The relation between fetal malnutrition and chronic disease in later lifeBMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7112.825 (Published 04 October 1997) Cite this as: BMJ 1997;315:825
Good nutrition and lifestyle matter from womb to tomb
- Nevin S Scrimshaw, Directora
- a Food and Nutrition Programme for Human and Social Development, United Nations University, PO Box 500, Boston, MA 02114 0500, USA
David Barker's group has greatly increased our understanding of the factors contributing to chronic diseases in later life. In over 50 papers1 the group has presented evidence from British populations that low birth weight at term and, in some cases, low weight at 1 year of age are associated with an increased adult risk of hypertension, coronary heart disease, non-insulin dependent diabetes, and autoimmune thyroid disease.2 The importance of these findings is that they provide overwhelming evidence that malnutrition at a very early age (in utero and in infancy) in Britain this century resulted in earlier and more severe adult chronic disease. This week Barker and Finnish colleagues provide further data and offer an explanation for the epidemic of heart disease that accompanies Westernisation.3
The Barker group's initial observations were so surprising that they met considerable scepticism. Some suggested that birth weight was reflecting other socioeconomic factors, not just maternal malnutrition, while others doubted the generalisability of the findings. But, no matter what combination of poor nutrition and other environmental factors is responsible for fetal growth retardation, the concept of fetal origins of adult disease is still valid, and the associations have been found in other populations wherever investigated. For blood pressure alone a recent review clearly showed that at all ages and in all populations examined, blood pressure tends to increase as birth weight falls.4 Confounding socioeconomic factors do not provide an adequate explanation for this association. For coronary heart disease, the early findings in Sheffield, England,5 have been have corroborated in Caerphilly, Wales6; Uppsala, Sweden7; the nurses health study in the United States8; and now in Helsinki, Finland.3 A study in Mysore, India, provided the first confirmatory evidence from a contemporary developing country.9 In the Gambia the blood pressure of children at 8 years was inversely proportional to their mothers' weight gain in the last trimester of pregnancy.10 The earlier and more frequent death from heart disease among veterans of the American civil war who were shorter at recruitment also suggests the lasting effects of early malnutrition.11
Concurrent with the Barker group's studies are others in several countries showing that iodine deficiency during pregnancy affects fetal brain development at a critical stage and can permanently affect cognitive performance.12 In populations with endemic goitre the distribution of IQ can be depressed by as much as 10 points.13 Convincing evidence also exists that iron deficiency during infancy has the same kind of lasting effect on cognitive performance.14 15 Low weight for age of preschool children was reflected in poorer neurointegration in lower socioeconomic groups in Mexico but not in middle and upper socioeconomic groups.16 In Guatemala nutritional supplementation during pregnancy and of the child up to 2 years was reflected 15 years later in better scholastic achievement and cognitive performance than in a control group.17 To these examples of ways in which malnutrition can permanently damage the expression of the genetic potential of the fetus and young child can be added the adverse effects of drugs, alcohol, and smoking during this critical development period.
Thus we must conclude that fetal malnutrition can lead to structural or functional changes in utero that permanently increase susceptibility to chronic diseases. Describing this as “programming, however, is misleading: rather, it is an increased propensity to develop these diseases when adult diet and lifestyle are conducive to them. For atherosclerosis overwhelming evidence has accumulated on the importance of controlling diet, exercise, smoking, and other risk factors at any age. Regardless of susceptibility, some populations are essentially free from mortality from heart attacks. In the 1960s serial necropsies were obtained from eight public hospitals in Latin America and Charity Hospital in New Orleans. The aortas and coronary vessels were dissected out, stained for fat, and evaluated blindly for the degree of atherosclerosis. In some Latin American populations there was almost no clinical disease, even in people aged over 60.18 In New Orleans, however, atherosclerosis increased sharply after the age of 20 and some men in their 30s and 40s were at risk of myocardial infarction. Thus, although the prevalence of low birth weight was relatively high in the Latin American populations, the low proportion of dietary energy from fat and other lifestyle factors made the “Barker effect” irrelevant to ischaemic heart disease.
The falling death rates from heart disease in countries that have aggressively promoted healthier diets and lifestyles confirm the importance of paying attention to disease prevention at later stages of life. It does not detract from the seminal contributions of the Barker group to suggest that a broader paradigm is emerging that extends the concept of the fetal origins of adult disease. This recognises that most human embryos have the potential for a long and healthy life. From the moment of conception, however, adverse environmental forces limit this potential. Intrauterine growth retardation due to poor maternal malnutrition is an important factor;but so are diet at all ages, cigarette smoking, a sedentary lifestyle, the use of drugs, and others.
The Barker group's findings have made it clear that preventive measures should begin with improving the nutrition and health of women to prevent damage to their fetuses. This will require attention to the risk factors for low birth weight before pregnancy since nutritional supplements during pregnancy are inadequate.19 Moreover, for a long and healthy life good nutrition and lifestyle are necessary throughout the entire life span. While not all individuals have the same genetic potential for avoiding premature degenerative disease, their chances of doing so can be dramatically improved by good nutrition and health practices from womb to tomb.