insights

Read time: 4 minutes

Cardiovascular disease (CVD), including heart disease and stroke, is the leading cause of death in the United States for people of most racial and ethnic groups in the United States.¹ High blood pressure and high blood cholesterol are key risk factors for heart disease. 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, 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 and discrimination are examples of social determinants of health and have all been suggested to impact CVD risk.^2-10 For example, a 2020 cross-sectional analysis that investigated the relationship between social determinants of health and ischemic strokes found the following results:¹⁰

• 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 were significantly associated 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.¹¹ A 2014 systematic review that included 44 studies (N=32,651) indicated that reports of racial discrimination were associated with increased prevalence of hypertension.¹² 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.¹³ According to 2022 reporting by the American Heart Association, prevalence of high blood pressure among Black Americans is among the highest in the world, with approximately 55% diagnosed with hypertension.¹⁴ Studies suggest that racial disparities in hypertension may be influenced by various factors including environmental factors such as racial residential segregation and neighborhood poverty levels.^13,15

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
• Perceived discrimination in general may influence the acute stress response and heighten levels of inflammation²⁰ that may play a role in CVD risk.
• Perceived discrimination specific to race has been associated with increased risk of hypertension, elevated measures of systemic inflammation, and an increased risk of CVD.³

A 2022 systematic review found that among young African American women, psychosocial factors such as perceived stress, racial discrimination, internalized racism, and depression are related to higher BMI and blood pressure and may increase overall CVD risk for this population.²¹ 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.²² 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.²²

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).

Related Articles

Chronic Stressors, Disease Burden, and Sustainable Lifestyle Interventions

Lifestyle Interventions to Modify Cardiovascular Disease Risk

How Do Sleep Duration and Quality Influence Cardiometabolic Outcomes?

References

1. National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and Stroke Prevention. Heart disease facts. Centers for Disease Control and Prevention. Reviewed October 14, 2022. Accessed November 16, 2022. https://www.cdc.gov/heartdisease/facts.htm
2. Virani SS, Alonso A, Aparicio HJ, et al. Heart disease and stroke statistics—2021 update: a report from the American Heart Association. Circulation. 2021;143(8):e254-e743. doi:1161/CIR.0000000000000950
3. Panza GA, Puhl RM, Taylor BA, Zaleski AL, Livingston J, Pescatello LS. Links between discrimination and cardiovascular health among socially stigmatized groups: a systematic review. PLoS One. 2019;14(6):e0217623. doi:1371/journal.pone.0217623
4. 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:5888/pcd13.160088
5. Safford MM, Reshetnyak E, Sterling MR, et al. Number of social determinants of health and fatal and nonfatal incident coronary heart disease in the REGARDS study. Circulation. 2021;143(3):244-253. doi:1161/CIRCULATIONAHA.120.048026
6. Qin P, Luo X, Zeng Y, et al. Long-term association of ambient air pollution and hypertension in adults and in children: a systematic review and meta-analysis. Sci Total Environ. 2021;796:148620. doi:1016/j.scitotenv.2021.148620
7. Parekh T, Xue H, Cheskin LJ, Cuellar AE. Food insecurity and housing instability as determinants of cardiovascular health outcomes: a systematic review. Nutr Metab Cardiovasc Dis. 2022;32(7):1590-1608. doi:1016/j.numecd.2022.03.025
8. Daniel H, Bornstein SS, Kane GC, et al. 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:7326/M17-2441
9. 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:3390/ijerph16091498
10.  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:1136/openhrt-2019-001189
11.  Leng B, Jin Y, Li G, Chen L, Jin N. Socioeconomic status and hypertension. J Hypertens. 2015;33(2):221-229. doi:1097/HJH.0000000000000428
12.  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:1037/a0033718
13.  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:1093/aje/kwr116
14.  American Heart Association editorial staff. High blood pressure among Black people. American Heart Association. Reviewed March 4, 2022. Accessed November 16, 2022. https://www.heart.org/en/health-topics/high-blood-pressure/why-high-blood-pressure-is-a-silent-killer/high-blood-pressure-and-african-americans
15.  Gao X, Kershaw KN, Barber S, et al. Associations between residential segregation and incident hypertension: the multi-ethnic study of atherosclerosis. J Am Heart Assoc. 2022;11(3):e023084. doi:1161/JAHA.121.023084
16.  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:1001/jama.2012.14306
17.  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:1161/CIR.0000000000000228
18.  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:1161/CIR.0000000000000534
19.  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):E22 8336. doi:1371/journal.pone.0228336
20.  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:1016/j.bbi.2018.07.010
21.  Harris LK, Berry DC, Cortés YI. Psychosocial factors related to cardiovascular disease risk in young African American women: a systematic review. Ethn Health. 2022;27(8):1806-1824. doi:1080/13557858.2021.1990218
22.  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:1016/j.ctim.2019.102277