Priority for Cardiovascular Health Equity among U.S. Women: The Need for a Greater Emphasis on Social Determinants of Health
Last Updated: April 20, 2023
"Health is more than the absence of disease. Health is about jobs and employment, education, the environment, and all of those things that go into making us healthy." 1
-Joycelyn Elders, MD, Former U.S. Surgeon General
Achieving optimal cardiovascular health may be an idealistic rather than pragmatic objective for scores of U.S. women. A declining proportion (44%) of U.S. women are aware that cardiovascular disease is the leading cause of death among women in the U.S.2 Less than 6% of women of child-bearing age have attained controlled levels of all traditional cardiovascular risk factors.3 While these dismal statistics apply broadly to U.S. women across all segments of the population, the incidence and prevalence of cardiovascular disease risk factors vary by racial and ethnic group, with minoritized racial and ethnic women having the greatest risks and comorbidities.4 A higher sum of individual cardiovascular risk factors confer not only an elevated risk of coronary heart disease but also lead to higher future risks of heart failure, stroke, and all-cause death, outcomes also varying across racial and ethnic groups.5,6 Thus, achieving optimal cardiovascular health and health equity will require strategies that differ from current conventional methods.
Addressing social determinants of health may be a key approach to achieving ideal cardiovascular health among diverse racial and ethnic U.S. women. This starts with recognizing that race and ethnicity are primarily socio-cultural rather than genetic constructs, and the populations defined by current definitions of race and ethnicity are heterogeneous, often inappropriately aggregated, and/or excluded entirely from national population studies.7,8 The history of race and ethnicity in most countries, often mired by racism, sexism, classism, and xenophobia,9 has also led to major health inequities that disadvantage the same groups. Current and past policies in the U.S. and many other countries have contributed to increased risk of cardiovascular disease among minoritized racial and ethnic groups by creating de facto discrimination through segregation of housing, education, wealth, access to healthy foods, and greater exposure to air pollution, crowding, and toxic wastes.10,11 These social determinants of health are associated with various biological changes, including increased inflammation, higher stress and allostatic load, telomere shortening, accelerated aging, and increased oxidative stress,10,12,13 contributing to elevated risk of cardiovascular disease. Thus, addressing the social determinants of health underlying many of these inequities, may both prevent cardiovascular disease and lead to better control of cardiovascular disease risk factors among diverse women in the U.S. and globally.
In this issue of Circulation, Mehta et al. described how cardiovascular disease risk factors vary by race and ethnicity among U.S. women.14 Mehta et al. shared that approximately 60% of Non-Hispanic Black women have at least one form of cardiovascular disease (defined as coronary heart disease, heart failure, cerebrovascular accident, or hypertension), and this population has the highest risk of dying from cardiovascular disease compared to other races.4,14 Approximately 40% of Hispanic women have cardiovascular disease, and while cardiovascular mortality is lower for Hispanic women than Non-Hispanic White women, much of this may be related to inappropriate aggregation of heterogeneous Hispanic populations.14,15 The prevalence of coronary heart disease ranges from 18% to 27% in American Indian women,16 approximately 50% have two or more risk factors, and more than a third of deaths occur before the age of 65 years in American Indian and Alaska Native women.14,17 Non-Hispanic Asian women have a 45% prevalence of cardiovascular disease and variability in mortality rates across Asian subgroups,18 with Asian Indian and Filipino women having higher death rates than other Asian women but lower than White women.14 The authors described how many of these differences in cardiovascular disease are driven by disparities in access to care and social determinants of health.
Cardiovascular risk calculators were described as a step towards addressing these disparities. Cardiovascular risk calculators are being reenvisioned to capture facets of a diverse U.S. In their statement, Mehta et al. emphasized how current cardiovascular risk calculators can be improved upon by considering experiences of diverse racial and ethnic populations beyond Black and White race groups, incorporating sex-specific factors such as age at menarche, age at menopause, and pregnancy complications (which often vary by race and ethnicity),19 as well as social determinants of health.14 In addition to the authors' recommendations, it is important to consider the appropriate use of racial and ethnic constructs in calculators so that further bias is not introduced into the process of accessing cardiovascular healthcare.20
This statement on cardiovascular disease in women ends with a call to address social determinants of health. We wholeheartedly agree that this issue requires more attention. Multiple studies have identified how culturally tailored research21,22 and interventions 23–25 may be efficacious at reducing cardiovascular disease in historically underserved populations. These successful studies have included the populations of interest from the start of the study as investigators, stakeholders, and study participants,21–25 and rigorously identified and addressed the most pertinent factors contributing to their risks of cardiovascular disease. Supporting and sponsoring studies with diverse teams may accelerate research on the reduction of cardiovascular disease, including narrowing health disparities. While social determinants of health may appear unsurmountable to individual healthcare professionals, targeted interventions can be readily implemented at the bedside and clinical team level by identifying social determinants of health and matching to individual and center-level interventions such as coaching, education, and other support.12
Achieving optimal cardiovascular health should not be a lofty goal for U.S. women. Identifying and treating social determinants of health may make achieving optimal cardiovascular health a pragmatic reality across racial and ethnic groups. As the former U.S. Surgeon General, Dr. Joycelyn Elders, has highlighted throughout her career, we must prioritize social determinants of health to achieve optimal health.
Mehta LS, Velarde GP, Lewey J, Sharma G, Bond RM, Navas-Acien A, Fretts AM, Magwood GS, Yang E, Blumenthal RS, Brown R-M, Mieres JH; on behalf of the American Heart Association Cardiovascular Disease and Stroke in Women and Underrepresented Populations Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Hypertension; Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Lifestyle and Cardiometabolic Health; Council on Peripheral Vascular Disease; and Stroke Council. Cardiovascular disease riskfactors in women: the impact of race and ethnicity: a scientific statement from the American Heart Association [published online ahead of print April 10, 2023]. Circulation. doi: 10.1161/CIR.0000000000001139
- Joycelyn Elders Quotes (Author of Harmful to Minors) n.d. https://www.goodreads.com/author/quotes/84684.Joycelyn_Elders (accessed February 14, 2023).
- Cushman M, Shay CM, Howard VJ, Jiménez MC, Lewey J, McSweeney JC, et al. Ten-Year Differences in Women's Awareness Related to Coronary Heart Disease: Results of the 2019 American Heart Association National Survey: A Special Report From the American Heart Association. Circulation 2021;143:e239–e248. doi:10.1161/CIR.0000000000000907.
- Zheng Y, Wen X, Bian J, Zhao J, Lipkind HS, Hu H. Racial, Ethnic, and Geographic Disparities in Cardiovascular Health Among Women of Childbearing Age in the United States. Journal of the American Heart Association 2021;10:e020138. doi:10.1161/JAHA.120.020138.
- Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, et al. Heart Disease and Stroke Statistics—2023 Update: A Report From the American Heart Association. Circulation n.d.;0. doi:10.1161/CIR.0000000000001123.
- Breathett K, Leng I, Foraker RE, Abraham WT, Coker L, Whitfield KE, et al. Risk Factor Burden, Heart Failure, and Survival in Women of Different Ethnic Groups: Insights From the Women's Health Initiative. Circ Heart Fail 2018;11:e004642. doi:10.1161/CIRCHEARTFAILURE.117.004642.
- Jiménez MC, Manson JE, Cook NR, Kawachi I, Wassertheil-Smoller S, Haring B, et al. Racial Variation in Stroke Risk Among Women by Stroke Risk Factors. Stroke 2019;50:797–804. doi:10.1161/STROKEAHA.117.017759.
- Ford C, Harawa NT. A NEW CONCEPTUALIZATION OF ETHNICITY FOR SOCIAL EPIDEMIOLOGIC AND HEALTH EQUITY RESEARCH. Soc Sci Med 2010;71:251–258. doi:10.1016/j.socscimed.2010.04.008.
- Breathett K, Spatz ES, Kramer DB, Essien UR, Wadhera RK, Peterson PN, et al. The Groundwater of Racial and Ethnic Disparities Research: A Statement From Circulation: Cardiovascular Quality and Outcomes. Circ Cardiovasc Qual Outcomes 2021;14:e007868. doi:10.1161/CIRCOUTCOMES.121.007868.
- Historical Foundations of Race. National Museum of African American History and Culture 2019. https://nmaahc.si.edu/learn/talking-about-race/topics/historical-foundations-race (accessed December 1, 2020).
- Sistrunk C, Tolbert N, Sanchez-Pino MD, Erhunmwunsee L, Wright N, Jones V, et al. Impact of Federal, State, and Local Housing Policies on Disparities in Cardiovascular Disease in Black/African American Men and Women: From Policy to Pathways to Biology. Front Cardiovasc Med 2022;9:756734. doi:10.3389/fcvm.2022.756734.
- Churchwell Keith, Elkind Mitchell S.V., Benjamin Regina M., Carson April P., Chang Edward K., Lawrence Willie, et al. Call to Action: Structural Racism as a Fundamental Driver of Health Disparities: A Presidential Advisory From the American Heart Association. Circulation 2020;142:e454–e468. doi:10.1161/CIR.0000000000000936.
- Powell-Wiley TM, Baumer Y, Baah FO, Baez AS, Farmer N, Mahlobo CT, et al. Social Determinants of Cardiovascular Disease. Circulation Research 2022;130:782–799. doi:10.1161/CIRCRESAHA.121.319811.
- Albert MA, Ridker PM. C-Reactive Protein as a Risk Predictor Do Race/Ethnicity and Gender Make a Difference? Circulation 2006;114:e67–e74. doi:10.1161/CIRCULATIONAHA.106.613570.
- Mehta L, Velarde G, Lewey J, Sharma G, Bond R, Navas-Acien A, et al. Cardiovascular Disease Risk Factors in Women: The Impact of Race and Ethnicity A Scientific Statement from the American Heart Association. Circulation 2023.
- Rodriguez CJ, Allison M, Daviglus ML, Isasi CR, Keller C, Leira EC, et al. Status of cardiovascular disease and stroke in Hispanics/Latinos in the United States: a science advisory from the American Heart Association. Circulation 2014;130:593–625. doi:10.1161/CIR.0000000000000071.
- Howard BV, Lee ET, Cowan LD, Fabsitz RR, Howard WJ, Oopik AJ, et al. Coronary heart disease prevalence and its relation to risk factors in American Indians. The Strong Heart Study. Am J Epidemiol 1995;142:254–268. doi:10.1093/oxfordjournals.aje.a117632.
- Breathett K, Sims M, Gross M, Jackson EA, Jones EJ, Navas-Acien A, et al. Cardiovascular Health in American Indians and Alaska Natives: A Scientific Statement From the American Heart Association. Circulation 2020;141:e948–e959. doi:10.1161/CIR.0000000000000773.
- Hastings KG, Jose PO, Kapphahn KI, Frank ATH, Goldstein BA, Thompson CA, et al. Leading Causes of Death among Asian American Subgroups (2003-2011). PLoS One 2015;10:e0124341. doi:10.1371/journal.pone.0124341.
- Bond RM, Gaither K, Nasser SA, Albert MA, Ferdinand KC, Njoroge JN, et al. Working Agenda for Black Mothers: A Position Paper From the Association of Black Cardiologists on Solutions to Improving Black Maternal Health. Circ Cardiovasc Qual Outcomes 2021;14:e007643. doi:10.1161/CIRCOUTCOMES.120.007643.
- Johnson AE, Brewer LC, Echols MR, Mazimba S, Shah RU, Breathett K. Utilizing Artificial Intelligence to Enhance Health Equity Among Patients with Heart Failure. Heart Fail Clin 2022;18:259–273. doi:10.1016/j.hfc.2021.11.001.
- Hines AL, Brody R, Zhou Z, Collins SV, Omenyi C, Miller ER, et al. Contributions of Structural Racism to the Food Environment: A Photovoice Study of Black Residents With Hypertension in Baltimore, MD. Circ Cardiovasc Qual Outcomes 2022;15:e009301. doi:10.1161/CIRCOUTCOMES.122.009301.
- Sealy-Jefferson S, Misra DP. Neighborhood Tax Foreclosures, Educational Attainment, and Preterm Birth among Urban African American Women. Int J Environ Res Public Health 2019;16:904. doi:10.3390/ijerph16060904.
- Brewer LC, Jenkins S, Hayes SN, Kumbamu A, Jones C, Burke LE, et al. Community-Based, Cluster-Randomized Pilot Trial of a Cardiovascular Mobile Health Intervention: Preliminary Findings of the FAITH! Trial. Circulation 2022;146:175. doi:10.1161/CIRCULATIONAHA.122.059046.
- Viramontes O, Swendeman D, Moreno G. Efficacy of Behavioral Interventions on Biological Outcomes for Cardiovascular Disease Risk Reduction among Latinos: a Review of the Literature. J Racial Ethn Health Disparities 2017;4:418–424. doi:10.1007/s40615-016-0242-z.
- Kandula NR, Dave S, De Chavez PJ, Bharucha H, Patel Y, Seguil P, et al. Translating a heart disease lifestyle intervention into the community: the South Asian Heart Lifestyle Intervention (SAHELI) study; a randomized control trial. BMC Public Health 2015;15:1064. doi:10.1186/s12889-015-2401-2.
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-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --
Pub Date: Monday, Apr 10, 2023
Author: Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA; JoAnn E. Manson, MD, DrPH, MACP, FAHA
Affiliation: Division of Cardiovascular Medicine, Indiana University, Indianapolis, IN (KB); Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (JEM)