Background: Nutrition during the first 1000 days influences short and long term health outcomes including growth and chronic conditions such as blood pressure. Although several studies have examined the effect of nutritional supplementation on growth from birth to 24 months, few have evaluated the long-term effects of early supplementation. The International Lipid-based Nutrient Supplements (iLiNS)-DYAD trial in Ghana showed that small-quantity lipid-based nutrient supplements (LNS) provided during pregnancy and 6 months postpartum for the mother and from 6 to 18 months for the child had a positive effect on birth weight and subsequent growth. Our current objectives were to: 1) examine the effect of the intervention on growth, body composition and blood pressure at 4-6 y of age, 2) identify maternal and child factors related to blood pressure in the cohort of children, and 3) determine the association between diet, physical activity, maternal BMI and body composition in this cohort of Ghanaian preschool children. Methods: We conducted a follow-up study of children born to women who participated in the iLiNS-DYAD trial in Ghana. The trial was a partially double-blind, randomized controlled trial which assigned women (n=1320) at ≤ 20 weeks gestation to one of three supplementation groups: (a) daily iron and folic acid tablet during pregnancy and a calcium tablet (placebo) for the first 6 months postpartum, (b) daily multiple micronutrient tablet (1-2 RDA of 18 vitamins and minerals) during both periods or (c) daily 20 g (118 kcal) LNS during both periods Children whose mothers received LNS also received LNS from 6 to 18 months of age. At 4-6 y of age, we determined the effect of the intervention (LNS vs. non-LNS) on the primary outcomes height, height-for-age z-score (HAZ) and percent body fat determined by the deuterium dilution method, and secondary outcomes (other growth indicators and blood pressure). High blood pressure was defined as systolic or diastolic blood pressure ≥ 90th percentile based on the U.S. National Heart Lung Blood Institute reference. Dietary patterns were extracted from food frequency data using factor analysis and physical activity was measured using accelerometers. Results: Follow-up anthropometric results represent 76.5% of live births (n=961) from the main trial. There were no significant differences between non-LNS vs LNS groups in height [106.3 vs. 106.7 cm (beta = 0.36; 95% CI -0.23, 0.95; p=0.226)], HAZ [-0.57 vs.-0.49 (beta = 0.08; 95% CI -0.05, 0.21; p=0.226)], stunting (<-2 SD) [6.3 vs. 6.5% (beta = 1.00; 95% CI 0.58, 1.73; p=0.993)], or percent body fat [15.3 vs. 15.5% (beta = 0.16; 95% CI -0.49, 0.81; p=0.630)]. However, there was a significant interaction between intervention group and maternal baseline BMI with regard to child height and HAZ: among children of women with BMI <25 kg/m2, the LNS group was taller than the non-LNS group (+1.1 cm, p=0.046), whereas there was no significant difference among children of women with BMI <25kg/m2. Mean systolic and diastolic blood pressure and prevalence of high blood pressure did not differ between the groups. Overall prevalence of high blood pressure was 30.4%. We observed a positive association between birth weight and blood pressure at 4-6 y in bivariate analysis, which was largely mediated through concurrent WAZ in a path model. Concurrent WAZ and maternal blood pressure were the factors most strongly related to child blood pressure. Percent body fat was positively associated with maternal BMI [beta (SE) = 0.10 (0.03); p=0.003] and negatively associated with physical activity [β (SE) = -0.15 (0.05); p=0.003, when not adjusted for child gender] but not associated with either of the two dietary patterns identified, the snacking pattern [beta (SE) = 0.06 (0.03); p=0.103] and cooked food pattern [beta (SE) = -0.05 (0.07); p=0.474], in regression analysis. Boys were significantly more active (boys vs. girls, 1470 vs. 1314 vector magnitude count, p<0.0001) and had significantly lower percent body fat (13.8 vs. 16.9%; p<0.0001). Conclusions: Although there was no overall effect of LNS on height at 4-6 y of age in this cohort, which had a low stunting rate, there was an increase in height in the LNS group among children of non-overweight/obese women. There was no adverse impact of LNS on body composition or blood pressure. The key factors related to blood pressure in this preschool population at high risk for adult blood pressure were child WAZ and high maternal blood pressure. Maternal overweight and child physical activity, especially among girls, may be important targets for reducing child overweight in this Ghanaian population.