# Cumulative Effects of Multiple Modifiable Risk Factors on Cardiovascular Disease Mortality

## TL;DR

This study shows that combining multiple modifiable risk factors, like income and healthcare access, increases cardiovascular disease deaths more than expected in West Virginia counties.

## Contribution

The study reveals that the combined effect of multiple risk factors on CVD mortality is greater than the sum of their individual effects.

## Key findings

- Combined risk factors are more strongly linked to CVD mortality than any single factor alone.
- Income, PCP ratio, and food desert status each significantly correlate with CVD mortality.
- Two-way interactions between income and other factors show stronger associations than expected.

## Abstract

Background/Objectives: The study evaluated whether the cumulative burden of multiple, modifiable risk factors worsened cardiovascular disease (CVD) mortality in West Virginia. Methods: This retrospective observational study looked at all CVD mortality rates per county of West Virginia between 2011 and 2020 and each county’s modifiable risks. Income, ratio of people per PCP (PCP Ratio), and Food Desert Status (FDS), and the death rate from the Census Bureau, AMA, US Department of Agriculture, and the West Virginia Department of Health and Human Services (WV HHS) were collected, respectively. Multiple linear regression and ANOVA analyses were performed for each combination of factors towards the death rate. Results: Multiple linear regression demonstrated that combined risk factors were more strongly associated with CVD mortality than any single factor alone. Over the 10-year period, West Virginia’s population aged overall. Each individual risk factor was significantly associated with CVD mortality (Income: F(1,537) = 53.39, p < 0.0001; PCP Ratio: F(1,537) = 21.49, p < 0.0001; FDS: F(1,537) = 5.13, p = 0.024). Two two-way interactions were significant (PCP Ratio:Income: F(1,537) = 22.03, p < 0.001; FDS:Income: F(1,537) = 5.23, p = 0.022), while the PCP Ratio:FDS interaction and the three-way interaction were not. Conclusions: Counties burdened by several modifiable risk factors experienced disproportionately elevated CVD mortality, exceeding what would be predicted by the additive effects of each risk factor individually. These findings highlighted the importance of addressing cumulative socioeconomic and healthcare access factors at the county level.