The Time Is Now: Reducing Racial Risk of Hypertension with Postpregnancy Follow-Up

African American women have the highest prevalence of hypertension in the United States compared with other racial/ethnic groups and sexes.1 Multiple factors contribute to racial and gender differences in hypertension such as lifestyle, socioeconomic position, and pregnancy-related factors.1 A large proportion of incident hypertension is explained by dietary and lifestyle risk factors in women,1 and obesity is a well-recognized risk factor for hypertension.1 African American women are more likely to be obese than white women2 and have less adherence to recommendations on diet and weight management.3 Inadequate blood pressure control in African Americans is also linked to socioeconomic challenges such as underinsurance and lower health literacy.3 Many African Americans have lower socioeconomic positions, which contribute to increased stress and unhealthy lifestyles.1 Pregnancy is a stressful period in a woman's life and may be complicated by gestational hypertension, pre-eclampsia, or worsening of pre-existing hypertension. Pre-eclampsia is more common in African American women than in white women4 and has been associated with an increased risk of future hypertension.5 The postpartum period may be a window to perform a comprehensive wellness assessment and initiate a framework for future care in African American women.6 Margerison et al. contribute to the literature by investigating the role of hypertension risk factors measured at midlife and previously at the time of pregnancy.7 Using the POUCHMoms study, they demonstrated that racial differences in hypertension between African American women and white women are attenuated by midlife risk factors and eliminated after accounting for pregnancy-related risk factors.7 The risk factors for hypertension that were measured included socioeconomic status, psychosocial, behavioral, and physiological factors. Socioeconomic status is linked to blood pressure control3 and was assessed as a composite score based on reported education, marriage status, income, investments, and ownership of private health insurance. Psychosocial factors are associated with blood pressure progression particularly with an accumulating number of stressful events1,3 and included depression, hostility, and job strain in this study. The behavior assessment included self-report of smoking, diet quality, weekly sedentary hours, and sleep summary score. Physiological factors are known determinants of blood pressure1 and included body mass index, lipids, and C-reactive protein levels. Risk factors measured during pregnancy included socioeconomic status, body mass index, maternal lipids, C-reactive protein levels, and pregnancy complications. These risk factors are important because they frequently occur together, possibly have additive effects, and can be modified to reduce the risk of future hypertension in African American women. For instance, obesity commonly exists with abnormal lipid profiles and elevated inflammatory markers. Midlife socioeconomic status explained most of the disparities in hypertensive status between African American women and white women in Margerison's study.7 However, the order of entry of the risk factors into the models could affect their relative importance as acknowledged by Margerison. Although pregnancy complications are recognized as sex-specific risk factors for cardiovascular disease,8 they did not account for racial disparities for hypertension in this study. In the POUCHMoms study, pre-eclampsia was less common in African American women.7 A major limitation of this study is that genetics, racial discrimination, neighborhood environment, and social support have been associated with racial disparities were not accounted for.