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Early Life Lasts a Lifetime: INEQUALITY AND HEALTH

Early Life Lasts a Lifetime: INEQUALITY AND HEALTH. Stephen Bezruchka MD, MPH Depts. of Health Services, & Global Health School of Public Health University of Washington. Agenda. US Vital Signs Explanations Inequality Early life Stress as mediator

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Early Life Lasts a Lifetime: INEQUALITY AND HEALTH

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  1. Early Life Lasts a Lifetime: INEQUALITY AND HEALTH Stephen Bezruchka MD, MPH Depts. of Health Services, & Global Health School of Public Health University of Washington

  2. Agenda • US Vital Signs • Explanations • Inequality • Early life • Stress as mediator • Socioeconomic Gradient: health & health care • Social medicines

  3. KEY MESSAGE All of us in the US have worse health than we should Early life & inequality are major reasons Issues of neglecting early life in US affect us all

  4. US VITAL SIGNS Life expectancy at birth Infant Mortality Low Birth Weight, Pre-Term Birth Maternal Mortality Child Mortality Adult Mortality Life Expectancy at age 50 County life expectancy trends SCALE of health inequities

  5. How Healthy is the US?Health Olympics • Number one Gold • 1-5 _______ • 6-10 _______ • 11-15 _______ • 16-20 _______ • 21-25 _______ • 26-30 _______ • 31+ _______

  6. restricted to UN Countries Life Expectancy (years)

  7. 1st & 4th yr US Medical Student Knowledge of Population Health (2002) Agrawal, J. R., J. Huebner, et al. (2005). "Medical students' knowledge of the U.S. health care system and their preferences for curricular change: a national survey." Acad Med 80(5): 484-8.

  8. PTB % Excluding <22wks Gestation (2004), US & EUROPE MacDorman & Mathews 2009

  9. PRETERM BIRTHS OUTCOMES, US & EUROPE MacDorman & Mathews 2009

  10. % Raphael 2010

  11. Australia, Canada, Japan, Sweden, US Under 5 Mortality 1970-2010 IHME 2011

  12. Australia, Canada, Japan, Sweden, USMaternal Mortality 1970-2010 IHME 2011

  13. Maternal Mortality Olympics (2008)

  14. Health Olympics Age 50 (2006) 5 10 15 20 years 25 30 WHO 2009

  15. FEMALE Life Expectancy Age 50 Trends 1955-2007 Glei et al. 2010

  16. County Life Expectancy 2007 FEMALE MALE Kulkarni et al. 2011

  17. County Life Expectancy 2007 YEARS BEHIND FRONTIER NATIONS FEMALE MALE Kulkarni et al. 2011

  18. County Black Life Expectancy 2007 YEARS BEHIND FRONTIER NATIONS FEMALE MALE Kulkarni et al. 2011

  19. HEALTH INEQUITIES USA France Sweden Netherlands OECD 2006

  20. 66 million Gravlee 2009 Singh 2006

  21. WHY DO WE DIE SO YOUNG? Not personal health-related behaviors Not medical care

  22. Cancer 5 year Survival Rates (%) (dx 2000-2) Verdecchia et al. (2007).

  23. "As dramatic and consequential as medical care is for individual cases and for specific conditions, much evidence suggests that such care is not and probably never has been the major determinant of levels or changes in population health." Pg 4.

  24. HEALTH - Traditional Disease Approach medical intervention PREVENTION Primary Secondary tertiary CHRONIC DISEASE RISK Life course

  25. POPULATION HEALTH • Health has been improving most of the last century, • Health improvements are not shared equally • Health Inequities (poorer people have poorer health) • Early Life: critical for adult health

  26. Health and Social Problems are Worse in More Unequal Countries www.equalitytrust.org.uk • Index of: • Life expectancy • Math & Literacy • Infant mortality • Homicides • Imprisonment • Teenage births • Trust • Obesity • Mental illness – incl. drug & alcohol addiction • Social mobility Source: Wilkinson & Pickett, The Spirit Level (2009)

  27. Deaths attributable to excess income inequality 1 / 3 Kondo et al. 2009

  28. Wilkinson & Pickett 2009 Spirit Level Child Well-Being

  29. DEVELOPMENTAL ORIGINS BIOLOGYFetal and subsequent GROWTH Ovum made maternal grandmother’s womb Fertilized ovum (zygote) divides ~42 times to produce newborn Further ~5 cycles of cell division to produce adult

  30. Normal Severe Maternal Stress Enzyme Deficiency Seckl, J. R. and M. C. Holmes (2007). "Mechanisms of Disease: glucocorticoids, their placental metabolism and fetal 'programming' of adult pathophysiology." Nature Clinical Practice Endocrinology & Metabolism 3(6): 479-488.

  31. Early Life Natural Experiments • Hurricane Katrina • World Trade Center 911 • Dutch Hunger Winter • HIGH EXPOSURE: • Pre-term delivery, • Low Birth Weight • Increase LBW exposure at periconception and first two trimesters & PTD

  32. Dutch hunger winter November 1944-May 1945 Mental disorders Roseboom et al. 2006

  33. Poor Pregnancy Conditions Related to entire life history of woman before she become pregnant Impacted by parents Impacted by grandparents Impacted by previous generations

  34. Poor Pregnancy ConditionsIncreased Risk of • Pre-term Delivery • Low Birth Weight • Caesarian Section • Infant Mortality • Behavioral Problems • Poor School Performance • Earlier reproduction • Cardiovascular Disease • Obesity • Metabolic syndrome • Diabetes • Hypertension • Common Cancers • Early death EARLY LATER LIFE

  35. Z-Scores of Helskini Birth Cohort who had CAD as adults (tracking all hospital admissions 1971-98) CNS Stress-associated Hormone Response

  36. Poor Pregnancy ConditionsIncreased Risk of • Pre-term Delivery • Low Birth Weight • Caesarian Section • Infant Mortality • Behavioral Problems • Poor School Performance • Earlier reproduction • Cardiovascular Disease • Obesity • Metabolic syndrome • Diabetes • Hypertension • Common Cancers • Early death EARLY LATER LIFE

  37. LBW Associated With Hypertension Type 2 diabetes Obesity, metabolic syndrome Coronary heart disease Stroke Osteoporosis Depression and psychoses (e.g. schizophrenia) Age-related cognitive impairments Chronic renal failure Altered gonadal responses Altered immune responses Overall reduced life expectancy Seckl, J. R. and M. C. Holmes (2007). "Mechanisms of Disease: glucocorticoids, their placental metabolism and fetal 'programming' of adult pathophysiology." Nature Clinical Practice Endocrinology & Metabolism 3(6): 479-488.

  38. BIOLOGYof INEQUALITY

  39. DO Poorer people have poorer outcomes with MEDICAL CARE?

  40. Life Course Health Model pathway cumulative LATENT Conception

  41. PRENATAL&PARENTALPAID LEAVE

  42. SOCIETAL HEALTH Approach CHRONIC DISEASE RISK PRIMORDIAL PREVENTION Trans-generational Conception DEATH

  43. GET INVOLVED IN EARLY LIFE ISSUES http://www.dohad2011.org/ http://www.msfhr.org/news/news_blog/2011/06/DOHaD

  44. SUMMARY We neglect early life for all at OUR peril (i.e. we all die young) Not a problem so long as an informed choice

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