by guest blogger Pam Peeke, MD, MPH, FACP, FACSM, best-selling author and expert on health, fitness, and nutrition
For years I’ve listened to women and men recount an agonizing spectrum of verbal, emotional, and physical abuse and trauma that occurred during their childhood, often continuing through adolescence. Most remember that period in their life as the time when they began to overeat.
Neglect, abandonment, isolation, and physical harm usually send young people on a desperate search for a way to numb and soothe their pain. Of course, food is the main accessible and primal reward. Laurie has her “Cheerios moments”—a habit of bingeing on cereal in the face of anxiety and stress—just as she did when her addict mother would play a twisted game of “Let’s pretend you’re adopted and not a member of this family.” Alice remembers her father adamantly declaring, “No one loves a fat woman.” She was 10, and believing that statement sent her into a panic, with years of fridge raids and bingeing and, eventually, bariatric surgery as an adult. Then there’s Erica, whose As in school were never good enough for her dad, who insisted on A-pluses. Emily endured years of physical and sexual abuse, resulting in constant self-soothing with food and an extra 100 pounds born of her pain.
I call them painful pounds.
The good news is that there is now evidence-based science to explain the connection between the trauma of childhood abuse and weight gain. And it’s beginning to revolutionize how we approach nutrition and weight management.
If you are one of the countless people who continue to repeat endless cycles of every imaginable diet and exercise craze to shed those extra pounds to no avail, early-life abuse and trauma might be a factor you should consider. Mounting scientific evidence is now linking early-life abuse and stress with eating behaviors that can lead to overweight and obesity and disordered eating. Childhood abuse of any kind often leads to self-soothing with foods that can counteract the pain of ongoing emotional and physical abuse. It’s not surprising that overeating hyper-palatable (sugary, fatty, salty) food combinations creates a long-term psychobiological habit of seeking out these products in the face of life’s stresses.
Recently, Harvard researchers studied 57,321 women enrolled in the long-term Nurses’ Health Study II (NHSII), specifically examining the association between child abuse victimization and food addiction, a form of stress-related overeating. They used the Yale Food Addiction Scale to assess the presence of addictive eating patterns. Their findings were striking: Both severe physical and sexual abuse were associated with a stunning 90 percent increase in food addiction risk. Women with food addiction were 6 units of BMI heavier than women without food addiction. The researchers concluded that, “A history of child abuse is strongly associated with food addiction in this population.”
In a follow-up study, the researchers examined the relationship between post-traumatic stress disorder (PTSD) and food addiction. Noting that PTSD appears to increase obesity risk, they once again surveyed the NHSII population, this time studying how food addiction could be related to the age of trauma onset as well as the type of trauma.
Once again, the scientists uncovered extraordinary links, revealing that approximately 80 percent of the study group had been exposed to some kind of trauma, with 66 percent noting at least one lifetime PTSD symptom. As the number of PTSD symptoms increased, so did the prevalence of food addiction. The women who had noted the highest levels of PTSD had more than twice the incidence of food addiction as the women with no PTSD symptoms or trauma history. This study informed health professionals that it is critical to assess past history of any trauma, stress, or abuse in order to individualize treatment plans that directly address how to manage trauma-based behavior.
You may be wondering about your own unique history. First, examine your eating behavior by answering the following two questions:
- If I consume a particular food/beverage, do I feel a loss of control?
- If I consume a particular food/beverage, do I feel shame, blame, or guilt?
Typically, people with addictive binge-eating behavior will answer yes to both questions. If this is the case for you, then the next step is to examine whether abuse and trauma may have played a role in the development of any painful pounds. A simple way to assess this is to take the adverse childhood experience (ACE) assessment and then correlate your score with health consequences. The ACE test was created Vincent J. Felliti, MD, founder of the California Institutes of Preventive Medicine, as a tool to assess the prevalence of abuse and neglect in a population of 17,000 adult Kaiser Permanente Medical Care Program members. Felliti and his team found that almost two-thirds of study participants reported at least one ACE, and more than one in five reported three or more ACEs. As the number of ACEs increased, so also did the risk for an extensive laundry list of conditions, including substance abuse, depression, suicide, domestic violence, poor academic performance, and obesity.Please keep in mind that you don’t need to have experienced severe childhood abuse to become an adult who self-soothes with food. There’s a wide spectrum of childhood abuse and trauma. Each child or adolescent perceives life events uniquely, and what is traumatic to one might be something another easily manages. The key is to know your own story and, in knowing it, enable yourself to customize a strategy to switch out self-destructive habits for health-promoting behaviors.
Here are some first steps to guide you as you begin your own healing journey.
- Therapy. If you’ve never confronted your past history, it’s advisable to get help in doing that. If you seek out a therapist who specializes in abuse and trauma, he or she can provide homework and immediate practical tools you can use. The key tenets of trauma and abuse-based therapy are to help clients reframe what happened to them and, thus, better manage issues related to trust, safety, and trauma processing—then the person, armed with that knowledge, re-integrates into a healthy and productive life.
- Trauma and food-addiction resources. Here are a few reading and organization resources you might find helpful:
- Bessel van der Kolk, MD, is a renowned trauma expert, and his book The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma is a terrific summary of abuse and trauma science and therapeutic solutions. The audio version is excellent. His Massachusetts-based trauma center provides client services and hosts events.
- Yoga teacher Ana Forrest is the founder of Forrest Yoga and the author of Fierce Medicine: Breakthrough Practices to Heal the Body and Ignite the Spirit, (also available as an audio book, which she narrates). A child abuse and trauma survivor, she found healing in her yoga practice, eventually creating a unique trauma-healing-focused yoga that is now used worldwide.
- Christine Courtois, PhD, ABPP, is a preeminent scholar in trauma science and therapy. Her seminal scholarly text is Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach. She recently wrote It”s Not You, It’s What Happened to You for a more general audience; in it, she outlines practical steps for reframing the past and beginning the healing process.
- I address trauma-based food addiction in my book The Hunger Fix: The Three Stage Detox and Recovery Plan for Overeating and Food Addiction. Professionals can find the clinical and bench science studies on the topic in Food and Addiction, a textbook edited by Kelly Brownell and Mark Gold.
Becoming aware of the abuse-weight connection is key to beginning your own healing journey. Taking action requires courage, self-compassion, and support. In his poem “Invictus,” the poet William Ernest Henley declared that each of us has an “unconquerable soul.” The poem ends with the line “I am the master of my fate, I am the captain of my soul.”
Believe those words and let the healing begin.
Pamela M. Peeke, MD, MPH, FACP, FACSM, is an internationally renowned expert in integrative and preventive medicine. Dr. Peeke is a Pew Foundation Scholar in nutrition and metabolism, assistant professor of medicine at the University of Maryland, and a fellow of the American College of Physicians and American College of Sports Medicine. A nutrition and fitness pioneer, she has been the recipient of numerous fitness-industry lifetime achievement awards, including the IDEA Health and Fitness Association Inspiration Award and the Zumba Fitness International Role Model Award. Known as “the doc who walks the talk,” Dr. Peeke is a Senior Olympic triathlete and a member of the National Senior Games Foundation Board. As senior advisor to the 18th Surgeon General of the U.S., Regina Benjamin, MD, MBA, Dr. Peeke created the Surgeon General’s Walks for a Healthy and Fit Nation program. Dr. Peeke’s work includes WebMD’s lifestyle expert, Discovery Health TV’s chief correspondent for nutrition and fitness, host of both Discovery Health TV’s series Could You Survive? and National Body Challenge, acclaimed TEDx presenter, and regular commentator for the national networks. Dr. Peeke is a New York Times best-selling author; her books include Fight Fat after Forty, Body for Life for Women, and The Hunger Fix.
Childhood trauma leads to food deprivation later in life
Feb. 20, 2015
Traumatic experiences in childhood are predictive of food insecurity for adults, researchers at the Drexel University School of Public Health report in a Jan. 22 study in Public Health Nutrition. Conducted by the school’s Center for Hunger-Free Communities, the study examined 31 mothers of children under age 4, and was published as “The Relationship Between Childhood Adversity and Food Insecurity.” In addition to Drexel’s Mariana Chilton, Molly Knowles and Kimberly Arnold, the research team included Jenny Rabinowich of Liberian-American charity Last Mile Health.
Knowles, the qualitative research coordinator at the Center for Hunger-Free Communities, said in an online interview that the idea was inspired by a previous study. The findings of “Witnesses to Hunger” showed that “families experiencing food insecurity were also often dealing with issues of trauma and exposure to violence,” she said. Around the time the study was being conducted, the Center for Hunger-Free Communities was also learning more about Adverse Childhood Experiences.
In the field of public health, ACEs can be defined as “stressful experiences before the age of 18 that include: emotional and physical abuse; emotional and physical neglect; and household instability, including parental separation, domestic violence, and mental illness, substance abuse, or incarceration of a household member,” according to the research brief associated with the study. The brief also stated that “ACEs are associated with poor adult mental and physical health and economic outcomes.” The study was meant to examine and investigate the relationship between ACEs and food security in households.
Participants in the study were first quantitatively surveyed and given an ACE “score” from 0 to 10, which reflected the participant’s cumulative number of adverse or traumatic childhood experiences. Jocelyn, 20-year-old mother of one, scored 9 on her ACEs test. Jocelyn’s traumatic childhood experiences include her parents’ drug abuse and physical fighting, her parents’ separation, her experience of being raped by her stepbrother, being diagnosed with depression and the following hospitalization, school enrollment changes, and finally, young motherhood and moving back in with her abusive mother.
The interview portion of the study was used to help the researchers define the ways in which ACEs and traumatic childhood events had serious and lasting impacts on caregivers and their relationships with their own children. Emotional and physical abuse and neglect as well as drug or substance abuse that could lead to either of those factors was key in defining relationships that appear to exist between ACEs and adult food insecurity.
Jocelyn described instances of having little to no food availability as a child. “We barely had food. I don’t even know if food stamps existed,” Jocelyn said. She also described in the interview being so hungry as a child that she would eat the paint chips off her wall, which eventually gave her lead poisoning. After being fired from the only job she ever had, Jocelyn was forced to move back into her neglectful mother’s house where her younger siblings still lived. Now, Jocelyn struggles to feed her own child, in addition to her siblings, and admits to skipping meals or stretching budgets to ensure her family has enough to eat.
The research brief defined household food insecurity as a “lack of access to enough food for an active and healthy life due to economic hardship.” There are two types of food insecurity: ;ow food security, which indicates issues with access to food and poor diets in households; and very low food security, which shows that at least one household member has reduced their food intake, and that eating patterns within the household have been disrupted due to inadequate food or money resources. Using the U.S. Household Food Security Survey Module, the researchers were able to identify caregivers of children younger than the age of 4 who could be classified as being either household or child low or very low food secure.
Claudia, a 22-year-old mother of one, scored a 9 on her ACEs test and was ranked as household very low food secure and child low food secure. Claudia’s descriptions of childhood hunger showed how much of an effect ACEs have on food insecurity for adults who went through those experiences. In her interview, Claudia said, “I know how much my stomach hurt from the hunger, how much my body ached, having pains and not having the medication for it, you know? … The hunger, the pain, the depression — it always comes back. It’s like a bird nesting in your head.” Claudia’s descriptions of being haunted by her childhood hunger depicted the relationship later found to exist by the researchers between ACEs and adult food insecurity.
The emotional abuse endured by some participants can be modeled by Tamira. With an ACEs score of 9, and a reported household with very low food secure and child low food secure, Tamira’s emotional abuse and neglect as a child showed strong reasons why she still suffers from food insecurity now as a 22-year-old mother of one. “If a person always says you’re nothing; you’re nothing. Then for a while I used to think I’m not anything. … Because I can’t find a job I cannot feed my daughter. How am I supposed to? I cannot buy her what she needs.”
Knowles commented on the emotional difficulty of the qualitative interviews conducted in the study: “Some of the stories the mothers told us were very painful, and many of them have really stayed with me. But we also saw a lot of resilience — many of the moms talked about how their experiences made them stronger and more determined to ensure that their kids didn’t experience the same adversity.” In a blog post, Knowles also said it was upsetting to realize how incapable current aids-programs and social support services are of assisting with behavioral and trauma-induced issues. She wrote: “According to the moms we spoke with, social service providers often re-traumatize families through punitive policies and negative attitudes that stigmatize those seeking help.”
A strong relationship between higher ACEs scores and low food security or very low food security was found in the study’s results. Of the 19 households defined as very low food secure, 16 scored above a four on the ACEs test, while only three scored between zero and three on the ACEs test. Statistical testing verified this relationship, according to the published findings. These findings will be used to redefine how policies and programs dealing with needy families treat mental and behavioral health of the caregivers as a primary issue in moving forward.
Knowles commented that the Center for Hunger-Free Communities “will continue educating policymakers on how trauma and violence affect families experiencing poverty and food insecurity… [The center is] also trying to work with other faculty and staff at Drexel who work on issues of trauma to figure out how to best prevent and address trauma in Philadelphia and throughout the country.”
Editor’s note: Pseudonyms were used for the names of the participants of the survey.
Food Research & Action Center © December 2017 n www.frac.org
The Impact of Poverty, Food Insecurity, and
Poor Nutrition on Health and Well-Being
Hunger & Health
There is growing awareness and acknowledgment in the health care community that
health outcomes and disparities, more often than not, are driven by social determinants
of health than by medical care.1
Social determinants of health include social, economic,
physical, or other conditions where people live, learn, work, and play that influence their
Poverty and food insecurity are social determinants of health, and are associated
with some of the most serious and costly health problems in the nation.
* Hartline-Grafton, H. (2017). The Role of the Supplemental Nutrition
Assistance Program in Improving Health and Well-Being.
Washington, DC: Food Research & Action Center.
† Hartline-Grafton, H. (2017). The Role of the Federal Child Nutrition
Programs in Improving Health and Well-Being. Washington, DC:
Food Research & Action Center. [The federal Child Nutrition
Programs include the Special Supplemental Nutrition Program
for Women, Infants, and Children (WIC); National School Lunch
Program (NSLP); School Breakfast Program (SBP); Child and Adult
Care Food Program (CACFP); Summer Food Service Program
(SFSP); and Afterschool Nutrition Programs.]
Food Research & Action Center © December 2017 n www.frac.org n 2
unintentional injury,33 and physical inactivity.34 Low-income
adolescents also are more likely to engage in healthcompromising
behaviors, such as smoking.35
Childhood poverty and socioeconomic inequalities have
health implications that carry through into adulthood as
well — for example, lower childhood socioeconomic status
is associated with chronic disease, poor mental health, and
unfavorable health behaviors in adulthood.36, 37, 38 Poverty
in childhood also has been linked to serious, long-term
economic consequences, including higher health care
expenditures, lower educational achievement (e.g., not
completing high school and college), lost productivity and
lower earnings in adulthood, and increased risk of poverty
later in life.39, 40, 41
Toxic Stress and Adverse Childhood Experiences
Growing up in poverty is associated with toxic
stress — which is chronic stress that can have
enormous impacts on child development and
health.42, 43, 44 Under prolonged stress, stress hormone
levels become excessively high for long periods of
time. This leads to a “wear and tear” on the brain
and body, referred to as allostatic load. Toxic stress
can inhibit normal brain and physical development
and metabolic processes among children, making
them more susceptible to learning and behavior
impairments and physical and mental illness later
Toxic stress in children often results from strong,
repeated, or prolonged exposure to adversity, such
as adverse childhood experiences (ACEs).46 ACEs are
potentially traumatic experiences, such as economic
hardship, loss of a parent due to divorce, witnessing
domestic violence, or the incarceration of a parent.
ACEs are more common among children living in
poverty.47 Exposure to more ACEs puts children at
greater risk for health and economic problems later
in life.48, 49 For instance, one study found that female
caregivers’ ACEs were associated with current
household and child food-insecurity status.50
Adults living in poverty are at greater risk for a number
of health issues, such as diabetes,51 heart disease and
stroke,52, 53 obesity (primarily among women),54 depression,55
disability,56 poor oral health,57 and premature mortality.58
Those living in poverty also have higher rates of physical
inactivity, cigarette smoking, and inadequate micronutrient
intake.59, 60 In addition, the high levels of stress facing lowincome
families, including children, can contribute to, or
worsen, existing health problems.61, 62 While the enactment of
the Affordable Care Act of 2010 improved health insurance
coverage and health care access in the nation, poor and
near-poor adults are still more likely to be uninsured, less
likely to have a regular place to go to for medical care, and
are more likely to forgo needed medical care due to cost,
compared to their not-poor counterparts.63, 64
Finally, poverty reduces life expectancy and quality of
life. One study found a 4.5 year gap in life expectancy
at birth between counties with the highest versus lowest
socioeconomic ranking.65 Another estimate found that living
at less than 200 percent of the federal poverty line results
in a net loss of 8.2 years of quality-adjusted life expectancy
at age 18.66 Research shows that these inequalities have
widened over time as life expectancy has risen more rapidly
for higher-income groups than lower-income groups.67
Hunger & Health: Impact of Poverty, Food Insecurity, and Poor Nutrition
Did you know? Treat or Eat
In general, one out of three chronically ill
adults is unable to afford medicine, food,
Food Research & Action Center © December 2017 n www.frac.org n 3
Food Insecurity, Health, and Well-Being
In 2016, approximately 28.3 million adults (11.5 percent
of all adults) and 12.9 million children (17.5 percent of all
children) lived in food-insecure households.69 Food
insecurity — even marginal food security (a less severe level
of food insecurity)70, 71, 72 — is associated with some of the
most common and costly health problems and behaviors in
the U.S., as shown in Figure 1 on the next page. While food
insecurity has direct and indirect impacts on physical and
mental health for people of all ages, food insecurity is
especially detrimental to the health, development, and
well-being of children in the short and long terms.73, 74, 75, 76
“After multiple risk factors are considered, children
who live in households that are food insecure,
even at the lowest levels, are likely to be sick
more often, recover from illness more slowly,
and be hospitalized more frequently. Lack of
adequate healthy food can impair a child’s ability
to concentrate and perform well in school and is
linked to higher levels of behavioral and emotional
problems from preschool through adolescence.”
— American Academy of Pediatrics’ Policy Statement,
Promoting Food Security for All Children77
According to a study of working-age adults living at or below 200 percent of the federal poverty line:
“In general, lower food security is associated with higher probability of each of the chronic diseases examined
— hypertension, coronary heart disease (CHD), hepatitis, stroke, cancer, asthma, diabetes, arthritis, chronic
obstructive pulmonary disease (COPD), and kidney disease … Moreover, differences between adults in
households with marginal, low, and very low food security are very often statistically significant, which suggests
that looking at the entire range of food security is important for understanding chronic illness and potential
economic hardship. Indeed, food security status is more strongly predictive of chronic illness in some cases even
than income. Income is significantly associated with only 3 of the 10 chronic diseases — hepatitis, arthritis, and
COPD — while food insecurity is significantly associated with all 10.”
— From Food Insecurity, Chronic Disease, and Health Among Working-Age Adults78