hypertension: net worth as risk factor in African-American women

 

 

 

 

A recent study found a significant relationship between negative net worth (ie, debt) and higher blood pressure in African-American women, controlling for some of the other measures of social economic status including educational level and family income (see htn networth assoc BP in AfAm women jama2022 in dropbox or doi:10.1001/jamanetworkopen.2022.0331)

 

Details:

--384 African-American women were enrolled in the Mechanisms Underlying the Impact of Stress and Emotions on African American Women's Health cohort who participated in the study, from 2016 to 2019

--all were aged 30 to 45 at screening, were premenopausal, and were not pregnant/lactating 

--exclusion criteria included a history of clinical cardiovascular disease, illnesses that might influence CVD risk (eg, autoimmune disease, HIV, kidney disease), psychiatric disorder treatment, illicit drug use, or shift-working (owing to alterations in circadian rhythm)

--50% of the participants by design were above and 50% below the median income of $50,000 in Georgia at the time of their recruitment

--mean age 38, educational level overall less than college 29%/some college 22%/finished at least college 49%), income overall 25% had <$35,000, 21% $35,000-$50,000, 22% $50,000-$75,000, 32% >$75,000 in this highest income group; current smoker 10%  versus; 39% were married or had a live-in partner

    -- positive net worth was reported in 48% and negative net worth in 29% (23% had neutral net worth)

    -- comparing those with positive versus negative net worth: income >$75,000 in 47% versus 16%, college graduates in 59% versus 42%, being married/living with a partner 46% versus 28%,  lower BMI 8% versus 9%, less likely to smoke 6% versus 16%, less likely to report debt stress 4% versus 6%, less likely to have depressive symptoms 4% versus 8%

 

--48-hour ambulatory blood pressure monitoring (ABPM) was performed, as well as initial in-person visits in which height, weight, two seated measures of resting blood pressure, and additional clinical information was assessed

-- net worth was assessed by asking: "suppose you and others in your household were to sell all of your major possessions (including your home), turn all of your investments and other assets into cash, and pay off all of your debts. Would you have something left over, break even, or be in debt?", a question asked in prior research studies

 

--Main outcome: mean daytime and nighttime blood pressure levels, assessed by 48-hour ambulatory blood pressure monitoring (ABPM), and sustained hypertension (ABP daytime and clinic BP>130/80 mmHg)

--linear regression models were adjusted for age, marital status, educational level, family income, and family size

 

Results:

--Ambulatory blood pressure readings, comparing positive versus negative net worth groups:

    -- daytime systolic blood pressure: 119 mmHg (SD 12 mmHg) versus 124 mmHg (SD 12mmHg), p<0.001

    -- nighttime systolic blood pressure: 109 mmHg (SD 11 mmHg) versus115 mmHg (SD 12 mmHg), p<0.001

    -- daytime diastolic blood pressure: 76 mmHg (8 mmHg) versus 79 mmHg (SD 8mmHg),p=0.01

    -- nighttime diastolic blood pressure 67 mmHg (SD eight mmHg), versus 71 mmHg (SD nine mmHg), p=0.002

-- sustained hypertension: 25% in those with positive net worth versus 40% in those with negative net worth, p=0.02

--Antihypertensive use was not significantly different between debt groups, 17%

-- debt stress: 3.6 (standard deviation, SD 3) versus 5.6 (SD 3), p<0.001

-- depressive symptoms: 4.4 (SD 5) versus 7.6 (SD 8), p<0.001

-- comparing women reporting a negative net worth to those with a positive net worth, controlling for age, marital status, educational level, family income, and family size:

    --higher levels of daytime and nighttime systolic blood pressure, both with p<0.001

    --sustained hypertension: OR 2.5 (1.3-4.7)

-- these associations remained significant after adjusting for smoking, BMI, psychosocial stress due to debt, and depressive symptoms

-- results were attenuated slightly when the 66 women who were on anti-hypertensive medications were included in the analysis (the above numbers excluded them)

 

Commentary:

-- net worth may well be a very important marker of SES, since it does reflect long-term financial stability and economic reserve. and this study suggested it might well be a much more sensitive marker than some of the other surrogate markers of SES, such as education or family income in this study. a couple of other studies have found that housing instability (see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3665966/, though in this study was only found in white women), negative social interactions (see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4182094/), or other social factors (see https://www.researchgate.net/profile/William-Dressler/publication/281870723_Dressler_William_W_1996_Hypertension_in_the_African_American_community_social_psychological_and_cultural_determinants_Seminars_in_Nephrology_16_71-82/links/55fc885608aeafc8ac495615/Dressler-William-W-1996-Hypertension-in-the-African-American-community-social-psychological-and-cultural-determinants-Seminars-in-Nephrology-16-71-82.pdf ). there was a study i saw many decades ago (sorry, cannot find it) finding that a social insecurity index, a combination of largely neighborhood stressors (do you feel safe in your neighborhood? and several questions about people's feelings about their living situation, crime, and generally whether they felt their neighborhood was "desirable") largely negated any racial differences in hypertension. newer studies reinforced this conclusion: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-3741-2

 

    -- It was notable in the study that net worth categories stratified all of the income levels as well as educational levels of these women, and that net worth itself was significantly associated with hypertension when controlling for these other socioeconomic factors

-- ambulatory blood pressure is the most sensitive marker of future clinical events and is considered the gold standard; it is the current recommendation of the USPSTF and several European health agencies (eg NICE in UK). for many studies documenting the superiority of ABP, see http://gmodestmedblogs.blogspot.com/search?q=ambulatory+blood )

 

--Though we do not have multiple measures of blood pressure over time, it was clear from the study that in terms of important socioeconomic variables to assess for middle-aged African-American women, net worth was clearly superior to income or educational status.

-- Net worth is influenced by a number of factors, all of which are much more deficient in African-American women:

    -- racism (and the constant daily stress associated), lower likelihood of dual earner partnerships, less likely to achieve higher wage jobs independent of educational status (and wage differentials between men/women, white/nonwhite), redlining of properties, decreased access to many colleges and universities, and generally decreased ability to achieve upward mobility and wealth

    -- also, a big issue is inherited wealth, so important for many people in our society, is very limited in the African-American community

    -- in 2016 dollars: white vs Black income median $61K vs $35K; networth $171K vs 18K, per https://www.visualcapitalist.com/racial-wealth-gap/

 

Limitations:

-- much of the information was self-report, including net worth, educational level, and income. The accuracy of these assessments may be limited without objective data

-- we do not know what the blood pressure level or control was at start of the study,. Nor the access to health care, ability to afford medications

--this study provided an association between net worth and elevated blood pressure, and therefore cannot determine a causal relationship. 

-- negative debt is a very low bar for this association. there are many people who do have some assets or are living in a situation that allows them to survive with a small surplus who would not be classified as having negative debt

-- hypertension is an intermediate marker for clinical events, be they cardiovascular disease, renal disease, strokes, atrial fibrillation, etc. But, though the association is strong, this study did not assess actual clinical endpoints (which is what really matters)

 

so, the real relevance of this study to me is:

--some of our quick and dirty assessments of socioeconomic status (e.g. income, education level) may be quite inadequate measures of the potentially adverse health and comes associated with lower SES

-- this study further lays bare that social/economic inequities are associated with significant health consequences in our society: it is pretty shocking in the richest country in the world that lower income people live in debt and, associated with that, poor health outcomes. especially at a time when income inequalities are accelerating so rapidly. and, there are so many factors as noted above (racism, higher cost of living in inner city/rural communities, housing/food insecurity, wage differentials, generational inequalities, stress,...

.

so, there are a few take-aways from this study

    -- it reinforces the well-accepted understanding that social inequities are associated with poor health outcomes

    -- in terms of assessing social inequities, this study argues strongly that some of the easy-to-measure markers (income, education) may be inadequate, and that networth may be much more strongly associated with clinical outcomes.

    -- and, this opens the arena further: is hypertension/cardiovascular disease/peptic ulcer disease/uncontrolled diabetes related to other aspects of social inequities such stress, or feeling safe in one's community, or food/housing insecurity, or racism, or single parenthood, or personal violence, or...  (not that these issues are only in poorer communities, but may be more frequently occurring there)

geoff

 

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