AREA-LEVEL POVERTY AND CARDIOMETABOLIC RISK AMONG UNITED STATES ADOLESCENTS: A HIERARCHICAL ANALYSIS OF PATHWAYS TO DISEASE
Williams, Andrew David
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Background: In the United States, 26% of deaths are attributable to cardiometabolic diseases. Cardiometabolic risk in adolescence tracks over time and can presage cardiometabolic health during adulthood. Area-level determinants of cardiometabolic risk among adolescents are underexamined. This study contributes evidence regarding the association between area-level poverty and cardiometabolic risk among U.S. adolescents. Methods: 1999-2012 National Health and Nutrition Examination Survey data was linked via census tract with 2000 Census data and 2005-2009 and 2009-2013 American Community Survey data. The sample included 10,415 adolescents, aged 12-19 years. Area-level poverty was parameterized by percent population living in poverty, grouped into quartiles for analysis. Cardiometabolic risk was parameterized by summing z-scores of systolic and diastolic blood pressure, glycosylated hemoglobin, waist circumference, HDL cholesterol, and total cholesterol. Hierarchical linear models were used to examine the relationship between area-level poverty and cardiometabolic risk. Cotinine levels and physical activity were assessed as mediators. Post-hoc analysis explored associations between area-level poverty and family poverty-to-income ratio. Analyses were conducted for the overall sample and by race/ethnicity. Results: For the overall sample, compared to the first quartile of area-level poverty, residence in second (.218, 95% CI: .012, .424), third (.438, 95% CI: .213, .665), and fourth (.451, 95% CI: .204, .698) quartiles of area-level poverty was associated with increased cardiometabolic risk. Area-level poverty was associated with cardiometabolic risk among non-Hispanic Whites and Mexican Americans, but not among non-Hispanic Blacks. No evidence of mediation was observed. In post-hoc analysis, overall mean family Poverty-income-ratio declined from 3.34 in quartile 1 to 1.42 in quartile 4 (p< .001), however, this differed by race/ethnicity. Discussion: Residence in the highest area-level poverty quartiles was associated with increased cardiometabolic risk. Race/ethnicity specific analyses are consistent with literature on the Hispanic Paradox, and exposure to adversity among non-Hispanic blacks. Evidence suggests specific biomarker choice results in different cardiometabolic profiles within the same racial/ethnic group. Post-hoc analyses suggest the effect of area-level poverty on family PIR is greatest among non-Hispanic whites. Efforts to improve cardiometabolic health and reduce racial/ethnic disparities in cardiometabolic diseases should include targeted community-level investments aimed to improve the social conditions for all residents.