Posts tagged ‘CDC’

July 10, 2019

Adverse Childhood Experiences Can Detrimentally Affect Health

Even when current stress is low, the lingering effects from adverse childhood experiences can detrimentally affect health. We’re often reminded that current or ongoing stress is bad for us, but the stress we experienced long ago can be just as significant. Researchers who conducted The CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study concluded: “We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults”.1
woman
This week I’m going to give you information about the study. Next week, I’ll talk more about real-life scenarios that are playing out in the statistics. With adverse childhood experiences affecting more than half of us, this is a very big topic. And with the increase in chronic disease, it seems important and timely.

How The Study Came About

As sometimes happens, a doctor set out on one mission only to have his curiosity piqued by something he discovered along the way. This eventually led to the groundbreaking ACE Study. Vincent Felitti, head of Kaiser Permanente’s Department of Preventive Medicine in San Diego, set out to determine why the dropout rate of participants at Kaiser Permanente’s obesity clinic there was about 50% even though all of the dropouts successfully lost weight under the clinic’s program.

While conducting interviews with people who had left the program, Dr. Felitti discovered that a majority of some 286 people he had spoken to reported sexual abuse as children. Felitti wondered if weight gain was being used to cope with depression, anxiety, and fear. He decided to learn more.

Participants in the Study

With a team, Dr. Felitti and the CDC’s Dr. Robert Anda interviewed 17,337 study participants asking five questions relating to personal trauma and five relating to trauma within the family. About half of the participants were female; 74.8% were white; the average age was 57; 75.2% had attended college; all had jobs and good health care. Each positive response to a question counted as one point. The resulting total is the ACE score.

About two-thirds of participants had experienced at least one adverse childhood event. Of those, 87% (almost 10,000) had experienced more than one. Over 15% of women and 12% of men in this mostly white, middle and upper-middle class, college educated group had experienced more than four.

According to the CDC, rates of child abuse and neglect are five times higher for those who live in families with low socioeconomic status as compared to children in families with higher socioeconomic status. That means the original ACE rates of occurrence may be much higher in some segments of the population.

Questions That Were Asked

The questions asked included physical abuse, verbal abuse, sexual abuse, physical neglect, and emotional neglect, a parent who’s an alcoholic, a mother who’s a victim of domestic violence, a family member in jail, a family member diagnosed with a mental illness, and the disappearance of a parent through divorce, death or abandonment. All of these are major stressors chosen in part because they had been identified in earlier research, but they are not a comprehensive list of adverse childhood experiences.

The study did not address food insecurity, homelessness, loss of a caregiver other than a parent, surviving a severe accident, recurring hospitalization, a medically fragile family member, neighborhood violence, living with a hoarder, drug addiction within the family, involvement with the foster care system, racism, bullying, watching a sibling being abused, witnessing a father being abused by a mother, witnessing a grandmother abusing a father, or involvement with the juvenile justice system. All of these events and others that create toxic stress can increase the risk of long-term health consequences.

How Answers Relate to Health Risks

Through 2015, more than 70 publications have expanded on the knowledge gained through The ACE Study and parallel research has shown the effects of traumatic stress on children’s developing brains. In general, an ACE score of 4 or higher increases the likelihood of chronic pulmonary lung disease 390%; hepatitis 240%, depression 460% and attempted suicide 1220%. Yes, you read that right. The risk for attempted suicide increases over 1000 percent.

In addition, children who experience four or more categories of exposure compared to those to have none will have a 4- to 12-fold increased health risk for alcoholism, drug abuse, and depression; a 2- to 4-fold increase in smoking, poor self-rated health, ≥50 sexual intercourse partners and sexually transmitted disease; and a 1.4- to 1.6-fold increase in risk for physical inactivity and severe obesity.

Costs of Adverse Childhood Events

While the greatest cost of ACEs is to the individual and, by extension, the family, societal costs are also great. According to the CDC, “In the United States, the total lifetime economic burden associated with child abuse and neglect was approximately $124 billion in 2008. This economic burden rivals the cost of other high profile public health problems, such as stroke and type 2 diabetes.” And it appears that it contributes to those high profile health costs as well.

There are also intangible costs. ACEs affect our classrooms, our friendships, our marriages, and our ability to work well with others. They can also be self-perpetuating. A child who does not feel valued may not value the lives of others including his/her children. Without intervention or mitigating circumstances, the cycle repeats.

Addressing the Problem

The CDC has developed a technical package that identifies a number of strategies to help communities prevent and reduce child abuse. They include strengthening economic support, providing quality child care & early education, enhancing parenting skills, intervening to lessen harm & future risk, and changing social norms.

We Have a Long Way to Go

At this moment, I cannot stop thinking about the two-month-old child living in Missouri who is being kept at home by a total stranger while her parents vacation in the Caribbean. There is significant risk in this scenario. Yes, the caregiver works for a service and, in theory, has been vetted by the employer, but the parents will not meet him/her in advance.

On top of this, the mother’s housekeeper has observed this baby being repeatedly left alone in bed in her room all day other than feeding time. When she cries, she is not talked to, picked up, or comforted. It’s easy to say: she’s too little to know the difference; kids are resilient; she won’t remember; I’m sure they usually pick her up; her parents have plenty of money so she’ll be fine…. But taken together these are red flags that are significant and indicative of insidious neglect that often flies under the radar.

My cousin who is a psychologist relayed the story of this baby to me a few weeks ago. She and the mother are friends who share both a yoga class and a housekeeper. She is concerned, but there is a stable home; the baby is changed, fed, bathed, and dressed in cute clothes; and she sees the pediatrician as scheduled. There is simply no documentable problem.

I’m not sure how to help this baby. My high school friend whose daughter has become addicted to opioids after back surgery struggles to determine how to and how often to step in to help her son-in-law with the grandchildren who live 3 hours away. In the past year, I’ve seen babies removed from parental care while lying in CVICU. They may be legally fostered by a physician, but they are experiencing traumatic procedures in a noisy, unfriendly environment without a consistent caregiver to comfort them. It is heartbreaking.

The only ACE questions I’ve seen in a healthcare setting were on a proposed opioid risk assessment recently reviewed by the PFCC Hospital Advisory Council on which I sit. I cannot recall ever having a physician ask me a question related to ACEs. In spite of the strong relationship between ACEs and health risk, in the 20 years since the original study, we have not managed to incorporate this important piece of patient history into routine preventative care.

It feels like we are spinning our wheels in a place where we have plenty of data to support systematic change, but not the will or courage to implement it. Instead, we continue to spend billions to fight chronic disease without including programs to reduce or mitigate the effects of adverse childhood experiences.

We Can Make a Difference With Simple Changes

We may not be able to prevent every occurrence of child abuse, but we can improve overall community health by including ACE assessment questions in our patient information forms, then providing trauma-informed treatment for those with high ACE scores.

We can lose the us vs them language of mental health care. Saying abuse “changes who you are” is not productive, helpful, or even true. Abuse and neglect change how you respond to the world, but they do not change the person you can get back to with healing. Calling a patient’s response to a wound inflicted by someone else a “disorder” or “mental illness” is uninformed. It makes his/her adaptation for survival (an internally heroic thing) sound like a defect. Many victims already feel defective. Confirming that feeling does significant damage. Detrimental behavior that results from adaptation can still be dealt with, but in a different manner. The ability to reframe past events can make the difference between hope and hopelessness.

We can train all health professionals, social workers, teachers, human services workers, and law enforcement professionals in Mental Health First Aid.

We can focus on mindfulness (shown to change the brains of PTSD patients) in fitness and mental health programs and let weight loss be a side effect.

Gynecological exams can begin with a conversation while the patient is clothed before proceeding to the physical exam. I think this is good policy no matter what the patient’s background, but can be extremely important for some survivors of childhood sex abuse.

Pediatricians can include questions regarding indicators of attachment in well-care exams and instruct parents regarding the importance of bonding.

Breastfeeding education can include information regarding the benefits of holding a child close and looking into his/her eyes while feeding in addition to the health benefits of consuming breast milk.

Parents can be gently reminded that they must comfort, sooth, protect, and respond to their child’s needs before the child can learn to sooth itself. Withdrawing into itself is not the same as self-soothing. It may mean the child is quiet, but it is dysfunction.

We can stop trying to make ourselves feel better by dismissing subtle signs of distress in our grandchildren, nieces, nephews, and students. Acknowledging a problem is the first step toward fixing a problem.

And we must remember that it is extremely stressful to make life and death decisions; to care for ill and dying patients; to go into homes of severely abused children; and to watch an addict relapse. If we expect professionals to approach patients with compassion, we have to provide them adequate emotional support and safe environments in which to voice their feelings.

Compassion is Always Appropriate

More than likely, you interact with multiple people who had adverse childhood experiences on a regular basis. You may not even know who they are. Some of them will suffer health effects. Some of them will not. Some will act out. Some are doing their best just to get through the day. A high ACE score is both an indicator of risk and a call to practice compassion and patience with everyone you encounter-especially the difficult ones. Compassion is a great starting point for improving health.

Stevens, Jane Ellen (8 October 2012). “The Adverse Childhood Experiences Study — the Largest Public Health Study You Never Heard Of”. The Huffington Post.

https://www.ajpmonline.org/article/S0749-3797(98)00017-8/abstract
Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults
The Adverse Childhood Experiences (ACE) Study
Vincent J Felitti MD, FACPA,*’Correspondence information about the author Vincent J Felitti, Robert F Anda MD, MSB, Dale Nordenberg MDC, David F Williamson MS, PhDB, Alison M Spitz MS, MPHB, Valerie Edwards BAB, Mary P Koss PhDD, James S Marks MD, MPHB

https://acestoohigh.com/got-your-ace-score/

https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/about.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4917040/

August 21, 2017

Sandwich in Some Healthy Habits

Today when the moon gets sandwiched between the earth and the sun seems like the perfect opportunity to sandwich in some healthy habits. I’m sure you’ve seen a million warnings in the past two weeks about protecting your eyes during today’s eclipse. You probably prepared by purchasing some special viewing glasses or creating a pinhole viewer. That tiny bit of preparation will protect your eyes as you view something spectacular.

eclipse

Eclipse


Making tiny changes in preparation for better health as you age can be just as easy and have a big impact over time. If you look at everything you think you should be doing to live a perfectly healthy lifestyle, it may so overwhelming that you don’t ever get started. Statistics indicate that the majority of us fall in this group. The CDC reports that only 20% of Americans meet physical activity recommendations and a 2016 study indicates only 3% of us live a healthy lifestyle.

It is important to note that you can improve your health by making small changes over time. A study published July 13, 2017, in the New England Journal of Medicine found that “Improved diet quality over 12 years was consistently associated with a decreased risk of death. A 20-percentile increase in diet scores (indicating an improved quality of diet) was significantly associated with a reduction in total mortality of 8 to 17%….” In other words, it didn’t take 100% improvement in diet to result in a significant reduction in mortality. And mortality is the extreme. Just imagine how much small changes can improve your everyday energy level, stamina, strength, flexibility, mental acuity, mood, and comfort level.

So often we look at eating well and working out as all or nothing propositions. When all seems like more than we can handle, we go for nothing. Knowing that even small changes can make a difference seems to indicate we should look at healthy habits more like a savings or investment account with benefits that grow slowly, but surely.

What do small changes look like?

Drink water 95% of the time rather than soda, diet soda, energy drinks, sweetened coffee drinks, lemonade, sweet tea, hot chocolate, or any other sweetened drink.
Eat an orange for breakfast rather than drinking orange juice.
Eat plain, unsweetened yogurt topped with fresh fruit rather than flavored yogurt.
Choose eggs and whole grain toast for breakfast rather than cereal and milk.
Snack on raw, unsalted nuts rather than the salted, roasted version.
Choose black beans over pinto beans.
Order a side of mixed vegetables rather than a choice of potato most of the time.
Reserve dessert for special occasions.
Snack on fruit rather than candy.
Pop your own popcorn using a tiny bit of olive oil spray.
Get salad dressing on the side and limit to 1 tbsp.
Buy frozen vegetables rather than canned when you can’t get fresh.
Cook with olive oil.
Take leftovers for lunch rather than eating fast food.
Substitute baked fish for one serving of red meat each week.
Eat less prepared meat.

Sandwich in some activity

Even if you don’t have an hour to spend in the gym, you can increase physical activity during your daily routine.

Stretch every morning.
Walk to lunch.
Walk a few flights of stairs before catching the elevator.
Do stair stretches before you head upstairs to shower.
Regularly park on the far side of the parking lot.
Do some yoga breathing at your desk.
Carry your own boxes.
Wear ankle weights on Saturday.
Do tricep curls with your cast iron skillet before cooking.
Find a video workout you can do at home when there’s no time to go to the gym.
Combine lifting light weights with warrior poses and lunges.

Make sure to rest

Get the electronic lights out of the bedroom.
Allow plenty of time for sleep.
Plan some down time each week.
Do something fun each week.
Don’t skip vacations.

As you can see, nothing on these lists sounds like a big deal. Everything is easily doable. In fact, it’s hard to believe that these changes can make any significant difference in your health. The great thing is, they can. Simple changes like these when made for an extended period of time can have many positive effects. Why not sandwich a few into your day?

https://www.cdc.gov/media/releases/2013/p0502-physical-activity.html

http://www.mayoclinicproceedings.org/article/S0025-6196(16)00043-4/abstract

http://www.nejm.org/doi/full/10.1056/NEJMoa1613502

November 16, 2015

It’s a Good Day for Chicken Soup!

It’s a good day for chicken soup! It’s raining outside and I have a cold…or something. I don’t feel horrible, but I don’t feel good. At first my sinuses hurt, then my throat got scratchy, and now I’m getting a cough, but certainly not the worst I’ve ever had. I really just want to go to sleep.
Soup
Sometimes it’s really hard to know when to give in, go to bed and rest, and when to push on. I was able to work out this morning. That didn’t seem to increase my cough or leave me feeling drained. I knocked out some work and went to the post office. It was when I got back that I began to feel draggy and my cough increased.

I’ve been chugging orange juice and it seems like the perfect time to add some chicken soup! Of course I don’t really feel like a lengthy cooking session.

Luckily, I keep organic chicken stock and rice in the pantry and I always have baby carrots in the fridge. Today, I also have celery. It may not look quite the same as my favorite recipe, but I can have some warm, tasty soup ready in a matter of minutes.

Here’s my simple soup making plan:
32 oz box Imagine Low Sodium Free Range Chicken Broth
3/4 cup water
3/4 tsp salt
3/4 tsp garlic powder
1/4 tsp Italian Herbs paste
Pinch of black pepper
12 – 15 baby carrots, sliced into thin rounds
3 stalks celery, finely chopped
2/3 cup quick-cooking Texmati rice

Pour chicken broth and water into a large saucepan. Add salt, garlic powder, herb paste, and pepper, then stir. Bring to a boil. Add carrots, celery, and rice to broth and stir. Cover and turn heat to low. Allow to simmer for 15 minutes. Serve hot.

If I had a leftover chicken breast or a roasted chicken from the grocery store, I’d tear it into small pieces and add it to the broth along with the rice. This isn’t the first time I’ve fixed chicken soup in a pinch. Sometimes I add a little turmeric or substitute curry powder for the Italian spices. Sometimes I throw in fresh rosemary and sage in place of the herb paste or top things off with arugula or green peas. Of course there are a million options. Since I’m feeling under the weather, the point is to use what’s handy and keep it simple.

I’m planning to pair the soup with a piece of homemade gluten-free bread from the freezer and a cup of hot herbal tea…followed by a nap.

I should be back to normal in no time. I won’t be reaching for the meds unless some complication develops. After all, this is Get Smart About Antibiotics Week – when the CDC reminds us that we overuse and misuse antibiotics which, by the way, are not helpful for colds and flu in the first place.

So if you’re feeling just a bit under the weather, won’t you join me for a cup of comforting chicken soup?


http://www.hhnmag.com/articles/6720-hospitals-around-the-world-unite-to-battle-antibiotic-overuse