Black women developed hypertension up to 9.6 years earlier than White women in this national US cohort, and the gap remained even in less-disinvested neighborhoods, highlighting the need for earlier prevention strategies and action on structural drivers of cardiovascular health inequities.
Study: Neighborhood Disinvestment and Racial Disparities in Early Hypertension Onset Among Women. Image credit: SeventyFour/Shutterstock.com
A recent study in the journal JAMA Network Open found that hypertension occurred almost a decade earlier in Black women compared with White women in the US, and that this persisted across all levels of neighborhood disinvestment.
Biology, stress, and race shape hypertension risk
High blood pressure is a major contributor to cardiovascular disease, and its impact is particularly pronounced in women. Compared with men, women experience a faster rise in blood pressure over their lifetime, and high blood pressure is more strongly associated with cardiovascular disease mortality. Older women are also more likely to develop hypertension and less likely to achieve adequate blood pressure control than men of the same age.
These differences may reflect a combination of biological and social influences. Female-specific cardiometabolic changes across the life course, including pregnancy, menopause, and gynecological disorders, may increase susceptibility to hypertension, while chronic stressors such as sexism, caregiving responsibilities, and intimate partner violence may further contribute to cardiovascular risk.
Racial disparities add another layer of complexity. Black women are more likely than White women to develop hypertension and experience poorer blood pressure control throughout life. Emerging evidence also suggests that Black women develop hypertension at younger ages, increasing their lifetime risk of cardiovascular disease.
Although these individual-level differences are well recognized, less is known about the role of broader structural factors, such as neighborhood conditions, in shaping the timing of hypertension onset. Neighborhoods influence access to health-promoting resources and services, while disadvantaged environments may contribute to chronic physiological stress and earlier disease development.
Because racially and socioeconomically marginalized communities are more likely to live in neighborhoods with fewer resources, neighborhood disadvantage may compound the effects of racism and sexism on cardiovascular health. To better understand these relationships, the current study investigated whether neighborhood socioeconomic disinvestment contributes to racial differences in the age at which women develop hypertension.
National cohort tracks hypertension across neighborhoods
This longitudinal cohort study examined the role of neighborhood socioeconomic disinvestment in racial differences in the age of onset of hypertension in women. The researchers analyzed data from 15,313 women in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, with 46% identifying themselves as Black and the rest as White.
The participants were examined at home at baseline ( between 2003 and 2007) and during a second visit (between 2013 and 2016). The onset of hypertension was identified using participants’ self-reported age at physician diagnosis or the first study encounter with measured high blood pressure.
Neighborhood disinvestment reflects low resource allocation due to inequitable planning policies and decisions, resulting in low neighborhood socioeconomic status. It was estimated using socioeconomic scores calculated at the census-tract neighborhood level from measures such as household income, housing unit value, educational status, and occupation. Disinvestment levels were accordingly stratified as low, moderate, or high.
In addition, the analysis was adjusted for factors like income, education, employment status, body mass index (BMI), smoking, exercise, health insurance, and rurality.
Most Black women in the study (49.5%) lived in highly disinvested neighborhoods, whereas nearly half of White women (48.3%) lived in the least disinvested neighborhoods. Over the follow-up period, hypertension developed in 71.7% of participants overall. However, the condition was substantially more common among Black women than White women (82.7% vs. 62.2%) and among women living in highly disinvested compared with less disinvested neighborhoods (80.4% vs. 62.5%).
Black women developed hypertension nearly a decade earlier
After adjusting for socioeconomic characteristics, Black women developed hypertension a median of 9.6 years earlier than White women, at 56 versus 66 years, respectively. Adjusting for health-related factors like exercise did not change the median age of onset in Black women, though for White women it decreased to 63 years.
Neighborhood disadvantage did not eliminate racial disparities
Neighborhood disinvestment did not attenuate racial disparities in the age at onset of hypertension. In low disinvestment neighborhoods, the median age remained at 56 years for Black versus 65 years for White. However, with high disinvestment, the median age of onset decreased for both Black and White women, at 53 and 60 years, respectively. The gap narrowed from 9.4 years to 7.3 years with increasing disinvestment, mostly because White women had a lower age at onset.
When adjusted for other social and demographic factors, Black women became hypertensive a median of 9.2 years earlier than White women in the less disinvested neighborhoods, and 8 years earlier in highly disinvested neighborhoods.
Adjusting for rurality and health-related factors led to reduced age of onset among White but not Black women. In less disinvested neighborhoods, Black women developed hypertension a median of 6.6 years before White women. In highly disinvested neighborhoods, the difference decreased to 6.4 years. Further analyses confirmed these patterns.
Earlier hypertension may reflect cumulative physiological stress
The findings are consistent with emerging research showing an accelerated aging profile and poorer cardiovascular risk among Black compared to White women, beginning as young as 45 years.
The authors suggest that the findings are consistent with chronic stress beginning early in life and accumulated socioeconomic and demographic disadvantage. This is usually met with highly demanding coping strategies among Black women. Taken together, these factors may potentially lead to cumulative physiological wear and reduced resilience over the life course.
Findings highlight the need to address chronic racialized stressors earlier in the life course to eliminate racial inequities in accelerated cardiovascular risk
Equally important is the observed reduction in median age of hypertension onset among Black and White women with the level of neighborhood disinvestment. The narrowing of the gap in highly disinvested neighborhoods might potentially be because the majority of Black women in this study lived in highly disinvested neighborhoods, while most White women lived in less disinvested neighborhoods.
Moreover, prior research suggests that Black individuals may be subject to persistent racialized stress and discrimination both within and outside their neighborhoods, even in less-disinvested neighborhoods.
Study accounted for multiple sources of potential bias
The age of hypertension was determined by either objective measurement or self-reported age at the time of physician diagnosis, potentially introducing misclassification bias. Health-seeking behavior could influence the results. Unmeasured confounding cannot be excluded despite adjusting for several factors.
Neighborhood disinvestment was estimated by baseline measures with no longitudinal follow-up. The measures used could have been subsequent to the onset of hypertension. The mechanisms of disinvestment also need to be explained in future research.
Additionally, because the cohort included adults aged 45 years and older, the authors note that future longitudinal studies in younger populations are needed to better characterize the onset of early hypertension across the life course.
Persistent racial disparities in hypertension highlighted
This study is among the first to use a large prospective cohort to demonstrate that Black women develop hypertension nearly a decade in advance of White women, and that this disparity persists across levels of neighborhood disinvestment.
This indicates that prevention efforts should begin early in life and address structural inequalities beyond neighborhood disinvestment. Future studies should explore the respective role of neighborhood contexts versus chronic race-linked stressors in hypertension onset.
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