Obesity prevention is now topping the charts as a public health priority. There is an escalating obesity epidemic in the United States with the rate of childhood obesity having tripled in the past thirty years. A highly informative, four-part HBO film series, called “Weight of the Nation,” documents a national public health crisis that is affecting the long-term health of adults and children (www.weightofthenation.hbo.com). The Centers for Disease Control and Prevention (CDC) sponsored a “Weight of the Nation” Conference in May 2012 to highlight progress in the prevention and treatment of obesity through policy and environmental strategies (www.weightofthenation.org). Overall, these efforts, accompanied by a proliferation of public service announcements being aired by public health departments across the nation, promote good nutrition, exercise and healthy lifestyle choices. But isn’t there something missing? Didn’t the chain of events leading up to the ACE Study begin with the discovery of the connection between childhood sexual abuse and adult obesity? What about the weight of trauma on obesity and various types of disordered eating?
An insightful article by Rose Eveleth in the October 2011 issue of Scientific American sheds light on some of the “hidden drivers” of childhood obesity. Eye-opening statistics are quoted from peer-reviewed journals including Pediatrics and Adolescent Medicine as well as data from the STRONG Kids Project to demonstrate how television, the number of hours of sleep a child gets each night, and children not eating meals with their families are powerful predictors of childhood obesity. A key theme of the article is that there is more to preventing obesity than just emphasizing diet, exercise, and educational strategies. I agree. We’ve got solid research that tells us that adverse childhood experiences (ACEs) are another hidden driver of obesity.
In her exquisite article, “The Adverse Childhood Experiences Study—the Largest Public Health Study You Never Heard Of,” Jane Ellen Stevens (founder of the AcesTooHigh.com website), provides a detailed account of Dr. Vincent Felitti’s experiences with a highly effective weight loss program at Kaiser Permanente that ultimately led to the ACE Study. Dr. Felitti’s frustration with a 50% drop-out rate in the obesity clinic he was running was even more perplexing when he discovered that the patients who had dropped out were losing weight when they left the program. As he kept digging into the medical records of patients who had left the program, he learned that these patients had typically not gained the weight slowly over several years. Rather, they gained weight abruptly and stabilized at that weight. Dr. Felitti’s quest for understanding the why behind these puzzling facts would lead to interviews with patients that educated him about the silent benefits of obesity for trauma survivors. Patients described how eating was a coping mechanism—not only a source of comfort but how being overweight could create a sense of physical safety. Dr. Felitti was so intrigued that he conducted a case control study which clearly documented a higher prevalence of adverse childhood experiences —sexual and physical child abuse and household dysfunction—among obese patients compared to patients who had never been obese. When colleagues and experts discounted his findings, the CDC partnered with Dr. Felitti to conduct a large, rigorous study which clearly established the correlation between ACES and obesity as well as many other leading causes of morbidity and mortality.
The association between ACEs and obesity was especially pronounced for patients with higher body mass indexes (BMI) and while the impact of emotional abuse is often under-estimated, it was the strongest predictor of obesity (Williamson et al, 2012). Frequent verbal abuse increased the risk of a person having a BMI≥40 by 88%. Frequent physical abuse increased the risk of a BMI≥40 by 71% while sexual abuse increased the risk by 42%. Overall, nearly one out of 5 (17.3%) persons with a BMI≥40 could be attributed to abuse (this is called the population attributable risk or PAR).
The connection between childhood trauma and obesity is not just a weight control concern for adult survivors—the role of trauma starts early. Children exposed to domestic violence are 80% more likely to be obese before they are 5 years old compared to children who do not live in homes with domestic violence (Boynton-Jarrett et al, 2010). Girls who were physically punished as children are 4.8 times more likely to be 150% or more over normal body weight as adolescents and young adults (Johnson et al, 2002). For girls who were physically abused, the risk of being significantly overweight as an adolescent or young adult is 6.6 times higher.
So what did providers at Kaiser Permanente do at their obesity clinic to address the connection between trauma and obesity? They began by asking the following question when patients disclosed ACEs during their health history: “How has what happened to you affected your life?” That simple question appears to have helped patients with self-understanding because follow-up with these patients demonstrated a dramatic drop in doctor office visits over the following year. Next steps included integrating weekly, small discussion groups into the Kaiser Permanente Weight Loss Program. These weekly discussions were guided by a series of questions including:
- Why (not how) do you think people become overweight?
- How old were you when you first began putting on weight? Why do you think it was then and not a few years later?
- Sometimes people, who lost a lot of weight, regain it all, if not more. When that happens, why do you think it happens?
- What are the advantages of being overweight?
As a nation, we need a comprehensive, trauma-informed approach to obesity prevention that goes beyond talking about healthy lifestyle choices to addressing hidden drivers of obesity including trauma over the lifespan. Failure to do so not only undermines the effectiveness of existing efforts to address obesity but also does not acknowledge how weight loss might be threatening to trauma survivors. As public health and primary care clinics across the nation implement routine screening for BMI and counseling on weight control, there needs to be a parallel effort for trauma-informed services to minimize re-traumatization by understanding how food may be used as a means of self-medicating and obesity might be a person’s intentional or unconscious solution to what we have viewed as the problem. A trauma-informed response to obesity prevention and weight control should include:
- Providing training and strategies to ensure trauma-informed services in public health and healthcare settings;
- Integrating routine assessment for ACEs as part of screening and counseling patients on weight loss;
- Educating patients about the role of ACEs in obesity and eating disorders;
- Offering support, counseling and referrals as needed to address feelings and trauma that may resurface unexpectedly for trauma survivors in weight loss programs.
As Dr. Felitti discovered while working with patients in the obesity clinic more than two decades ago, the emphasis should not be on what’s wrong with you, but rather what happened to you—that translates to being more trauma-informed and that’s where we really need to go to effectively prevent many leading public health plagues today including obesity.
Boyton-Jarrett R, Fargnoli J, Suglia SF, Zuckerman B, Wright RJ. Association between Maternal Intimate Partner Violence and Incident Obesity in Preschool-aged Children: Results from the Fragile Families and Child Well-Being Study. Archives of Pediatric and Adolescent Medicine. 2010;164(6):540-546.
Eveleth, R. Hidden Drivers of Childhood Obesity Operate Behind the Scenes. Scientific American. Downloaded 11/17/2011 at http://www.scientificamerican.com/article.cfm?id=hidden-drivers-of-childhood-obesity
Johnson JG, Cohen P, Kasen S. Brook JS. Childhood Adversities Associated with Risk for Eating Disorders or Weight Problems during Adolescence or Early Adulthood. American Journal of Psychiatry. 2002;159(30):394-400.
Stevens, Jane Ellen. The Adverse Childhood Experiences Study—the Largest Public Health Study You Never Heard Of. HUFF POST IMPACT, October 9, 2012;1-17.
Williamson DF, Thompson TJ, Dietz WH, Felitti V. Body Weight and Obesity in Adults and Self-Reported Abuse in Childhood. International Journal of Obesity. 2202;25:1075-1082.
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