As soon as conception occurs, the rapidly developing embryo uses the mother’s nutrient stores to support its growth.⁸If there are not adequate stores of nutrients, including micronutrients like zinc and iron, to meet the high metabolic demands of early pregnancy, fetal growth and organ development will be compromised.^{8, 12} Babies born at the low or high ends of the birthweight scale have high risks for type 2 diabetes, obesity and heart disease.  

The mechanisms for acquiring nutrients are key issues addressed in the Developmental Origins of Health and Disease (DOHaD) body of research. Current data demonstrate that adequate nutrition is important for health throughout all stages of development—especially during sensitive or critical periods of growth.^{6, 14} Evidence is mounting that good nutrition during the preconception period, or the two to three months before pregnancy, is also critical. Nutrition during this period may be as important for development as nutrition during pregnancy.^{8, 12} Thus, it is important to improve nutrient stores before pregnancy because a significant portion of the nutrients provided to the growing embryo and fetus come from established nutrition stores. 

Studies show poor nutrition before and during pregnancy causes harm in the next generation
Evidence has shown that poor nutrition during the preconception period can lead to long-term health effects.^{1, 4, 15}The Dutch Famine Birth Cohort Study, which investigated the lasting health effects of acute maternal undernutrition during the 1944-1945 Dutch famine, shows how the health effects from famine exposure vary by gestational stage.¹Infants who were conceived during the famine and exposed to nutrient deprivation in the first trimester of pregnancy had worse lifelong physical and mental health outcomes compared to infants exposed to famine during the second or third trimester of pregnancy.¹ Since organs begin forming early in gestation, it’s not surprising that future physical health is most impacted by a nutrient deficient environment at pregnancy onset.¹ 

Given the developmental consequences and lifelong health impacts of poor nutritional status at conception, it is important that nutrition interventions start long before pregnancy.¹² This includes ensuring that all people of reproductive age face no barriers to accessing a wide variety of nutritious foods.¹² 

Relationship between food access and food insecurity
Conversations surrounding food access often revolve around food insecurity, defined as having limited or uncertain access to adequate food.⁵ In 2020, 10.5% of U.S. households were food insecure. However, food insecurity is not distributed equally across society.⁶Low-income, racial/ethnic minority, and single parent households are more likely to experience food insecurity.⁶Communities or geographical regions can also be food insecure if the food environment is lacking in availability of affordable, nutritious, and culturally appropriate foods.⁶ 

Across the globe, economic, political and social factors shape what and how people eat.⁷ In the United States, these factors have produced a variable food landscape that is scattered with geographic areas that have either an over-abundance of unhealthy food options (food swamps), or little access to affordable, nutritious foods (food deserts). On top of this, the expense of food is a massive barrier that affects the dietary choices individuals and families are able to make. And in the U.S., the foods that are cheapest and most readily available are usually the least nutritious.¹³ 

When people or communities experience food insecurity, they often have limited choice when it comes to the foods they are able to access or afford. Food insecurity has been linked with poor nutritional status at all stages of life — from childhood to older adulthood.^{10, 11} In order to support nutrition during critical periods of development across the life course, including the preconception period, interventions must move beyond individual food choice and advance structural changes that promote healthy and just food environments.^{2, 9} 

An Oregon community working to advance preconception nutrition
Klamath County in Southern Oregon, is making strides towards ensuring that people have access to the nutritional resources they need before and throughout pregnancy. The Klamath ‘hub’, which is part of the OHSU Moore Institute’s statewide Nutrition Oregon Campaign, is a multi-sector network of community and organizational leaders working together to implement community-identified health-promoting strategies that are grounded in DOHaD science. The Klamath hub is currently targeting birth outcomes, and has established a bold goal for reducing the percentage of low birth weight babies in their community from 8% to 5% (below the Oregon statewide average of 6.6%).  

The initial phase of Klamath hub’s low birth weight action plan involves developing evidence-based nutritional education resources and training curriculums for community health workers and health care providers. By targeting the health sector, the Klamath Hub is working to ensure that people of reproductive age are receiving unified, culturally appropriate nutrition messaging along all points of interaction with the health system. It will also ensure that people are directed to the appropriate resources to support nutrition and food access (such as Special Supplemental Program for Women, Infants, and Children aka ‘WIC’) if need-be.  

The Klamath Hub is taking action to ensure that the nutritional needs of people of reproductive age in their community are met. Even at the earliest stages, development is impacted by the environments that exist outside of the womb.^{1, 14} If the food environment is insecure and contains limited access to healthy food options, it prevents communities from meeting the nutritional needs of its members now for the next generation. As the DOHaD evidence base shows, advancing food access, nutrition, and nutritional education during the preconception stage will support healthy infant growth and development, and have a lifelong impact on the health of future generations.¹ 

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References 
(1) Bleker, L., de Rooij, S., Painter, R., Ravelli, A., & Roseboom, T. (2021). Cohort profile: the Dutch famine birth cohort (DBFC)--a prospective birth cohort study in the Netherlands. BMJ Open, 11(3). https://doi.org/10.1136/bmjopen-2020-042078  

(2) Bodnar, L., Simhan, H., Parker, C., Meier, H., Mercer, B., Grobman, W., Haas, D., Wing, D., Hoffmann, M., Parry, S., Silver, R., Saade, G., Wapner, R., Iams, J., Wadhwa, P., Elovitz, M., Peaceman, A., Esplin, S., Barnes, S., & Reddy, U. (2017). Racial/ethnic and socioeconomic inequalities in adherence to national dietary guidance in a large cohort of US pregnant women. Journal of the Academy of Nutrition and Dietetics, 117(6), 867-877. https://doi.org/10.1016/j.jand.2017.01.016  

(3) Brunst, K., Wright R., DiGioia, K., Enlow, M., Fernandez, H., Wright, R., & Kannan, S. (2013). Racial/ethnic and sociodemographic factors associated with micronutrient intakes and inadequacies among pregnant women in an urban US population. Public Health Nutrition, 17(9), 1960-1970. doi:10.1017/S1368980013003224  

(4) Fleming, T. P., Watkins, A. J., Velazquez, M. A., Mathers, J. C., Prentice, A. M., Stephenson, J., Barker, M., Saffery, R., Yajnik, C. S., Eckert, J. J., Hanson, M. A., Forrester, T., Gluckman, P. D., & Godfrey, K. M. (2018). Origins of lifetime health around the time of conception: causes and consequences. Lancet, 391(10132), 1842–1852. https://doi.org/10.1016/S0140-6736(18)30312-X 

(5) Hartline-Grafton, H., & Hassink, S. (2021). Food Insecurity and Health: Practices and Policies to Address Food Insecurity Among Children. Academic Pediatrics, 21(2), 205-2010. https://doi.org/10.1016/j.acap.2020.07.006  

(6) Herman, D., Baer, M.T., Adams, E., Cunningham-Sabo, L., Duran, N., Johnson, D., & Yakes, E. (2014). Life Course Perspective: Evidence for Role of Nutrition. Maternal and Child Health Journal, 18, 450-461. https://doi.org/10.1007/s10995-013-1280-3  

 (7) Horst, M., McClinktock, H., & Hoey, L. (2017). The Intersection of Planning, Urban Agriculture, and Food Justice: A Review of Literature. Journal of the American Planning Association, 83(3), 277-295. https://doi.org/10.1080/01944363.2017.1322914  

(8) Marshall, N., Abrams, B., Barbour, L., Catalano, P., Christian, P., Friedman, J., Hay, W., Hernandez, T., Krebs, N., Oken, E., Purnell, J., Roberts, J., Soltani, H., Wallace, J., & Thornburg, K. (2021). The importance of nutrition in pregnancy and lactation: lifelong consequences. American Journal of Obstetrics & Gynecology. https://doi.org/10.1016/j.ajog.2021.12.035  

(9) McKerracher, L., Oresnik, S., Moffat, T., Murray-Davis, B., Vickers-Manzin, J., Zalot, L., Williams, D., Sloboda, D.M., & Barker, M. (2020). Addressing embodied inequities in health: how do we enable improvement in women’s diet during pregnancy. Public Health Nutrition, 23(16), 2994-3004. doi:10.1017/S1368980020001093 

(10) Olson, C. (1999). Nutrition and Health Outcomes Associated with Food Insecurity and Hunger. The Journal of Nutrition, 129(2), 521-524.  https://doi.org/10.1093/jn/129.2.521S  

(11) Pereira, M., Pereira, M.L., Campos, G., & Molina, M. (2021). Food insecurity and nutritional status among older adults: a systematic review. Nutrition Reviews, 80(4), 631-644. https://doi.org/10.1093/nutrit/nuab044   

 (12) Stephenson, J., Heslehurst, N., Hall, J., Schoenaker, D., Hutchinson, J., Cade, K., Poston, L., Barrett, G., Crozier, S., Kumaran, K., Yanjik, C., Barker, M., Baird, J. & Mishra, G. (2018). Before the beginning: nutrition and lifestyle in the preconception period and its importance for future health. Lancet, 391, 1830-1841.https://doi.org/10.1016/S0140-6736(18)30311-8  

(13) Thurow, R. (2016). The First 1,000 Days: A Crucial Time for Mothers and Children—And the World. Breastfeeding Medicine, 11(8), 416-418. https://doi.org/10.1089/bfm.2016.0114 

(14) Wallack, L., & Thornburg, K. (2016). Developmental Origins, Epigenetics, and Equity: Moving Upstream. Maternal and Child Health Journal, 20, 935-940. https://doi.org/10.1007/s10995-016-1970-8 

(15) Watkins, A. J., Wilkins, A., Cunningham, C., Perry, V. H., Seet, M. J., Osmond, C., Eckert, J. J., Torrens, C., Cagampang, F. R., Cleal, J., Gray, W. P., Hanson, M. A., & Fleming, T. P. (2008). Low protein diet fed exclusively during mouse oocyte maturation leads to behavioral and cardiovascular abnormalities in offspring. The Journal of physiology, 586(8), 2231–2244. https://doi.org/10.1113/jphysiol.2007.149229