Table 1.

New and Updated Metrics for Measurement and Quantitative Assessment of CVH (see Notes for implementation of each metric; See Supplemental Material for additional information on scoring of the Diet Metric, scoring in children at different ages, and examples of overall CVH scores in diverse scenarios)

Domain	CVH metric	Method of measurement	Quantification of CVH metric: adults (≥20 y of age)		Quantification of CVH metric: children (up to 19 y of age)
Health behaviors	Diet	Measurement: Self-reported daily intake of a DASH-style eating pattern Example tools for measurement: DASH diet score130,131 (populations); MEPA132 (individuals)	Quantiles of DASH-style diet adherence or HEI-2015 (population)		Quantiles of DASH-style diet adherence or HEI-2015 (population) or MEPA (individuals)*; ages 2–19 y (see Supplemental Material for younger ages)
			Scoring (population):		Scoring (population):
			Points	Quantile	Points	Quantile
			100	≥95th percentile (top/ideal diet)	100	≥95th percentile (top/ideal diet)
			80	75th–94th percentile	80	75th–94th percentile
			50	50th–74th percentile	50	50th–74th percentile
			25	25th–49th percentile	25	25th–49th percentile
			0	1st–24th percentile (bottom/least ideal quartile)	0	1st–24th percentile (bottom/least ideal quartile)
			Scoring (individual):		Scoring (individual):
			Points	MEPA score (points)	Points	MEPA score (points)
			100	15–16	100	9–10
			80	12–14	80	7–8
			50	8–11	50	5–6
			25	4–7	25	3–4
			0	0–3	0	0–2
	PA	Measurement: Self-reported minutes of moderate or vigorous PA per week Example tools for measurement: NHANES PAQ-K questionnaire133	Metric: Minutes of moderate- (or greater) intensity activity per week:		Metric: Combustible tobacco use or inhaled NDS use at any age (per clinician discretion); or secondhand smoke exposure
			Scoring:		Scoring:
			Points	Minutes	Points	Minutes
			100	≥150	100	≥420
			90	120–149	90	360–419
			80	90–119	80	300–359
			60	60–89	60	240–299
			40	30–59	40	120–239
			20	1–29	20	1–119
			0	0	0	0
	Nicotine exposure	Measurement: Self-reported use of cigarettes or inhaled NDS Example tools for measurement: NHANES SMQ134	Metric: Combustible tobacco use or inhaled NDS use; or secondhand smoke exposure		Metric: Combustible tobacco use or inhaled NDS use at any age (per clinician discretion); or secondhand smoke exposure
			Scoring:		Scoring:
			Points	Status	Points	Status
			100	Never smoker	100	Never tried
			75	Former smoker, quit ≥5 y	50	Tried any nicotine product, but >30 d ago
			50	Former smoker, quit 1–<5 y
			25	Former smoker, quit <1 y, or currently using inhaled NDS	25	Currently using inhaled NDS
			0	Current smoker	0	Current combustible use (any within 30 d)
			Subtract 20 points (unless score is 0) for living with active indoor smoker in home		Subtract 20 points (unless score is 0) for living with active indoor smoker in home
	Sleep health	Measurement: Self-reported average hours of sleep per night Example tools for measurement: “On average, how many hours of sleep do you get per night?” Consider objective sleep/actigraphy data from wearable technology if available	Metric: Average hours of sleep per night		Metric: Average hours of sleep per night (or per 24 h for age ≤5 y; see notes for age-appropriate ranges)
			Scoring:		Scoring:
			Points	Level	Points	Level
			100	7–<9	100	Age-appropriate optimal range
			90	9–<10	90	<1 h above optimal range
			70	6–<7	70	<1 h below optimal range
			40	5–<6 or ≥10	40	1–<2 h below or ≥1 h above optimal
			20	4–<5	20	2–<3 h below optimal range
			0	<4	0	≥3 h below optimal range
Health factors	BMI	Measurement: Body weight (kilograms) divided by height squared (meters squared) Example tools for measurement: Objective measurement of height and weight	Metric: BMI (kg/m2)		Metric: BMI percentiles for age and sex, starting in infancy; see Supplemental Material for suggestions for age <2 y
			Scoring:		Scoring:
			Points	Level	Points	Level
			100	<25	100	5th–<85th percentile
			70	25.0–29.9	70	85th–<95th percentile
			30	30.0–34.9	30	95th percentile–<120% of the 95th percentile
			15	35.0–39.9	15	120% of the 95th percentile–<140% of the 95th percentile
			0	≥40.0	0	≥140% of the 95th percentile
	Blood lipids	Measurement: Plasma total and HDL cholesterol with calculation of non–HDL cholesterol Example tools for measurement: Fasting or nonfasting blood sample	Metric: Non–HDL cholesterol (mg/dL)		Metric: Non–HDL cholesterol (mg/dL), starting no later than age 9–11 y and earlier per clinician discretion
			Scoring:		Scoring:
			Points	Level	Points	Level
			100	<130	100	<100
			60	130–159	60	100–119
			40	160–189	40	120–144
			20	190–219	20	145–189
			0	≥220	0	≥190
			If drug-treated level, subtract 20 points		If drug-treated level, subtract 20 points
	Blood glucose	Measurement: FBG or casual HbA1c Example tools for measurement: Fasting (FBG, HbA1c) or non-fasting (HbA1c) blood sample	Metric: FBG (mg/dL) or HbA1c (%)		Metric: FBG (mg/dL) or HbA1c (%), symptom-based screening at any age or risk-based screening starting at age ≥10 y of age or onset of puberty per clinician discretion
			Scoring:		Scoring:
			Points	Level	Points	Level
			100	No history of diabetes and FBG <100 (or HbA1c <5.7)	100	No history of diabetes and FBG <100 (or HbA1c < 5.7)
			60	No diabetes and FBG 100–125 (or HbA1c 5.7–6.4) (prediabetes)	60	No diabetes and FBG 100–125 (or HbA1c 5.7–6.4) (prediabetes)
			40	Diabetes with HbA1c <7.0	40	Diabetes with HbA1c <7.0
			30	Diabetes with HbA1c 7.0–7.9	30	Diabetes with HbA1c 7.0–7.9
			20	Diabetes with HbA1c 8.0–8.9	20	Diabetes with HbA1c 8.0–8.9
			10	Diabetes with Hb A1c 9.0–9.9	10	Diabetes with Hb A1c 9.0–9.9
			0	Diabetes with HbA1c ≥10.0	0	Diabetes with HbA1c ≥10.0
	BP	Measurement: Appropriately measured systolic and diastolic BPs Example tools for measurement: Appropriately sized BP cuff	Metric: Systolic and diastolic BPs (mm Hg)		Metric: Systolic and diastolic BP (mm Hg) percentiles for age through 12 y. For age ≥13 y, use adult scoring. Screening should start no later than age 3 y and earlier per clinician discretion
			Scoring:		Scoring:
			Points	Level	Points	Level
			100	<120/<80 (optimal)	100	Optimal (<90th percentile)
			75	120–129/<80 (elevated)	75	Elevated (≥90th–<95th percentile or ≥120/80 mm Hg to <95th percentile, whichever is lower)
			50	130–139 or 80–89 (stage 1 hypertension)	50	Stage 1 hypertension (≥95th–<95th percentile+12 mm Hg, or 130/80 to 139/89 mm Hg, whichever is lower)
			25	140–159 or 90–99	25	Stage 2 hypertension (≥95th percentile+12 mm Hg, or ≥140/90 mm Hg, whichever is lower)
			0	≥160 or ≥100	0	Systolic BP ≥160 or ≥95th percentile+30 mm Hg systolic BP, whichever is lower; and/or diastolic BP ≥100 or ≥95th percentile+20 mm Hg diastolic BP
			Subtract 20 points if treated level		Subtract 20 points if treated level

Points	Level (kg/m2)
100	18.5–22.9
75	23.0–24.9
50	25.0–29.9
25	30.0–34.9
0	≥35.0

BMI indicates body mass index; BP, blood pressure; CVH, cardiovascular health; DASH, Dietary Approaches to Stop Hypertension; FBG, fasting blood glucose; HbA1c, hemoglobin A1c; HDL, high-density lipoprotein; HEI, Healthy Eating Index; MEPA, Mediterranean Eating Pattern for Americans; NDS, nicotine-delivery system; NHANES, National Health and Nutrition Examination Surveys; PA, physical activity; PAQ-K, Physical Activity Questionnaire K; and SMQ, smoking assessment.

^*Cannot meet these metrics until solid foods are being consumed.

Notes on implementation:

Diet: See Supplemental Material Appendix 1. For adults and children, a score of 100 points for the CVH diet metric should be assigned for the top (95th percentile) or a score of 15 to 16 on the MEPA (for individuals) or for those in the ≥95th percentile on the DASH score or HEI-2015 (for populations). The 75th to 94th percentile should be assigned 80 points, given that improvement likely can be made even among those in this top quartile. For individuals, the MEPA points are stratified for the 100-point scoring system approximately by quantiles. In children, a modified MEPA is suggested that is based on age-appropriate foods. The writing group recognizes that the quantiles may need to be adjusted or recalibrated at intervals with population shifts in eating patterns. In children, the scoring applies only once solid foods are being consumed. For now, the reference population for quantiles of HEI or DASH score should be the NHANES sample from 2015 to 2018. The writing group acknowledges that this may need to change or be updated over time. Clinicians should use judgment in assigning points for culturally contextual healthy diets. For additional notes on scoring in children, see Supplemental Material Appendix 2.

PA: Thresholds are based in part on US Physical Activity Guidelines. For adults, each minute of moderate activity should count as 1 minute and each minute of vigorous activity should count as 2 minutes toward the total for the week. For children, each minute of moderate or vigorous activity should count as 1 minute. The score for PA is not linear, given that there is a greater increase in health benefit for each minute of marginal exercise at the lower end of the range and the association tends to approach an asymptote at the higher end of the range.

If scoring is desired for children ≤5 years of age, see Supplemental Material. For additional notes on scoring in children, see Supplemental Material Appendix 2.

Nicotine exposure: The writing group recommends subtracting 20 points for children and adults exposed to indoor secondhand smoke at home, given its potential for long-term effects on cardiopulmonary health.¹³⁵ For additional notes on scoring in children, see Supplemental Material Appendix 2.

Sleep health: Thresholds are based in part on sleep guidelines. Clinicians may consider subtracting 20 points from the sleep score for adults or children with untreated or undertreated sleep apnea if information is available. Note that overall scoring reflects the inverse-U–shaped association of sleep duration with health outcomes, such that excessive sleep duration is also considered to be suboptimal for CVH.

For children, age-appropriate optimal sleep durations are as follows¹²¹:

Age 4 to 12 months, 12 to 16 hours per 24 hours (includes naps);

Age 1 to 2 years, 11 to 14 hours per 24 hours;

Age 3 to 5 years, 10 to 13 hours per 24 hours;

Age 6 to 12 years, 9 to 12 hours; and

Age 13 to 18 years, 8 to 10 hours.

For additional notes on scoring in children, see Supplemental Material Appendix 2.

BMI: Thresholds are based in part on National Heart, Lung, and Blood Institute (NHLBI) guidelines. The writing group acknowledges that BMI is an imperfect metric for determining healthy body weight and body composition. Nonetheless, it is widely available and routinely calculated in clinical and research settings. BMI ranges may differ for individuals from diverse ancestries. For example, the World Health Organization has recommended different BMI ranges for individuals of Asian or Pacific ancestry. For individuals in these groups, point scores should be aligned as appropriate:

Clinicians may want to assign 100 points for overweight individuals (BMI, 25.0–29.9 kg/m²) who are lean with higher muscle mass. For underweight individuals (<18.5 kg/m² in adults or below the fifth percentile in children), the writing group defers to clinician judgment in assigning points on the basis of individual assessment as to whether the underweight BMI is healthy or unhealthy. Conditions that should be considered unhealthy include chronic catabolic illnesses (eg, cancer), eating disorders, and growth failure (for children). For additional notes on scoring in children, see Supplemental Material Appendix 2.

Blood lipids: Thresholds are based in part on 2018 Cholesterol Clinical Practice Guideline.^129a The levels of non–HDL cholesterol for adults were selected on the basis of current guideline recommendations and in concert with the observation that non–HDL cholesterol levels are generally ≈30 mg/dL higher than low-density lipoprotein cholesterol levels in normative ranges in the population. For children, thresholds for non–HDL cholesterol were chosen on the basis of NHLBI pediatric guidelines, pediatric low-density lipoprotein cholesterol thresholds for diagnosis of familial hypercholesterolemia phenotypes (+30 mg/dL), and current distributions of non–HDL cholesterol to smooth transitions to adult point scales. The writing group recommends subtracting 20 points from the blood lipid score if the level of non–HDL-cholesterol represents a treated value, given the residual risk present in those who require treatment. There may be a modest shift in point scores for this metric as individuals age from pediatric to adult metrics. For additional notes on scoring in children, see Supplemental Material Appendix 2.

Blood glucose: Thresholds are based in part on American Diabetes Association guidelines.^129b If an individual patient with prediabetes (ie, not yet diagnosed formally with diabetes) is being treated with metformin to prevent the onset of diabetes and has normoglycemic levels, the writing group recommends clinician judgment for assigning point values (ie, consider subtracting 20 points). The maximal point value for patients with well-controlled diabetes was set at 40, given the residual risk present in those with diabetes. For additional notes on scoring in children, see Supplemental Material Appendix 2.

BP: Thresholds are based in part on the 2017 Hypertension Clinical Practice Guidelines and the guidelines for children.^129c The writing group recommends subtracting 20 points from the BP score if the level of BP represents a treated value, given the residual risk present in those who require treatment. For additional notes on scoring in children, see Supplemental Material Appendix 2.