Addressing social factors critical for continued fight against heart disease and stroke in the USA


Deaths from heart attacks, strokes and other heart diseases have been declining, but social factors, including race, income, environment and education could reverse that trend, according to a first of its kind scientific statement from the American Heart Association.

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 USA, according to the statement, published in the association’s journal Circulation.

“The steady decline of death from cardiovascular disease that began in the 1970s might be coming to an end. Overall population health cannot improve if parts of the population do not benefit from improvements in prevention and treatment,” says Edward P Havranek, chair of the writing group and a cardiologist at Denver Health Medical Center and professor of cardiology at the University of Colorado School of Medicine, Denver, USA.

Social determinants include circumstances in which people are born, grow, live, work and age. The statement notes several areas in which clear associations between societal factors and cardiovascular health have been shown.

Among those, education is a top indicator of one’s socioeconomic status because it affects what kind of job a person has, their access to healthcare, income, stress and more. Research indicates that people with lower educational levels die younger, largely due to cardiovascular disease, according to Havranek.

Furthermore, the lower the income, the higher the risk for cardiovascular disease. In one study of more than 500,000 men, researchers found a 40% to 50% decrease in risk of cardiovascular death, with increasing levels of family income.

There is overlap between race and poverty in the USA, which is especially evident among African Americans. While some differences in cardiovascular risk among races might be explained by genetics and biology, there are other factors. “Whether or not bias and prejudice lead to less care or poorer care is an area that people are actively studying,” Havranek says. “There also is evidence that people who experience the chronic stressors, such as racism, might have higher blood pressure as a result.”

Studies support that the neighbourhoods in which people live likely affect their heart disease risk. “We need to learn more about why that is, but contributing factors could include less access to healthy food, less opportunity for physical activity, higher stress levels with higher crime, noise, traffic, etc.,” Havranek says.

Emerging evidence suggests that one’s tendency to develop high blood pressure and perhaps diabetes as adults is in some way determined by things that happen before birth and through early life. There is evidence that children with low birth weight tend to have structural changes to the heart and kidneys that may predispose them high blood pressure and diabetes, when they are adults.

A study also found that preschool children in an enhanced daycare programme, where they were educated, referred to a pediatrician and received healthy meals seemed to have lower risk for heart disease 30 years later compared to preschoolers in usual daycare. “There may be an opportunity to prevent adults’ chronic illnesses by doing a better job of taking care of preschool kids,” Havranek says.

Health insurance access could improve significantly with the Affordable Care Act. “But we still need to have a healthcare system that is welcoming to people who might fall into disadvantaged groups, where people can find primary care doctors and can get timely care,” Havranek notes.

The number of cardiovascular disease cases in the USA is expected to rise about 10% between 2010 and 2030. The social dynamic of cardiovascular disease is helping to drive the increase, according to the statement. Addressing the social influences, as well as biological and genetic influences, on cardiovascular health in America is necessary to achieve what the American Heart Association calls the inclusive “culture of health.”

“Failure to address the social dynamic of cardiovascular disease will compromise the American Heart Association’s 2020 Impact Goal to improve cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%,” Havranek says.

The statement suggests doctors and consumers pay attention to how social factors might impact cardiovascular health and recommends specific steps for improving social factors that could negatively impact cardiovascular health. These include a focus on a new kind of advocacy.

“We are used to public health programmes that educate people to know their blood pressure or cholesterol numbers. We are less comfortable with public health programmes focused on getting three-year-olds into daycare programmes, which may improve their health down the road. We might be less accustomed to (but need) public health programmes that look at how urban planners can improve neighborhoods that are seeing higher rates of cardiovascular disease,” he says.