The effects of birth weight and postnatal linear growth retardation on blood pressure at age 11-12 years

Maternal-Infant Supplementation with Small-Quantity Lipid-Based Nutrient Supplements Does Not Affect Child Blood Pressure at 4-6 Y in Ghana: Follow-up of a Randomized Trial

BACKGROUND

In the International Lipid-Based Nutrient Supplements (iLiNS)-DYAD-Ghana trial, prenatal small-quantity lipid-based nutrient supplements (LNSs) had a positive effect on birth weight. Birth weight may be inversely related to blood pressure (BP) later in life.

OBJECTIVES

We examined the effect of the intervention on BP at 4-6 y of age, and maternal and child factors related to BP.

METHODS

The iLiNS-DYAD-Ghana study was a partially double-blind, randomized controlled trial which assigned women (n = 1320) ≤20 weeks of gestation to daily supplementation with: 1) iron and folic acid during pregnancy and 200 mg Ca for 6 mo postpartum , 2) multiple micronutrients during pregnancy and postpartum, or 3) LNSs during pregnancy and postpartum plus LNSs for infants from 6 to 18 mo of age. At 4-6 y of age (n = 858, 70% of live births), we compared BP, a secondary outcome, between non-LNS and LNS groups and examined whether BP was related to several factors including maternal BP, child weight-for-age z score (WAZ), and physical activity.

RESULTS

Non-LNS and LNS groups did not differ in systolic (99.2 ± 0.4 compared with 98.5 ± 0.6 mm Hg; P = 0.317) or diastolic (60.1 ± 0.3 compared with 60.0 ± 0.4 mm Hg; P = 0.805) BP, or prevalence of high BP (systolic or diastolic BP ≥90th percentile of the US National Heart, Lung, and Blood Institute reference: 31% compared with 28%; P = 0.251). BP at 4-6 y of age was positively related to birth weight; this relation was largely mediated through concurrent WAZ in a path model. Concurrent WAZ and maternal BP were the factors most strongly related to child BP.

CONCLUSIONS

Despite greater birth weight in the LNS group, there was no intervention group difference in BP at 4-6 y. In this preschool population at high risk of adult hypertension based on BP at 4-6 y, high maternal BP and child WAZ were key factors related to BP. This trial was registered at clinicaltrials.gov as NCT00970866.

Correlates of elevated blood pressure in healthy children: a systematic review

The prevalence of hypertension in children is increasing globally. Addressing this will require a robust understanding of associated risk factors. To this end, we conducted a systematic review to identify correlates of elevated blood pressure (BP) in children. Literature searches were conducted using pre-defined search terms from three academic databases. The abstract and full text of identified studies were screened for eligibility by two independent reviewers. A total of 100 studies were included in this systematic review. An assessment tool was first used to assess study quality; a narrative synthesis was then performed. We found a broad range of physiological, social and behavioural factors associated with elevated BP in children. The most common correlate observed was adiposity, suggesting that childhood obesity may be implicated in the increased prevalence of hypertension observed in children. However, the broad range of other factors identified underscores the multi-factorial aetiology of hypertension. Data from a broad range of studies showed that the correlates of hypertension in children are multi-factorial. Therefore, approaches aimed at preventing hypertension must in turn be multi-factorial to ensure that the burden of hypertension in childhood is addressed.

Differences in the anthropometry of Asian children and its role in metabolic health in later life: A narrative review

BACKGROUND

The increasing incidence of childhood obesity in Asia could be a reflection of early life programming in which environmental/nutritional challenges during pregnancy and first two years of life (the so-called first 1000 days) influence later health.

OBJECTIVE OF NARRATIVE REVIEW

To assess differences/similarities of anthropometric measures in early life and their influences on metabolic health risk in later life among children in Asia.

METHODS

Literature search for publication in English using selected key words from Medline (PubMed), Scopus, Science Direct and Google Scholar published from 1994 to October 2014. Some comparisons with Caucasian setting were made when relevant.

RESULTS

From 152 publications selected for this narrative review, differences in foetal growth and birth weight were deducted between Asian and Caucasian children. Infants in India and Hong Kong had increased fat mass at birth and early infancy as compared to those from other parts of the world. Pre- and during pregnancy conditions influenced birth weight; feeding practices and gender influenced post-natal growth and body composition development. High and low birth weights followed by rapid postnatal growth were linked to increased risks of obesity, insulin resistance and high blood pressure in later life.

CONCLUSION

Foetal and postnatal growth trajectories are different between countries within and outside Asia. Extremes in birth weight followed by rapid postnatal growth were linked to increased risks of metabolic health of children in this region. As there is limited evidence in Asia, it is important to conduct thorough investigations by using longitudinal studies on early life programming.

Association of Breast Feeding and Birth Weight with Anthropometric Measures and Blood Pressure in Children and Adolescents: The CASPIAN-IV Study

BACKGROUND

Noncommunicable diseases (NCDs) and their risk factors are major health threats especially for developing countries. The aim of this study was to assess the association between breast feeding (BF) and birth weight (BW) with anthropometric measures and blood pressure (BP) in a nationally-representative sample of Iranian children and adolescents.

METHODS

In this national survey, 14,880 children and adolescents, aged 6-18 years, were selected using a multistage, cluster sampling method from rural and urban areas of 30 provinces of Iran. BF duration and BW were assessed by validated questionnaires completed by parents.

RESULTS

The study participants were 13,486 students (participation rate of 90.6%). They consisted of 49.24% girls, 75.6% urban residents, with a mean age of 12.5 years (95% confidence interval: 12.3-12.6). The family history of obesity had a significant association with BW (p < 0.001). A substantial association was found between BF duration and the order of children in the family, both in boys (p < 0.001) and girls (p < 0.001). The mean values for height, weight, body mass index, as well as waist, wrist, and hip circumferences were higher in those with higher BW categories (p for trend < 0.001). As BW increased, there was a linear decrease in underweight (p for trend < 0.001) and a linear increase in the prevalence of generalized obesity (p for trend < 0.001) was documented.

CONCLUSION

BW was associated with a higher prevalence in general obesity and a lower prevalence of being underweight. Duration of BF had no significant association with anthropometric measures and BP. Future longitudinal studies are necessary to determine the clinical implications of these findings.

Maternal perception of malnutrition among infants using verbal and pictorial methods in Kenya

OBJECTIVE

To compare mothers' perceptions of their own infants' nutritional status with anthropometric indicators of undernutrition.

DESIGN

A qualitative study and cross-sectional quantitative survey. The qualitative study involved developing tools to assess mother's perception. Two methods of verbal description and a pictorial scale were developed. The quantitative survey involved measuring maternal perception and comparing it with the anthropometric measures of weight-for-age Z-score (WAZ) and mid-upper arm circumference-for-age Z-score (MUACZ).

SETTING

A rural community setting in Kenya.

SUBJECTS

Seventy-four infants aged between 4 and 6 months, and their mothers, living in rural Kenya were enrolled.

RESULTS

Using verbal description, the positive and negative likelihood ratios were 3.57 (95 % CI 1.44, 9.98) and 0.69 (95 % CI 0.50, 0.96) respectively for MUACZ<-2; and 4.60 (95 % CI 1.60, 13.3) and 0.67 (95 % CI 0.49, 0.92) respectively for WAZ<-2. Using the pictorial scale, the positive and negative likelihood ratios were 8.30 (95 % CI 1.91, 36.3) and 0.69 (95 % CI 0.52, 0.93) respectively for MUACZ<-2; and 4.31 (95 % CI 1.22, 15.0) and 0.78 (95 % CI 0.61, 1.00) respectively for WAZ<-2.

CONCLUSIONS

In a rural community, mothers better identify undernutrition in their infants using a pictorial scale than verbal description. However, neither can replace formal anthropometric assessment. Objective anthropometric tools should be validated for identification of severe acute malnutrition among infants aged less than 6 months.

Developmental programming of hypertension and kidney disease

A growing body of evidence supports the concept that changes in the intrauterine milieu during "sensitive" periods of embryonic development or in infant diet after birth affect the developing individual, resulting in general health alterations later in life. This phenomenon is referred to as "developmental programming" or "developmental origins of health and disease." The risk of developing late-onset diseases such as hypertension, chronic kidney disease (CKD), obesity or type 2 diabetes is increased in infants born prematurely at <37 weeks of gestation or in low birth weight (LBW) infants weighing <2,500 g at birth. Both genetic and environmental events contribute to the programming of subsequent risks of CKD and hypertension in premature or LBW individuals. A number of observations suggest that susceptibility to subsequent CKD and hypertension in premature or LBW infants is mediated, at least in part, by reduced nephron endowment. The major factors influencing in utero environment that are associated with a low final nephron number include uteroplacental insufficiency, maternal low-protein diet, hyperglycemia, vitamin A deficiency, exposure to or interruption of endogenous glucocorticoids, and ethanol exposure. This paper discusses the effect of premature birth, LBW, intrauterine milieu, and infant feeding on the development of hypertension and renal disease in later life as well as examines the role of the kidney in developmental programming of hypertension and CKD.

Early determinants of chronic disease in developing countries

The prevalence of non-communicable diseases (NCDs) is rising in developing countries. The extent to which this is due to a nutritional mismatch in foetal and adult life is unknown however, studies in such countries show that the risk of chronic diseases is increased in low birthweight subjects who become obese adults. Immune dysfunction is also linked to low birthweight. Therefore, in countries where communicable diseases are prevalent, infection may be exacerbated by factors acting in utero. It is also possible that the foetal growth-retarding effects of maternal Human Immunodeficiency Virus (HIV) and malaria infection may contribute to an increased risk of NCDs later in life. Low birthweight and postnatal growth faltering followed by rapid weight gain define subjects who develop NCDs. Dietary interventions at specific time points in the life course may therefore be important for reducing disease risk.

Impact of prenatal multiple micronutrients on survival and growth during infancy: a randomized controlled trial

BACKGROUND

Although prenatal multiple micronutrients can improve fetal growth, their benefit on postnatal health remains uncertain.

OBJECTIVE

We assessed the effect of the UNICEF/WHO/United Nations University multiple micronutrient supplement for pregnant and lactating women (UNIMMAP) compared with the usual iron and folic acid supplement (IFA) on survival, growth, and morbidity during infancy.

DESIGN

In a double-blind, randomized trial, we followed 1294 singleton newborns whose mothers had prenatally received either the UNIMMAP or IFA. We assessed monthly anthropometric measures and health variables up to age 12 mo. Children were assessed again at a mean age of 30 mo. Mixed-effects models accounted for repeated measurements.

RESULTS

The UNIMMAP resulted in a 27% (HR: 0.73; 95% CI: 0.60, 0.87; P = 0.002) reduction in the rate of stunting in 15,261 infant-months with a higher length-for-age z score of 0.13 (95% CI: 0.02, 0.24; P = 0.02) over the whole observation period. However, by age 30 mo, this difference was not observed. An effect of the UNIMMAP on weight-for-length (P-interaction = 0.004) and head circumference-for-age (P-interaction = 0.03) became apparent by the end of the first year of life. By the age of 30 mo, children from the UNIMMAP group had a higher weight-for-height z score of 0.20 (95% CI: 0.06, 0.34; P = 0.004). No difference in mortality or morbidity was identified in groups, except a 14% reduction in reported episodes of fever (95% CI: 1%, 28%; P = 0.04).

CONCLUSIONS

Improved linear fetal growth with continuation into early life and enhanced postnatal growth were 2 mechanisms that mediated the effect of the prenatal UNIMMAP on infant nutritional status. Additional follow-up to assess long-term effects is warranted.

Neurobehavioral and neurodevelopmental effects of pesticide exposures

The association between pesticide exposure and neurobehavioral and neurodevelopmental effects is an area of increasing concern. This symposium brought together participants to explore the neurotoxic effects of pesticides across the lifespan. Endpoints examined included neurobehavioral, affective and neurodevelopmental outcomes among occupational (both adolescent and adult workers) and non-occupational populations (children). The symposium discussion highlighted many challenges for researchers concerned with the prevention of neurotoxic illness due to pesticides and generated a number of directions for further research and policy interventions for the protection of human health, highlighting the importance of examining potential long-term effects across the lifespan arising from early adolescent, childhood or prenatal exposure.

How can the Developmental Origins of Health and Disease (DOHaD) hypothesis contribute to improving health in developing countries?

The relevance of nutrition during pregnancy and early infancy in defining short-term health and survival has been well established. However, the Developmental Origins of Health and Disease (DOHaD) paradigm provides a framework to assess the effect of early nutrition and growth on long-term health. This body of literature shows that early nutrition has significant consequences on later health and well-being. In this article, we briefly present the main consequences of malnutrition that affect human growth and development and consider how the DOHaD paradigm, with its evolutionary implications, might contribute to better addressing the challenge of improving nutrition. We examine how this paradigm is particularly appropriate in understanding the health and nutrition transition in countries that face the double burden of nutrition-related diseases (acute malnutrition coexisting with obesity and other chronic diseases). We focus on stunting (low height-for-age) to examine the short- as well as long-term consequences of early malnutrition with a life-course, transgenerational, and multidisciplinary perspective. We present current global and regional prevalence of stunting and discuss the need to reposition maternal and infant nutrition not only in health and nutrition intervention programs but also in consideration of the emerging research questions that should be resolved to better orient program and policy decisions.

Respostas cardiopulmonares durante o esforço em crianças e adolescentes nascidas prematuras

OBJETIVO: Descrever as respostas cardiopulmonares durante o esforço em crianças e adolescentes nascidos prematuros. FONTES DE DADOS: Busca nas bases científicas em saúde SciELO, Lilacs e PubMed, utilizando-se os descritores: "pressão arterial", "capacidade física", "cardiovascular", "prematuro", "criança", adolescente", "função pulmonar", nos idiomas inglês e português. Foram selecionados artigos publicados nos últimos 20 anos. SÍNTESE DOS DADOS: Crianças e adolescentes com histórico de prematuridade apresentam sinais de obstrução das vias aéreas, menores valores de função pulmonar e de capacidade ao exercício, maior incidência de hipertensão arterial e/ou valores mais elevados da pressão arterial sistólica do que os nascidos a termo. Além disso, há indícios de que as alterações na resistência vascular sistêmica desde os primeiros dias de vida comprometam o desenvolvimento cardiovascular até a idade adulta, predispondo a maiores riscos cardiovasculares. CONCLUSÕES: O esforço físico nos indivíduos nascidos prematuros acarreta respostas cardiopulmonares diferentes dos nascidos a termo, atribuídas a particularidades no desenvolvimento desses sistemas inerentes ao prematuro.

Neurobehavioral deficits and increased blood pressure in school-age children prenatally exposed to pesticides

BACKGROUND

The long-term neurotoxicity risks caused by prenatal exposures to pesticides are unclear, but a previous pilot study of Ecuadorian school children suggested that blood pressure and visuospatial processing may be vulnerable.

OBJECTIVES

In northern Ecuador, where floriculture is intensive and relies on female employment, we carried out an intensive cross-sectional study to assess children's neurobehavioral functions at 6-8 years of age.

METHODS

We examined all 87 children attending two grades in the local public school with an expanded battery of neurobehavioral tests. Information on pesticide exposure during the index pregnancy was obtained from maternal interview. The children's current pesticide exposure was assessed from the urinary excretion of organophosphate metabolites and erythrocyte acetylcholine esterase activity.

RESULTS

Of 84 eligible participants, 35 were exposed to pesticides during pregnancy via maternal occupational exposure, and 23 had indirect exposure from paternal work. Twenty-two children had detectable current exposure irrespective of their prenatal exposure status. Only children with pre-natal exposure from maternal greenhouse work showed consistent deficits after covariate adjustment, which included stunting and socioeconomic variables. Exposure-related deficits were the strongest for motor speed (Finger Tapping Task), motor coordination (Santa Ana Form Board), visuospatial performance (Stanford-Binet Copying Test), and visual memory (Stanford-Binet Copying Recall Test). These associations corresponded to a developmental delay of 1.5-2 years. Prenatal pesticide exposure was also significantly associated with an average increase of 3.6 mmHg in systolic blood pressure and a slight decrease in body mass index of 1.1 kg/m2. Inclusion of the pilot data strengthened these results.

CONCLUSIONS

These findings support the notion that prenatal exposure to pesticides-at levels not producing adverse health outcomes in the mother-can cause lasting adverse effects on brain development in children. Pesticide exposure therefore may contribute to a "silent pandemic" of developmental neurotoxicity.

Still life with less: North Korean young adult defectors in South Korea show continued poor nutrition and physique

North Korean defectors who settle in South Korea have experienced severe food shortage and transition of food environment which could affect their health status. However, little is known about their anthropometric measurements and dietary intake after settlement in South Korea. The purpose of this study is to compare anthropometric measurements and dietary intake between North Korean young adults who defected to South Korea and those of South Koreans. We hypothesized that North Korean young adults' physiques and dietary intake would be poorer than that of South Koreans. We compared anthropometric measurements and dietary intake from 3-day food records in a cross-sectional study of 103 North Korean young adult defectors, aged 12 to 24 and 309 South Korean subjects. North Korean subjects were significantly shorter (4.9 to 10.8 cm) and lighter (6.0 to 12.5 kg) than the control group. Body mass index were significantly different between North and South Korean groups only in men. North Korean young adult defectors had lower mean daily intakes of energy and most nutrients and food groups compared to the control group, while North Korean subjects had higher nutrient density diet than that of South Koreans. The proportion of subjects who had dietary intakes of nutrients of less than the Estimated Average Requirement was higher in North Korean subjects than in controls except for in the cases of vitamin A and vitamin C. In conclusion, we recommend providing nutrition support programs for North Korean young adult defectors to secure adequate nutrient intake.

Blood pressure levels in childhood: probing the relative importance of birth weight and current size

Several studies have reported data supporting the idea that an impaired intrauterine environment that deprives the fetus of optimal nutrient delivery results in the predisposition of the fetus to experience cardiovascular and metabolic dysfunction in later life. However, contradictory data still exist. Our purpose was to investigate the effects of both birth weight and weight gain on the risk for high blood pressure levels in 6- to 10-year-old children. This cross-sectional study included 739 children divided into quartiles of birth weight. The mean values of both systolic and diastolic pressure were significantly different between quartiles of birth weight, with increasing blood pressure values as the birth weight decreased (P<0.001). Covariance analysis adjusting for gender, prematurity, and body mass index (BMI) showed that both systolic and diastolic pressure remained greater in the lowest than in the highest birth weight quartile. Separating those with low and normal birth weight demonstrated that the risk of childhood hypertension was significantly higher among children with low birth weight and current obesity (odds ratio [OR]: 5.0, confidence interval [CI]: 3.3 to 16.1; P=0.023). The inverse association between birth weight and blood pressure levels appears to be programmed during fetal life, while weight gain during childhood adds to this risk.

Immediate postnatal growth is associated with blood pressure in young adulthood: the Barry Caerphilly Growth Study

There is a consistent inverse association between birth weight and systolic blood pressure; however, few studies have been able to examine the immediate postnatal period. We have examined whether accelerated postnatal growth predicts adult systolic and diastolic blood pressure. We followed up participants from the Barry Caerphilly Growth Study. Blood pressure data were obtained on 679 of the original 951 subjects (73%) aged approximately 25 years. Both multivariable linear regression and spline models were used to examine the association among weight, length, and growth velocities with systolic blood pressure and diastolic blood pressure. Both statistical approaches showed that birth weight was inversely associated with systolic blood pressure. Only the spline models found that immediate (0 to 5 months) weight gain (beta coefficient: 1.29 mm Hg; 95% CI: 0.36 to 2.23; P=0.007) and weight gain between 1 year and 9 months to 5 years (beta coefficient: 1.44 mm Hg; 95% CI: 0.31 to 2.57; P=0.01) were independently associated with systolic blood pressure, whereas only immediate weight gain (beta coefficient: 0.74 mm Hg; 95% CI: 0.08 to 1.41; P=0.03) was associated with diastolic blood pressure. This is the first study to demonstrate that only immediate postnatal growth predicts diastolic blood pressure in term births, whereas it adds further evidence that both birth weight and postnatal growth are associated with systolic blood pressure in support of both the fetal origins and growth acceleration hypotheses.

Revisiting the interaction between birth weight and current body size in the foetal origins of adult disease

The four models proposed for exploring the foetal origins of adult disease (FOAD) hypothesis use the product term between size at birth and current size to determine the relative importance of pre- and post-natal growth on disease in later life. This is a common approach for testing the interaction between an exposure (in this instance size at birth) and an effect modifier (in this instance current size)--incorporating the product term obtained by multiplying the exposure and effect modifier variables within a statistical regression model. This study examines the mathematical basis for this approach and uses computer simulations to demonstrate two potential statistical flaws that might generate misleading findings. The first of these is that the expected value of the partial regression coefficient for the product term (between exposure and effect modifier) will be zero when the outcome, exposure and effect modifier are all continuously distributed and follow a multivariate normal distribution. This is because testing the product interaction term amounts to testing for multivariate normality among the three variables, irrespective of the pair-wise correlations amongst them. The second flaw is that it is possible to generate a statistically significant interaction between exposure and effect modifier, even when none exists, simply by categorising either or both of these variables. These flaws pose a serious challenge to the four models approach proposed for exploring the FOAD hypothesis. The interaction between exposure and effect modifier variables should be interpreted with caution both here and elsewhere in epidemiological analyses.

Pesticide exposure and stunting as independent predictors of neurobehavioral deficits in Ecuadorian school children

OBJECTIVES

To examine possible effects on blood pressure, neurological function, and neurobehavioral tests in school-aged children with and without prenatal pesticide exposure in an area where stunting is common.

METHODS

In a community of Northern Ecuador with intensive floriculture and a high female employment rate, we invited 79 children attending the 2 lowest grades of a public school for clinical examinations. In addition to a thorough physical examination, we administered simple reaction time, Santa Ana dexterity test, Stanford-Binet copying, and Wechsler Intelligence Scale for Children-Revised Digit Spans forward. Maternal interview included detailed assessment of occupational history to determine pesticide exposure during pregnancy. Recent and current pesticide exposure was assessed by erythrocyte acetylcholine esterase activity and urinary excretion of organophosphate metabolites.

RESULTS

All eligible children participated in the study, but 7 children were excluded from data analysis due to other disease or age >9 years. A total of 31 of the remaining 72 children were classified as stunted based on their height for age. Maternal occupational history revealed that 37 children had been exposed to pesticides during development. After confounder adjustment, prenatal pesticide exposure was associated with a higher systolic blood pressure than in the controls. On neurological examination, 14 exposed children and 9 controls showed > or =1 abnormalities. Of 5 neurobehavioral tests, the Stanford-Binet copying test showed a lower drawing score for copying designs in exposed children than in controls. Stunting was associated with a lower score on this test only, and both risk factors remained statistically significant in a multiple regression analysis with adjustment for demographic and social confounders. Increased excretion of dimethyl and diethyl metabolites of organophosphates was associated with increased reaction time and no other outcomes.

CONCLUSION

Prenatal pesticide exposure may cause lasting neurotoxic damage and add to the adverse effects of malnutrition in developing countries. The effects differ from those due to acute pesticide exposure.

Adult hypertension and kidney disease: the role of fetal programming

Hypertension (HTN) and chronic kidney disease are highly prevalent diseases that tend to occur more frequently among disadvantaged populations, in whom prenatal care also tends to be poor. More and more evidence is emerging highlighting the important role of fetal programming in the development of adult disease, suggesting a possible common pathophysiologic denominator in the development of these disorders. Epidemiologic evidence accumulated over the past 2 decades has demonstrated an association between low birth weight and subsequent adult HTN, diabetes, and cardiovascular disease. More recently, a similar association has been found with chronic kidney disease. Animal studies and indirect evidence from human studies support the hypothesis that low birth weight, as a marker of adverse intrauterine circumstances, is associated with a congenital deficit in nephron number. The precise mechanism of the reduction in nephron number has not been established, but several hypotheses have been put forward, including changes in DNA methylation, increased apoptosis in the developing kidney, alterations in renal renin-angiotensin system activity, and increased fetal glucocorticoid exposure. A reduction in nephron number is associated with compensatory glomerular hypertrophy and an increased susceptibility to renal disease progression. HTN in low birth weight individuals also appears to be mediated in part through a reduction in nephron number. Increased awareness of the implications of low birth weight and inadequate prenatal care should lead to public health policies that may have long-term benefits in curbing the epidemics of HTN, diabetes, and kidney disease in generations to come.

Low birth weight, nephron number, and kidney disease

More and more evidence is emerging that highlights the far-reaching consequences of prenatal (intrauterine) programming on organ function and adult disease. In humans, low birth weight (LBW) occurs more frequently in disadvantaged communities among whom there is often a disproportionately high incidence of adult cardiovascular disease, hypertension, diabetes mellitus, and kidney disease. Indeed, many epidemiologic studies have found an inverse association between LBW and higher blood pressures in infancy and childhood, and overt hypertension in adulthood. Multiple animal models have demonstrated the association of LBW with later hypertension, mediated, at least in part, by an associated congenital nephron deficit. Although no direct correlation has been shown between nephron number and birth weight in humans with hypertension, nephron numbers were found to be lower in adults with essential hypertension, and glomeruli tend to be larger in humans of lower birth weight. An increase in glomerular size is consistent with hyperfiltration necessitated by a reduction in total filtration surface area, which suggests a congenital nephron deficit. Hyperfiltration manifests clinically as microalbuminuria and accelerated loss of renal function, the prevalence of which are higher among adults who had been of LBW. A kidney with a reduced nephron number has less renal reserve to adapt to dietary excesses or to compensate for renal injury, as is highlighted in the setting of renal transplantation, where smaller kidney to recipient body-weight ratios are associated with poorer outcomes, independent of immunologic factors. Both hypertension and diabetes are leading causes of end-stage renal disease worldwide, and their incidences are increasing, especially in underdeveloped communities. Perinatal programming of these 2 diseases, as well as of nephron number, may therefore have a synergistic impact on the development of hypertension and kidney disease in later life. Existing evidence suggests that birth weight should be used as a surrogate marker for future risk of adult disease. Although the ideal solution to minimize morbidity would be to eradicate LBW, until this panacea is realized, it is imperative to raise awareness of its prognostic implications and to focus special attention toward early modification of risk factors for cardiovascular and renal disease in individuals of LBW.

Blood pressure among very low birth weight (<1.5 kg) young adults

Our objective was to compare the blood pressure of 20-y-old very low birth weight (VLBW; <1.5 kg) individuals with that of normal birth weight (NBW) control individuals. The population included 195 VLBW (92 female and 103 male) and 208 NBW (107 female and 101 male) individuals who were born between 1977 and 1979. Independent effects of birth weight status (VLBW versus NBW) and within the VLBW cohort of intrauterine growth (birth weight z score) were examined via multiple regression analyses. VLBW individuals had a higher mean systolic blood pressure (SBP) than NBW control individuals (114 +/- 11 versus 112 +/- 13 mm Hg). SBP for VLBW female infants was 110 +/- 9 versus NBW 107 +/- 12 and for VLBW male individuals was 118 +/- 11 versus NBW 117 +/- 11 mm Hg. After adjustment for gender, race, and maternal education, the difference in SBP between VLBW and NBW individuals was 1.9 mm Hg but was 3.5 mm after also adjustment for later size (20-y weight and height z scores), which reflects catch-up growth. For female individuals, the difference in SBP between VLBW and NBW individuals was significant both unadjusted and adjusted for later size, whereas for male individuals, the difference was significant only after adjustment for later size. Intrauterine growth did not have a significant effect on SBP within the VLBW group, even after adjustment for later size. VLBW individuals, specifically female individuals, have a higher SBP than NBW control individuals. This is not explained by intrauterine growth failure.

Secondary anthropometric data analysis of the National Food Consumption Survey in South Africa: the double burden

OBJECTIVE

There is an increase in the prevalence of overweight and obesity in children worldwide, including South Africa. We investigated the prevalences of overweight, obesity, and stunting in a current generation of children (ages 12 to 108 mo), which has a high prevalence of stunting, and evaluated the determinants of both nutritional disorders.

METHODS

Secondary data analysis of the weight and height measurements of 12- to 108-mo-old children (weighted n = 2200, non-weighted n = 2894) during the 1999 National Food Consumption Survey in South Africa is reported. The body mass index reference percentiles recommended for use in children by the International Obesity Task Force were used to determine the prevalence of overweight and obesity, and the National Center for Health Statistics (NCHS) percentiles were used to determine the prevalence of stunting.

RESULTS

Nationally, the prevalence of stunting (height-for-age < or = -2 standard deviations, NCHS 50th percentile) in these children was 19.3% (95% confidence interval [CI] = 17.49 to 21.16) and was highest in 1- to 3-y-old children (24.4%) and in children of farm workers on commercial farms (25.6%). The prevalence of combined overweight and obesity (body mass index > or = 25 kg/m(2) in 17.1%, 95% CI = 15.00 to 19.23) at the national level was nearly as high as that for stunting. Further, the types of determinants for stunting and overweight were generally similar (although directionally opposite in degree of risk conferred) and included type of housing, type of toilet in the home, fuel used in cooking, presence of a refrigerator or stove, presence of a television in the house, educational level of the caregiver, and maternal education level. An example of the directionally opposite degree of risk is exemplified by the use of paraffin as a fuel being protective against being overweight (odds ratio = 0.78, 95% CI = 0.63 to 0.97) but predictive of an increased risk for stunting (odds ratio = 1.24, 95% CI = 1.04 to 1.48). Stunting itself conferred an increased risk (odds ratio = 1.80, 95% CI = 1.48 to 2.20) of being overweight.

CONCLUSION

Certain defined determinants appear to play important roles in children's nutritional outcomes in relation to stunting and to overweight and obesity.

Adult BMI and fat distribution but not height amplify the effect of low birthweight on insulin resistance and increased blood pressure in 20-year-old South Africans

AIMS/HYPOTHESIS

We examined whether associations between low birthweight and adult chronic cardio-metabolic disease were dependent upon birthweight alone, or on interactions with BMI, fat accumulation either generally or abdominally, or attained height in young South African adults.

METHODS

Blood pressure (BP), lipids, glucose tolerance, insulin sensitivity and secretion (homeostasis model) were measured in 20-year-olds (n = 132) born at full term and with birthweights on or below the tenth centile (underweight for gestational age [UFA]) or between the 25th and 75th centiles for gestational age (appropriate weight for gestational age, [AFA]). Sex-specific median measurements of BMI, waist circumference, percentage body fat and height defined current anthropometric status, providing four groups for each measure: UFA-low or UFA-high and AFA-low or AFA-high.

RESULTS

The UFA-high BMI group was more insulin-resistant than both low BMI groups (p < 0.04), but not the AFA-high BMI group. In contrast, plasma triglycerides and systolic BP were higher in the UFA-high than in all other groups (all p < 0.04). When characterised by body fatness, both high percentage (%) body fat groups had higher fasting [insulin] than low percentage (%) body fat groups (p < 0.03), and higher [total cholesterol] and [LDL cholesterol] than the UFA-low percentage (%) body fat group (p < 0.05). The UFA-high group had higher systolic and diastolic BP than all other groups (all at least p < 0.03). A similar pattern was observed when groups were characterised by waist circumference; however, current height status had no effect.

CONCLUSIONS/INTERPRETATION

These data indicate that the "fetal origins" expression of the chronic disease phenotype is not dependent on birthweight alone, but on its interaction with subsequent fat accumulation, though not on attained height, in this cohort of young adults.

The prevalence of wasting, but not stunting, has improved in the Democratic People's Republic of Korea

The Democratic People's Republic of Korea (DPRK) is one of the nutritionally vulnerable countries of the world. The objectives of this paper were to determine the current prevalence of undernutrition among children using data from the latest national survey and to compare the findings with those from the previous national survey in 1997. In 2002 with cooperation from UNICEF and the World Food Program (WFP), the government of the DPRK conducted a survey of 6000 households with children < 7 y old using multiple-stage sampling methods. Data were collected for sociodemographic variables, use of WFP food aid, and anthropometric measures of the youngest child in the household. The prevalence of stunting (height for age Z-score less than -2.0) in all children was 39.4% (40.2 and 38.5% for boys and girls, respectively). The prevalence of wasting (weight for height Z-score less than -2.0) was 8.2% in all children (9.1 and 7.3% for boys and girls, respectively). Although the prevalence of wasting has decreased from 1997 (16.5%) to 2002 (8.2%), the prevalence of stunting has not changed between those years, 38.2 vs. 39.4%. Thus, we conclude that acute undernutrition is decreasing in the DPRK, but chronic undernutrition that results in stunting is still highly prevalent. Continued surveillance of nutritional status of children in the DPRK is warranted given the continued state of undernutrition in that country.

Birth weight and blood pressure in childhood: results from the Health Survey for England

Findings of previous reports relating low birth weight with raised blood pressure in childhood and adolescence have been inconsistent. The present study uses cross-sectional data from a series of nationally representative annual surveys--the Health Survey for England--between 1995 and 2002, totaling a sample of 15 629 children aged 5 to 15. A significant negative relationship between birth weight, in quartiles or dichotomized as low (<2.5 kg) and normal (> or =2.5 kg) and systolic blood pressure was apparent. Linear regression analyses confirmed these findings. When current weight was included in the model, the strength of the relationship increased. An interaction term between birth weight and current weight was not significant. A life-course plot for those aged 13 to 15 (n=3900), converting the weight measurements at birth and as a teenager to standard deviation scores to make the regression coefficients comparable, showed the importance of weight gain on blood pressure (1 standard deviation increase in weight from birth to age 13 to 15 was associated with an increase in systolic blood pressure of 0.8 mm Hg). Separating those with low and normal birth weight demonstrated that the increase in weight from birth to adolescence had an effect on blood pressure in both those with low and normal birth weight. Postnatal changes in size have a more important effect on blood pressure in childhood and adolescence than birth weight. Reducing the prevalence of overweight among children may reduce their systolic blood pressure importantly and, particularly among children with lower birth weight, the prevalence of hypertension later in life.

Higher income is more strongly associated with obesity than with obesity-related metabolic disorders in Jamaican adults

OBJECTIVE

This study compares how income is related to obesity vs two obesity-related cardiovascular disease (CVD) risk factors-diabetes and hypertension-in adults from Jamaica.

DESIGN

A cross-sectional population-based survey was used. In total, 847 men and 1249 women aged 25-74 y were randomly recruited from a periurban area in 1993-1998.

MEASUREMENTS

Trained interviewers measured anthropometry and blood pressure, obtained fasting blood and collected self-reported data on income and disease history.

RESULTS

Income was strongly and positively associated with obesity in men. In women, obesity levels were high even among the very poor, and the income gradient was more moderate. Although obesity-and particularly central fatness-was strongly associated with diabetes and hypertension prevalence, income was not significantly related to these disorders.

CONCLUSIONS

Future research in developing countries should independently explore associations between income and obesity vs obesity-related disorders, and identify factors that explain any disparities.

Differential association of birth weight with cardiovascular risk variables in African-Americans and Whites: the Bogalusa heart study

PURPOSE

To study the relationship between low birth weight and the subsequent development of cardiovascular risk factors and to compare this relationship between African-Americans and whites at 7 to 21 years of age.

METHODS

The relationship of birth weight with cardiovascular risk factors, namely, systolic and diastolic blood pressure (BP), BMI, HDL, LDL, triglycerides, and HOMA insulin resistance (HOMA-IR) was examined retrospectively using information on 1155 participants (730 whites and 425 African-Americans) from two cohorts of the Bogalusa Heart Study.

RESULTS

Participants with lower birth weight had higher systolic BP, HOMA-IR, triglycerides, and LDL. The association of birth weight with LDL, triglycerides, and HOMA-IR was stronger in African-Americans, while the association with systolic BP was stronger in whites. Subjects with birth weight <2500 g were at increased risk of having values of HOMA-IR and LDL in the upper quartile of the observed range compared with those with birth weight >2500 g.

CONCLUSIONS

These results support a relationship between low birth weight and the later development of important cardiovascular risk factors in young African-Americans and white individuals. This relationship tends to be stronger in African-Americans than in whites, except for systolic blood pressure.

A life course approach to diet, nutrition and the prevention of chronic diseases

OBJECTIVE

To briefly review the current understanding of the aetiology and prevention of chronic diseases using a life course approach, demonstrating the life-long influences on the development of disease.

DESIGN

A computer search of the relevant literature was done using Medline-'life cycle' and 'nutrition' and reviewing the articles for relevance in addressing the above objective. Articles from references dated before 1990 were followed up separately. A subsequent search using Clio updated the search and extended it by using 'life cycle', 'nutrition' and 'noncommunicable disease' (NCD), and 'life course'. Several published and unpublished WHO reports were key in developing the background and arguments.

SETTING

International and national public health and nutrition policy development in light of the global epidemic in chronic diseases, and the continuing nutrition, demographic and epidemiological transitions happening in an increasingly globalized world. RESULTS OF REVIEW: There is a global epidemic of increasing obesity, diabetes and other chronic NCDs, especially in developing and transitional economies, and in the less affluent within these, and in the developed countries. At the same time, there has been an increase in communities and households that have coincident under- and over-nutrition.

CONCLUSIONS

The epidemic will continue to increase and is due to a lifetime of exposures and influences. Genetic predisposition plays an unspecified role, and with programming during fetal life for adult disease contributing to an unknown degree. A global rise in obesity levels is contributing to a particular epidemic of type 2 diabetes as well as other NCDs. Prevention will be the most cost-effective and feasible approach for many countries and should involve three mutually reinforcing strategies throughout life, starting in the antenatal period.

Maternal and child nutritional supplementation are inversely associated with fasting plasma glucose concentration in young Guatemalan adults

Cardiovascular disease and diabetes may be programmed early in life by abnormal development associated with undernutrition. We investigated whether maternal nutritional status (MNS; height, pregnancy weight gain, nonpregnant BMI, and prenatal supplementation) or childhood nutritional status (CNS; birth weight, length, ponderal index, height-for-age Z-score at 24 mo, and supplementation from 0 to 24 mo) were related to fasting plasma glucose levels in rural-born Guatemalan adults. We studied 209 men and 220 women (mean age 24.4 y) who were involved in a randomized trial of nutritional supplementation of their mothers during pregnancy and during their early childhoods, conducted from 1969 to 1977. In 2 villages, residents were offered Atole (3.8 MJ and 64 g protein/L); 2 other villages were offered Fresco (1.4 MJ/L, no protein). No associations were observed between anthropometric measures of MNS or CNS and fasting plasma glucose levels. In subgroup analyses, inverse associations (all P < 0.15) with birth size were found among women born to fatter mothers, women with low supplement intake, men born to short mothers, and men more severely stunted at 24 mo. Prenatal supplementation was inversely associated with fasting plasma glucose among women [-0.40 +/- 0.17 mmol/(L. MJ. d), P = 0.02]. Among men, postnatal intake of supplementation of 0.10 to 0.20 MJ/d was associated with up to a 0.56 mmol/L reduction in fasting plasma glucose (P = 0.03), but intake in excess of 0.20 MJ/d provided no added benefit. Among women, the benefit of postnatal supplementation was restricted to those born thin (test for interaction P = 0.10). Improving the nutritional status of undernourished women and children may have positive long-term consequences.

Effect of Birth Weight on Blood Pressure and Body Size in Early Adolescence

The fetal programming theory that birth weight contributes to blood pressure or body size in later life is examined in this study. A prospective longitudinal study was conducted on subjects who were examined as newborns and prospectively interviewed and re-examined at 11 to 14 years old. Low birth weight (<2500 g) was present in 36% of the sample. The adolescent examination included measurements of blood pressure (BP), both auscultation and oscillometric methods; anthropometrics (height, weight, and body mass index [BMI]); health status; and health behaviors. Data were analyzed on 250 subjects. Correlation coefficients of birth weight with all BP measures were nonsignificant, except for the last auscultated diastolic BP ( r =0.19, P <0.01), which had a positive relationship. The simple correlation coefficients of birth weight with adolescent body size were significant and positive for weight and BMI. After multiple linear regression analyses with adjustments for age, Tanner stage, and gestational age, there was no significant effect of birth weight on adolescent weight or BMI. No significant correlations were detected for ponderal index at birth with adolescent measures. This study, which includes a substantial portion of low-birth-weight cases (36%), indicates that birth weight does not correlate negatively with later BP. These results do not support the low-birth-weight theory and indicate that childhood factors that are more proximal have a greater effect on adolescent BP than intrauterine factors.

Infant nutrition and blood pressure in early adulthood: the Barry Caerphilly Growth study

BACKGROUND

Evidence suggests that environmental factors acting early in life may affect blood pressure in adulthood.

OBJECTIVE

The objective was to test the hypothesis that dried formula milk (derived from cow milk) intake in infancy is positively associated with blood pressure in early adulthood.

DESIGN

We conducted a long-term follow-up (1997-1999) of the Barry Caerphilly Growth study cohort (1972-1974) into which mothers and their offspring had originally been randomly assigned to receive a milk supplement or usual care. Participants were the offspring, who were aged 23-27 y at follow-up. The main outcome measures were systolic and diastolic blood pressure.

RESULTS

The social and demographic characteristics of the subjects who were (n = 679) and were not (n = 272) followed up were similar. For each increase in quartile of dried milk consumption (in oz) at 3 mo of age, there was a 1.28-mm Hg (95% CI: 0.46, 2.10 mm Hg) increase in systolic and a 0.63-mm Hg (95% CI: 0.04, 1.22 mm Hg) increase in diastolic blood pressure after adjustment for sex, intervention group, birth weight z scores, social class in childhood, age at follow-up, alcohol consumption, and pack-years of smoking. These coefficients were attenuated when adult body mass index and height were included in the models, but the association of dried milk consumption at 3 mo of age with systolic pressure remained significant (1.07 mm Hg; 95% CI: 0.27, 1.87 mm Hg).

CONCLUSIONS

Our findings are consistent with the hypothesis that high blood pressure in later life is influenced by early postnatal nutrition. Thus, interventions to optimize infant nutrition may have important long-term health benefits.

Rapid child growth raises blood pressure in adolescent boys who were thin at birth

Catch-up growth in previously growth-restricted children is a suggested risk factor for chronic disease risk. We use data from 2026 Filipino adolescents to identify periods of growth that matter more for risk of high blood pressure (BP). Subjects were drawn from the Cebu Longitudinal Health and Nutrition Survey, which enrolled pregnant women and followed up their offspring through age 14 to 16 years. High BP was defined as the top 10% of residuals from gender-specific regressions of systolic and diastolic BP on age and height. After controlling for birth length, current body mass index, age, and height, the odds of high BP in males were significantly decreased with each kilogram increase in birth weight. The highest odds of elevated BP occurred among males who were relatively thin at birth but relatively heavy as adolescents. Larger weight increments from birth to 2 years decreased the odds of high BP in boys, whereas larger increments from 8 to 11 and 11 to 16 years increased the odds of high BP. Thinness at birth significantly interacted with growth rate after age 8, such that a high rate of weight gain increased risk only among boys who were in the lower two thirds of the body mass index distribution at birth. Results in girls indicated small or no effects of early growth. The synergistic effect on adolescent BP of rapid weight gain from late childhood into adolescence with thinness at birth is further evidence of fetal programming of BP in males and suggests long-term health risks associated with rapid growth, even in the absence of obesity.