Bixby Lecture on Fetal Origins of Adult Obesity by Michael G. Ross, MD, MPH

1. Perinatal Origins of
Childhood and Adult Obesity
Michael G. Ross, M.D., M.P.H.
Mina Desai, Ph.D.
Department of Obstetrics & Gynecology
Harbor-UCLA Medical Center

2. Metabolic Syndrome
• Traits:
• Obesity
• Hypertension
• Type 2 diabetes mellitus
• Dyslipidemia
• Mortality: Leading cause of death in the United States
• Obesity: U.S. adults 65% overweight, 31% obese,
Childhood obesity 20%
• Hypertension: 29% of U.S. population
• Diabetes: 27% of U.S. population

3. Obesity Trends* Among U.S. Adults
CDC, 1985
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data <10% 10%–14%

4. Obesity Trends* Among U.S. Adults
CDC, 1995
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
<10% 10%–14% 15%–19%

5. Obesity Trends* Among U.S. Adults
CDC, 2005
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
<10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

6. Obesity Trends* Among U.S. Adults
CDC, 2009
15%–19% 20%–24% 25%–29% ≥30%

7. Obesity Trends* Among U.S. Adults
CDC, 2013
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% 30%-34% ≥35%

8. Prevalence of Obesity* Among U.S.
Children and Adolescents (2 –19 Years)
05101520
Percent
1971-1974 1976-1980 1988-1994 2003-2006
National Health and Nutrition Examination Surveys
*Sex-and age-specific BMI > 95th percentile based on the CDC growth charts
■ 2-5 years ■ 6-11 years ■ 12-19 years
3 fold

9. Etiology of Obesity
Food Availability
High Fat Diets
Reduced Energy
Expenditure
Propensity for
Obesity
Developmental
Programming

10. Developmental Programming
Altered cell number
and differentiation
Modified gene expression
altered function
Fetal Nutrition, Stress
? Environmental Toxins

11. Programming vs. Mutations
Genetic mutations: Long epochs,
irreversible
Programmed phenotypes: Respond to
acute environmental stresses

12. Environmental Stresses on Survival
Drought and Famine
•Famine: nutrient reduction
Famine/drought during pregnancy
results in low birth weight infants
“Thrifty Phenotype”
Increased food intake, gorging
Efficient metabolism
Reduced energy expenditure
Survival Advantage in an
environment of reduced nutrient
availability

13. “Thrifty” vs. “Inadvertent Thrifty”
Phenotype
• Intrauterine Growth Restricted Newborns
– Improved Fecundity:
• Maternal medical illness
– Etiologies:
• Substance abuse, cigarette smoking
– Twins and higher order:
• Natural and In Vitro Fertilization
• Enhanced Neonatal Survival: viability 400 g

14. High fat, high calorie diet
Thrifty Phenotype Obesity

15. Barker Hypothesis
Developmental Programming
Small for Gestational Age (SGA) and/or
Low Birth Weight (LBW) human newborns
• Paradoxical increased risk of
hypertension, obesity, and diabetes as
adult

16. Hertfordshire Birth Records
1911-1949

17. Electronic Medical Record

18. Birth Weight and Metabolic Syndrome
Prevalence of Metabolic Syndrome according to birth weight in
407 men, aged 65 years, born in Hertfordshire

19. Birth Weight and Adult Diseases
Epidemiological Studies
 Obesity
 Diabetes
 Cardiovascular Disease
 Hypertension
 Lipids
 Fatty Liver
 Immuno-compromise, Allergies
 Addiction, Substance abuse

20. The relationship between deciles of birth weight and systolic blood
pressure (SBP) among Swedish males at 18 years old
Nilsson: J Hypertens, Volume 15(12).December 1997.1627–1631
Fig. 1
Birth Weight and Blood Pressure

21. Ponderal Index and Coronary Heart Disease
395 deaths in 6856 men in Helsinki
Ponderal
index at birth
(kg/m3)
Body mass index at 12 years (kg/m2)
Hazard
ratio
>18 -18 -17 -16
-29
>29
-27
-25
4
3
2
1
0
5
Eriksson JG et al BMJ 2001

22. Birth Weight and Type 2 Diabetes
1179 Pima Indians aged 201179 Pima Indians aged 20--39 years39 years
McCance DR et al BMJ 1994;308:942-5
0
10
20
30
<2.5 -3.0 -3.5 -4.0 4.0
Birthweight (kg)
Ageadjustedprevalence(68%CI)

23. Hovi P et al. N Engl J Med 2007;356:2053-2063
Glucose, Insulin Concentrations and the Insulin-Resistance Index
Adults with Very Low Birth Weight (VLBW) versus Adults Born at Term
Birth Weight and Insulin Resistance

24. Models of Fetal Programming
• Maternal Obesity
• Low Birth Weight
• Environmental Toxins: Bisphenol A
• Phenotype
• Mechanisms of Appetite and Adipose
Programming

25. Prevalence of Maternal Obesity
◌ ≥ 200 lb
● ≥ 250 lb
□ ≥ 300 lb
■ > 29 kg/m3
In USA women at first prenatal visit
2 fold

26. Model of Maternal Obesity
High Fat Diet
OFFSPRING
• Litter size: Culled to 4 males and 4 females at birth
• Nursing: All pups nursed by same dams until p21
• Weaning: At p21 to ad Libitum food and water

27. Body Weight of Male Offspring
1 Day 3 Weeks 6 Months
Mean ± SE; * p < 0.01
Control HF
BodyWeight(g)
0
2
4
6
8
Control HF
BodyWeight(g)
0
20
40
60
80
*
Control HF
BodyWeight(g)
0
300
400
500
600 *
Accelerated Growth During Nursing
Control Mat-OB Control Mat-OB Control Mat-OB

28. Percentage Body Fat: Male Offspring
3 Weeks 6 Months
Mean ± SE; * p < 0.001
Control HF
BodyFat(%)
0
2
4
6
8
10
12
14
16
*
Control HF
BodyFat(%)
0
5
10
15
20
25
30 *
Early Onset Obesity
Control Mat-OB Control Mat-OB

29. Plasma Triglycerides: Male Offspring
1 Day 3 Weeks
Mean ± SE; * p < 0.01
Control HF
Triglyceride(mg/dl)
0
40
80
120
160
*
Triglyceride(mg/dl)
0
40
80
120
160
*
Control HF
Hypertriglyceridemia
Control Mat-OB Control Mat-OB

30. Systolic Blood Pressure
6 Week Obese Males
Control HF
BloodPressure(mmHg)
0
120
130
140
150
160
*
* P < 0.05 vs. Control
Early Onset Hypertension
Control Mat-OB

31. Glucose, Insulin and GTT
3 Month Obese Males
Time (mins)
BloodGlucose(mg/dl)
0
80
120
160
200
Control
HF
*
*
*
* *
*
0 15 30 60 120 180
Control HF
Glucose(mg/dl)
0
60
80
100
120
140
160
*
Control HF
Insulin(ng/ml)
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6 *
Insulin Resistance
Control Mat-OB
Control Mat-OB
Mat-OB

32. Low Birth Weight Trends in USA
15
12
9
6
3
1981 1985 1990 1995 2000 2005 2010
+28%
+12%
-1%
All races
White
Hispanic
Black
Change from
1989
+16%

33. Model of Intrauterine Growth Restriction (IUGR)
Maternal Food Restriction (FR)
OFFSPRING
• Litter size: Culled to 4 males and 4 females at birth
• Nursing: All pups cross-fostered to ad libitum fed Control dams
until p21
• Weaning: At p21 to ad Libitum food and water

34. Body Weight of Male Offspring
1 Day 3 Weeks 9 Months
Mean ± SE; * p < 0.01 Desai et al, Am J Physiol, 2005
Control FR
BodyWeight(g)
0
2
4
6
8
*
Control FR/AdLib
BodyWeight(g)
0
20
30
40
50
60
*
Control FR/AdLib
BodyWeight(g)
0
500
600
700
800
*
Rapid Catch-up Growth
Control IUGR Control IUGR Control IUGR

35. % Body Fat of Male Offspring
3 Weeks 9 Months
Mean ± SE; * p < 0.001 Desai et al, Am J Physiol, 2005
Control FR/AdLib
%BodyFat
0
4
8
12
16
Control FR/AdLib
%BodyFat
0
5
10
15
20
25
*
Adult Obesity
Control IUGR Control IUGR

36. Systolic Blood Pressure
3 Month Obese Adult Males
Control IUGR
BloodPressure
(mmHg)
120
130
140
150
160
*
* P < 0.05 vs. Control
Hypertension

37. Lipid Profile
9 Month IUGR Obese Adult Males
Mean ± SE; * p < 0.001 Desai et al, Am J Obstet Gynecol, 2007
Hypertriglyceridemia
Control FR/AdLib
Triglyceride(mg/dl)
0
40
60
80
100
120
*
Control FR/AdLibCholesterol(mg/dl)
0
60
80
100
Triglyceride Cholesterol
Control IUGR Control IUGR

38. Glucose, Insulin and GTT
9 Month IUGR Adult Males
Time (mins)
0 30 60 90 120 150 180 210Glucose(mg/dl)
0
80
120
160
200
240
*
* *
*
*
*
Control
FR/AdLib
Desai et al, Am J Obstet Gynecol, 2007
Insulin Resistance
Control FR/AdLib
Glucose(mg/dl)
0
80
90
100
110
120
*
Control FR/AdLib
Insulin(ng/ml)
0.0
0.2
0.4
0.6
0.8
1.0
*
Control IUGR
Control IUGR
IUGR

39. Maternal Undernutrition and Overnutrition:
Offspring Programming of Metabolic Syndrome
Obesity
Adiposity
Hypertension
Hyperlipidemia
Fatty Liver
Diabetes

40. Non-alcoholic
fatty liver
disease
Increased fat
storage
Reduced satiety
FAT
FAT
FAT
FAT
FAT
Double Hit: High Fat Diet

41. Postnatal High Fat Diet
Body Composition: Controls and IUGR
* vs Control; # vs High Fat Diet
Control FR/AdLib
BodyWeight(g)
0
500
600
700
800
900
*
*
#
Control FR/AdLib
%BodyFat 0
10
15
20
25
30
35
*
*
#
#
Normal diet High fat diet
Control IUGRControl IUGR

42. Bisphenol A (BPA)

43. NHANES: BPA Levels during Pregnancy
Breast Milk
1.1 ng/ml
Maternal Serum
1 - 2 ng/ml
Placenta
1 – 105 ng/ml
Amniotic Fluid
8.3 – 8.7 ng/ml
Fetal Serum
0.2 – 9.2 ng/ml

44. Model of Maternal Bisphenol A (BPA)
OFFSPRING
• Litter size: Culled to 4 males and 4 females at birth
• Nursing: All pups nursed by same dams until p21
• Weaning: At p21 to ad libitum food and BPA-free water

45. Maternal BPA: Birth Weight at 1 Day
SYSBP_MSYSBP_M
Control BPA
BodyWight(g)
0
2
4
6
8
Control BPA
MALES FEMALES
Normal Birth Weight

46. Offspring Body Composition at 3 Weeks
0
5
10
15
MALES FEMALES
FatMass(g)
0
20
40
60
80
100
MALES FEMALES
TotalMass(g)
* * * *
Control BPA

47. Offspring Body Composition at 6 months
0
20
40
60
80
100
MALES FEMALES
FatMass(g)
0
200
400
600
MALES FEMALES
TotalMass(g)
0
5
10
15
20
MALES FEMALES
Fat(%)
*
*
Increased Body Fat
in Males
*
Control BPA

48. Programming Mechanisms
Appetite Increased Food Intake
IMPAIRED MATERNAL
NUTRITION
Altered
adipose
Obesity
Defective
β cell
function
Insulin deficiency
Renal
Renal InsufficiencyHypertension
Blood vessels
Lung
Pulmonary
Insufficiency
Placenta
Placental
Dysfunction
Immune
Immune
Deficiency
Brain
Neurogeneration

49. Major Contributors of Obesity
Food Intake
Fat

50. “Appetite Efficiency”
Time Spent Eating vs. Obesity Rate

51. Mechanism of Obesity
Weekly food intake; Mean ± SE
Age (weeks)
4 5 6 7 8 9 10 11 12
FoodIntake(g/day)
10
15
20
25
30
35
40
*
*
*
* *
* *
Control
HF
Age (weeks)
4 5 6 7 8 9 10 11 12
FoodIntake(g)
10
15
20
25
30
35
40
*
*
*
*
*
* * *
Control
FR
Under-Nutrition Over-Nutrition
Increased Food Intake
IUGR Mat-Ob

52. PVN
ARC POMC
NPY
Appetite Regulation

53. ARC Nucleus Development
• ARC cells arise from Neural Stem Cells in periventricular region
• Appetite (NPY) and Satiety (POMC) neurons populate the ARC
during fetal life and this continues to develop during postnatal life
Appetite Regions Neural Stem Cells
3V
A
R
C

54. In Vivo Neural Stem Cell Migration
1 Day Newborn Hypothalamus
3V = Third Ventricle
Control IUGR
MigrationRate(BrdUCells)
0
20
40
60
80
100
120
*
3V
Nestin = marker of NSC
BrdU = proliferation
* P < 0.01
Control
IUGR

55. Hypothalamic Neurospheres
Undifferentiated
Early Differentiation

56. Hypothalamic NSC Proliferation
Control IUGR
Control IUGR
Foldchange
0.0
0.2
0.4
0.6
0.8
1.0
1.2
*
Nestin
Decreased Proliferation
Control IUGR
Foldchange
0.0
0.2
0.4
0.6
0.8
1.0
1.2
*
Proliferation Index

57. Hypothalamic NSC Differentiation
Neuron Astrocyte
Decreased Differentiation
Control IUGR
FoldChange
0.0
0.2
0.4
0.6
0.8
1.0
1.2
*
Tuj1
Control IUGR
FoldChange
0.0
0.2
0.4
0.6
0.8
1.0
1.2
*
GFAP

58. Differentiated Neural Stem Cell
NPY Neurons
NPYCells(%pertotalcells)
0
2
4
6
8
*
Control IUGR
Control IUGR
* P < 0.05 vs. Control
Increased NPY
(appetite neurons)

59. Hypothalamic Tissue Protein: 1 Day FR
Appetite Satiety
Control SGA
POMC 0.0
0.5
1.0
1.5
2.0
*
Increased Appetite to Satiety Ratio
DNMT1
Control SGA
AgRP
0.0
0.5
1.0
1.5
2.0
*
Control IUGR Control IUGR

60. BPA: Neural Stem Cell Proliferation
BPA (M)
0 1 10 20
Proliferation
Index
0.0
0.1
0.2
0.3
*
*
BPA 0M
BPA 10M
Increased Proliferation
MTT

61. BPA Neural Stem Cell Differentiation
Control BPA
FoldChange
0.0
0.5
1.0
1.5
2.0 *AgRP
Control BPA
FoldChange
0.0
0.5
1.0
1.5
2.0
*
NPY
Control BPA
FoldChange
0.0
0.5
1.0
1.5
2.0
*
POMC
BPA Increases Appetite/Satiety Ratio
Appetite Satiety

62. Mechanism of Enhanced Appetite
Appetite (NPY) neurons Satiety (POMC) neurons
Increased Food Intake
Altered Nutrition / BPA

63. What Programs Adiposity ?
• Adipose Proliferation and Differentiation
• Lipogenesis

64. Adipogenesis
Preadipocyte
Mature
Adipocytes
Differentiation
Increased Number
of Preadipocytes
Proliferation
Hypertrophy
Lipid filled
Adipocytes
Pref1
PPARg
C/EBPa
SREBP1

65. Primary Cell Culture
• Adipose tissue from 1 day old offspring
• Preadipocytes
• Adipocyte
Control IUGR

66. Preadipocytes from 1 Day Newborn
Proliferation
CONTROL
IUGR
ProliferationIndex
0.0
0.2
0.4
0.6
0.8
1.0
*
*
*
*
*
*
c
c
c
c
Insulin (g/ml)
0 5 20 40
Control IUGR

67. Adipocytes from 1 Day Newborn
Lipid Storage
CONTROL
IUGR
Oil Red Stain; x10
O-R-OAbsorbance
0.0
0.1
0.2
0.3
*
*
*
* *
*
c
c
c
c
Insulin (g/ml)
0 5 20 40
Control IUGR

68. BPA: Preadipocytes
Control BPA (10g)
BPA (M)
ProliferativeIndex
0.0
0.2
0.4
0.6
0.8
0 1 10 20
*
* *
Adipogenesis Lipogenesis
Increased Proliferation and Lipid Storage

69. Mechanisms for Developmentally
Programmed Obesity
Appetite
Fetal
Nutrition/
BPA

70. IUGR NSC
HES1
SIRT1 Mash1
-
HES1
Ngn3
Low
Energy
Hes1 gene
Ac
Mash1/Ngn3 genes
POMC
NPY
-
-
+
NSC
Proliferation
renewal
Neural Stem Cell Programming:
Epigenetic Regulation

71. Adipose Stem Cells:
Epigenetic Regulation

74. MOTHER INFANT ADULT OFFSPRING
Normal
Normal Normal
Medical Illness
Placental Insufficiency
Twins, Triplets, etc.
IUGR Improved Survival
- Food availability
- High fat diet
Obese/Diabetic
Obese/ BPA
Macrosomic
- Food availability
- High fat diet
Obesity/
Hypertension/
Diabetes
Epidemic of Metabolic Syndrome

75. Journals.cambridge.org/DOH