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Book REVIEW A Life Course Approach to Chronic Disease Epidemiology Diana Kuh and Yoav Ben-Shlomo, editors. New York: Oxford University Press, 1997, ISBN: 0-19-262782-1. US $65.00. ‘The axioms in epidemiology postulate that diseases have causes; that disease occurrence is determined by external exposures that interact with individual susceptibility to initiate the pathogenetic process; and that external ex- posures sometimes may be removed or reduced, or indi- vidual susceptibility may be reduced. Therefore, some diseases are preventable. Most of our research activities have been devoted to identifying extemal causes, because individual suscepti bility was believed to be determined mainly by genetic factors. Most of the research on extemal determinants has focused upon exposures with an incubation time from 0 to 10 oF 20 years. Recent research indicates that individual susceptibility may be shaped by nongenetic factors operating in the prenatal or early postnatal pe- riod, but which manifest their effect much later in lif This prenatal time period may be much more important than previously believed, and in the future we may have to focus our attention on even longer incubation times. Ie is well accepted that our social and psychological well-being can only be understood by taking a life course approach. The same may be true for part of our somatic well-being. This book provides current documentation for this point of view, which is well timed and most needed. Every week brings new results linking fetal growth to chronic diseases in adult life, or proxy mea- sures of hormonal exposures in fetal life to certain can- cers, or perinatal exposures to environmental exposures, or specific dietary factors to (for example) brain devel- ‘opment and cognitive function. We also have two te- view books from Barker,!? which focus mainly upon the landmark results his group has produced. He has more than anyone else provided empirical evidence that “or- gan programming’ is not only a phenomenon in exper- imental animal studies but may be operating in humans as well. Iftrue, the implications are important, and much more research should be devoted to this area, since thus far we have only circumstantial evidence. Most studies are based upon rather primitive correla- tions between birthweights or other indicators of fetal growth and clinical signs or diseases decades later with- ‘out much control for what took place in the interim. SR Epdemalogy Reece: ne Results may rightly be criticized for not being adjusted for intermediate confounders, just as results from the many cohort studies that start in adult life may be confounded by preadult exposures of importance for individual suscepebility Barker has focused upon nutrition in early life. Ac cording to his theory, one would expect children born during periods of famine to be at high risk for certain diseases, an outcome that has not been seen in all studies. Fetal nutrition depends, however, on many factors other than maternal nutrition; the role of all determinants of fetal growth on “organ programming” needs much more attention. Underlying genetic factors may also play a role for fetal growth as well as suscepti- bility, and results of twin studies indicate that this factor cannot be riled out’ ‘Any hypothesis must be evaluated according to its power to explain and predict, and itis of interest that Kuh and Ben-Shlomo take up this challenge in the book just as readily as they discuss implications for public health. The results of their analyses are expectedly abit meager. We still have much to lear if disease patterns are to be explained by taking a life course approach. Nevertheless, the book provides strong arguments for this approach. Not all will agree with their narrative reviews, but the book isa highly qualified starting point for the’ debate. All who take an. interest in modern epidemiology and who do not read major clinical jour- nals regularly should take this opportunity to be brought up to date. New findings probably will make the book passé, but it will remain a useful summary of pioneer research of huge potential importance for public health, Jorn Olsen Danish Elemis Saence Cente Sater Serum est, 3 Atlee, 1K 00 Copenagen 5, Dene (Glia for comependence) 2 Raker Jf, Maher Babi, and Duewe in Laer Lif, London: BM) Pblhing Gro. 1994 3. Kant V Chtrensen , Vavgl JW. No incase marae ae he forcabars hon rg imine.) Epona 1997145387 994 4, Stet SA Binet: Andis ©. Lantevt OF, Borana V. Poten VV. Yadkin Des enacton aun Serie Gabe and cornay het Asese i iuthood” Reus fom the Lene Siege Stat 2