Elsevier

Annals of Epidemiology

Volume 20, Issue 8, August 2010, Pages 617-628
Annals of Epidemiology

Socioeconomic and Ethnic Disparities in Cardiovascular Risk In the United States, 2001–2006

https://doi.org/10.1016/j.annepidem.2010.05.003Get rights and content

Purpose

To quantify socioeconomic status and ethnic differences in risk for coronary heart disease (CHD) accrued from major risk factors in the United States.

Methods

Data came from the National Health and Nutrition Examination Survey 2001–2006. Outcomes examined were (a) 10-year risk for CHD events as predicted by the National Cholesterol Education Program Adult Treatment Panel III 2004 Updated Guidelines; and (b) the prevalence of the metabolic syndrome and overt diabetes mellitus (a CHD risk-equivalent).

Results

Strong inverse socioeconomic gradients with risk were present in all race/ethnicity groups except foreign-born Mexican American men, and were attenuated by controls for physical activity, smoking, and abdominal obesity. In contrast, race/ethnicity disparities were seen in some but not all socioeconomic strata, with some non-Hispanic Blacks and US-born Mexican Americans having higher risk and some foreign-born Mexican Americans having lower risk.

Conclusions

Disparities in cardiovascular risk in the United States are primarily related to socioeconomic status and less to race/ethnicity. Socioeconomically disadvantaged individuals should be targeted for lifestyle counseling and early screening for risk factors, regardless of race/ethnicity, to reduce social disparities in cardiovascular outcomes.

Introduction

The incidence of cardiovascular disease in the United States (US) and other high-income countries is higher in low socioeconomic status (SES) and minority ethnic groups 1, 2, 3, 4, 5, with SES disparities reflecting not just a threshold effect of poverty versus nonpoverty, but rather a risk gradient across the SES range 2, 6. Reduction of these disparities has been a focus of interest for policy makers 7, 8, and requires the early detection and management of risk factors in underprivileged groups. Indeed, low SES and minority ethnic groups do report higher values of risk factors for cardiovascular disease 1, 9, 10.

Some studies, however, suggest that SES gradients in cardiovascular risk factors may be diminished in minority groups 11, 12, 13, 14, possibly because of racial discrimination and residential segregation 15, 16, 17, and greater psychological distress (18) at all SES levels. If SES associations with risk do vary by race/ethnicity, then in any study of ethnic disparities, SES effects cannot be controlled completely simply by including SES indicators as covariates in regression 19, 20. It is therefore, not clear if ethnic differences in cardiovascular risk primarily reflect SES differences, or if there are SES-independent race/ethnicity associations with risk; the two scenarios have different implications for health policy.

Moreover, few studies have examined SES/ethnic differences in global or overall cardiovascular risk accrued from all major risk factors. When SES/ethnic disparities in individual risk factors are of varying size and/or are in opposite directions 5, 21, their combined effect can only be assessed by the use of global risk measures. Current clinical guidelines assess global risk for coronary heart disease (CHD) events using the Framingham risk score, the metabolic syndrome, and history of CHD and CHD risk-equivalent conditions (such as diabetes mellitus that confer equivalent risk) 22, 23, 24. Accordingly, in this work, we studied ethnic and SES disparities in the U.S. population in (a) the 10-year risk for CHD events, as assessed by the National Cholesterol Education Program (NCEP) Adult Treatment Panel III adaptation of the Framingham risk score 22, 25; and (b) the prevalence of diabetes mellitus and metabolic syndrome, as defined by the NCEP (22) and the European Group for the Study of Insulin Resistance (EGIR) (26). In particular, our objectives were to answer the following questions:

  • Q1.

    Are there SES gradients in global CHD risk and metabolic syndrome/diabetes prevalence, and do the SES gradients differ by race/ethnicity (i.e., do minority groups not get the same benefit from climbing the SES ladder as the majority ethnic group)?

  • Q2.

    Are there race/ethnicity differences in global CHD risk and metabolic syndrome/diabetes prevalence after adequately controlling for differences in SES?

  • Q3.

    Are SES and race/ethnicity associations with global CHD risk and metabolic syndrome/diabetes prevalence explained by differences in health behaviors and abdominal obesity (a surrogate for both diet and exercise)?

Section snippets

Methods

Data for this study came from the National Health and Nutrition Examination Survey (NHANES), conducted between 2001 and 2006, of a nationally representative sample of the U.S. population (27).

Results

The analytic samples were older, were more likely to be non-Hispanic White and from higher socioeconomic strata, and had better biological profiles than the rest of the NHANES sample (see Table 1). Median age in the analytic samples was 45 years, 49% were male, 73% were non-Hispanic White, 18% had less than high school education, median PIR was 3.1 and 12% had PIR less than 1, 11%–12% fell in the low SES category, and 45% were classified high SES. There were marked SES differences between

Discussion

Our objective was to determine the independent associations of SES and race/ethnicity with global CHD risk and metabolic syndrome/diabetes prevalence in the U.S. population. SES was strongly, inversely associated with global CHD risk in both men and women from all race/ethnicity groups, except in foreign-born Mexican American men. SES was also strongly, inversely associated with metabolic risk in women from three of the four race/ethnicity groups and in non-Hispanic White men. Stronger SES

References (48)

  • M.G. Marmot

    Socioeconomic factors in cardiovascular disease

    J Hypertens Suppl

    (1996)
  • E. Pamuk et al.

    Socioeconomic Status and Health Chartbook: Health, United States, 1998

    (1998)
  • K.J. Hunt et al.

    All-cause and cardiovascular mortality among Mexican-American and non-Hispanic white older participants in the San Antonio Heart Study—evidence against the “Hispanic paradox”

    Am J Epidemiol

    (2003)
  • G.A. Mensah et al.

    State of disparities in cardiovascular health in the United States

    Circulation

    (2005)
  • N.E. Adler et al.

    Socioeconomic status and health: the challenge of the gradient

    Am Psychol

    (1994)
  • U.S. Department of Health and Human Services

    Healthy People 2010. With Understanding and Improving Health and Objectives for Improving Health

    (November 2000)
  • The World Health Organization. World Health Report

    2003: Shaping the Future

    (2003)
  • S. Sharma et al.

    Racial, ethnic and socioeconomic disparities in the clustering of cardiovascular disease risk factors

    Ethn Dis

    (2004)
  • Racial/ethnic and socioeconomic disparities in multiple risk factors for heart disease and stroke—United States, 2003

    MMWR Morb Mortal Wkly Rep

    (2005)
  • D.R. Jacobs et al.

    Relationships of low density lipoprotein cholesterol with age and other factors: a cross-sectional analysis of the CARDIA study

    Ann Clin Res

    (1988)
  • J.F. Kraus et al.

    Socioeconomic status, ethnicity, and risk of coronary heart disease

    Am J Epidemiol

    (1980)
  • M.A. Winkleby et al.

    Pathways by which SES and ethnicity influence cardiovascular risk factors

    Ann NY Acad Sci

    (1999)
  • R. Clark et al.

    Racism as a stressor for African Americans: a biopsychosocial model

    Am Psychol

    (1999)
  • I.H. Meyer

    Prejudice as stress: conceptual and measurement problems

    Am J Pub Health

    (2003)
  • Cited by (163)

    • The Association Between Socioeconomic Factors and Incident Peripheral Artery Disease in the Chronic Renal Insufficiency Cohort (CRIC)

      2022, Annals of Vascular Surgery
      Citation Excerpt :

      Further, we found no interaction between annual income and other SES factors with regard to PAD incidence. The association between income and CVD has been well documented for other disease entities with similar results to ours.5,17 The etiology of the association between low-income level and CVD is likely multifactorial.

    View all citing articles on Scopus
    View full text