AHA: More research, education needed to reduce CV health disparities in LGBTQ adults
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More research and education are needed on the impact of significant stressors on CV health in LGBTQ adults to reduce disparities, according to an American Heart Association scientific statement.
The AHA scientific statement published in Circulation has been endorsed by the American Academy of Physician Assistants and affirmed by AMA as having educational benefit.
“Over the past decade, there has been increasing recognition of cardiovascular health disparities among LGBTQ adults,” Billy A. Caceres, PhD, RN, FAHA, assistant professor at Columbia University School of Nursing and chair of the writing group, told Healio. “There has been growing evidence that LGBTQ adults have worse cardiovascular health than non-LGBTQ persons, yet LGBTQ adults remain largely invisible within cardiovascular research. Also, the research conducted thus far has clear weaknesses that have limited a greater understanding of the cardiovascular health of LGBTQ adults. Although discrimination is often hypothesized as a contributor to cardiovascular health disparities in LGBTQ adults, very few studies have examined this.”
There are approximately 11 million LGBTQ adults in the U.S., which represents a marginalized group of patients with significant health disparities vs. their cisgender and heterosexual counterparts, according to the statement.
Stressors increasing CV risk
Stress exposure is a hypothesized major driver of health disparities in this population. Individual and intrapersonal stressors that the LGBTQ community faces may be related to their sexual orientation and gender identity, including expectations of rejection, self-stigma and concealment of their gender identity and sexual orientation, according to the statement. This group also experiences interpersonal stressors, including family rejection, discrimination and violence, which is linked to higher rates of poor mental health, substance use and cardiometabolic risk. Structural stressors may also play a role in compromising the health of LGBTQ adults, which may include the lack of nondiscrimination laws and laws focused on public restroom use.
General stressors, including financial stress and life adversity, also play a role in negative CV health in LGBTQ adults. Compared with non-LGBTQ adults, LGBTQ adults are more likely to report interpersonal violence in adulthood, physical and sexual abuse in childhood, and poverty, for example. Economic disparities in this population may also be driven by structural stressors such as a lack of legal protection against employment discrimination, according to the statement.
“Multilevel minority and general stressors can interact across levels to impair the health of LGBTQ adults by limiting opportunities for proper employment, housing and access to health care,” Caceres and colleagues wrote.
HIV in transgender women and sexual minority men can pose a disproportionate burden when compared with non-LGBTQ people, according to the statement. HIV can increase the risk for CVD from treatments and physiological effects of the disease itself.
Gender-affirming hormone therapy can also contribute to poor CV health in transgender people due to its potential CV effects, which may include venous thromboembolism in transgender women taking estrogen, for example.
The writing group of this scientific statement used components of Life’s Simple 7 to assess evidence on CVD diagnoses in LGBTQ adults. Lifetime tobacco use is often higher in LGBTQ adults compared with cisgender heterosexual adults. This increased use is also seen in sexual minority women compared with heterosexual men and women, in addition to sexual minority men.
Research showed that sexual minority women were more likely to have obesity compared with heterosexual women. In addition, gay men had a lower prevalence of obesity vs. heterosexual men. Findings on BMI in transgender people are limited and have shown mixed results, as they typically focus on BMI changes in transgender men after starting gender-affirming hormone therapy.
With regard to glycemic status, some analyses have shown that sexual minority women were more likely to have diabetes than heterosexual women, particularly in younger women with elevated BMI. National Health and Nutrition Examination Survey data showed that bisexual men were three times as likely to have diabetes than heterosexual men, according to the statement. Few differences were found regarding diabetes in transgender and cisgender adults.
Research on particular components of Life’s Simple 7 are either mixed or lacking. This includes findings on physical activity, total cholesterol, lipids and BP. In contrast, no differences have been observed regarding diet quality.
Other risk factors may also play a role in poor CV health in LGBTQ adults, including heavy alcohol use, which is elevated in this population. Despite this observation, research on the CV effects of heavy drinking in LGBTQ adults is limited. Poor sleep quality and inadequate sleep duration is also somewhat common in LGBTQ adults, which can serve as risk factors for diabetes, CVD and incident hypertension.
Despite these risk factors in LGBTQ adults, research has found few differences regarding CVD diagnoses in this population.
“There is a notable discrepancy between observed CVD risk and CVD prevalence in sexual minorities,” Caceres and colleagues wrote.
More research needed
Few studies have found higher CVD prevalence in transgender women vs. cisgender adults, although researchers used health records rather than appropriate measurement of CVD endpoints, according to the statement.
There are several limitations of existing research that hinders the development of interventions to promote CV health in LGBTQ adults, including a lack of understanding about mechanisms of stressors with CV health, weakness of existing literature and a need for more research on multilevel social determinants of CV health in LGBTQ adults, according to the statement.
“We need more research that examines the causes of the cardiovascular health disparities that have been documented in LGBTQ adults,” Caceres said in an interview. “This is a critical step to addressing and reducing these health disparities. Another important area for future research is understanding how protective factors, such as community connectedness and social support, can reduce the negative effects of discrimination and other stressors on the cardiovascular health of LGBTQ adults.”
More research focus is also needed on treating LGBTQ adults.
“Because of limitations of existing studies, there are few evidence-based interventions for cardiovascular risk reduction that are tailored to LGBTQ adults,” Caceres told Healio. “Research in this area is important to identify effective strategies to improve the cardiovascular health of LGBTQ adults.”
The writing group details the potential benefits of collecting data on sexual orientation and gender identity via electronic health records, which has been required since 2018. Despite this, clinicians are not required to collect this data. Practicing clinicians and students may benefit from education on LGBTQ health and how to properly assess gender identity and sexual orientation in health care settings.
“As health care providers, we play an essential role in assessing and reducing health disparities,” Caceres said in an interview. “This scientific statement highlights that health care organizations need to do more to provide inclusive care to LGBTQ adults. Routine assessment of sexual orientation and gender identity in clinical practice is one step that can help LGBTQ adults feel seen and heard by their health care providers. Health care providers also need more training on LGBTQ health issues and understanding on social and clinical factors that contribute to poor cardiovascular health in this group.”
For more information:
Billy A. Caceres, PhD, RN, FAHA, can be reached at bac2134@cumc.columbia.edu; Twitter: @bcaceres0601.
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