Social Determinants of Health May Drive CVD Risk in Black Americans

Batya Swift Yasgur MA, LSW

October 20, 2021

A new analysis has shown disparities in cardiovascular risk factors between black and white adults in the United States, disparities that may be largely attributable to social determinants of health.

Investigators analyzed 20 years of data on over 50,500 US adults drawn from the National Health and Nutrition Examination Surveys (NHANES) and found that, in the overall population, body mass index (BMI) and hemoglobin A1c were significantly increased between 1999 and 2018, while serum total cholesterol and cigarette smoking were significantly decreased. Mean systolic blood pressure (BP) decreased between 1999 and 2010, but then increased after 2010.

The mean age- and sex-adjusted estimated 10-year risk for atherosclerotic cardiovascular disease (ASCVD) was consistently higher in black participants vs white participants, but the difference was attenuated after further adjusting for education, income, home ownership, employment, health insurance, and access to healthcare.

"These findings are helpful to guide the development of national public health policies for targeted interventions aimed at eliminating health disparities," Jiang He, MD, PhD, Joseph S. Copes Chair and professor of epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, told | Medscape Cardiology.

"Interventions on social determinants of cardiovascular health should be tested in rigorous designed intervention trials," said He, who is also the director of the Tulane University Translational Science Institute.

The study was published online October 5 in JAMA.

"Flattened" CVD Mortality?

Recent data show that the CVD mortality rate flattened, while the total number of cardiovascular deaths increased in the US general population from 2010 to 2018, "but the reasons for this deceleration in the decline of CVD mortality are not entirely understood," He said.

Moreover, "racial and ethnic differences in CVD mortality persist in the US general population [but] the secular trends of cardiovascular risk factors among US subpopulations with various racial and ethnic backgrounds and socioeconomic status are [also] not well understood," he added. The effects of social determinants of health, such as education, income, home ownership, employment, health insurance, and access to healthcare on racial/ethnic differences in CVD risk, "are not well documented."

To investigate these questions, the researchers drew on data from NHANES, a series of cross-sectional surveys in nationally representative samples of the US population aged 20 years and older. The surveys are conducted in 2-year cycles and include data from 10 cycles conducted from 1999 - 2000 to 2017 - 2018 (n = 50,571, mean age 49.0 - 51.8 years; 48.2% - 51.3% female).

Every 2 years, participants provided sociodemographic information, including age, race/ethnicity, sex, education, income, employment, housing, health insurance, and access to healthcare, as well as medical history and medication use. They also underwent a physical examination that included weight and height, blood pressure, lipid levels, plasma glucose, and hemoglobin A1c.

Social Determinants of Health

Between 1999 - 2000 and 2017 - 2018, age- and sex-adjusted mean BMI, and hemoglobin A1c increased, while mean serum total cholesterol and prevalence of smoking decreased (all P < .001).

CVD Risk Factors 1999 - 2000, 2017 - 2018

Risk Factors 1999 - 2000 (99% Confidence Interval) 2017 - 2018 (99% Confidence Interval)
Mean BMI 28.0 (27.5 - 28.5) 29.8 (29.2 - 30.4)
Mean hemoglobin A1c 5.4 (5.3 - 5.5) 5.7 (5.6 - 5.7)
Mean serum total cholesterol (mg/dL) 203.3 (200.9 - 205.8) 188.5 (185.2 - 191.9)
Smoking prevalence (%) 24.8 (21.8 - 27.7) 18.1 (15.4 - 20.8)

Mean systolic BP initially decreased, but then ultimately increased.


Mean Systolic Blood Pressure Over Time

Measure 1999 - 2000 2009 - 2010 2017 - 2018
Mean Systolic Blood Pressure (mm Hg) 123.5 (122.2 - 124.8) 120.5 (119.6 - 121.3) 122.8 (121.7 - 123.8)

Age- and sex-adjusted 10-year ASCVD risk decreased from 7.6% (6.9% - 8.2%) in 1999 - 2000 to 6.5% (6.1% - 6.8%) in 2011 - 2012, with no significant changes thereafter.

When the researchers looked at specific racial and ethnic groups, they found that age- and sex-adjusted BMI, systolic BP, and hemoglobin A1c were "consistently higher" in non-Hispanic black participants compared with non-Hispanic white participants, but total cholesterol was lower (all P < .001).

Participants with at least a college education or high family income had "consistently lower levels" of cardiovascular risk factors. And although the mean age- and sex-adjusted 10-year risk for ASCVD was significantly higher in non-Hispanic black vs non-Hispanic white participants (difference, 1.4% [1.0% - 1.7%] in 1999 - 2008 and 2.0% [1.7% - 2.4%] in 2009 - 2018), the difference was attenuated (by –0.3% in 1999 - 2008 and 0.7% in 2009 - 2018) after the researchers further adjusted for education, income, home ownership, employment, health insurance, and access to healthcare.

The differences in cardiovascular risk factors between black and white participants "may have been moderated by social determinants of health," the authors note.

Provide Appropriate Education

Commenting on the study for | Medscape Cardiology, Mary Ann McLaughlin, MD, MPH, associate professor of medicine, cardiology, Icahn School of Medicine at Mount Sinai, New York City, pointed out that two important cardiovascular risk factors associated with being overweight — hypertension and diabetes — remained higher in the black population compared with the white population in this analysis.

"Physicians and healthcare systems should provide appropriate education and resources regarding risk factor modification regarding diet, exercise, and blood pressure control," advised McLaughlin, who was not involved with the study.

"Importantly, smoking rates and cholesterol levels are lower in the Black population, compared to the White population, when adjusted for many important socioeconomic factors," she pointed out.

McLaughlin added that other "important social determinants of health, such as neighborhood and access to healthy food, were not measured and should be addressed by physicians when optimizing cardiovascular risk."

The research reported in this publication was supported by the National Heart, Lung, and Blood Institute and by the National Institute of General Medical Sciences. Investigator Bundy was supported by a grant from the National Institutes of Health/Eunice Kennedy Shriver National Institute of Child Health and Human Development. He and coauthors and McLaughlin report no relevant financial relationships.

JAMA. Published online October 5, 2021. Abstract

For more news, follow Medscape on Facebook, Twitter, Instagram, YouTube, and LinkedIn.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.