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FIT Insights

Stress Coincides With Worse Cardiovascular Health in Black Americans

Whether you read medical literature or prefer a casual lifestyle magazine, it is widely accepted that psychosocial stress is inversely associated with overall health. In recent years, evidence has emerged that depression and other psychosocial stressors adversely affect cardiovascular health (CVH)1, 2, 3. Couple that with recent epidemiologic studies showing significant disparities in CVH between blacks and whites4, 5; with black Americans disproportionately affected by morbidity and mortality from cardiovascular disease (CVD). So, to summarize, psychosocial stressors lead to poorer CVH -- and black Americans suffer from worse CVH than whites. It seems intuitive for one to ponder, especially in the current sociopolitical state of the country, whether poorer CVH in blacks is potentially secondary to significantly more psychosocial stress than that faced by other demographics.

Brewer et al., in Stress and Achievement of Cardiovascular Health Metrics: The American Heart Association Life’s Simple 7 in Blacks of the Jackson Heart Study, aimed to “examine the associations of multidimensional stressors (chronic stress, minor stressors, and major life events) with the [Life’s Simple 7] components in blacks.”6 The American Heart Association (AHA) has determined 4 health behaviors and 3 health factors, tagged Life’s Simple 7 (LS7), as targets for improving the CVH and decreasing death from CVD in the US, both by 20%, by the year 2020. Table 1 both identifies the factors composing the LS7 and highlights how they are assessed. The investigators performed a secondary analysis of data originally collected and published in the Jackson Heart Study (JHS). The JHS is a population-based, prospective, cohort study designed to examine CVD risk in 5,306 black adults aged 21 to 95 years residing in Jackson, MS from 2000 to 2004. After excluding those without data sufficient to analyze, Brewer et al assessed 4383 black adults for degree of minor, chronic and cumulative stress, and the subsequent odds of achieving intermediate/ideal levels of CVH.6

Of the LS7 factors, black adults performed worst with respect to diet (39% of participants met ideal/intermediate level), body mass index (47%) and physical activity (51%).6 Among other observations, the investigators found that higher stress scores were particularly associated with reduced odds of achieving ideal or intermediate levels of smoking habits; mainly cessation for over one year or never smoked. They reference research studies of depression, CVH and smoking when proposing a theory as to why this profound correlation (Figure 1) exists. The studies referenced identify smoking as an adverse behavioral response to psychosocial stress, similar to how we may think of “stress eating” or “binging”.

One brief observation I made when reading the study is that it is 100% comprised of black individuals living in the Southern US. Shikany et al published data in 2015 supporting the notion that a Southern US dietary pattern was associated with a greater risk of CVD. “After adjustment for sociodemographics, lifestyle factors, and energy intake, highest consumers of the Southern pattern (characterized by added fats, fried food, eggs, organ and processed meats, and sugar-sweetened beverages) experienced a 56% higher hazard of acute coronary heart disease.”7 It’s possible that the results of the Brewer et al study are slightly exaggerated by the fact that the subjects reside in Mississippi, and therefore more likely to eat a typical Southern diet. As mentioned earlier, diet was in fact the LS7 area that the study individual performed worst in, with only 39% being categorized as ideal or intermediate level.7

Nonetheless, the data presented in the paper by Brewer et al is a welcome addition to the growing wealth of literature aimed at investigating the causes for long-standing health disparities between races in America. The study highlights the pervasive effects of stress, through discrimination, institutional racism, classism, job insecurity, unsafe neighborhood and lack of education, on the CVH of blacks living in the US. It is imperative for healthcare administrators, policy makers and providers to identify and target the root causes of these stresses going forward. The downstream cascade of positive impacts from such a shift in ideology will not only result in marked reductions in cardiovascular morbidity and mortality, but an increase in overall quality of life among black Americans.

Author

Adedapo Iluyomade, MD, MBA

Dapo Iluyomade MD, MBA, is a Cardiovascular Disease Fellow at the University of Miami Miller School of Medicine and Jackson Memorial Hospital in Miami, FL. His interests pertain to preventive Cardiology, cardiovascular outcomes research and healthcare administration. He was formerly a chief resident at the Icahn School of Medicine at Mount Sinai in New York, N.Y.

Reference

  1. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, Greenlund K, Daniels S, Nichol G, Tomaselli GF, Arnett DK, Fonarow GC, Ho PM, Lauer MS, Masoudi FA, Robertson RM, Roger V, Schwamm LH, Sorlie P, Yancy CW, Rosamond WD; American Heart Association Strategic Planning Task Force, Statistics Committee. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic impact goal through 2020 and beyond. Circulation. 2010;121:586–613.
  2. Shay CM, Ning H, Allen NB, Carnethon MR, Chiuve SE, Greenlund KJ, Daviglus ML, Lloyd-Jones DM. Status of cardiovascular health in US adults: prevalence estimates from the National Health and Nutrition Examination Surveys (NHANES) 2003–2008. Circulation. 2012;125:45–56.
  3. Bambs C, Kip KE, Dinga A, Mulukutla SR, Aiyer AN, Reis SE. Low prevalence of “ideal cardiovascular health” in a community-based population: the heart strategies concentrating on risk evaluation (Heart SCORE) study. Circulation. 2011;123:850–857.
  4. Carnethon MR, Pu J, Howard G, Albert MA, Anderson CAM, Bertoni AG, Mujahid MS, Palaniappan L, Taylor HA Jr, Willis M, Yancy CW; American Heart Association Council on Epidemiology and Prevention; Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Functional Genomics and Translational Biology; and Stroke Council. Cardiovascular health in African Americans: a scientific statement from the American Heart Association. Circulation. 2017;136:e393–e423.
  5. Djousse L, Petrone AB, Blackshear C, Griswold M, Harman JL, Clark CR, Talegawkar S, Hickson DA, Gaziano JM, Dubbert PM, Correa A, Tucker KL, Taylor HA. Prevalence and changes over time of ideal cardiovascular health metrics among African-Americans: the Jackson Heart Study. Prev Med. 2015;74:111–116.
  6. Brewer LC, Redmond N, Slusser JP, Scott CG, Chamberlain AM, Djousse L, Patten CA, Roger VL, Sims M. Stress and Achievement of Cardiovascular Health Metrics: The American Heart Association Lifes Simple 7 in Blacks of the Jackson Heart Study. Journal of the American Heart Association, 7(11). doi:10.1161/jaha.118.008855
  7. Shikany JM, Safford MM, Newby PK, Durant RW, Brown TM, Judd SE. Southern Dietary Pattern Is Associated With Hazard of Acute Coronary Heart Disease in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study. Circulation, 132(9), 804-814. doi:10.1161/circulationaha.114.014421