We Should Probably Talk About the ACE Study
Content warning for usage of the word “obesity”
The ACE study was developed by Dr. Vincent Felitti, MD to assess the relationship between traumatic life events in a child’s life and health risks as an adult, such as alcoholism, cancer, and yes, obesity (Felitti et al., 1998). It began when Dr. Felitti was the chief physician at Kaiser Permanent’s Department of Preventive Medicine overseeing a weight loss program. He had a patient who was losing weight on a “near-fasting diet” until a coworker “complimented and propositioned” her. The weight gain that ensued baffled Dr. Felitti until the patient disclosed a history of sexual abuse (Khazan, 2015).
Two things came from this encounter: a quest to understand how traumatic events from childhood shape our lives and later, the belief that healing trauma will lead to weight loss or: you’re fat because you have trauma you have not processed. The ACEs that came from De. Felitti’s work was revolutionary. Because of his work, we better understand the role trauma plays in our health, beyond our emotional wellness and mental health. And, we’ve seemed to get really stuck on its relationship with obesity. Later studies on the ACEs have further identified that physical and verbal abuse are the “most strongly associated with body weight and obesity” (Williamson et al, 2002) and women who were physically or sexually abused as children were twice as likely to have a “food addiction” versus women who did not experience this abuse. (Brauser, 2013). Food addiction is in quotes one because that’s the language the study uses and also because I personally do not buy into the food addiction model.
What is missing from many of these studies? The relationship between trauma and eating disorders, dieting, and anti fatness. We know this relationship exists; a study in 2022 looked at how eating disorders relate to ACE scores and found that those with eating disorders report higher ACE scores too, specifically sexual abuse, household divorce, and mental illness in the home. Most importantly, binge eating disorder had the highest total ACE scores, followed closely by anorexia nervosa - restricting type (Reinecke et al., 2002).
Binge eating disorder is the most common, least understood and most stigmatized eating disorder; not surprising considering how deeply ingrained we are in anti-fatness and diet culture. Binge eating is oftentimes associated with fatness, laziness, gluttony, not caring about one’s health, lack of will power and it is not taken seriously. Just eat less. Exercise more. It’s your own fault. We assume fat people are fat because they binge eat, and all people who binge eat must be fat.
Eating disorders can impact body size, and efforts to lose weight can result in eating disorders. While the relationship between larger body sizes and eating disorders has mostly focused on binge eating disorder and bulimia nervosa, any person of any size can struggle with any eating disorder. (da Luz FG et al., 2018) I regularly work with clients in larger bodies with atypical anorexia (that diagnosis is a whole other conversation) or not specified eating disorders. I’ve worked with clients in thinner bodies who struggle with binge eating disorder. I do not believe our efforts should be focused on “curing obesity” and helping people lose weight but focused on helping people to cultivate a relationship with their body that is caring and compassionate, which may not include weight loss. Dr. Felitti has stated that the “root cause of weight gain” are high ACE scores and “no weight loss program will ever work” unless people’s trauma is addressed (Alman, 2021). Yikes!
And other providers have geared up to take advantage of this anti-fat narrative. If you want to lose weight, heal your trauma. There’s an entire diet book on “The Trauma Healing Diet” and plenty of therapists and coaches that specialize in obesity, weight loss, and nutrition for trauma (The privilege that oftentimes comes with certain diets is another story). Nutrition obviously has a huge impact on how we function physically, and I do believe that nutrition plays a role in our emotional wellness. I do not believe that we can “whole foods” or “organic” our way out of trauma.
I love that there are providers focused on helping clients with their trauma; I love that people are becoming more aware of how their childhoods continue to impact them today. But as a therapist that works with both eating disorders and trauma, I can’t help but feel that tying weight loss and trauma together is just another trap. It ignores the reality of body diversity in favor of the BMI scale, which is at this point, infamously irrelevant to determining someone’s health. But even our usage of BMI is inaccurate to what we know about it, as one of the “unhealthiest” categories is underweight. Let’s not forget that literally overnight, 29 million Americans became either overweight or obese and weirdly enough, the people who funded these new guidelines were weight loss drug companies (Squires, 1998). Again, another story.
The “just lose weight” narrative is just another leg of the neverending race to thinness, which may or may not be possible or healthy for all persons. It’s not uncommon for people who lose weight to go through something called weight cycling, sometimes multiple times. Weight cycling is the process of losing and regaining weight over your lifetime. It’s been found to increase risk for eating disorders, type 2 diabetes, hypertension, increased mortality and more. It’s been suggested that it’s actually more important to maintain a stable body weight than pursue weight loss for the sake of our cardiovascular health (Rhee, 2017). It’s not a secret that many people gain weight after losing weight, and it’s not uncommon for people to actually gain more weight than what their weight was before losing the weight. But the notion that weight loss may not actually be healthy is still controversial, despite decades of research on dieting and its relationship to eating disorders.
I worry that the more we try to simplify losing weight, whether it’s “just heal your trauma!” or “just take this diet pill or GLP-1 antagonist that may or may not actually give you really severe, unpleasant, long term side effects!”, we’re completely invalidating people who do not want to lose weight, people who have struggled to lose weight, and people who don’t have traumatic experiences to “blame” their body size on. I worry that it does nothing to change our obsession with thinness and health, which are oftentimes conflated with one another. I worry that anti-fatness will actually get worse the more we try to simplify weight loss. Because if you don’t choose these options, it’s really your fault you’re fat.
In the quest for a “cure” for fatness, is it a quest for health or adherence to maintaining thinness no matter what? If we truly value health, why do we engage in behaviors and beliefs that contribute to eating disorders, compulsive exercise, poor relationships with our bodies, weight cycling, stigmatizing and discriminatory practices in the workplace and in healthcare and more? Why was the takeaway from the ACE study “we can eradicate obesity”? Which is a rhetorical question, because the answer is obviously anti-fatness.
Everyone has their own relationship with health. For some, health might not actually be a priority. And I respect that. Everyone has their own relationship with their body. For some, a good relationship with one’s body includes weight loss. And I respect that. I’m not a doctor, I’m not here to comment on the relationship between a person’s weight and their health and what decisions people make for their health. Frankly, that isn’t your place either. Yet, we’ve created a culture where body size is everyone’s business and fatness is a moral failing, whether it’s due to laziness, not addressing your trauma, or refusing to take a diet pill.
I don’t have a wildly thoughtful ending to this. Antifatness sucks. Most weight loss is a scam. We all deserve to be respected in our bodies as they are and however they may change.
CITATIONS
da Luz FQ, Hay P, Touyz S, Sainsbury A. Obesity with Comorbid Eating Disorders: Associated Health Risks and Treatment Approaches. Nutrients. 2018 Jun 27;10(7):829. doi: 10.3390/nu10070829. PMID: 29954056; PMCID: PMC6073367.
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998 May;14(4):245-58. doi: 10.1016/s0749-3797(98)00017-8. PMID: 9635069.
Khazan Ogla, The Second Assault. The Atlantic, December 2015, https://www.theatlantic.com/health/archive/2015/12/sexual-abuse-victims-obesity/420186/
Rhee EJ. Weight Cycling and Its Cardiometabolic Impact. J Obes Metab Syndr. 2017 Dec 30;26(4):237-242. doi: 10.7570/jones.2017.26.4.237. PMID: 31089525; PMCID: PMC6489475
Rienecke, R.D., Johnson, C., Le Grange, D. et al. Adverse childhood experiences among adults with eating disorders: comparison to a nationally representative sample and identification of trauma profiles. J Eat Disord 10, 72 (2022). https://doi.org/10.1186/s40337-022-00594-x
Squires, Sally, Optimal Weight Threshold Lowered. The Washington Post, June 1998 https://www.washingtonpost.com/wp-srv/style/guideposts/fitness/optimal.htm
Williamson DF, Thompson TJ, Anda RF, Dietz WH, Felitti V. Body weight and obesity in adults and self-reported abuse in childhood. Int J Obes Relat Metab Disord. 2002 Aug;26(8):1075-82. doi: 10.1038/sj.ijo.0802038. PMID: 12119573.
https://irenelyon.com/2023/03/19/why-unresolved-trauma-can-make-it-difficult-to-lose-weight/
