fat among the Thai population; and developing self-monitoring
systems in all educational institutions and other public settings
to produce primary health information, such as weight, waist cir-
cumference and blood pressure, of their related people and make
follow-up actions on update of such information.

The study provided priority recommendations stemming from
consensus between state and non-state actors. The process and set
of agreed priorities will serve as a platform for helping to drive
Thailand's future policy actions, facilitate greater collaboration be-
tween different stakeholders operating within and across sectors,
and establish a baseline and targets to measure progress in the fu-
ture. This forms a core part of a broader strategy for accelerating
the government and stakeholders to be more responsive and ac-
countable to their citizens.

**Keywords:** Healthy food environments, priority actions, obesity, non-communicable diseases, state and non-state actors

proposed FEP actions were prioritized with 5 identified domains. The prioritized policies were to restrict unhealthy food promotion to children, establish food composition targets in selected foods, support mandatory nutrition labelling for sodium and total sugar for package foods and display calorie labelling in fast food outlets with >20 outlets, optimize existing anthropometric monitoring system for providing feedback, and provide population nutrition budget commensurate with population health burden, and fund research related to reduction in obesity and diet-related NCDs.

**Conclusions:** This is the first benchmarking process per-
formed on FEP implemented in Malaysia. Findings will stimulate
strategies to fill gaps in implementation of FEP, thus strengthening
advocacy to effectively address the burden of NCDs and obesity.

**Keywords:** Food environment, policy, nutrition, non-commu-
nicable diseases, obesity

## MAPPING THE EXTENT OF IMPLEMENTATION OF FOOD ENVIRONMENT POLICIES FROM THE PERSPECTIVE OF A LOW-MIDDLE-INCOME COUNTRY-MALAYSIA

(1)Ng, See Hoe; (2)Kelly, Bridget; (2)Yeatman, Heather; (3)Swinburn, Boyd; (4)Vandevijvere, Stefanie; (5)Noor, Mohd Ismail; (6)Karupaiah, Tilakavati.

(1)MSc. University of Wollongong, Australia; (2)PhD. University of Wollongong, Australia; (3)MD. University of Auckland. New Zealan.; (4)PhD. University of Auckland, New Zealand; (5)PhD. Taylor's University, Malaysia; (6)PhD. The National University of Malaysia, Malaysia

**Background and objective:** Unhealthy diets are associated with non-communicable diseases (NCDs) and obesity. Efforts to reduce exposure to NCD risk factors through appropriate policy development towards modulating the food environment is now been mooted. This study sets out to benchmark food environment policy (FEP) implementation for the first time in Malaysia.

**Methods:** The Food-Environment Policy Index tool was adapted to assess data on FEP implementation in Malaysia relating to policies and infrastructure support covering 13 domains with 47 indicators. Evidence evaluation was performed by a panel of 26 independent Experts with ratings performed for policies as per indicator according to international best practice. Policies were shortlisted by Experts for possible improvement of implementation. This process was cross-validated with government stakeholders. A prioritization process was then completed by the Experts to rank policy actions as per ‘importance’ and ‘achievement’ criteria.

**Results:** Experts rated 61.7% indicators as “low” implementation and 38.3% as “medium” implementation (interrater reliability = 0.65, 95%CI 0.56-0.74). Establishment of food-based dietary guidelines (70.4%), population intake targets (64.6%), monitoring nutrition status and intakes (65.8%), monitoring NCDs risk factors and prevalence (65.0%) and ingredient lists and nutrient declaration (61.2%) were the highest scored indicators. In total, 32

## THE FOOD ENVIRONMENT POLICY INDEX (FOOD-EPI), IN SOME LATIN AMERICAN COUNTRIES: RESULTS AND PROCESS EVALUATION

(1)Barquera, Simon; (2)Sánchez-Bazán, Karina; (3)Nieto, Claudia;

(3)Tolentino Mayo, María Lizbeth; (4)Kroker, María Fernanda;

(5)Corvalan, Camila; (6)Vandevijvere, Stefanie.

(1)MD, MS, PhD. Director. Nutrition and Health Research Center. National Institute of Public Health. Mexico.; (2)MA. Researcher. Nutrition and Health Research Center. National Institute of Public Health. Mexico.; (3)MS. Researcher. Nutrition and Health Research Center. National Institute of Public Health. Mexico.; (4)PhD. Senior Researcher. Instituto de Nutrición de Centroamérica y Panamá. Guatemala.; (5)PhD. Senior researcher. Instituto de Nutrición y Tecnología de los Alimentos. Universidad de Chile.; (6)PhD. Senior Research Fellow. School of Population Health. University of Auckland. New Zealand.

Unhealthy food environments are a major driver of obesity and Non-Communicable Diseases (NCDs). Government actions are essential to prevent these conditions. The international network INFORMAS has developed a monitoring framework, called the Healthy Food Environment Policy Index (Food-EPI), to assess the extent of implementation of government policies and actions for creating healthy food environments, compared to international best practices. This is composed by a set of 42 indicators, divided in two components: 1) policy and 2) infrastructure support. Teams in Mexico (INSP), Guatemala (INCAP) and Chile (INTA) worked together to implement the Food-EPI in Latin America (LATAM) throughout 2016, with support of IDRC (International Development Research Centre). First, we translated and adapted the Food-EPI to the LATAM context. The tool in Spanish was tested in each country. The 42 international indicators, with additional LATAM-specific ones, were included; and evidence of implementation was gathered and validated with government officials for all of them in each country. Some of the LATAM-specific indicators explore: a) access to free drinking water both in public spaces and inside elementary schools; b) policy harmonization, c) regula-
tions on sale and promotion of unhealthy foods inside and around schools; d) governance bodies that look after for policy design, implementation and evaluation; and e) measures to prevent conflict of interest in policymaking.

To assess the indicators, we developed an on-line tool to apply an electronic questionnaire to public health experts using Red-Cap and internal web platforms. Public health experts from academia and civil society were mapped and invited to participate in the electronic assessment. Each country held workshops with the evaluators to discuss the questionnaire results and to prioritize specific actions that could address the identified policy gaps. In the case of Mexico –given the sensitive political context surrounding NCDs prevention and control policies– government officials, legislators and food industry representatives were also assessed; and an additional consensus meeting was held between academia, civil society and government relevant actors.

The most important result of this exercise is that none of the indicators received a global general aggregated score of 'highly implemented'. For the case of Mexico and Guatemala, none of the indicators was rated with a high level of implementation. Some of the challenges of the Food-EPI in LATAM were: 1) to maintain a common set of indicators to allow international comparisons in relevant policy areas, while including new relevant indicators; 2) to find a large group of experts that that could participate, for example, Guatemala still faces under-nutrition and most of the experts alleged having expertise only in this area; 3) to have all the country territories represented in the assessment. The Food-EPI process is useful to identify policy agreements and oppositions. The entire exercise could become a platform for continued policy dialogue towards effective actions to address the burden of NCDs and obesity in LATAM and other developing countries.

**Keywords:** Food environments, INFORMAS, obesity prevention, health policies, global health

**Further collaborators:**

Boyd Swinburn, MD, University of Auckland and the INFORMAS (International Network for Food and Obesity/non communicable diseases Research, Monitoring and Action Support) group (obesity reviewa (2013) 14 (suppl. 1), 1-12

## OPPORTUNITIES AND CHALLENGES OF BENCHMARKING GOVERNMENT FOOD ENVIRONMENT POLICIES GLOBALLY

(1) Vandevijvere, Stefanie; (2) Swinburn, Boyd.

(1)Phd. Senior Research Fellow. School of Population Health. The University of Auckland. New Zealand.; (2)Professor. School of Population Health. The University of Auckland. New Zealand.

The International Network for Food and Obesity/Non-Communicable Diseases (NCDs), Research, Monitoring and Action Support (INFORMAS) developed the Healthy Food Environment Policy Index (Food-EPI) to measure progress by governments on implementing priority policies to improve the healthiness of food environments compared to international best practice. The Food-EPI is being applied in more than 10 countries globally. National

Expert Panels of public health experts, and representatives from medical associations and NGOs rate the extent of implementation of policies on food environments by their governments against international best practice. Their ratings are informed by documented evidence, validated by government officials and international best practice exemplars (benchmarks). In addition, experts propose concrete actions for implementation by their government and prioritize those according to importance and achievability. The aim of this study is to compare the extent of policy implementation on food environments by governments in different regions globally, to evaluate the Food-EPI tool and process and make recommendations for its future use and implementation.

The good practice indicators (19 for the “policy” Food-EPI component and 23 for the “infrastructure support” Food-EPI component) were grouped into “very little, if any”, “low”, “medium” and “high” implementation and proportions of indicators across those 4 categories were compared among countries. In addition, the Food-EPI score was calculated using weightings for impact of each of the good practice indicators on improving population nutrition as derived from a Delphi process with international food policy experts. Semi-structured interviews were organized with the different country teams applying the Food-EPI to gather insights into the major strengths and limitations of the tool and process.

The Food-EPI dashboard of indicators shows major implementation gaps in different countries globally. Key strengths of the Food-EPI include the comprehensiveness and structure of the tool, the use of evidence in the rating process, the priority setting process, the degree of engagement from experts and policymakers, and the two-way learning process. Some countries involved policymakers very extensively, e.g. policymakers compiled the evidence rather than only verifying it (Australia), or they participated in rather than observing the rating process (Thailand and Mexico). The limitations of the Food-EPI mainly relate to the benchmarks: for some indicators it is hard to find what the benchmarks are (e.g. funding, governance), some benchmarks are low since no countries are doing really well, and for some countries the benchmarks are truly aspirational while in other countries experts argue they are too far away from the ideal. Rating against the benchmarks however is more acceptable for policymakers, and it is anticipated the benchmarks will improve over time, if more countries implement the Food-EPI. The efficiency of the process could be improved as well as the time burden is considerable for people involved.

The Food-EPI allows comparing progress on policy implementation to create healthy food environments among countries and has the potential to increase accountability of governments for implementation of recommended policies. It is anticipated the Food-EPI can be used by many more countries if some of its limitations are addressed.

**Keywords:** Food environments, policy implementation, accountability, political priority
EMPOWERING WOMEN & WOMEN-HEADED HOUSEHOLDS THROUGH PRODUCTION, NUTRITION EDUCATION AND CONSUMPTION STRATEGIES: LESSONS LEARNED FROM PULSE-BASED NUTRITION SENSITIVE AGRICULTURAL STRATEGIES IN ETHIOPIA

(1)Henry, Carol; (2)Fereja, Mengistu; (3)Mesfin, Addisalem; (4)Whiting, Susan J.; (5)Regassu, Nigatu.

(1)PhD. Associate Professor. College of Pharmacy and Nutrition. University of Saskatchewan. Canada.; (2)MSc. Research Associate. College of Agriculture. Hawassa University. Ethiopia.; (3)MSc. Lecturer. College of Agriculture. Hawassa University. Ethiopia.;

(4)PhD. Professor. College of Pharmacy and Nutrition. University of Saskatchewan. Canada.; (5)PhD. Visiting Scholar. College of Pharmacy and Nutrition. University of Saskatchewan. Canada.

Undernutrition remains one of the greatest human and economic development challenges, especially in developing countries. One in four children under five years of age suffers from stunting, or chronic undernutrition, which is caused by poor quality and quantity diets, inappropriate care and feeding practices in early life, and high rates of infectious disease. Poor nutrition can result in an inter-generational cycle of undernutrition, since undernourished women are more likely to give birth to children that begin life nutritionally disadvantaged by the age of five years and therefore are more likely to grow into disadvantaged adults. Recent national statistics in Ethiopia indicate a high prevalence of maternal malnutrition (30%) and food insecurity (>50%) especially among women-headed households, and very low women's autonomy and empowerment index scores. Improving nutrition requires a multi-sectoral, multi-disciplinary approach that brings together stakeholders in health, agriculture, nutrition, women's affairs, and education, among others. This talk will examine the impact of an innovative pulse-based nutrition-sensitive agricultural strategy implemented in Southern Ethiopia on empowering thousands of women and women-headed households in decision making through participation in production, nutrition education, and skills training for improved household food consumption and livelihood. It draws on data from several field research projects conducted in six districts of Southern Ethiopia over the last five years (2011-2016). Our studies on pulse-based nutrition education resulted in significant improvements in knowledge and practice scores regarding complementary feeding (p < 0.001), pulse based recipe preparation, and in improvement of the dietary diversity (p = 0.02) and nutritional status of children (p < 0.05). Women's participation in pulse production created an enabling environment for improved decision making and autonomy (p < 0.001). There was opportunity for food preparation skills training, such as household processing of pulses and trying new recipes. Taken together, pulse-based nutrition sensitive agriculture strategies have

effectively responded to growing concerns of hidden hunger and malnutrition by empowering women and women-headed households.

The project is funded by the Canadian International Food Security Research Fund, through the International Development Research Center and Global Affairs Canada.

THE ROLE OF SMALL SCALE AQUACULTURE AND ENHANCED HOMESTEAD FOOD PRODUCTION IN IMPROVING HOUSEHOLD FOOD SECURITY AND NUTRITION

(1)Talukder, Aminuzzaman; (2)Mundy, Gary; (3)Hou, Kroeun; (4)Stormer, Ame; (5)Michaux, Kristina; (6)McLean, Judy; (7)Whitfield, Kyly C; (8)Lynd, Larry; (9)Green, Timothy J.; (10)Wesley, Annie.

(1)MPH. Technical Advisor. Nutrition-Sensitive Agriculture. Helen Keller International. Canada.; (2)BA Hons. MA. Regional M & E Advisor. Asia-Pacific Regional Office. Helen Keller International. Cambodia.; (3)MPH. Cambodia Deputy Country Director. Helen Keller International. Cambodia.; (4)PhD. Regional Director of Programs. Helen Keller International. Cambodia.; (5)MSc. Project Manager Fish on Farms. Faculty of Land and Food Systems. University of British Columbia. Canada.; (6)PhD. Senior Instructor. Faculty of Land and Food Systems. University of British Columbia. Canada.; (7)PhD. Assistant Professor. Department of Applied Human Nutrition. Mount Saint Vincent University. Canada.; (8)PhD. Professor. Faculty of Pharmaceutical Sciences. University of British Columbia. Canada.; (9)PhD. Principal Nutritionist. South Australian Health and Medical Research Institute. Adelaide. Australia.; (10)PhD. Senior Program Specialist. International Development Research Centre. Canada.

**Background and Objectives:** There is scant evidence of the impact of small-scale aquaculture and homestead food production programs in Cambodia. This study evaluated the effect of aquaculture and enhanced homestead food production (EHFP) on maternal and child anemia, child anthropometry, household food security, production, and income in four districts of Prey Veng Province.

**Methods:** In this 22-month cluster-randomized controlled trial, 900 households were randomized to 1) plant-based EHFP; 2) plant-based EHFP and fishponds (EHFP+F); or 3) control. Household food security (HFIAS), dietary diversity, weight, length/height, hemoglobin, and self-reported estimates of production and income were measured at baseline and at 22 mo. A venous blood sample was collected in a subset (n=450) of women at baseline and endline. Differences in study outcomes between study groups were measured at endline, controlling for baseline values.

**Results:** We found that EHFP+F households were more likely (OR: 1.73; 95% CI: 1.09, 2.75) to be food-secure compared with control households (p=0.02). We saw significant endline differences in production among EHFP and EHFP+F groups, compared with the control group: EHFP group (mean ratio: 3.04; p<0.001); EHFP-F group (mean ratio: 4.01; p<0.001). There were significant endline differences in income from sales of HFP produce: EHFP
group (mean ratio: 1.77; p<0.05); EHFP+F group (mean ratio: 1.58;p<0.001). Across all groups, income was used to buy micro-nutrient-rich foods such as beef, pork, chicken and fish.

Women in both intervention groups were more likely to have consumed >6 foods groups in the previous 24h, compared to women in the control group (OR: 1.63; 1.01, 2.12; p<0.01; 1.46; 1.01, 212; p=0.01, among EHFP and EHFP-F, respectively). After adjusting for hemoglobinopathies, we found no improvements in anemia prevalence among non-pregnant women and children, or maternal and child anthropometry measures.

**Conclusions:** EHFP both with and without fishponds improved household production, income, food security and women's dietary diversity, but there was no additional benefit to food security or dietary diversity from the addition of aquaculture to the EHFP intervention. There were no significant improvements observed in hemoglobin, nutrition biomarker concentrations, or anthropometric indices for mothers or children after 22 months.

DIETARY DIVERSITY AND SCALING UP THE PRODUCTION OF IRON AND ZINC-RICH YELLOW POTATOES IN COLOMBIA

(1)del Castillo, Sara Eloisa; (2)Melgar-Quiñonez, Hugo.

(1)PhD. Associate Professor. School of Nutrition. Universidad Nacional de Colombia. Colombia; (2)MD. PhD. Associate Professor. School of Dietetics and Human Nutrition. McGill University. Canada.

Food insecurity among rural Colombian households is high, reaching 90% in some regions. Almost all farmers from the Colombian-Andean region rely on potatoes as their staple food as well as their main income source. In this presentation, we will discuss an ongoing project in Nariño, a region dependent on potato farming that has high rates of food insecurity, malnutrition, and nutritional deficiencies, particularly iron and zinc. Our aim is to increase the availability of more nutritious potatoes for Colombian consumers through a strategy that integrates agriculture and nutrition. We will introduce three varieties of yellow potatoes with better agronomic properties and higher zinc and iron content compared to potatoes currently being grown.

Potatoes are a staple food for Colombians, therefore the introduction of novel high-mineral potatoes may be part of a sustainable option to combat micronutrient deficiencies when it is part of a diverse and varied diet, such as alongside increased consumption of locally produced fruits and vegetables from home gardens. Although the iron and zinc in the novel potato varieties are not as bioavailable as animal-source foods, Colombian consumers do not always have the economic resources to purchase these foods. If we are successful this may help to meet the nutritional needs of vulnerable communities in the region.

To date, we have conducted a baseline survey and one follow-up survey measuring: the production and consumption of the varieties of yellow potatoes among the families of the project; dietary diversity (dietary diversity score through 24 hour recalls. In

children under 5, we will conduct anthropometric measurements height and biochemical assessment including iron status (hemoglobin, ferritin, transferrin), zinc and vitamin A.

COST-EFFECTIVENESS OF USING SUNFLOWER OIL FORTIFIED WITH VITAMIN A: RESULTS FROM TANZANIA

(1)Horton, Susan; (2)Mosha, Theobald; (3)Saleh, Nadira; (4)Belt, John;

(5)Ndau, Edna; (6)Walters, Dylan.

(1)Ph.D. Professor. School of Public Health and Health Systems. University of Waterloo. Canada.; (2)PhD. Professor. Faculty of Agriculture. Sokoine University of Agriculture. Tanzania.; (3)MSc. Project Manager. Mennonite Economic Development Associates Canada. Waterloo. Canada; (4)MSc. Senior Advisor. Sustainable Economic Development. Royal Tropical Institute (KIT). Netherlands.; (5)MSc. Doctoral Student. Faculty of Agriculture. Sokoine University of Agriculture. Tanzania.; (6)MSc. Doctoral Student. Institute for Health Policy, Management and Evaluation. University of Toronto. Canada.

This study aims to estimate the cost-effectiveness of fortified unrefined sunflower oil produced by small and medium enterprises (SMEs). Tanzania has high levels of vitamin A deficiency which has negative consequences for morbidity and mortality especially in children under five. Although there is mandatory fortification of edible oils, until recently this has applied only to large-scale producers. However some regions prefer locally-grown and locally milled sunflower oil, and fortified oil currently does not reach many poor and remote households.

We utilize data from a three-year project piloting production of fortified oil by three SMEs in two regions of Tanzania. The data include information from the producers on costs and technology, and information from retailer surveys and from eVouchers regarding sales. Baseline and endline household surveys were conducted for intervention and control areas, which collected socio-demographic and health information from lactating women and their children under five, household oil samples which were tested for retinol content, and finger-prick blood samples from mothers and children for retinol binding protein.

**Findings are as follows:**

• "Gold standard" technology was used for the pilot, but a lower cost technology would need to be used for scale-up, provided regulatory approval could be obtained.

• SMEs are able to produce oil which maintains vitamin A content up to the point of consumption by households, and SMEs are key to reaching vulnerable households.

We use this information to model the cost-effectiveness of fortification by enterprises of varying scale among the SME sector.

**Conclusions:**

• Fortification is a key way to improve vitamin A levels for pregnant and lactating women, who are key to the vitamin A status of infants. Safety concerns mean that mega-dose supplements cannot be used for this group.

• Fortification by SMEs can – if implemented appropriately – be a cost-effective intervention.
## FORTIFIED COMPLEMENTARY FOODS IN VIETNAM: VALUE CHAINS TO SUPPORT LOCAL WOMEN FARMERS AND ENTREPRENEURS

(1)Yeudall, Fiona; (2)Huy, Nguyen Do; (3)Rocha, Cecilia; (4)Phuong, Huynh Nam; (5)Tuyen, Le Danh; (6)Phu, Phan Van; (7)Trung, Le The; (8)Medonca, Melody; (9)Brown, Matthew.

(1)PhD. RD. Associate Professor. Centre for Studies in Food Security. Ryerson University. Canada.; (2)PhD. Associate Professor and Head of Food and Nutrition Training Center. National Institute of Nutrition. Vietnam.; (3)PhD. Professor and Director School of Nutrition. Centre for Studies in Food Security. Ryerson University. Canada.; (4)MD. PhD. Deputy Head of Food and Nutrition Training Center. National Institute of Nutrition. Vietnam.; (5)MD. PhD. Associate Professor. Director National Institute of Nutrition. Vietnam.; (6)MD. PhD. Associate Professor and Deputy Head of Nutrition and Food Safety Department. Hanoi Medical University. Vietnam.; (7)MPH. Deputy Head of Nutrition Department. Nam Dinh Nursing School. Vietnam.; (8)MHSc. Centre for Studies in Food Security. Ryerson University. Canada.; (9)MSc. Centre for Studies in Food Security. Ryerson University. Canada.

The ECOSUN project aims to contribute to reduction of levels of food and nutrition insecurity in three northern Provinces in Vietnam by scaling up local production of fortified complementary food using locally grown crops, and local manufacturing facilities and distribution channels. Our food systems approach aims to enhance agricultural livelihoods of small scale women farmers through their integration into an agricultural value chain and increase availability of fortified complementary foods in Lao Cai, Lai Chau and Ha Giang by establishing Small Scale Food Processing (SSFP) plants. Vietnam's National Institute of Nutrition and their business subsidiary NINFoods developed and field tested fortified complementary foods made from local ingredients, developed partnerships to establish two SSFP plants and recruited and trained small scale women farmers to supply ingredients to the plants. Named after the project's ecosystem approach (ECO) and Vietnam's Little Sun maternal child counselling centres (SUN), the ECOSUN project sites were selected due to the estimated 31% (iron) and 81% (zinc) prevalence of deficiencies among children in the region. An instant rice based complementary porridge fortified with iron (0.9mg/30g) and zinc (0.45mg/30g) was developed for ease of preparation, given time constraints and limited cooking facilities accessible to the target population when their children accompany them to the field for example. Legislation requiring mandatory fortification of wheat flour was recently introduced, signaling acceptance of fortification as a cost effective and sustainable intervention. This presentation focuses on the baseline survey results of over 800 child/caregiver pairs as the first stage of the project impact evaluation. Interviews assessed KAP related to infant feeding practices, gender (Abbreviated Women's Empowerment in Agriculture Index) and standard sociodemographic indicators.

Household level food security was assessed using validated HFIAS and Mean Adequate Household Food Provision scales. Nutrition Security was assessed via core IYCF indicators minimum diet diversity, meal frequency and acceptable diet), child anthro-

pometric and hemoglobin (via Hemocue) measures. Data analysis is ongoing at the time of writing of the abstract.

Funded by the International Development Research Centre and Global Affairs Canada from the Canadian International Food Security Research Fund.

## TECHNOLOGY DEVELOPMENT AND SCALING UP FOR DOUBLE FORTIFICATION OF SALT WITH IODINE AND IRON

(1)Diosady, Levente; (2)Mannar, M.G. Venkatesh.

(1)Ph.D. P.Eng. Professor Emeritus. Department of Chemical Engineering and Applied Chemistry. University of Toronto. Canada.; (2)D.Sc. hon. causa. P.Eng. Adjunct Professor. Department of Chemical Engineering and Applied Chemistry. University of Toronto. Canada.

Iodine deficiency is the largest cause of preventable developmental problems, while iron deficiency is a major cause of reduced work capacity, reduced immunity, maternal and infant mortality and impaired development in children. Iron deficiency affects some 2 billion people, mostly in the developing world.

Iron and iodine deficiency may be addressed by fortification of a food staple that is universally consumed in quantities essentially independently of economic or social status. Salt is an ideal vehicle for micronutrients, as it is centrally processed, and purchased or bartered by even the poorest rural consumers. Salt is now iodized in most countries, and iodized salt reaches nearly 85% of the world's population, resulting in significant decreases in iodine deficiency disorders.

Since iodine and iron interact, resulting in the loss of iodine and reducing the bioavailability of iron, double fortification requires technology that keeps these micronutrients separated in salt. We developed microencapsulation-based technology for producing an iron premix that can be added to iodized salt, which does not interact with iodine and remains bioavailable for at least one year. The product was tested for efficacy in two large trials in Bangalore and Darjeeling, India confirming its positive impact in improving iron status and reducing anemia and iodine deficiency. The technology was scaled up and applied in a school lunch program in Tamil State benefiting nearly 5 million school children over the past 8 years. A new program to provide double fortified salt to 24 million people in the lowest income quintiles through a subsidized food commodity distribution program in Uttar Pradesh State has been initiated this year. A baseline health and nutrition survey was completed in late 2016, and the impact of the intervention will be measured after 12 months of sustained utilization of the double fortified salt.

This talk will describe the many stages of the scale-up from 100g batches to 600ton lots of double fortified salt, resulting in a proven and feasible means of combating both iodine and iron deficiency with potential for replication across large regions of the world where these deficiencies continue to be significant problems.
## WHAT TO DO: FRAMEWORKS AND WAYS FORWARD FOR IMPROVING NUTRITION THROUGH AGRICULTURE AND FOOD SYSTEMS

Garrett, James.

Sr Research Fellow. Bioversity International. Italy

A more holistic focus has led to increased attention to the determinant roles played by agriculture and food systems in achieving healthy diets and improved nutrition. An integrated framework for understanding how agriculture and food systems affect diets and nutrition will be presented, particularly from the perspective of low- and middle-income countries. Impact pathways and key actions to make agriculture and food systems more nutrition sensitive will be highlighted, including specific points of entry along the stages of a value chain (from inputs to consumption) and for the food system overall. This includes special attention to production, transport and transformation, and consumption, as well as the enabling policy and program environment, gender, equity, and environmental sustainability. The issues of capacity, governance, and scaling up will also be noted. The presentation will also build a bridge between research and action, highlighting key emerging questions about choice, design, and implementation of actions to promote agriculture- and food-based approaches to creating more sustainable food systems for healthy diets and improved nutrition.

**Keywords:** Nutrition-sensitive agriculture, food systems, value chains, Rome-based agencies (RBAs)

**Further collaborators:**

Charlotte Dufour (FAO), Juliane Friedrich (IFAD), Gina Kennedy (Bioversity), Nancy Aburto and Quinn Marshall (WFP)

## HOW TO DO IT BETTER: EVIDENCE AND COMMUNICATIONS FOR HEALTHY DIETS AND SUSTAINABLE AGRICULTURE AND FOOD SYSTEMS

Kennedy, Gina.

PhD. Senior Scientist. Bioversity International.

This presentation will highlight what we already know and what we need to know in order for agriculture to contribute more effectively toward healthy diets and sustainable food production systems. The latest evidence on what works – the theory of change, the impact pathways – for how agriculture and sustainable food systems can contribute to improving nutrition will be reviewed. What we currently know about the best actions to take in agriculture and food systems to create diverse, healthy diets in a sustainable way, including areas that may not now be receiving attention,

such as the importance of agrobiodiversity, biofortification, sustainability, systems thinking, and “multi” actions (multi-sectoral, -disciplinary, -actor, -value chains, -SDGs) will be described.

The presentation will also emphasize the importance of evidence-based decision making, including the importance of strengthening monitoring and evaluation (M&E) systems and of closing the gaps between research, policymaking, and operations. It will also describe new and innovative tools and methods that are available to design more effective policies and programs.

The presentation will note where there are remaining information needs and knowledge gaps, such as data on individual and household food consumption patterns and food composition, particularly of local varieties, and appropriate and reliable project-friendly tools and indicators for nutrition-sensitive agriculture. It will also look at how national and international research and data initiatives are addressing these issues, such as the CGIAR's Research Program on Agriculture for Nutrition and Health (A4NH), GIFT, an FAO initiative for open access data on individual dietary assessment, and the RBA Working Group on Sustainable Value Chains for Nutrition. Areas for further research, such those around multisectoral governance, capacity strengthening, food safety, consumer behaviors, food environments, effects of urbanization and food system assessment will also be highlighted.

**Keywords:** Nutrition-sensitive agriculture, food systems, diets

**Further collaborators:**

James Garrett, Bioversity International
Juliane Friedrich, IFAD
Charlotte Dufour, FAO
Nancy Aburto, WFP
Quinn Marshall, WFP

## PROJECT DESIGN, IMPLEMENTATION, AND POLICY ENGAGEMENT FOR NUTRITION-SENSITIVE AGRICULTURE

Friedrich, Juliane.

Nutritionist, International Fund For Agricultural Development (IFAD).

An integrated framework for understanding nutrition-sensitive agriculture, and the current evidence base, has been presented in this symposium, but practically how do we make agricultural projects and policies nutrition sensitive?

The presentation will take real-world experiences to highlight what needs to happen on the ground for effective design and implementation of nutrition-sensitive agricultural projects and policies, as well as note key challenges and gaps. It will describe specific potential interventions and enabling frameworks and look at issues of identifying appropriate point of entry, integration of nutrition into agricultural projects (rather than setting up separate stand-alone interventions), appropriate project indicators, working multisectorally, and the need for design and implementation capacities across levels.

The presentation will note the importance of working at both sectoral project and broader policy and institutional levels. Ac-
tions can be taken both to mainstream food security and nutrition in sectoral strategies and investments; and support the contribution of food and agriculture to multi-sectoral nutrition strategies. Attention to the broader policy environment is crucial since most governments allocate funds by sector, so for nutrition to receive adequate financial and operational support, a case for nutrition and agriculture must be made at a supra-sectoral level.

In addition to identification of appropriate actions, attention has to paid to capacities and funding. Without sufficient individual, organizational, and systemic capacities or without sufficient funding even well-designed projects and policies will not work. The role of organizations like the RBAs are critical here: from technical advice and policy support, to logistics, to development of evidence, and finance, these organizations can assist to develop the needed capacities and provide needed knowledge and investment funds. The rise of nutrition as a corporate priority for these organizations, and others such as the World Bank, means that there is an excellent opportunity to increase operational synergies among them on nutrition and action and provide strong, integrated support for country actions to mainstream nutrition in agricultural investments.

**Keywords:** Nutrition-sensitive agriculture, project design and implementation, multi-sectoral approaches, Rome-based Agencies (RBA)

**Further collaborators:**

James Garrett (Bioversity), Charlotte Dafour (FAO), Gina Kennedy (Bioversity), Nancy Aburto and Quinn Marshall (WFP)

## GETTING IT DONE: FRAMEWORKS, APPROACHES, AND TOOLS FOR NATIONAL CAPACITIES IN AGRICULTURE AND NUTRITION

Aburto, Nancy.

Nutrition Division. United Nations World Food Programme. Italy.

Beyond conceptual frameworks, evidence, and field-based guidance for action on making agriculture and food systems more nutrition-sensitive, the RBAs also offer a range of knowledge and operational support to help countries achieve their commitments under ICN2, SUN, and the SDGs. This presentation will highlight the particular contributions of each RBA in the area of nutrition-sensitive agriculture and food systems, how they work together, and what they can offer to countries to support actions at global, regional, and country level.

FAO, for example, provides technical assistance to governments on mainstreaming nutrition in agricultural-related policies and investments (including agriculture, social protection, livestock, forests, and fisheries). IFAD is an international financial institution providing loans and grants primarily for development of smallholder agriculture in low- and middle-income countries, with special attention to climate change, women, youth, and indigenous peoples. WFP is the leading global humanitarian organization fighting hunger, with a focus on emergency assistance, relief and rehabilitation, development assistance and special operations

to build resilience and improve nutrition. Bioversity International is a member of the CGIAR and, along with 6 other institutions, a partner in the CGIAR's Agriculture for Nutrition and Health (A4NH) research program. It is an international research institution delivering scientific evidence, management practices and policy options to use and safeguard agricultural and tree biodiversity to attain sustainable global food and nutrition security. Just as important as the individual organizational mandates are the coordinating mechanisms such as the UNSCN, CFS and SUN, which provide a common platform and discussion space for inter-agency and international exchange of best practices.

These organizations can provide knowledge publications to build awareness of frameworks and design processes (e.g., Guidance for Nutrition-Sensitive Programming, Designing Nutrition-Sensitive Agricultural Investments, Guidance on Design of Nutrition-Sensitive Value Chain Projects, Resource Framework for Home-grown School Feeding, Meals Programme, Cost-Benefit Analysis, Fill the Nutrient Gap, Food-based Dietary Guidelines), project indicators (e.g., Compendium of Indicators for Nutrition-Sensitive Agriculture), and capacity strengthening (e.g., design and use of national food-based dietary guidelines, courses on nutrition education). They disseminate research publications and deliver capacity strengthening activities around critical areas of overlap between agriculture, food systems and nutrition, such as: food systems for healthier diets; biofortification; food safety; policies, programmes and enabling actions; and improving human health (which are also the five flagship research areas of A4NH). They also provide policy support (e.g., through country offices) and finance for agricultural investments (IFAD), knowledge generation (FAO), and operations (WFP) as well as support for country action on SUN.

**Keywords:** Nutrition-sensitive agriculture, food systems, value chains, Rome-based agencies (RBAs)

**Further collaborators:**

Charlotte Dafour (FAO), Juliane Friedrich (IFAD), Gina Kennedy (Bioversity), James Garrett (Bioversity), Quinn Marshall (WFP)

## THE ROLE OF AGRICULTURE IN IMPROVING NUTRITION IN THE GLOBAL CONTEXT: COMMITMENTS GUIDELINES AND THE ROME-BASED AGENCIES

(1) Dafour, Charlotte; (2) Garrett, James; (3) Friedrich, Juliane; (4) Kennedy, Gina; (5) Aburto, Nancy; (6) Marshall, Quinn.

(1) UN Food and Agriculture Organization; (2) CGIAR A4NH;

(3) International Fund for Agricultural Development; (4) Bioversity International; (5) UN World Food Programme.

This presentation will introduce the Symposium organized by the Rome-based Agencies (RBA's) - the UN Food and Agriculture Organization (FAO), the World Food Programme (WFP), the International Fund for Agricultural Development (IFAD) and the CGIAR center Bioversity International – on the topic “From
Sustainable Farms to Better Nutrition: Linking Commitments to Research, Policy and Practice".

This presentation will describe how, over the past decade, gov-
ernments and the global development community have increas-
ingly recognized the importance of good nutrition to economic
growth and social development, and introduce progress in the
global governance for nutrition. The binding commitments that
governments have made to eradicate malnutrition through the
Second International Conference on Nutrition (ICN2), the Sus-
tainable Development Goals, and the Scaling Up Nutrition Move-
ment, will be presented, along with the UN Decade of Action on
Nutrition, which presents a unique opportunity to promote nutri-
tion worldwide as it pushes even more attention to global moni-
toring of government actions and progress on nutrition. The pres-
entation will also describe the role of the UN Standing Committee
for Nutrition (UNSCN) and the World Committee for Food Secu-
rity (CFS) in supporting member states in making, implementing
and reporting on commitments for nutrition will be introduced.

Linkages to other global movements of relevance to food sys-
tems and nutrition – such as the ongoing Decade on Biodiversity
and the Convention on Biological Diversity, and the Save FOOD
initiative – will also be made. The presentation will highlight the
implications of such global commitments for country level action.

These commitments require action on agriculture and food
systems, an area that governments are often not familiar with and
one for which international guidance and national experiences are
limited. Countries are rightfully now asking: "We've made com-
mitments on nutrition, what do we actually need to do to fulfill
them?" and "Agriculture and food systems may play roles in im-
proving nutrition. But what are they, and what do we need to do?"

The presentation will highlight why attention to agriculture
and food systems is essential to improving nutrition in today's
world (and commonalities between issues in low-, middle- and
high-income countries), and introduce the other presentations in
the Symposium, which will describe the support that the Rome-
based agencies (RBAs) can provide to help countries close the gap
between commitment and action, and successfully achieve their
pledged goals. The presenters will share concrete frameworks,
evidence, approaches and tools that have been developed by the
RBAs and others to catalyse and promote evidence-based action
by governments and other stakeholders in this area, in order to
fulfil those international commitments and end hunger, achieve
food security and improved nutrition, and promote sustainable
agriculture.

**Keywords:** Nutrition-sensitive agriculture, food systems, nu-
trition governance, political commitment, Rome-based agencies
(RBAs)

FOOD AID RESEARCH: UPDATE ON FOOD AID FOR PREVENTING AND TREATING UNDERNUTRITION

(1)Michaelsen, Kim F.; (1)Fabiansen, Christian; (2)Briend, André; (1)Friis, Henrik.

(1)Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Denmark.; (2)Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Denmark. Department of International Health, University of Tampere Medical School, Tampere, Finland.

There is a current discussion if dairy protein is needed in food
products for preventing and treating moderate and severe acute
malnutrition (MAM, SAM), because it is an expensive ingredi-
ent. A WHO technical note (2012) on supplementary foods for
the management of MAM in children 6-59mo recommends that
the protein source has a PDCAAS >70%, corresponding to opti-
mized cereal/legume mixtures, milk and animal proteins. A foot-
note mentions that milk powder improves the amino acid profile
and bioavailability of calcium and potassium, has stimulating ef-
fect on IGF-1 and linear growth and contains no anti-nutrients.
WFP (2016) specifies that at least 1/3 of the protein should come
from milk powder in ready-to-use-supplemental-foods (RUSF)
and lipid-based nutrient supplements, medium quantity (LNS-
MQ). For ready-to-use-therapeutic-foods (RUTF) USAID (2015)
specifies that at least 50% of protein must come from dairy, from
either milk powder or whey protein concentrate (WPC). Specifi-
cations for fortified blended foods (FBF) also include milk pro-
tein. FBF specifications from WFP (2015) for Super Cereal plus is
that 8%w/w should be dried skimmed milk (DSM). USAID (2011)
specifies that 3% w/w of WPC80 is added to CSB14. DSM and
WPC34 have a high content of lactose (~50%w/w) which poten-
tially has prebiotic effects and positive effects on growth (Grenov
et al, FNB 2016). Other dairy products (WPC80 and WPI) have
considerably lower lactose content (10 and 1 % w/w, respectively).

Recent intervention studies have examined the effect of dairy
in treatment of MAM and SAM. In a study in Malawi and Mo-
zambique, 6-59 mo old children with MAM were randomized to
a RUSF with soy or a combination of whey protein and permeate.
The RUSF with dairy resulted in higher recovery and improved
growth (Stobaugh et al. AJCN 2016). In a noninferiority study in
Congo children with SAM aged 6-23 and 24-59mo were rand-
omized to a RUTF with soy-maize-sorghum (SMS-RUTF) or with
peanut and DSM. In children ≤23mo the recovery rate of SMS-
RUTF was inferior, but it was concluded that in children ≥24mo
SMS-RUTF can be used to treat SAM (Bahwere et al. 2016).

We examined the effect of different amounts of DSM in a randomized intervention study among 1609 children 6-23mo old with MAM in Burkina Faso. It was a 2x2x3 factorial design where we assessed the effectiveness of a) matrix, ie LNS vscorn-soy blend,
b) soy quality, ie dehulled soy vs soy isolate, and c) level of dry skimmed milk, ie 50 and 20% vs 0% of protein. The primary outcome was fat-free tissue accretion over a 12 week intervention, measured by deuterium dilution. Secondary outcomes included recovery rates and other anthropometric measures. The results will be presented at the meeting.

The effects of dairy on recovery and weight gain are impor-
tant outcomes, but examining the effects on body composition
and long-term effects on growth, development and health of using
dairy in prevention and treatment of MAM and SAM should also
be examined.

**Keywords:** Dairy, protein, acute malnutrition, food aid

**Conflict of Interest disclosure:** KFM and HF: Funding from USDEC, ARLA and Danish Dairy Foundation; AB and CF: None

RATIONALE AND EVIDENCE REGARDING
SMALL-QUANTITY LIPID-BASED NUTRIENT
SUPPLEMENTS FOR FOOD ASSISTANCE

Dewey, Kathryn G.

PhD. Professor. Department of Nutrition. University of California, Davis. USA.

Lipid-based nutrient supplements (LNS) are a family of forti-
fied, lipid-based products that deliver vitamins and minerals, es-
sential fatty acids, protein and energy in a lipid matrix. The low
moisture content of LNS ensures resistance to spoilage. Large- and
medium-quantity LNS are being used to treat and prevent acute
malnutrition. Small-quantity products (SQ-LNS, < 20 g/d, ~110-
120 kcal/d) have been developed to complement the diet with
key nutrients for infants and young children, and for pregnant
and lactating women, with the goal of preventing undernutrition.
They typically include 22 micronutrients, in addition to essential
fatty acids and a small amount of high quality protein. In food
assistance programs, SQ-LNS have several potential advantages.
Because the quantity is small and the product is ready-to-eat by
itself or mixed with other foods, the entire intended daily ration
is easily consumed even by infants, ensuring that the micronutri-
ent needs of these vulnerable target groups will be met each day.
The small quantity also minimizes transport and storage costs and
reduces the likelihood of sharing of the supplement with others,
by comparison to larger-quantity food assistance products such
as cereal-legume blends. When necessary (e.g. widespread food
insecurity), provision of SQ-LNS for these target groups can be
coupled with provision of staple foods or cash transfers for the en-
tire household. Several efficacy and effectiveness trials have been
conducted with SQ-LNS. Taken as a whole, the evidence suggests
that prenatal SQ-LNS supplementation promotes fetal growth,
and SQ-LNS for the mother and/or young child can promote
child growth and development and reduce anemia, though there
is heterogeneity in these effects both within and across study pop-
ulations. In some settings, a growth response appears to be con-
strained by certain contextual factors such as frequent infections.
Further research would be valuable to evaluate the effectiveness of

SQ-LNS within food assistance programs in different contexts (in-
cluding acceptance, utilization and cost-effectiveness), and when
integrated with other strategies to reduce infections and promote
child development.

**Keywords:** Lipid-based nutrient supplements; infants; preg-
nant women; malnutrition; child growth

SCALING-UP ACCESS TO NUTRITIOUS COM-
PLEMENTS TO YOUNG CHILDREN'S DIETS FOR
FOOD ASSISTANCE AND BEYOND

de Pee, Saskia.

PhD. Nutritionist. UN World Food Programme, Rome, Italy.

Intake of essential nutrients, including vitamins, minerals, es-
sential amino acids and essential fatty acids is often below required
levels among populations that receive food assistance as well as
among other populations whose diet has limited diversity due to
availability and affordability constraints. For young children (6-23
months of age), special nutrient-rich commodities that can com-
plement their diet of breastmilk and complementary foods are a
good way to introduce them to the family diet and local foods,
and at the same time ensure that their needs for essential nutri-
ents are met. Different options for enriching the young child's diet
are being developed and tested for acceptability, stability, cost as
well as nutrient bioavailability and impact of its consumption on
nutritional status and functional outcomes. Such options include
small-quantity LNS, special fortified blended foods (also known as
infant cereals), micronutrient powder and other fortified comple-
ments in powder form that contain micronutrients, high-quality
protein and some essential fatty acids. Food assistance can pro-
vide access to these types of products in different ways, including
in-kind distribution where the product is handed out at a specific
distribution point or by a designated person (health care center,
food aid distribution site, community health worker); by pro-
viding a commodity-specific voucher that can be redeemed at a
distribution point, i.e. the voucher can be provided through the
health center while a site that handles foods, including stores, can
provide the commodity; or indirectly by providing cash or e-card
together with promotion activities to stimulate purchasing of spe-
cific commodities, which hence need to be available in the area
and liked by the consumer. For a sustainable supply chain to devel-
op, there needs to be sustainable demand, which can be from both
self-purchasing consumers and the public sector, whether the gov-
ernment, UN agencies or NGOs. This requires that the products
meet a need from the consumers, i.e. they like the product and are
prepared to pay for it, using their resources, including cash but
also opportunity costs, i.e. the effort they have to put into obtain-
ing, also a free, product. The use of vouchers can be considered in
developing markets where manufacturers are putting different po-
tentially suitable products on the market to meet a (growing) de-
mand from different groups of consumers. Monitoring these initi-
atives for product take-up (acceptance), utilization, and impact on
young children's diets and nutrient intake will be very important.
**Keywords:** Small quantity lipid-based nutrient supplements, Food assistance, Complementary feeding, Vouchers.

## COST-EFFECTIVENESS: WHAT HAVE WE LEARNED?

(1)Rogers, Beatrice; (2)Cliffer, Ilana; (3)Suri, Devika; (4)Shen, Ye;

(5)Langlois, Breanne; (6)Walton, Shelley; (7)Vosti, Steve; (8)Webb, Patrick.

(1)PhD. Professor of Economics and Food Policy. Friedman Nutrition School. Tufts University. Boston MA USA.; (2)MPH. Field Research Coordinator. Food Aid Quality Review. Friedman Nutrition School Tufts University Boston MA USA; (3)MS. MPH. Data Manager. Food Aid Quality Review. Friedman Nutrition School Tufts University Boston MA USA; (4)MPH. Data analyst. Food Aid Quality Review. Friedman Nutrition School Tufts University Boston MA USA; (5)BS. Data analyst. Food Aid Quality Review. Friedman Nutrition School Tufts University Boston MA USA; (6)MPH. RD. Project Manager. Food Aid Quality Review. Friedman Nutrition School Tufts University Boston MA USA; (7)PhD. Adjunct Professor. Dept of Agricultural and Resource Economics. University of California Davis. Davis CA.; (8)PhD. Alexander McFarlane Professor of Nutrition. Friedman Nutrition School Tufts University Boston MA USA.

Prevention and treatment of childhood undernutrition in LMICs typically relies on supplementary foods given in quantities calibrated to the needs of the target child. Foods used in supplementary feeding programs (SFPs) include fortified blended flours (FBF), prepared as porridge often with vegetable oil, multiple micronutrient powders (MNP) added to children's food, or lipid-based ready-to-use supplementary food (RUSF), consumed directly from individual single-dose packets. Controlled trials have assessed the efficacy of such foods, but their effectiveness depends on their programmatic context. Proper preparation and feeding to the target child per protocol determine effectiveness, beyond the composition of the food.

In the context of SFPs, cost-effectiveness (CE) is the cost of achieving the desired nutritional or health outcome. CE can vary widely depending on the outcome. CE depends on the cost of the daily ration, but also on the number of doses required to achieve the outcome and the amount needed for a sufficient quantity to reach the target child. Other program costs that affect CE include transportation, storage, distribution, and the losses incurred at each stage. Packaging affects shelf life and resistance to infestation and contamination; appropriate packaging can also affect the time required, and therefore staff cost, of distribution. As behavior change communication affects correct preparation and feeding, the planning, labor, and other costs of delivering it, are part of the CE calculation; indeed, program costs can be larger than product costs. Costs include the value of resources provided without charge: volunteer labor and (importantly) caregiver time.

Current FAQR studies in Burkina Faso and Sierra Leone assess the CE of four supplementary foods to treat wasting (Sierra

Leone) or prevent wasting and stunting (Burkina Faso). The foods are three FBFs and one RUSF. Two of the FBFs require preparation with added oil; two (including one that does not require added oil) contain a dairy component; the RUSF contains dairy, and has high lipid density, comparable to the FBF if prepared with added oil in the recommended ratio of 30 g oil: 100 g FBF. In Burkina Faso, children received a food supplement from ages 6 – 23 months; CE was measured in terms of the percentage of children treated with each food who were not stunted by 24 months of age, and who experienced no episodes of wasting during the treatment period. In Sierra Leone, the primary outcome is recovery from MAM, but lean mass accretion and neurological performance are additional outcomes. Costs include the cost of the food and all programmatic costs.

CE requires investment in data collection and analysis, but is essential to decision-making about the most appropriate foods to include in SFPs and the most efficient way to deliver them. One food may be more effective, but less cost-effective; in the face of limited program resources, the more cost-effective product will allow successful treatment of more children. More broadly, CE gives a concrete basis for choosing cost-effective investments in health and nutrition.

**Keywords:** Cost-effectiveness, supplementary feeding, nutrition, child malnutrition, food aid programs

**Further collaborators:**

Institut de Recherche en Sciences de la Sante, Ouagadougou, Burkina Faso

Washington University in St. Louis, St. Louis, MO, USA

Project Peanut Butter, Freetown, Sierra Leone

ACDI/VOCA, Burkina Faso

Save the Children, Burkina Faso

World Food Programme, Sierra Leone

Funding from US Agency for International Development, Office of Food for Peace

## COST-EFFECTIVENESS: HOW CAN WE USE WHAT WE KNOW?

El-Kour, Tatyana.

Nutrition Expert Consultant. Independent Practice. Middle East and North Africa. Egypt. Africa

**Background:** At a time when the world's nutrition care is moving toward accountable care, cost-effectiveness in food aid research offers an innovative approach to reducing cost and increasing quality of nutrition intervention. It empowers practitioners to prevent and treat undernutrition by informing both the cost and outcomes of nutrition interventions. It also provides evidence by comparative evaluation of the costs and consequences of using different food aid products to prevent and treat undernutrition.

**Objective:** The aim of this presentation is to review implications of findings from cost-effectiveness studies in food aid research for impactful nutrition practice.

**Methods:** The presentation provides: (1) application of the main concepts and key steps in integrating cost-effectiveness re-
search with practice, and (2) a summary of the lessons learned about interventions inspired by findings from cost-effectiveness in food aid research to evaluate nutrition interventions compared to current practice.

**Discussion:** Empirical research from cost-effectiveness on food aid suggests that linking programmatic costs with effectiveness outcomes are critical to influencing the impact of nutrition interventions. Different factors influence this link, including: determining cost of items, characteristics of beneficiaries, food system environment; food aid mechanism and amount; and approaches to handling cost and addressing administrative, operational, and contextual complexity. Experiences show that results of cost-effectiveness food aid evaluations influence resource allocation decisions, support advocacy efforts, improve policy design, highlight partner and community contributions, inform programmatic evaluation and learning, improve the quality and efficiency of delivering nutrition care, and estimate future nutrition care expenses.

**Conclusion:** Cost-effectiveness research impose both a systemic challenge and a growing opportunity to encourage global action on reducing malnutrition and realizing a world of zero hunger by 2030. Efforts to draw on lessons learned from cost-effectiveness food aid research suggest a set of practice options that are paramount to guiding practitioners and informing the global practice and policy debate with considerations to the underlying determinants of food and nutrition, strategic and operational context, cross-cultural adaptation, and gender-responsiveness. Advances in cost-effectiveness methodology, expanding use of technology for data collection and utilization, partnership coordination, and addressing socioeconomic, cultural, and institutional factors are needed, in addition to greater systematic integration of cost-effectiveness approaches into mainstream programming to affect nutrition and population health response.

**Keywords:** Cost-effectiveness, food aid, practice implication, nutrition care, response

**Conflict of Interest disclosure:** Since June 2016, I have assumed several positions within Action Against Hunger. I currently coordinate strategic nutrition policy efforts for Action Against Hunger in Lebanon.

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# POTENTIAL OF MONITORING FOOD ENVIRONMENTS FOR IMPROVING ACCOUNTABILITY AND POLICY

## USES OF FOOD ENVIRONMENT DATA FOR POLICYMAKING: OVERVIEW OF CASE STUDIES FROM CANADA

L'Abbé, Mary.

PhD. Earle W McHenry Professor and Chair. Dept of Nutritional Sciences. University of Toronto. Canada.

Monitoring the food environment over time is essential for informed policy-making. Data that examines a number of as-

pects related to the quality of the food environment serve several purposes throughout the policymaking process: it provides policymakers with evidence regarding the need for development of new policies to address gaps; needed updates to existing policies; and can be used to help shape and evaluate a number of different policy options to address the above. Finally, information on the food environment is essential in policy implementation, whether it be through education, guidelines or regulations, as it can help inform the potential effectiveness of proposed policies that are under consideration by governments, and then can help to evaluate the effectiveness of large-scale policies on influencing the quality of the food environment after they have been rolled out. Examples will be provided from the Canadian context on how food environment data has been used by government officials to inform policy decisions in Canada, and by researchers and NGOs to help shape the policy agenda. Examples include information on the nutritional quality of the packaged foods before and after voluntary sodium and trans fat reduction targets, modelling the proposed benefits of including information on added sugars to the Nutrition Facts table, the impact of provincial menu labelling legislation on the quality of restaurant foods before and after implementation, and the potential efficacy of proposed nutrient profiling systems for front-of-package labelling regulations and and for restricting marketing to children, among others. These case studies provide examples of the important role of collaboration between food environment researchers, NGOs and policy makers to understand the food environment and interpret the implications of policy on it, and highlight the importance of collecting historical data to track changes over time.

**Keywords:** Food environment, monitoring, food policy,

## GLOBAL BENCHMARKING OF THE COMPOSITION OF FOOD PRODUCTS

Dunford, Elizabeth; Neal, Bruce.

PhD. The George Institute for Global Health. Australia.

**Background:** Non-communicable diseases now account for more than 60% of total deaths globally. Governments from a number of countries are now calling for population-wide preventive measures based upon an improved food supply. Improvements will only be achieved if there are definitive data describing the food supply and how it can be improved. A number of nutrient profiling schemes exist which aim to determine the healthiness of packaged food products. The Health Star Rating is one such system which assigns a product a value between 0.5 and 5.0 stars, in half star increments, with a higher number of stars indicating a healthier product.

**Objective:** Our primary objective will be to compare the overall healthiness of packaged foods in supermarkets across a range of countries using the Health Star Rating system. Secondary objective will be to examine the levels of energy, saturated fat, total sugars and sodium per 100g of product.

**Methods:** Nutrient content data will be obtained for a sample of 10 countries currently involved in the INFORMAS network for
which existing data are available. A range of high, middle and low
income countries will be included. Products will be categorised
into 18 major food categories developed by the Food Monitoring
Group. For our primary objective, the Health Star Rating will be
calculated for all eligible food and beverage products. For our sec-
ondary objective, means (SD) levels of energy, saturated fat, to-
tal sugars and sodium per 100g will be calculated. If the data are
found to be skewed, the median and range will be reported. Differ-
ences between countries will be examined.

**Results:** The data used for each country analysis will be sum-
marized. The mean Health Star Rating for foods in each country
overall and in each major food category will be reported and com-
pared. Countries will be ranked by mean Health Star Rating and
by mean levels of each nutrient. Examples of how the data have
been used by government to inform policy development, as well
as by industry to inform internal product reformulation will also
be presented.

**Conclusions:** With processed foods playing a central causative role in diet-related disease burden, understanding differences in the global food supply is central to the prevention effort. Standardised data that can be collected in the same way over time and across jurisdictions can support this goal. Outputs can be tailored to support food manufacturers, retailers, government and consumers in a diverse range of strategies targeting improvements in the world's food supply. Data can also be used to prepare media releases that highlight the issue to the population at large.

**Keywords:** Food labels; processed foods; public health nutrition; nutrient profiling, diet related disease, food supply

**Conflict of Interest disclosure:** ED and BN have no conflicts of interest.

**Further collaborators:**
INFORMAS

BENCHMARKING FOOD ADVERTISING ON TELE-
VISION AMONG COUNTRIES GLOBALLY

(1)Kelly, Bridget; (2)Vandevijvere, Stefanie.

(1)PhD. Dietitian. Early Start Research Institute. University of
Wollongong. Australia; (2)PhD. Global Health, Food Policy,
Obesity and NCD prevention. Department of Epidemiology
and Biostatistics. School of Population Health. University of
Auckland. New Zealand.

Children's exposure to unhealthy food promotions contributes to poor diets and has been identified as a global priority issue for obesity and non-communicable disease prevention. Monitoring of unhealthy food promotions is necessary to: identify the extent of children's exposure and the need for policy interventions; inform the basis of policy specifications, such as marketing media and techniques that are restricted; and, over time and across places, to evaluate the impact of policy interventions on reducing children's exposure to this marketing and its persuasive power. This study aims to compare the extent and nature of unhealthy food and non-alcoholic beverage advertising to children on television

across countries and/or regions with different types and strengths
of regulations in place.

A literature review was undertaken to identify studies that had captured data on children's exposure to television food advertising. Corresponding authors were contacted and asked if they would be willing to contribute their data for a global comparison of food advertising to children. Researchers were required to reclassify information on advertised foods according to the World Health Organization European Nutrient Profile Model. All included datasets needed to include information on the hours during which the adverts occurred, to enable estimates of the frequency of advertising per hour. Sample days (weekdays/weekends) were weighted to give mean advertising frequencies. Researchers who were also known to have collected data on television food advertising using the INFORMAS protocol (but had not yet published their data) were also approached. A review of included countries' food marketing policies was undertaken to compare food advertising rates by policy types.

Around 15 research groups, spanning countries from Aus-
tralasia, Europe, North America, and South America agreed to
contribute television advertising data. Mean frequencies of food
and unhealthy food advertising (per hour/per channel) will be
described across countries and regions. Rates will be analysed ac-
cording to peak viewing times of children, during regulated hours
and during popular children's programs. For a subset of countries
were data are available, the 'persuasive power' of food promotion
will be determined, including the use of promotional characters
and premium offers. Finally, the 'impact' (no. ads per timeslot x
no. children watching) of unhealthy food advertising to children
will be determined, including how this impact could be reduced
through different policy scenarios.

This global comparison of children's exposures to television
food promotions highlights the potential of INFORMAS for
benchmarking food environments across countries and regions,
and for evaluating the potential for policy actions in reducing chil-
dren's exposure to unhealthy television food advertising.

**Keywords:** Marketing, Advertising, Child, Food, Beverage

IMPLEMENTATION OF THE ADVERTISING AND
LABELLING LAW IN CHILE: EARLY RESULTS OF
IMPACT ON FOOD REFORMULATION

(1)Kanter, Rebecca; (2)Reyes, Marcela; (2)Corvalan, Camila.

(1)PhD. Unit of Public Health. Institute of Nutrition and Food
Technology-University of Chile. Chile.; (2)MD, PhD. Unit of Public
Health. Institute of Nutrition and Food Technology-University of
Chile. Chile.

Background and objectives: In 2012 Chile passed the Law of Food Labeling and Advertising (Law 20.606). The law specifies limits for solids (per 100g) and liquids (per 100ml) for critical nutrients (sodium, sugars, and saturated fats) and energy; applying only to products with added sodium, sugars and/or saturated fat. A product can have up to four “High in” front-of-pack warning la-
bels, one for each critical nutrient and calories. The study objective was to evaluate potential anticipatory changes ahead of the implementation of this law in June 2016 by examining food composition changes. Specifically, if food product reformulation occurred regarding selected nutrients between early 2015 and early 2016.

**Methods:** The INFORMAS framework for monitoring the composition of the food supply was used. In February 2015 and 2016, fieldworkers photographed a representative sample of packaged food products (n=5421 and n=5479) from 6 different supermarkets in Santiago, Chile. Foods were excluded if they required reconstitution, had missing information or if total labeled energy was estimated as incorrect. To study reformulation, only the food products collected in both data collection rounds were included in the analysis (n=2,428). Foods were grouped into 17 categories, consisting of 141 subcategories. The average change in energy and each critical nutrient was estimated for each food category averaging the change of each product; the food subcategories with the largest decreases between 2015 and 2016 were identified. Finally, foods were classified based on whether they would receive a "High in" Calories, Sodium, Sugars and/or Saturated Fats warning (solids/liquids: >350/100 kcal; >800/100 mg sodium; >22.5/6 g total sugars; >6/3 g saturated fats) and prevalence compared between 2015 and 2016.

**Results:** Between 2015 and 2016, 12 of the 17 (70%) food categories had overall reductions in calories (kcal) and sodium, 11 food categories experienced declines in average total sugar levels, while only two food categories (cereal-based products and salty snacks) experienced a decline in average saturated fat levels. The greatest declines in critical nutrient levels observed were with respect to sodium levels; especially, in the subcategories of instant rice (-192.4 mg/100 g) and frozen marinated fish (-164 mg/100 g). The largest reductions regarding energy and the other critical nutrients were: instant rice (-35.7 kcal / 100 g), pastry icing (-3 g sugars / 100 g) and hamburger buns (-0.5 g saturated fats / 100 g). These overall reductions illustrate a low impact in terms of the new labeling as the prevalence of "High in" food products declined >1% in less than half of the food categories ("High in saturated fats" in 6 food categories, "High in sugars" (n=4), "High in sodium" (n=3) and "High in calories" (n=1)).

**Conclusions:** From 2015 to 2016, modest changes in food product reformulation were observed prior the implementation of the regulation. It is uncertain whether the notable reductions in sodium levels can be attributed to law 20.606 or overall global trends in sodium reduction. Data collected after the implementation of the law will serve to assess the actual impact of the new regulatory norms.

**Keywords:** Reformulation, INFORMAS, critical nutrients, food environment, Chile

**Conflict of Interest disclosure:** Funding: CONICYT-FONDECYT (R.K., Number: 3150183); and IDRC (C.C., M.R. Number: 107731-002). All authors report no conflicts of interest.

# UNHEALTHY FOOD ENVIRONMENTS IN GUATEMALA AND COSTA RICA. ARE REGULATIONS NEEDED?

**Background and objectives:** The Central American region is facing the nutrition transition and excess body weight and diet-related non-communicable diseases –NCD’s are highly prevalent. An unhealthy food environment –FE- is considered the prevailing driver of population unhealthy weight gain. Our objective was to measure the healthiness of the FE in Guatemala and Costa Rica, using standardized methodology from the International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support (INFORMAS) on Food Composition (FC), Food Labelling (FL), Food promotion on TV (FP), and the extent of implementation of FE policies through the Healthy Food Environment Policy Index (Food-Epi).

**Methods:** For FC and FL, we extracted levels of critical nutrients, persuasive marketing techniques (PMT) and health and nutritional claims (HNC), from pictures of foods products sold in the major supermarkets in Guatemala City (n=3459) and San Jose (n=2469). FP was analyzed recording TV advertising in cable and national channels with the highest child audience during 864 hours in Guatemala and 576 hours in Costa Rica (weekends and weekdays). Food products were classified using the WHO nutrient profile (European system) to indicate whether they were marketing permitted or not-permitted. The Food-Epi was calculated with the perception of non-government experts, on the level of implementation of food policies, and priority actions were identified.

**Results:** In Guatemala and Costa Rica, FC and FL measures revealed that products with an excess of critical nutrients use PMT, HNC and poor labelling practices. FP measures revealed that TV advertising of food products with marketing restrictions, according with WHO nutrient profile, is higher compared with those with a healthier nutrient profile (p<0.05). In Guatemala, the Food-Epi index revealed low implementation of food policies by the government to prevent obesity and NCD’s.

**Conclusions:** Guatemala and Costa Rica have an unhealthy FE characterized by persuasive marketing and availability of energy-dense low-nutrient food products targeted to children. In Guatemala, current actions from the public sector are not tackling unhealthy FE. National regulatory actions such as a front-of-pack food labelling system and the limitation of child-oriented promotion are needed in order to prevent childhood obesity and NCD’s.

<footnote>(¹)Krober-Lobos, Maria F; (¹)Alarcon, Amarilys; (¹)Cosenza, Emma L;</footnote>

<footnote>(²)Gamboa, Tatiana; (¹)Pineda, Andres; (¹)Sanchez, Carmen Maria;</footnote>

<footnote>(²)Zamora, Irina; (³)Blanco, Adriana; (⁴)Vandevijvere, Stefanie;</footnote>

<footnote>(¹)Ramirez Zea, Manuel.</footnote>

<footnote>(¹)INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC). Institute Nutrition of Central America and Panama (INCAP). Guatemala.; (²)School of Public Health. University of Costa Rica. Costa Rica.; (³)National Plan to reduce public consumption of Salt/sodium in Costa Rica, Costa Rican Institute of Research and Teaching in Nutrition and Health (INCIENSA);</footnote>

<footnote>(⁴)Department of Epidemiology and Biostatistics, School of Population Health, University of Auckland, New Zealand.</footnote>
**Keywords:** Food environment, food policy, INFORMAS, Central America

**Conflict of Interest disclosure:** Funding: International Development Research Center, Canada, gran number 107213-001 and 107731-001. Food Labelling and Composition in Costa Rica: The research leading to these results has received funding from IDRC Grant Number 107213-002. And the Program to Decrease Salt/Sodium Consumption in Costa Rica with the financial support of the Food, Environment and Health Program del IDRC (project # 106888-001) facilitated the 2015 National Plan to Reduce Consumption of Salt/Sodium in Costa Rica database. The opinions expressed in this article are the authors' own and do not reflect the opinion of the IDRC o their board of governors (Memorandum of Grant Conditions IDRC-FUNDEVI from project # 106888-001, Feb 14, 2012).

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# HEALTHY CONSUMPTION PATTERNS AND SUSTAINABLE PRODUCTION: EXPLORING THE LINKS BETWEEN AGRICULTURE, DIET AND LIFESTYLE USING ORGANIC AS AN EXAMPLE

## THE ORGANIC FOOD SYSTEM AS A MODEL LINKS AGRICULTURE, DIET AND LIFESTYLE – PRESENTING THE CASE

(1)Kahl, Johannes; (2)Strassner, Carola; (1)Bügel, Susanne.

(1)University of Copenhagen. Denmark.; (2)University of Applied Sciences Münster. Germany.

Today's understanding of food systems includes product-specific values (e.g. palatability, taste, nutritional and safety values, health promotion) and process-oriented values (e.g. environmental impact, animal welfare and social fairness). These values are currently challenged and changing. Food habits, cultural, social, ethical, economic and political criteria play an increasingly important role as values. Dietary patterns are becoming more Westernized worldwide. This has tremendous impact on food consumption, the environment, society and individual human as well as public health. The socio-cultural context of food consumption and production has been recognized as an essential part of a sustainable food system. A sustainable food system comprises agriculture, environment, nutrition and human health. Indeed, it has been suggested that food systems as well as diets or dietary patterns should be assessed in all different dimensions of sustainability including impacts on health (nutrition). The central questions can be described as: how can we transform the whole food system to be more sustainable by a combination of sustainable consumption and sustainable production. For understanding, measuring and improving a system approach in food and nutrition research is required. This includes the description of the system boundaries, the actors and activities on different levels and scales. One crucial question is how to link measurable parameters to system scales

or dimensions. Furthermore models are needed for conceptualization and simulation. The organic food system offers such an example of successfully combining sustainable food production and sustainable consumption patterns within one system. Based on central findings through surveys and other studies around the world, consumers and producers of organic products share specific attitudes to food that are mainly oriented towards health and environment. Drivers of system transformation process towards enhanced sustainability including better nutrition needs to be identified and evaluated as well as translated into tools that enhance and reinforce the necessary changes in lifestyle. Another requirement for a system approach is interdisciplinary working, taking natural and social science perspectives together. The presentation will contribute with conceptualize the food system approach, taking organic food system as a model as well as present examples from different entry point of food systems. Furthermore future research challenges in taking a system approach in food and nutrition science will be discussed.

**Keywords:** Food system approach, sustainability, organic food systems

**Further collaborators:**

Carola Strassner, Susanne Bügel

## PUBLIC PROCUREMENT AS A MEANS TO LINK SUSTAINABLE PRODUCTION WITH DIET AND LIFESTYLE – THE NEW NORDIC DIET WAY

Bügel, Susanne.

Professor, PhD, Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark.

The Danish Government has made a goal about doubling the agricultural area used for organic production in 2020 compared to 2007. Therefore the government supports a number of initiatives which increases the production, export and consumption of more organic products. One of these initiatives is the transition from conventional products to organic products in public procurement in Denmark.

The municipality of Copenhagen decided in 2001 that by 2011 75% of food served by public kitchens should be from organic production. In 2007 the goal was raised to 90%. The aim of this presentation is to show how transformation to organic produce without increasing costs can change diets to more healthy and sustainable diets.

Governmental support of organic agriculture, mandatory change from conventional food products to organic food products in public food service in the Municipality of Copenhagen without increasing the costs. Designation of Københavns Madhus to be the driving force behind the transition supporting the public kitchens with knowledge, motivation, education, ideas etc to make the changes.

Today that goal that 90% of public meals should be made from organic produce has been reached. Not only because it was a political decision, but also because the staff in the public kitchens have
replaced whole and semi-finished products with seasonal produce
and have limited waste. The transition has been done without in-
creasing costs. This has resulted in kitchens using more seasonal
produce and more vegetables, legumes and fruits and less meat.

Mandatory change to organic food, without increasing cost, results in changes towards more healthy diets. The Copenhagen model is exported to other municipalities in Denmark, but it still remains to be shown that the transition to organic produce also transfers to people not dependent on public food service and if the transition has health promoting effects in the Danish population.

**Keywords:** Sustainability, organic food, public procurement

**Further collaborators:**

Carola Strassner and Johannes Kahl

SUSTAINABILITY IN DIETARY PATTERNS AC-
COUNTING FOR FARMING PRACTICES: FIND-
INGS FROM THE BIONUTRINET PROJECT

Kesse-Guyot, Emmanuelle.

Nutritional Epidemiologist. Nutritional Epidemiology Research
Team- Inserm (U1153) Inra (U1125) Cnam, Université Paris13 -
Centre de Recherche en Epidémiologie et Statistiques Sorbonne
Paris Cité. France

Sustainable food market is developing and consumers' growing concerns for food quality is more and more prominent. However, little is known about the potential sustainability of the organic diet at the individual level. The aim of the study was to address the sustainability, using numerous indicators, of individual diets according to contribution of organic food to the diet.

Conventional and organic food intakes of 29,210 French adults included in the NutriNet-Santé cohort were assessed using an organic food frequency questionnaire. Weighted (on French census data) quintiles of the contribution of organic food to the diet were calculated.

Quality of the diet was estimated using two indexes (mPNNS-
GS and PANDiet) evaluating the adherence to food-based and nu-
tritional guidelines.

Daily dietary GHGEs (expressed in kgCO2eq/year) and energy uses (at production level) of the diet were computed, taking into account farming practices (organic or conventional production) using mostly data from the Dialecte database.

Diet costs were also calculated accounting for food consump-
tion, mode of production and place of purchase.

Adjusted means were compared between weighted quintiles (Q) of contribution of organic food, using ANCOVA models. For environmental impact, scenarios (100% organic and 100% conventional) were computed to disentangle the effect of organic diet from those of composition of the diet.

In our sample, 20% of participants were never or little consum-
ers of organic food while 20% consumed at least 50% of their diet
in the organic form.

High organic consumers were more often women (Q5 versus
Q1: 55.3 versus 45.1%), highly educated (Q5 versus Q1: 30.9 ver-

sus 15.6% postgraduate), and living more often in rural area (Q5
versus Q1: 29.62 versus 22.86%).

They exhibited healthier lifestyle (no smoking, low alcohol
consumption, elevated physical activity) and high consumption of
plant food. Plant to animal protein ratio was 13.42 in the Q5 and
0.46 in the Q1. Energy intake was 2,125 and 2,040 Kcal/d in the Q5
and Q1 respectively. Heme iron intake was 1.02 and 1.91 mg/d in
the Q5 and Q1 respectively.

After adjustment for age, energy intake and sex mean mPNNS-
GS (/13.5) and mean PANDiet (/100) were 8.83 and 69.18 in the
Q5 and 7.80 and 62.52 in the Q1.

Diet cost (euro/d) was 8.79 in the Q5 and 7 in the Q1.

A decrease in GHGe was observed across quintiles with 1,158 in Q5 versus 1,850 kg CO2eq/year in Q1. Similar findings were observed for Primary energy consumption (Q5 versus Q1: 5,359 vs 7,202 MJ/year).

Model scenarios revealed that for GHGe, the structure of the diet was mostly responsible for the observed association; whereas for primary energy consumption, mode of production was also an important lever.

Using observational data, our study provides new arguments concerning the potential of organic diet to contribute to sustainable diets, in particular through the modification of the diet composition.

Our results highlight the importance of promoting holistic
changes in dietary patterns to meet future environmental chal-
lenges, including the mitigation of global warming.

**Keywords:** Climate change, Dietary pattern, greenhouse gas emissions, organic food

**Further collaborators:**

Julia Baudry, Louise Seconda, Pilar Galan, Serge Hercberg, Benjamin Allès, Philippe Pointereau, Brigitte Langevin, Marie-Joséphe Amiot, Jean-Pierre Cravedi, Laurent Debrauwer, Roldolphe Vidal, Bruno Taupier-Letage, Louis Georges Soler, Denis Lairon

LINKING A FOOD SYSTEM WITH PUBLIC HEALTH
NUTRITION: WHAT DO WE LEARN FROM ORGAN-
IC?

Strassner, Carola.

Professor Sustainable Food Systems and Nutrition Ecology.
Department of Food - Nutrition - Facilities. FH Muenster
University of Applied Sciences. Germany.

Background and objectives: Organic food and farming can be described as a food system and it can be studied as such due to its legally defined production and processing methods, as well as the ability to follow organic products from farm to fork via independently audited labelling schemes in more than 80 countries worldwide. The aim of this study is to examine for any evidence of effects of the organic food system on public health nutrition. Methods: Linkages between organic agriculture, food, nutrition, and public health overall and in particular settings were explored
in literature. Results: Organic increasingly plays a role in public policy: Many countries or regions have subsidy schemes for organic agriculture for differing reasons and some of these integrate organic food products into (sustainable) public procurement goals. In particular, organic foods have been included in school meal systems. Studies in Europe show that schools with a healthy-food policy also support organic food; alternatively, an organic school policy can promote healthy eating. Consumer studies show that organic is believed to be healthier for humans and better for the environment, also providing the reasons for its selection. Recently it has been shown in national nutrition surveys that regular consumers of organic products make healthier and more sustainable food choices, including choosing a more plant-based diet. Field observations from foodservice consultancy suggest a similar pattern for so-called large-scale consumers. Here, too, buying and using organic foodstuffs seems to be associated with better diet and better knowledge of foods. On the production side, promoting health at various levels, from the individual to communities, is considered one of four central principles of organic agriculture (health, ecology, fairness, care). It aims to produce high quality, nutritious food that contributes to preventive health care and well-being. The organic process has significant impacts on the quality of organic foods compared to non-organic foods. At the same time some developed organic markets may be showing a product range increase in processed foods above other categories. In this connection the limitations on product formulation and applied processing technologies given by organic frameworks need further study. Conclusions: The nexus between public procurement, public diet and public health nutrition can be studied within the frame of organic food systems in varying geo-socio-cultural regions worldwide. Further studies are needed to validate or counter initial findings.

**Keywords:** Organic food system, public diet, organic processing, school meals, public procurement

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# SWEETENERS: ADVANTAGES AND APPLICATIONS IN THE 21ST CENTURY

## SWEETENERS AND NEW FLAVORS

World Health Organization (WHO) recommends no more than 10% of daily calories from added sugars or "free sugars" like syrup, honey or juices. Excessive consumption is linked to cardiometabolic diseases and certain cancers. However, desirable taste for sweet flavors is innate. Health recommendations limit the use of caloric sweeteners as sucrose, high fructose corn syrup (HFCS), molasses, honey, agave nectar, maple syrup or brown rice syrup.

However perception of consumers of them as "healthy or unhealthy" is not uniform and can be deceiving when one of them is viewed as more "natural" in its source. This idea can produce overconsumption.

HFCS obtained through enzymatic processing of corn syrup to increase the fructose content increase its sweetness, being the main caloric sweetener in the soft drink industry. There is debate concerning whether HFCS presents greater risks than the other sugars concerning metabolic disorders.

WHO and other health organizations recommendations increased the debate of sugars substitution by non caloric sweeteners. Intense sweeteners are food additives containing significantly less or none calories compared to sugar. These additives may be derived from natural or synthetic sources.

Other option used by food industry are sugar alcohols like sorbitol, mannitol, xylitol and more recently erythritol, with some advantages over their predecessors because of its neutral metabolic profile, and very low energy density. Erythritol, xylitol and sorbitol have been studied as alternatives to sugars against dental caries.

Artificial sweeteners are into two categories. The first one is the chemically synthesized: sucralose, alitame, cyclamate, aspartame, neotame, potassium acesulfame, and sacharin (discovered in 1878). The second is intense sweeteners extracted from plants: Stevia rebaudiana, Luo Han Guo and glycyrrhizin. Sweet tasting proteins from fruits includes thaumantin, monellin and brazzein. Lisozyme is a protein from egg whites. High intensity sweeteners have differienciated characteristics related to their structure: show delay the onset of sweetness, lingering, bitter or metalic aftertaste, non-linear sweetener consentration to sweetness equivalency ratio, adaptation or desensitizing, and a lack of mouthfeel or body, compared with sucrose.

Flavor enhancers are used to make the high intensity sweeteners taste more like sucrose: maltol, ethyl-maltol, strawberry furanone and vanillyls. Sugar alcohols and other polyols are used to provide mouthfeel, viscosity or cooling effect.

Sacharine is a coal tar derivative sold as powder and used in a variety of foods, beverages and baked products. It has a bitter aftertaste. Aspartame is composed of two amino acids: aspartate and fenylalanine. It is 200 times sweeter than sucrose. Its caloric value is insignificant. Acesulfame-K has similar sweetening power, but resist the heat. Sucralose is 600 times sweetener than sucrose, formulated by clorination of glucose, with great stability. Cyclamates are 30 times sweeter than sugar, with little aftertaste and are heat resistant. Stevia is 250 times sweeter than the reference, and it is shelf stable when dry. Has a bitter taste when consumed in high quantities.

Formulation of food and beverages with sugars substitutes is a complex task which requieres combination of some of the intense sweeteners with other modifiers of taste and texture.

**Keywords:** Sweeteners, artificial non caloric sweeteners, flavors, food, formulation

**Conflict of Interest disclosure:** Received honorarium as scientific advisor or invited speaker for both pharmaceutical and food industry.

<footnote>(1)Laviada-Molina, Hugo; (2)Molina-Segui, Fernanda.</footnote>

<footnote>(1)MD, MSc. Endocrinologist. Universidad Marista de Merida.
Mexico.; (2)MSc. Nutritionist. Universidad Marista de Merida.
Mexico.</footnote>
Track 1: Advances in Nutrition Research

SS_144/159

COHORT STUDIES IN IBERO-AMERICA

A LOOK INTO PREGNANCIES IN VENEZUELA:
THE IMPACT OF ADVERSE CONDITIONS IN
PREGNANCY DEVELOPMENT AND NEWBORNS

(1)Herrera-Cuenca, Marianella; (2)Hernandez, Pablo; (3)Mangia, Karina; (4)Mercadante, Yazareni; (5)Crespo, Jessica; (6)Rodríguez, Rodmar; (6)Khawam, Rania.

(1)PhD. MSc. MD Centro de Estudios del Desarrollo. CENDES/Fundación Bengoa. Venezuelan Health Observatory. Caracas. Venezuela.; (2)MSc. Nutritionist School of Nutrition Central University of Venezuela. Venezuelan Health Observatory. Venezuela;

(3)Nutritionist. Alcaldía de Municipio Sucre. Health Department.
Venezuela.; (4)Nutritionist. Venezuelan Health Observatory.

Venezuela; (5)Venezuelan Health Observatory. Venezuela.; (6)MD.
Alcaldía de Municipio Sucre. Health Department. Venezuela.

Nutrition and wellbeing conditions during pregnancy and early infancy are relevant in defining short and long term health. The Developmental Origins of health and Disease (DOHaD) paradigm provides a framework to assess the effect of early exposures (adequate or not) on long term health. Based on the evidence that adequate nutrition and good environmental conditions including those social determinants of health that ensure the wellbeing of population; it is expected that advantageous consequences in the predictive adaptive responses will show, thus preparing the fetus for the later environment that is anticipated based on its developmental experience (Uauy, 2011).

Low and middle income countries are showing an increase in chronic diseases prevalence all of which are associated with poor environmental conditions at the beginning of life.

In consequence, impairment of pre-conceptional and during
pregnancy nutrition status, living within a food insecure house-
hold and having an income below the line of poverty level are ad-
verse conditions that might promote the development of diseases
in the long term.

The last decade Venezuela has been facing a severe economic
crisis that has promoted important alterations for the quality of life
of Venezuelans (ENCOVI, 2014,2015, 2016)

A pilot for a cohort study was conducted in a low income urban
area within the Venezuelan Capital city, Caracas. During 2013 a

sample of 171 pregnant women was recruited from the ambula-
tory clinics of Sucre Municipality in Caracas, and the follow up
of neonates was completed for 70. Of those women, 44% had it
first pregnancy before age 17, and the majority of pregnant wom-
en (66%) were categorized as IV Graffar Méndez Castellano SEL
(low). Impairment of pre-conceptional nutrition status was re-
ported in 40% of women, 30% started pregnancy with a BMI >
25, and 10% with a BMI that showed undernutrition. 20.8% has a
history of abortion (Mercadante, 2016). 49.8% of pregnant women
with excess weight had 4 or more pregnancies and pre-concep-
tional nutrition status of the late pregnancy was associated with
number of pregnancies. 15% of neonates were small for gestational
age. It should be highlighted that 69% of the households had at
least one characteristic of food insecurity and 30% of the sample
reported no income at all. 15% of women referred going to bed
at night with hunger because there was no money to buy foods
and, an inverse significant association was found between the ex-
perience of hunger and family income. Logistic regression analysis
showed that the probability of living in a food secure household
diminished if there was a pregnant woman living in there and if
the household family income was below the poverty line. In con-
clusion: The conditions in which Venezuelan women are facing
pregnancies do not guarantee their wellbeing and their neonate's.
These conditions: food insecurity, living in a household with an in-
come below the poverty line and multiple pregnancies are factors
that require effective policies for implementing strategies to guar-
antee a good lifestyle standard for Venezuelans and for preventing
diseases in the future.

**Keywords:** Venezuela, Food security, pregnant women, low income households

EARLY LIFE FACTORS AND CHILDHOOD HABITS IN-
FLUENCING EXCESS BODY WEIGHT IN A SPANISH
MULTICULTURAL COHORT (CALINA COHORT)

Rodríguez, Gerardo.

PhD. Professor of Pediatrics. Instituto de Investigación Sanitaria Aragón. University of Zaragoza. Spain.

Childhood obesity is a major public health problem. Despite the reported stabilization of its prevalence in developed countries, overall trends in childhood obesity mask significant and increasing differences between children from upper and lower socioeconomic status (SES) backgrounds and in those who accumulate more early life risk factors and family predisposition (a mixture of cultural, genetic or behaviour habits). Differences in obesity prevalence among vulnerable groups exist but it remains unclear
whether these differences may be partly determined by SES, pa-
rental adiposity or pregnancy and infancy risk factors. Several
early-life risk factors have been identified in the literature, includ-
ing maternal pre-pregnancy overweight/obesity, smoking during
pregnancy, excess gestational weight gain, prematurity, high and
low birth weight, caesarean section, not being breastfed and rapid
early infant weight gain.

To explore early-life risk factors of overweight/obesity at age 6y and their cumulative effect on overweight/obesity at ages 2-,4- and 6y. To investigate longitudinal associations between belonging to a minority group and being overweight/obese at 6 years old, as well as between accumulation of social vulnerabilities.

Study design: 1,031 children were evaluated at birth and re-ex-
amined during a 6-year follow-up in a representative cohort of
Aragon (Spain). Maternal smoking during pregnancy, gestation-
al weight gain, gestational age, birth weight, caesarean section,
breastfeeding practices and rapid infant weight gain from birth to
6 months of age were the factors studied. Parental body mass index
(BMI), maternal education, parental/ethnicity origin were defined
as main confounders. Children from minority groups (vulnerna-
ble groups) included Spanish Roma/gypsies, Eastern Europeans,
Latin Americans and Africans. Two more vulnerable groups were
defined at baseline as children whose parents reported low occu-
pational status and low education. We used logistic mixed-effects
models to assess the associations investigated.

Parental BMI and parental ethnicity/origin were the strong-
est predictors of overweight/obesity and they confounded sever-
al associations. Among early life factors, rapid infant weight gain
(OR=2.29;[1.54-3.42]99%CI) and smoking during pregnancy
(OR=1.61;[1.01-2.59]99%CI) remained statistically significant as
predictors of overweight/obesity at the age of 6y after adjusting
for confounders. A higher number of early-life risk factors was
associated with higher odds of being overweight/obese at the age
of 6; two early-life risk factors (OR=2.72;[1.54-3.42]99%CI); three
early-life risk factors (OR=5.02;[2.28-11.04]99%CI) and four to
six early-life risk factors (OR=7.33;[3.01-17.84]99%CI). Roma/
gypsy children (OR=4.30;[1.13-16.23]99%CI) and with Latin
American background (OR=2.93;[1.26-6.79]99%CI) were more
likely to be overweight/obese at age 6 compared with non-gyp-
sy Spanish group. Children with three social vulnerabilities
(OR=2.08;[1.08-4.04]99%CI) were more likely to be overweight/
obese at age 6 compared with children with no vulnerabilities. No
associations were found at earlier ages.

Rapid infant weight gain, parental BMI and origin/ethnicity are important determinants of childhood obesity. Those with a higher number of early risk factors had elevated odds for obesity at age 6 suggesting cumulative effects. Monitoring children with rapid infant weight gain is especially important for childhood obesity prevention. Early interventions should be developed targeting Roma/gypsy children, Latin American children and those who accumulate more social vulnerabilities as they are at higher risk of being overweight/obese later in life.

**Keywords:** Overweight, early life factors, sociocultural, feed-
ing, growth

ASSESSING THE IMPACT OF GROWTH TRAJECTO-
RY OF VERY LOW BIRTH WEIGHT INFANTS ON EX-
ECUTIVE FUNCTIONS AT 11 YEARS OF AGE

(1)Vivas, Silvana; (2)Dinerstein, Alejandro; (2)Solana, Claudio;

(3)Granovsky, Gustavo; (2)Casale, Marita; (2)Conti, Roxana; (4)Cúneo
Libarona, María Lucrecia; (2)Schapira, Iris; (2)Apres, Norma.

(1)Educational Psichology. Pediatrics Outpatient department.
Hospital Materno Infantil Ramón Sardá, Buenos Aires, Argentina;

(2)Medical doctor Ramón Sarda Maternity. Argentina; (3)Phonoau-
diologist. Ramón Sarda Maternity. Argentina.; (4)Physical Therapy
Doctor. Ramón Sarda Maternity. Argentina.

**Background and objectives:** Several studies on pre-
term-born children have identified birth weight (BW) as a potent
predictor of later cognitive functioning and academic success,
with poorer outcomes in those born SGA (small for gestational
age) compared with those appropriate for GA (AGA). The ob-
jective of the study was to compare SGA and AGA born preterm
(<=1500g) children between 10-12 years old (y/o) on growth at 1
and 2 years of life and on the outcomes of the rings subtest (RSubt)
of the ENFEN (Evaluación Neuropsicológica de las Funciones
Ejecutivas en Niños).

**Methods:** 92 born preterm (<1500g) children between 10-
12 y/o (53 girls, 39 boys) were studied. Children with congenital
malformations, genetic syndromes, studied intrauterine infections
or cerebral palsy were excluded. Instruments: Growth chart and
outcomes on the rings subtest (RSubt) of the ENFEN. This test
depends more on the cognitive resources that children have and
less on culture, education or socioeconomic influence. It requires
high attention span, efficient working memory and inhibition of
interference. It is one of the tests that requires more executive
functions subtasks including: ability to program behavior to facil-
itate sequencing (only and in sequence it leads to a specific goal),
behavior planning and previewing, ability to break down a prob-
lem into stages by trying to discover the rules of the processes,
cognitive flexibility; abstraction ability (estimation), prospective
memory, motor skills and working memory. The child must fol-
low certain rules in order to copy 14 colored-rings and axis fig-
ures of increasing difficulty by moving the rings from one axis to
another. Statistical analysis: Outcomes range from 1-10 (lower to
higher performance). RSubt performance scores were divided in 2
categories: 1-4 and 5-10. Low RSubt score was defined as a score
less than 4. Normal RSubt score was defined as a score >=5. Cat-
egorical data was analyzed using Chi2 or Fisher test. Significance
level was set at p<0.05.

**Results:** 92 born preterm children (10-12 y/o) were studied. 31.52 % were SGA (n=29) and 68.47 % AGA (n=63). There were 68.96% of girls in SGA group and 52.38% in the AGA group. Mean+/-SD of BW and GA by group are shown in table 1. Table 2 shows the Chi2 results of the RSubt scores (<4 and >=5) for each group (SGA and AGA) and for each growth z score group at 1 and 2 years of life (YOL). There were no statistically significant differences between AGA children z score's groups at 1 or 2 YOL. However, the Chi2 test resulted significant between SGA z score's groups at 1 and 2 YOL (p<0.05).
**Conclusions:** Preterm SGA children are at special risk for cognitive impairment. We found that SGA preterm (<1500g) children with growth restriction at 1 and 2 years of life was associated to lower scores in the RSubt of the ENFEN (p<0.05).

**Keywords:** Prematurity, small for gestational age (SGA), executive functions, growth trajectory, nutrition.

**Further collaborators:** Gisela Germotta Educational Psychology; Victoria de la Fuente Educational Psichology; Mónica Brundi Medical Doctor

## THE LIMACHE BIRTH COHORT STUDY IN CHILE

(1)Amigo, Hugo; (2)Bustos, Patricia; (3)Rona, Roberto.

(1)PHD. Nutrition Department Faculty of Medicine. University of Chile. Chile.; (2)MD. Nutrition Department. Faculty of Medicine. University of Chile. Chile.; (3)MD. Phd department of Psychological Medicine. King's College. London. United Kingdom.

**Background:** By the seventies, the health and nutritional profile in Chile was of high infant mortality (>50/1000 live births) and high prevalence of nutritional and infectious diseases, but over a couple of decades birth weight increased markedly, malnutrition dropped to less than 1% and infant mortality fell to 14.6 by 1991. The current rate is 7/1000 live births.

**Objective:** The Limache cohort aims at assessing life course events -cardiovascular risk factors and chronic respiratory conditions- under the Developmental Origins of Health and Disease (DOHaD) paradigm in two stages of development in Chile: before and after an unprecedented economic growth and remarkable epidemiological and nutritional change.

**Method:** Ambidirectional follow-up study (non concurrent up to participants 22 years old, concurrent thereafter), with two birth cohorts born 12 years apart: Cohort A, a representative sample of 1232 subjects born between 1974 and 1978 -impoverished prone period- in the main public hospital of Limache and measured at 22 to 28 years (2000-2002) and at 32 to 38 years (2010-2012); Cohort B (n=1000), a representative sample of new-borns between 1988-1992 -wealthier prone period- of mothers residing in the same counties, evaluated during at 22-28 (2014-2017). Equal methods were applied to register anthropometry at birth, over the first year and in adulthood, socioeconomic position (SEP), demographic and life style traits along with respiratory, cardiovascular and mental health parameters measured in each contact in adulthood.

**Results:** Cohort A: Metabolic syndrome increased from 9.3% (95% CI:7.5-11.1) to 27.3 (95% CI: 25.0 to 31.0) from 1st to 2nd measurement, twofold for triglycerides, threefold for waist circumference and fivefold for blood glucose. People without risk factors fell from 32.5%; (95% CI:27.4-37.6) to 14.6% (95% CI:9.3-19.9). Median BMI was 27.8 (IQR:25.0-31.1) at 2nd measurement, an increase of three units over 10 years. Increases were also ascertained in cardiovascular risk factors: glycaemia ≥110 mg/dL from 5 (95% CI:4-7) to 24% (95% CI:22 to 27); triglycerides ≥150 mg/dL from 18 (95% CI:15-20) to 35.3% (95% CI:32.0-38.0); elevated waist circumference from 17 (95% CI:15-19) to 42% (95% CI:39-45). We found inverse associations between birth weight and gly-

caemia, blood pressure, and cholesterol in adult life but not between birth weight and insulin resistance or metabolic syndrome. Also, there were no association between weight at 12 months and blood pressure or lipids in adulthood.

Cohort B: Median BMI at 22-28 years (ongoing follow-up, completing data) is being estimated in 26.3 (IQR:23.4-30.1), almost the level reached by Cohort A when had 10 years older.

**Discussion:** Results show the unfavorable evolution of cardiovascular risk factors in young adults over time, still maintained in a younger generation. This evidence supports prevention policies directed to early ages without neglecting young adults, which currently, is not a target for health nutrition programs. This will allow to delay the onset of chronic diseases and improve the quality of life of adults.

**Acknowledgements:** Supported by The Wellcome Trust Grant 05944827; National Research Fund Chile Grants 1010572, 1100414 and 1140453.

**Keywords:** Cohort study, young adult, Chile

**Further collaborators:** Ximena Vasquez. Nutrition Department, Faculty of Medicine. University of Chile

## RETROSPECTIVE COHORTS STUDIES IN CHILE

Mardones, Francisco

MD, MSc. Department of Public Health. Pontificia Universidad Catolica de Chile. Chile

I have been involved in three retrospective cohort studies performed in Chile. All retrospective cohorts studies presented here were designed by linking present data of children with perinatal records which were complete for about 98% of the cases. The individual identification number is recorded in the birth certificate and also in the identification card of the children; its presence enabled us to link the live birth and childhood files. This unique identification number has been recorded at birth in Chile since the 1990s.

Two publications reported results of one of our studies with a sample of about 3,300 children, with mean age of 11 years, attending public schools in a county from Santiago, Chile; a much smaller sub-sample of 156 children from that study was informed in the third publication. These three reports were the following: A) Mardones F et al. J Devel Orig Health Dis 2012;3(4):237-244. B) Mardones F et al. Biomed Research International 2014:472017. doi: 10.1155/2014/472017. C) Krause BJ et al. PLoS ONE 2015;10(6): e0128140. doi:10.1371/journal.pone.0128140. 1-18). In the first two papers we showed that some indicators of the metabolic syndrome and insulin resistance were U-shaped or J-shaped associated to birth weight, in a similar manner to findings of previous studies that have established that infants at the normal extremes of birth weight are more likely to develop chronic disease (Hales & Barker DJ. Int J Epidemiol. 2013; 42(5): 1215-22; Cnattingius S, et al. Int J Obes (Lond). 2012; 36(10):1320-4). In the third publication, it was concluded that micro-RNAs Let7e and 126 can be considered as early markers of metabolic disease; linear associations were found between those variables and U-shaped or J-shaped
associations could not be tested due to the small sample size under consideration. The remaining two studies were respectively related to child obesity and school performance (1. Mardones F, et al. Int J Epidemiol 2008;37:902-910. 2. Villarroel L et al. J Dev Orig Health Dis 2013; 4(3):232-238). The first one covered the whole school-age population of Chile and the second one covered around 90% of it. Our findings on child obesity showed that just high birth weight values were related to that outcome during childhood; this was also the case for the association with obesity in our previously commented study of 3,300 children. Given that those studies have been done in school age populations, it is important to consider information from previous studies, notably the 1958 birth cohort in the United Kingdom which was able to assess birth weight in relation to body mass index at five different time points in the lifecourse from 7 to 33 years old (Parsons TJ et al. BMJ. 2001; 323(7325):1331-5). That analysis showed a direct association between infant birth weight and BMI, becoming more j-shaped by the age of 33. The study of the association of school performance with perinatal variables showed a positive association of birth weight and birth length with higher scores of school achievement.

**Keywords:** Cohort studies, children, obesity, metabolyc syndrome, birth weight

## CRITICAL WINDOWS FOR PREVENTION OF OBEsITY AND ASSOCIATED CONDITIONS: THE GOCS AND CHIMINO CHILEAN COHORTS

Although obesity and related chronic diseases are observed in adulthood, there is now consistent evidence that originate in early life. In 2006 initiated the longitudinal follow-up of 1195 Chilean children -The Growth and Obesity Cohort Study (GOCS)- with the support of the Chilean National Preschool Program. All children 2.6 to 4.0 y of age attending public nursery schools of six counties in Santiago and who met the inclusion criteria were invited to participate. The main aim was to assess the association between early weight and linear growth and BMI trajectories in preschool children. Retrospective weight and height measurements were abstracted from health records. From age of 3 years, children had annual appointment at INTA to collect standardized anthropometric measurements. A second follow-up was initiated in 2009 aimed to assess the relation between early growth and adiposity, metabolic/inflammatory, and hormonal markers during adrenarche. We added skeletal maturation, bio-impedance and body composition measurements, blood samples (insulin, glucose, lipid profile, adiponectin, leptin, and IGF1) and physical activity. Since 2011, GOCS aimed to assess the role of early growth and adrenarche on mammary development and putative markers of breast

development. We also added measurements of diet, EDC, inflammatory markers, and DNA methylation. GOCs results showed that pregestational obesity and excessive gestational weight gain related to obesity and associated metabolic conditions for both mother and offspring. Based on GOCS findings, in 2012, INTA initiated collaboration with the South East Health Area of Santiago to establish the Chilean Maternal and Child Health Observatory (CHIMINO). This observatory aims to provide evidence (at the population, clinical and basic science level) for achieving healthy nutrition for mothers and infants during the 1000-day early life window. The study optimizes data collection in the real world, through data linkage of electronic primary care and hospital records. The first initiative of this collaboration was the CHIMINCS study. CHIMINCS is a cluster randomized controlled trial in 12 primary health care centers that aimed to assess the effectiveness of a low intensity by high coverage intervention that enhances the implementation of updated nutritional health care standards (diet, physical activity, and breastfeeding promotion) during pregnancy on maternal weight gain and infant growth. The nutritional intervention was delivered through the national health care system under standard operating conditions. 4781 pregnant women were recruited. The second initiative of CHIMINO is the MIGHT study who aimed to assess the effectiveness of two prenatal nutritional interventions (home-based diet and physical activity counseling and/or n3LC-PUFAs supplementation) delivered to obese/ overweight pregnant women in achieving better metabolic control in both the mother (lower incidence of gestational diabetes mellitus) and the offspring (lower incidence of macrosomia and lower prevalence of insulin resistance at birth). A substudy of the MIGHT study will evaluate if neonates born from obese mothers supplemented with n3LC-PUFA during pregnancy show a lower percent of body fat at birth and at 4 months of age, as well as the reversion of functional and epigenetic changes in neonatal monoacyles at birth, compared to neonates from obese mothers with low n3LC-PUFA intake.

**Keywords:** Obesity, Chronic Diseases, Prevention, Cohort, Chile

**Further collaborators:** Dr Juliana Kain, Institute of Nutrition and Food Technology, University of Chile, Chile

Dr. Veronica Mericq, Faculty of Medicine, University of Chile, Chile

Dr José Luis Santos, Faculty of Medicine, Pontifical Catholic University of Chile, Chile

Dr Karin Michels, School of Public Health, UCLA, USA

Dr Juan Cristobal Gana, Faculty of Medicine, Pontifical Catholic University of Chile, Chile

Dr Alvaro Vergés, Faculty of Psychology, Pontifical Catholic University of Chile, Chile

Dr Marcela Araya, Faculty of Medicine, University of Chile, Chile

Dr Paola Casanello, Faculty of Medicine, Pontifical Catholic University of Chile, Chile

Dr Juan Pedro Kusanovic, Faculty of Medicine, Pontifical Catholic University of Chile, Chile

<footnote>(1)Corvalan, Camila; (2)Garmendia, María Luisa; (3)Pereira, Ana;</footnote>

<footnote>(3)Uauy, Ricardo.</footnote>

<footnote>(1)PhD. MD.MPH. Institute of Nutrition and Food Technology. University of Chile. Chile.; (2)PhD. Institute of Nutrition and Food Technology. University of Chile. Chile.; (3)PhD. Institute of Nutrition and Food Technology.University of Chile. Chile.</footnote>
Track 2: Nutrition Through Life Course

SS_144/1030

PROMOTION AND CONSUMPTION OF COMMER-
CIALLY-PRODUCED SNACKS DURING THE COM-
PLEMENTARY FEEDING PERIOD: COUNTRY EXPE-
RIENCES, POLICY IMPLICATIONS

SNACKS AND NUTRITION DURING THE COMPLE-
MENTARY FEEDING PERIOD: A CROSS-SECTIONAL
STUDY AMONG CHILDREN 12-23 MONTHS OF AGE
IN KATHMANDU VALLEY, NEPAL

(1)Pries, Alissa; (2)Sharma, Nisha; (3)Upadhyay, Atul; (4)Zehner, Elizabeth; (5)Filteau, Suzanne; (6)Ferguson, Elaine.

(1)MPH. Helen Keller International. USA.; (2)MPH. Helen Keller International. Nepal.; (3)PhD. Helen Keller International. Nepal.;

(4)PhD. London School of Hygiene and Tropcial Medicine. UK.

The availability of snack foods and sugar-sweetened beverag-
es (SSBs) has grown rapidly in recent decades, with consumption
of these foods increasing globally, noted across both high-income
and low and middle income countries (LMIC). Consumption of
snack foods and SSBs has also increased among children, including
infants and young children below two years of age. While snacks
can provide energy and potentially micronutrients during the nu-
tritionally vital complementary feeding period, consumption of
unhealthy snacks and SSBs, which are typically high in sugar and
salt, is cause for concern, because they could displace nutrient-rich
foods in diets of young children. Complementary feeding diets
high in sugar and salt could also result in excess energy intakes
and contribute to over-nutrition among young children. More re-
search is needed in this area, given the limited information on the
role of unhealthy snack foods and SSBs in the diets and nutrition
of infants and young children in LMIC contexts. Therefore, this
study in Kathmandu, Nepal aimed to assess the association be-
tween high consumption of unhealthy snack foods and SSBs and
the nutritional status of children during the complementary feed-
ing period, and to investigate factors associated with consumption
of these products. A cross-sectional survey was conducted from
February to April, 2017 on a representative sample of 12-23 month
old children (n=702) living in Kathmandu Valley. Dietary intake
(24-hour recalls), anthropometric (length and weight) and mi-
cronutrient status (vitamin A and iron) data were collected; and
are currently being analysed. Preliminary findings related to the
children's nutritional status and snack consumption patterns will
be presented. This study intends to increase awareness of snack
consumption patterns in a LMIC context and to inform policies
and programs aimed at improving infant and young child nutri-
tion in Nepal.

Keywords: Snacks, IYCF, Nepal, nutrition, double burden

POINT-OF-SALE PROMOTION OF FOODS FOR
CHILDREN UNDER THREE YEARS OF AGE ACROSS
RETAIL OUTLETS IN BANDUNG CITY, INDONESIA

(1)Hadihardjono, Dian; (2)Green, Mackenzie; (3)Ong, Agustino;

(4)Zakiyah, Rima; (5)Champeny, Mary; (6)Zehner, Elizabeth.

(1)MD. MSc. IBCLC. ARCH Project. Helen Keller International. Indonesia.; (2)MHS. ARCH Project. Helen Keller International. Cambodia.; (3)MSc. ARCH Project. Helen Keller International. Indonesia.;

(4)SP. ARCH Project. Helen Keller International. Indonesia.; (5)BSc. ARCH Project. Helen Keller International. USA; (6)MPH. ARCH Project. Helen Keller International. USA.

**Background and objectives:** Caregivers of young children should be able to make decisions about breastfeeding and complementary feeding free from commercial pressure. Preventing promotion of breastmilk substitutes (BMS), curbing inappropriate promotion of complementary foods, and discouraging use of unhealthy commercial snacks are important to protect child nutrition.

**Methods:** A cross-sectional survey of retail outlets was conducted to document the prevalence of point-of-sale (POS) promotions of commercial foods fed to children under three years of age in Bandung City, Indonesia. Researchers compiled a comprehensive list of all BMS and commercial complementary foods for sale in Bandung, and then visited 33 purposely selected small stores in closest walking distance to public sector health facilities and ten large retail outlets purposely selected for their high volume of products. Promotional activity for any BMS and commercial complementary foods in these stores was recorded and photographed using an electronic mobile data collection system. The proportion of sampled stores which had POS promotions for each product category and the total number of POS promotions for BMS and commercial complementary foods were calculated. Any POS promotions for select categories of commercial snacks (sweet biscuits, savory snacks, jellies, candies/chocolates and sweetened milks) were also documented and assessed for child-targeted marketing elements including images of children, free gifts, or statements directed to caregivers about young children.

**Results:** In the 43 stores, a total of 147 BMS products and 218 commercial complementary foods were for sale. A preliminary total of 3000 promotions for BMS, commercial complementary foods and select snack categories were documented. A single promotion often featured multiple products; overall, the 3000 promotions featured approximately 900 BMS, 700 complementary foods, 2400 sweet biscuits, 1400 savory snacks, 2900 candies/chocolates, 80 jellies, and 1700 sweetened milks.

**Conclusions:** These findings will contribute to the Indonesian government's efforts to strengthen policies regulating promotion of products fed to young children.

**Keywords:** Breastmilk substitute, infant formula, snacks, promotion, complementary feeding
SNACK CONSUMPTION DURING THE COMPLE-
MENTARY FEEDING PERIOD: A CROSS-SECTION-
AL STUDY AMONG CHILDREN 6-23 MONTHS OF
AGE IN URBAN SENEGAL, TANZANIA, NEPAL AND
CAMBODIA

(1)Pries, Alissa; (2)Huffman, Sandra; (3)Vitta, Bineti; (4)Sy Gueye, Ndeye Yaga; (5)Diop, El Hadji Issakha; (6)Mengkheang, Khin; (7)Adhikary, Indu; (8)Champeny, Mary; (9)Zehner, Elizabeth.

(1)Helen Keller International. ARCH Project. (2)ScD. Consultant. USA.; (3)PhD. Consultant. USA.; (4)MSc. Helen Keller International. Senegal.; (5)PhD. Helen Keller International. Africa Regional Office. Senegal.; (6)MSc. Consultant for Food Security and Nutrition. Cambodia.; (7)MPH. Consultant. Nepal.; (8)BSc. Helen Keller International. USA.; (9)MPH. Helen Keller International. USA.

**Background and objectives:** Dietary patterns associated with the nutrition transition have resulted in increases in consumption of commercially produced snack foods in many low and middle-income countries. Many snack foods are nutrient-poor and high in salt, sugar, and/or transfats making them inappropriate for young child feeding. This survey assessed consumption of foods and liquids including commercially produced snack foods among children 6-23 months of age and mothers' exposure to promotions for these products.

**Methods:** Health facility-based interviews were conducted among 218 randomly sampled mothers utilizing child health services in Dakar, Senegal; 229 in Dar es Salaam, Tanzania; 228 in Kathmandu Valley, Nepal; and 222 in Phnom Penh, Cambodia.

**Results:** In the day prior to the interview, 58.7% of 6-23 month olds in Dakar, 23.1% in Dar es Salaam, 74.1% in Kathmandu Valley, and 55.0% in Phnom Penh had consumed a commercially produced snack food. In the previous week, the majority of children in Dakar (79.8%), Kathmandu Valley (91.2%) and Phnom Penh (80.6%) had consumed such products. Among 12-23 month olds, snack foods were the second most commonly consumed food group in Dakar, and third most common in Kathmandu Valley and Phnom Penh. Sweet snack foods, such as cookies and candy, were the most commonly consumed snack products in Kathmandu Valley and Dar es Salaam, while savoury snack foods, such as chips or crisps, were the most commonly consumed in Phnom Penh and Dakar. In all four sites, the primary reason reported among mothers was because the child liked the snack food. Over one-third of mothers in Kathmandu Valley reported feeding commercially produced cookies (40.4%), candy (33.8%) or cakes (34.4%) because they were convenient food options and one-fifth (21.5%) of Phnom Penh mothers reported feeding cookies because they believed they were healthy for their child. Observations of promotions for snack foods were reported by almost all mothers in Dakar and Phnom Penh, over 3/4ths in Kathmandu and half in Dar es Salaam.

**Conclusions:** Snack consumption during the critical complementary feeding period demands attention. Overconsumption of commercial snack foods may contribute to undernutrition and may also lead to excess energy intake and increased risk for childhood overweight.

**Keywords:** Snacks, IYCF, complementary feeding, double burden, undernutrition

SS_144/1058

FIRST-FOODS: ACCELERATING PROGRESS TO
IMPROVE THE QUALITY OF COMPLEMENTARY
FOODS AND FEEDING PRACTICES FOR CHILDREN

COMPLEMENTARY FEEDING PRACTICES: CUR-
RENT GLOBAL AND REGIONAL ESTIMATES AND
ASSOCIATION WITH STUNTING AMONG YOUNG
CHILDREN IN LOW- AND MIDDLE-INCOME
COUNTRIES

(1)Begin, France; (2)White, Jessica M.; (3)An, Xiaoyi; (4)Kumapley, Richard; (5)Murray, Colleen; (6)Frongillo, Edward; (7)Krasevec, Julia.

(1)PhD. Nutrition Section. Programme Division. UNICEF Headquarters. New York. USA.; (2)Nutrition specialist. Nutrition Section. Programme Division. UNICEF Headquarters. New York. USA.;
(3)Data and Analytics Section. Division of Data, Research and Policy. UNICEF Headquarters. New York. USA.; (4)Statistics and monitoring officer. Data and Analytics Section. Division of Data, Research and Policy. UNICEF Headquarters. New York. USA.;
(5)Statistics Specialist. Data and Analytics Section. Division of Data, Research and Policy. UNICEF Headquarters. New York. USA;
(6)PhD. Professor. Department of Health Promotion, Education and Behavior. University of South Carolina. Columbia. South Carolina. USA; (7)Statistics and Monitoring Specialist. Data and Analytics Section. Division of Data, Research and Policy. UNICEF Headquarters. New York. USA.

Adequate quantities and quality of complementary foods, to-
gether with age-appropriate feeding practices are essential for chil-
dren's health and nutrition. We use the UNICEF global database to
report on complementary feeding at the global and regional levels
as sufficient data to generate estimates only became available re-
cently. We also examined the association between two indictors
of dietary quality - dietary diversity and animal source food (ASF)
consumption - and stunting (length-for-age z-score) employing
existing data from 39 Demographic and Health Surveys. Data
for children aged 6-23 months were pooled and multiple logistic
regression models, adjusting for child, maternal, and household
characteristics, employed to assess the association between die-
tary quality and stunting. We found that children 6-11 months old
had the lowest rates of minimum dietary diversity (MDD) than
any other age group (~17 per cent compared to 31.5 and 37.6 per
cent for the 12-15 and 16-23 months old, respectively). The rate
for MDD among children in the richest households was two times
higher than children in the poorest households at the global level.
Across regions, consumption of fruits and vegetables and animal
source foods was particularly low. Children who had consumed
zero food groups in the previous day had a 1.345 higher odds of
being stunted when compared to the reference group (≥ 5 food
groups); those who did not consume any ASF in the previous day had a 1.436 higher odds of being stunted compared to children consuming all 3 types of ASF (egg, meat and dairy). In summary, far too few children are benefitting from minimum complementary feeding practices and meeting the minimum dietary diversity is particularly of concern. Dietary diversity and ASF consumption were associated with stunting. Efforts are needed to improve children's diets for their survival, growth and development.

**Keywords:** Infant and young child feeding. Diet diversity. Animal source foods. Complementary feeding. Child growth.

## CONSUMPTION OF COMMERCIAL SNACK FOOD PRODUCTS AMONG YOUNG CHILDREN

(1)Pries, Alissa; (2)Huffman, Sandra; (3)Champeny, Mary; (1)Zehner, Elizabeth; (4)Filteau, Suzanne; (4)Ferguson, Elaine.

(1)MPH. Helen Keller International. USA.; (2)ScD. Consultant. USA.;

(3)BSc. Helen Keller International. USA.; (4)PhD. London School of Hygiene and Tropcial Medicine. UK.

The global food system has been marked by increased production and availability of processed foods. Commercially produced snack foods and sugar-sweetened beverages (SSBs) have become common in children's diets across high-income countries and are increasingly noted in the diets of infants and young children in low- and middle-income countries (LMIC). A recent cross-sectional survey among mothers found high consumption of sweet and savory snack food products among children 6-23 months of age in urban Cambodia (55.0%), Nepal (74.1%), Senegal (58.7%), and Tanzania (23.1%), and other studies have noted similar consumption rates in Central and South America. Snacks can be an important source of energy and potentially nutrients for young children; however, this prevalent consumption of commercial snack food and beverage products, often energy-dense and nutrient-poor, among young children in LMIC is concerning. There is a need to understand the role of such foods in young children's diets and their influence on dietary adequacy and nutritional status. In 2016, a literature review was conducted to identify studies assessing snack food and SSB consumption among children in Asian LMIC, and associations between this consumption and nutritional status; 68 articles resulted from this search. While studies detailing snack food and SSB consumption among preschool- and school-age children were common, only 9 studies assessed the contribution of such foods to diets during the complementary feeding period. Across these studies among children below two years of age, snack food and beverage consumption rates increased with age, and consumption of snack foods was more common than consumption of SSB. Only 4 of the studies including infants and young children gathered quantitative dietary intake data. Of these, the contribution of energy intake from snack food and beverages among young children ranged from 25-42%, comparable to snack food and beverage consumption among children in high-income settings. Twenty-one of the 68 studies included in this review assessed associations between snack food and beverage consump-

tion and nutritional status among pre-school/school-age children. Those investigating over-nutrition among children noted positive associations with overweight/obesity or waist circumference, while those considering undernutrition found negative associations with wasting, underweight and HAZ. However, only one study assessing these associations included children below two years of age. This review indicates a large gap in the literature regarding the contribution of commercial snack food and beverages products to diets of young children in LMIC, as well as the associations between consumption of these products and diet adequacy, micronutrient status, and linear and ponderal growth among children below two years of age. Further research is needed in order to understand how consumption of nutrient-poor snack foods influences both under- and over-nutrition in young children during the complementary feeding period.

**Keywords:** Snacks, IYCF, nutrition, double burden

## USING BEHAVIOR CHANGE TO IMPROVE COMPLEMENTARY FEEDING PRACTICES

(1)Sanghvi, Tina; (2)Baker, Jean; (3)Seidel, Renata; (4) Jimerson, Ann.

(1)PhD. Nutritionist. Alive & Thrive FHI360 Washington DC. USA.;

(2)MPH. Alive&Thrive. FHI360. Washington DC. USA.; (3)MPH.

FHI360. Washington DC. USA.; (4)Senior Behavior Change Advisor.

FHI360. Washington DC. USA.

There are few well-documented program experiences that can provide insights on operational steps needed to improve complementary feeding practices. This paper compares four examples of complementary feeding programs from Bangladesh, Malawi, Peru and Zambia to document different context-specific ways of designing and implementing programs. After searching published and unpublished reports, four programs met the criteria for inclusion: scalability and impact on complementary feeding practices, and detailed documentation including impact evaluation. This paper identifies similarities and differences in the program designs and in operational strategies that were used for implementation. All programs applied social and behavior change principles and used diverse, multiple program delivery platforms. The contexts in each country were different and also the challenges encountered. This provides a rich source of lessons learned for future programs. The results show that complementary feeding practices can be improved rapidly in a variety of settings using available program channels. To achieve success, interventions should systematically address specific constraints to food access and should apply effective behavior change strategies to encourage caregivers to prepare and feed appropriate foods. Programs can use a five-step process to develop effective programs: 1. Select a few practices to focus the strategy based on best potential to benefit the population, using criteria such as high efficacy, low baseline levels and high acceptability and feasibility to improve; 2. fill knowledge gaps and obtain an understanding of the determinants of complementary feeding, investing in activities that address underlying barriers and build on the facilitating factors for behavior change in the community;
3. thoroughly test and verify concepts, recipes, messages, processes and tools before large scale implementation; 4. work through channels of service delivery and communication that reach mothers repeatedly at the right ages and also engage key influential groups; and, 5. maintain high reach and frequency for at least two years while making rapid mid-course corrections as indicated by monitoring data.

**Keywords:** Complementary feeding, child nutrition, behavior change, implementation research, framework for scaling up

## TIME TO REVISE THE COMPLEMENTARY FEEDING GUIDELINES?

Grummer-Strawn, Laurence.

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

In 2003 and 2005, WHO published the Guiding Principles for Complementary Feeding of the Breastfed Child and Guiding Principles for Feeding Non-Breastfed Children 6-24 Months of Age. These documents were largely focused on ensuring that young children received enough of the nutrients they need for optimal health and development. The primary outcomes of interest were prevention of wasting and stunting. Over the past decade, the growing problem of childhood obesity and the establishment of dietary patterns that predispose toward non-communicable diseases have increasingly been recognized as important issues for infant and young child feeding. In addition, new evidence has emerged on key issues of feeding, including the importance of quality and quantity of protein, animal source foods, fat quality, and sugar intake. New issues on the effect of the young child's diet on body composition and gastrointestinal microbiota may also be important.

With this backdrop, WHO is embarking on a process to develop new guidelines on complementary feeding. The WHO guidelines process is very rigorous and includes steps to scope the coverage of the guideline, create a diverse external Guideline Development Group, screen members for conflicts of interest, formulate key questions for systematic literature reviews, conduct evidence reviews, formulate recommendations, conduct external peer review, and finally publish the guideline. For complex guidelines that include a number of recommendations, such as complementary feeding, this process can take a couple of years.

Nutrition in the first 1000 days of life is critically important for child development and prevention of health problems related to both undernutrition and non-communicable diseases. Thus, it is important that we develop evidence-based feeding recommendations that will lead to optimal health and development.

**Keywords:** Complementary feeding, infant and young child feeding

# Track 3: Public Health Nutrition and Environment

SS_144/1049

## SCALING UP RICE FORTIFICATION IN LATIN AMERICA AND THE CARIBBEAN

### SCALING UP RICE FORTIFICATION IN LATIN AMERICA AND THE CARIBBEAN: TRANSLATING EVIDENCE TO PRACTICE FOR DEMAND CREATION AND EFFECTIVE PROGRAMMING

(1)Kraemer, Klaus; (2)Pachón, Helena; (3)Martinez-Fonseca, Jose Antonio; (4)Irizarry, Laura; (4)Prost, Marc-André.

(1)Sight and Life Magazine; (2)Food Fortification Initiative; (3)National Association of Rice Millers of Costa Rica; (4)World Food Programme.

Fortification of staple foods with essential vitamins and minerals is the most cost-efficient public health tool for the prevention and control of micronutrient deficiencies. Micronutrient deficiencies such as iron deficiency anemia, zinc deficiency and vitamin A deficiency remain a serious public health concern in most Latin American and Caribbean countries, particularly amongst women of reproductive age, children and indigenous groups. Most countries mandate wheat flour and salt fortification; fortification of other products like corn flour and sugar is voluntary in others. There are currently 125 national programs addressing micronutrient deficiencies across the region, most of them through supplementation. Known challenges, such as lack of reliable data, poor acceptability and adherence, weak monitoring and evaluation, limit their impact.

Rice is the staple food to a third of humanity, and represent a sizeable part of energy intake in South America and the Caribbean sub-regions. While milled rice is a good source of energy, it is a poor source of micronutrients. In countries with widespread micronutrient deficiencies and large per capita rice consumption, making rice more nutritious can effectively increase micronutrient intake, and improve nutritional status. Only six countries globally have passed legislation for the mandatory fortification of rice, including three in Central America. In practice, only Costa Rica has a standing, successful, mandatory rice fortification programme in the region. Over the years, one of the key challenges to the implementation rice fortification in country was technological limitations; today, affordable technology exists to produce fortified rice kernels that look and taste like non-fortified rice.

The World Food Programme's Rice Fortification Initiative started in 2016 and supports seven countries in the region to advance towards the mandatory fortification of rice, through technical assistance for stakeholder engagement and policy making, transfer of technology, behavior change communication, social
marketing, monitoring systems, and feasibility trials. As part of this initiative a Special Supplement on Rice Fortification for Latin America, available in Spanish and English, was published together with the Sight and Life Magazine.

In this symposium, we will present three country case studies and discuss effective policy and programme planning options taken to introduce rice fortification in the region.

**Keywords:** Rice fortification, food fortification, Latin America and the Caribbean, micronutrients, public health.

**Conflict of Interest disclosure:** The World Food Programme and DSM Nutritional Products have an ongoing global partnership. WFP does not endorse any product or service.

SS_144/1034

# LEVERAGING FOOD SYSTEMS TO IMPROVE FOOD SYSTEMS AND NUTRITION

## FOOD SYSTEMS ROLE IN ACHIEVING GOALS OF THE DECADE OF ACTION FOR NUTRITION

Lartey, Anna.

PhD. Nutritionist, Food and Agriculture Organization of the UN.
Rome Italy.

Although global food production has increased, addressing malnutrition remains a huge challenge. About one in three persons suffers from some form of malnutrition. The current food system is contributing to worsening the nutrition situation by not delivering on healthy diets. Unhealthy diets have become the number one risk factor for the global burden of disease for adults. Concerns about the global nutrition situation was an impetus for the United Nations declaration of the period 2016 to 2025 as the UN Decade of Action on Nutrition. The aim of the Nutrition Decade is to accelerate action on implementation of commitments to achieve global nutrition and diet-related targets by 2025, and contribute to the realization of the 2030 Agenda of the Sustainable Development Goals (SDG); and leaving no one behind. The Nutrition Decade provides a momentum and direction in global action to address all forms of malnutrition. A Decade is rather short but what are the low-hanging fruits to harvest to achieve the goals of the Decade? Transforming the food system is an absolute necessity. We need functioning food systems that would deliver the diverse, safe and nutritious foods all year round. Transforming the food system is integral to the goals of the Decade and the SDGs. Transforming the food system will require a change in national policies to ensure that nutrition objectives are embedded in agriculture, trade and other sectors policies; consumers are empowered to make healthy food choices the easier choice and above all, governments must plan cities with a food systems perspective.

**Keywords:** Food systems, Decade of Action on Nutrition, Goals

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# LESSONS LEARNED FROM MULTI-SECTORAL IMPLEMENTATION OF NUTRITION PROGRAMS

## WHY IS A MULTI-SECTORAL APPROACH NEEDED FOR NUTRITION, AND WHY IS IT SO HARD TO ACTUALLY PUT THAT IT INTO PRACTICE?

Guyon, Agnes.

John Snow Incorporated (JSI). USA.

The World Health Organization estimates that child under-nutrition is associated to 45% of under-five death and that maternal short stature and iron deficiency anemia contribute to at least 20% of maternal deaths. The landmark Lancet Series on Maternal and Child Undernutrition, published in 2008 and updated in 2013 reviewed global data from randomized control trials and confirmed that if implemented at scale during the window of opportunity (from conception up to 24 months of age) packages of nutrition-specific and nutrition-sensitive interventions can significantly reduce nutrition related mortality and related morbidity and disability. In addition in 2013 the World Health Organization (WHO) released a guide entitled, Essential Nutrition Actions: improving maternal, newborn, infant and young child health and nutrition, which also draws on the findings of systematic reviews such as those of the Lancet to highlight the proven actions that need to be taken to scale within the health sector.

This Satellite Symposium attempts to be a technical forum on "Lessons from multi-sectoral implementation of nutrition programs". During this symposium, JSI and its partner agencies will share results, insights and lessons from a broad range of nutrition State of the Art Implementation practices. Three renowned experts will present the latest technical information and current trends and key lessons learned for nutrition implementation within and across sectors: programming nutrition sensitive agriculture, nutrition within the health sector, and WASH in nutrition programs. Following presentations, participants will experience two interactive knowledge coffee sessions in break-out groups, facilitated by guest experts who will share expertise, facilitate discussion and answer questions., Some of these sessions will be:

1. District approach on the control of anemia: training and programming activities and tools – Experiences from Ghana, Nepal and Uganda

2. Different approaches to Farmer Field Schools for improved nutrition – Experiences from Bangladesh and Ghana

3. Multi-sectoral approach of engaging district government in joint planning, budgeting, implementation – Experience from Ghana

4. Pathways for better nutrition: a tool to track country nutrition budgets across sectors – Experiences from Nepal and Uganda

5. Multiple behavioral themes in one strategy and one program – Experiences from multiple countries

6. A successful integrated approach – The Suaahara Project in Nepal
7. Programmatic approaches to impact dietary diversity – Experiences from multiple countries

8. Gender transformative approaches critical to achieving the goals of multi-sectoral nutrition programming – Experiences from multiple countries

9. Marketing of complementary foods: Findings from multiple countries – The ARCH Project

10. Use of applied technology to monitor nutrition outcomes

11. Platforms to reach adolescents to improve nutrition

At the end of the knowledge coffee sessions, participants will share their take-away messages and a guest expert will summarize how to move forward the successes shared on implementing nutrition programs across sectors.

**Keywords:** Guest speakers and knowledge coffee

**Further collaborators:** Heather Danton, MSc. Director, Food Security and Nutrition. SPRING Project, John Snow Inc.

Francesco Bianca, MD. Director Nutrition Division Director of Nutrition for Health and Development, World Health Organization

Jennifer Nielsen, DrPH. Senior Nutrition Advisor. Helen Keller International

## WHAT HAVE WE LEARNED ON PROGRAMMING NUTRITION SENSITIVE AGRICULTURE?

Danton, Heather.

BSc. MSc. Food Security and Nutrition Director. SPRING Project.

JSI Research and Training Institute Inc. USA.

A multi-sectoral approach is needed to meet the global targets for nutrition, including scaled-up, proven nutrition-specific and nutrition-sensitive interventions.(1) But the literature has been weak on how investments have bridged the often siloed agriculture and nutrition interventions and goals. In 2012, SPRING conducted a landscape analysis of activities of the U.S. Government's global hunger and food security initiative, Feed the Future, in 19 focus countries in Africa, Asia, and Latin America, and the Caribbean.(2) The findings of the landscape analysis pointed to specific gaps in implementing nutrition-sensitive agriculture, including the lack of:

* effective approaches for multi-sectoral coordination;

* appropriate context assessments to inform design of nutrition-sensitive agriculture interventions;

* indicators that track the intermediate steps along the agriculture-to-nutrition pathways; and

* effective behavior change interventions that target the actors along value chains and agriculture-nutrition pathways.

This presentation will review the work SPRING has done since the publication of the landscape analysis to help fill these gaps, especially related to how to make multisectoral collaboration operationally feasible.

In developing guidance and resources to address the gaps listed above, SPRING found key areas of convergence and tension between the agriculture and nutrition sectors related to the design

and implementation of nutrition-sensitive agriculture programs including beneficiary targeting, intervention approaches, commercialization of food, and monitoring and evaluation. (3) These observations underscored the need for better design guidance to reconcile the tensions and leverage convergences to maximize agriculture's contribution to nutrition. We therefore developed a range of materials and tools, beginning with a database of resources for conducting a context assessment specifically for nutrition-sensitive agriculture. We also developed process guidance to enable agriculture market development activities to identify appropriate intermediate outcomes and develop custom indicators to monitor agriculture's contribution to nutrition. Finally, SPRING created an online training course, called Accelerating Behavior Change in Nutrition-Sensitive Agriculture, for designing behavior centered practices. The training helps implementers select, prioritize and then increase use of nutrition-sensitive agriculture practices.

At the same time, SPRING conducted research to better understand existing efforts to coordinate nutrition across USAID portfolios in Bangladesh, Guatemala, and Rwanda. Our findings resulted in a set of recommendations for multi-sectoral collaboration strategies for nutrition organized along a project life cycle.

SPRING has learned that not every agriculture investment can or should focus on nutrition. However, nearly all have some contribution they can make towards improving nutrition. We hope our resources help donors and practitioners design, deliver, and document their unique 'win' for nutrition.

### References

1. Ruel, M. T., H. Alderman, and the Maternal and Child Nutrition Study Group. 2013. "Nutrition-Sensitive Interventions and Programmes: How Can They Help to Accelerate Progress in Improving Maternal and Child Nutrition?" The Lancet 382(9891): 536-51.

2. Du, Lidan. 2014. Leveraging Agriculture for Nutritional Impact through the Feed the Future Initiative: A Landscape Analysis of Activities Across 19 Focus Countries. Arlington, VA: USAID/ Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) Project.

3. USAID. 2016. "Convergences and Tensions in Nutrition-Sensitive Agriculture Market Development Activities: A Discussion Paper. Washington, D.C.: USAID.

**Keywords:** Nutrition-sensitive, multi-sectoral, agriculture, coordination

## WHY IS IT SO IMPORTANT TO INCLUDE WASH IN NUTRITION PROGRAMS?

Nielsen, Jennifer.

PhD. Senior Nutrition Advisor. Helen Keller International. New York. NY. USA.

The 2013 Lancet Series on Maternal and Child Undernutrition estimated that if the full package of 10 evidenced-base nutrition-specific interventions were delivered at 90 percent coverage across the countries with the highest burden of undernutrition,
stunting prevalence could be reduced by 20 percent and severe wasting by 61 percent. This leaves a considerable proportion of the burden that must be overcome using other strategies.

Poor water, sanitation and hygiene (WASH) conditions and practices also contribute significantly to undernutrition. Contaminated water, soils and hands cause diarrheal disease, parasitic infections, foodborne infections and many other illnesses that contribute to nutritional deficiencies. These infections cause blood loss, diminished appetite, reduced absorption and increased permeability of the intestinal lining, and trigger immune responses that divert nutrients from fueling growth to fighting infection. Both human and animal feces contain high levels of dangerous pathogens, and are often in the vicinity of living and cooking quarters. Infections can result from eating with unwashed hands, eating inadequately washed plants grown in contaminated soils or foods on which mycotoxins have grown, and by walking barefoot. In addition, flies carry pathogens from feces to foods, and microbes quickly multiply in foods that are stored at ambient temperature or insufficiently cooked or reheated. Toddlers crawl on the ground and explore their environment by putting hands and objects into their mouths, greatly increasing their exposure to dangerous pathogens. Infants and young children are especially vulnerable because their immune systems are still immature, and pregnant women also have decreased immune function.

There are many WASH interventions, most of which, like nutrition interventions, require changes in behavior, habits and norms that are challenging to achieve. These include promoting the appreciation and practice handwashing with soap, community-wide latrine construction and utilization strategies, household water treatment and safe storage techniques, food and utensil hygiene and storage, designating safe play areas for young children, and keeping animals at a remove from living spaces. While the pathways from contamination to undernutrition are clear, there is still a limited evidence base for the impact of these interventions on nutritional outcomes, thus innovative intervention strategies and further research are needed.

**Keywords:** Handwashing, water treatment, food hygiene

**Further collaborators:** Agnes Guyon, Director of the Material and Child Health Center, John Snow Incorporated (JSI).

(1)Zapata, María Elisa; (2)Soruco, Ana Ines; (3)Carmuega, Esteban.

(1)MSc. Nutritionist. Centro de Estudios sobre Nutrición Infantil (CESNI). Buenos Aires. Argentina.; (2)MSc. Nutritionist. Ministry of Health of Jujuy. Argentina; (3)Director. Centro de Estudios sobre Nutrición Infantil (CESNI). Buenos Aires. Argentina.

**Background:** Malnutrition during critical stages of life as infancy, childhood, reproductive age and pregnancy, are associated with significant functional impairment as well as health and socioeconomic consequences.

**Objective:** The aim of this analysis was to assess the prevalence of five forms of malnutrition (wasting/underweight, overweight, obesity, stunting/short stature and anemia) by socio economic status and education level among children, adolescents and women of reproductive age from Argentina.

**Design:** Cross-sectional analysis of the National Survey of Health and Nutrition carried out in 2005. Anthropometric indicators and anemia were estimated from 27015 children (aged <5y), 1729 girls (11-19y) and 4401 women (20-49y). Socioeconomic level was classified according to the proportion of contributors in the household, educational level, employment status and medical coverage.

**Results:** In Argentina 26% of households lived with unsatisfied basic needs and 23% receives at least one food assistance in 2005. The 23% of children, 36% of girls 10-19y and 56% of women were affected from any form of malnutrition.

Children were specially affected by anemia, overweight/obesity and stunting (15.2, 9.9, 7.4% respectively). Girls were affected by overweight/obesity, anemia and stunting (22.5, 15.2, 6.2% respectively). Women were strongly affected by overweight/obesity, anemia and stunting (43.8, 19.8, 10.5%). Stunting or short stature was higher in lower SES, doubling the prevalence between low and high level, reaching the quadruple among women in reproductive age (p<0.05). In children excess weight increased when improved SES, meanwhile in women the tendency was inverse. Anemia showed different tendency according SES.

**Conclusions:** The data showed high rates of excess weight and anemia, moderate prevalence of stunting and low frequency of wasting/underweight. Public health policies to date have been focalized in wasting/underweight, but have not responded adequately to the increase in overweight and obesity.

**Keywords:** Argentina, malnutrition, obesity, stunting, anemia
MALNUTRITION IN ALL ITS FORMS AND SOCIO-
ECONOMIC STATUS IN BOLIVIA

(1)Miranda, Melissa; (2)Bento, Alenkar; (3)Aguilar, Ana María.

(1)Phd. Nutritionist. Institute of Nutrition and Food Technology.
University of Chile. Chile.; (2)MSc. Public Health. Faculty of Med-
icine. University of San Francisco Xavier of Chuquisaca. Bolivia.;

(3)MD. Health and Development Research Institute Higher.
University of San Andrés. Bolivia.

**Background:** Malnutrition in all its forms is a growing public health problem in many developing countries. In Bolivia main public policies are mainly directed to control stunting and anemia, with few efforts to address the already high prevalence of overweight and obesity. In a country with substantial socioeconomic inequalities the current burden of malnutrition denotes a difficult challenge.

**Objective:** The aim of this study was to describe the charac-
teristics of all forms of malnutrition and its association with socio-
economic status in Bolivia in order to recommend effective public
health and nutrition policies to appropriately address this burden.

**Design:** By using the 2008 nationally representative Bolivian DHS, we estimated malnutrition's prevalence by socioeconomic status. The study comprised 8.432 children <5y, 3.258 women adolescents (15-19 y), and 12.297 women (20-49 y) with available information on anthropometric measurements. The socioeconomic status was calculated based on the DHS wealth index and nutritional status by using WHO 2006 and 2007 standards.

**Results:** Main prevalent problems found in this study were: underfive stunting 23% (95% CI: 22,14-24,29) and anemia 63.11% (95% CI: 60,82-65,40); overweight/obesity in women of 20-49 years old 56,88% (95% CI: 56,01; 57,76). Considering socioeconomic status lower terciles showed the higher prevalence of stunting (>30%) and anemia (>40%) in all ages. Prevalence of overweight/obesity had an upward trend from 10.81% (95% CI:10.02;11.60) in childhood to 29.46% (95% CI: 27,90;31,03) in adolescents women and 56.88% (95% CI: 56,01; 57,76) in women 20 to 49 years; with significant differences (p<0.05) across lower and high terciles (27.69% compared with 32,56%) in adolescent and low and medium terciles (p<0.05) in women (50,92 % compared with 63.08%, respectively).

**Conclusions:** The results reaffirms the existing double burden of malnutrition in Bolivia with high prevalence of overweight and obesity increasing throughout the course of life. Lower socioeconomic terciles have the worst situation of malnutrition. This study calls for public specific policies which need to keep in mind the differential characteristics of malnutrition across the levels of socioeconomic status.

**Keywords:** Bolivia, malnutrition, socioeconomic status

MALNUTRITION IN ALL ITS FORMS AND SOCIO-
ECONOMIC STATUS IN BRAZIL

(1)Canella, Daniela; (2)Duran, Ana Clara; (3)Monteiro, Carlos.

(1)Professor. PhD. Department of Applied Nutrition. Rio de Janeiro State University. Rio de Janeiro. Brazil.; (2)Research Fellow. PhD. Center for Epidemiological Research in Nutrition and Health. University of São Paulo. São Paulo. Brazil.; (3)Professor, PhD. Department of Nutrition. School of Public Health. University of São Paulo. São Paulo. Brazil.

**Background and objectives:** Despite worldwide progress in undernutrition, the condition is still present in a few countries and among some socioeconomic and age groups. At the same time, obesity levels are growing across the globe, including in low- and middle-income countries. The objective of this study was to describe malnutrition (over and undernutrition) by socioeconomic status (SES), level of education, and race/ethnicity in Brazil.

**Methods:** We used nationally representative data from the Brazilian Household Budget Survey conducted in 2008-2009 in the analysis. Measures of weight (kg) and height (cm) were collected by trained interviewers. Anthropometric indicators (overweight; obesity; overweight or obesity – excess weight; wasting or underweight; stunting or short stature) were estimated for children aged <5 years old, adolescent girls aged 11-19 years old, and women aged 20-49 years old using the World Health Organization recommendations. Prevalence of each indicator was presented by tertiles of socioeconomic status (per capita household income), level of education (years of schooling of the head of the household for children and adolescents and of the women themselves for adults, grouped in low [0-6y], medium [7-12y] and high [>12y]), and race/ethnicity (white, black, mixed-race, Asian, and indigenous). Results: The sample was composed by 73,620 individuals (n=14,580 children <5y; n=15,606 girls 11-19y; n=43,434 women 20-49y). Among children, the prevalence of excess weight, wasting and stunting was 16.91%, 2.75% and 5.97%, respectively. Differences related to SES, education, and race/ethnicity were verified, except for the prevalence of child wasting by the education level. Adolescent girls presented 18.40% of excess weight, 2.80% of underweight, and 5.52% of stunting. Prevalence of excess weight varied by SES and race/ethnicity, while stunting varied by SES and education level. Stunting prevalence was lower among white girls, as compared with mixed-race adolescent girls. Over three quarters of women aged 20-49 y presented excess weight (42.17%), 13.75% were found to be obese obesity, 3.86% of underweight, and 5.71% of short stature. Prevalence of excess weight was higher among lower educated and black women aged 20-49 y, as compared with highly educated and white women. Short stature was also more prevalent among black and mixed-race, low educated, and low-income women. Underweight prevalence was higher among lower educated and black and mixed-race women, as compared with highly educated and white women. Conclusions: In Brazil, the prevalence of excess weight was at least 3-fold higher than that of undernutrition for children and for adolescent girls. In adult women, the prevalence of excess weight was at least 7-fold higher than that of undernutrition. Lower income, less educated, as well as black and mixed-race women presented both more obesity and
stunting as compared with more privileged women. Public pol-
icies were successful at reducing undernutrition, however, con-
trolling or reducing obesity is still a challenge.

**Keywords:** Malnutrition; socioeconomic status; education; race relations; health status disparities; Brazil.

IS INEQUALITY AFFECTING THE NUTRITIONAL STATUS OF ADULT CHILEAN POPULATION? NU- TRITIONAL STATUS IN ADULT CHILEAN POPULA- TION: INEQUALITIES IN A POST-TRANSITIONAL COUNTRY

(1)Navarro-Rosenblatt, Deborah; (2)Mujica, Maria Fernanda; (3)Lopez-Arana, Sandra; (4)Corvalan, Camila.

(1)PhD. School of Public Health. University of Chile. Santiago. Chile.; (2)PhD. Food, Nutrition and Health. Faculty of Land and Food Systems. The University of British Columbia. Vancouver. BC. Canada.; (3)RD, PhD. Institute of Nutrition and Food Technology (INTA). University of Chile. Santiago. Chile.; (4)MD. PhD. Institute of Nutrition and Food Technology (INTA). University of Chile. Santiago. Chile.

**Background and objectives:** Previous research in Latin America shows that socioeconomic status (SES) influences dietary patterns and obesity distribution. However, it is unclear how SES impacts overall nutrition status, in a post-transitional country such as Chile. The objective of this study was to assess the relationship between nutritional status (overweight, short stature and anemia), and two key aspects of SES-income and educational level in adult Chilean population.

**Methods:** Nationally representative data of 1,413 women (20-49y) and 819 men (>49y) from the 2003 and the 2009-2010 Chilean National Health Surveys were included in these secondary analyses. Body mass index (BMI) was categorized as underweight, overweight and obesity according to WHO criteria. Overnutrition was defined as BMI ≥25 kg/m2. Short stature (height <1.49m) and anemia (hemoglobin concentration <12 mg/L) data were assessed only for women. Descriptive statistical analysis and Chi square tests were used to compare prevalence (%; 95% CI) by educational level (low=0-7 y, middle=8-12y, and high>12y) and income tertiles.

**Results:** Overweight [(34.0% (30.1%-38.2%)) in women] and [47.8% (41.5-54.1) in men] and, as well as, obesity [(27.1% (23.5%-30.9) in women] and [28.9 (23.7-34.8) in men], were high while underweight was negligible. Less educated women had higher prevalence of overnutrition (80.2%; 68.8%-88.1%) and short stature (14.9%; 8.5%-13.7%) than higher educated women (49.2%; 40.9%-57.5% and 3.7%; 2.0%-6.9%, respectively) (P<0.05 for both). Poorer women had higher prevalence of short stature (10.1%, 7.4%-13.8%) than richer women (2.2%, 1.0%-5.0%) (P<0.05). Anemia did not differ by SES. In men, nutritional status did not vary by income or educational level (all p>0.05).

**Conclusions:** In a post-transitional country such as Chile we observed SES and gender inequalities in adult nutritional status; this poses important challenges for future nutrition policies.

**Keywords:** Chile, nutritional status, inequalities

MALNUTRITION IN ALL ITS FORMS BY SOCIOECO- NOMIC STATUS IN COLOMBIA

(1)Cediel, Gustavo; (2)Gaitan-Charry, Diego; (3)González-Zapata, Laura Inés; (2)Pérez-Tamayo, Eliana; (4)Sarmiento, Olga.

(1)Post-doctoral fellow. Department of Nutrition. University of São Paulo. Brazil.; (2)PhD. Nutrition and Dietetics School. University of Antioquia. Medellín-Colombia.; (3)PhD. Nutritionist. School of Nutrition and Dietetics, University of Antioquia, Medellín. Colombia.; (4)PhD. Faculty of Medicine. Los Andes University. Colombia.

**Background and objectives:** Understanding the socio-ecological inequalities of malnutrition in Colombian population is important in order to effectively address the double burden of malnutrition and associated health consequences. This study examined the association of all forms of malnutrition by socio-ecological status (SES) in preschools and non-pregnant women, in Colombia.

**Methods:** A Secondary analysis of data from the 2010 Colombian National Nutrition Survey was conducted. Sample for this analysis comprised children less than 5 y (preschools), and non-pregnant women (11-49 y). Criteria for malnutrition were: overweight/obesity (preschools: BMI-for-age-z-score >2; non-pregnants 11-19: BMI-for-age-z-score >2; non-pregnants 20-49: BMI ≥25kg/m2), wasting/underweight (preschools: weight-for-age-z-score <-2; non-pregnants 11-19: BMI-for-age-z-score <-2; non-pregnants 20-49; BMI <18.5kg/m2), stunting/short Statute (preschools: height-for-age-z-score <-2; non-pregnants 11-19: height-for-age-z-score <-2; non-pregnants 20-49: height<1.49m) and anemia (preschools: hemoglobin <110g/L; non-pregnants: hemoglobin <120g/L). SES was stratified in tertiles. Individual sample weights were applied to all regression analysis of malnutrition variables and their association with SES.

**Results:** Prevalence of overweight/obesity was 45.2% in non-pregnants 20-49 y, 16.2% in non-pregnants 11-19 y and 5.2% in preschools. Prevalence of wasting/underweight was: 2.9% in non-pregnants 20-49 y, 1.8% in non-pregnants 11-19 y and 1.2% in preschools. Prevalence of stunting/short-statute was: 13.8% in preschools, 11.3% women 20-49y and 11% in women 11-19y. While, prevalence of anemia was 27.4% in preschools, 12.4% in non-pregnants 20-49y, and 7.8% in non-pregnants 11-19 y. Preschools from the lowest tercile of SES presented the lowest prevalence of overweight/obesity (4.4%), but the highest prevalence of wasting (1.5%), stunting (17.3%), and anemia (30.8%) (p<0.05). On the other hand, non-pregnants 11-19 y in the lowest tercile of SES presented the highest prevalence of overweight/obesity (17.0%), underweight (2.1%), short-statute (13.7%), and anemia (10.3%) (p<0.05). Similarly, non-pregnants 20-49y in the lowest tercile of SES presented the highest prevalence of overweight/obesity (47.6%), underweight (3.5%), short-statute (15.1%), and anemia (15.4%) (p<0.05).

**Conclusions:** Socioeconomic inequalities are present in the epidemiological context of the double burden of malnutrition. Public health nutrition policies should address these inequalities.

**Keywords:** Colombia, socioeconomic status, malnutrition, in-equalities
**Further collaborators:** The “Instituto Colombiano de Bienestar Familiar” (ICBF) and PROFAMILIA, provided support and allowed the use of ENDS/ENSIN data base.

## MALNUTRITION IN ALL ITS FORMS DIFFERS BY SOCIOECONOMIC STATUS, EDUCATION LEVEL AND RACE/ETHNICITY IN ECUADOR

(1)Ramirez-Luzuriaga, Maria J; (2)Belmont, Philippe; (3)Waters, William F; (3)Freire, Wilma.

(1)MSc. Nutrition and Health Science Program. Laney Graduate School. Emory University. Atlanta. Georgia. USA.; (2)MSc. Health and Nutrition Research Institute. University of San Francisco de Quito. Ecuador.; (3)PhD. Health and Nutrition Research Institute. University of San Francisco de Quito. Ecuador.

**Background:** In Ecuador, undernutrition in the form of stunting has modestly declined but remains high in some regions and subpopulations, whereas overweight and obesity have increased at alarming rates in all age, racial, and socioeconomic groups. Objective: Describe the prevalence and distribution of malnutrition in all its forms (stunting, wasting, anemia, overweight, and obesity) by ethnicity/race, level of education, and socioeconomic status.

**Methods:** We analyzed data of the last National Health and Nutrition Survey to estimate national prevalences for stunting, wasting, anemia, overweight, and obesity in children <5 y, adolescent women 11-19 y, and women 20-49 y. Level of education was defined by the mother's or the woman years of schooling: low (0 to 6 y; primary school or less); medium (7 to 12 y; secondary to high school); and high (more than 12 y; more than high school). Socioeconomic status was divided into tertiles and measured by using a multidimensional poverty index, which identifies deprivations across three dimensions (health, education, and standard of living). Results: In children <5 y and adolescent women the prevalence of stunting and anemia is significantly higher in indigenous groups and among children and adolescent women of low level of education and of low socioeconomic status. Indigenous women have the highest prevalence of overweight (41.3%) compared to Afro-Ecuadorian (31.8%) and Mestizo (38.9%), whereas obesity is higher in Afro-Ecuadorian women (34.9%) compared to Indigenous and Mestizas (13.3% and 25.4%, respectively). Conclusions: Stunting, anemia, overweight and obesity significantly differ by race and by socio-economic status. Racial minorities are proportionally more affected by malnutrition than mestizo children and women in Ecuador.

**Keywords:** Malnutrition, double burden, overweight, obesity, Ecuador, SES

## MALNUTRITION IN ALL ITS FORMS AND SOCIO-ECONOMIC INDICATORS IN GUATEMALA

(1)Mazariegos, Monica; (1)Kroker-Lobos, Maria F.; (2)Ramirez-Zea, Manuel.

(1)Researcher. INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC). Institute of Nutrition of Central America and Panama (INCAP). Guatemala.; (2)Director. INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC). Institute of Nutrition of Central America and Panama (INCAP). Guatemala.

**Background and objectives:** Malnutrition results from the interaction of poor-quality diets and healthcare environments, and unhealthy behaviors, all of which are shaped by political instability, poor economic development, social inequalities, and globalization. Socioeconomic disparities in malnutrition denote the degree to which the prevalence of malnutrition in all its forms (MAF) differ between more or less social and economically advantaged groups. In Guatemala, data is lacking about how MAF distributes across socioeconomic indicators for the subsequent identification of health disparities. Therefore, our objective was to reveal disparities of MAF by socioeconomic indicators in children <5y, adolescents, and women of reproductive age (WRA).

**Methods:** We used the 2008 National Maternal and Child Health Survey conducted in Guatemala. We estimated the prevalence (95%CI) of MAF: stunting/short stature, anemia and overweight/obesity in children <5 y (n=10,645), adolescent girls (15-19 y) (n=2,894), and WRA (20-49 y) (n=13,925). Then we evaluated whether the prevalence of MAF differed according to SES tertiles, educational level (classified as low for 0-6 y, middle for 6-12 y, and high for ≥12y), and ethnicity. Disparities are shown as the ratio of low to high-SES, and low to high educational level and the ratio of indigenous to non-indigenous. Results: Stunting/short stature national prevalence was 48.0% (45.8,50.2) among children, 51.1% (48.4,53.8) among adolescents, and 29.0% (27.5,30.1) among WRA. The prevalence of stunting in these age groups was 3.1, 1.9, and 3.0 times significantly higher in the poorest SES compared to the richest tertile; 3.4, 1.9 and 3.5 times significantly higher in the lower educational level than in the highest level; and 1.8, 1.9 and 2.6 times significantly higher in indigenous than in non-indigenous population. Anemia national prevalence was 49.2% (47.1,51.3) among children, 25.1% (22.7,27.7) among adolescents, and 26.9% (25.3,28.5) among WRA. The prevalence of anemia in these age groups was 1.3, 1.8 and 1.7 times significantly higher in the poorest SES compared to the richest tertile; 1.2, 1.7 and 1.7 times significantly higher in the lower educational level than in the highest level. The prevalence of anemia was 1.2 times higher in indigenous vs. non-indigenous only in WRA. Overweight/obesity national prevalence was 6.0% (5.3,6.6) among children, 21.3% (19.3,23.4) among adolescents and 57.8% (56.5,59.2) among WRA. Overweight/obesity prevalence between SES and educational level was only significantly different in WRA (richest SES tertile was 1.4 higher compared to the poorest tertile; the medium educational level was 1.1 higher than the lower level). Among adolescents, overweight/obesity was 1.3 significantly higher in indigenous than in non-indigenous; whereas for WRA run in the opposite direction as the higher prevalence was 1.1 times among the non-in-
digenous. Conclusions: In Guatemala, stunting/short stature and anemia were more prevalent among low-income, low education level, and indigenous population. Overweight/obesity was more prevalent in high-income, medium educational level, and non-in-digenous WRA. These outcomes demonstrate socio-economic and ethnic disparities for MAF. Therefore, a national priority should be given to a set of the most cost-effective interventions which can be scaled up immediately. Not addressing malnutrition disparities has social, economic and moral implications.

**Keywords:** Malnutrition, socioeconomic status, ethnicity, edu-
cational level, nutrition policy

MALNUTRITION IN ALL ITS FORMS BY SOCIOECO-
NOMIC STATUS IN MEXICO

(1)Batis, Carolina; (2)Denova-Gutiérrez, Edgar; (3)Estrada-Velasco, Bárbara I.; (4)Rivera-Dommarco, Juan Ángel.

(1)CONACYT Nutrition and Health Research Center. National Institute of Public Health of Mexico. Mexico; (2)Hospital Infantil de México. Mexico City. Mexico; (3)Componente de Nutrición, Departamento de Atención a la Salud de la Infancia y Adolescencia. Servicio de Salud de Morelos. Mexico; (4)National Institute of Public Health. Mexico.

Background: In Mexico, undernutrition has declined and over-
nutrition has become a public health concern. However, the distri-
bution of both conditions is not equal throughout the population,
therefore it is important to document disparities by socioeconom-
ic indicators, particularly among the most vulnerable populations
such as children and women of reproductive age.

Objective: Compare the prevalence of malnutrition (over and undernutrition) by socioeconomic indicators in Mexican children and women of reproductive age.

**Methods:** We included children <5 y old (n=10 658) and non-pregnant women of reproductive age (n=8,044 for women 11—19 y; n=14,542 for women 20—49 y) from the Mexican National Health and Nutrition Survey 2012. We defined overweight, obesity, wasting/underweight, stunting/short stature following the World Health Organization criteria, and anemia as altitude-adjusted hemoglobin <110 g/L for children <5 y; and <120 g/L for women 11—49 y. We compared the prevalence of malnutrition by tertiles of SES, education level (of the mother in the case of children and adolescents), and ethnicity (indigenous/non-indigenous).

**Results:** In all age groups those with low SES, low educa-
tion and indigenous compared to high SES, high education and
non-indigenous had 2.8—4.4 times higher prevalence of stunting
or short stature, and those with low SES had 1.1—1.4 times higher
prevalence of anemia. For overweight and obesity, among children
<5 y old the prevalence was similar across groups; among wom-
en 11-19 y those with low SES and indigenous had 1.3—1.5 times
lower prevalence; and among women 20-49 y those with low edu-
cation had 1.3 times higher prevalence.

**Conclusions:** Disadvantaged populations (low SES, low edu-
cation and indigenous) have a higher prevalence of malnutrition,

whereas the prevalence of overnutrition is either equal (children
<5 y), slightly lower (women 11-19 y) or even higher (women 20-
49 y with lower education). These results highlight the need for
specific actions to address nutrition inequalities in the Mexican
population.

**Keywords:** Undernutrition, overnutrition, socioeconomic in-
dicators, Mexico

MALNUTRITION IN ALL ITS FORMS AND SOCIO-
ECONOMIC STATUS IN PERU

(1)Quinto, Katherine; (2)López de Romaña, Daniel.

(1)PhD. Student. Nutritionist. National Institute of Public Health.
Mexico.; (2)PhD. Technical Advisor. Micronutrient Initiative. Canada.

**Background and objectives:** Peru is undergoing the double burden of malnutrition. There is an unequal distribution among subgroups of the population between the increase in overweight and the persistence of undernutrition that are likely explained by social disparities. We compared the distribution of malnutrition in children under five, adolescents (15-19 y) and women of child-bearing age (WCA; 20-49 y) by socioeconomic status (SES), education and ethnicity.

**Method:** The 2015 Peruvian National Demographic and Family Health Survey were used for the present analysis. We calculated the prevalence of overweight and obesity combined (OW), wasting/underweight, stunting/short stature and anemia in children under 5 y, adolescents and WCA as per WHO standards. A crude prevalence ratio (PR) was calculated dividing the prevalence of the highest stratum to that of the lowest stratum for SES, education or ethnicity. A t-test for complex surveys was used to identify if the differences in prevalence were statistically significant (p<0.05).

**Results:** In children the prevalence of OW, wasting, stunting and anemia was 9.1% (8.5-9.8), 0.9% (0.7-1.1), 14.1% (13.4-14.9) and 32.0% (31.0-33.0), respectively. OW was higher in children from households with high SES and whose mother's education was high [PR=3.5 and 2.6, respectively] and lower in indigenous children [PR=0.4]; wasting, stunting and anemia was higher among indigenous children [PR=2.3, 2.8 and 1.5, respectively] and lower in children from households with high SES [PR=0.3, 0.2 and 0.6, respectively] and whose mother's education is high [PR=0.1, 0.1 and 0.6, respectively]. In adolescents the prevalence of OW, underweight, stunting and anemia was 31.7% (29.5, 33.9), 0.5% (0.2, 0.9), 22.9% (21.1, 24.6) and 20.6% (18.7, 22.5), respectively. OW was higher among high SES adolescents [PR=1.4] and lower in those with indigenous ethnicity [PR=0.7], whereas stunting was higher among indigenous adolescents [PR=1.6] and lower in high SES and educated adolescents [PR=0.4 and 0.2, respectively]. In WCA the prevalence of OW, underweight, short stature and anemia was 65.2% (64.3-66.2), 0.9% (0.8-1.1), 34.5% (33.5-35.6) and 21.7% (20.8-22.6), respectively. OW was higher among women with high SES [PR=1.1], and lower among indigenous and high educated women [PR=0.8 for both]; underweight was higher among highly educated women [PR=2.6]; stunting was higher among indigenous woman [PR=1.5] and lower in women with
high SES and high education [PR=0.5 and 0.3; respectively] and anemia was higher among indigenous woman [PR=1.2].

**Conclusions:** The double burden of malnutrition is still prevalent in Peru. Anemia remains the most prevalent indicator of undernutrition for children and WCA, and OW is most prevalent among WCA. There was a significant difference in the distribution of malnutrition by social indicators. In general, undernutrition is negatively associated to SES, education and being indigenous, whereas OW is positively associated to SES.

**Keywords:** Malnutrition, social disparities, children and women nutritional status in Peru.

## MALNUTRITION IN ALL ITS FORMS AND SOCIO-ECONOMIC STATUS IN URUGUAY

(1)Severi, Cecilia; (2)Medina, Mercedes; (3)Moratorio, Ximena; (4)Natero Felipe, María Virginia; (5)Barreto, Patricia.

(1)Interdisciplinaire group of family studies. Preventive Medicine. Faculty of Medicine. Universidad de la República. Uruguay;

(2)MSc. Nutricionist. Interdisciplinaire Group of families studies. Universidad de la República. Uruguay.; (3)MSc. Nutricionist.

Ministry of Health. Uruguay; (4)MSc. Nutricionists. School of Nutrition. Universidad de la República. Uruguay; (5)MSc. Nutricionist.

Ministry of Social Development. Uruguay

**Objective:** to describe the forms of malnutrition in children under 4 y.o and women 20-49 by SES.

**Method:** two data bases were used, National Survey of Nutrition, Health and Development, carried on 2013 (<4 y.o) and the Second National Survey of Noncommunicable Disease Risk Factors (20 to 49 y.o) carried on 2013. To know the degree of association of the quantitative variables, Pearson Chi-square hypothesis test (chi2) was used. All tests were considered statistically significant with a status (α) of 0.05 (p <0.005). Income was studied in terciles in the first data base and in ranges of income in the second.

**Results:** Regarding the socioeconomic characteristics of Uruguayan households, it could be highlight that their general conditions are good, since it was observed that almost 100% of households have electric light (99.25%), drinking water (94.83%), motor vehicle (94.37%), television (97.12%), Computer (93.98%) and refrigerator (97.48%). No significant differences were found either by income tertile or by mothers' educational level.

In the only situation it was found significant differences in the first tertile of income was the health system that children were attended.

From a nutritional point of view in children under 4 years old, the public health problem what is stands out is overweight and obesity, (17.73%), finding no significant differences by income tertile or mother's educational level.

Under weight does not seemed to be a public health problem although there are significant differences in the lowest tertiles of socioeconomic status (SES) and educational level, although the percentages are very low (0.84% and 0.38%). As short stature is around 5%, there are significant differences in the third tertile of income and the second and third mothers' educational level.

Regarding to women from 20 to 49 y.o it was found that 53% were overweight or obese (29.8% overweight and 23.3% obese), while on the other hand, 2.7% were low weight and 2.1% had short stature.

The women educational level, was low in the 15.8%, 57.1% had the medium level, and 27% had a high level.

While in the study of the level of income, 46% were found in the lowest income range, 27.4% were within the second level of income (medium-low), 13.5% in the third (medium), 9.2% in the fourth (medium high) and 4.0% in the highest level of income.

A statistically significant association was found between obesity in the low SES (25.6%) with the medium and high level (17.0%) (p <0.005). As well as a significant association between malnutrition due to overweight and obesity in the low SES (55.4%) vs. medium (43.5%) and medium high (44.5%) (p <0.005).

Regarding the analysis of nutritional status and educational level, it was found a positive association between overweight or obesity with low educational level (61.5%) in relation to a high level (36.2%). (P <0.005). In the case of obesity, it is observed that a lower level of education, increase the probability of developing obesity in all cases (33.8% in the first level of education, 24.2% in middle and 15.6% in high level) (p < 0.005).

**Keywords:** Forms of malnutrition, age, socio economic level

**Further collaborators:** Mercedes Medina, Ximena Moratorio, Virginia Natero, Patricia Barreto

## MALNUTRITION IN ALL ITS FORMS AND SOCIO-ECONOMIC STATUS IN CHILE

(1)Navarro-Rosenblatt, Deborah; (2)Mujica, Maria Fernanda; (3)Lopez-Arana, Sandra; (4)Corvalan, Camila.

(1)PhD Student. School of Public Health. University of Chile. Santiago. Chile; (2)PhD. Food, Nutrition and Health. Faculty of Land and Food Systems. The University of British Columbia. Vancouver. BC. Canada.; (3)RD. PhD. Institute of Nutrition and Food Technology (INTA). University of Chile. Santiago. Chile.; (4)MD. PhD. Institute of Nutrition and Food Technology (INTA). University of Chile. Santiago. Chile.

**Background and objectives:** Previous research in Latin America shows that socioeconomic status (SES) influences dietary patterns and obesity distribution in population. However, it is unclear how SES impacts overall nutrition status, in a post-transitional country such as Chile. The objective of this study was to assess the relationship between nutritional status (overweight, short stature and anemia), and two key aspects of the socio-economic status (SES), monthly income and educational level, in adult Chilean population.

**Methods:** Nationally representative data of 2574 women and 1695 men (>20 years) from the 2003 and the 2009-2010 Chilean National Health Surveys were included in this secondary analyses. Body mass index (BMI) was categorized as underweight, overweight and obesity according to WHO criteria. Over-nutrition was defined as BMI ≥25 kg/m2. Short stature was considered as a height <1.49m for women and <1.62m for men. Women with he-
moglobin <12 mg/L were classified as anemic. Descriptive statisti-
cal analysis and Chi square tests were used to compare prevalence
(%; 95% CI) by educational level (low=0-7 y, middle=8-12y, and
high>12y) and income tertiles.

**Results:** Overweight [(34.6% (31.6%-37.7%)) in women] and [48.3% (44.1-52.2) in men] and, as well as, obesity [(32.7% (29.7%-35.8) in women] and [21.3% (18.4-24.6) in men], were high while underweight was negligible. Less educated women had higher prevalence of overnutrition [(82.0% (77.3%-85.8%)) and short stature [14.9% (8.5%-13.7%)] than higher educated women [(50.3% (42.8%-57.8%)) and [3.7% (2.0%-6.9%)], respectively) (P<0.05 for both). Poorer women had higher prevalence of short stature [10.1% (7.4%-13.8%)] than richer women [2.2% (1.0%-5.0%)] (P<0.05). Anemia did not differ by SES or educational level. High educated men showed a higher prevalence of overweight [(55.1% (46.2-63.7%)) compared with those with a medium educational level (all p>0.05).

**Conclusions:** Chile, considered as a post-transitional country, faces a significant SES and gender inequality which affects the nutritional status of the adult population. This situation is a challenge for future public nutritional policies.

**Keywords:** Malnutrition, anemia, inequalities, obesity, Chile

**Conflict of Interest disclosure:** Deborah Navarro-Rosен-
blatt, MF Mujica-Coopman, Sandra Lopez-Arana and Camila
Corvalan have no conflicts of interest.

between usual consumption of adequate breakfast with a lower
risk of obesity, lower risk of inadequacy of calcium intake and oth-
er nutrients.

In Spain recent data show that 92% of men and 93% of women usually have breakfast. This intake on average yields 18% of the calories of the day, 18% in men and 17% in women. Some 8% of the Spanish school age population age does not take any food or beverage before beginning their school tasks. There is unequal distribution of the proportion of usual breakfast consumers across age groups, gender and socioeconomic level, with a higher rate of non-consumers in adolescents and lower socioeconomic level.

Among Spanish people, foods and beverages consumed with this first intake of the day are similar on working days and weekend days. It usually consists of milk (76% usual consumers), coffee (54%), bread (45%), with optional added oil (16%), tomato (7%), butter (11.8%), margarine (3%) and / or marmalade (9.8%). Other options include cookies (25%), bakery products and pastries (17%) or breakfast cereals (13.5%). Less frequent options can be cold meats and sausages (11%), cheese (4.4%) or yogurt (3%). Fruit is usually consumed by 9% and/or natural freshly pressed juices 10.4%, or to a lesser extent bottled juices (6.5%). The proportion of schoolchildren who complete an adequate breakfast, including a dairy food or beverage, a choice of either bread or cereal and a portion of fruit is below 10%, even lower (3%) in adolescents. Correlates of adequate breakfast consumption include having breakfast in the company of other family members, sitting at the table and dedicating enough time, at least 10 minutes, for consumption.

**Keywords:** Breakfast. Population studies. Diet adequacy.
Health inequalities

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ADVANCES AND CONTROVERSIES OF NUTRITION
IN LATIN AMERICA

BREAKFAST, PERFORMANCE AND DIETARY BAL-
ANCE: HOW IS BREAKFAST INTAKE IN SPANISH
PEOPLE?

Pérez-Rodrigo, Carmen.

MD. PhD. Spanish Society of Community Nutrition (SENC). FIDEC Foundation. University of the Basque Country (UPV/EHU). Bilbao. Spain.

Breakfast is the first intake of the day and must provide the energy needed to start daily activities. Scientific evidence supports that adequate breakfast consumption induces metabolic and neurohormonal changes in the short and medium term that favor a better performance of cognitive capacities, attention and even help to better physical performance throughout the morning. Breakfast consumption also contributes to nutritional balance and adequate intake of several nutrients. Studies conducted in schoolchildren as well as in adults have investigated associations between breakfast consumption and cognitive effects, exploring outcomes such as attention, sensorimotor responses, recent memory, problem solving or verbal capacity. Results are not conclusive, but they provide some evidence of a positive effect on sensorial-motor responses and problem solving. Different studies have shown an association

BREAKFAST HABITS IN VENEZUELA AND COLOMBIA:
A REVEALING COMPARISON

Bernal, Ines Jennifer.

PhD. Nutritionist. Food and Nutrition Consultant. Venezuela.

Colombia and Venezuela have a similar geography, tropical climate and influence of Spain and Africa for their food pattern. Traditionally, both countries share similar foods, preparations and customs, such as arepa based on corn flour. Breakfast is similar in both regions with foods such as coffee, arepa, cheese and egg. According to ENSIN 2010, 91.8% of Colombians eat breakfast. The Nielsen study showed how Colombians keep the tradition at breakfast of consuming eggs, bread, homemade arepa, coffee and chocolate. These foods are consumed by 7 out of 10 Colombians in their households. A Colombian breakfast is made up of 37% for beverages and 61% for solid foods. Within the solids, about 3/4 of the food is processed at homes. According to the ENCOVI 2016 study in Venezuela, of the three main daily meals, breakfast is omitted by 22% of the population, but also is the most absent meal. From 2014, 11.3% of the population was reported to eat only two or fewer meals a day. 80% of the population and 88.7% of the poorest do not have resources for the weekly purchase of food,
which affects the quality and quantity of the diet. A recent report from the NGO Caritas shows how the Venezuelan diet has deteriorated at an accelerated rate, in the last 5 years. This NGO evidenced that 61% of households have changed their usual pattern of meals, more than 71% of families have deteriorated their diet and 80% have had some food deprivation. 8% of these households have resorted to eating in the street and 3% have requested food on the street. The Food and Nutrition Security Outlook for Latin America and the Caribbean reported by FAO in 2016, remarked that food inflation reached 315% in Venezuela, the highest in the region for several decades, while in Colombia it has reached 10.8% for the same period. Moreover, the price of breakfast has increased more than 2210% in the last 3 years, according to the ENCOVI 2016 study. More than five years ago there were concordances between the breakfasts of Colombians and Venezuelans. Today, the Colombians maintain their traditions, quantity and quality in the first meal of the day, while the breakfast of Venezuelans is submerged between food shortages, low quality and high prices. In Venezuela there is an unprecedented food crisis. The FAO Global Information and Early Warning System, which lists and updates the list of countries requiring external assistance for food, has placed Venezuela on its list of warning since 2017.

**Keywords:** Breakfast, Morning meal, Meals, Venezuela, Colombia

## BREAKFAST HABIT AND NUTRITIONAL QUALITY, IN STUDENTS OF THE LICENCIATE IN NUTRITION, ATTENDING TO UNIVERSIDAD NACIONAL DE CÓRDOBA, ARGENTINA

Breakfast is the first daily meal used to interrupt with the overnight fast. Etymologically the term “breakfast” means “to break the fast.”

It has been demonstrated that the breakfast habit contributes significantly to the nutritional balance of food as a whole.

Breakfast must pay 20-25% of the total daily energy; its quality depends largely on the variety of elements which is composed. It has been suggested that a good breakfast should contain, at least 3 food groups: dairy, cereals and derivatives and fruit.

A nutritionally adequate breakfast is associated with a better physical and intellectual performance, better health and the prevention of certain pathologies (overweight/obesity).

**Objective:** To inquire into the habit, nutritional quality and conditioning factors during breakfast in 2nd to 5th year students attending the Licentiate in Nutrition at Universidad Nacional de Córdoba in 2015.

**Material and Methods:** Cross-sectional descriptive study. Universe 1287 students. Random sampling n = 98 students (8%) who gave consent. Variables: age (years old) <24 and ≥24, origin

(Córdoba-capital, Córdoba-interior, other provinces), habits (frequency, composition, time, use of electronic devices). Instruments: Alibefis-Glanc Project Questionnaire (reduced) Habits, Uses and Habits of Food, Recreation and Physical Activity in Latin America (SENC). Approved by the Ethics Committee of the Hospital Nacional de Clínicas, UNC (REPIS No. 2706/15). Nutritional quality of the usual breakfast: Adapted Breakfast Quality Index (BQI-a) whose total score = 10. Quality categories: deficient, average and adequate. Statistical analysis: Infostat.

**Results:** The average student's age was 22.93±3.07 years old. 6.1% of respondents never had breakfast and 39.8% did not daily. The main causes were: lack of time (50%), lack of appetite (33.3%) and feeling of discomfort at breakfast time (16.7%). 64.1% of those students who used to have breakfast, recognized doing so using an electronic device. The average breakfast time was 17.5±7.5 minutes (max. 45, min. 3). 61.4% consumed dairy drinks, and 94.7% bakery products derived from cereals. Only 15.8% consumed fruits. 14% exceeded the recommendation about the daily intake of free sugars according to WHO only during breakfast and 54.9% used artificial sweeteners. Breakfast did not cover energy recommendation in 80.7% of the cases.

Usual breakfast quality obtained from BQI-a showed that most students do not have adequate nutritional qualities breakfast (p <0.01), only 10.5% were at this level, and almost ¼ presented deficient quality breakfast. The average score was 5.28±1.63. No ideal score breakfast was recorded. The group of students ≥24 years old, from Córdoba Capital who did not attend classes regularly showed better quality.

**Conclusion:** 60.2% of the surveyed students had breakfast daily. None presented ideal nutritional quality and only 10.5% showed adequate quality, showing very low fruits intake. The rest did not have breakfast or did it infrequently

**Keywords:** Breakfast, nutritional quality, University students, eating habits

**Further collaborators:** Acknowledgment: Canale, MG.

## BREAKFAST FOOD CONSUMPTION IN PERUVIAN SCHOOLCHILDREN: A COMPARISON BETWEEN RURAL AND URBAN AREAS

**Background:** An unbalanced diet, whether due to excess or deficit of ingested calories, is one of the main causes of (overweight and obesity) malnutrition. Breakfast is considered the most

<footnote>(1)Asaduroglu, Ana Virginia; (2)Herrera Cussó, Gonzalo Federico;</footnote>

<footnote>(2)Celoira Peña, María Victoria.</footnote>

<footnote>(1)PhD. Nutritionist. Universidad Nacional de Córdoba. Argentina;</footnote>

<footnote>(2)Graduate in Nutrition. Argentina</footnote>

<footnote>(1)Arija, Victoria; (2)López-Toledo, Sabina; (3)Ballonga, Carla; (4)Canals, Josefa.</footnote>

<footnote>(1)Professor of Preventive Medicine and Public Health. Faculty of Medicine and Health Sciences. Rovira i Virgili University. Tarragona. Spain; (2)Predoctoral student. Faculty of Medicine and Health Sciences Doctoral Program in Nutrition and Metabolism; (3)Predoctoral student. Faculty of Medicine and Health Sciences Doctoral Program in Biomedicine.; (4)Professor of Psychopathology. Faculty of Psychology. Rovira i Virgili University. Tarragona. Spain.</footnote>