Childhood Matters Health and Early Childhood Experiences Michael

Childhood Matters: Health and Early Childhood Experiences Michael Gardner MD, MPH Hillcrest Chairman and Professor of Obstetrics and Gynecology School of Community Medicine Jennifer Hays-Grudo, Ph. D George Kaiser Family Foundation Chair in Community Medicine Professor of Internal Medicine School of Community Medicine

Welcome to the womb…

You really can blame your mother?

Developmental Origins of Adult Health and Disease (DOHa. D) � Barker hypothesis (Barker & Osmond, 1986; Barker, 1995) ◦ Fetal undernutrition associated with adult obesity, CVD and type II diabetes (Law et al. , 1992; Sayer et al. , 2004) ◦ Fetal undernutrition + rapid “catch-up growth” (Ong, 2006; Stettler et al. , 2003, 2005) � Thrifty phenotype (Hales & Barker, 2001) ◦ Adaptive response for deprived pretnatal environment maladaptive for postnatal environment � Developmental Origins of Adult Health and Disease (DOHa. D) (Gluckman et al 2005; Taylor & Poston, 2007) ◦ Fetal environment either nutritionally deprived or over-rich increases risk for child and adult obesity and its sequelae (Catalano, 2003; Oken & Gillman, 2003; Ehrenberg et al. , 2004)

Barker Hypothesis Based on medical archives from Preston, Hertfordshire, and Sheffield, England 16, 000 men and women born in Hertfordshire, 1911 - 1930: ● 2 -fold increase in coronary heart disease from largest to smallest BW ● Impaired GT increased from 14% to 40% Barker, et al Clin Sci 1998; 115: 118

Death Rates From Coronary Artery Disease According to Birthweight

Prevelance of Type II DM and Impaired Glucose Tolerance in Men Age 59 -70

The Nurses Health Study ● 121, 701 RNs aged 30 - 55 yrs, followed since 1976 ● BW self-reported, validated by birth certificate Rich-Edwards, et al BMJ 1997; 315: 396

The Nurses Health Study < 2269 g 2268 -2495 g 2496 -3175 g 3176 -3856 g 3857 -4536 g ≥ 4537 g CAD MI Stroke 1. 32 1. 15 1. 02 (ref) 0. 92 0. 68 1. 29 0. 95 0. 92 (ref) 0. 92 0. 68 2. 29 1. 38 1. 25 (ref) 0. 99 0. 66 Rich-Edwards, et al BMJ 1997; 315: 396

Thrifty Phenotype Hypothesis During periods of starvation, the fetus reduces insulin secretion, and increases peripheral insulin resistance, thus directing more glucose to the brain and heart, and less to skeletal muscle, etc. Hales and Barker Diabetologica 1992; 35: 595

What happens inside matters outside �Antenatal stress associated with: �Decreased cognitive function ◦ Quebec Ice Storm -1998 - loss of electricity & water for up to 5 weeks �Children had lower MDI scores �Lower language development scores �These held when controlling for Ob complications, birth weight , post partum depression (La. Plante et al, 2004) � Maternal exposure to traumatic events associated ◦ Schizophrenia (OR – 1. 5 in cohort from Dutch famine) ◦ Depression in adulthood with:

Chinese Famine Rate of Schizophrenia Year of birth 1959 Adjusted risk P 0. 89 (0. 78 -1. 03) 0. 13 1960 2. 30 (1. 99 -2. 65) <0. 001 1961 1. 93 (1. 68 -2. 23) <0. 001 1962 0. 95 (0. 87 -1. 04) 0. 28 Proportion of familial cases unchanged (17 -18%) St. Clair, et al JAMA 2005; 294: 557

Childhood behaviors – Mom’s input �In pregnant women in the top 15% of symptoms of anxiety at 32 weeks ◦ Children had double the risk of behavioral problems at age 4 and 7 ◦ Higher risk for ADHD, depression or conduct disorders ◦ Attributable risk may be as high as 15% ◦ If true – economic consequences for special education and even incarceration are stunning ◦ annual societal ‘‘cost of illness’’ for ADHD is estimated to be between $36 and $52 billion – prenatal stress accounting for $5 -7 billion per year

Pay attention Oklahoma!

How? � Epigenetic modifications represent a potential way that “metabolic programming” occurs � Alteration in the hypothalamic-pituitary-adrenal axis involving: ◦ Mobilizing energy stores ◦ Response to stress ◦ Inhibiting inflammatory responses during stress � Post natal stress is cumulative with prenatal stress leading to increased vulnerability to stressors � Prenatal stress can lead to impaired fetal growth � Attention disorders and increased anxiety observed

Metabolic “Programming” via Genetic Imprinting ● Imprinting turns gene off ● Gene dosage effect- only one gene operational ● Some imprinting reflects gender of transmitting parent ● Many imprinted genes involve metabolism i. e. Igf 2 , Igf 2 r, H 19

Programmed to be ill?

Tulsa - We’re Number 1!! �Statistics published in Newsweek �Tulsa, Oklahoma Smokers: 24. 6% Cigarettes per day: 16. 2 Tried to quit with gum: 26. 9% Tried to quit with patch: 32. 8% Tried to quit with support program: 7. 4%

Smoking in Pregnancy �Decreased fetal growth �Increase in Preterm Birth �Increase in placental abruption

Children Born with IUGR (< 2. 5 K): ↓ Nephron number Fewer glomeruli ↓ Renal volumes Adult glomeruli : 1, 400, 000 / kidney in controls 700, 000 / kidney in HTN Rostand Nephol Dial Transplant 2003; 18: 1434

Smoking effects �Children exposed to tobacco prenatally: ◦ Decreased memory skills at age 6 ◦ Deficits in auditory processing �Effects more pronounced then children who were exposed prenatally only to marijuana smoking (those children have decreased “executive function”)

Alcohol �Fetal Alcohol Syndrome – associated with 6 or more drinks per day �Leads to neurologic impairment �Post natal growth restriction �Microcephaly

Alcohol – other effects �alcohol ingestion during pregnancy represents a risk factor in terms of later alcohol-related problems in offspring �hypothesis that low to moderate levels of maternal ethanol intoxication during late pregnancy set the opportunity for fetal learning about ethanol

Meth exposure �Meth-exposed children scored lower on measures of visual motor integration, attention, verbal memory and long-term spatial memory �children exposed to Meth prenatally exhibit smaller subcortical volumes

Maternal Obesity �Higher rates of macrosomia �Higher rates of pregnancy induced hypertension �Higher rates of Gestational Diabetes (a precursor for Type 2 DM)

DULCE Program �Provides culturally competent group prenatal care for Diabetic mothers �Education emphasizes diet and life style changes (i. e. just a 20 minute walk a day can smooth out blood sugars) �Teaches self reliance in managing DM �Early review of findings shows a decrease in LGA babies in the Group prenatal care as compared to

SUMMARY ●The intrauterine environment exerts a permanent influence on postnatal metabolism and growth ●The mother’s fetal life can affect the development of her own offspring ●Influential factors include calories, content of diet, micronutrients, stressors

Welcome to your childhood…

Poverty, children and health: Oklahoma

Two complementary theories �Critical periods (latency model) ◦ Barker hypothesis ◦ Organogenesis �Fewer beta cells in pancreas – type 2 diabetes �Fewer nephrons - hypertension �Cumulative experiences (pathways model) ◦ Allostasis and allostatic load ◦ Behavioral responses

Poverty and health Childhood SES Critical periods Adult SES Accumulation of insults Childhood health Adult health Conroy K et al. JDBP 2010; 31: 154 -160

Allostasis and Allostatic Load The stress response and development of allostatic load are illustrated. Perception of stress is influenced by one’s experiences, genetics, and behavior. When the brain perceives an experience as stressful, physiologic and behavioral responses are initiated leading to allostasis and adaptation. Over time, allostatic load can accumulate, and the overexposure to neural, endocrine, and immune stress mediators can have adverse effects on various organ systems, leading to disease. Mc. Ewen 1998

Let’s look at that again

Adverse Childhood Experiences (ACE) study � Felitti V, Anda R et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. Am J Prev Med 1998; 14: 245 -258. � 9, 508 Kaiser-Permanente adults � 7 categories of childhood exposure ◦ Abuse: psychological, physical, sexual ◦ Dysfunction: substance abuse, mental illness, domestic violence, criminality � 10 health risk factors ◦ Smoking, obesity, inactivity, depressed mood, suicide attempts, alcoholism, drug abuse, parenteral drug abuse, >50 sexual partners, history of STDs. � Disease conditions: ◦ Ischemic heart disease, cancer, stroke, COPD, diabetes, hepatitis, skeletal fractures, general health rating

ACE results � Childhood behaviors stressors linked to adult health risk Stressors Risk Factors 0 >4 0 56% 1% >4 14% 7% � Childhood stressors linked to disease conditions (OR) diabetes (1. 6), COPD (3. 9), fractures (1. 6), hepatitis (2. 3), self-rated poor health (2. 2) � Strong dose-response relationship between number of childhood stressors and each of 10 behavioral RFs (p<. 05) and for heart disease, cancer, COPD, hepatitis, fractures, poor self-rated health (not for stroke or diabetes).

More recent follow-up At least 1 ACE was reported by 64% of respondents. For persons with ≥ 4 ACEs, the risk of panic reactions, depressed affect, anxiety, and hallucinations were increased 2. 5 -, 3. 6 -, 2. 4 and 2. 7 -fold, respectively The mean number of comorbid outcomes in the study sample was 2. 1 (range: 0– 14); means are adjusted for age, sex, race, and educational attainment. The trend in the means is significant (P<0. 0001); vertical error bars represent 95% confidence intervals Anda et al Eur Arch Psychiatry Clin Neurosci (2006) 256 : 174– 186

Implications of ACE Study “Clearly, further research and training are needed to help medical and public health practitioners understand how social, emotional, and medical problems are linked throughout the lifespan. Such research and training would provide physicians with the confidence and skills to inquire and respond to patients who acknowledge these types of childhood exposures. The magnitude of the difficulty of introducing the requisite changes into medical and public health research, education, and practice can be offset only by the magnitude of the implications that these changes have for improving the health of the nation. ” Felitti et al. . Am J Prev Med 1998; 14: 245 -258.

Health and stress in Tulsa families ◦ Health issues Tulsa Educare – 2 sites �Allergies Yearly parent interviews at �Child’s health �“What happened to you last year” – 18 items �Asthma �Eczema �Obesity (0) ◦ 4 categories of stressors 247 parents �Financial Interviews conducted by �Relationship family support specialists �ACE Data analyzed for links to �Life Changes child health

Preschool health by demographics Total No health At least one issue Male 141 (57. 1%) 101 (59. 8%) 40 (51. 3%) Female 106 (42. 9) 68 (40. 2%) 38 (48. 7) 2. 5 (1. 2) 2. 5 (1. 3) 2. 3 (1. 1) Race White 27 (10. 9%) 17 (10. 1%) 10 (12. 8%) Black 94 (38. 1%) 50 (29. 6%) 44 (56. 4%) Biracial 17 (6. 9%) 11 (6. 5%) 6 (7. 7%) Other* 109 (44. 1%) 91 (53. 8%) 18 (23. 1%) Ethnicity Hispanic 105 (42. 5%) 86 (50. 9%) 142 83 (49. 1%) *95 of the 105 Hispanic parents selected race as “other” Non- p health issue Gender Age: M (SD) X 2 19 (24. 4%) 59 (75. 6%) 1. 6 0. 211 1. 1 0. 255 22. 0 <0. 001 15. 4 <0. 001

Family stress and child health 81% of healthy children had at least one stressor (M=2. 6 [SD=2. 4]) 95% of children with a health problem had at least one stressor (M=3. 5 [SD=2. 3]) (all p values < 0. 05)

Health problem by stress category � Children 90 80 70 60 50 40 0 30 >1 20 10 Fi na n ci al AC R el E at io ns hi p C ha ng e 0 with asthma, allergies and eczema were more likely to have experienced a family stress in the past year � Children with health problems were more likely to have stressors from multiple categories (2. 1) than healthy children (1. 5)

Tulsa Children’s Project � Based at Tulsa Educare � Community-based participatory research � Multiple partners � Interdisciplinary design � Highly integrated set of interventions � Funded by George Kaiser Family Foundation http: //youtu. be/3 AKYdr 2 VGxo

TCP Partners Annie Van Hanken Monica Basu Caren Calhoun, Vicki Wolfe Master Teachers Ruth Slocum Elizabeth Miranda GKFF Tulsa Educare TC P FCS Julie Miller-Cribbs Natalie O’Reilley Trishia Pratt Candice Weed Harvard CDC UTAustin OU SCM OU SW Jack Shonkoff Bill Beardslee Snow, Yoshikawa OU Educ Diane Horm, Lisa Monroe Chris King Bob Glover Jennifer Hays-Grudo Jerry Root Juell Homco

Intervention Model Children prepared to succeed in school (foundation for life-long success) Nutrition Social. Emotional Health Physical activity Edu. Careers: Adult Education and Workforce Training h Ed u Medical Home alt Lowopportunity communities Early Childhood Education He Children (0 -5) enrolled in Tulsa Educare ca tio n Lowincome families Healthy Competent Children in Healthy Competent Families Parents actively improving their own & their children’s life circumstances Economic security Reduction in intergenerational poverty Current Situation Intervention Short-term outcomes Long-term outcome

Integrated components �Improve quality of classroom experience ◦ Enhance curriculum and ◦ Professional development for teachers and staff �Provide opportunities for parents ◦ Adult education ◦ Workforce training �Promote physical health ◦ Health promotion for parents and staff ◦ Improved access to care through on-site clinic

Early Childhood Education � Developed and implemented new curriculum – Catherine Snow from Harvard Graduate School of Education � Conducted monthly full or half-day professional development sessions with master teachers and Harvard consultants � Assisted teachers in developing plans for improved outdoor play program Expected long-term outcomes: Øimproved language skills in children Øimproved effectiveness in teachers

Health and Health Promotion � Dr. Charlie Homer/NICHQ coaching � Increased clinic hours � Hired bilingual staff � Health promotion ◦ Weekly yoga & Zumba classes (parents) ◦ Bi-monthly yoga classes (staff) ◦ Monthly parent nutrition “make and take” classes ◦ Monthly health workshops ◦ RECESS instructors in class Expected long-term outcomes: ØIncrease utilization of clinic within community ØImproved health and fitness in Educare community

Edu. Careers: adult education and workforce training for parents � Three options for ◦ Nursing cohort: 9 ◦ Adult Education parents: � ESL: 30 � GED: 8 ◦ Ind’l Career Coaching: 4 � Established partnerships: ◦ TCC and TTC ◦ Workforce Oklahoma ◦ Union Public Schools � Support meetings, gas cards, incentives, child care Family Literacy class Expected long-term outcomes: ØIncreased earned income/career opportunities in parents ØIncreased educational achievement in both generations

Nursing cohort � 9 of 9 passed certification exam for CNA � 8/9 completing CNA III classes at TCC � 7/9 passed first block of LPN classes (Medical Terminology, Anatomy & Physiology 1 and 2) with A averages � Will start clinical blocks Fall 2011

Mental health � Emphasized socioemotional development in curriculum � Taught teachers to recognize and address parental depression (Bill Beardslee’s program Family Connections) � Built relationships with Educare teachers, staff, parents and community � Assessed staff perceptions of Educare (physical, socioemotional safety in variety of contexts) � Trained nursing cohort in life skills (building relationships, solving problems, resolving conflict, etc. ) � Provided additional mental health support for parents and children as appropriate (K. Coon) Expected long-term outcomes: ØImprove interactions among teachers, parents, peers & children ØReduce negative impact of depression on children ØReduce staff absences and turnover

Welcome to your future…

tulsa county 2000 median income: $41, 666 gini coefficient denmark eur. union canada usa oklahoma mexico tulsa county swaziland city of tulsa peru namibia 24. 7 31. 0 32. 1 45. 0 46. 1 47. 4 50. 4 52. 0 76. 0 Data from the US Census Bureau and the CIA Factbook.

Social determinants of health The World Health Organization Commission defined social determinants of health as the conditions in which people are born, grow, live, work and age, including the health system. ” “The structural determinants and conditions of daily life constitute the social determinants of health and are responsible for a major part of health inequities between and within countries” (WHO Commission on Social Determinants of Health, Final Report, 2008). WHO Commission on Social Determinants of Health, final report, 2008.

Interventions to address SDH l l l Downloading: what do we know? (health outcomes tied to SDH: education and income) Seeing fresh: what are we not seeing? (programs don’t address root causes, not coordinated) What do we sense is needed? (partners, communication, trust) What are we called we do? (build relationships, develop organic programs) What would it look like? (user friendly, responsive) Let’s try it.

Usual approach to health problems values governments insurers health care churches Typical Disciplines family built environment schools genes Clinical medicine Behavioral science Public health Nutrition Exercise science behavior Individual physical resources Environment Systems retailers norms Policy Culture workplace school boards regulatory agencies

Ecological model of intervention attitudes government agencies funders Academic Disciplines economic environment health care physical resources churches family Community partners schools Individual retailers built environment Systems Environment norms Policy school boards Culture values Behavioral sciences Clinical medicine Health promotion Education Social work Economics Public health Public policy /law Architecture/ Urban design Marketing & media

TCP: Highly integrated engagement of community partners with common goals Partners Educare admin, staff and parents built environment churches family economic funders attitudes schools environment health school boards Individual physical care values resources vendors government Systems agencies norms Environment Policy Culture Psychologists & social workers Physicians & mental health Clinical medicine & health promotion Education Social work Economics Public policy /law Architecture/ Urban design Marketing & media

Post-natal nutritional programming Gluckman & Hanson, 2004

Developmental Origins of Adult Health and Disease Hypothesis From Mc. Millen & Robinson 2005

Mc. Millen & Robinson 2005