Neighborhoods Are Key for Heart Health
Where patients live may be an important contributor to their risk of developing cardiovascular disease, according to a growing body of literature. The research suggests that, because of the complex interplay between individual- and neighborhood-level risk factors, addressing both simultaneously may be necessary to improve patient outcomes.
Epidemiological studies of cardiovascular disease risk have traditionally focused on personal characteristics, including physical activity levels, diet, and smoking, and biological measurements, as well, like blood cholesterol levels, explained Ana Diez-Roux, MD, PhD, MPH, dean and professor of epidemiology at Drexel University’s Dornsife School of Public Health. These have led clinicians to appropriately emphasize healthier lifestyles to their patients.
Over the past decade, however, scientists have begun to tease out how an individual’s environment may contribute to whether a person smokes, what kind of diet he or she has, and how much activity he or she gets, Diez-Roux said. Results so far have suggested that neighborhood characteristics like socioeconomic status, segregation, walkability, pollution levels, and access to healthy foods are associated with cardiovascular risk levels.
“Neighborhood matters to cardiovascular health,” said Tiffany Powell-Wiley, MD, MPH, an assistant clinical investigator at the National Heart, Lung, and Blood Institute. “You can’t just think of your patients as individuals, you have to think of where they are coming from as being important in what their cardiovascular outcomes are.”
Studies of the relationship between heart health and neighborhood characteristics are revealing a complex web of interrelated social, economic, and physical factors that appear to influence health behaviors and cardiovascular risk.
The Multi-Ethnic Study of Atherosclerosis, a longitudinal study that followed nearly 7000 individuals from 6 communities across the United States for >10 years, has identified an array of neighborhood factors that are associated with elevated cardiovascular risks. Some of the study’s results have been relatively straightforward, linking a lack of health resources or greater exposure to pollution to increased heart risk.
“People who live in areas with greater physical activity resources and greater resources tend to be more active,” Diez-Roux said. “People who live in areas with better access to healthy foods have better diets.”
But other results have shown that social factors can have a substantial impact on heart health. For example, the study found that risky health behaviors like smoking and not exercising are more common among individuals who report experiencing racial or ethnic discrimination, and in individuals who report being less connected to or less able to count on their neighbors, as well. Blacks who experienced residential segregation were also at greater risk of developing cardiovascular disease.
Individuals’ perceptions of their neighborhoods also appear linked to heart risks. The Dallas Heart Study, which included nearly 6000 individuals, found that individuals who viewed the physical environment in their neighborhood poorly were more likely to be obese. Specifically, those who viewed their neighborhood as having heavy traffic, lots of litter, and a lack of recreational areas or sidewalks were more likely to be obese.
“That was really eye-opening,” Powell-Wiley said.
The socioeconomic status of a neighborhood also makes a difference. Results from the Jackson Heart Study showed that black women living in neighborhoods with worse economic and social conditions have increased cardiovascular disease risk.
In many communities, factors like segregation, poverty, low social cohesion, pollution, and lack of resources may cluster and compound one another, Diez-Roux noted.
Moving to a new neighborhood has been shown to have an effect on cardiovascular risk, for better or worse. The Dallas Heart Study found that individuals who move to more socioeconomically deprived neighborhoods gain more weight than individuals who stay put or move to a wealthier neighborhood.
Many of the studies are observational, so they cannot prove a causal effect, “but it’s a way to start,” Diez-Roux said. Studying these relationships and trying to understand the underlying mechanisms may help point to neighborhood-level interventions that might reduce cardiovascular risk, she noted.
A randomized trial also showed that low-income families living in a high-poverty neighborhood who were randomly selected to receive a voucher to move to a low-poverty neighborhood experienced reduced rates of extreme obesity and diabetes mellitus.
“We have to figure out what it is about those neighborhoods that helped [people who moved to them] improve, then make those changes in [high-risk] neighborhoods through policy,” she said.
For cardiologists, recognizing the role that neighborhood factors may be playing in their patients’ heart health and their ability to make healthy lifestyle changes is an important first step.
“If we understand where people are coming from, it can change how we counsel them on behavior changes,” Powell-Wiley said. She said it is not enough to tell someone to get more exercise or eat better. Healthcare providers or health systems need to know what their patients’ environment is like and how to connect patients with local resources for physical activity and healthy foods.
Powell-Wiley suggested that practices should start by electronic health records systems for assessing social or environmental factors that may influence their patients’ health. One possible way to do this would be to have electronic health records that provide recommendations for free or affordable local resources, for example, by listing recreation facilities or fitness classes in the patients’ neighborhood. Diez-Roux noted that some groups are already testing such technology.
Some organizations are already working on building such assessment tools, and the Centers for Medicare & Medicaid Services is evaluating demonstration projects that seek to integrate social factors into clinical care, Powell-Wiley noted.
Enlisting community groups in health promotion may be another approach. Powell-Wiley and her colleagues have worked with community groups and churches in predominantly black, disadvantaged neighborhoods in Washington, DC, to test the feasibility of using wearable fitness trackers to boost activity levels among residents. Although this feasibility study did not set goals for activity, some participants were motivated to try to boost their activity levels.
“We were really surprised how many people wanted to use the technology we were providing as part of the study,” Powell-Wiley said.
Some changes, such as regulations that affect racial discrimination, redevelopment, zoning, and the allocation of certain resources, need to be addressed at the level of public policy rather than in the clinic.
“There are policies outside the clinical realm that are as important or even more important than what physicians can do,” Diez-Roux said. n
Circulation is available at http://circ.ahajournals.org.
- © 2017 American Heart Association, Inc.