Childhood adversity and cardiometabolic health The role of

Childhood adversity and cardiometabolic health The role of social context Shakira F Suglia, Sc. D, MS, FAHA Associate Professor Department of Epidemiology Rollins School of Public Health Emory University

How do we define childhood adversity? External events or conditions that threaten the child’s bodily, familial, or social safety or security Suglia et al, Circulation 2017

Center for Disease Control and Prevention

2016 National Survey of Children's Health – children 0 -17 and parent reported

Impact of Childhood Adversities Health Risk Behaviors Alcohol Abuse Drug Abuse Obesity Smoking Reproductive Health/Sexual Behavior Fetal Death Sexual Risk Behaviors in Women Sexually Transmitted Diseases Teen Pregnancy Unintended Pregnancy Anda et al AJPM 2010 Mental Health Autobiographical Memory Disturbances Depression/Depressed Affect Anxiety Hallucinations Neurobiology Suicidality Chronic Disease Autoimmune Disease Chronic Obstructive Pulmonary Disease Frequent Headaches Health-Related Quality of Life Ischemic Heart Disease Liver Disease Lung Cancer

• Adverse Child experiences • • Physical abuse Sexual Abuse Psychological Abuse Substance Abuse by household member Mental Illness of household member Domestic Violence Parents Divorced Parental Incarceration Am J Prev Med 1998

Child Adversity and CVD • In 2013 we conducted a systematic review of the literature on violence and cardiovascular health. (Suglia et al AJPM 2013) • Consistent relation between violence in childhood and • Hypertension • Myocardial Infarction • Coronary Heart Disease

Child Adversity and CVD (cont) • Recent systematic review childhood maltreatment associated with CVD (myocardial infarction, stroke, ischemic heart disease, coronary heart disease) in 91. 7% (22 of 24) of published studies. (Basu et al Clin Psychol 2017)

Suglia et al Circulation 2017

Add Health: Child Maltreatment • Participants retrospectively reported on perpetrated abuse and neglect that occurred before the sixth grade at wave 3 (age 21) by using modified versions of existing scales. • Maltreatment was defined as acts of omission (physical neglect) and acts of commission (physical or sexual abuse) in accordance with the definitions of the Centers for Disease Control and Prevention.

Cardiometabolic Health in Add Health • Obesity – BMI ≥ 30 or greater • Hypertension – systolic BP ≥ 140 mm. Hg, diastolic BP ≥ 90 mm. Hg, or anti-hypertensive medication use • Diabetes – hemoglobin A 1 C ≥ 6. 5%, or hypoglycemic medication use • High Cholesterol – total cholesterol in top three deciles of samples or medication use

Suglia SF et al, BMC Public Health 2014 14

Clark C et al, Pediatrics 2014

Clark C et al, Pediatrics 2014

Child maltreatment and composite cardiometabolic risk factors (2 or more factors) in young adulthood Men Model 1 OR (95%CI) Model 2 OR (95% CI) Women Model 1 OR (95%CI) Model 2 OR (95% CI) Physical Abuse 0. 91 (0. 74, 1. 13) 0. 90 (0. 73, 1. 12) 1. 11 (0. 87, 1. 42) 1. 13 (0. 88, 1. 46) Sexual Abuse 0. 80 (0. 49, 1. 30) 0. 78 (0. 47, 1. 27) 1. 57 (1. 02, 2. 41) 1. 63 (1. 06, 2. 51) Neglect 1. 16 (0. 86, 1. 56) 1. 21 (0. 89, 1. 64) 1. 08 (0. 83, 1. 42) 1. 15 (0. 88, 1. 42) Model 1: Adjusted for race/ethnicity, age, educational attainment Model 2: Further adjusted for smoking status, physical activity, frequent fast food consumption and frequent consumption of SSB

Are cumulative social risk factors associated with obesity in early childhood?

Cumulative Social Risk in Childhood Fragile Families and Child Wellbeing Study • • • Intimate Partner Violence Father Incarceration Maternal Depression (CIDI-SF) Maternal Alcohol/Drug Use Housing Insecurity Food Insecurity

Suglia et al Pediatrics 2012

Suglia SF et al, J Dev Beh Peds 2013

Liu et al Childhood Obesity 2018

Suglia et al Circulation 2017

Gary-Webb et al Curr Diab Rep 2013

Prevalence of obesity among youth aged 2– 19 years, by sex and race/ethnicity: US, 2015– 2016 SOURCE: NCHS, National Health and Nutrition Examination Survey, 2015– 2016.

Boricua Youth Study- Healthy Heart Assessment

Daviglus et al, JAMA 2012

Bird HR et al J Am Acad Child Adolesc Psychiatry 2007

Boricua Youth Study (BYS) Timeline 2001 -2004 W 1 -W 2 -W 3 Ages 5 -13 PI- Bird 2012 -2017 W 4 Ages HIV/STI PI-Duarte Mental Health PI-Alegria, Duarte & Canino 2014 -2019 W 4 (Subsample) Ages 19 -21 HHA PI-Suglia

Boricua Youth Study Healthy Heart Assessment: Conceptual Framework Health Behaviors Cardiovascular Health Childhood Adversity Substance and Mental Disorders Moderators Use of Health Services Familism Social Support Acculturation Cultural Identity

BYS: Healthy Heart Assessment Child Adversity Assessment • Baseline examination Wave 1 (2001 -2004) • Childhood adversity was defined as experiencing child physical or sexual abuse, parental substance use, any parental psychopathology or neglect.

Prevalence of childhood adversities among Puerto Rican youth (n=2491) Childhood Adversity Loss of a parent Death Divorce/separation Maltreatment Neglect Physical abuse Sexual abuse Emotional abuse Parental maladjustment Intimate partner violence Antisocial personality Substance use problems Mental/Emotional problems Environmental stressor Exposure to violence Prevalence (N=2491) N(M) %(SD) Bronx (N=1137) N(M) %(SD) Puerto Rico (N=1353) N(M) %(SD) 115 1254 4. 6 50. 3 61 693 5. 36 60. 9 54 561 3. 99 41. 5 269 393 114 378 10. 8 15. 8 4. 6 15. 2 117 205 58 241 10. 28 18. 0 5. 1 21. 2 152 188 56 137 11. 23 13. 9 4. 1 10. 1 68 356 380 635 2. 7 14. 3 15. 3 25. 5 15 197 143 249 1. 32 17. 3 12. 6 21. 9 53 159 237 386 3. 9 11. 8 17. 5 28. 5 500 20. 1 235 20. 7 265 19. 6

Child Adversity and Pubertal Development among boys and girls, Boricua Youth Study Males Females Estimated PDS Score by CA category

Longitudinal associations between childhood adversities (CA) and sleep disturbances in youth 10 -16 years, BYS 1 -3 Child Adversities 0 CA 1 CA 2 -3 CA 4+ CA Trouble Falling/ Staying Asleep Sleeping During the Day Bad Dreams/Nightmares APR Ref. 1. 53 3. 73 7. 68 95%CI 0. 61 -3. 79 1. 52 -9. 15 2. 67 -22. 04 Ayana April-Sanders Work in Progress Ref. 0. 70 2. 02 3. 67 95% CI 0. 29 -1. 69 0. 85 -4. 80 1. 32 -10. 23 APR Ref. 1. 56 2. 62 3. 42 95% CI 0. 54 -4. 50 0. 94 -7. 34 1. 04 -11. 27

BYS: Healthy Heart Assessment Study • Home visit to assess: diet, physical activity, family history of CVD, smoking and alcohol use • Anthropometric measures (height, weight and waist circumference) and blood pressure assessment • Blood sample collected using a finger prick during the home visit. Samples analyzed for high sensitive- C reactive protein, total cholesterol, tryglicerides and Hemoglobin A 1 C.

BYS HHA Study: Prevalence of risk factors by study Site (Mean age 22) Bronx, NY San Juan, PR Current Smoking 16% 9% Alcohol use (≥ 10 days/month) 10% 6% Physical Activity (moderate/vigorous ) Fruits and Vegetables <= 1 fruit/veg per day 2 -4 fruit/veg per day >=5 fruit/veg per day 82% 74% 44% 12% 21. 7% 51% 38% 11. 4% 21. 7% 21. 4% Trouble Falling or Staying Asleep Slept More During the Day Than Usual

BYS HHA Study: Prevalence of CA and Cardiometabolic risk factors by study site (Mean age 22) Bronx, NY San Juan, PR Any Adversity 79% 63% Obesity (BMI >=30) 36% 19% % Body Fat ≥ 30% (Males), ≥ 40% (Females) 29% 23% Waist Circumference ≥ 37 in (Males), ≥ 31. 5 in (Females) 61% 53%

Childhood adversities (CA) and adiposity in young adults, BYS HA, South Bronx, NY Child Adversity None Any BMI Obesity Waist Circumference Body Fat ß 95%CI APR 95% CI APR 95%CI Ref. 1. 58 0. 33, 2. 83 Ref. 1. 45 0. 95, 2. 22 Ref. 1. 43 0. 98, 2. 09 1. 17 0. 76, 1. 79 Models adjusted for age and gender

Childhood adversities (CA) and adiposity in young adults, BYS HA, San Juan metro area, Puerto Rico Child Adversity None Any BMI Obesity Waist Circumference Body Fat ß 95%CI APR 95% CI APR 95%CI Ref. 0. 58 0. 11, 2. 92 Ref. 0. 80 0. 70, 2. 30 Ref. 0. 90 0. 50, 1. 62 Ref 1. 06 0. 65, 1. 72 Models adjusted for age and gender

BYS HHA Summary of Measures Health Behaviors Alcohol Use Drug use Tobacco Diet Sleep Physical Activity Stressors Adverse Child Experiences Perceived Stress Experiences of Discrimination Intimate Partner Violence Negative Life Events Economic Hardship Food and Housing Insecurity Mediators and Modifiers Coping John Henryism Social Support Familism Religiosity Acculturation Medical and Social Services Environment Housing Quality and Deterioration Neighborhood Environment Perceived Neighborhood Safety Asthma History and Symptoms Asthma medication adherence Quality of life Asthma control

Boricua Youth Study (BYS) 2001 -2004 2012 -2017 2014 -2019 2017 -2022 W 1 -W 2 -W 3 Ages 5 -13 W 4 Ages HIV/STI PI-Duarte W 4 (Subsample) Ages 18 -23 Mental Health PI-Alegria, Duarte, Canino HHA PI-Suglia ECHO PI- Duarte, Monk, Canino, Posner

Limitations • Need to expand on child adversity measures • Severity and timing are rarely studied • Need to focus on populations most at risk • Reliance on retrospective studies • Potential to understand mechanisms if we focus on effects earlier in the life course • Need for intervention studies and examination of potential buffering factors

Recommendations for Future Directions • Determinants of Resilience • Understanding Mechanisms • Further exploration of social context as well as other potential mediators and modifiers • Modifiers of Vulnerability

Given the high prevalence of adversity and its detrimental impact on health addressing these upstream factors would be a more fruitful strategy than targeting more downstream factors later in the life course.

Thank you Colleagues • • Ayana April-Sanders Danielle Crookes Cristiane Duarte Glorisa Canino Hector Bird Cari Clark Renee Boynton-Jarrett Karestan Koenen Funding • K 01 HL 103199 • R 01 HL 125761 • R 01 AG 058704 Contact: Shakira F Suglia Shakira. Suglia@emory. edu

Improving the Adverse Childhood Experiences Study Scale Finkelhor et al JAMA Pediatrics 2013

Cronholm et al 2015 AJPM

Social Science and Medicine 2017

Table 1. Prevalence of childhood adversity by sex a P-value for gender differences adjusted for SES. Loss of a parent Death Divorce/separation Child maltreatment Neglect Physical abuse Sexual abuse Emotional abuse Parental maladjustment Intimate partner violence Antisocial personality Substance use problems Emotional problems Environmental stressors Exposure to violence Boys N = 1015 N (%) Girls N = 953 N (%) P-valuea 51 (4. 1) 509 (59. 0) 45 (5. 2) 495 (63. 6) 0. 4881 0. 0465 111 (10. 3) 200 (22. 2) 49 (6. 0) 155 (19. 2) 77 (9. 2) 99 (13. 0) 41 (5. 1) 126 (17. 5) 0. 9794 0. 0010 0. 4517 0. 7601 29 (1. 9) 129 (14. 8) 168 (15. 4) 262 (23. 1) 27 (2. 0) 143 (17. 2) 144 (13. 6) 250 (24. 1) 0. 8541 0. 1978 0. 8298 0. 5999 243 (24. 9) 135 (15) 0. 0002