Developmental Influences on Racial Inequities in Cardiovascular Health: The Push–Pull Forces That Uncouple Cardiovascular Disease From Birth Weight

In 2009 we published an article in the American Journal of Human Biology arguing for a developmental contribution to US racial inequities in cardiovascular disease (CVD), inspired by emerging evidence that stress during pregnancy reduces birth weight (BW) while also elevating offspring CVD risk. The 15 years since our piece was published provide an opportunity to update the status of the hypothesis. Although relevant studies are sparse, work to date has revealed an apparent paradox: although Black Americans have lower BWs and higher CVD rates, and even though lower BW elevates future CVD risk, studies generally report stronger inverse BW–CVD relationships in white compared to Black samples. Drawing on current understandings of intergenerational pathways, we propose an updated model that could help explain the weakening of BW–CVD relationships in Black Americans: Structural racism not only elevates CVD risk through pathways that reduce BW, as we originally emphasized, but also increases the likelihood of maternal weight gain and elevated glucose, which elevate offspring CVD risk but increase BW. We review newer evidence that these offsetting, “push–pull” effects on BW operate across the full BW spectrum. As a result, when BW is used as a marker, a dimension of CVD risk is rendered invisible, with the degree of invisibility proportionate to the strength of these opposing pathways. BW will thus be particularly uncoupled from CVD risk in minoritized US populations, who often face psychosocial stress but are also more likely to be exposed to environments that lead to weight gain and metabolic dysregulation.