1. Nutrition 526 - 2008 Introduction

2. 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

3. 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

4. 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?

5. 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

6. 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,

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

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

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

10. 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

12. Maternal-infant dyad

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

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

15. 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.

22. 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

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

24. 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.

25. 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

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

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

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

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

34. 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.”

35. Causes of Infant Death

36. Health Affairs, Vol 23, Issue 5, 2004

37. INDICATOR HEALTH1: PERCENTAGE OF INFANTS BORN WITH LOW BIRTHWEIGHT BY MOTHER'S RACE AND HISPANIC ORIGIN, 1980–2005

38. 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

39. 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

40. 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

41. 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”

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

43. 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

44. 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”

45. Maternal Mortality

46. 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.

47. 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.

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

49. Ferrara. A. Diabetes Care. Jul 2007

50. Ferrara. A. Diabetes Care. Jul 2007

51. Chu SY, Diabetes Care. August 2007

54. Dabelea, D Diabetes care. July, 2007

55. Pettit DJ. Diabetes Care, July 2007.

56. 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.

57. 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

58. 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

59. Healthy People 2010 Goals Related to Maternal and Infant & Nutrition

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

61. Reduce preterm births

62. 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.

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

64. Multivitamin Use

65. Multivitamin Use

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

67. MMWR, December 24, 2004

68. Alcohol

70. Smoking

74. Increase the proportion of mothers who breastfeed their babies

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

76. Breastfeeding Duration

77. Breastfeeding Duration

78. 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 (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).

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

80. 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 < g/dL) in 1996

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

82. Population vs.. individual