Discrimination a Key Social Determinant of Health in Frailty, Outcomes

Discrimination is emerging as another social determinant of health, with yet another study connecting the weathering hypothesis to healthcare outcomes. This latest report, published in the journal Cancer, outlined a link between discrimination and frailty among Black cancer survivors.

Studies like this are important for quantifying how discrimination impacts patient health. The data add to an evidence base confirming the weathering hypothesis and discrimination as a social determinant of health.

The weathering hypothesis states that experiences of racism and discrimination can add cumulative stress onto an individual’s life that ultimately manifests as adverse health outcomes, according to Jeanne Mandelblatt, MD, MPH, the study’s lead investigator. In this case, stress contributes to frailty, which the researchers defined as having several chronic diseases, poor muscle strength, and difficulty performing activities of daily living.

“Discrimination can act as a chronic stressor which can throw the body off balance, resulting in increases in blood pressure, heart rate, metabolism, inflammation, and numerous other factors,” Mandelblatt, who is also director of the Georgetown Lombardi Institute for Cancer and Aging Research, said publicly.

“These stressors can also increase rates of aging, leading to greater risk of frailty. We hypothesize that discrimination can lead to an older biological age than a person’s actual chronological age. This is important to understand as there have been virtually no studies of the relationships between discrimination and aging in the setting of cancer survivorship.”

The researchers surveyed over 2,200 Black people who were in remission but were also within five years of diagnosis of breast, lung, prostate, and colorectal cancer. Survey questions looked at both signs of frailty and experiences with racism and discrimination within their lifetime, specifically:

• Unfair treatment in the workplace
• Discrimination in the hiring process
• Discrimination and unfair abuse by police
• Unfair treatment from teachers or discouragement in seeking higher education
• Unfair or unequal medical care
• Discrimination in the home-buying or renting process
• Interpersonal discrimination from neighbors

Three-quarters of respondents were either pre-frail (42.7 percent) or frail (32.9 percent), and there were key overlaps with those who had also experienced discrimination in their lifetime. Overall, 63.2 percent of respondents said they’d experienced major discrimination. On average, participants experienced 2.4 of the different types of discrimination listed above.

Mandelblatt, also a professor of oncology and medicine at the Georgetown University School of Medicine, said those who had experienced between four and seven different types of discrimination were more likely to have higher frailty scores, too, indicating that weathering has an impact on clinical outcomes.

“Significantly, this pattern of discrimination affecting frailty was consistent across the four types of cancer surveyed, indicating that discrimination is an important factor to study and understand in Black cancer survivors in order to improve their quality and length of life,” she stated.

Notably, experiences of racism have just as much of an impact on health outcomes as other common social determinants of health, like income, said Ann Schwartz, PhD, MPH, a study co-author and the co-principal director of the Detroit Research on Cancer Survivors (ROCS), which collaborated with Georgetown on the study.

“Regardless of whether you were rich or poor, if you experienced more discrimination then you had greater frailty,” said Schwartz, who’s also professor and associate chair of oncology at Wayne State University School of Medicine, and deputy center director and executive vice president for research and academic affairs at Karmanos.

This study adds to the emerging literature quantifying the impact that discrimination has on clinical outcomes. In March 2023, researchers from Boston University reported that discrimination in high-stakes situations, like during a police stop, adds undue stress to an individual’s life and can lead to a greater risk of cardiovascular disease.

The researchers looked at 60,000 Black women and found that those who experienced more discrimination in high-stress situations—work, housing, or police interactions—went on to develop cardiovascular disease.

This trend was not apparent among those who mostly experienced racism during everyday interactions, like eating in a restaurant, potentially because those individuals employed coping mechanisms to mitigate the impact of that stress.

Even still, these findings about racism and health outcomes will be important for patients and providers working to achieve well-being. Lucile Adams-Campbell, PhD, a co-author of the Cancer study and a professor of oncology and associate director for Minority Health and Health Disparities Research at Georgetown Lombardi, said these findings should influence patient-provider communication.

“We have long since recognized the impact of discrimination on health and well-being in Black communities,” Adams-Campbell said in the press release. “We hope that this study leads to more discussions between providers and their patients about the types of discrimination they have experienced and gives providers a greater understanding of how discrimination impacts frailty.”