The Relationship Between Ideal Cardiovascular Health Behaviors And Factors In Chinese Population And The Risk Of Atherosclerotic Cardiovascular Disease

Background and objectiveDespite encouraging advances in the prevention,diagnosis,and treatment of cardiovascular disease(CVD),CVD remains a major cause of premature death and disability both worldwide and in China.China is suffering from heavier and heavier health burden attributed to CVD in recent years.Numerous studies have proved that smoking,obesity,physical inactivity,unhealthy diet,hypertension,diabetes,and hypercholesterolemia are well-established risk factors contributing to CVD.In this context,the American Heart Association(AHA)has proposed a new concept of ideal cardiovascular health(CVH)and formulated the following 2020 Strategic Impact Goals in 2010:"By 2020,to improve the cardiovascular health of all Americans by 20%while reducing deaths from cardiovascular diseases and stroke by 20%." To define CVH,the AHA used 7 simple,easily producible metrics,known as CVH metrics.The 7 CVH metrics,often referred as Life's Simple 7 as well,include 4 modifiable health behaviors(smoking,body mass index(BMI),physical activity,and diet)and 3 modifiable biological health factors(blood pressure(BP),serum total cholesterol(TC),and fasting glucose).Each of the 7 CVH metrics can be categorized as ideal,intermediate,or poor.The AHA 2020 Strategic Impact Goal focused on promotion of CVH,modification of lifestyles and control of risk factors,rather than solely preventing the development of specific cerebro-cardiovascular diseases,aligning more closely with the concept of primordial prevention.Over the past few years,there have been plenty of studies investigating the epidemic of CVH metrics and their associations with the risk of multiple cardiovascular or non-cardiovascular end points across different countries in the world.Previous data have shown a low prevalence of these ideal CVH metrics in general populations across different countries,and many prospective studies have indicated the inverse associations between the number of ideal CVH metrics and the risks of acute myocardial infarction(AMI),stroke,heart failure,CVD mortality,and all-cause mortality.However,evidence from Asia was still insufficient,while existing evidence was mainly derived from Western populations and two East Asian populations,including a Korean male population and a Chinese occupational population(Kailuan study).It remained unclear about the epidemic characteristics of these 7 ideal CVH metrics and their exact effect on atherosclerotic CVD(ASCVD)risk among general Chinese populations.Therefore,we performed the current study using 3 large cohorts from the China-PAR(Prediction for ASCVD Risk in China)project to investigate the distribution of 7 ideal CVH metrics and estimate the joint association and population attributable risk percentage(PAR%)of these metrics in relation to the risk of ASCVD and its subtypes.Our results may provide some valuable evidence and theoretical suggestions for future application of CVH metrics in ASCVD prevention in China.Subjects and MethodsParticipants for the current study were recruited from 3 Chinese longitudinal cohorts in the China-PAR project,including the China Multi-Center Collaborative Study of Cardiovascular Epidemiology(China MUCA-1998),the International Collaborative Study of CVD in Asia(InterASIA),and the Community Intervention of Metabolic Syndrome in China&Chinese Family Health Study(CIMIC).After exclusion of those with a history of ASCVD at entry,without complete data on CVH metrics,or lost to follow-up,a total of 93 987 participants aged over 20 years old were included in this study.A standardized questionnaire comprising information on demographic characteristics,lifestyle information,history of chronic diseases and medication were administrated by trained interviewers with unified survey methods.A stringent quality control program was implemented during the follow-up investigation.An expert committee at Fuwai Hospital reviewed and adjudicated all the final end-point events by reviewing all incidence and death records.The outcome of interest was incidence of ASCVD events during the follow-up from baseline examnination.ASCVD was defined as the first occurrence of nonfatal AMI,or coronary heart desease(CHD)death or fatal or non-fatal stroke.We further classified the total ASCVD events into 3 event types,including CHD(fatal or nonfatal CHD events),stroke(fatal or nonfatal stroke events) and ASCVD death.According to the standards proposed by AHA,baseline status of smoking,BMI,physical activity,TC,BP,and fasting glucose was defined and devided into two categories of ideal/non-ideal or three categories of ideal/intermediate/poor.However,we used a modified definition of ideal diet to comply with Chinese dietary habits based on food frequency questionnaire in current survey.We proposed 5 healthy dietary habits,including(1)fish ?200 g/week,(2)vegetables and fresh fruits ?500 g/day,(3)soybean products ?125 g/day,(4)red meat<75 g/day,and(5)tea ?50 g/month,in accordance with the current "Dietary Guidelines for Chinese Residents" and AHA's recommended dietary goals.In the description of baseline distribution of dietary metric,4-5/2-3/0-1 healthy dietary habits was categorized as ideal/intermediate/poor,respectively.While for the association analyses,we combined the two subgroups of 4-5 and 2-3 healthy dietary habits,and defined ideal diet as ? 2 healthy dietary habits.We then summed up the total number of ideal CVH metrics,assigned a score according to the category of each CVH metric:2=ideal,1=intermediate,0=poor,and calculate the total CVH score of each individual.Ideal CVH status was therefore defined as the simultaneous presence of 7 ideal CVH metrics.A multivariate logistic regression model was used to explore the sociodemographic factors influencing the distribution of ideal CVH metrics at baseline.All the participants were classified into several groups according to the number of ideal CVH metrics or the composite CVH score.The Kaplan-Meier survival curves for cumulative incidence of these CVH groups were drawn,and a log-rank test was conducted to determine the difference across these groups.Hazard ratios(HRs)and corresponding 95%confidence intervals(CIs)for ASCVD risk were calculated using Cox proportional hazards regression models.Restricted cubic splines were further used to flexibly model potential dose-response association between the number of ideal CVH metrics as a continuous variable and the risk of ASCVD events.We also calculated the multivariable-adjusted PAR%and 95%CIs for each CVH metric and the number of ideal CVH metrics.ResultsOverall,the current study included 37 805 males and 56 182 females,with a mean age of 51.6 years old.The prevalence of ideal status for each CVH metric ranged from 4.2%for ideal BP to 77.9%for ideal fasting glucose.In total,only 0.4%of the study participants had all the 7 ideal CVH metrics,while 76.6%of them had 3-5 ideal CVH metrics.After adjustment of cohort sources and other sociodemographic risk factors,female sex,younger age,living in southern and rural areas are independent protective factors for cardiovascular health.During a median follow-up of 15,13,and 6 years for ChinaMUCA-1998,Inter ASIA,and CIMIC cohort respectively,3 457 ASCVD events,including 788 CHD,2 718 stroke,and 1 383 ASCVD deaths were recorded among the 93987 participants.A strong inverse gradient relationship was present between the number of ideal CVH metrics and sex-and age-adjusted incidence rate of total ASCVD events as well as each event type.In the multivariable-adjusted Cox regression models including age,sex,living region,urbanization,alcohol use,education level,family history of ASCVD and cohort sources,compared with those having 0-2 ideal metrics,the fully adjusted HRs and 95%CIs for participants with 3,4,5,6,and 7 ideal metrics were 0.83(0.74-0.93),0.66(0.59-0.74),0.55(0.48-0.61),0.44(0.38-0.50)and 0.24(0.18-0.31),respectively.Likewise,compared with participants with a total CVH score of 0-8,the multivariable adjusted HRs and 95%CIs for those with a CVH score of 9-10 and 11-14 were 0.70(0.64-0.75)and 0.49(0.45-0.54),respectively.To be with a larger number of ideal metrics was also associated with a significantly lower risk of each ASCVD event type(all P for trend<0.0001).The adjusted PAR%was 62.1%for ASCVD events,38.7%for CHD,66.4%for stroke,and 60.5%for ASCVD mortality,respectively,for not achieving all the 7 ideal CVH metrics.The adjusted PAR%of not achieving 4 ideal health behaviors was 17.4%for ASCVD events,18.0%for CHD,16.7%for stroke,and 10.1%for ASCVD death after adjusting for potential covariates as well as the number of ideal health factors.Among all the metrics,ideal BP status ranked the first according to the magnitude of PAR%after multivariable adjustment(PAR%of 44.1%for ASCVD events,33.0%for CHD,46.0%for stroke,and 47.2%for ASCVD mortality).Furthermore,results remained consistent in multiple sensitivity analyses and subgroup analyses across sex,age group,living region,and urbanization.ConclusionIn conclusion,the prevalence of ideal cardiovascular health status of general Chinese adults is extremely low.Among the 7 CVH metrics,the prevalence of ideal diet and ideal BP was relatively low.Men,the elderly,northern and urban residents are of special concern.Besides,our large prospective cohort study has proven that there was a gradient inverse association between the number of ideal CVH metrics and the development of various ASCVD events,supporting the application of AHA's CVH metrics for ASCVD risk assessment and health promotion among general Chinese adults.The more ideal CVH metrics adults have,the less ASCVD burden there is in China.Promotion of CVH is considered as a key part of the population health agenda.Special efforts of health education and behavior modification should be made on keeping ideal BP,adhering to scientific dietary habits and physical exercise in general Chinese population to prevent the epidemic of ASCVD.