The capacity–load model is a conceptual model developed to improve understanding of the life-course aetiology of non-communicable diseases (NCDs) and their ecological and societal risk factors. The model addresses continuous associations of both (a) nutrition and growth patterns in early life and (b) lifestyle factors at older ages with NCD risk. Metabolic capacity refers to physiological traits strongly contingent on early nutrition and growth during the first 1000 days, which promote the long-term capacity for homeostasis in the context of fuel metabolism and cardiovascular health. Metabolic load refers to components of nutritional status and lifestyle that challenge homeostasis. The higher the load, and the lower the capacity, the greater the NCD risk. The model therefore helps understand dose–response associations of both early development and later phenotype with NCD risk. Infancy represents a critical developmental period, during which slow growth can constrain metabolic capacity, whereas rapid weight gain may elevate metabolic load. Severe acute malnutrition in early childhood (stunting, wasting) may continue to deplete metabolic capacity, and confer elevated susceptibility to NCDs in the long term. The model can be applied to associations of NCD risk with socio-economic position (SEP): lower SEP is generally associated with lower capacity but often also with elevated load. The model can also help explain ethnic differences in NCD risk, as both early growth patterns and later body composition differ systematically between ethnic groups. Recent work has begun to clarify the role of organ development in metabolic capacity, which may further contribute to ethnic differences in NCD risk.
Subscribe to Journal
Get full journal access for 1 year
only $41.58 per issue
All prices are NET prices.
VAT will be added later in the checkout.
Rent or Buy article
Get time limited or full article access on ReadCube.
All prices are NET prices.
Barker DJ. The developmental origins of adult disease. J Am Coll Nutr. 2004;23(6 Suppl):588S–95S.
Bianco-Miotto T, Craig JM, Gasser YP, van Dijk SJ, Ozanne SE. Epigenetics and DOHaD: from basics to birth and beyond. J Dev Orig Health Dis. 2017;8:513–9.
Rook G, Backhed F, Levin BR, McFall-Ngai MJ, McLean AR. Evolution, human-microbe interactions, and life history plasticity. Lancet. 2017;390:521–30.
Hales CN, Barker DJ. Type 2 (non-insulin-dependent) diabetes mellitus: the thrifty phenotype hypothesis. Diabetologia. 1992;35:595–601.
Hales CN, Barker DJ, Clark PM, Cox LJ, Fall C, Osmond C, et al. Fetal and infant growth and impaired glucose tolerance at age 64. BMJ. 1991;303:1019–22.
Bhargava SK, Sachdev HS, Fall CH, Osmond C, Lakshmy R, Barker DJ, et al. Relation of serial changes in childhood body-mass index to impaired glucose tolerance in young adulthood. N Engl J Med. 2004;350:865–75.
Petry CJ, Dorling MW, Pawlak DB, Ozanne SE, Hales CN. Diabetes in old male offspring of rat dams fed a reduced protein diet. Int J Exp Diabetes Res. 2001;2:139–43.
Rich-Edwards JW, Colditz GA, Stampfer MJ, Willett WC, Gillman MW, Hennekens CH, et al. Birthweight and the risk for type 2 diabetes mellitus in adult women. Ann Intern Med. 1999;130(4 Pt 1):278–84.
Li Y, Ley SH, Tobias DK, Chiuve SE, VanderWeele TJ, Rich-Edwards JW, et al. Birth weight and later life adherence to unhealthy lifestyles in predicting type 2 diabetes: prospective cohort study. BMJ. 2015;351:h3672.
Wells JC. The thrifty phenotype: an adaptation in growth or metabolism? Am J Hum Biol. 2011;23:65–75.
Wells JC. The metabolic ghetto: an evolutionary perspective on nutrition, power relations and chronic disease. Cambridge: Cambridge University Press; 2016.
Dominguez-Salas P, Moore SE, Baker MS, Bergen AW, Cox SE, Dyer RA, et al. Maternal nutrition at conception modulates DNA methylation of human metastable epialleles. Nat Commun. 2014;5:3746.
Hemachandra AH, Klebanoff MA. Use of serial ultrasound to identify periods of fetal growth restriction in relation to neonatal anthropometry. Am J Hum Biol. 2006;18:791–7.
Lucas A, Fewtrell MS, Cole TJ. Fetal origins of adult disease-the hypothesis revisited. BMJ. 1999;319:245–9.
Singhal A, Kennedy K, Lanigan J, Fewtrell M, Cole TJ, Stephenson T, et al. Nutrition in infancy and long-term risk of obesity: evidence from 2 randomized controlled trials. Am J Clin Nutr. 2010;92:1133–44.
McEwen BS, Stellar E. Stress and the individual. Mechanisms leading to disease. Arch Intern Med. 1993;153:2093–101.
Keys A, Brozek J, Henschel A, Mickelsen O, Taylor HL. The biology of human starvation. Minneapolis: University of Minnesota Press; 1950.
Enesco M, LeBlond CP. Increase in cell number as a factor in the growth of the organs and tissues of the young male rat. J Embryol Exp Morphol. 1962;10:530–62.
Adair LS, Martorell R, Stein AD, Hallal PC, Sachdev HS, Prabhakaran D, et al. Size at birth, weight gain in infancy and childhood, and adult blood pressure in 5 low- and middle-income-country cohorts: when does weight gain matter? Am J Clin Nutr. 2009;89:1383–92.
Leon DA, Koupilova I, Lithell HO, Berglund L, Mohsen R, Vagero D, et al. Failure to realise growth potential in utero and adult obesity in relation to blood pressure in 50 year old Swedish men. BMJ. 1996;312:401–6.
Li Y, Ley SH, VanderWeele TJ, Curhan GC, Rich-Edwards JW, Willett WC, et al. Joint association between birth weight at term and later life adherence to a healthy lifestyle with risk of hypertension: a prospective cohort study. BMC Med. 2015;13:175.
Whincup PH, Kaye SJ, Owen CG, Huxley R, Cook DG, Anazawa S, et al. Birth weight and risk of type 2 diabetes: a systematic review. JAMA. 2008;300:2886–97.
Wu CY, Chou YC, Huang N, Chou YJ, Hu HY, Li CP. Association of body mass index with all-cause and cardiovascular disease mortality in the elderly. PLoS ONE. 2014;9:e102589.
Lelijveld N, Seal A, Wells JC, Kirkby J, Opondo C, Chimwezi E, et al. Chronic disease outcomes after severe acute malnutrition in Malawian children (ChroSAM): a cohort study. Lancet Glob Health. 2016;4:e654–662.
Office for National Statistics. Inequality in healthy life expectancy at birth by national deciles of area deprivation: England, 2009–11. London: Crown; 2014.
Marmot M. Social determinants of health inequalities. Lancet. 2005;365:1099–104.
Victora CG, Barros FC, Vaughan JP, Martines JC, Beria JU. Birthweight, socio-economic status and growth of Brazilian infants. Ann Hum Biol. 1987;14:49–57.
Barros AJ, Victora CG, Horta BL, Goncalves HD, Lima RC, Lynch J. Effects of socioeconomic change from birth to early adulthood on height and overweight. Int J Epidemiol. 2006;35:1233–8.
Subramanian SV, Özaltin E, Finlay JE. Height of nations: a socioeconomic analysis of cohort differences and patterns among women in 54 low- to middle-income countries. PLoS ONE. 2011;6:e18962.
de la Grandmaison GL, Clairand I, Durigon M. Organ weight in 684 adult autopsies: new tables for a Caucasoid population. Forensic Sci Int. 2001;119:149–54.
Borghol N, Suderman M, McArdle W, Racine A, Hallett M, Pembrey M, et al. Associations with early-life socio-economic position in adult DNA methylation. Int J Epidemiol. 2012;41:62–74.
Wardle J, Waller J, Jarvis MJ. Sex differences in the association of socioeconomic status with obesity. Am J Public Health. 2002;92:1299–304.
Martorell R, Khan LK, Hughes ML, Grummer-Strawn LM. Obesity in women from developing countries. Eur J Clin Nutr. 2000;54:247–52.
Hruschka DJ, Brewis AA. Absolute wealth and world region strongly predict overweight among women (ages 18-49) in 360 populations across 36 developing countries. Econ Hum Biol. 2012;11:337–44.
Monteiro CA, Conde WL, Lu B, Popkin BM. Obesity and inequities in health in the developing world. Int J Obes. 2004;28:1181–6.
Misra A, Sharma R, Pandey RM, Khanna N. Adverse profile of dietary nutrients, anthropometry and lipids in urban slum dwellers of northern India. Eur J Clin Nutr. 2001;55:727–34.
Bentley A, Das S, Alcock G, Shah More N, Pantvaidya S, Osrin D. Malnutrition and infant and young child feeding in informal settlements in Mumbai, India: findings from a census. Food Sci Nutr. 2015;3:257–71.
Kelly Y, Panico L, Bartley M, Marmot M, Nazroo J, Sacker A. Why does birthweight vary among ethnic groups in the UK? Findings from the Millennium Cohort Study. J Public Health (Oxf). 2009;31:131–7.
Yajnik CS, Fall CH, Coyaji KJ, Hirve SS, Rao S, Barker DJ, et al. Neonatal anthropometry: the thin-fat Indian baby. The Pune Maternal Nutrition Study. Int J Obes. 2003;27:173–80.
Stanfield KM, Wells JC, Fewtrell MS, Frost C, Leon DA. Differences in body composition between infants of South Asian and European ancestry: the London Mother and Baby Study. Int J Epidemiol. 2012;41:1409–18.
Wells JC. Ethnic variability in adiposity and cardiovascular risk: the variable disease selection hypothesis. Int J Epidemiol. 2009;38:63–71.
Nightingale CM, Rudnicka AR, Owen CG, Wells JC, Sattar N, Cook DG, et al. Influence of adiposity on insulin resistance and glycemia markers among United Kingdom children of South Asian, Black African-Caribbean, and White European origin: Child Heart and Health Study in England. Diabetes Care. 2013;36:1712–9.
Wells JC, Chomtho S, Fewtrell MS. Programming of body composition by early growth and nutrition. Proc Nutr Soc. 2007;66:423–34.
Martorell R. Improved nutrition in the first 1000 days and adult human capital and health. Am J Hum Biol. 2017;29. https://doi.org/10.1002/ajhb.22952.
Kinra S, Rameshwar Sarma KV, Ghafoorunissa, Mendu VV, Ravikumar R, Mohan V, et al. Effect of integration of supplemental nutrition with public health programmes in pregnancy and early childhood on cardiovascular risk in rural Indian adolescents: long term follow-up of Hyderabad nutrition trial. BMJ. 2008;337:a605.
Petry CJ, Desai M, Ozanne SE, Hales CN. Early and late nutritional windows for diabetes susceptibility. Proc Nutr Soc. 1997;56:233–42.
Latini G, De Mitri B, Del Vecchio A, Chitano G, De Felice C, Zetterstrom R. Foetal growth of kidneys, liver and spleen in intrauterine growth restriction: “programming” causing “metabolic syndrome” in adult age. Acta Paediatr. 2004;93:1635–9.
Wells JC, Devakumar D, Grijalva-Eternod CS, Manandhar DS, Costello A, Osrin D. Blood pressure and the capacity-load model in 8-year-old children from Nepal: testing the contributions of kidney size and intergenerational effects. Am J Hum Biol. 2016;28:555–65.
Coppoletta JM, Wolbach SB. Body length and organ weights of infants and children: a study of the body length and normal weights of the more important vital organs of the body between birth and twelve years of age. Am J Pathol. 1933;9:55–70.
Wells JC, Pomeroy E, Walimbe SR, Popkin BM, Yajnik CS. The elevated susceptibility to diabetes in india: an evolutionary perspective. Front Public Health. 2016;4:145.
Conflict of interest
The author declares that he has no conflict of interest.
About this article
Cite this article
Wells, J.C.K. The capacity–load model of non-communicable disease risk: understanding the effects of child malnutrition, ethnicity and the social determinants of health. Eur J Clin Nutr 72, 688–697 (2018). https://doi.org/10.1038/s41430-018-0142-x
Prevention of child wasting: Results of a Child Health & Nutrition Research Initiative (CHNRI) prioritisation exercise
PLOS ONE (2020)
A Comparison of the Socio-Behavioral-Metabolic Risk Profiles and Associated Factors for Chronic Diseases of Lifestyle in Urban and Rural Communities in Central South Africa
Frontiers in Public Health (2020)
Effects of Dose and Duration of Zinc Interventions on Risk Factors for Type 2 Diabetes and Cardiovascular Disease: A Systematic Review and Meta-Analysis
Advances in Nutrition (2020)
Nature Medicine (2019)
Higher Weight and Weight Gain after 4 Years of Age Rather than Weight at Birth Are Associated with Adiposity, Markers of Glucose Metabolism, and Blood Pressure in 5-Year-Old Ethiopian Children
The Journal of Nutrition (2019)