# Clustering of behavioral and chronic health risk factors and their association with self-reported health and cardiovascular disease outcome among adults in North Carolina

## TL;DR

This study identifies health risk clusters in North Carolina adults and finds that one cluster is strongly linked to worse cardiovascular and mental health outcomes.

## Contribution

The study is novel in examining behavioral and chronic health risk clustering patterns specific to North Carolina and their associations with health outcomes.

## Key findings

- Two distinct health risk profiles were identified: one with moderate drinking and overweight status, and another with high behavioral and chronic risk factors.
- Membership in the high-risk profile was significantly associated with increased odds of cardiovascular disease and poor mental and physical health.
- Young adults showed the strongest associations between high-risk profiles and adverse health outcomes.

## Abstract

In 2024, North Carolina (NC) had a smoking rate of 17.2% and a higher-than-average rate of binge and heavy drinking. These behaviors often cluster with other health risks such as hypertension, hypercholesterolemia, and diabetes, thus leading to significant disparities in cardiovascular, physical, and mental health outcomes across the state. However, limited research has examined these clustering patterns within North Carolina.

This study seeks to investigate the associations between latent class membership, defined by clustering of behavioral and chronic health risk factors, and cardiovascular disease, self-reported health status, physical health status, and mental health status.

We conducted a cross-sectional analysis using the 2017, 2019, and 2021 North Carolina Behavioral Risk Factor Surveillance System (BRFSS) data. A latent class analysis (LCA) was used to identify distinct health risk profiles among adults based on smoking, alcohol use, physical activity, fruit and vegetable intake, hypertension, elevated cholesterol, and diabetes status. Multivariable logistic regression models were used to examine associations between latent class membership and four outcomes: cardiovascular disease (CVD), self-reported general health, physical health status, and mental health status. Analyses were adjusted for sociodemographic variables, and age-stratified analyses were conducted.

The LCA identified two distinct classes: “Moderate drinking overweight non-smokers” (Class 1) and “High behavioral and chronic risk profile” (Class 2). Class 1 was characterized by moderate alcohol consumption, overweight status, and low smoking prevalence, while Class 2 reflected a higher prevalence of smoking, binge drinking, hypertension, diabetes, and elevated cholesterol. Membership in Class 2 was significantly associated with increased odds of CVD (OR = 1.93; 95% CI: 1.60–2.34), poor self-reported health (OR = 1.69; 95% CI: 1.46–1.96), ≥14 days of poor physical health (OR = 1.82; 95% CI: 1.55–2.15), and ≥14 days of poor mental health (OR = 1.68; 95% CI: 1.43–1.97). In age-stratified analyses, the strongest associations were observed among young adults (18–39 years), with significantly higher odds of CVD (OR = 6.84; 95% CI: 2.79–16.72), poor physical health (OR = 2.32; 95% CI: 1.58–3.40), and poor mental health (OR = 2.12; 95% CI: 1.60–2.81). Similar but attenuated associations were observed among adults aged 40–59 and ≥60 years.

These findings support the importance of targeted public health efforts in North Carolina that address the co-occurrence of behavioral and chronic health risk factors, especially among younger populations. Syndemic-informed interventions which focus on behavioral and proximal chronic disease risk factors may help reduce CVD burden and improve the population health.