Associations between race, healthcare coverage, adiposity, and cardiometabolic risk among underserved U.S adolescents

Background Obesity in youth contributes to lifelong cardiometabolic disorders, including cardiovascular disease, type 2 diabetes, hypertension, and dyslipidemia, yet prevention efforts have sustained little impact on population health. In the US, obesity affects 21% of youth aged 2–19, with disproportionate risk among ethnoracial minorities. While health coverage influences access to prevention, its interaction with adiposity and cardiometabolic risk is unknown, particularly among African American (AA) and Hispanic (H) adolescents. Clarifying this relationship can inform decision-making to address the clinical and systemic burden of disease. Purpose To characterize associations between healthcare coverage, adiposity, and cardiometabolic risk profiles in a large sample of underserved AA and H adolescents. Methods A cross-sectional retrospective analysis (2018–2020 ± 6 weeks) was conducted among adolescents 12–17y. Data was analyzed using R (3.6.3); group differences assessed via t-test and χ². Multivariate logistic regression evaluated associations between exposures (age, sex, race/ethnicity, insurance type, adiposity) and outcomes (impaired glucose metabolism [IGM via A1c], metabolic syndrome [metS], elevated BP, abnormal lipids [low HDL, elevated total cholesterol, LDL, or triglycerides], MAFLD [ALT], and inflammation [hs-CRP, fibrinogen]) adjusted for age and sex. Results Among 2,119 adolescents (31.7% AA, 67.3% H; mean age 13.8y), cardiometabolic risk profile compared was more severe in AA regardless of coverage type, with higher severe obesity (3.0x), elevated BP (1.6x), hypertension (1.7x) pre-diabetes (3.0x), diabetes (7.0x), and inflammation (1.2x). Commercial coverage was associated with worsened outcomes than Medicaid, including higher severe obesity (2.5x), pre-diabetes (1.8x), LDL-C (2.2x), inflammation (1.2x), and metS (1.3x). Consequently, disparities in risk were highest among commercially insured AA, with the highest obesity/severe obesity (68.1%), hypertension (23.9%), IGM (38.8%), and metS (24.5%). Though disparities within H were milder by coverage, Medicaid H had dyslipidemia (1.8x, driven by 5.0x higher hypertriglyceridemia), and MAFLD (1.6x), despite a lower adiposity (1.7x more overweight) than AA. Conclusions Commercial insurance was associated with severity of cardiometabolic risk. Regardless of coverage, AA exhibit a more atherogenic risk profile, while H exhibit more metabolic-driven abnormalities. These findings echo prior studies indicating disparate susceptibility to atherosclerotic CVD among AA originating youth and compounding into adulthood. Given the limitations in commercial insurance options, we are observing the impact of disincentivizing care-seeking for early detection and prevention. This adds to the barriers that AA face in addressing their underlying CVD morbimortality.