Dyslipidemia

How to Improve Dyslipidemia Care in Underresourced Populations

Laurence Sperling, MD; Karol E. Watson, MD, PhD

Disclosures

November 15, 2021

This transcript has been edited for clarity.

Laurence Sperling, MD: Welcome to Medscape's InDiscussion series on dyslipidemia. This is episode three. Today we'll be focusing on the impact of social determinants of health on lipid management, a critically important topic.

I'd like to start off with a case that I think is relevant. This is a case of Mrs S who's 62 years old. She's a Black Hispanic woman treated for diabetes and metabolic dyslipidemia. She's a former smoker with stable lower extremity peripheral arterial disease. She's had challenges consistently adhering to her medication regimen of a high-intensity statin and aspirin and metformin.

She is first generation in this country and predominately speaks Spanish. Review of her current social situation is notable for temporary housing, food insecurity, and transportation issues. You learn that she's concerned about her vascular risk given that her mother died of a heart attack at age 65. She's requesting your advice and becomes tearful. I ask our listeners, how would you manage a case like this?

Today we have Dr Karol Watson who is a professor of medicine and cardiology. She's co-director of the UCLA Program in Preventive Cardiology. She's also the director of the Barbra Streisand Women's Heart Health Program at the David Geffen School of Medicine at UCLA, and the John Mazziotta, MD, PhD, Term Chair in Medicine. Karol, welcome today to InDiscussion.

Karol Watson, MD, PhD: Thank you so much Larry. It's really great to be here. And thank you for holding this so important conversation.

Sperling: Well, people know you across the country as an expert in preventive cardiology, a champion for all the spaces that you're in. So you are juggling a lot there at UCLA, but we want to learn something about you that many people might not know. Tell us a fun fact about Dr. Karol Watson.

Watson: Oh, fun fact: I used to be a professional dancer.

Sperling: Wow, so what type of dancing?

Watson: I did modern dance. I was with the Alvin Ailey Academy in New York, and then after a very fun, exciting, brutal, painful year, I decided medicine was easier.

Sperling: Hopefully you're still dancing on the side a little bit. We know we want to keep our heart healthy as we serve others in preventive cardiology. So I think a good way to start might be just to help our listeners better understand some important concepts. I'd like you to help them understand what is health equity, what are health-related disparities, and how do we conceptualize the social determinants of health?

Watson: So a lot of different questions, all very important and related. Health equity means everyone has exactly what they need to live as healthful a life as they can. If I start off with excellent health, excellent home security, income, and food security, I don't need a lot. Maybe I need just to make sure I get my insurance and everything's fine. But if I start out homeless, food insecure, and have poor health habits, I'm going to need a lot more support. Health equity means giving everyone the support they need to be as healthy as they can.

Sperling: And then what about just health disparities? How do we think about that in the context? Is that lack of health equity? Or is it different?

Watson: That's a good question. Disparities are not merely differences in health status; sometimes these differences are due to genetics or other things. The term "disparities" implies that these differences are unjust. They're due to lack of good housing, lack of access to medical care, and lack of money to afford medications. Any time there's a health difference that's unjust, it's due to disparities.

Sperling: Coming back to social determinants of health, how do they really play into cardiovascular risk?

Watson: One of the things that's most humbling, I think, for physicians is to realize that most of a person's health status has less to do with the interventions we do as physicians and more to do with the social determinants of health. How we live, what we eat, where we can exercise, how much discrimination we face. These are the social determinants that determine how well our patients are going to do.

Sperling: I think that's a really important point. We often think that health and prevention occur during these 15-minute office visits. When we have a patient in the hospital, for instance, we can impact their health and well-being, but we need to think way beyond our traditional medical models and reach out to our communities and understand how we can interface and hopefully move the bar on a population level.

Sperling: For our listeners, hopefully they're very familiar with the American College of Cardiology/American Heart Association (ACC/AHA) Risk Estimator. Or the Risk Estimator Plus. What's absent in the estimator is exactly what you just outlined for us. We put in age, sex, ethnicity, and traditional heart risk factors, but it doesn't capture those social determinants. How can we do a better job as clinicians in what we ask our patients, and should this be built into the risk estimator?

Watson: That's a great question Larry. Unfortunately, the risk estimator, which I was involved with developing, is constrained by the data we have to put into it. And so one of the big steps forward in this risk estimator was including race. Race is a social construct. It is not based in biology or genetics, but many clinical conditions do segregate along racial lines. So race is a very crude proxy. We're trying to understand some of these social determinants.

We understand it's not perfect — it's not perfect at all. But right now, it's the best we have. What we have to do is get better research collecting data on things like health disparities, social determinants. Unfortunately, these are hard things to measure. One person's experience of discrimination is different from someone's else. One person's experience of stress may be activating, another person's experience maybe deflating or demoralizing. These are really hard concepts.

Sperling: Now, the 2018 ACC/AHA multi-specialty cholesterol guideline has called out risk-enhancing factors — chronic inflammatory diseases, certainly in women, that pose challenges in and around the time of pregnancy, like gestational diabetes, preeclampsia, etcetera.

Should we as clinicians, as we get to know our patients beyond just their traditional risk factors, think about these social determinants of health as risk-enhancing factors? And there is an index called the Social Vulnerability Index. Is there a way we can start capturing that, to not only learn about how we can better care for our patients but also better appreciate their risk?

Watson: I definitely believe that we have to, in every encounter, think about the social determinants. You cannot care for a patient without understanding the world they live in. I can't ask you to eat five servings of fruits and vegetables a day when you're living on a fixed income.

I had a patient say to me, "How can I do that? I have a limited number of dollars I can spend. If I buy those grapes or those apples, they're going to waste in my refrigerator and then I can't eat for the rest of the month." We have to understand where our patients are coming from. I wish there was an easy index that could capture that all in a perfect way, but there's not. I do think right now that even asking the questions, paying attention, and introducing the discussion is an important thing to do for our patients.

Sperling: We know some of these social determinants, as you said, are where we live, where we work, where we spend our time, where we were born, and the lives that we encounter across our journey. We know that living in areas of food insecurity or what sometimes are referred to as food swamps, they are a little bit different, but they're connected in terms of risk. Transportation challenges, housing issues, and language barriers can be predictors of negative risk.

And so I'm wondering, how do you ask your patients about these things? I guess we're used to asking patients about their smoking habits, exercise, and diets, and we learn about their family histories, but how do you reach out and ask these questions?

Watson: What's important is to ask the questions and ask them in a nonjudgmental, very open way. As part of your physical activity history, find out if they live near healthy places to exercise. As part of their dietary history, find out if they are able to eat healthy food, if they're food insecure, and things like that. I remember a conversation I overheard with some colleagues once, really judgmentally complaining about a patient who came into their clinic visit carrying a McDonald's bag.

I get it. We want our patients to eat healthy all the time. But I had a patient say to me once, "I do go to McDonald's for my breakfast. I know I can get a hot cup of coffee and get free Wi-Fi. I can get full for $1.50; there's nowhere else I can do that."

Once you think about their life from their point of view, you start to think about everything differently. I don't say they cannot go to McDonald's. I say let's try to do it in a healthy way. These are some food choices. These are some options.

Sperling: Well, this is a lipid-related podcast, so are there any special considerations for lipid-related medical therapy adherence that are related to our discussion today? Or any specific lipid-related risks we should think about related to these social determinants of health?

Watson: Accessing the medical care system so they can get plugged in, getting their lipid panel measured, and making sure they can access drugs, which now are mostly generic. And making sure we give them tools to help them adhere. I am a firm believer that people want to do the right thing.

We can make sure they get their 3-month supply of statin that's automatically refilled. Make sure that there's a way that everyone can access the care they need.

Sperling: I know you live and practice in Los Angeles, and I'm sure you're exposed to many different ethnicities and cultures and languages. You talked about asking, listening, and partnering. How do we do that when we don't speak the same language as our patients? How do we do that when we're not part of that culture or ethnicity? Are there any tips you can give?

Watson: Language concordance is so important. I spent a summer in Mexico when I was in college learning Spanish. And patients appreciate it so much.

There's always a way I think as people we can connect. We don't come from the same community or the same culture, but there's something that we probably can connect on, and a lot of it can deal with their health.

Sperling: So what can we do? You've described some of these really important concepts and challenges. What can we do on the level of a clinician or a health system? How can we be helpful and contribute to bridging these gaps in health equity?

Watson: One of the most important things we can do as individual clinicians is that we can all make sure, as much as we can, to keep our biases in check. Every human being has biases. They are sometimes explicit, but much more commonly, they're implicit. How many times have you heard someone say, "So-and-so is a 65-year-old male who's noncompliant or nonadherent?"

How about we rewrite that script? We can say, "So-and-so is a 65-year-old male who has difficulty obtaining his medications because he lost his job," or something like that. Very few people are making an appointment to go to see their doctor, taking time off work, and paying their copay just to not listen to what you say. People want to do the right thing.

Sperling: Yeah. There are many hurdles, and we want to understand those better.

Let's come back to our case. Mrs S is 62 years old. She's a Black Hispanic woman, she's diabetic, and she is in a metabolic dyslipidemic state. She has peripheral artery disease, and she tells us that she's had some trouble keeping her usual medication regimen on track. A lot of her trouble taking the high-intensity statin, aspirin, and metformin has to do with these social determinants. She speaks predominately Spanish, and she lives in temporary housing in an area of food insecurity. She also has transportation issues.

Give us some guidance. How do you listen, and how do you begin to set a course for improvement in her care together? Also, how do you create that trusting environment where you know she's going to come back to see you again?

Watson: Well, you said so many things that we could dive into. One of the most important is that she's housing and food insecure. I can tell you, almost no one will think about their medication if they don't know where their next meal is coming from. We have to make sure to try to get her whatever services she needs to make sure that happens. That's a big, big ask for busy clinicians, but every health system has a social work or other agency in their environment where they could access this. That's really important.

But it's also important to just acknowledge. And most — like I said — most people want to do the right thing. Have someone who can speak to her in her language about why this is so important that she take her medication. Everybody has a "why." That "why" is usually kids, grandkids, spouse, or friends. Whatever her "why" is, make sure you figure out how you can make that important connection between her "why" — little Susie, her grandchild — and taking her statin; for example, being around to see little Susie turn 16.

Sperling: So listen, and listen for the "why." Thankfully Mrs S's clinical care team listened. They learned about her concerns and challenges with the help of a Spanish-speaking staff member to interpret. Then, her primary care physician discussed how her medications could help prevent premature death, addressed her questions, and referred her to a community support program with a bilingual staff.

Today we've had a national expert, Dr. Karol Watson, discussing the crux of care — understanding our patients beyond just their medical issues. We've talked about the importance of focusing on health equity, the impact of health disparities, and social determinants of health in cardiovascular disease prevention and lipid management. So Karol, thanks for joining us.

Watson: Thank you so much, Larry.

Sperling: Another important topic today for InDiscussion. Keep an eye out for our next episode, which will be on the top take-home messages from the 2018 cholesterol guidelines with Dr Neil Stone. He's the Robert Bonow Professor of Medicine at Northwestern and co-chair of the 2018 Cholesterol Guideline Writing Committee. This is Dr Laurence Sperling for InDiscussion.

Resources

2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol

Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease

New AMA Policies Recognize Race as a Social, Not Biological, Construct

Race/Ethnicity, Neighborhood Socioeconomic Status and Cardio-metabolic Risk

Disparities in Hypertension and Cardiovascular Disease in Blacks: The Critical Role of Medication Adherence

Racial and Ethnic Disparities in Heart and Cerebrovascular Disease Deaths During the COVID-19 Pandemic in the United States

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