Associations of child sexual and physical abuse with obesity and depression in middle-aged women

Abstract

Objective

Examine whether (1) childhood maltreatment is associated with subsequent obesity and depression in middle-age; (2) maltreatment explains the associations between obesity and depression; and (3) binge eating or body dissatisfaction mediate associations between childhood maltreatment and subsequent obesity.

Methods

Data were obtained through a population-based survey of 4641 women (mean age = 52 years) enrolled in a large health plan in the Pacific Northwest. A telephone survey assessed child sexual and physical abuse, obesity (BMI ≥ 30), depressive symptoms, binge eating, and body dissatisfaction. Data were analyzed using logistic regression models incorporating sampling weights.

Results

Both child sexual and physical abuse were associated with a doubling of the odds of both obesity and depression, although child physical abuse was not associated with depression for the African American/Hispanic/American Indian subgroup. The association between obesity and depression (unadjusted OR = 2.82; 95% CI = 2.20–3.62) was reduced somewhat after controlling for sexual abuse (adjusted OR = 2.54; 1.96–3.29) and for physical abuse (adjusted OR = 2.63; 2.03–3.42). Controlling for potential mediators failed to substantially attenuate associations between childhood maltreatment and obesity.

Conclusions

This study is the first to our knowledge that compares associations of child abuse with both depression and obesity in adults. Although the study is limited by its cross-sectional design and brief assessments, the fact that child abuse predicted two debilitating conditions in middle-aged women indicates the potential long-term consequences of these experiences.

Introduction

Both obesity [defined as a body mass index, or BMI (kg/m²), of 30 or greater] and depression are highly prevalent in the USA and associated with a number of diseases and health complications (e.g., Blazer, Kessler, McGonagle, & Swartz, 1994; Olshansky et al., 2005). It is also fairly well-established that these two public health problems are associated (Faith, Matz, & Jorge, 2002; Stunkard, Faith, & Allison, 2003). Community surveys in the US and Canada have found associations between obesity and depressive symptoms (Heo, Pietrobelli, Fontaine, Sirey, & Faity, 2006; Johnston, Johnston, McLeod, & Johnston, 2004), diagnosis of depressive disorder (Carpenter, Hasin, Allison, & Faith, 2000; Onyike, Crum, Lee, Lyketsos, & Eaton, 2003), and history of depression (Dong, Sanchez, & Price, 2004; Simon et al., 2006). Longitudinal studies indicate a bidirectional relationship. Depression predicts subsequent development of obesity (Goodman & Whitaker, 2002; Hasler et al., 2004) and obesity predicts subsequent development of depression (Herva et al., 2006; Roberts, Deleger, Strawbridge, & Kaplan, 2003). This relationship may differ by gender, with positive associations between obesity and depression among women and either negative or no associations among men (Carpenter et al., 2000; Istvan, Zavela, & Weidner, 1992; Linde et al., 2004, McElroy et al., 2004, Onyike et al., 2003; Palinkas, Wingard, & Barrett-Connor, 1996). The present authors recently contributed to this literature, finding that depression was strongly and consistently associated with obesity in a large sample of middle-aged women (Simon et al., 2008).

The reasons for an obesity–depression association have not been established and there may be several contributing factors. One potential explanation for this association is childhood maltreatment. Childhood maltreatment is known to be associated with a range of psychological difficulties and physical health outcomes, including both obesity and depression (Felitti et al., 1998, Green, 1993; Gustafson & Sarwer, 2004). Self-reported childhood abuse is strongly associated with increased body weight and obesity in adulthood (Walker et al., 1999), with risk of obesity increasing as a function of the number and severity of each type of abuse (Williamson, Thompson, Anda, Dietz, & Felitti, 2002). Childhood maltreatment has also been found to be a distal risk factor for depression (Hankin, 2005; McNally, Perlman, Ristuccia, & Clancy, 2006), with increased psychiatric consequences as the number of different types of abuse or chronicity increases (Molnar, Buka, & Kessler, 2001; Teacher, Samson, Polcari, & McGreenery, 2006). Child abuse could increase the likelihood of either obesity or depression through multiple mechanisms, including actual physical changes (e.g., impaired brain development, poor physical health), psychological sequelae (e.g., low self-esteem, sense of powerlessness, social isolation), or behavioral consequences (e.g., delinquency, teen pregnancy, low academic achievement) (e.g., Chalk, Gibbons, & Scarupa, 2002; Colman & Widom, 2004; Finkelhor & Browne, 1986; Nemeroff, 2004).

Child sexual and physical abuse are examined separately in the present study, as the two forms of childhood maltreatment have different associations with both adult obesity and depression. Child physical abuse may be more predictive of depression in adults than child sexual abuse (Grilo et al., 2005; Roosa, Reinholtz, & Angelini, 1999), whereas child sexual abuse, but not physical abuse, was associated with elevated BMI in a large sample of adult women (Walker et al., 1999).

Given that childhood maltreatment could be a common factor predicting both negative outcomes, the first goal of the present study was to examine and contrast the associations of obesity and depression with childhood maltreatment. Specifically, the questions of whether child abuse is associated with both obesity and depression and whether the associations remain significant controlling for the demographic factors of age and race/ethnicity were examined; other common demographic factors, such as education, marital status, and SES, were not considered as they could be outcomes influenced by the experience of childhood abuse (e.g., Walker et al., 1999). Some data indicate that the relationship between obesity and depression may be moderated by race or ethnic status (Blazer, Moody-Ayers, Craft-Morgan, & Burchett, 2002; Heo et al., 2006; Stecker, Fortney, Steffick, & Prajapati, 2006). For example, Simon et al. (2006) reported that the association between obesity and diagnosis of MDD varied as a function of both race/ethnicity, being strongest in non-Hispanic whites. Given that the association of sexual abuse and later depression may vary as a function of race/ethnicity (e.g., the association was significant for non-Hispanic Whites and Mexican American young women but not African or Native American women in Roosa et al., 1999), we also considered whether the magnitude of associations between abuse and the two examined outcomes varied as a function of race/ethnicity. The sample size and demographic composition of the sample did not allow us to examine all categories of race/ethnicity separately. Rather, three composite categories were created (i.e., White non-Hispanic; Asian/Pacific Islander; and other, i.e. African American, Hispanic, and American Indian/Alaskan Native) based on the relative prevalence of obesity among adult women (e.g., Ogden et al., 2006; Sundaram, Ayala, Greenland, & Keenan, 2005).

If childhood maltreatment is associated with both obesity and depression and precedes both in time, then it could explain at least some of that association. As our second aim, we examined whether the obesity/depression association became nonsignificant or less significant controlling for the presence of either form of childhood maltreatment.

If childhood maltreatment increases the risk of developing obesity later in life, then this relationship should be mediated by specific changes in attitudes or behaviors. Both binge eating and body dissatisfaction have also been found to be associated with child abuse and with adult obesity and are thus also examined as potential mediators of this relationship as the third aim of this paper. Binge eating, which refers to discrete episodes in which the person ate an unusually large amount of food with a perceived lack of control, has been found in several studies to be associated with obesity (e.g., Reichborn-Kjennerud, Bulik, Sullivan, Tambs, & Harris, 2004) and with a history of child abuse in community samples of women (e.g., Fairburn et al., 1998; Kenardy & Ball, 1998; Striegel-Moore, Dohm, Pike, Wilfley, & Fairburn, 2002) and among obese individuals seeking bariatric surgery (Gustafson et al., 2006). In addition, rates of physical, sexual, and emotional childhood maltreatment among adults with binge eating disorders are elevated (e.g., Grilo & Masheb, 2001). Body dissatisfaction, which refers to negative thoughts and feelings regarding one’s size and weight, is higher among obese woman than nonobese women (Sarwer, Wadden, & Foster, 1998) and is associated with past sexual abuse in young community-residing women (Kenardy & Ball, 1998) and with emotional but not physical or sexual abuse in extremely obese patients seeking bariatric surgery (Grilo et al., 2005). Binge eating, body dissatisfaction, and depressive symptoms are strongly associated in both obese women and men (Womble et al., 2001).