The “First 1,000 Days+” as Key Contributor to the Double Burden of Malnutrition

Abstract

Growth from conception through age 2 years, the "First 1,000 days," is important for long-term health of the growing fetus and child and is influenced by several factors including breastfeeding and complementary feeding. Low- and middle-income countries face a complicated array of factors that influence healthy growth, ranging from high food insecurity, poor sanitation, limited prenatal or neonatal care, and high levels of poverty that exacerbate the "vicious cycle" associated with intergenerational promotion of growth retardation. It is now well recognized that the period prior to conception, both maternal and paternal health and diet, play an important role in fetal development, giving rise to the concept of the "First 1,000 Days+". Breastfeeding and complementary feeding practices can be improved through a combination of interventions such as baby-friendly hospitals, regulations for marketing of foods and beverages to children, adequate counseling and support, and sound social and behavior change communication, but continued research is warranted to make such programs more universal and fully effective. Thus, improving the overall understanding of factors that influence growth, such as improved breastfeeding and age-appropriate and adequate complementary feeding, is critical to reducing the global prevalence of the double burden of malnutrition.

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Ann Nutr Metab 2019;75:99–102
The “First 1,000 Days+” as Key Contributor to the
Double Burden of Malnutrition
Daniel Hoffman
a Maaike Arts
b France Bégin
b
a Department of Nutritional Sciences, Program in International Nutrition, New Jersey Institute for Food, Nutrition,
and Health, Center for Childhood Nutrition Research, Rutgers, the State University of New Jersey, New Brunswick,
NJ, USA; b Nutrition Section, Programme Division, United Nations Children’s Fund (UNICEF), New York, NY, USA
Received: August 8, 2019
Accepted: September 11, 2019
Published online: November 19, 2019
Daniel Hoffman
Department of Nutritional Sciences, Program in International Nutrition
Rutgers, the State University of New Jersey, New Jersey Institute for Food, Nutrition,
and Health, 61 Dudley Road, New Brunswick, NJ 08901 (USA)
E-Mail dhoffman @ sebs.rutgers.edu
© International Atomic Energy Agency 2019
Published by S. Karger AG, Basel
E-Mail karger@karger.com
www.karger.com/anm
DOI: 10.1159/000503665
Keywords
Breastfeeding · Complementary feeding · Growth · Double
burden · Malnutrition
Abstract
Growth from conception through age 2 years, the “First
1,000 days,” is important for long-term health of the growing
fetus and child and is influenced by several factors including
breastfeeding and complementary feeding. Low- and mid-
dle-income countries face a complicated array of factors that
influence healthy growth, ranging from high food insecurity,
poor sanitation, limited prenatal or neonatal care, and high
levels of poverty that exacerbate the “vicious cycle” associ-
ated with intergenerational promotion of growth retarda-
tion. It is now well recognized that the period prior to con-
ception, both maternal and paternal health and diet, play an
important role in fetal development, giving rise to the con-
cept of the “First 1,000 Days+”. Breastfeeding and comple-
mentary feeding practices can be improved through a com-
bination of interventions such as baby-friendly hospitals,
regulations for marketing of foods and beverages to chil-
dren, adequate counseling and support, and sound social
and behavior change communication, but continued re-
search is warranted to make such programs more universal
and fully effective. Thus, improving the overall understand-
ing of factors that influence growth, such as improved
breastfeeding and age-appropriate and adequate comple-
mentary feeding, is critical to reducing the global prevalence
of the double burden of malnutrition.
© International Atomic Energy Agency 2019
Published by S. Karger AG, Basel
The “First 1,000 Days+” and the Double Burden of
Malnutrition
Fetal growth is characterized by rapid cell division and
differentiation. As tissues and organ systems grow and
develop, the need for essential nutrients and energy to
support the growth increases. Thus, improper nutrient
availability or delivery threatens healthy growth. The pre-
and periconceptual period has also been found to be a
factor that influences fetal growth [1] and this time peri-
od, the first 1,000 days+, has a significant impact on
growth and adult health. Therefore, to fully understand
how to prevent or reverse the double burden of malnutri-
tion (DBM), it is important to discuss all aspects of the
first 1,000 days+, beginning with the preconception pe-
riod through a child’s first 1,000 days up to age 2.
Preconception and Pregnancy
Paternal and maternal body composition and diet influ-
ence the first generation of offspring and may have an influ-
ence on the second generation as well [2]. In a study of grand-
paternal obesity, the second-generation offspring of obese
mice showed defects in lipid and glucose metabolism when
fed a high fat diet [1]. It has also been found that maternal
The article is part of the Proceedings of the International Symposium on
Understanding the Double Burden of Malnutrition for Effective Interven-
tions organized by the International Atomic Energy Agency (IAEA) in coop-
eration with United Nations Children‘s Fund (UNICEF) and World Health
Organization (WHO) (10–13 December 2018, Vienna, Austria).
All rights reserved.
This is an Open Access article licensed under the terms of the Creative
Commons Attribution 3.0 IGO License (CC BY 3.0 IGO)https://cre-
ativecommons.org/licenses/by/3.0/igo/#). Usage, distribution and re-
production in any medium or format, even for commercial purposes,
is permitted, provided the original work is properly cited.

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Ann Nutr Metab 2019;75:99–102
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DOI: 10.1159/000503665
body composition was the most significant predictor of fetal
growth [3]. Moreover, siblings born during or after the Dutch
Famine Winter had epigenetic differences in genes associ-
ated with chronic diseases, depending on the period of intra-
uterine famine exposure [4]. These studies suggest that pre-
venting the DBM not only begins with the health of the par-
ents but also has significant implications for the growth of the
child. Innovative strategies to improve the health of men and
women in low- and middle-income countries (LMICs) is
clearly needed to effectively address the DBM. Such strategies
would have to be broad and address the preconception health
of both men and women, such as improved community-lev-
el access to nutrient dense foods, nutrition education for ad-
olescents, but most important include improvements in so-
cial, income, and health-care inequalities [5, 6].
Breastfeeding and the DBM
One of the most important infant feeding practices to
prevent the DBM is breastfeeding. Breastfeeding is essen-
tial for healthy growth and development [7], protects
children against infections, overweight, and protects
mothers from certain types of cancer and type 2 diabetes.
Suboptimal breastfeeding is related to over 800,000 deaths
in children under 5 years of age and 20,000 maternal
deaths per year [8] with estimated economic losses at
USD 302 billion per year [7].
Breastfeeding rates are far from optimal. In LMICs,
less than half of all new-borns initiate breastfeeding in the
first hour of life, only 41% of infants under 6 months of
age are exclusively breastfed, and 45% of 2-year olds are
breastfeed [9]. This situation may be explained by various
factors. In 2014, the global sales of breastmilk substitutes
were almost USD 45 billion [7], and the marketing of
breastmilk substitutes negatively impacts breastfeeding
practices [10]. Other factors include inadequate support
for breastfeeding in health facilities, communities, fami-
lies, and the workplace. Yet, every dollar invested in
breastfeeding brings USD 35 in economic returns [11].
At the 2018 IAEA/UNICEF/WHO symposium on the
DBM, Dr. Nigel Rollins outlined factors that create barri-
ers to exclusive breastfeeding around the globe [12] and
noted that there is a dearth of environments that support
breastfeeding at school, work, or home. More important,
there is a lack of collective responsibility for low rates of
breastfeeding, and the sole responsibility of breastfeeding
is often delegated to the woman. Substandard science is
used in the development of policies and claims for breast-
milk substitutes often go unchallenged. As well, nutrition
and health professionals often do not hold institutions
and governments accountable for breastfeeding practices
considering the inadequate regulation of the marketing of
breastmilk substitutes.
Complementary Feeding and the DBM
During the first year of life, lean body mass nearly dou-
bles, yet the energy provided from breastmilk remains
constant and the gap in energy needs versus supply is met
by the introduction of complementary foods, making it
essential for healthy growth. When complementary foods
are introduced after 6 months of age, energy and nutrient
requirements are not met and growth either slows or
ceases [13]. While delayed introduction of complemen-
tary feeding has been associated with a greater risk of
overweight in life [14, 15], the evidence is not conclusive
[16, 17]. Nonetheless, to prevent the DBM, it is necessary
that parents and caregivers understand the importance of
introducing appropriate foods at the right time with con-
tinued breastfeeding. In particular, complementary foods
need to be introduced from 6 months of age, provided
with an age-appropriate frequency and amount and in a
responsive manner, safely prepared and stored, of good
quality (diverse, with an adequate micronutrient and en-
ergy content and a low anti-nutrient content), and con-
tinued during and after illness [13]. However, among
LMICs, only 25% of children 6–23 months received foods
from the minimum number of food groups that is recom-
mended for their age, and nearly 1/3 of children aged
6–8months did not receive complementary foods [9].
Programs to promote complementary foods have been
found to be somewhat effective, but challenges remain to
make them fully effective [18]. Understanding risk factors
and barriers to adequate complementary feeding, con-
ducting situation analysis and formative research to in-
form strategies and interventions to put in place, having
good monitoring and evaluation systems in place and suf-
ficient resources are key elements to make programs more
effective to promote adequate complementary feeding
[18]. Also, many programs focus on stunting, the most
severe form of growth retardation, as the primary out-
come studied. Yet, a number of successes can be claimed
for programs that do not necessarily influence stunting,
such as improved iron status, increased maternal empow-
erment or education, and so on. Thus, it is important for
evaluations to focus on changes in growth and other areas
of interest rather than a single programmatic cutoff that
may be influenced by a number of competing factors.

The First 1,000 Days+ and the DBM
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Potential Interventions to Improve Nutrition in the
“First 1,000 Days”
There are a number of avenues through which improved
fetal growth and child health may be influenced. Aside
from poverty reduction and improved diet quality for ado-
lescents and adults who may become parents, breastfeed-
ing and complementary feeding remain the primary driv-
ers of child growth and health. Breastfeeding practices can
be improved by providing adequate support via different
delivery platforms, the community, and the home. A large
review of the evidence found that combining interventions
via different delivery platforms improved exclusive breast-
feeding by 79% with a doubling of the effect when combin-
ing health system and the community [19]. As well, regula-
tions for the marketing of breastmilk substitutes and for
maternity protection are crucial to ensure optimal breast-
feeding practices [10, 20]. Other avenues to improve
breastfeeding practices include implementing the actions
of the Baby-friendly Hospital Initiative (WHO and
UNICEF 2018) [21] and adherence to the 10 Steps [22].
Recently, UNICEF and WHO established the Global
Breastfeeding Collective [23, 24] with 7 policy actions that
advocate for improved breastfeeding practices at the glob-
al level, including increased funding, implementing the In-
ternational Code of Marketing of Breastmilk Substitutes,
maternity protection regulations and the BFHI’s 10 Steps,
and strengthening monitoring systems to track progress.
For designing a set of comprehensive actions to im-
prove complementary feeding, countries are recommend-
ed to conduct barrier and bottleneck analyses, as used by
UNICEF, government counterparts, and partners in a
range of settings and countries, to assess the main deter-
minants of effective coverage or optimal practices for se-
lected interventions [25]. Quantitative and qualitative
data are combined to characterize the environment (e.g.,
social norms, policies, and budget), supply- and services-
related factors (e.g., availability of materials and access to
services), and demand-related factors (e.g., financial, so-
cial, and cultural factors) [26]. This approach was applied
in Ethiopia for complementary feeding and brought to-
gether stakeholders to review and prioritize bottlenecks
and potential solutions. The results showed that food ta-
boos, weak multisectoral engagements, limited father/
male involvement, limited availability of fruits and vege-
tables, and poor knowledge and awareness from caregiv-
ers were identified as key bottlenecks to proper comple-
mentary feeding. The involvement of the stakeholders
helped build consensus and prioritize solutions and strat-
egies that were felt to be manageable by the stakeholders.
Bottleneck analysis should be part of an ongoing process
to improve programs and coverage by making adjust-
ments as needed. Apart from infant feeding practices, it is
also important to emphasize the importance of parental
health for the prevention of the DBM given that that the
health and diet of parents, even prior to conception of a
child, has a profound influence on the health of their child
during gestation and perhaps for the life of their child.
Conclusions
As the DBM continues to increase across the world,
particularly in LMICs, addressing proper nutritional
practices during pregnancy and early childhood remains
a high priority. Determining how best to support and
normalize such behaviors depends on availability and ac-
cess to nutrient-rich foods, access to education, empow-
erment of women to control household resources, and
greater father’s involvement in child care. As well, the
health and nutrition community needs to advance poli-
cies that promote healthy and sustainable diets, starting
with breastfeeding, and investments in the implementa-
tion and scale up of evidence-informed interventions to
prevent the DBM. It is also important to emphasize that
the health and diet of parents, even prior to conception of
a child, have a profound influence on the health of their
child during gestation and, perhaps, for life. Finally, in-
novative and interdisciplinary research and interventions
with responsible public–private partnerships have key
roles to play to ensure that such knowledge and policies
function in a coordinated fashion to reduce the DBM.
Acknowledgments
The authors would like to thank Nigel Rollins for his contribu-
tion on breastfeeding and Cornelia Loechl, Theodora Mouratidou,
and Pernille Kaestel for their critical reviews of the manuscript.
Statement of Ethics
The authors have no ethical conflicts to disclose for this
review because there were no humans or animals involved di-
rectly.
Disclosure Statement
The authors have no conflicts of interest to declare.

Hoffman/Arts/Bégin
Ann Nutr Metab 2019;75:99–102
102
DOI: 10.1159/000503665
Funding Sources
No external funding source contributed to the writing of this
paper.
Open access provided with a grant from the International
Atomic Energy Agency.
Author Contributions
All authors conceptualized the overall design of the manuscript
and contributed to writing of the final manuscript. All authors read
and approved the draft.
Disclaimer
The statements, opinions and data contained in this publica-
tion are solely those of the individual authors and contributors, not
of the publishers and the editor(s), and do not necessarily reflect
the views of the cooperating organizations, IAEA, UNICEF and
WHO. The use of particular designations of countries or territories
does not imply any judgement by the cooperating organizations,
as to the legal status of such countries or territories, of their au-
thorities and institutions or of the delimitation of their boundaries.
The mention of names of specific companies or products (wheth-
er or not indicated as registered) does not imply any intention to
infringe proprietary rights, nor should it be construed as an en-
dorsement or recommendation on the part of the cooperating or-
ganizations.
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