1. Impact of Lifestyle Intervention on the American Heart Association’s New Definition of Ideal Cardiovascular Health
Bethany Barone Gibbs, PhD
University of Pittsburgh,
Department of Health and Physical Activity

2. Objectives
Review the AHA’s new definition of Ideal Cardiovascular Health
Summarize how American’s are doing on measures of Ideal Cardiovascular Health
Present results using Ideal Cardiovascular Health as an outcome in the ACTIVE Life intervention study
Methodological discussion and future directions

3. AHA’s 2020 Impact Goals
Lloyd-Jones, et al, Circulation, 2010
‘By 2020, to improve the cardiovascular health of all American’s by 20% while reducing deaths from cardiovascular disease and stroke by 20%’

4. AHA’s 2020 Impact Goals
‘By 2020, to improve the cardiovascular health of all American’s by 20% while reducing deaths from cardiovascular disease and stroke by 20%’

5. Leading Causes of Death in U.S. 2009
- Though CVD death rates have been going down for 4 decades, still easily the leading cause of death
National Vital Statistics Reports, Vol. 59, No. 4, March 16, 2011

6. Population trends that are good for CVD Mortality ↓ Cholesterol ↓ Blood pressure ↓ Smoking Better treatment for existing CVD
Population trends that are bad for CVD Mortality Aging population ↑ Atrial Fibrillation and Heart Failure ↑ Obesity ↑ Diabetes
**at younger ages**

7. AHA’s 2020 Impact Goals
‘By 2020, to improve the cardiovascular health of all American’s by 20% while reducing deaths from cardiovascular disease and stroke by 20%’

8. Defining and Measuring Cardiovascular Health
Key Concepts
Primordial Prevention
CVD Risk Factors and Cardiovascular Diseases often develop early in life
Population-level approaches vs. approaches targeting high-risk subgroups

9. Primordial Prevention of CVD
Cardiovascular Health
Primordial Prevention
Cardiovascular Risk Factors
Primary Prevention
First Cardiovascular Event or Early Stage CVD
Secondary Prevention
Repeat Cardiovascular Event or Further Complications
Tertiary Prevention
Cardiovascular Mortality

10. Primordial Prevention
‘A strategy to prevent whole societies from experiencing epidemics of the risk factors’
Target: population-level (including young people)
Goal: maintain cardiovascular health
Lloyd-Jones, et al, Circulation, 2010

11. Need for Primordial Prevention?
On the absolute level
Majority of CVD events occur in people without or with only mildly elevated CVD risk
Thus primordial + primary/secondary prevention are needed to reduce the absolute population burden of CVD

12. Illustration Diastolic Blood Pressure and Coronary Heart Disease in White Men aged 35-64
Adapted from Cook et al, Archives of Internal Medicine, 1995
DBP
Prevalence
Absolute Number of Expected CHD Events per 100K
Reduction in CHD Events with a 2 mmHg decrease in DBP
<90
69.5%
1490 (56.8%)
-80 (-3.1%)
90+
30.5%
1130 (43.2%)
-70 (-2.6%)
Total
100%
2620 (100%)
-150 (-5.7%)
█ DBP >90 █ DBP 90+

13. Defining Ideal Cardiovascular Health – Criteria Used by the AHA
Based on data
Face validity
Consistent with current guidelines
Simple and accessible
Healthcare practitioners
To individuals in all subsets of the population
Components should be
Actionable
Measureable

14. Ideal Cardiovascular Health 7 Components
Health Behaviors
Nonsmoker
Healthy BMI
Meeting Physical Activity Recommendations
Healthy Diet
Health Factors
Total Cholesterol
Blood Pressure
Fasting Plasma Glucose

15. Prevalence of meeting all 5 criteria? 4%
Healthy Lifestyle Factors in the Primary Prevention of Coronary Heart Disease in Men Chiuve et al, Circulation, 2006 from the Health Professionals Follow-up Study
Factors
Current non-smoker
BMI <25 kg/m2
Diet score in top 40%
Exercise ≥ 30 min/day
Moderate EtoH (5-30 g/d)
Prevalence of meeting all 5 criteria? 4%
CHD reduction expected if the population met all 5 criteria? 62%

16. AHA Metrics 1) Smoking Poor Health Intermediate Health Ideal Health
Current Smoker
Former Smoker
<12 months
Never or
Quit >12 months age

17. Cardiovascular Health in the U. S. Where are we now
Cardiovascular Health in the U.S. Where are we now? SHAY et al, Circulation, 2012
Data from the National Health and Nutrition Survey (NHANES )
Results stratified by
Gender
Age group
20-39y
40-64y
65+
Objective to serve as the baseline for assessing 20% improvement in CVD Health by 2020

18. % of Adults Meeting Ideal Smoking Criteria (Never or Quit >12 months Ago)

19. AHA Metrics 2) Body Mass Index
Poor Health
Intermediate Health
Ideal Health
≥ 30 kg/m2
Obese
kg/m2
Overweight
<25 kg/m2
Healthy BMI

20. % of Adults Meeting Ideal (<25 kg/m2) or Intermediate BMI (25-29
% of Adults Meeting Ideal (<25 kg/m2) or Intermediate BMI ( kg/m2) Criteria

21. AHA Metrics 3) Physical Activity
Poor Health
Intermediate Health
Ideal Health
None
1-149 min moderate
1-74 min vigorous
1-149 min moderate + vigorous
≥ 150 min moderate
≥ 75 min vigorous
≥ 150 min moderate + vigorous

22. % of Adults Meeting Ideal Physical Activity Criteria

23. AHA Metrics 4) Healthy Diet
Poor Health
Intermediate Health
Ideal Health
0-1 Components
2-3 Components
4-5 Components
1) Fruits and vegetables: ≥4.5 cups/d 2) Fish: 3.5 ounces, twice x week 3) Sodium: <1500 mg/d 4) Sugary beverages: <450 kcal/week 5) Whole grains: ≥3 servings per day

24. % of Adults Meeting Ideal (4-5 Components) or Intermediate (2-3 Components) Health Diet Criteria

25. Which Criteria are More or Less Likely to be Met?
Prevalence of attaining individual components of the Health Diet Score according to Poor (█), Intermediate (█), or Ideal (█) Healthy Diet Score Category
Sugar-sweetened Beverages most likely to be met.
Fruits & Vegetables and Fish criteria somewhat likely to be met.
Fewer young adults meeting the Whole Grain or Sodium criteria.

26. Prevalence of attaining individual components of the Health Diet Score according to Poor (█), Intermediate (█), or Ideal (█) Healthy Diet Score Category

27. AHA Metrics 5) Total Cholesterol
Poor Health
Intermediate Health
Ideal Health
≥ 240 mg/dL
mg/dL (untreated)
<200 mg/dL (treated)
<200 mg/dL
(untreated)

28. % of Adults Meeting Ideal or Intermediate Health Cholesterol Criteria

29. AHA Metrics 6) Blood Pressure
Poor Health
Intermediate Health
Ideal Health
SBP ≥ 140 mmHg or
DBP ≥ 90 mmHg
SBP mmHg
DBP mmHg
treated to goal
SBP <120 mmHg
and
DBP <80 mmHg

30. % of Adults Meeting Ideal or Intermediate Health Blood Pressure Criteria

31. AHA Metrics 7) Fasting Plasma Glucose
Poor Health
Intermediate Health
Ideal Health
≥ 126 mg/dL
mg/dL or
treated to goal
<100 mg/dL

32. % of Adults Meeting Ideal or Intermediate Plasma Glucose Criteria

33. Overall Cardiovascular Health in the U.S.
Healthy Behaviors
Most meet smoking criteria
Almost half for physical activity
~ ⅓ meet BMI criteria
Almost no one meets diet criteria
Health Factors
Age effect – younger adults more likely to meet criteria for all health factors

34. One more Thing… Final Criteria: absence of clinical CVD
Ideal Cardiovascular Health
Meeting 7 metrics of ideal CVD health
No history of clinical CVD
Intermediate Cardiovascular Health
Having clinical CVD

35. <1% of population meets all 7 components of ideal CV health
Table: Typical Number of Ideal CV Health Components by Gender and Age
Women
Men
20-39 years
4-5
3-4
40-65 years 3
2-3
65+ years
<1% of population meets all 7 components of ideal CV health

36. Summary Improving AHA’s Ideal CV Health Components
Comprehensive, population-based approach that includes primordial prevention of CVD
NHANES data from indicates much room to improve
Diet and BMI
CV health factors – especially in older adults
New metric that assesses ‘cardiovascular health’ rather than ‘cardiovascular risk’

37. Using Ideal Cardiovascular Health in a lifestyle intervention trial
Changes in Cardiovascular Health in the ACTIVE Life Study

38. ACTIVE LIFE Study
Setting: Study Population: Design: Exclusion Criteria:
, Providence, RI, PI Dr. John Jakicic N=201 overweight/obese women, aged month randomized, controlled trial with 4 arms based on exercise volume (1000 or 2000 kcal/week) and intensity (moderate or vigorous). All participants received identical dietary intervention. Active, history of cardiovascular disease, medication or medical history that would affect metabolism or ability to lose weight/exercise

40. Figure 1. Percentage weight loss based on randomized group assignment (n=191)

41. Hypothesis: Lifestyle Intervention will Improve Cardiovascular Health
Statistical Methods
Proportions meeting ideal and intermediate cardiovascular health criteria calculated at baseline and 24 months
Change in proportion of ‘ideal’ health using McNemar’s test of paired proportions
Change in proportion of ‘ideal’ vs. ‘intermediate’ vs. ‘poor’ calculated using Stuart-Maxwell’s paired 3x3 test for homogeneity
Continuous variables compared using paired t-tests or signed rank tests
No group interactions  data presented in full study population

42. Cardiovascular Health of ACTIVE Life Participants at Baseline
IDEAL (%)
INTERMEDIATE or IDEAL (%)
Assessment Notes
Nonsmoking
98%
Current smoking question on Block Questionnaire
Healthy BMI, kg/m2
33 ± 4 0%
29%
BMI<25 was exclusionary
Physical Activity, min per week
12 [0, 98]
12%
54%
Exercise >3 times per week exclusionary
Healthy Diet,
# of components
1.2 ± 0.5
22%
Block FFQ
Total Cholesterol, mg/dL
194 ± 32
58%
94%
Fasting blood
Blood Pressure, mmHg
117/77
± 11/9
52%
86%
BP > 160/100 was exclusionary
Fasting Glucose
103 ± 10
44%
97%
DM was exclusionary
Number of Components
2.6 ± 1.0
3.9 ± 0.9

43. 24-month Change in BMI Mean % Ideal % Intermediate Baseline 32.6 kg/m20%
29%
24-month
30.8 kg/m2
14%
32%
P-value
<0.001
<0.001*
* Tests change across 3 categories

44. 24-month Change in Physical Activity
Median (IQR)
% Ideal
% Intermediate
Baseline
12 [0, 98] min/wk
12%
42%
24-month
173 [32, 340] min/wk
50%
36%
P-value
<0.001
<0.001*
* Tests change across 3 categories

45. 24-month Change in Healthy Diet
# Components
% Ideal
% Intermediate
Baseline
1.2 ± 0.5 0%
22%
24-month
1.4 ± 0.6
34%
P-value
0.008
n/a
0.015*
* Tests change across 3 categories

46. 24-month Change in Total Cholesterol
Mean ± SD
% Ideal
% Intermediate
Baseline
193 ± 32
58%
36%
24-month
189 ± 31
66%
27%
P-value
0.006
0.024
0.054*
* Tests change across 3 categories

47. 24-month Change in Blood Pressure
SBP
DBP
% Ideal
% Intermediate
Baseline
117 ± 11
77 ± 9
53%
37%
24-month
113 ± 12
56%
P-value
<0.001
0.98
0.62
0.64
* Tests change across 3 categories

48. 24-month Change in Fasting Glucose
Mean ± SD
% Ideal
% Intermediate
Baseline
103 ± 10
44%
53%
6-month
95 ± 9
73%
27%
P-value
<0.001
* Tests change across 3 categories

49. Number of Ideal Cardiovascular Health Components At Baseline and 24 Months
p-value
Ideal
2.6 ± 1.0
3.6 ± 1.3
<0.001
Ideal + Intermediate
3.9 ± 0.9
4.6 ± 0.8

50. Effect of the ACTIVE LIFE Intervention on Ideal Cardiovascular Health
At baseline, subjects met on average 2.6 criteria
Few subjects met criteria for diet, exercise, and BMI
About half met criteria for health factors
At 24 months, subjects met on average 3.6 criteria
Significant improvements in BMI, physical activity, cholesterol, glucose
No improvement in BP criteria
Diet improved, but not to ideal

51. Conclusions and Future Directions
A lifestyle intervention aiming to reduce weight through changes in diet and physical activity does improve cardiovascular health
Ideal cardiovascular health metric
May be more sensitive to improvements in a healthier population
Includes behaviors and health factors
Using the AHA’s Ideal Health definition as part of an intervention
Additional incentive or primary goal

52. Life’s Simple 7 and the ‘My Life Check’ on AHA’s Website

53. Methodological Discussion
Determining Components of Dietary Ideal Cardiovascular Health from the Block FFQ

54. 24-month Change in Healthy Diet
# Components
% Ideal
% Intermediate
Baseline
1.2 ± 0.5 0%
22%
6-month
1.4 ± 0.6
34%
P-value
0.008
n/a
0.015*
* Tests change across 3 categories

55. Ideal Cardiovascular Health - Diet Active Life vs. NHANES
ACTIVE LIFE (Baseline)
NHANES
Women
21 – 45 years
80% Caucasian
20-39 years
64% Caucasian
100% Caucasian
CV Health Category
Ideal 0% 1%
Intermediate
22%
17%
Poor
78%
83%
Assessment Method
Block FFQ
2-day Diet Recall
Scale
Not scaled
Scaled to 2000 kcal/day diet

56. Specific Dietary Components
Mean ± SD or Median [IQR]
% Ideal
Fruits & Vegetables
(servings per day from Block FFQ)
Baseline
24 months
3.9 ± 1.8
4.5 ± 2.6
p<0.001 1% 8%
p=0.003
Fish
(servings per day of tuna, fried fish, or other fish scaled to portion size)
0.9 ± 0.9
1.0 ± 1.0
p=0.18 3% 5%
p=0.34
Sodium
(mg per day estimated by Block FFQ)
3132 ± 1320
2304 ± 1366 7%
21%
Sugary Beverages
(oz. per week of non-juice, part-juice, and soda from Block FFQ)
3 [0, 7]
2 [0, 5]
99%
p=0.99
Whole Grains
(estimated by fiber from grains and number of grains servings from Block FFQ) -
13%
p=0.011

57. Fruits and Vegetables
FFQ is not the preferred method for estimation of actual intake
Better for ranking
FFQ likely overestimates amount of fruits/vegetables
Very few individuals meet the ‘9 serving’ criteria – consistent with NHANES estimates

58. Questions for the Group
Block gives servings of fruit and servings of vegetables. Ideal CVD Health Criteria is ≥ 4.5 cups/day. Is 9 servings the appropriate cutoff?
Bias: nondifferential or systematic from pre- to post?

59. Specific Dietary Components
Mean ± SD or Median [IQR]
% Ideal
Fruits & Vegetables
(servings per day from Block FFQ)
Baseline
24 months
3.9 ± 1.8
4.5 ± 2.6
p<0.001 1% 8%
p=0.003
Fish
(servings per day of tuna, fried fish, or other fish scaled to portion size)
0.9 ± 0.9
1.0 ± 1.0
p=0.18 3% 5%
p=0.34
Sodium
(mg per day estimated by Block FFQ)
3132 ± 1320
2304 ± 1366 7%
21%
Sugary Beverages
(oz. per week of non-juice, part-juice, and soda from Block FFQ)
3 [0, 7]
2 [0, 5]
99%
p=0.99
Whole Grains
(estimated by fiber from grains and number of grains servings from Block FFQ) -
13%
p=0.011

60. Whole Grains Definition:
‘Whole grains or foods made from them contain all the essential parts and naturally-occurring nutrients in the entire grain seed – bran, germ, and endosperm.’ – Whole Grain Council
AHA lists whole grains as containing ≥1.1g of fiber per 10g carbohydrate
Criteria for meeting ‘whole grain’ component, is oz. servings per day

61. Meeting the Whole Grain Criteria
Block Gives
Estimate of grain servings
Estimate of fiber from grains
We assumed
1 oz serving = 28 grams
28g x (1.1g of fiber/10g) = 3.1g fiber/serving
Non-whole grains had 1g fiber/serving
Meeting Criteria defined as:
1) Grain servings ≥3
and
2) Fiber from grains ≥ (3 servings)(3.1g fiber) + (servings–3)(1g fiber)

62. To Scale or not to Scale? Distributions Absolute vs. scaled For health
Within an intervention prescribing dietary restriction

63. Mean SD
Median
IQR
Minimum
Maximum
2160
844
2033
1564, 2583
761
5111

64. To Scale or not to Scale? Distributions Absolute vs. scaled For health
Within an intervention prescribing dietary restriction

65. ACTIVE Life National Heart, Lung, and Blood Institute RO1 # HL64991 The Effect of a Technology-enhanced Lifestyle Intervention on Cardiovascular Health in Overweight and Obese Young Adults American Heart Association 12BGIA