Artículo Sueño y Corazón

Circulation
AHA PRESIDENTIAL ADVISORY
Life’s Essential 8: Updating and Enhancing

the American Heart Association’s Construct of
Cardiovascular Health: A Presidential Advisory
From the American Heart Association
Donald M. Lloyd-Jones, MD, ScM, FAHA, Chair; Norrina B. Allen, PhD, MPH, FAHA; Cheryl A.M. Anderson, PhD, MPH, MS, FAHA;
Terrie Black, DNP, MBA, CRRN, FAHA; LaPrincess C. Brewer, MD, MPH; Randi E. Foraker, PhD, MA, FAHA;
Michael A. Grandner, PhD, MTR, FAHA; Helen Lavretsky, MD, MS; Amanda Marma Perak, MD, MS, FAHA; Garima Sharma, MD;
Wayne Rosamond, PhD, MS, FAHA; on behalf of the American Heart Association
ABSTRACT: In 2010, the American Heart Association defined a novel construct of cardiovascular health to promote a paradigm
shift from a focus solely on disease treatment to one inclusive of positive health promotion and preservation across the life
course in populations and individuals. Extensive subsequent evidence has provided insights into strengths and limitations
of the original approach to defining and quantifying cardiovascular health. In response, the American Heart Association
convened a writing group to recommend enhancements and updates. The definition and quantification of each of the original
metrics (Life’s Simple 7) were evaluated for responsiveness to interindividual variation and intraindividual change. New
metrics were considered, and the age spectrum was expanded to include the entire life course. The foundational contexts
of social determinants of health and psychological health were addressed as crucial factors in optimizing and preserving
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cardiovascular health. This presidential advisory introduces an enhanced approach to assessing cardiovascular health: Life’s
Essential 8. The components of Life’s Essential 8 include diet (updated), physical activity, nicotine exposure (updated), sleep
health (new), body mass index, blood lipids (updated), blood glucose (updated), and blood pressure. Each metric has a new
scoring algorithm ranging from 0 to 100 points, allowing generation of a new composite cardiovascular health score (the
unweighted average of all components) that also varies from 0 to 100 points. Methods for implementing cardiovascular
health assessment and longitudinal monitoring are discussed, as are potential data sources and tools to promote widespread
adoption in policy, public health, clinical, institutional, and community settings.
Key Words: AHA Scientific Statements ◼ health promotion ◼ healthy lifestyle ◼ life change events
◼ public health ◼ social determinants of health
I THE CONCEPT OF CARDIOVASCULAR

n 2010, after decades of declines in cardiovascular
disease (CVD) death rates, the American Heart Asso-
ciation (AHA) expanded its focus from addressing
HEALTH
existing CVD and risk factors to adding strategies that In defining CVH, the AHA’s 2010 writing group acknowl-
would also directly promote the health of the popula- edged that health is a broader, more positive construct than
tion and individuals. Central to this new approach was merely the absence of disease. It leveraged relevant exist-
the creation of a novel and operational definition for the ing data and emerging prevention concepts to formulate a
construct of cardiovascular health (CVH).1 definition that was intended to be accessible for all, with

Supplemental material is available at https://www.ahajournals.org/doi/suppl/10.1161/CIR.0000000000001078.
© 2022 American Heart Association, Inc.
Circulation is available at www.ahajournals.org/journal/circ
Circulation. 2022;146:00–00. DOI: 10.1161/CIR.0000000000001078 TBD TBD, 2022 e1

Lloyd-Jones et al Life’s Essential 8
CLINICAL STATEMENTS
AND GUIDELINES
Figure 1. Life’s Essential 8.

Life’s Essential 8 includes the 8
components of cardiovascular health:
healthy diet, participation in physical activity,
avoidance of nicotine, healthy sleep, healthy
weight, and healthy levels of blood lipids,
blood glucose, and blood pressure.
actionable components for individuals, practitioners, re- as a new CVH component—to catalyze ongoing efforts to
searchers, and policymakers to focus efforts for improve- improve CVH in all individuals and the population.
ment in CVH for all. Readers are referred to that document
for a more detailed discussion of the rationale and genesis
of the CVH construct. The initial definition of CVH1 was
REVIEW OF KNOWLEDGE GAINED SINCE
based on 7 health behaviors and health factors that, when 2010
optimal, were associated with greater CVD-free survival To date, >2500 scientific articles have cited the original
and total longevity and higher quality of life. The 7 compo- 2010 document describing the AHA’s construct of CVH
nents of CVH, subsequently called Life’s Simple 7, included and explored the prevalence, determinants, outcomes,
indicators of dietary quality, participation in physical activ- and mechanisms of CVH in diverse populations across
ity (PA), exposure to cigarette smoking, and measures of the life course. A number of findings are highlighted here.
body mass index, fasting blood glucose, total cholesterol,
and blood pressure (BP) levels. Each metric was classified
as poor, intermediate, or ideal on the basis of accepted clini- Prevalence of CVH
cal thresholds. Overall, ideal CVH was defined as having all In the United States, the prevalence of ideal CVH is ex-
7 metrics at ideal levels. Ideal CVH also formed the basis of ceedingly low (<1%) for all age groups studied, including
a new definition of optimal brain health published in 2017.2 among individuals as young as 12 years of age.3 Overall
The rich experience with and evidence in support of CVH declines with age: The prevalence of having ≥5 met-
this powerful new health construct over the past 12 years rics at ideal levels is only 45% among US adolescents, 32%
have created an opportunity to update the measurement of among adults 20 to 39 years of age, 11% among adults
CVH in the current context. Now is the time to enhance the 40 to 59 years of age, and 4% among adults ≥60 years of
approach to quantifying the original metrics and to assess age.3 Thus, although some individuals can preserve higher
the potential value of additional metrics and data sources levels of CVH, most will require some attention to achieve
to better represent the full range of CVH and to further and maintain it into later life. The prevalence of ideal diet
motivate individual and population health improvement. (as defined in 2010) is consistently negligible (<1%)
This advisory presents an updated and enhanced approach across all age groups, driving the overall low prevalence of
to measuring, monitoring, and modifying CVH—now called ideal CVH. Population levels of CVH in the United States
Life’s Essential 8 (Figure 1) after the inclusion of sleep have been low and fairly stagnant over the past 15 to 20
e2 TBD TBD, 2022 Circulation. 2022;146:00–00. DOI: 10.1161/CIR.0000000000001078

years,4 but this overall observation conceals several impor- in determining CVH.24 Indeed, pursuing and sustaining
CLINICAL STATEMENTS
tant findings. First, although some segments of the popula- a healthier lifestyle from a young age is a successful
AND GUIDELINES
tion are experiencing modest improvements in CVH, other strategy for maintaining higher CVH into middle age.25–31
groups (generally those at a lower socioeconomic position) However, one’s ability to choose healthy lifestyles across
are experiencing worsening CVH, creating a bimodal dis- the life course is strongly influenced by psychological
tribution.5 Second, there are persistent differences in the health factors32,33 and social and structural determi-
prevalence of CVH levels by self-reported race and ethnic- nants,34 as addressed later in detail (in the Foundational
ity, and these disparities are larger at younger ages.3 The Factors for CVH: Psychological Health/Well-Being and
prevalence of high CVH also varies geographically6 and Social Determinants section).
is higher in those who live in urban7 areas compared with
those who live in rural areas. Furthermore, recent data in- Mechanisms of CVH
dicate that the prevalence of high CVH is <1 in 10 during
pregnancy,8 and poor CVH in pregnancy is associated with Investigations of mechanisms through which high-
poor CVH in offspring, suggesting that ideal CVH is not er CVH is associated with lower CVD risk (or lower
universal even at birth.9 CVH with higher risk) have identified several potential
pathways involving inflammation, endothelial function,
atherosclerosis, cardiac stress and remodeling, hemo-
Outcomes of CVH static factors, and epigenetics,35,36 among others.13,37,38
Numerous studies have shown strong, stepwise, inverse Two studies examined multiple potential pathways from
associations between the number of ideal CVH metrics or low CVH status to clinical CVD events and found only
overall CVH score and total CVD and CVD mortality, all- partial statistical attenuation of the relationship after
cause mortality, and a wide variety of non-CVD outcomes. adjustment for a wide array of subclinical disease mea-
In all studies, those with higher CVH have markedly lower sures and biomarkers presumed to be in the causal
risks for CVD events. In a meta-analysis of 9 prospective pathway.13,37 Thus, beyond known CVD risk pathways,
cohort studies, having the highest number of ideal CVH the protection conferred by optimal CVH may be “more
metrics (generally ≥5 versus 0 to 2) was associated with a than the sum of its parts.”39
relative risk of 0.20 for CVD (95% CI, 0.11–0.37), 0.31 for Taken together, the substantial body of knowledge
stroke (95% CI, 0.25–0.38), 0.25 for CVD mortality (95% gained about CVH indicates that it is uniquely positioned
CI, 0.10–0.63), and 0.55 for all-cause mortality (95% CI, as a health outcome itself related to upstream genetic,
0.37–0.80).10 Similar associations are observed across all social, behavioral, and environmental factors, and as
age groups, down to as young as 8 years of age,11–15 and a determinant of major downstream health outcomes.
regardless of race and ethnicity or socioeconomic position. Across the life course, assessment of CVH status has
All 7 original CVH metrics contribute to risks for health been shown to be an effective means to monitor pub-
outcomes,12 and the importance of CVH behaviors is lic and individual health and a strong indicator of the
underscored by the association of optimal CVH behaviors extraordinary potential of primordial prevention strate-
with nearly 50% lower risk for coronary events among gies to improve and extend countless lives.
individuals at high genetic risk.16,17 It is never too late to
realize benefits from improvement in CVH.18–20 However, LESSONS LEARNED ABOUT CVH AND
the earlier that CVH is optimized, the better the outcomes
are. Having higher CVH is associated with favorable long- RATIONALE FOR REDEFINITION
term health outcomes at every age, and improvement in As is evident from the previous review, a number of les-
CVH over time is associated with lower risk for CVD.18–20 A sons have been learned about the original construct of
recent analysis estimated that if all US adults maintained CVH through its application and study in diverse settings.
high CVH (defined in that article as 12–14 of 14 points on The collective experience of the scientific and medical
the CVH score), 2.0 million CVD events would be prevented community in using the original CVH construct to mea-
each year.21 Better CVH has also been associated with sure and improve CVH suggested several important con-
lower risks for cancer, dementia, end-stage renal disease, siderations for this update.
and chronic obstructive pulmonary disease; better cogni- First, some features of CVH component definitions
tive function and quality of life; compression of morbidity may not have allowed appreciation of the full scope of
(longer health span); and lower health care costs despite a health behaviors and practices in the current environ-
longer life span, among many other positive outcomes.22,23 ment. For example, the original diet metric assessed
intake of only 5 foods or nutrients (fruit and vegeta-
bles, fish, whole grains, sugar-sweetened beverages,
Determinants of CVH and sodium). These dietary components were selected
The heritability of overall CVH is low, indicating that be- to represent an overall healthy eating pattern such as
havioral and environmental exposures are paramount the DASH (Dietary Approaches to Stop Hypertension)

eating pattern from variables available at the time in can lead to successful outcomes (as discussed in Imple-
CLINICAL STATEMENTS
NHANES (National Health and Nutrition Examination mentation of CVH in Clinical Practice section).
AND GUIDELINES
Surveys). However, those 5 components are not the only Last, the original writing group contemplated the
features of a contemporary healthful eating pattern. The inclusion of sleep, stress, and other factors as metrics
new metrics attempt to allow credit for a broader scope and acknowledged their contributions to overall CVH.
of health in each CVH component. However, at the time, the means for reliably measur-
Second, over time, application of the CVH construct ing these domains in individuals and populations were
has increasingly been used to assess individual- and limited. In the ensuing years, improved assessment
population-level CVH. This application has revealed techniques and emerging evidence have bolstered the
limitations in how the metrics are quantified. Specifi- importance of sleep and psychological health/well-being
cally, the original definitions of ideal, intermediate, and for CVH. In addition, there is increased awareness of the
poor CVH for each component are less sensitive to critical importance for CVH of social determinants of
interindividual differences and intraindividual change health (SDOH) and the underlying societal and structural
than is desirable. For example, the PA metric quantified issues that create them. These factors were of signifi-
intermediate CVH as 1 to 149 minutes of moderate cant importance in the deliberations of the writing group.
to vigorous activity per week. Thus, 2 distinct individu- In the next sections, we introduce the AHA’s new
als with widely different amounts (eg, 1 min/wk versus Life’s Essential 8, including affirmation of the founda-
149 min/wk) would be categorized as having interme- tional roles that psychological health/well-being and
diate PA, and an individual who changed their own PA SDOH play in achieving optimal and equitable CVH in
from 1 to 149 min/wk would receive no credit for the the population (in the Foundational Factors for CVH:
substantial improvement in this health behavior. The Psychological Health/Well-Being and Social Determi-
newer approach to quantification of CVH is designed nants section); a new CVH component metric related to
to be more sensitive and responsive to these consid- sleep (in the Sleep Health as a New Component of CVH
erations. There were also large shifts in some individu- section); and novel, updated methods for defining and
als’ CVH scores as they transitioned from childhood to quantifying CVH (in the Updated Definitions and Novel
adult metrics (some of which is unavoidable) that we Quantitative Assessment of CVH Metrics section).
have attempted to address.
Third, although CVH was designed to measure and
monitor health trajectories over time, a novel contribu- FOUNDATIONAL FACTORS FOR CVH:
tion of this construct, it has also been used effectively to

PSYCHOLOGICAL HEALTH/WELL-BEING
predict future risk for CVD and other health outcomes
across the life course. This has proved to be a useful AND SOCIAL DETERMINANTS
feature, especially for younger individuals (for whom risk Over the past decade, key findings have illuminated the
equations are typically unavailable). essential, foundational context of psychological health
Fourth, although the metrics used to measure and and well-being and SDOH for maintaining or improving
monitor CVH are useful for describing health status and CVH (Figure 2). Positive psychological health character-
trajectories, they should not necessarily be used to pro- istics such as optimism, purpose in life, environmental
mote specific interventions. In the example of the original mastery, perceived reward from social roles, and resilient
diet metric, clinicians could recommend and consumers coping are associated with more favorable CVH40–42;
should pursue numerous strategies to improve their eat- conversely, greater psychosocial stress and depres-
ing pattern beyond focusing solely on the 5 original nutri- sion are associated with poorer CVH.43–45 SDOH pro-
ents and food groups. Generally speaking, then, in the vides the daily context for CVH and often determine the
promotion of CVH, the specific metrics (eg, the diet com- lifelong potential for CVH preservation and success or
ponents) should not be confused with the health mes- failure of interventions to improve CVH. A variety of
saging (ie, people should pursue an overall heart-healthy favorable individual-level socioeconomic and social in-
diet such as the DASH- or Mediterranean-style eating dicators are associated with higher CVH such as higher
patterns). income, educational attainment, occupational status, and
Fifth, the data on CVH change and its benefits consis- subjective social status and less social isolation, fewer
tently suggest that maintaining the highest possible lev- racial discrimination experiences, and less incarcera-
els of CVH on all metrics will lead to the best outcomes. tion.46–50 Likewise, favorable neighborhood-level factors
Clinicians and consumers should focus on strategies such as greater resources, social cohesion, and built en-
that reinforce success and maintain high levels of over- vironment are also associated with higher CVH, although
all CVH over time. However, if >1 metric is suboptimal fewer neighborhood and community health resources
or trending worse, they do not all need to be addressed are associated with poorer CVH.48,51–54 The writing
simultaneously. Picking 1 CVH component at a time to group therefore judged that the context of psychologi-
improve, particularly if it is aligned with patient motivation, cal health/well-being and SDOH must be considered in

CLINICAL STATEMENTS
AND GUIDELINES
Figure 2. The foundational context of
CVH.
As depicted in the social-ecological model
in the base of the figure 8, a variety of
socioeconomic and structural determinants
of health provide the foundational framework
that affects an individual’s or a community’s
ability to optimize cardiovascular health (CVH).
Several interacting factors provide critical
context for CVH, including structures and
systems (general socioeconomic, cultural,
and environmental conditions), community
resources (ie, education, agriculture, food
production, employment, water and sanitation,
health care, and housing), institutions and
organizations (in which people learn, grow, eat,
sleep, play, and pray), interpersonal social and
community networks, and individual genetic
and behavioral factors. These foundational
social-ecological factors work through and
alongside an individual’s psychological health
(represented at the top of the 8 in the figure)
to provide the context for what is possible
in improving or maintaining CVH. There is
a continuous interplay of brain-mind-heart-
body connections that can positively and
negatively affect CVH, which is represented
by the 8 component metrics (diet, physical
activity, nicotine exposure, sleep, body mass

index, blood lipids, blood glucose, and blood
pressure) as interacting gears.
attempts to assess and improve CVH in any patient or ways (such as inflammatory response, glucose and lipid
population. We therefore highlight these 2 critical, foun- homeostasis, and coagulation) related to chronic stress,
dational factors first. indirect effects on health behaviors that influence CVH,
and changes in psychosocial resilience factors that pro-
mote or impair health or buffer detrimental effects of
Psychological Health and Well-Being stressful experiences.33,55–59 The preponderance of data
A growing body of evidence supports the brain-mind- suggests that interventions to improve psychological
heart-body connection that can positively or negatively af- health can have a beneficial impact on CVH.33 However,
fect CVH, individual CVD risk factors, and cardiovascular agreement on which psychological factors are the most
outcomes. A recent AHA scientific statement33 reviewed robust predictors and correlates of CVH is lacking. Rela-
a large number of studies that address a broad range of tively simple questionnaires can be used by clinicians to
positive (eg, optimism, sense of purpose, happiness) and assess psychological health status in the evaluation and
negative (eg, stress, depression, anxiety) psychological management of patients with or at risk for CVD.33
health factors and their significant associations with CVH On the basis of the reviewed evidence, the writing
and CVD risk. That statement guided much of the current group judged that psychological health and well-being
writing group’s deliberations on the interactions of psy- form a critical context and interact bidirectionally with
chological health and well-being with CVH. the potential for preserving and improving CVH. Psy-
There are multiple direct and indirect pathways by chological health is multidimensional, and at this time,
which psychological health and well-being may influence it is not clear how best to combine measures of psy-
CVH and CVD risk. These include physiological path- chological health or which indicator(s) may be most

important for influencing CVH. When the writing group SLEEP HEALTH AS A NEW COMPONENT
CLINICAL STATEMENTS
considered the nature of CVH metrics and improve-

OF CVH
AND GUIDELINES
ment strategies, psychological health and well-being

were judged to be more foundational, underlying all of Sleep is a foundational element of human biology and
the CVH metrics, rather than a distinct metric of CVH a requirement for life.72 Sleep is defined as “a naturally
per se. For these reasons, the writing group elected recurring, reversible state of perceptual disengagement,
to acknowledge the critical importance of psychologi- reduced consciousness, and relative immobility,”72 al-
cal health and well-being and to strongly encourage though its functions are wide ranging and affect nearly
more routine assessment and intervention in the clini- every physiological system.73 Numerous epidemiological
cal domain but not to include them as formal metrics of studies have identified poor habitual sleep as a risk fac-
CVH at this time. tor for all-cause mortality,74–83 and subsequent research
has explored potential mechanisms,84–86 including impli-
cations for cardiometabolic health.
SDOH and Considerations for Equitably Much of the existing research has focused on sleep
Improving CVH Across Contexts duration, although it should be noted that sleep health
SDOH is defined as the “structural determinants and is a multidimensional construct with overlapping com-
conditions in which people are born, grow, live, work, and ponents, including duration, timing, regularity, efficiency,
age” that affect health, functioning, and quality of life.60 satisfaction, and impact on daytime alertness.87 Popula-
There are 5 key domains of SDOH: economic stability, tion-level studies have shown that inappropriate sleep
neighborhood and built environment, education, social duration (either shorter or longer than ideal) is associ-
and community context, and health and health care.61,62 ated with coronary heart disease.88 Sleep duration is
Given this context, it is easy to understand how SDOH associated with each of the original 7 components
may directly and importantly affect an individual’s ability of CVH72,89–107 and with overall CVH score.108 Recent
to optimize their CVH; the availability of healthy food and trends toward decreased sleep health in the population
the ability to pay for it, safe places in which to pursue PA, appear to account for some of the variance in changing
health literacy, social support structures and networks, cardiometabolic risk prevalence.109 Furthermore, recent
and access to and ability to pay for health care all directly evidence suggests that sleep metrics add independent
influence CVH status.61 predictive value for CVD events over and above the origi-
Disparities in CVH exist across a wide range of social nal 7 CVH metrics.110 It should be noted that poor sleep
strata, including race and ethnicity, socioeconomic posi- health is also known to be associated with poor psycho-
tion, geography, and rurality, among others,63,64 and logical health111–114 and SDOH,84,115–120 important con-
inequities persist as a result of societal and structural textual drivers of CVH; therefore, for some individuals,
barriers.34,64 The need to address CVH disparities has sleep health assessment and intervention may require
recently received considerable attention because per- customized approaches that consider the surround-
sistence of these pervasive issues hinders achievement ing context. As with many of the other CVH component
of health equity.34,65,66 Prior CVD disparities–focused metrics, sleep may also serve to integrate and mediate
interventions and initiatives have not proactively incor- some of the effects of SDOH and psychological health
porated the full spectrum of complex psychosocial on CVH. Several organizations have adopted sleep dura-
influences on CVH.67–71 tion guidelines, recognizing the population health value
Substantial research activity is currently focused on of ≈7 to 8 hours of habitual sleep for adults and age-
discovering the best means for representing and measur- appropriate ranges of sleep duration for children.91,121–127
ing SDOH in individuals and neighborhood environments. Although there is a paucity of evidence indicating that
As with psychological health and well-being, the writing improving sleep duration or quality reduces CVD inci-
group judged that the best methods for measuring and dence, several other lines of evidence support its con-
quantifying SDOH are inadequately understood at this nection with CVH. For example, laboratory studies show
time, and the most important factors for preserving CVH that experimentally manipulated sleep affects BP, inflam-
in individuals and populations remain to be elucidated. mation, glucose homeostasis, and other relevant factors.
Likewise, SDOH factors underlie much of the ability to Larger observational studies show that small changes in
optimize CVH rather than forming a single component of sleep at the population level are associated with changes
CVH. Accordingly, the writing group encourages further in CVD-related risk factors. Research indicates that real-
research on SDOH and CVH and urges consideration world manipulation of sleep time is possible and that
of SDOH in individual clinical attempts to improve CVH therefore sleep time is modifiable. Last, a limited number
and in the design of community and population policies of studies demonstrate that real-world sleep manipula-
and interventions (see Implementation of CVH in Clini- tion is associated with changes in CVD-related risk fac-
cal Practice and Context and Opportunities for Improving tors.128,129 Nonetheless, overall, this is a research gap for
CVH Going Forward). which further investigation is warranted.

As a result of the above evidence, the ease and • Nicotine exposure: Use of inhaled nicotine-
CLINICAL STATEMENTS
increasing reliability of measurement, and its compa- delivery systems (eg, e-cigarettes or vaping
AND GUIDELINES
rable and independent contributions to overall and car- devices) has been added to the former metric,
diometabolic health and health outcomes, the writing which included only combustible cigarette use, to
group elected to add sleep duration as an eighth metric reflect adult and childhood use of these products
to the formal definition of CVH. Its measurement and and their implications for long-term health.137,138
quantification are described in the next section with the Secondhand tobacco smoke exposure has also
other metrics. been added to the definition to reflect its adverse
impact on health.135,139
• Sleep health: As noted, the writing group endorses
UPDATED DEFINITIONS AND NOVEL the systematic assessment and inclusion of sleep
duration as the current means for reflecting sleep
QUANTITATIVE ASSESSMENT OF CVH
health within the construct of CVH.
METRICS • Blood lipids: The metric for blood lipids has been
Here, we propose updated definitions and rescoring of updated to consider non–high-density lipoprotein
the original 7 CVH metrics and the new sleep metric on cholesterol as the metric of interest rather than
a more continuous scale to better account for interindi- total cholesterol because non–high-density lipopro-
vidual difference and intraindividual change (Table 1). The tein cholesterol can be measured in the nonfasting
table should not be used as the sole guide for individu- state and reliably calculated in all patients (unlike
als to shape prevention or health promotion strategies. low-density lipoprotein cholesterol) and because of
It is provided for the AHA, researchers, health systems, the lifelong associations demonstrated for differ-
and policymakers to create standardized tools to measure ent atherogenic lipoprotein fractions, all of which
and monitor CVH in individuals and populations. In the fol- are represented in the non–high-density lipoprotein
lowing paragraphs, descriptions of new or updated metric cholesterol measurement.
definitions are first presented, followed by a discussion of • Blood glucose: The metric for blood glucose has
new measurement and quantification techniques. been expanded to include hemoglobin A1c mea-
Several of the original 7 metrics have been redefined surement (in individuals with or without diabetes)
for consistency with newer clinical guidelines, to better and to better reflect glycemic control among dia-
represent their biological impact, or for compatibility with betic patients.
new measurement tools, as summarized here: • PA, body mass index, and BP: The writing group dis-
• Diet: A new method is proposed for assessing cussed these metrics and elected to use the same
dietary quality for both rapid individual assessment metric definitions (but with updated scoring, as for
in clinical settings and population-level assess- all the metrics).
ment in other settings, along with a suggested Childhood metrics were updated to reflect current
means for linking and aligning these assessments, pediatric guidelines, to extend to younger ages when
when needed, through the Healthy Eating Index136 appropriate, and to better align with transitions to
(see Supplemental Material for full details). The adulthood. More detailed discussion of the approach
writing group supports the overall goal of pursu- to quantifying CVH in children, especially children <6
ing DASH- and Mediterranean-style eating pat- years of age, is provided in the Supplemental Material
terns as being most consistent with optimal CVH. Appendix 2.
That said, there is no one such eating pattern, and For ease of reference in clinical or research settings,
there are limited tools for assessing alignment the 8 metrics making up the new CVH definition have
with these eating patterns. The DASH-style eat- been grouped into the 2 domains of health behaviors
ing pattern is more easily assessed at the popula- (diet, PA, nicotine exposure, sleep) and health factors
tion level for the United States, although it is more (body mass index, blood lipids, blood glucose, BP).
difficult at the individual level. Therefore, a rapid For the approach to quantification of the metrics and
dietary assessment tool is suggested for individu- overall CVH, various methods were considered. Also
als that is a modified Mediterranean Eating Pattern considered was the desire for ease of programming
for Americans (MEPA). The writing group selected metric scores to create applications (apps) and online
what we judge to be the best available tools and CVH assessment tools, as well as for incorporation into
calls for directed research to advance the field and electronic health records (EHRs) and other platforms.
identify even better standardized and rapid assess- Because some metrics do not lend themselves to fully
ment tools. This new approach provides a focus continuous quantification scales and because some
on individuals’ eating patterns and intake of whole associations of metrics with health are nonlinear, the
foods, rather than nutrients, that should promote writing group judged that an ordinal point scoring system
implementation in clinical and research settings. for each metric (ranging from 0 to 100 points) was most

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
CLINICAL STATEMENTS
ages, and examples of overall CVH scores in diverse scenarios)

AND GUIDELINES
Quantification of CVH metric: adults Quantification of CVH metric: children

Domain CVH metric Method of measurement (≥20 y of age) (up to 19 y of age)
Health behaviors Diet Measurement: Self-reported Quantiles of DASH-style diet adherence Quantiles of DASH-style diet adherence or
daily intake of a DASH-style or HEI-2015 (population) HEI-2015 (population) or MEPA (individu-
eating pattern als)*; ages 2–19 y (see Supplemental
Scoring (population):
Example tools for measure- Material for younger ages)
Points Quantile
ment: DASH diet score130,131
100 95th percentile (top/ideal
≥ Scoring (population):
(populations); MEPA132 (indi-
viduals) diet) Points Quantile
80 75th–94th percentile 100 ≥95th percentile (top/ideal diet)
50 50th–74th percentile 80 75th–94th percentile
25 25th–49th percentile 50 50th–74th percentile
0 1st–24th percentile (bottom/ 25 25th–49th percentile
least ideal quartile) 0 1st–24th percentile (bottom/
Scoring (individual): least ideal quartile)
Points MEPA score (points) Scoring (individual):
100 15–16 Points MEPA score (points)
80 12–14 100 9–10
50 8–11 80 7–8
50 5–6
25 4–7
25 3–4
0 0–3 0 0–2
PA Measurement: Self-reported Metric: Minutes of moderate- (or greater) Metric: Minutes of moderate- (or greater)
minutes of moderate or vigor- intensity activity per week intensity activity per week; ages 6–19 y
ous PA per week Scoring: (see notes and Supplemental Material for
Example tools for measure- Points Minutes younger ages)
ment: NHANES PAQ-K ques- 100 ≥150 Scoring:
tionnaire133 Points Minutes
90 120–149
100 ≥420
80 90–119
90 360–419
60 60–89
80 300–359
40 30–59
60 240–299
20 1–29
40 120–239
0 0
20 1–119
0 0
Nicotine Measurement: Self-reported Metric: Combustible tobacco use or Metric: Combustible tobacco use or inhaled
exposure use of cigarettes or inhaled inhaled NDS use; or secondhand smoke NDS use at any age (per clinician discre-
NDS exposure tion); or secondhand smoke exposure
Example tools for measure- Scoring: Scoring:
ment: NHANES SMQ134 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 Currently using inhaled NDS
25 Former smoker, quit <1 y, or
currently using inhaled NDS 0 Current combustible use (any
within 30 d)
0 Current smoker
Subtract 20 points (unless score is 0) for liv-
Subtract 20 points (unless score is 0) for
ing with active indoor smoker in home
living with active indoor smoker in home
Sleep health Measurement: Self-reported av- Metric: Average hours of sleep per night Metric: Average hours of sleep per night (or
erage hours of sleep per night Scoring: per 24 h for age ≤5 y; see notes for age-
Example tools for measure- Points Level appropriate ranges)
ment: “On average, how many 100 7–<9 Scoring:
hours of sleep do you get per Points Level
night?” 90 9–<10
100 Age-appropriate optimal
Consider objective sleep/ 70 6–<7 range
actigraphy data from wearable 40 5–<6 or ≥10 90 <1 h above optimal range
technology if available 70 <1 h below optimal range
20 4–<5
40 1–<2 h below or ≥1 h above
0 <4 optimal
20 2–<3 h below optimal range
0 ≥3 h below optimal range
(Continued )

Table 1. Continued
CLINICAL STATEMENTS
Quantification of CVH metric: adults Quantification of CVH metric: children
AND GUIDELINES
Domain CVH metric Method of measurement (≥20 y) (up to 19 y)
Health factors BMI Measurement: Body weight Metric: BMI (kg/m2) Metric: BMI percentiles for age and sex,
(kilograms) divided by height Scoring: starting in infancy; see Supplemental Mate-
squared (meters squared) rial for suggestions for age <2 y
Example tools for measure- Points Level
Scoring:
ment: Objective measurement 100 <25 Points Level
of height and weight 70 25.0–29.9 100 5th–<85th percentile
30 30.0–34.9 70 85th–<95th percentile
15 35.0–39.9 30 95th percentile–<120% of
0 ≥40.0 the 95th percentile
15 120% of the 95th percentile–
<140% of the 95th percentile
0 ≥140% of the 95th percentile
Blood lipids Measurement: Plasma total and Metric: Non–HDL cholesterol (mg/dL) Metric: Non–HDL cholesterol (mg/dL), start-
HDL cholesterol with calcula- Scoring: ing no later than age 9–11 y and earlier per
tion of non–HDL cholesterol clinician discretion
Points Level
Example tools for measurement: Scoring:
100 <130
Fasting or nonfasting blood Points Level
sample 60 130–159
100 <100
40 160–189
60 100–119
20 190–219
40 120–144
0 ≥220
20 145–189
If drug-treated level, subtract 20 points
0 ≥190
If drug-treated level, subtract 20 points
Blood glucose Measurement: FBG or casual Metric: FBG (mg/dL) or HbA1c (%) Metric: FBG (mg/dL) or HbA1c (%), symp-
HbA1c Scoring: tom-based screening at any age or risk-based
Example tools for measurement: screening starting at age ≥10 y of age or on-
Points Level
Fasting (FBG, HbA1c) or non- set of puberty per clinician discretion
100 N
o history of diabetes and
fasting (HbA1c) blood sample Scoring:
FBG <100 (or HbA1c <5.7)
Points Level
60 No diabetes and FBG
100–125 (or HbA1c 5.7–6.4) 100 No history of diabetes and
FBG <100 (or HbA1c < 5.7)
(prediabetes)
40 Diabetes with HbA1c <7.0 60 No diabetes and FBG 100–125
(or HbA1c 5.7–6.4) (prediabetes)
30 Diabetes with HbA1c 7.0–7.9
40 Diabetes with HbA1c <7.0
10 Diabetes with Hb A1c 9.0–9.9
0 Diabetes with HbA1c ≥10.0
10 Diabetes with Hb A1c 9.0–9.9
0 Diabetes with HbA1c ≥10.0
BP Measurement: Appropriately Metric: Systolic and diastolic BPs Metric: Systolic and diastolic BP (mm Hg)
measured systolic and diastolic (mm Hg) percentiles for age through 12 y. For age
BPs Scoring: ≥13 y, use adult scoring. Screening should
Example tools for measurement: start no later than age 3 y and earlier per
Points Level
Appropriately sized BP cuff clinician discretion
100 <120/<80 (optimal)
Scoring:
75 120–129/<80 (elevated)
Points Level
50 1
30–139 or 80–89 (stage 1
100 Optimal (<90th percentile)
hypertension)
75 Elevated (≥90th–<95th per-
25 140–159 or 90–99
centile or ≥120/80 mm Hg to
0 ≥160 or ≥100 <95th percentile, whichever
Subtract 20 points if treated level is lower)
50 Stage 1 hypertension (≥95th–
<95th percentile+12 mm Hg,
or 130/80 to 139/89 mm Hg,
whichever is lower)
25 Stage 2 hypertension (≥95th
percentile+12 mm Hg, or
≥140/90 mm Hg, whichever
is lower)
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 dia-
stolic BP
Subtract 20 points if treated level
(Continued )

Table 1. Continued
CLINICAL STATEMENTS
BMI indicates body mass index; BP, blood pressure; CVH, cardiovascular health; DASH, Dietary Approaches to Stop Hypertension; FBG, fasting blood glucose;
AND GUIDELINES
HbA1c, hemoglobin A1c; HDL, high-density lipoprotein; HEI, Healthy Eating Index; MEPA, Mediterranean Eating Pattern for Americans; NDS, nicotine-delivery sys-
tem; 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:
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
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 for-
mally 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 sub-
tracting 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.
appropriate. We used a modified Delphi approach among health. Final point scores for each metric are displayed
the expert panel members to arrive at point score levels, in Table 1. The writing group acknowledges that these
informed by health outcomes and risk associations. We point scores are somewhat arbitrary, but we judge that
also examined US population distributions (from recent this approach is a substantial improvement to be able
NHANES) and resulting effects on the metric-specific to detect interindividual differences and population and
and overall CVH scores to arrive at the final point assign- individual changes in CVH over time. Further research
ments for each metric. The group also strove to ensure is warranted to understand all of the implications of the
that, across metrics, similar point value differences algorithm. The writing group judged that use of categori-
were associated with approximately similar impacts on cal descriptors (ideal, intermediate, poor) for each metric

was no longer desirable, electing instead for less pejo- and populations going forward. Large health information
CLINICAL STATEMENTS
rative and more supportive presentations of the entire exchanges such as the National Patient-Centered Clinical
AND GUIDELINES
spectrum of each metric, from lower to higher, to encour- Research Network140 offer comprehensive EHR registries
age intervention and change for improvement. that can be used to track individuals over time. As these
For overall CVH, the writing group continues to endorse a health information exchanges have evolved, many now
composite, aggregate score for measuring, monitoring, and include large swaths of the United States and compre-
assessing change in CVH. The new aggregate score is also hensively cover most major metropolitan areas, although
scaled from 0 to 100 points, calculated as the unweighted information on CVH in rural populations may still be limited.
average of all 8 component metric scores. Examples of Notably, EHRs include only individuals who seek care; they
CVH calculation for different scenarios are shown in the miss individuals who have difficulty accessing or paying for
Supplemental Material. The writing group recommends that care, particularly well care. EHRs have been shown to pro-
presentation of CVH score or status for individuals and vide reliable prevalence rates for some chronic conditions
populations should consider images or icons that reflect such as diabetes that require routine care, although their
the entire spectrum of CVH, including some indication of validity and reliability for other conditions such as obesity141
more and less desirable states (such as red/yellow/green are lower. Although EHR systems have great potential, at
coloration; example shown in Figure 3) across a range of present, they typically contain limited behavioral and life-
0 to 100. For some purposes, it may continue to be use- style information; thus, they may need dedicated work to
ful to consider categorical consideration of overall CVH; the generate systematic and standardized inputs that include
writing group recommends that overall CVH scores of 80 diet, PA, smoking, and sleep metrics of CVH and to struc-
to 100 be considered high CVH; 50 to 79, moderate CVH; ture these data in useful formats. The AHA can continue to
and 0 to 49 points, low CVH. New research is encouraged lead in this arena by identifying brief and valid methods of
in samples from diverse populations, across the life course, assessing these lifestyle constructs that can then be docu-
and in diverse settings to assess the implications of the mented within the medical records. Several are suggested
new scoring of the metrics and overall CVH. Further discus- in this document (Table 1). In addition, understanding and
sion of implementation considerations in various contexts tracking the fundamental roles of SDOH and psychologi-
is provided below (see Implementation of CVH in Clinical cal health in CVH through EHRs remain challenging but
Practice and Context and Opportunities for Improving CVH important (see Implementation of CVH in Clinical Practice
Going Forward sections). section).
Combining EHR data with lifestyle data collected
via surveys or wearable technology offers the ability for

DATA SOURCES FOR MONITORING CVH individuals (or their health care professionals) to moni-
In the original 2010 monograph defining CVH, NHANES tor their CVH over time and to help preserve high CVH
data were identified as the best available source with which when it exists or intervene early if declines in CVH are
to monitor population-level CVH. NHANES continues to detected. A variety of strategies have been proposed to
have a number of advantages, including representative collect lifestyle data and house it within the EHR sys-
sampling across demographic groups, inclusion of all CVH tem,142 including the use of brief questionnaires on com-
metrics (including the newly added sleep metric) at most puters or tablets in the waiting room or through patient
ages, in-person examinations, and sustainability as part of portals before a visit. Some investigators and companies
population health monitoring by the Centers for Disease have created standalone apps to collect self-reported
Control and Prevention. NHANES data have limitations, in- lifestyle data,143,144 although these have the disadvantage
cluding missing some CVH metrics at the youngest ages, of not being integrated within the EHR. As technology
small samples in any given year of some racial and ethnic continues to evolve, wearable devices may offer the abil-
subgroups, limited generalizability for individuals living in ity to replace self-reported data on PA, BP, and sleep
the most deprived conditions, and being limited to the US with objectively measured data. Ultimately, pragmatic—
population. Additional data sources will be needed to fully and automated if feasible—data collection is central to
understand the scope of CVH within these populations and simple and effective individual and population monitor-
beyond the United States. Alternative data sources such as ing of CVH over time. In turn, the aforementioned health
cohort data, EHRs, national surveys, and registries may be technology platforms can provide motivation to individu-
useful in many instances but can have significant limitations als to engage in behavior change to favorably affect
that currently prevent their routine use for population moni- CVH. The writing group encourages the AHA to be a
toring of CVH. For now, it is recommended that NHANES leader in the development and dissemination of these
remain the main data source for tracking the US popula- technologies to improve CVH.
tion’s CVH over time, although focused efforts to optimize Taken together, these advances offer the possibility
other data sources, as described below, are encouraged. of monitoring CVH across an individual’s life span and
Major advances in data science and informatics should for surveillance within the population in the near future.
be harnessed to better understand CVH in individuals These more systematically collected and comprehensive

CLINICAL STATEMENTS
AND GUIDELINES
Figure 3. Example presentation of CVH score.

The figure provides an example of how to represent an individual’s cardiovascular health (CVH) assessment with the new Life’s Essential 8. The
gauge at the top corresponds to the individual’s overall CVH score (which can range from 0–100 points), with higher scores shown toward the
right (a “full tank” of CVH) in green. The individual’s status for each of the 8 component metrics is shown below, thus identifying health behaviors
and risk factors on which the individual can focus to achieve and maintain a full tank of overall CVH. The overall CVH score is the unweighted
average of the 8 component metric scores.
data may ultimately assist the AHA and policymakers Implementing the CVH Metric in Diverse
in providing insight into population CVH metrics. Other Populations and Settings and Leveraging
opportunities may arise through existing or new large-
scale crowd-sourcing efforts to monitor health (eg, Proj-
Health Technologies for Pragmatic Data
ect Baseline, Health eHeart). Collection and CVH Intervention
Most CVH metrics (body mass index, BP, cholesterol, fast-
IMPLEMENTATION OF CVH IN CLINICAL ing glucose/hemoglobin A1c, and smoking status) are cap-
tured as structured fields in the EHR. Health systems are
PRACTICE well positioned to leverage the EHR for population health
In addition to the social-ecological context for CVH pro- monitoring, risk prediction, and intervening on CVH in patient
motion (Figure 2), clinical implementation is crucial. With populations across the life course.146 Examples of CVH data
the proliferation of health technologies noted previously, visualization tools that have been integrated with the EHR
health systems, individuals, and families can participate in in learning health care systems include Stroke Prevention
the pragmatic collection of CVH data. In turn, the AHA or in Healthcare Delivery Environments and Priorities Wizard,
health systems need to provide platforms that assist in- among others.147 Clinicians have the opportunity to use these
dividual patients and their health care teams in assessing tools with patients at the point of care to raise awareness of
their CVH and tracking their progress over time through CVH and use shared decision-making approaches to help
online websites or apps. These same health technology patients preserve or achieve optimal CVH.148 For greater
platforms can serve to aggregate CVH data for popula- success, it is suggested that clinicians use motivational inter-
tion health monitoring and risk prediction or for interven- viewing strategies to help patients identify those metrics that
ing in CVH by motivating behavior change among diverse would benefit from improvement and for which the patient
populations.145 expresses some motivation for change and can envision the

means to do so. Better skills training for clinicians in these aimed at preserving and improving population-wide CVH
CLINICAL STATEMENTS
areas is critical for success. Likewise, it may be helpful to across the life course. Taken together, these interven-
AND GUIDELINES
have the patient focus on a single health behavior or health tions can serve as road maps for policymakers, health
factor at a time for improvement rather than trying to change systems, institutions, clinicians, researchers, and com-
too many things at once, which may risk the patient feeling munities for the future development and translation of
overwhelmed or experiencing a sense of failure. SDOH-informed, equitable solutions to ensure attain-
Universal efforts and tailored, culturally appropriate ment of CVH equity for diverse populations.
methods will be needed to direct individuals to resources
for improving or maintaining CVH, potentially ameliorat-
ing the negative impacts of SDOH and psychological Policies
health and promoting positive social and psychological Over the past decade, the AHA has partnered with
assets.143,149 Ubiquitous health technology can put impor- other volunteer science organizations on presidential
tant CVH information in the hands of traditionally under- advisories, clinical practice guidelines, and health policy
served populations. However, contextual factors (SDOH, statements focused on primordial, primary, and second-
access to health care and health technology, health liter- ary prevention and promotion of optimal CVH through-
acy, and psychological health) mediate individuals’ access out the life course. These efforts have also increased
to health technology and information and can affect their awareness about the SDOH and their driving influence
ability to maintain or achieve optimal CVH.145 The AHA and on CVH disparities and have provided recommenda-
other stakeholders will need to be mindful of these issues tions for addressing them.2,33,71,147,161,188–192 Although
in the design of data collection and intervention tools. interventions focused on the entire construct of CVH
are exceedingly rare, health policy statements have fo-
cused on several important structural, contextual, and
Communication of the New CVH Score With intergenerational factors that can promote overall opti-
Patients mal CVH (Table 2), including but not limited to access to
Clinical and general populations alike are accustomed to quality health care, healthy foods, and recreational fa-
hearing health status framed as risk (implying negative cilities for leisure-time PA.193 Ongoing advocacy efforts
or bad) for a given disease or condition. When the new at the federal, state, and community levels must con-
CVH, Life’s Essential 8, is implemented in diverse settings, tinue for improvement in population-wide CVH. Indeed,
it should be presented in a positive manner through a lay- policy-level solutions are often the only ways to address
friendly format to ensure accurate interpretation, to indicate issues such as health care reform (for CVH monitor-
its strong associations with favorable health outcomes, and ing and intervention), transformation of PA and healthy
to provide motivation for behavior change as needed. In- meal programs in schools, regulation of tobacco/
deed, high CVH is a positive outcome in and of itself and nicotine products, and accessibility to a healthier food
can bring about immediate health benefits for an individual. supply.
Each assessment and reassessment serve as reinforce- The writing group particularly acknowledges the
ment of CVH metrics that have remained favorable with an emerging evidence on the critical importance of precon-
opportunity to arrest decline in others. Tools from the AHA ception maternal health, gestational health, pregnancy
and its partners for clear communication will be needed outcomes, and follow-up peripartum care to improve
so that it can be delivered by health care professionals, the health of women and children to launch succes-
EHRs, and health technologies and accompanied by sug- sively healthier generations.161,194,195 Further research
gested steps one can take to improve CVH and monitor and expanded programs are needed, including better
progress over time. Health care system and government metrics for monitoring progress in addressing dispari-
programs should also be designed to catalyze implementa- ties in maternal health outcomes. Likewise, a number of
tion of CVH improvement strategies in venues beyond the successful policies for promoting and sustaining better
clinic such as through evidence-based individual, family, or health from childhood through adolescence have been
group interventions. Newer strategies of patient self-man- developed, demonstrated, and supported by the AHA
agement also show promise for engaging and empowering and its partners.193 Future efforts are needed, given
patients to improve aspects of their CVH.150 the COVID-19 pandemic and its associated worsening
health inequities.
CONTEXT AND OPPORTUNITIES FOR Public Health Programs

IMPROVING CVH GOING FORWARD Several successful public health programs have been de-
In this section and Table 2, we highlight selected examples veloped to address CVH disparities in recent decades. In
of successful and promising strategies across the spheres alignment with the AHA, the US Department of Health
of influence of the social-ecological model (Figure 2), and Human Services–led Healthy People 2020 and 2030

Table 2. Multilevel Efforts to Improve CVH Across Social-Ecological Contexts

CLINICAL STATEMENTS
Ecological level Selected examples Examples of key gaps and needed directions
AND GUIDELINES
Policies
Federal FDA regulation of tobacco products Premarket approval of newer tobacco products154
Robust school nutrition standards and healthy school meals Regulating synthetic nicotine155
for all Removing all characterizing flavors from all tobacco prod-
Active transportation infrastructure investment ucts156
Ensuring affordable, equitable, adequate access to health Continued support for implementation and increasing sodium
insurance for all151 reduction, promotion of whole grains; developing an added
Public health infrastructure investment, data modernization, sugars standard
and surveillance systems upgrade152,153 Ensuring that federal appropriations flow effectively to the
state and local levels for biking, walking, and rolling, reaching
all people equitably, particularly those in the most underserved
and underinvested communities157
Preserving and building on the Affordable Care Act
Optimizing value-based insurance design158,159
Continued federal investment of the data modernization and
surveillance systems upgrade to ensure seamless integration
across all levels of government and health systems
Protecting and expanding the public health workforce
State Tobacco end game strategies (eg, comprehensive smoke-free air Effective coordination and engagement across public health,
laws, tobacco excise taxes, comprehensive coverage and access social justice, and equity partners
to tobacco cessation services, tobacco retail strategies, and re- Need for robust public and private investment in the tobacco
moving all characterizing flavors from all tobacco products)138 end game, overcoming industry product innovation, targeted
Medicaid expansion and Medicaid coverage of extended post- marketing, and positioning
partum coverage, self-measured BP, telehealth160–162 Housing, income, and transportation issues for the Medicaid
population
Ensuring that states can use all means at their disposal to off-
set costs of expansion163 and to increase access to services
Local Sugar-sweetened beverage taxes164,165 Combatting industry opposition and preemption efforts
Increasing access to early care and education166 Significant commitment to funding for advocacy campaigns
and ground softening efforts
State preemption of local efforts
Inadequate workforce compensation167,168

Disruption caused by the COVID-19 pandemic169
Advocacy groups AHA Voices for Healthy Kids grantees policy work
Public health programs
Federal Healthy People 2020 and 2030 Tailored sociocultural messaging for diverse populations in
Million Hearts partnership with relevant stakeholders
WISEWOMAN
NHLBI ENRICH/home visiting program partnership
Head Start
State/national AHA’s Go Red for Women Tailored sociocultural messaging for diverse populations in
partnership with relevant stakeholders
Local Mass media campaigns to promote healthy behaviors and risk
factor control170,171
Institutions
Early childcare/education Chicago Child-Parent Center Education Program Longitudinal Broader implementation
Study172
Schools and colleges AHA/NFL Play60 Delineate specific intervention components most effective in
AHA/Clinton Foundation Alliance for a Healthier Generation promoting CVH and best approaches to implementation174
AHA Kids Heart Challenge
School-based tobacco prevention,171,173 PA promotion, sugar-
sweetened beverage reduction
Workplaces AHA Workforce Well-Being Playbook and Corporate Recog- Implementation, particularly including workplaces more
nition Program175 likely to employ individuals who may be socioeconomically
NIOSH Total Worker Health Centers of Excellence impacted
Health care systems (eg, AHA Get With The Guidelines Broader implementation
insurance/payers, hospitals, SPHERE176
practitioners)
Neighborhoods and communities
(Continued )

Table 2. Continued
CLINICAL STATEMENTS
Ecological level Selected examples Examples of key gaps and needed directions
AND GUIDELINES
Community-serving programs Strong Hearts, Healthy Communities intervention 177,178
Outreach to broader rural communities with geographic bar-
AHA SFRN-funded Hearts & Parks/Bull City Fit intervention179 riers to access
CDC Prevention Research Centers
Private community settings Faith-based interventions (FAITH trial, FAITH!) Evaluation of design elements sufficient for large-scale dis-
Barbershop interventions semination and implementation in community settings and
broad population health impact180
Expansion of rigorously tested CVH promotion interventions
to other community venues (eg, hair salons,181 community
centers) in partnership with civic organizations182 (eg, sorori-
ties, fraternities)
Neighborhood environments Green space, corner store interventions183,184 Development of methods to increase consumer demand and
to foster sustainability of corner store interventions in various
neighborhood/environmental contexts (eg, urban vs rural)185
Specific assessment of impacts of green space interventions
on health equity and potential adverse effects (eg, gentrifica-
tion and reduced access)186
Virtual communities Interactive, group social media interventions187 Culturally responsive interventions to promote CVH
Families and individuals
Parents/children AHA Simple Cooking With Heart for Kids
AHA/Aramark Health for Life nutrition education curriculum
INSIGHT intervention
STRIP intervention
Adults Health-partner intervention
Mobile technology for stroke prevention
AHA indicates American Heart Association; BP, blood pressure; CDC, Centers for Disease Control and Prevention; CVH, cardiovascular health; ENRICH, Early
Intervention to Promote Cardiovascular Health of Mothers and Children; FAITH, Faith-Based Approaches in the Treatment of Hypertension; FAITH!, Fostering African-
American Improvement in Total Health; FDA, US Food and Drug Administration; INSIGHT, Intervention Nurses Start Infants Growing on Healthy Trajectories; NFL, Na-
tional Football League; NHLBI, National Heart, Lung, and Blood Institute; NIOSH, National Institute for Occupational Safety and Health; PA, physical activity; SFRN,
Strategically-Focused Research Network; SPHERE, Stroke Prevention in Healthcare Delivery Environments; STRIP, Special Turku Coronary Risk Factor Intervention
Project; and WISEWOMAN, Well-Integrated Screening and Evaluation for Women Across the Nation.
public health initiatives have identified identical indicators Institutions

for overall CVH for nationwide health improvement goals,
including CVD prevention.196 The systematic, evidence- Institutions such as early childhood care or education cen-
based approach encourages cross-sector community col- ters, schools, and workplaces have unique opportunities to
laborations for health promotion, including state-specific preserve and promote optimal CVH through engagement
benchmarks, with an overarching mission to achieve health of their large, captive populations. For example, preschool
equity for all population groups. Nonetheless, disparities by programs providing comprehensive educational and fami-
race and ethnicity and geographic regions have persisted, ly support172 can improve multigenerational CVH and pos-
indicating the complexity of SDOH and psychological itively affect numerous life course outcomes other than
health as key barriers and facilitators to optimal CVH.197,198 CVH such as socioeconomic position, justice-system in-
Additional broad-based initiatives focused on risk fac- volvement, and addiction.209 School-based programs such
tor control in individuals (eg, the Million Hearts and Well- as health education and screenings retain their influence
Integrated Screening and Evaluation for Women Across through adolescence and young adulthood, including at
the Nation programs) complement these efforts.199–201 The colleges and universities, to promote positive CVH behav-
AHA’s Go Red for Women and similar programs have been iors among youth,171,173 although widespread implementa-
instrumental in raising heart disease awareness to promote tion remains a challenge.174 Starting in adolescence and
CVH among women.125,127,202–204 Room for optimization of extending through most of adulthood, workplace well-
these initiatives exists through enhanced cross-fertilization ness programs gain importance. Workplace programs
efforts across key stakeholder groups for tailored sociocul- align employee and employer incentives; they can gen-
tural messaging among high-priority populations.205–208 The erate savings not only from reduced health care costs
writing group urges the AHA to engage all of its partners but also reduced absenteeism and improved employee
in new broad-based communication strategies to raise engagement.210 The AHA Workplace Wellness Playbook
awareness and to enhance engagement with the new CVH offers recognition for workplaces with high-quality pro-
construct across all sectors to improve population CVH. grams.210,211 Implementation of such programs across all

CLINICAL STATEMENTS
AND GUIDELINES
Figure 4. Life course of CVH.

The figure describes sensitive periods and transitions for cardiovascular health (CVH) across the life span, along with example opportunities for
intervention to preserve or promote CVH at each age or stage. Opportunities to improve CVH occur across public health and policy, institutional,
neighborhood- and community-level, and clinical contexts. Red arrow indicates the feedback loop of primordial prevention strategies that can
maintain CVH through early life, leading to healthier parents before conception and a subsequent generation of healthier children.
types of workplaces, including those most relevant to in- Of utmost importance are collaborative, equitable com-
dividuals who may be socioeconomically impacted, needs munity health needs assessments to allow a better under-
focused attention. standing of community priorities/needs, socioeconomic
constraints/barriers, and strengths/assets to ensure that

deployed interventions within underserved communities
Neighborhoods and Communities are relevant, meaningful, scalable, and sustainable.237–246
Promising interventions to promote CVH have demonstrated Through its Empowered to Serve initiative and significant
the importance of going beyond traditional venues (outside investments through its Social Impact Funds, the AHA
of the clinical setting or academia) to places where indi- has galvanized a movement to reduce CVH disparities in
viduals actually live, learn, work, play, and pray within neigh- underresourced communities by supporting community
borhoods and communities.212 This paradigm of “meeting advocates, social justice leaders, social entrepreneurs, and
people where they are” while considering the sociocultural locally owned businesses in implementing community-led
context of individuals and their families is at the heart of sev- models to improve SDOH.247
eral community-based interventions. These programs have
successfully leveraged social capital and trust building with
Life Course and Intergenerational Perspectives
individuals belonging to traditionally underserved and mar-
ginalized groups, especially for underrepresented racial and on CVH Promotion Across Ecological Levels
ethnic populations.213–218 Successful examples of multidis- Figure 4 depicts key windows and transitions in the life
ciplinary hypertension interventions for Black men based course of CVH, along with examples of opportunities to
in barbershops and other community venues are justifiably preserve or improve CVH at every stage. Pregnancy and
celebrated. In addition, culturally tailored interventions in- the periods around it (preconception, postpartum) set the
corporating faith-based tenets and delivered in partnership stage for the offspring’s CVH potential and represent an
with churches have resulted in significant improvements in important transition period and physiologic stressor for
CVH.219–226 Other community-serving programs with a clinic- mothers. It is at once a period of great opportunity given
to-community link by way of municipal parks and recreation universal coverage of (although not necessarily access
centers179,227,228 have aimed to build a culture of health for to) health care during pregnancy but also a taxing and
youth by providing community-centered support for a life- vulnerable time for mothers and families. Early childhood
long commitment to healthy lifestyle.177,178 Furthermore, is key for establishing healthy CVH behaviors, with pre-
there is evidence to support multicomponent corner store school age thought to be a particularly important window.
interventions in addressing food insecurity in food deserts/ Adolescence through very early adulthood is a period
swamps in both rural and urban areas.183,184,229–236 of rapid development physically, mentally, emotionally,

Table 3. Example Research Needs and Future Directions

RESEARCH GAPS AND FUTURE
CLINICAL STATEMENTS
Enhanced definition and scoring and potentially different metrics for CVH DIRECTIONS
AND GUIDELINES
in pregnancy, at birth, and during the earliest years of life (especially <2 y
of age); enhanced data collection at individual and population levels during The extensive knowledge gained about the construct of
these life stages
CVH since 2010 provided the basis for the current update
Assessment of the new CVH scoring algorithm across the life course and and enhancement. Nonetheless, numerous knowledge
in diverse populations to understand its utility for describing individual and
population health, strengths and limitations, and trends in CVH over time gaps and research opportunities remain to ensure that the
Focused research to tie classification of existing metrics at the youngest
utility, implementation, and impact of CVH can be optimized.
ages based on guidelines (eg, PA) to meaningful outcomes, eg, CVH or In addition, there is now need for study of this new approach
BMI at older ages in childhood or subclinical CVD in midlife to measuring and monitoring CVH in diverse settings. Some
Investigation of novel measures or biomarkers to represent overall CVH at research gaps and proposed future directions identified by
young age
the writing group are presented in Table 3.
Development and validation of short, clinically feasible surveys for each age
group/developmental stage in children
Utility of new CVH score for predicting diverse health outcomes, including
total mortality, healthy longevity (compression of morbidity), cardiovascular
events, and other chronic disease outcomes, especially in younger people
CONCLUSIONS AND VISION FOR LIFE’S
Research driving to consensus on best tools for assessment of health be- ESSENTIAL 8
haviors in clinical settings
The formal definition of CVH in 2010 represented the
Greater routine and standardized assessment of diet, PA, nicotine exposure, culmination of decades of evolution in epidemiology,
and sleep health in clinical and population settings to facilitate CVH mea-
surement and monitoring public health, clinical care, and prevention concepts.
Greater routine and standardized assessment of psychological health and
Supported by the AHA, the rapid uptake of the CVH
well-being and SDOH, as well as their associations with CVH in clinical and concept by researchers, policymakers, funding agen-
population settings cies, communities, and, to a certain extent, patients
Discovery, demonstration, and dissemination of successful strategies (eg, and clinicians has provided a road map for reenergizing
policies, clinical strategies, community interventions, individual behavioral
changes) to preserve or improve overall CVH in individuals and in diverse
individual and population health promotion strategies
settings and populations and reducing the ongoing substantial burden of CVD
Research on other metrics of sleep related to CVH and interventions to im- and other chronic health conditions. The CVH construct
prove CVH through improved sleep health provided the means for positive, actionable steps that
could be taken to measure, monitor, and modify CVH
Enhanced medical education and training to equip clinicians with the tools
to assess CVH, to implement motivational interviewing, to assist patients through primordial, primary, and secondary prevention
with behavioral change or maintenance, to promote wellness strategies, and
to avoid bias and stigma around adverse health behaviors and factors (eg, approaches. The knowledge gained over the past 12
nicotine exposure or obesity) years has reinforced the need for addressing limita-
Deployment of apps, online tools, and code for implementation of CVH tions and enhancing utility to advance this construct
scoring in consumer-facing, clinical, population, and research settings
even further. The goal is to unite efforts around improv-
Optimization of broad-based communication strategies to promote and ing a wide array of health outcomes and quality of life
preserve CVH and tailored communication strategies for diverse cultural
settings and demographic groups through a positively framed, responsive health construct
of CVH used consistently across the life course and in
Apps indicates applications; BMI, body mass index; CVD, cardiovascular
disease; CVH, cardiovascular health; PA, physical activity; and SDOH, social diverse settings. Greater insight into the foundational
determinants of health. aspects of SDOH and psychological health in which
CVH occurs will likely lead to further refinements of
CVH definitions in the future.
and socially. The transition to full responsibility for self The present document presents a substantial update of
comes with competing priorities for limited resources of and enhancement to the means for measuring and moni-
attention, often including parenthood, and appears to be toring CVH to address the current context of public health
a sensitive period for CVH loss.248 Contexts outside of and to assist the AHA and its partners in efforts to achieve
the young adult’s own health care such as college, work- greater health equity by promoting better CVH for all. The
place, community, and family-based/child health care new means for defining and measuring CVH, Life’s Essen-
settings gain importance. Middle age may offer new per- tial 8, in individuals and populations represents a major
spectives and changing roles that can be leveraged by step forward in our ability to intervene by promoting and
workplace, community, and health care contexts to con- reinforcing healthy metrics while averting decline of those
trol risk factors, improve CVH, and prevent CVD events. with potential for unfavorable trajectories. It should help
In older age, access to well-being supports through com- re-energize efforts to develop, test, and disseminate inter-
munities, neighborhoods, and health care systems can ventions to maintain or improve CVH at every stage across
help prevent frailty, promote active living, extend healthy the life course, in diverse settings, and for all people. Pri-
longevity, and improve quality of life through CVH promo- mordial prevention efforts focused on early life are likely
tion. to have particularly beneficial effects in initiating healthier

trajectories of lifelong CVH and creating healthier parents Disclosure Questionnaire showing all such relationships that might be perceived
as real or potential conflicts of interest.
CLINICAL STATEMENTS
of healthier babies in future generations. This advisory was approved by the American Heart Association Science Advisory
AND GUIDELINES
In business management, it is often said that “if you can- and Coordinating Committee on May 9, 2022, and the American Heart Associa-
not measure it, you cannot improve it.” With this enhanced tion Executive Committee on May 16, 2022. A copy of the document is available at
https://professional.heart.org/statements by using either “Search for Guidelines &
measurement tool for CVH, the AHA and its numerous Statements” or the “Browse by Topic” area. To purchase additional reprints, call 215-
multisector partners in schools, communities, government, 356-2721 or email [email protected].
health care, business, and beyond have new opportunities The American Heart Association requests that this document be cited as fol-
lows: Lloyd-Jones DM, Allen NB, Anderson CAM, Black T, Brewer LC, Foraker RE,
to catalyze CVH improvement by raising awareness of its Grandner MA, Lavretsky H, Perak AM, Sharma G, Rosamond W; on behalf of
importance, promoting platforms for its measurement, fund- the American Heart Association. Life’s essential 8: updating and enhancing the
ing research on interventions, and disseminating successful American Heart Association’s construct of cardiovascular health: a presidential
advisory from the American Heart Association. Circulation. 2022;146:e•••–e•••.
strategies. Capitalizing on these opportunities will be a criti- doi: 10.1161/CIR.0000000000001078
cal step toward ensuring that every person has the oppor- The expert peer review of AHA-commissioned documents (eg, scientific
tunity for optimal CVH and a full, healthy life. statements, clinical practice guidelines, systematic reviews) is conducted by the
AHA Office of Science Operations. For more on AHA statements and guidelines
development, visit https://professional.heart.org/statements. Select the “Guide-
lines & Statements” drop-down menu, then click “Publication Development.”
Permissions: Multiple copies, modification, alteration, enhancement, and/or
ARTICLE INFORMATION
distribution of this document are not permitted without the express permission of
The American Heart Association makes every effort to avoid any actual or poten- the American Heart Association. Instructions for obtaining permission are located
tial conflicts of interest that may arise as a result of an outside relationship or a at https://www.heart.org/permissions. A link to the “Copyright Permissions Re-
personal, professional, or business interest of a member of the writing panel. Spe- quest Form” appears in the second paragraph (https://www.heart.org/en/about-
cifically, all members of the writing group are required to complete and submit a us/statements-and-policies/copyright-request-form).
Disclosures
Writing Group Disclosures
Speak-
Other ers’ Consultant/
Writing group research bureau/ Expert Ownership advisory
member Employment Research grant support honoraria witness interest board Other
Donald M. Northwestern University None None None None None None None
Lloyd-Jones Feinberg School of Medicine
Norrina B. Allen Northwestern University NIH†; AHA† None None None None None None
Feinberg School of Medicine
Cheryl A.M. UCSD None None None None None WW†; None
Anderson McCormick
Science
Foundation†
Terrie Black University of Massachusetts None None None None None None None
College of Nursing
LaPrincess C. Mayo Clinic College of AHA*; NIH*; CDC*; ACC* None None None None None ABC*;
Brewer Medicine ACC*; Am
J Prev
Card*;
J Am Med
Assoc*
Randi E. Foraker Washington University in St. NIH/NCI (1R01CA226078)† None None None None None None
Louis, School of Medicine
Michael A. University of Arizona Col- None None None None None None None
Grandner lege of Medicine
Helen Lavretsky UCLA NIH (PI)†; PCORI (PI)†; None None None None None None
NCCIH†
Amanda Marma Lurie Children’s Hospital NHLBI (K23 grant that exam- None None None None None None
Perak and Northwestern Uni- ines molecular mechanisms of
versity CVH in children)†; Northwest-
ern University (multiple small
pilot grants investigating CVH
in pregnant people and youth)†
Wayne University of North Carolina None None None None None None None
Rosamond Gillings School of Global
Public Health
Garima Sharma Johns Hopkins University None None None None None None None
School of Medicine
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclo-
sure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives
$5000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or
owns $5000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.

Reviewer Disclosures
CLINICAL STATEMENTS
Other Speakers’ Consultant/
AND GUIDELINES
Research research bureau/ Expert Ownership advisory
Reviewer Employment grant support honoraria witness interest board Other
Donna K. Arnett University of Kentucky None None None None None None None
Robert H. Eckel University of Colorado Anschutz Medical None None None None None None None
Campus
Heather M. Christine E. Lynn Women’s Health & Well- NIH/NHLBI None None None None None None
Johnson ness Institute Charles E. Schmidt College (coinvesti-
of Medicine, Florida Atlantic University gator)*
Amit Khera UT Southwestern Medical Center None None None None None None None
Latha P. Stanford University NIH (K24 None None None None None None
Palaniappan Award)†
Linda V. Van Horn Northwestern University, Feinberg School NIH† None None None None None None
of Medicine
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure
Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $5000 or more during
any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $5000 or
more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.
10. Fang N, Jiang M, Fan Y. Ideal cardiovascular health metrics and risk
REFERENCES of cardiovascular disease or mortality: a meta-analysis. Int J Cardiol.
2016;214:279–283. doi: 10.1016/j.ijcard.2016.03.210
1. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L,
Greenlund K, Daniels S, Nichol G, Tomaselli GF, et al; on behalf of the American 11. Perak AM, Ning H, Khan SS, Bundy JD, Allen NB, Lewis CE, Jacobs
Heart Association Strategic Planning Task Force and Statistics Commit- DR Jr, Van Horn LV, Lloyd-Jones DM. Associations of late adoles-
tee. Defining and setting national goals for cardiovascular health promotion cent or young adult cardiovascular health with premature cardiovascu-
and disease reduction: the American Heart Association’s strategic Impact lar disease and mortality. J Am Coll Cardiol. 2020;76:2695–2707. doi:
Goal through 2020 and beyond. Circulation. 2010;121:586–613. doi: 10.1016/j.jacc.2020.10.002
10.1161/CIRCULATIONAHA.109.192703 12. Folsom AR, Yatsuya H, Nettleton JA, Lutsey PL, Cushman M, Rosamond
2. Gorelick PB, Furie KL, Iadecola C, Smith EE, Waddy SP, Lloyd-Jones DM, WD; ARIC Study Investigators. Community prevalence of ideal cardiovas-
cular health, by the American Heart Association definition, and relationship
Bae HJ, Bauman MA, Dichgans M, Duncan PW, et al; on behalf of the
American Heart Association/American Stroke Association. Defining optimal with cardiovascular disease incidence. J Am Coll Cardiol. 2011;57:1690–
brain health in adults: a presidential advisory from the American Heart As- 1696. doi: 10.1016/j.jacc.2010.11.041
sociation/American Stroke Association. Stroke. 2017;48:e284–e303. doi: 13. Polonsky TS, Ning H, Daviglus ML, Liu K, Burke GL, Cushman M, Eng J,
10.1161/STR.0000000000000148 Folsom AR, Lutsey PL, Nettleton JA, et al. Association of cardiovascu-
3. Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, lar health with subclinical disease and incident events: the Multi-Ethnic
Chamberlain AM, Chang AR, Cheng S, Delling FN, et al; on behalf of the Amer- Study of Atherosclerosis. J Am Heart Assoc. 2017;6:e004894. doi:
ican Heart Association Council on Epidemiology and Prevention Statistics 10.1161/JAHA.116.004894
Committee and Stroke Statistics Subcommittee. Heart disease and stroke 14. Allen NB, Krefman AE, Labarthe D, Greenland P, Juonala M, Kähönen
statistics—2020 update: a report from the American Heart Association. Cir- M, Lehtimäki T, Day RS, Bazzano LA, Van Horn LV, et al. Cardiovascular
culation. 2020;141:e139–e596. doi: 10.1161/CIR.0000000000000757 health trajectories from childhood through middle age and their associa-
4. Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, Boehme tion with subclinical atherosclerosis. JAMA Cardiol. 2020;5:557–566. doi:
AK, Buxton AE, Carson AP, Commodore-Mensah Y, et al; on behalf of the 10.1001/jamacardio.2020.0140
American Heart Association Council on Epidemiology and Prevention Statis- 15. Liu M, Kou F, Yang S, Wang S, He Y, Zhang W. Ideal cardiovascular health
tics Committee and Stroke Statistics Subcommittee. Heart disease and stroke in the oldest-old and centenarians and its association with disability and
statistics—2022 update: a report from the American Heart Association. Circu- health-related quality of life. Front Cardiovasc Med. 2021;8:603877. doi:
lation. 2022;145:e153–e639. doi: 10.1161/CIR.0000000000001052 10.3389/fcvm.2021.603877
5. Huffman MD, Capewell S, Ning H, Shay CM, Ford ES, Lloyd-Jones DM. 16. Khera AV, Emdin CA, Drake I, Natarajan P, Bick AG, Cook NR, Chasman DI,
Cardiovascular health behavior and health factor changes (1988-2008) Baber U, Mehran R, Rader DJ, et al. Genetic risk, adherence to a healthy
and projections to 2020: results from the National Health and Nutri- lifestyle, and coronary disease. N Engl J Med. 2016;375:2349–2358. doi:
tion Examination Surveys. Circulation. 2012;125:2595–2602. doi: 10.1056/NEJMoa1605086
10.1161/CIRCULATIONAHA.111.070722 17. Hasbani NR, Ligthart S, Brown MR, Heath AS, Bebo A, Ashley KE,
6. Pilkerton CS, Singh SS, Bias TK, Frisbee SJ. Changes in cardiovas- Boerwinkle E, Morrison AC, Folsom AR, Aguilar D, et al. American Heart
cular health in the United States, 2003-2011. J Am Heart Assoc. Association’s Life’s Simple 7: lifestyle recommendations, polygenic risk, and
2015;4:e001650. doi: 10.1161/JAHA.114.001650 lifetime risk of coronary heart disease. Circulation. 2022;145:808–818. doi:
7. Lawrence E, Hummer RA, Harris KM. The cardiovascular health of young 10.1161/CIRCULATIONAHA.121.053730
adults: disparities along the urban-rural continuum. Ann Am Acad Pol Soc 18. Lee H, Yano Y, Cho SMJ, Lee HH, Kim DW, Lloyd-Jones DM, Kim
Sci. 2017;672:257–281. doi: 10.1177/0002716217711426 HC. Associations of ideal cardiovascular health and its change
8. Perak AM, Ning H, Khan SS, Van Horn LV, Grobman WA, Lloyd-Jones during young adulthood with premature cardiovascular events:
DM. Cardiovascular health among pregnant women, aged 20 to 44 a nationwide cohort study. Circulation. 2021;144:90–92. doi:
years, in the United States. J Am Heart Assoc. 2020;9:e015123. doi: 10.1161/CIRCULATIONAHA.121.054212
10.1161/JAHA.119.015123 19. Gaye B, Tajeu GS, Vasan RS, Lassale C, Allen NB, Singh-Manoux A,
9. Perak AM, Lancki N, Kuang A, Labarthe DR, Allen NB, Shah SH, Lowe Jouven X. Association of changes in cardiovascular health metrics and
LP, Grobman WA, Lawrence JM, Lloyd-Jones DM, et al; HAPO Follow-Up risk of subsequent cardiovascular disease and mortality. J Am Heart Assoc.
Study Cooperative Research Group. Associations of maternal cardiovascu- 2020;9:e017458. doi: 10.1161/JAHA.120.017458
lar health in pregnancy with offspring cardiovascular health in early adoles- 20. Wang L, Song L, Li D, Zhou Z, Chen S, Yang Y, Hu Y, Wang Y, Wu S, Tian
cence. JAMA. 2021;325:658–668. doi: 10.1001/jama.2021.0247 Y. Ideal cardiovascular health metric and its change with lifetime risk of

cardiovascular diseases: a prospective cohort study. J Am Heart Assoc. 35. Joyce BT, Gao T, Zheng Y, Ma J, Hwang SJ, Liu L, Nannini D, Horvath S,
2021;10:e022502. doi: 10.1161/JAHA.121.022502 Lu AT, Bai Allen N, et al. Epigenetic age acceleration reflects long-term
CLINICAL STATEMENTS
21. Bundy JD, Zhu Z, Ning H, Zhong VW, Paluch AE, Wilkins JT, Lloyd-Jones cardiovascular health. Circ Res. 2021;129:770–781. doi: 10.1161/
AND GUIDELINES
DM, Whelton PK, He J, Allen NB. Estimated impact of achieving optimal CIRCRESAHA.121.318965
cardiovascular health among US adults on cardiovascular disease events. J 36. Pottinger TD, Khan SS, Zheng Y, Zhang W, Tindle HA, Allison M, Wells
Am Heart Assoc. 2021;10:e019681. doi: 10.1161/JAHA.120.019681 G, Shadyab AH, Nassir R, Martin LW, et al. Association of cardiovascular
22. Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway health and epigenetic age acceleration. Clin Epigenetics. 2021;13:42. doi:
CW, Carson AP, Chamberlain AM, Cheng S, Delling FN, et al; on be- 10.1186/s13148-021-01028-2
half of the American Heart Association Council on Epidemiology and Pre- 37. Xanthakis V, Enserro DM, Murabito JM, Polak JF, Wollert KC, Januzzi
vention Statistics Committee and Stroke Statistics Subcommittee. Heart JL, Wang TJ, Tofler G, Vasan RS. Ideal cardiovascular health: associa-
disease and stroke statistics—2021 update: a report from the American tions with biomarkers and subclinical disease and impact on incidence
Heart Association. Circulation. 2021;143:e254–e743. doi: 10.1161/CIR. of cardiovascular disease in the Framingham Offspring Study. Circulation.
0000000000000950 2014;130:1676–1683. doi: 10.1161/CIRCULATIONAHA.114.009273
23. Rasmussen-Torvik LJ, Shay CM, Abramson JG, Friedrich CA, Nettleton 38. Gaye B, Tafflet M, Arveiler D, Montaye M, Wagner A, Ruidavets JB, Kee
JA, Prizment AE, Folsom AR. Ideal cardiovascular health is inverse- F, Evans A, Amouyel P, Ferrieres J, et al. Ideal cardiovascular health and
ly associated with incident cancer: the Atherosclerosis Risk in Com- incident cardiovascular disease: heterogeneity across event subtypes and
munities study. Circulation. 2013;127:1270–1275. doi: 10.1161/ mediating effect of blood biomarkers: the PRIME study. J Am Heart Assoc.
CIRCULATIONAHA.112.001183 2017;6:e006389. doi: 10.1161/JAHA.117.006389
24. Allen NB, Hwang S-J, Cupples LA, Levy D, Fox C, O’Donnell C, Lloyd-Jones 39. Lloyd-Jones DM. Cardiovascular health and protection against CVD:
D. The heritability of ideal cardiovascular health: the Framingham Heart more than the sum of the parts? Circulation. 2014;130:1671–1673. doi:
Study. Circulation. 2010;122:A17245–A17245. Abstract 17245. 10.1161/CIRCULATIONAHA.114.012869
25. Pahkala K, Laitinen TT, Niinikoski H, Kartiosuo N, Rovio SP, Lagström H, 40. Kim JH, Islam SJ, Topel ML, Ko YA, Mujahid MS, Vaccarino V, Liu C, Sims
Loo BM, Salo P, Jokinen E, Magnussen CG, et al. Effects of 20-year infan- M, Mubasher M, Searles CD, et al. Individual psychosocial resilience, neigh-
cy-onset dietary counselling on cardiometabolic risk factors in the Special borhood context, and cardiovascular health in Black adults: a multilevel in-
Turku Coronary Risk Factor Intervention Project (STRIP): 6-year post-investigation from the Morehouse-Emory Cardiovascular Center for Health
tervention follow-up. Lancet Child Adolesc Health. 2020;4:359–369. doi: Equity Study. Circ Cardiovasc Qual Outcomes. 2020;13:e006638. doi:
10.1016/S2352-4642(20)30059-6 10.1161/CIRCOUTCOMES.120.006638
26. Matthews LA, Rovio SP, Jaakkola JM, Niinikoski H, Lagström H, Jula A, 41. Stewart A, Barinas-Mitchell E, Matthews KA, Magnani JW, Khoudary SE, Jackson
Viikari JSA, Rönnemaa T, Simell O, Raitakari OT, et al. Longitudinal effect EA, Brooks MM. Social role stress, reward and the American Heart Association
of 20-year infancy-onset dietary intervention on food consumption and Life’s Simple 7 in midlife women: the Study of Women’s Health Across the
nutrient intake: the randomized controlled STRIP study. Eur J Clin Nutr. Nation. Abstract. Circulation. 2018;137:AMP56. Accessed February 15, 2022.
2019;73:937–949. doi: 10.1038/s41430-018-0350-4 https://www.ahajournals.org/doi/10.1161/circ.137.suppl_1.mp56
27. Allen NB, Lloyd-Jones D, Hwang SJ, Rasmussen-Torvik L, Fornage M, Morrison 42. Boehm JK, Soo J, Chen Y, Zevon ES, Hernandez R, Lloyd-Jones D, Kubzansky
AC, Baldridge AS, Boerwinkle E, Levy D, Cupples LA, et al. Genetic loci associ- LD. Psychological well-being’s link with cardiovascular health in older adults.
ated with ideal cardiovascular health: a meta-analysis of genome-wide associa- Am J Prev Med. 2017;53:791–798. doi: 10.1016/j.amepre.2017.06.028
tion studies. Am Heart J. 2016;175:112–120. doi: 10.1016/j.ahj.2015.12.022
43. Brewer LC, Redmond N, Slusser JP, Scott CG, Chamberlain AM, Djousse
28. Liu K, Daviglus ML, Loria CM, Colangelo LA, Spring B, Moller AC,
L, Patten CA, Roger VL, Sims M. Stress and achievement of cardiovascular
Lloyd-Jones DM. Healthy lifestyle through young adulthood and the pres-
health metrics: the American Heart Association Life’s Simple 7 in Blacks

ence of low cardiovascular disease risk profile in middle age: the Coronary
of the Jackson Heart Study. J Am Heart Assoc. 2018;7:e008855. doi:
Artery Risk Development in (Young) Adults (CARDIA) study. Circulation.
10.1161/JAHA.118.008855
2012;125:996–1004. doi: 10.1161/CIRCULATIONAHA.111.060681
44. Ogunmoroti O, Osibogun O, Spatz ES, Okunrintemi V, Mathews L, Ndumele
29. Spring B, Moller AC, Colangelo LA, Siddique J, Roehrig M, Daviglus ML,
CE, Michos ED. A systematic review of the bidirectional relationship
Polak JF, Reis JP, Sidney S, Liu K. Healthy lifestyle change and sub-
between depressive symptoms and cardiovascular health. Prev Med.
clinical atherosclerosis in young adults: Coronary Artery Risk Develop-
2022;154:106891. doi: 10.1016/j.ypmed.2021.106891
ment in Young Adults (CARDIA) study. Circulation. 2014;130:10–17. doi:
10.1161/CIRCULATIONAHA.113.005445 45. Winning A, McCormick MC, Glymour MM, Gilsanz P, Kubzansky LD. Child-
30. Gooding HC, Shay CM, Ning H, Gillman MW, Chiuve SE, Reis JP, Allen NB, hood psychological distress and healthy cardiovascular lifestyle 17-35 years
Lloyd-Jones DM. Optimal lifestyle components in young adulthood are associ- later: the potential role of mental health in primordial prevention. Ann Behav
ated with maintaining the ideal cardiovascular health profile into middle age. J Med. 2018;52:621–632. doi: 10.1093/abm/kax001
Am Heart Assoc. 2015;4:e002048. doi: 10.1161/JAHA.115.002048 46. Caleyachetty R, Echouffo-Tcheugui JB, Muennig P, Zhu W, Muntner P,
31. Pahkala K, Hietalampi H, Laitinen TT, Viikari JS, Rönnemaa T, Niinikoski Shimbo D. Association between cumulative social risk and ideal car-
H, Lagström H, Talvia S, Jula A, Heinonen OJ, et al. Ideal cardiovascular diovascular health in US adults: NHANES 1999-2006. Int J Cardiol.
health in adolescence: effect of lifestyle intervention and association with 2015;191:296–300. doi: 10.1016/j.ijcard.2015.05.007
vascular intima-media thickness and elasticity (the Special Turku Coronary 47. Saiz AM Jr, Aul AM, Malecki KM, Bersch AJ, Bergmans RS, LeCaire TJ,
Risk Factor Intervention Project for Children [STRIP] study). Circulation. Nieto FJ. Food insecurity and cardiovascular health: Findings from a state-
2013;127:2088–2096. doi: 10.1161/CIRCULATIONAHA.112.000761 wide population health survey in Wisconsin. Prev Med. 2016;93:1–6. doi:
32. Whitaker KM, Jacobs DR Jr, Kershaw KN, Demmer RT, Booth JN 3rd, 10.1016/j.ypmed.2016.09.002
Carson AP, Lewis CE, Goff DC Jr, Lloyd-Jones DM, Gordon-Larsen P, et 48. Foraker RE, Bush C, Greiner MA, Sims M, Henderson K, Smith S, Bidulescu
al. Racial disparities in cardiovascular health behaviors: the Coronary Artery A, Shoben AB, Hardy NC, O’Brien E. Distribution of cardiovascular
Risk Development in Young Adults Study. Am J Prev Med. 2018;55:63–71. health by individual- and neighborhood-level socioeconomic status: find-
doi: 10.1016/j.amepre.2018.03.017 ings from the Jackson Heart Study. Glob Heart. 2019;14:241–250. doi:
33. Levine GN, Cohen BE, Commodore-Mensah Y, Fleury J, Huffman JC, Khalid 10.1016/j.gheart.2019.04.007
U, Labarthe DR, Lavretsky H, Michos ED, Spatz ES, et al; on behalf of the 49. Shockey TM, Sussell AL, Odom EC. Cardiovascular health status by occupa-
American Heart Association Council on Clinical Cardiology; Council on tional group–21 states, 2013. MMWR Morb Mortal Wkly Rep. 2016;65:793–
Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovas- 798. doi: 10.15585/mmwr.mm6531a1
cular and Stroke Nursing; and Council on Lifestyle and Cardiometabolic 50. Piedra LM, Andrade FCD, Hernandez R, Perreira KM, Gallo LC, González
Health. Psychological health, well-being, and the mind-heart-body connec- HM, Gonzalez S, Cai J, Chen J, Castañeda SF, et al. Association of subjec-
tion: a scientific statement from the American Heart Association. Circulation. tive social status with Life’s Simple 7s Cardiovascular Health Index among
2021;143:e763–e783. doi: 10.1161/CIR.0000000000000947 Hispanic/Latino people: results from the HCHS/SOL. J Am Heart Assoc.
34. Churchwell K, Elkind MSV, Benjamin RM, Carson AP, Chang EK, Lawrence 2021;10:e012704. doi: 10.1161/JAHA.119.012704
W, Mills A, Odom TM, Rodriguez CJ, Rodriguez F, et al; on behalf of the 51. Islam SJ, Kim JH, Baltrus P, Topel ML, Liu C, Ko YA, Mujahid MS, Vaccarino
American Heart Association. Call to action: structural racism as a funda- V, Sims M, Mubasher M, et al. Neighborhood characteristics and ideal
mental driver of health disparities: a presidential advisory from the American cardiovascular health among Black adults: results from the Morehouse-
Heart Association. Circulation. 2020;142:e454–e468. doi: 10.1161/CIR. Emory Cardiovascular (MECA) Center for Health Equity. Ann Epidemiol.
0000000000000936 2022;65:120.e1–120.e10. doi: 10.1016/j.annepidem.2020.11.009

52. Unger E, Diez-Roux AV, Lloyd-Jones DM, Mujahid MS, Nettleton JA, health disparities in cardiovascular disease in African Americans. Ethn Dis.
Bertoni A, Badon SE, Ning H, Allen NB. Association of neighborhood 2009;19:204–208.
CLINICAL STATEMENTS
characteristics with cardiovascular health in the multi-ethnic Study of 70. Davis AM, Vinci LM, Okwuosa TM, Chase AR, Huang ES. Cardiovascular
AND GUIDELINES
Atherosclerosis. Circ Cardiovasc Qual Outcomes. 2014;7:524–531. doi: health disparities: a systematic review of health care interventions. Med Care
10.1161/CIRCOUTCOMES.113.000698 Res Rev. 2007;64(suppl):29S–100S. doi: 10.1177/1077558707305416
53. Laitinen TT, Pahkala K, Venn A, Woo JG, Oikonen M, Dwyer T, Mikkilä V, 71. Kris-Etherton PM, Petersen KS, Després JP, Braun L, de Ferranti SD, Furie
Hutri-Kähönen N, Smith KJ, Gall SL, et al. Childhood lifestyle and clinical KL, Lear SA, Lobelo F, Morris PB, Sacks FM; on behalf of the American
determinants of adult ideal cardiovascular health: the Cardiovascular Risk Heart Association Council on Lifestyle and Cardiometabolic Health; Council
in Young Finns Study, the Childhood Determinants of Adult Health Study, on Cardiovascular and Stroke Nursing; Stroke Council; Council on Clinical
the Princeton Follow-Up Study. Int J Cardiol. 2013;169:126–132. doi: Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology;
10.1016/j.ijcard.2013.08.090 and Council on Hypertension. Special considerations for healthy lifestyle
54. Matthews KA, Boylan JM, Jakubowski KP, Cundiff JM, Lee L, Pardini DA, promotion across the life span in clinical settings: a science advisory from
Jennings JR. Socioeconomic status and parenting during adolescence in the American Heart Association. Circulation. 2021;144:e515–e532. doi:
relation to ideal cardiovascular health in Black and White men. Health Psy- 10.1161/CIR.0000000000001014
chol. 2017;36:673–681. doi: 10.1037/hea0000491 72. Grandner MA, Fernandez FX. The translational neuroscience of sleep:
55. Maia DB, Marmar CR, Mendlowicz MV, Metzler T, Nóbrega A, Peres MC, a contextual framework. Science. 2021;374:568–573. doi: 10.1126/
Coutinho ES, Volchan E, Figueira I. Abnormal serum lipid profile in Bra- science.abj8188
zilian police officers with post-traumatic stress disorder. J Affect Disord. 73. Kryger MH, Roth T, Goldstein CA. Principles and Practice of Sleep Medicine.
2008;107:259–263. doi: 10.1016/j.jad.2007.08.013 Elsevier Health Sciences; 2021.
56. Schins A, Honig A, Crijns H, Baur L, Hamulyák K. Increased coronary 74. Chastin S, McGregor D, Palarea-Albaladejo J, Diaz KM, Hagströmer M,
events in depressed cardiovascular patients: 5-HT2A receptor as miss- Hallal PC, van Hees VT, Hooker S, Howard VJ, Lee IM, et al. Joint associa-
ing link? Psychosom Med. 2003;65:729–737. doi: 10.1097/01.psy. tion between accelerometry-measured daily combination of time spent in
0000088596.42029.10 physical activity, sedentary behaviour and sleep and all-cause mortality: a
57. von Känel R, Hepp U, Buddeberg C, Keel M, Mica L, Aschbacher K, pooled analysis of six prospective cohorts using compositional analysis. Br J
Schnyder U. Altered blood coagulation in patients with posttraumatic Sports Med. 2021;55:1277–1285. doi: 10.1136/bjsports-2020-102345
stress disorder. Psychosom Med. 2006;68:598–604. doi: 10.1097/01.psy. 75. Pienaar PR, Kolbe-Alexander TL, van Mechelen W, Boot CRL, Roden LC,
0000221229.43272.9d Lambert EV, Rae DE. Associations between self-reported sleep duration and
58. Slavich GM, Irwin MR. From stress to inflammation and major depressive mortality in employed individuals: systematic review and meta-analysis. Am J
disorder: a social signal transduction theory of depression. Psychol Bull. Health Promot. 2021;35:853–865. doi: 10.1177/0890117121992288
2014;140:774–815. doi: 10.1037/a0035302 76. He M, Deng X, Zhu Y, Huan L, Niu W. The relationship between sleep
59. Sumner JA, Nishimi KM, Koenen KC, Roberts AL, Kubzansky LD. Posttrau- duration and all-cause mortality in the older people: an updated and
matic stress disorder and inflammation: untangling issues of bidirectionality. dose-response meta-analysis. BMC Public Health. 2020;20:1179. doi:
Biol Psychiatry. 2020;87:885–897. doi: 10.1016/j.biopsych.2019.11.005 10.1186/s12889-020-09275-3
60. Di Thiene D, Marceca M. Closing the gap in a generation: health equity 77. García-Perdomo HA, Zapata-Copete J, Rojas-Cerón CA. Sleep duration and
through action on the social determinants of health: a challenge for the risk of all-cause mortality: a systematic review and meta-analysis. Epidemiol
international community [in Italian]. Ann Ig. 2008;20:595–601. Psychiatr Sci. 2019;28:578–588. doi: 10.1017/S2045796018000379
61. Havranek EP, Mujahid MS, Barr DA, Blair IV, Cohen MS, Cruz-Flores S, 78. Yin J, Jin X, Shan Z, Li S, Huang H, Li P, Peng X, Peng Z, Yu K, Bao W,
Davey-Smith G, Dennison-Himmelfarb CR, Lauer MS, Lockwood DW, et al. Relationship of sleep duration with all-cause mortality and cardio-
et al; on behalf of the American Heart Association Council on Quality vascular events: a systematic review and dose-response meta-analysis
of Care and Outcomes Research, Council on Epidemiology and Preven- of prospective cohort studies. J Am Heart Assoc. 2017;6:e005947. doi:
tion, Council on Cardiovascular and Stroke Nursing, Council on Lifestyle 10.1161/JAHA.117.005947
and Cardiometabolic Health, and Stroke Council. Social determinants of 79. Liu TZ, Xu C, Rota M, Cai H, Zhang C, Shi MJ, Yuan RX, Weng H, Meng XY,
risk and outcomes for cardiovascular disease: a scientific statement from Kwong JS, et al. Sleep duration and risk of all-cause mortality: a flexible,
the American Heart Association. Circulation. 2015;132:873–898. doi: non-linear, meta-regression of 40 prospective cohort studies. Sleep Med
10.1161/CIR.0000000000000228 Rev. 2017;32:28–36. doi: 10.1016/j.smrv.2016.02.005
62. US Department of Health and Human Services. Social determinants of 80. Shen X, Wu Y, Zhang D. Nighttime sleep duration, 24-hour sleep duration
health: Healthy People 2020. Accessed January 30, 2022. https://www. and risk of all-cause mortality among adults: a meta-analysis of prospective
healthypeople.gov/2020/topics-objectives/topic/social-determinants-of- cohort studies. Sci Rep. 2016;6:21480. doi: 10.1038/srep21480
health 81. Cappuccio FP, D’Elia L, Strazzullo P, Miller MA. Sleep duration and all-cause
63. Diaz CL, Shah NS, Lloyd-Jones DM, Khan SS. State of the nation’s cardiovas- mortality: a systematic review and meta-analysis of prospective studies.
cular health and targeting health equity in the United States: a narrative re- Sleep. 2010;33:585–592. doi: 10.1093/sleep/33.5.585
view. JAMA Cardiol. 2021;6:963–970. doi: 10.1001/jamacardio.2021.1137 82. Gallicchio L, Kalesan B. Sleep duration and mortality: a system-
64. Gao X, Kershaw KN, Barber S, Schreiner PJ, Do DP, Diez Roux AV, Mujahid atic review and meta-analysis. J Sleep Res. 2009;18:148–158. doi:
MS. Associations between residential segregation and incident hyper- 10.1111/j.1365-2869.2008.00732.x
tension: the Multi-Ethnic Study of Atherosclerosis. J Am Heart Assoc. 83. Grandner MA, Hale L, Moore M, Patel NP. Mortality associated with short
2022;11:e023084. doi: 10.1161/JAHA.121.023084 sleep duration: the evidence, the possible mechanisms, and the future. Sleep
65. Lloyd-Jones DM, Elkind M, Albert MA. American Heart Association’s 2024 Med Rev. 2010;14:191–203. doi: 10.1016/j.smrv.2009.07.006
Impact Goal: every person deserves the opportunity for a full, healthy life. 84. Grandner MA. Sleep, health, and society. Sleep Med Clin. 2020;15:319–
Circulation. 2021;144:e277–e279. doi: 10.1161/CIRCULATIONAHA. 340. doi: 10.1016/j.jsmc.2020.02.017
121.057617 85. Paudel ML, Taylor BC, Ancoli-Israel S, Blackwell T, Stone KL, Tranah G,
66. Angell SY, McConnell MV, Anderson CAM, Bibbins-Domingo K, Boyle Redline S, Cummings SR, Ensrud KE; Osteoporotic Fractures in Men
DS, Capewell S, Ezzati M, de Ferranti S, Gaskin DJ, Goetzel RZ, et al. The (MrOS) Study. Rest/activity rhythms and mortality rates in older men:
American Heart Association 2030 Impact Goal: a presidential advisory from MrOS Sleep Study. Chronobiol Int. 2010;27:363–377. doi: 10.3109/
the American Heart Association. Circulation. 2020;141:e120–e138. doi: 07420520903419157
10.1161/CIR.0000000000000758 86. Hossin MZ. From habitual sleep hours to morbidity and mortality: exist-
67. Health, United States, 2011: With Special Feature on Socioeconomic Status ing evidence, potential mechanisms, and future agenda. Sleep Health.
and Health. National Center for Health Statistics; 2012. 2016;2:146–153. doi: 10.1016/j.sleh.2016.01.006
68. Purnell TS, Calhoun EA, Golden SH, Halladay JR, Krok-Schoen JL, 87. Buysse DJ. Sleep health: can we define it? Does it matter? Sleep.
Appelhans BM, Cooper LA. Achieving health equity: closing the gaps in 2014;37:9–17. doi: 10.5665/sleep.3298
health care disparities, interventions, and research. Health Aff (Millwood). 88. Yang X, Chen H, Li S, Pan L, Jia C. Association of sleep duration with
2016;35:1410–1415. doi: 10.1377/hlthaff.2016.0158 the morbidity and mortality of coronary artery disease: a meta-analysis
69. Crook ED, Bryan NB, Hanks R, Slagle ML, Morris CG, Ross MC, Torres HM, of prospective studies. Heart Lung Circ. 2015;24:1180–1190. doi:
Williams RC, Voelkel C, Walker S, et al. A review of interventions to reduce 10.1016/j.hlc.2015.08.005

89. Itani O, Jike M, Watanabe N, Kaneita Y. Short sleep duration and health 109. Tubbs AS, Ghani SB, Valencia D, Jean-Louis G, Killgore WDS, Fernandez
outcomes: a systematic review, meta-analysis, and meta-regression. Sleep F-X, Grandner MA. Racial/ethnic minorities have greater declines in sleep
CLINICAL STATEMENTS
Med. 2017;32:246–256. doi: 10.1016/j.sleep.2016.08.006 duration with higher risk of cardiometabolic disease: an analysis of the U.S.
AND GUIDELINES
90. Grandner MA. Sleep and obesity risk in adults: possible mechanisms; con- National Health Interview Survey. Sleep Epidemiol. 2022;2:100022. doi:
textual factors; and implications for research, intervention, and policy. Sleep 10.1016/j.sleepe.2022.100022
Health. 2017;3:393–400. doi: 10.1016/j.sleh.2017.07.014 110. Makarem N, Castro-Diehl C, St-Onge M-P, Redline S, Shea S, Lloyd-Jones
91. St-Onge MP, Grandner MA, Brown D, Conroy MB, Jean-Louis G, Coons M, DM, Ning H, Aggarwal B. The role of sleep as a cardiovascular health met-
Bhatt DL; on behalf of the American Heart Association Obesity, Behavior ric: does it improve cardiovascular disease risk prediction? Results from the
Change, Diabetes, and Nutrition Committees of the Council on Lifestyle Multi-Ethnic Study of Atherosclerosis. Abstract. Circulation. 2020;141:A36.
and Cardiometabolic Health; Council on Cardiovascular Disease in the Accessed February 15, 2022. https://www.ahajournals.org/doi/10.1161/
Young; Council on Clinical Cardiology; and Stroke Council. Sleep dura- circ.141.suppl_1.36
tion and quality: impact on lifestyle behaviors and cardiometabolic health: 111. Hertenstein E, Feige B, Gmeiner T, Kienzler C, Spiegelhalder K, Johann
a scientific statement from the American Heart Association. Circulation. A, Jansson-Fröjmark M, Palagini L, Rücker G, Riemann D, et al. Insomnia
2016;134:e367–e386. doi: 10.1161/CIR.0000000000000444 as a predictor of mental disorders: a systematic review and meta-analysis.
92. Grandner MA, Seixas A, Shetty S, Shenoy S. Sleep duration and diabe- Sleep Med Rev. 2019;43:96–105. doi: 10.1016/j.smrv.2018.10.006
tes risk: population trends and potential mechanisms. Curr Diab Rep. 112. Baglioni C, Nanovska S, Regen W, Spiegelhalder K, Feige B, Nissen C,
2016;16:106. doi: 10.1007/s11892-016-0805-8 Reynolds CF, Riemann D. Sleep and mental disorders: a meta-analysis
93. Che T, Yan C, Tian D, Zhang X, Liu X, Wu Z. The association between sleep of polysomnographic research. Psychol Bull. 2016;142:969–990. doi:
and metabolic syndrome: a systematic review and meta-analysis. Front 10.1037/bul0000053
Endocrinol (Lausanne). 2021;12:773646. doi: 10.3389/fendo.2021.773646 113. Tubbs AS, Gallagher R, Perlis ML, Hale L, Branas C, Barrett M, Gehrels JA,
94. Bock JM, Vungarala S, Covassin N, Somers VK. Sleep duration and hy- Alfonso-Miller P, Grandner MA. Relationship between insomnia and de-
pertension: epidemiological evidence and underlying mechanisms. Am J pression in a community sample depends on habitual sleep duration. Sleep
Hypertens. 2022;35:3–11. doi: 10.1093/ajh/hpab146 Biol Rhythms. 2020;18:143–153. doi: 10.1007/s41105-020-00255-z
95. Makarem N, Alcántara C, Williams N, Bello NA, Abdalla M. Effect of sleep 114. Hall MH, Brindle RC, Buysse DJ. Sleep and cardiovascular disease: emerg-
disturbances on blood pressure. Hypertension. 2021;77:1036–1046. doi: ing opportunities for psychology. Am Psychol. 2018;73:994–1006. doi:
10.1161/HYPERTENSIONAHA.120.14479 10.1037/amp0000362
96. Makarem N, Shechter A, Carnethon MR, Mullington JM, Hall MH, Abdalla M. 115. Etindele Sosso FA, Holmes SD, Weinstein AA. Influence of socioeco-
Sleep duration and blood pressure: recent advances and future directions. nomic status on objective sleep measurement: a systematic review and
Curr Hypertens Rep. 2019;21:33. doi: 10.1007/s11906-019-0938-7 meta-analysis of actigraphy studies. Sleep Health. 2021;7:417–428. doi:
97. Lu H, Yang Q, Tian F, Lyu Y, He H, Xin X, Zheng X. A meta-analy- 10.1016/j.sleh.2021.05.005
sis of a cohort study on the association between sleep duration and 116. Tomfohr-Madsen L, Cameron EE, Dhillon A, MacKinnon A, Hernandez
type 2 diabetes mellitus. J Diabetes Res. 2021;2021:8861038. doi: L, Madigan S, Tough S. Neighborhood socioeconomic status and child
10.1155/2021/8861038 sleep duration: a systematic review and meta-analysis. Sleep Health.
98. Anothaisintawee T, Reutrakul S, Van Cauter E, Thakkinstian A. Sleep dis- 2020;6:550–562. doi: 10.1016/j.sleh.2020.02.012
turbances compared to traditional risk factors for diabetes development: 117. Chattu VK, Chattu SK, Spence DW, Manzar MD, Burman D, Pandi-Perumal
Systematic review and meta-analysis. Sleep Med Rev. 2016;30:11–24. SR. Do disparities in sleep duration among racial and ethnic minorities
doi: 10.1016/j.smrv.2015.10.002 contribute to differences in disease prevalence? J Racial Ethn Health
99. Antza C, Kostopoulos G, Mostafa S, Nirantharakumar K, Tahrani A. The Disparities. 2019;6:1053–1061. doi: 10.1007/s40615-019-00607-7
links between sleep duration, obesity and type 2 diabetes mellitus. J 118. Rangaraj VR, Knutson KL. Association between sleep deficiency and
Endocrinol. 2021;252:125–141. doi: 10.1530/JOE-21-0155 cardiometabolic disease: implications for health disparities. Sleep Med.
100. Barragán R, Zuraikat FM, Tam V, Scaccia S, Cochran J, Li S, Cheng B, 2016;18:19–35. doi: 10.1016/j.sleep.2015.02.535
St-Onge MP. Actigraphy-derived sleep is associated with eating behavior 119. Grandner MA, Williams NJ, Knutson KL, Roberts D, Jean-Louis G.
characteristics. Nutrients. 2021;13:852. doi: 10.3390/nu13030852 Sleep disparity, race/ethnicity, and socioeconomic position. Sleep Med.
101. Makarem N, Sears DD, St-Onge MP, Zuraikat FM, Gallo LC, Talavera GA, 2016;18:7–18. doi: 10.1016/j.sleep.2015.01.020
Castaneda SF, Lai Y, Mi J, Aggarwal B. Habitual nightly fasting duration, 120. Jackson CL, Walker JR, Brown MK, Das R, Jones NL. A workshop re-
eating timing, and eating frequency are associated with cardiometabolic port on the causes and consequences of sleep health disparities. Sleep.
risk in women. Nutrients. 2020;12:E3043. doi: 10.3390/nu12103043 2020;43:zsaa037. doi: 10.1093/sleep/zsaa037
102. St-Onge MP, Zuraikat FM. Reciprocal roles of sleep and diet in cardiovas- 121. American Academy of Pediatrics. Healthy sleep habits: how many hours
cular health: a review of recent evidence and a potential mechanism. Curr does your child need? 2016. Accessed January 28, 2022. https://www.
Atheroscler Rep. 2019;21:11. doi: 10.1007/s11883-019-0772-z healthychildren.org/English/healthy-living/sleep/Pages/healthy-sleep-
103. Tracy EL, Reid KJ, Baron KG. The relationship between sleep and physi- habits-how-many-hours-does-your-child-need.aspx
cal activity: the moderating role of daily alcohol consumption. Sleep. 122. Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D,
2021;44:zsab112. doi: 10.1093/sleep/zsab112 Dinges DF, Gangwisch J, Grandner MA, Kushida C, et al. Recommended
104. Baron KG, Reid KJ, Zee PC. Exercise to improve sleep in insomnia: explo- amount of sleep for a healthy adult: a joint consensus statement of the
ration of the bidirectional effects. J Clin Sleep Med. 2013;9:819–824. doi: American Academy of Sleep Medicine and Sleep Research Society. Sleep.
10.5664/jcsm.2930 2015;38:843–844. doi: 10.5665/sleep.4716
105. Rosenberger ME, Fulton JE, Buman MP, Troiano RP, Grandner MA, Buchner 123. Hirshkowitz M, Whiton K, Albert SM, Alessi C, Bruni O, DonCarlos L, Hazen
DM, Haskell WL. The 24-hour activity cycle: a new paradigm for physi- N, Herman J, Adams Hillard PJ, Katz ES, et al. National Sleep Foundation’s
cal activity. Med Sci Sports Exerc. 2019;51:454–464. doi: 10.1249/MSS. updated sleep duration recommendations: final report. Sleep Health.
0000000000001811 2015;1:233–243. doi: 10.1016/j.sleh.2015.10.004
106. Patterson F, Grandner MA, Malone SK, Rizzo A, Davey A, Edwards DG. 124. Paruthi S, Brooks LJ, D’Ambrosio C, Hall WA, Kotagal S, Lloyd RM,
Sleep as a target for optimized response to smoking cessation treatment. Malow BA, Maski K, Nichols C, Quan SF, et al. Recommended amount of
Nicotine Tob Res. 2019;21:139–148. doi: 10.1093/ntr/ntx236 sleep for pediatric populations: a consensus statement of the American
107. Catoire S, Nourredine M, Lefebvre S, Couraud S, Gronfier C, Rey R, Academy of Sleep Medicine. J Clin Sleep Med. 2016;12:785–786. doi:
Peter-Derex L, Geoffroy PA, Rolland B. Tobacco-induced sleep dis- 10.5664/jcsm.5866
turbances: a systematic review and meta-analysis. Sleep Med Rev. 125. National Heart, Lung, and Blood Institute. The heart truth. Accessed January
2021;60:101544. doi: 10.1016/j.smrv.2021.101544 10, 2022. https://www.nhlbi.nih.gov/health-topics/education-and-
108. Makarem N, St-Onge MP, Liao M, Lloyd-Jones DM, Aggarwal B. awareness/heart-truth
Association of sleep characteristics with cardiovascular health among 126. Eunice Kennedy Shriver National Institute of Child Health and Human
women and differences by race/ethnicity and menopausal status: findings Development. How much sleep do I need? Accessed January 31, 2022.
from the American Heart Association Go Red for Women Strategically https://www.nichd.nih.gov/health/topics/sleep/conditioninfo/how-much
Focused Research Network. Sleep Health. 2019;5:501–508. doi: 127. American Heart Association. Go Red for Women. 2022. Accessed January
10.1016/j.sleh.2019.05.005 10, 2022. https://www.goredforwomen.org/

128. Hale L, Troxel W, Buysse DJ. Sleep health: an opportunity for public health 140. Fleurence RL, Curtis LH, Califf RM, Platt R, Selby JV, Brown JS. Launching
to address health equity. Annu Rev Public Health. 2020;41:81–99. doi: PCORnet, a national patient-centered clinical research network. J Am Med
CLINICAL STATEMENTS
10.1146/annurev-publhealth-040119-094412 Inform Assoc. 2014;21:578–582. doi: 10.1136/amiajnl-2014-002747
AND GUIDELINES
129. Alvarez GG, Ayas NT. The impact of daily sleep duration on health: a 141. Klompas M, Cocoros NM, Menchaca JT, Erani D, Hafer E, Herrick B,
review of the literature. Prog Cardiovasc Nurs. 2004;19:56–59. doi: Josephson M, Lee M, Payne Weiss MD, Zambarano B, et al. State and local
10.1111/j.0889-7204.2004.02422.x chronic disease surveillance using electronic health record systems. Am J
129a. Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, Public Health. 2017;107:1406–1412. doi: 10.2105/AJPH.2017.303874
Braun LT, de Ferranti S, Faiella-Tommasino J, Forman DE, et al. 2018 AHA/ 142. Lobelo F, Rohm Young D, Sallis R, Garber MD, Billinger SA, Duperly J,
ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/ Hutber A, Pate RR, Thomas RJ, Widlansky ME, et al; on behalf of the
PCNA guideline on the management of blood cholesterol: a report of the American Heart Association Physical Activity Committee of the Council
American College of Cardiology/American Heart Association Task Force on Lifestyle and Cardiometabolic Health; Council on Epidemiology
on Clinical Practice Guidelines. Circulation. 2019;139:e1082–e1143. doi: and Prevention; Council on Clinical Cardiology; Council on Genomic
10.1161/CIR.0000000000000625 and Precision Medicine; Council on Cardiovascular Surgery and
129b. American Diabetes Association. Practice Guidelines Resources. Accessed Anesthesia; and Stroke Council. Routine assessment and promotion of
February 15, 2022. https://professional.diabetes.org/content-page/ physical activity in healthcare settings: a scientific statement from the
practice-guidelines-resources American Heart Association. Circulation. 2018;137:e495–e522. doi:
129c. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison 10.1161/CIR.0000000000000559
Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, et al. 143. Montgomery RM, Boucher EM, Honomichl RD, Powell TA, Guyton SL,
2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/ Bernecker SL, Stoeckl SE, Parks AC. the effects of a digital men-
PCNA guideline for the prevention, detection, evaluation, and manage- tal health intervention in adults with cardiovascular disease risk factors:
ment of high blood pressure in adults: a report of the American College analysis of real-world user data. JMIR Cardio. 2021;5:e32351. doi:
of Cardiology/American Heart Association Task Force on Clinical 10.2196/32351
Practice Guidelines [published correction appears in Hypertension. 144. Burke LE, Ma J, Azar KM, Bennett GG, Peterson ED, Zheng Y, Riley W,
2018;71:e140–e144]. Hypertension. 2018;71:e13–e115. doi: 10.1161/ Stephens J, Shah SH, Suffoletto B, et al; on behalf of the American Heart
HYP.0000000000000065 Association Publications Committee of the Council on Epidemiology and
130. Mellen PB, Gao SK, Vitolins MZ, Goff DC Jr. Deteriorating dietary hab- Prevention, Behavior Change Committee of the Council on Cardiometabolic
its among adults with hypertension: DASH dietary accordance, NHANES Health, Council on Cardiovascular and Stroke Nursing, Council on
1988-1994 and 1999-2004. Arch Intern Med. 2008;168:308–314. doi: Functional Genomics and Translational Biology, Council on Quality of Care
10.1001/archinternmed.2007.119 and Outcomes Research, and Stroke Council. Current science on consum-
131. Gao S. Diet and Exercise: Behavioral Management of Hypertension and er use of mobile health for cardiovascular disease prevention: a scientific
Diabetes [dissertation]. Seattle: University of Washington, 2006. statement from the American Heart Association [published correction ap-
132. Cerwinske LA, Rasmussen HE, Lipson S, Volgman AS, Tangney CC. pears in Circulation. 2015;132:e233]. Circulation. 2015;132:1157–1213.
Evaluation of a dietary screener: the Mediterranean Eating Pattern for doi: 10.1161/CIR.0000000000000232
Americans tool. J Hum Nutr Diet. 2017;30:596–603. doi: 10.1111/ 145. Kozik M, Isakadze N, Martin SS. Mobile health in preventive cardiology: cur-
jhn.12451 rent status and future perspective. Curr Opin Cardiol. 2021;36:580–588.
133. National Health and Nutrition Examination Survey. Physical activity and doi: 10.1097/HCO.0000000000000891
physical fitness: PAQ-K. 2019. Accessed February 15, 2022. https:// 146. Schorr EN, Gepner AD, Dolansky MA, Forman DE, Park LG, Petersen
wwwn.cdc.gov/nchs/data/nhanes/2019-2020/questionnaires/PAQ_K. KS, Still CH, Wang TY, Wenger NK; on behalf of the American Heart
pdf Association Cardiovascular Disease in Older Populations Committee of

134. National Health and Nutrition Examination Survey. Smoking and tobacco the Council on Clinical Cardiology and Council on Cardiovascular and
use: SMQ. 2015. Accessed February 15, 2022. https://wwwn.cdc.gov/ Stroke Nursing; Council on Arteriosclerosis, Thrombosis and Vascular
nchs/data/nhanes/2015-2016/questionnaires/SMQ_I.pdf Biology; and Council on Lifestyle and Cardiometabolic Health. Harnessing
135. Raghuveer G, White DA, Hayman LL, Woo JG, Villafane J, Celermajer D, mobile health technology for secondary cardiovascular disease pre-
Ward KD, de Ferranti SD, Zachariah J; on behalf of the American Heart vention in older adults: a scientific statement from the American Heart
Association Committee on Atherosclerosis, Hypertension, and Obesity Association. Circ Cardiovasc Qual Outcomes. 2021;14:e000103. doi:
in the Young of the Council on Cardiovascular Disease in the Young; 10.1161/HCQ.0000000000000103
Behavior Change for Improving Health Factors Committee of the Council 147. Foraker RE, Benziger CP, DeBarmore BM, Cené CW, Loustalot F, Khan Y,
on Lifestyle and Cardiometabolic Health and Council on Epidemiology Anderson CAM, Roger VL; on behalf of the American Heart Association
and Prevention; and Stroke Council. Cardiovascular consequences of Council on Epidemiology and Prevention; Council on Arteriosclerosis,
childhood secondhand tobacco smoke exposure: prevailing evidence, Thrombosis and Vascular Biology; and Council on Lifestyle and
burden, and racial and socioeconomic disparities: a scientific statement Cardiometabolic Health. Achieving optimal population cardiovascular
from the American Heart Association [published correction appears in health requires an interdisciplinary team and a learning healthcare system:
Circulation. 2016;134:e366]. Circulation. 2016;134:e336–e359. doi: a scientific statement from the American Heart Association. Circulation.
10.1161/CIR.0000000000000443 2021;143:e9–e18. doi: 10.1161/CIR.0000000000000913
136. US Department of Agriculture. Healthy Eating Index (HEI). 2020. Accessed 148. Bombard Y, Baker GR, Orlando E, Fancott C, Bhatia P, Casalino S,
January 27, 2022. https://www.fns.usda.gov/healthy-eating-index-hei Onate K, Denis JL, Pomey MP. Engaging patients to improve qual-
137. Bhatnagar A, Whitsel LP, Ribisl KM, Bullen C, Chaloupka F, Piano ity of care: a systematic review. Implement Sci. 2018;13:98. doi:
MR, Robertson RM, McAuley T, Goff D, Benowitz N; on behalf of the 10.1186/s13012-018-0784-z
American Heart Association Advocacy Coordinating Committee, Council 149. Brewer LC, Fortuna KL, Jones C, Walker R, Hayes SN, Patten CA, Cooper
on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, LA. Back to the future: achieving health equity through health infor-
and Council on Quality of Care and Outcomes Research. Electronic ciga- matics and digital health. JMIR Mhealth Uhealth. 2020;8:e14512. doi:
rettes: a policy statement from the American Heart Association. Circulation. 10.2196/14512
2014;130:1418–1436. doi: 10.1161/CIR.0000000000000107 150. McManus RJ, Mant J, Franssen M, Nickless A, Schwartz C, Hodgkinson
138. Bhatnagar A, Whitsel LP, Blaha MJ, Huffman MD, Krishan-Sarin S, Maa J, Bradburn P, Farmer A, Grant S, Greenfield SM, et al; TASMINH4
J, Rigotti N, Robertson RM, Warner JJ. New and emerging tobacco prod- Investigators. Efficacy of self-monitored blood pressure, with or without
ucts and the nicotine endgame: the role of robust regulation and com- telemonitoring, for titration of antihypertensive medication (TASMINH4):
prehensive tobacco control and prevention: a presidential advisory from an unmasked randomised controlled trial. Lancet. 2018;391:949–959.
the American Heart Association. Circulation. 2019;139:e937–e958. doi: doi: 10.1016/S0140-6736(18)30309-X
10.1161/CIR.0000000000000669 151. Warner JJ, Benjamin IJ, Churchwell K, Firestone G, Gardner TJ, Johnson
139. Centers for Disease Control and Prevention, Office on Smoking and Health. JC, Ng-Osorio J, Rodriguez CJ, Todman L, Yaffe K, et al; on behalf of the
Health effects of secondhand smoke. 2020. Accessed April 26, 2022. American Heart Association Advocacy Coordinating Committee. Advancing
https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_ healthcare reform: the American Heart Association’s 2020 statement
smoke/health_effects/index.htm of principles for adequate, accessible, and affordable health care: a

presidential advisory from the American Heart Association. Circulation. 167. Maier M. Investing in the early care and education workforce. 2020.
2020;141:e601–e614. doi: 10.1161/CIR.0000000000000759 Accessed February 10, 2022. https://www.mdrc.org/publication/
CLINICAL STATEMENTS
152. Roger VL, Sidney S, Fairchild AL, Howard VJ, Labarthe DR, Shay CM, investing-early-care-and-education-workforce#:~:text=Inadequate%20
AND GUIDELINES
Tiner AC, Whitsel LP, Rosamond WD; on behalf of the American Heart compensation%3B%20demanding%2C%20often%20stressful%20
Association Advocacy Coordinating Committee. Recommendations for working%20conditions%3B%20and,and%20turnover%20that%20
cardiovascular health and disease surveillance for 2030 and beyond: are%20exacerbated%20by%20the%20pandemic
a policy statement from the American Heart Association. Circulation. 168. US Department of Health and Human Services, Administration for Children
2020;141:e104–e119. doi: 10.1161/CIR.0000000000000756 and Families: Office of Child Care. Federal and state funding for child care
153. Hagan CN, Holubowich EJ, Criss T; Council of State and Territorial and early learning. 2014. Accessed June 1, 2022. https://childcareta.acf.
Epidemiologists. Driving public health in the fast lane: the urgent need for hhs.gov/sites/default/files/public/federal_and_state_funding_for_child_
a 21st century data superhighway. 2019. Accessed June 1, 2022. https:// care_and_early_learning_edited.pdf
debeaumont.org/wp-content/uploads/2019/09/DSI-White-Paper_v15- 169. Impact of the COVID-19 pandemic on early childhood care and education.
Spreads.pdf Early Child Educ J. 2020;48:533–536. doi: 10.1007/s10643-020-01082-0
154. US Food and Drug Administration. Premarket tobacco product appli- 170. Bala MM, Strzeszynski L, Topor-Madry R. Mass media interven-
cations. 2022. https://www.fda.gov/tobacco-products/market-and- tions for smoking cessation in adults. Cochrane Database Syst Rev.
distribute-tobacco-product/premarket-tobacco-product-applications 2017;11:CD004704. doi: 10.1002/14651858.CD004704.pub4
Accessed February 10, 2022. 171. von Philipsborn P, Stratil JM, Burns J, Busert LK, Pfadenhauer LM, Polus
155. Jordt SE. Synthetic nicotine has arrived [published online September 7, S, Holzapfel C, Hauner H, Rehfuess E. Environmental interventions to
2021]. Tob Control. doi: 10.1136/tobaccocontrol-2021-056626. https:// reduce the consumption of sugar-sweetened beverages and their ef-
tobaccocontrol.bmj.com/content/early/2021/09/07/tobaccocon- fects on health. Cochrane Database Syst Rev. 2019;6:CD012292. doi:
trol-2021-056626.long 10.1002/14651858.CD012292.pub2
156. American Heart Association. New and emerging tobacco products and the 172. Reynolds AJ, Ou SR, Eales L, Mondi CF, Giovanelli A. Assessment of a
nicotine endgame: the role of robust regulation and comprehensive to- comprehensive early childhood education program and cardiovascu-
bacco control and prevention. 2019. Accessed June 1, 2022. https://www. lar disease risk in midlife. JAMA Netw Open. 2021;4:e2120752. doi:
heart.org/-/media/Files/About-Us/Policy-Research/Policy-Positions/ 10.1001/jamanetworkopen.2021.20752
Tobacco-and-Clean-Air/New-and-Emerging-Tobacco-Products-and-the- 173. MacArthur G, Caldwell DM, Redmore J, Watkins SH, Kipping R, White
Nicotine-Endgame--Policy-In-Brief.pdf J, Chittleborough C, Langford R, Er V, Lingam R, et al. Individual-, fam-
157. Young DR, Cradock AL, Eyler AA, Fenton M, Pedroso M, Sallis JF, Whitsel ily-, and school-level interventions targeting multiple risk behaviours in
LP; on behalf of the American Heart Association Advocacy Coordinating young people. Cochrane Database Syst Rev. 2018;10:CD009927. doi:
Committee. Creating built environments that expand active transporta- 10.1002/14651858.CD009927.pub2
tion and active living across the United States: a policy statement from 174. Wolfenden L, Nathan NK, Sutherland R, Yoong SL, Hodder RK, Wyse RJ,
the American Heart Association. Circulation. 2020;142:e167–e183. doi: Delaney T, Grady A, Fielding A, Tzelepis F, et al. Strategies for enhancing the
10.1161/CIR.0000000000000878 implementation of school-based policies or practices targeting risk factors
158. Stecker EC, Ayanian JZ, Fendrick AM. Value-based insurance de- for chronic disease. Cochrane Database Syst Rev. 2017;11:CD011677.
sign: aligning incentives to improve cardiovascular care. Circulation. doi: 10.1002/14651858.CD011677.pub2
2015;132:1580–1585. doi: 10.1161/CIRCULATIONAHA.114.012584 175. American Heart Association. Workplace health playbook. Accessed
159. Joynt Maddox KE, Bleser WK, Das SR, Desai NR, Ng-Osorio J, O’Brien January 30, 2022. https://playbook.heart.org/
E, Psotka MA, Wadhera RK, Weintraub WS, Konig M. Value in Healthcare 176. Foraker RE, Shoben AB, Kelley MM, Lai AM, Lopetegui MA, Jackson
Initiative: summary and key recommendations. Circ Cardiovasc Qual RD, Langan MA, Payne PR. Electronic health record-based assessment
Outcomes. 2020;13:e006612. doi: 10.1161/CIRCOUTCOMES.120. of cardiovascular health: the Stroke Prevention in Healthcare Delivery
006612 Environments (SPHERE) study. Prev Med Rep. 2016;4:303–308. doi:
160. Buchmueller TC, Cliff BQ, Levy H. The benefits of Medicaid expan- 10.1016/j.pmedr.2016.07.006
sion. JAMA Health Forum. 2020;1:e200879–e200879. doi:10.1001/ 177. Seguin RA, Paul L, Folta SC, Nelson ME, Strogatz D, Graham ML,
jamahealthforum.2020.0879 Diffenderfer A, Eldridge G, Parry SA. Strong Hearts, Healthy Communities:
161. Mehta LS, Sharma G, Creanga AA, Hameed AB, Hollier LM, Johnson a community-based randomized trial for rural women. Obesity (Silver
JC, Leffert L, McCullough LD, Mujahid MS, Watson K, et al; on behalf of Spring). 2018;26:845–853. doi: 10.1002/oby.22158
the American Heart Association Advocacy Coordinating Committee. Call 178. Seguin-Fowler RA, Strogatz D, Graham ML, Eldridge GD, Marshall GA,
to action: maternal health and saving mothers: a policy statement from Folta SC, Pullyblank K, Nelson ME, Paul L. The Strong Hearts, Healthy
the American Heart Association. Circulation. 2021;144:e251–e269. doi: Communities Program 2.0: an RCT examining effects on Simple 7. Am J
10.1161/CIR.0000000000001000 Prev Med. 2020;59:32–40. doi: 10.1016/j.amepre.2020.01.027
162. Shimbo D, Artinian NT, Basile JN, Krakoff LR, Margolis KL, Rakotz MK, 179. Armstrong SC, Windom M, Bihlmeyer NA, Li JS, Shah SH, Story M, Zucker
Wozniak G; on behalf of the American Heart Association and the N, Kraus WE, Pagidipati N, Peterson E, et al. Rationale and design of
American Medical Association. Self-measured blood pressure moni- “Hearts & Parks”: study protocol for a pragmatic randomized clinical trial of
toring at home: a joint policy statement from the American Heart an integrated clinic-community intervention to treat pediatric obesity. BMC
Association and American Medical Association [published correction ap- Pediatr. 2020;20:308. doi: 10.1186/s12887-020-02190-x
pears in Circulation. 2020;142:e64]. Circulation. 2020;142:e42–e63. doi: 180. Dunn CG, Wilcox S, Saunders RP, Kaczynski AT, Blake CE, Turner-
10.1161/CIR.0000000000000803 McGrievy GM. Healthy eating and physical activity interventions in faith-
163. Ward B; The Commonwealth Fund. The impact of Medicaid expan- based settings: a systematic review using the reach, effectiveness/
sion on states’ budgets. 2020. Accessed June 1, 2022. https:// efficacy, adoption, implementation, maintenance framework. Am J Prev
www.commonwealthfund.org/publications/issue-briefs/2020/may/ Med. 2021;60:127–135. doi: 10.1016/j.amepre.2020.05.014
impact-medicaid-expansion-states-budgets 181. Linnan LA, D’Angelo H, Harrington CB. A literature synthesis of health pro-
164. Lee Y, Mozaffarian D, Sy S, Liu J, Wilde PE, Marklund M, Abrahams-Gessel motion research in salons and barbershops. Am J Prev Med. 2014;47:77–
S, Gaziano TA, Micha R. Health impact and cost-effectiveness of volume, 85. doi: 10.1016/j.amepre.2014.02.007
tiered, and absolute sugar content sugar-sweetened beverage tax policies 182. Brown AG, Hudson LB, Chui K, Metayer N, Lebron-Torres N, Seguin RA,
in the United States: a microsimulation study. Circulation. 2020;142:523– Folta SC. Improving heart health among Black/African American women
534. doi: 10.1161/CIRCULATIONAHA.119.042956 using civic engagement: a pilot study. BMC Public Health. 2017;17:112.
165. Powell LM, Andreyeva T, Isgor Z. Distribution of sugar-sweetened beverage doi: 10.1186/s12889-016-3964-2
sales volume by sugar content in the United States: implications for tiered 183. Ayala GX, Baquero B, Laraia BA, Ji M, Linnan L. Efficacy of a store-based
taxation and tax revenue. J Public Health Policy. 2020;41:125–138. doi: environmental change intervention compared with a delayed treatment
10.1057/s41271-019-00217-x control condition on store customers’ intake of fruits and vegetables. Public
166. RAND Education and Labor. Improving access to early childhood educa- Health Nutr. 2013;16:1953–1960. doi: 10.1017/S1368980013000955
tion. Accessed February 10, 2022. https://www.rand.org/capabilities/so- 184. Minkler M, Estrada J, Thayer R, Juachon L, Wakimoto P, Falbe J. Bringing
lutions/improving-access-to-early-childhood-education.html healthy retail to urban “food swamps”: a case study of CBPR-informed

Policy and neighborhood change in San Francisco. J Urban Health. 198. US Department of Health and Human Services. Social determinants of
2018;95:850–858. doi: 10.1007/s11524-018-0234-x health: Healthy People 2030. Accessed January 10, 2022.https://health.
CLINICAL STATEMENTS
185. Robles B, Barragan N, Smith B, Caldwell J, Shah D, Kuo T. Lessons learned gov/healthypeople/objectives-and-data/social-determinants-health
AND GUIDELINES
from implementing the Supplemental Nutrition Assistance Program 199. Frieden TR, Berwick DM. The “Million Hearts” initiative: preventing
Education Small Corner Store project in Los Angeles County. Prev Med heart attacks and strokes. N Engl J Med. 2011;365:e27. doi: 10.1056/
Rep. 2019;16:100997. doi: 10.1016/j.pmedr.2019.100997 NEJMp1110421
186. World Health Organization. Urban green space interventions and health: 200. Wright JS, Wall HK, Ritchey MD. Million Hearts 2022: small steps are
a review of impacts and effectiveness. 2017. Accessed June 1, 2022. needed for cardiovascular disease prevention. JAMA. 2018;320:1857–
https://www.cbd.int/health/who-euro-green-spaces-urbanhealth.pdf 1858. doi: 10.1001/jama.2018.13326
187. Petkovic J, Duench S, Trawin J, Dewidar O, Pardo Pardo J, Simeon 201. Centers for Disease Control and Prevention. Wisewoman locations.
R, DesMeules M, Gagnon D, Hatcher Roberts J, Hossain A, et al. 2021. Accessed February 15, 2022. https://www.cdc.gov/wisewoman/
Behavioural interventions delivered through interactive social media locations/
for health behaviour change, health outcomes, and health equity in the 202. Mosca L, Hammond G, Mochari-Greenberger H, Towfighi A, Albert MA;
adult population. Cochrane Database Syst Rev. 2021;5:CD012932. doi: on behalf of the American Heart Association Cardiovascular Disease
10.1002/14651858.CD012932.pub2 and Stroke in Women and Special Populations Committee of the Council
188. Spring B, Ockene JK, Gidding SS, Mozaffarian D, Moore S, Rosal MC, on Clinical Cardiology, Council on Epidemiology and Prevention, Council
Brown MD, Vafiadis DK, Cohen DL, Burke LE, et al; on behalf of the on Cardiovascular Nursing, Council on High Blood Pressure. Fifteen-
American Heart Association Behavior Change Committee of the Council year trends in awareness of heart disease in women: results of a 2012
on Epidemiology and Prevention, Council on Lifestyle and Cardiometabolic American Heart Association national survey. Circulation. 2013;127:1254–
Health, Council for High Blood Pressure Research, and Council on 1263, e1–e29. doi: 10.1161/CIR.0b013e318287cf2f
Cardiovascular and Stroke Nursing. Better population health through be- 203. St-Onge MP, Aggarwal B, Allison MA, Berger JS, Castañeda SF, Catov
havior change in adults: a call to action. Circulation. 2013;128:2169–2176. J, Hochman JS, Hubel CA, Jelic S, Kass DA, et al. Go Red for Women
doi: 10.1161/01.cir.0000435173.25936.e1 strategically focused research network: summary of findings and net-
189. Pearson TA, Palaniappan LP, Artinian NT, Carnethon MR, Criqui MH, Daniels work outcomes. J Am Heart Assoc. 2021;10:e019519. doi: 10.1161/
SR, Fonarow GC, Fortmann SP, Franklin BA, Galloway JM, et al; on behalf of JAHA.120.019519
the American Heart Association Council on Epidemiology and Prevention. 204. Suero-Abreu GA, Barajas-Ochoa A, Perez-Peralta A, Rojas E, Berkowitz
American Heart Association guide for improving cardiovascular health at R. Assessment of the effect of the Go Red for Women campaign on
the community level, 2013 update: a scientific statement for public health search engine queries for cardiovascular disease in women. Cardiol Res.
practitioners, healthcare providers, and health policy makers. Circulation. 2020;11:348–352. doi: 10.14740/cr1107
2013;127:1730–1753. doi: 10.1161/CIR.0b013e31828f8a94 205. Ma M, Ma A. Racial/ethnic differences in knowledge of personal and
190. Kris-Etherton PM, Petersen KS, Després JP, Anderson CAM, Deedwania P, target levels of cardiovascular health indicators. J Community Health.
Furie KL, Lear S, Lichtenstein AH, Lobelo F, Morris PB, et al; on behalf of 2015;40:1024–1030. doi: 10.1007/s10900-015-0027-z
the American Heart Association Council on Lifestyle and Cardiometabolic 206. Ma M, Dollar KM, Kibler JL, Sarpong D, Samuels D. The effects of prim-
Health; Council on Cardiovascular and Stroke Nursing; Stroke Council; ing on a public health campaign targeting cardiovascular risks. Prev Sci.
Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and 2011;12:333–338. doi: 10.1007/s11121-011-0228-3
Vascular Biology; and Council on Hypertension. Strategies for promotion of 207. Revere D, Calhoun R, Baseman J, Oberle M. Exploring bi-directional and
a healthy lifestyle in clinical settings: pillars of ideal cardiovascular health: SMS messaging for communications between public health agencies and
a science advisory from the American Heart Association. Circulation. their stakeholders: a qualitative study. BMC Public Health. 2015;15:621.
2021;144:e495–e514. doi: 10.1161/CIR.0000000000001018 doi: 10.1186/s12889-015-1980-2

191. Carnethon MR, Pu J, Howard G, Albert MA, Anderson CAM, Bertoni 208. Gooding HC, Brown CA, Liu J, Revette AC, Stamoulis C, de Ferranti SD. Will
AG, Mujahid MS, Palaniappan L, Taylor HA Jr, Willis M, et al; on be- teens go red? Low cardiovascular disease awareness among young wom-
half of the American Heart Association Council on Epidemiology and en. J Am Heart Assoc. 2019;8:e011195. doi: 10.1161/JAHA.118.011195
Prevention; Council on Cardiovascular Disease in the Young; Council on 209. Reynolds AJ, Temple JA, Ou SR, Arteaga IA, White BA. School-based early
Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council childhood education and age-28 well-being: effects by timing, dosage, and
on Functional Genomics and Translational Biology; and Stroke Council. subgroups. Science. 2011;333:360–364. doi: 10.1126/science.1203618
Cardiovascular health in African Americans: a scientific statement from 210. Fonarow GC, Calitz C, Arena R, Baase C, Isaac FW, Lloyd-Jones
the American Heart Association. Circulation. 2017;136:e393–e423. doi: D, Peterson ED, Pronk N, Sanchez E, Terry PE, et al; on behalf of the
10.1161/CIR.0000000000000534 American Heart Association. Workplace wellness recognition for op-
192. Brown HL, Warner JJ, Gianos E, Gulati M, Hill AJ, Hollier LM, Rosen SE, timizing workplace health: a presidential advisory from the American
Rosser ML, Wenger NK; on behalf of the American Heart Association and Heart Association. Circulation. 2015;131:e480–e497. doi: 10.1161/CIR.
the American College of Obstetricians and Gynecologists. Promoting risk 0000000000000206
identification and reduction of cardiovascular disease in women through 211. American Heart Association. Workplace health. Accessed January 6,
collaboration with obstetricians and gynecologists: a presidential advi- 2022. https://www.heart.org/en/professional/workplace-health
sory from the American Heart Association and the American College of 212. Elgazzar R, Nolan TS, Joseph JJ, Aboagye-Mensah EB, Azap RA, Gray DM
Obstetricians and Gynecologists. Circulation. 2018;137:e843–e852. doi: 2nd. Community-engaged and community-based participatory research
10.1161/CIR.0000000000000582 to promote American Heart Association Life’s Simple 7 among African
193. American Heart Association. Our policy positions. Accessed January 6, American adults: a systematic review. PLoS One. 2020;15:e0238374. doi:
2022. https://www.heart.org/en/get-involved/advocate/policy-research/ 10.1371/journal.pone.0238374
our-policy-positions 213. Palmer KNB, Rivers PS, Melton FL, McClelland DJ, Hatcher J, Marrero
194. Eliason EL. Adoption of Medicaid expansion is associated with lower DG, Thomson CA, Garcia DO. Health promotion interventions for African
maternal mortality. Womens Health Issues. 2020;30:147–152. doi: Americans delivered in U.S. barbershops and hair salons: a systematic review.
10.1016/j.whi.2020.01.005 BMC Public Health. 2021;21:1553. doi: 10.1186/s12889-021-11584-0
195. Sharma G, Grandhi GR, Acquah I, Mszar R, Mahajan S, Khan SU, Javed Z, 214. Turner J, Smith J, Bryant K, Haynes T, Stewart MK, Kuo DZ, Harris K,
Mehta LS, Gulati M, Cainzos-Achirica M, et al. Social determinants of sub- McCoy S, Lovelady N, Sullivan G, et al. Community building community:
optimal cardiovascular health among pregnant women in the United States. the distinct benefits of community partners building other communities’
J Am Heart Assoc. 2022;11:e022837. doi: 10.1161/JAHA.121.022837 capacity to conduct health research. Prog Community Health Partnersh.
196. Pahigiannis K, Thompson-Paul AM, Barfield W, Ochiai E, Loustalot F, 2017;11:81–86. doi: 10.1353/cpr.2017.0010
Shero S, Hong Y. Progress toward improved cardiovascular health in 215. Spencer MS, Rosland AM, Kieffer EC, Sinco BR, Valerio M, Palmisano
the United States. Circulation. 2019;139:1957–1973. doi: 10.1161/ G, Anderson M, Guzman JR, Heisler M. Effectiveness of a community
CIRCULATIONAHA.118.035408 health worker intervention among African American and Latino adults
197. US Department of Health and Human Services. Social determinants: with type 2 diabetes: a randomized controlled trial. Am J Public Health.
Healthy People 2020. Accessed January 10, 2022. https://www. 2011;101:2253–2260. doi: 10.2105/AJPH.2010.300106
healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/ 216. Liao Y, Siegel PZ, Zhou H, Grimm K, Njai R, Kent C, Giles W. Reduced
Social-Determinants disparity in vegetable consumption in 16 disadvantaged Black

communities: a successful 5-year community-based participatory interven- 232. Thorndike AN, Bright OM, Dimond MA, Fishman R, Levy DE. Choice
tion. J Racial Ethn Health Disparities. 2015;2:211–218. doi: 10.1007/ architecture to promote fruit and vegetable purchases by families par-
CLINICAL STATEMENTS
s40615-014-0065-8 ticipating in the Special Supplemental Program for Women, Infants, and
AND GUIDELINES
217. Victor RG, Lynch K, Li N, Blyler C, Muhammad E, Handler J, Brettler J, Children (WIC): randomized corner store pilot study. Public Health Nutr.
Rashid M, Hsu B, Foxx-Drew D, et al. A cluster-randomized trial of blood- 2017;20:1297–1305. doi: 10.1017/S1368980016003074
pressure reduction in Black barbershops. N Engl J Med. 2018;378:1291– 233. Paek HJ, Oh HJ, Jung Y, Thompson T, Alaimo K, Risley J, Mayfield K.
1301. doi: 10.1056/NEJMoa1717250 Assessment of a healthy corner store program (FIT Store) in low-income,
218. Joseph JJ, Nolan TS, Williams A, McKoy A, Zhao S, Aboagye-Mensah E, urban, and ethnically diverse neighborhoods in Michigan. Fam Community
Kluwe B, Odei JB, Brock G, Lavender D, et al. Improving cardiovascular Health. 2014;37:86–99. doi: 10.1097/FCH.0000000000000014
health in Black men through a 24-week community-based team lifestyle 234. Lawman HG, Vander Veur S, Mallya G, McCoy TA, Wojtanowski A, Colby L,
change intervention: the Black Impact pilot study. Am J Prev Cardiol. Sanders TA, Lent MR, Sandoval BA, Sherman S, et al. Changes in quantity,
2022;9:100315. doi: 10.1016/j.ajpc.2022.100315 spending, and nutritional characteristics of adult, adolescent and child ur-
219. Campbell MK, Hudson MA, Resnicow K, Blakeney N, Paxton A, Baskin ban corner store purchases after an environmental intervention. Prev Med.
M. Church-based health promotion interventions: evidence and lessons 2015;74:81–85. doi: 10.1016/j.ypmed.2014.12.003
learned. Annu Rev Public Health. 2007;28:213–234. doi: 10.1146/ 235. Leak TM, Setiono F, Gangrade N, Mudrak E. Youth willingness to purchase
annurev.publhealth.28.021406.144016 whole grain snack packs from New York City corner stores participating in
220. Schoenthaler AM, Lancaster KJ, Chaplin W, Butler M, Forsyth J, Ogedegbe a healthy retail program. Int J Environ Res Public Health. 2019;16:E3233.
G. Cluster randomized clinical trial of FAITH (Faith-Based Approaches in doi: 10.3390/ijerph16183233
the Treatment of Hypertension) in Blacks. Circ Cardiovasc Qual Outcomes. 236. Handbury J, Rahkovsky I, Schnell M. Is the focus on food deserts fruitless?
2018;11:e004691. doi: 10.1161/CIRCOUTCOMES.118.004691 Retail access and food purchases across the socioeconomic spectrum.
221. Skolarus LE, Cowdery J, Dome M, Bailey S, Baek J, Byrd JB, Hartley National Bureau of Economic Research. 2015. Accessed June 1, 2022.
SE, Valley SC, Saberi S, Wheeler NC, et al. Reach Out Churches: a https://www.nber.org/papers/w21126
community-based participatory research pilot trial to assess the feasibil- 237. Wynn TA, Wyatt SB, Hardy CM, Walker SS, Thomas TF, Williams AG, Partridge
ity of a mobile health technology intervention to reduce blood pressure EE. Using community feedback to improve community interventions: results
among African Americans. Health Promot Pract. 2018;19:495–505. doi: from the Deep South Network for Cancer Control Project. Fam Community
10.1177/1524839917710893 Health. 2016;39:234–241. doi: 10.1097/FCH.0000000000000101
222. Flórez KR, Payán DD, Palar K, Williams MV, Katic B, Derose KP. Church- 238. Smith SA, Whitehead MS, Sheats JQ, Ansa BE, Coughlin SS, Blumenthal
based interventions to address obesity among African Americans and DS. Community-based participatory research principles for the African
Latinos in the United States: a systematic review. Nutr Rev. 2020;78:304– American community. J Ga Public Health Assoc. 2015;5:52–56.
322. doi: 10.1093/nutrit/nuz046 239. Su D, Garg A, Wiens J, Meyer E, Cai G. Assessing health needs in
223. Ralston PA, Wickrama KKAS, Coccia CC, Lemacks JL, Young-Clark IM, African American churches: a mixed-methods study. J Relig Health.
Ilich JZ. Health for Hearts United longitudinal trial: improving dietary be- 2021;60:1179–1197. doi: 10.1007/s10943-019-00924-5
haviors in older African Americans. Am J Prev Med. 2020;58:361–369. 240. Azap RA, Nolan TS, Gray DM 2nd, Lawson K, Gregory J, Capers Q 4th,
doi: 10.1016/j.amepre.2019.09.024 Odei JB, Joseph JJ. Association of socioeconomic status with ideal cardio-
224. Brown DL, Conley KM, Sánchez BN, Resnicow K, Cowdery JE, Sais E, vascular health in Black men. J Am Heart Assoc. 2021;10:e020184. doi:
Murphy J, Skolarus LE, Lisabeth LD, Morgenstern LB. A multicomponent 10.1161/JAHA.120.020184
behavioral intervention to reduce stroke risk factor behaviors: the Stroke 241. Zhang K, Lovasi GS, Odden MC, Michael YL, Newman AB, Arnold AM,
Health and Risk Education cluster-randomized controlled trial. Stroke. Kim DH, Wu C. Association of retail environment and neighborhood socio-
2015;46:2861–2867. doi: 10.1161/STROKEAHA.115.010678 economic status with mortality among community-dwelling older adults in
225. Brewer LC, Balls-Berry JE, Dean P, Lackore K, Jenkins S, Hayes SN. the United States: Cardiovascular Health Study [published online October
Fostering African-American Improvement in Total Health (FAITH!): 20, 2021]. J Gerontol A Biol Sci Med Sci. doi: 10.1093/gerona/glab319.
an application of the American Heart Association’s Life’s Simple 7 https://academic.oup.com/biomedgerontology/advance-article/
among Midwestern African-Americans. J Racial Ethn Health Disparities. doi/10.1093/gerona/glab319/6406617?login=false
2017;4:269–281. doi: 10.1007/s40615-016-0226-z 242. Ko YA, Shen J, Kim JH, Topel M, Mujahid M, Taylor H, Quyyumi A, Sims M,
226. Brewer LC, Hayes SN, Jenkins SM, Lackore KA, Breitkopf CR, Cooper Vaccarino V, Baltrus P, et al. Identifying neighbourhood and individual resil-
LA, Patten CA. Improving cardiovascular health among African-Americans ience profiles for cardiovascular health: a cross-sectional study of Blacks
through mobile health: the FAITH! app pilot study. J Gen Intern Med. living in the Atlanta metropolitan area. BMJ Open. 2021;11:e041435. doi:
2019;34:1376–1378. doi: 10.1007/s11606-019-04936-5 10.1136/bmjopen-2020-041435
227. Bull City Fit: about us. Accessed January 9, 2022. https://www.bullcityfit. 243. Savin KL, Roesch SC, Oren E, Carlson JA, Allison MA, Sotres-Alvarez
org/about-us D, Sallis JF, Jankowska MM, Talavera GA, Rodriguez TM, et al. Social
228. Hoffman J, Frerichs L, Story M, Jones J, Gaskin K, Apple A, Skinner A, and built neighborhood environments and blood pressure 6 years later:
Armstrong S. An integrated clinic-community partnership for child obesity Results from the Hispanic Community Health Study/Study of Latinos and
treatment: a randomized pilot trial. Pediatrics. 2018;141:e20171444. doi: the SOL CASAS ancillary study. Soc Sci Med. 2022;292:114496. doi:
10.1542/peds.2017-1444 10.1016/j.socscimed.2021.114496
229. Mozaffarian D, Afshin A, Benowitz NL, Bittner V, Daniels SR, Franch HA, 244. Lapidos A, Lapedis J, Heisler M. Realizing the value of community health
Jacobs DR Jr, Kraus WE, Kris-Etherton PM, Krummel DA, et al; on behalf of workers: new opportunities for sustainable financing. N Engl J Med.
the American Heart Association Council on Epidemiology and Prevention, 2019;380:1990–1992. doi: 10.1056/NEJMp1815382
Council on Nutrition, Physical Activity and Metabolism, Council on Clinical 245. South EC, Hohl BC, Kondo MC, MacDonald JM, Branas CC. Effect of
Cardiology, Council on Cardiovascular Disease in the Young, Council on the greening vacant land on mental health of community-dwelling adults:
Kidney in Cardiovascular Disease, Council on Peripheral Vascular Disease, a cluster randomized trial. JAMA Netw Open. 2018;1:e180298. doi:
and the Advocacy Coordinating Committee. Population approaches to im- 10.1001/jamanetworkopen.2018.0298
prove diet, physical activity, and smoking habits: a scientific statement from 246. Branas CC, South E, Kondo MC, Hohl BC, Bourgois P, Wiebe DJ,
the American Heart Association. Circulation. 2012;126:1514–1563. doi: MacDonald JM. Citywide cluster randomized trial to restore blighted vacant
10.1161/CIR.0b013e318260a20b land and its effects on violence, crime, and fear. Proc Natl Acad Sci U S A.
230. Gittelsohn J, Rowan M, Gadhoke P. Interventions in small food stores to 2018;115:2946–2951. doi: 10.1073/pnas.1718503115
change the food environment, improve diet, and reduce risk of chronic dis- 247. American Heart Association. Current impact: EmPOWERED to Serve’s im-
ease. Prev Chronic Dis. 2012;9:E59. pact on social determinants of health. Accessed January 9, 2022. https://
231. Wensel CR, Trude ACB, Poirier L, Alghamdi R, Trujillo A, Anderson Steeves www.empoweredtoserve.org/en/about-empowered-to-serve/current-impact
E, Paige D, Gittelsohn J. B’more Healthy Corner Stores for Moms and 248. Krefman AE, Labarthe D, Greenland P, Pool L, Aguayo L, Juonala M,
Kids: identifying optimal behavioral economic strategies to increase WIC Kähönen M, Lehtimäki T, Day RS, Bazzano L, et al. Influential periods
redemptions in small urban corner stores. Int J Environ Res Public Health. in longitudinal clinical cardiovascular health scores. Am J Epidemiol.
2018;16:E64. doi: 10.3390/ijerph16010064 2021;190:2384–2394. doi: 10.1093/aje/kwab149

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Circulation

AHA PRESIDENTIAL ADVISORY

Life’s Essential 8: Updating and Enhancing

I THE CONCEPT OF CARDIOVASCULAR

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Figure 1. Life’s Essential 8.

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tion of this construct, it has also been used effectively to

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activity, nicotine exposure, sleep, body mass

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considered the nature of CVH metrics and improve-

ment strategies, psychological health and well-being

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ages, and examples of overall CVH scores in diverse scenarios)

Quantification of CVH metric: adults Quantification of CVH metric: children

100 Never smoker 100 Never tried

75 Former smoker, quit ≥5 y 50 Tried any nicotine product, but

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via surveys or wearable technology offers the ability for

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Figure 3. Example presentation of CVH score.

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CONTEXT AND OPPORTUNITIES FOR Public Health Programs

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Table 2. Multilevel Efforts to Improve CVH Across Social-Ecological Contexts

Inadequate workforce compensation167,168

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public health initiatives have identified identical indicators Institutions

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Figure 4. Life course of CVH.

constraints/barriers, and strengths/assets to ensure that

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Table 3. Example Research Needs and Future Directions

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health metrics: the American Heart Association Life’s Simple 7 in Blacks

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pdf Association Cardiovascular Disease in Older Populations Committee of

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2021;144:e495–e514. doi: 10.1161/CIR.0000000000001018 doi: 10.1186/s12889-015-1980-2

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75 Former smoker, quit ≥5 y 50 Tried any nicotine product, but

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