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
Low SES
Race
Positive
and
Negative
Events
Positive
and
Negative
Emotion/
Attitudes
CV Risk
Sleep
disturbance
Reserve
Capacity
Life Course
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
3
2.5
CRP
2
1.5
1
0.5
0
Lowest
Highest
Hollingshead SES Quartiles
Pulse Wave Velocity- Methods
Carotid
Probe
Pulse Wave Velocity = Distance / Time
Distance = The distance between the two
points measured over
the body.
Femoral
Probe
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
Income
Education
Neighborhood SES
Pulse Wave Velocity
700
650
600
550
500
450
400
Low
Medium
High
Thurston & Matthews, 2009
Carotid AtherosclerosisMethods
ECA
ICA
CCA
Bulb
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
0.57
0.56
IMT
0.55
0.54
0.53
0.52
0.51
Low
Medium
High
Assets
Thurston & Matthews, 2009, Soc Sci Med
Reserve Capacity Model
Low SES
Race
Positive
and
Negative
Events
Positive
and
Negative
Emotion/
Attitudes
CV Risk
Sleep
disturbance
Reserve
Capacity
Life Course
Depressive symptoms are associated with
arterial stiffness in adolescents
580
560
PWV
540
520
500
480
0-7
0-14
15-47
CES-Depressive Symptoms
Dietz & Matthews. J Adol Health. 2011; 48:579-589.
Increasing DBP reactivity to acute stress
is associated with carotid IMT
0.55
• Increasing DBP
reactivity associated
with IMT (β = .18)
IMT (mm)
0.545
0.54
0.535
0.53
0.525
0.52
Low
Med
High
DBP reactivity (mm Hg)
Increases in DBP Reactivity
• Increasing negative
events associated
with DBP reactivity (β
= .19)
16
14
12
10
8
6
4
2
0
Low
Med
High
Increases in Chronic Stress
Low et al. Psychosom Med. 2009; 71:927-31.
Percent SBP nondippers increases
with decreasing family income
35
30
25
%
20
15
10
5
0
Lowest
Highest
Family Income Quartiles
Higher trait negative emotions are
associated with higher SBP night/day
ratios
0.960
SBP night/day ratio
0.940
0.920
0.900
0.880
Low negative emotion
High negative emotion
0.860
0.840
0.820
0.800
Caucasian
African American
Race
Project Pressure II BP Diary Questions
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!
More unpleasant social interactions are
related to higher SBP night/day ratios
0.920
SBP night/day ratio
0.910
0.900
0.890
0.880
Low Unpleasant
low
high
High Unpleasant
0.870
0.860
0.850
0.840
Caucasians
n
African Americans
Race
Project Pressure II BP Diary Questions
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
Odds of 2+ metabolic syndrome
components in healthy adolescents
2.5
2
OR
1.5
1
0.5
0
Trait
Trait
State
Conflicted Pleasant
Negative
Positive
Negative Interaction Interaction
Emotion Resources Emotion
Midei & Matthews 2012
Reserve Capacity Model
Low SES
Race
Positive
and
Negative
Events
Positive
and
Negative
Emotion/
Attitudes
CV Risk
Sleep
disturbance
Reserve
Capacity
Life Course
Blacks and males sleep less than whites
during the school week (actigraphy)
6.5
Hours
6.3
6.1
5.9
5.7
5.5
Black
White
Males
Black
White
Females
Is sleep duration associated
with 24-hr SBP?
122
121
24-Hr SBP
120
119
118
117
116
115
114
113
≤ 5.8
≤ 6.3
≤ 6.6
≤ 7.0
≤ 9.2
Hours Sleep
Mezick et al. Hypertension. 2012.
HOMA Index
Is sleep duration associated
with insulin resistance?
4.7
4.6
4.5
4.4
4.3
4.2
4.1
4
3.9
3.8
3.7
3.6
.282
.248
.275
.214
< 5.4
< 6.0
< 6.48
> 6.49
Quartiles of Weekday Sleep Duration (hours)
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
2.5
Clustering of Metabolic Risk
Factors (3 of 6)
2
CRP>3 mg/L
1.5
1
0.5
0
Low SES
Social Isolation
Definite
Social Isolation
Maltreatment
Danese. Arch Pediatr Adolesc Med. 2009.
Relationships between Childhood SES
and Health: Dunedin Birth Cohort
SES
Adult health at 26 years old
Physical:
BMI
Waist/hip ratio
SBP
V02 max
Dental:
Tooth cleanliness
Dental caries > 4
Mental:
Major depression
Child
Adult

















Alcohol dependency
Tobacco dependency
Social Origin

Lancet. 2002; 360:1640-1645.
Alcohol Dependence and Waist/Hip
Ratio at Age 26 in Relation to SES
in Childhood and Age 26
84
30
25
82
20
80
15
10
78
5
0
76
High
Downward
mobility
Upward
mobility
Low
% Alcohol Dependence
High
Downward
mobility
Upward
mobility
Low
Mean Waist/Hip Ratio
Lancet. 2002; 360:1640-1645.
Reserve Capacity Model
Low SES
Race
Positive
and
Negative
Events
Positive
and
Negative
Emotion/
Attitudes
CV Risk
Sleep
disturbance
Reserve
Capacity
Life Course
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