Sex Differences in Social, Behavioral, and Metabolic Risk Factors for Cardiovascular Disease Mortality among US Adults.

Background: Prevalence and associations of risk factors for cardiovascular disease (CVD) may differ between women and men, but previous findings are inconclusive. We investigated the simultaneous contributions of social determinants of health (SDOH), behavioral factors, and metabolic factors to CVD mortality among women and men in the US general population. Methods: We included 50,808 participants aged ≥20 years from the National Health and Nutrition Examination Survey 1999-2018, linked to the National Death Index for CVD mortality follow-up through December 31, 2019. SDOH, behavioral factors, and metabolic factors were collected in each survey cycle. We estimated the simultaneous impact of SDOH, behavioral factors, and metabolic factors on CVD mortality in women and men using average population attributable fractions (PAFs), which consider both the prevalence and strength of association of all risk factors with CVD mortality in one model. Results: During a mean 9.4-year follow-up, 2,589 CVD deaths were recorded (1,140 in women; 1,449 in men). Women had higher prevalence of unemployment and central obesity than men. Men had higher prevalence of no regular healthcare access, current smoking, heavy alcohol drinking, unhealthy diet, and high cholesterol than women. In fully adjusted models, associations of risk factors with CVD mortality were mostly similar among women and men. However, unemployment was more strongly associated with CVD mortality among men (hazard ratio [95% CI], 1.97 [1.62-2.39]) compared with women (1.19 [1.00-1.43; p-value for interaction <0.001). In those older than age 60, sleep duration <6 or >8 hours/day was independently associated with CVD mortality among women but not men. Hypertension (14.3%), albuminuria (10.0%), low family income-to-poverty ratio (8.7%), leisure-time physical inactivity (6.6%), and diabetes (6.3%) were top population-level contributors to CVD mortality in men, while leisure-time physical inactivity (14.7%), albuminuria (11.7%), low family income-poverty ratio (10.0%), low estimated glomerular filtration rate (8.9%), and diabetes (6.5%) were top contributors among women. Conclusions: Although the prevalence of CVD risk factors varied by sex, magnitudes of association with CVD mortality were mostly similar among women and men. SDOH and behavioral risk factors collectively accounted for a third of CVD deaths in both men and women living in the US. Clinical Perspective: What Is New?: Associations of a wide array of social determinants of health, behavioral factors, and metabolic factors with CVD mortality are similar among men and women in the US. However, prevalence of these risk factors and associated population attributable fractions vary by sex.Hypertension, lower kidney function, and leisure-time physical inactivity are top population-level contributors to CVD mortality among men, while leisure-time physical inactivity, low kidney function and diabetes are top population-level contributors among women.What Are the Clinical Implications?: Low kidney function showed the largest absolute mortality rate in both men and women compared to other risk factors, and increased efforts targeting prevention of kidney disease are warranted.Sex-specific strategies may be warranted to target the primordial prevention of social determinants of health and behavioral factors to reduce the burden of CVD mortality.