Abstract(resumo):

Purpose: This study aimed to investigate the association between racism and cardiometabolic multimorbidity and explore whether gender can modify this association in the Brazilian context. Methods: Cross-sectional analysis of 2,765 participantswave 4 of the Pró-Saúde longitudinal study (2011-2012). Logistic regression was used to investigate the association between race/color and cardiometabolic multimorbidity (physician diagnosis of two or more self-reported cardiometabolic conditions). Analyses were stratified by gender and adjusted for age and education. Results: Black women had a higher prevalence of cardiometabolic multimorbidity when compared to White women (35.4% vs. 20%). Race/color was associated with greater odds of cardiometabolic multimorbidity only in women, mainly Black women (OR 2.19; 95%CI 1.64-2.91), followed by Brown women (OR 1.46; 1.11; 1.91), compared to White women. After adjustments, the statistically significant association persisted only in Black women (OR 1.72; 95%CI 1.26-2.34). Conclusion: There is racial disparity in cardiometabolic multimorbidity in Brazil, especially for Black women.

Keywords(palavra-chave):

cardiometabolic disease; multimorbidity; racism; race; gender inequality

Content(conteúdo):

INTRODUCTION
Cardiometabolic diseases, including cardiovascular diseases (CVD), diabetes, and hypertension, are among the leading global causes of mortality1,2. CVD affects more than 17 million people a year, while diabetes affects 1 in 28 people worldwide2. Given their shared risk factors and pathophysiological mechanisms3,4, these diseases often occur concomitantly, leading to cardiometabolic multimorbidity (MM), defined as the simultaneous presence of two or more cardiometabolic diseases in the same individual4.
Cardiometabolic MM poses a significant global health challenge, particularly in low- and middle-income countries3, which has been experiencing higher preventable cardiovascular mortality related to these conditions5. Reducing the CVD burden is a complex task since there is a social pattern of cardiometabolic morbidity. Higher prevalence of these health conditions is observed among socioeconomically disadvantaged individuals, and historically marginalized groups, such as Blacks and Browns (mixed)6,7. For example, Blacks individuals facing significant disadvantages compared to Whites in terms of prevalence, incidence, progression, and mortality related to cardiometabolic morbidity in several countries8,9. The situation is no different in Brazil, a country historically marked by structural racism, where Blacks and Browns exhibit higher prevalence and incidence of obesity10,11, type II diabetes12, and hypertension12-15, as well as higher prevalence of electrocardiographic abnormalities16 , greater arterial stiffness, and subclinical atherosclerosis17 .
The mechanisms that explain racial inequities in cardiometabolic morbidity involve multiple complex factors. First and foremost, it is crucial to emphasize that there is no evidence supporting the idea that these inequalities are due to biological differences between races. Robust evidence shows that race does not exist biologically, as genetic variability among individuals is much greater within racial groups than between them18. On the other hand, we are aware that race/color is a fundamental cause of health inequality, as it represents a social construct historically based on phenotype that governs the distribution of specific risks and opportunities in society19, that generates disparities in educational, income, occupational, and other opportunities18,20. For example, Blacks and Browns are more exposed to economic deprivation, residential segregation, racial discrimination, difficulties in accessing health services and engaging in risky behaviors as a strategy to cope with constant social stress21-23. Thus, race/color measures the exposure to the societal constraints associated with race/color identity in consequence of the racist structure of society. Consequently, race/color has been considered an excellent measure of exposure to racism19.
Although Brazil is a society strongly marked by racism24 and the CVD has been the country’s leading cause of death for half a century25, it is only in recent years that the investigation of racial inequities in the occurrence of cardiometabolic diseases has become more frequent10-17. However, the evidence about racial inequalities related to cardiometabolic MM in the country is still incipient, as we are not aware of studies that have investigated if racism impacts the occurrence of cardiometabolic MM. Previous studies that reported racial inequality in self-reported multimorbidity, without restricting for cardiometabolic morbidities, found conflicting results showing absence of association between race/color multimorbidity26, higher prevalence among Whites27 and higher prevalence among Blacks and Browns22. It is possible that these differences are due to variations in the types of morbidities included and differences in the barriers within the health system for the medical diagnosis of each condition observed among Whites, Blacks, and Browns.
Racial inequality in the occurrence of cardiometabolic MM also appears to be influenced by gender28. Higher prevalence of cardiovascular risk factors has been reported among women, particularly Black women29,30. However, we found only one previous study in the country that investigated the racial inequality in multimorbidity considering potential differences between women and men. In this study, the racial disparity was particularly important in women. Compared to White men, there was no difference in the prevalence of multimorbidity among Brown and Black men, but Black and Brown women were in the worst situation22. Gender-based disparities are also influenced by social mechanisms, as women may be more affected by the consequences of social and racial inequalities28.
The objective of this study was to investigate the association between racism and cardiometabolic multimorbidity, using self-reported Black and Brown race/color as a marker of racism. We also explored whether gender might modify this association. Our study hypotheses were that Black and Brown Brazilians show higher prevalence of cardiometabolic multimorbidity compared to Whites, and that this association is stronger among women. We expect that by including only cardiometabolic morbidities, whose screening and diagnostic protocol is more standardized in health services than other morbidities, it may help in understanding racial and gender inequality in self-reported multimorbidity in the Brazilian context.

METHODS
Study design and population
This cross-sectional analysis used data from the Pró-Saúde Study, a prospective cohort with non-faculty civil servants from university campuses in the State of Rio de Janeiro, Brazil. Four waves of data collection were performed from 1999 to 2015, with the main objective of investigating the role of social position markers and other dimensions of social life in various domains of quality of life, morbidity, and health-related behaviors. The study characteristics and methodological aspects have been described previously31.
The study population initially included 2,933 participants in wave 4 of the Pró-Saúde Study, conducted in 2011-2012. From this initial population, we excluded participants with missing data on education (N=25), race/color (N=27), and cardiometabolic multimorbidity (N=82). Asian-descendent and indigenous individuals were also excluded due to their limited numbers (N=34). The analyses reported here include 2,765 participants. The study’s wave 4 protocols were approved by the Research Ethics Committee of the Institute of Social Medicine, State University of Rio de Janeiro (CAE 0041.0.259.000-11). All participants signed an informed consent form.

Response variable: cardiometabolic multimorbidity
Cardiometabolic multimorbidity (no/yes) was defined as self-reported history of two or more of the following medical diagnoses: hypertension, diabetes, hypercholesterolemia, acute myocardial infarction, angina, and stroke. All affirmative answers to the following question were considered for creation of the variable: “Has a doctor ever told you that you had or have...?” The pattern of cardiometabolic multimorbidity was previously identified through factor analysis involving 18 chronic conditions investigated in the same population of the present study32.

Explanatory variable: racism
Race/color self-reported as Black or Brown was considered a social marker of racism in the present study18-20. Race/color was measured through the question “The Brazilian Census (IBGE) uses the terms Black, Brown, White, Asian-descendent, and Brazilian indigenous to classify people's color or race. If you had to respond to the IBGE Census today, how would you classify yourself regarding your color or race?” For purposes of this analysis, we considered White, Brown, and Black.

Covariates
The investigated covariates were sex (male and female), used as a “proxy” for gender; age (categorized into <50, 50-59, and ?60 years); and education (? complete higher education / ? complete secondary education).

Analyses
The study population’s characteristics are presented as frequencies with the respective 95% confidence intervals (95%CI). Prevalence of cardiometabolic multimorbidity is described according to race/color and gender.
Logistic regression modeling was conducted to investigate the associations between race/color and presence of cardiometabolic multimorbidity, via odds ratios (OR) and 95% confidence intervals. Crude ORs were then adjusted for age (Model 1) and education (Model 2).
To determine the presence of effect modification, by gender, of the association between race/color and cardiometabolic multimorbidity, we included multiplicative interaction terms in models 1 and 2 (race/color*gender). Since there was evidence of multiplicative interaction (p-value <0.05 for women*Brown and women*Black), all analyses were further stratified by gender. There was no evidence of interaction between race/color and education (p-value>0.05 for Brown*education or Black*education). All statistical analyses were performed with Stata 14.0 (Stata Corporation, College Station, USA).

RESULTS
The study population consisted predominantly of women, who accounted for 57.2% (95%CI 55.4–59.1) of the participants. Most of the participants were under 50 years of age (42.8%; 95%CI: 41.0–44.7) and had completed higher education or more (53%; 95%CI 51.1–54.8). Approximately half of the participants self-identified as White (50.2%; 95%CI 48.3–52.0) (Table 1).
Overall prevalence of cardiometabolic multimorbidity in the total population was 24.38%. While only 21.3% (95%CI 19.2-23.5) of Whites reported cardiometabolic multimorbidity, prevalence was 24.4% (95%CI 21.6-27.4) in Browns and 32.5% (95%CI 28.6-36.6) in Blacks. Prevalence of cardiometabolic multimorbidity was highest among individuals with less schooling (31.3%; 95%CI 28.8-33.9 vs. 18.2%; 95%CI 16.3-20.2), besides increasing with age (Table 1).
Figure 1 illustrates the prevalence of cardiometabolic multimorbidity according to race/color and gender. Black men showed slightly higher prevalence of cardiometabolic multimorbidity compared to White men (difference of 4.5 percentage points). Racial disparities in the prevalence of cardiometabolic multimorbidity were 15.4 percentage points higher in Black women and 6.7 percentage points higher in Brown women, both compared to White women.
Table 2 presents the multivariate analyses of associations between race/color and presence of cardiometabolic multimorbidity, stratified by gender. Among women, we observed that the odds of cardiometabolic multimorbidity were 119% (95%CI 1.64-2.91) higher in Blacks and 46% (95%CI 1.11-1.91) higher in Browns compared to White women. After adjusting for age (Model 1), this pattern persisted, but with a slight reduction in the magnitudes of associations (Brown women: OR 1.38; 95%CI 1.04-1.83; Black women: OR 1.91; 95%CI 1.41-2.57). Finally, after further adjustment for education (Model 2), statistically significant higher odds of cardiometabolic multimorbidity remained only among Black women but reduced to 72% (95%CI 1.26-2.34).

DISCUSSION
The study’s results confirmed our hypothesis that racism is associated with cardiometabolic multimorbidity (MM), particularly among women. Black and Brown women had 91% and 38% higher odds of cardiometabolic MM than White women, respectively. After adjusting for education, a marker of socioeconomic position, the association remained statistically significant only among Black women. No significant association between race/color and cardiometabolic MM was observed among Brazilian men.
Evidence indicates that arterial hypertension is more prevalent among Black individuals compared to Whites21,33,34. This could explain the higher occurrence of cardiometabolic MM in this group, since hypertension is a risk factor for cardiovascular disease, diabetes35, and stroke, which are also more prevalent among Blacks36. The social consequences of slavery and persistent structural racism appear to partially explain the higher prevalence of hypertension in the Black Brazilian population37. Blacks were exposed to behavioral risk factors such as unhealthy diet, smoking, alcoholism, as a coping strategy to deal with the social stress37. According to data from the Brazilian survey Surveillance System of Risk and Protective Factors for Chronic Diseases by Telephone Survey (2019)38, Blacks showed a higher prevalence of excessive alcohol consumption, while Browns had a higher prevalence of overweight and irregular consumption of fruits and vegetables compared to White individuals. Regarding smoking, Brown and Black men showed a higher prevalence smoking compared to White men38. Additionally, Black and Brown individuals residing in highly segregated neighborhoods have a higher prevalence of hypertension and diabetes than Whites, highlighting how economically segregated residential environments can negatively impact the cardiometabolic health conditions of disadvantaged racial groups12.
Race is an important determinant of socioeconomic conditions39, which may explain how socially stigmatized ethnic-racial groups are more exposed to such adverse conditions and have less access to material resources20,40, thereby predisposing them to multimorbidity7. Contrary to observations in Brown women, the Black-White disparity in prevalence of multimorbidity in women was not completely mediated by education, indicating that other mechanisms may be involved in this relationship, such as racial discrimination, which may explain the higher odds of cardiometabolic MM among Black women41. In fact, a previous cross-sectional study of Black North American adults (n=5,191) found that those who experienced higher levels of discrimination were more likely to report multimorbidity when compared to people who did not report discrimination (OR: 3.82; 95%CI 2.67–5.45)42.
Structural racism creates a network of stressful mechanisms such as discrimination and trauma and is associated with greater exposure to unemployment, violence, worse housing, and reduced socioeconomic mobility8,9,41. Recurrent exposure to these stressors throughout life can lead to changes in the hypothalamic-pituitary-adrenal axis, resulting in dysregulation of stress hormones42 as well as inflammation and increased blood pressure8, predisposing individuals to CVD.
In this study, racial inequality in the occurrence of cardiometabolic MM was observed only among women. It is possible that these findings are related to the way of our outcome was measured: through self-reported medical diagnosis. We know that women have a longer life expectancy and more frequently seek health services, increasing the rates of disease diagnoses43. Therefore, the prevalence of cardiometabolic multimorbidity depended on the use of health services, which is lower among men44, especially among Black and Brown men45,46. Additionally, Black men have higher premature mortality rates than White men46,47, and it is possible that Black men with multimorbidity were less likely to have been included in this study. These facts may have contributed to underestimating the association between race/color and the prevalence of multimorbidity in men. Our results are consistent with previous study conducted with adults from the ELSA-Brasil. Using an intersectional approach, this study revealed that, compared to White men, there was no difference in the prevalence of ? 2 morbidities among Brown and Black men. However, this prevalence was 16% (CI95%: 1.13-1.19) and 20% (CI95%: 1.16-1.23) higher in Black and Brown women compared to White men, respectively22. Unfortunately, other previous studies that investigated racial inequality in multimorbidity in the country did not evaluate gender difference in this association26,27,48, making it difficult to compare results.
It is well-established that race-gender intersectionality (experiences jointly associated with these two attributes) potentiate health inequalities29. Women may suffer more from the effects of poverty23, which may be even stronger among Black women, as there is an overlap of experiences that impact access to health and lifestyle choices, leading to greater risk of CVD29.
Several limitations should be considered when interpreting our results. Firstly, the medical diagnoses of the chronic conditions used to define cardiometabolic MM were self-reported, which may lead to their underestimation. Moreover, the self-recorded prevalence of cardiometabolic diseases in men may be underestimated in comparison to women, thereby potentially obscuring the detection of such a correlation among male counterparts.
Secondly, we use the variable race/color as an indirect marker of racism. However, racism is a complex phenomenon that operates on multiple levels, and the use of one single indicator is uncapable of capturing all the multiple facets and nuances of this construct. For example, race/color does not capture the perceptions or consequences related to the trauma of perceiving oneself as a victim of a discriminatory action. Such impacts are assessed only through direct measures of racism, like self-reported experiences of unfair or discriminatory treatment based on race/color49. Nonetheless, this pathway represents just one of the mechanisms that contribute to health inequities. On the other hand, using self-reported race/color as an indirect measure of racism has the advantage of capturing broader aspects of racism that go beyond individual perception and can only be assessed by considering the experiences of other individuals within the same racial group49. For example, inequalities in wages, education, occupational prestige, access to healthcare services as a consequence of race/color. Thus, using the variable race/color to access racism is an important approach to understanding racial health inequities.
Thirdly, we cannot rule out the possibility of confounding due to omitted variables, since it is possible that certain factors influencing the construction of racial identity may also be causally implicated in cardiovascular disease. Fourth, the use of the sex variable to capture gender aspects related to social constructs and patterns that go beyond biological differences is limited, as it only allows for necessarily binary formulations and assumes that all participants have a gender identity that aligns with their sex recorded at birth.
Fifth, as discussed before, survival bias may also exist; Brown and Black individuals, characterized by heightened prevalence of multimorbidity, may have experienced premature mortality. Consequently, their representation (especially that of Black men) in the study could be limited. This could potentially lead to underestimation of the real racial disparities.
Meanwhile, our study contributes to the understanding of how racism impacts the occurrence of cardiometabolic multimorbidity. The problem is recognized by the Brazilian Ministry of Health and addressed in its National Policy for Integral Health of the Black Population46, reinforcing the need for public policies that consider the impacts of racism and that aim to improve health indicators in this population, with markedly higher prevalence of chronic diseases and premature mortality. Concrete measures are needed to reduce the prevalence of risk factors for chronic diseases in Brown and Black individuals, such as increasing the number of public spaces suitable for physical activity and improving access to healthy food, especially in vulnerable areas, in addition expanding access to health promotion and prevention services. However, it is also crucial to acknowledge that structural racism impacts individuals' opportunities in the job market, as well as their access to housing, quality education, and various goods and services50. Consequently, continuous policies targeting the different mechanisms through which racism operates are needed to address the racial inequality in cardiometabolic multimorbidity. Combating racism involves transforming and dismantling the policies and institutions that uphold the racial hierarchy in Brazil. Achieving this requires greater Black representation in the political sphere to drive the necessary changes in the long-standing values that have promoted the belief in White superiority and Black inferiority, affecting the lives and health of Black and Brown people across generations.

CONCLUSION
Racism was associated with the presence of cardiometabolic multimorbidity in women living in Brazil's second-largest metropolitan region, suggesting that mechanisms of oppression and discrimination increase the chances of developing cardiometabolic diseases. This study expands the understanding of how racial inequalities, historically neglected in Brazilian society, impact cardiometabolic health, a phenomenon of increasing importance that accompanies the aging of the Brazilian population.

FUNDING
This study was financed by the
Center of Excellence for Investigation of Biological Determinants and Consequences, Behavioral and Social of Obesity (Núcleo de Excelência para Investigação de Determinantes e Consequências Biológicas, Comportamentais e Sociais da Obesidade). Edital 46/2014 - PRONEX - Faperj. Processo E-26/010.001266/2016 - Ref. 210.889/2016.

COMPETING INTERESTS
The authors declare there are no competing interests.

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