An evidence-informed approach to address food and nutrition security: the ecology of infant feeding practices

Introduction

There has been increasing attention paid to the need for a deeper understanding of those factors that contribute to the daunting level of food and nutrition insecurity in the US and globally. The ability to achieve the aspirations of these efforts requires a life course approach that begins with the critical developmental period referred to as the “First 1,000 Days” encompassing pregnancy through the first 2 years of life. Multiple global health targets have been disseminated to address this critical period and most directly the efforts to develop and sustain resilient approaches to infant feeding (1).

In the US, the historical interest in the promulgation of evidence-informed guidance was reinforced most recently by a series of activities aimed at integrating the 1,000 days period in the US Dietary Guidelines for Americans (DGA). These efforts were stimulated by a project that ultimately became known as the “B-24 Project” aimed at evaluating the evidence to support the integration of infants and children from birth to 24 months into the DGA (2). Due to the tremendous advocacy of the US government (USG) public health community, dietary guidance during pregnancy and the first two years of life was included in the 2020–2025 DGA and will be fully integrated into all future DGA iterations. In addition, since the finding that a critical gap exists in our knowledge about the factors affecting human milk composition (3), the USG community has initiated a concerted effort to compile existing and generate new data to address this need (4).

The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)

Since its inception 60 years ago, NICHD has supported research in the nutrition and infant feeding spaces. More recently, NICHD has further codified its mission with the publication of its Strategic Plan (5), which highlights the critical and cross-cutting topic of nutrition and, in particular, the importance of an expanded understanding of the complexities of the inherent biology and implications of factors affecting decisions and implementation of best practices to support nutrition, health, and development via context-specific equitable, safe, and efficacious infant feeding practices.

The 2022 White House Conference on Hunger, Nutrition, and Health

In September 2022, the Biden-Harris Administration released its National Strategy on Hunger, Nutrition, and Health (referred to as the “National Strategy”) and the Administration hosted the White House Conference on Hunger, Nutrition, and Health, both organized around five pillars that highlight the continuum of activity across all agencies that directly or indirectly impact food and nutrition insecurity and diet-related diseases and the need for an evidence base to support these efforts (6) (Box 1). In addition, these pillars are illustrative of a recognition that research and translational efforts demand a deeper understanding of the full spectrum of issues impacting on the biology, choice, and implementation of context-specific, equitable, safe, and efficacious programs, policies, and standards of care.

BOX 1

BOX 1. The National Strategy: organizing pillars

The “Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN)” Project

The complexity of this new understanding is exemplified by the myriad factors to consider in addressing infant feeding practices, including human milk feeding. Because of the inherent complexity of that new understanding, a new approach is required that recognizes that these issues represent an “ecology” in which human milk is a complex biological system affected by both internal (biology, genetics, nutrition, health) and external (social determinants, food system, physical) environments. The BEGIN Project – initiated by NICHD in 2020 – was incepted to apply this ecological framework to our efforts to support and expand the infant feeding agenda in the US and globally.

Discussion

Human milk is the gold standard source of nutrition and other critical bioactive components to support the growth and development of infants. It is, in most circumstances, the best source of nutrition and serves as nature's barrier against food insecurity for infants. Breastfeeding remains the primary mode of delivery of human milk. However, our ability to achieve a greater prevalence of exclusive and extended breastfeeding based on accepted guidance remains a challenge, particularly for underserved populations in the US and globally. Moreover, due to changing social and economic environments, new modes have emerged as options for parents wanting to provide human milk to their babies, including feeding of expressed milk and, in cases where the parent's own milk is not available, use of donor/banked human milk. In addition, in cases where neither parent's own milk nor donor milk is a viable option, a need exists for safe and efficacious human milk substitutes. Our ability to make evidence-informed recommendations/guidance about various aspects of infant feeding practices and related aspects of the determination of nutritional requirements for infants thus demands a deeper appreciation of the factors that affect the composition and delivery of human milk.

The BEGIN Project was designed to provide evidence with regard to a deeper understanding of human milk composition and its ecology (the interactions amongst the infant feeding triad, i.e., parental biology, the breastfeeding infant, and the unique nature of human milk as an interactive biological system affected by both an internal and external environment). The information derived from the BEGIN Project is intended to inform those agencies/organizations in the public and private sectors involved in the development and promulgation of evidence-informed guidance about safe and efficacious infant feeding practices and the development of a research agenda to support all aspects of those efforts (7). Hopefully through the efforts described above a stronger foundation can be built upon which to mount the programs and policies needed to fulfill the promise outlined by the White House Conference and those pillars to support the health and development of generations to come.

Author contributions

Both authors contributed to the writing of the manuscript. All authors contributed to the article and approved the submitted version.

Acknowledgments

The authors would like to acknowledge Alison Steiber and her staff at the Academy of Nutrition and Dietetics for their contributions to the BEGIN Project.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. In addition, the contents of this article do not constitute an official position of the National Institutes of Health or the United States Government. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

References

1. World Health Organization Global Nutrition Targets 2025. Available at: https://www.who.int/publications/i/item/WHO-NMH-NHD-14.2 (Accessed February 22, 2023).

2. Raiten DJ, Raghavan R, Porter A, Obbagy JE, Spahn JM. Executive summary: evaluating the evidence base to support the inclusion of infants and children from birth to 24 mo of age in the Dietary Guidelines for Americans–“the B-24 project”. Am J Clin Nutr. (2014) 99(3):663S–91S. doi: 10.3945/ajcn.113.072140

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3. Dietary Guidelines for Americans, 2020–2025. Available at: https://www.dietaryguidelines.gov/resources/2020-2025-dietary-guidelines-online-materials (Accessed February 22, 2023).

4. Human Milk Composition Initiative. Available at: https://www.nichd.nih.gov/research/supported/HMCI#more (Accessed February 22, 2023).

5. The Eunice Kennedy Shriver National Institute of Child Health and Human Development. NICHD Strategic Plan (2020). Available at: https://www.nichd.nih.gov/about/org/strategicplan (Accessed February 22, 2023).

6. White House Conference on Hunger, Nutrition, and Health. Available at: https://health.gov/our-work/nutrition-physical-activity/white-house-conference-hunger-nutrition-and-health (Accessed February 22, 2023).

7. Raiten DJ, Steiber AL, Papoutsakis C, Rozga M, Handu D, Proaño GV, et al. The “Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN)” Project – executive summary. Am J Clin Nutr. (2023). 117(Suppl 1):S1–S10. doi: 10.1016/j.ajcnut.2022.12.020

PubMed Abstract | CrossRef Full Text | Google Scholar