Social and Medical Determinants of Cardiometabolic Health: The Big Picture.

Cardiometabolic diseases, including diabetes and heart disease, account for >12 million years of life lost annually among Black adults in the United States. Health disparities are geographically localized, with ~80% of health disparities occurring within ~6000 (16%) of all 38,000 US ZIP codes. Socio-economic status (SES), behavioral and environmental factors (social determinants) account for ~80% of variance in health outcomes and cluster geographically. Neighborhood SES is inversely associated with prevalent diabetes and hypertension, and Blacks are four times more likely than Whites to live in lowest SES neighborhoods. In ZIP code 48235 (Detroit, 97% Black, 16.2% unemployed, income/capita $18,343, 23.6% poverty), 1082 Medicare fee-for service (FFS) beneficiaries received care for type 2 diabetes (T2D) and coronary artery disease (CAD) in 2012. Collectively, these beneficiaries had 1082 inpatient admissions and 839 emergency department visits, mean cost $27,759/beneficiary and mortality 2.7%. Nationally in 2011, 236,222 Black Medicare FFS beneficiaries had 213,715 inpatient admissions, 191,346 emergency department visits, mean cost $25,580/beneficiary and 2.4% mortality. In addition to more prevalent hypertension and T2D, Blacks appear more susceptible to clinical complications of risk factors than Whites, including hypertension as a contributor to stroke. Cardiometabolic health equity in African Americans requires interventions on social determinants to reduce excess risk prevalence of risk factors. Social-medical interventions to promote timely access to, delivery of and adherence with evidence-based medicine are needed to counterbalance greater disease susceptibility. Place-based interventions on social and medical determinants of health could reduce the burden of life lost to cardiometabolic diseases in Blacks.