Abstract
Low socioeconomic status (SES) in the form of educational level and income has been linked to greater cardiovascular risk across cohorts; however, associations have been inconsistent for African American individuals. Net worth, a measure of overall assets, may be a more relevant metric, especially for African American women, because it captures longer-term financial stability and economic reserve. To examine whether net worth is associated with increased ambulatory blood pressure (ABP), a marker of cardiovascular disease (CVD) risk, independent of educational level and income, in young to middle-aged African American women. A cross-sectional, community-based study conducted in the southeastern US was performed using 48-hour ambulatory BP monitoring. Participants included 384 African American women aged 30 to 46 years without clinical CVD recruited between December 16, 2016, and March 21, 2019; data analysis was performed from September 2020 to December 2021. Self-reported net worth (total financial assets minus debts), self-reported educational level, and self-reported income. Mean daytime and nighttime BP levels, assessed via 48-hour ABP monitoring and sustained hypertension (ABP daytime and clinic BP ≥130/80 mm Hg). The 384 African American women in this study represented a range of SES backgrounds; mean (SD) age was 38.0 (4.3) years. Excluding 66 women who were not receiving antihypertensive medications, in linear regression models adjusted for age, marital status, educational level, family income, and family size, women reporting a negative net worth (debt) had higher levels of daytime (β = 6.7; SE = 1.5; P < .001) and nighttime (β = 6.4; SE = 1.4; P < .001) systolic BP, compared with women reporting a positive net worth. Similar associations were observed with sustained hypertension: women reporting a negative net worth had 150% higher odds (odds ratio, 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, body mass index, psychosocial stress due to debt, and depressive symptoms and were similar, although attenuated, when women receiving antihypertensive medications were included and treatment was controlled for in all analyses. In this cross-sectional study, having a negative net worth (ie, debt) was associated with elevated BP in African American women, independent of traditional indicators of SES. This finding suggests that limited assets or a lack of economic reserve may be associated with poor CVD outcomes in this at-risk group.
Highlights
In this cross-sectional study, having a negative net worth was associated with elevated blood pressure (BP) in African American women, independent of traditional indicators of socioeconomic status (SES). This finding suggests that limited assets or a lack of economic reserve may be associated with poor cardiovascular disease (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,[18,19] the most likely to be single parents/heads of households,[19,20] and among college-educated adults, the most burdened by student loan debt.[21]
We focused on early midlife, because previous studies have reported that this is a life stage when increases in BP are steepest for African American women compared with other race-gender groups,[53,54] and more recent research has noted that women experience CVD events at lower thresholds than men, with associations pronounced in those younger than 52 years.[55]
Summary
Evidence has documented associations between low socioeconomic status (SES), traditionally measured at the individual level by educational level and/or income, and greater cardiovascular disease (CVD) morbidity and mortality.[1,2] in the US, these associations have been less consistently observed for African American individuals relative to White individuals.[3,4,5] Some have argued that this difference is primarily owing to the inability of traditional SES measures to adequately capture resources, such as wealth and/or assets, that are limited among the African American population, largely due to historical policies stemming from racism.[6,7,8] Differential access to US Government Issue bill benefits,[9] redlining (linking risk to residential maps based on racial composition),[10,11] and deed covenants (preventing the sale of homes in some areas to African American individuals)[10,11] constrained access to homeownership and home equity accrual in highvalue areas, which, in addition to laws impeding enrollment in many colleges and universities across the US through the 1960s and early 1970s, directly affected opportunities for African American individuals to achieve upward mobility and attain generational wealth.[6,12] The legacy of these historical policies has ongoing importance, as recent data found that on average, African American households had $46 600 in total assets, compared with $264 700 in White households.[13] the connection between traditional SES indicators and CVD is well studied, the association between the presence or absence of assets and CVD risk is relatively underexplored, especially among the African American population.[14]. Evidence has documented associations between low socioeconomic status (SES), traditionally measured at the individual level by educational level and/or income, and greater cardiovascular disease (CVD) morbidity and mortality.[1,2] in the US, these associations have been less consistently observed for African American individuals relative to White individuals.[3,4,5] Some have argued that this difference is primarily owing to the inability of traditional SES measures to adequately capture resources, such as wealth and/or assets, that are limited among the African American population, largely due to historical policies stemming from racism.[6,7,8] Differential access to US Government Issue bill benefits,[9] redlining (linking risk to residential maps based on racial composition),[10,11] and deed covenants (preventing the sale of homes in some areas to African American individuals)[10,11] constrained access to homeownership and home equity accrual in highvalue areas, which, in addition to laws impeding enrollment in many colleges and universities across the US through the 1960s and early 1970s, directly affected opportunities for African American individuals to achieve upward mobility and attain generational wealth.[6,12] The legacy of these historical policies has ongoing importance, as recent data found that on average, African American households had $46 600 in total assets, compared with $264 700 in White households.[13]. African American women may be uniquely vulnerable to the association between limited assets (ie, debt) and CVD risk
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