Cardiovascular disease (CVD) is one of the most serious health challenges facing women today.1,2 According to the World Health Organization,3 CVD is the single leading cause of mortality among women, accounting for one-third of all deaths worldwide; similarly, in the United States and Canada, CVD accounts for 1 of every 3 deaths.4,5 For approximately 38 million women in the United States and 1.3 million women in Canada, CVD is a chronic and often debilitating disease.6,7 Empirical evidence suggests that women not only live longer than men with CVD but also have worse prognoses and spend approximately twice as many years disabled as measured by loss of productivity, functional limitations, and emotional distress.1,6,8
However, women’s health remains a relatively new area of interest within the cardiovascular arena; only within the past few decades have women been purposefully included in large cardiovascular research initiatives.9,10 These efforts have identified important sex-based biological and physiological differences between men and women (eg, differences in the size of coronary arteries; the role of estrogen in CVD) that have better informed the prevention, assessment, diagnosis, and treatment of CVD among women.6,11,12 Despite medical advances, mortality from CVD is not decreasing as rapidly among women as among men for reasons that remain largely unknown.2 One explanation may be that we have failed to take into account the contextual gendered aspects of a woman’s life that affects health.
Gender refers to the “array of socially constructed roles, attitudes, personality traits, behaviors, values, and relative power and influence that society ascribes to two sexes on a differential basis.”13(p1) Evidence is rapidly accumulating to suggest that gender significantly influences health. For example, health risk behaviors such as cigarette smoking and physical inactivity are known to be different among men and women, primarily because of societal and cultural norms attributed to gender.12,13 Therefore, decontextualizing women’s health from gender-based influences greatly mitigates against identification of risk factors uniquely affecting women’s health.10 One proposed gendered risk factor that may influence the cardiovascular health of women is abuse.
The purpose of this article was to put forward a conceptual model derived from empirical and theoretical knowledge that delineates how lifetime abuse (current and/or past) may increase the risk for CVD among women (Figure). Within this model, lifetime abuse is positioned as a chronic stressor directly increasing the risk of CVD through physiological changes within the body.14–16 Common coping strategies for dealing with stress from abuse, such as smoking and overeating, are known CVD risk behaviors.14,17 These CVD risk factors are an indirect pathway by which lifetime abuse can affect CVD. In addition, women with abuse histories have higher rates of depressive symptoms.18,19 Depression is associated with CVD and can also potentiate the adoption of CVD risk behaviors.14,20–22 Therefore, depressive symptoms are proposed to mediate the effect of lifetime abuse on CVD as well as the CVD risk behaviors of smoking and overeating. A better understanding of the complex pathways by which abuse may increase CVD risk is an important step in reducing the burden of this disease among vulnerable groups of women.
Cardiovascular disease is a broad term that refers to any disease involving the cardiovascular system and is caused by the interaction of genetics, health risk behaviors, and environment.4 Besides being a leading cause of death and disability among women,3 it is estimated that CVD costs the Canadian economy more than $22 billion annually in physician services, drug costs, hospital costs, disability, and lost productivity.7 In 2008, in the United States, an estimated $298 billion was spent on CVD-related healthcare costs; this is in comparison with $228 billion spent for all cancers combined.5
Despite significant reductions in CVD mortality in most developed countries between 1980 and 2000, recent trends in CVD risk factors are worrisome, especially among younger age groups.23 Decreases in smoking rates have slowed, whereas rates of obesity, diabetes, and hypertension are on the rise, translating into a projected new increase in the incidence of CVD, especially among young women.23–26 Prevention therefore becomes paramount in reducing the economic impact and in improving the health of women. Unfortunately, established risk factors (ie, smoking, physical inactivity, improper nutrition, general stress, overweight/obesity, high blood pressure, and diabetes) explain only a portion of the incidence and prevalence of CVD.27 To reduce the burden further, additional risk factors need to be identified and investigated; gender-specific risk factors for women, such as abuse offer a critical new field for exploration.
Abuse as a Gendered Risk Factor
Abusea against women is globally recognized as a gendered issue and a major public health problem affecting one quarter to one-half of all women within their lifetime.28–30 It is a universal phenomenon affecting women regardless of ethnicity, age, socioeconomic status, level of education, or religion.31 Abuse is defined as the “intentional use of physical force or power, threatened or actual, against another person that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation”32(p4) Abuse against women is inextricably linked to gender-based inequalities perpetuated by religious, ethnic, cultural, societal, and political norms that uphold women’s subordinate status in society, ultimately creating power inequality between men and women.33,34 This power imbalance has led to the domination and discrimination of women by men through physical, psychological, and sexual abuse; rape; sexual exploitation; sexual harassment; trafficking; and prostitution, thereby validating abuse as a pervasive gendered issue greatly affecting women.33,35 Although men are also victims of abuse, the overall incidence is lower in comparison with women, and women continue to bear the brunt of more serious forms of abuse.36,37
Abuse can manifest in various types throughout the lifecycle, including child sexual, physical, and/or psychological abuse; child physical and emotional neglect; adult sexual assault; and intimate partner violence. It is an unfortunate reality that those who experience abuse are frequently the victims of multiple types of abuse (eg, physical, sexual, and psychological) that often co-occur and reoccur across the lifespan, resulting in a cumulative abuse profile.38 These cumulative experiences of abuse are believed to compound over time, leading to incrementally worse health outcomes, highlighting the importance of examining abuse across the lifespan.38 For example, Fogarty and colleagues39 demonstrated a “super-additive risk” of depressive symptoms for women exposed to abuse in both childhood and adulthood compared to women who experienced abuse at only 1 of the time points.
Abuse and Cardiovascular Disease
Abuse is associated with a wide array of adverse health outcomes40,41; however, research examining the relationship between abuse and CVD is relatively new. In seminal works, Dong42 provided evidence of a link between childhood trauma (inclusive of abuse) (n = 17 337) and heart disease in adulthood, reporting a 30% to 70% (dose response relation) greater risk of heart disease among those with childhood trauma(s). Using data from the National Comorbidity Study (n = 5308), Batten and colleagues43 found that women with abuse histories had a 9-fold increase in CVD compared with women with no abuse history and researchers using US national survey data (n = 70 156) discovered that women with a history of intimate partner violence were almost twice as likely to report CVD as women with no such history.44 Despite identified associations between abuse and CVD, elucidating the causal pathways by which abuse may increase CVD risk has been limited. One emerging pathway receiving attention is chronic stress. And although stress itself is not a “new” risk factor in the development and progression of CVD, the identification of abuse as a chronic stressor increasing the risk is a fresh perspective within cardiovascular research.
Abuse and Chronic Stress
Abuse is a significant stressor that often results in persistent and chronic stress, regardless of whether the abuse exposure is current or in the past.14 In other words, stress continues long after the abuse stops. Any single experience of abuse can produce chronic stress; however, women often experience cumulative abuse across the lifespan, leading to greater stress and augmented health risk.38 Furthermore, for women who have experienced abuse, a multitude of factors commonly coexist that continue to generate stress, such as fear, lack of control, isolation, conflict with family and friends, poor health, changes in economic status, ongoing harassment, and abuse.45–47
When a stressor is encountered, a powerful physiological response involving the cardiovascular, immune, neuroendocrine, and nervous systems is initiated.16 Activation of these systems during times of acute, short-term stress is adaptive as it promotes the survival and well-being of the individual.15 However, in situations where stress is persistent, as is often the case with abuse, chronic activation of the stress response becomes maladaptive, producing significant and long-term neuroendocrine, metabolic, haemostatic, immunologic, and inflammatory changes within the body.16 This compromised state is known as allostatic load (or overload), which leads to vulnerability for disease development, such as CVD.15
The physiological mechanisms at play in situations of chronic stress that increase the risk for CVD are complex and interrelated. For example, according to the works of McEwen and Lasley15 and Sapolsky,48 chronic stress can lead to the dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, the primary structure in the brain responsible for maintaining physiologic balance in the face of stress (ie, homeostasis and allostasis). The result is a prolonged release of stress hormones, such as cortisol and epinephrine, which causes the heart to beat more rapidly, produce more efficient contractions, and increases blood pressure as a means to promote greater blood flow and delivery of oxygen and glucose to vital muscles and organs required in the stress response. Chronic or frequent cardiovascular stimulation via this mechanism can result in hypertension. Hypertension in turn reduces the external diameter of blood vessels through a process known as “vascular remodeling,” leading to even greater resistance in vascular blood flow and perpetuating the hypertensive state.49 Chronic hypertension has numerous damaging effects on the cardiovascular system, including, but not limited to, left ventricular hypertrophy, congestive heart failure, and even kidney failure.49,50 In addition, high levels of circulating cortisol as a result of chronic stress leads to the suppression of the immune system.15 Immune suppression results in a low-grade chronic inflammatory state, which leads to endothelial damage of blood vessels and the development/progression of atherosclerosis, a major contributor to CVD.15,51,52 The presence of a chronic inflammatory state has been supported by studies demonstrating an association between past abuse and higher physiological markers of inflammation.53,54 For a detailed review on the physiologic changes associated with abuse and stress, see Keeshin et al,55 Black and Garbutt,51 or Out et al.54
Cardiovascular Disease Risk Behaviors
Abuse also affects health indirectly through health risk behaviors. Women use a range of behaviors to cope with the stress radiating from the abuse (current or past).14,42 Some behaviors, such as smoking and overeating, which are common among women with abuse histories, unfortunately increase the risk for CVD. For example, Scott-Storey and colleagues17 found that within a community sample (n = 309), women with abusive histories were 3 times more likely to be current smokers compared with the national population average (44.1% vs 15.5%, respectively). Similarly, Dichter et al56 reported that among a sample of 21 162 women, the odds of smoking were 3 times higher for women reporting intimate partner violence.
Cigarette smoking is one of the most significant modifiable risk factors for the development of CVD,4,25 with smokers being 2 to 4 times more likely than nonsmokers to develop the disease.57 Inhaling the mixture of chemicals in tobacco smoke increases CVD risk through a number of biological pathways, including the promotion of thrombosis formation, platelet aggregation, chronic inflammation, lipid abnormalities, and endothelial damage; also, it increases circulating levels of catecholamines and fibrinogen and increases myocardial workload.58
Women with abuse histories are at greater risk for being overweight/obese, likely in part related to stress.40 In a population-based survey, adult women who reported a history of child sexual or physical abuse had approximately twice the likelihood of being obese compared with women with no such history.59 In a sample of more than 11 000 California women, researchers discovered that those who were overweight were 32% more likely to report that they had been abused as children compared with women of normal weight.60
Stress is believed to influence the development of overweight/obesity through adverse changes in eating behaviors.61 Although stress can suppress appetite, approximately 70% of individuals will increase their food intake (overeating) during times of stress, particularly of high-fat, carbohydrate-dense foods.62 This type of behavior is referred to as “emotional” or “comfort” eating because it serves as both a coping mechanism and a mood stimulant but unfortunately leads to adverse weight gain.61 In addition, depression is associated with decreased energy and engagement in less physical activity, thereby contributing to adverse weight gain.14,63 In turn, overweight and obesity are independent risk factors for CVD, being associated with left ventricular hypertrophy, hypertension, cardiomyopathy, ischemic heart disease, atherosclerosis, dyslipidemia, metabolic syndrome, heart failure, and atrial fibrillation.64–66 Moreover, stress can influence the development of overweight and obesity through more direct biophysical mechanisms. For instance, unremitting stress results in chronic hyperactivity of the HPA axis, leading to sustained cortisol production.15 The result of prolonged cortisol exposure is weight gain, especially visceral/abdominal fat accumulation, which is a particularly potent risk factor for CVD.66 Furthermore, the excess adipose tissue itself expresses proinflammatory molecules, which in turn potentiates the inflammatory state underlying CVD processes such as atherosclerosis.65
The final pathway through which abuse can affect CVD is through depression. Depression is characterized by feelings of intense sadness or depressed mood, as well as some combination of feelings of hopelessness, guilt, worthlessness, changes in appetite, sleep disturbances, loss of interest, irritability, lack of energy, and difficulties in concentration.67 Evidence suggests that both clinical depression and subclinical depressive symptoms (symptoms that do not meet the diagnostic criteria threshold for clinical depression but that still significantly impact the well-being of the individual) are associated with increased morbidity and mortality.68
Researchers have demonstrated both prospectively and retrospectively that women who have experienced any type of abuse across the lifespan are at a greater risk for clinical depression and subclinical depressive symptoms when compared with those with no such history.18,69 For example, in her meta-analysis, Golding19 found that the odds of depression occurring in women with a history of intimate partner abuse were approximately 4 times greater than that of women with no abusive history. Recently, Dichter et al56 reported similar results, finding the odds of having depression to be nearly 4 times greater for those women with a history of intimate partner violence (n = 21 162). Furthermore, childhood sexual and physical abuse has been associated with doubling the odds of depression in adulthood, speaking to the long-lasting effects of abuse.59
A multitude of complex cognitive, social, behavioral, psychological, and biological mechanisms are at play, increasing vulnerability to depression among those with a history of abuse.14,40 Focusing solely on biology, depression may partially be the consequence of physiological abuse-related changes in brain structures (eg, corpus collosum, hippocampus, amygdala) and the HPA axis, which ultimately impacts behavior and mood.55,70 For instance, dysregulation of the HPA axis results in increased cortisol levels, which can lead to the breakdown of serotonin, an important neurotransmitter in the regulation of mood.40
Depression is often identified as an outcome of abuse; however, it may also influence the extent to which abuse adversely impacts a woman’s physical health, thereby positioning it as a mediator between abuse and physical health.14 Empirical evidence suggests that depression/depressive symptoms are associated with CVD. The results of 4 systematic reviews and meta-analyses indicate that in individuals with no known CVD, depression predicts the development of the disease, with a relative risk of 1.5 to 2.7, even after controlling for conventional risk factors.20–22,71 Although the precise physiological mechanisms are not well understood, depressed individuals both with and without established CVD have been shown to have chronically increased levels of cortisol, catecholamines, and inflammatory markers, all of which promote the development and progression of CVD.27,40,51
Depression may also foster CVD through engagement in health risk behaviors.14 It is well established that cigarette smoking is more prevalent among depressed individuals compared with nondepressed individuals, probably because it offers a way to cope with the negative emotions associated with depression.40,68,72 In a population-based survey of 3213 adults in the St Louis Epidemiologic Catchment Area study, individuals with a diagnosis of major depression had 2.9 times the odds of being a smoker compared with their nondepressed counterparts.73 Furthermore, depressed individuals with a history of abuse are more likely to smoke in comparison with depressed individuals with no such history, possibly representing an augmented effect of abuse on smoking behavior among depressed individuals.72
Depressive disorders and depressive symptoms are also positively associated with adverse weight gain.74,75 Results from a recent systematic review and meta-analysis of 9 prospective longitudinal studies showed that depressed individuals had a 58% increased risk of becoming obese with time.76 Furthermore, the severity of depressive symptoms seemingly has a linear relationship to weight, with greater depressive symptoms related to a faster rate of weight gain.77 It has been postulated that depression may lead to deleterious weight gain through changes in eating behavior, similar to what is seen in stress situations. Emotional or comfort eating is thought to function as a mood stimulant for many individuals and is more prevalent among individuals who are depressed or show depressive symptoms.75,78 As well, depression is characterized by long-term overactivity of the HPA axis and increased cortisol secretion.79–81 As mentioned previously, increased cortisol levels, in turn, have been positively associated with the development of obesity and specifically visceral obesity, a particularly potent CVD risk factor.66 This places depression as an important mediator of the relationship between experiences of abuse and overweight/obesity.
The proposed conceptual model is an important contribution to women’s health as it addresses current gaps in our understanding of CVD by taking into account gendered influences such as abuse. This model provides a roadmap by which to understand the complex web of biological, psychological, and behavioral pathways increasing CVD risk among women who have experienced abuse. In particular, it suggests that lifetime abuse increases the risk of CVD through direct biological changes, as well as indirectly through CVD risk behaviors of smoking and overeating and depressive symptoms.
Implications for Practice and Research
Nurses, in all aspects of their work, will encounter women who have experienced abuse. This model provides a guide for nurses to work with these women in the context of reducing the risk for CVD. Notably, the model highlights the link between lifetime abuse and CVD risk and underscores the importance of inquiring about abuse history in all women presenting with CVD risk factors, symptoms, and/or pathology. In light of the long-term cumulative effects of chronic stress on health, it is critical that nurses inquire about current and past abuse experiences.82 However, few nursing programs currently provide specific content on assessing and responding to abuse; therefore, training and institutional support to be able to appropriately respond to disclosures of abuse are necessary. Simply asking the questions without understanding the sensitive nature of the issue, nor having the capacity to offer support or access to resources, will mitigate efforts to reduce the impact of abuse on cardiovascular health.
A key message emerging from the model is the importance of a coordinated, multimodal approach to CVD risk reduction among women with abuse histories. Because of the intertwined connection among the physical, mental, and behavioral consequences of abuse, one cannot be adequately treated in isolation of the others, and without a multimodal approach targeted at both mental and physical health, efforts to reduce the risk of CVD will be attenuated at best. For example, the importance of assessing for and addressing depressive symptoms within the context of overall CVD risk reduction becomes clear as depression contributes not only to the pathophysiology of CVD but also to behavior and risk reduction adherence, particularly that of smoking cessation and weight management.83,84
Viewing abuse as a chronic stressor that is linked to risk behaviors provides a lens through which nurses can work with women. Traditional CVD lifestyle modification approaches that focus primarily on eliminating health risk behaviors such as smoking and unhealthy eating may not be appropriate for women who are coping with the stress of abuse. It is unsupportive and potentially harmful to condemn smoking or emotional eating without understanding the role that such behaviors play in the women’s life as a coping strategy. Rather, a harm reduction approach85 in which nurses work with women in identifying and reducing negative health behaviors while concurrently arming her with new healthy coping strategies might prove to be a more successful method. A harm reduction approach results in the formulation of individualized and realistic goals. Achievement of these goals may provide women, who have been in life situations where they feel powerless, with an opportunity to gain a sense that they have control over their life/body. The achievement of such goals, no matter how small they may be, improves not only the cardiovascular health of these women but also their mental well-being.
Positioning lifetime abuse as a gendered risk factor for CVD is a promising direction in our efforts to understand CVD among women. This model serves to direct research initiatives aimed at investigating women’s health, with the ultimate goal of being able to develop more effective health promotion and prevention strategies that improve cardiovascular health among women who have experienced abuse. Empirically testing the validity of the proposed model, as well as evaluating alternative models, will be the next step in understanding CVD risk among abused women.
What’s New and Important
- Abuse is identified as a potential gendered risk factor for the development of cardiovascular disease (CVD) amongwomen.
- Amultivariable model is proposed by which abuse increases the risk for CVD through complex biological, behavioral, and psychological pathways.
- Gendered sensitive thinking and research are needed to develop more effective health promotion and prevention strategies that reduce cardiovascular risk and ultimately improve cardiovascular health among women who have experienced abuse.
The author thanks Dr Judy Wuest and Dr Marilyn Hodgins for their invaluable insight and mentorship.
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aAlthough often used interchangeably, for the purpose of this article, the terms abuse and violence will be termed abuse.