Excessive weight gain and effects on lipids with intensive therapy of type 1 diabetes.

To the Editor.—To address the racial disparity in cardiovascular disease (CVD), Dr Winkleby and colleagues1 recommend theneedfortargeted interventionprograms,changes inhealth policy reforms, and changes in the health care industry. These are indeed important remedies to reduce the growing health status gaps among women and men of color. It is equally important to better understand the role of different life experience as a potential pathway contributing to CVD risk factors among racial and ethnic populations. Winkleby et al report that a higher proportion of African American and Mexican American women lived below the poverty line compared with white women. They also report that African American women (with similar years of age as white women) were more likely to be unmarried and that Mexican American and African American women were also more likely to live in urban areas. Indeed, a higher proportion of Hispanic and African American women do in fact reside in crowded, urbanized settings; a higher proportion of single mothers are also African American.2 Economic, time, and residential constraints may therefore partially explain the higher constellation of interrelated primary risk factors observed among women of color in the study by Winkleby et al. Research shows higher socioeconomic status (SES) provides economic protection and reduces risk factor prevalence.3 However, Winkleby et al show that African American and Mexican American women with the highest measure of SES (.12 years of education) had greater levels of risk factors compared with white women who have similar years of education. The rate of African American and Mexican American women with more than 12 years of education who were living inpovertywasalsodoubletherateamongwhitewomen(18.9% and 18.6% vs 7.1%). Such information suggests that higher socioeconomic position may not provide equal protection among persons of color. Emerging evidence is beginning to establish a link between overt and subtle exposures to racial discrimination and higher levels of blood pressure among African Americans.4 Racial discrimination as well as constraints on other aspects of the life experience may compete with positive lifestyle modification associatedwiththesequelaeof less leisure-timeexercise,overweight, hypertension, and diabetes among African American and Mexican American women. The president recently announced the Racial and Ethnic Health Disparities Initiative with the policy objective of eliminating health status disparities among racial and ethnic minorities by the year 2010.5 The seminal work by Winkleby and colleagues highlights the need for investigators to design studies that not only assess genetic and behavioral determinants but also assess a priori hypotheses that quantify the relative role different life contraints contribute as a pathway to CVD risk factors among men and women of color. The subsequent challenge is for policymakers to develop tools and instruments that will effectively intervene at both individual and societal levels.