• Jiang He, Joshua D Bundy, Siyi Geng, Ling Tian, Hua He, Xingyan Li, Keith C Ferdinand, Amanda H Anderson, Kirsten S Dorans, Ramachandran S Vasan, Katherine T Mills, and Jing Chen.
• Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine; Tulane University Translational Science Institute; and Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana (J.H.).
• Ann. Intern. Med. 2023 Sep 1; 176 (9): 120012081200-1208.

BackgroundCardiovascular disease (CVD) mortality is persistently higher in the Black population than in other racial and ethnic groups in the United States.ObjectiveTo examine the degree to which social, behavioral, and metabolic risk factors are associated with CVD mortality and the extent to which racial differences in CVD mortality persist after these factors are accounted for.DesignProspective cohort study.SettingNHANES (National Health and Nutrition Examination Survey) 1999 to 2018.ParticipantsA nationally representative sample of 50 808 persons aged 20 years or older.MeasurementsData on social, behavioral, and metabolic factors were collected in each NHANES survey using standard methods. Deaths from CVD were ascertained from linkage to the National Death Index with follow-up through 2019.ResultsOver an average of 9.4 years of follow-up, 2589 CVD deaths were confirmed. The age- and sex-standardized rates of CVD mortality were 484.7 deaths per 100 000 person-years in Black participants, 384.5 deaths per 100 000 person-years in White participants, 292.4 deaths per 100 000 person-years in Hispanic participants, and 255.1 deaths per 100 000 person-years in other race groups. In a multiple Cox regression analysis adjusted for all measured risk factors simultaneously, several social (unemployment, low family income, food insecurity, lack of home ownership, and unpartnered status), behavioral (current smoking, lack of leisure-time physical activity, and sleep <6 or >8 h/d), and metabolic (obesity, hypertension, and diabetes) risk factors were associated with a significantly higher risk for CVD death. After adjustment for these metabolic, behavioral, and social risk factors separately, hazard ratios of CVD mortality for Black compared with White participants were attenuated from 1.54 (95% CI, 1.34 to 1.77) to 1.34 (CI, 1.16 to 1.55), 1.31 (CI, 1.15 to 1.50), and 1.04 (CI, 0.90 to 1.21), respectively.LimitationCausal contributions of social, behavioral, and metabolic risk factors to racial and ethnic disparities in CVD mortality could not be established.ConclusionThe Black-White difference in CVD mortality diminished after adjustment for behavioral and metabolic risk factors and completely dissipated with adjustment for social determinants of health in the U.S. population.Primary Funding SourceNational Institutes of Health.

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