Fetal and Developmental Origins of Childhood and Adult Disease

“Counting the Cost”

A 3-day workshop to explore

“The economic cost ofLow Birth Weight

andSub-optimal Growth in Infancy and Childhood”

PHD HouseNew Delhi

India8th-10th November 2006

Organised by

Department of Paediatrics, Sunderlal Jain Hospital, Delhi *Department of Cardiology, All India Institute of Medical Sciences, New Delhi**Department of Paediatrics and Clinical Epidemiology, Sitaram Bhartia Institute ofScience and Research, New Delhi***&Sneha-India

In association with

International DOHaD SocietyMRC Epidemiology, Resource Centre, University of Southampton, UKThe Centre for Developmental Origins of Health and Disease,University of Southampton, UKLiggins Institute, New ZealandICDDR, B: Centre for Health & Population Research, BangladeshWorld Bank&Public Health Foundation of India**

Programme coordinators

Dr. Santosh K. Bhargava* Dr. K.S. Reddy** Dr. H.P.S. Sachdev***

“The economic cost ofLow Birth Weight

andSub-optimal Growth in Infancy and Childhood”

Executive Summary & Plan of Action

Dr Santosh K BhargavaDepartment of Paediatrics

S.L. Jain HospitalDelhi

Dr H.P.S.SachdevDepartment of Paediatricsand Clinical EpidemiologySitaram Bhartia Institute of

Science and ResearchNew Delhi

“The Economic Cost of Low Birth Weightand Sub-optimal Growth in Infancy and Childhood”

Contents

� Rationale for the conferences� Pre-conference promotion� Registration� Programme� Presentation of lead papers

1. Dr Peter Gluckman The purpose of the meeting and what we hopeto achieve

2. Dr Harold Alderman: Previous analyses of the economic cost of lowbirth weight

3. Dr Santosh K Bhargava:\ The New Delhi Birth Cohort

4. Dr HPS Sachdev: Early growth and adult disease; findings from theNew Delhi Birth Cohort

5. Dr Dorairaj Prabharkar: The epidemiology, medical and economic burdenof cardiovascular disease in India

6. Dr Nikhil Tandon: The epidemiology, medical and economic burdenof diabetes in India

7. Dr Siddharth Ramji: The burden of low birth weight in India

� SummaryThe WorkshopKey workshop questionsMeasuring poor birth outcomeInterventions to reduce low birth weightDeveloping the economic model of low birth weightSpecific issues

� Action PlanGovernanceAdviceManagementFundingActionsPriorities

� Media CoveragePress releaseMedia Reports

� Appreciation by participants

� Acknowledgements

“The economic cost of Low Birth Weightand Sub-optimal Growth in Infancy and Childhood”

Rationale for the conferences

The decision to organize these conferences in New Delhi was taken after detailed discussions between ProfPeter Gluckman, President, DOHaD, Prof. Caroline Fall, Secretary DOHaD, and Governing body of SNEHA.Dr H.P.S. Sachdev and Dr Santosh K. Bhargava at the SNEHA meeting in Alibaugh, Bombay. It was felt thatthis is the most opportune time to discuss the findings of Delhi Cohort, with its follow up extending into 36th

year. It was further felt that the findings of this cohort could be used to develop a model on the Cost of LowBirth Weight in India. There is a Western model developed by Dr Harold Alderman but no such model from thedeveloping World, which contributes maximally to the occurrence of Low Birth Weight globally.

In India almost 30% of births are low birth weight, 7 – 14 % are premature and 2/3 of all Low Birth Weightinfants are fetal growth retarded. It is an established fact these infants are prone to higher mortality andmorbidity (Morbidity and Mortality being inversely related to Birth Weight and gestation) and to long-termsequelae of physical growth (stunted child), cognitive development, skeletal and sexual growth, learningdisabilities and so forth.

The Delhi cohort longitudinal studies on physical growth, body mass index and body composition has alsodemonstrated that the onset of chronic adult diseases such diabetes, hypertension and dyslipedemia occursfrom early childhood to adolescence and young adult.

The frightening aspects and implications of the results of this cohort study further relates to the nutritionaltransition currently occurring in the country with over weight and frank obesity being reported in almost 20%of school going children. The heartening feature and positive aspect of the study is that it suggests thepossibility of tracking these diseases from infancy and early childhood by simple clinical tools such as bodyweight, height, and subcutaneous fat and waist hip ratio measurements and offers an opportunity for earlyintervention.

It is in this context that it was decided to have a composite meeting on three different days with specificobjectives and outcome for each one of them.

The first workshop on “Fetal and Developmental Origins of Childhood and Adult Diseases: Countingthe Economic Cost” was scheduled for first 2 days. A selective core groups of 10-15 experts in this fieldfrom different disciplines of Medicine, Pediatrics, Neonatology, Endocrinology, Cardiology, Nutrition and healtheconomists from different parts of the world and India were invited to share experience and develop a modelon “Cost of Low Birth Weight in India”.

As this core group comprised of leading experts, the organizers decided to take full advantage of the presenceof eminent scientists and investigators in this exciting field and share their experiences and organize aNational CME on “Fetal Origin of childhood and adult diseases: Its clinical application” withprofessionals, residents and students from different subjects and specialties of Pediatrics, Obstetrics,Genetics, Cardiology, Cardiology, Endocrinology, Neonatology and Nutrition participating in it.

The third conference was organized to discuss and present the model developed in the first two days on theCost of Low Birth Weight in India and present it to selective audience of leaders and opinion makers amongst

National and International government and non government organizations, donors, stake holders andprofessionals for their reactions and views on it’s application in national health policies and planning.

Pre-conference promotion

The conferences were extensively publicised in 7 national professional society journals, by sending 1262emails and by posting 2830 pre-conference brochures, personal letters and communication.

For details please see the composite report of the conferences

Registration

Over 250 participants were registered or invited as faculty and guest to these meetings. These belonged toa spectrum of national and international organizations, institutions, administrators, opinion makers, andleaders and from different discipline of medicine, nutrition, genomic and health economists.

For details of list of participants and their specialties please see the composite report of the conferences.

Programme

On each day the programme was different and planned as per the theme of the day, the composition andneed of participants.

For details please see the composite report of the workshop and CME.

Presentations of lead papers

Dr Peter Gluckman

The purpose of the meeting and what we hope to achieve

Peter Gluckman set out the evidence, collected over the last 15 years, that an adverse environment in veryearly life impairs health throughout the life course, and is an important cause of chronic disease in adult life.

This was first shown for cardiovascular disease and diabetes, and there is now evidence of early-life effectson the risk of cancer, musculo-skeletal disease, respiratory disease, and psychiatric disorders. The initialstudies were carried out by Professor David Barker’s group at the University of Southampton, UK, whotracked men and women whose early growth was documented in obstetric and child health records. Low birthweight and poor weight gain in infancy were followed in adult life by premature death from coronary heartdisease and stroke, and a high risk of type 2 diabetes and metabolic syndrome (Figure 1). The highest ratesof disease were in men and women who were small newborns and infants, but had above average weight gainin childhood. The research has particular relevance for India and other developing countries, where maternalunder-nutrition remains widespread, reflected in high rates of low birth weight, and faltering infant growth, butwhere rapid urbanization and economic growth are leading to increased weight gain among children.

As a result of this research the major international agencies have made strong recommendations that resourcesbe invested in maternal and child health (1,2). However little action has been taken, in any country, bygovernments and policy makers.

A more persuasive approach may be to calculate the cost of sub-optimal growth in economic terms.Assessments of the economic effects of low birth weight have alreadybeen reported, notably by Harold Alderman (see below) and Jere Behrmann (3,4). However, for a number ofreasons, the analyses probably underestimated the effects. Birth weight was dichotomised (above and below2500 g, ‘normal’ and ‘low’ birth weight by WHO definition), while associations between birth weight and adultdisease are generally continuous trends across the whole range of birth weight. The analyses did not allow forthe recently described adverse effects of large birth weight (macrosomia) caused by maternal obesity andgestational diabetes (5,6). The analyses limited adult outcomes to diabetes and heart disease, whereasrecent evidence suggests much wider health effects.

.A more robust model is needed to capture the full costs, including a more holistic view of the complex causesand multiple outcomes of sub-optimal early development. These outcomes include maternal ill health, impairedfetal development, reduced newborn and infant survival and health, impaired cognitive development andphysical growth of the child, adult disease, impaired reproductive health, and adverse effects on subsequentgenerations.

The purpose of the meeting was to bring together the following key groups of people:

� Bio-medical researchers in the field of developmental origins of health and disease� economists� Indian investigators with datasets in which to model the effect of early-life exposures on childhood

and adult outcomes� Indian clinicians and epidemiologists who know the data on incidence, demography and economic

costs of cardiovascular disease, diabetes, etc� Indian policy makers

To achieve the following:

� Raise awareness of these issues among Indian scientists and clinicians, economists, ‘moversand shakers’ in government and non-governmental organizations, and (through the press)the general public.

� Form a working network of DOHaD researchers and economists, who will, over the followingmonths, create an agenda, assemble data, and re-model the estimates of economic costsof impaired early development.

Dr Harold Alderman

Previous analyses of the economic cost of low birth weight

The huge worldwide burden of low birth weight justifies action on human rights grounds alone. He has estimatedthe economic benefit of one low birth weight baby averted as $510. Forty percent of this was from benefits oncognitive development and improved adult productivity; 14% from savings on health care costs in childhood,smaller percentages from health care costs averted in adult life and benefits to the health of future generations.An intervention that prevented low birth weight, and cost less than 510$, would be a worthwhile investmentin economic terms.

These benefits accrue at different times. Reduced costs of neonatal care accrue near the time of possibleinterventions. Improved productivity starts to produce economic benefits at about 15 years of age, which lastthroughout the working lifetime. Economists use ‘discount rates’ to allow for the lag time between initialexposure and later impact. Lower discount rates increase the potential later benefits, while higher discountrates reduce them (Figure 2).

Information on which to base calculations comes from experimental studies (e.g. impact on cognitivedevelopment of maternal iodine supplementation, and improved childhood growth following maternal foodsupplementation); cross-sectional observational data linking birth weight with later outcomes (e.g. cognitiveability or chronic disease); comparisons of outcomes in twin pairs of differing birth weight (4); and inferredassociations (e.g. between cognitive ability and earning power).

It is difficult to put a value on lives saved. Lifetime earnings do not take into account the investment neededin the child. Another approach is to use what different countries spend in order to save lives, including thecosts of raising revenue.

In contrast, it is relatively easy to put costs on parental time spent on looking after sick children, andeconomic effects of loss of IQ on earnings. The link between stature growth and earnings is indirect, and it isdifficult to separate socio-economic from biological effects.

The results of iron/folate supplementation for Nepali mothers (5) showed that 1 LBW baby was prevented per11 women reached. The unit cost of the intervention was $64 per woman in the trial, but could (it is estimated)be reduced to $13, which would be an economically viable intervention.

However, even such calculations appear to have limited effects on policy. Why? Why does iodine deficiencyremain prevalent in Asia despite massive cost-benefit. One reason is that economic gains are often made atthe level of the private individual or family, and may not benefit the ‘state’.

Dr Santosh K Bhargava

The New Delhi Birth Cohort

Economic modeling of the costs of low birth weight will require high quality datasets linking early-life eventsto later (childhood and adult) outcomes. Dr Bhargava presented the history of the New Delhi birth cohort,which he established in 1969 with Dr Shanti Ghosh, head of paediatrics at Safdarjung Hospital, Delhi, statisticianDr I Moriyama, and Dr Shantha Madhavan. Its original purpose was to quantify the burden of low birth weight,congenital malformations and other poor pregnancy outcomes, and to study effects on childhood growth anddevelopment.

After considering other locations in the city, Lajpat Nagar in South Delhi was chosen and a census carried ofa 12 sq km area. The total population was 119,799 (23,700 families), from whom 20,755 married women in thereproductive age group were followed up. Of these, 9,169 became pregnant, and 8,181 delivered live bornbabies (8,030 singleton and 151 twin pairs). Twenty-one percent of the babies were LBW and 17% were pre-term. The average family income was Rs 200 per month, compared with a Delhi average of Rs. 28 at thattime. Most families lived in one room, but the cohort encompassed a wide variety of housing quality andamenities. 50% had flush toilets, 30% had access to scavenger-cleaned latrines and 14% had no toiletfacilities (used the open field). The cohort parents were well educated: 32% of fathers and 17% of motherswere college educated; 6% of males and 24% of males were illiterate. 93% of women were housewives, 6%were engaged in clerical/secretarial work, and only 1% worked in hard physical labour. Infant mortality amongthe cohort births was 47/1000 (most deaths were from infection).

Childhood growth was measured using custom built equipment, as anthropometric equipment was notcommercially available. Bio-demographic data was collected according to well-designed protocols and storedon punch cards, before the computer age. It was later transferred onto magnetic tapes. Funding for the cohortwas intermittent, so follow-up took place in phases, but continued until the age of 21 years, resulting in alarge number of publications covering the mortality, growth and cognitive development of the children (7-14).

The project was re-awakened in 1996, when Prof Barker and Caroline Fall visited Delhi with a view tocollaboration on a study of adult health outcomes in the cohort. It proved possible to trace 2,253 members ofthe original cohort, now aged 26-32 years, and living in the original study area, the wider Delhi area, elsewherein India and even in other countries. The original magnetic tapes were deciphered by ICMR statistician Mr.Dey Biswas, who worked through the night in the only facility in Delhi, which still had a system that could playthem – a process that took 2 years.

With a grant from the British Heart Foundation, 1,583 of these were studied in 1998-2002, with measurementsof glucose tolerance, other cardiovascular risk factors, and anthropometric body composition, and data onfamily history and lifestyle habits collected by questionnaire (15,16). For results see presentation by Dr HPSSachdev (below).

Ongoing studies including measurement of cardiac structure and function, intima media thickness, andendothelial function, and more sophisticated measurements of body composition (using DXA), as well asgenetic studies.

The Delhi cohort team has also started documenting the next generation – 1,426 members of the 2,253original cohort members re-traced have had children. Birth weight is known for 786 of these (142 LBW).

Dr HPS Sachdev

Early growth and adult disease; findings from the Delhi cohort

Until the age of 12 years, less than 1% of the children in the New Delhi birth cohort were obese by IOTFcriteria, while 30-50% (depending on age) were underweight by international definitions.

The prevalence rates of impaired glucose tolerance (IGT) and diabetes (DM) when they were re-traced andstudied as adults were 15% and 4% respectively. Figure 3 shows their height and BMI SD scores from birthto adulthood. The men and women who developed abnormal glucose tolerance (either IGT or DM) werethinner on average than the cohort mean at birth (not statistically significant) and had lower BMI SD scoresat the age of 1 and

2 years. After the age of two years, their BMI SD scores rose steadily; they crossed the cohort mean at about10 years, and by the age of 12 they were significantly higher than the cohort mean. The pattern of BMI growthassociated with adult glucose intolerance was therefore smallness and thinness in infancy, combined withaccelerated BMI gain through childhood and adolescence (15).

Analysis of body composition (16) suggested a reason for the above growth associations. BMI (and fasterBMI gain) in infancy and early childhood is more strongly correlated with adult lean mass than with fat mass•Faster BMI gain in late childhood and adolescence is strongly associated with increased adult fat mass andwaist/hip ratio.

Measurements of blood pressure and plasma lipid concentrations, and the combination of risk factors (metabolicsyndrome) all show associations with rapid BMI in childhood (unpublished). The dip in BMI in infancy, seenwith IGT/diabetes, is not present for these outcomes.

Prediction of risk of adult IGT/diabetes and metabolic syndrome are superior if serial BMI measurements inchildhood are available, and BMI change across time, as well as absolute BMI at any single time point isincluded in the predictive equation.

Socio-economic measures in adult life included a ‘material possessions’ score, education level and occupation.Adult height, material possessions score and achieved schooling were positively related to birth weight, andweight SD score in infancy, associations that were statistically significant even after adjusting for childhoodsocio-economic status.

47%, 46% and 16% of Indian children are currently underweight, stunted and wasted, according to the 2nd

National Family Health Survey 1998-1999, compared with prevalence rates of 78%, 79% and 18% in theNational Nutrition Monitoring bureau data from 1975-1979. There is thus a steadily ‘improving’ picture in Indiain terms of indices of under nutrition. However, in an ongoing survey of over 12,000 Delhi schoolchildren, asmany as 15% of children in higher income groups (HIG) were overweight (1% of low income group children,LIG). Hypercholesterolaemia (>200 mg/dl) was present in 9% of LIG children and 20% of HIG children. Highblood pressure and hypertriglyceridaemia (>140 mg/dl) were present in about 5% and 10% of childrenrespectively – these were similar in all income groups, but marginally worse in the LIG.

In conclusion, there is declining anthropometric under nutrition and rapidly escalating metabolic over nutritionoccurring in Indian children. Sustained upward centile crossing in childhood is associated with adverse adultoutcomes such as diabetes and the metabolic syndrome.

Dr Dorairaj Prabharkar

The epidemiology, medical and economic burden of cardiovascular disease in India

Recent surveys show that the current prevalence of coronary heart disease (CHD) in India is around 3-4% inrural and 8-10% in urban populations. At a conservative estimate there are around 30 million patients withCHD in India, 2.5 million coronary events every year and 1.5 million premature deaths from CHD annually.

Despite this huge burden of disease, there is a marked lack of awareness among the general public about itscauses. For example, people who took part in community surveys did not realize there was a link between‘well-known’ major risk factors such as diabetes, lack of physical activity and smoking, and heart disease.

In addition, there are gross misconceptions about the disease. Firstly, it is perceived as a disease only of therich. This may have been true in the past, but there has been a reversal of the socio-economic gradient, withboth higher incidence rates and higher case mortality rates, in the poorest and least educated sectors(17,18). An ongoing survey of 10,000 adults shows a higher prevalence of hypertension, diabetes and metabolicsyndrome in the lower socio-economic strata. The reason is unknown, but may be due to ‘developmentalmismatch’ exaggerated by rapid economic transition, whereby an individual’s early nutritional level differsfrom that later in life.

Another misconception is that cardiovascular disease (CVD) is a disease only of men. In fact, it is thecommonest cause of death in women worldwide. This is an evolving situation - more women than men areexpected to suffer from CVD in developing countries by 2040 (19). The Inter heart Study showed that whenwomen acquire CVD risk factors, they are more sensitive to them, and show a steeper risk-disease relationship(20,21).

There is a misconception that CVD afflicts only ‘old people’. However, the average age of first heart attack inIndia is 10 years younger than in the West, and 50% of first events are in the under-70 age range.

Finally, there is a misconception that Indians are genetically susceptible to cardiovascular disease, and thatthe usual environmental and lifestyle risk factors are unimportant in the Indian context. This is despite clearevidence that the same risk factors associated with disease in other populations show similar associationsto disease in India.

At the household level, cardiovascular disease can be devastating. The high costs of medical care can leadto catastrophic spending, sudden impoverishment and reliance on loans. It has been shown that the loss ofthe main family breadwinner leads to a 12-fold increase in under-2 mortality in the children, a high probabilityof girl children dropping out of education, and problems for dependant elderly.

Direct costs of medical care have been calculated by the National Council for Macroeconomics and Health,and by TPP for the state of Kerala (Indrani Gupta). The latter estimated the cost for the state of Kerala aloneat 9 billion rupees in 2004-2005, in the most favourable of several scenarios modeled.

Dr Nikhil Tandon

The epidemiology, medical and economic burden of diabetes in India

WHO projections estimate that India will have 80 million patients with diabetes by 2030 (22). Publishedsurveys show a doubling in prevalence in the last decade. There is a wealth of data. The National UrbanDiabetes Survey, which was carried out in 6 cities (Delhi, Mumbai, Bangalore, Hyderabad, Chennai andKolkata) and had a sample size of >12,000 adults (23; Table 1) showed that risk increases with age, BMI, andwaist/hip ratio. Higher socio-economic status and a positive family history were additional risk factors.

Table 1 National Urban Diabetes Survey: Age specific prevalence (from reference 15)

Age groups IGT DM

n % n %20-29 301 11.6 60 2.330-39 400 14.3 212 7.640-49 381 15.5 441 17.950-59 248 14.8 463 27.760-69 194 16.6 364 31.1>69 107 20.2 144 27.2

The PODIS (Prevalence of Diabetes in India Study; 24) sampled people from 77 areas around India, half fromcities and half from rural communities, and showed an overall age-and-sex-standardised prevalence of 6%.This agrees with the prevalence found in the ongoing multi-centre sentinel CVD surveillance project, and witha meta-analysis carried out by the Indian Council of Medical Research from published prevalence data inIndia, which found an overall prevalence of around 12% in urban and 4% in rural populations.

Direct costs of the disease include consultations, investigations, drugs and other treatment, glucose monitoring,and hospital admissions. Indirect costs include those due to days of employment lost due to medical visitsand disability. Intangible costs include the pain and anxiety of illness.

The Bangalore Urban Diabetes Survey studied 600+ patients attending government and private clinics. 28%were attending government clinics and 78% attended private facilities. Only 8% were diagnosed by a diabetesspecialist – the remainder by GPs. Differences in age at diagnosis between socio-economic groups and

education groups suggested a delay of several years in diagnosis among those of lower SES – likely to bevery important in terms of risk of developing complications. 70% of patients had at least one complication.

The BUDS study (25) estimated the direct costs of diabetes at Rs 6,000 per year (if hospital admission notrequired) and Rs 10,000 per year with hospital admission. This rose to Rs 35,000 per year if indirect costswere included. A small study in North India compared 50 patients from a tertiary care hospital and controls(healthy adults in the same household) (26). Assessment included psychological disability. This study estimateddirect costs of diabetes at Rs 10,000, and indirect costs at Rs 4,000, per year.

The CODI study included patients from 187 towns, and concluded that diabetes eats up 5% on average of thehousehold income. It estimated that the cost of adequately treating the 17 million patients with diabetes inIndia in 1997 would be Rs 75 billion. The entire health budget for India in 1997 was Rs 25 billion (27).

Dr Siddharth Ramji

The burden of low birth weight in India

The National Neonatal Perinatal Database (NNPD; 28) records the incidence of low birth weight (LBW) in Indiaat 31% in 2003. This agrees with other recent estimates of 38% in Mumbai slums (29), 39% in Delhi slums(30), and 35% in rural Maharashtra by Bang A et al (31).

There has been little, if any, change in incidence in the past 15 years. Although there is evidence of 70-130g increases in birth weight (32), this is counter-acted by an increase in urban slum populations, which havehigh rates of LBW.

The problem equates to 8.6 million low birth weight babies born every year (3.1 million pre-term, 2.6 milliongrowth retarded) of whom 0.8 million die, accounting for 75% of neonatal deaths in India and 20% of the wholeworld’s neonatal deaths. The NNPD data shows that mortality is 6% in babies weighing <2.5 kg, 15% in thoseweighing <2.0 kg and 30% in those <1.5 kg.

Although growth retardation is the main cause of low birth weight, premature delivery is a significant part ofthe problem. Gestation is on average approximately one week shorter in India than in western series. Estimatesof prematurity rates range between 10 and 15% (NNPD 15%, Bang et al 10%, ICMR (rural 2002) 13%). About30% of pre-term babies are also growth retarded, and these have the worst mortality profile.

Among all low birth weight babies, 25% die in the first year (33). Hospital-based studies suggest that infectionis a major cause (34). The incidence of diarrhoea was 8-fold higher than in normal weight babies in onestudy (35).

Data published by Dr Bhargava showed that both pre-term and growth retarded low birth weight babiesremain shorter by about 3 cm in final height compared with controls(36-38).

LBW babies also experience significant deficits in neurodevelopmental outcomes. One study estimateda 7-point reduction in their mental and motor developmental quotients compared with normal weight babies at18 months (39). Another showed similar deficits at the age of 6 years, with 13% of children having borderlineor low scores, and with the worst outcome being in pre-term growth retarded LBW’s (40). The deficits persistedor worsened at the age of 12 years, when 24% of children scored low (41). 47% of the 12-year old children hadvisuo-motor impairments, and a high proportion had difficulty with writing and mathematics. The wideningdeficit with age is also observed in Dr Bhargava’s data (42) and from studies in western populations.

Another possible disadvantage for LBW children is earlier menarche, especially in the presence of adequatepost-natal nutrition. This can be associated with early cessation of growth, and short stature, which impingeson fetal growth in the next generation.

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33. Hirve S, Ganatra B. A prospective cohort study on the survival experience of under five children inrural western India. Indian Pediatrics 1997; 34:995-1001.

34. Chaudhari S, Kulkarni S, Pandit A, Deshmukh S. Mortality and morbidity in high risk infants during asix year follow-up. Indian Peadiatrics 2000; 37:1314-20.

35. Bhargava S.K., Kumari S., Choudhary P., Ghosh S., Bhutani R., and Bhargava V.: A Longitudinalstudy of linear physical growth in preterm infants from birth to six years, Indian J.Med.Res.78: 74,1983.

36. Bhargava S.K., Kumari S., Chaudhury P., Ghosh S.,Bhutani R., and Bhargava V.: longitudinal studyof linear physical growth of infants growth of infants with birth weight of 2500 gm. Or less from birthbirth to six years. Indian J. Med Res.78: 78.1983.

37. Bhargava S.K., Choudhary P., and Kumari S.: Physical growth in small for gestation age childrenfrom birth to 10 years Indian Pediatr. 21:919.1984.

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Summary

The Cost Of A Poor Start To Life (Psl)

Working Group

Prof. Peter Gluckman (chair) pd.gluckman@auckland.ac.nz

Dr. Harold Alderman halderman@worldbank.org

Dr. Dewan Alam dsalam@icddrb.org

Dr. Santosh Bhargava drskbhargava@yahoo.com

Dr. Caroline Fall chdf@mrc.soton.ac.uk

Dr. Indrani Gupta

Dr. Barun Kanjial barun@iihmr.org

Dr. Mark Hanson M.Hanson@soton.ac.uk

Dr. Susan Morton s.morton@auckland.ac.nz

Kate O’Connor kc.oconnor@auckland.ac.nz

Dr. Siddiqur Osmani sr.osmani@ulster.ac.uk

Dr. Clive Osmond co@mrc.soton.ac.uk

Dr. D. Prabhakaran prabhakar61@yahoo.com

Dr. S. Ramji sumisid@vsnl.com

Dr. K.S. Reddy ksreddy@ichealth.org

Dr. H.P.S. Sachdev hpssachdev@gmail.com

Dr. Nikhil Tandon nikhil_tandon@hotmail.com

The Workshop

The aim the meeting was to continue the dialogue surrounding the costs of low birth weight (LBW) which waslater generalized as a poor start to life (PSL), and to develop a generic model for these costs so that policyefforts might be refocused on early development as the optimal approach to preventing later poor outcomes.Dr Harold Alderman’s original economic model of the costs of LBW in a stylized low-income country provideda starting point for the continued dialogue. A particular strength of this model is its life course approach; whilesuch life history approaches have to date gained little traction with governments, it is hoped that robusteconomics in partnership with robust science will produce convincing arguments to influence policy makersand health agencies. There was considerable discussion on the classes of cost: direct, indirect and intangible.These costs burdens are carried by the state as expenses in education, welfare, healthcare and the labourmarkets, and are also felt by individuals and their families.

By reviewing the current body of knowledge, and in particular the data available from different populations,steps may be taken to fill in the knowledge gaps, and apply real world data to the Alderman model, initially ina country specific fashion and latterly (if possible) in a generic fashion. While there remain aspects of knowledgestill to be fully understood, it was agreed that this lack of certainty either about precise causality, should notobstruct momentum for beginning advocacy related to the problems of a less than optimal start to life.Increasingly the evidence suggests that poor birth outcomes have large costs to society throughout the lifecourse of individuals across different populations. By quantifying these costs governments can be encouragedto invest more into early development, maternal health and nutrition, and female empowerment and education.

Furthermore, even though all possible solutions (and the practicalities of their implementation), and the costsof these interventions have yet to be fully identified, understanding the costs of PSL will become a criticalpart of any request to government for additional resources for research into those solutions. Estimates of thekind of shifts achievable, in terms of either cost savings or increases in productivity, will be required toinfluence government investment.

The Developmental Origins of Health and Disease (DOHAD) paradigm, which has led to a greater emphasison early life as a key period of influence for chronic diseases in adulthood. This paradigm underpinned thediscussions taking place at this workshop.

KEY WORKSHOP QUESTIONS

� How is a poor start to life best measured for this purpose?� How is the measurement of birth weight, in particular, to be treated?� What are the direct and indirect costs associated with a less than optimal start to life?� When should the interventions be applied to obtain the best cost-benefit ratio?� If interventions are available what might be their impact?� What data are available to be used in the Alderman model to generate real-world cost

estimates?� What are the research and policy priorities?

MEASURING POOR BIRTH OUTCOME

How well does the measure of birth weight serve as an indicator for adverse long term and population levelhealth outcomes?

There was much discussion about the inadequacy of absolute birth weight as the measure on which ‘pooroutcome’ is defined. In particular the inappropriateness of the use of a universal cut-off of 2500 g to defineLBW regardless of the birth weight distribution of each specific population group being considered. However,despite the generally held view that BW is indeed a blunt and inaccurate measure of ‘poor outcome’, it wasagreed that it is currently the most available and accessible measure for use both as proxy for a sub-optimalgestational environment, and as a predictor for increased health and social burdens, and economic costs.

The issues are made more complex by the recognition that the known associations between size at birth andlater health outcomes are not unidirectional. In fact some poor later life outcomes may develop from largesize at birth, for example gestational diabetes and maternal obesity can lead to higher birth weight babieswho in turn have a poor adult incomes. This pathway may be particularly prevalent in populations currentlyundergoing nutritional transition.

The potential of viewing birth weight as a continuous variable and the subsequent ability to view health risksacross the distribution of birth weight was discussed. By analyzing the shape of the risk curves across thedistribution, the effect of any intervention – either to the tails, or shifts to the entire population distribution –might be estimated. It was concluded that significant improvements to the economic model would be attainedin the first instance by applying a step function to estimates.

The strongest reason to apply a framework of birth weight bands is that many health and cognitive problemsdo not arise from a low birth weight per se, but from a sub-optimal fetal environment. For example, a shift indevelopmental trajectory to a metabolic-type phenotype caused by a constrained fetal environment may bereflected in a lower birth weight than would otherwise have been the case – but one which falls within a“normal” birth weight range. Understanding the net benefit of any intervention will require understanding theeffect of the intervention on the entire birth weight distribution, not only the effect on either tail.

In deciding how to treat the measurement of birth outcome in different populations the “magic number” of2500 g birth weight needs reconsideration. The key question is “how is poor birth outcome to be determined

across populations?” Comparing the population based U-shaped curve of the relationship between birth sizeand the risk of diabetes, heart disease etc is useful. While in both developed and developing countries, theshape of the left hand side of the curves (smaller birth weights) is similar, at the middle and right handportions of the curve even a “normal” baby can have macrosomic-type risk in a context such as in India. Thismeans that even a baby in a “normal” range may be bigger than they would otherwise have been because themother had undiagnosed gestational diabetes.

Without recognizing these scenarios the intergenerational effects will be underestimated. For this reason, it isinsufficient to consider only the low weight portion of any population. The capacity to consider birth weightdistribution should be built into the model. Thinking about it in terms of deviations away from the mean, in risk“steps”, or in quintiles, might be a useful way to make the model generalisable across populations noting thatit is important however that the model does not become so complicated that it is unfathomable (and notuseful) for policy makers.

At present, a better measure than birth weight for identifying children who have had theirdevelopment trajectory shifted, as a result of adverse fetal environment, is not available. Birthweight is the best available proxy for poor birth outcome. Additionally, it can become anobjective or focus for policy intervention. The dichotomous view centered around the 2500 gcut-off is not as useful as viewing birth weight as a continuous variable or as step functions ofrisk across the entire distribution and across different populations.

INTERVENTIONS TO REDUCE LOW BIRTH WEIGHT

The impact and magnitude of any intervention or campaigns are largely still uncertain. Some possibleinterventions might involve modifying social, family, nutritional, educational and economic environments,rather than applying a therapy or treatment. In campaigns for which successful shifts in birth weight distribution,(or the rate of PSL) are to be achieved, the interventions almost certainly have to involve a number of factors:good results may not be attributable to any single factor on its own. Little is yet known about the pathways forthe various individual interventions, or how they work together. Focusing on a single intervention (or outcome,such as improved nutritional or cognitive status) is not as useful as attempting to understand how themeasures interact with each other. Any change to the prevalence of obesity, for example, will also havecognitive and mood effects: the results must be understood as a cluster of traits (some of which may notnecessarily be desirable), and in the context of the whole of society.

There was considerable discussion on the classes of cost: direct, indirect and intangible. These costs burdensare carried by the state as expenses in education, welfare, healthcare and the labour markets, and are alsofelt by individuals and their families. Examples of the kind of costs incurred by PSL are given

Examples of cost incurred by families

The workshop agreed that social change is extremely difficult to enact. Any progress towards policy aimed atpositive social change will depend on a solid groundwork of fact and reliable measures. Although some dataexist about a range of possibly effective measures, (such as changing the age of first pregnancy, nutritionaland micro-nutrient interventions), real information about the mechanisms for, or the results of, large scalesocial interventions (such as the empowerment of women, or improving the preconception health of women)is not yet available.

It was noted that breaking the cycle of PSL is not just a developing world issue: the problems of mismatchalso exist in the developed world. That is, the significant costs associated with mismatch and sub-optimalfetal development is a global phenomenon. Finding a way to quantify these costs is the primary task of theproject being developed.

Quantifying all the costs of interventions, both direct and indirect, is important. Resources for social, healthand education programmes have to be raised by governments, whether they be directed at individual householdsor society in general. Therefore, it is important that they are fully costed because the purpose of economicmodeling is to show that any effective intervention which costs less than the total value of costs of PSL isone worth pursuing. The policy instruments that are recommended to governments and which show considerationfor all costs will be more attractive to decision makers. The cost model should also include the deadweightcost of raising revenue (assumed to be 25% in the Alderman model).

Note: when comparing the costs and benefits of interventions it is important to use costs-to-scale (as wouldaccrue from population-level interventions), rather than those inflated per capita costs as apply to small-scaleexperimental trials.

FAMILY INDIVIDUAL SOCIAL Household Income – extended absence from workforce

Health care costs of chronic disease & co-morbidities

Neonatal Intensive Care

Lost wages – attending to sick children

Psychological burden of stunting, mood disorders etc

Excess hospitalizations

Emotional and psychological burdens

Reduced earnings potential (IQ, schooling, height)

Special education

Sibling impacts – constraints on household resources and parental investment

Costs of the inter-generational cycle - the poverty trap

Social Services (welfare, case management, respite care)

Out-of-pocket costs – travel, accommodation, child-care

Inpatient and Pharmacy resources

Increased utility costs of running household (e.g. heating), home modification

Costs of reduced human capital development and lost productivity

Increased medical and pharmacy costs (or costs of alternative therapies)

Costs of early intervention or therapy

Cost of mortality

The current lack of specific recommendations about the range of interventions to addresslow birth weight should not delay progress towards developing the generic economicmodel.At a theoretical level the models will point towards when in the life course interventionsmay be most beneficial.ANY effective intervention(s) that costs less than the total cost of PSL per individual movedout of a PSL category will be shown to be a sound investment at a policy level.

DEVELOPING THE ECONOMIC MODEL OF LOW BIRTH WEIGHT

Purposes of a developed economic model of poor birth outcome / PSL

� To feed real world data about the costs of chronic disease and reduced productivity associated withPSL into the preliminary model to provide accurate estimates of costs for different populations indifferent stages of nutritional and economic transition.

� To quantify the total costs of PSL at various stages of the life course,� To show the lifetime cost-benefit gained from theoretical interventions, and� To support advocacy for greater investment of public resources in fetal and early development, and

research into prevention and treatment; i.e. to attain traction to shift the problems of PSL out of amerely epidemiological paradigm to one where social policy is informed, particularly in those populationsat higher risk (such as those undergoing a nutritional transition, where maternal diet and educationconsiderably increase the risk of poor pregnancy outcome, or where there is an excess of PSL).

Main Steps

1. Apply real world data from specific countries (developed, transitional and developing) to thestylized model. For example, obtain data about excess hospital days of PSL neonates (and costper day) from individual countries and substitute this information into the algorithm, get furtherdata on cognitive impairment.

2. Provide details for the adult-illness and intergenerational effects (especially the probability ofPSL having at-risk children) N.B. such risk may be marked by, but is not limited to PSL off-spring. Whilst both of these buckets of costs will be discounted, it is important to complete thesedata as a separate project. Results may then be incorporated in the economic model.

3. Revise the model, originally conceived as a “crossing the threshold” one, and convert it into onewhere BW as a continuous variable or which has step-wise costs and risks according to birthweight category. In the revised model it is assumed that the total cost will depend on how far achild is from an optimal birth weight.

Sources of Data

A strong body of data already exists across the world about the prevalence of PSL, the incidence and age ofonset of chronic diseases, and their costs (including hospital costs and work-loss). There is also a largequantity of data about the various pathways for metabolic diseases (especially in animals), and how thesepathways may be manipulated. It was agreed that the priority now is to gather together all useful datasets(e.g. the Delhi Cohort, Bangladesh, Jamaica, Southampton, Minnesota, Singapore, China, and New Zealandlongitudinal studies), and to identify and areas of missing data. Data may then be applied to the modifiedAlderman model using the life-stages as described below.

Note: Of special interest is information about the incidence of gestational diabetes amongst those that areborn smaller in India.

SPECIFIC ISSUES

1. Reducing Infant Mortality

Determining the value of a life saved remains a challenge to the discipline of economics. The easiestway (but by no means the best) to cost it is to use the average value of earnings over a lifetime. Thismodel could be run using 2 – 3 different methodologies (such as that used in valuing a “risky” job overa “safe” one, or the value used in economic models of road-traffic deaths). Alternatively this aspectof the economic modeling may even be left out. If omitted, the model would result in a cost of PSLthat was over and above the economic value of a life saved (for which there will always be disagreementabout a definitive answer).

Determining a relative risk of mortality (with a step function for different categories of BW) will requirecontrolling for socio-economic drivers within the model. For example, there is an implicit assumptionthat birth weight and infant mortality are linked, but even if birth weight were shifted, without shiftingthe poor environment into which a child were born, how would the relative risk of mortality change, ifat all? Controlling for socioeconomic status, (not something that was done in the original model)might be conceptually better (where possible, given the constraints of existing data) to at leastpartially acknowledge the effects of SES on birth weight and subsequent development.

Given the tremendous variability in the frequency and accuracy of birth weight measurementbetween different countries, data from sentinel sites should be used, where possible, toobtain country specific estimates of neonatal mortality amongst PSL babies (controllingfor other maternal and environmental factors).

1. Reducing neonatal (& childhood) medical care

From existing data it should be a relatively straightforward exercise to take the excess number ofhospital days a PSL neonate or child spends in hospital and multiply these by the resource costs ofhospital stays. Out-patient care for older children may be factored into the cost portfolio. Once again,using a step function of birth weight category is useful. Controlling from socio-economic confounderswill be necessary and each country’s deadweight costs of raising revenue will need to be included.

It is certain that caring for sick children involves opportunity and indirect costs for families, such asextra costs for transportation, or lost wages. It is possible that data relating to these costs could beobtained from national family surveys, or, if they were omitted from the model, the final result wouldneed to be presented as an underestimate of the true costs.

2. Reducing the costs of adult disease

� When in the life course do the problems start to appear?� If, as in the case of diabetes, the disease may be recognized earlier on in life, what is the effect

on the progression of the illness, and the costs associated with earlier recognition?

The timing of onset is a very significant issue, because if health problems are occurring earlier in life,the costs of them (such as those represented by reduced earnings, or by larger medical expenses)will be accrued over a longer period of time. Even if health problems, stunting or poor cognitivedevelopment do not limit participation in the formal employment market, then they might somehowlimit engagement with the informal or private sector. Assessing the cost of these may well prove tobe important, albeit challenging.

As part of applying stepwise cost functions into the model, it is important to determine the probabilityof developing chronic disease in the light of any country’s birth weight distribution. In other words thehypothesis that disease risk is greater amongst those in the “tail” of birth weight distribution, (oramongst those that exhibit some other marker of poor birth outcome) needs to be tested. As part ofthis task it is important to avoid the trap of relating birth weight alone to disease risk. Therefore weshould state at the outset that birth weight is accepted for use in our model as the best and mostwidely available marker for poor fetal outcome. As other markers relating to infant and childhoodgrowth, disease risks, cognitive development and adult earnings potential, as well as biochemicalindicators of diseases such as diabetes, become available they could also be tested for their potentialfor inclusion in a similar economic model.

Excellent data relating to the costs of treatment of certain diseases such as diabetes and heartdiseases should be readily obtainable from many countries, including India.

Any evidence showing changing age at onset of adult disease should be gathered, as this will havesignificant impact on the costs-outcome through greater years of medical treatment and lostproductivity.

The timing of onset of health problems and chronic disease will have significant impacton the total costs of health care calculated by the economic model. Robust scientificevidence of not only the risk of disease but also the age of onset is required.

3. Birth Weight and Adult Productivity

� What is the increase in earnings expected either by an increase in height or an increase incognition and schooling attainment?

� What is the influence of socio-economic status and gender on the impact of PSL on adultearnings?

Increased earnings as a result of increased height or cognition (including the value of additionalyears of schooling) may be treated in a very similar fashion, despite the presence of bias betweenheight and IQ.. Data relating birth weight to adult height and cognitive function are available; therelationship between adult height and earnings is also straightforward. Thus, these parameters maybe fixed quite well, either in two pieces or taken together.

In general terms, it appears that PSL as indicated by LBW is associated with a loss of a one halfstandard deviation of IQ. Most sets of wage and IQ studies (some of which control for schooling),show that the labour market rewards smarter people. Using a step function of birth weights andrelating these to IQ and subsequent earnings (or a material assets possession or consumption proxymeasures) would be an interesting feature of the developed economic model.

4. Intergenerational costs

The intergenerational burden of PSL is thought to be significant. Modeling this burden should not belimited to those small women who give birth to small babies, but also PSL mothers who deliver muchlarger babies (macrosomic), and the costs associated with health problems related to this. As part ofdetermining the intergenerational effect (and costs) of PSL, analysis of the proportion of PSL babieswho develop into mothers with gestational diabetes is a research priority. Existing data, such as theDelhi cohort should be re-interrogated for this information.

Important aspects of this part of the model follow:

� The “average” effects of PSL mothers having small babies can be costed out using existingdata.

� Consideration that some of these intergenerational costs occur at the same time as costsare being accrued for the parent’s generation (especially true in the case of very youngmothers).

� Further epidemiological research into the prevalence of gestational diabetes (and subsequentmacrosomic offspring) amongst PSL women should proceed immediately.

� Scientific evidence must be produced in a form that is translatable for economists; a commonmetric should be used so that the costs and benefits or various interventions may be compared.

It is very important to take a life course and intergenerational approach in order to completea convincing picture of poor birth outcome, despite the discounting that applies to thesecosts.

5. Sensitivity analysis

As no single discount rate (whereby future benefits or costs are discounted to present value) isagreed upon by economists the model should be sensitive to a range of discount rates, for e.g. 3%,5% and 10%.

Sensitivity analyses should be applied to other components of the model.

Action Plan

It was agreed to establish a formal international collaboration to undertake the project.

Initially the project would focus on New Zealand and the UK as developed countries and India and Bangladeshas countries undergoing transition but it was recognized that the project was likely to expand to East Asia,Latin America and Africa.

Governance

The project would be governed by a coordinating group comprising P Gluckman (interim chair), S Morton,Prof Hanson, one from MRC ERC (UK), H Alderman , Prof Santosh K. Bhargava and Prof H.P.S.Sachdevfrom India plus one from any other country involved.

Advice

An international advisory panel consisting of Prof C Victora, Prof R Shrimpton, Prof S Osmani, Prof S Reddywould be establish

Two working committees would be established

� Economics modeling group

Dr S Morton (coordinator), Dr John Yeabsley (NZ Institute of Economic Research), Prof S Osmani,Prof H Alderman , Prof Indrani Gupta (IndiaIf she agrees)

� Epidemiological and health economics data group

Dr C Osmond, Dr D Prabakaran, Dr N Tandon, Dr S. Ramji

Management

The project would be managed by a project coordinator for developed country data.

The Delhi cohort was seen as particularly valuable resource particularly in the context of a considerableamount of public health and health economic data in India and will appoint a research coordinator in Delhi foran initial one year period to expedite the project.In particular this coordinator would work with his/her colleagues to identify and interrogate specific data setsrelevant to the model and to also find sources of relevant economic and health statistical data for the Indianpopulation. This appointee is thus likely to come from a public health/epidemiological background. Dr SantoshBhargava and Dr H.P.S. Sachdev will manage this appointee, and will act as the key members of the groupfor the purposes of this project.

Funding

External funding will be sought from Grants, Agencies Foundations, Government andnon Government sources

Actions

– Workshop summary to be prepared (done)– Website established (K O’Connor)– Coordinating group to be established ASAP– Indian team members to recommend placement and appointment of a local coordinator.– Work plan mapped out in detail– Aim is to have project team in place and plan agreed in 6 months– First papers within 18 months

Priorities:

� Recalculate effect on DOHAD related diseases in two populations(India and UK/NZ)

� Develop fuller economic model

Media Coverage

Press release

Workshop on Fetal and Developmental Origins of Childhood and Adult Disease:“Counting the Economic Cost”

The last three days have seen an important and timely international workshop taking place in Delhi. This hasfocused on the economic burden caused to India by the under-nutrition of Indian mothers, the consequentunder-development and poor growth of babies and young children, and the long-term effects of this on adulthealth and productivity.

Low birth weight has long been recognized as an important problem in India. Approximately one in threeIndian babies are born low birth weight (less than 2.5 kg). Indian babies are the smallest in the world, weighingon average 2.8 kg. This has severe consequences for the babies in infancy and childhood, because intra-uterine under-nutrition leads to a failure of the complete development of immunity, and of the brain and otherorgans. The short-term results are high mortality in the first year of life, due to increased vulnerability toinfection, and impaired brain development, resulting in a loss of roughly 10 IQ points in childhood comparedto babies of normal birth weight.

India is also currently witnessing an epidemic of diabetes, high blood pressure and cardiovascular disease inadult life. Approximately 10% of urban Indians have developed diabetes by the age of 40 years. This will riserapidly in the next 20 years, and India is predicted to have 80 million people with diabetes by the year 2030.Diabetes is a strong risk factor for cardiovascular disease. With the rising tide of diabetes, heart disease isnow India’s main cause of premature adult death.

Link between low birth weight and adult disease

Few would have guessed that the problems of low birth weight, and adult diabetes and heart disease, areintimately linked together. Scientific evidence, initially from the UK, Europe and the USA, and now from Indiaitself, shows that babies who had a poor start in life because of maternal malnutrition and low birth weight,are at the highest risk of later diabetes and heart disease. The risk is made even worse by a particular patternof growth in childhood – children who were small at birth but become heavy or fat children. This excessivechildhood weight gain is occurring more and more commonly nowadays, because of urbanization, and the lowlevels of physical activity of Indian children.

It is now known that prevention of India’s epidemic of diabetes and heart disease will require improvementsin the nutritional status of Indian mothers, babies and infants (to prevent low birth weight), and attention to thegrowth pattern of children (to prevent excessive weight gain). These measures are as important as achievinghealthy lifestyles (preventing obesity and encouraging more physical activity and physical fitness) inadult life.

Economic cost to India of sub-optimal growth in early life

Low birth weight thus produces a huge economic burden for India, quite apart from the high ‘human’ cost ofexcessive mortality in the first year of life. Add together the costs of health care needed by small babies, thereduced educational achievement and productivity resulting from their impaired brain development, and themedical costs of treating adult diabetes and heart disease – this amounts to a heavy, and increasingly heavy,burden for the people of India.

The Delhi workshop

The Delhi workshop brought together a team of Indian and international experts to calculate the costs moreprecisely, in an effort to harness the will of the political, medical, and research communities to invest inmaternal and child nutrition and health. The team included economists from India, the USA, and UK,paediatricians from all over India, and doctors responsible for the care of people with diabetes and heartdisease, as well as experts in maternal nutrition and fetal growth.

Why Delhi?

The workshop was convened in Delhi because of a unique resource here that enables the study of the effectsof early-life factors on adult health and economic parameters. A large project, started in 1969 by Dr ShantiGhosh and Dr Santosh Bhargava, paediatricians from Safdarjung Hospital, has studied the growth of thousandsof Delhi babies and children from birth to the age of 30-35 years. The high quality data, and the completenessof follow-up of this cohort, makes it one of few such studies in the entire world.

What next?

The three-day workshop started off the process of calculating the economic cost of intra-uterine and childhoodgrowth. The group of experts has agreed to form a collaboration to continue this work and report over thecoming months. Key members of the team will be (from India): Dr Santosh Bhargava, Dr Srinath Reddy, DrHPS Sachdev, Dr Siddharth Ramji, Dr Nikhil Tandon, and Dr D Prabharkaran, Dr Anand Pandit; and(internationally) Dr Harold Alderman (USA) economist from the World Bank; Dr Siddiqur Osmani (UK),development economist from the University of Belfast; Dr Peter Gluckman (New Zealand), Dr Mark Hansonand Dr Caroline Fall (UK), from the International Society for Developmental Origins of Health and Disease; DrClive Osmond (UK) from the University of Southampton; Dr Dewan Alam (Bangladesh) from ICDDR,B, Dhaka,and Dr Susan Morton and Dr Katherine O’Connor (New Zealand) from the Liggins Research Institute, Auckland.

Media Reports

Media Reports

Appreciation of the Conferences

From: ”Dr. Dewan S. Alam” <dsalam@icddrb.org>To: ”santosh bhargava” < drskbhargava@yahoo.com>Date: Tue, 21 Nov 2006 15:09:19 +0600Subject: RE: Fetal and Developmental Origins of Childhood and Adult Diseases: Counting the EconomicCost

Dear Dr. Bhargava, This is a small note of thanks to you and, through you, to our other friends colleagues in New Delhi. It was agreat opportunity to meet a wonderful person like you who I only knew through excellent published work. Itwas amazing to see your wonderful research back in late 60’s has so much relevance and importance for thecurrent planned research in developing countries. It was a great oportunity to meet and listen to the excellentpresentations of Drs. Harold Alderman, Peter Gluckman, Caroline Fall, Mark Hanson, Susan Morton, SiddiqurOsmani, SPS Sachdev and yours. The workshop has probably changed the view of the audience how weshould look at low birth weight as a problem and its implications for health, survival and enormous economiccost for the current and subsequent generations. One of the greatest opportunities was to meet yours and many others legendary mentor, Prof (Dr) ShantiGhosh who I met many years ago in our Centre (ICDDR,B). I am glad to see her so strong and enthusiasticabout low birth weight research. It was amazing to see her foresightedness in the design of Delhi cohort. Iwish her good health and long life to serve and inspire the scientists in developing countries. It may be nottoo much to say that the lesson we all should learn from her contribution in research and human resourcedevelopment that resource limitations cannot always be blamed as the hardest constraint for good researchwhen didicated and caring leadership is there . Finally, thanks a lot again for the wonderful hospitality and care during my stay in New Delhi. With best wishes and warm regards, DewanDr. Dewan S. AlamMBBS, MMedSc, PhDAssociate ScientistPublic Health Sciences DivisionICDDR,B, G.P.O. Box 128, Dhaka - 1000Phone: +880 2 886 0523-32 Ext. 2209 01713 093870 (Mobile)

Dear Santosh / HPS.

Thank you very much for organizing one of the best meetings I have ever attended. Let us hope somethingconcrete comes out of this meeting.Best personal regards,

President, SNEHA

Dr Harold AldermanThank you for facilitating my participation in the recent workshop. It was a stimulating opportunity to meetwith you and your colleagues. I look forward to future collaboration.

Regards

H.AldermanSocial Protection Advisor - Africa Region

Dear Santosh,

It was very fulfilling to be back among genuine friends who care for the babies the scientific feast was alsogood. There were emotional moments to share with you and the way you recognized Shanthi gosh was simplywonderful. Very rarely one gets opportunity to share such moments with your mentor.

i was thinking that i will join hands in this lbw work in Tamilnadu.

Let me get back to you with some plans. Congratulations. Primary health care champion for babies.

Jayam

From: Peter Gluckman

To: Prof. H.P.S. Sachdev ; santosh bhargava

Sent: Thursday, November 16, 2006 4:06 AM

Subject: delhi followup

Thanks so much for all your input into what was a very valuable meeting.I am sorry I had to rush away without thanking you enough.I will get the notes together re the way ahead in the next few daysIn the meantime I really would appreciate copies of your CVs as I am trying to get a grant together tosupport the work going aheadCould you email me your CV -...= does not have to be absolutely up to date but good enough from grantapplication to the NZ government

Regards

Prof PD Gluckman FMedSci FRS

University Distinguished ProfessorProfessor of Paediatric and Perinatal BiologyDirector, Liggins InstituteDirector, National Research Centre for Growth and Development

Liggins InstituteUniversity of AucklandPrivate Bag 92019Auckland, New Zealandpd.gluckman@auckland.ac.nzph +64 9 3737599 ext 86634

Dear Dr. Bhargava,

It was great to meet with you and participate in the workshop in Delhi. It was very interesting in deepeningunderstanding of the work in the area of nutrition that SNEHA has been engaged in, as well as the otheraspects such the economic costs of poor nutrition, modeling on the basis of the Delhi Cohort, and policyimplications of this work for India.

Given that we have organized our work at the Social Initiatives Group around indicators of chronic undernutrition such as Low Birth Weight and stunting in early childhood, it would be really useful if you could shareany presentations/papers/report from the workshop that are available for circulation with us. This would reallyhelp inform our work in this area.

Thank you once again for making all the arrangements for us in Delhi. As you had discussed with Abhijit, dosend us the invoices of the expenditures incurred.

Sincerely,

Devanshi ChanchaniSocial Initiatives GroupICICI Bank TowersBandra-Kurla Complex Phone: 2653-7065Mobile: 98217 66358

To,Dr Santosh K. BhargavaNew Delhi Respected Sir, Thank you very much for inviting me for the workshop on “The Cost of Low Birth Weight in India” on 10th

November, 2006. As always you are the pioneer in initiating and implementing new research in issues that are very relevant tothe prevention of low birth weight and improvement of health of our nation. This was particularly important for me because you had inspired and encouraged me when I was the ResearchAssociate for the first six years of the “High Risk Follow up Project” under Dr Anand Pandit and Dr SudhaChaudhari. I specially remember your searching questions followed by your good words for the paper I hadpresented on Follow up of Preterms at the Manipal Conference in 1990 and still appreciate your warm gestureto a budding pediatrician, then. I was happy to be at the workshop and meet all the experts as I have had the opportunity to work for one yearon the Pune Southampton Study as Research Officer with Dr Caroline Fall and Dr Yajnik in 1992. I will be happy to contribute my bit for spreading awareness and taking this further. I look forward to continuedassociation, interaction and collaboration with you in future. With warm regards Thanking you, Yours sincerely Dr Sujata KanherePresident Maharashtra State Chapter of NNFAssociate Professor,Department of Pediatrics

K. J. Somaiya Medical College & Hospital, Mumbai

Dear Dr. Bhargava,

It was a pleasure speaking to you over the phone. Once again I wish to thank you for the opportunity toparticipate and learn from the workshop. I could write this mail only today after having a discussion.

I request you for the presentations shared at the workshop. In particular, the presentation of Dr. SiddarthRamji on enormity of the problem of low birth weight in India on a priority basis. I’ll be happy if the same canbe mailed to me at apuri@unicef.org.

Regards

Dr. Anju Puri, MD (Preventive & Social Medicine)Consultant (Health)UNICEF73, Lodhi Estate, New Delhi 110003, IndiaPh: 91-11-24690401, Extn. 251 Mobile: 9911135145Email: apuri@unicef.org

Acknowledgement

The organizers of these meetings deeply appreciate the support provided by their respective management inorganization of these conferences.

We are grateful to international DOHaD Society, MRC Epidemiology, Resource Centre, University ofSouthampton, UK. The centre for developmental original of Health and Disease University of Southampton,UK. Liggins Institute, New Zealand, ICDDRB; Centre for Health and Population Research, Bangladesh, WorldBank and Public Health Foundation of India for the technical support and advice.

We are thankful to Indian Council of Medical Research, Medical Council of India and Department ofBiotechnology and Sunder Lal Jain Charitable Eye Hospital Society for providing financial support fororganization of the National CME on “ Fetal and Developmental Origins of Childhood and Adult Disease:Implications for Clinical Practice”

We are grateful to ICICI Social Initiative Group for sponsoring the workshops on “Fetal and DevelopmentalOrigins of Childhood and Adult Diseases: Counting the Economic Cost” and the Cost of Low Birth Weight inIndia