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Stress affects all systems of the body, from endocrine and nervous system pathways to cardiovascular and gastrointestinal functioning.1 The cumulative burden of chronic stress and negative life events has been associated with poorer health outcomes, including an increased risk of inflammatory disease development2,3 and a suppressed immune system.4,5 Sustained psychological stress may also influence sleep quality and pain experiences and increase depressive symptoms and fatigue.6-8 Further, experiencing chronic stress may decrease mitochondrial energy production capacity and even alter mitochondrial morphology.9
Recurrent exposure to social, physical, or environmental stressors is considered a social determinant of mental and physical health impacting a patient’s quality of life and wellness. Patients may also experience multiple chronic stressors that compound negative health effects and disease burden.10 What lifestyle tools help clinicians support patients who experience various stressors associated with social determinants of health?
Chronic Stress, Allostatic Load, and Disease Burden
Social determinants of health are defined as conditions that influence the way people are born, grow, work, live, and age. This range of economic, social, and physical environment factors shape a person’s daily life, impact their access to health care, and influence their health and disease risks. Experiencing continuous stressors such as racism and discrimination, food and/or financial insecurity, and unsafe neighborhood conditions has been shown to contribute to multiple chronic diseases such as cardiovascular diseases, metabolic dysfunction, and depression.11-14
As an example, a recent observational study analyzed data collected from the Black Community Mental Health project in Canada and found that those individuals experiencing a high level of racial discrimination were 36.4 times more likely to present severe depressive symptoms when compared to those reporting a low level of discrimination.15 Also, a 2021 systematic review that included 267 original investigations found that lower socioeconomic status, poor neighborhood health, and high racial discrimination and hostility were associated with high levels of allostatic load and that the cumulative burden of chronic stress was associated with poorer health outcomes.10
Therapeutic Interventions: Tools and Approaches
When organizing and assessing health information, a patient’s experiences and continuous exposure to stressors are vital pieces of their health story. Social determinants of health are potential antecedents and mediators of physiological dysfunction in the functional medicine matrix model, and multiple sources of chronic stress experiences may weave throughout a patient’s timeline, impacting multiple life stages. These social, economic, and environmental chronic stress exposures may also impact the patient-practitioner relationship, patient engagement and empowerment, and ultimately the implementation of successful and sustainable interventions.
Collaboration and trust between a patient and practitioner are essential and are established through underrecognized yet important clinical skills such as prioritizing patient-centered care, clarifying factors in a patient’s timeline, and considering a patient’s cultural background, traditional lifestyle and diet, and any healthcare access barriers. A therapeutic connection that considers a patient’s health goals as well as all elements of a patient’s story, including the financial, social, and community conditions in which they live, may also increase patient engagement and empowerment when codeveloping a sustainable treatment plan. Consideration of chronic social stressors and understanding healthcare system disparities that are beyond an individual’s control may help in developing lifestyle-based therapies that are modifiable and accessible to support the health of patients across populations and cultures.
More observational and clinical trials are beginning to investigate the efficacy of culturally adaptive interventions that may target social determinants of health for the prevention or management of chronic stress and chronic diseases such as cardiovascular disease and depression. A randomized controlled trial of 132 African American patients with mild to moderate depressive symptoms compared the changes in depressive symptoms between those patients in the standardized control arm (Coping with Depression [CWD] course) and the culturally adapted treatment group (Oh Happy Day Class [OHDC] course).16 Both groups received either intervention for 12 weeks, meeting at weekly in-person group sessions. Upon evaluation, both interventions reduced depressive symptoms; however, an increased attendance at the culturally adapted intervention showed a greater reduction of symptoms.16 For Black women experiencing chronic race-based stress who are also at risk for cardiovascular disease, studies continue to evaluate the benefits of the stress and coping intervention, the Resilience, Stress, and Ethnicity (RiSE) model that empowers patients, builds mindfulness strategies, and promotes improved coping associated with racism, discrimination, and other sources of stress.17,18 Research studies continue to echo the importance of cultural modifications to health interventions for the improvement of patient engagement and clinical outcomes.
The functional medicine approach honors the individual patient’s health story and experiences in order to help identify root causes of disease and to develop the most appropriate and beneficial health treatment plan. The IFM Toolkit provides easy and accessible resources to personalize lifestyle-based therapies. For example, IFM’s Phytonutrient Spectrum is a helpful visual tool that uses the color of foods to incorporate more servings of fruits and vegetables into daily diets and is a first step toward healthier eating. The suite of IFM’s therapeutic food plans can be adapted to suit both health needs and personal preferences of patients. In addition, other nutrition-based IFM Toolkit items such as Eating on a Budget and Food Resources provide suggestions and direction for both the patient and practitioner. Strategies for Transforming Stress is one more IFM Toolkit item that suggests a range of stress transformation practices that may best suit a patient’s lifestyle and preferences, from community support, spiritual practice, and laughter to journaling, practicing gratitude, and meditation. Learn more about how lifestyle factors can be modified specific to the cultural, economic, and health needs of your patients to deliver personalized, effective, and sustainable interventions to combat chronic stress and disease.
- American Psychological Association. Stress effects on the body. Published November 1, 2018. Accessed August 5, 2022. https://www.apa.org/topics/stress/body
- Cardel MI, Min YI, Sims M, et al. Association of psychosocial stressors with metabolic syndrome severity among African Americans in the Jackson Heart Study. Psychoneuroendocrinology. 2018;90:141-147. doi:1016/j.psyneuen.2018.02.014
- Javed Z, Haisum Maqsood M, Yahya T, et al. Race, racism, and cardiovascular health: applying a social determinants of health framework to racial/ethnic disparities in cardiovascular disease. Circ Cardiovasc Qual Outcomes. 2022;15(1):e007917. doi:1161/CIRCOUTCOMES.121.007917
- Segerstrom SC, Miller GE. Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry. Psychol Bull. 2004;130(4):601-630. doi:1037/0033-2909.130.4.601
- Liu YZ, Wang YX, Jiang CL. Inflammation: the common pathway of stress-related diseases. Front Hum Neurosci. 2017;11:316. doi:3389/fnhum.2017.00316
- Salvagioni DAJ, Melanda FN, Mesas AE, González AD, Gabani FL, Andrade SM. Physical, psychological and occupational consequences of job burnout: a systematic review of prospective studies. PLoS One. 2017;12(10):e0185781. doi:1371/journal.pone.0185781
- Chapagai S, Martyn-Nemeth P. Sleep health, acculturation, and acculturative stress in immigrants in the United States: a scoping review. J Transcult Nurs. 2022;33(3):398-415. doi:1177/10436596211072884
- Hollis F, Pope BS, Gorman-Sandler E, Wood SK. Neuroinflammation and mitochondrial dysfunction link social stress to depression. Curr Top Behav Neurosci. 2022;54:59-93. doi:1007/7854_2021_300
- Picard M, McEwen BS. Psychological stress and mitochondria: a systematic review. Psychosom Med. 2018;80(2):141-153. doi:1097/PSY.0000000000000545
- Guidi J, Lucente M, Sonino N, Fava GA. Allostatic load and its impact on health: a systematic review. Psychother Psychosom. 2021;90(1):11-27. doi:1159/000510696
- Acosta JN, Leasure AC, Both CP, et al. Cardiovascular health disparities in racial and other underrepresented groups: initial results from the All of Us research program. J Am Heart Assoc. 2021;10(17):e021724. doi:1161/JAHA.121.021724
- Parekh T, Xue H, Cheskin LJ, Cuellar AE. Food insecurity and housing instability as determinants of cardiovascular health outcomes: a systematic review. Nutr Metab Cardiovasc Dis. 2022;32(7):1590-1608. doi:1016/j.numecd.2022.03.025
- Hill-Briggs F, Ephraim PL, Vrany EA, et al. Social determinants of health, race, and diabetes population health improvement: Black/African Americans as a population exemplar. Curr Diab Rep. 2022;22(3):117-128. doi:1007/s11892-022-01454-3
- Hankerson SH, Moise N, Wilson D, et al. The intergenerational impact of structural racism and cumulative trauma on depression. Am J Psychiatry. 2022;179(6):434-440. doi:1176/appi.ajp.21101000
- Cénat JM, Kogan C, Noorishad PG, et al. Prevalence and correlates of depression among Black individuals in Canada: the major role of everyday racial discrimination. Depress Anxiety. 2021;38(9):886-895. doi:1002/da.23158
- Ward EC, Brown RL, Sullivan-Wade L, Sainvilma S. A culturally adapted depression intervention for African American adults: an efficacy trial. WMJ. 2021;120(4):273-280.
- Conway-Phillips R, Dagadu H, Motley D, et al. Qualitative evidence for Resilience, Stress, and Ethnicity (RiSE): a program to address race-based stress among Black women at risk for cardiovascular disease. Complement Ther Med. 2020;48:102277. doi:10.1016/j.ctim.2019.102277
- Saban KL, Motley D, Shawahin L, et al. Preliminary evidence for a race-based stress reduction intervention for Black women at risk for cardiovascular disease. Complement Ther Med. 2021;58:102710. doi:1016/j.ctim.2021.102710