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,RDNstang002@umn.edu

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

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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%

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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

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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

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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

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Obesity and Maternal-fetal Outcomes ✔ Obesewomenaretwiceaslikelytorequireinductionoflabor

✔ 4timesriskofinductionsecondarytogestationalhypertension✔ 11timestheriskofinductionsecondarytopre-eclampsiaand/orGDM

✔ C-sectionratesaretwiceashighamongobesewomen✔ 26%prevalenceamongidealweightandoverweightwomen✔ 38%amongclassIobesewomen✔ 43%amongclassIIobesewomen✔ 50%amongclassIIIobesewomen

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Obesity and Gestational Weight Gain

31%ofwomengainwithinIOMguidelines✔ 25%gainbelowand44%gainabove✔ Whitewomenmostlikelytogainabove(48%)

✔ Asian/PImostlikelytogainbelow(32%)

HaugenetalPregChildbirth2014;Endresetal.ObstetGynceol.2015;Kirkegaardetal.AmJClinNutr.2014

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Prepregnancy Weight and Birth Defects ✔ Overweightandobesitypriortopregnancyisanindependentriskfactorforsomebirthdefects✔ NTDs(espspinabifida)✔ Cardiacdefects✔ Hypospadia✔ Omphalocele✔ Anorectalatresiaandlimbreduction(obesityonly)

✔ Underweightpriortopregnancyisariskfordefects✔ cleftlipandpalate

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Nutrition-Related Risk Factors for Infant Mortality ✔ Pre-pregnancyweightstatus

✔ Underweightpriortopregnancy✔ Overweight/obesitypriortopregnancy

✔ Chronichealthconditionspriortopregnancy✔ Diabetes✔ Hypertension

✔ Inadequatenutrition✔ Inadequateweightgaininpregnancy✔ Inadequateintakesofvitamins/minerals✔ Possiblyexcessiveintakeofsomemacronutrients?

✔ Psychosocialstress–foodinsecurity

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Role of Nutrition in Preterm Birth and Low Birthweight Outcomes ✔ Manystudiesarepoorlydesigned

✔ Nutritionstatusorweightstatusoftenasecondaryoutcome

✔ Poormeasurementofdietaryintakeornutritionstatus✔ Measuretotalweightgainratherthanrateofgain

✔ Mechanismsnotwellunderstood✔ Relyonanimalmodelsor“naturalexperiments”✔ Influencesoninfectionandinflammationarecommontheories✔ Nutritionplaysaroleinmediatingboth

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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

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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

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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

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Preventing Gestational Hypertension and Diabetes ✔ UnclearifdietarychangereducestheriskofGDMorgestationalhypertension✔ Mediterranean-typedietappearstohavesomebenefitinpreconceptionperiod✔ unclearaboutdietarychangeinpregnancy

✔ LowglycemicindexdietmayreduceriskofLGAbyupto91%✔ Ponderalindexesmaybelowerinbabiesborntomothersonlowglycemicdiets

✔ Highfiberdietsdonotshowsimilareffects✔ Glycemicindexof51showedeffectsinseveralstudies

✔ evenwith46%KcalsfromCHO

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Postpartum Weight Retention ✔ Lessthanhalfofwomenwillreverttotheirpre-pregnancyweight✔ morethanoneinfourwomenwillretain>10lbby12monthspostpartum

✔ Aprospectivecohortstudyfoundthat75%hadahigherweightat12monthspostpartumthantheirpre-pregnancyweight✔ 47%retaining>10lb✔ 24%retaining>20lb

✔ Acohortstudyof56,000womenfoundthat✔ 15%ofwomenretained5kgby6monthspostpartum✔ 13%movingfromanormalpre-pregnancyBMItoanoverweightBMIclassification

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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

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Maternal Obesity and Breastfeeding

✔ Themajorityofstudieshavefoundthatobesityreducedtheinitiationanddurationofbreastfeeding✔ ObesityhadgreatereffectonbreastfeedingamongLatinasthanamongblackwomen,withwhitewomenfallinginbetweenthesegroups

✔ Greaterdegreeofobesityassociatedwithlowerratesofbreastfeeding✔ MaybeconfoundedbygreaterriskforGDM,hypertension,C-sectionorassisteddeliveryandothermaternalcomplications

RasmussenAnnuRevNutr2007;Turcksinetal.MaternChildNutr2014

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Child Nutrition

✔ OneinthreeUSchildrenisoverweight✔ 17%areobese✔ Disparitiesinobesityarepresentatallagegroup✔ Weightstatusisamajorcauseofbullyingamongschool-agedchildren

✔ CYSHCNhavemanynutritionneeds✔ 12%havefoodallergies✔ 27%ormorerequiremedicationthatmayinteractwithfood

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ASPHN Resources

✔ ImprovingtheNutritionalWell-BeingofWomen,ChildrenandFamilies✔ TheRoleofNutritioninInfantMortality:APublicHealthPerspective✔ IncorporatingNutritionintheTitleVMCHServicesBlockGrantNationalPerformanceMeasures

✔ PreconceptionHealth:TheRoleofNutrition✔ ObesityPreventionMatrix✔ TheIntersectionofPublicHealth,CommunityandClinicalDietetics✔ ASPHNCollaborationPrimer✔ BlueprintforNutritionandPhysicalActivity

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Innovative Nutrition Integration

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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

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AIM

✔ InnovativelyIntegrateNutritionintoTitleVMCHBlockGrantandotherMCHPrograms.

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First Primary Driver

✔ ImproveaccesstoqualitynutritionservicesprovidedbyqualifiedprovidersinallTitleVsupportedandaffiliatedprograms.

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Second Primary Driver

✔ OptimizethenumberofpublichealthnutritionFTEsintheLocal,StateandNationalTitleVworkforce.

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Third Primary Driver

✔ IncreasethebasicnutritioncompetencyoftheentireTitleVWorkforce,whileexpandingtheirawarenessofavailablenutritionexpertsandappropriatereferralcriteria.

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Fourth Primary Driver

✔ MaximizepartnershipstointegratenutritionintotheTitleVBlockGrantapplication,allTitleVsupportedandaffiliatedprograms.

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Fifth Primary Driver

✔ DevelopreliableandaccuratemessagingonthevalueofintegratingnutritionintoallTitleVsupportedandaffiliatedprograms.

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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

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Step 2: Change Packages ✔ October–November2018✔ Nationalexpertstoreviewthetopissuesandidentifytrends.✔ Groupstatesinto“Teams"ofsimilarpriorities.✔ Holdmeetingsforeach“Team”togenerateideastoaddresstheirpriority.

✔ ExpertcommitteedevelopChangePackagesforeach“Team”

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Step 3: Team Work

✔ November2018–September2018✔ PDSAcyclesconsistentwithChangePackage.✔ Meetregularlytodiscusssuccessesandchallenges

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Time Line Summary

✔ September2018–HoldNeedsAssessmentMeeting✔ October2018–SubmitMeetingSummary✔ November2018–DevelopChangePackage✔ December2018–Start“Team”work

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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

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Evaluation

✔ WebinarEvaluationconductedbyAMCHP✔ EmaillinktosurveyfromCherylClark,cclark@amchp.org✔ Surveywillbeopenfor2weeks.

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Upcoming Calls

✔ PAWorkstreamNetworkingCall✔ July25,2018at1pmET

✔ CHW-CoIINWebinar✔ August15,2018at1pmET

✔ BFWorkstreamNetworkingCall✔ August30,2018at1pmET