Stress is a psychosocial adaptation that accommodates or attempts to alter reactivity of an event/effect. There is a known connection between stress and obesity from associated deleterious health behaviours, metabolic processes, and disrupted patterns of activity. This relationship has a circular causality as obesity is a stressful state and connects through multi-directional pathways that are prevalent in society. Some examples of these can be seen in Figure 1. The global upsurge in obesogenic populations has been labelled as an ‘epidemic’ with more than 2 billion children and adults measuring as overweight/obese by the World Health Organisation in 2016.
Figure 1 - The links between stress and obesity
An obesity ‘syndemic’
The addition of the COVID-19 global pandemic has prompted multi-system conditions that have demonstrated a vulnerable preference to obesogenic populations. The susceptibility relates to the cardiometabolic deviations concomitant with obesity. It has become evident that the underlying conditions linked with obesity have substantiated adverse/susceptible outcomes with COVID-exposure (Figure 2). Thus, indicating an interplay of two pandemics that result in a ‘syndemic’, a concurrent interaction of two or more biological or biosocial epidemics across conditions and states (Singer, Bulled, & Ostrach, 2020; Singer & Clair, 2003). Early observations have indicated that those with a high BMI (Figure 3) have demonstrated a weakened immune response to COVID severity, compounded by associated stress increased the likelihood of co-morbidity and mortality.
Figure 2 - The links between obese symptoms and COVID susceptibility
Figure 3 - Body Mass Index (BMI) and associated risk
The implications of a stress during a syndemic
This syndemic indicates that stress has collateral damage across physical, emotional, psychological, social, and economic levels. The increased stress from COVID has also intensified the risk of unemployment and economic uncertainty across communities, especially with those with low socioeconomic status (SES). An already at-risk population for obesogenic outcomes. These challenges may translate as an increase in instances of obesity due to the affordability of high processed food, often resultant in a double burden of malnutrition.
The COVID-19 pandemic has presented concerns from the government recommended self-isolation and diminished social interaction. The ramifications of confinement and reduced income may result in a reconfiguration of lifestyle, as well as challenging dietary and alcohol intake. These prolonged COVID disruptions present mental health issues like anxiety, depression, feelings of helplessness, and/or loneliness. Several recent studies indicate that overwhelming stressful feelings often leads to an overconsumption (e.g., binge eating/drinking) of unhealthy food and/or alcohol. These psychosocial burdens place those who already suffer from obesity (or high BMI), at an increased risk from both COVID and the related implications of stress-related conditions/outcomes.
Recommended strategies
Proactive approaches will be needed on multiple levels to address the relationship between stress, obesity and COVID that contribute to negative health outcomes. Nutritional intake suggestions from The European Association for the Study of Obesity (EASO) and The World Health Organisation (WHO) recommend a hypocaloric and micronutrient intake to reduce BMI and stress, as well as the inclusion of core vitamins and minerals (A, C, D, E vitamins, complex B, folate, zinc, potassium, copper, magnesium, selenium, calcium, iron, and omega-3 polyunsaturated fatty acids). In places where nutrient dense food is unattainable, the use of a dietary supplements facilitates the recommended dietary intake and can improve physical and psychological health.
Psychological interventions using ‘stress reappraisal’ and ‘stress mindset’ strategies may mitigate maladaptive stress outcomes and aid in effective coping. The reframing of stress as a positive ‘challenge’ (as opposed to avoidance), allows the ‘stress reappraisal’ approach to create a buffering or resilience that permits optimal performance. Complimented by ‘stress mindset theory’ that takes a ‘stress-is-enhancing’ mindset; this theorises that stress creates an opportunity for development that may facilitate enhanced function, health, and performance. The evidence suggest that this dual approach is both low-cost and efficacious in alleviating the deleterious consequences of stress hyperactivity during COVID. These stress management interventions are based on strong stress theory, low-risk, effective on both a short- and long-term basis, and can be facilitated/administered remotely.
Increasing daily activity and exercise can assist with weight-loss, stress-management and well-being. As well as ensuring adequate sleep and regular sleep-patterns are both necessary for building immunity and balancing stress hormones. Future recommendations suggest complimentary multi-level strategies that tackle the abovementioned vulnerabilities and daily habits that contribute towards stress and weight-gain. If successful, these strategies may provide increased immunity towards the COVID virus and increased stress resilience with the reconfiguration of daily practices.
References
Centers for Disease Control and Prevention (CDC). (2020, September, 17). Defining Adult Overweight and Obesity: Adult Body Mass Index (BMI). Retrieved December 10, 2020, from https://www.cdc.gov/obesity/adult/defining.html
Hagger, M. S., Keech, J. J., & Hamilton, K. (2020). Managing stress during the coronavirus disease 2019 pandemic and beyond: Reappraisal and mindset approaches. Stress and health: journal of the International Society for the Investigation of Stress, 36(3), 396–401. https://doi.org/10.1002/smi.2969
Hill, M., Sowers, J., & Mantzoros, C. (2020). Commentary: COVID-19 and obesity pandemics converge into a syndemic requiring urgent and multidisciplinary action. Metabolism, 114, 154408. doi: 10.1016/j.metabol.2020.154408
Rychter, A. M., Zawada, A., Ratajczak, A. E., Dobrowolska, A., & Krela-Kaźmierczak, I. (2020). Should patients with obesity be more afraid of COVID-19? Obesity reviews: an official journal of the International Association for the Study of Obesity, 21(9), e13083. https://doi.org/10.1111/obr.13083
Soeroto, A. Y., Soetedjo, N. N., Purwiga, A., Santoso, P., Kulsum, I. D., Suryadinata, H., & Ferdian, F. (2020). Effect of increased BMI and obesity on the outcome of COVID- 19 adult patients: A systematic review and meta-analysis. Diabetes & metabolic syndrome, 14(6), 1897–1904. Advance online publication. https://doi.org/10.1016/j.dsx.2020.09.029