Geographic Variations in Cardiovascular Health in the United States: Contributions of State- and Individual-Level Factors

Background-Improving cardiovascular health (CVH) of all Americans by 2020 is a strategic goal of the American Heart Association. Understanding the sources of variation and identifying contextual factors associated with poor CVH may suggest important avenues for prevention. Methods and Results-Cross-sectional data from the Behavioral Risk Factor Surveillance System for the year 2011 were linked to state-level coronary heart disease and stroke mortality data from the National Vital Statistics System and to state-level measures of median household income, income inequality, taxes on soda drinks and cigarettes, and food and physical activity environments from various administrative sources. Poor CVH was defined according to the American Heart Association definition using 7 selfreported CVH metrics (current smoking, physical inactivity, obesity, poor diet, hypertension, diabetes, and high cholesterol). Linked micromap plots and multilevel logistic models were used to examine state variation in poor CVH and to investigate the contributions of individual-and state-level factors to this variation. We found significant state-level variation in the prevalence of poor CVH (median odds ratio 1.32, P<0.001). Higher rates of poor CVH and cardiovascular disease mortality were clustered in the southern states. Minority and low socioeconomic groups were strongly associated with poor CVH and explained 44% of the state-level variation in poor CVH; state-level factors explained an additional 28%. State-level median household income (odds ratio 0.89; 95% CI 0.84-0.94), taxes on soda drinks (odds ratio 0.94; 95% CI 0.89-0.99), farmers markets (odds ratio 0.91; 95% CI 0.85-0.98), and convenience stores (odds ratio 1.09; 95% CI 1.01-1.17) were predictive of poor CVH even after accounting for individual-level factors. Conclusions-There is significant state-level variation in poor CVH that is partly explained by individual-and state-level factors. Additional longitudinal research is warranted to examine the influence of state-level policies and food and physical activity environments on poor CVH.