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Early Programming of Adult Diseases in Resource Poor Countries 429 GLOBAL CHILD HEALTH Arch Dis Child: first published as 10.1136/adc.2004.059030 on 21 March 2005. Downloaded from Early programming of adult diseases in resource poor countries A M Prentice, S E Moore ............................................................................................................................... Arch Dis Child 2005;90:429–432. doi: 10.1136/adc.2004.059030 Considerable evidence now exists to suggest that early particularly vulnerable to nutritional insults, and that certain organs such as the brain tend to be exposure to nutritional deprivation can have long term spared at the expense of others.3 consequences to health, with low birth weight now At the current time Barker’s theories still considered a risk factor for later health outcomes such as remain the subject of intense scrutiny and not inconsiderable controversy,4 but few would now coronary heart disease, stroke, type 2 diabetes, and the deny the underlying tenet that early exposure to metabolic syndrome. Of importance, such effects are most nutritional deprivation can have long term exaggerated when faced with over-nutrition in later life, consequences to health. In summary, there is considerable evidence that fetal and early post- forming the basis for the ‘‘thrifty phenotype’’ hypothesis. natal undernutrition can invoke the following The evidence in support of these associations comes largely changes: metabolic adaptations that affect variables from retrospective cohort studies in which adult outcomes such as hepatic enzyme profiles,5 lipoprotein 6 7 were correlated with birth weight records. Relatively little profiles, and clotting factor production; anato- mical adaptations that affect processes such as end data is available from developing countries, where long organ glucose uptake8 and renal solute hand- term record keeping of birth weight data has not been a ling;9 and endocrine adaptations that affect the high priority. Arguably however, such countries are at the hypothalamic-pituitary-adrenal axis,10 insulin signalling,11 and leptin levels.12 These changes greatest risk from the mismatch of early nutritional map onto health outcomes such as coronary deprivation and later nutritional affluence. This paper heart disease, stroke, type 2 diabetes, and the explores the importance of the ‘‘developmental origins of metabolic syndrome, all of which have been shown to be increased in low birth weight health and disease’’ hypothesis in resource poor countries. babies.3 ........................................................................... The evidence for these associations originated largely from retrospective cohort studies in which adult outcomes were correlated with birth http://adc.bmj.com/ n the late 1980s Prof David Barker and his weight records. The main controversies over the colleagues from Southampton observed that evidence have centred on four questions: (1) Ithe geographical distribution of heart disease whether socioeconomic differences (which can in the UK was more closely related to a person’s 1 affect both birth weight and later health) have place of birth than where they currently lived. been adequately controlled for in the analyses; This suggested that early life events can cause (2) the possibility that the correlations between permanent changes in physiology that, depend- low birth weight and later outcomes could arise ing on the environment, may later predispose on September 25, 2021 by guest. Protected copyright. from a common genetic factor that affected people to disease. Associations with birth weight both;13 (3) statistical issues in relation to how and with growth in infancy suggested that early we adjust for later changes in body size and nutrition was an important component of these fatness;14 and (4) failure to replicate the observa- ‘‘programmed’’ effects. These first clues opened tions in all studies. Reinforcement for the cross- up a vast new area of research in a field now sectional analyses has come from a wide range of officially termed ‘‘the developmental origins of mechanistic studies in animal models in which health and disease’’ (DOHAD). the effects of maternal nutrient restriction In fact suggestions that early life events can during pregnancy and lactation can be investi- impose permanent changes to human form and gated more easily at the biochemical level.15 behaviour stretch back several millennia to the Finally there have been studies showing that earliest debates about ‘‘nature versus nurture’’. See end of article for babies randomised to different forms of feeding We can trace these thoughts through the ideas of in early life show profound later sequelae, even authors’ affiliations people such as Lamarck in relation to ‘‘organic ....................... when the period of randomisation was extremely evolution’’,* and Pasteur in terms of early short.16 Thus, although there remains much to be Correspondence to: modification of the immune system. In this learnt, the totality of evidence is strong and it is Prof. A M Prentice, MRC century the main proponents of early program- International Nutrition ming were Robert McCance and Elsie Group, London School of *It is particularly interesting that Lamarck’s ideas that Hygiene & Tropical Widdowson,2 whose experiments on caloric physical changes adopted in one generation could be Medicine, Keppel Street, restriction of piglets and rats established several transmitted through the gamete to the next generation are London WC1E 7HT, UK; of the underlying principles of modern day Andrew.Prentice@lshtm. now being validated by discoveries in relation to ac.uk ‘‘Barkerology’’; namely that there are critical transgenerational effects on outcomes such as birth weight ....................... windows in which a growing organism may be and epigenetic imprinting. www.archdischild.com 430 Prentice, Moore Current thinking is that a combination of a thrifty Arch Dis Child: first published as 10.1136/adc.2004.059030 on 21 March 2005. Downloaded from A focus on thrifty genotypes and thrifty genotype and a thrifty phenotype amplifies the predisposition phenotypes of populations in developing countries to developing diseases of affluence. This is particularly so in countries passing The latter half of the last century saw virtual epidemics of type through a rapid economic and nutritional transition, or in 2 diabetes in many traditional populations, as their lifestyles peoples from poor countries who migrate to wealthy ones.21 changed from hunting, gathering, and subsistence agricul- The evidence in support of this is pieced together from a ture to a modernised pattern characterised by sedentary variety of different observations involving, for instance, the occupations and energy-dense foods.39 These changes were increased susceptibility of peoples of Asian origin to highlighted in a number of specific population groups, such diabetes22 and of African origin to hypertension.23 In such as the Micronesian populations of the small Pacific island of work it has proved difficult to separate out in-born genetic Nauru39 and the Pima Indians of Arizona.40 In 1962, as a effects from life-time programmed effects, but both are preliminary explanation for this observation, JV Neel considered significant. proposed the ‘‘thrifty genotype’’ hypothesis.20 To Neel, type With regard to the early-life programming hypothesis it 2 diabetes presented an enigma in that a relatively frequent must be admitted that there is a scarcity of data from disease, which often interfered with reproduction by virtue of developing countries because almost no institutions in such its onset during the reproductive or even pre-reproductive countries have maintained reliable archives of birth records years, had continued to exist and even to increase in which can be compared against adult health outcomes. prevalence. To have persisted through centuries of evolution, Nonetheless the theory is that when there is a transition from and in the face of the obvious and strong genetic selection energy and nutrient deprivation in early life to abundance or against this condition, the diabetogenic gene or genes must over-abundance in later life this generates a disadapted state have had some survival advantage. Neel’s ‘‘thrifty geno- that is especially prone to metabolic disease (fig 1). type’’ hypothesis suggested therefore that the diabetogenic Studies from Mysore in India have shown evidence that gene, or genes, persisted at a high level in the population later outcomes are associated with birth weight and because they somehow conferred a survival advantage in length,24 25 but the data do not permit the conclusion that times of nutritional deprivation, though were detrimental at these associations are any stronger than seen in European or times of adequate or over-nutrition. American cohorts. A small number of other studies from With the emergence of preliminary evidence to suggest a developing countries similarly support the early program- relation between indices of fetal and infant growth and adult ming theory, but without any evidence of any additional disease in the early 1990s, Hales and Barker suggested the potency. Importantly a study from The Gambia26 failed to find ‘‘thrifty phenotype’’ hypothesis in the aetiology of type 2 any association between early life growth faltering and later diabetes.41 The concept underlying their hypothesis is that metabolic disease, but concluded that this was because the poor fetal and early postnatal nutrition imposes mechanisms adults being studied were still living
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