AMCHP Webinar: Obesity/Overweight and Preconception Health, Part 1

good afternoon everyone and welcome to this webinar on obesity overweight and preconception health part one defining the challenges and connecting the partners again my name is Megan Philippi and I'm a program analyst of women's an infant health at the association of maternal and child health programs before we begin with our presenters I do have a few housekeeping items audio is available through your computer speaker if you're having any technical difficulties with your audio please use the chat feature on the webinar interface an amp chip staff will be able to assist you today's webinar is being recorded the slides will be available on the amp ship website along with a recorded file a week after the broadcast we will have time after presentations for a question and answer period we invite you to submit questions throughout the call by using the chat box on the lower left-hand side of the screen please send your questions to the chairperson and also be sure to include to which presenter or presenters you are addressing your question finally you will receive a short evaluation after this webinar has ended please take a few moments to provide some feedback as your input is very helpful in planning future events and learning opportunities and also just to note on the webinar recording will also be housed on the before and beyond org website in the news section I'll now turn it over to Aaron bonds on who will provide you with a little background for today's webinar and introduce our speakers Aaron Thank You Megan hi my name is Aaron bonds on I am the Associate Director for women's an infant health at am chip on behalf of em chip I'd like to welcome you to today's learning events the purpose of today's webinar is to focus attention on the impact of obesity on the health of young women and any future children they may wish to have as well as to share ideas and strategies for addressing this public health crisis among maternal and child health and chronic disease partner our learning objectives are as follows by the end of this webinar we hope that attendees will be able to describe the prevalence population and trends in obesity and related chronic conditions in the u.s. among women of childbearing age discuss the clinical impact of overweight and obesity on women's health pregnancy and infant health describe the MCH perspective and opportunities for addressing overweight and obesity and discuss new approaches to chronic disease prevention and management we have a great lineup of speakers this afternoon and I'd like to kick it off and start by introducing shin Kim miss Kim is an epidemiologist in the maternal and infant health branch in the division of reproductive health at the Centers for Disease Control and Prevention's her major research topic areas of interest include gestational related obesity weight and nutrition with particular interest in the short and long term effects of in utero exposure to excess glucose and offspring health she's published peer review Eric articles on topics including gestational diabetes maternal obesity gestational weight gain childhood growth and obesity and tobacco use and with that I will turn it over titian okay good afternoon I'm Shen and today I will present the prevalence and trends and obesity in the u.s. among women of reproductive age so here's a brief overview of the presentation first I will describe the general population of adults and adolescents by providing definition of weight status and prevalence and trends by age group and race ethnicity then i will describe obesity and pregnancy in this relationship with gestational weight gain gestational diabetes and large for gestational age and then I'll wrap up with a brief discussion of obesity implications with chronic disease for this presentation I am using the wh 0 definition of body mass index with overweight being 25 to 29.9 kilograms meter squared and obese being greater than or equal to 30 so here is an overall trend slide in this slide we're examining obesity defined as BMI greater than equal to 30 among women of reproductive ages 30 20 to 39 years of age using an tains data this includes women who have not had a pregnancy who have had a pregnancy or who are done having children this is important to note as women who go on to have a pregnancy are different and deal with different issues so here as you can see in this overall population obesity increased rapidly between the 80s and mid two thousand and now it looks like obesity may be leveling off in the most in the more recent years between 2009 and 2012 using an haynes data we also see that there is great racial and ethnic disparity with the highest prevalence of overweight and obesity combined and non-hispanic black women and the highest prevalence of just overweight in Hispanic women in this slide on presenting overweight and obesity among 20 to 49 year olds in 2005 and 2006 using in haines data in this ad hoc analysis we show that obesity is highest in women ages 40 to 49 years of age and that obesity increases with increasing age overweight is fairly constant across the age group around twenty percent so next I'm going to talk about adolescent obesity and for adolescent obesity we are using percentiles based on CDC growth charts and referring to those that are 8580 5th and 95th percentile as overweight and greater than and equal to 95th percentile as obese so unlike women from 20 to 39 years of age among adolescent girls aged 12 to 19 years using Ann Haynes data obesity continues to increase the red line indicates where the healthy people 2020 goal is and as you can see we clearly are continuing to move away from it as in through all the years similarly to women 20 to 39 years of age the greatest prevalence of overweight and obesity is in non-hispanic black girls with Hispanic girls with the next highest prevalence this high prevalence and obesity among adolescent girls is problematic as these girls may one day become pregnant so now I'm going to talk about obesity and pregnancy why is pre-pregnancy obesity important obesity is associated with a number of undesirable outcomes but in the context of reproductive health for the mother obesity has a negative impact on the ability to get pregnant and to maintain an early pregnancy risk of miscarriage increases as BMI increases and gdm hypertensive disorders of pregnancy and thromboembolic disorders and other words blood clots are more common among pregnant women that are obese obesity can also adversely affect labor and delivery increased incidence of labor induction difficulty in fetal and uterine monitoring increased cesarean delivery increased difficulty in performing emergency c-sections increased risk for postpartum hemorrhage and longer hospital stays obese women also have a high incidence of poor lactation and difficulties in breastfeeding for the child maternal obesity is associated with increased risk of fetal death particularly late and unexplained and some congenital anomalies obesity also makes it more difficult to detect birth defects with ultrasound obesity does not appear to increase the risk of preterm birth from preterm labor premature rupture of membranes however it is more common what is more common is not preterm birth due to maternal and fetal complications pre-pregnancy obesity during our major risk factors for large for gestational infants or big babies and this increases the risk of shoulder dystocia which is a difficult delivery where the shoulders get stuck birth trauma need for cesarean delivery fetal distress need for resuscitation after birth and admission to the neonatal intensive care unit high birth weight infants born to obese mothers are also at increased risk for childhood obesity as well as early onset a medical problem such as diabetes and hypertension so here's a summary of surveillance data and these slides show the prevalence of normal BMI across time span from several different data sources it includes sources such as Ann Haynes which includes all women of reproductive age and then also sources such as prams pins in California mija data which are among women who became pregnant and as you can see here across all the data sources fewer women are entering pregnancy at a healthy weight and again the red line indicates where the healthy people 2020 goal is which is for normal for women to enter to have a normal pre-pregnancy weight of fifty three point four percent so this slide presents the prevalence of pre-pregnancy weight in 2003-2006 and 2009 in 20 states using prams the pregnancy risk assessment monitoring system data france data are among all women who recently delivered a live birth and they are responding to a questionnaire three to six months after they have had a delivery so unlike the inane zestimate in this population you can see that actually obesity is increasing so earlier in that first slide that I showed it showed that obesity just overall in a women every productive age may may be leveling off but here obesity is increasing and the mean percent change as you can see it in the obese women from 2003-2006 is about 2 percentage points and two thousand six to two thousand nine is one percentage point and more specifically if we look at obesity class we see that there is an eighty percent increase in class 2 and class 3 obesity between 2003 and 2009 and that nearly half of all of these women entering pregnancy are severely obese so these slides are to further demonstrate that pre-pregnancy obesity is a continuing to increase and so as you can see as more stage have greater than twenty percent of obesity which is in the yellow and the dark yellow colors between 2003 to 2009 you can see that there's just there's more and more of the yellow so gestational weight gain is a very important component of obesity and pregnancy it can easily move a woman from normal weight to overweight or obese or overweight for women who are already overweight obese it can contribute to greater difficulty in losing weight after delivery in 2009 the Institute of Medicine revised their recommendations one specifically more specific to pre pregnancy BMI where underweight women require the most away gain and obesity required the least amount of weight gain to be switched over to using the wh 0 BMI categories and three they establish a range of gestational weight gain for obese women however they had insufficient data to stratify by specific be on obesity class so with this slide I'm presenting the prevalence of added gestational weight gain adequacy of using prams data in 24 states in 2010 so this is stratified by BMI which across the x-axis and to orient you to the slide the green bars indicate the proportion of women who gained appropriately while the red bars indicate those who gained an excess and the blue bars are those who gate and adequately so as you can see over half a women were normal weight so 50 1.5% were normal weight when entering pregnancy and there were approximately equal proportion of these women who gained in each of the three categories about twenty-two twenty-three percent or twenty-three point six percent of women were classified as overweight and sixty-four percent of these women who were overweight gained in excess during their pregnancy and over so overweight women had the highest prevalence of excess weight gain and then this was followed by obese class 10 bees cross two and obese class three gestational diabetes is also strongly associated with obesity women who develop gdm are at increased risk for diabetes later in life so this slide shows the weighted probability of gestational diabetes or gdm by pre-pregnancy body mass index and this is by race ethnicity using birth certificate hospital discharge linked data in Florida from 2004 to 2007 we have mothers pre-pregnancy BMI on the x-axis and the estimated probability of gdm on the y-axis so as you can see the probability of gdm increases with increasing BMI for all racial ethnic groups there was no clear BMI threshold below which a dose-response relationship was not evident although the risk of gdm only slightly increased for those less than B Emma less than 20 with a BMI less than 20 another thing I'd like to just notice that among Asia Pacific Islanders they their BMI or their arm probability of gdm starts at a higher higher prevalence at a lower BMI point so this slide is looking at the adjusted population triple fraction of gdm attributable to overweight and obesity again using linked hospital discharge and birth certificate data in Florida from 2004 to 2007 we wanted to estimate the contribution of over and obesity to show the potential impact of obesity prevention on gdm so if we look at the first column the overall column this is essentially saying that you can prevent forty-one percent of gdm cases if overweight obese women were normal weight or if you got rid of overweight and obesity as you can see this ranged quite there's a wide range by race ethnicity but in non-hispanic black women in American Indian women you can essentially prevent over 50 or nearly 50 half of gdm cases by just eliminating overweight and obesity so in this slide we're looking at the population of chewable fraction of overweight obesity access gestational weight gain and gdm on large for gestational age births or large babies and here you can see that if we prevent it excess gestational weight gain or if you had women gain at adequate gestational weight gain during pregnancy then you could prevent about a third of large for gestational age cases and for if you got rid of overweight obesity or overweight obese women were normal weight then you could prevent anywhere from ten to twenty percent of LGA cases and then for gdm you could prevent about two to eight percent of gdm of LGA cases if you prevent a gdm more specifically if we look at this by BMI categories across all race ethnic groups you can see that even in the normal weight women you could prevent as much as a third of LGA cases by preventing excess gestational weight gain or in other words if you had women gain weight in the adequate category and as much as thirty to forty eight thirty seven to forty eight percent in the overweight category and then or four thirty seven to forty forty three percent in the overweight category and then a little less in the obese category for white black and Hispanic women but as much as forty eight percent of the Asian Pacific Islander women in the obese category so why is LGA important when here in this slide we show that the z-scores for body weight for children born SGA and LGA and as you can see children born LGA increased in size from thirty six months to eighty three months of age and further not only our kids born LGA more likely to be overweight but kids born to obese moms are likely to be obese so here you see that only five percent of kids born to underweight moms are obese at five years of age whereas twenty-seven percent of kids born to obese moms are obese at five years of age also postpartum weight retention also contributes to obesity development of women in their reproductive age studies show that failure to return to pre-pregnancy weight by twelve months postpartum is an important predictor of long-term obesity so in this slide you can see that women who had excess gestational weight gain which is the top dashed line have the highest amount of postpartum weight retention compared to those who had inadequate gestational weight gain and finally women who are overweight and obese or an increased risk of cardiovascular disease so as you can see here diabetes hypertension and dyslipidemia increases with increasing BMI so now what well I think it's important to really emphasize the need to promote healthy weight goals including a healthy normal BMI before pregnancy achieving adequate gestational weight gain during pregnancy and returning to pre-pregnancy weight by one year postpartum after pregnancy the implications for the mom is that this will prevent entering into the next pregnancy obese and feature preventing future health risks and the implications for the infant is that it reduces the risk of being large for gestational age and by sharing healthy lifestyle behaviors with the mom is a further reduces risk of future obesity and metabolic abnormalities which hopefully can stop this vicious cycle of obesity thank you Thank You shin as a reminder we will take questions after all of the presenters have finished I would now like to introduce our next speaker and Dunlop and as a family and preventive position maternal child health researcher an associate professor with Emory University she served as a member of the clinical work group of the CDC atsdr select panel on preconception health and has a long-standing interest in evidence-based approaches to improving women's preconception and Inter conception health as a strategy for improving women's health and maternal child health outcome and great thank you and good afternoon everyone it's my pleasure to speak with you today about the clinical implications and considerations in overweight and obesity among women of reproductive age in the first important point is that as it's been a bit summarized by the first speaker is to realize that the health effects of obesity among women of reproductive age are not simply realized by the woman during her pregnancy but extend to her ability to get pregnant for ability to have a live or interim pregnancy to experience complications and even depth during that pregnancy to her long-term health effects and to the long-term health effects of her birth in instant so it is one of the most impactful can ditions that we can eject dress from a public health in clinical standpoint the range of health effects for the women in her shop for the woman and her child are outlined here and we'll discuss each of these in a bit more detail in the slides that follow the first is impaired fecundity are looking at not just the difficulty in conceiving a pregnancy but more broadly so come to be encompasses difficulty conceiving as well as in carrying that pregnancy to live birth and then we'll discuss some of the increased rates of complications during the pregnancy increased rates of outcomes of that pregnancy for the woman and her child and some increased rates of adverse fetal and child health outcomes so let's start by looking at the impact of obesity on the probability of a woman conceiving there is strong evidence demonstrating that women who are overweight or obese experience difficulties and delays in conceiving a pregnancy specifically there's a dose-dependent relationship between her degree of adiposity or her degree of body fatness I've measured by BMI or by waist to hip ratio and her time till next time to pregnancy specifically if we look at the probability of conception in a given cycle it's reduced by eight percent in women who are overweight and by eighteen percent in women who are obese and this translates into an additional three months longer for overweight women to conceive and about nine months longer for obese women to conceive and that's when we look at all women if we look at just nulliparous women or women who have not given birth before these probabilities are doubled there are several overlapping reasons we won't go into the details today but several overlapping reasons for this decrease in their ability to get pregnant and these include biological effects such as disruption of the hypothalamus pituitary ovary access hyper insulin insulin emia both of which contribute to chronic and ovulation which can have long-term health effects or the will as well as polycystic ovarian syndrome in addition when overweight release women do a late they're finally have ova of lower fertilization potential and then even if in the setting of a fertilized OVA that endometrial abnormalities that can accompany some of the problems with an ovulation and irregular cycles can also interfere with implantation also there's some thought that social biological factors also contribute to this difficulty in conceiving such as decreased frequency of intercourse and sort of the partner selection that overweight and obese women are at a greater likelihood of having a male partner who's themselves overweight or over be obese who could then have problems with sir motility and fertility so kind of a multifactorial reason for that also important is the life stage at which obesity on sex underscoring the importance in particular of avoiding outside obesity during early life its data demonstrate that timing is critical young adults who are obese they tend to enter puberty earlier than their normal weight counterparts and these early maturing girls is true tend to initiate sexual activity sooner more likely to have body and self-esteem issues and also early puberty is shown to be a risk factor for self-reported depression importantly these obese adolescents are even higher risk for polycystic ovarian ovarian syndrome and its attendant risk for conception and metabolic effects as well not only is natural reproduction affected by obesity but so too is artificial reproduction there's solid data that obese women undergoing art or artificial reproductive technology require higher doses of exogenous grenadier children's to induce ovulation the experience retrieval of fewer eggs and lower implantation during the cycle and they have an elevated risk for spontaneous abortion even following artificial reproductive technologies and pregnancy complications and each of these is progressively increased with the degree of obesity that the woman has prior to her conception so it's definitely clear that there are risks relating to fecundity or we want to say a probability of conception and carrying that pregnancy through to a live birth so what do we know about the impact of intervention apologies we before when it become pregnant is there any evidence but it works and indeed there is evidence shows that adverse effects of the adverse effects of obesity and fecundity are reversible and importantly and even achieving a mineral to modest amount of weight loss even losing just five to ten percent of the initial body weight translates to an approximately thirty percent reduction in visceral adiposity which is shown to be effective for inducing ovulation in obese women listen without PCOS to improve their chance of conception those naturally and artificially and decreasing their chance of spontaneous abortions should they become pregnant and I think this slide is really important because sometimes when women are obese especially system as the obesity is increasing there's a sense that you know a Chiva a normal or a healthy way is kind of unachievable so even learning that modest or minimal amounts of weight can have an effect I think is is encouraging for a woman in terms of changing behaviors and for providers so now let's move on to the effects of obesity upon pregnancy house following conception the obese women also is it an increased risk for a range of pregnancy complications that can affect her own health and well-being as well as that of her infant again just to reiterate these include gestational hypertension and preeclampsia gestational diabetes shoulders social obstructed labor and both of which commonly end in a cesarean section and all of which can be associated to with an indicated preterm delivery as well as complications of the pregnancy maternal pre-pregnancy obesity is also linked with a number of adverse homes for that pregnancy as I mentioned including medically indicated preterm birth that is resulting from that range of complications we just discussed intrauterine fetal desk which we mentioned with spontaneous abortion but as well as still birth or death of a fetus beyond 20 weeks gestation and as well as maternal death we don't have a strong of data on maternal deaths but if we look at the range of studies looking at dilworth studies report a five-fold increase in silver among obese women and that this risk too is dose-dependent progressive increase in risk with the longer duration of obesity before pregnancy so not just degree of obesity but duration of pregnancy further underscoring the need to really work on preventing weight gain and early development of obesity and overweight among our adolescents and teens the birth limit the work infant of an overweight or obese model is also an increased risk for adverse female and child health conditions including congenital anomalies particularly in strongly neural tube defects but also cleft disorders and heart defects as well as macrosomia which again was discussed by the previous speaker and that macrosomia is itself linked to several neyland of complications such as hypoglycemia and an increased risk of obesity later in life thus underscoring the potential for intergenerational effect of obesity among women of reproductive age also later in life these children born to women who are overweight are more likely themselves to be obese and affected by chronic disease so again we've seen that the preconception weight loss impact women's probability of conception but what about its impact on these other reproductive outcomes well again modest weight loss preconception lee also decreases the incidence of gestational diabetes and the prevention of weight gain between pregnancies so in that inter conception period also decreases pregnancy complications again underscoring the critical importance of preconception weight loss so women who are overweight their RVs and postpartum and inner conception strategies targeting women to help them avoid the postpartum weight retention between their pregnancies in fact there was a recent paper published that did some modeling of national data examining the public health impact of decreasing rates of pre-pregnancy obesity among our women of reproductive age so in the first circumstance the model looked at if know us women of reproductive age were obese probably not achievable if they just want to give us an idea of what could be accomplished so it's know us women were obese when they became pregnant nearly 7,000 fetal deaths could be prevented and about 2,800 baby could be born without a heart defect each year now if we look at probably a more realistic scenario in which the prevalence could be reduced by about ten percent nearly 700 fetal deaths would be prevented in 300 congenital heart defects so again underscoring the probability for true public health impact with lieber to achieve even beginning to achieve modest reductions in the prevalence of this important condition now let's move on to existing clinical recommendations for screening for overweight and obesity presently a number of national bodies and professional organizations all support that screening for overweight and obesity be performed again the US Preventive Services Task Force has us as a standing recommendations for all adults with the recommended screening being that calculation of a BMI body mass index based on the height in centimeters per I'm sorry weight in kilograms over hyper in centimeter squared and our previous speaker showed you the cutoff values for that so I won't repeat that and in particular a Cobb the American College of will be dying in the clinical work group of the select panel and preconception care provide guidance that all women of reproductive age have their BMI calculated at least annually and have even those who might fall into a normal or healthy BMI category should review medical social and family risk for weight related conditions I'm sorry test that find an important point related to the importance of the use of BMI is that it's an objective screening measure and that's really critical critical as studies that have looked at perceptions of weight find that many women us who are themselves overweight or obese are unaware of their weight status they're not seeing themselves as overweight obese and these misperceptions are particularly common among those belonging to racial and ethnic minority groups or who are lower socioeconomic status and of course the concern about this misperception is that might interfere with a woman motivation to begin to change her behaviors to improve her health if she doesn't feel that she is overweight or obese or perhaps not knowledgeable of the conditions associated with them so now we move on to managing overweight and obesity and there are solid clinical recommendations for managing these conditions and including those for women of reproductive age the first important point regarding this is that weight loss during pregnancy is not advisable for any woman regardless of her pre-pregnancy weight status again weight loss during pregnancy is not advisable thus the conclusion is that weightloss interventions before pregnancy are really essential to minimize miss for minimizing these obesity related risks in both the clinical work group of the select panel and a comp recommend that women receive counseling about the risks of being overweight or obese and what it poses in terms of their own health their fertility in their future pregnancy outcomes and that baby offered intensive behavioral strategies to decrease their caloric intake change their eating peb eating behaviors and improve their physical activity behaviors and in fact to be encouraged to enroll in structured weight loss programs and as for the sake of time today we don't have time to go in-depth into this but this is important to real but the evidence to support the impact of behavioral strategies in helping women improve their eating and activity behaviors but those strategies those interventions have to be intensive in terms of having a regular frequency over time as well as free as a duration of time over which to receive them it can't be kind of a simple one time office visit that you expect to be impactful it really takes engaging them in a behavioral strategy where they can have ongoing support both groups also underscore the importance of preconception counseling for women who are overweight and obese and the recommendation is shown there again just really emphasizing the importance of counseling to help women understand the risk to their reproductive health and their own health that is posed by overweight and obesity because in fact it is found that the women are responsive to messages around how a given health condition whether it's smoking drinking alcohol chronic disease can impact pregnancy outcomes and that can be very motivating for helping women change behaviors additionally there are readily available clinical practice guidelines from medical iam both medically and behaviorally managing women for overweight and obese and I'll refer you to one available from the American College of Physicians that the reference at the bottom of this slide and enough these guidelines really begin by emphasizing again this behavioral works that has to be part of this intervention and that behavioral work starts by working with the woman to establish realistic weight loss goals such that you know small successes can lead to the development of self-advocacy kind of self empowerment and then what that goal is achieved moving on to the next goal also that the guidelines underscore the importance of offering specific behavioral strategies to decrease caloric intake and increase physical activity not simply saying to a woman you need to lose 5 pounds or you need to lose 10 pounds but having her set at least one eating behavior change and one physical activity behavior change as a goal in helping her take concrete steps or envision concrete steps that can help her achieve that goal and then having her doing some self-monitoring on her own in terms of how she's doing in reaching those behavioral goals and not sending the weight loss as the goal but rather the behavioral change of the goal this American College of Physicians guidelines also do outline if a woman has a BMI greater than between 27 and 30 essentially with comorbidities that pharmacotherapy could be considered and I've listed the range of medications that are improved approved in the u.s. although I will point out that the buter mean towards the end of the list is no longer available in the u.s. it within the American College of Physicians guideline so these are the list of medications if you would like to refer to that guideline to learn more about them but as you can see one important thing that may catch your eye is that you know those that are used commonly such as orlistat and center mean these are pregnancy category X drugs meaning they are known teratogen and some of the others are pregnancy class C and dieter proteon is actually pregnancy class b so if you have an overweight and obese woman who is a you know elk seems appropriate to prescribe pharmacotherapy considering this pregnancy risk category if she does desire to become pregnancy or thinking about her contraceptive plan is an essential piece of that also just to point out that the guideline gets very specific and regarding the degree of overweight and obesity and goes on to to recommend pharmacotherapy if the body mass index is greater than thirdly 30 regardless of comorbidities and even to consider bariatric surgery if the body mass index is over 40 or greater than 30 with comorbidities again it's more depth than what we can go into today but just to refer you to that and also to point out that some guidance that more tailored to women of reproductive age is available from the National preconception inter conception care clinical tool kit the website for which you can find at the bottom of this slide and this next slide is really just a snapshot of what that website looks like the preconception toolkit for Commission house is a great deal of evidence-based information about a range of chronic health conditions nutritional disorders and obesity is found under nutritional disorders so you can go and get more information there and we do encourage everyone to check out this website and its resources when you get to the website you'll find that the content of the toolkit there's menus along the left-hand side where you can look at various conditions according to the women's reproductive plans she desiring to become pregnancy or become pregnant at risk for pregnancy or not our sort of unsure or not designing the pregnancy and the guidelines get more specific in terms of working with contraception plans for women according to their pregnancy intentions as well again don't have time to go into that detail here but would really encourage you to check out that toolkit on the website for more information there are some special consideration for achieving weight loss among women of reproductive age 41 postpartum weight retention as we've seen is known to be a very important contributor to access a lot of weight and this postpartum weight content retention is particularly more common among low-income and minority women especially those who have already started that pregnancy who are overweight or obese so a key point here is that interventions targeting that postpartum in inner conception period may be especially important for minority women and in particular for those who already are overweight or obese another consideration relates to the nutrient density of the diet as you know we mentioned in the intro conception and pre pregnancy periods we would be recommending some dot reduced caloric intake of the women to help achieve a healthier body weight and you know there are a number of nutrients known to be broke particularly important to women average out of age and it's known that diets less than 1,200 calories per day are likely to require supplementation of these nutrients in particular folic acid calcium and vitamin D in fact even by greater than 1,200 kilocalories a day may require supplementation of these nutrients given how difficult it is to meet them meet the RDA for these through diet alone so that's an important the content of the diet and nutrient content is really important to consider particularly for women of reproductive age with a little bit of time I'd like to say something more about to nutrients in particular those being folic acid and vitamin D folic acid is a nutrient of particular concern as its deficiency during the perry conception period is definitively associated with an increased risk of neural tube defects as well as other congenital anomalies and we know from a recent meta-analysis that neural tube defects and these other congenital anomalies are at least twice as common among women who are obese and I think I think that's a fairly staggering number not and you know the reason for this is probably a few reasons for this obese women are less likely to supplement with folic acid prior to pregnancy and less likely to ingest folate through food sources so that's something to pay a good deal of attention to is the Foley extension we care about that for always every part of age but in particular overweight women vitamin D is another nutrient of particular concern because its associated with pregnancy come its deficiency associated with pregnancy complications of the mother as well as pro growth of the foetus and later rickets and skeletal problems and again it's well established that overweight and obese women commonly have poor vitamin D status if it's a fat-soluble vitamin then do women of healthy body weight and I have a lip bit more detail on these slides then we can go into today but I just wanted to have it there for your reference should you want to look back on these slides another special consideration related to weight management of obese women is contraception of course contraception is an important part of the health care of all women including those who are overweight in the least and sometimes what we find just like with other chronic health conditions providers are more likely to shy away from contraception in women with obesity or other chronic conditions we just wanted to take some time to point out what the considerations are here so if we look at contraceptive efficacy there are some theoretical concerns among women who are overweight and obese for example there's been some concern of decreased advocacy of combined oral contraception for women who exceed 70 kilograms and efficacy of the contraceptive patch for women who exceed 90 kilograms but just to point out that our CDC medical eligibility criteria for obesity for obesity as a health condition do point out that really all of the methods available to us are either category 1 or category two methods and that they can be used essentially easier without restriction if they're category one or that the advantages of using them outweigh the risks and have less of a comment about concerns about ever see or concerns about safety if that is the only if we're looking at that condition in isolation finally I know I'm driving to the end of my time I just wanted to end with saying if you've heard from the preceding presentation obesity is one of the 10 leading health indicators and you can see that its impact is right upon the nation and as such you know the clinical preventive and treatment strategies that I presented are of course very important but they should not stand alone if we are to achieve both individual and population level impacts in reducing the prevalence of obesity and the prevalence of the conditions that it is associated with and certainly to be effective in Urdu cities outcome to the population level it's imperative that population based strategies that improve the social environment l context in which women are living their lives are essential and that will really lead us to the next presentation which will focus more on those public health strategies thank you very much thanks and before we move on there was a technical question I think we might benefit from addressing before we move on and there was a request could you just explain the pregnancy drug category as in a bit more detail for those not familiar okay sure certainly um the FDA the Food and Drug Administration provides a pregnancy classification for prescription of work for medications that get it is a classification that conveys the risk of using that medication during pregnancy in the classification system is a true x and I will start the bottom because that's the most clear pregnancy risk classification X means that is a known teratogen or a medicine that is we know from studies causes birth defects it's teratogenic or causes birth defects going up from their pregnancy class D means this is a potential teratogen there's a studies that support that it could have an association with birth defects and adverse outcomes and then pregnancy risk category C means there's some risk of using the medicine but you know it's kind of a balance of risks and benefits pregnancy risk category a and going back up to the top here means you know research shows safe and pregnancy no real concerns B is more you know shown to be safe in animal studies that necessarily human studies to support safety but animal studies supporting it and there's a great website that i use i can't give an exact website the URL but I always just googled drugs and pregnancy and lactation and it takes you to a great website where you can get both the pregnancy as well the lactation classifications of medications it's very useful thanks very much we'll get that website up for folks to as well and now I'd like to introduce dr. Sarah Berbice she will be our next presenter Sarah is the executive director of the Center for maternal and infant health and research assistant professor in the ob/gyn department at the school medicine at unc-chapel Hill she coordinates the North Carolina recurring preterm birth prevention program a statewide smoking cessation program for pregnant and new mothers a postpartum visit program in several projects serving high-risk pregnant women new mothers and their infants she serves on the North Carolina child fatality taskforce co-chairs the North Carolina perinatal Health Committee is a member of the CDC leadership team on preconception health and serves on am ships best practice review committee Sara thanks Erin hi everybody um it's great to have so many people on the webinar and to have a chance to really unpack this really important issue so well there are potentially many opportunities for professionals in the maternal and child health and chronic disease specialties to work together it's important to first understand more about each other's perspective drivers and directions so as we go through the next part of the webinar our goal is to cross and form each other and also spark ideas about where connections can happen on because ultimately a win-win is when two different groups can work together toward a common goal when at the same time there are also meeting expectations in their own field so I'm going to be offering the maternal and child health perspective and something that I wanted it's been mentioned briefly before but something that has really caught our attention over the past few years is the increase in maternal mortality which we know is a tip of an iceberg the iceberg in terms of also concerns about maternal illness and as you can see from the slide we are now experiencing 16 deaths per 100,000 live births which has significantly decreased our national ranking as the safe country in which to give birth and of relevance to this particular discussion as we have done more increased assessment and review of maternal death the link between chronic disease particular cardiovascular conditions has become more evident and so this increasing contribution of chronic diseases to death suggests the change in the birthing population and also really has brought this to the forefront of something that we're really concerned about so traditionally the field of maternal and child health is focused on pregnancy and sense kids adolescents and children and youth with special needs but over time research has really expanded our perspective more broadly with an increased focus on the health of young women and men else's families maternal wellness focusing on equity and also being much more mindful about the conditions and impact health and while I only have a few minutes I'm just going to kind of do a little bit of quick highlights and a couple of these key areas of connection kind of consider them the top playlist I guess in currently in maternal and child health so when we think of the risk factors for heart disease we often think of smoking and high blood pressure cholesterol and obesity so forth but do we often think about low birth weight what a low birth weight have to do with heart disease forty to fifty years later in life well Barker and his colleagues worked on a theory for over 20 years but there are critical periods of development during which the functions of an organ or system are being programmed and if things don't go right then then that organ or system may never function optimally over the entire life course so for example if a baby is undernourished inside the womb especially during the second trimester when the pancreas is developing that maybe may end up with the smaller pancreas and then an average adult and that smaller pancreas may not be able to handle a sugar load as well which leads to an increased susceptibility for the development of diabetes in the future so end of it in the womb the baby protects the growth of its brain at the expense of other parts of its body and so this trade-off can permanently change an organs function and potentially lead to disease and later life so there's then a lot of growing evidence that people born low birth weight may have increased risk for chronic disease in the future and back there's study just published in December 2014 that found that low birth weight was directly predictive of higher risk of type 2 diabetes later in life for the women that were in the study well MCH professionals are clearly concerned about tobacco use during pregnancy to its impact on birth weight preterm birth and some birth defects new evidence suggests a connection with increased risk for chronic diseases for those babies when they grow up so we can see here that in utero tobacco exposure has been shown to be associated with obesity after adjusting for age education and personal smoking and for hypertension and decisional diabetes and adult women on the niehs scientists have also reported at exposure to tobacco in utero can we do increase levels of triglycerides and lower levels of good cholesterol and adult 18 to 44 years later other research suggests that maternal smoking can also program her baby to be at risk for addiction to nicotine in the future so if we take kind of this concept of the Barker theory and we look at the list course model the Barker theory that I just described falls in the arrow that you see at the bottom this is early programming so the life course perspective is a way to look at life as an integrated continuum so instead of these different disconnected stages it's a conceptual framework and some people even call it a paradigm shift in our field which recognizes that each stage of life is influenced by the stages that preceded and in turn influenced the stages that follow it if you look at the image you can see along the y-axis is our health potential and the lifetime is charged on the x-axis and then you'll see two lines that suggest different trajectories over life and so as I mentioned before we had a lot of concerned about equity and maternal child health and this model helps us better understand where we see gaps in health equity in different phases of life and then over the life course on the green arrows that you see pictured there are protective factors we know that the things in our life such as access to healthy food strong families good schools can help improve our health over time and that risk factors which are the red arrows can cause challenges over time and so this model challenges us to make sure that we are balancing adequate supports and services to counter risk factors over time so this really has given us an opportunity in our field to think about an intergenerational approach to our work and to start to think a little bit more cyclically about kind of the health of that adolescent woman who may become pregnant and kind of the impact of that pregnancy on her health the health of her child and even on the health of her own parents something that we've also been working on in our field is development of life course metrics so that as we start to find ways to apply a life course in our practice that we're also able to have some ways that we can be able to measure progress on in our field of maternal and child health and there are several indicators on life course indicators that are related to obesity and we just wanted to highlight those a little bit here since how we measure changes important for all of us and so you can see on the slide some of the measures that we have around diabetes percent of children exclusively breastfed at three months food nutrition and physical activity household food insecurity etc and they may be very similar and familiar to some of our chronic disease colleagues and so just to give a couple of quick examples that kind of elevate this life course theory and also show our connectivity to chronic disease breastfeeding is really a great example so we know that there's a very sensitive period of time for initiating breastfeeding we have a very small window from when the baby is born until that we want to make sure that that baby can eat well on that breastfeeding chip is is established early we know that breastfeeding is really great for healthy weight and nutrition for baby we also know that breastfeeding can be really good for how and really good for mom in terms of a really effective tool for her to help her return to her pre-pregnancy weight it's a great relationship builder for mom and baby which we know have positive effects over time and we also know that it can be a cancer risk reduction for mom and baby over time so this is something that in our field we have an obligation to get right because we know that down the road it can help reduce chronic disease we also are a better understanding that pregnancy is really a stress test for life and really elevating the importance of ongoing investments in health care services for moms especially for those that had a high-risk pregnancy or poor birth outcomes and for example MC is one example of really a flag that we as a system should do better at capturing and magnet and addressing over time so as you can see from the slide that preeclampsia is not uncommon in pregnancy and that women who have a history of preeclampsia have an increased risk of developing cardiovascular disease stroke type 2 diabetes and chronic kidney disease later at life and they're also at greater risk of death later in life from some of those conditions and we know that the risk increases the earlier in gestation that a woman experiences preeclampsia and also the number of affected pregnancies that she's experienced so to switch gears a little bit also in our field there's been a growing recognition of the importance of place and socioeconomic status is impact on the health and well-being in our fields and we've known this for many years and we really are recognizing that issues such as childhood obesity and infant mortality I want influenced by factors far outside of the clinic far outside of prenatal care in the health department and actually outside of some of our typical MCH scope of services so we as a field are really to think how can we do more at addressing the conditions in which our populations live on including neighborhood education and poverty if we recognize that if we want to see and meet our goals for moms and babies so we have to step out into some new arenas in order to do that as discussed earlier there are also a number of factors that we've come to understand that impact birth outcomes many of which need to be addressed prior to pregnancy or in the first early weeks of pregnancy in order to do reduce risk and likewise many of these risks negatively impact the health of the woman and also of new moms so as you can see from this slide here are some really strong evidence and also growing evidence of health risks for women in infants and again as we've said several times you can see in clear evidence that there's some direct link with our with chronic disease and health of our moms and babies and so preconception at Newark inception health which is really defined as interventions that aims to identify and modify these biomedical behavior on social risks a woman's health or a man's health and pregnancy through prevention now calm I'd not exactly get that out correctly but I think you can read the slide and know what I was trying to say so that's really how we would define preconception health and so this concept of improving women in men's health prior to conception has really forced people in our field to broaden our perceptions of target audience as well as our strategies particularly since in some cases we would be working with young adults if you want to avoid childbearing and want to avoid meeting maternal and child health services this is also helps us broaden our thinking in our field to meet the needs of new mothers postpartum as well as in between pregnancies and in our second webinar will be providing more resources that are available to you through the National preconception health and healthcare initiative we also have a set of preconception health indicators that we won't describe in detail but as you can see some somewhat similar to the life course indicators and when we're looking at nutrition physical activity chronic conditions um associate determinates of health that there certainly is some connection and crossover with chronic disease intended pregnancies are more likely to result in healthy birth outcomes and those which were not and as such MCHS are increasingly focused on asking this key question would you like to become pregnant in the next year and we've really been doing a lot more to educate ourselves about how to effectively counsel and talk with women about a reproductive life plan a reproductive life plan is basically a set of personal goals about having or not having children if when how many and how far apart reproductive life plans include statements about how to achieve those goals and they're really based on personal values and resources and something that we have been finding is that often women with young women with chronic conditions um may not be asked about every productive intentions by their specialists so as we've seen through all of the prior presentations that it's really important that we work with these moms around pregnancy but descriptive woman may be the least likely to have a reproductive life plan also in our field we are experienced some important increased collaboration between MCH and Titletown family planning and we're really excited about these guidelines for quality family planning that were just released last year that highlight the importance of preconception health services to both men and women and we in our field looking at our home visitors and our case managers are increasingly starting to address the topic of family planning and then finally our kind of our last link over the past 30 years obesity prevalence has more than doubled among children and tripled among adolescents and we know that obesity and young children can result in long-term adverse health outcomes throughout the life course which we've discussed already and that it can impact an individual's quality of life and drive medical expenditures at the individual state and national level and there has been a recent moderate decrease in obesity and two to five year olds and we feel like this highlights a continued opportunity to effect change that healthy nutrition and physical activity from pregnancy through a child's fifth birthday I can help ensure healthy childhood development and a healthy foundation for future good behaviors and so essentially addressing chronic disease through primary prevention via preconception prenatal and early childhood intervention says a lot of possibility for decreasing chronic disease among adults and lots of opportunity for our fields to work together and with that I'd like to turn it over to our next speaker who is going to offer the chronic disease perspective thank you Sarah and now let's introduce Jean Alon G Jean is a public health consultant with experience in national state and local level practice her professional interests center on building the capacity of public sector public health agencies to effectively address population health through evidence-based practice dr. Alon G served in the public health prevention service at the Centers for Disease Control and Prevention before comes becoming the director of the arthritis and osteoporosis programs in the California Department of Health Services she has consulted on national and state based chronic disease prevention and other health promotion activities in the areas of healthy aging arthritis epidemiology and program integration and collaboration she is the recipient of the Secretary's Award for distinguished service from the US Department of Health and Human Services Jean thanks so much hi everybody and so to quote John Cleese I guess now for something completely different I am here to tell you about what's happening in chronic disease prevention and control primarily in state health departments and some of the changes that have happened over the last 10 or so years the hope that it will help you identify what kinds of opportunities are coming up in the landscape to to work across programs and across sectors for the betterment of diabetes and and pregnancy so what I want to talk to you about today is where we are in chronic disease prevention and health promotion mostly at the state Health Department level how we came to be here and where it's going with the landscape is changing but before I tell you about where we are let me tell you about how we came to be here with some history in 2006 the National Association of chronic disease directors and CDC's National Center for chronic disease prevention and health promotion came together to have an in-depth conversation and workshop about how administrative ly chronic disease grant programming impacts the way public health is practiced in state health departments what are the ways that grants get in the way of good of good innovative work that meets the needs of a particular state and some of the things that came out of this workshop who were were challenges posed by a categorical orientation where a state might have instructions about a grant that required an advisory committee for arthritis and advisory committee for their diabetes work and an advisory committee for their stroke prevention work that would often include many of the same partners at the state and community level and so it was burdensome to those partners they would have plans in all of these different areas that maybe were in conflict with each other at worst but at best were inefficient because the priorities and activities weren't leveraged across areas and then things as simple as like having an epidemiology who had to be assigned just to one program rather than somebody who could use expertise across programs in a way that made sense and so CDC responded to these challenges with some creativity and they experimented with putting different grants together on the same cycle or even in the same package same categorical grants some things about these ideas worked some things didn't in 2009 they tried the really innovative idea of allowing for states to negotiate their entire chronic disease portfolio CDC funded portfolio these four states didn't get any extra money to do chronic disease above and beyond what they were all getting in their categorical grants but they were given the opportunity to look at it across the entire set of awards and think innovatively about how they might structure their chronic disease work how did what was included in their portfolio beyond CDC funding fit into a and operation that could take them into the future and then they were given a little bit of money to evaluate what they did each of the four states tried things a little bit differently we're still we're still seeing releases of some of the lessons learned from those experiments a couple of the key things are that there isn't one structure for state health departments that is the right one that we should all adopt that structure needs to remain fluid and dynamic so it can be responsive to emerging needs that there are ways that public health practice is changing based on the science of Public Health practice and what we're learning about prevention and systems change that the old way of doing business and chronic disease prevention is challenged by so bringing in expertise in health systems and policy and environmental change strategic communication evaluation on a broad sense not evaluation as tied together with basic analysis skills all came up as being important and culture change and how we approach the work the way that we had been funded to do chronic disease before at the state level really engendered a system where when you hired someone into your state health department to work on cardiovascular health it was very difficult from an organizational psychology perspective to maintain an alignment with the State Health Department instead of with your project officer at CDC so there got to be some complications about who do we work for and whose objectives are we trying to make and how is that serving what CDC needs to see accomplished out of the funding and what the state needs to address for their constituents not that it's really important to say here that that isn't a sign that people were you know selfish about their orientation are not approaching their work in an open-hearted and creative way it's human nature and organizational behavior nature that was being manipulated in unintended ways and so how could we address that how can we structure chronic disease activities in a way that really leverages all of this knowledge and science to the best effect rather than getting in our way in 2011 CDC was able to fund all states and territories to look at a coordinated chronic disease prevention across across all of their work not just what splendid in CDC but everything that that they need to do in their specific states and territories and thus funding cycle was neither as long or as large as originally envisioned which caused some challenges of course but what it did enable states to do was to do some coordinated planning about how chronic disease prevention might happen in their particular state how partners can can be engaged strategically and effectively in that work how prevention activities will happen not just what the state will do but in an entire system that's made up of communities and healthcare systems and community-based organizations and schools etc how does that how does that work happen my screen savers just came on and not letting me back in to advance my slides I apologize ok here we go and that has now moved on to CDC's approach to categorical funding and or coordinated way and many of you I'm sure I've heard about the 1305 grants that I will talk about here shortly but that the idea is that although the funding for the coordinated chronic disease prevention grant is doesn't exist anymore the coordinated approach to chronic disease prevention absolutely does and the expectation is that states and more and more at the local level also will be approaching chronic disease in a way that is not categorically focused so although money will continue to come from Congress to CDC and from CDC to its grantees with categorical objectives attached to it and categorically mandated reporting cycles and instructions for example the idea is that this will sit in a basket of coordination of a coordinated approach in the health department there are challenges to this obviously that 1305 which in part funds states to to work with schools on physical activity needs to sit in an environment where states are working across all of their chronic disease and linking this work with other work that they're doing but it's still categorically focused and it is it is still it is still a challenge what I want to talk to you about next here we go is some of the philosophies and and operating guidelines behind a coordinated approach to chronic disease prevention one is domains and these are domains that were a tick you lated by our slab our the director of the chronic disease center at CDC after lots of conversations with folks working in states and communities and looking at the way grants had been structured in the past about what kind of work was being done and how it was being done and these domains are epidemiology working in policy and environmental change clinical community linkages and health systems and her thoughts were that the work that we are doing now in chronic disease prevention is is really dependent on success in these four areas and I'll talk about these areas and some depth in a moment there are also core functions of practice and so regardless of what domain you're working in regardless of what categorical subject matter expertise you need to affect a certain objective there are core functions that every health department should have to be able to do this work those are things like communications policy evaluation partnership this might this might look like cross-cutting positions in a health department it might not and we see it happening in different ways across the country and that culture change is going to be important and I talked a little bit about alignment and position bias these are facts of life and leadership and management journals so how do we take that knowledge and use that here to support a coordinated approach that's going to be successful I only have about five minutes left to talk with you but I wanted to spend a little bit of time on the domains so that you can see where there may be some opportunities for you to intersect with your State Health Department colleagues who are working in chronic disease I'm going to go through a little bit fast but you'll have this information on your slides and of course I am more than happy to talk to anybody after the webinar if you want to dig in a little bit deeper deserve these are topics that we wrestle with and are continuing to understand over the course of the last five years so this is a rich area for for some exploration domain when I mentioned is epidemiology and surveillance and and this is where we look at providing data to inform the work that's happening and and what the what the emerging public health needs are for our different state or community this is important because we need to make sure that the work that we're doing is the work that's needed this is also making sure that we have the data that our partners need to do the work that they do that we're communicating with decision-makers about the work that needs to be done and how well it's going some examples of work in this domain are their traditional surveillance of risk factors for example developing and disseminating data reports that describe multiple chronic disease conditions looking at return on investment more and more our partners in the private sector and and the legislators really want to see return on investment for our prevention activities I'm we're also looking at linking different kinds of data sets to traditional public health data through Medicaid and other healthcare systems in particular domain 2 is environmental approaches this is where some of the policy and environmental change that we've seen comes into play making sure that the it's easier for folks to make the health behavior choices that they want to make it's not always just a matter of deciding you want to be healthier it's how much support is there in the environment that you're living in for you to make that that change some examples of this are active transportation to reduce obesity safe routes to school is a great example of that nutritional standards for the food offered in schools and childcare settings secondhand smoke has had some some good interventions in this area and water quality of course domain 3 and domain for are the two domains that come up for me a lot as I'm listening to these presentations domain three as healthcare systems domain for is community clinical linkages domain three is really looking at how health systems how we can leverage what's happening in health systems to the betterment of population health and that might be links to quality care that might be links to for folks who are at risk for diabetes or identified with pre-diabetes to getting into care sooner a lot of the the structured weight interventions that some of the speakers have talked about a preconception would fit into into this domain nicely and domains for the community clinical linkages here we see the need to link what's happening in the clinical encounter in the healthcare system with what's happening in the community for people who are at risk for diabetes or other chronic diseases so in the community we see lots of opportunity for interventions like self-management like weight loss like lactation support how do we link this kind of work to what's happening in the clinic some of the things that are happening here are experiments with reimbursement getting Medicaid waivers using community health workers and other health care extenders this is a really exciting part of the public health work that's happening in states and something to pay attention to as it as it continues to grow so what's coming is the continued focus i think on domain centered objectives and federal grants so on the chronic disease grants anyway from CDC the Center will continue to align their their funding opportunities i believe on these domains so that we continue to build this body of work the system transformation focus is very important right now this is where we're going to see the biggest change and health outcomes not working independently as public sector public health but really trying to work in the universe as a whole the whole person whole life perspective of this you've heard from the other speakers as well we want to apply that not just to an individual who is contemplating pregnancy but to a whole community that we into a whole population that we want someone to be able to access all of the prevention and care needs that they have where they live for the entire course of their lives not have to come out for different categorical needs or different timely need different parts of their life needs are different parts of their family needs but to live in this more holistic way and of course a focus on population health outcomes and helping partners who haven't really looked at population health the same way public health does before really understand what public health brings to support the work that they're doing so with that thank you so much and I look forward to your questions thank you and thank you to all of our speakers Megan can you take just a minute and remind folks the ways who ask questions absolutely to submit your questions please type it into the chat box and please indicate which presenter to whom you're addressing your questions we will flag that and we will pass it on to each presenter great thanks and we've got about six minutes and we've got five questions or so already in the chat box so let's go ahead and dive into those there's a question as a home visitor obesity and overweight can be a very sensitive issue to address what kind of language can we use to increase the awareness I'm not sure who this is addressed to but perhaps when I the earlier speakers could could talk to this question hi this is Anne Dunlop I will do my best answer but this is definitely a very complex and you know culturally sensitive issue the words you might use my change depending on that but certainly good focus group work has been done to find that women in particular do not like words like obesity or body fatness but using the term overweight or just saying you know above a healthy way to convey that the concern about the weight isn't about the body image or about the look of the person or the shape of the body but that being above a healthy body weight that there are health the concern is for the health risks that are associated with that but even when I know someone you know fits the GDP criteria for obesity I do not use that word particularly you know with women because it's a very sensitive word I use you use the word overweight or talk about them being above a healthy body weight for which you know or add a weight which we know there are health risks and others may have you no more culturally tailored messages and just speaking kind of very generic generically about some of the words that I use thanks and along those lines this is for all of the speakers I think where are those evidence-based programs where can-can mothers or women before pregnancy or postpartum where can they go to find weight loss programs and are their programs out there that you'd recommend especially for those who maybe there's a someone here asked about women who may be undocumented or not have the resources to seek out certain program so this is sarah and i think that um some of that we were going to try to highlight more in the part two of our webinar to really highlight and elevate those evidence-based practices I do know that for example in North Carolina we've had the eat smart move more campaign that offers 1010 very simple well nothing's ever simple right but ten very concrete doable action steps that people can take such as rethink your drink or turn off the TV so that they're on there are some things that are out there at least in North Carolina they can help people I'm starting to take steps towards making healthier on choices this is an time up again and yes I was understanding that the second webinar will focus a good deal on those community and public health based interventions but just to say something a little more about that you know these you know tend to be very local you know and what women can access and what they can access locally so you know i do not have knowledge of mine of what might be available to to you but one thing that I think is really helpful r22 resources one is a website of the National Cancer Institute they have their reach research tested intervention programs attract it's called arcus the National Cancer Institute arctic i'll try to post that in the chat and what I love about that is you can do LOL Cancer Institute they put in their database of community-based research studies they include a number of studies that are focused on changing eating and activity behavior simply because those things behaviors as well as obesity itself plays such a role in cancer so it's a great way to see you know what sorts of interventions have been tested in other communities in what has been found to work at the community level the other resource is that unity of anything that the community guide and again i'll try to post that in the chatham not very good at close to him to chat but the community guide to preventive resources if I'm saying the guide to community Preventive Services also has an overview of community-based interventions in their components that have found to be effective in impacting physical activity eating behaviors in obesity thanks Anne and we've got about one minute left there were a series of questions that came in asking for information from studies so those who are more research oriented we love your thoughts on these and perhaps we can gather a list of resources and studies to send out after the webinar there's a request for information are there studies on women obese women who have had bariatric surgery and then later become pregnant are there studies on tobacco exposure and secondhand smoke and are there any studies linking overweight or obesity to the incidence of SIDS death so that some food for thought for the presenters we can gather information send that back out to everybody and then I think finally to wrap things up this question is for Sarah if there was one message you could send regarding preconception and obesity what would that be I just I think along the lines that and was mentioning and I think consistent with um jeans perspective also is that really our focus needs to be on helping young women and young men be at a healthy weight so that they feel good about themselves that they feel healthy and well and strong um and that that that is something that's good for them and I think that's really where we need to be focusing on it's not just because someone could become pregnant but because being at a healthy way we know is good for them across their life and so I really think that that's a really key message I would say second to that that this is why it's good to ask of every product a person's reproductive life plan so that we can also match interventions if becoming pregnant is something that's very important to someone and we know that they're overweight or obese and that gives a focus to kind of and maybe some incentive for them to work towards achieving that healthy weight but overall for our country if we could all work it having young women and then be healthier in terms of their weight it would be great for us as a country that's kind of broad but that's my my god great thank you so much Sarah and with that Sarah did you want to say a few words about our next webinar sure so first of all thank you everyone for listening in today we are going to have a second part for our webinar where we are going to be focusing on strategies on evidence-based practice and ideas for action in terms of improving and healthy weight and also for working together across maternal and child health and chronic disease so we hope that you all will come join us for that webinar as well thanks Erin will make registration available for that soon just to before we go I want to thank everyone for joining us today again the recording of the webinar will be available on before and beyond org as well as the am chip website listed up here this information will also be emailed to you and those recording should be available within the next week as we close out you'll be given a short evaluation to complete please do take some time to provide us some feedback to help inform future learning events and again thank you for attending and thank you to our speakers for your willingness to share your expertise operator you may end the call at this time thank you ladies and gentlemen

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