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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

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Improving preconception health healthcare in tulsa

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


Improving preconception health healthcare in tulsa

Why

Preconception Care?


Why preconception care
Why Preconception Care?

  • Early prenatal care is too late.


Improving preconception health healthcare in tulsa

When Does the Fetal

Heart Begin to Beat?


Early prenatal care is too late to prevent some birth defects
Early Prenatal Care Is Too LateTo Prevent Some Birth Defects

  • 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
Early Prenatal Care Is Too LateTo 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
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 from A Life-Course Perspective

  • Early prenatal care is too late to restore allostasis and optimize women’s health before pregnancy


Improving preconception health healthcare in tulsa

What Is

Preconception Care?


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 Group; 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):1-23.


Improving preconception health healthcare in tulsa

Summary of the CDC/ATSDR Select Panel’s Recommendations to Improve Preconception Health and Health Care in the United States

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 Group; 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):1-23.


Components of preconception care
Components of Improve Preconception Health and Health Care in the United StatesPreconception Care

  • Risk Assessment

  • Health Promotion

  • Medical & Psychosocial Interventions

Lu MC. Recommendations for preconception care. Am Fam Physician. 2007;76:397-400.


Preconception health promotion
Preconception Health Promotion Improve Preconception Health and Health Care in the United States

Ask about reproductive life plan

Start prenatal care before you get pregnant

Start eating for two

Eat more brain foods

Avoid toxic foods

Take a multivitamin everyday

Achieve a healthy weight

Learn how not to get stressed out

Give your immune system a tune-up

Detoxify your environment


Improving preconception health healthcare in tulsa

Get ready to get pregnant Improve Preconception Health and Health Care in the United States


Improving preconception health healthcare in tulsa

Tip #1 Improve Preconception Health and Health Care in the United States

Ask About

Reproductive Life Plan


Reproductive life plan
Reproductive Life Plan Improve Preconception Health and Health Care in the United States

  • 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
Examples of a Reproductive Life Plan Improve Preconception Health and Health Care in the United States

  • Do you hope to have any (more) children?

  • How many children do you hope to have?

  • How long do you plan to wait until you (next) become pregnant?

  • How much space do you plan to have between your pregnancies?

  • What do you plan to do until you are ready to become pregnant?

  • What can I do today to help you achieve your plan?


Improving preconception health healthcare in tulsa

Tip #2 Improve Preconception Health and Health Care in the United States

Start prenatal care

before you get pregnant


Components of preconception care1
Components of Improve Preconception Health and Health Care in the United StatesPreconception Care

  • Risk Assessment

    • Reproductive life plan

    • Past pregnancy history

    • Past medical & surgical history

    • Medications & allergies

    • Family & genetic history

    • Social history

    • Behavioral & nutritional assessment

    • Mental health

    • Laboratory testing

  • Health Promotion

  • Medical & Psychosocial Interventions

    • 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
Examples of Drugs to Avoid Improve Preconception Health and Health Care in the United States


Questions about drug use in pregnancy
Questions about Improve Preconception Health and Health Care in the United StatesDrug Use in Pregnancy

OTIS (Organization of Teratogen Information Specialists)

http://www.otispregnancy.org

Toll-free (866) 626-OTIS


Improving preconception health healthcare in tulsa

Tip #3 Improve Preconception Health and Health Care in the United States

Start “eating for two”

(in quality, not in quantity)


Make healthy food choices
Make Healthy Food Choices Improve Preconception Health and Health Care in the United States

http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/pyramid

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


Make healthy food choices1
Make Healthy Food Choices Improve Preconception Health and Health Care in the United States

  • Eat more whole foods and less processed foods

  • Use a menu planner

    • www.MyPyramid.gov


Improving preconception health healthcare in tulsa

Tip #4 Improve Preconception Health and Health Care in the United States

Eat more brain foods


Top 10 brain foods
Top 10 Brain Foods Improve Preconception Health and Health Care in the United States

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


Improving preconception health healthcare in tulsa

Tip #5 Improve Preconception Health and Health Care in the United States

Eat less toxic foods


Top 10 toxic foods
Top 10 Toxic Foods Improve Preconception Health and Health Care in the United States

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


Improving preconception health healthcare in tulsa

Fish: Improve Preconception Health and Health Care in the United States

Brain Food or Toxic Food?


What you need to know about mercury in fish shellfish
What You Need to Know about Mercury Improve Preconception Health and Health Care in the United Statesin Fish & Shellfish

2004 EPA/FDA Joint Advisory for

Women who might become pregnant

Women who are pregnant

Nursing mothers

Young children

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

Check local advisories about locally caught fish

www.epa.gov/ost/fish

www.epa.gov/mercury


Improving preconception health healthcare in tulsa

Tip #6 Improve Preconception Health and Health Care in the United States

Take a multivitamin

everyday


Micronutrients choosing your multivitamin
Micronutrients: Improve Preconception Health and Health Care in the United StatesChoosing Your Multivitamin

Folic acid

400 mcg a day

4000 mcg a day with prior NTD

Avoid excess(more isn’t always better)

A>10,000 IU

D>4,000 IU

Nutrition first!


Improving preconception health healthcare in tulsa

Tip #7 Improve Preconception Health and Health Care in the United States

Achieve a healthy weight


Achieve a healthy pre pregnancy weight
Achieve A Healthy Pre-Pregnancy Weight Improve Preconception Health and Health Care in the United States

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 weight1
Achieve A Healthy Pre-Pregnancy Weight Improve Preconception Health and Health Care in the United States

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


Improving preconception health healthcare in tulsa

Tip #8 Improve Preconception Health and Health Care in the United States

Learn How Not to Get

Stressed Out


Stress preterm birth
Stress & Preterm Birth Improve Preconception Health and Health Care in the United States

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
Fetal HPA Maturation Improve Preconception Health and Health Care in the United States

(+)

Hypothalamus

+ CRH

(+)

Pituitary

CRH

+ ACTH

Adrenal

(+)

Cortisol

DHEA-S

Placenta


Maternal hpa activation
Maternal HPA Activation Improve Preconception Health and Health Care in the United States

Hypothalamus

(+)

CRH

Hypothalamus

Pituitary

+ CRH

Pituitary

(+)

CRH

+ ACTH

ACTH

Adrenal

(+)

(+)

Cortisol

DHEA-S

Placenta

Adrenal

Cortisol

Norepinephrine


Learn how not to get stressed out

Exercise Improve Preconception Health and Health Care in the United States

Eat right

Get a good night’s sleep

Learn how not to get stressed out


Improving preconception health healthcare in tulsa

Relaxation techniques Improve Preconception Health and Health Care in the United States

Breathing exercises

Progressive relaxation

Meditation

Mindfulness

Learn how not to get stressed out


Improving preconception health healthcare in tulsa

Positive Mental Health Improve Preconception Health and Health Care in the United States

A sense of meaning

Self-acceptance

Autonomy

Positive relations with others

Satisfaction with life

Optimism

Learn how not to get stressed out


Improving preconception health healthcare in tulsa

Develop Positive Mental Health Improve Preconception Health and Health Care in the United States

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


Learn how not to get stressed out1

Relationality is primary, Improve Preconception Health and Health Care in the United States

All else is derivative.

-Ronald David

Learn how not to get stressed out


Improving preconception health healthcare in tulsa

Tip #9 Improve Preconception Health and Health Care in the United States

Tune-up your

immune system


How to give your immune system a tune up
How to Give Your Immune System A Tune-Up? Improve Preconception Health and Health Care in the United States

Get rid of ongoing infections & inflammation

Make lifestyle changes to improve immune fitness


Immune tune up
Immune Tune-Up Improve Preconception Health and Health Care in the United States

Brush

Floss

Go see your dentist


How to avoid toxoplasmosis
How to Avoid Toxoplasmosis Improve Preconception Health and Health Care in the United States

Wear gloves when you garden

Cook all meat thoroughly

Wash raw vegetables thoroughly

Exercise precautionsaround cats

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
How to Avoid Cytomegalovirus Improve Preconception Health and Health Care in the United States

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 up1
Immune Tune-Up Improve Preconception Health and Health Care in the United States

Update your immunizations

Tdap

Hepatitis B

Influenza

MMR

Chickenpox

HPV


Improving preconception health healthcare in tulsa

Tip #10 Improve Preconception Health and Health Care in the United States

Detoxify Your Environment


Detoxify your home
Detoxify Your Home Improve Preconception Health and Health Care in the United States

Bathroom

Get rid of antibacterial soap

triclocarban and triclosan

Get rid of air fresheners

phthalates, formaldehyde,glycol ethers, and petroleum

Get rid of personal care products containing

Phthalates, formaldehyde, glycol ethers, petroleum

Get rid of bathroom cleaners containing

ammonia, alkylphenol ethoxylate, chlorine bleach, glycol ether, sodium hydroxide, sodium lauryl sulfate

Get rid of molds & mildew


Detoxify your home1
Detoxify Your Home Improve Preconception Health and Health Care in the United States

Kitchen & dining room

Get rid of non-stick pans

perfluorinated chemicals

Don’t microwave plastic

Unless it says “microwave safe”

Get rid of glass & window cleaners containing

Glycol ethers or ammonia

Get rid of stovetop, countertop & oven cleaners

Lye, sodium hydroxide, chlorine bleach, silica

Get rid of drain cleaners containing

Sodium hydroxide, sodium hypochlorite

Avoid using pesticides


Detoxify your home2
Detoxify Your Home Improve Preconception Health and Health Care in the United States

Living Room and Bedrooms

Get rid of vinyl wallpapers & blinds

Phthalates

Replace furniture containing

urea-formaldehyde (ask for “exterior grade” products)

Replace mattress & sofas containing

polybrominated diphenyl ethers (PBDEs)

Replace old carpets

Volatile organic compounds, dusts & dustmites


Improving preconception health healthcare in tulsa

Which # Plastic Bottles Should Be Avoided? Improve Preconception Health and Health Care in the United States


Tap vs bottled water
Tap vs. Bottled Water Improve Preconception Health and Health Care in the United States

Tap water

Test your tap water for lead

Use a water filter

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
Avoid Occupational Exposures Improve Preconception Health and Health Care in the United States

OSHA (Occupation Safety and Health Act)

MSDS (Material Safety Data Sheet)

OTIS (Organization Teratogen Information Specialists

http://www.otispregnancy.org

Toll-free (866) 626-OTIS


Improving preconception health healthcare in tulsa

Preconception Care Improve Preconception Health and Health Care in the United States

for Men


Preconception care for men
Preconception Care for Men Improve Preconception Health and Health Care in the United States

  • 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)

    • Infection/inflammation

    • Hyperthermia

    • Radiation


Improving preconception health healthcare in tulsa

How Many Sperm Improve Preconception Health and Health Care in the United States

Does a Man Make

in a Lifetime?


Preconception care for men1
Preconception Care for Men? Improve Preconception Health and Health Care in the United States

  • 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


Improving preconception health healthcare in tulsa

Where is the F Improve Preconception Health and Health Care in the United States

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
Father Involvement Improve Preconception Health and Health Care in the United StatesBarriers

Individual

Knowledge, attitude, behaviors

Human capital

Interpersonal

Gender relations (mother, grandmother, new partner)

Institutional & community

Unemployment

Incarceration

Sterotypes

Racism

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
Improving Father Involvement Improve Preconception Health and Health Care in the United StatesAn Ecological Approach

Individual

Educational programs

Employment related services

Legal & social services

Interpersonal

Marriage counseling, family therapy

Communication skills, conflict resolution skills, emotional intelligence

Institutional & community

Full employment economy

Criminal justice system

Change norms, expectations, values, stereotypes

Undo racism

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
Father Involvement Improve Preconception Health and Health Care in the United StatesA Life-Course Perspective

How do boys become men, and how do men become fathers?



Improving preconception health healthcare in tulsa

Interconception how to be fathers.

Care


Improving preconception health healthcare in tulsa

Benjamin Franklin


Improving preconception health healthcare in tulsa