Abstract
Introduction: Cardiovascular mortality has increased among middle-aged US adults since 2011. Despite these alarming trends, it is unknown how the burden of cardiovascular risk factors has changed for this population by income level over the past two decades. Methods: We conducted a serial cross-sectional analysis of the NHANES to evaluate changes in the prevalence, treatment, and control of cardiovascular risk factors among low-income (<200% federal poverty threshold) and higher-income middle-aged adults (ages 40-64) between 1999 and March 2020. Results: Among 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 experienced a significant increase in hypertension (37.2% [95% CI: 33.5-40.9] to 44.7% [95% CI: 39.8-49.5]) over the study period, but no changes in diabetes or obesity. In contrast, higher-income adults did not experience a change in hypertension but had significant increases in diabetes (7.8% [5.0-10.6] to 14.9% [12.4-17.3]) and obesity (33.0% [26.7-39.4] to 44.0% [40.2-47.7]). Hyperlipidemia decreased in both groups. Cigarette use was high and stagnant among low-income adults (33.2% [28.4-38.0] to 33.9% [29.6-38.3]) but significantly decreased among their higher-income counterparts (18.6% [13.5-23.7] to 11.5% [8.7-14.3]). Income-based inequities in cardiovascular risk factors persisted in recent years even after adjustment for insurance coverage, health care access, and food insecurity. Treatment and control rates for hypertension were unchanged in both groups (>80%), while diabetes treatment rates only improved among the higher-income group. Conclusions: The burden of several cardiovascular risk factors worsened among middle-aged adults (ages 40-64) over two decades with varying trends by income level. Income-based inequities in hypertension, diabetes, and smoking have not meaningfully narrowed.
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