Elsevier

Social Science & Medicine

Volume 73, Issue 5, September 2011, Pages 711-718
Social Science & Medicine

Early life undernutrition and chronic diseases at older ages: The effects of the Dutch famine on cardiovascular diseases and diabetes

https://doi.org/10.1016/j.socscimed.2011.04.005Get rights and content

Abstract

Nutritional conditions in early life may causally affect health at older ages. This paper examines the effects of early life exposure to the Dutch famine (Winter 1944–45) on the prevalence of heart diseases, peripheral arterial diseases (PAD) and diabetes mellitus (DM) at ages 60–76.

Analyses are performed using data from the fifth cycle of the Longitudinal Aging Study Amsterdam. Exposure to the famine is determined by reported place of residence during the Dutch famine, with those living in the cities in the West of the Netherlands defined as exposed (n = 278) and those living in the rural areas in the West or living in the North or East defined as non-exposed (n = 521). We successively compare the prevalence of heart diseases, PAD and DM at ages 60–76 of 370 males and 429 females exposed and non-exposed to the famine in early life. We distinguish four age classes of exposure in early life: gestation and infancy (ages 0–1), childhood (age 1–5), pre-adolescence (ages 6–10) and adolescence (ages 11–14).

The analysis shows that exposure to severe undernutrition at ages 11–14 is significantly associated with a higher probability of developing DM and/or PAD at ages 60–76. The associations are found only in women, but not in men. If suggests that adolescence may be a critical period with respect to exposure to adverse (nutritional) conditions and that research should take this into account. These findings are relevant for children in developing countries who are exposed to severe nutritional deprivation.

Highlights

► Older females exposed to a famine at ages 11–14 are more likely to have Diabetes. ► Older females exposed to a famine at ages 11–14 are more likely to have PAD. ► Adolescence may be a critical period in the etiology of Diabetes and PAD.

Introduction

Adverse nutritional conditions in utero and during infancy are positively associated with the development of cardiovascular and respiratory diseases, stroke, and diabetes mellitus at older ages (Kuh and Ben-Shlomo, 2004, Newnham and Ross, 2009). These observed relationships may be the result of direct effects as suggested by the Fetal Origins Hypothesis of diseases (Barker, 1992). Barker postulates that exposure to poor nutritional conditions in utero and/or during the first months of postnatal life leads to alterations in the development of vital organs, tissues and/or body systems. These alterations, though likely advantageous for the survival in the short-term, may increase the predisposition to chronic diseases at older ages. Following the theory of Barker (1992), most past research has focussed on the long-term consequences of prenatal exposure to undernutrition (Kuh & Ben-Shlomo, 2004). For that reason, evidence is scarce on the effects of nutritional conditions during infancy, childhood, pre-adolescence and adolescence on chronic diseases at older ages.

This study addresses the long-term effects of undernutrition during pregnancy and until 14 on the prevalence of cardiovascular diseases and diabetes mellitus (DM). The exposure to undernutrition is determined by the place of residence during the severe famine that parts of the Netherlands faced during the winter 1944–45 at the end of World War II. The study distinguishes two types of cardiovascular diseases: heart diseases and peripheral arterial diseases (PAD). Cardiovascular diseases are currently the leading causes of death and account for 30% of all deaths globally (American Heart Association, 2009). The world prevalence of DM among adults was about 7% in 2009. It is expected to increase by 20% in developed countries and by 69% in developing countries between 2010 and 2030 (Shaw, Sicree, & Zimmet, 2009). The findings of the study will help to understand the etiology of cardiovascular diseases and DM at older ages and might enhance the identification of high-risk groups, for example in developing countries facing severe food restrictions. Prevention programs that aim at reducing the prevalence of cardiovascular diseases and/or DM may then more specifically focus on these high-risk populations.

Section snippets

The Dutch famine

The Dutch famine provides a unique historical context for the study at hand. This is for three main reasons. First, the famine took place during a very well-defined time period, specifically from November 1944 until May 1945, at the end of World War II. In October 1944, the Germans, who occupied the Netherlands, prohibited all transport, including food, to the Western part of the country as a response to a railroad strike initiated by the Dutch government in exile. The food embargo was highly

Cardiovascular diseases

A large number of studies find increased risks of cardiovascular disease at older ages for those with lower birth weight, those with shorter stature or smaller head circumference at birth, and those whose placenta was disproportionally large (e.g. Barker, 1997; Eriksson, Forsen, Tuomilehto, Osmond, & Barker, 2001; Khan and Shearman, 2005, Victora et al., 2008). These studies use birth outcomes as a proxy for the nutritional conditions in utero. However, birth outcomes may depend on unobserved

Dataset and sample

The data for this study are derived from the Longitudinal Aging Study Amsterdam (LASA) (Deeg, van Tilburg, Smit, & de Leeuw, 2002). LASA constitutes a nationally representative cohort of 3107 Dutch older individuals sampled from municipal registries, with oversampling of men and older individuals, followed since 1992. Initial ages at baseline were 55–85 years. The sample was constructed so as to reflect the national distribution of urbanization and population density. All LASA respondents at

Descriptive analysis

Table 1 reports descriptive statistics on all included variables by gender. 81 respondents were in utero or under age 1 during the famine, 293 were aged 1–5 years, 244 were aged 6–10 years, and 181 were aged 11–14 years. 278 respondents were exposed to the Dutch famine and 521 were non-exposed. In 2005–06, 186, 68, and 91 individuals had a heart disease, PAD, and DM, respectively. Table 1 also shows that exposed males have significantly more DM, fewer siblings, have moved significantly less

Discussion

The study shows significant associations between exposure to undernutrition during adolescence and the presence of PAD and DM at ages 60–76 for females. These associations remain after controlling for variations in parental educational level, number of siblings, smoking behavior and waist circumference.

Conclusions

Our study shows significant associations of exposure to famine at adolescent ages for PAD and DM for females. Exposure to severe undernutrition at ages 11–14 is associated with a higher probability of developing DM and/or PAD at ages 60–76 for females. As such, our study suggests that adolescence is a critical period with respect to exposure to adverse (nutritional) conditions and that future research should take this into account. The findings of our study are relevant for example for girls

Acknowledgments

The Longitudinal Aging Study Amsterdam (LASA) is primarily supported by a long-term grant from the Dutch ministry of Health, Welfare and Sports.

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