Public health experts and data from the Centers for Disease Control and Prevention report a steady decline in cardiovascular health, including an increase in deaths from heart disease — specifically among middle-aged adults with low incomes.

New research led by investigators at Harvard-affiliated Beth Israel Deaconess Medical Center helps explain the recent reversal in cardiovascular mortality among the population and underscores the need to address the social determinants of health that contribute to it.

The findings, presented at the American Heart Association Scientific Sessions and published in the Annals of Internal Medicine, demonstrate a significant increase in cardiovascular risk factors among those aged 40 to 64 years, as well as enduring inequities between higher-income and low-income individuals.

“Our study highlights a smoldering cardiovascular health crisis among the younger segment of the U.S. population that warrants urgent public health and policy responses,” said corresponding author Rishi K. Wadhera, section head of Health Policy and Equity at the Richard A. and Susan F. Smith Center for Outcomes Research at BIDMC and associate professor of medicine at Harvard Medical School.

The low-income group experienced a significant increase in hypertension, while the higher income group experienced a significant rise in diabetes and obesity.

Wadhera and colleagues evaluated trends in the prevalence, treatment, and control of cardiovascular risk factors such as hypertension, obesity, and smoking of more than 20,000 adults ages 40-64 years who participated in a nationally representative health survey between 1999 and 2020. The team also assessed how social determinants of health, including income levels, insurance coverage, and access to routine care, were associated with cardiovascular health.

Among middled-aged adults, low-income adults consistently experienced higher rates of hypertension, diabetes, and cigarette use than their higher-income counterparts over the past two decades. The burden of several cardiovascular risk factors either worsened or remained unchanged for middle-aged adults, with differing trends by income level. The low-income group experienced a significant increase in hypertension, while the higher income group experienced a significant rise in diabetes and obesity.

“Concerningly, we observed that poor cardiovascular health remains concentrated in low-income middle-aged adults,” said lead author Michael Liu of the Medical School. “These disparities by income level persisted even after we accounted for insurance coverage, healthcare access, and food insecurity. These results emphasize the importance of addressing these and other social determinants of health that may contribute to the relationship between income and cardiovascular health, such as stable housing, green space for regular physical activity, medication affordability, environmental burdens, and adequate social support.”

Co-authors included: Rahul Aggarwal, Zhao-Nian Zheng, Robert W. Yeh, and Dhruv S. Kazi of BIDMC; and Karen E. Joynt Maddox of Washington University School of Medicine, Saint Louis.

This research was funded by the National Institutes of Health (R01HL164561).