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A Report: 6th International Conference on Nutrition and Growth Valencia, Spain March 7–9, 2019

As mentioned by the Organizing Committee, the purpose of the conference is to bring together pediatricians, nutritionists, neonatologists, experts in child development and other specialists to discuss the challenges of the interplay between Nutrition and Growth in the pediatric age group. It is also expected that the meeting will enable the exchange of ideas and knowledge between the different disciplines for facilitating research and clinical interdisciplinary collaborations focusing on nutrition and growth.

The conference started by a session “Before the First 1000 days: Before Conception and After Birth” presenting three topics, i.e. 1) influence of early nutritional factors on obesity in the offspring, 2) nutrition, conception and offspring epigenome, and 3) breastfeeding and growth. The following are the abstracts of each topic:


L. Moreno1. 1GENUD research group- Universidad de Zaragoza- Instituto Agroalimentario de Aragón IA2- Instituto de Investigación Sanitaria de Aragón IIS Aragón- Centro de Investigación Biomédica en red de Fisiopatología de la Obesidad y Nutrición CIBEROBN- Zaragoza- Spain, Facultad de Ciencias de la Salud, Zaragoza, Spain.

Childhood obesity is the most prevalent nutritional disorder during childhood. It develops in individuals with a genetic predisposition substrate and the presence of factors related with nutrition, sedentary behaviours and others as short sleep duration. During early periods of life, starting at conception and until the end of the second year, there is a large number of factors that could influence the development of obesity later in life: pre-pregnancy maternal body mass index (BMI), gestational weight gain, gestational diabetes, maternal malnutrition, maternal smoking during pregnancy, alcohol consumption during pregnancy, free sugars intake during pregnancy, low polyunsaturated fat (omega 3) intake during pregnancy, low physical activity levels during pregnancy, antibiotics consumption during pregnancy, high or low body weight at birth, lack of breast feeding, consumption of high protein content infant formulas, rapid infant weight gain, high protein, fat or free sugars intake during infancy, early introduction of complementary feeding and short sleep duration. From all these candidate risk factors, the ones more strongly associated with obesity development during childhood are maternal obesity before pregnancy, low birth weight and rapid weight gain during infancy. Perinatal factors also influence the expression of some genes related with obesity development. For instance, birth weight modifies the effect of the FTO gene polymorphism in the development of obesity and breastfeeding also modulate the effect of the PPAR-gamma 2 gene polymorphism on the excess of adiposity in adolescents. Interventions trying to prevent obesity should start as early as possible as the possibility to positively influence the early programming of the condition is optimal in this period.

  1. nutrition, conception and offspring epigenome

M. Silver1. 1MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine, Nutrition, London, United Kingdom.

Our group has a long-standing interest in exploring links between early life nutritional exposures and long-term health outcomes. Much of our research centres on a rural community in The Gambia in Sub-Saharan West Africa.

A key focus is on epigenetics - the study of modifications to the genome that can affect gene expression without altering the underlying DNA sequence. Mounting evidence from animal and human studies suggests such modifications may mediate observed associations between early-life nutrition and later health and disease.

For our epigenetic studies we are able to exploit an ‘experiment of nature’ in rural Gambia whereby fluctuations in energy balance and maternal nutritional exposures show a distinct bimodal seasonal pattern. We have shown for example that season of conception and blood levels of key maternal nutritional biomarkers relating to one-carbon metabolism (B2, B6, cysteine and homocysteine) predict DNA methylation in infants at a number of metastable epialleles (MEs) - genomic regions where methylation is established stochastically in the early embryo, leading to systemic (cross-tissue) inter-individual variation.

I will give an overview of our work in this area and describe some of the interesting candidate MEs that we have selected for follow up in our population including a region at the POMC gene with links to obesity in children and adults.

  1. breastfeeding and growth

K. Michaelsen1. 1Department of Nutrition- Exercise and Sports, University of Copenhagen, Denmark, Denmark.

Breastfeeding has a marked effect on early growth and there are some indications that there are also effects on growth later in life. Breastfed infants grow faster during the first 2-3 months and have thereafter a slower growth velocity up to the age of about 12 months, compared to infants that are not breastfed. This growth pattern, which is regarded as optimal, is also reflected in differences in body composition. There are studies suggesting a modest reduction in risk of obesity, but some studies show no effect. The vast majority of studies of the effect of breastfeeding on growth are observational and it is therefore difficult to conclude on causality as residual confounding and reverse causation are likely to influence the associations. There is an increasing number of studies examining the association between composition of breastmilk and growth of the infant. Especially the content of macronutrients, human milk oligosaccharides and appetite related hormones seem to have an effect on growth. A better understanding of these associations are likely to improve our understanding on how breastfeeding is regulating short and long term growth. Future studies should include analysis of milk composition and measurements of body composition when possible. Furthermore, data should also be analyzed according to sex as several studies have suggested that the association between milk intake and composition and growth is different in boys and girls.

During the session entitled Water, Sanitation and Hygiene (WASH) Intervention to Improve child Health, there are three topics presented, as follows:

  1. Pathways linking wash and growth

S. Sinharoy1. 1Emory University, Environmental Health, Atlanta, USA.

The relationship between water, sanitation, and hygiene and child nutrition remains unclear, with mixed results from ecological and intervention studies. This presentation will provide an overview of key components of water, sanitation and hygiene (WaSH) and will outline the mechanisms and pathways through which WaSH may influence child nutritional status. Specifically, poor WaSH conditions may lead to diarrhea, environmental enteric dysfunction (a subclinical disorder of the small intestine), and intestinal parasitic infection. These in turn may result in undernutrition through appetite suppression, nutrient loss, malabsorption, and inflammation. Our understanding of these mechanisms provides a strong theoretical rationale for combining WaSH interventions to improve child nutrition. To illustrate how these relationships may operate in a real-world setting, the presentation will include results from a matched cohort effectiveness evaluation of a combined on-premise piped water and improved sanitation intervention in rural Odisha, India. We collected data in mid-2016 on anthropometry for children under age 5 (N=1826) in 45 intervention and 45 control villages. Children under age 5 living in communities that received the intervention had higher mean height-for-age z-score (HAZ) (+0.17 HAZ, 95% CI:0.03-0.31) compared to children in control villages. A structural modeling equation (SEM) approach quantified the direct and indirect intervention effects on HAZ through a complex system of divergent water, sanitation, and hygiene pathways. The results of the SEM analysis suggest that piped water and sanitation together influenced HAZ, and that both may be necessary for programs to impact child linear growth.

  1. the shine and wash benefits trials

J. Humphrey1. 1Johns Hopkins Bloomberg School of Public Health, International Health- Center for Human Nutrition, Baltimore, USA.

The WASH Benefits Bangladesh, WASH Benefits Kenya, and Sanitation Infant Feeding Efficacy (SHINE, Zimbabwe) trials were cluster-randomized controlled trials to test the independent and combined effects of improving household water and sanitation/hygiene (WASH) and improving infant diet on child stunting and anemia at 18 mo (SHINE) or 24 mo (WASH Benefits trials). In addition, 7-day prevalence of diarrhea at 12 and 18 or 24 months was a primary outcome of WASH Benefits and secondary outcome of SHINE. Together the three trials included more than 18,000 children; provided free pit latrines, soap, chlorine, and lipid-based micronutrient supplement; delivered behaviour change modules based on years of formative research and pilot testing, and grounded in behaviour change theory, and measured outcomes by standardized and supervised research staff.

WASH Benefits included 7 arms [sanitation, handwashing with soap, point of use water chlorination, all these interventions combined (WASH), infant feeding, WASH+infant feeding, and a double sized control arm (passive in Bangladesh, active in Kenya)]. Thus, it was also designed to compare the benefits of single or combined WASH interventions. SHINE was a 2x2 factorial trials (WASH, Infant feeding, WASH+infant feeding, and an active control).

In all three trials:

  • · the interventions were delivered with high fidelity and achieved substantial behavior change;

  • · the infant feeding intervention had a modest benefit but WASH had no effect on stunting;

  • · the infant feeding intervention improved haemoglobin but WASH had no effect on haemoglobin concentration.

In Bangladesh, all the intervention arms except water chlorination reduced diarrhea by a relative 30-40% from a very low prevalence (~5%); in the two Africa sites there was no effect of any intervention on diarrhea from a 10% prevalence in Zimbabwe and 27% prevalence in Kenya in the control arms.

This presentation will discuss:

  • · The stunting results which contrast to a very large published literature of observational studies demonstrating that these same household level WASH interventions are strongly associated with stunting;

  • · the differential results on diarrhea; and

  • · the reasons why the trial interventions may have failed to reduce stunting.

  1. where next? might wash interventions work?

A. Prentice1. 1MRC UNIT The Gambia at London School of Hygiene & Tropical Medicine, Nutrition, Keneba, United Kingdom.

Where Next? Might WASH++ interventions work? Andrew M Prentice, MRCG@LSHTM, Keneba, The Gambia Most children living in poor environments in low- and middle-income countries suffer from various forms of malnutrition of which stunting and anemia represent the most easily detectable syndromes. It has long been understood that the etiology of such conditions is not solely dependent on primary nutritional deficiencies, and that there are numerous so-called ‘nutrition sensitive’ causes that exacerbate the shortages of nutrients. Key amongst these is the issue of poor hygiene. The first presentation in this session, by Dr Sinharoy, will outline the mechanisms and pathways by which poor hygiene impairs nutrient uptake and utilisation. Combatting these effects ought to be possible by the implementation of interventions to improve water, sanitation and hygiene (WASH). The second presentation, by Dr Humphrey, will summarise the outcomes from the WASH Benefits and SHINE Trials in Bangladesh, Kenya and Zimbabwe. These were very large cluster-randomised trials to test the effectiveness of improving WASH and promoting better infant and young child feeding (IYCF). IYCF had a small benefit in each trial but there was no effect of WASH nor a positive interaction with IYCF. This final presentation will try to examine some of the possible reasons for these very disappointing results. Data from The Gambia suggest that there is a very high threshold of WASH that must be reached before growth will respond, and that it may be necessary to introduce piped water into homes to achieve the benefit. The challenges around such WASH++ or Transformative WASH solutions will be discussed.

The session on Growth, Nutrition and sport only provide one topic presented with its abstract entitled as follows:

eating patterns, food intake and supplements use in adolescent athletes

M. Yackobovitch-Gavan1. 1National Center for Childhood Diabetes- Schneider Children’s Medical Center of Israel., The Jesse Z and Lea Shafer Institute for Endocrinology and Diabetes, Petach Tikva, Israel.

Adolescence is a period of significant changes, including fast growth and physical development as well as social, emotional and sexual development, which has implications on how adolescents view themselves and on their sporting achievements. In terms of nutrition, adolescence is an important time in establishing an individual’s lifelong relationship with food.

Proper nutrition is especially vital for adolescents with a high activity level, as they experience numerous nutritional challenges, such as meeting nutrient needs for growth, maintenance of health, training and competing. Inadequate energy and nutrients consumption can cause growth retardation, delayed puberty, reduced accumulation of muscle and bone mass and increased susceptibility to fatigue, injury or illness.

According to the recent published data, Adolescent athletes usually do not adjust their nutrient intake to the demands of the training and do not meet nutritional recommendations. Many young athletes are using dietary supplements with the belief they will improve performance and health; however, may not always have reliable information. Special considerations in adolescent female athletes, mainly iron deficiency and disordered eating, should be addressed and studied.

To ensure that the adolescent athlete fulfils his or her potential (both, performance and physical growth), nutrition and eating patterns should be supported by a professional team. Further interventional RCTs are needed in this population.

While session on How to Achieve Optimal Growth in Preterm Infants provided two from three abstract presentation, as follows:


M. Finken1. 1Emma Children's Hospital- Amsterdam UMC, Pediatric Endocrinology, Amsterdam, The Netherlands.

Preterm birth is associated with long-term metabolic risks, such as abdominal fat distribution, insulin resistance, type 2 diabetes mellitus, and raised blood pressure. Early postnatal growth restriction is common among ill preterm infants, but should be avoided to enable the brain to develop optimally. In contrast, rapid weight gain in neonatal life and infancy could augment metabolic risks. The evidence from nutritional intervention studies aimed at the reduction of the long-term metabolic sequelae of preterm birth will be reviewed. More individualized nutritional care, based on the assumption that the long-term metabolic risks can be mitigated by ensuring appropriate linear growth without excess fat mass accretion, seems warranted.


M. de Pipaon1. 1MD, Neonatology, Madrid, Spain.

There is increasing evidence from preclinical and human studies that nutrition in the late foetal and early neonatal period has a significant impact on neurodevelopment across the lifespan. Large difference in intelligence between extremely or very preterm children and controls, which was stable in children born between 1990 and 2008. A fall in the weight z-score from birth to 36 weeks in very preterm infants could predict neurodevelopment. There is a positive association between nutrition during the first four weeks after birth and brain volumes. Moreover, a positive relationship between nutrition, white matter maturation at term equivalent age, and neurodevelopment in infancy. These findings emphasize the importance of a balanced protein, fat, and caloric content for brain development. Beneficial effects of breast milk on cognitive skills and behavior ratings have been demonstrated in term and very low birth weight infants. For every 10-mL/kg per day increase in breast milk ingestion, the Mental Development Index increased by 0.53 points, the Psychomotor Development Index increased by 0.63 points and the Behavior Rating Scale percentile score increased by 0.82 points. Brain imaging studies reveal increased white matter and sub-cortical gray matter volume, and parietal lobe cortical thickness, associated with IQ, in adolescents who were breastfed as infants compared to those who were exclusively formula-fed. Very preterm infants who received formula with an ω-6/ω-3 ratio of 2/1 had better psychomotor development, compared with very preterm newborns who consumed formula with an ω-6/ω-3 of 1/1. Therefore, formula milk with an arachidonic acid quantity double that of docosahexaenoic acid should be considered for feeding very preterm infants.

Plenary session on Yearbook provided three from eight presented topics with abstracts, as follows:


S. Demol1, P. Kotnik2, M. Phillip3, A. Faisal4. 1Schneider Children’s Medical Center of Israel, Jesse Z. and Sara Lea Shafer Institute for Endocrinology and Diabetes- National Center for Childhood Diabetes-, Petach Tikva, Israel. 2Department of Endocrinology- Diabetes and Metabolism, University Children’s Hospital- University Medical Centre Ljubljana, Ljubljana, Slovenia. 3Schneider Children's Medical Center of Israel, The Jesse Z. and Sara Lea Shafer Institute for Endocrinology and Diabetes- National Center for Childhood Diabetes, Petach-Tikva, Israel. 4Royal Hospital for Sick Children- University of Glasgow, Developmental Endocrinology Research Group, Glasgow, United Kingdom.

The physiology of growth in children is still not fully elucidated. In recent years, with the availability of new technologies, our understanding of the interactions between the genetic, epigenetic, internal (microbiome) and external environments and children’s growth has increased.

The manuscripts published in peer-review journals in the past year (from July 1, 2017 to June 30, 2018) contributed to the expansion of our understanding of the physiology of growth and especially the interaction between nutrition and growth. The chapter covers various aspects in this field, including the effect of nutrition on growth, catch up growth in preterm and term infant, mechanisms of growth in the growth plate, the influence of nutrition and supplements on growth and puberty, and new tools to diagnose endo-genetic growth disorders.


N. Fisch1. 1Schneider Children’s Medical Center of Israel-, Jesse Z. and Sara Lea Shafer Institute of Endocrinology and Diabetes- National Center for Childhood Diabetes-, Petach Tikva, Israel.

Michal Yackobovitch-Gavan1,2, Naama Fisch Shvalb1,2 & Zulfiqar Bhutta3,4

1 Jesse Z. and Sara Lea Shafer Institute of Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petach Tikva ; 2Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; 3Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada; 4Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan.

This chapter of the 2019 yearbook reviews the most recent data on childhood malnutrition and catch-up growth, published between July 1, 2017 and June 30, 2018.

Two publications were selected for oral presentation. The first, by Krasevec et al., is a large cross-sectional study which evaluated the association between two indictors of dietary quality - dietary diversity and animal source food (ASF) consumption - and stunting. The analyses were based on data of 74,548 children aged 6–23 months, from demographic and health surveys in 39 different countries. The authors found a significant association both between dietary diversity and less stunting, and between the consumption of ASF and less stunting in infants aged 6-23 months. The number of food groups consumed and number of ASF on the previous day were associated with less stunting, in a dose response manner, even after adjusting for child, maternal, and household covariates.

The second publication by Christian et al. is a review on undernutrition in an under-studied population – adolescents. Normal adolescent growth, a process subject to endocrine control, is particularly sensitive to undernutri­tion. To allow for this process to take place, dietary re­quirements, including those for energy, protein, iron and cal­cium, increase. If dietary intake is insufficient, anemia and micronutrient deficien­cies will emerge; while deficiencies that are treated may allow for catch-up growth. Because there is limited data on interventions for adolescent stunting, the needs of this unique age group are not sufficiently addressed. Different aspects of adolescent undernutrition and stunting are discussed, and directions for future research are highlighted.


A. Prentice1. 1MRC UNIT The Gambia at London School of Hygiene & Tropical Medicine, Nutrition, Keneba, The Gambia.

Stunting of Growth in Developing Countries Andrew M. Prentice, MRCG@LSHTM, Keneba, The Gambia

This year’s summary of the key publications in 2018 on stunting in LMIC countries covers a broad remit. The most important publications where the twin papers from the WASH Benefits Trials in Bangladesh and Kenya. These large and very well conducted cluster-randomised trials found a small benefit of improved infant and young child feeding (IYCF) but no benefit of improved water, sanitation and hygiene (WASH). These profoundly disappointing results have been covered elsewhere in the programme. The results from the SHINE Trial from Zimbabwe were published after the window for selection of YearBook abstracts had closed, but found almost identical results. A trial from The Gambia tested the impact of physician-prescribed lipid-based nutrient supplements given to sick children presenting to clinic. There was no benefit on the primary outcome of repeat clinic visits and only a very small effect on linear growth. In a post hoc analysis there was an increase in infections in the f