The first 2000 days: Giving our kids the best start for a healthier life

Gretchen Miller: Hello and welcome to Prevention Works, the podcast of The Australian Prevention Partnership Centre. Gretchen Miller with you, and we’re talking about the very early days of our life’s journey and how influential they are in preventing future health issues. A parent’s role here is critical, but so is the larger setting in which a family operates; what supports and what hinders us from doing what we can to give our kids the best start in life.

On the line, two guests who have just finished a knowledge synthesis looking at the first 2000 days of our lives across the combined research from CERI, the Prevention Centre’s Collaboration for Enhanced Research Impact. CERI is made up of 10 Centres of Research Excellence, all with an interest in chronic disease. From Monash University, Professor Helen Skouteris, a Developmental Psychologist and Implementation Science expert, she’s also head of the Health and Social Care Unit at the School of Public Health and Preventive Medicine. With Helen, and also from the Monash School of Public Health and Preventive Medicine, Dr Alexandra Chung, a VicHealth Postdoctoral Research Fellow whose interests include childhood obesity prevention, and the role of policy in equitably improving children’s diets. They’ve mobilised a number of researchers from the various Centres of Research Excellence that make up CERI to bring together all we’ve learned about the importance of the first 2000 days in a child’s life for the prevention of future chronic disease.

So, let’s get started. Helen, I’m interested in this framing of the first 2000 days. We’re talking, I think, from conception to the age of about four and three quarters. What message does this convey?

Helen Skouteris: For me, the message that it conveys is that those first 2000 days from, as you say, conception to almost age five are fundamentally and critically important. They’re the formative years of a child’s life, and so we know that there is overwhelming evidence that a group of children are potentially growing up with circumstances that lead to worse outcomes, and we need to prevent as far as possible children not having a best start to life. All children deserve the best start to life, and if we can get it right in those first 2000 days then we are more likely to see better outcomes for children, for families, and for society.

Gretchen: And it sounds to me in a way that when you frame it as days, it’s almost like every day matters, so each day needs to be attended to.

Helen: That’s such a good point, and as a developmental psychologist, I know that every day actually does matter in those formative years. In actual fact, the brain development and the social, emotional development of children across those first 2000 days are again, as noted, fundamental to longer-term health and wellbeing outcomes for children. So you’re absolutely right, Gretchen, every single day matters and every single day we need to be thinking about how we support children and families across those first 2000 days, so that they actually are experiencing the best outcomes possible.

Gretchen: And really the framing issue here is that prevention is bang for buck, right, it’s super effective at this age because parents of young kids are particularly motivated to set healthy behaviours for life. So who is this research for?

Alex Chung: The research is designed for policy makers, there’s a really strong impetus in this work to bring policy partners into the knowledge synthesis process, so that we could answer research questions that were of interest to policy partners and discuss findings and implications from the research evidence with policy partners to produce findings that are relevant for policy and practice, and not just based on research experience.

Gretchen: And who did you do it with?

Alex: This knowledge synthesis was undertaken by a group of researchers, it was led by the Prevention Centre, and a number of research Centres of Excellence whose work focuses on prevention in the first 2000 days, came together to undertake this knowledge synthesis.

Gretchen: And so that’s what actually makes this knowledge synthesis quite different, is that invitation to policy makers to actively participate.

Alex: I think that’s right, there’s a really active participation by policy makers, as you say, they were invited in the first instance to a round table to help frame the questions that came out of the knowledge synthesis, and they were invited back later in the process after I’d been through some of the research evidence to talk about the findings and the implications for policy and practice. That’s quite different from a tractional academic research synthesis or knowledge synthesis, where a group of researchers might identify a research question, go away and explore the research evidence, and present a summary of findings from that evidence. In this instance, we drew quite heavily on the expertise of policy partners to make sure that the research findings were relevant to their context and their daily work.

Gretchen: And the idea here is to demonstrate that this is economically and socially worth doing.

Alex: Yeah, I think that’s right. There’s certainly advice, I suppose, that we receive from policy partners that they would like further support from research evidence to make a case for prevention, so that they can use that in their daily work to advocate for an investment in prevention, particularly around the first 2000 days where we know there’s a real window of opportunity to get things right for children and young people. So we drew heavily on that request from policy partners to see where we could use the research evidence coming out of the Prevention Centre and the CERI member CREs, or Centres of Research Excellence, to really demonstrate how and why prevention in the first 2000 days is such a good investment.

Gretchen: And Helen, did you want to add something?

Helen: Yes, I just wanted to add that we know that supporting optimal child growth and development is definitely a compelling and social and economic priority for the government. They actually have prioritised the first 2000 days, the Federal Government, in terms of maternal and child health and wellbeing. So we know the what, what we don’t know as well is the how, and that is how do we actually provide that optimal support for families, for women, for parents, for children, across the first 2000 days. And so the scoping review that Alex took part in is a way to also help policy makers understand that we do have some evidence that we can leverage and that we can run with. We don’t want to wait and take 17 years to find out how to support through the first 2000 days, we do now have a lot of evidence, we have amassed a lot of evidence, a lot of that evidence is coming out of the Centres of Research Excellence, it’s time for us as researchers to partner with policy makers with community service organisations, with health services, across multiple sectors, to make a difference across this priority area.

Gretchen: And I guess the point that you make too is, as you say, you want to get started, but it doesn’t mean that you do the research, the answer is there, and then you apply it. This is research in action as well, so things will be tweaked as you continue to explore, as you start to make those interventions and activate appropriate systems to help parents support their children in healthier futures.

Helen: That’s right, Gretchen, and in particular it’s about partnering with consumers of community to do this work well and effectively. So, by listening to the voices of those with lived experience, by partnering with women through pregnancy, through preconception, with dads, with parents, families, and communities, we are more likely to be able to make a difference across those first 2000 days. It’s about progressing our research in a really pragmatic way, and in a way that we know will lead to sustainable outcomes.

Gretchen: So the review looks at the evidence for action in this time. What is the key evidence?

Alex: We know that prevention in the first 2000 days is a real window of opportunity to establish good health and health behaviours for children that they can carry on throughout life. We also know that prevention in the first 2000 days is a sound investment. There’s economic evidence that demonstrates interventions delivered in early childhood are effective and also cost effective. This is in part due to the lifelong cost savings from reduced incidences of poor health, and that includes reduced medical costs, reduced hospitalisations, and improved productivity, reduced absenteeism from school for children, and from the workplace for their parents.

There’s a wide impact of prevention interventions and we know the benefits are seen both for individuals, but also for broader society and the community. We can look at specific stages, so we can look at evidence for action in the preconception period where we can support parents to be of optimal health before they fall pregnant. We can look at evidence that demonstrates interventions in pregnancy are necessary, they’re effective and cost-effective, to support women to be of healthy weight throughout their pregnancy, and we can see that interventions such as structured diet and physical activity interventions lead to good health outcomes for women and their babies.

If we look a bit further along that sort of life phase of the first 2000 days, we can look at early childhood, and we know in early childhood there are family-based interventions that can lead to improved rates of breastfeeding, they can lead to healthy feeding practices for infants and young children, they can lead to healthier physical activity behaviours and reduced sedentary time, like reduced TV viewing. So we know that there are interventions across different stages of the first 2000 days that are effective for healthy behaviours for children and also for parents.

We also know that there are other ways we can intervene, not just looking at individuals, whether it’s parents or children, but we can also look at the settings where children spend their time. For example, interventions delivered in early childhood education and care have been shown to be very effective in increasing children’s physical activity behaviour. So it’s not just a matter of looking at individuals, but also the places, the settings, where they spend their time.

Gretchen: What I’m thinking about is that as adults we think back to our first five years, do we remember much at all, so I’m assuming what’s going on here is to lay an almost subconscious groundwork in that child’s early neurological development.

Helen: A great question, Gretchen. We know from children’s development that behaviours formed across the first 200 days may become entrenched, that doesn’t mean they can’t change, but it is harder and less likely to be able to make change as a child moves beyond the 2000 days into early childhood and then adolescence. So what we hope to do is to support families and children to create optimal behaviours for optimal health, and that might include, for instance, the provision of health foods and the encouraging of children to consume healthy foods and to avoid foods that are high in saturated fats, sugar, and salt, and so forth, and for children to be active rather than sedentary across those first 2000 days.

But we do need to also understand that when we do support families and children across the first 2000 days for optimal child growth and development that we need to look at that much more holistically and move beyond just, for instance, healthy eating and physical activity. We need to make sure that children are secure and safe in their homes and in their communities, that they are receiving responsive care giving, that they have opportunities for early learning, and when we combine all of those factors with adequate nutrition we will see really good health outcomes and wellbeing outcomes for children and families across the first 2000 days.

Gretchen: So your answer, Helen, makes me think of a question for Alex, which is what kind of equity there is in terms of prevention and healthcare delivery across Australia at the moment? Each community is very different in its needs, each community has cultural influences, each community has economic differences, how can we make sure that all children in Australia have equal access?

Alex: We certainly know that at the moment we don’t have equal access to prevention interventions, we don’t have equal access to healthcare and education opportunities for children in Australia, so there is a great need to improve equity for children and for families. When we’re thinking about prevention interventions to ensure that we’re meeting the needs of all people, all children and families, we need to think about reaching out to children and families who are perhaps less able to access universal services and interventions that are designed to meet the needs of most, so we need to go and talk to people, we need to understand their realities and their lived experiences to make sure that prevention interventions are being designed and delivered to meet the unique needs of specific population groups who may not otherwise benefit from the services that are being rolled out across the country.

Gretchen: Perhaps we could look at what your knowledge synthesis showed would contribute on the ground in the way of programs, some sort of examples of what you found working efficiently across Australia.

Alex: When we’re thinking about prevention in the first 2000 days, we’re looking to prevent chronic diseases. So prevention in the first 2000 days might look at smoking cessation programs to reduce smoking in preconception and pregnancy for mothers and fathers. Prevention in the first 2000 days might look like structured diet and physical activity programs to support pregnant women and maintain good health, and reduce the risk of excess weight gain during pregnancy. This leads to improved health outcomes for women and for their infants.

In early childhood, family-based interventions have been shown to increase breastfeeding duration and lead to healthy feeding practices for children. These programs have also been shown to reduce television viewing or sedentary behaviour in young children, and this leads to healthy weight among young children. We also know that settings-based programs are important. For example, interventions delivered across early childhood education and care settings have been found to have a positive impact on children’s physical activity behaviour.

We know though that some of these programs don’t reach everybody, so when we’re looking to make sure that our prevention interventions have benefit for all population groups, we need to design interventions that meet the needs of population groups with unique needs. This can include Aboriginal and Torres Strait Islander people, it can include families with culturally and linguistically diverse backgrounds, and it can include families who are experiencing social and economic disadvantage. And it’s a matter of making sure that when interventions are being designed they’re taking into consideration the realities, the lived experience of these different population groups, and that programs are being delivered in ways that are sensitive and supportive of the unique needs of different population groups living in Australia.

Gretchen: So you found that this needs to be a really comprehensive approach at both individual- and population-based levels. Could you give examples of how that might be built into policy?

Alex: Yeah, when you’re thinking about prevention there’s a huge range of stakeholders who are involved. So, starting right at the top, we need government commitment and government investment in prevention, first of all, and more specifically prevention in the first 2000 days. Policy action needs to then consider the needs of each of the stakeholders who are involved, so obviously policy makers, policy partners are an important stakeholder. But once we look at the design and delivery of interventions, we also need to think about the families, the parents and children who are experiencing and going to benefit from prevention interventions. We need to think about the practitioners, the service providers who are on the ground delivering these services. We also need to think about what happens in the research world, there’s a role for researchers in terms of the design, the evaluation of prevention interventions, as well as monitoring – are these interventions actually having the effect that we want, so we can monitor individual- and population-level behaviours to understand if the interventions are having the effects that we hope.

Gretchen: Okay, so when you have to consider that, sure, we’re talking about populations and that’s where you’ll see the evidence manifesting, I guess, in the larger figures that you look at, but you’re also looking at individuals and their very unique circumstances. How might a policy address those two needs, I guess, how might a policy remember the individual in amongst the broader picture?

Helen: For me it’s really important that these solutions and the ways that we target policy are multidisciplinary and multisectoral because that’s more likely to get to the ear of policy makers because you’re not approaching the first 2000 days and the importance of the first 2000 days in siloed ways. And so when liaising with policy makers and advocating on behalf of, for example, the first 2000 days, the individual case studies will be of interest, because they are definitely concerned with individual stories, and so if you create those individual stories they do want to listen. But, as you say Gretchen, you need to move beyond the individual and to show that this is impacting significantly across society, because if it’s only down to a few individuals then it may not be of major concern, but because we do know that the first 2000 days is a national priority, because we do know that, for instance, strategies, national strategies now like the National Obesity Strategy, have embedded equity into their priorities, have embedded removing stigma into their priorities, we are now starting to see governments who are focused on societal issues that are impacting many, not a few, and they are issues of equity and they are issues of stigma, and if we do, for instance, just have wait and see policies and practices, we’re not going to get it right for Australians.

So it is about thinking strategically and working with the language and the evidence that policy makes want to hear that is also going to resonate with our lay Australians, with our consumers, with the people that we’re serving. Because if we don’t do that and we speak at a level that does not resonate with people out there who aren’t in academic world, who aren’t researchers, who don’t understand p-values, who don’t really understand why it’s important to do randomised control trials, then we’re not going to succeed.

Gretchen: On that, your review points to a lack of evidence for specific and priority groups, including Aboriginal and Torres Strait Islander populations, including, as you say Alex, culturally and linguistically diverse people, and those with socioeconomic disadvantage. Now those groups together are actually a very large part of the population, and I know that targeted research is deeply problematic for a number of reasons in some ways, but I wonder if it’s time that research programs allowed for acknowledgement of these differences and analyse the data accordingly. I kind of wonder why that isn’t happening when we’ve known for a long time that the research, like so many things, is targeted towards some idea of mainstream, where in fact mainstream is ridiculously diverse. Why isn’t it happening, and is there a big catch-up that needs to go on in this space?

Alex: You’re right, Gretchen, there is a catch-up that needs to happen in this space, the knowledge synthesis showed that we do need greater evidence of how we can support health and wellbeing for Aboriginal and Torres Strait Islander people, for families who have culturally and linguistically diverse backgrounds, and for families experiencing socioeconomic disadvantage. We know that we need to do more work to understand the needs of different groups of people within the population and how we can best meet the needs of all people within Australia, not just, as you say, the mainstream population, whoever that might be, but in fact make sure that we’re reaching out to all population groups to understand and address their needs, and there is more work that needs to be done to identify how we can design and deliver and ultimately evaluate programs to make sure that we’re giving every child the best start in life.

Helen: Yeah, agree totally with everything that Alex said, and bringing back the discussion to the fact that we know that structural interpersonal, institutional, internalised racism is a problem in our country, and so in many ways we now know that for many reasons the privileged will remain healthy and those that aren’t as privileged are more at risk of experiencing poorer health development, educational outcomes, financial outcomes. And so for me it’s a matter of also us now understanding that if we are going to be able to support culturally diverse communities in Australia, we need to be led by those communities, and so it’s about researchers and policy makers understanding that they need to take a back step and enable those communities, Aboriginal-led research, culturally-and-linguistically-diverse research, to be pioneered and to enable them, with the resources and with the support, to do what they need to do to empower their communities for better health across the first 2000 days.

Gretchen: And we call this co-design, don’t we?

Helen: Correct, and genuine co-design, where we literally are in service of our communities and we are supporting their voice to be at the forefront.

Gretchen: And your findings show that people, that is the general public, do value prevention. Why is it important to state that?

Alex: Yeah, I think it’s really important to point out that the knowledge synthesis found public support for prevention, I think it’s really helpful for policy makers to know that there is public support for prevention, and the knowledge synthesis showed strong support in particular for prevention in early childhood, there was strong support for prevention interventions that would have benefits for children. Some of the actions that came out of the research that have strong support behind them include restricting unhealthy food and drink advertising targeted towards children, local planning to promote health in neighbourhoods, such as fast-food density zoning laws, improved walking and cycling infrastructure to enable physical activity for children and families, and the implementation of prevention interventions in childcare and health-service settings, places where children and families spend a lot of their time. So we do see strong support for prevention, particularly prevention that promotes and protects children’s health.

Gretchen: So what are the complexities that the knowledge synthesis brought up for you, what are some of the limitations that are currently in place that need to be addressed?

Alex: I think the complexities that came out of the knowledge synthesis, we’ve perhaps touched on them when we’ve talked about equity, I think the complexities that came out are around making sure that prevention interventions meet the needs of everybody, and that includes designing interventions that are specifically tailored to meet unique needs of groups within the Australian population, that includes Aboriginal and Torres Strait Islander families, it includes culturally diverse families, it includes families who perhaps have limited resources due to socioeconomic disadvantage. And I think that takes me to something that we found in the knowledge synthesis when we’re looking at the types of interventions that are required to support prevention across the first 2000 days, we know that we need interventions that support individuals, we know that we need interventions that improve the health in the settings where children and families spend their time, and we also know that we need interventions that really help improve the structural determinants of health, the social determinants of health, if you like. That means ensuring that people have adequate income and social protection, it means making sure people have adequate employment opportunities, safe places to live from a housing perspective, from a neighbourhood perspective, to ensure that people are then well placed to meet their health and wellbeing needs.

Gretchen: Multidisciplinary, as you said, and across departments, not just a Health Department issue here.

Alex: That’s right, this is not just a health issue. Prevention across the first 2000 days needs to encompass people across all different sectors, all different government departments, and it needs a coordinated approach to bring everybody onto the same page.

Gretchen: Can we zoom out for a moment here and talk about what a knowledge synthesis is and how this one worked at CERI within the Prevention Centre, involving a number of Centres of Research Excellence?

Alex: So in a general sense a knowledge synthesis is a process of gathering evidence to answer a specific research question. In this knowledge synthesis we used the firsthand experience of a number of researchers from six different Centres of Research Excellence, all part of CERI, the Collaboration for Enhanced Research Impact. The research questions in this case though weren’t designed by the researchers, they were informed by policy makers.

So to get this knowledge synthesis underway we held two policy round tables where we invited policy makers from around Australia. Our knowledge synthesis had two policy round tables with input from 12 prevention policy makers from eight jurisdictions across Australia. Once we had our research questions developed, with input from the policy partners, we went away and sought research evidence from the Prevention Centre and the six Centres of Research Excellence that were contributing to this research process. After I’d reviewed the 60 peer-reviewed articles that had come through from Prevention Centre and CERI member research teams, I synthesised those findings and we collectively took those back to the policy partners at the second of two policy round tables where we could talk about findings from the research evidence, and then understand how that research evidence could be useful in a policy and practice context.

Gretchen: What an incredible thing you’ve pulled off here.

Alex: It was a group effort, so I had Helen’s oversight from a supervisory perspective but the process also had great oversight from the Prevention Centre, so there was great leadership from the Prevention Centre in convening the policy round tables, using the Prevention Centre’s connections, I guess, with policy partners, and we also had input from a number of early-career researchers and their supervisors, each of whom lead Centres of Research Excellence, to really select the research, I suppose, that was relevant to the first 2000 days, and help shape the findings that were ultimately presented back to policy partners.

Gretchen: What it sounds like is that CERI develops capacity in emerging leaders in the field, so it really supports early-career researchers.

Helen: CERI definitely is a fantastic platform for early- and mid-career researchers because it affords them the opportunity to network with, to learn from, to share information with other early- and mid-career researchers, but also with senior researchers from the extensive number of Centres of Research Excellence that are part of the network, and so that to me is amazing, because what we tend to do with Centres of Research Excellence is build capacity in our early- and mid-career researchers within our siloed Centre of Research Excellence approach. That’s very good and that’s needed, but to take it to this national level, to take it to a level for early- and mid-career researchers that is on a platform, as I said, that’s unprecedented is for my career, and I’ve been an academic for over 26 years, something that I’ve never seen before, so I do congratulate CERI, and I would love to hear of Alex’s personal experience with it.

Alex: I absolutely love being part of CERI. I’ve had the opportunity to meet and work with researchers from all around the country. I’ve also been lucky enough to take on a leadership opportunity in leading this knowledge synthesis on prevention in the first 2000 days, and that’s all due to my participation and the support of the CERI network. I think through the Emerging Leaders’ Network that CERI hosts I’ve been able to be connected to a diverse range of researchers, practitioners, and also policy makers all working in prevention, this has provided great opportunities for professional development, it’s really challenged and expanded my thinking around prevention and around what we need to do to further prevention in Australia. As Helen mentioned, I think one of the benefits of CERI is that opportunity to meet and network with researchers from around the country, and that includes early-career researchers who are perhaps at a similar career stage, but also more senior researchers who can offer guidance and mentorship as we all navigate our academic careers.

Gretchen: And CERI also has a role in speaking up for prevention as a critical health framework, right…

Alex: Yes, CERI is really active, I think, in advocating for prevention, and in a space where it can be difficult to get airtime, it’s really nice to be able to work with other researchers who share that passion for prevention and who really want to speak up for prevention and advocate for prevention. I think for me, being part of CERI really gives that sense of you’re not alone in this. Sometimes research is hard, and sometimes research can be a little bit lonely, particularly when you’re working from home all the time, as we are through this pandemic, so the opportunity to engage with other researchers through CERI and through the Emerging Leaders’ Network really provides a sense of team and a sense of we’re all in this together.

Gretchen: Helen, you’re also the Director of the Centre of Research Excellence in Health in Preconception and Pregnancy, how does that work align with the Prevention Centre?

Helen: It aligns perfectly with the Prevention Centre, and in actual fact the Prevention Centre also auspiced a grant through the Medical Research Future Fund prior to us being funded by the National Health and Medical Research Council as a Centre of Research Excellence. So we’ve been working with the Prevention Centre since 2018 in this area of wanting to establish effective supports, resources, and interventions that will enable and assist women to maintain healthy weight prior to conception and through pregnancy, and so it’s absolutely aligned and that’s why it’s important for the Centre of Research Excellence in Health in Preconception and Pregnancy to be part of CERI, as it is also to learn from other Centres of Research Excellence that are focused on prevention across the lifespan.

Gretchen: So where to next for this research?

Alex: So we know that this knowledge synthesis provides just a snapshot in time of the work that’s been done to date by the Prevention Centre and the six CREs in terms of what works, and building an economic argument for why we need to do prevention in this early space of children’s lives. There’s lots more to come from the Centres of Research Excellence who have contributed to this first 2000 days knowledge synthesis. We know that some of the CREs whose work has been included in the knowledge synthesis to date are still well and truly in the midst of undertaking their research, so there’s much more to come. I’d say watch this space.

Gretchen: Dr Alexandra Chung and Professor Helen Skouteris from Monash University’s School of Public Health and Preventive Medicine. This is Prevention Works with me, Gretchen Miller, and if you’d like more information please go to the website of The Australian Prevention Partnership Centre, you’ll find us there. Catch you next time.

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