The Impact of Combined Exposure to Metals and Per- and Polyfluoroalkyl Substances on Stress, Cardiovascular Disease Risk and Mortality

The health and life outcomes of individuals are influenced by the environments in which they live. The totality of exposures across the life course can affect health both in the short term and over decades. Environmental exposure to multiple contaminants can increase stress levels in individuals and communities, with psychosocial stressors such as crime, substance misuse, and violence further impacting well-being. The organization and quality of local institutions and infrastructure also influence health outcomes. Individuals may be simultaneously exposed to a combination of environmental and psychosocial stressors. Exposure to pollutants such as lead (Pb), cadmium (Cd), mercury (Hg), perfluorooctane sulfonic acid (PFOS), and perfluorooctanoic acid (PFOA) is independently associated with adverse health outcomes, but little is known about their combined effects on individual stress, community stress, cardiovascular disease (CVD) risk, and CVD mortality. This study will examine the combined impact of Pb, Cd, Hg, PFOS, and PFOA on (a) allostatic load, a measure of chronic individual stress, (b) cumulative census tract risk of psychosocial stress (CCRPS), a measure of community stress, and (c) CVD risk and mortality. We hypothesize that combined exposures will increase both individual- and community-level stress, as well as CVD risk and mortality. Understanding the combined effects of these contaminants will inform interventions to reduce high-risk exposure patterns. Study findings will also contribute to improved statistical modeling techniques for complex environmental mixtures while accounting for survey design.