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Social factors major determinant of stroke, CVD risk
Various socioeconomic determinants predispose patients to developing CVD and stroke, especially in the United States, according to a presentation at the International Stroke Conference.
“The United States is a relatively unique example of representing a lot of variation in social conditions and therefore a lot of variation in disease,” Edward P. Havranek, MD, professor of medicine-cardiology at University of Colorado School of Medicine in Denver, said in the presentation.
Trends in life expectancy
Since 1968, the mortality rate has declined in the United States, but the decline has stopped in white Americans of working age.
“You’d think this is largely due to things like the opioid epidemic, drug overdoses and suicide, but that explains really less than half of the increase in mortality,” Havranek said. “Could it have something to do with cardiovascular disease? It kind of seems unlikely, doesn’t it?”
The decrease in mortality is an effect of medical advances such as mechanical thrombectomy, medications, implantable cardioverter defibrillators and stents. The decline of mortality from CVD slowed down between 2011 and 2013 from 3.79% to 0.65%. Starting in 2014 and 2015, the rates of mortality caused by CVD started to increase from 167 to 168.5 per 100,000.
“I’m going to posit that this is the result of social change in the United States,” Havranek said.
Income distribution and inequality is one of the contributing factors to an increased mortality rate. Since 1980, the share of total income received by the top 1% of earners in the United States increased from 10% to around 20% to 25% in 2013. Regarding life expectancy, there was no change at the lowest ventile for household income, but as income increased, improvement in life expectancy continued.
“Overall health is linked to increased income, so as we see more increased income inequality, we’re going to expect to see poorer health in the United States,” Havranek said.
Socioeconomic position goes beyond income and also includes achievements of minimal standards of health, education, living standards, access to valued activities such as work, political voice and physical insecurity such as crime and violence. Race and ethnicity also factors into this, in addition to education and income.
The combination of physical environment, place in social hierarchy and individual psychology contributes to behavioral and biological effects, which therefore leads to changes in health outcomes, according to the presentation.
In a study published in The New England Journal of Medicine in 2001, researchers found that the incidence of CHD was higher in participants who lived in poor neighborhoods compared with those in other neighborhoods, and it was consistent in all races and sexes. When adjusting for individual socioeconomic position, the status of the neighborhood was still relevant.
“What this means is that if you take two people, exactly the same education, same income, they may work in the same place, if you put one in a poor neighborhood, one in a better-off neighborhood, their likelihood of developing coronary heart disease differs by where they live,” Havranek said.
In a study published in The BMJ in 1997, researchers analyzed data from 10,308 participants who were civil servants in the United Kingdom. Participants who had the lowest levels of job control had about twice the likelihood of developing CHD over time compared with those with higher levels of job control.
“Where you stand in the hierarchy plays itself out in ways that alter your likelihood of developing heart disease down the road,” Havranek said.
Researchers in a study published in the American Journal of Public Health in 2015 found that the odds for mortality for both black and white participants were higher in communities with higher levels of prejudice. When social capital was removed, the bias effect was no longer a significant predictor of mortality, according to the presentation.
“The implication here is in communities in which there are tighter social bonds, there’s better health,” Havranek said.
In a study published in Science in 2013, researchers found that cognitive control declined in participants who were poor when faced with a financially stressful situation, though it did not affect those who were rich.
“What this says is that people of low income, lower in the socioeconomic scale have cognitive loads that few of us can understand,” Havranek said. “When they take their medicines less often [and] miss their visits, it should be understandable to us.”
Patients who have a lower birth weight are more likely to have CHD as a cause of death later in life, according to a study published in The Lancet in 1989. This shows that early childhood deprivation contributes to the risk for CVD, according to the presentation.
Methods to reverse effects
Researchers analyzed the effects of an intensive intervention in children in a study published in Science in 2014. Children who were assigned to receive the intensive intervention, which included preschool, pediatrician access and meals, had improved school performance compared with the control group. For children assigned the intensive intervention before age 5 years, they had a lower BP at between ages 30 years and 40 years vs. the control group. Men from this group also had a lower overall Framingham risk score and were more likely to have health insurance at age 30 years.
In a study published in The New England Journal of Medicine in 2011, patients who were given vouchers that allowed them to move to enhanced housing had lower BMIs and lower A1Cs compared with those who did not receive vouchers.
“We can do something about this if we put our minds to it,” Havranek said. – by Darlene Dobkowski
References:
Havranek EP. Session 095 – Social Determinants of Stroke in Latin America. Presented at: International Stroke Conference; Jan. 23-26, 2018; Los Angeles.
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Disclosure: Havranek reports he received research grants from Agency for Healthcare Research and Quality, American Heart Association, NIH/NHLBI and Patient-Centered Outcomes Research Institute.