Cardiovascular Disease Risk Factors in US Adults With Vision Impairment

Isabel Mendez, MS; Minchul Kim, PhD; Elizabeth A. Lundeen, PhD; Fleetwood Loustalot, PhD, FNP; Jing Fang, MD, MS; Jinan Saaddine, MD, MPH

Disclosures

Prev Chronic Dis. 2022;19(7):e43

Abstract and Introduction

Abstract

Introduction: Adults with vision impairment (VI) have a higher prevalence of cardiovascular disease (CVD) compared with those without VI. We estimated the prevalence of CVD and CVD risk factors by VI status in US adults.

Methods: We used nationally representative data from the 2018 National Health Interview Survey (N = 22,890 adults aged ≥18 years). We estimated the prevalence of self-reported diagnosis of CVD (coronary heart disease [including angina and myocardial infarction], stroke, or other heart disease) by VI status. We used separate logistic regression models to generate adjusted prevalence ratios (aPRs), controlling for sociodemographic covariates, for those with VI (reference group, no VI) for CVD and CVD risk factors: current smoking, physical inactivity, excessive alcohol intake, obesity, hypertension, high cholesterol, and diabetes.

Results: Overall, 12.9% (95% CI, 12.3–13.5) of the sample had VI. The prevalence of CVD was 26.6% (95% CI, 24.7–28.6) in people with VI versus 12.2% (95% CI, 11.7–12.8) in those without VI (aPR = 1.65 [95% CI, 1.51–1.80]). Compared with adults without VI, those with VI had a higher prevalence of all risk factors examined: current smoking (aPR = 1.40 [95% CI, 1.27–1.53]), physical inactivity (aPR = 1.14 [95% CI, 1.06–1.22]), excessive alcohol intake (aPR = 1.29 [95% CI, 1.08–1.53]), obesity (aPR = 1.28 [95% CI, 1.21–1.36]), hypertension (aPR = 1.29 [95% CI, 1.22–1.36]), high cholesterol (aPR = 1.21 [95% CI, 1.14–1.29]), and diabetes (aPR = 1.54 [95% CI, 1.38–1.72]).

Conclusion: Adults with VI had a higher prevalence of CVD and CVD risk factors compared with those without VI. Effective clinical and lifestyle interventions, adapted to accommodate VI-related challenges, may help reduce CVD risk in adults with VI.

Introduction

Cardiovascular disease (CVD), including heart disease, stroke and vascular disease, is a major cause of illness and death in the US, claiming 800,000 lives each year.^[1] CVD contributes $363 billion annually in health care costs and lost productivity.^[1]

CVD can be prevented or delayed through lifestyle modifications to control or manage risk factors. Approximately 34% of deaths from heart disease could be prevented by modifying key risk factors.^[2] The American Heart Association (AHA) promotes Life's Simple 7 (LS7),^[3] which identifies and quantifies 7 factors that influence cardiovascular health (smoking status, physical activity, body weight, diet, blood pressure, cholesterol, and blood glucose), with higher LS7 scores associated with better cardiovascular health and lower risk of all-cause and CVD mortality.^[1,4]

A strong connection between cardiovascular health and eye health has been noted;^[5] they share risk factors such as older age, current smoking, high blood glucose, and hypertension. One study found that adults aged 40 years or older who had better cardiovascular health had lower odds of ocular diseases such as age-related macular degeneration (AMD), diabetic retinopathy, cataract, and glaucoma.^[5] Research has also shown that compared with adults without vision impairment (VI), those with VI have a higher prevalence of CVD, contributing to increased mortality risk among the 7 million Americans with VI.^[6,7] A study of US adults aged 65 years or older found that compared with people without VI, people with VI had a higher prevalence of 13 self-reported chronic conditions, including heart disease and stroke.^[7]

Although studies have examined the relationship between VI and CVD,^[7–9] less is known about differences in prevalence of CVD risk factors between people with and without VI. Better understanding the relationship between VI and CVD risk factors may aid in prevention and management of CVD among those with VI. Our objective was to assess the relationship between VI and CVD risk factors in US adults.

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Abstract and Introduction
Methods
Results
Discussion
References
Sidebar

Table 1. Selected Characteristics of Adults Aged ≥18 Years, by Self-Reported Vision Status, Study of Cardiovascular Disease Risk Factors in US Adults With Vision Impairment, 2018
Characteristic	All, % (95% CI) (N = 22,890)	Distribution by vision status, % (95% CI)^a
Characteristic	All, % (95% CI) (N = 22,890)	Vision impairment (n = 3,214)	No vision impairment (n = 19,676)
Age, y^b
18–44	46.3 (45.3–47.3)	31.1 (28.9–33.3)	48.5 (47.5–49.6)
45–64	33.4 (32.6–34.2)	40.8 (38.7–43.0)	32.3 (31.4–33.1)
≥65	20.3 (19.6–21.0)	28.1 (26.3–29.9)	19.2 (18.4–19.9)
Sex^b
Male	48.8 (47.6–49.2)	43.0 (40.8–45.2)	49.7 (48.9–50.5)
Female	51.2 (50.4–51.9)	57.0 (54.8–59.2)	50.3 (49.5–51.1)
Race and ethnicity^b
Black, non-Hispanic	11.2 (10.3–12.1)	14.0 (12.2–16.0)	10.8 (9.9–11.7)
Hispanic	16.0 (14.7–17.4)	16.0 (13.9–18.3)	16.0 (14.7–17.4)
Other	8.9 (8.1–9.7)	7.4 (6.0–9.1)	9.1 (8.3–10.0)
White, non-Hispanic	63.9 (62.3–65.5)	62.6 (59.9–65.3)	64.1 (62.5–65.7)
Education level^b
Less than high school	11.0 (10.3–11.8)	14.8 (13.2–16.5)	10.4 (9.7–11.2)
High school/GED	24.3 (23.4–25.1)	27.6 (25.6–29.8)	23.8 (22.9–24.7)
More than high school	64.7 (63.6–65.8)	57.6 (55.3–59.9)	65.8 (64.6–66.9)
Marital status^b
Married/domestic partnership	60.3 (59.4–61.2)	54.7 (52.5–56.8)	61.2 (60.2–62.1)
Not married^c	39.7 (38.8–40.6)	45.3 (43.2–47.5)	38.8 (37.9–39.8)
Employment status^b
Work for pay at job/business	63.0 (62.1–64.0)	46.7 (44.4–48.9)	65.5 (64.5–66.4)
Not working for pay	37.0 (36.0–37.9)	53.3 (51.1–55.6)	34.5 (33.6–35.5)
Income-to-poverty ratio^b,d
<1	10.0 (9.4–10.6)	15.0 (13.5–16.6)	9.2 (8.6–9.8)
1 to <2	16.7 (16.0–17.5)	22.9 (21.1–24.9)	15.8 (15.0–16.6)
≥2	73.3 (72.3–74.4)	62.1 (59.7–64.3)	75.0 (73.9–76.0)
Health insurance^b
Public	23.9 (23.0–24.8)	36.2 (33.9–38.5)	22.0 (21.2–22.9)
Private	54.6 (53.5–55.7)	39.0 (36.6–41.3)	56.9 (55.7–58.0)
Both	11.4 (10.8–12.0)	14.7 (13.3–16.2)	10.9 (10.3–11.5)
None	10.2 (9.5–10.8)	10.2 (8.7–11.8)	10.2 (9.5–10.9)

Abbreviation: GED, general education development.
^aPercentages are weighted and may not add up to 100% due to rounding.
^bPrevalence of vision impairment varied by sociodemographic characteristic (P < .05, χ² test).
^cWidowed, divorced, separated, or never married.
^dRatio of the family income to the poverty threshold, based on the US Census Bureau federal poverty thresholds given the family's size and number of children (https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-thresholds.html).

Table 2. Prevalence and Prevalence Ratio of Self-Reported Cardiovascular Disease and Cardiovascular Disease Risk Factors Among US Adults Aged ≥18 Years, by Vision Status, 2018
Risk factor	Total prevalence, % (95% CI)^a	Prevalence by vision status, % (95% CI)^a		PR (95% CI)^b	aPR (95% CI)^c
Risk factor	Total prevalence, % (95% CI)^a	Vision impairment	No vision impairment	PR (95% CI)^b	aPR (95% CI)^c
Cardiovascular disease^d	14.1 (13.5–14.7)	26.6 (24.7–28.6)	12.2 (11.7–12.8)	2.18 (2.00–2.37)	1.65 (1.51–1.80)
Risk behaviours
Current smoking^e	13.8 (13.2–14.4)	19.5 (17.9–21.1)	13.0 (12.3–13.6)	1.50 (1.37–1.64)	1.40 (1.27–1.53)
Physical inactivity^f	25.7 (24.7–26.8)	34.6 (32.4–36.9)	24.4 (23.3–25.5)	1.42 (1.33–1.51)	1.14 (1.06–1.22)
Excessive alcohol intake^g	5.3 (4.9–5.6)	6.0 (5.2–7.1)	5.2 (4.8–5.5)	1.17 (0.99–1.39)	1.29 (1.08–1.53)
Health conditions
Obesity^h	33.0 (32.2–33.9)	42.4 (40.1–44.7)	31.7 (30.7–32.6)	1.34 (1.26–1.42)	1.28 (1.21–1.36)
Hypertensionⁱ	31.7 (30.9–32.5)	47.5 (45.2–49.7)	29.3 (28.5–30.2)	1.62 (1.53–1.71)	1.29 (1.22–1.36)
High cholesterolⁱ	27.9 (27.1–28.7)	38.5 (36.5–40.6)	26.3 (25.5–27.1)	1.46 (1.38–1.55)	1.21 (1.14–1.29)
Diabetesⁱ	10.1 (9.6–10.6)	18.5 (16.8–20.3)	8.9 (8.4–9.3)	2.09 (1.88–2.32)	1.54 (1.38–1.72)

Abbreviations: CVD, cardiovascular disease; PR, prevalence ratio; aPR, adjusted prevalence ratio.
^aPercentages are weighted percentages and may not add up to 100% due to rounding.
^bSeparate logistic regression models were performed to generate prevalence ratios for CVD and each CVD risk factor, comparing the prevalence among those with vision impairment to the prevalence of those without vision impairment.
^cAdjusted for age (continuous variable), sex, race and ethnicity, education, marital status, employment status, income-to-poverty ratio, and health insurance status.
^dSelf-reported CVD ascertained by asking whether respondent has ever been told by a doctor or other health professional that they had any of the following conditions: coronary heart disease, angina/angina pectoris, heart attack/myocardial infarction, stroke, or any kind of heart condition or heart disease.
^eCurrent smoker was defined as those who had smoked more than 100 cigarettes in their lifetime and now smoke every day or some days.
^fPhysical inactivity was defined as performing <10 min per week of light, moderate, or vigorous leisure-time physical activities.
^gExcessive alcohol intake was defined as consuming ≥12 drinks in lifetime and >14 drinks/week in past year (for men) or >7 drinks/week in past year (for women).
^hObesity was defined as a body mass index >30. Body mass index was calculated, using self-reported data, as weight (in kilograms) divided by height (in meters) squared.
ⁱHealth conditions were defined as an affirmative response to the question of whether the respondent had ever been told by a doctor or other health professional that they had 1) hypertension or high blood pressure, 2) high cholesterol, or 3) diabetes or sugar diabetes.

Table 3. Prevalence of Self-Reported Cardiovascular Disease Risk Factors Among US Adults ≥18 Years, by Vision Status and Age Group, 2018
Risk factor	Total prevalence % (95% CI)^a	Prevalence by vision status % (95% CI)^a		PR (95% CI)^b	aPR (95% CI)^c
Risk factor	Total prevalence % (95% CI)^a	Vision impairment	No vision impairment	PR (95% CI)^b	aPR (95% CI)^c
Cardiovascular disease^d
18–44 y	5.4 (4.9–6.1)	13.4 (10.5–16.9)	4.7 (4.2–5.3)	2.85 (2.19–3.72)	2.53 (1.95–3.28)
45–64 y	14.1 (13.1–15.1)	25.2 (22.3–28.3)	12.0 (11.1–13.0)	2.10 (1.83–2.41)	1.78 (1.55–2.05)
≥65 y	33.8 (32.4–35.3)	43.4 (40.0–46.7)	31.7 (30.2–33.3)	1.37 (1.25–1.49)	1.38 (1.25–1.53)
Risk behaviors
Current smoking^e
18–44 y	14.3 (13.4–15.3)	20.7 (17.5–24.4)	13.7 (12.8–14.7)	1.51 (1.27–1.80)	1.36 (1.14–1.62)
45–64 y	16.3 (15.2–17.4)	24.4 (21.6–27.5)	14.7 (13.7–15.8)	1.66 (1.45–1.89)	1.40 (1.22–1.59)
≥65 y	8.6 (7.8–9.4)	10.9 (9.0–13.2)	8.1 (7.3–8.9)	1.35 (1.09–1.68)	1.22 (0.97–1.53)
Physical inactivity^f
18–44 y	20.3 (19.0–21.7)	25.5 (21.5–30.0)	19.8 (18.5–21.2)	1.29 (1.09–1.53)	1.10 (0.92–1.31)
45–64 y	26.5 (25.0–28.0)	34.8 (31.6–38.2)	24.9 (23.4–26.5)	1.40 (1.26–1.55)	1.15 (1.04–1.28)
≥65 y	36.9 (35.3–38.6)	44.2 (40.7–47.8)	35.3 (33.6–37.1)	1.25 (1.15–1.37)	1.16 (1.05–1.28)
Excessive alcohol intake^g
18–44 y	5.4 (4.9–6.0)	7.1 (5.4–9.4)	5.3 (4.7–5.8)	1.35 (1.01–1.81)	1.45 (1.08–1.94)
45–64 y	5.7 (5.1–6.3)	6.5 (5.3–8.1)	5.5 (4.9–6.2)	1.19 (0.93–1.51)	1.29 (1.02–1.65)
≥65 y	4.3 (3.7–4.9)	4.1 (3.0–5.7)	4.3 (3.7–5.0)	0.97 (0.68–1.38)	1.02 (0.72–1.46)
Health conditions
Obesity^h
18–44 y	30.6 (29.3–31.9)	41.4 (36.8–46.2)	29.6 (28.2–30.9)	1.40 (1.24–1.58)	1.33 (1.19–1.50)
45–64 y	37.3 (35.9–38.7)	47.2 (43.8–50.6)	35.4 (33.9–37.0)	1.33 (1.23–1.45)	1.26 (1.16–1.37)
≥65 y	31.7 (30.3–33.0)	36.4 (33.2–39.8)	30.6 (29.1–32.2)	1.19 (1.07–1.32)	1.18 (1.05–1.32)
Hypertensionⁱ
18–44 y	12.1 (11.3–13.0)	22.2 (18.6–26.2)	11.2 (10.4–12.0)	1.99 (1.66–2.39)	1.82 (1.52–2.19)
45–64 y	39.5 (38.2–40.9)	50.6 (47.2–54.1)	37.5 (36.0–38.9)	1.35 (1.25–1.46)	1.24 (1.15–1.34)
≥65 y	63.4 (62.0–64.7)	70.7 (67.6–73.6)	61.7 (60.2–63.2)	1.15 (1.09–1.20)	1.16 (1.09–1.23)
High cholesterolⁱ
18–44 y	9.7 (9.0–10.5)	15.2 (12.2–18.9)	9.2 (8.5–10.0)	1.66 (1.32–2.09)	1.60 (1.29–2.00)
45–64 y	36.9 (35.6–38.2)	42.9 (39.5–46.5)	35.8 (34.4–37.2)	1.20 (1.10–1.31)	1.16 (1.07–1.27)
≥65 y	54.6 (53.2–56.0)	57.9 (54.4–61.3)	53.9 (52.3–55.4)	1.07 (1.01–1.15)	1.10 (1.02–1.19)
Diabetesⁱ
18–44 y	3.2 (2.8–3.7)	8.7 (6.2–11.9)	2.7 (2.3–3.1)	3.19 (2.23–4.54)	2.71 (1.92–3.82)
45–64 y	12.5 (11.6–13.6)	21.7 (18.8–25.0)	10.8 (9.9–11.8)	2.01 (1.71–2.35)	1.66 (1.41–1.94)
≥65 y	21.7 (20.6–23.0)	24.7 (21.9–27.7)	21.1 (19.8–22.5)	1.17 (1.02–1.34)	1.11 (0.96–1.28)

Abbreviations: aPR, adjusted prevalence ratio; CVD, cardiovascular disease; PR, prevalence ratio.
^aBecause of rounding, weighted percentages may not add up to 100%. Sample sizes (unweighted) were n = 8,771 for adults aged 18–44 years, n = 7,670 for adults aged 45–64 years, and n = 6,449 for adults aged ≥65 years.
^bSeparate logistic regression models with STATA's adjrr command were performed to generate prevalence ratios for CVD and each CVD risk factor, comparing the prevalence among those with vision impairment to the prevalence of those without vision impairment. Each model contained an interaction term between vision impairment and age group to test effect modification by age.
^cAdjusted for sex, race and ethnicity, education, marital status, employment status, income-to-poverty ratio, and health insurance status.
^dSelf-reported cardiovascular disease ascertained by asking whether respondent has ever been told by a doctor or other health professional that they had any of the following conditions: coronary heart disease, angina/angina pectoris, heart attack/myocardial infarction, stroke, or any kind of heart condition or heart disease.
^eCurrent smoker was defined as those who had smoked more than 100 cigarettes in their lifetime and now smoke every day or some days.
^fPhysical inactivity was defined as performing <10 min per week of light, moderate, or vigorous leisure-time physical activities.
^gExcessive alcohol intake was defined as consuming ≥12 drinks in lifetime and >14 drinks/week in past year (for men) or >7 drinks/week in past year (for women).
^hObesity was defined as a body mass index >30. Body mass index was calculated, using self–reported data, as weight (in kilograms) divided by height (in meters) squared.
ⁱHealth conditions were defined as an affirmative response to the question of whether the respondent had ever been told by a doctor or other health professional that they had 1) hypertension or high blood pressure, 2) high cholesterol, or 3) diabetes or sugar diabetes.

Table 4. Percentage Distribution of Adults by Number of Cardiovascular Disease Risk Factors and Vision Status, Study of Cardiovascular Disease Risk Factors in US Adults With Vision Impairment, 2018
No. of risk factors	Total prevalence % (95% CI)^a	Prevalence by vision status% (95% CI)^a
No. of risk factors	Total prevalence % (95% CI)^a	Vision impairment	No vision impairment
0	28.0 (27.1–28.9)	16.0 (14.3–17.9)	29.8 (28.9–30.7)
1	29.2 (28.5–30.0)	22.8 (21.0–24.8)	30.2 (29.4–31.0)
2	21.4 (20.7–22.1)	23.9 (22.0–25.9)	21.0 (20.3–21.7)
3	12.7 (12.2–13.2)	19.3 (17.6–21.1)	11.7 (11.2–12.2)
4–7	8.7 (8.3–9.2)	18.0 (16.4–19.7)	7.4 (6.9–7.8)