The weight of abuse

How an obesity clinic sparked one of the nation’s most revolutionary health surveys

In 1985, a 28-year-old woman walked into Vincent Felitti’s obesity clinic and asked for help. She weighed 408 pounds, and she wanted to get thin.

She’d come to the right place. Felitti, an internist, was founder and chief of the Department of Preventive Medicine at the managed-care giant Kaiser Permanente San Diego. As part of that work, he’d developed a program to help people safely shed 300 pounds or more.

In just a year, the woman lost 276 pounds and reached her goal weight: 132. But she didn’t stay there long.

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Felitti, distressingly, was seeing the same problem with many patients. They lost hundreds of pounds, vastly improved their health, then quit the program and regained the weight in short order. “I thought, “What the hell is going on?” Felitti says.

Now this woman, too, was fleeing success. In a single three-week period, she gained nearly 40 pounds.

When he asked her what triggered it, she confided that a co-worker, a much older man, had sexually propositioned her. She’d been bingeing ever since. Mostly, she ate while sleepwalking.

“How long have you been doing that?” Felitti asked. At first, she said she had no idea. But as they kept talking she divulged her secret: Her grandfather sexually abused her for years, starting when she was 10. That’s when the sleep eating started.

That one patient, he says, is the person who sparked the ACE Study, one of the largest and most groundbreaking of its kind. The woman’s story of sexual abuse and rapid weight gain made Felitti wonder how many other patients had childhood traumas.

He started interviewing other patients in the weight program and asked colleagues to do the same. They found that, out of 286 people, 55 percent reported they’d been sexually abused as children. It was a rate more than double the estimated prevalence of childhood sexual abuse in the country.

When Felitti presented his findings to a conference of obesity specialists in 1990, he was greeted by snorts of disbelief. But researchers at the Centers for Disease Control were intrigued. How was early trauma connected to future health?

Felitti and CDC epidemiologist Robert Anda co-founded the ACE study to find out. The large-scale epidemiological survey tallied the incidence and lifetime impacts of an entire spectrum of what the physicians called “adverse childhood experiences.”


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“Adverse childhood experiences are the main determinant of the health and social well-being of the nation." Vincent Felitti and Robert Anda, in the ACE study

Up to that point, childhood trauma research tended to examine a single issue and outcome — for example, child sexual abuse and adult depression. Anda and Felitti looked at multiple intersecting traumas that fed upon each other in families.

More than 17,000 Kaiser Permanente members in San Diego — most of them white, educated and middle-to-upper-class — answered the ACEs questionnaire.

The survey asked about adversities in 10 categories, including physical, sexual or psychological abuse; emotional or physical neglect; divorce; mental illness, substance abuse, domestic violence, criminality in the household; and parental absence. A “yes” answer counted as one point, with a maximum score of 10.

Participants’ ACE scores were compared to their medical records, among other analyses. The results, published in 1988, showed that ACEs were everywhere.

According to the survey:

  • Nearly two-thirds of participants — 64 percent — reported at least one adverse childhood experience.
  • More than 20 percent reported three or more; 12 percent had four or more.
  • Women had higher rates of trauma, nearly across the board.

Adverse experiences put people at greater risk of cognitive, emotional or social impairments, mental illness and chronic disease.

As a person’s ACEs score increased, so did the odds of bad outcomes — a march-step known as a dose-response. With four or more ACEs, health risks rose significantly.

For people with four or more adversities, as compared to people with none, the risk of a suicide attempt increased 1,200 percent. The risk of alcoholism rose seven-fold; the odds of cigarette smoking jumped two-to-four-fold.

The lifelong high stress substantially increased the risk of heart, liver or lung disease; stroke; diabetes; hepatitis; autoimmune disorders and cancer. Having six or more ACEs could shorten a person’s life by 20 years.

Follow-up surveys established similar rates nationwide and around the world. In 2010 the World Health Organization reported the results of a survey spanning 52,000 adults in 21 nations: 62 percent had one ACE, almost exactly the rate in the 1998 study.

“Adverse childhood experiences are the main determinant of the health and social well-being of the nation,” Felitti and Anda concluded in a 2004 study, one of 86 they’ve now published.

Are ACEs still such a dire problem?

Felitti doesn’t hesitate. “Oh yes.”