Many factors influence the prevalence and incidence of type 2 diabetes in the United States. The majority of current intervention strategies focus on the primary prevention and management of type 2 diabetes through individual life modifications. Health education is a commonly implemented approach used to facilitate dietary changes and increase physical activity. While this method is effective, there is an additional factor to consider in preventing and managing diabetes. This factor is known as stress, which can arise from the structures that shape community behavior and at-risk populations’ environment. Considering stress and how it can impact diabetes may provide a new paradigm for creating intervention strategies in the future.
Stress can be defined as our body’s physiological reaction in response to the changes, threats, or pressures placed upon it, otherwise known as stressors.1 Societally, stress is viewed in a negative light, with difficult or painful events being labeled as “stressful”. It is essential to realize that stress is both positive and negative and arises from internal and external forces alike. Pleasant stress, also known as eustress, can be described as events we view in a positive light. Common examples of eustress are excitement, joy, and happiness. The more traditionally referenced stress is called distress, which includes anger, sadness, and loss. It is important to emphasize the individual fluidity of stress and stressors. The magnitude of physiological reactions imposed on us from stressors can vary across our lifespan and across individuals. Additionally, stress is also subjective in nature, with events categorized as eustress or distress varying in the same fashion as the magnitude of stressors.
Structural factors in the United States can cause specific populations to experience more negative stressors compared to others, appearing in such forms as patriarchal norms, racism, and redlining. These structures directly impact poverty levels, access to food, and living environments. While these may appear to be external factors, internal stressors can result from structural factors, including poor physical health, low self-esteem, anxiety, depression, and avoidance.
These structures affect individuals in varying degrees as they progress through different stages in life. For example, the educational system directly impacts the youth through its system of standardization which has proven to be insufficient in measuring true aptitude for students across backgrounds. Those students most often harmed by this system are made up of individuals from historically marginalized groups – those more likely to be negatively impacted by structures. Various external stressors which impact their home lives lead to incidences of chronic absenteeism and increased behavioral issues, which can have a negative impact on school performance. Additionally, healthcare inequities heavily impact uninsured or underinsured families, causing families to go into debt or avoid medical treatment altogether, leading to worse overall health outcomes long term. Disparities in terms of access to healthcare is also a stressor, especially for the elderly, leaving many with unmet needs.
Certain structures impact specific demographic groups their entire lives. A history of redlining and income equalities still creates financial hardships for Black, Indigenous, People of Color (BIPOC) communities, with previous generations being denied the ability to create wealth for their descendants. BIPOC communities tend to live in under-resourced areas and have poor access to quality education, food, and healthcare facilities. Additionally, racism itself is a negative stressor. Research shows that Black individuals are 2.5 times more likely to experience race-related stressors and seven times more likely to experience three or more stressors compared to White individuals.2
Episodes of distress can cause abnormal eating patterns. Emotional eating is a tendency for individuals to overeat while experiencing negative emotions.3 Research has shown children and adults experiencing negative emotions are more prone to episodes of emotional eating.4 Children who experience more negative events were noticed to consume more sugary and fatty foods while also consuming fewer fruits and vegetables.3 In adults, emotional eating was observed to have a positive correlation with weight gain, which is a precursor to diabetes.4 Children and adults experiencing episodes of emotional eating may require specialized care to make dietary changes.
Increased physical activity, another method used in the prevention of diabetes, can also be a challenge in individuals experiencing high levels of distress. Motivation can be impacted by patients experiencing distress, preventing individuals from taking part in physical activity.5 Additionally, distress causes the release of cortisol and adrenaline which increases insulin resistance.6 Lowering this insulin resistance is an important function of increased physical activity and a reason why it is a common recommendation by health care providers. However, this can be made challenging with chronic increases in cortisol levels from individuals with frequent episodes of distress.
It is essential to note that there is no current data that supports that distress directly leads to type 2 diabetes. This article simply aims to highlight populations who are most susceptible to negative stressors, which can lead to behaviors that increase the likelihood of developing type 2 diabetes. Traditional health education strategies used to prevent and treat diabetes can be reimagined to account for distress. The way we speak and write about the lifestyle changes needed to combat diabetes should not focus merely on educating individuals about the benefits of eating healthy and exercising. Health education programs can put the blame solely on the individual rather than the systems and structures that individuals live in. Holistic approaches should be taken to reinforce the likelihood of favorable behavior changes and provide knowledge on how to operate within their respective environment. Health Centers can normalize mindfulness-based stress management programs, counseling services such as family therapy, and life coaching programs to aid in the reduction of distress. These programs can operate in tandem with current health education programs aiming to increase physical activity, create dietary changes, and reduce the prevalence and incidence of type 2 diabetes in these at-risk populations.
This publication is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of awards as follow: Health Outreach Partners (HOP) National Training & Technical Assistance National Cooperative Agreement totaling $847,285.00 with 0 percent financed with non-governmental sources and MHP Salud National Training & Technical Assistance Cooperative Agreement totaling $678,959.00 with 0 percent financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government. For more information, visit www.HRSA.gov