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Cardiovascular disease (CVD), including heart disease and stroke, is the leading cause of death in the United States, and according to the American Heart Association, if hypertension is included, nearly half of US adults have a cardiovascular disease.1-3 Prevention and interventions that address modifiable lifestyle factors such as diet, exercise, and smoking are important clinical considerations for CVD. In addition, researchers are finding that social determinants of health are essential to understanding the complete scope of a patient’s health and CVD risk, and to informing optimal prevention and treatment strategies.
Social determinants of health are economic, social, and physical environment factors and conditions that shape a person’s daily life,4 impact their access to health care, and influence their risk of developing chronic diseases. Socioeconomic status including education; income and occupation measures; food insecurity and healthy food access; social relationships and support; environmental factors such as air pollution; and social conditions such as chronic stress, racial residential segregation, and discrimination are examples of social determinants of health and have all been suggested to impact CVD risk.3,5-12 For example, a 2020 cross-sectional analysis that investigated the relationship between social determinants of health and ischemic strokes found the following results:12
- Communities with high rates of ischemic strokes also had poor rankings for health outcomes, health behaviors, physical environment, and socioeconomic factors.
- Communities with either air pollution measures or violent crime rates that exceeded the national average had a significant association with ischemic stroke hospitalizations.
Specific to hypertension prevalence, research suggests a positive correlation with lower socioeconomic status, neighborhood poverty, and racial discrimination. A 2015 meta-analysis of 51 studies found an overall increased risk of hypertension among the lowest socioeconomic status, which was statistically significant in high-income countries.13 With data from 8,071 Black and white participants in the National Health and Nutrition Examination Survey (1999-2006), analysis indicated that Black participants had a 2.74 times higher risk of hypertension than white participants.14 This analysis was made after adjustments for age, gender, and socioeconomic status. Further, the findings suggested that the racial disparities in hypertension may be influenced by environmental factors such as racial residential segregation and neighborhood poverty levels.3,14 A 2014 systematic review that included 44 studies (N=32,651) indicated that reports of racial discrimination were associated with increased prevalence of hypertension.3,15
The burden of cardiovascular disease is higher for Black populations in the United States, with Black people experiencing a greater risk of development and a two to three times greater chance of dying from heart disease than white counterparts.16-18 Studies have investigated CVD health disparities and the relationship between discrimination, racism, chronic stress, and CVD, with results that suggest:
- A higher allostatic load is associated with higher all-cause and CVD-specific mortality rates for all US adults aged 25 years or older.19
- Chronic stress that includes racial discrimination experiences may be related to higher carotid intima-media thickness.5
- Perceived discrimination may influence the acute stress response and heighten levels of inflammation20 that may play a role in CVD risk.
For Black women experiencing chronic race-based stress who are at risk for CVD, a small 2020 clinical trial evaluated the stress and coping intervention, the Resilience, Stress, and Ethnicity (RiSE) model for reducing stress and building resilience in Black, Indigenous, and People of Color (BIPOC) communities.21 After an eight-week group-based treatment that included sharing experiences related to race-based stress, cognitive-behavioral and mindfulness strategies, and skill building and empowerment, researchers found that the intervention was practical and effective for chronic stress management.21
Personalized assessments and innovative prevention and treatment strategies are cornerstones of functional medicine care. In addition to diet, exercise, and lifestyle interventions for the prevention and treatment of cardiovascular diseases, awareness of health disparities and social factors that may be root causes of CVD risk is essential. Social determinants of health are antecedents and mediators of physiological dysfunction in the functional medicine matrix model. Meeting a patient where they are helps to identify barriers and to understand how those barriers or unmet social needs may inform CVD intervention strategies.
Research studies continue to highlight health disparities and barriers in an attempt to develop strategies and techniques that de-escalate CVD risk. Learn more from functional medicine field experts at IFM’s Cardiometabolic Advanced Practice Module (APM).
- Centers for Disease Control and Prevention. Heart disease facts. Reviewed September 8, 2020. Accessed September 23, 2020. https://www.cdc.gov/heartdisease/facts.htm
- American Heart Association News. Cardiovascular diseases affect nearly half of American adults, statistics show. American Heart Association. Published January 31, 2019. Accessed September 23, 2020. https://www.heart.org/en/news/2019/01/31/cardiovascular-diseases-affect-nearly-half-of-american-adults-statistics-show
- Benjamin EJ, Muntner P, Alonso A, et al. Heart disease and stroke statistics—2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56-e528. doi:10.1161/CIR.0000000000000659
- Office of Disease Prevention and Health Promotion. Social determinants of health. Updated September 30, 2020. Accessed October 5, 2020. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
- Troxel WM, Matthews KA, Bromberger JT, Sutton-Tyrrell K. Chronic stress burden, discrimination, and subclinical carotid artery disease in African American and Caucasian women. Health Psychol. 2003;22(3):300-309. doi:10.1037/0278-6188.8.131.520
- Shaw KM, Theis KA, Self-Brown S, Roblin DW, Barker L. Chronic disease disparities by county economic status and metropolitan classification, behavioral risk factor surveillance system, 2013. Prev Chronic Dis. 2016;13:E119. doi:10.5888/pcd13.160088
- Hernandez DC, Reitzel LR, Wetter DW, McNeill LH. Social support and cardiovascular risk factors among Black adults. Ethn Dis. 2014;24(4):444-450.
- Lee BJ, Kim B, Lee K. Air pollution exposure and cardiovascular disease. Toxicol Res. 2014;30(2):71-75. doi:10.5487/TR.2014.30.2.071
- Suarez JJ, Isakova T, Anderson CA, Boulware LE, Wolf M, Scialla JJ. Food access, chronic kidney disease, and hypertension in the U.S. Am J Prev Med. 2015;49(6):912-920. doi:10.1016/j.amepre.2015.07.017
- Daniel H, Bornstein SS, Kane GC; Health and Public Policy Committee of the American College of Physicians. Addressing social determinants to improve patient care and promote health equity: an American College of Physicians position paper. Ann Intern Med. 2018;168(8):577-578. doi:10.7326/M17-2441
- Tan J, Wang Y. Social integration, social support, and all-cause, cardiovascular disease and cause-specific mortality: a prospective cohort study. Int J Environ Res Public Health. 2019;16(9):1498. doi:10.3390/ijerph16091498
- Wang A, Kho AN, French DD. Association of the Robert Wood Johnson Foundations’ social determinants of health and Medicare hospitalisations for ischaemic strokes: a cross-sectional data analysis. Open Heart. 2020;7(1):e001189. doi:10.1136/openhrt-2019-001189
- Leng B, Jin Y, Li G, Chen L, Jin N. Socioeconomic status and hypertension: a meta-analysis. J Hypertens. 2015;33(2):221-229. doi:10.1097/HJH.0000000000000428
- Kershaw KN, Diez Roux AV, Burgard SA, Lisabeth LD, Mujahid MS, Schulz AJ. Metropolitan-level racial residential segregation and black-white disparities in hypertension. Am J Epidemiol. 2011;174(5):537-545. doi:10.1093/aje/kwr116
- Dolezsar CM, McGrath JJ, Herzig AJM, Miller SB. Perceived racial discrimination and hypertension: a comprehensive systematic review. Health Psychol. 2014;33(1):20-34. doi:10.1037/a0033718
- Safford MM, Brown TM, Muntner PM, et al. Association of race and sex with risk of incident acute coronary heart disease events. JAMA. 2012;308(17):1768-1774. doi:10.1001/jama.2012.14306
- Havranek EP, Mujahid MS, Barr DA, et al. Social determinants of risk and outcomes for cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2015;132(9):873-898. doi:10.1161/CIR.0000000000000228
- Carnethon MR, Pu J, Howard G, et al. Cardiovascular health in African Americans: a scientific statement from the American Heart Association. Circulation. 2017;136(21):e393-e423. doi:10.1161/CIR.0000000000000534
- Borrell LN, Rodríguez-Álvarez E, Dallo FJ. Racial/ethnic inequities in the associations of allostatic load with all-cause and cardiovascular-specific mortality risk in U.S. adults. PLoS One. 2020;15(2):e0228336. doi:10.1371/journal.pone.0228336
- Saban KL, Mathews HL, Bryant FB, et al. Perceived discrimination is associated with the inflammatory response to acute laboratory stress in women at risk for cardiovascular disease. Brain Behav Immun. 2018;73:625-632. doi:10.1016/j.bbi.2018.07.010
- Conway-Phillips R, Dagadu H, Motley D, et al. Qualitative evidence for Resilience, Stress, and Ethnicity (RiSE): a program to address race-based stress among Black women at risk for cardiovascular disease. Complement Ther Med. 2020;48:102277. doi:10.1016/j.ctim.2019.102277