1000 Days of Good Nutrition: In the United States or Abroad, It Is About Equity, Evidence, and Leadership

The first 1000 days, from pregnancy through a child’s second birthday, is a critical window of opportunity for good nutrition for mothers and children. This concept was a highlight of the foundational 2008 series on Maternal and Child Undernutrition, which focused on low- and middle-income countries.¹ I applaud the same concept being applied in the United States. Domestic and global nutrition have often been perceived as dichotomous, but, as presented in the articles in this AJPH supplement, it is striking to see how similar the gaps, opportunities, and root cause of inequity are in both settings, as well as the need for evidence-informed leadership to drive change.

GLOBAL POTENTIAL TO SURVIVE AND THRIVE

When I started in public health nutrition four decades ago, child growth was assessed relative to the US National Center for Health Statistics references, and there was often conjecture regarding whether these were applicable globally. Landmark studies across the world have shown that growth patterns are similar when mothers’, infants’, and young children’s nutritional and health needs are met.^2,3 In the United States and globally, inequity is the fundamental driver of our failure to enable all children to realize their potential.⁴ A key 2021 series states, “Socioeconomic inequalities persist as a major distal determinant of undernutrition, as shown by between-country and within-country analyses.”⁵ Although average differences across countries are declining, “economic inequality has grown within many countries.”⁶ Evidence-informed leadership, in the United States and globally, is essential to secure nutrition equity and provide an environment where all children can achieve their potential.

Although the relative manifestation of malnutrition in terms of undernutrition, micronutrient deficiencies, and overweight and obesity may differ between the United States and other countries, there are key lessons to drive progress that are applicable everywhere.

FAILING TO DELIVER IN THE UNITED STATES AND ABROAD

Access to good health and nutrition services for mothers and children in the first 1000 days is essential but neglected. In this supplement, Hamner et al. (p. S817) and Jefferds et al. (p. S826) lay out key gaps in the United States. Globally, it is recognized that the peak incidence of stunting and wasting occurs in the first 6 months of life, in part already existing at birth, and that low birth weight prevalence has declined slowly.⁴ In the United States, deficiencies of essential nutrients before conception and during pregnancy continue to pose a public health burden. These are stark reminders of how systems globally and in the United States fail to provide adequate nutrition to women during this critical period.

Breastfeeding is the optimal source of infant nutrition, and achieving nearly universal breastfeeding would avert more than 800 000 child deaths and 20 000 maternal deaths and would yield significant economic benefits. The 2016 breastfeeding series concluded that the world is still not providing a supportive and enabling environment for most women who want to breastfeed, despite known interventions, policies, and programs.⁷ In the United States, the Maternity Practices in Infant Nutrition and Care Survey⁸ and the Breastfeeding Report Card⁹ are excellent examples of strengthening the continuum of care required to support breastfeeding, and they are contributing to improving breastfeeding practices.

Good nutrition in the first 1000 days requires both food and health systems to deliver nutritious food and nutrition services. However, in the United States and globally, both are failing. Worldwide, only 29% of children aged 6–23 months benefit from minimum dietary diversity,¹⁰ and stark socioeconomic disparities in children’s quality of diet persist.¹¹ In 2020, almost 3.1 billion people worldwide, including 4.9 million in the United States, could not afford a healthy diet, 112 million more than in 2019.¹² Hamner et al. highlight gaps in the health system in the United States, and others have underscored the failure of health systems to deliver critical nutrition solutions in low- and middle-income countries.⁴ These preexisting inequities and failure to deliver are being exacerbated by the COVID-19 pandemic, the climate crisis, and conflict, including the global food crisis driven by Russia’s invasion of Ukraine.^12–15

DESIGNING WITH DATA

To address inequities and buffer the most nutritionally vulnerable from shocks, social protection programs have an increasingly important role to play. However, to be effective, they need to be designed purposefully. Globally, there is an increasing body of evidence on key design elements that improve nutrition outcomes.^16,17 The accompanying editorial by Bleich and Dean (p. S773) provides important guidance for the United States.

To effectively respond to the continued global crisis of malnutrition, we need appropriate and timely data to drive priorities. However, in the United States and globally, major data gaps remain, most acutely for micronutrient status; quality and affordability of safe, diverse, and nutritious diets; and coverage of key nutrition services.⁴ Hamner et al. and Jefferds et al. underscore data gaps in the United States. The Demographic and Health Surveys Program is an essential platform for nutrition data across low- and middle-income countries, and updates in 2019 are a step change in improving relevance, number, and quality of nutrition-related indicators.¹⁸

According to the 2021 Global Nutrition Report, we are off track to meet the World Health Assembly nutrition targets and all diet-related noncommunicable disease targets. The challenges to reach these targets, both in the United States and globally, can seem daunting. However, there is also a growing body of evidence from a number of countries showing that change is possible.^19–21 The recurring theme in these examples is that political leadership is necessary to drive progress. For example, research into Senegal’s impressive reductions in stunting, a condition that had largely been invisible to decision-makers, link back to a major 2001 policy decision creating a Nutrition Coordinating Unit in the prime minister’s office that drew in all relevant ministries and facilitated robust nutrition policies and programs.²²

THE WAY FORWARD

We are at a critical crossroads for nutrition in the first 1000 days, both in the United States and around the world. However, there is reason for optimism, thanks to President Biden’s announcement of domestic and global commitments at the United Nations Food Systems Summit; the US government’s global financial and policy and domestic policy announcements at the Tokyo Nutrition for Growth Summit; the endorsement of the US Government Global Nutrition Coordination Plan by the US secretaries of state, agriculture, and health and human services, the United States Agency for International Development administrator, and chief executive officers of the Development Finance Corporation, Millennium Challenge Corporation, and Peace Corps; and the first White House Conference on Hunger, Nutrition, and Health in 50 years being organized in September this year.^23–26

Our partners stand with us, as evidenced by the 66 partner governments, mainly from low- and middle-income countries, that made robust commitments at the Nutrition for Growth Summit and by the African Union adopting nutrition as the theme for 2022.^27,28 We know that all children everywhere have the potential to survive and thrive when provided adequate nutrition. Solutions are at hand at home and globally, and US leadership on nutrition for mothers and children in the first 1000 days is more important now than ever.