Study reveals income-based disparities for hypertension, obesity, diabetes

Key takeaways:

• High BP is increasing in low-income adults while diabetes and obesity are increasing in high-income adults.
• The trends in high-income adults may reflect a rise in sedentary behaviors and poor dietary patterns.

A study published in Annals of Internal Medicine revealed income-based disparities in diabetes, smoking and hypertension — findings that one expert called worrying.

Rishi K. Wadhera, MD, MPP, MPhil, an assistant professor of medicine at Harvard Medical School and a cardiologist at Beth Israel Deaconess Medical Center, and colleagues conducted a serial cross-sectional study on trends in cardiovascular mortality in the United States over the last 20 years.

The researchers analyzed data from the National Health and Nutrition Examination Survey on 20,761 adults aged 40 to 64 years. Wadhera and colleagues measured factors such as the age-standardized prevalence of hypertension, obesity, cigarette use, diabetes and more.

Healio spoke with Wadhera to learn more about the trends they observed and what primary care physicians should know.

Healio: Why did you decide to research this subject? Why is it important?

Wadhera: For many decades, the U.S. has experienced steep declines in cardiovascular mortality. However, these declines have recently started to stagnate. And alarmingly, there’s been an increase in cardiovascular deaths, specifically among middle-aged adults (40-64 years). We wanted to explore the factors that might be contributing to this alarming increase in cardiovascular deaths among middle-aged adults, particularly among those with low income, who we know are at higher risk of poor cardiovascular health.

Healio: Will you briefly describe your study’s findings and their clinical implications?

Wadhera: Between 1999 and March 2020 in the United States, low-income middle-aged adults consistently had higher rates of hypertension, diabetes, obesity and cigarette use than their higher income counterparts. Hypertension significantly increased among low-income adults from approximately 37% to 45% between 1999 and March 2020, but higher income adults experienced no change.

In contrast, diabetes did not change in low-income adults but nearly doubled among higher income adults. These patterns were similar for obesity, with higher income adults experiencing a significant increase from 33% to 44%. By the end of the study period, nearly one in two middle-aged adults had obesity.

We were also surprised to find nearly one in three low-income middle-aged adults smoke cigarettes, and that this has not improved over nearly 2 decades, while high-income adults have experienced big declines. Over the past 2 decades, income-based disparities in hypertension, diabetes, obesity and cigarette use have not narrowed — that should worry us.

Healio: What factors do you think contributed to these trends?

Wadhera: The increasing rates of diabetes and obesity in higher income middle-aged adults surprised us and may reflect increasing sedentary behaviors and worsening dietary patterns.

Healio: What should be done to address these disparities?

Wadhera: The higher burden of cardiovascular risk factors in low-income adults is concerning. What’s even more concerning is that we’ve made very little progress in narrowing income-based inequities over the past 2 decades. The etiology of these disparities is multifactorial but reflects differences in early-life exposures, access to health care and other social determinants that are strongly linked to cardiovascular health, including stable housing, green space for regular physical activity, medication affordability, and environmental burdens. Multifaceted interventions are needed to address these income-based inequities, including expansion of tailored community-based programs, large-scale health system initiatives and public health and policy efforts to address the social determinants of health that fundamentally drive these inequities.

Healio: What is the take-home message for primary care physicians? What should they know about your study?

Wadhera: We are in the midst of a smoldering epidemic of cardiovascular risk factors among younger adults, which could ultimately result in a tsunami of cardiovascular disease. The onset of cardiovascular risk factors earlier in life increases life-time risk of life-threating cardiovascular events — like heart attacks and strokes — as well as deaths. Our findings make it clear that we need to intensify targeted campaigns at the health system, community and policy levels that focus on guideline-recommended screening, prevention and treatment of cardiovascular risk factors in middle-aged adults.

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