Social Determinants of Health and Obesity

Implications for Clinical Research and Practice

Thank you to Jillian Randolph BA, and Janna Stephens RN, PhD for this article connecting the social seterminants of health and obesity.

Obesity and cardiovascular disease are related to the social determinants of health (SDOH), although this relationship is complex and different for each individual. Understanding how the SDOH interact with genetic and biological factors is essential to positively impact health outcomes. We simply cannot treat individuals within a vacuum without consideration to the environments where they are born, live, learn, work, play, and worship.1

For our patients with obesity, it is not enough to direct lower calorie intake or increased activity without fully understanding the impacts and barriers of these recommendations on treating this chronic disease. For an individual living in a food desert without access to healthy foods or vegetables, or a patient whose living circumstances make a walk around the neighborhood risky, or even someone for whom meals are prepared by someone else whose interest in healthy eating is lacking, making ‘healthy decisions’ is more than just a unilateral declaration each day.

The SDOH are broken into six domains – economic stability, education access and quality, food, neighborhood and built environment, social and community context, and healthcare system access and quality – and they influence individuals through the individual, familial, community, and societal levels.2 Inequities in any of the domains and on any level create disparate health outcomes amongst marginalized groups and individuals. As preventive health care experts it is essential to understand the interactions of these social factors to provide excellent and appropriate person-focused care and prevention.

The SDOH have large implications for how we–as nurses and providers focused on cardiovascular care–engage with our patients. One of the first steps is to understand the communities in which our patients engage. One valuable resource is to examine county health rankings, which provide statistics on obesity, smoking, access to healthy foods, and other risk factors related to CVD.3 We understand that certain communities are at higher risk for mortalities from cardiovascular disease, including those with more non-white residents, those with a higher proportion of individuals who did not complete high school, and communities with higher rates of violent crimes. Applying the SDOH, we know that these CVD outcomes are also a result of systemic political, economic, and social inequities that our current healthcare system continues to perpetuate. Additionally, higher mortality rates are focused in communities with known higher rates of obesity, diabetes, smoking, and other modifiable risk factors for CVD.4 While we tend to focus on these modifiable risk factors and promoting behavior change, we must also think about non-modifiable risk factors and how those are impacting our patients and their risk for CVD.

Just as our patients exist within a specific set of SDOH, so do we as providers. One of the first steps we can take is to acknowledge our own positionalities when engaging in our work. This starts with our individual level identifiers: age, race/ethnicity, socioeconomic status/educational background, gender identity, and sexual orientation. This also involves an understanding of our own implicit bias. Everyone has implicit biases and we must work to understand these in order to provide the best possible patient care. Many workplaces now offer implicit bias training and other learning opportunities; it is important for us to engage in this training annually.

For our patients with obesity that experience feelings of shame on a regular basis, who are met with bias not only in everyday situations such as the grocery store or restaurant but potentially in our own practices, what efforts can we make to ensure that we are treating them with respect, truly listen and understand their barriers to health, and providing or recommending resources that can help manage these barriers? 

Within the context of SDOH, we must address the patient at the individual level but also consider community-level interventions and policy changes to address unhealthy communities. Although we as providers might not have a large impact on policy changes, we can start by understanding the importance of the social environment and addressing it within our practices or healthcare environment. Utilizing readily available tools is one useful strategy to addressing community and population-level disparities.5

Another way to connect patients with resources related to modifiable and non-modifiable risk factors is to engage them with research studies or clinical trials. Research studies can offer new pathways for engagement in the health care system and serve a profound benefit to potential participants. However, investigators and referring clinicians tend to gatekeep information from those they do not recognize as ideal participants, typically because of their implicit biases.9 Studies have shown “differences in referral and treatment patterns by providers, after controlling for medical need, to be associated with a patient’s race or ethnicity”.9 To rectify these gaps in representation and access, we should keep up to date on clinical trials and research studies (using resources like clinicaltrials.gov), increase our understandings about the psychological basis of bias, and engage in direct and honest conversations with our patients.10

In summary, here are some tips to understanding SDOH and our patients who may be at risk for CVD and facing chronic conditions such as obesity:

  • Understand and assess our patient’s community
  • Understand modifiable and non-modifiable risk factors
  • Examine county-level data specific to our patient
  • Understand our own implicit bias
  • Understand our own identities

References

  1. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Social Determinants of Health. Accessed Jan. 8, 2022.
  2. Jilani MH, Javed Z, Yaha T, et al. Social Determinants of Health and Cardiovascular Disease: Current State and Future Directions Towards Healthcare Equity. Current Atherosclerosis Reports. 2021;23(55).
  3. Savoy M, Wilder VT, O’Gurek D, editors. American Academy of Family Physicians. Addressing Social Determinants of Health in Primary Care: Team-Based Approach for Advancing Health Equity (PDF). 2018. Accessed Jan. 8, 2022.
  4. American Heart Association. U.S. COVID death rate drops overall, county-level data signals ongoing disparities. 2021. Accessed Jan. 10, 2022.
  5. Centers for Disease Control and Prevention. Heart-Healthy and Stroke-Free: A Social Environment Handbook. 2007. Accessed Jan. 9, 2022.
  6. Centers for Disease Control and Prevention. Best Practices for Cardiovascular Disease Prevention Programs. Accessed Jan 10, 2022.
  7. American Heart Association/American Stroke Association. Tools and Resources. Accessed Jan. 8, 2022
  8. American Stroke Association. Stroke Risk Factors. Accessed Jan. 10, 2022
  9. Niranjan SJ, Martin MY, Fouad MN, et al. Bias and Stereotyping Among Research and Clinical Professionals: Perspectives on Minority Recruitment for Oncology Clinical Trials. Cancer. 2020;126:1958-1968. doi: 10.1002/cncr.32755.
  10. Burgess D, van Ryn M, Dovidio J, Saha S. Reducing racial bias among health care providers: lessons from social-cognitive psychology. J Gen Intern Med. 2007;22:882-887.

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