This transcript has been edited for clarity. For more episodes, download the Medscape app or subscribe to the podcast on Apple Podcasts, Spotify, or your preferred podcast provider.
Nihar R. Desai, MD, MPH: Hello. I'm Dr Nihar Desai from the Yale School of Medicine. Welcome to season 1 of the Medscape InDiscussion: Cardiorenal Metabolic Syndrome podcast series. Today we're discussing the interplay of social determinants of health and cardiorenal metabolic conditions. I'm absolutely delighted to welcome today's expert guest, my very good friend and colleague, Dr Erica Spatz, who's an associate professor of cardiology and associate professor of epidemiology at the Yale School of Medicine. She's also director of the Preventive Cardiovascular Health Program and associate director of population health at Yale Medicine.
Erica, I can't think of a better guest to help us think about the topic today, which is social determinants of health and the interplay with cardiorenal metabolic conditions. In episode 1, we had a great discussion about some of the key epidemiology, what's happening out there in terms of cardiorenal metabolic health, some of the underlying conditions, the predisposing factors that are all contributing to what we're observing in terms of an uptick in the prevalence of these very important conditions on the cardiorenal metabolic spectrum side, both in the United States and around the globe. I now want to have a discussion with you about how social determinants of health interplay with that and underlie many of the epidemiologic trends that we are observing. I thought we could level-set. From your standpoint, can you give us a definition of social determinants of health? How do we think about that concept?
Erica S. Spatz, MD: We know that to achieve good outcomes for our patients, for our populations, we need to look beyond ourselves and think about the medical factors directly impacting their care, and this is where we find ourselves in this big world of social determinants of health.
What are they? These are nonmedical factors, primarily, that are impacting health outcomes. The definition that the CDC and the WHO apply is the conditions that people are born into, the conditions in which children are raised, where we work, where we live our day-to-day lives, and how we age. And when we think about those social conditions, we can think about the family unit, and then we can think about the neighborhood and the community.
And then we can think about the policies and forces that are influencing how we live our lives. This includes what we have access to, be it healthcare or green spaces to exercise. What is the social and cultural contextual milieu that we are living in? We have learned to codify these and make it clear so that we have some common language and common metrics to understand the contribution of different aspects of social determinants of health at different levels, ranging from the individual up to the policy level. We can think about the different factors across those levels that are contributing to health outcomes.
Desai: Let's bring this now into the cardiorenal metabolic sphere. As we think about obesity, diabetes, hypertension, cardiovascular disease, and chronic kidney disease, talk to us a little bit about what we know about the social determinants of health and how they impact some of the specific conditions in the cardiorenal metabolic space.
Spatz: We have a conceptual model for thinking about how these different domains impact cardiorenal metabolic syndrome. For example, think about poverty. What is it like to grow up poor and to have poor access to healthy food? When we think about neighborhoods, we think about neighborhood violence or noise or safety, right?
These social aspects, the conditions where we live, impact us both directly and indirectly. Many of these forces directly impact our inflammatory pathways, our stress pathways; our hypothalamic-pituitary-adrenal access is activated. And we know that from the earliest times in childhood, if there are trauma and adverse childhood experiences, these are leaving biological imprints on people, on children, that are altering their stress pathways, increasing systemic inflammation, activating their amygdala system, and having a direct biological effect. And what is the direct biological effect leading to? It's leading to things like increased obesity and increased blood pressure. We're seeing a lot of patients with diabetes, and this is subsequently leading to early heart disease and early cardiovascular events. When we think about the indirect aspects of how these cardiometabolic conditions are increasing, we can think about what it's like to grow up in a food desert.
How do we encourage people to eat healthy when those options aren't available? What are the physical exercise opportunities in that community? Is healthcare accessible? Can people get to the doctor for early, for premorbid and primary preventive, care? Do they have money to afford medications or to afford programs that support healthy lifestyle behaviors? We can see that there's direct biological impact as well as indirect impact through health and health behaviors that are impacting cardiorenal metabolic syndrome, epidemiology, and outcomes.
Desai: The impact of social determinants of health really can't be overstated; without addressing that, we will not make progress, I think, on the cardiorenal metabolic framework. It's what our patients deserve, what our communities need, and what the country needs if we're going to get healthier and deliver better-quality, better-value care in a way that is cost-sensitive.
We're going to have to think about these larger issues and all the impacts, from biological all the way to care delivery and ultimately to the outcomes that are achieved. We're reminded that social determinants really do have biological impact, from the way genes are expressed to the way different proteins are interacting and the way that certain conditions are manifesting.
I guess one has to wonder about the role of social determinants of health and even the cardiorenal metabolic framework. As much as I think it is a very positive step for the field to think outside of the realm of just cardiology or just nephrology or endocrinology or these particular conditions, whether that be hypertension or diabetes or obesity or atherosclerotic cardiovascular disease, the fact is that we have to bring them all together to think about common pathways. Do you think, in the way that we phenotype patients and the way that we think about these different conditions, that social determinants of health have a role to play in that?
Spatz: I think we're starting to explore those questions and ask about the longitudinal impact of having exposure to adverse milieus over a lifetime. When you think about our risk models, we are usually taking one cross-section of time: What's your LDL today? What's your blood pressure today?
We're seeing through studies like the MESA (Multi-Ethnic Study of Atherosclerosis) cohort some new approaches to using longitudinal data to understand the result of ongoing exposure to elevated cholesterol, LDL, inflammation, obesity, and recognizing that there are cumulative effects. Now, that's the outcome. Usually, we have to look a little deeper to ask why that person is having elevated blood pressure or elevated LDL, inflammation, or glucose. Why is it that they're experiencing that? But when we start to see that these longitudinal exposures are sometimes more associated with adverse cardiovascular outcomes, we need to think in a more nuanced way. The effect is not going to be uniform for everyone.
It's not necessarily because you grew up in this environment; we know that people respond differently to different adverse events. We are biologically different, we are socially different, and we need to think about what kinds of metrics are useful so that we can individualize our approach and really identify the people who are at highest risk.
We're starting to do that with deconstructing race, which is not a biological genetic variable; it's a social construct. That is becoming more common in our discourse. And we're asking, what is the social construct of race? What is the lived experience? Where are there racism and microaggressions? How do we disentangle that to understand people's individual experience so that we can better capture that risk that has been previously bound up in a social variable like race? We're now seeing calculators come out. For instance, PREVENT is taking our traditional pooled cohort equation and then adding on the renal and metabolic variables like hemoglobin A1c and urine albumin-creatinine ratio. We then have a more expansive view of what people are experiencing biologically. What does this syndrome look like?
But we're also capturing things like zip code, because zip code can tell us a lot. We have good data systems to tell us what that means. What's the income level? What's the educational level? What's the poverty level? What's housing quality like in that environment? We're starting to deconstruct that.
Again, we can get a little closer to what the phenotypes are for any one individual.
Desai: How would one get started? If a health system or a provider group or those that are involved in health and the promotion of population health wanted to start to systematically capture some elements of social determinants of health, how do we start? To your point, we'll never be able to make progress if we don't systematically characterize and capture these important elements of data, whether that be race, ethnicity, income insecurity or housing insecurity, or all the other dimensions of social determinants of health that we know are now critically important when we think about cardiorenal metabolic health.
Can you give us your sense of where the field is in terms of starting to capture and really think deep about social determinants of health and its impact on cardiorenal metabolic health? Let's just focus in on the example of trying to capture some of these data elements.
Spatz: I think that's the perfect place to start. We need robust data systems that help us surveil where are we with social determinants and the effect of any interventions. Health systems are getting better at recognizing that we need better race and ethnicity variables in our data collection.
These variables were previously assigned, sometimes by the person at the front office, sometimes by the person's last name. We need people to self-identify because that gives us some window into how they identify and thereby what are their likely experiences. It's also becoming more common to capture standardized data around social determinants of health.
And CMS (Centers for Medicare & Medicaid Services) has really led the way with this, through their Accountable Health Communities effort, which captured five domains of social determinants of health. Those included things like housing, food security, and transportation — the most important things that are essential for maintaining health.
The challenge is, where do we ask people those questions? Who's asking them? They're sensitive questions. We need to figure out best practices for doing that. I know that our health system is actually doing that hard work of piloting social determinative health surveys, so that we have that data on our patients and can learn best practices for how to get that information in a respectful, sensitive manner.
When we ask, we also need to think about what we do once we get the answer that yes, this person is experiencing housing insecurity, they're at risk of losing their home or experiencing food insecurity. The data are really important. Then we need to go beyond that.
It can feel very overwhelming, right? We're in the hospital, we're in the clinic, and we're taking care of a patient with complex cardiorenal metabolic syndrome; you're looking at 10 medications that they need to take on a daily basis. We're talking to them about nutrition. We're talking to them about exercise, de-stressing their lives. It's really overwhelming when you have a person who you know is living in an impoverished area, living with a lot of neighborhood stressors including, again, noise, violence, lack of cohesion and social support. Maybe they're socially isolated. These are all different aspects of social determinants of health that are impacting our patients.
As a physician, as a nurse, we're not experts in social determinants of health, nor do we have the time and we're not the most effective. So those partnerships are critical. State by state, we're increasingly seeing reimbursement for community health worker support, especially for conditions like diabetes and postpartum hypertension.
We're seeing community health workers actually be paid for their services. And I think that this is absolutely necessary. If we're going to achieve good health outcomes, we need to address the social determinants of health. We need to ask the experts in our community how to do that.
Desai: There's so much there that I want to extend our discussion with. Maybe I'll pick up on that last point that you were just referencing, which is this idea of who or what is the real clinical care team when it comes to cardiorenal metabolic health.
In a very narrow, maybe in a very antiquated fashion, the days of that being the physician and the team in the office or in the hospital — that was kind of where all the focus has been when it has come to cardiovascular health and probably even when it comes to cardiorenal metabolic health. But to pick up on that point that you were making, what do you think the care team of the future looks like?
Spatz: Let me give a concrete example because this is where I think the field is going or needs to go. We have been focused around hypertension. It's super-common and impacts young people, especially young Black men and women at a disproportionate prevalence, and the health outcomes are also disproportionately poor — for instance, being in the hospital.
We're seeing young people come in with advanced cardiomyopathy and end-stage renal disease from preventable, modifiable health conditions. About 5 years ago, we established a hypertension program within our cardiology clinic, serving some of our most needy patients. These are patients that our cardiology fellows are serving who are coming from low-income communities and who are experiencing a lot of the social determinants of health. We're trying to get their blood pressure under good control because blood pressure control rates are abominable, even for people coming into care, even for people coming into cardiology; only about a quarter to half of people actually have their blood pressure under control.
We started by giving them blood pressure cuffs, having them monitored at home, and extending our care team to include pharmacists to work with them to monitor their blood pressure at home. This was working really nicely, but, of course, you get people who engage and people who don't engage. The people who don't engage, it's not necessarily that they don't care; you've got to think about, again, what's their capacity to do this?
We had this wonderful opportunity, in partnership with local organizations who had a grant from CDC, called REACH, which stands for Racial and Ethnic Approaches to Community Health. They wanted to bring community health workers into the health system, taking them out of the community and matching them with healthcare providers. We screened everybody who came into our hypertension program for social determinants of health, and those who had a need and who were interested in getting help were matched with a community health worker from a local nonprofit organization. The beauty of it was that we were there, as the cardiologist and the cardiology fellows working with the pharmacists to help close gaps in care, supported by the community health worker who was addressing all of the barriers for that person: measuring their blood pressure at home, attending visits, taking their medication, really providing the contextual role and understanding of what's happening in that person's life. They could say to us, "Hey, listen, this person's struggling right now but we're working through this. Let's hold off on making any changes. We're going to get them back, after this other thing that's taking priority." I think that these kinds of teams that include a community health worker, a health advocate, a trusted member of the community who's really providing that glue between the medical team and the patient, is critically important, but it's not going to happen through grants. Grants are not going to change this. And it's not going to happen through volunteership or because it's the right thing to do.
It really needs to be supported. And I think our payers are increasingly seeing the value of this and seeing that it's important for their bottom line. If they want a cost-effective strategy to manage cardiometabolic syndrome, they need to think about how they're going to support social determinants of health.
Desai: Thanks so much for sharing that example, and congratulations to you guys. It's really exciting work. I think you are really at the frontier of what we're going to have to do and the important work that's multidisciplinary, that's collaborative, that's community based. We really have to engage in this if we want to tackle and improve cardiorenal metabolic health.
Erica, on that very optimistic note about the work that you're doing, I think we can reflect on this as we close this episode. We're in the midst of this new paradigm. I think this notion of cardiorenal metabolic health, really requiring multidisciplinary, cross-disciplinary care for the patients, is important. We also have an incredible opportunity because of the epidemiology, the growing prevalence of these conditions to recognize the social determinants of health and how they interplay with all of these factors.
Given the criticality of these factors on cardiorenal metabolic health, we have to think holistically about the therapies that we want to administer, the risk stratification that we want to do, but also all the upstream contextual factors that are relevant for a patient's health and their ultimate health outcome from a cardiorenal metabolic standpoint.
Do you have any closing thoughts? Do you share that optimism about the important work that lies ahead? Because of the work that you're doing, the work that others are doing, we are charting this path in the right way, in a systematic way, to make sure that we are incorporating and thinking about social determinants of health as we think about cardiorenal metabolic syndrome.
Spatz: There's a groundswell of not just interest but advocacy in this area. Social determinants of health used to primarily live in the space of public health or schools of public health or population health. Now we are seeing interventionalists and surgeons saying, "Wait a second — us too, because our patients and our outcomes are affected by social determinants of health." I think that we can do a lot with our communities. But where the real change needs to happen is in the structures and policies that help to start to change the way that our country allocates resources and starts to support all people.
I'm very hopeful that we are moving in the right direction. There's an urgency to this because every day we are seeing the devastating consequences of preventable disease that could have gone better had we had better systems and policies in place. I'm hopeful. I'm also pounding the table that change happens quickly.
It's with partners like you, it's with Medscape bringing attention to these kinds of issues, that I think we're going to see real momentum. I really thank you, with a ton of gratitude for bringing attention so early in the broadcast to these very essential aspects of how we address cardiorenal metabolic health for our populations.
Desai: Thank you, Erica. We couldn't have asked for a better guest and expert to help us think about these important topics. I think you've raised many of the key issues for our audience. There has to be a sense of urgency around these issues. I wish you all the very, very best in your endeavors. I think our patients need it. Our communities need it. The health of our nation and the globe, frankly, needs it.
Today we discussed the interplay of social determinants of health and cardiorenal metabolic health with our terrific guest and my colleague, Dr Erica Spatz, from the Yale School of Medicine. Please take a moment to download the Medscape app to listen and subscribe to this podcast series.
Thank you again for joining us. This is Dr Nihar Desai for the Medscape InDiscussion: Cardiorenal Metabolic Syndrome podcast.
Resources
Cardiovascular-Kidney-Metabolic (CKM) Syndrome: A State-of-the-Art Review
What Is a Social Determinant of Health? Back to Basics
Multi-Ethnic Study of Atherosclerosis (MESA): JACC Focus Seminar 5/8
What to Know About PREVENT, the AHA's New Cardiovascular Disease Risk Calculator
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Cite this: Social Determinants of Health in Cardiorenal Conditions - Medscape - Jun 18, 2024.
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