First-ever Birth-24 Month Dietary Guidelines: Deliberations and Complications

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By Emma Hitt Nichols, Ph.D.

The expert committee for the next Dietary Guidelines for Americans (DGA) has begun to deliberate on the first-ever set of guidelines for the “birth-to-24-month” population. This effort is part of the “Pregnancy and Birth to 24 Months (P/B-24) Project,” a joint initiative led by the U.S. Departments of Agriculture and Health and Human Services (USDA-HHS).

Childhood obesity now affects one in five school-age children,[1] a grim statistic that seems to be linked to food choices in the first vulnerable months of life.[2] Moreover, signs of overweight or obesity in this age group are linked to health problems later in life, including persistent obesity and heart disease.[3]

Until now, the DGA has provided dietary advice for individuals aged two years and older. However, when Congress passed the Agricultural Act of 2014 (the “Farm Bill”), it broadened the mandate of the Guidelines to include guidance for the B-24 cohort as well as for women who are pregnant. This expanded DGA mandate was slated to start with the 2020-2025 Guidelines, the iteration currently under development.[4]

Possible Undue Industry Influence?

An important question is whether the influence of the $70 billion global baby food and formula industries could be at play in influencing these guidelines.[5] While the development of B-24 advice is needed, worrisome signs have emerged that there is limited data for this age group and that these guidelines could, in fact, become little more than a giveaway to the infant formula and food manufacturers.

“We thought if we focus on the first 1,000 days, we have this window of opportunity,” stated Lucy Sullivan, former management consultant and executive director of 1,000 Days, a nonprofit focused on maternal and child nutrition in a recent article in the Washington Post.[6] The organization has been cited in several news stories as the principal voice favoring the new B-24 Guidelines, and while the organization has many non-profit supporters, it is worth noting that one of its founding partners is the W.K. Kellogg Foundation, whose parent company is a major manufacturer of cereals actively promoted to infants and toddlers, including through government programs.[7, 8]

These government programs feed one in four Americans each year[9] and are therefore a huge source of income for any food-company supplier. Through the B-24 addition, Kellogg may possibly be looking to solidify or expand its market in such government programs. Indeed, Kellogg’s cereals are already a staple of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), one such program at USDA.[10] WIC cereals include Frosted Mini-Wheats and Frosted Mini-Wheats Little Bites®, each packing half of a child’s daily sugar limit per serving.[11-13]

Warnings about an excessive reliance on cereals for B-24 are not uncommon among experts in the field. At a recent meeting of the Institute of Food Technologists, for instance, Frank Greer, emeritus professor of pediatrics and nutritional science at the University of Wisconsin – Madison School of Medicine, urged his colleagues to recommend alternatives to iron-fortified rice cereal. “It’s not a terribly nutrient-dense food…we need to have more complementary foods that are naturally rich in heme iron as in red meat.”[14]

Five Facts About B-24

  • After decades of pressure from the food and sugar industry, the Federal Trade Commission has given up its efforts to restrict advertising of sugary products to children, with “the industry essentially now regulating itself.”[34]
  • One in three of 1,074 infant and toddler food products - dinners, snacks and juices - contain at least one source of added sugar, with sugar constituting an average 35% of infant and toddler calories.[35]
  • Exclusive breast-feeding for the first six months of life cuts the chances of a child becoming obese by 25% according to a recent major European study.[36]
  • “Inappropriate marketing of formula milk may lead some mothers to believe it as a good for babies as breast milk,” warns the study’s lead author.[35] Yet at least two of the B-24 six-member subcommittee have ties to infant formula manufacturers. [16, 17, 21]
  • The BMJ has announced it will no longer carry advertisements for formula milk after an investigation showed ‘substantial harms caused by aggressive promotion of breast milk substitutes and the biases introduced into research and clinical practice by industry influence’.[37]

Committee Disclosures

Among the B-24 subcommittee members, the presence of commercial ties is a concern. Lydia Bazzano of Tulane University and Elsie Taveras from Harvard Medical School appear to have few ties in related industries, but other subcommittee members report multiple commercial connections, which could potentially influence their recommendations.[15]

The committee is chaired by Kathryn (“Kay”) Dewey, Professor Emerita of Nutrition at the University of California, Davis, who, while clearly a leader in the area of maternal and child nutrition, reports receiving research funding from Mead-Johnson Nutrition, a manufacturer of infant formula.[16, 17]

Ronald Kleinman, vice chair of the B-24 subcommittee and one of Harvard’s most highly regarded experts in pediatric nutrition, is linked to multiple commercial interests including Nestlé Nutrition Institute,[18] General Mills [19] and the International Life Sciences Institute (ILSI) Research Foundation, a non-profit financed by such commercial behemoths as Nestlé, Abbott, and the Kellogg Company.[20]

Other members of the subcommittee include Baylor College of Medicine’s Teresa Davis, who receives funding from Abbott,[21] a manufacturer of infant formula and Ajinomoto Co. which has a baby foods division,[22] as well as the commercially-funded ILSI.[23] University of Illinois’ Sharon Donovan has disclosed multiple ties with commercial supporters, including Nestlé Infant Nutrition.[24]

Lack of Evidence

Another key concern is that the evidence underpinning the new guidelines could be “inadequate,” which was the conclusion of a systematic scientific review undertaken by USDA’s Food and Nutrition Service recently.[25]

At the first meeting of the DGA expert committee, in March, members repeatedly questioned whether there was sufficient data to issue new guidelines for this new population.

For instance, Dewey asked about the sample size for children between six and 24 months in the National Health and Nutrition Examination Survey (NHANES), an observational study operated by the government which has measured the health and nutritional status of Americans for decades. Responding to Dewey’s concerns, lead nutritionist TusaRebecca Pannucci of the Center for Nutrition Policy and Promotion (CNPP), the USDA office in charge of the Guidelines, said that the “sample size is certainly smaller in those age ranges, but by combining cycles we can still look at estimates of food group and nutrient intake.”[26]

However, later in the meeting, DGA committee member Regan Bailey reemphasized worries about the limited numbers among subgroups and “the availability of data to answer some of the questions that we have, even when combining NHANES cycles.”[27]

After a brief pause with no response from Pannucci, DGA committee member Carol Boushey followed up with a related question: “do we actually have to do a review to ensure [against] inadequate or limited data…or can we do it by group consensus for some of the questions that were in there?”[28]

Another committee member, Jamie Stang, then asked, “What do we know about the adequacy of the databases, particularly when it comes to infants and children under the age of 2 with respect to cultural and ethnic specific feeding patterns?”[29]

In an attempt to respond to the concerns, CNPP’s Julie Obbagy, who leads the scientific reviews underpinning the DGA, said “I do think it’s really important to go through the process of doing the literature search and identifying what is out there.” She added, apologetically, that research recommendations can be drafted where there is no evidence. “If there are no studies, then we can really simplify the process of answering the question,” she stated.[30]

Earlier in the meeting, Kleinman had asked whether the Committee would consider using an industry-sponsored database as a solution to the overall lack of data. “For B-24, there is the FITS (Feeding Infants and Toddlers Study, funded by Nestle)[31] – is there any opportunity to take advantage of what’s published?” he enquired.[32]

Two other DGA committee members: Barbara Schneeman and Beth Mayer Davis followed suit, asking similar questions about using industry data, yet this line of interrogation was shut down by the USDA’s Pannucci, who firmly ended the session, stating “Our plan is to be using the federally available datasets.”[33]

So far, the Committee mostly seems to agree upon the lack of sufficient data for this age group.

An acceptable outcome would be simply to acknowledge the lack of data and to refrain from making recommendations based on weak or insufficient evidence.

Parents do need helpful advice about how to best to feed their children, but The Nutrition Coalition’s Executive Director, Nina Teicholz, stated that this advice should be informed by ample rigorous evidence, uncontaminated by corporate influence from food or formula manufacturers.

References:

  1. https://www.cdc.gov/healthyschools/obesity/facts.htm

  2. https://www.ncbi.nlm.nih.gov/pubmed/28133360

  3. https://www.thelancet.com/pb/assets/raw/Lancet/stories/series/nutrition-eng.pdf

  4. https://www.fns.usda.gov/resource/pregnancy-and-birth-24-months

  5. https://www.statista.com/statistics/249469/global-baby-food-market-size-2015/

  6. https://www.washingtonpost.com/business/2019/04/03/what-feed-your-baby-new-dietary-guidelines-weigh-pregnant-women-infants-young-children/?utm_term=.1aa2f9ff4b94

  7. https://thousanddays.org/about/our-partners/

  8. https://www.healthybeginnings.com/en/products.aspx

  9. https://www.fns.usda.gov/programs

  10. https://www.global.kelloggsnutrition.com/en_US/wic/wic-foods/wic-image-library.html

  11. https://www.aappublications.org/news/2016/08/23/Sugar082316

  12. smartlabel.kelloggs.com/Product/Index/00038000319211

  13. http://smartlabel.kelloggs.com/Product/Index/00038000596827

  14. https://www.foodbusinessnews.net/articles/13872-babies-could-eat-more-red-meat-says-ift19-speaker

  15. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3954632/

  16. https://www.sciencedirect.com/science/article/pii/S0022347695703950

  17. http://pediatrics.aappublications.org/content/89/6/1035..info

  18. https://www.nestlenutrition-institute.org/docs/default-source/global-dcoument-library/publications/secured/46797f126eac26ebaaedcc97e7912446.pdf?sfvrsn=4c59da11_0

  19. https://jamanetwork.com/journals/jamapediatrics/article-abstract/2716798

  20. https://ilsi.org/wp-content/uploads/2016/01/Members.pdf

  21. https://www.bcm.edu/people/view/teresa-davis-ph-d/baylor-college-of-medicine-faculty-faculty-a-f-children-s-nutrition-research-center/b26970c7-ffed-11e2-be68-080027880ca6/6ac5aa48-196b-11e3-ba52-005056b104be

  22. https://store.nexternal.com/cbfi2000/babys-first-foods-c44.aspx#.XPuwFy2ZN0s

  23. https://academic.oup.com/DocumentLibrary/jn/JN%20COI%20form.pdf

  24. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5998350/pdf/cdn000570.pdf

  25. https://www.ncbi.nlm.nih.gov/pubmed/30982878

  26. 2020 DGAC Public Meeting 3/28/19 https://youtu.be/BigM7_GyJw8 timestamp: 1:37.18-1:37.37

  27. 2020 DGAC Public Meeting 3/28/19 https://youtu.be/BigM7_GyJw8 timestamp: 2:21:09—2:21.22

  28. 2020 DGAC Public Meeting 3/28/19 https://youtu.be/BigM7_GyJw8 timestamp: 2:21:42—2:22:07

  29. 2020 DGAC Public Meeting 3/28/19 https://youtu.be/BigM7_GyJw8 timestamp: 2:22:11—2:22:34

  30. 2020 DGAC Public Meeting 3/28/19 https://youtu.be/BigM7_GyJw8 timestamp: 2:22:48— 2:23:25

  31. https://academic.oup.com/jn/article/148/suppl_3/1516S/5026328

  32. 2020 DGAC Public Meeting 3/28/19 https://youtu.be/BigM7_GyJw8 timestamp: 1:41:20— 1:41:48

  33. 2020 DGAC Public Meeting 3/28/19 https://youtu.be/BigM7_GyJw8 timestamp: 1:43:50— 1:45:07

  34. https://www.ucsusa.org/center-science-and-democracy/fighting-misinformation/hooked-for-life-weak-policies-added-sugar

  35. https://www.ncbi.nlm.nih.gov/pubmed/25647681

  36. http://www.euro.who.int/en/health-topics/disease-prevention/nutrition/news/news/2019/4/new-who-studies-europe-battles-childhood-obesity-and-experts-confirm-breastfeeding-protects-against-child-obesity

  37. https://www.bmj.com/content/364/bmj.l1279


*The Conflicts of Interest listed for the subcommittee are to the best of our knowledge. We welcome corrections and additional information in the ‘Comments’ section below.

About the Author:

Emma Hitt Nichols, Ph.D., is a health writer and founder of BestShape50.com.

 

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