hserv 482 session 6 human development & early life effects on later health first dissemination...

Hserv 482 Session 6

Human development

&

early life

effects on later health

FIRST DISSEMINATION EXERCISEDue in 2 weeks

LAST CLASS SummarySubjective well-being (SWB), happiness as a national

indicator is culture dependent

SWB has not improved over time or with increasing wealth this past century

SWB correlates with equality, human rights, fulfillment of basic human needs

US SWB has declined since the early 1970s, and the declines have been greater in women

USA does not fare well in most health outcomes in comparison with other rich countries, happiness not doing so well either and trends are in the unfortunate direction

NEXT: EARLY LIFE effects

Summary to hereDefining health, considering what produces it

– Mortality (objective), well-being happiness (subjective)

US not that healthy compared to other countries in many health outcomes, including well-being.

Range of hierarchy (gap between rich and poor) is related to health in a society) and this reflects amount of caring and sharing present there

WHEN DOES HIERARCHY MATTER MOST?

Agenda

Look at comparative data on child health

Fetal development and programming

Infancy and biological embedding

Population health perspective

Intergenerational aspects

impact of early life on adult health?

STUDENT THOUGHTS?

How important?

impact of early lifeon adult health?

STUDENT THOUGHTS?

How to study?

In any discussion 3 questions to ask:

What are the facts?

What are the interpretations of those facts.

What are the presuppositions behind the interpretations.

Making Transition Work for Everyone: Poverty and Inequality in Europe and Central Asia, World Bank 2001

Child Health among rich countries

Collison et. al. 2007 Public Health

BE

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HE

AL

TH

MORE EQUALITY

Child Poverty Olympics (2005)

UN

ICE

F L

eagu

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of

Chi

ld A

buse

Dea

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UNICEF League Table of Child Well-Being

UNICEF League Table of Child Well-Being

UNICEF League Table of Child Well-Being

UNICEF League Table of Child Well-Being

Pickett et. al. 2007

Studies on outcomes in childhoodCDC states (US health 1998) : "A healthy childhood

is a foundation of success and health in later life. pg 46

Infants born to mothers of lower socioeconomic status tended to have poorer health, as measured by their rates of low birth weight and infant mortality."

"Several measures of health status ... indicated that children from lower SES families had worse health status and more risk factors for poor health"

Hispanic ParadoxRoseto issues?

most important factor influencing child health is SES

behaviors can't have much to do with the health of a child, or infant--– they don't smoke, drink, shoot guns (much)

Expect downstream effects from SES:– environmental quality (more exposure to lead among US

poor)– nurturing child rearing environments (fewer in US poor)– poor more likely to undertake adverse health behaviors

• smoking• drinking• injection drug use

AT WHAT LEVEL DOES SES ACT?

BASIC IDEA SO FAR

SES matters for children's health

our children don't seem to be doing so well lately

Next step:

What might this have to do with adult health?– seems obvious that it should, – does what happens in early childhood impact adult

health?

Study fetal programming (life long changes) of adult disease

Biological embedding (after birth)

David Barker in UKCoronary Heart Disease mortality rates correlated

with birth weights – UK archives in Hertfordshire, Preston and Sheffield had

detailed records going to early 1900s– have birth weights, obstetrical records with body

proportions and placenta weights and growth in infancy,

– (birth data from 1911-1930 followed to present)

conditions in early life PROGRAM later effects in adults (fetal origins hypothesis)– animal experiments show that undernutrition

(stress) in utero leads to persisting changes in variety of metabolic, endocrine and immune functions (in later life)

Barker

newborns small at birth (for dates, because they failed to grow, rather than premature), were at risk for adult heart disease

highest prevalence of Type 2 Diabetes in people who were small at birth and obese as adults

studies replicated in US, Finland and South India and see similar association with hypertension, and diabetes (UK, US, Sweden)

have critical periods of fetal development (coincide with rapid cell division), – If lack of nutrients or oxygen (or stress), rate of cell

division is slowed

poor fetal growth (thinness) results in insulin resistance

thin neonate lacks skeletal muscle and fat, but brain is spared (fetus, when stressed, tries to make sure brain gets enough nutrients, sparing muscle)

fetal Glucocorticoids (cortisol) – Fetal cortisol effects cell differentiation

– placenta is barrier to maternal glucocorticoids but can have deficiency in enzyme establishing barrier so get fetal glucocorticoid elevations in response to maternal stress

Barker

Newsweek September 27, 1999

fetal nutritionpoor nutrition (stress) impairs growth during

critical periods of fetal life and permanently affects structure and physiology of endocrine pancreas, liver, blood vessels

fetal nutrition depends on: 1. mother's dietary intakes

2. mother's nutrient stores• sheep studies show that maternal undernutrition in mid-

pregnancy has profoundly different effects on fetal and placenta growth depending on whether mother entered pregnancy with high or low nutritional stores

fetal nutrition3. fetal nutrition depends on

– mother's nutritional state AT TIME OF CONCEPTION• conditions then reflects particular sensitivity of early embryo growth

to concentration of nutrients– in fetus with fast growth trajectory, placenta may consume fetal amino

acids to maintain lactate (energy) production,

– nutrient delivery to placenta– placenta's transfer capabilities

4. Age of mother– mature mothers optimize flow of nutrients to fetus– adolescent mothers may thrive at expense of fetus

5. Hormonal programming (fetus produces cortisol)

WOMB WITH A VIEW

womb with a view

Maternal nutrition (stress) in pregnancySUMMARY

Early pregnancy undernutrition (stress) leads to large placenta

Nutrition (stress) in mid-trimester effect depends on maternal stores (stress) when entered pregnancy– maternal stores conditioned by mother's early life, and

her mother (intergenerational---fetus' grandmother)

Nutrition (stress) in third trimester effect depends on whether fetus is growing rapidly or not – Rapid growth rates could result in placenta consuming

fetal protein to produce lactate energy stores and resulting fetal wasting

Biological embedding Growth in infancy

Growth mainly from development and enlargement of existing cells, rather than addition of new ones

Babies short at birth tend to grow slowly after birth

Low rates of infant weight gain predict CAD in men– (not sure if growth in later childhood can be protective)– low weight gain leads to LV hypertrophy in childhood

and adulthood

Biological embedding of early life experiencesRapid neuronal (brain) cell growth in fetus and by birth have pretty well

all your neurons (Central Nervous System CNS)– Neurons are then "sculpted" ie neuron-to-neuron connections reinforced, others

suppressed

Child's early years spend in unstimulating, emotionally and physically unsupportive environments adversely affects brain development– leads to cognitive, social & behavioral delays– results in acute & chronic stress in school

CNS "talks to" hormone, immune and clotting systems leading to systematic differences in experience of life to increase or decrease resistance to disease via long-term function of vital organs as expression of SES (gradient)

BIOLOGICAL EMBEDDING is effect of human experience on health over life course (Hertzman)

Biological embedding mechanismsHPA axis (hypothalamo pituitary adrenal)

– handling in rats, during early life permanently changes way HPA axis responds over life course (handling reduces total lifetime exposure of corticosterone to brain) (Meany)

– highly reactive rhesus monkeys have higher cortisol (Suomi)• later show more depressive-like behaviors with separation, longer HPA

activation, rapid noradrenergic turnover (related to maternal attachment) which remain stable throughout development & appear heritable (epigenetic)

Baboons (Sapolsky) four factors lead to variation in basal cortisol levels in the wild

1. rank of a baboon2. troop social stability & its enforcement

– lack of violence and coercion

3. animal's experience of rank, stability and enforcement 4. personality and coping styles

Social Emotional Regulationvia early attachmentto a mother figure

Harlow and wire-cloth motherovercame food as need

See quieter stress response, lower cortisol levels whenmonkey in front of motherleading to secure attachment(Suomi)

Gorilla

Bonobo

Orangutan

Gibbon

0

10

20

30

40

50

60

70

Birth 6 mo. 1 2 5 10 15 AdultAge

Synaptic Density

Visual

Auditory

Prefrontal

Synaptic Density

Rivkin, 2000: 70

Summary so far:Health in early childhood patterns SES of the

mother/(father)

Early childhood has profound impacts on adult health

Fetal programming is a major mechanism throughfetal-placenta relationshipendocrine aspects

early growth retardation, and compensatory catch-up later leads to obesity

Biological embedding (early life experiences)

population health perspectivecross-sectional studies like the UNICEF charts,

demonstrate there is a problem, but hard to tease out where it comes from

Ideally: cohort studies, following people from before birth, gathering data at conception, or before– best available is at first ante-natal visit

Birth-onwards cohort studies

prospective cohort studies to look at life course issues,

What matters over various parts of a life, from being a gleam in your

parents' eyes to death?

1958 British Birth Cohort Study

Everyone born in UK (England, Scotland and Wales) in week of March 3-9, 1958 – included more than 17,000 subjects

follow up at age 7, 11, 16, 23, and most recently at 33 years

Impacting health at age 33 years from early childhood?

Latent effects – impacts adult health independent of

intervening experience

Pathway effects

– early life sets trajectories that affect health status over time, such as education

Cumulative effects

– intensity and duration of exposure of unfavorable environments adversely affects health, (usually dose-response)

BirthBirthDeathDeath

Contributions to Self-rated Health at Age 33, 1958 British Birth Cohort

““pathway” factors:pathway” factors:

““latent” factors:latent” factors:

““cumulative” factors:cumulative” factors:

BirthBirthDeathDeath

MACRO Socio-EconomicEnvironment

Meso Civil Society

micro Social

Network

Contributions to Self-rated Health at Age 33, 1958 British Birth Cohort

BirthBirthDeathDeath

““pathway/cumulative” pathway/cumulative” factors:factors: OR=6.15OR=6.15

Contributions to Self-rated Health at Age 33, 1958 British Birth Cohort

““latent” factors: latent” factors: OR=5.03OR=5.03

BirthBirthDeathDeath

MACRO Socio-EconomicEnvironment

OR=1.87

Meso Civil Society OR=2.05

micro Social

Network

OR=N.S.

Contributions to Self-rated Health at Age 33, 1958 British Birth Cohort

““Intersecting” Intersecting” factors: factors: OR=3.83OR=3.83

BirthBirthDeathDeath

MACRO Socio-EconomicEnvironment

OR=1.87

Meso Civil Society OR=2.05

micro Social

Network

OR=N.S.

““pathway/cumulative” pathway/cumulative” factors: OR=6.15factors: OR=6.15

Contributions to Self-rated Health at Age 33, 1958 British Birth Cohort

““latent” factors: latent” factors: OR=5.03OR=5.03

““Intersecting” Intersecting” factors: factors: OR=3.83OR=3.83

socio-economic circumstances birth to age 16

Latent factors that matter most:– read to consistently– how easily adjusted to school– fraction of adult health reached by age 7

HIERARCHY?

Of all aspects of children’s early environment, the family’s socioeconomic status is most powerfully associated with children’s cognitive skills when they enter school. … the influence of socioeconomic status during early childhood years appears to be stronger than SES in later years. Children in single-parent families are at greater risk for poor developmental outcomes. There are a few critical periods in brain development during which impairment of stimulation of the nerve pathways will forever limit functioning

Social Expenditure on Family Benefits

CanadaCanada 0.510.51 66

Australia Australia 1.361.36 55

USAUSA 0.22 0.22 77

NorwayNorway 1.91 1.91 33

SwedenSweden 2.232.23 11

FinlandFinland 1.901.90 44

FranceFrance 2.132.13 22

Source: OECD Social Expenditure Database Source: OECD Social Expenditure Database (1998)(1998)

% of GDP Rank

Low-wage earners, social expenditures and percent lone-parent households

Percent of full-time workers

earning less than 65% of median earnings (1994)

Social expenditures on

the non-elderly as percent of GDP

(1999)

Percent of households that are lone parent

United States 25% (highest) 2.8 (lowest) 10.6 (most)

Canada 23% 6.0 7.3

United Kingdom 20% 6.4 9.0

Germany 13% 8.9 4.0

Netherlands 12% 10.5 3.5

Belgium 7% 8.9 4.3

Finland 6% 12.1 5.7

Sweden 5% 12.6 7.9

Parental Leave, Child Care OECD 94Ranked by Social Transfer %Share GDP 1995 Parental Leave (wks) Separate Maternal

Leave (wks)Gov't Payments

Infant.Care %GDP

High social-transfer benefits

Sweden 62 1.36

Finland 26-156 17.5 1.08

Denmark 10-52 18 1.21

Norway 52 0.91

Belgium 130 15 0.08

France 0-156 16 0.24

Intermediate transfer budgets

W. Germany 156 14 0.27

Italy 26 22 0.10

United Kingdom (none) 14+40 0.35

Austria 112 16 n.a.

Low transfer budgets

Switzerland (1988) 8-12 8-12 n.a.

New Zealand 52 0.04

Canada 10 17 0

Australia 52 52 0.19

United States (unpaid) 12 0.01

Japan 52 14 0

only countries that don'tPapua New GuineaLesotho, Swaziland

United States of America

164 countries have laws saying those who work

are guaranteed paid maternity leave.

Intergenerational AspectsMaternal constraint : limited capacity of mother to

deliver nutrients to fetus

Mothers constrain fetal growth to the degree they were constrained themselves in utero

Fathers influence fetal growth trajectories only when maternal constraint to fetal growth is relaxed

Benefit for fetus to adapt to level of nutrition over many years (generations) may be important in places with periodic famines

The daughterIs the motherOf the woman

The daughterIs the motherOf the woman

pathwaypathway

latentlatent

cumulativecumulative

Genetics AdultSOCIAL SUPPORT

STRESS in Adult Life

Cope

Breakdown

Susceptible+

-

+

-

Resistant

Cope

Cope

S O C I E T A L F A C T O R S

Early Childhoodbiological embedding

in uteroprogramming

maternal stress

maternalgrandparentsmaternal constraint

adolescent

mature

+

-

+

-

+

-

+

-

+

-

+

Relaxed (fathers matter)

Population test of family situation on child health?