(Benediktsson et al., 1993; Lindsay et al., 1996). Pro- tein deprivation and glucocorticoid excess are likely related. In utero, excess cortisol may occur either from fetoplacental stress (and undernutrition is one type of stress), or from deficiency in the normal placental en- zyme barrier that protects the fetus from its mother’s glucocorticoids.
The fetus normally has much lower levels of physiologic glucocorticoids than the mother, owing to their rapid conversion by placental 11-β-OHSD to in- ert forms. This placental barrier is effective in protect- ing the fetus against overexposure to corticosteroids. The enzyme is normally maintained in humans until the end of gestation, but it may be attenuated in IUGR, which would explain higher cortisol levels observed in growth retarded human fetuses (Goland et al., 1993; Seckl, 1998a,b). An inverse association of plasma cor- tisol concentrations and birth weight was observed in adults aged from 20 to 65 years from three different populations (Phillips et al., 2000). Birth length (but not PI) was also inversely correlated with cortisol. This association was independent of age, sex, smoking, current body weight, and socioeconomic status. Plasma cortisol was positively correlated with blood pressure, and this relationship was stronger in obese people, sup- porting an amplification role of the programming effects by obesity.
Permanent alterations in the expressions of gluco- corticoid receptors in specific tissues of the offspring and hyperactivity of the HPA axis (Levitt et al., 1996) may contribute to the observed rise in blood pressure and glucose. Chronic activation of the HPA axis with high fetal cortisol levels could permanently alter gene expression through chromatin remodeling, as sug- gested by Radunovic et al. (2000). In the protein restricted rat model, the offspring had glucocorticoid- dependent raised systolic blood pressure throughout life, there was a marked decline of expression of 11-β- OHSD, and the expression of glucocorticoid (but not mineralocorticoid) receptor protein and mRNA was reduced (Bertram et al., 2001). Observations of an in- verse association of birth weight with plasma cortisol concentrations in human adults (Phillips et al., 2000),
F
rom experimental data, there is clear evidence that transient events in early life have permanent and profound effects on physiology and metabolism. Impaired structure or function, or metabolic adapta- tions, may link unfavourable intrauterine exposure and chronic disease. For instance, in the case of type-2 diabetes, pancreatic β-cell function (Hales et al., 1991; 1996), or insulin action (Phillips et al., 1994) may be impaired. Fetal programming by nutritional and hor- monal factors has been demonstrated in animals, and there is growing evidence from experimental, clinical, and epidemiological data, that it also operates in humans. The underlying mechanisms are not clear, although animal models provide more than hints on the molecular basis of programming itself and of its metabolic consequences (Holness, Langdown & Sugden, 2000). Lucas (1998) speculated that nutrients may be critical signals acting on receptors in sensitive tissues. When programming, or resetting of a later function is involved, a key question is: how is the memory of these early events stored throughout life in spite of continuous cell replication and renewal? Pro- posed mechanisms include adaptive effects on gene expression, or on differential cell proliferation for which there is indirect evidence from animal studies. Intergenerational effects of programming may be ex- plained by epigenetic inheritance, based on DNA meth- ylation (Holliday, 1993).Alterations in set-points of major hormonal axes are now gathering support as the most likely dominant mechanisms of fetal programming. In particular, the IGF-1 and insulin axis, and the HPA axis are suspected of important modifications in fetal malnutrition, which could explain increased CVD and insulin resistance syndrome in adulthood.
5.1 Fetal glucocorticoids and resetting of the
hypothalamus-pituitary-adrenal axis
From animal studies, it is inferred that maternal nu- tritional deprivation or imbalances, (particularly pro- tein) and fetal exposure to excess glucocorticoids, may result in higher blood pressure and hyperglycemia
and of a positive association of cortisol with insulin resistance, blood pressure triacylglycerol level, fasting and 2-h glucose (Phillips et al., 1998; 2000) are con- sistent with programming of the HPA axis in utero.
The role of intrauterine glucocorticoids and the long-term consequences of high fetal exposure was re- viewed (Fowden, Li & Forhead, 1998; Dodic et al., 1999). Prenatal glucocorticoids stimulate tissue differ- entiation and hence organ maturation rate, including the lung, heart, kidney, and immune system. They co- ordinate the various adaptations needed to survive the transition from intra- to extra-uterine life. While in normal conditions glucocorticoid concentrations only rise before term as a signal for tissue maturation, fetal cortisol levels become elevated earlier, possibly as a consequence of HPA axis activation, in stressful intrau- terine conditions such as placental insufficiency, un- dernutrition, or restricted blood flow. Elevated cortisol induces an early shift from cell proliferation to cell dif- ferentiation, with an inappropriate pattern of growth for the stage of development, and possibly adverse con- sequences much later in life. Fetal glucocorticoid ex- cess may achieve a short term benefit by increasing the availability of glucose and other fuels, but adverse effects may result in the longer term. Glucocorticoids may well have a pivotal role in the prenatal program- ming of adult disease. According to Langley-Evans et al. (1999), the chain of events leading from glucocorti- coid action in the fetus to hypertension in the adult involves the development of hypersensitivity to glucocorticoids in adult life, with activation of the renin-angiotensin system, and increased sensitivity of the vessels to angiotensin II. Glucocorticoids can also impair the development of blood vasculature and pro- gramme the renin-angiotensin system of the kidney, as suggested by animal studies (Langley-Evans & Jackson, 1994; Langley-Evans et al., 1999; Martyn, Barker & Osmond, 1996). Impaired fetal nephrogenesis is also likely involved, with lifelong impact on renal function and cardiovascular control. Low birth weight babies have fewer nephrons, and this may be related to the renin-angiotensin involvement in explaining higher blood pressure in such individuals. Additional evidence for programming of the sympatho-adrenal function comes from the observation that resting pulse rate, an indicator of increased sympathetic nervous system activity, is raised in subjects with LBW (Phillips & Barker, 1997; Pharoah, Stevenson & West, 1998).
The hypercorticoidism of the fetus exposed to ex- cessive maternal cortisol could not only enhance sus- ceptibility to hypertension but also reset, in the long term, the HPA axis controlling cortisol metabolism (James, 1997; Lesage et al., 2001). While severe mater-
nal undernutrition was shown in rats to activate ma- ternal HPA and affect the development of fetal HPA axis secondary to transplacental corticosterone trans- fer (Lesage et al., 2001), Gluckman (2001) suggests that less severe undernutrition may cause more subtle elevations in fetal glucocorticoid exposure which may impair fetal growth, but without impacting on fetal HPA axis development. Such resetting of the HPA axis controlling cortisol metabolism has been observed in adults who have abdominal obesity (Björntorp, 1993). While stress-related cortisol secretion is likely an in- ducer of the HPA axis, a depressed function of the HPA axis may be present in a small proportion of adults, and associated with low secretion of sex steroid and growth hormones (Björntorp, 1999). The resetting of corticosteroid responses may be established in utero, leading to exaggerated cortisol responses that, in turn, promote both accumulation of abdominal fat and in- sulin resistance.
Overexposure to glucocorticoids in utero may lead to adult glucose intolerance and insulin resistance through several mechanisms: glucose production may be permanently enhanced by the cortisol-induced up- regulation of gluconeogenesis in the liver and kidney; although little evidence exists, there may be changes in pancreatic β-cell function; and glucocorticoids may also alter the expression of glucoregulatory genes in tissues, such as skeletal muscle, which make a major contribution to insulin-sensitive glucose disposal. It is noteworthy that the major systems affected by early life programming also appear to be glucocorticoid sen- sitive (Seckl, 1998b). Glucocorticoids regulate insulin growth factors, their receptors and several binding pro- teins, and they may consequently affect fetal growth and programming through this route.
5.2 The “thrifty phenotype” hypothesis
This represents the second part of the fetal origins hy- pothesis (Hales & Barker, 1992), and the environmen- tal pendant of the thrifty genotype hypothesis of Neel (1962; 1982). It was proposed by Barker and his co-workers to account for the associations observed between fetal or early growth restriction and the sub- sequent development of chronic disease, in particular insulin resistance and impaired glucose tolerance.
According to more recent updates, the theory pos- tulates that changes in fetal growth evolve to aid fetal and postnatal survival (“fetal salvage” according to Hofman et al., 1997) by selective changes in growth rates of specific organs, or more likely, by adaptations in fetal metabolism. Studies in rats, as discussed earlier, show that during periods of inadequate nutri-
tion, growth of the brain and lungs is protected, while that of the kidneys is reduced. Growth of pancreas is impaired in females, not in males. More subtle changes in organ structure and function are imposed during periods of inadequate nutrition, and these may not be obvious on the basis of organ weight. Resetting of metabolism may be involved, with changes intended for the metabolism to become “thrifty” when the nu- trient supply is reduced (Hales, 1997a). These meta- bolic changes would serve to adapt the offspring for survival in the poor nutritional environment experi- enced by the mother. While these adaptations may be beneficial in times of short nutrient supply, they would become a liability in nutritional abundance, with risk of obesity and type-2 diabetes. These adaptive proc- esses are as yet unclear, although animal data provide partial explanation.
The endocrine alterations could be intended for survival, through redirecting limited nutrient supply for development of vital organs such as the brain, at the expense of growth. This is where insulin resistance could be beneficial, in gaining more growth stimula- tion from hyperinsulinaemia through redirecting glucose away from the skeletal muscle and towards vital organs like the brain and placenta. As discussed by Ozanne & Hales (1998), there is evidence that re- sistance to glucose transport action of insulin is not necessarily accompanied by resistance to its anabolic effect. There could be selective resistance to insulin, and this would be coherent with Neel’s (1962; 1982) and Reaven’s (1988; 1998) postulated survival advantage as- sociated with insulin resistance, but also associated in- creased risk of diabetes. Reduced peripheral insulin sensitivity would stimulate β-cells to produce larger amounts of insulin to maintain normal glycaemia, con- tributing to pancreas exhaustion. This is supported by animal studies showing reduced glucose transporter protein concentration in skeletal muscle in IUGR fetuses but normal concentration in the brain (Simmons, Flozak & Ogata, 1993).
5.2.1 Resetting of the insulin-like growth factor system
Insulin-like growth factors (IGFs) are major media- tors of pre- and postnatal growth in humans as well as in rodents, and their production in utero appears largely independent of GH (Rosenfeld, 1997). The growth-promoting role of GH appears to be largely confined to the postnatal period, while IGFs have a primary role in the prenatal period. IGF-1 and IGF-2 bind to the type 1 receptor, which appears to mediate the major mitogenic actions of both peptides. Both IGFs also bind to the insulin receptor, but with lower
affinity than does insulin. The role of the insulin receptor as an alternative growth promoting receptor requires further evaluation. The type 2 receptor binds IGF-2 with high affinity, but has little affinity for IGF- 1 or insulin. Its primary role appears to be to degrade IGF-2. In plasma and other biological fluids, IGFs are complexed to a large family of binding proteins (IGFBPs) exhibiting various levels of affinity and ca- pable of regulating the access of IGFs to their receptors, or by direct effects upon the cells. The regulation of IGFs and IGFBPs is very complex. It is not clear why both IGFs have a role in early embryonic development while IGF-1, but not IGF-2, has a role in later fetal (and perinatal) growth. According to Gluckman (1997), IGF-2 is dominant early in gestation, when placenta is not limiting for substrate availability. Later in gesta- tion, when the fetus must compete with the placenta and mother for substrate, and when placenta function is limiting, it is important that the IGF system be regu- lated by nutrition. The system would then switch to IGF-1, which is under acute nutritional regulation, explaining that IGF dominates later in pregnancy, while the expression of IGF-2 is then reduced (Gluckman, 1997).
Based on animal studies, it was proposed that the primary axis regulating fetal IGF-1, and therefore fetal growth, is the glucose-insulin-IGF-1 axis (Gluckman, 1997). Fetal IGF-1 is secreted in response to fetal insu- lin, which is itself determined by placental glucose transfer. Fetal insulin acts primarily as an adipogenic factor, while its effect on lean body mass is probably mediated through IGF-1. GH has a small but demon- strable effect on fetal growth, also through regulation of IGF-1.
The increase in plasma IGF-1 in childhood has implicated this factor in fetal programming through intricate mechanisms (Fall et al., 1995b). Different studies suggest that IGF-1 bioavailability or action may be altered whenever fetal growth is threatened (Langford et al., 1995; Cianfarani et al., 1998). Low IGF- 1 (and low IGFBP-3) at birth appears to be an indica- tor of fetal malnutrition in humans (Léger et al., 1996; Cance-Rouzaud et al., 1998), as well as in animals (Gallaher et al., 1998). Evidence of the link between IUGR and low IGF-1 comes from the severe IUGR observed in animals and humans with IGF-1 gene mutagenesis or deletion, as reviewed by Cianfarani et al. (1998) . It addition, low levels of IGF-1 and IGF- BP-3 were observed in children born SGA but who did not show catch-up growth and had remained short, compared to normal or short stature children but with adequate size for gestational age at birth (Boguszewski et al., 1997). A reduced rate and abnormal pattern of
GH secretion was also present, suggesting that a per- sistent defect of the GH-IGF-1 axis may occur in those SGA children who do not experience postnatal catch- up.
According to the catch-up growth hypothesis of Cianfarani, Germani & Branca (1999), tissues are de- pleted of insulin and of IGF-1 during fetal life when there is a shortage of nutrient substrates, as the IGF-1 system is then switched off. After birth, faced with ample supply of both hormones (IGF-1 and insulin) because of adequate nutrient supply, it is speculated that insulin resistance develops as a defense mechanism against hypoglycemia. The overactivation of the IGF system determines early postnatal catch-up growth, but also induces insulin resistance as metabolic adaptation with potentially detrimental effects in the long term. Catch-up growth and its relation with chronic disease risk is further discussed with postnatal factors modu- lating the effect of impaired fetal growth, in Section 7.
5.2.2 A role for leptin?
Leptin, a peptide hormone involved in growth and metabolism, likely plays a role in the regulation of body weight and fat mass. Interactions with other hormones, including insulin, IGF-1, and cortisol have been re- ported in vivo and in vitro (Kolazynski et al., 1996). In newborns, serum leptin concentrations are higher in females than males, and they are particularly strongly correlated with birth weight and insulin level. There is also a significant relationship with IGF-1 and cortisol. However, cortisol is apparently the only hormone hav- ing an independent effect on serum leptin (Maffeis et al., 1999). Concentrations are low in growth retarded or premature babies and appear to predict weight gain and catch-up growth in early infancy (Jaquet et al., 1998; Ong, Ahmed & Dunger, 1999). The association of birth weight with adult leptin was examined (Phillips et al., 1999). In adults aged 61–73 years, leptin levels were higher in women than in men. In both sexes, fast- ing leptin correlated positively with BMI, fasting insu- lin, and 2-hour insulin and glucose levels. Leptin was also positively correlated with waist-hip ratio in men. At given obesity levels, those who had lower birth weight had higher leptin levels than those of higher birth weight. The highest leptin levels were found in those who were small at birth and obese as adults. Jaquet et al. (1999) examined the role of leptin in catch- up growth in a longitudinal study of children born with IUGR, compared to children without IUGR. It was found that at the age of one year, children born with IUGR had significantly higher leptin levels than nor- mal children, independent of BMI (Jaquet et al., 1999).
The lack of correlation of BMI and leptin in IUGR children, as well as the absence of sex-related differ- ence in leptin concentrations, suggest that IUGR chil- dren develop leptin resistance, as also speculated in rats born to underfed mothers (Vickers et al., 2000), with resulting benefit for catch-up growth. An alternative hypothesis for the authors is that the high leptin levels reflect adipocyte dysfunction as a consequence of altered adipose tissue development in IUGR. However, multivariate analyses did not show a role for leptin in the association of lower birth weight with lower glu- cose tolerance (Phillips et al., 1999). It is suggested that higher leptin concentrations reflect altered body com- position or other physiological changes associated with small size at birth. It may reflect the hypercortisolemia resulting from resetting of the HPA axis, and hyperinsulinaemia, also associated with LBW. There is some evidence that catch-up growth in small babies is strongly related to cord blood level of leptin (Ong, Ahmed & Dunger, 1999).
The hypothesis that low leptin may be part of the phenotypic expression of the thrifty genotype could not be confirmed in a study on Pima Indians and non- Pima subjects in Mexico (Fox et al., 1998). While leptin concentrations were correlated with percentage of body fat and waist circumference in both groups, there was no differences in leptin concentrations between groups even after adjusting for percent body fat, waist circum- ference, age, and sex.
At this stage, there is therefore little evidence of a role for leptin in fetal programming of chronic dis- ease, other than perhaps as a predictor of catch-up growth in individuals born with IUGR.
5.3 Structural impairment during fetal life,
and later adaptation
As a result of impaired fetal growth, several structural changes may be implicated in early programming of chronic diseases, in addition to the resetting of major metabolic axes.
It is hypothesized that a reduced number of nephrons may explain the negative association of birth weight (or gestational age) with blood pressure (Bren- ner & Chertow, 1994), as suggested by experimental models in rats. Maintenance of renal haemodynamic functions following structural impairment during fetal life may require adaptations which raise blood pressure and promote a more rapid progression to renal failure (Nwagwu, Cook & Langley-Evans, 2000). Activation of the renin-angiotensin system is likely in-