Neighborhoods and racial/ethnic differences in ideal cardiovascular health (the Multi-Ethnic Study of Atherosclerosis)
Introduction
Persistent and pervasive racial/ethnic differences in health are a major public health concern (Institute of Medicine (US) Commitee on the Review and Assessment of the NIH's Strategic Research Plan and Budget to Reduce and Ultimately Eliminate Health Disparities, 2006, Kelley et al., 2005, Smedley et al., 2003). Racial/ethnic differences in the prevalence of cardiovascular disease (CVD) risk factors and incidence of and mortality due to cardiovascular diseases have been well documented, with blacks disproportionately burdened by adverse outcomes (Go et al., 2014, Mensah et al., 2005). Underlying causes of these differences remain poorly understood, but are most likely generated by multifactorial and multilevel causes that occur over the life-course. Much of the extant literature has focused on individual-level risk factors as explanations for racial/ethnic disparities (genetic, biological, socioeconomic, and psychosocial) (Kramer et al., 2004, Mensah and Dunbar, 2006, Safford et al., 2012). However, more attention has recently been placed on contextual factors such as neighborhood environments.
The increased interest in the intersection of race/ethnicity, neighborhood, and health has emerged in part from the increasing interest in the effects of neighborhoods on health generally. Studies have shown that living in socioeconomically disadvantaged neighborhoods is associated with increased morbidity and mortality, independent of individual-level factors (Borrell et al., 2004, Pickett and Pearl, 2001, Truong and Ma, 2006), and some of the most consistent evidence is from the area of cardiovascular disease (CVD) outcomes. (Borrell et al., 2004, Chaix, 2009, Diez Roux, 2003, Morenoff et al., 2007, Mujahid et al., 2011, Pickett and Pearl, 2001). In the area of CVD, studies have also shown that living in neighborhoods with poor physical environments (e.g. more unhealthy foods on average and fewer opportunities for physical activity) and social environments (e.g. less safety and social cohesion) are associated with increased risk of CVD risk factors such as obesity, diabetes, and hypertension, and fatal and non-fatal CVD (Christine et al., 2015, Diez Roux et al., 2016, Kaiser et al., 2016, Kershaw et al., 2015). Studies have also documented that blacks and other racial/ethnic minorities disproportionately reside in neighborhoods that are socioeconomically disadvantaged, and have poor access to health promoting resources. Combined, the aforementioned supports the hypothesis that neighborhood environments may be one underlying cause of racial/ethnic disparities in health. However, there is little empiric investigation explicitly testing this notion (Do et al., 2007, Dubowitz et al., 2008b, Morenoff et al., 2007, Mujahid et al., 2011, Robert and Reither, 2004).
Studies that have empirically investigated the contribution of neighborhood environments to racial/ethnic differences in health have most consistently examined estimates of differences before and after adjustment for neighborhood environments in a multivariable regression model without an explicit discussion of the major challenges and limitations in this approach (Do et al., 2007, Dubowitz et al., 2008b, Mujahid et al., 2011, Robert and Reither, 2004). These challenges include how best to: deal with the non-independence of observations within neighborhoods (Hubbard et al., 2010, Subramanian and O'Malley, 2010), account for the neighborhood context when all relevant factors may not be measured in a given study, and account for insufficient within-neighborhood sample size and variation in exposures and outcomes. A recent review by Schempf et al. (Schempf and Kaufman, 2012) provides an in-depth discussion of these issues, a comparison of analytic approaches that may address these issues, and compares the strengths and limitations of each analytic approach. Studies providing similar comparisons across analytic approaches remain scarce in the literature. (Morenoff et al., 2007, Schempf and Kaufman, 2012).
Given the increased attention to and importance of primordial prevention, as underscored by the recent American Heart Association 2020 Strategic Impact Goals to reduce cardiovascular mortality by 20% and increase ideal cardiovascular health by 20% (Lloyd-Jones et al., 2010), exploring the contribution of neighborhood environments to racial/ethnic differences in CVD risk in a multi-ethnic study is timely (Havranek et al., 2015). Thus, the overall goal of this study was to determine if cross-sectional racial/ethnic differences in ideal cardiovascular health (CVH) indicators were reduced after adjustment for neighborhood environments, and if results were robust to statistical methods of neighborhood adjustment.
Section snippets
Study population
MESA is a prospective study of 6,814 adults of diverse racial/ethnic backgrounds (self-identified race/ethnicity as non-Hispanic white, non-Hispanic black, Hispanic, and non-Hispanic Chinese) from six study sites (Los Angeles County, California; Chicago, Illinois; Baltimore City and County, Maryland; St. Paul, Minnesota; Forsyth County, North Carolina; New York City, New York) (Bild et al., 2002). Study participants were 45–84 years of age and free from clinical cardiovascular disease at
Results
Among the 6191 MESA Neighborhood participants that provided consent to participate in the MESA Neighborhood Study, we excluded 728 Chinese participants for whom sample sizes were too small to examine neighborhood context. Additional exclusions included address errors (N=133) and missing information on study covariates (N=67) for a final analytic sample of N=5,263 representing 1033 neighborhoods with an average of 5 study participants per neighborhood (range 1–250). Among this analytic sample,
Discussion
In a multi-ethnic cohort of middle-aged adults, we found significant black-white and Hispanic-white differences for all ideal health factors (blood pressure, cholesterol, and glucose), three of four ideal health behaviors (diet, body mass index, and smoking) and all ideal CVH summary measures (health factors, health behaviors, and overall ideal cardiovascular health), independent of sociodemographic characteristics. Adjustment for neighborhood context slightly reduced racial/ethnic differences,
Acknowledgements
This research was supported by contracts N01-HC-95159 through N01-HC-95169 from the National Heart, Lung, and Blood Institute and by grants UL1-RR-024156 and UL1-RR-025005 from NCRR and R01 HL071759 from National Heart, Lung, and Blood Institute at the National Institutes of Health. Dr. Mujahid is funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health, grant 5K01HL115494. The findings and conclusions in this report are those of the author(s) and do not
References (51)
- et al.
Improving retrospective characterization of the food environment for a large region in the United States during a historic time period
Health Place
(2012) - et al.
Validation of a self-administered diet history questionnaire using multiple diet records
J. Clin. Epidemiol.
(1990) - et al.
The impact of neighborhoods on CV risk
Glob. Heart
(2016) - et al.
Neighborhood context and ethnicity differences in body mass index: a multilevel analysis using the NHANES III survey (1988–1994)
Econ. Hum. Biol.
(2007) - et al.
Individual and neighborhood differences in diet among low-income foreign and U.S.-born women
Women’s. Health Issues
(2008) - et al.
Neighborhood socioeconomic status and fruit and vegetable intake among whites, blacks, and Mexican Americans in the United States
Am. J. Clin. Nutr.
(2008) - et al.
Racial/Ethnic differences in hypertension and hypertension treatment and control in the multi-Ethnic study of atherosclerosis (MESA)
Am. J. Hypertens.
(2004) - et al.
Understanding social disparities in hypertension prevalence, awareness, treatment, and control: the role of neighborhood context
Soc. Sci. Med.
(2007) - et al.
The availability of local-area commercial physical activity–related facilities and physical activity Among adolescents
Am. J. Prev. Med.
(2007) - et al.
A multilevel analysis of race, community disadvantage, and body mass index among adults in the US
Soc. Sci. Med.
(2004)
Accounting for context in studies of health inequalities: a review and comparison of analytic approaches
Ann. Epidemiol.
Activity space environment and dietary and physical activity behaviors: a pilot study
Health Place
Moderate physical activity patterns of minority women: the Cross-Cultural Activity Participation Study
J. Women’s Health Gend. Based Med.
The association between physical activity and subclinical atherosclerosis: the multi-ethnic study of Atherosclerosis
Am. J. Epidemiol.
Multi-ethnic study of atherosclerosis: objectives and design
Am. J. Epidemiol.
Neighbourhood characteristics and mortality in the atherosclerosis risk in communities study
Int J. Epidemiol.
Geographic life environments and coronary heart disease: a literature review, theoretical contributions, methodological updates, and a research agenda
Annu Rev. Public Health
Longitudinal associations between neighborhood physical and social environments and incident Type 2 diabetes mellitus: the Multi-Ethnic Study of Atherosclerosis (MESA)
JAMA Intern. Med.
A comparison of regression approaches for analyzing clustered data
Am. J. Public Health
Investigating neighborhood and area effects on health
Am. J. Public Health
Residential environments and cardiovascular risk
J. Urban Health
Neighborhoods and health
Ann. N. Y. Acad. Sci.
Reliability of self-reported neighborhood characteristics
J. Urban Health
Heart disease and stroke statistics-−2014 update: a report from the American Heart Association
Circulation
Inequality in the built environment underlies key health disparities in physical activity and obesity
Pediatrics
Cited by (56)
The social determinants of ideal cardiovascular health: A global systematic review
2022, Annals of EpidemiologySpatially varying racial inequities in cardiovascular health and the contribution of individual- and neighborhood-level characteristics across the United States: The REasons for geographic and racial differences in stroke (REGARDS) study
2022, Spatial and Spatio-temporal EpidemiologyCitation Excerpt :While CTs for each REGARDS participant ranges in size, CTs are common units of analysis used in assessing the spatial patterning of various health outcomes (Chen et al., 2006; Tabb et al., 2018). Similar to previous studies that examined neighborhood characteristics and their impact on CVH (Tabb et al., 2020b; Unger et al., 2014; Mujahid et al., 2017), we considered the following CT density measures of: (1) physical activity resources, (2) walkability, (3) favorable food stores, and (4) social engagement venues. Physical activity resources included physical activity venues where participants could engage in activities considered light, moderate, or vigorous, such as gyms.
A comparison of cardiovascular risk factors between Asian-Americans and non-Asian Americans: An analysis from the NHANES database
2021, Progress in Cardiovascular Diseases