Thinness at birth and insulin resistance in adult life

Type 2 (non-insulin-dependent) diabetes mellitus may originate through impaired development in fetal life. Both insulin deficiency and resistance to the action of insulin are thought to be important in its pathogenesis. Although there is evidence that impaired fetal development may result in insulin deficiency, it is not known whether insulin resistance could also be a consequence of reduced early growth. Insulin resistance was therefore measured in 81 normoglycaemic subjects, and 22 subjects with impaired glucose tolerance, who were born in Preston, UK, between 1935 and 1943. Their birth measurements had been recorded in detail. Insulin resistance was measured by the insulin tolerance test which uses the rate of fall in blood glucose concentrations after intravenous injection of insulin as an index of insulin resistance. Men and women who were thin at birth, as measured by a low ponderal index, were more insulin resistant. The association was statistically significant (p = 0.01) and independent of duration of gestation, adult body mass index and waist to hip ratio and of confounding variables including social class at birth or currently. Thinness at birth and in adult life has opposing effects such that resistance fell with increasing ponderal index at birth but rose with increasing adult body mass index. It is concluded that insulin resistance is associated with impaired development in fetal life.

Outcome of low birthweight

Babies who are small at birth and during infancy are now known to be at an increased risk of developing coronary heart disease, hypertension and diabetes during adult life. This has led to the suggestion that these diseases are 'programmed' by an inadequate supply of nutrients or oxygen in utero or immediately after birth. The phenomenon of 'programming', whereby undernutrition in early life permanently changes body structure and function, is well documented in animals. As yet we know little about cellular and molecular changes which underlie it, but persisting changes in the secretion of hormones or in the sensitivity of tissues to them may be important in determining adult disease.

Growth in utero and serum cholesterol concentrations in adult life

OBJECTIVE

To see whether reduced rates of fetal growth are related to raised serum cholesterol concentrations in adult life.

DESIGN

Follow up study of men and women whose size at birth had been recorded.

SETTING

Jessop and Northern General Hospitals, Sheffield.

SUBJECTS

219 men and women born in the Jessop Hospital during 1939-40.

MAIN OUTCOME MEASURES

Serum concentrations of total cholesterol, low density lipoprotein cholesterol, and apolipoprotein B.

RESULTS

Men and women who had had a small abdominal circumference at birth had raised serum concentrations of total and low density lipoprotein cholesterol and apolipoprotein B. This was independent of the duration of gestation. Serum concentrations of total cholesterol fell by 0.25 mmol/l (95% confidence interval 0.09 to 0.42) with each 1 in (2.54 cm) increase in abdominal circumference. The corresponding figure for serum low density lipoprotein cholesterol was 0.26 mmol/l (0.11 to 0.42) and for serum apolipoprotein B 0.04 g/l (0.02 to 0.07). Small head and chest circumferences at birth and short length were each associated with raised serum low density lipoprotein cholesterol concentrations but the trends disappeared in a simultaneous regression with abdominal circumference at birth. The association between abdominal circumference at birth and low density lipoprotein cholesterol concentration was independent of social class, current body weight, cigarette smoking, and alcohol consumption.

CONCLUSION

Raised serum cholesterol concentrations in adult life are associated with impaired growth during late gestation, when fetal undernutrition has a disproportionate effect on liver growth. Impaired liver growth may permanently alter low density lipoprotein cholesterol metabolism.

Early growth and death from cardiovascular disease in women

OBJECTIVE

To determine whether the link suggested between growth in utero and during infancy and death from cardiovascular disease in men is also present in women.

DESIGN

Follow up study of women and men whose birth weight and weight at 1 year of age had been recorded.

SETTING

Hertfordshire, England.

SUBJECTS

5585 women and 10,141 men born during 1911-30.

MAIN OUTCOME MEASURES

Standardised mortality ratios for cardiovascular disease.

RESULTS

Among women and men death rates from cardiovascular disease fell progressively between the low and high birth weights groups (chi 2 = 4.3, p = 0.04 for women, chi 2 = 8.5, p < 0.005 for men). Cardiovascular deaths in men but not women were also strongly related to weight at 1 year, falling progressively between the low and high weight groups (chi 2 = 27.5, p < 0.0001). The highest cardiovascular death rates in women were among those with below average birth weight but above average weight at 1 year. In men the highest rates were among those with below average birth weight and below average weight at 1 year.

CONCLUSION

Relations between cardiovascular disease and birth weight are similar in men and women. In men cardiovascular disease is also related to weight gain in infancy.

Housing in early life and later mortality

STUDY OBJECTIVES

The aim was to examine the influence of domestic crowding and household amenities in early life on later mortality from all causes and specifically from stomach cancer, chronic obstructive pulmonary disease, and rheumatic heart disease.

DESIGN

This was a retrospective cohort study of people whose houses had been surveyed in 1936 and whose household size was known from the 1939 census. Subjects were followed through the National Health Service Central Register from 1951 to 1989.

SETTING

The housing survey had been carried out in the midland town of Chesterfield.

SUBJECTS

Subjects comprised 8138 men and women born after 1900.

RESULTS

A total of 2929 deaths were observed during the follow up period. All causes mortality in the full cohort was not consistently related to any of the housing variables examined, but among subjects who were still children at the time of the housing survey, death rates were higher in those whose houses were crowded or lacked a hot water tap. No associations could be shown between stomach cancer and domestic crowding or food storage facilities; chronic obstructive pulmonary disease and domestic crowding or use of gas for cooking; or rheumatic heart disease and domestic crowding. There were few deaths from these causes, however, in subjects who were children at the time of housing survey.

CONCLUSIONS

The findings suggest that the housing of young adults in Chesterfield during the 1930s had little effect on their later mortality. Further follow up of the cohort is needed before firm conclusions can be drawn about the influence of housing at younger ages.

Relation of fingerprints and shape of the palm to fetal growth and adult blood pressure

OBJECTIVE

To examine how finger and palm prints are related to fetal growth and adult blood pressure.

DESIGN

Follow up study of babies born around 50 years ago whose birth weight, placental weight, head circumference, and length at birth were recorded.

SETTING

Preston, Lancashire.

SUBJECTS

139 men and women born in Sharoe Green Hospital in Preston during 1935-43 and still living in Lancashire.

MAIN OUTCOME MEASURES

Finger and palm prints and current blood pressure.

RESULTS

People who were thin at birth had more whorl patterns on their fingers. People who were short at birth in relation to their head circumference had longer hands and a narrower palmer angle. Mean systolic blood pressure was 8 mmHg higher (95% confidence interval 2 to 13; p = 0.01) in the 93 men and women with a whorl pattern on one or more fingers compared with the 46 who had no whorls. The greater the number of fingers with whorls the higher the systolic blood pressure. Whorls on the right hand were more strongly associated with higher systolic pressure than whorls on the left, mean systolic pressure rising by 2.2 mmHg (0.2 to 4.1; p = 0.03) for each additional whorl on the right hand. People with long hands and a narrow palmar angle also had higher systolic pressure. Again, these associations were stronger for the right hand. Mean systolic pressure rose by 0.49 mmHg (-0.03 to 1.01; p = 0.03) for each degree decrease in palmar angle on the right hand.

CONCLUSIONS

Fingertip whorls and a narrow palmar angle are indelible markers of impaired fetal development at different stages in pregnancy. Both are associated with raised blood pressure in adult life.

Infant feeding, fetal growth and adult thyroid function

Prolonged breast-feeding in humans is associated with increased low-density lipoprotein cholesterol and higher death rates from ischaemic heart disease in adult life. The reasons for this link are unclear. A possible explanation is that thyroid hormones present in breast milk and absorbed by the suckling infant could, by the process of hormonal imprinting, permanently down-regulate the set point of thyroid homeostasis. Thyroid hormones influence cholesterol metabolism, and could explain the link between infant feeding and the regulation of cholesterol levels in the adult. We therefore investigated whether infant feeding was related to adult thyroid function in 303 women aged 60-71 years who were born in the county of Hertfordshire, UK, where birthweight, the weight at 1 year and the method of infant feeding had been recorded routinely. Free thyroxine (FT4) concentrations but not free triiodothyronine (FT3) or thyrotrophin (TSH) were increased in the women who, as infants, had been breast-fed beyond 1 year of age (p < 0.01). In women who were bottle-fed, with or without breast-feeding, serum TSH rose and FT4 fell with increasing birthweight (p = 0.01 and p = 0.04, respectively). Although the metabolic significance of these findings is unclear, they suggest that the set point of thyroid function in the adult is determined by fetal growth and infant feeding.

Thinness at birth in a northern industrial town

OBJECTIVE

To determine whether babies in an area of Britain with unusually high perinatal mortality have different patterns of fetal growth to those born elsewhere in the country.

DESIGN

Measurement of body size in newborn babies.

SETTING

Burnley (perinatal mortality in 1988 15.9/1000 total births) and Salisbury (perinatal mortality 10.8/1000 total births), England.

SUBJECTS

Subjects comprised 1544 babies born in Burnley, Pendle, and Rossendale Health District, and 1025 babies born in Salisbury Health District.

MAIN OUTCOME MEASURES

Birthweight, length, head, arm and abdominal circumferences, and placental weight were determined.

RESULTS

Compared with babies born in Salisbury, Burnley babies had lower mean birthweight (difference 116 g, 95% confidence interval (CI) 77,154), smaller head circumferences (difference 0.3 cm, 95% CI 0.2, 0.4), and were thinner as measured by arm circumference (difference 0.3 cm, 95% CI 0.3, 0.4), abdominal circumference (difference 0.5 cm, 95% CI 0.4, 0.6) and ponderal index (difference 0.8 kg/m3, 95% CI 0.6, 1.0). The ratio of placental weight to birthweight was higher in Burnley (difference 0.6%, 95% CI 0.4, 0.9). These differences were found in boys and girls and did not depend on differences in duration of gestation or on the different ethnic mix of the two districts. Mothers in Burnley were younger, shorter in stature, had had more children, were of lower social class, and more of them smoked during pregnancy than mothers in Salisbury. These differences did not explain the greater thinness of their babies.

CONCLUSIONS

Babies born in Burnley, an area with high perinatal mortality, are thin. The reason is unknown. Poor maternal nutrition is suspected because Burnley babies have a higher ratio of placental weight to birthweight. The greater thinness at birth of Burnley babies could have long term consequences, including higher rates of cardiovascular disease.

Fetal nutrition and cardiovascular disease in adult life

Babies who are small at birth or during infancy have increased rates of cardiovascular disease and non-insulin-dependent diabetes as adults. Some of these babies have low birthweights, some are small in relation to the size of their placentas, some are thin at birth, and some are short at birth and fail to gain weight in infancy. This paper shows how fetal undernutrition at different stages of gestation can be linked to these patterns of early growth. The fetuses' adaptations to undernutrition are associated with changes in the concentrations of fetal and placental hormones. Persisting changes in the levels of hormone secretion, and in the sensitivity of tissues to them, may link fetal undernutrition with abnormal structure, function, and disease in adult life.

Maternal nutrition and cardiovascular disease

This paper presents evidence that restraint of growth and development during critical periods of fetal life and infancy have an important effect on the development of cardiovascular disease.

Fetal growth and autoimmune thyroid disease

To determine whether fetal and infant growth could influence susceptibility to autoimmune disease in adults, the occurrence of thyroid autoantibodies and autoimmune thyroiditis was studied in 305 women, aged 60-71, born in Hertfordshire and for whom details of birthweight, infant growth, and feeding were routinely recorded. Thyroglobulin autoantibody was detected in 37% of the women, thyroid peroxidase autoantibody in 41%, and autoimmune thyroiditis, defined as biochemical or clinical hypothyroidism in association with thyroid autoantibodies, in 5.6%. The proportion of women with thyroglobulin and thyroid peroxidase autoantibodies fell with increasing birthweight but was not related to weight at 1 year of age or the method of infant feeding. The prevalence of both autoantibodies rose with increasing adult body mass index but fell as the waist to hip ratio increased. These results demonstrate the importance of early environment in determining the susceptibility to autoimmune thyroid disease. The contrasting effects of adult body mass index and waist to hip ratio on antibody prevalence could be explained by their associations with different hormonal environments.

Fetal growth and impaired glucose tolerance in men and women

A follow-up study was carried out to determine whether reduced fetal growth is associated with the development of impaired glucose tolerance in men and women aged 50 years. Standard oral glucose tolerance tests were carried out on 140 men and 126 women born in Preston (Lancashire, UK) between 1935 and 1943, whose size at birth had been measured in detail. Those subjects found to have impaired glucose tolerance or non-insulin-dependent diabetes mellitus had lower birthweight, a smaller head circumference and were thinner at birth. They also had a higher ratio of placental weight to birthweight. The prevalence of impaired glucose tolerance or diabetes fell from 27% in subjects who weighed 2.50 kg (5.5 pounds) or less at birth to 6% in those who weighed more than 3.41 kg (7.5 pounds) (p < 0.002 after adjusting for body mass index). Plasma glucose concentrations taken at 2-h in the glucose tolerance test fell progressively as birthweight increased (p < 0.004), as did 2-h plasma insulin concentrations (p < 0.001). The trends with birthweight were independent of duration of gestation and must therefore be related to reduced rates of fetal growth. These findings confirm the association between impaired glucose tolerance in adult life and low birthweight previously reported in Hertfordshire (UK), and demonstrate it in women as well as men. It is suggested that the association reflects the long-term effects of reduced growth of the endocrine pancreas and other tissues in utero. This may be a consequence of maternal undernutrition.

The relation of small head circumference and thinness at birth to death from cardiovascular disease in adult life

OBJECTIVE

To determine how fetal growth is related to death from cardiovascular disease in adult life.

DESIGN

A follow up study of men born during 1907-24 whose birth weights, head circumferences, and other body measurements were recorded at birth.

SETTING

Sheffield, England.

SUBJECTS

1586 Men born in the Jessop Hospital.

MAIN OUTCOME MEASURE

Death from cardiovascular disease.

RESULTS

Standardised mortality ratios for cardiovascular disease fell from 119 in men who weighed 5.5 pounds (2495 g) or less at birth to 74 in men who weighed more than 8.5 pounds (3856 g). The fall was significant for premature cardiovascular deaths up to 65 years of age (chi 2 = 5.0, p = 0.02). Standardised mortality ratios also fell with increasing head circumference (chi 2 = 4.6, p = 0.03) and increasing ponderal index (weight/length3) (chi 2 = 3.8, p = 0.05; for premature deaths chi 2 = 6.0, p = 0.01). They were not related to the duration of gestation. Among men for whom the ratio of placental weight to birth weight was in the highest fifths the standardised mortality ratio was 137.

CONCLUSION

These findings show that reduced fetal growth is followed by increased mortality from cardiovascular disease. They suggest that reduction in growth begins early in gestation. They are further evidence that cardiovascular disease originates through programming of the body's structure, physiology, and metabolism by the environment during fetal life. Maternal nutrition may have an important influence on programming.

Initiation of hypertension in utero and its amplification throughout life

OBJECTIVE

To determine whether the relation between high blood pressure and low birth weight is initiated in utero or during infancy, and whether it changes with age.

DESIGN

A longitudinal study of children and three follow up studies of adults.

SETTING

Farnborough, Preston, and Hertfordshire, England, and a national sample in Britain.

SUBJECTS

1895 children aged 0-10 years, 3240 men and women aged 36 years, 459 men and women aged 46-54 years, and 1231 men and women aged 59-71 years. The birth weight of all subjects had been recorded.

MAIN OUTCOME MEASURE

Systolic blood pressure.

RESULTS

At all ages beyond infancy people who had lower birth weight had higher systolic blood pressure. Systolic blood pressure was not related to growth during infancy independently of birth weight. The relation between systolic pressure and birth weight became larger with increasing age so that, after current body mass was allowed for, systolic pressure at ages 64-71 years decreased by 5.2 mm Hg (95% confidence interval 1.8 to 8.6) for every kg increase in birth weight.

CONCLUSIONS

Essential hypertension is initiated in fetal life. A raised blood pressure is then amplified from infancy to old age, perhaps by a positive feedback mechanism.

The diet of girls and young women at the beginning of the century

Recent research has shown that retarded growth during fetal life and infancy is linked to the development of cardiovascular disease (coronary heart disease and stroke) in adult life. Maternal nutrition has an important effect on early growth and the diets of young women may therefore influence cardiovascular disease in the next generation. Samples of women aged 80 years and over were interviewed in six areas of England and Wales with different cardiovascular death rates. The women, 281 in total, were asked about their diets when they were aged 10 to 15 years. Those who grew up in areas which now have low cardiovascular mortality tended to eat four meals a day rather than three, to live in households which had gardens, kept hens or livestock, and to go into domestic service, where diets were generally good. Those who grew up in areas which now have high cardiovascular mortality tended to eat less red meat, to live in houses without gardens, to enter industrial occupations and have higher fertility rates.

Type 2 (non-insulin-dependent) diabetes mellitus, hypertension and hyperlipidaemia (syndrome X): relation to reduced fetal growth

Two follow-up studies were carried out to determine whether lower birthweight is related to the occurrence of syndrome X-Type 2 (non-insulin-dependent) diabetes mellitus, hypertension and hyperlipidaemia. The first study included 407 men born in Hertfordshire, England between 1920 and 1930 whose weights at birth and at 1 year of age had been recorded by health visitors. The second study included 266 men and women born in Preston, UK, between 1935 and 1943 whose size at birth had been measured in detail. The prevalence of syndrome X fell progressively in both men and women, from those who had the lowest to those who had the highest birthweights. Of 64-year-old men whose birthweights were 2.95 kg (6.5 pounds) or less, 22% had syndrome X. Their risk of developing syndrome X was more than 10 times greater than that of men whose birthweights were more than 4.31 kg (9.5 pounds). The association between syndrome X and low birthweight was independent of duration of gestation and of possible confounding variables including cigarette smoking, alcohol consumption and social class currently or at birth. In addition to low birthweight, subjects with syndrome X had small head circumference and low ponderal index at birth, and low weight and below-average dental eruption at 1 year of age. It is concluded that Type 2 diabetes and hypertension have a common origin in sub-optimal development in utero, and that syndrome X should perhaps be re-named "the small-baby syndrome".

Why Londoners have low death rates from ischaemic heart disease and stroke

OBJECTIVE

To explain the low death rates from cardiovascular disease in London.

SETTING

London and the other counties of England and Wales.

SUBJECTS

Women living in London during 1901-10 and people in London dying during 1968-78.

RESULTS

At the beginning of the twentieth century young women aged 15-34 in London had remarkably low death rates, largely because of low rates for tuberculosis and other infectious diseases and low mortality during childbirth. Their low death rates contrasted with the high rates in girls under 15 years.

CONCLUSIONS

Large numbers of young women had migrated into London from agricultural counties in southern England and went into domestic service, where the diet was usually very good. Recent findings suggest that a mother's nutrition and health has a major effect on the risk of cardiovascular disease in the next generation. The low cardiovascular mortality in London is consistent with this, and contrasts with the high mortality from other common diseases.

The fetal origins of adult hypertension

AIM

To elucidate the fetal origins of hypertension.

METHODS

A systematic search was made for records of early growth, comprising measurements taken either at birth and/or during infancy, for groups of men and women now in middle-late life. Over 25,000 men and women born before 1931 were successfully traced.

RESULTS

Retarded growth in fetal life was strongly related to high blood pressure in adult life.

CONCLUSION

Hypertension is programmed by an adverse environment in utero. It is linked to impaired development in both early and late gestation.