Salty Subjects: Unpacking Racial Differences in Salt-Sensitive Hypertension.

PURPOSE OF REVIEW: To review underlying mechanisms and environmental factors that may influence racial disparities in the development of salt-sensitive blood pressure. RECENT FINDINGS: Our group and others have observed racial differences in diet and hydration, which may influence salt sensitivity. Dietary salt elicits negative alterations to the gut microbiota and immune system, which may increase hypertension risk, but little is known regarding potential racial differences in these physiological responses. Antioxidant supplementation and exercise offset vascular dysfunction following dietary salt, including in Black adults. Furthermore, recent work proposes the role of racial differences in exposure to social determinants of health, and differences in health behaviors that may influence risk of salt sensitivity. Physiological and environmental factors contribute to the mechanisms that manifest in racial differences in salt-sensitive blood pressure. Using this information, additional work is needed to develop strategies that can attenuate racial disparities in salt-sensitive blood pressure.

Exploring the intersection of income and race in an age diverse sample of people with Type 1 diabetes.

Prior literature suggests that the social gradient in health is racialised such that Black individuals receive fewer health benefits from socioeconomic status than White individuals, yet scarce research studies examine whether this relationship persists in the context of Type 1 diabetes (T1D). Further, most research studies on racial health disparities in T1D outcomes focus on health during early life. We used data from the 2017-2018 wave of the T1D Exchange Registry (N = 11,963) and examined the relationship between household income, race and HbA1c in an age diverse sample of people with T1D. Results revealed that the inverse association between income and HbA1c is stronger for Black T1Ds compared to White T1Ds. Despite this, Black T1Ds with an income of $100,000 or more had higher HbA1c values compared to White individuals with an income of less than $25,000. Further, Black adolescents with T1D had particularly high HbA1c values. There is an urgent need for more research on the interpersonal and structural barriers associated with suboptimal glycaemic control among Black individuals.

Environmental Justice: Where It Has Been, and Where It Might Be Going.

Taking stock of environmental justice (EJ) is daunting. It is at once a scholarly field, an ongoing social movement, and an administrative imperative adopted by government agencies and incorporated into legislation. Moreover, within academia, it is multidisciplinary and multimethodological, comprising scholars who do not always speak to one another. Any review of EJ is thus necessarily restrictive. This article explores several facets of EJ activism. One is its coalitional and "inside-outside" orientation. EJ activists are constantly forming alliances with other stakeholders, but these coalitions do not flout the importance of engaging with formal institutions. The review next turns to one set of such institutions-the courts and regulatory agencies-to see how well EJ claims have fared there. I then survey scientific findings that have been influenced by EJ. The review concludes with future directions for activists and scholars to consider: the changing nature of EJ coalitions, fragmentation within EJ and with other fields, the historical roots of environmental injustice, and opportunities for stronger infusion of the EJ lens.

Tubal factor infertility and its impact on reproductive freedom of African American women.

In the past, the reproductive freedom of African American women was hindered by forced reproduction and sterilization campaigns. Unfortunately, these involuntary practices have now mostly been replaced by inequality because of disproportionate tubal factor infertility rates within African American communities. Our work aimed to describe the inequities in increased rates of pelvic inflammatory disease and tubal factor infertility as it relates to African American women. In addition, we highlighted the need for improved access to screening and treatment of sexually transmitted infections, access to barrier contraception, and health literacy related to the understanding and prevention of tubal factor infertility in African American women.

Healing the past, reimagining the present, investing in the future: What should be the role of race as a proxy covariate in health economics informed health care policy?

In this perspective, the assertion that race-free risk assessment would harm patients of all races is critiqued from the viewpoint that race is not just another covariate in our arsenal. Although race may be associated with outcome, it is nevertheless a proxy for a myriad of other potential explanatory variables that could be genetic/biological but in many circumstances are more likely to be sociological/socioeconomic. It is argued that the pursuit of health maximization through the use of socially constructed variables like race must be done sensitively, recognizing that racial covariates in the medical arena can be subject to structural, institutional or personal biases. Even when such biases are thought to be minimized, the appearance of such bias may be sufficient to justify the removal of its use, particularly where employing a racial covariate could further increase existing disparities. While racial covariates may have descriptive value in helping to understand such disparities, it is beholden on the scientific community to explore alternatives to racial covariates that may provide the same or perhaps even better prognostic value in our analyses.

Patient-centered appraisal of race-free clinical risk assessment.

Until recently, there has been a consensus that clinicians seeking to assess patient risks of illness should condition risk assessments on all observed patient covariates with predictive power. The broad idea is that knowing more about patients enables more accurate predictions of their health risks and, hence, better clinical decisions. This consensus has recently unraveled with respect to a specific covariate, namely race. There have been increasing calls for race-free risk assessment, arguing that using race to predict health risks contributes to racial disparities and inequities in health care. In some medical fields, leading institutions have recommended race-free risk assessment. An important open question is how race-free risk assessment would affect the quality of clinical decisions. Considering the matter from the patient-centered perspective of medical economics yields a disturbing conclusion: Race-free risk assessment would harm patients of all races.

Racialized disablement and the need for conceptual analysis of "racial health disparities".

It is well established that racial health disparities are impacted by structural racism, but the imbrication of racialization processes with processes of disablement remains underdeveloped. This essay advocates for a conceptual lens that looks historically and politically at the co-constitution of "race" and "disability." Racism and ableism intersect in ways that manifest what I call racialized disablement, a key heuristic for building a fuller understanding of "race" and "racial health disparities." This terminology, I propose, helps illuminate the following about race and racism in healthcare: first, racialized disablement seeks to denaturalize both race and disability to focus on their political production. Using process-based terms related to both race and disability heightens the sense in which neither inhere in particular, individual bodies, but rather persist in contexts of ongoing structural oppressions, materializing populations subject to racialization and disablement. Secondly, and relatedly, racialized disablement aims to identify racism and ableism as co-constitutive-historically, politically, and conceptually intertwined. Without an awareness of the fluidity of race- and disability-based markers and the systems of power generating their materialization, our understandings of racial disparities in health and healthcare are incomplete.

What Is a "Racial Health Disparity"? Five Analytic Traditions.

What exactly is a "racial health disparity"? This article explores five lenses that have been used to answer that question. It contends that racial health disparities have been presented-by researchers both within academia and outside of it-as problems of five varieties: biology, behavior, place, stress, and policy. It also argues that a sixth tradition exploring class-and its connection to race, racism, and health-has been underdeveloped. The author examines each of these conceptions of racial disparities in turn. Baked into each interpretive prism is a set of assumptions about the mechanisms that produce disparities-a story, in other words, about where racial health disparities come from. Discursive boundaries set the parameters for policy debate, determining what is and is not included in proposed solutions. How one sees racial health disparities, then, influences the strategies a society advocates-or ignores-for their elimination. The author ends by briefly discussing problems in the larger research ecosystem that dictate how racial health disparities are studied.

Slavery, Health, and Healing Now: The State of the Field.

The scholarship on slavery, health, and healing has dramatically transformed over the past two decades. This essay synthesizes several themes within the thriving subfield, highlighting its relevance to historians of medicine and science working in adjacent fields, and suggesting new directions forward. The recent scholarship builds on research begun in the 1970s, but where earlier scholarship relied on quantitative methods and retrospective diagnoses, the new scholarship takes a social constructivist approach. Scholars today are exploring how slavery shaped the natural and built environment to create new disease environments in the New World; how Black healing knowledge was either circulated or suppressed by White physicians; and how gender and race intersected in slave societies to influence diagnoses and the categorization of specific diseases. Most importantly, the new scholarship suggests that medical knowledge produced in slave societies was not marginal-but central-to the rise of early modern medicine. The lack of any synthesis of the recent literature, combined with the recent public attention given to racial health disparities, make this literature vitally important to all historians of medicine and allied sciences. It can provide useful insights for scholars working in other areas, and it can diversify and complicate the stories we tell about the origins of modern medicine.

Evaluating the efficacy of telephone-based outreach in addressing hypertension control among black men with severe hypertension: An observational study.

BACKGROUND: The high prevalence of uncontrolled hypertension (systolic blood pressure [SBP] ≥140 mmHg or diastolic blood pressure [DBP] ≥90 mmHg) in Black patients represents a significant racial health disparity in the United States. AIMS: This study evaluated the efficacy of a telephone-based strategy for inviting high-risk patients with severe hypertension to weekly self-management education classes. Further, the study assessed how the outreach intervention correlated with relevant quality improvement outcomes, including improved blood pressure and primary care follow-up among our clinic population of Black men with severe hypertension. METHODS: A cohort of 265 Black men aged ≥18 years with SBP ≥160 mmHg or DBP ≥100 mmHg at the most recent clinic visit were identified using Epic reports formatted for Federal Uniformed Data Set annual reporting. Telephone outreach was used to invite the cohort to attend weekly in-person classes facilitated by various healthcare professionals. Logistic regression was performed to determine the associations between being reached by phone with (1) class attendance and (2) follow-up appointment attendance. RESULTS: Most of the Black men were single (57.4%, n = 152), 49.1% had history of alcohol or substance use (n = 130), and 35.8% (n = 95) was uninsured. The average age was 55.6 years (SD = 11.6). After controlling for sociodemographic factors, being reached by phone was significantly associated with an increased likelihood of patient attendance at follow-up appointments (OR = 1.91, p = .038) but not with class attendance (OR = 2.45, p = .155). Patients who attended a follow-up appointment experienced significant reductions in both SBP and DBP at 9 months. LINKING EVIDENCE TO ACTION: Telephone outreach was labor-intensive but effective in keeping under-resourced patient populations engaged in primary care. Future work should aim to develop more efficient strategies for engaging high-risk patients in self-monitoring education to manage hypertension.

Culture, COVID-19, and collectivism: A paradox of American exceptionalism?

Do geographic differences in collectivism relate to COVID-19 case and death rates? And if so, would they also replicate across states within arguably the most individualistic country in the world-the United States? Further still, what role might the U.S.'s history of ethnic strife and race-based health disparities play in either reinforcing or undermining state-level relations between collectivism and COVID-19 rates? To answer these questions, we examined archival data from 98 countries (Study 1) and the 48 contiguous United States (Study 2) on country/state-level collectivism, COVID-19 case/death rates, relevant covariates (per-capita GDP, population density, spatial dependence), and in the U.S., percent of non-Whites. In Study 1, country-level collectivism negatively related to both cases (r = -0.28) and deaths (r = -0.40) in simple regressions; however, after controlling for covariates, the former became non-significant (r p = -0.07), but the latter remained significant (r p = -0.20). In Study 2, state-level collectivism positively related to both cases (r = 0.56) and deaths (r = 0.41) in simple regressions, and these relationships persisted after controlling for all covariates except race, where a state's non-White population dominated all other predictors of COVID-19 cases (r p = 0.35) and deaths (r p = 0.31). We discuss the strong link between race and collectivism in U.S. culture, and its implications for understanding COVID-19 responses.

From Florence to fossil fuels: Nursing has always been about environmental health.

BACKGROUND: Since its founding, professional nursing has applied an environmental lens to healing. METHODS: This CANS 2020 Keynote article describes the history of nursing environmental science and nurses important contributions to the US Environmental Justice Movement. Starting with Florence Nightingale's Notes on Nursing, which established Environmental Theory, the paper introduces key figures throughout nursing history who have studied and advocated for environmental health and justice. FINDINGS: The paper emphasizes that nursing has always been about environmental health and that, regardless of specialty or practice setting, all nurses are called to incorporate environmental science and translation into their research and practice. CONCLUSION: This call to action is especially critical today in the context of urgent issues like climate change, environmental racism and racial health disparities, emerging infectious diseases like COVID-19, and chemical exposures in the home and workplace (among others).

The Role of Social Support in Moderating the Relationship between Race and Hypertension in a Low-Income, Urban, Racially Integrated Community.

In the US, African Americans have a higher prevalence of hypertension than Whites. Previous studies show that social support contributes to the racial differences in hypertension but are limited in accounting for the social and environmental effects of racial residential segregation. We examined whether the association between race and hypertension varies by the level of social support among African Americans and Whites living in similar social and environmental conditions, specifically an urban, low-income, racially integrated community. Using data from the Exploring Health Disparities in Integrated Communities-Southwest Baltimore (EHDIC-SWB) sample, we hypothesized that social support moderates the relationship between race and hypertension and the racial difference in hypertension is smaller as the level of social support increases. Hypertension was defined as having systolic blood pressure greater than 140 mmHg and/or diastolic blood pressure greater than 90 mmHg, or the participant reports of taking antihypertensive medication(s). The study only included participants that self-reported as "Black/African American" or "White." Social support was measured as functional social support and marital status. After adjusting for demographics and health-related characteristics, we found no interaction between social support and race (DUFSS score, prevalence ratio 1.00; 95% confidence interval 0.99, 1.01; marital status, prevalence ratio 1.02; 95% confidence interval 0.86, 1.21); thus the hypothesis was not supported. A plausible explanation is that the buffering factor of social support cannot overcome the social and environmental conditions which the participants live in. Further, these findings emphasize social and environmental conditions of participants in EHDIC-SWB may equally impact race and hypertension.

Explained and unexplained racial and regional inequality in obesity prevalence in the United States.

Objective: There are substantial racial and regional disparities in obesity prevalence in the United States. This study partitioned the mean Body Mass Index (BMI) and obesity prevalence rate gaps between non-Hispanic blacks and non-Hispanic whites into the portion attributable to observable obesity risk factors and the remaining portion attributable to unobservable factors at the national and the state levels in the United States (U.S.) in 2010. Design: This study used a simulated micro-population dataset combining common information from the Behavioral Risk Factor Surveillance System and the U.S. Census data to obtain a reliable, large sample representing the adult populations at the national and state levels. It then applied a reweighting decomposition method to decompose the black-white mean BMI and obesity prevalence disparities at the national and state levels into the portion attributable to the differences in distribution of observable obesity risk factors and the remaining portion unexplainable with risk factors. Results: We found that the observable differences in distribution of known obesity risk factors explain 18.5% of the mean BMI difference and 20.6% of obesity prevalence disparities between non-Hispanic blacks and non-Hispanic whites. There were substantial variations in how much the differences in distribution of known obesity risk factors can explain black-white gaps in mean BMI (-67.7% to 833.6%) and obesity prevalence (-278.5% to 340.3%) at the state level. Conclusion: The results from this study demonstrate that known obesity risk factors explain a small proportion of the racial, ethnic and between-state disparities in obesity prevalence in the United States. Future etiologic studies are required to further understand the causal factors underlying obesity and racial, ethnic and geographic disparities.

Reducing health disparities among black individuals in the post-treatment environment.

An important step in reducing health disparities among racial and ethnic minorities with substance use disorders involves identifying interventions that lead to successful recovery outcomes for this population. The current study evaluated outcomes of a community-based recovery support program for those with substance use disorders. Participants included 632 residents of recovery homes in three states in the US. A multi-item recovery factor was found to increase over time for these residents. However, rates of improvement among Black individuals were higher than for other racial/ethnic groups. Black Americans perhaps place a higher value on communal relationships relative to all other racial/ethnic groups, and by adopting such a communitarian perspective, they might be even more receptive to living in a house that values participation and involvement. The implications of these findings for health disparities research are discussed.

Mass incarceration and public health: the association between black jail incarceration and adverse birth outcomes among black women in Louisiana.

BACKGROUND: A growing body of evidence is beginning to highlight how mass incarceration shapes inequalities in population health. Non-Hispanic blacks are disproportionately affected by incarceration and criminal law enforcement, an enduring legacy of a racially-biased criminal justice system with broad health implications for black families and communities. Louisiana has consistently maintained one of the highest rates of black incarceration in the nation. Concurrently, large racial disparities in population health persist. METHODS: We conducted a cross-sectional analysis of all births among non-Hispanic black women in Louisiana in 2014 to identify associations between parish-level (county equivalent) prevalence of jail incarceration within the black population and adverse birth outcomes (N = 23,954). We fit a log-Poisson model with generalized estimating equations to approximate the relative risk of preterm birth and low birth weight associated with an interquartile range increase in incarceration, controlling for confounders. In sensitivity analyses, we additionally adjusted for the parish-level index crime prevalence and analyzed regression models wherein white incarceration was used to predict the risk of adverse birth outcomes in order to quantify the degree to which mass incarceration may harm health above and beyond living in a high crime area. RESULTS: There was a significant 3% higher risk of preterm birth among black women associated with an interquartile range increase in the parish-level incarceration prevalence of black individuals, independent of other factors. Adjusting for the prevalence of index crimes did not substantively change the results of the models. CONCLUSION: Due to the positive significant associations between the prevalence of black individuals incarcerated in Louisiana jails and estimated risk of preterm birth, mass incarceration may be an underlying cause of the persistent inequities in reproductive health outcomes experienced by black women in Louisiana. Not only are there economic and social impacts stemming from mass incarceration, but there may also be implications for population health and health inequities, including the persistence of racial disparities in preterm birth and low birth weight.

Role of bleeding recognition and evaluation in Black-White disparities in endometrial cancer.

BACKGROUND: Advanced stage at diagnosis is an independent, unexplained contributor to racial disparity in endometrial cancer. OBJECTIVE: We sought to investigate whether, prior to diagnosis, provider recognition of the cardinal symptom of endometrial cancer, postmenopausal bleeding, differs by patient race. STUDY DESIGN: Black and White women diagnosed with endometrial cancer (2001 through 2011) from Surveillance, Epidemiology, and End Results-Medicare who had at least 2 years of claims prior to diagnosis were identified. Bleeding diagnoses along with procedures done prior to diagnosis were captured via claims data. Multinomial logistic regression was used to evaluate the association of race with diagnostic workup and multivariate models built to determine the association of appropriate diagnostic procedures with stage at diagnosis. RESULTS: In all, 4354 White and 537 Black women diagnosed with endometrial cancer were included. Compared to White women, Black women were less likely to have guideline-concordant care: postmenopausal bleeding and appropriate diagnostic evaluation (70% vs 79%, P < .001), with adjusted relative risk ratios of 1.12-1.73 for different nonguideline-concordant pathways: bleeding without diagnostic procedures, alternative bleeding descriptions, and neither bleeding nor procedures. These pathways were associated with higher odds of advanced stage at diagnosis (adjusted odds ratio, 1.90-2.88). CONCLUSION: The lack of recognition and evaluation of postmenopausal bleeding is associated with advanced stage at diagnosis in endometrial cancer. Older Black women are at highest risk for the most aggressive histology types, yet they are less likely to have guideline-concordant evaluation of vaginal bleeding. Efforts aimed at improving recognition-among patients and providers-of postmenopausal bleeding in Black women could substantially reduce disparities in endometrial cancer.

The Impact of Urban US Policing Practices on Black Men Who Have Sex with Men's HIV Vulnerability: Ethnographic Findings and a Conceptual Model for Future Research.

This paper advances research on racism and health by presenting a conceptual model that delineates pathways linking policing practices to HIV vulnerability among Black men who have sex with men in the urban USA. Pathways include perceived discrimination based on race, sexuality and gender performance, mental health, and condom-carrying behaviors. The model, intended to stimulate future empirical work, is based on a review of the literature and on ethnographic data collected in 2014 in New York City. This paper contributes to a growing body of work that examines policing practices as drivers of racial health disparities extending far beyond violence-related deaths.

The Association of Socioeconomic Status With Subclinical Myocardial Damage, Incident Cardiovascular Events, and Mortality in the ARIC Study.

The association between socioeconomic status (SES) and subclinical cardiovascular disease is not well understood. Using data from the Atherosclerosis Risk in Communities Study, we sought to evaluate the cross-sectional and prospective associations of SES, measured by annual income and educational level, with elevated high-sensitivity cardiac troponin T (hs-cTnT) concentrations (≥14 ng/L) using Poisson and multinomial logistic regressions, respectively. We used Cox proportional hazard models to compare the risks of coronary heart disease, heart failure, and mortality according to SES, stratified by baseline hs-cTnT concentration. Our study baseline was 1990-1992, with follow-up through 2011. We found an independent association between SES and hs-cTnT. When comparing participants in the lowest educational level group to those in the highest, the adjusted prevalence ratios for elevated hs-cTnT were 1.36 (95% confidence interval: 1.05, 1.75) overall, 1.83 (95% confidence interval: 1.23, 2.71) in blacks, and 1.05 (95% confidence interval: 0.73, 1.52) in whites (P for interaction = 0.08). Among participants with nonelevated hs-cTnT concentrations, when comparing those in the lowest income groups to those in the highest, the adjusted hazard ratios were strongest for heart failure and death. Having elevated baseline hs-cTnT doubled the risk of heart failure and death. Persons with low SES and elevated hs-cTnT concentrations have the greatest risk of cardiovascular events, which suggests that this group should be aggressively targeted for cardiovascular risk reduction.

Interaction of Alu Polymorphisms and Novel Measures of Discrimination in Association with Blood Pressure in African Americans Living in Tallahassee, Florida.

African Americans are 40% more likely to be afflicted with hypertension than are non-Hispanic, white Americans, resulting in a 30% higher instance of mortality due to cardiovascular disease. There is debate about the relative contributions of genetic and sociocultural risk factors to the racial disparity in hypertension. We assayed three Alu insertion polymorphisms located in the ACE (angiotensin 1 converting enzyme), PLAT (plasminogen activator, tissue), and WNK1 (lysine deficient protein kinase 1) genes. We also estimated West African genetic ancestry and developed novel measures of perceived discrimination to create a biocultural model of blood pressure among African American adults in Tallahassee, Florida (n = 158). When tested separately, the ACE Alu noninsertion allele was significantly associated with higher systolic and diastolic blood pressure. In multiple regression analyses, West African genetic ancestry was not associated with blood pressure and reduced the strength of all blood pressure models tested. A gene × environment interaction was identified between the ACE Alu genotype and a new measure of unfair treatment that includes experiences by individuals close to the study participant. Inclusion of the WNK1 Alu genotype further improved this model of blood pressure variation. Our results suggest an association of the ACE and WNK1 genotypes with blood pressure that is consistent with their proposed gene functions. Measures of perceived unfair treatment of others show a threshold effect, with increased blood pressure occurring at higher values. The interaction between the ACE genotype and unfair treatment highlights the benefits of including both genetic and cultural data to investigate complex disease.