Consistent evidence has identified childhood adversity as a significant determinant of physical and mental health. Childhood adversities, which include experiences such as child maltreatment, household dysfunction, bullying, exposure to crime, discrimination, bias, and victimization occurring before adulthood, place a substantial burden of adaptation on children and are recognized as social determinants of cardiovascular disease.¹ Endorsement of childhood adversities is prevalent with >60% of US adults reporting ≥1 types of adversities.² Exposure to adversities during childhood is associated with increased risk for mental health disorders, substance abuse, suicidal attempts, a myriad of chronic diseases, including heart disease, obesity, diabetes, and cancer, and premature mortality.³ The Adverse Childhood Event study noted a higher risk of stroke, ischemic heart disease, and myocardial infarction with increasing number of adverse experiences in childhood.⁴ Strong evidence also shows that exposure to childhood adversities directly impacts cardiometabolic risk in adulthood.⁵ The degree to which childhood adversity contributes to achieving ideal cardiovascular health, however, has been examined less frequently and has the potential to inform mechanisms for supporting cardiovascular health across the life course.

See Article by Ortiz et al

In this issue of Circulation—Quality and Outcomes, Ortiz et al⁶ contribute to the existing literature by demonstrating associations between higher risky family environments and lower odds of achieving ideal cardiovascular health (CVH; defined as American Heart Association Life’s Simple 7) among participants in the CARDIA study (Coronary Artery Risk Development in Young Adults; N=2074, mean baseline age 25.3±3.5 years, 56% female). To assess childhood adversity, Ortiz et al⁶ used the Risky Family Environment Questionnaire, which retrospectively assessed participants’ experiences and frequency of emotional abuse, physical abuse, substance use in the home, and adult affection and support before 18 years of age. Adversities were summed and operationalized as a continuous measure with values ranging from 7 to 28; increasing scores indicated an increasingly adverse risky family environment. CVH scores were captured longitudinally at years 0, 7, and 20 of the CARDIA study. The present study found that for every 1-unit increase in Risky Family score, the odds of attaining high CVH (≥10) decreased by 3.6% (odds ratio, 0.9645 [95% CI, 0.94–0.98]). This study adds to a series of work^7,8 identifying the role of childhood adversity in influencing modifiable risk factors for cardiovascular disease. It expands the conceptualization of adversity by considering the frequency of experiences, which has not always been considered in prior work.

Emerging evidence points to several mechanisms that may drive these associations, namely physiological, psychological, and behavioral factors.⁹ For example, work with the National Survey of Midlife Development in the United States has shown depressive symptoms to mediate associations between childhood trauma and cardiovascular health.⁷ Behavioral factors such as sleep quality and quantity have also been associated with childhood adversity, as well as mediated the association between adversities and cardiovascular health.⁷ In fact, sleep is now the eighth component of American Heart Association’s cardiovascular health metric, given its importance in the development of cardiovascular disease.¹⁰ Physiologically, experiences of trauma in early life have been shown to promote a proinflammatory state, as well as dysregulate the hypothalamic-pituitary-adrenal-axis and the sympathetic and adrenomedullary system, which may influence the development of cardiometabolic risk factors.

Ortiz et al also examined modifiers of this association, including caregiver warmth and socioeconomic status (SES). Specific Risky Family Environment measures of child abuse and caregiver warmth were associated with 12.8% lower and 11.7% higher odds of ideal CVH (≥10), respectively. The results also varied by adulthood income (at year 7), suggesting that associations between Risky Family Environment and CVH persisted for those in the highest income category (>$74K), but not the lowest (<$35K). The potential for contextual factors to modify the associations between adversity and cardiometabolic outcomes has not been extensively studied in the literature, though it is recognized that context may alter the timing, type, and severity of the adversities experienced. For example, non-Hispanic Blacks and Latinos are exposed to a high number of childhood adversities compared with non-Hispanic Whites. People belonging to minoritized groups and those from financially disadvantaged households experience higher levels of the most common childhood adversities, including high rates of economic hardship, parental separation, and incarcerated parents,² as well as experience higher exposure to environmental pollutants. Marginalized and underserved populations may also experience stressors that other populations may not experience, for example, discrimination and community violence. In addition, marginalized populations may have limited resources to manage and cope with adverse experiences, potentially resulting in worse health outcomes. Previous studies have shown that the impact of adversities on cardiovascular health is worse for adults among lower SES households⁸ or those who live in lower SES neighborhoods.¹¹ In contrast, the paper by Ortiz et al notes that while adult SES modifies the adversities and cardiovascular health association, it is among those in higher adult SES, where the associations are observed. It is important to note that while childhood SES may modify the experiences of adversity on health outcomes, adult SES can be conceptualized as a potential mediator of how adversities impact cardiovascular health. Work in the CARDIA study has demonstrated that adult educational attainment partially explains associations between risky family environments and cardiovascular disease incidence, which may explain the lack of associations noted in the lower income strata in the current study.¹² Nonetheless, further examinations on both positive and adverse socio-contextual factors as modifiers of the adverse childhood experience and cardiovascular health relation are needed to better inform the development of intervention and prevention efforts.

While most of the work on early childhood experiences and cardiovascular health has centered on negative risk factors that adversely affect health outcomes, recent work has shifted to focus on positive aspects of childhood that may promote good health outcomes. The work by Ortiz et al demonstrates that caregiver warmth is associated with better cardiovascular health in adulthood. These findings, which are consistent with existing literature, imply that we can positively improve cardiovascular health by promoting positive parent-caregiver relationships in childhood. Children thrive in home environments that are safe and stable and from caregiving relationships that nurture their development. These positive aspects of childhood are known to promote good socio-emotional development, behavior, resilience to the effects of adverse experiences, and cardiovascular health.¹³ For example, work by Slopen et al has shown that positive childhood experiences (eg, high parental SES, residential stability, parental warmth) are associated with ideal cardiovascular health. These positive factors are not just the absence of negative experiences but factors that positively impact development. They are hypothesized to affect cardiovascular health throughout the lifecourse in a similar manner as adverse experiences by promoting heart healthy behaviors (ie, not smoking, engaging in physical activity), positive mental health, strong social networks, and social support.

In spite of the increasing knowledge that childhood adversities are associated with cardiovascular health, as well as cardiovascular disease and mortality, little progress has been made in understanding how to address adversities and limit their impact on cardiovascular health in the long term. Current interventions to address the sequelae of childhood adversities mainly focus on cognitive-behavioral therapy that addresses mental health outcomes. Still, little is known of interventions that can be delivered to address cardiovascular health and best practices for implementing those interventions. Identifying targets for intervention, such as health and behavioral components of CVH, that are in the causal pathway between adversities and cardiovascular disease is needed to advance this work. The work by Ortiz et al suggests that supporting positive caregiver-child relationships in childhood can promote positive cardiovascular health. Understanding whether interventions that strengthen caregiver-child relations can promote positive cardiovascular health across the lifecourse would address a critical gap in our knowledge of how we ameliorate the impact of adversities. It is also important to consider that interventions to promote CVH need to consider how these interventions should be delivered to populations impacted by adversities and other social stressors.¹⁵ As noted, populations are differentially impacted by adversities given the relation between adversities and social factors, resulting in a potentially increased risk of exposure and differential impact among minoritized and disadvantaged groups. Further understanding how social context modifies the child adversity and cardiovascular health association could help us advance our understanding of how to tailor interventions. As we work to understand how we can prevent the harmful effects of adversity from affecting cardiovascular health, we need to consider socio-contextual factors so that all may benefit from such prevention strategies.

None.

Disclosures None.

For Sources of Funding and Disclosures, see page 126.

The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

一致的证据表明，童年逆境是身心健康的重要决定因素。童年时期的逆境，包括儿童虐待、家庭功能障碍、欺凌、犯罪、歧视、偏见和成年前受害等经历，给儿童带来了巨大的适应负担，并被认为是心血管疾病的社会决定因素。¹对童年逆境的认可很普遍，超过 60% 的美国成年人报告了 ≥ 1 种逆境。²童年时期遭遇逆境会增加精神健康障碍、药物滥用、自杀企图、多种慢性疾病（包括心脏病、肥胖、糖尿病和癌症）以及过早死亡的风险。³不良童年事件研究指出，随着儿童时期不良经历的增多，中风、缺血性心脏病和心肌梗死的风险也会增加。⁴强有力的证据还表明，童年时期的逆境会直接影响成年后的心脏代谢风险。⁵然而，人们对童年逆境在多大程度上有助于实现理想心血管健康的研究较少，但有可能为整个生命过程中支持心血管健康的机制提供信息。

请参阅 Ortiz 等人的文章

在本期《循环质量和结果》中，Ortiz 等人⁶通过证明高风险家庭环境与参与者实现理想心血管健康（CVH；定义为美国心脏协会 Life's Simple 7）的较低几率之间的关联，为现有文献做出了贡献。 CARDIA 研究（年轻人冠状动脉风险发展；N=2074，平均基线年龄 25.3±3.5 岁，56% 为女性）。为了评估童年逆境，Ortiz 等人⁶使用了危险家庭环境问卷，该问卷回顾性评估了参与者在 18 岁之前遭受情感虐待、身体虐待、家庭物质使用以及成人情感和支持的经历和频率。逆境被总结并可操作为连续测量，数值范围为 7 至 28；分数的增加表明家庭环境的风险日益不利。CVH 评分是在 CARDIA 研究的第 0 年、第 7 年和第 20 年纵向捕获的。本研究发现，风险家庭评分每增加 1 个单位，获得高 CVH (≥10) 的几率就会降低 3.6%（比值比，0.9645 [95% CI，0.94–0.98]）。这项研究是对一系列工作的补充，^7,8确定了童年逆境在影响心血管疾病可改变危险因素中的作用。它通过考虑经历的频率来扩展逆境的概念化，这在之前的工作中并不总是被考虑到。

新出现的证据指出了可能驱动这些关联的几种机制，即生理、心理和行为因素。⁹例如，与美国国家中年发展调查的合作表明，抑郁症状可以调节儿童创伤与心血管健康之间的关联。⁷睡眠质量和数量等行为因素也与童年逆境有关，并调节逆境与心血管健康之间的关联。⁷事实上，鉴于睡眠在心血管疾病发展中的重要性，睡眠现在已成为美国心脏协会心血管健康指标的第八个组成部分。¹⁰从生理学角度来看，早年经历的创伤已被证明会促进促炎症状态，并使下丘脑-垂体-肾上腺轴以及交感神经和肾上腺髓质系统失调，这可能会影响心脏代谢危险因素的发展。

Ortiz 等人还研究了这种关联的修饰因素，包括照顾者的热情和社会经济地位 (SES)。虐待儿童和照顾者温暖的具体风险家庭环境测量与理想 CVH (≥10) 的几率分别降低 12.8% 和升高 11.7%。结果还因成年收入（7 岁时）而异，表明风险家庭环境与 CVH 之间的关联对于收入最高类别（> 74,000 美元）的人来说仍然存在，但收入最低类别（< 35,000 美元）的人则不然。背景因素改变逆境与心脏代谢结果之间关联的潜力尚未在文献中得到广泛研究，尽管人们认识到背景可能会改变所经历逆境的时间、类型和严重程度。例如，与非西班牙裔白人相比，非西班牙裔黑人和拉丁裔在童年时期遭遇的逆境较多。少数群体和经济困难家庭的人在童年时期最常见的逆境的程度较高，包括经济困难、父母分居和父母入狱的比例较高，²并且接触环境污染物的程度也较高。边缘化和服务不足的人群也可能会经历其他人群可能不会经历的压力，例如歧视和社区暴力。此外，边缘化人群管理和应对不良经历的资源可能有限，可能导致更糟糕的健康结果。先前的研究表明，对于社会经济地位较低的家庭⁸或生活在社会经济地位较低的社区的成年人来说，逆境对心血管健康的影响更严重。¹¹相比之下，Ortiz 等人的论文指出，虽然成人 SES 改变了逆境和心血管健康之间的关联，但在较高的成人 SES 中，观察到了这种关联。值得注意的是，虽然儿童时期的社会经济地位可能会改变逆境经历对健康结果的影响，但成人社会经济地位可以被概念化为逆境影响心血管健康的潜在中介因素。CARDIA 研究表明，成人受教育程度部分解释了危险家庭环境与心血管疾病发病率之间的关联，这可能解释了当前研究中低收入阶层中缺乏关联的原因。¹²尽管如此，需要进一步检查积极和不利的社会背景因素作为不良童年经历和心血管健康关系的修饰因素，以便更好地为干预和预防工作的发展提供信息。

虽然大多数关于幼儿期经历和心血管健康的工作都集中在对健康结果产生不利影响的负面风险因素上，但最近的工作已转向关注可能促进良好健康结果的童年积极方面。Ortiz 等人的研究表明，照顾者的温暖与成年后更好的心血管健康有关。这些发现与现有文献一致，表明我们可以通过促进儿童时期积极的父母与照顾者关系来积极改善心血管健康。儿童在安全稳定的家庭环境以及促进其发展的照护关系中茁壮成长。众所周知，童年的这些积极方面可以促进良好的社会情感发展、行为、对不良经历影响的恢复能力以及心血管健康。¹³例如，Slopen 等人的研究表明，积极的童年经历（例如，父母社会经济地位高、居住稳定、父母温暖）与理想的心血管健康相关。这些积极因素不仅仅是没有负面经历，而是对发展产生积极影响的因素。据推测，它们会通过促进心脏健康行为（即不吸烟、参加体育活动）、积极的心理健康、强大的社交网络和社会支持，以与不良经历类似的方式影响整个生命过程中的心血管健康。

尽管人们越来越认识到儿童期逆境与心血管健康以及心血管疾病和死亡率有关，但在了解如何应对逆境并限制其对心血管健康的长期影响方面进展甚微。目前解决儿童逆境后遗症的干预措施主要集中于解决心理健康问题的认知行为疗法。尽管如此，人们对可用于解决心血管健康问题的干预措施以及实施这些干预措施的最佳实践知之甚少。为了推进这项工作，需要确定干预目标，例如 CVH 的健康和行为组成部分，这些目标是逆境与心血管疾病之间的因果关系。奥尔蒂斯等人的研究表明，在儿童时期支持积极的照顾者与儿童的关系可以促进积极的心血管健康。了解加强照顾者与儿童关系的干预措施是否可以在整个生命过程中促进积极的心血管健康，这将弥补我们在如何改善逆境影响方面的知识中的一个关键差距。同样重要的是要考虑促进 CVH 的干预措施需要考虑如何将这些干预措施提供给受逆境和其他社会压力因素影响的人群。¹⁵如前所述，鉴于逆境与社会因素之间的关系，人们受到逆境的影响存在差异，导致少数群体和弱势群体的暴露风险和影响存在潜在增加。进一步了解社会背景如何改变儿童逆境和心血管健康关联可以帮助我们加深对如何制定干预措施的理解。当我们努力了解如何防止逆境对心血管健康产生有害影响时，我们需要考虑社会背景因素，以便所有人都可以从此类预防策略中受益。

没有任何。

披露无。

有关资金来源和披露信息，请参阅第 126 页。

本文表达的观点不一定代表编辑或美国心脏协会的观点。