Cardiovascular risk factor prevalence, treatment, and control among US adults by income, 2009-2023

Background Cardiovascular (CV) mortality is rising in the US, and low-income adults bare a greater burden of CV risk factors than their higher-income counterparts. The COVID-19 pandemic threatened to widen these disparities, but relief policies expanding healthcare access & affordability may have had a protective effect. Understanding how CV risk factors changed before and after the pandemic -- and whether trends differed by income -- is critical for addressing disparities in CV health nationwide. Purpose To assess changes in CV risk factor prevalence, treatment, and control among US adults from 2009 to 2023, and to determine whether post-pandemic trends deviated from pre-pandemic trajectories, overall and by income. Methods We included adults age ≥ 18 years from the 2009-2010 to the 2021-2023 cycles of the National Health and Nutrition Examination Survey, a nationally representative dataset with clinical, biometric, and laboratory data. Low-income was defined as <200% of the federal poverty level. CV risk factors (hypertension, diabetes, high cholesterol, obesity, and smoking) were defined by clinical guidelines (Table). We estimated age- and sex- adjusted prevalence, treatment, and control rates from 2009-2023, and used linear probability models and Wald tests to assess pandemic-related changes. A significant "level-shift" indicated that the post-pandemic values deviated from pre-pandemic trends. Results Of the 62,108 adults (weighted mean age 46.3 years; 52% female), 28,598 were low-income. Hypertension prevalence, treatment and control were stable from 2009-2023, but post-pandemic, prevalence declined more than expected (level shift -3.1 percentage points [95% CI -5.8 ,-0.5]) and treatment rates increased, driven by gains among low-income adults (+7.8 [1.8, 13.8]). Diabetes prevalence rose from 10.8% in 2009 to 14.1% in 2023, and post-pandemic, glycemic control declined sharply among low-income adults (-8.7 [-16.7, -0.6]). High cholesterol prevalence, treatment, and control improved from 2009-2023, but despite post-pandemic treatment gains (+5.8 [1.6, 10.1] for low-income adults), control rates declined (-3.9 [-7.4, -0.5]). Obesity increased steadily, while smoking rates declined, with no significant pandemic-related shifts (Table, Figure). Conclusion Between 2009-2023, lipid management improved but diabetes prevalence rose among US adults. Post-pandemic, treatment rates for high cholesterol and hypertension increased, particularly among low-income adults, likely due to expansions in telehealth, mail-order pharmacies, and insurance coverage. However, cholesterol control rates declined and glycemic control worsened among low-income adults, possibly due to pandemic-related disruptions in health behaviors and A1c & lipid monitoring. As pandemic-era policies end, targeted interventions will be critical for sustaining treatment gains, restoring control rates, and addressing income-based disparities in diabetes management.