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

People who adhere to a healthy lifestyle have markedly reduced rates of incident cardiovascular events.

“Much evidence has also shown that persons who adhere to a healthy lifestyle have markedly reduced rates of incident cardiovascular events.25–30”

For cardiovascular disease mortality, the adjusted population attributable fraction for insufficient physical activity was 11.9% (95% CI 1.3-22.3).

“11.9% (95% CI, 1.3–22.3) for insufficient physical activity”

For cardiovascular disease mortality, the adjusted population attributable fraction for high blood pressure was 40.6% (95% CI 24.5-54.6).

“40.6% (95% confidence interval [CI], 24.5–54.6) for high blood pressure”

For cardiovascular disease mortality, the adjusted population attributable fraction for smoking was 13.7% (95% CI 4.8-22.3).

“13.7% (95% CI, 4.8–22.3) for smoking”

For cardiovascular disease mortality, the adjusted population attributable fraction for poor diet was 13.2% (95% CI 3.5-29.2).

“13.2% (95% CI, 3.5–29.2) for poor diet”

For cardiovascular disease mortality, the adjusted population attributable fraction for abnormal glucose levels was 8.8% (95% CI 2.1-15.4).

“8.8% (95% CI, 2.1–15.4) for abnormal glucose levels”

Male high school students were more likely than female students to report current smokeless tobacco use (12.8% vs 2.2%).

“and current smokeless tobacco use (12.8% compared with 2.2%; YRBS).1”

In 2011, 23.4% of US high school students reported any current tobacco use.

“Overall, 23.4% of students reported any current tobacco use”

In 2011, 18.1% of US high school students reported current cigarette use.

“In 2011, in grades 9 through 12:18.1% of students reported current cigarette use”

In 2011, 7.7% of US high school students reported current smokeless tobacco use.

“7.7% of students reported current smokeless tobacco use”

In 2011, 13.1% of US high school students reported current cigar use.

“13.1% of students reported current cigar use”

Male high school students were more likely than female students to report current cigar use (17.8% vs 8.0%).

“Male students were also more likely than female students to report current cigar use (17.8% compared with 8.0%)”

Male high school students were more likely than female students to report current cigarette use (19.9% vs 16.1%).

“Male students were more likely than female students to report current cigarette use (19.9% compared with 16.1%).”

Non-Hispanic white high school students were more likely than Hispanic or non-Hispanic black students to report any current tobacco use (26.5% vs 20.5% and 15.4%).

“Non-Hispanic white students were more likely than Hispanic or non-Hispanic black students to report any current tobacco use, which includes cigarettes, cigars, or smokeless tobacco (26.5% compared with 20.5% for Hispanic students and 15.4% for non-Hispanic black students; YRBS).1”

In 2011, 49.9% of high school students who currently smoked cigarettes had tried to quit in the previous 12 months.

“In 2011, 49.9% of students in grades 9 to 12 who currently smoked cigarettes had tried to quit smoking cigarettes during the previous 12 months.”

Girls were more likely than boys to report inactivity (17.7% vs 10.0%).

“Girls were more likely than boys to report inactivity (17.7% versus 10.0%).1”

The prevalence of watching television 3 or more hours per day was highest among black girls (54.9%) and boys (54.4%), followed by Hispanic boys (38.4%) and girls (37.2%), and white boys (27.3%) and girls (23.9%).

“The prevalence of watching television ≥3 hours per day was highest among black girls (54.9%) and boys (54.4%), followed by Hispanic boys (38.4%) and girls (37.2%) and white boys (27.3%) and girls (23.9%).1”

In 2011, 31.1% of adolescents used a computer for activities other than school work for 3 or more hours per day on an average school day.

“Nationwide, 31.1% of adolescents used a computer for activities other than school work (eg, videogames or other computer games) for ≥3 hours per day on an average school day.1”

A meta-analysis pooling approximately 2.4 million smokers and nonsmokers found that the relative risk ratio of smokers to nonsmokers for developing coronary heart disease was 25% higher in women than in men (95% CI 1.12-1.39).

“A meta-analysis comparing pooled data of ≈2.4 million smokers and nonsmokers found the relative risk (RR) ratio of smokers to nonsmokers for developing CHD was 25% higher in women than in men (95% CI, 1.12–1.39).12”

The prevalence of using computers or watching television 3 or more hours per day was highest among black (41.1%) and Hispanic boys (36.3%), followed by white boys (33.3%), black girls (35.2%), Hispanic girls (28.3%), and white girls (22.6%).

“The prevalence of using computers or watching television ≥3 hours per day was highest among black (41.1%) and Hispanic boys (36.3%), followed by white boys (33.3%), black girls (35.2%), Hispanic girls (28.3%), and white girls (22.6%).1”

In 2011, 32.4% of adolescents watched television for 3 or more hours per day.

“32.4% of adolescents watched television for ≥3 hours per day.1”

The prevalence of inactivity was highest among black (26.7%) and Hispanic (21.3%) girls, followed by white girls (13.7%), black boys (12.3%), Hispanic boys (10.7%), and white boys (8.5%).

“The prevalence of inactivity was highest among black (26.7%) and Hispanic (21.3%) girls, followed by white girls (13.7%), black boys (12.3%), Hispanic boys (10.7%), and white boys (8.5%).1”

Nationwide, 13.8% of adolescents were inactive during the previous 7 days.

“Nationwide, 13.8% of adolescents were inactive during the previous 7 days”

Physical education class participation declined from the 9th through the 12th grades among boys and girls.

“Physical education class participation declined from the 9th through the 12th grades among boys and girls.1”

Despite recommendations from the National Association for Sport and Physical Education that schools require daily physical education for students in kindergarten through 12th grade, only 51.8% of students attended physical education classes daily (56.7% of boys and 46.7% of girls).

“Despite recommendations from the National Association for Sport and Physical Education that schools should require daily physical education for students in kindergarten through 12th grade,6 only 51.8% of students attended physical education classes in school daily (56.7% of boys and 46.7% of girls).1”

In 2011, more high school boys (38.3%) than girls (18.5%) self-reported being physically active at least 60 minutes per day on all 7 days; self-reported rates were higher in white (30.4%) than in black (26.0%) or Hispanic (26.5%) adolescents.

“In 2011, more high school boys (38.3%) than girls (18.5%) self-reported having been physically active at least 60 minutes per day on all_7 days; self-reported rates of activity were higher in white (30.4%) than in black (26.0%) or Hispanic (26.5%) adolescents.1”

Little more than half (58.4%) of high school students played on at least 1 school or community sports team in the previous year; the prevalence declined with increasing grade level, from 61.4% in 9th grade to 52.5% in 12th grade.

“Little more than half (58.4%) of high school students played on at least 1 school or community sports team in the previous year; however, the prevalence declined with increasing grade level, from 61.4% in the 9th grade to 52.5% in the 12th grade.1”

In 2011, the proportion of students meeting activity recommendations of at least 60 minutes of physical activity on 7 days of the week was 28.7% nationwide and declined from 9th (30.7%) to 12th (25.1%) grades; at each grade level, the proportion was higher in boys than in girls.

“In 2011, the proportion of students who met activity recommendations of at least 60 minutes of PA on 7 days of the week was 28.7% nationwide and declined from 9th (30.7%) to 12th (25.1%) grades. At each grade level, the proportion was higher in boys than in girls.1”

Blacks aged 18 years or older (38.9%) and American Indians or Alaska Natives (40.8%) were more likely to be obese than whites (27.2%) and Asians (9.3%).

“Blacks ≥18 years of age (38.9%) and American Indians or Alaska Natives (40.8%) were more likely to be obese than were whites (27.2%) and Asians (9.3%).12”

In 2011 NHIS data, blacks aged 18 years or older (26.4%), American Indians or Alaska Natives (27.6%), and whites (36.6%) were less likely than Asians (56.7%) to be at a healthy weight.

“Blacks ≥18 years of age (26.4%), American Indians or Alaska Natives (27.6%), and whites (36.6%) were less likely than Asians (56.7%) to be at a healthy weight.12”

In the multigenerational Framingham Heart Study, only 75% of participants with a documented parental history of heart attack before age 55 reported that history when asked.

“only 75% of participants with a documented parental history of a heart attack before age 55 years reported that history when asked.1”

Fewer than half of all people who qualify for any kind of lipid-modifying treatment for coronary heart disease risk reduction are receiving it.

“Fewer than half of all people who qualify for any kind of lipid-modifying treatment for CHD risk reduction are receiving it.”

Only about one third of treated patients achieve their LDL goal, and fewer than 20% of patients with coronary heart disease are at their LDL goal.

“Only approximately one third of treated patients are achieving their LDL goal; <20% of patients with CHD are at their LDL goal.”

The prevalence of abnormal lipid levels among US youths 12 to 19 years of age is 20.3%.

“The prevalence of abnormal lipid levels among youths 12 to 19 years of age is 20.3%; 14.2% of normal-weight youths, 22.3% of overweight youths, and 42.9% of obese youths have at least 1 abnormal lipid level (NHANES 1999–2006, NCHS).1”

For a 65-year-old man with 2 risk alleles at 9p21.3 and no other traditional risk factors, 10-year heart disease risk is about 13.2%, compared with about 9.2% for a similar man with 0 alleles.

“The 10-year HD risk for a 65-year-old man with 2 risk alleles at 9p21.3 and no other traditional risk factors is ≈13.2%, whereas a similar man with 0 alleles would have a 10-year risk of ≈9.2%.”

At the 9p21.3 single-nucleotide polymorphism, about 27% of the white population is estimated to have 0 risk alleles, 50% to have 1, and 23% to have 2.

“At this single-nucleotide polymorphism, ≈27% of the white population is estimated to have 0 risk alleles, 50% is estimated to have 1 risk allele, and the remaining 23% is estimated to have 2 risk alleles.12”

Among US youths 12 to 19 years of age, 14.2% of normal-weight, 22.3% of overweight, and 42.9% of obese youths have at least one abnormal lipid level.

“The prevalence of abnormal lipid levels among youths 12 to 19 years of age is 20.3%; 14.2% of normal-weight youths, 22.3% of overweight youths, and 42.9% of obese youths have at least 1 abnormal lipid level (NHANES 1999–2006, NCHS).1”

The most consistently replicated genetic marker for heart disease in European-derived populations is located at 9p21.3.

“The most consistently replicated genetic marker for HD in European-derived populations is located at 9p21.3.”

Fewer than 1% of US adolescents are potentially eligible for pharmacological treatment based on American Academy of Pediatrics guidelines.

“Fewer than 1% of adolescents are potentially eligible for pharmacological treatment on the basis of guidelines from the American Academy of Pediatrics.1,2”

For a 40-year-old woman with 2 risk alleles at 9p21.3 and no other traditional risk factors, 10-year heart disease risk is about 2.4%, compared with about 1.7% for a similar woman with 0 alleles.

“The 10-year HD risk for a 40-year-old woman with 2 alleles and no other traditional risk factors is ≈2.4%, whereas a similar woman with 0 alleles would have a 10-year risk of ≈1.7%.12”

Fewer than half of even the highest-risk people, those with symptomatic coronary heart disease, are receiving lipid-lowering treatment.

“Fewer than half of even the highest-risk people (those with symptomatic CHD) are receiving lipid-lowering treatment.”

Data from the 2007-2008 BRFSS, NHIS, and NHANES surveys found that 27.8%, 28.5%, and 30.7% of US adults were told they had hypertension, respectively.

“Data from the 2007–2008 BRFSS, NHIS, and NHANES surveys found 27.8%, 28.5%, and 30.7% US adults were told they had hypertension, respectively.1”

Low levels of HDL cholesterol occurred in 21.7% of male adolescents and 10.7% of female adolescents during 2007-2010.

“Low levels of HDL cholesterol occurred in 21.7% of male adolescents and 10.7% of female adolescents during 2007 to 20101”

High levels of triglycerides occurred in 9.4% of male adolescents and 6.7% of female adolescents during 2007-2010.

“High levels of triglycerides occurred in 9.4% of male adolescents and 6.7% of female adolescents during 2007 to 2010.1”

High levels of LDL cholesterol occurred in 7.3% of male adolescents and 7.6% of female adolescents during 2007-2010.

“High levels of LDL cholesterol occurred in 7.3% of male adolescents and 7.6% of female adolescents during 2007 to 2010.1”

Analysis of NHES, HHANES, and NHANES/NCHS surveys from 1963-2002 found that blood pressure, pre-high blood pressure, and high blood pressure trends in children and adolescents 8 to 17 years of age moved downward from 1963 to 1988 and upward thereafter.

“Analysis of the National Health Examination Survey (NHES), the Hispanic Health and Nutrition Examination Survey, and the NHANES/NCHS surveys of the NCHS (1963–2002) found that the BP, pre-HBP, and HBP trends in children and adolescents 8 to 17 years of age moved downward from 1963 to 1988 and upward thereafter.”

Data from NHANES 2007-2010 found that about 6% of US adults have undiagnosed hypertension.

“Data from NHANES 2007–2010 found that ≈6% of US adults have undiagnosed hypertension.”

Pre-high blood pressure and high blood pressure increased 2.3% and 1%, respectively, between 1988 and 1999.

“Pre-HBP and HBP increased 2.3% and 1%, respectively, between 1988 and 1999.”

Increased obesity, especially abdominal obesity, partially explained the rise in high blood pressure and pre-high blood pressure from 1988 to 1999.

“Increased obesity (abdominal obesity more so than general obesity) partially explained the HBP and pre-HBP rise from 1988 to 1999.”

Among younger children, type 1 diabetes accounted for at least 80% of diabetes; among older youths, the proportion of type 2 diabetes ranged from 6% to 76%.

“Among younger children, type 1 DM accounted for ≥80% of DM; among older youths, the proportion of type 2 DM ranged from 6% (0.19 per 1000 for non-Hispanic white youths) to 76% (1.74 per 1000 for American Indian youths).”

In SEARCH, the prevalence of diabetes mellitus in US youths younger than 20 years in 2001 was 1.82 cases per 1000 youths, with 0.79 per 1000 among youths aged 0-9 and 2.80 per 1000 among those aged 10-19.

“In SEARCH, the prevalence of DM in youths <20 years of age in 2001 in the United States was 1.82 cases per 1000 youths (0.79 per 1000 among youths 0–9 years of age and 2.80 per 1000 among youths 10–19 years of age).”

This translates to 154,369 youths with physician-diagnosed diabetes mellitus in the United States in 2001, an overall prevalence estimate of about 0.18% in children and adolescents.

“This translates to 154 369 youths with physician-diagnosed DM in 2001 in the United States, for an overall prevalence estimate for DM in children and adolescents of ≈0.18%.1”

In 2004 to 2006, the prevalence of diagnosed diabetes was more than twice as high for Asian Indian adults (14%) as for Chinese (6%) or Japanese (5%) adults.

“In 2004 to 2006, the prevalence of diagnosed DM was more than twice as high for Asian Indian adults (14%) as for Chinese (6%) or Japanese (5%) adults.12”

In 1999 to 2004, approximately 4.5% of US adolescents 12 to 17 years of age had metabolic syndrome according to the International Diabetes Federation definition.

“In 1999 to 2004, ≈4.5% of US adolescents 12 to 17 years of age had metabolic syndrome according to the definition developed by the International Diabetes Federation.12”

The prevalence of metabolic syndrome increased from 1.2% among adolescents 12 to 13 years of age to 7.1% among those 14 to 15 years of age and was higher among boys (6.7%) than girls (2.1%).

“It increased from 1.2% among those 12 to 13 years of age to 7.1% among those 14 to 15 years of age and was higher among boys (6.7%) than girls (2.1%).”

In 2006, this prevalence would have represented approximately 1.1 million adolescents 12 to 17 years of age with metabolic syndrome.

“In 2006, this prevalence would have represented ≈1.1 million adolescents 12 to 17 years of age with metabolic syndrome.”

In 1999 to 2004, 4.5% of white adolescents, 3.0% of black adolescents, and 7.1% of Mexican American adolescents had metabolic syndrome.

“Furthermore, 4.5% of white adolescents, 3.0% of black adolescents, and 7.1% of Mexican American adolescents had metabolic syndrome.”

The prevalence of metabolic syndrome remained relatively stable during successive 2-year periods: 4.5% for 1999 to 2000, 4.4% to 4.5% for 2001 to 2002, and 3.7% to 3.9% for 2003 to 2004.

“The prevalence of metabolic syndrome remained relatively stable during successive 2-year periods: 4.5% for 1999 to 2000, 4.4% to 4.5% for 2001 to 2002, and 3.7% to 3.9% for 2003 to 2004.”

Blacks, Hispanics, Asian Americans, and Native Americans have higher ESRD rates than whites.

“Blacks, Hispanics, Asian Americans, and Native Americans have higher rates of ESRD than do whites.”

In 2010, ESRD prevalence was 593,086, and 65% of prevalent cases received hemodialysis.

“The prevalence of ESRD was 593 086, with 65% of these prevalent cases being treated with hemodialysis.1”

In 2010, the median age of the ESRD population was 57.9 years for Native Americans, 58.1 for blacks, 59.7 for Asians, and 61.2 for whites.

“The median age of the population with ESRD in 2010 varied across different racial/ethnic groups: 57.9 years for Native Americans, 58.1 years for blacks, 59.7 years for Asians, and 61.2 years for whites.1”

In 2010, 114,083 new ESRD cases were reported.

“114 083 new cases of ESRD were reported.1”

In 2010, 16,843 kidney transplants were performed.

“16843 kidney transplants were performed.1”

Since 2000, new ESRD rates increased by 6.1% among whites.

“since 2000 new ESRD rates have increased 6.1% for whites”

Since 2000, new ESRD rates increased by 2.5% among Asians.

“and 2.5 percent among Asians”

ESRD treatment is more common among men than women.

“Treatment of ESRD is more common in men than in women.1”

Since 2000, new ESRD rates decreased by 7.0% among blacks.

“while rates have decreased 7.0% for blacks.1”

Newer evidence indicates a link between BMI and worsening CKD.

“Recent evidence suggests that BMI is associated with worsening CKD.”

The total annual cost of treating ESRD in the US was $26.8 billion in 2008, nearly 6% of the total Medicare budget.

“The total annual cost of treating ESRD in the United States was $26.8 billion in 2008, which represents nearly 6% of the total Medicare budget.1”

CKD prevalence was higher among people with diabetes (40.1%) and hypertension (23.2%) than among those without these conditions.

“CKD prevalence was greater among those with DM (40.1%) and hypertension (23.2%) than among those without these chronic conditions.1”

Among 652 African American patients with hypertensive nephrosclerosis, BMI independently predicted urine total protein and albumin excretion.

“In a cohort of 652 African American individuals with hypertensive nephrosclerosis, BMI was independently associated with urine total protein and albumin excretion.12”

CKD prevalence increases with age: 5.7% for ages 20-39, 9.1% for 40-59, and 35.0% for ≥60.

“According to current definitions, the prevalence of CKD is higher with older age1:5.7% for those 20 to 39 years of age9.1% for those 40 to 59 years of age35.0% for those ≥60 years of age”

Awareness of heart disease as the leading cause of death among women approximately doubled among white and Hispanic women and tripled among black women between 1997 and 2009.

“Awareness of HD as the leading cause of death among women has approximately doubled among white and Hispanic women and tripled among black women between the first survey in 1997 and the current 2009 survey.”

After adjustment for age and education, African American, Hispanic, and Asian women were significantly less likely than white women to be aware that heart disease/heart attack is the leading cause of death.

“However, after adjustment for age and education level, African American, Hispanic, and Asian women were significantly less likely to be aware that HD/heart attack is the leading cause of death than white women.12”

In 2009, awareness of heart disease as the leading cause of death among women was 54%, significantly higher than in 1997.

“in 2009, awareness of HD as the leading cause of death among women was 54%, significantly higher than in 1997.12”

Substantial proportions of deaths could be prevented or postponed with greater achievement of ideal cardiovascular health.

“which suggests that substantial proportions of deaths could be prevented or postponed with greater achievement of ideal cardiovascular health.”

Higher numbers of ideal health metrics were also associated with lower cancer mortality.

“Higher numbers of ideal health metrics were also associated with lower cancer mortality.11”

Over 14.8 years of follow-up, Yang and colleagues observed a graded reduction in all-cause, cardiovascular disease, and ischemic heart disease mortality in conjunction with having greater numbers of metrics at ideal levels at baseline.

“Similarly, over 14.8 years of follow-up, Yang and colleagues11 observed a graded reduction in all-cause, cardiovascular disease, and ischemic heart disease mortality in conjunction with having greater numbers of metrics at ideal levels at baseline”