Young Stroke Risk Factors Include Social Determinants and Race

“Everyone is talking about young stroke,” said Lakeisha M. Mixon, MSW, LCSW-C, and understanding the racial and ethnic differences in risk factors is an important part of that conversation. Mixon is a health program manager at the University of Maryland School of Medicine and she presented at this week’s International Stroke Conference, held by the American Heart Association.

Stroke is currently estimated to be the eighth leading cause of death in the US for people aged 25 to 45, and the incidence of ischemic stroke in young adults is estimated to be higher among Black and Hispanic individuals compared with white individuals. Mixon gave an overview of young stroke, including some of the known differences in risk factors by race/ethnicity, and how physicians can begin to address those differences and close the gap on risk.

Increased Risk of Young Adult Stroke

One way to address young stroke concern is by looking at the underlying risk factors, such as hypertension, obesity, and diabetes – all of which have increased prevalence in Black and/or Hispanic young adults compared with white young adults. For example, Mixon cited a study that showed that the rate of adults with diabetes diagnosed before age 40 was 35% for Mexican Americans and 25% for African Americans compared with only 14.4% in white young adults.

In addition to these health conditions, several lifestyle choices can put young adults at increased risk. These include smoking and alcohol consumption, which are often glamourized in targeted marketing and advertising, or ingrained in the social norms or attitudes of certain races or ethnic groups, noted Mixon.

Social Determinants in Stroke Risk

A person’s social determinants of health (SDOH) can also affect stroke risk. SDOH include conditions in which people are born, grow, live, work, and age, and each of these shapes health outcomes, Mixon said.

She broke down SDOH into three categories: upstream, midstream, and downstream. Upstream SDOH are those with community impact and can include things like socioeconomic status of the community, available education, and the physical environment.

“When we look at race/ethnic differences, most of the time SDOH are driven by structural racism,” Mixon said.

Midstream SDOH are those things related to an individual’s social needs.

“We have found that young people who experience food insecurity are more likely to suffer health problems like elevated blood pressure or prediabetes,” Mixon said.

Finally, downstream SDOH are those that have an immediate impact on a person’s healthcare such as clinical care, health literacy, medication adherence, and health behaviors.

When addressing stroke risk in young patients, it is important for physicians to assess not only health risk factors, but also to put those risk factors in context of a person’s SDOH to gain a more complete picture of that person and their risk.

Commenting on the topic, Mary Ann Bauman, MD, current American Heart Association president for the Western States region board of directors and a primary care physician, said that primary care physicians are always trying to convince patients to make the lifestyle changes that will reduce risk.

“This is especially challenging in young people who have many competing priorities,” Dr. Bauman said. “Adding to that, African American and Hispanic young adults’ risks are negatively impacted by historic and present-day factors outside of their control.”

Closing the Gap in Racial and Ethnic Stroke Risk

There are a range of methods that providers can adopt to begin to try to close the gap on stroke risk tied to racial and ethnic differences. One approach employed by Mixon is Person-in-Environment framework, which is based on the belief that an individual can only be understood in the context of their environment.

The Strengths-Based Perspective is another valuable way to address stroke risk factors, she said. This approach puts the strengths and resources of people and their environments or communities at the center of the helping process rather than focusing on their problems or pathologies.

“Everyone has a strength that can be built upon that can help with health outcomes and goals,” Mixon said. “It is good to use a strength-based perspective when working with African American families and communities because historically their voices have been silenced.”

Finally, a trauma-informed care approach changes the focus from “What’s wrong with you?” to “What happened to you?” This approach acknowledges the impact of structural inequality and is responsive to the unique needs of a diverse community whether that is represented by gender, culture, race, or religion.

“This can only be accomplished by addressing one’s own biases and providing inclusive spaces for patients,” Mixon said.

Dr. Bauman agrees that these techniques are useful for providers. “We can recognize the patient’s strengths while acknowledging the added risk and challenges imposed by the social determinants of health and structural racism,” she said.