‘ZIP code matters’: COVID-19 hospitalizations, CV outcomes differ by where people live
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Social and economic factors have the greatest impact on COVID-19 outcomes, including an “epidemic” of CV diseases and hospitalizations, and social determinants of health must be addressed to counter disparities, according to a speaker.
“The COVID-19 pandemic really did show us how unfair many health outcomes were,” Karol Watson, MD, PhD, FNLA, FACC, FAHA, co-director of the UCLA program in preventive cardiology and member of the Cardiology Today Editorial Board, said during a presentation at the World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease. “When we look at mortality by race, we see significant disparities. We also saw hospitalization disparities.”
Data from 2020 and 2021 show that adults who lived in a low-income area were 22% more likely to be hospitalized with COVID-19 compared with those living in higher income regions, with factors such as obesity, Medicare or Medicaid vs. commercial insurance and Black race all associated with worse disease outcomes. Data show those living in low-income ZIP codes were generally more vulnerable to disease, Watson said; people living in low-income areas tended to have less access to testing and vaccines and were more likely to work “essential” in-person jobs, where social distancing was difficult.
“This pandemic has exposed so many things, including economic and health social disparities,” Watson said. “COVID-19 is an opportunity to implement known solutions that can hopefully address these deep-seated inequities. They were highlighted over 20 years ago by the Institute of Medicine.”
What makes us healthy
Watson said data clearly show social and economic factors have much greater influence on health outcomes compared with genes and biology, health care delivery and the environment, each of which contributes about 10% toward outcomes.
The social determinants of health — loosely defined as where people live, work, play and pray — often predict how well a person will do across all aspects of life, Watson said.
“We have risk behaviors that are important, and everyone is responsible for their own individual risk behaviors, but social determinants play a big role in that also,” Watson said. “It is really hard to think about nutrition when you are worried about how you are going to eat. Calories are cheap, nutrients are expensive. All of these things are at play. Adverse conditions prevent people from practicing healthy behaviors.”
“I work in west L.A.; if you travel 5 miles south from where I work, life expectancy can differ by 20 years,” Watson said. “Just by virtue of where you live, your health outcomes are very different.”
A myth persists that such differences in outcomes come down to race or ethnicity because race is easy to classify, Watson said; yet there are very few biological differences between races.
“The features we use to categorize people into a race is just a function of their movement [over time] and how they end up looking,” Watson said. “The idea of race as a valid biologic or genetic factor has been debunked many times. Any two randomly selected people from throughout the world share 99.9% genetic identity and, in fact, many people within a given race have more genetic diversity that people of different races.”
Median household incomes do vary by race, due to generations of systemic racism, Watson said. Data show income level is associated with everything from education outcomes to health outcomes.
“Everything is determined by income,” Watson said.
COVID-19 and ‘an epidemic of CVD’
Data from the more than 17,000 participants in the U.K. Biobank show COVID-19 is associated with incident CV events, including MI, stroke, HF, atrial fibrillation, venous thromboembolism (VTE), pericarditis and CV death, with risk rising sharply if the person is hospitalized, Watson said. For those with a primary COVID-19 hospitalization, there was a 27-fold increased risk for VTE, a 21-fold increased risk for HF and a 17-fold increased risk for stroke.
“The acute respiratory syndromes and respiratory failure are what we think of,” Watson said. “But there is an epidemic of CVD related to SARS-CoV-2.”
Looking at data stratified by race, out-of-hospital cardiac arrests, heart disease death and cerebrovascular death rates rose along with SARS-CoV-2 infections in 2020 compared with data before the pandemic, with markedly higher rates of CV events for Black and Hispanic adults compared with white adults.
“The COVID-19 pandemic has laid bare the inequalities in health care,” Watson said. “Most of the disparities in COVID-19 morbidity and mortality were due to social determinants of health. These same social determinants of health that drive disparities in COVID-19 outcomes drive disparities in CV outcomes. We’re never going to counter disparities in anything until we address social determinants of health — not in COVID-19; not in CVD.”
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Watson K. Session 2: COVID-19 & Metabolism. Presented at: World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease; Dec. 1-3, 2022; Universal City, California (hybrid meeting).
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