Undernutrition in the womb has many surprising life-long health outcomes. To better understand undernutrition, we’ll review the scientific studies generated by one of the most amazing natural experiments in history—the Dutch Hunger War. For one year, an entire population was severely malnourished. After that year, food was available again. This natural experiment gives us a window on undernutrition in the womb and its role in our health.

Cover image from Pixabay. http://www.pixabay.com

What We’ll Talk About

  • What undernourished is.
  • The Dutch Hunger War.
  • The health and emotional problems faced by children of undernourished parents.
  • The weight issues of children born to undernourished parents.
  • The importance of the first three months of life in establishing a healthy weight and metabolism.


You may encounter unfamiliar terms in this post. Go to the Miller Keane Medical Dictionary to look up medical terms. https://books.google.com/books/about/Encyclopedia_and_Dictionary_of_Medicine.html?id=oZfgAAAAMAAJ Follow this link for definitions of terms in this post. https://carbohydrateconfessions.com/terms-youll-want-to-know/

Malnutrition Doesn’t Equal Undernutrition

When we think of people who don’t get enough food to maintain body functions, we say they’re malnourished. Images come to mind of emaciated holocaust victims or the bulging bellies of starving African children. We’re wrong.

Allied medical staff standing by dead captives at a slave labor camp at Nordhausen. Photo illustrates the starvation occupied populations experienced during the German occupation.

American soldiers viewing emaciated bodies in slave labor camp

Malnutrition Defined

Malnutrition happens when the body does not get the vitamins, minerals, and other nutrients it needs to maintain healthy tissues and organ function. Malnutrition occurs in people who are undernourished or overnourished. Malnutrition can result from situations other than starvation including illness, excessive dieting, overeating the wrong foods, food allergies, severe injuries, hospitalization, substance abuse, or age-related illnesses. http://www.freedictionary.com

Life size sculpture of Miss Jane Campbell. a circus performer, at Circus Museum. Miss Campbell was the "fat lady".

The fat lady in the circus could also be malnourished. Photo from Circus World Museum, Baraboo WI, Library of Congress.

Think of undernourished this way. If you eat a diet which doesn’t provide enough calories in kilocalories or kcal and which lacks the diversity necessary to meet the complex nutritional needs of the body, you are undernourished. Your body may be either underweight or overweight.

The Dutch Hunger War

For one year, the entire population of The Netherlands was severely malnourished. After that year, the country’s food supply was restored. This natural experiment gives us a window on undernutrition and its role in child development and long-term health.

Goose Stepping through The Netherlands

Occupying German Army marching past Verdun Monument.

Does this photo of Nazi soldiers marching in front of the Verdun monument make you think of Audrey Hepburn? The photo is from the Library of Congress.

Audrey Hepburn and the Dutch Hunger War

The photo of the German Army should make us think of Audrey Hepburn. She survived the Dutch Hunger War (1944-1945). This time period is also known as the Winter of Hunger. Audrey lived with her mother in The Netherlands during the German Army’s food blockade.

The famine was severe. More than 20,000 Dutch citizens died as a result of the famine of the Winter of Hunger (Carey, 2015).

How Did the Dutch Hunger War Start?

Although Germany occupied The Netherlands in 1940, the brutal Hunger War started four years later. By September 1944, Allied troops had liberated most of the south of the country, but their advances toward the north came to a stop at the Waal and Rhine Rivers with the disastrous Battle of Arnhem. The Battle of Arnhem was so embarrassing to Allied Forces that photographs taken at the time were classified for 75 years. The mistakes made by Allied Military leadership were documented in the film, A Bridge Too Far.

Allied soldiers captured at Battle of Arnhem. Photos were suppressed until 75 years after the battle.

Allied soldiers in recently released Battle of Arnhem photo.

Dutch Government in Exile Calls for Railway Strike

The Dutch Government in Exile rallied the Dutch people to facilitate the efforts of the Allied Army. The government called for a National Railway Strike to disrupt the transport of Axis military supplies and troops during a winter so severe that the canals froze.

In retaliation, the German authorities embargoed all food supplies to the west and north of the country (Lumey, Stein, Kahn, & Romijn, 2009; Lumey et al., 2007; Stein, Zybert, van de Bor, & Lumey, 2004).

What happened to Dutch Nutrition?

Nutrition was adequate in The Netherlands until 1944 at about 1800 kcal per person. After this, food supplies became increasingly scarce. By November 26, 1944, official rations fell to 1000 kcal per day and by April 1945 they were as low as 500 kcal per day.

The Dutch population tried to survive on about 30% of their normal daily calorie intake. If they didn’t have rations of bread and potatoes, people ate grass and tulip bulbs (Carey, 2015).

Bar graph of calories available to Dutch people during the Dutch Hunger War.

What Happened to Audrey?

Audrey’s youngest son, Luca Dotti, discussed his mother’s struggles during the Winter of Hunger (Dotti, 2015). The severely malnourished Audrey survived on low-calorie green leafy vegetables, tulip bulbs, and water. At times, she was too weak to stand or  work. She spent days in bed, and she read to divert her mind from obsessive thoughts about food.

Audrey described a series of ailments including asthma, jaundice, anemia, and a serious form of edema. She described the edema this way. “It begins with your feet and when it reaches your heart, you die. With me, it was above the ankles when I was liberated.”

R. Matzen's book cover describes Audrey Hepburn's political activities during World War II

R. Matzen described Audrey’s political and humanitarian activities during the war.

Audrey Is Liberated

Audrey was 16 years old and weighed about 88 pounds when a United Relief Organization worker gave her 7 candy bars and a can of evaporated milk. Audrey ate the candy bars at one sitting.

Audrey and Chocolate

Luca Dotti described his mother as a fierce eater who never dieted. She loved pasta and chocolate. She associated chocolate with freedom, and she was famous for keeping a stash of chocolate near at hand.

Audrey’s love of chocolate is so well known that a company recently produced this advertisement recreating her likeness to sell chocolate. Note: This is not archival footage. You must watch this video.

Meals with Audrey

Luca Dotti published this best selling book in 2015.

The Unexpected Good from the Winter of Hunger

The Dutch Hunger War gave epidemiologists a unique opportunity to study the long-term health effects of undernutrition in the womb because

  • All of the Dutch people, both rich and poor, experienced the same event.
  • The start and end times of the undernutrition were well documented.
  • The famine stopped immediately after the liberation with a massive distribution of food relief (Stein, Zybert, & Lumey, 2004).
  • The Dutch kept excellent health and demographic records.

Epidemiologists and the Winter of Hunger

For decades after World War II ended, epidemiologists have been examining the birth and health records and the adult health situations of those who were conceived during the Winter of Hunger.

Today many of the people conceived near or at the time of the famine are elderly. Over the intervening years, researchers have contacted these people and have enrolled them in a variety of  studies.

Surprising Findings

Several findings from these epidemiological studies left me scratching my head. I’d learned that although the babies appeared healthy at birth, the undernourishment in the womb altered the courses of their health for the rest of their lives. Although adequate nutrition was quickly restored for most of these babies, they nonetheless had higher obesity rates than expected. Second, these babies had more health problems than expected (Carey, 2012).

The Conventional Wisdom of the Good Old Days

How could such a powerful impact on health be achieved in the first few months of life?

Vintage picture of a horse and buggy to illustrate that concepts we once believed can become outdated.

The good old days

Remember the days not too long ago when we were taught that the fetus took whatever it needed, even if it was at the expense of the mother. During adversity, the mother’s health was sacrificed for her child. That idea has been turned on its head. The course of our adult health is very much dependent on our mother’s diet during a brief critical period of the pregnancy.

What Is a Critical Period?

A critical period is a maturational stage in the lifespan of an organism during which the nervous system is especially sensitive to certain environmental stimuli. If, for some reason, the organism does not receive the appropriate stimulus during this critical period […] it may be difficult, ultimately less successful, or even impossible to develop associated functions later in life.


The Immediate Aftermaths on Women and Babies

Half of Dutch women experienced amenorrhea at the height of the famine, and fewer children were conceived. For women who were pregnant or became pregnant during the Winter of Hunger, they lost rather than gained weight during their pregnancies. The impacts of undernutrition on the babies were the following:

  • Babies weighed 300 grams less on the average.
  • The head circumference and length were reduced when undernutrition happened during the second and third trimesters (Painter et al., 2008).
  • Babies had a variety of health problems–including being low in birth-weight, obesity at birth, or being born with birth defects (Veenendaal et al., 2013).

Does Undernutrition in the Womb Affect Health After Birth?

The answer to this question is an unequivocal “Yes”. If a baby develops in an undernourished mother, the long-term impacts on health are many and far ranging. Undernourished babies who were born small stayed small all their lives and had lower obesity rates than the general population even though they had access to as much food as they wanted.

Somehow their bodies never recovered from the early period of undernutrition.

Complex Relationship Between Adult Obesity and Undernutrition in the Womb

There are two very different scenarios of weight gain for babies exposed to undernutrition in the womb. Babies exposed to undernutrition during the last trimester are born small, and they develop into people who are small in both weight and height (Schulz, 2010). These folk seldom become obese (Roseboom, 2000).

Babies exposed to undernutrition in the womb during the first trimester have a different weight trajectory. They’re normal size at birth, but they’re more likely to become obese (Schulz, 2010) and have atherogenic or unhealthy lipid profiles (Roseboom, 2000; Schulz, 2010).

Gender and Undernourishment

Lumey et al. (2009) studied people conceived just before or during the Winter of Hunger. Of these sixtyish aged people who’d been exposed to undernutrition in the womb, males fared better than females. Males are less likely to be obese, have abnormal fat distribution, and have changes in standard metabolic measures. It is women who develop unhealthy fat distribution and atherogenic metabolic changes.

Intertwined blue male and female symbols.

Is undernourishment harder on the female gender?

Does Undernourishment in the Womb Predict Cardiovascular Health?

It’s safe to say that “…an adverse fetal environment contributes to several aspects of cardiovascular risk in adult life (Roseboom, 2000).”

When a Mother Starves, Her Child’s Heart Health Suffers

People conceived during the famine had a higher prevalence of coronary heart disease than those who weren’t exposed to famine (Roseboom, 2000). Blood pressure in adult life isn’t related to exposure to famine, but smaller undernourished babies tend to have higher blood pressure (Roseboom, 2000).

People exposed to undernutrition in the womb during the first three months of life have more cardiovascular problems than who are undernourished during the second and third trimesters. Later exposure to undernutrition in the later trimesters is more benign.

Daily Caloric Intake Is Important

The fewer calories the mother has available during the first trimester, the greater is the risk for her child. Caloric intake of less than1000 kcal is more dangerous (Opler & Susser, 2005).

Setting Metabolic Parameters During Fetal Life

Undernutrition in the womb is linked to the development of type II diabetes, impaired glucose homeostasis, and increased insulin resistance decades later (de Rooij et al., 2006). If the undernourished adult was small at birth, the risks of insulin resistance and glucose tolerance are increased.

The adrenal gland may also be impacted by undernourishment in the womb. Undernourished sheep and guinea pigs have altered hypothalamic-pituitary-adrenal axis functions as adults. Their basal plasma cortisol concentrations and adrenocortical responsiveness to adrenocorticotropic hormones are altered (de Rooij et al., 2006).

What Causes These Metabolic Changes?

Perhaps, undernourishment during early life changes the set point of the hypothalamic-pituitary-adrenal axis (de Rooij et al., 2006). This, in turn, causes increased adrenal activity, glucose intolerance, and insulin resistance.

When Is the Set Point Altered?

Believe it or not our finger prints may give us part of the answer. Finger prints are laid down in the first trimester of life. The finger prints of individuals who were exposed to undernutrition during the Dutch Hunger War have an identifiable pattern of fingertip ridges (Kahn, Graff, Stein, & Lumey, 2009).

Finger print ridges. The pattern of our finger tip ridges may tell us about our early development and the probability of later illness.

The number of ridges on our finger tips is linked to our mother’s nutrition

Cognitive Function

Exposure to undernutrition in the womb during the Dutch Hunger War affected selective attention skills in later life. People exposed to famine and undernutrition early in their development have reduced ability to do a selective attention task late in life (age 56 to 59 years) (Schulz, 2010). Selective attention is the ability to maintain focus and shift efficiently from one idea to another.

Does Early Undernutrition Affect Emotional Health?

Susser and colleagues were interested in the mental health of people exposed to fetal undernutrition during the Dutch Hunger War (Bresnahan, Schaefer, Brown, & Susser, 2005; Brown & Susser, 2008; Brown et al., 1996; Brown, Susser, Lin, Neugebauer, & Gorman, 1995; Opler & Susser, 2005; Susser & Lin, 1992). Undernutrition during the first three months after conception increases the risk of several mental illnesses.

  • Schizophrenia (Brown & Susser, 2008).
  • Schizoaffective disorder (Brown & Susser, 2008).
  • Affective disorders such as depression (Lumey et al., 2009; Opler & Susser, 2005).

The Critical First Three Months of Life

Although we don’t fully understand why good nutrition during the first three months of life is so important, we have some good working hypotheses. The first three months of life are a critical period for programming the developing brain (Schulz, 2010). Some very important rules are being laid down during the first three months of life. These parameters impact the course of our lives.

Undernutrition and Birth Defects

Chart showing the neural tube and the anterior and posterior ends of the neural tube. Two ultrasounds show the lack of brain development if the anterior end of the tube fails to close and lack of spinal cord development if the posterior end fails to close.
Types of birth defects seen after undernutrition during the first trimester

The central nervous system is developing during the first trimester, and the basic neural tube is elaborated into the brain and spinal cord. Undernutrition during the first trimester is linked to more abnormalities in the development of the neural tube (Brown & Susser, 2008). There were more than the expected number of children born with spina bifida and anencephaly (without a brain) among a birth cohort conceived during the height of the famine.

To learn more, watch this YouTube lesson.

The Fetal Brain Is Programmed

The fetus must adjust to the environment in which he or she finds himself/herself (Roseboom, 2000). Let’s say that the baby is female, she’s in the first three months of her life, and she is in the womb of a woman who’s living through a famine.

Our baby must adapt herself to the starvation world in which she finds herself. She must set up the way in which she handles basic functions such as cholesterol metabolism, sugar metabolism, appetite regulation, the reward center for carbohydrates, etc.

Changes After the Critical Period

What happens if the first three month critical period has passed and her mother is no longer starving? What if her mother now has all the food she needs? Does our baby readjust her metabolism to suit the changed environment?

“No”. She doesn’t. Her brain will forever view her world through the lens of starvation. For good or ill, she’s programmed her computer.

Much More to Learn

Your brain may be reeling from information overload. Mine is. Let’s allow these ideas to gel for awhile. We’re not finished with what the Dutch Hunger War has to teach us about cardiovascular, metabolic, and mental health.

Our Commitment

We want to bring high quality content based upon recent scientific studies. We hope our efforts will guide your future learning and that our citations are useful to you. If we’ve failed, please let us know. Read more about the internet information jungle. https://carbohydrateconfessions.com/internet-information-jungle/

Our Book

Check out our book on Carbohydrate Addiction, Confessions of a Carbohydrate Addict. https://carbohydrateconfessions.com/


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Brown, A. S., & Susser, E. S. (2008). Prenatal nutritional deficiency and risk of adult schizophrenia. Schizophr Bull, 34(6), 1054-1063. doi:10.1093/schbul/sbn096

Brown, A. S., Susser, E. S., Butler, P. D., Richardson Andrews, R., Kaufmann, C. A., & Gorman, J. M. (1996). Neurobiological plausibility of prenatal nutritional deprivation as a risk factor for schizophrenia. J Nerv Ment Dis, 184(2), 71-85. doi:10.1097/00005053-199602000-00003

Brown, A. S., Susser, E. S., Lin, S. P., Neugebauer, R., & Gorman, J. M. (1995). Increased risk of affective disorders in males after second trimester prenatal exposure to the Dutch hunger winter of 1944-45. Br J Psychiatry, 166(5), 601-606. doi:10.1192/bjp.166.5.601

Carey, N. (2012). The Epigenetics Revolution: How Modern Biology Is Rewriting Our Understanding of Genetics, Disease, and Inheritance. NY: Columbia University Press.

de Rooij, S. R., Painter, R. C., Roseboom, T. J., Phillips, D. I., Osmond, C., Barker, D. J., . Bleker, O. P. (2006). Glucose tolerance at age 58 and the decline of glucose tolerance in comparison with age 50 in people prenatally exposed to the Dutch famine. Diabetologia, 49(4), 637-643. doi:10.1007/s00125-005-0136-9

Dotti, L. (2015). Audrey at Home: Memories of My Mother’s Kitchen. NY: Harper Collins.

Kahn, H. S., Graff, M., Stein, A. D., & Lumey, L. H. (2009). A fingerprint marker from early gestation associated with diabetes in middle age: the Dutch Hunger Winter Families Study. Int J Epidemiol, 38(1), 101-109. doi:10.1093/ije/dyn158

Lumey, L. H., Stein, A. D., Kahn, H. S., & Romijn, J. A. (2009). Lipid profiles in middle-aged men and women after famine exposure during gestation: the Dutch Hunger Winter Families Study. Am J Clin Nutr, 89(6), 1737-1743. doi:10.3945/ajcn.2008.27038

Lumey, L. H., Stein, A. D., Kahn, H. S., van der Pal-de Bruin, K. M., Blauw, G. J., Zybert, P. A., & Susser, E. S. (2007). Cohort profile: the Dutch Hunger Winter families study. Int J Epidemiol, 36(6), 1196-1204. doi:10.1093/ije/dym126

Matzen, R. (2019). Dutch Girl: Audrey Hepburn and World War II. Pittsburg, PA: GoodKnight Books.

Opler, M. G., & Susser, E. S. (2005). Fetal environment and schizophrenia. Environ Health Perspect, 113(9), 1239-1242. doi:10.1289/ehp.7572

Painter, R. C., Osmond, C., Gluckman, P., Hanson, M., Phillips, D. I. W., & Roseboom, T. J. (2008). Transgenerational effects of prenatal exposure to the Dutch famine on neonatal adiposity and health in later life. BJOG : an international journal of obstetrics and gynaecology, 115(10), 1243-1249. doi:10.1111/j.1471-0528.2008.01822.x

Roseboom, T. J., van der Meulen, J. H. P., Osmond, C., Barker, D. J. P., Ravelli, A. J. C., Schroeder-Tanka, van Montfrans, G. A., Michels, R. P. J., Bicker, O. P. (2000). Coronary heart disease after prenatal exposure to the Dutch famine, 1944-45. Heart, 84, 595-598.

Schulz, L. C. (2010). The Dutch Hunger Winter and the developmental origins of health and disease. Proc Natl Acad Sci U S A, 107(39), 16757-16758. doi:10.1073/pnas.1012911107

Stein, A. D., Zybert, P. A., & Lumey, L. H. (2004). Acute undernutrition is not associated with excess of females at birth in humans: the Dutch hunger winter. Proc Biol Sci, 271 Suppl 4, S138-141. doi:10.1098/rsbl.2003.0123

Stein, A. D., Zybert, P. A., van de Bor, M., & Lumey, L. H. (2004). Intrauterine famine exposure and body proportions at birth: the Dutch Hunger Winter. Int J Epidemiol, 33(4), 831-836. doi:10.1093/ije/dyh083

Susser, E. S., & Lin, S. P. (1992). Schizophrenia after prenatal exposure to the Dutch Hunger Winter of 1944-1945. Arch Gen Psychiatry, 49(12), 983-988. doi:10.1001/archpsyc.1992.01820120071010

van Abeelen, A. F. M., Elias, S. G., Bossuyt, P. M. M., Grobbee, D. E., van der Schouw, Y. T., Roseboom, T. J., & Uiterwaal, C. S. P. M. (2012). Famine Exposure in the Young and the Risk of Type 2 Diabetes in Adulthood. Diabetes, 61(9), 2255-2260. doi:10.2337/db11-1559

Veenendaal, M. V. E., Painter, R. C., de Rooij, S. R., Bossuyt, P. M. M., van der Post, J. A. M., Gluckman, P. D., . . . Roseboom, T. J. (2013). Transgenerational effects of prenatal exposure to the 1944-45 Dutch famine. BJOG : an international journal of obstetrics and gynaecology, 120(5), 548-553. doi:10.1111/1471-0528.12136

Whincup, P. H., Kaye, S. J., Owen, C. G., Huxley, R., Cook, D. G., Anazawa, S., Yarbrough, D. E. (2008). Birth weight and risk of type 2 diabetes: a systematic review. JAMA, 300(24), 2886-2897. doi:10.1001/jama.2008.886


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