Lifestyle changes for cardiometabolic health: Planting the seeds for long-term benefit

Abstract

With nearly three-quarters of global deaths attributed to lifestyle-associated diseases, effective lifestyle modifications are more urgent than ever. The American Heart Association’s framework for cardiovascular health has evolved significantly, transitioning from 'Life’s Simple 7' to 'Life’s Essential 8' with the incorporation of sleep, and further to 'Life’s Essential 9' by adding mental health as a key component. Despite these advancements, recent evidence reveals a persistently low prevalence of ideal cardiovascular and cerebrovascular health behaviors across populations. These findings highlight the critical gap in addressing modifiable lifestyle and psychosocial factors. To reduce the global disease burden, public health strategies must prioritize comprehensive interventions that encompass physical, neurological, and mental well-being.

Key Words: Cardiovascular diseases; Cerebrovascular diseases; Health behaviors and factors; Public health initiatives; American Heart Association

Core Tip: Lifestyle-related diseases account for nearly three-quarters of global deaths, highlighting the urgency of preventive measures. A recent study on cardiovascular health (CVH) metrics in the Kailuan population revealed a low prevalence of ideal CVH behaviors and factors. These findings underscore the need for comprehensive lifestyle interventions that address physical, neurological, and mental well-being. Targeted strategies, such as promoting physical activity, reducing salt intake, and strengthening tobacco control, are crucial to prevent cardiovascular events and improve CVH outcomes in diverse populations.

INTRODUCTION

Cardiovascular health (CVH), introduced by the American Heart Association (AHA) in 2010, incorporates seven metrics to guide health promotion[1]. These include four behaviors—smoking, diet, physical activity, and body weight—and three factors—blood pressure, cholesterol, and blood glucose. This approach represents a shift from disease management to preventive care by encouraging ideal health behaviors and factors. By promoting ideal health behaviors and risk factor control, this framework sought to reduce the incidence of cardiovascular disease (CVD) and improve population health. During the period of the Kailuan study (2006-2011), China experienced rapid economic transformation and industrialization, which significantly influenced the lifestyle and health behaviors of the population. Economic reforms led to changes in employment patterns, urbanization, and access to healthcare, all of which had profound impacts on CVH. However, global adherence to these guidelines remains suboptimal despite its potential, highlighting the need for more effective implementation strategies. The Kailuan study, a large-scale longitudinal cohort in China, starkly illustrates this challenge[2]. Between 2006 and 2011, the study revealed alarmingly low prevalence rates of ideal CVH metrics. These findings underscore the urgent need for targeted interventions to address modifiable risk factors and improve CVH outcomes, particularly in high-risk populations.

CVH IN THE KAILUAN POPULATION

The Kailuan study revealed critical disparities in CVH metrics. Among men, only 13.12% achieved ideal physical activity, 9.34% reported low salt intake, and 20.55% had ideal blood pressure. Women fared slightly better, with 12.00% achieving ideal physical activity and 36.92% maintaining ideal blood pressure levels. Smoking prevalence among men exceeded 50%, contrasting sharply with 98% of women classified as never smokers. Over the three survey cycles (2006-2007, 2008-2009, and 2010-2011), modest improvements were observed in some metrics. For instance, the proportion of men with ideal salt intake rose from 9.34% to 17.65%, and women with ideal cholesterol levels increased from 64.28% to 67.85%. However, physical activity levels declined for both genders by the third cycle. The study also highlighted a stark gender gap, with women consistently outperforming men in most metrics except physical activity.

URGENT NEED FOR LIFESTYLE INTERVENTIONS: A GLOBAL IMPERATIVE

Although the prevalence of nutritional deficiencies has significantly decreased over the past three decades, new challenges such as obesity, hypertension, and diabetes have emerged, placing a substantial burden on the population[3,4]. China’s CVD burden is extremely substantial, with over 40% of deaths attributed to CVD[5,6]. This crisis is driven by modifiable lifestyle factors, including smoking, unhealthy diets, physical inactivity, and rising rates of obesity and hypertension. These health issues are closely linked to modifiable lifestyle factors, as highlighted by the AHA's "Life's Simple 7 (LS7)" framework, which emphasizes seven key metrics for CVH: Managing blood pressure, controlling cholesterol, reducing blood sugar, increasing physical activity, improving diet, maintaining a healthy weight, and avoiding smoking. These challenges are not limited to specific regions but are global issues. The global prevalence of CVD is rising at an alarming rate[7]. In 2021, there were 612 million cases of CVD globally, accounting for 26.8% of all deaths[7].

PROMOTING BALANCED DIETS

Dietary habits play a critical role in CVD risk. High salt intake, primarily from household cooking, is a major contributor to hypertension, a leading risk factor for CVD[8]. The Kailuan study revealed that fewer than 20% of participants adhered to low-salt diets, highlighting a significant gap in dietary awareness and practices. To address this, local initiatives such as promoting low-sodium salt and salt-reduction tools have shown promise[9]. Additionally, tools like limited salt spoons, oil pots, and waist circumference rulers are being introduced to improve nutrition literacy at the household level. However, broader public education and policy enforcement are needed to ensure widespread adoption of these practices.

ENCOURAGING PHYSICAL ACTIVITY

Available data indicate that 31% of the global population fail to meet the minimum recommended levels of physical activity[10]. Declining physical activity levels, as observed in the Kailuan study, underscore the need for community-based interventions to promote regular exercise. Strategies such as creating accessible public spaces for physical activity, implementing workplace wellness programs, and leveraging digital health technologies to track and encourage exercise can help address this issue. For example, mobile apps and wearable devices have been effective in motivating individuals to meet daily activity goals. Additionally, public health campaigns should emphasize the importance of physical activity for all age groups, from children to older adults, to foster a culture of lifelong fitness.

REDUCING TOBACCO USE

Globally, the prevalence of adult smoking remains alarmingly high, with 32.6% of men and 6.5% of women smoking in 2020[11]. This high smoking prevalence is particularly concerning given that smoking is a predominant risk factor for CVD and other chronic conditions[12]. In China, the situation is even more severe, especially among men, where smoking prevalence exceeds 50% in some regions[13]. The Healthy China Initiative aims to reduce smoking prevalence to 20% by 2030, but achieving this target requires robust tobacco control policies and public education campaigns[14]. Measures such as increasing tobacco taxes, enforcing smoke-free laws, and providing accessible smoking cessation programs are critical. Additionally, integrating smoking prevention into school curricula and community health programs can help reduce initiation rates among younger generations.

ADDRESSING OBESITY AND WEIGHT MANAGEMENT

The rising prevalence of obesity and overweight in China poses a significant threat to CVH. Obesity is closely linked to hypertension, diabetes, and other CVD risk factors[15]. Interventions to promote healthy weight management should focus on early life stages, emphasizing the importance of balanced diets and regular physical activity. Public health initiatives can also leverage technology, such as telemedicine and mobile health platforms, to provide personalized weight management support. Furthermore, policies to reduce the availability of high-calorie, low-nutrient foods and beverages in schools and workplaces can help create an environment conducive to healthy choices.

ENHANCING MENTAL HEALTH AND WELL-BEING

Emerging evidence highlights the role of psychological health in cardiovascular outcomes. Stress, anxiety, and depression are increasingly recognized as modifiable risk factors for CVD[16]. Integrating mental health screening and support into routine clinical care can help address these issues. Public health campaigns should also promote stress management techniques, such as mindfulness and physical activity, to improve overall well-being.

UPDATING CVH METRICS AND FUTURE DIRECTIONS

In 2022, the AHA updated its CVH framework to include sleep as the eighth metric under “Life’s Essential 8 (LE8)”[17]. Sleep health, a critical component of overall well-being, is strongly associated with CVH and aims to reduce CVD risks across all populations. Poor sleep is linked to shared risk factors such as hypertension and obesity[18]. Studies indicate that high baseline LE8 scores and their improvement correlate with significantly lower 10-year and lifetime risks of CVD[19-21]. For example, individuals with high LE8 scores demonstrated a 65% reduction in all-cause mortality risk[22]. The introduction of LE8 has been a significant step forward in the comprehensive assessment of CVH. It provides a more holistic view of health by incorporating sleep, which has been shown to be a crucial factor in reducing CVD risks across all populations. This framework encourages cardiologists and clinicians to recognize the significance of regular office visits in assessing patients' psychological well-being and its impact on CVH.

Emerging evidence also highlights the role of psychological health in cardiovascular outcomes. A recent framework, “Life’s Crucial 9” (LC9), builds on LE8 by integrating psychological health metrics, including depression screening[23]. Incorporating psychological assessments alongside traditional CVH metrics has shown potential in further lowering CVD risks. A previous study found shared gene signatures and pathways linking atherosclerosis and depression and identified 24 crosstalk genes, highlighting "lipid and atherosclerosis" and "tryptophan metabolism" as key pathways, thus mechanistically linking mental health to atherosclerosis progression[24]. Pooled data including 370 urban and 314 rural communities from 21 economically diverse countries on 5 continents (n = 45862) reveals that depression was strongly associated with CVD risk (hazard ratio = 1.14, 95% confidence interval = 1.05-1.24)[25]. Each 10-point higher overall LE8 score was associated with lower risk by 22% to 40% for CVD, while for LS7, the reduction in CVD risk is around 20% to 30% for each 10-point increase[26]. Although LC9 shows a significant reduction in CVD risk, direct comparisons with LS7 and LE8 are limited in the available literature[27]. Leveraging frameworks like LE8 and LC9 can provide a more comprehensive strategy for addressing modifiable risk factors and enhancing population health. Future research should focus on head-to-head comparisons of these three metrics to better understand their relative effectiveness in predicting and reducing CVD risk.

CONCLUSION

Understanding local health behaviors and factors is crucial for planning targeted health policies and prioritizing resources. The Kailuan study provides crucial insights into the prevalence and trends of CVH behaviors and factors, revealing significant gaps that must be addressed through targeted interventions. Leveraging health technologies to monitor CVH and promote adherence, combined with sustained public health efforts, will be crucial for reducing the burden of CVDs and achieving long-term population health improvements. To reduce CVD burden, we propose community-based screening programs targeting high-risk populations identified through epidemiological studies like Kailuan; digital health integration using wearable devices and AI-driven platforms to enable real-time CVH monitoring and personalized behavioral nudges, and policy-level interventions including taxation on tobacco/alcohol and subsidies for heart-healthy foods and public-private partnerships to scale up hypertension/diabetes management initiatives in workplace settings, building on the Kailuan cohort's occupational health insights. Sustained impact will require ongoing health literacy campaigns, multi-sectoral collaboration, and longitudinal evaluation systems to ensure equitable CVD risk reduction across socioeconomic groups.