Moderate-to-severe obesity (body mass index (BMI) of ≥35 kg/m2) affects 9% of Canadians and has increased in prevalence by 400% over the last two decades [
There is an association between sexual abuse and obesity [
Sexual abuse is important to identify in all at-risk populations, but particularly so in patients seeking bariatric treatment because it has been (albeit inconsistently) associated with poorer weight loss outcomes [
Subjects were recruited from the Edmonton Weight Wise regional obesity program for adults. Edmonton Weight Wise was established in 2005 to deliver integrated, patient-focused, evidence-based care to the Edmonton Zone of Alberta Health Services (AHS). The Edmonton Zone is one of the largest integrated health delivery regions in Canada, serving a catchment population of approximately 1.6 million residents within greater Edmonton. Weight Wise consists of a central, regionwide, single-point-of-access referral system; community education and weight management sessions; and a bariatric specialty clinic. The clinic provides both medical and surgical treatment to practitioner-referred patients of 18 years of age or greater with BMI levels of ≥35 kg/m2 who have been unsuccessful with prior attempts at managing chronic obesity. Not all patients seek surgery—some are referred for intensive medical management alone. At the time the study was conducted, wait-times to enter the program were over 2 years; 800 new referrals were seen yearly; and 200 bariatric surgeries were performed annually.
In this cross-sectional analysis, baseline data from five hundred consecutive, consenting adult (age ≥18 years) subjects recruited from Edmonton Weight Wise and comprising the Alberta Population-based Prospective Evaluation of the Quality of Life and Economic Impact of Bariatric Surgery (APPLES) cohort were examined. Details of the APPLES study, including the design and analytic plan, have been previously published [
Self-reported sexual abuse was assessed during a private, in-person interview and as part of baseline data collection by asking subjects, “Do you have a history of sexual abuse, in the past or currently?” Hereafter, we refer to a positive answer to this item as self-reported sexual abuse, and this included any lifetime incident perceived by the patient as sexually abusive including a sexual attack. All patients received both verbal and written explanation that their answers were confidential and would not affect their status in the clinic nor their eligibility for bariatric treatments, including surgery (answers remained part of the research data collection and remained separate from the clinical record). None of the patients included in the study reported current sexual abuse.
We collected basic sociodemographic information and clinical data. Subjects were asked to rate their overall state of health from 0 to 100 using a visual analogue scale (VAS) with 100 reflecting the “best imaginable state of health” [
Subjects were considered hypertensive if they self-reported hypertension, if they were receiving treatment with antihypertensive medication, or if their screening blood pressure was ≥140/90 mm Hg (or ≥130/80 mm Hg in patients with diabetes). The diagnosis of diabetes, dyslipidemia, depression, and other psychiatric disorders was based on self-report or medication usage. The presence of all other comorbidities, including alcohol abuse and personality disorders, was determined by self-report.
Baseline data from all 500 APPLES subjects were combined for the purposes of this analysis. Descriptive analyses, consisting of means, medians, and proportions, were first conducted and the prevalence of sexual abuse was calculated. Baseline characteristics were compared using
Baseline characteristics.
Variable | History of sexual abuse |
No history of sexual abuse |
|
---|---|---|---|
Female sex (%) | 104 (95.4) | 337 (86.2) | 0.008 |
Mean age (years) | 42.2 (9.2) | 44.1 (9.7) | 0.08 |
Weight (kg) | 129.8 (23.4) | 132.5 (25.5) | 0.3 |
Body mass index (kg/m2) | 47.8 (8.1) | 47.9 (8.1) | 0.8 |
Health status on visual analog scale | 53.1 (21.2) | 58.0 (20.1) | 0.03 |
| |||
Marital status | 0.003 | ||
Married/common-law | 55 (50.5) | 234 (59.9) | |
Separated/divorced/widowed | 30 (27.5) | 54 (13.8) | |
Single/never married | 24 (22.0) | 103 (26.3) | |
| |||
Employment status | 0.06 | ||
Full-time | 60 (55.1) | 254 (65.0) | |
Part-time | 13 (11.9) | 51 (13.0) | |
Other1 | 36 (33.0) | 86 (22.0) | |
| |||
Annual household income | <0.0001 | ||
Less than $30 000 | 28 (25.7) | 40 (10.2) | |
$30 000–$79 999 | 55 (50.5) | 170 (43.5) | |
$80 000 or greater | 23 (21.1) | 164 (41.9) | |
Not answered | 3 (2.8) | 17 (4.4) | |
| |||
Ethnicity | 0.1 | ||
Caucasian | 96 (88.1) | 362 (92.6) | |
Study arm | 0.07 | ||
Medical | 50 (45.9) | 150 (38.4) | |
Surgical | 23 (21.1) | 127 (32.5) | |
Wait list | 36 (33.0) | 114 (29.2) | |
| |||
Smoking status | 0.4 | ||
Current smoker | 12 (11.0) | 37 (9.5) | |
Former smoker | 52 (47.7) | 164 (41.9) | |
Never smoked | 45 (41.3) | 190 (48.6) | |
| |||
Hypertension | 70 (64.2) | 258 (66.0) | 0.7 |
Dyslipidemia | 36 (33.0) | 130 (33.3) | 0.9 |
Diabetes mellitus | 41 (37.6) | 141 (36.1) | 0.7 |
Coronary artery disease | 2 (1.8) | 20 (5.1) | 0.1 |
Sleep apnea | 41 (37.6) | 126 (32.2) | 0.2 |
Nonalcoholic fatty liver disease | 10 (9.2) | 28 (7.2) | 0.4 |
Gastroesophageal reflux disease | 45 (41.3) | 132 (33.7) | 0.1 |
Asthma | 40 (36.7) | 86 (22.0) | 0.002 |
Osteoarthritis | 38 (34.9) | 115 (29.4) | 0.2 |
Polycystic ovary syndrome | 21 (19.3) | 42 (10.7) | 0.02 |
| |||
Fibromyalgia | 13 (11.9) | 38 (9.7) | 0.5 |
Depression | 91 (83.5) | 228 (58.3) | <0.0001 |
Bipolar and psychotic illness | 16 (14.7) | 13 (3.3) | <0.0001 |
Posttraumatic stress disorder | 35 (32.1) | 22 (5.6) | <0.0001 |
Binge eating disorder | 44 (40.4) | 104 (26.6) | 0.005 |
Obsessive compulsive disorder | 15 (13.8) | 34 (8.7) | 0.1 |
Addiction to drugs | 10 (9.2) | 9 (2.3) | 0.003 |
Addiction to alcohol | 13 (11.9) | 3 (0.8) | <0.0001 |
Borderline personality disorder | 14 (12.8) | 5 (1.3) | <0.0001 |
Of the 500 patients enrolled, 459 (91.8%) were white and 441 (88.2%) were females (Table
Abused and nonabused patients had similar age and BMI distributions; however, abuse was more common in females compared to males (23.6% versus 8.5%;
Study-arm was not independently associated with abuse (
Independent predictors of sexual abuse: multivariable logistic regression analysis.
Variable | Estimate (standard error) | Adjusted odds ratio (95% CI) |
---|---|---|
Age (years) | −0.008 (0.013) | 0.99 (0.97–1.02) |
Female sex | 1.025 (0.613) | 2.79 (0.84–9.27) |
BMI (kg/m2) | 0.010 (0.016) | 1.01 (0.98–1.04) |
| ||
Annual household income | ||
Less than $30 000 versus $80 000 or greater | 1.208 (0.376) | 3.35 (1.60–6.99) |
$30 000–$79 999 versus $80 000 or greater | 0.665 (0.297) | 1.94 (1.09–3.48) |
Not answered versus $80 000 or greater | 0.059 (0.740) | 1.06 (0.25–4.52) |
| ||
Posttraumatic stress disorder | 1.585 (0.338) | 4.88 (2.52–9.46) |
Addiction to alcohol | 2.762 (0.703) | 15.8 (3.99–62.8) |
Depression | 0.857 (0.302) | 2.36 (1.30–4.26) |
Borderline personality disorder | 1.320 (0.665) | 3.75 (1.02–13.8) |
Model c-statistic = 0.79.
Significant predictors of sexual abuse: multivariable logistic regression analysis. Estimates adjusted for age, BMI, and all variables listed in the figure: female sex, annual household income of less than $30 000 compared to $80 000 or more, depression, borderline personality disorder, posttraumatic stress disorder, and addiction to alcohol.
In this study of 500 patients enrolled in a population-based regional obesity program, the prevalence of self-reported sexual abuse was 21.8%, and psychosocial issues such as addiction and psychiatric illnesses were the major independent predictors of abuse. Abused patients were more likely to be women than men, and they reported clinically important impairments in health status compared to those not abused.
The prevalence of sexual abuse in our study is within the range reported by other studies examining bariatric surgery candidates or recipients [
To our knowledge, only one other study has attempted to identify independent predictors of sexual abuse in a bariatric population [
The reported prevalence of sexual abuse varies according to the survey method used, the definition of sexual abuse (i.e., actual rape versus other types of inappropriate contact), the strength of the patient-researcher rapport, and the degree to which the patient may conceal, repress, or be unwilling to disclose past abusive experiences [
Low socioeconomic status, depression, addiction to alcohol, borderline personality disorder, and posttraumatic stress disorder were independent predictors of abuse. These findings are consistent with previous research demonstrating univariable associations between abuse and psychosocial pathology [
We also found that abused patients reported diminished health status compared to nonabused patients. The five-point mean difference in VAS scores is large enough to be clinically significant and the low VAS scores reflect a high degree of health impairment in this population (i.e., worse than VAS scores in type 2 diabetes and post-hip-fracture patients) [
What are the clinical implications, if any, of our work? If routine screening is not to be undertaken, we believe at the least those patients exhibiting one or more of the independent predictors for sexual abuse (especially addiction to alcohol given its very high odds ratio) should be specifically screened for abuse so that they may be offered supportive counseling or other treatments. The presence/absence of these other factors is often already documented during a standard medical history or medication review whereas sexual abuse screening is not commonly routinely performed. Previous studies examining the association between sexual abuse and weight loss after bariatric surgery have reported mixed results, and several of these analyses were underpowered. The preponderance of data suggests that sexual abuse is associated with lower early (i.e., after one year) postsurgical weight loss [
In conclusion, sexual abuse was common in the severely obese patients we studied and it affected their quality of life. Given the strong, independent associations between several psychosocial variables and sexual abuse, we recommend that these readily identifiable and high-risk patients be screened and offered supportive counseling or other treatments. Attention to these issues should improve weight-related outcomes and quality of life.
Canadian Institutes of Health Research under Grant no. 86642 supported this study. D. L. Gabert was funded by a CIHR Health Professional Student Research Award. C. F. Rueda-Clausen is a fellow supported by CIHR and Alberta Innovates-Health Solutions (AI-HS). R. S. Padwal had full access to the data and takes responsibility for the integrity of the data and accuracy of the data analysis. R. S. Padwal developed the initial study concept, which was then refined by the remaining authors. R. S. Padwal was responsible for statistical analysis. D. L. Gabert and R. S. Padwal wrote the initial draft of the paper. All remaining authors contributed to the final draft and approved the final submitted version of the paper. R. S. Padwal, S. W. Klarenbach, S. R. Majumdar, and A. M. Sharma are supported by an alternative funding plan from the Government of Alberta and the University of Alberta. A. M. Sharma is supported by an Alberta Health Services Chair in Obesity Research and Management. S. W. Klarenbach and S. R. Majumdar hold salary support awards from Alberta Heritage Foundation for Medical Research and Alberta Innovates-Health Solutions. S. R. Majumdar holds the Endowed Chair in Patient Health Management of the Faculties of Medicine and Dentistry and Pharmacy and Pharmaceutical Sciences, University of Alberta. S. Karmali has received honoraria from and has consulted for bariatric surgery equipment manufacturers (Ethicon Endo-Surgery, Covidien and Gore). D. W. Birch has received research funding from Johnson and Johnson and Ethicon Endo-Surgery and has consulted for Johnson and Johnson, Ethicon Endo-Surgery, Covidien, Bard, Baxter, and Olympus. The other authors declare no conflict of interests with respect to this work.