1
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Kallak TK, Serapio S, Visser N, Lager S, Skalkidou A, Ahlsson F. Differential gene expression in two consecutive pregnancies between same sex siblings and implications on maternal constraint. Sci Rep 2024; 14:4210. [PMID: 38378837 PMCID: PMC10879170 DOI: 10.1038/s41598-024-54724-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 02/15/2024] [Indexed: 02/22/2024] Open
Abstract
The objective of this study was to investigate how placental gene expression differs in two consecutive pregnancies in same sex siblings, and its possible association with the "maternal constraint" hypothesis. Material was gathered from the BASIC study (Biological, Affect, Stress, Imaging, and Cognition in Pregnancy and the Puerperium), a population based prospective study that was started in 2009 in Uppsala. Over 900 specimens of placenta biopsies were collected and out of these 10 women gave birth twice, to the same sex child, and were included in this study. The total RNA was isolated and prepared from frozen villous tissue from the placenta and further analyzed by use of Ion AmpliSeq Human Transcriptome Gene Expression kit. A total of 234 genes differed significantly between the first and second pregnancy placentas, when adjusting for delivery mode, maternal BMI and gestational age. Of special interest was the down-regulated group of genes in the second pregnancy. Exemplified by Pentraxin 3, SRY-Box Transcription Factor 9, and Serum Amyloid A1, which all were associated with biological processes involved in the immune system and inflammation. Further, protein-protein interaction analysis visualized them as hub genes interacting with several of the other differentially expressed genes. How these altered gene expressions affect maternal constraint during pregnancy needs further validation in lager study cohorts and also future validation in functional assays.
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Affiliation(s)
| | - Solveig Serapio
- Department of Women's and Children's Health, Uppsala University, 751 85, Uppsala, Sweden
| | - Nadja Visser
- Department of Women's and Children's Health, Uppsala University, 751 85, Uppsala, Sweden
| | - Susanne Lager
- Department of Women's and Children's Health, Uppsala University, 751 85, Uppsala, Sweden
| | - Alkistis Skalkidou
- Department of Women's and Children's Health, Uppsala University, 751 85, Uppsala, Sweden
| | - Fredrik Ahlsson
- Department of Women's and Children's Health, Uppsala University, 751 85, Uppsala, Sweden
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2
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Yoshida A, Kaneko K, Aoyama K, Yamaguchi N, Suzuki A, Kato S, Ebara T, Sugiura-Ogasawara M, Kamijima M, Saitoh S. Relationship between Birth Order and Postnatal Growth until 4 Years of Age: The Japan Environment and Children’s Study. CHILDREN 2023; 10:children10030557. [PMID: 36980116 PMCID: PMC10047297 DOI: 10.3390/children10030557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/11/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023]
Abstract
Later-borns tend to be shorter than first-borns in childhood and adulthood. However, large-scale prospective studies examining growth during infancy according to birth order are limited. We aimed to investigate the relationship between birth order and growth during the first 4 years of life in a Japanese prospective birth cohort study. A total of 26,249 full-term singleton births were targeted. General linear and multivariable logistic regression models were performed and adjusted for birth weight, parents’ heights, maternal age at delivery, gestational weight gain, maternal smoking and alcohol drinking status during pregnancy, household income, breastfeeding status, and Study Areas. The multivariate adjusted mean length Z-scores in “first-borns having no sibling”, “first-borns having siblings”, “second-borns”, and “third-borns or more” were −0.026, −0.013, 0.136, and 0.120 at birth and −0.324, −0.330, −0.466, and −0.569 at 10 months, respectively. Results similar to those at 10 months were observed at 1.5, 3, and 4 years. The adjusted odds ratios (95% confidence intervals) of short stature at 4 years in “first-borns having siblings”, “second-borns”, and “third-borns or more” were 1.08 (0.84–1.39), 1.36 (1.13–1.62), and 1.50 (1.20–1.88), respectively, versus “first-borns having no sibling”. Birth order was significantly associated with postnatal growth and may be a factor predisposing to short stature in early childhood.
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Affiliation(s)
- Aya Yoshida
- Department of Pediatrics and Neonatology, Graduate School of Medical Sciences, Nagoya City University, Nagoya 4670001, Japan
| | - Kayo Kaneko
- Department of Occupational and Environmental Health, Graduate School of Medical Sciences, Nagoya City University, Nagoya 4670001, Japan
| | - Kohei Aoyama
- Department of Pediatrics and Neonatology, Graduate School of Medical Sciences, Nagoya City University, Nagoya 4670001, Japan
- Correspondence: ; Tel.: +81-52-853-8246
| | - Naoya Yamaguchi
- Department of Pediatrics and Neonatology, Graduate School of Medical Sciences, Nagoya City University, Nagoya 4670001, Japan
| | - Atsushi Suzuki
- Department of Pediatrics and Neonatology, Graduate School of Medical Sciences, Nagoya City University, Nagoya 4670001, Japan
| | - Sayaka Kato
- Department of Occupational and Environmental Health, Graduate School of Medical Sciences, Nagoya City University, Nagoya 4670001, Japan
| | - Takeshi Ebara
- Department of Occupational and Environmental Health, Graduate School of Medical Sciences, Nagoya City University, Nagoya 4670001, Japan
- Department of Ergonomics, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Kitakyushu 8078555, Japan
| | - Mayumi Sugiura-Ogasawara
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Nagoya City University, Nagoya 4670001, Japan
| | - Michihiro Kamijima
- Department of Occupational and Environmental Health, Graduate School of Medical Sciences, Nagoya City University, Nagoya 4670001, Japan
| | - Shinji Saitoh
- Department of Pediatrics and Neonatology, Graduate School of Medical Sciences, Nagoya City University, Nagoya 4670001, Japan
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3
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Dearden L, Ozanne SE. Considerations for designing and analysing inter-generational studies in rodents. Nat Metab 2023; 5:1-4. [PMID: 36609721 DOI: 10.1038/s42255-022-00721-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Laura Dearden
- University of Cambridge Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome MRC Institute of Metabolic Science, Cambridge, UK.
| | - Susan E Ozanne
- University of Cambridge Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome MRC Institute of Metabolic Science, Cambridge, UK.
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4
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Morisaki N, Yoshii K, Yamaguchi TO, Tamamitsu AM, Kato N, Yokoya S. Preschool-children's height, trend, and causes: Japanese national surveys 1990-2010. Clin Pediatr Endocrinol 2022; 31:10-17. [PMID: 35002063 PMCID: PMC8713064 DOI: 10.1297/cpe.2021-0041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/04/2021] [Indexed: 11/07/2022] Open
Abstract
We observed trends in the height of children aged 3 to 6 in Japan using data from the
National Growth Survey on Preschool Children in the years 1990, 2000, and 2010. Average
standard deviation (SD) scores of height decreased from 0.39 (SD 1.02) in 1990 (n = 3,684)
to 0.37 (SD 1.05) in 2000 (n = 2,981) and 0.33 (SD 1.07) in 2010 (n = 2,027). Mothers of
children in later waves were taller, older, and more likely to be primiparous; children in
later waves had shorter gestational age, lower birth weight, and were less likely to have
been fed less with formula or solid foods before 6 mo. The only factor that consistently
contributed to a reduction in children’s height for both 1990–2000 and 2000–2010 was a
reduction in birthweight SD score (indirect effect on height –1.5 [95% CI: –1.9, –1.1] mm
for 1990–2000 and –1.2 [95% CI: –1.8, –0.8] mm for 2000–2010). Factors that contributed,
although not significantly or consistently between the two periods, were changes in
pre-pregnancy BMI, smoking during pregnancy, multiple pregnancies, gestational age, BMI at
birth, and use of formula and solid foods before 6 mo. Secular increases in maternal age,
height, and primiparity contributed to increasing children’s height.
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Affiliation(s)
- Naho Morisaki
- Department of Social Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Keisuke Yoshii
- Division of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | - Tomoe Ogawa Yamaguchi
- Division of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | | | - Noriko Kato
- Department of Early Childhood and Elementary Education, Jumonji University, Niiza, Japan
| | - Susumu Yokoya
- Fukushima Global Medical Science Center, Fukushima Medical University, Fukushima, Japan
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5
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Ziyab AH, Almari M, Mohammad A, Al-Taiar A, Karmaus W. Sex Differences in the Association of Sibship Size and Position in Sibship with Lipid Profile during Adolescence: A Cross-Sectional Study. Int J Endocrinol 2022; 2022:8727922. [PMID: 36204482 PMCID: PMC9532113 DOI: 10.1155/2022/8727922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 09/17/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Epidemiologic studies have reported associations of sibship size and position of the child in the sibship with multiple health outcomes, including adiposity and diabetes. However, little is known about sibling effects on lipids. Hence, this study sought to evaluate associations of the number of total, older, and younger siblings with lipid profile among adolescents. METHODS In a cross-sectional study among high school students aged 14 to 19 years, lipid levels were measured in capillary blood. Parents reported the number of siblings (total, older, and younger). Geometric means of lipids were calculated, and linear regression was used to estimate the ratio of geometric means (RoGM) and 95% confidence intervals (CI). Analyses were sex stratified. RESULTS Of the total study sample (n = 1,584), 758 (47.9%) were boys and 826 (52.1%) were girls, with median age of 16.0 years. Total cholesterol (TC) was lower by 8% (adjusted-RoGM = 0.92, 95% CI: 0.88-0.96) among boys with ≥3 older siblings compared to those with no older siblings. Similarly, boys with ≥3 younger sibling compared to those with no younger siblings had reduced TC by 7% (adjusted-RoGM = 0.93, 0.87-0.99). Moreover, an increased number of total siblings (≥4 vs. 0/1: adjusted-RoGM = 0.80, 0.67-97) and older siblings (≥3 vs. 0: adjusted-RoGM = 0.90, 0.82-0.98) were associated with reduced low-density lipoprotein cholesterol (LDL-C) among boys. Similarly, lower levels of triglycerides (TG) were seen among boys with ≥3 older siblings compared to those with no older siblings (adjusted-RoGM = 0.87, 0.78-0.96). A higher number of younger siblings was associated with increased high-density lipoprotein cholesterol (HDL-C) among boys (≥3 vs. 0: adjusted-RoGM = 1.08, 1.01-1.17). Sibship characteristics were not associated with lipids among girls. CONCLUSIONS Increased number of total, older, and younger siblings were associated with favorable lipid profiles among adolescent boys, but not girls. Mechanisms underlying these associations need further investigations.
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Affiliation(s)
- Ali H. Ziyab
- Department of Community Medicine and Behavioral Sciences, Faculty of Medicine, Kuwait University, Safat, Kuwait
| | - Mohammad Almari
- Department of Health Policy and Management, Faculty of Public Health, Kuwait University, Safat, Kuwait
| | - Anwar Mohammad
- Biochemistry and Molecular Biology Department, Research Division, Dasman Diabetes Institute, Kuwait, Kuwait
| | - Abdullah Al-Taiar
- School of Community and Environmental Health, College of Health Sciences, Old Dominion University, Norfolk, VA, USA
| | - Wilfried Karmaus
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, TN, USA
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6
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German A, Rubin L, Raisin G, Hochberg Z. Family Size and the Age at Infancy-Childhood Transition Determine a Child's Compromised Growth in Large Families. Front Pediatr 2022; 10:821048. [PMID: 35573956 PMCID: PMC9100426 DOI: 10.3389/fped.2022.821048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/31/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Data on growth of Israeli school children show that children from Jewish ultra-orthodox Haredi and Bedouin Arab families have a higher prevalence of stature below the 3rd percentile. While these populations are usually from lower socioeconomic strata, they also have larger families. This study aimed to evaluate if family structure and the timing of a child's infancy-childhood transition (ICT) are central to variations in stature. STUDY DESIGN We analyzed the association between family size, birth order and inter-birth interval with child growth and the age at ICT in 3 groups of children, 148 high birth order children from large families (LF ≥ 6), 118 low birth order children from large families (LF ≤ 3) and 150 children from small families (SF). RESULTS High birth order children from large families were shorter in childhood than children from small families with a difference of 0.5 SDS in length. We found that birth length and birth order explained 35% of the total variance in infancy length whereas ICT age and infancy length explained 72% of the total variance in childhood length. CONCLUSION Infancy and childhood length are compromised in children from large families. As the family grows larger the younger children tend to be shorter. Reduced length gain in the period between infancy to childhood is when growth is most affected.
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Affiliation(s)
- Alina German
- Department of Pediatrics, Haemek Medical Center, Afula, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Lisa Rubin
- School of Public Health, University of Haifa, Haifa, Israel
| | - Galiya Raisin
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Ze'ev Hochberg
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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7
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Sanchez-Escobedo S, Azcorra H, Bogin B, Hoogesteijn AL, Sámano R, Varela-Silva MI, Dickinson F. Birth weight, birth order, and age at first solid food introduction influence child growth and body composition in 6- to 8-year-old Maya children: The importance of the first 1000 days of life. Am J Hum Biol 2020; 32:e23385. [PMID: 31994809 DOI: 10.1002/ajhb.23385] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES To analyze the relationship of birth weight, birth order, breastfeeding duration, and age of introduction of solid foods with height, fat mass, and fat-free mass in a sample of Maya children when aged 6 to 8 years old. METHODS We collected data on anthropometry, body composition, children's birth weight, birth order, early feeding practices, and household socioeconomic characteristics in a sample of 260 Maya children aged 6 to 8 years living in Merida and Motul, two cities in Yucatan, Mexico. Multiple regression models were performed to identify variables associated with height-for-age (HAZ), fat mass index (FMI), and fat-free mass index (FFMI). The predictors included in the models were birth weight (kg), birth order, duration of breastfeeding (months), age at introduction of solid foods (months), maternal age (years), and height (cm). Models were adjusted for the influence of children's age and sex, maternal educational level, and household overcrowding. RESULTS HAZ was positively associated with child birthweight and maternal height and age, but inversely associated with birth order and age of introduction of solid foods. FMI was positively associated with birth weight, maternal age, and height, and negatively associated with birth order. FFMI was positively associated with maternal age and birth weight. CONCLUSIONS These results are evidence of the importance of the first 1000 days of life for the growth and body composition of Maya children and contributed to understand the development of nutritional dual burden in this population.
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Affiliation(s)
- Samantha Sanchez-Escobedo
- Departamento de Ecología Humana, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, Mérida, Yucatán, Mexico.,Universidad Vizcaya de las Américas, Mérida, Yuc, Mexico
| | - Hugo Azcorra
- Departamento de Ecología Humana, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, Mérida, Yucatán, Mexico.,Centro de Investigaciones Silvio Zavala, Universidad Modelo, Carretera a Cholul 200 mts periférico norte, Mérida, Yucatán, México
| | - Barry Bogin
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK.,UCSD/Salk Center for Academic Research and Training in Anthropogeny (CARTA), Palo Alto, California
| | - Almira L Hoogesteijn
- Departamento de Ecología Humana, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, Mérida, Yucatán, Mexico
| | - Reyna Sámano
- Departamento de Nutrición y Bioprogramación, Instituto Nacional de Perinatología, Miguel Hidalgo, Ciudad de México, Mexico
| | - Maria I Varela-Silva
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Federico Dickinson
- Departamento de Ecología Humana, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, Mérida, Yucatán, Mexico
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8
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Abstract
Humans show marked variation in body size around the world, both within and among populations. At present, the tallest people in the world are from the Netherlands and the Balkan countries, while the shortest populations are central African Pygmies. There are genetic, genetic plasticity, developmental, and environmental bases for size variation in Homo sapiens from the recent past and the present. Early populations of Homo species also have shown considerable size variation. Populations from the present and the past are also marked by sexual dimorphism, which, itself, shows group variation. There is abundant evidence for the effects of limited food and disease on human growth and resultant adult body size. This environmental influence has been reflected in "secular trends" (over a span of years) in growth and adult size from socioeconomic prosperity or poverty (availability of resources). Selective and evolutionary advantages of small or large body size also have been documented. Heritability for human height is relatively great with current genome-wide association studies (GWAS) identifying hundreds of genes leading to causes of growth and adult size variation. There are also endocrinological pathways limiting growth. An example is the reduced tissue sensitivity to human growth hormone (HGH) and insulin-like growth factor (IGF-1) in Philippine and African hunter-gatherer populations. In several short-statured hunter-gatherer populations (Asian, African, and South American), it has been hypothesized that short life expectancy has selected for early maturity and truncated growth to enhance fertility. Some island populations of humans and other mammals are thought to have been selected for small size because of limited resources, especially protein. The high-protein content of milk as a staple food may contribute to tall stature in East African pastoral peoples. These and other evolutionary questions linked to life history, male competition, reproduction, and mobility are explored in this paper.
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9
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Pesch MH, Pont CM, Lumeng JC, McCaffery H, Tan CC. Mother and Infant Predictors of Rapid Infant Weight Gain. Clin Pediatr (Phila) 2019; 58:1515-1521. [PMID: 31556703 DOI: 10.1177/0009922819877875] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Objective. To examine characteristics of the infant and mother associated with rapid infant weight gain (RIWG). Methods. Electronic health records (N = 4626) of term infants born were reviewed. Multivariable logistic regression examined the presence of RIWG (vs not) using participant characteristics in the whole sample and in stratified groups. Results. The prevalence of RIWG was 18.7%. Predictors of RIWG were infant male sex, younger infant gestational age, firstborn (vs later born) status, maternal Black or Other (Asian, American Indian, etc), non-Hispanic race/ethnicity (vs White non-Hispanic), Medicaid (vs non-Medicaid insurance), and maternal cigarette smoking status (vs never smoker). The regression model explained between 7.0% and 11.4% of the variance in RIWG. There were few differences in predictors of RIWG in stratified samples. Conclusions. Early childhood obesity intervention efforts may target the modifiable risk factors for RIWG starting prenatally.
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Affiliation(s)
| | | | | | | | - Cin C Tan
- University of Michigan, Ann Arbor, MI, USA
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10
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Rapaport T, Villaseñor FA, Altman RM, Nepomnaschy PA. Sex ratio and maternal age in a natural fertility, subsistence population: Daughters, sons, daughters. AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 2019; 169:368-376. [DOI: 10.1002/ajpa.23838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 04/02/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Tomas Rapaport
- Maternal and Child Health Laboratory, Faculty of Health SciencesSimon Fraser University Burnaby British Columbia Canada
| | - Fernando A. Villaseñor
- Maternal and Child Health Laboratory, Faculty of Health SciencesSimon Fraser University Burnaby British Columbia Canada
- Department of Statistics and Actuarial ScienceSimon Fraser University Burnaby British Columbia Canada
| | - Rachel M. Altman
- Department of Statistics and Actuarial ScienceSimon Fraser University Burnaby British Columbia Canada
| | - Pablo A. Nepomnaschy
- Maternal and Child Health Laboratory, Faculty of Health SciencesSimon Fraser University Burnaby British Columbia Canada
- Crawford Laboratory of Evolutionary StudiesSimon Fraser University Burnaby British Columbia Canada
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11
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Cai L, Ma B, Lin L, Chen Y, Yang W, Ma J, Jing J. The differences of lipid profiles between only children and children with siblings: A national survey in China. Sci Rep 2019; 9:1441. [PMID: 30723228 PMCID: PMC6363803 DOI: 10.1038/s41598-018-37695-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 12/07/2018] [Indexed: 11/17/2022] Open
Abstract
With the increasing number of the one-child family, it is important to investigate whether the only-child status is associated with dyslipidemia. Among a national sample of 65,347 Chinese children aged 6–17 years, 16,100 lipid profiles were available. Children’s height, weight, total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) were measured. In comparison to children with siblings, only children (OC) were more likely to be boys and live in urban areas. OC had less physical activity, less fried food intake, but more meat and dairy intakes. OC had significantly higher levels of TC (3.97 ± 0.78 vs. 3.89 ± 0.77) and LDL-C (2.12 ± 0.65 vs. 2.06 ± 0.64) in the overall group, and also in the subgroups of rural boys and girls. The prevalence of hyper-TC (5.48% vs. 4.43%) and hyper-LDL-C (3.97% vs. 2.96%) were significantly higher in OC than their counterparts. Furthermore, we found higher odds of hyper-LDL-C [1.43 (1.12, 1.83)] in OC after adjustments. In the subgroup analysis, only-child status was associated with increased risk of hyper-TC [1.86 (1.06, 3.26)] and hyper-LDL-C [2.65 (1.14, 6.16)] among rural boys, and hyper-LDL-C among rural girls [2.20 (1.14, 4.22)]. In conclusion, higher levels of TC and LDL-C were found in OC especially for rural children. Being an only-child was associated with increased risk of hyper-LDL-C.
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Affiliation(s)
- Li Cai
- Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Bingjie Ma
- Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Lizi Lin
- Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, Guangzhou, China.,Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Yajun Chen
- Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Wenhan Yang
- Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Jun Ma
- Institute of Child and Adolescent Health, School of Public Health, Peking University, Beijing, China.
| | - Jin Jing
- Department of Maternal and Child Health, School of Public Health, Sun Yat-sen University, Guangzhou, China.
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12
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Belva F, Roelants M, Kluijfhout S, Winter C, De Schrijver F, Desmyttere S, De Rycke M, Tournaye H, Liebaers I, Bonduelle M. Body composition and blood pressure in 6-year-old singletons born after pre-implantation genetic testing for monogenic and structural chromosomal aberrations: a matched cohort study. Hum Reprod Open 2018; 2018:hoy013. [PMID: 30895254 PMCID: PMC6276641 DOI: 10.1093/hropen/hoy013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/19/2018] [Accepted: 08/22/2018] [Indexed: 11/12/2022] Open
Abstract
STUDY QUESTION Does Day 3 embryo biopsy for pre-implantation genetic testing for monogenic (PGT-M) and structural chromosomal aberrations (PGT-SR) affect body composition and blood pressure readings of 6-year-old singletons? SUMMARY ANSWER This study of 87 PGT-M and PGT-SR conceived singletons showed no differences in anthropometric measurements and blood pressure readings in comparison with a matched cohort of peers born after ICSI without embryo biopsy. WHAT IS KNOWN ALREADY While neonatal outcomes after PGT conception have been found comparable to those after ICSI without embryo biopsy, only a few studies have reported outcomes after PGT at older ages. Moreover, embryo biopsy is also applied in couples who opt for PGT-M and PGT-SR and hence are not necessarily infertile. Health parameters and in particular body composition data in this group of children are lacking. STUDY DESIGN SIZE DURATION This single-centre matched-pair cohort study evaluated body composition of 6-year-old children born after fresh blastocyst embryo transfer with or without embryo biopsy performed at Day 3 for the purpose of PGT-M and PGT-SR. For each child born after embryo biopsy, a singleton born after transfer of a fresh ICSI embryo at the blastocyst stage and reaching the age of 6 years between May 2011 and June 2017 was matched as closely as possible for gender, age, maternal educational level and birth order. PARTICIPANTS/MATERIALS SETTING METHODS Anthropometry (weight, height, BMI, skinfold thickness, waist and mid-upper arm circumference) and blood pressure readings in a longitudinally followed cohort of 87 singletons conceived by PGT-M and PGT-SR and a pairwise matched sample of 87 children conceived by ICSI are described. Results are adjusted for current, neonatal and parental characteristics. MAIN RESULTS AND THE ROLE OF CHANCE From the 124 eligible PGT-M and PGT-SR families, 110 could be reached of whom 23 refused and 87 (87/110 = 79%) participated. All anthropometric measurements, including z-scores of BMI, waist and mid-upper arm circumference, were comparable between the PGT-M and PGT-SR (-0.23; 0.27; 0.17, respectively) and ICSI (-0.29; 0.11; 0.11, respectively) groups (all P > 0.05). Furthermore, indices of peripheral (triceps) and central (subscapular) adiposity derived from skinfold thickness were comparable (PGT-M and PGT-SR: 14.7 mm; 11.6 mm and ICSI: 15.5 mm; 11.5 mm) as well as the percentage total body fat mass derived from these (PGT-M and PGT-SR: 13.7% and ICSI: 13.9%) (all P > 0.05). Z-scores for blood pressure were also comparable between the PGT and ICSI groups (all P > 0.05). Results did not change when adjusted for neonatal (birthweight, birth order), current (age) and parental (smoking during pregnancy, parental BMI) characteristics. Hospitalization rate and surgical intervention rate were not different for PGT-M and PGT-SR children compared to matched peers born after ICSI. LIMITATIONS REASONS FOR CAUTION Although our study describes the largest cohort of singletons born after embryo biopsy worldwide, we were only able to detect moderate differences in anthropometrics and blood pressure with our sample size. WIDER IMPLICATIONS OF THE FINDINGS Although Day 3 embryo biopsy followed by blastocyst transfer is not associated with adverse outcomes regarding anthropometry and blood pressure, future studies should focus on outcomes in children born after trophectoderm biopsy and/or transfer of warmed embryos after vitrification. STUDY FUNDING/COMPETING INTERESTS This study was supported by Methusalem grants and by grants from Wetenschappelijk Fonds Willy Gepts; all issued by the Vrije Universiteit Brussel (VUB). All co-authors, except M.B. declared no conflict of interest. M.B. has received consultancy fees from MSD, Serono Symposia and Merck. The Universitair Ziekenhuis Brussel (UZ Brussel) and the Centre for Medical Genetics have received several educational grants from IBSA, Ferring, Organon, Shering-Plough, Merck for establishing the database for follow-up research and organizing the data collection.
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Affiliation(s)
- F Belva
- Centre for Medical Genetics, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, Brussels, Belgium
| | - M Roelants
- Department of Public Health and Primary Care, Environment and Health/Youth Health Care, KU Leuven, Kapucijnenvoer 35, Leuven, Belgium
| | - S Kluijfhout
- Centre for Medical Genetics, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, Brussels, Belgium
| | - C Winter
- Centre for Medical Genetics, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, Brussels, Belgium
| | - F De Schrijver
- Centre for Medical Genetics, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, Brussels, Belgium
| | - S Desmyttere
- Centre for Medical Genetics, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, Brussels, Belgium
| | - M De Rycke
- Centre for Medical Genetics, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, Brussels, Belgium
| | - H Tournaye
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, Brussels, Belgium
| | - I Liebaers
- Centre for Medical Genetics, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, Brussels, Belgium
| | - M Bonduelle
- Centre for Medical Genetics, Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, Brussels, Belgium
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Hidaka BH, Thodosoff JM, Kerling EH, Hull HR, Colombo J, Carlson SE. Intrauterine DHA exposure and child body composition at 5 y: exploratory analysis of a randomized controlled trial of prenatal DHA supplementation. Am J Clin Nutr 2018; 107:35-42. [PMID: 29381793 PMCID: PMC5972598 DOI: 10.1093/ajcn/nqx007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 10/13/2017] [Indexed: 12/31/2022] Open
Abstract
Background Observational studies find associations between maternal docosahexaenoic acid (DHA) and greater fat-free mass and lower percentage of body fat, but randomized trials of prenatal DHA supplementation have not found significant intent-to-treat effects on childhood body composition. Objective This study sought to explore associations between intrauterine DHA exposure and body composition and size at 5 y in the offspring of women who participated in a randomized trial of prenatal DHA supplementation (corn and soybean oil placebo or 600 mg/d). Design At 5 y, body composition was measured by air displacement plethysmography in 154 offspring of women who had participated in the Kansas University DHA Outcomes Study and who had red blood cell (RBC) phospholipid (PL) fatty acids assessed at enrollment and delivery. We used linear regression models to analyze the relation among 3 indicators of intrauterine DHA exposure-1) intent-to-treat (placebo or DHA), 2) maternal RBC PL DHA status at delivery, and 3) change in maternal DHA (delivery minus enrollment)-and 6 outcomes of interest: 5-y fat mass, fat-free mass, percentage of body fat, height, weight, and body mass index z score. Results Change in maternal RBC PL DHA correlated with higher fat-free mass (r = 0.21, P = 0.0088); the association was unchanged after adjustment for maternal, perinatal, and childhood dietary factors. Intent-to-treat and DHA status at delivery showed positive trends with fat-free mass that were not statistically significant. There was no evidence relating intrauterine DHA exposure to any other body composition measure. Conclusions Change in maternal DHA status during pregnancy was related to higher offspring 5-y fat-free mass. The other 2 indicators of intrauterine exposure to DHA suggested a trend for higher offspring 5-y fat-free mass. Our findings agree with an earlier observational study from the United Kingdom. This trial was registered at clinicaltrials.gov as NCT00266825.
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Affiliation(s)
- Brandon H Hidaka
- Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City, KS
| | - Jocelynn M Thodosoff
- Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City, KS
| | - Elizabeth H Kerling
- Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City, KS
| | - Holly R Hull
- Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City, KS
| | - John Colombo
- Department of Psychology, University of Kansas, Lawrence, KS
| | - Susan E Carlson
- Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City, KS
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Associations of Birth Order with Early Adolescent Growth, Pubertal Onset, Blood Pressure and Size: Evidence from Hong Kong's "Children of 1997" Birth Cohort. PLoS One 2016; 11:e0153787. [PMID: 27088360 PMCID: PMC4835083 DOI: 10.1371/journal.pone.0153787] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 04/04/2016] [Indexed: 12/01/2022] Open
Abstract
Background Birth order has been proposed as a cardiovascular risk factor, because the lower birth weight and greater infant weight gain typical of firstborns could programme metabolism detrimentally. Methods We examined the associations of birth order (firstborn or laterborn) with birth weight-for-gestational age, length/height and body mass index (BMI) z-scores during infancy, childhood, and puberty using generalized estimating equations, with age at pubertal onset using interval-censored regression and with age-, sex- and height-standardized blood pressure, height and BMI z-scores at 13 years using linear regression in a population-representative Chinese birth cohort: “Children of 1997” (n = 8,327). Results Compared with laterborns, firstborns had lower birth weight-for-gestational age (mean difference = -0.18 z-score, 95% confidence interval (CI) -0.23, -0.14), lower infant BMI (-0.09 z-score, 95% CI -0.14, -0.04), greater childhood height (0.10 z-score, 95% CI 0.05, 0.14) and BMI (0.08 z-score, 95% CI 0.03, 0.14), but not greater pubertal BMI (0.05 z-score, 95% CI -0.02, 0.11), adjusted for sex, parental age, birthplace, education and income. Firstborns had earlier onset of pubic hair (time ratio = 0.988, 95% CI 0.980, 0.996), but not breast or genitalia, development. Firstborns had greater BMI (0.07 z-score, 95% CI 0.002, 0.15), but not height (0.05 z-score, 95% CI -0.01, 0.11), at 13 years, but similar blood pressure. Conclusions Differences by birth order continue into early adolescence with firstborns being heavier with earlier pubic hair development, which could indicate long-term cardiovascular risk.
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Abstract
OBJECTIVES The prevalence of stunting in Armenia more than doubled since the 1990 s. This study aimed to investigate the prevalence and the predictors of stunting among children younger than 5 years in a rural region of Armenia, Talin, targeted by the World Vision (WV) nutrition interventions. METHODS Anthropometric measurements were conducted among a large representative sample of children 0 to 59 months old to identify the prevalence of stunting. Children identified as stunted were included in a case-control study as cases and compared with normally growing controls randomly selected from the same pool of children. The mothers of cases and controls were interviewed. Logistic regression analysis was applied to identify the predictors of stunting. RESULTS Of 739 measured children, 101 (13.7%) were undernourished, including 94 (12.7%) who were stunted. The fitted logistic regression model identified 7 independent predictors of stunting, of which 4 were protective: mother's height, child's birth length, number of child's hand washings per day, and the full set of WV interventions carried out in the community; whereas 3 were risk factors, that is, never/rarely using soap during hand washing, being the fourth or later child in the family, and family size. CONCLUSIONS The study findings suggest that although WV nutrition interventions have shown impact, there is also a nonnutritional pathway of child stunting in rural Armenia. Thus, antistunting interventions should include sanitation and hygienic measures along with adequate perinatal care and maternal and child nutrition to further reduce childhood stunting, ensuring long-term health benefits for children not only in rural Armenia but also in rural communities in other low/middle-income countries.
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Derraik JGB, Ahlsson F, Lundgren M, Jonsson B, Cutfield WS. First-borns have greater BMI and are more likely to be overweight or obese: a study of sibling pairs among 26,812 Swedish women. J Epidemiol Community Health 2015; 70:78-81. [PMID: 26311896 DOI: 10.1136/jech-2014-205368] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 07/27/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND A number of large studies have shown phenotypic differences between first-borns and later-borns among adult men. In this study, we aimed to assess whether birth order was associated with height and BMI in a large cohort of Swedish women. METHODS Information was obtained from antenatal clinic records from the Swedish National Birth Register over 20 years (1991-2009). Maternal anthropometric data early in pregnancy (at approximately 10-12 weeks of gestation) were analysed on 13,406 pairs of sisters who were either first-born or second-born (n=26,812). RESULTS Early in pregnancy, first-born women were of BMI that was 0.57 kg/m(2) (2.4%) greater than their second-born sisters (p<0.0001). In addition, first-borns had greater odds of being overweight (OR 1.29; p<0.0001) or obese (OR 1.40; p<0.0001) than second-borns. First-borns were also negligibly taller (+1.2 mm) than their second-born sisters. Of note, there was a considerable increase in BMI over the 18-year period covered by this study, with an increment of 0.11 kg/m(2) per year (p<0.0001). CONCLUSIONS Our study corroborates other large studies on men, and the steady reduction in family size may contribute to the observed increase in adult BMI worldwide.
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Affiliation(s)
- José G B Derraik
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Fredrik Ahlsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Maria Lundgren
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Björn Jonsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Wayne S Cutfield
- Liggins Institute, University of Auckland, Auckland, New Zealand
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17
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Zheng W, Suzuki K, Shinohara R, Sato M, Yokomichi H, Yamagata Z. Maternal smoking during pregnancy and growth in infancy: a covariance structure analysis. J Epidemiol 2014; 25:44-9. [PMID: 25327186 PMCID: PMC4275437 DOI: 10.2188/jea.je20140040] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Smoking during pregnancy is related to fetal constraint and accelerated postnatal growth. However, the pathways between these factors have not been clarified. Pathway analyses that link these factors can help us better understand the mechanisms involved in this association. Therefore, this study aimed to examine pathways between maternal smoking during pregnancy and growth in infancy. Methods Participants were singletons born between 1993 and 2006 in rural Japan. The outcome was the change in weight z-score between birth and 3 years of age. Pathways from maternal smoking and other maternal factors (such as maternal body mass index and work status) to growth in infancy via birth factors (such as birth weight and gestational age) and breastfeeding were examined using structural equation modeling. Results Complete data were available for 1524 children (775 boys and 749 girls). The model fit appeared adequate. Lower birth weight and non-exclusive breastfeeding mediated the association between maternal smoking during pregnancy and rapid growth in infancy. Maternal smoking was also directly linked to rapid growth in infancy (standardized direct effects 0.06, P = 0.002). Taking all pathways into account, the standardized total effect of maternal smoking on growth in infancy was 0.11. Conclusions Maternal smoking during pregnancy may both indirectly, through birth weight and breastfeeding status, and directly influence growth during infancy; however, there may be other pathways that have not yet been identified.
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Affiliation(s)
- Wei Zheng
- Department of Health Sciences, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi
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18
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Abstract
Referral for an assessment of tall stature is much less common than for short stature. Although the commonest cause is an underlying familial tendency to tallness, there are important disorders that should be considered at the initial assessment. Distinguishing these conditions from normal variations of growth is the key objective when managing the child and family. In some children, further targeted investigations will be needed and in rare instances intervention to limit final height may be appropriate. This article discusses a structured approach to the assessment and management of a child with tall stature.
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Affiliation(s)
- Justin H Davies
- Department of Paediatric Endocrinology, Southampton Children's Hospital, Southampton, UK
| | - Tim Cheetham
- Institute of Genetic Medicine, Newcastle University, c/o Department of Paediatric Endocrinology, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
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Among overweight middle-aged men, first-borns have lower insulin sensitivity than second-borns. Sci Rep 2014; 4:3906. [PMID: 24503677 PMCID: PMC3915551 DOI: 10.1038/srep03906] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 01/10/2014] [Indexed: 12/30/2022] Open
Abstract
We aimed to assess whether birth order affects metabolism and body composition in overweight middle-aged men. We studied 50 men aged 45.6 ± 5.5 years, who were overweight (BMI 27.5 ± 1.7 kg/m(2)) but otherwise healthy in Auckland, New Zealand. These included 26 first-borns and 24 second-borns. Insulin sensitivity was assessed by the Matsuda method from an oral glucose tolerance test. Other assessments included DXA-derived body composition, lipid profiles, 24-hour ambulatory blood pressure, and carotid intima-media thickness. First-born men were 6.9 kg heavier (p = 0.013) and had greater BMI (29.1 vs 27.5 kg/m(2); p = 0.004) than second-borns. Insulin sensitivity in first-born men was 33% lower than in second-borns (4.38 vs 6.51; p = 0.014), despite adjustment for fat mass. There were no significant differences in ambulatory blood pressure, lipid profile or carotid intima-media thickness between first- and second-borns. Thus, first-born adults may be at a greater risk of metabolic and cardiovascular diseases.
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The association of birth order with later body mass index and blood pressure: a comparison between prospective cohort studies from the United Kingdom and Brazil. Int J Obes (Lond) 2013; 38:973-9. [PMID: 24097298 PMCID: PMC4024316 DOI: 10.1038/ijo.2013.189] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 08/29/2013] [Accepted: 09/24/2013] [Indexed: 01/15/2023]
Abstract
Background: Previous studies have found greater adiposity and cardiovascular risk in first born children. The causality of this association is not clear. Examining the association in diverse populations may lead to improved insight. Methods: We examine the association between birth order and body mass index (BMI), systolic and diastolic blood pressure (SBP/DBP) in the 2004 Pelotas cohort from southern Brazil and the Avon Longitudinal Study of Parents and Children (ALSPAC) from Bristol, south-west England, restricting analysis to families with two children in order to remove confounding by family size. Results: No consistent differences in BMI, SBP or DBP were observed comparing first and second born children. Within the Pelotas 2004 cohort, first born females were thinner, with lower SBP and DBP; for example, mean difference in SBP comparing first with second born was −0.979 (95% confidence interval −2.901 to 0.943). In ALSPAC, first born females had higher BMI, SBP and DBP. In both cohorts, associations tended to be in the opposite direction in males, although no statistical evidence for gender interactions was found. Conclusions: The findings do not support an association between birth order and BMI or blood pressure. Differences to previous studies may be explained by differences in populations and/or confounding by family size in previous studies.
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Lawson DW, Makoli A, Goodman A. Sibling configuration predicts individual and descendant socioeconomic success in a modern post-industrial society. PLoS One 2013; 8:e73698. [PMID: 24040031 PMCID: PMC3765256 DOI: 10.1371/journal.pone.0073698] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Accepted: 07/20/2013] [Indexed: 11/28/2022] Open
Abstract
Growing up with many siblings, at least in the context of modern post-industrial low fertility, low mortality societies, is predictive of relatively poor performance on school tests in childhood, lower levels of educational attainment, and lower income throughout adulthood. Recent studies further indicate these relationships hold across generations, so that the descendants of those who grow up with many siblings are also at an apparent socioeconomic disadvantage. In this paper we add to this literature by considering whether such relationships interact with the sex and relative age of siblings. To do this we utilise a unique Swedish multigenerational birth cohort study that provides sibling configuration data on over 10,000 individuals born in 1915–1929, plus all their direct genetic descendants to the present day. Adjusting for parental and birth characteristics, we find that the ‘socioeconomic cost’ of growing up in a large family is independent of both the sex of siblings and the sex of the individual. However, growing up with several older as opposed to several younger siblings is predictive of relatively poor performance on school tests and a lower likelihood of progression to tertiary education. This later-born disadvantage also holds across generations, with the children of those with many older siblings achieving lower levels of educational attainment. Despite these differences, we find that while individual and descendant income is negatively related to the number of siblings, it is not influenced by the relative age of siblings. Thus, our findings imply that the educational disadvantage of later-born children, demonstrated here and in numerous other studies, does not necessarily translate into reduced earnings in adulthood. We discuss potential explanations for this pattern of results, and consider some important directions for future research into sibling configuration and wellbeing in modern societies.
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Affiliation(s)
- David W. Lawson
- Department of Anthropology, University College London, London, United Kingdom
- * E-mail:
| | - Arijeta Makoli
- Centre for Health Equity Studies (CHESS), Stockholm University/Karolinska Institute, Stockholm, Sweden
| | - Anna Goodman
- Centre for Health Equity Studies (CHESS), Stockholm University/Karolinska Institute, Stockholm, Sweden
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
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