Invited commentary: Discrimination--an emerging target for reducing risk of cardiovascular disease?

Does everyday discrimination account for the increased risk of vasomotor symptoms in Black women?: the Study of Women's Health Across the Nation (SWAN)

OBJECTIVES

Vasomotor symptoms (VMS), including hot flashes and night sweats, are hallmark symptoms of the menopause transition. Previous research has documented greater frequency, duration, and severity of VMS in Black women compared with women from other racial/ethnic groups, even after accounting for other factors. This analysis examined the association between discrimination and VMS and the extent to which discrimination accounts for the disproportionate burden of VMS in Black women.

METHODS

Using available discrimination and VMS data from the SWAN cohort study (n = 2,377, 48% White, 32% Black, 6% Japanese, 4% Chinese, and 9% Hispanic women) followed approximately yearly in midlife from premenopause (42-52 y) through postmenopause (~20 y), we assessed concurrent associations between discrimination and VMS frequency in the past 2 weeks using weighted generalized mixed models. We also assessed associations between chronic discrimination across first four visits and VMS trajectories from premenopause to postmenopause using weighted multinomial logistic regression. Models were adjusted for known risk factors for VMS.

RESULTS

Higher levels of discrimination were associated with concurrent reporting of any (odds ratio [OR], 1.57 [1.31-1.89]) and frequent (≥6 d) VMS (OR, 1.55 [1.21-1.99]). After adjustment, associations remained significant for any (OR, 1.30 [1.09-1.54]) but not frequent VMS. For any VMS trajectories, chronic discrimination was associated with "continuously high" (OR, 1.69 [1.03-2.77]) and "high pre-FMP-decline post-FMP" (OR, 1.70 [1.01-2.88]) versus "FMP-onset low" trajectories. After adjusting for discrimination, odds of reporting any, frequent, and of being in the "continuously high" any VMS trajectory remained elevated for Black versus White women.

CONCLUSIONS

Discrimination is associated with greater concurrent risk of any (but not frequent) VMS, and chronic discrimination is associated with a continuously high reporting of any VMS over time, independent of known risk factors. Adjusting for discrimination attenuates but does not eliminate the increased risk of VMS for Black women.

Relational and individual stress pathways linking discrimination and ageing cardiometabolic health

Perceived discrimination is a significant risk factor for worse ageing health outcomes. Yet, the specific individual and relational stress pathways linking discrimination to disease are less understood, especially in the context of cardiometabolic health. We tested family stress and psychophysiological distress (negative affect and high-risk lipid/fat metabolism) as mediators linking perceived discrimination to cardiometabolic morbidity and health appraisal over 20 years for midlife adults. Using data from participants who completed the Biomarker Project (2004-2009) of the Midlife in the U.S. project, and examining data over the study's three waves (1995-1996, 2004-2006, and 2013-2014), we used structural equation modelling to test pathways for participants who reported zero cardiometabolic conditions at baseline (n = 799). Greater Time 1 discrimination was associated with greater Time 2 family strain, which was in turn associated with worse negative affect; worse Time 2 negative affect was associated with worse Time 3 health appraisal; metabolic lipids risk did not serve as an indirect pathway to Time 3 cardiometabolic morbidity (χ²  = 147.74, p < 0.001; RMSEA = 0.056; CFI = 0.902; SRMR = 0.047). The inclusion of family in interventions to mitigate the impact of discrimination may be indicated for promoting cardiometabolic wellness.

Race and Gender Differences in the Association Between Experiences of Everyday Discrimination and Arterial Stiffness Among Patients With Coronary Heart Disease

BACKGROUND

Self-reported experiences of discrimination have been linked to indices of cardiovascular disease. However, most studies have focused on healthy populations. Thus, we examined the association between experiences of everyday discrimination and arterial stiffness among patients with a history of myocardial infarction (MI).

PURPOSE

We hypothesized that higher reports of discrimination would be associated with greater arterial stiffness and that associations would be more pronounced among Black women, in particular, relative to other race-gender groups, using an "intersectionality" perspective.

METHODS

Data were from 313 participants (49.2% female, mean age: 50.8 years) who were 6 months post-MI in the Myocardial Infarction and Mental Stress 2 study. Data were collected via self-reported questionnaires, medical chart review, and a clinic visit during which arterial stiffness was measured noninvasively using pulse wave velocity.

RESULTS

Reports of discrimination were highest in Black men and women and arterial stiffness was greatest in Black and White women. After adjustment for demographics and relevant clinical variables, discrimination was not associated with arterial stiffness in the overall study sample. However, discrimination was associated with increased arterial stiffness among Black women but not White women, White men, or Black men.

CONCLUSIONS

Despite no apparent association between discrimination and arterial stiffness in the overall study sample, further stratification revealed an association among Black women but not other race-gender groups. These data not only support the utility of an intersectionality lens but also suggest the importance of implementing psychosocial interventions and coping strategies focused on discrimination into the care of clinically ill Black women.

An investigation of racial/ethnic and sex differences in the association between experiences of everyday discrimination and leukocyte telomere length among patients with coronary artery disease

Leukocyte telomere length (LTL) may be sensitive to psychosocial stressors such as discrimination. An inclusive examination of experiences of discrimination on LTL across racial/ethnic and sex groups is currently lacking. Baseline data were obtained from 369 White and African American patients with coronary artery disease (CAD) in the Mental Stress Ischemia Mechanisms and Prognosis Study. LTL was measured from peripheral blood leukocytes by quantitative polymerase chain reaction and calculated in kilobase pairs. Discrimination was measured using the 10-item Everyday Discrimination Scale (EDS). Responses were rated using 4-point Likert scales ranging from never = 1 to often = 4 and summed. Regression models were stratified by race/ethnicity and sex to estimate associations between discrimination and LTL. Each 10-unit increase in experiences of everyday discrimination was associated with an average of .20 fewer kilobase pairs (or 200 base pairs) among both African American women (β = -0.19; 95% CI: -0.35, -0.04; p-value: 0.02) and White women (β = -0.19; 95% CI: -0.37, -0.01; p-value: 0.04), after adjusting for basic demographic factors. Results were similar after further adjusting for behavioral, disease, and psychosocial risk factors (depression and stress). There were no significant associations between experiences of everyday discrimination and LTL for White men or African American men. Overall, experiences of discrimination were associated with shorter LTL among women and not in men. Discrimination may be a potential source of stress associated with shorter LTL among women with CAD. Future studies should explore longitudinal associations between everyday experiences of discrimination and telomere length and also with adverse cardiovascular outcomes.

Co-Occurrence of Posttraumatic Stress Disorder and Cardiovascular Disease Among Ethnic/Racial Groups in the United States

OBJECTIVE

Trauma and/or symptoms of posttraumatic stress disorder (PTSD) have been linked to the onset of cardiovascular disease (CVD), but the exact mechanism has not been determined. We examine whether the risk of CVD is different among those who have a history of trauma without PTSD symptoms, those who have experienced trauma and developed any symptoms of PTSD, and those with a PTSD diagnosis. Furthermore, we examine whether this association varies across ethnic/racial groups.

METHODS

We used two data sets that form part of the Collaborative Psychiatric Epidemiology Surveys - the National Latino and Asian American Study and the National Comorbidity Survey Replication.

RESULTS

We found an increased likelihood of cardiovascular events for those with a diagnosis of PTSD (odds ratio [OR] = 2.10, 95% CI = 1.32-3.33) when compared with those who had not experienced trauma. We did not find an increased risk for those who had experienced trauma without symptoms or with subclinical symptoms of PTSD. The higher likelihood of having a cardiovascular event in those with PTSD was significant for non-Latino whites (OR = 1.86, 95% CI = 1.08-3.11), Latinos (OR = 1.94, 95% CI = 1.04-3.62), and non-Latino blacks (OR = 3.73, 95% CI = 1.76-7.91), but not for Asian respondents.

CONCLUSIONS

The constellation of symptoms defining PTSD diagnosis reflect adverse reactions to traumatic events and indicate that complex responses to traumatic events may be a risk factor for CVD.

The Role of Perceived Discrimination in Obesity Among African Americans

INTRODUCTION

African Americans, especially those in the South, suffer a disproportionate burden of obesity and are at high risk for perceived discrimination (PD). This study investigates the association between PD and weight status among African Americans and clarifies the role of perceived stress and health behaviors in this relationship.

METHODS

Data came from the Jackson Heart Study, Examination 1 (2000-2004; analyses conducted in 2016 using Stata, version 14). African Americans from Jackson, Mississippi, aged 21-95 years were recruited (N=5,301). Weight status was measured using anthropometric data with BMI; waist circumference (in centimeters); and obesity class (I, II, III). Survey instruments were used to measure PD, perceived global stress, and health behaviors. Multivariate regression was used to model weight status outcomes as a function of PD, perceived stress, and health behaviors.

RESULTS

After controlling for sociodemographic factors and health status, perceived everyday discrimination was associated with higher BMI (b=0.33, p<0.01); higher waist circumference (b=0.70, p<0.01); and higher relative risk of Class III obesity versus non-obesity (relative risk ratio, 1.18; p<0.001). Global perceived stress was linked to higher BMI (b=0.42, p<0.05) and higher waist circumference (b=1.18; p<0.01) and partially mediated the relationships between PD and these weight status outcomes. Health behaviors led to suppression rather than mediation between PD and weight status and between stress and weight status.

CONCLUSIONS

PD and perceived stress are potential risk factors for higher weight status. They should be considered as a part of a comprehensive approach to reduce obesity among African Americans.

NEIGHBOURHOOD POVERTY, PERCEIVED DISCRIMINATION AND CENTRAL ADIPOSITY IN THE USA: INDEPENDENT ASSOCIATIONS IN A REPEATED MEASURES ANALYSIS

This study examines the independent effects of neighbourhood context (i.e. neighbourhood poverty) and exposure to perceived discrimination in shaping risk of obesity over time. Weighted three-level hierarchical linear regression models for a continuous outcome were used to assess the independent effects of neighbourhood poverty and perceived discrimination on obesity over time in a sample of 157 non-Hispanic Black, non-Hispanic White and Hispanic adults in Detroit, USA, in 2002/2003 and 2007/2008. Independent associations were found between neighbourhood poverty and perceived discrimination with central adiposity over time. Residents of neighbourhoods with high concentrations of poverty were more likely to show increases in central adiposity compared with those in neighbourhoods with lower concentrations of poverty. In models adjusted for BMI, neighbourhood poverty at baseline was associated with a greater change in central adiposity among participants who lived in neighbourhoods in the second (B=3.79, p=0.025) and third (B=3.73, p=0.024) poverty quartiles, compared with those in the lowest poverty neighbourhoods. The results from models that included both neighbourhood poverty and perceived discrimination showed that both were associated with increased risk of increased central adiposity over time. Residents of neighbourhoods in the second (B=9.58, p<0.001), third (B=8.25, p=0.004) and fourth (B=7.66, p=0.030) quartiles of poverty were more likely to show greater increases in central adiposity over time, compared with those in the lowest poverty quartile, with mean discrimination at baseline independently and positively associated with increases in central adiposity over time (B=2.36, p=0.020). The results suggest that neighbourhood poverty and perceived discrimination are independently associated with a heightened risk of increase in central adiposity over time. Efforts to address persistent disparities in central adiposity in the USA should include strategies to reduce high concentrations of neighbourhood poverty as well as discrimination.

Self-reported experiences of discrimination and health: scientific advances, ongoing controversies, and emerging issues

Over the past two decades, research examining the impact of self-reported experiences of discrimination on mental and physical health has increased dramatically. Studies have found consistent associations between exposure to discrimination and a wide range of Diagnostic and Statistical Manual of Mental Disorders (DSM)-diagnosed mental disorders as well as objective physical health outcomes. Associations are seen in cross-sectional as well as longitudinal studies and persist even after adjustment for confounding variables, including personality characteristics and other threats to validity. However, controversies remain, particularly around the best approach to measuring experiences of discrimination, the significance of racial/ethnic discrimination versus overall mistreatment, the need to account for "intersectionalities," and the importance of comprehensive assessments. These issues are discussed in detail, along with emerging areas of emphasis including cyber discrimination, anticipatory stress or vigilance around discrimination, and interventions with potential to reduce the negative effects of discrimination on health. We also discuss priorities for future research and implications for interventions and policy.

Perceived discrimination and chronic health in adults from nine ethnic subgroups in the USA

OBJECTIVE

This comparative analysis examines the association between chronic cardiovascular, respiratory and pain conditions, race, ethnicity, nativity, length of residency, and perceived discrimination among three racial and nine ethnic subgroups of Asian Americans (Vietnamese, Filipino, and Chinese), Latino-American (Cuban, Portuguese, and Mexican), and Afro-Caribbean American (Haitian, Jamaican, and Trinidadian/Tobagonian) respondents.

DESIGN

Analysis used weighted Collaborative Psychiatric Epidemiology Surveys-merged data from the National Latino and Asian American Study and the National Survey of American Life. Logistic regression analysis was conducted to determine which groups within the model were more likely to report perceived discrimination effects.

RESULTS

Afro-Caribbean subgroups were more likely to report perceived discrimination than Asian American and Latino-American subgroups were. Logistic regression revealed a significant positive association with perceived discrimination and chronic pain only for Latino-American respondents.

CONCLUSION

Significant differences in reports of perceived discrimination emerged by race and ethnicity. Caribbean respondents were more likely to report high levels of perceived discrimination; however, they showed fewer significant associations related to chronic health conditions compared to Asian Americans and Latino-Americans. Examination of perceived discrimination across ethnic subgroups reveals large variations in the relationship between chronic health and discrimination by race and ethnicity. Examining perceived discrimination by ethnicity may reveal more complex chronic health patterns masked by broader racial groupings.

When identifying health disparities as a problem is a problem: pedagogical strategies for examining racialized contexts

The current study presents a critical discussion on community responses to health disparity research and the need for utilizing pedagogical strategies to prepare students to understand and address health disparities in racialized contexts. Qualitative research methods were used to examine community responses to media stories on two health disparity research projects, and four themes emerged: naming health disparities is a tool for dividing, structural racism does not exist, naming of health disparities is a political act, and health disparities exist because of individual-level deficiencies. The implications for teaching students about racial health disparities are presented and discussed.

Self-Reported Experiences of Discrimination and Cardiovascular Disease

Researchers have long speculated that exposure to discrimination may increase cardiovascular disease (CVD) risk but compared to other psychosocial risk factors, large-scale epidemiologic and community based studies examining associations between reports of discrimination and CVD risk have only emerged fairly recently. This review summarizes findings from studies of self-reported experiences of discrimination and CVD risk published between 2011-2013. We document the innovative advances in recent work, the notable heterogeneity in these studies, and the considerable need for additional work with objective clinical endpoints other than blood pressure. Implications for the study of racial disparities in CVD and clinical practice are also discussed.

Discrimination, other psychosocial stressors, and self-reported sleep duration and difficulties

OBJECTIVES

To advance understanding of the relationship between discrimination and sleep duration and difficulties, with consideration of multiple dimensions of discrimination, and attention to concurrent stressors; and to examine the contribution of discrimination and other stressors to racial/ ethnic differences in these outcomes.

DESIGN

Cross-sectional probability sample.

SETTING

Chicago, IL.

PARTICIPANTS

There were 2,983 black, Hispanic, and white adults.

MEASUREMENTS AND RESULTS

Outcomes included self-reported sleep duration and difficulties. Discrimination, including racial and nonracial everyday and major experiences of discrimination, workplace harassment and incivilities, and other stressors were assessed via questionnaire. In models adjusted for sociodemographic characteristics, greater exposure to racial (β = -0.14)) and nonracial (β = -0.08) everyday discrimination, major experiences of discrimination attributed to race/ethnicity (β = -0.17), and workplace harassment and incivilities (β = -0.14) were associated with shorter sleep (P < 0.05). The association between major experiences of discrimination attributed to race/ethnicity and sleep duration (β = -0.09, P < 0.05) was independent of concurrent stressors (i.e., acute events, childhood adversity, and financial, community, employment, and relationship stressors). Racial (β = 0.04) and non-racial (β = 0.05) everyday discrimination and racial (β = 0.04) and nonracial (β = 0.04) major experiences of discrimination, and workplace harassment and incivilities (β = 0.04) were also associated with more (log) sleep difficulties, and associations between racial and nonracial everyday discrimination and sleep difficulties remained after adjustment for other stressors (P < 0.05). Racial/ethnic differences in sleep duration and difficulties were not significant after adjustment for discrimination (P > 0.05).

CONCLUSIONS

Discrimination was associated with shorter sleep and more sleep difficulties, independent of socioeconomic status and other stressors, and may account for some of the racial/ethnic differences in sleep.

Association of race consciousness with the patient-physician relationship, medication adherence, and blood pressure in urban primary care patients

BACKGROUND

Race consciousness (the frequency with which one thinks about his or her own race) is a measure that may be useful in assessing whether racial discrimination negatively impacts blood pressure (BP). However, the relation between race consciousness and BP has yet to be empirically tested, especially within the context of the patient-physician relationship and medication adherence.

METHODS

Race-stratified generalized estimating equations were used to assess the relationship of race consciousness on BP, measures of the patient-physician relationship, and self-reported medication adherence, controlling for patients being nested within physicians and for patient age and sex.

RESULTS

The mean age of the patients was 61.3 years, 62% were black, and 65% were women. Black patients were more likely to ever think about race than were white patients (49% vs. 21%; P < 0.001). Race-conscious blacks had significantly higher diastolic BP (79.4 vs. 74.5 mm Hg; P = 0.004) and somewhat higher systolic BP (138.8 vs. 134.7 mm Hg; P = 0.13) than blacks who were not race conscious. Race-conscious whites were more likely to perceive respect from their physician (57.1% vs. 25.8%; P = 0.01) but had lower medication adherence (62.4% vs. 82.9%; P = 0.05) than whites who were not race-conscious.

CONCLUSIONS

Among blacks, race consciousness was associated with higher diastolic BP. In contrast, among whites, there was no association between race consciousness and BP, but race consciousness was associated with poor ratings of adherence, despite more favorable ratings of the patient-physician relationship. Future work should explore disparities in race consciousness and its impact on health and health-care disparities.

The associations of multiple dimensions of discrimination and abdominal fat in African American adults: the Jackson Heart Study

BACKGROUND

Discrimination may be adversely associated with abdominal obesity, but few studies have examined associations with abdominal fat.

PURPOSE

The purpose of this study was to examine whether discrimination was independently associated with visceral (VAT) and subcutaneous (SAT) fat and whether these associations differed by sex and age.

METHODS

Participants self-reported experiences of everyday and lifetime discrimination. The main reason for and the coping response to these experiences were also reported. VAT and SAT were quantified by computed tomography.

RESULTS

In fully adjusted models, higher reports of everyday discrimination were associated with greater SAT, but not VAT, volumes in men only: SAT increased by 3.6 (standard error = 1.8) cm(3) for each unit increase in the everyday discrimination score. In women, higher reports of lifetime non-racial discrimination were associated with greater VAT (71.6 ± 32.0, P < 0.05) and SAT (212.6 ± 83.6, P < 0.05), but these relationships were attenuated after controlling for body mass index.

CONCLUSIONS

These cross-sectional findings do not fully support the independent hypothesis of discrimination and abdominal fat. Additional investigations involving longitudinal designs are warranted.

Stress and the social determinants of maternal health among Puerto Rican women: a CBPR approach

This qualitative research project explores how poverty, the built environment, education, working conditions, health care access, food insecurity and perceived discrimination are experienced by Puerto Rican Latinas through the course of their lives. Five focus groups were conducted with the primary objective of documenting community experiences and perspectives regarding: 1) stress, including perceived discrimination based on race/ethnicity (racism); 2) the impact of stress on Puerto Rican women of reproductive age, their families, and/or their community; and 3) stressors that affect maternal health. Focus groups were conducted in English and Spanish in the two cities with the highest rates of premature birth and low infant birthweight in the state of Connecticut. Focus group findings indicate that participants perceived poverty, food insecurity, lack of access to quality education, and unsafe environments as significant life stressors affecting maternal and child health.