The Nation’s Cardiometabolic Health Is In Peril

An alarming report looking at blood pressure, blood glucose, adiposity, and cholesterol found that over a 20-year period (as of 2017-2018), just 6.8% of adults in the United States have optimal levels of all five of these components. Unsurprisingly, the study authors found racial and economic disparities, with a modest increase in optimal health for non-Hispanic Whites, but decreases for other racial and ethnic groups. Results are published in the Journal of the American College of Cardiology.

"Increasing obesity and one of its consequences, diabetes, were the leading drivers of the adverse trends….If this were an individual patient rather than a multinational trend, someone would probably be calling a code blue," Thomas E. Kottke, MD, MSPH, and colleagues from HealthPartners, Minneapolis, Minnesota, wrote in an editorial comment on the report.

"These numbers are striking. It’s deeply problematic that in the United States, one of the wealthiest nations in the world, fewer than 1 in 15 adults have optimal cardiometabolic health," said Meghan O’Hearn, MS, a doctoral candidate at the Friedman School and the study’s lead author noted in a press release on the study. "We need a complete overhaul of our healthcare system, food system, and built environment, because this is a crisis for everyone, not just one segment of the population."

In their study, O’Hearn and colleagues focused on cardiometabolic health data, which "is characterized by optimal levels of multiple risk factors jointly. The concept of cardiometabolic health can also increase assessment and understanding of health inequities, by age, sex, race/ethnicity, and socioeconomic status. These issues have been further highlighted by the striking relationships between poor cardiometabolic health and more severe Covid-19 outcomes, especially in disadvantaged populations," the study authors explained and noted that national trends and disparities in this area have not been well established.

Using the National Health and Nutrition Examination Survey (NHANES) O’Hearn and colleagues assessed just over 55,000 adults 20 years or older from 1999-2002 to 2017-2018.

"Optimal cardiometabolic health was defined by optimal levels of adiposity, blood glucose, blood lipids, blood pressure (BP), and absence of prior clinical CVD events, adapted from the American Heart Association (AHA) definition of ideal cardiovascular health with extension to include metabolic health," they wrote.

They also looked at subgroups stratified by "age (20-34, 35-49, 50-64, ≥65 years), sex, race/ethnicity (non-Hispanic White, non-Hispanic Black, Mexican American, other Hispanic, Asian/other), education (<high school graduate, high school graduate, some college or Associate’s degree, college graduate or above), and income (income-to-poverty ratio <1.3, 1.3–2.99, and ≥3, representing the ratio of family income, adjusted for family size, to the federal poverty level)."

Among their findings:

• 6.8% (95% CI: 5.4%-8.1%) had optimal cardiometabolic health from 2017 to 2018, which was a decline from 1999 to 2000 (P_trend=0.02).
• Optimal adiposity levels decreased from 33.8% (95% CI: 30.9%-36.6%) to 24.0% (95% CI: 21.5%-26.4%) compared with poor levels, which saw an increase from 47.7% (95% CI: 43.8%-51.5%) to 61.9% (95% CI: 58.6%-65.2%).
• Glucose levels declined from 59.4% (95% CI: 56.0%-62.7%) to 36.9% (95% CI: 34.5%-39.2%) compared with poor levels with an increase from 8.6% (95% CI: 7.2%-10.0%) to 13.7% (95% CI: 12.4%-14.9%).
• There was a more modest decrease in optimal blood pressure 40.3% (95% CI: 37.2%-43.5%) to 36.5% (95% CI:34.2%-38.7%) (P_trend=0.03) and poor levels remained stable from 19.2% (95% CI: 16.7%-21.7%) to 19.5% (95% CI: 17.6%-21.4%).
• There was an increase in the prevalence of optimal blood lipids levels from 29.9% (95% CI: 26.8%-33.0%) to 37.0% (95% CI: 34.0%-39.9%), with poor levels declining from 28.3% (95% CI: 25.2%-31.4%) to 14.7% (95% CI: 12.6%-16.8%).

"Disparities by age, sex, education, and race/ethnicity were evident in all years, and generally worsened over time," O’Hearn and colleagues wrote. "By 2017-2018, prevalence of optimal cardiometabolic health was lower among Americans with lower (5.0% [95% CI: 2.8%-7.2%]) versus higher education (10.3% [95% CI: 7.6%-13.0%]); and among Mexican American (3.2% [95% CI: 1.4%-4.9%]) versus non- Hispanic White (8.4% [95% CI: 6.3%-10.4%]) adults."

The study authors noted during the two decades of the study period — "U.S. adults age 65+ years increased from 15.8% to 20.4%, whereas those aged 20-34 years declined from 31.8% to 27.6%The proportion identifying as non-Hispanic White adults decreased from 70.3% to 62.2%, and those identifying as Other races (including Asian and multiracial) increased from 4.4% to 10.5%. Educational attainment grew, whereas family income distributions were relatively stable."

O’Hearn and colleagues note that their study results call for "new multisectoral approaches to address clinical care of cardiometabolic components, the food and built environment, and supportive policy and business innovations at the population level. In addition, the identified health disparities support prioritization of population-level interventions toward traditionally marginalized groups. Major new national investments in foundational and translational research, public and private health care, leveraging of federal nutrition assistance programs, use of regulatory powers, and increased cross government coordination can each help improve cardiometabolic health and associated health disparities."

Added Kottke and colleagues: "To understand the origins of cardiovascular disease and how interventions might control it, the Boston-based cardiologist Paul Dudley White urged the study of ’nature’s experiments’ that occur when similar populations live under different conditions and differing populations live under similar conditions. This advice led to the epidemiologic observations, clinical trials, and community-based interventions that generated the massive declines in coronary heart disease death rates in the developed economies. If personal commitment by all and a societal will to act emerge, the same strategy could also contribute the knowledge and action necessary to reverse the rising burden of obesity and put the world’s populations back on the path to cardiovascular health."

Limitations of O’Hearn et al’s study include the NHANES database that focuses on population health not individual health, data on fasting metrics were missing in some cases and medication usage may have been misclassified.

The study was supported by the National Institutes of Health and the National Heart, Lung, and Blood Institute, Bethesda, Maryland.

O’Hearn and Kottke disclosed no relevant relationships.

O’Hearn M, et al " Trends and disparities in cardiometabolic health among U.S. adults, 1999-2018" J Amer Coll Cardiol 2022; 80(2): 138-151.

Kottke TE, et al "Failing cardiovascular health: A population Code Blue" J Amer Coll Cardiol 2022; 80(2): 152-154.