Where Is MCH In Relation to the Life-Course Perspective? Michael C. Lu, MD, MPH Associate Professor Department of Obstetrics & Gynecology David Geffen.

Where Is MCH

In Relation to the Life-Course Perspective?

Michael C. Lu, MD, MPHAssociate Professor

Department of Obstetrics & GynecologyDavid Geffen School of Medicine at UCLA

Department of Community Health SciencesUCLA School of Public Health

National MCH Life Course MeetingOakland, CAJune 9, 2008

Major Disconnects in MCH

Longitudinal Disconnect Contextual Disconnect Methodological Disconnect

Longitudinal Disconnect

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.

Developmental Programming

Programming

The process whereby a stimulus or insult, at a sensitive or ‘critical’ period, has lasting or lifelong impact on health or function.

Barker DJP. Mothers, babies and health in later life. Edinburgh: Churchill Livingstone. 1998.

Prenatal Programming of Childhood Obesity

Maternal Diabetes & Intrauterine Hyperglycemia

Intrauterine Hyperinsulinemia (Fetal Pancreatic β Cells)

Prenatal& Postnatal

Hyperleptinemia

Preadipocyte Differentiation

Adipocyte Hyperplasia

HypothalamicLeptin Resistance

Pancreatic β- Cell Leptin Resistance

HyperphagiaHyperinsulinism

Programmed Insulin

Resistance

Postnatal Hyperinsulinemia

Adipogenesis

Prenatal Programming of Childhood Obesity

Epigenetics

Gibbs WW. The Unseen Genome: Beyond DNA. Scientific American 2003

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

Allostasis: Maintain Stability through Change

McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.

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.

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

Allostasis & Allostatic Load

McEwen BS, Lasley EN. The end of stress: As we know it. Washington DC: John Henry Press. 2002

“Weathering”

The effects of social inequality on the health of populations may compound with age, leading to growing gaps in health status through young and middle adulthood that can affect fetal health.

Geronimus AT (1996)

Contextual Disconnect

Epidemiological Model

Environment

HostAgent

(Parasite)

Multiple Determinants

Evans RG, Stoddart GL. Producing health, consuming health care. Soc Sci Med. 1990;31:1347-63.

Ecological Model

Bronfenbrenner U. Ecology of Human Development: Experiments by Nature and Design. Cambridge MA: Harvard University Press. 1979.

Toxic Environments

MethodologicalDisconnect

Transdisciplinary Research Multidisciplinary Research

researchers from different fields work independently or sequentially, each from his or her own disciplinary perspective, to address a particular research topic

Interdisciplinary Research

entails greater sharing of information and closer coordination among researchers from various fields than occurs in multidisciplinary projects, yet the participants remain anchored in their respective disciplinary models and methodologies

Transdisciplinary Research

researchers work together to develop a shared conceptual framework that integrates and extends discipline-based concepts, theories, and methods to address a common research topic. Transdisciplinary research collaborations are intended to achieve the highest levels of intellectual integration across multiple fields and yield shared conceptual formulations that move beyond the disciplinary perspectives represented by team members.

Stokols D. Toward a science of transdisciplinary action research. Am J Community Psychol. 2006 Sep;38(1-2):63

Community-Based Participatory Research (CBPR)

A collaborative process that equitably involves all partners in the research process and recognizes the unique strengths that each brings. CBPR begins with a research topic of importance to the community with the aim of combining knowledge and action for social change to improve community health and eliminate health disparities

Minkler M, Wallerstein N, eds. Community Based Participatory Research for Health. San Francisco, Calif: Jossey-Bass Publishers; 2003

Praxis

Integration of theory and practice

Now What?

Integration

Integration Longitudinal Integration

Measurements Data Infrastructure

Data linkages Longitudinal studies National Children’s Study

Longitudinal modeling

Contextual Integration Measurements Bias & confounding Multilevel modeling

Interactions Gene-environment

Cumulative risks

Methodological Integration Transdisciplinary Research Community-Based Participatory Research Praxis

Integrated Science of MCH Life Course

Theory Research Practice Policy Education