AHA Scientific Statement Social Determinants of Risk and Outcomes for Cardiovascular Disease A Scientific Statement From the American Heart Association Edward P. Havranek, MD, FAHA, Chair; Mahasin S. Mujahid, PhD, MS, Co-Chair; Donald A. Barr, MD, PhD; Irene V. Blair, PhD; Meryl S. Cohen, MD, FAHA; Salvador Cruz-Flores, MD, FAHA; George Davey-Smith, MA(Oxon), MD, BChir(Cantab), MSc(Lond); Cheryl R. Dennison-Himmelfarb, RN, PhD, FAHA; Michael S. Lauer, MD, FAHA; Debra W. Lockwood; Milagros Rosal, PhD; Clyde W. Yancy, MD, FAHA; on behalf of the American Heart Association Council on Quality of Care and Outcomes Research, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, Council on Lifestyle and Cardiometabolic Health, and Stroke Council INFLUENZA DEI FATTORI SOCIALI NELLA VALUTAZIONE DI RISCHIO E CONSEGUENZE DELLA MALATTIA CARDIOVASCOLARE n Institute of Medicine report titled U.S. Health in The prevalence of CVD in the United States is expected to AInternational Perspective: Shorter Lives, Poorer Health rise 10% between 2010 and 2030.6 This change in the trajec- documents the decline in the health status of Americans rela- tory of cardiovascular burden is the result not only of an aging tive to people in other high-income countries, concluding that population but also of a dramatic rise over the past 25 years “Americans are dying and suffering from illness and injury at in obesity and the hypertension, diabetes mellitus, and physi- rates that are demonstrably unnecessary.”1 The report blames cal inactivity that accompany weight gain. Although there is many factors, “adverse economic and social conditions” no consensus on the precise causes of the obesity epidemic, among them. In an editorial in Science discussing the find- a dramatic change in the underlying biology of Americans is ings of the Institute of Medicine report, Bayer et al2 call for a not postulated. More likely culprits are changes in societal and national commission on health “to address the social causes environmental conditions that have led to changes in diet and that have put the USA last among comparable nations.” physical activity. At the same time, there is increasing aware- Although mortality from cardiovascular disease (CVD) in the ness that the benefits of advances in prevention and treatment United States has been on a linear decline since the 1970s, the have not been shared equally across economic, racial, and burden remains high. It accounted for 31.9% of deaths in 2010.3 ethnic groups in the United States. Overall population health There is general agreement that the decline is the result, cannot improve if parts of the population do not benefit from in equal measure, of advances in prevention and advances in improvements in prevention and treatment. treatment. These advances in turn rest on dramatic successes The purpose of this statement is to increase awareness in efforts to understand the biology of CVD that began in of the influence of social factors on the incidence, treatment, the late 1940s.4,5 It has been assumed that the steady down- and outcomes of CVD; to summarize the current state of ward trend in mortality will continue into the future as further knowledge about these factors; and to suggest future direc- breakthroughs in biological science lead to further advances tions in research, particularly research on effective interven- in prevention and treatment. This view of the future may not tions to attenuate or eliminate these adverse social influences. be warranted. The statement is not intended to be a comprehensive review; The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on February 4, 2015, and the American Heart Association Executive Committee on May 22, 2015. A copy of the document is available at http://my.americanheart.org/statements by selecting either the “By Topic” link or the “By Publication Date” link. To purchase additional reprints, call 843-216-2533 or e-mail [email protected]. The American Heart Association requests that this document be cited as follows: Havranek EP, Mujahid MS, Barr DA, Blair IV, Cohen MS, Cruz-Flores S, Davey-Smith G, Dennison-Himmelfarb CR, Lauer MS, Lockwood DW, Rosal M, Yancy CW; on behalf of the American Heart Association Council on Quality of Care and Outcomes Research, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, Council on Lifestyle and Cardiometabolic Health, and Stroke Council. Social determinants of risk and outcomes for cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2015;132:873–898. Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit http://my.americanheart.org/statements and select the “Policies and Development” link. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright- Permission-Guidelines_UCM_300404_Article.jsp. A link to the “Copyright Permissions Request Form” appears on the right side of the page. (Circulation. 2015;132:873-898. DOI: 10.1161/CIR.0000000000000228.) © 2015 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0000000000000228 873 874 Circulation September 1, 2015 Table 1. Social Determinants of Health determined by the relations these groups have with systems of economic production. Members of advantaged groups con- SEP = socioeconomic position trol resources (whether material, economic, political, social, Race, ethnicity or cultural) in a way that may exclude and dominate the dis- Social support advantaged. Unequal distribution and control over resources Culture and language influence patterns of exposures, which act at different stages Access to care of the life course, resulting in unequal distribution of disease Residential environment in different groups within a society. Health and SEP are seen SEP indicates socioeconomic position. as inextricably linked, with health itself seen as a marker of SEP in some schemes (Table 2). It is important to highlight references are intended to be illustrative and to highlight sig- that, although measured at the individual level, SEP is deter- nificant knowledge in the field. The premise underlying this mined at least partly by structural relations between groups scientific statement is that, at present, the most significant within society. For example, the level of education attained by opportunities for reducing death and disability from CVD in an individual may be constrained by educational opportunities the United States lie with addressing the social determinants available to a particular group. We discuss area-level factors in of cardiovascular outcomes. Although social determinants are more detail in the Residential Environments section. most often invoked in discussions of inequalities or disparities in health, we take a broader view that social factors can and do Measuring SEP affect cardiovascular health in all. Thus, a consideration of the There is no single best indicator of SEP. Each indicator of SEP role of social determinants is essential if we are to achieve the emphasizes a particular aspect of social stratification, which American Heart Association 2020 Impact Goals: to improve may be more or less relevant to different health outcomes and cardiovascular health of all Americans by 20% while reducing at different stages in the life course.9 Individual-level indica- deaths from CVD and stroke by 20%.7 tors of SEP include income, education, and occupation-based indicators, and ideally, they should be considered simultane- Defining Social Determinants of Health ously. Others10 have emphasized that SEP should consider The World Health Organization defines the social determi- both actual resources and status as determined by prestige nants of health quite broadly as “the circumstances in which or rank-related characteristics. This multidimensional nature people are born, grow, live, work, and age, and the systems of SEP has been emphasized in the work of the Commission put in place to deal with illness.”8 This definition encom- on the Measurement of Economic Performance and Social passes the view that health and illness are not distributed ran- Progress11 headed by the Nobel Laureate Joseph Stiglitz. domly throughout human society, and neither are resources Although the Commission was focused on a critique of gross to prevent illness and its effects. Instead, they cluster at the domestic product as a measure of the performance of societ- intersections of social, economic, environmental, and inter- ies or nations, some of its conclusions can be applied to indi- personal forces. viduals. Broadly, the commission concluded that well-being is determined by a number of interwoven dimensions