Black Americans have been persistently hard-hit with heart disease risk factors for the past 20 years -- and social issues like unemployment and low income account for a good deal of it, a new study finds.
Cardiovascular disease, which includes heart disease and stroke, is the No. 1 killer of Americans, and it's well-known that it exacts a disproportionate toll on Black Americans.
The new study -- published Oct. 5 in the Journal of the American Medical Association -- focused on risk factors for heart and blood vessel disease, such as high blood pressure, diabetes and obesity. And Black Americans carried a heavier burden of those conditions than white, Asian and Hispanic folks, the study authors said.
But the findings also highlight a key reason why.
"A lot of the difference may be explained by social determinants of health," said lead researcher Dr. Jiang He, of Tulane University School of Public Health and Tropical Medicine, in New Orleans.
That term refers to the wider context of people's lives and its impact on their health: A healthy diet and exercise might do a heart good, for instance, but it's easier said than done if you have to work two jobs to pay the rent.
In their study, He and his colleagues were able to account for some of those social determinants: people's educational attainment, income, whether they owned a home, and whether they had health insurance and a regular health care provider.
It turned out those factors went a long way in explaining why Black Americans faced particularly high heart disease risks.
The study is not the first to trace the nation's health disparities to social factors, including structural racism -- the ways in which society is set up to give advantages to one race over others.
Dr. Keith Churchwell was the lead author of a recent statement from the American Heart Association (AHA) on the subject.
In it, the AHA said structural racism needs to be recognized as a "fundamental cause of persistent health disparities in the United States."
Churchwell said the new findings are in line with past evidence, the kind that drove the AHA statement.
Racial disparities in health start with things as fundamental as educational opportunities, nutrition, stable housing and transportation, according to Churchwell, who is also president of Yale New Haven Hospital in Connecticut.
"I think we're all coming to the realization that if we're going to improve the health of our communities, these social determinants have to be addressed," said Churchwell, who was not involved in the new study. "They have a bigger impact than the medications we give and the procedures we do."
For the study, He's team used data from a long-running federal health survey.
The investigators found that between 1999 and 2018, Americans saw an increase in certain risk factors for heart disease and stroke. The prevalence of obesity soared from 30% to 42%, while the rate of diabetes rose from 8% to almost 13%.
Meanwhile, average blood pressure levels held fairly steady, while blood sugar levels rose.
The picture differed by race and ethnicity, however, and Black Americans were consistently worse off than white, Asian and Hispanic Americans.
And by 2018, Black adults had, on average, an 8% chance of developing heart disease or stroke in the next 10 years (based on their risk factors). That compared with a roughly 6% chance among white Americans, the investigators found.
Then He's team weighed the social factors that they could. And those issues appeared to explain a large amount of the difference between Black and white Americans' cardiovascular risks.
Still, He said, the survey did not capture other, more nuanced factors. For example, can people afford healthy food? Do they have safe places for exercise?
Even asking people about "access" to health care fails to tell the whole story, He noted: The quality of that care -- including whether providers and patients are communicating well with each other -- is critical.
"If we want to improve population health," He said, "we need to pay attention to these social determinants."
According to Churchwell, health care systems can help tackle broader issues in various ways, including partnering with community organizations and evaluating themselves -- with the help of electronic medical records -- to ensure they are providing equitable care.
It is not enough to simply tell patients to eat better and exercise, Churchwell said.
From the patient side, he encouraged people to ask about resources in their community, for help with anything from exercise to mental health support.
"Say to your provider, 'Help me figure this out,'" Churchwell said.
The American Heart Association has more on structural racism and health disparities.
SOURCES: Jiang He, MD, PhD, chair and professor, epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans; Keith Churchwell, MD, president, Yale New Haven Hospital, New Haven, Conn.; Journal of the American Medical Association, Oct. 5, 2021