Author: Allyson Garner

An interview with Dr. Kofi Essel, Community Pediatrician, Children’s National Hospital

What inspired you to become a pediatrician?

I always found the field of pediatrics to be a very fertile ground.  Families are interested in the wellbeing of their children, doing whatever it takes to improve the health of the next generation.  This made my clinical experiences very positively reinforcing as we engaged in effective, shared decision-making.  In addition, my mentors in my early training were all pediatricians and huge community advocates.  I knew I wanted my career to expand beyond the clinical examination room, and I found the opportunity to advocate for marginalized young children and families to be meaningful and necessary.

Your recently published a paper entitled, “The first 1,000 days: A Missed Opportunity for Pediatricians.” Why are the first 1,000 days important?

The first 1,000 days are a critical stage for young children.  Unfortunately, healthcare is often very reactionary and prioritizes management and treatment of disease.  However, the opportunity to engage young children and families in prevention and take advantage of these early years to optimize brain development and maturation, eating patterns, and healthy family relationships is critical.  We know that children are incredibly vulnerable during these first 1,000 days and small insults to their brain and environment can cause permanent challenges down the line.  Helping families and creating systems that protect and support the most vulnerable is essential for our nation.

Why is this a missed opportunity for pediatricians?

This article gave me a chance to highlight the gaps in nutrition education for future and practicing providers, but also magnify the importance of pediatricians like myself to take the mantle to support our young children and families.  Systemic change is crucial and necessary, but the need for strong counseling and advocacy is always going to be an important piece of the puzzle.  The gap in nutrition education is a disservice to our patients, so I call on our training programs to recognize the essential nature of equipping our current and future pediatricians with the knowledge, tools, and skill to work alongside our patients and through shared decision-making support their desire to optimize the health of their children.  We also must remember that the 21st century clinician must engage using modern tools of integration.  We must seamlessly integrate our clinical work with population health to provide more voices to advocate for the changes needed that our families share with us each and every day.

How does your awareness of nutrition in the 1,000-day window influence who you are as a pediatrician and what you prioritize?

I truly believe nutrition is a powerful tool that I use in my clinical arsenal, and it deserves more attention.  Food is medicine, and I use this medicine with confidence in the same way I have developed confidence in the tried-and-true inhalers, pills, and liquid solutions that my prescriptions help my families acquire.  Unfortunately, as a pediatrician I realize that the access to the medicine of food is often limited for many populations and this inequity leads to worsening disease with its origins beginning in the womb.  As a pediatrician with an awareness of the power of nutrition I am compelled to advocate for programs, tools, and interventions that support equitable access to nutritious foods so that all my families can have a chance from the start.

What needs to happen to support pediatricians with this opportunity?

In order to support pediatricians to use food and nutrition as medicine to impact the first 1,000 days of young children, it is important to keep a few things in mind: 

1. Incorporate required, high-quality, substantial and practical nutrition education in medical schools and residency training, so that future providers become aware of its necessity.
2. Ensure curricula that inform current and future providers engage with the tangible social needs that are ubiquitous throughout the country, such as food and nutrition security.  If not integrated into training, we set the stage for worsening inequities by only promoting a message that appears unreachable for many. 
3. We often focus on the challenges within communities, but we need to recognize their strengths and assets. Pediatricians need support to screen families for food insecurity and must have in place strong, community, clinical-collaborative referral programs to seamlessly connect families from clinics and health systems to meaningful, nutrition-based, local and federal programs as needed and beneficial (i.e. food as medicine, local pantries, community cooking classes, WIC, SNAP, etc).
4. Systems change requires systemic solutions.  To redirect the health system will require more than a few pediatric advocates on the ground, but rather larger licensing bodies and federal policy to turn the tide, such as the recent bipartisan resolution authored by Congressman McGovern & Burgess in May of 2022 calling for “substantial training in nutrition” for physicians.

Research question: What is the state of nutrition during the 1,000-day window for families in the United States, and what are the opportunities to strengthen federal research and surveillance, programs, and communication and dissemination efforts aimed at improving nutrition and influencing the health and well-being of pregnant people and children?

Why this research was needed: An analytical essay published in The American Journal of Public Health summarizes the current state of nutrition for families in the 1,000-day window in the United States. It further proposes a framework by which nutrition during this period can be improved. These recommendations could inform policymakers, public health and health care communities, and program leaders.

The 1,000-day window is the period between pregnancy and a child’s 2nd birthday and is a critical time in the development of a child. Good nutrition during the first 1,000 days can have a profound impact on the health and well-being of pregnant people and children.

How the research was conducted: The researchers carefully reviewed dietary intake compared with the US Department of Agriculture and US Department of Health and Human Services Dietary Guidelines for Americans 2020–2025, as well as the primary literature covering health, nutrition, and clinical outcomes for pregnant people and children during the 1,000-day window. They then created a high-level summary on the status of nutrition in the United States with focuses on dietary status, health, and outcomes of pregnant people, infants, and toddlers during the 1,000-day window. They also provided a framework for future improvements to research and public health surveillance, programmatic approaches, and communication and dissemination initiatives.

What the research found: The current state of nutrition during the 1,000-day window shows numerous gaps between dietary intake and recommendations, with race and ethnicity disparities across the spectrum. The average intake of total vegetables, fruits, and dairy are below federal recommendations during pregnancy and lactation. At the same time most pregnant and lactating people exceed the thresholds for sugars (70% and 51%), saturated fat (75% and 77%), and sodium (88% and 97%) respectively. In addition, nearly 50% of pregnant persons gain more than the recommended amount of weight during pregnancy and 20% gain less.

While it is recommended for infants to be exclusively fed human milk for the first 6 months, data from 2019 revealed that only 24.9% of infants exclusively received human milk through 6 months. Race- and ethnicity-based disparities in human milk feeding remain. Moreover, while it is recommended that complementary foods—those other than human milk or formula—should not be introduced before 4 months, this is the case with about 31.9% of infants.

Children between 12–23 months had total vegetable intake below recommendations while total intake of fruits, grains, and dairy were above recommendations. The average intake of added sugars and sodium were above recommendations.

What the research proposed: The proposed framework to improve nutrition encompassed three aspects—strengthening federal research and surveillance, optimizing programs, and improving communication and dissemination.

Historically, surveys have not included, or have had insufficient samples of pregnant and lactating women, infants and toddlers, and different racial and ethnic groups, leading to gaps in the data. Improving research and surveillance can start with modifying existing systems to improve coverage and data gathering for underrepresented subpopulations.

Programs can be optimized by reducing barriers to participation and reducing inequity among participants to alleviate disparity. Improving participation and engagement in these programs, as well as implementing standards, recommendations, and interventions that affect these programs could improve health and nutrition outcomes.

Scientific nutritional recommendations can be communicated through tailored and specific messages that target key audiences and are consistent with the Dietary Guidelines for Americans and supplemental recommendations. With the rapidly changing landscape of reaching audiences, implementing agencies and organizations need to collaborate effectively to provide tools and messaging that are culturally and linguistically relevant.

What this research means for key stakeholders: The framework proposed in this paper could inform key stakeholders in the following ways.

For policymakers: Data-gathering objectives to fill the current information gaps can be met by early care and education programs (ECE), clinics implementing the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and federally qualified health care centers that act as sentinel surveillance sites. Implementing standards that affect programs (e.g., licensing standards in ECEs) could improve health and nutrition outcomes. Updating clinical guidelines could also help improve how care is provided. Targeted, audience-specific messaging can help disseminate information to vulnerable groups.

For the public health and health care communities: The electronic health records of underrepresented populations can be used to bolster technological advances in supplementing existing data like feeding decisions, health outcomes, and biologic data. Clinical guidelines and recommendations for programs can be improved by healthcare delivery through tele-health visits, engaging health care support teams, and updating guidelines to improve how and when care is provided. Interventions should be prioritized that have significantly affected health outcomes, can be scaled, reach high-risk populations, reduce inequities, and complement existing federal or state programs. Linguistically and culturally sensitive communication could improve nutrition status in vulnerable populations.

For program leaders: Improving participation and engagement in programs such as WIC, the Child and Adult Care Food Program, and the Maternal, Infant, and Early Childhood Home Visiting Program could contribute to improving health and nutrition outcomes. The following interventions should be prioritized—those that have significantly affected health outcomes, can be scaled, reach high-risk populations, reduce inequities, and complement existing federal or state programs. Tailored, audience-specific messaging will help communicate and disseminate information on early childhood care and education more effectively.

Key takeaway: Optimal nutrition in the first 1,000 days can have lifelong effects on the health and well-being of pregnant people and children. Working collectively through a framework focused on advancing research and surveillance, programs, and communication and disseminationcould improve health equity, reduce maternal mortality and morbidity, and improve child health outcomes for current and future generations.

*DISCLAIMER: This write-up is derived from a published article and does not reflect the views of the author of the article, their affiliation, or the journal in which this content is published.

Authors/Reference/DOI: Heather C. Hamner, PhD, MS, MPH, Jennifer M. Nelson, MD, MPH, Andrea J. Sharma, PhD, MPH, Maria Elena D. Jefferds, PhD, Carrie Dooyema, MPH, MSN, RN, Rafael Flores-Ayala, DrPH, MApStat, Andrew A. Bremer, MD, PhD, Ashley J. Vargas, PhD, MPH, RDN, Kellie O. Casavale, PhD, RD, Janet M. de Jesus, MS, RD, Eve E. Stoody, PhD, Kelley S. Scanlon, PhD, RD, and Cria G. Perrine, PhD. Improving Nutrition in the First 1000 Days in the United States: A Federal Perspective. American Journal of Public Health. doi: 10.2105/AJPH.2022.307028. 2022

Corresponding author contact information: To speak with the author, please contact CDC press office: (404) 639-3286 or media@cdc.gov. To speak with the media team at 1,000 Days, contact Blythe Thomas

July is bringing hot temperatures to the Nation’s Capital and work is also heating up on Child Nutrition Reauthorization and the White House Conference on Hunger, Nutrition and Health. To the delight of child nutrition advocates, House Education and Labor Chairman Bobby Scott (D-VA) and House Civil Rights and Human Services Subcommittee Chair Suzanne Bonamici (D-OR) released the Healthy Meals, Healthy Kids Act, the Committee’s much-anticipated Child Nutrition Reauthorization bill. The legislation addresses critical needs and recommended improvements in the programs that serve children including the National School Lunch Program, Summer Food Service Program, Supplemental Nutrition Program for Women, Infants and Children (WIC) and the Child and Adult Care Food Program (CACFP). Proposals in the bill are designed to increase access to these programs and strengthen the nutritional resources provided to participants. Many of the recommendations are based on learnings from the COVID-19 pandemic about strategies to reach more children and meet the critical needs of program providers to ensure program sustainability.

1,000 Days is particularly excited to see provisions that

• modernize WIC by improving access to telehealth so that receiving program benefits is not limited due to physical burdens;
• expand the WIC Breastfeeding Peer Counselor Program to ensure more families have access to breastfeeding support;
• strengthen CACFP by providing reimbursement for an additional meal or snack per child, allowing young children in care for longer hours to receive the nutrition they need; and
• permit children in households participating in the Supplemental Nutrition Assistance Program (SNAP) to be automatically eligible for CACFP, ensuring more young children will receive nutritious meals and snacks.

The team at 1,000 Days will monitor the Committee markup on Wednesday, July 27 and work closely with partners and lawmakers to advance this bill and its critical components that improve nutrition security for birthing people, young children, and their families.

1,000 Days also worked across the public health community and in specific coalitions to inform the Administration about our priorities for the White House Conference on Hunger, Nutrition and Health by the July 15 deadline. Examples include working with Council for a Strong America’s CEO Barry Ford to submit this letter to reinforce the need for policies to support maternal and child health, equitable policy implementation and more. Paid Leave for All, where Blythe Thomas, 1,000 Days’ Initiative Director, serves on the steering committee, submitted a letter leveraging 1,000 Day’s report that demonstrates paid leave is a public health imperative and must be considered as an intersectional policy that supports and builds stability for low-income and other marginalized communities. Finally, although it’s not an official part of White House property, the Task Force on Hunger, Nutrition and Health collected policy reports and white papers to help inform their recommendations. That portal includes four papers authored by 1,000 Days and four papers from other organizations with a focus on the 1,000-day window in the title. We’re working hard to ensure the White House hears us!

The U.S. Departments of Health and Human Services (HHS) and Agriculture (USDA) are preparing for the next edition of the Dietary Guidelines for Americans. They recently proposed a list of scientific questions to inform the next version, with a focus on diet and health outcomes across the lifespan. In response, 1,000 Days submitted comments emphasizing the critical importance of nutrition in shaping future health and outcomes. Our comments specifically recommend adding developmental milestones as outcomes of study for infant and toddlers, including key questions on maternal and child nutrition and health outcomes from the 2020 Dietary Guidelines Advisory Committee report, and updating research on breastmilk composition and consumption.

See the comments here.