“You Are What Your Mother Ate”: The Dutch Hunger Winter Study

 

If the global nutrition community appears to agree on one thing at present, it is that the first 1,000 days of life matter. “The first 1,000 days, from conception to 2 years of age,” write the authors of The Biology of the First 1,000 Days, “is a critical window of growth and development. Exposures to dietary, environmental, hormonal and other stressors during this period have been associated with an increased risk of health outcomes. Researchers using cell culture, animal models, and humans have identified this time as a period of rapid physiological change and plasticity with significant potential for lasting effects. As such, interventions during the first 1,000 days will have the greatest impact on outcomes, particularly in low- and middle-income countries where the need is greatest.”1

A severely malnourished infant in the Hunger Winter, photographed on May 31, 1945
Source: Netherlands National Archive

The Hongerwinter
Arguably no study in the history of nutrition science bears this out as clearly as the Dutch Hunger Winter Study – the most-studied famine in the literature on the long-term effects of malnutrition in utero.2 Robert S. Scholte and coauthors of a discussion paper on the subject provide an excellent summary of the historical context that gave rise to the Hongerwinter, as it is known in Dutch:

“In the fall of 1944, towards the end of World War II, parts of the south of the Netherlands had been liberated by Allied forces, whereas the other parts were still occupied by German forces. The London-based ‘Dutch government in exile’ called out a railroad strike in the occupied parts in order to support Allied military advances and in order to display its authority over the nation. As a reaction, the occupying forces initiated an embargo that prohibited food transports to the densely populated western part of the country, i.e. the provinces of North and South Holland and Utrecht. The decision by Allied Command to postpone the liberalization of the Netherlands and instead move east towards the German mainland caused a military stalemate in the western part of the Netherlands that lasted until the end of the war (European Theater) in May 1945. The effects of the food transport embargo were exacerbated by the early onset of a harsh winter, the freezing of the waterways, the generally bad state of transport infrastructure, and a naval trade blockade. As a result, the western part of the country was closed off from any imports of food, fuel, medication, etc. This caused a famine in the western part that was particularly severe in the cities (Stein et al., 1975). The situation lasted until the end of the occupation, which coincided with the end of World War II in Europe (early May 1945).”3

Starting in November 1944 and lasting approximately five months, this systematic attempt to starve a civilian population into submission was to claim over 20,000 lives before eventually food supplies were restored via the intervention of the Allies.4 “At one point the population was trying to survive on only about 30 percent of the normal daily calorie intake,” writes Prof. Nessa Carey in her 2012 study of the subject. “People ate grass and tulip bulbs, and burned every scrap of furniture they could get their hands on, in a desperate effort to stay alive.”5

“At the end of the war, our hunger drove my parents to exchange the grand piano and their gold wedding rings to provide food for their children”

The account of Pieter van Marken, who was a teenager in Holland during World War II, brings the plight of the Dutch population vividly to life:

“At the end of the war, our hunger drove my parents to exchange the grand piano and their gold wedding rings to provide food for their children … For quite a time, we had a good food reserve [in the cellar], but finally everything ran out. And the shops finally, in the winter of 1944, had nothing. No milk, no bread, eggs, fruit or vegetables or all the other grocery terms one takes for granted. There was a soup kitchen somewhere, serving a sort of horrible thin vegetable soup. Not exactly filling, but even the soup kitchen ceased to operate at the beginning of 1945. We preserved energy by lying down, mostly … I went on long bicycle rides, on food raids. ‘Hongertochten’ or literally, hunger trips, they were called, to get food. You went to so-called ‘friendly’ or ‘good’ farmers to collect wheat. Other ‘bad’ and greedy farmers collected a fortune for their food … You would cycle for hours in the biting cold and then you stood in long queues for hours in the snow and the cold, to end up collecting perhaps only a pound of wheat. At home, this was ground into flour to make bread with, in a sort of coffee grinder-sized mill, screwed onto the window sill. We also desperately ate ground tulip bulbs; I remember you had to take out the green core, which was poisonous, but the cake which was made of ground tulip bulbs was edible in comparison to the raw grated sugar beet boiled into a kind of porridge. Awful stuff, that. It had such an awful taste.”6

A composite picture of a daily ration of food for the Dutch populace during the Hunger Winter
Source: Netherlands National Archive

Operation Manna/Chowhound
The Hongerwinter came to an end on May 6, 1945, one day after the capitulation of the German forces. In what the British called “Operation Manna” and the Americans “Operation Chowhound,” Allied planes dropped food over the Netherlands. Pieter van Marken recalls:

“I ‘helped’ collect the food, and I had positioned myself on a barge in the canal – the ‘Ringvaart’ – adjoining [Schipol] airfield. Others came to offload the sacks of food they had collected on the fields and runways, loaded on primitive vehicles. I helped offload the sacks into the barge. I remember the tins of butter burst open and the sacks of sugar and broken tins of bacon. Dipping my fingers into the butter and the sugar, I gorged myself on this as well as scooping and eating the bacon out of the broken tins. Everybody else did the same thing. Gorgeous. The RAF had dropped tins of hard biscuits – emergency rations – and tins of corned – ‘bully’ – beef. I came to love corned beef. Everything was subsequently distributed. Soon after, we also got rationing tickets to collect so-called ‘Swedish bread’, bread made from Swedish flour. Originally I thought that the loaves had also been dropped by air but it is only recently that I found out that the bread was made from the flour the Swedes had sent by ship. Beautiful white loaves. We also got margarine to go with it. You can’t imagine what a glorious taste a slice of that white bread and margarine had. You had to stand in a long queue at the bakery shop to collect your bread rations. But you didn’t mind. Thank you again, Sweden.”

“You can’t imagine what a glorious taste a slice of that white bread and margarine had”

Dutch citizens gathered around an airdrop of vital food supplies provided by the Allies in Operation Manna/Chowhound.
Source: Netherlands National Archive

In his report Starvation in Western Holland 1945, Sir Jack Cecil Drummond – the architect of the rationing policy that had kept Great Britain from starvation during the German U-boat blockade, and who oversaw British efforts to help the Dutch population ¬recover from the Hunger Winter – gave a precise description of the damage that had been inflicted on the populace, and of the initial remedial measures that were taken to restore them to health:

“Dietary surveys indicated that on and just before liberation the average food consumed per person contained about 1,000 calories daily. Those unable to forage for themselves obtained only the bare rations, equivalent to about 500 calories. Between the second and third week after liberation, rations increased to about 2,000 calories daily for the normal consumer. Some 200,000 persons, representing about 10 per cent of the population of the cities, were found to be seriously undernourished: of these some 2,500 were admitted to hospital, while the remainder were given, as out-patients, a supplementary ration of high protein content providing 1,500 calories. In the early phase of relief about 10 per cent of those admitted to hospital died. Three types of death were observed: (1) sudden unexplained, early after admission to hospital; (2) unexpected, after the patient appeared to be recovering, a turn for the worse leading to death in about an hour; (3) a slow death, the patient lapsing into coma, as in any exhausting disease. In most cases bronchopneumonia was found at autopsy; some showed atrophy of the liver, heart and spleen.

All the patients complained of bodily and mental exhaustion, of dizziness, and of a tendency to collapse if they remained standing for long. Nearly always there had been periods of diarrhea. Emaciation was the most striking feature. Hunger edema occurred, but not in the majority of the patients. No definite signs of vitamin deficiency were found. The body temperature was low with a tendency to poikilothermia. All the patients were anemic, the hemoglobin usually being about 11 gm. per 100 ml. with a color index of 1; cases of marked anemia occurred, usually in seriously ill patients. Bone dystrophies were observed in some starved patients.

Treatment with protein hydrolysates was tried, but met with little success, partly because they were disagreeable to take, and provoked vomiting unless given in large volumes of fluid.

Hydrolysates in low concentration and amounts had little effect on edema, adynamia or apathy: 2 liters of a 7.5–10 per cent hydrolysate had a moderately good effect. A pappy diet containing 80 g of protein (mainly as skimmed milk powder) and 2,000 calories was well tolerated, led to disappearance of edema but too little gain in weight. The best results were obtained with a diet of 300 g of protein (no hydrolysate) and 3, 200 calories. On this diet patients recovered from their depression and apathy in two days; the edema and adynamia disappeared and they got up quicker than patients who were given hydrolysates alone. The best results in infants and young children were obtained with skimmed milk powder supplemented with glucose and fruit juices.”8

“The Dutch Hunger Winter has served as an unplanned experiment in human health”

TABLE 1: Size at birth according to exposure to famine in specific trimesters among births in midwife training schools in Amsterdam and Rotterdam, 1943–46.9

Click table to enlarge

TABLE 2: Change in z-score of selected measures of size at birth following exposure to famine during specific trimesters of pregnancy, relative to births in the same hospitals without exposure to famine in gestation. Births in midwife training schools in Amsterdam and Rotterdam, 1943–1946.10

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FIGURE 1: Weekly caloric rations and averages of z-scored linear measures of weight, length, and head circumference at birth, for births in two institutions in the Western Netherlands, 1944–1946.11

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FIGURE 2: Yearly mortality per 1,000 inhabitants, the Netherlands, 1935–1949.12

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FIGURE 3: Deaths within the first year of life per 1,000 live births, the Netherlands, 1940–1949.13

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FIGURE 4: Composition of mortality by age and birth year, the Netherlands, 1943–1947.14

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“Uniquely vulnerable”
The sufferings afflicted on Dutch citizens by a desperate and vengeful occupying power in 1945 might seem far removed from the Netherlands of today – a country that, in the words of the OECD, is “experiencing strong growth and tight labor markets, with favorable economic prospects and sound public finances.”15 Yet only on January 31 2018, the New York Times ran an article with the headline: “The Famine Ended 70 Years Ago, but Dutch Genes Still Bear Scars.”16 The author, Carl Zimmer, succinctly explains why:

“The Dutch Hunger Winter has proved unique in unexpected ways. Because it started and ended so abruptly, it has served as an unplanned experiment in human health. Pregnant women, it turns out, were uniquely vulnerable, and the children they gave birth to have been influenced by famine throughout their lives.

When they became adults, they ended up a few pounds heavier than average. In middle age, they had higher levels of triglycerides and LDL cholesterol. They also experienced higher rates of such conditions as obesity, diabetes and schizophrenia.”17

The consequences of prenatal malnutrition
Prof. Tessa Roseboom of the University of Amsterdam – herself a grandchild of a Dutchwoman who was pregnant during the Hongerwinter18 – has explored the present-day health of people conceived during the period, tracing all the babies born around the same time in one hospital in Amsterdam, and investigating them from the age of 50. “What we found was really quite striking,” she observes. “People conceived during the famine, who were exposed to a very poor maternal diet when they had just been conceived, had double the rates of cardiovascular disease, already at the age of 50.19 They were more obese, they had higher cholesterol levels, higher blood pressure levels, they felt less healthy, and more of them died of cardiovascular disease.” Prof. Roseboom draws the conclusion that “prenatal malnutrition does have long-term consequences. Even though the absolute amount of nutrients an embryo needs is tiny. Lots of people initially told me, ‘But the fetus is the perfect parasite, it just takes whatever it needs,’ but that’s not true. The fetus is responsive to the environment, and the environment does have lasting consequences.” The effects of famine are most significant when the fetus is exposed early in gestation. “We know that in the first trimester all of the organs are laid down. So it’s not surprising that especially exposure in early gestation had so many effects on brain, on heart, on liver, on lungs, and different organs.”

It may nevertheless seem strange that the babies of the Hunger Winter did not recover fully from the nutritional insults received in the womb, despite growing up in a society that could fully provide for their nutritional needs. Prof. Nessa Carey observes: “We are all used to the idea that fetuses do most of their growing in the last few months of pregnancy. But epidemiologists were able to study these groups of babies for decades, and what they found was really surprising. The babies who were born small stayed small all their lives, with lower obesity rates than the general population. For forty or more years, those people had access to as much food as they wanted, and yet their bodies never got over the early period of malnutrition. Why not? How did their early life experiences affect these individuals for decades? Why weren’t they able to go back to normal once their environment reverted to the way it should be?”20

Dutch citizen and film icon Audrey Hepburn, best known for her starring role in Breakfast at Tiffany’s and famous for her gamine looks. “The Dutch Hunger Winter ended when she was 16 years old, but the after-effects of that period, including poor physical health, stayed with her for the rest of her life.”21
Source: Not required.

“For forty or more years, those people had access to as much food as they wanted, and yet their bodies never got over the early period of malnutrition”

A recent epigenetic study by Elmar W. Tobi et al.22 suggests that the Dutch Hunger Winter “silenced certain genes in unborn children – and that they’ve stayed quiet ever since.”23 While speculating that such as changes in DNA methylation (DNAm) – which underlie the relationship between adverse intrauterine conditions and adult metabolic health – might be responsible for the patterns they had found in the Hunger Winter cohort group, the authors’ evaluation of their findings is cautious: “Our data are consistent with the hypothesis that epigenetic mechanisms mediate the influence of transient adverse environmental factors in early life on long-term metabolic health. The specific mechanism awaits elucidation.”24

While investigations into the specific mechanism continue, adequate nutrition during the first 1,000 days of life remains a burning issue, even in parts of the globe not racked by poverty, disenfranchisement, and natural and manmade disasters. Prof. Tessa Roseboom’s observation that “you are what your mother ate”25 should perhaps serve as the nutrition community’s rallying cry.

Acknowledgements
The author would like to thank Callum Cliffe for his assistance in researching this article.


Featured image caption: Dutch citizens tear up the sleepers from tramlines to burn as fuel
Source: Netherlands National Archive

Background image caption: Food drop in April 1945
Source: Netherlands National Archive


References
01. Karakochuk CD, Whitfield KC, Green TJ, Kraemer K. The biology of the first 1,000 days. Boca Raton, LA: CRC Press; 2018: xv.
02. Scholte RS, van den Berg GJ, Lindeboom M. Long-run effects of gestation during the Dutch Hunger Winter famine on labor market and hospitalization outcomes. J Health Econ. 2015 Jan;39:17-30.
03. Ibid.
04. Carey N. Beyond DNA: Epigenetics. Natural History. Internet: http://www.naturalhistorymag.com/features/142195/beyond-dna-epigenetics (accessed 25 October 2018).
05. Ibid.
06. Pieter van Marken. A teenager in Holland in WWII. More than Food. Internet: http://operationmanna.secondworldwar.nl/pietervanmarken.php (accessed 25 October 2018).
07. Ibid.
08. Burger GCE, Sandstead HR, Drummond, Sir J. Starvation in Western Holland: 1945. Lancet. 1945 Sep 1;246(6366):282-3.
09. Stein AD, Zybert PA, van de Bor M, Lumey LH. Intrauterine famine exposure and body proportions at birth: the Dutch Hunger Winter. Int J Epidemiol. 2004 Aug 1;33(4):831-6.
10. Ibid.
11. Statistics Netherlands, statline.cbs.nl. Reproduced in Scholte RS, van den Berg GJ, Lindeboom M. Long-run effects of gestation during the Dutch Hunger Winter famine on labor market and hospitalization outcomes. J Health Econ. 2015 Jan;39:17–30.
12. Ibid.
13. Ibid.
14. Ibid.
15. OECD Economic Surveys: Netherlands. 2018. Internet: https://www.oecd-ilibrary.org/economics/oecd-economic-surveys-netherlands-2018_eco_surveys-nld-2018-en (accessed 25 October 2018).
16. Zimmer, C. The famine ended 70 years ago, but Dutch genes still bear scars. The New York Times. 31 January 2018. Internet: https://www.nytimes.com/2018/01/31/science/dutch-famine-genes.html (accessed 25 October 2018).
17. Ibid.
18. Prof. Tessa Roseboom, University of Amsterdam, presenting on The Dutch Winter Hunger Study. 4 November 2014. Internet: https://www.youtube.com/watch?v=LeCUUCsfc2I (accessed 25 October 2018).
19. Cardwell-Smith, S. Interview with Dr. Tessa Roseboom: The Dutch Hunger Winter and the importance of prenatal nutrition. 9 June 2017. Internet: http://www.destinationhealtheu.org/healthemory/interview-with-dr-tessa-roseboom-the-dutch-hunger-winter-and-the-importance-of-prenatal-nutrition (accessed 25 October 2018).
20. Carey N. Beyond DNA: Epigenetics. Natural History. Internet: http://www.naturalhistorymag.com/features/142195/beyond-dna-epigenetics (accessed 25 October 2018).
21. Ibid.
22. Tobi EW, Slieker RC, Luijk R, Dekkers KF, Stein AD 4, Xu KM, et al. DNA methylation as a mediator of the association between prenatal adversity and risk factors for metabolic disease in adulthood. Sci Adv. 2018 Jan 31;4(1):eaao4364.
23. Zimmer, C. The famine ended 70 years ago, but Dutch genes still bear scars. The New York Times. 31 January 2018. Internet: https://www.nytimes.com/2018/01/31/science/dutch-famine-genes.html (accessed 25 October 2018).
24. Tobi EW, Slieker RC, Luijk R, Dekkers KF, Stein AD 4, Xu KM, et al. DNA methylation as a mediator of the association between prenatal adversity and risk factors for metabolic disease in adulthood. Sci Adv. 2018 Jan 31;4(1):eaao4364.
25. Prof. Tessa Roseboom, University of Amsterdam, presenting on The Dutch Winter Hunger Study. 4 November 2014. Internet: https://www.youtube.com/watch?v=LeCUUCsfc2I (accessed 25 October 2018).

First published in Sight and Life magazine VOL 32(2) 2018 (www.sightandlife.org)

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