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

2. Why Preconception Care?

3. Why Preconception Care? Early prenatal care is too late.

4. When Does the Fetal Heart Begin to Beat?

5. Early Prenatal Care Is Too Late To 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

6. Early Prenatal Care Is Too Late To Prevent Implantation Errors Norwitz ER, Schust DJ, Fisher SJ.Norwitz ER, Schust DJ, Fisher SJ. Implantation and the survival of early pregnancy. N Engl J Med. 2001 Nov 8;345(19):1400-8.

7. 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.

8. Early Prenatal Care Is Too Late from A Life-Course Perspective Early prenatal care is too late to restore allostasis and optimize womens health before pregnancy

9. What Is Preconception Care?

10. 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.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.

11. Summary of the CDC/ATSDR Select Panels 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 womens 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.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.

12. Components of Preconception Care Risk Assessment Health Promotion Medical & Psychosocial Interventions Lu MC. Recommendations for preconception care. Am Fam Physician. 2007;76:397-400.

13. 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

14. Get ready to get pregnant

15. Tip #1 Ask About Reproductive Life Plan

16. 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

17. 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?

18. Tip #2 Start prenatal care before you get pregnant

19. Components of Preconception 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.

20. Examples of Drugs to AvoidAgentComments ACE inhibitors, ARBs Kidney abnl if exposed in 2 nd or 3 rd tri StatinsAbnormalities if exposure 4–9 th week TestosteroneMasculinization of female fetus CarbamazapineFetal death, mental retardation, malformations of heart, genitals; cleft palate and arteries Coumadin derivatives (warfarin) Risk of bone+ cartilage deformities, mental retardation, vision problems LithiumIncreased risk of CV anomalies PhenytoinRisk of fetal hydantoin syndrome Valproic acid Use in 3-4 divided doses; not with carbamazapine + phenobarbitol IsotretinoinElevated risk of SAB and anomalies

21. Questions about Drug Use in Pregnancy OTIS (Organization of Teratogen Information Specialists) http://www.otispregnancy.org Toll-free (866) 626-OTIS

22. Tip #3 Start eating for two (in quality, not in quantity)

23. Make Healthy Food Choices 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

24. Make Healthy Food Choices Eat more whole foods and less processed foods Use a menu planner www.MyPyramid.gov

25. Tip #4 Eat more brain foods

26. Top 10 Brain Foods 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

27. Tip #5 Eat less toxic foods

28. Top 10 Toxic Foods 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

29. Fish: Brain Food or Toxic Food?

30. What You Need to Know about Mercury in 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

31. Tip #6 Take a multivitamin everyday

32. Micronutrients: Choosing Your Multivitamin Folic acid 400 mcg a day 4000 mcg a day with prior NTD Avoid excess (more isnt always better) A>10,000 IU D>4,000 IU Nutrition first!

33. Tip #7 Achieve a healthy weight

34. Achieve A Healthy Pre-Pregnancy Weight 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

35. 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

36. Tip #8 Learn How Not to Get Stressed Out

37. 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

38. Fetal HPA Maturation Hypothalamus Pituitary Adrenal + CRH + ACTH CRH Placenta (+) Cortisol DHEA-S (+)

39. Maternal HPA Activation Hypothalamus Pituitary Adrenal + CRH + ACTH CRH Placenta (+) Cortisol DHEA-S (+) Hypothalamus Pituitary Adrenal (+) CRH ACTH Cortisol Norepinephrine

40. Exercise Eat right Get a good nights sleep Learn how not to get stressed out

41. Relaxation techniques Breathing exercises Progressive relaxation Meditation Mindfulness Learn how not to get stressed out

42. Positive Mental Health A sense of meaning Self-acceptance Autonomy Positive relations with others Satisfaction with life Optimism Learn how not to get stressed out

43. Develop Positive Mental Health Find your purpose (follow your bliss) Use your strengths Count your blessings Live in gratitude Learn to forgive Savor lifes joy Spend time with friends and families Practice daily acts of kindness Learn to be optimistic Learn how not to get stressed out

44. Relationality is primary, All else is derivative. - Ronald David Learn how not to get stressed out

45. Tip #9 Tune-up your immune system

46. How to Give Your Immune System A Tune-Up? Get rid of ongoing infections & inflammation Make lifestyle changes to improve immune fitness

47. Immune Tune-Up Brush Floss Go see your dentist

48. How to Avoid Toxoplasmosis Wear gloves when you garden Cook all meat thoroughly Wash raw vegetables thoroughly Exercise precautions around 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

49. How to Avoid Cytomegalovirus 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

50. Immune Tune-Up Update your immunizations Tdap Hepatitis B Influenza MMR Chickenpox HPV

51. Tip #10 Detoxify Your Environment

52. Detoxify Your Home 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

53. Detoxify Your Home Kitchen & dining room Get rid of non-stick pans perfluorinated chemicals Dont 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

54. Detoxify Your Home 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

55. Which # Plastic Bottles Should Be Avoided?

56. Tap vs. Bottled Water 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 Dont reuse water bottles

57. Avoid Occupational Exposures 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

58. Preconception Care for Men

59. Preconception Care for Men 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

60. How Many Sperm Does a Man Make in a Lifetime?

61. Preconception Care for Men? 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

62. 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.

63. Father Involvement Barriers 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

64. Improving Father Involvement An 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

65. Father Involvement A Life-Course Perspective How do boys become men, and how do men become fathers?

66. The primary task of every civilization is to teach young men how to be fathers. Margaret Mead

67. Interconception Care

68. The definition of insanity is doing the same thing over and over and expecting different results Benjamin Franklin

69. "We must become the change we want to see. - MOHANDAS GANDHI