Chronic disease, planetary social thought, and social epigenetics

In addition to physical environmental challenges, the Anthropocene has ushered in complex societal changes, bringing with them new understandings of disparities in health. Recent literature has begun to systematically and empirically underscore the role of the biopsychosocial in the presentation of these patterns, often referred to as social epigenetics¹.  Systemic lupus erythematosus (SLE, or lupus) is a chronic autoimmune condition uniquely gendered, racialized, episodic, invisible and idiosyncratic, primarily impacting women, and most severely, women of colour. Cardiovascular disease (CVD) is a main driver of morbidity and mortality among SLE populations². CVD risks and outcomes are conceptualized as biopsychosocial, and concomitant with place³, standing to compound existing health inequities in SLE. However, such biological-social mechanisms are not well understood. This paper presents the results of an investigation of the role social factors play in the development of CVD among SLE populations and how this varies according to place.

Drawing on biosocial theory, feminist geographies, and the social determinants of health (SDOH) framework, a scoping review was conducted according to PRISMA⁴ guidelines using Covidence software. An integrated knowledge translation (iKT) approach included knowledge users throughout the process⁵. A search strategy was developed in collaboration with a university librarian to capture all terminology related to SLE, SDOH, and CVD. Four databases were searched: PubMed, Scopus, CINAHL, and PsychINFO. Peer-reviewed articles in English were retrieved from years 2000-2022. All records were imported into Covidence. 682 studies were screened in duplicate using pre-determined inclusion/exclusion criteria. 7 studies met the criteria for data extraction and analysis. 

All 7 studies were conducted in the US using established SLE cohorts (6/7) or national health databases (1/7). Four employed a cross-sectional design, while three were longitudinal. Of the social factors examined, the influence of socioeconomic status (SES)/education and race/ethnicity on CVD in SLE were most often studied (4/7 each). Low SES was associated with increased cardiovascular risk⁶, while years of education were associated with decreased cardiovascular damage⁷ and subclinical disease⁸. Race/ethnicity was found to modulate this relationship⁶, with Black men⁹ and women¹⁰ at increased risk of CVD compared to their white counterparts. Black women with SLE were younger at hospital admission for CVD and hospital-related death due to CVD¹². Mental health was explored less often; two studies found that depression, in particular, was associated with increased subclinical¹³ and clinical⁸ CVD. Several studies examined included gender as a social variable: two studies found increased cardiovascular damage among men^7,9 while others limited their analyses to women only^8,10,12. However, distinctions between gender and biological sex were not made explicit, limiting social-contextual interpretations.

This review reveals significant relationships between social factors - including SES, education, race/ethnicity and mental health - and CVD in SLE, which compound existing SLE health disparities. However, substantive gaps remain as many social factors described herein remain understudied (e.g. gender, race) and others remain unexplored (e.g. employment, cultural factors, healthcare access, etc.). These results call for extended investigation of this social-biological interplay in SLE, in additional geographic contexts, and for more robust theorizations of intersectionality to inform this inquiry.