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Are Race and Ethnicity a Risk Factor for Spondylitis?

Posted on April 14, 2022
Medically reviewed by
Ariel D. Teitel, M.D., M.B.A.
Article written by
Eli Sachse, RN

People of certain racial and ethnic groups appear to be at increased risk for developing spondylitis and experiencing more severe symptoms. It’s still unclear what causes spondylitis, though it’s believed to involve a variety of risk factors that include certain genes and details about the environment in which people live.

Links between race, ethnicity, and disease are complex and not yet well understood. It’s important to keep in mind that many biological, social, and cultural factors inform every person’s unique racial and ethinic identity. These factors can also influence health.

Who Is More Likely To Be Diagnosed With Spondylitis?

Studies have found that white people are more often diagnosed with spondylitis when compared with Black and Hispanic people, though studies find different rates. One U.S.-based study found white people were 10 times more likely to be diagnosed with ankylosing spondylitis (AS) — a severe form of spondylitis — than African Americans.

Another study of Americans with insurance coverage estimated that white people were at twice the risk of being diagnosed with AS compared to Black people. The same study found that white Americans with insurance were five times more likely to be diagnosed with psoriatic arthritis (one type of spondylitis) compared with Black Americans.

There are fewer studies that cover differences in spondylitis among other populations. One study from 2012 examining the frequency of spondyloarthritis in Mexican Americans showed similar frequency as white Americans.

Are People of Color Underdiagnosed?

Multiple researchers have raised concern about detection bias with regard to diagnosing spondylitis among people of color. Since it has been believed that white people are at higher risk for AS, health care providers may tend to suspect AS more often when treating white people while missing symptoms of spondylitis in people of color.

Some researchers have noted that reduced access to diagnostic tests and specialists may also affect the numbers of people of color diagnosed with rheumatic diseases. Multiple studies show that Black Americans are less likely to receive appropriate treatment for chronic pain.

Additionally, research has found that Black Americans are less likely to have access to health insurance and primary health care that might make it easier to receive referrals to a rheumatologist for diagnosis.

Researchers suggest these disparities may make it harder to know the true incidence and prevalence rates of spondylitis in the U.S. among people of color.

Are Genetics a Factor?

Traditionally, it has been assumed that diseases that appear linked to race and ethnicity also share a genetic link. However, research increasingly proves that there is no genetic basis for race.

Some researchers use spondylitis as an example of this. A particular variation of a gene known HLA-B27 is linked to AS. Testing for HLA-B27 is sometimes performed as part of the process for diagnosing spondylitis. White people are seven times more likely to have an HLA-B27 allele than Black people, according to past research. Other research has found that “the prevalence of HLA-B27 and AS is higher in whites and certain Native Americans than in African Americans, Asians, and other non-white ethnic groups.”

Some researchers suggest that the focus on this specific gene may lead to Black people not being diagnosed with AS if they do not test positive for HLA-B27.

Race, Ethnicity, and Severity

A study from 2017 found that “Black and, albeit less so, Latino patients have more severe disease than white patients with AS.” Black participants showed more functional impairment and greater elevation in inflammation markers, such as erythrocyte sedimentation rate and C-reactive protein. They also had a lower frequency of HLA-B27. However, the researchers could not determine the reason for these discrepancies.

Diversifying Research and Rheumatology

More research is needed in order to understand how race and ethnicity influence the risk for developing spondylitis and experiencing more severe symptoms.

The question is further complicated by the fact that people of color are underrepresented in clinical trials for inflammatory arthritis and genetic research as a whole. Efforts are underway to better understand why clinical research lacks diversity and to ensure that trial participation will be more inclusive in the future.

Rheumatology is one of the least diverse fields of medicine, with only an estimated 25 percent of people of color among health care providers in the U.S. However, the American College of Rheumatology has announced plans to actively recruit trainee doctors with more diverse backgrounds into rheumatology programs going forward.

Talk With Others Who Understand

MySpondylitisTeam is the social network for people with spondylitis and their loved ones. On MySpondylitisTeam, more than 81,000 members come together to ask questions, give advice, and share their stories with others who understand life with spondylitis.

Do you have questions about how race and ethnicity affects disease? Share your experience in the comments below, or start a conversation by posting on your Activities page.

References
  1. Ethnicity and Disease Severity in Ankylosing Spondylitis a Cross-Sectional Analysis of Three Ethnic Groups — Clinical Rheumatology
  2. Social Determinants of Health — Health.gov
  3. Racial Differences in Clinical Features and Comorbidities in Ankylosing Spondylitis in the United States — The Journal of Rheumatology
  4. Racial Differences in Prevalence and Treatment for Psoriatic Arthritis and Ankylosing Spondylitis by Insurance Coverage in the USA — Rheumatology and Therapy
  5. Prevalence of Axial Spondylarthritis in the United States: Estimates From a Cross-Sectional Survey — Arthritis Care & Research
  6. True Difference or Detection Bias: Racial Differences in Clinical Features and Comorbidities in Ankylosing Spondylitis in the United States — Journal of Rheumatology
  7. Treatment Disparities Among the Black Population and Their Influence on the Equitable Management of Chronic Pain — Health Equity
  8. Race and Genetics Versus ‘Race’ in Genetics: A Systematic Review of the Use of African Ancestry in Genetic Studies — Evolution, Medicine, & Public Health
  9. Genetics of Ankylosing Spondylitis — Focusing on the Ethnic Difference Between East Asia and Europe — Frontiers in Genetics
  10. What Are the Racial Predilections for Ankylosing Spondylitis (AS) and Undifferentiated Spondyloarthropathy (USpA)? — Medscape
  11. Inclusion of Racial and Ethnic Minorities in Genetic Research: Advance the Spirit by Changing the Rules? — The Journal of Law, Medicine & Ethics
  12. Factors Associated With Participation in Rheumatic Disease–Related Research Among Underrepresented Populations: A Qualitative Systematic Review — Arthritis Care & Research
  13. New ACR Subcommittee Will Advance Diversity, Equity & Inclusion — The Rheumatologist
  14. Overview of Types of Spondylitis — Spondylitis Association of America
  15. Ankylosing Spondylitis: Chinese Perspective, Clinical Phenotypes, and Associated Extra-Articular Systemic Features — Current Rheumatology Reports
  16. Epidemiology of Spondyloarthritis in North America — The American Journal of the Medical Sciences
  17. Trends in Diagnostic Prevalence and Treatment Patterns of Male and Female Ankylosing Spondylitis Patients in the United States, 2006–2016 — BMC Rheumatology
  18. Psoriasis and Psoriatic Arthritis in African-American Patients — The Need To Measure Disease Burden — Clinical Rheumatology

All updates must be accompanied by text or a picture.
Ariel D. Teitel, M.D., M.B.A. is the clinical associate professor of medicine at the NYU Langone Medical Center in New York. Review provided by VeriMed Healthcare Network. Learn more about him here.
Eli Sachse, RN is a registered nurse living in California. He has written about health topics for Sonoma Medicine and Microcosm Publishing. Learn more about him here.

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