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LETTER |
Ann Bullock is with the Health and Medical Division, Eastern Band of Cherokee Indians, Cherokee, NC. Ronny A. Bell is with the Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC.
Correspondence: Requests for reprints should be sent to Ann Bullock, MD, Health and Medical Division, Eastern Band of Cherokee Indians, John Crowe Hill, Cherokee, NC 28719 (e-mail: annbull{at}nc-cherokee.com).
In the May 2005 issue, which focused on Native Americans/Alaska Natives, we were especially interested in the article by the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP) Team, "Social Epidemiology of Trauma Among 2 American Indian Reservation Populations."1 This study quantified exposure to trauma among American Indians, adding to the existing evidence2,3 that this population experiences a disproportional amount of trauma. We were intrigued by the statement "It may be that high rates of trauma exposure contribute to the increasing prevalence of cardiovascular disease among American Indian men and women, the leading cause of death among this population"1(p858) and wanted to lend support to this assertion. Indeed, American Indians now have the highest rates of cardiovascular disease in the United States.4
In a study similar to the AI-SUPERPFP study, Koss et al.5 documented adverse childhood exposures among 7 Native American tribes and compared these exposures to levels observed in the Adverse Childhood Experiences (ACE) Study conducted by Kaiser Permanente and the Centers for Disease Control and Prevention in a health maintenance organization population. Compared with participants in the ACE study, not only did the American Indians have a significantly higher rate of exposure to any trauma (86% vs 52%), but they also had a more than 5-fold risk of having been exposed to 4 or more categories of adverse childhood experiences (33% vs 6.2%).
We know from the ACE study that there is a linear, dose–response relationship between the number of adverse childhood experiences and not only coronary heart disease (CHD) risk factors such as cigarette smoking6 but also the occurrence of ischemic heart disease.7 The INTERHEART study8 found that large traumatic exposures were associated with increased risk of myocardial infarction and, further, that current or recent psychosocial stress alone resulted in a population attributable risk of 33% for myocardial infarction. Because 1 of the 2 most important risk factors in the INTERHEART study was smoking, and because there is a strong association between cigarette smoking and psychosocial stress, psychosocial stress may contribute even more strongly to CHD risk than even this high population-attributable risk would indicate.
We are indebted to studies such as these for helping to answer the myriad questions associated with the relationship between stress and trauma and CHD risk. Such research allows those of us in clinical and academic medicine to turn our attention to the challenge of developing interventions to mitigate the health effects associated with traumatic life experiences.
References
1. Manson SM, Beals J, Klein SA, Croy CD, and the AI-SUPERPFP Team. Social epidemiology of trauma among 2 American Indian reservation populations. Am J Public Health. 2005;95:851–859.
2. Robin RW, Chester B, Rasmussen JK, Jaranson JM, Goldman D. Prevalence and characteristics of trauma and posttraumatic stress disorder in a Southwestern American Indian community. Am J Psychiatry. 1997; 154:1582–1588.
3. Duran B, Malcoe LH, Sanders M, Waitzkin H, Skipper B, Yager J. Child maltreatment prevalence and mental disorders outcomes among American Indian women in primary care. Child Abuse Negl. 2004;28:131–145.[Medline]
4. Howard BV, Lee ET, Cowan LD, et al. Rising tide of cardiovascular disease in American Indians. The Strong Heart Study. Circulation. 1999;99:2389–2395.
5. Koss MP, Yuan NP, Dightman D, et al. Adverse childhood exposures and alcohol dependence among seven Native American tribes. Am J Prev Med. 2003; 25:238–244.[CrossRef][ISI][Medline]
6. Anda RF, Croft JB, Felitti VJ, et al. Adverse childhood experiences and smoking during adolescence and adulthood. JAMA. 1999;282:1652–1658.
7. Dong M, Giles WH, Felitti VJ, et al. Insights into causal pathways for ischemic heart disease: adverse childhood experiences study. Circulation. 2004;110: 1761–1766.
8. Rosengren A, Hawken S, Ounpuu S, et al. Association of psychosocial risk factors with risk of acute myocardial infarction in 11 119 cases and 13 648 controls from 52 countries (the INTERHEART study): case–control study. Lancet. 2004;364:953–962.[CrossRef][ISI][Medline]
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