No Place Like Home: How Environmental Factors Impact Disparities in Obesity Treatment

ENDO 2021 will feature “How Do We Confront Disparities in Obesity and COVID-19 Treatment?” which will have three different programs with individual Q&A sessions on Monday March 22 at 12:15 p.m. Rebecca E. Hasson, PhD, FACSM, highlights what attendees can expect from her presentation on obesity-related metabolic risk factors caused by one’s environment.

ENDO 2021 is only weeks away, but of course the premier annual meeting for endocrinologists has been moved to a virtual platform as the COVID-19 pandemic continues to wrap its tentacles around just about every aspect of daily life. Nothing has been untouched.

These pages have covered just how much the novel coronavirus has upended healthcare and research, and indeed shown how COVID-19 has exposed the stark inequities experienced by communities of color and socioeconomically disadvantaged populations. And now, a session at ENDO will further highlight these problems and provide attendees ways to address this important but extremely delicate situation. “How Do We Confront Disparities in Obesity and COVID-19 Treatment?” on March 22 will feature several presentations from experts talking about disparities in obesity, as well as how the pandemic has affected their efforts.

For her talk, Rebecca E. Hasson, PhD, FACSM, associate professor at the University of Michigan and director of the university’s Childhood Disparities Research Laboratory and Active Schools & Communities Initiative, will focus on how external factors contribute to disparities in obesity. Her presentation, titled “Environmental Determinants that Contribute to Racial/Ethnic Disparities in Obesity-Related Metabolic Risk Factors” will provide an overview of the different dimensions of psychosocial stress and highlight the psychosocial pathways that contribute to metabolic health disparities in pediatric populations, according to the abstract.

“I’ve done a lot of research over the past 10 years focused on the behavioral factors that increase a child’s risk for type 2 diabetes and obesity and the environmental factors that contribute to unhealthy behaviors that lead to, or directly contribute to, increased obesity, increased insulin resistance, inflammation, and type 2 diabetes risk,” Hasson says.

Impacts of Chronic Stress

Everyone experiences stress from time to time – it’s unavoidable. But when it’s chronic stress, that becomes a problem. Hasson says the body was simply not designed to handles stress repeatedly over a long period of time. The body will maladapt and dysregulate cortisol, which leads to behavioral changes, which affect metabolic health.

For those lacking resources to address chronic stress, this cycle is even more severe. There is an old saying: “It’s expensive to be poor.” An adolescent in a low-income house may be stressed about studying for an exam, but can’t afford a tutor, or take time off from a job to study, which of course leads to more stress. Meanwhile, the parents are worried about keeping the lights on, or having enough food to eat, then you become food insecure. Minority adolescents experience discrimination in the form of unfair treatment to where you lose out on different opportunities,” Hasson says.

“I think having a broader understanding of these social factors that shape behaviors and shape health outcomes will help the endocrinologist get a better picture of what they’re dealing with and may help to make their prescriptions a little more precise.” – Rebecca E. Hasson, PhD, FACSM, associate professor; director, Childhood Disparities Research Laboratory and Active Schools & Communities Initiative, University of Michigan, Ann Arbor, Mich.

Minorities experience racial discrimination at a rate up to five times more than non-Hispanic whites – another chronic stressor. And now, another thing keeping children up at night is community violence. It’s not a new phenomenon, but evenings punctuated with gunshots or walking through the neighborhood and witnessing punches thrown can have not just an effect on a child’s psyche, but their metabolic health as well. Hasson and her co-authors in a paper recently published in Psychoneuroendocrinology identified a cross-sectional association between community violence and hypothalamic-pituitary-adrenal axis dysregulation in adolescents who were overweight/obese.

“We’ve shown our findings, even in suburban areas, that if a child has heard a gunshot, and they hear it repeatedly, that also has dysregulation in their cortisol responses because now you’re talking about their perceptions of neighborhood safety,” Hasson says.

Impacts of Global Stress

One of the main resources a person has to protect against stress and even chronic stress is social support and connectedness — travel or meeting a friend for lunch or a backyard barbecue or a simple hug from a loved one. But of course, those kinds of things have been extremely limited or non-existent during the ongoing pandemic.

Then come the stressors of contracting COVID-19, of losing a job, of the social isolation. “You have this compounding problem and not only are you going through it, but so is everyone around you,” Hasson says. “We have this global stressor on top of these individual and community stressors. That’s not even a perfect storm, that’s a tsunami.”

And while adults have turned to other coping skills, children don’t have the same ones, at least ones that are healthy and effective. Children live in an ecosystem, and even if the child doesn’t feel stressed, how the parents respond to stressors can indeed affect the child’s weight. In 2019, Hasson and her co-authors published a paper in the Journal of Obesity that found parents’ exposure and appraisal of stressors related to community safety are associated with increased adolescent obesity in African American youth.

Hasson says that we don’t teach children how to cope with stress, and that children as young as two can start to stress eat. “A two-year-old can’t go out for a run,” she says. “The only stress reduction that they have is, ‘Ooh, that little fruit loop actually tasted good.’ And we know that sugar activates the brain reward system. They really will feel good after they eat some sugar or something sweet, and you can train the brain at a very young age to start stress eating.”

Hasson also implicates things like video games and social media – which also activate the brain’s reward system – as sedentary coping mechanisms that children have turned to, especially as COVID-19 has limited exercise opportunities. “School’s closed, gym’s closed, park’s closed,” she says. “And if you don’t live in a safe neighborhood, you’re not exercising.”

Kids on the Move

Hasson and her team have shown that children do enjoy exercise if they get the chance. They tested this theory in the laboratory, offering children the choice of two minutes of activity or two minutes of a video game. The children preferred the activities – Hasson and her team published a paper in Journal of Physical Activity and Health, finding that the children’s mood was significantly higher after engaging in activity breaks and the children rated the activities as more enjoyable than video games. “Kids do want to move,” Hasson says. “We just have to give them that opportunity.”

Before COVID-19, Hasson and her team had developed a program for children who were sitting too much in classrooms. They trained teachers to implement five-minute activity breaks throughout the day. But then the schools closed, so the Michigan state board of education reached out, asking if it was possible to adapt the program for the home environment.

What followed was a Detroit Public Television show available for wide consumption called “Impact at Home” on the Michigan Learning Channel, since almost one third of children in Michigan don’t have Internet access. Hasson and her team have also been working with a team of school psychologists, health coordinators, and teachers to develop a family engagement toolkit that focuses on resilience. “How do we help parents engage in that conversation?” Hasson says. “Because a lot of parents see that their kids are stressed out, but they don’t really know what to do about it. One is you can move with them. You can think with them and then you can just be with them.”

Hasson and her team plan to collect data on the initiative, to determine how family engagement is helping build resilience in children, and how exercise is helping children cope with stress. “How was the exercise helping the kids just feel better even if they’re not metabolically improving. But if they’re feeling better, if they’re in a better state, I think that that will transition into engaging in other health behaviors that can change their metabolic health over time,” Hasson says.

Treating the Whole Patient

And these external, environmental factors again speak to the importance of personalized medicine, of treating the whole patient. A question about how many gunshots a child hears in a week might not be on an endocrinologist’s list of questions. Hasson says it’s important to know what’s going on in a patient’s life that may make it more difficult for them to fill their prescription of Metformin or physical activity or to follow nutritionist recommendations. “I think having a broader understanding of these social factors that shape behaviors and shape health outcomes will help the endocrinologist get a better picture of what they’re dealing with and may help to make their prescriptions a little more precise,” she says.

“A two-year-old can’t go out for a run. The only stress reduction that they have is, ‘Ooh, that little fruit loop actually tasted good.’ And we know that sugar activates the brain reward system. They really will feel good after they eat some sugar or something sweet, and you can train the brain at a very young age to start stress eating.” – Rebecca E. Hasson, PhD, FACSM, associate professor; director, Childhood Disparities Research Laboratory and Active Schools & Communities Initiative, University of Michigan, Ann Arbor, Mich.

Hasson is an exercise physiologist, and she jokes that of course exercise is the answer to all the world’s problems, but she does point to the fact that exercise does dampen the stress response. “We do know that it has a direct and independent effect on that cortisol release, and so it is elevated during exercise,” she says. “And if you encounter a stressor after you exercise, you will actually have a dampened response.”

But for, say, an adolescent going through puberty — the crucial biological period where children become more insulin resistant — who has low levels of physical activity and high levels of food consumption, the metabolic risk factors are serious. Tack on the fact that this child may live in a lower-resource community and these stressors are even more taxing. “I think focusing on unhealthy eating habits is only giving us half the picture, half the story, and by paying attention to some of these other factors an endocrinologist can really help to move the needle in the right direction for prevention and treatment,” Hasson says.

Bagley is the senior editor of Endocrine News. In the February issue, he wrote the cover story on how endocrine nurses have become more essential than ever during the COVID-19 pandemic.