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• W4213360701 abstract "HomeCirculationVol. 145, No. 7Geographic Differences in Prepregnancy Cardiometabolic Health in the United States, 2016 Through 2019 Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessLetterPDF/EPUBGeographic Differences in Prepregnancy Cardiometabolic Health in the United States, 2016 Through 2019 Natalie A. Cameron, MD, Priya M. Freaney, MD, Michael C. Wang, BA, Amanda M. Perak, MD, MS, Brigid M. Dolan, MD, MEd, Matthew J. O’Brien, MD, S. Darius Tandon, PhD, Matthew M. Davis, MD, William A. Grobman, MD, MBA, Norrina B. Allen, PhD, Philip Greenland, MD, Donald M. Lloyd-Jones, MD, ScM and Sadiya S. Khan, MD, MSc Natalie A. CameronNatalie A. Cameron https://orcid.org/0000-0002-0613-7580 Department of Medicine, Division of Internal Medicine and Geriatrics (N.A.C., M.C.W., B.M.D., M.J.O.), Northwestern University Feinberg School of Medicine, Chicago, IL. Search for more papers by this author , Priya M. FreaneyPriya M. Freaney https://orcid.org/0000-0001-6466-2407 Division of Cardiology (P.M.F., P.G., D.M.L.-J., S.S.K.), Northwestern University Feinberg School of Medicine, Chicago, IL. Search for more papers by this author , Michael C. WangMichael C. Wang https://orcid.org/0000-0002-1042-8428 Department of Medicine, Division of Internal Medicine and Geriatrics (N.A.C., M.C.W., B.M.D., M.J.O.), Northwestern University Feinberg School of Medicine, Chicago, IL. Search for more papers by this author , Amanda M. PerakAmanda M. Perak Department of Preventive Medicine (A.M.P., N.B.A., P.G., D.M.L.-J., S.S.K.), Northwestern University Feinberg School of Medicine, Chicago, IL. Department of Pediatrics (A.M.P., M.M.D.), Northwestern University Feinberg School of Medicine, Chicago, IL. Search for more papers by this author , Brigid M. DolanBrigid M. Dolan Department of Medicine, Division of Internal Medicine and Geriatrics (N.A.C., M.C.W., B.M.D., M.J.O.), Northwestern University Feinberg School of Medicine, Chicago, IL. Search for more papers by this author , Matthew J. O’BrienMatthew J. O’Brien Department of Medicine, Division of Internal Medicine and Geriatrics (N.A.C., M.C.W., B.M.D., M.J.O.), Northwestern University Feinberg School of Medicine, Chicago, IL. Search for more papers by this author , S. Darius TandonS. Darius Tandon Department of Medical Social Sciences (S.D.T.), Northwestern University Feinberg School of Medicine, Chicago, IL. Search for more papers by this author , Matthew M. DavisMatthew M. Davis Department of Pediatrics (A.M.P., M.M.D.), Northwestern University Feinberg School of Medicine, Chicago, IL. Search for more papers by this author , William A. GrobmanWilliam A. Grobman Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine (W.A.G.), Northwestern University Feinberg School of Medicine, Chicago, IL. Search for more papers by this author , Norrina B. AllenNorrina B. Allen Department of Preventive Medicine (A.M.P., N.B.A., P.G., D.M.L.-J., S.S.K.), Northwestern University Feinberg School of Medicine, Chicago, IL. Search for more papers by this author , Philip GreenlandPhilip Greenland https://orcid.org/0000-0002-6327-2439 Division of Cardiology (P.M.F., P.G., D.M.L.-J., S.S.K.), Northwestern University Feinberg School of Medicine, Chicago, IL. Department of Preventive Medicine (A.M.P., N.B.A., P.G., D.M.L.-J., S.S.K.), Northwestern University Feinberg School of Medicine, Chicago, IL. Search for more papers by this author , Donald M. Lloyd-JonesDonald M. Lloyd-Jones https://orcid.org/0000-0003-0847-6110 Division of Cardiology (P.M.F., P.G., D.M.L.-J., S.S.K.), Northwestern University Feinberg School of Medicine, Chicago, IL. Department of Preventive Medicine (A.M.P., N.B.A., P.G., D.M.L.-J., S.S.K.), Northwestern University Feinberg School of Medicine, Chicago, IL. Search for more papers by this author and Sadiya S. KhanSadiya S. Khan Correspondence to: Sadiya S. Khan, MD, MS, Assistant Professor of Medicine, Division of Cardiology, Department of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 North Lake Shore Drive, 14-002, Chicago, IL 60611. Email E-mail Address: [email protected] https://orcid.org/0000-0003-0643-1859 Division of Cardiology (P.M.F., P.G., D.M.L.-J., S.S.K.), Northwestern University Feinberg School of Medicine, Chicago, IL. Department of Preventive Medicine (A.M.P., N.B.A., P.G., D.M.L.-J., S.S.K.), Northwestern University Feinberg School of Medicine, Chicago, IL. Search for more papers by this author Originally published14 Feb 2022https://doi.org/10.1161/CIRCULATIONAHA.121.057107Circulation. 2022;145:549–551Poor prepregnancy cardiometabolic health is independently associated with severe maternal morbidity and mortality, adverse pregnancy outcomes, and long-term cardiovascular disease risk.1–3 Given known state-level differences in pregnancy-related outcomes,2 this analysis sought to describe the geographic distribution of prepregnancy cardiometabolic health among states in the United States from 2016 to 2019.This was a nationwide, serial cross-sectional analysis of maternal birth records from all live births in the Centers for Disease Control and Prevention Natality Database from 2016 to 2019, when all states adopted a revised birth certificate containing information on body mass index (BMI) and prepregnancy diabetes. Individuals 20 to 44 years of age with available data on prepregnancy BMI, diabetes, and hypertension were included. Because of censoring of limited sample size at the state level (<10) for individuals ≥44 years of age, older women were not included. Favorable prepregnancy cardiometabolic health was defined by the following health factors available in the database: normal weight (BMI 18–24.9 kg/m2), absence of diabetes, and absence of hypertension. The age-specific and age-standardized prevalence of favorable cardiometabolic health and prevalence of each risk factor (overweight [BMI ≥25 kg/m2], obesity [BMI ≥30 kg/m2], diabetes, and hypertension) were calculated. The Joinpoint software was used to quantify the annual average percent change overall, by census region, and by state. The percentage of individuals with live births with a high school education or less or enrolled in Medicaid was determined for each state and correlated with cardiometabolic health. A sensitivity analysis restricted to nulliparous individuals was conducted. In a secondary analysis, nonsmoking status was included in the definition of favorable cardiometabolic health. This study was exempt from institutional review board review because of deidentified and publicly available data. All data and materials have been made publicly available through the National Vital Statistics System at the Centers for Disease Control and Prevention WONDER system (Wide-Ranging Online Data for Epidemiological Research) and can be accessed at https://wonder.cdc.gov/natality.html.Of 14 174 625 individuals with live births, 81.4% were 20 to 34 years of age, 22.7% were Hispanic/Latina, 14% were non-Hispanic Black, and 52.7% were non-Hispanic White. From 2016 to 2019, prevalence of favorable cardiometabolic health per 100 live births decreased from 43.5 (95% CI, 43.3–43.6) to 40.2 (40.1–40.2; average percent change, –2.6%/year [–2.9% to –2.4%/year]; Figure). Prevalence of favorable cardiometabolic health declined similarly in each 5-year age stratum from 2016 to 2019 and ranged from 37.1 (36.8–37.3) in 40- to 44-year-old individuals to 42.2 (42.0–42.2) in 30- to 34-year-old individuals in 2019.Download figureDownload PowerPointFigure. State-level differences. State-level differences in age-standardized prevalence of favorable prepregnancy cardiometabolic health in 2016 (A) and 2019 (B) and percentage of individuals with a high school education or less (C) and enrolled in Medicaid (D) among 20- to 44-year-old individuals with live births. Prevalence of favorable prepregnancy cardiometabolic health in the United States declined from 2016 to 2019 in each state. Geographic patterns in favorable prepregnancy cardiometabolic health, high school education status, and Medicaid enrollment were similar at the state level in 2019.All regions and states experienced declines in favorable cardiometabolic health; however, there was significant geographic variation. In 2019, prevalence of favorable prepregnancy cardiometabolic health was lower in the South (38.2 [38.1–38.3]) and Midwest (38.8 [38.6–38.9]) compared with the West (42.2 [42.1–42.3]) and Northeast (43.6 [43.5–43.7]) and ranged from 31.2 (30.7–31.7) in Mississippi to 47.2 (46.7–47.6) in Utah. State-level patterns were similar for individual risk factors. There was an inverse correlation between state-level percentage of favorable cardiometabolic health and state-level percentage of high school education or less (r=–0.62, P<0.01) and enrollment in Medicaid (r=–0.52, P<0.01) at time of live birth in 2019.In the sensitivity analysis, prevalence and trends of favorable cardiometabolic health were similar in nulliparous individuals from 2016 (48.7 [48.6–48.8]) to 2019 (45.0 [44.9–45.1]; average percentage change, –2.6%/year [–3.1 to –2.2%/year]) compared with the overall population. In addition, geographic and temporal patterns were similar when favorable cardiometabolic health included nonsmoking status.These data demonstrate that fewer than half of individuals with live births entered pregnancy with favorable cardiometabolic health. The proportion of individuals with favorable prepregnancy cardiometabolic health declined significantly by 3.2% between 2016 and 2019. There was also substantial geographic variation in cardiometabolic health, with a pattern of less favorable health in the southern and midwestern states, which reflects state-level differences in the prevalence of overweight/obesity, hypertension, and diabetes. State-level differences in educational status and Medicaid enrollment were associated with prepregnancy cardiometabolic health. Future work is needed to identify additional upstream social determinants of health that drive geographic differences in prepregnancy cardiometabolic health and establish effective programs to eliminate disparities, such as the planned National Institutes of Health/National Heart, Lung, and Blood Institute Early Intervention to Promote Cardiovascular Health in Mothers and Children program.4 Furthermore, similar results among nulliparous individuals highlights the need to target cardiometabolic health before the first pregnancy.Limitations of these analyses include the potential miscoding of prepregnancy cardiometabolic health factors. However, because validation studies using birth certificate data typically report low sensitivity and high specificity for cardiometabolic disease,5 this analysis likely overestimates the prevalence of favorable cardiometabolic health. In addition, data on cholesterol, diet, or physical activity were not available, and the database does not distinguish between types 1 and 2 diabetes. Only individuals with live births were included, which may eliminate a potentially high-risk group; however, late pregnancy losses represent <0.3% of all pregnancies. Despite these limitations, the Natality Files contain the largest database for live births in the United States and allowed for the quantification of key prepregnancy health factors by state.These data reveal critical deficiencies and geographic disparities in prepregnancy cardiometabolic health. Future research is needed to equitably improve health before pregnancy and quantify the potential benefits in cardiovascular disease outcomes for birthing individuals and their offspring.Article InformationSources of FundingThis work was supported by grants from the National Heart, Lung, and Blood Institute (1R01HL159250 and 1U01HL160279-01) and the American Heart Association Transformational Project Award (19TPA34890060) to Dr Khan. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr Cameron is supported by the Northwestern University Feinberg School of Medicine Division of General Internal Medicine and Geriatrics Research Fellowship.Disclosures None.FootnotesCirculation is available at https://www.ahajournals.org/journal/circThis article is part of the Science Goes Red™ collection. Science Goes Red™ is an initiative of Go Red for Women®, the American Heart Association’s global movement to end heart disease and stroke in women.For Sources of Funding and Disclosures, see page 551.The podcast and transcript are available as Supplemental Material at https://www.ahajournals.org/doi/suppl/10.1161/CIRCULATIONAHA.121.057107.Correspondence to: Sadiya S. Khan, MD, MS, Assistant Professor of Medicine, Division of Cardiology, Department of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 North Lake Shore Drive, 14-002, Chicago, IL 60611. Email [email protected]eduReferences1. Harville EW, Viikari JS, Raitakari OT. Preconception cardiovascular risk factors and pregnancy outcome.Epidemiology. 2011; 22:724–730. doi: 10.1097/EDE.0b013e318225c960CrossrefMedlineGoogle Scholar2. US Department of Health and Human Services.The Surgeon General’s Call to Action to Improve Maternal Health.Published 2020. Accessed July 31, 2021. https://www.hhs.gov/sites/default/files/call-to-action-maternal-health.pdfGoogle Scholar3. Yanit KE, Snowden JM, Cheng YW, Caughey AB. The impact of chronic hypertension and pregestational diabetes on pregnancy outcomes.Am J Obstet Gynecol. 2012; 207:333.e1–333.e6. doi: 10.1016/j.ajog.2012.06.066CrossrefGoogle Scholar4. US Department of Health and Human Services.Early Intervention to Promote Cardiovascular Health of Mothers and Children (ENRICH) Multisite Clinical Centers (Collaborative UG3/UH3 Clinical Trial Required).Accessed August 14, 2021. https://grants.nih.gov/grants/guide/rfa-files/RFA-HL-22-007.htmlGoogle Scholar5. Dietz P, Bombard J, Mulready-Ward C, Gauthier J, Sackoff J, Brozicevic P, Gambatese M, Nyland-Funke M, England L, Harrison L, et al.. Validation of selected items on the 2003 U.S. standard certificate of live birth: New York City and Vermont.Public Health Rep. 2015; 130:60–70. doi: 10.1177/003335491513000108CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Chambers M, De Zoysa M and Hameed A (2022) Screening for Cardiovascular Disease in Pregnancy: Is There a Need?, Journal of Cardiovascular Development and Disease, 10.3390/jcdd9030089, 9:3, (89) Ramirez V, Ferraro-Borgida M and Lindsay S (2022) Antiabortion Laws and Implications for Patients With Cardiovascular Disease in Pregnancy, JAMA Cardiology, 10.1001/jamacardio.2022.1665 February 15, 2022Vol 145, Issue 7Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.121.057107PMID: 35157521 Originally publishedFebruary 14, 2022 KeywordsdemographypregnancyhealthPDF download Advertisement SubjectsDiabetes, Type 2EpidemiologyHypertensionObesityPregnancy" @default.
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