A call for joined-up action to promote nutrition across the first 2000 days of life using a food systems approach October 2022, Volume 32, Issue 3

Introduction

Nutrition across the first 2000 days of life, from conception to age five, is considered critical in providing the foundations for optimum growth and development across the lifespan.^1,2 Despite widespread recognition of this, poor nutrition and related health outcomes are evident in early childhood, frequently tracking from infancy into childhood and adulthood.² Globally, suboptimal dietary behaviours are evident in young children, including declining breastfeeding rates by age 3–6 months, increased consumption of highly processed foods, and low fruit and vegetable intakes.³ As a consequence, more than 41 million children aged under 5 years experience overweight/obesity², with associated negative health consequences⁴, weight stigma and bullying⁵, and substantial economic impacts.⁶ Australia shows similar trends, with children aged 2–3 years not meeting dietary recommendations for vegetable consumption, consuming foods/beverages high in fats, sugars and sodium, and experiencing high rates of overweight/obesity (21%).⁷

A combination of food system factors frequently undermines the opportunity to establish healthy dietary behaviours.³ This includes the provision of healthy, affordable and sustainable diets often not being a priority for food producers, manufacturers and suppliers when determining what foods to grow, produce, distribute and sell.⁸ Identifying potential policy, programmatic and research opportunities is essential to inform and progress changes to the food system to optimise nutrition across the first 2000 days of life. Australia has a timely opportunity to prioritise action for early years nutrition through its recently released National obesity strategy 2022–2032⁹, with a focus on developing a healthy, equitable food system. In addition, an accompanying statewide opportunity exists with the Victorian government’s Healthy kids, healthy futures 5-year action plan¹⁰ to support beneficial food provision across settings frequented by children. There is a strong policy mechanism for implementation through statutory state policy requirements – the Public Health and Wellbeing Act 2008¹¹, the Victorian public health and wellbeing plan 2019–2023 (VPHWP), and Municipal public health and wellbeing plans (MPHWPs).¹² The Act requires the Victorian Department of Health to develop a VPHWP every 4 years, alongside an Outcomes Framework, which address priorities that impact health, including nutrition. The Act also requires each local government (municipality) to develop local MPHWPs in response to the VPHWP. Therefore, this mechanism provides an opportunity to align local and state health priorities. Applying a systems approach is also familiar within Victoria, as it was used to strengthen health promotion infrastructure within the Healthy Together Initiative during 2013–2015.¹³

This research was undertaken to provide an overview of the evidence support, policy mechanisms and stakeholder perspectives on opportunities to improve nutrition across the first 2000 days of life, to guide future investments and inform policy dialogues with relevant government, non-government and external agencies within Victoria, Australia. This research was commissioned by VicHealth, an independent statutory health promotion organisation in Victoria, as part of an Early Years Nutrition Scoping project and received ethics approval through Deakin University Faculty of Human Ethics Advisory Group (HEAG-H: 142_2020).

Methods

We chose to use the UNICEF Innocenti Framework⁸ as an underpinning conceptual model to explore determinants within the food system relevant to the first 2000 days of life. The Framework comprises four determinants: caregiver behaviours; personal food environments; external food environments; and food supply chains. In a healthy, sustainable food system, the interactions across these determinants independently and collectively have a role to play in ensuring children’s healthy diets. Caregivers are considered the gatekeepers of “food procurement, preparation, supervision and eating practices of young children”, namely parents, extended family, and carers/educators/other staff in early childhood education (ECE) settings.⁸ Personal food environments relate to individual and household factors that influence food choice, such as purchasing power, access, convenience, and desirability.⁸ The external food environment includes the price, availability, marketing and advertising of food, properties of food retail/food service outlets, and products. Together with the food supply chain – production, storage, processing, distribution, packaging, retail and markets, and waste disposal – these factors provide multiple opportunities to maximise or deplete the nutritional value of produce.⁸

The research comprised three components: a) a rapid review of existing systematic reviews supplemented with key grey literature; b) mapping of potential policy and programmatic levers and partnerships within the broader food system; and c) qualitative semi-structured interviews with key practice and policy stakeholders across a range of sectors to explore perceived policy and programmatic opportunities and points for intersectoral action.

Rapid review

The rapid review was designed to provide a concise summary of evidence regarding what is likely to be effective in improving nutrition across the first 2000 days of life, using a food systems approach. A search strategy was developed to examine a range of public health scientific databases, targeting meta-analyses and systematic reviews published in English between January 2010 and July 2021. This was supplemented with expert recommendations identified from the grey literature. The Assessment of Multiple Systematic Reviews 2 (AMSTAR 2) was used to assess the methodological quality of included reviews. A total of 60 eligible systematic reviews were identified and assessed aligned with the following determinants: caregiver behaviours (n = 49); personal food environments (n = 7), external food environments (n = 4). No reviews were included in relation to food supply chains. Using AMSTAR 2, quality was assessed as high for 11 reviews (18%), low for 21 (35%) and critically low for 28 (47%) reviews. The full rapid review is reported elsewhere.¹⁴

Mapping report

The mapping report aimed to identify policy and programmatic levers and partnerships within the Victorian context to enhance nutrition in the first 2000 days of life. In consultation with VicHealth,¹⁴ policy and programmatic areas were identified (Table 1), and a comprehensive online search was conducted between 1 July–21 August 2020 using keywords for these identified areas. Using the four iterative stages of policy content analysis¹⁵, data were extracted for name, lead agency, and the extent to which the policy/program could be leveraged. Leverage was graded under three categories: policy infrastructure (strong alignment to existing policies/programs; consultation with stakeholders required to adapt/implement); policy scaffolding (low-to-moderate alignment to existing policies/ programs; consultation with stakeholders required to develop and be fit-for-purpose); and policy void (an absence of alignment with existing policies/programs).

Table 1.   Statewide policy/program areas identified for mapping, aligned to UNICEF Innocenti Framework determinants⁸

CB =caregiver behaviour; EFE = external food environments; FSC = food supply chains; PFE = personal food environments

Stakeholder interviews

The mapping report informed the creation of a list of key stakeholder organisations (n = 21), developed in consultation with VicHealth. These included a range of sectors representing state health and education, local government, community health, non-government and not-for-profit organisations, and peak bodies. All identified stakeholder organisations were invited to participate in qualitative interviews. Consenting organisations nominated an appropriate interviewee based on the provided study information and understanding of the purpose of the interview. Fourteen interviews were conducted with representation across the identified sectors, namely health (n = 4), education (n = 2), local government (n = 1), non-government/not-for-profit organisations (n = 5), and peak bodies (n = 2). Interviews occurred between August–September 2020 via the Zoom video conferencing platform, were of 45–60 minutes in duration, and audio recorded with consent, using a semi-structured interview guide (Supplementary File 1, available from figshare.com/articles/journal_contribution/Supplementary_File_1_Stakeholder_Interview_Guide_pdf/20967601). No incentives were offered or provided to participants. All interviews were transcribed verbatim by a professional transcribing service. They were inductively coded by one author (PL) using reflexive thematic analysis¹⁶, identifying patterns of meaning and constructing candidate themes through an iterative process of data familiarisation, coding, categorisation and review. All coding was completed using NVivo12 (QSR International, Melbourne, Australia). Coding verification and consensus on final themes were developed in agreement by all researchers.

Results

Findings from the three research components are summarised using the four determinants from UNICEF’s Innocenti Framework.⁸ (Table 2).

Thematic analysis of stakeholder interviewers revealed three key themes: continuity of care from pre-conception to childcare, consistency and strengthening of early years nutrition messages, and capacity for early years nutrition initiatives. Interviewees identified multiple points of potential intersection between services which could be enhanced to provide greater continuity of care for caregivers of young children. Early intervention in pregnancy (preferably pre-conception) and primary health care services (general practitioners, general practice nurses, dietitians) were considered missed opportunities to discuss maternal and infant nutrition. Supporting caregivers with consistent information was a key consideration in the context of continuity of care, especially through the delivery of evidence-based initiatives such as the Victorian Infant Program.¹⁷ Interviewees described limited capacity as a major barrier to the implementation of early years nutrition initiatives, with small local, state and national preventive health budgets. In line with this, they suggested there was a need for specifically funded capacity to coordinate early years prevention initiatives within each local government (municipality).

Table 2.     Study component findings aligned to UNICEF Innocenti Framework determinants⁸

^a  Three key themes of stakeholder interviewer were: Continuity of care from pre-conception to childcare; consistency and strengthening of early years nutrition messages; and capacity for early years nutrition initiatives
BFHI = Baby Friendly Health Initiative; ECE = early childhood education; MCH = maternal and child health; SSB = sugar-sweetened beverages; MPHWP= Municipal public health and wellbeing plan; VPHWP = Victorian public health and wellbeing plan

This research identified a number of opportunities to improve nutrition across the first 2000 days of life, within national, state and local government systems, utilising policy, practice and research mechanisms (See Box 1 and Supplementary File 2, available from figshare.com/articles/journal_contribution/Supplementary_Fle_2_Detailed_opportunities_pdf/20967652). Further exploration is required, in collaboration with stakeholders, to determine the feasibility, acceptability and equity impacts of such actions.

Discussion

While this research has a specific state and country context, namely Victoria, Australia, the applicability of these identified opportunities to other jurisdictions and countries are apparent in light of the supporting evidence.¹⁴

In the early years, caregivers have the most impact on shaping a child’s eating behaviours.⁸ Targeting caregiver behaviours is the usual starting point for developing evidence-based practice and government intervention, most notably in health service delivery but also more recently in the ECE sector.¹⁸ Caregiver behaviours supportive of nutrition across the first 2000 days include healthy lifestyle behaviours during pregnancy, support, knowledge and self-efficacy to breastfeed, parenting confidence to feed, responsive feeding practices, provision of a variety of core foods, healthy family meals, food literacy, role modelling, and curriculum development to support developmentally appropriate healthy eating in ECE settings.¹⁴ The key focus continues to be the development of a ‘breastfeeding culture’ and changing social attitudes through population-level promotion of breastfeeding, strengthening maternal legal rights (such as longer paid parental leave), legislation to limit marketing of breast milk substitutes, supporting maternal wellbeing, and continuity of care across health services.¹⁹

Personal food environments represent the individual and household factors that inform “why people chose to procure the foods that they do”.⁸ Across the first 2000 days of life and later, children are dependent upon decisions made for them by their caregivers. Ensuring healthy foods are accessible, available and affordable is essential to enable caregivers to provide healthy food options.²⁰ More importantly, household income needs to be adequate to achieve food and nutrition security, especially for single-parent households. In the absence of sufficient wages and income support, income supplement initiatives and the use of food vouchers, such as the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in the US and Healthy Start in the UK, have been shown to reduce food insecurity at the household level and may increase vegetable consumption.^21,22

External food environments are the interface between food systems and caregivers. They exist in specific sociocultural, political, physical and economic contexts, sharing common sites of activity, such as food retail and food service outlets, schools and ECE settings.⁸ The advertising and marketing of discretionary foods (nutrient poor, energy dense foods high in energy, fat, added sugars and/or salt) is ubiquitous and it is well understood that caregivers of young children are influenced by marketing practices when making food choices for children.²³ Over the last decade, there has been a significant rise in commercially prepared baby and toddler food and drink products²⁴, with the majority considered to be ultra-processed.²⁵ The evidence is growing that ultra-processed foods/drinks have negative impacts on health.²⁶ The proliferation and marketing of these products as early childhood foods/drinks needs to be restricted through policy levers such as the World Health Organization (WHO) Set of recommendations on the marketing of foods and non-alcoholic beverages to children²⁷ and country responses to the WHO International code of marketing of breastmilk substitutes such as the Marketing in Australia of infant formula (MAIF) agreement²⁸ (although the MAIF is considered a policy void, being voluntary, self-regulated and not addressing toddler milks and commercially available complementary food).

The actors and activities involved in each stage of the food supply chain all shape dietary intakes. The EAT-Lancet Commission on healthy diets from sustainable food systems²⁹ and the Food and Agriculture Organization of the United Nations’ report, Food security and nutrition: building a global narrative towards 2030³⁰, both argue for a shift towards a global food system with health, environmental sustainability, and equity at its core. Australia produces enough food to feed the population three times over³¹, yet across the lifespan, dietary recommendations are not being achieved⁷, and food distribution is inequitable, often scarce and more expensive and of poorer quality in regional and rural areas.^32,33 The presence of a national food/nutrition strategy linking agriculture, environmental sustainability, and health has been shown to positively change consumption behaviours through improvements along the food supply chain, such as the Scottish Governments’ Good food nation 2014–2025 policy.³⁴ There has been no national nutrition policy in Australia since 1992, and the current national agricultural plan focuses on high productive outputs primarily for export, supporting long and complex supply chains.³¹

Conclusion

Policy makers, practitioners and researchers acknowledge the value of considering the research evidence, policy mechanisms and stakeholder perspectives when determining what course of action is likely to be most effective for promoting nutrition across the first 2000 days of life. This research has addressed these three considerations, identifying relevant opportunities that cut across the four determinants of UNICEF’s Innocenti Framework to ensure children’s healthy diets. Overall, this research highlights the potential and urgent need for more joined-up action using a food systems approach and funded capacity to facilitate delivery of coordinated and integrated services to address nutrition across the first 2000 days.

Acknowledgements

This research was commissioned by VicHealth, an independent statutory health promotion organisation in Victoria, as part of an Early Years Nutrition Scoping project and had ethics approval through Deakin University Faculty of Health.

This paper is part of a special issue of the journal focusing on obesity prevention, which has been produced in partnership with the Health and Social Care Unit, School of Public Health and Preventive Medicine, Monash University, with support from VicHealth.

Peer review and provenance

Externally peer reviewed, invited.

Copyright:

© 2022 Love et al. This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence, which allows others to redistribute, adapt and share this work non-commercially provided they attribute the work and any adapted version of it is distributed under the same Creative Commons licence terms.