Childhood Adversity and Adult Onset of Hypertension and Heart Disease in São Paulo, Brazil

Using data from the São Paulo Megacity Mental Health Survey and logistic regression models, we studied how childhood neglect, physical abuse, sexual abuse, and family violence were related to adult hypertension and heart disease. After adjustment for sociodemographic factors, child physical abuse was associated with hypertension and heart disease, whereas family violence was associated with hypertension. Efforts to curb child physical abuse could potentially reduce subsequent hypertension and heart disease.

Family violence significantly predicted hypertension (adjusted OR [AOR] = 1.48; 95% CI, 1.20-1.83) but not heart disease in models adjusted for sociodemographic factors. After adjustment for sociodemographic variables alone or for sociodemographic variables and onset of depression, neglect and sexual abuse were not significantly associated with hypertension or heart disease ( Table 2). As in the models adjusted for sociodemographic varibles alone, the association between family violence and hypertension was significant in the adjusted models for depression, but it was slightly attenuated (AOR = 1.37; 95% CI, 1.10-1.71).
In the full model, which contained all 4 childhood adversities and all covariates, only physical abuse was significantly associated with hypertension (AOR = 1.59; 95% CI, 1.22-2.07), and the previously significant association between family violence and hypertension disappeared ( Table 2).

Discussion
Participants reporting childhood physical abuse were more likely to develop hypertension and heart disease than who did not report such abuse. Additionally, family violence was associated with a greater likelihood of adult hypertension.
In the model that included all 4 adversities simultaneously, only physical abuse was significantly associated with hypertension. Thus, of the 4 adversities and in the context of our study, physical abuse may be the more salient predictor of hypertension and heart disease, because childhood adversities often occur simultaneously (2,9,10). A plausible mechanism is that stress in early life triggers greater sensitivity of the hypothalamic-pituitary-adrenal axis, which then results in physiological consequences (1,11). Also, maltreatment early in life can alter psychological development (12), possibly leading later in life to poor health choices (eg, unhealthful diet, tobacco use) that contribute to the development of hypertension (2,12).
To our knowledge, apart from the WHO pooled analyses (2,10), no studies exclusively from low-or middle-income countries have reported on the association of childhood adversities with cardiovascular health. For heart disease, our study demonstrated an effect size for physical abuse similar to that found in the literature, but we found a larger effect for family violence and a smaller effect for sexual abuse (2,3,10). The effect of these adversities on adult health appears to vary by location (2), which may allude to an important contextual influence (2,9).
One limitation of our study is that the variables were assessed via self-report and were not verified by medical records. The use of self-report may result in underreporting of these outcomes, particularly in non-Western countries (10). Also, because few survey participants reported sexual abuse and heart disease was fairly uncommon, our study may have been underpowered. Therefore, it may be difficult to draw strong conclusions from our data.
Our findings highlight that support for early childhood interventions are critical. When funds for early interventions are limited, our findings may help inform more targeted interventions (3,5). Because some childhood adversity effects appear stronger than others, further study is warranted on the mechanisms driving the effects.  The RIS file format is a text file containing bibliographic citations. These files are best suited for import into bibliographic management applications such as EndNote , Reference Manager , and ProCite . A free trial download is available at each application's web site.