Multi-Systemic Biological Risk and Cancer Mortality: The NHANES III Study

Allostatic Load and Depression Symptoms in Cancer Survivors: A National Health and Nutrition Examination Survey Study

BACKGROUND

Individuals with cancer often experience stress throughout the cancer trajectory and have a high risk of experiencing depression.

OBJECTIVE

The aim of this study was to examine the relationship between allostatic load (AL), a measure of cumulative stress-related physiologic dysregulation of different body systems, and symptoms of depression in cancer survivors.

METHODS

Participants were 294 adult cancer survivors from the US National Health and Nutrition Examination Survey (NHANES 2007-2018). Allostatic load was measured using 14 indicators representing cardiometabolic risk, glucose metabolism, cardiopulmonary functioning, parasympathetic functioning, and inflammation. Depressive symptoms were measured with the Patient Health Questionnaire-9. The relationship between AL and depressive symptoms was investigated using multiple regression adjusted for diverse sociodemographic and diagnosis variables.

RESULTS

Higher AL was associated with higher depressive symptom scores. The higher risk of depression was concentrated among those survivors in the highest AL quartile, with 21% (95% confidence interval, 11%-32%) of survivors presenting a high risk of depression compared with 8% to 11% of survivors in the lower quartiles. In exploratory analyses, the relationship between AL and depressive symptoms was only significant among survivors with a lower income. In contrast, in survivors in the highest income group, depressive symptoms were lower and unrelated to AL.

CONCLUSION

High AL is associated with more depressive symptoms among cancer survivors.

IMPLICATIONS FOR PRACTICE

Nurses have an important role in identifying psychological distress in cancer patients and survivors. Further research is needed to investigate the usefulness of AL as a marker in the context of cancer follow-up care and screening for psychological distress.

Retrospective operationalization of allostatic load in patients with cancer: A systematic review

Allostatic load (AL) has been shown to impact cancer outcomes. At present, no gold standard exists surrounding AL computation. As such, a systematic review of the literature was performed to identify studies that retrospectively calculated AL in patients with cancer. The following variables were collected for each study: AL calculation method, including the biomarkers used and their cutoff values, number of biosystems represented, definition of high AL, and the use of proxy biomarkers. Thirteen articles were included for full-text review. The number of biomarkers used in the calculation of AL varied considerably, ranging from 6 to 16. Considerable variability was also observed in terms of utilized biomarkers and biosystem representation. This lack of standardization complicates retrospective AL calculation among patients with cancer. Nonetheless, determining AL in patients with cancer presents an important step in the optimization of patient care and outcomes.

Association of food insecurity with overall and disease-specific mortality among cancer survivors in the US

PURPOSE

To investigate the association of food insecurity with overall and disease-specific mortality among US cancer survivors.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES 1999-2018) were used to examine the impact of food insecurity on mortality risks among cancer survivors in the US. Study participants aged ≥ 20 years who had a history of cancer and completed the Adult Food Security Survey Module were included. Mortality data [all-cause, cancer, and cardiovascular (CVD) specific] through December 31, 2019 were obtained through linkage to the National Death Index. Using multivariable Cox proportional hazard regression, hazard ratios of mortality based on food security status were estimated.

RESULTS

Among 5032 cancer survivors (mean age 62.5 years; 58.0% women; 86.2% non-Hispanic White), 596 (8.8%) reported food insecurity. Overall, 1913 deaths occurred (609 cancer deaths and 420 CVD deaths) during the median follow-up of 6.8 years. After adjusting for age, food insecurity was associated with a higher risk of overall (HR = 1.93; 95% CI = 1.56-2.39), CVD-specific (HR = 1.95; 95% CI = 1.24-3.05), and cancer-specific (HR = 1.70; 95% CI = 1.20-2.42) mortality (P < 0.001). However, after adjusting for socioeconomic characteristics and health-related factors (physical activity, diet quality measured by healthy eating index), the association between food insecurity and overall mortality was no longer statistically significant.

CONCLUSIONS

Food insecurity was associated with a greater risk of overall mortality among cancer survivors. Further studies are needed to confirm these findings and evaluate whether the observed association represents a causal phenomenon and, if so, whether the effect is modifiable with food assistance programs.

Berry Consumption in Relation to Allostatic Load in US Adults: The National Health and Nutrition Examination Survey, 2003-2010

INTRODUCTION

Berries are a rich source of antioxidant polyphenols and other nutrients that are associated with good health. Allostatic load (AL) is an aggregate measure of chronic stress-induced physiological dysregulations across cardiovascular, metabolic, autonomic, and immune systems; the extent of these dysregulations, collectively or in each system, can be characterized by a composite score or a domain score assessed by integrated biomarkers. It was hypothesized that the anti-inflammatory and other effects of berries lower AL. The association was determined between berry consumption and AL composite and domain scores in the 2003-2010 National Health and Nutrition Examination Survey (NHANES).

METHODS

Berry intake was measured using two 24 h dietary recalls collected from US adults in the 2003-2010 NHANES (n = 7684). The association with AL and its specific domains was examined using population weight-adjusted multivariable linear regression.

RESULTS

The mean AL composite scores for consumers of any berries (11.9), strawberries (11.6), and blueberries (11.6), respectively, were significantly lower than nonconsumers (12.3), after fully adjusting for sociodemographic, lifestyle, and dietary confounders. A significant dose-response relationship was determined between greater consumption of total berries, strawberries, and blueberries and lower mean AL composite scores (p-trend < 0.05, for all). Consistently, mean cardiovascular and metabolic domain scores remained significantly lower in the consumers of total berries (mean cardiovascular domain score: 4.73 versus 4.97 for nonconsumers; mean metabolic domain score: 2.97 versus 3.1), strawberries (4.73 versus 4.95; 2.99 versus 3.1), and blueberries (4.6 versus 4.95; 2.92 versus 3.11). Berry consumers also had significantly lower mean AL immune scores (1.52 versus 1.56) and lower mean AL autonomic scores (2.49 versus 2.57) than nonconsumers (initial sample: n = 15,620).

CONCLUSIONS

The current study indicates that consumption of berries lowers the AL composite scores and potentially reduces stress-related disease risks in the US adult population.

The Role of BMI in Allostatic Load and Risk of Cancer Death

INTRODUCTION

Obesity and proinflammatory conditions are associated with increased risks of cancer. The associations of baseline allostatic load with cancer mortality and whether this association is modified by body mass index (BMI) were examined.

METHODS

A retrospective analysis was performed in March-September 2022 using National Health and Nutrition Examination Survey years 1988 through 2010 linked with the National Death Index through December 31, 2019. Fine and Gray Cox proportional hazard models were stratified by BMI status to estimate subdistribution hazard ratios of cancer death between high and low allostatic load status (adjusted for age, sociodemographics, and health factors).

RESULTS

In fully adjusted models, high allostatic load was associated with a 23% increased risk of cancer death (adjusted subdistribution hazard ratio=1.23; 95% CI=1.06, 1.43) among all participants, a 3% increased risk of cancer death (adjusted subdistribution hazard ratio=1.03; 95% CI=0.78, 1.34) among underweight/healthy weight adults, a 31% increased risk of cancer death (adjusted subdistribution hazard ratio=1.31; 95% CI=1.02, 1.67) among overweight adults, and a 39% increased risk of death (adjusted subdistribution hazard ratio=1.39; 95% CI=1.04, 1.88) among obese adults, when compared to those with low allostatic load.

CONCLUSIONS

The risk of cancer death is highest among those with high allostatic load and obese BMI, but this effect was attenuated among those with high allostatic load and underweight/healthy or overweight BMI.

Nonlinear, Multicomponent Physical Exercise With Heart Rate Variability-Guided Prescription in Women With Breast Cancer During Treatment: Feasibility and Preliminary Results (ATOPE Study)

OBJECTIVE

The purpose of this study was to examine the feasibility, safety, adherence, and preliminary efficacy of the ATOPE program during radiotherapy (RT) or chemotherapy (CT) for women with breast cancer.

METHODS

This single-blind, pretest-posttest feasibility study included 38 women with breast cancer at the beginning of their treatment. The ATOPE program consisted of 12 to 18 sessions of a multimodal physical exercise program, prescribed based on daily heart rate variability and clinimetric assessments using the ATOPE+ mHealth system. Overall health was assessed with quality of life, autonomous balance, and body composition, whereas health-related fitness was measured through functional capacity, physical activity levels, and upper and lower limb strength.

RESULTS

The rates of recruitment, retention, and adherence were 52.35, 73.68, and 84.37%, respectively, and the satisfaction rating was 9.2 out of a possible 10 points. The perceived health status change score was 3.83 points, scored on a -5 to 5 point scale. No adverse effects were found. Compliance results showed that the ATOPE+ mHealth system was used on 73.38% of the days, and the Fitbit bracelet (Google, Mountain View, CA, USA) was used on 84.91% of the days. Women stayed physically active 55% of days. Regarding preliminary results, for overall health, the percentage of body fat in the RT group decreased by 1.93%, whereas it increased by 5.03% in the CT group. Lower limb strength increased in the RT group, specifically knee extensor isometric strength (6.07%), isokinetic knee flexors 180 degree/second (1.53%), and isokinetic knee extensors 300 degree/second (4.53%), in contrast with the reductions found in the CT group (11.07, 18.67, and 14.89%, respectively).

CONCLUSION

The ATOPE program, through nonlinear prescription based on daily monitoring with the ATOPE+ mHealth system, is feasible and safe for application during breast cancer treatment. The results suggest that the overall health can be maintained or even improved regarding most variables.

IMPACT

This study focused on the feasibility, safety, and completion of a physical therapist-led program at early diagnosis for adults with breast cancer. The multimodal, supervised, tailored, nonlinear physical exercise program is feasible and safe, showed a good completion rate, and was able to prevent the quality-of-life deficits that are often triggered by systemic breast cancer treatment. This study highlights the importance of daily morning assessments using the ATOPE+ mHealth system in patients with breast cancer to prescribe nonlinear physical exercise.

Neighborhood deprivation, racial segregation and associations with cancer risk and outcomes across the cancer-control continuum

The racial/ethnic disparities in cancer incidence and outcome are partially due to the inequities in neighborhood advantage. Mounting evidences supported a link between neighborhood deprivation and cancer outcomes including higher mortality. In this review, we discuss some of the findings related to work on area-level neighborhood variables and cancer outcomes, and the potential biological and built/natural environmental mechanisms that might explain this link. Studies have also shown that residents of deprived neighborhoods or of racially or economically segregated neighborhoods have worse health outcomes than residents of more affluent neighborhoods and/or less racially or economically segregated neighborhoods, even after adjusting for the individual-level socioeconomic status. To date, little research has been conducted investigating the biological mediators that may play roles in the associations of neighborhood deprivation and segregation with cancer outcomes. The psychophysiological stress induced by neighborhood disadvantage among people living in these neighborhoods could be a potential underlying biological mechanism. We examined a number of chronic stress-related pathways that may potentially mediate the relationship between area-level neighborhood factors and cancer outcomes, including higher allostatic load, stress hormones, altered epigenome and telomere maintenance and biological aging. In conclusion, the extant evidence supports the notion that neighborhood deprivation and racial segregation have unfavorable impacts on cancer. Understanding how neighborhood factors influence the biological stress response has the potential to inform where and what types of resources are needed within the community to improve cancer outcomes and reduce disparities. More studies are warranted to directly assess the role of biological and social mechanisms in mediating the relationship between neighborhood factors and cancer outcomes.

Allostatic Load Measurement: A Systematic Review of Reviews, Database Inventory, and Considerations for Neighborhood Research

BACKGROUND

Neighborhoods are critical to understanding how environments influence health outcomes. Prolonged environmental stressors, such as a lack of green spaces and neighborhood socioeconomic disadvantage, have been associated with higher allostatic load levels. Since allostatic load levels experienced earlier in life have stronger associations with mortality risk, neighborhoods may be uniquely suited to monitor and mitigate the impacts of environmental stressors. Researchers often study allostatic load in neighborhoods by utilizing administrative boundaries within publicly accessible databases as proxies for neighborhoods.

METHODS

This systematic review of reviews aims to identify commonly used biomarkers in the measurement of allostatic load, compare measurement approaches, inventory databases to study allostatic load, and spotlight considerations referenced in the literature where allostatic load is studied in neighborhoods. The review was conducted using the search term "allostatic load" in the MEDLINE, CINAHL, and PsychINFO databases. The search results were filtered to include reviews.

RESULTS

The search returned 499 articles after deduplication. Overall, 18 synthesis reviews met the inclusion criteria and were retained for extraction. The synthesis reviews analyzed represented 238 studies published from 1995 to 2020. The original ten biomarkers were most often used to measure allostatic load. More recently, body mass index and C-reactive protein have additionally been frequently used to measure allostatic load burden.

CONCLUSIONS

The scientific contributions of this study are that we have identified a clear gap in geographic considerations when studying allostatic load. The implication of this study is that we have highlighted geographic concepts when conducting neighborhood-level research using administrative databases as a neighborhood proxy and outlined emerging future trends that can enable future study of allostatic load in the neighborhood context.

Bearing allostatic load: insights into a more equitable future within cardio-oncology

Chronic stress is often regarded as a significant cause of morbidity and mortality; however, the mechanistic link between stress and various disease states has not yet been fully characterized. We explore the concept of allostatic load, a measurement of the physiological burden of chronic stress, as well as its potential role in disease pathogenesis as it relates to cardiovascular disease, cancer, and health-related disparities. Building from this framework, we then posit the potential implications of allostatic load on patient care and research in cardio-oncology. We identify allostatic load as a potential clinically actionable tool to improve health equity in cardio-oncology.

Exploring racial disparities on the association between allostatic load and cancer mortality: A retrospective cohort analysis of NHANES, 1988 through 2019

Background

Methods

Results

Conclusions

Impact

•

Allostatic load (AL) is a biologic measure for the ‘wear and tear’ of chronic stress.

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Studies suggests that racial minorities have higher allostatic load.

•

There is limited knowledge on the association between allostatic and cancer, by race.

•

We observed that AL may increase the risk of cancer death by 14%.

•

Among those aged <40 years, high AL increased cancer death risk by more than 80%.

Gender- and Sexual Orientation- Based Inequities: Promoting Inclusion, Visibility, and Data Accuracy in Oncology

Sexual and gender minority (SGM) people, including agender, asexual, bisexual, gay, gender diverse, genderqueer, genderfluid, intersex, lesbian, nonbinary, pansexual, queer, and transgender people, comprise approximately 10% or more of the U.S. population. Thus, most oncologists see SGM patients whether they know it or not. SGM people experience stigma and structural discrimination that lead to cancer disparities. Because of the lack of systematic and comprehensive data collection, data regarding SGM cancer incidence, outcomes, and treatment responses are limited. Collection of data regarding sexual orientation, gender identity, transgender identity and/or experience, anatomy, and serum hormone concentrations in oncology settings would drastically increase collective knowledge about the impact of stigma and biologic markers on cancer outcomes. Increasing the safety of oncology settings for SGM people will require individual, institutional, and systems changes that will likely improve oncologic care for all patients.

Interrogating Patterns of Cancer Disparities by Expanding the Social Determinants of Health Framework to Include Biological Pathways of Social Experiences

The objective of this article is to call for integrating biological pathways of social experiences in the concept model of cancer disparities and social determinants of health (SDH) fields. Black, Indigenous, and People of Color (BIPOC) populations experience more negative outcomes across the cancer continuum. Social conditions are instrumental in better understanding the contemporary and historical constructs that create these patterns of disparities. There is an equally important body of evidence that points to the ways that social conditions shape biological pathways. To date, these areas of research are, for the most part, separate. This paper calls for a bridging of these two areas of research to create new directions for the field of cancer disparities. We discuss inflammation, epigenetic changes, co-morbidities, and early onset as examples of the biological consequences of social conditions that BIPOC populations experience throughout their lifespan that may contribute to disproportionate tumorigenesis and tumor progression.

Breastfeeding Is Inversely Associated with Allostatic Load in Postpartum Women: Cross-Sectional Data from Nationally Representative US Women

BACKGROUND

The postpartum period is a critical transition period when exposures to protective factors such as breastfeeding can have long-lasting health impact. Studies have suggested downregulating effects of breastfeeding on stress biomarkers such as cortisol but have not explored the way breastfeeding interacts with allostatic load, a multisystem indicator of chronic stress.

OBJECTIVE

We aimed to examine the association between breastfeeding and maternal allostatic load among women within 2 y postpartum using nationally representative data.

METHODS

A cross-sectional analysis of 10 waves of data from the NHANES (1999-2018) was conducted in a sample of 1302 women aged ≥18 y who provided information on breastfeeding through the reproductive health questionnaire. Clinical and empirical allostatic load scores (range: 0-10; higher numbers associated with increased risk) were derived for each participant based on 10 biomarkers reflecting metabolic, cardiovascular, and immune health. Multiple linear regression tested associations between breastfeeding and allostatic load, adjusting for maternal age, race and ethnicity, education, poverty level, and survey wave.

RESULTS

Breastfeeding had a significant inverse association with allostatic load in unadjusted and adjusted models. Controlling for age, race and ethnicity, education, poverty level, and survey wave, breastfeeding women had a 0.36-point lower clinical allostatic load score than nonbreastfeeding women (β = -0.36, SE = 0.11; 95% CI: -0.59, -0.14; P = 0.002) and a 0.44-point lower empirical allostatic load score (β = -0.44, SE = 0.15; 95% CI: -0.74, -0.14; P = 0.005).

CONCLUSIONS

Our study suggests that breastfeeding is protective of maternal stress and provides a more comprehensive picture of breastfeeding's influence on multiple body systems, exemplifying physiological benefits beyond effects on single biomarkers. However, limitations of cross-sectional data and non-classification of breastfeeding duration, mode, and intensity should be considered when interpreting these findings, and further research to address the role of breastfeeding and allostatic load is needed.

Allostatic Load in Cancer: A Systematic Review and Mini Meta-Analysis

BACKGROUND

Individuals with cancer experience stress throughout the cancer trajectory. Allostatic load (AL), a cumulative multi-system measure, may have a greater value in stress assessment and the associated biological burden than individual biomarkers. A better understanding of the use of AL and its operationalization in cancer could aid in early detection and prevention or alleviation of AL in this population.

PURPOSE

To consolidate findings on the operationalization, antecedents, and outcomes of AL in cancer.

METHODS

Seven databases (CINAHL, Ovid MEDLINE, Web of Science, APA PsycInfo, Scopus, Embase, and Cochrane CENTRAL) were searched for articles published through April 2020. The NIH tools were used to assess study quality.

RESULTS

Twelve studies met inclusion criteria for this review. Although variability existed in the estimation of AL, biomarkers of cardiovascular, metabolic, and immune systems were mostly used. Associations of AL with cancer-specific variables were examined mostly utilizing population-databases. Significant associations of AL with variables such as cancer-related stress, positive cancer history, post traumatic growth, resilience, tumor pathology, and cancer-specific mortality were found. Mini meta-analysis found that a one-unit increase in AL was associated with a 9% increased risk of cancer-specific mortality.

CONCLUSION

This review reveals heterogeneity in operationalization of AL in cancer research and lack of clarity regarding causal direction between AL and cancer. Nevertheless, AL holds a significant promise in cancer research and practice. AL could be included as a screening tool for high-risk individuals or a health outcome in cancer. Optimal standardized approaches to measure AL would improve its clinical utility.