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Original Investigation
June 7, 2017

Income Disparities in Absolute Cardiovascular Risk and Cardiovascular Risk Factors in the United States, 1999-2014

Author Affiliations
  • 1Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario, Canada
  • 2Centre for Statistics in Medicine, University of Oxford, Oxford, England
  • 3Division of Nephrology, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
  • 4Department of Medicine, School of Medicine, University of Tasmania, Hobart, Australia
  • 5Department of Physiology, Anatomy, and Genetics, University of Oxford, Oxford, England
  • 6St John’s College, University of Oxford, Oxford, England
JAMA Cardiol. Published online June 7, 2017. doi:10.1001/jamacardio.2017.1658
Key Points

Question  Are there socioeconomic disparities in 10-year predicted absolute cardiovascular disease risk and individual risk factors (systolic blood pressure, smoking, diabetes, and total cholesterol) among US adults?

Findings  In this analysis of 17 199 adults without established cardiovascular disease, the percentage of adults with predicted cardiovascular disease risk of 20% or more, mean systolic blood pressure, and the percentage of current smokers declined among adults in the high-income stratum, but there was little evidence of a change among adults with incomes at or below the federal poverty level. The trend in diabetes and cholesterol level did not vary by income.

Meaning  Adults in each socioeconomic stratum have not benefited equally from efforts to improve control of cardiovascular risk factors.

Abstract

Importance  Large improvements in the control of risk factors for cardiovascular disease have been achieved in the United States, but it remains unclear whether adults in all socioeconomic strata have benefited equally.

Objective  To assess temporal trends in 10-year predicted absolute cardiovascular risk and cardiovascular risk factors among US adults in different socioeconomic strata.

Design, Setting, and Participants  A cross-sectional analysis was conducted using data on adults 40 to 79 years of age without established cardiovascular disease from the 1999 to 2014 National Health and Nutrition Examination Survey.

Exposures  Socioeconomic status was based on the family income to poverty ratio and participants were divided into the following 3 groups: high income (family income to poverty ratio, ≥4), middle income (>1 and <4), or at or below the federal poverty level (≤1).

Main Outcomes and Measures  We assessed predicted absolute cardiovascular risk using the pooled cohort equation. We assessed the following 4 risk factors: systolic blood pressure, smoking status, diabetes, and total cholesterol.

Results  Of the 17 199 adults whose data were included in the study (8828 women and 8371 men; mean age, 54.4 years), from 1999-2014, trends in the percentage of adults with predicted absolute cardiovascular risk of 20% or more, mean systolic blood pressure, and the percentage of current smokers varied by income strata (P ≤ .02 for interaction). For adults with incomes at or below the federal poverty level, there was little evidence of a change in any of these outcomes across survey years (cardiovascular risk ≥20%, 14.9% [95% CI, 12.9%-16.8%] in 1999-2004; 16.5% [95% CI, 13.7%-19.2%] in 2011-2014; P = .41; mean systolic blood pressure, 127.6 [95% CI, 126.1-129.0] mm Hg in 1999-2004; 126.8 [95% CI, 125.2-128.5] mm Hg in 2011-2014; P = .44; and smoking, 36.5% [95% CI, 32.1%-41.0%] in 1999-2004; 36.0% [95% CI, 31.1%-40.8%] in 2011-2014; P = .87). For adults in the high-income stratum, these variables decreased across survey years (cardiovascular risk ≥20%, 12.0% [95% CI, 10.7%-13.3%] in 1999-2004; 9.5% [95% CI, 8.2%-10.7%] in 2011-2014; P = .003; systolic blood pressure, 126.0 [95% CI, 125.0-126.9] mm Hg in 1999-2004; 122.3 [95% CI, 121.3-123.3] mm Hg in 2011-2014; P < .001; and smoking, 14.1% [95% CI, 12.0%-16.2%] in 1999-2004; 8.8% [95% CI, 6.6%-11.0%] in 2011-2014; P = .001). Trends in the percentage of adults with diabetes and the mean total cholesterol level did not vary by income.

Conclusions and Relevance  Adults in each socioeconomic stratum have not benefited equally from efforts to control cardiovascular risk factors.

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