Elsevier

Social Science & Medicine

Volume 74, Issue 8, April 2012, Pages 1146-1154
Social Science & Medicine

Subjective social status and psychosocial and metabolic risk factors for cardiovascular disease among African Americans in the Jackson Heart Study

https://doi.org/10.1016/j.socscimed.2011.12.042Get rights and content

Abstract

Subjective social status has been shown to be inversely associated with multiple cardiovascular risk factors, independent of objective social status. However, few studies have examined this association among African Americans and the results have been mixed. Additionally, the influence of discrimination on this relationship has not been explored. Using baseline data (2000–2004) from the Jackson Heart Study, an African American cohort from the U.S. South (N = 5301), we quantified the association of subjective social status with selected cardiovascular risk factors: depressive symptoms, perceived stress, waist circumference, insulin resistance and prevalence of diabetes. We contrasted the strength of the associations of these outcomes with subjective versus objective social status and examined whether perceived discrimination confounded or modified these associations. Subjective social status was measured using two 10-rung “ladders,” using the U.S. and the community as referent groups. Objective social status was measured using annual family income and years of schooling completed. Gender-specific multivariable linear and logistic regression models were fit to examine associations. Subjective and objective measures were weakly positively correlated. Independent of objective measures, subjective social status was significantly inversely associated with depressive symptoms (men and women) and insulin resistance (women). The associations of subjective social status with the outcomes were modest and generally similar to the objective measures. We did not find evidence that perceived racial discrimination strongly confounded or modified the association of subjective social status with the outcomes. Subjective social status was related to depressive symptoms but not consistently to stress or metabolic risk factors in African Americans.

Highlights

► Subjective social status has been shown to be associated with increased cardiovascular risk independent of objective status. ► Few studies have examined this association among African Americans and the results have been mixed. ► The influence of discrimination on this association is not known. We used a large African American sample from the US South to study this. ► Subjective status was associated with depressive symptoms and insulin resistance (in women) independent of objective status. ► The subjective status-cardiovascular risk association did not vary depending on levels of perceived racial discrimination.

Introduction

Socioeconomic status (SES) shows robust inverse associations with cardiovascular disease (CVD) as well as with psychosocial, behavioral and biological risk factors for CVD (Kaplan & Keil, 1993). Among the many indicators of SES, subjective social status (SSS) has been posited to capture health-relevant dimensions that are not directly measured by objective social status (OSS) indicators such as income, and education (Adler et al., 2008). SSS is a measure of an individual's self-assessment of his/her position in a social hierarchy. It has been hypothesized that SSS may tap into the psychosocial consequences of relative position within a social hierarchy (Singh-Manoux, Marmot, & Adler, 2005), and may be more strongly associated with health outcomes linked to psychosocial characteristics than OSS measures.

SSS has been found to be inversely associated with cardiovascular risk factors such as obesity (Goodman et al., 2003), depression (Adler et al., 2008; Goodman et al., 2003), hypertension (Adler et al., 2008), increased heart rate (Adler, Epel, Castellazzo, & Ickovics, 2000), abdominal fat deposition (Adler et al., 2000), greater morning rise in cortisol (Wright & Steptoe, 2005), and metabolic syndrome (Manuck, Phillips, Gianaros, Flory, & Muldoon, 2010). Notably, these associations were independent of OSS. However, few studies have examined SSS and CVD risk factors among African Americans and the results have been mixed (Adler et al., 2008; Manuck et al., 2010; Ostrove, Adler, Kuppermann, & Washington, 2000). Adler et al. (2008) used data from the Coronary Artery Risk Development in Young Adults (CARDIA) study and found that lower SSS was associated with poor self-rated health and greater depression among both black and white individuals. However, the associations were weaker among blacks than among whites. Additionally, an inverse association between SSS and prevalence of hypertension was found among African American women but not African American men. These results correspond with the findings of Ostrove et al. (2000), who reported that SSS was not associated with self-rated health among African American women, while it was inversely associated with self-rated health for white and Chinese American women. On the other hand, Manuck et al. (2010) found that lower SSS was associated with higher prevalence of metabolic syndrome and this was not modified by race.

Few if any studies have investigated the influence of racial discrimination on the association of SSS and health. There are at least three ways in which SSS and discrimination could interrelate to affect health. The first relates to the incorporation of experiences and consequences of discrimination into the assessment of subjective social status. Research has suggested that individuals arrive at their SSS by taking into account OSS, as well as an assessment of their current and/or future socioeconomic prospects – an overall assessment, or cognitive averaging (Singh-Manoux, Adler, & Marmot, 2003). Adler et al. (2008) posited that experiences of racism might influence this assessment. Thus, among African Americans, assessments of SSS may tap into a person's assessments of what income and education may realistically “buy” him/her in society in the presence of discrimination. It has been well established that for a given level of income and education African Americans experience lower social and economic returns compared to whites (Braveman et al., 2005; Krieger, Williams, & Moss, 1997). As a result, among African Americans, SSS may actually better capture the material implications of social position. In addition, to the extent that discrimination affects perceptions of relative worth or standing, measures of SSS may also tap into the psychosocial consequences of discrimination. Both of these processes would result in SSS being an especially strong predictor of health outcomes in African Americans.

A second possibility is that discrimination is causally related to both perceptions of social status and health outcomes through separate pathways. This would result in discrimination confounding associations of SSS with health. If higher levels of perceived discrimination cause both lower rating of SSS and poorer health, then the association of SSS with health would be overestimated if discrimination is not adjusted for. A third possibility is that perceived discrimination modifies the association of SSS with health. For example, it is possible that the adverse health consequences of low SSS are magnified in the presence of the additional stress resulting from discrimination. To our knowledge, no study has examined the extent to which discrimination confounds or modifies the association of SSS with health. Furthermore, the few studies of SSS that have included African Americans have reported limited information about the relationships between subjective and objective measures of social status in this population.

We quantified the association between SSS and selected psychosocial and metabolic risk factors of CVD using data from the Jackson Heart Study (JHS), a large population-based study of African Americans. We also contrasted the strength of the associations of SSS and OSS with these risk factors. To address existing gaps in research, we examined whether the association between SSS and risk factors was independent of OSS. We also investigated whether this association was confounded or modified by perceived racial discrimination. Given the previous report of inverse association of SSS with hypertension among African American women but not men (Adler et al., 2008), we tested whether gender modified the association of SSS with risk factors. We hypothesized that SSS would be negatively associated with depressive symptoms, stress, waist circumference, insulin resistance and diabetes, and that this association would be independent of OSS. We also expected a stronger association of SSS with these risk factors among individuals with higher versus lower levels of perceived racial discrimination. Additionally, we hypothesized that the associations of SSS with the risk factors would be stronger among women than men.

Section snippets

Data

We used baseline examination data (2000–2004) from the JHS, the largest single-site, population-based cohort study of CVD among African Americans. The study population consists of non-institutionalized African American adults aged 21–95 residing in the Jackson, MS metropolitan area (Taylor et al., 2005). Participants were recruited from the tri-county region: Hinds County (which includes the City of Jackson – the capital of Mississippi), Madison County, and Rankin County through four methods:

Exclusions

We excluded any participant who was missing data on the outcomes or any of the covariates which resulted in the following analytic sample sizes (Table 1): 2458 (depressive symptoms), 3631 (stress), 4002 (waist circumference), 3939 (diabetes) and 3123 (insulin resistance). We examined whether those who were missing data on the outcomes differed from those with data on SSS, OSS and perceived discrimination (see below).

Description of the sample

The different analytic sample sizes available for each of the outcomes after excluding records with missing data on covariates are shown in Table 2. The average age among men ranged from 52.6 to 55.1 years and from 53.5 to 55.7 among women. The distribution of both measures of SSS, income and education did not vary to a great extent across the various analytic datasets. The CES-D sample had a greater proportion of participants with at least a college degree than the full JHS dataset (Table 2).

Discussion

Using data from a large population-based cohort of African Americans, this study presents three important findings: SSS was associated with depressive symptoms (men and women) and insulin resistance (women) independent of OSS; the magnitude of the SSS-risk factor association was, on average, similar to that observed with OSS; and associations of SSS with the risk factors were generally not strongly confounded by and did not vary depending on levels of perceived racial discrimination. To our

Author contributions

MAS developed the research idea, conducted analyses, and wrote the paper. ADR supervised the work and contributed to the analytical approach and writing. Other authors helped with acquisition of data, interpretation of results and provided comments on drafts. They are listed in alphabetical order.

Acknowledgments

This research was supported in part by the Michigan Center for Integrative Approaches to Health Disparities (P60MD002249) funded by the National Center on Minority Health and Health Disparities. The Jackson Heart Study is supported by NIH contracts N01-HC-95170, N01-HC-95171, and N01-HC-95172 that were provided by the National Heart, Lung, and Blood Institute and the National Center for Minority Health and Health Disparities.

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