The independent effects of obesity and body fat distribution on blood pressure in black adults: the Pitt County study

The relationship of obesity measures to blood pressure and hypertension prevalence was assessed in a community probability sample of 25-50-year-old black adults (1101 women and 655 men) who were examined in 1988 in Pitt County, North Carolina. Among black women, both body mass index and waist-to-hip ratio had independent relationships with systolic and diastolic blood pressures and hypertension prevalence after controlling for the effects of age, socio-economic status, physical activity, alcohol, and the other obesity measure (P < 0.05). Body mass index also had independent relationships with blood pressure levels and hypertension prevalence in black men (P < 0.05), while waist-to-hip ratio was associated with hypertension prevalence (P = 0.05) and diastolic blood pressure (P < 0.05), but not with systolic blood pressure. The relationships of waist-to-hip ratio with blood pressure and hypertension prevalence were considerably reduced in both sex groups after controlling for body mass index. This study presents new evidence that waist-to-hip ratio is related to hypertension and blood pressure level independent of body mass index, in young to middle-aged black adult women and men.

The excess risk of treated end-stage renal disease in blacks in the United States

Analysis of national data from the United States Renal Data System for 1988 revealed an important joint effect of age and race in determining the higher risk of ESRD for blacks as compared with whites. For adults, both hypertension and diabetes made important contributions to the combined effect of age and race. In contrast, glomerulonephritis was not considered to be an important contributor to this joint effect. The combined effect of gender and race was weaker than that of age and race; however, among blacks, differences in the proportions of ESRD attributed to hypertension and diabetes across gender were observed. The age-race joint effect is consistent with the hypothesis that a combined effect of lack of treatment and aging on the process that leads to ESRD may play an important role in the excess risk for ESRD among blacks.

Racial and ethnic differences in infant mortality and low birth weight. A psychosocial critique

Recent studies on differences in infant mortality and low birth weight (LBW) among non-Hispanic whites, African Americans, and Mexican Americans were reviewed. Despite similar socioeconomic profiles, infant mortality among Mexican Americans (8/1000 live births) is less than half that of African Americans (18/1000 live births). In fact, the rate for Mexican Americans is identical to that of non-Hispanic whites. The data for LBW follow a similar pattern. What accounts for this unexpectedly low frequency of poor birth outcomes among Mexican Americans, especially given their economic disadvantages, reduced access to prenatal care, and exposure to discrimination based on ethnicity? Does adherence to a traditional Mexican cultural orientation protect otherwise high-risk Mexican Americans from poor pregnancy outcomes, as has been suggested? What is the "protective" social and psychological content of a traditional Mexican cultural orientation? And what are the implications of this line of reasoning for understanding the excess risk for poor birth outcomes among African Americans? This article explores these and related questions and concludes that new conceptual models are needed to guide research in this area.

Psychosocial stressors and low birth weight: development of a questionnaire

Low birth weight is a major public health problem because it is a major contributor to infant mortality as well as to various types of morbidity among young children. Of particular concern is that black women have an increased risk of low birth weight babies compared with white women. Many etiologic factors for low birth weight have been identified, but even within homogeneous strata of risk, black women have a greater risk of low birth weight babies than do white women. The reasons for this excess risk are not well understood. Available evidence suggests that exposure to psychosocial stressors is associated with adverse pregnancy outcomes. However, prior work in this area has been limited by the lack of a valid and reliable tool to assess exposure to stressors among pregnant women. We report on the development and testing of such a questionnaire, the Prenatal Social Environment Inventory. In this questionnaire, exposure to stressors is conceptualized and measured in the context of chronic stressful conditions. The questionnaire is self-administered and can be used in clinical settings with pregnant women. Findings of psychometric evaluations showed that the questionnaire has acceptable levels of 30-day temporal stability (reliability), internal consistency, and construct validity.

Socioeconomic and behavioral correlates of body mass index in black adults: the Pitt County Study

BACKGROUND

Obesity is more prevalent among Black women than Black men, but there is little information on the correlates of obesity in Blacks. This study describes the relations of sociodemographic factors and health behaviors to body mass index in a southern, Black population.

METHODS

In 1988, a community probability sample of 1784 Black adults, aged 25 to 50, was examined in Pitt County, NC.

RESULTS

More women than men were at least 20% overweight (57% vs 36%). The relation of socioeconomic status (a composite of education and occupation) to age-adjusted body mass index level was inverse in women but not in men. Body mass index did not differ with either current energy intake or energy expenditure. Smokers and drinkers had lower age-adjusted levels than non-smokers and abstainers.

CONCLUSIONS

Since the excess body mass index levels associated with low socioeconomic status in women could not be explained after controlling for adverse health behaviors, further epidemiologic study of risk factors for obesity in Black women is recommended.

Distribution and correlates of waist-to-hip ratio in black adults: the Pitt County Study

A 1988 community-based survey of 1,784 black adults aged 25-50 years in Pitt County, North Carolina, found mean waist-to-hip ratios of 0.890 for men and 0.852 for women. Based on guidelines from the US Department of Agriculture, 20% of the men and 76% of the women had an elevated waist-to-hip ratio. Sedentary behavior was associated with elevated waist-to-hip ratio in men, while a similar excess was associated with alcohol consumption in women. Weak, nonsignificant associations with waist-to-hip ratio were observed for smoking. Socioeconomic status was unrelated to waist-to-hip ratio in men, but it had a strong inverse relation for women.

Socioeconomic status, John Henryism, and blood pressure in black adults. The Pitt County Study

The joint influence of socioeconomic status and John Henryism on blood pressure was examined in a probability sample of 1,784 black adults aged 25-50 years in Pitt County, North Carolina, in 1988. John Henryism was measured by means of the John Henryism Active Coping Scale. Socioeconomic status (low, medium, and high) was based on respondents' education and occupation. Prior research indicated that, for blacks, the inverse association between socioeconomic status and hypertension may be stronger for individuals who score high in John Henryism. In this more urban sample of blacks, the hypothesized interaction achieved modest statistical support (p less than 0.08) only for hypertension prevalence. For individuals with high levels of John Henryism, adjusted prevalences declined with increasing socioeconomic status (29.4%, 26.2%, and 20.5% for low, medium, and high socioeconomic status, respectively); for individuals with low levels of John Henryism, hypertension prevalence was similar in the low (22.6%) and medium (22.8%) socioeconomic categories but higher in the high socioeconomic category (25.9%). Elevated psychological stress in white-collar workers was probably responsible for the nonsignificant inverse gradients between socioeconomic status and mean blood pressures and for the weak interaction between socioeconomic status and John Henryism with regard to hypertension prevalence.

Socioeconomic status and electrolyte intake in black adults: the Pitt County Study

BACKGROUND

Although the inverse association between socioeconomic status (SES) and blood pressure has often been observed, little is known about the relationship between SES and dietary risk factors for elevated blood pressure. Therefore, this study described the distribution of dietary intakes of sodium, potassium, and calcium and examined the association between electrolyte intake and SES among 1784 Black men and women aged 25 to 50 residing in eastern North Carolina.

METHODS

Household interviews were conducted in 1988 to obtain information on psychosocial and dietary correlates of blood pressure. Electrolyte intake (mg/day) was assessed using a food frequency questionnaire adapted to reflect regional and ethnic food preferences. SES was categorized into three levels defined by the participant's educational level and occupation.

RESULTS

After adjustment for age and energy intake, potassium and calcium intake increased with increasing SES for both sexes. Sodium intake was high for all groups and did not vary markedly with SES, but sodium to potassium and sodium to calcium ratios decreased with increasing SES. In addition, high SES individuals were more likely to believe that diet affects risk for disease and to report less salt use at the table and less current sodium consumption than in the past.

CONCLUSION

These data indicate that nutritional beliefs as well as the consumption of electrolytes are associated with SES in Black adults.

Physical activity and hypertension in black adults: the Pitt County Study

The relation of physical activity to hypertension was examined in 1751 Black adults in Pitt County, NC. More women (65%) than men (44%) were classified as sedentary. Sedentary behavior was not associated with the prevalence of hypertension in men, but was associated with a 31% increase in prevalence for women (sedentary-26.2%; active-20.0%; P less than .01). The association in women was independent of other risk factors for hypertension.

Alcohol consumption and blood pressure in black adults: the Pitt County Study

While there is a clear consensus in the epidemiologic literature on the direct association between alcohol consumption and blood pressure, the shape of this relation and its strength in blacks are uncertain. Therefore, the association between alcohol and blood pressure was examined in a community-based random sample of 1,784 black adults aged 25 to 50 years living in eastern North Carolina. These individuals were interviewed in 1988 for a study of psychosocial and dietary risk factors for elevated blood pressure. Alcohol consumption was estimated from responses to a food frequency questionnaire and was divided into four categories, which ranged from abstention (52% of the sample) to greater than or equal to seven drinks/week (12%). After adjustment for age and body mass, the systolic blood pressure of adults reporting greater than or equal to seven drinks/week exceeded that of nondrinkers by 6.8 mmHg for men and women (p less than 0.001). There was no evidence of a threshold effect, and similar patterns were observed for diastolic blood pressure. Being in the highest category of alcohol consumption was related to low socioeconomic status, lower social integration, and higher levels of socioeconomic stressors. These data are consistent with a graded association between alcohol and blood pressure in black adults and suggest the importance of social factors underlying this association.

Work-related physical exertion and risk of preterm, low birthweight delivery

Although many women work during pregnancy, the effect of maternal job experience on pregnancy outcome is controversial. We investigated whether work-related physical exertion increases a woman's risk of delivering a preterm, low birthweight infant. We studied 773 employed, pregnant women included in the National Longitudinal Survey of Labor Market Experience, Youth Cohort (NLSY), a nationally representative sample of young adults. Data concerning work status, job title during pregnancy, and other factors affecting the outcome of pregnancy were obtained from the NLSY. Assessment of physical exertion was based on job title, using an established catalogue of occupational characteristics. Women in jobs characterised by high physical exertion experienced a higher rate of preterm, low birthweight delivery, defined as maternal report of delivery more than 3 weeks early and birthweight under 2,500 g (adjusted RR = 5.1, 95% CI = 1.5, 17.7). These findings support a policy of limiting work-related physical exertion during pregnancy.

Work-related psychosocial stress and risk of preterm, low birthweight delivery

We investigated whether work-related psychologic stress--defined as work characterized by both high psychologic demands and limited control over the response to these demands--increases a woman's risk of delivering a preterm, low birthweight infant. We studied 786 employed pregnant women included in the National Longitudinal Survey of Labor Market Experience, Youth Cohort (NLSY), a nationally representative sample of 12,686 young adults. Data concerning work status, job title, and other factors affecting pregnancy outcome were obtained from the NLSY. Assessment of job experience was based on job title, using an established catalogue of occupation characteristics. After accounting for the physical exertion entailed in a job, occupational psychologic stress as measured by job title was not associated with preterm, low birthweight delivery for the sample as a whole (Relative risk = 1.16, 95% confidence interval .45, 2.95). For those women who did not want to remain in the work force, work-related stress increased their risk of experiencing this outcome (RR = 8.1, 95% CI 1.5, 50.2). Personal motivation toward work, as well as the physical effort of work, should be considered in evaluating the impact of a job's psychologic characteristics on pregnancy outcome.

A Social Environment Inventory for the pediatric office

Exposure to psychosocial stressors is associated with deleterious physical and mental health outcomes among children and adults, as well as with school-related and behavioral problems among children. However, research and intervention in this area have been hampered by the lack of a valid measurement tool to assess exposure to stressors among mothers. This paper reports on the development and testing of a self-administered questionnaire for use in the pediatric setting to assess maternal exposure to stressors. The questionnaire was developed to facilitate the early identification of mothers exposed to high levels of stressors, since exposure to stressors often precedes the onset of problems. Early identification of mothers and children, in the pediatric office, could facilitate the prevention of various behavioral, school, and other problems among children.

Chronic stressors and maternal depression: implications for prevention

We report on the use of an instrument to measure exposure to stressors among 149 women presenting with their children for pediatric care at an urban primary care center. Overall, 38.3 percent of the women had significant levels of depressive symptoms; 71.4 percent of those in the "high stress" group had an adjusted prevalence odds ratio of 5.00 [95% CI = 2.12, 11.82]. We conclude that screening in the pediatric office is feasible for identifying women at high risk of becoming depressed.

The association between depressive symptoms and mortality among older participants in the Epidemiologic Catchment Area-Piedmont Health Survey

The association between depression and two-year mortality risk was assessed in 1,606 elderly community participants in the 1982-83 Epidemiologic Catchment Area-Piedmont Health Survey. Two depression measures were formed from the Diagnostic Interview Schedule (DIS) depressive symptom items. Neither measure was associated with mortality in univariate or multiple logistic regression analyses. The adjusted relative risk of mortality comparing the lowest to highest levels of a three-level depression variable was 0.9 (95% confidence interval = 0.5-1.4). Similar results were obtained with other versions of the depression variables, with each depressive symptom category, and within sex, chronic disease, widowhood status, and age groups. These results indicate that depression does not increase mortality in elderly adults, but the short follow-up, sample characteristics, and operationalization of depression may have affected this association.

"John Henryism" and blood pressure in a Dutch population

In a stratified, random sample of 100 men and 100 women, aged 20-59 years, residing in Zutphen, the Netherlands, the hypothesis was tested that high scores on "John Henryism," a strong behavioral predisposition to cope actively with psychosocial environmental stressors, would be associated with higher blood pressure, especially among persons of lower education. In univariate analyses higher scores on John Henryism were strongly associated with higher blood pressures in men. Among women there was only an association of John Henryism and systolic blood pressure, but this association was no longer statistically significant after adjustment for potential confounders such as age, alcohol consumption, physical activity, Quetelet Index, and education. Among men, however, the association between John Henryism and systolic blood pressure remained statistically significant after adjustment for potential confounders. The association between John Henryism and blood pressure was more pronounced for men of low educational background.

Hypertension control in a rural southern community: medical care process and dropping out

As part of the Edgecombe County High Blood Pressure Control Program, we conducted a medical record review within a private group practice to assess the interrelationships between patient characteristics, the process of medical care, and dropping out of care by hypertensive patients. Twenty-one percent of 641 randomly selected hypertensive patients did not have a clinic visit in the year before their record review date. Loss to follow-up varied from 31% for black men to 13% for white women. More intense prior contact with the medical care system was associated with remaining under medical care for all groups by race and sex. Black men were much less likely to have intense contact with the medical care system than the other groups. Physician aggressiveness in the use of drug therapy was associated with a nearly 40% reduction in the risk of being lost to follow-up. These findings suggest that patient characteristics and several factors that reflect the process of medical care are associated with dropping out of medical care by hypertensive patients.

Teaching the medical interview: an intervention study

To study the effects of teaching specific interviewing techniques on verbal behaviors and on health outcomes, internal medicine residents working in a screening clinic were assigned to either an experimental or a control group. The entire clinic visit was audiotaped, transcribed, and coded according to the Verbal Response Mode (VRM) system. Residents in the experimental group were taught interviewing behaviors (patient exposition and physician explanation) that had been found in previous studies to be associated with patient outcomes. Through telephone interviews, patient satisfaction, compliance, and symptom status were determined for all patients. Two hundred and sixty-eight interviews (156 in the experimental group and 112 in the control group) were included in the study. Training did increase patient exposition and physician explanation, but did not affect health outcomes. Residents' attitudes and behaviors during the training are described.

Effects of race and marginally elevated blood pressure on responses to stress

A total of 228 men, aged 18 to 22 years (109 black and 119 white), underwent monitoring of heart rate (HR) and systolic (SBP) and diastolic blood pressure (DBP) responses during several stressor conditions and a 30-minute posttask rest period. Stressors included the cold pressor test and three reaction-time tasks: noncompetitive, competitive, and competitive plus money incentive. Substantial within-subject variations in blood pressure and heart rate were induced, varying from 119/70 to 148/94 mm Hg and from 63 to 91 beats/min on the average. Men (25 black and 39 white) with marginal SBP elevations during initial casual determinations had higher SBP under all conditions compared with men whose casual SBP levels were normal, and they also showed greater elevations over baseline levels in heart rate, SBP, and DBP during the stressors and the initial casual determination. Black and white subjects did not differ in their blood pressures at baseline or during the initial casual determinations, although blacks had slightly lower heart rates. Blacks did show greater SBP elevations over baseline levels than whites during the stressors, primarily because the blacks with marginally elevated SBP showed substantially greater stress-induced increases than whites with marginally elevated SBP. This enhanced pressor response to stress in blacks with marginal blood pressure elevations may be due to higher vascular resistance during enhanced sympathetic activity and could contribute to the higher incidence of hypertension among blacks.

Socioeconomic status, John Henryism, and hypertension in blacks and whites

The joint influence of socioeconomic status and John Henryism on risk for elevated blood pressure was examined in a biracial, community sample of 820 adults, aged 21-50 years, who resided in Edgecombe County, North Carolina, and were interviewed in 1983. John Henryism refers to a strong personality predisposition to cope actively with psychosocial environmental stressors. In keeping with an earlier finding for black men, it was hypothesized that the inverse association between socioeconomic status and blood pressure would be stronger for persons who scored high on John Henryism than for persons who scored low. Using race-specific definitions of socioeconomic status, the study found support for the hypothesis among blacks. At low levels of John Henryism, socioeconomic status differences in hypertension prevalence were small (1.6%), whereas at high levels of John Henryism, low socioeconomic status blacks were nearly three times as likely to be hypertensive as higher status blacks (31.4% vs. 11.5%, p = 0.02 for the socioeconomic status X John Henryism interaction term). The findings for systolic and diastolic blood pressures were in a similar direction but did not reach statistical significance. The study hypothesis was not supported among whites. Analyses of the correlates of John Henryism as well as the blood pressure findings are discussed in terms of the different socioeconomic circumstances that characterize the lives of blacks and whites in this rural, southern community.

Psychosocial precursors of hypertension: a review of the epidemiologic evidence

This article provides a selective overview of epidemiologic studies on the relationship between psychosocial factors and blood pressure elevation. The review focuses on English-language reports published since 1975 and emphasizes two broad areas of research: changes in mean blood pressures of third world populations undergoing modernization, and psychosocial correlates of elevated blood pressure in low socioeconomic status (SES) and black populations within the continental United States. The recent modernization studies provide additional evidence that rapid sociocultural change is associated with increased prevalence of hypertension. To account for these effects, several studies have advanced the general thesis that modernization impacts traditional value systems of third world populations in ways that frequently engender discrepancies between their newly acquired aspirations for a Western lifestyle and their socioeconomic resources to successfully pursue that lifestyle. There is overlap between this formulation and recent investigations of hypertension in low SES and black populations in the United States. The report concludes with a discussion of epidemiologic studies of anger and hypertension, emphasizing some of the complexities that characterize this area of research.