Obesity and diabetes climbed while long-running cardiovascular gains lost momentum
The broad arc of cardiovascular prevention in the United States is no longer moving in a single direction. In a 24-year analysis of NHANES data covering 60,199 nonpregnant adults, obesity rose from 47.4% to 57.2%, and class III obesity more than doubled from 4.7% to 9.7%. Diabetes followed a similar pattern, increasing from 8.2% to 12.7%. At the same time, current smoking fell sharply from 24.4% to 14.9%, a reminder that population risk is being pulled in opposite directions by competing forces.
Those opposing trends matter because excess adiposity is not just a weight metric; it is a metabolic engine that drives insulin resistance, inflammatory signaling, dyslipidemia, and vascular dysfunction. Even when smoking exposure falls, rising obesity can keep pressure on the same arterial and cardiometabolic pathways that clinicians have spent decades trying to blunt.
Blood pressure improved in the middle of the time series, then slipped backward
Hypertension itself did not show a significant linear trend across the full study period, but the management story was less stable than the prevalence curve. Mean systolic blood pressure declined from 124.2 mm Hg to 120.2 mm Hg, suggesting that treatment intensity, adherence, and risk-factor awareness improved enough to move the population average. Yet blood pressure control reached a high point of 32.5% in 2013-2014 before falling to 21.5% in 2021-2023.
That reversal is clinically consequential. Hypertension control depends on persistent medication use, access to follow-up care, and regular dose adjustment, all of which were strained during and after the pandemic period. A few points on a population mean may look small on paper, but at the bedside they translate into fewer patients crossing the threshold into stroke, left ventricular hypertrophy, and chronic kidney injury.
Lipid control improved, but the gains were uneven
Cholesterol trends moved more favorably. Total cholesterol declined from 203.6 mg/dL to 188.1 mg/dL, and other lipid measures improved alongside it. Dyslipidemia awareness and treatment both increased over time, and LDL cholesterol control rose from 17.0% to 34.2%.
The improvement is real, but it still leaves a large residual burden. LDL lowering remains one of the most direct ways to reduce atherosclerotic plaque progression, stabilize vulnerable lesions, and lower the chance that a patient presents with a first myocardial infarction. Doubling a control rate from a very low baseline still does not mean the job is done; it means the system has moved from poor performance to incomplete performance.
Diabetes awareness rose, but glycemic control deteriorated after an early peak
Diabetes awareness increased over the study period, yet treatment trends were not significant. Glycemic control peaked at 51.2% in 2003-2004 and later fell to 41.9%, with nonlinearity testing indicating a meaningful departure from a straight-line trajectory. In practical terms, more adults know they have diabetes, but the pathway from diagnosis to sustained control appears less reliable than it was two decades ago.
That pattern is especially concerning because diabetes accelerates atherosclerosis and also promotes heart failure through myocardial fibrosis, microvascular dysfunction, and volume-handling abnormalities. The burden is not limited to coronary events. Poor glycemic control shapes ventricular remodeling and may help explain why predicted heart failure risk moved in the opposite direction from predicted ASCVD risk.
Predicted ASCVD risk edged down while heart failure risk climbed
Among adults without self-reported cardiovascular disease, PREVENT equations estimated a modest decline in 10-year total cardiovascular risk from 5.66% to 5.28%. More specifically, predicted ASCVD risk declined by 0.16 percentage points per decade, with 95% confidence limits of 0.22 to 0.09. Predicted heart failure risk moved the other way, increasing by 0.10 percentage points per decade, with 95% confidence limits of 0.03 to 0.17.
The 2021-2023 estimates were nearly identical for the two 10-year endpoints, at 3.20% and 3.19%, respectively. On the surface, that looks balanced. Biologically, it is not. ASCVD risk is most tightly linked to atherothrombotic injury, lipid burden, and smoking exposure, all of which improved. Heart failure risk, by contrast, is strongly shaped by obesity, diabetes, blood pressure burden, renal stress, and myocardial strain, which have not moved in the same favorable direction.
The post-pandemic profile is more fragmented than earlier prevention narratives suggested
This analysis shows a prevention environment in which some classic cardiovascular threats are receding while others intensify. Smoking prevalence fell, systolic pressure and cholesterol improved, and awareness and treatment of hypertension and dyslipidemia increased. Yet obesity and diabetes rose steadily, blood pressure control weakened after an earlier peak, and glycemic control slipped after a mid-2000s high point.
Those shifts help explain why predicted risk is separating into two stories rather than one. Atherosclerotic events depend heavily on lipid and tobacco exposure, while heart failure increasingly tracks metabolic disease, body weight, and cumulative hemodynamic load. When the latter worsens faster than the former improves, the population can look better on traditional prevention metrics while still accumulating future heart failure burden.
Survey design and measurement limits still shape the interpretation
The study used 11 NHANES cycles from 1999-2000 through 2021-2023 and applied survey-weighted regression with age-standardized estimates, subgroup analyses, and measurement-change sensitivity testing. It also relied on publicly available, deidentified data, which strengthens transparency but leaves the analysis observational by design. Because this is a preprint and not yet peer reviewed, the findings should be read as a careful population signal rather than a final clinical verdict.
Even so, the central message is hard to miss: U.S. adults have made real progress against smoking, lipids, and some blood pressure measures, but the metabolic load behind cardiovascular disease has not eased. Rising obesity and diabetes now sit alongside improving lipid control and worsening heart failure projections, a combination that will complicate future prevention unless risk management expands beyond the traditional focus on atherosclerosis alone.