Although mortality from cardiovascular disease (CVD) in the United States has been declining since the 1970s, the burden of the disease remains high, accounting for nearly 32% of all deaths in the U.S., according to recent data. “It was assumed that the steady downward trend in mortality would continue into the future as further breakthroughs in science led to advances in prevention and treatment,” explains Edward P. Havranek, MD. “However, advances in the field have stalled substantially in recent years.”
Research suggests that the prevalence of CVD in the U.S. will rise 10% between 2010 and 2030. “This change in the trajectory of cardiovascular burden is the result of an aging population as well as a dramatic rise in obesity and the hypertension, diabetes, and physical inactivity that accompanies weight gain,” Dr. Havranek says. “Considering this altered trajectory, it’s important to think about the role of social issues in the management of CVD.”
The American Heart Association has released a scientific statement on social determinants of risk and outcomes for CVD with the purpose of increasing awareness of these important factors. Social determinants include circumstances in which people are born, grow, live, work, and age (Table). Published in Circulation and available for free at http://circ.ahajournals.org, the statement summarizes current knowledge about these factors and offers recommendations for future directions in research. The latter includes efforts to develop effective interventions to reduce or eliminate these adverse social influences.
According to the statement, advances in prevention and treatment have driven the decline in cardiovascular deaths, but the benefits have not been shared equally across economic, racial, and ethnic groups in the U.S. “The statement notes several areas in which clear associations between societal factors and cardiovascular health have been shown,” says Dr. Havranek, who was chair of the writing group. “These issues go beyond simple healthcare disparities and include factors that affect everyone, including education, income, and sociodemographic considerations.”
Education has been identified as a top indicator of socioeconomic status because it affects the type of job people have, their access to healthcare, income, stress, and other factors. Studies suggest that people with lower educational levels tend to die at younger ages from CVD. In addition, people with lower incomes are more likely to develop CVD. “A patient’s socioeconomic standing drives health in ways that we don’t often think about,” says Dr. Havranek.
Some differences in cardiovascular risk among races might be explained by genetics and biology, but Dr. Havranek says there are other factors to consider. Several areas are actively being studied with regard to racial disparities in CVD, including the effects of bias, prejudice, and other chronic stressors. Investigators are also exploring the effect of access to healthy foods and opportunities for physical activity among racial and ethnic groups.
Prenatal Care & Early Childhood
According to the scientific statement, there is emerging evidence suggesting that the tendency for adults to develop hypertension and diabetes may be determined by factors that happen before birth and throughout early life. “Children with low birth weight are at risk for structural changes to the heart and kidneys that may predispose them to hypertension and diabetes when they reach adulthood,” says Dr. Havranek. “We now have evidence suggesting that educating preschool children, referring them to pediatricians, and providing them with healthy meals can lower risks for CVD later in life. This is an important opportunity to consider, but more research is needed on effective interventions for preschoolers.”
Access to Healthcare Issues
The scientific statement notes that health insurance access may improve significantly with the Affordable Care Act, but greater efforts are needed to deal with disadvantaged patient groups. There are many barriers to accessing care, including issues involving patient beliefs, literacy, culture, and language. There is also a poor geographic distribution of cardiac services throughout the country.
Dr. Havranek says that although access to health insurance is necessary, it is not a sufficient intervention for improving cardiovascular health. “To improve access, we need multifaceted efforts that require the provision of insurance coverage and a better distribution of services,” he says. “Ultimately, we need to address social, biological, and genetic influences on cardiovascular health in order to achieve a ‘culture of health.’”
Physicians and consumers are recommended to pay attention to how social factors might impact cardiovascular health. “We need greater awareness of the role of social factors in CVD and should take specific steps to ask patients about these factors during our encounters with them,” says Dr. Havranek. “We also need to develop advocacy efforts that go outside the box and implement innovate, cost-effective public health programs that aim to reduce the burden of CVD.”
Readings & Resources (click to view)
Havranek EP, Mujahid MS, Barr DA, et al; on behalf of the American Heart Association Council on Quality of Care and Outcomes Research, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, Council on Lifestyle and Cardiometabolic Health, and Stroke Council. Social determinants of risk and outcomes for cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2015;132:873-898. Available at: http://circ.ahajournals.org/content/132/9/873.full.
Lloyd-Jones DM, Hong Y, Labarthe D, et al; American Heart Association Strategic Planning Task Force and Statistics Committee. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond. Circulation. 2010;121:586-613.
Marmot M, Friel S, Bell R, Houweling TA, Taylor S; Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet. 2008;372:1661-1669.