er education. 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. Conclusions: ELANS provides a unique dataset for Latin America, enabling cross-country comparisons of energy, macro- and micro-nutrient 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 and discussed.

**Keywords:** Food intake - physical activity - nutritional status - cross-sectional study - Latin America

**Conflict of Interest disclosure:** This study was funded by an unrestricted research grant from The Coca-Cola Company

**Further collaborators:** Viviana Guajardo, Ioná Zimberg, Agatha Nogueira Predivelli

## RELATIONSHIP BETWEEN DIET QUALITY AND OBESITY RISK: IS IT POSSIBLE TO DEVELOP A LA DIET QUALITY INDEX?

(1)Gómez Salas, Georgina; (2)Nogueira Previdelli, Agatha; (3)Fisberg, Mauro; (4)Kovalskys, Irina; (5)Cortes, Lilia Yadira; (6)Herrera-Cuenca, Marianella; (7)Yepez Garcia, Martha Cecilia; (8)Pareja, Rossina Pareja; (9)Guajardo, Viviana Beatriz; (10)Rigotti, Attilio.

(1)MSc. Nutritionist. Departamento de Bioquímica. Escuela de Medicina. Universidad de Costa Rica.; (2)PhD. Professor. Faculdade de Ciências Biológicas e da Saúde. Universidade São Judas Tadeu São Paulo. Brazil; (3)PhD. MD. Instituto Pensi. Fundação Jose Luiz Egydio Setubal. Hospital Infantil Sabara. São Paulo. Brazil PhD. Professor. Departamento de Pediatria. Universidade Federal de São Paulo. São Paulo. Brazil; (4)MD. Nutrition and Health Area. International Life Science Institute (ILSI). Buenos Aires. Argentina; (5)PhD. Nuticionist. Departamento de Nutrición y Bioquímica, Pontificia Universidad Javeriana, Bogotá, Colombia; (6)PhD. MSc. MD. Centro de Estudios del Desarrollo, Universidad Central de Venezuela (CENDES-UCV)/Fundación Bengoa, Caracas, Venezuela; (7)MSc. Bch. Med. Tech. Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Ecuador; (8)MSc. Nutritionist. Instituto de Investigación Nutricional, Lima, Perú; (9)BSc. Psychologist. Nutrition and Health Area. International Life Science Institute (ILSI). Buenos Aires. Argentina; (10)PhD. MD. Centro de Nutrición Molecular y Enfermedades Crónicas, Departamento de Nutrición, Diabetes y Metabolismo, Escuela de Medicina, Pontificia Universidad Católica, Santiago, Chile.

The Latin American Study of Nutrition and Health/Estudio Latinoamericano de Nutrición y Salud (ELANS), which is randomized cross-sectional multicenter investigation of food intake and physical activity status of adolescents and adults in eight Latin American countries (Argentina, Brazil, Chile, Colombia, Costa Rica, Ecuador, Peru, and Venezuela) was designed and executed simultaneously, using the same protocols to gather information,

and provide accurate and updated information on diet, dietary patterns, physical activity and nutritional status of the region. Dietary patterns have been widely used for the assessment of dietary intake and evaluation of diet's association with several health outcomes. To our knowledge, only few studies have assessed diet quality of Latin American population and none has applied the same index in several populations at the same time. Thus, we aim to develop and apply a single and simple index of diet quality index for Latin American adolescents and adults and to evaluate its association with excess weight.

We will model two different dietary patterns: one based on relatively high consumption of ten healthy items (fruits, vegetables, beans and legumes, nuts and seeds, whole grains, milk, total polyunsaturated fatty acids, fish, vitamin D, and dietary fiber); and another based on relatively low consumption of ten unhealthy items (unprocessed red meats, processed meats, sugar-sweetened beverages, added sugar, saturated fat, trans fat, dietary cholesterol, refine grains, sodium and high glycemic index foods). For comparison, we will also model a third overall dietary pattern that incorporated all 20 dietary factors together. A diet quality score will be derived from each pattern; higher scores will be equivalent of healthier diets. Then, diet quality score association with excess weight will be analyzed using logistic regression analysis. Also, Factor Analysis will be performed to identify factor loading of each variable in two dietary patterns, using the average weight consumed (g/d) by each individual of 20 dietary items. Dietary intake will be adjusted for 2000 Kcal, in order to access diet quality independently of the quantity consumed. Preliminary analysis has shown a high prevalence of excess weight among eight countries, and a high intake of certain foods, food groups and nutrients, such as added sugar, sweetened beverages, fats (total, saturated and trans) and sodium, and a low intake of fruits and vegetables, vitamin D and calcium. Following this analysis, it will be possible to develop a diet quality index for Latin American countries, using the same tool that will allow us to compare diet quality by age and sex and country, and will provide information to evaluate and monitor dietary intake. It will also help to better understand the association between diet quality and increased weight in each population in order to contribute to the planning of public health politics to reduce obesity prevalence in the region.

**Keywords:** Dietary Patters, Diet Quality, Latin American

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

**Further collaborators:** On behalf of ELANS Study Group
LATIN AMERICAN POPULATION: MAINLY ACTIVE OR SEDENTARY? IS THERE AN ASSOCIATION BETWEEN LIFESTYLE AND DIET NUTRITIONAL COMPOSITION?

(1)Fisberg, Mauro; (2)Kovalskys, Irina; (3)Gómez Salas, Georgina;

(4)Previdelli, Ágatha Nogueira; (5)Rigotti, Attilio; (6)Cortes, Lilia Yadira;

(7)Yepez Garcia, Martha Cecilia; (8)Pareja, Rossina Pareja; (9)Herrera-Cuenca, Marianella.

(1)MD, PhD, pediatrician and nutrologist. Coordinator of Nutrition and Feeding Difficulties Center Pensi Institute Fundação Jose Luiz Setubal. Associate Professor of Pediatrics Escola Paulista de Medicina UNIFESP. Brazil; (2)MD. International Life Science Institute ILSI Argentina; (3)Departamento de Bioquímica, Escuela de Medicina, Universidad de Costa Rica, San José, Costa Rica; (4)Faculdade de Ciências Biológicas e da Saúde - Universidade São Judas Tadeu - São Paulo, Brazil; (5)Centro de Nutrición Molecular y Enfermedades Crónicas, Departamento de Nutrición, Diabetes y Metabolismo, Escuela de Medicina, Pontificia Universidad Católica, Santiago, Chile; (6)Departamento de Nutrición y Bioquímica, Pontificia Universidad Javeriana, Bogotá, Colombia; (7)Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Ecuador; (8)Instituto de Investigación Nutricional, Lima, Perú; (9)Centro de Estudios del Desarrollo, Universidad Central de Venezuela (CENDES-UCV) Fundación Bengoa, Caracas, Venezuela.

The enormous increment of the excess weight in humans all over the world in the last 40 years is a new epidemiological situation, not seen in other nutritional problems.

It is very probable that excess weight and obesity is not a one only disease or caused by one only cause. The combination of genetic heritage with external conditions as a modification of food intake (amount or density) and a decrease in energy expenditure, determines a final condition that results in excess weight, an increase in fatty mass and metabolic alterations.

In the last years, modernization and the urban modifications, with sedentary behavior and excess energy intake, have modified the ways human beings are managing energy.

There are no reported papers of evaluating nutritional status and physical activity in Latin American populations, using a standardized methodology and representative surveys for adolescent and adult population, at the same time. ELANS- Estudio Latinoamericano de Nutrición Y Salud- or Latin America Study on Nutrition and Health, has evaluated more than 9000 people in 8 countries (15-65y), in urban settlements, in a randomized domiciliary census.

Anthropometric measurements, nutrition evaluation by means of two 24hs- recall survey and a food frequency questionnaire was performed with physical evaluation by two methodologies-IPAQ (International Physical Activity questionnaire large version) - In person-reported physical activity; leisure-time and transport activity were included; Mexican (Spanish) version of IPAQ (Salvo et al, 2014) was adapted for ELANS. Outcomes: total vigorous, moderate, sedentary time in minutes/week, Transport and Leisure time vigorous, moderate, sedentary time in minutes/week by week and weekend days.

An active evaluation was done by means of accelerometry measurement (model GT3X+, ACTi Graph, Pensacola, FL, USA) in 40% of the whole population, representing more than 3000 people. Ac-

celerometers were fixed by elasticized belt at hip level on the right mid-axillary line, being used for 7 days, and for at least 5 days of valid measurements.

By anthropometric evaluation, 60% of ELANS population presented excess weight, varying from 54%-62%(male-female), with lowest prevalence in Colombia and higher in Chile. Energy intake was lower in Chile, for plausible cases (excluding misreporting).

As for physical evaluation by questionnaires observation (IPAQ), it was seen that 48% of ELANS population were insufficiently active, with 22% in Ecuador and 65% in Venezuela.

When actively observed (accelerometry), the overall sedentary time was higher than 9 hours a day, being higher during weekends and in adolescents. Senior adults have lower physical activity in all measurements in all countries.

As conclusion, we can observe that excess weight epidemic has strongly reached Latin American countries and some observations must be discussed- despite low energy intake, food density must be evaluated. Physical inactivity and sedentary behavior is strongly associated with excess weight, in all countries, and being much important in adults and senior people. Political and educational policies must be implemented for preventing obesity and its morbidities. Implementing changes toward public policies and education interventions must be made for preventing obesity and its co-morbidities.

**Keywords:** Physical activity, sedentarism, obesity, accelerometry, IPAQ

**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:** Guajardo Viviana, Zimberg Iona.
HABITS & CULTURE: RELATIONSHIP BETWEEN
FOOD HABITS AND NUTRITIONAL PROFILE
BASED ON MICRONUTRIENTS

(1)Kovalskys, Irina; (2)Fisberg, Mauro; (3)Gómez Salas, Georgina;

(4)Rigotti, Attilio; (5)Cortes, Lilia Yadira; (6)Yepez Garcia, Martha Cecilia; (7)Pareja, Rossina Pareja; (8)Herrera Cuenca, Marianella;

(9)Nogueira Previdelli, Agatha.

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

(3)MSc. Nutritionist. Departamento de Bioquímica. Escuela de Medicina. Universidad de Costa Rica. Costa Rica; (4)PhD. MD. Centro de Nutrición Molecular y Enfermedades Crónicas, Departamento de Nutrición, Diabetes y Metabolismo, Escuela de Medicina, Pontificia Universidad Católica, Santiago, Chile;

(5)PhD. Nuticionist. Departamento de Nutrición y Bioquímica, Pontificia Universidad Javeriana, Bogotá, Colombia; (6)MSc. Bch. Med. Tech. Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Ecuador; (7)MSc. Nutritionist. Instituto de Investigación Nutricional, Lima, Perú; (8)PhD. MSc. MD. Centro de Estudios del Desarrollo, Universidad Central de Venezuela (CENDES-UCV)/Fundación Bengoa, Caracas, Venezuela; (9)PhD. Professor. Faculdade de Ciências Biológicas e da Saúde. Universidade São Judas Tadeu São Paulo. Brazil.

LA countries have been experiencing the nutrition transition during the last 40 years moving from under to overweight but also experiencing nutritional deficiencies. As a result of this transition, alarming rates of overweight and obesity have been described in LA, which coexist with hidden malnutrition especially in developing countries. It has been suggested that the excessive energy intake is also associated with the decreased of food quality and multiple micronutrient deficiencies.

The deep knowledge about LA diet is still a scientific concern. Few studies have investigated the LA diet composition reporting not only the differences across countries but also among the regions within a country. ELANS (Latin American Study of Nutrition and Health) has examined the pattern of habits and micronutrient's food sources in 8 LA, using a single methodology for data collection and analysis. Data were analyzed by country, gender, socioeconomic level (SEL) and group of age.

Micronutrients outcomes of ELANS were Calcium, Vitamin A, D, C and Iron and the estimated average requirements of the Food and Nutrition Board of the Institute of Medicine were the references used for making comparisons. The prevalence of inadequate intake of Vitamin A was 52% (range: 21-80,) no association with socio economical level and/or nutritional status was observed. Intake of Vitamin D was very low for all the countries with little variations between them and higher intake in men was observed (mean: 3.1 mcg/d EAR: 10 mcg/d). On the contrary, Calcium intake showed a wide variation of inadequate intake with lower rates in Argentina (70%) and higher ones in Costa Rica and Peru (95 and 97% respectively). Iron deficiency is higher in Brazil and significantly associated with SEL. Vitamin C inadequate con-

sumption is higher in southern countries (Argentina and Chile) and lower in northern ones, associated with natural juice and fruit consumption. Combined prevalence of inadequate micronutrient intake showed to be higher in vulnerable age groups (adolescents and older adults) and this is a common pattern in all the eight countries. Differences observed in culture and meal habits from one country to another seem to be associated to micronutrient intake and centered in two key aspects: main food sources, and behavior regarding fruit and vegetable consumption

In conclusion, despite the eight Latin American countries show alarming rates of micronutrient deficiencies, cultural differences in meal patterns and food sources explain variations in consumption between the countries. Vulnerable groups are the youngest and oldest of the sample that do not reach to meet intake recommendations and this pattern is shared by all the countries, gender, and social and economic groups within the Latin American region.

**Keywords:** Epidemiology Macronutrients Nutrition Food patterns ELANS

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

**Further collaborators:**

On behalf of the ELANS Study Group
LEARNING FOR RESEARCHERS: A MULTICENTER
STUDY SHARING METHODS OF EVALUATION
OF PHYSICAL ACTIVITIES AND INTAKE IN EIGHT
COUNTRIES

(1)Guajardo, Viviana Beatriz; (2)Kovalskys, Irina; (3)Fisberg, Mauro;

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

(7)Yepez Garcia, Martha Cecilia; (8)Pareja, Rossina Pareja; (9)Herrera

Cuenca, Marianella; (10)Nogueira Previdelli, Agatha; (11)Zalcman
Zimberg, Ioná.

(1)BSc. Psychologist. Nutrition and Health Area. International Life Science Institute (ILSI). Buenos Aires. Argentina;

Nutrition and Health Area. International Life Science Institute
(ILSI). Buenos Aires. Argentina; (3)PhD. MD. Instituto Pensi.

Fundação José Luiz Egydio Setubal. Hospital Infantil Sabara.

São Paulo. Brazil PhD. Professor. Departamento de Pediatria.

Universidade Federal de São Paulo. São Paulo. Brazil; (4)MSc.

Nutritionist. Departamento de Bioquímica. Escuela de

Medicina. Universidad de Costa Rica. Costa Rica; (5)PhD. MD.

Centro de Nutrición Molecular y Enfermedades Crónicas,
Departamento de Nutrición, Diabetes y Metabolismo, Escuela
de Medicina, Pontificia Universidad Católica, Santiago, Chile;

(6)PhD. Nuticionist. Departamento de Nutrición y Bioquímica,
Pontificia Universidad Javeriana, Bogotá, Colombia; (7)MSc. Bch.

Med. Tech. Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Ecuador; (8)MSc. Nutritionist. Instituto de Investigación Nutricional, Lima, Perú; (9)PhD. MSc. MD. Centro de Estudios del Desarrollo, Universidad Central de Venezuela (CENDES-UCV)/Fundación Bengoa, Caracas, Venezuela;

(10)PhD. Professor. Faculdade de Ciências Biológicas e da Saúde. Universidade São Judas Tadeu São Paulo. Brazil; (11)PhD.

Faculdade de Ciências Biológicas e da Saúde - Universidade São
Judas Tadeu - São Paulo, Brazil.

The interest on developing public health policy interventions to reduce obesity and improve nutrition in last decades has progressively grown as a response to increasing overweight and obesity prevalence. ELANS (Estudio Latinoamericano de Nutrición y Salud) or Latin America Study on Nutrition and Health, is a household-based multi-national cross-sectional survey whose aim is to describe the nutritional status of the Latin-American people, and investigate food and nutrients intake as well as physical activity status of nationally representative samples from urban populations. This study evaluated with an unique methodology, a randomized sample with 9218 people (15-65y) in 8 countries simultaneously (Argentina, Brazil, Chile, Colombia, Costa Rica, Ecuador, Peru and Venezuela).

Many challenges and barriers to conduct this study arose at the
very beginning: the complexity of the selection of team members,
communications, inclusion of technical scientific advisors. The re-
quirement of having a common protocol with the same set of data
collection tools, involved 15 months of collaborative work. In addi-
tion, obtaining ethical approval from 8 different boards plus a cen-
tralized external Institutional Review Board (IRB) at a similar range
of time became an extra challenge. A Contract Research Organi-
zation (CRO), was responsible for the recruitment and data collec-
tion. To ensure the feasibility, efficiency and adherence to the study

protocol and procedures a pilot study was crucial. A simultaneous
fieldwork, under standardized and uniformed conditions of appli-
cation of questionnaires and measurements required a continuous
and exhaustive work from the Coordination Center consisted in two
chairs, one co-chair and two project managers. A tight collaboration
with each academic / research team was performed. During the field-
work periodical controls of data quality were carried out and a gen-
eral consistency after completion of data collection was developed.
Specifically, the dietary intake consistency was the most complex:
technical support and guidance to all research teams were necessary.

From ELANS many lessons were learned regarding the con-
duction and coordination of a multicenter study: 1- the inclusion
of a multidisciplinary team with deep knowledge in specific areas
was essential, 2-the key role of a proactive supervision and coor-
dination of an international team allowed the simultaneous devel-
oped of the study at every country, 3- designing and following a
feasible and realistic protocol required more effort than expected,
4- the value of taking care of local characteristics of each site at
the moment of planning and developing the fieldwork allowed to
identify and solve local barriers 5- the communication with the
CRO and the supervision of its work was critical to ensure data
quality. These are a tiny example of many other learnings achieved.
The findings of this study will provide scientific information on
nutrition and physical activity, and due to strict procedures of data
quality control allowing the comparison between the LA coun-
tries. It is also a good example of a multi center collaboration study
that contributes with learnings and tools for other research teams.

**Keywords:** Multicenter study, feasibility, learnings, Latin America.

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

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

PS_144/73

50 YEARS OF NUTRITION RESEARCH SUPPORT IN
LOW INCOME COUNTRIES: ACHIEVEMENTS AND
NEEDS

THE NESTLÉ FOUNDATION 50TH ANNIVERSARY

Suter, Paolo M.; Wahli, Walter.

Nestlé Foundation, Lausanne, Switzerland.

In 2016 the Nestlé Foundation (NF) celebrated its 50th anni-
versary. To the best of our knowledge, the NF is one of the oldest
foundations exclusively focused on improving child health and
nutrition in low-income countries, through supporting research and capacity building.

During these fifty years the Foundation supported over 300 research projects in more than 55 low / lower-middle income countries, which resulted in nearly 600 publications, many of them in high impact journals. The key criteria for support continue to be the relevance of the research question for improving local nutrition conditions, the potential for implementation in the long term, and the quality and quantity of local capacity building.

During these 5 decades the NF supported many individuals in their research activities and to obtain advanced degrees at internationally-recognized universities. Many of our awardees are currently engaged at local universities, Ministries of Health, public health NGO's or international organizations such as UNICEF and WHO. These alumni of the Foundation carry on our conviction that only the strong involvement of locally-based, well-trained health professionals will lead to a sustainable improvement in health and nutrition in developing countries. During the symposium we will present typical examples of projects from 3 continents, which will give an opportunity to discuss further strategies to improve the health of children in low-income countries by advancing research capacity at the local level.

**Keywords:** Capacity Building, Nutrition Research, Health research capacity, maternal and child health, sustainability

weekly ration (2 Kg) of pearl millet or maize flour for the family. 178 children were enrolled [90 from maize and 88 pearl millet villages]. Anthropometry was measured at baseline, midyear and end year. Data was obtained from 133 children [67 maize and 66 pearl millet] at the end of the study.

Children on the pearl millet supplementation attained higher height (79.2 +3.5) as compared to the maize supplemented (76.4+7.7), p<0.016. More children from the maize supplementation villages were stunted (17.1% stunted, 5% severely stunted) as compared to the pearl millet (stunted 13.6%, severely 1%), p< 0.001. Children on pearl millet supplementation had higher Z-score indices (Height-for-age = -1.42 +2.4) than children on maize (-1.03 +1.0). Hemoglobin levels, mid upper arm circumference and head circumference were not significantly different between the two groups.

Malnutrition in rural Eastern Kenya is still pronounced. However, children supplemented with pearl millet attained slightly better nutritional parameters compared to their maize supplemented counterparts. Results from this study could infer that consumption of pearl millet may better nourish children in arid and semi-arid areas. Further research is needed to assess the impact of pearl millet consumption in a controlled clinical trial.

**Keywords:** Keywords: Pearl millet; maize, stunting, children, Mbooni west

## THE EFFICACY OF PEARL MILLET VERSUS MAIZE IN CHILDREN < 2 Y IN RURAL EASTERN KENYA: A RANDOMIZED COMMUNITY TRIAL

(1)Ndiku, Hellen; (2)Sabate, Joan.

(1)DrPH. Associate Professor. University of Eastern Africa, Baraton Kenya School of Science and Technology; (2)DrPH MD Professor of Nutrition Loma Linda University CA USA.

Twenty six percent of under five children in Kenya are stunted as a result of chronic malnutrition. Stunting in the first 2 years of life leads to irreversible damage, including shorter adult height, lower attained schooling, reduced IQ, reduced adult income and decreased offspring birth weight. Until about 50 years ago pearl millet was a staple crop in Eastern Kenya, but it has now been replaced by maize in most areas.

The objective of this study was to assess the efficacy of a one year supplementation with pearl millet compared to maize in children less than one year of age at baseline on physical growth as measured in stunting rate, attained height, body weight, mid upper arm circumference and head circumference. Hemoglobin levels were also assessed.

The study used a randomized community dietary intervention trial design. It was conducted in Mbooni West Sub County because it has a semi-arid climate and most villages currently grow maize. Four villages, at least 50 km away from each other to avoid contamination, were randomized to a one-year pearl millet or maize intervention. The dietary interventions consisted of food distribution and nutrition education. Mothers were provided a

## IMPROVING NUTRITION BY LINEAR PROGRAMMING

(1)Fahmida, Umi; (2)Htet, Min Kyaw.

(1)PhD. Academic Staff. South East Asian Ministers of Education Organization Regional Center for Food and Nutrition (SEAMEO RECFON), Pusat Kajian Gizi Regional Universitas Indonesia, Jakarta, Indonesia; (2)PhD. Research Fellow. Sydney School of Public Health. University of Sydney. Sydney. Australia.

Goal/linear programming (LP) is an optimization method that can be used to identify optimal but realistic, available, and affordable complementary feeding recommendation (CFR) to meet Recommended Nutrient Intakes (RNIs) of energy and nutrients given the food availability, food patterns, food portions, and cost. LP approach can also be used to identify nutrient gap and formulate complementary intervention such as fortification. Several intervention studies where optimized CFRs developed using LP were promoted have been conducted in Indonesia and Myanmar. Findings from 6-month intervention in Lombok Indonesia showed that 12-17mo children whose mothers received nutrition education with optimized CFRs had higher dietary diversity score, consumed the nutrient-dense foods more frequently, and had higher nutrient intakes and nutrient densities for problem nutrients (Fe, Zn, Ca) in their CF diet than children in control group. While difference in growth was not found by the end of the 6mo intervention, a follow-up study conducted two years later on these children (mean age 47±3 months) showed that there was lower prevalence of stunting in CFR than control group (36.6% and 45.8% in CFR and non-CFR, respectively, p=0.05). Six month intervention study on stunted 12-23mo children in Dompu
Indonesia showed that children receiving optimized CFR without fortified food (meeting approximately 65% RNI or close to Estimated Average Requirement) showed better length and length-for-age gain than those who received standard and high nutrient density CF diets which included fortified food. In 6-month intervention trial in Myanmar, optimized CFR for 12-18mo children can minimize the negative effect of iron supplementation (15mg elemental iron in the form of ferric NaEDTA) on zinc status and gut microbiota. The findings suggest the benefit as well as the sustainability of promoting optimized CFR and further study is needed to provide more evidence of its effectiveness at the public health level.

**Keywords:** Complementary feeding recommendation, Indonesia, linear programming, Myanmar, problem nutrient

**Conflict of Interest disclosure:** The invited speakers have received a grant from the Nestlé Foundation without any obligation or restriction

## THE NEED FOR EFFECTIVE NUTRITION RESEARCH IN AFRICA

Lartey, Anna.

President of the International Union of Nutritional Sciences (IUNS). Director of Nutrition at the Food and Agriculture Organization of the United Nations (FAO). Rome. Italy.

Africa is the region where improvements in nutritional status has been slow. About 37% of the world's 156 million are stunted children and 28% of the world's 50 million wasted children are in Africa. Malnutrition has a huge cost affecting cognitive development, educational attainment and subsequently affecting adult productivity and economic earnings. Economic losses due to malnutrition are estimated at 11% of the GDP for Africa. Noting this, at the Malabo declaration, Heads of States and Governments of the Africa Union committed to end hunger and improve nutritional status, specifically by reducing child stunting to 10% and underweight to 5% by 2025. These commitments must be translated into actions. Attempts to address malnutrition in Africa would not be effective if efforts are not made to invest in research. The unique nutritional problems in sub-Saharan Africa call for effective research to identify interventions that fit the context. Unfortunately, the current nutrition research environment is not conducive for effective research. A survey among African researchers identified the lack of recognition by policy makers on the relevance of nutrition research, absence of nutrition research priorities, low capacity, poor infrastructure and inadequate funding. As a result, the research agenda is determined by donors not too familiar with the real nutrition problems of the Africans. For example, the food systems in most sub-Saharan countries are fast changing, traditional diets rich in whole grains, legumes, fruits and vegetables are being replaced by highly processed foods. There is little research on-going to explore the use of local food ingredients in improving diets, especially for children. Very few African countries have analysed the nutritional composition of their foods. Until African researchers and governments take and lead the nutrition research agenda, the large research funding channeled into Africa will not make the expected impact of

moving the malnutrition situation in the continent. To move forward, African researchers must position themselves to take advantage of the current opportunities presented by the SDGs to address malnutrition by developing their capacity to source needed funds to carry out the research that really address the nutritional problems of Africa.

**Keywords:** Research, nutrition. SGD. Africa

**Conflict of Interest disclosure:** Symposium is organized by Nestle Foundation

## THE FUTURE OF YOUNG AFRICAN RESEARCHERS

Ashong, Joseph.

Nutriton Specialist. USAID Ghana.

Nurturing and empowering young African researchers is important to the success of reducing malnutrition in Africa. The young African researcher is faced with numerous obstacles in his quest to contribute to reducing malnutrition in Africa. The first obstacle is the 'system'; the 'system' rejects the young African researcher simply because he is young and inexperienced irrespective of his qualification. The system fails to realize the young African is well trained and ready to work for mother Africa. The response to this obstacle is, the young African leaves to other countries, commonly to North America or Europe. There are very talented and hardworking young Africans performing and contributing to research in the Americas and Europe who are refusing to return home simply because the 'system' is not welcoming. It is the same 'old' faces who attend conferences, workshops or symposia to discuss solutions to malnutrition in Africa, with no room for the opinion of the young African. Unfortunately, donors and funding agencies contribute to 'embolden' the 'system' by funding proposals, travel grants and fellowships of the 'known' faces, who are mostly the older generation to the neglect of the young African. Another major obstacle facing the young African is the non-availability of opportunities such as localized funding opportunities. Most funding opportunities are from outside the continent with their attached conditionalities which limits the young African to explore in his quest to find solutions to the malnutrition problem. It is high time African leaders, philanthropists and other stakeholders invest substantially in research funding to encourage the young African to explore in terms of research to the benefit of the continent. Given the opportunity and "freedom" to contribute their quota, young Africans are more than willing to contribute meaningfully to the fight against malnutrition. What the young African needs is the exposure, platform and freedom to contribute their part. The African Graduate Nutrition Students Network (AGSNet) seeks to build in its members at their formative stages of their studies and professional careers, the spirit of collaborating and sharing of ideas to solve problems. AGSNet was initiated in 2002 by a group of African students then studying at Cornell University, USA, as a platform for networking and relationship building among mostly African students studying nutrition and related courses, and young professionals. AGSNet aims to build core nutrition competencies, organizational and leadership skills as well as appropriate attitudes and values while fostering the development of strong African nutrition advocates or champions who will keep the fight
against malnutrition in Africa at the forefront of their work. The AGSNet approach is to explore all available platforms, partnerships and opportunities both within and outside the continent to build the capacity of its members. Nestle Foundation prioritizes projects in Africa which leads to sustainable development with a strong emphasis on capacity building. This fits perfectly with the objectives of the AGSNet. Nestle Foundation has thus supported AGSNet over the years to provide capacity building opportunities for its members

**Keywords:** Africa, Capacity building, Young African Researcher, AGSNet, Nestle Foundation

PS_144/1017

OXYGEN: A NEGLECTED NUTRIENT

HYPOXIA AND ADIPOSE TISSUE DYSFUNCTION
IN OBESITY

Trayhurn, Paul.

Obesity Biology Unit. University of Liverpool. UK. and Clore Laboratory. University of Buckingham. UK.

Oxygen is rarely considered as a nutrient and this is princi-
pally because it is delivered through the lungs rather than by the
diet via the gastrointestinal tract. However, oxygen is an essential
'macronutrient' without which oxidative metabolism, particular-
ly oxidative phosphorylation in mitochondria, cannot take place.
Once absorbed from the lungs, the delivery of oxygen to cells from
the circulation by haemoglobin parallels the carrier mechanisms
by which a number of nutrients are transported. At a physiological
level the consequences of, and adaptations to, low oxygen tension
have been extensively investigated, especially in relation to high
altitude. A relative lack of oxygen is apparent in a range of diseases
where lung function is impaired, such as pulmonary fibrosis and
chronic obstructive pulmonary disease. These conditions impact
on the provision of oxygen to the body as a whole, but a reduction
in individual tissues can occur even when the total body supply
is not compromised; examples include the site of wound healing
following tissue damage and in solid tumors. There is growing rec-
ognition that low oxygen tension, and indeed overt hypoxia, can
also occur in normal tissues with important implications for cellu-
lar function. White adipose tissue (WAT), a major endocrine and
signalling organ with adipocytes secreting a multiplicity of protein
and lipid factors, is one site where hypoxia has been demonstrat-
ed. There is substantial evidence from animal studies that hypoxia
develops in WAT as the tissue mass expands with obesity, resulting
in changes in adipocyte function which may underpin the dys-
regulation that leads to obesity-associated disorders - including
insulin resistance and the metabolic syndrome. In particular, the
reduction in oxygen tension is considered to underlie the inflam-
matory response with the expression and secretion of several in-
flammation-related adipokines being up-regulated; these include
major adipokines such as leptin, IL-6 and VEGF. In contrast,
the expression and secretion of the key adipocyte hormone adi-
ponectin is inhibited by low oxygen levels. Adipocytes in culture,

both murine and human, exhibit extensive functional adaptations to hypoxia, there being changes in the expression of up to 1,300 genes. A switch from oxidative metabolism to anaerobic glycolysis is evident, glucose utilisation being greatly increased in hypoxic adipocytes with a corresponding elevation in lactate production, both changes involving increased recruitment of the key transporters GLUT1 and MCT1, respectively. Importantly, hypoxia directly induces insulin resistance in fat cells and leads to the development of adipose tissue fibrosis. Exposure to graded levels of oxygen indicate that adipocytes titrate small differences in oxygen tension with alterations in gene expression and glucose utilisation. Other cell types within WAT also respond to hypoxia, with the differentiation of preadipocytes to adipocytes being inhibited and preadipocytes transformed into leptin-secreting endocrine cells. Overall, hypoxia has pervasive effects on the function of white adipocytes and appears to be a key factor in adipose tissue dysfunction in obesity. Finally, oxygen should be recognised as a critical nutrient and part of the landscape of nutritional science.

**Keywords:** Adipocytes; Hypoxia; Obesity ; Oxygen tension; White adipose tissue

OXYGEN DEPRIVATION IN TUMOURS

Gilkes, Daniele.

Johns Hopkins University School of Medicine.

Intratumoral hypoxia has been identified in a majority of solid
tumors and has been associated with an increased risk of metasta-
sis and cancer patient relapse. Hypoxia within a solid tumor arises
from an increase in oxygen utilization by rapidly proliferating can-
cer cells, which ultimately results in a decrease in oxygen avail-
bility. The abnormal blood vessels formed within tumors further
limit the diffusion of oxygen. Cancer cells adapt to the hypoxic mi-
croenvironment by increasing the activity of the hypoxia-induci-
ble factors, HIF-1 and HIF-2. In breast cancer, regardless of lymph
node status, patient survival is significantly decreased in patients
with the highest HIF-1α levels in their diagnostic breast cancer
biopsies. This is consistent with studies showing HIF-1α over-
expression within metastatic lesions arising from breast tumors.
A growing body of data from preclinical and clinical studies has
shown that hypoxia can induce and/or select for cells with altered
characteristics, including (a) maintenance of replicative potential,
(b) maintenance of stem cell properties, (c) genetic instability, (d)
angiogenesis, (e) metabolic reprogramming, (f) autocrine growth
factor signaling, (g) invasion, (h) metastasis, and (i) resistance to
radiation and chemotherapy. We will discuss how cells alter their
metabolism to support continuous growth and proliferation in
challenging hypoxic environments. Furthermore, we will discuss
how hypoxia forces changes in cell behavior and the associated
extracellular matrix to increase their migratory and metastatic be-
havior.

**Keywords:** Oxygen, hypoxia, tumour, HIF, cancer
SCIENCE UPDATE OF PHYTONUTRIENTS

Miyazawa, Teruo.

Tohoku University.

Attention to the benefits of phytonutrients has been increased recently. Our vision is to make phytonutrients as the first value of people's health for consumers and scientists, as a part of daily life based upon scientific evidence. Objective of Global Phytonutrient Society (GPS) is to promote usefulness of phytonutrients based on advanced scientific evidence from the world; to utilize promising phytonutrients applying to super-aging society; to link to global leading experts and societies for use in supplements/health foods and as essential choice to achieve optimal health; to collaborate with governmental scientific organizations in major legions; and to establish global subsidiaries in the future. Our goal is that botanicals, especially sources phytonutrients, are universally accepted by policy makers, regulators, academia and consumers for use in supplements/health foods and as essential choice to achieve optimal health.

For example, phospholipids are of critical importance in mammalian cell biology, both through providing a permeability barrier and acting as substrates for synthesis of lipid mediators. Such membrane lipid peroxidation receives attention to evaluate nutritional states and also to cellular aging. For measuring phosphatidylcholine hydroperoxide (PCOOH) as a primary oxidation product of membrane lipids, CL-HPLC and/or with LC-MS/MS is employed. High PCOOH concentration as a biomarker of membrane lipid peroxidation is confirmed in atherosclerotic plasma with angiographically significant stenosis. In Alzheimer patients, aged RBC rich in PCOOH is found significantly in peripheral blood, and such PCOOH-rich RBC lacks CO2/O2 exchange function that contributes to develop the senile dementia. The data further indicate that radical and/or enzymatic oxidation is recognized to cause oxidation of membrane lipids in our body. Age-dependent accumulation of PCOOH is confirmed in cultured human diploid cells, the microsomal and plasma membrane of the rat hepatocytes, and the brain and liver of the rat, and intensely in a mouse model for hepatitis C virus associated hepatocarcinogenesis.

Phytonutrients (vitamin E, C, carotenoid, polyphenols and so on) prevent the membrane lipid oxidations, and intake of phytonutrients as dietary antioxidants would be recommendable for public health.

**Keywords:** Aging, Phytonutrients, Botanicals, Lipid Peroxidation, Antioxidants

PHYTONUTRIENTS IN AGING SOCIETIES: A PRAC-
TICAL APPROACH

Williamson, Gary.

Prof. University of Leeds. Leeds. UK. LS29JT.

Phytonutrients include flavonoids, phenolic acids, sulfur-containing compounds, isoflavones and other secondary metabolites which are found in plant-based food and beverages, and are consumed as part of the diet. According to epidemiological and intervention studies, diets rich in these compounds protect against developing the chronic diseases of aging, such as cancer, type 2 diabetes and cardiovascular disease [1-4]. Studies on human cells in vitro have indicated mechanisms by which this protection might occur, and these have been complemented by experimental animal models and by studies in healthy and at risk human volunteers. Taken together, this huge effort has provided part of the scientific platform for government recommendations on consumption of diets high in fruit and vegetables, to maintain health and slow down aging processes. Many mechanisms of action have been suggested, but the most viable effects are those which take into account the bioavailability of phytonutrients. Pathways of absorption and metabolism for the major classes have been studied extensively and are in general well understood [5]. It is clear that the beneficial effects of phytonutrients are on specific cellular targets and are not due to direct chemical antioxidant action [6]. Taken together, the current data in the literature indicate a robust and widely applicable protective effects of phytonutrient-rich foods against chronic diseases of aging. However, the doses required and to what extent the phytonutrients can be supplied as supplements both remain issues of debate, and probably depend on formulation, processing, combination with other ingredients, time and frequency of consumption.

1. Guo, X. F., Yang, B., Tang, J., Jiang, J. J. and Li, D. (2017) Apple and pear consumption and type 2 diabetes mellitus risk: a meta-analysis of prospective cohort studies. Food Funct. 8, 927-934

2. Santos, R. M. and Lima, D. R. (2016) Coffee consumption, obesity and type 2 diabetes: a mini-review. Eur J Nutr. 55, 1345-1358

3. Hooper, L., Kroon, P. A., Rimm, E. B., Cohn, J. S., Harvey, I., Le Cornu, K. A., Ryder, J. J., Hall, W. L. and Cassidy, A. (2008) Flavonoids, flavonoid-rich foods and cardiovascular risk: a meta-analysis of randomized controlled trials. Am J Clin Nutr. 88, 38-50.

4. Schmit, S. L., Rennert, H. S., Rennert, G. and Gruber, S. B. (2016) Coffee Consumption and the Risk of Colorectal Cancer. Cancer Epidemiol Biomarkers Prev. 25, 634-639

5. Del Rio, D., Rodriguez-Mateos, A., Spencer, J. P., Tognolini, M., Borges, G. and Crozier, A. (2013) Dietary (poly)phenolics in human health: structures, bioavailability, and evidence of protective effects against chronic diseases. Antioxid. Redox. Signal. 18, 1818-1892

6. Sies, H. (2007) Total antioxidant capacity: appraisal of a concept. J. Nutr. 137, 1493-1495

**Keywords:** Flavonoid; diabetes; cancer; cardiovascular; supplements

**Conflict of Interest disclosure:** Consultant for Nutrilite USA. Received funding and/or consultant from Florida Department of Citrus, Nestle and Suntory in the last 5 years. Received funding from European Union framework programme, European Research Council and from BBSRC DRINC UK in the last 5 years,
with multiple industrial partners in EU projects and industrial support from multiple companies in the DRINC programme.

## MEDITERRANEAN DIET AND PHYTONUTRIENTS FOUND IN SUCH DIET CAN HELP TO SUPPORT IN PREVENTING AND REDUCING AGE-RELATED DISEASES

Bilia, Ana Rita.

PhD professor. Department of Chemistry. University of Florence. Italy.

Benefits of Mediterranean diet type have been known for well over half a century. In the last decade, an increasing amount of scientific evidence has supported its beneficial effects in human health confirming how this diet could be useful in preventing and reducing cardiovascular disorders, in diabetes type II, metabolic syndrome and fatty liver, and the cognitive decline of neurodegenerative diseases. A number of plant constituents naturally occurring in foods, particularly polyphenols, terpenoids, glucosinolates have a dramatic role in the modulation of cellular signaling pathways and nutritional genomic is a developing research field to study the effects of foods and food constituents on gene expression, focusing on identifying and understanding molecular-level interaction between nutrients and other dietary bioactives with the genome. Olive oil is the main source of fat and health-promoting component of the Mediterranean diet. Solid evidence was obtained on the homeostatic control of genes having a role in lipid metabolism, immune-inflammatory pathways, vessel protection and blood pressure control, metabolic regulation and detoxification of reactive species. Oleurepein, hydroxytyrosol and oleocanthal are the principal constituents responsible for such natural functional food. Citrus fruits such as oranges, bergamots, lemons and grapefruit contain special classes of flavonoids (polymethoxy-lated flavone and flavanones), are emerging for their considerable nutraceutical value. Juices from fruits or single flavonoids constituents can reduce the incidence of cardiovascular disease risk, pre-clinical investigations highlight cellular and subcellular targets that are responsible for these beneficial effects. Typically, plants from Brassicaceae family represent a large botanical family comprising many edible species. The organosulfur compounds of these species, denominated isothiocyanate derivatives (deriving from a myrosinase-mediated transformation of glucosinolates) have an important preventive effect in many human diseases, particularly prevention of neurodegenerative processes and cardiovascular diseases. Similarly, species belonging to Allium genus such as garlic, contain sulfur derivatives. S-allyl cysteine (SAC) is the active and main component of aged garlic extract with anti-inflammatory, neuroprotective, and nootropic potential.

**Keywords:** Mediterranean diet; prevention and reduction aged-related diseases; polyphenols; terpenoids; glucosinolates

## THE CURRENT STATE OF COMPUTER SUPPORT FOR GENOTYPE-BASED NUTRITION AND LIFE-STYLE GUIDANCE

Kohlmeier, Martin.

MD PhD. Nutrigenetics Laboratory. UNC Nutrition Research Center. University of North Carolina Chapel Hill. USA.

The responses to many foods, nutrients and bioactives differ greatly between individuals. In many instances known gene variants are the underlying cause for such distinct differences in effects and outcomes. A typical example is the persistence of intestinal lactase expression in carriers of variants located in enhancer regions of the LCT gene. These variant carriers usually tolerate the consumption of significant lactose amounts while non-carriers respond with bloating, abdominal cramps and other discomfort to such intake. In light of the rising number of such well-documented examples of actionable genetic information, the call for genotype-based nutrition guidance is getting stronger.

Current-generation nutrition information tools should meet several key requirements: (1) Estimate individual dietary targets by flexibly integrating genetic data with variable layers of personal information such as age, gender, body size, activity level, intolerances and dietary preferences; (2) Shield raw genetic information both from the user to avoid distress and from third parties to avoid abuse; and (3) Generate individually actionable information such as personal nutrition suggestions, life-style tips, and tailored meal plans.

The tailoring of meal plans to individual nutritional needs and personal preferences is a major challenge because of the large number of factors that have to be taken into account. The macro-nutrients, sugar, saturated fat, sodium, minerals, a few vitamins, a few trace elements, fruits, vegetables, vegetarian, vegan, gluten-free, low-lactose and pork-free already add up to more than twenty targets and conditions.

Fully configured food databases are essential for generating individually tailored meal plans. Building such a database is a tall order because it can only include items with all the data used by the search criteria. To be suitable for a gluten-free meal plan, the absence of gluten in every single meal component has to be known. Foods with even one missing data item missing are useless. The lack of comprehensive nutrition information for most commercially available foods is the major limiting factor.

So far, PONG (Personal Online Nutrition Guidance) appears to be the only computer-supported nutrition information tool that meets these minimal requirements. It is a comprehensive platform that can integrate all types of personal information for generating nutrition target estimates. To the extent that evidence-supported rules are available, an unlimited number of genetic variants and other factors can be used to estimate individual nutrition targets. Another set of rules dependent on the acquired information and estimated targets provides a personalized narrative of major di-
etary and life-style goals, tips for practical implementation, and hints for daily success. Most importantly, the tool offers individualized meal plans that fully meet the user's personal needs. The tool lists the nutrient composition of suggested meal plans next to the intended target amounts. Plans that are reasonably close to what the user wants can be further modified to personal preferences and food availability. Colors and other visual aids signal the suitability of combinations.

Head-to-head comparisons with other available nutrition information tools should assess how well they meet these advanced criteria for safe, effective and user-friendly translation of genetic information into daily nutrition and life-style choices.

**Keywords:** Nutrigenetic, responders, meal plans, gluten-free, meal planning

## GENOMICS OF EATING BEHAVIOR IN RELATION TO OBESITY

Santos, José Luis.

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

The prevalence of obesity (Body Mass Index BMI> 30 kg/m2) has increased in the last decades via "obesogenic" environments characterized by easy access to high energy-density foods and a reduction in physical activity levels. In Chile, a middle-income country, childhood obesity prevalence has tripled over the last decades and continues to rise. The evaluation of the change in the population distribution of BMI over time indicates that the increase in body weight is not uniform in the population, implying that there are groups of subjects that are resistant to the development of obesity, while other groups are especially susceptible. Among the multi-level factors that are related to obesity, increased energy intake is likely to play a dominant role. In this context, eating behaviour is acquired in early childhood, and changes over time according to personal subjective experiences and family influences, which ultimately determines food consumption patterns. Despite the decisive influence of the environment on the obesity epidemic, twin studies have reported that both BMI and eating behaviour scores are traits with important genetic basis. Genetic variation in taste receptors (for example, TAS2R38 among others) and components of neuroendocrine systems (FGF21, MC4R, among others) have been linked with variation in food responsiveness, food selection and hunger. Additionally, genome-wide association studies have identified more than 200 loci related to BMI that can be used to create genetic risk scores for obesity. Appetitive traits have been proposed to mediate the relation between genetics and obesity, in accordance to the "behavioural susceptibility theory" (Llewelyn and Fildes. Curr Obes Rep 2017; 6: 38-45) that states that individual differences in eating behaviour scores are the mediators of the relation between genetic susceptibility and the development of obesity. In relation to rare monogenic syndromes characterized by obesity and hyperphagia, most cases diagnosed with genetic 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. It was reported that subcutaneous leptin administration to obese patients with genetic leptin deficiency reduced dramatically their energy intake and body weight. Recently, new therapeutic strategies based on MC4R agonism have led to the modification of eating behaviour and body weight in patients with POMC deficiency, (a rare obesity syndrome with hyperphagia). In conclusion, the study of monogenic forms of obesity and hyperphagia has led to new biological knowledge and therapeutic strategies to manage eating behaviour and increased body weight. On the other hand, intricate relations of obesity-related variables have led to the concept of eating behaviour as a mediator connecting genetics and the development of obesity in the context of a modern obesogenic food environment.

**Keywords:** Obesity, eating, behaviour, melanocortin, taste

## NUTRITION AND GENETICS: THE MISSING LINK

Escott-Stump, Sylvia.

MA, RDN, LDN, FAND. Clinical Assistant Profesor. Department of Nutrition Science. East Carolina University. USA.

The aims of this presentation will be to provide a deeper appreciation of the role of nutrition in genetics. Differences between the stable human genome and the ever-changing microbiome have led to discoveries of the single nucleotide variants and dietary changes that affect human health. The Human Variome Project documents specific genes and their relationship with diseases. Recent studies show that epigenetic programming during the developmental years and alterations during aging have important implications in disease management. Key nutrients affecting gene expression include folic acid, Vitamins B-12 and Vitamin D. Tumorigenesis and several age-related diseases are linked to DNA methylation-dependent activities. Thus, dietitians should understand the significance and be ready to create new employment opportunities in the emerging fields of Nutrigenomics and Nutritional Genetics. Competencies, knowledge and desirable professional traits have been identified and adopted for interpretation of genetic and genomic information and personalized nutrition therapy.

**Keywords:** Nutrigenomics, Nutritional Genetics
PRECISION NUTRITION BASED ON OMICS
KNOWLEDGE

(1)Martínez, J. Alfredo; (2)Abete, Itziar; (2)Milagro, Fermin I.; (3)Zulet, Maria Angeles; (4)Van Ommen, Ben.

(1)Department of Nutrition, Food Science and Physiology. Centre for Nutrition Research. University of Navarra. Pamplona. Spain. CIBER Fisiopatología Obesidad y Nutrición (CIBERObn). Instituto de Salud Carlos III. Madrid. Spain. IMDEA. Madrid. Spain.;

(2)Department of Nutrition, Food Science and Physiology. Centre for Nutrition Research. University of Navarra. Pamplona. Spain. CIBER Fisiopatología Obesidad y Nutrición (CIBERObn). Instituto de Salud Carlos III. Madrid. Spain.; (3)Department of Nutrition, Food Science and Physiology. Centre for Nutrition Research. University of Navarra, and IdiSNA. Pamplona. Spain. CIBER Fisiopatología Obesidad y Nutrición (CIBERObn). Instituto de Salud Carlos III. Madrid. Spain.; (4)TNO. Zeist. The Netherlands.

Chronic diseases, including obesity, diabetes, and cardiovas-
cular events, are related to important clinical complications and
lower longevity. Nutrition and dietary patterns, as well as other
lifestyle factors, are crucial elements with potential interactions on
genes impacting on health outcomes. Personalized nutrition re-
lies on knowing the genotype of the individual, which influence
the response to foods and also on the principle that nutrients reg-
ulate gene expression. Thus, precision nutrition depends on the
genetic make-up (i.e., DNA sequence and epigenetic markers), on
clinical and physiological issues (i.e., phenotypical traits, perinatal
nutrition, diseases history and drug prescriptions, allergies,...) and
on social/cultural differences (i.e., lifestyle, physical activity, food
habits and preferences, mating, religion and food accessibility,
likes and dislikes, etc...)...

Precision nutrition is evolving as an important part of disease
management accounting the individual's genetic and epigenetic
information, together with subject's personal aspects (previous or
current diseases, endocrine disruptions, fat distribution, sex, age)
and environmental influences (including diet). Indeed, omic ad-
vances are generating a better knowledge about the involvement of
genetic variants/SNPs and epigenetic marks as well as gene expres-
sion patterns or metabolites/microbiome changes depending on
nutrition and their interactions with the development/treatment
of acute and chronic diseases.

The convenience of modern omic technologies, the discovery
of new biomarkers based on genomic and metabolic data togethe-
rer with a wider understanding of gene and lifestyle interactions
are becoming important endeavors in precision nutrition areas.
Also, metabolomics and metagenomics (microbiota) studies are
contributing, together with progress in dietary assessment and bi-
ochemical/genetic tests, to better interpreting every person indi-
viduality through blood, urinary, and fecal differentiating features.

Investigations to unravel omic markers in groups with differ-
ent genetic and epigenetic backgrounds (i.e., GWAS and EWAS
strategies), together with advances in NGS or Omic tools and bio-
informatics are enabling to deduce new relationships among genes
and dietary factors. These findings are disentangling the genetic
predisposition to complex metabolic diseases and providing suita-
ble recommendations for precision nutrition.

The "Nutrient-gene interactions: Knowledge to action" IUNS
Task Force has been since 2005 specifically devoted to these tasks.
Indeed, the number of publications related to nutritional genom-
ics and associated omics branches, such as Nutrigenetics, Nu-
trigenomics, Metabolomics and Metagenomics, are continuously
evolving (more than 1.000 documents with more than 12.000 ci-
tations since 2001), which is paving the way to provide an efficient
precision nutrition for a healthy life.

Fitó M, et al. Advances in Integrating Traditional and Omic Bi-
omarkers When Analyzing the Effects of the Mediterranean Diet
Intervention in Cardiovascular Prevention. Int J Mol Sci 2016;17.
doi: 10.3390/ijms17091469

Ferguson LR, et al. Guide and Position of the International So-
ciety of Nutrigenetics/Nutrigenomics on Personalised Nutrition:
Part 1. Fields of Precision Nutrition. J Nutrigenet Nutrigenomics
2016;9:12-27.

Goni L, et al. Future Perspectives of Personalized Weight Loss Interventions Based on Nutrigenetic, Epigenetic, and Metagenomic Data. J Nutr 2016;146:905-12S.

San-Cristobal R, et al. Future challenges and present ethical considerations in the use of personalized nutrition based on genetic advice. J Acad Nutr Diet 2013;113:1447-54.

**Keywords:** Obesity, Metagenomics, Metabolomics, Nutrigenomics, Nutrigenetics

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HYDRATION AND WORK

HYDRATION IN THE WORK ENVIRONMENT

Figueredo Grijalba, Rafael.

MD, MSc. Faculty of Health Sciences. Catholic University.
Asuncion. Paraguay.

The human organism is composed of approximately 60% water.
The function of water is essential for the maintenance of health,
acting in the development of different physiological processes, all
essential for life. Therefore, it is evident the need for a person to
be adequately hydrated, both to maintain health, and to properly
perform their tasks.

Different causes can make a worker quickly lose body water,
become dehydrated and suffer complications both in their work
capacity and in their own health. In industrial work, among these
causes we can mention:

1. Use of encapsulated protective clothing that can raise sweat rates by 2.25 liters per hour.

2. Intense physical work, for example, construction workers.

3. Work in hot environments, for example, mining.

4. Air conditioning in offices, shops, gyms, hospitals, even in vehicles that are used in long journeys, which can accelerate losses by skin or respiratory tract.

5. Difficulties in access to water, for example, in long distance driving, work in controlled environments, construction sites, hospitals and also in educational institutions.
Different researchers have shown that body water losses around 2% of body weight, regulate changes in mood, can cause fatigue and reduce the level of alertness, conditioning the individual's work capacity.

Institutions and companies should ensure that workers have adequate availability of drinking water. In addition, accessibility should be ensured, i.e. there should be water in strategic locations, visibly marked and with the necessary utensils (glasses, etc.) to drink it.

There are no specific recommendations on water consumption for the worker, considering environmental factors such as protective clothing, high temperature, work in heated or outdoor environments, work intensity, etc.

The Institute of Medicine (IOM) of the National Academy of Sciences of the United States of America recommends adequate fluid consumption for adults 2.7 to 3.7 liters / day. The worker should consume at least the maximum recommendation cited and increase this consumption until reaching 5 or 6 liters daily, according to work intensity and environmental conditions. The American Occupational Safety and Health Administration recommends replenishing liquids by drinking a 250cc glass of water every 20 to 30 minutes.

Finally, we can conclude that a correct hydration at work is oriented to avoid diseases, reduce absenteeism at work and increase productivity.

**Keywords:** Hydration, Work.

## HYDRATION AND PHYSICAL ACTIVITY

Sangenis, Patricia.

MD. Cardiologist. Sport Medicine. Instituto Deporte y Salud, Buenos Aires. Argentina.

A well-hydrated athlete always functions at a higher physiological and performance level than a dehydrated one

Prolonged exercise leads to progressive water and electrolyte loss from the body as sweat is secreted to promote heat loss. The rate of sweating depends on many factors and is increased in proportion to the work rate and the environmental temperature and humidity. Sweat rate is highly variable between individuals and can exceed 2, 5 l/h for prolonged periods.

Since it is established that the dehydration will impair exercise capacity and can pose a risk to health, the intake of fluid during exercise to offset sweat loss is important.

Fluid intake is also aimed at providing a source of substrate, usually in the form of carbohydrate. The availability of ingested fluids may be limited by gastric emptying or by intestinal absorption. Gastric emptying of liquids is slowed by the addition of carbohydrates in proportion to the carbohydrate concentration and osmolality of the solution.

Water absorption in the small intestine is a passive process and is stimulated by the active absorption of glucose and sodium.

The optimum fluid for rehydration during exercise depends on many factors, particularly the intensity and duration of the exercise, the environmental conditions and the individual physiology of the athlete. The composition of fluids to be used will depend on the relative needs to replace water and to provide substrate.

Where rehydration is a priority the solution should contain some glucose or polymers and sodium and should not exceed isotonicity.

Dehydration refers to an imbalance in fluid dynamics when fluid intake does not replenish water loss. A moderate exercise workout generally produces a 0,5 to 1,5 liters sweat loss over a 1 hour period. Significant water loss occurs during several hours of heavy exercise in a hot environment.

Intracellular and extracellular compartments contribute to the fluid deficit (dehydration) which can rapidly reach levels that impede heat dissipation, reduce hot tolerance and severely compromise cardiovascular function and exercise capacity.

Because sweat is hypotonic with other body fluids, the hypovolemia caused by sweating correspondingly increases blood plasma osmolality

Just about any degree dehydration impairs physiologic function and thermoregulation. Adequate fluid replacement sustains the exceptional potential for evaporative cooling of acclimatized humans.

Changes in body composition indicate the extent of water loss during exercise and the adequacy of rehydration during and after exercise or athletic competition. Voiding small volumes of dark yellow urine with a strong odor also provides a qualitative indication of inadequate hydration. Well hydrated individuals typically parode urine in large volumes, light in color, and without a strong smell.

Prepubescent children have a lower sweating rate and exhibit a higher core temperature during heat stress than adolescents and adults, despite their larger number of heat-activated sweat glands per unit skin area. For a practical standpoint, children exposed to heat stress should exercise at reduce intensity and receive additional time to acclimatize compared to more mature competitors.

**Keywords:** Well hydrated, Health, Sweat

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## ADVANCES IN FEEDING BEHAVIOR RESEARCH AND ITS RELATION TO NUTRITION

### THE WHY? AND FOR WHAT? OF FEEDING BEHAVIOR RESEARCH AND ITS RELATION TO NUTRITION

López-Espinoza, Antonio.

Behavioral Feeding and Nutrition Research Center (CICAN)
CUSur. University of Guadalajara. México.

The why? and for what? of feeding behavior research and its relation to nutrition

The development of a perspective that links knowledge related to how, what with, where, whom with, when, what for and why we feed, and its effects on well-being, life quality and health, has a particular dimension. Its importance lies in the fact that the development of such a perspective is a crucial element to understand the current world food situation, and therefore is also the best possibility to prevent and control feeding related pathologies among
others. In this sense, it is possible to indicate that such scientif-
ic perspective is the study and research of feeding behavior. One
of the major challenges of this young area of science has been to
place behavior and conduct as central elements of study. This task
has not been easy, given the historical bias towards biologically
based explanations. In general, there is a great ignorance of issues
as basic as identifying what a behavior is, and not to mention the
techniques and theories that explain their relationships and func-
tion. However, resistance and ignorance have not only been of the
biological area, psychology in particular and radical behaviorism
especially, disdain to establish cooperation links with other scien-
tific perspectives. The same is true of anthropological, social, po-
litical or economic perspectives. It would seem, then, that we are
hopelessly seeking to understand, predict, and control phenome-
na, blindly, with partial visions, which might be described as petty.
Therefore, it is necessary to question ourselves, why is it pertinent
to establish behavior and conduct as central elements to explain
the feeding phenomenon? For this, it is necessary to consider the
preponderant role of behavior as a mean and regulatory mecha-
nism in biological, psychological and social processes. A second
point is that behavior is a distinctive element of organisms, prod-
uct of the evolutionary process. Finally, the last point to consider
is the perception that organisms have of the behavior of their con-
specifics or other organisms, that is, what is perceived in the first
instance in a moment of interaction, is necessarily the behavior
of the persons or other organisms with whom we interact. In this
sense, the behavior of the demonstrator subject acts as stimulus
and modifies the behavior of the observer. These three points are
necessary and sufficient conditions to point to behavior as an inte-
grating element of other scientific perspectives knowledge around
on food. Thus, the study and investigation of feeding behavior is
characterized as the conjunction of knowledge and understand-
ing related to everything that organisms do to feed. Therefore, this
particular perspective integrates the basic, applied, theoretical, ex-
perimental and non-experimental knowledge, as well as the con-
jectures, predictions, and the analysis of the different disciplines
and scientific perspectives that are linked in one way or another to
the act of feeding.

**Keywords:** Feeding behavior, research, nutrition

EXPERIMENTAL APPLICATIONS OF FEEDING BEHAVIOR RESEARCH

Experimentation has been established as a fundamental part
in the generation of knowledge in all the sciences. At the study
of feeding behavior is not an exception. The empirical evidence
generated from experimentation in animal and human models it
has allowed the application of theories and models that explain the

relationship among physiological, environmental and behavioral
factors with respect to an essential act for the survival of organism:
feed. Since the proposal of Homeostasis Theory by Walter Can-
non in 1929 whose origin is precisely based on evidence generated
from experimentation, the considerations of John B. Watson in
1924 with regard to the physiological functionality of organism
is observable through of the behavior and the incorporation of
the behavior as a fundamental part in the homeostatic regulation
of organism by Curt Richter in 1947, are only some findings that
have consolidated the base of feeding behavior studies. Feeding
behavior was defined as: Everything that an organism does to feed
itself (López-Espinoza & Martínez Moreno, 2012). If feed is stud-
ied as a process in which the actions connected with the intake as:
eating, drinking, smell, taste, look for food, buy it, select it, cook
it, produce it etc. A fruitful space is generated for the realization
of experimental studies to characterize: what?, how?, when?, how
much?, with whom? and for what? Eat. In this process, the learn-
ing is a key element in understanding the responses of human and
animal organisms in the presence and absence of food. The re-
search about preferences, aversions, hungry, appetite, satiety, se-
lection, choice, intake, energy expenditure, sensation, perception,
social interaction etc., are phenomena that have been observed,
measured, evaluated and explained through experimentation
demonstrating the versatility but also the complexity of the study
of food behavior and above all in order to understand the relation-
ship between organisms and the process of feeding themselves. In
this way is explained for example: a) How the food deprivation
and the experience with palatable food increase the intake; b)
The neophobia (refuse) to eat different foods; c) Determine how
post-ingestive effects encourage or reduce the probability of intake
food; d) Explain how eating behavior can occur even when there
is no physiological stimulus of hunger and c) As well as identify-
ing the fundamental role of women in convincing other to accept
and consume novel foods "The Eva Effect" (López Espinoza, et al.
2011). In this way, it proves that experimentation in humans and
animals models helps to characterize the phenomena and identify
the variables that lead to these and accordingly to plan different
strategies of intervention in the process of feeding in people of all
ages in conditions of health and disease.

**Keywords:** Feeding behavior, experimentation, applications.

CLINICAL APPLICATIONS OF FEEDING BEHAVIOR RESEARCH

Martinez Moreno, Alma Gabriela.

PhD. Analysis of Behavior. Behavioral Feeding and Nutrition
Research Center. University of Guadalajara.

Eating is often seeming as a simple process. But that is an il-
lusion. Eating behavior is an extraordinary complex process that
can be challenging for many individuals. Human eating behavior
is defined as an individual´s fed actions that have one or more di-
mensions that can be observed and recorded. Feeding and eating
behaviors have an impact on the physical and social environment.

<footnote>(1)Aguilera Cervantes, Virginia Gabriela; (1)López-Espinoza, Antonio;</footnote>

<footnote>(1)Martinez Moreno, Alma Gabriela; (2)Katz, Mónica.</footnote>

<footnote>(1)Behavioral Feeding and Nutrition Research Center (CICAN)
CUSur - University of Guadalajara - México; (2)MD. Nutrition
Specialist. Favaloro University Buenos Aires Argentina.</footnote>
For this reason, feeding behavior research can provide to nutrition professionals a comprehensive set of postulates from Applied Behavior Analysis (ABA) to modify some feeding problematic behaviors. It distinguished by types of clinical problems addressed, the mode of therapeutic intervention, and settings in which therapy is typically conducted. Within clinical contexts, ABA is used extensively in a variety of circumstances and it has proven its efficacy in many areas including: developmental disabilities, mental illness, education and special education, rehabilitation, community psychology, clinical psychology, business, industry, and human services; self-management, child behavior management, prevention sports performance, health-related behaviors; and lately, educational settings above feeding behavior. One of the biggest challenges is helping our people to be a good eaters and no to be a problem or a resistant eater. We all want our kids, patients and all people to eat nutritious foods from a wide variety of sources in the proper portion sizes. But eating the right foods is not easy. Behavior modification procedures can help to resolve eating difficulties. Besides of a medical, nutritional and sensorial evaluation we need a behavioral evaluation. Just as you need to identify any medical, physical, and sensory issues that may be contributing to your feeding problems before starting to food chain, you need to understand behaviors that may be playing a role. ABA principles have helped to identify a negative and positive behaviors in eating time. Reinforce the positive and change the negative is no too difficult that we think. Clinical applications of feeding research provide an evaluation to the behaviors in meals and common positive and negative behaviors identification, procedures to modification and rules to maintain an optimum feeding. The importance of maintaining a well-balanced perspective when managing problems with eating. Parents and professionals must seek out support and training in their community and strive for excellence and consistency when working with special population. A collaborative approach within a multidisciplinary team will ensure the long-term success of the program: Are you a problem eater? Are you a normal eater? Are you a resistant eater? Maybe you can resolve this questions if you learn about behavior and feeding behavior research.

**Keywords:** Feeding behavior, eating behavior, applied behavior analysis, behavior modification

## FOOD COMPOSITION DATA FOR DECISION-MAKING TO PROMOTE HEALTHY DIETS

(1)Coates, Jennifer; (2)Rogers, Beatrice; (2)Bell, Winnie; (2)Colaiezzi, Brooke; (2)Gersten, Zachary; (2)Wafa, Sarah; (3)Leclercq, Catherine; (3)Charrondiere, U. Ruth.

(1)Associate Professor, Tufts University Friedman School of Nutrition Science and Policy; (2)Tufts University Friedman School of Nutrition Science and Policy; (3)Food and Agriculture Organization of the United Nations.

Food composition data are critical inputs into the process of food security and nutrition assessment, food labeling, nutrition education, poverty estimation and agricultural investment

for healthy diets, such as crop breeding for nutrient dense cultivars. However, in most countries food composition data are out-of-date, incomplete, and inaccurate. When such data exist, they are not always publicly available or in a format that can be easily matched to information on the quantity of food produced or consumed. Though standards for identifying foods and describing their attributes exist, such as the FoodEx2 classification system and CODEX guidelines for nutrient labeling, they have not yet been widely adopted. The data gaps and associated needs continue to grow, with the global trend toward more diversified diets and increased consumption of processed foods, alongside a rapid decline in the biodiversity of food species. These types of weaknesses in food composition data are rarely revealed as limitations or uncertainties in relevant data analyses to inform policy.

This presentation will discuss a set of theoretical and empirical case studies in which poor food composition data could either slow the process of policy formulation or lead to fuzzy or inaccurate conclusions. Case studies will include: the role of food composition data in diagnosing and acting on anemia in Ethiopia; the sensitivity of the global prevalence of undernourishment indicator to food composition assumptions; the challenge of isolating the role of diet in the rapid rise of overweight in Bangladesh; and how an accurate understanding of the effects of agricultural management practices, crop breeding, and climate change on the nutrient value of food supply depends on up-to-date food composition values.

Despite progress by actors like INFOODs, food technology institutes, and academics to remedy these data gaps, donors have been reluctant to scale up support to their endeavors. As a step toward crystallizing an investment agenda, the authors propose an ambitious set of approaches for rounding out food composition resources. Potential investments include: applying a standardized food coding system (FoodEx2) to all food composition databases to facilitate food identification and matching with food consumption data (e.g. through the FAO/WHO GIFT and INDDEX 24 platforms); creating a central repository for food composition data that can be more easily linked to dietary data (INDDEX24); honing innovative technological solutions to reduce the cost and speed of food analysis; strengthening regional composition databases with the mandate and funds for routine updates; incorporating more mixed dishes, fortified and biofortified foods, wild foods, and biodiverse cultivars into existing FCTs; and exploring private sector partnerships for amassing processed food composition information. These types of solutions, if adequately resourced, would mark a significant step toward improving the ability to make sound decisions that affect the diet quality of people worldwide.

**Keywords:** Food composition, Food policy, Diet quality, Diet assessment
NUTRIGENOMICS CASE STUDIES AS TEACHABLE MOMENTS IN NUTRITION EDUCATION FOR HEALTH PROFESSIONALS

Kohlmeier, Martin.

MD PhD. Nutrigenetics Laboratory. UNC Nutrition Research Center. University of North Carolina Chapel Hill. USA.

Curricula of health professionals are crowded and leave little room for further content. It is difficult to add disciplines such as nutrigenomics despite their importance in clinical research and practice. The challenge can be met by integrating nutrigenomic case studies into many different parts of existing curricula. There are numerous opportunities to highlight specific roles of the genome while explaining key concepts in a wide range of foundational and clinical subjects. Such teachable moments may bring to life important complexities of intestinal absorption, metabolic homeostasis and clinical pathologies. Other examples may highlight how specific anatomical structures, the blood coagulation system, genetic disposition and avoidable behavior may trigger catastrophic clinical outcomes.

An example that may bring together multiple levels and topics of instruction is the well-documented correlation of the common FUT2 variant rs601338G>A (W143X) with vitamin B12 inadequacy. At the simplest level, here is an opportunity to weave a tapestry illuminating vitamin B12 function and macrocytic anaemia, the mechanisms governing vitamin B12 absorption, secretor status and atrophic gastritis due to chronic H. pylori infection. Vitamin B12 supports DNA methylation, which may explain the slower fetal brain development in mothers with FUT2 variants and the risk of accelerated cognitive decline with aging due to a stomach bug. At another level, the FUT2-vitamin B12 link could transition to fucosylation of proteins including ABO antigens and intrinsic factor, the epithelial exocrine origin of Lewis antigens on red blood cells, vulnerability of secretors to gastrointestinal virus infections, and overly simplified links of blood groups to health risks in general. Yet another conversation could explore the analogous importance of different FUT2 missense variants in non-Caucasian populations, such as I129F (rs1047781A>T) in people of Indian and Chinese descent. This could raise awareness of risks from limiting human research to mostly Caucasian cohorts and thereby potentially failing to serve the needs of many others.

Teaching the urea cycle may become less tedious with case histories illustrating potentially fatal consequences of high-protein foods in seemingly healthy young women who happen to carry a loss-of-function variant of the X-linked gene ornithine transcarbamylase. An unaccustomed large steak may be enough to trigger an episode of ammonia accumulation in blood. At the simplest level, the presentation would probably cover the biochemistry and pathophysiology of ammonia metabolism, best diagnostic practices and treatment options. Another strand could emphasize that uncommon variants taken together are not rare, mention copy-number variants, X-inac-

tivation and mosaicism. Instructors could also highlight how some people respond differently to nutritional exposures than others, explore the metabolic consequences of diverse eating patterns, and recognize that pressuring adolescents to discontinue vegan lifestyles may put some of them at grave risk.

Another teachable moment could explore the intersection of vitamin C, cardiovascular disease and common haptoglobin variants Hp1/Hp2. Presentations could touch on iron-mediated oxidative stress, hemoglobin clearance rates differing by genotype, and increased cardiovascular risk with mega-dose vitamin C supplementation in Hp2-Hp2 carriers.

Illustrative examples of nutrient gene interactions abound everywhere we look and can add color and context to many subjects in healthcare education.

**Keywords:** Medical education, case studies, nutrigenetics, teaching omics, personalized nutrition

OMIC EDUCATION FOR GRADUATES IN NUTRITION AND HEALTH-RELATED SCIENCES

Santos, José Luis.

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

We show herein a Chilean experience providing postgraduate courses on "-omics" disciplines to MSc and PhD students at School of Medicine of Pontificia Universidad Católica de Chile. After an introduction on genetics concepts and nutritional epidemiology studies, a nutrigenetic approach of classical topics is first presented in the context of day-to-day nutrition examples and human evolution (focused on genetic variation of lactase persistence, salivary amylase, taste sensitivity). Strong emphasis is provided to nutrition strategies that apply to management of severe monogenic diseases (for example, glycogen storage diseases, phenylketonuria, GLUT1 deficiency), as examples of precision medicine based on nutritional strategies. We specially focus on strategies involving the use of next-generation sequencing techniques to find new genetic causation of diseases that might be eventually actionable through nutrition (examples of monogenic forms of autism with epilepsy are presented). Additionally, selected examples are provided for gene-environment interaction and/or mediation in complex traits in a genomic context, with especial focus on the study of Body Mass Index. Examples of nutrition-related variables as effect modifiers (gene x environment interactions; sweetened beverages) or as mediators (eating behaviour variables) are provided in the context of childhood obesity. Nutrigenomic studies assessing gene expression modulated by nutrients are shown in different contexts, ranging from acute or chronic nutritional interventions. Epigenomic studies on body weight regulation are mainly contextualized within the description of animal models (for example, obesity in the Agouti mice with viable-mutations, methylation in honey bees) and in the study of human eating behaviour (example: methylation in the POMC gene). Metabolomic contribution in the study of human nutrition is presented from the point of view of the assessment of biomarkers of intake on one hand, and in the in-depth study of human metabolome after the ingestion of nutrients (for example, after oral glucose loads) on the other hand. The incorporation of the study of microbiome adds an additional layer of complexity in
the assessment of the relation between nutrients/diets and human health. In general, we perceived a great and growing interest in our postgraduate students and in general in the biomedical community in Chile for acquiring knowledge on techniques, approaches and methods of analysis that apply to the integration of omics disciplines in the study of nutrition-related diseases and traits.

**Keywords:** Nutrigenetics, nutrigenomics, nutrigenomics, metabolomics, microbiome, education

## THE STATE OF NUTRIGENOMICS EDUCATION

(1)Chmurzynska, Agata; (2)Młodzik, Monika.

(1)PhD. Nutritionist. Department of Human Nutrition and Hygiene. Poznan University of Life Sciences. Poland. International Society of Nutrigenetics/Nutrigenomics (ISNN); (2)MSc. Biotechnologist. Department of Human Nutrition and Hygiene. Poznan University of Life Sciences. Poland.

The European higher education system formerly varied from country to country, until 1999, when 29 states signed the Bologna Declaration and the European Higher Educational Area was created. This European higher education system is divided into three sequential cycles, leading to bachelor's, master's, and doctoral degrees. The European Qualification Framework was also established by the European Union. Teaching programs can vary from country to country, but also between universities in the same country.

In Poland, 45 third-level institutions, including medical and life science universities, teach dietetics. Of these, 14 offer nutrigenomic or nutrigenetic courses. Specifically, almost 40% of private universities and 26% of public universities teach nutrigenetics.

In addition, summer schools of nutrigenomics have been organized by the NuGO and the International Society of Nutrigenetics and Nutrigenomics. The latter was the organizer of the European Summer School of Nutrigenomics in Camerino (Italy), as well as of national summer schools, which have been held in Poland and France, among other places.

Separate nutrigenetic or nutrigenomic courses are not commonly included in the programs of dietetics courses.

Evaluation of the courses usually shows that students of dietetics generally expect information about the practical aspects of nutrigenomics.

**Keywords:** Higher education, dietetics, nutrigenomics, summer school

## LEARNING COMPLEX NUTRIGENOMICS TOPICS USING IN SILICO LAB ACTIVITIES AND WEBEX™ CONFERENCING

Good, Deborah.

Ph.D. Department of Human Nutrition, Foods, and Exercise, Virginia Tech. USA.

Upper level undergraduate and graduate course should not only teach students advanced concepts, but also help them to utilize the

information in their research projects. Within the department of Human Nutrition, Foods, and Exercise at Virginia Tech, the undergraduate/graduate joint class in Nutritional Genomics is structured to provide concept learning, hands-on activities, and weekly discussions with international scientists doing nutrigenomics research. The course is held in a "scale-up" room that was specifically designed to facilitate active learning, with round tables, four projection screens, walls of whiteboards, and connected laptops for all students in the course. The course is structured as a 3-times-per-week, 50-minute time period, with lectures and discussion Mondays, in silico hands-on exercises on Wednesdays, and invited international speakers, via WebEx™ conferencing, on Fridays. The topics in the course are built on one another such that students start off examining single nucleotide variants (SNVs) in a gene of nutritional interest (i.e. methylene tetrahydrofolate reductase gene, MTHFR), and then examine these SNV-specific allele frequencies in populations. In the subsequent weeks, they examine whether an SNV changes the amino acid sequence or if it is in a non-coding region and affects gene or protein expression. In the later weeks of the course, the topics include increasingly complex areas, such as gene-gene and gene-environment interactions, and the ethical and societal implications of nutritional genomics. Students utilize online analysis sites, such as the National Center for Biotechnology Information (NCBI) website (http://www.ncbi.nlm.nih.gov/), other free genomic databases and software, such as My Family Health Portrait (https://familyhistory.hhs.gov/FHH/html/index.html), Howard Hughes' biointeractive site "Creating Phylogenetic Trees" (http://www.hhmi.org/biointeractive/creating-phylogenetic-trees-dna-sequences), and some pages devoted to specific genetic diseases, such as the G6PD page (http://www.g6pd.org/en/Home.aspx) and Online Mendelian Inheritance in Man page (http://omim.org/). The students write up their lab reports weekly, and the course culminates in a final paper in which students choose a gene of interest to them, and analyze this gene using at least five of the tools they had learned. On Fridays, WebEx™ conferencing brings in renowned speakers from all over the world, including the United States, England, Spain, Tanzania, and Italy. Speakers are chosen based on the weekly topic, giving a ~25-minute seminar on that topic, followed by a ~10-minute question and answer period. Since the WebEx site allows for live interaction, the speakers are able to control their own presentations and students are able to hear and see the slides, regardless of the time zone. Likewise, the speakers are able to see and hear each of the students through their own live video feeds and audiocasts. Overall, this course structure gives students the background knowledge they need to understand nutrigenomics, as well as hands-on activities to use this knowledge in their own studies, and interactions with scientists working in nutritional genomics around the world.

**Keywords:** Nutritional genomics, genetics, graduate, undergraduate, hands-on
# Track 2: Nutrition Through Life Course

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## AGING GRACEFULLY: STAYING HEALTHY AND WELL LATE INTO LIFE

### NUTRITION FOR THE AGING BRAIN: FUNCTIONAL ASPECTS AND STRATEGIES

(1)Thuret, Sandrine; (2)Champ, Claire; (3)Dye, Louise; (4)Farrimond, Jonathan A.; (5)Geurts, Lucie; (6)Kivipelto, Miia; (7)Mohajeri, M. Hasan; (8)Miquel-Kergoat, Sophie; (9)Sijben, John; (10)Spencer, Jeremy P.E.; (11)Van den Berghe, Wim; (12)Vauzour, David; (5)Vidry, Stéphane.

(1)PhD. Head of the Neurogenesis and Mental Health Laboratory. Institute of Psychiatry, Psychology & Neuroscience. Department of Basic and Clinical Neuroscience. King's College London. United Kingdom.; (2)MSc. Human Appetite Research Unit. School of Psychology. University of Leeds. Leeds. LS2 9JT. United Kingdom.; (3)PhD. Human Appetite Research Unit. School of Psychology. University of Leeds. Leeds. LS2 9JT. United Kingdom.; (4)PhD. Lucozade Ribena Suntory Ltd. Uxbridge. United Kingdom.; (5)PhD. International Life Sciences Institute, Europe (ILSI Europe). Brussels, Belgium.; (6)PhD. Department of Neurobiology. Karolinska Institutet. Stockholm, Sweden; (7)PhD. DSM Nutritional Products Ltd. Kaiseraugst. Switzerland.; (8)PhD. Wrigley (Mars Inc.). Chicago. IL. United States of America.; (9)PhD. Nutricia Research. Nutricia Advances Medical Nutrition. Utrecht. The Netherlands.; (10)PhD. Hugh Sinclair Unit of Human Nutrition and Institute for Cardiovascular and Metabolic Research. Department of Food and Nutritional Sciences. University of Reading. United Kingdom.; (11)PhD. Universiteit Antwerpen. Campus Drie Eiken. Wilrijk. Belgium.; (12)PhD. University of East Anglia. Norwich Research Park. Norwich. United Kingdom.

Aging is a highly complex process marked by a temporal cascade of events that promote alterations in the normal functioning of an individual organism. The triggers of normal brain aging are not well understood, even less so the factors which initiate abnormal cognitive decline or steer neuronal degeneration which underlies disorders such as dementia. A wealth of data on how nutrients and diets may support cognitive function and preserve brain health is available yet the neurobiological mechanisms of action of nutrition in both normal aging, age-related cognitive decline and in the development of neurodegenerative disorders have not been clearly elucidated.

This talk aims at evaluating the vulnerabilities associated with poor cognitive aging, highlighting potential protective mechanisms and evaluate dietary interventions as a strategy to promote these mechanisms, and addressing vulnerabilities which predispose towards accelerated or dysfunctional brain aging.

This presentation will focus on some of the current state of knowledge on nutrition and cognitive aging reflecting the academ-

ic research talks and discussions held during the 2nd workshop 'Nutrition for the Aging Brain: Functional Aspects and Mechanisms', held in Copenhagen in June 2016 and produced by the Nutrition and Mental Performance Task Force under the auspice of the International Life Sciences Institute Europe (ILSI Europe).

In the first part of this talk, we will examine early-life stress, the gut-microbiome and non-communicable diseases such as obesity and diabetes as vulnerabilities associated with poor cognitive aging. We will then highlight potential cellular and molecular mechanisms mediating cognitive health such as adult hippocampal neurogenesis, inflammation and epigenetics. Finally, we will show evidence that those mechanisms can be targeted and modified by nutritional intervention such as Omega-3 fatty acids and polyphenols to mitigate cognitive aging.

**Conclusion:** We will conclude that future research on the impact of nutrition on cognitive aging will need to adopt a "longitudinal" approach to ensure the effect of early-life is adequately controlled, and multimodal nutritional interventions will likely need to be imposed in early-life to observe significant impact in older age.

**Keywords:** Cognitive aging, nutrition, early-life stress, neurogenesis, epigenetics

**Conflict of Interest disclosure:** ST declares no conflict of interest. This review highlights some of the academic reports from the workshop 'Nutrition for the Aging Brain: Functional Aspects and Mechanisms', held in Copenhagen in June 2016. This workshop was organized with funds from the ILSI Europe Nutrition and Mental Performance Task Force. Industry members of this task force are listed on the ILSI Europe website at www.ilsi.eu.

### COMPARING HEALTH INDICATORS ACROSS GEOGRAPHY: A LOOK AT ASIA AND LATIN AMERICA

Amarra, Sofia.

PhD, Director, Research (Nutrition), International Life Sciences Institute Southeast Asia Region, Singapore.

**Background and objectives:** The One ILSI (International Life Sciences Institute) Healthy Aging Project is a multi-branch research collaboration whose goal is to identify mid-life factors that contribute to healthy vs. pathological aging in Asia and Latin America. The purpose of this presentation is to compare selected countries in these two regions with respect to: 1) indicators describing the health status of the adult population; 2) disease causes of premature mortality, causes of disability, and risk factors for disease and disability among adults. Methods: Indicators (health status indicators, risk factor indicators) were chosen from the Global Reference List of Core Health Indicators adopted by the United Nations for reporting health priorities of the Sustainable Development Goals (SDGs). Country-specific data for these indicators were obtained from WHO reports. Information for disease causes of mortality, causes of disability, and risk factors for disease and disability were obtained from the Global Burden of Disease (GBD) 2015 studies. Data for 15 countries in Asia and 17 countries in Latin America were extracted and compared. Results: As a region, Latin America was
in America had higher average life expectancy, higher healthy life expectancy (HALE), and lower probability of dying between exact ages 30 and 70 from CVD, cancer, diabetes or chronic respiratory diseases than Asia. Within Asia, high income Asia Pacific countries (Brunei, Japan, Singapore, South Korea) had the longest life expectancy, HALE, and lowest probability of dying between ages 30 and 70 from chronic diseases. Within Latin America, Southern Latin American countries (Argentina, Chile, Uruguay) had the longest average life expectancy and HALE, while Andean countries (Bolivia, Ecuador, Peru) had the lowest probability of dying between ages 30 and 70 from chronic diseases. The greatest health risk factors for the Latin American region were overweight, obesity, and per capita consumption of pure alcohol, while those for Asia were smoking and diets low in whole grains. In both regions, high blood pressure was a risk factor for premature death and disability. High income Asia Pacific and Andean Latin American countries had the lowest prevalence of raised blood pressure in adults. Results of GBD studies showed that ischemic heart disease is a cause of mortality across all countries in both regions. Common causes of disability in both regions were migraine, depression, skin and subcutaneous diseases, sense organ diseases, and low back and neck pain. Diabetes was a leading cause of disability across Latin America while stroke was a leading cause of death across Asia. Conclusion: In Asia, better population health is associated with higher socio-economic development but is not the case in Latin America. Both regions had similar causes of mortality and disability and a few differences. Risk factors differed between the two regions. The One ILSI Healthy Aging Project seeks to uncover underlying factors that drive these similarities and differences, both within and between geographic regions, and identify country- and region-specific best practices, policies, and programs to promote healthy and successful aging.

**Keywords:** Aging, Asia, Latin America, core health indicators, risk factors

**Conflict of Interest disclosure:** The presentation is supported by ILSI, which is funded primarily by its industry members.

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# IMPACT OF MENOPAUSE ON THE NUTRITIONAL HEALTH OF ARGENTINIAN WOMEN" UBACYT PROJECTS 2008-2017

## BODY MODIFICATIONS IN ADULT WOMEN AND INCREASED CARDIOMETABOLIC RISK. PROJECT PRESENTATION UBACYT 2008-2017

Torresani, María Elena.

PhD Nutritionist. Chair of Adult Dietary Therapy. Nutrition Career of the School of Medicine. UBA. Director Ubacyt Project 2008-2017. Argentina.

The line of research on Nutrition in Perimenopause begins as an activity within the 1st Chair of Adult Dietary Therapy in the Nutrition Career of the School of Medicine at the UBA.

The topic was chosen evaluating the global problem and the statistical data that show that coronary disease and stroke are the main cause of mortality in adult women worldwide, being osteoporosis the second health problem for women during this period of their lives.

Cardiovascular disease in women appear later (an average of ten years later) than in men, mainly because the hormonal profile of the woman protects her until the onset of menopause.

The original objective of our research was to consider the impact at the bone and cardiometabolic level of the most prevalent nutritional risk factors in adult women, by screening population-related risk factors related to nutrition and analyzing the intake of certain nutrients critical in this population under investigation.

During aging per se, and particularly during the perimenopausal period, a number of body modifications are generated at a general level, with loss of height, increase of body weight and increase of abdomen-visceral fat distribution, the main anthropometric variations documented by Literature several years ago.

Regarding the corporal modifications undergone in this stage, the main results were:

- Loss of average height of 1.26 cm, being accentuated as from the age of 55, postmenopause and time spent in menopause over 5 years. Only 10.8% lost> 3 cm, cut value considered a risk of increased osteoporotic fractures.

- Regarding body weight, although at the onset of perimenopause, it was already increased by most of the women being studied, more than half of these women reported an increase of body weight ³ 10% of their usual weight. This gain of weight was independent of the caloric intake, and it was inversely correlated with the time elapsed in menopause. Being the greatest impact observed during the first years of estrogen deficiency.

With regards to cardiometabolic risk, the lipid profile is affected in this stage, with an increase in total cholesterol (ColT) and low density lipoprotein (LDL), triglyceride elevation (TG) and reduction of high density lipoprotein (HDL).

The waist-height index (CWI) showed a good correlation with the CVR factors and components of the metabolic syndrome. There was a strong positive linear correlation between the CI and the of WC and BMI values, and weaker but equally significant with age.

It is a priority to find a good indicator of risk at this stage, since the SF recognized worldwide as one of the main tools for its calculation, underestimates in this population the risk by not considering any of its variables any anthropometric component, nor the values of TG characteristic of the abdominovisceral phenotypic distribution.

Facing all these problems, it is essential that both, women and the professionals who accompany them, recognize cardiovascular risk factors, estimate it over time and understand the importance of making lifestyle changes that can reduce it, and implement preventive strategies more intense when necessary.

**Keywords:** Body changes; Cardiometabolic Risk; Adult woman; Perimenopause.
# CHANGES IN EATING BEHAVIOR: CARB COMPULSION, BINGE EATING AND NIGHT-EATING IN RELATION TO THE STATE OF ANXIETY, STRESS AND SELF-ESTEEM OF WOMEN

Oliva, María Laura.

Nutritionist. Nutrition School. University of Buenos Aires (UBA). Argentina.

The objective of this dissertation is the analysis of the changes in the alimentary behavior during the hormonal transition of the adult woman and its relation with the own mood of this stage.

Eating is a complex behavior in which intervene, in addition to numerous hormones and systems of the body, a pleasure / reward mechanism that obeys specific and natural stimuli, regulated by neurotransmitters, allows the individual to develop learned behaviors. Estrogens seem to intervene in the regulation of appetite. Its modulating effect on the neurotransmitter system is broad and includes regulation of the synthesis and metabolism of various neurotransmitters. Substances that decline during the hormonal transition.

On the other hand, insulin, one of the hormones responsible for the regulation of dietary intake, plays an important role in the control of body weight. Its increase in blood, mediated by carbohydrate intake, significantly decreases the concentration of serotonin's competing amino acids, allowing a greater entrance of the same to the brain, thus causing a greater increase of serotonin. In turn, increased serotonergic agents reduce the intake of foods rich in carbohydrates and stimulates the secretion of melanocortins, the most potent anorectic agents in the brain. Serotonin-dependent defects in neurotransmission have been postulated to cause mood disorders and an over-enthusiasm for consumption of foods rich in carbohydrates; This has led to the description of a syndrome called "carbohydrate addiction" characterized by signs of atypical depression accompanied by an urgency to consume foods rich in carbohydrates and consequent obesity. These signs are very common during this stage of a woman's life, being an obstacle to controlling the increase in body weight. Influencing negatively in all the cardiovascular risk factors that are presented.

**Keywords:** Alimentary behavior - menopause - serotonin

# BONE CHANGES AND NUTRITIONAL APPROACH TO REDUCE THE RISK OF OSTEOPOROSIS. PROJECT UBACYT 2008-2017

Torresani, María Elena.

PhD Nutritionist. Chair of Adult Dietary Therapy. Nutrition Career of the School of Medicine. UBA. Director Ubacyt Project 2008-2017. Argentina.

Life expectancy has increased significantly worldwide, rising in women over the past 160 years at a steady pace of about 3 months per year. However, the age when menopause occurs has remained relatively stable, so that, nowadays women will live more than a third of their lives with estrogen deficiency. It will produce specific

effects in all organs that have estrogen receptors, among them the skeletal system.

The WHO refers to osteoporosis as the second health problem in adult women, after cardiovascular diseases. It is a global public health problem. It affects more than 200 million people and it is estimated that between 30 and 50% of postmenopausal women will develop this disease. But although it is a frequent disease, its real prevalence is difficult to establish since it is asymptomatic until the appearance of its complications. The peak bone mass of premenopausal women is the major determinant of subsequent risk of osteoporotic fracture. Therefore, maximizing bone mass during skeletal growth, developing it and maintaining it in the premenopausal years, will be important strategies in the prevention of osteoporosis.

According to the Argentine Society of Osteoporosis, in Argentina, there are 298 fractures annually per 100,000 women over 50 years of age. It is assumed that 25% of osteoporotic fractures are due to the lack of an adequate bony capital during adolescence; and the remaining 75% to have had excessive postmenopausal losses. Among the modifiable factors involved in progressive bone demineralization with age, lifestyle (less physical activity, smoking and alcohol consumption) and the type of diet consumed (low intake of calcium and vitamin D, increased ratio P / Ca, and consumption of sodium, protein and caffeine by participating in increased urine calcium excretion).

In this Symposium data on the research about the risk of osteoporosis, risk of fractures, the study of bone mineral density in relation to the lifestyle and the dietary profile of the women studied will be presented.

As expected, the social cost of morbidity and mortality associated to female menopause is very high, so it would be convenient to evaluate during this period the possibility of establishing a model of primary health prevention, applicable to women who begin this stage of their life, and that could include actions on their lifestyle, tending to reduce the risk of osteoporosis and fractures. In this context, the health care in during the Climateric implies considering the nutritional aspects due to the great impact they can have on the quality of life. And within them, food education plays a predominant role in the prevention during this biological stage in the life of a woman.

**Keywords:** Bone changes. Risk of osteoporosis. Adult woman. Perimenopause.

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# EARLY NUTRITION AND ITS EFFECTS ON HEALTH

## GENETIC SUSCEPTIBILITY OF EARLY METABOLIC SYNDROME IN CHILDREN AND LATER CONSEQUENCES

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.

Childhood obesity is one of the most important public health problems of the 21st century, affecting both developed and de-
developing countries. Obesity plays an important pathophysiologic
role in the development of insulin resistance, dyslipidemia, and
hypertension, leading to type 2 diabetes (T2D) and a risk of early
cardiovascular disease (CVD). Obese children can exhibit met-
abolic syndrome (MetS) when a number of cardio-metabolic
criteria, namely, hypertension, dyslipidemia, or altered glucose
metabolism, all of them features of insulin resistance (IR), are
present. However, there is a strong debate on the diagnosis and
early phenotypic expression of the MetS in children. Nonetheless,
our group has shown that irrespective of the classification used,
the MetS is not only present in pubertal but also in prepubertal
children. Indeed, international definitions of the MetS should
consider criteria specific for children in the prepubertal period,
i.e. children aged <10 years. In addition specific biomarkers of in-
flammation, insulin resistance and CDV risk are already associat-
ed with central obesity and early onset of MS in prepubertal obese
children. The association of a continuous MetS score with specific
risk biomarkers of inflammation, endothelial damage and CVD
supports its use in the early identification of children at increased
risk of metabolic dysfunction.

Numerous gene variants including SNPs and CNVs have been reported to be associated with obesity and some features of the MetS in adults, particularly, dislipidemia and hypertension. However, scarce data are found in children. We have described some variants in 11-BSDH, NPY and NPR genes, as well as to others related to the antioxidant defence system genes, namely CAT, GPX and PRDX, which are associated with some features of MetS in children. Characterization of the genes expressed in adipose tissue (AT) is key to understanding the pathogenesis of obesity and to developing treatments for this condition. Indeed, we have recently compared the gene expression in visceral AT (VAT) between obese and normal-weight prepubertal children and found previously unreported dysregulated genes that may be candidate genes in the aetiology of obesity and MS. As validated by qPCR, expression was upregulated in genes involved in lipid and amino acid metabolism (CES1, NPRR3 and BHMT2), oxidative stress and extracellular matrix regulation (TNMD and NQO1), adipogenesis (CRYAB and AFF1) and inflammation (ANXA1); by contrast, only CALCRL gene expression was confirmed to be downregulated. Additional functional studies of some genes as CAT, NPR document the importance of those genes in the control of glucose and lipid metabolism and their potential implication in the early development of MetS.

**Keywords:** Childhood obesity. Genes. Insulin resistance. Lipid metabolism. Metabolic syndrome.

EPIGENETICS OF UNDERNUTRITION AND OBESITY

(1)Ramos-Lopez, Omar; (2)Riezu Boj, José Ignacio; (3)Milagro, Fermin I.;

(4)Martínez, J. Alfredo.

(1)Department of Nutrition, Food Science and Physiology. Centre for Nutrition Research. University of Navarra. Pamplona. Spain. Department of Molecular Biology in Medicine. Civil Hospital of Guadalajara; (2)Department of Nutrition, Food Science and Physiology. Centre for Nutrition Research. University of Navarra. Pamplona. Spain.; (3)Department of Nutrition, Food Science and Physiology. Centre for Nutrition Research. University of Navarra. Pamplona. Spain. CIBER Fisiopatología Obesidad y Nutrición (CIBERObn). Instituto de Salud Carlos III. Madrid. Spain.;

(4)Department of Nutrition, Food Science and Physiology. Centre for Nutrition Research. University of Navarra. Pamplona. Spain. CIBER Fisiopatología Obesidad y Nutrición (CIBERObn). Instituto de Salud Carlos III. Madrid. Spain. IMDEA. Madrid. Spain.

Malnutrition involves either energy undernutrition or nutrient deficiencies, as well as overnutrition implicating calories or food excess consumption. Undernutrition usually concerns underfeeding, famine and poor nutritional status while obesity refers to excessive fat accumulation. These conditions are largely dependent on unbalanced energy equilibrium or in some nutrients, which are associated with starvation, impaired food consumption, or diseases, which trigger metabolic alterations. Interestingly, maternal undernutrition or overnutrition during gestation/lactation (inadequate maternal diet or health) negatively impact child growth and future physiopathological functions. Additionally, malnutrition is related to immunodeficiency, disease onset and accelerated aging, and has adverse influences on health in the adulthood, including excessive body weight, diabetes, dyslipidemia, cardiovascular events and eventually cancer or other diseases. Growing scientific evidences are supporting the view that environmental and social factors, including undernutrition, can alter epigenetic signatures (particularly DNA methylation, covalent histone modifications and non-coding RNA expression), affecting gene expression and subsequently cell functions, with lasting effects on adult life health. In this context, inadequacies in dietary methyl-donors (folate, choline, betaine or B vitamins) and other micronutrients, low-protein diets or calorie restriction and famine exposure during early stages, but also excessive calorie intake, high-fat and high-sugar diets, or obesity itself may modify the epigenome and promote the onset of several pathological conditions by impairing epigenetic mechanisms affecting genes associated with insulin sensitivity, growth, inflammation, adipogenesis, lipid turnover, etc. Interestingly, these breakthroughs are contributing to devise original dietary approaches targeting the epigenome.

Differences among individuals in disease predisposition rely on the DNA sequence (e.g. SNPs), and also on epigenetic phenomena affecting gene expression including the regulatory actions of DNA methylation and miRNA. Indeed, the recognition of individuals eliciting epigenetic changes at a perinatal period in the methylation profiles of specific genes might contribute to assess the future susceptibility for obesity and related comorbidities in adulthood. Furthermore, newer approaches for individualized dietary treatments by means of algorithms based on genetic and epigenetic
knowledge are paving the way for their possible implementation in precision individual's nutrition by better understanding the role of genes regulating appetite, thermogenesis, nutrient turnover and deposition, oxidative and reticulum stress, and other metabolic pathways.

Summing up, current undernutrition and obesity research should be focused on understanding epigenetic marks and messengers related to the regulation of cell signaling, inflammatory and intermediate metabolic pathways, accentuating health interactions with social and environmental factors (diet, physical activity, stress, sleep) to achieve precision nutrition. Actually, recent findings have demonstrated an epigenetic underlying of different metabolic disorders with appearance in adulthood, such as obesity, cardiovascular diseases, and type 2 diabetes as well as cancer, and the involvement of some specific processes participating in the developmental origin of disease in the adult known as the DoHAD hypothesis.

Cordero P, et al. Dietary supplementation with methyl donors reduces fatty liver and modifies the fatty acid synthase DNA methylation profile in rats fed an obesogenic diet. *Genes Nutr* 2013;8:105-13.

Geraghty AA, et al. Nutrition during pregnancy impacts offspring's epigenetic status-evidence from human and animal studies. *Nutr Metab Insights* 2016;8:41-47.

Keywords: Malnutrition, DoHAD, miRNA, DNA methylation, gestation

## PREVENTION OF UNDERNUTRITION AND OBEsITY IN CHILDREN AND ADOLESCENTS: A GLOBAL PERSPECTIVE

Moreno, Luis A.

PhD. Md. Faculty of Health Sciences, University of Zaragoza, Zaragoza, Spain.

Obesity prevalence is high in both developed and developing countries. Different types of undernutrition coexist with obesity, and this is more the case in developing than in developed countries. Growth retardation is often observed in children having obesity. Some micronutrient deficiencies are also frequent in children with obesity, such as iron deficiency anaemia or insufficient serum concentrations of vitamin D, as the most widely documented. This double burden of malnutrition observed at the population and at the individual level may be due to different causes. First of all, metabolic imprinting related with foetal malnutrition may be related with low birth weight in an important proportion of the new-borns. Obesity in the mothers and an excessive weight gain during pregnancy may also result in infants born large for their gestational age. Maternal micronutrient deficiencies should also be considered as part of the antenatal causes, mainly vitamin A and zinc.

During infancy and early childhood, children are often exposed to energy dense foods with low nutritional value. In addition, they are often sedentary. These factors may lead to the development of

the double burden of malnutrition even at the individual level. Adequate nutrition is an essential driver of sustainable development because it plays a critical role in child brain development and generates broad-based economic growth.

Different strategies to prevent under- and over-nutrition are possible. At the general population level, policy changes should be introduced in order to reduce the exposure to the above mentioned determinants. Targeting the child, the family, the school, the community and the primary care health centres is also a necessary approach. Nutrition-specific interventions should be implemented by clinicians, including promotion of breastfeeding and complementary feeding practices and micronutrient supplementation and food fortification. Provision of nutrient dense foods with low energy density and reducing food insecurity are also efficient strategies. The final goal will be to reduce both sides of the malnutrition issue, affecting mainly low-income populations.

**Keywords:** Obesity, undernutrition, prevention, child, epidemiology

## NEW EVIDENCE OF THE IMPORTANCE OF EARLY NUTRITION DURING THE FIRST 1,000 DAYS OF LIFE

Martorell, Reynaldo.

Robert W. Woodruff Professor of International Nutrition. Hubert Department of Global Health. Rollins School of Public Health. Emory University.

The first 1000 days of life (gestation and the first 2 years) represents a window of vulnerability for human development for several reasons: it is a period of high nutritional requirements, greater susceptibility to infections, rapid growth and development and full dependence on others for care, nutrition and social interaction. An area of great interest is the high sensitivity to programming affects during early life. In this presentation, we will review evidence of nutritional conditions that reduce human capital in the first 1000 days, among them iodine deficiency, iron deficiency and anemia, lack/short duration of breastfeeding, severe acute malnutrition, stunting and exposure to famine. Also, poor nutrition as well as excess in early life enhance risk of chronic diseases, perhaps through epigenetic changes, but the extent to which they do is not clear. It is important to recognize that the environment of the first 1000 days in low and middle-income countries has changed and is changing dramatically. From a combination of maternal underweight, short adult stature and micronutrient deficiencies, we are transitioning to maternal short adult stature (although heights are increasing slowly through improved growth in the first 1000 days) and obesity. In summary, the first 1000 days are a period of vulnerability but also a window of opportunity because it is during this time that nutrition interventions will be most effective in improving human capital and adult health. Effective policies and programs are needed for optimal child development in a globalized environment.

**Keywords:** 1000 days, human capital, adult health
INTRODUCTION: USING IMPLEMENTATION RESEARCH IN THE CONTEXT OF COMPREHENSIVE EVALUATIONS OF MULTISECTORAL PROGRAMS TO ASSESS PATHWAYS OF IMPACT AND INTERPRET IMPACT FINDINGS

Ruel, Marie; Olney, Deanna.

International Food Policy Research Institute.

There is increasing evidence that multisectoral programs can improve maternal and child nutrition outcomes. However, multisectoral programs are complex and understanding the pathways by which such programs achieve impacts, and how these pathways can be leveraged to optimize impacts and coverage is not well understood. Some of the knowledge gaps can be addressed by working with program implementers as early as possible in the program cycle to design a program theory framework and the hypothesized pathways by which the program is expected to achieve impact, and embed data collection along these pathways as an integral part of the overall evaluation process. In recent years, there has been growing interest in using implementation research to fill the knowledge gaps related to program operation and implementation, as reflected for example in the launch of the Society for Implementation Science in Nutrition (SISN) in 2016. In response to this interest, a new generation of well-designed large-scale comprehensive evaluations of multisectoral programs focused on improving nutrition now includes implementation research as part of their overall evaluation plan.

This symposium reports on recent experience using implementation research in the context of comprehensive evaluations of multisectoral programs to assess how programs achieve impact and how researchers have worked with program implementers to promote uptake of the findings for program strengthening and scale-up. The target audience for this session includes researchers program implementers, donors, and policy makers who are interested in understanding how implementation research can be used to build better multisectoral programs.

The three learning objectives of this session are:

1) To strengthen the collective understanding of how implementation research can be used to build better multisectoral programs

2) To understand some of the challenges and opportunities of having program implementers and researchers working together to conduct implementation research

3) To catalyze collective action on using implementation research to build better multisectoral programs.

The introductory presentation in this session provides a general overview of what implementation research is and how it can be used to build better and more effective programs, drawing upon concepts highlighted by SISN.

**Keywords:** Multisectoral programs; implementation research; maternal and child nutrition; program evaluation

LESSONS LEARNED FROM THE PROCESS EVALUATION OF HKI'S HOMESTEAD FOOD PRODUCTION PROGRAM IN BURKINA FASO

(1)Nielsen, Jennifer; (2)Nielsen, Jennifer; (3)Olney, Deanna;

(4)Ouedraogo, Marcellin; (5)Pedeombga, Abdoulaye; (6)Rouamba, Hippolyte.

(1)PhD. Senior Nutrition Advisor. Helen Keller International. New York NY; (2)PhD. Senior Nutrition Advisor. Helen Keller International. New York. USA.; (3)PhD. Senior Research Fellow. International Food Policy Research Institute. Washington DC. USA.; (4)Project Coordinator. Helen Keller International. Ouagadougou. Burkina Faso; (5)Researcher. Agence de Formation, de Recherche, et d'Expertise en Sante pour l'Afrique. Ouagadougou. Burkina Faso; (6)Social and Behavior Change Communication Officer. Engender Health. Ouagadougou. Burkina Faso.

Helen Keller International (HKI) has implemented its nutrition-sensitive agriculture model, Enhanced Homestead Food Production, across Asia for over 30 years, but only recently begun to adapt if for the context of sub-Saharan Africa. Thus, the collaboration with the International Food Policy Research Institute (IFPRI) on the first effort to deliver the program in Eastern Burkina Faso was especially valuable, both to evaluate the extent to which this multisectoral approach can improve nutritional outcomes in mothers and young children and to understand and strengthen the impact pathways in this setting. The study included a process evaluation carried out at midterm to assess the quality of delivery, request feedback from implementers, partners and participants, and recommend necessary adjustments to strategy. A program impact pathways framework that identified how inputs and activities were expected to lead to changes in knowledge, practices and impact shaped questions for key informant and semi-structured interviews administered with implementing agents and beneficiaries, and with residents of control communities. Data were analyzed by IFPRI and shared with project managers and partners through a series of workshops, where weaknesses were discussed and solutions proposed. Overall, findings indicated that knowledge of both production and nutrition concepts was good and enthusiasm for the program was strong. However, water shortages due to fragile infrastructure and high poultry mortality posed major challenges to production, while lower than expected activity by community volunteers reduced the potential for impact on behavior change. To address constraints along the production pathways, the project team supported reparations to water points, promoted additional water conservation techniques, more drought resistant garden vegetables for the dry season, and expansion of vegetable production to the rainy season, and strengthened links to government veterinary health services. Solutions on the nutrition knowledge and practice pathways included organizing public recognition and
small gifts for community volunteers, and additional training to strengthen skills for interpersonal counseling and group facilitation and knowledge of key practices such as control of anemia and feeding the sick child. Changes were made to the program model as well to adapt it more closely to the local context. There were challenges to implementers in managing a complex, multisectoral intervention while meeting the demands of a rigorous research design with multiple rounds of data collection, analysis and application of learning. However, exposure to IFPRI's research methodologies also developed new skills among the implementing partners and deeper understanding of both quantitative and qualitative analysis. The collaboration between the research and implementing teams contributed to stronger program delivery and richer understanding of implementation challenges.

**Keywords:** Nutrition-sensitive agriculture, process evaluation

## SCALING UP BEHAVIOR CHANGE INTERVENTIONS TO IMPROVE CHILD FEEDING: REFLECTIONS ON THE USE OF RESEARCH FINDINGS IN PROGRAM IMPLEMENTATION AND SCALE-UP

(¹)Sanghvi, Tina;

PhD. Nutritionist. Alive & Thrive FHI360 Washington DC. USA;

Alive & Thrive's main purpose in using implementation research is to learn what works for program delivery. After developing an implementation framework based on experience across three countries in 2009-2014, we now apply implementation research as a tool for tailoring this framework and its components to new contexts in the following ways:

1. Making program design choices, specifically finding the priority behaviors in each program context that have the greatest potential to benefit and the specific determinants or drivers of these behaviors plus key influentials that need to be engaged including how best to reach these audiences for maximum coverage at the right time. The choice of program platforms is often driven by reach and timing of contacts.

2. Engaging the needed stakeholders and additional donors in the program by generating and compiling the evidence they need on critical gaps as well as what works.

3. Identifying exactly how and when to engage with other sectors such as WASH, education, and livelihoods by reviewing past experiences and conducting joint operations research and assessments to understand how these sectors can address design gaps or enhance program outcomes.

4. Monitoring, learning & evaluation to reach scale, and strengthen sustainability and equity components. This involves, continuous monitoring of reach and uptake, addressing gaps in quality as programs scale up, identifying where investments in institutional strengthening need to take place, conducting special studies.

Evaluation surveys conducted by IFPRI strengthened program strategies through identifying: the important role of local health providers in shaping IYCF practices in Bangladesh, negative im-

pact of C-section deliveries on early initiation of breastfeeding in Viet Nam, and dose-response relationship between the number of communication channels reaching mothers and their IYCF practices (all countries). IFPRI also demonstrated the value of investing in rigorous evaluation methods to advance credibility and global investments in large scale behavior change programs.

Implementation research covered a range of topics and methods in A&T countries:

* Qualitative rapid household trials in all countries on the feasibility of adopting new behaviors

* Willingness to pay study in Ethiopia on the viability of a processed complementary food

* Assessment of a franchising model within a government primary health care structure for IYCF counseling services in Viet Nam

* Media habits studies and opinion leader surveys in all countries

* Feasibility study of a package of maternal nutrition intervention integrated within an MNCH program in Bangladesh

* Studies on fasting in Ethiopia and the role of religious leaders to improve dietary diversity

* Testing a multi-component approach to improving washing hands with soap before feeding children in Bangladesh

* Assessing the role of husbands in Viet Nam and how to engage them effectively for supporting exclusive breastfeeding.

Challenges in A&T's use of implementation research included, limited research and analysis capacity in countries, reluctance to utilize research findings to shift program designs once the processes and materials were finalized at the start, short period of time to build a deep understanding of and commitment to a continuous cycle of 'design-learn-re-design' approach.

**Keywords:** Program delivery research, behavior change evidence, scaling up, breastfeeding, complementary feeding

## ADDRESSING ISSUES OF SCALE, RIGOR AND CONTEXT IN THE DESIGN OF EVALUATIONS OF LARGE-SCALE BEHAVIOR CHANGE INTERVENTIONS IN BANGLADESH, VIETNAM AND ETHIOPIA

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

(¹)PhD. Senior Research Fellow. International Food Policy Research Institute. Washington DC USA.; (²)PhD. Research Fellow. International Food Policy Research Institute. Washington DC. USA; (³)PhD. Technical Officer. World Health Organization;

(⁴)PhD. Professor. University of South Carolina Columbia USA;

(⁵)PhD. Division Director. Poverty Health and Nutrition Division. International Food Policy Research Institute.; (⁶)PhD. Program Officer. Bill & Melinda Gates Foundation.

Multisectoral programs are being launched globally to address the multiple determinants of poor nutrition simultaneously. As these program are designed and rolled out, it is apparent that interventions to support behavior change are a necessary major component of most multisectoral programs. However, the evidence
base on how to roll out and achieve impact through large-scale
nutrition behavior change programs is limited, partly because of
limited program efforts that are truly at scale and partly due to the
challenges of rigorously evaluating complex large-scale programs.
This presentation and its accompanying presentation (Sanghi et al,
on Alive & Thrive) together address issues related to design and
implementation of large-scale behavior change interventions and
the evaluation of these large-scale interventions.

The evaluation of Alive & Thrive (A&T), a multi-year initia-
tive that aimed to improve IYCF practices in Bangladesh, Viet-
nam and Ethiopia using multiple delivery platforms, addresses
several evaluation challenges including: the technical aspects
related to evaluating the nutritional impact of interventions tar-
geted during the first two years of life when rapid growth fal-
tering occurs; the identification of proper counterfactuals in the
context of rapidly scaling-up programs; and the development of
methodologies and tools to assess implementation, utilization
and program impact pathways within evolving program portfo-
lios. We designed the impact and process evaluations through
a technically robust and programmatically engaged, step-wise
process in three countries.

In Bangladesh and Vietnam, cluster-randomized probability
evaluation designs were used; in Ethiopia, the evaluation used an
adequacy design. In addition, different methodological approach-
es were utilized to answer critical “how” questions and to generate
information on the many processes and pathways to program im-
pact. The methodological approach that guided all process evalu-
ation activities included four components: 1) developing detailed
program impact pathway models, 2) linking data collection to pro-
gram impact pathways (PIPs) utilizing mixed methods, and mul-
tiple data sources, 3) linking evaluation timelines with program
implementation timelines, and 4) engagement with the program
implementation and management teams.

Using these approaches, in all three countries, theory-driven
impact and process evaluations based on program impact path-
ways, and using mixed methods, generated information on impact
of the interventions and on factors that facilitated or prevented
achievement of impact and scale. Intervention impacts on infant
and young child feeding practices, were largely positive, but mixed.
Behavioral impacts were greater with intervention platforms that
were able to reach higher coverage and where the population con-
text was conducive to behavior change. There was no impact on
child growth in any of the contexts, although impacts were seen on
motor and language milestone achievement in Bangladesh.

We conclude that robust impact and process evaluations of
complex, large-scale nutrition programs are feasible, but that early
implementer-evaluator engagement and shared vision and moti-
vation to establishing rigorous designs are essential. The positive,
but mixed, impacts on behaviors suggests that accompanying mul-
tisectoral interventions that address other constraints may deliver
much greater impact. The program and evaluation experience of-
fer multiple lessons for implementation and evaluation of behav-
ior change interventions at scale.

**Keywords:** Behavior change, program evaluation, scale

LESSONS LEARNED FROM DESIGNING AND IMPLEMENTING AN INTEGRATED NUTRITION, LIVELIHOOD AND ECD PROJECT IN MALAWI

Abstract In Malawi, 37 percent of children aged 6-59 months are stunted and 63 percent are anaemic (DHS, 2016). As a member of the Scaling Up Nutrition movement, the government promotes a multi-sectoral approach to tackling malnutrition in Malawi. The national Early Childcare and Development (ECD) programme targets all children aged 0-8 years by providing safe, stimulating environments, access to health and nutrition services, and capacity building for parents and caregivers through community based preschools and parenting groups. Today, there are an estimated 9,000 community-run preschools across Malawi, serving 32 percent of all 3-5 year olds in the country, of which 20% are orphans and vulnerable children.

One of the main causes of low preschool attendance and closure in Malawi is lack of food (The World Bank, 2014), when communities are not able to provide food for the mid-morning snack. To address this issue, Save the Children began integrating nutrition, agriculture and livelihood components to its ECD programmes to build community capacity to provide nutritious food in preschools all year round, and improve household food security and nutrition at the same time. Best practice was drawn from large nutrition and livelihood projects like the USAID funded Wellness and Agriculture for Life Advancement project (WALA) and used to create an ECD nutrition and livelihood package. It was piloted and implemented in the World Bank Protecting Early Childhood Development Project (PECD) reaching 199 preschools in 4 districts with support from Conrad N Hilton Foundation. It was then further improved and evaluated in Save the Children's ongoing ECD programme in Zomba district with support from PATH's Nutrition Embedding Evaluation Program (NEEP).

Using preschool kitchens and gardens and parent groups as training platforms, parents and community members learn new recipes, food processing and preparation techniques, agricultural methods, and techniques to grow and store climate resilient nutritious foods all year round. A village savings and loans system is also set up to help community members, women in particular, set up small businesses and earn cash. This integrated ECD, nutrition and livelihood package benefits the preschool, the households and the community as a whole to become more organised, climate resilient and food secure, which in turn helps improve child nutrition and development.

Where community preschools are present, they provide a valu-
able platform for building community and household capacity and
resilience to improve food security, child health, nutrition and de-
velopment. A cluster randomised trial has been conducted by IFPRI,
the University of Malawi and Save the Children to evaluate the im-
pact of this integrated package on agricultural production, caregiver
behaviours, child nutrition and development (presented separately).
Further work is needed to simplify the training package and priori-
tise messages across the sectors before scale up nationwide.

**Keywords:** Malawi, preschools, livelihood, early childhood development, ECD

<footnote>(1)Roschnik, Natalie; (2)Twalibu, Aisha Laila.</footnote>

<footnote>(1)MSc. Senior Nutrition Advisor. Save the Children UK; (2)MSc.
Research Officer. Save the Children Malawi.</footnote>
**Further collaborators**

Peter Phiri, Save the Children Malawi
Mangani Katundu, Chancellor College, University of Malawi
Aulo Gelli, IFPRI

# OPTIMIZING AN ECD-BASED, AGRICULTURE AND NUTRITION PROGRAM TO IMPROVE THE DIETS OF PRE-SCHOOL CHILDREN IN MALAWI

Gelli, Aulo.

PhD. Nutrition. Poverty Health and Nutrition Division. IFPRI.

The Nutrition Embedded Evaluation Program Impact Evaluation (NEEP-IE) study is a cluster randomised controlled trial designed to evaluate the impact of a childcare centre-based integrated nutrition and agriculture intervention on the diets, nutrition and development of young children in Malawi. The intervention includes activities to improve nutritious food production and training/behaviour change communication to improve food intake, care and hygiene practices. This presentation summarises the findings of the cluster randomised trial and the implications for policy and implementation.

**Keywords:** Impact evaluation, early childhood, diets, policy, implementation.

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## THE WHA GLOBAL NUTRITION TARGETS FOR 2025: TACKLING THE DOUBLE BURDEN OF MALNUTRITION THROUGH THE LIFECYCLE

### WHO TOOLS TO SUPPORT COUNTRIES IN SETTING NATIONAL NUTRITION TARGETS

The translation of global targets into national targets needs to consider country context. This involves, first, the identification of nutrition challenges and, second, setting targets to address those challenges. The WHO Nutrition Landscape Information System (NLIS) provides country profiles with key indicators in nutrition s a system that links to all WHO nutrition databases. It provides country profiles that combine data from WHO and its partners on nutrition outcomes and causal factors related to food, health and care at the immediate, underlying and basic level. National targets are adapted from the Global Nutrition Targets, using tools such as the WHO Tracking Tool.

Third, countries need to select priority interventions to address the identified problems and reach their national targets. The WHO Global Nutrition Targets Policy Briefs provide a summary of action needed to effectively address the targets. Furthermore, the WHO e-Library on Evidence for Nutrition Action (eLENA) provides the evidence, the current recommendations and the rationale for more than 100 nutrition interventions. Interventions in eLENA are also linked to the Global Nutrition Targets, where evidence suggest linkages exist.

Fourth, the detailed planning for scaling up priority interventions will depend on the political willingness, the health system, human resources and other infrastructure in the country. The Landscape Analysis country assessment tools provides a methodology for rapid assessment of country commitment and capacity, as a measure of their readiness to scale up nutrition action. The UN OneHealth Tool allows countries to do the detailed costing and planning of different scaling-up scenarios. The Tool contains a series of health programme modules including one for nutrition covering the WHO Essential Nutrition Actions that target the 1000-days window of opportunity from conception to 2 years of age. It incorporates the Lives Saved Tool (LiST), which estimates the impact of planned programmes on child mortality and morbidity as well as stunting, wasting, anaemia, low birth weight and breastfeeding. The WHO Global Database on the Implementation of Nutrition Action (GINA) provides information on policies and actions being implemented in countries, including lessons learnt and best practices that would be helpful to other countries.

The fifth and final step involves monitoring of progress made and evaluation and outcomes reached, using key indicators such as those in the Global Nutrition Monitoring Framework. Another aspect of monitoring includes tracking of expenditures to nutrition specific and sensitive actions implemented through the health sector, which could be facilitated by the Health Accounts.

**Keywords:** Evidence-informed nutrition policy planning; National nutrition target setting; Evidence-informed nutrition actions; Costing of nutrition actions; Nutrition policy monitoring

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## OBJECTIVE ASSESSMENT OF BREASTFEEDING PRACTICES

### THE IMPORTANCE OF OBJECTIVE ASSESSMENT FOR EVALUATION OF BREASTFEEDING PRACTICES IN AFRICAN INFANTS

Exclusive breastfeeding has been recommended by the World Health Organization for the first six months of an infant's life, yet

<footnote>(1)Engesveen, Kaia; (2)Nishida, Chizuru; (3)Montez, Jason.</footnote>

<footnote>(1)MSc. Technical Officer. Department of Nutrition for Health and Development. World Health Organization. Switzerland;</footnote>

<footnote>(2)PhD. Coordinator. Department of Nutrition for Health and Development. World Health Organization. Switzerland;</footnote>

<footnote>(3)Department of Nutrition for Health and Development. World Health Organization. Switzerland.</footnote>

<footnote>(1)Mulol, Helen; (2)Coutsoudis, Anna.</footnote>

<footnote>(1)PhD. Paediatrics. Department of Paediatrics and Child Health. Nelson R Mandela School of Medicine. University of KwaZulu-Natal. Durban. South Africa.; (2)PhD. Paediatrics. Department of Paediatrics and Child Health. Nelson R Mandela School of Medicine. University of KwaZulu-Natal. Durban. South Africa.</footnote>
in Africa reported exclusive breastfeeding rates are low. There are
many cultural barriers and breastfeeding myths that prevail and in a
continent with high levels of HIV infection, HIV-infected mothers
also experience many challenges when wishing to practice exclusive
breastfeeding.

The dose-to-mother deuterium dilution technique has made it possible to distinguish between water ingested by the baby via breastfeeding and water from sources other than human milk thus allowing objective evaluation of whether a mother is exclusively breastfeeding her infant as well as the volume of human milk. This technique makes it possible to compare this objective measure of exclusive breastfeeding with maternal recall of infant feeding practices. Furthermore the technique also enables these objective measures of infant feeding to be used to assess the true impact of exclusive breastfeeding on other infant outcome measures.

The dose-to-mother deuterium dilution technique was used to evaluate human milk intake and the exclusivity of breastfeeding, which was taken to be ≤25g/day of water from sources other than human milk. Determination of exclusive breastfeeding by maternal recall was established from a list of foods / liquids that the mother gave to the baby.

Infants from seven African countries were enrolled as part of various national and regional projects supported by the International Atomic Energy Agency. Reported and objective exclusive breastfeeding data was collected at 3 months (459 infants) and 6 months (154 infants).

Using the human milk intake data, further studies were carried
out in South Africa, viz. human milk output in HIV-infected and
-uninfected mothers and the effect of early breastfeeding practices
on infant body composition at 12 months.

The pooled results revealed that at 3 months there was no sig-
nificant correlation between reported and objectively measured ex-
clusive breastfeeding (P=0.14, K=0.03). At 6 months the correlation
was significant but the Kappa value was low (P=0.00, K=0.28) indi-
cating only a poor agreement between the two methods of deter-
mining exclusive breastfeeding.

Other key findings using the dose-to-mother technique in South Africa included that HIV-infected mothers were able to produce sufficient volumes of human milk, which were comparable to non-infected mothers and without compromising their own health; and that infants who were exclusively breastfed up to 6 months had a lower percentage fat mass at 12 months.

The large discrepancies found between reported and objectively measured exclusive breastfeeding suggest that maternal recall, while being a good indicator for large-scale health surveys, is not ideal when an objective measure is needed to study the impact of exclusive breastfeeding interventions. Measurement of exclusive breastfeeding using the dose-to-mother technique has thus made it possible to objectively study important infant outcomes that could result from early infant feeding choices.

The benefits of an objective measurement of exclusive breast-
feeding in this pooled study of African infants were highlighted by
the poor correlation with maternal recall of exclusive breastfeeding
and its potential to be used to study other important infant out-
comes.

**Keywords:** Exclusive Breastfeeding; Deuterium dilution; Maternal recall; HIV-infected mothers; Human milk intake

**Conflict of Interest disclosure:** The various national and regional projects were supported by the International Atomic Energy Agency.

**Further collaborators**

Ir Amoussa Hounkpatin Waliou, Yolande Sissinto Savi de Tové (Benin); Marianne Patricia Foh Mengo (Cameroon); Philomene Wabolou (Central African Republic); David Kwaku Bansa (Ghana); Khalid El Kari (Morocco); Elisaphinate Moses Urio (Tanzania).

BREASTFEEDING IMPACT ON BODY COMPOSITION AND GROWTH IN THE FIRST YEAR OF LIFE IN LATIN AMERICAN INFANTS

(1)Mazariegos, Monica; (2)Weisstaub, Sergio Gerardo; (3)Slater, Christine; (4)Ramirez-Zea, Manuel.

(1)Researcher. INCAP Research Center for the Prevention of Chronic Diseases (CIPEC). Institute of Nutrition of Central America and Panama (INCAP). Guatemala.; (2)Researcher. University of Chile. Chile.; (3)Formerly Division of Human Health. International Atomic Energy Agency (IAEA). Vienna, Austria.; (4)Director. INCAP Research Center for the Prevention of Chronic Diseases (CIPEC). Institute of Nutrition of Central America and Panama (INCAP). Guatemala.

Breastfeeding promotes infant growth through its nutritional and bioactive properties, by reducing incidence and severity of potentially growth-affecting infections, and by improving feeding during illness. Besides preventing growth deficit, especially among poorer populations, breastfeeding may prevent obesity during childhood. Evidence about breastfeeding, growth, and body composition has rarely been studied in Latin America. Therefore, we aimed to assess the association of breastmilk intake with body composition and growth in the first year of life in Latin American infants.

290 Latin American mother-infant pairs, who were part of an IAEA regional project in Latin America, were evaluated. They were from Argentina (n=18), Brazil (n=32), Chile (n=81), Cuba (n=24), Dominican Republic (n=50), Ecuador (n=27), Guatemala (n=36) and Uruguay (n=22). Infants were eligible if they had adequate length-for-age (>-2 SD) and BMI-for-age (-2SD>BMI-for-age<+2SD), and if they were receiving breast milk at 3 months. Breast milk and non-breast milk water intakes were measured using the deuterium-oxide 'dose-to-mother' technique at 3 months. Exclusively breastfed (n= 170) and non-exclusively breastfed infants (n=120) were defined based on mother's report. Growth was evaluated with length-for-age z-scores, and body composition was also determined using the deuterium dilution technique at 3 and 12 months. To assess the association between breastmilk intake, body composition and growth in the first year of life we ran random effects models with exposure defined as breastmilk intake at 3m, and outcomes defined as change in z-scores for length-for-age, and change in fat mass index (FMI) and fat-free mass index (FFMI) from 3 to 12 months, adjusted for sex.
48% were girls. At enrollment, the mean (SD) age was 3.8 (0.6) months, mean length-for-age and BMI-for-age z-scores were -0.83 (1.19) and, 0.64 (1.13), respectively. Exclusively breastfed infants received 857.6 (821.8, 893.4) g/day (mean, 95% CI) of human milk and 69.7 (46.3, 93.1) g/day of non-breast milk water, whereas non-exclusively breastfed infants received 516.0 (454.2, 577.8) g human milk and 451.2 (358.9, 543.6) g non-breast milk water per day at 3m. We did not find differences in body composition and length-for-age (z-scores) between exclusively breastfed and non-exclusively breastfed infants at 3 and 12 months, and no effect on changes in body composition was observed. However, a daily breastmilk intake of 100 g/day was associated with a mean increment of 0.01 (95% CI= 0.003, 0.11) length-for-age (z-scores) during the first year of life in infants who were exclusively breastfed at 3 months of age.

This study in eight Latin American countries did not find any association between breastfeeding patterns at 3 months and changes in body composition in the first year of life. Exclusive breastfeeding led to a modest increment in length in the first year of life.

**Keywords:** Breastfeeding, body composition, growth, infants, Latin America

## BREASTMILK INTAKE AND COMPLEMENTARY FEEDING PRACTICES IN INFANTS AND YOUNG CHILDREN IN URBAN AND RURAL AREAS OF INDIA

Exclusive breastfeeding for first six months of life, followed by complementary feeding and continuation of breastfeeding is advocated by international health agencies. The preliminary results of the National Family Health Survey of India (NFHS-4, Year 2015-16) show that the prevalence of stunting, wasting and underweight in under-5 children is 38.4, 21 and 35.7% respectively. Percentage of children under age 3 years who are breastfed within one hour of birth is 41.6, and only 55% of infants under age 6 months are exclusively breastfed. Complementary feeding is introduced in 42.7% of infants aged 6 to 8 months, and minimum adequate diet, as defined by the WHO-UNICEF, is seen in only 8.7% of breastfed infants in the age group 6 to 23 months.

Our observation of infant and young child feeding practices in 500 urban and rural infants in India are similar. The rate of continued breastfeeding in rural infants at 12 months was 90% and

at 24 months it was up to 52%. In longitudinal follow up of rural breastfed infants, human milk intake measured using stable isotope technique, was 693 ± 178 g/d (190 ±37 g/kg/d) at 1 month age, 866 ± 127 g/d (128 ±18 g/kg/d) at 6, 596 ± 193 g/d (79 ±29 g/kg/d) at 12, and 380 ± 239 g/d (38 ±24 g/kg/d) at 24 months. The total human milk intake per day observed in this population was comparable to that reported from other developing and developed populations. Poor dietary diversity in infants beyond 6 months age was predominated by low consumption of animal-source food and also of vitamin-A rich fruits and vegetables.

High rates of continued breastfeeding beyond the age of 12 months in rural infants underpins the need to ensure adequate nutrition of lactating women. Ensuring optimal dietary diversity in infants through complementary feeding should also be a priority to prevent growth faltering.

Use of stable isotope technique helps not only to measure intake of human milk and non-milk oral water intake in breastfed infants, thereby providing quantitative information about the practice of exclusive breastfeeding, but also the follow up measurements give valuable information about milk intake volume in infants who continue to be breastfed beyond 6 months of age. Combination of data obtained from stable isotope techniques (viz. human milk intake and infant's body composition) and data from anthropometry and dietary intake provide important tools to measure determinants of growth in early life. This research was funded by the International Atomic Energy Agency, Vienna, Austria.

**Keywords:** Breastfeeding, complementary feeding, stable isotope, India.

## PS_144/13

### INFECTIONS IN PREGNANCY: A HUGE, AND AVOID-ABLE, CAUSE OF MALNUTRITION IN CHILDHOOD

### MAINSTREAMING THE CONTROL OF MATERNAL INFECTIONS INTO NUTRITION PROGRAMMES

Across the world, many women suffer from infections during pregnancy. Even when not specific to the reproductive organs, these infections can disrupt the normal course of pregnancy and/or reduce the flow of nutrients to the foetus, causing premature delivery, intrauterine growth restriction, or both. Both prematurity and intrauterine growth restriction manifest in small body size at birth, and very often these low birth weight babies fail to catch up their growth during infancy and childhood and remain visibly malnourished into adolescence and beyond. Given the high prevalence in some locations of infections such as malaria and peri-

<footnote>(1)Deshmukh, Urmila; (2)Thomas, Tinku; (3)Swaminathan, Sumathi;</footnote>

<footnote>(4)Kurpad, Anura Vishwanath.</footnote>

<footnote>(1)MD. Director. BioTRaK Research Foundation. Akola. Maharashtra. India.; (2)Associate Professor. Biostatistics. Division of Nutrition. St John's Research Institute. St. John's National Academy of Health Sciences. Bangalore. Karnataka. India.;</footnote>

<footnote>(3)Associate Professor. Division of Nutrition. St John's Research Institute. St. John's National Academy of Health Sciences. Bangalore. Karnataka. India.; (4)Professor and Head. Division of Nutrition. St John's Research Institute. St. John's National Academy of Health Sciences. Bangalore. Karnataka. India.</footnote>

<footnote>(1)Morris, Saul; (2)Askari, Sufia Askari; (3)Smith, Jeffrey.</footnote>

<footnote>(1)Director. Strong Start. Children's Investment Fund Foundation. United Kingdom.; (2)Manager. Strong Start. Children's Investment Fund Foundation.; (3)Vice President, Technical Leadership. Jhpiego. USA.</footnote>
odontal disease, and the high attributable risk of others such as
syphilis, it is quite plausible that maternal infections could con-
tribute as much as one third of the total burden of low birth weight
in Africa and Asia.

At present, the detection and treatment of infections during
pregnancy is not considered an integral part of nutrition pro-
gramming in low or middle income countries. Instead, nutrition
programmes delivered during pregnancy tend to focus on the
provision of micronutrients (particularly, iron and folic acid) and
dietary advice. Interventions which are not focused on increasing
intake of one or a combination of nutrients are seen as "somebody
else's business". A concerted effort needs to be made to re-concep-
tualise nutrition programmes, during pregnancy and beyond, as
a comprehensive set of interventions delivered to clients with the
aim of improving nutritional outcomes—such an approach would
immediately elevate the importance of tackling infections during
pregnancy.

We propose a \*R-A-D-I-C-A-L\* approach to mainstreaming
the control of infections in pregnancy within the context of nutri-
tion programmes. This would involve:

- \*R\*eviewing the local epidemiology of relevant infections to determine which are likely to be contributing to prematurity and small-for-gestational age in specific sub-groups of women;

- \*A\*ntenatal care promotion as a key component of nutrition programming;

- Point-of-care \*d\*iagnostics in antenatal care to screen for in-
fections such as malaria or asymptomatic bacteriuria;

- \*I\*mmunising pregnant women against preventable infec-
tions such as influenza;

- \*C\*ounselling to encourage appropriate management of
illness such as STIs;

- \*A\*ward recognition for health workers who increase the
prevalence of detection and treatment;

- \*L\*ine-listing and follow-up of all pregnant women to ensure
that tests and treatments are not missed and treatments are effective.

The recent publication of new WHO guidelines on "antenatal
care for a positive pregnancy experience" provide an ideal op-
portunity for strengthening the co-delivery of effective nutrient
and infection control interventions. In India, this has coincided
with the announcement of a new Prime Ministerial Initiative to
improve antenatal screening at each health facility once a month.
Building on these opportunities, the Children's Investment Fund
Foundation is supporting Jhpiego and the Government of Rajast-
han to pilot the R-A-D-I-C-A-L approach in four districts in the
state, with results expected early in 2019.

**Keywords:** Infections, pregnancy; low birthweight; nutrition programmes.

PRESUMPTIVE TREATMENT OF PREGNANT WOM-
EN WITH ANTIMALARIALS AND ANTIBIOTICS IN
MALAWI: IMPACT ON CHILD GROWTH, DEVELOP-
MENT AND MORTALITY UP TO FIVE YEARS

(1)Ashorn, Per; (2)Hallamaa, Lotta; (3)Cheung, Yin Bun; (4)Maleta, Kenneth; (5)Luntamo, Mari; (6)Ashorn, Ulla; (7)Gladstone, Melissa; (8)Kulmala, Teija; (9)Mangani, Charles.

(1)Professor of Paediatrics, University of Tampere, Finland;

(2)Data manager, Center for Child Health Research, University of Tampere, Faculty of Medicine and Life Sciences, Tampere, Finland; (3)Professor of Biostatistics, Center for Quantitative Medicine, Duke-NUS Medical School, Singapore; (4)Professor of Public Health and Nutrition, Department of Public Health, School of Public Health and Family Medicine, College of Medicine Malawi, Blantyre, Malawi; (5)PhD-student, Center for Child Health Research, University of Tampere, Faculty of Medicine and Life Sciences, Tampere, Finland; (6)Senior Scientist, Center for Child Health Research, University of Tampere, Faculty of Medicine and Life Sciences, Tampere, Finland;

(7)Neurodevelopmental Paediatrics Department of Women and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom; (8)Scientist, Center for Child Health Research, University of Tampere, Faculty of Medicine and Life Sciences, Tampere, Finland; (9)Senior Lecturer, Department of Public Health, School of Public Health and Family Medicine, College of Medicine Malawi, Blantyre, Malawi.

**Background:** Stunting affects a quarter of the world's children and is associated with increased mortality and developmental delay. We showed earlier that intermittent preventive treatment against malaria and other infections in pregnancy was associated with reduced prevalence of neonatal stunting in Malawi. In this follow-up, we assessed whether these gains were sustained and reflected in the epidemiology of childhood growth, development, and mortality.

**Methods:** We enrolled 1320 women with uncomplicated second-trimester pregnancies in a randomised, partially placebo-controlled, outcome assessor-blinded, three-arm clinical trial in rural Malawi and preventively treated them for malaria and other infections with either two doses of sulfadoxine-pyrimethamine (SP, control), monthly SP, or monthly SP and azithromycin twice (AZI-SP). Child height/length and mortality were recorded at one, six, 12, 24, 36, 48 and 60 months and child development at 60 months of age. Our primary hypothesis was that the difference in mean length at birth would be retained for five years and reflected in a permanently lower incidence and prevalence of stunting among babies born to women treated with AZI-SP. We also hypothesized that these children would have a higher mean developmental score at the age of five and a lower mortality by five years than children born to women in the control group.

Findings. Between December 1, 2003 and October 11, 2006 we
enrolled 1320 women to the study and randomised them to the
control (n=436), monthly SP (n=441) and AZI-SP group (n=443).
There were 3, 2 and 2 twin pregnancies in the control, month-
ly SP and AZI-SP groups, respectively, resulting in 1327 fetuses
for follow-up. Throughout the follow-up mean child length was
0.4–0.7 cm higher (p<0.05 at 1-12 months), prevalence of stunting 6-11% lower (p<0.05 at 12-36 months) and five-year cumulative incidence of stunting 13% lower (hazard ratio 0.70, 95% CI 0.60 to 0.83) in the AZI-SP than control group. Mean developmental score was 108.6, 110.2 and 112.4 (difference in means AZI-SP vs control 3.8, 95% CI 1.1 to 6.4; AZI-SP vs monthly SP 2.2, -0.4 to 4.8) in the control, monthly SP and AZI-SP group, respectively. There were no statistically significant differences between groups in the cumulative five-year mortality (hazard ratio AZI-SP vs control 0.84, 95% CI 0.59 to 1.20; AZI-SP vs monthly SP 0.85, 0.60 to 1.21). Total mortality during pregnancy (abortion/stillbirth) and childhood was 15.3%, 15.1%, and 13.1% (risk ratio AZI-SP vs control 0.86, 95% CI 0.62 to 1.19; AZI-SP vs monthly SP 0.87, 0.62 to 1.20) in the control, monthly SP and AZI-SP group, respectively. For postneonatal mortality (secondary outcome), the proportions were 5.5%, 3.3%, and 1.9%, respectively (risk ratio AZI-SP vs control 0.34, 0.15 to 0.76; AZI-SP vs monthly SP 0.56, 0.24 to 1.32).

Interpretation. Provision of AZI-SP rather than two doses of SP during pregnancy reduced the incidence of stunting in childhood in Malawi. AZI-SP during pregnancy also had a positive effect on child development and may have reduced postneonatal mortality.

**Keywords:** Maternal, infection, treatment, child, growth

**Conflict of Interest disclosure:** Conflict of Interest disclosure: Azithromycin and its placebo used in the study were provided free of charge by Pfizer Inc (New York), which had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

## MATERNAL HIV EXPOSURE AND POOR CHILD GROWTH

Filteau, Suzanne.

Professor, London School of Hygiene and Tropical Medicine.

Areas of high HIV prevalence, mainly in Sub-Saharan Africa, overlap with areas of food insecurity and high exposure to other infectious diseases. Simultaneous exposure to maternal HIV, deficient diet, and infectious diseases can have both additive and synergistic adverse effects on infant and child growth and nutrition.

With the roll-out of antiretroviral therapy (ART) in Africa, including Option B+ which permits safer breastfeeding by HIV-infected, ART-treated women, the proportion of HIV-exposed infants who themselves become HIV-infected has decreased dramatically. However, those who do become HIV-infected continue to suffer high levels of malnutrition. Growth deficits of HIV-exposed infants start in utero, as indicated by their lower birth weight than that of HIV-unexposed infants, so that even those who remain HIV-uninfected themselves are at risk of stunting. Once a child becomes HIV-infected, growth faltering can be progressive so that the earlier in life HIV infection occurs, the greater the growth failure. Fortunately, growth faltering can be mitigated by early infant HIV diagnosis and treatment with ART. In addition, it is now recognized that many children who became HIV-infected years ago, before ART was widely available, are surviving

into adolescence and adulthood with chronic malnutrition and frequent infections. Diagnosing these older children and getting them onto ART in order to improve their growth, nutrition and health is a priority.

Slow growth in itself is not a major concern unless it is associated with functional problems. In the case of maternal HIV exposure, there is evidence that the poor growth is associated with functionally important deficits to the immune system and in mental and motor development. Although as yet data are limited for African children, HIV-exposed children may be at high risk for chronic diseases in later life because of low birth weight, early growth faltering and, for the HIV-infected children, being treated with ART for most of their lives.

The causes of poor growth among HIV-exposed children are likely multiple and interacting. Socioeconomic consequences of parental HIV infection may contribute to malnutrition. Parental HIV infection, with consequent increased household exposure to opportunistic pathogens, increases rates of child infections which reduce growth. In the past, reduced duration of breastfeeding in order to reduce risk of child HIV infection could have reduced children growth through both poor nutrition and reduced immunological protection; however, with Option B+, breastfeeding rates by HIV-infected African women have improved. Placental abnormalities, including inflammation and infection, may contribute to the prenatal growth faltering and, through reduced placental transfer of immunoglobulins, increase risk of infant infection.

Maternal ART, in spite of its potential side effects on child growth, has both direct and indirect, through reduced maternal infection and improved ability to care for her family, benefits on health of HIV-exposed children so programs scaling up maternal ART should be supported. Since there is evidence that the growth faltering begins in utero, all forms of maternal care during pregnancy, including improved nutrition and treatment of infections, will likely benefit the infant's growth and nutrition.

**Keywords:** HIV, growth, infant, breastfeeding, maternal health
# THE IMPACT OF SCREENING AND TREATMENT OF MATERNAL GENITOURINARY TRACT INFECTIONS ON PRETERM BIRTH AND SMALL FOR GESTATIONAL AGE IN RURAL BANGLADESH

Approximately half of preterm births are attributed to infections in pregnancy, which are commonly undetected and untreated in low-resource settings. Maternal genitourinary tract infections may result in systemic infection and inflammation, increasing risk of preterm birth and, potentially, fetal growth restriction. Two infections that are potential targets for antenatal screening include abnormal vaginal flora (AVF) and urinary tract infection (UTI).

We aimed to determine the impact of early pregnancy screening and treatment of maternal genitourinary tract infections (AVF and UTI) on the incidence of preterm live birth and small-for-gestational-age (SGA) in Sylhet, Bangladesh.

We conducted a cluster-randomized, community-based trial in rural Sylhet district, Bangladesh. Twenty-four clusters (population/cluster: ~4000; births/year: ~120), each served by a community health worker (CHW), were randomized to either: 1) the intervention arm, which received routine home-based antenatal and postnatal care, plus screening and treatment of pregnant women between 13-19 weeks of gestation for genitourinary tract infections, or 2) the control arm, which received routine home-based antenatal and post-natal care only. In the intervention clusters, CHWs performed home-based screening for AVF and UTI. Self-collected vaginal smears were Gram stained and Nugent scored. Women with AVF (Nugent score ≥4) were treated with oral clindamycin, rescreened and retreated after 3 weeks as needed. Urine culture was performed and UTI treated with nitrofurantoin. Repeat urine culture was performed after 1 week for test of cure.

Between January 2012 and March 2016, 9712 pregnancies were enrolled (n=4840 intervention clusters, n=4391 control clusters). There were 3818 live births in the intervention arm and 3557 in the control arm. The prevalence of AVF infection was 16.3% (95%CI: 15.1-17.6%) and UTI was 8.6% (95%CI: 7.7-9.5%) in the intervention arm. Coverage of home-based treatment and rates of cure were 86.2% and 58.0%, respectively, for AVF, and 85.5% and 70.7% for UTI. There were no significant differences between intervention (I) and control (C) groups in: mean gestational age (I: 38.7 wks [SD 3.1], C: 38.9 wks [SD 3.1]); mean difference: -0.14 [95%CI: -0.37-0.07]), incidence of preterm birth (I: 21.8%, C: 20.6%, relative risk (RR): 1.07 [95%CI: 0.91-1.24]), incidence of low birthweight (I: 21.4%, C: 20.7%; RR: 1.03 [95% CI: 0.78-1.37]), or SGA (Intergrowth 21st) (I: 29.7%, C: 33.1%; RR: 0.90 [95%CI: 0.76-1.06]). Rates of stillbirth (I: 53.3/1000 births, C: 44.6/1000; RR: 1.19 [95%CI: 0.91-1.55]) and neonatal mortality (I: 31.4/1000 live births, C: 37.7/1000; RR: 0.82 [95%CI: 0.57-1.18]) did not significantly differ between groups.

A community-based screening and treatment program for AVF and UTI did not reduce the incidence of preterm birth or SGA in rural Sylhet, Bangladesh. Potential reasons for the lack of population-level impact include the relatively low prevalence of infection and rates of cure, as well as heterogeneity in the composition of AVF. Further research is needed to understand the microbiota of AVF in different populations and its role in preterm birth, as well as the identification of other targets for the primary prevention of preterm birth.

## Keywords

Abnormal vaginal flora, urinary tract infection, preterm birth, small for gestational age, low birthweight

PS_144/33

# ADOLESCENT NUTRITION GLOBALLY: A NEW FRONTIER FOR ACTION

## ADOLESCENT HEALTH AND NUTRITION ANALYSIS FROM OBSERVATIONAL STUDIES: KEY FINDINGS FROM A GLOBAL LEARNING INITIATIVE

McLean, Mireille.

The Sackler Institute for Nutrition Science. The New York Academy of Sciences.

Supporting the transition from childhood to adulthood is an important element of the Sustainable Development Goals. Researchers have started addressing the information gap about the adolescent's demographic group, examining issues of health and access to health services, food security, empowerment, nutritional status, enrollment in education, etc. The Sackler Institute has been contributing to this global effort by focusing on describing the multi-faceted nature of challenges faced by adolescents in low and middle income countries through a collaborative learning initiative.

Nine studies were funded in 2015 with the goal of mining existing datasets for information on adolescent's nutritional status from

<footnote>(1)Lee, Anne CC; (2)Mullany, Luke; (3)Quaiyum, Mohammad;</footnote>

<footnote>(2)Labrique, Alain Labrique; (4)Mitra, Dipak; (5)Christian, Parul;</footnote>

<footnote>(6)Ahmed, Parvez; (7)Uddin, Jamal; (8)Rafiqullah, Iftekhar; (9)DasGupta, Sushil; (10)Koumans, Emilia; (11)Rahman, Mahmoodur; (12)Saha, Samir; (13)Baqui, Abdullah H.</footnote>

<footnote>(1)MD. MPH. Assistant Professor. Harvard Medical School. Department of Pediatric Newborn Medicine. Brigham and Women's Hospital. Boston. USA.; (2)PhD. Johns Hopkins Bloomberg School of Public Health. Baltimore. Maryland. USA.;</footnote>

<footnote>(3)MBBS. Center for Reproductive Health. International Center for Diarrhoeal Disease Research- Bangladesh. Dhaka. Bangladesh;</footnote>

<footnote>(4)PhD. School of Public Health. Independent University. Dhaka. Bangladesh.; (5)PhD. Gates Foundation. Seattle, Washington. USA.; (6)MBBS. Center for Reproductive Health. International Center for Diarrhoeal Disease Research- Bangladesh. Dhaka.</footnote>

<footnote>Bangladesh.; (7)MBBS. Child Health Research Foundation. Dhaka Shishu Hospital. Dhaka. Bangladesh.; (8)MS. Child Health Research Foundation. Dhaka Shishu Hospital. Dhaka. Bangladesh.; (9)MS. Center for Reproductive Health. International Center for Diarrhoeal Disease Research- Bangladesh. Dhaka.</footnote>

<footnote>Bangladesh.; (10)MD. MPH. Center for Disease Control. Atlanta. Georgia. USA.; (11)MBBS. Projahnmo Research Group. Sylhet.</footnote>

<footnote>Bangladesh.; (12)PhD. Child Health Research Foundation. Dhaka Shishu Hospital. Dhaka. Bangladesh.; (13)DrPH. Johns Hopkins Bloomberg School of Public Health. Baltimore. Maryland. USA.</footnote>
Asia (China, Bangladesh, India, the Philippines), Africa (South Africa, Ethiopia, Gambia, Ghana) and Latin America (Peru), thus gathering and comparing data from cross-sectional surveys, longitudinal studies and intervention trials. Taken together, these studies painted a heterogeneous picture in terms of size and direction of effects of known predictors (e.g. living in rural areas, household income, schooling, and gender) on dietary adequacy and quality. Regarding nutritional status, rising rates of overweight and obesity at an increasingly younger age prompts the need to better capture food decisions and the influence of the food environment in low and middle income countries. When discussing implications for future interventions, this group of studies illuminated an unanticipated research gap: there is a dearth of knowledge relating to the type of activities and occupations adolescent girls and young women engage in, including formal and informal, full time or part time, employment. Describing occupation types and how it links to nutrition and health will highlight a potentially important pathway towards empowerment, and help inform intervention strategies aimed directly at this group. An additional round of studies, funded in 2017, will be addressing this specific question.

**Keywords:** Adolescent, Nutrition, Occupation, Collaboration

## GLOBAL BURDEN AND EPIDEMIOLOGY OF ADOLESCENT NUTRITION: ISSUES AND RISK FACTORS

Christian, Parul.

DrPH. Nutrition Team. Bill & Melinda Gates Foundation. USA.

Globally there are 1.2 billion adolescents, equivalent to almost 20% of the total world population, 90% of whom live in low and middle income countries (LMIC). In the coming decade, regions with high fertility rates such as sub-Saharan Africa will see rapid growth in their adolescent populations, as compared to regions where fertility is declining, such as in Asia and Latin America. Adolescence is a period of rapid growth and development when the influence of adequate nutrition may be high. Peak linear growth velocity occurs in adolescence, wherein 15-25% of adult height and 50% of adult weight is attained. As such, adolescence and the growth spurt that occurs in this period is often thought of as a period of potential catch up of growth deficits that occurred in early childhood. Nutritional status also influences onset of menarche and subsequent linear growth, both of which have a wealth differential.

In many settings, adolescents especially girls fail to reach their full growth and development potential. Although global data are lacking on the burden of poor growth and nutritional deficiencies, stunting, low BMI and anemia (largely related to iron deficiency) have been identified as public health concerns. Another rising concern in LMIC is the trend of high BMI, although the cluster of countries where low and high BMI exist tends to be different. Iron deficiency has been identified as one of the top 15 leading global risk factors for death and DALYs in ages 10-19 y among box sexes in 2013. Additionally, vitamin A deficiency was included in the 15 top ranking factors for DALYs in ages 10-14. Micronutrient

deficiencies beyond these are not well recorded and dietary intake data are urgently needed to determine inadequacies, given high nutritional requirements for energy, protein, calcium, iron, and other nutrients during this time.

Social factors such as gender norms discriminating against girls, early marriage, school drop out, and sexual abuse are important drivers of poor adolescent health and nutritional well-being, especially among girls. Eating patterns, food habits and preferences, peer and parental influences, and body image all influence the diets of adolescents in addition to socioeconomic and cultural factors influencing food intake. In some settings, adolescents may be vulnerable to food insecurity. In contrast, snacking, lower physical activity, and alcohol and tobacco use frequently begin during this period of life, especially in urban locales, and likely impact nutritional status during this age.

Adolescent pregnancy, especially in girls 15-19 y of age, not only increases morbidity and mortality risk but compounds the nutritional problems. Young mothers are at an increased risk of adverse birth outcomes, including preterm birth and fetal growth restriction. Preconception undernutrition and increased nutrient requirements of pregnancy takes a toll on both the young woman and her infant. Premature pregnancy can result in halting linear growth among adolescents with consequences for short stature in adulthood.

The period of adolescence is overwhelmingly data-poor related to nutritional status, calling for the need for systematic assessment of nutritional indicators, diet, and factors influencing these, globally.

**Keywords:** Adolescence, nutrition, stunting, anemia, diet

## EFFECTIVENESS OF NUTRITION INTERVENTIONS AMONG ADOLESCENT GIRLS; HOW DOES THE EVIDENCE STACK UP?

(1)Bhutta, Zulfiqar; (2)Lassi, Zohra; (3)Keats, Emily.

(1)Robert Harding Chair in Global Child Health & Policy, Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M6S 1S6, Canada; (2)University of Adelaide, Australia; (3)Centre for Global Child Health, Toronto, Canada.

Adolescence is a critical stage in the lifecycle and adequate nutrition is necessary for the proper growth and development of individuals, and of their offspring. In this paper we have comprehensively reviewed all published systematic reviews (till October 2016) on adolescents (10-19 years) and women of reproductive age including pregnant women that targeted interventions related to nutrition. For interventions where there was no existing systematic review on adolescents, we reviewed primary studies/trials. We included interventions on micronutrient supplementation, food energy/protein supplementation, nutrition education for pregnant adolescent, obesity prevention and management and management of gestational diabetes.

We identified a total of 35 systematic reviews of which only five were conducted on adolescents; and 107 primary studies on adolescents. Our review suggests that iron alone, iron-folic acid,
zinc and multiple micronutrient supplementation can significantly improve serum hemoglobin concentration. While there was a lot of variability in study design to detect dose-response results, the overall evidence suggests that daily IFA supplementation reduced the prevalence of anemia (RR 0.52; 95% CI 0.28, 0.96; 3 studies, n=1979) and improved the serum hemoglobin concentrations (MD 10.07; 95% CI 4.05, 16.10; 5 studies, n=822) among adolescent girls; and that weekly iron/folic acid supplementation also led to reduction in anemia (RR 0.73; 95% CI 0.58, 0.92; 9 studies) and improved the serum hemoglobin concentration (MD 2.24; 95% CI 0.36, 4.12; 6 studies, n=2839). While, zinc supplementation among pregnant adolescent showed improvement in preterm birth and low birth weight, we found paucity of trials on food protein/energy supplementation and other micronutrients. We shall also share findings from the individual subject data analysis from a recent collaborative exercise on the impact of multiple micronutrient supplements on adolescents during pregnancy compared to other age groups. Interventions to prevent and manage obesity showed a non-significant impact on reducing body mass index.

This review underscores the importance of adolescent nutrition interventions and paucity of policy relevant information therein. It is imperative that countries should design nutritional interventions particularly for adolescents.

**Keywords:** Adolescence, Nutrition, Micronutrients

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## HOW CAN COMMUNICATIONS FOR MATERNAL INFANT AND YOUNG CHILD NUTRITION BE IMPROVED? LESSONS FROM SOUTH ASIA

### CHALLENGES IN DEVELOPMENT AND IMPLEMENTATION OF M-SAKHI – (MOBILE-SOLUTIONS AIDING KNOWLEDGE FOR HEALTH IMPROVEMENT) TO IMPROVE MATERNAL AND CHILD HEALTH AND NUTRITION IN RURAL MAHARASHTRA, INDIA

(1)Patel, Archana; (2)Kuhite, Priyanka; (3)Puranik, Amrita; (4)Khan, Samreen Sadaf; (5)Dibley, Michael.

(1)MD. DNB.Masters in clinical epidemiology.PhD.Community Medicine and Clinical Epidemiology.Chief Functionary Officer and Program Director.Lata Medical Research Foundation. Nagpur.India; (2)BHMS. Assistant Study coordinator. Lata Medical Research Foundation.Nagpur.India.; (3)MSc. Project Manager. Lata Medical Research Foundation.Nagpur.India.; (4)BAMS. Project Manager. Lata Medical Research Foundation.Nagpur.India.; (5)BSc(Med).MBBS. MPH. Professor. Global Public Health Nutrition. School of Public Health. University of Sydney. Australia.

Innovative mHealth solutions have the potential to enhance the monitoring and delivery of nutrition, healthcare and other supportive services to pregnant and lactating women and their

infants even in remote rural areas of India. We recently deployed M-SAKHI (Mobile-Solutions Aiding Knowledge for Health Improvement) a mobile based IT solution in 241 villages of central India that has enrolled 1540 pregnant women, for improving nutrition and health outcomes in the first 1000 days of life. This multi-component package aims to promote data collection by community health workers (CHW), aid in counseling of beneficiaries, provides timed targeted text and voice messages, and, real time monitoring of beneficiaries on the server. Numerous challenges are encountered when new technology is deployed. Identification, addressing and sharing of experienced challenges serves to enable sustainability and inform other M-health interventions.

To describe the challenges identified in development and deployment of M-SAKHI

This qualitative study collected data on challenges during technical development, and deployment in the field in the following ways i) weekly meetings with developers and the implementers, ii) daily reporting using Whatsapp groups, iii) daily reporting of challenges put into a "challenge reporting box". The recorded challenges were then sorted and categorized under various themes.

Challenges identified were in the following area - i) Obtaining government approvals for the use of M-Health technology by the existing government health providers, ii) obtaining funding, iii) sourcing technological partners, public health, nutrition and clinical expertise to develop technology that responds to the nutrition and health needs of rural pregnant women, iv) recruiting experienced staff for implementation, v) developing culture and language specific counseling messages and videos embedded in the App, vi) formulating nutritionally appropriate, culturally acceptable text and voice messages of suitable length, vii) synchronization of triggers for delivery of server based alert messages, viii) data entry and synchronization of data across different delivery platforms of multiple health providers, ix) training and retention of CHW, x) beneficiary outreach - poor cell phone network, unavailability of personal phones, missed calls, switched off phones, frequent change of contact numbers, wrong mobile numbers, "do not disturb" category of clients, xi) other nutrition related issues- unaffordability, lack of availability of foods, and cultural barriers that deter behavior change.

M-Health solutions requires initial technological investments and support, frequent training of project staff and proficient monitoring for its sustenance. Despite the multiple challenges, it has the potential to enhance coverage of appropriate nutrition and health practices in hard to reach rural areas.

**Keywords:** Mobile Technology, mHealth, innovation, challenges, nutrition
# USE OF MOBILE PHONES FOR INFANT AND YOUNG CHILD FEEDING COUNSELLING IN SRI LANKAN TEA ESTATES: A FEASIBLE OPTION FOR HEALTH SYSTEM STRENGTHENING

(1)Senarath, Upul; (2)Godakandage, Sanjeeva; (2)Jayawickrama, Hiranya; (3)Weerasinghe, Manuj; (4)Wickramasinghe, Aravinda;

(5)Siriwardena, Indika; (6)Partheepan, Kunarathinam; (7)Gamagedera, Nimal; (8)Alam, Ashraful; (9)Dibley, Michael.

(1)MBBS. MSc. MD. Professor in Community Medicine. Faculty of Medicine, University of Colombo, Sri Lanka; (2)Consultant Community Physician. Family Health Bureau. Ministry of Health, Nutrition and Indigenous Medicine. Sri Lanka.; (3)Senior Lecturer in Community Medicine. Faculty of Medicine. University of Colombo. Sri Lanka.; (4)Registrar in Community Medicine. Management, Development & Planning Unit. Ministry of Health, Nutrition & Indigenous Medicine. Sri Lanka.; (5)National Science and Technology Commission. Sri Lanka.; (6)South Asia Infant Feeding Research Network. Sri Lanka.; (7)Consultant Community Physician. Office of the Provincial Director of Health Services. Uva Province. Sri Lanka.; (8)Postdoctoral Fellow. Sydney School of Public Health. Sydney Medical School. The University of Sydney.; (9)Professor in Global Public Health Nutrition. Sydney School of Public Health. Sydney Medical School. The University of Sydney.

In Sri Lanka, 0.9 million people (4.3% of population) live in plantations, predominantly in tea and rubber estates. Nutritional status of children in these estates is poor, and innovative strategies are needed to improve this situation. With the advancement of technology, mobile health communications (m-health) have been used effectively in many countries to strengthen primary health care. However, it is rare to find use of m-health for infant and young child feeding (IYCF) counselling in South Asia. The SAIFRN Sri Lankan group used a stepwise and scientific approach towards using m-health for IYCF counselling in the tea estates. This presentation aims to discuss development and feasibility of the m-health intervention.

Our approach consisted of:

Phase I: Formative study to explore perceptions of stakeholders

Phase II: Development of mobile phone intervention package

Phase III: Pilot testing of the intervention

Phase I: A formative study was conducted among pregnant mothers, mothers of children, family members, and health staff in two tea estates, using Focus Group Discussions and In-depth Interviews. We found that mobile phone usage was common in this community and m-health platform could be a promising initiative to strengthen the existing face-to-face nutritional advice provided by the health staff to improve the nutritional status.

Phase II: Age appropriate text and voice messages were developed for pregnant women and mothers of children. Overall there were 108 messages, which were incorporated to a mobile platform.

Phase III: In this pilot study, 108 participants (pregnant mothers over 28 weeks of gestation and mothers of infants up to 2 years of age) were enrolled from one tea estate, and provided with mobile phones. Age appropriate voice and text messages were sent according an automated schedule. Each participant received 2 voice and 2 text messages per week for 12 months period. Pre- and

post-intervention assessments were performed using qualitative research.

Estate health team and study participants expressed positive attitudes toward IYCF counselling through mobile phone, message delivery times, and content of messages. Use of mobile health technologies reduced the workload of the estate health care team. Husbands helped their wives to answer the calls, reading the text when his wife was involved in the household work; and provided cash for maintenance phone account. Few young participants shared the messages with their family members, friends and neighbours. Most of participants confirmed that the intervention improved their knowledge and behaviours on IYCF.

Perceived barriers included weak signal strength and network coverage, lack of recharge facilities, and poor literacy.

We found that IYCF counselling through mobile phones is a culturally acceptable and efficient communication method. Mobile health is a possible technology to deliver IYCF counselling, with relatively lower costs in these settings by improving access, quality, and timeliness. Use of mobile phone technology could strengthen the existing services to improve the nutritional status of children.

The study resulted in a m-health package. We recommend that a large-scale trial be conducted to evaluate the effects of this m-health package in improving nutrition status of infant and young children.

**Keywords:** Mobile health. m-health. infant and young child feeding. undernutrition. South Asia.

**Further collaborators:**

Renuka Jayatissa. UNICEF. Sri Lanka.

Gamini Jayakody. UNICEF. Sri Lanka.

Basuru Kumarasena. Dialog Axiata PLC. Colombo. Sri Lanka.

Madushanka Wanigasuriya. Dialog Axiata PLC. Colombo. Sri Lanka.

Archchuna Ramanathan. SAIFRN. Sri Lanka. Claudio Umesh, SAIFRN. Sri Lanka.

Prasantha Arumapperuma. Ministry of Health Nutrition and Indigenous Medicine. Sri Lanka.

# LEARNING FROM IMPLEMENTATION: EXPERIENCE OF REACHING URBAN WORKING MOTHERS IN BANGLADESH

(1)Rasheed, Sabrina; (2)Khan, Nazib Uz Zaman; (2)Sharmin, Tamanna;

(3)Nahar, Syeda Kamrun.

(1)PhD, Associate Scientist, Health systems and population studies division, icddr,b; (2)Assistant Scientist. icddr,b. Bangladesh; (3)Breastfeeding counselor. Dhaka. Bangladesh.

Exclusive breastfeeding for 6 months followed by continued breastfeeding along with adequate complementary feeding for 2 years is recommended as the feeding pattern providing the best child survival and nutritional status. Community-based interventions peer counseling have shown to improve breast feeding practices in many countries. However, successful models of improving breastfeeding patterns of low income working mothers are not