A meeting held last week in Washington, DC prompted me to reflect on a conversation I had several decades ago with a teenage patient with obesity. Her words have taken on a new meaning for me. “I eat because I want to keep people away from me,” she said, as we talked in her room in the Clinical Research Center one evening. She had been a victim of sexual abuse as a young child, and was now a participant in a study that was the basis of my doctoral work. We were discussing what she thought made her develop obesity and why she found it so difficult to control her weight.
The adverse childhood experience of abuse had a very powerful impact on the development of her obesity and her motivation to remain, as she suggested, protected by her excess weight. Research has shown that 8 percent of obesity and 17 percent of severe obesity in adults can be attributed to abuse in childhood – physical, verbal, or sexual.
Perhaps most striking to me now is the connection between obesity and adverse childhood experiences in the context of an adverse community environment. High rates of adversity in a particular neighborhood or zip code – including abuse, but also homelessness, incarceration, violence, unemployment, and poor access to food and safe places to play – tracks with high burden of disease, including severe obesity, diabetes, and heart disease.
There is an inextricable link between the burden of disease and the burden of adversity in communities. A key mediating factor is community resilience, as I’ve learned from Wendy Ellis, a manager of child health policy in the Office of Child Health Policy and Advocacy at Nemours and a doctoral student here at the Milken Institute School of Public Health at The George Washington University. Ellis observes that resilience at the community level is a network of supports that helps its members to "bounce back," and it is critical to the health and health outcomes of that community.
Last week, the Sumner M. Redstone Global Center for Prevention and Wellness at the Milken Institute School of Public Health at GW and Nemours hosted a convening of the Building Community Resilience (BCR) initiative. GW has partnered with Nemours on this innovative project with the support of the Kresge Foundation and the Doris Duke Charitable Foundation.
The BCR initiative is now operating in five cities across the country and BCR leaders from DC, Wilmington, Dallas, Portland and Cincinnati came together last week at Milken Institute School of Public Health to learn from one another. Ellis and I work together as Co-Principal Investigators on the project, which aims to address the childhood and community adversity that have such powerful influence over health outcomes including obesity.
The BCR approach is novel, as it connects existing, yet disparate, community services and supports with the medical system for the first time. In DC, the medical component of the work is through Children’s National and MedStar Georgetown.
The need here in Washington, DC is very real. At Deanwood Metro station on March 26th, Davonte Washington, age 15, was fatally shot. According to The Washington Post, “Police said the suspected shooter was apparently angry over a glance or a stare and shot the youth unprovoked as he was on his way for an Easter haircut.” Washington had been waiting for a train with his mother and younger sisters when he was killed. On April 11, a second 15-year-old boy was stabbed to death at the same station.
Violent behavior can be a consequence of exposure to adversity in one’s community. The assailants in the Deanwood Metro killings may have been acting out, to devastating effect, their own exposure to community adversity
Deanwood Metro is in DC’s Ward 7, which, along with neighboring Ward 8, suffers significant community adversity. They also experience significant health disparities, with some of the District’s highest rates of obesity, diabetes, and cardiovascular disease.
There is no system in place to ensure that family members who suffer or are exposed to violence or other adversities are referred to supportive services. While the medical system is equipped, for example, to identify, refer and seek legal remedies for patients who’ve experienced sexual or physical abuse, no such system exists for adults and children who live in environments where they are repeatedly exposed to trauma such as hunger, homelessness, violence or neglect.
The BCR initiative envisions that a physician trained in the importance of community resilience – and the negative health outcomes that can develop where it is missing – would ask what a patient or family had experienced, tailor their care, and connect them to existing community supports and services. Perhaps a connection would be made to Martha’s Table, one of BCR’s DC partners, if the parent is in need of a reliable food source, day care, after school programming or clothing. Connections between the medical system and support services can begin to nurture community resilience.
Decades ago I lacked the insight to know how to address my patient’s obesity in the context of her abuse. However, I’m inspired by the Building Community Resilience approach. I believe it will be essential to helping reduce the likelihood that severe obesity and other negative consequences will result from exposure to adverse childhood experiences.