preconception health & health care: a life-course...
TRANSCRIPT
![Page 1: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/1.jpg)
Preconception Health & Health Care:A Life-Course Perspective
Mi h l C L MD MPHMichael C. Lu, MD, MPHAssociate Professor
Department of Obstetrics & GynecologyDavid Geffen School of Medicine at UCLA
Department of Community Health SciencesUCLA School of Public Health
August 3, 2010
![Page 2: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/2.jpg)
Why Why Preconception Care?p
![Page 3: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/3.jpg)
Why Preconception Care?
Early prenatal care is too lateEarly prenatal care is too late.
![Page 4: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/4.jpg)
Early Prenatal Care Is Too LateEarly Prenatal Care Is Too LateTo Prevent Some Birth Defects
The heart begins to beat at 22 days after conceptionThe heart begins to beat at 22 days after conceptionThe neural tube closes by 28 days after conceptionThe palate fuses at 56 days after conceptionCritical period of teratogenesis – Day 17 to Day 56
![Page 5: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/5.jpg)
Early Prenatal Care Is Too LateEarly Prenatal Care Is Too LateTo Prevent Implantation Errors
Norwitz ER, Schust DJ, Fisher SJ. Implantation and the survival of early pregnancy. N Engl J Med. 2001 Nov 8;345(19):1400-8.
![Page 6: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/6.jpg)
Early Prenatal Care Is Too Late yfrom A Life-Course Perspective
A way of looking at life not as disconnected A way of looking at life not as disconnected stages, but as an integrated continuum
![Page 7: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/7.jpg)
Early Programming
![Page 8: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/8.jpg)
Barker HypothesisBarker HypothesisBirth Weight and Coronary Heart Disease
1.5
1
1.25Age Adjusted Relative Risk
0.75
1
0.25
0.5
0<5.0 5.0-5.5 5.6-7.0 7.1-8.5 8.6-10.0 >10.0
Birthweight (lbs)Birthweight (lbs)
Rich-Edwards JW, Stampfer MJ, Manson JE, Rosner B, Hankinson SE, Colditz GA et al. Birth weight and risk of cardiovascular disease in a cohort of women followed up since 1976. Br Med Jr 1997;315:396-400.
![Page 9: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/9.jpg)
Barker HypothesisBarker HypothesisBirth Weight and Hypertension
170
51
mm
Hg)
165
Pres
sure
(m
160
Syst
olic
P
155
<=5.5 5.6-6.5 6.6-7.5 7.6-8.5 >8.5Birthweight (lbs)Birthweight (lbs)
Law CM, de Swiet M, Osmond C, Fayers PM, Barker DJP, Cruddas AM, et al. Initiation of hypertension in utero and its amplification throughout life. Br Med J 1993;306:24-27.
![Page 10: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/10.jpg)
Barker HypothesisBarker HypothesisBirth Weight and Insulin Resistance Syndrome
18
12
14
16 Odds ratio adjusted for BMI
8
10
12
2
4
6
0
2
<5.5 5.6-6.5 6.6-7.5 7.6-8.5 8.6-9.5 >9.5Birthweight (lbs)Birthweight (lbs)
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.
![Page 11: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/11.jpg)
Maternal Stress & Fetal Programming
![Page 12: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/12.jpg)
Prenatal Stress & e a a S ess &Programming of the Brain
Prenatal stress (animal model)Prenatal stress (animal model)Hippocampus
Site of learning & memory formationStress down-regulates glucocorticoid receptorsLoss of negative feedback; overactive HPA axis
Amygdala
Site of anxiety and fearStress up regulates glucocorticoid receptorsStress up-regulates glucocorticoid receptorsAccentuated positive feedback; overactive HPA axis
Welberg LAM, Seckl JR. Prenatal stress, glucocorticoids and the programming of the brain.J Neuroendocrinol 2001;13:113-28.
![Page 13: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/13.jpg)
Prenatal Programming of the Prenatal Programming of the Hypothalamic-Pituitary-Adrenal Axis
Welberg LAM, Seckl JR. Prenatal stress, glucocorticoids and the programming of the brain.J Neuroendocrinol 2001;13:113-28.
![Page 14: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/14.jpg)
EpigeneticsEpigenetics
Gibbs WW. The Unseen Genome: Beyond DNA. Scientific American 2003
![Page 15: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/15.jpg)
EpigeneticsEpigeneticsSame 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
![Page 16: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/16.jpg)
Prenatal Programming of g gChildhood Obesity
![Page 17: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/17.jpg)
Epidemic of Childhood Overweight & Obesity
25
20
25Children 6-18 Overweight
10
15
Perc
en
t
5
10
01976-1980 1988-1994 1999-2002
Black Hispanic Whitep
Source: National Center for Health Statistics, National Health and Nutrition Examination Survey
Note: Estimate not available for 1976-1980 for Hispanic; overweight defined as BMI at or above the 95th percentile ofr the CDC BMI-for-age growth charts
![Page 18: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/18.jpg)
Prenatal Programming ofPrenatal Programming ofChildhood Overweight & Obesity
![Page 19: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/19.jpg)
Prenatal Programming of Childhood e a a og a g o C d oodObesity
Maternal Diabetes & Intrauterine Hyperglycemia
Intrauterine Hyperinsulinemia (Fetal Pancreatic β Cells)β )
Prenatal& PostnatalHyperleptinemia
Preadipocyte Differentiation
Programmed Insulin
ResistanceAdipocyte
Hyperplasia
Hypothalamic Pancreatic β-
Postnatal Hyperinsulinemia
ypLeptin Resistance
βCell Leptin Resistance
HyperphagiaHyperinsulinism
Adipogenesis
![Page 20: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/20.jpg)
C l ti P thCumulative Pathways
![Page 21: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/21.jpg)
Photo: http://www.lam.mus.ca.us/cats/encyclo/smilodon/
![Page 22: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/22.jpg)
Allostasis: Maintain Stability through Change
McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.
![Page 23: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/23.jpg)
Allostastic Load:os as c oadWear and Tear from Chronic Stress
McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.
![Page 24: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/24.jpg)
Stressed vs. Stressed OutStressed Stressed OutStressed
Increased cardiac output
Stressed Out
Hypertension & cardiovascular diseases
Increased available glucose Glucose intolerance &
insulin resistance
Enhanced immune functions
Infection & inflammation
Growth of neurons in hippocampus & prefrontal cortex
Atrophy & death of neurons in hippocampus & prefrontal cortex
![Page 25: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/25.jpg)
Allostasis & Allostatic Load
McEwen BS, Lasley EN. The end of stress: As we know it. Washington DC: John Henry Press. 2002
![Page 26: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/26.jpg)
Rethinking Preterm Birth
![Page 27: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/27.jpg)
Sequelae of Preterm BirthSequelae of Preterm Birth
75%Perinatal Perinatal MortalityMortality
12%
NeurologicNeurologic50%
Term Births
NeurologicNeurologicDisabilitiesDisabilities
Preterm Birth
![Page 28: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/28.jpg)
Racial & Ethnic DisparitiespPreterm Births < 37 Weeks
18
14
16
18Percent of Live Births
17.9
10
12
14
11.5
6
8 Year 2010 Goal
2
4
0African American White
NCHS 2006
![Page 29: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/29.jpg)
Racial & Ethnic DisparitiespVery Preterm Births < 32 Weeks
4 5 P t f Li Si l t Bi th
3.5
4
4.5 Percent of Live Singleton Births
4.05
2.5
3
3.5
1 631.5
2 Year 2010 Goal
1.63
0.5
1
0African American White NCHS 2006
![Page 30: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/30.jpg)
Racial & Ethnic DisparitiespInfant Mortality
14
12
14Deaths Per 1,000 Live Births
13.78
10
4
6 Year 2010 Goal
5.72
4
0African American White
NCHS 2006
![Page 31: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/31.jpg)
Rethinking Preterm BirthRethinking Preterm Birth
Vulnerability to preterm delivery may be traced to not only exposure to stress & infection during pregnancy, but host response to stress & infection (e.g. stress reactivity & inflammatory dysregulation) patterned over the life course inflammatory dysregulation) patterned over the life course (early programming & cumulative allostatic load)
![Page 32: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/32.jpg)
An important objective of preconception care is An important objective of preconception care is to restore allostasis to women’s health before pregnancy
![Page 33: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/33.jpg)
Preterm Birth &Maternal Ischemic Heart Disease
Smith et al Lancet 2001;357:2002-06
Kaplan-Meier plots of cumulative probability of survival without admission or death from ischemic heart disease after first pregnancy in relation to preterm birth
![Page 34: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/34.jpg)
Why Preconception Care?Why Preconception Care?Summary
Early Prenatal Care Is Too LateEarly Prenatal Care Is Too LateTo prevent some birth defectsTo prevent implantation errorsTo restore allostasis quickly enough to optimize fetal programming
![Page 35: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/35.jpg)
Why Preconception Care?
![Page 36: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/36.jpg)
Before, Between, and Beyond PregnancyPregnancy
![Page 37: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/37.jpg)
Put the W Back in MCH
![Page 38: Preconception Health & Health Care: A Life-Course ...poweryourlife.org/wp-content/uploads/2010/08/Dr.-Lu-ppt.pdf · Preconception Health & Health Care: A Life-Course Perspective](https://reader031.vdocuments.us/reader031/viewer/2022022511/5ae30db17f8b9a5b348cf853/html5/thumbnails/38.jpg)
INTERCONCEPTION CARECARE