Download nutrition and lifestyle for a healthy pregnancy and child

Nutrition 526 - 2009
A Framework for Maternal &
Infant Nutrition
Learning Objectives for Today
• Integrate the science of maternal &
infant nutrition into social-ecological
framework
• Apply course learnings in the context of
the maternal & infant population in the
US and the nutrition-related concerns of
this population
Resources
& Biology
Adaptive
Mechanisms
Goals of Reproduction
DNA & metabolic
programming
Physiologic
responses to
reproduction
& growth
Healthy mother who can
nourish infant & produce
further offspring
Access to Food
Knowledge &
Skills
Support: basic needs,
health care,
cultural/social
Behavioral
responses
Optimal growth &
development of offspring
Questions to Consider…
• Given individual variations in the physiology of
pregnancy and infancy, what ranges of nutrient intake
best support optimal outcomes? (and what are those
optimal outcomes?)
• What are the best indices of nutritional status in
pregnancy and infancy?
– individual
– population
• What services & systems best promote nutritional
health in pregnancy and infancy?
– individual
– population
Social-Ecological Model for Determinants of
Access to Resources & Nutrition Behaviors
Structures, Policies, Systems
Local, state, federal policies and laws
Institutions
Rules, regulations, policies &
informal structures
Community
Social Networks, Norms, Standards
Interpersonal
Family, peers, social networks,
associations
Individual
Knowledge, attitudes,
beliefs
Individual - Pregnancy
• Physiology and Psychology of Pregnancy
• Maternal Preconceptual status
– Inter-generational programming
• Diet in pregnancy: energy/weight gain, macro
& micronutrients
• Behaviors that impact nutritional status
–
–
–
–
Substances: alcohol, caffeine, tobacco, drugs
Physical activity
Oral health
Pregnancy intendedness
• Stage of development: adolescence
• High risk situations: GDM, PIH,
Intrapersonal/Community
• Social and cultural environments
• Support from friends and family
• Health and nutrition care providers
Institutional
• Hospital breastfeeding & formula
policies
• Child Care policies
• School policies for pregnant and
parenting teens
• Worksite lactation policies
Policy & Environment
• Nutrition Assistance Programs for
pregnancy, lactation and early
childhood.
• Insurance policies for lactation support
Maternal-infant dyad
A Public Health Approach to
Maternal and Infant Health
• Assessment
• Policy Development
• Assurance: Surveillance and monitoring
progress towards goals
Assessment
• Pregnancy population characteristics
• Maternal health indicators
• Infant health indicators
In 2007
• 4,317,119 births highest number ever
registered for the US
• general fertility rate
increased by 1 percent
in 2007, to 69.5 births
per 1,000 women aged
15–44 years, the highest
level since 1990
National Vital Statistics Reports. 2009; 57:12
National Vital Statistics Reports. 2009; 57:12
Percentage of all births to unmarried women by age of mother, 1980 and 2007
In 2007, 40% of all US births were to unmarried women
National Center for Health Statistics, National Vital Statistics System.
Percentage of Parents Who Were Married or Cohabiting
at Birth of First Child, by Race/Ethnicity and Sex
MMWR; September 15, 2006 / 55(36);998
Population Indicators & Trends
for Maternal Health
•
•
•
•
•
•
Pre-conceptual indicators
Weight gain
Diabetes in pregnancy
Pre-eclampsia
Cesarean delivery
Maternal death
Weight Gain During Pregnancy: Reexamining the Guidelines, IOM. 2009
Per birth certificate – includes all diabetes in pregnancy
Ferrara. A. Diabetes Care. Jul 2007
Ferrara. A. Diabetes Care. Jul 2007
African American and White Women Who Died of
Pregnancy Complications,* United States
* Annual number of deaths during pregnancy or within 42 days after delivery, per 100,000
live births.
† The apparent increase in the number of maternal deaths between 1998 and 1999 is the
result of changes in how maternal deaths are classified and coded.
Source: CDC, National Center for Health Statistics.
Risk of Maternal Death
• The risk of death for African American women
is almost four times that for white women.
• The risk of death for Asian and Pacific
Islander women who immigrated to the
United States is two times that for Asian and
Pacific Islander women born in the United
States.
• The risk of death is nearly three times greater
for women 35–39 years old than for women
20–24 years old. The risk is five times greater
for women over 40.
Population Indicators of Infant
Health
• Infant mortality
• Birthweight
• Gestational age
Infant Mortality
• Infant mortality rate – Deaths of infants
aged under 1 year per 1,000 or 100,000 live
births. The infant mortality rate is the sum of
the neonatal and postneonatal mortality rates.
• Neonatal mortality rate – Deaths of infants
aged 0-27 days per 1,000 live births. The
neonatal mortality rate is the sum of the early
neonatal and late neonatal mortality rates
• Postneonatal mortality rate – Deaths to
infants aged 28 days-1 year per 1,000 live
births.
http://www.chipublib.org/004chicago/disasters/infant_mortality.html
Infant Mortality
• Sensitive indicator of community health
because reflects influences by various social
factors
– E.g. environment (housing, sanitation, safe food
and water)
• Historically decrease in infant mortality
associated with improvements in living
conditions and health services
INDICATOR HEALTH2: DEATH RATES AMONG INFANTS
BY RACE AND HISPANIC ORIGIN OF MOTHER, 1983–2004
http://mchb.hrsa.gov/mchirc/chusa_05/healthstat/infants/0307iimr.htm
Muntaner, C et al. ECONOMIC INEQUALITY, WORKING-CLASS
POWER,SOCIAL CAPITAL, AND CAUSE-SPECIFIC
MORTALITY IN WEALTHY COUNTRIES. International Journal of Health
Services, Volume 32, Number 4, Pages 629–656, 2002
• “In summary, the rates of low birth weight and
infant deaths from all causes were lower in
those countries with more voter turnout, more
left votes, more left members of parliament,
more years of social democratic government,
more women in government, a stronger social
pact and various aspects of the welfare state,
and low income inequality, as measured in a
variety of ways.”
Health Affairs, Vol 23, Issue 5, 2004
Birthweight
INDICATOR HEALTH1: PERCENTAGE OF INFANTS BORN WITH LOW
BIRTHWEIGHT BY MOTHER'S RACE AND HISPANIC ORIGIN, 1980–
2005
http://www.childstats.gov/americaschildren/health1.asp
Defining Small for Gestational Age (SGA) and Large for
Gestational Age (LGA)
Distribution of Births, by Gestational Age --- United States, 1990 and 2005
MMWR, April 2007
LBW Rate
(%)
African
Americans
Asians
Premature Infant
Birth Rate Mortality
(%)
Rate
(%)
13.4
17.7
13.5
7.8
10.4
4.6
Native
Americans
Whites
7.2
13
9.7
6.9
11
5.7
Hispanics
6.5
11.6
5.4
NGA Center for Best Practices, June 2004
Policy approach
• Access to food
– Individual maternal-infant
dyad
– Community based
– Public health and health
services
• Knowledge and beliefs
– individual
– Family, community
– Public health and health
services
Determinants of infant feeding
practices
• Maternal employment
• Health sector activities
• Commercial availability and promotion
of processed milks and cereals
• Urbanization vs.. modernization
• Poverty and maternal nutrition
• Perceived insufficiency of breast milk
History
• Child welfare movements became
noticeable in industrialized countries
(U.S. and Western Europe
– “Political, economic, and humanitarian
motivations all converged to reduce the
large wastage of child life”
History
• World War 1 and 2
– Recruits unfit for service
– “weaklings”
History
• Child welfare movements directed
toward general hygiene for disease
prevention, dietary improvements, and
antepartum care
– Infant Stations: to provide clean milk,
instruct new mothers on child/infant care,
encourage breastfeed
– Innovative approach in 1908 establishment
of Division of Child Hygiene in NYC
Child Hygiene Bureau NYC
•
•
•
•
Tracked from register of live births
Home nursing visits
Education on infant care
Milk stations
– “there were 1200 fewer deaths when
comparable to previous summer”
Policy Development: Poor
Pregnancy Outcomes are Costly
• Medicaid finances 40% of annual births
in the US and pays for 50% of hospital
stays for premature and LBW.
– Medicaid-funded deliveries represented
45.6% of births in WA in 2003.
• The care cost for children with one of 17
common birth defects is $8 billion per
year in the US.
Top Three “Best Practices” to Improve Birth
Outcomes and Reduce High Risk Births
(NGA, June 2004)
• Improve access to medical care and health
care services
• Encourage good nutrition and healthy
lifestyles
–
–
–
–
Eating healthy foods
Taking folic acid
Harmful substances
Violence
• Reduce use of harmful substances
O’connor J et al. Health Promotion Practice, (1) 2005
Assurance: Healthy People
2010 Goals Related to
Maternal and Infant & Nutrition
Reduce low birth weight (LBW) and
very low birth weight (VLBW).
Reduction in Low and
Very Low Birth Weight
Low birth weight (LBW)
Very low birth weight
(VLBW)
1998
Baseline
Percent
7.6
1.4
2010
Target
5.0
0.9
Reduce preterm births
Reduction in
Preterm Births
1997
Baseline (%)
2010
Target (%)
Total preterm
11.4
7.6
Live births at 32 to 36
weeks of gestation
9.4
6.4
Live births at less
than 32 weeks of
gestation
1.9
1.1
Reduce the occurrence of spina bifida
and other neural tube defects (NTDs)
• Target: 3 new cases per 10,000 live births.
• Baseline: 6 new cases of spina bifida or
another NTD per 10,000 live births in 1996.
Increase the proportion of pregnancies
begun with an optimum folic acid level.
Increase in Pregnancies
Begun With Optimum
Folic Acid Level
1991–94
Baseline*
2010
Target
Consumption of at least
400 μg of folic acid each
day from fortified foods or
dietary supplements by
nonpregnant women aged
15 to 44 years
21%
80%
161 ng/ml
220 ng/ml
Median RBC folate level
among nonpregnant
women aged 15 to 44
years
Increase abstinence from alcohol,
cigarettes, and illicit drugs among
pregnant women
1996–97
Baseline %
2010
Target %
86
94
Binge drinking
99
100
Cigarette smoking†
87
98
Illicit drugs
98
100
Increase in Reported
Abstinence in Past
Month From
Substances by
Pregnant Women*
Alcohol
Smoking
Increase the proportion of mothers
who breastfeed their babies
Increase in Mothers
Who Breastfeed
1998
Baseline (%)
2010
Target (%)
In early postpartum
period
64
75
At 6 months
29
50
At 1 year
16
25
Increase smoking cessation during
pregnancy
• Target: 30 percent.
• Baseline: 12 percent smoking cessation
during the first trimester of pregnancy in 1991
(age adjusted to the year 2000 standard
population).
Reduce growth retardation among low
income children under age 5 years
• Target: 5 percent.
• Baseline: 8 percent of low-income children
under age 5 years were growth retarded in
1997 (defined as height-for-age below the
fifth percentile in the age-gender appropriate
population using the 1977 NCHS/CDC growth
charts;31 preliminary data; not age adjusted).
Reduce iron deficiency among young
children and females of childbearing age.
1988–94
Baseline (%)
2010
Target (%)
Children aged 1 to 2
years
9
5
Children aged 3 to 4
years
4
1
Nonpregnant females
aged 12 to 49 years
11
7
Reduction in Iron
Deficiency*
Reduce anemia among low-income
pregnant females in their third trimester
• Target: 20 percent.
• Baseline: 29 percent of low-income
pregnant females in their third trimester
were anemic (defined as hemoglobin <
11.0 g/dL) in 1996
Anemia Rates - 1996
African American, non-Hispanic
American Indian/Alaska Native
Asian/Pacific Islander
Hispanic
White, non-Hispanic
44%
31%
26%
25%
24%
Population vs.. individual