Transcript Slide 1

Improving Preconception Health &
Healthcare in Tulsa
Michael C. Lu, MD, MPH
Associate Professor
Department of Obstetrics & Gynecology
David Geffen School of Medicine at UCLA
Department of Community Health Sciences
UCLA School of Public Health
Tulsa, Oklahoma
October 11, 2011
Why
Preconception Care?
Why Preconception Care?
 Early prenatal care is too late.
When Does the Fetal
Heart Begin to Beat?
Early Prenatal Care Is Too Late
To Prevent Some Birth Defects
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The heart begins to beat at 22 days after conception
The neural tube closes by 28 days after conception
The palate fuses at 56 days after conception
Critical period of teratogenesis – Day 17 to Day 56
Early Prenatal Care Is Too Late
To Prevent Implantation Errors
Norwitz ER, Schust DJ, Fisher SJ. Implantation and the survival of early pregnancy. N Engl J Med.
2001 Nov 8;345(19):1400-8.
The Role of the Placenta in
Fetal Programming
Godfrey KM. The role of the placenta in fetal programming-a review. Placenta. 2002;23
Suppl A:S20-7.
Early Prenatal Care Is Too Late
from A Life-Course Perspective
 Early prenatal care is too late to restore
allostasis and optimize women’s health before
pregnancy
What Is
Preconception Care?
What is Preconception Care?
 A set of interventions that aim to identify and
modify biomedical, behavioral, and social risks
to a woman's health or pregnancy outcome
through prevention and management.
Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS, Boulet S, Curtis MG; CDC/ATSDR Preconception Care Work Grou
Select Panel on Preconception Care. Recommendations to improve preconception health and health care--United States. A report of the
CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep. 2006 Apr 21;55(RR-6):1
Summary of the CDC/ATSDR Select Panel’s Recommendations to Improve Preconception
Health and Health Care in the United States
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Recommendation 1. Individual responsibility across the life span. Each woman, man
and couple should be encouraged to have a reproductive life plan.
Recommendation 2. Consumer awareness. Increase public awareness of the importance
of preconception health behaviors and preconception care services by using information and
tools appropriate across various ages; literacy, including health literacy; and cultural/linguistic
contexts.
Recommendation 3. Preventive visits. As a part of primary care visits, provide risk
assessment and educational and health promotion counseling to all women of childbearing
age to reduce reproductive risks and improve pregnancy outcomes.
Recommendation 4. Interventions for identified risks. Increase the proportion of women
who receive interventions as follow-up to preconception risk screening, focusing on high
priority interventions (i.e. those with evidence of effectiveness and greatest potential impact).
Recommendation 5. Interconception care. Use the interconception period to provide
additional intensive interventions to women who have had a previous pregnancy that ended in
an adverse outcome (i.e., infant death, fetal loss, birth defects, low birthweight, or preterm
birth).
Recommendation 6. Prepregnancy checkup. Offer, as a component of maternity care,
one prepregnancy visit for couples and persons planning pregnancy.
Recommendation 7. Health insurance coverage for women with low incomes.
Increase public and private health insurance coverage for women with low incomes to
improve access to preventive women’s health and preconception and interconception care.
Recommendation 8. Public health programs and strategies. Integrate components of
preconception health into existing local public health and related programs, including
emphasis on interconception interventions for women with previous adverse outcomes.
Recommendation 9. Research. Increase the evidence base and promote the use of the
evidence to improve preconception health.
Recommendation 10. Monitoring improvements. Maximize public health surveillance and
related research mechanisms to monitor preconception health.
Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS, Boulet S, Curtis MG; CDC/ATSDR Preconception Care Work Grou
Select Panel on Preconception Care. Recommendations to improve preconception health and health care--United States. A report of the
CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep. 2006 Apr 21;55(RR-6):1
Components of
Preconception Care
 Risk Assessment
 Health Promotion
 Medical & Psychosocial Interventions
Lu MC. Recommendations for preconception care. Am Fam Physician. 2007;76:397-400.
Preconception Health Promotion
1. Ask about reproductive life plan
2. Start prenatal care before you get pregnant
3. Start eating for two
4. Eat more brain foods
5. Avoid toxic foods
6. Take a multivitamin everyday
7. Achieve a healthy weight
8. Learn how not to get stressed out
9. Give your immune system a tune-up
10.Detoxify your environment
Get ready to get pregnant
Tip #1
Ask About
Reproductive Life Plan
Reproductive Life Plan
 A set of personal goals about having (or not having)
children based on personal values and resources
 A plan to achieve those goals
http://www.cdc.gov/ncbddd/preconception/QandA.htm#5
Examples of a Reproductive Life Plan
1. Do you hope to have any (more) children?
2. How many children do you hope to have?
3. How long do you plan to wait until you (next)
become pregnant?
4. How much space do you plan to have between
your pregnancies?
5. What do you plan to do until you are ready to
become pregnant?
6. What can I do today to help you achieve your
plan?
Tip #2
Start prenatal care
before you get pregnant
Components of
Preconception Care
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Risk Assessment
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Reproductive life plan
Past pregnancy history
Past medical & surgical history
Medications & allergies
Family & genetic history
Social history
Behavioral & nutritional assessment
Mental health
Laboratory testing
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Health Promotion
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Medical & Psychosocial Interventions
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Preventive services and primary care
Individualized for identified risks
Lu MC. Recommendations for preconception care. Am Fam Physician. 2007;76:397-400.
Examples of Drugs to Avoid
Agent
Comments
ACE inhibitors, ARBs
Kidney abnl if exposed in 2nd or 3rd tri
Statins
Abnormalities if exposure 4–9th week
Testosterone
Masculinization of female fetus
Carbamazapine
Fetal death, mental retardation,
malformations of heart, genitals;
cleft palate and arteries
Coumadin derivatives
(warfarin)
Risk of bone+ cartilage deformities, mental
retardation, vision problems
Lithium
Increased risk of CV anomalies
Phenytoin
Risk of fetal hydantoin syndrome
Valproic acid
Use in 3-4 divided doses; not with
carbamazapine + phenobarbitol
Isotretinoin
Elevated risk of SAB and anomalies
Questions about
Drug Use in Pregnancy
 OTIS (Organization of Teratogen Information
Specialists)
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http://www.otispregnancy.org
Toll-free (866) 626-OTIS
Tip #3
Start “eating for two”
(in quality, not in quantity)
Make Healthy Food Choices
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Whole grain foods: 5-7 servings
Plant oils: 6 teaspoons
Vegetable and fruits: 5 servings
Nuts, beans and lentils: ½ to 1 cup
Fish, poultry or egg: 1 serving a day
Dairy: 3 servings
Multivitamin: 1 a day
http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/pyramid
Make Healthy Food Choices
 Eat more whole foods and less processed
foods
 Use a menu planner
 www.MyPyramid.gov
Tip #4
Eat more brain foods
Top 10 Brain Foods
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Beans
Eggs
Nuts & seeds
Olive oil
Alaskan wild salmon
Yogurt & kefir
Whole grains
Spinach, collards, kale & broccoli
Prunes, raisin, blueberries
Oranges, red bell pepper, tomato
Tip #5
Eat less toxic foods
Top 10 Toxic Foods
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Swordfish, shark, king mackerel and tile fish
Soft cheese and unpasteurized milk
Hot dogs, luncheon meats, deli meats, raw or smoked
seafood
Raw or undercooked meat
Unwashed vegetables, raw vegetable sprouts, and
unpasteurized juices
Liver
Saturated fats, trans fats, and partially hydrogenated
oils
Added sugars
Refined flour
Herbal preparations
Fish:
Brain Food or Toxic Food?
What You Need to Know about Mercury
in Fish & Shellfish
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2004 EPA/FDA Joint Advisory for
 Women who might become pregnant
 Women who are pregnant
 Nursing mothers
 Young children
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Do not eat Shark, Swordfish, King Mackerel, or Tilefish
Eat up to 12 ounces (2 average meals) a week
 Shrimp, canned light tuna, salmon, pollock, catfish are low in
mercury
 Albacore (“white”) tuna has more mercury than canned light tuna
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Check local advisories about locally caught fish
 www.epa.gov/ost/fish
www.epa.gov/mercury
Tip #6
Take a multivitamin
everyday
Micronutrients:
Choosing Your Multivitamin
 Folic acid
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400 mcg a day
4000 mcg a day with prior NTD
 Avoid excess (more isn’t always better)
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A>10,000 IU
D>4,000 IU
 Nutrition first!
Tip #7
Achieve a healthy weight
Achieve A Healthy Pre-Pregnancy Weight
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Underweight: BMI<18.5
Normal: BMI = 18.5-24.9
Overweight: BMI = 25-29.9
Obese BMI>30
National Heart, Lung, and Blood Institute at www. www.nhlbi.nih.gov
Achieve A Healthy Pre-Pregnancy Weight
 For weight loss,
 Decrease calories in
 Increase calories out (exercise)
 Keep track of weight & nutrition
 Maintain a healthy weight for 3-6 months
before pregnancy
National Heart, Lung, and Blood Institute at www. www.nhlbi.nih.gov
Tip #8
Learn How Not to Get
Stressed Out
Stress & Preterm Birth
And his daughter in law, Phinehas' wife, was with
child, near to be delivered; and when she heard
the tidings that the ark of God was taken, and that
her father in law and her husband were dead, she
bowed herself and travailed; for her pains came
upon her.
Samuel 4:19
Fetal HPA Maturation
(+)
Hypothalamus
+
(+)
CRH
Pituitary
CRH
+ ACTH
Adrenal
Placenta
(+)
Cortisol
DHEA-S
Maternal HPA Activation
Hypothalamus
(+)
CRH
Hypothalamus
Pituitary
+
CRH
(+)
CRH
Pituitary
+ ACTH
ACTH
Adrenal
(+)
(+)
Cortisol
DHEA-S
Placenta
Adrenal
Cortisol
Norepinephrine
Learn how not to get stressed out
 Exercise
 Eat right
 Get a good night’s sleep
Learn how not to get stressed out
 Relaxation techniques
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Breathing exercises
Progressive relaxation
Meditation
Mindfulness
Learn how not to get stressed out
 Positive Mental Health
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A sense of meaning
Self-acceptance
Autonomy
Positive relations with others
Satisfaction with life
Optimism
Learn how not to get stressed out
 Develop Positive Mental Health
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Find your purpose (“follow your bliss”)
Use your strengths
Count your blessings
Live in gratitude
Learn to forgive
Savor life’s joy
Spend time with friends and families
Practice daily acts of kindness
Learn to be optimistic
Learn how not to get stressed out
Relationality is primary,
All else is derivative.
- Ronald David
Tip #9
Tune-up your
immune system
How to Give Your Immune
System A Tune-Up?
 Get rid of ongoing infections & inflammation
 Make lifestyle changes to improve immune fitness
Immune Tune-Up
 Brush
 Floss
 Go see your dentist
How to Avoid Toxoplasmosis
 Wear gloves when you garden
 Cook all meat thoroughly
 Wash raw vegetables thoroughly
 Exercise precautions around cats
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Have someone else change the litter box
Wear gloves when you change the litter box
Change the litter box daily
Cover outdoor sandboxes
Never feed your cat raw meat
Keep indoor cats indoors
www.cdc.gov/ /toxoplasmosis
How to Avoid Cytomegalovirus
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Wash hands with soap and water after contact with
diapers or saliva
Do not share food, drinks, or utensils (spoons or forks)
with young children
Check your CMV titer if you work in day care
www.cdc.gov/cmv
Immune Tune-Up
 Update your immunizations
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Tdap
Hepatitis B
Influenza
MMR
Chickenpox
HPV
Tip #10
Detoxify Your Environment
Detoxify Your Home
 Bathroom
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Get rid of antibacterial soap
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Get rid of air fresheners
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Phthalates, formaldehyde, glycol ethers, petroleum
Get rid of bathroom cleaners containing
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phthalates, formaldehyde, glycol ethers, and petroleum
Get rid of personal care products containing
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triclocarban and triclosan
ammonia, alkylphenol ethoxylate, chlorine bleach, glycol ether,
sodium hydroxide, sodium lauryl sulfate
Get rid of molds & mildew
Detoxify Your Home
 Kitchen & dining room
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Get rid of non-stick pans
 perfluorinated chemicals
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Don’t microwave plastic
 Unless it says “microwave safe”
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Get rid of glass & window cleaners containing
 Glycol ethers or ammonia
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Get rid of stovetop, countertop & oven cleaners
 Lye, sodium hydroxide, chlorine bleach, silica
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Get rid of drain cleaners containing
 Sodium hydroxide, sodium hypochlorite
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Avoid using pesticides
Detoxify Your Home
 Living Room and Bedrooms
 Get rid of vinyl wallpapers & blinds
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Phthalates
 Replace furniture containing
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urea-formaldehyde (ask for “exterior grade” products)
 Replace mattress & sofas containing
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polybrominated diphenyl ethers (PBDEs)
 Replace old carpets
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Volatile organic compounds, dusts & dustmites
Which # Plastic Bottles
Should Be Avoided?
Tap vs. Bottled Water
 Tap water
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Test your tap water for lead
Use a water filter
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www.nsf.org
 Bottled water
 Check the recycle number on bottle
 Plastics to Avoid
#3 (polyvinyl chloride, which may contain phthalates)
#6 (polystyrene)
#7 (polycarbonate, which may contain BPA)
 Keep bottled water away from heat
 Don’t reuse water bottles
Avoid Occupational Exposures
 OSHA (Occupation Safety and Health Act)
 MSDS (Material Safety Data Sheet)
 OTIS (Organization Teratogen Information Specialists
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http://www.otispregnancy.org
Toll-free (866) 626-OTIS
Preconception Care
for Men
Preconception Care for Men
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Protect Your Sperm DNA
 Xenobiotics
 Pesticides, insecticides, fumigants
 Nonylphenol (super detergents)
 Polycyclic aromatic hydrocarbons (PAHs) (smoking)
 Polychlorinated biphenyls (fishing, old appliances)
 Dioxins (animal fat)
 Phthlates (plastics)
 Acrylamide (overcooking)
 Heavy metals (lead, cadmium, etc)
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Infection/inflammation
Hyperthermia
Radiation
How Many Sperm
Does a Man Make
in a Lifetime?
Preconception Care for Men?
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Reproductive life plan
Past reproductive history
Current medical conditions
Medications
Family history & genetic risks
Work & hobbies
Risk behaviors
Mental health
Weight
Blood pressure
Physical examinations
Laboratory testing
Immunizations
Go see your dentist
Where is the F
In MCH?
Lu MC, Jones L, Bond MJ, Wright K, Pumpuang M, Maidenberg M, Jones D, Garfield C, Rowley DL.
Where is the F in MCH? Father involvement in African American Families. Ethn Dis. 2010;20:S2-49-61.
Father Involvement
Barriers
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Individual
 Knowledge, attitude, behaviors
 Human capital
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Interpersonal
 Gender relations (mother, grandmother, new partner)
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Institutional & community
 Unemployment
 Incarceration
 Sterotypes
 Racism
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Society & policy
 Temporary Assistance for Needy Families
 Earned Income Tax Credit
 Child Support
Lu MC, Jones L, Bond MJ, Wright K, Pumpuang M, Jones D. et al. Where is the F in MCH? Father
involvement in African American families. Ethnicity and Disease. 2010
Improving Father Involvement
An Ecological Approach
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Individual
 Educational programs
 Employment related services
 Legal & social services
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Interpersonal
 Marriage counseling, family therapy
 Communication skills, conflict resolution skills, emotional intelligence
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Institutional & community
 Full employment economy
 Criminal justice system
 Change norms, expectations, values, stereotypes
 Undo racism
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Policy reforms
 Temporary Assistance for Needy Families
 Earned Income Tax Credit
 Child Support
Lu MC, Jones L, Bond MJ, Wright K, Pumpuang M, Jones D. et al. Where is the F in MCH? Father
involvement in African American families. Ethnicity and Disease. 2010
Father Involvement
A Life-Course Perspective
How do boys become men, and how do
men become fathers?
The primary task of every civilization is to teach
young men how to be fathers.
Margaret Mead
Interconception
Care
 The definition of insanity is doing the same
thing over and over and expecting different
results
Benjamin Franklin
 "We must become the change we want to see.”
- MOHANDAS GANDHI