COVID-19, Unhealthy lifestyle behaviors and chronic disease in the United States: Mapping the social injustice overlay

The commentary challenges the siloed approach to understanding health outcomes, arguing that they are shaped by complex, multifactorial relationships. It uses the COVID-19 pandemic as a case study, highlighting how pre-existing conditions like heart disease, exacerbated by unhealthy lifestyles, increased the risk of severe COVID-19 outcomes. The authors point to a previous commentary illustrating the overlap of COVID-19 deaths, unhealthy lifestyles, and heart disease deaths concentrated in the US Southeast. This geographic clustering suggests a syndemic—a combination of multiple epidemics—linking unhealthy lifestyle behaviors, chronic diseases, and COVID-19. However, the authors argue this syndemic is further complicated by socioeconomic factors, race, and health equity. Underserved communities and underrepresented minorities experienced disproportionately worse outcomes during the pandemic. This commentary expands on their previous work by mapping additional data from the CDC, including education levels, income, food assistance program participation, health insurance coverage, poverty rates, income inequality, and racial demographics. These maps reinforce the concentration of negative health indicators in the Southeast, disproportionately impacting Black/African American communities. The commentary posits a hypothesis that unhealthy lifestyles increase the risk of chronic diseases and severe COVID-19, and that social determinants of health (low income, education, poverty, lack of insurance, minority status) increase the likelihood of these unhealthy lifestyles and poorer health outcomes.

The commentary cites several previous publications by the authors and others, supporting the link between unhealthy lifestyles and increased risk of chronic diseases and severe COVID-19. They reference studies demonstrating racial and ethnic disparities in COVID-19 outcomes and the role of social determinants of health in shaping health disparities. The Framingham Heart Study is mentioned as a landmark study identifying cardiovascular disease risk factors but also highlighted as insufficient to address the population-level interventions needed. The authors refer to their own prior work on healthy living strategies, the concept of a "healthy living polypill," and the need for causal systems mapping to understand the complex interactions driving the syndemic.

The methodology of this commentary is primarily descriptive and visual. The authors utilize maps generated from CDC data to illustrate the geographic distribution of several social determinants of health and health outcomes across the United States. These maps visually represent the prevalence of factors like lack of high school diploma, median household income, food stamp recipients, lack of health insurance, poverty, income inequality, and the percentage of Black/African American population. The data is presented visually to highlight geographic correlations and disparities. The commentary uses these visualizations to support the authors' argument about the overlapping nature of the syndemic and the role of social injustice.

The key findings, presented visually through maps (Figs. 1-7), demonstrate a strong geographic clustering of negative health indicators in the Southeastern United States. These indicators include low educational attainment, poverty, reliance on food assistance programs, lack of health insurance, high rates of poverty and income inequality, and a high percentage of Black/African American residents. The overlap of these indicators with the previously established geographic clustering of COVID-19 deaths, unhealthy lifestyles, and heart disease mortality strengthens the authors' argument for a syndemic driven by social injustice. This geographic concentration is presented as evidence for a "Syndemic Hotspot" requiring urgent attention. The commentary highlights the disproportionate impact on Black/African American communities, emphasizing the social injustice aspect of the syndemic. The findings suggest a causal pathway where social injustice contributes to unhealthy lifestyles, leading to chronic diseases and poorer COVID-19 outcomes.

The discussion section reinforces the need to move beyond a siloed understanding of health and address the underlying social factors contributing to the syndemic. The authors emphasize the urgent need for large-scale, population-based interventions and policy changes to address social injustice and promote health equity. They suggest the use of causal systems mapping as a valuable tool to understand the complex interactions driving the syndemic and to inform the development of effective interventions tailored to specific communities. The commentary underscores that a "one-size-fits-all" approach will be insufficient, highlighting the need for community-specific solutions that address the unique local factors contributing to unhealthy lifestyles.

The commentary concludes by emphasizing the need to recognize and address the syndemic of unhealthy living, chronic disease, COVID-19, and social injustice, particularly focusing on the “Syndemic Hotspot” in the Southeastern United States. It calls for a shift from reactive to proactive, primary prevention strategies focusing on healthy living and addressing systemic inequities through policy changes and community-specific interventions. Causal systems mapping is highlighted as a critical tool for understanding complex interactions, enabling the design of effective, targeted interventions. The authors advocate for large-scale longitudinal prevention trials funded at the federal level.

The commentary's primary limitation is its descriptive nature. While the maps present compelling visual evidence, they do not establish definitive causal relationships. The study relies on correlational data and does not include detailed qualitative data that would provide a richer understanding of the social and cultural factors driving the observed disparities. Furthermore, the focus on the US Southeast might not be generalizable to other geographic regions facing similar challenges.