Adverse life experiences among patients with morbid obesity. / Belastende livserfaringer blant pasienter med sykelig overvekt.

BACKGROUND: The association between highly stressful life experiences and morbid obesity is well documented internationally, but this knowledge is not incorporated to any great extent in Norwegian clinical practices. We have studied the reports of previous life stresses from a sample of Norwegian patients under assessment for morbid obesity at a centre where the topic of life experiences was included during the recording of patient histories. MATERIAL AND METHOD: In the summer of 2018, an invitation to participate in the study was distributed to the last 200 patients to have been examined at the Regional Centre for Morbid Obesity in Bodø. Information on lifetime adversity was collected in clinical interviews. Data were retrieved from the patient's discharge summaries, and these texts were analysed using a qualitative approach. Stressful life experiences were divided into twelve categories. RESULTS: The study recruited 70 participants (57 women) with morbid obesity. Of these, 64 (91 %) related at least one significant and stressful life experience, and 39 (56 %) reported three or more different types. The most frequent types included serious relationship ruptures, parental neglect and other negative childhood experiences. INTERPRETATION: In a sample of Norwegian patients who were undergoing examination for morbid obesity there were many who reported distressing life histories. Lack of existential security in childhood, often linked to complex traumas, was prominent. In light of international research on the association between trauma and obesity, our results indicate that the patient's life history should be included in an assessment of patients with morbid obesity.

Primary care emergency team training in situ means learning in real context.

OBJECTIVE: The purpose of our study was to explore the local learning processes and to improve in situ team training in the primary care emergency teams with a focus on interaction. DESIGN, SETTING AND SUBJECTS: As participating observers, we investigated locally organised trainings of teams constituted ad hoc, involving nurses, paramedics and general practitioners, in rural Norway. Subsequently, we facilitated focus discussions with local participants. We investigated what kinds of issues the participants chose to elaborate in these learning situations, why they did so, and whether and how local conditions improved during the course of three and a half years. In addition, we applied learning theories to explore and challenge our own and the local participants' understanding of team training. RESULTS: In situ team training was experienced as challenging, engaging, and enabling. In the training sessions and later focus groups, the participants discussed a wide range of topics constitutive for learning in a sociocultural perspective, and topics constitutive for patient safety culture. The participants expanded the types of training sites, themes and the structures for participation, improved their understanding of communication and developed local procedures. The flexible structure of the model mirrors the complexity of medicine and provides space for the participants' own sense of responsibility. CONCLUSION: Challenging, monthly in situ team trainings organised by local health personnel facilitate many types of learning. The flexible training model provides space for the participants' own sense of responsibility and priorities. Outcomes involve social and structural improvements, including a sustainable culture of patient safety. KEY POINTS Challenging, monthly in situ team trainings, organised by local health personnel, facilitate many types of learning. The flexible structure of the training model mirrors the complexity of medicine and the realism of the simulation sessions. Providing room for the participants' own priorities and sense of responsibility allows for improvement on several levels. The participants demonstrated a consistent, long-term motivation to strengthen safety, both for their patients and for themselves.

Is childhood stress associated with shorter telomeres?

BACKGROUND: It has been shown that severe stress in childhood is harmful to later health. New research aims to ascertain whether ­ and if so, how ­ the telomeres, the protective caps at the end of our chromosomes, may be one of the links between this type of experience and later morbidity. Here we present an overview of studies which have examined the association between stress in childhood and length of telomeres. METHOD: The review encompasses 26 original studies found through a literature search in PubMed. We included studies of the relationship between length of telomeres and various stress-inducing factors from conception throughout childhood and adolescence. RESULTS: The studies were grouped into four topics. The empirical research base for mother's stress in pregnancy and parents' ability to care for their children is too small to draw any conclusions. Psychosocial stress in childhood was associated with shorter telomere length in 12 of 14 studies. Socioeconomic status in childhood was not unequivocally associated with telomere length. INTERPRETATION: Shorter telomeres are possibly associated with psychosocial stress in childhood. This field of research is still new, and more longitudinal studies are needed with an emphasis on childhood experiences and coordination of measurement variables and results measurement in order to confirm this association.

The medically unexplained revisited.

Medicine is facing wide-ranging challenges concerning the so-called medically unexplained disorders. The epidemiology is confusing, different medical specialties claim ownership of their unexplained territory and the unexplained conditions are themselves promoted through a highly complicated and sophisticated use of language. Confronting the outcome, i.e. numerous medical acronyms, we reflect upon principles of systematizing, contextual and social considerations and ways of thinking about these phenomena. Finally we address what we consider to be crucial dimensions concerning the landscape of unexplained "matters"; fatigued being, pain-full being and dys-ordered being, all expressive momentums of an aesthetic of resistance.

"I base my life on sadness": Apparently paradoxical sources of resilience among young Haitians.

Haitian expressions of resilience also hold deep knowledge of human vulnerability. This longitudinal, qualitative study with young Haitians from urban shantytowns combines ethnographic and participatory methods to explore the complexities behind such idioms. Artistic and creative products made by or with the youth facilitated interviews, focus group discussions, and workshops. Through the life stories of participants and rich ethnographic material, this study presents locally situated idioms of resilience (and distress). By including local social ecology, the idioms were framed as historically and culturally rooted, thus shaping contextual, pragmatic, and gendered coping strategies grounded in embodied experiences of vulnerability and resistance. The study adds essential insights into Haitian resilience, revealing the local logics behind seemingly paradoxical statements. By drafting a conceptual framework for further studies on idioms of resilience, the study also makes a theoretical contribution to international resilience research.

The human biology--saturated with experience.

BACKGROUND: The human being is a self-reflecting, relationship-oriented, goal-directed organism in search of meaning. The process of coordinating and developing knowledge about how experience associated with self-conscience, relationships and values can contribute to development of health and disease is a great challenge for the medical profession. MATERIAL AND METHODS: We present a theory-guided synthesis of new scientific knowledge from fields such as epigenetics, psycho-neuro-endocrino-immunology, stress research and systems biology. The sources are articles in acknowledged journals and books, chosen to provide insight into associations between life history (biography) and the human body (biology) in a wide sense. RESULTS: Research shows that information about biography, i.e. experienced meaning and relationships, is literally incorporated into the human organism. Epigenetics illustrates the fundamental biological potential for context-dependent adaptation. Further, studies have shown that different types of existential strain may disturb systems for human physiological adaptation, affect structures in the brain and subsequently render the organism vulnerable for disease. However, a sense of belonging and a perception of being supported and acknowledged can contribute to strengthening or restoring health. INTERPRETATION: The traditional approach to increasing biomedical knowledge has prevented insight into the medical significance of experience. The new knowledge necessitates a reorientation of theory and practice within the medical profession both with respect to individuals and society.

[A different cardiovascular epidemiology]. / En annen kardiovaskulaer epidemiologi.

BACKGROUND: Cardiovascular diseases constitute the leading cause of sickness and death in Western countries. They are therefore embraced with much attention in medical research, treatment and preventive programmes for which quantifiable biological risk factors comprise the common conceptual basis. We want to demonstrate that the current narrow biological focus may prohibit a deeper understanding of the sickness expressions. THEORY, MATERIAL AND METHOD: The present paper is grounded in a theory of human beings as self-reflecting and capable of creating and conveying meaning affected by culture, time and relationships with others. From such a perspective, the human body is seen as a lived body, a centre for expression of experience. Two cases are interpreted in light of more recent epidemiological evidence of associations between traumatic experiences and cardiovascular disease. RESULTS: Research shows that traumatic experiences in general and early trauma in particular are potent pathogens. Different types of trauma are, however, not consistently related to specific diseases, but rather to complex patterns of so called co-morbidity. These patterns blur the mind-body-distinction and thereby the classification systems for somatic and mental diseases. When such patterns are interpreted as expressions of embodied life, insight is provided into how traumatic experience informs the lived body. INTERPRETATION: Correlations between traumatic experience and cardiovascular disease challenge the dominating biological framework of cardiovascular epidemiology. An analysis of the evidence by means of two cases opens up new perspectives. Knowledge about the path from particular and painful experience to particular and painful disease is an inevitable premise for an adequate treatment of the individual. It is also a prerequisite for development of adequate preventive measures.

From wholes to fragments to wholes-what gets lost in translation?

The highly demanding and, in a certain sense, unique, working conditions of general practitioners (GPs) are characterized by two phenomena: First, they involve an increasing familiarity with individual patients over time, which promotes a deepening of insight. Second, they enable the GP to encounter all kinds of health problems, which in turn facilitates pattern recognition, at both individual and group levels, particularly the kind of patterns currently termed "multimorbidity." Whereas the term "comorbidity" is used to denote states of bad health in which 1 disease is considered to predate and evoke other ailments or diseases, the term multimorbidity is applied when finding several presumably separate diseases in a person who suffers from them either sequentially or simultaneously. Encounters with patients whose suffering fits the biomedical concept and terminology of multimorbidity are among the most common which GPs face, presenting them with some of their most demanding tasks. The term multimorbidity needs to be examined, however. As it alludes to a multiplicity of diseases, it rests on an assumption of separateness of states of bad health that might not be well founded. An adequate determination of what to deem a "separate" state of bad health would require that the biomedical concept of causation be scrutinized.

[Heavy burdens and complex disease--an integrated perspective]. / Overlast og kompleks sykdom--et integrert perspektiv.

Complex chronic diseases require an increasing proportion of society's resources and represent a growing challenge. Valid biomedical models of etiology, pathogenesis, treatment and prognosis are inadequate for understanding these diseases. The article discusses current knowledge about the impact of stress on the immune-, hormonal - and central nervous systems, and integrates this knowledge with a phenomenological understanding of the body in an attempt to explain the complex chronic fatigue syndrome. The medical significance of the individual's biography is highlighted, and the inadequacy of statistically grounded biomedical research when aiming to understand complex disease is presented. By regarding human beings as persons who experience bodily and who both create and convey meaning, we claim to have transgressed the mind-body-dichotomy in complex disease development. The dichotomy converges in the living body.

Creating chronicity.

An authentic sickness history is the vantage point for juxtaposing a biomedical and a biographical-phenomenological reading. What, in a biomedical framework, appears to be a longstanding state of comorbidity of different and unrelated types of diseases is rendered transparent in a biographical reading. This particular reading, evidencing the shortcomings of a biomedical framework regarding identifying the social sources of an increasingly complex burden of disease, is reflected upon in light of recent research in the neurosciences. Thus, the biomedical contribution to a sickness history is demonstrated, with its resultant multimorbidity, chronification, and complete incapacitation of a woman despite the continuing and nearly excessive involvement of the health care system.

Patients' 'thingification', unexplained symptoms and response-ability in the clinical context: in response to 'Patients' substantialization of disease, the hybrid symptom and the metaphysical care', by Alexandra Parvan.

The types of diseases, or categories of suffering, referred to as medically unexplained symptoms or syndromes (MUS) are the focus for the following commentary. Such cases seem to invite reflection. The very nature of such complex patterns of disease and suffering raises a number of fundamental epistemological and ontological issues. Furthermore, such health challenges can serve as the basis for an exploration of how the suffering person as well as the medical caretaker comes to grip with disease, incapacitation or suffering. We have structured our comments into two parts: first, we will describe medically unexplained health problems as the background for an inquiry into a process wherein patients reify their suffering in order to meet their doctors on equal terms, which carries a potential for alienation. Second, we will reflect on Alexandra Parvan's text as regards patients' 'substantialization' of their disease, the resulting 'hybrid symptom' and a proposed model for care and healing.

Medicine's perception of reality - a split picture: critical reflections on apparent anomalies within the biomedical theory of science.

Escalating costs, increasing multi-morbidity, medically unexplained health problems, complex risk, poly-pharmacy and antibiotic resistance can be regarded as artefacts of the traditional knowledge production in Western medicine, arising from its particular worldview. Our paper presents a historically grounded critical analysis of this view. The materialistic shift of Enlightenment philosophy, separating subjectivity from bodily matter, became normative for modern medicine and yielded astonishing results. The traditional dichotomies of mind/body and subjective/objective are, however, incompatible with modern biological theory. Medical knowledge ignores central tenets of human existence, notably the physiological impact of subjective experience, relationships, history and sociocultural contexts. Biomedicine will not succeed in resolving today's poorly understood health problems by doing 'more of the same'. We must acknowledge that health, sickness and bodily functioning are interwoven with human meaning-production, fundamentally personal and biographical. This implies that the biomedical framework, although having engendered 'success stories' like the era of antibiotics, needs to be radically revised.

Does 'existential unease' predict adult multimorbidity? Analytical cohort study on embodiment based on the Norwegian HUNT population.

OBJECTIVES: Multimorbidity is prevalent, and knowledge regarding its aetiology is limited. The general pathogenic impact of adverse life experiences, comprising a wide-ranging typology, is well documented and coherent with the concept allostatic overload (the long-term impact of stress on human physiology) and the notion embodiment (the conversion of sociocultural and environmental influences into physiological characteristics). Less is known about the medical relevance of subtle distress or unease. The study aim was to prospectively explore the associations between existential unease (coined as a meta-term for the included items) and multimorbidity. SETTING: Our data are derived from an unselected Norwegian population, the Nord-Trøndelag Health Study, phases 2 (1995-1997) and 3 (2006-2008), with a mean of 11 years follow-up. PARTICIPANTS: The analysis includes 20 365 individuals aged 20-59 years who participated in both phases and was classified without multimorbidity (with 0-1 disease) at baseline. METHODS: From HUNT2, we selected 11 items indicating 'unease' in the realms of self-esteem, well-being, sense of coherence and social relationships. Poisson regressions were used to generate relative risk (RR) of developing multimorbidity, according to the respondents' ease/unease profile. RESULTS: A total of 6277 (30.8%) participants developed multimorbidity. They were older, more likely to be women, smokers and with lower education. 10 of the 11 'unease' items were significantly related to the development of multimorbidity. The items 'poor self-rated health' and 'feeling dissatisfied with life' exhibited the highest RR, 1.55 and 1.44, respectively (95% CI 1.44 to 1.66 and 1.21 to 1.71). The prevalence of multimorbidity increased with the number of 'unease' factors, from 26.7% for no factor to 49.2% for 6 or more. CONCLUSIONS: In this prospective study, 'existential unease' was associated with the development of multimorbidity in a dose-response manner. The finding indicates that existential unease increases people's vulnerability to disease, concordant with current literature regarding increased allostatic load.

The quantified self: closing the gap between general knowledge and particular case?

RATIONALE, AIMS AND OBJECTIVES: This paper addresses the movements 'evidence-based' (EBM) and 'personalized' (PM) medicine. The former is being criticized for failing to do justice to clinical complexity and human individuality. The latter aims at tailoring medical knowledge for every patient in a personalized fashion. Instrumental to this effort is the technological development engendering unlimited amounts of data about bodily fragments. The aim of this article is to stimulate a debate about the notion of the body and knowledge in medicine. METHODS: An authentic sickness history is used as a vantage point for a more comprehensive account of biomedicine. RESULTS: The analysis of the sickness history demonstrates how biomedical logic guided all approaches in the care for this particular patient. Each problem was identified and treated separately, whereby neglecting the interaction between body parts and systems, and between the woman's bodily condition and her experiences. The specialists involved seemed to look for phenomena that fit categories of disorders 'belonging' to their field. These approaches engendered unintended effects: chronification, poly-pharmacy and multi-morbidity, leading to an unsustainable increase in medical costs. CONCLUSIONS: The article elucidates how the status that professionals ascribe to the body has vital implications for what they regard as relevant and how they interpret the information they have collected. On this ground, we challenge both the prevailing and tacitly accepted separation between the physical body and human experience and the view of knowledge underpinning EBM and PM. The growing molecularization of the body veils decisive sources of human illness.

Exploring the relationship between childhood adversity and oral health: An anecdotal approach and integrative view.

During the past two decades, increasing recognition has been given to a relationship between oral health and systemic diseases. Associated systemic conditions include cardiovascular disease, diabetes, low birth weight and preterm births, respiratory diseases, rheumatoid arthritis, obesity, osteoporosis, and, in particular among oral conditions, periodontal disease. Low-grade inflammation is a common denominator linking these disorders. Applying an anecdotal approach and an integrative view, the medical and dental histories of two women document increasing ill health subsequent to incidences of maltreatment and sexual abuse, including oral penetration, at an early age. Comprehensive oral rehabilitation was required in both cases. These cases open for medical insight with regard to their implicit patho-physiology, when integrated with current evidence from neuroscience, endocrinology, and immunology, converging in the concepts of allostasis and allostatic load. In cases such as those presented in this paper, primary care physicians (family doctors, General Practitioners) and dentists may be the first to identify an etiological pattern. This report underlines the importance of increased and enhanced multidisciplinary research cooperation among health professionals. Our hypothesis is that childhood adversity may affect all aspects of human health, including adult oral health.

Self Reported Childhood Difficulties, Adult Multimorbidity and Allostatic Load. A Cross-Sectional Analysis of the Norwegian HUNT Study.

BACKGROUND: Multimorbidity receives increasing scientific attention. So does the detrimental health impact of adverse childhood experiences (ACE). Aetiological pathways from ACE to complex disease burdens are under investigation. In this context, the concept of allostatic overload is relevant, denoting the link between chronic detrimental stress, widespread biological perturbations and disease development. This study aimed to explore associations between self-reported childhood quality, biological perturbations and multimorbidity in adulthood. MATERIALS AND METHODS: We included 37 612 participants, 30-69 years, from the Nord-Trøndelag Health Study, HUNT3 (2006-8). Twenty one chronic diseases, twelve biological parameters associated with allostatic load and four behavioural factors were analysed. Participants were categorised according to the self-reported quality of their childhood, as reflected in one question, alternatives ranging from 'very good' to 'very difficult'. The association between childhood quality, behavioural patterns, allostatic load and multimorbidity was compared between groups. RESULTS: Overall, 85.4% of participants reported a 'good' or 'very good' childhood; 10.6% average, 3.3% 'difficult' and 0.8% 'very difficult'. Childhood difficulties were reported more often among women, smokers, individuals with sleep problems, less physical activity and lower education. In total, 44.8% of participants with a very good childhood had multimorbidity compared to 77.1% of those with a very difficult childhood (Odds ratio: 5.08; 95% CI: 3.63-7.11). Prevalences of individual diseases also differed significantly according to childhood quality; all but two (cancer and hypertension) showed a significantly higher prevalence (p<0.05) as childhood was categorised as more difficult. Eight of the 12 allostatic parameters differed significantly between childhood groups. CONCLUSIONS: We found a general, graded association between self-reported childhood difficulties on the one hand and multimorbidity, individual disease burden and biological perturbations on the other. The finding is in accordance with previous research which conceptualises allostatic overload as an important route by which childhood adversities become biologically embodied.