Heart disease is the number one killer of Americans, yet Black Americans are 30% more likely than White Americans to die from heart disease. Though a growing body of evidence indicates this disparity is likely caused by a complex network of psychosocial factors, Phillip Duncan, MD, sees many of his Black patients facing three common problems.

Those problems, Dr. Duncan says, are “high blood pressure, diabetes and obesity.” And because they’re connected to so many other factors, Dr. Duncan identified their most common contributors and developed seven questions he asks every patient he cares for.

Food: What’s in your diet?

What we eat is significant. More than a simple matter of what a person chooses to eat, diets are often an important part of a person’s cultural identity. In many Black communities, Dr. Duncan says, there’s a lot of fried foods and high salt contents.

“My family, we’re Jamaican,” says Dr. Duncan. “So, I understand how culturally important food is.” When he reviews a patient’s diet and sees they’re eating a lot of fried or heavily processed and salted foods, he knows the importance of having that difficult conversation.

Most importantly, Dr. Duncan asks how their food is cooked and seasoned. “We talk about what can be baked instead of fried,” he says about his dietary talks with patients. “Or being aware of how much salt is in their food, and other seasonings they can use when they cook.” These two changes, he says, are the simplest and most effective ways to improve diet.

Income: Can you afford the care you need?

The second thing Dr. Duncan asks his patients about is their income. If a patient needs particular medicine or treatment that costs more than they can afford, they’re unlikely to get either. Without being able to afford the care they need, patients will likely see much worse outcomes for their heart.

In Richmond, a living wage for a single adult with no children is $18.59 per hour, which adds up to $38,667.20 annually for a full-time job. Adults making less than that are likely to cut costs in areas of their lives that don’t present an immediate need. Such as health care.

And while wages are beyond the control of most workers, there are programs in place to help with the costs of unexpected medical bills. Financial assistance is available through Virginia’s indigent care program, and VCU Health offers assistance based on income, assets and needs.

Village: What does your social environment look like?

The third pillar of good heart health in Dr. Duncan’s approach is the environment in which a patient lives. Is there safe space to walk in their neighborhood? Do they live near a grocery store with fresh, healthy options for food? How prevalent are drugs and violence in their neighborhood?

All of these factors can make it challenging for heart patients to adopt a heart-healthy lifestyle. One heart failure patient Dr. Duncan worked with was struggling to recover from addiction. She was faced with the effect her addiction was having on her heart, he says. With drugs being sold on every street in her neighborhood, this patient knew she would have to leave if she wanted to change her life. “She said, I’m not going to survive if I stay where I’m living.”

Education: What do you understand about your heart?

Dr. Duncan’s fourth consideration in his understanding of a patient’s heart health the patient’s education. That doesn’t necessarily mean that college graduates will have better heart health. Research does indicate college graduates tend to have better health, but the reasons for this are complex. For Dr. Duncan, a patient’s education is less about what they’ve learned and more about how they learn.

“If I’m using a lot of words the patient won’t know, a lot of big medical terms or three-syllable words, and the patient’s eyes glaze over and they’re nodding quietly, I know they don’t understand what’s going on,” Dr. Duncan says. For him, this moment is where the ‘magic’ of medicine begins.

The ‘magic’ can be described as how well a provider connects with their patient. If a patient feels like they can relate to their provider and their provider can relate to them, they’re more likely to have better outcomes. Providers who can communicate clearly and effectively with their patients are more likely to establish deeper connections with their patients, building trust. As Dr. Duncan sees it, trust is a vital part of patient care.

“The magic is at the bedside,” he says. “It has to do with the people.”

This magic allows providers to instill in their patients the knowledge needed to improve their heart health. By understanding how a patient learns and how to communicate to them effectively, providers can guide their patients to lifestyles better-suited for a healthy heart.

Shelter: Do you have a consistent and reliable place to live?

Shelter is one of the most basic needs for human life. Without it, a person lives in constant stress, wondering where they’ll sleep or eat, how safe they are, or how they’ll survive extreme cold or heat. And since 2013, the number of unsheltered people living in the Greater Richmond area has fluctuated, but the number averages to a little more than 700 people each year.

Among other factors contributing to higher rates of heart disease among unsheltered people, living without a home puts a person in a state of constant stress. Increased stress, research has shown, is linked to a greater risk of bad heart-related events such as heart attack or stroke.

In addition to stress and other risk factors, people without the most basic needs for survival are much less likely to seek out health care when they need it most. Unsheltered people have greater rates of anxiety, depression, and drug abuse. All of which are risk factors for heart disease.

Behavior and Drug Use: How are you helping or hurting your heart?

The last two questions Dr. Duncan asks all of his patients are additions to his original list. As he sees it, the two go together, though they are two separate considerations. “We know about the negative effects of recreational drugs like alcohol and illicit drugs like cocaine,” Dr. Duncan says, “but we’re still learning about the impact of cannabis on the heart.” Because of the known damages of alcohol and other drugs and the uncertain effects of cannabis, Dr. Duncan recommends his patients avoid drugs and alcohol altogether.

Aside from drug use, there are endless behaviors that can work against good heart health. This means that improving heart health must be intentional. Everyone should stay moderately active for at least 150 minutes every week. While an occasional sweet or a moderate amount of salt is enjoyable, a heart healthy diet requires more thought about what’s being eaten and how much is eaten.

There is a growing body of evidence indicating the heart health is affected by many psychosocial factors, but providers like Dr. Duncan have long understood that good heart health starts with lifestyle. Societal changes will be needed to address the psychosocial aspects of African American heart health, but everyone, regardless of race or culture, should have a basic understanding of what they can do to shape their own health. And Dr. Duncan’s FIVES+BD list serves as a great way to keep the most important factors in mind during any stage of the journey to good heart health.