Trends in Cardiovascular Health Metrics and Associations With All-Cause and CVD Mortality Among US Adults

Study Questions:

What are the time trends for meeting cardiovascular (CV) health metrics in the United States, and what are the joint associations and population-attributable fractions of these metrics in relation to all-cause and CV disease (CVD) mortality risk?


This was a 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). CV health metrics include seven defined ideal CV health behaviors or factors including not smoking; being physically active; having a normal blood pressure, blood glucose, total cholesterol, and weight; and eating a healthy diet. Primary outcomes were all-cause, CVD, and ischemic heart disease (IHD) mortality.


Mean age was 46 years for men and 51 years for women. Significant changes from 1988 through 2010 included: decrease in current smokers, increase in some physical activity, increase in body mass index >30 (from 22.8% to 34%), decrease in healthy diet, increase in dysglycemia, and improved cholesterol. Few participants met all seven CV health metrics (2.0%; 95% confidence interval [CI], 1.5%-2.5% in 1988-1994, 1.2% [95% CI, 0.8%-1.9%] in 2005-2010, p = NS). Among NHANES III participants, 2,673 all-cause, 1,085 CVD, and 576 IHD deaths occurred (median follow-up, 14.5 years). Among participants who met one or fewer CV health metrics, age- and sex-standardized absolute risks were 14.8 deaths per 1,000 person-years for all-cause mortality, 6.5 for CVD mortality, and 3.7 for IHD mortality. Among those who met six or more metrics, corresponding risks were 5.4 for all-cause mortality, 1.5 for CVD mortality, and 1.1 for IHD mortality. Adjusted hazard ratios were 0.49 for all-cause mortality, 0.24 for CVD mortality, and 0.30 for IHD mortality, comparing participants who met six or more versus one or fewer CV health metrics. Adjusted population-attributable fractions were 59% for all-cause mortality, 64% for CVD mortality, and 63% for IHD mortality. Each of the hazard ratios was highly significant.


Meeting a greater number of CV health metrics was associated with a lower risk of total and CVD mortality, but the prevalence of meeting all seven CV health metrics was low in the study population.


Considering the resources committed to promote CV health metrics over the past 25 years, it is both surprising and disappointing that there was no improvement in meeting the seven metrics in NHANES 2005-2010 compared to 1988-1994. In fact, there was a significant increase in the prevalence of having 0-1 health metrics. Much of the decrease in healthy metrics over time appeared to be related to nutrition and weight gain. These data need to be used to increase the focus on CVD prevention in adults, and in particular in children and young adults. But new paradigms to enhance behavioral change are sorely needed including within and outside of the medical model.

Clinical Topics: Congenital Heart Disease and Pediatric Cardiology, Dyslipidemia, Prevention, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Lipid Metabolism, Nonstatins, Diet, Smoking

Keywords: Myocardial Ischemia, Follow-Up Studies, Data Collection, Blood Pressure, Risk Factors, Weight Gain, Health Behavior, Smoking, Child, Prevalence, Cholesterol, Body Mass Index, Blood Glucose, Cardiovascular Diseases, Motor Activity, Diet, Confidence Intervals, Nutrition Surveys, United States

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