Thriving or Surviving: The Connection Between Chronic Stress, Chronic Disease, and Social Determinants of Health (Deol - 9/6/23)

 A recording of this presentation can be viewed HERE. 

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Thank you to Dr. Navi Deol, PGY3, who gave an excellent presentation this week titled Thriving or Surviving: the intersection between chronic stress, chronic disease, and the social determinants of health. Each of the items in the subtitle is a HUGE topic, and Dr. Deol was able to weave them together beautifully and powerfully. I encourage you to watch yourself.

Image from https://www.glasbergen.com/stress-management-cartoons/cartoons/page/3

If you prefer the written word, see my notes:

• stress: how certain stimuli (stressors) affect a person's mind, body and spirit
• stress response: how our body reacts normal, a normal physiologic and psychologic response to stressors
• some stressors evoke positive emotions and can be beneficial (eustress); some evoke negative emotions and cause problems (distress)

A certain amount of stress is important and necessary to generate optimum productivity and performance, but too much stress can lead to anxiety, overload, and burnout (see image below of the Yerke's-Dodson Law).

Yerke's-Dodson Law, image fromhttps://stock.adobe.com/

Stress causes physiologic changes in our bodies. We are all familiar with the autonomic nervous system, which responds to acute stress with the sympathetic "fight or flight" and the balancing parasympathetic "rest and digest", but what happens when the stress response is constantly being activated? 

Image from: https://www.backtothebooknutrition.com/adrenal-fatigue-hpa-axis-dysregulation/

The answer is that our long-term stress response leads to a cascade of responses that make us more vulnerable to chronic diseases.

A 2019 study published in the Journal of ACC looked at the link between SES factors such as low income and higher crime on MACEs (cardiac death, myocardial infarction, unstable angina, cerebrovascular accident, peripheral artery disease with revascularization, or heart failure). This study suggests that a biological pathway contributes to this link, involving, in series, higher amygdala activation, increased activation of the bone marrow (with release of inflammatory cells), which in turn leads to increased atherosclerotic inflammation and its atherothrombotic manifestations

Patients were categorized according to quartiles of their neighborhood median income and neighborhood crime rates.  Amygdalar activity (A) and arterial inflammation (B) were lower as neighborhood median income increased. Amygdalar activity was higher (C) and arterial inflammation trended toward an increase (D) as neighborhood crime rate increased. One image from that study is seen below. For more information, click the link above or see the study link below the image.

https://www.jacc.org/doi/10.1016/j.jacc.2019.04.042

Chronic diseases are non-communicable illnesses that persist for long periods of time and result from a combination of genetic, environmental, and psychological factors. These include cardiovascular disease (e.g. hypertension, coronary artery disease, and strokes), metabolic disorders (e.g. type 2 diabetes and obesity), mental health issues (e.g. depression, generalized anxiety disorder), and substance use disorders.

We know that inflammatory cascades play an important (and damaging role) in the onset and progression of chronic disease. While acute inflammation is technically "good" for us because it cleans up disease states in our body, chronic inflammation is bad bad bad.

Financial stress

Are you aware that money (finances and inflation) is a tremendous source of chronic stress for a shocking number of US adults. A 2022 survey found that 57% of US adults reported not having enough money to pay for essential items; 43% reported that they are not saving enough, and 56% had to make different choices due to their lack of money. 

Violent stress

Mass shootings, gun violence, and crime are also sources of tremendous chronic stress, particularly for people living in poverty and disproportionately for BIPOC people. 

Social Determinants

This leads us directly into a discussion of the importance of the Social determinants of health (SDOH), the conditions into which individuals are born, grow, live, work and age. There is an unsurprising link between chronic stress and the SDOH. These include your neighborhood and built environment, healthcare, education, economic stability, and social and community context. 

image from Healthy People 2030

If this is news to you, check out this video about how zip codes influences an individual's health: A Tale of Two Zip codes.

And for something even closer to home, check our our local Sonoma County data on how the SDOH vary based on zip code in the report titled A Portrait of Sonoma County 2021 Update, available here:  https://upstreaminvestments.org/impact-make-a-change/portrait-of-sonoma-county

https://upstreaminvestments.org/impact-make-a-change/portrait-of-sonoma-county

What can we do about all this stress?

Dr. Deol encouraged us to take a deep breath and realize that we cannot tackle these complex issues alone. First, we must acknowledge the deep-rooted history of structural and systemic racism, oppression, and discrimination that have led to health inequities that require interventions at multiple levels to reduce disparities. 

When caring for individuals, we should be careful about using the term "non-compliance" and better recognize the daily barriers our patients face due to their own SDOH. In our communities, we should be screening for SDOH and get to know and refer to appropriate community services. And at the state level, she encouraged us to support CAFP Bill AB85, which requires SDOH screening and provides resources and education for providers in referring to community health workers. 

More information for AB85 can be found HERE.