Exposure to the Great Famine in Early Life and the Risk of Obesity in Adulthood: A Report Based on the China Health and Nutrition Survey.

Intrauterine malnutrition has a long-term effect on human health. This study aimed to evaluate the associations between exposure to famine in early life and obesity in adulthood in Chinese adults. A total of 5033 participants (22,132 observations) of the China Health and Nutrition Survey (CHNS) in 1991-2015 were classified into three famine exposure groups according to their birth year: unexposed (1963-1966), fetal-exposed (1959-1962) and childhood-exposed (1955-1958). Compared with the unexposed group, the fetal-exposed group had higher levels of body-mass-index (BMI) and waist-circumference (WC), and higher prevalence of overweight and central obesity, whereas the childhood-exposed group had lower levels of the measurements. However, the positive associations of fetal exposure with BMI, WC and prevalence of overweight and central obesity were attenuated by additionally adjusting for age at survey. Stratified analysis showed that the adverse effect of fetal exposure to famine was only observed in subjects at several specific age-groups, and in men living in rural areas and in women living in more severe famine exposed areas (p for interaction < 0.05). Our results provide evidence for the weak effect of fetal exposure to famine on body measurements in adulthood, and suggest the importance of severity of famine exposure and timing of exposure.

Association of famine exposure with the risk of type 2 diabetes: A meta-analysis.

PURPOSE: The association between famine exposure and type 2 diabetes (T2DM) remains controversial. A meta-analysis was performed to clarify the relation of famine exposure to T2DM risk in detail. METHODS: A systematic literature search was performed in PubMed, Cochrane library, Web of Science, China National Knowledge Infrastructure (CNKI), Sinomed (CBM), Wanfang Data Knowledge Service Platform and China Science and Technology Journal VIP Database. The articles were limited to be available in English or Chinese before 10 April 2019. The pooled relative risk (RR) with 95% confidence interval (CI) was used to estimate the effect of famine exposure on T2DM. The I square value (I2) was used to assess heterogeneity, and the random effects model (REM) was adopted as the pooling method. RESULTS: This meta-analysis included 24 published articles with 1,660,385 subjects. A significant association of famine exposure with increased risk of T2DM was observed (RR = 1.433, 95% CI: 1.101-1.865). The pooled RRs were different in terms of publication year, location, study design, sample size, famine duration and definition of diabetes (criteria). Longer the famine exposure experienced, greater the effect of famine exposure on T2DM would be. Compared to WHO criteria, studies of which diabetes diagnosed by ADA criteria and other criteria might more likely to find this association. Compared to moderate famine exposure, the pooled RR in severe famine was statistically significant. Furthermore, the pooled RR adjusted for the most confounders in females was 1.517 (95% CI: 1.018-2.261). In terms of period of famine exposure, compared to adult exposure, people who exposure famine in fetal, childhood, and adolescent were likely to be diabetes. CONCLUSION: Famine exposure may increase the risk of T2DM. The risk may vary with famine duration, definition of diabetes, gender and period of famine exposure.

Successful management and recovery following severe prolonged starvation in a dog.

OBJECTIVE: To describe the successful management of a dog following a period of prolonged food deprivation. CASE SUMMARY: A 7-year-old, intact male Labrador Retriever presented with profound weakness and loss of nearly 50% of his body weight due to severe prolonged starvation after being trapped in a well for 27 days. Electrolyte concentrations were managed with intensive intravenous supplementation during refeeding. The dog's electrolyte abnormalities resolved, wounds healed, and strength returned during the first 3 weeks of treatment. During the next 3 months, body condition score normalized and muscle mass improved. NEW OR UNIQUE INFORMATION PROVIDED: This report describes the management of a severely malnourished dog during refeeding, and highlights treatment considerations that may be important in the prevention of refeeding syndrome in such cases.

Bone marrow fat analysis as a diagnostic tool to document ante-mortem starvation.

Veterinary diagnostic clinicians are increasingly presented with emaciated animals involved in suspected neglect cases. A rise in public awareness and media attention towards animal welfare, combined with changes in legislation and a demand for a higher standard of evidence be presented in animal neglect cases submitted for prosecutions, have created a need for an objective measurement of starvation, particularly given the lack of quantitative assessments at post-mortem examinations. Bone marrow fat (BMF) is the final fat reserve to be mobilised for energy by a calorie-deprived animal during a state of emaciation. Percentage of BMF has been used to study starvation in several species and may provide an objective measure of ante-mortem body condition. This paper reviews the literature on the use of BMF analysis as a post-mortem diagnostic test for ante-mortem starvation. Beginning with a general overview of starvation and usual methods of assessment to describe animals in poor condition, the analysis of BMF is then introduced. Various methods of BMF analysis are discussed, as well as factors that influence the amount of BMF. This review also discusses the limitations of BMF analysis and makes suggestions where future research should be primarily focused.

Adelantar la muerte dejando de comer y beber. ¿Un nuevo tipo de "suicidio asistido"? / Hastening death by voluntary stopping of eating and drinking. A new mode of assisted suicide?

En los últimos años ha comenzado a aparecer en la literatura médica y bioética la dicción inglesa "voluntary stopping of eating and drinking". Se trata de una práctica que se propone con la "intención primaria" de anticipar la muerte de una persona que no quiere seguir viviendo, como alternativa a la eutanasia y al suicidio asistido. Algunos autores la presentan como una opción válida tanto desde el punto de vista ético como legal, sosteniendo que no se trata de un suicidio sino de una "muerte natural", en la línea de la limitación de tratamientos. En este artículo presentamos una síntesis de la bibliografía reciente, y una valoración crítica que llega a la conclusión que este tipo de acción difícilmente puede considerarse algo distinto a una modalidad de suicidio. Como consecuencia, el personal sanitario debería considerarla extraña al ethos médico y a la buena praxis clínica

In the last few years, the new catch phrase "voluntary stopping of eating and drinking" has made its appearance in the medical and bioethical literature. The practice, whose "primary intention" is to hasten the death of a person who does not want to continue living, has been proposed as an alternative to euthanasia and assisted suicide. Some authors present it as a valid option from both the ethical and legal point of view arguing that it is basically a "natural death" in the same line as a limitation of treatment and does not involve suicide. In this article we present a critical review of the recent literature and reach the conclusion that it is very difficult to consider this practice as anything other than a type of suicide. In consequence, healthcare workers should consider it alien to medical ethos and good clinical practice

The effect of adverse intrauterine conditions, early childhood growth and famine exposure on age at menopause: a systematic review.

When the follicle reserve, which is developed solely during the fetal period, is depleted, women enter menopause. Intrauterine and childhood adverse conditions might affect the ovarian capacity by influencing follicle production in the first trimester, limiting the initial follicle pool or mediate an accelerated follicular loss thereafter. To investigate if adverse early life influences result in younger age at menopause, the following online databases were systematically searched: PubMed, EMBASE, CINHAL (EBSCO) and Cochrane library (Wiley) up to 1 January 2017. Eligibility, data extraction and quality assessment was independently performed by two researchers. A total of 5278 studies were identified, 11 studies were deemed eligible and included. Nine were cohort studies, 1 case-control study and 1 twin study. Due to the diversity of reported data and risk estimates we were unable to pool data or perform meta-analysis on pooled data. Prenatal and childhood exposure to famine was significantly associated to an earlier age at menopause in three studies. Mean differences in age at menopause varied from 4 months up to 1.7 years between famine exposed and unexposed women. Three studies described a significant association between a low weight at ages 1 or 2 and a younger age at menopause. A younger age at menopause was associated with a higher weight at birth in only one study and with a high ponderal index, a measure for fatness at birth in another study. None of the nine studies reporting on low birth weight and age at natural menopause find a significant association.

Case of Fatal Starvation: Can Stable Isotope Analysis Serve to Support Morphological Diagnosis and Approximate the Length of Starvation?

The diagnosis of death as a result of starvation is established on anthropological measurements, visual appearance of the deceased on external and internal examination, microscopic analysis, laboratory testing, and exclusion of other causes of death. Herein, we present our findings on a case of 95-year-old man who died of starvation. After the diagnosis of starvation was established by traditional forensic medicine methods, we have conducted retrospective segmental analysis of stable carbon (δ13 C) and nitrogen (δ15 N) isotope ratios in hair sample. This method reveals periods of starvation through decrease in δ13 C and increase in δ15 N along the strand of hair. Our analysis revealed the decrease of 0.6 ‰ in δ13 C during the last 10-12 weeks prior to death, similar as reported in other investigations. Also, a decrease of 0.7 ‰ in δ15 N during the last 8-10 weeks prior to death was determined that was different than observed in previous studies.

The Great Irish Famine: Identifying Starvation in the Tissues of Victims Using Stable Isotope Analysis of Bone and Incremental Dentine Collagen.

The major components of human diet both past and present may be estimated by measuring the carbon and nitrogen isotope ratios (δ13C and δ15N) of the collagenous proteins in bone and tooth dentine. However, the results from these two tissues differ substantially: bone collagen records a multi-year average whilst primary dentine records and retains time-bound isotope ratios deriving from the period of tooth development. Recent studies harnessing a sub-annual temporal sampling resolution have shed new light on the individual dietary histories of our ancestors by identifying unexpected radical short-term dietary changes, the duration of breastfeeding and migration where dietary change occurs, and by raising questions regarding factors other than diet that may impact on δ13C and δ15N values. Here we show that the dentine δ13C and δ15N profiles of workhouse inmates dating from the Great Irish Famine of the 19th century not only record the expected dietary change from C3 potatoes to C4 maize, but when used together they also document prolonged nutritional and other physiological stress resulting from insufficient sustenance. In the adults, the influence of the maize-based diet is seen in the δ13C difference between dentine (formed in childhood) and rib (representing an average from the last few years of life). The demonstrated effects of stress on the δ13C and δ15N values will have an impact on the interpretations of diet in past populations even in slow-turnover tissues such as compact bone. This technique also has applicability in the investigation of modern children subject to nutritional distress where hair and nails are unavailable or do not record an adequate period of time.

Cardiovascular reactivity patterns and pathways to hypertension: a multivariate cluster analysis.

Substantial evidence links exaggerated mental stress induced blood pressure reactivity to future hypertension, but the results for heart rate reactivity are less clear. For this reason multivariate cluster analysis was carried out to examine the relationship between heart rate and blood pressure reactivity patterns and hypertension in a large prospective cohort (age range 55-60 years). Four clusters emerged with statistically different systolic and diastolic blood pressure and heart rate reactivity patterns. Cluster 1 was characterised by a relatively exaggerated blood pressure and heart rate response while the blood pressure and heart rate responses of cluster 2 were relatively modest and in line with the sample mean. Cluster 3 was characterised by blunted cardiovascular stress reactivity across all variables and cluster 4, by an exaggerated blood pressure response and modest heart rate response. Membership to cluster 4 conferred an increased risk of hypertension at 5-year follow-up (hazard ratio=2.98 (95% CI: 1.50-5.90), P<0.01) that survived adjustment for a host of potential confounding variables. These results suggest that the cardiac reactivity plays a potentially important role in the link between blood pressure reactivity and hypertension and support the use of multivariate approaches to stress psychophysiology.

Forensic aspects of starvation.

Fatal starvation is a rare cause of death in industrialized countries. However, it may have major medicolegal importance if death results from the deliberate withholding of food, especially from infants. In such cases, the task of the forensic pathologist and the medical examiner, respectively, is to clarify the cause of death and give an expert opinion on the degree and duration of starvation. Several classification systems have been developed to estimate protein-energy malnutrition in developing countries. Simpler classifications, such as the Gomez classification, use the weight expected for the respective age group as the standard. However, smaller infants will be lighter, and therefore the classification may not be accurate in this case. Following the Waterlow classification, the extent of stunted growth (referring to growth retardation in cases of chronic malnutrition) is calculated using the ratio of the measured body height to that expected for the age. Using such classification systems, grading of stunting and wasting can be achieved and may greatly help in the assessment of a given child's nutritional status in legal cases. The application of the Waterlow classification to the authors' case material and previously published cases in the literature is herein demonstrated. The Waterlow classification is not only of importance for grading the final stage of fatal starvation, but also for the chronological development of the nutritional status if anthropometrical data have been repeatedly recorded from the affected individual in vivo.

Unsatisfactory knowledge and use of terminology regarding malnutrition, starvation, cachexia and sarcopenia among dietitians.

BACKGROUND & AIMS: Clinical signs of malnutrition, starvation, cachexia and sarcopenia overlap, as they all imply muscle wasting to a various extent. However, the underlying mechanisms differ fundamentally and therefore distinction between these phenomena has therapeutic and prognostic implications. We aimed to determine whether dietitians in selected European countries have 'sufficient knowledge' regarding malnutrition, starvation, cachexia and sarcopenia, and use these terms in their daily clinical work. METHODS: An anonymous online survey was performed among dietitians in Belgium, the Netherlands, Norway and Sweden. 'Sufficient knowledge' was defined as having mentioned at least two of the three common domains of malnutrition according to ESPEN definition of malnutrition (2011): 'nutritional balance', 'body composition' and 'functionality and clinical outcome', and a correct answer to three cases on starvation, cachexia and sarcopenia. Chi-square test was used to analyse differences in experience, work place and number of malnourished patients treated between dietitians with 'sufficient knowledge' vs. 'less sufficient knowledge'. RESULTS: 712/7186 responded to the questionnaire, of which data of 369 dietitians were included in the analysis (5%). The term 'malnutrition' is being used in clinical practice by 88% of the respondents. Starvation, cachexia and sarcopenia is being used by 3%, 30% and 12% respectively. The cases on starvation, cachexia and sarcopenia were correctly identified by 58%, 43% and 74% respectively. 13% of the respondents had 'sufficient knowledge'. 31% of the respondents identified all cases correctly. The proportion of respondents with 'sufficient knowledge' was significantly higher in those working in a hospital or in municipality (16%, P < 0.041), as compared to those working in other settings (7%). CONCLUSIONS: The results of our survey among dietitians in four European countries show that the percentage of dietitians with 'sufficient knowledge' regarding malnutrition, starvation, cachexia and sarcopenia is unsatisfactory (13%). The terms starvation, cachexia and sarcopenia are not often used by dietitians in daily clinical work. As only one-third (31%) of dietitians identified all cases correctly, the results of this study seem to indicate that nutrition-related disorders are suboptimally recognized in clinical practice, which might have a negative impact on nutritional treatment. The results of our study require confirmation in a larger sample of dietitians.

Protein-energy malnutrition in the rehabilitation setting: Evidence to improve identification.

Methods of identifying malnutrition in the rehabilitation setting require further examination so that patient outcomes may be improved. The purpose of this narrative review was to: (1) examine the defining characteristics of malnutrition, starvation, sarcopenia and cachexia; (2) review the validity of nutrition screening tools and nutrition assessment tools in the rehabilitation setting; and (3) determine the prevalence of malnutrition in the rehabilitation setting by geographical region and method of diagnosis. A narrative review was conducted drawing upon international literature. Starvation represents one form of malnutrition. Inadequate energy and protein intake are the critical factor in the aetiology of malnutrition, which is distinct from sarcopenia and cachexia. Eight nutrition screening tools and two nutrition assessment tools have been evaluated for criterion validity in the rehabilitation setting, and consideration must be given to the resources of the facility and the patient group in order to select the appropriate tool. The prevalence of malnutrition in the rehabilitation setting ranges from 14-65% worldwide with the highest prevalence reported in rural, European and Australian settings. Malnutrition is highly prevalent in the rehabilitation setting, and consideration must be given to the patient group when determining the most appropriate method of identification so that resources may be used efficaciously and the chance of misdiagnosis minimised.

Circumstances, Descriptive Characteristics, and Pathologic Findings in Dogs Suspected of Starving.

The authors reviewed the case circumstances, population characteristics, gross, and histopathologic findings in 40 cases of emaciated dogs with a suspected diagnosis of starvation. The dogs' estimated age ranged from 3 months to geriatric. Nineteen breeds were represented, including small-breed (n = 11), large-breed (n = 13), and pit bull-type (n = 16) dogs. The median body condition score was 1 out of 9 (Purina scale). Various diseases were identified as the cause of death in 7 dogs, while the cause of death in the other 33 dogs was starvation due to exogenous causes (SEC). Circumstances associated exclusively with SEC included being found in a vacated residence and death during temperature extremes or severe weather. Dogs with SEC did not differ significantly from diseased dogs in body condition score, sex, neuter status, or breed category (small, large, or pit bull type). Gross findings associated exclusively with SEC included severe hair matting and traumatic injuries. Diseased dogs had an empty stomach significantly more often than SEC dogs, which frequently had food and/or foreign material in the stomach. In 5 of the 7 cases where disease was the cause of death, disease involved the gastrointestinal tract. Gross and histopathologic changes commonly found in SEC and diseased dogs included the following: gross loss of muscle mass and absence of subcuticular fat; serous atrophy of omental, perirenal, epicardial, and bone marrow fat; atrophy of the liver, skin, thyroid gland, and testicle; gastric mucosal petechiae and ecchymoses; melena; and splenic hemosiderophages.

The clinical geneticist and the evaluation of failure to thrive versus failure to feed.

Common clinical genetic referrals for the pediatric patient include a single major or multiple minor anomalies, dysmorphic features, especially when accompanied by developmental delay or intellectual disability, and failure to thrive (FTT). This review provides pediatric definitions of FTT and the genetic differential for FTT, which includes chromosomal disorders, microdeletion/duplication syndromes, uniparental disomy/methylation disorder, disorders of DNA repair, teratogens, metabolic syndromes, and skeletal dysplasias. Three clinical genetics cases highlight challenges in deciphering the cause of FTT. The review concludes with a ten-step approach that might improve diagnostic ability in differentiating FTT cases (those with genetic or other metabolic causes) from "failure to feed," in other words FTT as the direct result of neglect and/or child abuse.

Diagnosis of famine: a discursive contribution.

This paper recommends the incorporation of an additional discursive dimension in famine diagnosis that draws on the number of reports referring to famine in the United Nations Office for the Coordination of Humanitarian Affairs (OCHA)'s ReliefWeb database. Present-day diagnostic tools already apply the principle of triangulation with multiple indicators; the addition of a discursive diagnostic dimension would enable even more refined analysis, allowing more forcefully for the incorporation of the aspect of change. The newly devised discursive famine indices are used both to identify famines--in Ethiopia (2000), Malawi (2002), and Somalia (2011)--and to analyse key socioeconomic determinants of famine. The study finds that income (or poverty) together with state fragility appear to be the major determinants of cross-country variations in famine reporting, while political regimes do not appear to have any independent effect. The indices appear largely robust with regard to concerns about cross-country, semantic, and temporal biases.

Signs of malnutrition and starvation--reconstruction of nutritional life histories by serial isotopic analyses of hair.

The diagnosis of starvation in children or adults is an important topic in paediatric and geriatric medicine, and in law assessment. To date, few reliable techniques are available to reconstruct the onset and duration of undernourishment, especially in cases of wilful neglect or abuse. The intention of this research project is to introduce a method based on isotopic analysis to reconstruct nutritional life histories and to detect starvation. For this purpose the specific signature of stable carbon and nitrogen isotopes in human hair samples is investigated and measured in the course of serious nutritional deprivation. Previous study of our research group on anorectic patients has shown that incremental hair analyses can monitor the individual nutritional status of each patient. Increasing δ(15)N-values indicate the catabolism of bodily protein and are associated with a very low BMI. In contrast, the changes of the δ(13)C values and BMI were in phase, which can be linked to the lack of energy in the consumed diet and the break down of body fat deposits. These findings were now applied to various forensic cases, in which severe starvation occurred recently prior to death. We are aiming at establishing an unbiased biomarker to identify the individual timeframe of nutritional deprivation to detect and prevent starvation.

The complexity of treating wasting in ambulatory rehabilitation: Is it starvation, sarcopenia, cachexia or a combination of these conditions?

Nutritional status is often impaired in ambulatory rehabilitation patients. Wasting conditions can be classified as starvation, sarcopenia or cachexia but differences between these are not well defined, and misdiagnosis may lead to inappropriate intervention. A secondary analysis of data from 187 ambulatory rehabilitation patients aged >=60 years aimed to identify patients with one or more wasting condition, and investigate the impact on common rehabilitation outcomes. Starvation was defined by fat-free mass index and the Council on Nutrition Appetite Questionnaire score; sarcopenia by fat-free mass index and quadriceps strength; and cachexia by fat-free mass index and serum C-reactive protein. Selected rehabilitation outcomes were compared for those who were, and those who were not, identified as having one or more wasting condition. Of those identified with starvation (n=30), all were also identified as sarcopenic and 20 as cachectic; of those identified as sarcopenic (n=75), 30 had starvation and 37 were cachectic; and of those identified as cachectic (n=37), 20 had starvation and all were sarcopenic. Twenty participants were identified as having all three conditions. Those with starvation had higher level of depression (p=0.003), lower self-rated health (p=0.032), and lower levels of physical function (motor p=0.006; process p=0.004) than those with no evidence of a wasting condition. Those who had sarcopenia had lower physical function (motor p=0.012; process p=0.003) as did those with cachexia (motor p=0.025; process p=0.042). Results suggest problems in operationalising definitions in an ambulatory clinical setting. The overlap identified in this analysis suggests that up to 40% (75/187) of patients could be misidentified and prescribed inappropriate nutritional support.