Tackling Adversity and Cardiovascular Health: It is About Time

HomeCirculationVol. 147, No. 1Tackling Adversity and Cardiovascular Health: It is About Time Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBTackling Adversity and Cardiovascular Health: It is About Time Sarah K. Westcott, Tené T. Lewis and Michelle A. Albert Sarah K. WestcottSarah K. Westcott Department of Medicine and Center for the Study of Adversity and Cardiovascular Disease (NURTURE Center), Division of Cardiology, Department of Medicine, University of California, San Francisco (S.K.W., M.A.A.). Search for more papers by this author , Tené T. LewisTené T. Lewis https://orcid.org/0000-0003-3905-8931 Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (T.T.L.). Search for more papers by this author and Michelle A. AlbertMichelle A. Albert Correspondence to: Michelle A. Albert, MD, MPH, University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143. Email E-mail Address: [email protected] https://orcid.org/0000-0001-9887-685X Department of Medicine and Center for the Study of Adversity and Cardiovascular Disease (NURTURE Center), Division of Cardiology, Department of Medicine, University of California, San Francisco (S.K.W., M.A.A.). Search for more papers by this author Originally published28 Dec 2022https://doi.org/10.1161/CIRCULATIONAHA.122.061763Circulation. 2023;147:e1–e3One of the most foundational shared human experiences is adversity. Defined by Merriam-Webster Dictionary as “a state or instance of serious or continued difficulty or misfortune,” adversity can catalyze personal development and shape our values. However, the potency, life-course timing, duration, and type of adversity an individual or population faces affect biological adaptation, psychosocial responses, and health behaviors. Experiences with adversity, particularly when long term, lead to untoward health and well-being. This effect is markedly evident within the realm of cardiovascular disease. Certainly, decades of primary research, especially in the psychosocial literature, documents associations between various types of adversity and both cardiovascular risk factors and disease. Categories of adversity include but are not limited to exposure to harsh childhood environments, life-course trauma, violence, discrimination, economic and neighborhood stressors, environmental disasters, and even sociopolitical anxiety. For example, self-reported everyday discrimination is positively associated with hypertension, poor sleep, visceral fat, elevated C-reactive protein levels, coronary artery calcification, and mortality.1 In addition, exposure to a single traumatic life event such as violence or death of someone close is related to higher odds of atrial fibrillation.2Psychosocial stress (stress) represents a core component of adversity. However, stress is not always health damaging. For example, manageable amounts of psychosocial stress, if associated with adequate social and emotional support, along with mastery and control, may preserve healthy brain architecture. However, cumulative chronic stress (cumulative stress), defined as repeated detrimental stress exposures over time, can result in biological maladaptation, that is, allostatic load, leading to a range of conditions, including cardiovascular disease. Therefore, when we characterize adversity, it is crucial to evaluate stress from a life-course perspective to capture its full impact on physiology and well-being. Indeed, cardiologists and other clinicians often state that reports of stress are subjective and difficult to quantify, making stress problematic to adequately characterize in the context of disease. However, this assertion ignores the contextual nature of stressors and perpetuates the traditional lack of serious priority and attention given to adversity as a source of health care inequities in multiple realms.Cumulative stress is biologically embedded and results in cardiovascular disease through various mechanisms, including altered neurological activity, augmented and unchecked inflammation, and neurohormonal dysregulation through the hypothalamic-pituitary-adrenocortical axis (Figure). Life-course adversity through epigenetic processes is one potential mechanism through which intergenerational propagation of certain health conditions and disadvantage occurs from nonsurrogate pregnant individuals to their children.3 Indeed, ≈80% of cardiovascular disease is dictated by preventable factors, including behavioral, psychological, and social factors.4 Despite this, the majority of research and clinical efforts in cardiovascular medicine have focused largely on and overwhelmingly rewarded efforts outside the study of adversity and psychosocial stress. Indeed, efforts aimed at primordial, primary, and secondary cardiovascular disease prevention have limited success when their interplay with adverse life experiences is ignored because uptake of recommendations will be consistently low. Characterization of and interventions aimed at attenuating or eliminating the adversity–health outcome relationship should capture several principles: (1) life-course perspective, (2) overlapping influences of multiple sources of adversity, (3) biological context, (4) social context, (5) geographic context, (6) multidisciplinary and cross-disciplinary teams, (7) diverse professionals who understand the lived experience of adversity, and (8) health care justice.Download figureDownload PowerPointFigure. Relationship between life-course adversity and health outcomes. CAD indicates coronary artery disease; HPA, hypothalamic-pituitary-adrenocortical; PNS, parasympathetic nervous system; and SNS, sympathetic nervous system.As the American Heart Association and other entities double down on their health equity focus and the role of structural racism on cardiovascular health trajectories and outcomes, understanding the effect of adversity on cardiovascular disease as a thematic element is imperative and extremely relevant. Garnering sustained support from a comprehensive group of stakeholders will in part relate to these individuals envisioning themselves within the adversity definition, along with their belief that consequential progress can be achieved. From a health-equity perspective, empirical adversity research considering parallel as well as intersecting cumulative stressors is still sorely needed. However, more importantly, there is a need for interventions that interrupt the biology of adversity. This interventional research must leverage mixed-research methodology (eg, focus groups, real-world pragmatic interventions, clinical trials) and community organizational partnerships. An example of research incorporating some of these concepts using a real-world case study comes from the childhood adversity literature. Sheridan and colleagues5 showed that institutionalization in early childhood is associated with smaller cortical white matter volume, a finding not observed in children who were not institutionalized. Furthermore, children who were placed in supportive foster care after institutionalization had a cortical white matter volume similar to that of children who were never institutionalized, indicating brain plasticity and the ability to developmentally improve with a real-world intervention. This work incorporated the principles of overlapping multiple influences of adversity (eg, potential abandonment, isolation, and economics), social context, and biological context. Similarly, implementation science research related to adverse life-course experiences with an aim of cardiovascular event reduction or improvement in well-being should also incorporate the principles outlined previously to address unmet needs faced by individuals and communities. If there were easy solutions to chronic adversity–related problems such as poverty or structural racism, scalable solutions would be at the ready. However, first there must be the collective will to solve these issues.ConclusionsAlthough adversity is experienced by almost everyone, it is not uniformly distributed across individuals or populations. Given that cardiovascular disease remains the foremost cause of disability and death, as a global cardiovascular community, we must resolve to rally intensely around a mission to address adversity-related cardiovascular conditions. To do so, we must address vexing psychological, social, economic, and medical issues that either independently or in combination amplify to promote health inequities and disadvantage.Investment in adversity-related science and people who tackle this arena remains imperative.Article InformationSources of FundingNone.Disclosures Dr Albert discloses the following relationships: president, American Heart Association; and founding director, Center for the Study of Adversity and Cardiovascular Disease (NURTURE Center), Division of Cardiology, Department of Medicine, University of California, San Francisco. The other authors report no conflicts.FootnotesFor Sources of Funding and Disclosures, see page e3.Circulation is available at www.ahajournals.org/journal/circCorrespondence to: Michelle A. Albert, MD, MPH, University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143. Email michelle.albert@ucsf.eduReferences1. Lewis TT, Cogburn CD, Williams DR. Self-reported experiences of discrimination and health: scientific advances, ongoing controversies and emerging issues.Annu Rev Clin Psychol. 2015; 11:407–440. doi: 10.1146/annurev-clinpsy-032814-112728CrossrefMedlineGoogle Scholar2. Westcott SK, Beach LY, Matsushita F, Albert CM, Chatterjee N, Wong J, Williams DR, Vinayagamoorthy M, Buring JE, Albert MA. Relationship between psychosocial stressors and atrial fibrillation in women >45 years of age.Am J Cardiol. 2018; 122:1684–1687. doi: 10.1016/j.amjcard.2018.07.044CrossrefMedlineGoogle Scholar3. Scorza P, Duarte CS, Hipwell AE, Posner J, Ortin A, Canino G, Monk C; Program Collaborators for Environmental Influences on Child Health Outcomes. Intergenerational transmission of disadvantage: epigenetics and parents’ childhoods as the first exposure.J Child Psychol Psychiatry. 2019; 60:119–132. doi: 10.1111/jcpp.12877CrossrefMedlineGoogle Scholar4. Global Burden of Cardiovascular Diseases Collaboration. The burden of cardiovascular disease among US states 1990-2016.JAMA Cardiol. 2018; 3:375–389. doi: 10.1001/jamacardio.2018.0385CrossrefMedlineGoogle Scholar5. Sheridan MA, Fox NA, Zeanah CH, McLaughlin KA, Nelson CA. Variation in neural development as a result of exposure to institutionalization early in childhood.Proc Natl Acad Sci U S A. 2012; 109:12927–12932. doi: 10.1073/pnas.1200041109CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited ByAlbert M (2023) Economic Adversity and Health Care: Synopsis of American Heart Association Presidential Address, Circulation, 147:14, (1115-1117), Online publication date: 4-Apr-2023. January 3, 2023Vol 147, Issue 1 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.122.061763PMID: 36576955 Originally publishedDecember 28, 2022 PDF download Advertisement SubjectsCardiovascular DiseaseEpidemiologyRisk Factors