Why where you live matters for heart health — even in childhood
Atherosclerotic cardiovascular disease (ASCVD), commonly known as heart disease, is still the No. 1 cause of death in the U.S. and the world, despite the huge gains made in modifying known risk factors. Growing evidence shows a link between environmental exposures at all stages of life, including airborne particulate matter, heavy metal exposures, climate change and microplastics, and the development of ASCVD. Environmental exposures affect cardiovascular health through mechanisms including increased oxidative stress, altered metabolic demands, and disruptions to supply chains and healthcare delivery, as summarized in our article. Environmental health runs in parallel with social drivers of health and therefore disproportionately affects marginalized communities.
As pediatric cardiologists focused on preventing ASCVD throughout the life course, we recently wrote a narrative review examining the relationship between environmental exposures and ASCVD risk in youth, using Native Americans (identified in the paper as American Indian/Alaska Native (AI/AN)) as an illustrative example.
Cardiovascular disease (CVD) is the leading cause of death for AI/AN people. In addition to traditional cardiovascular disease risk factors, unique historical contexts, including land allocation and relocation, and specific exposures, such as mining waste, may increase the risk of CVD in AI/AN communities.
Emerging research suggests that AI/AN youth have increased exposure to microplastics and endocrine-disrupting chemicals, often through contaminated waterways. They are also more likely to be exposed to outdoor air pollution and to indoor pollutants due to reliance on solid fuels for heating and cooking. AI communities are also more likely to experience heatwaves and work outdoors, with the highest increase in heat-related mortality between 2000 and 2023 among AI/AN people. 
At the same time, disruptions to traditional food systems have driven increased reliance on commodity foods, which are high in sodium, sugar, and fat, thereby increasing risks of cardiometabolic risk factors for CVD. Finally, exposure to abandoned mining sites and subsequent groundwater contamination has resulted in disparate exposures to arsenic, uranium, tungsten, mercury, and cadmium, which have been associated with the development of CVD.
Our work underscores the urgent need for continued research and targeted interventions to both decrease exposures and mitigate consequences in AI/AN communities. This review also complements our ongoing research using the Strong Heart Family Study, the largest longitudinal cohort study of CVD risk factors in AI people, to better understand how environmental factors shape cardiometabolic risk in AI youth.
Ultimately, we highlighted the links between environmental exposures and ASCVD to identify important ways to improve the health of AI/AN youth and to illustrate the potential role of policy decisions in ASCVD health throughout the life course. Protecting cardiovascular health must extend beyond the clinic with policies that ensure clean air, safe water, and healthy environments for all children.
By Drs. Joe Burns, clinical Instructor, pediatric cardiology; Emily Masterson, fellow physician, pediatrics – cardiology; and Justin Zachariah, associate professor in pediatrics – cardiology Baylor College of Medicine/Texas Children’s Hospital
