Geographic Variation in Cardiometabolic and Lifestyle Risk Factors Across US States, 2011 to 2021

Although cardiovascular death rates vary markedly across US states, little is known about whether state-based inequities in the burden of cardiometabolic and lifestyle risk factors have changed over the past decade. We conducted a serial cross-sectional analysis of US adults using the Behavioral Risk Factor Surveillance System (BRFSS) survey, to evaluate changes in the age- and sex-adjusted prevalence of cardiometabolic risk factors (diabetes, hypertension, hyperlipidemia, and obesity) and lifestyle risk factors (binge alcohol drinking, physical inactivity, and cigarette smoking) across US states from 2011 to 2021. The study population included 945,160 adults in 2011 and 2021. The age- and sex-adjusted prevalence of diabetes (10.9% [95% CI, 10.7%, 11.0%] to 12.4% [12.2%, 12.6%]), hypertension (32.4% [32.1%, 32.7%] to 33.7% [33.4%, 34.0%]), and obesity (27.5% [27.2%, 27.7%] to 33.1% [32.8%, 33.5%]) increased from 2011 to 2021, while hyperlipidemia decreased (38.5% [38.2%, 38.8%] to 35.5% [35.2%, 35.9%]). State-based inequities in the prevalence of diabetes, hypertension, and obesity widened over this period. Across lifestyle factors, the prevalence of binge alcohol use (18.3% [18.0%, 18.5%] to 15.4% [15.2%, 15.7%]), physical inactivity (25.7% [25.4%, 27.4%] to 24.0% [23.6%, 23.7%]), and cigarette smoking (20.1% [19.8%, 20.3%] to 13.4% [13.2%, 13.7%]) decreased, while state-based inequities across these factors generally narrowed. In conclusion, the prevalence of hypertension, diabetes mellitus, and obesity increased among US adults from 2011 to 2021 while state-based inequities in the prevalence of these risk factors widened. In contrast, binge alcohol drinking, physical inactivity, and cigarette smoking all declined. Our findings suggest an urgent need for targeted strategies to address widening state-based inequities in cardiometabolic risk factors.