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Social support as a comfort or an encouragement: A systematic review on the contrasting effects of social support on cardiovascular reactivity

Teoh AN, Hilmert C

Br J Health Psychol, 2018 11;23(4):1040-1065.
PMID: 30084181 DOI: 10.1111/bjhp.12337

PURPOSE: The stress-buffering hypothesis (Cohen & McKay, 1984, Handbook of psychology and health IV: Social psychological aspects of health (pp. 253-256). Hillsdale, NJ: Lawrence Erlbaum) suggests that one way social support enhances health is by attenuating cardiovascular reactivity (CVR) to stress. Research that has tested this hypothesis has reported inconsistent findings. In this review, we systematically reviewed those findings and proposed a dual-effect model of social support and CVR as a potential explanation for the inconsistency in the literature. Specifically, we proposed that when participants are more engaged during a stressor, social support acts primarily as social comfort, attenuating CVR; and when participants are not engaged, social support acts primarily as social encouragement, elevating CVR.
METHODS: We reviewed 22 previous studies that (1) empirically manipulated social support in a stressful situation, (2) measured CVR, and (3) tested a moderator of social support effects on CVR.
RESULTS: Although a majority of studies reported a CVR-mitigating effect of social support resulting in an overall significant combined p-value, we found that there were different effects of social support on CVR when we considered high- and low-engagement contexts. That is, compared to control conditions, social support lowered CVR in more engaging situations but had no significant effect on CVR in less engaging situations.
CONCLUSION: Our results suggest that a dual-effect model of social support effects on CVR may better capture the nature of social support, CVR, and health associations than the buffering hypothesis and emphasize a need to better understand the health implications of physiological reactivity in various contexts. Statement of contribution What is already known on this subject? According to the stress-buffering hypothesis (Cohen & McKay, ), one pathway social support benefits health is through mitigating the physiological arousal caused by stress. However, previous studies that examined the effects of social support on blood pressure and heart rate changes were not consistently supporting the hypothesis. Some studies reported that social support causes elevations in cardiovascular reactivity (CVR) to stress (Anthony & O'Brien, ; Hilmert, Christenfeld, & Kulik, ; Hilmert, Kulik, & Christenfeld, ) and others showed no effect of social support on CVR (Christian & Stoney, ; Craig & Deichert, ; Gallo, Smith, & Kircher, ). What does this study add? When participants were in more engaging conditions, social support decreased CVR relative to no support. When participants were in less engaging conditions, social support did not have a significant effect on CVR. Provide an alternative way to explain the ways social support affects cardiac health.
Associations of pre-pregnancy body mass index, middle-upper arm circumference, and gestational weight gain

Ng CM, Badon SE, Dhivyalosini M, Hamid JJM, Rohana AJ, Teoh AN, et al.

Sex Reprod Healthc, 2019 Jun;20:60-65.
PMID: 31084820 DOI: 10.1016/j.srhc.2019.03.002

OBJECTIVES: An optimal gestational weight gain is essential for maternal health and to reduce adverse birth outcomes. Current guidelines to monitor gestational weight gain are based on pre-pregnancy body mass index (BMI). However, middle-upper arm circumference (MUAC) is increasingly used as an alternative nutritional status measure for pregnant women. Hence, this study aimed to determine associations of MUAC and pre-pregnancy BMI with gestational weight gain rate among Malaysian pregnant women.
STUDY DESIGN: A cross-sectional study was conducted among 444 pregnant women (≥20 weeks gestation).
MAIN OUTCOMES MEASURES: Women completed questionnaires on sociodemographic data, maternal characteristics and pre-pregnancy weight. Height, current weight and MUAC were measured at study visit (from 1st February 2016 to 31st January 2017).
RESULTS: About a third (34.24%) of pregnant women were overweight or obese prior to pregnancy. MUAC was inversely associated with an inadequate rate of gestational weight gain (OR = 0.77; 95% CI: 0.68, 0.87) as compared to normal gestational weight gain. In contrast, a higher MUAC was associated with a higher odds ratio (OR = 1.28; 95% CI: 1.11, 1.49) of having excessive rate of gestational weight. No associations were found for pre-pregnancy BMI categories for gestational weight gain rate.
CONCLUSION: Our findings revealed that women with low MUAC were more likely to have an inadequate gestational weight gain rate during pregnancy whereas higher MUAC was associated with an excessive gestational weight gain rate. MUAC may be a useful indicator of nutritional status associated with GWG. Routine measurement of MUAC in pregnant women may help health professionals, particularly in middle-income countries, to counsel women about gestational weight gain.
Fulltext Chrononutrition is associated with melatonin and cortisol rhythm during pregnancy: Findings from MY-CARE cohort study

Teoh AN, Kaur S, Shafie SR, Mohd Shukri NH, Ahmad Bustami N, Takahashi M, et al.

Front Nutr, 2022;9:1078086.
PMID: 36687684 DOI: 10.3389/fnut.2022.1078086

Chrononutrition has been suggested to have an entrainment effect on circadian rhythm which is crucial for metabolic health. Investigating how chrononutrition affects maternal circadian rhythm can shed light on its role during pregnancy. This study aims to determine chrononutrition characteristics of healthy primigravida during pregnancy and its association with melatonin and cortisol rhythm across gestation. A total of 70 healthy primigravidas were recruited from ten randomly selected government maternal and child clinics in Kuala Lumpur, Malaysia. During the second and third trimesters, chrononutrition characteristics including meal timing, frequency, eating window, breakfast skipping, and late-night eating were determined using a 3-day food record. Pregnant women provided salivary samples at five time-points over a 24 h period for melatonin and cortisol assay. Consistently across the second and third trimesters, both melatonin and cortisol showed a rhythmic change over the day. Melatonin levels displayed an increment toward the night whilst cortisol levels declined over the day. Majority observed a shorter eating window (≤12 h) during the second and third trimesters (66 and 55%, respectively). Results showed 23 and 28% skipped breakfast whereas 45 and 37% ate within 2 h pre-bedtime. During the third trimester, a longer eating window was associated with lower melatonin mean (β = -0.40, p = 0.006), peak (β = -0.42, p = 0.006), and AUCG (β = -0.44, p = 0.003). During both trimesters, a lower awakening cortisol level was observed in pregnant women who skipped breakfast (β = -0.33, p = 0.029; β = -0.29, p = 0.044). Only during the second trimester, breakfast-skipping was significantly associated with a greater cortisol amplitude (β = 0.43, p = 0.003). Findings suggest that certain chrononutrition components, particularly eating window and breakfast skipping have a significant influence on maternal melatonin and cortisol rhythm. Dietary intervention targeting these characteristics may be useful in maintaining maternal circadian rhythm.
Fulltext Maternal melatonin levels and temporal dietary intake: results from MY-CARE cohort study

Teoh AN, Kaur S, Shafie SR, Shukri NHM, Bustami NA, Takahashi M, et al.

BMC Pregnancy Childbirth, 2023 Jul 04;23(1):491.
PMID: 37403031 DOI: 10.1186/s12884-023-05796-y

Chrononutrition emerges as a novel approach to promote circadian alignment and metabolic health by means of time-of-the-day dietary intake. However, the relationship between maternal circadian rhythm and temporal dietary intake during pregnancy remains understudied. This study aimed to determine the change in melatonin levels in pregnant women across gestation and its association with temporal energy and macronutrient intake. This was a prospective cohort involving 70 healthy primigravidas. During the second and third trimesters, pregnant women provided salivary samples collected at 9:00, 15:00, 21:00, and 3:00 h over a 24 h day for melatonin assay. Data on chrononutrition characteristics were collected using a 3-day food record. Parameters derived from melatonin measurements including mean, amplitude, maximal level, area under the curve with respect to increase (AUCI), and area under the curve with respect to ground (AUCG) were computed. A rhythmic melatonin secretion over the day that remained stable across trimesters was observed among the pregnant women. There was no significant elevation in salivary melatonin levels as pregnancy advanced. In the second trimester, higher energy intake during 12:00-15:59 h and 19:00-06:59 h predicted a steeper melatonin AUCI (β=-0.32, p = 0.034) and higher AUCG (β = 0.26, p = 0.042), respectively. Macronutrient intake within 12:00-15:59 h was negatively associated with mean melatonin (Fat: β=-0.28, p = 0.041) and AUCG (Carbohydrate: β=-0.37, p = 0.003; Protein: β=-0.27, p = 0.036; Fat: β=-0.32, p = 0.014). As pregnant women progressed from the second to the third trimester, a flatter AUCI was associated with a reduced carbohydrate intake during 12:00-15:59 h (β=-0.40, p = 0.026). No significant association was detected during the third trimester. Our findings show that higher energy and macronutrient intakes particularly during 12:00-15:59 h and 19:00-06:59 h are associated with the disparities in maternal melatonin levels. Findings suggest the potential of time-based dietary approaches to entrain circadian rhythm in pregnant women.
Psychological state during pregnancy is associated with sleep quality: preliminary findings from MY-CARE cohort study

Teoh AN, Kaur S, Mohd Shukri NH, Shafie SR, Ahmad Bustami N, Takahashi M, et al.

Chronobiol Int, 2021 07;38(7):959-970.
PMID: 33779445 DOI: 10.1080/07420528.2021.1902338

Psychological distress during pregnancy may increase the risk of adverse maternal and infant outcomes. Past studies have demonstrated the association between circadian disturbances with psychological health. However, the roles of chronotype and social jetlag on psychological state during pregnancy are yet to be identified. We aimed to examine the psychological state in pregnant women and its relations to chronotype, social jetlag (SJL), sleep quality and cortisol rhythm. The current study included a subsample of participants from an ongoing cohort study. A total of 179 primigravidas (mean age 28.4 ± 4.0 years) were recruited. Chronotype and sleep quality during the second trimester were assessed using the Morning-Eveningness Questionnaire (MEQ) and Pittsburgh Sleep Quality Index (PSQI), respectively. SJL was calculated based on the difference between mid-sleep on workdays and free days. Psychological state of participants was evaluated using the Depression, Anxiety, and Stress Scale-21 (DASS-21). Subsamples (n = 70) provided salivary samples at 5 time points over a 24 h period during the second trimester for cortisol assay. A higher proportion of pregnant women experienced moderate to severe anxiety symptoms (n = 77, 43.0%), followed by depressive (n = 17, 9.5%) and stress (n = 14, 7.8%) symptoms. No association was observed between chronotype and psychological distress during pregnancy. There was no significant difference in cortisol rhythms in relation to psychological distress. SJL and sleep quality were significantly associated with stress symptoms among pregnant women in the second trimester. Poor sleep quality, particularly daytime dysfunction (β = 0.37, p = .006) and sleep disturbances (β = 0.23, p = .047), were significantly associated with psychological distress (depressive, anxiety and stress symptoms) during the second trimester. The findings suggest that sleep is a potential modifiable lifestyle factor that can be targeted to improve psychological health among pregnant women.
Fulltext Circadian rhythm and its association with birth and infant outcomes: research protocol of a prospective cohort study

Kaur S, Teoh AN, Shukri NHM, Shafie SR, Bustami NA, Takahashi M, et al.

BMC Pregnancy Childbirth, 2020 Feb 11;20(1):96.
PMID: 32046676 DOI: 10.1186/s12884-020-2797-2

BACKGROUND: Circadian rhythm plays an important role as our internal body's clock that synchronizes behavior and physiology according to the external 24-h light-dark cycle. Past studies have associated disrupted circadian rhythm with higher risk of miscarriages, preterm birth and low birth weights. This paper described the protocol of a prospective cohort study which aims to determine the circadian rhythm in pregnant women, identify its association with maternal factors during pregnancy, gestational weight gain, birth and infant outcomes.
METHODS: Ten government maternal and child health clinics in Kuala Lumpur, Malaysia will be randomly selected. Sample size of 438 first-trimester pregnant women will be followed-up until the birth of their infant. Salivary melatonin and cortisol concentration among subsample will be determined using enzyme-linked immunosorbent assay. Data on sleep quality, psychological distress and morningness/eveningness chronotype of pregnant women will be collected using validated questionnaires. Pedometer will be used to measure 5-day physical activity data. Total gestational weight gain will be determined at the end of pregnancy. Utilization of 3-day food record is to capture meal timing and nutrient intake. All measurements will be done in 2nd and 3rd trimester. Birth outcomes will be collected through clinic records and Centers for Disease Control and Prevention (CDC) Neonatal questionnaire. Infants will be followed-up at 6 and 12 months old to obtain anthropometric measurements.
DISCUSSION: There is a growing recognition of the role of maternal circadian rhythm, which entrains fetal circadian rhythms that may subsequently have long-term health consequences. The present study will identify the effect of circadian rhythm on pregnancy outcomes and infant growth in the first year of life.