Strategies for Promotion of a Healthy Lifestyle in Clinical Settings: Pillars of Ideal Cardiovascular Health: A Science Advisory From the American Heart Association

Food Insecurity and Its Cardiovascular Implications in Underresourced Communities

BACKGROUND

Food insecurity is linked to poorer cardiovascular health (CVH) outcomes, particularly in underresourced communities, where social determinants of health play a critical role. Despite the recognized connections, there remains a lack of empirical evidence delineating the implications of food insecurity on CVH. CVH, a broader concept than cardiovascular disease, encompasses the overall well-being of the cardiovascular system and is supported by favorable lifestyle choices and physiological metrics. Particularly in underresourced communities, the study of CVH could provide valuable insights for early intervention and targeted public health initiatives. This study aimed to fill this knowledge gap.

METHODS AND RESULTS

We conducted a cross-sectional analysis of baseline data from the E-DUCASS (Educational Strategy on a Vulnerable Population to Improve Cardiovascular Health and Food Insecurity) program (NCT05379842), a 24-month randomized study targeting participants at risk for food insecurity. CVH was assessed using the Life's Essential 8 score. The sample included 451 participants aged 12 to 80 years, stratified by age (30.6% children [aged 12-19 years], 35.9% young adults [aged 20-39 years], and 33.5% adults [aged 40-80 years]) and sex (42.1% men and 57.9% women). The mean CVH score was 65.1 (95% CI, 63.9-66.4), with diet, physical activity, nicotine exposure, and body mass index being the lowest-scoring metrics. Food insecurity significantly influenced CVH; those participants with severe food insecurity had lower CVH scores than those without (effect size, -2.83 [95% CI, -5.10 to -0.56]; P<0.05).

CONCLUSIONS

Our findings highlight the negative association between food insecurity and CVH in underresourced Mediterranean communities. These results underscore the need for strategies aimed at reducing cardiovascular risk, potentially through health literacy programs like E-DUCASS, that focus on improving lifestyle and alleviating food insecurity.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique Identifier: NCT05379842.

Effect of Daily Avocado Intake on Cardiovascular Health Assessed by Life's Essential 8: An Ancillary Study of HAT, a Randomized Controlled Trial

BACKGROUND

The effect of single food-based dietary interventions on the American Heart Association's cardiovascular health score, Life's Essential 8 (LE8), is unclear. The aim of this study was to examine the effect of daily avocado intake for 26 weeks on LE8 in adults with abdominal obesity.

METHODS AND RESULTS

An ancillary analysis including participants (n=969; aged 51±14 years) from the HAT (Habitual Diet and Avocado Trial), a randomized controlled trial, was conducted. The Avocado-Supplemented Diet Group was provided with 1 avocado per day, and the Habitual Diet Group was instructed to maintain their usual diet. LE8 component scores (diet, physical activity, nicotine exposure, sleep health, body mass index, blood lipids, blood glucose, and blood pressure) were calculated using a modified American Heart Association algorithm. The LE8 score was calculated as the unweighted average of each component (range, 0-100 points). Between-group differences in the 26-week change in LE8 were assessed using general linear models. No significant between-group difference in the 26-week change in the LE8 score from baseline was observed (0.79 points [95% CI, -0.41 to 2.00]). However, avocado intake increased the LE8 component scores for diet (3.53 points [95% CI, 1.38-5.68]), sleep health (3.20 points [95% CI, 0.38-6.02]), and blood lipids (3.46 points [95% CI, 1.03-5.90]) compared with the Habitual Diet Group.

CONCLUSIONS

Intake of 1 avocado per day for 26 weeks did not significantly affect the total cardiovascular health score in US adults with abdominal obesity. However, diet quality, sleep health, and blood lipids improved with daily avocado intake.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03528031.

Social Determinants of Health in the Development of Cardiovascular-kidney-metabolic Syndrome

Cardiovascular-kidney-metabolic (CKM) syndrome is characterized by the interactions among the metabolic risk factors, chronic kidney diseases (CKD) and cardiovascular diseases (CVD). Social determinants of health (SDOH) include society, economy, environment, community and psychological factors, which correspond with cardiovascular and kidney events of the CKM population. SDOH are integral components throughout the entire spectrum of CKM, acting as key contributors from initial preventative measures to ongoing management, as well as in the formulation of health policies and the conduct of research, serving as vital instruments in the pursuit of health equity and the improvement of health standards. This article summarizes the important role of SDOH in CKM syndrome and explores the prospects of comprehensive management based on SDOH. It is hoped that these insights will offer valuable contributions to improving CKM-related issues and enhancing health standards.

How perceived risk of recurrence strengthens health management awareness in stroke patients: the chain mediating role of risk fear and health literacy

Background

Prior research has found that perceived risk in stroke patients motivates health behaviors in visitors. However, the role that perceived risk of recurrence in stroke patients plays in reinforcing health management awareness during the motivation phase is unclear.

Objective

This study explores this issue by examining the effects of risk fear and health literacy on health management awareness due to perceived risk of recurrence in stroke patients.

Methods

We validated the effect of perceived risk of recurrence on health management awareness and its internal mechanism by constructing a structural equation model and including 763 stroke patients, extending the relevant literature and application of the Healthy Behavior Procedural Approach (HAPA) model.

Result

The results suggest that perceived risk of recurrence in stroke patients can effectively reinforce and improve health management awareness, with risk fear and health literacy having a chain-mediated role in this group relationship.

Conclusion

This study reveals the differential effects of perceived risk of recurrence, risk fear, and health literacy in stroke patients on health management awareness at the individual level, providing valuable guidance for healthcare practitioners and families to improve patients' health outcomes and health well-being.

Risk Factors Associated With Coronary Disease in Saudi Arabia: A Comprehensive Review

Coronary artery disease (CAD) has become a major health challenge across the globe and is one of the major causes of mortality and morbidity in several countries. In Saudi Arabia, recent studies have emphasized the burden of CAD. Therefore, in this study, we aim to assess the risk factors associated with CAD in Saudi Arabia. The Population, Intervention, Comparison, and Outcome (PICO) model was used to refine the research question, which defined patients with CAD and identified risk factors and prevention strategies. PubMed, Web of Science, and Google Scholar were searched from January 1, 2010, until December 1, 2024. The common risk factors were diabetes, hypertension, obesity, and smoking, indicating their significant impact on health outcomes and the urgency for focus prevention strategies such as education and routine clinical screening. The risk factors contributing to CAD emphasize the need for targeted public health intervention and improvement in the management of risk factors in addition to specific health education content to improve healthy habits in the community.

A Proposed Framework to Aid Primary Care Clinicians in Promoting Cardiovascular Health

Healthy lifestyle behaviors play a significant role in promoting cardiovascular health. Primary care clinicians (PCCs) are tasked with promoting cardiovascular health through the assessment of lifestyle behaviors and the use of behavior change counseling. However, PCCs face several barriers including a lack of training in counseling techniques. We propose a framework to guide the development of a patient-centered digital communication bundle that can aid PCCs in helping their patients create and sustain feasible lifestyle changes. Our framework proposes that this digital communication bundle contains the following features: assess and analyze an individual's cardiovascular health status; communicate personalized information in a health-literacy-friendly, visual format; assess behavioral components of change (e.g., motivation) that can inform the PCC's approach in guiding behavior change; provide PCCs with brief, behavior change counseling prompts that are grounded in motivational interviewing; and assess and address potential structural, socioeconomic, and environmental barriers, thereby fostering resilience in patients' lifestyle change efforts. We highlight the available research to support the need for such a tool and its potential ability to guide PCCs while also promoting behavior change in a patient-centered manner.

Understanding Cardiovascular Health and Lifestyle Choices Among Healthcare Professionals in Medically Underserved Regions in Illinois

This study assesses the prevalence of cardiovascular risk factors, such as diabetes, obesity, high blood pressure, and stress, as related to healthy lifestyle behaviors among healthcare professionals (HCPs), including medical doctors, nurses, pharmacists, laboratory scientists, and radiologists, in medically underserved regions (MURs). Using a cross-sectional study design, an online survey was administered to HCPs in MURs of West Central Illinois. A total of 316 HCPs completed the survey. The study population was predominantly White, female, and aged 55 or older. The findings of this research imply that HCPs in medically underserved regions (MURs) with high cholesterol generally do not engage in physical activity. The study showed a correlation between HCP age, high blood pressure, Type 2 diabetes, and high cholesterol, implying that as HCPs age like every other individual, the likelihood of developing these conditions increases. This study emphasizes the role of time constraints and a lack of motivation in limiting HCPs' participation in physical activity in rural areas. Additionally, the study suggests that inadequate access to nutritious food and exercise facilities in rural regions contributes to lower rates of healthy eating and physical activity. Findings demonstrate how essential it is for healthcare professionals to remain vigilant about cardiovascular disease risk factors.

The Role of Primary Care in Achieving Life's Essential 8: A Scientific Statement From the American Heart Association

To reduce morbidity and mortality rates of cardiovascular disease, an urgent need exists to improve cardiovascular health among US adults. In 2022, the American Heart Association issued Life's Essential 8, which identifies and defines 8 health behaviors and factors that, when optimized through a combination of primary prevention, risk factor management, and effective treatments, can promote ideal cardiovascular health. Because of its central role in patient care across the life span, primary care is in a strategic position to promote Life's Essential 8 and improve cardiovascular health in the United States. High-quality primary care is person-centered, team-based, community-aligned, and designed to provide affordable optimized health care. The purpose of this scientific statement from the American Heart Association is to provide evidence-based guidance on how primary care, as a field and practice, can support patients in implementing Life's Essential 8. The scientific statement aims to describe the role and functions of primary care, provide evidence for how primary care can be leveraged to promote Life's Essential 8, examine the role of primary care in providing access to care and mitigating disparities in cardiovascular health, review challenges in primary care, and propose solutions to address challenges in achieving Life's Essential 8.

Projected Impact of Nonpharmacologic Management of Stage 1 Hypertension Among Lower-Risk US Adults

BACKGROUND

The 2017 American College of Cardiology/American Heart Association blood pressure guideline classified 31 million US adults as having stage 1 hypertension and recommended clinicians provide counseling on behavioral change to the low-risk portion of this group. However, nationwide reductions in cardiovascular disease (CVD) and associated health care expenditures achievable by nonpharmacologic therapy remain unquantified.

METHODS

We simulated interventions on a target population of US adults aged 35 to 64 years, identified from the 2015-2018 National Health and Nutrition Examination Survey, with low-risk stage 1 systolic hypertension: that is, untreated systolic blood pressure 130 to 139 mm Hg with diastolic BP <90 mm Hg; no history of CVD, diabetes, or chronic kidney disease; and a low 10-year risk of CVD. We used meta-analyses and trials to estimate the effects of population-level behavior modification on systolic blood pressure. We assessed the extent to which restricting intervention to those in regular contact with clinicians might prevent the delivery of nonpharmacologic therapy.

RESULTS

Controlling systolic blood pressure to <130 mm Hg among the 8.8 million low-risk US adults with stage 1 hypertension could prevent 26 100 CVD events, avoid 2900 deaths, and save $1.7 billion in total direct health care costs over 10 years. Adoption of the Dietary Approaches to Stop Hypertension diet could prevent 28 000 CVD events. Other nonpharmacologic interventions could avert between 3800 and 19 500 CVD events. However, only 51% of men and 75% of women regularly interacted with clinicians for counseling opportunities.

CONCLUSIONS

Among low-risk adults with stage 1 hypertension, substantial benefits to cardiovascular health could be achieved through public policy that promotes the adoption of nonpharmacologic therapy.

Implementation of Obesity Science Into Clinical Practice: A Scientific Statement From the American Heart Association

Obesity is a recognized public health epidemic with a prevalence that continues to increase dramatically in nearly all populations, impeding progress in reducing incidence rates of cardiovascular disease. Over the past decade, obesity science has evolved to improve knowledge of its multifactorial causes, identifying important biological causes and sociological determinants of obesity. Treatments for obesity have also continued to develop, with more evidence-based programs for lifestyle modification, new pharmacotherapies, and robust data to support bariatric surgery. Despite these advancements, there continues to be a substantial gap between the scientific evidence and the implementation of research into clinical practice for effective obesity management. Addressing barriers to obesity science implementation requires adopting feasible methodologies and targeting multiple levels (eg, clinician, community, system, policy) to facilitate the delivery of obesity-targeted therapies and maximize the effectiveness of guideline-driven care to at-need patient populations. This scientific statement (1) describes strategies shown to be effective or promising for enhancing translation and clinical application of obesity-based research; (2) identifies key gaps in the implementation of obesity science into clinical practice; and (3) provides guidance and resources for health care professionals, health care systems, and other stakeholders to promote broader implementation and uptake of obesity science for improved population-level obesity management. In addition, advances in implementation science that hold promise to bridge the know-do gap in obesity prevention and treatment are discussed. Last, this scientific statement highlights implications for health research policy and future research to improve patient care models and optimize the delivery and sustainability of equitable obesity-related care.

Health-Promoting Lifestyle and Its Predictors in Renal Transplant Recipients in Hunan, China: A Cross-Sectional Study

Background

Kidney transplantation is a critical treatment for end-stage renal disease (ESRD), with health-promoting lifestyle (HPL) significantly impacting patient outcomes. HPL involves behaviors like regular exercise, balanced nutrition, stress management, and habit modification. However, few studies have analyzed the HPL of renal transplant recipients, addressing a significant gap in current research.

Objective

This study aimed to determine the predictors of HPL in renal transplant recipients using the Chinese Health Promoting Lifestyle Profile (HPLP).

Methods

This cross-sectional study enrolled renal transplant recipients completing the revised Chinese HPLP at organ transplant center in a tertiary hospital in Hunan Province of China between May 2022 and July 2022.

Results

A total of 450 patients were included, comprising 256 males (56.9%), with a mean age of 44.85 ± 10.57 years. The mean score of self-actualization, health responsibility, interpersonal support, physical activity, stress management, nutrition, and overall HPLP were 15.27 ± 5.03 (possible range: 0-24), 11.41 ± 4.18 (possible range: 0-24), 11.61 ± 3.13 (possible range: 0-18), 7.53 ± 3.79 (possible range: 0-18), 12.68 ± 3.61 (possible range: 0-21), 11.17 ± 2.41 (possible range: 0-15), and 69.66 ± 16.98 (possible range: 0-120), respectively. Multivariate logistic regression analysis showed that urban residence (OR = 2.061, 95% CI: 1.350-3.148, P = 0.001), non-smoking after transplantation (OR = 2.010, 95% CI: 1.123-3.600, P = 0.019) and two post-transplant complications (OR=0.387, 95% CI: 0.218-0.689, P = 0.001).

Conclusion

Although renal transplant recipients exhibit a moderate level of HPL, targeted interventions are essential to improve these behaviors. These interventions should focus especially on individuals from rural households, post-transplant smokers, and those experiencing post-transplant complications, to enhance their quality of life and clinical outcomes.

Psychometric Properties of the Healthy Lifestyle Behaviors Scale in Portuguese Pregnant Women

BACKGROUND

Pregnancy provides a privileged and opportune moment to implement interventions promoting healthy lifestyle behaviors and significantly improving perinatal outcomes. The Healthy Lifestyle Behaviors Scale (HLBES) can be used to assess health promoting behaviors, such as diet, physical activity, and mental health.

PURPOSE

This study aimed to examine the psychometric properties of the HLBES in Portuguese pregnant women.

METHODS

A methodological study was conducted on a convenience sample of 192 pregnant women receiving prenatal care. After cross-cultural adaptation, an exploratory factor analysis and internal consistency assessment were carried out to evaluate the psychometric properties of the scale. Data collected included the Healthy Lifestyle Beliefs Scale to assess the HLBES' criterion validity.

RESULTS

Exploratory factor analysis with Varimax rotation yielded 2 subscales that explained 45.23% of the total variance. The scale revealed an overall internal consistency of 0.78 and a good criterion validity with the Healthy Lifestyle Beliefs Scale (r = 0.65, P < .01).

CONCLUSION

Our results suggest that the HLBES is an instrument for reporting healthy lifestyle behaviors in Portuguese pregnant women; however, further studies are recommended. This scale can be used to not only describe healthy lifestyle behaviors in pregnant women but also to determine the effects of health promoting interventions.

Mechanisms and benefits of cardiac rehabilitation in individuals with stroke: emerging role of its impact on improving cardiovascular and neurovascular health

Human and animal studies have demonstrated the mechanisms and benefits of aerobic exercise for both cardiovascular and neurovascular health. Aerobic exercise induces neuroplasticity and neurophysiologic reorganization of brain networks, improves cerebral blood flow, and increases whole-body VO2peak (peak oxygen consumption). The effectiveness of a structured cardiac rehabilitation (CR) program is well established and a vital part of the continuum of care for people with cardiovascular disease. Individuals post stroke exhibit decreased cardiovascular capacity which impacts their neurologic recovery and extends disability. Stroke survivors share the same risk factors as patients with cardiac disease and can therefore benefit significantly from a comprehensive CR program in addition to neurorehabilitation to address their cardiovascular health. The inclusion of individuals with stroke into a CR program, with appropriate adaptations, can significantly improve their cardiovascular health, promote functional recovery, and reduce future cardiovascular and cerebrovascular events thereby reducing the economic burden of stroke.

A Social Media-Based Mindfulness Psycho-Behavioral Intervention (MCARE) for Patients With Acute Coronary Syndrome: Randomized Controlled Trial

BACKGROUND

Psychological distress is common among patients with acute coronary syndrome (ACS) and has considerable adverse impacts on disease progression and health outcomes. Mindfulness-based intervention is a promising complementary approach to address patients' psychological needs and promote holistic well-being.

OBJECTIVE

This study aims to examine the effects of a social media-based mindfulness psycho-behavioral intervention (MCARE) on psychological distress, psychological stress, health-related quality of life (HRQoL), and cardiovascular risk factors among patients with ACS.

METHODS

This study was a 2-arm, parallel-group randomized controlled trial. We recruited 178 patients (mean age 58.7, SD 8.9 years; 122/178, 68.5% male) with ACS at 2 tertiary hospitals in Jinan, China. Participants were randomly assigned to the MCARE group (n=89) or control group (n=89). The 6-week intervention consisted of 1 face-to-face session (phase I) and 5 weekly WeChat (Tencent Holdings Ltd)-delivered sessions (phase II) on mindfulness training and health education and lifestyle modification. The primary outcomes were depression and anxiety. Secondary outcomes included psychological stress, HRQoL, and cardiovascular risk factors (ie, smoking status, physical activity, dietary behavior, BMI, blood pressure, blood lipids, and blood glucose). Outcomes were measured at baseline (T0), immediately after the intervention (T1), and 12 weeks after the commencement of the intervention (T2).

RESULTS

The MCARE group showed significantly greater reductions in depression (T1: β=-2.016, 95% CI -2.584 to -1.449, Cohen d=-1.28, P<.001; T2: β=-2.089, 95% CI -2.777 to -1.402, Cohen d=-1.12, P<.001) and anxiety (T1: β=-1.024, 95% CI -1.551 to -0.497, Cohen d=-0.83, P<.001; T2: β=-0.932, 95% CI -1.519 to -0.346, Cohen d=-0.70, P=.002). Significantly greater improvements were also observed in psychological stress (β=-1.186, 95% CI -1.678 to -0.694, Cohen d=-1.41, P<.001), physical HRQoL (β=0.088, 95% CI 0.008-0.167, Cohen d=0.72, P=.03), emotional HRQoL (β=0.294, 95% CI 0.169-0.419, Cohen d=0.81, P<.001), and general HRQoL (β=0.147, 95% CI 0.070-0.224, Cohen d=1.07) at T1, as well as dietary behavior (β=0.069, 95% CI 0.003-0.136, Cohen d=0.75, P=.04), physical activity level (β=177.542, 95% CI -39.073 to 316.011, Cohen d=0.51, P=.01), and systolic blood pressure (β=-3.326, 95% CI -5.928 to -0.725, Cohen d=-1.32, P=.01) at T2. The overall completion rate of the intervention (completing ≥5 sessions) was 76% (68/89). Positive responses to the questions of the acceptability questionnaire ranged from 93% (76/82) to 100% (82/82).

CONCLUSIONS

The MCARE program generated favorable effects on psychological distress, psychological stress, HRQoL, and several aspects of cardiovascular risk factors in patients with ACS. This study provides clues for guiding clinical practice in the recognition and management of psychological distress and integrating the intervention into routine rehabilitation practice.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2000033526; https://www.chictr.org.cn/showprojEN.html?proj=54693.

Association Between the Composite Cardiovascular Risk and mHealth Use Among Adults in the 2017-2020 Health Information National Trends Survey: Cross-Sectional Study

BACKGROUND

Numerous studies have suggested that the relationship between cardiovascular disease (CVD) risk and the usage of mobile health (mHealth) technology may vary depending on the total number of CVD risk factors present. However, whether higher CVD risk is associated with a greater likelihood of engaging in specific mHealth use among US adults is currently unknown.

OBJECTIVE

We aim to assess the associations between the composite CVD risk and each component of mHealth use among US adults regardless of whether they have a history of CVD or not.

METHODS

This study used cross-sectional data from the 2017 to 2020 Health Information National Trends Survey. The exposure was CVD risk (diabetes, hypertension, smoking, physical inactivity, and overweight or obesity). We defined low, moderate, and high CVD risk as having 0-1, 2-3, and 4-5 CVD risk factors, respectively. The outcome variables of interest were each component of mHealth use, including using mHealth to make health decisions, track health progress, share health information, and discuss health decisions with health providers. We used multivariable logistic regression models to examine the association between CVD risk and mHealth use adjusted for demographic factors.

RESULTS

We included 10,531 adults, with a mean age of 54 (SD 16.2) years. Among the included participants, 50.2% were men, 65.4% were non-Hispanic White, 41.9% used mHealth to make health decisions, 50.8% used mHealth to track health progress toward a health-related goal, 18.3% used mHealth to share health information with health providers, and 37.7% used mHealth to discuss health decisions with health providers (all are weighted percentages). Adults with moderate CVD risk were more likely to use mHealth to share health information with health providers (adjusted odds ratio 1.49, 95% CI 1.24-1.80) and discuss health decisions with health providers (1.22, 95% CI 1.04-1.44) compared to those with low CVD risk. Similarly, having high CVD risk was associated with higher odds of using mHealth to share health information with health providers (2.61, 95% CI 1.93-3.54) and discuss health decisions with health providers (1.56, 95% CI 1.17-2.10) compared to those with low CVD risk. Upon stratifying by age and gender, we observed age and gender disparities in the relationship between CVD risk and the usage of mHealth to discuss health decisions with health providers.

CONCLUSIONS

Adults with a greater number of CVD risk factors were more likely to use mHealth to share health information with health providers and discuss health decisions with health providers. These findings suggest a promising avenue for enhancing health care communication and advancing both primary and secondary prevention efforts related to managing CVD risk factors through the effective usage of mHealth technology.

Projected Impact of Nonpharmacologic Management of Stage 1 Hypertension Among Lower-Risk US Adults

Background

The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines newly classified 31 million US adults as having stage 1 hypertension. The ACC/AHA guidelines recommend behavioral change without pharmacology for the low-risk portion of this group. However, the nationwide reduction in cardiovascular disease (CVD) and associated healthcare expenditures achievable by evidence-based dietary improvements, sustained weight loss, adequate physical activity, and alcohol moderation remain unquantified. We estimated the effect of systolic BP (SBP) control and behavioral changes on 10-year CVD outcomes and costs.

Methods

We used the CVD Policy Model to simulate CVD events, mortality, and healthcare costs among US adults aged 35-64. We simulated interventions on a target population, identified from the 2015-2018 National Health and Nutrition Examination Survey, with low-risk stage 1 systolic hypertension: defined as untreated SBP 130-139 mmHg and diastolic BP <90 mmHg; no history of CVD, diabetes, or chronic kidney disease; and low 10-year risk of CVD. We used published meta-analyses and trials to estimate the effects of behavior modification on SBP. We assessed the extent to which intermittent healthcare utilization or partial uptake of nonpharmacologic therapy would decrease CVD events prevented.

Results

Controlling SBP to <130 mmHg among the estimated 8.8 million U.S. adults (51% women) in the target population could prevent 26,100 CVD events, avoid 2,900 deaths, and save $1.6 billion in healthcare costs over 10 years. The Dietary Approaches to Stop Hypertension (DASH) diet could prevent 16,000 CVD events among men and 12,000 among women over a decade. Other nonpharmacologic interventions could avert between 3,700 and 19,500 CVD events. However, only 5.5 million (61%) of the target population regularly utilized healthcare where recommended clinician counseling could occur.

Conclusions

As only two-thirds of U.S. adults with Stage 1 hypertension regularly receive medical care, substantial benefits to cardiovascular health and associated costs may only stem from policies that promote widespread adoption and sustained adherence of nonpharmacologic therapy. Future work should quantify the population-level costs, benefits, and efficacy of improving the food system and local infrastructure on health behavior change.

Next Generation, Modifiable Cardiometabolic Biomarkers: Mitochondrial Adaptation and Metabolic Resilience: A Scientific Statement From the American Heart Association

Cardiometabolic risk is increasing in prevalence across the life span with disproportionate ramifications for youth at socioeconomic disadvantage. Established risk factors and associated disease progression are harder to reverse as they become entrenched over time; if current trends are unchecked, the consequences for individual and societal wellness will become untenable. Interrelated root causes of ectopic adiposity and insulin resistance are understood but identified late in the trajectory of systemic metabolic dysregulation when traditional cardiometabolic risk factors cross current diagnostic thresholds of disease. Thus, children at cardiometabolic risk are often exposed to suboptimal metabolism over years before they present with clinical symptoms, at which point life-long reliance on pharmacotherapy may only mitigate but not reverse the risk. Leading-edge indicators are needed to detect the earliest departure from healthy metabolism, so that targeted, primordial, and primary prevention of cardiometabolic risk is possible. Better understanding of biomarkers that reflect the earliest transitions to dysmetabolism, beginning in utero, ideally biomarkers that are also mechanistic/causal and modifiable, is critically needed. This scientific statement explores emerging biomarkers of cardiometabolic risk across rapidly evolving and interrelated "omic" fields of research (the epigenome, microbiome, metabolome, lipidome, and inflammasome). Connections in each domain to mitochondrial function are identified that may mediate the favorable responses of each of the omic biomarkers featured to a heart-healthy lifestyle, notably to nutritional interventions. Fuller implementation of evidence-based nutrition must address environmental and socioeconomic disparities that can either facilitate or impede response to therapy.

Understanding Health Attitudes and Behavior

Individual attitudes and behavior related to health and disease are major components of clinical encounters. These factors shape lifestyle, presentation of symptoms, access to patient care, interactions between patients and physicians, adherence to medical advice, and response to treatment. Health attitudes and behavior may range from anxiety and worry about illness to various forms of denial, such as delay of seeking care and lack of adherence to treatment. When attitudes result in health-damaging behavior, they may be particularly difficult to understand and become a source of frustration to both physicians and patients. Devising appropriate responses by health care providers may contribute to improving final outcomes and decrease health care costs. In particular, health behavior is likely to play a major role in the process of convalescence, in self-management of chronic conditions, in determining a state of recovery, and whenever a rehabilitation process is involved. Understanding the spectrum of health attitudes and behavior is also crucial for motivating people to make beneficial changes (lifestyle medicine), as well as for implementing safety procedures in the community.

Preventive Medicine via Lifestyle Medicine Implementation Practices Should Consider Individuals' Complex Psychosocial Profile

Noncommunicable chronic diseases are associated with lifestyle behaviors. Psychological and social factors may influence the adoption of such behaviors. Being mentally and physically energized or fatigued may influence the intention-behavior gap of healthy lifestyle adoption accordingly. We investigated the associations of age, sex, lifestyle behaviors, mood, and mental and physical energy and fatigue at both the trait and state levels. The participants (N = 670) completed questionnaires assessing their sleep, mood, mental and physical state energy and fatigue, physical activity, mental workload, and diet. The ordinary least squares regression models revealed an overlap between the mental state and trait energy levels for males who consume polyphenols, have a high mental workload, and sleep well. Being younger, having a high stress level, bad sleep habits, and being confused and depressed were associated with high mental fatigue. Physical energy and fatigue shared the same commonalities with the previous results, with greater discrepancies observed between the state and trait indicators compared to that between mental energy and fatigue. Diet and stress management seem to be predictors of high physical energy, and females report higher physical fatigue levels. Health care professionals should consider this psychosocial complex profiling in their differential diagnosis and when one is implementing lifestyle behavioral changes to address the facets of preventive medicine, wellness, and health promotion.

Effects of a vegetarian diet combined with exercise on lipid profiles and blood pressure: A systematic review and meta-analysis

We aimed to evaluate the combined effects of a vegetarian diet (VD) and exercise on total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglyceride (TG), systolic blood pressure (SBP), and diastolic blood pressure (DBP) parameters. A literature search was conducted in electronic databases from build to February 27, 2022. Data were synthesized using random effects model and were expressed as standardized mean difference (SMD)/weighted mean difference (WMD) and 95% confidence interval (CI). Overall, 27 trials with 9,251 participants were included. Pooled results indicated that the combination of a VD and exercise significantly reduced TC (SMD: -0.524; 95% CI: -0.602, -0.446; p < 0.001), LDL-C (SMD: -0.379; 95% CI: -0.471, -0.287; p < 0.001), HDL-C (SMD: -0.213; 95% CI: -0.299, -0.126; p < 0.001), TG (SMD: -0.090; 95% CI: -0.160, -0.020; p = 0.012), SBP (WMD: -7.664 mm Hg; 95% CI: -9.219, -6.109 mm Hg; p < 0.001), and DBP (WMD: -4.347 mm Hg; 95% CI: -5.099, -3.596 mm Hg; p < 0.001). These parameters were reduced more following a low-fat VD, or a mixed high-frequency exercise, especially under strict supervision. Surprisingly, the decreased HDL-C due to VD was observed to recover with the prolongation of exercise.

Economic Evaluation of Health Behavior Interventions to Prevent and Manage Type 2 Diabetes Mellitus in Asia: A Systematic Review of Randomized Controlled Trials

Health behavior interventions implemented in Asian countries often lack economic evaluations that effectively address the problems of type 2 diabetes mellitus. This review systematically assessed the existing literature on economic evaluation of health behavior interventions to prevent and manage type 2 diabetes mellitus for people living in Asian countries. Eligible studies were identified through a search of six bibliographic databases, namely, PubMed, Scopus, Public Health Database by ProQuest, Cumulative Index to Nursing and Allied Health Literature Complete, Web of Science, and Google Scholar. Randomized controlled trials of health behavior interventions and studies published in the English language from January 2000 to May 2022 were included in the review. The search yielded 3867 records, of which 11 studies were included in the review. All included studies concluded that health behavior interventions were cost-effective. Eight of these studies undertook an evaluation from a health system perspective, two studies used both societal and health system perspectives, and one study utilized a societal and multi-payer perspective. This review identified the time horizon, direct and indirect medical costs, and discount rates as the most important considerations in determining cost effectiveness. These findings have implications in extending health behavior interventions to prevent and manage type 2 diabetes mellitus in low-resource settings, and are likely to yield the most promising outcomes for people with type 2 diabetes mellitus.

Life's Essential 8: Updating and Enhancing the American Heart Association's Construct of Cardiovascular Health: A Presidential Advisory From the American Heart Association

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 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.

Special Considerations for Healthy Lifestyle Promotion Across the Life Span in Clinical Settings: A Science Advisory From the American Heart Association

At a population level, engagement in healthy lifestyle behaviors is suboptimal in the United States. Moreover, marked disparities exist in healthy lifestyle behaviors and cardiovascular risk factors as a result of social determinants of health. In addition, there are specific challenges to engaging in healthy lifestyle behaviors related to age, developmental stage, or major life circumstances. Key components of a healthy lifestyle are consuming a healthy dietary pattern, engaging in regular physical activity, avoiding use of tobacco products, habitually attaining adequate sleep, and managing stress. For these health behaviors, there are guidelines and recommendations; however, promotion in clinical settings can be challenging, particularly in certain population groups. These challenges must be overcome to facilitate greater promotion of healthy lifestyle practices in clinical settings. The 5A Model (assess, advise, agree, assist, and arrange) was developed to provide a framework for clinical counseling with consideration for the demands of clinical settings. In this science advisory, we summarize specific considerations for lifestyle-related behavior change counseling using the 5A Model for patients across the life span. In all life stages, social determinants of health and unmet social-related health needs, as well as overweight and obesity, are associated with increased risk of cardiovascular disease, and there is the potential to modify this risk with lifestyle-related behavior changes. In addition, specific considerations for lifestyle-related behavior change counseling in life stages in which lifestyle behaviors significantly affect cardiovascular disease risk are outlined. Greater attention to healthy lifestyle behaviors during every clinician visit will contribute to improved cardiovascular health.