• Michael Liu, Rahul Aggarwal, Zhaonian Zheng, Robert W Yeh, Dhruv S Kazi, Karen E Joynt Maddox, and Rishi K Wadhera.
• Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts (M.L., R.W.Y., D.S.K., R.K.W.).
• Ann. Intern. Med. 2023 Dec 1; 176 (12): 159516051595-1605.

BackgroundAlthough cardiovascular mortality has increased among middle-aged U.S. adults since 2011, how the burden of cardiovascular risk factors has changed for this population by income level over the past 2 decades is unknown.ObjectiveTo evaluate trends in the prevalence, treatment, and control of cardiovascular risk factors among low-income and higher-income middle-aged adults and how social determinants contribute to recent associations between income and cardiovascular health.DesignSerial cross-sectional study.SettingNHANES (National Health and Nutrition Examination Survey), 1999 to March 2020.ParticipantsMiddle-aged adults (aged 40 to 64 years).MeasurementsAge-standardized prevalence of hypertension, diabetes, hyperlipidemia, obesity, and cigarette use; treatment rates for hypertension, diabetes, and hyperlipidemia; and rates of blood pressure, glycemic, and cholesterol control.ResultsThe study population included 20 761 middle-aged adults. The prevalence of hypertension, diabetes, and cigarette use was consistently higher among low-income adults between 1999 and March 2020. Low-income adults had an increase in hypertension over the study period (37.2% [95% CI, 33.5% to 40.9%] to 44.7% [CI, 39.8% to 49.5%]) but no changes in diabetes or obesity. In contrast, higher-income adults did not have a change in hypertension but had increases in diabetes (7.8% [CI, 5.0% to 10.6%] to 14.9% [CI, 12.4% to 17.3%]) and obesity (33.0% [CI, 26.7% to 39.4%] to 44.0% [CI, 40.2% to 47.7%]). Cigarette use was high and stagnant among low-income adults (33.2% [CI, 28.4% to 38.0%] to 33.9% [CI, 29.6% to 38.3%]) but decreased among their higher-income counterparts (18.6% [CI, 13.5% to 23.7%] to 11.5% [CI, 8.7% to 14.3%]). Treatment and control rates for hypertension were unchanged in both groups (>80%), whereas diabetes treatment rates improved only among the higher-income group (58.4% [CI, 44.4% to 72.5%] to 77.4% [CI, 67.6% to 87.1%]). Income-based disparities in hypertension, diabetes, and cigarette use persisted in more recent years even after adjustment for insurance coverage, health care access, and food insecurity.LimitationSample size limitations could preclude detection of small changes in treatment and control rates.ConclusionOver 2 decades in the United States, hypertension increased in low-income middle-aged adults, whereas diabetes and obesity increased in their higher-income counterparts. Income-based disparities in hypertension, diabetes, and smoking persisted even after adjustment for other social determinants of health.Primary Funding SourceNational Institutes of Health.

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