Optimizing Metabolism

by Ingrid Kohlstadt, MD, MPH

A Classic Public Health Study Important for Today’s Clinicians

Introduction

A classic public health study emerged from a humanitarian crisis that ended 70 years ago this month. I present historical, scientific and political perspectives based on my conversations with three men uniquely connected to the crisis. Their science and stories give today’s clinicians a take-home message to glean, which I summarize at the end of this column.

Overview

The Dutch Famine of 1944–1945 resulted when the Nazis blockaded Holland and flooded its fields in retaliation for its wartime resistance. Food was rationed to a few hundred calories a day from November through early May. Then Allied Forces negotiated with the Nazis to allow food to be air-dropped to the Dutch people, effectively ending the famine in May 1945.

Historical Perspective

The Center for Human Nutrition at Johns Hopkins University holds an annual lecture in memory of physician nutritionist and humanitarian Dr. George G. Graham. This year’s lecture, “The Long Shadow of the Dutch Famine of 1944–1945,” included Richard L Hall, PhD, among its speakers.

Hall helmed the science and technologic advances of McCormick & Company during a period of expanding globalized trade. Less known is his first life-saving nutrition intervention. Hall served as Navigator, 493rd Bomb Group, 8th Air Force, where he led the May 1945 food drop over Holland. Hall’s inspiring collection of stories was instructive. It spoke to what lasts, what’s remembered 70 years later.

Kindness reciprocated

. Dr. Hall recounted a story of an international business meeting when the dinner conversation shifted to tulips as an export crop in Holland, “When do the tulips bloom?” “May 6,” answered Hall, causing surprise that an American took the question intended for the Dutch guests. Then he explained, “The Dutch wrote ‘Thank You’ for us in fresh-cut tulips as we flew above them.”

Make the best decision with what you’ve got.

Hall was certain that no nutritionist was consulted about what kind of food was dropped. Since food was being rationed in England at the time as well, the food included military rations. When someone in the audience wryly added, “Military rations included cigarettes at that time,” Hall quickly put it in context. He reminded us that the Allied Forces had to negotiate with the Nazis to even make the historic mission possible. If the Allied Forces’ bombers went slightly off course, the Nazis were to only shoot with red flares. Yet some planes took fire underscoring the safety concerns surrounding the humanitarian mission.

Mindfulness.

“The British called the food drop Operation Manna. which was a good name for what we were doing, well, even if the food only came from a few hundred feet above.” He then disparagingly shook his head at the American name for the mission, Operation Chowhound. He said that to this day he felt embarrassed by the insensitivity reflected in the name.

Scientific Perspective

L. H. Lumey, MD, MPH, PhD, also spoke at the Johns Hopkins seminar. Scientists David Barker and Bertie Lumey together theorized that the Dutch children born in 1945 may be at increased risk of chronic diseases later in life because of the fetal exposure to famine. The lack of maternal food could alter how genes are turned on and off during development, a field of research now called epigenetics. Barker’s hypothesis appeared in the 1992 British Medical Journal with the title “Fetal and Infant Origins of Adult Disease.”

The birth cohort of the Dutch Famine had all the attributes an epidemiologist would want in a population cohort (a study design wherein a certain group of people who had an exposure of scientific interest are followed over time and compared to an unexposed control group). The Dutch kept meticulous birth records and military service records, and the government wanted to support the research. The population at that time was genetically similar. The famine had an abrupt onset and clear end, giving an “exposure window” seldom found in nutrition.

Overall the data substantiate Barker’s hypothesis and fine-tune details relevant to public health. The researchers initially thought that the famine would increase the risk of cancer and cardiovascular disease in the birth cohort. Instead there was increased susceptibility to diabetes and schizophrenia. Molecular studies show that methylation pathways are disrupted and that diabetes occurs at a lower body weight. Another finding is that first trimester exposure caused greater effects long term, even though those exposed in the third trimester showed the early effects of low birth weight. The magnitude of the effects appear smaller than Barker would have projected. However, they seem distinct from genetic effects, such as mothers with greater body fat and therefore greater genetic risk of diabetes being more likely able to sustain a pregnancy during famine.

Research now in its third decade is involving the third generation, offspring of the original birth cohort. Ongoing studies include MRI analysis of body fat distribution, twin studies, comparison cohorts from famines worldwide, and maternal wartime stress exposure in the absence of famine.

Political Perspective

An early collaborator of Dr. Barker’s is Sir Peter Gluckman, MMedSC, DSc, the chief science advisor to the prime minister of New Zealand. He coauthored The Fetal Matrix (2005) and founded the Liggins Institute within the University of Auckland. The institute’s research premise is that not only famine but inadequate nutrition of all forms can have lasting but preventable effects.

I had the opportunity to correspond with Gluckman about my NutriBee intervention and meet the lead nutritionist at the Liggins Institute. I learned why my young son showed interest in my work when he told his schoolmates his mother works with a real knight. Perhaps in this political era of belt-tightening and corporate influence, public health does require brave defense in a shining armor sort of way.

Summarizing the Relevance to Today’s Clinical Practice

Make the best decision with what you’ve got.

The shadow of the Dutch famine stretches 70 years and many questions continue. The food choices of our day are thought to adversely affect the fetal matrix in similar ways. Yet our public health policies and health-care financing poorly reflect this knowledge. Some say that they are waiting for additional evidence, but they aren’t disclosing that the population evidence which they want will realistically take 70 years from the time of exposure.

Don’t unnecessarily settle for determinism.

For my mother, who was malnourished during World War II, her epigenetically imposed health risk was identified early. She received great care and did all the right things, and now the only place her diagnosis is found is in old medical charts. I suspect that many Dutch citizens acted similarly, determined not to be shadowed by Nazi oppression. This type of human resilience may help explain why Lumey’s January 2015 research findings published in the American Journal of Epidemiology show less effect in adult mortality from the Dutch famine birth cohort than might have been anticipated from earlier studies.

Reframe the family dynamics.

In my experience, epigenetics helps some of my weight-management patients find the path to self-acceptance. The negative self-talk sounds like this, “My family is slim, but I’m not. I guess I just don’t have willpower.” Dedicated but discouraged, these dieters benefit from knowing that their dieting success may be harder to realize due to a well-accepted biologic reason.

Ingrid Kohlstadt, MD, MPH, FACPM, FACN

Faculty Associate, Johns Hopkins Bloomberg School of Public Health

Executive Director, NutriBee National Nutrition Competition Inc.

Editor, Advancing Medicine with Food and Nutrients (CRC Press; 2013)