Everyday Stress: Child & Adolescent Obesity 2015

the relationships between stress and obesity and also giving you some guidelines to how to assess stress in a brief but effective manner during a visit and um and also touching a little bit on weight bias. However, I think Dr. Pant is going to talk about that in a little bit more detail. So stress has been implicated in the development, the maintenance, and the exacerbation of obesity and obesity-related comorbidities, and it can act upon those. Uh, problems in a couple of different ways. So we know that stress can exert its influences both physiologically and behaviorally. It can disregulate the endocrine system, causing elevations of stress hormones as well as insulin levels, um, and it can over time contribute to the accumulate accumulation of visceral fats. We also know that cognition and mood are also negatively impacted by chronic stress. So, those who are stressed out are more likely to worry, they're more likely to have problems concentrating and planning and focusing. Uh, we also see a decrease in sleep quality for many people who are stressed out, and we see a decrease in healthy behaviors, a healthy diet, regular physical activity, and restful sleep. And so we can see that it's a reciprocal relationship such that when stress impacts our daily life, it's very difficult to maintain healthy behaviors which as a result, contribute to weight gain, which can then exacerbate the body's stress response as well. And you hear people talk about good stress and bad stress. Really they all have the same effects on our body, but it's really a matter of how long those stress responses last in our body and whether we get any respite from them that determines whether we consider it good or bad. So when we're talking about good or positive stress, this is the normative stress we experience that causes perhaps a brief elevation in our heart rate. Mild elevations of stress hormones. Um, it's a typical stress we associate with, um, at least with children, for things like recitals, um, giving speeches, um, perhaps in this instance, giving a talk. Um, we see our stress levels increase slightly, and then they gradually diminish as the stressor subsides and our body returns to homeostasis. Tolerable stress, um, maybe stress that's a little bit more longer in duration and a little bit more severe in its intensity. Um, I think good examples of tolerable stress are things like the loss of a loved one, perhaps a grandparent or an extended family member, um, moving to a new city, adjusting to a new school. Um, all of those instances have, uh, stress associated with them, but they're often buffered by social support or any kind of stress management techniques that we have in our toolbox. Uh, when we're talking about toxic stress or chronic stress, these are the type of stressors that really, um, don't give us a break. So they require prolonged activation of the stress response in our bodies. And there's some evidence that it can actually lead to adverse changes to our brain structures and our organ systems, and some examples of toxic stress might be residing in a home where there's domestic violence, um, abusive situations, poverty, and particularly for children who are struggling with their weight, um, the teasing and the bullying that a lot of them experience in the school setting. So, why is this so important for kids? Well, we know that children are in a constant state of growth and development. Um, and so their, their systems have not yet fully matured. Um, And we know that this can have fundamental effects on their metabolic systems, on the neurocognitive development, and we also see surprisingly that stress can actually exacerbate medical problems like asthma, diabetes, um, and we also see an increase in mental health problems for children. Among girls in particular, we see an increase in internalizing disorders like anxiety and depression. And among boys, we may more commonly see um children acting out, um, so, uh, conduct disorder or behavioral problems in the school. And what's even more concerning for children who are struggling with their weight is that the excess weight that they already have may have elevated these stress hormones. On top of that, we have stress that's further exacerbating this situation. So the CDC recently conducted a study, uh, it was a retrospective study looking at approximately 18,000 adults and asked them to identify how many adverse childhood experiences they've had in their lifetime, and any adverse childhood experience could include neglect, trauma, abuse, anything that was considered particularly stressful for them. And there were several findings out of this, but one of the main findings was the strong correlation between um the presence of an ACE or an adverse childhood experience, and then later development of health, uh, medical problems and mental health problems. And what was even more interesting was that individuals who experienced at least one adverse childhood experience were also more likely to then have subsequent experiences. So it really suggests that it's, it's very important to see if we can intervene as early as possible to either prevent or minimize the likelihood of subsequent ACEs occurring. We also know that there are particular um subsets of the population that may experience greater stress than the majority. Um, so, individuals who identify as an ethnic minority often report greater stress levels on a daily basis. We also see the same goes for, um, immigrant populations, particularly those who are first generation or 2. Um, and those are individuals who either relocated here from another country or children that are the first in their families to be born here. And it's really not that hard to imagine why they might be under greater stress, um. Some of those things can be um overt discrimination, um, or subtle prejudice and stereotypes, and particularly for our immigrant families, we see um language barriers that can be very stressful, particularly those um that are trying to navigate the medical, um, or the healthcare setting. Um, in addition to language barriers, we often find that Um, the family dynamics can often change because, um, often children are the ones that are more fluent in both English and their native tongue. Parents end up relying more on their children to navigate, um, interactions with government or healthcare settings. That can create stress. And then we also have issues of deportation and legal status, um. That can impact these populations particularly and the most concerning piece of this is that these are also the groups that are less likely to seek help, so they're less likely to actually look for additional services, mental health services or any other kind of resources. And we've also found a very strong link between the experience of stress for those living in poverty and relationships between those two factors and obesity. So typically, uh, traditionally, we might think of those who are in poverty as being malnourished and skinny and underweight. Um, that picture has changed and we really see a lot of overlap between communities that are very low FPS and rates of obesity. Um, and one of the things that may be going on is the concept of food deserts, which is these concentrations of areas where there's really a lack of access to fresh fruits and vegetables, a lack of grocery stores, and a really an overabundance of calorie dense but nutritionally poor convenience foods. So, kids that are living in these um uh environments are at a greater risk for obesity. Um, we think about the kind of stressors that these parents are facing, um, You know, these parents are also facing financial stressors, economic stressors, and we know that that is also tied to a child's stress level. So what do we see when we typically um see a child that's in distress? Well, similar to adults, um, they may have a lot of um physical symptoms as well as difficulties with concentration and attendance. So, a child who is stressed may exhibit some problems academically, particularly in the school setting. We may also see, um, we commonly see, um, school nurses see this a lot, these vague gastrointestinal problems or stomach aches or belly aches, and that really have no, uh, medical cause. Um, in cases of extreme stress, we may see, um, some children, um, bedwetting. Social withdrawal and sleep disturbances? Um, and psychologically too, we may see, children who are, um, stressed out may ruminate more. They may, um, have increased anxiety, possibly panic attacks, and with others, their children may be behaviorally acting out in school. Um, one of the common stress responses that we see in clinic is, um, stress eating or emotional eating. And You know, I think all of us have had the experience of when we're stressed out or we've had a bad day, it's nice to go home and for some of us, it's a bowl of ice cream or whatever that comfort food is. I think all of us engage in that to some extent or the other. For some people it's a very rewarding response and it's one that sort of perpetuates the cycle of Of um short term relief because engaging in comfort eating can actually provide some short-term relief, and there's some evidence that the foods that we crave during those periods, you know, it's never the broccoli and the lima beans and the fresh fruit that we're craving. It's always something that's highly salty or highly fattening. Um, or highly sugary. And there's some evidence that those, those types of foods can actually diminish, um, some of that arousal in our bodies. So, we're drawn towards these foods, um, for that short-term relief. But inevitably, there is this letdown, uh, and often, um, especially for children or adults who are struggling with their weight, um, there's, there are feelings of shame, of guilt, of regret, um, and negative aspect in general, uh, because these types of behaviors are contributing to excess weight gain. You end up having a cycle of short-term relief, long-term, um, Uh, disappointment or regret, um, And then for some individuals, they turn back to food to um suppress some of those emotions as well. Um, so this is, it was a very strong response. We see this a lot in many of the children that we see in clinic. Um, and there have been some studies to suggest that When youth are stressed out and they start to go towards food, um, when they're stressed out, they also tend to engage in eating, um, in response to other emotions as well. So not just, um, in response to stress. So, what kind of stress um are our children experiencing? Um, it depends on their age and what they're going through. Um, listed here are some of the sort of appropriate traditional, um, Changes that children go through, um, for early, um, or younger children, elementary age children starting school, separating from their parents. Um, those are common stressors that are usually, um, buffered by social support, um, and that was, I think those are good examples of, of tolerable stress. Uh, lack of consistent routine. Um, I know most of the families that we see in clinic have multiple children of different ages. It can be very challenging to Um, have a consistent routine for dinners and bedtimes, um, and physical activity. Um, but what we know is that children thrive with that. They really, uh, do well when they know what to expect, um, and that meal crimes occur at certain times and that we engage in play at this time. Um, so a lack of a consistent routine can be stressful for young children. When we look at our, um, middle school age children or preteens, um, you know, their bodies are going through so many changes due to puberty. Um, this can be a source of embarrassment. It can be a source of, um, standing out from others in your class. So, um, uh, uh, children end up being pretty easy targets for bullying and teasing. They're also uh experiencing increase in their um academic expectations. So, I think, um, starting in the preteen years, you really start to see some of that stress coming from peers and um Expectations um from their friends and, um, and as we talk about teenagers, we definitely see um a greater importance of um what others think of their appearance. Uh, um, they may feel more pressure from their friends. To engage in certain behaviors. We see a natural separation, um, from the parents and the family, um, And this can also create tension in the house. Um, and this is also an age when, uh, body image and how we present ourselves, um, teenagers are forever reinventing themselves and trying to figure out their identity. And so this can be particularly stressful time for them. And As many of you have seen, uh, teens in your practice, I'm sure they also are notorious for their pretty horrendous sleep patterns. Um, so their sleep cycles have been shifting. Um, they have hectic schedules, and so all of this contributes to, um, increased stress on the body. And I'm going to talk about sleep, um, in a little bit more detail in a minute, but I wanted to, um, just briefly touch on some of the stress that Are, um, teens who are struggling with their weight experience even more than, um, you know, most kids in their classes. Uh, you know, we have, um, kids that come to clinic all the time and they, will tell us that they have, um, they no longer eat lunch in the cafeteria because they're targets of ridicule or, um, teasing. They feel judged by others about what they're eating. Um, many of the times our teens aren't even able to sit in the chairs in their classrooms because they have these desks with the chairs with the desks attached, which makes it very difficult if you are even slightly overweight to sit comfortably. Um, and so these kind of, uh, logistical issues that, you know, perhaps people who are not dealing with these problems would even consider, these are things that they're dealing with on a daily basis and have to learn how to, um, uh, handle. And I have a picture, uh, on the far right there, I think of the toilet. Um, and some of you may wonder what that is, but we've actually, um, heard from our, our own patients that, um, there is a fear of using public facilities at times because they may or may not be able to hold their weight. So imagine if, you know, you're in a school setting where perhaps these facilities aren't designed for you and imagine the embarrassment for you to use those facilities, um, and they, they can't bear your weight and something embarrassing happens. So, so I think, um, Doctor Pan is gonna talk about some of these, um, issues in more detail, but, but, you know, it's just, it's good to keep in mind there are additional stressors that perhaps we don't think of, um. Unless we walked in, in, in their shoes. So how do you assess this in an effective, um, in a brief way in your, um, in your practice. I think the easiest way to assess stress with younger children. It's simply to talk with them, to ask them questions about their family life, how, how things are going at school. Um, but for older kids, you know, they may or may not be very forthcoming with you, um, depending on your relationship, how comfortable they feel opening up to someone. And in these cases, um, there are some measures out there that are, um, fairly simple to administer. Um, the perceived Stress scale is one of the most widely used measures of, um, Of stress that it's about 10 items, it takes less than 10 minutes to administer and a higher score simply indicates that someone feels more overwhelmed, uh, more out of control, um, and more stressed out in general. Um, it's, it's written at a middle school level, so it's appropriate to be used for, um, adolescents. Um, and it gives you a sense of not necessarily how many types or what kind of stress the patient is feeling, but really their, their perception of their ability to handle that stress, and that's really the most important thing is not necessarily what they're going through, but do they have, do they feel they have the confidence to meet that stress head on. So, I wanted to talk very briefly about some age-appropriate stress management skills. Um, I think Kathleen, uh, talked about this a bit in the morning, um, the importance of having brain breaks, um, doing some kind of physical activity, and And she's right. One of the biggest barriers to physical activity that we hear in clinic is um that we, the kids have too much homework. We know that physical activity does wonders for um Improving mood, improving concentration, focus, um, it's a great way to, uh, get the blood circulating again. So, one of the things that we often recommend is even just brief bouts of physical activity during homework, um, can help manage some of that stress. It could be anything from just picking 4 songs off their iPod. And dancing around the room, doing jumping jacks, taking a short walk, anything to get their blood circulating, get their mind off of things, um, and give them a moment to refocus. Um, the other technique that's very simple to teach and to use is diaphragmatic breathing. Um, diaphragmatic breathing has been shown to activate the parasympathetic nervous system. Um, it helps to decrease the heart rate, boost the mood, boost blood circulation, help the body return back to homeostasis, and it literally takes less than 3 minutes to teach a child how to do deep breathing. Um, typically when I'm instructing a child, I will ask them to place their feet firmly on the floor, um, and just have them place their hands on their belly. And for 15 seconds, I just ask them to breathe normally, um, just as they normally would, and count how many breaths they typically take. Uh, after that period, I'll ask them to slow down their breaths, and we'll count again for 15 seconds how many breaths they take. And I ask them to sort of imagine that their belly is like a balloon. So if they inhale, their belly's expanding, and it's, and then when they exhale, um, it's deflating like a balloon. Um, and then we just reflect on that for a few minutes. Um, if you recommend deep breathing, if it's something you talk about with a child, I find that it's helpful to recommend that they practice twice a day if they really want to use this as a tool, and have them practice just for 3 or 4 minutes, either when they're brushing their teeth, taking a shower. It's helpful to pair it with something that they do on a daily basis so that it's easily remembered and not forgotten. And sleep. Um, getting a good night's rest for our kids is so important. Uh, Children and adolescents are recommended to get at least 9 hours of sleep, and, uh, most of our teens fall pretty short of that, um, at least 1 to 2 hours short. Um, we know that sleep deprivation can Um, have, um, a depressed effect on, on mood. It can decrease one's energy and it makes it difficult to engage in effective coping strategies. So, anything that we can do to improve our kids' um, sleep quality can help with stress management as well. And so, again, going back to physical activity, um, any kind of daily physical activity can help to increase sleep pressure at night. Um, eliminating caffeine in the afternoons. And establishing bedtime routines, um, having kids wake up and go to bed at the same time and really limiting the amount of screens that they have access to 30 minutes before bed, um. It's it's, it's particularly challenging for teenagers, I think, to, to work on their sleep, but um really when we're talking about the, the, the stress they're already experiencing from academics and peers, if we can help in any way to get their bodies to relax and to rest. It can help. Um, and what, what do you do if you're worried that, um, a patient may have an underlying anxiety disorder as opposed to simply stress? Um, that, it can be quite complicated, and most people who are anxious will tell you they're also feeling very stressed as well. Um, so it's possible that they have both. Um, In any case, the first line for treatment for anxiety would involve teaching a patient how to manage their stress more effectively. So implementing stress management techniques, whether that's diaphragmatic breathing, um, increasing physical activity, working on their sleep, um, all of that can help clarify the diagnostic picture. And what else can we do to help? Kids manage their stress. Uh, we know kids are not brought up in a bubble. They are influenced by their parents and the caregivers around them, and there have been some studies that have shown that the level of parental stress, uh, That children perceive, um, has been associated with increases in child fast food consumption, poor sleep quality, um, A decreased, uh, or they're less likely to meet um physical activity recommendations and less likely to have boundaries on, um, things like screen time. And that's not really hard to, um, imagine. Um, if parents are stressed out, if they're unable to cope with the, um, whatever events are going on in their life, it's very difficult then to set boundaries and to be present with their children. Um, and so, they may tend towards the more convenient path of, uh, eating out. Um, and, um, like Kathleen was saying, if you're busy and you're stressed out and you don't have physical activity on the calendar, it often gets missed. So, how can we help our parents to be, um, to, to help their own kids with stress management? Um, I think You know, kids, kids look to their parents for how to interact with the world, and if they see a parent who is managing their time efficiently, who makes time for physical activity and healthy habits, um, that's, that's, those are the behaviors that are going to seem natural to them, and they're going to be able to see how that can fit into their own lives. So being a good role model, having consistent routines, like I said, it's very challenging, but Consistent routines help with sleep. They help with activity, and they help with mood. Um, and so any, any way possible to help parents, um, plan these things, to, to get into a routine with the children so the children know what to expect, um, can go a long way. And, um, and having family time, I mean, it's, um. It's very difficult to sit down around the table 7 nights a week and have dinner together, but family time doesn't just have to be at the dinner table. It can be in the car driving back and forth to sports activities. It could be a game night. It could be a, it's a time to connect and really find out what's going on in their kids' lives. And let's say you've done an assessment. You you've perhaps you've used something like a perceived stress scale or a depression measure and you found that a child has scored high. Um, what do you do at that point? I think, you know, there's only so much you can do, um, in a time-limited visit. And so if you ever feel like Um, family stressors are going beyond what you can, um, address in your own practice. I think that's a great time to refer for mental health services, um, and try to distinguish between, um, the stress, perhaps the underlying anxiety. And, um, and, and therapy may be a great way to get those families the um the skills, the tools they need to manage that stress better. That's it. Thank you guys. If there's any questions, I'm happy to take any. No, thank you, Sheel. So in the office, um, what are some, what are some tools that the primary care doc can, can use, uh, to quickly assess the level of stress in a, in a, in a child in the office? Yeah, I think, um, you know, I think something like the perceived stress scale is pretty quick to administer, um, depending on, um, The relationship with that patient, um, simply asking them about, you know, school and, um, their family life might lead to a discussion of stress. Um, there's, there are a couple of other measures as well. Um, there is the PASQL, which is another measure of kind of overall well-being, um, and how children just feel they're adjusting. Um, there's a number of them out there that are, um, pretty free and, um, easy to access. Um, but any of those could give you at least, uh, a cursory glimpse into how, how the child is doing. Great, that's great. Uh, don't forget, everybody, we have, uh, several polls that are live now. I encourage everybody to participate, uh, and, uh, I think any other questions for Shiel. Uh, I just wanted to say I love the fact that you talked about the role modeling because I think we've really gotten to the point where it's, uh, like to be busy is considered something good. People are walking around all the time talking about how busy and stressed they are, and instead of seeing the negative effects of it, we're all really proud of how busy we are. So I'm glad you talked about that. It's important to show our kids how to de-stress and how to be a role model and take care of themselves. Absolutely it's a great point, yeah, and it's um there's, I was reading somewhere recently they were talking about how, you know, we're so busy on our phones, we're so busy on our computers that, um, you know, children see this and they, they assume that this is how, uh, you know, their life should be structured and what we find is that as um Kids are um using so, so many screens, they're actually uh losing that time to be creative and that time to be bored. There's actually a, uh, it's actually not a bad thing to be bored. Yeah. So, that's what I can say when my youngest tells me that she's bored. Yeah, it's not a bad thing. It's OK to be bored.