Inverse Associations Between Perceived Racism and Coronary Artery Calcification
Introduction
Despite years of increased attention to prevention and decreasing mortality rates, coronary heart disease (CHD) remains the leading cause of death in the United States 1, 2. Furthermore, African Americans are more likely to have earlier onset of, and to die from, CHD compared with their Hispanic and non-Hispanic White counterparts even when controlling for other potential explanatory factors, such as socioeconomic position (SEP) 3, 4, 5, 6, 7. In part, these racial disparities are attributed to differences in CHD risk factors and issues surrounding access and utilization of health services (3). However, embodiment (8) of discrimination and unfair treatment, of which African Americans bear a substantial amount in the United States (9), may act as an additional cause of these disparities. Models of disease causation, including allostatic load and the ecosocial and biopsychosocial models, hypothesize that broader social, economic, and interpersonal insults lead to increased chronic stressors that culminate in somatic malfunction 10, 11, 12, 13. Based on those models, researchers have sought to demonstrate how racial discrimination uniquely contributes to disease, including CHD 9, 14, 15. Although several experimental studies found positive associations between exposure to discrimination and cardiovascular reactivity, among other outcomes 16, 17, observational studies have less consistent positive findings. Some studies showed associations between racial discrimination and some CHD risk markers/risk factors, including depression and smoking 9, 12, 18; others found negative and neutral findings 9, 12, 18. Therefore, additional research is needed to address the incongruent findings.
Attention to antecedent risk factors of CHD may further elucidate the biological responses that could occur owing to exposure to racism. An indicator of subclinical CHD is coronary artery calcification (CAC). Atherosclerotic progression is a long-term process in which coronary calcification appears in more advanced lesions (fibroatheroma), occurring as a consequence of lesion instability and rupture, with subsequent calcification as part of the healing process (19). It can be easily quantified and expressed as a coronary artery calcium score (20). The presence of calcification increases cardiovascular events and mortality by 3- to 4-fold (21) and can therefore serve as a marker of atherosclerotic disease progression (22). Mechanistically, CAC progression seems to be consistently associated with the classic CHD risk factors blood pressure, obesity, and lipids; inconsistent relations have been found for CAC progression with smoking and diabetes (19). Given that racial discrimination has been associated with some CHD risk factors/markers, such as cardiovascular reactivity, smoking, and depression, as well as increased hypertension in some studies 15, 16, 17, 18, 23, it may be that racial discrimination triggers biologic (e.g., hypertension, obesity) and behavioral (e.g., smoking) mechanisms that could lead to CAC development. Few studies have explicitly evaluated associations of racial discrimination with CAC, and those that have did not demonstrate significant findings 24, 25. Consequently, the objective of this study was to evaluate associations of racial discrimination with CAC in a well-characterized population of Black men and women in the United States. Understanding this relationship may help to explain additional biological and social mechanisms of the CHD disparities between Black and White Americans.
Section snippets
Sample
The study sample was from the Coronary Artery Risk Development in Young Adults (CARDIA) Study; the described in detail elsewhere (26). Data were obtained from the National Heart, Lung and Blood Institute. At baseline (1985–1986) study participants included 2,637 Black and 2,478 White young adults, all of whom were 18 to 30 years old, and were recruited in 4 U.S. cities. Data used for this study are from the 15-year follow-up assessment. Among the 3,672 participants who were assessed in the year
Results
Characteristics of the sample stratified by quartiles of perceived racial discrimination scores are shown in Table 1. Perceived racial discrimination was positively associated with educational attainment, income, father’s occupation, anger expression score, reactive responding score, and depressive symptomatology. There were no marked associations between perceived racial discrimination and age, gender, blood pressure, hypertensive medication use, diabetes, BMI, total cholesterol, HDL
Discussion
This study hypothesized that CAC presence would increase with higher levels of perceived discrimination. However, our analyses found an inverse relationship between racial discrimination and CAC (OR, 0.94; 95% CI, 0.90–0.98) after adjusting for age and gender. Furthermore, adjusting for psychosocial variables, SEP, and CHD risk factors (e.g., blood pressure, cholesterol, and BMI) had little impact on the findings, suggesting that these variables may not be important explanatory pathways.
Future Directions
Although this study has added to the literature on associations of racial discrimination with risk for CHD, future work should implement more comprehensive measures of racial discrimination that incorporate not just explicit perceived racial discrimination, but also implicit, institutional, and internalized racism 15, 54. Capturing these forms of racism requires multiple quantitative and qualitative methods of assessing racism in longitudinal studies. This analysis contributes new findings to
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2021, SSM - Population HealthCitation Excerpt :Although discrimination has been repeatedly linked to mental health outcomes, perceived discrimination as a risk factor for disease and poor health, has produced inconsistent results. Perceived discrimination (both overall and race-specific) has been associated with blood pressure (Krieger & Sidney, 1996), self-rated health (Colen et al., 2018), hypertensive status (Cozier et al., 2006; Dolezsar et al., 2014), risk of CVD (D. H. Chae et al., 2010), elevated diastolic blood pressure (Lewis et al., 2009), coronary artery calcification (Everage et al., 2012; Lewis et al., 2006), and poor physical and mental health (Borrell et al., 2006). The findings are mixed, however, because most of the relationships have qualifiers such as beliefs about Black people, chronological age, type of discrimination (lifetime versus chronic), nativity and childhood residence, and coping.
Differential associations between everyday versus institution-specific racial discrimination, self-reported health, and allostatic load among black women: implications for clinical assessment and epidemiologic studies
2019, Annals of EpidemiologyCitation Excerpt :However, our finding provides support for the notion that reporting chronic racial discrimination may promote a blunted stress-response for black women. The paradoxical relationship between reporting high levels of racial discrimination and a reduced stress-response has been previously reported [25,28,40,46]. Krieger and Sidney showed that working-class blacks reporting the highest frequency of EOD had lower risk of elevated systolic blood pressure, and the effect was stronger for women [40].
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2016, PsychoneuroendocrinologyCitation Excerpt :However, findings on racial discrimination and physical health outcomes have been equivocal. For example, one study reported an inverse association between reports of racial discrimination and coronary artery calcification (Everage et al., 2012); another found an inverse association with hypertension among African American men, albeit non- significant (Roberts et al., 2008). An earlier study reported a U-shaped association, with working-class African Americans reporting no racial discrimination having the highest blood pressure (Krieger and Sidney, 1996).
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