Case Study: Does Childhood Abuse Prevent Weight Loss? Pt. 2

This is an important topic for nurses. We need to understand the connection between childhood trauma and mind/body issues to build trust with patients and identify healing modalities. Specialties Critical Case Study

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Case Study: Does Childhood Abuse Prevent Weight Loss? Pt. 2

I discuss my own experiences with childhood sexual abuse (trigger warning), the Adverse Childhood Events (ACEs) Study, and the specific impact of childhood trauma on the body and mind. In part 3, I will cover the use of psilocybin to treat PTSD. 

Obesity Clinic Dropouts

It was the Summer of 1985. People were drinking New Coke, the Unabomber had just claimed his first victim, and the pop industry had united to sing "We Are The World" to raise money to relieve famine in Africa. I was a senior in high school and trying to solve the problem of which college to attend after receiving two good offers. Halfway across the United States, Dr. Vincent Felitti, head of the Department of Preventive Medicine at Kaiser Permanente had a problem as well. Since 1980, more than half of the people in his obesity clinic had dropped out. The clinic was designed for people who were 100 to 600 pounds overweight. Felitti wondered why people who were successfully losing hundreds of pounds were dropping out of the program. He started digging into the medical records of the dropouts and found that all of them had been born a normal weight. The dropouts had all gained weight abruptly and then stabilized. If they lost weight, they gained it back - or more - in a very short time. Nothing in their medical records explained this problem, so Felitti decided to do face-to-face interviews with the dropouts. Weeks passed and he found nothing unusual until he accidentally asked a loaded question.1

In previous interviews, Felitti had asked, "How old were you when you were first sexually active?” However, at his most recent interview, he had asked a nervous young woman, "How much did you weigh when you were first sexually active?” The woman had responded, "40 pounds.” Felitti was confused and asked the question a second time. The woman gave the same answer, then burst into tears and said, "It was when I was four years old, with my father.”

As Felitti continued the interviews, about 50% of the people he talked with provided information about childhood sexual abuse. He wondered how this could be happening. Nothing he had been taught in medical school had prepared him for this. Out of concern that he was biased, he asked colleagues to do some of the interviews, but reports of childhood abuse continued.1

Of the 286 dropouts interviewed, most of them had experienced childhood sexual abuse. The findings suggested that weight gain might be a way for the participants to cope with the depression, anxiety and fear that can go with being a survivor. He hypothesized that the obese people he was interviewing were overweight because eating was a solution to emotional pain. They didn't see obesity as a problem but as a solution. Eating soothed anxiety and depression, and the weight helped them feel invisible to possible abusers. A woman who had been raped at the age of 7 by her father reported that he told her that the only reason he wasn't raping her 9-year-old sister was because she was fat. For many of the dropouts, losing weight increased anxiety, depression and fear to levels that were intolerable.1

One woman who participated in the obesity clinic dropped out because she consistently regained any weight she lost. The woman reported she was sexually abused by two uncles and a school bus driver; the first time occurred when she was four years old. She then married a man who abused her repeatedly. The woman stated, "I imagine I've lost 100 pounds about six times and gained it back.” She would lose weight, but as soon as someone commented on her attractive appearance, she would gain it back again.1

In 1990, Felitti felt he had enough information to present at a conference for the North American Association for the Study of Obesity. He flew to Atlanta and gave a speech on the results of his interviews. When he finished, one of the experts in the audience told Felitti that he was naïve to believe his patients, stating that it was commonly understood by those more familiar with such matters that patient statements about abuse were fabrications to provide a cover explanation for their failed lives.1

Luckily for the rest of the world, Felitti met two sympathetic researchers at the conference. Dr. David Williamson and Dr. Robert Anda were epidemiologists from the U.S. Centers for Disease Control and Prevention. Together, they framed the idea for the Adverse Childhood Events (ACEs) study.1

Holding All The Aces

While Felitti and colleagues were formulating the ACEs study, I was struggling through my first few years of college. Away from home for the first time, I found navigating adult relationships to be painful and difficult, I was experiencing bizarre dissociative events in which I would leave my body and float up to the ceiling and I had a newly diagnosed duodenal ulcer. I eventually came to realize that the way my stepfather had treated me when I was living at home had a label - childhood sexual abuse. I was one of the 20% of girls and 5% of boys in the U.S. who are victims of a crime that at the time wasn't much talked about. I went through some dark times learning to cope with what happened to me. Many years of therapy have brought me to this time and place where I now type these words, hoping to provide some hope and healing to others.2

Since then, I've done a lot of healing and a lot of learning about my childhood. I've tried to live my life to the fullest, though I don't always have the skills to get where I want to go. I've had my share of relationship, financial, health, and employment issues, but I had never linked those issues to what happened to me as a kid. A few years ago, at the suggestion of a colleague, I attended a conference on the Adverse Childhood Events (ACEs) Study. I was stunned to learn that some of my problems might be linked to the abuse I suffered as a child. I had been a nurse for more than 10 years when I attended the conference; why had I never heard of this groundbreaking research?

In the ACEs study, over 17,000 patient volunteers were surveyed (demographics: half were female, 74.8% white, average age 57, 75.2% attended college, all were in employed and in good health). The participants were asked if they had experienced any of the following ACEs:3

  • Physical abuse
  • Sexual abuse
  • Emotional abuse
  • Physical neglect
  • Emotional neglect
  • Exposure to domestic violence
  • Household substance abuse
  • Household mental illness
  • Parental separation or divorce
  • Incarcerated household member

ACE Statistics3

  • 28% of study participants reported physical abuse
  • 21% reported sexual abuse
  • 66% reported one ACE
  • 40% reported two or more ACEs
  • 12.5% experienced four or more ACEs

The number of ACEs is strongly associated with adulthood high-risk health behaviors like smoking, alcohol, drug abuse, promiscuity, and severe obesity. High ACE scores correlate with ill-health including depression, heart disease, cancer, chronic lung disease, and shortened lifespan.3

Compared to an ACE score of zero, having four ACEs was associated with a 700% increase in alcoholism, doubled risk of cancer, fourfold increase in emphysema. An ACE score of above 6 was associated with a 30-fold increase (3000%) in attempted suicide. Subsequent studies have confirmed the high frequency of ACEs and have found even higher incidences in urban populations.3

In one study, as many as 80% of young adults who had been abused met the diagnostic criteria for at least one psychiatric disorder at age 21, including depression, anxiety, eating disorders, and suicide attempts. Neglected and abused children are 25% more likely to experience delinquency, teen pregnancy, low academic achievement, being arrested as juveniles. They are less likely to graduate from high school. Abuse and neglect increased the likelihood of adult criminal behavior by 28% and violent crime by 20%.3&4

Just taking a peek at the CDC website on the ACEs study that lists publications by year, I found articles on sleep disturbances (2011), frequent headaches (2010), premature death and autoimmune disease (2009), prescription drug use, COPD (2008), and on and on.3

Neurobiology

Maltreatment during childhood can cause important regions of the brain to develop improperly with long term consequences. The stress of chronic abuse may cause hyperarousal in certain areas of the brain, which may result in hyperactivity and sleep disturbances.4

Exposing the developing brain to stress hormones exerts consequences by affecting gene expression, myelination, neural morphology, neurogenesis, and synaptogenesis. There are four factors involved in the severity of outcomes from childhood abuse: genes, timing, type of ACE, and protective factors. Traumatic stress can be associated with lasting changes in the amygdala, hippocampus and prefrontal cortex. It is associated with increased cortisol and norepinephrine responses.5

In a normal brain, the interaction between the hippocampus and the amygdala is important for processing emotional memory. Disruption of memory consolidation and retrieval may be involved in generating dissociative states. An impaired hippocampus has been shown to be involved in the pathophysiology of depression.4 In one study, brain scans from women with a history of severe childhood sexual abuse and a diagnosis of current PTSD were compared to women without childhood abuse. The study simulated a fearful state and those with PTSD showed greater activation of the left amygdala, and decreased function in the prefrontal cortex during fear conditioning.5 In other studies of recent military veterans and coal miners with PTSD, smaller volumes were found in both the hippocampus and amygdala.6

PTSD patients with ACEs have shown significantly decreased gray matter volume, including a reduced area in the corpus callosum. A smaller corpus callosum makes it difficult to integrate left and right hemisphere information. This provides a possible model for the genesis of dissociation and multiple distinct identities. At best, the outcome is a rapid and uncontrolled shifting between a logical and rational state to a highly emotional state. This may be associated with dysfunctional emotional memory processing leading to symptoms of hyper-arousal or avoidance.7

Childhood trauma can even cause temporal lobe seizures (Why Is This Patient Smelling Music? - The Mind-Body Connection Pt. 1)

Taking The ACEs Quiz

I found an NPR article on the ACEs study and took the ACEs quiz for free. I was sad to see my score is a 6. With that kind of score, statistically speaking, I should be depressed, or anxious, or overweight, or financially ruined, or alone. I've been all of those things at one time or another, but I've always bounced. I've got resiliency like nobody's business, making me wonder why I continue to be okay while other people, statistically speaking, are not?

I think it's important to consider that the ACEs score doesn't measure the positive things that can help build resilience and protect a child from trauma. Having one person who gives you unconditional love (like my grandma did) can make all the difference. A teacher who believes in you or a trusted friend can all decrease the effects of early trauma. Resilience builds throughout life and close relationships are key.

Hope

There is hope. There is research showing that antidepressants can cause the hippocampus and amygdala to increase in size. Trauma-informed therapy centering on art, yoga or mindfulness training can help. I've written about the successful use of EMDR in the treatment of PTSD and childhood trauma (Keep What You Love, Return the Rest: Healing from Trauma with EMDR), and EMDR: Another Tool for Your Mental Health Toolbox).

I've recently been reading about other treatments that are controversial, but promising. Please consider reading part 3 which discusses the use of psilocybin to treat PTSD, depression and anxiety.

Please also know, that no matter what happens to you, you can be okay and that there is help. If you are struggling, consider reaching out. Call the National Domestic Abuse Hotline: 1-800-799-7233 or 1-800-787-3224 (TTY). You can go to their website and chat online if you don't want to talk on the phone. There is also a 24/7 crisis text line: Text HOME to 741741 anytime day or night to connect with a human who cares.

References

  1. The Adverse Childhood Experiences Study — the largest, most important public health study you never heard of — began in an obesity clinic
  2. Adverse Childhood Experiences (ACEs)
  3. Limbic system tool and ACES study presentation.pdf
  4. Traumatic stress: Effects on the brain6/
  5. Amygdala volumes decrease in veterans with PTSD
  6. PTSD, the Hippocampus, and the Amygdala – How Trauma Changes the Brain

DISCLAIMER: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills.

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SafetyNurse1968

About SafetyNurse1968, BSN, MSN, PhD

Patient Safety Columnist / Educator

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com.

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Specializes in ER.

Fascinating, although harsh childhoods have been around throughout history and the obesity crisis started in the 20th century, along with processed foods, the fast food industry and the automobile age.

Add to that the view that children should only play outside while supervised, the escalating reliance on digital devices, the unholistic educational system that devalues physical activity and outdoor play, and you have a nation of children facing a lifetime of chronic illness and a healthcare system that will not be able to cope.

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Specializes in Education, Informatics, Patient Safety.
22 minutes ago, Emergent said:

Fascinating, although harsh childhoods have been around throughout history and the obesity crisis started in the 20th century, along with processed foods, the fast food industry and the automobile age.

Add to that the view that children should only play outside while supervised, the escalating reliance on digital devices, the unholistic educational system that devalues physical activity and outdoor play, and you have a nation of children facing a lifetime of chronic illness and a healthcare system that will not be able to cope.

I wonder if the obesity crisis might be incredibly complicated? I am not suggesting that experiencing childhood trauma is the only reason for obesity. I agree with much of what you state - that processed foods, lack of physical activity and digital devices all contribute to obesity, as well as the overwhelming prevalence of antibiotics in our food and our systems. I don't think this means that we can't find a useful link between obesity and childhood abuse and use that information to support those people. What do you think?

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Specializes in ER.

Victims of abuse always deserve our support.

I think there are certain realities of modern life that are stressing all of us to one degree or another in the ways you discuss. Our pharmaceutical responses are really only bandaids, and don't repair the underlying causes. In fact, many psyche meds contribute to obesity, and obesity disrupts many hormones in the body.

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Thank you for sharing, @SafetyNurse1968. I thoroughly love your articles- they are so informative and interesting, and I'm happy (from reading another thread) to see that sharing with others your nursing insights is a form of therapy. As someone with a history of depression, I enjoyed reading this though my heart goes out to those who have survived such an ordeal. This is truly heartbreaking.

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Specializes in LTC.

My ACE score is an 8. That explains a lot, though I am acutely aware of the long-term adverse effects of such a childhood.

I am, and will always be a work in progress. Here's to hope. ?

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Specializes in Education, Informatics, Patient Safety.
On 3/1/2019 at 9:15 AM, bluegeegoo2 said:

My ACE score is an 8. That explains a lot, though I am acutely aware of the long-term adverse effects of such a childhood.

I am, and will always be a work in progress. Here's to hope. ?

Sending so many good vibes your way. Thank you for sharing. Thank you for reading. Thanks for continuing to fight.

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Specializes in Education, Informatics, Patient Safety.
On 2/28/2019 at 5:24 PM, safetypin said:

Thank you for sharing, @SafetyNurse1968. I thoroughly love your articles- they are so informative and interesting, and I'm happy (from reading another thread) to see that sharing with others your nursing insights is a form of therapy. As someone with a history of depression, I enjoyed reading this though my heart goes out to those who have survived such an ordeal. This is truly heartbreaking.

Oh my! You made my day. It means so much to know that someone is reading and enjoying. So appreciate you.

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Specializes in Wound care; CMSRN.

Looks like our favorite Nursing prerequisite, "empathy", may be a direct result of said trauma (mines 7 by the way).

Here's the Cliff notes version: https://bigthink.com/mind-brain/childhood-trauma-adult-empathy?rebelltitem=2#rebelltitem2

And the professional one: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0203886

I've long had the opinion that genuine empathic ability was an early acquired defense mechanism to anticipate the risk of harm and was manipulative in the sense that it could give the operant the ability to manipulate his/her interactions to avoid harm. Somebody else needs to do that study because I've run out of time.

So much for "learning" to be empathic, especially as it applies to nursing skills.

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Specializes in Education, Informatics, Patient Safety.
On 3/24/2019 at 8:12 AM, Tomascz said:

Looks like our favorite Nursing prerequisite, "empathy", may be a direct result of said trauma (mines 7 by the way).

Here's the Cliff notes version:

https://bigthink.com/mind-brain/childhood-trauma-adult-empathy?rebelltitem=2#rebelltitem2>

And the professional one: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0203886

I've long had the opinion that genuine empathic ability was an early acquired defense mechanism to anticipate the risk of harm and was manipulative in the sense that it could give the operant the ability to manipulate his/her interactions to avoid harm. Somebody else needs to do that study because I've run out of time.

So much for "learning" to be empathic, especially as it applies to nursing skills.

This is a great addition to this conversation. I went and quickly read the "cliff notes". I'm wondering about something you said at the end "so much for learning to be empathetic" - are you suggesting we can't learn to be empathetic? I don't think you are. There's interesting research out there about how to teach empathy as well. I have two daughters - one is adopted, with a traumatic childhood, and she has empathy levels off the charts, the other is my biological child - we've really had to work with her to be empathetic with her siblings. I know it's anecdotal, but wanted to share my personal experience.

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