Early Life Lasts a Lifetime
Stephen Bezruchka MD, MPH
Depts of Health Services, & Global Health
School of Public Health
University of Washington
Key ideas
Talked here before
-about inequality and worse health outcomes
-about economic growth in rich countries limiting
health improvements
BIG IDEA
Early life (first 1000 days) is when half of
health as adults is programmed
Population Health Concepts
Health has been improving most of the
last century
Health improvements are not shared
equally
Poorer people have poorer health
Early life is most critical period for
health
US WOMEN YEARS LEFT AT AGE 50
haven’t kept pace since 1955
Glei et al. 2010
Population Health Concepts
Health has been improving most of the
last century
Health improvements are not shared
equally
Poorer people have poorer health
Early life is most critical period for
health
QUIZ
If you are a girl aged 15
in which country do you have a
better chance of reaching age 60?
United States or Sri Lanka
Sri Lanka US
Adult Female Mortality 1970-2010
YOUR EARLY LIFE?
Life course health model
DEVELOPMENTAL ORIGINS BIOLOGY
Fetal and subsequent GROWTH
Ovum made maternal grandmother’s
womb
Fertilized ovum (zygote) divides ~42
times to produce newborn
Further ~5 cycles of cell division to
produce adult
Erection to Resurrection
First 1000 days:
9 months in mother
– starting in maternal grandmother
First two years outside
HALF of adult health programmed
SENSITIVE DEVELOPMENT PERIODS
Moore et al. 2003
Early Life Natural Experiments
Hurricane Katrina
HIGH EXPOSURE:
– Pre-term delivery,
– Low Birth Weight
World Trade Center 911
Dutch Hunger Winter
Increase LBW exposure at
periconception and first
two trimesters & PTD
Dutch hunger winter
November 1944-May 1945
Mental disorders
Roseboom et al. 2006
Poor Pregnancy Conditions
Related to entire life history of woman
before she become pregnant
Impacted by parents
Impacted by grandparents
Impacted by previous generations
womb with a view
Poor Pregnancy Conditions
Increased Risk of
EARLY
–
–
–
–
–
–
Pre-term Delivery
Low Birth Weight
Caesarian Section
Infant Mortality
Behavioral Problems
Poor School Performance
LATER LIFE
Earlier reproduction
Cardiovascular Disease
Obesity
Metabolic syndrome
Diabetes
Hypertension
Common Cancers
Early death
Poor Pregnancy Conditions
Increased Risk of
EARLY
–
–
–
–
–
–
Pre-term Delivery
Low Birth Weight
Caesarian Section
Infant Mortality
Behavioral Problems
Poor School Performance
LATER LIFE
Earlier reproduction
Cardiovascular Disease
Obesity
Metabolic syndrome
Diabetes
Hypertension
Common Cancers
Early death
LBW (proxy) associated with
Hypertension
Type 2 diabetes
Obesity, metabolic syndrome
Coronary heart disease
Stroke
Osteoporosis
Depression and psychoses (e.g. schizophrenia)
Age-related cognitive impairments
Chronic renal failure
Altered gonadal responses
Altered immune responses
Overall reduced life expectancy
Seckl, J. R. and M. C. Holmes (2007). "Mechanisms of Disease: glucocorticoids,
their placental metabolism and fetal 'programming' of adult pathophysiology."
Nature Clinical Practice Endocrinology & Metabolism 3(6): 479-488.
MOTHERHOOD
A girl is a mother
from the time of
her own
conception
Differential Exposures
in US Over Lifetime
Lu & Halfon 2003
Intergenerational Stress
Prenatal psychosocial
stress
Cytokine production in women
offspring (34 subjects and 28
comparison) mean age 24, healthy
Pregnancy stress: divorce,
breakup, paternity denial,
marital infidelity, death of
partner, parent, child,
illness in other (cancer, MI,
stroke), financial problems
(loss of house by flooding,
husband unemployed,
foreclosure, MVA,
unmarried (father not
accepted by family),
political refugee
(Entringer et.al. 2008)
IMMUNE SYSTEM TESTING of lymphocytes:
Production: no difference
Activation
in vitro phytohemaglutinin (PHA)
induced cytokine production
Efficacy not tested
PS = Prenatal Stress
PS
CG
IFN interferon
Entringer et. al. 2008
UNICEF League Table of Child Well-Being
Wilkinson & Pickett 2009 Spirit Level
Child Well-Being
Stressful early life on girls
Reach sexual maturity at earlier age
If brought up without a father:
– More likely to become sexually active earlier
– More likely to become pregnant
Likely hormonal prompting, than conscious decision
– If conditions tougher, better to breed early & often,
putting less investment into each child
– If conditions easier, better to wait until you have partner
and make larger investments in fewer children
– BALANCE: quantity vs. quality
Stressful early life on boys
Increases risk taking among young men
– Low-status males with little or no access to females are
to avoid "one-way road to genetic nothingness," they
may have to be aggressive and adopt high-risk strategies
– Rates of violence higher among young men in deprived
areas, and see higher accident rates, other behaviors with
pronounced social gradient
Biological Embedding
Of Childhood Adversity
Etches et al. 2006
UNICEF League Table of Child Abuse Deaths
Rate of Child abuse and Neglect
er 1,000 children (0-17 years), Alaska and U
Only Washington, DC has a higher rate
US Prevalence of Individual
Adverse Childhood
Experiences
Adverse Child Experiences (ACE)
Abuse
– emotional - recurrent humiliation (11%)
– physical - beating, not spanking (28%)
– contact sexual abuse (28% women, 16% men; 22% overall)
Household dysfunction
mother treated violently (13%)
household member was alcoholic or drug user (27%)
household member was imprisoned (6%)
household member was chronically depressed, suicidal, mentally ill,
in psychiatric hospital (17%)
not raised by both biological parents (23%)
Neglect
physical (10%)
emotional (15%)
Felitti et. al.Kaiser San Diego studies
Effect of ACEs on Death Rate
ACE Score and Rates of Antipsychotic
Prescriptions
(Null hypothesis)
Age Group
19-34
35-49
50-64
>=65
50
40
30
20
10
0
0
2
ACE Score
4
12
Prescription rate
(per 100 person -years)
Percent in Age Group
60
10
8
6
4
2
0
0
1
2
3
ACE Score
4
>=5
Life course health model
pathway
LATENT
Conception
cumulative
MEDICAL CARE
impact on
Early Life?
What to do?
Doyle et. al. 2009
Trauma Informed Care
& Adverse Childhood Experiences (ACE)
Chanda K. Aloysius, MBA
Vice President
and
Laureen Young, LMFT
Clinical Supervisor Dena A Coy Residential and Outpatient
Behavioral Services
Southcentral Foundation
National Prevalence of Trauma
• 90% of public mental health customers have been exposed to trauma
(Mueser et al., 2004; Mueser et al., 1998)
• Most have multiple experiences of trauma (Ibid)
• 34-53% report childhood sexual or physical abuse (Kessler et al.,
1995; MHA NY &NYOMH, 1995)
• 43-81% report some type of victimization
(Ibid)
• Boys who witness domestic violence are 2x’s more likely to abuse
their own partners and children when they become adults (Strauss,
Gelles, Smith, 1990)
“Many providers
may assume that
abuse experiences
are additional
problems for the
person, rather than
the central
problem…”
(Hodas, 2004)
Summary
• Prevention is possible:
– To date, prevention studies have explored
whether a specific intervention reduces abuse.
– A more important question is how to create
optimally effective prevention programs
– An integrated prevention model may be more
effective (e.g., linking FWWI, quality birth
experience and improved parenting skills).
Summary
•
-
Trauma Informed Care as an intervention:
Discuss AST and CSR at intake
PTSD screening at intake
Safety groups for PTSD and SUD
Trauma Sensitive Yoga and Prenatal Yoga
Mindfulness, traditional values and healthy
relationships
- Baby massage
Typical
disease approach
Traditional
RISK
FACTORS??
medical
management
Life course birth
DEATH
PREVENTION
Primary
Secondary
tertiary
SOCIETAL HEALTH approach
CHRONIC
DISEASE RISK
PRIMORDIAL
PREVENTION
Trans-generational
Conception
DEATH
Higher Taxes
Social Safety Net
“The legitimate object of
government is to do for a
community of people
whatever they need to have
done, but can not do, at all,
or can not so well do, for
themselves.”
WHAT WOULD WARREN DO?
Don't Lower Corporate
Taxes
Levy Higher Taxes On
The Rich
No Foreign-profit
Repatriation
moral hazard
Curb Speculative Gains
Get Tough On Directors
forfeit five years' pay if
bailed out
Get Rid Of Private
Schools
So rich invest in K-12
Reform Health Care
tapeworm
POLICY PRIORITIES
PAID FAMILY LEAVE
PAID PRENATAL LEAVE
DECREASE GAP BETWEEN RICH AND POOR TO
PAY FOR LEAVE POLICIES
PRENATAL
PAID LEAVE
Chile: 6 weeks mandatory paid prenatal leave
OECD 2009
164 countries have laws saying those who work
are guaranteed paid maternity leave.
only countries that don't
Papua New Guinea
Liberia, Swaziland
United States of America
DEMOCRATIC
CAPITALISM
Crisis
DEMOCRATIC CAPITALISM 3
Crises
After WWII social security & rising standard of
living, employment
1) Inflation in 1970s
DEMOCRATIC CAPITALISM
3 Crises
After WWII social security & rising standard of
living, employment
1) Inflation in 1970s led to unemployment
Volcker shock
2) Public debt
3) Private debt
US Crises of Democratic Capitalism 1970-2010
First CRISIS
Second CRISIS
Third CRISIS
Streeck 2011
Inflation Rates 1970-2010
Ravaillon 2010
Streeck 2011
Harvey 2005
Streeck 2011
Unemployment Rates 1970-2010
Strike Volume 1970-2010
Streeck 2011
Fiscal consolidation,
private debt (% GDP),
1995−2008
Streeck 2011
http://www.phac-aspc.gc.ca/ph-sp/determinants/index-eng.php
Population Health
CAUSAL concepts
Do POORER People
Have POORER PROTOPLASM?
Hegewald et. al. 2007
164 countries have laws saying those who work
are guaranteed paid maternity leave.
only countries that don't
Papua New Guinea
Liberia, Swaziland
United States of America
OECD 2009
Rate of Child abuse and Neglect
er 1,000 children (0-17 years), Alaska and U
Only Washington, DC has a higher rate
QUIZ
If you are a boy aged 15
in which country do you have a
better chance of reaching age 60?
Peru or United States
Peru US Adult Male Mortality 1970-2010