Elsevier

The Lancet

Volume 348, Issue 9037, 9 November 1996, Pages 1269-1273
The Lancet

Articles
Fetal growth and coronary heart disease in South India

https://doi.org/10.1016/S0140-6736(96)04547-3Get rights and content

Summary

Background

Coronary heart disease is predicted to become the commonest cause of death in India within 15 years. People from India living overseas already have high rates of the disease that are not explained by known coronary risk factors. Small size at birth is a newly described risk factor for coronary heart disease, but associations between size at birth and the disease have not been examined in India.

Methods

We studied 517 men and women who were born between 1934 and 1954 in a mission hospital in Mysore, South India, and who still lived near to the hospital. We related the prevalence of coronary heart disease, defined by standard criteria, to their birth size.

Findings

25 (9%) men and 27 (11%) women had coronary heart disease. Low birthweight, short birth length, and small head circumference at birth were associated with a raised prevalence of the disease. Prevalence fell from 11% in people whose birthweights were 5·5 Ib (2·5 kg) or less to 3% in those whose birthweights were more than 7 Ib (3·1 kg), p for trend=0·09. The trends were stronger and statistically significant among people aged 45 years and over (p=0·03 for birthweight, 0·04 for length, and 0·02 for head circumference). High rates of disease were also found in those whose mothers had a low body weight during pregnancy. The highest prevalence of the disease (20%) was in people who weighed 5·5 Ib (2·5 kg) or less at birth and whose mothers weighed less than 100 Ib (45 kg) in pregnancy. These associations were largely independent of known coronary risk factors.

Interpretation

In India, as in the UK, coronary heart disease is associated with small size at birth, suggesting that its pathogenesis is influenced by events in utero. The association with low maternal bodyweight is further evidence that the disease originates through fetal undernutrition. Prevention of the rising epidemic of the disease in India may require improvements in the nutrition and health of young women.

Introduction

Coronary heart disease is both common and on the increase in India. Rates of death from coronary heart disease are expected to overtake those from infectious disease by around the year 2010.1 High rates of coronary heart disease have also been recorded in Indian populations living in the UK and are largely unexplained by known coronary risk factors.2 Associations have been demonstrated between small size at birth and coronary heart disease and its risk factors, hypertension, non-insulin dependent diabetes, and abnormalities in lipid metabolism and blood coagulation.3, 4, 5, 6 These associations are independent of adult lifestyle, including smoking, obesity, and social class, and have led to the hypothesis that the disease is programmed in utero. The fetal origins hypothesis proposes that adaptations made by the fetus in response to undernutrition lead to persisting changes in metabolism and organ structure. This hypothesis is supported by experimental evidence in which offspring of undernourished pregnant animals show permanent changes including raised blood pressure and abnormal glucose-insulin and lipid metabolism.7, 8, 9

Low rates of fetal growth and small size at birth are common in India. To explore associations between fetal growth and coronary heart disease in India we traced 517 men and women who were born in a hospital in the city of Mysore, South India, where detailed records have been kept on each birth since 1934.

Section snippets

Methods

Holdsworth Memorial Hospital is a mission hospital governed by the Church of South India. It was built as a maternity hospital in 1905 and is in a poor, crowded area of the city. Since 1934 birthweight, length, and head circumference have been recorded routinely for babies born in the hospital. These measurements were made by one of three midwives over the period of our study, under an agreed protocol. The birth records also contain the parents' names, occupations, address, religion or caste,

Results

The age range of the 517 men and women was 38–60 years (mean 47 years). 184 (36%) were Hindu, 279 (54%) were Muslim, and 54 (10%) were Christian. The men and women were short, light, and thin (table 1) compared with British people of the same age.15 They were smaller at birth in all measurements compared with babies born in the UK,16, 17 the difference being most pronounced for birthweight. Their mean (SD) birth measurements were birthweight 6·1(0·9) Ib, birth length 18·9(1·2) inches, and head

Discussion

Mysore City has changed little in the past 50 years and still has no major industries. By European standards the city is overcrowded and has poor sanitation and housing, but there is no poverty of the kind seen in the slums of large Indian cities. The people of Mysore are relatively well nourished, although men and women are considerably shorter than in British populations, and the men are thinner. Tobacco smoking is common among men, but only one woman in our study smoked. The prevalence of

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