Improving Maternal & Child Health in America: A Life-Course Perspective - Michael Lu, HRSA
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Transcript of Improving Maternal & Child Health in America: A Life-Course Perspective - Michael Lu, HRSA
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Improving Maternal & Child Health in America:A Life-Course Perspective
Michael C Lu, MD, MPHAssociate Administrator
Maternal and Child Health BureauHealth Resources and Services Administration
Department of Health and Human Services
Throughout the Reproductive Life Course:Opportunities & Challenges forEmpowering Girls and Women
Washington, DCApril 2, 2014
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Life-Course Perspective• A way of looking at life not as disconnected
stages, but as an integrated continuum
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Life Course Perspective
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective.Matern Child Health J. 2003;7:13-30.
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Life Course Perspective• Early programming• Cumulative pathways• Improving Maternal & Child Health in America
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Early Programming
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Barker HypothesisBirth Weight and Coronary Heart Disease
0
0.25
0.5
0.75
1
1.25
1.5
<5.0 5.0-5.5 5.6-7.0 7.1-8.5 8.6-10.0 >10.0Birthweight (lbs)
Age Adjusted Relative Risk
Rich-Edwards JW, Stampfer MJ, Manson JE, Rosner B, Hankinson SE, Colditz GA et al. Birth weight and risk of cardiovascular disease in a cohort of women followed up since 1976. Br Med Jr 1997;315:396-400.
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Barker HypothesisBirth Weight and Hypertension
155
160
165
170
Syst
olic
Pre
ssur
e (m
mH
g)
<=5.5 5.6-6.5 6.6-7.5 7.6-8.5 >8.5Birthweight (lbs)
Law CM, de Swiet M, Osmond C, Fayers PM, Barker DJP, Cruddas AM, et al. Initiation of hypertension in utero and its amplification throughout life. Br Med J 1993;306:24-27.
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Barker HypothesisBirth Weight and Insulin Resistance Syndrome
0
2
4
6
8
10
12
14
16
18
<5.5 5.6-6.5 6.6-7.5 7.6-8.5 8.6-9.5 >9.5Birthweight (lbs)
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.
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Maternal Stress & Fetal Programming
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Prenatal Stress & Programming of the Brain
• Prenatal stress (animal model)• Hippocampus
• Site of learning & memory formation• Stress down-regulates glucocorticoid receptors• Loss of negative feedback; overactive HPA axis
• Amygdala• Site of anxiety and fear• Stress up-regulates glucocorticoid receptors• Accentuated positive feedback; overactive HPA axis
Welberg LAM, Seckl JR. Prenatal stress, glucocorticoids and the programming of the brain.J Neuroendocrinol 2001;13:113-28.
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Prenatal Programming of the Hypothalamic-Pituitary-Adrenal Axis
Welberg LAM, Seckl JR. Prenatal stress, glucocorticoids and the programming of the brain.J Neuroendocrinol 2001;13:113-28.
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Epigenetics
Gibbs WW. The Unseen Genome: Beyond DNA. Scientific American 2003
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EpigeneticsSame Genome, Different Epigenome
R.A. Waterland, R.A. Jirtle, "Transposable elements: targets for early nutritional effects on epigenetic gene regulation," Mol Cell Biol, 23:5293-300, 2003. Reprinted in the New Scientist 2004
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Cumulative Pathways
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Photo: http://www.lam.mus.ca.us/cats/encyclo/smilodon/
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Allostasis: Maintain Stability through Change
McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.
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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.
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Stressed vs. Stressed Out• Stressed
• Increased cardiac output
• Increased available glucose
• Enhanced immune functions
• Growth of neurons in hippocampus & prefrontal cortex
• Stressed Out
• Hypertension & cardiovascular diseases
• Glucose intolerance & insulin resistance
• Infection & inflammation
• Atrophy & death of neurons in hippocampus & prefrontal cortex
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Allostasis & Allostatic Load
McEwen BS, Lasley EN. The end of stress: As we know it. Washington DC: John Henry Press. 2002
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Rethinking Preterm Birth
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Sequelae of Preterm Birth
Term Births
Preterm Birth
75%Perinatal Perinatal MortalityMortality
NeurologicNeurologicDisabilitiesDisabilities
50%
12%
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Racial & Ethnic DisparitiesPreterm Births < 37 Weeks
17.9
11.5
0
2
4
6
8
10
12
14
16
18
African American White
Percent of Live Births
NCHS 2006
Year 2010 Goal
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Racial & Ethnic DisparitiesVery Preterm Births < 32 Weeks
4.05
1.63
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
African American White
Percent of Live Singleton Births
Year 2010 Goal
NCHS 2006
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Racial & Ethnic DisparitiesInfant Mortality
13.7
5.7
0
2
4
6
8
10
12
14
African American White
Deaths Per 1,000 Live Births
NCHS 2006
Year 2010 Goal
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Rethinking Preterm Birth
Vulnerability to preterm delivery may be traced to not only exposure to stress & infection during pregnancy, but host response to stress & infection (e.g. stress reactivity & inflammatory dysregulation) patterned over the life course (early programming & cumulative allostatic load)
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Preterm Birth &Maternal Ischemic Heart Disease
Kaplan-Meier plots of cumulative probability of survival without admission or death from ischemic heart disease after first pregnancy in relation to preterm birth
Smith et al Lancet 2001;357:2002-06
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Improving Maternal & Child Health in America:A Life Course Perspective
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Improving Maternal and Child Health in America:A Life Course Perspective
To improve maternal and child health in America, you start by improving the health of girls and young women.
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HealthDevelopmentEducational
Development
CommunityDevelopment
Economic Development
CollectiveImpact
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If you want 1 year of prosperity, grow grain. If you want 10 years of prosperity, grow trees. If you want 100 years of prosperity, grow people.
Chinese Proverb
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If you want to grow healthy people, you start by improving the health of girls and young women.
Not a Chinese Proverb
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The definition of insanity is doing the same thing over and over and expecting different results.
Benjamin Franklin
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We must become the change we want to see.
- MOHANDAS GANDHI
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