Cardiovascular Risk Factors in Younger Black Women: Results from the 10,000 Women Community Screening Project

Abstract

Background

Cardiovascular Disease (CVD) risk factors are prevalent in black women, but when these risk factors arise is not clear. We aimed to determine when obesity, hypertension, and hyperlipidemia appear in black women within a community screening program.

Methods

945 black women who enrolled in the 10,000 Women community screening project in the metro Atlanta area were included (2015-2018). Socioeconomic, lifestyle, and traditional CVD risk factor information was patient-reported and measured. Characteristics of three cohorts stratified by age, 20-39 years old (yo), 40-59 yo, and ≥60 yo, were compared using pairwise analysis.

Results

All cohorts had class 1 obesity. Mean systolic blood pressure was higher in older cohorts [20-39 yo: 122 ± 15; 40-59 yo: 133 ± 19; ≥60 yo: 142 ± 20 mmHg; p < 0.001]. All age groups had mean total cholesterol levels below 200 mg/dL and were lowest in women 20-39 yo, (p < 0.001). All age groups had mean LDL levels below 100 mg/dL and were highest in women 20-39 yo, (p < 0.01). All age groups had mean HDL levels greater than 50 mg/dL and were highest in women ≥60 yo, (p-value = 0.03). A higher proportion of ≥60 yo limited salt intake, (p ≤ 0.001), and ate fast food less than three times a week, (p < 0.001), compared to younger women.

Conclusion

We report that CVD risk factors, like elevated blood pressure and obesity, are prevalent at young ages in black women, which could be due to lifestyle practices. Earlier initiation of CVD preventive care in black women could be beneficial; however, this needs to be studied further.

1. Introduction

Cardiovascular disease (CVD) is the leading cause of mortality in the United States. There are sex and ethnic disparities in CVD and associated risk factor diagnosis, management, response to treatment, and overall outcomes [1], [2], [3]. Specifically, CVD affects black women more than other groups [1], [2], [3], [4], [5], [6], [7], [8], [9]. According to the 2020 Heart Disease and Stroke Statistics update, 57.1% of black women have CVD compared to 43.4% of white, 42.6% of hispanic, and 37.2% of asian women [1]. Furthermore, the uneven distribution of CVD among racial groups within the female population begins early, as black women develop CVD earlier in life [7]. The higher prevalence and earlier onset of heart disease among black females translates to increased heart disease-associated morbidity and mortality within this group compared to other female groups [1], [2], [3], [4], [5], [6], [7], [8], [9].

The reasons driving the high proportion of CVD in black women are complex and centered around social determinants of health [1], [4], [7], [8], [9], [10], [11], [12], [13]. Hypertension (HTN) is one of the most significant contributors to cardiovascular morbidity and mortality among black women. It often occurs earlier, goes uncontrolled, and is associated with higher stroke and end-stage renal disease rates compared to caucasian people [1], [4], [7], [14]. From 2009 to 2012, the prevalence of HTN among black women aged 20 and older was approximately 11% higher than the adult average [7]. In 2011, black women had nearly twice the age-adjusted death rate per 100,000 attributable to hypertension – a finding consistent with other studies showing higher hypertension-related mortality among black women [1], [4], [7]. Moreover, black women are affected more by obesity and are less likely to be treated for conditions like hyperlipidemia than other groups [1], [9], [10], [11].

Controlling these risk factors through medications and lifestyle modifications improves CVD morbidity and mortality among the black female population [15], [16], [17], [18], [19], [20], [21], [22]. However, as with other groups, CVD risk factors among black women often go unrecognized and untreated [1], [9], [10], [11], [23], [24], [25]. Gaps in treating risk factors such as hypertension and hyperlipidemia among black women compared to white women, especially at younger ages, have been reported [10], [12]. Thus, further preventive intervention and education are warranted in the black female population. Due to the higher proportion of younger black women afflicted with CVD and associated risk factors, intervention timing is critical [2], [4], [8]. A comparison of CVD risk factors between different age groups of black women could help inform caregivers and medical societies on when to screen and intervene on these risk factors in this group. Our study compared CVD risk factor burden in young, middle-aged, and elderly black women and assessed lifestyle behaviors across different generations of black women in the Atlanta metropolitan area. We hypothesized that CVD risk factors, such as HTN, obesity, and hyperlipidemia (HLD), may arise at young age groups in black women.

2. Methods

This study analyzed data from 945 consecutive black women enrolled in the 10,000 Women project screened from 2015 to 2018. The 10,000 Women project is an ongoing study that aims to screen and educate 10,000 black women for CVD risk factors in Atlanta and the surrounding communities. Led by the Emory Women's Heart Center and a group of healthcare volunteers, the project aims to improve CVD risk factor awareness and screening in the underserved population and provide resources and educational materials to improve heart health, encourage follow-up, and encourage reevaluation of high-risk women. Partnered with community organizations, risk factor screenings through health fairs were done at various locations, including churches, shopping malls, local community centers, and organizations. At these screenings, women who completed an informed consent via institutional review board protocol were enrolled in the study to have their health data analyzed. Most, but not all, women at these screening events consented to be enrolled in the study. During the screening, women completed a questionnaire about socioeconomic risk factors, such as education, income, and health insurance; lifestyle risk factors, such as smoking, diet, and exercise; as well as medical risk factors, including the history of CVD, high cholesterol, hypertension, and diabetes (DM). Volunteers collected basic vitals and point-of-care cholesterol at screenings, so medical indices, including body mass index (BMI), blood pressure, and cholesterol, were directly measured at events. Alere Cholestech LDX analyzer (Waltham, Massachusetts, USA) was used at the time of screening to measure point-of-care cholesterol levels – including low and high-density lipoprotein and triglycerides. Since screening events were held between 8 am and 2 pm, many women were non-fasting at the time of screening. An ASCVD risk score was calculated using the 2018 ACC/AHA guideline pooled cohort equation [14]. Participants received one-on-one risk assessment education by trained healthcare professionals with recommendations on follow-up and education to address their risk factor profile. Participants and their corresponding CVD risk factor data were divided into three age range groups: 20 to 39 years old to represent young black women in child-bearing years, 40 to 59 years old to represent middle-aged black women who are perimenopausal or menopausal, and ≥60 years old to represent elderly black women who are near retirement age and are postmenopausal.

2.1. Statistical analysis

Statistical analysis was performed using R 4.0.2. All tests were two-sided with a 0.05 significance level. Descriptive statistics were used to summarize patient characteristics and CVD risk factors for each age group. Continuous and categorical variables were compared using one-way ANOVA and chi-square test, respectively. To further test for differences between age groups, we performed pairwise comparisons. Based on Bonferroni correction, we determined the adjusted p-value of significance to be 0.0015 for the pairwise comparisons of categorical variables. Tukey's post hoc tests were performed to compare age cohorts following ANOVA tests for continuous variables. Finally, to reduce potential confounding effects of income and education on the association between age group and CVD risk factors, a linear regression model was used to adjust for incomes below the poverty line of $12,000/year and education levels below a high school degree.

3. Results

3.1. CVD lifestyle risk factors: smoking, exercise, diet

CVD lifestyle risk factors such as smoking, exercise, and diet were analyzed. Results showed 87.9% of black women reported they never smoked, 9.2% of individuals said they exercised at least three times a week for 30 min, 69.8% of women limited salt intake, and 76.0% women reported they ate fast food less than three times a week (Table 1). There were similarities and differences among the three age cohorts in the above parameters when performing the pairwise analysis (Table 1). The percentage of women who never smoked did not differ between the three age groups [percent never-smoking: 20-39 years old: 89.7%; 40-59 years old: 89.2%; 60 years old or older: 84.0%; p > 0.0015 for all comparisons, Table 1]. Although a higher percentage of black women 60 years old or older exercised for 30 min or more at least three times a week when compared with those 40-59 years old and 20-39 years old [13.4%, 8.2%, and 6.5%, respectively, Table 1], this difference did not reach adjusted significance using pairwise comparison with Bonferroni correction (p > 0.0015). When analyzing diet, we found that a significantly higher proportion of black women ≥60 years old limited salt intake and ate fast food less than three times a week compared to black women aged 20-39 years old, (p < 0.001), and 40-59 years old, (p < 0.001) (Table 1).

Table 1.

Frequency (percent) of sample baseline characteristics.

Risk factor	20 to 39 year olds (N = 217)	40 to 59 year olds (N = 469)	>60 years old (N = 259)	Total (N = 945)	P-value (Chi-Square)	20 to 39 year old vs. 40 to 59 year old P-value	40 to 59 year old vs. > 60 year old P-value	20 to 39 year old vs. > 60 year old P-value
Smoking					0.014	0.202	0.005	0.199
Current smoker	6 (2.8%)	25 (5.4%)	10 (3.9%)	41 (4.4%)
Former smoker	16 (7.5%)	25 (5.4%)	31 (12.1%)	72 (7.7%)
Never smoke	191 (89.7%)	411 (89.2%)	216 (84.0%)	818 (87.9%)
Days with > 30 min of exercise					0.043	0.348	0.074	0.025
0	44 (20.4%)	102 (22.5%)	42 (17.0%)	188 (20.5%)
1	103 (47.7%)	183 (40.4%)	96 (38.9%)	382 (41.7%)
2	55 (25.5%)	131 (28.9%)	76 (30.8%)	262 (28.6%)
3	14 (6.5%)	37 (8.2%)	33 (13.4%)	84 (9.2%)
Fast Food > 3 times per week					< 0.001	0.087	<0.001	<0.001
Yes	69 (31.9%)	119 (25.6%)	37 (14.3%)	225 (24.0%)
No	147 (68.1%)	345 (74.4%)	221 (85.7%)	713 (76.0%)
Limit salt intake					< 0.001	0.051	0.001	<0.001
No	51 (42.5%)	84 (32.2%)	30 (18.2%)	165 (30.2%)
Yes	69 (57.5%)	177 (67.8%)	135 (81.8%)	381 (69.8%)
Income level					< 0.001	<0.001	<0.001	0.009
Less than $12,000 per year	27 (12.9%)	37 (8.3%)	18 (7.7%)	82 (9.2%)
$12,000 ~ $24,000 per year	29 (13.9%)	37 (8.3%)	47 (20.2%)	113 (12.7%)
$24,000-$48,000 per year	71 (34.0%)	117 (26.2%)	55 (23.6%)	243 (27.4%)
$48,000-$96,000 per year	69 (33.0%)	160 (35.9%)	86 (36.9%)	315 (35.5%)
more than $96,000 per year	13 (6.2%)	95 (21.3%)	27 (11.6%)	135 (15.2%)
Education					0.002	0.794	0.001	0.001
12th grade or below	9 (4.2%)	16 (3.4%)	17 (6.6%)	42 (4.5%)
high school graduate	14 (6.5%)	40 (8.6%)	36 (14.0%)	90 (9.6%)
some college	47 (21.8%)	111 (23.9%)	78 (30.2%)	236 (25.1%)
college graduate	117 (54.2%)	242 (52.0%)	98 (38.0%)	457 (48.7%)
post-graduate	29 (13.4%)	56 (12.0%)	29 (11.2%)	114 (12.1%)
Health insurance					< 0.001	0.704	<0.001	<0.001
Yes	191 (88.0%)	413 (89.0%)	252 (98.4%)	856 (91.4%)
No	26 (12.0%)	51 (11.0%)	4 (1.6%)	81 (8.6%)
Hypertension	22 (10.1%)	187 (39.9%)	166 (64.1%)	375 (39.7%)	< 0.001	< 0.001	< 0.001	< 0.001
Cardiovascular disease	0 (0.0%)	11 (2.3%)	26 (10.0%)	37 (3.9%)	< 0.001	0.023	< 0.001	< 0.001
Diabetes	5 (2.3%)	52 (11.1%)	50 (19.3%)	107 (11.3%)	< 0.001	< 0.001	0.002	< 0.001
Hyperlipidemia	14 (6.6%)	107 (23.7%)	106 (42.1%)	227 (24.8%)	< 0.001	< 0.001	< 0.001	< 0.001

3.2. CVD socioeconomic risk factors: income, educational level, health insurance

Patient reported income, education level, and health insurance were evaluated as social risk factors for CVD. As a whole, 9.2% of the sample was below the poverty line, which is about $12,000/year. The majority of participants reported at least a high school degree, as 4.5% of the women screened had an education level of 12th grade or below. Participants were insured, with 91.5% of black women stating that they had health insurance. There were significant differences in these three socioeconomic risk factor parameters when comparing the three age range cohorts. A higher proportion of black women 20-39 years old had an income level under the poverty line, less than $12,000/year, than women aged 40-59 years old and 60 years old or older [12.9%, 8.3%, and 7.7%, respectively, p < 0.001, Table 1]. Despite these differences in income level, young and middle-aged black women were more educated, as a higher percentage of black women 20-39 years old and 40-59 years old attained a college degree than women 60 years old or older [54.2%, 52.0%, and 38.0%, respectively, p = 0.001, Table 1]. A higher percentage of black women 60 years old or older had health insurance than women aged 40-59 and 20-39 years old, [98.4%, 89.0%, and 88.0%, respectively, p < 0.001, Table 1].

3.3. Self-reported CVD medical risk factors

Many women in our sample self-reported a history of CVD or CVD risk factors in the screening questionnaires. Among those screened, 11.3% reported diabetes, 39.7% reported HTN, 24.8% reported HLD, 3.9% reported CVD (Table 1). Compared with young black women, a higher proportion of middle age (p < 0.001) and elderly black women (p < 0.001) reported a history diabetes, [20-39 years old: 2.3%; 40-59 years old: 11.1%; 60 years old or older: 19.3%; Table 1]; HTN, [20-39 years old: 10.1%; 40-59 years old: 39.9%; 60 years old or older: 64.1%; Table 1]; and HLD, [20-39 years old: 6.6%; 40-59 years old: 23.7%; 60 years old or older: 42.1%; Table 1]. A higher proportion of women 60 years old or older reported HTN, HLD, and DM compared to women aged 40-59 years old, but this only reached significance, after Bonferroni correction of the pairwise analysis, for HTN and HLD (p < 0.001).

3.4. Measured CVD medical risk factor at screening events

The mean age of screened participants was 50.4 ± 13.8 years. Overall, the sample was obese with a mean BMI of 31.6 ± 7.2 kg/m². Additionally, on average, participants had elevated measured blood pressures at screening events, with mean systolic blood pressure (SBP) of 132.7 ± 19.7 mmHg and mean diastolic blood pressure (DBP) of 82.2 ± 11.9 mmHg. The sample as a whole had a normal point-of-care lipid profile at the screening events with mean total cholesterol (TC) of 190.0 ± 38.7 mg/dL, triglycerides (TG) of 128.2 ± 79.9 mg/dL, low-density lipoprotein (LDL) cholesterol of 72.6 ± 62.4 mg/dL, and high-density lipoprotein (HDL) cholesterol of 60.1 ± 16.9 mg/dL.

Using pairwise analysis adjusted for education and income level to compare the three age cohorts, we found similarities and differences in measured medical CVD risk factors, including BMI, blood pressure, and point-of-care lipid panels taken at the screening events (Table 2). All three 20-year age range cohorts had a BMI in the class 1 obesity range, with the middle-aged cohort having significantly higher BMI than their younger, (p = 0.004), and older counterparts, (p = 0.002), [mean ± SD BMI: 20-39 years old: 30.7 ± 8.3 kg/m²; 40-59 years old: 32.4 ± 7.0 kg/m²; 60 years old or older: 31.0 ± 6.0 kg/m²; Table 2]. Mean measured systolic blood pressure significantly differed between each 20-year cohort, with older black women having a significantly higher mean SBP than younger black women starting at age 40, (p < 0.001), [mean ± SD SBP: 20-39 years old: 122 ± 15.3 mmHg; 40-59 years old: 132.7 ± 19.1 mmHg; 60 years old or older: 141.8 ± 19.5 mmHg; Table 2]. Mean measured diastolic blood pressure only significantly differed in the middle age group who had higher DBP than younger (p < 0.001) and older age cohorts (p < 0.001), [mean ± SD DBP: 20-39 years old: 80.8 ± 11.5 mmHg; 40-59 years old: 84.1 ± 12.1 mmHg; 60 years old or older: 80.1 ± 11.4 mmHg; Table 2]. Although the two older age groups had similar total cholesterol levels that were significantly higher than the youngest age group, (p < 0.001), [mean ± SD TC: 20-39 years old: 173 ± 33.3 mg/dl; 40-59 years old: 194.1 ± 38.3 mg/dl; 60 years or older: 196.8 ± 39.7 mg/dl; Table 2], middle-aged and elderly black women had similar LDL levels that were significantly lower than young black women, (p < 0.001 and p = 0.011, respectively), [mean ± SD LDL: 20-39 years old: 87.9 ± 65.8 mg/dl; 40-59 years old: 66.7 ± 60.5 mg/dl; 60 years old or older: 70.7 ± 61.9 mg/dl; Table 2]. Elderly black women had significantly higher HDL levels than their middle-aged (p = 0.03) and young counterparts (p = 0.032), who had similar HDL levels, [mean ± SD HDL: 20-39 years old: 58.1 ± 16.6 mg/dl; 40-59 years old: 59.3 ± 16.8 mg/dl; 60 years old or older: 63.1 ± 17.2 mg/dl; Table 2].

Table 2.

Cardiovascular disease medical risk factor means (SD) and frequency (percentages) by age group.

Risk factor	20 to 39 year olds (N = 217)	40 to 59 year olds (N = 469)	>60 years old (N = 259)	Total (N = 945)	P-value (ANOVA)	40 to 59 year olds vs. 20 to 39 year olds p-value	>60 year olds vs. 20 to 39 year olds p-value	>60 year olds vs. 40 to 59 year olds p-value
Body mass index (kg/m2)	30.7 (8.3)	32.4 (7.0)	31.0 (6.0)	31.6 (7.1)	0.003	0.004	0.551	0.021
Systolic blood pressure (mmHg)	122 (15)	133 (19)	142 (20)	133 (20)	< 0.001	<0.001	<0.001	<0.001
Diastolic blood pressure (mmHg)	81 (12)	84 (12)	80 (11)	82 (12)	< 0.001	<0.001	0.75	<0.001
Total cholesterol (mg/dl)	173 (33)	194 (38)	197 (40)	190 (39)	< 0.001	<0.001	<0.001	0.83
Triglycerides (mg/dl)	120 (79)	130 (79)	133 (82)	128 (80)	0.289
LDL (mg/dl)	88 (65)	67 (60)	71 (62)	73 (62)	< 0.001	<0.001	0.011	0.297
HDL (mg/dl)	58 (17)	59 (17)	63 (17)	60 (17)	0.003	0.718	0.032	0.03

Many women did not report a history of CVD risk factor diagnosis in the screening questionnaire but had screening blood pressure or cholesterol measurements suggestive of HTN or HLD, respectively. A total of 341 (36.1%) black women in our sample who did not report a history of HTN on the screening questionnaire had systolic blood pressure measurements greater than or equal to 130 mmHg or had diastolic blood pressure measurements greater than or equal to 80 mmHg at the screening event. We measured elevated blood pressures in those with no self-reported history of HTN at our screening event more often in young and middle age cohorts than in the elderly cohort, [20-39 years old: 99 (45.6%); 40-59 years old: 174 (37.1%); 60 years old or older: 68 (26.3%); Fig. 1]. The differences in the above proportions reached significance when comparing the young cohort to the elderly cohort (p < 0.001) and the middle-aged cohort to the elderly cohort (p = 0.003). Many women who did not report a history of high cholesterol had elevated point-of-care cholesterol levels, which we defined as an LDL level greater than 100 mg/dL or a TC level greater than 200 mg/dL, at our screening. Overall, 286 (32.8%) black women who indicated that they had no history of high cholesterol on their questionnaire had either an LDL > 100 mg/dL or TC > 200 mg/dL at our event. Among those with no self-reported history of HLD, we measured elevated cholesterol levels more often in the young and middle-aged cohorts than in the elderly cohort, [20-39 years old: 65 (32.8%); 40-59 years old: 162 (37.7%); 60 years old or older: 59 (24.1%); Fig. 2]. The difference between the proportion of women with elevated point-of-care cholesterol levels and no self-reported history of HLD among age groups only reached significance when comparing the 40-59 years old cohort to the 60 years or older cohort, (p < 0.001). The difference between the 20-39 years old and the 60 years old or older cohorts was nearly significant, (p = 0.04).

Fig. 1.

Proportion of women with no history of hypertension and elevated blood pressure on point of care testing.

Proportion of individuals who did not report a history of hypertension on the questionnaire and had systolic blood pressure greater than or equal to 130 mmHg or diastolic blood pressure greater than or equal to 80 mmHg. Overlying brackets with asterisks indicate significant posthoc Bonferroni pairwise comparisons (adjusted significant p-value <0.017) between the two age-cohorts designated by the bracket.

Fig. 2.

Proportion of women with no history of hyperlipidemia and high cholesterol on point of care testing.

Proportion of high cholesterol on point-of-care testing (LDL > 100 mg/dL or TC > 200 mg/dL) in patients who previously did not report a history of hyperlipidemia. Overlying brackets with asterisks indicate significant posthoc Bonferroni pairwise comparisons (adjusted significant p-value <0.0015) between the two age-cohorts designated by the bracket.

Based on measurements at screening events, many women in our sample had certain CVD risk factors under control. As a whole, 161 (17.3%) women had a BMI under 30 kg/m², 595 (63.0%) women had blood pressures with a systolic pressure less than 130 mmHg and diastolic pressure less than 80 mmHg, 594 (63.3%) women had TC under 200 mg/dL, 373 (44.6%) women had LDL levels under 100 mg/dL, and 656 (70.2%) of women had HDL levels over 50 mg/dL (Fig. 3). When comparing the three age groups using chi-square analysis, there were significant differences in the percent of women with BMI, blood pressure, TC, LDL, and HDL under control among the three age groups (p < 0.05) (Fig. 3). Of note, there was a substantial drop in the proportion of women who had BMI's under 30 kg/m² after the age of 39, [20-39 years old: 56 (26.0%); 40-59 years old: 67 (14.5%); 60 years old or older: 38 (14.8%); Fig. 3]. Comparing percent of women who had blood pressures with a systolic pressure less than 130 mmHg and diastolic pressure less than 80 mmHg between age cohorts yielded similar results, with the percent of women with measured blood pressure at screenings below the hypertensive threshold dropping after age 39, [20-39 years old: 169 (77.9%); 40-59 years old: 272 (58.0%); 60 years old or older: 154 (59.7%); Fig. 3]. Contrasting proportions of women with TC under control, indicated by having a point-of-care TC less than 200 mg/dL, among age cohorts produced a similar pattern to blood pressure and obesity, with more younger women having TC under control, [20-39 years old: 174 (80.2%); 40-59 years old: 280 (60.3%); 60 years old or older: 140 (54.5%); Fig. 3]. Less women below the age of 40 had HDL over 50 mg/dL than older cohorts, [20-39 years old: 139 (64.1%); 40-59 years old: 325 (70.3%); 60 years old or older: 192 (75.3%); Fig. 3], but more women below the age of 40 had LDL under 100 mg/dL, [20-39 years old: 120 (62.5%); 40-59 years old: 156 (37.8%); 60 years old or older: 97 (42.0%); Fig. 3].

Fig. 3.

Percent of women with cardiovascular risk factor under control.

Percent of women in the sample and each age group with measured medical cardiovascular disease risk factor at screening events that were under control. From top to bottom: Percent with HDL over 50 mg/dL, percent with LDL under 100 mg/dL, percent with total cholesterol under 200 mg/dL, percent with systolic pressure under 130 mmHg and diastolic pressure under 80 mmHg, and percent with BMI under 30 kg/m². Overlying brackets with asterisks indicate statistically significant differences between the proportion of people with each respective CVD risk factor under control between the three age groups. Analysis was performed via chi-square analysis (significant p-value <0.05).

4. Discussion

We report that CVD risk factors are highly prevalent in young and older black women who participated in a metro Atlanta community screening program. Starting from the young age cohort of 20 to 39 years old, black women had a mean BMI measurement in the class 1 obesity range and had a mean blood pressure measurement in the pre-hypertensive range at screening events. Moreover, a substantial portion of young women reported a history of hypertension on the questionnaire. Blood pressures were higher in older ages, as the average SBP measured at screening events significantly increased in middle-aged and elderly cohorts. The increased blood pressure in older women was reflected by more black women in older cohorts self-reporting a history of HTN on the questionnaire than in younger cohorts in our sample. Furthermore, the proportion of women reporting a history of diabetes on the questionnaire significantly increased in women older than 39.

Despite many participants non-fasting at the time of testing at screening events, on average, the three age cohorts had point-of-care lipid panels that were grossly normal. Proportions of screened black women self-reporting hyperlipidemia on the questionnaire increased in the middle-aged and elderly cohorts. Still, these two cohorts’ mean point-of-care LDL levels at screening events were significantly less than the young cohort. Despite similar mean LDL levels, a significantly higher proportion of middle-aged black women with no self-reported history of HLD had elevated point of care cholesterol levels – with point-of-care LDL levels greater than 100 mg/dL or total cholesterol levels greater than 200 mg/dL – after screening than their older counterparts. This relationship, albeit non-significant, was similar when comparing the proportion of women aged 20 to 39 years old who did not report a history of HLD but had elevated point-of-care cholesterol levels to those 60 years old or older. The above patterns in point-of-care cholesterol testing and self-reported history of HLD could be due to medication use differences among age groups.

The results from this study, which suggest the early evidence of CVD risk factors in black women, mirror those of other studies in the US [2], [12], [26]. However, by analyzing lifestyle risk factors, our unique analysis, which directly compared the prevalence of various CVD risk factors between different age range cohorts using data from a community screening program, expounds on CVD risk factor trends in black women seen here and in other studies [2], [12], [26]. Along with CVD medical risk factors, there were differences in CVD lifestyle risk factors between the three age groups. Within our sample, when adjusting for socioeconomic factors like income and education, a higher proportion of black women younger than 60 years old ate fast food three or more times a week and were significantly less likely to limit salt intake. Additionally, though not significant in our study, a lower proportion of younger cohorts exercised three times or more a week, suggesting fewer young women follow recommended healthy lifestyle practices [27]. Adverse diet and exercise practices reported by young black women in our sample may contribute to medical CVD risk factors trends, like early obesity and elevated blood pressure, seen in our study; however, this needs to be studied further. An absence of CVD preventive focused care and education in young black women, due to social determinants of health, could explain unfavorable lifestyle practices, increased burden of obesity, and increased blood pressure that leads to CVD risk in this group [23], [24], [25].

CVD preventive care includes primary care prevention and risk factor modification by primary care providers (PCP). A scarcity of CVD awareness and education in black women has been shown to exacerbate CVD risk factors [1], [10], [11], [12], [21], [28], [29]. In one study, women reported a lack of awareness of CVD, financial burdens, absence of accessible care, and logistical issues such as lack of transportation and childcare as barriers to receiving preventive cardiac care [30]. These women cited lack of awareness of CVD as the number one barrier [30]. According to a study from Bairey Merz et al., 45% of women were unaware that CVD was the number one killer of women [31]. In the same study by Bairey Merz et al., only 39% of PCPs rated CVD as a top concern – behind weight and breast health – and less than half of PCPs and cardiologists reported feeling well prepared to assess CVD risk in women [31]. Consequently, the lack of preventive care access, provider CVD care mindfulness, and competent CVD risk assessment in young black women by PCPs leads to a deficit of early surveillance and lifestyle education – a failure of timely preventive CVD care in black women [3], [9], [23], [24], [25], [30], [32].

Accessible primary prevention, including education, risk factor modification, surveillance, and cross-collaboration between specialties, is the foundation for mitigating CVD morbidity and mortality in this population [3], [9], [15], [16], [17], [18], [19], [20], [21], [23], [24], [25], [33]. Non-pharmacologic interventions such as smoking cessation, blood pressure control, cholesterol management, weight loss, physical activity, and healthy eating patterns have proven to decrease the CVD burden [1], [3], [23], [24], [25], [33]. Kumanyika et al. showed that education on nutrition significantly reduced cholesterol levels and blood pressure in black women [19]. One study showed that making preventive care more accessible through placing clinics in geographically and historically black communities and encouraging follow-up with trained community health workers/nurses reduces CVD health disparities [18]. Additionally, health surveillance through group meetings and home calls can increase adherence to CVD lowering lifestyle changes, such as increased physical activity, in black women [15].

Based on our analysis that compared various CVD determinants between age cohorts, CVD preventive care implemented in black women in their twenties could be beneficial. Risk factors like obesity and elevated blood pressure start appearing around this age. Additionally, our screening showed that a higher proportion of younger black women who did not self-report a history of CVD risk factors had adverse CVD risk factor measurements, so screening at a young age can identify these CVD risk factors earlier, thereby preventing CVD risk factors from going untreated for extended periods [34]. By educating black women in their early twenties on nutrition and exercise, providers may help individuals make necessary lifestyle modifications to mitigate CVD risk factors [15], [16], [18], [19], [21]. A healthier lifestyle could increase the proportion of young black women controlling obesity and reduce the drop-off in women controlling cholesterol or blood pressure after 39 seen in our sample [15], [16], [18], [19], [21]. The need for early cardiac preventive care underscores the importance of CVD risk factor awareness, sensitivity, and competent management among PCPs – such as internal medicine, family medicine, preventive cardiologists, lipidologists, and OB/GYN – since PCPs are often the prominent healthcare advocates for young adults. Additionally, CVD preventive care needs to be made more accessible to young black women by recruiting providers, implementing mobile health strategies, organizing health screenings – like the ones in this study – and developing longitudinal community health programs for this group [35], [36].

5. Study limitations/future directions

Though our study adds to the extensive evidence of health disparities relating to CVD in black women, there were limitations to our study. More investigation needs to be done to better define CVD risk factor trends in black women. Our study only measured the averages of CVD risk factors in the three age cohorts, through self-reported history and point-of-care testing, at one time point and did not follow individuals for extended periods. Thus, we cannot tell if those who are 60 years old or above were more or less obese, had higher or lower blood pressures, or had higher or lower cholesterol levels when they were in their twenties. A future study that aims to follow individuals for extended periods to understand better how individual CVD risk factors change over time would be helpful.

Additionally, our sample's measured CVD risk factor prevalence patterns, like point-of-care lipid panels and blood pressure, could have been affected by medication use. Women in our sample did not report medication data, reported incomplete medication data, or could not remember what medications they were on. So, our analysis did not include medication and its effect on CVD risk factor prevalence among different age groups in our sample. Future research that includes medication data would be beneficial.

Since we did not compare our sample's age-related trends to other ethnic or gender groups, it is unclear whether the trends seen in this study reflect just black women or a microcosm of a more general trend seen in women or black people. In the future, analyzing the prevalence of CVD risk factors among black women in the context of CVD risk factor prevalence among other groups would help identify whether these CVD risk factors patterns are specific to black women or reflect a broader population. Consequently, risk factors that should be targeted in black women may be better defined.

There could have been a degree of selection bias in this study since only women who are motivated to find out about heart health may attend a screening event. A vast majority of women reported some form of insurance, which may have influenced their desire to seek medical care. It is also important to note the screenings were conducted in the metropolitan area around Atlanta, GA, so this data may not be entirely generalizable for other geographical populations. Studies with a larger sample size that includes other areas of the United States and those who may not be insured could be applicable.

Furthermore, most of the data were self-reported, without systematic collection of nutrition diaries or objective measures of physical activity via wearable devices, which can be subject to errors in memory and reporting. We did not screen for diabetes with point-of-care Hemoglobin A1c and thus cannot fully report on diabetes, which is a major risk factor in women. Additionally, our questionnaire did not ask specifics about preventive care screened women were receiving – whether these women had PCPs discussing CVD risk. Comparing the effectiveness of various preventive interventions in this group needs to be done. Specifically, studies that test the effect of different preventive healthcare strategies and the timing of these strategies on black women's CVD risk factors, morbidity, and mortality are needed.

6. Conclusions

We report that CVD risk factors are prevalent at young ages in black women. Elevated blood pressure and obesity are present in black women in their reproductive years and before age 40. Hypertension is present in perimenopausal women after the age of 39. As seen in our study, with a large proportion of younger women reporting no history of CVD risk factors but having screening measurements concerning for CVD risk factors, these risk factors may go largely undiagnosed in more youthful women without proper screening. A higher proportion of young black women practicing an unhealthy lifestyle due to untimely or inaccessible preventive CVD care is likely contributing to this early prevalence of CVD risk factors. Socioeconomic barriers and lack of appropriate utilization of CVD preventive care from providers are primary drivers of this untimely, inaccessible preventive CVD care. Since preventative care has been shown to mitigate CVD related morbidity and mortality in black women, we conclude that CVD prevention should begin as early as the early twenties in black women. To be effective, this care must be made accessible by removing of socioeconomic barriers and be led by PCPs who are apt at recognizing and managing CVD and associated risk factors.

Support

This work was supported by the Emory Women's Heart Center and Mrs. Marcia Taylor.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Table 1 Frequency and percent of baseline characteristics of the sample (from top to bottom), including CVD lifestyle risk factors, social determinants of health, and traditional CVD risk factors. P-values from left to right include chi-square analyses and posthoc Bonferroni pairwise comparisons between age groups (adjusted significant p-value <0.0015).

Table 2: CVD medical risk factor mean (SD) for the three 20-year age cohorts and total sample. P-values from left to right for measured BMI, blood pressure, and cholesterol include ANOVA comparison and posthoc Tukey pairwise comparisons between age groups adjusted for income and education (significant p-value <0.05).