By Amy Harris 

Heart disease is the leading cause of death for both men and women in the U.S. In Maine, heart disease accounts for one out of every five deaths; nationally, heart disease is implicated in one out of every three deaths. The ways people live, move, and eat play major roles in whether or not they develop heart disease. Unfortunately, limited access to health care because of socio-economic status, immigration status, limited language accommodation and interpreter services in medical establishments, and housing and food insecurity all increase the risks of developing heart disease.  

What is heart disease? 

“Heart disease” describes several types of heart conditions caused by a buildup of plaque in blood vessels, or arteries. The buildup of this sticky plaque can cause coronary artery disease, chest pain, heart attacks, and strokes.The most common type of heart disease in the United States is coronary artery disease (CAD), which slows the blood flow to the heart. Decreased blood flow to the heart can cause a heart attack. 

The social determinants of health shape whether or not someone develops heart disease. Social determinants of health are the conditions in the environment that affect health, quality of life, and risk for disease. Research on risk factors for cardiovascular health from MaineHealth’s Center for Outcomes Research and Evaluation (CORE)indicates that in a rural state like Maine, cardiovascular health is impacted most by food and physical activity.  

Maine Medical Center cardiologist Dr. Maxwell Afari knows first-hand how the social determinants of health keep cardiac patients from accessing  his clinics. As a self-proclaimed “soccer fanatic” and native of Ghana, he decided to train to be a cardiologist while still in medical school in Brazil, after the sudden cardiac death of Cameroonian footballer Marc-Vivien Foe. Far from the soccer pitch now, Afari sees how the social determinants of health make it hard for many of his patients to follow his recommendations for treatment or prevention of their heart disease. 

“There is a lot of data that shows that you are what you eat. But if you have very little money and struggle with food, housing, or status insecurity, you are not able to make the kinds of choices I would want you to make as your cardiologist.”  

— Dr. Maxwell Afari, Advanced Heart Failure and Transplant Cardiology, Maine Medical Center 

Preventing heart disease by addressing social determinants is complicated. Heart disease is chronic, and develops slowly over a long period of time with few warning signs. This makes prevention and treatment challenging for cardiac doctors, like Afari. Sometimes a heart attack presents as the first symptom of heart disease. When possible, following a healthy lifestyle, and paying attention to risk factors, can help prevent heart disease before it is too late, he said. 

Tips for preventing heart disease: 

  1. Follow a diet that is lower in fat and sugar, and filled with plenty of fruits and vegetables. 
  1. Sit less and move more (aim for 30 minutes of activity, five days a week). 
  1. See a doctor at least once a year to check blood sugar and cholesterol. 
  1. Quit smoking. 
  1. Get enough good quality sleep (seven to nine hours are recommended for adults). 

The U.S. Department of Health and Human Services Office of Minority Health blames factors such as language and cultural barriers, lack of access to preventive care, and the lack of health insurance for the heightened risk for cardiovascular disease faced by many Hispanic and non-Hispanic Black people. A 2020 article in the Journal of the American Heart Association noted that African-born Black immigrants in the U.S. have fewer risk factors for heart disease than their U.S.-born African American counterparts. However, African-born immigrants were also less likely to have health insurance, and without health insurance or a place to go when sick, immigrants often don’t access preventive care and screening for high blood pressure, diabetes, and heart disease until it is too late. The researchers in this study concluded that until data is separated by different subgroups instead of a single “African American” category, it is impossible to get an accurate picture of heart disease risk factors for individual groups. 

The two main ethnic groups in the United States are classified as either “Hispanic or Latino” or “not Hispanic or Latino.” Hispanics and Latinos trace their origins to Spanish-speaking countries. But they can belong to the white, Black, Native American, or Asian races. Prior to COVID-19, heart disease was also the leading cause of death among Hispanic adults in the U.S. Research shows that Hispanics and Latinos have heightened rates of obesity, diabetes, and other cardiovascular risk factors.  

However, how such risk factors for heart disease vary among subgroups of minorities and immigrants in the U.S – beyond the major racial and ethnic categories used to collect health data – is not yet clear. The Maine Center for Disease Control and Prevention (Maine CDC) does not collect data specific to the immigrant groups living here, a practice that resembles that of most other states. It does use for data collection for the categories of: American Indian or Alaskan Native, Asian, Black or African American, more than one race, Hawaiian or Pacific Islander, white, Hispanic, or non-Hispanic.  

Benjamin Hummel, Community Health Worker Project Coordinator at the Maine CDC, and Ian Yaffe, Director of the Maine CDC’s Office of Population Health Equity, agree that this lack of data impedes the understanding of risks for heart disease – as well as prevention strategies – in immigrant and refugee populations.  

Risk factors for heart disease are high blood pressure, high cholesterol, smoking, unhealthy diet, diabetes, excessive weight and obesity, alcoholism, a sedentary lifestyle, high levels of stress, and a family history of heart disease or stroke. 

“Just because the data aren’t there to show that there is a disparity in heart disease doesn’t mean that there isn’t one. We don’t need to wait for the data to try to do something about the social determinants of cardiovascular disease.”

– Ian Yaffe, Director of Maine CDC Office of Population Health Equity 

All of the medical providers, public health officials, and representatives of community service organizations interviewed for this article are concerned about limited access to healthcare in communities of color limited language accommodation and interpreter services for immigrants, and housing and food insecurity. LD 718, slated for review by the Maine Legislature this session, would restore MaineCare to asylum seekers, if passed. This would address one of these social determinants. (Currently, adult asylum seekers are virtually unable to regularly access healthcare in Maine). 

Lori Kaley is Program Manager for Maine SNAP-Ed at the University of New England. SNAP-Ed provides nutrition education services in settings like schools, food pantries, Head Starts, and other child care settings, grocery stores, and regional DHHS offices for recipients of the Supplemental Nutrition Assistance Program (SNAP). As Kaley explained, stable housing is a priority. “It is nearly impossible to follow a low-salt, low-fat diet if you are temporarily housed in a hotel room and the only way you have to prepare meals is in a microwave.”