Highlights
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This study provides national estimates on the associations between vision difficulty and several chronic health conditions using nationally representative, population-based survey data.
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Prevalence of most chronic health conditions differed by level of self-reported vision difficulty.
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Among adults aged 45 to 64 years, prevalence of hypertension, high cholesterol, arthritis, depression, diabetes, heart disease, weak/failing kidneys, and stroke increased with worsening vision difficulty.
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Among adults ≥65 years, associations with vision difficulty were evident but less pronounced for several conditions.
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Efforts to incorporate vision health into chronic disease prevention and management efforts may benefit from considering condition type, level of vision difficulty, and age group.
Objective
Examine the prevalence of select chronic health conditions by self-reported vision difficulty status among middle-aged and older adults in the United States.
Design
Cross-sectional, population-based analysis.
Participants
U.S. adults aged ≥45 years.
Methods
Self-reported data were from the 2020 to 2024 National Health Interview Survey (N = 85,026). Conditions included self-reported hypertension, heart disease, high cholesterol, stroke, arthritis, cancer, weak/failing kidneys, dementia, diabetes, depression, and obesity. Adjusted prevalence ratios (APRs) were estimated using multivariable logistic regression models for each condition by vision difficulty status (none, some, severe) stratified by age group (45-64, ≥65 years).
Main outcome measures
Unadjusted and adjusted prevalence and APRs of 11 chronic health conditions by vision difficulty status.
Results
Overall, 20.2% of adults aged ≥45 years reported some vision difficulty and 2.1% reported severe vision difficulty. Among adults aged 45 to 64 years, the adjusted prevalences of most chronic conditions were higher among those with some or severe vision difficulty compared to those with no vision difficulty. For example, the adjusted prevalence of hypertension was 32.9% (95% confidence interval [CI]: 31.0-34.5) among those with no vision difficulty compared to 47.8% (95% CI: 42.4-53.2) among those with severe vision difficulty, with an APR of 1.45 (95% CI: 1.32-1.60). Similar patterns were observed among adults aged ≥65 years.
Conclusions
Our findings highlight the importance of integrating vision health into chronic disease prevention and management strategies, considering the condition type, severity of vision difficulty and age when developing and tailoring these strategies.
INTRODUCTION
C hronic health conditions pose a significant public health challenge in the United States, affecting individuals across all age groups. As of 2018, over half of the U.S. population had at least one chronic health condition and nearly 30% of adults had multiple. Additionally, chronic diseases account for nearly 90% of total healthcare expenditures in the U.S. Growing evidence suggests that visual impairment is associated with a range of chronic health conditions, including cardiovascular conditions, ,, diabetes, ,,,, kidney disease, ,,,,, arthritis, , cancer, , and depression. ,,, Notably, sufficient evidence supporting the relationship between vision loss and cognitive decline ,,,, led to the Lancet Commission on Dementia Prevention, Intervention, and Care identifying vision impairment as a modifiable risk factor for dementia in 2024. Eye diseases and vision loss can be related to chronic health conditions in a variety of ways. Not only are they health conditions in their own right, they can also be both a risk factor for and outcome of other such systemic diseases. ,,, Recognizing this unique role of vision and eye health is important for understanding its impact on overall health and integrating vision care into chronic disease prevention and management strategies.
Assessing the population-level burden of chronic health conditions by vision difficulty status can help inform public health and clinical strategies by highlighting populations at increased risk, guiding resource allocation, and supporting integration of vision care into chronic disease prevention and management efforts. National population-level estimates of the associations between self-reported vision difficulty and various chronic conditions were last published by Crews et al. using 2010 to 2014 data from the National Health Interview Survey (NHIS). Since then, more recent NHIS data have been released which now also includes dementia, allowing for the opportunity to provide updated estimates on a broader array of chronic conditions related to vision. In addition, the NHIS question on vision difficulty has since been revised from utilizing a dichotomous to a scaled response, allowing for a more granular assessment of severity. Moreover, the previous analysis focused on adults aged 65 years and older, leaving the opportunity to examine middle-aged adults who are also at risk for chronic conditions. In fact, middle-aged adults are an important population to consider in relation to chronic conditions, since those impacted often face higher healthcare costs and are at increased risk for early retirement due to disability-related barriers.
Using 2020 to 2024 NHIS data, the primary purpose of our study was to estimate the prevalence of select chronic conditions by level of self-reported vision difficulty among middle-aged and older adults in the U.S. Understanding the relationship between vision difficulty and such chronic conditions at the population level can help inform chronic disease prevention and management strategies that also incorporate vision health.
METHODS
DATA SOURCE
NHIS is an annual cross-sectional household interview survey conducted by the National Center for Health Statistics. The sample adult response rates ranged from 47.0% (2023) to 50.9% (2021). We pooled 2020 to 2024 NHIS sample adult data limited to adults aged ≥45 years (n = 89,155). Among these, we excluded 4124 (4.6%) respondents who did not provide a valid answer (i.e., refused, not ascertained, don’t know) for all measures of interest, resulting in a final analytic sample of 85 026 respondents. Multiple years of NHIS data were pooled to increase sample size, improve precision of estimates, and enable stable estimates for less prevalent conditions and subgroups (e.g., severe vision difficulty).
MEASURES OF INTEREST
Vision difficulty was defined based on the question: “Do you have any trouble seeing, even when wearing glasses or contact lenses? Would you say no difficulty, some difficulty, a lot of difficulty, or you cannot do this at all?” Response categories included: no difficulty, some difficulty, a lot of difficulty, cannot do at all, refused, not ascertained, and don’t know. Due to small sample sizes in the “cannot do at all” group, we combined “a lot of difficulty” and “cannot do at all” into a single category labeled “severe vision difficulty.” As a result, vision difficulty was categorized into 3 levels for analysis: no, some, and severe vision difficulty.
Our selection of chronic conditions was based on several criteria. A condition was included if (1) the variable was available in NHIS for at least 1 survey year, and (2) prior evidence has suggested an association between it and vision difficulty or vision loss. We primarily relied on the chronic conditions identified in the previous HHS standard list utilized by Crews et al. , We also included obesity, which is recognized as a chronic disease by the American Medical Association and for which evidence suggests a bidirectional relationship with vision impairment, particularly through mechanisms involving diabetes, hypertension, and inflammatory pathways. In NHIS, all chronic conditions except obesity were identified from the question stem “Have you EVER been told by a doctor or other health professional that you had…?” This question stem identifies hypertension (also called high blood pressure); coronary heart disease; angina (also called angina pectoris); heart attack (also called myocardial infarction); high cholesterol; stroke; some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia; cancer (or a malignancy of any kind); weak/failing kidneys (only available in the 2020, 2021, and 2024 surveys); dementia (including Alzheimer’s disease); depression; and diabetes (excluding prediabetes or gestational diabetes). We defined heart disease by combining coronary heart disease, heart attack, and angina. Respondents were categorized as having obesity if their Body Mass Index (BMI) was 30 kg/m 2 or higher, calculated using self-reported height and weight. As a result, we identified the following 11 conditions from the 2020 to 2024 NHIS: hypertension, high cholesterol, arthritis, obesity, cancer, depression, diabetes, heart disease, stroke, dementia, and weak/failing kidneys (limited to 2020, 2021, and 2024).
We also included several demographic and health-related covariates: age group (45-64 years, ≥65 years), sex (male, female), race and ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic other), marital status (married/living with partner, widowed, divorced/separated, never married), education (less than high school, high school or equivalent, some college, college graduate or above), rurality (large central metropolitan, large fringe metropolitan, medium and small metropolitan, and nonmetropolitan), region (Northeast, Midwest, South, and West), health insurance coverage (private, public, other, no coverage), and smoking status (current smoker, former smoker, never smoked).
STATISTICAL ANALYSES
Sample characteristics were assessed overall and by age group ( Table 1 , Supplemental Table 1). Age differences in sociodemographic and health-related factors were examined using chi-square tests with a significant P -value threshold of 0.05. Survey-weighted multivariable logistic regression models were used to estimate the likelihood of having each chronic condition by level of vision difficulty stratified by age group. Models were both unadjusted and adjusted for sex, race and ethnicity, marital status, education, health insurance status, rurality, region, and smoking status. Differences in the unadjusted prevalence of each condition by vision difficulty was tested using pairwise contrasts for vision difficulty (i.e., no vs some, no vs severe, some vs severe; Figure 1 , Supplemental Table 2). Adjusted prevalence ratios (APRs) were derived from predicted marginal probabilities estimated from the fully adjusted models ( Table 2 ). APRs were calculated by dividing predicted probabilities for individuals with some or severe vision difficulty by those with no vision difficulty, within each age group. APRs represent the ratio of the adjusted prevalence of a given chronic condition among individuals with some or severe vision difficulty compared with those with no vision difficulty. Given the number of chronic health condition outcomes tested in our main analyses, results for both unadjusted and adjusted multivariable logistic regression models were evaluated using a Bonferroni correction for 11 comparisons ( P -value < 0.0045). Sampling weights provided by the NCHS account for unequal selection probabilities, nonresponse, and poststratification, and were applied to produce national estimates. All analyses were conducted in R (version 4.4.1) using the “survey” package to account for the complex sampling design. Data visualizations were created using the “ggplot2” package.
Table 1
Counts and Prevalence of Vision Difficulty and Select Chronic Health Conditions Among U.S. Adults Aged ≥ 45 Years, National Health Interview Survey, 2020-2024 .
| Overall | Age 45-64 years (n = 42 409) | Age ≥ 65 years (n = 42 617) | ||
|---|---|---|---|---|
| N | % (95% CI) | % (95% CI) | % (95% CI) | |
| Vision difficulty | ||||
| No vision difficulty | 65 881 | 77.7 (77.3-78.2) | 77.9 (77.3-78.5) | 77.6 (77.0-78.1) |
| Some vision difficulty | 17 245 | 20.2 (19.7-20.6) | 20.5 (19.9-21.0) | 19.7 (19.2-20.3) |
| Severe vision difficulty | 1900 | 2.1 (2.0-2.2) | 1.7 (1.5-1.8) | 2.7 (2.5-2.9) |
| Chronic health conditions | ||||
| Hypertension | 43 020 | 48.4 (47.9-48.9) | 39.1 (38.4-39.7) | 61.8 (61.1-62.4) |
| High Cholesterol | 37 712 | 42.8 (42.4-43.3) | 35.6 (35.0-36.2) | 53.2 (52.6-53.8) |
| Arthritis | 32 124 | 34.7 (34.2-35.2) | 25.7 (25.1-26.3) | 47.5 (46.9-48.2) |
| Obesity | 27 841 | 34.7 (34.2-35.2) | 38.3 (37.6-39.0) | 29.6 (29.0-30.2) |
| Cancer | 16 135 | 16.6 (16.2-17.0) | 9.8 (9.5-10.2) | 26.3 (25.7-26.9) |
| Depression | 15 277 | 16.9 (16.5-17.3) | 17.9 (17.3-18.4) | 15.5 (15.0-15.9) |
| Diabetes | 13 279 | 15.6 (15.2-15.9) | 12.3 (11.9-12.8) | 20.2 (19.7-20.8) |
| Heart Disease | 10 304 | 11.1 (10.8-11.3) | 6.1 (5.8-6.4) | 18.1 (17.7-18.6) |
| Stroke | 4525 | 4.7 (4.6-4.9) | 2.8 (2.6-3.0) | 7.5 (7.2-7.8) |
| Dementia | 1542 | 1.8 (1.7-1.9) | 0.4 (0.4-0.5) | 3.7 (3.5-4.0) |
| Weak/failing Kidneys , | 2160 | 4.7 (4.5-5.0) | 2.8 (2.5-3.1) | 7.5 (7.1-8.0) |
Abbreviation: CI = confidence interval.
Unadjusted prevalence of select chronic conditions by vision difficulty status and age group among U.S. adults aged ≥45 years, National Health Interview Survey, 2020-2024. Error bars represent the upper and lower bounds of the 95% CIs. Data on weak/failing kidney are only available for years 2020, 2021, and 2024. The prevalence estimate for dementia among adults aged 45-64 years with severe vision difficulty is suppressed because the sample size is below 30. Please refer to Supplemental Table 2 for specific numbers and contrast tests.
Table 2
Adjusted Prevalence and Prevalence Ratios of Select Chronic Health Conditions By Vision Difficulty Stratified By Age Group Among U.S. Adults Aged ≥ 45 Years, National Health Interview Survey, 2020-2024 a .
| Age 45-64 years | Adjusted Predicted Prevalence | Adjusted Prevalence Ratios (APRs) | |||
|---|---|---|---|---|---|
| None | Some | Severe | Some vs None b | Severe vs None c | |
| % (95% CI) | % (95% CI) | % (95% CI) | APR (95% CI) | APR (95% CI) | |
| Hypertension | 32.9 (31.0-34.5) | 39.1 (36.8-40.9) | 47.8 (42.4-53.2) | 1.19 (1.14-1.22) d | 1.45 (1.32-1.60) d , e |
| High cholesterol | 36.9 (35.3-38.7) | 44.2 (41.7-46.7) | 51.4 (47.2-56.5) | 1.20 (1.15-1.24) d | 1.39 (1.29-1.51) d , e |
| Arthritis | 13.5 (12.4-14.7) | 19.8 (18.3-21.7) | 24.5 (20.8-28.1) | 1.47 (1.40-1.54) d | 1.82 (1.60-2.05) d , e |
| Obesity | 27.8 (26.3-29.5) | 32.0 (30.2-34.4) | 31.9 (27.8-38.0) | 1.15 (1.11-1.20) d | 1.15 (1.00-1.32) d |
| Depression | 7.5 (6.7-8.3) | 13.8 (12.4-15.2) | 21.6 (18.2-25.5) | 1.84 (1.73-1.96) d | 2.88 (2.49-3.37) d , e |
| Diabetes | 6.5 (5.8-7.3) | 9.2 (7.9-10.3) | 14.6 (12.0-18.6) | 1.41 (1.30-1.50) d | 2.24 (1.85-2.82) d , e |
| Cancer | 10.8 (9.8-12.2) | 12.2 (10.9-14.3) | 16.2 (12.0-21.4) | 1.13 (1.05-1.21) d | 1.50 (1.16-1.94) d |
| Heart disease | 4.1 (3.5-4.8) | 6.2 (5.3-7.3) | 9.6 (7.5-12.5) | 1.51 (1.37-1.67) d | 2.33 (1.88-2.93) d , e |
| Weak/failing kidney f | 0.9 (0.6-1.3) | 2.0 (1.3-3.1) | 4.4 (2.3-6.9) | 2.23 (1.71-2.71) d | 4.78 (3.06-6.89) d , e |
| Stroke | 1.1 (0.8-1.4) | 1.7 (1.23-2.2) | 2.9 (2.0-4.2) | 1.55 (1.30-1.83) d | 2.67 (2.04-3.68) d , e |
| Dementia | 0.1 (0.1-0.2) | 0.2 (0.1-0.3) | 0.6 (0.2-1.5) | 1.58 (1.10-2.34) | – g |
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