And so it went. Another woman lost 150 pounds, but instead of being thrilled, she became stricken with terror and had anxiety attacks. As it happened, she'd been sexually abused by multiple people in her household, as well as the school-bus driver. At age 15, she married a brutal husband, got divorced, and then married somebody who was crazed with jealousy—he thought that she was sexually posturing to attract men in the neighborhood when she hung the wash up to dry outside. Gaining weight, she noticed, took the pressure off—he wasn't jealous of her when she was fat. Ultimately, she regained all her weight and seemed calmer, and even happier, in her fleshy cocoon.
As the program directors began a detailed exploration into the life histories of other patients whose very success seemed to undo them, some curious facts came to light. Virtually none of the patients was fat as a child and, while most overweight people gain pounds slowly over the years, they'd gained their weight abruptly, usually in response to a difficult life event. But the shocking news was that the interviews revealed an unsettling pattern of childhood sexual abuse, trauma, family suicides, brutality, and other evidence of severely dysfunctional family relationships. In a study of 286 obese people in the program, for example, Felitti discovered that half had been sexually abused as children—more than 50 percent higher than the normal rate reported by women and 300 percent higher than the rate reported by men. In fact, for these people, overeating and obesity weren't the central problems, but attempted solutions. Food was an old, reliable friend that soothed and calmed them, while being fat protected them from a hostile world. The bigger they were, the more invisible they seemed—a good thing if being "seen" had too often been synonymous with being hurt. As one woman, who gained 105 pounds after she was raped at 23, said, "Overweight is overlooked, and that's the way I need to be."
Having discovered what he thought was a fundamentally new and more accurate way of understanding obesity, Felitti presented his data in 1990 to a large meeting of the National Association for the Study of Obesity. He remembers being "wildly attacked" by many of the psychiatrists and psychologists in attendance and told that he was being na•ve to believe these people. They'd probably invented these tales to provide cover for their failed lives, said many of the critics, as if, says Felitti sardonically, "we all make false attributions of incest for social self-aggrandizement." However, one person at the meeting, an epidemiologist with the Centers for Disease Control and Prevention (CDC), found the data intriguing, but said nobody would believe any of it was true on the basis of 286 cases—Felitti needed to do a larger, epidemiological study.
From that little acorn of a conversation grew a mighty oak: the largest research study ever done on the effects of childhood abuse, neglect, and other serious stressors on adult mental and physical health. The ACE Study was led by Felitti and Robert Anda, a CDC medical epidemiologist researching the psychosocial origins of unhealthy behaviors, including overeating, alcohol abuse, smoking, high-risk sexual activities, and illicit drug use. They asked 26,000 consecutive Kaiser Permanente patients receiving a non-illness-related comprehensive medical exam if they'd be willing to answer a series of questions regarding unpleasant childhood experiences. Seventy-one percent agreed, yielding 17,337 study participants after exclusions for incomplete data and duplications.
This group comprised a mainstream, middle-class population: the average age was 57, Caucasians made up 77 percent, 74 percent had attended college, half were men, and half were women. The researchers surveyed and interviewed these people in candid detail about 10 categories of negative childhood experiences, subdivided into 3 major divisions (abuse, household dysfunction, and neglect) and each incorporating numerous questions: Were they sexually, physically, or emotionally abused? Did someone in the household commit suicide, go to prison, engage in crime, and/or abuse drugs or alcohol? Was someone chronically depressed, institutionalized, mentally ill, and/or suicidal? Did they witness their mother being threatened or beaten by a spouse or boyfriend? Did they feel loved, protected, and well cared for? The researchers then looked for correlations between what had happened to the participants as children and their health, well-being, and risk factors for disease as adults. Each category, not incident, was given a score of 1.
The results were stunning—both the prevalence of maltreatment and adversity and their impact on health and well-being 40 to 50 years later. The researchers found that adverse experiences in childhood were very common—only 33 percent had a score of 0, meaning that none of the categories had applied to them. More important, adversity usually came as a package deal—if one category (say, alcoholism) had been present, there was an 87-percent probability that at least one other (say, sexual or emotional abuse) was also present. One in six participants had an ACE score of 4 or more (maybe sexual abuse, alcoholism, physical abuse, and witnessing household violence). One in nine had an ACE score of 5 or more. As Felitti and Anda note in a chapter of The Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic, "Every physician sees several high ACE score patients. Typically, they are the most difficult patients of the day."