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Psychosomatic Medicine 66:651-655 (2004)
© 2004 American Psychosomatic Society

ORIGINAL ARTICLES

Socioeconomic Status Is Associated With Nocturnal Blood Pressure Dipping

Carl J. Stepnowsky, Jr., PhD, Richard A. Nelesen, PhD, Doug DeJardin, BA and Joel E. Dimsdale, MD

From the Department of Psychiatry (C.J.S., R.A.N., D.D., J.E.D.), University of California, San Diego, San Diego, California; and the Health Services Research & Development Service (C.J.S.), Veteran Affairs San Diego Healthcare System, San Diego, California.

Address correspondence and reprint requests to Carl J. Stepnowsky, Jr, PhD, Health Services Research & Development Service (111N-1), Veteran Affairs, San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161. E-mail: cstepnowsky{at}ucsd.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
OBJECTIVE: With the advent of ambulatory blood pressure monitoring has come the awareness that blood pressure (BP) normally drops, or "dips," at night by roughly 10%. A number of pathological conditions have been associated with the nondipping of nocturnal BP. In general, researchers have looked at dipping in neurological and cardiovascular disorders. We examined the extent to which nocturnal nondipping might be influenced by relatively gross measures of social environment.

METHODS: This study examined 78 healthy adults and adults with mild hypertension who were not currently receiving medication, aged 25 to 52 years (mean age = 38.2). Forty-two participants self-identified as black and 36 identified as white.

RESULTS: Age, body mass index, apnea–hypopnea index, screening BP, ethnicity, and socioeconomic status (SES) were significantly associated with nocturnal BP dipping, accounting for 41% of the variance in dipping (F[6,51] = 5.473, p < .001). When SES was entered on the last step of a hierarchical regression analysis, it independently accounted for 8% of the variance in dipping, even after accounting for ethnicity, such that the lower the SES, the more the nondipping.

CONCLUSION: It remains to be seen what aspect of the social environment may be driving this association between nondipping and lower social class. However, investigators might consider including social class in their models in future studies.

Key Words: blood pressure, • ambulatory blood pressure monitoring, • dipping status, • ethnicity, • social class.

Abbreviations: SES = socioeconomic status;; BP = blood pressure;; MAP = mean arterial pressure;; OSA = obstructive sleep apnea;; AHI = apnea–hypopnea index;; BMI = body mass index.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
It is well known that middle-aged and elderly adults from lower socioeconomic status (SES) groups are at elevated risk for cardiovascular disease (1–3). It is also well known that black populations from the United States, the Caribbean, and the United Kingdom have higher blood pressures (BPs), higher rates of hypertension, and higher mortality rates from cardiovascular and cerebrovascular disease than populations of European descent (4).

Evidence is accumulating that suggests that 24-hour ambulatory BP readings and nighttime BP values are more highly correlated with indices of end-organ damage than resting, or clinical, BP values. O’Brien et al. described the "dipper/nondipper" classification in 1988 and found that nondipping hypertensive subjects had a higher risk of stroke than the majority of subjects with a dipping pattern (5). Since then, it has been shown that a blunted nighttime dip in BP has adverse prognostic impact on patients with congestive heart failure (6), renal insufficiency (7), obstructive sleep apnea (8), and stroke (9). Patients with nocturnal nondipping have a higher mortality risk than those who dip at night (10,11). In fact, converging evidence from large prospective studies are showing that for each 5% increment in the dipping ratio (ie, nighttime BP divided by daytime BP), there is a resultant 20% to 30% increase in cardiovascular morbidity and mortality (11–13).

The determinants of dipping are underexplored. A recent review showed that blacks have higher rates of nondipping than whites (14). In that review of US studies, 16 of the 19 articles report that blacks had either more nondipping at night or higher levels of nocturnal BP than whites, despite similar levels of daytime BP. It is unclear what factors associated with the black ethnicity is related to nondipping at night. Cross-cultural studies indicate that ethnic differences in dipping may reflect ecological differences. Blacks residing in the US have higher nocturnal BP values and smaller declines in nocturnal BP than either US-born whites or South African-born blacks (15). And compared with US-born whites, nocturnal declines in BP and heart rate are smaller both among blacks that had lived in the United States their entire life (remote immigrants) and among African immigrants who had lived in the United States an average of 6 years (i.e., recent immigrants) (16).

Though it is known that individuals of lower SES and black ethnicity are at elevated risk for cardiovascular disease, the relative effects of SES and ethnicity on nocturnal dipping are not known. We had the opportunity to compare the effect of SES and ethnicity on dipping status in a sample of black and white middle-aged working adults.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Participants
Seventy-eight employed (30+ hours/week) men and women (black and white) were recruited from the local community via advertisement and referrals. Subjects were between the ages of 25 and 50, with an ideal body weight between 90% and 130% (Metropolitan life tables) and resting BP lower than 180/110 mm Hg at screening. Screening BP was defined as the average of three seated BP readings taken in the right arm. Individuals were excluded from the study who had any medical diagnosis other than hypertension, current drug or alcohol abuse, creatinine levels more than 1.4 mg/dl, renal bruit on physical exam, fasting glucose > 120 mg/dl, known sleep disorder, or shift work. In addition, women were excluded if postmenopausal, diagnosed with premenstrual syndrome, taking oral contraceptives, or pregnant.

Before enrollment in the study, subjects were given written informed consent forms that were approved by the University of California, San Diego, Institutional Review Board. All subjects received a history and physical by a licensed physician. Hypertensive patients taking medication were weaned off the drug(s) and closely monitored. If their BP remained below 180/110 for 3 weeks, they were enrolled in the study.

Forty-two self-identified as black and 36 self-identified as white; 31 were women and 47 were men. Demographic characteristics of the subjects are reported in Table 1. Sixty-nine participants completed the full protocol.


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  		TABLE 1. Sample Characteristics*
 
Procedures
Patients receiving anti-hypertensive medication had their medication tapered before the start of the study. Participants were studied in their homes with one night of polysomnography and one 24-hour period of ambulatory BP monitoring. The BP monitoring and sleep study did not occur simultaneously.

Measurements
BP Measurement
Screening BP was defined as the mean of three seated measurements, which were taken with a Dinamap Model 1846x monitor (Critikon, Tampa, FL) after the participant had rested for at least 5 minutes during one screening visit.

Ambulatory BP Monitoring
Ambulatory monitoring was performed for a 24-hour period using the Spacelabs model 90207 (Redmond, WA). The cuff was programmed to obtain a BP measurement every 15 minutes from 06:00 to 23:00 hours and every 30 minutes from 23:00 to 06:00 hours. Nighttime BP was determined as the period from self-reported "lights out" until "lights on." Artifacts were determined through visual inspection and rejection criteria were defined as BP changes greater than 35 mm Hg from previous and subsequent readings. During daytime hours, participants were instructed to go about their normal daytime activities. They completed an activity log that documented the various activities engaged in during the monitoring period. Dipping was defined as the ratio of nighttime mean arterial pressure (MAP) divided by daytime arterial pressure. This definition of dipping was highly associated with the "difference" definition of dipping (r = –0.983, p < .0001).

Sleep
Sleep at home was recorded with a polysomnograph (Embla, Flaga Medical, Reykjavik, Iceland) that recorded central and occipital electroencephalograph derivations (C3, C4, O1, O2), bilateral electrooculogram (LOC and ROC), submental and anterior tibialis electromyocardiogram, electrocardiogram, nasal/oral airflow using a thermistor and nasal canula, respiratory effort using chest and abdominal inductance belts, and finger pulse oximetry. Patients were set up for polysomnography in their homes between 19:00 and 20:00 hours and were instructed to go to sleep and awaken on their normal schedule. Sleep staging was manually scored according to standard criteria (17). Because obstructive sleep apnea (OSA) is both common and associated with nondipping, we characterized each participant in terms of OSA (18,19). Apneas were defined as decrements in airflow of ≥90% from baseline for a period of ≥10 seconds. Hypopneas were defined as decrements in airflow from baseline between 50% and 90% for a period of ≥10 seconds. The apnea–hypopnea index (AHI) was defined as the number of apneas plus hypopneas per hour of sleep. A minimum of 4 hours of scorable sleep was necessary for the sleep data to be included in the analyses. Sleep scorers had inter-rater reliability indices ({kappa}) greater than 0.85 for staging, arousal, and respiratory variables.

SES
Hollingshead’s two-factor index of SES is the most widely used measure of social class and takes into account both education and occupation levels (20). Social index, or SES, scores are derived by summing the occupation value, which has a weight of 7, and the education value, which has a weight of 4. Scores range from 11 to 77, with lower scores indicating higher SES. Hollingshead added the social class variable to make the social index variable more meaningful, with a social class value of 1 equal to social index scores of 11 to 17, 2 equal to scores of 18 to 27, 3 equal to 28 to 43, 4 equal scores of to 44 to 60, and 5 equal to scores of 61 to 77. The social index values were used in the regression analyses.

Data Analysis
Hierarchical regression analyses were performed to examine the proportion of variance accounted for in dipping by the covariates (age, body mass index [BMI], AHI, and screening BP) and independent variables (ethnicity and SES). Covariates were included in the model if the bivariate correlation significance levels with dipping were p < .10. The covariates were entered on step 1, ethnicity on step 2, and SES on step 3. The outcome of interest was the amount of variance accounted for by SES beyond that accounted for by the covariates on step 1 and ethnicity on step 2. The amount of variance (R2) values can be affected by sample size, so adjusted R2 values were also reported. Pair-wise plots of residuals by predicted values provided a check for normality, linearity, and heteroscedasticity. In tests of statistical significance, the {alpha} level was set to 0.05. Data were analyzed with SPSS v10.1 (Chicago, IL).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Participant characteristics are summarized in Table 1. Half of the sample reported being single; 20% were married; 15% were divorced, separated, or widowed; and the remainder did not report their marital status. The table also shows the mean and standard error values of the BP variables by ethnicity and gender. The ethnicities did not differ in age, BMI, AHI, screening BP level (as indicated by MAP), or social class. There were also few gender differences within ethnicity. White women were slightly younger, had fewer apneas and hypopneas, and were of higher SES than the white men; black women and men did not differ on any of the BP variables listed in Table 1. Table 2 provides the bivariate correlations between dipping and important demographic and physiological variables for the total group. Black ethnicity, obesity, and a lower social class score were associated with nondipping.


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  		TABLE 2. Bivariate Correlations With Dipping Variable for Total Sample
 
Table 3 displays the results of the hierarchical regression analysis and shows the unstandardized regression coefficients (B), associated standard error (SE B), R2, and adjusted R2. The adjusted R2 is adjusted for sample size. The four covariates (age, AHI, BMI, screening MAP) were significantly associated with dipping when entered on the first step (F[4,53] = 3.427, p = .015). Ethnicity was entered on step 2 and independently accounted for 12% of the variance in dipping beyond that accounted for on step 1 (F[1,52] = 9.320, p = .001). The model that included the four covariates and ethnicity was significantly associated with dipping, accounting for 33% of the variance in dipping (F[5,52] = 5.036, p = .001). SES was entered on step 3 and independently accounted for 8% of the variance in dipping beyond that accounted for on steps 1 and 2 (F[1,51] = 6.812, p = .012), such that the lower the SES, the more the nondipping. The full model, which included the four covariates, ethnicity, and SES, was significantly associated with dipping, accounting for 41% of the variance in dipping (F[6,51] = 5.801, p < .001). Figure 1 provides a bar graph of the dipping ratio by SES and race, where lower ratios represent greater nighttime dipping. When the SES x ethnicity interaction term was added to the model, it did not account for a significant amount of variance (0.8%; F[1,50] = 0.650, p = .424).


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  		TABLE 3. Prediction of Dipping Based on Hierarchical Regression Analysis
 


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  		Figure 1. Bar graph of dipping ratio by SES and race, where lower ratios represent greater nighttime dipping.

 
Finally, when the same regression described in Table 3 was performed with the "difference" definition of dipping (rather than the "ratio" definition of dipping), the results were not significantly changed. The only differences seen were that race independently accounted for 7.6% (F[1,55] = 5.147, p = .027) of the variance in dipping (decreasing from 12.1% in the previous regression analysis), whereas SES independently accounted for 11.6% (F[1,54] = 9.010, p = .004) of the variance in dipping (increasing from 7.9% in the previous regression analysis).

To tease apart which aspect of SES was associated with dipping, the four covariates (age, AHI, BMI, and screening MAP) were again entered on the first step, education was entered on the second step, and occupation on the third step. Occupation independently accounted for 7% of the variance in dipping after accounting for the covariates and education (F change[1,50] = 6.040, p = .017), whereas education was not significantly associated with dipping after accounting for the covariates (F change[1,51] = 1.770, p = .189).

The regression indicates that ethnicity and SES are each independently associated with nocturnal dipping even after a number of covariates are taken into account.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
ACKNOWLEDGMENTS
 REFERENCES
 
The principal finding is that SES explains a significant amount of variance in nocturnal BP dipping, even after controlling for the effects of age, BMI, sleep apnea severity level, screening BP level, and ethnicity. This study provides strong support for the finding that SES is highly associated with dipping status, such that the lower the SES, the less BP dips at night. There is increasing evidence to suggest that for every 5% increment in the dipping ratio, there is a resultant 20% to 30% increase in cardiovascular mortality and morbidity (11). The findings of our study suggest that based on the dipping ratio, individuals of lower SES are at increased risk. Furthermore, of the two components (i.e., education and occupation) of the SES measure used in this study, regression analysis showed that level of occupation appears to be driving the relationship with nocturnal dipping status, such that lower the level of occupation, the less BP dips at night.

This presents an obvious question—Is lower SES driving the nondipping of nocturnal BP? It is known that lower SES likely increases exposure to stressors associated with fewer economic and social resources, including living in noisier, more crowded environments, increased exposure to violence and crime, and having more stressors than those of higher SES (21). There have been also been a small number of innovative studies that have examined aspects of social class that might be pertinent to dipping. Ituarte et al. made the creative observation that merely having children was associated with less nocturnal BP dipping (22). An implication of this finding is that low SES individuals with families may be related to diminished dipping at night. Wilson et al. observed that individuals who had been exposed to major psychosocial stressors such as children were subsequently likely to be nondippers at night (23). Although these two studies suggest that psychosocial factors account for some of the relationship between SES and dipping, there are independent effects of SES and psychosocial factors on dipping, consistent with the findings of the present study. As investigators explore how 24-hour BP relates to SES, subtle differences may emerge depending on nuances of design, ie, how dipping is defined, how SES is measured, and most crucially, sample characteristics.

There are limitations to our study. There is admittedly some debate about the reliability of the dipping ratio (24–26). We have confidence in the findings of our study, but a larger sample size may be able to better look at race by SES interactions or multiple other confounders. The variables entered in the model were selected theoretically based on prior studies that suggested a relationship with dipping. Thus, to assess the relationship between SES and nocturnal BP dipping, these variables had to be considered first. Finally, the absence of textured psychosocial characteristics of SES was not examined, which is one of the limitations of using the Hollingshead two-factor index. Specifically, what aspects of SES are associated with nondipping? Increased stress? Lower income? Increased exposure to violence and crime? Poor diet? Some combination of these or other unmentioned factors? Future studies will need to examine this intriguing research area.

In conclusion, nocturnal BP dipping was associated with being white and of a higher SES, even after controlling for the effects of age, gender, BMI, and BP levels. Thus, SES joins a long list of pathophysiological findings associated with nocturnal BP dipping.


   ACKNOWLEDGMENTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
REFERENCES
 
This research was supported by National Institutes of Health Grants HL36005, HL44915, and RR0827 and the Department of Veteran Affairs MRP-02-266.

Received for publication August 29, 2003.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 

  1. Smith GD, Wentworth D, Neaton JD, Stamler R, Stamler J. Socioeconomic differentials in mortality risk among men screened for the Multiple Risk Factor Intervention Trial: II. Black men. Am J Public Health 1996; 86: 497–504.[Abstract/Free Full Text]
  2. Sorlie P, Backlund E, Keller J. US mortality by economic, demographic, and social characteristics: the National Longitudinal Mortality Study. Am J Public Health 1994; 85: 949–56.
  3. HDFP Cooperative Group. Race, education and prevalence of hypertension. Am J Epidemiol 1977; 106: 351–61.[Abstract/Free Full Text]
  4. Mayet J, Chapman N, Li CK, Shahi M, Poulter NR, Sever PS, Foale RA, Thom SA. Ethnic differences in the hypertensive heart and 24-hour blood pressure profile. Hypertension 1998; 31: 1190–4.[Abstract/Free Full Text]
  5. O’Brien E, Sheridan J, O’Malley K. Dippers and non-dippers. Lancet 1988; 2: 397.[Medline]
  6. Kastrup J, Wroblewski H, Sindrup J, Rolighed CH, Wiinberg N. Diurnal blood pressure profile in patients with severe congestive heart failure: dippers and non-dippers. Scand J Clin Lab Invest 1993; 53: 577–83.[Medline]
  7. Timio M, Venanzi S, Lolli S, Lippi G, Verdura C, Monarca C, Guerrini E. "Non-dipper" hypertensive patients and progressive renal insufficiency: a 3-year longitudinal study. Clin Nephrol 1995; 43: 382–7.[Medline]
  8. Suzuki M, Guilleminault C, Otsuka K, Shiomi T. Blood pressure "dipping" and "non-dipping" in obstructive sleep apnea syndrome patients. Sleep 1996; 19: 382–7.[Medline]
  9. Lip GY, Zarifis J, Farooqi IS, Page A, Sagar G, Beevers DG. Ambulatory blood pressure monitoring in acute stroke. The West Birmingham Stroke Project. Stroke 1997; 28: 31–5.[Abstract/Free Full Text]
  10. Ohkubo T, Imai Y, Tsuji I, Nagai K, Watanabe N, Minami N, Kato J, Kikuchi N, Nishiyama A, Aihara A, Sekino M, Satoh H, Hismichi S. Relation between nocturnal decline in blood pressure and mortality. Am J Hypertension 1997; 10: 1201–7.[CrossRef][Medline]
  11. Ohkubo T, Hozawa A, Yamaguchi J, Kikuya M, Ohmori K, Michimata M, Matsubara M, Hashimoto J, Hoshi H, Araki T, Tsuji I, Satoh H, Hisamichi S, Imai Y. Prognostic significance of the nocturnal decline in blood pressure in individuals with and without high 24-h blood pressure: the Ohasama study. J Hypertens 2002; 20: 2183–9.[CrossRef][Medline]
  12. Verdecchia P, Porcellati C, Schillaci G, Borgioni C, Ciucci A, Battistelli M, Guerrieri M, Gatteschi C, Zampi I, Santucci A. Ambulatory blood pressure. An independent predictor of prognosis in essential hypertension. Hypertension 1994; 24: 793–801.[Abstract/Free Full Text]
  13. Verdecchia P, Schillaci G, Borgioni C, Ciucci A, Gattobigio R, Porcellati C. Nocturnal pressure is the true pressure. Blood Press Monitor 1996; 1: S81–5.
  14. Profant J, Dimsdale JE. Race and diurnal blood pressure patterns. A review and meta-analysis. Hypertension 1999; 33: 1099–104.[Abstract/Free Full Text]
  15. Fumo MT, Teeger S, Lang RM, Bednarz J, Sareli P, Murphy MB. Diurnal blood pressure variation and cardiac mass in American blacks and whites and South African blacks. Am J Hypertens 1992; 5: 111–6.[Medline]
  16. Osei K, Schuster DP. Effects of race and ethnicity on insulin sensitivity, blood pressure, and heart rate in three ethnic populations: comparative studies in African-Americans, African immigrants (Ghanaians), and white Americans using ambulatory blood pressure monitoring. Am J Hypertens 1996; 9 (12 Pt 1): 1157–64.[CrossRef][Medline]
  17. Rechtschaffen A, Kales A, editors. A Manual of Standardized Terminology, Techniques and Scoring System for Sleep Stages of Human Subjects. Los Angeles: Brain Information Service, Brain Research Institute, UCLA; 1968.
  18. Loredo JS, Ancoli-Israel S, Dimsdale JE. Sleep quality and blood pressure dipping in obstructive sleep apnea. Am J Hypertension 2001; 14: 887–92.[CrossRef][Medline]
  19. Ancoli-Israel S, Stepnowsky C, Dimsdale JE, Marler M, Cohen-Zion M, Johnson S. The effect of race and sleep-disordered breathing on nocturnal BP "dipping": analysis in an older population. Chest 2002; 122: 1148–55.[Abstract/Free Full Text]
  20. Hollingshead AB. Two Factor Index of Social Position. New Haven, CT: Department of Sociology, Yale University; 1957.
  21. Lepore SJ. Social-environmental influences on the chronic stress process. In: Gottlieb B, editor. Coping with Chronic Stress. New York: Plenum Press; 1997. pp. 133–60.
  22. Ituarte PH, Kamarck TW, Thompson HS, Bacanu S. Psychosocial mediators of racial differences in nighttime blood pressure dipping among normotensive adults. Health Psychol 1999; 18: 393–402.[CrossRef][Medline]
  23. Wilson DK, Kliewer W, Teasley N, Plybon L, Sica DA. Violence exposure, catecholamine excretion, and blood pressure nondipping status in african american male versus female adolescents. Psychosom Med 2002; 64: 906–15.[Abstract/Free Full Text]
  24. Staessen J, Bulpitt CJ, O’Brien E, Cox J, Fagard R, Stanton A, Thijs L, Van Hulle S, Vyncke G, Amery A. The diurnal blood pressure profile. A population study. Am J Hypertens 1992; 5 (6 Pt 1): 386–92.[Medline]
  25. Kario K, Schwartz JE, Shimada K, Pickering TG. Is nocturnal blood pressure dipping reproducible? Am J Hypertens 1999; 12 (2 Pt 1): 241.[CrossRef][Medline]
  26. Dimsdale JE, von Kanel R, Profant J, Nelesen R, Ancoli-Israel S, Ziegler M. Reliability of nocturnal blood pressure dipping. Blood Press Monitor 2000; 5: 217–21.[CrossRef][Medline]



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