Interactions between early and later factors throughout the life course

Low birth weight, followed by subsequent adult obesity, has been shown to impart a particularly high risk of CHD (120,121), as well as diabetes (18). Risk of impaired glucose tolerance has been found to be highest in those who had low birth weight, but who subsequently became obese as adults (18). Anumber of recent studies (12,13,25,59-61,120) have demonstrated that there is an increased risk of adult disease when IUGR is followed by rapid catch-up growth in weight and height. Conversely, there is also fairly consistent evidence of higher risk of CHD, stroke, and probably adult onset diabetes with shorter stature (122,123). Further research is needed to define optimal growth in infancy in terms of prevention of chronic disease. A WHO multicentre growth reference study (124) currently under way may serve to generate much needed information on this matter.

4.3.1 Clustering of risk factors

Impaired glucose tolerance and an adverse lipid profile are seen as early as childhood and adolescence, where they typically appear clustered together with higher blood pressure and relate strongly to obesity, in particular central obesity (76, 78, 125, 126). Raised blood pressure, impaired glucose tolerance and dyslipidaemia also tend to be clustered in children and adolescents with unhealthy lifestyles and diets, such as those with excessive intakes of saturated fats, cholesterol and salt, and inadequate intake of fibre. Lack of exercise and increased television viewing add to the risk (10). In older children and adolescents, habitual alcohol and tobacco use also contribute to raised blood pressure and to the development of other risk factors in early adulthood. Many of the same factors continue to act throughout the life course. Such clustering represents an opportunity to address more than one risk at a time. The clustering of health-related behaviours is also a well described phenomenon (127).

4.3.2 Intergenerational effects

Young girls who grow poorly become stunted women and are more likely to give birth to low-birth-weight babies who are then likely to continue the cycle by being stunted in adulthood, and so on (128). Maternal birth size is a significant predictor of a child's birth size after controlling for gestational age, sex of the child, socioeconomic status, and maternal age, height and pre-pregnant weight (129). There are clear indications of intergenerational factors in obesity, such as parental obesity, maternal gestational diabetes and maternal birth weight. Low maternal birth weight is associated with higher blood pressure levels in the offspring, independent of the relation between the offspring's own birth weight and blood pressure (7). Unhealthy lifestyles can also have a direct effect on the health of the next generation, for example, smoking during pregnancy (9,130).

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