# Presentation: 153152

## Psychosocial Factors, Health Behaviors, and Physiologic Consequences

**Psychosocial Factors, Health Behaviors, and Physiologic Consequences**
**-The North Texas Healthy Heart Study-**

**Roberto Cardarelli, D.O., M.P.H., F.A.A.F.P.**
**Chief, Division of Research, Department of Family Medicine**
**Director of the North Texas Primary Care Practice-Based Research Network**

## Objectives

**To discuss the racial/ethnic differences in relationship between psychosocial factors, health behaviors, and physiologic measures**
**To discuss the potential impact of the study’s findings on clinical care**

## Importance

**CVD is the #1 cause of death**
**2004: CVD was the underlying cause of death  for 36.3% of all deaths (1 of every 2.8 deaths in the U.S)**
**Disparities in CVD exist**
**Prevalence: CVD highest in whites (11.9%) compared to Blacks (9.6%) **
**CVD death rate (per 100,000 people)**
**Whites males****	****335.7**
**Black males****	****448.9**
**White females****	****239.3**
**Black females****	****331.6**

## Background

**Growing evidence that psychosocial factors contribute **_**significantly**_** to CVD**
**Behavioral mechanisms**
**Direct pathophysiologic mechanisms**
**Patient oriented outcomes (CD, IHD, MI)**
**Anxiety → Sudden Cardiac Death (dose-dependent relationship) [RR = 4.7-6.1]**
**Depression → CD, MI [RR = 1.3-3.5]**
**Social support → All cause mortality, CD (gradient effect) [RR = 1.4-3.8]**

## Background

**Framework**

**“****Stressors”**

_**PSYCHOSOCIAL**_
**Depression**
**Social Support**
**Aggression**
**Perceived Discrimination**
**Perceived stress**

_**HEALTH BEHAVIORS**_
**Poor eating habits**
**Lack of exercise**
**Smoking**
**Substance abuse**

_**PHYSIOLOGICAL CONSEQUENCES**_
**BMI, Fibrinogen, CRP, IL-6, Calcium score, ACTH**

**CVD**

## Background

**Problem for the practicing clinician:**
**Where do we intervene?**
**Do the associations between the psychosocial factors and outcomes differ by race/ethnicity? Or, do we assume it is the same for everyone?**

## Study Questions

**Do psychosocial factors differ by race/ethnicity?**
**Are psychosocial factors associated with unhealthy behaviors and physiologic measures?**
**Are unhealthy behaviors associated with physiologic measures?**

## North Texas Healthy Heart Study funded by NIH/NCMHD (1-P20-MD001633-01)
Cross-sectional design involving the first 200 participants (May 2006 to October 2006)
75 African Americans
75 Hispanics/Latinos
50 Whites
14 NorTex clinics/community centers
Recruitment – 18 weeks (Referrals, active recruitment, flyers, word-of-mouth)
Currently in Phase 2 of the study – additional funding was secured in January 2007 and currently recruiting another 200 participants

**Cross-sectional design involving the first 200 participants (May 2006 to October 2006)**
**75 African Americans**
**75 Hispanics/Latinos**
**50 Whites**
**14 NorTex clinics/community centers**
**Recruitment – 18 weeks (Referrals, active recruitment, flyers, word-of-mouth)**
**Currently in Phase 2 of the study – additional funding was secured in January 2007 and currently recruiting another 200 participants**

- Methods

## Methods

**Inclusion/Exclusion criteria:**
**Males and females over the age of 45  **
**Ethnicity/Race: White, Hispanic/Latino, and/or African American**
**No current or previous self-reported history of stroke, peripheral arterial disease, renal failure, heart failure, coronary artery disease (history of angioplasty with/without stents, CABG, or any other diagnostically confirmed coronary artery disease).**
**Pregnancy is an exclusion to complete the study**

## Methods

**All patients came to the NorTex Research Office/Clinic**
**Interview – 1-1.5 hours**
**Body measurements (Waist/Hip circumferences, BMI, % fat by impedance)**
**Serum/Urine collection (CMP, CBC, hsCRP, lipid panel, catecholamine levels, fibrinogen, apolipoprotein-B, urinary microalbumin/creatinine ratio, ACTH, serotonin, and IL-6)**
**Multi-Slice Computed Tomography (CCS)**
**Contacted yearly (for 3 years) to assess for endpoints (deaths, hospitalizations, CV outcomes [MI, Stroke. Dx CAD, PAD, etc.]) and reassess psychosocial factors**

## Statistical analyses
Stratified by race/ethnicity
Descriptive (t-test, chi-square)
Will use regression models to investigate the association between the independent and dependent variables
0.05 LOS

**Stratified by race/ethnicity**
**Descriptive (t-test, chi-square)**
**Will use regression models to investigate the association between the independent and dependent variables**
**0.05 LOS**

- Methods

## Depression (CES-D)

**Social Support (M&R)**
**Aggression (Buss)**
**Perceived Discrimination (Krieger)**
**Perceived stress (Cohen)**

**Poor eating habits**
**Lack of exercise**
**Smoking**

**Fibrinogen**
**CRP**
**IL-6 **
**ACTH**
**Calcium score**

**Poor eating habits**
**Lack of exercise**
**Smoking**

_**Independent variables**_

_**Outcome variables**_

**Covariates: Age, Gender, DM, HTN, LDL, HDL, Smoking, BMI, CVD Family Hx, Diet**

## Results

| DEPRESSION – Univariate analysis |  |  |  |  |
| --- | --- | --- | --- | --- |
| Outcome | Race/Ethnicity | OR | 95% CI | P-value |
| Unhealthy Diet | Hispanic  | 1.02 | 0.97,1.07 | 0.49 |
|  | White | 1.14 | 1.04,1.26 | 0.005 |
|  | African American | 1.02 | 0.97,1.07 | 0.42 |
| Lack of Exercise | Hispanic  | 0.96 | 0.91,1.01 | 0.13 |
|  | White | 1.09 | 0.99,1.19 | 0.07 |
|  | African American | 1.01 | 0.96,1.06 | 0.69 |
| Drug Use | Hispanic  | 1.19 | 0.92,1.55 | 0.20 |
|  | White | 1.06 | 0.91,1.25 | 0.46 |
|  | African American | 1.10 | 1.00,1.21 | 0.05 |
| Fibrinogen | Hispanic  | 1.05 | 0.99,1.11 | 0.13 |
|  | White | 0.91 | 0.73,1.13 | 0.39 |
|  | African American | 1.06 | 1.01,1.12 | 0.03 |

- Health Behaviors

- CVM

## Results

- Health Behaviors

- CVM

| PERCEIVED DISCRIMINATION – Univariate analysis |  |  |  |  |
| --- | --- | --- | --- | --- |
| Outcome | Race/Ethnicity | OR | 95% CI | P-value |
| Unhealthy Diet | Hispanic  | 0.66 | 0.25,1.70 | 0.39 |
|  | White | 0.26 | 0.08,0.85 | 0.03 |
|  | African American | * | * | * |
| Lack of Exercise | Hispanic  | 2.31 | 0.85,6.23 | 0.10 |
|  | White | 1.50 | 0.23,9.87 | 0.67 |
|  | African American | 1.83 | 0.42,8.00 | 0.42 |
| IL-6 | Hispanic  | 0.51 | 0.05,5.20 | 0.57 |
|  | White | * | * | * |
|  | African American | 18.60 | 2.50,138.50 | 0.004 |

## Results

| AGGRESSION – Univariate analysis |  |  |  |  |
| --- | --- | --- | --- | --- |
| Outcome | Race/Ethnicity | OR | CI | p-value |
| Smoking | Hispanic  | 1.00 | 0.95,1.00 | 0.08 |
|  | White | 0.99 | 0.96,1.02 | 0.52 |
|  | African American | 0.99 | 0.96,1.02 | 0.56 |
| Unhealthy Diet | Hispanic  | 1.02 | 0.99,1.05 | 0.13 |
|  | White | 1.02 | 0.99,1.06 | 0.14 |
|  | African American | 1.04 | 1.00,1.08 | 0.04 |
| Drug Use | Hispanic  | * | * | * |
|  | White | 1.08 | 0.98,1.19 | 0.12 |
|  | African American | 1.05 | 0.99,1.12 | 0.10 |

## Results

| PERCEIVED STRESS – Univariate analysis |  |  |  |  |
| --- | --- | --- | --- | --- |
| Outcome | Race | OR | CI | p-value |
| Unhealthy Diet | Hispanic  | 1.09 | 1.00,1.19 | 0.06 |
|  | White | 1.12 | 1.02,1.23 | 0.02 |
|  | African American | 1.11 | 1.02,1.21 | 0.01 |
| Lack of Exercise | Hispanic  | 0.94 | 0.86,1.03 | 0.18 |
|  | White | 1.08 | 0.96,1.21 | 0.21 |
|  | African American | 1.07 | 0.99,1.15 | 0.08 |
| CRP | Hispanic  | 0.97 | 0.90,1.06 | 0.51 |
|  | White | 1.02 | 0.95,1.11 | 0.57 |
|  | African American | 1.06 | 0.99,1.14 | 0.10 |
| Fibrinogen | Hispanic  | 1.06 | 0.95,1.18 | 0.29 |
|  | White | 1.05 | 0.91,1.21 | 0.52 |
|  | African American | 1.21 | 1.09,1.35 | 0.001 |

- Health Behaviors

- CVM

## Slide 17

| Lack of Exercise – Univariate analysis |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- |
| Outcome | Race/Ethnicity | OR |  | CI | p-value |  |
| Fibrinogen | Hispanic  | 1.22 |  | 0.35,4.21 | 0.76 |  |
|  | White | 5.25 |  | 0.39,71.42 | 0.21 |  |
|  | African American | 2.90 |  | 1.03,8.19 | 0.04 |  |
| Unhealthy Diet – Univariate analysis |  |  |  |  |  |  |
| Outcome | Race/Ethnicity | OR | CI |  |  | p-value |
| CRP | Hispanic  | 1.38 | 0.55,3.44 |  |  | 0.50 |
|  | White | 4.33 | 1.30,14.47 |  |  | 0.02 |
|  | African American | 1.38 | 0.49,3.91 |  |  | 0.55 |
| BMI | Hispanic  | 4.42 |  *** |  |  | 0.002 |
|  | White | 4.43 |  *** |  |  | 0.06 |
|  | African American | 0.55 |  *** |  |  | 0.72 |
| Fibrinogen | Hispanic  | 1.25 | 0.38,4.15 |  |  | 0.72 |
|  | White | 2.70 | 0.23,31.89 |  |  | 0.43 |
|  | African American | 4.55 | 1.49,13.88 |  |  | 0.008 |
| Calcium Score | Hispanic  | 3.50 | 1.09,11.22 |  |  | 0.04 |
|  | White | 0.37 | 0.18,1.17 |  |  | 0.09 |
|  | African American | 0.56 | 0.18,1.73 |  |  | 0.32 |

## Adjusted for: Age, Gender, DM, HTN, FMHx CVD, LDL, HDL, Smoking, BMI, Diet

| PERCEIVED STRESS – Multivariate analysis |  |  |  |  |
| --- | --- | --- | --- | --- |
| Outcome | Race | OR | CI | p-value |
| Calcium Score | Hispanic  | 0.85 | 0.66,1.10 | 0.22 |
|  | White | 1.23 | 1.01,1.50 | 0.04 |
|  | African American | 0.93 | 0.83,1.04 | 0.22 |

| AGGRESSION – Multivariate analysis |  |  |  |  |
| --- | --- | --- | --- | --- |
| Outcome | Race/Ethnicity | OR | CI | p-value |
| CRP | Hispanic  | 1.04 | 1.00,1.08 | 0.06 |
|  | White | 1.04 | 0.94,1.16 | 0.47 |
|  | African American | 1.06 | 1.00,1.13 | 0.06 |
| Fibrinogen | Hispanic  | 0.97 | 0.91,1.04 | 0.38 |
|  | White | 0.96 | +++ | 0.96 |
|  | African American | 1.11 | 1.01,1.22 | 0.03 |
| Calcium Score | Hispanic  | 1.01 | 0.95,1.08 | 0.77 |
|  | White | 1.08 | 0.99,1.18 | 0.11 |
|  | African American | 1.07 | 1.01,1.14 | 0.03 |

**Adjusted for: Age, Gender, DM, HTN, FMHx CVD, LDL, HDL, Smoking, BMI, Diet**

## Summary

**Psychosocial factors ******** Health Behaviors**

_**Whites**_

_**African Americans**_

_**Hispanics**_

- Depre  Diet
- Depre  Exercise
- Per Disc  Diet
- Stress  Diet

- Depre  Drug use
- Aggress  Diet
- Aggress  Drug use
- Stress  Exercise
- Stress  Diet

- Per Disc  Exercise
- Aggress  Smoking
- Stress  Exercise
- Stress  Diet

**Psychosocial factors ******** Physiologic Consequences**

_**Whites**_

_**African Americans**_

_**Hispanics**_

- Depre  Fibrinogen
- Per Disc  IL-6
- Stress  Fibrinogen
- Stress  CRP
**Aggress ******** Fibrinogen**
**Aggress ******** CRP**
**Aggress ******** Cal Score**

**Agress ******** CRP**

**Stress ******** Cal Score**

## Conclusions

**Are psychosocial factors associated with unhealthy behaviors?**
**Yes**
**Are psychosocial factors associated with physiologic measures?**
**Yes**
**Do they differ by race/ethnicity?**
**Yes**

## How did my practice change?

**More sensitive to my patient’s needs based on psychological and social issues**
**Better able to assess the barriers to health behaviors**
**Better understanding to managing CVD beyond the traditional risk factors.**

## Limitations

**Cross-sectional – causality can not be established**
**Not complete database (N = 200)**
**Numerous analyses**
**Geographical variation**

## Future Directions

**3 -year extension study**
**Cohort with repeat measures (causality)**
**Disparities due to plaque destabilization?**
**Further analyses to understand the relationships between the psychosocial factors themselves**
**RCT to assess interventions to reduce stress and improve CV outcomes (R01)**