Intergenerational Nutritional Effects & Fetal Growth and Chronic Disease 2010

Intergenerational Effects Cohort studies maternal birthweight and fetal grown Dutch famine studies Experimental Study Supplementation in Guatemala

Godfrey KM, Barker DJP, Robinson S, Osmond C Godfrey KM, Barker DJP, Robinson S, Osmond C. Mother's birthweight and diet in pregnancy in relation to the baby's thinness at birth. Br J Obstet Gynaecol 1997;104:663–7

Illinois Study Coutinho et al. Am J Epi, 1997 146:804-809 N=15,287 Black and 117,708 white matched pairs of infants and mothers. Mothers were born between 1956-75, infants between 1989-1991

Results Father’s birthweight had effect on infant birthweight but not as strong as mothers. In multiple linear regression for infants who weighed more than 2500 g, parental birthweight accounted for 5% of variance among black infants and 4% among white infants. adjusted for parental age, years of schooling, marital status and adequacy of prenatal care Each 100 g increase in maternal birthweight was associated with 24-27 g increase in infant birthweight

FIGURE 3 Mean offspring birth weight (g) for categories of paternal birth weight in selected strata of maternal birth weight Bouchard, C. Am J Clin Nutr 2009;89:1494S-1501S Copyright ©2009 The American Society for Nutrition

Dutch Famine Studies Susser and Stein, Nutrition Reviews, 1994 Dutch famine winter lasted 6 months, from November 1944- when nazis imposed transport embargo on west Holland until- May 7, 1945 when Holland was liberated from the occupation Strong evidence for critical stages of development in several physiological systems

Dutch Hunger Winter: Calories

Affects of Famine Fertility decreased Maternal weight fell during pregnancy with famine exposure Third trimester famine exposure had strong effect on birthweight Third trimester famine exposure was associated with infant mortality at 30-90 days

Birth Cohorts

Obesity in Young Men after Famine Exposure in Utero and early Infancy (Ravelli et al NEJM, 1976) N=300, 000 Dutch military inductees at age 19 Famine exposure in first 2 trimesters lead to 80% higher prevalence of overweight (p<0.0005) Famine exposure in last trimester or famine exposure in first 5 months of life associated with 40% lower prevalence of overweight (p<0.005)

Adult Obesity

Interpretation? Cohort B1 Cohort D1 Conceived and gestated at time of moderate caloric restriction Born into time of famine Low rates of adult obesity Cohort D1 Conceived and gestated at a time of famine Born into food sufficiency High rates of adult obesity

Other Results for Infants Exposed to Famine Excess central nervous system disorders (such as NTD) Famine exposure associated with twofold risk of schizophrenia in 50 year old women.

Prenatal exposure to famine and brain morphology in schizophrenia Hulshoff Pol HE; Hoek HW; Susser E; Brown AS; Dingemans A; Schnack HG; van Haren NE; Pereira Ramos LM; Gispen-de Wied CC; Kahn RS; American Journal of Psychiatry , Jul 2000;

Methods Nine schizophrenic patients and nine healthy comparison subjects exposed during the first trimester of gestation to the Dutch Hunger Winter were evaluated with magnetic resonance brain imaging, as were nine schizophrenic patients and nine healthy subjects who were not prenatally exposed to the famine.

RESULTS: Prenatal famine exposure in patients with schizophrenia was associated with decreased intracranial volume. Prenatal Hunger Winter exposure alone was related to an increase in brain abnormalities, predominantly white matter hyperintensities.

Further evidence of relation between prenatal famine and major affective disorder. Alan S Brown; Jim van Os; Corine Driessens; Hans W Hoek; et al; The American Journal of Psychiatry; Washington; Feb 2000;

Methods Compared the risk of major affective disorder requiring hospitalization in birth cohorts who were and were not exposed, in each trimester of gestation, to famine during the Dutch Hunger Winter of 1944-1945.

Results The risk of developing major affective disorder requiring hospitalization was increased for subjects with exposure to famine in the second trimester and was increased significantly for subjects with exposure in the third trimester, relative to unexposed subjects.

Intergenerational Impact of Dutch Famine A mother's exposure to famine prior to conception of her offspring was associated with lower self-reported measures of mental health and quality of life in her adult offspring. Stein et al. Epidemiology. 2009 Nov;20(6):909-15 The expected increase in offspring birth weights with increasing birth order was not seen after maternal intrauterine exposure in the first trimester of pregnancy Lumey and Stein. Am J Epidemiol. 1997 Nov 15;146(10):810-9

Reproductive performance and nutrition during childhood Nutrition Reviews; Washington; Apr 1996; Martorell, Reynaldo; Ramakrishnan, Usha; Schroeder, Dirk G; Ruel, Marie;

Longitudinal Supplementation Trial (1969-1977) Guatemala, 4 Villages, one pair of villages had about 900 people each and the other about 500 each. 2 each randomized to: Atole (Incaparina, a vegetable protein mix developed by INCAP*, dry skim milk, sugar, and flavoring, 163 kcal/cup, 11/5 g protein) Fresco (flavored drink with sugar, vitamins and minerals, 59 kcal/cup) *Institute of Nutrition of Central America and Panama

Feeding center was open daily for over 7 years, from 1969 to 1977. Anyone in the village could attend, but careful recording of consumption, including of additional servings as well as of leftovers, was done only for women who were pregnant or breastfeeding and for children 7 years or younger. Supplements were available twice daily, in midmorning and midafternoon, so as not to interfere with meal times.

Conceptual framework “Malnutrition in early childhood constrains the future capacity of women to bear healthy newborns and their ability to feed and care for them, and through these mechanisms the growth and development of the next generation.”

Follow-Up data - 1990s The prevalence of low birthweight is currently 12% in Atole villages (n = 65) and 28% in Fresco villages (n = 58) among women exposed to the supplements during the intrauterine period and the first 3 years of life. Mean birthweights are 2.90 kg in Atole villages and 2.73 in Fresco villages.

Role of intergenerational effects on linear growth U Ramakrishnan; R Martorell; D G Schroeder; R Flores; The Journal of Nutrition; Bethesda; Feb 1999;

Methods The sample was restricted to singleton, term (>37 wk of gestation) births that occurred in the four study villages between 1991 and 1996, to women who were born during the original longitudinal study (1969-1977) Complete data were available for 215 mother-child pairs, and 60% of the mothers (n = 140)

Results For every 100 g increase in maternal birth weight, her infant's birth weight increased by 29 g after adjusting for the effects of maternal age, gestational age and sex of the infant. This relationship was highly significant (P < 0.001) For every centimeter increase in maternal birth length, her child's birth weight increased by 53 g.

Metabolic “Programming” in an Age of Plenty

Recent Studies on Impact of GWG on Offspring Obesity Zilko et al. Am J Obset Gynecol, 2010 In NLSY: GWG associated with child overweight Mamun et al. Circulation, 2009 In Australian cohort : Greater GWG associated with greater offspring BMI in early adulthood Von Kries et al. Int J Pediatr Obes, 2010 Large German cross-sectional study: higher than average GWG accounts for moderate increase in offspring overweight at ages 3-17

Fig. 1. Obesity and pregnancy are associated with insulin resistance and inflammatory changes that exacerbate in combination, increasing lipid transfer earlier in gestation Heerwagen, M. J. R. et al. Am J Physiol Regul Integr Comp Physiol 299: R711-R722 2010; Fig. 1. Obesity and pregnancy are associated with insulin resistance and inflammatory changes that exacerbate in combination, increasing lipid transfer earlier in gestation. Obesity is associated with adipose tissue inflammation and systemic insulin resistance, resulting in increased adipose tissue lipolysis and hepatic very-low-density lipoprotein (VLDL) secretion. When combined with pregnancy, this leads to an increase in maternal circulating lipids with advancing gestation. Subsequent hydrolysis of maternal triglycerides (TGs) by placental lipoprotein lipase (LPL) and increased free fatty acid (FFA) uptake and transport by the placenta results in excess lipid transfer to the developing fetus. This increase in fetal lipid exposure may impact the liver, skeletal muscle, adipose tissue, brain, and pancreas to increase the risk for metabolic disease in childhood. MCP-1, monocyte chemotractant protein-1; CM, chylomicron; NAFLD, nonalcoholic liver disease. Copyright ©2010 American Physiological Society

Fetal Nutrition and Chronic Diseases of Adulthood Developmental Origins of Health & Disease

UN Standing Committee on Nutrition, 2006 While undernutrition kills in early life, it also leads to a high risk of disease and death later in life. This double burden of malnutrition has common causes, inadequate foetal and infant and young child nutrition followed by exposure (including through marketing practices) to unhealthy energy dense nutrient poor foods and lack of physical activity. The window of opportunity lies from pre-pregnancy to around 24 months of a child’s age.

Barker’s Fetal Origins Theory Coronary heart disease, stroke, type 2 diabetes, hypertension and osteoporosis, originate through developmental plasticity, in response to malnutrition during fetal life and infancy. Certain cancers, including breast cancer, also originate in fetal life.

Fetal Origins Concepts Barker et al Nutrition in early life has permanent effects Undernutrition has different effects at different times of life. Rapidly growing fetuses and neonates are vulnerable to undernutrition Undernutrition results from inadequate maternal intake, transport, or transfer of nutrients.

The Barker Hypothesis Fetal Origins of Adult Disease Adverse intrauterine events permanently “program” postnatal structure/function/homeostasis “Adapted Birth Phenotype” * Better chance of fetal survival * Increased risk of adult disease Susan P. Bagby, MD, Professor of Medicine & Physiology/Pharmacology Division of Nephrology & Hypertension OHSU, Portland, OR

FETAL ORIGINS OF ADULT CVASC DISEASE Adverse Intrauterine Events In Utero Birth Childhood Adulthood Low Birthweight/IUGR MODIFIERS COFACTORS Adult “Metabolic Syndrome” Abd’l Obesity HTN CAD Diabetes  TG/ HDL Renal Failure

Coronary heart disease death rates, expressed as standardized mortality ratios, in 10,141 men and 5585 women born in Hertfordshire, United Kingdom, from 1911 to 1930, according to birth weight. (Osmond C, Barker DJP, Winter PD, Fall CHD, Simmonds SJ. Early growth and death from cardiovascular disease in women. BMJ 1993;307:1519–24)

Age-adjusted Relative Risk of Non- fatal Coronary Heart Disease and Stroke 5.0 7.5 10.0 0.50 0.75 1.00 1.25 1.50 Birthweight Relative Risk Mean ± 95% CL 121,700 American Nurses, self report study BMJ 315:396,1997

Catch-up growth in childhood and death from coronary heart disease: longitudinal study (Eriksson et al, BMJ, 1999) Subjects: 3641 men born in Helsinki between 1924-1933 Followed with school data for weight and height Deaths from coronary heart disease from 1971-95 (standardized mortality ratios) were endpoints.

Catch-up growth in childhood and death from coronary heart disease: longitudinal study (Eriksson et al, BMJ, 1999 Men who had low birth weight or were thin at birth have high death rates from coronary heart disease Death rates are even higher if weight "catches up" in early childhood Death from coronary heart disease may be a consequence of prenatal undernutrition followed by improved postnatal nutrition Programs to reduce obesity among boys may need to focus on those who had low birth weight or who were thin at birth

David J.P. Barker, F.R.S., Clive Osmond, Ph.D., Tom J. Forsén, M.D., Eero Kajantie, M.D., and Johan G. Eriksson, M.D. Trajectories of Growth among Children Who Have Coronary Events as Adults. N Engl J Med 2005;353:1802-9.

Diabetes in Low-Birth-Weight Men Birth Weight (lbs) % Impaired Gluc Tol or DM <5.5 6.5 7.5 8.5 9.5 >9.5 40 30 20 10 370 men Age 64 yrs Odds Ratio/Adj for BMI 8 6 4 2 Gestat’l DM Hales et al. BMJ 303: 1019, 1991

Fetal Milieu Affects Obesity Risk Trouble at Both Ends of the Birth Weight Spectrum Birth Weight (kg) Odds Ratio For Obesity Eriksson J et al Internatl J Obesity 2001

Birth Weight Predicts Blood Pressure at Age 31 Birth Weight (gm) <2500 -2999 -3499 -3999 -4499 >4500 130 128 126 124 122 Sys BP (mmHg) Birth Weight Predicts Blood Pressure at Age 31 1966 Northern Finland Birth Cohort +/- adjust for current BMI Jarvelin M et al. Hypertension 2004 Variables: Birth Weight Ponderal Index Sex Gestational age Mat’l Ht, Wt Parity Socioeconomic Current BMI n = 5960 offspring

Birthweight and Adult HTN in US Women Nurses Health Study I Birthweight Category (lbs) < 5.0 5.0-5.5 5.6-7.0 7.1-8.5 8.6-10.0 HTN Prevalence (%) 40 30 15 10 Age 46-71 8.4% 30-55 3.1%

Early Growth Patterns Predict Adult HTN Barker et al. J HTN 20:1951, 2002. Cohort Average (n=8760) }

Animal Models (Waterland and Garza) “Overall the data from animal models of metabolic imprinting support the observed epidemiological associations.”

Effect of Gestational Type 2 Diabetes on Body Weight in Adult Offspring

Framework for understanding the maternal regulation of fetal development and programming Godfrey & Barker. Fetal nutrition and adult disease. Am J Clin Nutr 2000 71: 1344-1352.

Asymmetric Growth Restriction Adverse Intrauterine Events Asymmetric Growth Restriction Low Birth Weight for Gestational Age Low Wt: Height Ratio (thinness) Relative sparing of heart, brain, adrenal Disproportionate reduction of kidney, liver, pancreas, skeletal muscle mass Reduced abdominal girth

Fetal Origins of Adult Disease * Thin * Small abdominal girth ( liver size) * Low arm cir- cumference ( muscle mass) * Preserved central fat mass From Barker, 1998 Asymmetric Growth Restriction “More powerful predictor than other risk factors”

? % Growth-Restricted Phenotype in Lower Birth Weight Categories Conceptual Graph

Structural Deficits  Reduced Functional Units in Organs Potential Mechanisms of Developmental Programming Structural Deficits  Reduced Functional Units in Organs Kidney  Nephron # HTN Pancreas  Islet Cell #  Insulin secretion  Glucose Muscle  muscle mass  Basal met rate  Exercise capacity Heart  myocyte #  Risk CHF Liver  cells # ?  lipid metabolism

What Conveys Risk of HTN in Lower Birth-weight Offspring ? Brenner et al. 1988,1994 Low Birth Wt, Low Nephron Number and HTN “… retardation of renal development as occurs in individuals of low birth weight gives rise to increased postnatal risks for systemic and glomerular hypertension as well as enhanced risk of expression of renal disease.”2 1Am J HTN 1988 1:335-47; 2Am J Kid Dis 1994 23: 171

New Nephrons Form in Concentric Layers during Gestation Branching Morphogenesis  Nephrogenesis New Nephrons Form in Concentric Layers during Gestation Condensing Mesenchyme Comma Shaped Bodies Outer Nephrogenic Layer Glomeruli

Birth Weight Predicts Nephron Number  230,000 nephrons per kg increase in birth weight In Term Births: Ages 1-17 yrs All Ages  Hughson et al, Kid Internat (2003) 63, 2113 Also: Merlet-Benichou et al, 1999 Manalich et al, 2000

Asymmetric Growth Restriction in Utero Maternal Protein Deficiency Asymmetric Growth Restriction in Utero “The Thrifty Phenotype” Impaired Kidney Development # Nephrons (permanent) FOOD CATCH-UP GROWTH # Nephrons BP BODY MASS

Rethinking “FOAD” Programming events may act: Periconceptually Prenatally Postnatally: infancy, childhood Cardiovascular outcomes may appear: In childhood, adolescence In midlife In elderly

and Risk of Childhood Adiposity Rapid Infant Growth and Risk of Childhood Adiposity Stettler et al, Ped. 109, 2002. Birthweight Rate of Wt Gain In first 4 mo Prevalence of Overweight at Age 7 Yrs

Barker DJ. TRENDS Endo Metab 13; Nov 2002 Infant Growth Rate and Coronary Disease BMI Weight Height Cohort 0 2 4 6 8 10 12 Age in Years Standard Deviation (Z) Score 0.05 - 0.05 - 0.10 - 0.15 - 0.20 - 0.25 4630 Helsinki boys 357 developed CHD Barker DJ. TRENDS Endo Metab 13; Nov 2002

DEVELOPMENTAL ORIGINS OF Infant Undernutrition 0-1 yr HEALTH & DISEASE In Utero Birth Childhood Adulthood Low Birthweight/IUGR Fetal Undernutrition “Metabolic Syndrome” Abd’l Obesity HTN CAD Diabetes  TG/ HDL Renal Failure Accelerated Growth + Infant Undernutrition 0-1 yr Food: Access Palatability Inter-Generational Transmission

Epigenetics Epigenetics = the study of stable alterations in gene expression that arise during development and cell proliferation Epigenetic phenomena do NOT change the actual, primary genetic sequence Epigenetic phenomena are important because, together with promotor sequences and transcription factors, they modulate when and at what level genes are expressed The protein context of a cell can be understood as an epigenetic phenomena. Examples include: DNA methylation, histone hypo-acetylation, chromatin modifications, X-inactivation, and imprinting. http://cnx.rice.edu/content/m11532/latest/

Examples of the impact of this inheritance: Epigenetic mechanisms for nutrition determinants of later health outcomes. (Zeisel, Am J Clin Nutr, 2009) “epigenetic code is a series of marks added to DNA or to proteins (histones) around which DNA is wrapped.” Methylation, covalent modifications of histones and chromatin and RNA Some “marks” can be inherited Examples of the impact of this inheritance: Grandmother’s smoking in pregnancy & risk of asthma in grandchildren Brains from suicide victims, methylation of 5’ regulatory region of genes encoding ribosomal RNA associated with early childhood abuse & neglect

FIGURE 1 Epigenetic marks alter gene expression Zeisel, S. H Am J Clin Nutr 2009;89:1488S-1493S Copyright ©2009 The American Society for Nutrition

Fig. 2. General example of epigenetic regulation of gene transcription General example of epigenetic regulation of gene transcription. Epigenetic regulation of gene expression is characterized by stable changes to DNA and chromatin structure that alter gene expression independent of gene sequence. The primary forms of epigenetic control involve DNA methylation by DNA methyl-transferase (DNMTs), and histone tail modifications, such as acetylation/deacetylation, by histone acetyl-transferase (HAT) and histone deacetylase (HDAC) activities, respectively. Additionally, microRNAs have recently been shown to regulate DNA methylation as well. Histone tail acetylation promotes an open-chromatin conformation, and is associated with regions of active gene expression, while histone tail deacetylation promotes a closed-chromatin conformation and is associated with gene silencing. DNA methylation of cytosine guanine (CpG) dinucleotides in the 5' promoter region of genes generally induces transcriptional silencing, both by blocking transcription factor binding and by promoting the recruitment of transcriptional corepressors or histone-modifying complexes. MeBP, methyl-CpG binding protein; TF, transcription factor; Pol II, DNA polymerase II. Heerwagen, M. J. R. et al. Am J Physiol Regul Integr Comp Physiol 299: R711-R722 2010; Copyright ©2010 American Physiological Society

DNA methylation differences after exposure to prenatal famine are common and timing- and sex-specific. Tobi et al, Hum Mol Genet. 2009 Nov 1;18(21):4046-53 Methylation of INSIGF was lower among individuals who were periconceptionally exposed to the famine (n = 60) compared with their unexposed same-sex siblings Methylation of IL10, LEP, ABCA1, GNASAS and MEG3 was higher “persistent changes in DNA methylation may be a common consequence of prenatal famine”

Are Nutrition-Induced Epigenetic Changes the Link Between Socioeconomic Pathology and Cardiovascular Diseases? Lopez-Jaramillo et al. Am J Ther. 2008 Jul-Aug;15(4):362-72.

Are Nutrition-Induced Epigenetic Changes the Link Between Socioeconomic Pathology and Cardiovascular Diseases? Lopez-Jaramillo et al. Am J Ther. 2008 Jul-Aug;15(4):362-72.

Early Risk Determinants and Later Health Outcomes: Research Priorities (Field, Am J Clin Nutr, 2009) ID biological mechanisms responsible for lasting and later health effects ID genes; research on genomics, metabolomics and epigenetics Understand imbalanced nutrition; focus on overnutrition during critical periods Understand social/environmental factors that influence critical windows ID how and when to intervene to prevent later disease