poverty, biology, and health: will the circle be …...2015/01/22 · recent scientific evidence...
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Poverty, Biology, and Health: Will the Circle Be Unbroken?
Craig T. Ramey and Sharon L. Ramey
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Basic Premises: “The circle” • Poverty impacts biology • Biology affects experiences, development,
and health • Health and experiences of parents exert
influences on the life course of future generations
• Intergenerational patterns of health, as well as educational attainment, can be altered by applying fundamental principles of developmental science
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Poverty: Conceptualization & Correlates • Poverty = inadequate resources and
insufficient experiences needed for survival, growth, and competence
• Federal Poverty Level (FPL) is based solely on income (2014: $23,850/yr for family of 4)
• In the U.S., race predicts income and poverty rates
• Children are disproportionately affected by poverty – foreshadowing entrenched health disparities that span generations
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U.S. Black household income is 59% that of white/non-Hispanic households
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Increasing Poverty Rates among Children: Black:White Disparities >2X
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Health: Conceptualization & correlates
• Health = composite of physical, mental, and social-emotional indicators
• No consensus definition of health • Health is more than absence of risk
conditions, disease, and injuries • The new vision for “precision
medicine” (individualized, genomic-based) could revolutionize treatments and health outcomes
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Being poor and/or Black predict(s) an excess of many health-related indicators
• Stress, anxiety, and depression • Obesity and inadequate exercise • Addictions • Cardiometabolic diseases • Injuries • Respiratory illnesses • Exposure to environmental toxins • Prematurity, low birth weight, and infant mortality • Disruptions in family structure, residence, work • Premature death
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Recent Scientific Evidence that “the circle can be broken”
1. Early educational and health interventions can disrupt expected intergenerational patterns of low educational attainment, poverty, and poor health (The Abecedarian Project)
2. Biological risks for non-optimal development can be overcome by systematic early supports (The Infant Health & Development Project)
3. Preconception and prenatal “stress and resilience” of parents can alter pregnancy outcomes and set the stage for lifelong health (The Community Child Health Network Study)
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The Central Questions of The Abecedarian (ABC) Project
To what extent can increasing the early educational and health supports for children from extremely impoverished homes prevent intellectual and learning disabilities? promote cognitive and social outcomes? improve lifelong health and well-being?
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The Abecedarian Project: Two-‐Phase Randomized Controlled Trial (RCT)
Birth 5 Year 8 Years 12 Year 1 5 Years 21 Years 30 Years
R
R
R
R = RANDOMIZATION
Preschool Intervention (N=57)
Preschool Control (N=54)
School-Age Control (N=23)
School-Age Intervention (N = 24)
School-Age Intervention (N = 25)
School-Age Control (N=24)
(N=25)
(N=22)
(N=21)
(N=22)
Timing of Intervention
Birth to 8
Birth to 5
Ages 5 - 8
None
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Control Group Adequate nutrition Supportive social services Primary health care delivered Referrals for follow-up made when problems detected
Abecedarian Project Intervention Services for Treatment and Control Groups
Treatment Group_ Adequate nutrition Supportive social services Primary health care delivered Preschool treatment: Highly qualified staff Implementation monitoring High dosage: 5 days/week, 50 weeks/year, 5 years “Learningames” Curriculum
Cognitive / Fine Motor Social / Self Motor Language Individualized pace
Ramey, Sparling, & Ramey Abecedarian: The Ideas, the Approach,
and the Findings (2012)
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The Abecedarian Intervention Prevented Intellectual Disabilities: % with IQs >84
Martin, Ramey, & Ramey, 1990 American Journal of Public Health
100% 100% 95% 95%
93%
78%
49%
45%
40%
50%
60%
70%
80%
90%
100%
6 Months 18 Months 36 Months 48 Months
Perc
ent
Child Age
ECE Group
Control Group
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Z Scores, Mean Standardized Scores, and Effect Sizes for Abecedarian Treatment and Control Children from 3 – 54 months
Ramey et al, 2000 Applied Developmental Science
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Estimated Cumulative Influences on IQ in the Abecedarian (ABC) Project sample
Regression Coefficients
Age in Months Educational Preschool Maternal IQ<70 Positive Home
Environment
12 + 7.9 1.0 + 4.9
24 + 12.7 - 4.3 + 5.1
36 + 18.6 - 8.2 + 8.6
48 + 13.2 - 11.7 + 8.9 Adapted from Martin, Ramey, & Ramey, American Journal of Public Health, 1996
Regression Coefficients
Age in Months ABC Intervention Maternal IQ<70 Positive Home
Environment
12 + 7.9 1.0 + 4.9
24 + 12.7 - 4.3 + 5.1
36 + 18.6 - 8.2 + 8.6
48 + 13.2 - 11.7 + 8.9
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Abecedarian Project: Woodcock-Johnson Age-referenced Reading Standard Scores at age 8
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Significant Health and Education Benefits of the Abecedarian (ABC) Intervention
15 Months to 35 Years Old Intelligence (IQ) Reading and math skills Academic locus-of-control Social Competence Years in school College attendance Earned 4 yr college degree Full-time employment Cardiometabolic health
Grade Repetition Special Education placement Teen Pregnancies Smoking & drug use Teen depression Welfare use Overweight/BMI Framingham Risk Score
Plus benefits to mothers of these children (education, employment) Ramey, Sparling, & Ramey (2012); Science (2014)
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The 8-site Infant Health and Development Program (IHDP)
• Designed to address the Abecedarian Project questions applied to a highly diverse, biologically at-risk population • Enrolled 985 infants who were premature (<37 wks GA) and low birthweight children (< 2500 gm) • Randomized Controlled Trial (RCT) in 8 cities/university partners • Adapted the ABC Early Health and Education supports
- home visiting added (birth – 36 mos) - center-based education from 12 – 36 mos.
• PREMATURITY RATES: 17.1% Blacks, 10.8% Whites LBW RATES: 13.5% Blacks, 7.1% Whites
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Stanford-Binet IQ Scores at 36 Months Heavier LBW Group (2001-2500gm)
Infant Health and Development, JAMA, 1990 Ramey, AAAS, 1996
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Outcomes Affected Positively (*p<.01) by the Infant Health & Development Program
12 Months 24 Months 36 Months Cognitive Development NS + + Adaptive and Prosocial Behavior - - + Reduction in Behavior Problems - + + Vocabulary - + + Receptive Language - + + Children’s Reasoning - - + Positive Home Environment NS - + Maternal-Child Interactive Behavior - - + Maternal Problem Solving - - +
Ramey 1999, adapted from Gross, Spiker, & Haynes, 1997,
Helping Low Birth Weight, Premature Babies
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The ABC intervention breaks the correlation between maternal education and child intelligence at age 3:
From IHDP 8-site replication of ABC
70
75
80
85
90
95
100
105
110
Some High School
High School Graduate
Some College College Graduate
IQ
Control ECE
(n=232) (n=162) (n=166) (n=104) (n=134) (n=63) (n=76) (n=48)
Adapted from Ramey, Sparling, & Ramey 2012
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The Community Child Health Network (CCHN): What we knew in 2002
1. Rigorous trials of high quality prenatal care failed to reduce prematurity and LBW, although it produced many other positive health behaviors in poor, Black women.
2. Retrospective studies showed support for fetal developmental programming of adult-onset illnesses (the Barker hypothesis), but many limitations in studies.
3. Experiences prior to conception likely to exert both biological and behavioral effects on parents and children.
4. Neighborhood and community effects documented as impacting pregnancy outcomes.
5. Maternal stress (as well as depression and anxiety) related to preparedness for pregnancy and parenting competency.
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How the Community Child Health Network (CCHN) originated
• 2002: CCHN sponsored by National Institute of Child Health and Human Development (NICHD) as a multi-phase, interdisciplinary, academic- and community-partnered network
• Goal: to develop innovative approaches to advance understanding of entrenched “maternal and child health disparities”
• Phase 1: Pilot research and community-academic partnerships; Phase 2: 5-site study of interconception care and pregnancy outcomes
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Innovations in CCHN Study • First to measure allostatic load (index of cumulative
wear-and-tear due to stress) in women during childbearing years
• Included multiple measures of stress - perceived stress and environmental stressors - and resilience, as well as perceived racism and discrimination, depression, anxiety, trauma, neighborhood resources
• Strong focus on fathers and relationship quality with partners/mothers and their children
• First NICHD research network using Community-Based Participatory Research (CBPR)
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Allostatic load
• A composite index of the wear-and-tear of exposure to episodic and chronic stress
• The consequences of allostasis – an ongoing set of processes to maintain homeostasis (regulate major body systems) while adapting to stress
• Predictive of disease (morbidity) and death in middle age to older age populations
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10 Indices of Allostatic Load in CCHN
• HPA Axis/Stress: Systolic blood pressure, diastolic blood pressure, salivary cortisol (diurnal)
• Immune/Inflammatory: High-sensitivity C-reactive protein, tumor necrosis factor, interleukin-6
• Metabolic: Body Mass Index (BMI), waist-to-hip ratio, glycosylated hemoglobin, lipid panel
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CCHN Phase 2 Study (2005-2012)
• Multisite, transdisciplinary, prospective, longitudinal study of the inter-pregnancy period in heterogeneous sample (with over-representation of low-income, black/African American, and Hispanic/Latino families and premature births)
• Enrolled 2510+ families at time of birth of one child, followed at least 24 mos or until next pregnancy and birth
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Mother Allostatic
Load
BIOMAKERS AND
PHYSICAL MEASURES
Mother
Mental & Physical Health, Health
Behavior, and
Parenting
Child Outcomes:
Health, Behavior,
and Neurocognitive Development
Father
Mental & Physical Health, Health
Behavior, and
Parenting
Father
Allostatic Load
BIOMAKERS
AND PHYSICAL
MEASURES
Parents’ Relationship Relationship
and Home
Environment
Mother Stress and Stressors
Mother Resilience and Social
Support
Father Resilience and Social
Support
Father Stress and Stressors SO
CIAL
& P
HYSI
CAL
ENVI
RONM
ENT:
NEI
GHB
ORH
OO
D &
COM
MUN
ITY
CONT
EXTS
SO
CIAL & PHYSICAL ENVIRONM
ENT: NEIGHBO
RHOO
D & COM
MUNITY CO
NTEXTS
SOCIAL & PHYSICAL ENVIRONMENT: NEIGHBORHOOD & COMMUNITY CONTEXTS
SOCIAL & PHYSICAL ENVIRONMENT: NEIGHBORHOOD & COMMUNITY CONTEXTS
Interpregnancy Interval
HEALTH CARE, EDUCATION, WORK, RECREATION, & SPIRITUAL RESOURCES
HEALTH CARE, EDUCATION, W
ORK, RECREATIO
N, & SPIRITUAL RESOURCES
HEALTH CARE, EDUCATION, WORK, RECREATION, & SPIRITUAL RESOURCES
HEAL
TH C
ARE,
EDU
CATI
ON,
WO
RK, R
ECRE
ATIO
N, &
SPI
RITU
AL R
ESO
URCE
S
Prenatal
Development and Birth Outcomes
The Preconception Origins of Family Health (CCHN Model) - Ramey et al (2014)
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Central Hypotheses tested from the CCHN Conceptual Framework
1. Parental stress and resilience will influence maternal allostatic load during the preconception period.
2. Parental stress and resilience will be associated with the quality of the mother-father relationship and social support as well as their mental health and parenting.
3. Maternal stress and allostatic load in the preconception period will influence prenatal development, including LBW and fetal programming of risk for stress-related health conditions. (new Phase 3 Study ongoing)
4. Community resources and challenges, including racism and discrimination, will impact parent stress, their health and health care utilization, and children’s neurocognitive development and cardiometabolic outcomes.
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Collectively, we have converging scientific findings to supporting the conclusion
that “the circle can be broken” 1. Early educational and health interventions can
disrupt expected intergenerational patterns of low educational attainment, poverty, and poor health.
2. Consequences of biomarkers for non-optimal development (e.g., low birthweight, prematurity) can be overcome by systematic supports to promote health and development.
3. Preconception and prenatal “stress and resilience” of parents can alter pregnancy outcomes and set the stage for improved (vs impaired) lifelong health.
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• We owe immense thanks to our many collaborators, community partners, and funding agencies (NIH, RWJ FoundaIon, MCHB, CDC, Pew Charitable trusts)
• All of these datasets are either in the public domain or scheduled for release to maximize scienIfic uIlity and build public trust
• For copies of this presentaIon and key supporIng citaIons, please contact us: [email protected] [email protected] 540-‐526-‐2033