Life Course Socioeconomic Status and Hypertension in African American Adults: The Jackson Heart Study.

BACKGROUND: Limited research has examined the association of life-course socioeconomic status (SES) with hypertension prevalence and incidence in a large cohort of African Americans. METHODS: Among 4,761 participants from the Jackson Heart Study (JHS), we examined the association of SES indicators with prevalent and incident hypertension. We used multivariable Poisson regression to estimate prevalence ratios (PR, 95% confidence interval-CI) of baseline (2000-2004) hypertension by adult (education, income, occupation, wealth) and childhood (mother's education) SES. Cox proportional hazards regression was used to estimate hazard ratios (HR, 95% CI) of incident hypertension by adult and childhood SES (2005-2013; 7.21 median years of follow-up). We also examined the association of childhood-to-adult SES mobility (parent-to-adult education) with prevalent and incident hypertension. Model 1 adjusted for age and sex. Model 2 added waist circumference, behaviors (smoking, alcohol, physical activity, diet), and diabetes prevalence. RESULTS: High (vs. low) adult SES measures were associated with a lower prevalence of hypertension, with the exception of having a college degree and upper-middle income (PR: 1.04, 95% CI: 1.01, 1.07; PR: 1.05, 95% CI: 1.01, 1.09, respectively). Higher childhood SES was associated with a lower prevalence and risk of hypertension (PR: 0.83, 95%: CI 0.75, 0.91; HR: 0.76, 95% CI: 0.65, 0.89, respectively). Upward mobility and consistent high SES (vs. consistent low SES) from childhood to adulthood was associated with a greater prevalence, but lower incidence of hypertension. CONCLUSION: Efforts to prevent hypertension among African Americans should consider childhood and current SES status.

Using Community Feedback to Improve Community Interventions: Results From the Deep South Network for Cancer Control Project.

The Deep South Network for Cancer Control (DSNCC), initiated in 2000, is a dual-state, community-based participatory research infrastructure composed of academic and community partners committed to reducing cancer disparities among underserved African Americans in 12 designated counties of the Alabama Black Belt and the Mississippi Delta, 2 historically underserved areas of the country. Local residents trained as Community Health Advisors as Research Partners implemented a 3-tier community action plan (CAP) focused on promoting cancer screening, physical activity, and nutrition. Breast, cervical and colorectal cancer screening, healthy eating habits, and physical activity levels increased among many, but not all, African American women in the 12-county DSNCC coverage area. Seeking to improve our reach to include participants who reported they had never heard of the DSNCC or participated in the CAP, we conducted in-depth conversations with community residents about reasons for selective nonparticipation and ways to improve participation in the DSNCC community health interventions. Three patterns and their associated themes described ways to improve the penetration of CAP strategies and tailor them to effectively reach underserved African Americans in the intervention counties. We conclude with lessons learned for future interventions.

The impact of neighborhood on physical activity in the Jackson Heart Study.

Physical inactivity is an independent risk factor for many diseases. Most research has focused on individual-level factors for physical activity (PA), but evidence suggests that neighborhood is also important. We examined baseline data collected between 2000 and 2004 from 5236 participants in the Jackson Heart Study to determine the effects of neighborhood on 2 types of PA: Active Living (AL), and Sports and Exercise (Sport) in an all-African American cohort. Participants were georeferenced and data from individual baseline questionnaires and US Census were analyzed using descriptive, bivariate, and multilevel models. In both types of PA, neighborhood factors had an independent and additive effect on AL and Sport. Living in an urban (p=0.003) or neighborhood with a higher percentage of residents with less than a high school education (p<0.001) was inversely associated with AL. There was an inverse interaction effect between individual and lower neighborhood education (p=0.01), as well as between age and urban neighborhoods (p=0.02) on AL. Individual level education (OR=1.30) and per capita income (OR=1.07) increased the odds of moderate-to-high sports. Future studies should focus on what contextual aspects of urban or less educated neighborhoods are influential in determining PA, as well as longitudinal multilevel analyses of neighborhood effects on PA.

The National Children's Study: Recruitment Outcomes Using the Provider-Based Recruitment Approach.

OBJECTIVE: In 2009, the National Children's Study (NCS) Vanguard Study tested the feasibility of household-based recruitment and participant enrollment using a birth-rate probability sample. In 2010, the NCS Program Office launched 3 additional recruitment approaches. We tested whether provider-based recruitment could improve recruitment outcomes compared with household-based recruitment. METHODS: The NCS aimed to recruit 18- to 49-year-old women who were pregnant or at risk for becoming pregnant who lived in designated geographic segments within primary sampling units, generally counties. Using provider-based recruitment, 10 study centers engaged providers to enroll eligible participants at their practice. Recruitment models used different levels of provider engagement (full, intermediate, information-only). RESULTS: The percentage of eligible women per county ranged from 1.5% to 57.3%. Across the centers, 3371 potential participants were approached for screening, 3459 (92%) were screened and 1479 were eligible (43%). Of those 1181 (80.0%) gave consent and 1008 (94%) were retained until delivery. Recruited participants were generally representative of the county population. CONCLUSIONS: Provider-based recruitment was successful in recruiting NCS participants. Challenges included time-intensity of engaging the clinical practices, differential willingness of providers to participate, and necessary reliance on providers for participant identification. The vast majority of practices cooperated to some degree. Recruitment from obstetric practices is an effective means of obtaining a representative sample.

The impact of lifecourse socioeconomic position on cardiovascular disease events in African Americans: the Jackson Heart Study.

BACKGROUND: Few studies have examined the impact of lifecourse socioeconomic position (SEP) on cardiovascular disease (CVD) risk among African Americans. METHODS AND RESULTS: We used data from the Jackson Heart Study (JHS) to examine the associations of multiple measures of lifecourse SEP with CVD events in a large cohort of African Americans. During a median of 7.2-year follow-up, 362 new or recurrent CVD events occurred in a sample of 5301 participants aged 21 to 94. Childhood SEP was assessed by using mother's education, parental home ownership, and childhood amenities. Adult SEP was assessed by using education, income, wealth, and public assistance. Adult SEP was more consistently associated with CVD risk in women than in men: age-adjusted hazard ratios for low versus high income (95% CIs), 2.46 (1.19 to 5.09) in women and 1.50 (0.87 to 2.58) in men, P for interaction=0.1244, and hazard ratio for low versus high wealth, 2.14 (1.39 to 3.29) in women and 1.06 (0.62 to 1.81) in men, P for interaction=0.0224. After simultaneous adjustment for all adult SEP measures, wealth remained a significant predictor of CVD events in women (HR=1.73 [1.04, 2.85] for low versus high). Education and public assistance were less consistently associated with CVD. Adult SEP was a stronger predictor of CVD events in younger than in older participants (HR for high versus low summary adult SEP score 3.28 [1.43, 7.53] for participants ≤50 years, and 1.90 (1.36 to 2.66) for participants >50 years, P for interaction 0.0846). Childhood SEP was not associated with CVD risk in women or men. CONCLUSIONS: Adult SEP is an important predictor of CVD events in African American women and in younger African Americans. Childhood SEP was not associated with CVD events in this population.

Socioeconomic status, John Henryism and blood pressure among African-Americans in the Jackson Heart Study.

John Henryism connotes a strong behavioral predisposition to engage in effortful, active coping with difficult social and economic stressors. This behavioral predisposition is measured by the 12 item John Henryism Scale for Active Coping (JHAC). The John Henry hypothesis predicts that the well-known inverse socioeconomic status (SES)-blood pressure association will be stronger among persons who score high rather than low on the JHAC. We tested this hypothesis in a large African American cohort using baseline data from the Jackson Heart Study. Unlike previous studies, we used multiple indicators of SES: income, education, occupation, childhood SES and cumulative SES. Because the hypothesis is most relevant for adults still in the labor force, we excluded retired participants, yielding a sample size of 3978. Gender-specific Poisson regression models for hypertension adjusting for age, John Henryism, SES, and a John Henryism-SES interaction term, were fit to examine associations. Separate models were fit for each SES indicator. We found some evidence that John Henryism modified the association between income and hypertension in men: low income was associated with higher prevalence of hypertension in men who scored high on John Henryism (prevalence ratio (PR) for low vs. high income tertile 1.12), but with lower hypertension prevalence among men who scored low on John Henryism (PR 0.85, one sided P value for multiplicative interaction <0.05). For women, the association of low income with higher hypertension prevalence was stronger at lower than higher levels of John Henryism (PR 1.27 and 1.06 at low and high levels of John Henryism respectively, P value<0.05). There was no evidence that John Henryism modified the associations of hypertension with other SES indicators in men or women. The modest support of the John Henryism Hypothesis in men only, adds to the literature on this subject, but underscores questions regarding the gender, spatial, socioeconomic and historical contexts in which the hypothesis is valid.

Framing body size among African American women and girls.

Obesity continues to affect African Americans in epidemic proportions, particularly among women and adolescent females. Perceptions, beliefs, behaviors, and body sizes of adolescents are associated with those of their mothers, yet little is known about the transgenerational meanings and experiences of obese African American adolescent girls and their mothers. An interpretive phenomenological study was conducted with seven African American adolescents between the ages of 11 and 17, and their adult female caregivers. Audio-taped interviews were transcribed and analyzed by a multicultural interpretive team. Two constitutive patterns and associated themes were identified. One pattern, 'Framing: sizing it up; sizing it down', with its three associated themes is presented. Mothers and daughters are engaged in multiple common practices in which they self-define body size, while protecting their self-esteem and self-image. This pattern illustrates how the women and girls created an image of their bodies as they confronted and acknowledged their self-perceptions, compared themselves to others in their environment, and evaluated themselves against specific parameters of acceptable size.

Sleep-disordered breathing symptoms among African-Americans in the Jackson Heart Study.

BACKGROUND: Sleep-disordered breathing (SDB) is an increasingly recognized risk factor for cardiovascular disease (CVD). Limited data are available from large African American cohorts. METHODS: We examined the prevalence, burden, and correlates of sleep symptoms suggestive of SDB and risk for obstructive sleep apnea (OSA) in the Jackson Heart Study (JHS), an all-African-American cohort of 5301 adults. Data on selected daytime and nighttime sleep symptoms were collected using a modified Berlin questionnaire during the baseline examination. Risk of OSA was calculated according to published prediction model. Age and multivariable-adjusted logistic regression models were used to examine the associations between potential risk factors and measures of sleep. RESULTS: Sleep symptoms, burden, and risk of OSA were high among men and women in the JHS and increased with age and obesity. Being married was positively associated with sleep symptoms among women. In men, poor to fair perceived health and increased levels of stress were associated with higher odds of sleep burden, whereas prevalent hypertension and CVD were associated with higher odds of OSA risk. Similar associations were observed among women with slight variations. Sleep duration <7h was associated with increased odds of sleep symptoms among women and increased sleep burden among men. Moderate to severe restless sleep was consistently and positively associated with odds of adverse sleep symptoms, sleep burden, and high risk OSA. CONCLUSIONS: Sleep symptoms in JHS had a strong positive association with features of visceral obesity, stress, and poor perceived health. With increasing obesity among younger African Americans, these findings are likely to have broad public health implications.

The contribution of stress to the social patterning of clinical and subclinical CVD risk factors in African Americans: the Jackson Heart Study.

It is often hypothesized that psychosocial stress may contribute to associations of socioeconomic position (SEP) with risk factors for cardiovascular disease (CVD). However, few studies have investigated this hypothesis among African Americans, who may be more frequently exposed to stressors due to social and economic circumstances. Cross-sectional data from the Jackson Heart Study (JHS), a large population-based cohort of African Americans, were used to examine the contributions of stressors to the association of SEP with selected cardiovascular (CVD) risk factors and subclinical atherosclerotic disease. Among women, higher income was associated with lower prevalence of hypertension, obesity, diabetes and carotid plaque and lower levels of stress. Higher stress levels were also weakly, albeit positively, associated with hypertension, diabetes, and obesity, but not with plaque. Adjustment for the stress measures reduced the associations of income with hypertension, diabetes and obesity by a small amount that was comparable to, or larger, than the reduction observed after adjustment for behavioral risk factors. In men, high income was associated with lower prevalence of diabetes and stressors were not consistently associated with any of the outcomes examined. Overall, modest mediation effects of stressors were observed for diabetes (15.9%), hypertension (9.7%), and obesity (5.1%) among women but only results for diabetes were statistically significant. No mediation effects of stressors were observed in men. Our results suggest that stressors may partially contribute to associations of SEP with diabetes and possibly hypertension and obesity in African American women. Further research with appropriate study designs and data is needed to understand the dynamic and interacting effects of stressors and behaviors on CVD outcomes as well as sex differences in these effects.

Social patterning of cumulative biological risk by education and income among African Americans.

OBJECTIVES: We examined the social patterning of cumulative dysregulation of multiple systems, or allostatic load, among African Americans adults. METHODS: We examined the cross-sectional associations of socioeconomic status (SES) with summary indices of allostatic load and neuroendocrine, metabolic, autonomic, and immune function components in 4048 Jackson Heart Study participants. RESULTS: Lower education and income were associated with higher allostatic load scores in African American adults. Patterns were most consistent for the metabolic and immune dimensions, less consistent for the autonomic dimension, and absent for the neuroendocrine dimension among African American women. Associations of SES with the global allostatic load score and the metabolic and immune domains persisted after adjustment for behavioral factors and were stronger for income than for education. There was some evidence that the neuroendocrine dimension was inversely associated with SES after behavioral adjustment in men, but the immune and autonomic components did not show clear dose-response trends, and we observed no associations for the metabolic component. CONCLUSIONS: Findings support our hypothesis that allostatic load is socially patterned in African American women, but this pattern is less consistent in African American men.

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

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.

Perceived discrimination and hypertension among African Americans in the Jackson Heart Study.

OBJECTIVES: Using Jackson Heart Study data, we examined whether perceived discrimination was associated with prevalent hypertension in African Americans. METHODS: Everyday discrimination, lifetime discrimination, burden of discrimination, and stress from discrimination were examined among 4939 participants aged 35 to 84 years (women = 3123; men = 1816). We estimated prevalence ratios of hypertension by discrimination, and adjusted for age, gender, socioeconomic status, and risk factors. RESULTS: The prevalence of hypertension was 64.0% in women and 59.7% in men. After adjustment for age, gender, and socioeconomic status, lifetime discrimination and burden of discrimination were associated with greater hypertension prevalence (prevalence ratios for highest vs lowest quartile were 1.08 [95% confidence interval (CI) = 1.02, 1.15] and 1.09 [95% CI = 1.02,1.16] for lifetime discrimination and burden of discrimination, respectively). Associations were slightly weakened after adjustment for body mass index and behavioral factors. No associations were observed for everyday discrimination. CONCLUSIONS: Further understanding the role of perceived discrimination in the etiology of hypertension may be beneficial in eliminating hypertension disparities.

The socioeconomic gradient of diabetes prevalence, awareness, treatment, and control among African Americans in the Jackson Heart Study.

PURPOSE: Little research has focused on the social patterning of diabetes among African Americans. We examined the relationship between socioeconomic status (SES) and the prevalence, awareness, treatment, and control of diabetes among African Americans. METHODS: Education, income and occupation were examined among 4,303 participants (2,726 women and 1,577 men). Poisson regression estimated relative probabilities (RP) of diabetes outcomes by SES. RESULTS: The prevalence of diabetes was 19.6% in women and 15.9% in men. Diabetes awareness, treatment, and control were 90.0%, 86.8%, and 39.2% in women, respectively, and 88.2%, 84.4%, and 35.9% in men, respectively. In adjusted models, low-income men and women had greater probabilities of diabetes than high-income men and women (RP, 1.94; 95% confidence interval [CI], 1.28-2.92; and RP, 1.35; 95% CI, 1.04-1.74, respectively). Lack of awareness was associated with low education and low occupation in women (RP, 2.28; 95%CI 1.01-5.18; and RP, 2.62; 95% CI, 1.08-6.33, respectively) but not in men. Lack of treatment was associated with low education in women. Diabetes control was not patterned by SES. CONCLUSIONS: Diabetes prevalence is patterned by SES, and awareness and treatment are patterned by SES in women but not men. Efforts to prevent diabetes in African Americans need to address the factors that place those of low SES at higher risk.

Socioeconomic position is positively associated with blood pressure dipping among African-American adults: the Jackson Heart Study.

BACKGROUND: Blunted nocturnal blood pressure (NBP) dipping is a significant predictor of cardiovascular events. Lower socioeconomic position (SEP) may be an important predictor of NBP dipping, especially in African Americans (AA). However, the determinants of NBP dipping are not fully understood. METHODS: The cross-sectional associations of individual and neighborhood SEP with NBP dipping, assessed by 24-h ambulatory BP monitoring, were examined among 837 AA adults (Mean age: 59.2 ± 10.7 years; 69.2% women), after adjustment for age, sex, hypertension status, body mass index (BMI), health behaviors, office, and 24-h systolic BP (SBP). RESULTS: The mean hourly SBP was consistently lower among participants in the highest category of individual income compared to those in the lowest category, and these differences were most pronounced during sleeping hours. The odds of NBP dipping (defined as >10% decline in the mean asleep SBP compared to the mean awake SBP) increased by 31% (95% confidence interval: 13-53%) and 18% (95% confidence interval: 0-39%) for each s.d. increase in income and years of education, respectively, after multivariable adjustment. CONCLUSIONS: NBP dipping is patterned by income and education in AA adults even after accounting for known risk factors. These results suggest that low SEP is a risk factor for insufficient NBP dipping in AA.

Race, stability of health insurance coverage, and prescription medication use.

OBJECTIVE: To determine the effects of health insurance and race on prescription medication use and expense. METHODS: An observational, non-experimental design was used. Multivariable regression analyses were conducted to evaluate the independent effects of health insurance status and race on prescription medication use and expense while controlling for sociodemographic, geographic, and health status characteristics. The sample consisted of 19,035 participants in the 1996 through 2003 Medical Expenditure Panel Survey. FINDINGS: European Americans spent about $300 to $400 more and used three to four more prescriptions annually compared to other racial groups. Prescription medication expenses increased as time spent uninsured increased. Participants with part-year coverage filled four fewer prescriptions than those with full-year health insurance coverage. Participants with private coverage spent less on prescription medications compared to those with public and those with dual public and private coverage ($1,194 vs. $1,931 and $2,076, respectively; p < or = 0.001). CONCLUSIONS: Significant racial and health insurance status disparities in prescription medication use and expenses exist after controlling for sociodemographic, geographic, and health status characteristics.

The role of community health advisors in community-based participatory research.

Mistrust and fear of research often exist in minority communities because of assumptions, preconceived ideas, and historical abuse and racism that continue to influence research participation. The research establishment is full of well-meaning 'outsider' investigators who recognize discrimination, health disparities, and insufficient health care providers in minority communities, but struggle in breaking through this history of mistrust. This article provides ethical insights from one such 'insider-outsider', community-based participatory research project implemented via community health advisors in the Mississippi Delta. Both community-based participatory research and community health advisors provide opportunities to address the ethical issues of trust, non-maleficence, and justice in minority communities. Implications for ethics-driven nursing research are discussed.

Physical activity and obesity in African Americans: the Jackson Heart Study.

OBJECTIVES: To better understand how obesity and low levels of physical activity (PA) contribute to racial health disparities, we examined the association of PA domains (work, home life, and leisure) with indicators of socioeconomic status and markers of obesity in African Americans. METHODS: These cross sectional analyses of interview and clinical measures from the baseline visit of the Jackson Heart Study of cardiovascular disease (CVD) in African Americans of the Jackson, Mississippi metropolitan statistical area included 3,174 women and 1,830 men aged 21-95 years. The main measures were active living, sport, work, home life, and total PA scores; participation in regular moderate or vigorous intensity leisure physical activity (MVLPA); demographics, body mass index (BMI), waist circumference (WC) and CVD risk factors. RESULTS: The sample was 63% female, 81% high school or college graduates, with 51% aged 45-64 years, and mostly overweight (32%) or obese (53%). Women were less active than men in all domains except home life. Total PA was inversely associated with WC in women and men. The overweight (BMI 25-29.9) group was most active in all domains except work; active living and sport PA and prevalence of MVLPA then declined in a dose response association with increasing BMI. Work PA was associated with the lowest BMI but otherwise with indicators of less favorable socioeconomic status and health. CONCLUSIONS: Observed differences in PA in African Americans by domain and association with obesity biomarkers suggest areas for future study and intervention to reduce health disparities.

Development and psychometric testing of a multidimensional instrument of perceived discrimination among African Americans in the Jackson Heart Study.

OBJECTIVE: Assessing the discrimination-health disparities hypothesis requires psychometrically sound, multidimensional measures of discrimination. Among the available discrimination measures, few are multidimensional and none have adequate psychometric testing in a large, African American sample. We report the development and psychometric testing of the multidimensional Jackson Heart Study Discrimination (JHSDIS) Instrument. METHODS: A multidimensional measure assessing the occurrence, frequency, attribution, and coping responses to perceived everyday and lifetime discrimination; lifetime burden of discrimination; and effect of skin color was developed and tested in the 5302-member cohort of the Jackson Heart Study. Internal consistency was calculated by using Cronbach alpha coefficient. Confirmatory factor analysis established the dimensions, and intercorrelation coefficients assessed the discriminant validity of the instrument. SETTING: Tri-county area of the Jackson, MS metropolitan statistical area. RESULTS: The JHSDIS was psychometrically sound (overall alpha = .78, .84 and .77, respectively, for the everyday and lifetime subscales). Confirmatory factor analysis yielded 11 factors, which confirmed the a priori dimensions represented. CONCLUSIONS: The JHSDIS combined three scales into a single multidimensional instrument with good psychometric properties in a large sample of African Americans. This analysis lays the foundation for using this instrument in research that will examine the association between perceived discrimination and CVD among African Americans.

Does socioeconomic status affect blood pressure goal achievement?

Hypertension is a major cause of disease burden in all racial, ethnic, and socioeconomic groups in developing and developed regions and countries. Differences in blood pressure likely begin early in life and reflect a complex relationship of biologic, genetic, social, and environmental interactions. The relationship between socioeconomic status and hypertension is complex and difficult to measure. Instituting lifestyle changes for the primary prevention and treatment of hypertension among the general population would decrease prevalence, improve blood pressure control, and be effective in eliminating many socioeconomic differences in risk factors for cardiovascular disease. Health care providers can potentially impact blood pressure control by incorporating knowledge of socioeconomic factors and mechanisms in care delivery. This review highlights socioeconomic status in the prevalence and incidence of hypertension and identifies contributing factors associated with blood pressure control.

Cumulative socioeconomic status across the life course and subclinical atherosclerosis.

PURPOSE: The purpose of this study is to investigate the relationship between individual-level and neighborhood-level socioeconomic status (SES) across the life course and subclinical atherosclerosis. METHODS: Participants from the Atherosclerosis Risk in Communities Study (n=12,332) were queried about individual-level SES and residential addresses across the life course. Individual-level measures were scored and summed to obtain a summary score (I-CumSES), whereas residential addresses were geocoded and linked to census data to obtain a summary neighborhood z score (N-CumSES) to evaluate the association of SES with intima-media thickness (IMT) and peripheral arterial disease (PAD). RESULTS: A 1-SD lower I-CumSES was associated with greater mean IMT in each race-sex group and greater odds of PAD in white men (odds ratio [OR], 1.28; 95% confidence interval [CI], 0.99-1.64), white women (OR, 1.18; 95% CI, 1.02-1.36), and black women (OR, 1.33; 95% CI, 1.00-1.76). Compared with the highest tertile of N-CumSES, the lowest tertile was associated with greater mean IMT among whites, but was not associated with PAD for whites or blacks. When I-CumSES and N-CumSES were considered simultaneously, associations remained for only I-CumSES and were attenuated after adjustment for cardiovascular disease (CVD) risk factors. CONCLUSIONS: Lower cumulative individual-level SES across the life course was associated with a greater burden of subclinical atherosclerosis, and this association was mediated in part by CVD risk factors.