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

This commentary addresses a multifactorial syndemic in the United States linking unhealthy lifestyle behaviors, chronic disease, and COVID-19 outcomes, with an emphasis on the social injustice overlay. Building on prior mapping that showed co-location of unhealthy behaviors, heart disease mortality, and COVID-19 deaths in the southeastern U.S., the authors hypothesize that social determinants—lower education and income, poverty, lack of insurance, and racial inequities—contribute to higher prevalence of unhealthy behaviors and worse health outcomes. The purpose is to illustrate, via U.S. maps, how social injustice acts as a common source epidemic amplifying this syndemic, and to argue against siloed assessments of health.

The commentary references prior work showing: (1) U.S. mapping of one million COVID-19 deaths aligning with unhealthy lifestyle behaviors and heart disease mortality, with a southeastern U.S. epicenter; (2) evidence that unhealthy behaviors elevate risk for chronic conditions and severe COVID-19 outcomes; (3) studies documenting racial and ethnic disparities in COVID-19 infections, hospitalizations, and deaths; (4) the Framingham Heart Study’s establishment of cardiovascular risk factors; (5) calls for causal systems mapping and healthy living medicine (HL-PIVOT) as strategies for pandemic preparedness; and (6) position statements on integrating social justice into healthy living to address inequities. Collectively, these works support the view that social determinants and inequities intersect with lifestyle and chronic disease to shape pandemic outcomes.

Using Centers for Disease Control and Prevention (CDC) surveillance data, the authors generated U.S. maps depicting: (1) Percent of population without a high school diploma (ages 25+, 2015–2019); (2) Median household income; (3) Percent of population receiving Supplemental Nutrition Assistance Program (SNAP) benefits (2015–2019); (4) Percent of population without health insurance (under age 65, 2018); (5) Percent living below the poverty level (all ages, 2018); (6) An index of income inequality; and (7) Percent of the population who are Black/African American (non-Hispanic, all ages, 2015–2019). These maps were qualitatively compared to previously published maps of COVID-19 deaths, unhealthy lifestyle behaviors, and heart disease mortality. The approach is descriptive and ecological, intended to visualize co-location patterns rather than establish causality.

- Socioeconomic and racial indicators—low educational attainment, lower median income, higher SNAP participation, lack of health insurance, higher poverty rates, greater income inequality, and higher percentages of Black/African American residents—concentrate in the southeastern United States. - These patterns align with previously mapped hotspots of unhealthy lifestyle behaviors, chronic disease (e.g., heart disease), and COVID-19 mortality, suggesting a syndemic with a southeastern U.S. epicenter. - The authors posit a reasonable hypothesis: unhealthy lifestyle behaviors prime populations for poor outcomes from chronic disease and viral infection; populations with lower income and education, higher poverty and assistance needs, more uninsured, and higher representation of underrepresented minorities are more likely to exhibit unhealthy behaviors and experience worse outcomes. - The mapping underscores social injustice as a plausible common source epidemic contributing to the unequal distribution of adverse health outcomes.

The visual overlap of socioeconomic disadvantage and racial composition with unhealthy behaviors, chronic disease, and COVID-19 mortality argues against siloed interpretations of health. The findings support treating social injustice as a foundational driver that shapes lifestyle risks and disease burden. Recognizing this syndemic framework has implications for policy and practice: interventions must address upstream determinants (education, income, insurance coverage, food security) alongside promotion of healthy living. The authors advocate for causal systems mapping to uncover local, multifactorial causes of unhealthy behaviors, thereby informing targeted, context-specific interventions. Equity-focused policies and laws at state and local levels should aim to ensure benefits are experienced across populations irrespective of race, education, or socioeconomic status.

Maps presented here, combined with earlier mapping, make a compelling case for an unhealthy living–chronic disease–COVID-19–social injustice syndemic, with the southeastern U.S. as a hotspot. The authors call for immediate action: federally funded, large-scale longitudinal primary prevention trials; incorporation of healthy living medicine and supportive social programs; and embedding social justice as a core principle. Future research should employ causal systems mapping to elucidate local drivers of unhealthy behaviors and guide tailored interventions. One-size-fits-all solutions are unlikely to succeed; instead, community-specific strategies delivering the healthy living “polypill” (move more, sit less, eat nutritious foods, maintain healthy weight, and avoid smoking) are needed to improve health and pandemic preparedness.

This work is a commentary using descriptive, ecological mapping of publicly available CDC indicators; it does not conduct formal statistical or causal analyses. The qualitative overlay of maps may be subject to ecological fallacy and cannot establish causality or temporal sequence. Data windows vary across indicators (e.g., 2015–2019 vs. 2018), and potentially relevant confounders are not analyzed. Findings should be interpreted as hypothesis-generating and illustrative rather than definitive.