Social Determinants of Health, Cardiovascular Health, and Mortality in Sexual Minority Individuals in the United States

Abstract

Background: Despite recent efforts to address health disparities regarding social determinants of health (SDOH), the intersection between SDOH and cardiovascular health (CVH) outcomes in sexual minority (SM) individuals remain largely underexplored.

Objectives: This study sought to investigate associations between SDOH profile and CVH and mortality outcomes among SM individuals in the United States.

Methods: All participants aged ≥18 years surveyed in the 2013 to 2017 National Health Interview Survey were included, except those with missing data on SM status, any CVH or SDOH domain, or any other covariate. SM status was self-reported and categorized as lesbian/gay, bisexual, or uncertain. Participants' SDOH profile was quantified using a 6-domain (economic stability, neighborhood/physical environment/social cohesion, community and social context, food, education, and health care system), 38-item score, with higher scores indicating greater social deprivation. CVH was adapted from the American Heart Association's Life's Essential 8 framework. Because detailed dietary data were unavailable, a 7-item (hypertension, diabetes mellitus, hypercholesterolemia, smoking, physical inactivity, inadequate sleep, and obesity) CVH score was used, with higher scores indicating worse CVH. Additionally, cardiovascular mortality was ascertained through the National Death Index using death certificate information.

Results: The study sample consisted of 57,182 participants, representing a population of 82,826,690 persons. A worse composite SDOH score was associated with a worse CVH score in both heterosexual (adjusted rate ratio: 1.14; 95% CI: 1.13-1.15; P < 0.001) and SM individuals (adjusted rate ratio: 1.16; 95% CI: 1.12-1.20; P < 0.001), with associations appearing to be potentially stronger in the latter (P_interaction = 0.042). Subgroup analysis demonstrated consistent associations among gay/lesbian individuals and bisexual individuals, but not in those with other or uncertain sexual orientations. Further exploratory analysis showed that a worse composite SDOH score was significantly associated with higher risk of cardiovascular mortality in both heterosexual (adjusted HR: 1.17; 95% CI: 1.06-1.28; P = 0.002) and SM individuals (adjusted HR: 2.25; 95% CI: 1.24-4.08; P = 0.008), with associations being significantly stronger in the latter (P interaction = 0.006).

Conclusions: An unfavorable SDOH profile was associated with worse CVH scores and higher cardiovascular mortality risk among SM individuals in the United States compared to their heterosexual counterparts.

Keywords: cardiovascular disease; cardiovascular health; sexual minority; social determinants of health.