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1. Decrease the # of African American adults in San Francisco hospitalizations due to cardiovascular disease in 2-3 years.

2. Decrease the # of deaths of African American adults in San Francisco due to cardiovascular disease in 2-3 years.

3. Decrease the # of African American adults in San Francisco who have cardiovascular disease in 2-3 years.

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Project Director (Part-Time)

Project Coordinator (Part-Time)

7 Hearty Ambassadors

Social Media Consultant

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Hearty Attitude
"don't make things hearter"

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1. Increase the # of African American adults in San Francisco eating healthier by 1 year (behavior)

2. Increase the # of African American adults in San Francisco that cook healthier meals by 1 year (behavior)

3. Decrease the # of African American adults in San Francisco smoking tobacco by 1 year (behavior)

4. Increase the # of daily activity African American adults exercise in San Francisco by 1 year (behavior)

5. Increase the # of African American adults in San Francisco that get screened for cardiovascular disease by 1 year (behavior)

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African American adults aged 40+ who live in San Francisco

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Cardiovascular Disease is the Leading Cause of Global Deaths 

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Cardiovascular Disease is the Leading Cause of Global Deaths 

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Cardiovascular diseases are the leading cause of global deaths in all regions of the world, in the us alone there were about 774,165 deaths from CVD in 2015

In the U.S., the age-adjusted mortality rates for heart disease and stroke in African-American people remain the highest.

Mensah, G. A. (2018, November). Cardiovascular diseases in African Americans: Fostering Community Partnerships to stem the Tide. American journal of kidney diseases : the official journal of the National Kidney Foundation. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6200348/#:~:text=Although%20the%20national%20age%2Dadjusted,compared%20to%20rates%20in%20Whites.

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Burden of cardiovascular disease on the African American adults

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Burden of cardiovascular disease on the African American adults

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In 2018, Black Americans were 30% more likely to die from heart disease and 40% more likely to have high blood pressure than white adults. Young, Black adults in particular were observed to have higher rates of health complications and poor hospital outcomes in the U.S. from 2007 to 2017. Despite the advancements in medication, screening, and diagnostic techniques, the rates of cardiovascular disease have yet to decrease among African American. Researchers found that in 2017, the patients were:

Younger (mean of age 30 vs 31 in 2007), male (30.4% vs 28.8% in 2007)

3 times more likely to have type 2 diabetes with chronic complications

More than 2 times likely to have obesity

2 times more likely to be tobacco smokers

(Penn Medicine, Why Heart Disease Is an Even Greater Threat to Black Adults, 2022) (Newsroom, Young, Black adults had a higher risk of heart disease, worse hospital outcomes, 2021)

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Why Heart Disease Is an Even Greater Threat to Black Adults

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Heart disease is the leading cause of death for all Americans, regardless of race or ethnicity. But Black adults are at greater risk than white adults and all other minorities in the United States.

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Lack of physical activity and obesity increases risk of heart and circulatory disease

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Lack of physical activity and obesity increases risk of heart and circulatory disease

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Being physically inactive and obese can lead to the buildup of fatty material in your arteries that can get damaged/clogged and as a result lead to a heart attack or stroke.

(British Foundation, Physical Inactivity) (British Foundation, Obesity) (British Foundation, Diabetes- causes, symptoms & treatments)

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Being physically inactive or sedentary can lead to heart and circulatory diseases like heart attack and stroke.
What is physical inactivity?

Physical inactivity or being sedentary is when you don't move your body for long periods of time. This can include sitting or lying on the sofa watching TV, and sitting at a desk or computer. Being physically active doesn't mean you need to join a gym or run a marathon. It can include things like housework and gardening - it's all about getting up and moving more.

How does physical inactivity increase the risk of heart and circulatory diseases?

Being inactive can lead to fatty material building up in your arteries (the blood vessels that carry blood to your organs). If the arteries that carry blood to your heart get damaged and clogged, it can lead to a heart attack. If this happens in the arteries that carry blood to your brain it can lead to a stroke. The good news is there are many ways to reduce the risk of this happening.

Why should I be more active?

The heart is a muscle, and like any other muscle it needs physical activity or exercise to help it work properly. When you're active, your lungs do a better job of getting oxygen into your blood so it can be pumped to all the tissues and cells of your body.

Being active can reduce your risk of developing some heart and circulatory diseases by as much as 35%. Regular physical activity:

helps control your blood pressure and keep it within healthy levels

raises your levels of good cholesterol, and reduces the bad cholesterol

can help to control your blood glucose levels, reducing your risk of Type 2 diabetes

increases the number of calories you burn and helps you maintain a healthy weight.

Not only does regular activity protect your heart, it can also help your general wellbeing by boosting your mood, improving your concentration and memory, and helping you sleep better.

How active do I need to be?

To reduce your risk of heart and circulatory diseases, you need to be active every day. You don't need to do specific exercises or take up a sport, you can go for a walk, mow the lawn, vacuum, or dance along to music. Any activity is better than none, and you should try to break up long periods of inactivity like sitting or lying down. When you're watching TV, get up and walk around during the ad breaks.

Aim to do at least 150 minutes of moderate intensity activity per week. This is anything that raises your heart rate, and makes you breathe faster and feel warmer, like brisk walking or cycling. You can spread out the 150 minutes over the week. You can even do short bursts of activity - every minute counts. You should also aim to do muscle strengthening activities like using hand weights, climbing the stairs, gardening such as digging, or carrying heavy shopping on at least two days a week.

Learn more about how physical activity can reduce your risk of heart and circulatory diseases.

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Being physically inactive or sedentary can lead to heart and circulatory diseases like heart attack and stroke.

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Program Activities Phase 1: Program Development (mos. 1-3)

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Program Activities Phase 1: Program Development (mos. 1-3)

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Hire staff

Find a space in San Francisco to rent that is easily accessible via walking or public transportation for program activities (recreation centers, parks, etc.)

Gather materials

Develop a curriculum to train Hearty Safety Ambassadors about cardiovascular disease (screening with doctors and upkeep, healthy cooking, exercising, stopping smoking Tobacco), public speaking, training skills, and media advocacy

Develop a curriculum to train San Francisco African-American adults on how to screen with doctors and upkeep, healthy cooking, exercising by walking daily, and stop smoking Tobacco

Partnerships with local farmers markets for deals with ingredients and local clinics for screenings

Recruit 7 African American adults as Hearty Ambassadors

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Smokers Increased Risk for Cardiovascular Disease 

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Smokers Increased Risk for Cardiovascular Disease 

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Smoking kills more than 400,000. people in the U.S. each year, those who smoke are at a higher risk of developing heart disease or stroke. According to CDC, 34,000 people who are nonsmokers die from second-hand smoking.

Smoking can cause changes to the hearts blood vessels, such as reducing blood flow to the heart, increases the risk for blood clots, reducing the amount of oxygen that goes to the body's tissues.

Out of all the risks to developing cardiovascular disease, smoking can be the most preventable cause of early death.

(John Hopkins Medicine / Smoking and Cardiovascular Disease, https://www.hopkinsmedicine.org/health/conditions-and-diseases/smoking-and-cardiovascular-disease)

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The American Heart Association (AHA) says diseases caused by smoking kill more than 440,000 people in the U.S. each year. Most new smokers are children and teens. Smokers have higher risk for lung disease. This includes lung cancer and emphysema. They also have increased risk for heart disease and stroke.

Facts about smoking and heart disease

One out of every 5 smoking-related deaths is caused by heart disease.

Women older than 35 who smoke and take birth control pills are at much greater risk for heart disease or stroke.

Cigarette smokers are 2 to 4 times more likely to get heart disease than nonsmokers.

Cigarette smoking doubles a person's risk for stroke.

How does smoking change the heart and blood vessels?

Smoking:

Causes an instant and long-term rise in blood pressure.

Causes an instant and long-term increase in heart rate.

Reduces blood flow from the heart.

Reduces the amount of oxygen that reaches the body's tissues.

Increases risk for blood clots.

Damages blood vessels.

Doubles the risk of stroke (reduced blood flow to the brain).

Smoking has also been linked with depression and stress.

What are the risks of secondhand smoke?

The CDC says about 34,000 nonsmokers die from heart disease each year from exposure to secondhand tobacco smoke. Secondhand smoke is smoke exhaled by smokers. It also includes smoke from the burning end of a lit cigarette, cigar, or pipe.

Exposure to smoke poses health hazards to pregnant women, infants, and young children. Children and infants exposed to tobacco smoke are more likely to have ear infections and asthma. They are also at higher risk for sudden infant death syndrome (SIDS).

These symptoms may be from exposure to secondhand smoke:

The symptoms of secondhand smoke may look like other medical conditions and problems. Always see your healthcare provider for a diagnosis.

Smoking and heart disease

Smoking, along with high cholesterol, high blood pressure, physical inactivity, obesity, and diabetes, tops the list as a primary risk factor for heart disease. In fact, smoking is the single most preventable cause of early death in the U.S.

Why quit smoking?

According to the AHA, stopping smoking reduces the risk for heart disease, the risk for repeat heart attacks, and death by heart disease by half. Research also shows that quitting smoking is key in the management of many contributors to heart attack. These include atherosclerosis, blood clots and abnormal heart rhythms.

To be successful, you should be mentally ready and relatively stress-free. Physically, you need to commit to exercising daily and getting plenty of sleep. A person trying to quit must overcome 2 obstacles: a physical addiction to nicotine and a habit. The National Cancer Institute offers these tips to help users quit using tobacco products:

Think about why you want to quit.

Pick a stress-free time to quit.

Ask for support and encouragement from family, friends, and co-workers.

Start doing some exercise or activity each day to relieve stress and improve your health.

Get plenty of rest.

Eat a balanced diet.

Join a smoking cessation program, or other support group.

Disconnect your activities of smoking and replace them with newer healthier activities.

In some cases, nicotine replacement products can help break a smoking habit. Nicotine replacement products continue to give smokers nicotine to meet their nicotine craving. However, nicotine replacement products do not contain the tars and toxic gases that cigarettes emit. Pregnant or nursing women and people with other medical conditions should consult with their healthcare provider before using any nicotine replacement products. Some examples of nicotine replacement products include:

Nicotine chewing gum. An over-the-counter chewing gum that releases small amounts of nicotine to help reduce nicotine withdrawal symptoms.

Nicotine patch. An over-the-counter patch applied to the upper body once a day that releases a steady dosage of nicotine to help reduce the urge to smoke.

Nicotine inhaler or nose spray. A prescription nicotine replacement product that releases nicotine to help reduce withdrawal symptoms (requires a doctor's approval before use).

Medicines to help you quit smoking

Bupropion. This is a non-nicotine option to help people stop smoking. It is approved by the FDA. Offered in pill form to smokers who want to quit, bupropion has been shown to alter mood transmitters in the brain that are linked to addiction. Bupropion must be prescribed by a healthcare provider and may not be right for everyone. Ask your healthcare provider for more information.

Varenicline. This is also a non-nicotine pill to help you quit smoking. It is approved by the FDA. It targets the nicotine receptors in the brain. Varenicline attaches to the receptors and blocks nicotine from reaching them. This decreases the desire for nicotine. Varenicline may not be right for everyone.

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Smokers not only have increased risk of lung disease, including lung cancer and emphysema, but also have increased risk of heart disease, stroke, and oral cancer.

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Program Activities Phase 2: Program Implementation (mos. 4-22)

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Program Activities Phase 2: Program Implementation (mos. 4-22)

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Training Hearty Ambassadors:

Train 7 Ambassadors who will meet for 3 hours a day for 4 days a week for a month. They will learn how to lecture about smoking and screening, learn basic cooking skills and recipes, learn what walking trails to lead nature walks on, know how to spread outreach messages, and social media campaigning.

Hearty Ambassadors Conduct Separate Sessions For Hearty Participants:

Every two months there will be a new group with 25 people for 16 months. After two months, a new group will be instilled. The first and third Tuesday of each month will be for teaching about screening and smoking. Every Wednesday of the month will be a workshop for cooking. Every Saturday morning will have a nature walk for all participants throughout the program to join.

Screening and Smoking Session:

Teach a course to 25 participants about the importance of screening and the dangers/debunking myths of smoking. (2 hours every first and third Tuesday for 16 months)

Cooking Session: Teach 25 participants about healthy eating habits, and give healthy recipes with YouTube tutorials, and live demonstrations to try a healthy dish. (3 hours every Wednesday for 16 months)

Nature Walks: Participants will learn the importance of being active and will take part and go on a 2-hour nature walk on local trails. All participants are allowed to join from previous months too. (2 hours, every Saturday morning for 16 months)

Training Approach:

Interactive

Workshops

Getting into a routine

Training Topics:

Identifying risk factors and preventative care

Learning basic recipes and kitchen skills

Implementing a low-intensity workout into their routine

Spread Outreach Messages/Social Media Campaigning:

Ambassadors create outreach messages that can be put out in the community and create social media posts/campaigns to advertise the program. (run for 8 months)

20 posters/billboards in San Francisco targeting African Americans (importance of screening, prevention of Cardiovascular Disease, and promoting the Hearty Attitude program)

100 social media posts on platforms using trends to show the importance of getting screened(Instagram, Twitter, Tiktok)

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Food Deserts Decrease Healthy Food Options

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Food Deserts Decrease Healthy Food Options

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Socioeconomic status disadvantages of education, employment, income, and even ZIP code can be an influence to the health of African Americans. The majority of the 94124 zip code, which is in the Bayview area of San Francisco, live in a food desert. With only two grocery stores in the neighborhood, there is not enough fresh food being offered. According to The City’s COVID-19 Command Center report, Latinos and Black seniors are twice as likely to be food insecure in San Francisco which in turn increases the risk of cardiovascular disease.

Graf, C. (2021, November 17). San Francisco’s Bayview district struggles to emerge from food desert. San Francisco Examiner. https://www.sfexaminer.com/archives/san-francisco-s-bayview-district-struggles-to-emerge-from-food-desert/article_f8cddb4b-9594-57d0-9700-c71b2f24e345.html

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Tiffany Carter grew up eating food grown in her grandmother's backyard. Plums, lemons and apples would fall from tree branches and practically land on her plate. Crunchy collard greens harvested from the same garden were a mealtime staple.

But Carter's childhood is not the norm in San Francisco's Bayview neighborhood, where she grew up. Today, most residents don't even enjoy access to a well-stocked grocery store much less a backyard garden.

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San Francisco's Bayview district struggles to emerge from food desert

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'It definitely has an impact on your psyche'

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Cardiovascular disease in adults San Francisco

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Cardiovascular disease in adults San Francisco

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23.4 percent of adults living in San Francisco have been told that they have high blood pressure with African Americans having the highest percentage (33.5 percent)

Cardiovascular disease and stroke. SFHIP. (n.d.). https://sfhip.org/chna/community-health-data/cardiovascular-disease-and-stroke/#:~:text=Heart%20disease%2FHeart%20failure%3A%20Overall,female%20adults%20

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Stroke: In 2015, 3.6% of the 69,947 Medicare beneficiaries were treated for stroke in San Francisco. The rate is very close to the rate for California and is ranked the 26th highest county in the state.

What is currently being done in San Francisco to improve health?

Data Sources

CHIS: California Health Interview Survey (CHIS), UCLA Center for Health Policy Research.
Medicare Chronic Conditions Dashboard: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Dashboard/Chronic-Conditions-County/CC_County_Dashboard.html
OSHPD: Office of Statewide Health Planning and Development (OSHPD).

Methods and Limitations

Hospitalizations and Emergency Room Visits:
Hospitalization and Emergency Room visit rates measure the number of admissions or visits, not the number of residents who are hospitalized. Admissions records may include multiple admissions by the same person.

​In October 2015, the diagnosis coding standard for Hospitalizations and Emergency Room visits was changed from ICD-9 to ICD-10. Caution should be used in comparing data using the two different standards.

Hypertension: Agency for Healthcare Research and Quality's Clinical Classification Software versions 2015 (ICD-9) and 2017 (ICD-10 ) were used to identify hospitalizations with a primary diagnosis of hypertension.

Heart Failure: ICD-9 and ICD-10 codes for heart failure were adapted from the PQI 08: Heart Failure Admission Rate (September 2017) and PQI 08 : Heart Failure Admission Rate (March 2015) technical specifications published by the Agency for Healthcare Research and Quality. The case definition used here varies from that in the PQI 08 in that records indicating cardiac procedures were not excluded. A medical visit was determined to be primarily due to heart failure if the primary diagnosis field contained the identified ICD-9-CM (discharges prior to October 2015) or ICD-10 (October 2015 and later) codes.
Population estimates for rates:

State of California, Department of Finance, Race/Hispanics Population with Age and Gender Detail, 2000-2010. Sacramento, California, September 2012.

California Department of Finance. Demographic Research Unit. 2018. State and county population projections 2010-2060 [computer file]. Sacramento: California Department of Finance. February 2017.

Standard Population for age adjustment:

Population Projections of the United States by Age, Sex, Race, and Hispanic Origin: 1995 to 2050. U.S. Department of Commerce, Economics and Statistics Administration, BUREAU OF THE CENSUS

Statistical instability: Statistically unstable estimates are not shown in this document. Statistical instability may arise from:

few respondents to a survey,

small population sizes, or

small numbers of affected individuals.

Statistical instability indicates a lack of confidence in the ability of an estimate to accurately and reliably represent the population. Due to statistical instability, estimates are not available for all age, gender, ethnicity, or other groups.

References

[1] American Heart Association. What is cardiovascular disease. http://www.heart.org/HEARTORG/Caregiver/Resources/ WhatisCardiovascularDisease/What-is-Cardiovascular-Disease_UCM_301852_Article.jsp, 2017.
[ 2] American Heart Association. What is heart disease and stroke. 2015. http://www.heart.org/idc/groups/heart-public/@wcm/@hcm/documents/downloadable/ucm_300313.pdf.
[ 3] Healthy People 2020. Heart disease and stroke. http://www.healthypeople.gov/2020/topics-objectives/topic/heart-disease-and-stroke, 2017.
[ 4] Centers for Disease Control, Prevention (CDC, et al. Vital signs: avoidable deaths from heart disease, stroke, and hypertensive disease-united states, 2001-2010. MMWR. Morbidity and mortality weekly report, 62(35):721, 2013.
[ 5] Lung National Heart and Blood Institute. What is metabolic syndrome. https://www.nhlbi.nih.gov/health/health-topics/topics/ms, 2016.
[ 6] American Heart Association. Why metabolic syndrome matters. http://www.heart.org/HEARTORG/Conditions/More/MetabolicSyndrome/Why-Metabolic-Syndrome-Matters_UCM_301922_Article.jsp#.WdVf4FtSzW4, 2016.
[ 7] American Heart Association. Cardiovascular disease and diabetes. http://www.heart.org/HEARTORG/Conditions/More/Diabetes/WhyDiabetesMatters/Cardiovascular-Disease-Diabetes_UCM_313865_Article.jsp#.WLchClXyuUk, 2015. Accessed March 1, 2017.
[ 8] American Heart Association. Facts: Bridging the gap, cvd health disparities. 2012.
https://www.heart.org/idc/groups/heart-public/@wcm/@hcm/@ml/documents/downloadable/ucm_429240.pdf.
[ 9] Donald Lloyd-Jones, Robert Adams, Mercedes Carnethon, Giovanni De Simone, T Bruce Ferguson, Katherine Flegal, Earl Ford, Karen Furie, Alan Go, Kurt Greenlund, Nancy Haase, Susan Hailpern, Michael Ho, Virginia Howard, Brett Kissela, Steven Kittner, Daniel Lackland, Lynda Lisabeth, Ariane Marelli, Mary McDermott, James Meigs, Dariush Mozaffarian, Graham Nichol, Christopher O'Donnell, Veronique Roger, Wayne Rosamond, Ralph Sacco, Paul Sorlie, Randall Stafford, Julia Steinberger, Thomas Thom, Sylvia Wasserthiel-Smoller, Nathan Wong, Judith Wylie-Rosett, Yuling Hong, American Heart Association Statistics Committee, and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2009 update: a report from the american heart association statistics committee and stroke statistics subcommittee. Circulation, 119:e21-181, January 2009.
[ 10] Centers for Disease Control and Prevention (CDC). Disparities in premature deaths from heart disease-50 states and the district of columbia, 2001. MMWR. Morbidity and mortality weekly report, 53:121-125, February 2004.
[ 11] J Adam Leigh, Manrique Alvarez, and Carlos J Rodriguez. Ethnic minorities and coronary heart disease: an update and future directions. Current atherosclerosis reports, 18:9, February 2016.
[ 12] Harvard Health Publishing. Race and ethnicity; clues to your heart disease risk. https://www.health.harvard.edu/heart-health/race-and-ethnicity-clues-to-your-heart-disease-risk, 2015.
[ 13] LaPrincess C Brewer and Lisa A Cooper. Race, discrimination, and cardiovascular disease. Virtual Mentor, 16(6):455, 2014.
[ 14] Garth Graham. Disparities in cardiovascular disease risk in the united states. Current cardiology reviews, 11:238-245, 2015.
[ 15] American Heart Association. Asian & pacific islanders and cardiovascular diseases. https://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319570.pdf, 2013.

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Stroke: In 2015, 3.6% of the 69,947 Medicare beneficiaries were treated for stroke in San Francisco. The rate is very close to the rate for California and is ranked the 26th highest county in the state. CHIS: California Health Interview Survey (CHIS), UCLA Center for Health Policy Research.

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How are African American adults impacted in San Francisco?

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How are African American adults impacted in San Francisco?

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In the southwest half of San Francisco, hospitalization and emergency room visit rates due to cardiovascular disease are higher among residents (100 vs 19 per 10,000 residents). 23.4% of adults living in San Francisco have been told that they have high blood pressure. Hospitalization rates from heart diseases (hypertension/heart failure) is 3-5 times higher for Black/African Americans than all other races.

(SF.GOV, Health Disparities Dashboard) (SFHIP, Cardiovascular Disease and Stroke)

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San Francisco Population Health & Equity Metrics

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Socioeconomic Status on Cardiovascular Risks 

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Socioeconomic Status on Cardiovascular Risks 

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SES disadvantages are education, employment, income, and even ZIP code can be an influence to the health of African Americans.

Lifestyle choices or behaviors can be influenced from the community and neighborhood, such as having access to healthy foods, neighborhood violence, safety, or community bond.

(NIH / Effect of Race and Socioeconomic Status on Cardiovascular Risk Factor Burden: The Cooper Center Longitudinal Study, December 15, 2014, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4266688/#:~:text=Results,have%20all%20three%20risk%20factors.)(Frierson, G. M., et al., Cardiovascular Diseases in African Americans: Fostering Community Partnerships to Stem the Tide, November 1, 2019, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6200348/#:~:text=The%20greater%20prevalence%20of%20adverse,risk%20factors%20in%20the%20former.)

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Gorita M. Frierson, PhD, Erica N. Howard, MS, Laura F. DeFina, MD, Tiffany M. Powell-Wiley, MD, MPH, and Benjamin L. Willis, MD, MPH

Abstract

Objectives

This study examines the prevalence of cardiovascular risk factors and chronic disease burden among African Americans compared to Caucasians in a population of higher socioeconomic status.

Design

The current study is a cross-sectional, secondary data analysis of the Cooper Center Longitudinal Study.

Setting

Patients with a medical examination from 1970-2010 at the Cooper Clinic.

Participants

762 African Americans and 40,051 Caucasians who met the criteria.

Outcome Measures

Racial differences in cardiovascular risk factors/burden of disease between African Americans and Caucasians.

Results

African Americans had higher prevalence of evaluated cardiovascular risk factors than did Caucasians after controlling for obesity, tobacco use, and physical fitness. Caucasians had greater likelihood of no risk factors while African Americans were more likely to have all three risk factors. Race was typically predictive of cardiovascular risk factors in African Americans compared to Caucasians.

Conclusions

Findings suggest that health differences persist despite greater socioeconomic status, and further investigations of biopsychosocial causes are warranted. (Ethn Dis. 2013;23[1]:35-42)

Keywords: Socioeconomic Status, Racial/ethnic Minorities, Preventive Medicine, Cardiovascular Risk Factors

Introduction

Despite the increasing life expectancy for the US population, a greater burden of disease continues to exist among African American (AA) men and women compared to their Caucasian counterparts. In 2007, the age-adjusted death rate was 1.3 times greater for African Americans than Caucasians.1 African Americans' lifespan is 4.8 years (on average) less than Caucasians.1 Cardiovascular disease (CVD) in African Americans accounted for 44.6% and 46.9% of deaths in men and women, respectively, in 2006.2,3 Data from the Centers for Disease Control and Prevention further demonstrate racial/ethnic health disparities by a 32.3% higher mortality rate due to strokes among African Americans compared to Caucasians.3 In addition to CVD, African Americans also have a higher prevalence of cardiovascular risk factors including hypertension, obesity, diabetes mellitus, and physical inactivity.2 For example, 48% of African Americans have multiple cardiovascular risk factors vs 37% of the remainder of the population.4 While race is commonly explored in the health disparities literature, its meaning and relationships to health are routinely discussed for additional clarity in these studies.

The meaning of race has varied over the decades to refer to physical traits or phenotypical features5 or a social political construct that places certain races above or below another race in a so-called hierarchy.6,7 The lack of a conceptual consensus, varied methods to assess, and nebulous operational definitions of race across disciplines has led to a growing methodological literature to further clarify the meaning, influences, and related factors to race. For example, the construct of ethnicity, which is not synonymous with race, could replace race in health disparities research as this term refers to values, customs, behaviors, and/or traditions.8 This construct can be added to a study with an acculturation measure.9 The influence of genes and/or environment on race and health outcomes has advanced with the growth of technology, genetic research, and quantitative methodologies.10 Furthermore, theory-driven constructs that are strongly correlated to race or certain races (eg, discrimination), while not reinforcing stereotypes, can be used to better delineate the relationships between race and various outcomes.11 Unfortunately, race has been confounded by low socioeconomic status (SES) over the past decades where it is not clear if low SES and/or race is contributing to specific poor health outcomes.12

Socioeconomic status pertains to occupation, income, employment, and at times ZIP Code and insurance status.13 While it is optimal to have all of these indicators of SES in health research, survey design, report bias, and privacy of the participant may prevent an actual or valid assessment of all indices. Race as previously defined does not explicitly explain or describe these prior areas of SES. Thus, the relationships are not between race and SES, and their influence on outcomes must be clearly defined in health research. Past research has attempted to do such where racial health inequality may stem predominantly from SES disadvantages in education, income, and employment status (ie, lower SES).14,15 The literature has attempted to address this prior relationship by statistically controlling for SES which has worked for some health outcomes (asthma) compared to others (hypertension).16,17 Thus, other factors can be influencing racial group differences. Discrimination at the personal and health care system level, medical mistrust, limitations in environmental protection, economic development, and limited access to health care also may contribute.18-22 Inadequate health insurance and access to quality health care are critical elements that impact medical care among racial/ethnic minorities.23 Studies demonstrate strong relationships between these sociodemographic and psychosocial factors and greater CVD mortality in African Americans.24,25 There are limited investigations in racial/ethnic minorities with higher SES, comparable to Caucasians, receiving preventive medical services.22,23 Thus it is not clear if racial/ethnic minorities compared to Caucasians, both with high SES levels, have similarly good health outcomes or the racial/ethnic minorities have poorer health similar to findings of minorities with lower SES in the health inequality literature. These issues may prevent a full understanding of the factors contributing to health and disease disparities between racial/ethnic minorities and non-racial/ethnic minorities. Studies assessing higher SES (ie, college educated and/or currently employed) for racial/ethnic minorities are warranted.

Our study compares the prevalence of cardiovascular risk factors and chronic disease burden between African Americans and Caucasians of higher SES and their access to prevennve health care.

Methods

The Cooper Center Longitudinal Study (CCLS) is a large cohort of men and women who underwent a preventive medical examination at the Cooper Clinic in Dallas, Texas from May 1970 to July 2010.26 Reported results are obtained from 762 self-identified African Americans, 61% men, and 40,051 Caucasians, 68% men, with complete cross-sectional data. Cooper Clinic patients are of higher SES and are self-referred or executives referred by their employer for these extensive preventive medicine examinations. Prior CCLS papers have described this database as primarily White, higher SES, and male.27,28 For the purpose of this investigation, high SES was defined as education attainment and ability to obtain said examination. This data set presents a unique opportunity to examine two racial groups (one being a historically defined minority group) from similar, higher SES backgrounds ( Table 1 ). Patients consented and approved the use of their data for research. The study was approved by The Cooper Institute Institutional Review Board.

Table 1

African American Men (n=463)

Caucasian Men (n=27,238)

P

African American Women (n=299)

Caucasian Women (n=12,813)

P

Chronic diseases - Self-reported history - n (%)

Phenotypic parameters - mean (SD) unless otherwise stated

Body mass index, kg/m ²

29.7 (5.3)

27.6 (4.3)

<.0001

28.2 (6.6)

24.5 (5.0)

<.0001

BMI ≥30 kg/m ², n (%)

162 (35.0)

5469 (20.1)

<.0001

87 (29.1)

1453 (11.3)

<.0001

TG, median (Q ₁,Q ₄), mg/dL

90.0 (69.0,123.0)

112.0 (80.0,164.0)

<.0001

74 (56.0,102.0)

86 (64.0,125.0)

<.0001

The medical exam included self-reported personal and family history and demographic information, physical examination by a physician, anthropometric measurements, electrocardiogram, blood chemistry analyses after an overnight fast of 12 hours, blood pressure assessment, and maximal exercise treadmill test. Weight and height were obtained using a standard physician's scale and stadiometer and used to calculate body mass index (BMI) in kilograms per meter squared (kg/m ²). Obesity was defined as a BMI of ≥30 kg/m ². Waist circumference was measured on a horizontal plane at the level of the umbilicus with a tape measure. Blood pressures were measured using the auscultatory technique with a mercury sphygmomanometer. Blood chemistry was analyzed using automated methods that corresponded to standards set by the CDC's Lipid Standardization Program. Cardiorespiratory fitness (CRF) was determined by the maximal time on the treadmill during the modified Balke protocol. A correlation of r=.92 was established between V02 max and Balke suess test time in minutes.29 A 5-level self-report physical activity (PA) index was calculated where 0 indicated no regular PA; 1, PA other than walking, jogging, or running; 2, walking, jogging, or running <10 miles per week; 3, 10 to 20 miles per week; and 4, >20 miles per week. This scale has been used as a valid measure of PA within the CCLS population.30,31 The Center for Epidemiologic Studies-Depression scale assessed the presence of depressive symptoms over the previous week. Scores range from 0-30; ≥10 indicates clinically significant depression warranting evaluation.32

The three risk factors for cardiovascular disease are defined below. Dyslipidemia was clinically defined as total cholesterol ≥200mg/dL, and/or high density lipoprotein cholesterol (HDL-C) ≤40mg/dL, and/or low density lipoprotein cholesterol (LDL-C) ≥130mg/dL, and/or triglycerides ≥150mg/dL, and/or a self-reported history of hyperlipidemia. Hypertension and diabetes were based on self-reported history and/or SBP >140 and/or DBP >90 and self-reported history and/or fasting blood glucose >126 mg/dL, respectively.

Statistical Analyses

Descriptive analyses, chi-square, and Student's t tests, when appropriate, were conducted on sociodemographics (eg, age, SES, education and employment, marital status), health behaviors (eg, tobacco use, PA), self-reported chronic diseases, and phenotypic parameters (eg, BMI, glucose, blood pressure). T tests were adjusted using Satterthwaite method to account for unequal sample size and variance when appropriate.33 Race/ethnicity findings were reported by sex. Multivariate logistic regression determined the association of race with three relevant cardiovascular risk factors (hypertension, dyslipidemia, and diabetes mellitus). The models were adjusted for race, age, SES, tobacco, obesity, and/or CRF. The number of cardiovascular risk factors (0-3) was determined for sex and racial strata. P ≤.05 was considered significant. Analyses were performed in SAS versiOn 9.1 (SAS Institute, Cary, NC).

Results

Demographic and clinical baseline characteristics (average age = mid-40s) are summarized in Table 1 . Among women, there were significant racial differences in age, education, employment, and personal perception of overall health. African American women were younger, more likely to be employed, but less likely ro be married than Caucasian women. African American men were younger, more likely to be employed, and used less tobacco than Caucasian men. Caucasians self-reported fewer chronic diseases, other than cancers, vs African Americans. African Americans had a significancly greater prevalence of self-reported hypertension (27.4% vs. 17.5% for men [ X² = 31.3, P≤.0001] and 27.10/0 vs. 13.5% for women [ X² = 45.3, P≤.000l]) and diabetes (5.4% vs. 2.0% for men [ X² = 26.0, P≤.0001] and 4.4% vs. 1.9% for women [ X= 9.27, P=.002]). African Americans had higher prevalence of obesity as well as greater systolic blood pressure and lower CRF than their Caucasian counterparts ( Table 1 ).

Figures 1a and ​and1b 1b illustrate the burden of cardiovascular risk factors by absolute numbers, comparing African Americans with Caucasians by sex. A greater proportion of Caucasian men reported none of the identified cardiovascular risk factors (20.5% vs 15.8% in African Americans, P=.012). A similar pattern was identified in women (Caucasian [39.9%] vs. African-American [29.1%], P<.001). A greater proportion of African American men (4.6% vs 2.4%, P=.00l) had all three of the risk factors.

Adjusted logistic regression models in Table 2 for African American men show greater odds for diabetes (OR= 1.94, 95% CI, 1.37, 2.75, P=.002) and hypertension (OR= 1.35, 95% CI, 1.11, 1.64, P=.002). The odds of prevalent hypertension in African American women in the unadjusted model was higher (OR=2.20, 95% CI, 1.74, 2.78, P<.001) and diabetes (OR=2.19, 95% CI, 1.33, 3.62, P=.002). After adjusting for obesity, however, the odds of diabetes in African American women, while greater than Caucasian, becomes statistically non-significant (OR= 1.58, 95% CI, .094, 2.66, P= .087).

Table 2

Hypertensiona

Dyslipidemiab

Diabetes Mellitusc

OR

95% CI

P

OR

95% CI

P

OR

95% CI

P

OR

95% CI

P

OR

95% CI

P

OR

95% CI

P

Discussion

Our study explored the relationship between sociodemographic factors including race and higher SES on CVD risk burden in African Americans and Caucasians with access ro a preventive medical examination. African Americans presented with a greater prevalence of the self-reported chronic diseases. African Americans had greater odds of prevalent hypertension and diabetes mellitus as compared ro Caucasians. Past research indicated greater morbidity from diabetes and hypertension for African Americans than Caucasians as well.34 In multivariate analyses, obesity strongly influences the risk of diabetes in African American women; in contrast, African Americans had lower risk for the lipid disorders.35 Our srudy found sex-specific health disparities between African Americans and Caucasians, and we examined the impact of additional covariates (obesity, tobacco use, age, SES, and CRF) that can increase cardiovascular risk factor burden. Race as a predictor appeared to be independent, given that our SES was homogenous and should not confound our analyses of other prevalent cardiovascular risk factors in the models. Addressing the overall burden of cardiovascular risk factors as a sum, Caucasians overwhelmingly had greater prevalence of being free of these factors. Despite being socioeconomically similar, African Americans had higher prevalence of multiple risk factors (3 factors). Similar to other health disparities research, our findings demonstrated racial/ethnic differences in chronic disease risk factor burden such as hypertension.14,36,37

Does race, SES, or combination affect health disparities between African Americans and Caucasians?14 Although SES is a complex variable to measure, it is seen as a predictor of racial/ethnic minority health outcomes. Past reports were inconsistent regarding health disparities after controlling for SES.38,39 We conrrolled for SES, but racial health disparities still existed. Greater understanding of these health disparities and correlates is needed. Our study suggests that being African American has unique medical implications, independent of SES, which must be taken into account by health care providers.

Recently, a debate has risen regarding the impact of race and ethnicity on health and disease status, stemming from the lack of clarity of the role of race/ethnicity within the genetic, environmental, psychosocial, and cultural milieu.40,41 Some factors can be linked to theories about the psychosocial and cultural implications of race.42,43 One theory is the "diminishing return hypothesis," suggesting that higher education or SES attained by African Americans does not lead to similar positive health outcomes comparable to Caucasians due to an incongruent relation between a person's daily experiences and economic status that lead to conflict and stress.42,44 This has rarely been explored in the literature.14 Our findings provide evidence for this theory. This research gap may be attributed to several factors: 1) prevailing focus on the "minority poverty hypothesis," which suggests disadvantages due to race and lower SES,45,46 2) targeted recruitment of lower SES, and 3) under-recruitment of a range of SES in African-American samples. The current study provides a unique opportunity to stan investigations of the diminishing return hypothesis in a cohort of highly educated African Americans with health care access.

To fully understand this hypothesis, our sample's sociodemographics and relations to chronic disease outcomes must be revisited. Despite comparable SES status, African Americans had more self-reponed chronic disease and cardiovascular risk factors. A plausible interpretation of these findings can come from the diminishing return hypothesis. But, our cohort may have experienced poorer health outcomes because of negative psychosocial factors such as stress, mistreatment/discrimination, less marital support, and/or lower quality of life. Overall health (a proxy for quality of life) is statistically lower for African American vs Caucasian women.47 However, our study found a lack of depressive symptoms (a proxy for stress) based on CES-D in both races.

With higher SES comes greater expectations of certain lifestyles and quality of life.42,43 If these expectations aren't met, an individual may experience a greater level of stress and/or allostatic load. 48,49 Stress has been associated with increased CVD.24 A concept, "John Henryism," suggests that active coping methods may result in a counterintuitive activation of the sympathetic nervous system in some African Americans.50,51 This may lead to greater negative health outcomes. These theories and hypotheses further support the importance of examining psychosocial factors and health outcomes in racial/ethnic minorities across the SES spectrum. This study provides one of the first epidemiological investigations supporting the diminishing return hypothesis as a plausible explanation of these findings.

There are several strengths of this study. The CCLS provides a large sample of African Americans and Caucasians of both sexes with sociodemo-graphic information, self-reported chronic disease history, and phenotypic data at a preventive medicine visit. This is the first CCLS study examining the effects of race, health behaviors, and SES on chronic burden cardiovascular risk factors. These data on African Americans in the CCLS are comparable to other published data such as the Dallas Heart Study and the National Health and Nutrition Examination Survey ( Table 3 ).52-55 While the absolute disease burden in our sample is lower, the relative burden is consistent with previous literature.52-55 Our data present clinically relevant information for physicians and social scientists. African Americans deserve a careful evaluation of their cardiovascular risk factors and disease even when presenting with higher SES (eg, education). The risk factors reviewed in this study are modifiable through health promotion programs (eg, diet, physical activity, stress management).

Table 3

Cooper Center Longitudinal Study

Dallas Heart Study

National Health and Nutrition Examination Study

Men

Women

Men

Women

Men

Women

AA

Cauc

AA

Cauc

AA

Cauc

AA

Cauc

AA

Cauc

AA

Cauc

Obesity

35

20.1

29.0

11.3

36.0 ⁵²

34.0 ⁵²

59.0 ⁵²

42 ⁵²

37.3 ⁵³

31.9 ⁵³

49.6 ⁵³

33.0 ⁵³

Hypertension

27.4

17.5

27.1

13.5

52.0 ⁵²

28.0 ⁵²

66.0 ⁵²

33 ⁵²

42.4 ⁵⁸

45.8 ⁵⁸

57.6 ⁵⁸

54.2 ⁵⁸

Dyslipidemia

24.6

25.2

19.4

21.8

2.0

7.4

1.1

2.8

45.6 ⁵⁴

55.0 ⁵⁴

47.7 ⁵⁴

58.7 ⁵⁴

Diabetes Mellitus

5.4

2.0

4.4

1.9

16.0 ⁵²

7.0 ⁵²

20.0 ⁵²

8.0 ⁵²

7.0 ⁵⁵

9.0 ⁵⁵

14.0 ⁵⁵

7.0 ⁵⁵

Several limitations must be taken into account. The comparison samples are unbalanced with respect to absolute numbers of African Americans and Caucasians, although this was addressed with statistical methods. The study is cross-sectional which limits causality. The chronic disease history is self-reported although confirmed by the clinic physician. Education and employment were used as proxies to define SES; however, actual income levels were not available. Our study did not include commonly used stress or quality of life measures such as the Perceived Stress Scale and SF-36.56,57

There are three important implications to aid physicians and social scientists working with African Americans. The assumption cannot be made that higher SES levels buffer poorer health outcomes. Health care providers need to proactively address health promotion with African Americans regardless of higher SES. Further research should be directed towards longitudinal epidemiologic evaluation of higher SES African Americans including the complex biopsychosocial needs and the impact on their health outcomes.24 Additional health disparity research examining the diminishing return hypothesis is warranted in other racial/ethnic minorities of higher SES. Our study presents data on African Americans in the CCLS, which addresses the relationship of race with health among higher SES individuals. Our study will improve the understanding of cardiovascular health issues of African Americans withhigher SES who are typically underrepresented in the literature.

​

Our study compares the prevalence of cardiovascular risk factors and chronic disease burden between African Americans and Caucasians of higher SES and their access to preventive health care.

Despite comparable SES status, African Americans had more self-reported chronic disease and cardiovascular risk factors.

Footnotes

Author Contributions

Design and concept of study: Frierson, DeFina

Data analysis and interpretation: Frierson, DeFina, Powell-Wiley, Willis

Manuscript draft: Frierson, Howard, DeFina, Powell-Wiley, Willis

Statistical expertise: Powell-Wiley, Willis

Administrative: Frierson, Howard, Powell-Wiley, Willis

Supervision: DeFina

References

35. Fryar CD, Hirsch R, Eberhardt MS, Yoon SS, Wright JD. Hypertension, high serum total cholesterol, and diabetes: racial and ethnic prevalence differences in U.S. adults, 1999-2006. NCHS Data Brief. 2010;(36):1-8. [[ PubMed] Google Scholar]

55. McDonald M, Hertz R, Lustik MB, Unger AN. Racial Differences in Diabetes Prevalence, Awareness, and T reatrnent: Findings from the National Health and Nutrition Examination Surveys (NHANES) III and 1999-2000 [ Google Scholar]

# data[].attributes.attachment_link.title
Effect of Race and Socioeconomic Status on Cardiovascular Risk Factor Burden: The Cooper Center Longitudinal Study

# data[].attributes.attachment_link.description
This study examines the prevalence of cardiovascular risk factors and chronic disease burden among African Americans compared to Caucasians in a population of higher socioeconomic status.The current study is a cross-sectional, secondary data analysis ...

# data[].attributes.body
The six common chronic conditions were estimated to incur nearly $141 billion in medical expenditures in California in 2016. In San Francisco alone, which has approximately a population of 871,185, was said to have spent $1,458,767,515 for the cost of chronic conditions; hypertension, coronary heart disease, stroke, and coronary heart failure

Hoch. J, et al. (2016). Chronic Disease Cause High Medical Cost. California Department Of Public Health. https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CDCB/CDPH%20Document%20Library/2016%20Estimated%20Health%20Care%20Expenditures%20of%20Chronic%20Disease%20in%20California.pdf

# data[].attributes.body
1. Increase the # of African American adults in San Francisco that believe eating a balanced diet decreases cardiovascular disease in 1-6 months (attitude)

2. Increase the # of African American adults in San Francisco that know physical activity decreases risk of cardiovascular disease (knowledge)

3. Increase the # of African American adults in San Francisco that know how to implement physical activity into their lives in 1-6 months (knowledge)

4. Increase the # of African American adults in San Fransisco who know that smoking tobacco increases cardiovascular disease and possible ways to quit smoking in 1-6 months (knowledge)

5. Increase the # of African American adults in San Francisco that know where to get screened and access resources in relation to cardiovascular disease in 3-4 months (knowledge)

6. Increase the # of African American adults in San Francisco who believe that they can maintain a healthy diet and be physically active in 3-4 months. (attitude)

# data[].attributes.headline
Program Activities Phase 3: Closing (mos. 23-24)

# data[].attributes.subject
Program Activities Phase 3: Closing (mos. 23-24)

# data[].attributes.body
Hold a Walk-a-Thon at a park to celebrate and highlight reduced risk and cases of cardiovascular disease among African American adults in San Francisco

Hold a pot-luck at a park and have participants bring their own healthy food that they cooked

Conduct evaluation activities

Develop final report about the Hearty program

# data[].attributes.body
7 Hearty Ambassadors

2 Curriculums which are 4 modules to train Hearty Ambassadors and then the other one is 3 modules for African American older adults in San Francisco

200 total participants in 16 months, 25 participants every 2 months.

10 interviews of Hearty Ambassadors on local news

100 social media posts about the program

20 posters/billboards in San Francisco about Cardiovascular Disease in African Americans