Improving Nutrition in the First 1000 Days in the United States: A Federal Perspective.

The first 1000 days begins with pregnancy and ends at the child's second birthday. Nutrition throughout the life course, and especially during the first 1000 days, supports maternal health and optimal growth and development for children. We give a high-level summary of the state of nutrition in the first 1000 days in the United States. We provide examples where continued efforts are needed. We then discuss select opportunities to strengthen federal research and surveillance, programs, and communication and dissemination efforts aimed at improving nutrition and positively, and equitably, influencing the health and well-being of mothers and children. (Am J Public Health. 2022;112(S8):S817-S825. https://doi.org/10.2105/AJPH.2022.307028).

Omega-3 Fatty Acid Dietary Supplements Consumed During Pregnancy and Lactation and Child Neurodevelopment: A Systematic Review.

BACKGROUND: Maternal nutrition during pregnancy and lactation has profound effects on the development and lifelong health of the child. Long-chain PUFAs are particularly important for myelination and the development of vision during the perinatal period. OBJECTIVES: We conducted a systematic review to examine the relationship between supplementation with omega-3 fatty acids during pregnancy and/or lactation and neurodevelopment in children, to inform the Scientific Report of the 2020 Dietary Guidelines Advisory Committee. METHODS: We identified articles on omega-3 fatty acid supplementation in pregnant and lactating women that included measures of neurodevelopment in their children (0-18 y) by searching PubMed, CENTRAL, Embase, and CINAHL Plus. After dual screening articles for inclusion, we qualitatively synthesized and graded the strength of evidence using pre-established criteria for assessing risk of bias, consistency, directness, precision, and generalizability. RESULTS: We included 33 articles from 15 randomized controlled trials (RCTs) and 1 prospective cohort study. Of the 8 RCTs that delivered omega-3 fatty acid dietary supplements during pregnancy alone (200-2200 mg/d DHA and 0-1100 mg/d EPA for approximately 20 wk), 5 studies reported ≥1 finding that supplementation improved measures of cognitive development in the infant or child by 6%-11% (P < 0.05), but all 8 studies also reported ≥1 nonsignificant (P > 0.05) result. There was inconsistent or insufficient evidence for other outcomes (language, social-emotional, physical, motor, or visual development; academic performance; risks of attention deficit disorder, attention-deficit/hyperactivity disorder, autism spectrum disorder, anxiety, or depression) and for supplementation during lactation or both pregnancy and lactation. Populations with a lower socioeconomic status and adolescents were underrepresented and studies lacked racial and ethnic diversity. CONCLUSIONS: Limited evidence suggests that omega-3 fatty acid supplementation during pregnancy may result in favorable cognitive development in the child. There was insufficient evidence to evaluate the effects of omega-3 fatty acid supplementation during pregnancy and/or lactation on other developmental outcomes.

Development of Food Pattern Recommendations for Infants and Toddlers 6-24 Months of Age to Support the Dietary Guidelines for Americans, 2020-2025.

BACKGROUND: Developing food-based dietary guidelines (FBDGs) for infants and toddlers is a complex task that few countries have attempted. OBJECTIVES: Our objectives are to describe the process of food pattern modeling (FPM) conducted to develop FBDGs for the Dietary Guidelines for Americans, 2020-2025 for infants 6 to <12 mo and toddlers 12 to <24 mo of age, as well as the implications of the results and areas needing further work. METHODS: The US 2020 Dietary Guidelines Advisory Committee, with the support of federal staff, conducted FPM analyses using 5 steps: 1) identified energy intake targets; 2) established nutritional goals; 3) identified food groupings and expected amounts, using 3 options for the amount of energy from human milk in each age interval; 4) estimated expected nutrient intakes for each scenario, based on nutrient-dense representative foods; and 5) evaluated expected nutrient intakes against nutritional goals. RESULTS: For human milk-fed infants (and toddlers), example combinations of complementary foods and beverages were developed that come close to meeting almost all nutrient recommendations if iron-fortified infant cereals are included at 6 to <12 mo of age. These combinations would also be suitable for formula-fed infants. For toddlers not fed human milk, 2 patterns were developed: the Healthy US-Style Pattern and the Healthy Vegetarian Pattern (a lacto-ovo vegetarian pattern). Achieving nutrient recommendations left virtually no remaining energy for added sugars. CONCLUSIONS: It is challenging to meet all nutrient needs during these age intervals. Added sugars should be avoided for infants and toddlers <2 y of age. Further work is needed to 1) establish a reference human milk composition profile, 2) update and strengthen the DRI values for these age groups, and 3) use optimization modeling, in combination with FPM, to identify combinations of foods that meet all nutritional goals.

A Proposed Framework for Identifying Nutrients and Food Components of Public Health Relevance in the Dietary Guidelines for Americans.

BACKGROUND: Identification of nutrients of public health concern has been a hallmark of the Dietary Guidelines for Americans (DGA); however, a formal systematic process for identifying them has not been published. OBJECTIVES: We aimed to propose a framework for identifying "nutrients or food components" (NFCs) of public health relevance to inform the DGA. METHODS: The proposed framework consists of 1) defining terminology; 2) establishing quantitative thresholds to identify NFCs; and 3) examining national data. The proposed framework utilizes available data from 3 key data sources or "prongs": 1) dietary intakes; 2) biological endpoints; and 3) clinical health consequences such as prevalence of health conditions, directly or indirectly through validated surrogate markers. RESULTS: In identifying potential NFCs of public health concern, the 2020 DGA Committee developed a decision-tree framework with suggestions for combining the 3 prongs. The identified NFCs of public health concern for Americans ≥1 y old included fiber, calcium (≥2 y old), vitamin D, and potassium for low intakes and sodium, added sugars, and saturated fats (≥2 y old) for high intakes that were associated with adverse health consequences. Iron was identified among infants ages 6-12 mo fed human milk. For reproductive-aged and pregnant females, iron (all trimesters) and folate (first trimester) were identified for low intake, based on dietary and biomarker data (iron) or the severity of the consequence (folic acid and neural tube defects). Among pregnant women, low iodine was of potential public health concern based on biomarker data. Other NFCs that were underconsumed, overconsumed, and pose special challenges were identified across the life course. CONCLUSIONS: The proposed decision-tree framework was intended to streamline and add transparency to the work of this and future Dietary Guidelines Advisory Committees to identify NFCs that need to be encouraged or discouraged in order to help reduce risk of chronic disease and promote health and energy balance in the population.

Addressing misinformation about the Dietary Guidelines for Americans.

The Dietary Guidelines for Americans (DGA) provides science-based advice on dietary intake to promote health, reduce risk of chronic disease, and meet nutrient needs. It is jointly published by the United States Departments of Health and Human Services and Agriculture (USDA) every 5 y. As chronic diseases continue to rise to pervasive levels, helping the United States population follow the DGA is especially important for improving the health of our nation. The DGA is developed using a rigorous and transparent scientific process, and with the advice of an independent, external committee of leading scientists. Career federal nutrition scientists who manage the process ensure that the methods used to develop the DGA remain state of the art. Unfortunately, misinformation about the scientific basis, transparency, and relevance of the DGA for the United States population threatens its credibility. The main objective of this article is to correct this misinformation with factual information about the process used to develop the DGA. The DGA provides guidelines for the general public, and its primary audience includes policymakers and nutrition and health professionals who help individuals and families consume a healthy dietary pattern. Providing accurate information may bolster trust in the recommendations among these audiences while improving implementation across sectors to promote better adherence to the DGA, thereby improving diet quality among the United States population.

Dietary Patterns and Health: Insights From NESR Systematic Reviews to Inform the Dietary Guidelines for Americans.

This perspective article shares unique insights from the extensive experience of the US Department of Agriculture Nutrition Evidence Systematic Review branch in conducting systematic reviews on dietary patterns and health outcomes to inform the Dietary Guidelines for Americans. Methodological approaches for reviewing dietary patterns research are described, including approaches to operationalizing definitions and analyzing labeled dietary patterns. The review also describes techniques for synthesizing dietary patterns research across life stages in systematic reviews that inform food-based, federal dietary guidance. Current research activities and recommendations for how to improve or address gaps in dietary patterns research in the future are also discussed.

Healthy Eating Index-2020: Review and Update Process to Reflect the Dietary Guidelines for Americans,2020-2025.

The purpose of this review is to share the process for reviewing, updating, and developing the most recent version of the Healthy Eating Index-2020 (HEI-2020) for ages 2 and older, following the release of the Dietary Guidelines for Americans (DGA), 2020-2025. The overall review process included: 1) gathering information from the updated DGA, experts, and federal stakeholders; 2) considering substantive changes and needs for new development, keeping in mind the HEI's key features and guiding principles, the US Department of Agriculture's Dietary Patterns that serve as the foundation for the HEI, and scoring considerations; and 3) completing evaluation analyses, including the examination of content validity. The review process led to the development of the HEI-2020; a separate HEI-Toddlers-2020 was developed for ages 12 through 23 months. The 13 components and scoring standards of the HEI-2020 fully align with the HEI-2015, although the index was renamed to clarify that it aligned with the most recent 2020-2025 DGA. As the evidence informing the DGA continues to evolve, various aspects of the HEI may need to evolve in the future as well. Further methodological research is encouraged to add to the scientific evidence base on dietary patterns, to examine needs specific to each life stage, and to model optimal trajectories of healthy dietary patterns over the lifespan.

Continuity, Considerations, and Future Directions for the Healthy Eating Index-Toddlers-2020.

The Dietary Guidelines for Americans, 2020-2025 includes guidance for infants and toddlers aged birth to 24 months. To assess alignment with this new guidance, the Healthy Eating Index (HEI)-Toddlers-2020 was developed for toddlers 12 through 23 months old. This monograph focuses on the continuity, considerations, and future directions of this new index for toddlers in the context of evolving dietary guidance. There is considerable continuity between the HEI-Toddlers-2020 and previous versions of the HEI. The same process, guiding principles, and features (with caveats) are repeated in the new index. However, there are unique considerations for measurement, analysis, and interpretation for the HEI-Toddlers-2020 that this article addresses, while identifying future directions for the HEI-Toddlers-2020. The continued evolution of dietary guidance for infants, toddlers, and young children will provide additional opportunities for index-based metrics: considering inclusion of multidimensional layers in dietary patterns, defining a healthy eating trajectory, bridging healthy eating across different life stages, and communicating the constructs of balance among dietary constituents.

Development of the Healthy Eating Index-Toddlers-2020.

The Healthy Eating Index-Toddlers-2020 (HEI-Toddlers-2020) is a measure for assessing how well a set of foods aligns with new guidance in the Dietary Guidelines for Americans, 2020-2025 (DGA) for toddlers aged 12 through 23 months. This new tool was developed using consistent features and the guiding principles of the HEI. The HEI-Toddlers-2020, like HEI-2020, has 13 components reflecting all constituents of dietary intake, except for human milk or infant formula. These components include the following: Total Fruits, Whole Fruits, Total Vegetables, Greens and Beans, Whole Grains, Dairy, Total Protein Foods, Seafood and Plant Proteins, Fatty Acids, Refined Grains, Sodium, Added Sugars, and Saturated Fats. Healthy dietary patterns for toddlers have unique considerations reflected in the scoring standards for Added Sugars and Saturated Fats. Toddlers have lower energy intake relative to high nutrient needs and added sugars should be avoided. Another distinctive difference is that there is no recommendation to limit saturated fats to <10% of energy intake in this age group; however, saturated fats cannot be unlimited without displacing the energy available to achieve other food group and subgroup goals. Calculations using the HEI-Toddlers-2020, like the HEI-2020, result in a total score and a set of individual component scores that reveal a dietary pattern. The release of a HEI-Toddlers-2020 will enable assessment of diet quality that aligns with the DGA and support additional methodological research to examine needs specific to each life stage and how to model trajectories of healthy dietary patterns.

Evaluation of the Healthy Eating Index-Toddlers-2020.

BACKGROUND: With the addition of new guidance for children from birth to 24 months in the Dietary Guidelines for Americans, 2020-2025 (DGA), a Healthy Eating Index (HEI) was developed for toddlers. OBJECTIVE: To evaluate the psychometric properties of the HEI-Toddlers-2020, 5 analyses relevant to construct and concurrent validity and 2 related to reliability were examined. DESIGN: Twenty-four-hour diet recall data from the cross-sectional National Health and Nutrition Examination Survey (2011-2018) were used. In addition, exemplary menus were analyzed. PARTICIPANTS/SETTING: The main analytic sample included toddlers aged 12 through 23 months (n = 838), with additional analyses of toddlers aged 12 through 35 months (n = 1,717) from the United States. Included participants had valid diet recalls and available weight-for-age data. MAIN OUTCOME MEASURES: Outcomes measures included HEI-Toddlers-2020 total and component scores on menus, population distributions, and correlations. STATISTICAL ANALYSES: HEI total and component scores were calculated using menus from the American Academy of Pediatrics and Healthy Eating Research. Score means and distributions were estimated using a Markov Chain Monte Carlo approach with National Health and Nutrition Examination Survey data (2011-2018). Principal component analysis explored dimensions and Pearson correlations examined components, energy, and Cronbach α. In addition, HEI-Toddlers-2020 and HEI-2020 scores were compared for identical intakes at age 24 months. RESULTS: For validity, exemplary menus received high scores with the HEI-Toddlers-2020. The mean ± SE total HEI-Toddlers-2020 score for toddlers aged 12 through 23 months was 62.9 ± 0.78 and ranged from 40.1 to 84.4 (1st to 99th percentile). Correlation between diet quality and diet quantity was low (-0.15); the scree plot revealed multiple factors. In addition, total scores for identical intakes were approximately 1.5 points higher for HEI-Toddlers-2020 compared with HEI-2020 (difference range for component scores, -4.97 to 4.89). For reliability, most of the intercorrelations among components were low to moderate (0 to 0.49), with a few exceptions among related components. Cronbach α was .48. These results indicate that the index is multidimensional, with no single component driving the total score, and no unnecessary components that are highly correlated with another component. CONCLUSIONS: The results demonstrated evidence supportive of validity and reliability. The HEI-Toddlers-2020 can be used to assess alignment with the DGA for toddlers.

Frequency of Eating in the US Population: A Narrative Review of the 2020 Dietary Guidelines Advisory Committee Report.

Background: A person's daily nutrient intake and overall nutritional status are determined by a complex interplay of the types and amounts of foods ingested in combination with the timing and frequency of eating. Objectives: The aim was to summarize frequency of eating occasion data examined by the 2020 Dietary Guidelines Advisory Committee, the macronutrient contributions they provide, and meal frequency relative to dietary quality among the US population (≥2 y), with a focus on sex, age, race/Hispanic origin, and income. Methods: Demographic and 24-h recall data from the 2013-2016 NHANES were examined. An eating occasion was defined as "any ingestive event (e.g., solid food, beverage, water) that is either energy yielding or non-energy yielding"; all eating occasions were further divided into discrete meals and snacks. Frequency of meals and snacks was defined as "the number of daily EOs [eating occasions]," respectively. Diet quality was assessed via the Healthy Eating Index (HEI)-2015. Results: Most Americans consume 2 (28%) to 3 (64%) meals on a given day and >90% consume 2 to 3 snacks on that day. Adult, Hispanic, and non-Hispanic Black and lower-income (<131% family poverty-to-income ratio) Americans had a lower frequency of eating than children or adolescents, non-Hispanic White, and non-Hispanic Asian Americans and higher-income Americans, respectively. Americans who reported 3 meals on a given day consumed a diet higher in dietary quality than Americans who consumed 2 meals on a given day (HEI-2015: 61.0 vs. 55.0), regardless of population subgroup. Conclusions: The frequency of the types of eating occasions differs according to age, race and Hispanic origin, and income. Dietary quality is associated with the number of meals consumed. Healthy dietary patterns can be constructed in a variety of ways to suit different life stages, cultural practices, and income levels; improved diet quality and careful consideration of nutrient density when planning meals are warranted.

Dietary and Complementary Feeding Practices of US Infants, 6 to 12 Months: A Narrative Review of the Federal Nutrition Monitoring Data.

Complementary foods and beverages (CFBs) are key components of an infant's diet in the second 6 months of life. This article summarizes nutrition and feeding practices examined by the 2020 Dietary Guidelines Advisory Committees during the CFB life stage. Breastfeeding initiation is high (84%), but exclusive breastfeeding at 6 months (26%) is below the Healthy People 2030 goal (42%). Most infants (51%) are introduced to CFBs sometime before 6 months. The primary mode of feeding (ie, human milk fed [HMF]; infant formula or mixed formula and human milk fed [FMF]) at the initiation of CFBs is associated with the timing of introduction and types of CFBs reported. FMF infants (42%) are more likely to be introduced to CFBs before 4 months compared with HMF infants (19%). Different dietary patterns, such as higher prevalence of consumption and mean amounts, were observed, including fruit, grains, dairy, proteins, and solid fats. Compared with HMF infants of the same age, FMF infants consume more total energy (845 vs 631 kcal) and protein (22 vs 12 g) from all sources, and more energy (345 vs 204 kcal) and protein (11 vs 6 g) from CFBs alone. HMF infants have a higher prevalence of risk of inadequate intakes of iron (77% vs 7%), zinc (54% vs <3%), and protein (27% vs <3%). FMF infants are more likely to have an early introduction (<12 months) to fruit juice (45% vs 20%) and cow's milk (36% vs 24%). Registered dietitian nutritionists and nutritional professionals should consider tailoring their advice to caregivers on dietary and complementary feeding practices, taking into account the primary mode of milk feeding during this life stage to support infants' nutrient adequacy. National studies that address the limitations of this analysis, including small sample sizes and imputed breast milk volume, could refine findings from this analysis.

Dietary Guidelines for Americans, 2020-2025: Understanding the Scientific Process, Guidelines, and Key Recommendations.

The Dietary Guidelines for Americans, 2020-2025 was issued jointly by the US Departments of Agriculture and of Health and Human Services in December 2020. It is the ninth edition of the Dietary Guidelines and is the first to provide recommendations by life stage, from birth to older adulthood. The Dietary Guidelines is grounded in the current body of scientific evidence on diet and health outcomes and aims to promote health and prevent chronic diseases. The process to develop the Dietary Guidelines involved 4 steps: (1) identifying the topics and supporting scientific questions, (2) appointing a Dietary Guidelines Advisory Committee (Committee) to review current scientific evidence, (3) developing the new edition of the Dietary Guidelines, and (4) implementing the Dietary Guidelines. The 2020-2025 edition provides 4 overarching guidelines and supporting key recommendations that encourage healthy dietary patterns across the life span. The foods and beverages that people consume have a profound impact on health, and it is never too late or too early to eat healthfully.

Perspective: Impact of the National Academy of Sciences, Engineering, and Medicine Report on the Process for the 2020 Dietary Guidelines Advisory Committee.

The National Academy of Sciences, Engineering, and Medicine (NASEM) recommended steps to redesign the process of developing the Dietary Guidelines for Americans (DGA) are based on 5 guiding principles (enhance transparency; promote diversity of expertise and experience; support a deliberative process; manage biases and conflicts of interest; and adopt state-of-the-art processes and methods). Using these principles and recommendations, the USDA and HHS updated the process for developing the 2020-2025 Dietary Guidelines, including the process for appointing members and managing the work of the 2020 Dietary Guidelines Advisory Committee. Modifications included having public comment on the topics and questions to be addressed by the Federal Advisory Committee, reviewing professional and financial activities on potential appointees to the committee prior to their appointment, redesigning the website to provide status updates on the work of the committee as analytical frameworks and draft conclusions were developed, strengthening the approaches for conducting systematic reviews, and adding a public meeting for discussion of the final report before its submission to the Secretaries of the USDA and HHS. Because the DGA is reviewed and updated every 5 y, it is possible to learn from each cycle what works well and where improvements in the process can be implemented. The current article illustrates, from the perspective of the advisory committee, the impact of the NASEM report on the development of the scientific report by examining changes in the process consistent with the 5 principles.

Evaluation of Dietary Patterns and All-Cause Mortality: A Systematic Review.

Importance: The 2020 Dietary Guidelines Advisory Committee conducted a systematic review of existing research on diet and health to inform the current Dietary Guidelines for Americans. The committee answered this public health question: what is the association between dietary patterns consumed and all-cause mortality (ACM)? Objective: To ascertain the association between dietary patterns consumed and ACM. Evidence Review: Guided by an analytical framework and predefined inclusion and exclusion criteria developed by the committee, the US Department of Agriculture's Nutrition Evidence Systematic Review (NESR) team searched PubMed, the Cochrane Central Register of Controlled Trials, and Embase and dual-screened the results to identify articles that were published between January 1, 2000, and October 4, 2019. These studies evaluated dietary patterns and ACM in participants aged 2 years and older. The NESR team extracted data from and assessed risk of bias in included studies. Committee members synthesized the evidence, developed conclusion statements, and graded the strength of the evidence supporting the conclusion statements. Findings: A total of 1 randomized clinical trial and 152 observational studies were included in the review. Studies enrolled adults and older adults (aged 17-84 years at baseline) from 28 countries with high or very high Human Development Index; 53 studies originated from the US. Most studies were well designed, used rigorous methods, and had low or moderate risks of bias. Precision, directness, and generalizability were demonstrated across the body of evidence. Results across studies were highly consistent. Evidence suggested that dietary patterns in adults and older adults that involved higher consumption of vegetables, fruits, legumes, nuts, whole grains, unsaturated vegetable oils, fish, and lean meat or poultry (when meat was included) were associated with a decreased risk of ACM. These healthy patterns were also relatively low in red and processed meat, high-fat dairy, and refined carbohydrates or sweets. Some of these dietary patterns also included intake of alcoholic beverages in moderation. Results based on additional analyses with confounding factors generally confirmed the robustness of main findings. Conclusions and Relevance: In this systematic review, consuming a nutrient-dense dietary pattern was associated with reduced risk of death from all causes.

The Pregnancy and Birth to 24 Months Project: a series of systematic reviews on diet and health.

Nutrition exposures during the earliest stages of life are integral to growth and development and may continue to affect health through adulthood. The purpose of the Pregnancy and Birth to 24 Months (P/B-24) Project was to conduct a series of systematic reviews on diet and health for women who are pregnant and for infants and toddlers from birth to 24 mo of age. The P/B-24 Project was a joint initiative led by the USDA and the US Department of Health and Human Services. The USDA's Nutrition Evidence Systematic Review team, previously known as the Nutrition Evidence Library, carried out the series of systematic reviews in collaboration with programmatic and scientific experts. Systematic review questions were prioritized based on federal policy, program, or guidance needs, potential to support the development of healthy dietary intake, and public health importance. Systematic reviews were conducted on specific topics related to dietary intake before and during pregnancy, infant milk feeding practices, complementary feeding, flavor exposures, and infant/toddler feeding practices. Across the reviews, relationships were observed between P/B-24 diet exposures and a variety of outcomes of public health importance. Evidence showed links between dietary intake before and during pregnancy, during the period of human milk or infant formula feeding, and through introduction of complementary foods and beverages and health outcomes. Additionally, the reviews on flavor exposure and infant/toddler feeding practices highlight the importance of maternal diet during pregnancy and lactation and caregiver feeding strategies and practices. Systematic reviews are an important tool to inform our understanding of the body of evidence related to diet and health, and scientists can use the P/B-24 Project reviews to continue to advance research in these areas.

Timing of introduction of complementary foods and beverages and growth, size, and body composition: a systematic review.

BACKGROUND: The systematic review described in this article was conducted as part of the USDA and Department of Health and Human Services Pregnancy and Birth to 24 Months Project. OBJECTIVES: The aim was to describe the relationship between timing of introduction of complementary foods and beverages (CFBs) and growth, size, and body-composition outcomes across the life span. METHODS: The literature was searched and selected using predetermined criteria. Data were extracted and risk of bias assessed for each included study. Evidence was qualitatively synthesized, conclusion statements were developed, and the strength of the evidence was graded. RESULTS: Eighty-one articles were included in this systematic review that addressed timing of CFB introduction relative to growth, size, and body-composition outcomes from infancy through adulthood. Moderate evidence suggests that introduction of CFBs between the ages of 4 and 5 mo compared with ∼6 mo is not associated with weight status, body composition, body circumferences, weight, or length among generally healthy, full-term infants. Limited evidence suggests that introduction of CFBs before age 4 mo may be associated with higher odds of overweight/obesity. Insufficient evidence exists regarding introduction at age ≥7 mo. CONCLUSIONS: Although several conclusions were drawn in this systematic review, additional research is needed to address gaps and limitations in the evidence on timing of introduction of CFBs and growth, size, and body composition, such as randomized controlled trials that examine multiple outcomes and/or CFB introduction between the ages of 4 and 6 mo, and research that accounts for potential confounders such as feeding practices and baseline growth status and considers issues of reverse causality.

Types and amounts of complementary foods and beverages consumed and growth, size, and body composition: a systematic review.

BACKGROUND: Systematic reviews (SRs) were conducted by the Nutrition Evidence Systematic Review (NESR) team for the USDA's and the Department of Health and Human Services' Pregnancy and Birth to 24 Months Project. OBJECTIVES: The aim was to describe the SRs examining the relationship between types and amounts of complementary foods and beverages (CFBs) and growth, size, and body-composition outcomes. METHODS: The NESR team collaborated with subject matter experts to conduct this SR. The literature was searched and screened using predetermined criteria. For each included study, data were extracted and risk of bias was assessed. The evidence was qualitatively synthesized to develop a conclusion statement, and the strength of evidence was graded. RESULTS: This SR includes 49 articles that examined type, amount, or both of CFBs consumed and growth, size, and body-composition outcomes. Moderate evidence suggests that consuming either different amounts of meat, meat instead of iron-fortified cereal, or types of CFBs with different fats or fatty acids does not favorably or unfavorably influence growth, size, or body composition. In relation to overweight/obesity, insufficient evidence is available with regard to the intake of meat or CFBs with different fats or fatty acids. Limited evidence suggests that type and amount of fortified infant cereal does not favorably or unfavorably influence growth, size, body composition, or overweight/obesity. Limited evidence suggests that sugar-sweetened beverage consumption during the complementary feeding period is associated with increased obesity risk in childhood but is not associated with other measures of growth, size, or body composition. Limited evidence showed a positive association between juice intake and infant weight-for-length and child body mass index z scores. Insufficient evidence is available on other CFBs or dietary patterns in relation to outcomes. CONCLUSIONS: Although several conclusions were drawn, additional research is needed that includes randomized controlled trials, examines a wider range of CFBs, considers issues of reverse causality, and adjusts for potential confounders to address gaps and limitations in the evidence.

Complementary feeding and developmental milestones: a systematic review.

BACKGROUND: Systematic reviews were conducted as part of the USDA and the US Department of Health and Human Services Pregnancy and Birth to 24 Months Project to examine the relation between complementary feeding and developmental milestones. OBJECTIVES: The aim of this study was to describe systematic reviews examining the relationship between timing of introduction of complementary foods and beverages (CFB), and the types and amounts of CFB consumed, and developmental milestones. METHODS: The literature was searched using 4 databases (PubMed, Cochrane, Embase, and CINAHL) to identify articles that met predetermined criteria for inclusion. Data extraction and risk of bias assessment were conducted for each included study. The body of evidence for each systematic review was qualitatively synthesized to develop a conclusion statement, and the strength of evidence was graded. RESULTS: Three included articles (1 randomized controlled trial; 2 observational studies) examined timing of introduction of CFB. Eight included articles (3 randomized controlled trials; 5 observational studies) examined types and amounts of CFB. There was insufficient evidence to draw conclusions about the relation between either timing of CFB introduction or types and amounts of CFB, and developmental milestones. CONCLUSIONS: The ability to draw conclusions about the relationship between complementary feeding and developmental milestones was restricted by an inadequate amount of evidence with potential for issues with reverse causality and wide variation in design, type/age of outcome assessment, exposure assessment, and reported results. Additional research to address these gaps and limitations would be useful.