Coping with Stress During COVID-19: What Bariatric Patients Need to Know

[PollyEster 228]

Coping with Stress During COVID-19: What Bariatric Patients Need to Know

May 1, 2020 by Harold Bays, MD, FOMA, and Lydia C. Alexander, MD, FOMA

Dr. Bays is Medical Director and President of the Louisville Metabolic and Atherosclerosis Research Center in Louisville, Kentucky. Dr. Alexander practices obesity medicine at Kaiser Permanente Medical Weight Management Group in San Francisco, California.

Funding: No funding was provided.

Disclosures: Harold Bays, MD, FOMA is Trustee, Chief Science Officer, and Lydia C. Alexander, MD, FOMA, is Secretary/Treasurer for the Obesity Medicine Association.

---

During this most unique of times, as frontline healthcare workers and hospital staff, we frequently face difficulties when treating patients threatened by a rapidly increasing pandemic. This is made even more difficult with the stress of limited essential medical supplies. Among all the turmoil and disruption, the emergence of COVID-19 has created special challenges for patients with obesity.

Many patients with obesity have impaired immunity, impaired lung function, sleep apnea, and hypoxia, making a virulent upper respiratory tract infection especially perilous. Added to this are obesity-related debilitation, immobility, orthopedic changes, polypharmacy, more limited access to medical/preventive care, and adiposopathic complications of diabetes mellitus, and cardiovascular disease.¹ Collectively, patients with obesity are more susceptible to COVID-19 disease and have worse outcomes once infection occurs.

For many bariatric patients, the rise of the novel coronavirus has created additional challenges, such as the effect of mental stress on their lives. Increased mental stress can worsen complications from obesity, such as hyperglycemia, high blood pressure, dyslipidemia, and might also worsen obesity itself. The good news is that if clinicians are attuned to the physical impacts of mental stress, then proactive measures can be taken to mitigate the potential adverse consequences of mental stress.

Acute Stress, Chronic Stress and COVID-19

Acute, or short-term, stress is a function of the natural “fight or flight” response. One of the systems activated by the stress response is the sympathetic nervous system, which increases production of hormones epinephrine and norepinephrine. The acute stress response can be beneficial—it can increase visual acuity, decrease pain, increase blood flow, and boost the immune system. This complex sequence of hormonal changes and physiological responses helps people when they need to fight or flee to safety.

Conversely, chronic, or long-term “submit and stay” stress has the potential to worsen health outcomes. Chronic stress can increase cortisol production, which might promote visceral fat accumulation.^2,3 Symptomatically, chronic stress can cause decreased cognitive ability, diminished healthful decision-making, and more pronounced pain. Physiologically, chronic stress can impair immune function, impair sleep patterns and increase blood sugar, high blood pressure, and body weight.⁴

The Toll of Chronic Stress on Patients with Obesity During COVID-19

Stress and anxiety are understandable during the COVID-19 situation. We are living in a time of an unprecedented global pandemic crisis. Doom and gloom are everywhere. Good news is rarely reported. Stress is to be expected. However, clinicians can assist patients with proactive stress management techniques, especially for people living with obesity.

Many patients are staying home to keep themselves and others safe and limit the spread of the novel coronavirus. Other patients are staying home because of governmental mandates. But while “distancing” from others could have potential benefits in preventing viral spread, staying home might result in less healthful nutrition and reduced physical activity. As we navigate the unparalleled COVID-19 crisis, it is critical that clinicians, including bariatric surgeons, counsel patients to recognize the signs of mental stress, as well as its potential negative impact to health. This would include increased blood sugar, high blood pressure, increased body weight, and challenges fighting viral respiratory infections. Bariatric patients should receive specific and actionable guidance on safely optimizing nutrition and physical activity during periods of shelter-in-place orders.⁵

Coping with Stress During COVID-19

As we await a cure or vaccine for the novel coronavirus, one of the most important measures clinicians can take in the interim is to address potential mental stress head-on, as one of the first topics of discussion during patient encounters (e.g., via telemedicine or otherwise). When appropriate, clinicians can then recommend patient-centered stress management techniques that might prove helpful. Here are some ways to get started:

Feel your feelings. While it might seem intuitively obvious, many patients might not truly recognize the degree by which mental stress is altering their behavior, lives, and overall health or might be avoiding addressing feelings of sadness or loss of previous routines and lifestyle. This should be a prime topic to discuss during any patient encounter. Patients should be educated to become in touch with their feelings and recognize how those feelings might be affecting their behavior. Negative or unproductive feelings and the potential adverse effect on behavior cannot be resolved until it is first acknowledged.

Take it one moment at a time. At this time, no one knows how or when the COVID-19 crisis will end. It is likely nothing will ever go back to “normal.” This might be a daunting notion to patients with obesity, who might already have a sense of hopelessness. Thus, instead of focusing on the seemingly unending days of isolation ahead, patients should be encouraged to focus on manageable, demonstrable, and accountable healthful measures that can be accomplished today. Behavior changes that are doable, accountable, and sustainable represent the mainstays of a behavior modification plan.

Perform a food inventory. It is common that patients with increased mental stress resort to “comfort food,” which is often energy dense and highly processed. Temptation to consume these foods is increased if these nutrition-deficient foods are in the location where people live. Thus, patients might best be advised to perform an inventory on the nutritional quality of food where they live. When ordering food or grocery delivery, patients should virtually shop when they are not hungry or exceptionally stressed. Having friends or family review the list might also be helpful for some to ensure healthy foods are chosen.

Stay physically active. When shelter-in-place regulations prevent leaving the house, patients can be advised to look for novel ways to keep moving. Pacing while on the phone, putting the laundry away one item at a time, listening to music and dancing, and taking a lap around the house or backyard are all ways to remain physically active while sheltering in place. Passive stress relievers, such as surfing the internet, watching television, and playing video games might seem like an ideal way to pass the time. But these do not contribute much to energy expenditure and might worsen anxiety. Too much time spent with passive screen activities can have a negative impact on health. It is a good idea for clinicians to specifically talk to their patients with obesity about limiting screen time.

Stick to routines and care plans. Now is not the time for patients to fall out of previous healthful routines and self-care that was either promoting health, or helping with health maintenance. Patients should be encouraged to think beyond COVID-19. They should avoid having these few months negate years of potential progress that were so hard to achieve. Patients should especially be advised to monitor their sleep patterns. Poor sleep can contribute to worsening metabolic disease, cardiovascular disease, and obesity. Closer clinician contact with bariatric patients at this time is critical to identifying early maladaptive behaviors and routines and ensure continued long-term success

Practice active stress reduction. Patients should be encouraged to explore activities, such as walks (where permissible), puzzles, books, yoga, meditation, and other hobbies. Maintaining social connection via phone and video calls while physically distancing can be an important method of stress reduction. These pastimes can have a soothing effect during this stressful time.

Look for the helpers. Fred Rogers said it best, “Look for the helpers. You will always find people who are helping.” During times of crisis, finding a way to join the helpers can be gratifying not just for the one being helped, but also the one doing the helping. Participating in community efforts to improve the lives of those affected by the COVID-19 crisis can have a relieving impact for everyone.

Maintain social connectivity. While the recommended jargon of “social distancing” is prevalent, perhaps the implication of this approach is not what was intended. Perhaps a better term is “physical distancing.” Remaining socially distant is not always the best plan, especially for patients with obesity who are already stressed and who might already feel isolated. For many patients, it might be best to recommend to seek and maintain social connection via a simple phone call, or FaceTime, Zoom, Google Hangouts, or any of the myriad digital communication solutions available.

As clinicians continue to look for ways to help their patients during these stressful and uncertain times, bariatric surgeons can empower patients via implementing simple techniques, such as the ones described here. The Obesity Medicine Association (OMA) offers a trove of resources for clinicians and health care professionals, including continuing medical education, American Board of Obesity Medicine (ABOM) exam preparation, Obesity Treatment Proficiency Badges™, and The Obesity Algorithm®, which offers comprehensive clinical guidance on the latest obesity management trends and evidence-based medical approaches to treatment.^6–8 To become an OMA member, visit: https://obesitymedicine.org/join/.

For more obesity medicine resources, visit: www.obesitymedicine.org.

References

1. Scott KA, Melhorn SJ, Sakai RR. Effects of chronic social stress on obesity. Curr Obes Rep. 2012;1(1):16–25.
2. Joseph JJ, Golden SH. Cortisol dysregulation: the bidirectional link between stress, depression and type-2 diabetes mellitus. Ann N Y Acad Sci. 2017;1391(1):20–34.
3. Kyrou I, Tsigos C. Chronic stress, obesity and gonadal function. Hormones (Athens). 2008;7(4):287–293.
4. Yaribeygi H, Panahi Y, Sahraei H, et al. The impact of stress on body function: a review. EXCLI J. 2017;16:1057–1072.
5. Bergmann N, Gyntelberg F, Faber J. The appraisal of chronic stress and the development of metabolic syndrome: a systematic review of cohort studies. Endocr Connect. 2014;3(2):R55–80
6. Obesity Medicine Association. https://obesitymedicine.org/badges/. Accessed March 24, 2020.
7. Obesity Medicine Association. https://obesitymedicine.org/. Accessed March 24, 2020.
8. Obesity Medicine Association. https://obesitymedicine.org/obesity-algorithm/. Accessed March 24, 2020

[AZhiker 2,251]

Thank you. This whole situation has created an undercurrent of low level anxiety for me. I am not in any dire straights financially or otherwise. I have my family together and I have enough food and TP! But I feel vulnerable and more emotionally labile. I find myself more tempted by emotional eating. There is a sense of uncertainty and loss of control. It is actually good to see these things surface, so they can be dealt with. I know this experience will make me more resilient and will help develop coping mechanisms to a higher level. Thanks for the article. We all need to use this as an opportunity to learn and grow.

[PollyEster 228]

1 hour ago, AZhiker said:

This whole situation has created an undercurrent of low level anxiety for me. I am not in any dire straights financially or otherwise. I have my family together and I have enough food and TP!

Ditto on both counts for me as well, even though I am about to run out of TP and still can't find any in my city.

1 hour ago, AZhiker said:

But I feel vulnerable and more emotionally labile. I find myself more tempted by emotional eating. There is a sense of uncertainty and loss of control. It is actually good to see these things surface, so they can be dealt with. I know this experience will make me more resilient and will help develop coping mechanisms to a higher level. Thanks for the article. We all need to use this as an opportunity to learn and grow.

Since you work in the healthcare profession, I expect that either directly or indirectly, you've been deeply affected by covid-19. I'm a biologist with a secure job and career, but also a long-time volunteer in the field of end of life care. The nature of my volunteer work hasn't changed lately, but the volume of patients we’re seeing and the environment in which we’re caring for them has been meaningfully altered. The pandemic does not allow the luxury of time with my patients and their relatives. News is broken quickly, visitors and families are largely absent, faces are obscured by masks and visors, and more people are dying alone. The atmosphere in hospitals and hospices is taking an emotional toll on us all. Perhaps you’re experiencing something similar at work, as well.

I'm grateful that my WLS surgery is in the rear-view mirror (or I’d be worrying about access to enough fresh foods, since pre-op I ate 3lbs of raw veg and fruit daily), but still not too far away, as I remain relatively uninterested in food (cooking and food science used to take up a lot of my free time and without a doubt I'd be doing way too much cooking and eating right now if I hadn't had surgery). I still have to work hard to adhere to a strict eating and exercise schedule, but I'm at ease with that and view this is a beneficial intensive training period that will serve me well over the long-term.

Like you, I embrace this as an opportunity to learn more about myself and others. One of the few consolations of the coronavirus is the possibility that it could (eventually) lead to some progressive economic and political changes. I find it (somewhat) helpful to frequently remind myself that none of what we are experiencing right now is permanent. Please take care, and stay as safe as you possibly can.

Edited May 3, 2020 by PollyEster

[GreenTealael 24,850]

4 hours ago, PollyEster said:

Coping with Stress During COVID-19: What Bariatric Patients Need to Know

May 1, 2020 by Harold Bays, MD, FOMA, and Lydia C. Alexander, MD, FOMA

Dr. Bays is Medical Director and President of the Louisville Metabolic and Atherosclerosis Research Center in Louisville, Kentucky. Dr. Alexander practices obesity medicine at Kaiser Permanente Medical Weight Management Group in San Francisco, California.

Funding: No funding was provided.

Disclosures: Harold Bays, MD, FOMA is Trustee, Chief Science Officer, and Lydia C. Alexander, MD, FOMA, is Secretary/Treasurer for the Obesity Medicine Association.

---

During this most unique of times, as frontline healthcare workers and hospital staff, we frequently face difficulties when treating patients threatened by a rapidly increasing pandemic. This is made even more difficult with the stress of limited essential medical supplies. Among all the turmoil and disruption, the emergence of COVID-19 has created special challenges for patients with obesity.

Many patients with obesity have impaired immunity, impaired lung function, sleep apnea, and hypoxia, making a virulent upper respiratory tract infection especially perilous. Added to this are obesity-related debilitation, immobility, orthopedic changes, polypharmacy, more limited access to medical/preventive care, and adiposopathic complications of diabetes mellitus, and cardiovascular disease.¹ Collectively, patients with obesity are more susceptible to COVID-19 disease and have worse outcomes once infection occurs.

For many bariatric patients, the rise of the novel coronavirus has created additional challenges, such as the effect of mental stress on their lives. Increased mental stress can worsen complications from obesity, such as hyperglycemia, high blood pressure, dyslipidemia, and might also worsen obesity itself. The good news is that if clinicians are attuned to the physical impacts of mental stress, then proactive measures can be taken to mitigate the potential adverse consequences of mental stress.

Acute Stress, Chronic Stress and COVID-19

Acute, or short-term, stress is a function of the natural “fight or flight” response. One of the systems activated by the stress response is the sympathetic nervous system, which increases production of hormones epinephrine and norepinephrine. The acute stress response can be beneficial—it can increase visual acuity, decrease pain, increase blood flow, and boost the immune system. This complex sequence of hormonal changes and physiological responses helps people when they need to fight or flee to safety.

Conversely, chronic, or long-term “submit and stay” stress has the potential to worsen health outcomes. Chronic stress can increase cortisol production, which might promote visceral fat accumulation.^2,3 Symptomatically, chronic stress can cause decreased cognitive ability, diminished healthful decision-making, and more pronounced pain. Physiologically, chronic stress can impair immune function, impair sleep patterns and increase blood sugar, high blood pressure, and body weight.⁴

The Toll of Chronic Stress on Patients with Obesity During COVID-19

Stress and anxiety are understandable during the COVID-19 situation. We are living in a time of an unprecedented global pandemic crisis. Doom and gloom are everywhere. Good news is rarely reported. Stress is to be expected. However, clinicians can assist patients with proactive stress management techniques, especially for people living with obesity.

Many patients are staying home to keep themselves and others safe and limit the spread of the novel coronavirus. Other patients are staying home because of governmental mandates. But while “distancing” from others could have potential benefits in preventing viral spread, staying home might result in less healthful nutrition and reduced physical activity. As we navigate the unparalleled COVID-19 crisis, it is critical that clinicians, including bariatric surgeons, counsel patients to recognize the signs of mental stress, as well as its potential negative impact to health. This would include increased blood sugar, high blood pressure, increased body weight, and challenges fighting viral respiratory infections. Bariatric patients should receive specific and actionable guidance on safely optimizing nutrition and physical activity during periods of shelter-in-place orders.⁵

Coping with Stress During COVID-19

As we await a cure or vaccine for the novel coronavirus, one of the most important measures clinicians can take in the interim is to address potential mental stress head-on, as one of the first topics of discussion during patient encounters (e.g., via telemedicine or otherwise). When appropriate, clinicians can then recommend patient-centered stress management techniques that might prove helpful. Here are some ways to get started:

Feel your feelings. While it might seem intuitively obvious, many patients might not truly recognize the degree by which mental stress is altering their behavior, lives, and overall health or might be avoiding addressing feelings of sadness or loss of previous routines and lifestyle. This should be a prime topic to discuss during any patient encounter. Patients should be educated to become in touch with their feelings and recognize how those feelings might be affecting their behavior. Negative or unproductive feelings and the potential adverse effect on behavior cannot be resolved until it is first acknowledged.

Take it one moment at a time. At this time, no one knows how or when the COVID-19 crisis will end. It is likely nothing will ever go back to “normal.” This might be a daunting notion to patients with obesity, who might already have a sense of hopelessness. Thus, instead of focusing on the seemingly unending days of isolation ahead, patients should be encouraged to focus on manageable, demonstrable, and accountable healthful measures that can be accomplished today. Behavior changes that are doable, accountable, and sustainable represent the mainstays of a behavior modification plan.

Perform a food inventory. It is common that patients with increased mental stress resort to “comfort food, ” which is often energy dense and highly processed. Temptation to consume these foods is increased if these nutrition-deficient foods are in the location where people live. Thus, patients might best be advised to perform an inventory on the nutritional quality of food where they live. When ordering food or grocery delivery, patients should virtually shop when they are not hungry or exceptionally stressed. Having friends or family review the list might also be helpful for some to ensure healthy foods are chosen.

Stay physically active. When shelter-in-place regulations prevent leaving the house, patients can be advised to look for novel ways to keep moving. Pacing while on the phone, putting the laundry away one item at a time, listening to music and dancing, and taking a lap around the house or backyard are all ways to remain physically active while sheltering in place. Passive stress relievers, such as surfing the internet, watching television, and playing video games might seem like an ideal way to pass the time. But these do not contribute much to energy expenditure and might worsen anxiety. Too much time spent with passive screen activities can have a negative impact on health. It is a good idea for clinicians to specifically talk to their patients with obesity about limiting screen time.

Stick to routines and care plans. Now is not the time for patients to fall out of previous healthful routines and self-care that was either promoting health, or helping with health maintenance. Patients should be encouraged to think beyond COVID-19. They should avoid having these few months negate years of potential progress that were so hard to achieve. Patients should especially be advised to monitor their sleep patterns. Poor sleep can contribute to worsening metabolic disease, cardiovascular disease, and obesity. Closer clinician contact with bariatric patients at this time is critical to identifying early maladaptive behaviors and routines and ensure continued long-term success

Practice active stress reduction. Patients should be encouraged to explore activities, such as walks (where permissible), puzzles, books, yoga, meditation, and other hobbies. Maintaining social connection via phone and video calls while physically distancing can be an important method of stress reduction. These pastimes can have a soothing effect during this stressful time.

Look for the helpers. Fred Rogers said it best, “Look for the helpers. You will always find people who are helping.” During times of crisis, finding a way to join the helpers can be gratifying not just for the one being helped, but also the one doing the helping. Participating in community efforts to improve the lives of those affected by the COVID-19 crisis can have a relieving impact for everyone.

Maintain social connectivity. While the recommended jargon of “social distancing” is prevalent, perhaps the implication of this approach is not what was intended. Perhaps a better term is “physical distancing.” Remaining socially distant is not always the best plan, especially for patients with obesity who are already stressed and who might already feel isolated. For many patients, it might be best to recommend to seek and maintain social connection via a simple phone call, or FaceTime, Zoom, Google Hangouts, or any of the myriad digital communication solutions available.

As clinicians continue to look for ways to help their patients during these stressful and uncertain times, bariatric surgeons can empower patients via implementing simple techniques, such as the ones described here. The Obesity Medicine Association (OMA) offers a trove of resources for clinicians and health care professionals, including continuing medical education, American Board of Obesity Medicine (ABOM) exam preparation, Obesity Treatment Proficiency Badges™, and The Obesity Algorithm®, which offers comprehensive clinical guidance on the latest obesity management trends and evidence-based medical approaches to treatment.^6–8 To become an OMA member, visit: https://obesitymedicine.org/join/.

For more obesity medicine resources, visit: www.obesitymedicine.org.

References

1. Scott KA, Melhorn SJ, Sakai RR. Effects of chronic social stress on obesity. Curr Obes Rep. 2012;1(1):16–25.
2. Joseph JJ, Golden SH. Cortisol dysregulation: the bidirectional link between stress, depression and type-2 diabetes mellitus. Ann N Y Acad Sci. 2017;1391(1):20–34.
3. Kyrou I, Tsigos C. Chronic stress, obesity and gonadal function. Hormones (Athens). 2008;7(4):287–293.
4. Yaribeygi H, Panahi Y, Sahraei H, et al. The impact of stress on body function: a review. EXCLI J. 2017;16:1057–1072.
5. Bergmann N, Gyntelberg F, Faber J. The appraisal of chronic stress and the development of metabolic syndrome: a systematic review of cohort studies. Endocr Connect. 2014;3(2):R55–80
6. Obesity Medicine Association. https://obesitymedicine.org/badges/. Accessed March 24, 2020.
7. Obesity Medicine Association. https://obesitymedicine.org/. Accessed March 24, 2020.
8. Obesity Medicine Association. https://obesitymedicine.org/obesity-algorithm/. Accessed March 24, 2020

I ❤ that the cited sources are available

[summerset 5,261]

This article made me think about the possibility that my current stomach problems might be more due to stress than to anything else.

There always seems to be this just-under-the-surface-anxiety. Doesn't matter if I'm at work, go shopping or being at home.