The first 1000 days: a window of opportunities for future health

Why should Europe and public health systems invest in the first 1.000 days of life, from pregnancy to a child’s second birthday? What does this early window have to do with the development of non-communicable diseases (NCDs) decades later?

The answer lies in a growing and compelling body of evidence: the foundations of lifelong health are laid well before birth. Since the 1980s, David Barker demonstrated the link between adverse conditions during fetal life and early infancy, particularly poor nutrition, and an increased risk of chronic diseases in adulthood, including cardiovascular disease and diabetes. This work laid the scientific foundations for what is now widely known as the “first 1,000 days” concept.

The first 1.000 days represent a uniquely sensitive period in which biological, social, and environmental exposures interact to shape metabolic regulation, immune function, cognitive development, and health-related behaviours. Crucially, this phase also constitutes an extraordinary window of opportunity: expectant parents and caregivers are often highly motivated and receptive to revisiting their health-related choices to secure the best possible start in life for their babies. Investing upstream during this critical period is therefore not only a matter of child wellbeing; it is a strategic lever for preventing NCDs, reducing health inequalities, and strengthening the long-term sustainability of European health systems.

NCDs such as cardiovascular diseases, type 2 diabetes, obesity, certain cancers, and mental health conditions are often understood primarily as the result of adult lifestyle choices. However, this narrative is incomplete. A life-course approach to health clearly shows that risk trajectories begin early, shaped by maternal health and nutrition, psychosocial stress, exposure to tobacco and alcohol, environmental pollutants, breastfeeding and infant feeding practices, and early caregiving environments. These determinants are coherently described within the Nurturing Care Framework for early child development, which highlights how health, nutrition, responsive caregiving, security, and early learning work together and reinforce one another, shaping children’s development from the very beginning.

During pregnancy and early infancy, organs and regulatory systems develop at a rapid pace. Adverse exposures during this phase can induce long-lasting physiological changes through epigenetic mechanisms, altering patterns of gene expression. Low birth weight, rapid catch-up growth, suboptimal breastfeeding, exposure to formula and breastmilk substitutes, and early consumption of highly processed foods and foods that are high in sugar, salt, and saturated fat are all associated with increased risks of obesity, hypertension, insulin resistance, and cardiovascular disease in adulthood. Similarly, early psychosocial stress can dysregulate stress-response systems, contributing to mental health disorders and maladaptive coping behaviours later in life.

From a public health perspective, many of the downstream costs of NCDs are therefore, at least in part, the delayed consequences of upstream neglect.

Europe is facing a dual challenge: an ageing population with a high burden of chronic disease, and persistent social and health inequalities that emerge early and widen across the life course. Interventions focused exclusively on adult behaviour change are necessary but insufficient. They are often costly, less effective, and unevenly distributed across socioeconomic groups.

By contrast, investing in the first 1000 days offers a rare opportunity for high-impact, equity-oriented prevention. Supportive policies and services during pregnancy and early childhood, including breastfeeding and parenting support, disproportionately benefit families facing social, economic, or environmental disadvantages, precisely those at higher risk of NCDs later in life. Early interventions can therefore flatten the social gradient of health before it becomes entrenched.

Economic evidence further reinforces this case. [Fig.2] Early-life investments consistently yield high returns, including reduced healthcare costs, improved educational outcomes, higher productivity, and stronger social cohesion. In a context of constrained public budgets and rising healthcare costs, prevention in early life should be seen not as a luxury; it is a rational and forward-looking strategic investment.

The “Baby-Friendly Community & Health Services” task of JA PreventNCD focuses on the implementation of Baby-friendly Community Health Services (BFCHS). The Norwegian BFCHS model was evaluated by the EU Commission as a Best Practice for the prevention of NCDs, as this structured intervention has been shown to increase the duration of exclusive breastfeeding until 6 months. The BFCHS is grounded in the Ten Steps for Successful Breastfeeding promoted by the World Health Organization and UNICEF under the Baby-friendly Hospital Initiative. It extends beyond maternity wards to the community health services, for strengthening the breastfeeding support after hospital discharge.

Baby-friendly Communities promotes an enabling environment for breastfeeding and other positive early-life exposures. This includes protecting, promoting, and supporting breastfeeding; ensuring access to healthy and affordable food; providing smoke-free and safe public spaces; offering parental support and mental health services; and fostering inclusive, socially connected neighbourhoods. Importantly, the BFC approach addresses the commercial, social, and environmental determinants that shape early-life exposures, rather than placing responsibility solely on individual parents. Common examples are the marketing of breast-milk substitutes and ultra-processed foods targeted at young children and families shaping early taste preferences and increasing long-term risk of diet-related NCDs.

What distinguishes the Baby-friendly Communities approach is its emphasis on systems and governance. Health services, local authorities, education, social services, urban planning, emergency systems, and civil society are called to work together, aligning policies and practices around a shared vision for early childhood health. In this way, the Baby-friendly Communities become platforms for translating national and European NCD prevention strategies into tangible local action.

Whereas the BFCHS is the focus of this JA PreventNCD’s task, the implementing countries have expanded with pilots addressing various environmental determinants.

Framing NCD prevention through the lens of the first 1.000 days challenges deeply rooted assumptions about responsibility and timing. It shifts the focus from correcting “unhealthy behaviours” in adulthood to creating health-supportive environments from the very beginning of life. This reframing has both ethical and practical implications.

Parents and caregivers cannot, on their own, overcome structural barriers such as poverty, insecure employment, aggressive marketing of unhealthy products, or inadequate access to supportive services. Baby-friendly Communities and their associated health services recognize early childhood health as a collective responsibility, requiring political commitment, regulatory action, and sustained investment.

For Europe, this approach aligns closely with broader policy priority of health promotion and prevention, including health equity, social inclusion, gender equality, and intergenerational justice.

The question, then, is not whether Europe can afford to invest in the first 1.000 days, but whether it can afford not to. Without decisive action, the current and future burden of NCDs will continue to strain health systems, widen inequalities, and undermine social and economic resilience.

“Baby-Friendly Community & Health Services” task offers a timely and pragmatic pathway forward. Seven EU countries are currently implementing the BFCHS approach, with the aim of scaling it up to policy level and integrating it into trans-sectoral health promotion systems. This experience demonstrates how robust evidence can be translated into integrated, locally grounded policies that address NCD prevention at its roots.

This editorial was written by the team coordinating the work on Baby-Friendly Community and Health Services (T6.5) within the JA PreventNCD

Angela Giusti, Francesca Zambri, Vincenza Di Stefano, Annachiara Di Nolfi, Flavia Splendore
Italian National Institute of Health.

Anne Bergljot Bærug, Ann-Magrit Lona, Hanne Christine Mosand Bliksås
Norwegian Directorate of Health.