Tuesday, August 25, 2009

Does Sexual Abuse Promote Obesity?

To anyone running a bariatric clinic, stories of sexual abuse linked to obesity should come as no surprise. Previous reports have estimated that as many as 20-40% of patients seeking weight loss, particularly bariatric surgery, may have histories of sexual abuse.

it therefore came as a surprise to me that data on the relationship between sexual abuse and obesity is perhaps less robust than I may have thought.

I take this information from a recent systematic review and meta-analysis on the relationship between sexual abuse and lifetime diagnosis of somatic disorders published in JAMA.

in this study, Molly Paras and colleagues from the Mayo Clinic, Rochester, MN, performed a systematic literature search of electronic databases from January 1980 to December 2008. Eligible studies were longitudinal (case-control and cohort) and reported somatic outcomes in persons with and without history of sexual abuse.

Based on the 23 eligible studies describing 4640 subjects, sexual abuse was significantly associated with a two-to-three fold increased risk for functional gastrointestinal disorders, nonspecific chronic pain, psychogenic seizures, and chronic pelvic pain. When studies were limited to those in which sexual abuse was defined as rape, there was also a three-fold increased risk for fibromyalgia. There was, however no significant relationship to obesity.

Interestingly, this “negative” finding on obesity is based on only obesity two studies that met the inclusion criteria.

The first one, by Vincent Felitti, published back in 1993, compared 100 sequential patients applying to a very low calorie diet (VLCD) program with a control group of 100 always-slender adults. Obese individuals were significantly more likely to have a history of childhood sexual abuse, nonsexual childhood abuse, early parental loss, parental alcoholism, chronic depression, and marital family dysfunction in their own adult lives. The obese patients in this study commonly reported using obesity as a sexually protective device; many reported overeating to cope with emotional distress. Maras and colleagues calculate an OR of 5.22 for the link between sexual abuse and obesity from this study (95% CI 2.04-13.39).

The second study, by Jennie Noll, published in 2007, prospectively examined 84 female subjects with substantiated childhood sexual abuse and 89 demographically similar comparison female subjects at 6 points during development. While obesity rates were not different across groups in childhood or adolescence, by young adulthood (ages 20-27), abused female subjects were significantly more likely to be obese (42.25%) than were comparison female subjects (28.40%). Also, abused female subjects, on average, acquired body mass at a significantly steeper rate from childhood through young adulthood than did comparison female subjects after controlling for minority status and parity. Maras and colleagues calculated an OR of 1.32 (95% CI 0.54-3.23) for the risk of obesity in the abused girls. 

Combining the data from both studies, Maras and colleagues calculate an OR of 1.47, which because of the large CI (confidence intervals) of 0.88-2.46, fails to reach statistical significance.

So does the meta-analysis by Maras change my opinion – not in the least.

As someone regularly dealing with bariatric patients, I would need far more robust data to convince me that what I hear reported from my patients is purely anecdotal. I will continue to maintain that no obesity history is complete without explicitly exploring sexual, mental, and physical abuse and their relationship to ingestive behavior.

Fortunately, as pointed out in the article by Maras and colleagues, cognitive behavioral and other psychological therapies are effective in reducing the suffering associated with post-traumatic stress, including that from sexual abuse. This is why psychologists are an integral part of our bariatric program.

I would certainly appreciate hearing views on this from my readers.

AMS
Edmonton, Alberta

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6 Responses to “Does Sexual Abuse Promote Obesity?”

  1. katja sawitsky says:

    Many years ago, I once did a guided imagery from the book Fat is a Feminist Issue, in which I was guided to imagine myself at a party. In the first part of the imagery I was thin, in the second I was instructed to see myself as fat. I was asked to notice what I was wearing, how I was acting, how others interacted with me. What I learned is that my sexuality is superbly related to my body size. When I was thin, I was a sexual being. When I was fat, I was not. This is not to say that everyone would learn this about themselves, but for me it was a very powerful exercise that helped to explain why I might want to protect myself from sexual notice with an increased body size. When I was fat I was able to avoid notice and that is just how I like it. This exercise has always helped me to realize that fat has both negative and positive attributes and obesity cannot be addressed if the positive attributes are not replace with other positive attributes.

  2. Anonymous says:

    Thank you! My psychologist helped me to learn that I no longer needed to eat to keep my abusers away from me. I learned once I had “hips” and “breasts” that there was no longer interest with these pedophiles. I think I was not aware on many levels of that even though I was always aware of the abuse.

    Another think I learned in therapy is that because of fear of physical abuse I learned to ‘swallow’ my anger.

    It is a learning journey and I am eating health and exercising, but it is still a challenge. I live with chronic pain (fybro) which I am certain is from internally still holding myself in constant fear, even though there is no longer a reason to be fearful.

    Obesity and morbid-obesity is such a complex disease and I thank God for your work in this area. The “judgement” in most society makes me even more fearful.

  3. Utkarsh Kulkarni says:

    I’m glad you’ve highlighted this. For some time now I’ve struggled to come up with a way of incorporating these sensitive issues into a routine rushed clinic setting – and then, having perhaps raised expectations, being unable to ensure adequate support is offered because the resources and expertise are not widely available to deal with abuse in the obesity setting. The problem is compounded by the social stigmas attached to both obesity and abuse, even among health professionals. Specialist services which might be able to perform good clinical evaluations can only see a small proportion of obesity, even severe obesity, so I am pessimistic about robust data ever becoming available. I hope I’m proved wrong!

  4. Anonymous says:

    I am an registered nurse working in a stress and anxiety clinic. I was originally hired to educate the clients here about lifestyle changes and improved diet when taking atypical antipsychotic medications due to the higher rates of diabetes and obesity in this population. Also we have a fairly large aboriginal population as clients. I soon learned that physical, emotional and sexual abuse is also very common to both the men and women. Often it began in early childhood, and would, for many, continue in adulthood in the form of repeated rapes. Fortunately we have several psychiatrists and psychologists to help with their complex therapy. We also, however, see many anorexic young women, and some men with similar histories.

  5. wellroundedtype2 says:

    Some people gain weight more easily than others.
    Some people respond to abuse by eating for soothing and comfort.
    Those who gain weight easily and eat to soothe and comfort themselves (rather than turning to other behaviors that might be similarly “self-medicating”) may develop bulimia or binge eating.
    Those who binge eat and gain large amounts of weight have few options for losing weight other than surgery.
    The people who are obese who you don’t see as patients might be better able to manage their obesity (that is, have good health in the presence of obesity) if they were not abused or received prompt treatment for abuse. So those who seek treatment for obesity might be more likely to have been abused than those who are obese but not seeking treatment for obesity.
    Also, discrimination, stigma and fat hatred may be harder to “tolerate” for someone who was abused than someone who was not. It may be experienced as more abuse.

  6. Lala says:

    I agree with this. I suffer from the same issues. I didn’t realize until a few years ago that beneath the comfort of my (very effective) “stay the hell away from me” obese body I had a strong desire to be a woman and to be effeminate but was scared to death of what that was like. I’m still waiting for the next step in this process- which is the healing and getting over the fear- to occur. Otherwise, I’ll continue wasting my life.

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