A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Children’s Health Weight CoIIN July18,2018
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Opportunities for Nutrition in Title V Programs
JamieStang,PhD,MPH,[email protected]
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Opportunities for Nutrition in Title V Programs ✔ Overweightandobesity✔ Breastfeedingpromotion✔ Pretermbirthandinfantmortality✔ Foodsecurity✔ Developmentalscreening✔ WellvisitsamongMCHpopulations✔ Bullying
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Epidemiology of Overweight & Obesity among US Women 20 Years and Older ✔ Two-thirdsofUSwomen20yearsorolderareoverweight(NHANES2011–2012)
✔ 33.8%of12–19yroldfemalesoverweightorobese✔ Followsimilarracial/ethnicpatternstoinfantmortality
>20Years(Total) 20-39Years 40-59Years
Allraces/ethnicities 65.8% 58.5% 71.7%
Non-Hispanicwhite 63.2% 55.0% 69.1%
Non-Hispanicblack 82.0% 80.0% 85.2%
Non-HispanicAsian 34.7% 26.2% 39.4%
Hispanic 77.2% 69.5% 84.0%
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Epidemiology of Obesity among US Women ✔ Morethanone-thirdofUSwomenareobeseGradeI(BMI>30)
>20Years(Total%) 20-39Years(%) 40-59Years(%)
Allraces/ethnicities 36.1 31.8 39.5
Non-Hispanicwhite 32.8 27.8 36.3
Non-Hispanicblack 56.6 55.8 58.6
Non-HispanicAsian 11.4 10.9 11.8
Hispanic 44.4 35.8 51.9
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Epidemiology of Obesity among US Women GradeII(BMI>35) >20Years(Total%) 20-39Years(%) 40-59Years(%)
Allraces/ethnicities 17.0 15.4 19.1
Non-Hispanicwhite 15.3 13.7 16.9
Non-Hispanicblack 29.2 30.6 30.4
Hispanic 20.2 15.1 25.5
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Epidemiology of Obesity among US Women GradeIII(BMI>40)
>20Years(Total%) 20-39Years(%) 40-59Years(%)
Allraces/ethnicities 8.3 7.7 9.8
Non-Hispanicwhite 7.4 6.8 8.8
Non-Hispanicblack 16.4 17.5 17.9
Hispanic 7.6 5.8 9.1
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Obesity and Maternal-fetal Outcomes ✔ Obesewomenaretwiceaslikelytorequireinductionoflabor
✔ 4timesriskofinductionsecondarytogestationalhypertension✔ 11timestheriskofinductionsecondarytopre-eclampsiaand/orGDM
✔ C-sectionratesaretwiceashighamongobesewomen✔ 26%prevalenceamongidealweightandoverweightwomen✔ 38%amongclassIobesewomen✔ 43%amongclassIIobesewomen✔ 50%amongclassIIIobesewomen
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Obesity and Gestational Weight Gain
31%ofwomengainwithinIOMguidelines✔ 25%gainbelowand44%gainabove✔ Whitewomenmostlikelytogainabove(48%)
✔ Asian/PImostlikelytogainbelow(32%)
HaugenetalPregChildbirth2014;Endresetal.ObstetGynceol.2015;Kirkegaardetal.AmJClinNutr.2014
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Prepregnancy Weight and Birth Defects ✔ Overweightandobesitypriortopregnancyisanindependentriskfactorforsomebirthdefects✔ NTDs(espspinabifida)✔ Cardiacdefects✔ Hypospadia✔ Omphalocele✔ Anorectalatresiaandlimbreduction(obesityonly)
✔ Underweightpriortopregnancyisariskfordefects✔ cleftlipandpalate
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Nutrition-Related Risk Factors for Infant Mortality ✔ Pre-pregnancyweightstatus
✔ Underweightpriortopregnancy✔ Overweight/obesitypriortopregnancy
✔ Chronichealthconditionspriortopregnancy✔ Diabetes✔ Hypertension
✔ Inadequatenutrition✔ Inadequateweightgaininpregnancy✔ Inadequateintakesofvitamins/minerals✔ Possiblyexcessiveintakeofsomemacronutrients?
✔ Psychosocialstress–foodinsecurity
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Role of Nutrition in Preterm Birth and Low Birthweight Outcomes ✔ Manystudiesarepoorlydesigned
✔ Nutritionstatusorweightstatusoftenasecondaryoutcome
✔ Poormeasurementofdietaryintakeornutritionstatus✔ Measuretotalweightgainratherthanrateofgain
✔ Mechanismsnotwellunderstood✔ Relyonanimalmodelsor“naturalexperiments”✔ Influencesoninfectionandinflammationarecommontheories✔ Nutritionplaysaroleinmediatingboth
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Nutrition and Preterm Birth ✔ Irondeficiencyisariskfactorforpretermbirth
✔ Strongesteffectamongwomenwhoareirondeficientinearlypregnancy✔ OR=2.7(1.2-6.2)✔ 22%ofblackwomenvs10%whitewomen
✔ FewstudiesofironsupplementationinUSbecausesupplementationat12weeksisstandard
✔ Possiblemechanismsinclude:✔ Hypoxia✔ Oxidativestress✔ Increasedriskofinfection
Schooletal.2011,Prena-Rosas&Viteria,2009,Allen2001,Lookereral2002
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Hypertension Before and During Pregnancy ✔ 16%ofmaternalmortalityisrelatedtohypertensivedisorders
✔ Gestationalhypertension->140or>90✔ Preeclampsia-GH+>300mgprotein/day
✔ 5%to10%ofpregnanciesexperienceahypertensivedisorder✔ 3%experiencepreeclampsia✔ 17%ofwomenwithgestationalhypertensiongoontodeveloppreeclampsia
✔ Womenwitheitherpre-eclampsiaorhypertensionbutwithoutGDMhavebeenshowntobeat3timestheriskofdevelopingtype2diabeteswithin1-4yearsafterdelivery✔ suggestingthatinsulinresistancemaybecontributingfactortoboth
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Obesity and Gestational Diabetes ✔ Womenobeseatconceptionareupto6timesmorelikelytodevelopGDMthannormalweightwomen✔ Riskincreasesincrementallywithclassofobesity
✔ 9.7%prevalencewithclassIobesity✔ 13.7%prevalencewithclassIIobesity✔ 16.6%prevalencewithclassIIIobesity✔ 6.1%prevalenceamongidealweightwomen
✔ WomenwhoexperienceGDMare13timesmorelikelytodeveloptype2diabeteslaterinlife✔ MorethanhalfwithexperienceGDMinsubsequentpregnancies
SchummersetalObstetGynecol2015;Bautista-CastanoetalPLoSOne2013;GaillardetalObesity2013;El-Chaaretal.JObstetGynaecolCan2013
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Preventing Gestational Hypertension and Diabetes ✔ UnclearifdietarychangereducestheriskofGDMorgestationalhypertension✔ Mediterranean-typedietappearstohavesomebenefitinpreconceptionperiod✔ unclearaboutdietarychangeinpregnancy
✔ LowglycemicindexdietmayreduceriskofLGAbyupto91%✔ Ponderalindexesmaybelowerinbabiesborntomothersonlowglycemicdiets
✔ Highfiberdietsdonotshowsimilareffects✔ Glycemicindexof51showedeffectsinseveralstudies
✔ evenwith46%KcalsfromCHO
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Postpartum Weight Retention ✔ Lessthanhalfofwomenwillreverttotheirpre-pregnancyweight✔ morethanoneinfourwomenwillretain>10lbby12monthspostpartum
✔ Aprospectivecohortstudyfoundthat75%hadahigherweightat12monthspostpartumthantheirpre-pregnancyweight✔ 47%retaining>10lb✔ 24%retaining>20lb
✔ Acohortstudyof56,000womenfoundthat✔ 15%ofwomenretained5kgby6monthspostpartum✔ 13%movingfromanormalpre-pregnancyBMItoanoverweightBMIclassification
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Depression and Postpartum Weight Retention
✔ Depressionmaybeaffectedbyweightgaininpregnancyandweightretention✔ 19%ofwomenofpregravidnormalweight,overview,orclassIobesityscreenpositiveforpostpartumdepression
✔ 32%amongwomenwithclassIIobesity✔ 40%withclassIIIobesitypriortopregnancy
✔ Riskofpostpartumdepressionincreasedwithpregravidweightstatus;comparedtonormalweightoroverweightwomen:✔ WomenwithclassIIobesityhave3xhigherrisk✔ ThosewithclassIIIobesityhave4xtherisk
✔ 55%to62%ofwomenwithpostpartumdepressiongainexcessivelyinpregnancy✔ Excessivegestationalweightgain,inturn,mayincreasetheriskofsignificantpostpartumweightretention,thuscreatinganongoingcycleofweightanddepressionissues
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Maternal Obesity and Breastfeeding
✔ Themajorityofstudieshavefoundthatobesityreducedtheinitiationanddurationofbreastfeeding✔ ObesityhadgreatereffectonbreastfeedingamongLatinasthanamongblackwomen,withwhitewomenfallinginbetweenthesegroups
✔ Greaterdegreeofobesityassociatedwithlowerratesofbreastfeeding✔ MaybeconfoundedbygreaterriskforGDM,hypertension,C-sectionorassisteddeliveryandothermaternalcomplications
RasmussenAnnuRevNutr2007;Turcksinetal.MaternChildNutr2014
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Child Nutrition
✔ OneinthreeUSchildrenisoverweight✔ 17%areobese✔ Disparitiesinobesityarepresentatallagegroup✔ Weightstatusisamajorcauseofbullyingamongschool-agedchildren
✔ CYSHCNhavemanynutritionneeds✔ 12%havefoodallergies✔ 27%ormorerequiremedicationthatmayinteractwithfood
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
ASPHN Resources
✔ ImprovingtheNutritionalWell-BeingofWomen,ChildrenandFamilies✔ TheRoleofNutritioninInfantMortality:APublicHealthPerspective✔ IncorporatingNutritionintheTitleVMCHServicesBlockGrantNationalPerformanceMeasures
✔ PreconceptionHealth:TheRoleofNutrition✔ ObesityPreventionMatrix✔ TheIntersectionofPublicHealth,CommunityandClinicalDietetics✔ ASPHNCollaborationPrimer✔ BlueprintforNutritionandPhysicalActivity
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Innovative Nutrition Integration
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
The Cornerstones ✔ Cornerstone1-Access✔ Cornerstone2–Collaboration✔ Cornerstone3-Science,ResearchandEvaluation✔ Cornerstone4–Workforce✔ Cornerstone5–Communication✔ Cornerstone6–PolicyandAdvocacy
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
AIM
✔ InnovativelyIntegrateNutritionintoTitleVMCHBlockGrantandotherMCHPrograms.
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
First Primary Driver
✔ ImproveaccesstoqualitynutritionservicesprovidedbyqualifiedprovidersinallTitleVsupportedandaffiliatedprograms.
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Second Primary Driver
✔ OptimizethenumberofpublichealthnutritionFTEsintheLocal,StateandNationalTitleVworkforce.
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Third Primary Driver
✔ IncreasethebasicnutritioncompetencyoftheentireTitleVWorkforce,whileexpandingtheirawarenessofavailablenutritionexpertsandappropriatereferralcriteria.
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Fourth Primary Driver
✔ MaximizepartnershipstointegratenutritionintotheTitleVBlockGrantapplication,allTitleVsupportedandaffiliatedprograms.
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Fifth Primary Driver
✔ DevelopreliableandaccuratemessagingonthevalueofintegratingnutritionintoallTitleVsupportedandaffiliatedprograms.
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Step 1: Needs Assessment ✔ September–October2018✔ InSeptember2018,eachstatewillmeetwithpartnerstobrainstormideasforimprovingnutritionintegrationwithintheirStatesTitleVprogramandidentifytop2priorities.
✔ InOctober2018,eachstatewillsubmitsummarytoCHW-CoIIN✔ CHW-CoIINwillidentifytherequiredandrecommendedinvitees✔ CHW-CoIINwillprovideareportingtemplate
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Step 2: Change Packages ✔ October–November2018✔ Nationalexpertstoreviewthetopissuesandidentifytrends.✔ Groupstatesinto“Teams"ofsimilarpriorities.✔ Holdmeetingsforeach“Team”togenerateideastoaddresstheirpriority.
✔ ExpertcommitteedevelopChangePackagesforeach“Team”
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Step 3: Team Work
✔ November2018–September2018✔ PDSAcyclesconsistentwithChangePackage.✔ Meetregularlytodiscusssuccessesandchallenges
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Time Line Summary
✔ September2018–HoldNeedsAssessmentMeeting✔ October2018–SubmitMeetingSummary✔ November2018–DevelopChangePackage✔ December2018–Start“Team”work
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Welcome New Intensive Learning States
Breastfeeding✔ Arkansas✔ Nevada
PhysicalActivity✔ Texas✔ Wisconsin
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Welcome Rebecca Leighton
✔ DevelopNewsletter✔ OrganizeWebinars✔ HelpmanagetheStateEvaluationform
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Evaluation
✔ WebinarEvaluationconductedbyAMCHP✔ EmaillinktosurveyfromCherylClark,[email protected]✔ Surveywillbeopenfor2weeks.
A S S O C I A T I O N O F S T A T E P U B L I C H E A L T H N U T R I T I O N I S T S
Upcoming Calls
✔ PAWorkstreamNetworkingCall✔ July25,2018at1pmET
✔ CHW-CoIINWebinar✔ August15,2018at1pmET
✔ BFWorkstreamNetworkingCall✔ August30,2018at1pmET
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