Reducing Disparities in Health through Nutrition: The Life Course Theory and Model

Reducing Disparities in Health through Nutrition: The Life Course Theory and Model

Jamie Stang, PhD, MPH, RD, LNUniversity of MinnesotaDivision of Epidemiology and Community Health

Health Equity Quiz

1. On average, which of the following in the best predictor of one’s health?

a. Whether or not you smokeb. What you eatc. Whether or not you are wealthyd. Whether or not you have health insurancee. How often you exercise

Health Equity Quiz

On average, which of the following in the best predictor of one’s health?

a. Whether or not you smokeb. What you eatc. Whether or not you are wealthyd. Whether or not you have health insurancee. How often you exercise

Health Equity Quiz

Chronic stress increases the risk of all of the following, except:

a. Hypertensionb. Obesityc. Sickle cell anemiad. Preterm birthe. Diabetes

Health Equity Quiz

Chronic stress increases the risk of all of the following, except:

a. Hypertensionb. Obesityc. Sickle cell anemiad. Preterm birthe. Diabetes

Health Equity Quiz

True or False? The gap between white and African American infant mortality rates is greater today than it was in 1950.

a. Trueb. False

Health Equity Quiz

True or False? The gap between white and African American infant mortality rates is greater today than it was in 1950.

a. Trueb. False

Quiz

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.

Quiz

One of the critical factors that increases risks for childhood obesity

a. High fat intake diet during pregnancyb. Low weight gain during pregnancyc. Rapid catch-up weight gain in LBW infantsd. Late introduction of solid foods.

What is the Lifecourse Theory and Model?

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

Critical Issues in Lifecourse Theory/Model

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?

Key Concepts of Lifecourse Theory and Model

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

Key Concepts of Lifecourse Theory and Model

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

4 Key Concepts of Lifecourse Theory/Model

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 mo 3 yrs 5 yrs

Read

y to

lear

nStrategies to Improve

School Readiness Trajectories

Appropriate Discipline

Poverty

Lack of health servicesFamily Discord

Social-emotional, Physical Cognitive, Language

function

Lower trajectory: With diminished function

Parent educationEmotional literacy

Strategies for Reducing Health Disparities

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

Lifecourse Theory and Model - Nutrition

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

Community Nutrition Programs in the Lifecourse Theory and Model

S Looney, K Eppig, PHCNPG Digest, 2011.

Improved Pre-pregnancy Weight Status and Gestational Weight Gain among Women

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

Prepregnancy Weight and Birth Defects

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

Weight Gain in Pregnancy

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%)

Actual Weight Gain among US Women

Illustration of Lifecourse Theory

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

Improved Pre-pregnancy Weight Status and Gestational Weight Gain among Women

Data from 1990-2008 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

Improved Pre-pregnancy Weight Status and Gestational Weight Gain among Women

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

Nutrition Concepts of Lifecourse Model

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

Lifecourse Theory and Model - Nutrition

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

Improved Pre-pregnancy Weight Status and Gestational Weight Gain among Women

Data from 1990-2008 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

Improved Pre-pregnancy Weight Status and Gestational Weight Gain among Women

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

Barker HypothesisBirth Weight and Insulin Resistance Syndrome

Odds ratio adjusted for BMI

Barker 1993

Barker HypothesisBirth Weight and Hypertension

Law 1993

Barker HypothesisBirth Weight and Coronary Heart Disease

Age Adjusted Relative Risk

Rich-Edwards 1997

Lifecourse Theory and Model Interventions to Improve Nutrition Before and During Pregnancy

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

Access to Healthy Foods in All Communities

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

Access to Healthy Food in All Communities

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

Access to Healthy Foods in All Communities: Food Deserts

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

Social-Ecological Model

IndividualInterpersonal

CommunityPopulation

Lifecourse Theory and Model Interventions to Improve Access to Healthy Foods in Communities

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

Integrating Nutrition into the Lifecourse Theory and Model of Care

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

Strategies for Reducing Health Disparities

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

Integrating Nutrition into the Lifecourse Theory and Model of Health

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

Intersection of Clinical and Public Health Services to Improve Lifecourse Trajectory

Lifecourse Theory and Model