The AHA Impact Goal for 2010-2020 that was released in January 2010 focuses on promotion of health and control of risk rather than on the treatment of specific cardiovascular diseases. This goal includes a new construct of cardiovascular health and presents metrics to monitor it over time3
. To the best of our knowledge, our study is the first to report the application of this construct to a cohort of participants in a community-based cardiovascular prevention study. We identified an extremely low prevalence of ideal cardiovascular health in a cohort that is composed of black and white individuals who are relatively free of overt CVD and who volunteered to participate in a cardiovascular prevention study. Even after using a less strict definition of ideal cardiovascular health (≥5 ideal health components instead of 7), less than 10% of the participants met the AHA's goal in all age groups between 45-75 years, in both black and whites, males and females, and across all subgroups of education and annual income.
Our findings add to previous reports that have demonstrated low prevalences of healthy lifestyles and health factors, both individually and in combination, in the general population and in ongoing epidemiologic studies. Reeves11
reported a 3% national prevalence of a healthy indicator composed of nonsmoking, BMI 18.5-25 kg/m2
, consuming ≥5 fruits and vegetables/day and regular physical activity (≥30 minutes ≥5 times per week). The age-adjusted prevalence of the four healthy lifestyles was 3.3% among whites and 1.4% in blacks. More recently, Ford12
used data from four national surveys to create an index of low risk (not currently smoking, untreated total cholesterol<200mg/dL, untreated SBP <120 mmHg and DBP <80 mmHg, BMI <25 kg/m2
and no previous diagnosis of diabetes). Ford reported that the overall prevalence of low risk was ≈8% in the general population, but much lower in the group corresponding to our Heart SCORE participants (3.5% and 0.8% in age groups of 45-64 and 65-74 years, respectively).
Due to the comprehensive nature of the new AHA construct of cardiovascular health, we anticipated a low prevalence of ideal categories. However, the fact that only one out of 1933 participants met the definition of ideal cardiovascular health and that the indices of ideal health behaviors and factors were only met by 2.0% and 1.4% of the participants respectively, is especially concerning because of the participatory nature of our project, the use of a community-based recruitment strategy, and the inherent healthy volunteer bias that we expected to be associated with more favorable findings. One potential explanation for our finding is the age range of Heart SCORE participants (45-75 years) because, with the exception of smoking, prevalences of healthy behaviors and factors are known to decrease with aging1,13
. However, several longitudinal studies have previously demonstrated that it is feasible for middle and older age subjects to maintain or even adopt a healthy lifestyle pattern and that this is associated with substantial CVD, stroke and all-cause mortality benefits6, 14-17
The national overweight and obesity epidemic may provide another explanation for our findings. Any definition of “health” that includes a BMI of <25 kg/m2
will be unmet by a large percentage of Americans, especially blacks and other minorities18
. In our study, 80.6% of the participants were classified as being overweight or obese. Furthermore, it is well recognized that other risk behaviors and factors such as poor nutrition, lack of exercise, elevated blood pressure and hyperglycemia tend to cluster with obesity. Therefore, a better understanding of the causes of overweight and obesity along with the successful implementation of programs targeting its prevention and treatment will likely increase the prevalence of ideal cardiovascular health. As an example, the efficacy of diet and physical activity counseling in class III (BMI >35 kg/m2
) and class IV (BMI >40 kg/m2
) obesity demonstrated by Goodpasture19
suggests that even for severely obese adults, lifestyle interventions may be associated with improvements in several components of cardiovascular health.
According to the model of determinants of health proposed by Healthy People 2010, population health can be influenced by both individual factors and an array of other critical determinants, such as physical and social environments, public health policies and interventions, and access to and affordability of health care, all of which continuously interact with each other and with individuals20
. Therefore, potential approaches to increasing attainment of AHA goals in the general population include: (1) Individual level:
Evolving research on the identification of individual predictors of success or failure of compliance with and the effectiveness of preventive interventions are expected to foster the development of a more personalized approach to preventive medicine. For instance, the application of genomics, metabolomics and neuroscience research may enable the development of cardiovascular prevention strategies tailored to individuals. (2) Physical and social environment levels:
Although it is well accepted that strategies that improve the provision of clean and safe places for people to work, exercise and play can promote good health, and that the social environment has a profound effect on health20
, there is an increasing recognition that health sciences and social sciences have been isolated within disciplinary silos. This led the National Institutes of Health to develop large-scale infrastructure programs that support interdisciplinary translational research integrating the biomedical, social, behavioral and psychological sciences21
. Team-based research addressing the effects of the built environment and social interventions on CVD holds promise for improving the attainment of AHA' s goals. (3) Policies and interventions level:
The National Prevention, Health Promotion, and Public Health Council was recently established with the purpose of developing a national strategy to improve health promotion and disease prevention, with an emphasis on lifestyle behavior modification and prevention measures for the five leading causes of death in the U.S. The council will also coordinate and provide leadership at the federal level22
. The national strategy, which is scheduled to be released by March 2011, will hopefully be designed to promote significant and sustained improvements in health and disease prevention, including CVD. (4) Access to quality health care level
: The Affordable Care Act enacted in March 2010 will guarantee access to health care for all Americans and stimulate effective integration of care provided by physicians and other health care professionals to improve outcomes, care productivity, and patient experiences23
. The proactive management of preventive care and the establishment of accountable care organizations and patient-centered medical homes are expected to improve the quality and lower the cost of care. Implementation of this legislation should increase access to and promote the provision of primary care, which is expected to improve the cardiovascular health status among the general population.
The 2020 AHA Impact Goal emphasizes the need for improvement of cardiovascular health of all Americans. Our results indicate that there is a significant race-related difference in attaining ideal cardiovascular health and its components. This finding is consistent with previous reports of blacks having a disproportionately greater burden of cardiovascular risk factors and higher CVD and stroke mortality rates compared to whites1, 6, 12, 24, 25
. We found that the effect of race on cardiovascular health indicators persisted after adjustment for a variety of relevant socio-demographic characteristics, including socioeconomic status. This observation is consistent with prior reports and reinforces the call for new research study designs that will increase the understanding of the underlying determinants of such disparities24, 26
. These study designs may benefit from a mixed methods approach because racial disparities are related to a combination of known (e.g., genetic, psychosocial, cultural, historical) and other unrecognized factors27
This is the first known report of the application of the new AHA definition of cardiovascular health to a community-based study cohort. The large gaps between the prevalence of ideal cardiovascular health and the AHA's goals were consistently identified in all subgroups evaluated and the significant effect of race on cardiovascular health was independent of sex, robust across different age groups, and persisted after adjustment for socioeconomic status. However, this study has several limitations. First, our population was subject to referral and healthy volunteer biases, which may explain the low prevalence of smoking and an overall high level of education. We did not find differences in cardiovascular health by education level, which should be interpreted in the context of this highly educated population, whose homogeneity in terms of years of education may limit comparisons. Although this may affect the generalizability of our findings, it does not explain the unexpectedly low prevalences of healthy behaviors and factors. Indeed, the prevalences of healthy behaviors and factors may actually be significantly lower in a more general population with lower levels of education. Second, all blood pressure measurements were obtained at a single examination visit, which may be associated with misclassification of blood pressure status as a result of the regression to the mean phenomenon28
. However, even if this resulted in inflated prevalences of the intermediate and poor blood pressure categories in our cohort, a misclassification would not explain the large gap between observed blood pressures and the AHA's blood pressure goal. Additionally, if regression dilution bias is affecting our statistical models, the true effect of race on cardiovascular health is expected to be stronger than that which is reported in this study.
Third, misclassification of nutritional and physical activities may have occurred because the PrimeScreen and the Lipid Research Clinic questionnaires were not designed to evaluate the total amount of nutrients and physical activity, respectively. Therefore, we used approximations of the recommended consumption of fruits and vegetables, as well as the level of physical activity. However, our systematic approach to classification of diet and physical activity should not affect comparisons of health behaviors and factors by race and other relevant socio-demographic variables. Additionally, although other nutritional components recommended by the AHA were not assessed in the current investigation, our use of fruits and vegetables consumption as a proxy of a heart healthy diet is supported by a large body of evidence that indicates that higher consumption of fruits and vegetables correlates with an array of beneficial health effects, including reduction in blood pressure, lower rates of overweight and obesity, and reduction in risks of diabetes, CHD, stroke and certain cancers29
. We anticipate that future studies using the AHA definition for a healthy diet score will likely report prevalences of ideal dietary categories lower than those observed in this study.
The prevalence of the new concept of “ideal cardiovascular health” is extremely low in a middle-aged cohort that was recruited from the general community to participate in a study of CVD risk assessment. Although black race emerged as an important determinant of the lack of achievement of “ideal cardiovascular health”, both whites and blacks have a long way to goal. The large gap between the prevalence of ideal cardiovascular health and AHA's goals suggests that the attainment of the stated goals for the next decade may be much more challenging than originally conceived. Targeted efforts will be required at multiple levels (e.g. individual, social, environmental, policies and intervention, and access to quality health care) in order to insure the achievement of these goals.
The AHA's 2020 Impact Goal focuses on promotion of health and control of risk rather than solely on prevention and treatment of specific cardiovascular diseases. This goal includes a new construct of cardiovascular health composed by seven behaviors and factors. Our study is the first report of the application of this construct to a cohort of black and white participants in a community-based cardiovascular prevention study. Only one out 1933 participants met all 7 components of the AHA's definition of ideal cardiovascular health. The indices of ideal health behaviors and ideal health factors were only met by 2.0% and 1.4% of participants, respectively. The large gap between the prevalence of ideal cardiovascular health and the AHA's goals was consistently identified in all subgroups evaluated by age, race, sex, education and income level. Although black race emerged as an important independent determinant of the lack of achievement of “ideal cardiovascular health”, both whites and blacks have a long way to goal. Our findings suggest that the attainment of the stated goals for the next decade may be more challenging than originally conceived. Practicing clinicians and their health care teams need to engage in coordinated efforts along with social sciences professionals, policymakers, and individuals and their communities in order to insure the achievement of these goals.