‘Code Blue’ for the Dire CVD Health Status of Most US Adults

Two new studies are raising alarm bells over significant declines in the cardiovascular health of the US population, a decline that is driven by increasing rates of obesity and diabetes.

In one study, researchers report that less than 7.0% of Americans had optimal cardiometabolic health, with significant disparities seen across age groups, sex, education levels, and race/ethnicity. The second analysis showed equally alarming trends, with researchers finding that control of risk factors in patients with cardiovascular disease is suboptimal and appears to be stagnating.

Thomas Kottke, MD, MSPH (HealthPartners, Minneapolis, MN), who wrote an editorial along with Ajay Gupta, MD, PhD, and Randal Thomas, MD, MS (also HealthPartners), said that if the United States population were an individual patient, “someone would probably be calling a code blue.”

“The reported findings of secular trends of stalling and worsening cardiometabolic profile should not be a surprise as the obesogenic lifestyle—unhealthy dietary patterns that feature foods and beverages high in saturated fat, sugar, salt, and calories; little or no physical activity; alcohol; too much or too little sleep; and hours of screen time—seems to be the norm for many Americans and other populations,” they write.

To regain momentum in the fight against CVD, something that isn’t going to happen overnight, physicians and policy makers will need to attack the problem at the personal, clinical, and community level, say editorialists.

Eugene Yang, MD, MS (University of Washington, Bellevue), chair of the American College of Cardiology’s Prevention of Cardiovascular Disease Council, said both papers paint an alarming picture where multiple CVD risk factors are going in the wrong direction. “Our national efforts to try to improve many of these important risk factors have really failed to be successful,” Yang told TCTMD, adding that the new data should sound a call to action for efforts to reverse the trends.

Clearly, these are humbling results that suggest a need to reengineer care. Seth Martin

The studies also draw attention to significant disparities among different ethnic groups, said Yang. For example, the cardiometabolic health of Mexican Americans is particularly poor in one study, while the other shows non-Hispanic Black adults with CVD have disproportionately worse control of various risk factors.

“Even though we have the guidelines, social determinants of health are really critical,” he said. “Access to care, food security, housing security—those are the things that are disproportionately impacting some of these communities. These social determinants affect all these different groups—Asians, Black Americans, Hispanic people—and that’s where we’re seeing a lot of the challenges.”

Both studies and editorial were published July 4, 2022, in the Journal of the American College of Cardiology.

‘Stubborn’ Trends in CVD Patients

In the first study, which was led by Yumin Gao, ScM (Johns Hopkins University School of Medicine, Baltimore, MD), researchers wanted to examine the 20-year trends in the cardiovascular risk profile of adults with CVD. To do so, they took a cross-sectional look at 6,335 adults with CVD participating in the National Health and Nutrition Examination Survey (NHANES) between 1999 and 2018. Over five surveys, the mean age of the study population ranged from 63.8 to 65.4 years and the proportion of men ranged from 49.9% to 55.7%. The percentage of non-Hispanic Black and Hispanic participants ranged from 11.3% and 7.8% to 13.0% and 9.5%, respectively.

“We knew there’d be gaps in risk factor control, but we were surprised to see how stubborn these have been,” senior researcher Seth S. Martin, MD, MHS (Johns Hopkins University School of Medicine), told TCTMD. “There’s been such exciting developments in the field of cardiology and preventive cardiology, with many new treatments we’ve been fortunate to have, but this paper really asks how well we’re doing using those new therapies. Clearly, these are humbling results that suggest a need to reengineer care.”

Overall, risk factor control either worsened or remain unchanged in patients with CVD between 1999 and 2018. The lone bright spot was in the control of non-HDL cholesterol levels.

• The proportion of patients with ideal hemoglobin A_1c values (< 7% with self-reported diabetes or < 5.7% without diabetes) declined to 52.4% in 2015-2018.
• The percentage of patients with optimal blood pressure (< 130/80 mm Hg) worsened after 2010, with just 49% of adults reporting optimal control in the last NHANES survey.
• Obesity is also on the rise, with 18% of adults reporting body mass index (BMI) less than 25 kg/m² in 2015-2018.
• Smoking rates were unchanged. Overall, 78% of adults reported never smoking or having quit in the last 2015-2018 survey. 
• Worsening trends for physical activity were observed overall, with just 22% of adults getting enough moderate-to-vigorous exercise in 2015-2018.
• Only 1% of adults achieved an ideal dietary profile as measured by the healthy eating index, but this was unchanged over time.
• Non-HDL cholesterol levels improved over the 20-year period: 30% of adults had non-HDL cholesterol levels less than 100 mg/dL in 2015-2018.

The researchers saw different trends in the percentage of adults with ideal risk profiles based on race/ethnicity, specifically for non-HDL cholesterol, smoking, and physical activity.

For example, among Hispanic adults, non-HDL cholesterol levels improved at a slower rate than the overall population. In contrast, more Hispanic adults were getting physically active over time and met the targets while physical activity was unchanged in white and non-Hispanic Black adults. Concerningly, smoking appeared to be on the rise in non-Hispanic Black adults. Also, fewer non-Hispanic Black adults met the optimal blood-pressure targets. Asian adults were less likely to have ideal hemoglobin A_1c values than white adults, but they did have better BMIs and were less likely to smoke. 

Only One in 15 With Optimal Cardiometabolic Health

In the second study, Meghan O’Hearn, MS (Tufts University, Boston, MA), and colleagues also turned to NHANES, focusing on trends in cardiometabolic health from 1999 to 2018 in patients largely without CVD. O’Hearn told TCTMD the focus of previous analyses had been on abnormal levels of different risk factors or disease conditions, such as dyslipidemia or metabolic syndrome. Their analysis focused instead on the prevalence of optimal health in the US. 

Overall, just 6.8% of adults in 2017-2018 had optimal cardiometabolic health, which was defined by ideal control of blood glucose levels, cholesterol levels, blood pressure, and adiposity, as well as having no clinical history of CVD.

“We knew that there was a cardiometabolic health crisis in the US, but we didn’t really understand the magnitude of it,” O’Hearn said. “I mean, 7% is a pretty low number. Roughly one in 15 US adults have good cardiometabolic health. I would say that’s pretty striking and alarming, and it’s definitely a call to action for clinicians, public health professionals, and policy makers to think about how we address it.”

There needs to be a lot stronger political will to address our very broken food system. Meghan O’Hearn

Adults aged 65 years and older were less likely to have optimal cardiometabolic health (0.4%) while just 15.3% of those aged 20 to 34 years had an ideal cardiometabolic profile. Among men, 3.1% had optimal control of all five cardiometabolic components compared with 10.4% of women. Over time, the prevalence of optimal cardiometabolic health of non-Hispanic white adults improved from 7.0% to 8.4% but decreased for Mexican American adults, as well as Hispanic adults, non-Hispanic Black adults, and those identifying as other races. Optimal cardiometabolic health varied little by income, but there were disparities seen across education levels achieved.

In terms of the individual components of cardiometabolic health, obesity and poor control of blood glucose levels were the two risk factors that worsened most over time. Between 1999 and 2018, the percentage of adults with a BMI < 25 kg/m² (and waist circumference ≤ 88 and 102 cm for women and men, respectively) declined from 33.8% to 24.0%. Optimal glucose levels declined from 59.4% to 36.9%. Optimal control of blood pressure also declined, although more modestly, say investigators. Control of blood lipids increased during the study period, which is likely due to medication use. History of CVD remained relatively stable over time.

The prevalence of metabolic syndrome increased from 36.2% in 1999-2000 to 47.3% in 2017-2018. Mexican American adults had the highest prevalence of metabolic syndrome—52.2% in 2017-2018—while Hispanic and non-Hispanic white adults had the lowest rates (45.9% and 46.6%, respectively). In general, the prevalence of the metabolic syndrome increased in each population subgroup.

More Frequent Touchpoints

Martin, the director of Johns Hopkins’ Center for Health Technology & Innovation, which is part of the American Heart Association’s Strategically Focused Research Network (SFRN), is working with his group, including Nino Isakadze, MD, MHS (Johns Hopkins School of Medicine), to further develop the CORRIE mobile health app. The app is meant to facilitate a hybrid approach to cardiac rehabilitation and to increase the number of patients who participate. The app will be tested in a clinical trial, but before that trial takes place, researchers wanted to get a sense of the current risk profile of CVD patients in the US.

“Knowing we have the tools to address the risk factors in front us, it’s disappointing to see our results at the national level,” said Martin. “The improvement in non-HDL cholesterol is encouraging and shows progress, but it’s not enough.”

In terms of how to alter current trends, Martin said there’s a need to make it easier for people to follow a healthy lifestyle in the real world. On the clinical side, changes in reimbursement are needed so that physicians and healthcare systems are compensated for counseling patients about lifestyle and getting various risk factors under control.

Our national efforts to try to improve many of these important risk factors have really failed to be successful. Eugene Yang

“That’s going to take more than seeing a patient in clinic every 6 months—that won’t get the job done,” he said. “Tracking blood pressure, adjusting therapy, coaching around lifestyle, adjusting cholesterol—it takes more frequent touchpoints. That’s where there’s an opportunity to find the balance between traditional clinic-based appointments but also telemedicine and digital-health approaches to increase the efficiency and reliability of care.”

Yang said that there are proven, effective therapies for many CVD risk factors, such as antihypertensive medications. But getting the drugs to patients, and getting them to take and adhere to them, can be a challenge, he added. For Yang, primordial prevention, which includes reinforcing healthy behaviors so that risk factors don’t develop, is critical.

“Things need to start at a very early level,” he said. “As you can see in the study, optimal cardiometabolic health almost goes completely away in the oldest population, whereas the younger population are much more likely—it’s still not great—to have better health. It tells us the interventions need to occur earlier. We need to be enforcing behavioral changes earlier to prevent the onset of high blood pressure, dyslipidemia, and obesity.”

A White House Conference Coming Soon

To TCTMD, O’Hearn said rising obesity in US, along with poor and worsening control of blood glucose, goes hand-in-hand with shoddy American diets. For that reason, there is a need to overhaul the current food system to address the poor diet quality, which is major driver of suboptimal cardiometabolic health.

“Other social determinants of health are also at play given the disparities we saw by ethnicity and education levels, but from our perspective there needs to be a lot stronger political will to address our very broken food system,” she said. Policy interventions, better consumer education, and engagement with the private sector will all be needed to fix it, she added.

Overall, O’Hearn said she’s optimistic about the possibility of change. “We’re at a really critical inflection point,” she said. “The COVID-19 pandemic and crisis did bring into the spotlight some of these health issues. About 60% of COVID-19 hospitalizations in the US are attributable to having some of these preexisting cardiometabolic health conditions. So [cardiometabolic health] is definitely in the spotlight right now but we actually need to see action and change.”

Later this year, the Biden-Harris administration is hosting a conference on hunger, nutrition, and health. This conference, the first in 50 years, will be focused on improving nutrition and physical activity levels and reducing diet-related diseases and health disparities. “We hope this will really catalyze change in terms of US food policy,” said O’Hearn.