Life Course Health Development: A Transformative Framework To Improve Children’s Health

1. Life Course Health Development: A Transformative Framework To Improve Children’s Health Neal Halfon, MD, MPH UCLA Schools of Public Health, Medicine, Public Affairs UCLA Center for Healthier Children, Families and Communities National Center for Infancy & Early Childhood Health Policy MCHB-AIM Child & Adolescent Policy Support Center CityMatCH ’08, Albuquerque September 21, 2008

2. Goals of this Presentation • To review the evidence, importance and potential impact of the developmental origins of health and disease • To consider the strategic role that the emerging Life Course Health Development approach can play in • Advancing a progression Health Policy Agenda • Enabling significant Health Systems Reform in the US

3. Take home Points: Power of LCHD • Life Course Health Development (LCHD) is different than a life course approach • LCHD –integrating framework • Connecting the disparate parts of MCH • Connecting MCH to rest of health and human development • Leverages MCH and Positions and Prioritizes MCH policy • Provides a new Operating Logic for Transforming the Health System • Powerful analytic model for solving MCH problems

4. From Lifespan to LCHD • Lifespan models – connect the dots- linking early life to later life • Life stage models – periods of psychological development • Life-course models – are concerned with patterns and pathways that connect the dots between early and later life • Life Course Health Development models- • Connect the dots • Describe the pathways or heath trajectories • Address the mechanisms that determine or influence health trajectories

6. LCHD Where We Have Been

7. Figure 22. Life expectancy at birth and at 65 years of age by sex: United States, 1901-2001 100 NOTE: See Data Table for data points graphed and additional notes. Females 80 SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System. Life Expectancy at birth Males Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004 60 Life expectancy in years 40 Females Life expectancy at 65 years 20 Males 0 1901 1910 1920 1930 1940 1960 1970 2001 1950 1980 1990 Year

8. Life Span Health Span Health / functional Status Performance Span 0 years 20years 80 years

9. Social/Nutritional/Epidemiological/ Developmental Shift • Social Conditions dramatically changes over this time period • Nature, Array, and Prevalence of Risk, Protective and Health Promoting factors • Nutritional Conditions change- high sugar, high fat diets • Types, prevalence, distribution of acute and chronic disease changes dramatically • Developmental expectancies change • Capacity of Medical Care to intervene, modify risk and treat disease

10. The Second Era (Today) The Third Era (Tomorrow) The Evolving Health Care System The First Era (Yesterday) • Focused on acute and infectious disease • Germ Theory • Medical Care • Insurance-based financing • Reducing Deaths • Increasing focus on chronic disease • Multiple Risk Factors • Chronic Disease Mgmt & Prevention • Pre-paid benefits • Prolonging Disability free Life • Increasing focus onachieving optimal health status • Complex Causal Pathways • Investing in population-based prevention • Producing Optimal Health for All Health System 2.0 Health System 1.0 Health System 3.0

11. 2004 National Research Council and Institute of Medicine Report

12. IOM/NRC Definition of Children’s Health (2004) “Children’s health is the extent to which individual children or groups of children are able or enabled to (a) develop and realize their potential, (b) satisfy their needs, and (c) develop the capacities that allow them to interact successfully with their biological, physical, and social environments.” From Children’s Health, the Nation’s Wealth, National Academies Press, 2004.

13. LCHD • Defines Health as a developmental process • Builds upon Ecological and Transactional models of Life Span Development • Utilizes a rapidly Expanding Evidence Base • Life Course Chronic Disease Epidemiology • Neurobiology • Early Intervention Research • Economics of Human Capital Formation • Gene-Environment/ Social Epidemiology

14. Health as a Developmental Process • Health is a developmental process • Health develops across the life course • Health development can be represented by health trajectories • Critical/ Sensitive periods • Gene - Environment – Interaction have different impacts during different periods • Macro and Micro pathways delineate how toxic environments and risky families get under the skin

15. RR Risk Reduction Strategies Risk Factors HP Health Promotion Strategies Trajectory Without RR and HP Strategies Optimal Trajectory RR RR HealthDevelopment RR HP HP HP Protective Factors 0 20 40 60 80 Age (Years) How Risk Reduction and Health Promotion Strategies influence Health Development FIGURE 4: This figure illustrates how risk reduction strategies can mitigate the influence of risk factors on the developmental trajectory, and how health promotion strategies can simultaneously support and optimize the developmental trajectory. In the absence of effective risk reduction and health promotion, the developmental trajectory will be sub-optimal (dotted curve). From: Halfon, N., M. Inkelas, and M. Hochstein. 2000. The Health Development Organization: An Organizational Approach to Achieving Child Health Development. The Milbank Quarterly 78(3):447-497.

16. Fig. From: Lamberts SWJ, van den Beld AW, van der lely A. The endocrinology of aging. Science. 1997;278:419-424.

17. From: Kuh D, Ben-Shlomo Y. A life course approach to chronic disease epidemiology. New York: Oxford University Press. 1997.

18. Pre-school Ready to learn Health Services Appropriate Discipline Reading to child Parent education Emotional Health Literacy Late Preschool Late Infancy Late Toddler Birth Age 6 mo 12 mo 18 mo 24 mo 3 yrs 5 yrs Early Infancy Early Toddler Early Preschool Strategies to Improve Health Development Trajectories Back to Overall Model Family Discord Lack of health services “Healthy” Trajectory Poverty “At Risk” Trajectory “Delayed/Disordered ” Trajectory Graphic Concept Adapted form Neal Halfon , UCLA

19. Risk and protective factors Risk Factors Child Family Community School Protective Factors Child Family Community School Outcome Negative vulnerability Positive resilience

20. LCHD Connecting the Dots

21. Adverse childhood events and adult depression Odds Ratio Adverse Events Chapman et al, 2004

22. Adverse childhood events and adult ischemic heart disease Odds Ratio Adverse Events Dong et al, 2004

23. Adverse childhood events and adult substance abuse % % Dube et al, 2002Dube et al, 2005 Self-Report: AlcoholismSelf-Report: Illicit Drug Use

24. LCHD Actionable Mechanisms for Intervention

25. Cumulative, Programming and Pathway Mechanisms Influence LCHD • Three basic mechanisms influence LCHD • Cumulative - additive effect of multiple risks and protective factors, weathering • Programming - time specific influence of stimulus or insult during a critical or sensitive period on selection, adaptation, compensatory processes • Pathways-chains of (eco-culturally constructed) linked exposures that create a constrained conduit of gene-environment transactions

26. Cumulative SES (birth - 33 yrs) poor health, age 33 % fair/poor health 4 5 6 7 8 9 10 11 12 13 14 15 16 best worst Lifetime SES score Source: Power et al, 1999

27. LCHD Programming

30. Life Course Chronic Disease Epidemiology: Barker Hypothesis • Affiliation: MRC Environmental epidemiology unit in South Hampton • Design: Historical Cohort • Key Finding: Fetal growth and development, and other factors, in first year(s) of life related to cardiovascular and other chronic disease in the fifth and sixth decade

34. Barker HypothesisBirth Weight and Coronary Heart Disease Age Adjusted Relative Risk Rich-Edwards 1997

35. Birthweight and CVD OutcomesNurses’ Health Study Curhan et al., Rich-Edwards et al.

37. Power, 2002 F Power, 2002 M Toschke, 2002 von Kries, 2002 Bergmann, 2003 Toschke, 2003 Wideroe, 2003 Whitaker, 2004 Adams, 2005 Oken, 2005 Reilly, 2005 Al Mamun, 2006 Chen, 2006 F Chen, 2006 M Dubois, 2006 Combined .5 1 5 Odds Ratio Smoking During Pregnancy & Offspring Obesity Pooled AOR 1.46 (1.33, 1.59) Oken et al., unpublished

39. Odds ratio of obesity: breast versus formula fed 0.87 (95% CI 0.85, 0.89) Owen et al, Pediatrics , 2005 (From Gilman)

40. LCHD Programming leads to Latent Effects Long time horizons between exposure and outcomes

41. Cumulative, Programming and Pathway Mechanisms Influence LCHD • Three basic mechanisms influence LCHD • Cumulative - additive effect of multiple risks and protective factors, weathering • Programming - time specific influence of stimulus or insult during a critical or sensitive period on selection, adaptation, compensatory processes • Pathways- chains of (eco-culturally constructed) linked exposures that create a constrained conduit of gene-environment transactions

42. Child Physical Development Parent Investment Family Income Poverty Child Cognitive Development Parent Behavior Financial Hardship Child Social-Emotional Development Parent Distress Neighborhood- and Community-Level Influences Poverty & ECD Parent- and Family-Level Predictors of Income And Hardship Parent Work Status Job Prestige Education Level Parent Marital Status Race-Ethnicity

46. LCHD: Childhood Antecedents of later Childhood and Adult Health Early social and material deprivation (financial, educational, environmental) Prior poor health, fetal nutrition, case-mix Immunologic & physiologic moderators Current poor health/ premature mortality Prior poor physical activity Current poor physical activity Prior adverse behavior Current adverse behavior Current social and material deprivation Source: van de Mheen et al, IJE 1998 From Starfield 02/03

47. LCHD: New Approaches to Old Problems

48. How are LCHD concepts being used • Health System Reform (US) • Aday’s Reinventing Public Health • Breslow’s 3rd Era of Health and Health Care • Snyderman’s Future Medical/Health System analysis • Health System Reform ( Intl) • UK – Acheson Report, Sure Start, Health Development Agency • Canada –CIAR, Major Measurement Strategy focused on curve shifting across the life course • WHO- ECD initiative, Commission on Social Determinants of Health

49. Disease Progression 1 = current practice 2 = current capability 3 = future capability 1 Symptoms Cost 3 2 Years Source: Snyderman R. AAP presidential address: the AAP and the transformation of medicine. Journal of Clinical Investigation. 2004;114(8):1169-1173 (suppl)

50. Traditional medical evaluation and record Prospectiveevaluation and record • Chief complaint • History of illness • Past medical history • Family history • Social history • Physical exam • Diagnostic tests • Assessment and plan • Health profile summary • Current (immediate) Health Status • Health risk analysis • Genetic • Environmental • Lifestyle • 1-year health plan • 5-year health plan • Requires: • Life Span Health Risk assessments • Early detection • Means for prevention/early intervention • Individual health plan • Effective Life course health delivery system • Effective reimbursement Paradigm Shift Source: Snyderman R. AAP presidential address: the AAP and the transformation of medicine. Journal of Clinical Investigation. 2004;114(8):1169-1173 (suppl)