title: Distal, intermediate, and proximal mediators of racial disparities in renal disease mortality in the United States.
abstract: BACKGROUND
  Kidney failure and associated mortality is one of the major components of racial disparities in the United States.
  
  
  OBJECTIVE
  The current study aimed to investigate the role of distal (socioeconomic status, SES), intermediate (chronic medical diseases), and proximal (health behaviors) factors that may explain Black-White disparities in mortality due to renal diseases.
  
  
  METHODS
  This is a nationally representative prospective cohort with 25 years of follow up. Data came from the Americans' Changing Lives (ACL) study, 1986 to 2011. The study included 3361 Black (n = 1156) or White (n = 2205) adults who were followed for up to 25 years. Race was the main predictor and death due to renal disease was the outcome. SES, chronic medical disease (diabetes, hypertension, obesity), and health behaviors (smoking, drinking, and exercise) at baseline were potential mediators. We used Cox proportional hazards models for data analysis.
  
  
  RESULTS
  In age and gender adjusted models, Blacks had higher risk of death due to renal disease over the follow up period. Separate models suggested that SES, health behaviors and chronic medical disease fully explained the effect of race on renal disease mortality.
  
  
  CONCLUSIONS
  Black-White disparities in rate of death due to renal diseases in the United States are not genuine but secondary to racial differences in income, health behaviors, hypertension, and diabetes. As distal, intermediate, and proximal factors contribute to racial disparities in renal disease mortality, elimination of such disparities requires a wide range of policies and programs that target income, medical conditions, and health behaviors.
authors.affiliation: Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA ; Center for Research on Ethnicity, Culture and Health, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Shervin
authors.initials: S
authors.lastname: Assari
keywords: African Americans; Diabetes; Ethnic groups; Hypertension; Mortality; Obesity; Renal diseases; Socioeconomic status