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Prediction and prevention of famine.

In general, famines have become less frequent and of decreasing magnitude in recent decades, a generalization to which sub-Saharan Africa is the striking exception. The underlying factors preventing famine continue to weaken in sub-Saharan Africa, while they grow stronger elsewhere. The basic elements of famine prevention are: a substantial surplus of agricultural production beyond the subsistence needs of the rural population; highly developed transportation systems within rural areas, between rural and related urban areas, and with the rest of the world; and a democratic form of government. The first makes a shortage of food and income to buy food less likely, the second makes it possible to deal with food and income shortages if they do occur, and the third ensures that necessary and feasible actions will be taken. In a democratic framework a free press brings attention to famine even in isolated areas, and public opinion refuses to countenance inaction by the bureaucracy. Once conditions of famine arise, market mechanisms concentrate food where the purchasing power exists, drawing food from the rural to the urban areas and from the poor to the rich. In such circumstances governments must take direct action to prevent starvation. Famine is predicted by successive years of poor crops, a rapid rise in food prices, a decline in the prices of goods that the poor sell (particularly including the livestock of pastoralists), and a decline in employment.

Africa↗

Prenatal exposure to the Dutch famine and disease in later life: an overview.

Low birth weight is associated with cardiovascular disease in adulthood. Poor maternal nutrition during gestation contributes to low birth weight. In this paper, we review the findings from a cohort of 2414 people, aged 50 years, born as term singletons around the time of the 1944-1945 Dutch famine, of which 912 people participated in an interview and 741 subjects were also available for hospital examination. We found more coronary heart disease, raised lipids, altered clotting and more obesity after exposure to famine in early gestation compared to those not exposed to the famine. Exposure in mid gestation was associated with obstructive airways disease and microalbuminuria. We found decreased glucose tolerance in people exposed to famine in late gestation. These findings show that maternal undernutrition during gestation has important effects on health in later life, but that the timing of the nutritional insult determines which organ system is affected. Future research should shed more light upon the underlying pathophysiology of the far-reaching effects of prenatal exposure to famine.

Adult↗

Perceived health of adults after prenatal exposure to the Dutch famine.

People who were undernourished in early gestation are more obese, have a more atherogenic lipid profile, and altered blood coagulation and seem to have an increased risk of coronary heart disease. We now report on whether they also feel less healthy. We therefore assessed the perceived health of 50-year-old-men and women born alive as singletons around the time of the Dutch famine in the Wilhelmina Gasthuis in Amsterdam. People who had been exposed to famine in early gestation, but not those exposed in mid- or late gestation, more often rated their health as poor (10.3% vs. to 4.9% in the unexposed, odds ratio (OR) 2.2 [1.0, 4.8]). The effect of exposure to famine in early gestation on perceived health could only partly be explained by an increased prevalence of coronary heart disease, respiratory diseases, hypertension, type 2 diabetes, hypercholesterolaemia or cancer (adjusted OR 2.2 [0.9, 5.2]). Adjustment for adult risk factors (BMI, LDL/HDL cholesterol ratio, blood pressure, smoking, lung function) also attenuated the results to some extent (adjusted OR 1.9 [0.6, 5.5]). People who were exposed to famine in early gestation were not only less healthy in terms of objective measures of health but they also felt less healthy. Because poor perceived health is a strong predictor of mortality, we may expect increased mortality in people who were exposed to famine in early gestation in the future.

Adult↗

The Dutch famine of 1944-45: mortality and morbidity in past and present generations.

During the last months of the Second World War the Western Netherlands was affected by an acute famine, known as the Hunger Winter. Food intake from all sources was reduced to extremely low levels. The effect on mortality at all ages was very large and immediate. By making use of unpublished data from the Dutch Central Bureau of Statistics, estimates could be made of the changes in mortality by cause of death and age for both sexes. Mortality due to hunger was most common in the very young and the very old whereas the effects in males were more pronounced than in females. Hunger was a contributing factor to the increased mortality due to infectious diseases and diseases of the digestive system. In several follow-up studies on selected populations, long-term consequences of the famine could be studied. They related to reproductive outcomes of women who gave birth during the Hunger Winter, to birth weight, malformations, and perinatal mortalitiy of the newborn who were exposed to the famine during gestation, and to the long-term effects of the famine on the medical and psychological situation of infants born during the famine. Several studies on reproductive outcomes in the subsequent generation are also discussed.

History, 20th Century↗

Decreased birthweights in infants after maternal in utero exposure to the Dutch famine of 1944-1945.

Using maternity records of the University of Amsterdam teaching hospital for births 1960-1984, obstetric outcomes in 1808 first-born singleton offspring of mothers born between 1 January 1944 and 30 June 1946 in The Netherlands were analysed. Most of these mothers had experienced, during intra-uterine life, a war-induced famine that lasted from November 1944 to May 1945. The study was prompted by a report on increased perinatal mortality in offspring of such mothers and it aimed at describing late effects, if any, of such an exposure. Mothers exposed to famine during their first and second trimester in utero had offspring with birthweights lower than mothers not exposed to famine. The decrease in birthweight was in part due to slower fetal growth rate, in part to shorter gestation. Birthweights in the offspring of mothers exposed in their third trimester in utero were, however, not reduced. These findings in mothers exposed to famine in utero are in contrast to the effects of the famine on their mothers during their pregnancies, where third trimester exposure was associated with a reduction in birthweight. The effect of in utero exposure on birthweight persisted after control for potential confounding and intervening variables. Paradoxically, similar effects were seen in offspring of some mothers presumably not exposed to malnutrition. In this study, clear effects on reproductive outcomes are seen in the generation following an environmental exposure in utero.

Birth Weight↗

Historical roots of famine relief paradigms: ideas on dependency and free trade in India in the 1870s.

The principles upon which famine policies are based have changed less than might be expected over the last century. This paper examines the origins of the Indian Famine Codes of the 1880s, which set the administrative and, it is argued, paradigmatic precedent for famine relief in 'developing' countries, managed by 'developed' ones. In particular, the still-current questions of avoiding the creation of dependency through over-generous aid and of relying on free-market solutions to the problems of food distribution are re-examined. Although both of these issues are difficult, it is suggested that strong emphasis on their importance has historically been based on wilful misinterpretation of complex situations. The result has been famine relief programmes which served the interests of 'relievers' (in this case the colonial state) more than the relieved. The nature of famine policy-making is thus reconsidered, with a call for greater appreciation of the role of influential individuals and hidden state agendas. These are as significant today as ever.

Colonialism↗

rRNA and poly-beta-hydroxybutyrate dynamics in bioreactors subjected to feast and famine cycles.

Feast and famine cycles are common in activated sludge wastewater treatment systems, and they select for bacteria that accumulate storage compounds, such as poly-beta-hydroxybutyrate (PHB). Previous studies have shown that variations in influent substrate concentrations force bacteria to accumulate high levels of rRNA compared to the levels in bacteria grown in chemostats. Therefore, it can be hypothesized that bacteria accumulate more rRNA when they are subjected to feast and famine cycles. However, PHB-accumulating bacteria can form biomass (grow) throughout a feast and famine cycle and thus have a lower peak biomass formation rate during the cycle. Consequently, PHB-accumulating bacteria may accumulate less rRNA when they are subjected to feast and famine cycles than bacteria that are not capable of PHB accumulation. These hypotheses were tested with Wautersia eutropha H16 (wild type) and W. eutropha PHB-4 (a mutant not capable of accumulating PHB) grown in chemostat and semibatch reactors. For both strains, the cellular RNA level was higher when the organism was grown in semibatch reactors than when it was grown in chemostats, and the specific biomass formation rates during the feast phase were linearly related to the cellular RNA levels for cultures. Although the two strains exhibited maximum uptake rates when they were grown in semibatch reactors, the wild-type strain responded much more rapidly to the addition of fresh medium than the mutant responded. Furthermore, the chemostat-grown mutant culture was unable to exhibit maximum substrate uptake rates when it was subjected to pulse-wise addition of fresh medium. These data show that the ability to accumulate PHB does not prevent bacteria from accumulating high levels of rRNA when they are subjected to feast and famine cycles. Our results also demonstrate that the ability to accumulate PHB makes the bacteria more responsive to sudden increases in substrate concentrations, which explains their ecological advantage.

Biomass↗

Coronary heart disease after prenatal exposure to the Dutch famine, 1944-45.

OBJECTIVE: To assess the effect of prenatal exposure to maternal malnutrition on coronary heart disease in people born around the time of the Dutch famine, 1944-45. DESIGN: Historical cohort study. SETTING: Community study. PATIENTS: Singletons born alive between November 1943 and February 1947 for whom detailed birth records were available. DESIGN: The prevalence of coronary heart disease was compared between those exposed to famine in late gestation (n = 120), in mid-gestation (n = 108), or in early gestation (n = 68), and those born in the year before the famine or those conceived in the year after the famine (non-exposed subjects, n = 440). MAIN OUTCOME MEASURES: Prevalence of coronary heart disease, defined as the presence of angina pectoris according to the Rose questionnaire, Q waves on the ECG, or a history of coronary revascularisation. RESULTS: The prevalence of coronary heart disease was higher in those exposed in early gestation than in non-exposed people (8.8% v 3.2%; odds ratio adjusted for sex 3.0, 95% confidence interval (CI) 1.1 to 8.1). The prevalence was not increased in those exposed in mid gestation (0.9%) or late gestation (2.5%). People with coronary heart disease tended to have lower birth weights (3215 g v 3352 g, p = 0.13), and smaller head circumferences at birth (32.2 cm v 32.8 cm, p = 0.05), but the effect of exposure to famine in early gestation was independent of birth weight (adjusted odds ratio 3.2, 95% CI 1.2 to 8.8). CONCLUSIONS: Although the numbers are very small, this is the first evidence suggesting that maternal malnutrition during early gestation contributes to the occurrence of coronary heart disease in the offspring.

Birth Weight↗

Further evidence of relation between prenatal famine and major affective disorder.

OBJECTIVE: In a previous study, the authors demonstrated an association between prenatal famine in middle to late gestation and major affective disorders requiring hospitalization. In this study, they sought to examine the association by using newly identified cases from the Dutch birth cohort used previously to examine the gender specificity of the association and to assess whether this relation is present for both unipolar and bipolar affective disorders. METHOD: The authors compared the risk of major affective disorder requiring hospitalization in birth cohorts who were and were not exposed, in each trimester of gestation, to famine during the Dutch Hunger Winter of 1944-1945. These cases of major affective disorder requiring hospitalization were newly ascertained from a national psychiatric registry. A larger data set from this registry was used for analysis by gender and diagnostic subtype. RESULTS: For the newly ascertained cases, the risk of developing major affective disorder requiring hospitalization was increased for subjects with exposure to famine in the second trimester and was increased significantly for subjects with exposure in the third trimester, relative to unexposed subjects. For the cases from the entire period of ascertainment, the risk of developing affective disorder was significantly increased for those exposed to famine during the second and the third trimesters of gestation. The effects were demonstrated for men and women and for unipolar and bipolar affective disorders. CONCLUSIONS: These results provide support for the authors' previous findings on the association between middle to late gestational famine and affective disorder.

Adolescent↗

Microalbuminuria in adults after prenatal exposure to the Dutch famine.

Maternal undernutrition during gestation is associated with an increase in cardiovascular risk factors in the offspring in adult life. The effect of famine exposure during different stages of gestation on adult microalbuminuria (MA) was studied. MA was measured in 724 people, aged 48 to 53, who were born as term singletons in a university hospital in Amsterdam, the Netherlands, around the time of the Dutch famine 1944 to 1945. Twelve percent of people who were exposed to famine in mid gestation had MA (defined as albumin/creatinine ratio >/=2.5) compared with 7% of those who were not prenatally exposed to famine (odds ratio 2.1; 95% confidence interval 1.0 to 4.3). Correcting for BP, diabetes, and other influences that affect MA did not attenuate this association (adjusted odds ratio 3.2; 95% confidence interval 1.4 to 7.7). The effect of famine was independent of size at birth. Midgestation is a period of rapid increase in nephron number, which is critical in determining nephron endowment at birth. Fetal undernutrition may lead to lower nephron endowment with consequent MA in adult life.

Albuminuria↗

[The demographic impact of famines].

"Demographic research into famine has long been dominated by studies of its impact on mortality. Only recently some attempts have been made to relate famine to the other demographic processes of fertility, marriage and migration. Based on five case-studies, this article tries to identify the often complex interrelationships between famine and the major demographic processes. At the same time, attention is paid to the interactions between the demographic processes themselves. Furthermore, two conceptual frameworks examining these relationships are discussed. Finally, the importance of this subject both for the study of demographic behaviour and for famine relief programmes is stressed." (SUMMARY IN ENG)

Conservation of Natural Resources↗

Malnutrition, measles, mortality, and the humanitarian response during a famine in Ehiopia.

CONTEXT: The World Food Programme estimated that 10 million people were at risk of starvation in Ethiopia in 2000 but later reported that a famine had been averted. However, no population-based data on mortality or nutrition existed for Gode district, at the epicenter of the famine in the Somali region of Ethiopia. OBJECTIVES: To estimate mortality rates, determine the major causes of death, and estimate the prevalence of malnutrition among children and adults for the population of Gode district. DESIGN AND SETTING: Two-stage cluster survey conducted from July 27 through August 1, 2000, which included anthropometric measures and 8-month retrospective mortality data collection. PARTICIPANTS: A total of 595 households comprising 4032 people living in Gode district of Ethiopia. MAIN OUTCOME MEASURES: Crude mortality rates and mortality rates for children younger than 5 years, causes of death, weight for height of less than -2 z scores among children aged 6 months to 5 years, and body mass index of less than 18.5 kg/m(2) among adults and older persons. RESULTS: Of the 595 households, 346 (58.2%) were displaced from their usual places of residence. From December 1999 through July 2000, a total of 293 deaths occurred in the sample population; 159 (54.3%) deaths were among children younger than 5 years and 72 (24.6%) were among children aged 5 to 14 years. The crude mortality rate was 3.2/10 000 per day (95% confidence interval [CI], 2.4-3.8/10 000 per day), which is 3 times the cutoff used to define an emergency. The mortality rate for children younger than 5 years was 6.8/10 000 per day (95% CI, 5.4-8.2/10 000 per day). Approximately 77% of deaths occurred before major relief interventions began in April/May 2000. Wasting contributed to 72.3% of all deaths among children younger than 5 years. Measles alone or in combination with wasting accounted for 35 (22.0%) of 159 deaths among children younger than 5 years and for 12 (16.7%) of 72 deaths among children aged 5 to 14 years. The prevalence rate for wasting (weight for height of <-2 z score) among children aged 6 months to 5 years was 29.1% (95% CI, 24.7%-33.4%). Using a method to adjust body mass index for body shape, the prevalence of undernutrition (body mass index <18.5 kg/m(2)) among adults aged 18 to 59 years was 22.7% (95% CI, 17.9%-27.5%). CONCLUSIONS: To prevent unnecessary deaths, the humanitarian response to famine needs to be rapid, well coordinated, and based on sound epidemiological evidence. Public health interventions, such as mass measles vaccination campaigns with coverage extended to children aged 12 to 15 years should be implemented as the first priority. The prevalence of wasting and undernutrition among children and adults, respectively, should be assessed in all prolonged, severe famines.

Adolescent↗

Adult mortality at age 57 after prenatal exposure to the Dutch famine.

Prenatal famine exposure has previously been shown to be associated with cardiovascular disease and type II diabetes in adulthood. In the current study, we could not demonstrate an effect of prenatal exposure to famine in 2254 term singletons born during the 1944-1945 Dutch famine on adult mortality up to the age of 57 years. Follow-up of this cohort will resolve whether famine exposure is linked to increased adult mortality.

Age Factors↗

Plasma fibrinogen and factor VII concentrations in adults after prenatal exposure to famine.

To assess the effect of maternal malnutrition during different stages of gestation on plasma concentrations of fibrinogen and factor VII, we investigated 725 people, aged 50 years, born around the time of the Dutch famine 1944-5. After adjustment for sex, plasma fibrinogen concentrations differed by -0.01 g/l (95% confidence interval, -0.14-0.11) in those exposed in late gestation, by -0.03 g/l (-0.16-0.11) in those exposed in mid gestation, and by 0.13 g/l (-0.03-0.30) in those exposed in early gestation, compared with non-exposed people (those born before and those conceived after the famine pooled together). Plasma factor VII concentrations differed by 0.4% (-5.4% to 6.6%) in those exposed to famine in late gestation, by 1.5% (-4.6% to 8.1%) in those exposed in mid gestation. and by -11.8% (-18.4 to -4.8%) in those exposed in early gestation, compared with nonexposed people. Size at birth was not associated with plasma concentrations of fibrinogen or factor VII. Our finding that factor VII concentrations were significantly lower in people whose mothers had been exposed to famine in early pregnancy suggests that liver function may be affected by undernutrition in early gestation.

Birth Weight↗

Plasma lipid profiles in adults after prenatal exposure to the Dutch famine.

BACKGROUND: Small body size at birth has been reported to be associated with an atherogenic lipid profile in humans, and animal experiments have shown that undernutrition during pregnancy permanently alters cholesterol metabolism in the offspring. There is no direct evidence in humans that maternal malnutrition during pregnancy affects the lipid profiles of the offspring. OBJECTIVES: We assessed the effects of maternal malnutrition during specific periods of gestation on plasma lipid profiles in persons aged approximately 50 y. DESIGN: This was a follow-up study of men and women born at term as singletons in a university hospital in Amsterdam between 1 November 1943 and 28 February 1947 around the time of a severe famine. RESULTS: Persons exposed to famine in early gestation had a more atherogenic lipid profile than did those who were not exposed to famine in utero. Their LDL-HDL cholesterol ratios were significantly higher (by 13.9%; 95% CI: 2.6-26.4%). Additionally, their plasma HDL-cholesterol and apolipoprotein A concentrations tended to be lower, and their plasma total cholesterol, LDL-cholesterol, and apolipoprotein B concentrations tended to be higher, although these differences were not statistically significant. The effect of famine was independent of size at birth and adult obesity. CONCLUSIONS: An atherogenic lipid profile might be linked to a transition from poor maternal nutrition in early gestation to adequate nutrition later on. This suggests that maternal malnutrition during early gestation may program lipid metabolism without affecting size at birth.

Apolipoproteins A↗

Early onset of coronary artery disease after prenatal exposure to the Dutch famine.

BACKGROUND: Limited evidence suggests that maternal undernutrition at the time of conception is associated with increased cardiovascular disease risk in adult offspring. OBJECTIVE: We investigated whether persons conceived during the Dutch famine of World War II had an early onset of coronary artery disease (CAD). DESIGN: We compared the age at onset and cumulative incidence of CAD between persons born as term singletons who were exposed to the 1944-1945 Dutch famine during late (n = 160), mid- (n = 138), or early (n = 87) gestation and 590 unexposed subjects at age 50 or 58 y. Age at CAD onset was defined as the age at which angina pectoris was identified (according to the Rose questionnaire), Q waves were observed on an electrocardiogram (Minnesota codes 1-1 or 1-2), or coronary revascularization was performed (by angioplasty or bypass surgery). RESULTS: Of the 83 CAD cases identified, persons conceived during the famine were 3 y younger than the unexposed persons at the time of CAD diagnosis (47 y compared with 50 y) and had a higher cumulative incidence of CAD [13%; hazard ratio (HR) adjusted for sex: 1.9; 95% CI: 1.0, 3.8] than did the unexposed persons. The HR changed little after adjustment for smoking (HR: 1.8), social class (HR: 2.0), or size at birth (HR: 2.0). CONCLUSIONS: We found an earlier onset of CAD among persons conceived during the famine, which suggests that maternal nutrition in early gestation may play a role in the onset of CAD. This finding agrees with evidence from animal experiments that identify periconceptional maternal diet as important in the offspring's adult health.

Age of Onset↗

Childhood exposure to the 1944-1945 Dutch famine and subsequent female reproductive function.

BACKGROUND: Childhood caloric restriction may lead to permanent changes in the hypothalamo-pituitary-gonadal axis, which could lead to impaired female reproductive ability. We assessed the effect of childhood exposure to the 1944-1945 Dutch famine on subsequent female reproductive function. METHODS: This was a population-based cohort study in Utrecht, The Netherlands. Between 1983 and 1985, 6030 women born between 1932-1941 were classified by questionnaire according to their famine exposure experiences. Dates of marriage, first and second childbirth, and information on a medical reason for having no children or fewer children than wanted were available from questionnaires, as well as ages and type of menopause. RESULTS: Severe famine exposure during childhood significantly decreased chances of first and second childbirth at any given time after marriage or first childbirth [adjusted hazard ratios (HR) 0.86, 95% confidence interval (CI) 0.76-0.96; and HR 0.87, 95% CI 0.78-0.97, respectively). Risk of a medical reason for having no or fewer children than wanted was increased in the severely exposed (odds ratio 1.88; 95% CI 1.29-2.74), as was the risk of a surgical menopause (HR 1.53; 95% CI 1.27-1.84). CONCLUSIONS: Our findings support the presence of longstanding modest effects of childhood famine exposure on reproductive function in women.

Adult↗

War, famine and excess child mortality in Africa: the role of parental education.

BACKGROUND: Civilian-targeted warfare and famine constitute two of the greatest public health challenges of our time. Both have devastated many countries in Africa. Social services, and in particular, health services, have been destroyed. Dictatorial and military governments have used the withholding of food as a political weapon to exacerbate human suffering. Under such circumstances, war and famine are expected to have catastrophic impacts on child survival. This study examines the role of parental education in reducing excess child mortality in Africa by considering Tigrai-Ethiopia, which was severely affected by famine and civil war during 1973--1991. METHODS: This study uses data from the 1994 Housing and Population Census of Ethiopia and on communities' vulnerability to food crises. Child mortality levels and trends by various subgroups are estimated using indirect methods of mortality estimation techniques. A Poisson regression model is used to examine the relationship between number of children dead and parental education. RESULTS: Although child mortality is excessively high (about 200 deaths per 1000 births), our results show enormous variations in child mortality by parental education. Child mortality is highest among children born to illiterate mothers and illiterate fathers. Our results also show that the role of parental education in reducing child mortality is great during famine periods. In the communities devastated by war, however, its impact was significant only when the father has above primary education. CONCLUSIONS Our findings suggest that both mother's and father's education are significantly and negatively associated with child mortality, although this effect diminishes over time if the crisis is severe and prolonged. The policy implications of our study include, obviously, reducing armed conflict, addressing food security in a timely manner, and expansion of educational opportunities.

Child↗