Adverse Childhood Experiences and Obesity

Abstract

This paper examines the effect of Adverse Childhood Experiences (ACEs) on obesity in adulthood. ACEs have been shown to be related to numerous physical and mental health conditions and challenges in adulthood. Research shows that the link between obesity and ACEs relates to using food as a coping mechanism, changes in eating habits, attempts to protect one’s physical body, and responses to trauma. The findings of this paper indicate that mental health practitioners treating obese patients should be aware of the significant relationship between ACEs and obesity.

Introduction

Adverse Childhood Experiences (ACEs) have been shown to relate to numerous physical and mental health challenges in adulthood. Studies have found that people who experience ACEs, such as abuse, neglect, or household dysfunction, are at increased risk of becoming obese as adults (Amiri et al., 2024). As the prevalence of obesity worldwide continues to increase exponentially, a thorough investigation of the issues underpinning the condition is necessary, especially regarding its root causes. It is imperative that this research explores factors beyond the traditional, often stereotypical explanations of excessive eating and inactive lifestyles. ACEs are now widely recognized as significant factors affecting an individual’s physical and mental health later in life, with effects showing as early as childhood and adolescence (Chu et al., 2022). Early identification and incisive action regarding the impact of ACEs are essential in creating trauma-informed treatment approaches (Wiss, D.A., & Brewerton, T.D., 2020). This, in turn, will lead to the effective management and long-term treatment of obesity, as a comprehensive understanding will allow healthcare professionals to better support patients categorized as obese and help them develop strategies for managing compulsive eating and binge eating as trauma responses.

Thesis

This paper argues that ACEs are significant contributors to obesity in adulthood because they influence coping strategies, affect hormonal regulation, and lead to socio-economic constraints (Wiss, D.A. et al, 2022). These factors necessitate trauma-informed interventions from healthcare professionals to support those with obesity effectively.

What Are ACEs?

ACEs are defined as potentially traumatic abuse, neglect, and household challenges during childhood and adolescence that can adversely affect health and wellbeing (Chu et al., 2022). The prevalence of ACEs is high, with the Centers for Disease Control and Prevention (CDC) reporting nearly 61% of adults having experienced at least one type of ACE before age 18 and one in six adults having experienced four or more types of ACEs (Centers for Disease Control and Prevention, 2019). The original longitudinal study of childhood experiences conducted by the CDC and Kaiser Permanente in 1995 found that two-thirds of over 17,000 individuals who filled out confidential surveys had experienced at least one adverse childhood experience (Centers for Disease Control and Prevention, 2019).

Researchers have examined how these experiences have affected people’s physical, mental, and emotional health and social functioning (Gil, Psychology Today, 2019). These events may include abuse, neglect, or household dysfunction, such as growing up with family members using illicit substances or mentally ill family members; experiencing domestic violence during childhood; and living in poverty (National Conference of State Legislatures, 2022). Negative situations a child may experience or witness as they grow up, such as emotional, physical, or sexual abuse; neglect; separation or divorce of parents; or living in a household where domestic violence occurs, can impact health and wellbeing for decades. Difficult situations associated with living with an alcoholic or substance abuser, a family member with mental illness, or an incarcerated member can raise the risk of depression, anxiety, eating disorders, substance abuse, or chronic diseases in adulthood (Chu, 2022).

Obesity is a condition marked by high body fat that raises the risk of serious health issues like heart disease, diabetes, and hypertension. It is usually measured by Body Mass Index (BMI), with a BMI of 25 or above classified as ‘overweight’ and 30 or more categorized as ‘obese.’ Worldwide, one-third of people are overweight, and over 1 billion are obese. The U.S. ranks 10th highest for men and 36th for women (650 million adults in the U.S.), including 340 million adolescents and 39 million children, according to the WHO (WHO, 2022). Obesity, defined as a BMI of 30 or more, is calculated by dividing one’s weight in kilograms by one’s height in meters squared or by dividing weight in pounds by height in inches squared, then multiplying by 703 (Harvard T.H. Chan School of Public Health, 2013). There may be limitations to using BMI in studies, as factors such as bone density and muscle mass are not considered.

ACEs increase stress and can lead to maladaptive coping (emotional eating) and poor mental health, which all contribute to weight gain. A study in the American Journal of Preventive Medicine (Yoon et al., 2022) showed a clear correlation between higher numbers of ACEs and increasing risk for obesity.

Obesity bears a strong correlation to growing up affected by ACEs, which can set in motion a lifetime cycle of stress responses that translate into poor physical health. Abuse, neglect, or household dysfunction are typical stressors that contribute to ACEs and can increase cortisol and other hormones in ways that alter how the body breaks down food, stores fat, and regulates appetite (Chao, A.M., et al., 2017). Additionally, people with a high ACE score may eat for emotional relief, which can lead to unhealthy eating patterns and weight gain. ACEs may also cause emotional dysregulation, anxiety, and depression, increasing the risk of overeating or a sedentary lifestyle, often promoting obesity in adulthood (Eik-Nes Tetlie et al., 2022). It has been shown that ACEs increase the risk of obesity in children and may interfere with psychosocial and neuroendocrine development, as they are associated with impairments in self-regulation, appetite, psychopathology, and family dynamics (Schroeder, 2021).

Supporting Claims

Maladaptive Coping Mechanisms 

Emotional eating as a response to childhood trauma highlights the psychological impact of ACEs because individuals use food to pacify unresolved distress (Rienecke, R.D. et al., 2022). Many studies have identified a distinct correlation between individuals who have encountered ACEs and those who regularly utilize food as a form of escapism, as food becomes a coping strategy for ACEs and consequent trauma-related stress (Rienecke, R.D., et al., 2022). While patients report that eating offers temporary relief, this maladaptive coping mechanism can lead to sustained weight gain over time (Bailey, A., 2022).

Chronic Stress from ACEs Affects Hormonal and Metabolic Regulation

The physiological ramifications of chronic stress for those who have encountered ACEs exemplify that obesity is not solely behavioral but rooted in hormonal and metabolic disruptions. The link between ACEs and prolonged stress responses that disrupt normal cortisol levels and metabolic function is strong (Eik-Nes Tetlie, T. et al, 2022). This dysregulation predisposes individuals to fat retention and affects appetite control, creating a physiological basis for weight gain associated with ACEs and unresolved childhood trauma (Chao, A.M., et al., 2017).

Socio-economic Constraints 

Socioeconomic limitations, which can sometimes be present from childhood if ACEs occur within low-income households, often accompany ACEs and further hinder healthy lifestyle choices, thereby compounding the risk of obesity (Kim, Y. et al, 2020). ACEs are often associated with socio-economic difficulties that limit food options and result in diets that lack variety, creating a reliance on affordable, high-calorie options. These financial and dietary constraints perpetuate generational obesity by limiting opportunities and knowledge to establish healthier food choices and positive dietary habits – an area healthcare professionals must seek to address (Kim, Y. et al, 2020).

How might ACEs influence food choices? 

Childhood trauma is strongly associated with poor health outcomes. There are many studies about the association between ACEs and diet quality; however, there is a strong establishment between ACEs and diet quality. In the original study by CDC-Kaiser, exposures were assessed by questionnaires.” Associations have been found between ACEs and many diet-related conditions such as obesity, binge-eating disorder, food addiction, irritable bowel syndrome, inflammatory bowel disease, bulimia nervosa, anorexia nervosa, elevated cortisol levels, pro-inflammatory gut microbiota and more general dysregulation of the immune and endocrine system” (Aquilina, 2021). This study concludes that having traumatic experiences during childhood significantly increases the odds of poor diet as an adult and studies whether these associations differ by race or sex among participants. However, none of these studies were conducted in a predominantly low socio-economic or racial/ethnic minority population (Russell, S.J., 2016).

A Japanese research Journal in 2020, 24 271 older adults in Japan found an association between low fruit and vegetable intake that was more pronounced among females (Yanagi, 2020). However, none of these studies were conducted in a primarily low socio-economic or racial/ethnic minority population (Russell, S.J., 2016). The strength of this study is that it is a comprehensive dietary assessment that studies the relationship between ACE and diet quality, which concludes ACEs are broadly associated with poor adult diet quality; examining the association independent of household income and access to high-quality diet could play a significant role. (Jackson, D.B., et al. 2019.)

Higher ACEs scores were associated with lower fruit consumption and higher fried potato, non-fried potato, and other vegetable consumption (Mendoza, I.D., et al., 2023). These findings highlight the need to understand food context and preparation when analyzing the relationship between ACEs and diet intake.

Coping mechanisms

For many who endure childhood trauma, food becomes more than nourishment: it becomes an escape.

Behavioral or psychological strategies that individuals utilize in an attempt to cope with stressful and emotionally distressing situations, usually stem from past traumatic experiences or adverse childhood experiences. Such coping mechanisms take both adaptive forms, which promote unhealthy responses to stress, and maladaptive forms, which, while perhaps offering temporary relief, habitually lead to damaging consequences in the long run, such as obesity. These are considered to be maladaptive coping mechanisms; for example, using food as an emotional escape in cases where one resorts to food as a numbing agent for painful emotions associated with unresolved trauma. (Brown, B., 2024)

Coping mechanisms include adaptive and maladaptive strategies in response to manage stress or difficult emotions associated with ACEs. Quite often, in most people, these mechanisms evolve from early experiences of stress or trauma, such as those associated with Adverse Childhood Experiences (Tucker, 2024). ACEs may result in long-lasting psychological consequences that impact all aspects of health, including eating behavior. Studies have, in fact, emphasized a strong relationship between ACEs and the establishment of unhealthy eating behaviors, with food as a medium to cope with distress.

In this context, “food as an escape” represents one’s maladaptive coping mechanism adopted by many with ACEs in the effort to regulate emotional pain or trauma-based stress. Studies have shown that individuals with ACEs – particularly those of abuse or neglect – show an increased vulnerability toward developing eating patterns marked by excessive intake or binge eating. The same occurred when Rienecke, in 2022,  reported that in their series, individuals with ACEs usually use eating as a form of emotional release. Stress generates this need for consolation, which makes them turn to high-calorie, high-fat foods that would provide that consolation in the short term, but result in weight gain in the long-term. It also indicates that rates of obesity are considerably higher in subjects who have such traumatic backgrounds, which, of course, plays into the idea that food, when it serves as an emotional buffer, becomes a frequent means of escaping persistent stress or unresolved trauma.

Further reinforcing this connection, (Kim, Y, et al., 2020) noted that women who reported ACEs, especially within contexts of economic hardship, demonstrated an increased risk for obesity in women. This economic dimension is one more layer to suggest that trauma, combined with restricted economic resources and with few means of access to healthy food, can increase obesity: food being utilized not only as an emotional escape but also for readily available and immediate comfort. These findings underline the interlinked nature of socio-economic factors, gender, and coping mechanisms.

Finally, binge eating within the context of obesity is a condition defined by periods of excessive eating with a loss of control. It has been associated with a history of physical neglect and family dysfunction (Grilo, C, et al., 2002). It may develop from a perceived lack of emotional protection during childhood when comfort and security are replaced with eating. Usually, eating acts as a maladaptive coping mechanism that proves temporary in soothing, usually with stress and guilt being created, which loops back to reinforce the initial trauma-linked relationship with food.

Overall, the connection between ACEs and obesity often acts through the mode of maladaptive eating behaviors as linked to trauma responses. Food as a coping mechanism facilitates an emotional escape. On the other hand, it opens avenues for obesity, which is one more complicated output of psychological, physiological, and socio-economic factors. Understanding such dynamics is crucial in formulating appropriate interventions that target the underlying traumatic experiences, unhealthy coping mechanisms, and provide healthier adaptive options for individuals with ACEs. 

Ace and Obesity Interventions

A better understanding of complex risk factors for obesity can inform targeted interventions, clinical practice, policy, and future research (Schroeder, K., et al., 2021.).ACE intervention would include ensuring child safety, implementing trauma-informed practices, and addressing mental health effects of ACEs. In contrast, obesity interventions traditionally focus on nutrition, physical activity, and other health behaviors. Thus, the untapped potential exists for integrating ACEs and obesity-focused interventions. For the intervention of obesity, there should be more pre-operative assessments in our region in the Middle East; there are trauma-informed approaches that should be included. For example, gastric bariatric surgery patients first, should be offered psychological support or therapy to make sure the root causes of the trauma resulting from obesity are stable before they start their weight loss journey. Also, there should be efforts with teenager events incorporated within school programs to promote healthy lifestyles and wellbeing practices for youth to help reduce and prevent obesity.

Cortisol, Metabolism, and the Relationship between ACEs and Obesity

Research increasingly links ACEs to dysregulated cortisol levels and disrupted metabolic function – both significant contributors to obesity development. Cortisol is a hormone produced in stress response, mediated by the body’s hypothalamic-pituitary-adrenal (HPA) axis. In terms of chronic stress, this system can remain on high alert for extended periods, causing consistently higher-than-normal cortisol levels. Where ACEs occur in an individual’s life course, these stress responses become further exaggerated and, with a high frequency of cortisol release, may become chronic physiological strains with longer-term consequences for metabolic rates and weight management. (Chao, A.M., et al., 2017) ACEs may increase childhood obesity risk via multiple pathways of chronic or severe stress (Schroeder, K., et al. 2021).

To support this, Felitti et al.’s (1998) study of over 17,000 participants found that the higher the ACE score, the greater the later risk of obesity and food disorders.  In another research paper that studied the ACE score and its effect on the severity of obesity, the data suggested a positive relationship between the ACE score and BMI. Patients with severe obesity are more likely to be at a high ACE risk (50%) compared to others (24-25%). The average BMI in the high ACE risk group is higher than that of the low ACE risk group (Mahmood, S., et al.). The linear regression also showed that as the ACE score increased by 1, BMI increased by 1 unit (Mahmood, S., et al.) These researchers discovered that long-term stress associated with childhood trauma disrupted the body’s innate stress response, which regulates food intake and produces cravings for high-calorie, sweet, and fatty foods. Over time, this hormonal imbalance will promote a cycle of comfort eating as a coping mechanism, increasing caloric intake and the likelihood of reduced metabolic efficiency, thereby promoting weight gain.

Wiss and Brewerton (2020) conducted a systematic review in line with the view on ACEs and obesity. This report reported that adults with any experiences of childhood adversity had a 46% increased likelihood of developing obesity. The study noted disruptions in the HPA axis and chronic stress responses as leading mechanisms through which ACEs develop into obesity. However, this review also addressed several limitations of the existing literature, including ACE variability in measurement and the resultant recall bias, which may blur these relationships.

Longitudinal research by (Koball, A. M. et al., 2024). suggests that chronic stress from ACEs encourages visceral fat accumulation in the body through the same HPA axis dysregulation. The authors note that this physiological stress response is heightened further by accompanying behavioral and environmental factors, such as physical inactivity, the use of substances, and disrupted sleep, which often accompany ACE history. Combined, these physiological and behavioral effects release a cumulative impact that increases vulnerability toward obesity via direct metabolic and indirect lifestyle influences.

In summary, findings suggested that childhood trauma may set up the body for long-term metabolic changes through a constant output of cortisol, which disturbs the body’s normal metabolic rates and encourages fat retention and subsequent weight gain. These results support the notion that the ACE-obesity link is not entirely behavioral but might include a physiological pathway through which stress-induced changes in hormone levels result in durable metabolic changes.

Overeating as Physical Protection

For some with ACEs, especially those who experienced abuse as children, overeating may serve as a form of protection-a way of protecting one’s body from violation. Certain forms of maltreatment during childhood, such as physical or sexual abuse, instill fear in the victim about being vulnerable; a person may involuntarily resort to measures that offer some protection, either physical or emotional. In such cases, weight gain becomes more than an unintended result; it can be a kind of bodily armor that puts distance between the individual and the outside world and decreases feelings of vulnerability (Oofana, B., 2018).

(P. Rohde, 2008) focused on women who had experienced child maltreatment and found a significant link between such traumatic incidents and adult obesity. This study found that many of these women overeat due to negative emotions and use food as a way of coping for immediate emotional comfort. On the other hand, it has been suggested from the research that some individuals may overeat as a subconscious effort to make them feel safer, using weight gain as a symbolic buffer zone of added physical protection against perceived threats.

Overeating can also be attributed to the physiological aspects of trauma. Trauma, when it happens at a time considered critical during the development process, may cause a detuning of the standard body signals of hunger and satiety, as noted in Rohde’s results. This dysregulation makes it impossible for an individual to know when he or she has had enough food, thus developing the habit of overeating and gaining much weight. The fact that food can be comfort and protection all rolled into one illustrates how complex the relation of ACEs to obesity: eating behaviors are motivated not only by emotions but by deep-seated, trauma-related needs for self-protection.

Findings

The overall findings of this paper highlight the multifaceted relationship between ACEs and obesity, demonstrating the original thesis that obesity often emerges not solely from lifestyle choices but as a response to deeper trauma-related issues. ACEs and unresolved childhood trauma can lead to maladaptive coping mechanisms, such as emotional eating, that contribute to sustained weight gain in adulthood or even earlier (Wiss, D.A., & Brewerton, T.D., 2020). The connection between ACEs and obesity has effects beyond behavior, including physiological changes, such as cortisol irregularity and metabolic disruption, which adversely affect an individual’s propensity to gain weight.

Conclusion

The association between ACEs and obesity underscores the crucial need for healthcare professionals to address childhood trauma when treating and preventing obesity. Such an approach can provide long-term physical and mental benefits to the patient. As established, obesity linked to ACEs may manifest in adulthood or even earlier, making early intervention vital. Effective intervention should address psychological and emotional factors related to trauma, thereby allowing healthcare professionals to mitigate some of the risks associated with obesity. When trauma-informed care is prioritized, professionals can promote healthier, long-term lifestyle changes that go beyond simple dietary or exercise advice, which may be insufficient for those struggling with trauma-related obesity (Bailey, A., 2022).

The role of mental health support in obesity treatment for individuals with ACEs is essential. Approaches grounded in an understanding of trauma demonstrate that lasting health improvements are more likely achieved by addressing the root causes of psychological and emotional obesity. This approach can help destigmatize obesity, framing it as a condition influenced by complex, multifaceted factors rather than purely lifestyle choices (Wiss, D.A., & Brewerton, T.D., 2020).

Finally, while links between ACEs, binge eating disorders (BEDs), and obesity exist, further research is essential to explore specific connections among these factors. A deeper understanding of their interactions could lead to more precise, evidence-based support tailored to individuals with a history of ACEs, moving away from a ‘one-size-fits-all’ approach to obesity treatment. Ultimately, this approach will foster resilience in individuals with ACEs and result in better, sustainable health outcomes.

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