Obesity and Trauma: When the Body Cries OutNovember 10, 2017
Obesity is often referred to as an epidemic in the United States, and with good reason, as more than 1 in 3 American adults are classified as obese. Many of us sought out weight loss surgery to help with our obesity, as we tried many other methods prior to this, all failing miserably.
Often though, we look at the solution and not the cause. Weight loss surgery veterans will often tell people starting their journey that, “surgery doesn’t fix your brain - if you don’t change your habits you’ll stay obese or gain weight.” The best bariatric surgeons frequently repeat this mantra.
This should give everyone struggling with weight loss pause because if obesity is merely a physical state, this advice would be worthless. And yet, despite the fact behavioral issues are not always adequately addressed during the pre-operative process, in my clinical experience those patients most successful long-term over five years out have adhered to this maxim. Time and time again we see in individuals with significant regain, that there is often a driving factor which is behavioral or psychological, and not physiological.
But why is this the case, though? This question has alternatively haunted and driven me for years, during my graduate education in clinical psychology, and even before that as someone who was super morbidly obese. Looking back on my own experiences, I often wonder why I was driven down the path of super morbid obesity. What drives my compulsions to eat? Am I really lazy, or stupid, or weak-minded? Is it medical? Is it mental? Am I crazy? As is the case with many things in life that we want simple answers for, the truth is always more complex and deeply-layered than we want it to be.
Obesity and Trauma
I found one answer in particular that stuck out as we don’t talk about very often, either as counselors or as clients: trauma. I was intrigued, because even during my own treatment, and later clinical training when I was in recovery, this was not often discussed.
Before a detailed discussion of trauma as a cause of obesity, I want to point out that, naturally, not all obesity is caused by trauma, and certainly not all overweight people may have experienced it. Being overweight has many causes, and not all of them are rooted in illnesses—lipedema, for example. These are exceptions, as are many other circumstances.
Nonetheless, despite these other causes, trauma is often overlooked as a causative factor in bariatrics. Even when it is not, the psychological care and interventions both pre-operatively and post-operatively are often, I find, inadequate at best. Bariatrics programs in large research hospitals tend to be more pro-active in this regard, as they provide more integrative health care.
As for the programs that lack behavioral health integration, I find this odd, as it has been known for a very long time that it is a factor in eating disorders  and since a psychiatric professional must provide an assessment regardless, it seems prudent to further probe about trauma. Perhaps the answer lies in the way we describe and define trauma.
The Definition of Trauma
This may surprise the layperson, but when we visit the definition of trauma, it makes sense, as typically we define it as: "a state having been caused by an individual’s exposure to stressful events which deteriorate their personal sense of integrity and security."
Trauma makes us feel unsafe, and it also often makes us feel a loss of cohesion, as we struggle to integrate the emotions and severe stress we experience. Trauma can be sudden or ongoing—and it isn’t what we might expect that instigates it. For example, it can be caused by:
- Bullying or humiliation (either as a child or an adult).
- Chronic and intractable illness, whether chronic and lifelong, or terminal.
- Chronic mental health issues.
- Chronic physical pain.
- Doxing and online harassment.
- Emotional harassment, abuse, and neglect.
- Sexual assault.
- Domestic violence.
- Having a minority status, such as people of color or LGBTQ individuals.
- Experiencing severe disappointment.
- Failure to do something that was anticipated.
- Living in severe poverty.
- Living in a dangerous neighborhood
- Natural disasters.
- The death, sudden or expected, of a loved one.
- Surgery, both planned and unexpected.
- Secondary trauma that occurs witnessing, or hearing about, the trauma of others.
Pain is Relative to Each of Us
Many of these we might not expect as patients. Even as clinicians sometimes we overlook them despite our training. Further complicating matters, individuals all have different levels of resiliency.
Just because we survive one of these situations does not mean we become traumatized. We can guess what will result in trauma, but we cannot predict it universally. Not everyone goes through these experiences and winds up with PTSD or an eating disorder. Our individual responses to these events are wide and varied.
It is vital to acknowledge this because it helps us to maintain empathy towards others. Even if someone has gone through far less than I, it may actually be more traumatic for them. Pain is relative to each of us. For some, these experiences can cripple them psychologically for life.
This ties into obesity, because as anyone who’s been obese will tell you, it is very easy to be misunderstood. In fact, the act of being obese can be traumatic in and of itself, creating a vicious cycle which causes more psychological pain, and also possibly increases our weight as we struggle with food in the wake of our suffering.
Typically, when trauma results in obesity, this is a result of what we call emotional dysregulation. In order to survive and overcome the trauma, our minds do whatever is needed. The human psyche is tenacious. Even if we may not feel like when we survive these experiences, this tenacity causes our cognition and behavior to change. Pain alters how we think, and it changes how we see ourselves and the world.
These changes just aren’t psychological—experiences actually rewrite the web of neurons in our brains, altering our anatomy. This is called neural plasticity. The brain constantly rewrites itself.
Regarding obesity and trauma, two of the systems implicated in possible pathology that leads to obesity are the limbic system and the hypothalamic-pituitary-adrenal (HPA) axis.
Fear is hardwired into the brain. We need fear to survive. This may sound odd, but fear actually protects us from things that will kill us by flooding us with a response to avoid, and flee, if necessary. This helps circumvent dangerous stimulus. With trauma, this switch gets broken for some people, and it starts to be activated outside of appropriate situations. When fear becomes a constant companion it wears us down.
Anxiety is very physical. The body is in a constant state of wariness, and this drains us emotionally and physically. In response, we develop skills or habits to deal with this fear. Some people will go for a walk. Others will listen to music. Some of us develop negative habits—drinking alcohol, self-harm, compulsive shopping, overeating, or undereating.
Being Overwhelmed by Fear
This loss of control is a significant factor in being overwhelmed by fear, and often we will experience this after assault or abuse. To re-establish our mental equilibrium, we again do this by any means necessary. One of these means is eating. Eating, for someone with binge eating disorder, re-establishes control, however briefly. Eating gives us stability and comfort.
Survivors of trauma are prone to developing addictions for similar reasons. The HPA axis is indicated and our pleasure centers are rewired.
We are wired to be drawn to the pleasurable, and the tasty, because they are advantageous for survival, normally. When we eat hyper-palatable foods, the reward system of the brain can be engaged. This is a powerful and unconscious system that deeply affect us. We actually need our reward system to survive—we must learn what is poisonous and what is safe.
Thus, this actually fuels survival and helps us avoid danger, by acclimating our taste and senses. It lets us know what is pleasant and safe, and what is harmful and painful. Pleasant experiences and stimuli are reinforced, while negative experiences and stimuli cause us to be avoidant. In theory, this means that we gravitate towards non-harmful things (such as healthy food), and veer away from poisonous or toxic items.
The Age of Engineered Food and Drugs
Unfortunately, we also live in an era where we have artificially engineered food and drugs which affect this response system in ways we did not evolve to adapt to. Our ancestors did not have opioids thousands of times stronger than their natural counterparts, or highly palatable foods which provide a strong response in the brain. High fat and high sugar foods were also not widely available until the 20th century. These, coupled with trauma, are a dangerous combination for some of us. They can cause addiction, eating disorders, or obesity.
While the causative factors between obesity and trauma are still being researched and explored, we do know a few things. We know that food can trigger this reward response mechanism which many drugs and alcohol also set off.
Addictive properties of food are a minimal factor. A far bigger one is that we know that powerful hormones, known as glucocorticoids, are secreted by the brain during times of stress. You may have heard of the most powerful one: cortisol.
Cortisol is involved in glucose metabolism, and its presence alters it. Normally this has a beneficial function, as when we experience danger, we need extra resources, physically and mentally, to get out of it. Trauma causes extended periods of stress, though, and so cortisol levels can be high for a prolonged period of time.
The Effects of Cortisol
Along with adrenaline, cortisol affects the amygdala, hippocampus, and the frontal lobes of the brain. It helps reinforce memories that occur paired with strong emotions. These are called flashbulb memories, and are very detailed and saturated with emotion. They can be positive or negative.
The problem is that in the case of trauma, these memories become aversive and we can relieve them over and over. In order to halt these memories, we turn to the skills we learned to survive when we first lived through these experiences. Often they are maladaptive, meaning they hurt us when we are healthy even though they helped us at the time we needed them, and they can disrupt relationships with people or substances.
Consider that many people, WLS patients or not, engage in eating during stress to feel better. In particular, individuals with trauma histories may eat to cope with the fear and anxiety they feel during similar situations more frequently than the average person just eating to “feel better.”
There is a big difference between eating your grandmother’s macaroni and cheese once a month when you had a bad day at work, and sitting to eat several pounds of food because you can’t cope with the shame or guilt you feel by how you were treated. Unaddressed, this can evolve into disordered eating, or even an eating disorder, down the road.
This is vital when it comes to weight loss surgery because it can vastly distort or change our outcomes. There is a great variation when it comes to behavioral health interventions pre-operatively. Many of us do not necessarily get the counseling we need. As the field moves further into the realm of more integrated healthcare this will hopefully change. It means that fewer of us will fall through the cracks.
Experienced Trauma and Weight Loss Surgery
What does this mean if you are someone who has experienced trauma who wants to get weight loss surgery? That you must be honest about your trauma, to yourself most of all, and to your providers. Seeking out counseling whether the bariatric program tells you to or not is an absolute must. It will provide support during the surgical process, and it will also help you begin to untangle the web that once led you to where you are now. If nothing else, it will help you deal with the pain the past has written in your psyche - a pain many of us have, but that few of us are willing to discuss. Healing, and being a whole and integrated person is the ultimate desired outcome of weight loss surgery.
Trauma is not a component for all of us, but for some of us, it may be the most vital piece of the whole we must sort out and resolve to make progress.
The truth is that, for many of us, we must break a broken bone before it can be reset. It is no different when it comes to trauma and obesity. Exploring the pain of what happened to us is vital for us to move forward.
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ABOUT THE AUTHORDonna Lordi, MA, is a counselor in the state of Illinois. Donna graduated from Lewis University with a Master’s in Counseling Psychology, and she has additional certification in working with children and adolescents. Donna is also a contributing author for the book Hooking Up: The Psychology of Sex and Dating by Dr. Katherine Helm, PhD.
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