Paul Underwood, MD

The ongoing coronavirus pandemic and recent social unrest has shed new light on health disparities, social determinants of health and racism. The recent article by Forde and colleagues provides insight into the link between everyday or lifetime discrimination and hypertension, a major driver of CV morbidity in African Americans.

This study examined the influence of social interactions such as perceived discrimination on the development of high BP over a decade in an adult cohort from the Jackson Heart Study. The authors were able to demonstrate that higher lifetime discrimination scores were associated with higher hypertension risk independent of age, gender, socioeconomic status and traditional hypertension risk factors.

As noted in the article, the classic risk factors for hypertension such as sedentary lifestyle, obesity, high salt intake and alcohol consumption are well known in the clinic; however, the authors identified discrimination as another epigenetic factor that significantly impacts the development of hypertension.

This investigation broadens our knowledge base regarding CVD by identifying a new potential therapeutic target for hypertension prevention. Stressful situations have long been associated with high BP; however, this study revealed that the lifetime accumulation of stress, specifically racial discrimination, may have a more deleterious effect on the CV system than the stresses encountered during everyday ‘microaggressions.’ The ability to objectively correlate the severity and occurrence of perceived discrimination with the risk for developing hypertension shows clinicians and patients alike the importance of managing discrimination-related stress to improve BP control rates.  

Subtle and overt discrimination is ubiquitous in our society. In the health care setting, it can be manifest while being referred to a specialist, when visiting a pharmacy or being discharged from the emergency department. Outside of the health care system, there are a myriad of situations that may lead one to experience discrimination. Understanding the role of discrimination and, more importantly, the individual’s response to perceived discrimination can identify maladaptive coping mechanisms that can be eliminated and replaced with adaptive coping strategies.   

Although this investigation focused on African Americans who reported predominantly racial discrimination, age, gender and body-size discrimination were included as potential confounders as well.

By realizing and understanding the impact repeated acts of discrimination may play in their hypertensive patients, clinicians can improve the health literacy of their patients. Clinicians are uniquely positioned to improve their patients’ health literacy and ability to successfully navigate the health care system. Not infrequently, obstacles to navigating the health care system are perceived as discrimination. A clinician’s ability to help patients avoid or manage discriminatory situations can have a significant impact on achieving long- and short-term health goals. Likewise, patients and the community must recognize the role a coping strategy may have on overall health. Adopting facilitative communication and stress management skills could play a significant role to prevent poor health consequences arising from repeated encounters with discrimination.

In today’s society, discrimination has many forms: racism, ageism, genderism, sizeism, classism, to name a few. Having greater knowledge to cope with discrimination without accelerating hypertension is a skill that can be taught to high-risk groups in similar fashion to meditation, yoga and other stress management techniques. Forde and colleagues shed light on the impact chronic discrimination has on the development of hypertension, a major CV risk factor. Although clinicians may not be able to control discrimination outside their practices, understanding the significance of discrimination and assisting patients to successfully manage the impact of discrimination will lead to improved health outcomes.

Overall, this work enhances our understanding of the epigenetic impact discrimination plays and opens the door toward novel strategies for hypertension prevention. Further work is needed in this field to determine if these findings are generalizable to the other forms of discrimination that are frequently encountered.