Abstract
BackgroundCardiovascular (CV) disease is the leading cause of death among United States women. Rural residence and ethnic-minority status are individually associated with increased CV mortality. Managing dyslipidemia is important in the prevention of CV mortality. However, the impact of race/ethnicity and location of residence on sex differences in dyslipidemia management is not well understood. Therefore, we sought to understand the joint effects of race/ethnicity and location of residence on lipid management differences between veteran men and women with type 2 diabetes (T2D).MethodsVeterans Health Administration and Centers for Medicare and Medicaid Services data were used to perform a longitudinal cohort study of veterans with T2D (2007–2016). Mixed effects logistic regression with a random intercept was used to model the association between sex and low-density lipoprotein (LDL) > 100 mg/dL and its interaction with race/ethnicity and location of residence after adjusting for all measured covariates.ResultsWhen female sex and rural location of residence were both present, they were associated with an antagonistic harmful effect on LDL. Similar antagonistic harmful effects on LDL were observed when the joint effect of female sex and several minority race/ethnicity groups were evaluated. After adjusting for measured covariates, the odds of LDL > 100 mg/dL were higher for urban women (OR = 2.66, 95%CI 2.48–2.85) and rural women (OR = 3.26, 95%CI 2.94–3.62), compared to urban men. The odds of LDL > 100 mg/dL was the highest among non-Hispanic Black (NHB) women (OR = 5.38, 95%CI 4.45–6.51) followed by non-Hispanic White (NHW) women (OR = 2.59, 95%CI 2.44–2.77), and Hispanic women (OR = 2.56, 95%CI 1.79–3.66).ConclusionAntagonistic harmful effects on LDL were observed when both female sex and rural location of residence were present. These antagonistic effects on LDL were also present when evaluating the joint effect of female sex and several minority race/ethnicity groups. Disparities were most pronounced in NHB and rural women, who had 5.4 and 3.3 times the odds of elevated LDL versus NHW and urban men after adjusting for important covariates. These striking effect sizes in a population at high cardiovascular risk (i.e., older with T2D) suggest interventions aimed at improving lipid management are needed for individuals falling into one or more groups known to face health disparities.
Highlights
Cardiovascular (CV) disease is the leading cause of death among United States women
All-Male antagonistic effects on low-density lipoprotein cholesterol (LDL) were observed when both female sex and rural location of residence were present. These antagonistic effects on LDL were present when evaluating the joint effect of female sex and several minority race/ethnicity groups
We found an antagonistic harmful effect on LDL when both female sex and rural location of residence were present
Summary
Cardiovascular (CV) disease is the leading cause of death among United States women. Rural residence and ethnic-minority status are individually associated with increased CV mortality. The impact of race/ethnicity and location of residence on sex differences in dyslipidemia management is not well understood. We sought to understand the joint effects of race/ethnicity and location of residence on lipid management differences between veteran men and women with type 2 diabetes (T2D). Several studies have demonstrated that women are more likely to have elevated low-density lipoprotein cholesterol (LDL) levels than men [3,4,5,6,7,8]. In a study of 22,888 veterans with CV disease, women were 44% less likely than men to have an LDL < 100 mg/dL (p < 0.001) [8]. Among approximately 112,000 veterans with diabetes, mean LDL levels were 110 mg/dL in women versus 101 mg/dL in men [7]
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