Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults.

CONTEXT Recent recommendations from the American Heart Association aim to improve cardiovascular health by encouraging the general population to meet 7 cardiovascular health metrics: not smoking; being physically active; having normal blood pressure, blood glucose and total cholesterol levels, and weight; and eating a healthy diet. OBJECTIVE To examine time trends in cardiovascular health metrics and to estimate joint associations and population-attributable fractions of these metrics in relation to all-cause and cardiovascular disease (CVD) mortality risk. DESIGN, SETTING, AND PARTICIPANTS Study of a nationally representative sample of 44,959 US adults (≥20 years), using data from the National Health and Nutrition Examination Survey (NHANES) 1988-1994, 1999-2004, and 2005-2010 and the NHANES III Linked Mortality File (through 2006). MAIN OUTCOME MEASURES All-cause, CVD, and ischemic heart disease (IHD) mortality. RESULTS Few participants met all 7 cardiovascular health metrics (2.0% [95% CI, 1.5%-2.5%] in 1988-1994, 1.2% [95% CI, 0.8%-1.9%] in 2005-2010). Among NHANES III participants, 2673 all-cause, 1085 CVD, and 576 IHD deaths occurred (median follow-up, 14.5 years). Among participants who met 1 or fewer cardiovascular health metrics, age- and sex-standardized absolute risks were 14.8 (95% CI, 13.2-16.5) deaths per 1000 person-years for all-cause mortality, 6.5 (95% CI, 5.5-7.6) for CVD mortality, and 3.7 (95% CI, 2.8-4.5) for IHD mortality. Among those who met 6 or more metrics, corresponding risks were 5.4 (95% CI, 3.6-7.3) for all-cause mortality, 1.5 (95% CI, 0.5-2.5) for CVD mortality, and 1.1 (95% CI, 0.7-2.0) for IHD mortality. Adjusted hazard ratios were 0.49 (95% CI, 0.33-0.74) for all-cause mortality, 0.24 (95% CI, 0.13-0.47) for CVD mortality, and 0.30 (95% CI, 0.13-0.68) for IHD mortality, comparing participants who met 6 or more vs 1 or fewer cardiovascular health metrics. Adjusted population-attributable fractions were 59% (95% CI, 33%-76%) for all-cause mortality, 64% (95% CI, 28%-84%) for CVD mortality, and 63% (95% CI, 5%-89%) for IHD mortality. CONCLUSION Meeting a greater number of cardiovascular health metrics was associated with a lower risk of total and CVD mortality, but the prevalence of meeting all 7 cardiovascular health metrics was low in the study population.

[1]  Yuling Hong,et al.  Ideal Cardiovascular Health and Mortality From All Causes and Diseases of the Circulatory System Among Adults in the United States , 2012, Circulation.

[2]  Katherine M Flegal,et al.  Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. , 2012, JAMA.

[3]  D. Mozaffarian,et al.  Heart disease and stroke statistics--2012 update: a report from the American Heart Association. , 2012, Circulation.

[4]  Martha L. Daviglus,et al.  Status of Cardiovascular Health in US Adults: Prevalence Estimates From the National Health and Nutrition Examination Surveys (NHANES) 2003–2008 , 2012, Circulation.

[5]  D. Nieman.  Low-Risk Lifestyle Behaviors and All-Cause Mortality: Findings From the National Health and Nutrition Examination Survey III Mortality Study , 2012 .

[6]  Roy J. Shephard,et al.  2011 Compendium of Physical Activities: A Second Update of Codes and MET Values , 2012 .

[7]  M. Burtscher.  Lifetime risks of cardiovascular disease. , 2012, The New England journal of medicine.

[8]  G. Tomaselli,et al.  The American Heart Association and the Million Hearts Initiative: a presidential advisory from the American Heart Association. , 2011, Circulation.

[9]  Chaoyang Li,et al.  Low-risk lifestyle behaviors and all-cause mortality: findings from the National Health and Nutrition Examination Survey III Mortality Study. , 2011, American journal of public health.

[10]  Donald M Berwick,et al.  The "Million Hearts" initiative--preventing heart attacks and strokes. , 2011, The New England journal of medicine.

[11]  David R Bassett,et al.  2011 Compendium of Physical Activities: a second update of codes and MET values. , 2011, Medicine and science in sports and exercise.

[12]  A. Folsom,et al.  Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence. , 2011, Journal of the American College of Cardiology.

[13]  A. Khera,et al.  Forecasting the Future of Cardiovascular Disease in the United States: A Policy Statement From the American Heart Association , 2011, Circulation.

[14]  D. Mozaffarian,et al.  Heart disease and stroke statistics--2011 update: a report from the American Heart Association. , 2011, Circulation.

[15]  T. Pechacek,et al.  Cigarette smoking - United States, 1965-2008. , 2011, MMWR supplements.

[16]  B. Cosman,et al.  Obesity epidemiology. , 2011, Clinics in colon and rectal surgery.

[17]  Morbidity and Mortality Weekly Report , 2022 .

[18]  Million hearts: strategies to reduce the prevalence of leading cardiovascular disease risk factors--United States, 2011. , 2011, MMWR. Morbidity and mortality weekly report.

[19]  Raymond J Carroll,et al.  A mixed‐effects model approach for estimating the distribution of usual intake of nutrients: The NCI method , 2010, Statistics in medicine.

[20]  D. Williamson,et al.  Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality, and prediabetes prevalence , 2010, Population health metrics.

[21]  S. Dube,et al.  Vital signs: Current cigarette smoking among adults aged >=18 years --- United States, 2009 , 2010 .

[22]  D. Mozaffarian,et al.  Interventions to Promote Physical Activity and Dietary Lifestyle Changes for Cardiovascular Risk Factor Reduction in Adults A Scientific Statement From the American Heart Association Endorsed by the Preventive Cardiovascular Nurses Association and the Society of Behavioral Medicine , 2010 .

[23]  J. Manson,et al.  Physical activity and cardiovascular disease prevention in women: a review of the epidemiologic evidence. , 2010, Nutrition, metabolism, and cardiovascular diseases : NMCD.

[24]  Farzad Mostashari,et al.  Deaths preventable in the U.S. by improvements in use of clinical preventive services. , 2010, American journal of preventive medicine.

[25]  D. Mozaffarian,et al.  Defining and Setting National Goals for Cardiovascular Health Promotion and Disease Reduction: The American Heart Association's Strategic Impact Goal Through 2020 and Beyond , 2010, Circulation.

[26]  K. Flegal,et al.  Prevalence and trends in obesity among US adults, 1999-2008. , 2010, JAMA.

[27]  E. Ford,et al.  Prevalence of Diabetes and High Risk for Diabetes Using A1C Criteria in the U.S. Population in 1988–2006 , 2010, Diabetes Care.

[28]  V. Basevi.  Standards of Medical Care in Diabetes—2010 , 2010, Diabetes Care.

[29]  B. Gersh.  Trends in the Prevalence of Low Risk Factor Burden for Cardiovascular Disease Among United States Adults , 2010 .

[30]  L. Tanoue.  Vital signs: current cigarette smoking among adults aged >or=18 years --- United States, 2009. , 2010, MMWR. Morbidity and mortality weekly report.

[31]  Qiang-sun Zheng,et al.  Dietary therapy in hypertension. , 2010, The New England journal of medicine.

[32]  Heidi M. Blanck,et al.  Vital signs: state-specific obesity prevalence among adults --- United States, 2009. , 2010, MMWR. Morbidity and mortality weekly report.

[33]  T. Greene,et al.  Physical activity and mortality in chronic kidney disease (NHANES III). , 2009, Clinical journal of the American Society of Nephrology : CJASN.

[34]  Alicia Bazzano,et al.  The Healthy Lifestyle Change Program: a pilot of a community-based health promotion intervention for adults with developmental disabilities. , 2009, American journal of preventive medicine.

[35]  E. Ford,et al.  Trends in the Prevalence of Low Risk Factor Burden for Cardiovascular Disease Among United States Adults , 2009, Circulation.

[36]  P. Kokkinos,et al.  Physical Activity and Cardiovascular Disease Prevention , 2009 .

[37]  L. Jackson.  Translating the Diabetes Prevention Program Into Practice , 2009, The Diabetes educator.

[38]  Desmond E. Williams,et al.  Full Accounting of Diabetes and Pre-Diabetes in the U.S. Population in 1988–1994 and 2005–2006 , 2009, Diabetes Care.

[39]  N. Unwin,et al.  Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Detection, Evaluation, and Treatment of High Blood Cholesterol Education Program (NCEP) Expert Panel on Executive Summary of the Third Report of the National , 2009 .

[40]  Benjamin Caballero,et al.  Will All Americans Become Overweight or Obese? Estimating the Progression and Cost of the US Obesity Epidemic , 2008, Obesity.

[41]  Judy Kruger,et al.  Prevalence of regular physical activity among adults--United States, 2001 and 2005. , 2007, MMWR. Morbidity and mortality weekly report.

[42]  A. Bauman,et al.  Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. , 2007, Circulation.

[43]  D. Spiegelman,et al.  Point and interval estimates of partial population attributable risks in cohort studies: examples and software , 2007, Cancer Causes & Control.

[44]  Dariush Mozaffarian,et al.  Fish intake, contaminants, and human health: evaluating the risks and the benefits. , 2006, JAMA.

[45]  S. Daniels,et al.  Summary of American Heart Association Diet and Lifestyle Recommendations Revision 2006 , 2006, Arteriosclerosis, thrombosis, and vascular biology.

[46]  Dolores Corella,et al.  Effects of a Mediterranean-Style Diet on Cardiovascular Risk Factors , 2006, Annals of Internal Medicine.

[47]  Judith Wylie-Rosett,et al.  Diet and Lifestyle Recommendations Revision 2006: A Scientific Statement From the American Heart Association Nutrition Committee , 2006, Circulation.

[48]  Michael M. Engelgau,et al.  Prevalence of Diabetes and Impaired Fasting Glucose in Adults in the U.S. Population , 2006, Diabetes Care.

[49]  D. Mozaffarian,et al.  Trans fatty acids and cardiovascular disease. , 2006, The New England journal of medicine.

[50]  C. Rochester,et al.  EFFECTS OF PROTEIN, MONOUNSATURATED FAT, AND CARBOHYDRATE INTAKE ON BLOOD PRESSURE AND SERUM LIPIDS , 2006 .

[51]  Frank M. Sacks,et al.  Dietary Approaches to Prevent and Treat Hypertension: A Scientific Statement From the American Heart Association , 2006, Hypertension.

[52]  B. Rosner,et al.  Effects of protein, monounsaturated fat, and carbohydrate intake on blood pressure and serum lipids: results of the OmniHeart randomized trial. , 2005, JAMA.

[53]  JoAnn E Manson,et al.  Epidemiological evidence for the role of physical activity in reducing risk of type 2 diabetes and cardiovascular disease. , 2005, Journal of applied physiology.

[54]  M. Gail,et al.  Efficacy and Tolerability of Long-Acting Injectable Naltrexone for Alcohol Dependence: A Randomized Controlled Trial , 2005, Gynecologic oncology.

[55]  H. Buttar,et al.  Prevention of cardiovascular diseases: Role of exercise, dietary interventions, obesity and smoking cessation. , 2005, Experimental and clinical cardiology.

[56]  A. Dyer,et al.  Favorable cardiovascular risk profile in young women and long-term risk of cardiovascular and all-cause mortality. , 2004, JAMA.

[57]  H. Kohl,et al.  Prevalence of no leisure-time physical activity--35 States and the District of Columbia, 1988-2002. , 2004, MMWR. Morbidity and mortality weekly report.

[58]  Fernando Costa,et al.  Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Ph , 2003, Circulation.

[59]  Harold W. Kohl,et al.  Prevalence of physical activity, including lifestyle activities among adults--United States, 2000-2001. , 2003, MMWR. Morbidity and mortality weekly report.

[60]  A. Mokdad,et al.  Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. , 2003, JAMA.

[61]  J. Mckenney,et al.  National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) , 2002 .

[62]  J. Skyler,et al.  Diabetes trends in the USA , 2002, Diabetes/metabolism research and reviews.

[63]  S. Grundy,et al.  National Cholesterol Education Program Third Report of the National Cholesterol Education Program ( NCEP ) Expert Panel on Detection , Evaluation , and Treatment of High Blood Cholesterol in Adults ( Adult Treatment Panel III ) Final Report , 2022 .

[64]  G. Bray,et al.  Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet , 2001 .

[65]  M. Engelgau,et al.  Diabetes trends in the U.S.: 1990-1998. , 2000, Diabetes care.

[66]  B E Ainsworth,et al.  Compendium of physical activities: an update of activity codes and MET intensities. , 2000, Medicine and science in sports and exercise.

[67]  Orton,et al.  EFFECTS ON BLOOD PRESSURE OF REDUCED DIETARY SODIUM AND THE DIETARY APPROACHES TO STOP HYPERTENSION ( DASH ) DIET , 2000 .

[68]  F. Rank,et al.  PRIMARY PREVENTION OF CORONARY HEART DISEASE IN WOMEN THROUGH DIET AND LIFESTYLE , 2000 .

[69]  A. Dyer,et al.  Low risk-factor profile and long-term cardiovascular and noncardiovascular mortality and life expectancy: findings for 5 large cohorts of young adult and middle-aged men and women. , 1999, JAMA.

[70]  H. Becher,et al.  Estimating the generalized impact fraction from case-control data. , 1997, Biometrics.

[71]  B Barnwell,et al.  SUDAAN User's Manual, Release 7.5, , 1997 .

[72]  Michael Witt,et al.  SUDAAN User's Manual, Release 9.0 , 2002 .

[73]  J. Mckenney,et al.  Summary of the second report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II) , 1993, JAMA.

[74]  David A. Schoenfeld,et al.  Partial residuals for the proportional hazards regression model , 1982 .