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 pregnancy
b. Low weight gain during pregnancy
c. Rapid catch-up weight gain in LBW infants
d. 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 t
o learn
Strategies to Improve School Readiness Trajectories
Appropriate Discipline
Poverty
Lack of health services
Family DiscordSocial-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
Individual
Interpersonal
Community
Population
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