Toxic weathering: How to talk to your patients about the impact of chronic stress

Why do certain groups of patients have higher burdens of disease? Through her more than 30 years of research, Dr. Arline Geronimus, ScD, found that being exposed to chronic stress, also known as allostatic load, may partially explain why people from marginalized backgrounds experience more chronic diseases at an earlier age. 

Extraordinary stress in an unjust society

Dr. Geronimus, a professor at the University of Michigan School of Public Health and author of Weathering: The Extraordinary Stress of Ordinary Life in an Unjust Society,^[] penned this constant flight or fight mode as “weathering.” Through her research, she found that weathering can lead to premature aging of the body and poor health outcomes.^[] Over the years, Dr. Geronimus has broadened her investigation to immigrants, Latinos, the LGBTQ+ community, and poor White people from Appalachia.^[]

Other researchers have supported Dr. Geronimus’ work. Shanshan Sheehy, MD, ScD, assistant professor of medicine at Boston University School of Medicine, and an investigator at Slone Epidemiology Center, has conducted numerous research studies exploring health disparities. One of these recent studies examined why Black women are disproportionately affected by heart disease.^[]

Dr. Sheehy explains that she followed 48,297 participants in the Black Women’s Health Study from 1997 until the end of 2019. At the beginning of the study, all were free of cardiovascular disease and cancer. At the end, the participants provided information on perceived interpersonal racism. 

“We found that perceived experiences of racism in the context of employment, housing, and the criminal justice system were associated with a 29% increased incidence of coronary heart disease among Black women,” she says. “Racism can act as a chronic stressor and lead to high blood pressure, which increases the risk of heart attack and stroke.”

Adjusting screening guidelines

Weathering can lead to minority patients’ experiencing earlier disease onset, according to a study published last year in JAMA Network Open.^[] The study found the onset of hypertension, insulin resistance, and diabetes occurred earlier in Black and Hispanic women compared with White women.

Researchers recommend doctors target interventions for Black and Hispanic women at earlier stages of their life, with hypertension screening beginning at 30 and screening for metabolic disease beginning at age 40.

Implicit bias in medicine

Although medical professionals strive to treat all patients equally, disparities in healthcare continue to exist. Recent research found that Black patients at an urban medical center had significantly higher odds of having negative descriptions in their EHRs than White patients.^[] This raised concerns about stigmatizing language in EHR systems and its potential to exacerbate racial and ethnic healthcare disparities. 

According to Harvard University’s Project Implicit, their online Implicit Association Test can help healthcare providers identify any potential biases they may have in regards to race, religion, and ethnicity. While acknowledging the test has limitations, Project Implicit notes that awareness is the first step in reducing implicit bias. 

Helping patients reduce the effects of weathering

There are ways physicians can help their patients who experience chronic stress. The American College of Obstetricians and Gynecologists makes the following recommendations for OB/GYNs and other healthcare providers to improve patient-centered care and decrease inequities:^[]

• Document social and structural determinants that can affect your patient’s health and use of healthcare resources, including access to stable housing, safety in the home and community, immigration status, and employment conditions.

• Acknowledge that racism and other forms of discrimination serve as social determinants of health.

• Recognize that stereotyping patients based on presumed cultural beliefs can negatively impact patient interactions.

Referring patients to psychosocial services

Physicians can refer their patients who experience chronic stressors to culturally competent and affirmative therapists. These trained professionals understand the harmful effects of discrimination and oppression and are trained to address trauma. As well, the AMA identifies racism as a public health threat and has adopted policies to mitigate the effects.[9]

Jack Turban, MD, MHS, director of the Gender Psychiatry Program at the University of California, San Francisco, says the minority stress framework shows how societal stigma is a major driver of the mental health disparities seen among LGBTQ+ people.

“More recently, researchers have focused on how public policies, in particular, are major determinants for mental health outcomes for LGBTQ people,” Dr. Turban tells MDLinx. “For example, recent anti-trans bills have been sending awful messages to young trans people—that their identity is a mental illness, that they are a risk to people in bathrooms, that they are a risk to their peers on sports teams. Though they know these things aren’t true, constantly hearing them still takes a toll on their mental health.”

Dr. Turban says there are resilience factors that can buffer against these negative impacts of societal stigma. 

“The two main ones are community connectedness and pride,” he says. “Connecting patients with others who have shared experiences is extraordinarily protective for mental health.”

What this means for you

Research supports the hypothesis that prejudice and discrimination can negatively affect the mental and physical health of millions of Americans.[8] To combat this, physicians can take steps to help their patients address these inequalities, such as acknowledging potential implicit biases and referring patients to culturally competent mental health practitioners.