The leading cause of death in the United States is heart disease—one person dies every 36 seconds from cardiovascular disease (CVD). In addition, heart disease is extremely expensive, costing the United States $363 billion each year due to health care services, medication, and lost productivity due to death. The three main risk factors for heart disease are high blood pressure, high cholesterol, and smoking, and 47% of Americans have at least one of these. There are many influential structural, behavioral and social factors linked to heart disease in today’s society that have led to this rising incidence, including depression, socioeconomic status (SES), and implicit bias. Studies have shown that people suffering from depression are 40% more likely to develop type 2 diabetes in comparison to the general population. Low socioeconomic status is related to low income, low levels of education, food deserts and lack of active transportation which in many cases can lead to cardiovascular disease. Implicit bias can adversely affect a patient-doctor relationship, especially among minority patients, disrupting the quality of care one may receive. Communities can address these factors through outreach, awareness, and policy.
Psychosocial distress has been increasingly recognized as a risk factor for heart disease. Depression, in particular, has been documented as one of the strongest psychosocial influencers of CVD. Depression affects mood, thoughts, feelings and behaviors, and in many cases leads to loss of interest in activities that used to be enjoyable. In some cases, clinical depression is an inherited condition—those with a first degree relative with depression have a 2.8-fold higher risk for suffering from it themselves. Depression is also linked with higher risk of smoking. People with depression often have tiny cells that cause blood clots, referred to as sticky platelets, and in patients with heart disease, these sticky platelets can accelerate atherosclerosis (plaque buildup on artery walls) and increase the chance of heart attack. It is important for healthcare providers to be aware of the affects depression has on the chances of getting heart disease.
Low-income and middle-income areas carry about 80% of the global burden of CVD. Disparities associated with low SES and education attainment have widened over time. Biological, behavioral and psychological risk factors prevalent in low socioeconomic areas accentuate the link between socioeconomic status and heart disease. Income level, education level, employment status and neighborhood conditions are consistently associated with CVD. Education quantity and quality affect our health tremendously; people with less education are more susceptible to suffering from CVD. Being well-educated can lead to more accurate health beliefs, knowledge, and lifestyle choices. Work-related issues and unemployment can affect physical, mental and emotional wellbeing. More specifically, loss of job can contribute to loss of identity, self-worth and increased stress and social pressure. Neighborhood characteristics also can greatly impact a person’s risk. Presence of sidewalks, gyms, healthy food options and public transportation affect a person’s health. Overall, individuals with lower socioeconomic status are measurably more impacted by CVD than those of high socioeconomic status. Socioeconomic status plays a crucial role in health disparities; work within schools, communities and research centers needs to be done to reduce poverty and socioeconomic health disparities.
Many health care providers in the United States appear to have implicit bias— positive attitudes towards white people and negative attitudes toward minority groups. Racial bias, specifically, has been shown to negatively impact heart disease care. Treatment decisions, treatment adherence, and patient health outcomes are all directly affected by implicit bias. When minorities are treated with implicit bias, they do not always receive the diagnosis or treatment that they deserve, which is unacceptable. In a national survey, it was reported that African Americans have a more difficult time getting approved for a heart transplant than other races. In a separate study, it was found that African immigrants experiencing discrimination were more likely to have multiple heart disease and stroke risk factors. Education training on implicit bias should be utilized in college, medical school and after medical school. Minority groups consistently have less access to healthcare than white people, and educational training on the subject could help reduce racial health care disparities within the United States. To reduce heart disease rates in the United States, we must reduce implicit bias.
Depression, low SES, and implicit bias are factors that clearly contribute to the increase in heart disease in America. Despite the progress and advancement in healthcare over the past decade, disparities based on race persist as a common denominator in access to health care, quality of care, and mortality. Behavioral changes can decrease a person’s risk for heart disease, but systemic change is needed to eliminate racial disparities in healthcare and CVD. There are many interventions that engage community health workers to prevent cardiovascular disease and reduce risk factors. Community-based change efforts include providing culturally appropriate education, offering social support and informal counseling, and connecting people with services related to cardiovascular disease.