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