How Social Determinants Shape Cardiac Aging More Than Traditional Risk Factors
Introduction
Heart disease remains the leading cause of death worldwide, despite decades of progress in prevention, diagnosis, and treatment. Traditionally, cardiovascular risk has been evaluated through clinical markers such as blood pressure, cholesterol levels, diabetes status, smoking history, and body mass index. While these factors are undeniably important, they do not fully explain why some individuals experience accelerated cardiac aging while others maintain relatively healthy hearts well into old age.
A growing body of research suggests that the answer lies beyond biology alone. The environments in which people live, work, and age play a critical role in shaping cardiovascular health. These conditions are collectively referred to as social determinants of health, or SDoH.
A landmark study published in Mayo Clinic Proceedings in December 2025 provides one of the most comprehensive examinations to date of how social determinants interact with traditional risk factors to influence cardiac aging and mortality. Using artificial intelligence–enhanced electrocardiograms and advanced statistical modeling, researchers demonstrated that social determinants have a stronger impact on cardiac aging than many conventional clinical factors.
This article breaks down the study’s findings, explains what cardiac aging really means, and explores why addressing social conditions may be one of the most powerful tools for improving heart health at both individual and population levels.
What Is Cardiac Aging and Why It Matters
Aging is not simply a function of the calendar. Two people of the same chronological age can have very different levels of physiological health. This discrepancy has led researchers to focus on biological aging, which reflects how well organs and systems are functioning relative to age expectations.
Cardiac aging refers specifically to age-related changes in the heart and cardiovascular system. These changes may include:
- Thickening of the heart muscle
- Reduced elasticity of blood vessels
- Electrical conduction abnormalities
- Declining efficiency of cardiac output
Accelerated cardiac aging is associated with higher risks of heart failure, arrhythmias, stroke, and premature death.
Measuring Cardiac Aging With AI-Enhanced ECG
The Mayo Clinic study used artificial intelligence–enhanced electrocardiography, or AI-ECG, to estimate cardiac age. This technology analyzes raw 12-lead ECG data and predicts an individual’s biological heart age. The difference between AI-estimated age and chronological age is called the cardiac age gap.
- A positive age gap indicates accelerated cardiac aging
- A negative age gap suggests healthier-than-expected cardiac aging
Previous research has shown that larger positive gaps are associated with higher cardiovascular and all-cause mortality.
Understanding Social Determinants of Health
Social determinants of health are the nonmedical factors that influence health outcomes. They shape daily behaviors, access to care, stress exposure, and long-term disease risk.
In this study, researchers evaluated nine domains of social determinants:
- Financial strain
- Food insecurity
- Housing instability
- Transportation needs
- Education level
- Nutrition quality
- Physical activity
- Social connection
- Stress levels
Each domain was assessed using validated patient questionnaires integrated into routine clinical intake.
Study Overview and Methodology
Study Population
- Total participants: 280,323 adults
- Age range: 18 to 90 years
- Average age: 59.8 years
- Female participants: 50.8 percent
- Study period: 2018 to 2023
All participants completed a social determinants questionnaire and had a clinically indicated ECG within one year.
Key Methods Used
- AI-ECG to estimate cardiac age
- Structural equation modeling to assess complex interactions
- Cox proportional hazards modeling to evaluate mortality risk
This approach allowed researchers to simultaneously examine biological, demographic, and social influences on cardiac aging.
Baseline Characteristics of the Study Population
| Category | Key Findings |
|---|---|
| Average BMI | 28.8 kg/m² |
| Hypertension | 33 percent |
| Diabetes | 11.9 percent |
| Ever smokers | 22.7 percent |
| Financial strain high risk | 3.99 percent |
| Food insecurity high risk | 6.8 percent |
| Physically inactive | 25.9 percent |
| Socially isolated | 65.3 percent |
These data highlight that even within a largely insured and healthcare-engaged population, social vulnerabilities were common.
The Most Powerful Predictors of Cardiac Aging
Social Determinants Outweigh Traditional Risk Factors
One of the most striking findings of the study was that social determinants collectively had the strongest association with cardiac aging, surpassing comorbidities and demographic variables.
A higher overall social determinants score, which reflects more favorable social conditions, was associated with significantly lower cardiac age gaps.
Top Social Contributors to Accelerated Cardiac Aging
| Social Determinant | Impact on Cardiac Aging |
|---|---|
| Financial strain | Strongest negative influence |
| Food insecurity | Second strongest influence |
| Housing instability | Significant contributor |
| Transportation barriers | Moderate contributor |
| Chronic stress | Independent contributor |
Financial strain alone showed a stronger association with cardiac aging than smoking, obesity, or diabetes in the statistical models.
Traditional Risk Factors Still Matter
While social determinants emerged as dominant predictors, traditional risk factors remained important contributors.
Among clinical conditions, hypertension showed the strongest association with accelerated cardiac aging, followed by:
- Chronic kidney disease
- Diabetes
- Congestive heart failure
- Peripheral vascular disease
Higher BMI and smoking history were also independently associated with increased cardiac age gaps.
Differences by Sex and Race
Sex Differences
- In both men and women, financial strain and food insecurity were the most impactful social determinants
- In men, social determinants had a slightly stronger effect than comorbidities
- In women, social and medical factors contributed almost equally
Racial and Ethnic Disparities
African American participants exhibited higher cardiac age gaps compared with non-Hispanic White participants, even after adjusting for clinical risk factors. This finding aligns with broader evidence linking structural inequities to cardiovascular disparities.
Social Determinants and Mortality Risk
Beyond cardiac aging, social determinants were also powerful predictors of survival.
Mortality Risk Highlights
| Factor | Hazard Ratio |
|---|---|
| Financial strain | 1.6 |
| Housing instability | 1.18 |
| Smoking | 1.27 |
| Prior myocardial infarction | 1.1 |
In some cases, social stressors posed equal or greater mortality risk than well-established medical conditions.
Why Financial Strain and Food Insecurity Matter So Much
Financial Strain
Economic instability affects health through multiple pathways:
- Reduced access to preventive care
- Increased chronic stress
- Limited ability to afford medications
- Poorer nutrition and physical activity opportunities
Large population studies have consistently linked income to life expectancy and cardiovascular outcomes.
Food Insecurity
Food insecurity often leads to reliance on calorie-dense, nutrient-poor foods. This dietary pattern increases the risk of obesity, diabetes, hypertension, and inflammation, all of which accelerate cardiovascular aging.
Implications for Healthcare and Public Policy
The findings of this study have profound implications:
- Clinical care must expand beyond biology
Routine screening for social determinants should be integrated into cardiovascular risk assessment. - Prevention strategies must be community-focused
Addressing housing, food access, and economic stability may yield greater benefits than medication alone. - Health equity requires structural change
Reducing disparities in cardiac aging requires policy interventions that address systemic inequality.
Limitations of the Study
While robust, the study has limitations:
- Observational design limits causal inference
- Predominantly non-Hispanic White population
- AI-ECG model validated primarily within Mayo Clinic settings
- Cause-specific mortality data were unavailable
Despite these limitations, the large sample size and advanced methodology strengthen the conclusions.
Conclusion
This landmark research reshapes how we understand heart aging. It demonstrates that the conditions in which people live have a profound influence on how their hearts age and how long they live. Financial strain and food insecurity emerged as more powerful predictors of cardiac aging than many traditional clinical risk factors.
For clinicians, policymakers, and individuals alike, the message is clear: improving cardiovascular health requires addressing social realities alongside medical treatment. The heart does not age in isolation. It ages within the context of daily life.
Sources
- Rajai N et al. Mayo Clinic Proceedings. December 2025
- U.S. Census Bureau Population Projections
- American Heart Association Scientific Statements
- National Health and Nutrition Examination Survey
- World Health Organization Social Determinants of Health
Medical Disclaimer
This article is for informational and educational purposes only and does not constitute medical advice. It is not intended to replace professional diagnosis, treatment, or consultation with a qualified healthcare provider. Always seek the advice of your physician or other qualified health professional regarding any medical condition or health decision.