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Volume 11, Number 10
Although deaths from heart disease have been declining over the past several decades, heart disease continues to be the leading cause of death in the United States. Unfortunately, the prevalence of cardiovascular disease (CVD) is projected to rise over the next two decades, largely due to the increasing incidence of obesity, physical inactivity, and related risk factors. Not only is this bad news for the health of many people, it will also hinder efforts to control increasing health care costs.
The American Heart Association (AHA) recently published a scientific statement in the journal Circulation, asserting that “…at present, the most significant opportunities for reducing death and disability from CVD in the United States lie with addressing the social determinants of cardiovascular outcomes.” The social determinants addressed in the statement include socioeconomic position, race and ethnicity, social support, culture, access to medical care, and residential environments.
Heretofore, the emphasis on heart disease prevention has been at the individual level. Persons have been encouraged to exercise, eat more vegetables and fruits, maintain a healthy weight, don’t smoke, and manage chronic conditions such as diabetes, hypertension, and high cholesterol. Of course, these behavioral admonitions continue to be vitally important, but the AHA statement now emphasizes the need to address societal factors that convey cardiovascular risk beyond individual health behaviors. For example, it is known that children who experience disadvantage early in life have increased cardiovascular risk, and studies indicate that lifestyle factors (i.e., diet, exercise, etc.) do not fully account for this increased risk. The chronic stress that accompanies socioeconomic disadvantage is associated with increased inflammation in the body, a factor in the development of cardiovascular disease.
Reducing the impact of social determinants of health is a different task than is encouraging healthy lifestyles on the individual level. It is one thing to encourage someone to modify her/his behavior in the interest of that person’s own health. It is clearly a different matter to encourage persons to modify their behavior in the interest of the health of others in one’s society. Increasing educational opportunities (especially early childhood education), reducing children’s exposure to poverty, increasing safe and affordable housing, reducing racial and ethnic discrimination, and increasing access to healthcare for all are obviously challenges about which opinions vary widely on the political spectrum. Making a dent in the impact of the social determinants of health will require initiative and momentum on a societal level.
Furthermore, seeing the benefit of population health efforts requires patience. Any cardiovascular risk reduction that comes from childhood interventions typically won’t be seen until the children are in adulthood. The AHA statement makes reference to research published in Science in 2014, which examined the health of persons who had been involved as children in the Carolina Abecedarian Project (ABC) in the 1970s. The goal of the ABC was to determine whether providing a stimulating early childhood environment to disadvantaged children could prevent the development of mild intellectual disability. Children were randomized to either the intervention or to a control condition. The investigators found that children in the intervention condition had a significantly lower prevalence of cardiovascular risk factors in their mid-30s, compared to those in the control group, and therefore will potentially avoid the significant costs associated with the treatment of cardiovascular disease.
Although health outcomes are frequently not included in discussions of the potential benefits of efforts to address social challenges, it is increasingly evident that improving health and decreasing health care costs requires attention to the social determinants of health. The American Heart Association is taking this position with their strong statement.
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