RobardUser Robard Corporation | June 2018

The Convergence of Depression, Trauma, and Obesity



Long before I was a Board Certified Family Medicine physician involved with Obesity Medicine, I was a Teaching Fellow and Performing Arts Consultant working for the Kennedy Center for the Performing Arts in their Very Special Arts Program. I had an assignment to travel to a remote and rural area of Vermont to do a week long workshop for a local school district, working with classroom teachers, physical education teachers and administrators on how to integrate dance into the classroom and how to integrate movement into the academic curriculum.

On touring this small town, population under 3,000, I was initially struck by the quiet beauty of the area and then quite literally by the size and body habitus of the population. Everywhere I looked it seemed that people, children and adults were incredibly large, with round faces and protuberant bellies hanging over their belts — those who could wear belts, that is; many were simply wearing pants with elasticized waist bands.

The next day at the school a teacher remarked to me that most of the kids in her classroom were extremely overweight and depressed, unable to concentrate. She remarked that most of them got that way because in this community there was a high incidence of alcoholism, domestic and sexual violence. It had become almost a cultural custom: “Protect your kids from the predator (usually in your own home) by making them fat, ugly, and hence unappealing. Fat boys and girls were not the ones who got raped, beaten or otherwise abused in this small community.”

The school had specifically wanted workshops and teacher training for their staff that included dance in the hopes that it would inspire the student population to get motivated to move and that the creative aspect of dance arts would inspire their souls. In his book, The Body Keeps the Score, Bessel Van Der Kolk, M.D., describes that one avenue toward healing trauma is to let the body have experiences that deeply and viscerally contradict the helplessness, rage, or collapse that results from trauma.

In her recently published book, Hunger: A Memoir of (My) Body, New York  Times bestselling author, Roxane Gay, writes about how her path to morbid obesity, self-loathing, despair, desperation and depression was precipitated by a gang rape at the hands of a school mate and his friends. Like the youth of the rural town in Vermont, Gay writes, “I was swallowing my secrets and making my body expand and explode. I found ways to hide in plain sight, to keep feeding a hunger that could never be satisfied — the hunger to stop hurting. I made myself bigger. I made myself safer.”

Many years later I would come to learn that the trauma was often the common denominator lurking behind the twin symptoms of depression and obesity. I would also learn that sometimes the obesity came first and that mental and emotional collapse would follow years later as a person struggled throughout their lifetime within a culture that tends toward cruelty, intolerance and indifference towards people living with larger bodies.

Everyday across all medical specialties, physicians see people living with obesity. At the very least, I would encourage all of our colleagues to fine tune their listening skills when taking the history of their patient and to use available tools to assess for depression, anxiety, and domestic violence — regardless of why the patient has initially sought out the visit. When there are any signs of depression, mood disorder, or mental illness, refer the patient to an Obesity Medicine Specialist whose four cornerstones of treatment are: Nutrition, Physical Activity, Medication, and Behavior. If the patient is in need of further support or treatment for psychosis, the Obesity Medicine specialist can also supply the appropriate referral to Psychiatry. With the appropriate continuum of care the result can be an engaged patient in a healing partnership that can change the outcomes of our system of providing healthcare.

Behavior change and extensive patient education materials are interwoven into all of Robard’s medially-supervised weight loss programs. If you’re a medical provider and would like more information, click here.

About the Author: Dr. Carol Penn is a physician with Medimorphosis and Ocean Health Initiatives as well as lead consultant with in AllOne Consulting Group in New Jersey, and Medical Correspondent for WURD Radio in Philadelphia, PA.  She is Board Certified in Family Medicine and Osteopathic Manipulative Treatment, Ambassador and Scholar, National Health Service Corps, Associate Clinical Professor, Rowan University School of Osteopathic Medicine; Faculty, Center for Mind Body Medicine; Certified Health, Wellness, and Fitness Coach and Founder/Director of Core of Fire Interfaith Dance Ministry.

References: The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, Bessel Van Der Kolkata, MD; Hunger: A Memoir of My Body, Roxane Gay.


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Patients’ Health Not Improving? It’s Why I Treat Obesity



I think we are at a crossroads in medicine right now. Imagine the perfect storm. Life expectancy is decreasing for the first time in generations. Public health measures have gotten a hold of cigarette smoking only to have obesity rise up and surpass it as the leading cause of preventable death. Major attempts at curbing obesity and diabetes have failed. The final data on Healthy People 2010 outcomes showed obesity and overweight individuals worsened over the measured period. At the same time, health care costs are high, outcomes are poor, and there is a scourge of physician and provider burnout — there’s even a shortage in some areas.

Is this a coincidence? I can still practically taste my frustration of seeing my patients get worse and worse every three months when I saw them. Their blood sugar, blood pressure, and cholesterol got just a little worse each time. Heartburn, reflux, sleep apnea, depression, etc., would creep up on them. The medication list, the problem list, the referral list, the order list, all got longer and longer. The patients kept saying the same thing, “I want to get better.” I would manage their numbers effectively, for the most part. Their “ABCs” of diabetes met my quality goals for my bonus. But they did not “feel” better — they felt worse, and so did I. Was this why I went to medical school? I did not feel I was healing anyone; rather, I was only managing numbers with pharmacology. Something had to change.

When I first started offering obesity counseling, it was based on a Mediterranean type diet and food exchange. I started to see some exciting trends in blood sugar, blood pressure, and weight, as you would expect. I did not expect to see the changes I saw in the patients themselves. They became more engaged and optimistic about their health. For some patients, this program was all they needed. But, for many people farther on the spectrum of obesity, it was only the beginning.

That was when I quit my safe and secure position at a large health system and opened my own practice based on the program offered by Robard. And that was when the really exciting results started happening. That was June 2015.

At first, it was the ones who already knew me from primary care who trickled in. Then, it was their friends, families, coworkers, kid’s teachers, and anyone who saw them. Word got around, and the floodgates opened. They all said the same thing. The program gave them hope and then gave them their life back. They wished they had had it sooner. They wished they had known it was out there. They wished their doctor had told them about it. They wished more people could hear of it.

Since then, I have opened a second clinic and the patients have lost a combined total of 29,572 pounds. They report the program is the easiest diet they have ever done, most of them enjoy the taste of the medical foods and would like to be reassured that they will still be allowed to have one for breakfast or lunch once they reach their goal weight. They typically report that taking food away for a period made a huge difference in the role that food plays in their life, their relationship with food, their eating habits, and their cravings. I have learned that taking food away is one of the most important behavioral aspects of the program, even if only for a month. Since food can be addictive for some people, taking it away completely can be crucial for long term change, which is the opposite effect that you may be warned about by some critics of a short term rapid weight loss program that is “unsustainable.”

When patients come in the first time, they are sick and tired of feeling sick and tired. They have a hard time making it through the day, let alone going to the gym after work. I tell them casually not to worry, after the first 40 pounds comes off, they will feel much more like being active, they look at me like I am crazy. When I tell them that they will most likely not need any insulin after four weeks, they burst into a smile. When I tell them that after all the dozens of diets they have tried, with cabbage and lemons and meal prepping, all they have to do is drink a shake every four hours and the weight will come off, and they can go on with their lives of caring for their kids, parents, sick spouses and full time job, they are truly relieved.

And, for me, I now know why I went to medical school. Obesity is like lupus. It does involve every system in the body. You do have to treat the whole patient for the best outcomes.

So, for me, I honestly had some selfish goals. I wanted to feel purposeful and like I was making a difference. I mean, I get to cure diabetes, taking people off of 150 units of insulin who had been told they would be on it for the rest of their lives, freeing them from over one hundred shots of insulin a month. It is like curing cancer or chronic pain. Now, the biggest problem with my work is that I am so busy and I can’t seem to tell anyone “no” because I know the results they will get and they cannot get similar treatment anywhere else — at least at this point. So, I am working longer hours, but I love every minute of it, and at least I am not a helicopter parent and I hope my kids are learning “grit” and determination and non-normative gender roles by observation, but that is another talk.

So, I implore you to take bold action. In the name of decreasing life expectancy, plummeting quality of life, astronomical health care costs, physician burnout and sell out, turn away from the focus on HEDIS measures, patient satisfaction, quality bonuses, resource allocation and meaningful use. Before we turn into Wally World, stop missing the forest for the trees. Be the little boy who called out the Emperor’s New Clothes. Choose the path less traveled, operate at the sharp end of the sword, do what no one else can without those initials after their name can do, and fix the underlying problem.


 

Editor’s Note: This post was originally published in October 2017 and has been updated for freshness, accuracy, and comprehensiveness.


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