Preventing Chronic Disease | Childhood Adversity and Adult Onset of Hypertension and Heart Disease in São Paulo, Brazil - CDC
Childhood Adversity and Adult Onset of Hypertension and Heart Disease in São Paulo, Brazil
Canada Parrish, MSPH; Pamela J. Surkan, ScD, PhD; Silvia S. Martins, MD, PhD; Wagner F. Gattaz, MD, PhD; Laura Helena Andrade, MD, PhD; Maria Carmen Viana, MD, PhD
Suggested citation for this article: Parrish C, Surkan PJ, Martins SS, Gattaz WF, Andrade LH, Viana MC. Childhood Adversity and Adult Onset of Hypertension and Heart Disease in São Paulo, Brazil. Prev Chronic Dis 2013;10:130193. DOI: http://dx.doi.org/10.5888/pcd10.130193.
Childhood (under age 18) adversity variables included self-reported neglect, physical abuse, sexual abuse, and family violence, as defined by the WHO World Mental Health Surveys (9). For hypertension, participants were asked if they had high blood pressure readings in the previous 12 months. To assess heart disease, participants were asked if a doctor or other health professional had ever told them that they had heart disease.
The analysis, conducted in Stata version 12 (StataCorp LP, College Station, Texas), used survey data procedures to account for weight and primary sampling units and strata information to account for the stratified, multistage, clustered-area sampling design (8). Descriptive statistics were calculated by using χ2 tests.
Each adversity variable was included in separate multivariable logistic regression models adjusted for sex, age (18–34, 35–49, 50–64, ≥ 65 y), education level (0–11, 12, 13–15, ≥ 16 y), and income (low, low-average, high-average, high). We included models also adjusted for onset of depression (first episode at age < 18 y; first episode at age ≥ 18 y) by using the WHO Composite International Diagnostic Interview (8). These covariates have demonstrated significant associations with cardiovascular conditions (1,3). Finally, we fit a full model that included all 4 childhood adversity variables and the covariates. Tests were 2-sided, and the significance level was set at P < .05.
Table 1). Of the sociodemographic covariates, only increasing age was associated with higher prevalence of hypertension or heart disease. The crude odds of developing hypertension (odds ratio [OR] = 1.54; 95% confidence interval [CI], 1.21–1.95) and heart disease (OR = 1.72; 95% CI, 1.01–2.93) were greater for participants who reported childhood neglect than for those who did not. Also, the crude odds of developing hypertension (OR = 1.95; 95% CI, 1.58–2.41) and heart disease (OR = 1.96; 95% CI, 1.27–3.04) were greater for participants who reported physical abuse than for those who did not.
Family violence significantly predicted hypertension (adjusted OR [AOR] = 1.48; 95% CI, 1.20–1.83) but not heart disease in models adjusted for sociodemographic factors. After adjustment for sociodemographic variables alone or for sociodemographic variables and onset of depression, neglect and sexual abuse were not significantly associated with hypertension or heart disease (Table 2). As in the models adjusted for sociodemographic varibles alone, the association between family violence and hypertension was significant in the adjusted models for depression, but it was slightly attenuated (AOR = 1.37; 95% CI, 1.10–1.71).
In the model adjusted for sociodemographic variables, participants reporting childhood physical abuse were significantly more likely to have adult hypertension (AOR = 1.76; 95% CI, 1.38–2.25) and heart disease (AOR = 1.74; 95% CI, 1.06–2.85). When we controlled for depression, the likelihood of hypertension was attenuated (AOR = 1.64; 95% CI, 1.30–2.07), and the association with heart disease was no longer significant (Table 2).
In the full model, which contained all 4 childhood adversities and all covariates, only physical abuse was significantly associated with hypertension (AOR = 1.59; 95% CI, 1.22–2.07), and the previously significant association between family violence and hypertension disappeared (Table 2).
In the model that included all 4 adversities simultaneously, only physical abuse was significantly associated with hypertension. Thus, of the 4 adversities and in the context of our study, physical abuse may be the more salient predictor of hypertension and heart disease, because childhood adversities often occur simultaneously (2,9,10). A plausible mechanism is that stress in early life triggers greater sensitivity of the hypothalamic–pituitary–adrenal axis, which then results in physiological consequences (1,11). Also, maltreatment early in life can alter psychological development (12), possibly leading later in life to poor health choices (eg, unhealthful diet, tobacco use) that contribute to the development of hypertension (2,12).
To our knowledge, apart from the WHO pooled analyses (2,10), no studies exclusively from low- or middle-income countries have reported on the association of childhood adversities with cardiovascular health. For heart disease, our study demonstrated an effect size for physical abuse similar to that found in the literature, but we found a larger effect for family violence and a smaller effect for sexual abuse (2,3,10). The effect of these adversities on adult health appears to vary by location (2), which may allude to an important contextual influence (2,9).
One limitation of our study is that the variables were assessed via self-report and were not verified by medical records. The use of self-report may result in underreporting of these outcomes, particularly in non-Western countries (10). Also, because few survey participants reported sexual abuse and heart disease was fairly uncommon, our study may have been underpowered. Therefore, it may be difficult to draw strong conclusions from our data.
Our findings highlight that support for early childhood interventions are critical. When funds for early interventions are limited, our findings may help inform more targeted interventions (3,5). Because some childhood adversity effects appear stronger than others, further study is warranted on the mechanisms driving the effects.
Author Affiliations: Pamela J. Surkan, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Silvia S. Martins, Columbia University Mailman School of Public Health, New York, New York; Wagner F. Gattaz, Laura Helena Andrade, Department/Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil; Maria Carmen Viana, Department of Social Medicine and Postgraduate Program in Collective Health, Federal University of Espírito Santo, Vitoria, Brazil.
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