Maternal obesity and the role of ACES - a service re-design

Hello Dr. Larkin,  I love your question!!  In my previous role as a public health nurse, I was perinatal services coordinator for a county of about 500K, with ~5K births per year.  Preconception prevention of maternal obesity was one of our local priority areas.  As my focus shifted more and more towards ACEs and trauma as precursors to maternal health disparities, I started to look a bit more deeply into the interesting intersection of ACEs and maternal obesity.  

Attached are two slide decks - use as you wish - or not!

The first deck shows a variety of journal articles which highlight an association between obesity and ACEs.  As you can tell, I am just starting to pull these together because, like you, I noticed a distinct knowledge gap and I had an assumption that the evidence for ACEs science was emerging, but not yet widely known.  So this deck reflects my early - very rough - work!    

The second deck is something I developed for California WIC Association 2017 statewide conference  - again I wanted to emphasize the intersection between ACEs / trauma and perinatal substance use.  This time - the slides are designed to encourage and empower WIC staff to support these at-risk moms - in a trauma informed way.      

I hope this is useful!  You are really onto something - please share your learnings here on ACN!  I can't wait to read more as your work evolves!  

Dr. Larkin,

I am an EMT that has been working with ACEs awareness in the field of EMS. Of recent I have learned that African Americans have the highest rate of preeclampsia in the nation. (Studies have also shown ACE scores as high as 85% scoring above 4.) I am curious of the relationship of high ACES, preeclampsia and high levels of cortisol. Do you test for cortisol levels and what percentage of your patients have preeclampsia?

Cortisol constricts the arteries which I believe contributes to high blood pressure.

Cortisol also tells the liver to release glucose and my curiosity lends me to believe that the body then converts it to fat stores. Also may lend itself to the cause of gestational diabetes. The cortisol creates a vicious cycle.

Preview attachment Obesity Felitti.pdf

 

 

Obesity Felitti.pdf

152 KB

 

It's worth keeping in mind that a maternal BMI of 35+ will likely translate into transmissible problems far beyond obesity.  The mechanisms will be patterns in upbringing related to responding to stresses, and by epigenetic processes just beginning to be uncovered.

An opening step in understanding the underpinnings of obesity will be to determine the age at which weight gain first began, then asking the individual why they think it began THEN and not three years earlier or ten years later.  Sometimes a meaningful insight is delivered; the rest of the time a seed has been planted for later harvesting.  The other big question is "What are the benefits of obesity?" because major weight loss typically poses an unrecognized threat to the person losing the weight.  This latter question is most productively asked of a group of obese patients rather than with individuals because of the mutual support in such a group, given a threatening question.

In addition, we have found a questionnaire filled out at home, before coming in, to be very helpful.  The one we developed over the years is attached.  Feel free to take from it.  Good luck in your work!

Karen Clemmer posted:

Hello Dr. Larkin,  I love your question!!  In my previous role as a public health nurse, I was perinatal services coordinator for a county of about 500K, with ~5K births per year.  Preconception prevention of maternal obesity was one of our local priority areas.  As my focus shifted more and more towards ACEs and trauma as precursors to maternal health disparities, I started to look a bit more deeply into the interesting intersection of ACEs and maternal obesity.  

Attached are two slide decks - use as you wish - or not!

The first deck shows a variety of journal articles which highlight an association between obesity and ACEs.  As you can tell, I am just starting to pull these together because, like you, I noticed a distinct knowledge gap and I had an assumption that the evidence for ACEs science was emerging, but not yet widely known.  So this deck reflects my early - very rough - work!    

The second deck is something I developed for California WIC Association 2017 statewide conference  - again I wanted to emphasize the intersection between ACEs / trauma and perinatal substance use.  This time - the slides are designed to encourage and empower WIC staff to support these at-risk moms - in a trauma informed way.      

I hope this is useful!  You are really onto something - please share your learnings here on ACN!  I can't wait to read more as your work evolves!  

Hi Karen, 

Thank you so much for taking the time to reply and for your kindness in sharing your knowledge and resources! I will share with the community when we have developed our thinking.

All the best

Warren 

Peter Chiavetta posted:

Dr. Larkin,

I am an EMT that has been working with ACEs awareness in the field of EMS. Of recent I have learned that African Americans have the highest rate of preeclampsia in the nation. (Studies have also shown ACE scores as high as 85% scoring above 4.) I am curious of the relationship of high ACES, preeclampsia and high levels of cortisol. Do you test for cortisol levels and what percentage of your patients have preeclampsia?

Cortisol constricts the arteries which I believe contributes to high blood pressure.

Cortisol also tells the liver to release glucose and my curiosity lends me to believe that the body then converts it to fat stores. Also may lend itself to the cause of gestational diabetes. The cortisol creates a vicious cycle.

Hi Peter, 

Many thanks for taking the time to reply. Can I check your abbreviations? EMT and EMS - sorry, I'm not familiar with terms.

Your theory makes a lot of sense based on my reading of the research but I confess I am a consultant clinical psychologist not a medic and as such your expertise is very much appreciated.

Anecdotally, I am not aware of women being tested locally for cortisol in pre-eclampsia - but others from the UK may be better placed to advise.

Thank you for the attachment and for sharing your expertise

all the best

Warren 

Vincent J. Felitti, MD posted:

It's worth keeping in mind that a maternal BMI of 35+ will likely translate into transmissible problems far beyond obesity.  The mechanisms will be patterns in upbringing related to responding to stresses, and by epigenetic processes just beginning to be uncovered.

An opening step in understanding the underpinnings of obesity will be to determine the age at which weight gain first began, then asking the individual why they think it began THEN and not three years earlier or ten years later.  Sometimes a meaningful insight is delivered; the rest of the time a seed has been planted for later harvesting.  The other big question is "What are the benefits of obesity?" because major weight loss typically poses an unrecognized threat to the person losing the weight.  This latter question is most productively asked of a group of obese patients rather than with individuals because of the mutual support in such a group, given a threatening question.

In addition, we have found a questionnaire filled out at home, before coming in, to be very helpful.  The one we developed over the years is attached.  Feel free to take from it.  Good luck in your work!

Good Evening Dr Felitti

Thank you so much for taking the time to reply to this enquiry here.  I expect you are inundated with requests for advice.

I very much appreciate your advice and that makes complete sense. Your advice on the assessment conversations above is powerful and I will be sure to include these steps in our service design.

I will make use of the questionnaire also!

Wishing you all the best

Warren 

Edith Mann posted:

Preview attachment Obesity Felitti.pdf

 

 

Obesity Felitti.pdf

152 KB

 

 

Edith, many thanks for the document!

all the best

Warren