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A 30-year Follow-up of the Effects of Child Abuse and Neglect on Obesity in Adulthood
Tyrone Bentley1,2 and Cathy S. Widom2
Childhood maltreatment has been implicated as a risk factor for adult obesity. We describe the first prospective assessment of adult obesity in individuals with documented histories of childhood physical and sexual abuse and neglect and a matched comparison group in a 30-year follow-up. Using a prospective cohort design, children with court substantiated cases of physical and sexual abuse and neglect (ages 011 years) from a Midwest county during 19671971 (n = 410) were matched with children without histories of abuse or neglect on age, sex, race/ethnicity and approximate family social class (n = 303) and followed up and assessed at mean age 41. Outcome measures include BMI and obesity assessed in 20032004 as part of a medical status examination and interview. Childhood physical abuse predicted significantly higher BMI scores in adulthood ( = 0.14, P < 0.05), even controlling for demographic characteristics, cigarette smoking, and alcohol consumption ( = 0.16, P < 0.01). Childhood sexual abuse ( = 0.07, not significant) and neglect ( = 0.02, not significant) were not significant predictors of adult BMI scores. These results demonstrate the long-term impact of childhood physical abuse on weight into adulthood and suggest that physically abused children may be at risk for other adverse health outcomes associated with increased weight. Health professionals need to understand this risk for physically abused children and researchers should identify and evaluate strategies for effective interventions.
Obesity (2009) 17, 19001905. doi:10.1038/oby.2009.160

INTRODUCTiON

Obesity is a major health concern for adults, adolescents, and children in the United States (1). Childhood maltreatment also represents a serious public health concern, with an estimated 3.3 million referrals to child protective agencies for suspected child maltreatment in 2005 and 899,000 cases substantiated after investigation (2). Childhood maltreatment has been implicated as a risk factor for adult obesity based on studies reporting associations between some form of childhood maltreatment and obesity (310). Contradictory findings have been reported as well (11,12). These studies are primarily cross-sectional, focus on sexual abuse and women, and use retrospective self-reports of child abuse, causing some ambiguity in understanding these relationships. Four prospective longitudinal studies (not dependent on retrospective self- reports of child maltreatment) have documented a relationship between childhood neglect (1315) and sexual abuse (16). None of these studies has traced the long-term impact of childhood maltreatment on adult obesity using documented cases of childhood physical and sexual abuse and neglect in male and female and black and white children. This article describes the first prospective assessment of risk for obesity in children with documented histories of

childhood physical and sexual abuse and neglect and a matched comparison group followed up into adulthood. Earlier articles from this project have described other mental health and behavioral outcomes (1721). We have two major goals: (i) to determine whether individuals who experienced physical or sexual abuse and/or neglect in childhood are at increased risk for higher BMI and obesity in adulthood compared to matched controls and (ii) to determine whether these relationships differ by sex and race.
METHODS AND PROCEDURES Description of the sample Data were collected as part of a prospective cohort design study in which abused and/or neglected children were matched with nonabused and nonneglected children and followed into adulthood. Because of the matching procedure, the participants are assumed to differ only in the risk factor; that is, having experienced childhood abuse or neglect. As it is not possible to assign children randomly to groups, the assumption of equivalency for the groups is an approximation. The controls may also differ from the abused and neglected group on other variables nested with abuse or neglect. Complete details of the study design and subject selection criteria have been described earlier (22). The original sample of abused and neglected children was made up of court substantiated cases of childhood physical and sexual abuse and neglect processed from 1967 to 1971 in one Midwestern metropolitan

1 Department of Pediatrics, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA; 2Psychology Department, John Jay College, City University of New York, New York, New York, USA. Correspondence:Cathy S. Widom (cwidom@jjay.cuny.edu)

Received 17 November 2008; accepted 23 April 2009; published online 28 May 2009. doi:10.1038/oby.2009.160
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county area. Cases of abuse and neglect were restricted to children 11years of age or less at the time of the incident and, therefore, represent documented instances of childhood abuse or neglect. A critical element of the design involved the selection of a comparison group, matched with the maltreated sample on the basis of age, sex, race/ethnicity, and approximate family social class during the time period under study. This matching was important because it is theoretically plausible that any relationship between child abuse and neglect and subsequent outcomes is confounded with or explained by social class differences (17,23). The matching procedure used here is based on a broad definition of social class that includes neighborhoods in which children were reared and schools they attended (24). Any potential control group child (n = 11) with an official record of abuse or neglect was eliminated, regardless of whether the record was before or after the period of the study. Children who were under school age at the time of the abuse and/or neglect were matched with children of the same sex, race, date of birth (1 week), and hospital of birth using county birth record information. For children of school age, records of >100 elementary schools for the same time period were used to find matches with children of the same sex, race, date of birth (6 months), class in elementary school during the years 19671971, and home address, preferably within a five-block radius of the abused/neglected child. Overall, matches were found for 74% of the abused and neglected children. Nonmatches occurred for several reasons: (i) birth record matchesthe abused and neglected child was born outside the county or state or date of birth information was missing and (ii) school recordsinadequate identifying information for the abused and neglected child or class rosters unavailable due to the closure of elementary schools over the years. The initial phase of the study compared the abused and/or neglected children (N = 908) to the matched comparison group (N = 667) on juvenile and adult criminal arrest records (17). A second phase involved tracking, locating, and interviewing the abused and/or neglected and comparison groups during 19891995 (N = 1,196) (1821). Subsequent follow-ups were conducted in 20002002 (N = 896) and again in 2003 2004 (N = 807). In this article, we use information from a medical status examination (physical tests and blood collection through venipuncture), health interview, and other assessments during 20032004. Although there has been attrition associated with death, refusals, and our inability to locate individuals over the study phases, the composition of the sample has remained about the same, with no significant differences in terms of age, sex, race/ethnicity, or group status. Table1 shows the reasons for attrition and the demographic characteristics of the sample at the first (19891995) and most recent (20032004) interviews.
Procedures Participants completed a medical status exam and interview in their homes or, if preferred, another appropriate place. The interviewers were blind to the purpose of the study and to the inclusion of an abused and/ or neglected group. Participants were also blind to the purpose of the study and told that they had been selected as part of a large group of individuals who grew up in that area in the late 1960s and early 1970s. Institutional Review Board approval was obtained for these procedures, and subjects gave written, informed consent. For individuals with limited reading ability, the consent form was presented and explained verbally. Measures Child abuse and neglect. Childhood physical and sexual abuse and neglect were identified through review of official records from 1967 to 1971 when the children were ages 011 years old. Physical abuse cases included injuries such as bruises, welts, burns, abrasions, lacerations, wounds, cuts, bone and skull fractures, and other evidence of physical injury. Sexual abuse cases had charges ranging from relatively nonspecific charges of assault and battery with intent to gratify sexual desires to more specific charges of fondling or touching in an obscene manner, sodomy, incest, rape, etc. Neglect cases reflected a judgment that the parents deficiencies in child care were beyond those found acceptable
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by community and professional standards at the time and represented extreme failure to provide adequate food, clothing, shelter, and medical attention to children. Height and weight. Height and weight were measured by trained health care workers using standardized equipment and procedures as part of the medical status examination. For height, the participant was asked to remove his/her shoes and stand against the wall with their back, heels and back of head against the wall. A cardboard measuring 8.5 11 was placed on the top of head so that it was parallel to the floor. A marker was placed at the underside of the cardboard and the participant was asked to step away from the wall. Using a standard measuring tape, height was measured in inches. Weight was measured to the nearest 0.2lb/0.1kg using a digital scale (Health O Meter digital battery scale, model no. 842; Sunbeam Products, Purvis, MS). Wherever participants refused the height and/or weight measurement, this information was obtained through self-report (n = 130). BMI was calculated as kilograms/square of the height in meters. National Heart, Lung and Blood Institutes recommendations for BMI were used to determine categories of underweight (BMI <18.5kg/m2), normal (BMI 18.524.9kg/m2), overweight (BMI 25.029.9kg/m2), and obese (BMI >30.0kg/m2) (25). Age, sex, race, cigarette smoking, and alcohol consumption were treated as control variables, given their relationships to adult obesity (2630). Respondents were classified as nonsmokers if they smoked fewer than 100 cigarettes in their lifetime or never smoked or smokers if they smoked at least 100 cigarettes in their lifetime but had quit smoking >1 year earlier, quit smoking within the preceding year, or still smoked (31). Alcohol consumption (number of grams of alcohol consumed per year) was calculated by multiplying the number of drinks consumed per day by the number of drinking days per year times 12g (refs. 32,33).
Statistical analyses Pearson 2 statistics were used to compare the distribution of abuse/ neglect and comparison groups across the four weight categories.
Table 1Rates of attrition and demographic characteristics of the sample
19891995 (N = 1,196) Base used to calculate attrition Attrition Unable to locate Deceased Incapable of being interviewed Refused to participate Demographic composition Female White, non-Hispanic African American, non-Hispanic Hispanic and other High school graduate Menial/unskilled/ semi-skilled work Professional/ semi-professional work Abuse/neglect
a

20032004 (N = 807) 1,196 % (n) 12.1 (145) 3.9 (47) 0.5 (6) 15.9 (190) 52.8 (426) 63.4 (478) 34.2 (276) 6.6 (53)b 58.9 (475) 54.6 (441) 13.3 (108) 56.8 (458)

1,575a % (n) 17.0 (268) 2.7 (43) 0.5 (8) 3.8 (60) 48.7 (582) 61.5 (735) 32.5 (389) 6.0 (72) 56.3 (674) 53.6 (641) 12.7 (153) 56.5 (676)

Original sample; bHispanics and other ethnic groups excluded from the present analyses. 1901

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Table 2 Mean BMI (kg/m2) scores in abused and/or neglected children and matched controls followed up into adulthood
BMI scores Overall N Control Abuse/neglect Neglect Physical abuse Sexual abuse 303 410 335 68 54 M (s.d.) 29.42 (7.04) 30.04 (8.08) 29.68 (7.47) 31.93 (10.31) 30.69 (9.63) 191 260 207 54 34 Whites M (s.d.) 28.67 (6.55) 30.11* (8.28) 29.72 (7.82) 31.66* (9.51) 30.25 (7.93) N 112 150 128 14 20 Blacks M (s.d.) 30.71 (7.67) 29.93 (7.76) 29.61 (6.90) 32.98 (13.30) 31.45 (12.18) N 148 184 155 36 10 Men M (s.d.) 28.64 (5.75) 28.91 (5.98) 28.63 (5.93) 30.62 (6.47) 29.93 (6.94) N 155 226 180 32 44 Women M (s.d.) 30.17 (8.04) 30.96 (9.37) 30.58 (8.49) 33.40 (13.34) 30.86 (10.20)

M = mean; s.d. = standard deviation; Hispanics and other ethnic groups (n = 53) and individuals with missing information on BMI (n = 41) are excluded from these analyses. Signicance levels based on t-tests comparing abuse/neglect group to controls; equal variances not assumed. *P < 0.05 P < 0.10.

T-tests for equal or unequal variances were used, as appropriate, with BMI scores for the abuse/neglect group overall and each type of abuse/ neglect. Ordinary least squares regressions were used to examine the effects of child abuse and neglect on BMI. Equation 1, unadjusted; Equation 2, adjustments for demographic characteristics (age, sex, and race); and Equation 3, adjustments for demographic characteristics and cigarette smoking and alcohol consumption. All statistical tests compare abuse/neglect to controls. Because there are sex and race/ ethnicity differences in obesity (34), we examined sex-stratified models (race/ethnicity controlled) and race-stratified models (sex controlled). Hispanics and other groups (Native Americans, Pacific Islanders, etc.) were excluded because of their small number (n = 53) and BMI was missing for an additional 41 people, leaving 713 participants for the current analyses. Statistical significance was set at 0.05 and SPSS version 15.0 used.
RESULTS

Table 3Ordinary least square regressions predicting the effects of Child abuse and neglect on BMI in middle adulthood
Equation 1 () Overall Abuse/neglect Physical abuse Sexual abuse Neglect Men Abuse/neglect Physical abuse Sexual abuse Neglect Women Abuse/neglect Physical abuse Sexual abuse Neglect Whites Abuse/neglect Physical abuse Sexual abuse Neglect Blacks Abuse/neglect Physical abuse Sexual abuse Neglect 0.08 0.11 0.01 0.11 0.10 0.11 0.06 0.13 0.08 0.11 0.07 0.11 0.11* 0.19** 0.12 0.09 0.10 0.18** 0.11 0.08 0.12* 0.18* 0.12 0.10 0.03 0.15 0.04 0.01 0.03 0.17* 0.03 0.00 0.06 0.16* 0.04 0.03 0.04 0.14 0.06 0.01

Equation 2 () 0.03 0.16** 0.04 0.01 0.03 0.15

Equation 3 () 0.05 0.16** 0.04 0.03 0.04 0.16 0.03 0.03

0.04 0.14* 0.07 0.02

0.04 0.01

Table 2 presents mean BMI scores in adulthood and the results of t-tests comparing abuse/neglect groups with controls. Among whites, abused/neglected overall (t(446) = 2.06, P< 0.05) and physically abused individuals (t(68) = 2.14, P < 0.05) had significantly higher BMI scores in adulthood than controls. Table 3 shows the results of regressions predicting BMI scores with abuse/neglect overall, type of abuse/neglect, by sex and race, compared to controls. Childhood physical abuse predicted significantly higher BMI scores in adulthood than controls, particularly for whites in the sample. This effect remained significant with the addition of covariates (cigarette smoking and alcohol consumption). For physically abused men and women, the unadjusted effect only approached significance, although the became significant for females with the inclusion of the covariates (Equations 2 and 3). Surprisingly, childhood sexual abuse or neglect did not predict higher BMI scores in adulthood. Table4 shows the distribution of National Heart, Lung, and Blood Institutes weight categories (underweight, normal, overweight, and obese) for the abuse/ neglect group overall and specific types, compared to controls. Surprisingly, we did not find significant differences between the groups. Although the percent of participants with a history of sexual abuse who are underweight (5.6%) appeared higher than the percent for the controls (1.7%), this difference was not statistically significant.
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weights are standardized measures. Equation 1 includes only abuse/neglect as a predictor; Equation 2 includes abuse/neglect plus controls for demographic characteristics (age, sex, and race); Equation 3 includes abuse/neglect, demographic characteristics, cigarette smoking, and alcohol consumption. P < 0.10 *P < 0.05 **P < 0.01.

As prior literature shows a trend toward under-reporting weight in self-report surveys (35), we compared measured and self-reported BMI and found that self-reported weights were higher than measured weights (physical abuse (t(18) = 2.44,
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Table 4Distribution of NHLBI weight categories in abused and/or neglected children and matched controls followed-up in middle adulthood
Underweight N Control Abuse/neglect Neglect Physical abuse Sexual abuse Women Control Abuse/neglect Neglect Physical abuse Sexual abuse Men Control Abuse/neglect Neglect Physical abuse Sexual abuse Whites Control Abuse/neglect Neglect Physical abuse Sexual abuse Blacks Control Abuse/neglect Neglect Physical abuse Sexual abuse
2

Normal % 24.80 27.30 28.70 22.10 25.90 25.80 27.90 28.30 25.00 27.30 23.60 26.60 29.00 19.40 20.00 28.30 26.90 29.00 16.70 23.50 18.80 28.00 28.10 42.90 30.00

Overweight % 33.70 29.30 29.30 29.40 20.40 29.00 22.60 22.80 21.90 18.20 38.50 37.50 36.80 36.10 30.00 32.50 28.50 27.50 35.20 17.60 35.70 30.70 32.00 7.10 25.00

Obese % 39.90 41.50 40.30 47.10 48.10 43.20 46.50 46.10 50.00 47.70 36.50 35.30 33.50 44.40 50.00 37.20 41.90 40.60 46.30 52.90 44.60 40.70 39.80 50.00 40.00

P value

% 1.70 2.00 1.80 1.50 5.60 1.90 3.10 2.80 3.10 6.80 1.40 0.50 0.60 0.00 0.00 2.10 2.70 2.90 1.90 5.90 0.90 0.70 0.00 0.00 5.00

303 410 335 68 54 155 226 180 32 44 148 184 155 36 10 191 260 207 54 34 112 150 128 14 20

1.70 1.92 1.17 6.45

0.64 0.59 0.76 0.09

2.36 1.87 0.95 4.41

0.50 0.60 0.82 0.22

0.93 1.50 1.24 0.83

0.82 0.69 0.74 0.84

1.44 1.38 3.21 5.70

0.70 0.71 0.36 0.13

3.06 3.92 6.70 3.59

0.38 0.27 0.08 0.31

tests used to compare abuse/neglect group (overall and by type) and controls. Number of different types of abuse/neglect sum to more than 410 because some individuals had more than one type of maltreatment.

P< 0.05) and sexual abuse (t(58) = 2.56, P < 0.01) overall were associated with higher self-reported BMI.) However, in retrospect, these findings are not surprising, as the scale used to measure weight in the current study was able to accommodate weight up to 300lb, which necessitated the severely overweight individuals to self-report.
DiSCUSSiON

The findings from this 30-year follow-up of children with documented histories of abuse and neglect demonstrate the long-term impact of childhood physical abuse on adult weight. Childhood physical abuse predicted adult BMI, despite controls for demographic characteristics, cigarette smoking and alcohol consumption. These results are consistent with previous
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research reporting an association between physical abuse and obesity in adulthood, (5,7,8,10,15) but extend our knowledge of this relationship using a prospective longitudinal design. The mechanisms linking childhood physical abuse to higher BMI scores in adulthood are not well understood, although a number of possible explanations have been proposed. (i)Childhood physical abuse may have an impact on the activation of the hypothalamic-pituitary-adrenal axis, through dysregulation of the hypothalamic-pituitary-adrenal axis and subsequent increases in peripheral cortisol, that have been linked to abdominal obesity (36,37). (ii) Physically abused children may eat as a form of coping with their childhood traumas and this pattern may continue into adulthood. Indeed, one study (15) reported a significant impact of neglect on central obesity,
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despite controlling for childhood obesity. (iii) The increase in size associated with weight gain in physically abused children may serve a protective mechanism against further harm. Why might the current findings differ from prior research reporting an association between childhood sexual abuse (3,4,6,9,16) and neglect (1315) and obesity? First, differences in designs may in part explain these discrepant findings. One prospective study found a greater risk of obesity in young adulthood (not earlier) in girls who had been sexually abused compared to a nonabused group (16). However, those sexual abuse cases were relatively unusual, restricted to those involving genital contact or penetration and a family member perpetrator. In addition, the girls in the Noll et al. study were on average older (mean age = 11.1, s.d. = 3.02) than the girls in the current study when the abuse was documented and this age differential may have led to a different outcome. Another possibility is that our sexual abuse group was relatively small and this may have contributed to the lack of significance through limited power. However, the physical abuse group was also fairly small in size and we found a significant impact of childhood physical abuse. Surprisingly, we did not find that childhood neglect predicted higher BMI scores in adulthood. This was unexpected, given the three previous prospective studies from Sweden, England, and the United States (1315). Lack of statistical power is not an issue with regard to the neglect sample, as the neglect group was quite large. However, in the other prospective studies, children were older than those in the current study when the assessment of neglect was made, the participants were younger at the age of follow-up for two of the three studies (13,14), and only one of the studies used documented cases of neglect (13). Another possible explanation for the discrepant findings is that earlier studies used community samples of children who did not necessarily receive services because of their neglect experiences. The neglected children in the present study were often under the care of the child protection system, many until they turned 18, and this may have exerted a protective influence on their eating behaviors. A final possibility is that the relatively high rates of being overweight and obese in the current sample may mask differences associated with neglect. The fact that we did not find an increase in risk for obesity using the four National Heart, Lung and Blood Institutes BMI categories was surprising. However, using categorical variables for obesity also leads to a loss of information and reduction in power due to small cell sizes for certain categories (38).
Strengths and limitations

from the lower end of the socioeconomic spectrum and may not be generalizable to cases of abuse and neglect in middle and upper class families; (iii) These cases were processed during the late 1960s and early 1970s (before mandatory reporting laws were enacted) in the Midwest part of the United States and, thus, may not be generalizable to other time periods (the 1990s and at present) and geographic areas; (iv) The extent of child abuse and neglect among the comparison group is not known. If there is unreported abuse or neglect in the control group, then this may underestimate the association between child maltreatment and adult BMI; (v) There is no measure of childhood BMI, a predictor of adult BMI and adult obesity (39); and (vi) Because much childhood victimization occurs in the context of multiproblem homes, the maltreatment may be a marker of other family problems that together lead to higher BMI. These findings do not take into account the likely contribution of hereditary influences on the predisposition to become overweight (40). Despite these limitations, this 30-year follow-up reveals the long-term impact of childhood physical abuse on BMI in adulthood and suggest that physically abused children may be at risk for other adverse health effects often associated with increased weight, including type 2 diabetes, hypertension, cardiovascular disease, chronic obstructive pulmonary disease, and arthritis. General practitioners, pediatricians and other health professionals concerned with the development of children need to understand this increased risk for physically abused children to be overweight in adulthood and researchers need to identify and evaluate strategies for effective interventions.
ACKNOWLEDGmENTS
This research was supported in part by grants from National Institute of Child Health and Human Development (HD40774), National Institute of Mental Health (MH49467 and MH58386), National Institute of Justice (86-IJ-CX-0033, 89-IJ-CX-0007, and 93-IJ-CX-0031), National Institute on Drug Abuse (DA17842 and DA10060), and National Institute on Alcohol Abuse and Alcoholism (AA09238 and AA11108). Points of view are those of the authors and do not necessarily represent the position of the United States Department of Justice. The authors express appreciation to Sally J. Czaja, Helen W. Wilson, Elizabeth Kahn, Elise Landry, Carrie Greene, and Emily Gladden for help with the preparation of this manuscript.

DiSCLOSURE
The authors declared no conflict of interest.
2009 The Obesity Society

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