Trend report: High blood pressure increasing in low-income adults; diabetes and obesity on the rise in higher-income adults

Embargoed for release until 5:00 p.m. ET on Monday 20 November 2023
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Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.
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1. Trend report: High blood pressure increasing in low-income adults; diabetes and obesity on the rise in higher-income adults 

Targeted initiatives needed to improve the prevention, diagnosis, and treatment of cardiovascular risk factors 

Abstract: https://www.acpjournals.org/doi/10.7326/M23-2109  
URL goes live when the embargo lifts   
A study of more than 20,000 middle-aged U.S. adults found that lower income status was associated with an increased risk for hypertension compared to other middle aged adults with higher incomes. Those with higher incomes were found to be at increased risk for diabetes and obesity. The findings are published in Annals of Internal Medicine.  

Declines in cardiovascular mortality have stagnated over the past decade in the United States, driven in part by an increase in deaths among middle-aged adults. There is growing concern that these changes have been concentrated in middle-aged adults with low incomes, a population that is disproportionately affected by social determinants linked to poor cardiovascular health. However, little is known about how the burden of cardiovascular risk factors has changed among middle-aged adults by income level over the past 2 decades. 

Researchers from Beth Israel Deaconess Medical Center and Harvard Medical School studied NHANES (National Health and Nutrition Examination Survey) data for 20,761 adults aged 40 to 64 years from 1999 to March 2020 to evaluate trends in the prevalence, treatment, and control of cardiovascular risk factors among low-income and higher-income middle-aged adults and how social determinants contribute to recent associations between income and cardiovascular health. The data showed that low-income adults had an increase in hypertension over the study period, with 44.7 percent of low-income adults diagnosed with hypertension by 2020. There were no changes in rates of diabetes or obesity in low-income adults. In contrast, higher-income adults did not have a change in hypertension but had increases in diabetes in obesity that, with 44 percent of higher-income adults having been diagnosed with obesity by 2020. Income-based disparities in hypertension, diabetes, and cigarette use persisted in more recent years even after adjustment for insurance coverage, health care access, and food insecurity. According to the authors, these findings suggest that targeted public health and policy initiatives to improve the prevention, diagnosis, and treatment of cardiovascular risk factors, particularly among low-income communities, are urgently needed to address the ongoing increase in cardiovascular mortality among middle-aged adults. 

Media contacts: For an embargoed PDF, please contact Angela Collom at [email protected]. To speak with the corresponding author, Rishi K. Wadhera, MD, MPP, MPhil, please contact [email protected]

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2. Few states require antiracism education in CME despite AMA recommendation

Abstract: https://www.acpjournals.org/doi/10.7326/M23-1476

Editorial: https://www.acpjournals.org/doi/10.7326/M23-2888 
URL goes live when the embargo lifts  
A research report evaluating state requirements for physicians’ continuing medical education (CME) found that only 12 states have implemented CME related to cultural competency, implicit bias, and other topics. The authors highlight that CME presents an important opportunity to expose practicing physicians to the large role of structural forces in racial health disparities. The report is published in Annals of Internal Medicine.

In 2021, after nationwide Black Lives Matter protests, the American Medical Association (AMA) released a plan to embed racial justice and health equity in physicians’ training. The rationale for educating physicians about racial justice is that they play a key role in perpetrating racial health disparities through various mechanisms, including biased clinical decision making and verbal and nonverbal communication. Although existing research describes the state of health equity and antiracism education in medical training, little is known about such topics in practicing physicians’ CME.

Researchers from Harvard Medical School and Yale Medical School analyzed data on accreditation requirements for each state to describe state licensing requirements for antiracism education for U.S. physicians. The authors reviewed these requirements for mentions of terms including race, racism, antiracism, equity, cultural competency, implicit bias, cultural awareness and linguistic competency, diversity, and inclusion. They found that 12 states currently require antiracism training with varying frequency and topics and 11 of those 12 states began training after 2019. They noted that New Jersey specifically requires training for health professionals working in perinatal care.

These findings present an opportunity to evaluate the effect of requiring antiracism training on physicians’ attitudes, practices, and patient outcomes. They also emphasize that there is a need to establish qualifications for trainers and develop best practices based on robust evidence because of differences in frequency, length of training required, and concepts emphasized, which may vary in effectiveness.

An accompanying editorial by authors from University of California Davis School of Medicine notes that this report comes at an opportune time as medicine grapples with racism and its role in perpetuating health inequities. Implicit bias training may influence how individual physicians treat patients, but how those biases contribute to health disparities and what constitutes effective training remain unclear.

Media contacts: For an embargoed PDF, please contact Angela Collom at [email protected]. To speak with the corresponding author, Max Jordan Nguemeni Tiako, MD, MS, please contact [email protected].

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3. Despite nonpharmacologic alternatives, 1 in 4 persons rely on medications to treat chronic pain

Abstract: https://www.acpjournals.org/doi/10.7326/M23-2004 
 URL goes live when the embargo lifts  
 A research report evaluating pharmacologic and nonpharmacologic pain management therapies found that 1 in 4 persons with chronic pain used only pharmacologic interventions to manage their pain, despite recommendations to increase use of nonpharmacologic alternatives. According to the authors, these findings highlight opportunities to increase nonpharmacologic therapy use among a variety of persons with chronic pain in the United States. The report is published in Annals of Internal Medicine.  

In 2021, approximately 1 in 5 adults in the United States experienced chronic pain. The Centers for Disease Control and Prevention (CDC) recommends maximizing nonpharmacologic and nonopioid therapies for pain as appropriate for the specific condition and patient. 

Researchers at CDC analyzed data from the 2020 National Health Interview Survey (NHIS) to estimate the prevalence of use of pharmacologic and nonpharmacologic therapies among 7,422 adults with self-reported chronic pain. The analysis showed that over-the-counter pain relievers and exercise were the most prevalent pain management therapies used, and prescription nonopioids were used more than twice as often as prescription opioids. Although most adults with chronic pain reported using both pharmacologic and nonpharmacologic therapies, approximately 1 in 4 adults reported using pharmacologic therapies only. However, few persons (1.0%) reported using prescription opioids alone to manage their chronic pain. According to the authors, these findings highlight opportunities to increase nonpharmacologic therapy use among specific populations with chronic pain including males, older adults, those with lower household income, those with less educational attainment, those residing in the South, and uninsured adults. However, barriers to nonpharmacologic therapies including cost and availability remain a challenge for persons with chronic pain.

Media contacts: For an embargoed PDF, please contact Angela Collom at [email protected]. To speak with the corresponding author, S. Michaela Rikard, PhD, please contact [email protected]

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