Post-traumatic stress disorder (PTSD) is a debilitating mental disorder that occurs following a trauma, with lifetime prevalence rates reaching up to 30% in US Vietnam War veterans. Obesity is a major epidemic, defined as a body mass index (BMI) ≥ 30 (kg/m2) in adults and a BMI above the 95th percentile for children. Research demonstrates that individuals with PTSD have a predisposition to obesity. This article explores the intricate relationship between PTSD and obesity, examining the underlying mechanisms and potential interventions.
Understanding PTSD and Obesity
Post-Traumatic Stress Disorder (PTSD)
Post-traumatic stress disorder is a severe mental health condition caused by witnessing or being involved in a terrifying, dangerous, or life-threatening event. It can manifest from a singular event or develop as complex trauma from ongoing traumatic experiences like physical, emotional, or sexual abuse. Symptoms of PTSD include nightmares, flashbacks, negative beliefs about oneself, profound guilt or shame, and avoidance of trauma-related stimuli. Women are twice as likely as men to develop PTSD, possibly related to the increased likelihood of women experiencing traumatic events such as child abuse and sexual assault.
Obesity as a Major Epidemic
Obesity is defined as a body mass index (BMI) ≥ 30 (kg/m2) in adults and a BMI above the 95th percentile for children. Around one-third of adults and 17% of youths were considered obese in 2009-2010. In the United States, the prevalence of obesity is similar in men and women. Obesity and its associated metabolic problems are increasing in prevalence and pose a tremendous threat to human health nationally and worldwide. Approximately a third of the US population is obese, another third overweight, and a quarter of the population have metabolic syndrome.
The Bidirectional Relationship
Research indicates a bidirectional relationship between PTSD and obesity. Obese individuals may be predisposed to developing PTSD after trauma exposure, and those with PTSD are more likely to develop obesity. One study found that obese individuals who lost weight had a parallel decrease in PTSD symptoms.
PTSD as a Risk Factor for Obesity
An increasing number of studies have shown that PTSD symptoms are associated with obesity and metabolic syndrome, particularly in veterans. PTSD has been associated with mortality related to heart disease. Patients with PTSD are more likely to have an increased risk of developing obesity and cardiovascular illnesses due to poor health habits, including substance abuse and lack of exercise. A study involving returning veterans from Iran and Afghanistan found many to be overweight and obese.
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Obesity and Trauma Exposure
In addition to combat veterans, women and children are frequently exposed to trauma and abuse and are at risk for developing PTSD. PTSD has been shown to have significant correlations with increased BMI, central adiposity, and waist-to-hip ratio in US civilian women with PTSD related to childhood traumatic stress.
Common Pathogenic Pathways
Several pathogenic pathways are common to both PTSD and obesity, including inflammation, the renin-angiotensin-aldosterone system, cellular structures, and neuroendocrine activation.
Inflammation
Obesity has been shown to be associated with increased markers of inflammation. Overweight people tend to have increased levels of interleukin-6 (IL-6) and C-reactive protein (CRP), which are considered markers of inflammation associated with cardiovascular risk factors. Adipose tissue is known to produce IL-6.
Renin-Angiotensin-Aldosterone System (RAAS)
In addition to the classic renal renin-angiotensin-aldosterone system (RAAS), studies have shown that adipose tissue harbors its own local RAAS endocrine pathway. The RAAS is an important regulator of blood pressure. Adipose tissue locally generates angiotensin II from angiotensinogen, which is now known to be present in adipose tissue, and has additional local effects.
Cellular Structures
Studies indicate an association of both PTSD and obesity with shortened telomere length. Telomeres, tandem repeats of hexamers found at the ends of chromosomes, protect against spontaneous DNA damage and preserve genomic integrity. Mitochondrial dysfunction has similarly been associated with obesity and PTSD. Mitochondria are cellular organelles that play a central role in adenosine triphosphatase production, energy expenditure, and the disposal of reactive oxygen species (ROS).
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Neuroendocrine Activation
The link between glucocorticoids and obesity has been well-studied. PTSD symptoms also have been linked to increased cortisol levels. Glucocorticoids, the body’s "stress hormones," are key regulatory agents of energy and are responsible for releasing high-energy compounds (fatty acids and glycerol) from adipocytes when the body requires them, including during periods of fasting or exercise.
Neural and Cognitive Changes in PTSD and Obesity
One possible mechanism underlying PTSD-associated obesity may be through neural changes known to occur in PTSD that may lead to altered cognitive/central control of feeding behaviors and thus, obesity. Studies examining functional brain changes in PTSD have implicated areas that overlap with food-related brain areas, such as the inferior frontal, insular, and parietal regions. These areas are also involved in food image processing and the control of eating behaviors.
Cognition is also altered in PTSD, which may lead to altered consumptive behaviors. Structural brain differences in the hippocampus and amygdala correlate with the severity of PTSD symptoms. Verbal memory impairments, particularly autobiographical memory, are consistently found in PTSD. These altered neural and cognitive changes, along with the association of PTSD with obesity, may suggest altered consumptive behaviors, such as increased eating of foods with high calorie content.
Appetite Hormones and Inflammatory Markers
Another potential modulator of the interactions between PTSD and obesity may be through altered control of appetite hormones, such as adipokines and certain cytokines. Disruptions in the hypothalamic-pituitary-adrenal axis and increased sympathetic nervous system activity may lead to PTSD-associated metabolic and cardiovascular disorders.
Leptin, a key adipokine regulating food intake, is increased in patients with PTSD. Neuropeptide Y (NPY), a hormone that regulates feeding behaviors in the hypothalamus and reduces stress more globally, is consistently lower in individuals with PTSD. PTSD also appears to affect inflammatory markers, such as IL-6 and CRP, although the link between CRP and PTSD needs to be better defined.
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The Impact of PTSD on Eating Habits
PTSD and its accompanying symptoms can negatively affect eating habits and patterns. Traumatic experiences can disturb the nervous system’s functioning, leading to emotional regulation issues. In an attempt to regulate emotions, individuals may turn to disordered eating behaviors, such as binging, purging, or restricting. Trauma may also cause negative body image or body dissatisfaction, increasing the risk of engaging in disordered eating behaviors.
PTSD and Eating Disorders
There is a significant relationship between PTSD and eating disorders, especially bulimia nervosa. Experts theorize that eating disorders and PTSD share similar genetic and biological overlapping factors that increase the chance of comorbidity. Research has revealed that many types of trauma can increase the risk of an eating disorder diagnosis, such as sexual assault, emotional and physical neglect, bullying, and physical abuse.
Managing Eating Patterns
If you struggle with PTSD and a co-occurring eating disorder, you may benefit from some tips on managing your eating patterns and developing a balanced relationship with food:
- Keep a journal of your triggers and coping skills.
- Cut back on caffeine, which can increase stress and anxiety.
- Learn and practice mindfulness to cope with distressing emotions.
- Practice self-care.
- Create a gratitude practice.
- Learn distress tolerance strategies.
- Practice body neutrality or body positivity.
- Build and foster a healthy support network.
- Ask for help when you need it.
- View food as fuel for your body.
Treatment Approaches
Treating co-occurring PTSD and an eating disorder requires integrated, trauma-informed care that fully addresses both conditions and how they influence and interact with each other. Therapies to treat eating disorders and PTSD include:
- Prolonged exposure therapy
- Eye movement desensitization and reprocessing (EMDR)
- Cognitive processing therapy
- Interpersonal psychotherapy
- Cognitive behavioral therapy
- Acceptance and commitment therapy
The Role of Weight Loss Programs
Large improvements in PTSD are associated with increased utilization of weight loss programs, and PTSD is not a barrier to seeking weight loss counseling. Patients with a clinically meaningful decrease in PTSD symptoms were more likely to use a weight loss program. Completing PTSD treatment has been associated with improved self-reported health, improved sleep, lower blood pressure, improved depression, decreased risk for type 2 diabetes, less mental health services use, and increased self-efficacy.
Exercise as an Intervention
Evidence suggests that PTSD may function as a risk factor for obesity, and individuals with PTSD also tend to decrease their participation in exercise. However, studies suggest that exercise may be a promising intervention for PTSD and is often included as an important part of weight loss treatment.
The Gut Microbiome Connection
The human gut microbiome has a significant impact on our health and can influence the development and response of emotions. A study found that participants who adhered to a Mediterranean diet experienced fewer PTSD symptoms. They identified Eubacterium eligens as the top PTSD putative protective species, which was positively associated with the enriched components of the Mediterranean diet.
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