1. Milton Kotelchuck, PhD, MPH California MCAH Action
Rethinking MCH: The Life Course Theory and Its Implications for Practice: Moving to Action – Knowledge Base, Social Strategy and Political Will
Milton Kotelchuck, PhD, MPH
MGH Center for Child and Adolescent Health Policy, and Harvard Medical School
California MCAH Action
May 19, 2011

2. Goal of Presentation
Build on the introduction to the MCH Life Course paradigm
Introduce the Richmond-Kotelchuck health policy framework as a strategic framework for MCH Life Course implementation
Provide examples of MCH Life Course research, practice and policies
End on a call to collaborative action 2

3. Ideas and Slides Freely Adapted
From my Colleagues
Amy Fine
Michael Lu
Cheri Pies
Deborah Allen
Neal Halfon 3

4. Richmond & Kotelchuck, 1983 4

5. MCH History and MCH Life Course
Title V/MCHB itself has a programmatic life course; it is at a critical transformative moment
MCH life course reflects new, and renewed, ideas about how to move us forward to improve MCH population health and reduce disparities

6. Life Course is not new to MCH
“MCH does not raise children, it raises adults.  All of tomorrow's productive, mature citizens are located someplace along the MCH continuum.  They are at some point in their creation either being conceived or born or nurtured for the years to come.  There is very little genuine perception that mature people come from small beginnings, that they've had a perilous passage every moment of the way.  All the population, everybody of every age were all at one time children.  And they bring to their maturity and old age the strength and scars of an entire lifetime.”
Pediatrician in Hawaii
Pauline Stitt, MCHB 1960

7. Incorporating Life Course, Social Determinants, and Health Equity into California’s MCAH Programs
Shabbir Ahmad, DVM, MS, PhD
Maternal, Child and Adolescent Health Program
Center for Family Health
California Department of Public Health
February 25, 2010
HRSA / MCHB

8. Social Determinants
The social determinants of health are those factors which are outside of the individual; they are beyond genetic endowment and beyond individual behaviors. They are the context in which individual behaviors arise and in which individual behaviors convey risk. The social determinants of health include individual resources, neighborhood (place-based) or community (group-based) resources, hazards and toxic exposures, and opportunity structures.
Camara Jones, 2010

9. Health Equity
Where systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair. It is this that we label health inequity.
Putting right these inequities – the huge and remediable differences in health between and within countries – is a matter of social justice.
World Health Organization
Commission on Social Determinants of Health

10. Life Course Model Posits a new scientific paradigm for the MCH field
Addresses enduring health issues with new perspectives (e.g., disparities)
Requires new longitudinal and holistic approaches to MCH programs, policy and research
Provides an integrated framework for facilitating the MCH policy agenda
Links the MCH community to adult and elderly health and social service policy development

11. Key concepts of the MCH Life- course Model
Today’s experiences and exposures determine tomorrow’s health (timeline)
Health trajectories are particularly affected during critical or sensitive periods (timing)
The broader environment – biologic, physical, and social – strongly affects the capacity to be healthy (environment)
Inequality in health reflects more than genetics and personal choice (health equity)
Amy Fine, Milt Kotelchuck, 2009 11

12. Life Course Perspective
This may be particularly important for all of us in MCH, where one developmental stage often gets disconnected from another. In perinatal health, we focus so much on events occurring in the 9 months of pregnancy we forget that there are a great deal of life course influences on perinatal outcomes, and a great deal of perinatal influences on life course outcomes.
For example, in explaining the Black-White gap in infant mortality, for decades we searched for maternal risk factors during pregnancy rather than looking at the mothers’ cumulative life course experiences. The danger of focusing solely on risk factors during pregnancy is not only that it doesn’t adequately explain the disparities, but more importantly it can misguide public health programs and policies. For two decades we thought if we could get women universal access to good quality prenatal care, then we can do something about reducing infant mortality and racial disparities in this country.
Many of us recognize now that to expect prenatal care, in less than nine months, to reverse all the cumulative disadvantages and inequities over the life course of the woman, may be expecting too much of prenatal care. If we as are serious as a nation about improving birth outcomes and reducing disparities, we have to start taking care of women and families not only during pregnancy, but before and between pregnancies and indeed, across their entire life course.
All four key concepts need to be addressed 12

13. MCH Life Course Goals
To optimize health across the lifespan for all people; and
To eliminate health disparities across populations and communities
Fine and Kotelchuck, 2010

14. MCH Life Course Could it be true?
Could we really transform disparities into equity?
The WHO Nutrition Standards

15. 15

16. WHO Multicentre Growth Reference Study Background / Context
Current growth curves developed from 1930’s Fels longitudinal studies (White middle class sample)
Should there be separate norms for each cultural / racial group?
Fierce debate among MCH Epidemiologists, especially given major LBW racial disparities in U.S.
Issue arose in Guatemalan INCAP study of the effects of malnutrition on mental development (since Guatemalans were shorter, why use U.S. norms?)

17. WHO Multicentre Growth Reference Study Purpose of Study
Goal: to assess optimal child growth (and motor development) and create standards usable throughout the world
Distinction between standards and norms
Ideal vs.. actual growth curves

18. WHO Multicentre Growth Reference Study Methods I
Sample selected for optimal growth
All upper middle class families
All infants exclusively breastfed for four + months
All full-term births, with no birth defects
Longitudinal (0 – 24 months) and cross-sectional samples (18 – 71 months)
N=1743 longitudinal, N=6697 cross-sectional (N=8440)
Six sites chosen around the world
U.S. (Palo Alto), Ghana (Accra), Oman (Muscat), India (South New Delhi), Brazil (Pelatos), Norway (Oslo), [China dropped out]

19. WHO Multicentre Growth Reference Study Methods II
Standardized measurement protocols, very well trained and supervised staff
Physical measurement recorded
Length / height, weight, weight for height, BMI
Monthly thru12 months, bi-monthly thru 24 months, then 4 times thru age 5
Motor development milestones
Sitting with support; hands and knees crawling; standing with assistance; standing alone; walking with assistance; walking alone
Measured at same age as above thru 24 months, plus utilized mother’s reports
All measurements were home-based

20. WHO Multicentre Growth Reference Study Detailed Results
Physical Growth (standards)
Essential similar everywhere (data combined)
Only 3.4% inter-site variations; 70% intra-site variability; 26% error
Motor Development
No sex differences
5/6 of motor developments sequential
No relationship between infant size and motor development
Birth Characteristics
Modest variations 3,300 mean birth weight ( Kg range)
3.2% LBW (vs.. national estimates (up to 30% in India)), shows powerful impact on SES on birth outcomes

21. WHO Multicentre Growth Reference Study Major Conclusions
Inter-cultural variability only 4% of variance
All growth retardation reflects environmental insults
Overall (genetic / cultural) longitudinal continuity for human growth and motor development under optimal conditions
Breastfeeding established as norm for growth standards
Supports social justice orientation

22. The New 21st Century Scientific Basis for the MCH Life Course
Provides an understanding of how the social environment gets built into or embodied into our physical bodies
Bridges our intuitive understanding of the social causes of ill health (poverty, malnutrition, stress) with our understanding of its clinical manifestations and treatment
Incorporates our growing scientific understanding of the biology of human development into our health trajectories
Focuses on root causes of illness and disparities

23. 23

24. Neurons to Neighborhoods Early Environments Matter and Nurturing Relationships are Essential
Parents and other regular caregivers in children’s lives are “active ingredients” of environmental influence during early childhood
Children’s early development depends on health and well being of parents
Early experiences affect the brain (the focus on the 0-3 period begins too late and ends too soon)
A wide range of environmental hazards threaten the developing central nervous system
The capacity exists to increase the odds of favorable development outcomes through planned interventions

25. 2004 National Research Council and Institute of Medicine Report25

26. IOM/NRC Definition of Children’s Health (2004)
“Children’s health is the extent to which individual children or groups of children are able or enabled to (a) develop and realize their potential, (b) satisfy their needs, and (c) develop the capacities that allow them to interact successfully with their biological, physical, and social environments.”
From Children’s Health, the Nation’s Wealth, National Academies Press, 2004. 26

27. Developmental Life Course Model
Harvard Center For the Developing Child, Jack Shonkoff 2008

29. Life Course Perspective
This may be particularly important for all of us in MCH, where one developmental stage often gets disconnected from another. In perinatal health, we focus so much on events occurring in the 9 months of pregnancy we forget that there are a great deal of life course influences on perinatal outcomes, and a great deal of perinatal influences on life course outcomes.
For example, in explaining the Black-White gap in infant mortality, for decades we searched for maternal risk factors during pregnancy rather than looking at the mothers’ cumulative life course experiences. The danger of focusing solely on risk factors during pregnancy is not only that it doesn’t adequately explain the disparities, but more importantly it can misguide public health programs and policies. For two decades we thought if we could get women universal access to good quality prenatal care, then we can do something about reducing infant mortality and racial disparities in this country.
Many of us recognize now that to expect prenatal care, in less than nine months, to reverse all the cumulative disadvantages and inequities over the life course of the woman, may be expecting too much of prenatal care. If we as are serious as a nation about improving birth outcomes and reducing disparities, we have to start taking care of women and families not only during pregnancy, but before and between pregnancies and indeed, across their entire life course.
Lu and Halfon, 1998 29

30. Education and Training
MCH Life Course Paradigm Shift MCH Life Course Conference June 2008, Oakland CA MCH Life Course Model Topics to be Addressed
Theory
Research
Practice
Policy
Education and Training
Kotelchuck, Lu, Pies, 2008

31. HRSA/MCHB Concept Paper
Rethinking MCH: The Life Course Model as an Organizing Framework
Prepared under contract by
Amy Fine and Milton Kotelchuck
October 2010

32. Richmond & Kotelchuck, 1983 32

33. Starting points for advancing the MCH Life Course
Strengthen the MCH life course knowledge base
Develop new programs and policy strategies
Engage and enhance MCH partnerships

34. Strengthening the Knowledge Base: Life Course Research Network
To overcome these disciplinary and institutional silos, the MCHB recently funded the MCH Life Course Research Network. The goal of the life course research network is to advance MCH life course research, and to maximize the impact of that research on MCH practices, programs and policies. UCLA will serve as the administrative and communication hub, but this cannot be a UCLA thing. By creating a network, we are hoping to breakdown disciplinary and institutional silos, and to engineer collaborative innovations. 34

35. Opportunities exist, and need to be nurtured
A Life-course Approach to MCH Epidemiology: MCH Data Needs and Applications
The current MCH EPI field is not yet well equipped to support a life course approach
Limited longitudinal analytic capacity
Scattered longitudinal data bases
Disciplinary and institutional silos
Virtually no measures of life-course trajectories, cumulative risks, cumulative experiences
Confidentiality legal infrastructure not in place
Few longitudinal data/life course training opportunities
Opportunities exist, and need to be nurtured 35

36. MCH – Life Course Health Development
Evolution of LCHD
Chronic Disease Epidemiology,
Health Demography,
Life Course
Social context on individual
Age, cohort, historical effects
Cumulative mechanisms
Health Prism
MCH LCRN
MCH – Life Course Health Development
Linked Lives
Pathways
Transitions
Trajectories
Developmental Pathways
Sensitive, critical period
Plasticity, resilience
Transitions, turning points
Cumulative, Pathway, and Programming mechanisms
Emergent Health Trajectories
Life Span Dev.
Development Individual Differences
Adaptivity, Plasticity, Resilience
DOAHD
Neurodevelopment
Intervention Research

37. New synthesis – MCAH Reframe/positioning Transdisciplinary
Life Course Perspective on Basic Mechanisms of Disease Causation
Life Course Chronic Disease Epidemiology
D O A D
Neruo-development
Economic Modeling
Intervention Studies
LCHD Theory
Life Course Health Development
New synthesis – MCAH Reframe/positioning
Transdisciplinary
Translation: MCAH Practice
Health is developmental
Complex pathways & Emergent Trajectories
Sensitive & Critical Periods
Programming, Cumulative , Pathway Mechanisms

38. Theory Development MCH Programs, Policy Neuro-dev Econ
LCCDE
DOAD
Neuro-dev
Early Inter
Econ
Analyses & Synthesis
LCHD
Sensitive periods
pathways
Theory Development
Transitions
Bio embedding
Trajectories
???
Translational Analysis
Translational Research
MCH Programs, Policy
spreading
Clinical
T-1 Cc
Program
PCc
T-4
T-2
Community Cc
scaling Cc
Systems
T-3

39. Clinical Trial of Weight Reduction
Maternal / Perinatal
Infancy
Early Childhood
Middle Childhood
Adolescents
Basic Mechanisms
Maternal Weight & Fetal Programming
T-1
Clinical Trial of Weight Reduction
T-2
Practice based intervention
T-3
Community Program
T-4
Health Policy Change

40. What We Want to Know about LCHD
Research Strategy: Advancing and Applying LCHD Research
What We Want to Know about LCHD =
Child
Interventions
Service system
Policies
Basic Mechanisms Research:
Influences on health, development, behavior, and education trajectories
Intervention Research:
That improves health, dev, beh, edu trajectories
Service & System Research:
organization, delivery, & payment of services systems
Policy Research:
Policies that promote, optimize, improve health, dev, beh, edu of children and youth
Research Methods
Provide better data
Create new measures
Develop better measurement systems
Develop innovative methods
Capacity
Building
Create multidisciplinary training pipeline
Increase analytic capacity at multiple sites
Increase $$ & funding opps.
How We Want To Do It
Policy Analysis
Communication
Inform key target audiences: academics, service providers, policy makers, parents, & communities
Develop better understanding of risk, protective, & promoting factors and how to improve health, dev, beh, and edu trajectories
Increase number of evidence-based interventions for deployment in services and service systems
Inform service system design, organization, improvement, and financing
Influence public policy at state, local, & national levels
Why We Want to Know It

41. Knowledge Base
What’s Needed: There is general agreement among those working on MCH life course strategies that the knowledge base around both concept and practice needs to be further strengthened. Among the key areas to be addressed:
Building and disseminating the scientific evidence supporting the need for a life course approach;
Documenting and disseminating information on the type of programs, practices, and policies to improve life course trajectories;
Developing new standards and measures that capture key life course concepts (i.e., timeline, timing, environment and equity);
Developing new methodological approaches for ongoing monitoring of longitudinal impact; and
Incorporating Life Course Theory concepts into training and continuing education programs to move the MCH field forward.
Fine and Kotelchuck, 2010

42. Program and Policy Strategies
What’s Needed: A thoughtful, integrated set of MCH and MCHB programs and policy strategies could provide an opportunity to improve health and well-being across the life course and across the population.
Translating life course theory into concrete programs and policies is perhaps the most difficult of the life course challenges.
Multiple interventions and policies at a variety of levels across multiple time periods are needed.
While many individual MCH programs and policies can and do improve the health of individuals served, more needs to be done to address alarming new trends in chronic diseases and disorders, and to reverse longstanding disparities in health and well-being.

43. Program and Policy Strategies
Life course theory implies the need to go beyond individual programs and policies, aimed at individual diseases and disorders, in order to promote and optimize health across generations and communities.
LCT suggests the need to consciously build a program and policy “pipeline for healthy development” – a continuum of services and supports that promote optimal health and development from birth throughout the lifespan, from the birth of one generation to the next.
What is needed is the integration of services and supports that are longitudinal (over time), vertical (within the health sector) and horizontal (across health and other sectors).
Also needed are programs and policies that address root causes of disparities in health by helping to reshape the conditions in which people live, work, play and develop.

44. MCH Life Course into Practice
Our field’s challenge is to transform this new MCH Life Course theory and research into new MCH practice and policies
Lots of MCH life course experimentation is now occurring
Here are some initial ideas to get us thinking how MCH life course could influence our practice and policy

45. Multiple time points for intervention
MCH Life Course Model Barbara Ferrar’s Overview of its Meaning for Practice
Multiple time points for intervention
Expanded settings for intervention
Policy is important at local, state and national levels
Ferrar, 2007 45

46. MCH Life Course Practice
The MCH Life Course Theory suggests a greater attention to four key continuities or discontinuities in health and health care that impact on achieving optimal health
Longitudinal continuity
Vertical continuity
Horizontal continuity
Holistic continuity
Kotelchuck et al 2008

47. New MCH Life-course programmatic integration and discontinuity themes
Longitudinal Integration
Continuity of care/services- school to workforce
Maintenance of longitudinal records (a la Europe)
Prevention, upstream approaches
Vertical Integration (within health service programs)
Good intra-health program hand offs (when WIC ends where do the mothers, children go)
Primary to tertiary handoffs;
Strong follow-up capacity
Horizontal Integration (cross-program, cross-sector collaboration)
Cross program linkages; (markers: common funded activities and protocols; regular meetings)
Systems matrix (M. Drummond)
Good inter-program hand offs and collaboration
Addressing broad risk factors
Holistic Integration
Not discrete safety net programs
Mental health/behavioral health and physical heath programs are joined, are one
Community involvement
Are the programs “individual” or “family “ focused, rather than program focused
Programmatic flexibility (e.g. too many home visitors) 47

48. Alameda County Building Blocks Collaborative Medical Care Housing Jobs
Childcare
Medical Care
Jobs
Healthy Food
Alameda
County
Building
Blocks
Collaborative
Clean Air
To the west coast
Parks and Activities
Policy Makers
Education
Economic Justice
Preschool
Safe Neighbor-hoods
Residents
Transportation 48 48

49. Barriers to life course practice
Addressing immediate needs versus future theoretical life course gains
Categorical mandates
There is no menu of life course interventions
Attributable risk benefits of proposed interventions not well demonstrated
BUT, while doing good now, we will not prevent current MCH problems from simply re-occuring in the future.

50. Policy concepts deriving from the MCH Life-course Model
Refocus the organization and delivery of MCH clinical and population health services
Enhance linkages between health services and other child and family services and supports sectors (e.g., educational, social services)
Rebuild and redirect social, economic and physical environments to support and promote the health of the population (e.g. building community capacity to support health)
Fine, Kotelchuck et al, 2009 50

51. MCH Life Course Policy Initiative
Realigning Health Services and Systems
Integrating Health and Other Service Systems for Women, Children and Families
Building Community Capacity to Support Health
Creating National and Federal Agenda to Address Social Determinants of Health
Draft, Kotelchuck and Fine 2010

52. MCH Life Course Practice and Policy
Integration initiatives for Clinical/Public Heath
Within health systems
Between health and other systems of care
Holistic approaches
Whole child, whole family, common root causes
Placed based initiatives
Transformative initiatives within the community
Initiatives that strengthen the community
Policy Initiatives
Draft, Fine and Kotelchuck, 2010

53. Policy Implications for the Government Sector
Avoid the allure of categorical solutions
Focus on upstream population needs
Assure that needed programmatic collaboration happens
Partner with all sectors
Invest in data for policy decisions
Install visionary leadership
Debbie Allen, 2008 53

54. MCH Life Course Partnerships
Generate new political will to implement the MCH life course models

55. MCH Partners/Political Will
What’s Needed: Building political will (i.e., engagement and buy-in) for a life course approach among a broad base of stakeholders. To build political will, at least six groups need to be engaged:
MCHB’s (and HRSA’s) staff;
The broader MCH “family”;
Other health and non-health Federal agencies;
Non-traditional stakeholders
Local community and political stakeholders; and
The larger MCH population itself.

56. Political Will
Building political will requires balancing the immediacy and more limited focus of specific legislative mandates with a broader, cross-cutting and longitudinal life course vision.
Political will doesn’t just happen, it must be nurtured and developed through activities such as preparing and training leaders, engaging communities, social marketing and media campaigns, and professional education.

57. MCH Life Course Training and Education Tasks
Integrate MCH life course models into MCH training programs
Leadership training
Retool the current MCH workforce
Enhance MCHB leadership competencies/long term training to prepare future MCH leadership

58. New Needed MCH Life Course Skills/Capacities
Coalition building and collaboration
Advocacy
Longitudinal data capacity
Community-based participatory research
Enhanced needs assessment capacities
And many other skills 58

59. A Call to Action
Transforming MCH life course theory and research into concrete programs and policies is our ultimate challenge
We need an MCH life course learning community to share our knowledge and experiences
We need to reframe our programs and policies to be more consistent with life course theory
We need to transform all of our organizations into life course supporting organizations
And we need a new strategic thinking - to give structure and direction to our efforts and to help achieve the life course goals of optimizing health and eliminating disparities

60. MCHB is at a critical historical moment
The MCH life course reintroduces and rebalances social determinants and life course perspectives within MCHB
It builds on the Title V/MCHB’s 75th Anniversary heritage/legacy
This is an exciting, transformational moment; it is our community’s call to the future
But MCH life course is a work in progress – a paradigm shift – that will require all of our collaborations and efforts to make it happen

61. Richmond & Kotelchuck, 1983 61

63. MCH Life Course Scientific Support
There is a convergence of similar life course frameworks in related health fields
Reproductive life course models
Child development models
Chronic Illness models
The knowledge base for the MCH Life Course perspective is strong and getting stronger 63

64. Epigenetics
What is fascinating to me about all this fetal programming business is this phenomenon called epigenetics. Epigenetics is basically volume control for genes. You can turn up or down, or switch on or off gene expressions based on your prenatal exposures. And you can do that simply by putting a chemical group – in this case it’s a simple methyl group – CH3 with one carbon and 3 hydrogen atoms – if you put a methyl group right in front of the DNA, which blocks the gene from ever being expressed. Whereas if you take away that methyl group, then the gene is allowed to freely express itself. Generally speaking, methylation turns off or silences gene expression, whereas de-methylation turns on gene expression.
So prenatal stress can determine the amount of glucocorticoid receptors that gets expressed inside the brain simply by methylating or demethylating the DNA. This is fascinating to me because you can now have two people with the exact same genetic code, but they can have very different output of stress hormones depending on whether the genes are turned on or off, which has to do with whether or not their DNA’s are methylated or demethylated, which has to do with whether or not their moms were stressed out during pregnancy, attesting to the important and potentially lifelong impact of maternal stress during pregnancy on children’s health and development. 64
Gibbs WW. The Unseen Genome: Beyond DNA. Scientific American 2003

65. Life Course Chronic Disease Epidemiology
Adolescent Origins of Adult Diseases
Childhood Origins of Adult Diseases
Fetal Origins of Adult Diseases
High blood pressure
Diabetes Mellitus
Coronary Heart Disease
Cancer
Obesity
The Barker Hypothesis: Historical Cohort Analysis

66. Barker Hypothesis Birth Weight and Coronary Heart Disease
Age Adjusted Relative Risk
Rich-Edwards 1997

67. New Science Underlying MCH Life Course
Cumulative Impact
Cumulative multiple stresses over time can have a profound direct impact on health and development, and an indirect impact through associated behavioral or health service seeking change (Weathering)
Early Programming
Early experiences can “program” an individual’s future health and development, either directly in a disease or condition or in a vulnerability to a disease in the future

68. Barker Hypothesis Birth Weight and Insulin Resistance Syndrome
Odds ratio adjusted for BMI
Barker 1993

71. MCH Life Course Theory There is no single MCH Life Course theory text
Yet there is a need for a unified conceptual framework to help move the MCH field forward
To date, Life Course theory has focused primarily on causal analysis, with limited guidance for strategic actions

72. MCH Life Course Integration
Social determinants, and health equity models are complementary, synergistic and integral to the MCH life course
Life course perspective offers an explanatory model for how social determinants influence health
Life course perspective offers an explanatory model for how health inequities develop
Life course better incorporates longitudinal perspectives and the biology of human development into our understanding of health

73. Addressing key MCH Life Course concerns
Life course goes beyond, but includes, medical/clinical care; it is complementary not antagonistic to medical/clinical care
Life course is not deterministic trajectories, but transformational and interactive
Life course values life at every age equitably

74. MCH Bureau Strategic Planning and Leadership
MCHB has a critical leadership role to foster the MCH life course paradigm shift
The life course perspective, along with the social determinants, and health equity models, offers MCHB the opportunity to reinvigorate its Title V and Children’s Bureau legacy and political mandate – to address all factors that impact on children’s health and well-being
The life course perspective provides the MCHB with a federal and national leadership opportunity to broadly improve the health and well being of mothers, children and families

75. Developing an agenda for change; (across three broad domains)
Strengthening the life course knowledge base
Developing new program and policy strategies
Enhancing political will
And training of MCH professionals (both long-term and continuing education) to participate in the development and implementation of the new MCH life course efforts
Draft, Fine and Kotelchuck, 2010

76. MCH Life Course Research
Paradigm Shift
In MCH research, we are in the middle of a paradigm shift.
M.Lu, 2010 76

77. Center on the Developing Child at Harvard University

78. Public Health Nutrition Discontinuities
Longitudinal
Public Health nutrition more thoughtful than other MCH areas (about upstream causes; longitudinality of impacts)
Limited downstream intervention effectiveness (TV monitoring itself; Adolescent diets)
Poor longitudinal nutrition records
Vertical or programmatic
WIC ends, where do the children or mothers go?
Limited primary care to tertiary care handoffs
Horizontal
Limited ties between physicians and schools
Difficulties of recruiting parents to community nutrition resources
Holistic
You are what you eat
Too many intervention overloads