Jamie Stang, PhD, MPH, RD, LN University of Minnesota Division of Epidemiology and Community Health

1. On average, which of the following in the best predictor of one’s health? a. Whether or not you smoke b. What you eat c. Whether or not you are wealthy d. Whether or not you have health insurance e. How often you exercise

On average, which of the following in the best predictor of one’s health? a. Whether or not you smoke b. What you eat c. Whether or not you are wealthy d. Whether or not you have health insurance e. How often you exercise

Chronic stress increases the risk of all of the following, except: a. Hypertension b. Obesity c. Sickle cell anemia d. Preterm birth e. Diabetes

Chronic stress increases the risk of all of the following, except: a. Hypertension b. Obesity c. Sickle cell anemia d. Preterm birth e. Diabetes

True or False? The gap between white and African American infant mortality rates is greater today than it was in a. True b. False

True or False? The gap between white and African American infant mortality rates is greater today than it was in a. True b. False

One of the critical factors that increases risks for childhood obesity a. High fat intake diet during pregnancy b. Low weight gain during pregnancy c. Rapid catch-up weight gain in LBW infants d. Late introduction of solid foods.

One of the critical factors that increases risks for childhood obesity a. High fat intake diet during pregnancy b. Low weight gain during pregnancy c. Rapid catch-up weight gain in LBW infants d. Late introduction of solid foods.

 Conceptual framework that addresses patterns of health and disease  Specific focus on causes and effects of health disparities  Focuses on social, economic and environmental factors  Community and population focused as well as individual focused model  Evolved from social determinants of health and health equity models  Community or population focused because environmental, social and economic factors linked to community

 Why do health disparities persist in populations even when improvements in individual conditions occur?  What factors influence the capacity of individuals, communities and/or populations to reach their maximal health potential?

 Health trajectory  A continuous pathway of expected health based on social, economic and environmental exposures and life experiences  Early programming of disease risk  Prenatal and early neonatal programming that alters genetic potential or susceptibility to disease ▪ Fetal origins hypothesis (Barker Hypothesis), Thrifty Gene Theory  Critical or sensitive periods  Developmental periods where exposures have the greatest impact ▪ Positive or negative effects can be seen ▪ Fetal development, early childhood, adolescence

 Cumulative impact  Additive effect of multiple stressors or behavior changes ▪ Also called alostatic load ▪ May be a significant factor in health disparities  Risk factors  Reduce health trajectory across lifespan ▪ Poverty, environment, stress, abuse/neglect, discrimination  Protective factors  Increase health trajectory across lifespan ▪ Access to healthcare, education, nurturing, social capital

 Current experiences and exposures affect future health status and trajectory  Health trajectory especially affected during critical development periods in the lifespan  Broad factors – environmental exposures, economic factors, social standing and support – affect health as much as physical and biological factors  Disparities in health reflect more than just genetic potential and personal choice

Birth Early Infancy Late Infancy Early Toddler Late Toddler Early Preschool Late Preschool Reading to child Pre-school Age 6 mo 12 mo 18 mo 24 mo3 yrs 5 yrs Ready to learn Strategies to Improve School Readiness Trajectories Appropriate Discipline Poverty Lack of health services Family Discord Social-emotional, Physical Cognitive, Language function Lower trajectory: With diminished function Parent education Emotional literacy

 Refocus system resources and effort to early determinants of health  Promote health among women of reproductive age  Earlier detection and intervention of risk factors for diseases rather than focusing on treating symptoms  Health promotion and disease prevention model  Promote positive factors on a broad scale to reduce inequities in health  Poverty, discrimination, education, transportation  Address the whole community, not just each individual  Address common factors on a population-based level

 Nutrition is a key component of the lifecourse theory  Can be both a protective and risk factor  Opportunities for nutrition to impact health trajectories throughout life span  Improved nutritional status through individualized clinical care and participation in federal food programs  Improved pre-pregnancy weight and gestational weight gain for women  Access to healthy foods in all communities ▪ Focus on rural and urban locations

S Looney, K Eppig, PHCNPG Digest, 2011.

 Overweight and obesity prior to pregnancy increases the risk of poor maternal and fetal outcomes  Gestational hypertension, pre-eclampsia, thromboebolitic disorders, Caesarean delivery, anesthesia-related complications, postpartum depression  Large for gestational age, macrosomia, preterm delivery, stillbirth, congenital anomalies

 Overweight and obesity prior to pregnancy is an independent risk factor for some birth defects  NTDs (esp spina bifida)  Cardiac defects  Hypospadia  Omphalocele  Anorectal atresia and limb reduction (obesity only)  Underweight prior to pregnancy is a risk for defects  cleft lip and palate  Overweight Prior to pregnancy protective factor for one specific birth defect  gastroschisis

31% of women gain within IOM guidelines  25% gain below and 44% gain above  White women most likely to gain above (48%)  Asian/PI most likely to gain below (32%)

Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. MCHJ. 2003;7:13-30.

 Data from found short, medium and long-term effects of high gestational weight gain on postpartum retention  Women who were obese prior to pregnancy 2-8 times higher risk of retaining 10 lb or more after a pregnancy if had excessive weight gain  May be significant contributor to health disparities  Infants born to women with excessive gain had higher BMI percentiles, larger waist circumferences and more total fat mass than women who gained within the IOM guidelines  Increased leptin production in visceral fat of large infants which promotes subcutaneous fat deposition after birth, leading to increased fat mass and leptin production  May explain higher rates of leptin and insulin resistance in LGA babies

 Inadequate pregnancy weight gain can lead to poor maternal and fetal outcomes  Preterm birth, intrauterine growth restriction  Potential increased risk of chronic disease in offspring  Less fetal fat deposition and reduced leptin production ▪ Become highly sensitized to leptin, insulin, growth factors  When catch up growth occurs, increased visceral fat stores that are highly sensitive to hormones, leptin and growth factors lead to increase central body fat deposits ▪ Increased risk for obesity, diabetes, chronic diseases

 Health trajectory of individuals is affected by mother’s preconception and pregnancy nutritional status as well as their own experiences and exposures from birth onward  Health trajectory especially affected during critical development periods such as fetal development, early childhood and adolescence when growth and development are rapid and elastic  Broad factors affect health as much as physical and biological factors  environmental exposures, economic factors, social standing, social capital  Disparities in health reflect more than just genetic potential and personal choice

 Nutrition is a key component of the lifecourse theory  Can be both a protective and risk factor  Opportunities for nutrition to impact health trajectories throughout life span – 3 examples  Improved nutritional status through individualized services and participation in federal food programs  Improved pre-pregnancy weight and gestational weight gain for women  Access to healthy foods in all communities ▪ Focus on rural and urban locations

 Data from found short, medium and long-term effects of high gestational weight gain on postpartum retention  Women who were obese prior to pregnancy 2-8 times higher risk of retaining 10 lb or more after a pregnancy if had excessive weight gain  May be significant contributor to health disparities  Infants born to women with excessive gain had higher BMI percentiles, larger waist circumferences and more total fat mass than women who gained within the IOM guidelines  Increased leptin production in visceral fat of large infants which promotes subcutaneous fat deposition after birth, leading to increased fat mass and leptin production  May explain higher rates of leptin and insulin resistance in LGA babies

 Inadequate pregnancy weight gain can lead to poor maternal and fetal outcomes  Preterm birth, intrauterine growth restriction  Potential increased risk of chronic disease in offspring  Less fetal fat deposition and reduced leptin production ▪ Become highly sensitized to leptin, insulin, growth factors  When catch up growth occurs, increased visceral fat stores that are highly sensitive to hormones, leptin and growth factors lead to increase central body fat deposits ▪ Increased risk for obesity, diabetes, chronic diseases

Odds ratio adjusted for BMI Barker 1993

Law 1993

Age Adjusted Relative Risk Rich-Edwards 1997

 Individual level  Access to comprehensive health care services for women, home visit programs, participation in nutrition assistance programs  Interpersonal level  Peer education programs, prenatal education groups (social capital), community health workers  Community level  Improved access to healthy foods & safe environments, access to accessible education/training programs, access to nutrition assistance programs, accessible & affordable comprehensive health care services, social marketing & awareness campaigns, training for health care professionals & community health workers, adequate transportation  Population level  Appropriate funding for federal nutrition programs, improvements in local and national food systems, health policies that ensure access to comprehensive & affordable healthcare, increased funding for research to investigate and disseminate effective intervention strategies, policies to expand postpartum and interconceptional healthcare services

 Proportion of individuals living in poverty is currently estimated at 14.3%  7% of working families  25% of households affected by unemployment  15% of households affected by layoffs  Disparities in rates of poverty  9% of whites, 26% of blacks, 25% of Hispanics, 12% of Asian Americans, > 45% of Native Americans  1 in 5 children lives in poverty, compared with 13% of persons aged 18 to 64 years and 9% of adults aged 65+ US Census Bureau, 2010

 15% of US population is not food secure  43% of households with incomes below the official poverty line ▪ $21,756 for a family of four in 2009  37% of households with children, headed by a single woman  28% of households with children, headed by a single man  25% of black households  27% of Hispanic households

 6% of US households experience access-related problems that limit the purchase of the type or quality of food  3% live from one-half to one mile from a supermarket and lacked access to a vehicle or other transportation  2% live a mile or more from a supermarket and without vehicle access  Lack of access to supermarkets due to distance and unavailability of transportation is more prevalent in low- income rural and urban areas  the same areas in which food insecurity rates are higher

Population

 Individual level  Food planning, purchasing and preparation skills, gardening  Interpersonal level  Parenting skills, conflict resolution skills, social capital  Community level  Community gardens, local farmers markets, CSAs, community coalitions and programs, transportation and infrastructure issues, worksite and school policies  Population level  Policies to improve food systems, improvements in federal food and nutrition programs, nutrition guidelines, alignment of agriculture and nutrition policies

 Nutrition interventions that address all factors that affect health and nutrition status  Access to appropriate, high quality health care services  Access to healthy foods and environments  Public policies that support development of infrastructure that is in line with health care policy and recommendations  Economic and social policies that increase protective factors and reduce risk factors for individuals and populations  Collaboration of clinical and public health nutrition programs and services is needed

 Refocus system resources and efforts toward early determinants of health  Promote health among women of reproductive age  Earlier detection and intervention of risk factors for diseases rather than focusing on treating symptoms  Health promotion and disease prevention model  Promote positive factors on a broad scale to reduce inequities in health  Poverty, discrimination, education, transportation  Address the whole community, not just each individual  Address common factors on a population-based level

 RDs and DTRs need to increasingly expand our involvement beyond traditional roles and services  Service on education, economic development, urban planning, transportation committees  Advocate for improved programs and policies  Local, state and federal involvement  Evaluate programs, services and policies  Hard to argue with evidence of positive outcomes  Use all opportunities to show how nutrition can affect health trajectories across life span  Improvements in educational attainment, reductions in health care costs, increased community capacity, improved social capital