Article Archive
May/June 2023

Reducing Racial Disparities in Cardiometabolic Health
By Jamie Santa Cruz
Today’s Geriatric Medicine
Vol. 16 No. 3 P. 14

Heart disease is the leading cause of death in the United States for people of most racial and ethnic groups. However, the risk of heart disease—and of poor cardiometabolic health in general—is significantly greater for some groups than others. A wealth of research demonstrates that racially marginalized groups, including Black, Hispanic, and Native Americans, have worse cardiometabolic measures on average than those of white Americans.

Unfortunately, these racial disparities in cardiometabolic health are getting worse. A 2022 study examined cardiometabolic health among US adults by looking at five different measures: blood pressure, blood sugar, blood cholesterol, adiposity, and presence or absence of cardiovascular disease (CVD). The study found that very few US adults—less than 7%—have optimal cardiometabolic health. But whereas the percentage of non-Hispanic white adults with optimal cardiometabolic health increased slightly in the last two decades, it decreased for Hispanic and Black adults, as well as for adults of other races.

Physicians should be concerned by these disparities in heart health, given that the goal of medicine is to promote the health of all patients. “If you are a physician, you want all of your patients to do well,” says Monica Peek, MD, MPH, a professor for health justice in the department of medicine at the University of Chicago School of Medicine. “And if you know that there are some patients who aren’t doing well, you need to find out why that is and what you can do to make sure all your patients have the best chance at having healthy long lives.”

How Significant Are the Disparities?
To understand the scope of the problem, consider the following disparities:

• Hypertension. Black Americans are at much higher risk of hypertension than are white Americans (45% prevalence compared with 34%), which is significant because hypertension is a major risk factor for CVD. Hispanic and Asian Americans have hypertension at similar rates as non-Hispanic white Americans, but these groups have lower rates of awareness and control.

• Diabetes. About 15% of American Indians, 13% of Hispanic Americans, and 12% of Black Americans have diagnosed diabetes, compared with less than 8% of non-Hispanic whites. While some Asian groups, namely Chinese Americans, have comparatively low rates of diabetes, certain other Asian Americans have much higher rates (13% for Indian Americans). Again, diabetes is a major risk factor for CVD.

• CVD and mortality. The rate of coronary heart disease between Black and white adults is similar, but mortality is significantly higher among Black Americans. Black adults are more than twice as likely to experience heart failure as whites, and they are also significantly more likely to experience strokes.

Not only are racially marginalized groups at higher risk of developing cardiometabolic conditions, but they are also more likely to develop these conditions at younger ages. Recent research from the University of Michigan found that hypertension occurs about five years earlier in Black and Hispanic women than in their white counterparts, and insulin resistance and diabetes occur about 11 years earlier. Other research has found that several Asian groups, including South Asian, Vietnamese, Filipino, and Korean populations also develop diabetes at much younger ages than do white Americans (four to 11 years earlier, depending on the specific group).

It’s not entirely clear what the long-term effects of this earlier onset of metabolic disease are. But according to Alexis Reeves, PhD, MPH, a postdoctoral scholar in the department of epidemiology and population health at the Stanford University School of Medicine and lead author of the University of Michigan study, the thinking is that earlier onset could have serious consequences. “The hypothesis is that if you have earlier onset of hypertension, then you might have a higher risk of cardiovascular disease earlier in life, or you could have a worse prognosis.”

Causes of the Disparities
There is a growing consensus that racial disparities in cardiometabolic health stem largely from social determinants of health (SDoH), which in turn stem from mostly invisible societal structures that disadvantage certain racial groups. Some of the major SDoH that affect cardiometabolic measures include the following:

• Economic status and housing situation. Low income and unstable employment are linked to worse cardiometabolic health, as is homelessness, neighborhood poverty, lack of access to reliable transportation, and neighborhood violence. The link is partially explained by the fact that low economic status and lack of quality housing can cause serious physical and psychological stress, which are important mediating factors in cardiometabolic health.

• Education level. Lower educational attainment is also linked to worse cardiometabolic measures, in part because lack of education is linked to worse employment opportunities and also because lower education is linked to greater smoking and alcohol consumption.

• Food access. Food insecurity and residence in a food desert (that is, a geographical area without grocery stores that provide nutritious food items) are both linked to a lower quality diet, which significantly affects cardiometabolic health.

• The health care system. Lack of health care insurance, provider bias, and lack of culturally competent care are also factors that affect cardiometabolic health.

“What we know is that marginalized populations are less likely to have the positive social determinants of health, like wealth and safe places to live,” Peek says. “They are more likely to have the negative things—like exposure to environmental toxins and poverty.”

In many cases, these negative social determinants can be traced to specific government policies. With respect to housing and neighborhood environment, for example, federal government policy going back to the 1930s encouraged home ownership among white families but discouraged it among Black families. The Federal Housing Administration made it difficult or impossible for Black applicants to get home loans, which prevented Black families from moving into desirable neighborhoods and prevented Black families from building up wealth through home ownership. Although targeted at Black Americans, these same policies affected Latinos as well. Such discriminatory policies are no longer officially on the books, yet the effects still linger and continue to impact health.

Unintentional bias on the part of health care providers appears to play a role as well. “There … have been growing numbers of studies that show implicit bias of clinicians including physicians can contribute to differential treatment and interventions for different patient groups,” especially among patients who aren’t English speakers, says Jane Jih, MD, MPH, MAS, an associate professor of medicine at the University of California, San Francisco School of Medicine and codirector of the Multiethnic Health Equity Research Center. For example, health care providers may make subconscious assumptions about a patient’s medication use or adherence due to the patient’s race or ethnicity, which may, in turn, affect the care the provider offers. One systematic review of provider bias found evidence of bias in 14 of the 15 studies included in the review.

That said, studies estimate that only about 20% of racial disparities in health stem from the health care system, whereas about 50% of the disparities are attributable to SDoH. Potential bias from providers is an important factor to address, but addressing SDoH would likely have greater impact.

Lifestyle Choice and Patient Attitudes Toward the Medical System
Of course, lifestyle choices among racially marginalized groups also play some role in disparities in cardiometabolic health.

Take diet, for example. Because of the clear link between diet quality and health outcomes, several experiments have sought to bring new grocery stores with nutritious food options into food deserts where no such options previously existed. The hope was that these interventions would improve the diet quality of residents of the surrounding neighborhood. But research shows that the new availability of nutritious food does not necessarily change residents’ eating habits; for the most part, residents simply continue consuming the same (less nutritious) foods they consumed previously.

Still, there can be a tendency to overemphasize the element of individual choice and blame the victim. It’s important to recognize that the lifestyle choices of minorities are often “constrained by historical context,” Peek says. “People have developed lifestyle patterns that reflect historical marginalization.”

Consider some of the foods common in African American communities. Slaves in American history were often given the worst part of the animals to eat—the feet, intestines, tongues, and tails. “Enslaved people made do with what they had, and they added salt and fat in order to make do with the otherwise inedible animal parts that they were given,” Peek says. Although African Americans do not necessarily have to eat the same foods today, “food becomes a part of your culture. Over generations, how and what we eat becomes a part of who we are and the narrative of who we are. There are people today who still continue the cultural traditions that have been handed down from the period of enslavement.”

In the same way that dietary preferences play a role in cardiometabolic health, so do patient attitudes toward the medical system and toward physician-recommended treatments. A range of studies have noted racial differences in the management of various cardiometabolic conditions that are unexplained by clinical factors, socioeconomic factors, or differences in access to care. The causes are likely multifactorial, but there is some evidence that minority patients are more likely than white patients to reject recommended treatments for their cardiometabolic conditions.

This tendency to reject recommended treatments is likely rooted in mistrust of the medical system. Research from the biotech company Genentech surveyed more than 2,000 Americans and found that while one-half of Americans at large think they are treated fairly by the medical system, only 27% of Black and Latino patients agree. The survey also found that minority patients are much more likely to avoid medical testing and to skip follow-up appointments because of mistrust and/or fear that they are not being understood.

In some cases, mistrust of physicians and the medical system is rooted in decades-old historical mistreatment. For instance, the infamous Tuskegee experiment—in which treatment for syphilis was withheld from Black men even as they went blind, became insane, and died, all because researchers wanted to study progression of the disease—continues to loom large in the consciousness of Black Americans and contributes to ongoing mistrust of the health care system.

What Physicians Can Do to Reduce Cardiometabolic Disparities
Racial health disparities are incredibly complex, and it will be impossible to address them in a clinical context alone. But there are steps physicians can take to help close the gaps.

1. Work to understand the life context of your patients.
Much of medical training focuses on cultivating technical expertise, but to reduce racial disparities, physicians also desperately need to focus on relationship-building and empathy. “Basically, get to know people as people. Understand their broader life experiences and how they contribute to their health,” says Lisa Cooper, MD, MPH, a professor of medicine at Johns Hopkins University School of Medicine and director of the Johns Hopkins Center for Health Equity. Doing so will not only promote trust with minority patients but also help physicians better understand and address the factors that are keeping patients from optimal health.

Is there evidence that this works to reduce disparities? Yes. Some of Cooper’s own research on hypertension found that people who had a doctor who had received training on a more empathetic approach were more likely to achieve blood pressure control. The results were not statistically significant, likely due to small sample size, but they were clinically significant.

2. When talking with patients about lifestyle choices, be conscious of historical context. Emphasize empowerment, not blame.
Consider, for example, the subject of physical activity for Black Americans, which is important for reducing cardiometabolic risk. Certain activities that white Americans enjoy for recreation and exercise—such as cycling or water sports—exist in a different cultural context for Black Americans. “For people with wealth, biking is a leisure time activity. If you’re in a Black community riding a bike, that may signal that you can’t afford a car or more expensive forms of transportation,” Peek says. “It’s a whole different context. So you’re going to have to change the cultural norms  about what it means to bike.”

Similarly, consider swimming: 64% of Black Americans have little to no swimming ability compared with 40% of whites, a fact that most likely reflects decades of segregation in which Blacks were prevented from swimming in white pools. It’s possible to change these norms, Peek says, but only by being very “historical” and “contextual.” One thing that can help is to emphasize the historical power that minority groups have had. “When you think about surfing, what do you think about? White guys in California. But surfing originated in the Polynesian Islands and was independently developed in Africa from Senegal to Angola. Those were the original surfers. If we want to get Black people back in the water, we need to say, ‘Hey, we used to be great swimmers and surfers. We were the original people of the water.’”

3. Get familiar with the resources in your community that can help minority patients overcome structural barriers.
“We can’t address all of poverty,” Peek says. “But if a patient comes to us and says they don’t have enough food for next week, we can say, we have a billing code for that. We can bring in case workers and additional team members [and] behavioral therapists” who can help address those social needs.

Physicians should also refer patients to community-based resources, Jih says—resources such as food banks, an on-site clinic-based food pharmacy, or paratransit.

4. Advocate for better systems in your community.
Using your knowledge of the structural barriers minority patients face—whether those barriers relate to housing, employment, transportation, health care access, and so on—advocate for policy change that will improve the lives of your patients. “Testify. Write op-eds,” Cooper says.

This kind of advocacy can be done on a community or state level, but physicians can also engage in advocacy even within their own institutions. For example, Cooper says, physicians can speak to hospital management to say, “We need resources for a care manager, for patients who have social needs that aren’t being addressed. I’m prescribing blood pressure meds, but there’s no one to help them figure out where to get it, how to get it covered, or how to sign up for health insurance.”

Reducing racial disparities in cardiometabolic health will take time, but there’s reason for physicians to be optimistic. “We are in a time and space where we have never been as a country before,” Peek says. “We have acknowledged that these larger structural issues affect individual patients that come into our clinic, and we can try to address them when these patients come to us for medical care.” Disparities won’t disappear overnight, she says, but with perseverance, clinicians can help change the tide and promote better cardiometabolic health for all.

— Jamie Santa Cruz is a health and medical writer in the greater Denver area.