Nutrition Education: Application of Theory and Strategies during the First 1,000 Days for Healthy Growth

Editor(s): Anne M. Dattilo, Jose M. Saavedra.

The prevalence of childhood obesity has significantly increased worldwide over the past 40 years in nearly all of 200 countries studied [1]. Currently, approximately 50 million girls and 74 million boys, aged 5–19 years, are obese. Although comparable global statistics are not available, nationally representative studies from the United States report that about 8.0% of infants and young children ≤2 years of age have anthropomet-ric values ≥95th percentile of weight-for-length. Overweight and obesity are realized in even greater proportions among some groups of infants and young children [2]. The World Health Organization [3] recommends that a multifaceted approach should be taken for obesity prevention and that interventions in early life, when biology is most “plastic” and amenable to change, are likely to have the greatest positive sustained effects. Despite the rise is obesity prevalence, globally, more children are under-weight than obese. In 2016, approximately 75 million girls and 117 mil-lion boys were moderately or severely underweight. Many regions of the world continue to deal with the double burden of rising obesity with persistent malnutrition and consequent stunting in infancy and childhood. While access to a safe food supply remains a factor in parts of the world, nutrition education remains paramount in improving the health of these populations.

Nutrition Education: Definition and Features

    While there may be no international standard definition, the Society
for Nutrition Education and Behavior adopted a definition of nutrition education as: 
“any combination of educational strategies, accompanied by environmental supports, designed to facilitate voluntary adoption of food choices and other food and nutrition related behaviors conducive to health and well-being and delivered through multiple venues, involving activities at the individual, institutional, community, and policy levels."

Table 1. Actionable, modifiable dietary and feeding-related behaviors associated with healthy growth during the first 1,000 days

Adjust energy intake/expenditure to achieve recommended weight gain during pregnancy
Consume a nutrient-dense diet during pregnancy and lactation
Breastfeed the infant
Offer nutritious complementary foods and beverages at the infant/toddler’s appropriate developmental stage
Utilize responsive feeding practices and foster healthy eating behaviors through shared family meals/mealtime routines
Provide the infant/toddler opportunities for physical activity; limit TV and screen viewing time
Ensure that the infant/toddler has adequate sleep via establishment of sleep hygiene routines

[4]”. Embedded within is the explicit distinction that nutrition education is not synonymous with the provision of nutrition information. Instead, comprehensive nutrition education strategies require actionable behaviors that individuals readily choose to achieve an intended effect.

Components of Interventions for Healthy Growth
Consistent with a Nutrition Education Approach

      Factors associated with healthy growth of infants and young children have previously been identified [5]. In addition to optimizing maternal health and lifestyle in preparation for pregnancy, some modifiable and actionable dietary and feeding-related behaviors have been included in a limited number of interventions (Table 1). Assessment of behavioral mediators, defined as underlying determinants that precede adoption of behaviors, is critical to nutrition education intervention success. Often, the resultant potential mediators included attitudes, beliefs, self-efficacy, social norms, skills, knowledge, and environmental constraints that influ-ence whether or not a target behavior is adopted.

      Evidence indicates that nutrition education strategies and interventions, likely to benefit participants, are guided by a theory of healthy behavior. The most frequently reported theories utilized with success include: Social Cognitive Theory, including promotion of self-efficacy, Theory of Planned Behavior, and the Health Belief Model. An educational approach rooted within anticipatory guidance, as a method to proactively deliver components of culturally appropriate behavioral messages to par-ents/caregivers during the period just prior to when the issue would be developmentally relevant to the infant or child has a strong theoretical rationale.

For maximum scalability, consideration of the delivery format of nutrition education interventions requires careful assessment. At present, randomized clinical trials that have included multiple intervention components during the first 1,000 days with outcomes related to growth of infants or young children are primarily clinic- or home-based. Although mHealth or digital interventions document encouraging results, results from multicomponent intervention trials with infants or young children addressing the prevention of excess weight gain, healthy growth, or measures of adiposity in scale-up interventions are limited.

1.  NCD Risk Factor Collaboration (NCD-RisC): Worldwide trends in body-mass index,
     underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416
     population-based measurement studies in 128.9 million children, adolescents, and
     adults. Lancet 2017;390:2627–42.
2.  Freedman DS, Sharma AJ, Hamner HC et al. Trends in weight-for-length among
     infants in WIC from 2000 to 2014. Pediatrics 2017; 139:pii: e20162034.
3.  World Health Organization: Interim Report of the Commission on Ending
     Childhood Obesity. Geneva, WHO, 2015.
4.  Contento IR: Nutrition Education: Linking Research, Theory, and Practice (ed 2).
     Burlington, Jones and Bartlett, 2011.
5.  Dattilo AM, Birch L, Krebs NF, et al: Need for early interventions in the prevention of
     pediatric overweight: a review and upcoming directions. J Obes 2012;2012:123023.


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