Sex Disparities in Ischemic Heart Disease Death Across the United States: The Southern Burden of Excess Body Weight and Diet

BACKGROUND: While prior studies have assessed sex disparities in ischemic heart disease (IHD) outcomes in the United States, little is known about how these differences vary across states. METHODS: We analyzed GBD (Global Burden of Disease) data from 2011 to 2021 for all 50 US states. Sex-specific IHD age-standardized mortality rates and IHD age-standardized prevalence rates were used to calculate the mortality-to- prevalence ratios per 100 000 inhabitants per year, enabling comparison of death rates relative to the population at risk. Hawaii, the state with the lowest age-standardized prevalence rate and age-standardized mortality rate in both sexes, served as the reference for Z score analyses, with 99% (Z>2.58) or 95% (Z>1.96) confidence thresholds. RESULTS: In 2011, 30 states had significantly higher mortality-to- prevalence ratios in women than men (Z>2.58), indicating an elevated mortality rate in women with IHD. By 2021, only Arkansas (6.7% [95% uncertainty interval, 4.6–9.3]) and Mississippi (7.1% [95% uncertainty interval, 4.8–9.7]) exceeded this threshold, while 11 additional states, mainly in the South, retained moderate disparities (Z>1.96). Higher mortality-to- prevalence ratios were inversely associated with state gross domestic product per capita. High body mass index, processed meat intake, low fiber, and low vegetable intake emerged as the most significant contributors (Z>1.96, 95% confidence level) to excess IHD death in women but not men. CONCLUSIONS: Despite an overall decline, sex disparities in IHD death persist, with Arkansas and Mississippi continuing to bear the highest burden. These disparities are largely driven by overweight/obesity and dietary risk factors, warranting targeted, state-level interventions.