Family Health Services Retreat October 25, 2013

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

11. Allostatic LoadHealth 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 HypothesisBirth 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 Centers for Disease Control and Prevention www.cdc.gov/ace

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

19. Long-term Impacts of Adverse Childhood Experiences Centers for Disease Control and Prevention www.cdc.gov/ace

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

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

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…