Relationship between discrimination, smoking, CVD indicators varies by race/ethnicity, sex
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Key takeaways:
- The relationship between discrimination, smoking and features of CVD differed by race/ethnicity and sex.
- Moderated mediation models can boost understanding of how a phenomenon relates to different subgroups.
The nature of the relationship between discrimination, smoking and features of CVD is complex and varies by race and sex, according to a moderated mediation analysis published in the Journal of the American Heart Association.
“Racial and ethnic minorities, particularly Black Americans, are more likely to experience mortality related to heart disease and hypertension disproportionately compared with white Americans. What is less clear is the mechanism underpinning these disparities such as behavioral coping mechanisms like smoking,” Stephanie H. Cook, DrPH, MPH, assistant professor of biostatistics and social and behavioral sciences at the NYU School of Global Public Health, told Healio. “The mechanisms have largely been overlooked when we have specifically looked at subgroups within these categories, ie, differences in biological sex between Black and white Americans. We just aren’t very clear on what these important mechanisms are, and thus it’s harder to create prevention interventions specifically aimed at these coping mechanisms if we don’t know what the mechanisms are.”
Cook and colleagues constructed four sex-stratified moderated mediation models using data from 6,814 participants from the Multi-Ethnic Study of Atherosclerosis (MESA) cohort aged 45 to 84 years who completed assessments on health behavior and perceived discrimination and were free from clinical CVD at baseline. The models assessed the relationship between discrimination, smoking and carotid intima-media thickness and carotid plaque, both of which can predict CVD risk.
Understanding complexity
“These models are useful when you are trying to understand complexity,” Cook told Healio. “Basically, we use these models so that we could examine not only different mechanisms, so for example, how cigarette smoking mediated the relationship between discrimination and plaque, but also in the same statistical model, we can look at this relationship as it relates to different subgroups: Black women, Black men, Chinese men, etc. You have a limited set of statistical tools in which you can do all of this in one modeling technique. So that’s why it’s helpful to use such a process.”
In Hispanic women, discrimination was associated with cigarette use and, in turn, higher carotid plaque (beta = 0.04; 95% CI, 0.01-0.08), according to the researchers.
In Hispanic men and white men, discrimination was associated with cigarette use and, in turn, higher carotid intima-media thickness (beta for Hispanic men = 0.003; 95% CI, 0.0001-0.007; beta for white men = 0.04; 95% CI, 0.01-0.08), Cook and colleagues found.
The researchers also observed a positive indirect effect of discrimination on carotid plaque in Hispanic men (beta = 0.03; 95% CI, 0.004-0.07).
There were no other differences observed by race/ethnicity or sex.
‘This must be where the field goes’
“I would like people to know how the unique lived experiences of people with different races, ethnicities and biological sexes influence the ways we internalize and cope with stress,” Cook told Healio. “Interventions to promote cardiovascular health across diverse populations cannot take a one-size-fits-all approach. We have to look at the ways in which cultural characteristics attenuate the relationship between kinds of discrimination and among who on plaque buildup and intima-media thickness, which are indicators of cardiovascular health. It’s vitally important to do so, and this must be where the field goes if we are to tackle cardiovascular health nationally and within subgroups where we see disproportionate rates of cardiovascular disease, hypertension and diabetes.”
Cook said that health care practitioners “need to think more critically about cultural experiences and individual lived experiences of people at the important intersections. For example, at the intersection of biological sex and race/ethnicity. Our findings highlighted the importance of the experiences of Hispanic women, and why different coping behaviors and results in cardiovascular health may be differently approached for this group of women vs. other groups of women. Practitioners should think more critically about how they approach cardiovascular health given the results of our study and similar studies highlighting the importance of examining the different experiences for people at these intersections.”
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