Emerging Issues

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Adverse Childhood Experiences

ACEs research continues, and some of the key issues identified include:

  • Toxic stress from ACEs impacts brain development as well as physical and emotional health
  • High levels of trauma over time can alter DNA and be passed from generation to generation
  • Trauma-informed care and resiliency-building interventions are both healing and preventative of future problems

Issues to be mindful of as you work on diabetes include:

  • Diabetes education, while available as a benefit through most forms of health insurance, is underutilized.
  • Short-term outcomes including cost savings may be more quickly achieved with interventions that decrease A1c in those with diagnosed diabetes. Also implementing interventions that prevent diabetes, particularly with those experiencing prediabetes, may help achieve cost reduction in the long term
  • New interventions such as group self-management support or engagement of community health workers may be more effective than older models of self-management education. However these new models are either not covered by health insurance or not paid for equally.
  • Evidence in both clinical trials and translational studies finds that onset of Type 2 diabetes can be prevented or delayed with lifestyle change support by trained coaches and peer groups over the course of one year. However these programs are often not covered by insurance.
  • Obesity is a health issue with a complex web of causes and co-morbidities. Generally speaking, obesity is the result of social, cultural, and physical environmental factors patients experience throughout their lives, genetic factors, and the interaction between those factors.
  • The environment where patients live, learn, work and play can increase or decrease risk of obesity. For instance, a community without safe areas for kids to play will make it harder to be physically active, which will increase risk for obesity.
  • Studies have shown that trauma experienced during childhood, as well as experiencing racism in daily life, are part of the complex set of causes of obesity.
  • Epigenetics is increasingly seen as a mechanism for obesity passing down through generations, as well as adult obesity and co-morbidities.
  • Increasing evidence shows a connection between maternal nutrition during pregnancy and adult obesity.

* Sources:

Centers for Disease Control, Drug Overdose Deaths 2013

Binswager, NEJM 2017


The emergence of electronic cigarettes/vapor products has caused serious concern in Washington State. A major concern of stakeholders is that these products may re-normalize smoking in public places.

A new a type of vapor product that is becoming more popular among youth includes a charger and pod. Teachers are finding students using them in classrooms, though they are hard to detect because the charger looks like a USB flash drive. They come in an assortment of flavors that appeal to youth (such as mint, mango, crème brulee), and the amount of nicotine in one pod is the equivalent of a pack of cigarettes.

More information, including pictures, is available from the Truth Initiative.

Recent studies have indicated a strong association between the use of e-cigarettes and the use of other burned tobacco products by young people.

An emerging body of research indicates electronic cigarettes/vapor products have unique health risks that are not yet completely understood.

Well Child Visits

There is an increase in the number of children with insurance coverage, and in many parts of the state there are not enough providers to meet the demand.

Some families are reluctant to access healthcare due to their nationality and citizenship status. Anecdotally, clinics report experiencing this even with immigrant patients who are legal residents. There may also be barriers due to language and/or comfort level.

There is increasing awareness of the need to address Adverse Childhood Experiences (ACEs) as part of preventive care. Some healthcare systems are implementing a Trauma Informed Approach to interactions with children and parents/caregivers. This has created demand for ACEs related training and tools.