Introduction
Non-communicable diseases (NCDs), including cardiovascular diseases, diabetes, stroke, and cancer, are the leading causes of mortality and morbidity in our century ( Wang & Wang, 2020 ; World Health Organization, 2000 ). According to WHO data, almost three quarters of all NCD deaths, and 82% of the 16 million people who died prematurely, occur in low- and middle-income countries ( World Health Organization, 2015 ). Preventable environmental factors such as smoking, sedentary lifestyle, unbalanced and inadequate nutrition are the major causes of NCDs ( Kelishadi, 2019 ). The need for efficient strategies in preventing of these diseases is evident as physiological, socioeconomical and psychological costs related with NCDs, which depend on several factors, become highly detrimental in modern societies ( Oliveira et al., 2023 ).

The Developmental Origins of Health and Disease (DOHaD) hypothesis states that early life and prenatal stages of development can permanently influence the postnatal phenotype and thus change susceptibility to NCDs risk during adulthood ( Barker et al., 2002 ). As a result of developmental plasticity, disadvantageous environmental stimulants, in particular maternal malnutrition, may trigger negative alterations in fetal metabolism and induce disease related mechanisms ( Gluckman, Hanson & Low, 2019 ). Initial evidence derived from the DOHaD hypothesis revealed that maternal undernutrition marked by low birth weight was associated with increased risk of obesity and NCDs in later life ( Wilkins et al., 2021 ). Over the last decade, there has been an increasing body of evidence from DOHaD related research, which indicated that the different aspects of fetal nutritional environment impacts upon the development of every baby. As such, both maternal and paternal undernutrition, high fat diets or obesity exerted negative effects on offspring metabolism ( O’Hara, Gembus & Nicholas, 2021 ; Velazquez, Fleming & Watkins, 2019 ). Since these issues are prevalent in most countries, there has been an increasing attempt to translate crucial findings from DOHaD research into public awareness ( McKerracher et al., 2019 ). However, some studies also indicate that conditioning on intermediates—through methods such as matching, restriction, stratification, or multivariable adjustment—can introduce bias in perinatal research, leading to misleading associations and incorrect biological conclusions ( Kramer et al., 2017 ; Schisterman, Cole & Platt, 2009 ). For instance, one study suggests that the strong inverse relationship between birthweight and later blood pressure may stem from insufficient consideration of random error, selective reporting, and inadequate adjustment for confounding factors ( Huxley, Neil & Collins, 2002 ). Additionally, analyses of anthropometric data related to small-for-gestational-age (SGA) births can produce conflicting results depending on the statistical methods used ( Kramer et al., 2017 ). Since these relationships are often cited as evidence for the fetal origins hypothesis, some studies critically reevaluate similar findings ( Ananth & Schisterman, 2017 ; Elmrayed et al., 2021 ; Paneth, Ahmed & Stein, 1996 ).

Improved understanding of the long-term impact of maternal diet may support strategies for NCD prevention. Epigenetics, defined as modifications in gene expression that occur independently of changes in the DNA sequence, plays a vital role in the framework of DOHaD by demonstrating how early environmental factors, including nutrition, stress, and social conditions, can influence long-term health outcomes, thereby emphasizing the necessity for early intervention and heightened awareness ( Gopal, Alenghat & Pammi, 2024 ). Research communities focusing on DOHaD principles mentioned the necessity of DOHaD knowledge translation ( Lynch et al., 2022 ; Molinaro et al., 2021 ). Supporting individual behavior changes towards a balanced diet may contribute to a healthier lifestyle in subsequent generations. In this context, Bay et al. (2012) reported that adolescents showed 30% more understanding of the link between maternal diet during pregnancy and the health of the fetus in adulthood after modules of course work consisted of DOHaD concepts. A further study conducted to examine the impact of The Healthy Start to Life Education for Adolescents Project revealed sustained positive behavior changes in dietary intake and health-related awareness ( Bay et al., 2017 ). In a different randomized control trial, intervention students who followed the LifeLab education programme designed with DOHaD concepts, exhibited greater understanding of DOHaD concepts at 12 months but this engagement did not result in behavior change ( Woods-Townsend et al., 2018 ). Although there are various personal and environmental factors influencing knowledge acquisition and desirable behavior alterations, elucidating the importance of nutrition education and establishing measurable goals may help to address the gap for setting consistent behavioral changes. World Health Organization (WHO) has indicated diet as a major behavior risk factor that can be optimized through well-understood, cost-effective and feasible interventions ( World Health Organization, 2010 ).

Elucidating the present condition of DOHaD knowledge and its possible influence on young individuals is crucially important in order to be able to set these measurable goals and take necessary precaution against the risk of non-communicable diseases. As indicated by Oyamada et al. (2018) , defining the baseline awareness and understanding of DOHaD concepts in young individuals is a required approach but to date only few studies examined the awareness levels of DOHaD concepts in young adults. Moreover, the studies examined the awareness levels of DOHaD concepts used basic questionnaires rather than a systematically developed and validated scale. The DOHaD awareness scale is designed to measure the awareness of healthcare professionals in their educational stages and to foster a broader societal consciousness regarding the prevention of unhealthy nutrition and chronic diseases. This dual purpose emphasizes both the immediate educational impact on professionals and the long-term benefits for future generations. Therefore, this study aimed to develop and validate the DOHaD awareness scale, which consists of twenty items that cover important aspects of DOHaD concepts, including epigenetics, social interactions, and life stages from pre-pregnancy to the age of two. Additionally, the scale was developed to measure the knowledge level related to the concepts underpinning the DOHaD hypothesis in a sample of university students and to examine whether an educational module consisting of DOHaD concepts may affect dietary behavior.