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.