Child and adolescent abuse in relation to obesity in adulthood: the Black Women's Health Study

Posttraumatic stress disorder, alone or additively with early life adversity, is associated with obesity and cardiometabolic risk

BACKGROUND AND AIMS

There is some evidence that posttraumatic stress disorder (PTSD) and early life adversity may influence metabolic outcomes such as obesity, diabetes, and cardiovascular disease. However, whether and how these interact is not clear.

METHODS

We analyzed data from a cross-sectional and longitudinal study to determine how PTSD severity influences obesity, insulin sensitivity, and key measures and biomarkers of cardiovascular risk. We then looked at how PTSD and early life adversity may interact to impact these same outcomes.

RESULTS

PTSD severity is associated with increasing risk of obesity, diabetes, and cardiovascular disease, with higher symptoms correlating with higher values of BMI, leptin, fibrinogen, and blood pressure, and lower values of insulin sensitivity. PTSD and early life adversity have an additive effect on these metabolic outcomes. The longitudinal study confirmed findings from the cross sectional study and showed that fat mass, leptin, CRP, sICAM-1, and sTNFRII were significantly increased with higher PTSD severity during a 2.5 year follow-up period.

CONCLUSIONS

Individuals with early life adversity and PTSD are at high risk and should be monitored carefully for obesity, insulin resistance, and cardiometabolic risk.

Aspects of abuse: consequences of childhood victimization

Childhood maltreatment is unfortunately a common occurrence in the United States, affecting 1 in 8 children annually.(1) The consequences of maltreatment can be considerable, and exact a heavy toll on the individual, family, and society. Child abuse and neglect can cause permanent, heritable changes in the body׳s response to stress, which in turn inflicts profound changes in the developing brain. While these changes allow a child to contend with a neglectful, chaotic, or possibly violent environment, they strongly influence an individual׳s behavioral, educational, physical, and mental functioning and well-being throughout his/her lifetime, long after the maltreatment has ended. As the adverse childhood experiences (ACE) studies clearly demonstrate, adult survivors of maltreatment experience significant health harms that can cause significant morbidity and contribute to early death. Further, the lifetime economic cost to society of childhood maltreatment is estimated to be $124 billion dollars.(2) The study of resilient individuals who appear to suffer fewer negative consequences of their maltreatment offers insights into possible interventions for clinical practice as well as advocacy and public policy opportunities that would begin to lessen the significant burdens of childhood maltreatment.

Stress- and PTSD-associated obesity and metabolic dysfunction: a growing problem requiring further research and novel treatments

Posttraumatic stress disorder (PTSD) is a growing public health concern. More recently, evidence has indicated that PTSD leads to obesity and associated metabolic dysfunction. Possible mechanisms of this link are through dysfunction of the hypothalamic-pituitary-adrenal axis and related moderation of appetite hormones and neural activity, leading to changes in consumptive behaviors. Although research has been examining associations between PTSD and obesity, diabetes, cardiovascular disease, and metabolic syndrome, future research should delineate potential mechanisms for these associations and develop targeted treatments to reduce these metabolic outcomes.

Body mass index and anxiety/depression as mediators of the effects of child sexual and physical abuse on physical health disorders in women

The relation between childhood sexual abuse (CSA) and physical health disorders in adulthood, and what factors may serve as mediators, remains poorly understood. Using data from the 2007 Adult Psychiatric Morbidity Survey (N=3,486), we tested whether CSA was associated with physical health disorders in adult women and if mediated effects via body mass index (BMI), anxiety/depression, alcohol dependence, and smoking were present. Compared to women with no CSA, women who had experienced CSA involving intercourse had more than twice the odds of being obese, more than 3 times the odds of experiencing mental health disorders, more than 4 times the odds of being alcohol dependent, more than 5 times the odds of being drug dependent, and more than 6 times the odds of attempting suicide. Those experiencing both CSA and child physical abuse (CPA) were on average over 11kg heavier than those with neither CSA nor CPA. After controlling for demographics, CPA, and childhood bullying, CSA was associated with the majority of physical health disorders studied (typically 50-100% increases in odds). Evidence was found consistent with mediation by BMI (typically accounting for 5-20% increases in odds) and anxiety/depression (typically accounting for 8-40% increases in odds), in a dose-response manner, for the majority of physical health disorders. Bidirectional relations among these mediators and physical health disorders, and residual confounding, may have led to overestimation of mediation through BMI and anxiety/depression and underestimation of mediation through alcohol/smoking. Relations between both CPA and childhood bullying and physical health disorders in adulthood were also found. Longitudinal studies employing more sensitive measures of potential mediators are now required.

Effects of childhood abuse on adult obesity: a systematic review and meta-analysis

Controversy exists surrounding the role of childhood abuse in obesity development. This is a meta-analysis of observational studies on the role of childhood abuse in adult obesity. Systematic searches of PubMed, PsycInfo, Medline and CINAHL resulted in 23 cohort studies (4 prospective, 19 retrospective) with n=112,708 participants, containing four abuse types (physical, emotional, sexual, general). Four studies reported dose-response effects. A random effects model was used to quantify effect sizes, meta-regression/subgroup analysis for identifying potential moderating variables and Egger's test for publication bias. Adults who reported childhood abuse were significantly more likely to be obese (odds ratio [OR]: 1.34, 95% confidence interval [CI]: 1.24-1.45, P<0.001). All four types of abuse were significantly associated with adult obesity: physical (OR: 1.28, 95% CI: 1.13-1.46), emotional (OR: 1.36, 95% CI: 1.08-1.71), sexual (OR: 1.31, 95% CI: 1.13-1.53) and general abuse (OR: 1.45, 95% CI: 1.25-1.69). Severe abuse (OR: 1.50, 95% CI: 1.27-1.77) was significantly more associated with adult obesity (P=0.043) compared with light/moderate abuse (OR: 1.13, 95% CI: 0.91-1.41). We found no significant effects of study design (prospective vs. retrospective, P=0.07), age (P=0.96) or gender (P=0.92). Publication bias was evident (Egger's test P=0.007), but effect sizes remained statistically significant in sensitivity analyses. Childhood abuse was clearly associated with being obese as an adult, including a positive dose-response association. This suggests that adverse life experiences during childhood plays a major role in obesity development, potentially by inducing mental and emotional perturbations, maladaptive coping responses, stress, inflammation and metabolic disturbances.

Dating violence, childhood maltreatment, and BMI from adolescence to young adulthood

BACKGROUND AND OBJECTIVES

This study tested whether dating violence (DV) victimization is associated with increases in BMI across the transition from adolescence to young adulthood and whether gender and previous exposure to child maltreatment modify such increases.

METHODS

Data were from participants (N = 9295; 49.9% female) in the National Longitudinal Study of Adolescent Health. BMI was calculated from measured height and weight at waves 2, 3, and 4 of the study. DV victimization was measured at waves 2, 3, and 4 by using items from the revised Conflict Tactics Scales. Linear regression by using generalized estimating equations with robust SEs was used to test the association. Models were stratified according to gender and history of child maltreatment.

RESULTS

From baseline to wave 4, BMI increased on average 6.5 units (95% confidence interval [CI]: 6.2-6.7) and 6.8 units (95% CI: 6.5-7.1) among men and women, respectively, and nearly one-half (45.5% of men; 43.9% of women) reported DV at some point. In stratified models, DV victimization (β: 0.3 [95% CI: 0.0-0.6]) independently predicted BMI increase over time in women. Exposure to childhood sexual abuse magnified the increase in BMI associated with DV victimization (β: 1.3 [95% CI: 0.3-2.3]). No other types of childhood maltreatment were significant modifiers of the DV-BMI association. Violence victimization was not associated with BMI among men.

CONCLUSIONS

Screening and support for DV victims, especially women who have also experienced childhood maltreatment, may be warranted to reduce the likelihood of health consequences associated with victimization.

The association between childhood sexual and physical abuse with incident adult severe obesity across 13 years of the National Longitudinal Study of Adolescent Health

BACKGROUND

Severe obesity has increased, yet childhood antecedents of adult severe obesity are not well understood.

OBJECTIVE

Estimate adult-onset severe obesity risk in individuals with history of childhood physical and/or sexual abuse compared with those who did not report abuse.

METHODS

Longitudinal analysis of participants from the US National Longitudinal Study of Adolescent Health (n = 10,774) wave II (1996; aged 12-22 years) followed through wave IV (2008-2009; aged 24-34 years). New cases of adult-onset severe obesity (body mass index [BMI] ≥ 40 kg/m2 using measured height and weight) in individuals followed over 13 years who were not severely obese during adolescence (BMI <120% of 95th percentile Centers for Disease Control and Prevention National Center for Health Statistics growth curves).

RESULTS

The combined occurrence of self-reported sexual and physical abuse during childhood was associated with an increased risk of incident severe obesity in adulthood in non-minority females (hazard ratio [HR; 95% Confidence Interval] = 2.5; 1.3, 4.8) and males (HR = 3.6; 1.5, 8.5) compared with individuals with no history of abuse.

CONCLUSION

In addition to other social and emotional risks, exposure to sexual and physical abuse during childhood may increase risk of severe obesity later in life. Consideration of the confluence of childhood abuse might be considered as part of preventive and therapeutic approaches to address severe obesity.

Childhood maltreatment and the risk of pre-pregnancy obesity and excessive gestational weight gain

The objective of this study was to estimate whether maternal history of childhood maltreatment was associated with pre-pregnancy obesity or excessive gestational weight gain. Pregnant women (n = 472) reported pre-pregnancy weight and height and gestational weight gain and were followed up to 16 years post-partum when they reported maltreatment on the Childhood Trauma Questionnaire (CTQ). CTQ score ranged from no maltreatment (25) to severe maltreatment (125). Prenatal mental health modified the association between CTQ score and maternal weight (P < 0.15), and thus stratified models are presented. After adjusting for race, prenatal tobacco, marijuana and alcohol use, a one standard deviation (1 SD) increase in CTQ score was associated with a 45% increase in the risk of pre-pregnancy obesity among the 141 women with elevated anxiety (≥75th percentile on the State Trait Anxiety Inventory) [relative risk, RR (95% confidence interval, CI): 1.45 (1.12, 1.88)], but was not associated among less anxious (<75th percentile) women [RR (95% CI): 1.10 (0.81, 1.51)]. Risk of excessive gestational weight gain was higher [adjusted RR (95% CI): 1.21 (1.07, 1.37)] with every 1 SD increase in CTQ score for anxious women. No association was observed for less anxious women [adjusted RR (95% CI): 0.89 (0.78, 1.02)]. Prenatal depression similarly modified the association between maltreatment and weight gain. Factors such as psychological status and traumatic experiences in early childhood may contribute to pre-pregnancy obesity and excessive gestational weight gain.

Early menarche and childhood adversities in a nationally representative sample

BACKGROUND

Epidemiological evidence suggests that early menarche, defined as onset of menses at age 11 or earlier, has increased in prevalence in recent birth cohorts and is associated with multiple poor medical and mental health outcomes in adulthood. There is evidence that childhood adversities occurring prior to menarche contribute to early menarche.

METHODS

Data collected in face-to-face interviews with a nationally representative sample of women age 18 and over (N = 3288), as part of the National Comorbidity Survey-Replication, were analyzed. Associations between pre-menarchal childhood adversities and menarche at age 11 or earlier were estimated in discrete time survival models with statistical adjustment for age at interview, ethnicity, and body mass index. Adversities investigated included physical abuse, sexual abuse, neglect, biological father absence from the home, other parent loss, parent mental illness, parent substance abuse, parent criminality, inter-parental violence, serious physical illness in childhood, and family economic adversity.

RESULTS

Mean age at menarche varied across decadal birth cohorts (χ(2)₍₄₎ = 21.41, p < .001) ranging from a high of 12.9 years in the oldest cohort (age 59 or older at the time of interview) to a low of 12.4 in the second youngest cohort (age 28-37). Childhood adversities were also more common in younger than older cohorts. Of the 11 childhood adversities, 5 were associated with menarche at age 11 or earlier, with OR of 1.3 or greater. Each of these five adversities is associated with a 26% increase in the odds of early menarche (OR = 1.26, 95% CI 1.14-1.39). The relationship between childhood sexual abuse and early menarche was sustained after adjustment for co-occurring adversities. (OR = 1.77, 95% CI 1.21-2.6).

CONCLUSIONS

Evidence from this study is consistent with hypothesized physiological effects of early childhood family environment on endocrine development. Childhood sexual abuse is the adversity most strongly associated with early menarche. However, because of the complex way that childhood adversities cluster within families, the more generalized influence of highly dysfunctional family environments cannot be ruled out.

Early life adversity is associated with elevated levels of circulating leptin, irisin, and decreased levels of adiponectin in midlife adults

CONTEXT

Early-life adversity, defined as physical, emotional, or sexual abuse and neglect before 18 years of age, is associated with metabolic syndrome, obesity, and type 2 diabetes mellitus in adult life. However, the underlying mechanism is not fully understood, and whether adipomyokines are associated with early-life adversity independent of other factors such as body mass index, psychosocial risks, and health behaviors is not known.

OBJECTIVES

The objective of the study was to evaluate the association between early-life adversity and circulating the levels of the adipomyokines such as leptin, adiponectin, and irisin and the inflammatory marker, C-reactive protein (CRP). DESIGN/SUBJECTS/SETTING: This study was a cross-sectional study of 95 adults at a university-based research center. We collected venous blood from participants and analyzed serum for leptin, adiponectin, irisin, and CRP.

RESULTS

Circulating leptin, irisin, and CRP levels were significantly higher in the highest adversity tertile group compared with low and middle tertile groups (P < .001 for leptin, P = .01 for irisin, and P = .02 for CRP). Adiponectin levels were lower in the highest tertile group compared with the low and middle tertile groups (P = .03). After adjusting for demographic variables, physical activity, diet, current mental health, and body mass index, the associations between early-life adversity leptin, irisin, and did not change. However, adiponectin and CRP levels were no longer significantly related to early life adversity.

CONCLUSION

Early-life adversity is directly associated with elevated circulating leptin and irisin, and indirectly associated with elevated CRP and decreased adiponectin. These findings suggest that these adipomyokines may play a role in the pathogenesis of metabolic abnormality in a population with significant early life adversity.

Childhood maltreatment and obesity: systematic review and meta-analysis

Obesity is a prevalent global-health problem associated with substantial morbidity, impairment and economic burden. Because most readily available forms of treatment are ineffective in the long term, it is essential to advance knowledge of obesity prevention by identifying potentially modifiable risk factors. Findings from experimental studies in non-human primates suggest that adverse childhood experiences may influence obesity risk. However, observations from human studies showed heterogeneous results. To address these inconsistencies, we performed Medline, PsycInfo and Embase searches till 1 August 2012 for articles examining the association between childhood maltreatment and obesity. We then conducted a meta-analysis of the identified studies and explored the effects of various possible sources of bias. A meta-analysis of 41 studies (190 285 participants) revealed that childhood maltreatment was associated with elevated risk of developing obesity over the life-course (odds ratio=1.36; 95% confidence interval=1.26-1.47). Results were not explained by publication bias or undue influence of individual studies. Overall, results were not significantly affected by the measures or definitions used for maltreatment or obesity, nor by confounding by childhood or adult socioeconomic status, current smoking, alcohol intake or physical activity. However, the association was not statistically significant in studies of children and adolescents, focusing on emotional neglect, or adjusting for current depression. Furthermore, the association was stronger in samples including more women and whites, but was not influenced by study quality. Child maltreatment is a potentially modifiable risk factor for obesity. Future research should clarify the mechanisms through which child maltreatment affects obesity risk and explore methods to remediate this effect.

Family violence and body mass index among adolescents enrolled in the Bolsa Família Program and treated at a primary care clinic

This article aimed to investigate the relationship between family violence and body mass index (BMI) in adolescents whose families were enrolled in the Bolsa Família Program. The cross-sectional study included 201 adolescents of both sexes, 10 to 19 years of age, in Rio de Janeiro, Brazil, 2008-2009. BMI and physical, psychological, and verbal abuse of adolescents by their parents were evaluated. The association between family violence and BMI was measured via linear regression models. In girls, verbal abuse was directly associated with BMI, showing a significant mean increase of 2.064, 2.438, and 2.403 in BMI when perpetrated by the mother, father, and both parents, respectively. Among boys, family violence was associated with lower BMI (but without reaching statistical significance). The findings point to the need for innovative practices and approaches in the nutritional care of adolescents enrolled in the Bolsa Família Program, considering family violence as a contributing factor to inadequate nutritional status.

Obesity and psychiatric disorders: commonalities in dysregulated biological pathways and their implications for treatment

Rates of obesity are higher than normal across a range of psychiatric disorders, including major depressive disorder, bipolar disorder, schizophrenia and anxiety disorders. While the problem of obesity is generally acknowledged in mental health research and treatment, an understanding of their bi-directional relationship is still developing. In this review the association between obesity and psychiatric disorders is summarised, with a specific emphasis on similarities in their disturbed biological pathways; namely neurotransmitter imbalances, hypothalamus-pituitary-adrenal axis disturbances, dysregulated inflammatory pathways, increased oxidative and nitrosative stress, mitochondrial disturbances, and neuroprogression. The applicability and effectiveness of weight-loss interventions in psychiatric populations are reviewed along with their potential efficacy in ameliorating disturbed biological pathways, particularly those mediating inflammation and oxidative stress. It is proposed that weight loss may not only be an effective intervention to enhance physical health but may also improve mental health outcomes and slow the rate of neuroprogressive disturbances in psychiatric disorders. Areas of future research to help expand our understanding of the relationship between obesity and psychiatric disorders are also outlined.

Sexual abuse is associated with obese children and adolescents admitted for psychiatric hospitalization

OBJECTIVE

To determine the relationship between a history of child abuse and obesity among children admitted for psychiatric hospitalization.

STUDY DESIGN

The charts of 1434 youth consecutively admitted to an inpatient psychiatric facility during a 10-month period were retrospectively analyzed. Rates of physical and sexual abuse, as well as other factors believed to increase the risk of obesity, were compared between children whose body mass index (BMI) percentiles were between 5 and 80 and whose BMI percentiles were >85.

RESULTS

After correcting for age, race, gender, and antipsychotic usage, we found that a reported history of sexual abuse was associated with increased probability of being overweight/obese (BMI percentile 85-99) compared with being of typical BMI (aOR 1.41). Reported physical abuse neither increased the risk of obesity nor moderated the association between sexual abuse and increased weight. Antipsychotic treatment and female gender also were associated with increased BMI percentiles, with antipsychotic usage being the only variable associated with increased risk of a BMI percentile >99.

CONCLUSIONS

Among youth with significant psychiatric illness, a history of sexual abuse increases the risk of being overweight or obese, an association that warrants further study regarding the temporal relationship between sexual abuse and obesity and may inform future obesity prevention and intervention programs in children.

High-risk sexual behaviors among depressed Black women with histories of intrafamilial and extrafamilial childhood sexual abuse

OBJECTIVE

National estimates of childhood sexual abuse histories among black women range from 34% to 40%. Poor outcomes in adulthood, including impaired psychiatric functioning (e.g., depression), high-risk sexual behaviors (e.g., unprotected sex, exchange of sex for money or drugs), and lifetime sexually transmitted infections are robustly associated with sexual abuse histories. In the current study, we examined the relationships of intrafamilial and extrafamilial perpetration of childhood sexual abuse to high-risk sexual behaviors and sexually transmitted infections among black women.

METHODS

We conducted a secondary analysis of data from 60 black women who participated in a depression treatment trial in a community mental health center.

RESULTS

Our results demonstrated that intrafamilial perpetration of childhood sexual abuse, as compared to extrafamilial perpetration, was more strongly associated with high-risk sexual behaviors in a clinical sample of depressed black women. There were no significant associations between intrafamilial or extrafamilial perpetration of childhood sexual abuse and sexually transmitted infections.

CONCLUSIONS

These findings suggest that characteristics of childhood sexual abuse among depressed black women may be important factors for health professionals to consider when conducting clinical assessments and providing treatment.

Mental Health Evaluations for Adolescents Prior to Bariatric Surgery: A Review of Existing Practices and a Specific Example of Assessment Procedures

OBJECTIVE

Best practice guidelines for adolescents considering bariatric surgery recommend a pre-operative mental health evaluation. However, only general information about these assessments appears in the literature, which makes consistency of administration challenging. This review proposes a specific empirically-derived format for pre-surgical mental health evaluations and summarizes currently available data on the psychiatric functioning of adolescents seeking bariatric surgery.

DESIGN

Studies of mental health evaluations for adults preparing for bariatric surgery are reviewed, as is the limited literature relevant to adolescent evaluations. A specific and detailed example of an evaluation (clinical interview, self-report questionnaires, cognitive assessment) used for younger patients at a major metropolitan hospital center is presented, followed by data from an initial group of adolescents completing this evaluation.

SUBJECTS

200 adolescents (n=139 female; age: 14-18 y, BMI: 35.4-83.3 kg/m²) presenting for bariatric surgery.

RESULTS

A notable subset of adolescents reported current Axis I conditions (31.5%) and current mental health treatment (29.5%), but reports of current illicit drug use (1.5%) and regular alcohol use (0.5%) were relatively rare. Procedures for using the completed evaluation and post-surgery monitoring of psychosocial issues are discussed.

CONCLUSIONS

Adolescents considering weight loss surgery should receive comprehensive pre-surgical mental health evaluations, but additional data are needed to develop specific recommendations the use of these evaluations in post-operative care.

Lifetime abuse victimization and risk of uterine leiomyomata in black women

OBJECTIVE

Uterine leiomyomata (UL) are a major contributor to gynecologic morbidity and medical costs, and black women are disproportionately affected by the condition. Previous studies have linked UL to psychosocial stress, including child abuse. We assessed the association between lifetime abuse victimization and UL among 9910 premenopausal women.

STUDY DESIGN

Data were derived from the Black Women's Health Study, a prospective cohort study. In 2005, participants reported their experiences of physical and sexual abuse within each life stage (childhood, adolescence, adulthood). Biennial follow-up questionnaires from 2005 through 2011 ascertained new UL diagnoses. Rate ratios (RRs) and 95% confidence intervals (CIs) were estimated using Cox regression.

RESULTS

There were 1506 incident UL cases diagnosed by ultrasound or surgery. UL incidence was higher among women who reported child abuse, particularly sexual abuse. Relative to no abuse across the life span, RRs were 1.16 (95% CI, 1.02-1.33) for physical abuse only, 1.34 (95% CI, 1.09-1.66) for sexual abuse only, and 1.17 (95% CI, 0.99-1.39) for both physical and sexual abuse in childhood. RRs for 1-3 and 4 or more incidents of child sexual abuse were 1.29 (95% CI, 1.04-1.61) and 1.41 (95% CI, 1.07-1.85), respectively, whereas the RRs for low, intermediate, and high frequencies of child physical abuse were 1.19, 1.04, and 1.23, respectively. The association was strongest for the highest category of child abuse severity (RR, 1.57; 95% CI, 1.19-2.07). No associations were found for teen or adult abuse.

CONCLUSION

In the present study, child sexual abuse was an independent risk factor for UL, supporting the hypothesis that childhood adversity increases UL risk.