1. The Life Course Framework and Family Health Services
Family Health Services Retreat
October 25, 2013

2. Acknowledgements Milton Kotelchuck, PhD, MPH Michael Lu, MD, MS, MPH
Neal Halfon, MD, MPH
Cheri Pies, MSW, DrPH
Deborah Allen, ScD
Deborah Klein Walker, EdD
Amy Fine, MPH
Reggie Caldwell, LCSW

3. Why Use the Life Course Framework?
Provides an organizing approach for services for women, infants, children and families
Incorporates a focus on health equity and on social determinants of health
Over 20 years of research to validate concepts
Adopted by the Federal Maternal and Child Health Bureau in 2010 and supported by organizations like the American Academy of Pediatrics.

4. Life Course Framework Core Concepts
Today’s experiences and exposures determine tomorrow’s health.
Health trajectories are particularly affected during critical or sensitive periods .
The broader environment –biologic, physical, and social –strongly affects the capacity to be healthy.
Inequality in health reflects more than genetics and personal choice.
Fine, Kotelchuck, Addess, Pies 2009; Amy Fine: Life Course "Cliff Notes"

5. Pathways/ Trajectories

6. “The Life Course Perspective”
Optimal Life Trajectory
Health potential
The experiences you have each day add up to determine your health throughout your life
Life Trajectory Impacted by Inequity
Early Programming
Cumulative Pathways
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J. 2003;7:13-30.

7. Cumulative Impact Allostasis and Allostatic Load

8. Allostasis: Maintain Stability through Larger Changes / Stresses
McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.

9. Allostastic Load: Wear and Tear from Chronic Stress
McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.

10. Stressed vs Stressed Out
Stressed = Protective
Increased heart rate
More energy through increased blood sugar
Enhanced immune functions
Improved brain response/function
Stressed Out = Toxic
High blood pressure and heart disease
Continuous high
blood sugar = Diabetes
Infection & inflammation
Short-term memory loss

11. Allostatic Load Health Inequities

12. MATERNAL LIFETIME EXPOSURE TO INTERPERSONAL RACISM IN 3 OR MORE DOMAINS AND INFANT BIRTH WEIGHT (Collins et al, AJPH, 2004)

13. Latency/ Early Programming

14. Barker Hypothesis
Adverse influences early in development, particularly during intrauterine life, can result in permanent changes in physiology and metabolism, which result in increased disease risk in adulthood

15. Barker Hypothesis Birth Weight and Insulin Resistance Syndrome
Odds ratio adjusted for BMI
Barker DJP, Hales CN, Fall CHD, Osmond C, Phipps K, Clark PMS. Type 2 (non-insulin-dependent) diabetes mellitus,
hypertension and hyperlipidaemia (Syndrome X): Relation to reduced fetal growth. Diabetologia 1993;36:62-67.

16. Adverse Childhood Experiences Study
One of the largest studies looking at the long-term impact on childhood maltreatment on long-term outcomes of health and well-being
Studied over 17,000 Kaiser members
Found a consistent and predictable correlation adverse childhood experiences and later adult health/well-being

17. Categories of Adverse Childhood Experience
ACE Category*
Women (N = 9,367)
Men (N = 7,970)
Total (N = 17,337)
Abuse
Emotional Abuse
13.1
7.6
10.6
Physical Abuse
27.0
29.9
28.3
Sexual Abuse
24.7
16.0
20.7
Neglect
Emotional Neglect1
16.7
12.4
14.8
Physical Neglect1
9.2
10.7
9.9
Household Dysfunction
Mother Treated Violently
13.7
11.5
12.7
Household Substance Abuse
29.5
23.8
26.9
Household Mental Illness
23.3
19.4
Parental Separation or Divorce
24.5
21.8
Incarcerated Household Member
5.2
4.1
4.7
Centers for Disease Control and Prevention

18. Adverse childhood events and adult ischemic heart disease
Odds Ratio
Adverse Events
Dong et al, 2004 18

19. Long-term Impacts of Adverse Childhood Experiences
Alcoholism and alcohol abuse
Chronic obstructive pulmonary disease
Depression
Fetal death
Health-related quality of life
Illicit drug use
Ischemic heart disease
Liver disease
Risk for intimate partner violence
Multiple sexual partners
Sexually transmitted diseases
Smoking
Suicide attempts
Unintended pregnancies
Early initiation of smoking
Early initiation of sexual activity
Adolescent pregnancy
Centers for Disease Control and Prevention

20. Stress And Health STRESSOR AFFECTS MULTIPLE ORGANS & SYSTEMS
Hypothalamus
CRH
Pituitary Gland
ACTH
Adrenal Glands
CORTISOL
AFFECTS MULTIPLE ORGANS & SYSTEMS
Source: Center on Social Disparities in Health, University of California San Francisco

21. Birth Outcomes & Stress
Chronically high cortisol before pregnancy may dysregulate immune responses, causing more stress reactivity &/or susceptibility to infection later
Physiological pathways have been documented in animals and humans about the impact of stress on birth outcomes
Release of stress hormones during pregnancy (cortisol, epinephrine, norepinephrine) could lead to LBW or PTB
Source: Center on Social Disparities in Health, University of California San Francisco

22. Risk Reduction Strategies Health Promotion Strategies
Adapted from Lu & Halfon (2003)
IMPROVING BIRTH OUTCOMES & REDUCING DISPARITIES
Risk Reduction Strategies
Conception
Birth
Pregnancy
Delivery
Age 5
Puberty
Reproductive Potential
Post-partum
Health Promotion Strategies

23. Shaping Health Potential
Risk Factors
Adverse childhood experiences
Poor nutrition
Stress
Unsafe neighborhood
Poor Education
Lack of health care
No family planning
Tobacco/alcohol/drug use
Protective Factors
Nutrition
Healthy relationships
Social support
Exercise
Health care
Family planning
Safe neighborhood
Financial security
Breastfeeding

24. Why Use the Life Course Framework?
Our clients are generally from low-income, multicultural communities with limited resources and opportunities.
We should take into account the many economic, social, and environmental factors that influence the lives of our clients.
Client decisions and behaviors will be strongly affected by their life circumstances.
Understanding and implementing the life course framework can enhance how we serve clients and communities, and result in better health outcomes.

25. Today we all have the opportunity to think BIG about improving health potential in our community…