Intergenerational Nutritional Effects

& Fetal Growth and Chronic Disease

2007

Effect of Women’s own Intrauterine Nutritional

Experience her Offspring

Two Studies of Effects of Maternal Birthweight on Infant

Birthweight

Godfrey KM, Barker DJP, Robinson S, Osmond C. Mother's birthweight and diet in pregnancy in relation to the baby's thinness at birth. Br J Obstet Gynaecol 1997;104:663–7

Illinois StudyCoutinho et al. Am J Epi, 1997 146:804-809

• N=15,287 Black and 117,708 white matched pairs of infants and mothers.

• Mothers were born between 1956-75, infants between 1989-1991

Black White

Mean infant birthweight

3139 g 3434

Mean parental birthweight

3133 3377

% low birthweight infants

12% 5%

% lbw born to women with lbw

18% 9%

% lbw born to women not lbw

11% 5%

Results

• Father’s birthweight had effect on infant birthweight but not as strong as mothers.

• In multiple linear regression for infants who weighed more than 2500 g, parental birthweight accounted for 5% of variance among black infants and 4% among white infants.

• (adjusted for parental age, years of schooling, marital status and adequacy of prenatal care)

Results, cont.

• Each 100 g increase in maternal birthweight was associated with 24-27 g increase in infant birthweight

Influence of Maternal Intrauterine & Childhood Nutrition on Outcomes of

Pregnancy

Reproductive performance and nutrition during childhood

Nutrition Reviews; Washington; Apr 1996; Martorell, Reynaldo; Ramakrishnan, Usha; Schroeder, Dirk G; Ruel, Marie;

Longitudinal Supplementation Trial (1969-1977)

• Guatemala, 4 Villages, one pair of villages had about 900 people each and the other about 500 each.

• 2 each randomized to:• Atole (Incaparina, a vegetable protein mix

developed by INCAP*, dry skim milk, sugar, and flavoring, 163 kcal/cup, 11/5 g protein)

• Fresco (flavored drink with sugar, vitamins and minerals, 59 kcal/cup)

*Institute of Nutrition of Central America and Panama

• Feeding center was open daily for over 7 years, from 1969 to 1977.

• Anyone in the village could attend, but careful recording of consumption, including of additional servings as well as of leftovers, was done only for women who were pregnant or breastfeeding and for children 7 years or younger.

• Supplements were available twice daily, in midmorning and midafternoon, so as not to interfere with meal times.

Conceptual framework

“Malnutrition in early childhood constrains the future capacity of women to bear healthy newborns and their ability to feed and care for them, and through these mechanisms the growth and development of the next generation.”

Follow-Up data - 1990s

• The prevalence of low birthweight is currently 12% in Atole villages (n = 65) and 28% in Fresco villages (n = 58) among women exposed to the supplements during the intrauterine period and the first 3 years of life.

• Mean birthweights are 2.90 kg in Atole villages and 2.73 in Fresco villages.

Role of intergenerational effects on linear growth

U Ramakrishnan; R Martorell; D G

Schroeder; R Flores; The Journal of Nutrition; Bethesda; Feb 1999;

Methods

• The sample was restricted to singleton, term (>37 wk of gestation) births that occurred in the four study villages between 1991 and 1996, to women who were born during the original longitudinal study (1969-1977)

• Complete data were available for 215 mother-child pairs, and 60% of the mothers (n = 140)

Results

• For every 100 g increase in maternal birth weight, her infant's birth weight increased by 29 g after adjusting for the effects of maternal age, gestational age and sex of the infant. This relationship was highly significant (P < 0.001)

• For every centimeter increase in maternal birth length, her child's birth weight increased by 53 g.

Influence of Maternal Nutrition in Pregnancy

Dutch Famine StudiesSusser and Stein, Nutrition Reviews, 1994

• Dutch famine winter lasted 6 months, from November 1944- when nazis imposed transport embargo on west Holland until-

• May 7, 1945 when Holland was liberated from the occupation

• Strong evidence for critical stages of development in several physiological systems

Dutch Hunger Winter: Calories

Affects of Famine

• Fertility decreased

• Maternal weight fell during pregnancy with famine exposure

• Third trimester famine exposure had strong effect on birthweight

• Third trimester famine exposure was associated with infant mortality at 30-90 days

Birth Cohorts

Obesity in Young Men after Famine Exposure in Utero and early Infancy(Ravelli et al NEJM, 1976)• N=300, 000 Dutch military inductees at age 19

• Famine exposure in first 2 trimesters lead to 80% higher prevalence of overweight (p<0.0005)

• Famine exposure in last trimester or famine exposure in first 5 months of life associated with 40% lower prevalence of overweight (p<0.005)

Adult Obesity

Interpretation?

• Cohort B1– Conceived and gestated at time of moderate

caloric restriction– Born into time of famine– Low rates of adult obesity

• Cohort D1– Conceived and gestated at a time of famine– Born into food sufficiency– High rates of adult obesity

Second Generation

• Modest association found in this cohort between birthweights of mothers and their offspring.

Other Results for Infants Exposed to Famine

• Excess central nervous system disorders (such as NTD)

• Famine exposure associated with twofold risk of schizophrenia in 50 year old women.

Prenatal exposure to famine and brain morphology in schizophrenia

Hulshoff Pol HE; Hoek HW; Susser E; Brown AS; Dingemans A; Schnack HG; van Haren NE; Pereira Ramos LM; Gispen-de Wied CC; Kahn RS; American Journal of Psychiatry , Jul 2000;

Methods

• Nine schizophrenic patients and nine healthy comparison subjects exposed during the first trimester of gestation to the Dutch Hunger Winter were evaluated with magnetic resonance brain imaging, as were nine schizophrenic patients and nine healthy subjects who were not prenatally exposed to the famine.

RESULTS:

• Prenatal famine exposure in patients with schizophrenia was associated with decreased intracranial volume.

• Prenatal Hunger Winter exposure alone was related to an increase in brain abnormalities, predominantly white matter hyperintensities.

Further evidence of relation between prenatal famine and

major affective disorder.

Alan S Brown; Jim van Os; Corine Driessens; Hans W Hoek;

et al; The American Journal of Psychiatry; Washington; Feb

2000;

Methods

• Compared the risk of major affective disorder requiring hospitalization in birth cohorts who were and were not exposed, in each trimester of gestation, to famine during the Dutch Hunger Winter of 1944-1945.

Results

• The risk of developing major affective disorder requiring hospitalization was increased for subjects with exposure to famine in the second trimester and was increased significantly for subjects with exposure in the third trimester, relative to unexposed subjects.

Fetal Nutrition and Chronic Diseases of Adulthood

Developmental Origins of Health & Disease

Fetal Origins ConceptsBarker et al

• Nutrition in early life has permanent effects

• Undernutrition has different effects at different times of life.

• Rapidly growing fetuses and neonates are vulnerable to undernutrition

• Undernutrition results from inadequate maternal intake, transport, or transfer of nutrients.

The Barker HypothesisThe Barker Hypothesis

Adverse intrauterine events Adverse intrauterine events permanently “program” postnatalpermanently “program” postnatal

structure/function/homeostasisstructure/function/homeostasis

FetalFetal Origins of Origins of AdultAdult Disease Disease

** Better chance of fetal survivalBetter chance of fetal survival** Increased risk of adult diseaseIncreased risk of adult disease

““Adapted Birth PhenotypeAdapted Birth Phenotype””

Susan P. Bagby, MD, Professor of Medicine & Physiology/PharmacologySusan P. Bagby, MD, Professor of Medicine & Physiology/PharmacologyDivision of Nephrology & Hypertension OHSU, Portland, ORDivision of Nephrology & Hypertension OHSU, Portland, OR

FETAL ORIGINS OF ADULT CVASC DISEASEFETAL ORIGINS OF ADULT CVASC DISEASE

MODIFIERS

COFACTORS

Low Birthweight/IUGR

Adverse Intrauterine Events

Adult “Metabolic Syndrome”

Abd’l Obesity HTN

CADDiabetes

TG/ HDLRenal Failure

In UteroIn Utero

BirthBirth

ChildhoodChildhood

AdulthoodAdulthood

Coronary heart disease death rates, expressed as standardized mortality ratios, in 10,141 men and 5585 women born in Hertfordshire, United Kingdom, from 1911 to 1930, according to birth weight.

(Osmond C, Barker DJP, Winter PD, Fall CHD, Simmonds SJ. Early growth and death from cardiovascular disease in women. BMJ 1993;307:1519–24)

Age-adjusted Relative Risk of Non- fatal Age-adjusted Relative Risk of Non- fatal Coronary Heart Disease and StrokeCoronary Heart Disease and Stroke

121,700 American Nurses, self report study121,700 American Nurses, self report study BMJ 315:396,1997BMJ 315:396,1997

5.0 7.5 10.00.50

0.75

1.00

1.25

1.50

Birthweight

Rel

ativ

e R

isk

Mean ± 95% CL

Catch-up growth in childhood and death from coronary heart disease: longitudinal

study (Eriksson et al, BMJ, 1999)

• Subjects: 3641 men born in Helsinki between 1924-1933

• Followed with school data for weight and height

• Deaths from coronary heart disease from 1971-95 (standardized mortality ratios) were endpoints.

Catch-up growth in childhood and death from coronary heart disease: longitudinalstudy (Eriksson et al, BMJ, 1999

• Men who had low birth weight or were thin at birth have high death rates from coronary heart disease

• Death rates are even higher if weight "catches up" in early childhood

• Death from coronary heart disease may be a consequence of prenatal undernutrition followed by improved postnatal nutrition

• Programs to reduce obesity among boys may need to focus on those who had low birth weight or who were thin at birth

Early Nutrition & Chronic Disease in

Adulthood (Waterland& Garza, Am J Clin Nutr, 1999;69:179-97)

• Epi studies: BMI, CVD, Htn, IGT

• Animal studies

• Potential mechanisms of metabolic imprinting

Diabetes in Low-Birth-Weight MenDiabetes in Low-Birth-Weight Men

Hales et al. BMJ 303: 1019, 1991Hales et al. BMJ 303: 1019, 1991

Birth Weight (lbs)

% I

mp

aire

d G

luc

To

l o

r D

M

<5.5 6.5 7.5 8.5 9.5 >9.5

40

30

20

10

0

370 menAge 64 yrs

Od

ds R

atio/A

dj fo

r BM

I

8

6

4

2

0

Gestat’l DM

Preadult Influences on Cardiovascular Disease and Cancer (Leon & Ben-Shlomo in A Lifecourse approach to chronic

disease epidemiology, 1997)

• 5 large retrospective studies - 4 found inverse relationship between birth weight and adult CVD

• Confounding issues include SES and BMI

• The relationship between birth weight and BMI complicates studies of birth weight and chronic disease

Fetal Milieu Affects Obesity RiskFetal Milieu Affects Obesity Risk

<2.52.5-3.0

3.0-3.53.5-4.0

>4.03-D Column 1

0

0.5

1

1.5

2

2.5

3-DColumn 1

Birth Weight (kg)

Odds RatioFor

Obesity

Eriksson J et al Internatl J Obesity 2001Eriksson J et al Internatl J Obesity 2001

Trouble at Both Ends of the Birth Weight SpectrumTrouble at Both Ends of the Birth Weight Spectrum

CVD

“The preponderance of data suggest an inverse association between birth weight and adult CVD risk.” (Waterland and Garza)

Blood Pressure

“Retrospective studies in diverse populations have found that birth weight is inversely correlated with adult blood pressure. Although each of the studies has some weaknesses, together they support a biological link between intrauterine growth and adult blood pressure” (Waterland and Garza)

Birth Weight (gm)<2500 -2999 -3499 -3999 -4499 >4500

130

128

126

124

122

Sys

BP (

mm

Hg)

Birth Weight Predicts Blood Pressure at Age 31Birth Weight Predicts Blood Pressure at Age 31

1966 Northern Finland Birth Cohort1966 Northern Finland Birth Cohort

+/- adjust for current BMI

Jarvelin M et al. Hypertension 2004

Variables:

Birth WeightPonderal IndexSexGestational ageMat’l Ht, WtParitySocioeconomicCurrent BMI

n = 5960 offspring

Birthweight and Adult HTN in US WomenBirthweight and Adult HTN in US Women

Nurses Health Study INurses Health Study I

Birthweight Category (lbs)

< 5.0 5.0-5.5 5.6-7.0 7.1-8.5 8.6-10.0< 5.0 5.0-5.5 5.6-7.0 7.1-8.5 8.6-10.0

HT

N P

reva

len

ce (

%) 4040

3030

1515

10 10

Age 46-71

8.4%

AgeAge 30-5530-55

3.1%

Early Growth Patterns Predict Adult HTNEarly Growth Patterns Predict Adult HTN

Barker et al. J HTN 20:1951, 2002.Barker et al. J HTN 20:1951, 2002.

Growth Patterns in 1404 Childrenwho later developed Hypertension

0 2 4 6 8 10 12 14-0.2

-0.1

0.0

0.1

0.2

BMIWeightHeight

_______________________________

Age (Yrs)

Z S

core

CohortAverage(n=8760)

}

Impaired Glucose Tolerance

• Several large retrospective cohort studies in several countries have found relationship between bw and IGT.

• 266 men and women at age 50: odds ratio for ITG or type II diabetes were 3.5 for men and 12 for women with birth weights < 2.5 compared to >3.4 (Phillips et al, Diabetologia, 1994)

Impaired Glucose Tolerance, cont..

• In some populations (ex: Pima Indians) both high and low birth weights are associated with IGT in adults.

Animal Models (Waterland and Garza)

“Overall the data from animal models of metabolic imprinting support the observed epidemiological associations.”

Effect of Gestational Type 2 Diabetes on Body Weight in Adult Offspring

Framework for understanding the maternal regulation of fetal development and programming. Keith M Godfrey and David JP Barker

(Fetal nutrition and adult disease Am J Clin Nutr 2000 71: 1344-1352)

Asymmetric Growth RestrictionAsymmetric Growth Restriction

Adverse Intrauterine Events

* Low Birth Weight for Gestational Age

* Low Wt: Height Ratio (thinness)

* Relative sparing of heart, brain, adrenal

* Disproportionate reduction of kidney, liver, pancreas, skeletal muscle

mass

* Reduced abdominal girth

Fetal Origins of Adult Fetal Origins of Adult DiseaseDisease

Asymmetric Growth RestrictionAsymmetric Growth Restriction

From Barker, 1998

““More powerful predictor than other risk factorsMore powerful predictor than other risk factors””

* ThinThin

* Small abdominalSmall abdominal girth ( liver size)girth ( liver size)

* Low arm cir-Low arm cir- cumference cumference ( muscle mass)( muscle mass)

* Preserved central fat masscentral fat mass

? % Growth-Restricted Phenotype in Lower ? % Growth-Restricted Phenotype in Lower Birth Weight CategoriesBirth Weight Categories

<5 5.0-5.5 5.5-6.0 6.0-6.5 6.5-7.0 7.0-7.5 >7.50

5

10

15

20

25

30

35% Term Births

BirthWeight Category (lbs)

% o

f T

erm

Bir

ths

Growth-Restricted Phenotype

Conceptual Graph

Potential Mechanisms ofPotential Mechanisms ofDevelopmental ProgrammingDevelopmental Programming

KidneyKidney Nephron # HTN

Pancreas Pancreas Islet Cell # Insulin secretion Glucose

Muscle Muscle muscle mass Basal met rate Exercise capacity

Heart myocyte # Risk CHF

Liver cells # ? lipid metabolism

Structural Deficits Structural Deficits Reduced ReducedFunctional Units in OrgansFunctional Units in Organs

Low Birth Wt, Low Nephron Number and HTN

Brenner et al. 1988,1994Brenner et al. 1988,1994

What Conveys Risk of HTN inWhat Conveys Risk of HTN inLower Birth-weight Offspring ?Lower Birth-weight Offspring ?

“… “… retardation of renal development as occursretardation of renal development as occursin individuals of low birth weight gives rise to in individuals of low birth weight gives rise to increased postnatal risks for systemic and increased postnatal risks for systemic and glomerular hypertension as well as enhanced risk glomerular hypertension as well as enhanced risk of expression of renal disease.”of expression of renal disease.”22

11Am J HTN 1988 1:335-47; Am J HTN 1988 1:335-47; 22Am J Kid Dis 1994 23: 171 Am J Kid Dis 1994 23: 171

Branching Morphogenesis Nephrogenesis

New Nephrons Form in Concentric Layers New Nephrons Form in Concentric Layers during Gestationduring Gestation

Condensing MesenchymeComma Shaped Bodies

Outer Nephrogenic Layer

Glomeruli

Birth WeightBirth WeightPredicts Predicts

Nephron NumberNephron Number

230,000 nephrons230,000 nephronsper kg increaseper kg increasein birth weightin birth weight

In Term Births:Ages 1-17 yrs

All Ages

 Hughson et al,Hughson et al,Kid Internat (2003) 63, 2113 Kid Internat (2003) 63, 2113

Also: Merlet-Benichou et al, 1999 Manalich et al, 2000

FOOD

CATCH-UP GROWTH

BPBP

Asymmetric Growth Restriction in Utero

Maternal Protein Deficiency

Impaired Kidney Development

# Nephrons(permanent)

“The Thrifty Phenotype”

BODY MASS

# Nephrons

Rethinking “Rethinking “FFOOAAD”D”

Programming events may act:Programming events may act: PericonceptuallyPericonceptually

PrenatallyPrenatally

Postnatally: infancy, childhoodPostnatally: infancy, childhood

Cardiovascular outcomes may appear:Cardiovascular outcomes may appear: In childhood, adolescenceIn childhood, adolescence

In midlifeIn midlife

In elderlyIn elderly

Rapid Infant Growth Rapid Infant Growth and Risk of Childhood Adiposityand Risk of Childhood Adiposity

Stettler et al, Ped. 109, 2002.

Birthweight

Rate of Wt GainIn first 4 mo

Prevalence of Overweight

at Age 7 Yrs

Infant Growth Rate and Coronary DiseaseInfant Growth Rate and Coronary Disease

BMI

Weight

Height

Cohort

0 2 4 6 8 10 12 Age in Years

Sta

nd

ard

Devia

tion

(Z

) S

core 0.05

0

- 0.05

- 0.10

- 0.15

- 0.20

- 0.25

4630 Helsinki boys357 developed CHD

Barker DJ. TRENDS Endo Metab 13; Nov 2002Barker DJ. TRENDS Endo Metab 13; Nov 2002

DEVELOPMENTAL ORIGINS OF DEVELOPMENTAL ORIGINS OF HEALTH & DISEASEHEALTH & DISEASE

In UteroIn Utero

BirthBirth

ChildhoodChildhood

AdulthoodAdulthood

Low Birthweight/IUGR

FetalUndernutrition

“Metabolic Syndrome”

Abd’l Obesity HTN

CAD Diabetes

TG/ HDLRenal Failure

AcceleratedAccelerated GrowthGrowth++

Infant Undernutrition 0-1 yr

Food: Access Palatability

Inte

r-Gen

era

tion

al

Tra

nsm

issio

n

Early Nutrition & Chronic Disease in

Adulthood (Waterland& Garza, Am J Clin Nutr, 1999;69:179-97)

• Potential mechanisms of metabolic imprinting

Epigenetics

• Epigenetics = the study of stable alterations in gene expression that arise during development and cell proliferation Epigenetic phenomena do NOT change the actual, primary genetic sequence

• Epigenetic phenomena are important because, together with promotor sequences and transcription factors, they modulate when and at what level genes are expressed

• The protein context of a cell can be understood as an epigenetic phenomena.

• Examples include: DNA methylation, histone hypo-acetylation, chromatin modifications, X-inactivation, and imprinting.

http://cnx.rice.edu/content/m11532/latest/

Metabolic Imprinting

“…the basic biological phenomena that putatively underlie relations among nutritional experiences of early life and later diseases.”

Metabolic Imprinting: Characteristics

• Susceptibility limited to a critical ontogenic window early in development

• Persistent effect lasting through adulthood

• Specific and measurable outcome

• Dose-response or threshold relation between exposure and outcome

Metabolic Imprinting: Potential Mechanisms

• Organ structure

• Cell number & function

• Clonal selection

• Metabolic differentiation

Organ Structure

• Organogenesis starts early: by 5 weeks rudimentary organs are in place, by 8 weeks organogenesis is nearly complete

• Driven by inductive signals from adjacent cells and morphogen gradients (ex: retinoic acid/vit. A)

• Local concentrations of nutrients and metabolites may modulate this process.

Cell Number

• Tissues go through limited periods of hyperplastic and hypertrophic growth

• Rate of growth is dependent on nutrient availability

• Winnick’s rat studies found severe malnutrition during critical periods limited brain cell number

• An organ’s metabolic activity is limited by cell number

Cell Function:

• Early nutrition may influence the cascade that establishes cell specific patterns.

• Ex: hepatocyte polyploidization - in adults hepatocytes often have > normal complement of chromosomes and increased metabolic activity. Lack of polyploidization could limit hepatic metabolic activity.

Clonal Selection

• Each organ is based on a finite number of founder cells which may have slight differences

• Founder cells that divide the most rapidly may disproportionally make up a tissue

• Nutrient availability may “select” cells with certain characteristics

• Ex: cells with more active lipogenic pathways could grow faster if access to fatty acids was limited

Metabolic Differentiation

• Process: cells develop stable patterns of basal and inducible gene expression

• Cells are characterized by the ability to express a limited number of genes.

• Mechanisms of control include:– chromatin structure (DNA “packaging”)– transcription factors (maintained through cell

divisions)– DNA methylation

Gluckman et al. Biology of the Neonate, 2005