Objective: To briefly review the current understanding of the aetiology and prevention of chronic diseases using a life course approach, demonstrating the lifelong influences on the development of disease. Design: A computer search of the relevant literature was done using Medline-‘life cycle’ and ‘nutrition’ and reviewing the articles for relevance in addressing the above objective. Articles from references dated before 1990 were followed up separately. A subsequent search using Clio updated the search and extended it by using ‘life cycle’, ‘nutrition’ and ‘noncommunicable disease’ (NCD), and ‘life course’. Several published and unpublished WHO reports were key in developing the background and arguments. Setting: International and national public health and nutrition policy development in light of the global epidemic in chronic diseases, and the continuing nutrition, demographic and epidemiological transitions happening in an increasingly globalized world. Results of review: There is a global epidemic of increasing obesity, diabetes and other chronic NCDs, especially in developing and transitional economies, and in the less affluent within these, and in the developed countries. At the same time, there has been an increase in communities and households that have coincident under- and over-nutrition. Conclusions: The epidemic will continue to increase and is due to a lifetime of exposures and influences. Genetic predisposition plays an unspecified role, and with programming during fetal life for adult disease contributing to an unknown degree. A global rise in obesity levels is contributing to a particular epidemic of type 2 diabetes as well as other NCDs. Prevention will be the most cost-effective and feasible approach for many countries and should involve three mutually reinforcing strategies throughout life, starting in the antenatal period.

/pdf/a-life-course-approach-to-diet-nutrition-and-the-prevention-1smoo3dz1o.pdf

A life course approach to diet, nutrition and the prevention of chronic diseases.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(07)61693-6.pdf

What works? Interventions for maternal and child undernutrition and survival.

Over the past three decades, the number of people with diabetes mellitus has more than doubled globally, making it one of the most important public health challenges to all nations. Type 2 diabetes mellitus (T2DM) and prediabetes are increasingly observed among children, adolescents and younger adults. The causes of the epidemic of T2DM are embedded in a very complex group of genetic and epigenetic systems interacting within an equally complex societal framework that determines behavior and environmental influences. This complexity is reflected in the diverse topics discussed in this Review. In the past few years considerable emphasis has been placed on the effect of the intrauterine environment in the epidemic of T2DM, particularly in the early onset of T2DM and obesity. Prevention of T2DM is a 'whole-of-life' task and requires an integrated approach operating from the origin of the disease. Future research is necessary to better understand the potential role of remaining factors, such as genetic predisposition and maternal environment, to help shape prevention programs. The potential effect on global diabetes surveillance of using HbA(1c) rather than glucose values in the diagnosis of T2DM is also discussed.

The worldwide epidemiology of type 2 diabetes mellitus--present and future perspectives

The "fetal" or "early" origins of adult disease hypothesis was originally put forward by David Barker and colleagues and stated that environmental factors, particularly nutrition, act in early life to program the risks for adverse health outcomes in adult life. This hypothesis has been supported by a worldwide series of epidemiological studies that have provided evidence for the association between the perturbation of the early nutritional environment and the major risk factors (hypertension, insulin resistance, and obesity) for cardiovascular disease, diabetes, and the metabolic syndrome in adult life. It is also clear from experimental studies that a range of molecular, cellular, metabolic, neuroendocrine, and physiological adaptations to changes in the early nutritional environment result in a permanent alteration of the developmental pattern of cellular proliferation and differentiation in key tissue and organ systems that result in pathological consequences in adult life. This review focuses on those experimental studies that have investigated the critical windows during which perturbations of the intrauterine environment have major effects, the nature of the epigenetic, structural, and functional adaptive responses which result in a permanent programming of cardiovascular and metabolic function, and the role of the interaction between the pre- and postnatal environment in determining final health outcomes.

https://www.physiology.org/doi/pdf/10.1152/physrev.00053.2003

Developmental Origins of the Metabolic Syndrome: Prediction, Plasticity, and Programming

Copper toxicity, oxidative stress, and antioxidant nutrients.

We have studied 477 8-year-old Indian children to define the relationship between birth weight and cardiovascular risk factors, including insulin resistance syndrome (IRS) variables and plasma total and LDL cholesterol concentrations. All risk factors were strongly related to current weight. After adjustment for current weight, age, and sex, lower birth weight was associated with higher systolic blood pressure (P = 0.008), fasting plasma insulin and 32-33 split proinsulin concentrations (P = 0.08 and 0.02), glucose and insulin concentrations 30 min postglucose (P = 0.06 and 0.04), subscapular/triceps skinfold ratio (P = 0.003), and plasma total and LDL cholesterol concentrations (P = 0.002 and 0.001). Lower birth weight was associated with increased calculated insulin resistance (homeostasis model assessment [HOMA], P = 0.03), but was not related to the HOMA index of beta-cell function. The highest levels of IRS variables and total and LDL cholesterol were in children of low birth weight but high fat mass at 8 years. Taller height at 8 years predicted higher fasting plasma insulin concentrations, insulin resistance, and plasma total and LDL cholesterol concentrations. The most insulin-resistant children were those who had short parents but had themselves grown tall. Although the implications of our findings in relation to height are unclear, interventions to improve fetal growth and to control obesity in childhood are likely to be important factors in the prevention of cardiovascular disease and IRS in India.

Insulin resistance syndrome in 8-year-old Indian children: small at birth, big at 8 years, or both?

Considerable clinical and experimental evidence now supports the idea that deficiencies or imbalances in certain highly unsaturated fatty acids may contribute to a range of common developmental disorders including Attention Deficit Hyperactivity Disorder (ADHD) Few intervention studies with LCPUFA supplementation have reported inconsistent and marginal results This pilot study evaluates the effect of alpha linolenic acid (ALA)-rich nutritional supplementation in the form of flax oil and antioxidant emulsion on blood fatty acids composition and behavior in children with ADHD Post-supplementation levels of RBC membrane fatty acids were significantly higher than pretreatment levels as well as the levels in control There was significant improvement in the symptoms of ADHD reflected by reduction in total hyperactivity scores of ADHD children derived from ADHD rating scale

Supplementation with flax oil and vitamin C improves the outcome of Attention Deficit Hyperactivity Disorder (ADHD)

INDIAN PEDIATRICS 559 VOLUME 41JUNE 17, 2004 IAP National Task Force for Childhood Prevention of Adult Diseases: Childhood Obesity 6.1 Primary prevention of childhood obesity: Public Health Approach 6.2 Do interventions work ? 6.3 Strategies and Aims 6.4 Special strategies for target groups 6.5 Channels of intervention 7. Management of established obesity 7.1 Approach to assessment 7.2 Approach to therapy 7.3 Principles of therapy 7.4 Intensive therapy 8. Key Messages 9. References 10. Annexures

IAP National Task Force for Childhood Prevention of Adult Diseases: Childhood Obesity.

Objective: To estimate frequency of acute bacterial meningitis (ABM) in early childhood in hospital admissions, to describe clinical and diagnostic features, and to analyze mortality, complications and long term sequelae. Design: Prospective study. Setting: Pediatric wards and Rehabilitation Center of KEM Hospital, Pune. Method: Study subjects between the ages of I months to 5 years with ABM were recruited. Clinical details were recorded. CSF was analysed by routine biochemical methods, antigen detection tests (Latex agglutination LAT) and microbiological studies on special media. Management was as per standard protocols. Survivors were followed up long term with neurodevelopmental studies and rehabilitation programmes. Results: In a study period of 2 years, 54 children (1.5% of all admissions) satisfied the criteria of ABM in early childhood; 78% were below one year and 52% were under the age of six months. Chief presentation was high fever, refusal of feeds, altered sensorium and seixures. Meningent signs were present in only 26%. CSF C-reactive protein was positive in 41%, gram stain was positive in 67%, LAT in 78% and cultures grew causative organisms in 50% of the cases. The final etiological diagnosis (as per LAT and/or cultures) were Streptococcus pneumoniae 39%, Hemophilus influenzae type b 26% and others in 35%. The others included one case of Neisseria meningitidis and 10 who were LAT negative and culture sterile. 39% patients developed acute neurological complications during the hospital course. 31% children with ABM died in hospital or at home soon after discharge. Six were lost to follow up. Of the 31 children, available for long term follow up (1-3 years), 14 (45%) had no sequelae. The remaining had significant neurodevelopmental handicaps ranging from isolated hearing loss to severe mental retardation with multiple disabilities. Conclusion: ABM in early childhood has a considerable mortality, morbidity and serious long term sequelae. Neurodevelopmental follow up and therapy should begin early. Etiological diagnosis can be enhanced by LAT and good culture media. H. influenzae b and S. pneumoniae account for more than 60% of ABM in early childhood.

Diagnosis and outcome of acute bacterial meningitis in early childhood.

Iron supplementation programs using pediatric tablets or drops have not been successful in the control of anemia amongst infants and children in India Sprinkles is an innovative multi-micronutrient home fortification strategy to control iron deficiency and anemia Objective We aimed to determine the hematologic response to different doses and forms of iron in Sprinkles and iron drops Setting Twenty two villages of Vadu Rural Health Program, KEM Hospital, Pune Design Double blind clustered randomized community-based trial Subjects Children (n=432) aged 6 to 18 mo age with Hb between 70 to 100 g/L were enrolled Methods Selected villages were randomized into 5 groups: Sprinkles 125, 20 or 30 mg ferrous fumarate, Sprinkles 20 mg micronized ferric pyrophosphate or drops 20 mg ferrous glycine sulphate (DROPS) for 8 weeks Household socio-demographic information was collected at baseline Side effects and compliance were monitored through weekly visits Hemoglobin was estimated at baseline, 3 and 8 weeks Ferritin was assessed at baseline and 8 weeks Results Baseline characteristics were similar across all groups Hemoglobin increased significantly (P 005) Conclusions Sprinkles 125 mg FF dose is as efficacious as higher doses of iron in Sprinkles or DROPS in increasing hemoglobin Sprinkles FF 125 mg is recommended as it has fewer reported side effects and better compliance compared to DROPS

Sheila Bhave

Papers

Insulin resistance syndrome in 8-year-old Indian children: small at birth, big at 8 years, or both?

Supplementation with flax oil and vitamin C improves the outcome of Attention Deficit Hyperactivity Disorder (ADHD)

IAP National Task Force for Childhood Prevention of Adult Diseases: Childhood Obesity.

Diagnosis and outcome of acute bacterial meningitis in early childhood.

Low dose 'Sprinkles'-- an innovative approach to treat iron deficiency anemia in infants and young children.