Diabetes and Chronic Stress: A Former Harold Amos Scholar Looks for the Connection

    • September 12, 2013

The problem. Certain risk factors for type 2 diabetes are well established, obesity being a primary one. But what about psychological stress? Can chronic stress trigger biological responses that put a person at increased risk for this destructive disease?

That question is a key research focus of Sherita Hill Golden, MD, MHS, Hugh P. McCormick Family Associate Professor of Medicine at Johns Hopkins University and a former scholar in RWJF’s Harold Amos Medical Faculty Development Program. (See the Program Results Report for more information.)

Stress, of course, can stem from highly individual factors. But the broader physical and social environment may also play a part, according to Golden, who trained as an endocrinologist.

“In neighborhoods where the social environment is poor, and there is less cohesion, more crime, [those conditions] could lead to individuals feeling more stress,” she says. “And that might contribute to hormonal alterations that could increase the risk for diabetes and heart disease.”

Diabetes—a major cause of coronary heart disease, stroke, kidney failure, and other health problems—is estimated to affect more than 25 million Americans, with an especially heavy toll on certain racial and ethnic minorities.

“The reason that the area of stress has been of interest to me is that I think it may relate to some of the disparities we see in health outcomes for people with diabetes and heart disease,” says Golden, who is African American.

The start. Golden grew up in suburban Maryland outside Washington and was on her way at an early age to becoming the family’s first scientist. Her dedicated parents allowed her to grow algae and fungus in the kitchen, and one morning her mother drove her in the freezing rain to a lab because her samples for a school science fair project had to be measured at a precise time.

“We were walking on ice with these boxes full of all of my bottles. My dad had cushioned them so nothing would break,” she says, chuckling at the memory. “We laugh because we say we took the journey together.”

The budding scientist was good in all school subjects, and from the outside her A’s seemed to come easily—but not from where she sat, which was at the kitchen table, doing homework late into the night. “I always worked really hard because I wanted to do well in what I did—to be the best at what I did, no matter what stage I was at in my career.”

In 1990 Golden graduated from the University of Maryland, College Park, summa cum laude with high honors in biology and four years later earned an MD at the University of Virginia.

A change in plans. When she entered medical school, Golden planned to be a general-practice pediatrician. “I think everyone thinks about the first doctor they ever interacted with, and you want to be that person.” It was her third-year pediatrics rotation that changed her mind:

I was taking care of these very sick children that had chronic conditions that weren’t going to get better, and it was heart-breaking for me. I remember I came home the first couple of days of the rotation almost in tears. I called my parents and said, “I always wanted to be a pediatrician, but it didn’t occur to me I would have to take care of sick children, too. I thought it would be all well-child visits.”

In contrast, her internal medicine rotation was a positive experience. The attending physician, Professor Eugene J. Barrett, an endocrinologist, was an inspiring teacher, and during the rotation Golden worked on a hospital floor with numerous diabetic patient admissions. “I really liked the idea that diabetes was a disease where the patient could partner with their physician to affect the outcome.” In short, she says, “I fell in love with endocrinology.”

An academic career. In addition to changing her specialty intentions, medical school steered Golden in another new direction. “I also realized that in the field of diabetes there were still many unanswered questions, like: How do we prevent complications? What are the different risk factors in various groups of people? What are the various interventions?”

That, she says, is what turned her sights to academic medicine—“because there were so many unanswered questions.”

Golden went to Johns Hopkins for her internal medicine residency—and stayed, completing a three-year endocrinology fellowship and simultaneously earning a master’s in clinical epidemiology at the university’s Bloomberg School of Public Health. In 2000 she joined the medical school faculty.

Today, in addition to her primary appointment in the school’s endocrinology, diabetes, and metabolism division, Golden is on the faculties of the Bloomberg School (epidemiology department) and the university’s interdisciplinary Welch Center for Prevention, Epidemiology, and Clinical Research.

Indeed, for Golden, Johns Hopkins medicine is very much a family affair. Her husband, W. Christopher Golden, MD, a neonatologist, is an assistant professor of pediatrics.

But while the two have a profession in common, their interests diverge when it comes to Atlantic Coast Conference basketball. “My husband went to Duke so it’s a little challenging,” says the Maryland grad. Their alma maters are conference rivals so “We have to watch [the televised tournament games] in different parts of the house.”

The research. The author or co-author of more than 80 articles and book chapters, Sherita Golden has investigated a range of hormone-related issues. But her primary interest is identifying endocrine risk factors associated with the development of diabetes and cardiovascular disease.

She is particularly interested in the role of chronic psychological stress and depression. Both are associated with diabetes “but the mechanism remains unclear,” she wrote in a 2007 article in Current Diabetes Review.

One project that received a lot of attention has suggested the connection between depression and diabetes is a two-way street. A team led by Golden found that individuals with symptoms of depression at baseline were more likely to develop diabetes—and vice versa: individuals being treated for diabetes were at increased risk of developing depressive symptoms.

In a Johns Hopkins news release summarizing the study results, Golden speculated that depression may lead to poor health behaviors that trigger diabetes—for example, overeating and shunning exercise. And the stiff regimen that diabetic patients need to follow to control the disease may lead to depressive tendencies, she suggested.

"It's important that doctors be attuned to look for both conditions in patients at risk for either diabetes or depression," she said. (The study was published in the Journal of the American Medical Association in 2008. Abstract online.)

Golden is a frequent speaker at medical and academic gatherings, but her work on the relationship between the hormonal system and mental health-related issues has also gotten attention outside the profession.

In an advice piece for women on dealing with stress, the website knowworthy.com quoted Golden on the negative impact of excessive amounts of cortisol, a hormone that the body produces in response to stress. She was also among experts contacted by the Washington Post for an article on how the stress of the presidency has taken a toll on the physical appearance of Barack Obama, as it did on his predecessors.

In addition to researching diabetes and heart disease risk factors, Golden has two other primary interests. One is reducing disparities, especially among Blacks. She directs the Training Core for the university’s Center to Eliminate Cardiovascular Health Disparities, and in 2012 led an Endocrine Society task force that identified key factors contributing to racial, ethnic, and sex differences in endocrine disorders. 

She also directs a Johns Hopkins Hospital program to improve glucose management of diabetic inpatients and reduce their length of stay in the hospital. “I see it as taking my tools as a population scientist and applying them to the hospital setting,” she says.

In 2013, she was honored with election to the American Society for Clinical Investigation.

The RWJF connection. Golden was beginning her final fellowship year and finishing her master’s degree when she applied to RWJF’s Harold Amos Medical Faculty Development Program. She was also, she recalls, pregnant—32 weeks’ worth the day she was interviewed for selection by the program’s National Advisory Committee.

Her Harold Amos award (ID# 38409) began the next year, as she was joining the Hopkins faculty. The funding “was absolutely critical to my future success because¼it protected my time for four years to really focus on developing my research,” she says.

Her RWJF-supported research on novel risk factors for diabetes and cardiovascular disease, including depression, led to a grant from the National Institute of Diabetes, Digestive, and Kidney Diseases to examine hormonal changes associated with stress. Indeed, her work on depression through the Harold Amos program “served as a foundation for all of the work I’m doing currently,” says Golden.

RWJF perspective. The Harold Amos Medical Faculty Development Program is a four-year postdoctoral fellowship launched by RWJF in 1983. Its purpose is to increase the number of faculty from minority and other historically disadvantaged backgrounds who achieve senior rank in academic medicine and dentistry. A commitment to eliminating health disparities is among the selection criteria.

The program supports one of RWJF’s major objectives: To increase diversification of the medical and dental professions and, as a consequence, improve the health care received by the nation’s underserved populations.

Of Amos program scholars, RWJF senior program officer David M. Krol, MD, MPH, says:

Ultimately, we would like to see these individuals from historically disadvantaged backgrounds becoming full professors at prestigious institutions, putting out important, valuable work, looking at a variety of different issues—including how to decrease the disparities between rich and poor, majority and minority—while climbing the academic ladder.

Sherita Hill Golden is one of more than 180 Amos program alumni in academic medicine today. Her career and research exemplify the academic achievement and professional contributions that the program was designed to stimulate.

“The measure of the success of the program is the success of the individuals” who participate in it, says Krol.