A growing body of literature suggests that stress, including chronic stress and acute physiologic stress reactivity, is one contributor to the development and maintenance of obesity in youth. Little has been done to apply the literature on stress and obesity risk to inform the development of pediatric behavioral weight control (BWC) interventions. The aims of this review are to (1) discuss research linking stress and pediatric obesity, (2) provide examples of the implications of the stress-obesity research for pediatric BWC development, and (3) propose that a mindfulness-based approach may be useful in targeting stress reduction within pediatric BWC.
Key points
- •
Stress, including chronic stress and acute stress reactivity, is associated with pediatric obesity risk.
- •
Stress has been associated with weight-related outcomes in basic research, yet translational research is needed to inform the development of pediatric behavioral weight control (BWC) trials.
- •
Mechanisms through which mindfulness interventions may benefit weight management include reduction of stress, enhancing self-regulatory behaviors, and acceptance of discomfort.
- •
There is a need for future pediatric BWC research examining mindfulness-based approaches, because these may be useful for decreasing the negative impacts of stress on weight management (eg, eating in response to stress).
A growing body of literature suggests that stress, broadly defined as an individual’s negative response to an aversive or threatening stimulus, is one contributor to the development and maintenance of obesity in youth. Stress has been associated with increased food intake and cravings for comfort foods (highly palatable, energy-dense foods) among adults and children. The literature on chronic stress and obesity risk, which is based on cross-sectional and longitudinal methodologies, focuses primarily on life stressors. A separate and smaller body of experimental literature has examined the effects of subjective (ie, perceived stress) and objective (eg, cortisol reactivity) acute stress response and obesity risk, including the effects of stress reactivity on food intake. To date, however, little has been done to apply this research on stress and obesity risk to inform the development of pediatric BWC interventions.
Standard BWC interventions for pediatric populations generally produce beneficial short-term weight loss outcomes by implementing dietary, physical, and behavioral changes. Compared with the BWC outcomes in school-aged children; however, outcomes for adolescents are less consistently favorable. This is important given that approximately 34% of US adolescents (ages 12–19) are overweight or obese, and that overweight adolescents are at increased risk for a host of negative cardiometabolic and psychosocial consequences. It may be particularly important to consider the impact of stress on weight management during the adolescent period. Adolescence is also a period of increased stress due to a multitude of concurrent psychosocial (eg, changing socioenvironmental contexts and emerging independence) and physiologic (eg, puberty) demands. Furthermore, overweight adolescents endorse higher levels of chronic emotional distress compared with lean adolescents. In addition, income disparities exist in pediatric weight management, in that children and adolescents from low-income households show poorer outcomes in traditional BWC treatment. Low-income populations, who likely experience multiple stressors, may be particularly susceptible to the impact of stress on weight outcomes. To date however, little treatment research has actively addressed stress (eg, stress reactivity and stress-related barriers to treatment engagement) in pediatric weight management.
Translational research is crucial to bridge the body of experimental research in stress and obesity to inform the development and implementation of effective pediatric BWC interventions. The primary aims of this review are, within a translational framework, to
- 1.
Discuss research linking stress (ie, chronic stress and acute stress reactivity) and pediatric obesity
- 2.
Provide examples of ways to integrate the stress-obesity research within pediatric BWC
- 3.
Propose that a mindfulness-based approach may be useful in targeting stress reduction within pediatric BWC
Given that there is a lack of child-specific and adolescent-specific literature in some areas discussed within this review article, findings based on adults samples are integrated to highlight key findings while also serving as a guide for areas in need of further investigation using pediatric samples.
Linking stress and risk for pediatric obesity: evidence from the chronic stress and acute stress reactivity literatures
Chronic Stress
Chronic stress is linked to increased risk for obesity in adults and youth. For example, in a 5-year prospective study of adolescents, persistent perceived stress was associated with higher body mass index (BMI) and waist circumference. Low socioeconomic status (SES), adverse life events (eg, high-crime neighborhood), and parent mental health (eg, maternal depression) are examples of chronic stressors that have been associated with greater weight status.
Consistent with Bronfenbrenner and Vasta’s socioecological model of child development, stressors can be understood as spanning from proximal (individual-level and parent-level) to more distal (environmental-level) domains. For example, markers of individual-level stress that have been correlated with higher child weight status have included child psychopathology and weight-related peer victimization. Parent-level chronic stressors, such as maternal depression, parenting stress, and time demands, have also been associated with higher youth weight status. For example, youth whose parents have many time demands may have fewer meals prepared at home. Parent-child conflict may also exacerbate stress eating or unhealthy behaviors. Environmental-level stressors, such as community violence, may also have an adverse impact on healthy pediatric weight management. SES can be conceptualized as an environmental-level risk that it is associated with poorer health outcomes and greater likelihood of obesity.
Some adolescent populations, such as youth from low-income households and racial/ethnic minority youth, are not only at greater risk for obesity but also more vulnerable to experiencing chronic stress and multiple adverse life events. For example, adolescents from low-SES communities may face greater community-level (eg, neighborhood violence), family-level (eg, financial strain and maternal depression), and individual-level (eg, poor academic achievement and internalizing/externalizing symptoms) stressors, which are known to adversely affect health. Financial strain may also affect food choices by encouraging the purchase of low-cost, energy-dense foods such that adolescents have decreased availability of healthy food choices. Furthermore, low-SES youth may be vulnerable to food insecurity (ie, limited or uncertain availability of nutritionally adequate food due to financial constraints), which has, paradoxically, been associated with increased risk for obesity. Because youth from low-SES backgrounds and racial/ethnic minority youth may be particularly vulnerable to experiencing chronic stress, it may be especially important to integrate an understanding of stress within BWC interventions for these populations.
Acute Stress
Laboratory-based research has examined associations between physiologic and behavioral responses to short-term external stressors and markers of obesity risk. The majority of emerging evidence suggests that laboratory-induced physiologic stress reactivity (eg, cortisol, blood pressure, and heart rate) is positively associated with greater BMI, central fat distribution, and percentage body fat in adults as well as in children and adolescents. For example, one study showed that changes in perceived stress and heart rate reactivity after a speech task predicted greater BMI percentile and percentage body fat in children, independent of ethnicity, age, and gender. This study was conducted, however, in a predominantly white, middle-class sample of school-aged children (ages 8–12 years); research is needed to examine the generalizability of these findings to overweight/obese youth from low-income households. See Table 1 for a summary of experimental research that has examined stress reactivity in the context of eating and weight-related outcomes in pediatric samples. Only one of these studies included ethnic/racial minority youth as the majority of their sample, although a majority of adolescent participants were from middle-income households. This study examined the associations between laboratory-induced stress, delayed discounting (impulsivity tendencies), and BMI among urban Chinese adolescents. The results showed that delayed discounting significantly mediated higher levels of stress reactivity and greater BMI. The remaining studies presented in Table 1 included predominantly white, middle-income to high-income pediatric samples, thus demonstrating the need to examine the relationship between stress and weight management in at-risk minority populations.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
