAS. It is conceivable that effective VAS coverage is likely to decline once VAS is solely under the control of the health system. Nonetheless, a successful public health intervention such as VAS cannot be abandoned without assurance that vulnerable groups have access to and consume sufficient vitamin A-rich foods, such as liver, eggs, milk, fruit, vegetables, and fortified foods. Sugar fortification in Guatemala and Nicaragua, for instance, could demonstrate a continuous decline in VAD in different population groups, including preschool-age children. In a recent assessment of sugar fortification with vitamin A in Zambia, however, almost 90% of retail sugar samples analyzed did not meet the legal requirements of 10 mg/kg. This clearly indicates that, before scale-back of VAS can be justified, effective regulatory monitoring of fortification programs and regular assessment of the vitamin A status of the target population must be in place.

Multiple exposures from VAS, micronutrient powder, and fortification have raised concerns about preschool-age children exceeding the Tolerable Upper Intake Level (UL) for vitamin A. However, the UL is not a threshold for adverse effects, and for this age group it is even extrapolated from adults. In addition, vitamin A plasma concentration is not suitable for monitoring, as it is homeostatically controlled and influenced by inflammation. There is a need for reliable biomarkers of excess, because the narrow margin between the Estimated Average Requirement (EAR) and UL could, most notably, disenfranchise vulnerable children. Recent developments addressing the limitations of intake and plasma vitamin A for monitoring for both fortification and supplementation include the application of stable isotope dilution techniques.

Neonatal vitamin A supplementation (NVAS) in the first few days of life has been proposed as an intervention to reduce infant mortality. The evidence for mortality reduction from NVAS in South Asia is overwhelming and, if implemented adequately, could save the lives of as many as 250,000 children annually. No effect of NVAS on mortality was found in studies from Africa in areas with little vitamin A deficiency and low mortality, however. We therefore need policies that support NVAS in settings with high vitamin A deficiency and early infant mortality, including South Asian countries.

**Keywords:** Vitamin A, supplementation, fortification, preschool-age children, neonatal children

**Conflict of Interest disclosure:** Klaus Kraemer is the Managing Director of the Sight and Life Foundation, a nutrition think tank primarily funded by the vitamin A manufacturer DSM.

DIETARY VARIATIONS: CLASSICAL KETOGENIC DIET, MODIFIED ATKINS DIET, LOW GLYCEMIC INDEX TREATMENT

Pfeifer, Heidi.

RD LDN. Clinical Nutrition Specialist. Massachusetts General Hospital for Children. Boston. USA.

Dietary therapies have been utilized as treatment modalities of epilepsy for centuries. The classic ketogenic diet (KD) has been used in clinical practice since the 1920s. Although it has been proven to be an efficacious treatment option, compliance with the rigidity of this treatment has led to continued elevated discontinuation rates. Therefore over the past few decades more liberalized versions of the KD such as the low glycemic index treatment (LGIT) and the modified Atkins diet (MAD) were developed. These liberalized diets do not require the exact weighing and measuring of foods consumed as is required by the classic diet, allowing for a more flexibility in meal planning, including the ability to eat out at restaurants.

The LGIT and MAD are being utilized globally and are demonstrating similar efficacy rates to the classic KD. The backgrounds of the diets are similar in that they contain higher amounts of fat and limit the amount of carbohydrate consumed daily to transition the body to utilizing fat as its primary energy source. Due to the metabolic changes occurring during treatment it remains important for those utilizing these treatments to be monitored closely for any untoward side effects by a team familiar with intricacies of dietary therapies.

**Keywords:** Classic Ketogenic diet, Modified Atkins Diet, Low Glycemic Index Treatment, Dietary Therapy, Epilepsy
## Track 5: Nutrients and Nutritional Assessment

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### NOVEL FUNCTIONS AND USES OF AMINO ACIDS

#### THE INFLUENCE OF NUTRITION ON TUMOR METABOLISM AND GROWTH

Vander Heiden, Matthew G.

Koch Institute at Massachusetts Institute of Technology.

Cells adapt metabolism to meet distinct physiological needs, and metabolic regulation influences tumor initiation and progression. To proliferate, cancer cells must adapt metabolism to support anabolic processes that allow the accumulation of biomass. This includes producing those metabolites that are most limiting for tumor growth in physiological tissue contexts. We find that nucleotide synthesis is often limiting, and how cells generate nucleotides is influenced by diet, tissue environment, and tumor type. For many tumors, access to oxygen or other electron acceptors limits the production of purines and pyrimidines. Analysis of metabolism in animal cancer models suggests that tumors can use different nutrients to allow tumor growth. Diet and whole body metabolism affects nutrient availability and influence tumor progression, and also contributes to tissue wasting that this commonly observed in cancer.

**Keywords:** Cancer metabolism, Diet and cancer, Cachexia

**Conflict of Interest disclosure:** M.G.V.H. is a consultant and SAB member for Agios Pharmaceuticals and Aeglea Biotherapeutics

#### BCAA FUNCTION AND INSULIN RESISTANCE FROM THE STUDIES USING GENETICALLY ENGENEERED MICE IN BCAA CATABOLISM

Kitaura, Yasuyuki; Shimomura, Yoshiharu.

PhD, Nagoya University, Japan.

Branched-chain amino acids (BCAAs) (leucine, isoleucine, and valine) are essential amino acids as ingredients for proteins in mammals. BCAAs also play as a nutrient signal for protein synthesis, and recently, their concentrations in blood are highly correlated with insulin resistance. So far, however, whether increased BCAAs would be responsible for insulin resistance or consequences of insulin resistance remains unclear. In fact, impaired BCAA catabolism that leads to increase BCAAs have been associated with insulin resistance, so that the genes related with BCAA catab-

olism are thought to be potential targets for the treatment of insulin resistance. The first two steps of BCAA catabolism are common for these three amino acids. The first reversible transamination reaction is catalyzed by BCAA aminotransferase (BCAT) isozymes, BCATm (mitochondria-type) and BCATc (cytosol-type), which form branched-chain alpha-keto acids (BCKAs) from BCAAs. The second step is an irreversible oxidative decarboxylation reaction by BCKA dehydrogenase (BCKDH) to produce branched-chain acyl-CoAs, which are eventually catalyzed to either acetyl-CoA or succinyl-CoA by each three individual pathways. The BCKDH activity is suppressed by phosphorylation of the dehydrogenase by BCKDH kinase (BDK) and activated by dephosphorylation by PP2Cm. BCATm-deficient mice with blocked BCAA catabolism at the first step showed high BCAA levels in blood, increased energy expenditure and improved insulin resistance by diet-induced obesity, however low exercise capacity. On the other hand, BDK-deficient mice with defect in negative regulation of the second step of BCAA catabolism showed low BCAA concentrations in blood and developed neurological disorder, however the insulin sensitivity of BDK-deficient mice are still unknown. Recently, we have generated the mice with BDK defect either in whole body (BDK-KO mice) or specifically in skeletal muscle and heart (BDK-mKO mice). Although BDK-KO mice showed the phenotype with neurological defects as the previous report, BDK-mKO mice were healthy without any obvious defects when feeding a protein-rich diet, and the concentration of myofibrillar protein was significantly decreased during protein undernutrition. We will discuss the role of BCAAs in insulin resistance with the results we observed using our animal models. This tissue-specific BDK deficient mouse model is very useful for further investigation to find out the importance of BCAAs in any interest tissues or cells.

**Keywords:** BCAA, insulin resistance, animal model

#### QUANTITATIVE PROTEOMICS REVEAL OVERALL AMINO ACID TRANSPORT SYSTEMS AND THE RELATED SIGNALING

Nagamori, Shushi.

Ph.D. Associate Professor. Department of Bio-system Pharmacology. Osaka University Graduate School of Medicine. Japan.

Amino acids are known as building blocks of proteins and substrates of metabolic and biosynthetic reactions. However amino acids are also recognized as the signaling molecules to regulate cellular metabolism and cell growth. Among amino acids, leucine is the most effective signaling molecule to regulate cell growth and metabolism by activating mechanistic target of rapamycin complex 1 (mTORC1) which is one of the well-recognized cellular signaling pathways mobilized by amino acids. Since leucine is one of essential amino acids, cell needs to take it up from outside by using transporters. It has been reported that Na+-dependent or Na+-independent plasma membrane transporters are able to transport leucine.
Normal cells control nutrient uptake and metabolic activities to prevent aberrant cell proliferation. On the other hand, in cancer cells, nutrient transporters are constitutively activated to facilitate the nutrient uptake for robust cell growth. Several studies have reported the overexpression of some amino acid transporters. However, there have been no report about comprehensive expression profile of amino acid transporters in cancer cells due to the problematic nature of transporter proteins. Thus, we have exploited comprehensive and quantitative proteomics to review the functional profiles of amino acid transporters in many cell lines. In our study, we found that cancer cell lines selectively expressed one transporter from each transporter family. Expressions of SLC1A5, LAT1/SLC7A5, SLC7A1 and SLC7A6 were conserved in most cell lines. These results strongly indicate that these transporters are the common transporters to supply amino acids for cancer cells.

Of the transporters, LAT1/SLC7A5 transports several large neutral essential amino acids including leucine. By addition of an LAT1-inhibitor BCH, leucine uptake by LAT1 was blocked, and then the phosphorylation of mTORC1 pathway was also suppressed. Therefore, we have applied quantitative proteomics to analyze the cellular responses to leucine transported via LAT1 comprehensively. Cells were stimulated by leucine in the presence or absence of BCH. Thus, the phosphorylation induced by LAT1-mediated leucine uptake was able to be distinguished. Our result shows that leucine-uptake by LAT1 regulated phosphoproteins involved in multiple cellular processes and revealed the linkage of signaling pathways and cellular responses. These data open a door let us explore the whole picture of signaling stimulated by leucine uptake. Moreover, this approach is not limited to investigate a particular amino acid or a cell type but applicable to various cases of studies.

**Keywords:** Amino acid, transporter, proteomics, phosphoproteomics

**Further collaborators:**

Yoshikatsu Kanai, Osaka University

## METHIONINE METABOLISM REGULATES THE FUNCTIONS OF HUMAN PLURIPOTENT STEM CELLS

Shiraki, Nobuaki.

PhD. Tokyo Institute of Technology. School of Life Science and Technology. Japan.

Recent evidence suggests that metabolic pathways are important for the establishment of pluripotency as well as the regulation of cell proliferation and differentiation in pluripotent stem cells (PSCs). Embryonic stem cells (ESCs) and induced pluripotent stem cells (iPSCs) have an unlimited ability to replicate and the potential to differentiate into any cell type. PSCs constitute a promising model for self-renewal and differentiation and may facilitate research about early development. They possess a unique transcriptional circuit that sustains the pluripotent state. These cells are in a specific epigenetic state that enables rapid cell fate decisions.

Furthermore, PSCs possess a characteristically high rate of proliferation as well as an abbreviated G1 phase. Recent reports have shown that metabolism is tightly linked to cellular signaling, and these two processes reciprocally regulate each other to modulate cell activities, such as survival, proliferation, and stem cell function. We and other groups have demonstrated that the universal methyl donor S-adenosyl methionine (SAM) is a key regulator for the maintaining undifferentiated PSCs and regulating their differentiation. In mouse PSCs, SAM is dependent on glycine converted from threonine by threonine dehydrogenase (Tdh). Threonine uptake and Tdh activity are required to maintain high levels of SAM. The human TDH gene is a nonfunctional pseudogene; accordingly, threonine cannot be used for SAM production in human cells. Therefore, human PSCs depend on extracellular methionine for SAM synthesis, and short-term methionine deprivation results in a loss of histone methylation, triggering the reducing NANOG expression, and promoting human PSC differentiation into all three germ layers (Shiraki et al., Cell metabolism 2014). Based on a gene expression analysis and the quantification of methionine metabolites, undifferentiated human PSCs are in a high-flux methionine metabolic state. In contrast, differentiated endoderm cells require a low amount of methionine for growth and are therefore not affected by methionine deprivation. This metabolic difference between undifferentiated PSCs and differentiated cells prompted us to test whether methionine deprivation eliminates the remaining undifferentiated cells. After prolonged (48 hr) methionine deprivation during mid-stage endoderm differentiation, residual undifferentiated cells were eliminated, and the overall differentiation efficiency increased. These results have implications for the elimination of variability in differentiation efficiency among cell lines and for the promotion of differentiation into specific cell lineages. Here I show methionine metabolism, which regulates the maintenance and differentiation of human PSCs, summarize the roles of SAM and epigenetic crosstalk in these processes, and compare these mechanisms in mouse and human PSCs.

**Keywords:** Methionine. Amino acid. iPSCs. ES cells. Differentiation

PS_144/143

## FOOD CONSUMPTION SURVEYS: RESULTS AND USES

### LATIN AMERICAN SURVEY OF NUTRITION AND HEALTH (ELANS). PRELIMINARY RESULTS

Kovalskys, Irina.

MD. Nutrition and Health Area. International Life Science Institute (ILSI). Buenos Aires. Argentina.

Determinations of total energy intake, diets nutrient composition and dietary patterns of Latin American countries are critical to address the epidemic of non-communicable diseases and the health consequences of physical inactivity. This information
would be of the greatest actionable value for developing dietary recommendations and policies for governments, and scientists

ELANS Protocol

The Latin American Study of Nutrition and Health/Estudio Latinoamericano de Nutrición y Salud (ELANS), is a randomized cross-sectional multicenter research designed to address the nutritional profile of Latin American (LA) people in eight LA countries (Argentina, Brazil, Peru, Colombia, Costa Rica, Ecuador and Venezuela). The study provides comparable data of dietary intake, physical activity, and anthropometric profile among representative urban populations of the eight countries; analyzed by socioeconomic status, age and gender. A sample of 9218 adolescents and adults aged 15.0-65.0 years, stratified by geographical location, gender, age and socioeconomic status was performed. The ELANS standardized protocol was followed by the eight countries and performed simultaneously. Intake data was collected by two 24 hs recall and physical activity information by both the Mexican (Spanish) version of International Physical Activity Questionnaire (IPAQ) and accelerometers in 2 household visits. Five anthropometric measurements were performed by the exact methods and instruments.

ELANS included 9,218 individuals (48% men and 52% women) with validated data. The age distribution of the sample was 13%, 38%, 28% and 21% for 15-19, 20-34, 35-49 and 50-65 years old, respectively. Mean body mass index (BMI) was 26 kg/m2 with higher values from women (27.5 kg/m2) than men (26.3 kg/m2). Overall, only 37% of the ELANS sample had normal body weight, while 3% exhibited underweight, 34% were overweight and 26% were obese. ELANS results show high rates of overweight and obesity in the region, coexistent with high prevalence of inadequate micro-nutrients intake. Despite different rates between countries were found, a shared pattern where the vulnerable age groups are mainly the adolescents and older adults, was found. Analyzing LA diets distribution of macro-nutrients but they are well balanced, differences in food sources, culture and meal habits were observed from one country to another expressing the cultural imprinting of each diet composition. The ELANS overall sample reported a higher level of active people at the transport dimension of IPAQ for men than for women. Men in 20-34 age range reported the highest (59%) level of active PA at leisure time while for female adolescents it was the lowest (29%). This is congruent with the sedentary time (hours/week) collected with the accelerometers where the highest levels were reported by adolescents 10 hours/week for both genders.

ELANS provides a unique dataset for Latin America, enabling cross-country comparisons of energy, macro- and micro-nutrients intake and physical activity as well as establishing associations between these lifestyle components and nutritional status within this region. In this symposium, the main results obtained in this study will be reported.

**Keywords:** Survey, Nutrition, Physical Activity, Latin America.

**Conflict of Interest disclosure:** The ELANS is supported by a scientific grant from the Coca Cola Company and support from the Instituto Pensi / Hospital Infantil Sabara, International Life Science Institute of Argentina, Universidad de Costa Rica, Pontificia Universidad Católica de Chile, Pontificia Universidad Javeriana, Universidad Central de Venezuela (CENDES-UCV)/

Fundación Bengoa, Universidad San Francisco de Quito, and Instituto de Investigación Nutricional de Peru. The funders had no role in study design, data collection and analysis, the decision to publish, or the preparation of this symposium.

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

PS_144/105

NUTRITION SCIENCE AT A CROSS-ROAD

BEST PRACTICES FROM THE ASN COMMITTEE ON PUBLIC TRUST

The American Society for Nutrition (ASN) created an Advisory Committee on Ensuring Trust in Nutrition Science. The ASN charged the committee with recommending best practices for sustaining public trust in all of ASN's collaborative undertakings with stakeholders across sectors and disciplines. Assuring transparency and rigor in those activities was stressed. Implementation of best practices is expected to uphold trust in nutritional science among all stakeholders, i.e., the public, industry, government, academia, and other nonprofit, nongovernmental organizations pertinent to the field of nutrition science. Their implementation also should help ensure objectivity, and comprehensiveness, achieve the best nutrition science, and assure required accountability and the realization of anticipated benefits to public and individual health.

**Keywords:** American Society for Nutrition; Nutrition Research; Public Trust; Rigor and Reproducibility; Best practices

**Conflict of Interest disclosure:** Patrick Stover: Consultant/Advisory Boards: Raze Therapeutics; NHSc-Pamlab; Biofortis, Marabou Foundation, ASN Board

REDUCTIONIST VERSUS HOLISTIC PARADIGMS IN NUTRITION SCIENCE

Fardet, Anthony.

PhD. Researcher in preventive and holistic nutrition. French National Institute for Agricultural Research (INRA). Unit of Human Nutrition. France.

Up to day nutrition science, in Western countries, has been mainly experimented according to the reductionist paradigm. Reductionism is based on the assumption that since reality is too complex to be studied as such it needs to be fragmented into isolated entities that are studied according to the view that the whole is equal to the sum of the part (2 = 1+1) on the basis of a linear

<footnote>(1)Stover, Patrick; (2)Ohlhorst, Sarah; (3)Field, Martha; (2)Garza, Cutberto.</footnote>

<footnote>(1)Cornell University and American Society for Nutrition. USA;</footnote>

<footnote>(2)American Society For Nutrition, 9211 Corporate Blvd., Suite 300 Rockville, Maryland, 20850, USA; (3)Cornell University, Division of Nutritional Sciences, Ithaca, NY 14850 USA.</footnote>
cause-effect relationship. As a result foods are considered as only sums of nutrients and calories; and one nutrient is generally associated with one deregulated metabolism then one chronic disease (e.g., relationship between saturated fats, dyslipidemia and atherosclerosis whereas it is a reducing association). Reductionism can be considered as the main deep cause at the roots of diet-related chronic diseases that are encountered in populations consuming the most fractionated/recombined and refined ultra-processed foods, the ultimate consequence of reductionism. Indeed, if foods are only sums of nutrients why not cracking them in a multitude of nutrients and to recombine them. Nutritional supplements, functional foods and ultra-processed foods are therefore the consequences of our modern reductionist science. They are also based on the assumption that food health potential is based on its composition only.

On the contrary, holism views whole foods as more than a sum of nutrients because of synergy of action of nutrients and food matrix effect. Holistic nutrition science defines food health potential as combination of both matrix and compositional effects. Food is more than the only sum of nutrients (2 > 1+1). Matrix effect is crucial because it impacts satiety potential and nutrient bioavailability, both playing a crucial role to maintain a good health. Therefore two foods of identical composition but with a different matrix have not the same health potential.

Therefore to fight against the increasing prevalence of diet-related chronic diseases we need today to base more nutrition science on the holistic paradigm. Whereas recombined/refined ultra-processed foods are the fruit of reductionism whole and complex foods participate more of the holistic paradigm which should encourage technologists to less process foods to preserve their matrix, and public authorities to lay emphasis on minimally-processed foods as a basis of a healthy diet.

In addition to food science and technology the holistic paradigm may find other important applications in the study of diets on human health. Randomized controlled studies are coming from reductionist and pharmacologist designs, very far from real life, and cannot yield long-term and effective applicable results. Nutrition science is not pharmacology and foods are not drugs: therefore application of holism should prompt nutritionists to carry out intervention studies in complex real life conditions (taking into account all aspects of dietary lifestyles), and not to control only one.

Finally reductionist and holistic paradigms are both necessary: however more importance to holism should be given. Reductionism only becomes meaningful when it is embedded and circumsumed in a thorough and holistic reflection. If not, reductionism turns around, and only produces partial scientific truths devoted to agro food industry benefits.

**Keywords:** Holism, Reductionism, Nutrition, Food matrix, Processing

# IS THE RCT THE BEST WE CAN DO?

Martínez-González, Miguel Ángel.

Universidad de Navarra. CIBEROBN. Spain. Harvard T.H. Chan School of Public Health. Boston, USA.

Large randomized controlled trials (RCTs) are apparently the only way to circumventing the methodological problems of observational research, such as misclassification, reverse causation and residual confounding.

But small, short-term RCTs with surrogate markers of disease as the outcome are clearly not the solution. To give a high value to changes in any single surrogate biomarker is a mistaken approach, given that there are multiple pathways leading from diet to disease. Moreover, the induction period can vary for the different pathways in which diverse biomarkers are involved, thus limiting the possibility of assessing multiple biomarker combinations at any time point. Furthermore, other lesser-known pathways could account for a substantial proportion of clinical events. Therefore, the gold standard should be long-term RCTs with hard clinical events. In them, participants should be willing for a long period (usually at least 5-6 years) to eat what the investigators decided that they should eat, not what they like to eat. This is very problematic.

A highly prevalent tenet in the current nutrition literature is that “prospective cohort studies provide evidence only of statistical associations (“mere correlations”) but not causation whatsoever, because only RCTs can answer causal questions”. Under that assertion, most of the current practices and policies in public health would lack sufficient scientific foundation. The truth is that sound and effective public health actions have been based in well-designed, conducted and analyzed observational epidemiologic studies. They do provide valid answers to causal questions in nutrition.

The criteria for causality established by Bradford Hill long time ago are the leading principles to obtain causal inferences from observational studies. They keep their validity nowadays. Cause and effect associations can be drawn when most of these criteria are met, especially when there is consistency among many well conducted observational studies.

Conversely, methodological challenges in designing RCTs in nutrition can frequently induce biases. They speak against any “fundamentalism” for the RCTs. They include the intensity of the “intervention” to be delivered to the control group, selection biases due to selective attritions, deficient adherence to the prescribed diet (suboptimal compliance is the rule and not the exception), contamination of the control group with the intervention protocol, erroneous assumptions about the induction period or potential effect modifiers, and, very especially a small and insufficient contrast in the diets of the intervention and control groups. These biases tend to operate towards the null and several RCTs in nutrition ended as non-informative, after astronomic expenses and many years of work. The PREDIMED trial, showing the benefits of the Mediterranean diet was an exception. But the results of PREDIMED were highly consistent with those of observational cohorts.

Therefore, very often, RCTs are not the best design to answer causal questions regarding long-term effects of dietary exposures. Because a well-conducted cohort study can simulate an RCT when the most important confounders have been controlled for, the