Cardiovascular disease (CVD) is a major cause of morbidity and mortality in women and men in the United States and globally.1 Within the cardiovascular healthcare and science communities, substantial attention including clinical and selected population-based efforts have focused on reducing the risk and burden of CVD and promoting cardiovascular health beginning early in life and extending across the life course.1 In 2010, the American Heart Association (AHA) advanced the concept of ideal cardiovascular health (ICVH), with a major goal of promoting cardiovascular health for children, adolescents, and adults in the United States.2 As defined in that oft-cited document, ICVH consists of 7 metrics and includes 3 physiologic health factors (optimal levels of blood pressure, total cholesterol, and fasting blood glucose) and 4 health behaviors (normal body mass index, nonsmoking, adequate physical activity, and healthful diet).2 Categorized separately for children/adolescents and adults, ideal levels of physiologic health factors and behaviors, as operationalized in 2010, were guided and informed by prevailing evidence-based guidelines.2 A recent scientific statement from the AHA suggested a reexamination of the metrics used for children, raising concerns about the suitability of using single thresholds to identify elevated cardiovascular risk throughout the childhood years.3 Most importantly, the statement emphasized primordial prevention and optimal cardiovascular health for all children and adolescents and also endorsed the life course approach.3

As originally advanced by Strasser,4 primordial prevention focuses on "prevention of the development of the risk factor in the first place." Relatedly, a report from a very recent National Heart, Lung, and Blood workshop reminds us that most individuals are born with ICVH and begin to lose that cardiovascular health status early in life.5 In a meta-analysis of genome-wide association studies, Allen and colleagues6 have shown that ICVH is only about 15% heritable, pointing to the importance of healthy lifestyle behaviors and primordial prevention. Clearly, a key component of primordial prevention strategies is the development and maintenance of health behaviors, including patterns of physical activity, dietary intake, and smoke-free lifestyles and environments. Viewed within a life course social-ecological framework, contexts that influence the development and maintenance of health behaviors are important targets for preventive interventions as well as multilevel policy initiatives that promote and facilitate healthy lifestyle patterns for more and less advantaged individuals and populations.7

Consistent with this perspective, social determinants of health emerge as critically important and inextricably linked with both individual/clinical and population-based initiatives designed to optimize cardiovascular health. The World Health Organization defines the social determinants of health broadly as "the circumstances in which people are born, grow, live, work and age, and [that] are shaped by the distribution of money, power, and resources at global, national and local levels."8 Some social determinants of health (ie, birthplace) are not modifiable, whereas others that are important contexts for optimizing cardiovascular health (ie, neighborhood, school, and workplace safety) are potentially modifiable.

The AHA embraced the World Health Organization definition in calling attention to the social determinants of risk and outcomes for CVD.9 In so doing, recommendations for interventions that change the context to make individuals' default decisions healthy were endorsed as having the potential for the greatest impact on population-wide health promotion and risk reduction.9 Most recently, the AHA issued a scientific statement underscoring the importance of housing as a social determinant of cardiovascular health and well-being.10 With a focus on addressing the pathway between housing and cardiovascular health, the authors concluded that housing conditions may be a direct driver of cardiovascular health and well-being, as well as being intermediate in the pathway between upstream social and economic disadvantages and downstream cardiovascular health outcomes.10 Particularly noteworthy are recommendations offered for multilevel efforts that promote optimal housing conditions that contribute to ICVH outcomes and the need to engage in public policy with goal of improving housing conditions in the United States.10

Underscoring the importance of efforts focused on upstream social determinants such as social structures and policies in improving population health is a recent review by Thornton and colleagues.11 Of note, as highlighted in that review, there is sufficient evidence to support policy interventions targeted at improving selected modifiable social determinants of health, particularly education and early childhood as well as urban planning and community development, housing, income enhancements and supplements, and access to employment.11 Challenges to the implementation of such interventions remain, including the need for long-term financing to scale up effective interventions for implementation at local, state, and national levels. Effective implementation will require political will, government investment, as well as social welfare reforms, such as universal access to high-quality early childhood education programs, access to affordable housing that is commensurate with demand, and efforts to increase housing mobility that are coupled with effective strategies for revitalizing neighborhoods.11

Taken together, accumulated data support the importance of addressing the social determinants of health as part of primordial prevention, with the ultimate goal of optimizing cardiovascular health across the life course for more and less advantaged individuals and populations. Evidence and anecdotal observations strongly support the importance of multilevel policies designed to create and sustain contexts including families, schools, worksites, and communities enabling the adoption and maintenance of healthy lifestyle behaviors and reduction of adverse environmental exposures. Clearly, science/evidence guides and informs policy, and instrumental strategic advocacy efforts on many levels are essential for implementation. As the largest group of healthcare professionals in the United States, nurses must advocate for the development and implementation of policies designed to mitigate adverse social influences and promote optimal cardiovascular health across the life course of individuals and populations.

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