Globally the impact of NCDs continues to grow, and they have become the leading cause of mortality, with type T2DM being the fourth most deadly NCD (1, 2). During the past three decades, the global prevalence of T2DM has doubled and now presents a significant public health challenge in almost every country. In 2019, the International Diabetes Federation (IDF) estimated the global prevalence of T2DM to be 9.3%; however, it is thought that around 50.1% of people with diabetes remain undiagnosed. Additionally, the prevalence is estimated rise to 10.2% by 2030 resulting in 115 million new cases between 2019 and 2030. The Middle East and North Africa (MENA) region is ranked the highest region for the prevalence of diabetes accounting for 54.9 million of the global prevalence (3), the United Arab Emirates (UAE) part of the three countries with the highest prevalence of diabetes in the MENA region with 12.3% of the population living with the disease (4, 5). In the UAE, four NCDs are responsible for 65% of all deaths; cardiovascular disease, cancer, diabetes, and chronic respiratory disease (6). A 2010 study in the UAE showed the prevalence of prediabetes to be 31% and undiagnosed diabetes mellitus 14.6%. Another significant health issue is metabolic syndrome (MetS), the concurrent existence of prediabetes, dyslipidemia, elevated blood pressure, and obesity (7).

It is widely acknowledged that most NCDs identified in adults have their origins in early life. The theory of the developmental origins of adult diseases, commonly known as the Barker hypothesis, associates nutrition during pregnancy, and risk of chronic disease in later life (8). Accumulating evidence shows that a balanced and varied diet plus a healthy lifestyle in the months leading up to conception, throughout pregnancy, during infancy, and to the second birthday, collectively known as the first 1,000 days of life, are influential to health and risk of disease later in life. For instance, full-term infants who are small-for-gestational age have an increased risk of cardiovascular disease (CVD) and T2DM in adulthood, and this is a known consequence of fetal undernutrition (9). Studies on the relationships of nutritional imbalances in early life with birth outcomes, growth patterns, and early determinants of NCDs, have revealed direct associations between limited maternal weight gain during pregnancy and both impaired fetal growth, and low birth weight (10). Also, excess maternal weight gain correlates with high birth weight and fetal growth (large-for-gestational age) (11, 12), as well as adverse cardiometabolic profiles in the offspring (13). In addition to maternal weight gain, maternal diet composition and micronutrient status during pregnancy seem to be associated with birth outcomes and child health status.

The first 1,000 days of life are a vital period that play a crucial role in the development of the immune, endocrine, metabolic, motor, and other developmental pathways. Maternal nutrition and lifestyle choices in preconception and during pregnancy have significant influences on the health, growth, and development of the fetus. Research shows that a maternal diet low in protein is connected to changes in the structure of the liver of the fetus and low birth weight (14), while a diet rich in fat effects adipocyte metabolism, fetal growth, and fat mass in the offspring (15, 16). Maternal anemia and iron, folate, or vitamin B12 deficiency during pregnancy is associated with an increased risk of fetal growth restriction, premature birth, and low birth weight (17–19). The effect of maternal nutrition on the cognitive capability and neurodevelopment of offspring is well established, particularly in the context of micronutrient deficiencies. Vitamin B12 deficiency is associated with spina bifida and infant insulin resistance (20), and maternal iodine deficiency with hypothyroidism. Prenatal maternal iron deficiency is associated with decreased myelination, disturbance in monoamine neurotransmitter synthesis and hippocampal energy metabolism in offspring (21), and there is evidence of an association between increased consumption of essential long-chain omega -3 fatty acids during pregnancy and better infant performance in development assessments, verifying the link between prenatal and postnatal diet to specific aspects of the brain development (22). The effect of prenatal maternal nutrition on neurodevelopment outcomes in children is not exerted solely through the effect of maternal nutrition on fetal growth and birth outcomes. It persists into the postnatal period, by impacting the quality and quantity of breast milk, maternal mood, and infant feeding practices.

Maternal and infant nutrition may influence the risk of later disease due to its critical associations with immunological development of the fetus and young infant (23). Adequate nutrition is necessary both for establishment of the immune system, normal organogenesis and development, and development of an adequate immune response. Undernutrition during early childhood exerts a concomitant effect on cognitive and developmental milestones through mid- and late- childhood and into adolescence. Studies consistently identify associations between stunting at ages 2 and 3 years with later cognitive deficit, as well as school achievement, even after controlling for socio-demographic confounders (24).

Global estimates of stunting and wasting in children under the age of five for 2018 were reported to be 21.9% (149 million) and 7.3% (49 million), respectively, and obesity in children of the same age group was reported to be 5.9% (40 million). The MENA region has the second highest rate of under 5 years overweight children, with an increase from 8.9% in 2,000 to 11.2% in 2018 (25). According to the UNICEF, in 2020 the UAE mortality rate for children under five was 6.6 per 1,000 live births, for infants was 5.6 per 1,000 live births, and neonatal mortality rate was 3.6 per 1,000 births (26). The percentage of overweight school and adolescent children (5–9 years) was estimated to be 37% in 2016 (27). However, there are no records for malnutrition, stunting and wasting of children in the country.

In some research from the UAE, the overall prevalence of global development delay and pervasive development disorder among 3-year old children was reported to be 2.44% and 29 in 10,000 for severe development delay/disorder with a prevalence of 8.4% and 58 in 10,000 for mild to moderate delay/disorder (28). Currently, there are no reports of the neurodevelopmental abilities of young children during the first 1,000 days of life from the UAE. These indicators are considered key public health factors, which contribute independently to mortality and burden of disease.

The design for the 3-year birth cohort study of pregnant Emirati women and their offspring has been thoroughly described in this study protocol. The study investigates relationships between nutrition and lifestyle factors with birth and growth outcomes in the UAE and explores the early determinants of NCDs. Existing studies of the UAE population has focused mainly on the determinants of obesity and NCDs in adults, with some studies focusing on investigating the prevalence of obesity and its determinants in adolescent children. There is a scarcity of detailed research on the dietary practices during pregnancy or infant and young child feeding practices in the UAE with previous studies mainly cross sectional in design, with small sample sizes which are not nationally representative (53–56).

Research has established that growth and development in early life is crucial to longer-term health status, wellbeing, and behavior across the lifespan (57). Nutrition and lifestyle behaviors are similarly critical for maternal and offspring health from preconception, through pregnancy and into early postnatal life (58). Given the rapidity of the development of the obesity epidemic and increased prevalence of related NCDs, particularly in the UAE, the changes cannot be explained by genetics alone but rather in key environmental factors (59, 60). Accordingly, optimal nutrition during pregnancy has important implications for fetal development and growth and may be protective for the long-term health outcomes of both the mother and child. Prenatal genetic and environmental factors that can affect the first 1,000 days of life have recently been shown to play a pivotal role in early childhood development including cognitive, social-emotional skills and motor development. Moreover, the global double burden of malnutrition is increasing, and the UAE lacks data for malnutrition, stunting and wasting of children. Undernutrition during early childhood exerts a concomitant independent effect on the cognitive and developmental abilities developing through mid- and late-childhood and into adolescence (61). Prospective cohort studies consistently show significant associations between stunting at age 2 or 3 years and later cognitive deficits, school achievement, and dropout, after controlling for socio-demographic confounders (24).

The overall prevalence of global developmental delay and pervasive developmental disorder among 3-year-old children in the UAE in 2016 was reported to be 2.44% and 29/10,000 for severe delay/disorder with a prevalence of 8.4% and 58/10,000 for mild to moderate delay/disorder, respectively, with no reports profiling the neurodevelopment abilities of young children during the first 1,000 days of life from UAE (28). Therefore, the importance of the first few years of a child’s life to decreasing the risk of disease morbidity, mortality, and later risk of chronic disease, and to promoting healthy growth and development, is important. Moreover, nutrition during the first 1,000 days of a child’s life has been identified as one of the significant modifiable factors, during this critical window of opportunity, to influence optimal growth, promote optimal neurodevelopment and reduce disease vulnerability later in life (61). In addition, the data obtained in this study will support the development and validation of a new tool, the Neo-NDA, to be used for the measurement of neurological status and maturity of new-borns in the UAE; explore the association between early childhood development (ECD) outcomes using the three inter-related tools: Neo-NDA, the OX-NDA and the INTER-NDA at < 5, 12, and 24 months of life; and use holistic and standardized measures of ECD, importantly including measure of vision, hearing and sleep at all developmental assessments. Prenatal maternal nutrition is an important predictor of fetal and child brain development, exerting its effect in both intrauterine (fetal growth and birth outcomes) and extrauterine (parenting, child feeding practices, maternal mood, quality, and quantity of breast milk) environments. There is limited understanding on what constitutes optimal ECD, with most studies employing heterogeneous methodologies for ECD assessment and being carried out in high-income western settings. This has limited both the comparability and generalizability of neurodevelopmental evaluations, between studies, and to other populations. It also restricts their scalability for measuring and monitoring ECD at a population level with routine ECD screening programs lacking in many parts of the world. To our knowledge, there are no studies profiling neurodevelopmental outcomes during the first 1,000 days of life in the UAE, and therefore our findings will fill this gap. There is a need for high quality data to be collected in country/geography-specific large birth cohorts, using standardized methodologies, to guide understanding of what constitutes optimal and sub-optimal child development in these contexts, to permit comparability between populations, representing a scalable solution to the application of ECD surveillance in these settings. Birth cohort studies that commence either during pregnancy or preconceptionally and then follow the offspring and the wider family into later life, can make a significant contribution to the development of dietary recommendations to expectant mothers during pregnancy to maximize the health and development of the offspring while simultaneously contributing to the understanding of optimal and sub-optimal ECD outcomes in the context of maternal nutrition. Maternal and infant nutrition, as well as early child growth, health, and development, should be a priority for health policy implementation, health promotion activities, and interventions.

The findings of this study will not only provide evidence and data for the UAE population that has never been collated before, but it will also survey infant and maternal body composition and contribute to reproductive health policy. In addition to laying the foundations for culture specific health policies and interventions for pregnant women, infants and young children, this study will provide the first database for the UAE and highlight gaps in the current evidence while identifying avenues for further research. The hallmark of the UAE birth cohort study protocol includes intersectoral collaborations and a versatile research team, and the comprehensive assessment of maternal and infant nutrition and lifestyle exposures. An important aspect of the study is the collaboration between OBYGYN clinics and selected health care facilities across the UAE with a panel of experts and research personnel in this study, particularly in recruitment, data collection and follow up. Importantly, the team of researchers involved in this study are experts in obstetrics, neonatal development, and nutrition epidemiology. Another key aspect of the study is the methodical observation, monitoring and examination of dietary intake lifestyle practices, body composition, and growth of mothers and their off springs from conception to 2 years of after birth.

The UAE-BCS will provide a key platform of evidence and skill to inform future strategies to optimize dietary and consequent nutrition-related health of women in child-bearing age and their children, and thereby, the health of the nation. It will also provide critical data to inform policy decisions, and public health interventions in the region, providing a path to reduce the growing impact of obesity and NCDs in the UAE and MENA region more broadly.

LS, AA, LC, AH, HA, MF, NH, RA, AS, and HK: conceptualization. SM and JF: writing—original draft preparation. LS, AA, LC, AH, HA, SK, MF, NH, RA, and AS: writing—review and editing. JF: visualization. LS and AA: supervision. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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