What about our daughters? Women's health begins in childhood

The term “women’s health” implies a separation between what a female does during adulthood to stay healthy from what she did – or had done for her – as a child. However, more attention than ever is focusing on urging and enabling children to adopt healthy habits that will last a lifetime.

What about our daughters? Women's health begins in childhood click to enlarge The first line of prevention of osteoporosis is to build strong bones early in life. Photo by Adam Gillum.

Media contact: Tom Hughes, 919-966-6047, tahughes@unch.unc.edu

Wednesday, Nov. 2, 2011

Written by Elizabeth Witherspoon for UNC Health Care

CHAPEL HILL, N.C. - The term “women’s health” implies a separation between what a female does during adulthood to stay healthy from what she did – or had done for her – as a child. However, more attention than ever is focusing on urging and enabling children to adopt healthy habits that will last a lifetime. The national epidemic of childhood obesity alone has pediatricians, policymakers, school administrators, even the First Lady, as well as parents, involved in a coast-to-coast conversation about eating habits, access to healthy foods and appropriate activity levels for our kids.

In addition to urging girls to substitute an apple for that bag of chips as an after-school snack, there are also some other important aspects of managing a girl’s health too though. The goal is to give her the best start on becoming a healthy woman and habits to maintain that health throughout her lifespan.

Establish a medical home
“We are training pediatricians now to provide medical home services for children,” said Julie Byerley, MD, MPH, a pediatrician and director of the pediatric residency training program at the University of North Carolina at Chapel Hill School of Medicine. “A medical home provides care that is comprehensive, patient-centered, culturally appropriate for an individual patient and family. It’s important that kids have access to that care and continuity with their provider and an ongoing relationship so that the family and child are well-known.”

The first thing that may come to mind is to make sure uninsured and underinsured girls have access to a medical home through a pediatric practice or community health center. Byerley also pointed out even girls who have a medical home may not fully benefit from it if their care is fragmented.

For example, while she says it is more important to get vaccinated rather than not, it is ideal for the vaccination or a sports physical to occur within the context of a check up at a girl’s medical home. There the check-up is more comprehensive about the entire realm of a girl’s health than what one would receive at a clinic devoted solely to walking kids through a series of stations for the sports physical or to administer a shot.  

She emphasizes that the medical home is a place where the provider has an opportunity to know the family and the girl’s history, build a relationship, anticipate questions about growth and development and answer questions the girl or her family might have.

“That way if a girl needs anything in the future, she feels comfortable returning to that relationship,” she said.

Build healthy bones. Now.

Beyond establishing a medical home, there are other specific aspects of a girl’s health that warrant consideration and may differ from the needs of a boy. One is bone health.

The first line of prevention of osteoporosis is to build strong bones early in life. According to the National Osteoporosis Foundation, 85 percent of adult bone mass is acquired by age 18 in girls (by age 20 in boys). Peak bone density for women is achieved by their mid-20s. After that it is all downhill. Women lose about 0.4 percent of their bone density per year after they reach peak density in their mid-20s, with a much faster rate of loss happening once they enter menopause.

“We are now considering osteoporosis a pediatric concern, not just something to think about for post-menopausal women,” said Michael Evers, MD, an OB/GYN at the UNC School of Medicine who both trains future OB/GYNs and practices in Chapel Hill, N.C. “I tell all of my residents here that no matter why a teen is in for an appointment, make sure she also gets the lecture on getting enough calcium- and vitamin D-rich foods. It’s during her teen years where you can potentially make the biggest impact on her bone health with something as simple as attention to diet or taking a supplement.”

The Institute of Medicine issued a report in 2010 updating recommendations for daily levels of calcium and vitamin D. Girls ages 9-18, should take in 1,300 mg./day of calcium and 600 mg./day of vitamin D, or the equivalent of two cups of milk. This means we want our girls and teens to consider it “cool” to keep drinking their milk.

“The key to bone health is to provide the body with the proper building blocks, that is, calcium and vitamin D, and then participate in regular, weight bearing exercise to encourage the bones to constantly remodel and strengthen,” added Evers.

Prevent cardiovascular disease
As if parents didn’t already have enough to worry about when their girls eschew fresh fruits and vegetables for favorite foods like pizza and hot dogs, cardiovascular health begins in childhood. Even an active girl or teen of healthy weight can have elevated cholesterol levels. Genetics may contribute, as well as eating habits.

Pediatrics has always been very focused on prevention, said Mike Steiner, MD, chief of the division of pediatrics and adolescent medicine and medical director of outpatient clinics at UNC School of Medicine.

“I think pediatricians are probably getting an increasing appreciation for things that can be done in childhood to improve the life of adult women,” he added.  

He said he thinks the jury is still out on how aggressive pediatricians should be in screening for or identifying traditional cardiovascular risk factors, such as through cholesterol screening. However, he noted, “There’s pretty good evidence that it’s beneficial to screen for high blood pressure. And there’s good evidence that it’s beneficial to screen and treat tobacco abuse, which are two important cardiovascular risk factors in adulthood.”

“Widespread cholesterol screening in children is controversial,” said Steiner. But he said concerns about family history or other risk factors, such as being overweight or obese, warrants it. In a nutshell, while lifelong cardiovascular risk is receiving more attention than ever, most pediatricians are not pushing daily fish oil supplements for children just yet.

Prevent cervical cancer

Each year, 12,000 women are diagnosed with cervical cancer nationally. Of those, nearly 4,000 die from an advanced stage of this fully preventable and treatable cancer. About half of women who die from cervical cancer did not receive regular Pap tests, which detect the abnormal cells that can lead to cervical cancer. African-American women and Latinas are disproportionately affected by cervical cancer and the least likely to be screened.

“In a wealthy nation like the United States, it is unforgivable to have women dying from cervical cancer, a fully preventable disease,” said Noel Brewer, PhD, director of Cervical Cancer-Free North Carolina and associate professor at the UNC Gillings School of Global Public Health.  “We can do better for our daughters, mothers, sisters and friends. We have to.” His initiative and others promote Cervical Health Awareness Month every January.

There are two lines of defense in the war on cervical cancer. One is vaccination against the human papillomavirus (HPV), in three doses when girls are 11- to 12-years old. The other is regular screening with a Pap test.

UNC’s Evers says he also encourages and supports immunization for boys as well with the following reminder.

“Immunization does not negate the need for a young woman to participate in routine pap smears starting at age 21, but it can go a long way in reducing her risk of developing cervical cancer.”

Empower our girls
To sum up, UNC’s Steiner feels strongly, and Byerley agrees, that we should look at health really broadly, not just in terms of physical health, when preparing girls to become women. If he had a magic wand to do one thing as a pediatrician for girls that would have the most impact it would be:

“To instill an empowerment and self-efficacy and self-confidence from an early age that would serve them well through their whole life related to physical health, overall well-being, relationships, career.”

Elizabeth Witherspoon, PhD, is a health and science writer in Durham, N.C. and parent of a tween girl whom she hopes will remain healthy throughout her lifespan.

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