Introduction
Background: translating the early life origins of metabolism-related non-communicable diseases (NCDs) to the public
Chronic NCDs – such as heart disease and Type 2 diabetes – represent leading causes of illness and death in high-, middle-, and low-income countries. Such diseases account for nearly 70% of deaths globally.1 The evidence indicates unequivocally that social and other environmental factors, particularly those related to diet/nutrition and psychosocial stress, largely determine wellness through and resilience to this NCD epidemic.Reference Donkin, Goldblatt, Allen, Nathanson and Marmot2
Most NCDs generally do not manifest until middle adulthood or later.1 In spite of this, an adult’s environment only weakly impacts her risks of developing NCDs.Reference Maner, Dittmann, Meltzer and McNulty3 Rather, the effects of environment on NCD risk are strongest during the earliest stages of growth and development.Reference Maner, Dittmann, Meltzer and McNulty3, Reference Godfrey, Gluckman and Lilycrop4 That is, adverse environments during life stages spanning from before conception, through pregnancy, birth, and infancy strongly predict poorer health outcomes and higher risk of developing NCDs in middle and older age.5–Reference Stephenson, Heslehurst and Hall12 The proposition that variation in risk of developing NCDs is determined largely by early life environmental exposures is most often referred to as the Developmental Origins of Health and Disease (DOHaD) concept.Reference Low, Gluckman and Hanson9, Reference Barnes, Heaton, Coates and Packer13
For at least the last two decades, researchers with relevant expertise from a variety of backgrounds have called for intervening action based on the substantial body of evidence supporting the DOHaD hypothesis. The evidence indicates that future morbidity, mortality, and health inequity related to NCDs is preventable through early life intervention.Reference Baird, Jacob and Barker6, Reference Hanson and Gluckman10, Reference Stephenson, Heslehurst and Hall12, Reference Barker14–Reference Godfrey, Gluckman and Hanson16 As such, the question looming is not so much if scientists who are familiar with this evidence should make efforts to transfer knowledge to policymakers, clinicians, other care workers and the general public, but rather, how to do so most impactfully and positively, on the shortest timeline.5, Reference Barker14, Reference Gage, Raats, Williams and Egan17
The process of communicating research-based knowledge to the people and organizations positioned to use such knowledge in their private lives, in their work or in the formation/reformation of policies and institutions (hereafter, knowledge users)18 is widely known as Knowledge Translation (KT). The term KT is often used interchangeably or in concert with the related terms ‘knowledge transfer’ and/or the deliberately multi-directional term ‘knowledge exchange’.Reference McKibbon, Lokker and Wilczynski19 Generally, KT requires bringing together multiple kinds of evidence from many studies into some kind of consensus, while considering the needs and capacities of potential groups of knowledge users.Reference Grimshaw, Eccles, Lavis, Hill and Squires20
Aims: reviewing efforts at and critiques of DOHaD KT
With the question of how best to translate the DOHaD concept from the research arena to knowledge users in mind, we aimed to comprehensively review published DOHaD KT efforts currently being made by researchers. We concentrated on KT efforts that attempt to relay core tenets of the DOHaD hypothesis itself directly to knowledge users who have the potential to use DOHaD knowledge in their private lives and/or in their everyday work practices. Specifically, we focused on DOHaD KT efforts targeting the following populations: couples planning pregnancies, expecting mothers, the personal supports of expecting mothers, health and other care workers who support expecting mothers (community care workers), and adolescents/young adults (i.e. the cohort of people not currently planning pregnancies but nonetheless likely to become parents within the next decades).
Our primary objectives were: (1) to outline what efforts at direct-to-public DOHaD KT have been made, or are ongoing as of the time of writing (2018), (2) to identify any early signs of benefits arising from these KT efforts and (3) to highlight areas in which further efforts at KT appear necessary.
Following our review, we reflect critically on the DOHaD KT efforts that have been made and engage with previous critiques of such efforts. In particular, previous critiques have cautioned that the messaging emerging from DOHaD-related literature is likely to focus disproportionately on women as drivers of behavior change for a healthier next generation.Reference Richardson21–Reference Winett, Wulf and Wallack24 A heavy focus on women can result in feelings of anxiety, stress, stigma and shame among mothers and mothers-to-be.Reference Warin, Zivkovic, Moore and Davies25–Reference Persky, McBride, Faith, Wagner and Ward28 At the same time, an approach centering on mothers can drive feelings of frustration, alienation and even helplessness among fathers and others who support mothers.Reference Steen, Downe, Bamford and Edozien29–Reference DeLorme, Gavenus and Salmen32 Further, a tendency to zero-in on individual parents-to-be may pull policy attention away from some of the larger structures (e.g. those involved in employment, in wealth distribution, and in food production and distribution)Reference Patel33–Reference Tarasuk and Beaton35 well-situated to improve children’s early life environmental conditions.Reference Richardson21, Reference Winett, Wallack, Richardson, Boone-Heinonen and Messer22, Reference Winett, Wulf and Wallack24, Reference Warin, Moore, Zivkovic and Davies27
In keeping with these critiques, we recommend full support of an approach that does not place sole or primary responsibility for the health of the next generation on individual pregnant women. However, we also note that currently, researchers may not be relaying the core principles of the hypothesis to pregnant women or people planning pregnancies at all. Prospects for finding a middle ground and its relevance to public health nutrition are discussed below.
Efforts at direct-to-public DOHaD KT to date
Direct-to-public DOHaD KT: What efforts have been made?
We reviewed efforts to date by researchers to translate knowledge of core DOHaD-related concepts and evidence to adolescents and young adults, expecting mothers, and their immediate supports (family members, community care workers). Specifically, we searched Google Scholar for ‘DOHaD’ OR its main synonyms (‘fetal origins’, ‘the Barker hypothesis’, ‘first 1000 days’, OR ‘the lifecourse approach’)Reference Barnes, Heaton, Coates and Packer13 AND ‘knowledge translation’ OR its main synonym (‘knowledge transfer’),Reference McKibbon, Lokker and Wilczynski19 limiting the search date range to the most recent decade (2008–2018). We focused our formal searches on the last ten years largely because preliminary searches in which we did not apply date limits seemed to indicate that the earliest efforts by academics at direct-to-public DOHaD KT were beginning to be evaluated in the early 2010s; we took the conservative approach and extended our search slightly before this timeframe, to 2008. Titles (and subsequently abstracts and full-texts) of the first 50 hits for each search term combination were hand-searched to identify papers reporting direct-to-public KT efforts. While we acknowledge that this search strategy is not exhaustive, this approach appears sufficient to consistently identify the most important scholarly works on a keyword-searched topic of interest.Reference Loan and Sheihk36 Notably, we restricted our review to reports in which the idea that early life environment shapes children’s developmental trajectories and affects their later-life health (i.e. DOHaD) is itself transferred to people positioned to behaviorally modify immediate environments to improve the health of the generation to come. We then snowball searched from the titles we selected, seeking out any relevant referenced materials and scanning corresponding authors’ homepages.
In the end, we identified 17 peer-reviewed reports to include in our review. As of search completion (June 2018), research groups that were in the early stages of working to translate DOHaD knowledge directly to key members of the general public and/or their front-line community care supports were doing so in (alphabetically): The Cook Islands,Reference Bay, Yaqona and Barrett-Watson37 Japan,Reference Oyamada, Lim, Dixon, Wall and Bay38 New Zealand,Reference Bay, Mora, Sloboda and Morton39 Tonga,Reference Bay, Fehoko and La’akulu40 UgandaReference MacNab and Mukisa41 and the United Kingdom.Reference Grace, Woods-Townsend and Griffiths42 Teams in New Zealand and the United Kingdom reported the most and earliest efforts, reaching the largest numbers of participants. Direct-to-public KT programs are currently under development in Australia, Canada and South Africa.
The earliest efforts at direct-to-general-public DOHaD KT were implemented via a currently ongoing program called ‘LENScience’, launched in New Zealand in 2006Reference Bay, Mora, Sloboda and Morton39, Reference Grace and Bay43–Reference Bay, Vickers, Mora, SLoboda and Morton45 and subsequently adapted and applied to other contexts in Oceania, namely The Cook Islands and Tonga.Reference Bay, Yaqona and Barrett-Watson37, Reference Bay, Fehoko and La’akulu40 LENScience targets primarily secondary school-aged adolescents (aged 11–18, most in their mid-teens) in classroom settingsReference Bay, Mora, Sloboda and Morton39, Reference Grace and Bay43–Reference Bay, Vickers, Mora, SLoboda and Morton45 although new programming now extends a truncated version of it to university-aged nursing students in New ZealandReference Oyamada, Lim, Dixon, Wall and Bay38 and to adult science teachers in Tonga.Reference Bay, Fehoko and La’akulu40 Adolescents participating in the LENScience program are given the opportunity to think through issues related to their own diets, health and well-being narratively and in relation to socio-environmental context.Reference Grace and Bay43 They are then offered tools to explore relevant scientific evidence related to the DOHaD hypothesis. Generally, participants who have engaged with these curricula emerge with the understanding that their health and nutrition influences not only their immediate well-being, but also their later-life health and the health of their future children. Significantly, they also tend to show improvements in overall health and science literacy (i.e. the ability to make sense of information and evidence related to health and the natural world)Reference Nutbeam46 and sense of general self-efficacy (perception of one’s control over one’s life and circumstances, and ability to overcome adversity).Reference Bandura47, Reference Sherer, Mercandante, Prentice-Dunn, Jacobs and Rogers48 Health and science literacies and general self-efficacy are independent predictors of better health and well-being, and better capacity for desirable behavior change.Reference AbuSabha and Achterberg49, Reference Carbone and Zoellner50 Students who had not participated in LENScience programming generally had poorer understanding of these sets of ideas about the long-term/multi-generational consequences of their health and nutrition and had lower health and science literacies.Reference Bay, Mora, Sloboda and Morton39, Reference Bay, Vickers, Mora, SLoboda and Morton45 Notably, many former LENScience students appear to retain a relatively deep understanding of DOHaD-related concepts at least a year after completion of curricula.Reference Oyamada, Lim, Dixon, Wall and Bay38, Reference Bay, Mora, Sloboda and Morton39 Furthermore, evaluations carried out at 3 and 12 months following completion of LENScience curricula on a subset of ∼200 students from New Zealand indicates that participants may be better equipped to engage in health-related behavior change relative to their non-participant peers.Reference Bay, Vickers, Mora, SLoboda and Morton45
Given LENScience’s preliminary signs of success, researchers and clinicians in the United Kingdom have adapted elements of its curriculum and pedagogical approach to a UK context. In the UK, through ‘LifeLab’, a learning environment established in 2008 in a Southampton hospital, researchers, educators and clinicians engage secondary school-aged youth (mostly 14–15 year olds) in hands-on learning activities related to their health and biology.Reference Grace, Woods-Townsend and Griffiths42, Reference Woods-Townsend, Leat and Bay51, Reference Barker52 Crucially, the LifeLab students engage in activities in which they are exposed to evidence – and related theoretical underpinnings – that their health and nutrition as teenagers impacts not only their own later-life health but also the health of their future children. Thus, students who have participated in this programming appear to have far better understandings of DOHaD concepts than their peers who have not.Reference Grace, Woods-Townsend and Griffiths42 A follow-up evaluation of a pilot version of this program suggests that, a year after participation in LifeLab activities, students retain knowledge of core DOHaD-related concepts.Reference Woods-Townsend, Leat and Bay51 Perhaps more importantly, as with LENScience participants, LifeLab participants show improvements in general health and science literacy and engagement,Reference Grace and Bay43 setting them up to better navigate health information and health structures as they mature.Reference Woods-Townsend, Leat and Bay51, Reference Woods-Townsend, Aiston and Bagus53 As these initial efforts have shown real promise, LifeLab is expanding its programming to reach more secondary school pupils in the city of Southampton and in neighboring communities.Reference Barker52
Efforts at DOHaD KT in Uganda contrast pedagogically with those being undertaken in New Zealand, The Cook Islands, Tonga and the United Kingdom, although they are also school-based and also focus on adolescents.Reference MacNab and Mukisa41, Reference MacNab, Daar, Norris and Pauw54, Reference MacNab and Mukisa55 The Ugandan program thus far is crowdsourcing pedagogy and messaging strategy directly from participating students. As part of a World Health Organization-sponsored program called Health Promotion in Schools, more than 100 Ugandan upper-level primary school students aged 11–13 were given, in a classroom setting, a brief introduction to DOHaD concepts. The students were then asked by researchers about: which elements of the DOHaD concept resonated most closely with their own experiences, from whom they would like to learn more about DOHaD, and in what form they would like future messages about DOHaD and public health to be shared. The participants indicated that they were most interested in learning about possible later-life economic benefits of early life health, about how to feed babies healthfully and responsively, and about the general health benefits of dietary diversity. They indicated that they wanted to learn about these topics through a variety of media and in the classroom, mainly peer-to-peer or possibly from celebrities. Messaging from parents or directly from experts was viewed as relatively unappealing. Students also highlighted that they were interested in hearing positive messages about health rather than about disease risks; they made clear that they could and should be ambassadors of KT to other Ugandan students if they could share positive and hopeful messages.Reference MacNab and Mukisa41 Researchers are now drawing on these findings to identify music videos featuring celebrities containing health and lifestyle messages related to DOHaD and appealing to Ugandan adolescents.Reference MacNab and Mukisa55
Finally, the first effort to translate DOHaD knowledge in Japan is focusing on front line community care providers.Reference Bay, Mora, Sloboda and Morton39, Reference Endo and Oyamada56 This work evaluates the familiarity of university students training to become nutritionists with the terms ‘life course’ approach and ‘DOHaD’. After baseline familiarity with these terms is assessed early in training, 1st-year students are given a 90-min lecture on DOHaD and the impacts of early life nutrition on later-life NCD risk. These same students are then assessed in their 2nd, 3rd and 4th years regarding their familiarity with key DOHaD-related terminology and their understanding of DOHaD concepts. The evaluations carried out to date suggest that 1st year students at baseline are entirely unfamiliar with the term DOHaD and largely unfamiliar with key concepts and evidence related to the DOHaD hypothesis. As students progress through their training, the majority show substantial improvements in their DOHaD knowledge. However, over a third of trainees, when assessed in their final year of training, disagree with the idea that early life nutrition and health largely determines risks for many NCDs, and many students appear not to have assimilated DOHaD knowledge concerning the preconceptional period or the role of fathers.Reference Tarasuk and Beaton35 We note here also that this training and evaluation of Japanese university students was done in parallel with New Zealand’s university-level rollout of DOHaD-KT efforts, and the results were broadly similar between the two countries, with most later-year students familiar with DOHaD concepts, but with a large minority seemingly not taking on these concepts.Reference Bay, Mora, Sloboda and Morton39
Beyond these DOHaD KT efforts in New Zealand, the Cook Islands, Japan, Tonga, Uganda and the United Kingdom, which are established and have undergone at least preliminary rounds of peer-reviewed evaluation, direct-to-public DOHaD KT programs are being set up in a number of other countries. Specifically, Australia is working with New Zealand to assemble a joint working group on DOHaD ‘Translation, Policy, and Communication’, mainly comprising DOHaD-focused researchers interested in KT.Reference Prescott, Allen, Armstrong and Collins57 This group seeks to synthesize evidence related to the DOHaD hypothesis and to deliver ‘a consistent message’ to various stakeholders and to the general public via as many different media and interpersonal forums as possible.Reference Prescott, Allen, Armstrong and Collins57 Importantly, this group intends to relay simple messages such as ones ‘explaining the basic principles of DOHaD’ and to listen carefully to public responses to this kind of messaging.Reference Prescott, Allen, Armstrong and Collins57 A similar set of working groups is being established for the continent of Africa,Reference MacNab, Daar, Norris and Pauw54, Reference Norris, Daar, Balasubramanian and Byass58 with South Africa following Uganda as being especially close to ready for DOHaD KT.Reference MacNab, Daar, Norris and Pauw54 Finally, in Canada, our group is leading the ‘Mothers to Babies (M2B)’ study, which is assessing pregnant women’s understanding of DOHaD-related concepts and asking for input from pregnant women (especially those experiencing vulnerability) and from frontline community care workers on how best to improve those understandings in the city of Hamilton, Ontario. Our preliminary investigation shows that some pregnant women, especially those with relatively high household incomes and with university degrees, have some familiarity with DOHaD-related concepts, and that this familiarity is associated with higher (self-reported) dietary quality during pregnancy, even after controlling for maternal age, income and general knowledge about pregnancy health.Reference McKerracher, Rao and Moffat59
Direct-to-public DOHaD KT efforts: progress and prospects
Our review shows that several research teams, spanning at least nine countries and four continents, are making or planning efforts to translate core DOHaD concepts to knowledge users who might make use of that knowledge through their individual behaviors. Most of these efforts have focused or are focusing on teenagers and on young care-workers-in-training. Such adolescents and young adults represent appropriate targets for DOHaD KT because they have the cognitive capacity and scaffolding to take on more complex ideas than children can, while at the same time still formulating key habits and health literacy skills, making them more likely to incorporate new ideas into sustained thought and behavior patterns than are adults in their mid 20 s and beyond.Reference Grace, Woods-Townsend and Griffiths42, Reference Brooks and Begley60 In addition, targeting adolescents means targeting the preconception health of all future parents, irrespective of their gender or whether pregnancies are planned.Reference Barker, Drombowski and Colbourn15, Reference Viner, Ozer and Denny61
Although adolescence/young adulthood indeed represents an appropriate life stage to target, so too does pregnancy. Pregnancy is well-understood to be a ‘teachable moment’ during which adults are relatively information-seeking, information-receptive and willing to engage in behavioral changes.Reference Phelan62 In addition, pregnancy health and nutrition plays a central role in shaping developmental trajectories. Yet, we found few published efforts to translate the core concepts underpinning the DOHaD hypothesis to expecting mothers, their partners or immediate supports, or couples who are planning pregnancies. The fact that expecting mothers/couples, or people planning pregnancies are not being targeted represents a surprising gap in current DOHaD KT programs, and highlights a need for further attention by researchers aiming to engage in DOHaD KT.
This gap is particularly striking given that there are clear benefits to the early efforts at DOHaD KT that have been made, which point us towards the need to further evaluate these preliminary indicators of positive effects. We found that, for all populations in which evaluations have been done, there is evidence that KT efforts have increased the target audiences’ understandings of the DOHaD hypothesis and its implications for health and well-being in the next generation(s).Reference Oyamada, Lim, Dixon, Wall and Bay38, Reference Bay, Mora, Sloboda and Morton39, Reference MacNab and Mukisa41–Reference Grace and Bay43, Reference Bay, Vickers, Mora, SLoboda and Morton45, Reference Woods-Townsend, Leat and Bay51, Reference Woods-Townsend, Aiston and Bagus53 Although there are many steps – and perhaps multiple personal and structural obstacles – between knowledge acquisition and desirable behavior changes,Reference Woods-Townsend, Aiston and Bagus53 understanding what is at stake and why it is important, reflects a necessary first condition for setting desirable behavioral change goals.Reference Hackman and Knowlden63–Reference Michie, Johnston, Francis, Hardeman and Eccles66
Another emergent theme in the literature is that the process of acquiring DOHaD knowledge through hands-on experience, self- and group- reflection, and narrative development/discussion appears to be associated with general improvements in health and science literacies and possibly in an improved sense of self-efficacy and behavioral control. This is apparent in adolescents in New Zealand and in the United Kingdom, the only populations for which these outcomes have been evaluated.Reference Bay, Mora, Sloboda and Morton39, Reference Bay, Morton and Vickers44, Reference Bay, Vickers, Mora, SLoboda and Morton45, Reference Woods-Townsend, Aiston and Bagus53 If this tendency extends to other populations, the case for direct-to-public KT of the DOHaD hypothesis will be made, in that health literacy skills and self-efficacy appear to be critical elements to resiliency and to sustained healthful behavior change, even in the face of substantial health barriers.Reference Nutbeam67 We thus suggest that approaches resembling those of LENScience and LifeLab be trialed with other populations such that we can assess the generalizability of these findings – and act on them – if they hold across contexts.
Finally, having DOHaD knowledge may be positively associated with a marker of actual behavior change, at least for the short-term in one small group of adolescents in New Zealand.Reference Bay, Mora, Sloboda and Morton39, Reference Bay, Vickers, Mora, SLoboda and Morton45 This is a tantalizing result, especially when coupled with our preliminary analyses in the M2B study showing a positive association between DOHaD knowledge and diet quality in pregnant women in Hamilton, Canada,Reference McKerracher, Rao and Moffat59 and when viewed together with the evidence that acquisition of DOHaD knowledge associates with improved health and science literacy and engagement. Together, these findings highlight clear avenues for investigation in the near future, including but not limited to: longitudinal follow up of LENScience participants to assess stability and sustainability of behavioral improvements, application to other segments of New Zealand’s adolescent population, and application to other populations in different environments.
Potential (unintended) consequences of direct-to-public DOHaD KT
Given the findings reviewed above, there are solid reasons to incorporate translation of DOHaD concepts into efforts at supporting individual behavior change to improve nutrition, health, and well-being. These efforts may support better health for the next generation(s) and reduce future health inequities.Reference Stephenson, Heslehurst and Hall12, Reference Barker, Drombowski and Colbourn15, Reference Prescott, Allen, Armstrong and Collins57, Reference Norris, Daar, Balasubramanian and Byass58, Reference Viner, Ozer and Denny61, Reference Barker, Baird and Tinati68 Nonetheless, previous work has identified a number of areas where translating DOHaD knowledge has the potential to cause social, psychological or even physical harm.Reference Richardson21–Reference Warin, Zivkovic, Moore and Davies25 These concerns include: placing undue emphasis and thus stress and blame on expecting mothers; marginalizing or minimizing the roles of pregnant women’s main supports; and, finally, taking emphasis away from the structural and policy-based factors shaping children’s environments during development.
How do we prevent blaming, shaming and stressing mothers, and marginalizing their supports?
Several research groups have raised the concern that direct-to-public DOHaD KT efforts are likely to focus their attention on pregnant women, largely to the exclusion of other individuals who shape children’s developmental environments.Reference Richardson21–Reference Warin, Zivkovic, Moore and Davies25 While our review of the evidence suggests that this prediction has not (yet) been borne out, our team and othersReference Prescott, Allen, Armstrong and Collins57, Reference McKerracher, Rao and Moffat59 are cautiously moving toward translating DOHaD knowledge to pregnant women and their partners. We thus must recognize that KT efforts targeting expecting mothers, without concurrent efforts to reach other individuals and institutional structures that influence maternal health and children’s developmental trajectories, could be problematic for a number of reasons.
Translating core DOHaD concepts to expecting mothers or to people planning pregnancies places yet another layer of psychological responsibility (essentially blame) on the shoulders of mothers-to-be.Reference Richardson21–Reference Warin, Zivkovic, Moore and Davies25, Reference Persky, McBride, Faith, Wagner and Ward28 DOHaD KT entails communicating the concept that the mother’s body is a crucial part of the environment that not only determines her children’s health through pregnancy, birth and infancy – as most expecting mothers are already very well awareReference Winett, Wallack, Richardson, Boone-Heinonen and Messer22, Reference Winett, Wulf and Wallack24 – but also that maternal effects persist through adolescence and adulthood. Placing disproportionate responsibility for children’s lifelong health on individual mothers-to-be is morally troublesome, is exclusionary to other individuals instrumental in shaping children’s development, and may have negative biological consequences for mothers- and children-to-be.
Placing responsibility solely or primarily on mothers for children’s health for their entire lifecourse is an inequitable and thus unfair process, with some mothers much more likely than others to have children who do not follow ‘healthy’ life trajectories.Reference Ismaili M’hamdi, de Beaufort, Jack and Steegers23 Many aspects of the environment are beyond the control of mothers, or of parents in general.Reference Winett, Wulf and Wallack24 Key early life environmental factors understood to influence children’s developmental trajectories and later-life health and disease risk include diet quality, exposure to environmental contaminants and pathogens, and exposure to a variety of psycho-social and other stressors.Reference Heindel, Balbus and Birnbaum69 People, communities and countries of lower socioeconomic status are often unable to prevent nutritional shortfalls, to avoid environmental contaminants, or to avoid (or reduce) psychological and/or physiological stress in the environments in which children are conceived and begin to develop. Notably, where and in what socioeconomic circumstances a person is born is due primarily to chance and is thus morally arbitrary, and any related inequalities are unfair and unjust.Reference Marmot and Bell70
Attributing sole or primary responsibility for children’s early life development to mothers ignores the roles of fathers, grandparents, extended families, teachers and community health workers, among others. It is becoming well-established that particularly fathers have direct, biological impacts on the health of their developing children.Reference Soubry71 The pre-conception health status of men influences sperm development and function which, following conception, can affect fetal development through changes in placental growth and function.Reference Fleming, Watkins and Velazquez72, Reference Hur, Cropley and Suter73 These effects appear independent of the sizable effects fathers-to-be and other household members can have on a developing fetus via their influences on a pregnant woman’s diet, or on her overall health and well-being. Failing to include fathers and/or other supports in DOHaD KT not only prevents them from making informed decisions regarding their impacts on the health of the pregnant women they support, but also leaves them feeling alienated, undervalued and underprepared.Reference Steen, Downe, Bamford and Edozien29–Reference Sternberg and Hubley31, Reference Fleming, Watkins and Velazquez72–Reference Simkhada, Porter and van Teijlingen74 This alienation can then result in tangible barriers to care and well-being for women, both before and during pregnancy.Reference Simkhada, Porter and van Teijlingen74 Moreover, engaging with and developing interventions for men with respect to reproductive health appears to be an effective and necessary complement to engaging with women on these same issues, and to promoting gender equity in reproductive health and childrearing spheres.Reference Sternberg and Hubley31
There are also known biological/health consequences of placing undue responsibility on women. The psychological burden of knowing that health behaviors affect not only one’s own quality of life but also the health of one’s children is experienced as a source of ‘anxiety’Reference Robinson, Pennel and McLean75 or ‘distress’Reference Jette and Rail76 by some expecting mothers. Acute stress during pregnancy has negative consequences for mothers, increasing risks of depression, anxiety and self-harm.Reference Schetter and Tanner77–Reference Robinson, Pennel, McLean, Oddy and Newnham79 Maternal psycho-social stress during pregnancy – especially if that stress is specific to concerns about the experience of pregnancy – is associated also with poorer physiological outcomes for children, including higher risks of preterm birth, of being born small-for-gestational-age, and of developing hyper-reactive stress axes.Reference Robinson, Pennel and McLean75, Reference Schetter and Tanner77, Reference Van den Bergh, van den Heuvel and Lahti78 Given this, DOHaD KT to pregnant women, if not done carefully, risks compounding psycho-social stress, causing harm to mothers- and children-to-be.
So, there appear to be both pragmatic and moral reasons to be cautious about translating DOHaD knowledge directly to mothers-to-be. However, it also must be acknowledged that the pregnant population is relatively receptive to learning and using new ideas, especially when related to health and diet.Reference Phelan62 Most expecting parents genuinely want up-to-date information about health and nutrition, and also want guidance in assessing the quality of the pregnancy health and nutrition information available, in what are often complex informational landscapes.Reference Jette and Rail76, Reference Keenan and Stapleton80 Failure to engage with such a receptive audience may miss an opportunity to affect positive psychological and/or behavioral changes.
In keeping with this, a number of studies demonstrate that mothers-to-be want access to concise and accessible guidance on pregnancy health and nutrition. For example, a study carried out with 60 pregnant women from Northern England found that many participants would have liked more information about gestational weight gain, weight management, and diet during pregnancy. They were frustrated that their care providers seemed reluctant to discuss pregnancy weight and nutrition with them.Reference Keenan and Stapleton80 Similarly, in a qualitative study of 15 mothers-to-be in Montreal, Canada, several participants indicated that they had received little or no pregnancy weight gain or nutritional guidance from their primary care providers, despite the fact that most of the study participants were dealing with challenges related to food insecurity and/or obesity.Reference Robinson, Pennel and McLean75 In a Pennsylvania-based study, 24 overweight or obese pregnant participants reported having received little guidance from their care providers with respect to gestational weight gain and were angry or exasperated about the lack of guidance offered.Reference Stengel, Kraschnewski, Hwang, Kjerulff and Chuang81
Failing to actively disseminate crucial information regarding pregnancy nutrition recommendations appears problematic, even paternalistic. As such, knowledge translators need to strike a balance between information overburdening and failure to communicate valuable and desired information. Simultaneously making information available to mothers while also looking ‘beyond the [maternal-child] dyad’Reference Pentecost, Ross and MacNab82 to include other influences on children’s development, paying particular attention to the role of public policy in shaping nutritional environments, may be one way forward.
Distraction from the structural factors that really matter?
The second major theme arising from literature critical of early efforts at direct-to-public DOHaD KT concerns the diversion of attention away from institutions and policies that structure peoples’ and populations’ access to resources.Reference Richardson21, Reference Tarasuk and Beaton35 Such structural factors in large part determine the parameters of children’s developmental environments.Reference Patel33, Reference Marmot83–Reference Popkin, Adair and Ng85 Since time and other resources are finite, KT requires tradeoffs,Reference Riley, Norman and Best86 such that researchers engaged in efforts toward developing, evaluating, maintaining, improving and expanding excellent direct-to-public programs like the UK’s LifeLab, New Zealand’s LENScience, and Uganda’s Health Promotion in Schools by definition have relatively less time, money, personnel and expertise to devote to informing policy or transforming institutions.
As mentioned previously, the main aspects of the environment known to influence children’s development include nutrition, infection and contaminant control, and psycho-social stress risks.Reference Heindel, Balbus and Birnbaum69 Of these environmental factors, we focus on the structures around nutrition because the evidence base for the crucial role of nutrition in a wide variety of NCDs is particularly strong.Reference Barker and Osmond7, Reference Popkin, Adair and Ng85, Reference Roseboom, van der Meulen and van Montfrans87, Reference Solomons88
Twenty-first century nutritional environments are largely determined by factors related to distribution, access and marketing rather than production and supply.Reference Mahoney89 That is, most foods are produced in quantities sufficient to feed all of the world’s people adequately in energy, in nutrient-density, and in diversity.Reference Patel33, Reference Popkin, Adair and Ng85 However, whether and in what quantities nutritious foods make it to different countries, regions, communities, neighborhoods or individual tables is highly variable, contingent on policies in multiple spheres.Reference Patel33, Reference Mahoney89, Reference Ruel and Alderman90 Key policy spheres include: (international) trade and tariffs on consumable goods; domestic food and agricultural subsidy, taxation and regulation; corporate (e.g. transnational food corporations) taxation and regulation; funding allocations to public health and preventative medicine; regulation of transportation and mobility infrastructure; subsidy of child care/education costs, and/or support of parental leave; gender equity; and employment (e.g. job security, livability of wages).
To date, DOHaD knowledge is being transferred to – and even brought on by – public health institutions in numerous countries91 and appears to have influenced key aspects of goal-setting in the arena of global health and well-being (namely, 2015’s Sustainable Development Goals).Reference Baye92 However, to our knowledge, no researchers have yet made efforts to relay DOHaD-related messaging to institutional leaders in the other major policy spheres responsible for the distribution of access to nutritious food, and thus the nutritional environments in which children develop. Without coordinated support from agriculture, corporate regulation, education, employment, gender equity and transportation sectors, public health is constrained in its capacity to reduce inequities among the nutritional environments in which children develop.Reference Patel33, Reference Baum93 As such, other relevant institutions should place gaining an understanding of the core principles of the DOHaD hypothesis onto their agendas. This approach will likely pay dividends with respect to lowering the NCD burden (and its massive human and financial costs) on the public health sector, while also being of benefit to the other sectors.Reference Barnes, Heaton, Coates and Packer13, Reference Barker, Baird and Tinati68, Reference Heckman and Mosso94, Reference Legler, Fletcher and Govarts95 We expect this to be the case insofar as understanding and being able to accurately predict a population’s health sits near the center of planning in most policy and regulatory spheres.
Implications, and next steps for DOHaD researchers engaged in KT
We reviewed published reports by researchers on their efforts to transfer understandings of the DOHaD hypothesis directly to individual people. In particular, we focused on KT efforts targeting people who may use such understandings in their own motivations/behaviors (in roles as future parents and/or as supports of future parents) to improve the health of the next generation. Such efforts have been established in several countries (Cook Islands, Japan, New Zealand, Tonga, United Kingdom, Uganda) and are being launched in a few more (Australia, Canada, South Africa). Surprisingly few of these systematically relay the main tenets of the DOHaD hypothesis to people planning pregnancies in the immediate future or to expecting parents. Rather, most of the direct-to-public DOHaD KT programs established to date have focused on adolescents and young adults, mainly in New Zealand, Uganda and the United Kingdom. These efforts to engage with young people are essential, and seem to be paying off. In at least some contexts, they have been associated with improvements not only in recipients’ understandings of DOHaD concepts but also in their health literacy, their general self-efficacy, and perhaps even their ability to achieve health goals.Reference Bay, Yaqona and Barrett-Watson37–Reference Grace, Woods-Townsend and Griffiths42, Reference Bay, Vickers, Mora, SLoboda and Morton45, Reference MacNab and Mukisa55
Yet, despite these early indications of success (especially in the efforts targeting young people), previous critiques of direct-to-public DOHaD KT have leveled at least two main criticisms against it. The first of these is that direct-to-public KT efforts have the potential to negatively and disproportionately impact a vulnerable population (i.e. expecting mothers), should they focus too heavily on the role of expecting mothers in shaping children’s environments, and thereby neglect other influences on those environments. The second is that researchers engaged in direct-to-public KT efforts have fewer resources to direct to ‘big picture’ structural factors (institutions, policies) that largely determine developmental environments, developmental trajectories, disease risks over the lifecourse and long-term health outcomes.Reference Donkin, Goldblatt, Allen, Nathanson and Marmot2, Reference Riley, Norman and Best86 These criticisms, when taken together with our review of the current state of DOHaD KT efforts, highlight several routes through which researchers interested in DOHaD KT may move forward.
Our first recommendation is that we build on and expand the strategies already proving successful, which focus on youth via school-based engagement. This youth focus is crucial, given that at least half of pregnancies globally are unplanned. In addition, outside of the Global North, many marriages and first births occur in adolescence. As such, improving preconception and early pregnancy health in a meaningful way requires ensuring that knowledge and resources to support preconception health are available to young people of all genders by early adolescence and can then be carried forward through the remainder of adolescence and adulthood.Reference Barker, Drombowski and Colbourn15, Reference Viner, Ozer and Denny61
Second, we recommend that people planning pregnancies and expecting parents should have ready access to the knowledge that health and nutrition before and during pregnancy impacts the long-term health and well-being of children. While potentially stressfulReference Marmot and Bell70 if not accompanied by equitable access to resources necessary to use this knowledge,91 evidence suggests that expecting mothers – including those living in challenging (e.g. food insecure) environments – want reliable information from health authorities about nutrition, weight gain, and health during pregnancy.Reference Persky, McBride, Faith, Wagner and Ward28, Reference Jette and Rail76, Reference Keenan and Stapleton80, Reference Stengel, Kraschnewski, Hwang, Kjerulff and Chuang81, Reference Tarasuk96–Reference Harper and Rail97 Thus, health researchers and health care workers should be thoughtful but not fearful of discussing these issues with expecting couples. One strategy for making DOHaD knowledge accessible to expectant mothers is to deliver this knowledge concurrently with the message that fathers and grandparents also share biological responsibility for children’s developmental trajectories and health.Reference Winett, Wulf and Wallack24 A further concurrent message should be that public institutions hold the lion’s share of moral responsibility for ensuring environmental nutrition/health equity. This approach might partly mitigate feelings of blame, shame and pregnancy-specific stress predicted to result from DOHaD KT. Mothers-to-be can be assured that, although they have some capacity to improve their children’s developmental environments, their bodies and behaviors comprise only a small piece of a large and complex environmental puzzle.Reference Winett, Wulf and Wallack24, Reference Pentecost, Ross and MacNab82
Third, we suggest that efforts to transfer DOHaD knowledge to the public should specifically include individuals other than mothers who impact children’s development, either via their own health status or via their direct impacts on maternal pre-conceptional/pregnancy health and nutrition. Actively tailoring messages to knowledge users like fathers-, partners- or grandparents-to-be will help support these individuals to feel included and connected with the pregnancy health experience and with the child’s development and health over the life course.Reference Steen, Downe, Bamford and Edozien29–Reference Sternberg and Hubley31 This will also send a signal to expectant mothers that they are not alone in their roles as buffers against their children’s later-life NCD risk.Reference Winett, Wallack, Richardson, Boone-Heinonen and Messer22, Reference Winett, Wulf and Wallack24, Reference Warin, Zivkovic, Moore and Davies25, Reference Pentecost, Ross and MacNab82 Similarly, community care workers like public/community health nurses, prenatal nutritionists, early childhood educators, family physicians, midwives, and social workers should also be brought into the conversation as much as possible. If such efforts are combined with attempts to include DOHaD knowledge as part of educational health science curricula targeting youth (like in LENScience or Health Promotion in Schools programming) and broader public health outreach efforts, the messaging will, ideally, come as a cultural shift in health knowledge and literacy, rather than as a strategy to blame, shame, and control the bodies of women in general and expecting mothers in particular.
Fourth, we call for a positive, empowering frame to be used in direct-to-public DOHaD KT efforts. The DOHaD hypothesis is a conceptual tool offering salient and perhaps motivating reasons to adhere to preconception, pregnancy, and infancy health guidelines. That being said, DOHaD may be psychologically demotivating if not framed appropriately: it is an acronym for a phrase that includes the prescriptive idea of ‘origins’ (suggesting irreversibility) and ‘disease’ (suggesting negative outcomes). A result of this is that DOHaD messaging can feel scary, negative and inalterable.Reference Patel33 We suggest, then, that knowledge translators should do their best to use positive language – focusing on health instead of disease, focusing on the development of the lifecourse trajectory instead of origins. It would likely be beneficial to draw on metaphors and perspectives from non-biomedical ways of thinking about the world to do this, especially for some groups of knowledge users.Reference MacNab and Mukisa55 While appeals to fear can sometimes be effective in public health messaging, that is only the case if these appeals are presented together with messages underlining what can be done, what resources are available, and what benefits can accrue from behavior changes.Reference Witte and Allen98–Reference Watson, Macaulay and Lamont102
Fifth, we argue for a full multi-level, multi-pronged approach to DOHaD KT. All direct-to-public KT efforts should not only target multiple, receptive populations, but should also be done in parallel with efforts to remodel the structural factors driving inequities among prospective parents. This is obviously a complex endeavor, especially since researchers engaged in direct-to-public KT are likely to have few resources to direct towards affecting changes in public policy. However, it is a necessary endeavor: with all the informational and motivational tools in the world at their fingertips, prospective parents and their supports cannot radically change the nutritional environments of their future children if they cannot afford nutritious food, if they cannot transport nutritious food to their homes, if they do not have adequate time to prepare nutritious food.Reference Tarasuk96 As such, we need to ensure that the policy leaders and makers, and those institutions responsible for structuring the distribution of wealth within a population, understand that this distribution will have tangible impacts on the health, wellbeing, resilience and productivity of the population across generations. Pragmatically, researchers doing basic biological/medical science may need to dedicate some resources to KT, including policy-oriented KT, by working in multi-disciplinary teams that include social scientists, and knowledge users. The evidence is clear and abundant that improving the early life environment results in health and resiliency over the lifecourse. Disseminating this simple – but pivotal – idea as soon as possible to the people and structures that can use it must be made our top priority.
Acknowledgments
The authors gratefully acknowledge members of the Sloboda Lab, the Atkinson lab, and Dr. Tracey Galloway for thoughtful comments and discussion that inspired the drafting of this manuscript.
Financial Support
This work was supported by the Canadian Institutes for Health Research (CIHR Team Grant: 2004-332) and by the Canada Research Chairs Program (Tier 2, Chair in Perinatal Programming, McMaster University).
