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Racial differences in incident hypertension driven by diet, education level
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Racial differences in men and women regarding incident hypertension were related to the dietary ratio of sodium to potassium, Southern dietary pattern and education level, according to a study published in JAMA.
Other key factors in women but not men included BMI and waist circumference, according to the study.
REGARDS study data
George Howard, DrPH, professor in the department of biostatistics at University of Alabama at Birmingham School of Public Health, and colleagues analyzed data from 6,897 black or white participants (mean age, 62 years; 26% black; 55% women) from the REGARDS study aged at least 45 years with normal BP at baseline and available hypertension status at follow-up.
A telephone interview and an in-person examination were conducted at baseline to assess patients’ CVD risk profile, which included venipuncture, BP measurements, electrocardiography and measures of adiposity. Patients underwent a similar assessment during follow-up.
Researchers selected potential mediating factors that may have contributed to the racial difference in the level of the risk factor, prevalence or evidence of hypertension. These factors included education level lower than high school, BMI, income less than $35,000, heavy alcohol use, waist circumference, high depression scale score, lack of exercise, low Dietary Approaches to Stop Hypertension (DASH) diet score, high perceived stress scale score, high Southern diet score, low Mediterranean diet score and high ratio of sodium to potassium.
During follow-up for a median of 9.4 years; 46% of black participants (95% CI, 44-49) and 33% of white participants (95% CI, 32-34) developed hypertension.
The adjusted mean Southern diet score was 0.81 in black men (95% CI, 0.72-0.9), –0.26 in white men (95% CI, –0.31 to –0.21), 0.27 in black women (95% CI, 0.2-0.33) and –0.57 in white women (95% CI, –0.61 to –0.54).
The Southern diet was significantly associated with the risk for incident hypertension in men (OR = 1.16 per 1 standard deviation [SD]; 95% CI, 1.06-1.27) with an incidence of 32.4% at the 25th percentile and 36.1% at the 75th percentile (difference = 3.7%; 95% CI, 1.4-6.2). This was also seen in women (OR = 1.17 per 1 SD; 95% CI, 1.08-1.28) with an incidence of 31% at the 25th percentile and 34.8% at the 75th percentile (difference = 3.8%; 95% CI, 1.5-5.8).
Mediating factors
The largest mediating factor for the differences in hypertension incidence was the Southern diet for both black men (51.6%; 95% CI, 18.8-84.4) and black women (29.2%; 95% CI, 13.4-44.9).
The excess risk for incident hypertension in black men without a high school degree was 12.3% (95% CI, 0.6-23.9), whereas those with a higher dietary ratio of sodium to potassium intake accounted for 12.3% of excess risk (95% CI, 1.1-22.8).
The mediating factors for hypertension in black women were BMI (18.3%; 95% CI, 11.9-24.6), larger waist circumference (15.2%; 95% CI, 9.8-20.6), income less than $35,000 (9.3%), less adherence to the DASH diet (11.2%), education level of high school or less (4.1%) and higher dietary ratio of sodium to potassium (6.8%).
“The findings herein identified more mediating factors of the racial difference in incident hypertension in women than men,” Howard and colleagues wrote. “This may be partially attributable to an observed stronger association of race with incident hypertension among women than men that would provide greater statistical power to detect mediating factors.” – by Darlene Dobkowski
Disclosures: Howard reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Clyde W. Yancy, MD, MSc, MACC, FAHA, MACP, FHFSA
As we address evident CVD disparities as a function of race and attempt to deconstruct those biological factors responsible for racial/ethnic differences in CV diseases from the influence of social determinants of health, the current data by Howard and colleagues from the REGARDS cohort study are quite important. The top-line message generated by the authors focuses on the strength of the association of a Southern Diet score (using a standardized scale that captures sodium intake and saturated fat intake) and the excess risk for hypertension, but there is a larger and more compelling message.
Not only diet, but also income, education, lesser adherence to the DASH diet and measures of obesity all contribute to the excess risk described. Thus, these data help quantify the consequences of the aggregate of adverse social determinants of health on the progression of CVD.
The clinically actionable point here is the need for a comprehensive approach for not only the patient at risk, but the communities at risk. Thus, social services, the adequacy of education, the available of healthy food choices vs. residing in food deserts and reasonable economic opportunities all contribute to the natural history of CVD.
If we are to change the disease trajectory for these populations and lengthen the lifespan, our focus should be global and holistic with multiple stakeholders involved. Importantly, community solutions should be actively considered in concert with our ongoing appropriate lifestyle coaching and use of evidence-based medical therapies.
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