Having more unfavorable social determinants of health, such as being unemployed, uninsured or not having education beyond high school, was associated with an increased likelihood of having risk factors for cardiovascular disease among Asian American adults, according to new research published today in the Journal of the American Heart Association, an open access, peer-reviewed journal of the American Heart Association.

The investigation also noted that the link between these unfavorable social determinants of health variables and cardiovascular disease risk factors varied widely among people in different Asian American subgroups in this study. An association does not mean that social determinants of health directly caused the risk factor.

Despite the perception that Asian Americans may be less impacted by social determinants of health compared to people in other racial/ethnic groups, our findings indicate unfavorable social factors are associated with higher prevalence of cardiovascular risk factors among Asian American adults."

Eugene Yang, M.D., lead study author, professor of medicine at the University of Washington School of Medicine in Seattle

"The Asian American population is the fastest growing racial/ethnic group in the United States," Yang said. "People of South Asian heritage have higher rates of premature heart disease globally, and they recently have been found to have higher cardiovascular mortality than non-Hispanic white people. Better understanding of why differences in cardiovascular risk exist among Asian subgroups is vital to reducing risk and improving outcomes."

Researchers examined data from the National Health Interview Survey conducted in the U.S. from 2013 to 2018, which included 6,395 adults who self-identified as Asian.

Researchers rated 27 social determinants of health factors as favorable or unfavorable in six areas: economic stability (which included employment and income status); neighborhood and social cohesion (which gauged neighborhood trust and whether homes were owned or rented); psychological distress; food security; education; and health care utilization.

The analysis found a significant relationship between unfavorable social determinants of health and cardiovascular disease risk factors. This relationship varied among people in different Asian American subgroups. Among the findings:

• For all Asian groups included in the data, a higher unfavorable social determinants of health score by one standardized unit was associated with a 14% greater risk of high blood pressure; a 17% greater risk of poor sleep; and a 24% greater risk of Type 2 diabetes -; all of which increase the risk for developing cardiovascular disease.

• Specifically, more unfavorable social determinants were associated with:
  • a 45% greater likelihood of Type 2 diabetes among Chinese adults and a 24% greater likelihood among Filipino adults;
  • a 28% greater risk of high blood pressure among Filipino adults;
  • a 42% increased likelihood of insufficient physical activity among Asian Indian adults, a 58% increased likelihood among Chinese adults and a 24% increased likelihood among Filipino adults;
  • a 20% likelihood of suboptimal sleep among Asian Indian adults; and
  • a 56% and 50% likelihood of nicotine exposure among Chinese adults and Filipino adults, respectively.
• Compared with other Asian American subgroups, adults who identified as Filipino reported the highest prevalence -; 4 out of 7 -; cardiovascular risk factors: poor sleep, high cholesterol, high blood pressure and obesity.

Yang said many social determinants of health are often interconnected, such as neighborhood cohesion, economic stability and use of the health care system.

"It is important to understand how different Asian subgroups are affected," he said. "When Asian people are lumped together, higher risk groups like South Asian people may not be treated aggressively enough, while groups with lower risk, like people of Korean and Japanese descent, may be overtreated for blood pressure or cholesterol."

Study background and details:

• The large, cross-sectional study reviewed data from 2013-2018 National Health Interview Surveys -; annual, nationally representative surveys of U.S. adults.
• Of the 6,395 Asian adults in the survey, about 22% self-identified as Filipino adults; 22% as Asian Indian adults; 21% as Chinese adults; and 36% as other Asian.
• The sample size of Asian American individuals in the national survey was too small to analyze several major Asian populations, including Japanese, Korean and Vietnamese people, as well as other smaller Asian subgroups.
• Nearly 56% of the group were women, and nearly 52% were between the ages of 18 and 44. About 77% of the participants were born outside the United States.
• Participants were assigned scores for social determinants of health by categorizing 27 variables as favorable or unfavorable.
• The cardiovascular risk factors were self-reported and were similar to the American Heart Association's Life's Essential 8 -; eight lifestyle metrics assessing ideal cardiovascular health. These eight metrics include: following a healthy diet, maintaining a healthy weight, getting regular exercise and enough quality sleep, avoiding nicotine exposure and maintaining healthy levels of blood pressure, glucose and cholesterol. However, healthy diet was not measured in this study. Reaching optimal levels of these eight metrics improves heart health and reduces the risk for heart disease and stroke.

Limitations of the study include that its small sample size did not allow for analysis of some Asian subgroups (Japanese, Korean, Vietnamese and other Asian people). In addition, it examined self-reported survey data on social factors and cardiovascular risk factors at a single point in time. Therefore, the analysis could not assess long-term social determinants of health patterns, and it could not prove that unfavorable social factors caused the development of cardiovascular disease risk factors. Furthermore, language barriers may have been a factor for some participants because the National Heath Interview Surveys were only conducted in English and Spanish.

Study authors noted that it is vital to include more Asian Americans in national surveys to reveal potential differences in optimal social determinants of health profiles and cardiovascular risk factor prevalence and outcomes.

Co-authors, disclosures and funding sources are listed in the manuscript.