May/June 2021

Social Determinants & Stroke
By Jennifer Lutz
Today’s Geriatric Medicine
Vol. 14 No. 3 P. 18

It’s no secret that the quality of individuals’ lives can affect the quantity of their years. Social determinants of health (SDOH), such as income level and education, can serve as predictors of negative health outcomes. Specifically, these indicators can increase patient risk for incident of stroke.1 SDOH are often outside the bounds of clinician control and can be a frustrating barrier to patient care. However, an awareness of these determinants can guide clinicians in their care of higher-risk patients.

How Do SDOH Influence Stroke Risk?
SDOH are often associated with aspects outside of a person’s immediate control. What someone eats is a behavioral choice, for example, but that choice is influenced by social determinants such as ZIP code poverty, income, and education. Healthy People 2020, a federal initiative to increase health equality, describes SDOH as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”2 The report goes on to specify that patterns of social engagement, a sense of security, and well-being are also affected by where people live.

“If you live in a food desert, this affects your food choices,” says Imran Ali, DrPH, a physician fellow at Palliative Care at Mount Sinai. “If you don’t have access to affordable and healthful food, you can’t exactly be on the Mediterranean diet, which has been shown to reduce stroke and microvascular damage, which is linked to vascular dementia. I tell my patients to be on a diet of fresh fruits and vegetables, nuts, olive oils … all the ‘fancy foods’ that you just don’t get at the local bodega.”

While diet is often seen as an important health component, the biopsychosocial aspects of health are sometimes overlooked. “Job insecurity increases stress, increases cortisol, increases catecholamines,” Ali says. “On a physiological level, stress can actually lead to heart attacks and strokes.” This is a universal principle; in a study of 16 European countries, researchers found a statistically significant relationship between job insecurity and poorer health in older employees.3 Stress is an inherent factor in many SDOH. Among the determinants of health acknowledged by Healthy People 2020, public safety, residential segregation, social support, and exposure to crime are some of the factors linked to stress and its health implications.

According to Sharon Horesh Bergquist, MD, Rollins Senior Distinguished Clinician at Emory University, the crossover between SDOH, stress, and stroke incident is multifactorial. “There are many ways that each of these determinants can influence health; stress is certainly one of the mechanisms, and the link between stress and stroke can be direct or indirect. We know that stress can directly increase inflammation, which is a biologic mechanism by which it can increase the risk for stroke, but stress can also indirectly alter health-related behaviors. For example, a person who is under stress—be it from a chronic or acute stressor—may not follow the healthiest habits. They may revert to stress eating or they may feel fatigued and not have the energy to exercise. Socioeconomics can also be a source of stress. Poverty, for example can not only affect access to nutritious food but can also cause stress that interferes with the ability to sleep. We also know that stress has a physiological effect on the body. So, there’s an indirect path of stress working via health behaviors as well as a direct physiologic effect it can have on the body that increases stroke risk.” Bergquist goes on to say, “These factors can act as ‘microtraumas,’ negatively impacting our health.”

These microtraumas can actually change the architecture of the brain, directly influencing both behavior and physiological markers of health. In the paper “A New Model of the Role of Psychological and Emotional Distress in Promoting Obesity,” Eric Hemmingsson, PhD, of the Obesity Center at Karolinska University Hospital in Stockholm, sought to better understand the link between certain social determinants and poor health. He found that psychological and emotional distress is the fundamental link between socio-economic disadvantage and weight gain, an important contributor to stroke risk. The study found that living in a neighborhood with high racial segregation predicted inflammation, obesity, and metabolic syndrome, and that unemployed adults reported two to five times higher rates of poor health. The effect was more pronounced in countries with less social welfare.4

The fact is, where one lives affects one’s health—both on a direct and indirect level. Access to fresh fruits and vegetables directly influences predictors of stroke.5 Another important factor is access to care, which influences the frequency at which individuals get health screenings and are prescribed needed medicines. As an example, a 2017 study on cardiovascular health found that among individuals with an indication for statins, only 45% of those with four or more SDOH were prescribed statins, as compared with 65% of people with no clear SDOH.6

The Additive Effects of SDOH on Stroke Risk
A recent study published in the American Heart Association journal Stroke, “Impact of Multiple Social Detriments of Stroke” measured the cumulative effect of SDOH on stroke risk. Among the study’s findings, an overall theme was that the incidence of stroke increased with the cumulation of SDOH. The researchers used data from participants in the REasons for Geographic And Racial Differences in Stroke, or REGARDS study, to examine information pertaining to 27,813 adults across the United States. Participants were limited to Black and white individuals, their average age was 65, and the average follow-up was 9.5 years. Within that timeframe, 1,470 cases of stroke (from the 27,813 study participants) were reported. The researchers based their SDOH markers on the Healthy People 2020 guidelines and included 10 specific SDOH: race, education, income, ZIP code poverty, health insurance, social isolation (not seeing friends or family for at least one month and/or having no one to care for them in illness), low annual household income, residence in health professional shortage areas, rural residence, and residence in one of the 10 lowest ranked states for public health infrastructure.7

The study also found that those participants who reported a greater number of SDOH were more likely to be Black, women, have a low annual income, be a resident in a state with poor public health infrastructure, and have hypertension and diabetes.7

Compared with people with no SDOH, the risk for stroke was 44% higher in those with one SDOH, 82% higher in those with two, and 2.38 times higher in those with three or more. When adjusted for individual characteristics, including risk factors, the increase was more than halved—there was a 26% increased risk for people with one SDOH, a 38% increase in those with two, and a 51% increase in people with three or more. While social determinants of health do increase a person’s stroke risk, addressing other risk factors can greatly lower that risk.

Stroke Risk, SDOH, and Lifestyle Intervention
How do practitioners help patients when the cards seem to be stacked against them? “One of the greatest areas where we can potentially help our patients, regardless of their ability to access certain types of care or their financial means, is through education. We can speak to the power of simple things they can do in their everyday lives to affect health outcomes. Sometimes, just making that direct connection for a patient can help them realize how they can make changes in their life to decrease their risk,” Bergquist says. “Some people may not have access to a gym, but home exercises and body resistance exercises are things that we can talk through with people. We can also discuss how to shop affordably at a grocery store and how to prepare a meal from scratch in a way that is healthy and inexpensive.”

Education is indeed a major factor in preventive care but isn’t always easy for the clinician to administer, especially given time constraints on patient visits and lack of nutrition education in medical schools.

To help address this gap, practitioners can reference trusted sources such as “A Clinician's Guide to Healthy Eating for Cardiovascular Disease Prevention,” a review published by Mayo Clinic that specifically deals with “the unique difficulties of dietary counseling in low–socioeconomic status environments and provides an evidence-based approach to better serve these populations.”8 As a broad stroke, the review recommends the DASH, Mediterranean, and vegetarian diets as the best for cardiovascular health. The review recommends a three-minute, 15-question assessment proposed by Eckel (and nine questions proposed by Lehr and colleagues to determine whether the ABCDs [Assess, Barriers, Commit, and Demonstrate] are useful for understanding opportunities for improved diet and activity). Overall, the review emphasizes that providers should ask patients what’s affordable and reasonable so they may make dietary recommendations that are in line with those answers.

Regarding patient education, Bergquist says, “I think most physicians would like to spend more time on patient education, but the health care system and the traditional office visit often do not allow time for a grocery store tour with a patient or any type of extensive education. To help our patients address a broad spectrum of social and economic determinants, I think we need to rethink how we deliver care. For example, we could consider a group visit model where we can incorporate more education. We can think about programs that bring together the resources of a health care facility to create multidisciplinary teams, such as bringing a dietitian or a behavioralist into a clinician’s office and integrating them into routine patient care.”

Sometimes it’s helpful to examine models that have worked elsewhere. For example, stroke was the leading cause of death in Japan until the country instituted social programs that combated many SDOH; since 1960, the number of deaths by stroke in Japan has fallen by more than 85%.9 The measures taken in Japan included regular health check-ups with information about healthful eating and exercise, and collaboration with schools and restaurants that resulted in programs such as summer cooking classes. An important feature of the Japanese model is that, although it was instituted by the central government, it was implemented at the community level. Despite the many difficulties facing both patients and clinicians, there are tools at their disposal.

“I get my social workers involved,” Ali says. “I provide resources. I get people transportation vouchers. I set people up with Meals on Wheels. I set people up with auxiliary programs. This is what stopped during COVID, which is hurting a lot of people. A lot of people are hurting, not just from the virus but from the other effects of the virus. Getting these social supports, getting these programs where people can get better meals, is important.”

Social support is a key part of health, and social isolation a key detriment. A systematic review and meta-analysis found that poor social relationships were associated with a 29% increase in risk of incident CHD and a 32% increase in risk of stroke.10 The analysis focused on loneliness and social isolation and reported that the impact on stroke risk was similar to that of other psychosocial risk factors, such as anxiety and job strain.

Concerning social isolation, Bergquist says, “It is a risk factor for multiple chronic diseases, including stroke. We know that social interactions and socialization are mechanisms for reducing stress, so the lack of social networks and social interactions may have the reverse effect and may heighten a person’s stress.” In addition, Bergquist says, “A lot of support groups can be formed through health care systems. I think a support group that is affiliated with a health care system can be a good resource. Support groups not only provide social support but can be a forum for people to attain and share information.”

Social Determinants and a Healthier Future — For All
The Centers for Medicare & Medicaid Services Office of Minority Health has initiatives in place to increase awareness of health disparities and help overcome them, including Health Equity Technical Assistance, which is available for health organizations dedicated to tackling health disparities.11

On a community level, health care systems are beginning to combat some of the social determinants of health. Independence Blue Cross and Signify Health launched Community Link, a community-based organization network targeting the social determinants of health in the Philadelphia region.12

One of New Jersey's largest academic health care systems, RWJBarnabas Health, has an initiative called Ending Racism, which is aimed at addressing SDOH that are connected to the disenfranchisement of certain communities.13 Earlier this year, RWJBarnabas also launched an SDOH program called Health Beyond the Hospital to refer and connect patients to community-based services.

The current health care model presents challenges for both patients and practitioners. And while there’s an increase in initiatives for equitable care, clinicians are often forced to do their best within a tangle of constraints.

“Within the constraints of social determinants, one way the physician can help is by asking questions about a person’s environment. A lot of times, we don’t ask questions regarding a patient’s level of social support or isolation at home or how they integrate with their community,” Bergquist says. “I think asking these questions helps the physician put the patient in the context of their everyday life. When we think of stroke, stroke is a chronic illness, and like all chronic illness, we have to take into consideration every dimension of a person’s care. Beyond just the physical (which is the primary emphasis in health care) we must look at psychosocial and environmental factors. I think by asking those questions and helping people find ways to improve their personal resources and environment, the physician can guide patients toward better health outcomes, even within the constraints of social determinants of health,” she says.

Environment and socialization do affect health. While social determinants can put people at a higher risk for stroke, clinicians who understand these determinants can guide patients toward behavioral changes and improved health outcomes.

—  Jennifer Lutz is a freelance journalist who covers health, politics, and travel. She has written for both consumer and professional medical magazines, as well as popular newspapers. Her writing can be found in Practical Pain Management, EndocrineWeb, Psycom Pro, The Guardian, New York Daily News, Thrive Global, BuzzFeed, and The Local Spain. In addition to journalism, Lutz works as a strategies and communications consultant for nonprofits focused on improving community health.

References
1. Quick maps of heart disease, stroke, and socio-economic conditions. Centers for Disease Control and Prevention website. https://www.cdc.gov/dhdsp/maps/quick-maps/index.htm. Updated February 8, 2021. Accessed March 16, 2021.

2. Heart disease and stroke. HealthyPeople.gov website. https://www.healthypeople.gov/2020/topics-objectives/topic/heart-disease-and-stroke. Accessed March 16, 2021.

3. László KD, Pikhart H, Kopp MS, et al. Job insecurity and health: a study of 16 European countries. Soc Sci Med. 2010;70(6):867-874.

4. Hemmingsson E. A new model of the role of psychological and emotional distress in promoting obesity: conceptual review with implications for treatment and prevention. Obes Rev. 2014;15(9):769-779.

5. Hu D, Huang J, Wang Y, Zhang D, Qu Y. Fruits and vegetables consumption and risk of stroke: a meta-analysis of prospective cohort studies. Stroke. 2014;45(6):1613-1619.

6. Schroff P, Gamboa CM, Durant RW, Oikeh A, Richman JS, Safford MM. Vulnerabilities to health disparities and statin use in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study. J Am Heart Assoc. 2017;6(9):e005449.

7. Reshetnyak E, Ntamatungiro M, Pinheiro LC, et al. Impact of multiple social determinants of health on incident stroke. Stroke. 2020;51(8):2445-2453.

8. Pallazola VA, Davis DM, Whelton SP, et al. A clinician’s guide to healthy eating for cardiovascular disease prevention. Mayo Clin Proc Innov Qual Outcomes. 2019;3(3):251-267.

9. Ui.ac.id. https://ocw.ui.ac.id/pluginfile.php/11320/mod_resource/content/1/PH-101-19.pdf. Accessed March 16, 2021.

10. Valtorta NK, Kanaan M, Gilbody S, Ronzi S, Hanratty B. Loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies. Heart. 2016;102(13):1009-1016.

11. CMS Office of Minority Health. Centers for Medicare & Medicaid Services website. https://www.cms.gov/About-CMS/Agency-Information/OMH. Updated March 19, 2021. Accessed March 16, 2021.

12. Signify Health, Independence Blue Cross. Independence Blue Cross and Signify Health launch CommunityLinkTM network. PR Newswire website. https://www.prnewswire.com/news-releases/independence-blue-cross-and-signify-health-launch-communitylink-network-301141511.html. Published September 30, 2020. Accessed March 16, 2021.

13. RWJBarnabas Health embarks on system-wide initiative to end racism. RWJBarnabas Health website. https://www.rwjbh.org/blog/2020/december/rwjbarnabas-health-embarks-on-system-wide-initia/. Published December 10, 2020. Accessed March 16, 2021.