It’s been three and half years since my family and I moved back to the USA, where I hoped to put my UK training and experience into immediate practice in Washington DC. It’s no exaggeration to say that this country is screaming out for for preventive care. Of the 11 countries evaluated by The Commonwealth Fund it ranked last in 2017. Reports are compiled every three years with a new one is due this year. The USA also currently ranks 37 in the world, nestled between Costa Rica and Slovenia, and way below the UK, which ranks significantly better at 18, (in close company with the Netherlands and Ireland) – thank you NHS! But no Government can afford to rest on its laurels when it comes to healthcare, and not just because of an increasing ageing population. Our children are suffering too. American children overall are eating a poor diet and more than 13.7 million of them are obese. American babies are 76% more likely than babies in other wealthy nations to die in their first year of life. Armed with this knowledge I was keen to start work.
But my good intentions were thrown a curveball by a series of unforeseen events that eventually come crashing into all of our lives one way or another and consign us to a form of hell on earth. If it hasn’t happened to you yet, it will. It’s called being human – and knowing it’s coming sooner or later is no help either.
More headaches (metaphorical and literal) followed. Trying to register as a Nutritional Therapist from the UK meant I had to deal with petty, mindless bureaucracy, ineptitude and apathy, as well as ridiculously slow communication by the relevant authorities (7 months to reply to a letter). I was expected to pay exorbitant costs to retrain (as a dietitian, mind you) or just study at my own expense and then pay (of course) to sit the (dietitian) exam. I explained that if I had wanted to be a dietitian I’d have trained in dietetics in the first place, not nutrition. (Is there a difference? Yes, and I’ll write about that in a future blog). I was frustrated; two science degrees, excellent references and 3 years of clinical practice under my belt wasn’t enough. It’s not like I wanted to wield a scalpel or prescribe drugs … I just wanted to help people eat better. The final straw came in a bizarrely specific Act of God when a basement flood completely destroyed all my notes and files on nutrition. Nothing else was damaged by the deluge.
I finally got the message: take stock – readjust – roll with the punches.
The decision was made one sunny spring day while out walking with my son and husband; I’d learn silversmithing. At first, I felt like I’d caved – was I giving up? Doubts haunted me. But hindsight is a valuable friend. I wouldn’t have had the stamina to give my best to therapy work back then. I kept up with my CPD (continuing professional development) but stepped back from seeing patients. Learning new practical and creative skills challenged me in all the right ways and gave me some space and clarity.
In the caring professions we are constantly reminded by our mentors to take care of ourselves before taking care of the needs of others. Who wants a burnt-out nurse, a stressed doctor, a psychologist on the edge of a breakdown? They can’t give their best, though to their credit, many still try, and manage to work wonders. The problem is that most of us (I’m being an optimist) are in these professions not just to make a living, but because helping others makes us feel good too.
I’ve thought about my patients many times over these past few years. Recalling their stories and re-reading my reflective notes, was more supportive during this time than I – or they – could ever have imagined. A majority of them had taken back control of their lives – and health – after they had been floored, and I remembered feeling humbled by their resilience, patience, and self- belief at the time.
Some of them had experienced a personal bombshell prior to a major illness, and had already made that connection. Not all did though, even when the timing showed astounding synchronicity. And sometimes there’s no connection to make.
All of my patients fill out a lengthy health history questionnaire. This allows me to pinpoint the times in their lives when illnesses struck. In the first 90min session I refer to this timeline when asking about any severe emotional upheavals they’ve been through. Any health ‘whiteouts’ that may (note, MAY) be associated with trauma or acute bouts of stress, grief, sadness etc. tend to pop up like beacons. I admit it’s a crude and laborious tool that would never pass muster as ‘serious scientific investigation’ (way too many variables). But it costs nothing and has proven really useful.
Science begins with observation, so here’s what I observed. Stress related flare ups of gut or skin conditions, as well as dramatic weight changes. Headaches, infertility, symptoms of OCD, mood swings, immune disorders … the list goes on, and all too often alongside these health issues on the timeline were episodes of profound sadness, loss, depression, fear, stress, anxiety. The patterns mirrored those being observed in recent research. There were other examples …
The middle aged man with a suboptimal diet may well have been courting a heart attack for years, but its timing closely followed the death of his wife. A vibrant young woman’s disabling PTSD was likely related to unavoidable trauma in her demanding work in the emergency services, but we both had little doubt it was severely exacerbated by the misogynistic bullying she endured in the primarily male workforce. Thyroid imbalances are common in peri-menopausal women, but all of my patients so afflicted presented with anxiety, stress, or loss of life purpose caused by marital discord, career burnout or years of stressful therapy for other health conditions. Breast cancer was often accompanied by deep rooted sadness, in at least three cases following the breakdown of a primary relationship, and in two cases, spousal abuse. One patient believed her child’s autism was associated with her cripplingly stressful pregnancy that, again, involved physical and mental spousal abuse, as well as the distress caused by racism and lack of emotional support at the hands of her health carers. Cases of Type 2 diabetes popped up suddenly in otherwise healthy people after a major shock. For one middle aged man, it surfaced six months after the tragic death of his only child. A much younger man succumbed to the same disease a few weeks after the death of his father, and hot on the heels of a messy break-up with his long-term girlfriend. People with eating disorders invariably had histories of parental conflict that engendered feelings of inadequacy or a loss of meaning in life (sometimes not recognised until much later on). The list goes on.
Of course, all of these stories are anecdotal; causality cannot be proven. But that doesn’t stop the patients themselves wondering, and it’s my job to listen.
We already know that depression and stress impact health physiologically, emotionally and behaviourally, so we must keep looking.
There has been an explosion of research focusing on psychological wellbeing and disease in the past 10 years. Most of the research doesn’t make headline news. Maybe because there’s already an assumption that a mind-body connection exists, or maybe because its considered too woolly to be “real science”. Too bad, because assuming this connection, or just ignoring it, will not change public health policy. Providing evidence will.
An increased understanding of stress and its impact on epigenetics is a case in point. Molecular mechanisms that explain how stress impacts the progression of cancer and diabetes are being discovered. A correlation between breast cancer and grief hasn’t yet been proven, but it is now being taken seriously. The timing of stressors in pregnancy and links with autism is an active field of research, as is the focus on placental susceptibility to maternal distress and its impact on epigenetic dysregulation. Longterm perceived wellbeing of cardiac arrest survivors is strongly associated with depressive symptoms – psycho-cardiology now being a recognised discipline, developed from a pressing need to better understand the connection between mind and heart.
I’ve linked to just a few studies, but research abounds.
The crucial importance of the mind in the paradigm shift towards Personalised and Lifestyle Medicine is already understood, we’re just filling in the details with more research on specific diseases.
I had the privilege of meeting some unforgettable people who revealed to me in practice what I was reading about in theory.
They reminded me that the lessons and challenges we face as individuals may be unique, but we are all part of a whole. We need each other – more than we sometimes know.
You know who you are – thank you!
References:
How Bad Is U.S. Health Care? Among High-Income Nations, It’s The Worst, Study Says https://www.newsweek.com/united-states-health-care-rated-worst-637114
Best Healthcare in the World 2020 http://worldpopulationreview.com/countries/best-healthcare-in-the-world/#dataTable
Diet quality in a nationally representative sample of American children by sociodemographic characteristics https://academic.oup.com/ajcn/article/109/1/127/5266900
Prevalence of Childhood Obesity in the United States https://www.cdc.gov/obesity/data/childhood.html
American babies are 76 percent more likely to die in their first year than babies in other rich countrieshttps://www.washingtonpost.com/news/wonk/wp/2018/01/09/american-babies-are-76-percent-more-likely-to-die-in-their-first-year-than-babies-in-other-rich-countries/
Consequences of Repression of Emotion: Physical Health, Mental Health and General Well Beinghttps://openaccesspub.org/ijpr/article/999
https://www.mentalhealth.org.uk/a-to-z/d/depression
https://www.mentalhealth.org.uk/a-to-z/s/stress
Epigenetic Regulation of the Social Brain https://www.sciencedirect.com/science/article/abs/pii/S0166223619300566
The Influence of Psychological Stress on the Initiation and Progression of Diabetes and Cancer https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628619/
Breast cancer: Is grief a risk factor? (de Paula et al, 2018) http://www.scielo.br/scielo.php?pid=S0104-42302018000700595&script=sci_arttext
Timing of Prenatal Stressors and Autism https://link.springer.com/article/10.1007/s10803-005-5037-8
Linking prenatal maternal adversity to developmental outcomes in infants: The role of epigenetic pathways https://www.cambridge.org/core/journals/development-and-psychopathology/article/linking-prenatal-maternal-adversity-to-developmental-outcomes-in-infants-the-role-of-epigenetic-pathways/7A665C6DA3A9E546569DE80CA804C5A7
The impact of psychological distress on long-term recovery perceptions in survivors of cardiac arresthttps://www.sciencedirect.com/science/article/abs/pii/S0883944118313844
Psycho-cardiology https://link.springer.com/chapter/10.1007/978-3-030-27080-3_12
Transgenerational impact of intimate partner violence on methylation in the promoter of the glucocorticoid receptor. https://www.nature.com/articles/tp201121
Prenatal Exposure to Maternal Depressed Mood and the MTHFR C677T Variant Affect SLC6A4 Methylation in Infants at Birth https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0012201
Exposure to Prenatal Psychobiological Stress Exerts Programming Influences on the Mother and Her Fetus https://www.karger.com/Article/Abstract/327017
Prenatal maternal stress predicts autism traits in 6½ year-old children: Project Ice Storm https://www.sciencedirect.com/science/article/abs/pii/S016517811400331X
Prenatal environmental exposures, epigenetics, and disease https://www.sciencedirect.com/science/article/pii/S0890623811000025
Epigenetics, maternal prenatal psychosocial stress, and infant mental health https://www.sciencedirect.com/science/article/abs/pii/S0883941718303297
The Role of Psychoneuroimmunology in Personalized and Systems Medicine https://link.springer.com/protocol/10.1007/978-1-62703-071-7_1
Lifestyle medicine – An evidence based approach to nutrition, sleep, physical activity, and stress management on health and chronic illness https://www.sciencedirect.com/science/article/abs/pii/S2186495019300173