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Intervention strategies to improve nutrition and health behaviours before conception


Abstract and Figures

The nutritional status of both women and men before conception has profound implications for the growth, development, and long-term health of their offspring. Evidence of the effectiveness of preconception interventions for improving outcomes for mothers and babies is scarce. However, given the large potential health return, and relatively low costs and risk of harm, research into potential interventions is warranted. We identified three promising strategies for intervention that are likely to be scalable and have positive effects on a range of health outcomes: supplementation and fortification; cash transfers and incentives; and behaviour change interventions. On the basis of these strategies, we suggest a model specifying pathways to effect. Pathways are incorporated into a life-course framework using individual motivation and receptiveness at different preconception action phases, to guide design and targeting of preconception interventions. Interventions for individuals not planning immediate pregnancy take advantage of settings and implementation platforms outside the maternal and child health arena, since this group is unlikely to be engaged with maternal health services. Interventions to improve women's nutritional status and health behaviours at all preconception action phases should consider social and environmental determinants, to avoid exacerbating health and gender inequalities, and be underpinned by a social movement that touches the whole population. We propose a dual strategy that targets specific groups actively planning a pregnancy, while improving the health of the population more broadly. Modern marketing techniques could be used to promote a social movement based on an emotional and symbolic connection between improved preconception maternal health and nutrition, and offspring health. We suggest that speedy and scalable benefits to public health might be achieved through strategic engagement with the private sector. Political theory supports the development of an advocacy coalition of groups interested in preconception health, to harness the political will and leadership necessary to turn high-level policy into effective coordinated action.
Content may be subject to copyright. Published online April 16, 2018
Preconception health 3
Intervention strategies to improve nutrition and health
behaviours before conception
Mary Barker, Stephan U Dombrowski, Tim Colbourn, Caroline H D Fall, Natasha M Kriznik, Wendy T Lawrence, Shane A Norris, Gloria Ngaiza,
Dilisha Patel, Jolene Skordis-Worrall, Falko F Sniehotta, Régine Steegers-Theunissen, Christina Vogel, Kathryn Woods-Townsend, Judith Stephenson
The nutritional status of both women and men before conception has profound implications for the growth,
development, and long-term health of their ospring. Evidence of the eectiveness of preconception interventions for
improving outcomes for mothers and babies is scarce. However, given the large potential health return, and relatively
low costs and risk of harm, research into potential interventions is warranted. We identified three promising strategies
for intervention that are likely to be scalable and have positive eects on a range of health outcomes: supplementation
and fortification; cash transfers and incentives; and behaviour change interventions. On the basis of these strategies,
we suggest a model specifying pathways to eect. Pathways are incorporated into a life-course framework using
individual motivation and receptiveness at dierent preconception action phases, to guide design and targeting of
preconception interventions. Interventions for individuals not planning immediate pregnancy take advantage of
settings and implementation platforms outside the maternal and child health arena, since this group is unlikely to be
engaged with maternal health services. Interventions to improve women’s nutritional status and health behaviours at
all preconception action phases should consider social and environmental determinants, to avoid exacerbating health
and gender inequalities, and be underpinned by a social movement that touches the whole population. We propose a
dual strategy that targets specific groups actively planning a pregnancy, while improving the health of the population
more broadly. Modern marketing techniques could be used to promote a social movement based on an emotional and
symbolic connection between improved preconception maternal health and nutrition, and ospring health. We
suggest that speedy and scalable benefits to public health might be achieved through strategic engagement with the
private sector. Political theory supports the development of an advocacy coalition of groups interested in preconception
health, to harness the political will and leadership necessary to turn high-level policy into eective coordinated action.
In 2016, the UN committed to “end all forms of
malnutrition, including achieving, by 2025, the
internationally agreed targets on stunting and wasting
in children under 5 years of age, and address the
nutritional needs of adolescent girls, pregnant and
lactating women, and older persons” in target 2·2 of
Sustainable Development Goal 2.1 Growth and
development targets for children, and the consequent
reduction in their risk of non-communicable disease in
adulthood, could be achieved through improving
women’s nutritional status and health behaviour before
conception.2 Two previous Lancet Series have called for
innovation in the design and delivery of aordable,
scalable nutrition interventions to improve maternal
and child health.3,4 In this Series paper, we review what
is known about the eectiveness of preconception
nutritional and behavioural interventions, and propose
a strategy for aligning interventions with individual
motivation and receptiveness at dierent preconception
action phases during the life course. We propose a
dual strategy targeting health improvement in men
and women planning a pregnancy, and in the general
population, on the basis that improvements in pre-
conception health require a supportive environment
(under pinned by a social movement and policy
initiatives), and on the engagement of the private sector.
Intervention strategies
We conducted a quasi-systematic review of trials of
preconception nutrition and health behaviour inter-
ventions, to identify eective interventions and specify
pathways to eect (appendix). We included interventions
assessing nutritional status and body composition
outcomes, excluding other clinical outcomes such as
improved glycaemic control. Pathways to eect were
Published Online
April 16, 2018
This is the third in a Series of
three papers about
preconception health
MRC Lifecourse Epidemiology
Unit, University of
Southampton, Southampton
General Hospital,
Southampton, UK
(M Barker PhD,
Prof C H D Fall DM,
W T Lawrence PhD, C Vogel PhD);
NIHR Southampton Biomedical
Research Centre, Southampton
General Hospital,
Southampton, UK
(M Barker, W T Lawrence, C Vogel,
K Woods-Townsend PhD);
Faculty of Natural Sciences,
Division of Psychology,
University of Stirling, Stirling,
UK (S U Dombrowski PhD); UCL
Institute for Global Health
(T Colbourn PhD, G Ngaiza PhD,
J Skordis-Worrall PhD), and UCL
EGA Institute for Women’s
Health, Faculty of Population
Health Sciences (D Patel MSc,
Prof J Stephenson FFPH),
University College London,
London, UK; The Healthcare
Key messages
Epidemiological data, and findings from developmental biology, suggest that
intervening to improve men’s and women’s nutritional status before pregnancy
improves long-term outcomes for mothers and babies
Trials of interventions to improve nutritional status before conception and birth
outcomes are scarce, but new trials are underway
Effective preconception nutritional interventions include supplementation or food
fortification to provide micronutrients, particularly folic acid and iodine
To maximise benefit and achieve health growth trajectories in the next generation,
preconception strategies should be broader than supplementation or fortification,
and address wider determinants of health
Motivations to engage with preconception nutrition differ according to age and life
phase; understanding and harnessing these motivations is key to successful intervention
Interventions should be context-specific and make use of existing platforms for delivery
Preconception interventions need to be supported by a social movement and political
will, both of which require skilful engagement with powerful commercial interests
2 Published online April 16, 2018
then incorporated into a life-course framework to aid the
targeting of interventions. Preconception interventions
were reviewed using the reach, eectiveness, adoption,
implementation, and main tenance (REAIM) framework.5
Finally, we applied a consumer-marketing approach to
the challenge of creating a social movement to strengthen
political resolve for wide-scale intervention.
We identified 14 controlled primary studies evaluating
three strategies: supplementation and fortification, cash
transfers or incentives, and behaviour change intervention.
We did not identify enough good quality studies conducted
in the preconception period to enable us to perform
a meta-analysis or draw firm conclusions about eective-
ness; however, epidemiological and biological evidence
points to the value of intervening prior to conception.
Intervention strategies were selected for review on the
basis of being scalable, low risk, and of likely benefit to
nutritional outcomes in the preconception period. We
developed a model describing the key pathways to be
quantified once more high quality data from randomised
trials become available (figure 1).
Supplementation and food fortification
Most evidence for the benefits of improving precon-
ception nutrition and health comes from trials examining
the eects of micronutrient and energy supplementation.
The Bacon Chow study,6 done in Taiwan, found that
supplementing the diets of women who were under-
nourished with 800 kcal and 40 g protein per day after the
birth of their first baby increased birthweight of the
second baby when compared with a control group given
just 80 kcal extra per day. A similar study in the USA7
also found increased birthweight of subsequent babies
among women given supplements for 5–7 months
following the birth of their first baby, compared with
those given supplements for up to 2 months. The
Mumbai Maternal Nutrition Project8,9 showed that a
locally sourced, micronutrient-rich snack, given daily
before conception and during pregnancy, reduced the
likelihood of gestational diabetes and increased
birthweight in a high-risk Indian population (but only
among mothers who were not underweight). These
studies represent the best available evidence for the
benefits of preconception nutritional supplemen tation.
Eective strategies to improve access to additional
calories before conception still need to be identified in
contexts where maternal undernutrition is common.
Supplementation interventions are generally accept-
able to women, but uptake is often hampered by poor
adherence. Several solutions have been proposed, in-
cluding a contraceptive pill containing folic acid available
in the USA;10,11 however, the impact of this solution
depends on contraceptive pill use, which varies widely
between countries. Fortifying foods such as flour or rice
has wide potential reach, and is currently mandated in
87 countries.12 The WHO has also issued a guideline for
the fortification of salt with iodine, which can prevent
irreversible mental impairment of the fetus.13 In
addition, reductions in the prevalence of neural tube
defects have been observed following mandatory folic
acid fortification in Canada, Chile, Costa Rica, South
Africa, and the USA.14,15 However, folic acid forti-
fication is not mandatory in Europe; in the UK,
there are concerns about increasing cancer risk in
older populations, potential masking of anaemia
caused by vitamin B12 deficiency, and removal of
individual choice.14 Despite these concerns, there is
little evidence of negative eects from folic acid
fortification.16 The UK’s Scientific Advisory Committee
on Nutrition continues to recommend mandatory folic
Improvement Studies Institute,
University of Cambridge,
Cambridge, UK
(N M Kriznik PhD); MRC
Developmental Pathways for
Health Research Unit,
Department of Paediatrics,
School of Clinical Medicine,
Faculty of Health Sciences,
University of the
Witwatersrand, Johannesburg,
South Africa
(Prof S A Norris PhD); Institute
of Health and Society,
Newcastle University and Fuse,
the UK Clinical Research
Collaboration Centre of
Excellence for Translational
Research in Public Health,
Newcastle upon Tyne, UK
(Prof F F Sniehotta PhD);
Department of Obstetrics and
Gynaecology, and Department
of Pediatrics, Division of
Neonatology, Erasmus MC,
University Medical Center,
Rotterdam, Netherlands
(Prof R Steegers-Theunissen PhD);
and Southampton Education
School, Faculty of Social and
Human Sciences, University of
Southampton, Southampton,
UK (K Woods-Townsend)
Correspondence to:
Prof Judith Stephenson, UCL EGA
Institute for Women’s Health,
Faculty of Population Health
Sciences, University College
London, Medical School
Building, 74 Huntley Street,
London WC1E 6AU, UK
See Online for appendix
Pregnancy trimester
First Second Third
1 month 6 months 12 months 24
Conception Birth
Risk factors
Maternal nutrition
(BMI <18)
(BMI 18–25)
(BMI 25–30)
(BMI >30)
Interventions Mechanisms Outcomes
Increased calorie
Increased micronutrient
consumption (including
fruit and vegetables)
Decreased calorie
Food/fortification and
Cash transfers or
Socioeconomic status
Behaviour change
maternal BMI
maternal BMI
Decreased neonatal
Increased WAZ, HAZ, WHZ
Improved early childhood
Addresses undernutrition
Addresses overnutrition
Figure 1: Conceptual model of pathways between interventions to improve maternal nutritional status and maternal and infant outcomes
BMI=body-mass index. WAZ=weight-for-age Z score. HAZ=height-for-age Z score. WHZ=weight-for-height Z score.
Series Published online April 16, 2018
acid fortification to improve the folate status of women
most at risk of neural tube defect-aected pregnancies.16
Cash transfers and incentives
None of the studies identified investigated the eects of
preconception cash transfers on birth or nutritional
outcomes. However, this strategy was included in the
model because cash transfers are eective in improving
school enrolment and attendance among girls, access to
preventive health care, and household food consumption
in low-income settings.17–19 These factors are risks for
poor birth and nutritional outcomes, suggesting that
preconception cash transfers could be useful.20,21 In high-
income settings, further work is needed to demonstrate
the eectiveness and acceptability of combating over-
weight and obesity through incentivising the purchase of
healthy foods.
Behaviour change interventions
Two systematic reviews22,23 examining 12 preconception
trials identified possible improvements in health
behaviours (including alcohol consumption and smok-
ing), and psychological mediators of intervention eects
(such as maternal self-ecacy and perceived control).
Neither review reported maternal nutritional status as an
outcome. Two studies tested the eect of preconception
nutritional or behavioural interventions on birth
outcomes: no eect on pregnancy outcomes was found
in a Dutch study24 when general practitioners counselled
couples on health behaviours; and a negative eect on
birthweight of counselling on risk factors including diet,
timing of next pregnancy, and specialist referrals was
noted in an Australian study.25 The authors of the latter
study speculated that improved preconception health
meant that previously unsustainable pregnancies were
sustained for longer, resulting in increased preterm
births and decreased birthweights. If true, this would
be an unexpected and adverse eect of preconception
Addressing preconception undernutrition in low-income
settings could require broader behavioural strategies than
tackling overnutrition in high-income settings. Low-
resource households cannot simply change their behaviour
if food is unavailable, and so strategies must combine
behaviour change with food access, as was done in the
CARING Trial26,27 in eastern India. A health-care approach
was used that successfully engaged women and reduced
maternal and neonatal mortality in rural, low-resource
settings, known as participatory learning and action
through women’s groups.28 Facilitated by a trained health-
care professional, this group-based, problem-solving
approach involves women of all ages, and tackles a variety
of maternal and newborn problems including nutrition.
Although the original trials testing this approach did not
report on nutritional outcomes, the CARING trial found
that the approach improved key secondary outcomes,
including dietary diversity and handwashing (although no
significant increase in child length was measured).
Interventions in high-resource contexts can focus on
individual choice, but multilevel interventions might be
more eective.29 Intervention trials developed as part of the
Canadian Government’s Healthy Life Trajectories Initiative
are good examples of multilevel interventions that aim to
address precon ception nutrition and health behaviour, but
also wider health and social determinants. These trials
will provide gold standard evidence of the eectiveness,
and cost-eectiveness, of multicomponent preconception
interventions in improving outcomes for children.
Preconception interventions often require engagement
from individuals who are not thinking about becoming
pregnant in the near future, and are unlikely to be using
maternal health services. Interventions to improve health
behaviours in adolescents and young adults might,
therefore, have to be placed outside maternal and child
health services and appeal to motivations unrelated to
health, such as self-image.30–32
Motivation and engagement
The complexities involved in changing individual and
population health behaviours are well recognised. It is
usually not enough to simply educate or give advice, as
knowing something is good for you is rarely sucient to
change behaviour. Successful behaviour change requires
the target population to engage with the need to change,
sustain the motivation to maintain the change, and be
supported by contexts that facilitate change (service
providers, society, social networks, and environments).33
Figure 2 shows a model of preconception action phases,
adapted from the Rubicon model of action phases and the
Action phase model of developmental regulation, and
applied to preconception motivations and interventions.34,35
The model is based on five assumptions: first, most
young adults intend to become parents at some point,
and this goal begins to form in childhood; second, young
adults have the adaptive capacity to pursue this goal
among their other developmental life-course goals, and to
translate it into action; third, the goal to become a parent
is nested within other facilitating and conflicting develop-
mental life-course goals, which are pursued as oppor-
tunities evolve over time; fourth, motivation to become a
parent is the driver that translates that goal into relevant
preconception behaviours; and fifth, translating the goal
to become a parent into conception and pre gnancy
outcomes is imperfect.
The model distinguishes four phases, characterised by
overarching biological or psychological agendas and
motives, in relation to the goal to become a parent. As an
individual moves through the phases, interventions
become less general and more targeted towards specific
populations (in keeping with the dual strategy for
promoting preconception health proposed here). In the
early phases of the model, intervention reach will be
increased, although eect sizes are likely to be small due
to low intensity. The benefits of interventions in these
For the Healthy Life Trajectories
Initiative see http://www.cihr-
4 Published online April 16, 2018
early phases will be general; healthy diets will benefit
both the individual and society, and enhance motivation
in those not planning imminent pregnancy. Creating a
social movement could raise awareness of the importance
of preconception nutrition, and generate a supportive
social environment for preconception health. It could also
help build engagement at each phase, and facilitate
preparation for pregnancy as a normal part of having a
baby within standard health-care practice.36
Intervening with children and adolescents
In the first phase of preconception action, motivation to
become a parent forms without any physical capability
for childbearing, which changes as children develop into
adolescents. Laying foundations for a healthy life is
essential for reasons independent of any preconception
health agenda, and there is a need to raise awareness of
healthy preparation for pregnancy as a concept from an
early age.
Recent recognition of the triple benefit from investment
in adolescent health—their health now, their health in the
future, and the health of the next generation—has
focused attention on this life-course phase.37–39 90% of the
world’s 1·8 billion adolescents live in low-income and
middle-income countries (LMICs); up to half experience
stunted growth and pregnancy is common.40 For this
group, a key intervention in improving outcomes for
mothers and babies is to delay first pregnancy beyond
18 years, when nutrients are no longer needed to support
maternal growth.40 In high-income countries, adolescents
have the poorest diets of any age group.41 Physiological
responses and health behaviours established during
adolescence continue into adulthood, and neurological
and epigenetic changes in adolescence suggest that it is a
crucial period for establishing long-term health risk.42,43
Adolescents typically disengage with traditional health
messages, prioritising the immediate over the long-term,
and having a strong desire for autonomy causes them to
reject instructive health education.44,45 Eective inter-
ventions with adolescents need to empower and
encourage by giving, rather than taking away,
The LifeLab programme is an example of a school-
based intervention, aimed at developing adolescents’
motivations for improving their diets and physical
activity levels through engagement with science, with an
emphasis on their health but with reference to benefits
for their future children (appendix).46,47 The students
report that being good parents in the future is important
to them; learning about preconception health motivates
Goal to
become parent Forming
• Developing biological
capacity to become
• Family role modelling
to influence
parenthood expectations
• Learning of lifestyle habits
• Increased investment of
thought, time, and effort
into becoming pregnant
• Receptive to pre-
pregnancy input
• Reflecting on lifestyle
habits and contemplating
• Previous experience of
pre-pregnancy phase and
• Activation of previous
habits and behaviours
• Lower receptiveness for
pre-pregnancy input
• Pregnancy physically
possible, but other life
goals more importatant
• Consolidation of
lifestyle habits
• Loss of capacity to have a
healthy child in future may
be motivating factor for
some (loss aversion)
• Consideration of personal,
normative, economic,
and social context
• Foster healthy lifestyle
independent of
preconception agenda
• Teach why and how
lifestyle is important for
preconception health
• Raise public awareness of
preconception health
• Signpost to available
information resources and
support tools, eg, online
information platforms
• Support foundations for
independent living
• Actively support
preconception health,
eg, text messaging
• Provide practical tools and
stratagies in an engaging
• For subgroups, provide
intense direct and tailored
individual support, eg,
one-to-one counselling
• Actively support
preconception health
tailored to parents
• Provide practical tools and
strategies in an engaging
way and relevant to parents
taking previous pregnancy
experience into account
Children and
Adults with no immediate
intention to become
Adults with intention to
become pregnant
Adults with intention to
become pregnant again
Maturation and socialisation
Intention formation
Intention prioritisation
Intention reactivisation
Figure 2: Model of preconception action phases
The model outlines four phases individuals move through in relation to the goal to become a parent, highlighting features and intervention opportunities for each
phase (adapted from the Rubicon model of action phases and the Action phase model of developmental regulation).34,35
Series Published online April 16, 2018
them to improve their diets and physical activity. LifeLab
has potential to help children and adolescents develop a
concept of preconception and parenthood, but this
concept alone might not motivate change because it is
not an immediate imperative. Motivation is a necessary
but not sucient condition for behaviour change.48 The
addition of an in-person intervention to LifeLab
would support students’ capabilities (ie, “you can do
this! I believe in you!”), and opportunities for behaviour
change (ie, “how are you going to exercise more and
what is your plan for eating healthily?”). Where female
participation in formal schooling is low, alternative
approaches are needed to ensure engagement of
adolescent boys and girls.
In rural South Africa, where there are high rates of
adolescent overweight and obesity, the Ntshembo (Hope)
intervention49 aims to achieve a healthy body-mass index in
14–19 year-olds through a 2-year programme of behaviour
change support. Working with adolescents, their carers,
and village leaders, Ntshembo is explicitly designed to
address individual and community motiva tions and
capabilities, and to provide opportunities for adolescents to
eat well and exercise more. It harnesses the power of social
influence on adolescent behaviour through peer support,
and employs community health workers trained to support
problem-solving and capitalise on adolescents’ need
for autonomy; the development of an adolescent-friendly
health service to deliver gender and context-specific
interventions is widely supported.50 As in LifeLab, the
preconception agenda in Ntshembo is largely that of
the intervention developers, who will need to engage
with adolescents’ own imperatives for the intervention
to succeed.
Interventions with adults not immediately intending to
become pregnant
In this second phase, the goal to become a parent is
refined and shaped by the individual’s psychological,
social, economic, and biological status.51–53 As young
adults mature, developmental goals such as completing
education, obtaining employment, and forming intimate
relationships generally take priority over becoming a
parent. Consequently, preconception health will have
little motivational currency during this phase. Eective
methods of engagement at this stage will be highly
In some cultures, marriage oers an opportunity to
engage couples in thinking about their nutrition and
health before conception, particularly in countries
where premarital testing aimed at reducing transmission
of inherited disorders is mandatory. The Jom Mama
project,54 supported by the Malaysian Government, uses
an existing premarital HIV screening and wellness
programme to provide preconception nutrition support
to couples, using a combination of an online platform
and in-person behaviour change support (appendix).
Newly married Malaysian women said that having a
healthy baby in the future was a major motivation for
improving their diets and physical activity (panel).
However, other life-course goals, such as work, were a
barrier to eating well and being active. The eectiveness
of this intervention might be constrained by its focus on
individual responsibility, and the fact that it does not
directly address the challenge of social influences or an
obesogenic environment.
The absence of dedicated preconception health care in
many countries means interventions to improve pre-
conception nutritional status need to take advantage of
routine contact between young adults and health-
care professionals.55 For example, oering support in
reproductive health clinics has the potential to improve the
preconception nutritional status of women who might or
might not be actively planning pregnancies. This requires
health-care professionals to be aware of the importance of
preconception nutrition, have the skills to intervene, and
see oering nutritional support as part of their job. To help
raise awareness, the USA’s Centers for Disease Control
and Prevention promotes a Reproductive Life Plan56
intended to encourage people of child-bearing age to
prepare for pregnancy, and maximise the preconception
benefit of interactions with health-care professionals.
Training for health-care professionals in skills to
support behaviour change is available in the form of
Healthy Conversation Skills;57 this set of easily acquired,
theory-based skills for practitioners is designed to
engage and motivate patients and clients during brief
consultations. Unlike giving information and advice,
the Healthy Conversation Skills training promotes the
use of open discovery questions, listening, reflecting,
and goal-setting to enable a woman or couple to prepare
for pregnancy, and support them in finding their own
solutions to challenges. The skills have been used in
maternal and child health contexts around the world, and
their use is both acceptable and feasible.58,59
Armed with these skills, practice and community
nurses, sexual and reproductive health clinic sta, those
working in early pregnancy units (who treat women who
have miscarried), and sta providing weight management
services are all potential agents for delivering appropriate,
timely, and culturally sensitive support to improve
preconception nutritional status at scale. Extending this
skills training to community health workers, with support
from local and national policies, has the potential for
widespread impact on preconception health; in other
contexts this approach can improve health outcomes in a
range of public health and primary care settings.60,61
An approach such as Healthy Conversation Skills enables
health-care professionals to provide care that is responsive
to women’s personal, social, and cultural environments.55
In contexts outside health care, supermarkets represent
an unexploited opportunity for promoting preconception
nutrition. Supermarkets have an unparalleled reach into
communities and expertise in customer engagement.
Women do most of the family food shopping, and in
For USA’s Centers for Disease
Control and Prevention
preconception health guidance
6 Published online April 16, 2018
high-income countries, these choices are made in super-
markets.62 The food choices of disadvantaged women are
particularly susceptible to the supermarket environment,
suggesting that modifications which encourage the
purchasing of healthy foods, might have greatest impact
on women with poor diets.63 In LMICs, the role of
supermarkets as food purveyors is rapidly expanding,
although not necessarily in remote and rural areas where
increasing the accessibility of nutrient-dense food
remains a priority.64,65 A model whereby supermarkets
oer precon ception nutritional support alongside sales of
folic acid and other supplements is one that could be
developed in high-income countries and, if successful,
translated to LMICs as supermarkets become more
Interventions with adults intending to become pregnant
In the third phase, the goal to become a parent has been
activated through a combination of social (eg, subjective
norms), situational (eg, marriage), and biological (eg, age)
Panel: Motivations for engagement in interventions to improve preconception health
In the development of the Jom Mama intervention, 18 couples
were interviewed about their motivations to engage with the
intervention programme, and to improve their health before
conception. Having a healthy pregnancy and a healthy child
were clear motives for improving diet and lifestyle:
“Because I want to conceive as I’ve never conceived before.
So getting pregnant will motivate us.” (Respondent 12)
“I wanted to be healthy for myself and for my child…I think
my commitment as a wife and mother is important.”
(Respondent 10)
Interviewees suggested that a range of incentives, including
financial and personalised support from health-care staff,
would sustain their engagement in a programme of diet and
lifestyle improvement, as would stories from others at the same
stage of life. They also proposed that programme content
should be simple, attractive, and specifically targeted to them,
and that it should not interfere with their working hours,
suggesting that delivery should be on a digital platform,
accessible at their convenience.
Participants described features of their lives as young, working
people that acted as barriers to improving their diets and
physical activity levels in preparation for pregnancy.
Working patterns: “I usually don’t take breakfast…and then I
start work, rest at 12.30 pm, but if I’m too busy I don’t rest
until the evenings, sometimes at 6 pm, sometimes until
8, 9 pm only then I go home.” (Respondent 8)
Eating habits: “Sometimes I have lunch at 12 noon…
sometimes at 3 pm…it’s uncertain.” (Respondent 13)
Exercise: “Not after marriage…can’t make it in the evening.
No time.” (Respondent 1)
In the UK, women who had recently had a child attending
routine appointments with health visitors were approached
and asked whether they would be planning another
pregnancy in the following 12 months. Those who indicated
they would be interested were invited to participate in a pilot
study of the effectiveness of the Smarter Pregnancy
intervention and subsequently provide an in-depth interview.
15 women were interviewed and their views of preconception
care were sought.
Women felt that just because they had already had a baby did not
mean they were aware of what was required for a healthy
conception and pregnancy. Because of their involvement in the
interconception study, they accepted that preconception care was
important, something they might not have considered before:
“We’ve not had something like this before and I felt like, at
that time when I wanted to get pregnant…you don’t know,
even though you’ve had three kids already before. You just
forget everything.” (Woman 31, married with three children
aged 14 years, 8 years, and 4 years)
“I know [now] that our body has to be ready before we get
pregnant. You need to be prepared. Everything has to be
enough. Since then, I know, I start to understand you have
to eat enough vitamins to get pregnant.” (Woman 31,
married with two children—a baby and a 10-year-old)
When they discussed the implications of their new
understanding, women highlighted the importance of
improving their health prior to conceiving, with specific focus
on improving their diet and being a healthy weight:
“In terms of...sometimes, you lose track of what is healthy.
So that is when I had to relook at my diet in terms of having
more vegetables and then taking my folic acid and looking
at all of these healthy things.” (Woman 40, previous
stillbirth, currently pregnant)
Key sources of information for preconception care were the
internet and friends and family. There was a desire for reliable
and accredited sources of information to put couples’ minds at
ease. What the women said suggests there is a gap in current
provision of preconception health information:
“I think the problem is if people don’t know, they go to
Google. And you go to Google, and you get some chat on
Mumsnet. And it’s a load of women feeding other women
garbage... there’s so much false information out there. But if
you don’t know that, you go ‘This is what it means.’ Stuff
like this [the intervention material] just keeping people on
the straight and narrow is quite helpful.” (Woman 32,
one child aged 1 year, recent miscarriage)
There was agreement among women that healthier lifestyles can
contribute to healthier pregnancies, a reflection that they had
not considered this for their previous pregnancy, and an
intention to improve their nutritional status in preparation for
the next pregnancy. Therefore, the inter-partum period might be
a fruitful time to engage women in preconception health care.
In the UK, women are under the care of the community health visiting services from
pregnancy up to 5 years of age of the child.
Series Published online April 16, 2018
factors, and is now actively pursued. This phase is
characterised by an increased investment of thought,
time, and eort into becoming pregnant. Willingness
to engage in interventions increases, and behaviours
can range from passive (eg, reduced investment in
contraception), to active. With appropriate support, pre-
conception interventions are likely to be translated into
behaviour change. Interventions need to allow for swift
and discrete implementation, given the sensitive nature
of couples’ plans for conception, and active promotion
through channels such as contraception counselling.
Since this group is likely to be engaged and seeking
information, preconception health services in primary
care, with a focus on nutrition, could be appropriate.
Interventions oered in this setting can improve pre-
conception health behaviours in women who are planning
to become pregnant.23,66,67 Screening for pregnancy
intention, as outlined in the first paper in this Series,
would enable practitioners in sexual and reproductive
health clinics to oer preconception support, for example,
to women attending for removal of implants and
intrauterine devices.
Digital interventions (online or smartphone-based)
oer privacy and easy access for disadvantaged or
disenfranchised groups less likely to engage with more
formal services. Smarter Pregnancy is a rare example of a
digital intervention designed specifically to support
improvements in preconception nutrition and health
behaviours, and has had some success with couples
who are actively preparing for pregnancy (appendix).68,69
Mobile phone interventions to improve maternal and
child health in LMICs have delivered tailored information
and supported improved infant feeding outcomes.70
Combining digital interventions with motivational
human interaction increases engagement with, and the
eectiveness of, behaviour change interventions.71 An
accessible, population-wide preconception health-care
service could be oered to women via a digital
intervention, and combined with face-to-face or
telephone contact with health-care sta trained in a
motivational approach, such as Healthy Conversation
Interventions with adults intending to become
pregnant again
In the fourth phase, the goal to become a parent is
reactivated. Preparation for pregnancy is likely to be influ-
enced by couples’ previous preconception experiences.
Previously uncomplicated pregnancies might decrease
receptiveness for preconception input; if their first baby
was healthy why would couples change their preparations?
However, women and their families have intensive
contact with health services and health-care professionals
during pregnancy, and are motivated to make dietary
changes. Therefore, interventions can support maternal
dietary behaviour change and reduce postnatal weight
In LMICs, interest has focused mainly on maternal
underweight and micronutrient deficiencies. Women are
willing to take nutritional supplements during pregnancy,
with con sequent reductions in low birthweight,77
however, few studies have focused on supporting change
in habitual dietary behaviour, likely because choices tend
to be limited in undernourished settings. Exceptions
include qualitative studies78 that have sug gested
modifiable dietary behaviours in populations in LMICs.
Young, rural Indian women report avoiding specific
nutritious foods because of fears they could harm a
pregnancy, undereat in the belief that this will make
delivery easier, consume the least nutritious foods after
other family members have eaten because of household
hierarchies, and observe women’s cultural fasting days
(eating predominantly low-nutrient foods).79,80 These data
provide further evidence for extending initiatives that
support wider social and cultural change to include
preconception nutritional interventions.
Maternal and child health-care systems oer post-
partum or interpartum opportunities for working with
women to support dietary behaviour change. Women
interviewed following an interpartum inter vention at a
health visitor clinic in London, UK, had a new awareness
that their nutritional status during and between
pregnancies had an impact on the baby (panel). In high-
income countries, post-partum studies have mainly
focused on limiting weight retention among normal or
overweight women, and improving glucose tolerance
among women with a history of gestational diabetes.81,82
Interventions to address both diet and physical activity
that include self-monitoring of progress, could be more
eective than interventions that focus on only one
behaviour or that do not support monitoring of weight.83,84
Some studies have successfully used education
programmes, or financial incentives, to improve dietary
quality by reducing energy intake and increasing fruit,
vegetable, and whole grain intake.85,86
Many post-partum randomised studies report low
recruitment or retention rates; post-partum mothers
report multiple barriers to participation, including little
spare time, stress, and sleep deprivation.87 Interventions
might need to take a supportive approach involving home
visits, and provision of foods, child care, and
self-monitoring facilities such as weighing scales.87 One
solution could be to integrate in-person support for
interpartum behaviour change with a digital service. Post-
partum weight retention is associated with lifetime obesity
risk and adverse outcomes in the next pregnancy.88 A
cluster randomised trial89 of an internet-based weight loss
programme, coupled with face-to-face support
(Fit Moms/Mamás Activas) in low-income women in
California, USA, found that women in the intervention
group maintained significantly greater weight loss at
12 months than did women who did not receive the
intervention (3·2 kg vs 0·9 kg; dierence 2·3 kg [95% CI
8 Published online April 16, 2018
Creation of a social movement
A social movement to optimise preconception health,
nutritional status, and health behaviours needs to involve
the whole population and harness political will and
leadership. A social movement in Brazil led to significant
improvements in preconception nutrition for women,
and virtual eradication of undernutrition and wasting
among children younger than 5 years, between 1994
and 2006.90,91 The movement involved, first, a national
cam paign against hunger that raised public aware-
ness of the need to tackle malnutrition, and, second,
development of an advocacy coalition with political
anities that created a critical mass of activists, and
monitored the government’s progress in reducing
malnutrition. Eradicating mal nutrition became a high-
profile social responsibility, prompting strong leadership
from central government in addressing food security.
Under pinning Brazil’s approach was an appreciation
that how women feed themselves and their children is
not solely an individual responsibility, but involves
wider determinants.
Social movements are distinct from social marketing
campaigns. The latter would traditionally attempt to
improve nutrition and health behaviour through providing
information and recommending behaviour change, but
could fail to reach the neediest groups and inadvertently
widen inequalities.92,93 The UK’s Change4Life intervention
adopted this approach, with little evidence of eective-
ness.94 Social practice theory provides some insight as
to why such campaigns are insucient; individuals
and communities require, not only knowledge, but also
resources to enact change, and a purpose or meaning to
provide motivation.95 A social movement providing these
factors might best be founded in socially constructed ideas
of human action, and allied to the field of consumer
marketing and brand creation.
Consumer marketing recognises that individual
behaviour and choices are a function of self-image,
and brands must develop an emotional and symbolic
connection with consumers, making the brand a form of
self-expression.96 A campaign using brand development
practice would target emotions that are central to an
individual’s identity. This approach is epitomised in such
campaigns as the handwashing with soap social move-
ment, which applied brand marketing practices and an
advocacy campaign to address infant mortality under the
tag-line Help a Child Reach 5. The media campaign
followed the principles of being personally relevant,
emotionally engaging, and easy to understand.97 The
evidence-based rationale for handwashing is given only
after the other appeals have been made. The campaign
was driven by a multinational company (Unilever),
supported by an alliance of public health activists and
academics. It has received strong endorsement by the
inclusion of handwashing with soap as an indicator in
the UN’s sustainable development goals, and government
policy initiatives to improve washing facilities.
The handwashing movement is an example of mutual
benefit for public health and for private sector profit that
can come from a joint social purpose. Companies are
more likely to do the right thing in a sustainable way if
public health benefit is accompanied by commercial gain.97
In 2013, Black and colleagues3 declared that “the private
sector is an important force in shaping nutrition outcomes
and has the potential to do more” to improve maternal and
child nutrition. Engaging with the food industry is crucial
because of their reach and power to shape consumer
behaviour. A major diculty with applying the mutual
benefit approach to improving preconception nutrition
and lifestyle through a relationship with the food industry
is their history of malpractice in respect to infant feeding,98
and their role in generating and sustaining an obesogenic
environment. Whether commercial and public health
interests can be aligned in the way they have been for
handwashing remains to be seen. One attempt is
Unilever’s campaign to market iron-fortified stock cubes
to reduce iron-deficiency anaemia in women in Nigeria.99
However, lobbying by some members of the food industry
against sugar-sweetened beverage taxes suggests that
caution is required to ensure the legitimacy of campaigns
and health actions from the food industry. Independent
monitoring of food industry activities by academia and the
public is crucial to building societal support that will
catalyse government and industry actions in respect of
preconception health.100
Marketing principles suggest that a preconception
social movement should be emotionally engaging and
positively framed, appealing to positive emotions, such as
love, as opposed to campaigns that call on personal
responsibility or fear. The call to action would target the
whole population and would ask people to, for example,
support young women or couples to achieve an optimal
pre-pregnancy weight, or eat a variety of fruits and
vegetables. The challenge is to identify simple actions
around which the campaign could be built.
Advocacy coalitions
Political science suggests that a strong advocacy coalition
within international, national, and local policy subsystems
should be developed to place preconception nutrition
firmly on government agendas to incite global policy
action.101 International organisations are already engaged
in advocacy to promote improved preconception health
care. In 2012, WHO coordinated a global consensus on
Preconception Care to Reduce Maternal and Childhood
Mortality and Morbidity, and provided a package of
evidence-based interventions, including nutritional inter-
ventions.102 Pre conception nutrition was then integrated
into a number of transnational organisation initiatives.
With the notable exception of the Netherlands, only
LMICs have shown political support for the adoption of
strategies to address social, environmental, and economic
determinants of maternal and child malnutrition.90,103
Political debate in the Netherlands was sparked by
For Help a Child Reach 5 see
Series Published online April 16, 2018
academics drawing attention to high national perinatal
mortality rates, especially among poor immigrant
communities. The promotion of preconception health to
reach the poorest in the Netherlands has since become a
priority, and includes addressing social deprivation and
broad determinants of maternal ill-health.
Policy change is more likely if advocacy coalitions are
developed to focus on a specific policy subsystem and
engage multiple participants (ie, government agencies,
research institutions, non-government organisations, the
media, commercial interests, and influential individuals)
to build critical mass.101 Strong leadership, adequate
resources, and a coordinated infrastructure are required
to ensure advocacy coalitions sustain engagement over
the potentially lengthy period of time necessary to achieve
high-level, coordinated policy action, particularly in
competitive policy subsystems with opposing advocacy
coalitions. Initiatives such as sugar taxes or marketing
restrictions to curb sugar intake have gained policy
traction in some countries following decades of increasing
evidence, advocacy, and public awareness, in spite of
strong opposition from food companies.104 A major
advantage of campaigning for better preconception
nutrition is that the focus is building stronger mothers
and babies and reducing non-communicable disease
burden in the next generation; these are uncontroversial
messages, easy for the public to engage with emotionally.
A dual strategy targeting women and couples planning a
pregnancy, coupled with promoting the health of all
women of child-bearing age, could be the most eective
approach to improving preconception health. Sparse
evidence from robust and context-relevant trials of
preconception nutrition and health behaviour inter-
ventions, makes it hard to draw firm conclusions about
their eectiveness in improving outcomes for mothers
and babies on a large scale. Trials of preconception
interventions are far fewer than those conducted during
pregnancy, because recruitment is more dicult and
Study design Participants Estimated
Nutritional Intervention Preconception
and During Pregnancy to Maintain Healthy
Glucose Metabolism and Offspring Health
(NiPPeR study, NCT02509988)
The aim is to assess whether a nutritional drink taken before conception and
continuing through pregnancy, assists in the maintenance of healthy glucose
metabolism in the mother and promotes offspring health
1800 women October, 2018 New Zealand,
Singapore, and UK
Inter-pregnAncy Coaching for a Healthy
fuTure (Inter-ACT, NCT02989142)
The intervention targets women with excessive weight gain in their first pregnancy,
and attempts to reduce complications in the second pregnancy through an
interpartum programme of coaching, combining face-to-face counselling with the use
of a mobile application connected to medical devices (scale and pedometer)
1100 women September, 2020 Belgium
Women First: Preconception Maternal
Nutrition (WF, NCT01883193)
Multicountry three-arm, individually randomised, non-masked, controlled trial to
ascertain the benefits of ensuring optimal maternal nutrition before conception,
and providing an evidence-base for programmatic priority to minimise the risk of
malnutrition in females of reproductive age. Women are required to take a lipid-based
micronutrient supplement. Run from University of Colorado, Denver, CO, USA
7374 women October, 2019 Democratic
Republic of the
Congo, Guatemala,
India, and Pakistan
Development of Pre-pregnancy
Intervention to Reduce the Risk of
Diabetes and Prediabetes (Jom Mama,
The aim is to assess the efficacy of a pre-pregnancy intervention to reduce the risk of
diabetes and prediabetes. A lifestyle intervention combines behaviour change
counselling from community health promoters trained to support behaviour change,
and utilisation of an eHealth platform providing preconception information and support
660 women November, 2017 Malaysia
Erasmus MC Care Innovation for a healthy
pregnancy (NTR4150)
To test whether use of the Smarter Pregnant intervention (a mobile application
comprising an interactive food and lifestyle coaching programme) leads to an
improvement in unhealthy food habits (intake of fruits and vegetables, and folic acid
use) after 6 months, measured as a decrease in the Food Risk Score of women and men
considering pregnancy
3000 men and
January, 2017* The Netherlands
Healthy Lifestyles Trajectory Initiative
Four interlinked preconception nutrition intervention trials planned by a consortium
of the Canadian Institute for Health Research, the WHO, the governments of Canada,
China, India, and South Africa, and academic partners in each country. These
randomised controlled trials aim to test the effect of a package of nutritional and
lifestyle interventions before conception on offspring body composition
Not applicable October, 2017
(start date)
Canada, China,
India, and South
The Low Birth Weight in South Asia Trial
This cluster randomised controlled trial aims to identify the most cost-effective means
of increasing birthweight by comparing birthweight in current programme areas with
birthweight in areas where one of three combinations of interventions is conducted:
first, a behaviour change strategy involving working with participatory women’s groups
and other community members, to change pregnant women’s eating behaviour and to
increase their intake of nutritious food; second and third combine this strategy with
provision of a food supplement or a cash payment, respectively. The primary outcome
of the trial is birthweight, accurate to 10 g, measured within 72 h of birth
17 000 pregnant
13 000 babies
Unknown Nepal (80 study
*This study has been extended as recruitment was slower than anticipated. †This trial is not a preconception trial, but will have implications for understanding the value of cash transfers and participatory
women’s groups in improving the nutritional status of women of childbearing age.
Table: Ongoing trials of preconception nutrition interventions
10 Published online April 16, 2018
5 Gaglio B, Shoup JA, Glasgow RE. The RE-AIM framework:
a systematic review of use over time. Am J Public Health 2013;
103: e38–46.
6 McDonald EC, Pollitt E, Mueller W, Hsueh AM, Sherwin R.
The Bacon Chow study: maternal nutrition supplementation and
birth weight of ospring. Am J Clin Nutr 1981; 34: 2133–44.
7 Caan B, Horgen DM, Margen S, King JC, Jewell NP.
Benefits associated with WIC supplemental feeding during the
interpregnancy interval. Am J Clin Nutr 1987; 45: 29–41.
8 Potdar RD, Sahariah SA, Gandhi M, et al. Improving women’s diet
quality preconceptionally and during gestation: eects on birth
weight and prevalence of low birth weight—a randomized controlled
ecacy trial in India (Mumbai Maternal Nutrition Project).
Am J Clin Nutr 2014; 100: 1257–68.
9 Sahariah SA, Potdar RD, Gandhi M, et al. A daily snack containing
leafy green vegetables, fruit, and milk before and during pregnancy
prevents gestational diabetes in a randomized, controlled trial in
Mumbai, India. J Nutr 2016; 146: 1453S–60S.
10 Pena-Rosas JP, De-Regil LM, Dowswell T, Viteri FE. Daily oral iron
supplementation during pregnancy. Cochrane Database Syst Rev
2012; 12: CD004736.
11 Lassi ZS, Bhutta ZA. Clinical utility of folate-containing oral
contraceptives. Int J Womens Health 2012; 4: 185–90.
12 Food Fortification Initiative. Say hello to a fortified future: 2016
year in review. 2017. http://
publications/documents/FFI2016Review.pdf (accessed
March 6, 2018).
13 WHO. Fortification of food-grade salt with iodine for the prevention
and control of iodine deficiency disorders: guideline. 2014.
foodgrade_saltwithiodine/en/ (accessed March 6, 2018).
14 Crider KS, Bailey LB, Berry RJ. Folic acid food fortification—
its history, eect, concerns, and future directions. Nutrients 2011;
3: 370–84.
15 Mastroiacovo P, Leoncini E. More folic acid, the five questions:
why, who, when, how much, and how. Biofactors 2011; 37: 272–79.
16 Scientifc Advisory Committee on Nutrition, Public Health England.
Folic acid: updated SACN recommendations. July, 2017.
sacn-recommendations (accessed March 6, 2018).
17 Manley J, Gitter S, Slavchevska V, et al. How eective are cash
transfers at improving nutritional status? A rapid evidence
assessment of programmes’ eects on anthropometric outcomes.
July, 2012.
transfers-2012manley-rae.pdf (accessed March 6, 2018).
18 Fenn B, Colbourn T, Dolan C, Pietzsch S, Sangrasi M, Shoham J.
Impact evaluation of dierent cash-based intervention modalities on
child and maternal nutritional status in Sindh Province, Pakistan,
at 6 mo and at 1 y: a cluster randomised controlled trial. PLoS Med
2017; 14: e1002305.
19 Fenn B, Pietzsch S, Morel J, et al. Research on Food Assistance for
Nutritional Impact (REFANI): literature review. March, 2015.
Refani-literature-review-final-03092015.pdf (accessed
March 6, 2018).
20 Ruel MT, Alderman H. Nutrition-sensitive interventions and
programmes: how can they help to accelerate progress in
improving maternal and child nutrition? Lancet 2013; 382: 536–51.
21 Rawlings LB, Rubio GM. Evaluating the impact of conditional cash
transfer programs. World Bank Res Obs 2005; 20: 29–55.
22 Whitworth MK, Dowswell T. Routine pre-pregnancy health
promotion for improving pregnancy outcomes.
Cochrane Database Syst Rev 2009; 4: CD007536.
23 Hussein N, Kai J, Qureshi N. The eects of preconception
interventions on improving reproductive health and pregnancy
outcomes in primary care: a systematic review. Eur J Gen Pract 2016;
22: 42–52.
24 Elsinga J, de Jong-Potjer LC, van der Pal-de Bruin KM, le Cessie S,
Assendelft WJ, Buitendijk SE. The eect of preconception
counselling on lifestyle and other behaviour before and during
pregnancy. Womens Health Issues 2008; 18: S117–25.
25 Lumley J, Donohue L. Aiming to increase birth weight: a randomised
trial of pre-pregnancy information, advice and counselling in
inner-urban Melbourne. BMC Public Health 2006; 6: 299.
outcomes can be assessed only in women who sub-
sequently become pregnant. Fortunately, several such
trials are underway (table). Meanwhile, public health
strategies to improve nutritional status in children and
in adults of reproductive age should be strengthened
without delay.
Interventions could be more eective for longer if they
use existing delivery platforms within a systems approach.
System-wide changes to accommodate preconception
health care will need support from a social movement
that establishes its importance for the health of the next
generation, stresses societal responsibility, and requires
strong local, national, and international leadership. The
strength of this social movement, and the capacity to
deliver eective nutrition and behavioural interventions,
could be enhanced through carefully negotiated engage-
ment with commercial interests.
MB conceptualised the paper in consultation with all authors and wrote
the first draft with substantial inputs from TC, JS-W, GN, SUD, FFS,
CHDF, SAN, CV, NMK, WTL, and JS. TC, JS-W, and GN carried out the
review and produced the pathways model of intervention eects.
The analysis of preconception action phases was developed by SUD and
FFS. SAN, RS-T, DP, and KW-T provided data and wrote descriptions of
exemplar intervention studies. CHDF wrote the first draft of the section on
interventions with adults intending to become pregnant again. Sections on
the creation of a social movement and advocacy coalitions were produced
by CV and NMK. JS oversaw and advised on all aspects of producing and
editing the paper. All authors saw successive drafts of the paper and
provided input. MB finalised the paper and is the overall guarantor.
Declaration of interests
We declare no competing interests.
The idea for this Series was conceived by JS and developed during a
4-day symposium, led by MB and JS and funded by The Rank Prize
Funds, on Preconception Nutrition and Lifelong Health in Grasmere,
UK, February, 2016. We thank a number of individuals who have
contributed their thoughts and time to this paper: Nicola Heslehurst
(Newcastle University, Newcastle,UK) for her contribution to an early
draft of the paper; Zulfi Bhutta (Aga Khan University, Karachi, Pakistan)
for his perspectives on interventions in LMICs; Chandni Jacob and
Mark Hanson (University of Southampton, Southampton, UK) for their
contribution to the review; Jayne Hutchinson and Janet Cade (University
of Leeds, Leeds, UK) for advice on fortification; Matthijs van Dijk
(Erasmus MC, Rotterdam, Netherlands) for data from Smarter
Pregnancy; Julius Cheah and the Jom Mama project partners comprised
of the Ministry of Health of Malaysia (Putrajaya, Malaysia), University of
Southampton (Southampton, UK), University of Witwatersrand
(Johannesburg, South Africa), Steno Diabetes Center (Gentofte,
Denmark), and Novo Nordisk (Gentofte, Denmark); Mike Kelly
(University of Cambridge, Cambridge, UK) for discussions on the value
of social practices; and Andy Last (MullenLowe salt, London, UK) for his
insights into how a social movement might be created around
preconception health.
1 UN Department of Economic and Social Aairs. Sustainable
Development Goal 2. 2016.
sdg2 (accessed March 6, 2018).
2 Godfrey KM, Gluckman PD, Hanson MA. Developmental origins of
metabolic disease: life course and intergenerational perspectives.
Trends Endocrinol Metab 2010; 21: 199–205.
3 Black RE, Alderman H, Bhutta ZA, et al. Maternal and child
nutrition: building momentum for impact. Lancet 2013; 382: 372–75.
4 Ceschia A, Horton R. Maternal health: time for a radical reappraisal.
Lancet 2016; 388: 2064–66.
Series Published online April 16, 2018
26 Nair N, Tripathy P, Sachdev HS, et al. Participatory women’s groups
and counselling through home visits to improve child growth in
rural eastern India: protocol for a cluster randomised controlled
trial. BMC Public Health 2015; 15: 384.
27 Nair N, Tripathy P, Sachdev HS, et al. Eect of participatory
women’s groups and counselling through home visits on
children’s linear growth in rural eastern India (CARING trial):
a cluster-randomised controlled trial. Lancet Glob Health 2017;
5: e1004–16.
28 Prost A, Colbourn T, Seward N, et al. Women’s groups practising
participatory learning and action to improve maternal and newborn
health in low-resource settings: a systematic review and
meta-analysis. Lancet 2013; 381: 1736–46.
29 Compernolle S, De Cocker K, Lakerveld J, et al. A RE-AIM
evaluation of evidence-based multi-level interventions to improve
obesity-related behaviours in adults: a systematic review
(the SPOTLIGHT project). Int J Behav Nutr Phys Act 2014; 11: 147.
30 Santos I, Sniehotta FF, Marques MM, Carraça EV, Teixeira PJ.
Prevalence of personal weight control attempts in adults:
a systematic review and meta-analysis. Obes Rev 2017; 18: 32–50.
31 Bhutta Z, Das J, Rizvi A, et al. Evidence-based interventions for
improvement of maternal and child nutrition: what can be done
and at what cost? Lancet 2013; 382: 452–77.
32 De-Regil LM, Harding KB, Roche ML. Preconceptional nutrition
interventions for adolescent girls and adult women: global
guidelines and gaps in evidence and policy with emphasis on
micronutrients. J Nutr 2016; 146: 1461S–70S.
33 Kwasnicka D, Dombrowski SU, White M, Sniehotta F.
Theoretical explanations for maintenance of behaviour change:
a systematic review of behaviour theories. Health Psychol Rev 2016;
10: 277–96.
34 Heckhausen H. Motivation and action. Berlin: Springer-Verlag, 1991.
35 Heckhausen J. Developmental regulation in adulthood:
age-normative and sociostructural constraints as adaptive
challenges. Cambridge: Cambridge University Press, 2006.
36 Steegers EA, Barker ME, Steegers-Theunissen RP, Williams MA.
Societal valorization of new knowledge to improve perinatal health:
time to act. Paediatr Perinat Epidemiol 2016; 30: 201–04.
37 United Nations Secretary-General. Global strategy for women’s,
children’s and adolescent’s health (2016–2030). 2015. http://www.
(accessed March 6, 2018).
38 WHO. Global Accelerated Action for the Health of Adolescents
(AA-HA!): guidance to support country implementation. 2017.
adolescence/framework-accelerated-action/en/ (accessed
March 6, 2018).
39 Patton GC, Sawyer SM, Santelli JS, et al. Our future: a Lancet
commission on adolescent health and wellbeing. Lancet 2016;
387: 2423–78.
40 King JC. A Summary of pathways or mechanisms linking
preconception maternal nutrition with birth outcomes. J Nutr 2016;
146: 1437S–44S.
41 Bates B, Lennox A, Prentice A, et al. National diet and nutrition
survey: results from years 1–4 (combined) of the rolling programme
(2008/2009–2011/12). May, 2014.
to_4_UK_report_full_text_revised_February_2017.pdf (accessed
March 6, 2018).
42 Craigie AM, Lake AA, Kelly SA, Adamson AJ, Mathers JC.
Tracking of obesity-related behaviours from childhood to adulthood:
a systematic review. Maturitas 2011; 70: 266–84.
43 Viner RM, Ross D, Hardy R, et al. Life course epidemiology:
recognising the importance of adolescence.
J Epidemiol Community Health 2015; 69: 719–20.
44 Vansteenkiste M, Simons J, Lens W, Sheldon KM, Deci EL.
Motivating learning, performance, and persistence: the synergistic
eects of intrinsic goal contents and autonomy-supportive contexts.
J Pers Soc Psychol 2004; 87: 246–60.
45 Blakemore SJ, Mills KL. Is adolescence a sensitive period for
sociocultural processing? Annu Rev Psychol 2014; 65: 187–207.
46 Grace M, Woods-Townsend K, Griths J, et al.
Developing teenagers’ views on their health and the health of their
future children. Health Educ 2012; 112: 543–59.
47 Woods-Townsend K, Bagust L, Barker M, et al. Engaging teenagers
in improving their health behaviours and increasing their interest
in science (evaluation of LifeLab Southampton): study protocol for a
cluster randomized controlled trial. Trials 2015; 16: 372.
48 Michie S, West R. Behaviour change theory and evidence:
a presentation to Government. Health Psychol Rev 2013; 7: 1–22.
49 Draper CE, Micklesfield LK, Kahn K, et al. Application of intervention
mapping to develop a community-based health promotion
pre-pregnancy intervention for adolescent girls in rural South Africa:
Project Ntshembo (Hope). BMC Public Health 2014; 14 (suppl 2): S5.
50 Bhutta ZA, Lassi ZS, Bergeron G, et al. Delivering an action agenda
for nutrition interventions addressing adolescent girls and young
women: priorities for implementation and research.
Ann NY Acad Sci 2017; 1393: 61–71.
51 Bachrach CA, Morgan SP. A cognitive-social model of fertility
intentions. Popul Dev Rev 2013; 39: 459–85.
52 Miller WB. Childbearing motivations, desires, and intentions:
a theoretical framework. Genet Soc Gen Psychol Monogr 1994;
120: 223–58.
53 Nettle D. Flexibility in reproductive timing in human females:
integrating ultimate and proximate explanations.
Philos Trans R Soc Lond B Biol Sci 2011; 366: 357–65.
54 Norris SA, Ho JCC, Rashed AA, et al. Pre-pregnancy
community-based intervention for couples in Malaysia: application
of intervention mapping. BMC Public Health 2016; 16: 1167.
55 Tuomainen H, Cross-Bardell L, Bhoday M, Qureshi N, Kai J.
Opportunities and challenges for enhancing preconception health
in primary care: qualitative study with women from ethnically
diverse communities. BMJ Open 2013; 3: e002977.
56 US Centers for Disease Control and Prevention. My reproductive
life plan. 2014.
reproductiveplan.html (accessed May 17, 2017)
57 Black C, Lawrence W, Cradock S, et al. Healthy Conversation Skills:
increasing competence and confidence in front-line sta.
Public Health Nutr 2014; 17: 700–07.
58 Baird J, Jarman M, Lawrence W, et al. The eect of a behaviour
change intervention on the diets and physical activity levels of
women attending Sure Start Children’s Centres: results from a
complex public health intervention. BMJ Open 2014; 4: e005290.
59 Lawrence W, Black C, Tinati T, et al. ‘Making every contact count’:
longitudinal evaluation of the impact of training in behaviour
change on the work of health and social care practitioners.
J Health Psychol 2016; 21: 138–51.
60 Gaziano TA, Abrahams-Gessel S, Denman CA, et al. An assessment
of community health workers’ ability to screen for cardiovascular
disease risk with a simple, non-invasive risk assessment
instrument in Bangladesh, Guatemala, Mexico, and South Africa:
an observational study. Lancet Glob Health 2015; 3: e556–63.
61 Patel V, Weobong B, Weiss HA, et al. The Healthy Activity Program
(HAP), a lay counsellor-delivered brief psychological treatment for
severe depression, in primary care in India: a randomised
controlled trial. Lancet 2017; 389: 176–185.
62 Pechey R, Monsivais P. Supermarket choice, shopping behavior,
socioeconomic status, and food purchases. Am J Prev Med 2015;
49: 868–77.
63 Vogel C, Ntani G, Inskip H, et al. Education and the relationship
between supermarket environment and diet. Am J Prev Med 2016;
51: e27–34.
64 Hawkes C, Fanzo J, Udomkesmalee E, et al. Global Nutrition Report
2017: Nourishing the SDGs. November, 2017. http://scalingup
(accessed March 6, 2018).
65 Hawkes C. Dietary implications of supermarket development:
a global perspective. Dev Policy Rev 2008; 26: 657–92.
66 Hammiche F, Laven JS, van Mil N, et al. Tailored preconceptional
dietary and lifestyle counselling in a tertiary outpatient clinic in
The Netherlands. Hum Reprod 2011; 26: 2432–41.
67 Twigt JM, Bolhuis ME, Steegers EA, et al. The preconception diet is
associated with the chance of ongoing pregnancy in women
undergoing IVF/ICSI treatment. Hum Reprod 2012; 27: 2526–31.
68 van Dijk MR, Koster MPH, Willemsen SP, Huijgen NA, Laven JSE,
Steegers-Theunissen RPM. Healthy preconception nutrition and
lifestyle using personalized mobile health coaching is associated with
enhanced pregnancy chance. Reprod Biomed Online 2017; 35: 453–60.
12 Published online April 16, 2018
69 van Dijk MR, Huijgen NA, Willemsen SP, Laven JSE, Steegers EAP,
Steegers-Theunissen RPM. Impact of an mhealth platform for
pregnancy on nutrition and lifestyle of the reproductive population:
a survey. JMIR mHealth uHealth 2016; 4: e53.
70 Lee SH, Nurmatov UB, Nwaru BI, Mukherjee M, Grant L, Pagliari C.
Eectiveness of mHealth interventions for maternal, newborn and
child health in low- and middle-income countries: systematic review
and meta-analysis. J Glob Health 2016; 6: 010401.
71 Dennison L, Morrison L, Lloyd S, et al. Does brief telephone support
improve engagement with a web-based weight management
intervention? Randomized controlled trial. J Med Internet Res 2014;
16: e95.
72 Muktabhant B, Lawrie TA, Lumbiganon P, Laopaiboon M. Diet or
exercise, or both, for preventing excessive weight gain in pregnancy.
Cochrane Database Syst Rev 2015; 6: CD007145.
73 Tanentsapf I, Heitmann BL, Adegboye ARA. Systematic review of
clinical trials on dietary interventions to prevent excessive weight
gain during pregnancy among normal weight, overweight and
obese women. BMC Pregnancy Childbirth 2011; 11: 81.
74 Gardner B, Wardle J, Poston L, Croker H. Changing diet and
physical activity to reduce gestational weight gain: a meta-analysis.
Obes Rev 2011; 12: e602–20.
75 Flynn AC, Seed PT, Patel N, et al. Dietary patterns in obese
pregnant women; influence of a behavioral intervention of diet and
physical activity in the UPBEAT randomized controlled trial.
Int J Behav Nutr Phys Act 2016; 13: 124.
76 Dodd JM, Cramp C, Sui Z, et al. The eects of antenatal dietary and
lifestyle advice for women who are overweight or obese on maternal
diet and physical activity: the LIMIT randomised trial.
BMC Med 2014; 12: 161.
77 Ramakrishnan U, Grant F, Goldenberg T, Zongrone A, Martorell R.
Eect of women’s nutrition before and during early pregnancy on
maternal and infant outcomes: a systematic review.
Paediatr Perinat Epidemiol 2012; 26 (suppl 1): 285–301.
78 Morrison J, Dulal S, Harris-Fry H, et al. Formative qualitative
research to develop community-based interventions addressing low
birth weight in the plains of Nepal. Public Health Nutr 2018;
21: 377–84.
79 Chorghade GP, Barker M, Kanade S, Fall CHD. Why are rural
Indian women so thin? Findings from a village in Maharashtra.
Public Health Nutr 2006; 9: 9–18.
80 Barker M, Chorghade G, Crozier S, Leary S, Fall C. Gender
dierences in body mass index in rural India are determined by
socio-economic factors and lifestyle. J Nutr 2006; 136: 3062–68.
81 Huseinovic E, Bertz F, Leu Agelii M, Hellebo Johansson E,
Winkvist A, Brekke HK. Eectiveness of a weight loss intervention
in postpartum women: results from a randomized controlled trial
in primary health care. Am J Clin Nutr 2016; 104: 362–70.
82 Peacock AS, Bogossian FE, Wilkinson SA, Gibbons KS, Kim C,
McIntyre HD. A randomised controlled trial to delay or prevent type 2
diabetes after gestational diabetes: walking for exercise and nutrition
to prevent diabetes for you. Int J Endocrinol 2015; 2015: 423717.
83 van der Pligt P, Willcox J, Hesketh KD, et al. Systematic review of
lifestyle interventions to limit postpartum weight retention:
implications for future opportunities to prevent maternal overweight
and obesity following childbirth. Obes Rev 2013; 14: 792–805.
84 Lim S, O’Reilly S, Behrens H, Skinner T, Ellis I, Dunbar JA.
Eective strategies for weight loss in post-partum women:
a systematic review and meta-analysis. Obes Rev 2015; 16: 972–87.
85 Ritchie LD, Whaley SE, Spector P, Gomez J, Crawford PB.
Favorable impact of nutrition education on California WIC families.
J Nutr Educ Behav 2010; 42 (3 suppl): S2–10.
86 Herman DR, Harrison GG, Jenks E. Choices made by low-income
women provided with an economic supplement for fresh fruit and
vegetable purchase. J Am Diet Assoc 2006; 106: 740–44.
87 Neville CE, McKinley MC, Holmes VA, Spence D, Woodside JV.
The eectiveness of weight management interventions in
breastfeeding women—a systematic review and critical evaluation.
Birth 2014; 41: 223–36.
88 Phelan S, Hagobian T, Brannen A, et al. Eect of an internet-based
program on weight loss for low-income postpartum women:
a randomized clinical trial. JAMA 2017; 317: 2381–91.
89 Poston L, Caleyachetty R, Cnattingius S, et al. Preconceptional and
maternal obesity: epidemiology and health consequences.
Lancet Diabetes Endocrinol 2016; 4: 1025–36.
90 WHO. Global nutrition targets 2025: stunting policy brief. 2014.
policybrief_stunting/en/ (accessed March 6, 2018).
91 Monteiro CA, Benicio MH, Conde WL, et al. Narrowing
socioeconomic inequality in child stunting: the Brazilian experience,
1974–2007. Bull World Health Organ 2010; 88: 305–11.
92 Adams J, Mytton O, White M, Monsivais P. Why are some
population interventions for diet and obesity more equitable and
eective than others? The role of individual agency. PLoS Med 2016;
13: e1001990.
93 Lorenc T, Petticrew M, Welch V, Tugwell P. What types of
interventions generate inequalities? Evidence from systematic
reviews. J Epidemiol Community Health 2013; 67: 190–93.
94 Kelly MP, Barker M. Why is changing health-related behaviour so
dicult? Public Health 2016; 136: 109–16.
95 Shove E, Pantzar M, Watson M. The dynamics of social practice:
everyday life and how it changes. London: Sage, 2012.
96 Birdwell L. A study of the influence of image congruence on
consumer choice. J Bus 1968; 41: 76–88.
97 Last A. Business on a Mission: How to Build a Sustainable Brand.
Abingdon, UK: Routledge, 2016.
98 Unilever. Knorr’s green food steps to improve health and
livelihoods. June, 2015.
health-and-livelihoods.html (accessed March 6, 2018).
99 Brady JP. Marketing breast milk substitutes: problems and perils
throughout the world. Arch Dis Child 2012; 97: 529–32.
100 Swinburn B, Kraak V, Rutter H, et al. Strengthening of accountability
systems to create healthy food environments and reduce global
obesity. Lancet 2015; 385: 2534–45.
101 Weible C, Sabatier P. A guide to the advocacy coalition framework.
In: Fischer F, Miller G, Sidney M, eds. Handbook of public policy
analysis: theory, politics, and methods. FL, USA: Taylor and Francis
Group, 2007: 123–36.
102 WHO. Meeting to develop a global consensus on preconception
care to reduce maternal and childhood mortality and morbidity,
6–7 February 2012. 2013.
handle/10665/78067 (accessed March 6, 2018).
103 Acosta AM. Examining the political, institutional and governance
aspects of delivering a national multi-sectoral response to reduce
maternal and child malnutrition. Analysing nutrition governance:
Brazil country report. September, 2011.
dmfile/DFID_ANG_Brazil_Report_Final.pdf (accessed
March 6, 2018).
104 Kirkpatrick S, Maynard M, Raoul A, Stapleton J. Population health
interventions to curb intake of sugars: gaps in the evidence.
FASEB J 2017; 31 (suppl 1): 640.26 (abstr).
105 Saville NM, Shrestha BP, Style S, et al. Protocol of the Low Birth
Weight South Asia Trial (LBWSAT), a cluster-randomised controlled
trial testing impact on birth weight and infant nutrition of
Participatory Learning and Action through women’s groups, with
and without unconditional transfers of fortified food or cash during
pregnancy in Nepal. BMC Pregnancy Childbirth 2016; 16: 320.
... Maternal metabolic health during pregnancy has critical influence on the metabolic health of the offspring and possibly even in the subsequent generations [8]. There is increasing evidence that pre-conception health of women is of critical importance in shaping the metabolic health of the next generation [9][10][11]. In addition, GDM has been shown to be associated with adverse fetal programming [12]. ...
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Background Gestational Diabetes Mellitus (GDM) is hyperglycaemia first detected during pregnancy. Globally, GDM affects around 1 in 6 live births (up to 1 in 4 in low- and middle-income countries- LMICs), thus, urgent measures are needed to prevent this public health threat. Objective To determine the effectiveness of pre-pregnancy lifestyle in preventing GDM. Methods We searched MEDLINE, Web of science, Embase and Cochrane central register of controlled trials. Randomized control trials (RCTs), case-control studies, and cohort studies that assessed the effect of pre-pregnancy lifestyle (diet and/or physical activity based) in preventing GDM were included. Random effects model was used to calculate odds ratio (OR) with 95% confidence interval. The Cochrane ROB-2 and the Newcastle-Ottawa Scale were used for assessing the risk of bias. The protocol was registered in PROSPERO (ID: CRD42020189574) Results Database search identified 7935 studies, of which 30 studies with 257,876 pregnancies were included. Meta-analysis of the RCTs (N = 5; n = 2471) in women who received pre-pregnancy lifestyle intervention showed non-significant reduction of the risk of developing GDM (OR 0.76, 95% CI: 0.50–1.17, p = 0.21). Meta-analysis of cohort studies showed that women who were physically active pre-pregnancy (N = 4; n = 23263), those who followed a low carbohydrate/low sugar diet (N = 4; n = 25739) and those women with higher quality diet scores were 29%, 14% and 28% less likely to develop GDM respectively (OR 0.71, 95% CI: 0.57, 0.88, p = 0.002, OR 0.86, 95% CI: 0.68, 1.09, p = 0.22 and OR 0.72, 95% CI 0.60–0.87, p = 0.0006). Conclusion This study highlights that some components of pre-pregnancy lifestyle interventions/exposures such as diet/physical activity-based preparation/counseling, intake of vegetables, fruits, low carbohydrate/low sugar diet, higher quality diet scores and high physical activity can reduce the risk of developing gestational diabetes. Evidence from RCTs globally and the number of studies in LMICs are limited, highlighting the need for carefully designed RCTs that combine the different aspects of the lifestyle and are personalized to achieve better clinical and cost effectiveness.
... Preconception interventions are described in a paper series in The Lancet. [39][40][41] The paper highlights the pregnancy-planning period as a highly motivated time for lifestyle changes, eg improving diet, reducing/ quitting smoking and/or alcohol, and increasing exercise to reduce the risk of developing pain during pregnancy. 42 Lastly, women with back pain and pelvic girdle pain should be referred to educational programs and exercise early in the pregnancy. ...
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Introduction Pain during pregnancy affects women's well‐being, causes worry and is a risk factor for the child and the mother during labor. The aim was to investigate the relative importance of an extensive set of pregnancy‐related physiological symptoms and psychosocial factors assessed in the first trimester compared with the occurrence of pregnancy‐related pain symptoms later in the pregnancy. Material and methods Included were all women who booked an appointment for a first prenatal visit in one of 125 randomly selected general practitioner practices in Eastern Denmark from April 2015 to August 2016. These women answered an electronic questionnaire containing questions on the occurrence of five pregnancy‐related pain symptoms: back pain, leg cramps, pelvic cavity pain, pelvic girdle pain and uterine contractions. The questionnaire also included sociodemographic questions and questions on chronic diseases, physical symptoms, mental health symptoms, lifestyle and reproductive background. The questionnaire was repeated in each trimester. The relative importance of this set of factors from the first trimester on the five pregnancy‐related pain symptoms compared with the second and third trimesters was assessed in a dominance analysis. Results A total of 1491 women were included. The most important factor for pregnancy‐related pain in the second trimester and third trimester is the presence of the corresponding pain in the first trimester. Parity was associated with pelvic cavity pain and uterine contractions in the following pregnancies. For back pain and pelvic cavity pain, the odds increased as the women's estimated low self‐assessed fitness decreased and had low WHO‐5 wellbeing scores. Conclusions When including physical risk factors, sociodemographic factors, psychological factors and clinical risk factors, women's experiences of pregnancy‐related pain in the first trimester are the most important predictors for pain later in pregnancy. Beyond the expected positive effects of pregnancy‐related pain, notably self‐assessed fitness, age and parity were predictive for pain later in pregnancy.
... Then, participants were asked to brainstorm around the following key questions: (1) What motivates our curiosity about TR and our desire to do this type of work? (2) What are the advantages of TR, over what you/we normally do to solve health and scientific problems? (3) What are the advantages of careers in/related to TR, over careers in fundamental or clinical research? ...
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Translational research (TR) is the movement of fundamental scientific discoveries into healthcare settings and population health policy, and parallels the goals of DOHaD research. Unfortunately, there is little guidance on how to become a translational researcher. To understand the opinions of DOHaD trainees towards TR, we conducted a workshop at the DOHaD World Congress 2022. We found that trainees were enthusiastic for their work to have translational impact, and that they feel that holistic, multidisciplinary solutions may lead to more generalisable research. However, there lacks support for TR career pathways, which may stall the execution of the long-term vision of the DOHaD agenda. We put forward recommendations for trainees to clarify their purpose in pursuing TR and for seeking relevant people and patronages to support their training paths. For mentors, training institutions, and scientific societies, we recommend developing TR-specific programmes, and implementing training opportunities, networking events, and funding to support these endeavours.
... Combining motivational human interaction with digital interventions can increase engagement and the effectiveness of behaviour change interventions. 66 To improve adherence throughout the study period, we offer an individualised exercise regimen and provide encouragement, support and monitor the participants regularly, both in person and over the phone. ...
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Introduction Gestational diabetes mellitus (GDM) is associated with increased risk for type 2 diabetes in the mother and cardiometabolic diseases in the child. The preconception period is an optimal window to adapt the lifestyle for improved outcomes for both mother and child. Our aim is to determine the effect of a lifestyle intervention, initiated before and continued throughout pregnancy, on maternal glucose tolerance and other maternal and infant cardiometabolic outcomes. Methods and analysis This ongoing randomised controlled trial has included 167 females aged 18–39 years old at increased risk for GDM who are contemplating pregnancy. The participants were randomly allocated 1:1 to an intervention or control group. The intervention consists of exercise (volume is set by a heart rate-based app and corresponds to ≥ 1 hour of weekly exercise at ≥ 80% of individual heart rate maximum), and time-restricted eating (≤ 10 hours/day window of energy intake). The primary outcome measure is glucose tolerance in gestational week 28. Maternal and offspring outcomes are measured before and during pregnancy, at delivery, and at 6–8 weeks post partum. Primary and secondary continuous outcome measures will be compared between groups based on the ‘intention to treat’ principle using linear mixed models. Ethics and dissemination The Regional Committees for Medical and Health Research Ethics in Norway has approved the study (REK 143756). The anonymised results will be submitted for publication and posted in a publicly accessible database of clinical study results. Trial registration number Clinical trial gov NCT04585581.
Aim To explore the nutritional content of meal kits from two main Australian companies over a 6‐week period against healthy eating guidelines for pregnancy. Method Across the 6‐week period, weekly meal kits from both Provider 1 and Provider 2 were purchased, 36 individual meals were assessed. All data were analysed for the development of a macronutrient and micronutrient profile of meals. Extracted data were macronutrient, vitamin, and mineral composition, which were compared against the healthy eating guidelines for pregnant women in Australia and New Zealand. Results Meal kits include higher levels of sodium, and lower levels of dietary fibre, calcium, magnesium, zinc, iron, thiamin, riboflavin, grains, and dairy when compared against the guidelines for healthy eating for pregnant women in Australia and New Zealand. Conclusions and implications Meal kits may increase meals prepared and consumed in the home, and thanks to the clear instructions and pre‐portioned ingredients, may reduce stress related to food preparation. They have the potential to provide nutritionally adequate meals to pregnant women as a way to mitigate food insecurity or hunger during pregnancy and may provide some nutritional benefits and have the potential to remove some of the challenges with maintaining an adequate diet when pregnant.
Aim Optimising preconception health increases the likelihood of conception, positively influences short‐ and long‐term pregnancy outcomes and reduces intergenerational chronic disease risk. Our aim was to synthesise study characteristics and maternal outcomes of digital or blended (combining face to face and digital modalities) interventions in the preconception period. Methods We searched six databases (PubMed, Cochrane, Embase, Web of Science, CINHAL and PsycINFO) from 1990 to November 2022 according to the PRISMA guidelines for randomised control trials, quasi‐experimental trials, observation studies with historical control group. Studies were included if they targeted women of childbearing age, older than 18 years, who were not currently pregnant and were between pregnancies or/and actively trying to conceive. Interventions had to be delivered digitally or via digital health in combination with face‐to‐face delivery and aimed to improve modifiable behaviours, including dietary intake, physical activity, weight and supplementation. Studies that included women diagnosed with type 1 or 2 diabetes were excluded. Risk of bias was assessed using the Academy of Nutrition and Dietetics quality criteria checklist. Study characteristics, intervention characteristics and outcome data were extracted. Results Ten studies (total participants n=4,461) were included, consisting of nine randomised control trials and one pre–post cohort study. Seven studies received a low risk of bias and two received a neutral risk of bias. Four were digitally delivered and six were delivered using blended modalities. A wide range of digital delivery modalities were employed, with the most common being email and text messaging. Other digital delivery methods included web‐based educational materials, social media, phone applications, online forums and online conversational agents. Studies with longer engagement that utilised blended delivery showed greater weight loss. Conclusion More effective interventions appear to combine both traditional and digital delivery methods. More research is needed to adequately test effective delivery modalities across a diverse range of digital delivery methods, as high heterogeneity was observed across the small number of included studies.
Background The metabolic changes that ultimately lead to gestational diabetes mellitus (GDM) likely begin before pregnancy. Cannabis use might increase the risk of GDM by increasing appetite or promoting fat deposition and adipogenesis. Objectives We aimed to assess the association between preconception cannabis use and GDM incidence. Methods We analysed individual‐level data from eight prospective cohort studies. We identified the first, or index, pregnancy (lasting ≥20 weeks of gestation with GDM status) after cannabis use. In analyses of pooled individual‐level data, we used logistic regression to estimate study‐type‐specific odds ratios (OR) and 95% confidence intervals (CI), adjusting for potential confounders using random effect meta‐analysis to combine study‐type‐specific ORs and 95% CIs. Stratified analyses assessed potential effect modification by preconception tobacco use and pre‐pregnancy body mass index (BMI). Results Of 17,880 participants with an index pregnancy, 1198 (6.7%) were diagnosed with GDM. Before the index pregnancy, 12.5% of participants used cannabis in the past year. Overall, there was no association between preconception cannabis use in the past year and GDM (OR 0.97, 95% CI 0.79, 1.18). Among participants who never used tobacco, however, those who used cannabis more than weekly had a higher risk of developing GDM than those who did not use cannabis in the past year (OR 2.65, 95% CI 1.15, 6.09). This association was not present among former or current tobacco users. Results were similar across all preconception BMI groups. Conclusions In this pooled analysis of preconception cohort studies, preconception cannabis use was associated with a higher risk of developing GDM among individuals who never used tobacco but not among individuals who formerly or currently used tobacco. Future studies with more detailed measurements are needed to investigate the influence of preconception cannabis use on pregnancy complications.
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This study aims to explore the association of maternal preconceptional folic acid (FA) supplementation with gestational age and preterm birth in twin pregnancies, and whether the association varies by chorionicity or conception mode. From November 2018 to December 2021, the information of FA supplementation and pregnancy outcomes were collected in twin pregnant women. The linear regression models and the logistic regression were used to test the association of preconceptional FA supplementation with gestational age at delivery and preterm birth and premature rupture of membranes (PROM). A total of 416 twin pregnancies were included. Compared with no use in twins, maternal preconceptional FA use was associated with a 0.385-week longer gestational age (95% CI 0.019–0.751) and lower risk of preterm birth < 36 weeks (adjusted OR 0.519; 95% CI 0.301–0.895) and PROM (adjusted OR 0.426; 95% CI 0.215–0.845). The protective effect on preterm birth < 36 weeks and PROM is similar whether taking FA supplements alone or multivitamins. However, the associations varied by chorionicity and conception mode of twins or compliance with supplementation. The positive associations between preconceptional FA use and gestational age only remained significant among twins via assisted reproductive technology or dichorionic diamniotic twins. Significant protective effects on preterm birth < 36 weeks and PROM were only found among women who took FA at least 4 times a week before conception. Maternal preconceptional FA supplementation was associated with longer gestation duration and lower risk of preterm birth < 36 weeks and PROM in twin pregnancies. To improve the success of their pregnancies, reproductive women should start taking FA supplements well before conception and with good compliance.
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The Global AA-HA! Guidance aims to assist governments in deciding what they plan to do – and how they plan to do it – as they respond to the health needs of adolescents in their countries. It is intended as a reference document for national-level policy-makers and programme managers to assist them in planning, implementing, monitoring and evaluation of adolescent health programmes. The Guidance summarizes the main arguments for investing in adolescent health, and details the key steps from understanding the country’s epidemiological profile, undertaking a landscape analysis to clarify what is already been done and by whom, conducting a consultative process for setting priorities, to planning, implementing, monitoring and evaluating national adolescent health programmes. It also includes key research priorities and case studies to illustrate that what is being recommended can be done, and in some cases has already been done. Global AA-HA! Guidance has 6 overarching messages 1. Approach The AA-HA! guidance provides a systematic approach for understanding adolescent health needs, prioritizing these in the country context and planning, monitoring and evaluating adolescent health programmes. 2. Prevention More than 3000 adolescents die every day from largely preventable causes such as unintentional injuries; violence; sexual and reproductive health problems, including HIV; communicable diseases such as acute respiratory infections and diarrhoea; noncommunicable diseases, poor nutrition and lack of physical activity; and mental health, substance use and suicide. Even more suffer from ill health due to these causes. Although much research is still needed, effective interventions are available for countries to ACT NOW. 3. Priority setting The nature, scale and impact of adolescent health needs vary between countries, between age groups and between the two sexes. Funds are limited, and governments should prioritize their actions according to the disease and injury risk factor profiles of their adolescent population, as well as the cost-effectiveness of the interventions. Adolescent health needs intensify in humanitarian and fragile settings. Leadership 4. Leadership Strong leadership at the highest level of government should foster implementation of adolescent-responsive policies and programmes. To accelerate progress for adolescent health, countries should consider institutionalizing national adolescent health programmes. Through the Sustainable Development Goals and the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030), globally agreed targets related to adolescent health exist, along with indicators to monitor progress towards these. Age and sex disaggregation of data will be essential. 5. Yields from investing in adolescent health span across generations There is a pressing need for increased investment in adolescent health programmes, to improve adolescent health and survival in the short term, for their future health as adults, and for the next generation. This is a matt er of urgency if we want to curb the epidemic of noncommunicable diseases, to sustain and reap the health and social benefits from the recent impressive gains in child health, and ultimately to have THRIVING and peaceful societies. 6. Together WITH adolescents, FOR adolescents. Adolescents have particular health needs related to their rapid physical, sexual, social and emotional development and to the specific roles that they play in societies. Treating them as old children or young adults does not work. National development policies, programmes and plans should be informed by adolescents’ particular health related needs, and the best way to achieve this is to develop and implement these programmes with adolescents. Whole-of-government. To achieve the Sustainable Development Goal targets, the health and other sectors need to normalize attention to adolescents’ needs in all aspects of their work. An Adolescent Health in All Policies (AHiAP) approach should be practised in policy formulation, implementation, monitoring and evaluation.
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Objective To explore the factors affecting intra-household food allocation practices to inform the development of interventions to prevent low birth weight in rural plains of Nepal. Design Qualitative methodology using purposive sampling to explore the barriers and facilitating factors to improved maternal nutrition. Setting Rural Dhanusha District, Nepal. Subjects We purposively sampled twenty-five young daughters-in-law from marginalised groups living in extended families and conducted semi-structured interviews with them. We also conducted one focus group discussion with men and one with female community health volunteers who were mothers-in-law. Results Gender and age hierarchies were important in household decision making. The mother-in-law was responsible for ensuring that a meal was provided to productive household members. The youngest daughter-in-law usually cooked last and ate less than other family members, and showed respect for other family members by cooking only when permitted and deferring to others’ choice of food. There were limited opportunities for these women to snack between main meals. Daughters-in-law’ movement outside the household was restricted and therefore family members perceived that their nutritional need was less. Poverty affected food choice and families considered cost before nutritional value. Conclusions It is important to work with the whole household, particularly mothers-in-law, to improve maternal nutrition. We present five barriers to behaviour change: poverty; lack of knowledge about cheap nutritional food, the value of snacking, and cheap nutritional food that does not require cooking; sharing food; lack of self-confidence; and deference to household guardians. We discuss how we have targeted our interventions to develop knowledge, discuss strategies to overcome barriers, engage mothers-in-law, and build the confidence and social support networks of pregnant women.
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Background Around 30% of the world’s stunted children live in India. The Government of India has proposed a new cadre of community-based workers to improve nutrition in 200 districts. We aimed to find out the effect of such a worker carrying out home visits and participatory group meetings on children’s linear growth. Methods We did a cluster-randomised controlled trial in two adjoining districts of Jharkhand and Odisha, India. 120 clusters (around 1000 people each) were randomly allocated to intervention or control using a lottery. Randomisation took place in July, 2013, and was stratified by district and number of hamlets per cluster (0, 1–2, or ≥3), resulting in six strata. In each intervention cluster, a worker carried out one home visit in the third trimester of pregnancy, monthly visits to children younger than 2 years to support feeding, hygiene, care, and stimulation, as well as monthly women’s group meetings to promote individual and community action for nutrition. Participants were pregnant women identified and recruited in the study clusters and their children. We excluded stillbirths and neonatal deaths, infants whose mothers died, those with congenital abnormalities, multiple births, and mother and infant pairs who migrated out of the study area permanently during the trial period. Data collectors visited each woman in pregnancy, within 72 h of her baby’s birth, and at 3, 6, 9, 12, and 18 months after birth. The primary outcome was children’s length-for-age Z score at 18 months of age. Analyses were by intention to treat. Due to the nature of the intervention, participants and the intervention team were not masked to allocation. Data collectors and the data manager were masked to allocation. The trial is registered as ISCRTN (51505201) and with the Clinical Trials Registry of India (number 2014/06/004664). Results Between Oct 1, 2013, and Dec 31, 2015, we recruited 5781 pregnant women. 3001 infants were born to pregnant women recruited between Oct 1, 2013, and Feb 10, 2015, and were therefore eligible for follow-up (1460 assigned to intervention; 1541 assigned to control). Three groups of children could not be included in the final analysis: 147 migrated out of the study area (67 in intervention clusters; 80 in control clusters), 77 died after the neonatal period and before 18 months (31 in intervention clusters; 46 in control clusters), and seven had implausible length-for-age Z scores (<–5 SD; one in intervention cluster; six in control clusters). We measured 1253 (92%) of 1362 eligible children at 18 months in intervention clusters, and 1308 (92%) of 1415 eligible children in control clusters. Mean length-for-age Z score at 18 months was –2·31 (SD 1·12) in intervention clusters and –2·40 (SD 1·10) in control clusters (adjusted difference 0·107, 95% CI –0·011 to 0·226, p=0·08). The intervention did not significantly affect exclusive breastfeeding, timely introduction of complementary foods, morbidity, appropriate home care or care- seeking during childhood illnesses. In intervention clusters, more pregnant women and children attained minimum dietary diversity (adjusted odds ratio [aOR] for women 1·39, 95% CI 1·03–1·90; for children 1·47, 1·07–2·02), more mothers washed their hands before feeding children (5·23, 2·61–10·5), fewer children were underweight at 18 months (0·81, 0·66–0·99), and fewer infants died (0·63, 0·39–1·00). Interpretation Introduction of a new worker in areas with a high burden of undernutrition in rural eastern India did not significantly increase children’s length. However, certain secondary outcomes such as self-reported dietary diversity and handwashing, as well as infant survival were improved. The interventions tested in this trial can be further optimised for use at scale, but substantial improvements in growth will require investment in nutrition- sensitive interventions, including clean water, sanitation, family planning, girls’ education, and social safety nets.
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Background Cash-based interventions (CBIs), offer an interesting opportunity to prevent increases in wasting in humanitarian aid settings. However, questions remain as to the impact of CBIs on nutritional status and, therefore, how to incorporate them into emergency programmes to maximise their success in terms of improved nutritional outcomes. This study evaluated the effects of three different CBI modalities on nutritional outcomes in children under 5 y of age at 6 mo and at 1 y. Methods and findings We conducted a four-arm parallel longitudinal cluster randomised controlled trial in 114 villages in Dadu District, Pakistan. The study included poor and very poor households (n = 2,496) with one or more children aged 6–48 mo (n = 3,584) at baseline. All four arms had equal access to an Action Against Hunger–supported programme. The three intervention arms were as follows: standard cash (SC), a cash transfer of 1,500 Pakistani rupees (PKR) (approximately US$14; 1 PKR = US$0.009543); double cash (DC), a cash transfer of 3,000 PKR; or a fresh food voucher (FFV) of 1,500 PKR; the cash or voucher amount was given every month over six consecutive months. The control group (CG) received no specific cash-related interventions. The median total household income for the study sample was 8,075 PKR (approximately US$77) at baseline. We hypothesized that, compared to the CG in each case, FFVs would be more effective than SC, and that DC would be more effective than SC—both at 6 mo and at 1 y—for reducing the risk of child wasting. Primary outcomes of interest were prevalence of being wasted (weight-for-height z-score [WHZ] < −2) and mean WHZ at 6 mo and at 1 y. The odds of a child being wasted were significantly lower in the DC arm after 6 mo (odds ratio [OR] = 0.52; 95% CI 0.29, 0.92; p = 0.02) compared to the CG. Mean WHZ significantly improved in both the FFV and DC arms at 6 mo (FFV: z-score = 0.16; 95% CI 0.05, 0.26; p = 0.004; DC: z-score = 0.11; 95% CI 0.00, 0.21; p = 0.05) compared to the CG. Significant differences on the primary outcome were seen only at 6 mo. All three intervention groups showed similar significantly lower odds of being stunted (height-for-age z-score [HAZ] < −2) at 6 mo (DC: OR = 0.39; 95% CI 0.24, 0.64; p < 0.001; FFV: OR = 0.41; 95% CI 0.25, 0.67; p < 0.001; SC: OR = 0.36; 95% CI 0.22, 0.59; p < 0.001) and at 1 y (DC: OR = 0.53; 95% CI 0.35, 0.82; p = 0.004; FFV: OR = 0.48; 95% CI 0.31, 0.73; p = 0.001; SC: OR = 0.54; 95% CI 0.36, 0.81; p = 0.003) compared to the CG. Significant improvements in height-for-age outcomes were also seen for severe stunting (HAZ < −3) and mean HAZ. An unintended outcome was observed in the FFV arm: a negative intervention effect on mean haemoglobin (Hb) status (−2.6 g/l; 95% CI −4.5, −0.8; p = 0.005). Limitations of this study included the inability to mask participants or data collectors to the different interventions, the potentially restrictive nature of the FFVs, not being able to measure a threshold effect for the two different cash amounts or compare the different quantities of food consumed, and data collection challenges given the difficult environment in which this study was set. Conclusions In this setting, the amount of cash given was important. The larger cash transfer had the greatest effect on wasting, but only at 6 mo. Impacts at both 6 mo and at 1 y were seen for height-based growth variables regardless of the intervention modality, indicating a trend toward nutrition resilience. Purchasing restrictions applied to food-based voucher transfers could have unintended effects, and their use needs to be carefully planned to avoid this. Trial registration ISRCTN registry ISRCTN10761532
This third edition provides translations of all chapters of the most recent fifth German edition of Motivation and Action, including several entirely new chapters. It provides comprehensive coverage of the history of motivation, and introduces up-to-date theories and new research findings. Early sections provide a broad introduction to, and deep understanding of, the field of motivation psychology, mapping out different perspectives and research traditions. Subsequent chapters examine major themes of human motivation, including achievement, affiliation, and power motivation as well as the fundamentals of motivation psychology, such as motivated and goal oriented behaviors, implicit and explicit motives, and the regulation of development. In addition, the book discusses the roles of motivation in three practical fields: school and college, the workplace, and sports. Topics featured in this text include: Social Relationships and its effects on sexual or intimacy motivation. Conscious and unconscious motivators of behavior. Drives and incentives in the fields of achievement, intimacy, sociability and power. How the biochemistry and structures of our brain shapes motivated behavior. How to engage in intentional goal-directed behavior. The potential and limits of motivation and self-direction in shaping our lives. Motivation and Action, Third Edition, is a must-have resource for undergraduate and graduate students as well as researchers in the fields of motivation psychology, cognitive psychology, and social psychology, as well as personality psychology and agency. © Springer International Publishing AG, part of Springer Nature 1991, 2010, 2018.
(Abstracted from JAMA 2017;317(23):2381–2391) Postpartum weight retention increases the lifetime risk of obesity, and this risk seems to be highest among low-income women. The current clinical trial aimed to test if an Internet-based weight loss program in addition to a special supplemental nutrition program for women, infants, and children (WIC program) could aid low-income postpartum women in greater weight loss than the WIC program alone.
Periconceptional nutrition and lifestyle are essential in pathogenesis and prevention of most reproductive failures, pregnancy outcome and future health. We aimed to investigate whether personalized mobile health (mHealth) coaching empowers couples contemplating pregnancy to increase healthy behaviour and chances of pregnancy. A survey was conducted among 1053 women and 332 male partners who received individual coaching using the mHealth programme ‘Smarter Pregnancy’ to change poor nutrition and lifestyle for 26 weeks, depending on pregnancy state and gender. Poor behaviours were translated into a total risk score (TRS) and Poisson regression analysis was performed to estimate associations with the chance of pregnancy adjusted for fertility status, age and baseline body mass index expressed as adjusted hazard ratio (aHR) and 95% confidence interval (95% CI). A lower (a)HR suggests a higher chance of achieving pregnancy. A higher TRS was significantly associated with a lower chance of pregnancy in all women (aHR 0.79, 95% CI 0.72–0.85) and (a)HR was lowest in women whose male partner participated (aHR 0.75, 95% CI 0.61–0.91). This survey shows that empowerment of couples in changing poor nutrition and lifestyle using personalized mHealth coaching is associated with an enhanced pregnancy chance in both infertile and fertile couples.
Importance Postpartum weight retention increases lifetime risk of obesity and related morbidity. Few effective interventions exist for multicultural, low-income women. Objective To test whether an internet-based weight loss program in addition to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC program) for low-income postpartum women could produce greater weight loss than the WIC program alone over 12 months. Design, Setting, and Participants A 12-month, cluster randomized, assessor-blind, clinical trial enrolling 371 adult postpartum women at 12 clinics in WIC programs from the California central coast between July 2011 and May 2015 with data collection completed in May 2016. Interventions Clinics were randomized to the WIC program (standard care group) or the WIC program plus a 12-month primarily internet-based weight loss program (intervention group), including a website with weekly lessons, web diary, instructional videos, computerized feedback, text messages, and monthly face-to-face groups at the WIC clinics. Main Outcomes and Measures The primary outcome was weight change over 12 months, based on measurements at baseline, 6 months, and 12 months. Secondary outcomes included proportion returning to preconception weight and changes in physical activity and diet. Results Participants included 371 women (mean age, 28.1 years; Hispanic, 81.6%; mean weight above prepregnancy weight, 7.8 kg; mean months post partum, 5.2 months) randomized to the intervention group (n = 174) or standard care group (n = 197); 89.2% of participants completed the study. The intervention group produced greater mean 12-month weight loss compared with the standard care group (3.2 kg in the intervention group vs 0.9 kg in standard care group, P < .001; difference, 2.3 kg (95% CI, 1.1 to 3.5). More participants in the intervention group than the standard care group returned to preconception weight by 12 months (32.8% in the intervention group vs 18.6% in the standard care group, P < .001; difference, 14.2 percentage points [95% CI, 4.7 to 23.5]). The intervention group and standard care group did not significantly differ in 12-month changes in physical activity (mean [95% CI]: −7.8 min/d [−16.1 to 0.4] in the intervention group vs −7.2 min/d [−14.6 to 0.3] in the standard care group; difference, −0.7 min/d [95% CI, −42.0 to 10.6], P = .76), calorie intake (mean [95% CI]: −298 kcal/d [−423 to −174] in the intervention group vs −144 kcal/d [−257 to −32] in the standard care group; difference, −154 kcal/d [−325 to 17], P = .06), or incidences of injury (16 in the intervention group vs 16 in the standard care group) or low breastmilk supply from baseline to month 6 (21 of 61 participants in the intervention group vs 23 of 72 participants in the standard care group) and from month 6 to 12 (13 of 32 participants in the intervention group vs 14 of 37 participants in the standard care group). Conclusions and Relevance Among low-income postpartum women, an internet-based weight loss program in addition to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC program) compared with the WIC program alone resulted in a statistically significant greater weight loss over 12 months. Further research is needed to determine program and cost-effectiveness as part of the WIC program. Trial Registration Identifier: NCT01408147
OBJECTIVE: To assess trends in the prevalence and social distribution of child stunting in Brazil to evaluate the effect of income and basic service redistribution policies implemented in that country in the recent past. METHODS: The prevalence of stunting (height-for-age z score below −2 using the Child Growth Standards of the World Health Organization) among children aged less than 5 years was estimated from data collected during national household surveys carried out in Brazil in 1974-75 (n = 34 409), 1989 (n = 7374), 1996 (n = 4149) and 2006-07 (n = 4414). Absolute and relative socioeconomic inequality in stunting was measured by means of the slope index and the concentration index of inequality, respectively. FINDINGS: Over a 33-year period, we documented a steady decline in the national prevalence of stunting from 37.1% to 7.1%. Prevalence dropped from 59.0% to 11.2% in the poorest quintile and from 12.1% to 3.3% among the wealthiest quintile. The decline was particularly steep in the last 10 years of the period (1996 to 2007), when the gaps between poor and wealthy families with children under 5 were also reduced in terms of purchasing power; access to education, health care and water and sanitation services; and reproductive health indicators. CONCLUSION: In Brazil, socioeconomic development coupled with equity-oriented public policies have been accompanied by marked improvements in living conditions and a substantial decline in child undernutrition, as well as a reduction of the gap in nutritional status between children in the highest and lowest socioeconomic quintiles. Future studies will show whether these gains will be maintained under the current global economic crisis.