HJAR Jan/Feb 2024

HEALTHCARE JOURNAL OF ARKANSAS I  JAN / FEB 2024 19 who were afflicted by that famine, despite not being exposed to nutrient deprivation them- selves, also had higher rates of obesity. The conclusion is that the acute period of starvation during 1944 and 1945 had somehow altered the genes, not just in those directly exposed to the event, but that the genetic message had been transmitted to their grandchildren as well. This alteration in “genetic memory” was not via any alteration of the genes them- selves. Rather, an interaction between the genes and their environment had changed phenotypic expression of a gene, thereby resulting in a higher propensity for obesity through no fault of the child or their parents. In addition to the impact of epigenetics on phenotypic expression of genes that can lead to obesity, the consequences of adverse child- hood experiences are well known. Adverse childhood experiences (ACEs) are traumatic events that can have negative, lasting effects on health and well-being of the children who experience them. They include abuse (emo- tional, physical, sexual), neglect (emotional and physical), and other household challenges such as domestic violence, substance abuse, mental illness, and parental separation or divorce. Chil- dren who suffer fromACEs aremore likely to suf- fer from arrested neurocognitive development, are more likely to engage in high-risk health behaviors, are more likely to suffer from addic- tion and substance use disorders, and are more likely to suffer from obesity and other chronic conditions, again, through no fault of their own. According to Centers for Disease Control (CDC), ACEs are quite common, with about 61% of adults reporting they have experienced at least one type of ACE before age 18 and nearly 1 in 6 reporting they had experienced four or more types of ACEs. Women and sev- eral racial/ethnic minority groups are at greater risk for experiencing four or more types of ACEs. And although my profession cannot completely prevent ACEs from occurring, we sure can transform the way we deliver care to better impact our patients who are victims of it. It will involve changing the way we deliver primary care. It means demonstrating empa- thy for those not fortunate enough to win the lottery of life. It means avoiding judgment and blame of those unfortunate enough to be vic- tims of ACEs or who were unlucky enough to inherit a genetic or epigenetic blueprint associ- ated with obesity. It involves moving away from the notion of commanding compliance where we tell affected individuals what to eat or how much to exercise. Instead, it means building collaborative, trusting relationships in which we develop a deep understanding of their cumu- lative set of life experiences and their unique challenges and obstacles, followed by helping them overcome those barriers to make prog- ress against their goals. Doing so requires time in the form of longer visits, more frequent por- tal messaging, as well as integration of diverse types of talent and multidisciplinary teamwork into the care model. It also hinges on address- ing maladaptive coping mechanisms, mental health impairments, and the socioeconomic factors that drive disparate health outcomes. These new models of care only become pos- sible and sustainable when we embrace new economic models supported by population- based payments that are no longer transac- tional in nature and that better enable us to address health and well-being holistically. Obesity, and the ignorance surrounding this disease, is such an important topic that we will devote the next couple of articles in this series to exploring it further. In the next issue, man- agement of pediatric obesity will be addressed by Amanda Staiano, MD, before turning our at- tention to management of adult obesity in the following one. But superseding any discussion of management, we cannot allow our atten- tion to waver from the reality that we are in the middle of yet another epidemic that is just as serious as any type of severe infectious disease or cancer. We are in a war against obesity that is every bit as important for our society as the one we are fighting against cigarettes. The food in- dustry is not blameless here, and just like the to- bacco industry, they will assert their right to sell products that consumers are demanding. And only through patience and perseverance will we ever make the same gains in nutritional health as we have against smoking. But even then, as the lessons of history repeat themselves, the battle rages on. The only question is whether we will gain wisdom from it, or act as fools. n Netherlands found itself cut off from its sup- ply of food. By the early winter of 1944 the population was edging toward famine, a situ- ation that raged on until well into 1945. Tens of thousands of people died from starvation and malnourishment. As would be expected by anyone who experiences adverse childhood traumatic experiences, the children who sur- vived these harsh conditions went on to suffer from a number of chronic health issues well into adulthood, including anxiety, depression, heart disease, osteoporosis, gum disease, and dia- betes. In the 1980s, an interesting pattern was recognized when the children born to women who were pregnant during the famine grew up with much higher rates of obesity and heart disease. This finding is not too unexpected because we know that malnourishment in utero causes changes in fetal physiology. A nutrient- starved fetus alters their metabolism to seques- ter higher amounts of fat to defend themselves against caloric deprivation, which results in the paradoxical development of late-onset obesity and impairments in metabolic health. However, the most intriguing finding of the Hongerwinter study came about in the 1990s when the grandchildren of the men and women