Exploring Demographic Health Differences—A Foundation for Addressing Health Disparities in Cardiovascular Disease

T he theme of this issue of The American Journal of the Medical Sciences is “Exploring Demographic Health Differences—A Foundation for Addressing Health Disparities in Cardiovascular Disease. ” There have been significant improvements in health indicators in the United States and developed countries over the last 20 years. However, evidence indicates that the improvements are not consistent across all groups of people with rates of disease, premature death and disability disproportionate across race/ethnicity, age and gender. Simply stated, health disparities refer to differences between groups of people. These differences can impact how frequently a disease affects a group, how many people get sick or how often the disease causes adverse health outcomes. Healthy People 2020 define a health disparity as “a particular type of health difference that is closely linked with social, economic and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location or other characteristics historically linked to discrimination or exclusion. ” Thus, health disparities result from multiple factors including not only poverty, environmental dangers and inadequate access to health care, but also individual and behavioral factors and educational inequalities. There is a critical need to develop knowledge and strategies to address this crisis. A first step is a better understanding of important differences in etiology, management and outcomes by race, age and sex. This knowledge can foster development of interventions tailored to individual needs and delivered at the right time to achieve the right outcome across all groups of people. This symposium issue includes a collection of articles that explore differences in cardiovascular and related diseases and thus provides a foundation for addressing health disparities in these chronic conditions. The first 2 articles presented in this symposium issue highlight the effect of early life experiences in boys and girls on cellular markers of stress and aging and health outcomes in adulthood. In a sample of inner city children subjected to social stressors, Drury et al found a significant association between 2 distinct biological markers, telomere length and testosterone reactivity, supporting the hypothesis that these factors are biologic markers of stress-related changes in development and aging. Furthermore, although stress exposure impacted development trajectories in both sexes, sex of the child significantly modulated the association between telomere length and testosterone, with testosterone reactivity being significantly associated with telomere length in males only, a finding that has not been previously reported. Future research examining the association between early life stress and telomere length in children should consider sex differences to further enhance our understanding of the relationship between puberty, hormone stress responses and cellular aging in youth as underlying mechanisms linking later life health outcomes with early life stress. In the second article, Li et al extend current knowledge regarding racial and sex differences in cardiovascular risk factors and related cardiovascular risk from childhood to adulthood by identifying associations between childhood risk factors and adulthood arterial stiffness (ie, brachial-ankle pulse-wave velocity) by race and sex. Using data from the Bogalusa Heart Study, the authors reported childhood systolic blood pressure as the only significant predictor of adulthood arterial stiffness. Assessment of interactions by sex and race revealed significant interactions on adulthood arterial stiffness between sex and childhood body mass index, sex and childhood low-density lipoprotein (LDL) cholesterol and race and childhood high-density lipoprotein cholesterol. The positive association between females, body mass index and arterial stiffness suggests that females may be more vulnerable to the adverse effect of obesity in childhood. Sex differences in the relationship between childhood LDL cholesterol and adult arterial stiffness suggest that males, particularly white males, may be more vulnerable to the adverse effect of increased LDL cholesterol on the arterial stiffening process. A better understanding of the impact of early life experiences, including stress and disease risk factors by race and sex on aging and health outcomes, has important potential implications for early raceand sex-specific interventions that may mitigate health disparities in adulthood. Future research is needed to address the feasibility and effectiveness of such programs. Although it is well established that statin medications reduce the risk of coronary heart disease (CHD) in high-risk individuals, heterogeneity in the use of statins across subgroups of adults at high risk for CHD events is not well known. In an effort to explore if statin use and LDL cholesterol control varied among people with CHD or risk equivalents, Gamboa et al analyzed data from the nationwide Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. Four high-risk groups including individuals with CHD, a history of stroke/ abdominal aortic aneurysm, diabetes or a Framingham Risk Score . 20% were studied. Overall, a substantial treatment gap for the U.S. adults at high risk for future CHD events, especially for those with Framingham Risk Score . 20%, was identified. Factors associated with not taking statins including being black, female gender, having a CHD risk equivalent and residing in the Southeastern United States. Tailoring of interventions to increase statin adherence especially among high-risk individuals may be needed to close this treatment gap and ultimately address disparities in treatment and health outcomes. With the aging of the U.S. population, there is increased interest in understanding disease prevalence, progression and From the Tulane University (MK-W), Ochsner Clinic Foundation (MK-W) and University of Queensland-Ochsner Clinical School (MK-W), New Orleans, Louisiana; University of Mississippi Medical Center (JR) Jackson, Mississippi; and the University of Alabama at Birmingham (PM), Birmingham, Alabma. The authors have no financial or other conflicts of interest to disclose. Correspondence: Marie Krousel-Wood, MD, MSPH, Tulane University, Ochsner Clinic Foundation, University of Queensland-Ochsner Clinical School, 1430 Tulane Avenue, New Orleans, LA 70112 (E-mail: mawood@tulane.edu).