Lifestyle Medicine and Cardiovascular Health

Abstract

Daily habits and actions exert a profound impact on both the short and long-term health and quality of life. This is particularly true of cardiovascular disease, although it also pertains to virtually all other chronic medical conditions. This is also a fundamental underlying principle of lifestyle medicine. The American Heart Association (AHA) and American College of Cardiology (ACC) have embraced this concept for several decades—most recently with the concept of “cardiovascular health” which is a strategic initiative to lower the risk factors for heart disease from ever occurring. This new initiative adds to the overall agenda for the AHA, in addition to reducing risk factors once they are present and treating cardiovascular disease. The rubric that the AHA has used to define this new initiative on “cardiovascular health” is “Life’s Essential 8.” The underlying principles of increasing physical activity, improving nutrition (more fruits and vegetables and whole grains), obtaining healthy restorative sleep, having positive relationships with others, reducing the likelihood of overweight and obesity, and treating high blood pressure and lipids are all key components of the initiative on cardiovascular health. These principles also apply equally well to the discipline of lifestyle medicine. This review focuses on the most recent evidence of how lifestyle medicine and cardiovascular health are coming evermore closely aligned with each other.

“The AHA recommends that CVH be utilized in a positive manner to help motivate individual patients to make needed behavioral and health related changes in their lives.”

Introduction

Practitioners of lifestyle medicine have long understood and supported the concept that daily habits and actions impact on both short and long-term health and quality of life.^1-4 This was indeed the fundamental principle that I articulated in the first edition of my multi-authored Lifestyle Medicine textbook. ⁵ This was the book that named the field “lifestyle medicine” in the academic literature. The basic premise of this book and the vision for multiple research projects that my team and I at Rippe Lifestyle Institute (RLI) have conducted over many years is that what individuals do in their daily lives including physical activity, healthy nutrition, weight management, avoiding tobacco and other addictive substances, stress reduction and positive relations with other all carry significant impact on the likelihood that individuals will develop chronic disease.

As a cardiologist, I have been particularly concerned about cardiovascular health (CVH) and lowering the risk of cardiovascular disease (CVD) since heart disease remains the number one killer of both men and women in the United States and around the world. ² The evidence base for lifestyle medicine has continued to grow and is incorporated in the recently published 4th edition of my Lifestyle Medicine textbook. ¹

It is clear now that the American Heart Association (AHA) has embraced the concept of “cardiovascular health” that these concepts are considered mainstream in lifestyle medicine.^6,7 Early evidence of AHA embracing lifestyle medicine occurred in 2013 when it changed the name of one of the Councils that I sat on from the “Council on Nutrition, Physical Activity and Metabolism” to the “Council on Lifestyle and Cardiometabolic Health.” ⁸ In addition, the AHA and the American Council of Cardiology (ACC) in 2013 issued guidelines for lifestyle management to reduce cardiovascular risk. ⁹ So it should come as no surprise that in 2010 the AHA issued a landmark Special Report entitled “Defining and Setting National Goals for Cardiovascular Health Promotion and Disease Reduction.” This concept has served as the cornerstone of the AHA’s Strategic Impact Goal 2020 and Beyond. ⁶

Since articulating this new strategy, this significant shift and focus from the AHA has resulted in over 2500 papers focusing on the issue of “cardiovascular health” rather than simply risk factor reduction or the treatment of cardiovascular disease. While these latter issues remain critically important and continue to be emphasized by the AHA, “cardiovascular health” is clearly a new concept and which has now taken center stage in the philosophy and writings of the AHA.

The 2010 document became the foundation for the consumer oriented framework from the AHA entitled “Life’s Simple 7.” ¹⁰ Life’s Simple 7 was based on four health behaviors and three health factors. The AHA concluded that abundant evidence existed that if individuals followed these factors they would improve cardiovascular health and lower the risk of developing risk factors in the first place. This would ultimately lower the risk of heart disease. These 7 factors also featured prominently in the Joint Presidential Advisory issued by the AHA and the American Stroke Association (ASA) entitled “Optimal Brain Health.” ¹¹ Clearly the impact of these factors influence not only the development of heart disease but also strongly influence brain health and many other related parameters.

Subsequently, the approach articulated by expert panels to many other chronic conditions has incorporated AHA’s clarion call to focus on health from the earliest time in individuals’ lives rather than focus solely on risk factor reduction and treatment.

Since the first AHA report defining the new term “cardiovascular health” was published an enormous further body of proof has arisen which necessitated updating and refining of these initial concepts. Therefore, the AHA published a Presidential Advisory in 2022 entitled “Life’s Essential 8: Updating and Enhancing the American Heart Association’s Construct of Cardiovascular Health: A Presidential Advisory From the American Heart Association.” ⁷ While multiple lifestyle factors were refined with important additional evidence perhaps the most important addition to the 2022 document was the addition of an eighth factor which has been shown to significantly improve cardiovascular health. This is sleep. The AHA mantra has now been updated with the addition of sleep to now be called “Life’s Essential 8.” ¹²

The current article will focus on cardiovascular health and the significant interaction between this AHA initiative in this area and the long-standing principles and practices of lifestyle medicine.

Defining and Measuring Cardiovascular Health

When the AHA committee met in 2010 to set national goals for cardiovascular health as a prelude to the 2020 strategic plan they were motivated by the profound importance of changing the fundamental paradigm for the AHA for the next decade. ⁶ In fact, they stated that the fundamental basis of their mandate was to define a new strategy for the AHA.

To establish a fundamentally new core mission of cardiovascular health they needed to develop broad and impactful underpinnings. Indeed as they stated “Success in this task would enable the AHA to undertake a new and more proactive organizational mission, not only continuing the tremendous success in improved treatment but also addressing the need for a new and expanded emphasis on prevention, control of risk, improving quality of life, and promoting health rather than solely treating disease.” It was acknowledged that at that time, no comprehensive metric for cardiovascular health existed, and the committee was charged with developing such a metric. ⁶ This statement could have been taken right out of my lifestyle medicine textbooks!^1,5

While this concept was new to the AHA, of course, it is central to the field of lifestyle medicine and has been the motivating principle in lifestyle medicine for the past 25 years.^1-5,13,14 In the hands of lifestyle medicine practitioners, the concept of articulating evidence-based behaviors and health factors and their impact on health in many areas not just cardiovascular health has been a central motivating principle.

Nonetheless, it is very significant that prestigious bodies such as the AHA have joined the effort to articulate why lifestyle behaviors and health factors are fundamentally important to health. Members of the lifestyle medicine community can be proud in opening the door to the serious academic pursuit of this effort. As both a researcher in lifestyle medicine and as a cardiologist, I am delighted that both of my primary medical disciplines are now pursuing very similar agendas.

The motivation for the AHA to define and measure “cardiovascular health” is based on two important concepts: the general concept of prevention and the specific concept of “primordial” prevention.

As the committee developing the AHA statement on cardiovascular health approached this topic, three key concepts in health promotion and disease prevention underpinned their work:

• • The power of primordial prevention.

• • The evidence that CVD and risk factors were often developed early in life.

• • The appropriate balance between population level approaches, health promotion, disease prevention and individualized high risk approaches. ⁶

These concepts also motivated how the AHA Committee framed cardiovascular health.

• • Primary Prevention

Most clinicians are familiar with the concepts of primary and secondary prevention. In primary prevention, the focus centers on preventing the first occurrence of a clinical event among individuals who are at risk. Multiple examples of this approach exist including blood pressure lowering medications, dietary intervention in patients with hypertension, etc. Thus, primary prevention efforts are focused on individuals who already have known risk factors. “Primordial” prevention takes this a step further by seeking to prevent risk factors before they occur. ¹⁵ .

• • Secondary Prevention

Secondary prevention efforts are aimed at preventing the recurrence of clinical events in patients who already have shown clinical disease. ¹⁶ Examples include various pharmaceutical treatments aimed at preventing recurrent myocardial infarction (MI) in individuals who have already experienced an MI.

• • Primordial Prevention

In the area of “cardiovascular health” it is essential to focus on the prevention of risks rather than minimizing their consequences. This is the key concept behind primordial prevention. It is well known that risk factors may result in the development of subclinical atherosclerosis occurring over a period of years or decades before manifestations occur. The goal in “cardiovascular health” is to avoid adverse levels of risk factors in the first place.^15,17,18 This is the core concept of the phrase “primordial intervention” which is basically to prevent the development of risk factors in the first place. This concept will be very familiar to practitioners of lifestyle medicine since it involves promoting healthy behaviors. This is recognized and common to many guidelines not only those recommended to prevent CVD but also other metabolic diseases. These healthy behaviors are best viewed as lifelong lifestyle behaviors to lower the risk or prevent risk factors that often begin in childhood. The concept of primordial prevention forms the cornerstone of the AHA Committee’s approach to defining a concept that they called “ideal cardiovascular health.”

Definitions of Cardiovascular Health

General Approach

The AHA effort in “cardiovascular health” is based on the broad concept that good health is more than just the absence of clinically evident disease. It is also important to note that cardiovascular health and general health are not synonymous.^6,7 Of course, there is a broad overlap, but this particular initiative focused on CVH, leaving broader issues of overall physical, mental and social functioning for future consideration. The concept of CVH was framed positively with the goal of promoting key positive lifestyle related factors and health behaviors that clearly impact on CVH. In order to be included in this list the factors needed to be evidence-based with regard to CVD free survival, longevity, health longevity and quality of life. These factors also had to be readily measured to allow assessment and monitoring of changes over time.

Ideal Cardiovascular Health

In order to meet these criteria, the AHA Committee defined the construct of ideal cardiovascular health. This construct was defined as simultaneous presence of four favorable health behaviors including abstinence of smoking in the past year, an ideal body max index (BMI), physical activity at goal and the consumption of a dietary pattern that promotes CVH.

In addition to the four health behaviors outline above, the concept of ideal CHV also includes the simultaneous presence of four favorable health factors including abstinence of smoking in the past year, untreated cholesterol less than 200 mg/dl., untreated blood pressure <120/80 mmHg and the absence of diabetes mellitus (T2DM). In addition, it was required that there was absence of current CVD. It should be noted that smoking appeared in both health behaviors and also factors because of the high level of importance of not smoking cigarettes.

As already mentioned, in the subsequent update in 2022, a fifth behavior of “healthy sleep” was added due to high level of evidence of healthy sleep and its impact on CVH.^17,18 This resulted in the AHA altering its original mantra for CVH from “Life’s Simple 7” to “Life’s Essential 8.”

It should be noted that in the 2022 revision the panel decided to list nicotine exposure as the new metric in keeping with inhaled delivery systems such as e-cigarettes or vaping devices. In addition, second hand tobacco smoke was added to this metric because of its established adverse effects on health.

Evidence for Health Behaviors

Abundant evidence supports the health behaviors chosen. In the Nurses’ Health Trial nurses who followed all five healthy lifestyle factors reduced their risk of coronary heart disease (CHD) by 83%. ¹⁹ Even after 14 years of follow-up, even women with three or four of the healthy behaviors had a 57%-66% decrease risk for CHD. It should be noted that these same behaviors also apply to older individuals. Studies have shown that even individuals over the age of 70 who adopt these behaviors substantially lower their risk of CHD. This is also true of health behaviors for individuals in middle age which are also associated with substantially less disability in older ages. ²⁰ For example, individuals with the least favorable patterns of health behaviors double cumulative disability in older age. ²¹

Evidence for Health Factors

Abundant evidence also supports the other health factors chosen by the AHA Committee.^22-27 These health factors include total cholesterol, blood pressure, and fasting plasma glucose. Even though those factors were listed with values without treatment, it is clear that treating lipids, blood pressure and fasting blood glucose all yield significant benefits although the benefits are not quite as great as if these risk factors were not present in the first place. It should be noted that cardiovascular health factors not only lower CVD mortality rates but also all-cause mortality as well. This is true both for middle age and older individuals.

Prevalence of Ideal Cardiovascular Health

Unfortunately, the prevalence of ideal cardiovascular health as defined by the AHA is extremely low. It was estimated at less than 5% back when these initial guidelines were promulgated. ⁶ Subsequent follow-up in 2022 indicated that, in fact, prevalence of ideal cardiovascular health was even lower at less than 1%. ⁷ Clearly, while both health behaviors and health factors are critically important to CVH, enormous room exists for improvement in the population in the United States.

Current Knowledge of Cardiovascular Health

Prevalence of CVD

As already indicated, the prevalence of ideal CVH in the United States is extremely low. (Less than 1% for all age groups). In addition, the prevalence of having greater than or equal to even 5 metrics at ideal levels is only 45% among US adolescents, 32% among adults aged 20-39 years of age, 11% among adults aged 40-59 years of age and only 4% among adults greater than 60 years of age. ²⁸ This indicates that maintaining even five components at ideal levels decreases substantially with age.

It has also been reported that some segments of the population are experiencing modest improvements in CVH.^29,30 Other groups, particularly those in lower socioeconomic status (SES), are actually experiencing worsening CVH.^29,30 There is also less than 10% of high CVH during pregnancy which suggests that there will be a decreased prevalence of CVH in offspring. Since we know that many risk factors exist in utero, it suggests that lower CVH is extremely rare even at birth. ³¹

Outcomes of CVH

The overall CVH score is associated with CVD and CVD mortality and also mortality from a wide variety of non-CVD outcomes. Better CVH has been associated with lower risk of cancer, dementia, end stage renal disease, chronic obstructive pulmonary artery disease as well as better cognitive function and quality of life, compression of morbidity (longer span of healthy living), and lower health care costs including many other positive outcomes.^32-38

Mechanisms of CVH

The pathophysiology of CVH represents an area of intense investigation. Some studies have suggested that level of CVH is associated with inflammation, endothelial function, atherosclerosis, cardiac stress and remodeling hemostatic factors and epigenetics, among other factors.^39-42 These data suggest that CVH is strongly positioned as a health outcome irrespective of genetic and environmental factors. This further suggests that primordial prevention strategies have great potential to improve health and longevity of an enormous number of lives. These facts should powerfully encourage physicians, particularly those practicing in the area of lifestyle medicine, to focus considerable attention on encouraging patients to improve the various factors related to CVH.

Foundational Factors for CVH: Psychological Health/Well-Being and Social Determinants

In the past 20 years, numerous studies have explored psychological health and well-being and SDOH and their impact on multiple conditions. Both of these factors carry enormous potential interest to help individuals improve multiple factors in CVH.^43,44 In fact, psychological well-being and SDOH are so important to multiple components of CVH factors that they are considered “foundational” implying that they underlie multiple components of CVH.

Psychological Health and Well-Being

Psychological health and well-being clearly influence both CVH and CVD risk. These involve such issues as inflammation, chronic stress, health behaviors and resilience.^43-45 Multiple studies have suggested that interventions that improve psychological health can have a positive impact on CVH. This is an area of great importance where further research is being undertaken by multiple investigators.^46,47

Social Determinants of Health to (SDOH) Considerations for Equitably Improving CDH Across Context

Health equity and SDOH are so important to overall health considerations that numerous organization such as the AHA, the American College of Physicians (ACP) and the American College of Lifestyle Medicine (ACLM) ⁴⁸ have all issued statements in these areas. Perhaps the most inclusive definition of SDOH states it as: “structural determinants and conditions in which people are born, grow, live, work and age.” These factors can effect both health, the ability to function in life and quality of life.^49-54 The ACP and the AHA have provided background in SDOH including the domains that impact on this concept.

SDOH impacts on virtually all of the components of CDH. At the current time, there is clearly a gap between health equity related to SDOH. Multiple ongoing research trials as currently underway to attempt to address ways that this gap can be bridged.

Metrics for Cardiovascular Health

An enormous body of literature exists that relates to how health behaviors impact on overall health as well as ideal cardiovascular health.^55-58 The focus on helping individuals improve behaviors throughout their lives is a key consideration of virtually all components of lifestyle medicine. ⁵⁹ This area is so important that a whole section in the 4th edition of my major Lifestyle Medicine textbook is devoted to helping individuals to develop positive behaviors strategies. Research has also been developed exploring how to study and improve health behaviors. ¹

Specific Behavioral Components of CVH

The specific components of CVH that have been included in this concept will be very familiar to individuals practicing in lifestyle medicine. In fact, many of the components that form the basis of CVH have are embodied in the Seven Components of Lifestyle Medicine.

Smoking

The data concerning the health risks of regular cigarette smoking and the multiple health benefits of abstinence or cessation of cigarette smoking is overwhelming. ⁶⁰ This has been summarized in multiple places and is a component of the lifestyle medicine pillar of “avoiding risky substances.”

Weight Management

Both overweight and obesity, as well as adult weight gain significantly increase the risk of CVD and multiple other related conditions such as Type 2 Diabetes (T2DM), the Metabolic Syndrome (MetS) and even cancer and cognitive decline. ⁶¹ Weight management is one of the seven components of lifestyle medicine and plays an important role in overall health as well as CVH.

Physical Activity

Physical activity is critically important to CVH. Multiple authoritative guidelines have been promulgated in this area including by the Physical Activity Guidelines 2018 (PAGA 2018), ⁶² the CDC, ⁶³ and the American College of Sports Medicine (ACSM). ⁶⁴ The concept of regular physical activity is central to lifestyle medicine and indeed is one of the key components of lifestyle medicine. It is also one of the behavioral components for CVH. Virtually, every authoritative, evidence-based guide in this area has recommended that adults should accumulate at least 150 min per week of moderate intensity physical activity or 75 min per week of vigorous intensity physical activity.^62-64

Nutrition

Consuming a healthy diet is critically important to overall health. For this reason, it is one of the key components of lifestyle medicine and is also one of the key behavioral components of CVH.^65-68 In the initial formulation of CVH, the AHA elected to simplify recommendations by emphasizing five components that were consistent with the Dietary Approach to Stop Hypertension (DASH) diet. These components are the following; fruits and vegetables ≥4.5 cups per day, fish ≥3.5 ounce servings per week, preferably oily fish, fiber rich whole grains (≥1.1 gram of fiber per ten grams of carbohydrate), sodium ≤1500 mg per day and sugar sweetened beverages ≤450 kcals (36 ounces per week).

Even in 2010, the AHA recognized that there were many other components that were important in the overall healthy dietary pattern. In the 2022 update of the CVH recommendations, the AHA made a broader recommendation that individuals should follow either a DASH type diet or a Mediterranean Diet (Med Diet) or the equivalent. ⁷ These diets are plant-forward and minimize the amount of red meat and processed meat and tropical oils. ⁶⁹

Sleep Health

Sleep health was added as a component to the CVH framework and the guidance was changed from “Life’s Simple 7” to “Life’s Essential 8” because of the addition of healthy sleep. The AHA has focused considerable attention on health benefits of sleep. Healthy sleep is a foundational element of human biology and a requirement for life itself. Healthy sleep is also related to at least 35%-40% of all CVD.^{17,18,20,21,70,71} The recommendation for this metric in CVH is that adults should obtain 7-8 hours of habitual sleep.

Health Factors

In addition to the four healthy behaviors already listed, the following health factors were considered to be important components of CVH. These include a healthy level of non-treated cholesterol, blood pressure within recommended guidelines and a blood glucose ≤100 mg/dL.^22-27 All of these were recommended to be at an untreated level. The only significant change by revision of CVH in 2022 was to use the metric for blood lipids as non-high density lipoprotein cholesterol rather than total cholesterol. ⁷ This is because non-high density lipid cholesterol can be measured in a non-fasting state and reliably calculated in all patients. The blood pressure guidelines for ideal CVH include a systolic ≤120 mm/Hg and diastolic ≤80 mm/Hg.

New Metrics for Management and Quantative Assessment of CVH Metrics

In the 2022 update of the AHA CVH metrics several important changes were made. In the original 2010 document the health behaviors and health factors were assessed based on three categories; poor health, intermediate health and ideal health. ⁶ Based on additional research done between 2010 and 2022, the evaluation of these factors was made more precise and points were awarded from zero to one hundred for each parameter. This change was made not only to be more accurate, but also to serve as a basis for CVH assessment tools and incorporation into the electronic health records (EHR) and other platforms. ⁷ The decision was made to apply an ordinal point scoring system to each metric ranging from zero to one hundred points. While the complete scoring mechanism is beyond the scope of this article, it can be obtained by going to the 2022 article on “Life’s Essential 8” published in the journal Circulation in 2022. ⁷

These new metrics were based on available information from a wide variety of evidence-based research trials. Childhood metrics were also updated and reflect current pediatric guidelines. The AHA Writing Committee recognized that while even this system was imperfect, this new framework represented a more precise way of looking at the impact of CVH at various levels of each of the health behaviors and health factors. ⁷ The overall score that was adopted represented a composite aggregate score which allowed for measuring, monitoring and assessing change in CVH. The Writing Committee scaled this aggregate score from zero to one hundred and calculated it as an average of 8 component metric scores. The recommended designation of the scores included a CVH score of 80 to 100 to be considered high CVH, 50 to 79 moderate CVH and 0 to 49 low CVH. ⁷ The AHA Writing Committee hoped that additional research will help fine tune these levels even further.

Implementation of CVH in Clinical Practice

In addition to utilizing this scoring metric, clinicians should pay close attention to the foundational factors of psychological health, and well-being and SDOH. The new format that the AHA has developed should facilitate use of this framework in individual counseling sessions. It will also allow clinicians and their health care teams to assess CVH in individual patients and track progress over time particularly utilizing online websites or apps. This same technology can also be used to aggregate health monitoring and risk prediction as well as motivating behavioral change.

The CVH approach from the AHA provides lifestyle medicine physicians with yet another tool in the tool box for helping individuals make changes in their heath behaviors. It should be emphasized that not all components of health behavior or health factors need to be changed at once. Rather, individuals can focus on one or two of the health behaviors or health factors which have scored at lower than the clinician and the patient desire and work to improve those scores. This improvement will, in turn, increase the aggregate score.

Advanced Health Technologies for Data Collection and CVH Intervention

By utilizing the EHR the clinician can readily track changes in multiple components of CVH.^72-75 In addition, institutions can track CVH across patient populations over the life course. Multiple health care systems are currently available to allow the aggregation of this data. These include stroke prevention and health care delivery environments and Priorities Wizard, among others.

It has also been recommended by the AHA that physicians should use some of the behavioral approaches which have been emphasized in lifestyle medicine such as motivational interviewing to help patients identify and work on metrics which could benefit from improvement. ⁷⁶ This type of approach is completely consistent with recommendations for behavior change which have been traditionally utilized in lifestyle medicine.

Communication of a new CVH Score With Patients

The AHA recommends that CVH be utilized in a positive manner to help motivate individual patients to make needed behavioral and health related changes in their lives. The framework of the eight health behaviors and health factors allows clinicians to single out those areas where a good job is already being accomplished by the patient and areas where improvement is needed. A variety of venues outside of the clinical encounter can also reinforce the positive message of how behavioral changes can significantly impact on cardiovascular health. ⁷⁷ This is completely consistent with the approach taken in lifestyle medicine for helping individuals make behavior alterations in the six pillars of lifestyle medicine.

The Relationship Between CVH and Lifestyle Medicine

This article has emphasized ways that physicians and other healthcare workers can utilize increased knowledge of the impact of various health behaviors on overall health and in particular, cardiovascular health. It is particularly important for physicians to focus on techniques to help communicate these messages to patients. The focus from the AHA on the new metric of cardiovascular health should come as “music to the ears” of lifestyle medicine practitioners since the information and approach found in the CVH initiative clearly resonates with lifestyle medicine messages. For this reason, the emphasis from the AHA on CVH, in addition to the traditional focuses of risk factor reduction and disease treatment, is very welcome and should assist in the prevention and treatment of cardiovascular disease in the United States and other countries. This is a much needed effort and completely consistent with the goals, vision, and practice of lifestyle medicine.