Social Determinants of Health – Let’s Talk About It: Understanding the Hidden Forces That Shape Our Health Outcomes

Social determinants of health (SDOH) represent the often-overlooked factors that have far more impact on our wellbeing than most people realize. As registered dietitian Clara Nosek explains, these are “basically all the things in your life that can affect your health. So like where you live, where you work, where you play, where you study, any of these things alongside your genetics and how that impacts your health outcomes.”

What makes this topic so crucial is that research shows medical care only contributes 10-20% to people’s health outcomes, while social determinants of health account for 80-90% of the contributing factors3. Yet these powerful influences remain largely invisible in many healthcare conversations, leading to oversimplified solutions that blame individuals rather than addressing systemic barriers.

The Five Key Domains of Social Determinants

1. Economic Stability

Economic factors form the foundation of many health outcomes. This domain includes2:

• Poverty levels and income inequality

• Employment status and job security

• Food security and access to nutritious meals

• Housing stability and affordability

As Clara Nosek notes from her clinical experience, even well-intentioned medical advice can become impossible to follow when economic barriers exist: “The American Heart Association recommends 150 minutes of moderate exercise weekly. How do you do that if where you live is unsafe? How do you do that if you don’t have access to parks to walk around, you don’t have sidewalks to safely walk on the highway?”

2. Education Access and Quality

Educational opportunities significantly impact health literacy and long-term wellness outcomes. This includes4:

• Access to quality education at all levels

• Health literacy skills for navigating medical information

• Digital literacy for accessing modern healthcare systems

• Food preparation knowledge and cooking skills

Clara emphasizes the importance of health literacy assessment: “I think it would be really good to assess – do they know how to read labels? Do they know how to build a meal? Do they know how to navigate healthcare systems?”

3. Healthcare Access and Quality

This domain encompasses both the availability and quality of medical services5:

• Health insurance coverage and affordability

• Geographic access to healthcare providers

• Cultural competency of healthcare providers

• Language barriers and communication challenges

The healthcare system often fails marginalized communitiesthrough what Clara describes as systemic biases: “When you combine [limited access] with the racism, the discrimination, the biases that aren’t checked within the healthcare system, it compounds these inequities and makes it harder for people, especially those in marginalized communities to have access to higher quality healthcare.”

4. Neighborhood and Built Environment

Physical surroundings profoundly impact health opportunities2:

• Air and water quality

• Safe housing and neighborhood safety

• Transportation access

• Access to healthy food retailers

• Recreation facilities and green spaces

Many communities face what researchers call “food apartheid” – systematic lack of access to fresh, nutritious foods, often combined with environmental hazards that compound health risks.

5. Social and Community Context

Social connections and community support systems play crucial roles in health outcomes5:

• Social support networks and family connections

• Community cohesion and sense of belonging

• Discrimination and social exclusion

• Cultural practices and traditions

How Social Determinants Impact Food and Nutrition

Beyond Individual Food Choices

Traditional nutrition advice often focuses solely on food selection, ignoring the complex factors that determine what people can actually access and afford. Clara explains this disconnect: “A lot of times people want to blame the individual like, ‘Oh, you’re not eating enough vegetables or you should be exercising more’ without pulling back and realizing that we have these social determinants of health that basically play a huge role in our health status.”

Practical barriers to healthy eating include4:

• Limited access to grocery stores with fresh produce

• Lack of cooking facilities or safe food storage

• Time constraints from multiple jobs or caregiving responsibilities

• Food insecurity and budget limitations

• Transportation challenges for grocery shopping

The Impact of Food Insecurity

Food insecurity creates lasting effects that extend far beyond immediate hunger. Clara emphasizes the importance of assessing food insecurity history: “Even if you’re not currently going through food insecurity, if you had food insecurity as a child, if you faced it in early adulthood, these adverse life outcome events may have ripples that you may not consciously think about, but it could show up in the ways that you choose to eat food.”

Research shows that individuals who have experienced food scarcity are more likely to make impulsive food choices, prioritizing immediate satisfaction and calorie-dense foods that provide security4.This creates a cycle where healthcare providers might criticize these choices without understanding their protective function.

Real-World Applications: Meeting People Where They Are

Clara’s Practical Approach to Nutrition Counseling

When working with clients facing social determinant challenges, Clara uses a stepped approach that prioritizes basic needs:

Step 1: “Eating something is always better than nothing” – addressing the harmful messaging that demonizes entire food groups and can lead to restriction.

Step 2: “Your besties – protein and carbohydrate” – establishing the foundation of balanced meals with accessible foods.

Step 3: Gradual expansion using the plate method while emphasizing that “frozen vegetables and fruit, canned vegetables and fruit, dried grains, beans, peas, legumes” are excellent, budget-friendly options.

Addressing Perfectionism and Food Shame

Clara challenges the optimization culture that makes healthy eating feel impossible: “I think that stems from this place where we always feel compelled to optimize everything in life. You want to optimize your time, optimize your diet, optimize your health, and it puts a lot of pressure on the individual… that’s really just capitalism reaching into your life, just trying to add to stress.”

This approach recognizes that:

• Frozen and canned produce often have equal or superior nutrition to fresh

• Convenience foods can be part of a healthy pattern when that’s what’s accessible

• Cultural food preferences should be honored rather than replaced

• Progress over perfection leads to sustainable change

The Healthcare System’s Role in Perpetuating Inequities

Systemic Failures

Clara describes the healthcare system as “a full-on Monet” – looking good from far away but revealing problems up close. Key issues include1:

Financial barriers: “BIPOC folks are most likely to be uninsured or underinsured, which means they can’t afford to get the healthcare that they need.”

Provider bias: “When they do seek the care, it’s often met with these biases, these unchecked internalized biases, racism, discrimination from the providers.”

Symptom-focused treatment: “I think a lot of Western medicine treats symptoms… there’s no actual getting to the root cause of a lot of these health outcomes that we’re seeing.”

The Compound Effect

These healthcare failures compound with other social determinants. Communities lacking healthcare access often also face:

• Food deserts or food apartheid limiting nutrition options

• Environmental hazards like pollution and unsafe neighborhoods

• Limited transportation affecting both food access and medical appointments

• Unsafe conditions preventing physical activity recommendations

Trauma, Stress, and Health: The Hidden Connections

Understanding Trauma-Informed Care

Clara advocates for trauma-informed approaches that recognize how adverse experiences shape current behaviors: “I think including a required CEU on patient-centered care, trauma-informed care is really important as well, because I think a lot of these life events really play a major role in the ways that a person lives their life.”

Persistent stress and trauma affect health through multiple pathways:

• Chronic inflammation from sustained stress responses

• Disrupted sleep patterns affecting metabolism and immune function

• Hypervigilance making it difficult to engage in self-care

• Food relationships shaped by scarcity, comfort-seeking, or control

Practical Stress Management Strategies

Clara emphasizes evidence-based, accessible approaches1:

• Boundary setting and screen time reduction

• Monotasking instead of constant multitasking

• Outdoor time for vitamin D and grounding

• Mindful eating to improve digestion and reduce food anxiety

The mind-body connection matters: “If you’re stressing about everything that you’re eating, that can play a role in the ways your body digests the food… people who are in a relaxed state and eating will take in their food much better than someone who’s in a heightened state of stress.”

Moving Beyond Individual Solutions

The Need for Systemic Change

Addressing social determinants requires moving beyond individual behavior change to systemic interventions6.Effective approaches include:

Policy-level changes:

• Housing assistance and affordable housing development

• Transportation infrastructure including public transit

• Living wage policies and job training programs

• Food access initiatives like mobile markets and incentive programs

Healthcare system reforms:

• Community health worker programs

• Social prescribing that addresses non-medical needs

• Provider training on cultural competency and bias

• Integration of social services with medical care

The Role of Healthcare Providers

Clara emphasizes that clinicians need comprehensive community resource knowledge: “I think it’s really important for clinicians to have that connection to their community to know like, where are the food banks? Where are the assistance programs? Where are the job training programs? Or at least know where to direct patients to.”

Key provider responsibilities include4:

• Asking the right questions about social circumstances

• Maintaining resource lists for community supports

• Advocating for patients facing systemic barriers

• Addressing personal biases through ongoing education

Cultural Considerations and Inclusive Care

Honoring Cultural Food Practices

Social determinants include cultural factors that shape food relationships and health practices. Effective nutrition counseling must:

• Respect traditional foods and preparation methods

• Understand cultural meanings of different foods

• Work within cultural frameworks rather than imposing external standards

• Recognize discrimination faced by marginalized communities

Language and Communication Barriers

Digital and health literacy challenges affect how people access and understand health information. Clara notes: “I think we should really start addressing health literacy including digital literacy… helping patients find ways to check all – do they know how to read labels? Do they know how to navigate healthcare systems?”

Evidence-Based Interventions That Work

Successful SDOH Programs

Research identifies effective interventions that address root causes rather than just symptoms7:

Housing programs: Stable housing reduces healthcare utilization and improves chronic disease management.

Food assistance: SNAP benefits and WIC programs not only reduce food insecurity but also improve children’s long-term health outcomes.

Education initiatives: Adult education and job training programs improve both economic stability and health literacy.

Community development: Investment in disadvantaged neighborhoods creates lasting improvements in multiple health indicators.

Return on Investment

SDOH interventions often provide excellent return on investment7.For every dollar spent on:

• Housing assistance: $1.20-7.50 in healthcare savings

• Nutrition programs: $1.30-8.00 in reduced healthcare costs

• Education programs: $3.20-8.50 in economic and health benefits

Practical Steps for Individuals and Communities

For Healthcare Providers

Clara’s recommendations for clinicians include1:

• Assess for food security history and current circumstances

• Evaluate housing stability and transportation access

• Build community resource networks and referral systems

• Pursue continuing education on trauma-informed care

• Challenge personal biases through ongoing self-reflection

For Community Members

Individual actions that support SDOH improvements:

• Advocate for policy changes at local and state levels

• Support community organizations addressing social needs

• Volunteer with food banks, housing assistance, or education programs

• Use your voice to challenge discrimination and promote equity

For Policymakers

Evidence-based policy priorities2:

• Affordable housing development and preservation

• Living wage policies and worker protections

• Transportation infrastructure including public transit

• Healthcare access expansion and quality improvement

• Education funding and adult learning opportunities

Looking Forward: A More Equitable Approach to Health

Shifting the Narrative

Understanding social determinants of health requires fundamentally shifting how we think about individual responsibility versus systemic factors. As Clara emphasizes: “Just because something is standard practice does not mean it is beyond questioning.”

This shift involves:

• Recognizing systemic barriers rather than blaming individuals

• Addressing root causes instead of just treating symptoms

• Promoting health equity through policy and practice changes

• Centering marginalized voices in health discussions

The Path Forward

Creating meaningful change requires coordinated action across multiple sectors. Healthcare providers, policymakers, community organizations, and individuals all have roles to play in addressing the social determinants that shape health outcomes.

Clara’s call to action resonates: “I think on a wider level how can we actually try to make things better and promote health equity.” This work isn’t optional – it’s essential for creating a society where everyone has the opportunity to achieve optimal health, regardless of their circumstances.

The conversation about social determinants of health challenges us to look beyond individual choices to the systems and structures that shape those choices. By understanding and addressing these powerful influences, we can move toward true health equity where zip code doesn’t determine lifespan, and everyone has access to the conditions that support wellbeing.

Frequently Asked Questions

Q1: How do social determinants of health differ from lifestyle choices?
A1: Social determinants are the conditions and circumstances people live in that are often beyond their individual control – like neighborhood safety, access to healthy food, housing stability, and income level. While lifestyle choices involve individual decisions, social determinants create the context that makes certain choices possible or impossible. For example, choosing to exercise is limited by whether you have safe places to be active.

Q2: Why should healthcare providers care about social determinants?
A2: Research shows that social determinants account for 80-90% of health outcomes, while medical care only contributes 10-20%. This means that addressing a patient’s housing, food security, or transportation challenges may have more impact on their health than clinical treatments alone. Providers who understand SDOH can offer more effective, patient-centered care.

Q3: How can I tell if social determinants are affecting my health or nutrition?
A3: Consider whether you have consistent access to nutritious food, safe housing, reliable transportation, and healthcare. Ask yourself: Do I worry about having enough food? Can I afford my medications? Do I feel safe in my neighborhood? Can I get to medical appointments easily? If you answer no to these questions, social determinants may be impacting your health.

Q4: What can communities do to address social determinants of health?
A4: Communities can advocate for policy changes like affordable housing development, improved public transportation, living wage policies, and better funding for schools and healthcare. Supporting local organizations that provide food assistance, job training, or housing support also helps. Voting for leaders who prioritize health equity is another important step.

Q5: How do social determinants specifically affect children’s health?
A5: Children are particularly vulnerable to social determinants because they’re still developing and have less control over their circumstances. Food insecurity can affect brain development and academic performance. Unsafe neighborhoods limit physical activity. Unstable housing creates chronic stress. Poor school funding affects educational opportunities. These early experiences create health impacts that can last throughout life.