Strengthening the Evidence Base for Inclusion of Children Less Than 2 Years of Age in the Dietary Guidelines for Americans

  • Date: Nov 18 2014
  • Policy Number: 20144

Key Words: Nutrition, Maternal And Child Health, Childrens Health, WIC Women Infants And Children

The Dietary Guidelines for Americans (DGAs) provide the foundation for federal policies that ultimately inform nutrition education programs, feeding programs, and dietary guidance for Americans 2 years of age and older, including those at increased risk of chronic disease. However, emerging scientific evidence indicates that the omission of children below the age of 2 years within the current US dietary guidelines framework may result in a significant gap in disease prevention efforts. Scientific societies, medical and nutrition organizations, the US Department of Health and Human Services, and the US Department of Agriculture recognize the need to compile the necessary research findings that can inform subsequent guidelines regarding nutritional needs in the first 1,000 days of life and have advocated for a congressional mandate to ensure that this age group becomes a focus for the 2020 Dietary Guidelines Advisory Committee. Since 1979, APHA has adopted several polices related directly to dietary guidelines for Americans 2 years old and older; however, all of these policies are outdated, and thus there is no current APHA policy addressing the DGAs. In addition, there is no APHA-specific policy statement that acknowledges the importance of including children under the age of 2 in the DGAs to establish a positive health trajectory early in life. This proposed policy statement voices APHA support for the dietary guidelines process; supports strengthening of the overall research base for the guidelines, especially in the case of children in their first 1,000 days of life; introduces support for inclusion of this age group in the DGAs; and aligns APHA’s voice with those of other experts and agencies.

Relationship to Existing APHA Policy Statements
This policy does not relate to any existing policy. APHA Policy Statements 7919 (Revision of the National Food Guide and Preparation of National Dietary Guidelines), 8127 (Dietary Guidelines for Americans), and 8208 (Preserving the Nutritional Integrity of the Special Supplemental Food Program for Women, Infants, and Children (WIC)) have been archived according to APHA’s policy protocol. As a result of this archiving, there is now a significant gap in the APHA policy platform related to the most important federal nutrition policy. Therefore, this proposed policy statement will both replace and expand upon these archived policies.

Although this policy statement addresses a public health issue that was not identified by the Joint Policy Committee and staff, it fills a significant nutrition policy gap now that several APHA policy statements have expired.

Problem Statement Update
Scientific issues: Increasing scientific evidence indicates that the diets of pregnant women and children under the age of 2 years may have a significant impact on the lifetime health trajectory of these children and may be of particular importance among members of low-income populations, who are at a greater risk of developing chronic diseases.[1,2] However, the current Dietary Guidelines for Americans (DGAs) address only the nutritional needs of those over the age of 2.[3] Given the significant proportion of the US population served by programs targeting low-income and minority families (the Special Supplemental Nutrition Program for Women, Infants, and Children serves more than 50% of US infants, and the Child and Adult Care Food Program serves children beginning at birth)[1], those involved in infant and toddler feeding, including health professionals, public feeding services, education and nutrition programs, public policy advocates, and private-sector health initiatives, are in need of guidance as how to best meet the needs of children in their first 1,000 days of life.[1] Scientific and health organizations have recognized this need and have advocated for expanding the DGAs to include children under the age of 2. In addition, a recent conference held by the US Department of Health and Human Services (DHHS) and the US Department of Agriculture (USDA) to examine the nutritional science evidence base for this age group highlighted the current gaps in dietary guidance.[1]

APHA has supported the DGAs in a number of approved policy documents addressing both the population at large and low-income populations (archived APHA Policy Statements 7919, 8127, and 8208). Given this history, APHA not only should have a current policy supporting the DGAs but should expand the policy to include those under the age of 2. This would also strengthen support for health professionals serving low-income families with children in this age group, who are often at risk for poor nutritional intake.

Political/resource issues: Section 4204 (Dietary Guidelines for Americans) of the Agricultural Act of 2014 states that “not later than the 2020 report and in each report thereafter, the Secretaries shall include national nutritional and dietary information and guidelines for pregnant women and children from birth until the age of 2.”[4]

The DHHS Office of Disease Prevention and Health Promotion and the USDA Center for Nutrition Policy and Promotion commissioned a group to evaluate the evidence base on dietary guidelines for children under 2.[1] There is a need for such a project given the current apparent conflicts regarding infant feeding practices (e.g., the differing recommendations of the American Association of Pediatrics and other groups on when to introduce complementary foods[5]) and the relative lack of guidance as to how emerging areas of intervention (e.g., infant-feeding styles) might differ with respect to their impact on populations targeted by federal nutrition programs.[6]

Ethical issues: Those who are most vulnerable to nutrition problems and their attendant diseases are the responsibility of all public health professionals. Therefore, APHA should adopt a policy that recognizes the need of those at highest nutritional risk to be included in the DGA document.
Evidence-Based Strategy to Address the Problem
The 2014 farm bill included language calling for dietary guidelines for children under the age of 2.[4] The evidence-based strategy is to expand the scope of the current DGA process to cover this age group.[1] Dietary guidelines for children 2 years or younger have the potential to affect 8 million children per year (based on the current US birth rate of 4 million per year).[7] It is important to note that the current DGA document (which covers Americans 2 years of age and older) is the guiding policy for all government-driven nutrition programs. The lack of federal dietary guidelines that reach down to birth leaves many nutrition programs and parental nutrition education efforts dependent on conflicting nutrition advice from independent medical, public health, and nutrition groups. One universal set of recommendations for the first 1,000 days of life, based on sound research, is possible, and these recommendations should be developed provided that Congress continues to invest in nutrition research at the USDA and DHHS.

Opposing Arguments/Alternative Points of View
Despite evidence that early childhood nutrition may significantly affect chronic disease risk in later life, very little specific evidence exists regarding how to lower this risk.[1] However, current initiatives, including the efforts of the two existing USDA nutrition laboratories, are targeting this need.[1] It is expected that the new evidence will be available to the 2020 Dietary Guidelines Advisory Committee to enable the committee’s development of these specific guidelines for children under age 2.

Action Steps
Therefore, APHA:
1.    Endorses the efforts cited above to expand the Dietary Guidelines for Americans to include children under the age of 2 years and advocates for this policy document to guide nutrition education and food and nutrition assistance programs for Americans.
2.    Calls upon Congress to appropriate funds for needed research to build the evidence base in support of the nutritional needs of all Americans, and specifically children in their first 1,000 days of life, as well as the funds needed to execute a robust dissemination plan for the DGAs.
3.    Urges the secretary of agriculture and the secretary of health and human services to establish and execute a robust research plan aimed at building the scientific evidence for nutritional recommendations among understudied groups, including children under 2 years of age, and a dissemination plan that aims to extend the reach and uptake of these recommendations.
4.    Encourages public health, medical, and nutrition organizations and professional societies to use the DGAs when providing nutrition education and counseling services.

1. Raiten D, Raghavan R, Porter A, Obbady J, Sphan J. Executive summary: evaluating the evidence base to support the inclusion of infants and children from birth to 24 months of age in the Dietary Guidelines for Americans: the B24 Project. Am J Clin Nutr. 2014;99:663S-691S.
2. Healthy People 2020 Summary of Objectives: Maternal, Infant, and Child Health. Washington, DC: US Department of Health and Human Services; 2012.
3. US Department of Agriculture, Office of Disease Prevention and Health Promotion. 2015 Dietary Guidelines for Americans. Available at: Accessed December 26, 2014.
4. Agricultural Act of 2014. Available at: Accessed December 26, 2014.
5. Kleinman R, Greer F. Pediatric Nutrition Handbook. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014.
6. Perrin EM, Rothman RL, Sanders LM, et al. Racial and ethnic differences associated with feeding- and activity-related behaviors in infants. Pediatrics. 2014;133:e857–e867.
7. Centers for Disease Control and Prevention. Birth data. Available at: Accessed December 26, 2014.