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Effects of Perceived Racism and Anger Inhibition on Ambulatory Blood Pressure in African Americans

From the Department of Psychiatry and Behavioral Sciences at Duke University Medical Center, Durham, North Carolina. E-mail: sherw002@mc.duke.edu

Address reprint requests to: Andrew Sherwood, PhD, Box 3119, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710.

	ABSTRACT

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OBJECTIVE: Hypertension is more prevalent in African Americans compared with Americans of European descent. Preliminary evidence indicates that perceived racism may play a role in elevated blood pressure in African Americans. The present study examined whether perceived racism was associated with higher ambulatory blood pressure measured during daily life. A potential contributing role for anger inhibition was also evaluated.

METHODS: Twenty-four–hour ABP was obtained from 69 African American men and women with normal or mildly elevated blood pressure. ABP was averaged over waking and sleep periods, and clinic BP was also assessed. Perceived racism and anger expression were measured using self-report questionnaires.

RESULTS: Greater perceived racism was related to higher ABP during waking hours for SBP (p < .01) and DBP (p < .05). Perceived racism was positively correlated with anger inhibition (r = .29, p < .05) but was not related to outwardly expressed anger (r = .01, NS). Anger inhibition was related to higher sleep DBP (p = .05) and a smaller drop in DBP from day to night (p < .05). Anger inhibition did not account for the relationship between perceived racism and blood pressure.

CONCLUSIONS: Perceived racism and anger inhibition are independently related to higher ABP. Both may contribute to the incidence of hypertension and hypertensive-related diseases observed in African Americans.

Key Words: ambulatory blood pressure, • perceived racism, • anger inhibition, • African American.

Abbreviations: ABP = ambulatory blood pressure;; BMI = body mass index;; BP = blood pressure;; DBP = diastolic blood pressure;; MAS = Multidimensional Anger Scale;; SBP = systolic blood pressure.

	INTRODUCTION

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Hypertension affects approximately 50 million people in the United States and is a primary risk factor in the development of heart disease, the leading cause of mortality (1, 2). Among African Americans, the prevalence of hypertension is substantially higher than among whites, with African Americans more than twice as likely to die from hypertension-related complications (3–5). Although genetic factors do not seem to account for this blood pressure difference (6–8), several environmental and psychosocial factors have been found to contribute to it (9–13). African Americans tend to consume a diet higher in fat and to have a larger body mass index than whites (13). African Americans also have less income and education than whites, both of which are related to increased cardiovascular morbidity and mortality (9–12).

African Americans and whites also differ with respect to their reported experiences with racism or discrimination (14, 15). Both historically and in the present day, African Americans have suffered significantly from racist practices and attitudes (16). Recent studies have documented that many African Americans still report encountering racism when seeking employment, in receiving equal pay, in obtaining educational opportunities, in securing loans for housing, and in everyday interpersonal interactions (15, 17). African Americans report experiencing significantly more interracial hostility than whites, who report having relatively little experience with racism or racial conflict, perceiving black-white relations as "smooth and congenial" (14, 18) .

Perceived racism has also been related to blood pressure among African Americans (19–21). Three studies examining cardiovascular responses to stressful experiences found evidence that racist stimuli tended to produce larger blood pressure responses and slower recovery to baseline levels when compared with neutral or other anger-provoking situations (19–21). A plausible pathway through which perceived racism may affect blood pressure is anger. Perceived racism has been related to higher levels of anger and hostility (22). As mentioned, African Americans are more likely to perceive interracial hostility than are whites (14, 18). Several large studies have also found that African Americans tend to score higher on measures of hostility and anger than whites (23, 24). This result is of particular importance because hostility has been found to be significantly related to cardiovascular disease in longitudinal studies (25, 26).

A meta-analysis of personality and blood pressure found that one of the strongest predictors of high blood pressure was high levels of anger combined with low levels of affect expression (27). In other words, those who experience high levels of anger but are less likely to express that anger have higher blood pressure. The authors also noted that the relationship between anger inhibition and blood pressure was stronger among African Americans than whites (27). Given that African Americans report higher levels of anger and hostility and that inhibition of anger affects blood pressure in this group disproportionately, a plausible pathway for perceived racism to affect blood pressure is through increased anger experience with inhibited expression of that anger (28).

Previous studies examining the relationship between perceived racism and blood pressure have been limited to the laboratory or clinic-based settings. To our knowledge, no studies to date have examined the relationship between perceived racism and ABP, which is a stronger predictor of cardiovascular morbidity and mortality than standard clinic BP (29–32). The purpose of the present study was to examine whether perceived racism was related to ABP and to evaluate whether anger inhibition may contribute to this relationship.

	METHODS

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Participants
The study sample was composed of 69 employed African American men and women, age 25 to 44 years, who participated in the Duke Biobehavioral Investigation of Hypertension study. Subjects were self-selected in response to advertisements in local newspapers and magazines. Exclusion criteria were clinic SBP greater than 180 mm Hg or DBP greater than 100 mm Hg, cardiovascular medication use, and tobacco product use.

Clinic Blood Pressure Measurement
To determine subject eligibility, clinic BP was assessed on three separate visits, each 1 week apart. At each visit, three seated BP readings were taken, each 2 minutes apart, by use of an appropriately sized occlusion cuff, mercury column sphygmomanometer, and stethoscope. SBP was recorded coincident with the first occurrence of Korotkoff sounds (phase I) and DBP with the disappearance of Korotkoff sounds (phase V).

Ambulatory Blood Pressure Measurement
A typical work day was chosen for the study. Participants were fitted with the AccuTracker II (Suntech, Raleigh, NC) ABP monitor (33). A calibration procedure ensured that stethoscopic blood pressure measurements were within ±5 mm Hg of the AccuTracker SBP and DBP determinations. The AccuTracker was programmed to take blood pressure measurements four times per hour, at variable intervals, throughout the workday. From 11:00 PM until 7:00 AM (or commensurate with the person’s sleep pattern, if different), readings were programmed to be reduced in frequency to two per hour. Participants removed the monitor the following morning and returned it to the laboratory, where the data were downloaded into computer files. All ABP readings were reviewed by an experienced staff member, and artifactual readings were deleted following criteria described previously (34).

Questionnaires
Demographics
Demographic and socioeconomic information was obtained by participant self-report. Because income can be a sensitive issue, it was obtained by the participants checking an income range rather than giving the exact number.

Anthropometrics
Body mass index was obtained by weighing and measuring subjects before ABP monitoring. BMI was calculated as weight in kilograms divided by height in meters squared (kg/m²).

Perceived racism
The Perceived Racism Scale (35) is a 51-question measure that assesses experiences with racism in three categories (frequency of exposure, emotional responses, and coping responses) across four different areas: racism on the job, racism in academic settings, racism in public settings, and exposure to racist statements. Participants rate their frequency of exposure in each of these areas in the past year and over the course of their lives. They also rate their emotional and coping responses. This measure has been shown to have good internal reliability (.87–.96) and adequate test-retest reliability (.71–.80). For this study, an overall score was used, summed across the four domains representing frequency of exposure to racism over the course of one’s life. The emotional and coping responses were not examined.

Anger
The MAS covers many dimensions of anger, including frequency, duration, magnitude, and mode of expression (36). Anger expression was of particular interest in this study, so only the anger-in (anger inhibition) and anger-out (outward anger expression) subscales were used. The MAS has been reported to have good reliability, internal consistency, and validity (defined by strong correlations with other measures of anger) (36).

Data Analysis
The purpose of this study was to examine the relationships among perceived racism, anger inhibition, and blood pressure while controlling for significant demographic and socioeconomic status variables. Therefore, correlation coefficients and hierarchical linear regression were selected as the main analytic tools. Correlation coefficients were used to assess the relationships between perceived racism and demographic or anthropometric variables. Hierarchical linear regression was used to evaluate the relations among perceived racism, anger inhibition, and blood pressure. Age, gender, income, and BMI were used in the analyses as covariates when they were significantly related to BP. The ambulatory blood pressure readings were aggregated into waking and sleep blood pressures, and the drop in blood pressure from waking to sleeping was calculated as waking blood pressure minus sleeping blood pressure. When the blood pressure drop was analyzed, waking blood pressure was used as a covariate in addition to significant demographic variables.

	RESULTS

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Sample Characteristics
Sample characteristics are presented in Table 1. Demographic, anthropometric, and clinic blood pressure data are given either as means ± standard deviations or as percentages, depending on the metric. All participants in this study were African American. The age range of the sample was 25 to 44 years, with 39 women and 30 men. The perceived racism composite score had a mean of 50.75 with a standard deviation of 28.42 (range, 0–117). Four participants (6% of the sample) reported having had no experiences with racism during their lifetime; these subjects are included in the analyses. Seventeen percent of participants reported experiencing racism a couple of times a year, 33% several times a month, 17% several times a week, and 26% several times a day.

Perceived Racism and Ambulatory Blood Pressure
Hierarchical linear regression was used to assess the relationship between perceived racism and ambulatory blood pressure. A two-stage process was used in which significant covariates were entered first and the independent variable of interest was entered second. Age, gender, BMI, and income were used as covariates when they were significantly related to blood pressure (for gender, 0 indicates male and 1 indicates female). Male sex and higher BMI were related to higher waking SBP, and increased age was related to higher waking DBP. On the second step, perceived racism was entered into the model. For waking BP, higher levels of perceived racism were related to increased SBP (b = .28, p < .05) and DBP (b = .24, p < .05; Tables 2 and 3). Perceived racism accounted for an additional 7% of the variance in waking SBP and 4% of variance in waking DBP after controlling for the significant covariates. Perceived racism was not related to sleep blood pressure or to the drop in blood pressure from day to night with the demographic covariates included in the model.

Anger Inhibition and Ambulatory Blood Pressure
Controlling for relevant covariates, anger inhibition was not related to waking SBP or DBP. Higher anger inhibition was related to increased sleep DBP (b = .23, p = .05) (Table 4) and a smaller drop in DBP (b = -.31, p < .05) from waking to sleep (Table 5). Higher income was related to increased sleep DBP, and this effect remained significant with the addition of anger inhibition. Anger inhibition contributed 4% unique variance to the prediction of sleep DBP and 8% unique variance to the prediction of the drop in ABP when controlling for the relevant covariates. When anger inhibition was included in the model with perceived racism and the demographic control variables, perceived racism remained a significant predictor of waking SBP and DBP.

	DISCUSSION

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Approximately 94% of the sample in this study reported having had some experience with racism in their life, with more than 40% having experiences with racism on average several times a week or more. Perceived racism has been hypothesized to contribute to increased blood pressure through negative interpersonal interactions and stress from cultural messages about personal worth (15). In this study, there was ample opportunity for perceived racist events to affect blood pressure. It was found that perceived racism was related to waking BP when controlling for demographic variables, and tp both waking and sleep BP when no controls were used. Perceived racism may be a particularly salient stressor during the daytime, when racist situations are more likely to be experienced directly (15).

Anger inhibition was correlated with perceived racism (r = .29, p < .05), but it did not contribute to the relationship between perceived racism and waking blood pressure. In fact, anger inhibition was only related to blood pressure during the sleeping hours, with higher levels of anger inhibition related to increased sleep DBP and a smaller drop in DBP from waking to sleep hours. This result is of note given that a blunted nocturnal decline in blood pressure has been found to be one of the strongest predictors of cardiovascular morbidity and mortality (29–32). Many studies have noted that African Americans are more likely to inhibit anger in response to provocation (18, 27, 28). It has also been noted that African Americans show less of a drop in blood pressure from day to night than whites, and that anger inhibition is more strongly related to blood pressure in African Americans than whites (27). One possibility is that anger inhibition may contribute to the lack of blood pressure dipping in African Americans.

There are several limitations to keep in mind when considering the results of the present study. First, it was a cross-sectional study, so no inferences can be made regarding causality. Future studies would benefit by focusing on the longitudinal effects of perceived racism on the development of high BP. Second, this is a young to middle-aged sample (age 25 to 44 years); it is not clear what results would be found among older people. Third, no assessment of perceived racism was made while the participants were wearing the ambulatory blood pressure monitors. Analyzing how perceived racism encountered during everyday interpersonal interactions was related to ABP could add potentially important information.

In conclusion, perceived racism and anger inhibition are independently related to increased ABP in African Americans. Perceived racism was related to increased waking ABP but not sleep ABP. Anger inhibition was related to increased sleep DBP and a smaller drop in DBP from day to night. Although anger inhibition was related to perceived racism, it did not contribute to the relation between perceived racism and ABP. This is the first study to show that, in African Americans, perceived racism is related to increased blood pressure measured during routine daily activities. It is also the first to relate anger inhibition to a smaller drop in ABP from day to night in African Americans. Both perceived racism and anger inhibition may contribute to the incidence of hypertension and hypertension-related diseases in African Americans.

	ACKNOWLEDGMENTS

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Supported by National Institutes of Health Grants HL49427 and M01-RR-30, National Center for Research Resources, General Clinical Research Centers Program.

	NOTES

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¹ Current Address: Brigham Young University, Provo, UT.

² Current Address: Harvard School of Public Health, Cambridge, MA and American Psychological Association, Washington, DC.

Received for publication June 12, 2002.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Steffen, P. R. Articles by Sherwood, A. Search for Related Content PubMed PubMed Citation Articles by Steffen, P. R. Articles by Sherwood, A. Related Collections Culture Personality Blood Pressure Other Cardiovascular Medicine