Cardiovascular health and validation of the self-reported score in Brazil: analysis of the National Health Survey

Comparison of cardiovascular health profiles across population surveys from five high- to low-income countries

Aims

With the greatest burden of cardiovascular disease morbidity and mortality increasingly observed in lower-income countries least prepared for this epidemic, focus is widening from risk factor management alone to primordial prevention to maintain high levels of cardiovascular health (CVH) across the life course. To facilitate this, the American Heart Association (AHA) developed CVH scoring guidelines to evaluate and track CVH. We aimed to compare the prevalence and trajectories of high CVH across the life course using nationally representative adult CVH data from five diverse high- to low-income countries.

Methods

Surveys with CVH variables (physical activity, cigarette smoking, body mass, blood pressure, blood glucose, and total cholesterol levels) were identified in Ethiopia, Bangladesh, Brazil, England, and the United States (US). Participants were included if they were 18-69y, not pregnant, and had data for these CVH metrics. Comparable data were harmonized and each of the CVH metrics was scored using AHA guidelines as high (2), moderate (1), or low (0) to create total CVH scores with higher scores representing better CVH. High CVH prevalence by age was compared creating country CVH trajectories.

Results

The analysis included 28,092 adults (Ethiopia n=7686, 55.2% male; Bangladesh n=6731, 48.4% male; Brazil n=7241, 47.9 % male; England n=2691, 49.5% male, and the US n=3743, 50.3% male). As country income level increased, prevalence of high CVH decreased (>90% in Ethiopia, >68% in Bangladesh and under 65% in the remaining countries). This pattern remained using either five or all six CVH metrics and following exclusion of underweight participants. While a decline in CVH with age was observed for all countries, higher income countries showed lower prevalence of high CVH already by age 18y. Excess body weight appeared the main driver of poor CVH in higher income countries, while current smoking was highest in Bangladesh.

Conclusion

Harmonization of nationally representative survey data on CVH trajectories with age in 5 highly diverse countries supports our hypothesis that CVH decline with age may be universal. Interventions to promote and preserve high CVH throughout the life course are needed in all populations, tailored to country-specific time courses of the decline. In countries where CVH remains relatively high, protection of whole societies from risk factor epidemics may still be feasible.

Association of Cardiovascular Health With Risk of Clinically Relevant Depressive Symptoms

Importance

Cardiovascular health may be used for prevention of depressive symptoms. However, data on the association of cardiovascular health across midlife with depressive symptoms are lacking.

Objective

To evaluate whether better baseline cardiovascular health and improvement of cardiovascular health over time are associated with a lower risk of both incident depressive symptoms and unfavorable trajectories of depressive symptoms.

Design, Setting, and Participants

Participants without depressive symptoms were included from a prospective community-based cohort in France (GAZEL cohort). Cardiovascular health examinations occurred in 1990 and 1997 and assessment of depressive symptoms in 1997 and every 3 years thereafter until 2015. Data were analyzed from January to October 2022.

Exposures

Number of cardiovascular health metrics (smoking, body mass index, physical activity, diet, blood pressure, glucose, and cholesterol) at an intermediate or ideal level in 1997 (range, 0-7) and 7-year change in cardiovascular health between 1990 and 1997.

Main Outcomes and Measures

Primary outcome was incident depressive symptoms (20-item Center for Epidemiologic Studies-Depression Scale [CES-D] score of 17 or greater in men or 23 or greater in women); secondary outcome was trajectories of depressive symptoms scores. Trajectories included consistently low scores, moderately elevated scores, low starting then increasing scores, moderately high starting, increasing, then remitting scores, and moderately high starting then increasing scores.

Results

Of 6980 included patients, 1671 (23.9%) were women, and the mean (SD) age was 53.3 (3.5) years. During a follow-up spanning 19 years after 1997, 1858 individuals (26.5%) had incident depressive symptoms. Higher baseline cardiovascular health in 1997 and improvement in cardiovascular health over 7 years were each associated with lower risk of depressive symptoms (odds ratio [OR] per additional metric at intermediate or ideal level at baseline, 0.87; 95% CI, 0.84-0.91; OR per 1 higher metric at intermediate or ideal level over 7 years, 0.91; 95% CI, 0.86-0.96). Also, better cardiovascular health was associated with lower risk of unfavorable depressive symptoms trajectories. Compared with the consistently low score trajectory, the lowest risks were observed for the low starting then increasing score trajectory (OR per additional metric at intermediate or ideal level at baseline, 0.70; 95% CI, 0.64-0.76; OR per 1 higher metric at intermediate or ideal level over 7 years, 0.73; 95% CI, 0.68-0.79) and the moderately high starting then increasing score trajectory (OR per additional metric at intermediate or ideal level at baseline, 0.71; 95% CI, 0.64-0.79; OR per 1 higher metric at intermediate or ideal level over 7 years, 0.71; 95% CI, 0.64-0.77).

Conclusions and Relevance

In this prospective community-based cohort study of adults, higher cardiovascular health was associated with a lower risk of depressive symptoms over time. Elucidating which set of cardiovascular factors may affect depression risk could be important for prevention.

Person-centered and measured life's simple 7 cardiovascular health concordance and association with incident cardiovascular disease

Person-centered cardiovascular health (CVH) may facilitate cardiovascular disease primordial prevention in low resources settings. The study aims to assess the validity of person-centered CVH compared to gold standard measured CVH by examining the concordance between person-centered vs. measured CVH together with their respective association with incident cardiovascular disease events (CVD). Life's Simple 7 (LS7) CVH metrics, including non-smoking, Body Mass Index, diet, physical activity, blood glycemia, blood pressure, and blood cholesterol were collected from 19,473 adults participating in the e-cohort NutriNet-Santé study from 2011 to 2014 and were followed until September 2020. Clinical examinations and blood analyses defined the measured biological metrics, while diagnoses, medication, or treatment for type 2 diabetes, hypertension, and hypercholesterolemia defined person-centered biological metrics. Declared behavioral metrics were common for both measured and person-centered CVH. The study included 18,714 CVD-free participants (mean age 51 years, 73% women), among whom 16.52% and 38.75% had 5-7 ideal LS7 metrics according to measured and person-centered CVH, respectively. Weighted concordance of person-centered and measured CVH was 0.87 [0.86; 0.88]. Over median follow-up of 8.05 years, 749 CVD events occurred. There was a 7% (HR 0.93 [0.88; 0.99]) and 13% (HR 0.87 [0.83; 0.92]) risk reduction of CVD risk by additional measured and person-centered ideal metrics, respectively. In conclusion, person-centered CVH may represent a reliable alternative to measured CVH.

Association of Midlife Cardiovascular Health and Subsequent Change in Cardiovascular Health With Incident Cancer

Background

The commonality of risk factors between cancer and cardiovascular disease suggests that primordial prevention (preventing the onset of risk factors) is a relevant strategy for cancer prevention.

Objectives

This study sought to examine the association between baseline and change in the cardiovascular health (CVH) score and incident cancer.

Methods

Using serial examinations of the GAZEL (GAZ et ELECTRICITE de France) study in France, we examined the associations between the American Heart Association's Life's Simple 7 CVH score (range: 0-to 14 [poor, intermediate, and ideal level of smoking, physical activity, body mass index, diet, blood pressure, diabetes status, or lipids]) in 1989/1990, their change over 7 years, and incident cancer and cardiac events up to 2015.

Results

The study population included 13,933 participants (mean age: 45.3 ± 3.4 years, 24% women). After a median follow-up of 24.8 years (Q1-Q3: 19.4-24.9 years), 2,010 participants had an incident cancer and 899 a cardiac event. The risk of cancer (any site) decreased by 9% (HR: 0.91; 95% CI: 0.88-0.93) per 1-point increase in the CVH score in 1989/1990 compared with a 20% (HR: 0.80; 95% CI: 0.77-0.83) risk reduction for cardiac events. The risk of cancer decreased by 5% (HR: 0.95; 95% CI: 0.92-0.99) per unit of change in the CVH score between 1989/1990 and 1996/1997 compared with a 7% risk reduction for cardiac events (HR: 0.93; 95% CI: 0.88-0.98). These associations remained after omitting the smoking metric from the CVH score.

Conclusions

Primordial prevention is a relevant strategy for the prevention of cancer in the population.

Prevalence of ideal cardiovascular health in the Brazilian adult population - National Health Survey 2019

OBJECTIVE

to analyze the prevalence of ideal cardiovascular health (CVH) in the Brazilian adult population based on the 2019 National Health Survey.

METHODS

this was a population-based cross-sectional study (n = 77,494); prevalence and respective 95% confidence intervals (95%CI) of ideal CVH (seven metrics achieved simultaneously) and by individual metrics (four behavioral and three biological metrics), as defined by the American Heart Association, were estimated.

RESULTS

only 0.5% (95%CI 0.4;0.6) of the study population presented ideal CVH, with higher prevalence among those with higher level of education (1.3%; 95%CI 0.9;1.6) and residents in urban areas (0.6%; 95%CI 0.5;0.7); the prevalence of behavioral and biological metrics was 0.7% (95%CI 0.6;0.8) and 63.3% (95%CI 62.7;63.9) respectively.

CONCLUSION

the prevalence of ideal CVH was very low, highlighting the need for public policies aimed at promotion, surveillance and CVH care in the Brazilian adult population.

ASSOCIATION BETWEEN UNDERWEIGHT AND EXCESS BODY WEIGHT BEFORE SARS-COV-2 INFECTION AND CLINICAL OUTCOMES OF COVID-19: MULTICENTER STUDY

Objectives

The present study aimed to identify associations between extremes in body weight status (underweight and excess body weight) before a COVID-19 diagnosis and clinical outcomes in patients infected with SARS coronavirus type 2.

Methods

A multicenter cohort study was conducted in eight different states in northeastern Brazil. Demographic, clinical (previous diagnosis of comorbidities), and anthropometric (self-reported weight and height) data about individuals who tested positive for COVID-19 were collected. Outcomes included hospitalization, mechanical ventilation, and death. Multivariable logistic regression models, adjusted based on age, sex and previous comorbidities, were used to assess the effects of extremes in body weight status on clinical outcomes.

Results

A total of 1308 individuals were assessed (33.6% were elderly individuals). The univariable analyses showed that only hospitalization was more often observed among underweight (3.2% versus 1.2%) and overweight (68.1% versus 63.3%) individuals. In turn, cardiovascular diseases were more often observed in all clinical outcomes (hospitalization: 19.7% versus 4.8%; mechanical ventilation: 19.9% versus 13.5%; death: 21.8% versus 14.1%). Based on the multivariable analysis, body weight status was not associated with risk of hospitalization (underweight: odds ratio [OR]: 1.10; 95% confidence interval [CI] 95%, 0.50–2.41 and excess body weight: OR: 0.81; 95 CI, 0.57–1.14), mechanical ventilation (underweight: OR: 0.92; 95% CI, 0.52–1.62 and excess weight: OR: 0.90; 95% CI, 0.67–1.19), and death (underweight: OR: 0.61; 95% CI, 0.31–1.20 and excess body weight: OR 0.88; 95% CI, 0.63–1.23).

Conclusions

Being underweight and excess body weight were not independently associated with clinical outcomes in patients with COVID-19 in the herein analyzed cohort. This finding indicates that the association between these variables may be confounded by both age and comorbidities.