National Heart, Lung, and Blood Advisory Council September 2020 Meeting Summary

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL INSTITUTES OF HEALTH NATIONAL HEART, LUNG, AND BLOOD INSTITUTE

NATIONAL HEART, LUNG, AND BLOOD ADVISORY COUNCIL MEETING SUMMARY

September 15, 2020

The 289th meeting of the National Heart, Lung, and Blood Advisory Council (NHLBAC) convened virtually on Tuesday, September 15, 2020. In addition to NHLBAC members, the meeting included the ad hoc Board of External Experts (BEE), scientists with research expertise in National Heart, Lung, and Blood Institute (NHLBI) mission areas who were recruited for this meeting as a special NHLBAC working group. The council meeting began at 8:05 a.m. EDT and ended at 3:34 p.m. EDT. The meeting was open to the public between 8:05 and 11:15 a.m. and between 1:45 and 3:34 p.m. Four working groups met from between 11:15 a.m. to 1:45 p.m. Dr. Gary H. Gibbons, Director of NHLBI, presided as chair.

NHLBAC Members Attending

E. Dale Abel, M.D., Ph.D.
Donna K. Arnett, Ph.D., M.S.P.H.
Grace Anne Dorney Koppel, J.D.
Martha U. Gillette, Ph.D.
Karen Glanz, Ph.D., M.P.H.
Garth Graham, M.D., M.P.H.
David H. Ingbar, M.D.
M. Luisa Iruela-Arispe, Ph.D.
Monica Kraft, M.D.
Kiran Musunuru, M.D., Ph.D.
Mohandas Narla, D.Sc.
Julie A. Panepinto, M.D., M.S.P.H.
Richard S. Schofield, M.D. (ex officio)
Dean Sheppard, M.D.
Kevin L. Thomas, M.D.
Sally E. Wenzel, M.D.
Andrew S. Weyrich, Ph.D.
Zachariah P. Zachariah, M.D.

Council Member(s) Unable to Attend

Jennifer E. DeVoe, D.Phil., M.D.

NHLBI Employees Attending

Several NHLBI staff members were present.

BEE

Michelle A. Albert, M.D., M.P.H.
Judy L. Aschner, M.D.
Timothy S. Blackwell, M.D.
Annetine C. Gelijns, Ph.D., J.D.
Nadia N. Hansel, M.D., M.P.H.
Bertha Hidalgo, Ph.D., M.P.H.
Mukesh K. Jain, M.D.
Darrell N. Kotton, M.D.
Elizabeth M. McNally, M.D., Ph.D.
Brian S. Mittman, Ph.D.
Matthias Nahrendorf, M.D., Ph.D.
Ellis J. Neufeld, M.D., Ph.D.
Laura Kristin Newby, M.D.
Bruce M. Psaty, M.D., Ph.D., M.P.H.
Susan Redline, M.D., M.P.H.
Herman A. Taylor, Jr., M.D.
Griffin M. Weber, M.D., Ph.D.

Members of the Public Attending

Dr. Brian Smedley
Dr. Ana V. Diez Roux

I. CALL TO ORDER AND OPENING REMARKS

Dr. Gary H. Gibbons, director of the National Heart, Lung, and Blood Institute (NHLBI), called the meeting to order at 8:05 a.m. He welcomed members of the National Heart, Lung, and Blood Advisory Council (NHLBAC) and other attendees to this joint meeting.

Dr. Gibbons explained that as part of NHLBI’s integrative approach to strategic visioning, this meeting would focus on ways to advance health equity by identifying ways to address health disparities and to predict, prevent, and preempt disease. Dr. Gibbons encouraged NHLBAC members and BEE attendees to challenge the NHLBI in identifying gaps and help the institute establish priorities for the future.

Many of the four goals and eight objectives in the NHLBI strategic vision address issues related to special populations and health disparities, and the social determinants of health (SDOH) are interwoven through many of these concepts. The SDOH provide a social context and environment for health and would be the focus of this meeting.

The impact of the SDOH on health disparities has been laid bare by the COVID-19 pandemic, which has had a disproportionate impact on certain communities, especially communities of color, in the United States. These populations have a high burden of COVID-19-associated hospitalizations and severe disease. Although some of this impact might be explained by high rates of diabetes and obesity in these populations, SDOH also play a role.

The charge for this meeting was to discuss innovative ways that NHLBI could support SDOH research to improve heart, lung, blood, and sleep (HLBS) health, prevent disparities, and promote health equity.

II. ADMINISTRATIVE ANNOUNCEMENTS

Dr. Laura K. Moen, director of the Division of Extramural Research Activities at NHLBI, reminded council members of the conflict-of-interest regulations.

III. PLACE, RACE, AND CHRONIC DISEASE: “INVERTING THE LENS” TO ADDRESS THE ROOTS OF HEALTH INEQUITIES

Dr. Brian D. Smedley, the American Psychological Association’s Acting Chief Diversity Officer, opened his presentation calling for inverting the lens to focus less on bench science and more on understanding society and the role of racism to produce healthy outcomes.

Dr. Smedley suggested that residential segregation is a direct result of policies and practices in this country for generations. For example, federal, state, and local governments have systematically imposed various policies and structures including residential segregation with racial zoning, public housing that segregated previously mixed communities, subsidies for builders to create Whites-only suburbs, and tax exemptions for institutions that enforce segregation.

In addition, Dr. Smedley presented data illustrating that racial segregation concentrates poverty and excludes and isolates communities of color from the mainstream resources needed for success. Segregation also restricts socioeconomic opportunities by channeling non-Whites into neighborhoods with poorer public schools, fewer employment opportunities, and smaller returns on real estate sales. African Americans are less likely than Whites to live in census tracts with supermarkets, parks and green spaces, and safe places to walk, jog, bike, and play.

Dr. Smedley concluded with evidence that supports addressing SDOH with multiple strategies across sectors, sustained investments and long-term policy agendas, and a focus on prevention. Investments in early childhood education and increases in housing mobility options are also proven to be effective in addressing SDOH effectively in the long-term.

IV. CARDIOVASCULAR HEALTH INEQUITIES: WHERE WE’VE BEEN AND WHERE WE SHOULD BE GOING

Dr. Ana V. Diez Roux, Dean of the Drexel University School of Public Health, opened her talk by noting that health inequities must be reduced to improve population health in general. The goals of research on health inequities are to describe the inequities, understand their causal mechanisms, and identify the most effective actions (policies and interventions) for reducing them. The causes of health inequities are at several levels, have long causal chains (from distal to proximal), and involve social, behavioral, health care, and biological factors. The relationships between these causes and their effects are dynamic, with feedbacks and dependencies. A single methodological approach to health inequities research is thus likely to be insufficient.

Dr. Roux suggested that research on cardiovascular health inequities needs to draw from several sources of evidence. To study cardiovascular disease (CVD) and neighborhoods as contexts for physical and social exposures, for example, Dr. Diez Roux measures neighborhood attributes using survey, geolocational, and systematic social observation data. Longitudinal studies have linked area features to disease incidence or changes in area features to changes in outcomes. However, this research is observational, and the results are not always consistent. Also, the findings from different studies cannot always be compared.
Experimental research on SDOH is not easy or always possible. But a 2011 study in the New England Journal of Medicine concluded that giving residents the opportunity to move from a neighborhood with a high level of poverty to one with less poverty was associated with modest but potentially important reductions in the prevalence of extreme obesity and diabetes.

Dr. Diez Roux called for etiologic, mechanistic understanding, policy evaluation, and implementation research. She also suggested training programs that emphasize a broad approach; more diverse trainees; and links between training and novel, broad-based research initiatives.

V. CHARGE FOR WORKING GROUPS

Charge: Discuss novel, innovative, and cross-cutting means by which NHLBI and its leadership can support social determinants of health research that promotes HLBS health and/or prevents disparities in HLBS conditions and promotes health equity.

VI. REPORTS FROM WORKING GROUP DISCUSSIONS

The reports summarized below are ideas that were discussed and will be taken under advisement by NHLBI staff in future decision making.

Group A: Scientific Opportunities—Economic Stability and Education

Dr. Karen Glanz summarized the responses to the key questions for Group A.

Additional research needed to understand the influences of these SDOH domains on biology and the causal processes that are most amenable to intervention include:

• Clinical research that is embedded with standardized measures and analyses, and includes data harmonization
• Research stemming from partnerships among academic health centers and community organizations
• Research relying on access and trust among Federal, State, and local agencies that collect data on SDOH
• Application of digital technology, social media, and surveillance to SDOH monitoring
• Intergenerational research to understand effects over time (in a changing world)

NHLBI may advance research on strategies to address heart, lung, blood, and sleep (HLBS)–related disparities and inequities related to these SDOH domains by instituting:

• Flexible research designs
• Adaptive approaches that let scientists pivot midstream if interventions and methods need modifications
• Supplements and cost sharing to evaluate SDOH in funded studies
• Informed consent processes at the appropriate literacy level
• Partnerships with key agencies and opportunities to take trials to communities
• Implementation strategies for evidence-based methods to address SDOH
• Use of T32 awards to mobilize the pipeline through opportunities to work in communities

Promising interventions to address these SDOH domains related to HLBS conditions include:

• Interventions in women and their infants in the postpartum period
• Evaluations of universal prekindergarten and healthy schools for low-income populations over a longer follow-up period
• Cross-sectoral air-quality interventions starting in early life to reduce asthma risk that leverage cutting edge opportunities
• Policy evaluations and rapid-response proposals that produce guidance for future policies
• Multisectoral intervention trials of better housing and reduced segregation

Group B: Scientific Opportunities—Social and Community Context, Health and Health Care, Neighborhood, and Built Environment

Dr. Brian S. Mittman summarized the responses to the key questions for Group B.

Additional research needed to understand the influences of SDOH domains on biology and the causal processes that are most likely amenable to intervention include:

• Identify disciplines, outreach, data sources, and measures needed to conduct this research
• Broaden range of target groups, settings, and partnerships
• Study multiple SDOH domains, settings, and populations
  • Expand existing lists and measures in different populations
• Expand the range of outcomes measured and studied to include resilience and clinical and intermediate behavioral outcomes (e.g., stress)

NHLBI may advance research addressing HLBS-related disparities and inequities related to SDOH domains through the following:

• Reach the unreachable
• Expand and leverage cohorts to include SDOH measures and broader populations
• Use a new prospective cohort study to examine these issues with explicit inclusion of SDOH measures
• Develop new funding mechanisms and new targeted requests for applications to move beyond the limitations of R01s to address the long term nature of the work
• Develop approaches involving multiple NIH institutes and centers and Federal agencies

Promising interventions to address SDOH domains related to HLBS conditions include:

• Etiological studies to support intervention development
• Implementation and/or adaptations of simple interventions that have broad impact
• Partnerships with institutions (e.g., public housing, correctional institutions, schools) to reach the most vulnerable groups
• Multimodal, multicomponent interventions
• Studies that address determinants and precursors in addition to later-stage outcomes of interventions

Group C: Scientific Opportunities—Workforce and Training

Dr. Michelle A. Albert summarized the responses to the key questions for Group C.

NHLBI may promote training of a diverse HLBS research workforce with expertise in addressing SDOH by:

• Training in research on SDOH throughout the workforce career pipeline
• Support interdisciplinary and transdisciplinary research, as well as, research infrastructure
• Cross-institutional training to leverage SDOH strengths at various institutions
• Funding arrangements that incorporate minority-serving institutions
• Administrative supplements for grants targeting SDOH
• Embedding trainees and community partners into large existing clinical studies

NHLBI may encourage and support community partnerships to address social barriers to HLBS research by:

• Leveraging and working to support the capacity of community partners
• Training for the scientific workforce in communicating and disseminating science
• Workshops with stakeholders to identify needs and inform consequential partnerships
• Training mechanisms to engage nonacademic investigators or groups
• Representative sectors: established community organizations, faith-based organizations, educational institutions, industry, technology, community health workers, traditional policy organizations

Regulatory considerations include:

• Type(s) of consent needed for SDOH research, with community engagement to understand needs
• The fact that training of institutional review boards (IRBs) on SDOH can be burdensome
• The possibility that inclusion of community organizations in IRBs and community IRBs would improve trust
• The need to determine the necessary curricular elements in training to address SDOH be required in projects that include community-based participatory research
  • Core training with or without specific elements, based on the type of research and intended learners
  • Leverage prior models for NHLBI involvement in curriculum development (e.g., from 2012 and 2017 nutrition workshops)
  • Cultural competency training: formal educational component (lecture) plus practicum

Group D: Scientific Opportunities—Challenges and Opportunities

Dr. Garth Graham summarized the responses to the key questions for Group D.

NHLBI and NIH may prevent unintended challenges for community organizations and less research-intensive institutions through:

• Fostering collaboration among NIH, research-intensive institutions, and less research-intensive institutions
• Leveraging existing relationships and use of motivators
• Determining appropriate funding mechanisms to establish non-traditional partnerships
• Regional training seminars for less research-intensive institutions on the grant submission process
• Inclusion of reviewers from less research-intensive institutions in study sections

Making NIH and NHLBI application review systems compatible with support for SDOH research by the following:

• Include diverse, knowledgeable people in study sections; offer reviewer training in SDOH
• Include SDOH metrics in the review process
• Broaden language around the term “community”
• Set aside funding or use select pay for SDOH research
• Combine studies that address SDOH and biology/disease
• Issue RFAs to support collection and linkage of SDOH data from other sources (e.g.,census data, geographical data, environmental data)

Other key stakeholders NHLBI should engage:

• Insurers and other private entities, pharmacies, and commercial companies
• Government agencies (e.g., Environmental Protection Agency, U.S. Department of Housing and Urban Development, Centers for Medicare & Medicaid Services)
• Communities
  • Consider the sustainability of community efforts, after the funding award ends

CLOSING REMARKS

Dr. Moen adjourned the meeting at 3:34 p.m.