Abstract
Objectives
The objective of this study was to assess the cardiovascular health status of baby boomers with diabetes mellitus (DM) in comparison to the same-age population with DM 10 years previously.
Methods
The study was conducted in baby boomers with DM using data from the National Health and Nutrition Examination Survey (NHANES) 2009–2012 compared with NHANES 1999–2002. Cardiovascular health metrics were derived from the American Heart Association’s Life’s Simple 7. The primary outcome was the comparison of the proportion of individuals with each characteristic, including healthy diet, healthy weight, not smoking, exercising regularly, and maintaining an optimal level of glycated hemoglobin (HbA1c), cholesterol, and blood pressure.
Results
Current baby boomers with DM (NHANES 2009–2012) had more obesity (70.9% vs 58.8%; P = 0.009) and a lower proportion of ideal physical activity (20.9% vs 31.7%; P = 0.01) than people of the same age 10 years ago; fewer than 1% adhere to an ideal healthy diet. Current baby boomers more often had ideal cholesterol (59.4% vs 47.2; P = 0.01) and reached an ideal HbA1c (51.0% vs 43.4%; P = 0.047). Blood pressure control, adherence to ideal diet, and smoking rates were not significantly different from 10 years ago. In logistic regression analyses controlling for likely confounders, baby boomers persisted in having more obesity and exercising less often, and reaching an ideal cholesterol level more often (P < 0.01).
Conclusions
Although improving in cholesterol and HbA1c, baby boomers demonstrated worsening in several key cardiovascular health indicators, particularly obesity and physical activity.
Keywords: cardiovascular, diet, exercise, obesity, hypertension
The 76.4 million baby boomers (individuals born in the United States between 1946 and 1964) represent close to one-fourth of the US population1 and are major contributors to the diabetes mellitus (DM) epidemic. It is projected that one in every four baby boomers soon will be living with this chronic disease.2,3 DM complications, disability, and the need for continuous management will put a greater demand on the healthcare system.4–7 The lifestyle habits of the baby boomer generation with DM are critical to their overall health and their cardiovascular risk. The baby boomers’ adherence to healthy lifestyle habits is likely to have profound implications on the health of the nation in the next few years because of the enormous size of the population cohort.4,7,8
The health status of the baby boomer generation has been examined in studies, with mixed results.9,10 Some studies have demonstrated lower rates of smoking and fewer heart attacks among baby boomers compared with previous generations, whereas others showed increased rates of DM and obesity.4,9–11
Based on evidence from randomized clinical trials and epidemiologic studies, the American Heart Association (AHA) identified seven ideal cardiovascular health metrics (“Life’s Simple 7”) to monitor health factors and behaviors at population levels.12 These factors are a key component of management of patients with DM. More information is needed regarding the adherence to healthy lifestyle habits and cardiovascular health characteristics of baby boomers with DM to assist public health policy makers in their efforts to address the nation’s health issues.13 As such, the goal of the present study was to compare the cardiovascular health characteristics of baby boomers with DM in the National Health and Nutrition Examination Survey (NHANES) 2009–2012 with the cardiovascular health characteristics from a same-age group of adults from 10 years previously in the NHANES 1999–2002.
Methods
Study Population
The NHANES is a series of complex and multistage surveys aiming to assess the health and nutritional status of the noninstitutionalized population of the United States. Detailed descriptions of the plan and operation of each survey have been published and NHANES received approval from the National Center for Health Statistics Research Ethics Review Board.14 To compare the difference in ideal cardiovascular health characteristics between baby boomers with DM and a similar population 10 years ago, we selected 46- to 64-year-old respondents from two cohorts, NHANES 1999–2002 and NHANES 2009–2012 (baby boomers), who responded positively to “told by a doctor that you have diabetes.”14
Definition of Cardiovascular Health Metrics
Life’s Simple 7, developed by the AHA as part of their 2020 goals, consists of seven key health factors and behaviors listed as blood pressure, physical activity, cholesterol, healthy diet, healthy weight, smoking status, and blood glucose. The metrics were chosen because of the important role they play in cardiovascular risk among all adults, especially baby boomers.10–13 The AHA definition of cardiovascular health metrics was modified according to our unique sample population and limitation of the information in the NHANES. The modified definition of ideal, intermediate, and poor cardiovascular health for each of the seven components for this study is presented in Table 1.
Table 1.
AHA definition of cardiovascular health metric (Life’s Simple 7)
| Levels | AHA definition | Modified definition | |
|---|---|---|---|
| Health factors | |||
| Blood pressure | Ideal | <120/<80 mm Hg, without treatment | <120/<80 mm Hg |
| Intermediate | SBP 120–139 or DBP 80–89 mm Hg or treated to <120/<80 mm Hg | SBP 120–139 or DBP 80–89 mm Hg | |
| Poor | SBP ≥140 or DBP ≥90 mm Hg | SBP ≥140 or DBP ≥90 mm Hg | |
| Fasting serum glucose | Ideal | <100 mg/dL, without treatment | HbA1C <7% |
| Intermediate | 100–125 mg/dL, or treated to <100 mg/dL | HbA1C 7%–9% | |
| Poor | ≥126 mg/dL | HbA1C >9% | |
| Total cholesterol | Ideal | <200 mg/dL. without treatment | <200 mg/dL |
| Intermediate | 200–239 mg/dL, treated to <200 mg/dL | 200–239 mg/dL | |
| Poor | ≥240 mg/dL | ≥240 mg/dL | |
| Behavioral factors | |||
| Smoking | Ideal | Never or quit >12 mo | Never (tobacco) or quit >12 mo (tobacco) |
| Intermediate | Former ≤12 mo | Former ≤12 mo (tobacco) | |
| Poor | Current | Current (tobacco) | |
| Physical activity | Ideal | ≥150 min/wk moderate or ≥75 min/wk vigorous or ≥150 min/wk moderate + vigorous | ≥150 min/wk moderate or ≥75 min/wk vigorous or ≥150 min/wk moderate + vigorous |
| Intermediate | 1–149 min/wk moderate or 1–74 min/wk vigorous or 1–149 min/wk moderate + vigorous | 1–149 min/wk moderate or 1–74 min/wk vigorous or 1–149 min/wk moderate + vigorous | |
| Poor | None | None | |
| Healthy weight | Ideal | <25 kg/m2 | <25 kg/m2 |
| Intermediate | 25–29.9 kg/m2 | 25–29.9 kg/m2 | |
| Poor | ≥30 kg/m2 | ≥30 kg/m2 | |
| Healthy dieta | Ideal | 4–5 components | 4–5 components |
| Intermediate | 2–3 components | 2–3 components | |
| Poor | 0–1 component | 0–1 component |
AHA, American Heart Association; DBP, diastolic blood pressure; HbA1C, glycated hemoglobin; SBP, systolic blood pressure.
The American Heart Association’s healthy diet category contains 5 components: consumption of fruits and vegetables (≥4.5 cups/day), fiber-rich whole grain (≥three 1-oz servings/day), sodium (<1500 mg/day), sugar-sweetened beverages (≤36 oz/week), and fish (≥two 3.5-oz servings/week). Our modified healthy diet category also consists of 5 components: consumption of fruits and vegetables (≥4.5 cups/day), fiber-rich whole grain (≥3 oz/day), sodium (<1500 mg/day), added sugar (<9 tsp/day for men, <6 tsp/day for women), and fish (≥2 times/week).
The AHA definition of cardiovascular health metrics includes the criteria of treatment to goal for two health factors: blood pressure and cholesterol. We used all of the available measurements for these two factors of the AHA’s metrics to determine whether a subject was in ideal, intermediate, or poor cardiovascular health for each factor.
Because the population studied currently had DM, rather than being at risk for DM, we used glycated hemoglobin (HbA1C) to evaluate subjects’ blood glucose level instead of fasting serum glucose used in the AHA definition. HbA1C values of <7%, 7% to 9%, and >9% were classified into ideal, intermediate, and poor categories of cardiovascular health metrics for blood glucose.
To locate information we could use to identify healthy diet components, we applied the Food Patterns Equivalents Database created by the US Department of Agriculture to designated NHANES cycles.15 Because no information regarding sugar-sweetened beverage intake was found in the two NHANES cohorts we selected, we replaced it with the added-sugar intake based on the daily intake recommendation from the AHA. Intake per day for fruits and vegetables, whole grains, sodium, added sugar, and number of times per week for all kinds of fish were calculated first, and then 1 point each was assigned to subjects who had goal consumption of fruits and vegetables (≥4.5 cups/day), whole grains (≥3 oz/day), sodium (<1500 mg/day), added sugar (<9 tsp/day for men and <6 tsp/day for women) and fish (≥2 times per week). The points then were summed and subjects were categorized into cardiovascular health dietary ranges such as 4 to 5 points for ideal, 2 to 3 points for intermediate, and 0 to 1 point for poor for the healthy diet component.
We followed the definitions of AHA cardiovascular health metrics to classify the three health behavioral factors, physical activity, healthy weight and smoking status. It was noted, however, that the NHANES questionnaires for physical activity changed after the 2005–2006 cycle. We adapted the physical activity data categories to maintain them as similar as possible to keep the physical activity metrics consistent.
Not all subjects had complete information on all seven categories of cardiovascular health metrics. To avoid losing any valuable information for the study, we included subjects with other missing values when comparing individual categories between the two cohorts but excluded them when we reported the percentages of subjects with ideal components in the overall cardiovascular health metrics calculations. Other demographic covariates used in the study included age, sex, race, and socioeconomic status (education and ratio of family income to poverty). Race was categorized consistent with NHANES data in four categories of white, black, Hispanic, and other race. Education was converted to a dichotomous variable with two levels of ≤11 years and >11 years completed. Ratio of family income to poverty was recoded as high for ≥1.0 and low for <1.0. Height and weight were obtained from the measured information for subjects. Body mass index also was classified as underweight (<18.5 mg/kg2), normal (≥18.5 and <25 mg/kg2), overweight (≥25 and <30 mg/kg2), and obese (≥30 mg/kg2) based on Centers for Disease Control and Prevention categories.16
Statistical Analysis
SAS version 9.3 (SAS Institute, Cary, NC) was used to perform the statistical analysis. Estimates for NHANES 1999–2002 were weighted using 4-year weights provided by the National Center for Health Statistics based on where the information was obtained. Estimates for NHANES 2009–2012 were weighted using 4-year weights calculated according to the method provided by the National Center for Health Statistics. Those weights were incorporated to account for the complex survey design (including oversampling), survey nonresponse, and poststratification. Presence of difference between the two NHANES periods was determined using a χ2 analysis with SURVEYFREQ (SAS Institute, Cary, NC).
To further analyze the data, we constructed a new dichotomous variable for each of seven components of the metrics based on our modified cardiovascular health metrics. Three health factors and healthy weight were recoded using “1” for ideal category and “0” for the other categories. As for the remaining three health behavior components, we combined categories of ideal and intermediate as “1” and used “0” for the category of poor. A logistic regression analysis using SURVEYLOGISTIC (SAS Institute) was then conducted to determine whether the results were consistent with the χ2 analysis when adjusted for age, sex, race, education and poverty level. P < 0.05 was used to count for statistical significance.
Results
Based on the inclusion criteria, a total of 969 participants, 358 from NHANES 1999–2002 and 611 from NHANES 2009–2012, were included in the study. Demographic characteristics of the study population are presented in Table 2.
Table 2.
Sociodemographic characteristics of subjects with type 2 diabetes mellitus (unweighted)
| Characteristic | NHANES 1999–2002 (n = 447)a | NHANES 2009–2012 (n = 787)a |
|---|---|---|
| Age, y, mean ± SD | 56.9 ± 5.6 | 56.5 ± 5.5 |
| Female sex, % | 46.3 | 42.9 |
| Weight, kg, mean ± SD | 88.8 ± 20.8 | 94.3 ± 24.6 |
| Race, % | ||
| Hispanic | 41.2 | 33.8 |
| White | 28.0 | 25.0 |
| Black | 25.7 | 31.9 |
| Other | 24.0 | 9.3 |
| Body mass index (kg/m2), % | ||
| Underweight (<18.5) | 0.24 | 0 |
| Normal weight (≥18.5–≤24.9) | 13.3 | 10.0 |
| Overweight (≥25–≤29.9) | 32.1 | 24.1 |
| Obese (≥30) | 54.5 | 65.9 |
| Family income:poverty ratio, mean ± SDb | 2.36 ± 1.55 | 2.27 ± 1.58 |
| Education, y, % | ||
| <12 | 49.7 | 34.4 |
| ≥12 | 50.3 | 65.6 |
SD, standard deviation.
Number of subjects in each cohort, some of whom may have missing values for some variables.
Ratio of annual family income to 100% of the poverty threshold (mean ± SD).
Among the sample population of 969 subjects, 774 had complete cardiovascular health metrics information and only one subject met all 7 ideal cardiovascular health metrics. The average years of having DM for all subjects were 10.5. The percentages of subjects meeting 3 to 7 ideal health metrics were 45.5% (95% confidence interval [CI] 38.7–52.3) in 1999–2002 and 49.3% (95% CI 41.6–57.1) in 2009–2012. There was no significant difference between the two cohorts (P = 0.46).
Table 3 presents the prevalence of modified cardiovascular health metrics in baby boomers with DM and same-age individuals 10 years previously in the two NHANES periods. The proportions of subjects across ideal, intermediate, and poor categories were similar in smoking status, healthy diet, and blood pressure. Significant differences were revealed in the other three components: healthy weight, physical activity, and total cholesterol. Baby boomers with diabetes had more obesity (69.9% vs 57.1%; P = 0.01) and a lower proportion of ideal physical activity (23.8% vs 30.6%; P = 0.04) than same-age individuals 10 years ago. More baby boomers than their counterparts, however, were in the ideal group from 1999–2002 cohort for total cholesterol (63.5% vs 47.3%; P = 0.0004) and for HbA1c (P = 0.047).
Table 3.
Comparison of the prevalence of the 7 components of cardiovascular health metrics (Life’s Simple 7) in subjects with type 2 DM in NHANES 1999–2002 and NHANES 2009–2012
| Cardiovascular health metric | NHANES 1999–2002 | NHANES 2009–2012 | Pa | ||
|---|---|---|---|---|---|
| No. | Prevalence, % | No. | Prevalence, % | ||
| Smoking | 0.44 | ||||
| Ideal | 175 | 42.3 | 343 | 47.4 | |
| Intermediate | 153 | 33.0 | 229 | 28.8 | |
| Poor | 105 | 24.7 | 174 | 23.9 | |
| Healthy weight, BMI | 0.009** | ||||
| Ideal, 18.5–24.9 | 56 | 15.1 | 76 | 8.9 | |
| Intermediate, 25.0–29.9 | 133 | 26.1 | 84 | 20.2 | |
| Poor, ≥30 | 226 | 58.8 | 503 | 70.9 | |
| Physical activity | 0.01* | ||||
| Ideal | 105 | 31.7 | 152 | 20.9 | |
| Intermediate | 88 | 23.0 | 122 | 19.2 | |
| Poor | 210 | 45.2 | 512 | 60.0 | |
| Total cholesterol, mg/dL | 0.01* | ||||
| Ideal | 195 | 47.2 | 423 | 59.4 | |
| Intermediate | 124 | 33.5 | 174 | 25.1 | |
| Poor | 89 | 19.2 | 120 | 15.4 | |
| Blood pressure, mm Hg | 0.21 | ||||
| Ideal | 97 | 27.3 | 230 | 34.1 | |
| Intermediate | 177 | 44.7 | 312 | 41.1 | |
| Poor | 141 | 28.0 | 206 | 24.7 | |
| HbA1C, % | 0.047* | ||||
| Ideal | 158 | 43.4 | 372 | 51.0 | |
| Intermediate | 166 | 35.2 | 243 | 34.8 | |
| Poor | 95 | 21.4 | 130 | 14.1 | |
| Healthy diet | 0.56 | ||||
| Ideal | 1 | 0.6 | 3 | 0.7 | |
| Intermediate | 97 | 21.3 | 129 | 17.1 | |
| Poor | 328 | 78.2 | 590 | 82.2 | |
BMI, body mass index; DM, diabetes mellitus; HbA1C, glycated hemoglobin; NHANES, National Health and Nutrition Examination Survey.
Value from χ2 test comparing the difference in the prevalence in each of the 7 components of cardiovascular health metrics between NHANES 1999–2002 and NHANES 2009–2012.
P < 0.05;
P < 0.01.
In regression analyses, after adjustment for age, sex, race, education, and poverty level, the significant differences between subjects from the two cohorts (2009–2012 vs 1999–2002) still remained for cholesterol (odds ratio [OR] 1.96, 95% CI 1.28–2.99), physical activity (OR 0.53, 95% CI 0.33–0.83), and healthy weight (OR 0.44, 95% CI 0.24–0.82). A significant difference also was found for blood pressure (OR 1.67, 95% CI 1.14–2.44) between the two cohorts (2009–2012 vs 1999–2002). After adjustment, there was no evidence of significant difference in smoking status, HbA1C, or adherence to an ideal diet. Adherence to the ideal healthy diet was <1% in both cohorts.
Discussion
At best, baby boomers with DM experience mixed results in achieving the goals outlined in the Life’s Simple 7 program. Current baby boomers are about half as likely to be participating in the recommended amount of physical activity and half as likely to have achieved ideal weight as their same-age counterparts from a decade earlier. Although the current baby boomers are more likely to have control of their cholesterol and HbA1C, they are not more likely to have quit smoking, controlled their blood pressure, or adhered to a healthy diet. The decline in adherence to healthy lifestyle practices is concerning given the enormous size of the baby boomer cohort and the importance of healthy lifestyle to DM management. Understanding the effects of this generation’s adherence to a healthy lifestyle pattern is essential to anticipate their healthcare needs and develop appropriate services.
On average, baby boomers are more likely than past generations to use healthcare resources because of the increasing frequency of having multiple chronic conditions and that they are living longer.4,17 The trends of decreased physical activity and increasing obesity are concerning. As a result of scientific advances, baby boomers have had better access to nutrition and medication, but decreased physical activity in combination with a lack of improvement in adherence to a healthy diet has likely contributed greatly to an increased proportion of overweight and obesity. Obese patients account for approximately $68 billion (2012 US dollars) in excess Medicaid costs.18 The epidemic of obesity among baby boomers could be a major contributor to future increases in disability and resulting healthcare expenses. Although new forms of insulin may have added to the weight gain control and slightly better glycemic control in baby boomers, declining adherence to lifestyle factors remains of concern.
The Life’s Simple 7 cardiovascular health metrics are key markers for general cardiovascular health.19,20 One purpose of these metrics is to track the nation’s cardiovascular health, promote adherence to the Simple 7, and ultimately reduce deaths from cardiovascular disease and stroke by 20% by 2020.19,20 Because of their increased risk of cardiovascular disease, patients with DM are a population that would benefit from attention to these metrics, compared with the adults without DM. The present study’s findings argue somewhat against the effectiveness of the efforts of providers and patients to address the desired lifestyle behavior changes to increase physical activity and decrease obesity. The findings also add to similar research evidence among middle-aged adults that found poor adherence to recommendations to increase dietary fiber intake, despite the well-documented benefits of such intake in individuals with DM.21,22
We found better control of cholesterol levels than 10 years ago, despite the lack of adherence to a healthy diet and the decrease in physical activity. The most likely explanation would be an increase in the use of statins and other drugs to control hyperlipidemia, but other changes in diet or activity may have contributed.23 After accounting for possible confounders in regression analyses, no other cardiovascular risk factors among the Life’s Simple 7 health metrics improved among the cohort of baby boomers with DM in our study.
The study has several strengths, including a nationally representative sample of US adults; the oversampling of minority and older adult individuals; and the use of standardized parameters and questionnaires for most of the measures, such as weight and height. The limitations of our study include, first, possible misclassification as a result of differences in the way NHANES asked questions in the two time periods. For example, there were different physical activity questions during the two time periods. Second, a modification to the Life’s Simple 7 characteristics was made to include HbA1C instead of fasting serum glucose, which makes comparisons with previous studies in non-DM populations more challenging. Third, medication use was not measured and likely influenced the achievement of ideal levels for blood pressure, glucose, and cholesterol.
Conclusions
Baby boomers with DM were less likely to achieve healthy weight and physical activity goals than their same-age counterparts a decade previously; however, they were more likely to reach appropriate cholesterol goals. Other elements of Life’s Simple 7 were unchanged. Because of the reduced levels of healthy weight and physical activity and the lack of improvement in many other parameters, more public health attention to cardiovascular risk in baby boomers with DM appears warranted.
Key Points.
Baby boomers have obesity in greater proportion than people of the same age 10 years ago.
Baby boomers have 30% less ideal physical activity than same-age people 10 years ago.
Fewer than 1% of baby boomers with diabetes mellitus adhere to an ideal healthy diet.
Acknowledgments
The study was supported by grant no. U54GM104942 from the National Institute of General Medical Sciences. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
To purchase a single copy of this article, visit http://sma.org/smj-home. To purchase larger reprint quantities, please contact reprints@wolterskluwer.com
The study was presented at the meeting of the North American Primary Care Research Group in New York, NY, November 23, 2014.
D.E.K. has received compensation or has had relationships with the following entities: Alcon Foundation, Allergan, Centers for Medicare & Medicaid Services, Health Resources and Services Administration, Oxford University Press, and Pfizer. The remaining authors have no financial relationships to disclose and no conflicts of interest to report.
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