Cardiovascular consequences of famine in the young

War-Related Life Course Stress and Late-Life Subjective Age in Northern Vietnam

Background and Objectives

The role of early life stressors in subjective aging is weakly understood, especially in low- to middle-income countries. This paper investigated how early life stressors encountered in armed conflict influence subjective age among Vietnamese older adults who experienced war over decades of their early life.

Research Design and Methods

We analyzed survey data from the 2018 Vietnam Health and Aging Study involving 2,447 Vietnamese older adults who encountered diverse war-related stressors in early adulthood. The analytical sample (N = 2,341) included 50.9% women and 49.1% men, with an average age of 69.8. 41.1% are military veterans. We conducted survey-adjusted multinomial logistic regression analyses with mediation to predict the probability of feeling younger or older than one's chronological age. We examined how childhood adversity (i.e., childhood hunger and low parental SES) and wartime stressors (i.e., war-related violence, malevolent environment, and military service) influenced late-life subjective age, both directly and as mediated by late-life mental, functional, and physical health.

Results

We found significant associations between early adulthood war-related stressors and subjective age. Formal military service significantly lessened the relative risk of feeling subjectively old, and more plentiful wartime violence exposures significantly increased the risk of feeling younger than one's chronological age. Violence exposure's effects were both direct and indirect through functional and mental health. Conversely, greater exposure to wartime malevolent conditions (e.g., shortages of clean water and evacuations) and multiple episodes of severe hunger in childhood increased the risk of feeling older, effects both direct and mediated by late-life functional and mental health.

Discussion and Implications

Results suggest wartime stressors, especially war's malevolent environments and severe childhood hunger, experienced in many conflict-affected populations globally, have the potential to subjectively "age" survivors. Yet, not all war exposures are equal, and some may yield psychological and socioeconomic resources that support healthy aging.

Long-term cardiovascular consequences of adolescent anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is associated with maladaptive cardiovascular changes. This study investigated whether individuals who recovered from AN during adolescence experience long-term cardiovascular risk in early adulthood.

METHODS

Former AN patients discharged from the Royal Children's and Monash Children's Hospital Eating Disorder Services in Melbourne, Australia underwent cardiovascular testing. Measurements were performed using an oscillometric device for blood pressure and pulse wave velocity, ultrasound for carotid wall structure/function, resting electrocardiogram for heart-rate variability, and the EndoPat 2000 (Itamar) system for endothelial function. Patient measures were compared to healthy controls and/or normal thresholds.

RESULTS

Ninety-one percent of the former AN patients (N = 22) and controls (N = 66) were female, aged approximately 25 years, with a healthy body mass index. The mean time interval from AN recovery to participation was 7.4 years. Pulse wave velocity was lower in the former AN patients than controls. Carotid intima-media thickness was not different; however, carotid distensibility and compliance were lower, and the elastic modulus higher in the former AN patients. Greater vagal tone was observed and endothelial dysfunction was evident in 46% of the former patients.

CONCLUSIONS

Young adults who recovered from adolescent AN exhibit persistent cardiovascular adaptations. Routine cardiovascular monitoring could manage potential disease risk.

IMPACT

Cardiovascular complications are common in patients with anorexia nervosa (AN) and population studies have revealed that developmental adaptations in response to undernutrition have long-term consequences for cardiovascular health. In this study of young adults treated for AN during adolescence, there was evidence of increased carotid artery stiffness, reduced aortic stiffness, vagal hyperactivity, and endothelial dysfunction in early adulthood when compared to healthy controls. It is important to consider the cardiovascular health of patients with AN beyond achieving medical stability. Interventions that monitor cardiovascular health could minimise the burden of future cardiovascular disease.

Exposure to the 1959-1961 Chinese famine and risk of non-communicable diseases in later life: A life course perspective

Child undernutrition and later-life non-communicable diseases (NCDs) are major global health issues. Literature suggests that undernutrition/famine exposure in childhood has immediate and long-term adverse health consequences. However, many studies have theoretical and methodological limitations. To add to the literature and overcome some of these limitations, we adopted a life course perspective and used more robust methods. We investigated the association between exposure to the 1959-1961 Chinese famine and later-life NCDs and if this association depends on: life stage at exposure, famine severity, and sex. We conducted a secondary data analysis of a large-scale, nationally representative, longitudinal study-the China Health and Retirement Longitudinal Study (2011-2018, 11,094 participants). We measured famine exposure/severity using self-reported experience, life stage using age at exposure, and health using the number of NCDs. We performed Poisson growth curve models. We obtained three findings. First, compared with unexposed participants, those exposed before age 18 had a higher risk of later-life NCDs, particularly if exposed in-utero (IRR = 1.90, 95% CI [1.70, 2.12], p < .001) and in the "first 1,000 days" of life (IRR = 1.86, 95% CI [1.73, 2.00], p < .001; for 0-6 months group, IRR = 1.95, 95% CI [1.67, 2.29], p < .001). Second, the famine effects among participants moderately and severely exposed were similar (IRR = 1.18, 95% CI [1.09, 1.28], p < .001 and IRR = 1.24, 95% CI [1.17, 1.32], p < .001). Third, the famine effects did not differ between females and males (IRR = 0.98, 95% CI [0.90, 1.07], p = .703). In an individual's life course, in-utero and the "first 1,000 days" are a particularly sensitive time period with marked long-term implications for NCDs if undernutrition/famine is experienced in this period. However, this window remains open until young adulthood. This highlights the need to invest more in preventing and treating child/adolescent undernutrition to tackle later-life NCDs.

Cardiovascular Remodeling Post-Ischemia: Herbs, Diet, and Drug Interventions

Cardiovascular disease (CVD) is a serious health burden with increasing prevalence, and CVD continues to be the principal global source of illness and mortality. For several disorders, including CVD, the use of dietary and medicinal herbs instead of pharmaceutical drugs continues to be an alternate therapy strategy. Despite the prevalent use of synthetic pharmaceutical medications, there is currently an unprecedented push for the use of diet and herbal preparations in contemporary medical systems. This urge is fueled by a number of factors, the two most important being the common perception that they are safe and more cost-effective than modern pharmaceutical medicines. However, there is a lack of research focused on novel treatment targets that combine all these strategies-pharmaceuticals, diet, and herbs. In this review, we looked at the reported effects of pharmaceutical drugs and diet, as well as medicinal herbs, and propose a combination of these approaches to target independent pathways that could synergistically be efficacious in treating cardiovascular disease.

Implication of the Mediterranean diet on the human epigenome

Epigenetics, defined as "hereditary changes in gene expression that occur without any change in the DNA sequence", consists of various epigenetic marks, including DNA methylation, histone modifications, and non-coding RNAs. The epigenome, which has a dynamic structure in response to intracellular and extracellular stimuli, has a key role in the control of gene activity, since it is located at the intersection of cellular information encoded in the genome and molecular/chemical information of extracellular origin. The focus shift of studies to epigenetic reprogramming has led to the formation and progressive importance of a concept called "nutriepigenetics", whose aim is to prevent diseases by intervening on nutrition style. Among the diet types adopted in the world, the renowned Mediterranean Diet (MD), being rich in unsaturated fatty acids and containing high levels of whole grain foods and large quantities of fruits, vegetables, and legumes, has shown numerous advantages in excluding chronic diseases. Additionally, the fact that this diet is rich in polyphenols with high antioxidant and anti-inflammatory properties has an undeniable effect in turning some cellular pathways against the disease. It is also apparent that the effects of polyphenols on the epigenome cause changes in mechanisms such as DNA methylation and histone acetylation/deacetylation, which have a regulatory effect on gene regulation. This review presents the effects of long-term consumption of nutrients from the MD on the epigenome and discusses the benefits of this diet in the treatment and even prevention of chronic diseases.

Neonatal ketone body elevation regulates postnatal heart development by promoting cardiomyocyte mitochondrial maturation and metabolic reprogramming

Neonatal heart undergoes metabolic conversion and cell cycle arrest preparing for the increased workload during adulthood. Herein, we report that neonatal ketone body elevation is a critical regulatory factor for postnatal heart development. Through multiomics screening, we found that the expression of 3-hydroxy-3-methylglutaryl-CoA synthase 2 (HMGCS2), the rate-limiting enzyme of ketogenesis, was transiently induced by colostrum in the neonatal heart. Hmgcs2 knockout caused mitochondrial maturation defects. Meanwhile, postnatal heart development was compromised and cardiomyocytes reacquired proliferation capacity in Hmgcs2 knockout mice. Consequently, over 40% of newborn Hmgcs2 knockout mice died before weaning. The heart function of surviving Hmgcs2 knockout mice was also impaired, which could be rescued by ketone body supplementation during the suckling stage. Mechanistically, ketone body deficiency inhibited β-hydroxybutyrylation but enhanced acetylation of mitochondrial proteins, which might be responsible for the inhibition of the enzyme activity in mitochondria. These observations suggest that ketone body is critical for postnatal heart development through regulating mitochondrial maturation and metabolic reprogramming.

Sex Differences at Early Old Stage in Glycolipid Metabolism and Fatty Liver in Offspring Prenatally Exposed to Chinese Great Famine

Background

About 50 years ago, Chinese Great Famine (CGF) affected the entire population in China, and its long-term influence on the offspring has attracted significant attention for research. However, information on possible metabolic differences between sexes is limited. This study explored whether there might be sex differences in the risks of development of glucolipid metabolic dysfunction and fatty liver following prenatal exposure to CGF.

Materials and Methods

There were 11,417 subjects around 55 years of age (6,661 women and 4,756 men). They were divided as the exposed group in which the fetal stage was in CGF, and the unexposed group included those born after CGF. Analysis focused on comparisons between sexes.

Results

Compared to the unexposed group, the BMI and triglyceride (P &lt; 0.05) in men were higher in exposed group, while waist circumference and blood sugar (P &lt; 0.05) in the exposed women were significantly higher. With the ages being properly balanced, the risks of glycolipid metabolic dysfunction were significantly higher in both men and women in the exposed than in the unexposed group (P &lt; 0.001). Prenatal exposure to CGF significantly increased risks of abnormal BMI (P &lt; 0.001, 95% CI: 2.305–2.93), blood sugar (P &lt; 0.05, 95% CI: 1.050–1.401), triglycerides (P &lt; 0.05, 95% CI: 1.006–1.245), and fatty liver (P &lt; 0.001, 95% CI: 1.121–1.390) in men, and increased risks of abnormal blood sugar (P &lt; 0.05, 95% CI: 1.024–1.689) and positive urine sugar (P &lt; 0.05, 95% CI: 1.062–6.211) in women. Height and body weight were either the same or higher in the exposed subjects compared with the unexposed ones, regardless of sexes.

Conclusion

This study is the first to identify sex differences in the long-term effects of CGF on metabolism and fatty liver. Importance of the findings include the benefits of prescribing medicine for the early prevention of certain diseases for each sex before aging based on the differences revealed. This study also shows “catch-up growth” in the offspring prenatally exposed to CGF as possible mechanisms underlying the long-term effects.

Early-life exposure to Chinese famine and stroke risk in mid- to late life: the mediating roles of cognitive function and depression

BACKGROUND

Limited research has examined the role that famine exposure plays in adulthood stroke risk. We aim to explore the causal implications of early exposure to the Great Chinese Famine on stroke risk and determine whether these associations were mediated by cognitive function, and depression.

METHODS

We sampled 12,681 individuals aged 45 years and older from the China Health and Retirement Longitudinal Study (CHARLS) and divided them into fetally exposed, childhood-exposed, adolescence/adulthood-exposed and unexposed groups. Stroke was defined by self- or proxy-reported physician diagnosis. Based on a counterfactual framework, marginal structural models were used to estimate the natural direct effect and the natural indirect effects through cognitive function and depression for causal inference.

RESULTS

We found that early-life exposure to Chinese famine was directly related to increased stroke risk in mid- to late life. Cognitive function and depression accounted for a greater part of the effect for childhood famine exposure, mediating 36.35% (95%CI: 14.19, 96.19%) of the overall association between famine exposure and incident stroke, than for the fetal, adolescence/adulthood famine exposure groups. However, the natural indirect effect through depression was not significant in the fetally exposed group. The results were robust in the sensitivity analysis of model specification and unobserved confounding.

CONCLUSIONS

Our findings are consistent with the latency, pathway, and accumulation models, supporting the life-course theory. Early stages of life exposed to the Chinese Famine were associated with higher risk of stroke in mid- to late life. Enhanced cognitive and depression interventions may reduce stroke risk in middle-aged and older Chinese adults who exposure to famine in early life.

Association of Famine Exposure on the Changing Clinical Phenotypes of Primary Hyperparathyroidism in 20 years

BACKGROUND & AIMS

Primary hyperparathyroidism(PHPT) has been evolving into a milder asymptomatic disease. No study has assessed the association between famine exposure and such a shift. We aim to explore the effects of China's Great Famine exposure on the changing pattern of PHPT phenotypes.

METHODS

750 PHPT patients diagnosed from 2000 to 2019 were studied. The clinical presentations were compared between them in recent 10 years (2010-2019) and previous 10 years (2000-2009). Participants were then categorized into fetal, childhood, adolescent, adult exposure, and unexposed groups. Logistic regression was used to estimate the odds ratios (ORs) and confidence intervals (CIs) of famine exposure as factors contributing to the changes in the clinical presentations of PHPT.

RESULTS

Serum levels of PTH, albumin-corrected Ca, tumor size, eGFR, BMDs (all P<0.001), and clinical symptoms became milder in recent 10 years. Famine exposure (72.6% vs 58.4%, P<0.001), especially the adult exposure (18.8% vs 4.1%, P<0.001)was significant less in recent 10 years. The ORs (95%CIs) of having upper 3^rd tertile PTH were 2.79(1.34,5.8), 2.07(1.04,4.11), 3.10(1.15,8.38) and 8.85(2.56,30.56) for patients with fetal, childhood, adolescent and adult famine exposure, respectively. The ORs (95%CIs) of upper 3^rd tertile albumin-corrected Ca and upper 3^rd tertile of tumor size was 4.78(1.39, 16.38) and 4.07(1.12,14.84) for participants with adult famine exposure, respectively. All these associations were independent of age, sex, disease duration and other confounders.

CONCLUSIONS

The clinical manifestations of PHPT in China continue to be milder. Exposure to famine is associated with PHPT. Less famine exposure might be responsible for the mile form of PHPT in recent years.

Early-Life Exposure to the Chinese Great Famine and Later Cardiovascular Diseases

Objectives: This study aimed to examine the association between early life famine exposure and adulthood cardiovascular diseases (CVDs) risk. Methods: A total of 5,504 subjects were selected using their birthdate from national baseline data of the China Health and Retirement Longitudinal Survey to analyze the association between famine exposure in early life and CVDs risk in adulthood. CVDs was defined based on the self-reported doctor's diagnosis. Results: The prevalence of CVDs in the unexposed group, fetal-exposed, infant-exposed, and preschool-exposed groups was 15.0%, 18.0%, 21.0%, and 18.3%, respectively. Compared with the unexposed group, fetal-exposed, infant-exposed and preschool-exposed groups had higher CVDs risk in adulthood (p < 0.05). Compared with the age-matched control group, infancy exposed to famine had a significantly higher adulthood CVDs risk (OR = 1.52, 95% CI: 1.15, 2.01; p = 0.006). The association seems to be stronger among population with higher education level (P _interaction = 0.043). Sensitivity analysis revealed consistent association between early-life famine exposure and adult CVDs risk. Conclusion: Early life exposed to the China great famine may elevate the risk of CVDs in adulthood.

Severe malnutrition or famine exposure in childhood and cardiometabolic non-communicable disease later in life: a systematic review

INTRODUCTION

Child malnutrition (undernutrition) and adult non-communicable diseases (NCDs) are major global public health problems. While convincing evidence links prenatal malnutrition with increased risk of NCDs, less is known about the long-term sequelae of malnutrition in childhood. We therefore examined evidence of associations between postnatal malnutrition, encompassing documented severe childhood malnutrition in low/middle-income countries (LMICs) or famine exposure, and later-life cardiometabolic NCDs.

METHODS

Our peer-reviewed search strategy focused on 'severe childhood malnutrition', 'LMICs', 'famine', and 'cardiometabolic NCDs' to identify studies in Medline, Embase, Global Health, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. We synthesised results narratively and assessed study quality with the UK National Institute for Health and Care Excellence checklist.

RESULTS

We identified 57 studies of cardiometabolic NCD outcomes in survivors of documented severe childhood malnutrition in LMICs (n=14) and historical famines (n=43). Exposure to severe malnutrition or famine in childhood was consistently associated with increased risk of cardiovascular disease (7/8 studies), hypertension (8/11), impaired glucose metabolism (15/24) and metabolic syndrome (6/6) in later life. Evidence for effects on lipid metabolism (6/11 null, 5/11 mixed findings), obesity (3/13 null, 5/13 increased risk, 5/13 decreased risk) and other outcomes was less consistent. Sex-specific differences were observed in some cohorts, with women consistently at higher risk of glucose metabolism disorders and metabolic syndrome.

CONCLUSION

Severe malnutrition or famine during childhood is associated with increased risk of cardiometabolic NCDs, suggesting that developmental plasticity extends beyond prenatal life. Severe malnutrition in childhood thus has serious implications not only for acute morbidity and mortality but also for survivors' long-term health. Heterogeneity across studies, confounding by prenatal malnutrition, and age effects in famine studies preclude firm conclusions on causality. Research to improve understanding of mechanisms linking postnatal malnutrition and NCDs is needed to inform policy and programming to improve the lifelong health of severe malnutrition survivors.

Concurrency of Early-Age Exposure to Chinese Famine and Diabetes Increases Recurrence of Ischemic Stroke

Background and Purpose: Early age exposure to the Chinese Great Leap Forward famine (1959–1961) is associated with the incidence of risk factors for ischemic stroke. This study aims to examine the relationship between early age famine exposure and 12-month stroke recurrence. We sought to explore the interaction between famine exposure status and metabolic phenotypes on stroke recurrence and how the adherence of crucial evidence-based key performance indicators (KPI) would modify this interaction.

Methods: We analyzed data of patients who were born between 1953 and 1964 in the China National Stroke Registry II (CNSR-II). The study population was further divided into five subgroups for comparing 12-month stroke recurrence. A multivariate Cox proportional hazard regression model was used in analyzing the impact of the concurrence of metabolic phenotypes—type 2 diabetes (T2D) or metabolic syndrome (MetS)—and early-age famine exposure on recurrent risk. The influence of the adherence to predefined KPI and concurrency of metabolic phenotype was also evaluated.

Results: Concurrent T2D and early age famine exposure was associated with an increased recurrence risk of ischemic stroke with 12 months [adjusted hazard ratio (HR): 1.63, 95% confidence interval (CI) 1.28–2.07]. Optimal adherence to KPI was not associated with significantly reduced risk of 12-month stroke recurrence (adjusted HR: 0.80, 95% CI: 0.51–1.26).

Conclusions: Concurrency of early-age famine exposure and diabetes mellitus was associated with a higher risk of stroke recurrence within 12 months, and adherence to evidence-based KPI did not reduce the risk significantly.

Fetal exposure to the Great Chinese Famine and risk of ischemic stroke in midlife

BACKGROUND AND PURPOSE

Epidemiological studies have reported an association between famine exposure and increased risk of cardiovascular disease. However, it is unclear whether fetal exposure to the Great Chinese Famine of 1959 to 1961 was associated with risk of ischemic stroke in midlife.

METHODS

A total of 17,787 participants of the Kailuan study, who were free of cardiovascular disease and cancer at baseline (2006) were enrolled in the study. All participants were divided into three groups: unexposed (born between 1 October 1962 and 30 September 1964, used as the reference group in current analyses), fetal exposure (born between 1 October 1959 and 30 September 1961), and early childhood exposure (born between 1 October 1956 and 30 September 1958). Incident ischemic stroke cases between 2006 and 2017 were confirmed by review of medical records. Cox proportional hazards regression was applied to analyze the effect of fetal famine exposure on ischemic stroke risk.

RESULTS

During the mean (10.4 ± 2.2) years of follow-up, 547 incident ischemic stroke cases were identified. After adjustment for potential confounders, the hazard ratio (HR) for ischemic stroke was 1.45, and the 95% confidence interval (CI) was 1.14, 1.84 for fetal famine-exposed compared with unexposed individuals. Similar associations were observed in men (adjusted HR: 1.40; 95% CI: 1.08, 1.80) and overweight individuals (adjusted HR: 1.56; 95% CI: 1.18, 2.07), but not in their counterparts. The results of the early childhood-exposed group were similar to the above.

CONCLUSIONS

Our findings support an association between fetal malnutrition and higher risk of ischemic stroke in adulthood.

Childhood exposure to hunger: associations with health outcomes in later life and epigenetic markers

Aim: To assess associations of early exposure to hunger with depressive symptoms and cardiovascular disease (CVD) and to investigate possible epigenetic pathways. Patients & methods: Data were based on a German population-based cohort of older adults (n = 9631). Regression models were performed for health outcomes in later life. An epigenome-wide association study for early-life exposure to hunger was performed in a subgroup (n = 2221) with whole blood DNA methylation data. Results: Childhood exposure to hunger was associated with CVD and depressive symptoms in later life. Prenatal or infant exposure was strongly associated with depressive symptoms. No CpG reached epigenome-wide significance after multiple testing correction. Conclusion: Childhood hunger is a risk factor for depressive symptoms and CVD at older age. DNA methylation could not explain this association.

The relationship between famine exposure during early life and carotid plaque in adulthood

BACKGROUND

Famine exposure is a potential risk factor for adverse cardiometabolic health. However, the relationship between famine exposure during early life and carotid plaque in adulthood remains unclear. Therefore, the aim was to investigate the relationship between famine exposure during early life and the risks for carotid plaque in adulthood.

METHODS

This was a cross-sectional study. Data were collected between 2017 and 2018 in Guangdong, China. Subjects who were born between 1 October 1952 and 30 September 1964, and had the carotid ultrasound measurement were enrolled. All included participants were divided into five groups: no exposure, fetal exposure, early-childhood exposure, mid-childhood exposure, and late-childhood exposure. Carotid plaque was assessed by carotid ultrasound examination. Multivariate logistic regression was used to estimate the odds ratio (OR) and confidence interval (CI) between famine exposure and carotid plaque.

RESULTS

There were 2652 subjects enrolled, 973 (36.7%) of them were males, and the mean age was 59.1 ± 3.6 years. The prevalence of carotid plaque in unexposed, fetal-exposed, early-childhood, mid-childhood, and late-childhood exposed groups were 40.2%, 40.8%, 55.3%, 56.8%, and 62.1%, respectively. When compared with the unexposed group, the fully adjusted ORs for carotid plaque from fetal-exposed, early-childhood, mid-childhood to late-childhood exposed were 1.023 (95% CI: 0.771, 1.357, P = 0.872), 1.755 (95% CI: 1.356, 2.275, P < 0.001), 1.780 (95% CI: 1.391, 2.280, P < 0.001), and 2.119 (95% CI: 1.643, 2.739, P < 0.001), respectively. Subgroup analyses showed that the famine effect on carotid plaque did not interact with body mass index, gender, smoking status, hypertension, and diabetes history (all P for interaction > 0.500).

CONCLUSIONS

Famine exposure during early life was significantly associated with an increased risk of carotid plaque in adulthood.

Foetal and childhood exposure to famine and the risks of cardiometabolic conditions in adulthood: A systematic review and meta-analysis of observational studies

A systematic review and meta-analysis of observational studies was performed to provide a deeper understanding of the associations between foetal and childhood exposure to famine and the risks of type 2 diabetes mellitus (T2DM), metabolic syndrome, hypertension, hyperglycaemia, dyslipidaemia, obesity, overweight, coronary heart disease, stroke, and nonalcoholic fatty liver disease (NAFLD) in adulthood. Both foetal and childhood exposure to famine were positively associated with the risks of T2DM (foetal exposure: RR 1.37, 95% CI, 1.23-1.52; childhood exposure: RR 1.33, 95% CI, 1.08-1.64), metabolic syndrome (RR 1.26, 95% CI, 1.07-1.50; RR 1.24, 95% CI, 1.13-1.35), hypertension (RR 1.30, 95% CI, 1.07-1.57; RR 1.33, 95% CI, 1.02-1.74), hyperglycaemia (RR 1.27, 95% CI, 1.11-1.45; RR 1.25, 95% CI, 1.10-1.42), dyslipidaemia (RR 1.48, 95% CI, 1.33-1.66; RR 1.27, 95% CI, 1.12-1.45), obesity (RR 1.19, 95% CI, 1.02-1.39; RR 1.13, 95% CI, 1.00-1.28), overweight (RR 1.17, 95% CI, 1.07-1.29; RR 1.07, 95% CI, 1.00-1.14), coronary heart disease (RR 1.22, 95% CI, 1.00-1.51; RR 1.21, 95% CI, 1.09-1.35), and moderate-to-severe NAFLD (RR 1.66, 95% CI, 1.07-2.57; RR 1.68, 95% CI, 1.41-1.99) in adulthood. No association was observed for the risks of stroke or mild NAFLD. Adjustments for age, alcohol, smoking, body mass index, and physical activity nullified some associations. The associations were generally stronger in women than in men. In summary, foetal and childhood exposure to famine may confer greater risks of developing certain cardiometabolic conditions in adulthood, particularly in women. The extent to which risks for cardiometabolic conditions are associated with early-life famine appears to be determined by certain factors in adulthood.

In utero exposure to the Great Chinese Famine and risk of intracerebral hemorrhage in midlife

OBJECTIVE

To investigate whether in utero exposure to the Great Chinese Famine in 1959 to 1961 was associated with risk of intracerebral hemorrhage (ICH) in adulthood.

METHODS

In this cohort analysis, we included 97,399 participants of the Kailuan Study who were free of cardiovascular disease and cancer at baseline (2006). Cases of incident ICH were confirmed by medical record review. We used the Cox proportional hazards model to calculate the hazard ratio (HR) and 95% confidence interval (CI) for ICH according to in utero famine exposure status.

RESULTS

Among 97,399 participants in the current analyses, 6.3% (n = 6,160) had been prenatally exposed to the Great Chinese Famine. During a median 9.0 years of follow-up (2006-2015), we identified 724 cases of incident ICH. After adjustment for potential confounders, the HR of ICH was 1.99 (95% CI 1.39-2.85) for in utero famine-exposed individuals vs individuals who were not exposed to the famine. When exposure to famine and severity of famine were examined jointly, the adjusted HR was 2.99 (95% CI 1.21-7.39) for in utero exposure to severe famine and 1.94 (95% CI 1.32-2.84) for in utero exposure to less severe famine relative to those without exposure to famine.

CONCLUSIONS

Individuals with in utero exposure to famine, especially those exposed to severe famine, were more likely to have ICH in midlife, highlighting the role of nutritional factors in susceptibility to this severe cerebral condition.

The impacts of intrauterine Bisphenol A exposure on pregnancy and expression of miRNAs related to heart development and diseases in animal model

This study aimed to examine the impact of BPA exposure on pregnancy and foetuses on cardiac tissues and the expression of cardiac microRNAs (miRNAs) related to heart development and diseases. Pregnancy is known to be the "critical windows" in determining the offspring physical and cells development in their life after birth. The increment of the risk of cardiovascular disease (CVD) in a later stage of life has been reported by few studies demonstrated from prenatal exposure of BPA. BPA has been shown to alter miRNAs expression profiles for organ development, regeneration and metabolic functions. These alterations have been associated with the risk of CVDs. However, the associations between pregnancy outcomes and miRNAs expression in cardiac of mother- and foetuses-exposed to BPA are still not entirely explored. In BPA-exposed pregnant rat groups, a significant weight gained was observed in comparison to control (p < 0.05). Interestingly, significant changes in systolic and diastolic blood pressure between the first and third trimester of BPA-exposed pregnant rats were also observed (p < 0.05). In BPA-exposed pregnant rats, miR-499-5p was significantly altered in the heart (p < 0.01). Meanwhile, altered miR-17-5p, -208-3p, and -210-3p expressions were observed in all heart of the foetuses from BPA-exposed pregnant rats (p < 0.05). In H&E staining, BPA-exposed foetal hearts showed a sign of fibrosis while BPA-exposed pregnant rats showed muscle remnant. Masson trichrome staining further confirmed the presence of fibrosis observed in BPA-exposed foetal heart and reduced expression of cardiac troponin I (cTnI) was also observed in BPA-exposed foetal heart. In summary, altered cardiac miRNAs with histological changes were observed in both mother- and foetus-exposed BPA These findings put forward the importance of future work to further understand how prenatal BPA exposure affect foetuses in their later stage of life.

Early-Life Famine Exposure and Risk of Cardiovascular Diseases in Later Life: Findings From the REACTION Study

Background

Previous studies reported that early‐life exposure to undernutrition is associated with the risk of diabetes mellitus and metabolic syndrome in adulthood, but the association with risk of cardiovascular disease (CVD) later in life remains unclear. The current study aimed to investigate whether exposure to Chinese famine in early life is associated with risk of CVD.

Methods and Results

We used data from REACTION (Risk Evaluation of Cancers in Chinese Diabetic Individuals: A Longitudinal Study), which recruited a total of 259 657 community‐dwelling adults aged 40 years or older from 25 centers across mainland China between 2011 and 2012. Compared with the nonexposed participants, those who had been exposed to famine in early life had a significantly increased risk of total CVD, myocardial infarction, stroke, and coronary heart disease. In the multivariable‐adjusted logistic regression model, the odds ratios (95% CI) for total CVD, myocardial infarction, stroke, and coronary heart disease in fetal famine exposure were 1.35 (1.20–1.52), 1.59 (1.08–2.35), 1.40 (1.11–1.78), and 1.44 (1.26–1.65), respectively; those odds ratios in childhood famine exposure were 1.59 (1.40–1.81), 2.20 (1.52–3.20), 1.82 (1.45–2.28), and 1.80 (1.56–2.09), respectively; and those in adolescent famine exposure were 1.52 (1.27–1.81), 2.07 (1.28–3.35), 1.92 (1.42–2.58), and 1.83 (1.50–2.24), respectively. The main finding of our study is that, compared with those who lived in the less severely affected famine area, individuals in the severely affected famine area had significantly increased risk of total CVD in all 3 exposed groups.

Conclusions

Early‐life exposure to undernutrition is associated with significantly increased risk of CVD in later life, especially among those who were in the severely affected famine area.

Early famine exposure and adult disease risk based on a 10-year prospective study of Chinese adults

OBJECTIVE

To comprehensively examine the potential impacts of prenatal experience of the Chinese Great Famine on chronic disease risks in the middle age.

METHODS

This study included 92 284 participants aged 39-51 years from China Kadoorie Biobank born around the famine period and without major chronic diseases at baseline. We categorised participants into non-famine births (born between 1 October 1956 and 30 September 1958, and 1 October 1962 and 30 September 1964) and famine births (born between 1 October 1959 and 30 September 1961). The outcomes were incident cardiovascular disease, cancer and respiratory system disease. Cox regression was used to estimate adjusted HR and 95% CI for famine exposure. Subgroup analyses were performed according to baseline characteristics.

RESULTS

During a median 10.1 years of follow-up, we identified 4626 incident ischaemic heart disease (IHD) cases, 7332 cerebrovascular disease cases, 3111 cancer cases and 16 081 respiratory system disease cases. In the whole population, prenatal famine exposure was not statistically associated with the risks of developing any chronic diseases in adulthood. However, for urban participants, compared with non-famine births, famine births had a higher risk of cerebrovascular disease (HR 1.18; 95% CI 1.09 to 1.28); such association was not shown for rural participants (p for interaction <0.001). Also, we observed the associations of prenatal famine exposure with IHD (HR 1.15; 95% CI 1.05 to 1.26) and cerebrovascular disease (HR 1.13; 95% CI 1.05 to 1.21) in participants with lower physical activity level, but not in those with higher ones (all p for interaction=0.003).

CONCLUSION

Our findings indicate that prenatal exposure to the Chinese famine might be associated with an increased cardiovascular risk and such risk may be modified by adult lifestyle.

Early life exposure to 1959-1961 Chinese famine exacerbates association between diabetes and cardiovascular disease

BACKGROUND

We aimed to assess whether early life exposure to the Chinese famine (1959-1961) modifies the association between type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD) in adulthood.

METHODS

Data from 4247 adults born between 1954 and 1964 from the 2011 and 2015 China Health and Retirement Longitudinal Study (CHARLS) were analyzed. CVD in 2011 and 2015 was based on self-reported doctor's diagnosis of cardiac events (heart attack, coronary heart disease, angina, congestive heart failure, or other heart problems) and stroke. Diabetes in 2011 was defined by fasting blood glucose, HbA1C, or known diabetes.

RESULTS

Diabetes in 2011 was cross-sectionally associated with an increase of CVD risk in 2011 (OR 1.91, 95%CI 1.53-2.40, P < 0.001) after adjusting for age and gender. Famine exposure changed the association between diabetes and CVD in areas severely affected by famine. The odds ratios (OR) of diabetes in 2011 for CVD in 2015 were 1.24 (95%CI 0.73-2.10), 1.27 (95%CI 0.72-2.24), 2.25 (95%CI 1.29-3.91), 4.31 (95%CI 2.07-8.97) and 1.72 (95%CI 0.84-3.51) among adults in late childhood-, mid-childhood-, early childhood-, fetal-, and nonexposed cohorts in severe famine areas, respectively.

CONCLUSION

T2DM is associated with the risk of CVD among Chinese adults. Fetal and early childhood exposure to the Chinese famine exacerbated the associated risk.

Is lipid goal one-size-fits-all: A review of evidence for recommended low-density lipoprotein treatment targets in Asian patients

The international guideline recommendations for low-density lipoprotein cholesterol (LDL-C) lowering were made based on the results of randomized controlled trials (RCTs), meta-analyses, and observational studies mostly in the White population. It was not clear whether these LDL-C targets could be applicable to other ethnic groups, for example, Asian patients. This review aimed to address major aspects related to the lipid goal and statin therapy in Asia, including the epidemiology of cardiovascular disease, the LDL-C profiles, the lipid goals from localized guidelines, genetics and lifestyles, and the efficacy and safety of statins. Owing to the geographic, ethnic, genetic, and cultural diversity in this region, we observed a geographic pattern of diversity in cardiovascular epidemiology and statin response in Central Asia, East Asia (particularly for Asia-Pacific region), and South Asia. The rapidly growing literature from Asian countries questioning "lower is better" hypothesis was noticed. However, owing to the nature of these dominantly observational data, the conclusion was hardly confirmative. Despite the rapid expansion of the current literature in this region, efforts should be made to ensure an adequate sample size to assess the significance of a given lipid parameter on overall cardiovascular outcomes in this Asian population.

Fetal and childhood malnutrition during the Korean War and metabolic syndrome in adulthood

OBJECTIVES

Koreans experienced unexpected shortages of food and refugee life during the Korean War (1950-1953). In the present study, we used the Korean War as a natural experiment for early life malnutrition with the aim of evaluating the risk for metabolic syndrome in adulthood according to participant exposure status during the Korean War.

METHODS

We used data from 25 708 participants from the fourth through seventh Korean National Health and Nutrition Examination Survey, a nationally representative database of Korea. By years of birth, we divided the study participants into non-exposed (1959-1963 and 1954-1958), fetal-exposed (1951-1953), early childhood-exposed (1946-1950), late-childhood-exposed (1941-1945), and adolescent-exposed (1936-1940) groups according to participants' ages during the Korean War. We calculated the risk for metabolic syndrome in adult life using logistic regression analysis.

RESULTS

Compared with the non-exposed group, women exposed to the Korean War while in utero and during early childhood were associated with increased risk for abdominal obesity and elevated triacylglycerol levels, whereas men showed low high-density lipoprotein cholesterol levels. Fetal and early childhood exposure increased the risk for metabolic syndrome in adults compared with the non-exposed group (fetal-exposed men: odds ratio [OR], 1.28; 95% confidence interval [CI], 0.93-1.76; fetal-exposed women: OR, 1.35; 95% CI, 1.01-1.80; early-childhood-exposed men OR, 1.25; 95% CI, 0.82-1.90; and early-childhood-exposed women OR, 1.41; 95% CI, 0.97-2.06).

CONCLUSIONS

Fetal and early childhood experiences during the Korean War were associated with increased risk for some components of metabolic syndrome. The present study suggested that early life malnutrition due to the Korean War may be associated with metabolic syndrome in later life.

Association of Maternal Prepregnancy Body Mass Index With Placental Histopathological Characteristics in Uncomplicated Term Pregnancies

INTRODUCTION

Prepregnancy obesity is a growing global health problem and has several risks for mother and child. The aim of this study was to systematically examine the effect of increased maternal body mass index (BMI) on placental pathology in otherwise uneventful term pregnancies.

METHODS

In this analysis, we studied data of the Netherlands Amniotic Fluid study, a prospective study of women delivering in Utrecht, the Netherlands, between 2006 and 2007. We included women with uncomplicated pregnancies, vaginal delivery, and data on prepregnancy weight and height (n = 382). Placental histopathology was compared between women of normal BMI (≤24.9 kg/m²), overweight (25-29.9 kg/m²), and obese (≥30 kg/m²).

RESULTS

Increasing prepregnancy BMI was associated with heavier placentas and higher mean infant's birth weight. In addition, obesity was positively associated with high-grade chronic villitis (odds ratio [OR]: 18.1, 95% confidence interval [CI]: 1.6-205.2), accelerated villous maturation (OR: 1.1, 95% CI: 1.0-1.2), and lower incidence of placental weight below the 10th percentile for gestational age (OR: 0.5, 95% CI: 0.3-1.0). There was a substantial effect of parity on maternal, placental, and neonatal weights.

CONCLUSIONS

Even in uncomplicated pregnancies, maternal obesity is associated with characteristic changes in placental pathology. Further research is needed to evaluate these changes in view of later-life health of infants born to obese mothers.

Epidemic T2DM, early development and epigenetics: implications of the Chinese Famine

The gene-environment interactions resulting from famine and the subsequent increased intergenerational risk of type 2 diabetes mellitus (T2DM) have contributed to the current epidemic of T2DM in China, which poses major social, health and economic challenges. The epidemic of T2DM could threaten national development in China through premature morbidity and mortality from T2DM and associated non-communicable diseases. The Chinese Famine (1959-1961), as a contributor to the nation's current national T2DM epidemic, provides an important and urgent public health warning. The effects of the famine give a strong message that research and actions that address the prevention of T2DM cannot be confined to lifestyle measures, as used in the landmark Da Qing study and the lifestyle prevention programmes and pharmaceutical interventions used in Western nations. To stem the T2DM epidemic, a new paradigm for prevention of T2DM must be developed. This paradigm should include a very strong emphasis on pregnancy planning and maternal and child health during and after the pregnancy. Without action, intergenerational cycles initiated by epigenetic modifications resulting from adverse environmental stimuli during the critical window of early development in utero might continue to fuel the T2DM epidemic in future generations.

The risk of stroke after prenatal exposure to famine

Prenatal exposure to famine is associated with an increased risk of metabolic and cardiovascular diseases in the offspring at adult age. The aim of this study was to assess whether prenatal exposure to undernutrition increases the risk of stroke. This study was performed in the Dutch famine birth cohort, which consist of 2414 members who were born between 1943 and 1947 in the Netherlands. In a subsample of 1177 individuals, interviews were conducted using standardized questionnaires to obtain information about medical history (which included specific questions regarding stroke) and lifestyle. Information on stroke-related mortality was collected by linking the cohort with Statistics Netherlands. A Cox's proportional hazard analysis was performed to calculate hazard ratios (HRs) comparing the incidence of non-fatal stroke between participants who were exposed, subdivided into early, mid and late gestation, and unexposed to famine prenatally. Three cohort members died of stroke. Of the 1177 subjects who responded to the questionnaires 49 (4.2%) survived a stroke. Unadjusted and adjusted HRs for the risk of non-fatal stroke did not show a significant difference between the unexposed and exposed subjects: HR 1.23 (95% CI 0.53-2.83), HR 1.23 (95% CI 0.53-2.82), HR 1.12 (95% CI 0.46-2.71) for those exposed in late, mid and early gestation, respectively. We were unable to find evidence for a major effect of prenatal exposure to famine on the risk of stroke in later life, although one should be aware that this study was underpowered and the study population too selected and young to identify smaller risks.

IGF-1 deficiency in a critical period early in life influences the vascular aging phenotype in mice by altering miRNA-mediated post-transcriptional gene regulation: implications for the developmental origins of health and disease hypothesis

Epidemiological findings support the concept of Developmental Origins of Health and Disease, suggesting that early-life hormonal influences during a sensitive period of development have a fundamental impact on vascular health later in life. The endocrine changes that occur during development are highly conserved across mammalian species and include dramatic increases in circulating IGF-1 levels during adolescence. The present study was designed to characterize the effect of developmental IGF-1 deficiency on the vascular aging phenotype. To achieve that goal, early-onset endocrine IGF-1 deficiency was induced in mice by knockdown of IGF-1 in the liver using Cre-lox technology (Igf1 ^f/f mice crossed with mice expressing albumin-driven Cre recombinase). This model exhibits low-circulating IGF-1 levels during the peripubertal phase of development, which is critical for the biology of aging. Due to the emergence of miRNAs as important regulators of the vascular aging phenotype, the effect of early-life IGF-1 deficiency on miRNA expression profile in the aorta was examined in animals at 27 months of age. We found that developmental IGF-1 deficiency elicits persisting late-life changes in miRNA expression in the vasculature, which significantly differed from those in mice with adult-onset IGF-1 deficiency (TBG-Cre-AAV8-mediated knockdown of IGF-1 at 5 month of age in Igf1 ^f/f mice). Using a novel computational approach, we identified miRNA target genes that are co-expressed with IGF-1 and associate with aging and vascular pathophysiology. We found that among the predicted targets, the expression of multiple extracellular matrix-related genes, including collagen-encoding genes, were downregulated in mice with developmental IGF-1 deficiency. Collectively, IGF-1 deficiency during a critical period during early in life results in persistent changes in post-transcriptional miRNA-mediated control of genes critical targets for vascular health, which likely contribute to the deleterious late-life cardiovascular effects known to occur with developmental IGF-1 deficiency.

Exposure to Famine at a Young Age and Unhealthy Lifestyle Behavior Later in Life

Background

A healthy diet is important for normal growth and development. Exposure to undernutrition during important developmental periods such as childhood and adolescence can have effects later in life. Inhabitants of the west of the Netherlands were exposed to severe undernutrition during the famine in the last winter of the second World War (1944–1945).

Objective

We investigated if exposure of women to the Dutch famine during childhood and adolescence was associated with an unhealthy lifestyle later in life.

Design

We studied 7,525 women from the Prospect-EPIC cohort, recruited in 1993–97 and aged 0–18 years during the Dutch famine. An individual famine score was calculated based on self-reported information about experience of hunger and weight loss. We investigated the association between famine exposure in early life and four lifestyle factors in adulthood: smoking, alcohol consumption, physical activity level and a Mediterranean-style diet.

Results

Of the 7,525 included women, 46% were unexposed, 38% moderately exposed and 16% severely exposed to the Dutch famine. Moderately and severely exposed women were more often former or current smokers compared to women that did not suffer from the famine: adjusted prevalence ratio 1.10 (95% CI: 1.05; 1.14) and 1.18 (1.12; 1.25), respectively. They also smoked more pack years than unexposed women. Severely exposed women were more often physically inactive than unexposed women, adjusted prevalence ratio 1.32 (1.06; 1.64). Results did not differ between exposure age categories (0–9 and 10–17 years). We found no associations of famine exposure with alcohol consumption and no dose-dependent relations with diet.

Conclusions

Exposure to famine early in female life may be associated with higher prevalence of smoking and physical inactivity later in life, but not with unhealthy diet and alcohol consumption.

Economic Benefits of Investing in Women's Health: A Systematic Review

BACKGROUND

Globally, the status of women's health falls short of its potential. In addition to the deleterious ethical and human rights implications of this deficit, the negative economic impact may also be consequential, but these mechanisms are poorly understood. Building on the literature that highlights health as a driver of economic growth and poverty alleviation, we aim to systematically investigate the broader economic benefits of investing in women's health.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we systematically reviewed health, gender, and economic literature to identify studies that investigate the impact of women's health on micro- and macroeconomic outcomes. We developed an extensive search algorithm and conducted searches using 10 unique databases spanning the timeframe 01/01/1970 to 01/04/2013. Articles were included if they reported on economic impacts stemming from changes in women's health (table of outcome measures included in full review, Table 1). In total, the two lead investigators independently screened 20,832 abstracts and extracted 438 records for full text review. The final review reflects the inclusion of 124 articles.

RESULTS

The existing literature indicates that healthier women and their children contribute to more productive and better-educated societies. This study documents an extensive literature confirming that women's health is tied to long-term productivity: the development and economic performance of nations depends, in part, upon how each country protects and promotes the health of women. Providing opportunities for deliberate family planning; healthy mothers before, during, and after childbirth, and the health and productivity of subsequent generations can catalyze a cycle of positive societal development.

CONCLUSIONS

This review highlights the untapped potential of initiatives that aim to address women's health. Societies that prioritize women's health will likely have better population health overall, and will remain more productive for generations to come.

Impact of oxidative stress during pregnancy on fetal epigenetic patterns and early origin of vascular diseases

Epidemiological studies have led scientists to postulate the developmental origins of health and disease hypothesis for noncommunicable diseases such as diabetes, cardiovascular diseases, hypertension, and obesity. However, the cellular and molecular mechanisms involved in the development of these diseases are not well understood. In various animal models, it has been observed that oxidative stress during pregnancy is associated with the early development of endothelial dysfunction in offspring. This phenomenon suggests that endothelial dysfunction may initiate in the uterus and could lead to increased risk of cardiovascular disease later in life. Currently, it is known that many of the fetal adaptive responses to environmental factors are mediated by epigenetic changes in the genome, especially by the degree of methylation in cytosines in the promoter regions of genes. These findings suggest that the establishment of a particular epigenetic pattern in the genome may be generated by oxidative stress.

The health pros and cons of continuous versus intermittent calorie restriction: more questions than answers

Beneficial effects on health of limiting food intake for certain periods of time have been recognized for a long time. While many diets can produce short-term weight loss, most fail to result in a long-lasting impact. Current data suggest that intermittent fasting may be beneficial for overall health and wellbeing. However, the lack of properly designed clinical studies makes it challenging to formulate evidence-based practice recommendations. Potential health risks of drastic changes in food intake are often ignored and might only be revealed after extensive follow-up. This review summarizes the popular intermittent dieting methods and their potential impact on fertility and reproduction.

Impaired cardiovascular structure and function in adult survivors of severe acute malnutrition

Malnutrition below 5 years remains a global health issue. Severe acute malnutrition (SAM) presents in childhood as oedematous (kwashiorkor) or nonoedematous (marasmic) forms, with unknown long-term cardiovascular consequences. We hypothesized that cardiovascular structure and function would be poorer in SAM survivors than unexposed controls. We studied 116 adult SAM survivors, 54 after marasmus, 62 kwashiorkor, and 45 age/sex/body mass index-matched community controls who had standardized anthropometry, blood pressure, echocardiography, and arterial tonometry performed. Left ventricular indices and outflow tract diameter, carotid parameters, and pulse wave velocity were measured, with systemic vascular resistance calculated. All were expressed as SD scores. Mean (SD) age was 28.8±7.8 years (55% men). Adjusting for age, sex, height, and weight, SAM survivors had mean (SE) reductions for left ventricular outflow tract diameter of 0.67 (0.16; P<0.001), stroke volume 0.44 (0.17; P=0.009), cardiac output 0.5 (0.16; P=0.001), and pulse wave velocity 0.32 (0.15; P=0.03) compared with controls but higher diastolic blood pressures (by 4.3; 1.2-7.3 mm Hg; P=0.007). Systemic vascular resistance was higher in marasmus and kwashiorkor survivors (30.2 [1.2] and 30.8 [1.1], respectively) than controls 25.3 (0.8), overall difference 5.5 (95% confidence interval, 2.8-8.4 mm Hg min/L; P<0.0001). No evidence of large vessel or cardiac remodeling was found, except closer relationships between these indices in former marasmic survivors. Other parameters did not differ between SAM survivor groups. We conclude that adult SAM survivors had smaller outflow tracts and cardiac output when compared with controls, yet markedly elevated peripheral resistance. Malnutrition survivors are thus likely to develop excess hypertension in later life, especially when exposed to obesity.

Obesity and lifespan health--importance of the fetal environment

A marked increase in the frequency of obesity at the population level has resulted in an increasing number of obese women entering pregnancy. The increasing realization of the importance of the fetal environment in relation to chronic disease across the lifespan has focused attention on the role of maternal obesity in fetal development. Previous studies have demonstrated that obesity during adolescence and adulthood can be traced back to fetal and early childhood exposures. This review focuses on factors that contribute to early developmental events, such as epigenetic modifications, the potential for an increase in inflammatory burden, early developmental programming changes such as the variable development of white versus brown adipose tissue, and alterations in organ ontogeny. We hypothesize that these mechanisms promote an unfavorable fetal environment and can have a long-standing impact, with early manifestations of chronic disease that can result in an increased demand for future health care. In order to identify appropriate preventive measures, attention needs to be placed both on reducing maternal obesity as well as understanding the molecular, cellular, and epigenetic mechanisms that may be responsible for the prenatal onset of chronic disease.

Intrauterine exposure to cigarette smoke is associated with increased ghrelin concentrations in adulthood

BACKGROUND

The appetite-stimulating hormone ghrelin is a fundamental regulator of human energy metabolism. A series of studies support the notion that long-term appetite and weight regulation may be already programmed in early life and it could be demonstrated that the intrauterine environment affects the ghrelin system of the offspring. Animal studies have also shown that intrauterine programming of orexigenic systems persists even until adolescence/adulthood.

METHODS

We hypothesized that plasma ghrelin concentrations in adulthood may be associated with the intrauterine exposure to cigarette smoke. We examined this hypothesis in a sample of 19-year-olds followed up since birth in the framework of the Mannheim Study of Children at Risk, an ongoing epidemiological cohort study of the long-term outcome of early risk factors.

RESULTS

As a main finding, we found that ghrelin plasma concentrations in young adults who had been exposed to cigarette smoke in utero were significantly higher than in those without prenatal smoke exposure. Moreover, individuals with intrauterine nicotine exposure showed a significantly higher prevalence of own smoking habits and lower educational status compared to those in the group without exposure.

CONCLUSION

Smoking during pregnancy may be considered as an adverse intrauterine influence that may alter the endocrine-metabolic status of the offspring even until early adulthood.

Functional Foods in Macedonia: Consumers’ Perspective and Public Health Policy

Background: The objective of our study was to explore the knowledge, attitudes and practices of Macedonian consumers towards functional foods, to predict future trends and to assess the national public health policies encompassing the functional foods market.Methods: Total of 518 respondents aged 18+, from all regions in the country participated in the study. They were sampled through three-staged national representative sampling procedures. The questionnaire comprised questions regarding the level of information about functional foods, trust in health claims, frequency of consumption and knowledge and attitudes related to those foods. Statistical significance was determined at p<0.05.Results: Respondents aged 18-34 were more informed compared to the total population (22 and 16 % respectively, p<0.05). Most of the consumers consume these products once a day. Employed consumers were willing to increase daily consumption from 3 to 18 % (p<0.05). On average 65.1% of the statements assessing knowledge were answered correctly. On a scale from -3 to +3 functional foods were considered as very healthy (mean=2.03, SD=1.42).Conclusion: On average, Macedonian consumers have a positive attitude and high expectations of functional foods. Public health policies still lag when compared to comprehensive approach of the food industry in market placement of these products.

Famine in childhood and postmenopausal coronary artery calcification: a cohort study

OBJECTIVE

To assess the effects of famine exposure during childhood on coronary calcium deposition and, secondarily, on cardiac valve and aortic calcifications.

DESIGN

Retrospective cohort.

SETTING

Community.

PATIENTS

286 postmenopausal women with individual measurements of famine exposure during childhood in the Netherlands during World War II.

INTERVENTION/EXPOSURE

Famine exposure during childhood.

MAIN OUTCOME MEASURES

Coronary artery calcifications measured by CT scan and scored using the Agatston method; calcifications of the aorta and cardiac valves (mitral and/or aortic) measured semiquantitatively. Logistic regression was used for coronary Agatston score of >100 or ≤100, valve or aortic calcifications as the dependent variable and an indicator for famine exposure as the independent variable. These models were also used for confounder adjustment and stratification based on age groups of 0-9 and 10-17 years.

RESULTS

In the overall analysis, no statistically significant association was found between severe famine exposure in childhood and a high coronary calcium score (OR 1.80, 95% CI 0.87 to 3.78). However, when looking at specific risk periods, severe famine exposure during adolescence was related to a higher risk for a high coronary calcium score than non-exposure to famine, both in crude (OR 3.47, 95% CI 1.00 to 12.07) and adjusted analyses (OR 4.62, 95% CI 1.16 to 18.43). No statistically significant association was found between childhood famine exposure and valve or aortic calcification (OR 1.66, 95% CI 0.69 to 4.10).

CONCLUSIONS

Famine exposure in childhood, especially during adolescence, seems to be associated with a higher risk of coronary artery calcification in late adulthood. However, the association between childhood famine exposure and cardiac valve/aortic calcification is less clear.

Coronary artery disease in Bangladesh: a review

Coronary artery disease (CAD) is an increasingly important medical and public health problem, and is the leading cause of mortality in Bangladesh. Like other South Asians, Bangladeshis are unduly prone to develop CAD, which is often premature in onset, follows a rapidly progressive course and angiographically more severe. The underlying pathophysiology is poorly understood. Genetic predisposition, high prevalence of metabolic syndrome and conventional risk factors play important role. Lifestyle related factors, including poor dietary habits, excess saturated and trans fat, high salt intake, and low-level physical activity may be important as well. Some novel risk factors, including hypovitaminosis D, arsenic contamination in water and food-stuff, particulate matter air pollution may play unique role. At the advent of the new millennium, we know little about our real situation. Large scale epidemiological, genetic and clinical researches are needed to explore the different aspects of CAD in Bangladesh.

Can the rural poor in India afford to treat non-communicable diseases

OBJECTIVE

Non-communicable diseases (NCD) are on the increase in low-income countries, where healthcare costs are paid mostly out-of-pocket. We investigate the financial burden of NCD vs. communicable diseases (CD) among rural poor in India and assess whether they can afford to treat NCD.

METHODS

We used data from two household surveys undertaken in 2009-2010 among 7389 rural poor households (39 205 individuals) in Odisha and Bihar. All persons from the sampled households, irrespective of age and gender, were included in the analysis. We classify self-reported illnesses as NCD, CD or 'other morbidities' following the WHO classification.

RESULTS

Non-communicable diseases accounted for around 20% of the diseases in the month preceding the survey in Odisha and 30% in Bihar. The most prevalent NCD, representing the highest share in outpatient costs, were musculoskeletal, digestive and cardiovascular diseases. Cardiovascular and digestive problems also generated the highest inpatient costs. Women, older persons and less-poor households reported higher prevalence of NCD. Outpatient costs (consultations, medicines, laboratory tests and imaging) represented a bigger share of income for NCD than for CD. Patients with NCD were more likely to report a hospitalisation.

CONCLUSION

Patients with NCD in rural poor settings in India pay considerably more than patients with CD. For NCD cases that are chronic, with recurring costs, this would be aggravated. The cost of NCD care consumes a big part of the per person share of household income, obliging patients with NCD to rely on informal intra-family cross-subsidisation. An alternative solution to finance NCD care for rural poor patients is needed.

Famine exposure in the young and the risk of type 2 diabetes in adulthood

The developmental origins hypothesis proposes that undernutrition during early development is associated with an increased type 2 diabetes risk in adulthood. We investigated the association between undernutrition during childhood and young adulthood and type 2 diabetes in adulthood. We studied 7,837 women from Prospect-EPIC (European Prospective Investigation Into Cancer and Nutrition) who were exposed to the 1944-1945 Dutch famine when they were between age 0 and 21 years. We used Cox proportional hazards regression models to explore the effect of famine on the risk of subsequent type 2 diabetes in adulthood. We adjusted for potential confounders, including age at famine exposure, smoking, and level of education. Self-reported famine exposure during childhood and young adulthood was associated with an increased type 2 diabetes risk in a dose-dependent manner. In those who reported moderate famine exposure, the age-adjusted type 2 diabetes hazard ratio (HR) was 1.36 (95% CI [1.09-1.70]); in those who reported severe famine exposure, the age-adjusted HR was 1.64 (1.26-2.14) relative to unexposed women. These effects did not change after adjustment for confounders. This study provides the first direct evidence, using individual famine exposure data, that a short period of moderate or severe undernutrition during postnatal development increases type 2 diabetes risk in adulthood.

Household food security is inversely associated with undernutrition among adolescents from Kilosa, Tanzania

Household food insecurity contributes to poor nutritional health, with negative consequences on growth and development during childhood. Although early childhood nutrition needs have received much attention, another important nutritional phase is adolescence. In a sample of 670 adolescents from Kilosa District, Tanzania, this study used 3 approaches to better understand the relationship between food insecurity and undernutrition. First, this study examined the associations between 3 commonly used measures of household food security and undernutrition among 670 adolescents from Kilosa District, Tanzania. The measures of household food security, energy adequacy per adult equivalent, dietary diversity score, and coping strategies index, were strongly correlated with each other and household assets (P < 0.05). Second, this study measured the nutritional status of adolescents in this district, finding a high prevalence of undernutrition (21% with BMI-for-age <5th percentile of the National Center for Health Statistics/WHO reference). Third, this study measured the association between the log odds of undernutrition (as the dependent variable) and each of the 3 measures of household food security. In separate models, household energy adequacy per adult equivalent and household dietary diversity score were inversely associated with undernutrition after adjusting for gender, age, puberty, and the interaction between age and puberty. By contrast, a greater use of coping strategies was not associated with undernutrition. Strategies focused on increasing household energy intake and improving dietary diversity among the most vulnerable households could improve the nutritional health of adolescents.

Cardiac responses of rats submitted to postnatal protein restriction

Undernutrition during critical stages of development and childhood has important effects on cardiovascular homeostasis. The present study was undertaken to evaluate the in vivo and ex vivo cardiac function of rats submitted to postnatal protein restriction. Male Wistar rats (28 days old) were fed a regular (20%) or low-protein (6%) diet over 5 weeks. After this period, cardiac function was analyzed by echocardiography and isolated heart preparation. Furthermore, the density of cardiac noradrenergic fibers and hematological profile were evaluated. We found that malnourished rats exhibited elevated arterial blood pressure, increased fractional shortening (echocardiography), increased systolic tension, increased ±dT/dt (isolated heart technique), impaired diastolic function characterized by a slight increase in the left ventricular end-diastolic diameter (echocardiography) and decreased diastolic tension (isolated heart technique), and cardiac hypertrophy evidenced by augmentation of the posterior left ventricular wall and discrete hematological changes. In addition, malnourished rats exhibited increased noradrenergic fiber density in their hearts (0.08% ± 0.02% area in control rats vs. 0.17% ± 0.03% area in malnourished rats). Our current data demonstrate that postnatal protein restriction causes cardiac adaptation characterized by an early overworking heart. This is at least in part mediated by an increase in the efferent sympathetic fibers to the heart. These findings provide important information for efforts to prevent and manage the consequences of undernutrition in the human population.