THE FIFTH ANNUAL INDIAN WORKHOP ON THE FETAL ORIGINS OF ADULT DISEASE
Item
- Title
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THE FIFTH ANNUAL INDIAN
WORKHOP ON THE FETAL
ORIGINS OF ADULT DISEASE - extracted text
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I
INDIA
.
■ v‘^sbto^BkSH
a
THE FIFTH ANNUAL INDIAN
WORKHOP ON THE FETAL
ORIGINS OF ADULT DISEASE
Goa, India
September 10th-13th 1998
Supported by:
SNEHA, India
The Medical Research Council, UK
The Wellcome Trust, London
The Department for International Development, UK
Contents:
page
Participants
Programme
Abstracts
Summary of proceedings
Important news
2-3
4-5
6-20
21-34
35
1
Participants
PARTICIPANTS
Dr Vasant Athavale
Retired Prof and Head, Paediatric Department, Sion Hospital, Mumbai. Present Consultant Paediatrician and
Vaidyacharya.
Dr B Antonisamy
Reader, Department of Biostatistics, Christian Medical College, Vellore
Dr David JP Barker
Director, MRC Environmental Epidemiology Unit, Southampton General Hospital, Southampton, UK.
Dr Ashish R Bavdekar
Senior Research Associate, Department of Paediatrics, KEM Hospital, Pune.
Dr Sheila Bhave
Associate Consultant in Paediatric Research, KEM Hospital, Pune.
Dr Debabrata Chatterjee
Professor of Paediatrics, Vivekananda Institute of Medical Sciences, Calcutta.
Dr Manoj C Chinchwadkar
Senior Research Associate, Department of Ultrasonography, KEM Hospital, Pune.
Ms Ginny Chorghade
MRC Research Fellow, CSSC, MN Roy Memorial Campus, Mumbai.
Dr Kurus J Coyaji
Director, Department of Obstetrics and Gynaecology, KEM Hospital, Pune.
Dr Caroline HD Fall
Paediatric Epidemiologist, MRC Environmental Epidemiology Unit, Southampton General Hospital,
Southampton, UK.
Dr Armida Fernandez
Professor and Head, Division of Neonatology, Department of Paediatrics, LTMG Hospital and LTMG College,
Mumbai.
Dr Jacqui Hill
MRC Research Fellow, Holdsworth Memorial Hospital, Mysore.
Dr Vijay Joshi
Director of Paediatric Pathology, Hartford Hospital, Hartford, CT 06102-5037, USA.
Ms Sam Kellingray
Statistician, MRC Environmental Epidemiology Unit, Southampton General Hospital, Southampton, UK.
Dr Vaman Khadilkar
Consultant Paediatric Endocrinologist, Joshi Hospital, Pune and Honorary Research Asssociate, KEM Hospital,
Pune.
Dr Arun S Kinare
Head, Department of Ultrasonography, KEM Hospital, Pune.
2
Participants
Dr GV Krishnaveni
Medical Officer, MRC Unit, Holdsworth Memorial Hospital, Mysore.
Dr K Kumaran
Research Fellow, MRC Unit, Holdsworth Memorial Hospital, Mysore.
Dr Lakshmi Lingam
Reader, Women’s Studies Unit, Tata Institute of Social Sciences, Mumbai.
Dr Leni Mathew
Lecturer, Department of Paediatrics, Christian Medical College, Vellore.
Dr Jayshree Mondkar
Associate Professor of Neonatology, LTMG Hospital and LTMG College, Mumbai.
Dr Anand N Pandit
Honorary Professor and Director of Paediatrics, KEM Hospital, Pune.
Dr Ramesh Potdar
Consultant Paediatrician, Jeevak Hospital, Mumbai.
Dr P Raghupathy
Professor and Head of Paediatrics, Christian Medical College, Vellore.
Dr Leela Raman
Retired Deputy Director, National Institute of Nutrition, Hyderabad.
Dr Shobha Rao
Head, Department of Biometry, Agharkar Research Institute, Pune.
Dr J Richard
Professor and Head of Biostatistics, Christian Medical College, Vellore.
Dr HPS Sachdev
Professor of Paediatrics and Chief, Division of Clinical Epidemiology, Maulana Azad Medical College, New
Delhi.
Ms Sabita Saldanha
Research Assistant and Co-ordinator, MRC Unit, CSSC, MN Roy Memorial Campus, Mumbai.
Dr Sudha Sane
Retired Professor of Paediatric Pathology, GS Medical College and KEM Hospital, Mumbai.
Dr Usha Shrivastava
Consultant in Public Health, Network for Child Development, New Delhi.
Dr SR Veena
Medical Officer, MRC Unit, Holdsworth Memorial Hospital, Mysore.
Dr CS Yajnik
Director, Diabetes Unit, KEM Hospital, Pune.
3
Programme
PROGRAMME
THURSDAY 10th SEPTEMBER
1730-19.00
SNEHA ACM (Members only)
Chairman: Dr Anand Pandit
19.00-20.00
CELEBRA TIONS ON THE BIRTH OFSNEHA
Compered by Dr Ramesh Potdar
FRIDAY 11th SEPTEMBER
Scientific Session 1
INTRA UTERINE GROWTH
Chairman: Dr Armida Fernandes
08.45-09.05
Opening words and introductions
09.05-0935
Where we are in 1998
09.35-10.05
The ‘Thrifty Phenotype’ Defined
10.05-10.25
The GLV Story
10.25-10.45
COFFEE
10.45-1130
Guest speaker: Dr Vijay Joshi
Dr Ramesh Potdar
Dr Caroline Fall
Dr CS Yajnik and Dr Kurus Coyaji
Dr Shobha Rao
Placental pathology in IUGR
11.30-11.50
Intra-uterine growth of rural Indian babies - fetal ultrasound
Dr Manoj Chinchwadkar
11.50-12.10
Intra-uterine growth of rural Indian babies - size at birth
12.10-1230
The Mysore Two-Generation Study
12.30-13.00
Low birthweight in South Asia
12.50-14.00
LUNCH
FRIDAY 11th SEPTEMBER
Scientific session 2
Dr Vaman Khadilkar
Dr SR Veena and Dr K Kumaran
Dr HPS Sachdev
CARDIOVASCULAR DISEASE AND RISK FACTORS
Chairman: Dr J Richard
14.00-14.30
Metabolic and cardiovascular correlates of low birthweight in children
Dr Ashish Bavdekar
15.00-15.20
Coronary risk factors - what does the man in the street know? Dr Usha Shrivastava
4
Programme
15.20-15.40
Neonatal autopsy studies
15.40-16.10
TEA
16.10-16.50
The Helsinki Study - a vision of India in the future?
16.50-17.35
Guest speaker: Dr Vasant Athavale
Dr Sudha Sane
Dr David Barker
Effects of intra-uterine growth on adult health - an Ayurvedic view
SATURDAY 12th SEPTEMBER
Scientific session 3
FOCUS ON WOMEN AND MOTHERS
Chairman: Dr P Raghupathy
Dr J Richard
09.00-09.25
Birthweight and age at menarche
09.25-09.45
Recurrence of low birthweight in successive pregnancies
09.45-10.05
Low birthweight in Bengali mothers
10.05-10.20
Trace elements and fetal growth
Dr Armida Fernandes
10.20-10.35
Maternal and placental determinants of fetal growth
Dr Jayshree Mondkar
10.35-10.55
Cord blood data from the Pune urban study
10.55-11.30
COFFEE and PHOTO SESSION
11.30-11.50
Guest speaker: Dr Lakshmi Lingam
Dr B Antonisamy
Dr Debabrata Chatterjee
DrCSYajnik
Women, education and health
11.50-12.10
Cultural influences on the nutrition of girls and women
Ginny Chorghade
12.10-12.30
Mothers and babies in Beijing
Dr David Barker
12.30
LUNCH
SUNDAY 13th SEPTEMBER
Scientific session 4
FINALE: MOTHERS, BABIES AND ADULT DISEASE
THREE KEY INDIAN STUDIES IN GESTATION
09.00-09.20
09.20-09.40
09.40-10.00
10.00-10.20
10.20-10.30
Chairman: Dr CS Yajnik
Dr Jacqui Hill
Dr Arun Kinare
Dr Caroline Fall
The Mysore Parthenon Study
Cardiac development in utero
Finlindia - the Delhi/Vellore studies
COFFEE
The Mumbai Office - New environment and how can it help you?
Sabita Saldanha
10.30-11.00
Open Discussion: ‘Where should our research go from here?’
Dr Ramesh Potdar
5
Abstracts
ABSTRACTS
1. INTRAUTERINE GROWTH OF RURAL INDIAN BABIES “ THE THRIFTY PHENOTYPE”
DEFINED
CSYajnik
Reduced fetal growth (reflected in small size at birth) is associated with an increased risk of adult coronary heart
disease (CHD) and type 2 diabetes. This has important implications for India, where 30% of babies have low
birth weight and rates of CHD and diabetes are rising. To develop interventions to improve fetal growth, a better
understanding of its relationship to maternal nutrition is required.
Methods Detailed anthropometry was carried out before and during pregnancy in a population sample (n=633)
of Indian women, and their newborn babies.
Results The mean weight, height and body mass index of the mothers were 42 kg, 1.52m, and 18kg/m2. Full
term birth weight was 2.7kg. Compared with UK babies, the Indian babies were small in all dimensions; the
deficit was greatest for non-fat soft tissue (mid-upper-arm 83% and abdomen 85%), while subcutaneous fat
(skinfold thickness 93%), head (94%) and length growth (95%) were relatively spared. Maternal head
circumference predicted all birth measurements. Maternal height and pre-pregnant fat mass predicted neonatal
length and skinfold thickness respectively, but the fattest babies were born to short fat mothers. Non-fat weight
gain during pregnancy was a significant predictor of birth size.
Conclusions The thin babies born to small Indian mothers have a substantial soft tissue deficit. Of the soft
tissues, in utero adaptations favour deposition of fat. Optimal fetal growth requires that mothers be well-nourished
throughout infancy, childhood and puberty, reflected in good head and height growth. Mothers in nutritional
transition (short but fat)j>roduce short fat babies. The propensity of Indian babies to lay down fat at the cost of
muscle may underlie adult insulin, resistance, diabetes and CHD.
2. THE GLV STORY
Shobha Rao
Earlier studies from India and other developing countries have shown that dietary intakes of rural women are
low and that they do not increase substantially during pregnancy. However, in view of the recent hypothesis by
Barker and his group about the ‘foetal origins of adult diseases’ it has become essential to understand the
maternal-fetal nutritional relationships. The Pune study had accordingly collected dietary intake data through
24-hr recall as well as FFQ. The placental weight showed an almost independent effect on all neonatal
anthropometry. Therefore, factors associated with placental weight were examined and indicated two important
food groups viz. green leafy vegetables and dairy products. The detailed analysis for GLV consumption scores
from FFQ data was therefore attempted. Higher frequency of consumption of GLV at 2St^ wkjwas associated
with higher weight gain between 1 Sth & 28th wk, higher placental weight, higher red cell folate at Visit II,
higher birth weight and also higher skinfold thicknesses of the baby. However, this effect was only seen among
thinnest women (lower tertile of birthweight distribution). Therefore, multiple regression analysis was undertaken
to control all other factors such as pre-pregnant weight, gestation, sex, parity, calorie intake at visit II and activity
score at visit II. The analysis showed that effect of GLV consumption on birth weight remained significant
(P<.01) even after controlling for these factors. It was interesting to observe that impact of GLV consumption
was also seen on neonatal skinfolds after adjusting for above factors. Thus it seemed that increased consumption
of GLV especially among thin mothers was associated with not only increase in birth weight but also with higher
skinfolds at birth. Thus fetuses born to undernourished mothers had tendency for fat deposition. The factors
associated with actual GLV consumption are being investigated.
3. PLACENTAL PATHOLOGY IN INTRAUTERINE GROWTH RETARDATION (IUGR)
Vijay Joshi
Introduction IUGR is usually defined in terms of body weight which is less than 10th percentile for the
gestational age. It is of two types: 1) Symmetrical and 2) Asymmetrical. It appears that in the articles and
chapter on placental pathology of IUGR, the authors mostly concentrate on the placental pathology in the more
common type of asymmetrical IUGR which occurs in the third trimester of pregnancy and is characterized by
normal body length and head size and lack of association with congenital anomalies (I). IUGR can be associated
with three types of factors: A) Maternal, B) Fetal and C) Placental. In some cases, association with any of these
factors cannot be demonstrated The maternal factors include: Cigarette smoking, drug abuse, chronic debilitating
disease, malnutrition, chronic infection (for example, malaria), and pregnancy related disorders (for example.
6
Abstracts
pre-eclampsia). Small size and hypovascularity of the placenta, and increased vascular resistance etc. have been
described in many of these conditions. It should be noted that small size of placenta in IUGR is a reflection of
growth disturbance affecting the conceptus as a whole. Placenta can be looked upon as extracorporeal organ.
Therefore small placenta and small fetus are the result of the same pathologic process and the former is not the
cause of the latter. However, in some cases of IUGR, the placentas may be relatively large. The combination of
IUGR and large placenta may have an accentuated affect on the degree of hypertension developing subsequently
in adulthood (1 A). An enigmatic maternal vascular lesion resembling acute atherosis occurring in the absence of
maternal hypertension or pre-eclampsia has been described in rare cases of IUGR (1B). The fetal factors mainly
include intrauterine fetal infections (for example, CMV, Syphilis, toxoplasmosis, etc.) and multiple congenital
anomalies. The placenta shows evidence of infection (villitis) in the former. In congenital anomalies associated
with chromosomal syndromes (for example, trisomy 13,18 or 21), the placenta tends to be small with a high
incidence of single umbilical artery. The villi may show delayed maturation, hypovasularity and migrating
trophoblast cells within the stroma of villi (2). The primary placental lesions associated with IUGR will be
discussed in some detail in this presentation.
Primary placental lesions in IUGR These are related to abnormalities of: A) Membrane insertion, B) Cord
insertion and C) Placental parenchyma.
Membrane insertion These are described as placental extrachorialis (circummarginate and circumvallate placenta)
in which the membranes are inserted a short distance from the edge of the chorionic plate. The circumvallate
placenta is associated with IUGR. It is possible that this type of placenta is inefficient in transfer of nutrients and
gas to and from the fetus (2,3).
Umbilical cord These include velamentous and marginal insertion of the cord, and single umbilical artery.
Compression of the cord resulting in placental hypoperfusion can occur when it is inserted abnormally. Single
umbilical artery may cause increased resistance to blood flow from fetus to placenta and thus may result indirectly
in chronic fetal hypoxia and IUGR.
Placental parenchyma These include circulatory disorders (extensive infarcts, perivillous fibrin deposition,
maternal flow infarct and twin transfusion syndrome), tumors (e.g. large chorangioma or teratoma) and villitis
(infectious and of unknown etiology).
Extensive placental infarction is seen in association with severe pre-eclampsia or severe hypertension, but it can
rarely occur without a demonstrable associated factor. Placenta has a large reserve capacity and involvement of
as much as 30% of otherwise normal placenta by infarction (or other lesions) may not cause placental insufficiency.
The etiology of extensive perivillous fibrin deposition, maternal flow infarct, (which is characterized by perivillous
fibrin deposition at maternal surface) is not known. These lesions interfere with placental perfusion, thus resulting
in IUGR. In twin transfusion syndrome, there are vascular anastamoses between the two placental territories in
a monochorionic twin placenta. The anastamoses are direct (vessel to vessel of the fetal surface) or through
shared lobules, that is, placental artery supplies a placental lobule in its own territory but the blood from that
lobule is drained into the placental vein of the other placental territory. The latter are of greater importance in
twin transfusion. Large chorangiomas can result in hypoperfusion of the placental parenchyma as a result of
shunting of blood through the lesion.
Infectious villitis can be seen in syphilis, toxoplasmosis and CMV infection and in other viral and bacterial
infections (for example, listeriosis). The spread to the placenta is by hematogenous route. In all these instances,
the fetus is also infected via transplacental transmission resulting in IUGR (although hydrops fetalis may also be
seen).
Recently emphasized placental abnormalities The placental lesions associated with maternal and fetal factors
and the primary placental lesions associated with IUGR described above are well known and established. The
more recently emphasized and interesting placental abnormalities in IUGR include: 1) Inadequate placentation,
2) Abnormalities of placental villous structure, 3) Villitis of unknown etiology (VUE), 4) Confined placental
mosaicism (CPM), 5) Placental and umbilical cord vascular changes and 6) Apoptosis in the placental trophoblast.
These lesions are briefly described below.
Inadequate placentation is characterized by inadequate conversion of endometrial and myometrial spiral arteries
into markedly dilated uteroplacental blood vessels due to defective trophoblastic invasion. The etiology of this
defect is not known but maternal immunologic factors have been implicated (3). Abnormalities of terminal villi
7
Abstracts
demonstrated by morphometry, and light andI scanning and transmission electron microscopy include small
diameter with reduced" villous surface, reduced cytotrophoblastic nuclei, increased stroma, reduced number of
capillary loops, increased syncytiotrophoblastic apoptosis and thickened basement membrane (4-6). In villitis of
unknown etiology (VUE), the most characteristic finding is infiltration of villi by lymphomononuclear cells.
VUE can be recurrent. The inflammatory cells in VUE are maternal T lymphocytes (2,3,7,8). This finding
suggests that VUE may be related to immunologic factors; viral infection has also been suggested as an etiologic
factor. Confirmed placental mosaicism (CPM) is characterized by discrepancy between fetal and placental
karyotypes (2,9). The placental chromosomal abnormality involves Trisomy 2,3,8,9,or 16 which is seen in the
trophoblast or villous stroma or both. It has been suggested that CPM may interfere with placental function and
fetal growth. In CPM, the placenta does not show any morphologic changes on routine pathologic examination
<2)Doppler studies of the umbilical arterial flow in IUGR have shown that there may be absence or actual reversal
of flow at the end of diastole. Morphometric and semiquantitative histologic assessment of villi and umbilical
cord has shown the following abnormalities: A) Medial hyperplasia and luminal narrowing of blood vessels of
the stem villi, hemorrhagic endovasculitis, hypovascularity of villi and B) Reduced Wharton s jelly, reduced
venous lumen and hypoplasia of arteries in the umbilical cord (10,11). Apoptosis represents programmed cell
death or cell suicide (distinct from necrosis) occurring normally in various normal tissues (particularly during
embryonic development) and tumors. The process is of great importance during the development of organs. It is
characterized by condensation and fragmentation of nuclei due to endonuclease activity. Apoptotic nuclei can be
identified by light and electron microscopy. More specific recognition is made by TUNEL (Terminal
deoxynucleotidyl transferase-mediated deoxyuridine triphosphate - dUTP - nick end labelling). The “nick end “
refers to DNA 3’ - hydroxy groups generated as a result of endonuclease activity. Apoptosis occurs normally in
the placenta. It has been shown that placental apoptosis is increased in IUGR (0.14% in normal controls versus
0.24% apoptotic cells in placentas in pregnancies with IUGR; p<0.01) (5). The authors concluded that increased
apoptosis due to unknown mechanism may play a role in the pathogenesis of IUGR.
References:
1. Brar,HS et al: Sem Perinatal 1988; 12:2
I A. Barker, DJP et al: Brit Med J 1990; 301:259.
IB. DeWolf, F et al: Brit J Obstet Gynecol 1980; 87:678
2. Joshi VV: Handbook of Placental pathology, 1994, Igaku Shein Medical Publishers, New York.
3. Fox, H: Pathology of the Placenta, 1997, W.B. Saunders Co., 2nd Edition, W.B.Saunders Co., Philadelphia.
4. Macara, L et al: Placenta 1996; 17:37.
5. Smith, SC et al: Am J Obstet Gynecol 1997; 177:1395.
6. Robinson, JS, Owens, J: In the Human Placenta, CWG, Sargent IL, Starkey PM (Editors), 1993, Blackwell Scientific
Publications, London, pp 558-578.
7. Redline RW et al: Am J Pathol 1993; 143:473.
8. Labarre, CA et al: Am J Obstet Gynecol 1990; 162:515.
9. Kalousek, D: Pediatric Pathol, 1990; 10:69.
10. Salafia, CM et al: Obstet Gynecol 1997; 90:830
11. Bruch, JF et al: Hum Pathol 1997; 28:1139.
ON
4. MID-PREGNANCY
PLACENTAL
DIAMETER,
EASILY
MEASURED
ULTRASOUND,PREDICTS BIRTHWEIGHT AND PLACENTAL WEIGHT AT BIRTH
Manoj Chinchwadkar
Introduction Correlations between mid - pregnancy placental volume (MPPV) and birth weight and placental
weight at birth have been shown (r=0.22,0.25 respectively; p<0.001). Interestingly a number of placentae were
found to be longer than 12.5cm and MPPV could not be measured. This initiated our interest in measuring the
dimensional aspects of the placental morphology contributing to the placental volume.
Subjects and methods 700 women underwent ultrasound examined between 15-21 weeks of gestation for
placental volume recording. In 137 women, two placental diameters and the maximum placental thickness
(MPPT) were also measured at the same time. Of these 114 women delivered live babies between 37-42 weeks
of gestation and were selected for analysis.
Results Longitudinal and transverse placental diameters correlated more strongly with the MPPV (r=0.64,0.60;
p<0.0001) than the thickness (MPPT; r=0.34;p<0.0001) Assuming the round shape of placenta, two diameters
were averaged to calculate mid-pregnancy placental diameter (MPPD). From 15 to 21 weeks, MPPT did not
change significantly; where as MPPD showed a significant correlation with gestation (r=0.37, p<0.0001). The
8
Abstracts
mean MPPT was 2.3 cm (SD 0.6, range 0.8-4.2 cm). After adjusting for gestation the mean MPPD was 10.1cm
(SD1.3, range 6.0-13.0 cm). MPPD showed a significant correlation with the birth weight and placental weight
at birth (r=0.31 for both, p=0.002) while MPPT was not related. Thus, there was gradual increase in the birth
weight with increasing centiles of placental diameter. Women with MPPD below the 10,h centile (Mean=7.7cm,
SD 0.7) had babies weighing 2492 g (SD 231). Women with MPPD above 90th centile (Mean 12.3 cm, SD 0.4)
had babies weighing 2866 g (SD 203).
Comments Measuring placental diameter between 15-21 weeks of gestation is extremely easy to perform
during an ultrasound examination. If the results are proved in a study involving larger numbers, mid-pregnancy
placental diameter (MPPD) would prove valuable in suspecting low birthweight early in gestation and indicate
a close monitoring of fetal biometric growth by subsequent serial ultrasound examinations.
5. GROWTH ANALYSIS OF RURAL MAHARASHTRA FULL TERM BABIES
Vaman Khadilkar
Background Reduced fetal growth is associated with an increased risk of adult type 2 diabetes and coronary
artery disease. The international definition of growth retardation is below 2500 grams full term. The average
birth weight is lower in Indian babies and hence it is inappropriate to use the same definition for our population.
A single cut off point for babies born at different gestation between 37 to 40 weeks is also not logical.
Aims and objectives
1. Define sex specific centile charts for rural Maharashtra babies from 37 to 40 weeks gestational age for
various growth parameters.
2. Compare centiles of rural Maharashtra babies with international centiles.
3. Identify and sub-classify the IUGR population and examine catch-up growth based on international centiles.
4. Examine correlation between Ponderal index and SD scores.
Methods Seven hundred and seventy one babies were measured at the time of delivery for various growth
parameters and every six months thereafter. First delivery took place in Nov 94 and last in Aug 96. Statistical
analysis was performed using SPSSPC+ package.
Results Gestation-specific birth centiles were lower as compared to the international centiles for both sexes,
weight being the lowest. The average weight gain each week from 37 to 40 weeks for boys and girls was 87.5 g.
There was no correlation between Ponderal index and SD scores for birth weight. When only Ponderal index
was used to diagnose IUGR, 83 individuals were recognized as having IUGR whereas only 12 individuals were
truly below - 2SD for birth weight on our own centiles. All 12 babies with birth weight SD scores below -2
caught up at the end of one year in all three parameters studied.
Conclusions
1. Centiles for birth weight in Rural Maharashtra when compared with international centiles were substantially
lower, length and head circumference being relatively spared.
2. It is inappropriate to use a single birth weight cut off value for full term babies (from 37 to 40 weeks
gestation) to define IUGR.
3. Ponderal index has limitations and is insensitive in diagnosing symmetrically retarded babies and when
used as a stand alone criteria gives a high false positive result.
4. We would like to study catch up growth based on international growth centiles.
6. RELATION OF FETAL GROWTH TO CORONARY HEART DISEASE AND ITS RISK FACTORS
IN SOUTH INDIAN ADULTS: AN INTERGENERATIONAL STUDY
SR Veena, K Kumaran, C Fall
Introduction and background Coronary heart disease (CHD) and its risk factors are common in India and the
rates are rising. CHD is also associated with the metabolic profile called “Insulin Resistance Syndrome” which
is common in India. The first Mysore study was conducted to study the relation between fetal growth and CHD
and its risk factors in South Indian adults aged 40-60 years. 517 men and women born in the Holdsworth
Memorial Hospital (HMH) between 1934 and 1953 and whose birth records included weight, length and head
circumference at birth participated. CHD was associated with low birth weight, smaller head circumference and
shorter length at birth. People whose mothers had been lighter during pregnancy also had higher rates of CHD.
The study also found high rates ofNIDDM in those adults who were short and had a high ponderal index at birth
and whose mothers had large pelvic diameters and had been heavier during pregnancy. We concluded that these
associations with maternal size reflected maternal adiposity and proposed that low birth weight women who
become obese are insulin resistant, develop hyperglycaemia in pregnancy and give birth to fat babies who
develop impaired insulin secretion and diabetes in adult life. Evidence from Pune and Southampton found that
9
Abstracts
a woman’s own fetal growth influences the fetal growth of her offspring. We therefore decided to study
glucose/insulin metabolism, lipid profiles and blood pressure in young adults aged 20-40 years old who were
born in HMH and whose mothers’ birth records were also available.
Methods
The HMH has preserved obstetric records from 1934 up to the present and it is possible to trace
families where 2 or more generations were born in the hospital and are still living in and around Mysore. In order
to find sufficient subjects for the second generation, the house to house survey of Mysore city has been extended
to cover an 8 sq. mile area surrounding the hospital. The birth records have been computerised up to 1977. The
team has traced 207 men and women aged 20 years and above who are suitable for the study and whose mothers’
birth records are also available. In most cases their mothers have taken part in the first Mysore study thus enabling
us to include maternal glucose/insulin metabolism in the analysis. The proposed cohort for the study is 250 men
and women between the ages of 20 and 40 years. The subjects are invited to the hospital after an overnight fast
for 12 hours and the following investigations are carried out:
Fasting blood samples, as well as 30 minute and 120 minute blood samples (after 75 grams oral glucose) to
1)
study plasma glucose/insulin metabolism.
2) Blood samples for fasting serum lipid concentrations.
3) Detailed anthropometric measurements.
4) Recording of blood pressure using an automated recorder (DINAMAP)
5) ECG
6) Information on diet, physical activity, occupation, smoking, alcohol intake and socio-economic status, obtained
by questionnaire.
Results The study started in December 1997 and data collection is expected to conclude in early 1999. 117
subjects have taken part so far. Analysis will be carried out in the later part of 1999, and will determine how
mother’s size at birth, body mass index during pregnancy and offspring’s size at birth are related to CHD and
NIDDM in these young adults.
7. ENDOCRINE, METABOLIC AND CARDIOVASCULAR CORRELATES OF LOW BIRTH WEIGHT
IN INDIAN CHILDREN
A Bavdekar, S Bapat, S Bhave, A Pandit, V Nagarkar, C Yajnik, S Kellingray, C Fall.
Methods A study carried out at our hospital 4 years ago in 4 year old children revealed that plasma glucose and
insulin concentrations 30 min after an oral glucose load were higher in children of low birth weight and fell with
increasing birth weight. These children have now been restudied at 8 years to determine if (i) features of syndrome
X are related to birth weight (ii) raised plasma glucose, insulin and IGF-I concentrations found in low birth
weight at 4 years track and persists at 8 years and (iii) children of lower birth weight have increased urinary
excretion of adrenal steroid metabolites and (in girls) polycystic ovaries. Our sampling frame comprised of (i)
children who had taken part in the earlier study and are now 8 years old (n=190) and (ii) additional children
selected from the labour wards during the same time frame as the earlier children (n=287). Children and their
parents were admitted overnight and the following studies were carried out the next day: (a) blood pressure (BP)
of children and parents (b) plasma glucose and insulin of children and parents (c) fasting serum lipids (d) measures
of central fatness (e) ultrasonography of abdomen in children and (f) 24 hr. urinary collection tor steroids.
Results The children ranged in age from 8.05 to 8.88 years (mean 8.47, SD 0.11) 256 boys and 226 girls were
studied. Boys had a higher mean birth weight and greater head circumference than girls at 8 years, while girls had
fatter skinfold thickness. No sex differences were seen in other parameters (like body weight, height and waist
hip ratio serum lipids and blood pressures). Blood pressures measured during sleep were consistently lower than
when the child was awake (p< 0.001). Girls had higher insulin, pro-insulin and split proinsulin than boys.
403 fathers and 461 mothers were also assessed. 98 fathers (24.4%) and 61 mothers (13%) and 8 children (1.7%)
had an abnormal glucose tolerance test (impaired glucose tolerance or diabetes mellitus).
After adjustment for current weight, age and sex, lower birth weight was associated with increased systolic BP
(p=0.008), plasma fasting insulin, pro-insulin and 32-33 split pro-insulin (p=0.07, 0.1 and 0.02), plasma glucose
and insulin concentrations 30 min. post glucose (p=0.06 and 0.02) and fasting serum triglycerides and cholesterol
concentrations (p-0.1 and 0.002). Low birth weight was also associated with increased insulin resistance as
calculate RIR-HOMA, but not with calculated indices of beta cells secretion/function. Lower birth weight was
alsp associated with an increased tendency to deposit fat centrally as measured by the ratio of subscapular^to
triceps skinfold (p=0.003). All insulin resistance variables were strongly related to current weight. There was an
interaction between birthweight and current weight, such that the highest levels of the insulin resistance variables
were seen in children who were with a low birth weight but attained weight at 8 years.
Conclusion Although current weight was more strongly correlated with insulin resistance variable than size at
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birth, our findings suggest that reduced intrauterine growth has a lasting effect on the development of insulin
resistance in later life.
8. KNOWLEDGE REGARDING CORONARY RISK FACTORS AND CORRELATION WITH RISK
FACTOR DISTRIBUTION IN AN INDIAN URBAN COMMUNITY
Usha Shrivastava, KS Reddy, LM Nath
Methods Public health strategies for control of cardiovascular disease epidemic require the ascertainment of the
community’s knowledge regarding modifiable risk factors. A cross- sectional survey of adults in the age group
of 35-64 years was conducted with random cluster sampling of the urban blocks on the basis of the census
records. The study estimated the present level of knowledge related to lifestyle related risk factors of coronary
heart disease and correlated this with the risk factor distribution of modifiable risk factors in this community. It
was conducted on 1064 adults (males 543, females 521).
Results Stress was perceived as the foremost risk factor for coronary heart disease (68.9%), followed by diet
(59.2%), and overweight (57.0%). Only 54.3% of them could recognise smoking as a risk factor for coronary
heart disease. It was observed that 71.7% of the respondents were not aware that diabetes was a risk factor for
coronary heart disease. The coronary risk score was computed based on the presence of various risk factors like
hypercholesterolaemia, level of HDL-cholesterol, history of smoking, and hypertension and diabetes in relation
to age and sex. The Spearman’s rank correlation coefficient between risk factor knowledge and coronary risk
score was 0.06.
Conclusion The knowledge of risk factors of coronary heart disease is inadequate in urban population of Delhi
and there is a poor correlation between risk factor knowledge and coronary risk score. There is thus a need for
population education regarding the modifiability of coronary risk factors.
9. PERINATAL AUTOPSY STUDY
Sudha Y Sane, Asha Shenoy, Rekha Udani and Sabita Saldanha.
Intrauterine growth retardation has been associated with ‘Hypertension and Coronary heart disease* in later life.
Fetal growth retardation may alter circulation and ventricular dynamics. Growth of heart occurs by hyperplasia
in fetal life and hypertrophy after birth. Wall thickness of heart and vessels is a function of mural tension.
Various parameters of growth retardation may show relation with cardiac measurements.
Methods We did prospective study of perinatal autopsies on cases beyond 37weeks gestation and dying within
7 days of birth. Cases of major malformations and hydrops were excluded. Various body parameters and organ
weights were recorded.
Weight of heart and thickness of right and left ventricles of heart was measured.
Microscopic measurements were performed with the help of image analyser:
1. Number of nuclei per square millimeter in myocardium of left ventricle and
2. Average thickness of myocardial fibers.
The data is analyzed to find if there is any relation of body parameters to cardiac measurements and compare
data of normal birth weight babies with cases of growth retardation.
10. EFFECTS OF INTRAUTERINE UNDERNUTRITION ON HEALTH IN LATER LIFE
(AYURVEDIC APPROACH)
VB Athavale.
Low birth weight babies i.e. intrauterine growth retardation is caused by1) Genetic constitutional factors and
2) Intrauterine environmental factors - Most important of which is nutrition received by fetus through placental
blood vessels. Ayurveda has studied the causes of intrauterine growth retardation and clinical manifestations
and treatment in these babies.
Ayurveda has also studied the effects of genes and constitution on intrauterine as well as postnatal growth and
development, and its effects on various tissues, organs and mind and the diseases to which the individual is
prone in childhood as well as in adult life. The undernourished low birth weight babies are thin and lean and are
included in babies with vataja constitution. Most of these babies continue to be vataka constitution throughout
their life. The purpose of this seminar is to study - 1) How undernutrition in fetus and infants determines the
constitution and diseases in later life. 2) How improving the nutrition of and health of girls, young women,
pregnant and lactating mothers will improve the health of their children throughout their lives.
In this presentation, I have divided the Ayurvedic approach to the subject in 3 parts 1) Fetal i.e. Intrauterine malnutrition.
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2) Constitution - Vataja constitution and its relation to adult diseases.
3) Planning for better progeny with balanced, physical and pyschological constitution.
Foetal malnutrition
In Ayurveda, three conditions of foetal malnutrition are described depending on the degree of failure of growth.
1) Upavishtaka - Where the foetus does not grow further. The foetal movements are less in frequency and
intensity.
2) Upashushkaka or Nagodara - Where the foetus loses weight and foetal movements become further weak
and occur less frequently.
3) Leena garbha - Where the foetus remains thin and lean and does not show signs of foetal movements.
The manifestations in mother, the causative factors, pathogenesis and treatment is described. Depending on
the dominant dosha, each of these conditions is divided into vataja, pittaja and kaphaja types. Their
manifestations and treatment are described.
Constitution
The constitution is basically genetic and is modified to a certain extent by environmental factors. The various
factors which determine constitution are derived from 1. Pitruja - Father
2. Matruja - Mother
3. Atmaja - Soul principle i.e. subtle body or linga deha
4. Satvaja-Mind
5. Rasaja i.e. Nutrition
6. Satmyaja - Ability to adapt to environmental factors.
Basic physical and biological atoms and molecules of Ayurveda
Space, Air, Energy, Water and Earth constitute the basic physical elements of the entire inanimate universe. Vata,
pitta and kapha are the basic biological elements which constitute the bodies of all living creatures including
plants and animals. Vata molecules are derived from combination of space and air elements. Pitta molecules are
derived from combination of energy and water elements. Kapha molecules are derived from combination of
water and earth elements. All the three biological elements have certain properties e.g. vata is dry, pitta is hot and
kapha is heavy. Since these elements are the constituents of the entire body as well as mind, their qualities are
reflected in the physical and mental characteristics of an individual. Vata is dry, light, mobile, expansile, quick,
cold, rough and clear. The dry quality of vata in the body manifests in the form of a dry, slim and small body. The
hair, nails, teeth and eyes appear dry. The voice is weak, low, cracked and dry. Because of dryness, the vata
individual does not get sleep and remains awake. Because of light nature of vata, the diet, movements and
activities of the person are light and quick. The mobile nature of vata results in unsteadiness and excessive
movements ofjoints, eyebrows, chin, lips, tongue, neck, shoulders and limbs.
The expansile nature of vata becomes manifest in prominent blood vessels and fascia in persons with vata
constitution. Because of quickness of vata, persons are quick to start their jobs but get tired, upset or emotionally
disturbed quickly. They grasp quickly, but forget as easily. The cold nature of vata gives rise to cold body,
intolerance to cold, stiffness of body or tremors or shivering. The roughness of vata result in rough hair, nails,
teeth, face and limbs. The clear quality of vata manifests in the form of well differentiated parts of the body and
cracking of joints during movements. The natural desires and cravings are for food and environment having
opposite qualities. Because of the combination the above mentioned qualities such persons are usually weak,
beget few children and have a short life span. Due to their physical weakness and wavering nature, they usually
do not earn enough money and are considered unfortunate. The diseases to which the individuals with vata
constitution are prone: higher functions: wavering mind, fear, greed, insomnia; CNS: hemiplegia, tremors,
giddiness; heart: sluggishness of heart (Hrunmoha), tachycardia (Hruddrava); skin: cracking of lips, nails, alopecia;
gastro-intestinal tract: constipation and fissures; reproductive system: amenorrhoea, oligospermia, cancer of
prostrate, few children, low birth weight babies; growth and development: emaciation, early ageing, short life
span. The various factors aggravating vata constitution and their prevention and treatment is given.
11. THE RELATIONSHIP BETWEEN BIRTH WEIGHT AND AGE AT MENARCHE
J Richard
The children born during 1969 to 1973 have been followed and their physical and mental measurements were
recorded at various points of time. For the girls the age at menarche was noted down at the appropriate time. The
birth weight of these girls were correlated with the age at menarche and the preliminary findings are presented.
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The mean age at menarche was 14.3 and the standard deviation was 1.2. The correlation coefficient was 0.204,
very small but significant with p=0.017.
12. RECURRENCE OF LOW BIRTHWEIGHT IN SUCCESSIVE PREGNANCIES
B Antonisamy and J Richard
Methods Using a population based prospective survey carried out in representative segments of rural and urban
areas of Vellore district during 1969-73, we examined the recurrence of low birthweight (LBW) in two successive
pregnancies and explored the genetic, obstetric and socio-economic risk factors for recurrence. Among the 475
women who had successive pregnancies with birthweight recorded, we observed the proportion in each of the
four groups of women based on LBW (<2500g) such as normal to normal, normal to low, low to low, and low to
normal and how these groups differ according to their maternal characteristics.
Results The recurrence of LBW in successive pregnancies was 9.5 percent and 5.3 percent in rural and urban
women respectively. The percentage of LBW in either of two successive pregnancies was 29.5 in rural and 18.0
in urban. Based on subgroup analysis, the risk of LBW in successive pregnancies was high in mothers of rural
background, teenage mothers, mothers of short gestation, illiterate fathers, and low maternal height and weight.
Conclusion The persistence of these risk factors emphasises the need for specific target interventions to achieve
further improvements in infant health.
13. STUDY OF LOW BIRTH WEIGHT BABY IN BENGALI MOTHERS OF CALCUTTA
Debabrata Chatterjee and Mousumi Bhattacharya
Methods A survey on low birth weight (LBW) Babies has been carried out on the basis of clinical diagnosis.
The baseline data has been collected from two hospitals in Calcutta a) general hospital and b) maternity hospital.
a) It is a teaching and general hospital. The patients usually undergo prenatal diagnosis and investigation for
pregnancy followed by regular Antenatal medical checkup for various aspects, delivery and also immediate
postnatal care. The delivery rate per year in the maternity ward is around 6000, having different income,
mostly higher and middle income group.
b) The second one is a maternity hospital with yearly delivery around 2500. Normally the prenatal care starts
from 2nd trimester followed up to delivery and subsequently postnatal care up to 7 days. Here the patients are
middle and low income group. Entirely routine breast feeding is practiced.
To consider the LBW of the newborn babies the survey has been initially carried out for about 1500 cases (from
a total birth of 8500 during one year). 300 cases have been recorded in detail giving emphasis on low to very low
birth weight (2.0 kg to 800 g). History for mothers age, parity, marital status, socio-economic conditions are
analyzed and the blood group parameter of mother/child combination for Rh D and ABO factors are also observed.
The occurrence of ‘O’ group was found to be frequent among the very low birth weight group (up to 2 kg).
100 individual cases were selected for detailed study. The mother and the father were interviewed in detail for
the factors like socio-economic status, parental age, previous sibling blood group, parity, mother’s education
etc. The heterozygous status of ABO and Rh were specially considered. The detailed physical examination
including the birth weight of the baby, height, morbidity pattern, anthropometric measurement, ponderal Index,
feeding pattern and the nutrition of the baby was observed by neonatologists.
Results LBW baby mortality in the general hospital is 13.5% but in the maternity hospital it is less than 2%.
Following are the mean anthropometric measurement in the general hospital: mid-arm circumference 8.16 cm;
chest circumference 27.65 cm and abdominal circumference 26.05 cm. The results show a positive relation on
the occurrence of LBW baby with ‘O’ blood group (30%). Incidence of‘O’ group for mother is (22%) and both
mother and child is 20%.
14. TRACE ELEMENTS IN MATERNAL BLOOD - THEIR CORRELATION WITH CORD BLOOP
LEVELS & NEONATAL ANTHROPOMETRY
Armida Fernandez and Jayashree Mondkar
Objectives
1. To determine the levels of Zinc, Copper, Iron, Lead and Cadmium, in maternal and fetal blood.
2. To correlate levels of these trace elements with fetal growth.
Design Prospective, pilot case-control study.
Setting Hospital based level III.
Subjects 85 mothers and their neonates having no medical or obstetric illness and no congenital anomalies.
Methods 85 mother -infant pairs were included in the study and divided into 3 groups.
Group I - 26 full term neonates
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Group 11-29 preterm neonates
Group III - 30 full term low birth weight neonates
Results and conclusions
1. Maternal levels of the trace elements had a positive relation with cord blood levels of full term, preterm, and
low birth weight babies.
2. Levels of Zn, Cu, Fe, in maternal and cord blood were significantly lower in preterm and low birth weight
babies as compared to full term neonates with birth weight more than 2.5 kg.
3. Neonatal anthropometry showed a positive correlation with maternal Zn, Cu, and Fe, levels - Higher levels
were associated with higher birth weights.
There was no correlation of the maternal Pb, and Cd levels with the neonatal anthropometry. There was no
significant difference in the maternal and cord blood Pb and Cd levels in the 3 groups.
15. WOMEN, EDUCATION AND HEALTH
Lakshmi Lingam
Education and health are engraved in the Directive Principles of the Constitution of India. An educated and
healthy population is considered a great human resource to any nation. The concern and focus on education and
health are evident in the several Five-Year Plan documents and the various national policies that have been
drafted at different points of time since India’s independence.
Education and Policy Documents The Universal Declaration of Human Rights (1948) is the first international
treaty, which recognises the right to education. The Declaration postulates that education shall be free at least in
the elementary and fundamental stages. One of the Directive Principles of State Policy of the Indian Constitution
enjoins that ‘The State shall endeavour to provide within a period of ten years from the commencement of this
Constitution, for free and compulsory education for all children until they complete the age of fourteen years’
(The Constitution of India, Art.45). This corresponds closely to Article 28 of the Universal Declaration of
Rights. The Five-Year Plan documents set the achievement of universal availability and equality of opportunity
for education as a basic means of promoting the general welfare.
The National Policy on Education (NPE) 1986, states the need for “an unqualified priority to universalisation of
elementary education (...) universal enrolment (...) and universal retention of children in school upto 14 years
of age” (Govt, of India, 1989). The NPE called for an investment of 6% of national income or GDP in education
during the Eighth Five-Year Plan. The NPE is a landmark in the field of women’s education and empowerment.
The section on ‘Education for Women’s Equality’ considers empowerment of women as a critical precondition
for their participation in the education process and other development activities. On the basis of the policy
statement a series of women’s empowerment programmes, popularly known as ‘Mahila Samakhya’, have been
initiated in different states of India. The programme is attaining a lot of significance in the lives of rural women.
The United Nations Convention on the Rights of the Child, which clearly states that signatories “recognise the
right of the child to education, and with a view to achieving this right progressively and on the basis of equal
opportunity, they shall, in particular make primary education compulsory and free to all” (Article 28), has been
ratified by India. Apart from basic education being a human right it also has economic rationality. Investment in
education is seen as vital instrument to achieve the country economic advancement.
Economic Aspects of Basic Education Education is the point of convergence in social policies and economic
approaches. Prior to the discovery of Human Capital Theory by Shultz in 1961, the concentration was on physical
capital, namely, machinery, equipment or buildings. It is observed that education contributes to the acquisition
of skills, attitudes and so on, which contributes to individual productivity. There is empirical evidence, which
shows that education, especially primary education, is a valuable unique investment that serves various facets of
development. First, it enhances the human capabilities to enjoy life, inculcating better habits and approaches to
life, thereby enhancing the quality of life. Second, it enhances productivity of the labour force in the labour
market, and thereby increases earnings. Third, education contributes to better health, reduction in age at marriage,
increased acceptance of contraception, reduction in family size and participation of women in the labour force.
Lastly, it improves not only efficiency of the system through increased productivity, personal and social
development, but it is also found to be an effective instrument of reduction of poverty, upward social and
occupational mobility and improvement of equity in the system (Tilak, 1996). Thus universal elementary education
is enshrined in the Constitution of India and in several declarations of the UNESCO and United Nations
Organisations.
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Women’s Education Formal education of women in India began a hundred years ago. Despite the early start,
the improvement in general literacy was slow till the time of independence. The ratio of female literacy to male
literacy in India between pre-independence period and the post-independence period has increased considerably,
however the significant difference between male literacy and female literacy persists.
The decennial census enumeration carried out by the Office of the Register General and Census Commissioner,
defines literacy as the ability to read and write with understanding in any language. A person who can read but
cannot write is not defined as literate. Children below the age of five are considered illiterate. According to the
Censuses, the progress of literacy in the total population is as follows: 24.90% in 1951, 34.46% in 1961, and
52.21% in 1991. The situation with respect to female literacy is even more disappointing. The progress has been
as follows: 7.83% in 1951, 12.96% in 1961, 18.69% in 1971, 24.82% in 1981, and 32.89% in 1991. It may be
noted that literacy among females in 1991 (32.89%) is a little less than literacy among males in 1961 (34.46%),
implying a lag of 30 years (Dandekar, 1996). Differentials also prevail in literacy rates in rural and urban areas,
with the rural population having lower rates than the urban population. Literacy rates for urban females are
higher than those for rural males (Karkal, 1991). There has been substantial increase in enrolment at all levels
including for girls and Scheduled Castes (SCs) and Scheduled Tribes (STs). Drop out rates, though declining,
are significantly large. Gender disparities are very conspicuous among SCs and STs as well, though this is
attributed more to poverty and access factors than to discrimination.
The all India literacy data masks the large variations across states, rural-urban regions, communities and gender
that exist. According to 1991 Census, the lowest female literacy rate in the country is 20% in Rajasthan and the
lowest male literacy rate was 52% in Bihar. In every state the percentage literate is higher for males than for
females and higher percentage of males have completed each level of schooling than females. The literacy gap
between males and females is particularly large in Rajasthan, Uttar Pradesh and Bihar where the male literacy
rate is more than twice the female literacy rate.
Girl Child’s Education Women and girls globally constitute the largest single category of persons denied full
and equal opportunities for education. The UNESCO’s 1995 World Education Report reopens the debate on
discrimination against women and girls. The report notes that: “women today represent two-thirds of the world s
illiterate adults, while girls account for a similar proportion of the world’s out-of-school population” (DPEP,
1996: 34).
The education of the girl child had attained specific focus during the year 1992, which was declared the ‘Year of
the Girl Child’. Considerable evidence had accumulated by this time in terms of low enrolment in schools and
high drop out rate after primary level, high work participation rates of girl children and the low age at marriage
prevalent in many parts of India. The education of girl children in general and SCs and STs in particular is an
issue of concern. The education of girls is of low priority for families that generally place a relatively better
emphasis on the education of the boys. Girls and women do not gain equal access to a range of resources and
services within the household. Moreover, the non-availability of schools in close proximity, irregular teacher
attendance in many schools, uninteresting and alienating school curriculum, teaching methods and materials
compound the problems. This is especially so in rural areas. There is a strong negative correlation between
school attendance rate and percentage of households having no literate members, indicating the inter-generation
effect of education. In case of rural females, the percentage of villages having primary school as well as allweather roads have positive effect on attendance (Unisa, 1995). Dearth of women teachers, quality of teaching,
class room climate and physical facilities in the school have been seen to have close relationship to
girl child education (Anandalakshmy, 1994).
The NFHS (1992-93) reports that: In the country as a whole, only 68% of children age 6-14 are attending school.
The gap between girls and boys in school attendance is more pronounced in rural than in urban areas, especially
at age 11-14 where only 48% of rural girls as opposed to 73% of rural boys are in school. In spite of the
substantial educational advances that have been made over.time, 41% of school-age girls in India are still not
attending school. Urban females experience a 7% decline in attendance and rural females, whose level of education
is much lower to begin with, experience a 13% decline in attendance from age 6-10 to age 11-14. Educational
attainment of women has been uneven corresponding to the class distinctions of the Indian society. Hence,
women from the middle and upper classes acquire education, though largely stereotyped, as opposed to women
from the lower classes where poverty coupled with the low valuation of the benefits of education, deter girls
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from going to school. The school enrolment, retention and achievement are also closely linked to economic
development, household incomes and poverty. Further to this are cultural practices like early age at marriage.
Social Structure and Women’s Health The health of a population is dependent on the social, economic,
cultural, political and environmental factors prevailing in that country. Health as an outcome is contingent on
factors that operate at three levels: the political, the societal and the household. Patriarchal values and cultural
perspectives intersect al all levels, which have implications to women. At the political level, the policies and
programmes of the State pertaining to wide range of issues, for example agriculture, industry, employment,
health, forests, and so on, impact household income and access to vital requirements to live in dignity. At the
societal level the caste, class, religious and ethnic differences determine the location of the household in the
social structure. At the household level, the total household income determines the purchasing power of health
goods and services. The physical location of the household in a social environment determines the access to
housing space, clean drinking water, air, sanitation, drainage, accessibility and availability of health services and
so on. The health culture at the community and household level influence and shape health beliefs and practices.
At the intra-household level, studies have observed that an unequal access to goods and services exist on the
basis of age, gender and kinship status. Woman’s health within the household is typically dependent on her age,
marital status and position in the household, and the status of women in society in general.
Patriarchal values manifest at each of these levels. At the political level, the values pertaining to the normative
roles that women play in society, as wives and mothers, determine the designing and implementation programmes.
Thus, women’s fertility is targeted through the Family Planning Programmes; and women as mothers are the
target clientele for a range of child health programmes. Paradoxically, while women are the guardians of household
health through their domestic roles, there is least empirical evidence to indicate women’s decision making
power in health matters. The societal and cultural desire for sons as opposed to daughters; the low value attached
to women’s non-monetised work inside and outside the house; and so on, impact women’s self.
Health Status The World Health Organisation (WHO) has defined health as “a state of physical, mental and
complete well being and not the absence of disease or infirmity” (1958). The health status of a population is
assessed through demographic indicators such as mortality rates, life expectancy, morbidity (disease incidence
and prevalence) rates and so on, which essentially point to the absence of health. The death rate in India is 10,
which is equivalent to the rates attained by any developed country. However, a close examination of the death
rates indicate that infant mortality rate (IMR), and deaths of women in the reproductive ages, a large percentage
of which is due to maternal causes (maternal mortality rate, MMR), continue to exist. The morbidity load that
women carry, specifically those concerning reproductive health are attaining a lot of attention at present. Women
are considered to be more vulnerable to contracting sexually transmitted diseases and specifically HIV/AIDS
through the heterosexual modes of transmission, where they lack the power to negotiate for safe sex either as
wives, sexual partners or as sex workers. Women’s status related issues have a larger role to play in health
outcomes than the mere presence of health care services.
Education and Health Linkages The positive outcomes of attaining education are considered to be many. The
particular association between education and its linkages to several health outcomes has come to light during the
last few decades. Research with macro data in examining this linkage covers areas such as fertility behaviour,
i.e., the preference to have small or big families; contraceptive use; child survival, i.e. infant mortality rates,
performance of immunisation, knowledge and use of Oral Rehydration Therapy (ORS), knowledge of AIDS/
STD. The knowledge pertaining to infections, diseases, the requisite individual and household practices, and
health seeking behaviour are areas that are examined at micro settings to understand the education and health
linkages.
Education and Fertility Behaviour Fertility behaviour understood in simple terms as the preference to have
big or small families is observed to be influenced by the level of education, specifically attained by women. The
examination of fertility behaviour is done with the help of demographic indicators such as crude birth rates
(CBR), general fertility rates (GFR), and total fertility rate (TFR). The states of Kerala and Tamil Nadu have
attained low birth rates and total fertility rates (TFR) and this is attributed to the female literacy levels of these
states which are 86.17% and 51.33% in I991, respectively. Table I provides the details of fertility by background
characteristics. The association of education to TFR and mean number of children may be observed. Given this
information it might be simplistically assumed that the preference for large families is due to the mere lack of
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education or superstitions. It needs to be understood that apart from fertility behaviour being culturally rooted, it
also has a host of economic dimensions. The following may be noted: (a) children contribute to the labour inputs
in agriculture and artisan families; (b) amongst poor families, children contribute to the family survival from
early ages; they are an asset rather than a liability; (c) in the absence of any old age pensions, children are seen
as a security during the period of old age or disability. It is also observed that high infant mortality rate (IMR)
creates the conditions of high fertility. Families have more children as a mechanism to ensure the survival of at
least a few children. Women’s health and child health are inter-linked issues. Hence, improvements in child
survival and the contingent declines in IMR induce the declines in TFR, which in turn improves women’s
reproductive health. Similarly, improvements in women’s health status which has an inter-generational affect
contributes significantly to the declines in the IMR.
Education and Child Survival A review of the World Fertility Survey data of 115 countries conducted among
child bearing women in several countries had identified the positive correlation of maternal education to declines
in child mortality (Caldwell, 1979). This observation has been reiterated by the recent National Family Health
Survey (1992-93), presented in Table 1. The Indian data on the relationship of 1MR by mother’s education is
presented in Table 2.
Male infant mortality is high compared to female infant mortality at an aggregate level. However, the detailed
data (not presented here), indicates that males have a higher risk of dying in the first month of life, whereas
females have this risk between the first and fifth birthday. This reversal is thought to reflect the relative nutritional
and medical neglect of girls after the cessation of breast feeding. Children of both very young and old mothers
are at higher risk of dying, mortality rates are relatively high for first births and high order births, and child
spacing patterns have a powerful effect on the survival chances of children. As the length of birth spacing
decreases the risk of infant dying is higher. Infant mortality declines sharply with increasing education of
mothers. Infant mortality is higher in rural areas than in urban areas. Scheduled Castes have higher levels of
infant mortality than Scheduled Tribes, who in turn have higher levels than non-SC/ST women. Hindus have
higher infant and child mortality than all other religious groups.
Table. 1: Fertility by background characteristics
Background characteristic
Total fertility rate*
Mean no. of children ever born
to women age 40-49
2.70
3.67
4.16
3.92
3.55
3.30
5.40
4.03
3.01
2.49
2.15
3.39
5.26
Residence
Urban
Rural
Caste/Tribe
Scheduled-Caste
Scheduled-Tribe
Other
Education
Illiterate
Literate(<middle)
Middle School Complete
High School Complete
Total
5.13
4.81
4.76
4.50
3.71
2.80
4.84
*Rate for women age 15-49 years; Source: NFHS, India, 1992-93, p.97.
Table 2: Child mortality by educational level of mother, 1981
Illiterate
Literate below middle
Middle-below metric
Metric below graduate
Graduated
BY AGE 2
BY AGE 5
138
96
63
43
28
170
107
71
48
32
Source: Registrar General, Census 1981, Occasional Paper No.2, 1989,
cited in Ghosh S (1995): Integrated Health of the Girl Child.
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Social Change: June-September, Vol. 25, Nos.2 &3.
Issues such as pre-natal, ante-natal and post-natal care at maternity, deliveries in an institutional set up, seeking
trained attendance at birth, the knowledge of vaccinations, immunisations, are all considered to be positively
associated to female education. However, the exact processes that connect women’s education to positive health
outcomes, has been a subject of conceptual modelling. The primacy given to education and behavioural variables
in research, to the neglect of economic variables that intersect with social variables, has been an area of contention.
A recent micro study that had examined the complex linkages between gender inequality, poverty and reproductive
behaviour, observed a powerful relationship of per capita income as an explanatory variable for fertility as
opposed to literacy indicators (ISST, 1996). Another study that critically examined the Tamil Nadu’s recent
demographic experience of declines in TER, with disaggregated district level data, indicated the falsity in broad
based generalisations of greater female autonomy of women in South India (ostensibly female friendly kinship
structures) as a factor that contributes to the decline in fertility. Vast intra-regional variations exist which baffle
these generalisations according to the author. Therefore, while high fertility rates resulting from lack of autonomy
is understandable and plausible, low fertility rates need not necessarily imply presence of autonomy for women
(Swaminathan, 1998). Jeffery and Basu’s (1996) recent publication had grappled with women’s autonomy, girl’s
schooling and fertility reduction in South Asia.
Conclusion The present paper has broadly outlined women’s education, understood as literacy and schooling, in
India. The macro-level data clearly indicate the steady increase in women’s education. Nevertheless, the gender
gap in access to education at all levels; the rural-urban and caste differences in enrolment, retention and
achievement in education, are issues of concern. The paper also highlights the close association of education and
health variables observed with macro-data. However, health outcomes are examined only in terms of child
survival, reduction in fertility, contraceptive use or acceptance of small family norm. The pathways at a micro
level to these demographic outcomes are still fuzzy. On the other hand, existing evidence conclusively indicates
the reduction in periods of exclusive breast feeding and reduction in the post partum period of amenorrhoea
among educated women. Research studies have still not directed their attention to examining the relationship of
women’s education and women’s proneness to Caesarean Section, menopausal problems, hysterectomy and
mental health problems. This is not to say that women’s education is undesirable. On the contrary, it has to be
considered as a goal/ end in itself, rather than a means/ instrument to achieve other goals.
References
i. Anandalakshmy, S. (1994): The Girl Child and the Family. An Action Research Study. Dept, of
Women and Child Development, HRD Ministry, Govt, of India, New Delhi.
2. Caldwell, J. C. (1979): Education as a Factor in Mortality Decline: An Examination of Nigeria Data. Population
Studies, 33, 395.
3. Dandekar, V. M. (1996): The Indian Economy 1947-92. Vol II, Population, Poverty and Employment, Sage
Publications, New Delhi.
4. DPEP (1996): Equal Opportunities for Women- An Impossible Dream? DPEP Calling, May,
p.34-36.
5. ISST (1996): Poverty, Gender Inequality, Reproductive Choice: Some from a Household Survey.
Occasional Paper I-5, ISST, New Delhi.
6. Jeffery, Roger & Basu, A.M. (1996): Girl’s Schooling, Women’s Autonomy and Fertility Change in
South Asia. Sage Publications, New Delhi.
7. Karkal, M. (1991): Progress in Literacy in India: A Statistical Analysis. Indian Journal of Social
Work, Vol.LII, No.2, p.229-243.
8. Swaminathan, P. (1998): Work and Reproductive Health: A Hobson’s Choice for Indian Women?
9. Tilak, J.B.G. (1996): How Free is ‘Free’ Primary Education in India? Economic and Political
Weekly, Vol.XXXl, No.5, p.275-282, No.6, p.355-366.
10. Unisa, S (1995): Demographic Profile of the Girl Child in India. Social Change, Vol.25, Nos.2-3,
p.30-37.
SOCIO CULTURAL FACTORS WHICH INFLUENCE NUTRITIONAL STATUS OF
WOMEN AND YOUNG GIRLS IN RURAL MAHARASHTRA, INDIA
Ginny P Chorghade
Background Women in Rural India are thin and short and give birth to small babies. The Pune Maternal
Nutrition Study (PMNS) conducted in Rural Maharashtra suggests that maternal height and pre-pregnant
weight are strong determinants to fetal growth. Interventions to improve fetal growth should aim at improving
16.
18
Abstracts
the nutritional status of young women. In order to develop an intervention, need arises to understand the social
and cultural factors which directly or indirectly influence nutritional status. This study aims to look in-depth at
these social and cultural behaviours that influence nutritional status of women in Pabal village, near Pune.
Methods The study started in January 1998, and will use both quantitative and qualitative methods. Sample
households containing at least one brother-sister pair in the age range 4-8 years were selected from the PMNS
database. Anthropometric measurements (height, weight, MUAC and triceps and subscapular skinfolds) of the
sibling pair, parents and grand parents were used to determine nutritional status. Socio-economic information
for every household was also collected. Comparison of BMI SD-scores and skinfold thickness data will be used
to select households for further interviews Focus group discussions held in the village and its hamlets gave
insight into the norms and beliefs on nutrition and health in the community. Data collection for the anthropometry
phase*and focus group discussions is complete and results will be presented at the conference.
17. FETAL GROWTH IN RELATION TO MATERNAL GLUCOSE TOLERANCE AND BODY
COMPOSITION - THE MYSORE, PARTHENON PROJECT
Jacqui Hill
Introduction The Parthenon project follows closely from the first Mysore project, in which it was found that
higher maternal weight was associated with increased rates of NIDDM in the adult offspring and that those
babies who developed NIDDM as adults were short and fat, with a higher ponderal index at birth. It was
hypothesised that low birth weight women who become obese as adults, are insulin resistant, develop relative
hyperglycaemia in pregnancy and give birth to heavy, fat babies which are hyperinsulinaemic and go on to
become diabetic as adults. This project was designed to test the hypothesis by determining how maternal glucose,
insulin, pro-insulin and 32-33 split pro-insulin concentrations relate to: 1. the mother’s own size at birth; 2. the
mothers adult body composition; 3. the size and proportions of her baby at birth; 4. the baby’s cord blood insulin
concentration.
Methods Women are being recruited from the ante-natal clinics at HMH and asked to attend our clinic between
28 and 32 weeks gestation. At this clinic we administer a questionnaire, carry out a series of anthropometric
measurements and perform a 100g (3 hour) oral glucose tolerance test. When these women deliver, we collect
cord blood for insulin and glucose measurements, weigh and measure the placenta and carry out anthropometric
measurements on the babies.
Discussion The project began in May 1997 and will end when all the women recruited have delivered their
babies (end December 1998). We will present the data and conclusions drawn from it by this time next year.
Sample size is less than originally projected and we will discuss some of the reasons for this. We will also
present comparative data relating to the mothers who were themselves born in HMH, and comparing the Mysore
mothers and babies to those in Pune and Southampton.
18. FETAL CARDIAC MEASUREMENTS AND ESTIMATION OF PLACENTAL RESISTANCE
Arun Kinare
Background Small babies are more prone to cardiovascular diseases and diabetes in adult-hood. Indian babies
are amongst the smallest in the world. Maternal Nutrition and Placental Volume as the predictors of neonatal
outcome were studied in the earlier project (PMNS). In the proposed study, Prof.Kent Thornburg’s hypothesis
for the link between reduced intrauterine growth and adult cardiovascular disease will be studied using
measurements of different fetal cardiac structures and the placental circulation. These will be Ultrasound and
Doppler-based measurements.
Methods In the pilot study we plan to evaluate 10 controls and 15 growth retarded fetuses (including asymmetric
as well as symmetric). The detailed protocol will be presented. In short, three examinations will be carried out at
20,28, and 36 (+/-2) weeks of gestation.
MATERNAL DATA, which includes weight, height and blood pressure will be recorded at the first visit. FETAL
DATA including BIOMETRY, the AMNIOTIC FLUID INDEX, CARDIAC MEASUREMENTS and
UMBILICAL HEMODYNAMICS will be studied at all three visits.
19. ‘FINLINDIA’ - THE DELHI AND VELLORE STUDIES
Caroline Fall
Last year, Dr Richard from Vellore, and Dr Usha Shrivastava from Delhi presented a detailed outline of these
proposed studies. They have now been granted funding by the British Heart Foundation, and fieldwork will go
ahead this year. Rather than repeat the details again, it was decided that I, as a ‘common factor’ to both studies
would present a brief view of their importance and context.
19
Abstracts
Background The studies are based on 1969-73 birth cohorts for whom similar data were collected in both Delhi
and Vellore: maternal weight and height, accurate gestational age, detailed anthropometry of the babies at birth,
and measurements of their growth during infancy and childhood. These cohorts are analogous to those in
Helsinki, Finland. Importantly, in the Indian context, they represent both urban and rural communities.
Methods The ‘babies’, now young adults, will be traced and a range of CHD risk factors measured. These will
be analysed in relation to their mother’s height and body mass, their size at birth and childhood growth, as well
as their current body composition and lifestyle. The studies will concentrate on the features of the Insulin
Resistance Syndrome, known to be a hallmark of Indian CHD patients.
Delhi The initial cohort, started by Dr Shanti Ghosh and Dr Santosh Bhargava, resulted from following up
women in a geographically-defined area of Delhi (Lajpat Nagar). There were 8,030 singleton live births. In a
pilot tracing exercise carried out by Dr Bhargava in 1994, 1,794 members of the cohort, now aged 25-29 years,
were found to be still living in or around Delhi. Data will be collected from these young men and women on
demographic and lifestyle factors relevant to CHD including socio-economic status, tobacco consumption, dietary
fat intakes and physical activity. Anthropometric measurements will be made, including measurements of body
fat distribution, and CHD risk factors: blood pressure, glucose/insulin concentrations, serum lipid concentrations
and plasma clotting factors will be measured. Clinical testing and laboratory investigations will be carried out at
the All India Institute of Medical Sciences, New Delhi, under the direction of Dr KS Reddy.
Vellore The initial cohort was started by Dr Richard as part of a longitudinal study in maternal and child health.
The study area included 26 rural villages of the KV Kuppam Panchayat Union, and 3 districts of varying socio
economic character in Vellore town. There were 3,831 singleton live births. In a pilot tracing exercise in 19956, 50% of rural and 28% of urban subjects were still living within the study area. It is estimated that 1,580 will
be traceable to form the sample for the study. The protocol in Vellore will be similar to that in Delhi, and
fieldwork will be under the direction of Dr Richard, Dr Raghupathy and Dr Leni Mathew. The rural part of the
study will use the infrastructure of RUHS A (the Rural Unit for Health and Social Affairs) centrally located in the
village area. The urban part of the study, and all laboratory investigations will be carried out at CMC Hospital in
Vellore.
Discussion These studies will produce data of great public health importance. India is undergoing a transition
in which the nutritional status of the adult population has improved, but fetal growth remains poor. The Finland
study has shown that the small baby is more vulnerable to the adverse effects of even mild obesity in childhood
and adult life, and to maternal obesity in pregnancy. It is hoped that, in addition to discovering if these same
processes apply in India, the Delhi and Vellore studies will help to define optimal body weights for pre-pregnant
Indian women in relation to their height, and optimal body mass index in Indian boys and girls, in relation to
their size at birth.
20
Summary
SUMMARY OF PROCEEDINGS
FRIDAY 11* SEPTEMBER
INTRA UTERINE GROWTH
Dr Caroline Fall - Where we are in 1998
News headlines for 1997-8: The official launch of SNEHA, India (Society for the Natal Effects of Disease in
Adults) is the main headline of the year. Credit goes to Dr Potdar for completing the official registration procedures.
Sabita Saldanha designed the SNEHA logo, showing an Indian mother, nurturing her child, first in utero and
then in her lap, with the curve of her sari sheltering the baby. Other headlines this year.
• Unicef covered the findings of the Pune Maternal Nutrition Study in its prestigious publication ‘The State of
the World’s Children 1998’
• The British Heart Foundation decided to fund the studies in Delhi and Vellore (see abstract 19).
• A collaboration was born between Dr Arun Kinare (KEM, Pune) and Dr Kent Thornburg (Portland, Oregon,
USA) to study fetal cardiac development.
• The Wellcome Trust launched two funding initiatives; a) to promote research into non-communicable diseases
in developing countries, and b) a series of Indian research fellowships.
• The Medical Research Council (UK) has selected Southampton University as for one of its new MRC
Centres, to study physiological mechanisms underlying fetal programming.
• Last but not least: Professor David Barker was awarded Fellowship of the Royal Society.
On the scientific side: Evidence linking small size at birth to adult CHD continues to grow. While the early UK
studies were based on relatively low follow-up rates, new studies from Finland1 and Sweden2, with excellent
birth data (including gestational age) and over 90% trace rates, show similar findings. They have sufficient data
on socio-economic and lifestyle factors to conclude that associations between low birthweight and adult disease
are unlikely to result from confounding factors in later life. The main areas of‘hot’ debate on the fetal origins
hypothesis are now:
The interaction of childhood growth with low birthweight Low birthweight effects are strongest in adults
who become obese. The Pune 8-year-old study (see abstract 7) showed similar effects with increased body
fat in childhood. This has public health implications: should interventions to control obesity be targeted to
people of low birthweight, and start in childhood?
• Maternal effects The Mysore and Finland studies suggest that obesity in mothers exacerbates the risk of
NIDDM and CHD in the next generation. Ranjan Yajnik’s data (abstract 1) shows how the nutritional history
of the mother predicts the body composition of the baby at birth, and may programme insulin resistance.
• Genes v environment While environmental effects on fetal growth are well established, the genetics of fetal
growth is in its infancy. In the last year, studies have shown effects on fetal growth of a) naturally occurring
polymorphisms of the insulin gene3, and b) mutations of the glucokinase gene4. In addition, more genes are
being identified which predict variation in CHD risk. In Hertfordshire there were additive effects of poor
early growth and Apolipoprotein E genotype on adult LDL-cholesterol concentrations5. New studies starting
this year in Hertfordshire will study gene/early growth interactions on CHD and risk factors.
• How important is the low birthweight effect? Calculations published this year show that if overall birthweight
increased by 300 g, CHD prevalence would be reduced by only 5-7%6. Such calculations are misleading,
since birthweight and birth length are at best only crude proxy measures of fetal experience. We need better
* endocrine and biochemical markers of programming.
• Mechanisms (The perennial question) The most exciting progress is in the field of steroid metabolism.
Animal studies show that environmental exposures early life imprint the hypothalamo-pituitary-adrenal
axis (HPAA), resulting in permanent modification of the neuroendocrine response to stress. Early evidence
of similar effects in humans is now emerging, with the demonstration of high fasting cortisol concentrations7
and a prolonged response to ACTH in men of low birthweight.
Dr Ranjan Yajnik and Dr Kurus Coyaji - The ‘Thrifty Phenotype’ defined (Abstract 1, page 6)
The Pune Maternal Nutrition Study (PMNS) has produced a wealth of data on the relationships between maternal
size, body composition and diet, and fetal growth, in a large population sample of women measured from before
pregnancy. Size at birth was related to various ‘components’ of the mother’s body composition, including her
head size, height and fat mass. Ranjan proposed that each of these reflected a different period in the mother’s
21
Summary
nutritional history: head circumference her nutrition in fetal life and infancy, height her nutrition in childhood
and adolescence, and fat mass her current energy balance. The mother’s head circumference was related to all
measurements of the baby (except the placenta), while her height was related only to the baby’s length, and her
fat mass to the baby’s skinfold thicknesses. This suggests important effects of a woman’s nutrition at every stage
of her life.
Compared with babies born in Southampton (Pune measurement/Southampton measurement), the Pune babies
were small in all dimensions. Head circumference, length and skinfold thicknesses were, however, relatively
‘spared’, compared with mid-arm circumference (a measure of muscle), and abdominal circumference (a measure
of liver size). The result was a thin baby with a ‘fat-sparing, muscle-depleted, abdomen-depleted’ phenotype.
While fat may have benefits for survival in the immediate post-natal period, this phenotype, if it persists into
adult life could cause centrally obesity and insulin resistance. Ranjan described similar phenotypic characteristics
(preserved head and length and increased abdominal fat) in pups born to a colony of undernourished rats in
Pune. The greatest mother-baby ‘transfer’ of subscapular fat was in short fat mothers, who were also centrally
obese, and had high glucose, insulin and triglyceride concentrations. The worst scenario was possibly therefore
the mother who was stunted in early life and becomes fat as an adult.
Finally Ranjan described his recent work on the inflammatory cytokines interleukin-6 (IL-6) and tumour necrosis
factor (TNF-a). These are produced by adipose tissue, and may contribute to the aetiology of heart disease.
Concentrations were low in the rural population (values similar to Londoners), but raised in urban (middle
class) Pune, and even more so in urban slum dwellers in Pune.
Discussion: Dr HPS Sachdev made the helpful comment that SD scores would be preferable to simple ratios in
comparing the Pune and Southampton babies.
Shobha Rao - The GLV story (Abstract 2, page 6)
Shobha presented fascinating data from the PMNS on pregnancy outcome in relation to the mother’s intake of
green leafy vegetables (GLV’s). Food intakes were measured by 24-hour recall and food frequency questionnaire
(FFQ). Of all the food groups measured, GLV’s and dairy products (mainly milk) showed direct relationships to
pregnancy outcome. Mothers with higher intakes of GLV’s had lower rates of premature delivery and of low
birthweight. Their babies were larger in all birth measurements. Although mothers with higher GLV intakes
were themselves heavier and fatter, and gained more weight during pregnancy, these relationships to neonatal
size were independent of maternal size. All the effects were strongest in lighter mothers. Shobha raised the
point that we do not yet know the long-term effects of differences in neonatal size associated with different
maternal GLV intakes.
Of great interest if this story is to move forward is knowing what distinguishes the mothers who were eating
GLV’s regularly from those who hardly ever ate them. Shobha has carried out a survey specifically to answer
this question. Main reasons for eating GLV’s were a) personal liking and b) availability of land and water. Some
people said they rarely ate GLV’s because of their reduction in volume on cooking and therefore ‘poor value .
Dr Vijay Joshi - Placental pathology in IUGR (Abstract 3, page 6)
Dr Joshi presented a comprehensive review of the function, structure and pathology of the placenta, which
provides nourishment, oxygen and protection to the fetus, as well as being an important endocrine organ. He
provided a full manuscript of his presentation (see abstract 3). Population- and gestation-specific charts are
essential to determine ‘normal’ placental weight, and PGI Chandigarh has constructed charts for India. Placental
weight measurement is influenced by the presence of maternal and fetal blood, and by fixation methods. Large
placentas (currently defined as >750g at term or 100g above normal at other gestational ages) occur in hydrops,
diabetes, and infection. Dr Joshi emphasised the need for further research, including systematic placental
examination in cases of IUGR, immunological investigations, correlation between pathology and outcome, and
follow-up to examine long-term effects.
P(
pan
Summary
Dr Manoj Chinchwadkar - Intra-uterine growth of rural Indian babies: fetal ultrasound (Abstract 4,
page 9)
Manoj presented ultrasound data from the PMNS. Scans in mid- and late-gestation showed that fetal head
growth was similar to western standards until 26 weeks, but abdominal circumference was markedly reduced
from as early as 22 weeks. Femoral length on the other hand kept up with western standards throughout gestation.
Low mid-pregnancy placental volume (MPPV) was associated with low birthweight, and a reduction in all birth
measurements. Examination of the possible maternal determinants of placental volume was, however, rather
disappointing: of all the mother’s measurements, only her weight predicted MPPV. MPPV predicted birthweight
independently of maternal weight. MPPV was unrelated to maternal blood pressure, or any of the blood parameters
measured, including haemoglobin, serum ferritin, red cell folate and plasma glucose and Vitamin C concentrations.
Manoj described the fascinating phenomenon of‘non-fitting’ placentas; many extended further over the uterine
surface than in Southampton and did not fit within the view of the ultrasound probe. This was striking in view
of the smaller overall MPPV and the use of a longer probe than in Southampton. He suggested that this placental
extension was a mechanism to increase materno-fetal exchange. Indeed, it was associated with larger fetal size.
He also described 2 new measurements: mid-pregnancy placental diameter (MPPD), the average of two
perpendicular diameters, and mid-pregnancy placental thickness (MPPT). MPPV correlated strongly with MPPD
(r=0.6), but less strongly with MPPT (r=0.3). MPPD also correlated with measurements of the baby at birth
(birthweight r=0.3, placental weight 0.3), and predicted low birthweight at least as strongly as MPPV. In contrast,
MPPT was not correlated with neonatal size. 68% of mothers with MPPD <9cm had babies weighing <2500g at
birth. MPPD can be measured using standard ultrasound equipment, and Manoj put this forward as a useful
clinical measurement, in contrast to MPPV, which is time-consuming and requires a special probe.
Dr Vaman Khadilakar- Intra-uterine growth of rural Indian babies: size at birth (Abstract 5, page 9)
Vaman grappled with the controversial issue of growth standards. Is it appropriate to use standards derived in
other populations, and to use universal definitions of IUGR and symmetry/asymmetry? Using data from the
PMNS, he compared rural Indian babies with UK (Castlemead) growth standards at birth, 6 months and one
year, using SD scores. 13% of PMNS babies had IUGR, defined as <2 standard deviations for birth weightfor
gestation. Head circumference and length were relatively spared, the latter most marked in boys. Ponderal
index was not a sensitive indicator of IUGR.
At 6 months 70% of IUGR babies had ‘caught up’ reaching or exceeding -2SD’s for weight. At one year,
however, most had dropped back again to some extent. This occurred in babies with both symmetrical and
asymmetrical IUGR (distinguished using on ponderal index), although asymmetrical tended to maintain catch
up slightly better than symmetrical. The length/height-sparing effect persists at 6 months and one year.
Vaman concluded that this rural Maharashtrian population has low rates of IUGR compared with all-India figures.
What, however, is the best measure of IUGR in this population? Head and length growth are spared in Indian
babies, and this persists postnatally. Catch-up growth is good at 6 months, but tends to regress in late infancy.
Dr SR Veena and Dr K Kumaran - An inter-generational study of coronary heart disease (Abstract 6,
page 10)
Dr Veena described the study currently taking place in Holdsworth Memorial Hospital, Mysore, of ‘second
generation’ adults born in HMH, whose mothers were also born there. The findings of the first Mysore study led
to the hypothesis that low birthweight women, especially if they are obese, develop insulin resistance and impaired
glucose tolerance in pregnancy. It was proposed that this causes hyperinsulinaemia and ‘macrosomia’ in the
fetus, who then develops deficient insulin secretion in adult life. The inter-generational study (and the Parthenon
Study: abstract 17) aim to test this hypothesis. Cardiovascular risk factors will be examined in relation to current
body size, size at birth, maternal glucose/insulin metabolism, maternal weight and height in pregnancy, and
maternal birthweight. . If the hypothesis is correct, the highest rates of NIDDM will be in subjects born to
shorter fatter mothers who had a low birthweight. The study started in December 1997, and will conclude in
July 1999. Results will be available for the next workshop.
23
Summary
Dr HPS Sachdev - Low birthweight in South-East Asia’
Implications of low birthweight, and the scale of the problem Low birthweight is associated with increased
perinatal morbidity and mortality, poor growth in childhood, and increased adult morbidity. Of the two main
causes of low birthweight: prematurity and IUGR, the latter is dominant in developing countries. WHO has
defined low birthweight as a birthweight <2500g; using this criterion, half of the global burden of LBW is in
South Asia, the prevalence being highest (50%) in Bangladesh, and 30% in India. Within India prevalence
ranges from 10% to 56% according to region, socio-economic status and rural or urban location. Reliable data
coHectedby^thg National Neonatology Forum fromJ^entres£l9951reports an overall LBW prevalence of
33% in India, one third (12% overall) due to prematurity9. A significant proportion of LBW in India is thus due
to prematurity; there is evidence that gestation at birth is ‘shifted to the left’ in India, with average gestation
being 39-40 weeks as opposed to the 40-41 weeks seen in the west. This is most marked in lower socio
economic communities.
Secular trends Although others have reported no changes in mean birthweight in India between the 1960’s and
1980’s, Dr Sachdev pointed out that this conclusion may be unreliable, since it was based on comparisons of
data from disparate settings. He has attempted to make a more valid analysis, using data from the same areas at
different time points. Based on 8 studies covering rural and urban populations, and community and hospital
births, he found a small, 50-100g, increase in birthweight over 30 years, and a small increase in gestational age
at birth. Despite these apparently small changes, percentages of low birthweight babies, have fallen by 8-12%.
Data from Europe and the USA show a similarly small (50-100g) increase in birthweight over the same period.
Interventions to improve birthweight Kramer, in his 1997 meta-analysis of the causes of low birthweight divided
the determinants of birthweight into ‘established/not established’, ‘important/not important , and modifiable/
not modifiable’10. For example he identified adolescent pregnancy as an important modifiable cause of low
birthweight. Trials of dietary supplementation in pregnancy have been disappointing, with, at best, only modest
increases in birthweight. The role of micronutrient supplementation is at present unclear. Earlier studies showing
benefits from folate supplementation have not been replicated. Supplementation trials have encountered difficulty
getting supplements to the target population. ICDS data from a recent pregnancy supplementation trial showed
that only 25% of eligible women received the intended supplements, and only 10% actually consumed them. In
>'X;. pregnancy, dietary restriction, in order toproduce a small baby, is still routinely practised. Dr Sachdev proposed
that improvements in birthweight will need multiple measures, aimed to tackle all modifiable factors within a
given community. In India, such measures may include:
• Delayed marriage and child-bearing
• Improvements in the nutrition of women and mothers
• Access to education and ante-natal care
• Adequate rest during pregnancy
• Prevention of tobacco-smoking and chewing
• Better sanitation and living conditions
• Malaria prophylaxis.
FRIDAY 1 im SEPTEMBER
CARDIOVASCULAR DISEASE AND RISK FACTORS
Dr Ashish Bavdekar and Dr Manoj Chinchwadkar - Endocrine, metabolic and cardiovascular correlates
of low birthweight in Indian children (Abstract 7, page 11)
The Pune 4-year old childrens’ study showed that children of lower birthweight had higher glucose and insulin
concentrations 30 minutes after oral glucose11, thought to represent early evidence of insulin resistance. The
children have now been re-studied at 8 years with a larger study sample especially at the extremes of birthweight.
In addition to repeating the risk factors measured at 4 years, urine was collected for estimation of adrenal steroid
hormones, and left ventricular mass, renal and pancreatic dimensions, and (in girls) ovarian volume, were measured
by ultrasound.
After adjusting for current body weight, children of lower birthweight had higher waking (but not sleeping)
systolic blood pressures, fasting and 30-minute insulin concentrations, calculated insulin resistance, subscapular/
triceps ratios, and total- and LDL-cholesterol concentrations. The highest values were in children who had a low
birthweight, but were heavy at 8 years. Thus, although risk factors were more strongly related to current weight
24
Summary
that birthweight, the study provides support for the hypothesis that reduced intra-uterine growth has lasting
endocrine and metabolic effects, and that these changes are detectable in childhood. Urinary adrenal steroids
were strongly related to 8-year body size, but not to birthweight.
The high prevalence of abnormal glucose tolerance in the parents (25% of fathers (mean age 40 years) and 12 %
of mothers (mean age 33 years) had either NIDDM or IGT) highlighted India’s diabetes problem.
Manoj presented preliminary ultrasound data. Mean left ventricular mass was strongly related to current body
size, especially surface area, but not to birthweight. It was not correlated with blood pressure. Pancreatic crosssectional area correlated with 30-minute insulin, but not fasting or 120-minute concentrations. It was unrelated
to birthweight.
Dr Usha Shrivastava - Knowledge regarding coronary risk factors in an Indian urban community (Abstract
8, page 11)
Since the details of the newly-commenced study of coronary risk factors in young Delhi adults have been
presented at earlier workshops, Usha presented data from another study, of public knowledge regarding heart
disease and its risk factors. The subjects, men and women aged 35-64, living in Delhi, were selected to derive a
varied sample in terms of socio-economic status. People’s beliefs were recorded using a questionnaire and focus
group discussions. An ECG was recorded, and a number of CHD risk factors were measured, including
anthropometry, blood pressure and serum cholesterol concentrations.
Levels of knowledge were highest in middle and upper class groups, but poor overall. Only 40% of diabetics
(and 18% of non-diabetics) were aware that diabetes was a risk factor for CHD. Stress was considered the
foremost risk factor (identified by 69% of subjects), and was thought to affect men more than women because of
responsibility outside the home. 59% of subjects said dietary factors were important, but only fried foods were
identified as risky, and ghee was seen as beneficial. Obesity was recognised as a risk factor by 57% of subjects,
and smoking by 54%, although the latter was considered a risk factor for lung disease more than for CHD.
Alcohol was considered very harmful in a general sense; ‘it burns the body’. There was little awareness that lack
of physical exercise, and high intakes of salt, influenced CHD. Usha concluded that public understanding of
lifestyle risk factors for CHD is inadequate, even in this urban setting. Strategies to control cardiovascular
disease should include education programmes informing the population about modifiable risk factors.
Dr Sudha Sane - Perinatal autopsy study (Abstract 9, page 12)
Dr Sane has shown great persistence in continuing this study against all odds, including major equipment failure.
Her aim is to measure organ size and tissue-specific histological characteristics in newborns born at full term but
dying within 7 days of birth, in Mumbai’s KEM Hospital. The study will test the hypothesis that asymmetrical
IUGR, in which the brain-sparing reflex is likely to have operated in utero, is associated with changes in the size
and structure of the heart, blood vessels and abdominal organs. Specifically, she expects an increase in cardiac
left ventricular thickness relative to right ventricular thickness and in the number of nuclei in cardiac myocytes,
reduction in the size of the liver, pancreas and kidneys, reduced numbers of renal nephrons and pancreatic islet
cells, and reduced elastin in the descending aorta and coronary arteries. So far 39 cases have been studied.
Cardiac weight rose with increasing birthweight. There was no relationship, however, between birthweight and
LV mass, LV or RV thickness, or their ratio. The number of nuclei per square millimetre in cardiac myocytes
was significantly increased in babies who had a low birthweight and ponderal index at birth. Liver and adrenal
gland weights were higher in babies with a higher birthweight and ponderal index. We await with interest data
from more cases, and her examination of vascular structure when the image analyser is sorted out.
Dr David Barker - The Helsinki study: a vision of India in the future?
David’s main theme was the nutritional transition, now taking place in many developing countries. A similar
transition in 19,h century Europe was followed by the 20,h century ‘epidemic’ of coronary heart disease and
diabetes.
He started by presenting findings of the Dutch Hunger Winter Study. The Dutch Famine of 1944 started and
ended abruptly. For 7 months the previously well-nourished population was reduced to a mean calorie intake of
500-600 kcal/day. Birthweights fell, although perhaps surprisingly little. The follow-up study has shown poorer
25
Summary
glucose tolerance in men and women who were exposed to famine in utero, especially those whose mothers
were thin, who themselves had a low ponderal index at birth, and who were exposed to famine in mid-late
gestation12. This ‘experiment of history’ shows that diabetes can be caused by intra-uterine under-nutrition. The
epidemiology of NIDDM makes it clear, however, that the disease does not result entirely from being an
undernourished baby born to a thin undernourished mother. The prevalence of the disease is rising in association
with increased affluence and urbanisation.
Finland, which since 1950 has progressed from being a very poor country, is a good place to study the effects of
transition. It has excellent records of birth measurements and childhood growth. The first Finland study showed
that low ponderal index at birth predicted increased adult mortality from CHD1. We now know that though thin
at birth, men who died from CHD had a higher than average body mass index throughout their childhood. In
other words men who were thin at birth and relatively fat as children had the highest mortality. The development
of body fat in children is still poorly understood, but there is some evidence that it is programmed. RollandCachera has shown that BMI at 2 years and 8 years is unrelated to dietary intakes at those times, but dietary
intakes at 2 years predict BMI at 8 years.
Possible explanations for the Finland findings:
• Because of the tendency for BMI to ‘track’, high BMI in childhood may simply be a marker for high BMI
as an adult (the adult BMI of the Finland cohort is not recorded)
• People who were thin at birth may have a low muscle mass. A high BMI in later life may therefore reflect
relatively more body fat.
• An unbalanced journey, from fetal undernutrition to post-natal over-nutrition. In rats, dietary restriction
of the mother during pregnancy followed by over-nutrition post-natally, reduces life-span.
• High childhood BMI may reflect programmed endocrine changes, in the insulin or GH/IGF axes.
These will be explored in future studies in Finland.
The other major finding of the Finland study was that men whose mothers had a high BMI also had increased
CHD mortality. The effect was seen only in short mothers, suggesting that the phenomenon is related to earlylife stunting of the mother. This is also supported by the finding that thin babies born to short fat mothers had
small placentas. In conclusion, the Finland data show that it is bad for an individual to start life as a thin baby
and become a fat child, and bad for the next generation for a thin baby girl to become a short fat mother. This,
David suggested, surely carried some strong public health messages for India.
Discussion: Dr Sachdev suggested that transition will bring these problems and that they are probably
unavoidable. Dr Barker replied that strategies to increase height growth and muscle mass, and avoid fat
deposition, may be possible. Dr Sachdev replied that at the moment we do not know how to change people's
height, or muscle andfat mass. Dr Joshi pointed out the large benefits in terms ofgeneral health and energy of
the nutritional transition. Dr Barker accepted this, but emphasised the major death toll from CHD among
Indian migrants to the west. Dr Armida Fernandes pointed out thatfat is a necessity and that babies needfat to
survive in the perinatal period.
Dr Vasant Athavale - An Ayurvedic approach to IUGR and its impact on health in later life (Abstract 10,
page 12)
We were very grateful to Dr Athavale for coming to the meeting, and for taking a great deal of trouble to
orientate himself to the ‘fetal programming hypothesis’. His lecture was fascinating, and explored concepts
entirely new to many in the audience. The word ‘Ayurveda’ is derived from ‘ayesh’ meaning ‘life’ and ‘veda’
meaning ‘knowledge’. It concerns the science and philosophy of life, and teaches the way to lead a long, healthy
and useful life. It recognises that life is an interaction with a changing environment, and requires constant
adaptation. At the basis of ayurvedic teaching is the concept of each individual’s ‘constitution’, determined by
genetic and environmental factors:
• Pitruja and mitruja: The father’s and mother’s seed, ie genes.
• Atmaja: The soul principle or linga deha resulting from our many previous lives.
• Satvaja: The mind.
• Rasaja: Nutrition and diet. Certain foods are intrinsically thought of as good, for example fresh fruits. Diet
has a broader meaning than just food; everything we see is ‘diet’ for our eyes, and everything we hear is
‘diet’ for our ears.
26
Summary
•
Satmyaja: Adaptation to various environmental factors. The aim is to evolve with each successive life,
towards a state in which, like Buddha or Krishna, one is without tension.
Space, air, energy, water and earth are the 5 basic physical elements of the universe, and as V ATA (space and air),
PITTA (energy and water) and KAPHA (water and earth) make up the bodies and constitutions of living creatures.
The typical VATA constitution is characterised by a small body, physical weakness, a low voice, a tendency to
restlessness and inability to focus. People with this constitution age early and have a short lifespan. As women
they tend to have low birthweight babies. The PITTA constitution is associated with an angry, fiery temperament,
and a quick intelligence. People with a KAPHA constitution are large, sluggish (phlegmatic), slow to understand
but retentive, calm, lazy and live a long life. All 3 constitutions have bad as well as good elements, and a healthy
constitution is a balanced one combining the good qualities from all three: He will enjoy the burning heat of
summer as well as the biting cold of winter’.
Intra-uterine growth retardation is caused by genetic and environmental factors, the most important environmental
factor being nutrition. Ayurveda describes 3 types of fetal malnutrition:
• Upavishtaka: ‘Sitting fetus’, not making progress, ie has stopped growing and moving.
• Upashushkaka: ‘Shrinking fetus’, actually losing weight. Also known as Nagodara (serpent-like
abdomen), ie the abdomen does not bulge in the normal way.
• Leena Gharba: Thin and lean fetus.
Manifestations described in the mother include a failure of abdominal girth to increase, reduced fetal movements
and vaginal bleeding. The causes include maternal factors such as insufficient or unsuitable diet (including
fasting, which is not recommended for pregnant women), suppression of natural urges (coughing, sneezing or
urination), over-exertion, and low maternal age (less than 16 years). They also include constitutional factors in
the fetus, especially over-expression of VATA characteristics. This problem becomes localised to the placenta,
affecting placental blood flow. Treatments recommended include certain foods (eggs, milk, chicken, peacock,
rice, carrot, radish, bilwa shoots), ghee impregnated with medications, application of oils to the abdomen, and
avoidance of aetiological factors.
Ayurveda prescribes a monthly regime for pregnant women, known as Masanumasa. This includes particular
dietary items and medications, specific for the woman’s constitution and stage of pregnancy, and aimed at
promoting fetal growth. It also recommends the ideal environment in pregnancy, with ‘good sensory inputs
such as music and fragrance, and the ideal code of conduct for the mother. Ayurveda says that the mother and
father should not be related to each other within 7 generations. It also recommends dietary changes in the preand periconceptual time, to promote the health of the fetus.
Returning to the programming hypothesis, Dr Athavale said that Ayurveda sees life as a continuous process
from birth to death. There is no concept of a ‘crucial’ or ‘critical’ period when the individual can be permanently
programmed. Rather, the opportunity for adaptation and improvement exists throughout life.
SATURDAY 12* SEPTEMBER
FOCUS ON WOMEN AND MOTHERS
Dr J Richard - Birthweight and age at menarche (Abstract 11, page 13)
Like Dr Shrivastava, Dr Richard decided not to present details of the Vellore arm of the British Heart Foundation
Study again this year. He analysed age at menarche in a sub-set of the same cohort of children, bom in rural and
urban areas of Vellore during 1969-1973. 278 girls were studied. Their mean birthweight was 2747g. Themean
age at menarche was 14.4 years (SD 1.2; range 11-19 years). There was a correlation between age at menarche
and birthweight (r=-0.136, p=0.023) such that girls with a higher birthweight attained menarche earlier. Although
statistically significant, this correlation was not impressively strong when displayed using a scatterplot. These
findings differ from those of two studies in the west: a study of one of the UK national cohorts, which showed
earlier menarche in girls of lower birthweight13, and Proos’ study of low birthweight Indian children adopted in
Sweden14. Further analysis is planned, taking into account childhood weight and height, which also influence
menarche.
27
Summary
Dr B Antonisamy - Recurrence of low birthweight in successive pregnancies (Abstract 12, page 14)
Dr Antonisamy examined maternal, genetic, obstetric, and socio-economic factors associated with recurrence of
low birthweight in two successive pregnancies, within the 1969-73 Vellore cohort. 475 mothers had two
pregnancies within the cohort, with birthweight available for both babies. Dr Antonisamy divided them into 4
groups, depending on low (<2.5 kg) or normal birthweight:
Group
l’1 pregnancy
2Bd Pregnancy
Frequency (%)
A
Normal birthweight
Normal birthweight
69
B
Low birthweight
Normal birthweight
11
C
Low birthweight
Low birthweight
7.5
D
Normal birthweight
Low birthweight
12.5
Recurrence of low birthweight occurred more frequently in rural (9.5%) pregnancies, than in urban pregnancies
(5.3%). Risk of recurrent low birthweight was raised in teenage mothers (RR 4.1), mothers of low body weight
(<40 kg: RR 2.9) and short stature (<145 cm: RR 3.5), and pregnancies where the father was uneducated (RR
2.6).
Dr Debabrata Chatterjee - Low birthweight babies in Bengali mothers (Abstract 13, page 14)
Dr Chatterjee presented data from a survey of 100 low birthweight babies born during a one year period (June
1997 to May 1998) in 2 Calcutta hospitals. Criteria for selection were birthweight <2.5 kg (irrespective of
gestation), a healthy mother, baby examined within one hour of birth, and no major congenital abnormality. The
babies were measured in detail, and data were collected on blood group, parental income and socio-economic
status, maternal age, education and age at menarche, and contraceptive methods.
There was no consanguinity. Mean age at menarche of the mother was 13 years, and earlier menarche was
associated with lower birthweight. An unexpected finding was that babies of blood group O, and babies whose
mother and/or father were of blood group O had lower birthweights.
Discussion: This study would have been more informative ifa control group of ‘normal weight babies had been
included, and ifLBW due to prematurity and IUGR were examined separately. Thefindingfor blood group was
interesting — there may be data in Pune and Mysore in which this could be examined.
Dr Armida Fernandes - Trace elements in maternal and cord blood (Abstract 14, p 15)
Relatively little is known about the relationship between trace elements and fetal growth, although higher maternal
zinc (Zn), copper (Cu) and iron (Fe) have been associated with larger size at birth, while lead (Pb) and cadmium
(Cd) have been associated with reduced fetal growth. Armida examined Zn, Cu, Fe, Pb and Cd in maternal and
fetal (cord) blood samples, and correlated these with size at birth. 85 mother-baby pairs delivered in LTMG
(Sion) Hospital were studied. Cases of maternal diabetes, renal failure, heart disease and tuberculosis were
excluded. Studied cases were divided into 3 groups according to birthweight and gestation: a) normal full-term
(birthweight >2.5 kg, gestation >37 weeks), b) preterm, and c) full-term low birthweight.
For all five trace elements, cord blood levels correlated positively with maternal blood levels. Iron concentrations
were significantly higher in the baby than the mother. Birthweight correlated positively with cord blood levels
and maternal levels of Zn, Cu and Fe, but was unrelated to Pb and Cd (see table).
28
Summary
Birthweight (kg)
Maternal weight (kg)
Blood zinc (|ig/dl)
Mother
Baby
Blood copper (|ig/dl)
Mother
Baby
Blood iron (|ig/dl)
Mother
Baby
A Normal full-term
(n=29)
B Preterm
(n=26)
C Full-term, low
birthweight (n=30)
2.7
47.5
1.7
45.4
2.1
44.5
840
439
660
204
675
313
226
61
116
42
125
47
47
58
37
45
38
51
Dr Jayshree Mondkar - Maternal and placental determinants of fetal growth
Jayshree presented findings of the study she and Dr Vasundara Kanbur carried out, of pregnant women living in
Dharavi, Mumbai, and delivering in LTMG (Sion) Hospital. The main aims were to correlate maternal
anthropometry and placental histology to fetal growth (measured by ultrasound and neonatal anthropometry).
Inclusion criteria at booking were: a certain LMP date, gestation less than 16 weeks, singleton pregnancy, and no
known major maternal disease. Maternal anthropometry, and fetal anthropometry on ultrasound, were measured
at 16, 20, 28, 32 and 36 weeks gestation.
The study was hampered by difficulty getting the women back for follow-up; many mothers decided to deliver
elsewhere. Of 116 women recruited, 51 were followed through to delivery. The womens’ characteristics at
booking were as follows: age 21 years, weight 44.7 kg, height 151.4 cm, body mass index 23.1 kg/m2, triceps
skinfold thickness 4.8 mm and subscapular skinfold 11.4 mm. Mean birthweight, birth length, head circumference
and placental weight were 2.61 kg, 49.1 cm, 33.7 cm and 463 g respectively. (Editorial note: Anthropometric
measurements were made using the same techniques as for the rural women in the Pune maternal Nutrition
Study. The Mumbai maternal values are similar to those recordedfor Pune rural women at a similar stage of
pregnancy. The babies were also ofsimilar weight in Pune (2.67 kg), while length and head measurements were
slightly smaller (47.8 and 33.1 cm). Mean placental weight was smaller in Pune (mean 360 g), but the Pune
placentas were trimmed ofcord and membranes before weighing.)
There were positive correlations between maternal weight gain in pregnancy, and the baby’s weight, mid-upper
arm circumference and skinfold thicknesses at birth. There was a high correlation (r=0.6) between placental
weight and birthweight. 33% of placentas showed gross pathology. On histology, lower birthweight was associated
with larger terminal villous diameter. The fetal ultrasound data are still to be analysed.
Dr CS Yajnik- Cord blood data from the Pune urban study
Ranjan presented data from the KEM Hospital ‘urban’ study (January-May 1998) which was designed to collect
data on urban mothers and babies comparable to that for the rural (PMNS) community. Anthropometry of
mothers and babies delivered at the KEM Hospital was measured within 24 hours post-delivery. The study
differed from the PMNS in that it was not community-based, and maternal anthropometry was measured for the
first time post-delivery.
Of 471 babies born in KEMH during the study period, maternal anthropometry was obtained for 353, and
neonatal anthropometry for 290. At delivery, blood was taken from mothers and babies (cord blood) for
measurement of haemoglobin, plasma glucose, and serum lipids, albumin and total protein. Blood was obtained
from 206 mother/baby pairs. Other data collected included a ‘migration’ history for the mother, ie. location
(rural/urban) at birth, during childhood and currently, and ultrasound measurements of neonatal subcutaneous
fat thickness.
Urban mothers were heavier, taller and fatter than rural mothers (Table). The babies were heavier, and slightly
fatter, though the differences are small. Placental weight was heavier in the urban sample, though Ranjan
queried whether this was a true difference, or due to the fact that the rural placentas were weighed after a longer
interval post-delivery.
29
Summary
MOTHERS
PUNE URBAN (n=353)
PMNS RURAL
Weight (kg)
Height (cm)
BMI (kg/m2)
Head circumference (cm)
Triceps (mm)
Subscapular (mm)
Biceps (mm)
Supra-iliac (mm)
Fat mass (kg)
Muscle mass (kg)
53.7
153.1
22.8
53.5
14.0
20.0
7.3
17.1
16.3
15.8
51.6
152.0
22.3
52.3
11.0
14.7
6.7
11.8
12.2
15.3
BABIES
PUNE URBAN (n=290)
PUNE RURAL
Birthweight (kg)
Birthlength (cm)
Ponderal index (kg/m3)
Head circumference (cm)
Triceps (mm)
Subscapular (mm)
Mid-upper-arm (cm)
Abdomen (cm)
Placenta (g)
2.788
47.8
2.57
33.3
4.4
4.2
9.8
28.8
420
2.665
47.8
2.44
33.1
4.2
4.2
9.7
28.6
360
A high proportion of mothers had pregnancy-induced hypertension (PIH, 32%), perhaps reflecting referral of
high-risk cases to the KEM. Their babies were small and thin. Babies born to diabetic mothers were large in all
dimensions, including length (Table).
KEM Urban Study
PIH (n=94)
DM (n=10)
2.301
47.3
25.2
32.7
4.1
3.9
9.4
27.9
382
2.970
51.4
25.4
34.0
5.4
5.3
10.5
30.6
500
Birthweight (kg)
Length (cm)
Ponderal index (kg/m3)
Head circumference (cm)
Triceps (mm)
Subscapular (mm)
MU AC (cm)
Abdomen (cm)
Placenta (g)
Maternal triglycerides and cholesterol concentrations were (as in the PMNS) positively correlated with birthweight,
and cholesterol and HDL-cholesterol concentrations with the baby’s skinfold measurements. Cord blood
triglyceride concentrations were inversely correlated with neonatal skinfold thicknesses. Maternal and cord
blood glucose (but not lipid) concentrations were highly correlated. Unlike glucose there is no direct crossplacental transfer of triglycerides, which have to be converted first to fatty acids. There was striking maternal
hyperglycaemia at the time of delivery; more than 50% of the mothers had a plasma glucose of > 140 mg/dl, even
when not on IV fluids, and this was most marked in premature deliveries. Is this a ‘stress’ response? There were
no relationships between maternal glucose at this time, and either maternal or neonatal anthropometry.
30
Summary
Dr Lakshmi Lingam - Women, education and health (Abstract 15, page 15)
Laksmi gave us a comprehensive referenced manuscript relating to the education and health of Indian women
(see abstract 15). Here I will summarise information which did not appear in this manuscript, and especially that
relating to ‘fetal’ matters. Lakshmi told us that as the only social scientist in the meeting she felt like a ‘fish out
of water*, but that she also felt that the strange current in which she found herself, was a friendly one. We greatly
appreciate the fact that she was willing to take the plunge!
Data from many countries show that infant mortality rates are inversely correlated with the level of education of
women. The National Family Health Survey (1992) confirmed that this phenomenon holds true in India. Recent
international policies for development enshrine the idea that empowering women to make choices will lead to
healthier, smaller and better nourished families, and better preservation of the environment. This is borne out by
data from India. Lakshmi outlined how the emphasis of government policies relating to the health of the population
has changed since Independence. Recent policies incorporate a ‘bottom-up’ programme, in other words, an
emphasis on training local village-level workers, like ANM’s. Now, also, the ‘girl child’ has come into focus,
with the realisation that though naturally and biologically stronger than the male, culturally many forces conspire
throughout childhood to weaken her. Lakshmi criticised the over-narrow continuing emphasis, in terms of policy
for womens’ health, on reproductive health issues.
Scientific proof that certain measures lead to better health are not enough on their own. To get people to change,
it is important to know how they think. For example ‘fatness’ is so strongly associated in the public psyche with
prosperity that it is difficult to persuade people that it can possibly be unhealthy. While a middle-class educated
mother appreciates the importance of nourishing her fetus, and makes sure she ‘eats for two’, many poorer
women still try to eat less, to make the baby as small a possible in order to ensure an easier delivery.
Mrs Ginny Chorghade-Socio-cultural influences on the nutrition of girls and women in rural Maharashtra
(Abstract 16, page 20)
Ginny described her study, which is taking place in Pabal, one of the PMNS villages. She is using communityand household-level techniques to investigate why young women are so poorly nourished in this community.
Focus group discussions identified factors that determine food intake and workload. Men are the ones who hold
the ‘purse-strings’ for buying food, although women invariably prepare it. Men also tend to eat first in the
household, and often do not know how much food their wives are getting. Although it was acknowledged that
girls get a slightly lower priority than boys when they fall sick, there was not a marked difference, and no
evidence that girls are neglected in this sense. Criteria for selection of a bride are that she is able to work hard,
and not be taller or better educated than her husband. On marriage, women said their food intakes changed little,
but workload increased enormously. This was especially the case within the increasingly common nuclear families.
Despite their heavy workload, there is a general expectation to produce a child within the first year after marriage.
In pregnancy, almost all are advised by the older women in the family to eat less and work hard. Most women
fast, as often as 2 days per week, and for a variety of reasons, including the welfare of the husband and ensuring
birth of a male child. One of Ginny’s most interesting findings so far is that ‘bride price’ has largely been
replaced by dowry in this community in recent years, and that social changes within the villages are encouraging
the dowry system. In the past girls expected to marry into farming families. Now, with the beginnings of rural
industrialisation and greater mobility, there are other alternatives, and, if their families can muster sufficient
dowry, girls have the chance to marry factory workers or government employees in nearby towns. Thus a good
dowry is seen as a way of getting your daughter out of a life of hard physical labour as a farmer’s wife.
Ginny’s study is now progressing to the stage of detailed questionnaire-based assessment within selected
households.
31
Summary
Dr David Barker - Mothers and babies in Beijing
Picking up on earlier discussion, David expressed the opinion that epidemiological transition in India does not
inevitably mean an epidemic of CHD. He cited France as an example of a country which has largely escaped the
disease despite a rapid transition to affluence over the last 200 years. History clearly shows the environmental
factors which impair fetal growth and lead to CHD; the areas of Britain which had low birthweights in the past,
and have high CHD rates now, were characterised by:
• poor agricultural land
• urban industrial development which led to employment of women in appalling working conditions
• unsanitary living conditions
• poorly paid heavy physical labour (eg coal-mining) where shortage of food meant that it all had to go to the
men, to allow them to work
Moving on to the main subject of his talk, David described the Beijing study of cardiovascular risk factors in
men and women born in the Peking Union Medical College Hospital during 1948-54. This was one of the few
hospitals to survive relatively unscathed from the Cultural Revolution. Data recorded included maternal weight
and height in early and late pregnancy, and the weight, length and head circumference of the babies at birth. In
addition to placental weight, detailed line drawings of the appearance of the placenta were recorded — although
it was not clear how to use these diagrams in the analysis. 795 people were traced, 86% of whom took part in the
study.
The mothers had a mean height of 156 cm (PMNS 152 cm; Southampton 163 cm), and a mean early pregnancy
weight of 51 kg {PMNS 44 kg; Southampton 65 kg). The Chinese babies had a small mean head circumference
(31.9 cm; PMNS 33.1 cm; Southampton 35.2 cm) and length (49.4 cm; PMNS 47.8; Southampton 50.2) at birth,
but were relatively heavy (birthweight 3.1 kg; PMNS 2.7 kg; Southampton 3.4 kg) and fat (ponderal index 25.6
kg/m3; PMNS 24.1; Southampton 27.1). David speculated that these characteristics reflect down-regulation of
intra-uterine growth at an early stage of gestation in Chinese babies. As in western populations, lower birthweight
and thinness at birth (low ponderal index) were associated with higher adult blood pressure, impaired glucose
tolerance and insulin resistance. There were no associations between size at birth and adult concentrations of
LDL-cholesterol or fibrinogen. The pattern of growth of Chinese babies, with ‘symmetrical’ growth retardation,
may prevent sacrifice of liver growth.
Maternal body mass index (measured during pregnancy) predicted adult glucose tolerance in the offspring. Men
and women born to thinner mothers were more likely to be diabetic. However, there was also evidence of a Ushaped relationship, such that the offspring of very fat mothers also had raised 120-m inute glucose concentrations.
There may be an ‘ideal’ body mass index in terms of future glucose tolerance in the offspring. Maternal weight
gain in pregnancy did not predict adult cardiovascular risk factors.
SUNDAY 13* SEPTEMBER
THREE KEY STUDIES IN GESTATION
Dr Jacqui Hill - The Mysore Parthenon Study (Abstract 17, page 21)
Jacqui described her ongoing study into the relationship between maternal glucose tolerance and fetal growth.
She is carrying out OGTT’s at 28 weeks gestation, in women booking antenatally at HMH, Mysore. Blood
samples will be analysed for insulin and glucose to study glucose tolerance, and insulin resistance and secretion.
The main research questions Jacqui will be asking are:
• Do lower birthweight, shorter, fatter mothers develop higher blood sugars during pregnancy?
• Is relative maternal hyperglycaemia within the normal range associated with changes in the baby’s phenotype
and cord blood insulin concentrations at birth?
Data collected so far show that the Mysore urban mothers are markedly fatter, but only slightly taller, than the
Pune rural mothers, and that the babies are larger in all dimensions. Data collection will be complete in December
1998, and the results will be ready for the next meeting. In the longer term, the babies will be followed up (by
Dr Krishnaveni) to examine the relationship of maternal glucose and insulin metabolism in pregnancy to the
development of the child’s glucose and insulin metabolism.
Summary
PUNE
(PMNS)
n=633
MYSORE
(Parthenon)
n=534
Mothers
Weight (kg)
Height (m)
Triceps (mm)*
Subscapular (mm)*
SS/TR
Babies
Birthweight (kg)
Length (cm)
Head circ (cm)
Triceps (mm)*
Subscapular (mm)*
Abdomen (cm)
MUAC (cm)
Placenta (kg)
17.2
24.4
(9.0)
(0.06)
(12.3,24.5)
(18.0, 34.1)
1.42
56.5
1.55
47.3
1.52
9.2
(5.2)
(0.05)
(7.1, 11.4)
(10.1, 15.9)
(1.2, 1.7)
12.9
1.4
2.898
48.8
(0.43)
2.633
(0.06)
47.8
(0.35)
(2.0)
33.9
(13)
4.2
4.4
(3.7, 4.8)
(3.9, 4.9)
(2.0)
(0.9)
(0.36, 0.47)
33.1
4.1
29.9
10.4
0.41
4.1
28.6
9.7
0.36
(0.4)
(1-2)
(3.6, 4.6)
(3.6, 4.6)
(1.9)
(0.9)
(0.08)
SOUTHAMPTON
(Wellbeing)
n=519
73.3
(11.7)
1.64
19.5
17.7
1.0
(0.06)
(15.4,24.7)
(13.3,25.1)
(0.8,0.9)
3.448 (0.46)
49.9
(2.0)
35.0 (1.2)
not
not
33.4
measured
measured
11.6
(1.6)
(0.9)
0.57
(0.13)
Mean and SD given; *for logged variables, mean and interquartile range
Dr Arun Kinare - Cardiac development in utero (Abstract 18, page 21)
Arun described his proposed study into the relationship of fetal cardiac morphology to placental resistance. It
will test the hypothesis set out at last year’s meeting by Dr Kent Thornburg, that in IUGR placental resistance
leads to increased right ventricular overload, which permanently alters the structure of the heart. Arun and
Manoj Chinchwadkar visited Kent’s unit earlier in 1998, to become familiar with ultrasound measurement of the
fetal heart. They now plan to do a pilot study, of 5 normal and 15 growth-retarded fetuses at 20 weeks gestation.
Measurements of fetal somatic growth (BPD, abdominal circumference, femur length), amniotic fluid index,
cardiac dimensions, and flow indices in umbilical and other vessels, will be made 20, 28 and 36 weeks, using Bmode, M-mode and Doppler ultrasound techniques. Middle cerebral artery flow will not be measured as it is
very influenced by treatment. Echocardiography will also be carried out in the neonatal period. The fetal
measurements take about one hour per visit, and can be difficult due to the small size of the fetal heart and
vessels, variable fetal position, and the need to make measurements at precise angles. Studies in Singapore have
shown greater difficulty in making fetal ultrasound measurements in mothers of Indian origin because of greater
deposits of abdominal fat.
Caroline Fall - ‘Finlindia’ - the Delhi and Vellore studies (Abstract 19, page 22)
The Delhi and Vellore groups did not want another detailed presentation of these studies this year. However,
since funding for the studies has now arrived, and in the light of new knowledge since last year, their special role
deserves to stay fresh in everyone’s mind. The Finland data have been referred to on several occasions during
this meeting: they have enabled study of maternal effects, and effects of childhood growth patterns, on adult
disease. The Delhi and Vellore data will allow similar analyses - hence the invention of this word ‘Finlindia’.
In terms of maternal effects: data from Finland, Beijing and Mysore suggest that both extreme thinness and
extreme fatness in the mother can have adverse effects on the offspring. We hope the Delhi and Vellore studies
will give us information on the ‘ideal’ range of BMI for height, for women before pregnancy. In terms of
childhood growth: the Finland and Pune (8-year-old study) data suggest that high body fat in childhood is
associated with increased CHD risk. We hope that the Delhi and Vellore studies will help determine ideal
patterns of childhood growth, and shed light on a) parental influences on these patterns of growth, and b) their
endocrine correlates.
33
Summary
Sabita Saldanha - The Mumbai office and how it can help you
Sabita informed everyone of the new Mumbai office address (see page 38), and reminded us of the facilities it
offers, including Medline searches, the SNEHA newsletter, and help with transfer of information, equipment,
and samples between India and Southampton. She described future plans to set up a Powerpoint slides service.
Suggestions put forward for other useful services the office could offer included the development of a SNEHA
website (see overleaf), and a list of contact addresses (including e-mail addresses) for all members.
Dr Potdar - Final words
It’s always a shame to precis Dr Potdar’s words, but these were the main points:
•
If Sneha’s members want the organisation to have a future as an agent for change this will depend on all the
groups developing a sense of‘fellowship’ with each other and being able to work together in an orchestrated
•
way.
A SERVICE or INTERVENTIONAL element should start to be introduced into our research investigations,
•
at least in a small way or in subsets. In this we would benefit from the help of social scientists.
Sneha should do more to increase its profile by getting sessions and workshops within specialist meetings
•
and conferences.
Sneha should look for sources of funding within India, and think about developing LOCAL strategies for
this.
References
i. Forsen T et al. Mother’s weight in pregnancy and coronary heart disease in a cohort of Finnish men: follow up study.
BMJ 1997;315:837-40.
2. Leon DA et al. Reduced fetal growth rate and increased risk of death from ischaemic heart disease: cohort study of
15,000 Swedish men and women born 1915-29. BMJ 1998;317:241-5.
3. Dunger D et al. Association of the INS VNTR with size at birth. Nature Genetics 1998;19:98-100.
4. Hattersley A et al. Mutations in the glucokinase gene of the fetus result in reduced birthweight. Nature Genetics
1998;19:268-70.
5.
6.
7.
8.
9.
Henry J A et al. The effects of genotype and infant weight on adult plasma levels of fibrinogen, factor VII, and LDLcholesterol are additive. J Med Genet 1997;34:553-8.
Joseph KS et al. Should we intervene to improve fetal growth? In: A Life Course Approach to Chronic Disease
Epidemiology. Eds.Kuh D, Ben-Schlomo Y. Oxford University Press, Oxford, 1997.
Phillips DI W et al. Elevated plasma cortisol concentrations: a link between low birthweight and the insulin resistance
syndrome? J Clin Endocrinol Metab 1998;83:757-60.
Sachdev HPS. Low birthweight in South Asia. In: Malnutrition in South Asia: A Regional Profile. Ed. Gillespie SR.
Rosa Publication No.5, Unicef, Regional Office for South Asia, Kathmandu, Nepal, 1997; pp23-50.
National Neonatology Forum. Neonatal morbidity and mortality - report of the National Neonatal/Perinatal database.
Indian Pediatrics 1997;34.
10. Kramer MS. Determinantsof low birthweight: methodological assessment and meta-analysis. Bull WHO I987;65:663737.
11. Yajnik CS et al. Fetal growth and glucose and insulin metabolism in four year old Indian children. Diabetic Med
12:330-336,1995.
12. Ravelli ACJ et al. Glucose tolerance in adults after prenatal exposure to famine. Lancet 1998;351:173-77.
13. Cooper C er a/. Childhood growth and age at menarche. BrJOG 103:814-817,1996.
14. Proos LA. Growth and development of Indian children adopted in Sweden. Acta Universitalis Upsaliensis, Upsala
University, 1992.
Summary compiled by Caroline Fall, with help from Sabita Saldanha, K Kumaran, Jacqui Hill, and Ginny
Chorghade.
34
Important News
NEXT MEETING
THE 1999 WORKSHOP WILL BE HOSTED BY THE VELLORE
GROUP, AND WILL TAKE PLACE OCTOBER 8th - 10th,
Venue: Mahabalipuram
SABITA SALDANHA
DEPARTURE
AS MANY OF YOU KNOW, SABITA IS GETTING MARRIED IN MAY 1999, AND
WILL BE LEAVING US TO LIVE IN THE USA. WE WOULDLIKE TOSAYTHANK
YOU FOR ALL YOU HA VE DONE FOR MRC AND SNEHA. YOU HA VE BEEN A
GREAT COLLEAGUE. WE WISH YOU ALL THE VERY BEST FOR YOUR
WEDDING AND IN YOUR NEW LIFE. PLEASE KEEP IN TOUCH.
ALIFIYA MOTIWALA WILL TAKE OVER FROM SARITA ON APRIL 9th 1999.
WEBSITE
THIS IS NOW IN PREPARATION. WOULD ALL MEMBERS PLEASE SEND A
PHOTOGRAPH AND 200-WORD SUMMARY OF THEMSELVES TO THE
MUMBAI OFFICE. THIS SHOULD INCLUDE QUALIFICATIONS, CLINICAL
EXPERTISE, AND RESEARCH INTERESTS, PLUS THE REFERENCE OF
YOUR SINGLE MOST IMPORTANT RECENT PUBLICATION.
FOR FURTHER DETAILS OF THESE AND OTHER MRC/SNEHA
MATTERS CONTACT:
Ms ALIFIYA MOTIWALA,
Plot No. 6, F Block,
Opp. Bldg. No. 326, C. G. S. Colony,
Bandra East, MUMBAI - 400 051.
Tel: (00 91) 22 6516439 or 6456763
Fax: (00 91) 22 6516438
E-mail: mrcssc@bom2.vsnl.net.in
35
- Media
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