Healthy Start Workforce Project introduced to the world

27 November 2015

The Healthy Start Workforce Project was under the spotlight at the recent international Developmental Origins of Health and Disease Congress.


The team presented at the prestigious conference in South Africa in November outlining various facets of the programme.


Our science advisor, Dr Anne Jaquiery, spoke in a session on “nutrition in migrating populations” about the metabolic effects of erratic eating.


Meanwhile, our research fellow, Dr Caroline Gunn, presented a poster about the policy context surrounding the Healthy Start Workforce Project and another on the comprehensive literature review that underpins the Healthy Start Workforce Project’s education programme.


Dr Gunn’s paper exploring the policy context in which the Healthy Start Workforce Project was implemented found that the need to address the developmental origins of health is increasingly recognised by governments around the world.


It went onto say that, “The Healthy Start Workforce Project offers a sustainable workforce development solution that could be translated into action in other countries.”


Dr Gunn’s paper exploring the literature review that underpins the project’s work highlighted the crucial importance of nutrition and physical activity during pregnancy for the infant’s long-term health.


It concluded that, “Maternal workforce education must prioritise and reflect current research evidence demonstrating the compelling need for healthy eating and physical activity during pregnancy and early life for long-term individual and societal health and economic benefits.”


Also in attendance at the conference was Dr Wendy Lawrence, who has helped to set-up the Healthy Conversation Skills training included in our workforce education. 


She spoke to a session about the importance of these skills in finding solutions to health problems or challenges faced by patients.


Dr Lawrence advised health practitioners to be more interactive with the patients by asking open discovery questions (i.e. what and how?) and to listen to the patients and show empathy in order to “explore” the patient’s world.


She recommended that they be less judgmental or interrogative, stop making assumptions, and stop telling patients what to do!


For more on the DoHaD conference, read our round-up of some of the key papers and sessions presented at this year.


Early Life Exposures and Later Outcomes

The principles of DOHaD describe how early life exposures in conception, pregnancy, infancy and childhood can have a significant impact on health and disease risk in later life. The presenters in this session sought to answer the above question by highlighting how early life environments affect children’s developmental outcomes such as body composition, cognition and cardio metabolism.


These were some of the findings reported by the speakers:

• Among indicators of physical development at birth, only head-circumference was the most prominent predictor of intelligence as measured by levels of IQ IN 1 year olds.

• It was reported that maternal HIV status was not associated with any outcomes. However, higher maternal cognitive ability improved cognition in boys and girls. Furthermore, it was reported that boy exclusive breast feeding (i.e. more than one year) had long-term benefits on cognition.

• Early life exposures such severe acute malnutrition have adverse long-term effects on children’s physical development (i.e. stunting, body composition associated with increased risk of cardio metabolic disorders and functional impairments).

• Methylation variations of the SLC6A4 gene in the umbilical cord were associated with differences in childhood adiposity as measured by % fat-mass and triceps skinfold.

• The Pune Maternal Nutrition Study (PMNS) showed that measuring femoral length from 18 weeks of gestation can predict stunting at 18 years.

• In the New Delhi Cohort it was found that mother-child versus father-child associations were stronger predictors of cardio metabolic risk, which they postulated to be due to an intergenerational transfer through intra-uterine programming.


DOHaD and Nutrition:

Are we doing enough to improve birth and long-term outcomes through maternal nutrition?


During this session, an overview of the current evidence on the role of nutrition in optimising short and long term infant outcomes was provided and key gaps in the research were identified for future prioritisation in this area.


Maternal micronutrient supplementation has well-documented effects on fetal growth and birth outcomes; however, each intervention (balanced protein-energy, iron-folate and multiple micronutrient supplementation) addresses individual nutritional causes of fetal growth restriction. It is important to start considering interventions in combination, rather than as independent of one another, as nutrient deficiencies are generally found in undernourished settings where they present as multiple, rather than single deficiencies. By doing so, we may begin to see the additive effects of providing a comprehensive package of interventions to vulnerable pregnant women, rather than the beneficial, but perhaps limited, effects of isolated interventions.


Additionally, and particularly relevant for DOHaD, evidence for the medium/long term health benefits of early life micronutrient interventions in humans is limited and existing follow-up studies have focused on periods of the life course when overweight/obesity and cardio metabolic risk is still low, i.e. during childhood/adolescence. If we are to gain a deeper understanding of the associations between early pregnancy nutrition and health risk across the life course, preconception and antenatal interventions need more and longer term follow-up, particularly in low-middle income undernourished and transitioning populations.


DOHaD and Epigenetics

This session explored the relationship between genetics, epigenetics and the effects on offspring phenotype. Epigenetics is defined as changes in the genome that can affect gene expression without altering gene sequence.


Matt Silver discussed nutritional epigenetics in The Gambia. He found seasonal variation in post-pubertal survival, which was 10 times lower in the rainy season compared to the dry season. He also reported increased methylation in rainy vs dry season pregnancies, and methylation was associated with maternal 1-carbon nutrient biomarkers.


Rebecca Richmond used Mendelian randomization to try and understand if there is a causal effect between maternal BMI and offspring BMI. Her study aimed to use large sample sizes and a genetic risk score using multiple SNP’s other than just FTO, which has been used in previous studies. She reported that a greater variation of maternal BMI on fetal BMI could be explained by those extra SNP’s than by using FTO alone. She reported no evidence that maternal pre-pregnancy BMI was transferred to offspring BMI once maternal genotype was considered. This was similar to previous findings.


Nicole Warrington aimed to understand genetic influences on gestational weight gain. She found that the maternal genome explained maternal weight gain while the fetal genome was associated with fetal weight gain. The novel PSG5 locus was identified as having genome wide significance for gestational weight gain in the offspring genome. A substantial proportion of the variability in weight gain could be explained by common genetic variation (30-40%). Three shorter presentations were then given; Lauren Capron discussed placental gene expression and maternal distress and found no associations, however an ethnicity interaction was seen. The sample size could have limited her conclusions and so further work is needed. Vanessa Pataia investigated the effect of paternal cholestasis on sperm damage and found an association using a mouse model. Offspring had increased body weight, decreased subcutaneous fat and increased cholesterol.


Kozeta Miliku showed that genetic variance associated with kidney function in adults, was also associated with kidney function in children, however microalbuminuria was not associated in children. Functional studies may establish causal genes andmechanisms underlying these


Breastfeeding: Putting Science into Practice

Four breastfeeding research luminaries presented a fascinating global overview of breastfeeding patterns and trends, determinants, and intervention evidence.


The session chair, South Africa’s own Jerry Coovadia, began by highlighting that the study of breastfeeding is largely a question of science trying to catch up with what we already know, that breastfeeding is beneficial to both infant and mother. This argument was substantiated by Victora’s overview of the findings of 28 systematic reviews on breastfeeding just published in Acta Paediatrica (Supplement, Dec, 2015). Coovadia also intimated that the practice of breastfeeding is under threat.


Using South Africa as an example, he highlighted how fear of HIV transmission alongside aggressive marketing by the formula industry has resulted in suboptimal breastfeeding. The threat of industry also was evident in data Rollins presented on the economic value of the formula market, particularly in emerging markets.


The formal presentation began with Professor Victora, who gave participants a sneak-peak of data on global patterns and trends of breastfeeding, which will be published in The Lancet early next year.


Linda Richter’s presentation followed, providing rich insight into why we find such large variations in breastfeeding practices over time and between populations. Using data from the 1970s until mid-2014 and an ecological approach, she presented a range of determinants from individual beliefs, e.g. milk insufficiency and family support to the ways our societies are structured in terms of social norms, labour (more women working), policies (maternity leave), health systems (training of workers), and market economies where formula continues to be marketed aggressively.


Rollins then provided evidence from a review of breastfeeding interventions that have targeted health systems, home/family environments, work environments and combinations thereof. While impact has varied, the evidence shows that combined interventions have the best results, but that the mix needs to vary by context. The results also give hope that practices can be changed, albeit against a backdrop of industry marketing and poor enforcement of the Code against the Marketing of Breastmilk Substitutes. Though the challenges of shifting breastfeeding practices were highlighted by all of the presenters, the overall tenor of the session was one of passion, determination and hope, guided centrally by a desire to improve the health outcomes of both children and their mothers.


Maternal ante- and post-natal depression and its impact

This year maternal mental health had its own session, a sign of the recognition of its significance in the DOHaD conversation.


Maternal depression has been linked to several adverse offspring outcomes such as poor growth, behavioural problems and poor emotional adjustment. Paul Ramchandani opened the session by summarising pertinent work done on the impact of antenatal depression (AND) on offspring outcomes. According to Paul the most exciting research questions for mental health in the next decade include establishing the extent to which the link between maternal depression and offspring outcomes is causal, and unpacking the mechanisms through which they are linked.


The other presentations covered both the risk factors for and effects of maternal depression. The prevalence of postnatal depression (PND) is quite high in India as reported by Meera Gandhi. Several social factors increase the risk of maternal depression in Indian slums, with more educated women being less at risk. In rural South Africa depression is highly prevalent among HIV positive pregnant women, with HIV diagnosis during pregnancy increasing the risk.  Rates of parenting stress are also high in HIV positive women, however these associations may be quite complex as risk factors for one disorder may be protective against another.


Dietary quality is also associated with PND as seen in the Norwegian study MoBa, as is pre-pregnancy obesity according to a study from University of Helsinki. The latter is attenuated by depressive symptoms during pregnancy.


Results from the ALSPAC Study in the UK show that both maternal ante- and post-natal depression are associated with depression in the offspring at 18-years of age. After adjusting for the sex of the offspring, ante-natal depression increased the risk of depression in girls more than in boys and vice versa for the boys. Maternal postnatal depression is also linked to offspring anxiety disorder at 18 years. A Californian study shows that AND is more strongly associated with persistent than transient
offspring obesity. The general consensus among the researchers present was the need for further work to elucidate causality pathways. 



                                                                                                                                                                Source: DoHAd newsletters