Next Generation, Modifiable Cardiometabolic Biomarkers: Mitochondrial Adaptation and Metabolic Resilience: A Scientific Statement From the American Heart Association.

Cardiometabolic risk is increasing in prevalence across the life span with disproportionate ramifications for youth at socioeconomic disadvantage. Established risk factors and associated disease progression are harder to reverse as they become entrenched over time; if current trends are unchecked, the consequences for individual and societal wellness will become untenable. Interrelated root causes of ectopic adiposity and insulin resistance are understood but identified late in the trajectory of systemic metabolic dysregulation when traditional cardiometabolic risk factors cross current diagnostic thresholds of disease. Thus, children at cardiometabolic risk are often exposed to suboptimal metabolism over years before they present with clinical symptoms, at which point life-long reliance on pharmacotherapy may only mitigate but not reverse the risk. Leading-edge indicators are needed to detect the earliest departure from healthy metabolism, so that targeted, primordial, and primary prevention of cardiometabolic risk is possible. Better understanding of biomarkers that reflect the earliest transitions to dysmetabolism, beginning in utero, ideally biomarkers that are also mechanistic/causal and modifiable, is critically needed. This scientific statement explores emerging biomarkers of cardiometabolic risk across rapidly evolving and interrelated "omic" fields of research (the epigenome, microbiome, metabolome, lipidome, and inflammasome). Connections in each domain to mitochondrial function are identified that may mediate the favorable responses of each of the omic biomarkers featured to a heart-healthy lifestyle, notably to nutritional interventions. Fuller implementation of evidence-based nutrition must address environmental and socioeconomic disparities that can either facilitate or impede response to therapy.

Joint Effects of Indoor Air Pollution and Maternal Psychosocial Factors During Pregnancy on Trajectories of Early Childhood Psychopathology.

BACKGROUND: Prenatal indoor air pollution and maternal psychosocial factors have been associated with adverse psychopathology. We used environmental exposure mixture methodology to investigate joint effects of both exposure classes on child behavior trajectories. METHODS: For 360 children from the South African Drakenstein Child Health Study, we created trajectories of Child Behavior Checklist scores (24, 42, 60 months) using latent class linear mixed effects models. Indoor air pollutants and psychosocial factors were measured during pregnancy (2nd trimester). After adjusting for confounding, single-exposure effects (per natural log-1 unit increase) were assessed using polytomous logistic regression models; joint effects using self-organizing maps (SOM), and principal component (PC) analysis. RESULTS: Three trajectories were chosen for both internalizing and externalizing problems, with "high" (externalizing) or "increasing" (internalizing) being the most adverse trajectories. High externalizing trajectory was associated with increased particulate matter (PM10) exposure (OR [95%-CI]: 1.25 [1.01,1.55]) and SOM exposure profile most associated with smoking (2.67 [1.14,6.27]). Medium internalizing trajectory was associated with increased emotional intimate partner violence (2.66 [1.17,5.57]), increasing trajectory with increased benzene (1.24 [1.02,1.51]) and toluene (1.21 [1.02,1.44]) and the PC most correlated with benzene and toluene (1.25 [1.02, 1.54]). CONCLUSIONS: Prenatal exposure to environmental pollutants and psychosocial factors was associated with internalizing and externalizing child behavior trajectories. Understanding joint effects of adverse exposure mixtures will facilitate targeted interventions to prevent childhood psychopathology.

Cumulative Stress Across the Life Course and Biological Aging in Adulthood.

OBJECTIVE: Psychosocial stressors have been linked with accelerated biological aging in adults; however, few studies have examined stressors across the life course in relation to biological aging. METHODS: In 359 individuals (57% White, 34% Black) from the Child Health and Development Studies Disparities study, economic (income, education, financial strain), social (parent-child relations, caretaker responsibilities) and traumatic (death of a sibling or child, violence exposure) stressors were assessed at multiple time points (birth and ages 9, 15, and 50 years). Experiences of major discrimination were assessed at age 50. Life period stress scores were then assessed as childhood (birth-age 15 years) and adulthood (age 50 years). At age 50 years, participants provided blood samples, and DNA methylation was assessed with the EPIC BeadChip. Epigenetic age was estimated using six epigenetic clocks (Horvath, Hannum, Skin and Blood age, PhenoAge, GrimAge, Dunedin Pace of Aging). Age acceleration was determined using residuals from regressing chronologic age on each of the epigenetic age metrics. Telomere length was assessed using the quantitative polymerase chain reaction-based methods. RESULTS: In linear regression models adjusted for race and gender, total life stress, and childhood and adult stress independently predicted accelerated aging based on GrimAge and faster pace of aging based on the DunedinPace. Associations were attenuated after adjusting for smoking status. In sex-stratified analyses, greater childhood stress was associated with accelerated epigenetic aging among women but not men. No associations were noted with telomere length. CONCLUSIONS: We found that cumulative stressors across the life course were associated with accelerated epigenetic age, with differences by sex (e.g., accelerated among women). Further research of this association in large and diverse samples is needed.

Childhood maltreatment and trajectories of cardiometabolic health across the reproductive life span among individuals with a first birth during the Coronary Artery Risk Development in Young Adults Study.

OBJECTIVE: Childhood adversity is associated with poor cardiometabolic health in adulthood; little is known about how this relationship evolves through childbearing years for parous individuals. The goal was to estimate differences in cardiometabolic health indicators before, during and after childbearing years by report of childhood maltreatment in the Coronary Artery Risk Development in Young Adults (CARDIA) cohort study. METHODS: Including 743 individuals nulliparous at baseline (1985-1986) with one or more pregnancies >20 weeks during follow-up (1986-2022), we fit segmented linear regression models to estimate mean differences between individuals reporting or not reporting childhood maltreatment (physical or emotional) in waist circumference, triglycerides, high-density lipoprotein cholesterol, systolic and diastolic blood pressure, fasting glucose, and body mass index (BMI) prior to, during, and following childbearing years using generalized estimating equations, allowing for interaction between maltreatment and time within each segment, and adjusting for total parity, parental education, and race (Black or white, self-reported). RESULTS: Individuals reporting maltreatment (19%; 141) had a greater waist circumference (post-childbearing: +2.9 cm, 95% CI (0.7, 5.0), higher triglycerides [post-childbearing: +8.1 mg/dL, 95% CI (0.7, 15.6)], and lower HDL cholesterol [post-childbearing: -2.1 mg/dL, 95% CI (-4.7, 0.5)] during all stages compared to those not reporting maltreatment. There were not meaningful differences in blood pressure, fasting glucose, or BMI. Individuals who reported maltreatment did not report faster changes over time. CONCLUSION: Differences in some aspects of cardiometabolic health between individuals reporting versus not reporting childhood maltreatment were sustained across reproductive life stages, suggesting potentially persistent impacts of childhood adversity.

Joint effects of prenatal exposure to indoor air pollution and psychosocial factors on early life inflammation.

It is hypothesized that air pollution and stress impact the central nervous system through neuroinflammatory pathways Despite this, the association between prenatal exposure to indoor air pollution and psychosocial factors on inflammatory markers in infancy has been underexplored in epidemiology studies. This study investigates the individual and joint effects of prenatal exposure to indoor air pollution and psychosocial factors on early life inflammation (interleukin-1ß (IL-1ß), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α)). We analyzed data from the South African Drakenstein Child Health Study (N = 225). Indoor air pollution and psychosocial factor measurements were taken in the 2nd trimester of pregnancy. Circulating inflammatory markers (IL-1ß, Il-6, and TNF-α) were measured in serum in the infants at 6 weeks postnatal. Linear regression models were used to investigate associations between individual exposures and inflammatory markers. To investigate joint effects of environmental and psychosocial factors, Self-Organizing Maps (SOM) were used to create exposure profile clusters. These clusters were added to linear regression models to investigate the associations between exposure profiles and inflammatory markers. All models were adjusted for maternal age, maternal HIV status, and ancestry to control for confounding. Most indoor air pollutants were positively associated with inflammatory markers, particularly benzene and TNF-α in single pollutant models. No consistent patterns were found for psychosocial factors in single-exposure linear regression models. In joint effects analyses, the SOM profile with high indoor air pollution, low SES, and high maternal depressive symptoms were associated with higher inflammation. Indoor air pollutants were consistently associated with increased inflammation in both individual and joint effects models, particularly in combination with low SES and maternal depressive symptoms. The trend for individual psychosocial factors was not as clear, with mainly null associations. As we have observed pro- and anti-inflammatory effects, future research should investigate joint effects of these exposures on inflammation and their health effects.

Racial/Ethnic and Sex/Gender Differences in Sleep Duration Trajectories From Adolescence to Adulthood in a US National Sample.

Racial/ethnic and sex/gender disparities in sleep duration have been documented in adolescence and adulthood. Identifying racial/ethnic and sex/gender differences in sleep duration trajectories from adolescence to adulthood can inform interventions on the developmental periods individuals are most at risk for short sleep duration. We examined racial/ethnic and sex/gender differences in self-reported sleep duration trajectories from adolescence to adulthood using data from waves I, III, IV, and V of the National Longitudinal Study of Adolescent to Adult Health (1994-2018; n = 12,593). Multigroup growth mixture modeling was used to enumerate sleep duration trajectories from adolescence to adulthood. There were 3 common trajectory types across race/ethnicity and sex/gender groups: 1) consistent increasing short sleepers (i.e., increasing probability of short sleep into adulthood) (67.3%); 2) late-onset short sleepers (i.e., no probability of short sleep duration in adolescence until adulthood) (20.2%); and 3) early-onset short sleepers (i.e., declining probability of short sleep duration from adolescence into adulthood) (12.5%). The prevalence of the consistent-increasing trajectory was highest among Black male respondents, while late onset was highest among White female respondents and early onset greatest among Latinx male respondents. Findings underscore the need to intervene in early adolescence to prevent short sleep duration in adulthood.

The Association of Mobility, Social Deprivation, and Pediatric Primary Care Outcomes in Community Health Centers.

OBJECTIVE: To examine how social deprivation and residential mobility are associated with primary care use in children seeking care at community health centers (CHCs) overall and stratified by race and ethnicity. STUDY DESIGN: We used electronic health record open cohort data from 152 896 children receiving care from 15 U S CHCs belonging to the OCHIN network. Patients were aged 3-17 years, with ≥2 primary care visits during 2012-2017 and had geocoded address data. We used negative binomial regression to calculate adjusted rates of primary care encounters and influenza vaccinations relative to neighborhood-level social deprivation. RESULTS: Higher rates of clinic utilization were observed for children who always lived in highly deprived neighborhoods (RR = 1.11, 95% CI = 1.05-1.17) and those who moved from low-to-high deprivation neighborhoods (RR = 1.05, 95% CI = 1.01-1.09) experienced higher rates of CHC encounters compared with children who always lived in the low-deprivation neighborhoods. This trend was similar for influenza vaccinations. When analyses were stratified by race and ethnicity, we found these relationships were similar for Latino children and non-Latino White children who always lived in highly deprived neighborhoods. Residential mobility was associated with lower rates of primary care. CONCLUSIONS: These findings suggest that children living in or moving to neighborhoods with high levels of social deprivation used more primary care CHC services than children who lived in areas with low deprivation, but moving itself was associated with less care. Clinician and delivery system awareness of patient mobility and its impacts are important to addressing equity in primary care.

Mentorship in adolescence and subsequent depression and adiposity among child maltreatment survivors in a United States nationally representative sample.

Child maltreatment (CM) is associated with multiple adverse health outcomes. Hence, there is a great need to identify factors that promote resilience in CM survivors. Mentorship may promote positive coping in CM survivors, but this may vary by health outcome and mentor/mentee characteristics. Among participants in a United States nationally representative sample, the National Longitudinal Study of Adolescent to Adult Health, who retrospectively reported any CM before age 18 (sexual, emotional or physical, abuse or neglect; N = 3364), we examined associations between mentorship during adolescence and body mass index (BMI), obesity, and depressive symptoms at ages 24-32 (in 2008-2009). We utilized linear regression and predictive margins with complex sample weighting. Models were stratified by sex and race/ethnicity. Thirty-one percent and 40% of participants' most influential mentor was inside and outside the family, respectively, and 29% reported no mentor. Any mentorship was associated with decreased depressive symptoms in females (adjusted beta for any mentor = -0.78, 95% CI:-1.54,-0.02). By contrast, any mentorship was associated with increased adiposity, namely among Latinas (adjusted beta for BMI = 2.23, 95% CI:0.45,4.02, adjusted risk ratio for obesity = 1.42, 95% CI:1.03,1.97). The influence of mentorship in CM survivors is heterogeneous. While mentorship was associated with reduced psychopathology, it was also linked with worse physical health, underscoring that mentoring does not necessarily promote long-term resilience to physical health outcomes, particularly in minorities. A better understanding of how mentors influence specific mentee behaviors may be important in informing how mentors can promote better physical health and lower obesity risk among CM survivors.

Characterization of trajectories of physical activity and cigarette smoking from early adolescence to adulthood.

BACKGROUND: Cigarette smoking and physical inactivity are two critical risk factors for noncommunicable diseases and all-cause mortality. However, few studies have compared the long-term trajectories of both behaviors, as well as multilevel factors associated with trajectory patterns. Using the National Longitudinal Study of Adolescent to Adult Health (Add Health) Wave I through V survey data, this study characterized distinct subgroups of the population sharing similar behavioral patterns from adolescence to adulthood, as well as predictors of subgroup membership for physical activity (PA) and cigarette smoking behavior respectively. METHODS: Using the Add Health Wave I through V survey data, we identified the optimal number of latent classes and class-specific trajectories of PA and cigarette smoking from early adolescence to adulthood, fitting latent growth mixture models with standardized PA score and past 30-day cigarette smoking intensity as outcome measures and age as a continuous time variable. Associations of baseline sociodemographic factors, neighborhood characteristics, and sociopsychological factors with trajectory class membership were assessed using multinomial logistic regression. RESULTS: We identified three distinct subgroups of non-linear PA trajectories in the study population: moderately active group (N = 1067, 5%), persistently inactive group (N = 14,257, 69%) and worsening activity group (N = 5410, 26%). Foror cigarette smoking, we identified three distinct non-linear trajectory subgroups: persistent non-smoker (N = 14,939, 72%), gradual quitter (N = 2357, 11%), and progressing smoker (N = 3393, 16%). Sex, race/ethnicity, neighborhood environment and perceived peer support during adolescence were significant predictors of both physical activity and cigarette smoking trajectory subgroup membership from early adolescence to adulthood. CONCLUSIONS: There are three distinct subgroups of individuals sharing similar PA and cigarette smoking behavioral profile respectively from adolescence to adulthood in the Add Health study population. Behavioral interventions that focus on neighborhood environment (e.g. establish community-based activity center) and relationship to peers during adolescence (e.g. peer counseling) could be key to long-term PA promotion and cigarette smoking cessation.

Shift-and-persist strategies as a potential protective factor against symptoms of psychological distress among young adults in Puerto Rico.

OBJECTIVE: Residents of Puerto Rico are disproportionately exposed to social and environmental stressors (e.g., Hurricane María and the 2020 sequence of tremors) known to be associated with psychological distress. Shift-and-persist (SP), or the ability to adapt the self to stressors while preserving focus on the future, has been linked with lower psychological distress, but no study has evaluated this in Puerto Rico. This study examined the association between SP and psychological distress (including that from natural disasters) in a sample of young adults in Puerto Rico. METHODS: Data from the Puerto Rico-OUTLOOK study (18-29 y) were used. Participants (n = 1497) completed assessments between September 2020 and September 2022. SP was measured with the Chen scale and categorized into quartiles (SPQ1-SPQ4). Psychological distress included symptoms of depression (CESD-10), anxiety (STAI-10), post-traumatic stress disorder (Civilian Abbreviated Scale PTSD checklist), and ataque de nervios (an idiom of distress used by Latinx groups). Outcomes were dichotomized according to clinical cutoffs when available, otherwise used sample-based cutoffs. Two additional items assessed the perceived mental health impact of Hurricane María and the 2020 sequence of tremors (categorized as no/little impact vs. some/a lot). Adjusted prevalence ratios (PR) and their 95% confidence intervals (CI) were estimated. RESULTS: The most commonly reported psychological distress outcome was PTSD (77%). In adjusted models, compared to SP Q1, persons in SP Q2-Q4 were less likely to have elevated symptoms of depression (PR Q2 = 0.79, 95% CI = 0.72-0.85; PR Q3 = 0.65, 95% CI = 0.58-0.73; and PR Q4 = 0.41, 95% CI = 0.35-0.48), PTSD (PR Q2 = 0.92, 95% CI = 0.87-0.98; PR Q3 = 0.86, 95% CI = 0.80-0.93; and PR Q4 = 0.76, 95% CI = 0.70-0.83), anxiety (PR Q2 = 0.39, 95% CI = 0.31-0.48; PR Q3 = 0.27, 95% CI = 0.20-0.37; and PR Q4 = 0.11, 95% CI = 0.07-0.17) and experiences of ataque de nervios (PR Q2 = 0.85, 95% CI = 0.76-0.94; PR Q3 = 0.79, 95% CI = 0.70-0.90; and PR Q4 = 0.68, 95% CI = 0.60-0.78). Compared to persons in SP Q1, persons in SP Q3-Q4 were less likely to report adverse mental health impacts from Hurricane María (PR Q3 = 0.66, 95% CI = 0.55-0.79; and PR Q4 = 0.53, 95% CI = 0.44-0.65) and the 2020 sequence of tremors (PR Q3 = 0.77, 95% CI = 0.61-0.98; and PR Q4 = 0.74, 95% CI = 0.59-0.94). CONCLUSION: SP was associated with lower psychological distress. Studies are needed to confirm our findings and evaluate potential mechanisms of action.

Association Between Optimism and Negative Emotional Eating in Caribbean Latinx Adults in the Northeast US.

BACKGROUND: Negative emotional eating (EE) is associated with unfavorable behavioral and health outcomes. Understanding its association with positive factors, such as optimism, may shed light into novel interventions. We examined the association between optimism and negative EE in US Caribbean Latinx adults, a population disproportionately exposed to adversity. METHOD: This cross-sectional analysis used data from the Latino Health and Well-being Study (21-84 years; n = 579). Optimism was measured with the Life Orientation Test-Revised version. EE was measured with the Three-Factor Eating Questionnaire R18-V2. Adjusted Poisson models with robust error variance estimated prevalence ratios (PR). RESULTS: The proportion of individuals reporting high EE was greater in the low (39.0%) and moderate (36.8%) optimism groups than that in the high optimism group (24.8%; p = 0.011). Individuals with high optimism (vs. low) were less likely to report high EE over no EE (PR = 0.68; 95% CI = 0.53-0.88). CONCLUSION: High optimism was negatively associated with high EE. Future studies are needed to confirm our findings and test interventions promoting optimism for preventing negative EE in US Caribbean Latinx adults.

Current Family Functioning and Youth Cardiometabolic Health in the SOL Youth Study.

BACKGROUND: Family functioning may impact children's cardiometabolic health; however, few studies have examined multiple cardiometabolic markers among a diverse racial/ethnic cohort. The relationship between child- and caregiver-reported family functioning and the cardiometabolic health of Hispanic/Latino youth was examined. METHOD: Data were from the Hispanic Community Children's Health Study/Study of Latino Youth (SOL Youth) (2012-2014), a population-based cohort study of children and adolescents whose parents participated in the HCHS/SOL (2008-2011). The relationship between youth- and caregiver-rated family functioning, and concordance of ratings is modeled, utilizing the general functioning subscale of the McMaster Family Assessment Device with youth objective cardiometabolic health markers (obesity, central adiposity, prediabetes/diabetes, prehypertension/hypertension, triglycerides, HDL cholesterol) adjusting for sociodemographic factors. RESULTS: Among boys, child/caregiver concordant ineffective family functioning rating was associated with higher cumulative cardiometabolic risk (adjusted B (95% CI): 0.30 (0.04, 0.56)), but no association was observed among girls (adjusted B (95% CI): 0.04 (-0.13, 0.21)). Among girls, ineffective child rating/effective caregiver rating was associated with higher cumulative cardiometabolic risk (adjusted B (95% CI): 0.27 (0.06, 0.48)), but no association was observed among boys (adjusted B (95% CI): 0.02 (-0.23, 0.27). CONCLUSION: Findings suggest that family functioning among this Hispanic/Latino population may influence cardiometabolic risk among youth. Observed differences in the associations by youth sex and concordant/discordant reports of family functioning suggest interventions at the family level, targeting both caregivers and youth, that consider differential sex effects are warranted.

Prescription Drug Monitoring and Child Maltreatment in the United States, 2004-2018.

OBJECTIVE: To test whether a policy approach aimed at decreasing prescription drug misuse, specifically, state monitoring of controlled substance prescriptions-prescription drug monitoring programs (PDMPs)-were associated with changes in Child Protective Services-reported maltreatment prevalence. STUDY DESIGN: Using a difference-in-differences design and maltreatment data (2004-2018) from 50 states and the District of Columbia, we compared the prevalence of total maltreatment incidents and total victims, in states with and without PDMPs, before and after implementation. Exploratory analyses further examined models disaggregated by maltreatment type (neglect, physical abuse, sexual abuse, psychological abuse) and among different racial/ethnic groups. Quasi-Poisson models included state-level covariates, state- and year-fixed effects, and cluster-robust standard errors. RESULTS: Difference-in-differences models identified greater relative reductions in PDMP states relative to controls (total prevalence ratio, 0.87; 95% CI, 0.80, 0.940; victimization prevalence ratio, 0.92; 95% CI, 0.85-0.98) over the observation period. Decreases seemed to be driven by changes in neglect (prevalence ratio, 0.87; 95% CI, 0.80-0.93) and physical abuse (prevalence ratio, 0.78; 95% CI, 0.71-0.87) incidents, and may have been especially salient for American Indian/Alaskan Native children (prevalence ratio, 0.78; 95% CI, 0.65-0.94). CONCLUSIONS: We found evidence supporting an association between prescription drug monitoring and reduced maltreatment prevalence at the state level. Policies aimed at restricting the prescribing and dispensing of controlled substances may have indirect implications for child welfare.

Immigrant-Related Policies and the Health Outcomes of Latinx Adults in the United States: A Systematic Review.

BACKGROUND: US federal and subfederal immigrant-related policy activity has increased in recent years. We hypothesize that these policies are structural determinants of health for Latinx communities, operating through access to resources, discriminatory enforcement, and stress. METHODS: We searched seven databases for quantitative studies, published as of September 2021, examining the association between the presence of federal, state, or local immigrant-related policy(ies), over time or cross-sectionally, and mental or physical health outcomes among immigrant or US-born Latinx adults. We rated studies on methodologic quality. RESULTS: Eleven studies were included. Policies included federal and state policies. Health outcomes included mental health (seven studies), self-rated health (n = 6), and physical disability (n = 1). Among immigrant, noncitizen, or Spanish-preferring Latinx adults, exclusionary policies were associated with poor self-rated health, physical disability, and poor mental health. Inclusive policies were associated with better health, although null findings were more common than among studies of exclusionary policies. Only three studies separately examined policy effects on US-born or citizen Latinx adults and these findings were often null. All studies received a weak overall study quality rating; among quality domains, studies were strongest in confounding control and weakest in outcome information bias and reporting missing data approaches. CONCLUSIONS: These results support the hypothesis that immigrant-related policies, especially exclusionary policies, are structural drivers of health for immigrant or noncitizen Latinx adults. However, evidence is scant among US-born or citizen Latinx adults. Studies of policies and physical health outcomes besides disability are lacking, as are results disaggregated by nativity and/or citizenship status.

Child Maltreatment and Inflammatory Response to Mental Stress Among Adults Who Have Survived a Myocardial Infarction.

OBJECTIVE: Experiences of child maltreatment are associated with cardiovascular risk and disease in adulthood; however, the mechanisms underlying these associations are poorly understood. METHODS: We examined associations between retrospectively self-reported exposure to child maltreatment (Early Trauma Inventory Self-Report Short Form) and inflammatory responses to mental stress among adults (mean age = 50 years) who recently had a myocardial infarction ( n = 227). Inflammation was assessed as blood interleukin-6 (IL-6), matrix metalloproteinase-9 (MMP-9), and monocyte chemoattractant protein-1 concentrations, measured before and after a standardized public speaking stress task. We used mixed linear regression models adjusting for cardiovascular disease severity, medication usage, and psychosocial, demographic, and life-style factors. RESULTS: In women, increases in IL-6 levels and MMP-9 levels with stress were smaller in those exposed to sexual abuse, relative to those unexposed (IL-6 geometric mean increases = 1.6 [95% confidence interval {CI} = 1.4-1.9] pg/ml versus 2.1 [95% CI = 1.8-2.4] pg/ml; MMP-9 geometric mean increases = 1.0 [95% CI = 0.9-1.2] ng/ml versus 1.2 [95% CI = 1.1-1.4] ng/ml). No differences were noted for emotional or physical abuse. By contrast in men, individuals exposed to sexual abuse had larger IL-6 responses than those not exposed to abuse. CONCLUSIONS: These findings suggest sex differences in stress response among survivors of a myocardial infarction exposed to abuse early in life. They also underscore the importance of examining sex as an effect modifier of relationships between exposure to early life adversity and inflammatory responses to mental stressors in midlife.

Racial and Ethnic Disparities in Acute Care Use for Pediatric Asthma.

PURPOSE: Previous work has shown that asthma-related emergency department (ED) use is greatest among Black and Latine populations, but it is unknown whether health care use for exacerbations differs across settings (outpatient, ED, inpatient) and correlates with use of routine outpatient services. We aimed to measure disparities by race, ethnicity, and language in pediatric acute asthma care using data from US primary care community health centers. METHODS: In an observational study using electronic health records from community health centers in 18 states, we compared non-Hispanic Black, English-preferring Latine, Spanish-preferring Latine, and non-Hispanic White children aged 3 to 17 years on visits for clinic-coded asthma exacerbations (2012-2018). We further evaluated asthma-related ED use and inpatient admissions in a subsample of Oregon-Medicaid recipients. Covariate-adjusted odds ratios (ORs) and rate ratios (RRs) were derived using logistic or negative binomial regression analysis with generalized estimating equations. RESULTS: Among 41,276 children with asthma, Spanish-preferring Latine children had higher odds of clinic visits for asthma exacerbation than non-Hispanic White peers (OR = 1.10; 95% CI, 1.02-1.18). Among the subsample of 6,555 children insured under Oregon-Medicaid, non-Hispanic Black children had higher odds and rates of asthma-related ED use than non-Hispanic White peers (OR = 1.40; 95% CI, 1.04-1.89 and RR = 1.49; 95% CI, 1.09-2.04, respectively). We observed no differences between groups in asthma-related inpatient admissions. CONCLUSIONS: This study is the first to show that patterns of clinic and ED acute-care use differ for non-Hispanic Black and Spanish-preferring Latine children when compared with non-Hispanic White peers. Non-Hispanic Black children had lower use of clinics, whereas Spanish-preferring Latine children had higher use, including for acute exacerbations. These patterns of clinic use were accompanied by higher ED use among Black children. Ensuring adequate care in clinics may be important in mitigating disparities in asthma outcomes.VISUAL ABSTRACT.

Investigating the associations between childhood trauma and cardiovascular health in midlife.

Growing evidence suggests that childhood trauma is associated with poorer cardiovascular health in adulthood, but few studies have examined potential mediators of these associations. We examined the links between different forms of childhood trauma (i.e., abuse, neglect, cumulative trauma) and cardiovascular health and explored potential mediators. Cross-sectional data from 1,251 participants in the National Survey of Midlife Development in the United States' II Biomarker Project were analyzed. Path analyses were conducted to examine the associations between childhood trauma and cardiovascular health (i.e., American Heart Association's Life's Simple 7 [LS7] score). Depressive symptoms and sleep quality were explored as potential mediators, and exploratory analyses examined whether these associations were moderated by sex. Women reported more severe childhood emotional and sexual abuse and emotional neglect, p < .001 to p = .018, and higher LS7 scores, p = .027, than men. Path analyses demonstrated the total effects of increasing severity of all forms of childhood trauma with LS7 scores were significant, and cumulative childhood trauma was inversely associated with LS7 score Bs = -0.306- -0.076, p < .001-p = .048. The range of total effects of different forms of childhood trauma on LS7 scores mediated by depressive symptoms and sleep quality was 26.8%-57.5%. Sex moderated the associations between all forms of childhood trauma and cardiovascular health. Longitudinal studies are needed that examine mediators of the associations between childhood trauma and cardiovascular health. Findings suggest sex-specific, trauma-informed approaches for cardiovascular disease prevention in adults exposed to childhood trauma may be needed.

Early life stress and autonomic response to acute mental stress in individuals with coronary heart disease.

Early life stress (ELS) has been associated with an increased risk of cardiovascular disease. We examined whether ELS was associated with autonomic function and stress reactivity among individuals with coronary heart disease (CHD). We included patients with stable CHD from two parallel studies, the Mental Stress Ischemia Prognosis Study (MIPS) and the Myocardial Infarction and Mental Stress Study 2 (MIMS2), and assessed ELS using the Early Trauma Inventory-Self-Report-Short Form. Participants underwent a laboratory-based mental stress task while undergoing ambulatory electrocardiographic monitoring. We used multivariate linear regression models to estimate the associations between ELS and heart rate variability (HRV; low frequency [LF], high frequency [HF], and LF and HF [LH] ratio). The analytic sample included 405 MIPS and 284 MIMS2 participants. Most participants endorsed at least one experience of ELS (92.2%). Although we did not observe associations between ELS and HRV outcomes in the overall sample, ELS was associated with lower LH ratio HRV during recovery in the posttraumatic stress disorder (PTSD) subgroup, ELS x PTSD interaction, p = .041. In the MIMS2 subgroup, ELS was associated with lower resting period LF HRV, B ̂ $ \widehat{B} $  = -0.16 ln ms2 ; 95% CI [-0.31, -0.02]. Exposure to physical trauma was associated with decreased HF HRV overall reactivity only among participants with high to moderate depressive symptoms, B ̂ $ \widehat{B} $  = -0.52 ln ms2 vs. B ̂ $ \widehat{B} $  = 0.01 ln ms2 , p = .013. Overall, heterogeneous associations between ELS and HRV emerged, suggesting the need for additional research regarding longer-term ambulatory HRV.

National Trends in Emergency Department Visits for Child Maltreatment, 2007-2014.

OBJECTIVE: To understand the prevalence of child maltreatment-related emergency department (ED) visits in the United States, we examined data from the 2007 to 2014 Nationwide Emergency Department Sample. METHODS: Based on existing literature, International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9 CM) ED discharge codes for children less than 10 years of age were characterized as specified child maltreatment, defined as visits with an explicit maltreatment ICD-9 CM or external causes of injury codes. The prevalence of child maltreatment visits per 100,000 children in the United States (based on Center for Disease Control Wide-ranging ONline Data for Epidemiologic Research estimates) overall and by sociodemographic factors was examined, and tests for trends over time were evaluated with Cochran-Armitage tests. Analyses were conducted in 2019. RESULTS: The prevalence of child maltreatment based in ICD-9 CM discharge codes ED visits dropped from 69.2 visits per 100,000 in 2007 to 65.9 visits per 100,000 in 2014; this trend was statistically significant. The prevalence was lowest in 2010 (60.1 visits per 100,000 children). There were increases observed for some demographic groups in this period. Throughout the 8-year period examined, the prevalence of child maltreatment visits was highest for physical abuse compared with other forms of maltreatment, higher for boys compared with girls; highest for children younger than 1 year, and higher for children living in neighborhoods with the lowest median income compared with children in higher-income neighborhoods. CONCLUSIONS: The Nationwide Emergency Department Sample data set is a valuable surveillance tool for examining trends in child maltreatment. Future studies should explore what factors may explain variations in child maltreatment over time to best develop prevention strategies.

ADHD and risk for subsequent adverse childhood experiences: understanding the cycle of adversity.

BACKGROUND: Children with adverse childhood experiences (ACEs) are more likely to develop Attention-Deficit/Hyperactivity Disorder (ADHD). The reverse relationship - ADHD predicting subsequent ACEs - is vastly understudied, although it may be of great relevance to underserved populations highly exposed to ACEs. METHODS: Participants were 5- to 15-year-olds (48% females) with (9.9%) and without ADHD (DSM-IV criteria except age of onset) in a longitudinal population-based study of Puerto Rican youth. In each wave (3 yearly assessments, W1-3), ten ACEs (covering parental loss and maladjustment and child maltreatment) were examined, plus exposure to violence. Logistic regression models examined ADHD (including subtypes) and subsequent risk for ACEs. Also considered were interactions by age, sex, number of W1 ACEs, and recruitment site. RESULTS: Children with W1 ADHD were more likely to experience subsequent adversity (OR: 1.63; 95% CI: 1.12-2.37) accounting for child age, sex, public assistance, maternal education, site, disruptive behavior disorders, and W1 ACEs. Inattentive (OR: 2.00; 95% CI: 1.09-3.66), but not hyperactive/impulsive or combined ADHD, predicted future ACEs. CONCLUSIONS: ADHD predicts subsequent risk for ACEs, and the inattentive presentation may confer the most risk. Inattentive presentations could pose a bigger risk given differences in symptom persistence, latency to access to treatment, and treatment duration. The present study suggests a pathway for the perpetuation of adversity, where bidirectional relationships between ADHD and ACEs may ensnare children in developmental pathways predictive of poor outcomes. Understanding the mechanism underlying this association can help the development of interventions that interrupt the cycle of adversity exposure and improve the lives of children with ADHD.