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Birth Weight and Subsequent Cholesterol Levels
Exploration of the "Fetal Origins" Hypothesis
Rachel Huxley, DPhil;
Christopher G. Owen, PhD;
Peter H. Whincup, FFPHM;
Derek G. Cook, PhD;
Sam Colman, BSc;
Rory Collins, FMedSci
JAMA. 2004;292:2755-2764.
ABSTRACT
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Context Inverse associations between birth weight and subsequent blood cholesterol levels have been used to support the "fetal origins" hypothesis of the relevance of fetal nutrition to adult disease.
Objectives To perform a systematic review of the association between birth weight and total blood cholesterol levels, and to explore the impact of including unpublished results, adjusting for potential confounders.
Data Sources and Study Selection Relevant studies published by September 30, 2004, were identified through literature searches using EMBASE and MEDLINE and MeSH heading search strategy (using terms such as birth weight, intrauterine growth retardation, fetal growth retardation and cholesterol, lipoprotein, lipid). Studies that reported qualitative or quantitative estimates of the association between birth weight and total blood cholesterol, or had recorded both measures but not reported on their associations, were included.
Data Extraction A total of 79 relevant studies involving a total of 74 122 individuals were identified; 65 had reported on the direction of the association between birth weight and total blood cholesterol. Although regression coefficients were published for only 11 studies and other quantitative estimates for 3 other studies, regression coefficients (published or unpublished) were obtained for 58 studies among 68 974 individuals.
Data Synthesis Inverse associations were observed in 11 of 14 studies that had previously published quantitative estimates but in only 18 of the remaining 51 that had reported on the direction of this association (heterogeneity P = .004). Similarly, the weighted estimate for the 11 studies was –1.89 mg/dL (–0.049 mmol/L) total cholesterol per kilogram birth weight compared with –0.69 mg/dL (–0.018 mmol/L) per kilogram for 47 studies that provided unpublished regression coefficients (heterogeneity P = .009). Overall, the weighted estimate from the 58 contributing studies was –1.39 mg/dL (–0.036 mmol/L) per kilogram (95% confidence interval, –1.81 to –0.97 mg/dL [–0.047 to –0.025 mmol/L]), but there was significant heterogeneity between their separate results (P<.001). Part of this heterogeneity appears to reflect stronger associations reported from smaller studies and studies of cholesterol levels in infants.
Conclusion These findings suggest that impaired fetal growth does not have effects on blood cholesterol levels that would have a material impact on vascular disease risk.
INTRODUCTION
The "fetal origins" hypothesis of adult disease postulates that fetal undernutrition is independently associated with increased susceptibility to the development of coronary heart disease and allied conditions in later life.1 It has been claimed that strategies aimed at improving fetal nutrition may hold the key to preventing vascular disease and other important disorders in adult life.2 Associations have been widely reported between impaired fetal growth (as a proxy marker for fetal undernutrition) and a range of adverse health outcomes, including elevated blood pressure,3 impaired glucose tolerance,4 and elevated total blood cholesterol.5
Much of the evidence for these associations has come from cohort studies that have correlated size at birth with biological risk factors in later life. The strongest evidence had previously been considered to be provided by the observation that lower birth weight was associated subsequently with higher blood pressure levels.6 However, a recent systematic review indicates that claims of a strong inverse association between birth weight and blood pressure may chiefly reflect the failure to take sufficient account of random error in smaller studies, unduly selective emphasis on particular results, and inappropriate adjustment for potential confounding factors, including current weight.7
A comparably large number of studies have reported on the association between size at birth and components of the lipid profile in later life, with most published estimates suggesting an association of between 2.0 to 10.0 mg/dL (0.05 to –0.25 mmol/L) higher total blood cholesterol per 1-kg lower birth weight.8-9 Similar inverse associations have also been reported between size at birth and blood levels of low-density lipoprotein cholesterol, apolipoprotein B, and triglycerides. These reports have contributed to the hypothesis that impaired fetal growth may be associated with abnormalities of cholesterol metabolism in later life.10 A previous meta-analysis of 32 studies involving 23 000 individuals estimated that 1-kg lower birth weight was associated with 2.0 mg/dL (0.05 mmol/L) higher total blood cholesterol.11 More recently, a qualitative review concluded that birth weight was associated only with triglyceride levels, and that this relationship was either inverse or U-shaped.12 Our goal is to update and extend these previous reviews by including previously unpublished data from a large number of studies and exploring the possible impact of adjustment for potential confounders, to determine the likely relevance of impaired fetal growth to subsequent blood lipid levels.
METHODS
Data Sources
Relevant studies were identified through EMBASE and MEDLINE using a combined text word and MeSH heading search strategy of birth weight (birth weight, intrauterine growth retardation, fetal growth retardation) and cholesterol (cholesterol, lipoprotein, lipid). References from identified studies, as well as from previous reviews,11-12 were manually scanned to identify any other relevant studies.
Study Selection
Studies reported by September 30, 2004, were included if they published qualitative or quantitative estimates of the association between birth weight and total blood cholesterol levels. In addition, published studies that recorded both birth weight and cholesterol but did not report on their association, were included. Studies were excluded if the study population involved pathological subgroups (including very low-birth-weight infants) or consisted entirely of preterm infants.
Data Extraction
Most studies reported either a linear correlation coefficient or a nonquantitative description (ie, direction) for the association between birth weight and total cholesterol but only a few reported regression coefficients. Principal investigators of all identified studies were asked to provide regression coefficients for the association of birth weight with total cholesterol level, adjusted for age and sex and, where possible, for some measure of socioeconomic status. Some studies had reported regression coefficients adjusted for current body size (ie, when blood cholesterol was measured), which may distort the associations of birth weight with risk factor levels in later life; therefore, regression coefficients were sought with and without adjustment for body mass index (calculated as weight in kilograms divided by the square of height in meters).
Data Synthesis
The contribution of each study was weighted according to an estimate of its statistical size, which was derived from the inverse of the variance of the regression coefficient (ie, studies with smaller variances, which typically involved larger numbers of individuals, were given greater weight). These weighted regression coefficients were combined by means of a fixed-effects approach, which reflects only the random error within each study and does not make assumptions about the representativeness of the available studies.13 Rather than using a random effects model when the strength of association appeared to differ in different studies, possible sources of such heterogeneity were investigated by comparing the weighted results for studies combined with respect to particular characteristics. All analyses were performed using STATA version 8 (StataCorp LP, College Station, Tex). P<.05 was considered statistically significant.
RESULTS
Availability of Published and Unpublished Results for Analysis
Seventy-nine relevant studies involving a total of 74 122 individuals had been published by September 30, 2004.5, 8-9,11, 14-39 40-83 The reports for 65 of these studies included comments on the association between birth weight and subsequent total blood cholesterol levels, but reports for 14 studies did not. Age-adjusted and sex-adjusted regression coefficients were obtained for the association among 68 974 individuals (93% of total) in 58 studies (Table 1 and Table 2 and Figure 1): 11 had been published previously and 22 were provided for an earlier meta-analysis,11 but results for 25 studies among 45 173 individuals (61% of total studied) were provided specifically for the present review. A further 3 studies involving 659 individuals recorded birth weight as a categorical variable and were able to provide crude regression coefficients, which are reported separately.64-66 Regression coefficients could not be obtained for the remaining 18 identified studies, which involved a total of only approximately 5000 individuals (Table 3).
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Table 1. Direction of the Association Between Birth Weight and Total Blood Cholesterol and Reported Associations With Other Components of the Lipid Profile in Published Reports of Studies That Provided Regression Coefficients for the Present Analyses
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Table 2. Direction of the Association Between Birth Weight and Total Blood Cholesterol and Reported Associations With Other Components of the Lipid Profile in Published Reports of Studies That Had Published Regression Coefficients
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Figure 1. Trend Toward Smaller Differences in Total Blood Cholesterol Concentration per 1-kg Birth Weight Difference in Studies With More Statistical Weight
Studies with more statistical weight providing regression coefficients for the association are included. Statistical size of study is defined in terms of the inverse of the variance of the regression coefficient. Black squares indicate point estimates, with area proportional to statistical size, and 95% confidence intervals for observed effect in each study. Dashed vertical line indicates inverse-variance–weighted regression line through point estimates.
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Table 3. Direction of the Association Between Birth Weight and Total Blood Cholesterol in Published Reports of Studies That Did Not Provide Regression Coefficients for the Present Analyses and Other Components of the Lipid Profile Reported for Those Studies
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Possible Impact of Publication Bias on the Apparent Association
Fourteen studies involving 45 359 individuals (61% of total studied) published quantitative estimates of the strength of the association between birth weight and total blood cholesterol: 11 reported regression coefficients,8-9,11, 25, 31, 33, 35, 39, 54, 58-60,63-66 and 3 reported the association between birth weight categories.64-66 In contrast with the inverse associations reported in all but 3 of those 14 studies (most of which appeared to be statistically significant when considered in isolation), only 18 of the 51 studies that previously reported on the direction but not the strength of the association found it to be inverse (heterogeneity P = .004) (Table 4). Similarly, whereas the mean inverse-variance–weighted estimate between birth weight and total cholesterol level was –1.89 mg/dL (–0.049 mmol/L) per kilogram (95% confidence interval [CI], –2.47 to –1.31 mg/dL [–0.064 to –0.034 mmol/L]) for the 11 studies that published regression coefficients, the estimate of –0.69 mg/dL (–0.018 mmol/L) per kilogram (95% CI, –1.35 to –0.04 mg/dL [–0.035 to –0.001 mmol/L]) derived from all of the other studies that provided regression coefficients for the present analyses was markedly weaker (heterogeneity P = .009) (Figure 2).
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Table 4. Relationship Between the Direction of the Association of Birth Weight With Total Blood Cholesterol in Studies That Did and Did Not Report Quantitative Estimates, Subdivided by Study Size*
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Figure 2. Impact of Selective Publication, Study Size, and Age at Measurement on Weighted Estimates of the Difference in Total Blood Cholesterol per 1-kg Difference in Birth Weight
This analysis was derived from studies that provided regression coefficients for the present analyses. Black squares indicate point estimates, with area proportional to statistical size, and 95% confidence intervals for observed effect in each study.
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Effect of Adjustment for Current Weight on the Apparent Association
Nine of 11 studies that published regression coefficients adjusted for a measure of current body size at the time when blood cholesterol levels were measured. Birth weight is positively associated with weight later in life and current weight is positively associated with current total blood cholesterol level. Hence, depending on the relative strengths of these separate associations, adjustment for current weight might produce a spurious inverse association even if birth weight and subsequent total blood cholesterol are not associated. Moreover, even if lower birth weight is in fact causally associated with somewhat higher blood cholesterol levels at any particular current weight, this effect might well be outweighed by the lower cholesterol level that is associated with the somewhat lower current weight associated with lower birth weight. Regression coefficients with and without adjustment for current body weight were obtained from 49 studies involving 62 430 individuals (85% of total studied). In those studies, removal of the adjustment for current weight approximately halved the apparent association between birth weight and blood cholesterol level, –2.16 mg/dL (–0.056 mmol/L) per kilogram (95% CI, –2.63 to –1.70 mg/dL [–0.068 to –0.044 mmol/L]) with such adjustment vs –1.12 mg/dL (–0.029 mmol/L) per kilogram (95% CI, –1.58 to –0.66 mg/dL [–0.041 to –0.017 mmol/L]) without it.
Effect of Potential Confounders on the Strength of the Association
Of 14 studies that published quantitative estimates of the association, only 5 included some adjustment for current social class,9, 11, 31, 60, 63 despite the well-known impact of socioeconomic status on lifestyle factors (such as smoking, physical activity, and diet) that are related both to birth weight and, independently, to cardiovascular risk factors, including blood cholesterol.84-85 Regression coefficients with and without adjustment for various markers of current social class could be obtained from only 12 studies involving 31 567 individuals (43% of total) and adjustment for these markers did not appear to have much impact on the apparent strength of the association, –2.01 mg/dL (–0.052 mmol/L) per kilogram (95% CI, –2.70 to –1.31 mg/dL [–0.070 to –0.034 mmol/L]) with such adjustment vs –2.16 mg/dL (–0.056 mmol/L) per kilogram (95% CI, –2.86 to –1.47 mg/dL [–0.074 to –0.038 mmol/L]) without it. But, because these indicators were crude measures of any real differences in socioeconomic status and underlying factors, and were provided only for selected studies, residual confounding may remain in the observed associations even after adjustment for the available indicators.
Twins experience similar environments before birth and in childhood, therefore studies within twin pairs should be less prone to the effects of confounding by other factors than are studies involving singleton births. Moreover, consideration of monozygotic twin pairs should avoid any genetic effects on the association between birth weight and blood cholesterol level in later life. Twins also tend to differ more substantially in weight (often by as much as 1 kg86) than do singletons, so any associated differences in subsequent risk factor levels should be greater between twins. But, because only approximately 100 monozygotic twin pairs were included in the 2 studies that have reported on this association,17, 33 the random errors are too large to provide reliable estimates.
Possible Sources of Heterogeneity Between Reported Associations
The overall age-adjusted and sex-adjusted weighted estimate for the 58 studies that contributed regression coefficients was –1.39 mg/dL (–0.036 mmol/L) per kilogram (95% CI, –1.81 to –0.97 mg/dL [–0.047 to –0.025 mmol/L]), but there was significant heterogeneity between the results reported from these studies ( 257 = 135.0; P<.001) (Figure 1). A small amount of this heterogeneity appears to reflect the stronger associations reported from small studies, with a weighted estimate of –5.68 mg/dL (–0.147 mmol/L) per kilogram (95% CI, –8.07 to –3.28 mg/dL [–0.209 to –0.085 mmol/L]) for the 20 studies with statistical size of less than 100 (typically involving about 250 participants) compared with an estimate of –1.24 mg/dL (–0.032 mmol/L) per kilogram (95% CI, –1.66 to –0.81 mg/dL [–0.043 to –0.021 mmol/L]) for the 38 larger studies (heterogeneity P<.001) (Figure 2). For the 3 small studies that only had birth weight classified as low or normal, the crude regression coefficients were –5.79 mg/dL (–0.15 mmol/L) per kilogram in 2 studies and +7.34 mg/dL (+0.19 mmol/L) per kilogram in 1 study, which was consistent with the larger estimates found in the other small studies.
There was also evidence of heterogeneity between the associations reported from studies that measured cholesterol levels at different ages, with weighted estimates of –3.71 mg/dL (–0.096 mmol/L) per kilogram (95% CI, –5.10 to –2.32 mg/dL [–0.132 to –0.060 mmol/L]) in studies of infants aged younger than 1 year vs –1.16 mg/dL (–0.030 mmol/L) per kilogram (95% CI, –1.62 to –0.69 mg/dL [–0.042 to –0.018 mmol/L]) in studies of older individuals (heterogeneity P<.001) (Figure 2). The larger effect size observed in newborns may be due at least in part to the estimate being based on only 6 of a possible 12 studies among 3781 newborns (about 5% of total in all studies). Moreover, even if there really is an inverse association of as much as –3.86 mg/dL (–0.1 mmol/L) per kilogram among newborns, which does not persist beyond the first year of life (as implied by the findings for older individuals), its biological significance may be limited, especially because lowering total blood cholesterol levels in adults has been shown to lower cardiovascular risk rapidly.87
It has been proposed that stronger associations observed between size at birth and later disease risk among men in some studies may partially explain higher male cardiovascular mortality rates in the general population.88 In our review, 5 of 25 studies that had conducted sex-specific analyses reported stronger associations among men, whereas 19 studies found no sex difference in the association and 1 reported an inverse association only for women.26 In the 4 studies conducted only among men,19, 34, 44, 58 the weighted estimate was –1.58 mg/dL (–0.041 mmol/L) per kilogram (95% CI, –3.51 to 0.35 mg/dL [–0.091 to 0.009 mmol/L]), which was similar to the estimate of –1.97 mg/dL (–0.051 mmol/L) per kilogram (95% CI, –4.44 to 0.50 mg/dL [–0.115 to 0.013 mmol/L]) in the 3 studies among women only27, 46, 57 (heterogeneity P = .81). These results parallel those from a recent review that found no sex difference in the association of birth weight with later blood pressure and concluded that "investigators may be more likely to undertake subgroup analyses when overall results are relatively weak."89
Associations With Other Lipid Measures and Other Measures of Size at Birth
Previous impressions of a robust link between size at birth and subsequent total blood cholesterol levels may have been reinforced by the large number of reports of associations with other lipid profile components. For example, associations with birth weight were also provided for blood levels of high-density lipoprotein cholesterol in 46 of 79 studies, low-density lipoprotein cholesterol in 34 studies, triglycerides in 43 studies, apolipoprotein A in 13 studies, and apolipoprotein B in 14 studies (Table 1 and Table 2 and Table 3). However, most of these associations were null, including those for triglycerides (in contrast with a recent review12) and, as was the case for total cholesterol, inverse associations tended to be observed more commonly in smaller studies (Table 5).
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Table 5. Reported Direction of the Association Between Birth Weight and Other Components of the Lipid Profile, Subdivided by Study Size
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COMMENT
Our systematic review of the data available from studies of birth weight and subsequent blood cholesterol levels indicates that 1-kg lower birth weight may be associated with only about 2.0 mg/dL (0.05 mmol/L) higher total cholesterol in later life. This could, however, still represent an overestimate of the strength of the association due to selective availability of results from particular studies compounded by retrospective emphasis on particular measures in selected studies. Moreover, as with the previous claim that lower birth weight is associated with higher blood pressure in later life,7 the adjustment for current weight may have exaggerated any association between impaired fetal growth and subsequent dyslipidaemia.
Evidence from animal and human studies of maternal diet also suggests that maternal undernutrition and lower birth weight are not strongly associated with higher blood cholesterol levels in offspring. For example, 1 study found that restricting protein intake in pregnant rats led both to reduced birth weight and to reduced rather than increased blood cholesterol levels in the adult offspring.90 Similarly, in human populations, the Dutch Famine study36 found that individuals who were exposed in utero to maternal undernutrition during mid-gestation or late-gestation had lower, not higher, blood cholesterol levels in adult life than did nonexposed controls (which is at odds with the suggestion that individuals conceived during the Dutch Famine had "a more atherogenic profile"91). No association was found between birth weight and subsequent total blood cholesterol in either the Dutch Famine study36 or the Leningrad Siege study.92 Therefore, there seems little need to postulate specific effects of other measures of birth size such as abdominal circumference (which might reflect impaired hepatic growth) on cholesterol metabolism in later life. In contrast, there is evidence from a randomized trial of preterm infants that nutrient-enriched preterm formula in early infancy is associated with increased cholesterol levels in adolescents compared with those infants who are fed breastmilk.93
Errors in the assessment of birth weight would, due to regression dilution bias,94 tend to produce some underestimation of the true strength of any association with subsequent outcomes. Most of the studies (83%) included in the present review involved birth weight values obtained from birth records but some, particularly the larger cohorts that were given greater weight in the combined analyses, involved parental recall or self-reports of birth weight. Although this may account for some of the observed difference in the strength of the association between smaller and larger studies (Figure 1 and Figure 2), it does not appear to account for much of it; –1.97 mg/dL (–0.051 mmol/L) per kilogram in studies that used birth records vs –1.74 mg/dL (–0.045 mmol/L) per kilogram in those studies that used self-reports, including the largest study of more than 25 000 individuals, and +1.35 mg/dL [+0.035 mmol/L] per kilogram in the 3 smaller studies that used parental recall. This small difference between studies that used birth records and those that relied on self-reports was consistent with the association of approximately 0.7 between birth weight measures obtained from these different sources,95 which would lead to an increase of about one third in the regression coefficient. In contrast, errors in the assessment of blood cholesterol would not be expected to produce any material underestimation of the association with birth weight, because systematic error would simply add a constant to the mean cholesterol value and random error would not change the mean value.96
The relevance to public health of an association between birth weight and subsequent total blood cholesterol levels of as little as –2.0 mg/dL (–0.05 mmol/L) per kilogram is likely limited. Assuming that nutritional interventions in pregnancy could increase birth weight by as much as 100 g (with comparable changes in any other relevant size-related factors),97 this association would translate into only approximately 0.19 mg/dL (0.005 mmol/L) lower total cholesterol level. A meta-analysis of prospective observational studies found 23 mg/dL (0.6 mmol/L) lower total blood cholesterol level to be associated in the long term with about 25% lower risk of coronary disease at ages 45 to 54 years, and with somewhat weaker associations at older ages.98 Therefore, a persistent reduction in total blood cholesterol of only 0.19 mg/dL (0.005 mmol/L) might be expected to reduce coronary disease risk by less than 0.025%. In contrast, a meta-analysis of randomized dietary intervention studies in free-living individuals indicates that reductions in total blood cholesterol of 15 mg/dL (0.4 mmol/L) can be achieved through feasible dietary modification,99 which would correspond to approximately 15% lower coronary disease risk in the long term.98 There is also consistent evidence from randomized trials that lowering blood cholesterol levels with drugs or diet in middle or old age (40-80 years) substantially reduces the risks of vascular events and death.87 Consequently, producing material changes in blood cholesterol levels that would impact on vascular disease risk seem likely to be more definite, and easier to achieve, through dietary modification during childhood and later life (as well as by altering other lifestyle factors) than through strategies aimed at increasing size at birth.
In conclusion, previous suggestions that there might be a strong inverse association between birth weight and subsequent blood cholesterol levels may chiefly, if not wholly, reflect unduly selective emphasis on particular study results and inappropriate adjustment for current weight and other confounding factors. In contrast, our systematic review indicates that any effects of impaired fetal growth on blood cholesterol levels are weak, and unlikely to influence materially the risks of vascular disease in the population.
AUTHOR INFORMATION
Corresponding Author: Rachel Huxley, DPhil, The George Institute, Level 10, King George V Bldg, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, Sydney, NSW 2050, Australia (rhuxley{at}thegeorgeinstitute.org).
Author Contributions: Dr Huxley had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Huxley, Owen, Whincup, Cook, Collins.
Acquisition of data: Huxley, Owen, Whincup, Cook.
Analysis and interpretation of data: Huxley, Owen, Whincup, Cook, Colman, Collins.
Drafting of the manuscript: Huxley, Owen, Whincup, Cook, Collins.
Critical revision of the manuscript for important intellectual content: Huxley, Collins.
Statistical analysis: Huxley, Owen, Whincup, Cook, Colman, Collins.
Obtained funding: Huxley.
Funding/Support: Dr Huxley is supported by a University of Sydney SESQUI Postdoctoral Fellowship and an International Postdoctoral Fellowship from the High Blood Pressure Research Council of Australia. Dr Owen is supported by the British Heart Foundation. Dr Collins is supported by a British Heart Foundation personal chair and by the UK Medical Research Council and Cancer Research UK.
Role of the Sponsors: The funding sources had no role in the study design, data analysis, data interpretation, writing of the manuscript, or the decision to submit the manuscript for publication.
Acknowledgment: We thank the following investigators for contributing additional data from their studies for these analyses: M. Antal, MD, M. Ban, MD, A. Bavedekar, MD, D. Barker, FRS, F. Bennett, PhD, E. Bergstrom, PhD, S. Bo, MD, L. Byberg, PhD, S. Cianfarani, MD, S. Chinn, FFPMM, G. Davey Smith, MD, J. Deanfield, FRCP, D. Dunger, PhD, P. Emmett, PhD, J. Eriksson, MD, B. Falkner, MD, C. Fall, MRCP, M. Fewtrell, MD, T. Forsén, MD, T. Forrester, DM, S. Garnett, MSc, C. Gale, BSc, S. Hulman, MD, R. Hegele, MD, L. Ibanez, MD, R. IJzerman, MD, C. Jensen, MD, H. Kawabe, MD, S. Koziel, MD, C. Kuzawa, PhD, L. Laurén, PhD, C. Law, MD, D. Lawlor, PhD, C. Leeson, PhD, N. Levitt, MD, C. Martyn, DPhil, J. Minami, MD, K. Miura, MD, I. Mogren, MD, R. Morley, MB, C. Morrell, PhD, M. Murtaugh, PhD, C. Osmond, PhD, M. de Oya, MD, S. Paaske, MD, I. Rogers, MD, R. Rona, PhD, T. Roseboom, MD, A. Sinaiko, MD, A. Stein, PhD, S. Tenhola, MD, M. Wadsworth, PhD, B. Walker, FRCPE, C. Yajnik, MD, and D. Yarbrough, BS. Helpful comments on previous drafts of this study were provided by C. Baigent, MSc, J. Chalmers, FAA, I. Chalmers, MSc, R. Doll, FRS, G. Davey Smith, MD, B. Neal, PhD, A. Neil, FRCP, and R. Peto, FRS; and A. Palmer, MSc, produced the figures.
Author Affiliations: The George Institute, University of Sydney, Camperdown, Sydney, Australia (Dr Huxley and Mr Colman); Department of Community Health Sciences, St George’s Hospital Medical School, London, England (Drs Owen, Whincup, and Cook); and Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, England (Dr Collins).
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