Nutrition 526 - 2008 Introduction

Learning Objectives for Today Integrate the science of maternal & infant nutrition into social-ecological framework Apply course learnings in the context of the maternal & infant population in the US and the nutrition-related concerns of this population

Preconception – Conception – Gestation – Birth - Infancy Sexual maturity - Childhood Resources & Biology Adaptive Mechanisms Goals of Reproduction DNA & metabolic programming Access to Food Knowledge & Skills Support: basic needs, health care, cultural/social Physiologic responses to reproduction & growth Behavioral responses Healthy mother who can nourish infant & produce further offspring Optimal growth & development of offspring

Questions to Consider… Given individual variations in the physiology of pregnancy and infancy, what ranges of nutrient intake best support optimal outcomes? (and what are those optimal outcomes?) What are the best indices of nutritional status in pregnancy and infancy? individual population What services & systems best promote nutritional health in pregnancy and infancy?

Social-Ecological Model for Determinants of Access to Resources & Nutrition Behaviors Structures, Policies, Systems Local, state, federal policies and laws Institutions Rules, regulations, policies & informal structures Community Social Networks, Norms, Standards Interpersonal Family, peers, social networks, associations The outer layer of the model is the Structures, Policies and Systems that operate at local, state and Federal level to regulate and support healthy actions. Individual Knowledge, attitudes, beliefs

Individual - Pregnancy Physiology and Psychology of Pregnancy Maternal Preconceptual status Inter-generational programming Diet in pregnancy: energy/weight gain, macro & micronutrients Behaviors that impact nutritional status Substances: alcohol, caffeine, tobacco, drugs Physical activity Oral health Pregnancy intendedness Stage of development: adolescence High risk situations: GDM, PIH,

Intrapersonal/Community Social and cultural environments Support from friends and family Health and nutrition care providers

Institutional Hospital breastfeeding & formula policies Child Care policies School policies for pregnant and parenting teens Worksite lactation policies

Policy & Environment Nutrition Assistance Programs for pregnancy, lactation and early childhood. Insurance policies for lactation support

Structures, Policies, Systems Adaptations of the Model for Course Framework Structures, Policies, Systems Institutions Community Interpersonal The outer layer of the model is the Structures, Policies and Systems that operate at local, state and Federal level to regulate and support healthy actions. Individual

Maternal-infant dyad

A Public Health Approach to Maternal and Infant Health Assessment: Trends & Demographics Policy Development: NGA Assurance: Surveillance and monitoring progress towards goals

A Public Health Approach to Maternal and Infant Health Assessment: Trends & Demographics Policy Development: NGA Assurance: Surveillance and monitoring progress towards goals

Health, United States, 2005: www.cdc.gov/nchs/hus.htm WA: The total number of live births has remained stable since 1998 at ~ 80,000 births per year.

Percentage of Parents Who Were Married or Cohabiting at Birth of First Child, by Race/Ethnicity and Sex MMWR; September 15, 2006 / 55(36);998

Distribution of Births, by Gestational Age --- United States, 1990 and 2005 MMWR, April 2007

Infant Mortality Infant mortality rate – Deaths of infants aged under 1 year per 1,000 or 100,000 live births. The infant mortality rate is the sum of the neonatal and postneonatal mortality rates. Neonatal mortality rate – Deaths of infants aged 0-27 days per 1,000 live births. The neonatal mortality rate is the sum of the early neonatal and late neonatal mortality rates Postneonatal mortality rate – Deaths to infants aged 28 days-1 year per 1,000 live births.

Infant Mortality Sensitive indicator of community health because reflects influences by various social factors E.g. environment (housing, sanitation, safe food and water) Historically decrease in infant mortality associated with improvements in living conditions and health services

Factors associated with infant mortality Birthweight: most critical Infection: bacterial, viral, parasitic

Interconnections Growth failure Infection Increased risk for infection Increased risk for growth failure

http://www.chipublib.org/004chicago/disasters/infant_mortality.html

FIGURE 2-- Birthweight distributions of 3 Illinois subpopulations David, R. et al. Am J Public Health 2007;97:1191-1197 Copyright ©2007 American Public Health Association

INDICATOR HEALTH2: DEATH RATES AMONG INFANTS BY RACE AND HISPANIC ORIGIN OF MOTHER, 1983–2004

http://mchb.hrsa.gov/mchirc/chusa_05/healthstat/infants/0307iimr.htm

Muntaner, C et al. ECONOMIC INEQUALITY, WORKING-CLASS POWER,SOCIAL CAPITAL, AND CAUSE-SPECIFIC MORTALITY IN WEALTHY COUNTRIES. International Journal of Health Services, Volume 32, Number 4, Pages 629–656, 2002 “In summary, the rates of low birth weight and infant deaths from all causes were lower in those countries with more voter turnout, more left votes, more left members of parliament, more years of social democratic government, more women in government, a stronger social pact and various aspects of the welfare state, and low income inequality, as measured in a variety of ways.”

Causes of Infant Death

Health Affairs, Vol 23, Issue 5, 2004

INDICATOR HEALTH1: PERCENTAGE OF INFANTS BORN WITH LOW BIRTHWEIGHT BY MOTHER'S RACE AND HISPANIC ORIGIN, 1980–2005 http://www.childstats.gov/americaschildren/health1.asp

Premature Birth Rate (%) Infant Mortality Rate LBW Rate (%) Premature Birth Rate (%) Infant Mortality Rate (%) African Americans 13.4 17.7 13.5 Asians 7.8 10.4 4.6 Native Americans 7.2 13 9.7 Whites 6.9 11 5.7 Hispanics 6.5 11.6 5.4 NGA Center for Best Practices, June 2004

Policy approach Access to food Knowledge and beliefs Individual maternal-infant dyad Community based Public health and health services Knowledge and beliefs individual Family, community

Determinants of infant feeding practices Maternal employment Health sector activities Commercial availability and promotion of processed milks and cereals Urbanization vs.. modernization Poverty and maternal nutrition Perceived insufficiency of breast milk

History Child welfare movements became noticeable in industrialized countries (U.S. and Western Europe “Political, economic, and humanitarian motivations all converged to reduce the large wastage of child life”

History World War 1 and 2 Recruits unfit for service “weaklings”

History Child welfare movements directed toward general hygiene for disease prevention, dietary improvements, and antepartum care Infant Stations: to provide clean milk, instruct new mothers on child/infant care, encourage breastfeed Innovative approach in 1908 establishment of Division of Child Hygiene in NYC

Child Hygiene Bureau NYC Tracked from register of live births Home nursing visits Education on infant care Milk stations “there were 1200 fewer deaths when comparable to previous summer”

Maternal Mortality

African American and White Women Who Died of Pregnancy Complications, African American and White Women Who Died of Pregnancy Complications,* United States * Annual number of deaths during pregnancy or within 42 days after delivery, per 100,000 live births. † The apparent increase in the number of maternal deaths between 1998 and 1999 is the result of changes in how maternal deaths are classified and coded. Source: CDC, National Center for Health Statistics.

Risk of Maternal Death The risk of death for African American women is almost four times that for white women. The risk of death for Asian and Pacific Islander women who immigrated to the United States is two times that for Asian and Pacific Islander women born in the United States. The risk of death is nearly three times greater for women 35–39 years old than for women 20–24 years old. The risk is five times greater for women over 40.

The Most common pregnancy complications Ectopic pregnancy Depression High blood pressure Infection Complicated delivery Diabetes Premature labor Hemorrhage

Ferrara. A. Diabetes Care. Jul 2007

Ferrara. A. Diabetes Care. Jul 2007

Chu SY, Diabetes Care. August 2007

Dabelea, D Diabetes care. July, 2007

Pettit DJ. Diabetes Care, July 2007.

Policy Development: Poor Pregnancy Outcomes are Costly Medicaid finances 40% of annual births in the US and pays for 50% of hospital stays for premature and LBW. Medicaid-funded deliveries represented 45.6% of births in WA in 2003. The care cost for children with one of 17 common birth defects is $8 billion per year in the US.

Top Three “Best Practices” to Improve Birth Outcomes and Reduce High Risk Births (NGA, June 2004) Improve access to medical care and health care services Encourage good nutrition and healthy lifestyles Eating healthy foods Taking folic acid Harmful substances Violence Reduce use of harmful substances O’connor J et al. Health Promotion Practice, (1) 2005

NGA: Specific policy actions for nutrition WIC – serves 45% of all US infants, governors can increase access Folic Acid initiatives Office-based education of health care providers College outreach programs Social marketing

Healthy People 2010 Goals Related to Maternal and Infant & Nutrition

Reduce low birth weight (LBW) and very low birth weight (VLBW).

Reduce preterm births

Reduce the occurrence of spina bifida and other neural tube defects (NTDs) Target: 3 new cases per 10,000 live births. Baseline: 6 new cases of spina bifida or another NTD per 10,000 live births in 1996.

Increase the proportion of pregnancies begun with an optimum folic acid level.

Multivitamin Use

Multivitamin Use

Increase abstinence from alcohol, cigarettes, and illicit drugs among pregnant women

MMWR, December 24, 2004

Alcohol

Smoking

Increase the proportion of mothers who breastfeed their babies

Increase smoking cessation during pregnancy Target: 30 percent. Baseline: 12 percent smoking cessation during the first trimester of pregnancy in 1991 (age adjusted to the year 2000 standard population).

Breastfeeding Duration

Breastfeeding Duration

Reduce growth retardation among low income children under age 5 years Target: 5 percent. Baseline: 8 percent of low-income children under age 5 years were growth retarded in 1997 (defined as height-for-age below the fifth percentile in the age-gender appropriate population using the 1977 NCHS/CDC growth charts;31 preliminary data; not age adjusted).

Reduce iron deficiency among young children and females of childbearing age.

Reduce anemia among low-income pregnant females in their third trimester Target: 20 percent. Baseline: 29 percent of low-income pregnant females in their third trimester were anemic (defined as hemoglobin < 11.0 g/dL) in 1996

Anemia Rates - 1996 African American, non-Hispanic 44% American Indian/Alaska Native 31% Asian/Pacific Islander 26% Hispanic 25% White, non-Hispanic 24%

Population vs.. individual