What does this research mean for the field?

State-level structural racism is associated with an increased risk of poor cardiovascular health among both Black and White Americans, though Black Americans are negatively impacted across a broader range of structural measures. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

This study investigates how state-level structural racism affects cardiovascular health among Black and White individuals.

April 22, 2026Open Access

Upstream Drivers of Poor Cardiovascular Health Among Black and White Americans

Key Points

This study investigates how state-level structural racism affects cardiovascular health among Black and White individuals.
Cross-sectional analysis using baseline data from the REGARDS study.

Structured PICO

Does state-level structural racism increase the odds of poor cardiovascular health in Black and White adults?

Population

24,811 Non-Hispanic Black and Non-Hispanic White adults, aged 45+ years, from the national REGARDS cohort (enrolled 2003-2007). Mean age 63.4 (Black) and 65.2 (White), 63.3% female (Black) and 50.1% female (White), United States.

Intervention

Residence in states with high structural racism (dichotomized at the median for Black:White ratios of jail incarceration, residential segregation, poverty, education, unemployment, and uninsured status).

Comparator

Residence in states with low structural racism (below the median for the respective measures).

Outcome

Cardiovascular health (CVH) operationalized using Life's Essential 8 (LE8) composite score, categorized as poor (<50), intermediate (50-79), or ideal (>=80).composite

State-level structural racism, particularly residential segregation and unemployment inequities, is associated with poorer cardiovascular health in both Black and White adults.

Abstract

Abstract Background and Objective Since cardiovascular health (CVH) precedes cardiovascular disease (CVD) outcomes, our study examines associations between state-level structural racism and CVH among Black and White participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. Design and Participants A cross-sectional analysis of baseline REGARDS data, a national prospective cohort of 30,239 Black and White adults, 45+ years, enrolled from 2003 to 2007 and followed for 15+ years. Main Measures CVH, the primary outcome, was operationalized using Life’s Essential 8 (LE8)–physical activity, BMI, blood pressure, diet, cholesterol, smoking, glucose, sleep—with each component scored 0–100 and composite scores categorized as poor ( 7 LE8 components and complete structural racism measures were included. All analyses were race-stratified. Ordinal logistic regression models were used to estimate associations and calculate adjusted proportional odds ratios and 95% confidence intervals. Key Results In total, 24,811 participants were included. Average LE8 scores were significantly lower among Black than White participants (56 vs. 64; p < 0.001). Among Black participants, higher odds of low CVH were observed in states with greater structural racism: high B:W unemployment (OR = 1.41, 95% CI 1.23–1.61), residential segregation (1.39, 1.26–1.53), education (1.37, 1.20–1.56), poverty (1.22, 1.11–1.35), uninsured status (1.12, 1.02–1.22). White adults in high structural racism states also had higher odds of low CVH for unemployment (1.16, 1.04–1.29), segregation (1.22, 1.13–1.30), education (1.12, 1.03–1.21). Conclusions Black participants in high structural racism states were at increased risk of poor CVH across measures of structural racism. White residents of these states were also at increased risk of poor CVH for fewer measures. Policy addressing structural factors like segregation and unemployment may help reduce Black–White CVH inequities.

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