Status of Cardiovascular Health in US Adults and Children Using the American Heart Association’s New “Life’s Essential 8” Metrics: Prevalence Estimates From the National Health and Nutrition Examination Survey (NHANES), 2013 Through 2018

HomeCirculationVol. 146, No. 11Status of Cardiovascular Health in US Adults and Children Using the American Heart Association’s New “Life’s Essential 8” Metrics: Prevalence Estimates From the National Health and Nutrition Examination Survey (NHANES), 2013 Through 2018 Free AccessResearch ArticlePDF/EPUBCME AvailableAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBCME AvailableStatus of Cardiovascular Health in US Adults and Children Using the American Heart Association’s New “Life’s Essential 8” Metrics: Prevalence Estimates From the National Health and Nutrition Examination Survey (NHANES), 2013 Through 2018 Donald M. Lloyd-Jones, Hongyan Ning, Darwin Labarthe, LaPrincess Brewer, Garima Sharma, Wayne Rosamond, Randi E. Foraker, Terrie Black, Michael A. Grandner, Norrina B. Allen, Cheryl Anderson, Helen Lavretsky and Amanda M. Perak Donald M. Lloyd-JonesDonald M. Lloyd-Jones Correspondence to: Donald M. Lloyd-Jones, MD, ScM, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N Lake Shore Dr, Suite 1400, Chicago, IL 60611. Email E-mail Address: [email protected] https://orcid.org/0000-0003-0847-6110 Northwestern University Feinberg School of Medicine, Chicago, IL (D.M.L.-J., H.N., D.L., N.B.A., A.M.P.). Search for more papers by this author , Hongyan NingHongyan Ning Northwestern University Feinberg School of Medicine, Chicago, IL (D.M.L.-J., H.N., D.L., N.B.A., A.M.P.). Search for more papers by this author , Darwin LabartheDarwin Labarthe Northwestern University Feinberg School of Medicine, Chicago, IL (D.M.L.-J., H.N., D.L., N.B.A., A.M.P.). Search for more papers by this author , LaPrincess BrewerLaPrincess Brewer https://orcid.org/0000-0002-6468-9324 Mayo Clinic College of Medicine, Rochester, MN (L.B.). Search for more papers by this author , Garima SharmaGarima Sharma https://orcid.org/0000-0001-7254-2077 Johns Hopkins University School of Medicine, Baltimore, MD (G.S.). Search for more papers by this author , Wayne RosamondWayne Rosamond https://orcid.org/0000-0001-5271-074X University of North Carolina Gillings School of Public Health, Chapel Hill (W.R.). Search for more papers by this author , Randi E. ForakerRandi E. Foraker https://orcid.org/0000-0001-9255-9394 Washington University School of Medicine, St Louis, MO (R.E.F.). Search for more papers by this author , Terrie BlackTerrie Black University of Massachusetts Amherst College of Nursing (T.B.). Search for more papers by this author , Michael A. GrandnerMichael A. Grandner University of Arizona College of Medicine, Tucson (M.A.G.). Search for more papers by this author , Norrina B. AllenNorrina B. Allen Northwestern University Feinberg School of Medicine, Chicago, IL (D.M.L.-J., H.N., D.L., N.B.A., A.M.P.). Search for more papers by this author , Cheryl AndersonCheryl Anderson https://orcid.org/0000-0002-1877-6873 The Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla (C.A.). Search for more papers by this author , Helen LavretskyHelen Lavretsky University of California Los Angeles (H.L.). Search for more papers by this author and Amanda M. PerakAmanda M. Perak Northwestern University Feinberg School of Medicine, Chicago, IL (D.M.L.-J., H.N., D.L., N.B.A., A.M.P.). Search for more papers by this author Originally published29 Jun 2022https://doi.org/10.1161/CIRCULATIONAHA.122.060911Circulation. 2022;146:822–835is corrected byCorrection to: Status of Cardiovascular Health in US Adults and Children Using the American Heart Association’s New “Life’s Essential 8” Metrics: Prevalence Estimates From the National Health and Nutrition Examination Survey (NHANES), 2013 Through 2018Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: September 12, 2022: Previous Version of Record June 29, 2022: Ahead of Print AbstractBackground:The American Heart Association recently published an updated algorithm for quantifying cardiovascular health (CVH)—the Life’s Essential 8 score. We quantified US levels of CVH using the new score.Methods:We included individuals ages 2 through 79 years (not pregnant or institutionalized) who were free of cardiovascular disease from the National Health and Nutrition Examination Surveys in 2013 through 2018. For all participants, we calculated the overall CVH score (range, 0 [lowest] to 100 [highest]), as well as the score for each component of diet, physical activity, nicotine exposure, sleep duration, body mass index, blood lipids, blood glucose, and blood pressure, using published American Heart Association definitions. Sample weights and design were incorporated in calculating prevalence estimates and standard errors using standard survey procedures. CVH scores were assessed across strata of age, sex, race and ethnicity, family income, and depression.Results:There were 23 409 participants, representing 201 728 000 adults and 74 435 000 children. The overall mean CVH score was 64.7 (95% CI, 63.9–65.6) among adults using all 8 metrics and 65.5 (95% CI, 64.4–66.6) for the 3 metrics available (diet, physical activity, and body mass index) among children and adolescents ages 2 through 19 years. For adults, there were significant differences in mean overall CVH scores by sex (women, 67.0; men, 62.5), age (range of mean values, 62.2–68.7), and racial and ethnic group (range, 59.7–68.5). Mean scores were lowest for diet, physical activity, and body mass index metrics. There were large differences in mean scores across demographic groups for diet (range, 23.8–47.7), nicotine exposure (range, 63.1–85.0), blood glucose (range, 65.7–88.1), and blood pressure (range, 49.5–84.0). In children, diet scores were low (mean 40.6) and were progressively lower in higher age groups (from 61.1 at ages 2 through 5 to 28.5 at ages 12 through 19); large differences were also noted in mean physical activity (range, 63.1–88.3) and body mass index (range, 74.4–89.4) scores by sociodemographic group.Conclusions:The new Life’s Essential 8 score helps identify large group and individual differences in CVH. Overall CVH in the US population remains well below optimal levels and there are both broad and targeted opportunities to monitor, preserve, and improve CVH across the life course in individuals and the population.Clinical PerspectiveWhat Is New?These data provide the first assessment of the cardiovascular health of the US population using the American Heart Association’s Life’s Essential 8 score.Cardiovascular health is well below optimal in adults and children and it declines with age beginning from ages 2 to 5 years; suboptimal diet, physical activity, and body mass index contribute most to lower Life’s Essential 8 scores.Compared with the original Life’s Simple 7 score, the new Life’s Essential 8 updated scoring algorithm and sleep information contribute to understanding disparities in cardiovascular health across sociodemographic groups.What Are the Clinical Implications?Clinicians and patients can measure the Life’s Essential 8 score and monitor it over time to assess an individual’s current cardiovascular health and opportunities to maintain or improve it to enhance long-term health outcomes.Measurement in clinical settings may require routine assessment of diet patterns, physical activity, and sleep habits using rapid questionnaires recommended by the American Heart Association.Cardiovascular health assessment appears useful at all ages and may particularly enhance communication and health promotion strategies in children and young adults, for whom the benefits of optimizing cardiovascular health may be especially large over the remaining life course.In 2010, the American Heart Association (AHA) published its novel definition of cardiovascular health (CVH)1 to promote improvements in individual and population health and to provide metrics for measuring and monitoring it. Assessment of CVH was on the basis of levels of 7 health behaviors and factors—diet, physical activity (PA), cigarette smoking, body mass index (BMI), total cholesterol, blood pressure (BP), and blood glucose—called Life’s Simple 7 (LS7). For each of these 7 metrics, 3 strata were defined as poor, intermediate, or ideal using clinical cut points. Overall CVH could be quantified by a summary score ranging from 0 (all 7 metrics at poor levels) to 14 (all 7 metrics at ideal levels).1,2The prevalence and distributions of CVH have been described in populations around the world.2 Higher CVH scores are associated prospectively with a multitude of favorable health outcomes across the life course.2–19 Numerous investigators have also described upstream determinants, cross-sectional correlates, and molecular mechanisms of higher CVH and its associations with health outcomes.19–24 This body of scientific evidence has substantially advanced our understanding of the life course of CVH, healthy aging, and the potential power of primordial prevention.25–28 At the same time, limitations of the original LS7 CVH score were identified. Therefore, the AHA recently enhanced and expanded the definition and methods for quantification of CVH29 to increase the sensitivity of scoring to interindividual differences and to change over time in both individuals and populations. In addition, sleep health was added as an eighth CVH metric. The critical contexts of social determinants of health and psychological health for maintaining CVH or improving it were also highlighted. The new CVH construct is now called Life’s Essential 8 (LE8).29We leveraged data from the National Health and Nutrition Examination Survey (NHANES) from 2013 through 201830 to demonstrate methods of assessing the LE8 score in the population and to describe current prevalence and distributions of CVH using the new score overall and by age, self-identified sex and race and ethnicity, socioeconomic position, and depressive symptom status. We also compared CVH scores overall and for each component metric using both the original LS7 score (0 to 14-point scale) and the new LE8 approach (0 to 100-point scale).MethodsStudy SampleAll data and guidance on analytical approaches are publicly and freely available from the US Centers for Disease Control and Prevention’s National Center for Health Statistics and can be accessed at https://www.cdc.gov/nchs/nhanes/index.htm. This cross-sectional analysis used 6 years of data from the 2013 to 2018 NHANES cycles. NHANES collected data in 2-year cycles and used a complex, multistage probability sampling design to select a sample representative of the civilian, noninstitutionalized US population.30 Participants were interviewed at home and were invited to attend a mobile examination center, where they underwent various anthropometric and physiologic examinations and blood tests. Written informed consent was obtained from all participants or their parents or guardians. This research was deemed exempt by the Northwestern University Institute Review Board given the use of fully de-identified data.The total combined sample of NHANES 2013 through 2018 (the most recent complete data given the disruptions caused by the COVID-19 pandemic) comprised 29 400 participants. We excluded individuals with an incomplete interview or examination (n=1339), those age >79 years or <2 years (n=2903 [given limited data or CVH metrics not collected]), those who were pregnant or breastfeeding at the time of examination (n=313 [given the nonrepresentativeness of some metrics (e.g., cholesterol values, pregnancy)]), and those having self-reported history of coronary heart disease, angina, heart attack, or stroke (n=1436 [given the focus on CVH before onset of cardiovascular disease (CVD)]). The analysis sample for the current report consisted of 13 521 adults (ages 20 to 79 years) and 9888 children (ages 2 to 19 years). Individuals self-identifying as multiracial (n=1374) were included in all analyses except for those stratified by race and ethnicity given the heterogeneous makeup of this group. We analyzed all available data, excluding individuals from analyses only if relevant variables were missing; participants with complete information for all 8 CVH components were included for calculation of the full CVH score.Demographic and Social CharacteristicsDemographic characteristics (age, self-reported sex and race and ethnicity, and annual household income) were queried during the home interview. Participants were stratified by age into 6 groups: preschoolers (2–5 years), childhood (6–11 years), adolescence (12–19 years), young adulthood (20–39 years), middle age (40–64 years), or older age (65–79 years). Self-reported race and ethnicity was categorized as non-Hispanic (NH) Asian, NH Black, NH White, Mexican American, or other Hispanic, according to NHANES protocol. Annual household income was categorized as <$45 000 or ≥$45 000.31 Household poverty was calculated as the ratio of monthly family income to poverty levels defined by Department of Health and Human Services guidelines and categorized as low income (≤1.30), low middle income (1.31–1.85), middle income (1.86–3.50), and high income (>3.50).32Depression StatusWhereas depression (or its absence) is only one aspect of psychological health, it is one of the more reliable psychological phenotypes measured in NHANES, which has not yet routinely measured aspects of positive psychological health. Depression was measured among participants ages 18 years and older using the Patient Health Questionnaire–2 (PHQ-2), a reliable short screening tool for assessing depression levels in the general population.33 Participants were asked “Over the last 2 weeks, how often have you been bothered by the following problems?” and responded to 2 items (“Feeling down, depressed, or hopeless” and “Little interest or pleasure in doing things”) on a scale with the response options “not at all,” “several days,” “more than half the days,” and “nearly every day”; responses are scored as 0, 1, 2, or 3, respectively. Scores of ≥3 out of 6 are the validated threshold for detecting probable cases of depression.34Quantification of CVHDetailed methods for applying the LE8 scoring algorithm for each of the metrics to NHANES data for adults and children are provided in the Supplemental Material and in the AHA Presidential Advisory.29 Definitions and scoring for the component metrics of CVH, including the 4 health behaviors (diet, PA, smoking, and sleep) and 4 health factors (BMI, non–high-density lipoprotein [HDL] cholesterol, blood glucose, and BP) for adults and children are outlined in Table S1. For each individual, each of the 8 CVH metrics was scored on a scale of 0 to 100 points according to the AHA algorithm. In adults, overall CVH was calculated for each individual by summing the scores for each of the 8 metrics together and dividing the total by 8, to provide an LE8 score ranging from 0 to 100. In children, overall CVH was calculated by summing the scores for all metrics available in NHANES for the given age range and dividing by the denominator of the number of metrics. For example, diet, PA, and BMI are available for ages 2 through 19, so a CVH score for all ages 2 through 19 could be calculated by summing the scores for metrics together and dividing the total by 3, to provide an LE8 score ranging from 0 to 100. There are 4 metrics available from ages 6 to 19 (including lipids), 5 metrics from 8 to 19 (including BP), 7 metrics from 12 to 19 (including nicotine and glucose), and all 8 metrics (including sleep) available for ages 16 to 19. The overall CVH score was calculated for each of these age ranges to assess the consistency of the LE8 score across different numbers of metrics and diverse ages.Statistical AnalysisAll analyses were performed using SAS version 9.4 (SAS Institute). To incorporate the complex multistage sampling design of NHANES in the statistical analysis, SAS procedures SURVEYFREQ and SURVEYMEANS were used. To create a larger sample, data from three 2-year cycles of the continuous NHANES were combined for 2013 through 2018. Per NHANES analytical guidelines for combining data across cycles, sample weights were constructed with rescaling of the weights such that the sum of weights matched the survey population at the midpoint of each survey period. Sample weights for laboratory and physical examination data were used to estimate the number of individuals in the US population overall and in each age, sex, and racial and ethnic group as appropriate. Final sampling weights were divided by the number of combined surveys to estimate population averages. Sample weights and design were incorporated in calculating prevalence estimates and standard errors. For prevalence estimates, nonoverlapping 95% CIs indicate statistical significance; in these analyses, these are all equivalent to P<0.001.ResultsSample CharacteristicsIn the NHANES samples, there were 13 521 adult and 9888 child participants, representing 201 728 000 and 74 435 000 US adults and children, respectively. Characteristics of the sample with weighted population numbers are presented in Table 1 for adults and Table 2 for children, stratified by sex. The data represent the sex, age, and race and ethnicity of the US population, with approximately half being female, a mean age of 45 years in adults and 10 years in children, and individuals identifying as NH Asian (6%), NH Black (11%), NH White (63%), Mexican (9%), other Hispanic (7%), and other race including multiracial (4%) in adults and NH Asian (5%), NH Black (14%), NH White (51%), Mexican (16%), other Hispanic (8%), and other race including multiracial (6%) in children. Characteristics are presented stratified by age groups in Tables S2 and S3 for adults and children, respectively.Table 1. Characteristics of US Adults (Ages 20 to 79 Years; Not Pregnant, Not Institutionalized) Without Cardiovascular Disease by Self-Reported SexCharacteristicsMen, prevalence, % (n [in millions], weighted)Women, prevalence, % (n [in millions], weighted)Total sample (n=13 521), weighted to 201 728 000 adults48.9 (98.7)51.1 (103)Age, y, mean (SE)44.3 (0.28)46.5 (0.35)Age strata, y 20–3942.0 (41.5)36.9 (38.0) 40–6446.2 (45.6)47.7 (49.1) 65–7911.8 (11.6)15.4 (15.9)Self-reported race and ethnicity Non-Hispanic Asian5.7 (5.7)6.3 (6.4) Non-Hispanic Black10.8 (10.7)12.0 (12.4) Non-Hispanic White62.8 (62.0)62.9 (64.8) Mexican10.2 (10.1)8.8 (9.1) Other Hispanic6.6 (6.5)6.7 (6.9) Other race, including multiracial3.9 (3.8)3.3 (3.4)Poverty index ≤1.3019.7 (17.9)22.6 (21.4) 1.31–1.859.8 (8.9)10.6 (10.0) 1.86–3.5024.5 (22.2)24.1 (22.8) >3.5046.0 (41.7)42.7 (40.3)Family income ≥$45 00062.4 (57.0)59.1 (56.3) <$45 00037.6 (34.3)40.9 (39.0)Depression PHQ-2 score <393.2 (86.3)90.9 (86.0) PHQ-2 score ≥36.8 (6.3)9.1 (8.6)AHA Life’s Essential 8 scores (100 possible points), mean (SE)Total CVH score63.6 (0.44)68.1 (0.48) DASH diet score38.1 (0.84)51.9 (0.90) Physical activity score54.0 (1.03)49.2 (1.18) Tobacco or nicotine exposure score63.1 (0.90)75.1 (0.82) Sleep health score84.0 (0.51)85.3 (0.38) BMI score57.8 (0.73)57.1 (0.88) Blood lipids (non-HDL cholesterol) score64.8 (0.68)69.9 (0.65) Blood glucose score76.8 (0.63)80.0 (0.43) BP score67.6 (0.68)73.8 (0.53)Data from National Health and Nutrition Examinations, 2013 through 2018. AHA indicates American Heart Association; BMI, body mass index; BP, blood pressure; CVH, cardiovascular health; DASH, Dietary Approaches to Stop Hypertension; HDL, high-density lipoprotein; and PHQ, Patient Health Questionnaire.Table 2. Characteristics of US Children (Ages 2 to 19 Years; Not Pregnant, Not Institutionalized) Without Cardiovascular Disease by Reported SexCharacteristicsBoys, % (n [in millions], weighted)Girls, % (n [in millions], weighted)Total sample (n=9888), weighted to 74 435 000 children50.9 (37.9)49.1 (36.5)Age, y, mean (SE)10.5 (0.11)10.6 (0.13)Age strata, y 2–521.4 (8.1)21.8 (8.0) 6–1133.3 (12.6)33.2 (12.1) 12–1945.2 (17.1)44.9 (16.4)Reported race and ethnicity Non-Hispanic Asian4.9 (1.9)4.8 (1.8) Non-Hispanic Black13.4 (5.1)13.9 (5.1) Non-Hispanic White51.8 (19.6)50.8 (18.5) Mexican15.6 (5.9)16.6 (6.1) Other Hispanic8.6 (3.2)7.6 (2.8) Other race, including multiracial5.7 (2.2)6.4 (2.3)Poverty index ≤1.3033.1 (11.6)34.1 (11.6) 1.31–1.8511.6 (4.1)12.3 (4.2) 1.86–3.5026.5 (9.3)24.1 (8.2) >3.5028.7 (10.0)29.6 (10.0)Family income ≥$45 00058.0 (20.5)57.5 (19.7) <$45 00042.0 (14.8)42.5 (14.6)Depression (ages 18 or 19) PHQ-2 score <393.6 (34.8)91.5 (34.7) PHQ-2 score ≥36.4 (0.2)8.5 (0.3)AHA Life’s Essential 8 scores (of 100 possible points), mean (SE)Total score, ages 16 to 19 years73.4 (0.71)73.6 (0.51)Total score, ages 12 to 19 years (includes diet, PA, nicotine, BMI, non-HDL cholesterol, glucose, BP)74.0 (0.54)74.1 (0.51)Total score, ages 8 to 19 years (includes diet, PA, BMI, non-HDL cholesterol, BP)70.3 (0.41)69.6 (0.43)Total score, ages 6 to 19 years (includes diet, PA, BMI, non-HDL cholesterol)65.3 (0.50)63.8 (0.52)Total score, ages 2 to 19 years (includes diet, PA, BMI)65.4 (0.61)65.5 (0.61) DASH diet score (ages 2 to 19 years)37.6 (0.97)43.6 (0.89) Physical activity score (ages 2 to 19 years)78.2 (0.79)71.8 (0.82) Tobacco or nicotine exposure score (ages 12 to 19 years)83.2 (1.1)88.0 (0.89) Sleep health score (ages 16 to 19 years)79.3 (1.2)77.0 (1.1) BMI score (ages 2 to 19 years)80.8 (0.64)81.4 (0.71) Blood lipids score (non-HDL cholesterol; ages 6 to 19 years)74.5 (0.64)72.5 (0.74) Blood glucose score (ages 12 to 19 years)90.5 (0.56)94.1 (0.48) BP score (ages 8 to 19 years)94.8 (0.38)97.3 (0.23)Data from National Health and Nutrition Examinations, 2013 through 2018. AHA indicates American Heart Association; BMI, body mass index; BP, blood pressure; DASH, Dietary Approaches to Stop Hypertension; HDL, high-density lipoprotein; PA, physical activity; and PHQ, Patient Health Questionnaire.Comparison of New LE8 With Original LS7 CVH Scores in AdultsFigure 1 displays the median and range of LE8 CVH 100-point scores at each level of the original LS7 14-point score in adults. There was a stepwise increase in LE8 CVH score with each higher point of the LS7 score but with a broad range of the new LE8 scores within each point level of the original score. When the LE8 score was stratified into discrete ranges, there was modest variation in LS7 scores (Figure S1). The overall correlation between the LE8 score and the LS7 score was 0.88 (P<0.0001); Figure S2 demonstrates that the correlation between the 2 scores remained strong across all sex, age, and race and ethnicity strata. Of note, as designed by the AHA writing group, within the original categorical levels (poor, intermediate, ideal) of the 7 metrics common to both CVH scores, there was a broader range of LE8 scores assigned (Figure S3). Most notably, there was wide variation in scores assigned to individuals within each of the original poor, intermediate, and ideal categories of the diet and lipid scores. Greater individual variation in scores was also particularly evident across the strata of the BP metric and within the original intermediate stratum of PA.Download figureDownload PowerPointFigure 1. Life’s Essential 8 CVH scores at each level of Life’s Simple 7 CVH score among US adults. Scores derived from National Health and Nutrition Examination Survey data, 2013 through 2018. Values are median (5th to 95th percentile). CVH indicates cardiovascular health.Both the revision of scoring for the original 7 components (noted previously) and the addition of the new sleep metric appeared to provide new information. The correlation of the original LS7 score with the new LE8 score not including sleep was 0.90 (P<0.0001). The sleep metric was significantly, although modestly, correlated with all of the other 7 CVH metrics except for lipids (Table S4); sleep score was more closely correlated with other health behaviors (diet, PA, and nicotine exposure) than with health factors. When participants were stratified into quartiles of LE8 score without considering sleep versus including sleep, 16.4% of participants were reclassified by inclusion of sleep; 7.9% of participants were reclassified into a higher quartile of LE8 score and 8.4% were reclassified downward to a lower quartile.Status of CVH in AdultsFigure 2 displays the mean (95% CI) and median (5th–95th percentile) LE8 CVH scores (possible range, 0 to 100) for adults overall and by sex, age, and race and ethnicity groups. The overall mean CVH score was 64.7 (95% CI, 63.9–65.6). Scores were significantly higher among women than men (mean, 67.0 versus 62.5) and among those age 20 to 39 years compared with older groups (68.7 versus ≈62.2). Mean scores were highest among those who identified as NH Asian (69.4) followed by NH White (65.0), other Hispanic (64.7), Mexican (61.6), and NH Black (60.0). Figure S4 displays the full distribution density plots of CVH scores by sex, age, and race and ethnicity groups. In total, only 32 adults from the sample, representing ≈762 000 US adults (0.45%), had an optimal CVH score of 100. Using the cut points suggested by AHA, 19.6% of adults (≈33 million) had high CVH (scores ≥80), 62.5% (≈106 million) had moderate CVH (scores of 50 to 79), and 17.9% (≈30 million) had low CVH (scores of <50). Those with high CVH were more likely to be younger and female.Download figureDownload PowerPointFigure 2. Life’s Essential 8 CVH scores. Scores derived from National Health and Nutrition Examination Survey data, 2013 through 2018. A, Mean (thick black bar) and 95% CI (thin bars). Proportions for race and ethnicity do not add up to 100% because of absence of the group identifying as multiracial or other race and ethnicity. B, Median (diamond) and 5th to 95th percentile (black lines) for US adults, overall and by sex, age, and race and ethnicity strata. CVH indicates cardiovascular health; and NH, non-Hispanic.The mean score (out of 100) for a nonclinical CVH score comprising 5 metrics (diet, PA, nicotine exposure, sleep, and BMI) among adults was 61.9 (95% CI, 60.7–63.0) and it was higher in women than men (63.9 versus 59.7), was higher in the older compared with the younger groups (65.1 versus ≈61), and ranged from 54.9 in NH Black to 68.4 in NH Asian individuals.As shown in Figure 3, mean scores were lowest for the diet, PA, and BMI metrics and highest for sleep and glucose. Women had significantly higher (although still low) diet scores than men and better scores on nicotine exposure, blood lipids, blood glucose, and BP; scores for women were similar to those for men for sleep and BMI and lower for PA. At older compared with younger ages, diet and nicotine exposure scores were significantly higher, sleep scores were similar, and PA, BMI, blood lipids, and especially blood glucose and BP scores were lower. Compared with NH Asian participants, NH Black participants had significantly lower scores for diet, nicotine exposure, sleep, BMI, and BP and higher lipid scores. NH White participants had lower diet and nicotine exposure scores and higher glucose scores compared with NH Asian individuals. Within all individuals identifying as Hispanic, many component metric scores were similar, although PA, BMI, and blood glucose scores were better among other Hispanic compared with Mexican American individuals. Comparing all Hispanic with NH Asian individuals, component metric scores for diet, nicotine exposure, and PA were lower and others were similar.Download figureDownload PowerPointFigure 3. Scores for individual cardiovascular health behaviors and health factors. Scores for individual CVH behaviors (A) and health factors (B), overall and by sex, age, and race and ethnicity strata among US adults. Mean scores derived from National Health and Nutrition Examination Survey data, 2013 through 2018. CVH indicates cardiovascular health; and NH, non-Hispanic.The specific distributions of point scores for each component metric are shown in Figure S5. Fewer than 10% of individuals had the highest level of diet scores and there were large proportions at high and low extremes for PA and nicotine exposure. More than 50% of individuals had maximal scores (100) for sleep health and glucose. BMI, non-HDL cholesterol, and glucose point distributions tended to show rising proportions at higher point scores. The effect of these point score distributions was that for some metrics there are wide disparities between mean and median values (Table S5).Status of CVH in ChildrenThe mean CVH scores for US children are shown in Figure 4A through 4E for the metrics available at each age range. For ages 2 through 19 years (Figure 4A), 3 metrics were available (diet, PA, BMI) and mean overall CVH score was 65.5 (95% CI, 64.4–66.6). With the addition of lipids starting at age 6 years (Figure 4B), the mean overall CVH score for ages 6 through 19 years was similar (64.6). The addition of BP starting at age 8 (Figure 4C), nicotine and glucose at age 12 (Figure 4D), and sleep at age 16 (Figure 4E) yielded somewhat higher overall CVH scores given that more children tended to score higher on these added metrics in the older age ranges. The approach recommended by the AHA for tracking CVH through childhood using available metrics and dividing by the denominator of the number of metrics appeared to provide a reasonable means for representing CVH across early life. There were differences noted between sociodemographic groups in overall CVH score (Figure 4). Figure S6 displays the full distribution density plots of CVH scores by sex, age, and race and ethnicity groups. However, for every age stratum of children, regardless of which metrics were available, scores were greater than those f