Childhood Roots of Disparities in Cardiovascular Disease in Adulthood
Karen A. Matthews, Ph.D. University of Pittsburgh
Overall Themes & Objectives
• To understand CVD disparities, need to focus on early CVD risk development
• Need to develop testable models that can identify pathways for intervention
• Evidence for psychosocial pathways as part of CVD disparities
AHA Special Report: Defining and Setting National Goals for Cardiovascular
Health Promotion and Disease Reduction
The American Heart Association’s Strategic Impact Goal Through 2020 and Beyond (Circ 2010)
Reduce deaths from CVD and stroke by 20%
Improve CV health of all
Americans by 20%
What is CV Health? • Nonsmoker • BMI < 25 • Physical activity > 150 min/wk moderate • Good diet (fruits, vegetables, fiber, low Na,
low sugary drinks) • Cholesterol < 200 mg/dl • BP < 120/<80 Hg/mm • Fasting glucose < 100 mg/dl
Lifetime Risk of Death from Cardiovascular Disease among Black
Men and White Men at age 55
Berry et al. N Engl J Med. 2012; 366:321-9.
Proportion of HeartSCORE with ideal CVD risk factors
Bambs et al. Circulation. 2011; 123: p. 854.
AHA Special Report:
“…many CVDs with ultimate outcomes in adulthood actually have their origins during
childhood.”
“…primordial prevention has relevance and urgency in the high-income nations of today, given the
substantial burden of obesity and the adverse health behaviors and environment that often begin in childhood and are present in most high-income
nations, especially the United States.”
Circulation. 2010; 21:586-613.
Atherosclerosis begins early in life, with lesions starting in adolescence.
Accumulation of standard CVD risk factors in childhood predicts:
• Coronary calcification in midlife (JACC 1996 Muscatine, Iowa Study)
• Maximum carotid IMT in midlife (JAMA 2003 Finnish cohort)
• Mean carotid IMT in young and middle-age adults (JAMA 2003 Bogalusa)
• Fatty streaks and fibrous plaque postmortem (NEJM 1998)
• What about the accumulation of adverse behaviors and environments starting in youth?
What adverse behaviors and environments in childhood
may be key to understanding CVD health disparities?
Utility of Conceptual Models
• Important to develop because many factors contribute to health disparities
• Guide formulation of research questions and study design
• Setting of bounds around a research problem
• Highlight key causal factors over others
Diez Roux. Annual Rev Public Health. 2012
Reserve Capacity Model
Life Course
Positive and
Negative Events
Positive and
Negative Emotion/ Attitudes
CV Risk
Sleep disturb-
ance
Reserve Capacity
Low SES
Race
Risk of CHD among Short Sleepers Compared to Normal Sleepers
Cappucio et al. Eur Heart J. 2011.
Two Studies on Development of Cardiovascular Risk in Adolescents
Project Pressure I
225 healthy black and white adolescents ages 14-16 followed for 3 years for CV
reactivity to stress, vascular stiffness, carotid IMT, and night/day ambulatory BP
Project Pressure II
250 healthy black and white high school students examined for metabolic syndrome,
night/day ambulatory BP, and sleep (actigraphy & diary)
Higher CRP is associated with lower family SES
0
0.5
1
1.5
2
2.5
3
CRP
Hollingshead SES Quartiles Lowest Highest
Carotid Probe
Femoral Probe
Pulse Wave Velocity- Methods
Pulse Wave Velocity = Distance / Time
Distance = The distance between the two points measured over
the body.
Time = The time the foot of the pressure wave takes to travel between
sites.
Higher values = Stiffer vessels
Lower SES is associated with greater arterial stiffness in adolescents
400
450
500
550
600
650
700
Low Medium High
Puls
e W
ave
Velo
city
Income Education Neighborhood SES
Thurston & Matthews, 2009
Carotid Atherosclerosis-Methods
ICA
ECA
Bulb CCA
Intima-Media Thickness (IMT): Average from the near and far walls of the CCA, and far walls of the bulb, ICA.
Plaque Index: Measure of focal plaque based on the number and size of plaques in the CCA, bulb, ICA and ECA.
Low assets are associated with carotid IMT in adolescents
0.51
0.52
0.53
0.54
0.55
0.56
0.57
Low Medium High
IMT
Assets Thurston & Matthews, 2009, Soc Sci Med
Reserve Capacity Model
Life Course
Positive and
Negative Events
Positive and
Negative Emotion/ Attitudes
CV Risk
Sleep disturb-
ance
Reserve Capacity
Low SES
Race
Depressive symptoms are associated with arterial stiffness in adolescents
480
500
520
540
560
580
0-7 0-14 15-47
CES-Depressive Symptoms Dietz & Matthews. J Adol Health. 2011; 48:579-589.
PWV
Increasing DBP reactivity to acute stress is associated with carotid IMT
02468
10121416
Low Med High
Increases in Chronic Stress
DB
P re
activ
ity (m
m H
g)
0.52
0.525
0.53
0.535
0.54
0.545
0.55
Low Med High
Increases in DBP Reactivity
IMT
(mm
) • Increasing DBP reactivity associated with IMT (β = .18)
• Increasing negative events associated with DBP reactivity (β = .19)
Low et al. Psychosom Med. 2009; 71:927-31.
Percent SBP nondippers increases with decreasing family income
0 5
10 15 20 25 30 35
%
Family Income Quartiles
Lowest Highest
Higher trait negative emotions are associated with higher SBP night/day
ratios
0.800
0.820
0.840
0.860
0.880
0.900
0.920
0.940
0.960
Caucasian African American
SBP
nigh
t/day
rat
io
Race
Low negative emotion High negative emotion
BP Diary 18. In past 10 minutes, were you talking to someone? (includes phone /email /text messaging /etc) NO YES If you answered YES to question 18, please answer the following four questions about your Most Recent Interaction: 1. Who were you talking with? (select one)
School Personnel Friend(s) Parent(s) Other Relative(s) Other 2. Did someone make you feel important, included or good about yourself?
NO! NO no yes YES YES!
3. Did you have a conflict or disagreement with someone? NO! NO no yes YES YES!
4. Did you have a pleasant interaction with someone? NO! NO no yes YES YES!
Project Pressure II BP Diary Questions
More unpleasant social interactions are related to higher SBP night/day ratios
0.840
0.850
0.860
0.870
0.880
0.890
0.900
0.910
0.920
Caucasians African Americans
SBP
nigh
t/day
rat
io
Race
low high
n
Low Unpleasant
High Unpleasant
BP Diary 5. At time of BP, are you Irritable? Not at all A little Moderately Quite a bit Extremely 6. At time of BP, are you Excited? Not at all A little Moderately Quite a bit Extremely 7. At time of BP, are you Cheerful?
Not at all A little Moderately Quite a bit Extremely 8. At time of BP, are you Angry? Not at all A little Moderately Quite a bit Extremely 9. At time of BP, are you Sad? Not at all A little Moderately Quite a bit Extremely 10. At time of BP, are you Interested? Not at all A little Moderately Quite a bit Extremely 11.At time of BP, are you Distressed?
Not at all A little Moderately Quite a bit Extremely 12.At time of BP, are you Happy?
Not at all A little Moderately Quite a bit Extremely 13.At time of BP, are you Sleepy? Not at all A little Moderately Quite a bit Extremely
Project Pressure II BP Diary Questions
Odds of 2+ metabolic syndrome components in healthy adolescents
0
0.5
1
1.5
2
2.5
Trait Negative Emotion
Trait Positive
Resources
State Negative Emotion
Conflicted Interaction
Pleasant Interaction
Midei & Matthews 2012
OR
Reserve Capacity Model
Life Course
Positive and
Negative Events
Positive and
Negative Emotion/ Attitudes
CV Risk
Sleep disturb-
ance
Reserve Capacity
Low SES
Race
Blacks and males sleep less than whites during the school week (actigraphy)
5.5
5.7
5.9
6.1
6.3
6.5
Black White Black White
Males Females
Hou
rs
113
114
115
116
117
118
119
120
121
122
≤ 5.8 ≤ 6.3 ≤ 6.6 ≤ 7.0 ≤ 9.2
24-H
r SBP
Hours Sleep
Is sleep duration associated with 24-hr SBP?
Mezick et al. Hypertension. 2012.
Is sleep duration associated with insulin resistance?
3.6 3.7 3.8 3.9
4 4.1 4.2 4.3 4.4 4.5 4.6 4.7
< 5.4 < 6.0 < 6.48 > 6.49
HO
MA
Inde
x
Quartiles of Weekday Sleep Duration (hours)
.282
.275
.214
.248
Matthews et al. Sleep. 2012.
Why poor sleep may be linked to metabolic factors and BP:
• Obesity • Increases in SNS and decreases in PNS
activation affecting BP • Leptin secretion inhibited by SNS and
ghrelin secretion inhibited by PNS • Glucocorticoids facilitate visceral fat
accumulation, affecting insulin resistance
Multivariate Risk Ratios of Childhood Predictors of CV Risk Factors at Age 32
0
0.5
1
1.5
2
2.5
Low SES Social Isolation Definite Maltreatment
Social Isolation
Clustering of Metabolic Risk Factors (3 of 6)
CRP>3 mg/L
Danese. Arch Pediatr Adolesc Med. 2009.
Relationships between Childhood SES and Health: Dunedin Birth Cohort
SES
Child Adult Social Origin
Alcohol dependency
Tobacco dependency
Adult health at 26 years old Physical: BMI Waist/hip ratio SBP V02 max Dental: Tooth cleanliness Dental caries > 4 Mental: Major depression
Lancet. 2002; 360:1640-1645.
Alcohol Dependence and Waist/Hip Ratio at Age 26 in Relation to SES
in Childhood and Age 26
0
5
10
15
20
25
30
High Downward mobility
Upward mobility
Low 76
78
80
82
84
High Downward mobility
Upward mobility
Low
% Alcohol Dependence Mean Waist/Hip Ratio Lancet. 2002; 360:1640-1645.
Reserve Capacity Model
Low SES
Race
Life Course
Positive and
Negative Events
Positive and
Negative Emotion/ Attitudes
CV Risk
Sleep disturb-
ance
Reserve Capacity
Future Directions
• Theory-driven studies on psychobiological pathways in relation to genetic factors
• Studies earlier in the life course, consideration of ethnicity and changing SES
• New tools and foci
Thank you for your attention