Social Determinants of Health: Contributions of Early Life Adversity to Cardiovascular Disparities in Adulthood Workshop - Executive Summary

Background

As noted in the 2015 American Heart Association (AHA) Scientific Statement on Social Determinants of Risk and Outcomes for Cardiovascular Disease, the most significant opportunities for reducing cardiovascular disease morbidity and mortality in the United States lie with addressing the social determinants of health (SDoH). Additionally, as addressed in the 2018 AHA Scientific Statement on Childhood and Adolescent Adversity and Cardiometabolic outcomes, early life adversity (ELA) (i.e., childhood experiences of abuse and neglect, parental disturbances, and living in adverse environments) is an SDoH that has health consequences across the lifespan and even across generations. According to the 2016 National Survey of Children’s Health, 46.3% of U.S children (< age 17) have experienced at least one adverse childhood event (ACE), and 21.7% have experienced more than two ACEs. Among health disparity groups, six in ten African American children have experienced an ELA and 58% of U.S. children who have experienced an ELA live with a family income less than 200 percent of the federal poverty level.  Such adverse exposures early in the life course increase the risk for cardiovascular disease (CVD), Type 2 diabetes, and other chronic diseases across the lifespan. NHLBI convened a two-day workshop in Bethesda, MD to identify research gaps, critical implications, and provide recommendations for future research directions to understand the contributions of SDoH in early life, such as ELA, to developing cardiovascular disease.

Workshop Objectives

• Outline putative behavioral, physiological, epigenetic, and hormonal mechanisms through which early life exposure to SDoH are associated with an increased risk for developing cardiovascular disease in adulthood, using ELA as a model.
• Examine whether outcomes and/or exposures to ELA may differ for health disparity populations.
• Identify critical developmental timing and vulnerability factors, such as exposure accumulation, recency, and sensitive life periods.
• Discuss the role of individual, family, and community resilience resources in mitigating CVD risk associated with ELA.

Recommendations

1. Create a more detailed and comprehensive model of mechanisms by which early life exposure to SDoH gets “under the skin” to impact subsequent CVD risk.

• Design longitudinal studies that examine the impact of ELA on physiological development in youth (i.e., early pubertal onset or hypothalmic-pituitary-adrenal axis developmental shifts) as a mechanism for subsequent CVD risk. 
• Investigate potential epigenetic mechanisms of ELA and CVD risk.
• Leverage existing cohorts using secondary and future analyses and form a large consortium to study ELA related DNA methylation modifications.
• Examine intergenerational transmission of associated cardiovascular risk with ELA.

2. Increase our understanding of whether and how exposures and their cardiovascular health consequences contribute to health disparities.

• Determine the impact of ELA exposure on vulnerable groups, including the interaction of low socioeconomic status and racial/ethnic minority status.
• Investigate heterogeneity of ELA exposure and impact within minority populations (including sexual minorities) that experience CVD disparities.
• Examine racial discrimination (direct and indirect) and historical trauma exposure as an ELA.

3. Utilize a lifespan approach to identify which developmental periods associated with SDoH have the greatest impact on cardiovascular outcomes for adulthood.

• Conduct longitudinal twin cohort studies to assess the impact of environmental factors on the manifestation of molecular and preclinical markers in a time sequential order.
• Leverage natural experiments or observational cohorts to understand the prospective nature of ELA exposure. 
• Examine longitudinal CVD outcomes in existing community-based interventions and home visiting programs aimed at addressing ELA or childhood trauma (e.g., HRSA-supported Maternal, Infant, and Early Childhood Home Visiting Programs ).

4. Broaden the perspective of ELA research from a risk model to a resilience and intervention-based model.

• Establish greater specificity of how to operationalize resilience in ELA, to include context, time domains, and circumstances. 
• Design interventions for individuals’ context that build on adaptive survival skills and protective resources instead of interventions developed in a high-resource environment.
• Promote implementation research of SDoH interventions that are multi-level and multi-factorial that address positive adaptation despite adversity.
• Identify mechanisms of protective social factors underlying early physiological development (i.e. prenatal, early life) in adverse environments.
• Understand which changes in SDoH (specific or combinations of SDoH domains) improve cardiovascular outcomes.

NHLBI Contacts

• Rebecca Campo, PhD, Division of Cardiovascular Sciences, NHLBI
• Catherine Stoney, PhD, Division of Cardiovascular Sciences, NHLBI
• Cheryl Anne Boyce, PhD, Center for Translation Research and Implementation Science, NHLBI

Workshop Chair

• Shakira Suglia, ScD, Associate Professor, Department of Epidemiology, Rollins School of Public Health, Emory University

Non-Federal Workshop Participants

• Linda Adair, PhD - University of North Carolina at Chapel Hill
• Allison Appleton, ScD, MPH - University of Albany
• Maria Bleil, PhD - University of Washington
• Renée Boynton-Jarrett, MD, ScD - Boston University
• Shanta R. Dube, PhD, MPH - Georgia State University
• Erin Dunn, ScD, MPH - Harvard University
• Bruce J. Ellis, PhD - University of Utah
• Christopher Fagundes, PhD - Rice University
• Nia Heard-Garris, MD, MSc - Northwestern University
• Sarah Jaffee, PhD – University of Pennsylvania
• Sara Johnson, PhD, MPH -- Johns Hopkins University
• Brenda Jones Harden, PhD - University of Maryland
• Mahasin Mujahid, PhD - University of California, Berkeley
• Natalie Slopen, ScD - University of Maryland
• Shaoyong Su, PhD - Augusta University
• Elsie Taveras, MD, MPH - Harvard University
• Sarah E. Watamura, PhD -  University of Denver

Federal Workshop Participants

• Sonia Arteaga, PhD – NHLBI
• Sean Coady, MS, MA - NHLBI
• Patrice Desvigne-Nickens, MD - NHLBI
• David C. Goff, Jr., MD, PhD - NHLBI
• Rosalind King, PhD - NICHD
• Lis Nielsen, PhD - NIA
• Anne O’Malley, CCRP - NHLBI
• Charlotte Pratt, PhD – NHLBI
• Nicole Redmond, MD, PhD, MPH - NHLBI