Negative net worth more than doubles hypertension risk for Black women
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Black women who reported having a negative net worth were 2.5 times more likely to have sustained hypertension compared with Black women reporting positive net worth, independent of education level and income, researchers reported.
This finding suggests that limited assets or a lack of economic reserve may be associated with poor CVD outcomes in this at-risk group.
“We focused on African American women because studies report that, compared with white men, white women and African American men, African American women are the most affected by the wage gap, the most likely to be single parents/heads of households, and among college-educated adults, the most burdened by student loan debt,” Tené T. Lewis, PhD, of the department of epidemiology at Emory University Rollins School of Public Health, and colleagues wrote in the study background. “Consequently, African American women may be uniquely vulnerable to the association between limited assets and CVD risk.”
In a cross-sectional study, Lewis and colleagues analyzed data from 384 Black women aged 30 to 46 years without clinical CVD, recruited from December 2016 to March 2019 for the Mechanisms Underlying the Impact of Stress and Emotions on African American Women’s Health cohort (mean age, 38 years). Researchers used ambulatory BP monitors to obtain ambulatory BP readings during 2 consecutive days.
In addition to education and income level, net worth was assessed with a single item: “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?” Participants were stratified into positive net worth (assets exceed debt), neutral net worth (an equal debt to assets ratio) and negative net worth (debts exceed assets). Researchers assessed mean daytime and nighttime BP levels and sustained hypertension.
The findings were reported in JAMA Network Open.
Debt and elevated BP
Within the cohort, 47.7% of women reported having a positive net worth, 23.2% reported having a neutral net worth and 29.2% of women reported having a negative net worth. Women reporting positive vs. negative net worth had higher incomes, were more likely to be college graduates, were more likely to be married or living with a partner and were less likely to report debt stress.
After excluding 66 women who were not receiving antihypertensive medications, women reporting a negative net worth (debt) had higher levels of daytime (beta = 6.7; standard error = 1.5; P < .001) and nighttime (beta = 6.4; standard error = 1.4; P < .001) systolic BP compared with women reporting a positive net worth.
“We observed an association between net worth and 48-hour ambulatory BP, with African American women who reported that they would be in debt having daytime systolic BP levels that were approximately 6.7 mm Hg higher than women who would have something left over, even after adjusting for sociodemographic and behavioral covariates, remaining significant after further adjustments for BMI and smoking,” the researchers wrote.
Similar associations were observed with sustained hypertension. Women reporting a negative net worth had 150% higher odds (OR = 2.5; 95% CI, 1.3-4.7) of sustained hypertension than those reporting a positive net worth. Associations remained significant after additional adjustments for smoking, BMI, psychosocial stress due to debt and depressive symptoms. The results were similar but attenuated when women receiving antihypertensive medications were included and treatment was controlled for in all analyses.
Impact of COVID-19
“Although further studies are needed to identify potential mechanisms that might explain the observed results, these findings have particular salience in the context of the COVID-19 pandemic, because job loss in 2020 disproportionately affected women, specifically those from racial and ethnic minority backgrounds,” the researchers wrote. “Furthermore, relative to all other race-gender groups, African American women experienced the slowest recovery in employment through November 2021. However, additional research is needed to document the longitudinal outcomes of the COVID-19 pandemic and resulting economic recession on net worth and CVD risk and outcomes in African American women, as well as other race-gender groups.”
The researchers noted that policies that reduce the enduring racial wealth gap could be potential structural-level interventions that might ultimately reduce CVD risk in Black women.
Perspective
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Joseph E. Ebinger, MD, MS
Hypertension represents a huge CV risk factor and is also the most common modifiable CV risk factor. Unfortunately, it is disproportionately experienced by people from racial and ethnic minority populations, particularly the African American population in the U.S.
Socioeconomic status is not a very effective measure for “non-white” populations. Researchers have tried to identify a variable that may help us understand why that is a bit more, such as net worth. What the authors did here is demonstrate that it is not just how much money you make. It is about where you sit in the larger economy.
What is it that net worth is a surrogate for? It is not necessarily the dollars and cents in someone’s bank account that causes their BP to go higher or lower. We need to ask about other factors. Is it their ability to afford medications? Is it their ability to afford healthy foods? Is their living environment driving up stress? This study is a recognition that the medications that we give patients may improve BP control but there are variables outside of the office that must be considered.
We need to have better conversations with our patients, asking what we can do to help them achieve the best BP possible, recognizing all the other things going on in their lives. This is where physicians must move away from saying, “Here is a pill, take this and you will get better,” to, “Here is a pill and let us talk about how we can work on all the other components that will improve your BP.”
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