Vitamin Angel Alliance’s Technical Director for US Programs, Colleen Delaney, PhD, RDN, has prepared a comprehensive landscape analysis of the US.
The report was conducted to explore the nutritional landscape of the United States (US) as it pertains to maternal, infant, and young child nutrition (MICYN), particularly in the areas of Multiple Micronutrient Supplementation (MMS), early and exclusive breastfeeding through 6 months of age, and nutrition support (e.g., supplementary feeding programs and social behavior change communication).
MICYN in the US:
Outlining Context, Offering Next Steps
This US Landsape Analysis:
1.) Outlines existing federal and state policies and programs that impact MICYN, and provides contextual information on both barriers and enablers to effective nutrition interventions in the US.
2.) Makes evidence-based recommendations for how Vitamin Angels can realize our strategic mission (helping underserved pregnant mothers, infants, and young children) in the US offering specific information to guide next steps.
From these recommendations, the Program division and Vitamin Angels as a whole, will have an evidenced-based compass to guide the development of a strategic roadmap and our technical work in the US, in 2023 and beyond.
Note: This information is for internal purposes only. The Programs and Marketing divisions will be working to translate this information, not only to guide the next steps for our programmatic efforts, but to fuel tangible development, donor relations, and marketing materials in the future. Please reach out to Vitamin Angels’ Technical Director for US Programs, Colleen Delaney, PhD, RDN with any questions on the report.
To conduct the landscape analysis, a comprehensive review of the scientific literature (including current US federal and clinical guidelines and recommendations) was conducted in the areas of:
- 1. Access & Adherence to MMS to Support Healthy Pregnancies
- 2. Breastfeeding & Lactation
- 3. Maternal Nutrition
- 4. Infant & Young Child Nutrition
1. MMS to Support Healthy Pregnancies
National data and research has found that women of reproductive age are not meeting adequate intakes for key micronutrients (e.g., calcium, choline, iron, folate, vitamin D, iodine) that support healthy pregnancies. To ensure women of reproductive age meet adequate intake for key micronutrients, clinical guidelines encourage early and regular use of MMS to support healthy pregnancies. Despite these recommendations, about 20% of women are not regularly consuming MMS and rates of intake are lower among those underserved by current systems.
- American College of Obstetricians and Gynecologists (ACOG) currently recommends that prenatal supplements include calcium, iron, iodine, choline, folate, and vitamins A, C, D, B6, and B12. Vitamin Angels utilizes the UNIMMAP formula, which mostly aligns with this recommendation (with the exemption of the exclusion of calcium and choline in the UNIMMAP formula and less iodine than recommended by ACOG). However, limited research has explored the impact of the UNIMMAP formula in the context of high-income countries.
- Despite research demonstrating the potential benefits of MMS, there is limited research describing barriers and enablers to access and adherence in the US. Furthermore, while US-based clinical guidelines recommend women of reproductive age regularly consume MMS at least 3 months prior to conception there is an indication that few are meeting this recommendation and limited research explores rates of coverage, adherence, and contextual factors associated with MMS in the preconception period.
Recommendations for MMS in the US:
- Ensure that underserved women of reproductive age have access to MMS during the preconception, pregnancy, and postpartum periods
- Explore barriers and enablers to effective nutrition intervention during these stages
- Collaborate with state and federal groups supporting MMS use
- Build consensus among key stakeholders on the importance of MMS in the context of underserved populations
- Explore the benefits of the UNIMMAP formula in high-income countries, like the US
- Research the impact of additional micronutrient supplementation (e.g., calcium, iodine)
2. Breastfeeding & Lactation
Early and exclusive breastfeeding in the US remains low, despite its well-documented emotional and physical benefits to mother and baby. Numerous environmental barriers lead to these low rates of breastfeeding, including few policies to support postpartum women (paid parental leave, Medicaid coverage of breast pumps and lactation services, and workplace break time for breastfeeding or pumping). Additionally, 70% of infants are born in hospitals not practicing positive maternity care practices (no availability of lactation consultants or breastfeeding support from hospital staff, rooming-in, or emotional support), which decreases the likelihood of breastfeeding success. In the US, there are also numerous barriers and enablers to breastfeeding related to racial, ethnic, and cultural bias, with significant additional barriers impacting Black, indigenous, and other people of color (BIPOC).
Recommendations for Breastfeeding & Lactation in the US:
- Advance federal and state advocacy for policies to support breastfeeding
- Advocate for improved maternity care practices throughout the healthcare system
- Conduct context-specific research identifying and addressing documented barriers to breastfeeding, to advance health equity and address racial and ethnic disparities
- Ensure a balanced approach is used that considers both physical and emotional advantages for mother and baby, along with the emotional and physical challenges (due to physiological inability to breastfeed, societal pressure to do so, and/or lack of environmental support).
3. Maternal Nutrition
Most US women of reproductive age are under-consuming key nutrients, leaving them at increased risk for micronutrient deficiencies, which can have negative outcomes on their health and pregnancy. Several diet-related diseases (e.g., diabetes, obesity, cardiovascular disease) and diet-related diseases of pregnancy (i.e., preeclampsia, anemia, gestational diabetes) are prevalent in the US. While these diseases are associated with poor pregnancy outcomes and can lead to lifelong health complications, they are also highly responsive to simple nutrition interventions.
US federal and clinical recommendations for a healthy pregnancy encourage diverse and nutrient-dense foods to support adequate gestational weight gain and promote maternal health and birth outcomes. Several existing federal programs aim to improve diet quality, particularly among those who are food insecure. This includes the Special Supplemental Program for Women, Infants and Children (WIC), the Supplemental Nutrition Assistance Program (SNAP), the Food Distribution Program on Indian Reservations (FDPIR), and the National School Lunch and Breakfast Program.
Despite current recommendations and existing federal programming, food insecurity is common in the US and results in poor maternal diet quality and negative pregnancy and birth outcomes.
Recommendations for Maternal Nutrition in the US:
- Advance federal and state advocacy for policies to support food security
- Advocate for programs that provide nutritional support (e.g., access to Medical Nutrition Therapy and regular prenatal and postpartum care) to mothers throughout pregnancy and the postpartum period
- Activate opportunities to collaborate with state and federal groups supporting maternal nutrition
- Develop context-specific and culturally sensitive nutrition resources that encourage dietary diversity and promote adequate gestational weight gain
- Tailor programs impacting food insecurity to complement national and state programming
- Build nutrition interventions to support underserved women living with diet-related chronic disease, both during pregnancy and postpartum
4. Infant & Young Child Nutrition
- There are high rates of poor birth outcomes and infant mortality in the US. Intake of MMS, along with a healthy dietary pattern, is recommended among all women of reproductive age to reduce the risk of poor birth outcomes, including birth defects.
Additionally, infants and young children are not meeting current nutrition recommendations in the US. For example, only a quarter of infants are exclusively breastfed through 6 months of age, and many do not follow a healthy dietary pattern once complementary foods are introduced. Nationally, young children have poor dietary quality and do not meet recommendations for total vegetable, dark-green vegetable, red/orange vegetable, whole grain, and seafood intake, while exceeding recommendations for refined grains, added sugars, saturated fat, and sodium.
Several factors put infants and young children at risk of not following an optimal dietary pattern. These include parental feeding practices, sociodemographic factors, and food and nutrition insecurity. Among older children, community support, the home food environment, and parenting style play a significant role in the development of a healthy dietary pattern.
Recommendations for Infant & Young Child Nutrition in the US:
- Advocate for programs supporting early and exclusive breastfeeding, adequate timing of complementary foods, a healthy dietary pattern, and positive parent feeding practices
- Activate opportunities to collaborate with state and federal groups supporting infant and young child nutrition
- Tailor nutrition interventions to support early and exclusive breastfeeding, adequate timing and introduction of complementary foods, a healthy dietary pattern, and positive parent feeding practices among those with infants and young children
Combined, the results of this landscape analysis provide clear contextual information on both barriers and enablers to effective nutrition interventions in the US and offer evidence-based recommendations to guide Vitamin Angels’ next steps and inform our strategy. From these recommendations, the Program division will build out a work plan in the US to guide our technical work in the coming months and years.