Abstracts

Introduction

Population nutritional status has been targeted for public health attention ¹1 . Zefferino AMB, Barros Filho AA, Bettiol H, Barbieri MA. Acompanhamento do crescimento. J Pediatr (Rio J.) 2003; 79 Suppl 1:S23-32.^,22 . Farias Junior JC. Validade das medidas auto-referidas de peso e estatura para o diagnóstico do estado nutricional de adolescentes. Rev Bras Saúde Matern Infant 2007; 7:167-74.. Measures initially focused on preventing and fighting undernutrition ³3 . Domene SMA, Zabotto CB, Meneguello R, Galeazzi MAM, Taddei JAAC. Perfil nutricional de crianças e suas mães em bolsões de pobreza do município de Campinas, SP 1996. Rev Nutr PUCCAMP 1999; 12:183-9.. However, changes in economic, social, demographic, and eating patterns in recent decades have led to changes in health and nutrition policies, expanded to incorporate interventions against overweight and obesity ⁴4 . Pinheiro ARO, Freitas SFT, Corso ACT. Uma abordagem epidemiológica da obesidade. Rev Nutr PUCCAMP 2004; 17:523-33..

In Brazil, the results of the Family Budgets Survey ⁵5 . Instituto Brasileiro de Geografia e Estatística. Pesquisa de Orçamentos Familiares (POF) 2008-2009: antropometria e estado nutricional de crianças, adolescentes e adultos no Brasil. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2010. showed an increase in excess weight and a decrease in underweight in all the country’s geographic regions and income strata. From 2008 to 2009, 20.5% of adolescents showed excess weight and 4.9% were obese, while only 3 to 4% were underweight.

According to the Brazilian Ministry of Health ⁶6 . Coordenação-Geral da Política de Alimentação e Nutrição, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para a população brasileira: promovendo a alimentação saudável. Brasília: Ministério da Saúde; 2006., the increasing rates of overweight and obesity in the country’s population can be explained by the consumption of high calorie- density and nutritionally poor foods, associated with lower energy expenditure due to the reduction in physical activity. As discussed by Enes & Slater ⁷7 . Enes CC, Slater B. Obesidade na adolescência e seus fatores determinantes. Rev Bras Epidemiol 2010; 13:163-71., changes in eating patterns and obesity in adolescents have been associated with the early emergence of comorbidities and emotional disorders. Excess weight has been associated with both adolescents’ behavior and other factors ⁸8 . World Health Organization. Strategy on diet, physical activity and health. http://www.who.int/dietphysicalactivity/childhood_why/en/index.html (accessed on 09/Jun/2013).
http://www.who.int/dietphysicalactivity/... that influence food intake and physical activity, such as the physical, social, and economic environment ⁹9 . Wang Y. Liang H, Tussing L, Blaunschwerg C, Caballero B, Flay B. Obesity and related risk factors among low socio-economic status minority students in Chicago. Public Health Nutr 2007; 10:927-38.. Evidence suggests that biological, behavioral, and environmental factors interrelate and reinforce each other to produce inadequate nutritional status ⁷7 . Enes CC, Slater B. Obesidade na adolescência e seus fatores determinantes. Rev Bras Epidemiol 2010; 13:163-71..

Environmental factors include family violence, which has received increasing attention in recent years due to its consequences for physical and mental health and overall morbidity and mortality ¹⁰10 . World Health Organization. Milestones of a global campaign for violence prevention. Geneva: World Health Organization; 2004..

The literature is recent on the relationship between family violence and inadequate nutritional status in adolescents. Studies have generally shown that young people exposed to violence among family members are more prone to excess weight ¹¹11 . Boynton-Jarrett R, Ryan LM, Berkman LF, Wright RJ. Cumulative violence exposure and self-rated health: longitudinal study of adolescents in the United States. Pediatrics 2008; 122:961-70.^,1212 . Greenfield EA, Marks NF. Violence from parents in childhood and obesity in adulthood: using food in response to stress as a mediator of risk. Soc Sci Med 2009; 68:791-8.^,1313 . Lohman BJ, Stewart S, Gundersen C, Garasky S, Eisenmann JC. Adolescent overweight and obesity: links to food insecurity and individual, maternal, and family stressors. J Adolesc Health 2009; 45:230-7.^,1414 . Nguyen-Rodriguez ST, Chou C, Unger JB, Spruejt-Metz D. BMI as a moderator of perceived stress and emotional eating in adolescents. Eat Behav 2008; 9:238-46.^,1515 . Jun J, Corliss HL, Boynton-Jarret R, Spielgelman D, Austin SB, Wright RJ. Growing up in a domestic violence environment: relationship with developmental trajectories of body mass index during adolescence into young adulthood. J Epidemiol Community Health 2012; 66:629-35.. Various factors point in this direction. According to some authors, exposure to violence in childhood can lead to greater food intake and facilitate the development of obesity, which can persist into adulthood ¹²12 . Greenfield EA, Marks NF. Violence from parents in childhood and obesity in adulthood: using food in response to stress as a mediator of risk. Soc Sci Med 2009; 68:791-8.^,1515 . Jun J, Corliss HL, Boynton-Jarret R, Spielgelman D, Austin SB, Wright RJ. Growing up in a domestic violence environment: relationship with developmental trajectories of body mass index during adolescence into young adulthood. J Epidemiol Community Health 2012; 66:629-35..

In addition, the fact that health professionals ignore cases of violence, aggravated by their lack of experience in approaching the subject of nutritional status, hinders their understanding of the association between physical and/or psychological abuse against adolescents, eating disorders, and inadequate nutritional status ¹⁶16 . Narvaz M, Oliveira LL. A relação entre abuso sexual e transtornos alimentares: uma revisão. Interam J Psychol 2009; 43:22-9.. Thus the current study investigated the association between body mass index (BMI) and family violence suffered by adolescents enrolled in the conditional cash transfer program known as Bolsa Família.

Methods

The survey was conducted in the Hélio Pellegrino Polyclinic in Rio de Janeiro, one of the units providing care to beneficiaries of the Bolsa Família Program ¹⁷17 . Ministério de Desenvolvimento e Combate a Fome. Programa Bolsa Família. http://www.mds.gov.br/bolsafamilia/ (accessed on 05/Jul/2010).
http://www.mds.gov.br/bolsafamilia/... . The unit is responsible for providing care to beneficiaries residing in Program Area 2.2 (AP 2.2), which includes the Praça de Bandeira and Morro do Turano neighborhoods. The current study used data from evaluation reports from August 2008 to August 2009 on 434 families enrolled in Bolsa Família.

In 2008 and 2009, a convenience sample of 386 adolescents was monitored by the nutrition department. Of these, 201 adolescents (52%) from 10 to 19 years of age who were in physical condition for taking anthropometric measurements were selected for the survey and assessed by the study project’s principal investigator. A total of 185 adolescents (48% of the original sample) were excluded for the following reasons: pregnancy or first trimester postpartum, adolescents with diseases affecting their nutritional status (genetic deficiencies), difficulties in understanding the questionnaire (hearing impairment), and those assessed by health professionals other than the project’s investigator.

Data were obtained with a pretested, validated questionnaire that included questions on the outcome variable (continuous BMI), central exposure (family violence), and covariates (adolescent’s socio-demographic characteristics, sexual maturation, and body image).

Evaluation of nutritional status was based on weight and height measurements taken with a Filizola scale, model 31 (Filizola S.A., São Paulo, Brazil) including a stadiometer with a capacity of 150kg, accurate to 100g, and a scale in millimeters, according to the standards recommended by the Food and Nutritional Surveillance System (SISVAN) ¹⁸18 . Ministério da Saúde. Vigilância Alimentar e Nutricional – SISVAN: orientações básicas para a coleta, processamento, análise de dados e informação em serviços de saúde. Brasília: Ministério da Saúde; 2004.. These measurements are used to calculate BMI [weight(kg)/height(m²)], classified by percentile criteria according to sex and age bracket as proposed by the World Health Organization (WHO) ¹⁹19 . World Health Organization. Growth reference data for 5-19 years. http://www.who.int/growthref/en/ (accessed on 20/Jun/2008).
http://www.who.int/growthref/en/... , which defines underweight as BMI < 3, normal weight as BMI ≥ 3 and ≤ 85, overweight as > 85 and ≤ 97, and obesity > 97, and numerically (continuous BMI).

Height measurement was classified according to height-for-age index, with low height defined as below the 3^rd percentile and adequate height as greater than or equal to the 3^rd percentile ¹⁹19 . World Health Organization. Growth reference data for 5-19 years. http://www.who.int/growthref/en/ (accessed on 20/Jun/2008).
http://www.who.int/growthref/en/... .

Family violence was assessed with two validated instruments that measured physical, verbal, and psychological abuse against the adolescents.

Verbal aggression and physical abuse were assessed using the Portuguese-language version of the Conflict Tactics Scales (CTS-1) ²⁰20 . Hasselmann MH, Reichenheim ME. Adaptação transcultural da versão em português da Conflict Tactics Scales Form R (CTS-1), usada para aferir violência no casal: equivalências semântica e de mensuração. Cad Saúde Pública 2003; 19:1083-93.. The study focused on relations between the parents (father and mother) and the adolescents. The scales for verbal aggression (items d, e, f, h, i, j), minor physical assault (items k, l, m), and serious physical assault (items n, o, p, q, r, s) were categorized as follows: had not occurred in the relationship versus had occurred at least once in the relationship ²¹21 . Straus MA, Gelles JR. Physical violence in American families: risk factors and adaptations to violence in 8,145 families. New Brunswick: Transaction Publishers; 1995.. The questions were addressed to cover the 12 months prior to the interview.

Psychological abuse was assessed using a Portuguese-language adaptation ²²22 . Avanci JQ, Assis SG, Santos NC, Oliveira RVC. Escala de violência psicológica contra adolescentes. Rev Saúde Pública 2005; 39:702-8. of the Psychological/Verbal Abuse Scale²³23 . Pitzner, JK, Drummond PD. The reliability and validity of empirically scaled instruments. J Psychosom Res 1997; 43:125-42.. The adapted scale consists of 18 closed items, with five possible answers: never, rarely, sometimes, almost always, and always, scored as 1, 2, 3, 4, and 5, respectively. The scoring was done by adding the scores for each item and dividing by the total points that each adolescent could score on the questionnaire, and multiplying by 100 to express percentage points. Presence or absence of psychological abuse was defined by the median in relation to the 18 items in the scale ²⁴24 . Assis SG, Avanci JQ, Santos NC, Malaquias JV, Oliveira RVC. Violência e representação social na adolescência no Brasil. Rev Panam Salud Pública 2004; 16:43-51.. A score greater than or equal to the median was defined as presence of psychological abuse.

Covariates included the adolescents’ following individual characteristics: age, sex, race/color (black vs. non-black), schooling, sexual maturation, and body image.

Sexual maturation was self-rated by viewing the Tanner table with photos corresponding to the five stages of pubertal development ²⁵25 . Tanner JM. Growth and maturation during adolescence. Nutr Rev 1981; 39:43-55..

Body image was obtained by self-assessment with five levels of satisfaction: very satisfied, satisfied, reasonably satisfied, dissatisfied, and very dissatisfied, using a scale covering specific body areas ²⁶26 . Conti MA. Imagem corporal e estado nutricional de estudantes de uma escola particular [Dissertação de Mestrado]. São Paulo: Faculdade de Saúde Pública, Universidade de São Paulo; 2002.. Body image classified for “all parts of the body” was dichotomized as satisfactory (combining very satisfied and satisfied) vs. unsatisfactory (combining reasonably satisfied, dissatisfied, and very dissatisfied).

Data storage and analysis used Epi Info 2000 (Centers for Disease Control and Prevention, Atlanta, USA). The means for the dependent variable (BMI) were compared to the covariates by sex using the Student t-test. Spearman’s correlation test was used to estimate the association between age and BMI.

Simple linear regression was used to analyze crude associations between the exposure and outcome variables. In the multivariate analysis, linear regression models were adjusted by the covariates that presented associations with p < 0.10 in the crude analyses. All the analyses were conducted separately for boys and girls, since the factors that affect BMI differ between the sexes in adolescents. Statistical significance was set at p < 0.05 in the multiple linear regression model.

The models were tested with Cook’s distance and showed good fit after excluding data points with a large influence on the results.

The study was approved by the Ethical Research Committee of the Rio de Janeiro Municipal Health Department (Ruling n. 122A/2007). The study only included adolescents that agreed to participate and who signed (together with their parents or guardians) the free and informed consent form authorizing their participation.

Results

The sample study consisted of 201 adolescents, including 110 girls (54.7%) and 91 boys (45.3%). As shown in Table 1, mean age was 12.9 years [standard deviation (SD) = 2.24]. The majority (71.6%) classified themselves as black, nearly all (92.4%) were enrolled in primary school, and more than 70% reported a satisfactory body image.

As for growth and development, most of the adolescents were in the final stage of sexual maturation, and the majority presented adequate height-for-age (96.5%). As for nutritional disorders, 18.4% showed excess weight (overweight and obesity), while only 4.5% were underweight. Obesity was three times more prevalent in girls, while underweight was four times more frequent in boys.

Table 2 shows the prevalence of family violence against the adolescents. Verbal abuse was the most frequently reported form of violence (n = 167, 83.1%) and was more common in girls (91.8%). Psychological abuse was also more frequent in girls (53.6%). As for physical violence, in general the rates decreased as the severity of the violent act increased. However, girls reported higher rates of minor physical abuse (51.8%), while boys reported more serious physical abuse (33%).

According to Table 3, the crude analyses between the variables and BMI showed statistically significant differences between mean BMI and race/color and age for both boys and girls. BMI increased with age in both girls (r = 0.678; p < 0.001) and boys (r = 0.475; p < 0.001). Adolescents that classified themselves as black showed higher mean BMI than non-blacks. In girls, the difference in mean BMI was also statistically significant according to sexual maturation (p < 0.001), body image (p < 0.001), and schooling (p = 0.019).

Table 4 shows the crude and adjusted results of the multivariate linear regression analysis for boys. Regardless of age and race/color, there was no significant association between the different types of abuse and BMI, but there was a reduction in BMI in adolescents who had suffered any type of violence (physical, psychological, or verbal abuse), although not statistically significant.

Meanwhile, for girls (Table 5), verbal abuse was significantly associated with BMI in both the crude and adjusted analyses, independently of age, race/color, schooling, body image, and sexual maturation. Girls showed an average increase of 2.064, 2.438, and 2.403 in BMI in the presence of maternal verbal abuse (p = 0.001), paternal verbal abuse (p = 0.003), and verbal abuse by both parents (p = 0.003), respectively.

Discussion

Anthropometry uses indicators such as BMI that associate weight and height, and has been widely applied in epidemiological studies for nutritional evaluation ²⁷27 . Veiga GV, Sichieri R. Avaliação nutricional de adolescentes. In: Kac G, Sichieri R, Petrucci D, organizadores. Epidemiologia nutricional, Rio de Janeiro: Editora Fiocruz/Editora Atheneu; 2007. p. 79-92.. BMI has been recommended as an anthropometric indicator for nutritional disorders in adolescence, despite the wide variation in this life phase due to age, sexual maturation, and growth ²⁸28 . World Health Organization. Physical status: the use and interpretation of anthropometry. Geneva: World Health Organization; 1995..

Unfavorable alterations in BMI can express excess weight (high BMI) or underweight (low BMI). Such nutritional states can indicate health problems ²⁹29 . Araujo F, Yamada AT, Markus MRP, Antelmi I, Latorre MRDO, Mansur AJ. Aumento do índice de massa corporal em relação a variáveis clínicas e laboratoriais quanto ao sexo em indivíduos sem evidência de cardiopatia. Arq Bras Cardiol 2007; 88:624-9. in childhood, adolescence, and adulthood ³⁰30 . Kelishadi, R. Childhood obesity today’s and tomorrow’s health challenge. Indian Pediatr 2008; 45:451-2..

According to the current study’s findings, verbal abuse of adolescents by parents was directly associated with BMI. Girls showed a mean increase of 2.064, 2.438, and 2.403 in BMI in the presence of maternal verbal abuse (p = 0.001), paternal verbal abuse (p = 0.003), and verbal abuse by both parents (p = 0.003), respectively, independently of age, race/color, schooling, body image, and sexual maturation. For boys, verbal abuse, physical abuse, and psychological abuse were associated with lower BMI (without statistical significance).

Little is known about the relationship between violence and its effect on nutritional status. The literature has suggested that victims of violence can present excess weight. The relationship is not clear, and authors have attempted to elucidate it by mechanisms that associate childhood trauma ³¹31 . Gustafson TB, Sarwer DB. Childhood sexual abuse and obesity. Obes Rev 2004; 5:129-35. and stress ¹³13 . Lohman BJ, Stewart S, Gundersen C, Garasky S, Eisenmann JC. Adolescent overweight and obesity: links to food insecurity and individual, maternal, and family stressors. J Adolesc Health 2009; 45:230-7. with obesity.

Individuals with a history of childhood abuse may adopt unhealthy eating behaviors as an attempt to cope with or compensate for the abusive acts ³¹31 . Gustafson TB, Sarwer DB. Childhood sexual abuse and obesity. Obes Rev 2004; 5:129-35.. In fact, trauma or stress can lead to withdrawal as a form of defense, leading in turn to a decrease in physical activity. Stressful experiences can also alter neuroendocrine responses related to increased activity in the hypothalamic-pituitary-adrenal axis, associated with constant cortisol hyper-secretion by the adrenal gland. All these mechanisms can trigger an energy imbalance and potentially favor obesity ¹³13 . Lohman BJ, Stewart S, Gundersen C, Garasky S, Eisenmann JC. Adolescent overweight and obesity: links to food insecurity and individual, maternal, and family stressors. J Adolesc Health 2009; 45:230-7..

Boynton-Jarret et al. ¹¹11 . Boynton-Jarrett R, Ryan LM, Berkman LF, Wright RJ. Cumulative violence exposure and self-rated health: longitudinal study of adolescents in the United States. Pediatrics 2008; 122:961-70. call attention to the limited understanding of the mechanisms by which violence leads to unfavorable health changes in the individual. Epidemiology defines determinants for the occurrence of a disease in social and biological terms that affect individuals over the course of life. Exposures to adverse situations in childhood and critical periods may have both latent and cumulative effects that negatively influence current and lifetime health outcomes.

There are no Brazilian studies to date that specifically relate family violence to nutritional status in adolescents, but some studies have attempted to explain the role of psychosocial factors in adolescents’ nutritional status. For example, stress has been proposed as a possible lifetime cause of nutritional disorders ¹³13 . Lohman BJ, Stewart S, Gundersen C, Garasky S, Eisenmann JC. Adolescent overweight and obesity: links to food insecurity and individual, maternal, and family stressors. J Adolesc Health 2009; 45:230-7.^,1414 . Nguyen-Rodriguez ST, Chou C, Unger JB, Spruejt-Metz D. BMI as a moderator of perceived stress and emotional eating in adolescents. Eat Behav 2008; 9:238-46.. The few studies on the specific issue of family violence and adolescents’ nutritional status have been published in other countries ¹²12 . Greenfield EA, Marks NF. Violence from parents in childhood and obesity in adulthood: using food in response to stress as a mediator of risk. Soc Sci Med 2009; 68:791-8.^,1313 . Lohman BJ, Stewart S, Gundersen C, Garasky S, Eisenmann JC. Adolescent overweight and obesity: links to food insecurity and individual, maternal, and family stressors. J Adolesc Health 2009; 45:230-7.^,1414 . Nguyen-Rodriguez ST, Chou C, Unger JB, Spruejt-Metz D. BMI as a moderator of perceived stress and emotional eating in adolescents. Eat Behav 2008; 9:238-46.^,3232 . Thomas C, Hypponen E, Power C. Obesity and type 2 diabetes risk in mid-adult life: the role of childhood adversity. Pediatrics 2008; 121:1240-9., and the results suggest that stressful experiences can lead to excess weight in both sexes. These results differ from the current study’s findings, since family violence was only associated with increased BMI in girls, suggesting a differential response to such trauma between male and female adolescents. Wisniewski & Chernausek ³³33 . Wisniewski AB, Chernausek SD. Gender in childhood obesity: family environment, hormones, and genes. Gend Med 2009; 6:76-85. mention that gender differences can occur in childhood and adolescence. Especially for adolescents, such differences can occur both before and during puberty. Various weight gain and body make-up patterns are observed, in addition to susceptibility to social and environmental factors that influence boys and girls differently.

According to some authors, among social factors, violence is related differently to health outcomes in males and females. As reported by Sundaram et al. ³⁴34 . Sundaram V, Helweg-Larsen K, Laursen B, Bjerregaard P. Physical violence, self-rated health, and morbidity: is gender significant for victimisation? J Epidemiol Community Health 2004; 58:65-70., there are probably gender differences in the way violence is experienced, in addition to different perceptions of health between men and women. While men tend to experience more lethal forms of violence, women show more significant associations between violence and negative health outcomes. Ditlevsen & Elklit ³⁵35 . Ditlevsen DN, Elklit A. The combined effect of gender and age on post-traumatic stress disorder: do men and women show differences in the lifespan distribution of the disorder? Ann Gen Psychiatry 2010; 9:32. suggest that gender differences may also be due to social expectations towards male and female gender roles. Society expects women to be more vulnerable and men to be tougher and more resistant to trauma. Stress may also be caused by different expectations in the various human life cycles, producing changes in neurobiological development due to different forms of exposure to trauma. Olofsson et al. ³⁶36 . Olofsson N, Lindqvist K, Shaw BA, Danielsson I. Long-term health consequences of violence exposure in adolescence: a 26-year prospective study. BMC Public Health 2012; 12:411. observed a difference between the sexes when studying exposure to violence and its long-term consequences in late adolescence and young adulthood. The authors found that young women with a history of violence showed a long-term association with negative health outcomes, while the same was not true for men.

Among the complex processes comprising stress pathways in childhood, family violence can lead to obesity, according to Greenfield & Marks ¹²12 . Greenfield EA, Marks NF. Violence from parents in childhood and obesity in adulthood: using food in response to stress as a mediator of risk. Soc Sci Med 2009; 68:791-8.. The latter authors report that individuals that suffer physical and psychological abuse from one or both parents show higher food consumption in response to stress and greater risk of obesity in adulthood. Their findings point to the need to consider the biological differences between individuals, since for some, exposure to violence can lead to greater food consumption and thus excess weight in childhood, adolescence, and adulthood.

Recently, some authors have reported findings that do not always suggest changes in nutritional status with the development of obesity. The results are conflicting as to the type of disorder – excess weight ¹⁵15 . Jun J, Corliss HL, Boynton-Jarret R, Spielgelman D, Austin SB, Wright RJ. Growing up in a domestic violence environment: relationship with developmental trajectories of body mass index during adolescence into young adulthood. J Epidemiol Community Health 2012; 66:629-35.^,3737 . Boynton-Jarrett R, Rosenberg L, Palmer JR, Boggs DA, Wise LA. Child and adolescent abuse in relation to obesity in adulthood: the Black Women’s Health Study. Pediatrics 2012; 130:245-53. and underweight ³⁸38 . Schneiderman JU, Mennen FE, Negriff S, Trickett PK. Overweight and obesity among maltreated young adolescents. Child Abuse Negl 2012; 36:370-8.^,3939 . Veldwijk J, Proper KI, Hoeven-Mulder HB, Bemelmans WJ. The prevalence of physical, sexual and mental abuse among adolescents and the association with BMI status. BMC Public Health 2012; 12:840. – and in relation to gender ¹⁵15 . Jun J, Corliss HL, Boynton-Jarret R, Spielgelman D, Austin SB, Wright RJ. Growing up in a domestic violence environment: relationship with developmental trajectories of body mass index during adolescence into young adulthood. J Epidemiol Community Health 2012; 66:629-35.^,3838 . Schneiderman JU, Mennen FE, Negriff S, Trickett PK. Overweight and obesity among maltreated young adolescents. Child Abuse Negl 2012; 36:370-8., type of abuse ³⁹39 . Veldwijk J, Proper KI, Hoeven-Mulder HB, Bemelmans WJ. The prevalence of physical, sexual and mental abuse among adolescents and the association with BMI status. BMC Public Health 2012; 12:840., and severity of trauma ³⁷37 . Boynton-Jarrett R, Rosenberg L, Palmer JR, Boggs DA, Wise LA. Child and adolescent abuse in relation to obesity in adulthood: the Black Women’s Health Study. Pediatrics 2012; 130:245-53..

Jun et al. ¹⁵15 . Jun J, Corliss HL, Boynton-Jarret R, Spielgelman D, Austin SB, Wright RJ. Growing up in a domestic violence environment: relationship with developmental trajectories of body mass index during adolescence into young adulthood. J Epidemiol Community Health 2012; 66:629-35. observed that a violent environment is associated with the development and maintenance of obesity in adolescents. The authors point to gender differences in the evolution of BMI. Strategies to deal with conflicts should thus take gender into account.

Boyonton-Jarret et al. ³⁷37 . Boynton-Jarrett R, Rosenberg L, Palmer JR, Boggs DA, Wise LA. Child and adolescent abuse in relation to obesity in adulthood: the Black Women’s Health Study. Pediatrics 2012; 130:245-53. showed a gradual association between the severity of abuse in childhood and adolescence and obesity in adulthood. The authors studied a prospective cohort of black women 21 to 69 years of age who had witnessed or experienced abuse in childhood and adolescence and found that higher frequency of abuse was associated with greater risk of developing excess weight in adulthood. The findings point to the impact of the severity of abuse on nutritional status, favoring obesity.

According to Veldwijk et al. ³⁹39 . Veldwijk J, Proper KI, Hoeven-Mulder HB, Bemelmans WJ. The prevalence of physical, sexual and mental abuse among adolescents and the association with BMI status. BMC Public Health 2012; 12:840., as BMI increased, adolescents showed higher rates of violence; 31% had suffered domestic violence. The authors also noted differences according to type of abuse, gender, and schooling. Their results point to a change in nutritional status both for underweight and excess weight among adolescents when gender was considered. These differences may result from defense mechanisms against the trauma such as distortions in eating behavior or weight gain or physiological changes that can develop differently between males and females.

Schneiderman et al. ³⁸38 . Schneiderman JU, Mennen FE, Negriff S, Trickett PK. Overweight and obesity among maltreated young adolescents. Child Abuse Negl 2012; 36:370-8. investigated whether violence is predictive of obesity in adolescents and observed that individuals in early adolescence with a history of abuse showed higher odds of obesity when compared to their non-abused peers. Considering gender in this association, they noted that only adolescent girls that were victims of sexual and physical abuse showed significantly lower odds of obesity as compared to non-abused girls. These findings show that the possible explanations for the relationship between violence and nutritional status do not necessarily lead to obesity.

Importantly, studies on this theme show methodological differences in their design (cross-sectional versus longitudinal) and techniques for taking anthropometric measurements and measuring family violence. Thus, it is not always possible to compare the results among the few existing studies.

In addition, the current study used a convenience sample consisting of individuals enrolled in the Bolsa Família Program, with similar socioeconomic characteristics. The program’s main prerequisites are low family income, regular school attendance, and proof of regular follow-up of the individual’s health by a health service. This type of sample, with homogeneous characteristics, differs from the other studies cited here, which can also limit comparison of the findings. It is thus important for future studies to focus on the association between family violence and nutritional status from a more comprehensive perspective, incorporating more representative samples of the population or adopting longitudinal study designs.

A single observation of nutritional status at a given time point (in adolescence) can mask possible manifestations of nutritional disorders that may affect these individuals over the course of their growth and development and persist into adulthood. The current study is thus not capable of inferring the temporal nature of the associations. In other words, does parental violence against the adolescent precede inadequate nutritional status, or does nutritional status interfere in interpersonal relations, making them more violent?

Meanwhile, the relationship between increased food intake and presence of stressful factors (emotional eating) is not a simple issue. Regardless of whether the individual’s nutritional status is adequate, compensatory strategies can be used or improved (eat less the following day, do more physical exercise), and there may be some individual protective characteristic that favors maintenance of adequate weight ¹⁴14 . Nguyen-Rodriguez ST, Chou C, Unger JB, Spruejt-Metz D. BMI as a moderator of perceived stress and emotional eating in adolescents. Eat Behav 2008; 9:238-46.. As described by Assis et al. ⁴⁰40 . Assis SG, Pesce RP, Avanci JQ. Resiliência: enfatizando a proteção dos adolescentes. Porto Alegre: Editora Artmed; 2006., in addition to family support, adolescents can draw on protective mechanisms such as individual capacity (autonomy, self-esteem, and affective and flexible temperament) and a favorable social environment (relationship with friends, partners, and school) that allow the young person to cope with an adverse situation (in other words, resilience). Such mechanisms may help some adolescents cope with family violence and possibly avoid obesity. More studies are needed to elucidate such compensatory mechanisms, with resilience as a potential target.

Importantly, the identification of violence as a stressor may help foster educational measures and healthy orientation for individuals treated at health services and elsewhere, including peer exchange and activities and a focus on adequate nutritional status in adolescents.

The debate on adverse health effects for adolescents should be promoted by health workers and teachers. Interdisciplinary actions with a broad scope should be implemented to help young people recognize and expose situations of violence and defend themselves.

Final remarks

According to the current study’s findings, adolescent girls showed higher BMI in the presence of verbal abuse from their parents. As for boys, no statistically significant difference was found in the relationship between BMI and family violence.

The study showed a high prevalence of verbal abuse in the family setting (83.1%). This observation may be useful when developing strategies to orient families on the harmful effects for adolescents’ health, including their nutritional status.

We believe that prospective approaches analyzing the adolescents’ nutritional status at different stages in life would lead to a better assessment of the consequences of family violence for their health.

Acknowledgments

The authors wish to thank the nutrition and social service team at the Hélio Pellegrino Polyclinic for their help, professionalism, and dedication in assisting the adolescent children of families enrolled in the Bolsa Família Program.

References

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