http://www.diva-portal.org This is the published version of a paper published in Global Health Action. Citation for the original published paper (version of record): Norris, S A., Daar, A., Balasubramanian, D., Byass, P., Kimani-Murage, E. et al. (2017) Understanding and acting on the developmental origins of health and disease in Africa would improve health across generations. Global Health Action, 10(1): 1334985 https://doi.org/10.1080/16549716.2017.1334985 Access to the published version may require subscription. N.B. When citing this work, cite the original published paper. Permanent link to this version: http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-138221
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http://www.diva-portal.org
This is the published version of a paper published in Global Health Action.
Citation for the original published paper (version of record):
Norris, S A., Daar, A., Balasubramanian, D., Byass, P., Kimani-Murage, E. et al. (2017)Understanding and acting on the developmental origins of health and disease in Africa wouldimprove health across generations.Global Health Action, 10(1): 1334985https://doi.org/10.1080/16549716.2017.1334985
Access to the published version may require subscription.
N.B. When citing this work, cite the original published paper.
Permanent link to this version:http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-138221
Full Terms & Conditions of access and use can be found athttp://www.tandfonline.com/action/journalInformation?journalCode=zgha20
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Understanding and acting on the developmentalorigins of health and disease in Africa wouldimprove health across generations
Shane A. Norris , Abdallah Daar, Dorairajan Balasubramanian, Peter Byass,Elizabeth Kimani-Murage, Andrew Macnab, Christoff Pauw, Atul Singhal,Chittaranjan Yajnik, James Akazili, Naomi Levitt, Jihene Maatoug, NolwaziMkhwanazi, Sophie E. Moore, Moffat Nyirenda , Juliet R. C. Pulliam , TamsenRochat, Rihlat Said-Mohamed, Soraya Seedat, Eugene Sobngwi , MarkTomlinson , Elona Toska & Cari van Schalkwyk
To cite this article: Shane A. Norris , Abdallah Daar, Dorairajan Balasubramanian, Peter Byass,Elizabeth Kimani-Murage, Andrew Macnab, Christoff Pauw, Atul Singhal, Chittaranjan Yajnik,James Akazili, Naomi Levitt, Jihene Maatoug, Nolwazi Mkhwanazi, Sophie E. Moore, MoffatNyirenda , Juliet R. C. Pulliam , Tamsen Rochat, Rihlat Said-Mohamed, Soraya Seedat, EugeneSobngwi , Mark Tomlinson , Elona Toska & Cari van Schalkwyk (2017) Understanding andacting on the developmental origins of health and disease in Africa would improve health acrossgenerations, Global Health Action, 10:1, 1334985, DOI: 10.1080/16549716.2017.1334985
To link to this article: http://dx.doi.org/10.1080/16549716.2017.1334985
Understanding and acting on the developmental origins of health and diseasein Africa would improve health across generationsShane A. Norris a,b, Abdallah Daara,c, Dorairajan Balasubramaniana,d, Peter Byassa,e, Elizabeth Kimani-Muragea,f, Andrew Macnaba,g, Christoff Pauwa, Atul Singhala,h, Chittaranjan Yajnika,i, James Akazilij,Naomi Levittk, Jihene Maatougl, Nolwazi Mkhwanazim, Sophie E. Mooren, Moffat Nyirenda o,Juliet R. C. Pulliam p, Tamsen Rochatb,q, Rihlat Said-Mohamedb, Soraya Seedatr, Eugene Sobngwi s,Mark Tomlinson t, Elona Toskau and Cari van Schalkwyk p
aStellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre at Stellenbosch University, Stellenbosch, South Africa;bMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of theWitwatersrand, Johannesburg, South Africa; cDalla Lana School of Public Health and Department of Surgery, University of Toronto,Toronto, Canada; dL V Prasad Eye Institute, Hyderabad, India; eDepartment of Public Health and Clinical Medicine, Umeå University,Umea, Sweden; fAfrican Population and Health Research Center, Kenya; gDepartment of Pediatrics, University of British Columbia,Vancouver, Canada; hInstitute of Child Health, University College London, London, UK; iKing Edward Memorial Hospital Research Centre,Pune, India; jINDEPTH Network, Ghana; kDepartment of Diabetic Medicine and Endocrinology, University of Cape Town, Cape Town,South Africa; lDepartment of Epidemiology, Hospital Farhat Hached, Sousse, Tunisia; mDepartment of Anthropology, University of theWitwatersrand, Johannesburg, South Africa; nDivision of Women’s Health, King’s College London, London, UK; oCollege of Medicine,University of Malawi, Zomba, Malawi; pDST-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), University ofStellenbosch, Stellenbosch, South Africa; qHuman and Social Development Research Programme, Human Sciences Research Council,Durban, South Africa; rDepartment of Psychiatry, Stellenbosch University, Stellenbosch, South Africa; sDepartment of AppliedEpidemiology, University of Yaoundé, Yaounde, Cameroon; tDepartment of Psychology, Stellenbosch University, Stellenbosch,South Africa; uDepartment of Social Policy and Intervention, University of Oxford, Oxford, UK
ABSTRACTData from many high- and low- or middle-income countries have linked exposures during keydevelopmental periods (in particular pregnancy and infancy) to later health and disease.Africa faces substantial challenges with persisting infectious disease and now burgeoningnon-communicable disease.This paper opens the debate to the value of strengthening thedevelopmental origins of health and disease (DOHaD) research focus in Africa to tackle criticalpublic health challenges across the life-course. We argue that the application of DOHaDscience in Africa to advance life-course prevention programmes can aid the achievement ofthe Sustainable Development Goals, and assist in improving health across generations. Toincrease DOHaD research and its application in Africa, we need to mobilise multisectoralpartners, utilise existing data and expertise on the continent, and foster a new generation ofyoung African scientists engrossed in DOHaD.
ARTICLE HISTORYReceived 10 October 2016Accepted 10 March 2017
RESPONSIBLE EDITORJennifer Stewart Williams,Umeå University, Sweden
KEYWORDSAfrica; developmentalorigins of health and disease(DOHaD); non-communicable disease; lifecourse epidemiology; policy;Sustainable DevelopmentGoals (SDGs)
Developmental origins of health and disease (DOHaD)has become a globally recognised concept (see theDOHaD Cape Town manifesto) [1]. DOHaD is amulti-disciplinary field, exploring how environmentalfactors acting during early life (in particular the periodof pregnancy and infancy) interact to change individualtrajectories that may increase risk for health conditionsin later life. The scientific evidence of DOHaD overwhel-mingly demonstrates that the environment in which theembryo, fetus and child grows and develops influencesboth short-term (stunting risk; cognitive function) andlonger-term health and wellbeing (non-communicablediseases [NCDs]; human capital) [2]. Consequently, thefirst 1000 days (from conception to second birthday) arecritically important, but there is recognition that the pre-conception period and later years also matter. DOHaDscience mandates a life-course approach, recognisingthat different needs emerge at various stages in life
(such as pregnancy, infancy, childhood, adolescenceand parenthood) [3], which form an intergenerationalcycle (Figure 1). Investing in early-life interventionscould effectively promote healthier trajectories lifelongand across generations.
Africa has persisting burdens of malnutrition andinfectious diseases (particularly HIV, TB and malaria).However, Africa now also faces a growingNCD encum-brance. Already by 2010, over two million deaths inSub-Saharan Africa were due to NCDs and this was a46% increase from 1990 [4]. In terms of DOHaDscience, the combination of early life malnutrition(under-nutrition) coupled with excess weight gain inchildhood, adolescence and adulthood accelerateincreases in NCDs, particularly type-2 diabetes [5].This epidemiological transition in Africa (increasingincidence of cardio-metabolic disease against a back-drop of maternal and child malnutrition such as
CONTACT Shane A. Norris [email protected] MRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics,Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, 2198 Johannesburg, South Africa
GLOBAL HEALTH ACTION, 2017VOL. 10, 1334985https://doi.org/10.1080/16549716.2017.1334985
anaemia and stunting), which is at varying stages oftransition across the African continent [6], will be detri-mental not only in health terms, but also for economicdevelopment due to escalating productivity losses andhealth care costs [7]. Shifting our attention to preven-tion would equate to millions of deaths averted andeconomic losses reduced [8]. DOHaD provides impor-tant insights for such a shift to prevention of NCDs inAfrica and is closely aligned with many of the targetsenshrined within the United Nations’ SustainableDevelopment Goals [9]. For example, ensuring genderequity will empower mothers to make better decisionsfor themselves and their children.
The recent Lancet Series on Early ChildhoodDevelopment underscores the importance of ‘nurturingcare’ and multi-sectoral health interventions in earlychildhood can bring extensive benefit to families andyoung children [10]. A number of evidence-based, cost-effective opportunities to improve maternal and infanthealth have been documented [11]. Some strategies forconsideration include: optimising maternal and infantnutrition (nutrient supplementation), reducing foetalexposure to toxins (such as smoking and alcohol) andtackling antenatal and postnatal maternal mental healthconditions (such as depression and anxiety). We believethat if these are applied systematically as part of nationalhealth strategies they will reduce the incidence andadverse effects of NCDs (obesity, type-2 diabetes,hypertension, coronary heart disease, chronic kidneydisease, musculoskeletal disorders, some mental healthconditions and a range of cancers) and improve humancapital. A key question is how these proposed interven-tions could be successfully and sustainably implemen-ted in Africa. Africa has had public health
implementation success stories, for example: (1)Zambia’s Malaria Booster Project reduced malaria-linked cases and mortality by 31% and 37% respectivelybetween 2006 and 2008; (2) HIV prevention efforts inmany African countries resulted in observed behaviourchange in young men and women and an increased useof condoms; and (3) The Southern Africa initiative hasalmost eliminated childhood mortality from measles inseveral African countries through effective vaccinationcampaigns (http://blogs.worldbank.org/africacan/african-successes-listing-the-success-stories). Learningfrom these, and other examples, could provide insightinto how to implement NCD prevention interventionsacross the life-course; however, more research is stillneeded to add to the local evidence base. Science fun-ders and institutions, like the African Academy ofSciences, could play a significant role in highlightingthe gaps and supporting African scientists.
To further advance the successful implementation ofDOHaD science, there is also a need for political vision,commitment and leadership at the highest level toencourage national dialogue within the African context.Multi-national efforts that may draw on the AfricanUnion could be particularly effective in facilitating dia-logue and supporting scientific efforts. It is crucial thatconcerned players from all sectors come together todesign and implement programmes aimed at improv-ing current and future health through prevention.
Africa lacks a critical mass of scientists and research-ers in many fields, and DOHaD is no exception. There isa need to attract and mentor young investigators toensure that the future research necessary to advanceDOHaD-related science can call on the necessaryhuman resources. Also, the DOHaD field needs to
pre-conception
fetal growth
birth
first two years
later childhood
adolescence
parenthood
toxic exposures to eggs and sperm
poor nutrition during pregnancy
traumas to mother and baby; low or high birth weight
promote healthy weight gain and early childhood development
promote school attendance and health literacy
Figure 1. The DOHaD intergenerational cycle, annotated with examples of relevant stresses and exposures and indicating(in italic text boxes) examples of recommended interventions.
inform and engage with the existing very high qualityscientists on the continent whose research may be rele-vant. The DOHaD paradigm has only been explored in afew African countries, possibly due to limited longitudi-nal data from birth to adulthood [12]. This situationcannot be remedied in the short term, but there may beindirect methods that could be used on existing data (forexample, data from African demographic surveillancesites that are part of the INDEPTH network; www.indepth-network.org), to assess the likely extent ofDOHaD effects in African populations.
Africa is heterogeneous, so context matters. Thereare not only distinct differences between African coun-tries, but often, within a country there are regionalcultural differences. Therefore, health policies, includ-ing those to address DOHaD, should take this intoaccount. For example, while prevention of stuntingand promotion of linear growth clearly has long-termbenefits for health and human capital [13], faster weightgain in infancy is also associated with a greater risk ofobesity and hence NCDs [14]. Therefore, for one popu-lation the intervention may be more centred on pro-moting infant linear growth with less concern aroundfaster weight gain, while in another population andcontext minimising excessive infant weight gain maybe more relevant to offset risk in later life [15]. Also, asthe levers to foster healthy nutritional practices andpatterns of growth in infancy may vary due to culturalpractices and context, more multi-site studies that takeinto account population and cultural variation withinand between African countries could be particularlyhelpful to elucidate pathways to impact [16,17].
Africa’s mothers, fathers and families need to beempowered as critical agents for change in setting uphealthier trajectories for their children (with knowledgefrom pre-conception, support during pregnancy, breast-feeding and child nutrition). This can only be achievedthrough a process of broad societal engagement, adopt-ing DOHaD-informed practices as feasible, positive andlifelong options. Africa’s youth are the next generation ofparents and are still able to modify their individual NCDtrajectories. DOHaD-informed knowledge and healthpractices need to be integrated into school curriculaand other youth-oriented arenas, using compelling mes-saging and novel means of engagement [18].
In conclusion, DOHaD principles in Africa need tomove forward in a joint evidential and implementation-focused programme. The knowledge base for implemen-tation is by no means complete but waiting to gatherfurther intergenerational evidence is not an option as thepotential risks to health and human capital are too high.
Disclosure statement
PB is Deputy Editor of Global Health Action but was notinvolved in the editorial handling of this article.
Acknowledgement
We acknowledge the support of the Stellenbosch Institutefor Advanced Study (STIAS) in South Africa. Ethics andconsent: As this paper is a commentary no direct researchwas done and did not require ethics submission or consent.
Author contributions
During 21–23 September 2016, a group of people with acommon interest in DOHaD held a Consultation Meetingat the Stellenbosch Institute for Advanced Study (STIAS) inSouth Africa to consider the topic: ‘DOHaD and the SDGs:Moving towards early implementation in Africa’. AD andCP organized the workshop. SAN drafted the article and allmembers of the Consultation Meeting are co-authors andinputted in the development of this paper. All authors haveread and approved the final version.
Ethics and consent
N/A
Funding information
The consultation meeting was funded through a STIASgrant from the Knut and Alice Wallenberg Foundation.
Paper context
Africa faces multiple burdens (infectious and non-communic-able diseases). From substantial evidence linking maternal andnutrition exposures that occur during pregnancy and infancyto adult health and disease, we propose a life-course frame-work to guide research and public health programmes inAfrica to optimise health. The implementation of this frame-work could see African researchers contributing more to thefield of developmental origins of health and disease, as well asoffsetting such intergenerational challenges as stunting.
ORCID
Shane A. Norris http://orcid.org/0000-0001-7124-3788Moffat Nyirenda http://orcid.org/0000-0003-2120-4806Juliet R. C. Pulliam http://orcid.org/0000-0003-3314-8223Eugene Sobngwi http://orcid.org/0000-0001-5457-6572Mark Tomlinson http://orcid.org/0000-0001-5846-3444Cari van Schalkwyk http://orcid.org/0000-0001-5154-1390
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