The Social and Psychosocial Determinants of Cardiovascular Health

In this episode of the Better Edge podcast, Nilay S. Shah, MD, MPH, discusses his recent study about the social and psychosocial determinants of racial and ethnic differences in cardiovascular health in the U.S.

He outlines several of the proposed interventions that emphasize the need for further studies in underrepresented populations that can then help inform tailored, effective preventive interventions. He identifies key knowledge gaps that need to be addressed, the clinical implications of the findings and what other physicians involved in cardiology should keep in mind when working with populations that experience disparities.
The Social and Psychosocial Determinants of Cardiovascular Health
Featured Speaker:
Nilay Shah, MD, MPH
Nilay Shah, MD, MPH is a physician-scientist, Assistant Professor of Cardiology and Preventive Medicine, and general and preventive cardiologist in the Bluhm Cardiovascular Institute, at Northwestern University Feinberg School of Medicine. His research focuses on understanding cardiometabolic health transitions and the development of cardiovascular diseases across the life course, working toward evidence-based CVD primordial prevention.
The Social and Psychosocial Determinants of Cardiovascular Health

Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. And joining me today is Dr. Nilay Shah. He's an Assistant Professor of Medicine in Cardiology and Preventive Medicine at Northwestern Medicine. And he's here to highlight the social and psychosocial determinants of cardiovascular health.

Dr. Shah, I'm so glad you're joining us. As we said off the air, this is a very important topic and it's such an important aspect of the communities that we live in. As we start, can you please tell us a little bit about the social determinants of health in urban areas we've recognized over the years, food deserts, accessibility? Can you outline for us the social determinants of health in the various populations and how it's been suggested that there are these important factors, whether they are upstream or downstream, and how those factors contribute to cardiovascular risk?

Dr Nilay Shah: Yes. Good morning. And thank you for the opportunity to share about our work and talk about this very important topic. So, social determinants of health can be best considered the underlying factors that contribute to health and disease. Some people refer to them as the factors that are associated with where we live, learn, work, and play. These are factors that influence our behaviors and our health in many different ways. And examples of them include things like socioeconomic status and position, things like income, employment, and education; food security and access to healthful foods; our social communities and the context of the social relationships we have with other people; our ability to access healthcare, including things like health insurance and care that's culturally concordant and linguistically matching as well; factors related to culture and place of birth; as well as psychosocial factors, things like the role of anxiety and depression. All of these are highly influential in our everyday lives and are a part of the environment in which all of us live and plays a significant role in determining our health and our risk for disease. So, these are factors that do occur upstream on the continuum of health and modifying these factors, although it's not easy, are likely to have a fairly significant impact in an individual's risk of disease and also a population's risk of disease.

And beyond social determinants, even more upstream, there are structural determinants. And so, I think it is becoming increasingly clear that there are factors built into the systems that we as a society have built, things like our access to housing and our justice system that include factors like discrimination and racism that underlie even social determinants. And all of these factors exist along the continuum of health. Social and structural determinants do occur upstream and are likely fundamental causes of health and health disparities.

Melanie Cole (Host): This is such a complex issue. For you to tackle this in research studies is really quite something. Because as you say, it can spread out not only for individual factors, but also then, you know, the wider community and then the particular state and then really all over the country and some of these upstreams when we look at sidewalks, parks, public pools, gym and recess. I mean, it really gets so complex that these each little individual areas are just very, very hard to target. So, this amazes me that you did this. Now, can you tell us a little bit about your research study? How did you get involved in something like this and summarize what we know now.

Dr Nilay Shah: Yes. And thank you for that very important point because I think it's important for all of us to realize that these factors that influence our health, they are related to each other. It's not really accurate to try to target or identify each one individually. Because as I think we all understand, so many of these social determinants are related to each other. Our socioeconomic position is related to our ability to access healthcare, is related to our access to healthful foods. The communities in which we live and our social networks and the social support we have are related to our ability to maintain health and engage in healthful behaviors. The environments and neighborhoods in which we live, like you referred to the built environment, influences our ability to engage in healthful behaviors like physical activity, but also the access that people have to transportation to even make it to their doctor's offices. And so, I think it's important to understand that we start with understanding that each of these factors are related to each other.

And the motivation for this research study was primarily recognizing that we, as a collective, have spent a lot of time describing disparities, meaning we know that they exist. There are considerable and substantial disparities that exist between groups in the United States. But we haven't really started to understand why these disparities exist and, even more specifically, to what degree each of these social factors explain the disparities. Because there's a lot of evidence that indicates that these social factors, like socioeconomic position and good and safe neighborhood environments and food security influence health. But the question we wanted to ask was how do each of these factors contribute to the disparities that exist?

So, for example, we know that populations who identify as black or Hispanic or Asian experience disparities in cardiovascular health. And when I talk about cardiovascular health, I'm talking about traditional cardiovascular risk factors like smoking and hypertension, cholesterol and diabetes. We know that populations, for example, identify as black or Hispanic, tend to have worse cardiovascular health compared with populations in the US who identify as white. And although we would hypothesize that social determinants would contribute to these differences, the purpose of this study and the motivation of this study was to better understand to what degree these social determinants actually explain the differences in cardiovascular health among racial ethnic groups in the United States.

And the idea is that if we can identify which factors have outsized influence, our ability to reduce disparities ought to focus on those factors. So, we use data from about 16,000 participants of NHANES, which is a nationally representative study in the United States, to evaluate the contribution of a range of social determinants to differences in cardiovascular health in black, Hispanic, Asian and white adults in the US. And we looked at social determinants that included education, income, food security; someone's social networks, including their marital status, health insurance, and access to care; their place of birth, whether they were born in the United States versus the outside the United States; and depression as a measure of psychosocial health. And our investigation was intended to help us understand what to focus on in order to reduce disparities.

Melanie Cole (Host): Wow. That is so interesting. You picked some areas that, you know, some of them are pretty glaring in the health disparities. We can see the mental health and lack of experts in different populations. We can see that access to care, all of these things. So, were you surprised by any of the results of your study? And if not, I mean, I feel like if I was reading your study directly, some of it would probably surprise me and some wouldn't.

Dr Nilay Shah: And that's exactly the reaction and response that I had once we took a look at the data and matched it against our hypothesis. So, although all of these findings are important and help us understand how to address health disparities, some were less surprising and others were more surprising.

So for example, we found that among men, education was the factor that contributed the most to differences between racial and ethnic groups. The magnitude of the contribution that education had to explaining the difference in cardiovascular health between black adults, Hispanic adults, Asian adults, and white adults, was particularly large. And I think this was less surprising because we've long known that educational attainment contributes to health outcomes because of all of the factors that are associated with educational attainment. In part, higher educational attainment is associated with higher literacy and health literacy, so people are better able to understand and adhere to the directions, for example, that their physician may give. But higher educational attainment is also linked to more successful employment with higher incomes that facilitate access to healthcare because of health insurance. So, there's a lot related to education that can be unpacked. But education itself was identified as one of the strongest contributors to disparities in cardiovascular health that were observed.

On the other hand, a more surprising finding was that among women, place of birth, meaning specifically being born in the US versus being born outside the US, was the factor that contributed most to the differences in cardiovascular health between groups, particularly for Hispanic and Asian women. So, in the NHANES study, women participants who identified as Hispanic or Asian, a large proportion of them were actually born outside the United States compared with being born inside the United States. And there's several implications from this, both in terms of how to interpret the data, but also what the next steps are from this research. So when I see this finding, that place of birth contributes significantly, and in particular that the proportion of women who were born outside the United States was higher than the proportion of women who were born inside the United States, and the evidence suggests that the place of birth being born outside the United States may actually be protective, it tells me that there are factors related to childhood environments and immigration that are contributing to the differences in cardiovascular health between groups.

One of the surprising findings is that we showed that women who identified as Asian and women who identified as Hispanic actually had better cardiovascular health compared with women who identified as white in this dataset. It was surprising. But then when you dig into it, there are several potential explanations. One of which is this idea of the healthy immigrant effect, which is to say the individuals who are able to immigrate to the United States through our usual immigration processes tend to be people who are of higher socioeconomic position because they completed an education in the countries from which they came and have economic opportunities such as moving to the US for a job that led to their immigration.

And so, there's a lot to unpack that we don't yet understand about the role of immigration and why people immigrate. But it was surprising to see that place of birth contributed so strongly to the differences in cardiovascular health. It tells me that in these particular populations, in individuals who identify as Hispanic and Asian, we have quite a bit left to understand about what it is about their environments and childhood, their environments in the countries from which they came, and what led to their immigration that likely influences their health.

Melanie Cole (Host): Wow, that is surprising. I mean, not really. Certainly not in the Asian populations because we've heard about the foods and the exercise and maybe the lower stress levels. I've always been fascinated by smoking populations that don't have high risk of cardiovascular and high incidence of cardiovascular disease, and yet they smoke. But they also walk everywhere and their food is of a different quality, their soil, the micronutrients. I mean, we could go on and on, right?

Dr Nilay Shah: We could. And one point that I'll just particularly highlight that you mentioned, which I think is important, is that there is evidence even beyond this study that people who immigrate to the United States, after immigration, they actually tend to have worse health because they've moved into an environment where our environments, they don't facilitate our health. We have really ready access to low quality food. We have less access to healthful food, both in terms of affordability, but also just the distribution and availability of it. Our built environments are suboptimal. In a country like the United States, most of us are dependent on transportation by car. We're doing less physical activity because our public transportation and our neighborhood environments are less facilitating a physical activity. The cultural norms of living in the United States tend to favor bigger portion sizes and particular kinds of foods. Whereas individuals who came from other countries, these things are less prevalent. And so, there is also a phenomenon that individuals who leave their home countries or countries of origin and immigrate to the United States tend to develop worse health after moving here.

Melanie Cole (Host): I have heard that too. And boy, oh boy, is this a complex situation that you have tackled and really, there are so many areas. I mean, we just jumped off into many different areas. Now as we speak of that end goal, Dr. Shah, of these types of studies and what interventions could help mitigate disparities in cardiovascular health, some we can do stuff about and some are bigger than you or I to even think about discussing, because they are those upstream that we can't necessarily really affect completely. However, can you outline some of the proposed interventions that emphasize that need for further studies? Because I think that's how we're going to raise awareness that can then help inform tailored effective prevention interventions. So, I'd like you to identify some of the knowledge gaps you think need to be addressed and the end goal to get more of these types of studies, so that they're out there and more people like yourself, which are awesome, can get involved in these community health initiatives.

Dr Nilay Shah: Thank you for that incredibly important question. And that really is what the purpose of this research is, is to build towards the interventions and actually making changes to support people's health.

And so, my response to that important question is in two parts because, as I think we've kind of already discussed and as I think people who see patients pretty readily understand, there are things we're able to do when we're sitting in front of a patient and we can either provide counseling or try to influence factors that contribute to health that occur outside of the clinician's office. And then, there are things that we could potentially do as they exist in the world.

And as I think anybody who sees patients understands, patients spend maybe an average of 20 or 30 minutes with us in the clinic, but otherwise, spend 24 hours a day, seven days a week, living in the real world. And so, our approaches to healthcare and what we do with patients in the clinical setting is part of what determines health. But it's not the only part, and I would argue it's not even the biggest part. After doing work in this area, I'm fairly convinced that the largest outsized influence on what influences health and determines health and disease in patients is most strongly what occurs in the environments in which people live. And the things we try to do, medications and other interventions are helpful and, you know, we know there are evidence-based interventions in the clinical setting that help. But especially as we talk about prevention, so much of that occurs outside the clinician's office.

So, some examples of individual level potential interventions that build on or leverage social determinants may include things like understanding somebody's social networks and their social support. So if you're a clinician seeing patients and you're thinking about recommending behavior change, whether it be increasing physical activity or making dietary pattern changes to support health in a patient who has or is at risk for a cardiovascular disease or diabetes, you might consider enlisting the help of a trusted social network member, like a spouse or a child or a friend for health behavior change. Because we've learned that social support and one's social networks have a fairly significant influence on an individual person's health behaviors. So if you're trying to encourage somebody to eat more healthfully, perhaps you might consider enlisting the help of somebody who's important to the patient to do it together.

Addressing things like built environment. Well, you know, I think it's unlikely, speaking frankly, that a clinician is going to be able to do much about a patient's built environment. But you could work to try to help patients identify avenues for physical activity, like local community centers or shopping malls that they could go to and have a safe place to do physical activity, even if it's just walking, which is great physical activity, beyond just staying in their homes.

But as I think you alluded to, the interventions that are likely to influence social determinants, these upstreaming factors that influence health are not only going to be successfully addressed at the individual level, there are absolutely community and policy level interventions that are needed to support access to education and access to care like Medicaid expansions, especially in states that haven't yet done that to support food security, bringing in healthful grocery stores to eliminate food deserts in areas where access to healthful food options aren't available. These are things that admittedly are far more challenging for individual clinicians to do, but your advocacy matters. And so if you have the opportunity to speak with your local representative and try to get involved to advocate for some of these things, it's certainly one direction that I'm planning to do with the results of this study.

And as far as next steps in the research go, it really is what you mentioned, which is our data so far are observational. NHANES is an observational study. These participants did not undergo any intervention. So now that we've identified what factors may most strongly influence health disparities, I think the next step is to try to intervene on those factors and see if they lead to reductions in disparities. And that's certainly easier said than done. You know, place of birth is not an intervenable factor, but the next steps in the research in that aspect, I think, is to better understand what it is about being an immigrant or coming from a different culture that influences health and changes when somebody immigrates, so that a community health worker or a clinician can be aware of those factors that influence health and try to mitigate the influence of them.

Melanie Cole (Host): Wow. That was beautifully put. And I've even seen, Dr. Shah, cardiologists get involved in community walks and, you know, meet me at the park kind of walk and reaching out to that broader community. And as we said, this is just such a complex issue. You and I could talk for a long time about this. As we wrap up, I'd like you to speak to other physicians involved in cardiology, what you'd like them to keep in mind based on the findings of these studies and what you would like the key message to be from this very important discussion you and I had today.

Dr Nilay Shah: So, I would recommend that clinicians in cardiology, at minimum, just think more broadly about what is influencing their patient's health. We see a lot of patients who have cardiovascular diseases or are trying to prevent cardiovascular diseases, and we are trained to think about some of the behavior changes and, even more heavily, some of the medications that may be used, and these absolutely have a role. But in my experience working with communities and in research about health disparities, I again have concluded that health and disease is actually largely determined by what happens outside the physician's office.

So, the influence of social determinants on health status and outcomes is incredibly important, and I would encourage clinicians to make sure they are asking questions of their patients to better understand their social determinants. For example, can your patient afford their medication? Does your patient have access to transportation to come to appointments? Does your patient have the ability to access healthy foods, or are they even getting enough food at all? Do your patients have support from others to maintain their health or are they influenced by people in their social networks to take up unhealthy behaviors? These kind of things have a huge influence on health. And the first step that I think will help clinicians take care of patients and understand their social determinants is just to ask about them. I think many of us would be surprised just how challenging it is for our patients to surmount the social determinants that exist in their lives and environments. And even if we're not able to fully address them within the scope of our practice, it will absolutely help us better understand why a patient, for example, may not be responding to the recommendations that we give them for medications or behavior change or otherwise.

Melanie Cole (Host): Well, Dr. Shah, thank you so much and I hope and invite you to come back on as often as you would like to update us as you learn more. And yes, you said these are observational, but your advice to other physicians and clinicians is spot on, that these are the ways that they can help these communities and help individual families by looking at the support system and offering resources. And what a great episode this was. Thank you so much for joining us.

To refer your patient or for more information, please visit our website at to get connected with one of our providers. That wraps up this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole.