Abstract
Purpose: Social support may have benefits on cardiovascular health (CVH). CVH is evaluated using seven important metrics (Life's Simple 7; LS7) established by the American Heart Association (e.g., smoking, diet). However, evidence from longitudinal studies is limited and inconsistent. The objective of this study is to examine the longitudinal relationship between social support and CVH, and assess whether psychosocial risks (e.g., anger and stress) modify the relationship in a racially/ethnically diverse population. Methods: Participants from three harmonized cohort studies – Jackson Heart Study, Mediators of Atherosclerosis in South Asians Living in America, and Multi-Ethnic Study of Atherosclerosis – were included. Repeated-measures modified Poisson regression models were used to examine the overall relationship between social support (in tertiles) and CVH (LS7 metric), and to assess for effect modification by psychosocial risk. Results: Among 7724 participants, those with high (versus low) social support had an adjusted prevalence ratio (aPR) and 95% confidence interval (CI) for ideal or intermediate (versus poor) CVH of 0.99 (0.96–1.03). For medium (versus low) social support, the aPR (95%CI) was 1.01 (0.98–1.05). There was evidence for modification by employment and anger. Those with medium (versus low) social support had an aPR (95%CI) of 1.04 (0.99–1.10) among unemployed or low anger participants. Corresponding results for employed or high anger participants were 0.99 (0.94–1.03) and 0.97 (0.91–1.03), respectively. Conclusion: Overall, we observed no strong evidence for an association between social support and CVH. However, some psychosocial risks may be modifiers. Prospective studies are needed to assess the social support-CVH relationship by psychosocial risks in racially/ethnically diverse populations.
| Original language | English (US) |
|---|---|
| Article number | 101284 |
| Journal | SSM - Population Health |
| Volume | 20 |
| DOIs | |
| State | Published - Dec 2022 |
Funding
The Multi-Ethnic Study of Atherosclerosis (MESA) study was supported by contracts 75N92020D00001 , HHSN268201500003I , N01-HC-95159 , 75N92020D00005 , N01-HC-95160 , 75N92020D00002 , N01-HC-95161 , 75N92020D00003 , N01-HC-95162 , 75N92020D00006 , N01-HC-95163 , 75N92020D00004 , N01-HC-95164 , 75N92020D00007 , N01-HC-95165 , N01-HC-95166 , N01-HC-95167 , N01-HC-95168 and N01-HC-95169 from the National Heart, Lung, and Blood Institute , and by grants UL1-TR-000040 , UL1-TR-001079 , and UL1-TR-001420 from the National Center for Advancing Translational Sciences ( NCATS ). A full list of participating MESA investigators and institutions can be found at http://www.mesa-nhlbi.org . Among 7724 participants, those with high (versus low) social support had an adjusted prevalence ratio (aPR) and 95% confidence interval (CI) for ideal or intermediate (versus poor) CVH of 0.99 (0.96–1.03). For medium (versus low) social support, the aPR (95% CI) was 1.01 (0.98–1.05). There was evidence for modification by employment and anger. Those with medium (versus low) social support had an aPR (95% CI) of 1.04 (0.99–1.10) among unemployed or low anger participants. Corresponding results for employed or high anger participants were 0.99 (0.94–1.03) and 0.97 (0.91–1.03), respectively.The exposure variable was time-fixed social support measured at Exam 1. Social support was assessed using the Interpersonal Social Support Evaluation List in JHS (Payne et al., 2012) and Social Support Inventory in MESA and MASALA (Mitchell et al., 2003). Since different social support scales were used, a subset of similar items was identified and harmonized indirectly (via item-to-item matching) across the cohorts. Specifically, topics of ‘someone to talk to,’ ‘someone to give advice,’ ‘someone to be there emotionally,’ and ‘someone to help with chores’ were summed, and the means of the sum were standardized onto a 0–1 scale. The median harmonized social support scores were similar across the three cohorts: 0.83 in JHS, 0.81 in MASALA, and 0.75 in MESA. The harmonized social support scale demonstrated acceptable internal consistency (Cronbach's alpha = 0.79) during our psychometric analysis of the harmonized measures. The harmonized social support variable was classified into tertiles in the analysis.Harmonized data from JHS Exam 1, MASALA Exams 1–2, and MESA Exams 1 and 5 were analyzed. Cohort exams that did not measure the outcome (i.e., complete LS7) by study design were excluded from the analysis. Among JHS, MASALA, and MESA participants (N = 13,284), participants were excluded if they had no social support assessment, no measures for potential confounders, sources of selection bias, or effect modifiers, or no CVH outcome during the relevant follow-up period.Table 2 shows the adjusted prevalence ratios (aPR) for ideal or intermediate CVH compared to poor CVH by social support levels among the included participants. Among participants who had high (versus low) social support, the aPR (95% CI) for ideal or intermediate CVH was 0.99 (0.96–1.03). Among those with medium (versus low) social support, the aPR (95% CI) was 1.01 (0.98–1.05). When social support and visit product terms were added to the outcome models, the findings by visit did not change meaningfully compared to findings without the product terms. Therefore, subsequent text refers to the results from outcome models without the social support-visit product terms.Table 3 shows the assessment for effect measure modifications of the aPRs by levels of psychosocial risks. The 95% CIs overlapped to some extent; however, some psychosocial risks among participants who reported medium (versus low) social support suggested some evidence for effect measure modification. Specifically, for participants who reported medium (versus low) social support, the aPR (95% CI) for ideal or intermediate (versus poor) CVH among those who were unemployed was 1.04 (0.99–1.10) compared to 0.99 (0.94–1.03) for those employed at least part-time. Also, a positive association among those who reported low anger was most compatible with the data (aPR: 1.04, 95% CI: 0.99–1.10), while those with high and medium anger showed aPR (95% CI) of 0.97 (0.91–1.03) and 1.01 (0.96–1.07), respectively. Based on the most compatible estimates, other psychosocial risks did not find meaningful support for effect measure modification. Findings by visit were similar (See Supplemental Table 1 for effect measure modification results by visit).Supplemental Table 2 shows the results for the cohort-specific analyses. Since only JHS Exam 1 data were included in the study, there were no estimates shown by visit for JHS. The aPRs for MASALA and MESA were similar for both high and medium social support suggesting either no association or a small positive association with ideal or intermediate CVH, while the findings for JHS suggested a small negative association with ideal or intermediate CVH.This study examined the longitudinal relationship between social support and CVH measured using LS7 metrics. We also assessed whether this relationship was modified by high, medium, and low levels of psychosocial risks. We did not find evidence to support an association between greater social support and better CVH. The assessment for effect measure modification suggested that some psychosocial risks, such as employment status and perceived anger, may modify the relationship between social support and CVH. Specifically, participants who reported that they were unemployed or had lower anger levels may have better CVH outcomes from having a medium level of social support. Further, by cohort, MASALA and MESA findings suggested a null or weak positive association. For JHS, results indicated a weak negative association; however, the 95% CIs included the null, and both a negative and positive association for social support and ideal or intermediate (versus poor) CVH were compatible with the data.Although our study findings generally suggested no strong association between social support and CVH, evidence from prior studies has been mixed. In one cross-sectional study using the 2007-08 National Health and Nutrition Examination Survey (NHANES), lack of social support was associated with poor LS7 metrics (Kieu et al., 2020), while a review study reported that individuals with better social relationships were more likely to achieve or maintain ideal CVH (Cabeza de Baca et al., 2018). Other studies have also shown that low social support was associated with a greater risk of adverse CVD outcomes (Angerer et al., 2000; Barth et al., 2010; Berkman et al., 1992; Blazer, 1982; Freak-Poli et al., 2021; Ikeda et al., 2008; Rozanski et al., 1999; Uchino et al., 2018). Conversely, in one study using MESA data, higher social support was not associated with incident CVD, and cross-sectional studies among Black and Hispanic/Latino adults showed that higher levels of social support were not associated with individual LS7 metrics (e.g., BMI, cholesterol, and blood pressure) (Hernandez et al., 2014, 2018). Evidence from a systematic review of prospective observational studies among participants with CVD suggested a positive association between higher social support and better clinical CVD outcomes (Hemingway & Marmot, 1999); however, conflicting evidence also exists (Lett et al., 2007). Interestingly, studies conducted in Europe have shown, in general, stronger associations between social support and CVD outcomes compared to studies conducted in the U.S (Hemingway & Marmot, 1999). Further, there have been inconsistent findings regarding gender differences in the relationship between social support and CVD outcomes; i.e., some studies suggest stronger associations among men (Hemingway & Marmot, 1999; Hu et al., 2021) while others suggest women may benefit more from social support (Leifheit-Limson et al., 2010; Low et al., 2010). Thus, findings for the relationship between social support and CVH and incident CVD are mixed and may contrast with theories and conceptual frameworks suggesting favorable health benefits of increased social support on CVH outcomes (Cohen & Wills, 1985; Uchino, 2006).Although informative, our study is not without limitations. First, the measure for social support was harmonized from different social support measures from three cohorts. We performed psychometric tests to explore how well the harmonized measure performed, and social support showed acceptable internal consistency (Cronbach's alpha = 0.79). However, since our harmonized measure differs from other social support measures, our findings should be interpreted with caution. Also, there is no gold standard measure of social support (Beckers et al., 2020; Hogan et al., 2002); hence, assessing the relationship between social support and CVH outcomes, as well as comparing findings across studies can be challenging. Further, social support was measured at Exam 1 during 2010–2013 in MASALA and during early 2000's in JHS and MESA. Given these different time frames and the study measures available in the cohorts, we could not account for potential variations in regional structural factors that may have affected social support levels and cardiovascular risks among participants. However, the findings for the social support and CVH relationship stratified by cohort did not show meaningfully different results. Second, we did not control for other resilience resources in our analysis, such as optimism and neighborhood social cohesion, which may confound the relationship between social support and CVH because they were assessed after the exposure. Third, there may be residual confounding bias, selection bias, or measurement error due to most measures being self-reported. Also, model misspecification in the outcome models may be an issue despite using restricted quadratic splines (Hernan & Robins, 2020; Howe et al., 2011) for the continuous age variable. Further, our approach does not account for additional correlation in the outcome that may occur because a participant moved to a different neighborhood (i.e., census tract) after Exam 1. However, 86.1% (6652/7724) of the included participants resided in the same census tract after Exam 1 (i.e., at Exam 2). Fourth, the three cohorts were not representative of the U.S. population. Although we used a harmonized data of the three cohorts, our findings may not be generalizable to other populations with varying demographic and psychosocial characteristics. Lastly, we may have had inadequate power to assess for effect measure modification.Research reported in this publication was supported by the National Heart, Lung, And Blood Institute of the National Institutes of Health under Award Number R01HL135200. One hundred percent of the total project costs ($1,489,225) are financed with Federal money. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.The Jackson Heart Study (JHS) is supported and conducted in collaboration with Jackson State University (HHSN268201800013I), Tougaloo College (HHSN268201800014I), the Mississippi State Department of Health (HHSN268201800015I) and the University of Mississippi Medical Center (HHSN268201800010I, HHSN268201800011I and HHSN268201800012I) contracts from the National Heart, Lung, and Blood Institute (NHLBI) and the National Institute on Minority Health and Health Disparities (NIMHD).The Multi-Ethnic Study of Atherosclerosis (MESA) study was supported by contracts 75N92020D00001, HHSN268201500003I, N01-HC-95159, 75N92020D00005, N01-HC-95160, 75N92020D00002, N01-HC-95161, 75N92020D00003, N01-HC-95162, 75N92020D00006, N01-HC-95163, 75N92020D00004, N01-HC-95164, 75N92020D00007, N01-HC-95165, N01-HC-95166,N01-HC-95167, N01-HC-95168 and N01-HC-95169 from the National Heart, Lung, and Blood Institute, and by grants UL1-TR-000040, UL1-TR-001079, and UL1-TR-001420 from the National Center for Advancing Translational Sciences (NCATS). A full list of participating MESA investigators and institutions can be found at http://www.mesa-nhlbi.org.The Mediators of Atherosclerosis in South Asians Living in America (MASALA) was supported by Grant Number R01HL093009 from the National Heart, Lung, And Blood Institute and the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through UCSF-CTSI Grant Number UL1RR024131. Research reported in this publication was supported by the National Heart, Lung, And Blood Institute of the National Institutes of Health under Award Number R01HL135200. One hundred percent of the total project costs ($1,489,225) are financed with Federal money. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The Mediators of Atherosclerosis in South Asians Living in America (MASALA) was supported by Grant Number R01HL093009 from the National Heart, Lung, And Blood Institute and the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health , through UCSF- CTSI Grant Number UL1RR024131 .
ASJC Scopus subject areas
- Health(social science)
- Health Policy
- Public Health, Environmental and Occupational Health
