Psychosocial Stress and CVD

It seems like eons that I have been trying to write a blog post that discusses how social factors influence health without losing the depth and complexity of the issue. Recently, I made a simple short status update on Facebook about psychosocial stress and cardiovascular disease(CVD). Quickly, some of my friends from all corners of the US chimed in and enriched my understanding of the topic. I then sat down trying to write another post after being influenced by all of my friend's input. Soon, I realized that this discussion took a more organic approach; similar to that of a grad seminar session, and it was already captured in print. After getting the permission of all but one of my friends/contributors, I posted it. I am so thankful to have such curious friends who love to engage in these types of deep discussions.


Chris Aloia:
Doing a lot of reading on psychosocial stress and CVD. Wow, mind blowing!

Katherine Moss: What's CVD?

Barbara Martinez: Cardiovascular disease

Katherine Moss: Ahhh thanks.

Name withheld and writing rephrased: Can you elaborate on what you are studying? It seems obvious that stress causes disease is there anything else?

Chris Aloia: a direct causative pathway has not been established etiologically, at least in humans. Most of the research points to stress as a modifier. Meaning that high stress causes poor lifestyle choices, which lead to poor health outcomes. Only a few researchers consider stress a direct cause. So there is a big debate that has been going on for at least 10 years and it has my full attention.

Dana Janezic: The evidence is there for a direct cause in baboons though so it really won't surprise me when they find it for humans.

Chris Aloia: yeah, Sapolsky again! But you can't randomize humans to stress. I think one group in Germany did it once, it is called torture. But there have been some awesome studies by extremely clever researchers. I buy it as a direct causal agent. The implications are intense!

Katherine Moss: Kind of gives new meaning to the phrase "broken hearted"

Dana Janezic: I'm of the school that thinks that when it comes to testing humans, we will be creative enough to come up with tests that don't involve torture. I really don't understand people who just give up and relegate human sciences to soft sciences... when we live in a world where people were creative enough to figure out how to test for the existence of neutrinos.

You're absolutely right, the implications are paramount. Think about the 30 year fixed rate mortgage in these terms. 30 years is a long long time for bad things to happen to a person all the while they have the stress of the obligation on that monthly note. It's particularly interesting when you consider the fact that the 30yfrm is a political creation...

Aaron Irons: Stress can indeed be a direct cause of cvd, whether left brained methods of perception, research or experimentation come to a widely held consensus or not. I mean that respectfully, while recognizing inherent biases in perception and thus accepted routes of validation which can become so familiar and accepted that the mental structures used to do analytical analysis can become their own barriers to equally valid insights and experience as well. With this respected such methods certainly have their use and place. As long as we remember to also release over attachment to them and allow for equal validity of so called right brain feeling, experiential, creative and perceptual capacities.
Even the short term effects of perceived stress with its effects of blood pressure, heart rate, adrenaline, fight or flight response can noticeably effect cardiovascular system unhealthfully to point of triggering angina, heart attacks and possibly strokes. Body sometimes overcompensates in its responses to perceived stressors by releasing, inhibiting or creating insulating fats, hormones or other chemicals which can have their own damaging effects.

Chris Aloia: Aaron, you bring up a great point. There is consensus that acute stress can induce a heart attack. However, short term stress does affect the cardiovascular system but to extrapolate that to CVD mortality is where things get VERY hazy.

And you are also right that individual perceptions of stress play major role, which again confounds the stress as direct causal agent theory because what triggers one person's stress response may not another.

Everyone is searching for hormones that are more stable markers for early stage CVD. Even Sapolsky has baboon blood in storage for the sole purpose of a discovery of a new hormones. Incredible! Thanks to all for posting. it helps me put this whole field into perspective.

Katherine Moss: Here's an idea for a study that doesn't involve torture. Put out a call for volunteers to participate in a study who describe themselves as "under severe stress". They would fill out a form describing their stressors: such as death in the family, job loss, divorce, child with medical issues, etc. Maybe they could be interviewed as well. Interview questions could include what level of social support people have, how often they see family and friends, if they feel comfortable discussing problems, if they belong to a church or other clubs, etc...Then they donate blood and it is examined. They have full cardiovascular workup. It could be a longitudinal study where they follow same subjects over time and ask about their stress levels and then compare results of heart tests? I realise that self selection isn't the best way to gather participants, BUT you would be getting people who subjectively see themselves as "stressed" which, as you say, varies from person to person even though they may be going through the same situations one person's stress might be greater than another. Just some thoughts. I'm sure someone is already doing this type of thing?

Chris Aloia: Yeah this has been done many times. The key is there is NO stable measure of stress. Self-reported stress can be confounded by lifestyle choices because people who report higher levels of stress are usually of low-income. low-education, they smoke more, etc etc. So no one knows which causes what. Does stress cause poor lifestyle choices? Do poor lifestyle choices create higher levels of stress? Is it education? Is it childhood SES? Crazy interwoven complexity and I love it.

Katherine Moss: What if the researchers eliminated those of low income or education or those who smoke from the pool?

Katherine Moss: I'm sure there are plenty of rich, well educated smokers who are stressed. In fact, they could use college professors as a start! LOL

Chris Aloia: Besides all these very interesting ideas above, there is also a political side. There is a mountain of evidence that shows a good chunk of the explanation for poor health outcomes are from social structures. The implication here is that what many call "human agency" is not as strong as some Republicans might argue. The pulling one up from the boot straps happens a lot a lot a lot less in low-income areas and even middle-income as well. This means the elites not only get the cash, the babes, the vacations, but they also live longer. Got to love that! Human civilization is more animal than human in my mind. I have no trouble with Darwin.

Katerine Moss: sad but true.

Sustainable Health Promotion

On February 2nd, Denise Stevens, the head of Matrix Public Health Solutions, the company that leads the Community Interventions for Health (CIH) project, was beamed into our classroom via Skype to present the CIH project strategy for chronic disease prevention. She laid out an extremely ambitious health promotion strategy that spanned 3 risk factors: tobacco, unhealthy diet, and physical activity; 3 countries: Mexico, India, and China; and 4 approaches: health education, social marketing, community mobilization, and structural change (Stevens, 2011).

The CIH intervention I think is the most emblematic of what it takes for sustainable health promotion is their tobacco reduction campaign in China, which has “smoking center inspectors” enforcing a city wide no-smoking ordinance. This one got my attention because not just anybody can waltz into China, a country that the WHO reports is “the world's largest producer and consumer of tobacco,” and establish an anti-smoking police force to enforce a CIH strategy. I had been studying sustainable health promotion for almost a decade, from WHO’s EPI to BRAC and including my own struggles with small-scale community health promotion. It seems I have never been able to grasp that elusive ingredient for sustainable health promotion. So here was someone drinking from the Holy Grail; I shot my hand up to ask, “how did you make that happen and who pays for it?”

It turned out that she knows the retired head of the Chinese version of the CDC and that the Pepsico foundation is a major funder behind CIH’s projects. She pointed out the prestige that comes from working with American partners is a bigger incentive for many of her international partners than money.

This funding and prestige revelation led me to research the Pepsico Foundation. Its goals and mission are in step with Pepsico’s own corporate mission and are found on the corporate website. CEO Indra Nooyi supports taking the lead in corporate responsibility and cultivating sustainability in the environment and health arenas (2010b). With Pepsico specifically in mind, I drew a concept map to illustrate the interaction between a corporation attempting to create a sustainable health promotion program in a globalized world and the communities it serves. With Pepsico’s war chest and corporate efficiency, they can fund community projects all over the world and gain access to academic and political elites “to help devise solutions to key global challenges” (Pepsico, 2010b). My map also shows the cycle of profits that fuel Pepsico, as their mission cannot be totally altruistic.

The hard truth is that health systems all over the world struggle to deliver primary care or health promotion, especially to the least fortunate (Frownfelter and Dean, 2006; Holman and Lorig, 2004). One of the main reasons for this is that the demand for secondary and tertiary care is less affected by price (Roberts et al, 2004). This means that when people are sick they are willing to pay whatever it costs to save their own life. This high demand creates a stable need for professionals and thus status becomes attached.

“Basic food” is another high demand commodity (Roberts et al., 2004 p. 164). There will always be a demand for food, and companies that control the food market are some of the richest and most powerful. Ironically, many of their products are partly responsible for exacerbating the prevalence of some chronic diseases.

In contrast, health promotion, and even primary care are extremely price sensitive and do not generate the high revenues like acute care services (Roberts et al., 2004). Simply put, people in general don’t value something that may prevent possible future costs and are less willing to create a demand for those services. This is why I believe that corporations are better poised to deliver health promotion. The new trend in corporate responsibility and sustainability provides the funding, visibility, and sustainability for health promotion in ways that other entities cannot support. Thus, it is important that we in public health can see this as an opportunity to develop public-private partnerships to ensure that such corporate campaigns deliver the right information.


References

Frownfelter, D., Dean, E. (2006). Cardiovascular and pulmonary physical therapy evidence and practice. St. Louis, Missouri: Mosby Inc.

Holman, H., Lorig, K. (2004). Patient self-management: a key to effectiveness and efficiency in care of chronic disease. Public Health Reports, 119:239-243.

Pepisco. (2010a). Corporate fact sheet. Retreived on . Retrieved on February 6, 2011 from www.pepsico.com/Download/PepsiCoCorporateFactSheet.pdf

Pepisco. (2010b). Letter from Indra Nooyi. Retrieved on February 6, 2011 from http://www.pepsico.com/Purpose/Performance-with-Purpose/Letter-from-Indra-Nooyi.html

Roberts, M. J., Hsiao, W., Berman, P., Reich, M.R. (2004). Getting Health Reform Right: A Guide to Improving Perfomance and Equity. New York, Oxford University Press.

Stevens, D. (2011). A systems oriented solution to a complex public health problem. [PowerPoint slides] Retrieved on February 19, 2011 from Simon Fraser University webct http://webct.sfu.ca/webct/cobaltMainFrame.dowebct?appforward=/webct/viewMyWebCT.dowebct

WHO. Towards a tobacco-free China. Retrieved on February 16, 2011 from http://www.wpro.who.int/china/sites/tfi/

The History of Tai Chi and Health-Part V: Tai Chi in Western Culture

This is the last article in the history of Tai Chi and Health series

The current view of Tai Chi in Western popular culture is that it is primarily a Chinese exercise for elderly people, and not one particularly ideal for cardiorespiratory fitness. Some people who are interested in martial arts see Tai Chi as a viable form of martial arts training. The definition used commonly by both Western and Eastern researchers is that “Tai Chi is a low impact, low to moderate intensity exercise incorporating elements of balance, strength, flexibility, relaxation, and body alignment” (Taylor-Piliae and Froelicher, 2004, p.49).

A broader view, however, is presented in a 2002 demographic survey done in the United States, which found that more than 2.5 million people practiced Tai Chi and 500,000 practiced Qigong (Birdee et al., 2009). The age range was evenly split throughout all age groups, countering the stereotype that Tai Chi is primarily for older adults. Birdee et al. posit that because Tai Chi has roots in martial arts, it increasingly may be viewed as masculine and attractive to younger people (2009). The majority of the Tai Chi and Qigong users was Caucasian, but proportionately there was no difference in race or ethnicity; most had a healthy BMI and self-reported good health. The authors also found that 11.4% of the users practiced Tai Chi for a cardiovascular workout. From this study, it would appear that a large number of people perceive Tai Chi as a cardiovascular workout and good for health maintenance.



It is really important to stay open and re-invent yourself and re-invent Tai Chi. Many people, especially physical activity researchers want to place activities into categories. As a researcher myself, I understand the rationale for this. There has to be some kind of standardization so other researchers can test hypotheses. The problem is then the practice becomes limited. As a Tai Chi practitioner and someone who wants their life to be a work of art, I seek to be unlimited. Tai Chi is fresh and new NOT only an ancient exercise for elderly people.

The History of Tai Chi and Health-Part IV: Tai Chi and Chronic Disease

In 1973 in Hunan Province, an archaeologist unearthed a silk scroll dating back to c. 168 B.C., which depicted exercise postures. Below each embroidered pictograph was a written “exercise prescription” for different types of diseases, many of which were chronic conditions (Cohen, 1997). This evidence suggests that long before this recent surge in research, early Taoists had devised a method of self-care in the form of exercise to manage chronic conditions. Today, a growing body of evidence suggests that Tai Chi may be an efficacious intervention for the primary, secondary and tertiary prevention of CVD, diabetes, and the determinants of those diseases (Kaptchuk, 2000; Taylor-Piliae and Froelicher, 2004; Thornton, 2008; Yeh et al., 2008). However, of all the studies conducted on a broad variety of diseases, the literature on Tai Chi for the primary prevention of CVD is one of the least explored.