Differences in growth and adiposity between UK Pakistani and White British children: the causes and consequences of smaller size and greater adiposity

Lead Research Organisation: Bradford Teaching Hosp NHS Found Trust
Department Name: Bradford Institute for Health Research

Abstract

Size at birth and growth in childhood are thought to be important stages of development in our lifespan and are known to be important to the risk of infant and childhood health and development problems. Over recent years these important phases of early development have also been linked to our risk of illness in later life, particularly diabetes and coronary heart disease. South Asian populations are known to be at particular risk of diabetes (2 - 4 fold higher) and coronary heart disease (50 - 80% higher) and this may be due to them having a tendency for more fat compared to lean mass. At birth, South Asian babies are generally smaller and lighter but recent studies show that like South Asian adults, they have more fat than White British individuals. This greater fatness for a given weight could be very important to the risk of diabetes and coronary heart disease but so far the reasons for it are not very clear. It is possible that being diabetic during pregnancy, which is more common in South Asian women, 'overfeeds' the infant leading to greater fatness at birth and possibly throughout life. If this is true then later generations would also overfeed their infants during pregnancy and a cycle of poor health and development could be set in motion. This continuation of risk could be made worse by the changes in environment and lifestyle experienced by South Asians who migrate to the UK such as the availability of high energy diets, a culture of less exercise and rising rates of obesity. How patterns of growth from birth to childhood differ in South Asian and White British children could also affect differences in health between these two groups in relation to childhood infections and other childhood health problems and could even affect how well children do in school. However research in this area has often used poorly designed studies with too few participants to give accurate results.

Using data and information from the Born in Bradford birth cohort study I will:
1.Look at whether how much a woman weighs at the start of pregnancy, how much weight she gains during pregnancy, her glucose (sugar) levels in pregnancy and whether she develops gestational diabetes, affect how much her child weighs and how fat they are at birth and also at age 4/5 years. I will look at whether the effect of any of these measurements is different depending on whether the mother and child are of Pakistani or White British origin.
2.Describe patterns of growth and differences in adiposity and blood pressure in UK born Pakistani origin children and UK born White British children
3.Look at whether different patterns of growth in UK born Pakistani origin and UK born White British children result in different rates of childhood infection and hospital admissions between these two groups. I will also look at whether different patterns of growth affect how well the children do in school.
4.Find out whether weight and fatness at birth and in childhood is different depending on whether parents and grandparents of Pakistani infants are born in the UK or South Asia.

To do this I will combine existing information from the BiB cohort with new information collected for the first time as part of this proposal. I will train and support school nurses in Bradford to collect skinfold measurements (used to estimate fatness) and blood pressure alongside the height and weight measurements recorded for all reception age children in the UK, including good coverage in Bradford. These measurements will be collected over 2 consecutive school years (2013/2014 and 2014/2015) and will involve approximately 8000 children. Cord blood
samples for the whole BiB cohort will be used to compare fat mass in Pakistani and White British infants at birth (approx 9000 samples). In addition I will merge information from routine health and education systems with the existing BiB data.

Technical Summary

Aim
To describe differences in growth and adiposity between Pakistani and White British children from birth to age 4/5, to examine maternal causes of any differences and to explore the consequences for child health and development.
Objectives
1.To examine associations between maternal characteristics associated with developmental overnutrition and offspring size and adiposity at birth and age 4/5 years in Pakistani and White British children.
2.To develop growth trajectories from birth to age 4/5 and compare growth, adiposity and blood pressure between Pakistani and White British children
3.To examine whether size at birth and child growth are associated with health and educational outcomes in Pakistani and White British children.
4.To determine whether growth and fatness differ depending on whether the parents and grandparents of Pakistani infants were born in the UK or South Asia
Methods
This proposal will use new and existing data collected for the BiB study and will link with routine health information databases. New data collection will include skinfold and blood pressure measurements at age 4/5. Cord leptin assays will be completed on the whole BiB cohort and child health, hospital admission and education information will be extracted from routine health and education systems. Existing data will include maternal measures of hyperglycaemia and offspring size measurements. Statistical analysis will include multivariable linear regression models and tests for statistical interaction. Growth trajectories will be estimated using linear spline mixed effects models for Pakistani and White British children.
Scientifc and medical opportunities
Recent studies draw attention to differences in adiposity between South Asian and White British infants and children. Understanding more about the causes and consequences of these differences is crucial for planning public health interventions to tackle ethnic inequalities in diabetes and cardiovascular disease.

Planned Impact

Understanding more about the causes and consequences of the thin-fat insulin resistant phenotype in South Asian populations is crucial for planning public health interventions to tackle the current ethnic inequalities in diabetes and cardiovascular disease, particularly as there is the potential for cross-generational cycles of increased risk. It is also important that additional measures of size (beyond height and weight) that can provide estimates of body fat are collected in childhood to contribute to our understanding of patterns of adiposity and their potential relationship with future cardiometabolic risk. The collection of blood pressure measurements at age 4/5 will also add importantly to this knowledge. The ethnic specific growth trajectories that will be developed through this fellowship will be useful for identifying important periods of child growth for UK born South Asian and White British children in, to my knowledge, the most detailed dataset currently available. Thus, the main beneficiaries of knowledge arising from this proposal are expected to be public health practitioners and clinicians who will be able to use the findings to inform public health policy (for example being able to identify at risk pregnancies and important patterns and periods of growth for the targeting of future interventions) and clinical practice (for example child obesity prevention strategies). Whilst my findings will not have an immediate impact and will not have all the answers, they will make an important contribution to the body of knowledge in this field that will, in time, underpin future public health interventions. Further, if patterns of child growth are also shown to be important to educational attainment, they have the potential to contribute to future social and education policy.

More specific beneficiaries include school nurses who will be trained to measure skinfold thicknesses. They will receive regular updates and feedback of results and will have the opportunity for greater involvement in this research and the Born in Bradford project from the outset. Their participation will give them access to current research that has particular relevance to their practice and the children they care for. Further, it will enhance their clinical skills and add importantly to their professional development. This will tie in closely with the NIHR CLAHRC for Leeds, York and Bradford which promotes stronger links between biomedical and applied research and in particular, is exploring how better measurement and feedback of data can translate into practice.

Ultimately, the output from this proposal will provide detailed information about the causes and consequences of the thin-fat phenotype seen in South Asian populations and will contribute to the development of interventions to lessen the inequalities in health and opportunity that they are currently exposed to.

Publications

10 25 50
 
Description Member of Bradford District Metropolitan Council Childrens Health Weight Group (school years)
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Membership of a guideline committee
 
Description NICE Public Health Advisory Committees (PHAC B)
Geographic Reach National 
Policy Influence Type Membership of a guideline committee
URL https://www.nice.org.uk/Media/Default/Get-involved/Meetings-In-Public/Public-Health-Advisory-Committ...
 
Description ActEarly: a City Collaboratory approach to early promotion of good health and wellbeing
Amount £6,600,528 (GBP)
Funding ID MR/S037527/1 
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 09/2019 
End 08/2024
 
Description Bradford Teaching Hospitals NHS Foundation Trust Charitable Fund studentship
Amount £61,202 (GBP)
Organisation Bradford Teaching Hospitals NHS Foundation Trust 
Sector Public
Country United Kingdom
Start 10/2016 
End 09/2019
 
Description British Heart Foundation (Co-applicant)
Amount £1,016,398 (GBP)
Funding ID CS/16/4/32482 
Organisation British Heart Foundation (BHF) 
Sector Charity/Non Profit
Country United Kingdom
Start 04/2017 
End 03/2020
 
Description Ethnic differences in kidney function in childhood and the role of kidney size: the Born in Bradford Cohort Renal Study.
Amount £173,563 (GBP)
Funding ID RP_007_20170301 
Organisation Kidney Research UK 
Sector Charity/Non Profit
Country United Kingdom
Start 01/2018 
End 12/2020
 
Description MRC/ESRC (Co-applicant)
Amount £2,849,674 (GBP)
Funding ID MR/N024397/1 
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start  
End 08/2020
 
Title Additional measurements of size for primary school children participating in the BiB study 
Description For my postdoctoral fellowship I have collected additional measurements beyond height and weight (subscapular and triceps skinfold thickness and BP) for BiB children in their reception year at a Bradford primary school. This has created a dataset that is matched to NCMP height and weight data. These measures have been collected by school nurse teams across Bradford and can be used to estimate adiposity in these children. 
Type Of Material Database/Collection of data 
Year Produced 2016 
Provided To Others? Yes  
Impact I have used this dataset for my own work to compare ethnic differences in adiposity and it has been requested by other researchers both nationally and for a meta-analyses of European cohort data (MOCO Collaboration). 
URL https://borninbradford.nhs.uk/research/documents-data/
 
Description Born in Bradford 2nd Wave 
Organisation University of Bristol
Department School of Oral & Dental Sciences
Country United Kingdom 
Sector Academic/University 
PI Contribution I am a co-applicant for this MRC/ESRC programme grant.
Collaborator Contribution This award is held by the University of York, the University of Bristol contribute to sample storage, analysis and statistical and methodological support
Impact None as yet, data collection commenced in February 2017
Start Year 2016
 
Description Born in Bradford 2nd Wave 
Organisation University of York
Country United Kingdom 
Sector Academic/University 
PI Contribution I am a co-applicant for this MRC/ESRC programme grant.
Collaborator Contribution This award is held by the University of York, the University of Bristol contribute to sample storage, analysis and statistical and methodological support
Impact None as yet, data collection commenced in February 2017
Start Year 2016
 
Description CHASE collaboration 
Organisation University of London
Country United Kingdom 
Sector Academic/University 
PI Contribution I have worked with professor Whincup to develop measurement guidelines for children in Born in Bradford based on those used in the Child Health and Heart Study in England.
Collaborator Contribution St Georges University of London have supported the development of our new measurement protocols and loaned equipment needed to complete the measurements. We have also worked collaboratively on publications relevant to this award.
Impact One published paper has been completed from this collaboration (West J, Wright J, Fairley L, Sattar N, Whincup P, Lawlor D A. Do ethnic differences in cord blood leptin levels differ by birthweight category? Findings from the Born in Bradford cohort study. International Journal of Epidemiology 2013; doi: 10.1093/ije/dyt225) and a second is in progress.
Start Year 2013
 
Description Early life determinants of pre-adolescent differences in cardiometabolic health between South Asian and White British children: The Born in Bradford (BiB) cohort 
Organisation University of Bristol
Department School of Social and Community Medicine
Country United Kingdom 
Sector Academic/University 
PI Contribution I am a co-applicant on a British Heart Foundation Clinical Study Grant (no CS/16/4/32482) and will be managing the Born in Bradford's contribution to the grant.
Collaborator Contribution The University of Bristol will hold the award. Co-applicants include Queen Mary University of London and the University of Glasgow.
Impact None so far, this project began Feb 2017
Start Year 2017
 
Description Ethnic differences in kidney function in childhood and the role of kidney size 
Organisation University of Southampton
Country United Kingdom 
Sector Academic/University 
PI Contribution this project is using data collected for the BiB study and new data colected for thsi grant. We are providing expertise regarding teh BiB study and are facilitating the data needed to complete the study. We will be co-authors on any output.
Collaborator Contribution Th eUniversity of Southampton hold this grant and are directing the research and will be leading the output from it.
Impact This is a new study and there are no outputs as yet
Start Year 2017
 
Description ActEarly City Collaboratory Workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact This workshop provided an important opportunity for all the academic, practice, policy and community partners to share ideas and plan projects but also a creative space to support learning and evaluation of our City Collaboratories.

The morning session consisted of cross-cutting theme updates that covered co-production, systems-thinking, modelling, data linkage and outcome measurement. The afternoon session included breakout sessions run by each theme lead to engage all our partners in the programme.

These covered:

1) Selection of interventions - partner-led, natural experiments or simulation studies
2) Design of co-production and evaluation
3) What outcomes are important to measure
Year(s) Of Engagement Activity 2019
 
Description Born in Bradford Family Festival 
Form Of Engagement Activity Participation in an open day or visit at my research institution
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Participants in your research and patient groups
Results and Impact The BiB family festival was held at the National Media Museum for parents children and families participating in BiB. A number of stands and interactive activities were available including measuring skinfolds and BMI which I assisted with and which led to discussions with parents about the work we are doing and hope to do in the future. The event was reported on a regional news programme and reported in local newspapers.

A number of parents asked about how they could see results from the study and have some input into future phases of data collection
Year(s) Of Engagement Activity 2014
 
Description Born in Bradford Study Conference 2015 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact The conference was attended by health professionals, academics, media (local and national) and school representatives including a Year 4 class who participated in the conference.
Year(s) Of Engagement Activity 2015
URL http://www.borninbradford.nhs.uk/research-scientific/bib-scientific-conference/bib-conference-2015/
 
Description Born in Bradford study newsletter for Bradford primary schools 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Schools
Results and Impact A section of this newsletter is dedicated to teh growth and size measurements collected in schools for the BiB study. This is used to provide an update of what has been achieved so far and what measurements are planned for the future. It is also an opportunity to thank schools for their continued support for the study.
Year(s) Of Engagement Activity 2015,2016,2017
 
Description Bradford Metropolitan District Council Obesity Summit 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact This event was a working group to define the systmes in plcae that influence obesity, it was attended by local authority departments, health partners, third sector and industry partners as well as public representatives.
Year(s) Of Engagement Activity 2017
 
Description Presentation to national Health Visitors conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Around 60 practicing health visitors attended the national conference. Lots of questions were asked about our work including how they could be involved or contribute to something similar locally.
Year(s) Of Engagement Activity 2017
URL http://www.profbriefings.co.uk/nihrihv2017/
 
Description Public Forum for Education Bradford Metropolitan District Council 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Schools
Results and Impact The Public Forum for Education (PFE) is an open forum, where everyone including parents and carers, young people and professionals, is welcome to come along and contribute. Council decision makers - senior elected members and officers, join the debates and listen to views. They report back to PFE what action they have taken as a result of the meeting. At the June 2015 forum I presented early results of my work around additional size measurements collected from reception age children at Bradford primary schools.
Year(s) Of Engagement Activity 2015
URL http://www.bradford.gov.uk/bmdc/education_and_skills/schools/public_forum_for_education
 
Description The Born in Bradford Study: engaging a city in research 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Undergraduate students
Results and Impact This was a presentation for undergraduates at the University of Bradford to introduce them to the study and our plans for developing a city of research. Many questions were asked especially how the students could contribute to and get involved with the study.
Year(s) Of Engagement Activity 2016
 
Description Update on school nurse growth and size measurements 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Schools
Results and Impact Presented an update to headteachers, teachers and school network representatives in Bradford regarding teh size and growth research measurements being collected in schools within teh Bradford area for Born in Bradford
Year(s) Of Engagement Activity 2017