Psychosomatics 47:108-111, April 2006
doi: 10.1176/appi.psy.47.2.108
© 2006 Academy of Psychosomatic Medicine
The Impact of a History of Sexual Abuse on Weight Loss in Gastric Bypass Patients
Bridget A. Oppong, M.D.,
Mark W. Nickels, M.D., and
Harry C. Sax, M.D., F.A.C.S.
Received January 8, 2004; revised June 15, 2004, March 9, 2005; accepted August 9, 2005. From the Dept. of Psychiatry and Dept. of Surgery, Univ. of Rochester School of Medicine and Dentistry, Rochester, NY. Send correspondence and reprint requests to Dr. Nickels, Univ. of Rochester Medical Center, Dept. of Psychiatry, 300 Crittenden Blvd., Rochester, NY 14642. e-mail: Mark_Nickels{at}urmc.rochester.edu
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ABSTRACT
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A history of sexual abuse has been associated with failure at weight loss. The authors sought to determine whether a history of sexual abuse influences success after gastric bypass surgery. Presurgical self-report questionnaires collected information, including sexual abuse history and previous psychiatric hospitalization, and 27% reported a history of sexual abuse. A history of sexual abuse correlated with (nonsignificantly) less loss of excess weight at 12 and 24 months after surgery. No significant difference in excess-weight loss was detected among those with history of sexual abuse. Therefore, such abuse histories should not preclude surgery for these patients.
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INTRODUCTION
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With an increasing epidemic of obesity that currently affects almost one-third of the adult population, there has been an emerging call for investigation into the risk factors for obesity as well as factors influencing successful weight loss. One risk factor gaining increased attention is sexual abuse. This interest was generated by observations made by many healthcare professionals that a large number of obese patients reported a history of childhood sexual abuse, especially those with increased difficulty with weight loss.1–3 Although such anecdotal evidence exists, it has been difficult to ascertain the rate of sexual abuse in the obese population because of a paucity of data.4 For that matter, clear information on the prevalence of sexual abuse in the general population is also limited, with rates in women being reported that expansively range from 10% to 70%.4–6
Nonetheless, the current literature does support an association between a history of sexual abuse and obesity. In one study, sexual abuse during infancy, childhood, or adolescence was acknowledged by 25% of the obese group, versus 6% of the slender group.2 Also, a history of sexual abuse is associated with an increased likelihood of becoming obese.4 Moyer et al.6 reported an increased prevalence of sexual abuse in obese individuals when compared with their non-obese counterparts. It has also been observed that the prevalence of sexual abuse tends to be lower among less-obese segments of our population and increases with increasing degrees of excess weight.3
Furthermore, having a history of sexual abuse has been associated with recidivism and failure in attempts at weight loss.1,2,7 Ray et al.8 reported preliminary data on obese patients who underwent a gastric bypass procedure and found that a history of sexual abuse may be a risk factor for failure at weight loss. Sexually abused patients had lost significantly less of their excess weight at 12 months than those without a history of abuse. Another study found that obese patients with a history of sexual abuse participating in a very-low-calorie diet program were more likely to drop out in the midst of success and rapidly regain weight.2 King et al.5 also found that among female participants in a weight-management program combining behavior therapy and a very-low-calorie diet, sexual abuse survivors appeared to show poorer outcome than women without abuse histories.
This increased difficulty noted in obese patients with a history of sexual abuse has been postulated to be secondary to a number of mediators, including the idea of excess weight serving as a protective factor2,4,7 and increased levels of stress and psychopathology.1,2,4–6,9 It has been theorized that sexual abuse survivors may perceive their body size as a defense against further abuse.2,4,7 In Felitti's study,2 one in three patients reported that obesity defended them against the threat of sexual proposals or else increased marital stability by reducing spousal jealousy. For these patients, then, "obesity may be the solution, and not the problem."2 Other theories hypothesize that the poorer weight-loss outcomes among obese victims of sexual abuse may be secondary to a higher prevalence of psychopathology than in the general population. It is generally accepted that sexual abuse is also a risk factor for psychiatric conditions such as depression.2,4,6 This depression is, in turn, associated with a strong predisposition to obesity, particularly, morbid obesity.1 Also, the presence of psychiatric comorbidity is associated with decreased compliance with weight-loss programs and resultant recidivism.2,4 Even in the absence of a diagnosable condition, there may be increased levels of stress and/or arousal in patients who have experienced abuse; this may promote increased eating.3
These findings warrant further investigation, considering the increasing prevalence of obesity in this country, in combination with the frequent occurrence of sexual abuse, especially in women. To this end, the purpose of this study is to determine the prevalence of sexual abuse in obese candidates for a Roux-en-Y gastric bypass procedure and whether a history of sexual abuse significantly influences the amount of postoperative weight loss.
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METHOD
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After April 1997, all patients seeking bariatric surgery from a single surgeon were asked to participate in a self-report study both preoperatively and yearly thereafter. The study was approved by the Institutional Research Subjects Review Board. Patients not willing to participate in the study were not precluded from being evaluated as candidates for gastric bypass surgery. It is not known how many patients did not elect to complete the questionnaire. The gastric bypass candidate questionnaire information included various areas: demographic information, history of previous psychiatric hospitalizations, pre- and postoperative weight and body mass index (BMI), previous and current weight-loss attempts, peer support, and history of sexual abuse. Individual patient responses on the self-report questionnaire were not used in determining surgical candidacy. Rather, surgical candidacy was determined through the standard practice of a surgical and psychiatric evaluation.
Outcomes are reported in terms of weight loss at follow-up (percentage of excess body weight lost). Ideal body weight (IBW) was calculated (in pounds) using standard formulas: for men, 110 + 5.05 x (height [in inches] –60); for women, 100 + 5.05 x (height [in inches] –60). Excess body weight was measured as preoperative weight minus IBW. BMI, by definition, is (weight [kg] ÷ height [m])2.
Differences between the sexual-abuse group and the non-sexual-abuse group were assessed with 2 x 2 chi-square analysis (df: 1) for categorical variables. Data are reported as mean (standard deviation [SD]); data for continuous variables were analyzed with Student's two-tailed, two-sample, unequal-variance t-test. Weight-loss data are presented as percent of excess weight lost.
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RESULTS
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Since 1997, 258 morbidly obese candidates for the gastric bypass procedure enrolled in the study and completed preoperative questionnaires. Eighty-one percent were women; 85% described themselves as Caucasian, 10% as African American, 3% as Hispanic, and another 2% as "Other" or did not report (Table 1); 54% reported being married; 34%, single; 11%, either divorced or separated; the remainder did not respond. The average weight of candidates was 324 pounds, with an average ideal body weight of 131 (Table 2). The mean preoperative BMI was 52 (SD: 11; [a BMI of  30 is obese; 35 is morbidly obese]).
Of the 258 candidates, 67 reported a history of sexual abuse, and 5 did not answer; this represented 27% of respondents (Table 3). Six patients reporting sexual abuse were men, and 61 were women; therefore, of those with a sexual abuse history, 9% were men, and 91% were women. All incidents of abuse occurred in childhood or adolescence, except for one patient who reported a rape at the age of 30. There was no significant presurgical association between BMI and a history of sexual abuse. The average BMI of patients with an abuse history was 51 (SD: 10), as compared with a mean of 52 (SD: 11) in those without a history of abuse (at p>0.05: 0.6152).
Data on the 258 candidates also show that 9% (24 respondents) reported a previous psychiatric hospitalization in the gastric bypass questionnaire and/or during the psychiatric evaluation. One hundred sixty-four denied previous hospitalization, and 70 did not respond to this question (there was no explicit report in the preoperative psychiatric evaluation). Of those who were sexually abused and who responded to the question, 13/67 (19%) versus 10/182 (5%) of the no sexual-abuse group had a previous psychiatric hospitalization (Table 4). There was a statistically significant association between sexual abuse and previous psychiatric hospitalization ( 2[1]=11.299; p 0.001).
Of our 258 candidates, 211 underwent the gastric bypass procedure, with outcome data available on 187 patients at 12 months and 99 at 24 months. The remainder have yet to reach the 1-year mark or did not receive follow-up. At 12 months, this population had an average weight loss of 111 pounds, which correlates with a 40% loss of excess weight over the ideal body weight (IBW). A history of sexual abuse correlated with poorer weight loss, with mean excess weight loss of 57.7% (SD: 13) versus 60.18% (SD: 17) in the non-abuse group at 12 months, although this difference was not statistically significant (at p>0.05: 0.3256; Figure 1). At 24 months, the mean weight loss in the sexual-abuse group was 112 pounds (58% loss of excess weight over the IBW). The mean excess weight loss in the sexual-abuse group was 60.48 (SD: 17), versus 59.23 (SD: 19) in the non-abuse group (p>0.05).
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DISCUSSION
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This study found that almost one-third of a majority White and female population of morbidly obese patients seeking gastric bypass had a history of sexual abuse. This prevalence is within the 10% to 70% range reported in the general population.4–6 That 9 out 10 patients with a history of sexual abuse were women is also similar to results of previous studies.1,7 As is common in studies investigating issues such as abuse, some patients did not respond to this question, and it is probable that some even falsely denied a history of abuse. Therefore, it is possible that an even higher prevalence of sexual abuse exists among our population.
There was a small, statistically insignificant difference in excess weight loss between patients with a history of sexual abuse and those without over a 2-year period of follow-up. The post-op success of those with abuse histories was initially less, at 57.7%, versus 60% in the no-abuse group. Overall, we are unable to reproduce the negative association between a history of sexual abuse and the failure at weight-loss attempts reported by other researchers.1,2,5,7 We also did not find obesity in the sexually abused group to be more severe;1,4 they had a mean baseline BMI similar to the no-abuse group. Furthermore, our two groups did equally well after the gastric-bypass procedure, at least at 12 and 24 months post-surgery, even though patients with a history of sexual abuse also had a higher rate of psychiatric hospitalizations. Continued follow-up may determine whether the abuse victims will be less likely to maintain the weight loss over many years and "beat" the gastric bypass procedure through nonadherence to the recommended dietary restrictions.
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CONCLUSIONS
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On the basis of our data thus far, a history of sexual abuse, as gathered during presurgical evaluation, does not necessarily predict poorer weight-loss outcome after gastric bypass, even in the presence of psychiatric comorbidity. Consequently, this information should not be used to deny patient access to surgical weight-loss therapy. With the multiple medical and psychosocial problems brought on by excess weight, clinicians currently need not be deterred from presenting patients with the option of surgical treatment.
Although previous studies have explored the possibility of an association between obesity and history of sexual abuse, few have tackled the mechanisms potentially responsible for this relationship.4,7 Further investigation is needed to establish the risk factors for obesity, and, most importantly, to establish predictors of successful weight loss. This will facilitate the ability to predict which patients will achieve the most success with the various weight-loss methods available, including gastric bypass. Specifically, to further investigate the differences in weight loss in survivors of sexual abuse, as compared with the general obese population, a prospective study should be conducted in which the two groups complete comparable weight-loss programs. The resulting data can be used to determine which method leads to higher success in those with abuse histories and whether interventions such counseling could possibly optimize weight loss.
Until the results of such a study are available, obesity treatment may have to be individually "tailored" for sexual-abuse survivors.4,5 Gastric bypass, currently the only intervention with durable long-term success,8 appears to be a viable option for these patients. Surgical treatment may even be a more suitable method of weight-loss than other methods, since patients who have experienced abuse have historically lost considerably less weight with other programs.2,4
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REFERENCES
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- Felitti VJ: Long-term medical consequences of incest, rape, and molestation. Southern Med J 1991; 84:328–331[Medline]
- Felitti VJ: Childhood sexual abuse, depression, and family dysfunction in adult obese patients: a case-control study. Southern Med J 1993; 732-736
- Frankel HM, Staeheli J: Childhood sexual abuse and adult obesity (comment). Southern Med J 1992; 85:671
- King TK: Sexual abuse and obesity: implications for the treatment of obesity. Med Health 1997; 80:364–366
- King TK, Clark MW, Pera V: History of sexual abuse and obesity treatment outcome. Addict Behav 1996; 21:283–290[CrossRef][Medline]
- Moyer DM, DiPietro L, Berkowitz RI, et al: Childhood sexual abuse and precursors of binge eating in an adolescent female population. Int J Eat Disord 1997; 21:23–30[CrossRef][Medline]
- Weiderman MW, Sansone RA, Sansone LA: Obesity among sexually abused women: an adaptive function for some? Women and Health 1999; 29:89–100
- Ray EC, Nickels MW, Sayeed S, et al: Predicting success after gastric bypass: the role of psychosocial and behavioral factors. Surgery 2003; 134:555–563[CrossRef][Medline]
- Lesserman J, Drossman DA, Zhiming L, et al: Sexual and physical abuse history in gastroenterology practice: how types of abuse impact health status. Psychosom Med 1996; 58:4–15[Abstract/Free Full Text]
This article has been cited by other articles:
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T. Stefaniak, D. Babinska, M. Trus, and A. Vingerhoets
The Impact of History of Sexual Abuse on Weight Loss in Gastric Bypass Patients
Psychosomatics,
June 1, 2007;
48(3):
270 - 271.
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ABSTRACT
INTRODUCTION
