Table Of ContentOUP CORRECTED AUTOPAGE PROOF – FINAL, 02/12/19, SPi
To our many colleagues who we have collaborated with in our research into
pregnancy, maternal health and human well being. And to Rosalind Schulkin,
mother, rational agent, medical realist, wonderful medical decision maker.
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FOREWORD
Integrating Evolution into Medical
Education for Maternal and Child
Healthcare Providers
Sadly, too few medical students or residents study narrative illustrates how a medical education that
evolution. Yet, in an era of powerful new genomic considers evolved traits can deepen our understand-
technologies an evolutionary approach to medicine ing of the complexities of the human body, variabil-
would direct physicians to ask and answer critical ity in health, susceptibility to disease, and ultimately
questions about why we get sick. In this book, edi- help guide treatment, prevention, and public health
tors Jay Schulkin, PhD, and Michael L. Power, PhD, policy.
build a compelling case for integrating evolution- As a medical school dean, I recognize the barriers
ary biology into undergraduate and postgraduate to integrating evolutionary biology into an already
medical education, as well as its intrinsic value to tightly packed medical curriculum with its many
medicine. Chapter by chapter the authors—experts competing priorities. However, as a maternal-fetal
in anthropology, biology, ecology, physiology, pub- medicine researcher and obstetric practitioner
lic health, and various disciplines of medicine—lay committed to finding solutions for preterm
out the rationale for clinically-relevant evolutionary delivery, recurrent pregnancy loss, and reducing
thinking. They do this within the broader context of maternal morbidity and mortality, I believe that
medicine but through the focused lens of maternal evolutionary medicine can help us provide better
and child health, with an emphasis on female repro- health for humankind and better outcomes for
duction and the early-life biochemical, im muno- mothers and babies.
logic al, and microbial responses influenced by Evolutionary changes to species happen over
evolution. millennia, so our genotypes have not kept pace
Reproduction is the engine that drives evolution, with modernity’s vastly different diets, sedentary life-
and much of human evolution reflects a patchwork styles, narrowed social support structures, and unique
quilt of “best practices” needed to accommodate the mental stresses. Chapter 1 describes how two different
large fetal brains and associated long gestations of pathways—evolutionary mismatches and develop-
Homo sapiens. The book’s authors provide power- mental mismatches—lead to an inability to physio-
ful examples of how humans have been shaped by logically cope with external challenges and increase
natural selection to maximize reproductive fitness, disease risk in humans. Examples, including substi-
even when such adaptation may compromise the tution of bottle feeding with cow’s milk formula for
health of a given individual, either early in develop- breast feeding and uteroplacental vascular insuffi-
ment or later in life. They detail how “mismatches” ciency, provide a greater understanding of maternal
between genes forged in our distant evolutionary metabolism and fetal growth regulation.
past and our modern environment promote certain The public health perspective on evolution is
diseases including obesity and its associated meta- explored in Chapter 2 that focuses on human adap-
bolic syndrome. The tightly woven, highly readable tation to new environments and stressors within the
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viii F OREWORD
lifespan and between generations (life history the- continuously released in the maternal circulation
ory) as well as the energy trade-offs that favor throughout pregnancy, have emerged as a hot topic
genetic fitness, affect metabolic capacity differently in women’s health. Chapter 7 focuses on the role
and shape disease vulnerability. This public health miRNA may play in various cancers of the female
framework presents a new opportunity to address reproductive system, including breast and ovarian
the social determinants of health and improve tumors, in the complications of pregnancy and the
prevention. possible functions of miRNA contained in milk. The
Today in many developed countries men stru- authors strongly contend that biomedical research
ation begins at younger ages, women have far investigating therapies to suppress or replace miR-
fewer children and breastfeed less than their ances- NAs would benefit from viewing these molecules
tors. Chapter 3 poses the question of how an evolu- from an evolutionary perspective.
tionary medicine perspective may help mitigate The role of evolutionary medicine in understand-
some of the reproductive health challenges that ing the global obesity epidemic is the focus of
women face today? The authors argue that a greater Chapter 8. Epigenetics and the coevolution of our
understanding of the cultural conditions under microbiome are highlighted as forces propelling the
which women’s reproductive biology evolved rapid intergenerational increases in weight at the
would bene fit treatment decisions, and also pro- population level; the authors propose that case studies
mote non-clinical options to improve the health of of obesity in pregnancy could help teach clini cians
both mothers and their babies, such as more social about evolutionary principles, concepts of popula-
support to start and maintain lactation. tion health, and the potential for pregnancy care to
Chapter 4 introduces the concept of the “4th tri- affect outcomes.
mester,” the early postpartum period critical for Chapter 9 distinguishes the movement known as
both child and maternal health. It discusses how “medical Darwinism” that emerged in the late nine-
health care providers could more effectively meet teenth century from current Darwinian medicine as
the needs of new mothers and their families if they a shift from disease to vulnerability to disease. In the
better understood the mismatch between the con- former, disease was seen as a hereditary defect in a
temporary demands of child rearing—including previously perfect human machine, whereas the
infant feeding practices, physical recovery from contemporary approach to evolutionary medicine
childbirth and return to work to name a few—and views the body as a product of natural selection
our evolutionary past where a village supported with trade-offs and vulnerabilities that often lead to
mothers and enabled infants to thrive. disease.
Human reproduction involves a “tug of war” Animals share human vulnerabilities to many
between mother and fetus with the goal of optimally common and deadly diseases including ath ero scler-
transmitting genetic information. The mother must osis, cancer, autoimmune disorders and biobehavio-
allocate enough resources to maintain her own ral conditions. Chapter 10 describes the Timbergean
health while providing adequate oxygen and nutri- approach to clinical medicine. Nikolaas Timbergen,
ents to the fetus. Chapter 5 discusses how preec- a Nobel Laureate animal behaviorist, advocated for
lampsia, gestational diabetes, and preterm birth including species-spanning phylogenic information
may be m aladaptive consequences of the struggle to in theories of causation. Recognizing that human
achieve this delicate balance. pathology evolved from hundreds of millions of
The effects of reproduction on health and longev- years of animal health and disease, the Tibergean
ity are complex. Chapter 6 uses the physiological approach encourages phys icians and medical stu-
adjustments of pregnancy, including the maternal dents to broadly consider questions about human
allocation of metabolic energy to fetal growth and disease in non-human animals to improve the qual-
the biological trade-offs this entails, to illustrate an ity of hypotheses and investigation.
evolutionary view of homeostasis. Chapter 11 continues delving into four categories
Small non-coding RNA molecules (miRNAs), central to Timbergen’s perspective on studying the
important in the regulation of gene expression and cause of any biologic phenomenon: how animal
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FOREWORD ix
behavior develops over a lifetime (ontogeny), how evolution and the benefits and potential harms of
its physiological machinery works (mechanism), increasingly precise genetic technologies such as
why a species evolves a trait to solve a reproductive the DNA editing tool CRISPR.
or survival problem (adaptive value) and the evolu- Finally, Chapter 13 introduces the concept of
tionary history of selective pressures across many “ecological rationality” in judgment and decision
generations (phylogeny). Using infectious disease making, its practical relevance to patient care and
and chronic inflammatory diseases as examples, the medical education, and its compatibility to with an
authors conclude that reproductive fitness and evo- evolutionary approach to medicine. The authors sug-
lutionary history should be c onsidered to more com- gest using evolutionary medicine to build a frame-
pletely understand the pathophysiology of disease. work based on ecological rationality to develop
Future physicians will be challenged by increas- educational tools that can enhance the health deci-
ing amounts of genomic information to incorporate sions of both physicians and patients.
into their clinical decision making. Chapter 12 In short, this excellent narrative makes a strong
contends that evolutionary medicine provides the case for incorporating evolutionary thinking early
foundation required to integrate genomic advances in medical training to help guide the types of crit-
into research and practice. Medical students would ic al questions physicians ask—or should be asking.
benefit from greater genetic literacy, including an
understanding of genetic variation as a driver of Charles J. Lockwood, MD, MHCM
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Preface
This book is expanded from a small conference we discovery and the more lasting in the cont inued nur-
held when we were the Research department at the tured colleagueship. And most importantly to be part
American college of Obsterticians and Gynecologist. of scientific and medical universe that promotes
The conference was held at the College in Washington women’s health.
DC. Some of the people in this book were with us We thank our many colleagues, those that con-
for that one delightful day. tributed to this book, and have collaborated with us
As for us, we have worked together for now 20 on matters important for human health.
years, merging worlds, and foraging new ones for Our work is supported by the Maternal and Child
ourselves. The lifeblood of the mind is in the inquiry Health Bureau of HRSA through cooperative agree-
and the fleeting satisfaction that emerges in explan ation, ment UA6MC31609. Many thanks for their support.
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List of Contributors
Heide Aungst, Division of Human Genetics, Center Michael L. Power, Smithsonian Conservation
for Prevention of Preterm Birth, Cincinnati Chil- Biology Institute, Smithsonian Institution,
dren’s Hospital Medical Center and Department Washington DC, USA.
of Pediatrics, University of Cincinnati College of Caroline W. Quaglieri, Medical College of Wiscon-
Medicine, Cincinnati, OH, USA. sin, Milwaukee, WI, USA.
Heather Brockway, Division of Human Genetics, Eda G. Reed, Conservation Ecology Center, Smith-
Cincinnati Children’s Hospital Medical Center, sonian Conservation Biology Institute, Washing-
CCHMC, USA. ton DC, USA.
Peter D. Gluckman, Liggins Institute, University of Karen R. Rosenberg, Department of Anthropol-
Auckland, Auckland, New Zealand. ogy, University of Delaware, Newark, DE, 19716,
Mark A. Hanson, Institute of Developmental Sci- USA.
ences, University of Southampton, Southamp- Robert Rossi, Department of Obstetrics and
ton, UK. Gynecology, University of Cincinnati College of
Barbara. N. Horowitz, Visiting Professor, Harvard Medicine, Cincinnati, OH, USA.
Department of Human Evolutionary Biology, Carsten Schradin, Université de Strasbourg,
Professor of Medicine, UCLA Division of Cardi- CNRS, IPHC UMR 7178, F-67000 Strasbourg,
ology, USA. France; School of Animal, Plant and Envi-
Charles J. Lockwood, Senior Vice President, USF ronmental Sciences, University of the Witwa-
Health, Dean, Morsani College of Medicine, tersrand, Johannesburg, South Africa.
Professor, Obstetrics & Gynecology, and Public Jay Schulkin, Research professor, Department of
Health University of South Florida, Tampa, Obgyn, University of Washington, and depart-
FLA, USA. ment of neuroscience, Georgetown University,
Felicia M. Low, Institute for Clinical Sciences, USA.
Singapore. Rainer H. Straub, Dept. of Internal Medicine I,
Sam Mesiano, Department of Reproductive Biol- Lab of Experimental Rheumatol. & Neuroen-
ogy, Case Western Reserve University, Cleve- docrine Immunology, University Hospital,
land, OH, USA. BIOPARK 1, Am Biopark 9, 93053 Regensburg,
Shabnam Mousavi, Max Planck Institute for Germany.
Human Development, Berlin, Germany. Alison M. Stuebe, Department of Obstetrics and
Louis J. Muglia, Director, Department of Obstet- Gynecology, University of North Carolina at
rics and Gynecology, University of Cincinnati Chapel Hill UNC, USA.
College of Medicine, Cincinnati, OH, USA. Wenda R. Trevathan, Department of Anthropology,
Robert Perlman, The University of Chicago, IL, New Mexico State University, Las Cruces, NM
USA. 88003-8001, Mexico.
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xvi LiST OF CONTRiBuTORS
Kristin P. Tully, Carolina Global Breastfeeding Reproductive Medicine, Brigham and Women’s
Institute, University of North Carolina at Chapel Hospital, Boston MA 02115, USA.
Hill, UNC, USA. Fabio Zampieri, Department of Cardiac, Thoracic
Jonathan C. K. Wells, Childhood Nutrition and Vascular Sciences, University of Padua
Research Centre, UCL Great Ormond Street Medical School, Via Aristide Gabelli 86, 35,121
Institute of Child Health, 30 Guilford Street, Padua, Italy.
London, UK. Chloe Zera, Assistant Professor, Harvard Medical
Louise Wilkins-Haug, Professor, Harvard Medical School, Maternal Fetal Medicine Division,
School, Chief, Maternal Fetal Medicine D ivision, Department of Obstetrics and Gynecology, Beth
Department of Obstetrics, Gynecology and Israel Hospital, Boston MA 02115, USA.
