Author: Allyson Garner

Q&A with Dr. Kofi Essel: AJPH Special Series on Nutrition in the 1,000-Day Window

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.

Nutrition During the First 1,000 Days in the United States: Current Status and Recommendations for Improvement

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

1,000 Days Applauds Bipartisan Introduction of Global Food Security Act

1,000 Days applauds the bipartisan and bicameral introduction of the Global Food Security Act (GFSA), which would primarily reauthorize funding for Feed the Future, a U.S. Government initiative to address the root causes of global hunger and poverty to improve nutrition and food security. The Senate bill (S. 4649) was introduced by Senators Bob Casey (D-PA), Jim Risch (R-ID), Chris Coons (D-DE), and John Boozman (R-AR). The House bill (H.R. 8446) was introduced by Representatives Betty McCollum (D-MN-04), Chris Smith (R-NJ-04), Gregory Meeks (D-NY-05), and Michael McCaul (R-TX-10).

The Global Food Security Act was first enacted in 2016 to reduce hunger and malnutrition, improve resilience in food insecure communities, and support agricultural-led development. GFSA authorized Feed the Future through 2018 and again through 2023. The recently introduced GFSA legislation would reauthorize the program through 2028. To date, Feed the Future has reached over 26 million children with nutrition-specific interventions.

Blythe Thomas, Initiative Director of 1,000 Days welcomes the introduction of GFSA – “We were particularly pleased to see the mention of the 1,000-day window in the House bill language as we know that is a critical period and good nutrition is of the utmost importance. As the bills move through committee, we encourage legislators to focus on the importance of nutrition interventions during the first 1,000 days. We look forward to meeting with Congressional offices and advocating for passage of GSFA during this critical period of global food and nutrition insecurity.”

Long term consequences of early childhood malnutrition

Published: December 2003 

Publication: International Food Policy Research Institution 

Authors: Harold Alderman, John Hoddinott, Bill Kinsey 

Background

  • Researchers studied the preschool nutritional status (measured by height, given age) of children in Zimbabwe who experienced civil unrest and/or a drought before the age of three
  • Civil war and droughts were used as an indicator of malnourishment
  • Nutritional status was then compared to subsequent health and education achievements of these children to show the effects of early-childhood malnutrition on adult outcomes

Summary

  • The study indicates that early childhood malnutrition can lead to continued stunting and lower school achievement in adolescence as compared to peers who experienced no malnutrition or a lesser degree of malnutrition in childhood
  • Children who measured at median height in preschool were more likely to measure at median height by adolescence and have completed an additional 0.7 grades of schooling than students who measured below median height in preschool
  • This study also indicates that improving preschool nutrition can facilitate growth and higher educational achievement in adolescence
  • Because of the negative impact of “shocks” (i.e. war and drought), interventions should focus on mitigating the impact of these shocks.

Read the original article here

A Conversation with Action Against Hunger

Blythe Thomas, Initiative Director at 1,000 Days, an initiative of FHI Solutions, recently spoke with Dr. Charles Owubah, CEO of Action Against Hunger, to discuss the vital work of his organization to detect, treat and prevent malnutrition. The two discussed the effects of COVID and climate change on food and nutrition, the role of women farmers in ending malnutrition, and LifePack, an innovative tool to raise money for malnutrition treatment.

Watch the video to learn more. 

Keeping Healthy During Pregnancy & Breastfeeding

During pregnancy and when you’re breastfeeding, nutritious food choices will help fuel your
baby’s growth and keep you healthy.

Watch and learn 6 steps you can take during your 1,000-day window to nourish you and your little
one.


Taking a Prenatal Vitamin

Eating the Rainbow

Limiting Certain Foods

Managing your Weight

Focusing on Good Nutrition

Breastfeeding for the Benefits to You and Baby

Follow us on social for more!

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What We’re Watching – July 2022

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!

Historic Commitment from US Government to Fight Severe Malnutrition

“There are many problems in this world that will take decades to solve sustainably. Ending child deaths from wasting is not one of them. This is something we can do now.” – Will Moore, CEO, Eleanor Crook Foundation at the State of Global Food Security and Nutrition event on July 18.

At the State of Global Food Security and Nutrition event hosted July 18, 2022, by the Center for Strategic and International Studies (CSIS), United States Agency for International Development (USAID) and the Eleanor Crook Foundation (ECF), USAID Administrator Samantha Power announced that the United States will provide UNICEF with an additional $200 million to procure and distribute ready-to-use therapeutic foods (RUTF). The announcement is the most significant commitment that has ever been made to treat wasted children and the largest leap in coverage on record. 

In addition to the $200 million commitment, the Eleanor Crook Foundation, the CRI Foundation and The ELMA Relief Foundation also pledged $50 million to support the effort. Administrator Power announced a goal to match another $250 million from the private sector, high net worth individuals, corporations and other philanthropies with hopes to announce additional funds raised at the U.N. General Assembly in September 2022. 

“Perhaps the most immediate, life saving, humanitarian aid we can provide is assistance to revive severely malnourished children,” said Administrator Power. “Despite the power of (RUTF) in the fight against child wasting, it is drastically underutilized.”

Malnutrition is the greatest threat to child survival worldwide, contributing to more child deaths than AIDS, malaria, and tuberculosis combined. Those who do survive severe malnutrition in early childhood are much more likely than their well nourished peers to suffer from physical and mental stunting that affect future educational attainment, health and earning potential. 

RUTF treatment for six weeks can help nearly 90 percent of children suffering from wasting recover.  According to UNICEF, “Reaching virtually every child in need can be achieved with just US$300 million in additional funding.” The $200 million pledge, coupled with the $50 million pledged today by private philanthropies, could equate to 80% of the way toward the UNICEF goal.

However, RUTF is not the only high-impact nutrition intervention ready to be scaled today. Using a modeling tool developed by the Johns Hopkins Bloomberg School of Public Health, researchers identified four of the most life-saving and cost-effective actions we can take. Known as the Power 4, they include the following: 

  1. Supply all pregnant women with prenatal vitamins;
  2. Support breastfeeding mothers;  
  3. Continue large-scale vitamin A supplementation; and 
  4. Expand coverage of specialized foods (RUTF) for treatment. 

Along with RUTF, the Power 4 have significant potential to reduce child deaths from malnutrition and make up some of the “best buys” in global development. In the United States, just over 1 percent of US global health funding in FY2022 goes to nutrition programming, while AIDS, malaria, and tuberculosis collectively net about 76 percent. It is time to increase global nutrition investments and end the preventable child and maternal deaths malnutrition causes. 

As Administrator Power said today, “No child should die from malnutrition when we have the tools to stop it, it’s that simple.” At 1,000 Days, we agree.

Paid Leave Must Have a Place at the White House Conference on Hunger, Nutrition, and Health

The following is a statement from the Paid Leave for All coalition, of which 1,000 Days is part.


Dear members of WHCHNH Advisory Committee Members,

As parents, caregivers, early childhood and public health experts, race and gender equity advocates, social justice organizations, and on behalf of our tens of millions of members, we strongly urge you to include paid family and medical leave in the White House Conference on Hunger, Nutrition, and Health and its national strategy. We recommend the White House continue to promote its original proposal of at least 12 weeks of inclusive and comprehensive paid family and medical leave for all working people as a public health imperative. 

Paid leave is a proven tool in addressing the United States’ most pressing health issues, whether it be mitigating the ongoing COVID-19 pandemic, addressing breastfeeding needs in light of a national formula shortage, addressing our worsening maternal mortality rates, or improving our overall health outcomes and families’ well-being. It is also a tool for alleviating the systemic racism and sexism in health care, by allowing more people and those with more caregiving responsibilities access and time to care for themselves along with their loved ones. Yet only 23 percent of workers in this country have access to paid family leave through their jobs and we remain one of the only countries in the world without this protection. 

Paid leave is interconnected with a broad number of health indicators and outcomes. Workers without access to paid leave are more likely than workers with paid leave to experience financial and material hardships, including being more than twice as likely to be unable to pay for rent or utilities and twice as likely to experience food insecurity. Implementing paid leave in California, for example, reduced very low household food security by about two percentage points. Workers without access to paid leave are also more likely to be uninsured, have trouble paying for medical bills, and have less access to medical care because of the cost. A quarter are not confident they could come up with $400 for an unexpected emergency.

Paid leave is also a critical tool to support healthier pregnancies, better birth outcomes, more successful breastfeeding, and both physical and mental health in the postpartum period. This is particularly important while the United States faces a formula shortage—and has the worst maternal mortality rate among wealthy countries, disproportionately impacting Black women, and one that is worsening after COVID-19. Paid leave is critical to giving birthing people the opportunity to establish breastfeeding patterns as an option for their family, and we know that for those who are able and choose to breastfeed, it plays a powerful role in women’s health. Research has shown that breastfeeding is associated with a lower risk of heart disease—the leading cause of death among women in the U.S.—as well as breast cancer, ovarian cancer, type-2 diabetes, and hypertension later in life. It also has health benefits for the child, including improving the digestive and immune system. The American Academy of Pediatrics recently increased their recommended duration of breastfeeding to two years or beyond, a near impossibility for working families without access to paid leave. For low-income families in New Jersey, where a statewide paid family leave program has been in effect since 2009, researchers found that new mothers who use the state paid leave program breastfeed, on average, one month longer than new mothers who do not use the program. According to the Department of Health and Human Services, if 90 percent of women in the United States breastfed their babies for the first 6 months of life, it would save 900 babies’ lives and $13 billion in healthcare expenses annually.

We know that paid sick, family, and medical leave are critical to the overall health—including mental and emotional health—and well-being of working people, families, and whole communities. They are key to diagnosis, treatment and recovery, and the containment of disease. 

Every one of us is going to need to give and receive care in our lifetimes, and without a federal guarantee of paid leave, we will all suffer. We urge you to include paid family and medical leave in this conference and its related strategies, and to prioritize it across the administration. 

Additional Resources: 

1,000 Days Submits Comments to USDA and HHS for Next Edition of the Dietary Guidelines for Americans

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.