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Racial residential segregation associated with systolic BP changes
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A reduction in exposure to racial residential segregation was linked to lower systolic BP, according to a study in JAMA Internal Medicine.
“Our study suggests that the stress and the inadequate access to health-promoting resources associated with segregation may play a role in these increases in [BP],” David C. Goff Jr., MD, director of the division of cardiovascular diseases of the NHLBI, said in a press release. “While stress raises [BP], access to health-promoting resources, such as full-service grocery stores, recreation centers and health care clinics, is critical to keeping [BP] at healthier levels.”
Neighborhood score
In the CARDIA study, researchers analyzed data from 2,280 black adults (43% men) aged 18 to 30 years who underwent baseline examinations between March 25, 1985 and June 7, 1986. Participants were followed up for a median of 25 years.
Once the neighborhood level of racial segregation score was calculated, researchers stratified participants into high, medium and low segregation categories. The score could change if a neighborhood’s level of segregation changed throughout the study or if a participant moved to a neighborhood with a different level of segregation.
The main outcome of the study was defined as within-person fluctuations in systolic and diastolic BP during six examinations throughout follow-up.
Most participants (94%) moved to a different neighborhood at least once during follow-up, and 51.7% of participants moved three or more times.
Systolic BP differences
A segregation score increase of 1 standard deviation was linked to a mean systolic BP increase of 0.16 mm Hg (95% CI, 0.06-0.26) once it was adjusted for time, baseline sex, age and field center. Changes in segregation score and category were not associated with variations in diastolic BP. When findings were adjusted for income, statistical significance and magnitude of data were similar.
Researchers found participants who lived in highly segregated neighborhoods at baseline experienced reductions in systolic BP once their exposure to segregation was reduced. When comparing data of participants in high-segregation with medium-segregation neighborhoods, the mean difference in systolic BP was –1.33 mm Hg (95% CI, –2.26 to –0.4) once adjusted. The mean difference in systolic BP when those in high-segregation neighborhoods were compared with those in low-segregation neighborhoods was –1.19 mm Hg (95% CI, –2.08 to –0.31) after adjustment.
“Reductions in systolic [BP] of this magnitude could have important implications for reducing [CV] events, particularly in black individuals,” Kiarri N. Kershaw, PhD, MPH, assistant professor of preventive medicine (epidemiology) at Northwestern University Feinberg School of Medicine, and colleagues wrote. “Systolic [BP] is more closely associated with incident [CV] events than diastolic [BP] among middle-aged and older adults, and recent work in CARDIA showed that systolic [BP] was associated with incident [CV] events in younger black adults as well. ... Given the higher burden of elevated [BP] and [CVD] seen among black persons, even a –1 mm Hg reduction in [BP], such as that seen in this study, has the potential to meaningfully combat persistent health disparities.” – by Darlene Dobkowski
Disclosure: This study was funded by the NHLBI and the National Institute on Aging. The researchers report no relevant financial disclosures.
Perspective
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Paul L. Douglass, MD, MACC, FSCAI
Kershaw et al offer a compelling argument as to a possible etiology of adverse CV outcomes in African Americans living in highly segregated neighborhoods. Their observational study suggests that the degree of racial segregation may contribute to a significant rise in systolic BP at the population level resulting in adverse CV outcomes and a disproportional burden of disease in African Americans. This study adds to the small but influential body of data suggesting that hypertension and its high prevalence in African Americans may undergird much of the health inequities documented in this population.
The study supports the notion that the degree of racial segregation likely contributes to the social determents that undermine health: poverty, income inequality, insufficient educational resources, poor access to quality health care, unsafe neighborhoods, lack of recreational areas, food deserts and unsafe environmental exposures. And this may be manifested by increases in systolic BP with its subsequent negative impact on CV health.
Studies like this should further inform health policy, urban design and legislation that is intended to shape and improve the overall health statistics in the United States. The focus on changing from a volume-based to a value-based health care delivery system is probably accurate in addressing the sustainability of the health cost curve. However, only by recognizing and resolving the health inequities of the most vulnerable in our country can we truly be a healthier and more productive nation.
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