Life’s Simple 7
The American Heart Association’s Life’s Simple 7 includes factors related to cardiovascular health. For each of the seven factors, data from individuals can be compared to AHA definitions and categorized as high, intermediate, or low cardiovascular health. A composite of the seven factors yields a measure of overall cardiovascular health. Life’s Simple 7 serves to highlight cardiovascular health but the potential impact of Americans achieving higher cardiovascular health by following Life’s Simple 7 remained unknown until recently.
Researchers used data from three cycles of the nationally representative National Health and Nutrition Examination Survey to estimate the proportions of US adults with high, moderate, and low cardiovascular health. Then the researchers pooled data from seven longitudinal studies of 30,447 US residents to estimate the incidence of major cardiovascular events.
Sadly, only 7.5 percent of US adults had high cardiovascular health, while 56.6 percent had low cardiovascular health. Compared to men aged 60 years or older with low cardiovascular health, men aged 60 years or older with high cardiovascular health had 66 percent lower risk of having a major cardiovascular event, such as a heart attack, during an average follow-up of 16 years. The comparable reduction for women was 71 percent. Of the estimated 2.85 million cardiovascular events in the US in 2019, an estimated 70 percent of those events were attributed to low and intermediate levels of cardiovascular health. Two million cardiovascular events could have been prevented if all Americans ate a high cardiovascular health diet. While this supposition isn’t realistic over the short term, it gives a sense of the huge potential to reduce cardiovascular disease if we Americans were to improve our cardiovascular health over the long term.
Optimal cardiovascular health declined
Have we Americans improved our cardiometabolic health since the start of the new millennium? Researchers at Tufts University answered this question with data from a nationally representative sample of 55,081 participants in the National Health and Nutrition Examination Survey from 1999-2000 to 2017-2018. Optimal cardiometabolic health was defined in terms of 1) body fat (BMi < 25 and waist circumference < 88/102 cm for women/men), 2) blood glucose (fasting blood glucose < 100 mg/dL and HbA1c < 5.7%, 3) blood lipids (total cholesterol/HDL-cholesterol < 3.5 with no medications), 4) blood pressure (<120 mm Hg systolic and < 80 mm Hg diastolic with no medications), and 5) history of cardiovascular disease (no history). During the 20-year study period, the proportion of participants with optimal cardiometabolic health declined to 6.8 percent. Declines in optimal cardiometabolic health were greater for participants with low education, male sex, greater age, and non-White race/ethnicity. For participants age 65 and older, only 4 out of every 1,000 participants had optimal cardiometabolic health. These results bode ill for the ability of the US medical care system to handle the influx of baby boomers.
Cardiovascular risk factors from 1999-2018
Researchers used cross-sectional data from 50,571 participants in 10 cycles of the National Health and Nutrition Examination Survey from 1999-2018 to evaluate trends in the prevalence of cardiovascular risk factors. Over that period, the average body mass index and blood glucose (measured as HbA1c) increased significantly. On the other hand, the age- and sex-adjusted average total cholesterol and prevalence of smoking declined significantly. Systolic blood pressure declined then increased for an overall small, non-significant decrease. The 10-year atherosclerotic cardiovascular disease risk declined then remained flat. Cardiovascular risk factors and cardiovascular deaths have both decreased significantly since 1950. However, Black Americans consistently showed higher levels of cardiovascular risk factors across the study period than other racial and ethnic groups. Some of the differences may have arisen from socioeconomic factors, such as education, income, health insurance that tend to penalize Black Americans.
Premature heart attack deaths declined but varied widely
Heart attack (also known as acute myocardial infarction) is a leading cause of premature death (less than age 65 years) in the US. Between 1999 and 2019, the rate of premature death from heart attack in the US declined by over one half from 20.4 deaths per 100,000 persons to 9.9 deaths per 100,000 persons. This equated to a decline of 3.4 percent per year. However, since 2011, the rate of decline in premature deaths from heart attack slowed. From 1999 to 2011, the rate was 4.3 percent per year, which slowed to 2.1 percent per year from 2011 to 2019.
During the study period, the rate of premature death due to heart attack varied widely across the US and across racial and ethnic groups. States with the highest rates (more than 20 deaths per 100,000) included Mississippi, Alabama, South Carolina, Arkansas, Tennessee, Kentucky, and Missouri. States with the lowest rates (0-10 deaths per 100,000) included Minnesota, New York, Montana, New Mexico, Arizona, Nevada, Colorado, California, Oregon, and Washington. In other words, you are more than twice as likely to die prematurely from a heart attack in Missouri as you are in Colorado. Men were more than twice as likely to die prematurely from a heart attack compared to women. Non-Hispanic Black Americans were 28 percent more likely to die prematurely from a heart attack than Non-Hispanic Whites. Thus, the risk of premature death from heart attack declined from 1999 to 2019 but the rate of decline varied widely among Americans.
Cardiovascular risk factor control for middle-aged Americans, 2001-2020
The National Health and Nutrition Examination Survey collects data relevant to cardiovascular disease risk factors and health issues every 2 years. A series of cross-sectional datasets every 2 years (except for 2017-2020 due to COVID) from 2001-2020 included 23,594 adult participants aged 40-79 years without atherosclerotic cardiovascular disease in 2001. During that period, the overall prevalence of elevated cardiovascular disease risk declined slightly and non-significantly from 41.5 to 38.6 percent. However, a different picture emerges for men vs. women, older vs. younger, and Black vs. non-Black participants. Risk of elevated cardiovascular disease risk increased by 6.4 percent in men, while it declined by 4.0 percent in women. Risk increased by 10.0 percent for Blacks but only by 2.4 percent for Hispanics. When considering participant age only, the prevalence of elevated cardiovascular disease risk increased by 8.8 percent, but after accounting for all other risk factors (such as diabetes, hypertension, excess blood fats), the risk declined by 3.8 percent from 2001-2020. Thus, risk factor control improved during the study period but was largely negated by the increasing age of the participants.
More diabetes and obesity in young adults
The risk of dying from cardiovascular disease has dropped for several decades, but that decline stalled over the last decade. Researchers tested whether the interrupted decline could be attributed to increased prevalence of cardiovascular risk factors (hypertension, diabetes, high blood fats, obesity, and tobacco use) for US adults aged 20 to 44 years from 2009 to 2020. Data came from 12,924 adults in the National Health and Nutrition Examination Survey from 2009 to March 2020 (when COVID -19 arrived in force). During this period, the prevalence of diabetes and obesity increased significantly from 3.0 to 4.1 percent and 32.7 to 35.3 percent, respectively. The prevalence of hypertension edged up but not significantly. The prevalence of excess blood fats declined significantly from 40.5 to 36.1 percent, while the prevalence of tobacco use changed little. Black participants had significantly larger increases in prevalence of diabetes and obesity compared to white participants. The proportion of participants who received treatment for hypertension and achieved blood pressure control did not change significantly; the same was true for participants who received treatment for diabetes. The disappointing results of this study show that young adults during 2009 to 2020 increased their prevalence of diabetes and obesity and, therefore, their risks of cardiovascular disease. Treatment for hypertension and diabetes failed to produce better results. The slower decline in cardiovascular deaths during the study period may reflect more diabetes and obesity and lack of improved treatment.
Cardiovascular-related hospitalizations up
The long-term decline in cardiovascular mortality risk in the US faltered in 2011. Some evidence points to decreased cardiovascular health in younger and middle-aged adults. Researchers in Boston used data from the Healthcare Cost Utilization Project National Inpatient Sample to determine hospitalizations and in-hospital mortality from heart attack, heart failure, and ischemic stroke for persons aged 25 to 64 years from 2008 to 2019. Overall, hospitalizations for heart attack increased significantly but modestly from 155 to 161 per 100,000 adults over the study period. In lower-income communities, the rate of heart attack hospitalizations declined significantly from 271 to 245 per 100,000 adults. Overall and for both high-income and low-income communities, heart failure and ischemic stroke hospitalizations increased significantly. Hospitalization rates for all three conditions increased far more for persons in low-income compared to high-income communities. On the other hand, in-hospitalization mortality rates for heart attack, heart failure, and ischemic stroke all declined significantly, possible due to improved technology and treatment. Increased hospitalizations for younger and middle-aged adults bode ill for the future as these adults age into older adults. Plus, hospitalization and mortality disparities between persons in high-income and low-income communities did not decrease.
What to do
Embrace the healthy lifestyle choice of Eat Better to help you minimize your cardiovascular disease risk factors (especially high blood pressure, type 2 diabetes, obesity) and reduce your risk of a major cardiovascular event, such as a heart attack.
