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Health Equity, the Forgotten Pillar

This year’s AHA21 Scientific Session placed an intense spotlight on understanding and achieving health equity in cardiovascular health (CVH). AHA has a broad vision for being transformative in all of the ways that structural inequities influence health outcomes. Specifically, AHA’s 2024 Impact Goal states that: Every person deserves the opportunity for a full, healthy life. As champions for health equity, by 2024, the American Heart Association will advance cardiovascular health for all, including identifying and removing barriers to health care access and quality.

On Day 1 of AHA21, during the ‘Cardiovascular Health After 10 Years: What Have We Learned and What is the Future?’ session, we engaged with experts about the genesis of CVH, how it has been studied throughout the life span over the past decade, and methods for influencing CVH at critical life stages. Darwin Labarthe, MD, MPH, PhD, provided a historical review of the conceptual origins and definition of CVH, and the meaning of CVH in translation. CVH is defined by key features of AHA’s Life’s Simple 7, including assessments of diet, smoking status, physical activity, weight management, blood pressure, cholesterol, and blood glucose.

Ideal CVH is determined by the absence of clinically diagnosed CVD together with the presence of the 7 metrics. Longitudinal evidence has shown that maintaining ideal CVH is more cardioprotective than improving and achieving CVH from a lower CVH level. But US NHANES data shows that about 13% of adults meet 5 of the 7 criteria, 5% have 6 of 7, and virtually 0% have ideal CVH or meet 7 of 7 metrics. This begs the question of how do we attain and maintain a high level of CVH? Ideally, maintaining CVH by Life Simple 7 standards should be SIMPLE…just ensure that all 7 metrics are met, and you will have ideal CVH! But realistically, it is near impossible for individuals to achieve ideal CVH. It is more likely that both individual and population-level efforts are needed to achieve and maintain CVH.

From a life course perspective, high CVH in adulthood is more likely when high CVH is present in early life. But as the panelist continued to describe the state of CVH in America, we quickly learned that while high CVH is consistently associated with lower risk of cardiovascular disease (CVD), disparities in CVD rates vary by sociodemographic factors like age, sex, race/ethnicity, and educational attainment. A recent study by panelist Amanda Marma Perak, MD, MS, FAHA, FACC, and colleagues (2020) using data from the CARDIA study found that less than a third of young adult participants had high CVH, and this was lower for Blacks than Whites and those with lower than higher educational attainment. These results demonstrate that CVH is far from ideal even among younger cohorts. Over the last few decades, we have witnessed increasing rates of cardiovascular abnormalities and subclinical and overt CVD in adolescents and emerging or young adults. The low prevalence of ideal CVH in young adults suggests that factors contributing to CVD risk may be embedded at earlier life stages. The experiences that happen or do not happen in early life settings (i.e., family, households, schools, communities, etc.) are important opportunities to achieve or maintain high CVH. The drivers of health disparities, like social determinants of health (SDOH), structural racism, and rural health inequalities, are necessary to achieve sustainable health equity and well-being for all. One method is effectively developing culturally-tailored community-engaged partnerships to promote CVH. LaPrincess Brewer, MD, MPH, shared the phenomenal community-based interventions being conducted to intervene on low CVH in Black neighborhoods by addressing SDOH at the community-level. These included the Fostering African-American Improvement in Total Health CVH (FAITH!) CVH wellness program, Community Health Advocacy and Training (CHAT) program, and The Black Impact Program.

The conversation on CVH and health equity continued strong on Day 2 of AHA21 at the ‘Achieving Health Equity: Advancing to Solutions’ session. With a panel of leading experts in health equity research, calls for action rang out at each presentation. David Williams, PhD, argued that racial inequalities in health are fortified from centuries of established institutional/structural racism, individual discrimination, and cultural racism, which result in a significant cost to mental health and millions of African-American lives lost each year. Sonia Angell, MD, MPH built on the discussion with a call to action in investing in understudied and marginalized communities that experience poorer CVH. Importantly, as clinicians, research scholars, and policymakers, we need to consider the significant impact of spending more time addressing intervention areas with the largest impact on health, like the structural causes of health inequities. When we work to eliminate structural causes of health inequities, we can begin to spend less time and energy working on small impact areas like counseling, education, and referrals for emergency foods and housing. Ultimately, we can reduce the time and costs of mitigating health inequities when we focus on eliminating the structural causes of health inequities.

Finally, in a powerful video, Health Equity: Patients’ Perspectives, we were invited to hear the stories and experiences of those from Black and Hispanic/Latino communities who were significantly affected by health inequities and failed by their healthcare systems. The tales were jarring and left the audience and panel with a strong sense of remorse. The impact of inequalities in health has been a regular staple in marginalized communities across America for centuries. Collectively, from these voices, we recognize that patients and participants need to be treated as humans. In seeking to meet AHA’s 2024 Impact Goal, I want to echo the sentiments of Kirsten Bibbins-Domingo, PhD, MD, MAS, that equity was always an important pillar in health quality and safety, but it is the forgotten pillar. We must make health equity front and center. As such, we need to 1) actively make health equity a priority and place it front and center in our professional and personal work; 2) have respect for all of humanity from all social groups; and 3) we need better science to understand how risk and disease are being experienced.

References

  1. Lloyd-Jones, Donald M., et al. “Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond.”Circulation 4 (2010): 586-613.
  2. Enserro, Danielle M., Ramachandran S. Vasan, and Vanessa Xanthakis. “Twenty‐year trends in the American Heart Association cardiovascular health score and impact on subclinical and clinical cardiovascular disease: the Framingham Offspring Study.”Journal of the American Heart Association 11 (2018): e008741.
  3. Benjamin, Emelia J., et al. “Heart disease and stroke statistics—2017 update: a report from the American Heart Association.”circulation 10 (2017): e146-e603.
  4. Perak, Amanda M., et al. “Associations of late adolescent or young adult cardiovascular health with premature cardiovascular disease and mortality.”Journal of the American College of Cardiology 23 (2020): 2695-2707.
  5. He, Jiang, et al. “Trends in Cardiovascular Risk Factors in US Adults by Race and Ethnicity and Socioeconomic Status, 1999-2018.”JAMA 13 (2021): 1286-1298.

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