12 More than just diet and exercise: social determinants of health and well-being

Introduction

Our health is determined by more than just our genetics and our physical well-being. In fact, according to the World Health Organization (WHO), health is not limited to the lack of disease but includes an individual’s physical, mental and social states.¹ The leading causes of death worldwide include heart disease, pulmonary disease and diabetes,² and these non-communicable diseases are impacted by our personal behavior and by larger factors such as where we live, our education level and our ability to access care. However, in the US and beyond, inequalities in these environments and social factors create health inequities.

According to the CDC, social determinants of health (SDH) are the conditions and circumstances surrounding an individual’s life that can affect their health outcomes.³ Healthy People, the US government’s agenda for improving health outcomes,⁴ defines these conditions as places in which people thrive or are adversely affected.⁵ Health disparities and health inequity exist when differences lie among these environments, particularly where obstacles to good health are many and great. Equity is “the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically.”⁶ Thus, health equity exists when access to resources linked to good health is equitable and fair, regardless of social status.⁷ Health inequities result from differences in SDH and unequal distribution of resources. Health equality is achievable when health inequities are addressed accordingly. SDH impact health disparities, defined as the differences seen in health outcomes as a result of an individual’s disadvantages, whether social, economic, or environmentally.⁸ Such negative outcomes include increased illnesses, lower quality care, higher mortality rates, and greater health care costs.

In order for populations and individuals to achieve health, many factors must be considered. This is clear when looking at the many outcomes and objectives of Healthy People 2030. Healthy People 2030provides a framework that helps to identify resources and tools to address SDH. The framework consists of five key determinants – economic stability, education access and quality, social and community context, health care access and quality, and neighborhood and built environment – all of which exhibit factors that can dictate an individual’s health-associated risks and outcomes.⁵ Healthy People 2030’s core objectives include a subset of high-priority objectives called Leading Health Indicators that all address SDH, health disparities, and health equity.⁹ Globally, there is also a concerted effort to improve the lives, health and well-being; the Sustainable Development Goals (SDG) were developed to ensure a sustainable future and to assist in achieving health for all by fighting poverty and inequalities. Good health as a human right should be obtainable by all. Thus, SDG 3 addresses health and well-being at all ages.¹⁰ There are multiple factors for health care providers to consider when providing care. It is especially pertinent to consider how socioeconomic status (e.g., income, education, occupation) impacts health, particularly when considering how it influences the ways individuals interact with their environment. For example, how might income affect health care access and utilization? How might education influence health literacy and the ability of an individual to feel empowered and engaged in their own health? Furthermore, how might differences in SDH contribute and exacerbate health disparities? These are important considerations we, as practitioners, must understand in order to aid others in achieving their full health potential.

Case

CC: “I’m here for a follow-up appointment.”

HPI: AJ is a 45-year-old, Hispanic male (69 in, 82 kg) who comes into the clinic today for an appointment to manage his medications and ensure his disease states are controlled.

PMH: T2DM; hypertension; COPD; high cholesterol

FH:

• Mother: alive, with T2DM
• Father: alive, with T2DM and HF
• Brother with pre-diabetes
• One daughter

SH:

• Drinks alcohol socially
• Previous smoker (1.5 PPD), quit 2 years ago
• Denies illicit drug use

Surgical history: N/A

ROS: (+) Chronic cough with sputum production

VS:

• BP 144/88 mmHg
• HR 60 bpm
• RR 16/min
• Temperature 37°C
• Pulse oximetry 93% on room air

Labs (drawn at last visit 1 month ago):

• Na 135 mEq/L
• K 4.2 mEq/L
• Cl 108 mEq/L
• CO₂ 26 mEq/L
• BUN 19 mg/dL
• SCr 1.1 mg/dL
• Glu 168 mg/dL
• Ca 9.6 mg/L
• Mg 3.6 mg/L
• A1c: 7.8%

Medications:

• Metformin 500 mg – 2 tablets PO BID
• Hydrochlorothiazide 25 mg – 1 tablet PO daily
• Lisinopril 20 mg – 1 tablet PO daily
• Atorvastatin 40 mg – 1 tablet PO daily
• Fluticasone/salmeterol 100/50 mcg – 1 inhalation BID
• Albuterol 90 mcg HFA – 1-2 puffs every 4-6 hours as needed

SDH and additional context: AJ is married and has a five-year-old daughter. He was born in the US, and his parents are immigrants from Mexico and made barely enough to support him and his younger brother. He grew up in a relatively under-resourced neighborhood in a small apartment with 1 bedroom, 1 bathroom, and a shared living/eating space. He often likes to tell short stories about how he grew up when he comes for clinic visits, describing how they had to squeeze his whole family into one bedroom at night, and often, how his little brother would accidentally kick or punch him in his sleep. He talks about growing up eating fast food hamburgers because they were inexpensive and his parents didn’t have much time to cook for him and his brother. Additionally, there was only one grocery in his neighborhood that was over five miles away, and since his parents did not own a car, they rarely went. He remembers sometimes the water ran a little strange colored from the faucets, that streets were almost always covered in trash, and that many buildings were broken down and not maintained. He and his brother did not play outside often because it was not safe to be out after dark, there was barely any clean park space, and so he would be at home and either watch tv or play card games with his brother.

AJ works as a bank teller at a local bank. He finished high school with average grades, but decided to go work immediately because his parents were getting old and he had to make money to support their life and health care. He mentioned once that he considered applying for college but could not afford it, and therefore, never bothered. His wife is a stay at home mom, taking care of the apartment and their daughter. She previously worked as a bank teller (this is how they met), but had to quit her job to take care of their daughter because child care was not affordable.

As an adult and father, AJ has made enough money to move out of the neighborhood he grew up in. His family now lives in two-bedroom apartment in a neighborhood that has a fairly average income. There are two grocery stores within walking distance, and one decent school that his daughter will eventually be able to go to. AJ makes sure he provides everything he can for his daughter, giving most of his income to pay for healthy meals, saving up for school supplies and eventually college, and providing her with toys and clothes that she needs. They use the second bedroom for her so she can have her own bed and room. Additional income goes to his mother and father, who are now retired and living off very little. Because most of his money goes to his family, he has very little for himself, often still eating the fast food hamburgers that he grew up on to leave the healthy meals for his family. Additionally, AJ sometimes skips picking up his medications because they can cost a lot. He will take medications every other day to make them last longer.  AJ is quite proud of what he has been able to provide for those he loves, especially because he was given so little as a child.

Case Questions

1. What aspects of AJ’s childhood may have influenced his current health status? Elaborate on each aspect and explain why it influences his current health status.

2. Compare and contrast the childhood AJ had and the one his daughter now has. What does she have (that AJ didn’t) that might impact her health in the future?

3. How do AJ’s current responsibilities impact his health? What advice would you give him as his healthcare provider?

4. Consider the neighborhood AJ grew up in and all those who lived in this neighborhood. How do you think this neighborhood’s poor resources and state may have impacted all of its residents?

5. What can pharmacists do to help patients and communities with low-resources?

Author Commentary

Health disparities and inequities drive negative health outcomes and have long-lasting impact on patients and entire communities. When communities are not healthy, it not only has negative implications for an individual’s health status, but it also has adverse effects on the community’s economy, safety and education. This creates a negative cycle as these same issues can further health disparities divides.  As pharmacists, we must care for the patients in front of us, but in our ever-expanding roles as public health professionals, we must also begin advocating for our patients and communities. We must educate ourselves on the implications of subpar and disparate housing, food access, parks and recreation, safety and violence, and education, as we must use our knowledge for advocacy and policy change a local, regional, national and international levels.

Patient Approaches and Opportunities

As pharmacists, we can do our best to optimize medication therapy; however, it is critical to think about the larger picture and the social determinants of health that are influencing a patient’s lifestyle and environment. Before making lifestyle-change recommendations, it is vital to consider what is possible for the patient to accomplish. Pharmacists must remember to recommend culturally appropriate diet and lifestyle changes that are within the realm of possibility for a patient so they have the ability to follow them. Additionally, pharmacists have the potential to make an impact at the population-health level by utilizing their patient-care experiences to advocate for larger community or district-level policy changes.