Upstream Drivers of Poor Cardiovascular Health Among Black and White Americans

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 (< 50), intermediate (50–79), ideal (≥ 80). State-level structural racism measures (dichotomized at the median), created using the 2000 U.S. Census, Vera Institute, U.S. Census Current Population Survey, included Black:White ratios (B:W) for jail incarceration, residential segregation, economic status, education, employment, and health insurance. Participants with > 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.