Intergenerational Nutritional Effects & Developmental Origins of Health and Disease 2012.

Intergenerational Nutritional Effects

& Developmental Origins of Health

and Disease

2012

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. 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 StudyCoutinho 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

Black White

Mean infant birthweight

3139 g 3434

Mean parental birthweight

3133 3377

% low birthweight infants

12% 5%

% lbw born to women with lbw

18% 9%

% lbw born to women not lbw

11% 5%

Results

• Father’s birthweight had effect on infant birthweight but not as strong as mothers.

• Each 100 g increase in maternal birthweight was associated with 24-27 g increase in infant birthweight

Dutch Famine StudiesSusser 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

Other Impacts of Famine Exposure

• Excess central nervous system disorders (such as NTD)• Schizophrenia (Hulshoff et al. J Psychiatry. 2000)

– Famine exposure associated with twofold risk of schizophrenia in 50 year old women.

– 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.

• Major Affective Disorder (Brown et al. J Psychiatry, 2000)

– Risk of developing major affective disorder requiring hospitalization increased significantly for subjects with exposure in the third trimester, relative to unexposed subjects.

Survival effects of prenatal famine exposure. Van Abeelen et al. Am J Clin Nutr. 2012

Other Famine Studies • China;1959-1961; FU 2008 (Zheng et al. Eur J Clin

Nutr, 2012)

• Women (n=1924) exposed to famine had higher risk of metabolic syndrome with fetal exposure (OR 1.87, 1.15-3.04) & postnatal exposure (OR 1.50, 1.20-1.87)

• NS for men (n=3116)

• Biafra;1967-1970; FU 2009 (Hult et al. PloS ONE, 2010):

• Fetal/infant exposure associated with increased prevalence of hypertension & obesity, higher waist circumference & blood glucose levels (n=1339)

Intergenerational Impacts 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

Children born to women who themselves were exposed to the famine while they were in utero have increased neonatal adiposity and poor health 1.8 (95% CI 1.1-2.7) times more frequently in later life (due to miscellaneous causes)

Painter et al. BJOG, 2008 Sep;115(10):1243-1249.

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 (Ramakrishnan et al, J Nutr, 1999

• Sample: 215 mothers who were born during the original longitudinal study (1969-1977) and their own offspring.

• 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. (P < 0.001)

– For every centimeter increase in maternal birth length, her child's birth weight increased by 53 g.

Fetal Nutrition and Chronic Diseases of Adulthood

• Epi studies

• Explanatory models

• Mechanisms

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 Age-adjusted Relative Risk of Non- fatal Coronary Heart Disease and StrokeCoronary Heart Disease and Stroke

121,700 American Nurses, self report study121,700 American Nurses, self report study BMJ 315:396,1997BMJ 315:396,1997

5.0 7.5 10.00.50

0.75

1.00

1.25

1.50

Birthweight

Rel

ativ

e R

isk

Mean ± 95% CL

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: longitudinalstudy (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 MenDiabetes in Low-Birth-Weight Men

Hales et al. BMJ 303: 1019, 1991Hales et al. BMJ 303: 1019, 1991

Birth Weight (lbs)

% I

mp

aire

d G

luc

To

l o

r D

M

<5.5 6.5 7.5 8.5 9.5 >9.5

40

30

20

10

0

370 menAge 64 yrs

Od

ds R

atio/A

dj fo

r BM

I

8

6

4

2

0

Gestat’l DM

Birth Weight (gm)<2500 -2999 -3499 -3999 -4499 >4500

130

128

126

124

122

Sys

BP (

mm

Hg)

Birth Weight Predicts Blood Pressure at Age 31Birth Weight Predicts Blood Pressure at Age 31

1966 Northern Finland Birth Cohort1966 Northern Finland Birth Cohort

+/- adjust for current BMI

Jarvelin M et al. Hypertension 2004

Variables:

Birth WeightPonderal IndexSexGestational ageMat’l Ht, WtParitySocioeconomicCurrent BMI

n = 5960 offspring

Birthweight and Adult HTN in US WomenBirthweight and Adult HTN in US Women

Nurses Health Study INurses Health Study I

Birthweight Category (lbs)

< 5.0 5.0-5.5 5.6-7.0 7.1-8.5 8.6-10.0< 5.0 5.0-5.5 5.6-7.0 7.1-8.5 8.6-10.0

HT

N P

reva

len

ce (

%) 4040

3030

1515

10 10

Age 46-71

8.4%

AgeAge 30-5530-55

3.1%

Early Growth Patterns Predict Adult HTNEarly Growth Patterns Predict Adult HTN

Barker et al. J HTN 20:1951, 2002.Barker et al. J HTN 20:1951, 2002.

Growth Patterns in 1404 Childrenwho later developed Hypertension

0 2 4 6 8 10 12 14-0.2

-0.1

0.0

0.1

0.2

BMIWeightHeight

_______________________________

Age (Yrs)

Z S

core

CohortAverage(n=8760)

}

Fetal Milieu Affects Obesity RiskFetal Milieu Affects Obesity Risk

<2.52.5-3.0

3.0-3.53.5-4.0

>4.03-D Column 1

0

0.5

1

1.5

2

2.5

3-DColumn 1

Birth Weight (kg)

Odds RatioFor

Obesity

Eriksson J et al Internatl J Obesity 2001Eriksson J et al Internatl J Obesity 2001

Trouble at Both Ends of the Birth Weight SpectrumTrouble at Both Ends of the Birth Weight Spectrum

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.

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.

Barker DJP. The origins of the developmental origins theory. J Intern Med. 2007.

Fetal Origins ConceptsBarker 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 HypothesisThe Barker Hypothesis

Adverse intrauterine events Adverse intrauterine events permanently “program” postnatalpermanently “program” postnatal

structure/function/homeostasisstructure/function/homeostasis

FetalFetal Origins of Origins of AdultAdult Disease Disease

** Better chance of fetal survivalBetter chance of fetal survival** Increased risk of adult diseaseIncreased risk of adult disease

““Adapted Birth PhenotypeAdapted Birth Phenotype””

Susan P. Bagby, MD, Professor of Medicine & Physiology/PharmacologySusan P. Bagby, MD, Professor of Medicine & Physiology/PharmacologyDivision of Nephrology & Hypertension OHSU, Portland, ORDivision of Nephrology & Hypertension OHSU, Portland, OR

FETAL ORIGINS OF ADULT CVASC DISEASEFETAL ORIGINS OF ADULT CVASC DISEASE

MODIFIERS

COFACTORS

Low Birthweight/IUGR

Adverse Intrauterine Events

Adult “Metabolic Syndrome”

Abd’l Obesity HTN

CADDiabetes

TG/ HDLRenal Failure

In UteroIn Utero

BirthBirth

ChildhoodChildhood

AdulthoodAdulthood

Proposed Mechanisms of Early Programming

• Permanent structural changes

• Epigenetic programming of gene expression

• Accelerated cellular aging

Tarry-Adkins & Ozanne. Mechanisms of early life programming: current knowledge and future directions. Am J Clin Nutr. 2011.

Asymmetric Growth RestrictionAsymmetric Growth Restriction

Adverse Intrauterine Events

* 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 Fetal Origins of Adult DiseaseDisease

Asymmetric Growth RestrictionAsymmetric Growth Restriction

From Barker, 1998

““More powerful predictor than other risk factorsMore powerful predictor than other risk factors””

* ThinThin

* Small abdominalSmall abdominal girth ( liver size)girth ( liver size)

* Low arm cir-Low arm cir- cumference cumference ( muscle mass)( muscle mass)

* Preserved central fat masscentral fat mass

? % Growth-Restricted Phenotype in Lower ? % Growth-Restricted Phenotype in Lower Birth Weight CategoriesBirth Weight Categories

<5 5.0-5.5 5.5-6.0 6.0-6.5 6.5-7.0 7.0-7.5 >7.50

5

10

15

20

25

30

35% Term Births

BirthWeight Category (lbs)

% o

f T

erm

Bir

ths

Growth-Restricted Phenotype

Conceptual Graph

Potential Mechanisms ofPotential Mechanisms ofDevelopmental ProgrammingDevelopmental Programming

KidneyKidney Nephron # HTN

Pancreas Pancreas Islet Cell # Insulin secretion Glucose

Muscle Muscle muscle mass Basal met rate Exercise capacity

Heart myocyte # Risk CHF

Liver cells # ? lipid metabolism

Structural Deficits Structural Deficits Reduced ReducedFunctional Units in OrgansFunctional Units in Organs

Low Birth Wt, Low Nephron Number and HTN

Brenner et al. 1988,1994Brenner et al. 1988,1994

What Conveys Risk of HTN inWhat Conveys Risk of HTN inLower Birth-weight Offspring ?Lower Birth-weight Offspring ?

“… “… retardation of renal development as occursretardation of renal development as occursin individuals of low birth weight gives rise to in individuals of low birth weight gives rise to increased postnatal risks for systemic and increased postnatal risks for systemic and glomerular hypertension as well as enhanced risk glomerular hypertension as well as enhanced risk of expression of renal disease.”of expression of renal disease.”22

11Am J HTN 1988 1:335-47; Am J HTN 1988 1:335-47; 22Am J Kid Dis 1994 23: 171 Am J Kid Dis 1994 23: 171

Branching Morphogenesis Nephrogenesis

New Nephrons Form in Concentric Layers New Nephrons Form in Concentric Layers during Gestationduring Gestation

Condensing MesenchymeComma Shaped Bodies

Outer Nephrogenic Layer

Glomeruli

Birth WeightBirth WeightPredicts Predicts

Nephron NumberNephron Number

230,000 nephrons230,000 nephronsper kg increaseper kg increasein birth weightin birth weight

In Term Births:Ages 1-17 yrs

All Ages

 Hughson et al,Hughson et al,Kid Internat (2003) 63, 2113 Kid Internat (2003) 63, 2113

Also: Merlet-Benichou et al, 1999 Manalich et al, 2000

FOOD

CATCH-UP GROWTH

BPBP

Asymmetric Growth Restriction in Utero

Maternal Protein Deficiency

Impaired Kidney Development

# Nephrons(permanent)

“The Thrifty Phenotype”

BODY MASS

# Nephrons

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 modulate when and at what level genes are expressed.

• The protein context of a cell can be understood as an epigenetic phenomena.

http://cnx.rice.edu/content/m11532/latest/

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

Copyright ©2009 The American Society for Nutrition

Zeisel, S. H Am J Clin Nutr 2009;89:1488S-1493S

FIGURE 1 Epigenetic marks alter gene expression

Copyright ©2010 American Physiological Society

Heerwagen, M. J. R. et al. Am J Physiol Regul Integr Comp Physiol 299: R711-R722 2010;

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.

Mechanisms Emerging… Sandovici et al. Proc Natl Acad Sci. 2011

• Transcription factor Hnf4a, implicated in the etiology of type 2 diabetes (T2D)

• Transcriptional activity of Hnf4a in islets is restricted to the distal P2 promoter through its open chromatin configuration and an islet-specific interaction between the P2 promoter and a downstream enhancer.

• Exposure to suboptimal nutrition during early development leads to epigenetic silencing at the enhancer region, which weakens the P2 promoter–enhancer interaction and results in a permanent reduction in Hnf4a expression.

• Aging leads to progressive epigenetic silencing of the entire Hnf4a locus in islets, an effect that is more pronounced in rats exposed to a poor maternal diet.

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”

Accelerated Cellular Aging

• Poor maternal nutrition followed by accelerated postnatal growth leads to telomere shortening and increased

markers of cell senescence in rat islets. (Tarry-Adkins, et al.

FASEB J, 2009)

– Shorter telomeres in rats exposed to gestational protein restriction compared to controls.

• Poor maternal nutrition followed by accelerated postnatal growth leads to alterations in DNA damage and repair, oxidative and nitrosative stress, and oxidative defense capacity in rat heart. (Tarry-adkins, et al. FASEB J, 2012)

– “poor fetal nutrition followed by accelerated postnatal growth results in increased cardiac nitrosative and oxidative-stress and DNA damage, which could contribute to age-associated disease risk.”

Developmental programming of type 2 diabetes and cardiovascular disease.

Martin-Gronert M S , Ozanne S E J. Nutr. 2010;140:662-666

©2010 by American Society for Nutrition

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

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.