Sex and Gender Differences Between Experiences of Discrimination and Physical Health: A Systematic Review

Abstract

Background:

Despite a plethora of previous research on experiences of discrimination and physical health outcomes, there has been less attention to sex/gender differences, although some research suggests a greater stress-related biological and behavioral impact on women.

Methods:

Five databases were reviewed up to May 2023 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. We included studies that examined self-reported experiences of discrimination and physical health outcomes among adults (aged 18+) in the United States if results were either stratified by sex/gender or tested a sex/gender-by-discrimination interaction term.

Results:

A total of 3,397 articles were extracted, and 50 met the inclusion criteria, including 3 articles found through an external search. Ten studies reported that the measure of association between discrimination and physical health outcomes was greater among women, 7 reported a greater association among men, 21 reported homogenous associations, and 12 studies reported that the associations varied by sex/gender across multiple outcome measures or in more complex modeling analyses (e.g., additional moderators, mediation analysis).

Conclusion:

Discrimination and physical health outcomes vary by sex/gender, irrespective of race/ethnicity. There are some limitations and methodological issues that were found in the literature. These considerations should be reconciled in future research for more streamlined and consistent analyses and reporting. We further provide recommendations on analyzing and interpreting sex/gender differences in future research. Future studies should also examine sex/gender differences between experiences of discrimination and mental health outcomes.

Keywords

sex gender discrimination physical health

Introduction

An increasing amount of empirical evidence suggests that perceived discrimination, or interpersonal mistreatment, is an adverse risk factor for negative physical and psychological health outcomes.^1–3 While there is a strong literature base supporting associations between specific forms of discrimination (most notable racial discrimination) on physical health outcomes,^1–11 it is important to note, however, that experiences of discrimination are not always race-related and can include experiences of unfair mistreatment due to age, sex, physical disability, or other characteristics. Despite the relative importance of racial/ethnic discrimination on health, specifically among African Americans, research has shown that experiences of unfair treatment due to any attribution can also lead to negative psychological and physiological health outcomes,³ as shown in previous reviews and meta-analyses, suggesting that both share common underlying physiological mechanisms.^2,11 Whether examining associations between specific forms of discrimination (e.g., racial discrimination) or overall experiences of discrimination (without regard to attribution) with adverse physical health outcomes, there has been less attention on the possible sex and gender differences in this relationship.

There is increasing recognition that there are sex and gender differences in health and disease, and research should be stratified or analyzed in a way that examines these differences and presents data that can inform the development of prevention strategies and treatment interventions for both women and men. Although there is a growing recognition that health and disease are influenced by both biological sex and social constructs of gender, there is still a lack of research empirically examining the heterogeneity of associations and showing disaggregation of data by sex or gender. While the terms of sex and gender are often used incorrectly or interchangeably in research, sex refers to biological and physical differences that distinguish men and women, expressed through sex-linked chromosomes, and gender refers to the social constructs related to being a man or a woman in a particular societal or historical context by the society in which individuals live regarding their gender roles and identities.^12,13 It is important that we define and make these distinctions in this article, although we will be limited to the mixed and ascribed reporting terms used in the published literature. It is also important to acknowledge that a dichotomous categorization of sex and gender does not accurately reflect or capture a range of human experiences.¹² However, there are limitations in the current literature and reporting of these terms and how to examine gender differences, which restrain us from using the dichotomous categories of sex and gender in this article. Thus, we will use the term “sex/gender” differences to encompass the search terms used and reported by the articles.

Examining sex and gender differences between experiences of discrimination and physical health outcomes for this systematic review builds upon the analytic framework that, irrespective of race/ethnicity, there are biological and social differences between women and men.¹⁴ Testing heterogeneity of associations and presenting disaggregated data by sex or gender can advance our knowledge of biological and social factors of sex and gender on health outcomes. However, this is often overlooked in research, which was the basis of the 2016 Policy on Sex as a Biological Variable at the National Institutes of Health (NIH).¹⁵

Previous research suggests that sex and gender can influence both the physiological response to psychosocial stressors,^16–18 such as discrimination, and also the psychological and behavioral coping responses.^2,18 Previous studies suggest that there are sex-specific physiological responses to stress through the sympathetic stress response and hypothalamic pituitary adrenal (HPA) axis,^19,20 much from the basis of differential sex steroids.²¹ Psychosocial stress is associated with increased glucocorticoid cortisol levels, a byproduct of HPA axis activation, and its repeated and prolonged elevation dysregulates the HPA axis. This dysregulation leads to accelerated health deterioration.^22,23 Repeated and prolonged exposure to stress can lead to dysregulation of the sympathetic stress processes, and some research suggests that more robust physiological stress activation leads to a disproportionate impact among women.^21,24–26

Sex/gender differences in psychological and behavioral responses have also been reported,¹⁸ although the literature in this area has some mixed findings and has samples restricted by certain racial/ethnic groups. For example, prior research has shown that Black men generally report higher levels of discrimination,²⁷ but Black women react or cope differently than Black men.²⁷ The Theory of Gendered Prejudice would suggest that Black men may be exposed to more egregious forms of racist/discriminatory content, which may have a stronger or longer-lasting impact.²⁸ The subordinate male target hypothesis argues that Black men are subject to more experiences of discrimination,²⁹ a possible pathway in why men suffer from worsened physical health outcomes such as abnormal glycemic control.³⁰ Despite existing literature which characterizes some men’s experiences of discrimination as more frequent, women may have worse physical health outcomes when exposed to a lower frequency of discrimination, although these findings were restricted to Asian Americans.²⁵ However, women generally experience a higher level of general psychological stress than men,^26,31 which could lead to more vulnerability to these experiences according to the stress sensitization theory, which posits that individuals can become more sensitive to stress occurrences, ultimately resulting in a decreased threshold for triggering future episodes.³² Gender-based coping responses to stress can also exaggerate the stress response or lead to maladaptive psychological outcomes or behaviors that can affect physical health outcomes.^18,33 Research also suggests that women ruminate about stressors more often than men,^34,35 and this may be particularly true for interpersonal stressors, such as discrimination.³⁶

However, Black or African American women may experience greater frequency of discriminatory experiences due to occupying more than one socially disadvantaged status (on the basis of sex and race) that interact to shape their experiences, as described by the intersectionality theory.^3,37–39 Thus, in our evaluation of articles examining sex/gender differences in the association between experiences of discrimination and physical health outcomes, we also sorted articles by studies using multiethnic samples, exclusively African American samples, and also studies using samples of “Other” races or evaluated associations stratified by gendered race subgroups if available.

Two previous systematic reviews and meta-analyses have examined sex/gender differences between discrimination and physical health outcomes concluding no significant differences; however, both exclusively included studies on racial discrimination and restricted to racial/ethnic minority populations rather than an inclusive examination of discriminatory experiences which may be an underestimate of all experiences of discrimination.^1,9 Our systematic review is not limited to racial discrimination alone because experiences of discrimination are not always race related. Further, due to this nature of capturing overall experiences of discrimination, the studies included in our review were not restricted to populations that only included racial/ethnic minority populations.

A previously published systematic review and meta-analysis² which included studies from 1986 to 2007 on overall experiences of discrimination, conducted a moderation analysis by sex/gender concluding no significant differences. However, it is difficult to match or ascertain the 13 associations that were included in that analysis with the studies included in the supplemental tables. There are also some methodological disadvantages inherent in meta-analyses including the heterogeneity among studies pertaining to variability in measures, populations, and covariates, potentially influencing the overall effect size and conclusions.⁴⁰ There is also variation in the literature in terms of how discrimination is measured (scale, questionnaires utilized), as well as how discrimination is modeled (continuous, mean, tertiles, quartiles), and with varied physical health outcome measures. Further, there are some limitations in which effect sizes from different studies cannot be compared or included because they do not contain the same set of covariates, which limit studies that can be included in a meta-analysis and may bias the results.

While the main objective of our systematic review is to examine sex/gender differences in overall experiences of discrimination (without regard to a specific attribute) and physical health outcomes, we also contribute beyond the previous literature by providing a thorough review and presentation of the literature while explicitly showing the variation and heterogeneity in questionnaires, how discrimination is modeled, the variation in physical health measures (endpoints as well as stratified by self-reported and objective measures), and diverse set of covariates across studies. While a meta-analysis presents an aggregated summary of association, our systematic review presents a thorough summary of the current literature and presentation of results without the limitations discussed. Thereby, we are able to present the diversity across studies and make recommendations for future research to help resolve inconsistencies and help to better compare studies for less biased conclusions. The specific review question is to examine whether the associations between overall experiences of discrimination and physical health are more adverse for women compared with men. We hypothesized that the studies would reveal sex/gender differences (irrespective of race/ethnicity), with women experiencing greater associations between perceived discrimination and adverse physical health outcomes.

Methods

A literature search of Medline Ovid was conducted by a professional research librarian on the topic of sex and gender differences related to experiences of discrimination on quality of life using MeSH headings (Quality of Life, Health Status, Epidemiological Studies, Sex Characteristics, Sex Factors, Sex Distribution, Prejudice, and Social Discrimination) as well as the equivalent keywords, phrases, and truncated terms. The exact strategy appears in the Supplementary material (Supplementary Table S1). The search strategy was then translated from Medline (Ovid) to Embase (Elsevier), Cochrane Library (Wiley), PsycINFO (Ovid), and Web of Science (Clarivate).

The searches were conducted on May 30, 2023, in all the databases. A total of 4,239 citations were identified on the subject matter. The citations were combined into an EndNote Library and de-duplicated within and between databases. A total of 842 citations were duplicates, and 3,397 were unique citations.

This review’s inclusion criteria comprised peer-reviewed observational studies written in English that examined self-reported experiences of any discrimination and subjective and/or objective physical health outcomes among adults (aged 18+ and of any race/ethnicity) in the United States. Moreover, the presented results needed to be stratified by sex/gender [categorized as binary for analysis (e.g., men/women)] and/or have tested for a sex/gender-by-discrimination interaction or have mentioned that they examined or tested for sex/gender differences. We also only included original, empirical research studies such that systematic reviews and meta-analyses were excluded from being included in the review; however, we scanned citations from systematic reviews, meta-analyses, and from the included articles on discrimination and physical health outcomes to determine if any articles may have been inadvertently missed from our literature search.

To be vetted for this systematic review, the EndNote library for the 3,397 articles that were identified was uploaded into Rayyan, an online platform for systematic reviews,⁴¹ to be assigned and screened by three reviewers. This platform allowed us to upload the titles and abstracts of the search results with highlighted keywords, and decide whether a article should be included, excluded, or put in the “maybe” category to be discussed at the end of the first round of reviews. In the case of exclusion, the reviewer detailed the reasons why within the Rayyan platform. To check reliability, each of the three reviewers was also randomly assigned 200 articles (100 from each of the other reviewer’s articles), which were blinded to the previous reviewer’s decisions. Weekly meetings were scheduled to discuss any uncertainties or questions or if the full article needed to be extracted and reviewed with the group. Following the completion of the title and abstract review, all reviewers met to discuss the full text of the included and undecided articles and to resolve disagreements. A unanimous consensus was needed for a article to be included in this systematic review. Any material in connection to this systematic review can be obtained from the corresponding author upon reasonable request. The Institutional Review Board at the University of Texas Health Science Center-Houston provided an exemption for this systematic review.

Results

A total of 3,397 articles were retrieved across the 5 databases using our focused search criteria, and 5 articles were found through an external search, totaling 3,402 articles. After a thorough individual abstract screening by each reviewer, 3,294 articles were excluded from this review. The remaining 103 articles were examined by the reviewing committee on a weekly basis, and from those remaining articles, 47 met the inclusion criteria for this review in addition to the 3 articles included during the external search. Thus, a total of 50 articles were included in this systematic review. Figure 1 provides a visualized breakdown of the review process.

FIG. 1.

The Summary of the Paper Reviewing Process using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISM) Guidelines.

The articles included a variety of objective and self-reported physical health measurements. Objective physical health measurements included inflammatory biomarkers, blood pressure, abnormal glycemic control, incident cardiovascular disease, leukocyte telomere length, arterial stiffness, body mass index (BMI), and left ventricular atrophy. Some of the commonly used subjective measures were self-rated physical health, symptoms, and health-related quality of life.

The authors used multiple questionnaires to assess experiences of discrimination. Some limited their discrimination measure to one type, but the most frequently used or adapted questionnaires were the Everyday Experiences of Discrimination Scale,⁴² the Lifetime or Major Experiences of Discrimination Scale,⁴³ and the Experiences of Discrimination scale⁴⁴ (Supplementary Tables S2 and S3). It is important to note that these scales were not restricted to racial discrimination alone or even gender discrimination, as discrimination can occur due to any physical attribute, and were most used to measure discrimination across multiethnic samples. The empirical research studies included cross-sectional and longitudinal studies. Multiethnic samples included in this study consisted of Hispanic, non-Hispanic White, Asian, and African American participants, but a few of the articles restricted their samples to one race/ethnicity.

In Figure 2, the sex/gender differences in the association between experiences of discrimination and physical health were designated into four groups based on the findings: (1) greater associations in women; (2) greater associations in men; (3) no sex/gender differences; and (4) varied associations (Complex models such as three-way interactions and mediation analysis).

FIG. 2.

An overview of results on the sex/gender differences in the association between experiences of discrimination and physical health.

Supplementary Table S4 provides the articles reporting greater associations between experiences of discrimination and objective physical health outcomes among women (n = 7). Five of these 7 studies used multiethnic study samples where discrimination was associated with greater inflammation (interleukin-6; IL-6)⁴⁵ and BMI among women.⁴⁶ However, only White women were found to have greater associations between discrimination and objective physical health outcomes, including kidney function²⁴ and C-reactive protein (CRP),⁴⁷ while a change in waist circumference and BMI was only significant among African American women.⁴⁸ Two of these 7 studies used exclusively African American samples with greater associations among women for outcomes of inflammatory burden (a composite measure of five biomarkers including CRP, IL-6, fibrinogen, E-selectin, and intercellular adhesion molecule)⁴⁹ and hypertension.⁵⁰ An additional study conducted among Asian Americans found that the association between discrimination and chronic headaches was greater among women.²⁵

There were 3 studies that also found greater associations among women using self-reported physical health outcomes (Supplementary Table S5). Of these 3 studies, 2 were conducted using exclusively African American samples and one using a national study of Asian Americans.^51,52

Supplementary Table S6 provides a summary of the 5 articles reporting a greater association between experiences of discrimination and objective physical health outcomes among men compared with women (3 using multiethnic samples, 1 using African American participants, and 1 among Latin American immigrants in the United States). For the studies using multiethnic samples (n = 3), discrimination was associated with greater incident cardiovascular events⁵³ and hypertension⁵⁴ among men. Also, using a multiethnic sample (including White, Asian, Latino, and Other), a study by Busse et al., examined whether discrimination was a mediator variable between Latino ethnicity and cortisol. They found that: (1) higher perceived discrimination was associated with higher cortisol activity and (2) discrimination mediated the association between Latino ethnicity and cortisol reactivity. This effect was moderated by sex, such that the indirect effect was significant only among Latino males. For the study which exclusively used an African American sample, discrimination was associated with glycemic control (HbA1c) among African American men but not women.³⁰ Using a sample of Latin American immigrants in Oregon, McClure et al. found that discrimination interacted with socioeconomic status (SES) to predict higher systolic blood pressure and Epstein–Barr virus among Latin American men, but not women. Two additional articles (Supplementary Table S7) reported greater associations between experiences of discrimination and self-rated physical health among men compared with women (1 conducted using multiethnic participants and 1 among Asian Indians).^55,56

There were 16 articles reporting no sex/gender differences in the association between experiences of discrimination and objective physical health outcomes (Supplementary Table S8). Physical health outcomes included: inflammatory biomarkers and cardiovascular risk indicators,⁵⁷ arterial stiffness,⁵⁸ BMI,^59–61 mental stress or conventional stress ischemia,⁶² cardiovascular measures including carotid intima media thickness and left ventricular hypertrophy,⁶³ leukocyte telomere length,⁶⁴ incident cardiovascular disease,⁶⁵ metabolic syndrome,⁶⁶ hypertension,^22,67–69 abdominal fat measures,⁷⁰ waist circumference,⁷¹ and cortisol.⁷² Of these 16 studies, 6 reported that the sex-stratified associations/effect sizes were greater among women^{58,62,64,66,69,70} and 1 reported that the sex-stratified associations were greater among men;⁷¹ however, the discrimination-by-sex interaction terms, which were not statistically significant, indicated that the associations between discrimination and physical health outcomes were not heterogeneous by sex.

Five additional articles reported no sex/gender differences in the association between experiences of discrimination and self-reported physical health outcomes (Supplementary Table S9). Two were measured across multiethnic samples,^73,74 1 across African American/Black participants,⁷⁵ 1 using Chinese American adults,⁷⁶ and lastly, 1 across Latina/o participants in the United States.⁷⁷

A summary of the 7 studies where sex differences in the association between discrimination and objective physical health outcomes had varied results are presented in Supplementary Table S10. These were most often due to varied associations across gender and racial categories or due to complex modeling involving mediation models or additional moderating variables (such as SES or social class). Studies examining sex differences between discrimination and objective physical health outcomes with varying results among multiethnic studies included telomere length,⁷⁸ cardiovascular health scores,^79,80 and blood pressure.⁸¹ There were 2 additional studies conducted exclusively among African American samples with leukocyte telomere length⁸² and cortisol as the main outcome.⁷² An additional study conducted among Latin American immigrants in Oregon examined the association between discrimination with three different outcome measures, including hypertension, glucose, and BMI.⁸³ Five studies utilized self-reported physical health outcomes (Supplementary Table S11), including 2 multiethnic studies, 1 using an African American sample, 1 among Mexican origin adults, and lastly, 1 among Latina/os in the U.S. Self-reported measures included health-related quality of life,⁸⁴ chronic pain-related outcomes,⁸⁵ self-reported physician diagnosed health conditions,⁸⁶ general health and health symptoms,⁸⁷ and self-rated physical health.⁷⁷

Discussion

This systematic review included 50 articles that met our inclusion criteria. More objective measures were used in the articles reviewed than subjective measures. The most frequently used or adapted measures of perceived discrimination were the Everyday Discrimination Scale,⁴² the Lifetime/Major Experiences of Discrimination scale⁴³, and the Experiences of Discrimination scale.^44,88 Even though these were the most frequently used questionnaires to measure self-reported experiences of discrimination, there was a variety of methods utilized in the regression analysis where discrimination scores may have been summed and used as a continuous measure, calculated as per standard deviation, averaged, or used as a categorical variable. Thus, there were many different approaches to measuring experiences of discrimination. Further, experiences of discrimination, as indicative of the questionnaires, were not limited to racial discrimination alone or exclusively among African American study samples, as discrimination can be due to unfair treatment due to many attributes. The samples used in the studies in this review were mostly multiethnic, with some studies limited to African Americans, Asian Americans, and Latinos.

Among the 50 studies included in this review for evaluation, 10 reported a greater association between discrimination and physical health outcomes among women, 7 reported greater associations among men, 21 reported no sex differences, and 12 studies reported that differences varied by gender and racial categories or due to complex modeling involving mediation models or additional moderating variables (such as SES or social class). Associations between self-reported experiences of discrimination were examined across objective as well as self-reported physical health outcomes and among studies with different race compositions without any noticeable pattern among summary tables.

In the studies included in this review, women had greater associations between experiences of discrimination and adverse physical health outcomes including: lower kidney function,²⁴ increased inflammatory biomarkers,^45,47,49 hypertension,⁵⁰ and a change in waist circumference.⁴⁸ Men had greater associations between experiences of discrimination and adverse physical health outcomes, such as abnormal glycemic control,³⁰ incident cardiovascular disease,⁵³ and elevated systolic blood pressure,⁸⁹ seen in an exclusively Latino American sample. There was some overlap in both groups’ having greater associations between experiences of discrimination and certain adverse physical health outcomes, such as poor self-rated health.^{51,52,55–57} One article reported women experiencing chronic headaches following exposure to experiences of discrimination.²⁵

Homogenous associations consisted of articles without a significant sex/gender-by-discrimination interaction term. While the formal test of sex/gender-by-discrimination interaction was not statistically significant, after stratification, there were greater effect sizes between discrimination and physical health outcomes among women. These health outcomes included increased arterial stiffness among African American women,⁵⁸ decreased leukocyte telomere length,⁶⁴ increased adverse cardiovascular outcomes,^{57,63,65,67–69} metabolic syndrome severity,⁶⁶ and increased odds of mental stress-induced myocardial ischemia among post-myocardial ischemia patients among women.⁶² In the case where the authors formally tested a sex/gender-by-discrimination interaction and then stratified their results, we relied on the interaction term to determine whether the stratified results were statistically different. There was some overlap between null interaction and associations found in either men or women, such as waist circumference.^48,71

Varied results were reported in studies using complex modeling, such as mediation analysis or testing for interactions in addition to sex, such as gendered race.^{46,72,77–87,90} In some of these articles, the association between discrimination and physical health outcomes varied by another variable (mediator or moderated mediation).

Due to the growing interest in this sphere of research, empirical studies have included a wide range of discrimination questionnaires and methods, as well as physical health measures. The variety of measures is evidenced in numerous reviews,^{30,47,49,53,73} which substantiate the challenges that contribute to inconsistent and inconclusive inferences across studies. Adding to these complexities are the inconsistent methodological assessment of sex/gender differences across studies. Some studies formally tested a sex/gender-by-discrimination interaction term and proceeded to present stratified analyses by sex/gender, while others only stratified their results by sex/gender. Studies that only stratified their results by sex/gender may have led to a type I error where greater effect sizes among one sex/gender indicated sex differences when they may not have been statistically different.

However, some studies tested an interaction term, showing that associations were not statistically heterogeneous, while stratified analyses showed greater associations or effect sizes for one sex/gender group. For these studies, even though the stratified associations tended to show greater effect sizes for women,^58,62–66 the formal test of interaction concluded that the associations were not heterogenous or statistically different between sexes/genders. It could be possible, however, that these studies did not have sufficient power to detect a statistically significant interaction, which would have led to a type II error.

Due to these inconsistent methods to assess sex/gender differences and the limitations discussed above, future research should consider these implications on the interpretation of the results along with recommendations to rely on robust data interpretations rather than solely on a p value and a dichotomized conclusion significance which is based on arbitrary cut-off values. Given that the reliance on p values alone as a criteria for significance can be misleading,^91–93 and along with our evaluation of the literature showing inconsistent methodological assessment of sex/gender differences across studies, we recommend that future studies consider: (1) Using p values as a guide to show that there is some indication of effect modification, but to be cautious of type II errors from relying solely on an arbitrary convention; (2) visualize and plot the interactions (or simple effects) to see if the slopes for the independent variable across levels of the moderating variable are parallel or intersect which can suggest an interaction effect; and (3) report the simple effects (effect sizes and confidence intervals) of the independent variable at different levels of the moderating variable which can be estimated from the regression equation including the interaction term in the model. More information on how to analyze and visualize interactions using statistical software for recommendations 2 and 3 listed above can be found online.⁹⁴

This is the first systematic review to show the heterogeneity in studies that examined sex/gender differences between experiences of perceived discrimination and physical health outcomes. However, there are limitations worth acknowledging. First, this review is limited to the dichotomous terminology of men and women. This limitation fails to accurately convey human experiences,¹² but could lead to future research. The population was also limited to the United States exclusively because experiences of discrimination may differ in the United States and countries given historical, societal, and cultural differences that may not translate well into the inclusion definitions required for this review. As a result, only articles written in English were considered. Finally, the literature search was completed by May 2023. Articles published after that time were not included in this review.

Conclusion

The results of this study emphasize that sex/gender differences should be considered and reported in the relationship between discrimination and physical health outcomes. Through a review of the literature, there are some methodological issues of concern, including variation in summary measures and types of variables used in the regressions (i.e., continuous, categorical, tertiles) when comparing results from studies that used similar questionnaires (e.g., Everyday Discrimination Scale). These considerations should also be reconciled in future research for more streamlined and consistent analyses and reporting. In addition, because most of the questionnaires to assess experiences of discrimination were developed in the 1990s, these scales should be revalidated and updated in current settings to capture a range of experiences in modern settings (e.g., discrimination experienced online or through social media).⁹⁵ As a final point, empirical research and other reviews are needed to address the sex/gender differences. To assess these differences in research, studies should formally test a sex/gender interaction term and report the results in conjunction with estimating sex-specific estimates given the three recommendations above for robust data interpretations. Future studies should also examine sex/gender differences between experiences of discrimination and mental health outcomes.

Authors’ Contributions

S.S. conceptualized the article, provided supervision, project administration, contributed to the methodology, software, data curation, first draft of the article, editing, and approved all article drafts. S.H. provided supervision, contributed to the project administration, methodology, software, data curation, first draft of the article, editing and approved all article drafts. M.A. contributed to the methodology, software, data curation, and review and editing of the final article draft. B.S. contributed to the methodology, data curation, and review and editing of the final article draft. A.F., S.T.H., and M.Á.C. reviewed and edited the final article draft.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

S.S. receives research support from the NIH/Division of Loan Repayment under Award Number L30HL148912 and a grant from NIH/National Heart, Lung, and Blood Institute under Award Number K01HL149982. S.T.H. receives research support from the National Heart, Lung, and Blood Institute through K01HL164763. These funders had no role in the conduct of the research, the preparation of the article, study design, or in the collection, analysis, or interpretation of data.

Supplemental Material

Abbreviations Used

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