Current Epidemiology Reports

, Volume 5, Issue 3, pp 262–271 | Cite as

Achieving Optimal Cardiovascular Health: a Social Epidemiological Approach

  • Tomás Cabeza de BacaEmail author
  • Eva M. Durazo
  • Fatima Rodriguez
Cardiovascular Disease (R Foraker, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Cardiovascular Disease


Purpose of Review

The American Heart Association (AHA) created the cardiovascular health (CVH) index to measure and monitor population-level reduction of cardiovascular disease (CVD) risk, with a goal of 20% reduction in CVD morbidity and mortality by 2020. Few U.S. adults meet all seven ideal CVH metrics (non-smoking behavior, healthy diet and body weight, active lifestyle, good cholesterol, glucose, and blood pressure scores), with 17% of men and women only achieving five or more ideal CVH metrics. This review describes the importance of considering sociodemographic, psychosocial, and behavioral factors as key strategies to achieve the AHA 2020 goals.

Recent Findings

Men, racial/ethnic minorities, and individuals of lower socioeconomic status are less likely to achieve ideal CVH—which may start in early childhood. An emerging body of literature indicates that individuals with high-quality social relationships, positive childhood experiences and psychological functioning, along with lifestyle factors, may impact attainment of optimal CVH. For example, exploring the role of food insecurity in CVH attainment demonstrates the complex interplay between contextual factors and lifestyle behaviors that may promote or deter ideal CVH. Evidence also suggests that the CVH index has convergent validity with intermediate and hard endpoints of CVD. Interventions that seek to promote multi-system resiliency may help close the gap in attainment of the AHA 2020 goals.


Research on psychosocial and behavioral factors suggests that social connections, psychological resources, and health-maintaining behaviors are important areas to target to improve CVH in minorities and other vulnerable groups.


Ideal cardiovascular health Cardiovascular disease risk Psychosocial factors Socioeconomic status Social epidemiology Social determinants of health 


Funding Information

Dr. Durazo was supported by a National Institute on Aging grant T32AG049663. Dr. Rodriguez was funded in part by the Center of Excellence Faculty Fellowship, Stanford University, the US Department of Health and Human Services, the Hispanic Center of Excellence.

Compliance with Ethical Standards

Conflict of Interest

Tomás Cabeza de Baca, Eva M. Durazo, and Fatima Rodriguez declare no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major Importance

  1. 1.
    •• Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, et al. Heart Disease and Stroke Statistics—2018 Update: A Report From the American Heart Association. Circulation. 2018;137:e67–492. This is comprehensive summary from the American Heart Association reports the reports prevalence rates of CVD and includes information regarding the Life’s Simple 7. CrossRefPubMedGoogle Scholar
  2. 2.
    •• Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic impact goal through 2020 and beyond. Circulation. 2010;121:586–613. Lloyd-Jones et al. articulate the creation of the CVH index and review the conceptual factors and goals considered in its design. CrossRefPubMedGoogle Scholar
  3. 3.
    Gillman MW. Primordial prevention of cardiovascular disease. Circulation. 2015;131:599–601.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Berkman LF, Kawachi I, Glymour MM, editors. Social epidemiology. Second edition. Oxford: Oxford University Press; 2014.Google Scholar
  5. 5.
    von dem Knesebeck O. Concepts of social epidemiology in health services research. BMC Health Serv Res [Internet]. 2015;15. Available from:
  6. 6.
    Adler NE, Stewart J. Health disparities across the lifespan: meaning, methods, and mechanisms: health disparities across the lifespan. Ann N Y Acad Sci. 2010;1186:5–23.CrossRefPubMedGoogle Scholar
  7. 7.
    Adler NE, Boyce T, Chesney MA, Cohen S, Folkman S, Kahn RL, et al. Socioeconomic status and health: the challenge of the gradient. Am Psychol. 1994;49:15–24.CrossRefPubMedGoogle Scholar
  8. 8.
    Williams DR, Mohammed SA, Leavell J, Collins C. Race, socioeconomic status, and health: complexities, ongoing challenges, and research opportunities: race, SES, and health. Ann N Y Acad Sci. 2010;1186:69–101.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Puterman E, Epel E. An intricate dance: life experience, multisystem resiliency, and rate of telomere decline throughout the lifespan. Soc Personal Psychol Compass. 2012;6:807–25.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Folsom AR, Yatsuya H, Nettleton JA, Lutsey PL, Cushman M, Rosamond WD. Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence. J Am Coll Cardiol. 2011;57:1690–6.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Bi Y, Jiang Y, He J, Xu Y, Wang L, Xu M, et al. Status of cardiovascular health in Chinese adults. J Am Coll Cardiol. 2015;65:1013–25.CrossRefPubMedGoogle Scholar
  12. 12.
    Graciani A, Leon-Munoz LM, Guallar-Castillon P, Rodriguez-Artalejo F, Banegas JR. Cardiovascular health in a southern Mediterranean European country: a nationwide population-based study. Circ Cardiovasc Qual Outcomes. 2013;6:90–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Janković J, Marinković J, Stojisavljević D, Erić M, Vasiljević N, Janković S. Sex inequalities in cardiovascular health: a cross-sectional study. Eur J Pub Health. 2016;26:152–8.CrossRefGoogle Scholar
  14. 14.
    • Simon M, Boutouyrie P, Narayanan K, Gaye B, Tafflet M, Thomas F, et al. Sex disparities in ideal cardiovascular health. Heart. 2017;103:1595–601. This paper documents in a French sample that women are more likely to have greater cardiovascular health, compared to men. CrossRefPubMedGoogle Scholar
  15. 15.
    Mathews L, Ogunmoroti O, Nasir K, Blumenthal RS, Utuama OA, Rouseff M, et al. Psychological factors and their association with ideal cardiovascular health among women and men. In: J Womens Health; 2018.Google Scholar
  16. 16.
    Pilkerton CS, Singh SS, Bias TK, Frisbee SJ. Changes in cardiovascular health in the United States, 2003–2011. J Am Heart Assoc [Internet]. 2015;4. Available from:
  17. 17.
    Caleyachetty R, Echouffo-Tcheugui JB, Muennig P, Zhu W, Muntner P, Shimbo D. Association between cumulative social risk and ideal cardiovascular health in US adults: NHANES 1999–2006. Int J Cardiol. 2015;191:296–300.CrossRefPubMedGoogle Scholar
  18. 18.
    Brown AF, Liang L-J, Vassar SD, Escarce JJ, Merkin SS, Cheng E, et al. Trends in racial/ethnic and nativity disparities in cardiovascular health among adults without prevalent cardiovascular disease in the United States, 1988 to 2014. Ann Intern Med. 2018;168:541.CrossRefPubMedGoogle Scholar
  19. 19.
    Siliki Mbassa RA, Zaslavsky AM, Williams DR, Natalie SB, Buring J, Albert MA. Abstract 18364: cumulative psychosocial stress and ideal cardiovascular health in women: data according to race/ethnicity. Circulation. 2016;134:A18364.Google Scholar
  20. 20.
    Pool LR, Ning H, Lloyd-Jones DM, Allen NB. Trends in racial/ethnic disparities in cardiovascular health among US adults From 1999–2012. J Am Heart Assoc [Internet]. 2017;6. Available from:
  21. 21.
    Djoussé L. Relation between modifiable lifestyle factors and lifetime risk of heart failure. JAMA. 2009;302:394.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Ning H, Labarthe DR, Shay CM, Daniels SR, Hou L, Van Horn L, et al. Status of cardiovascular health in US children up to 11 years of age: the National Health and Nutrition Examination Surveys 2003-2010. Circ Cardiovasc Qual Outcomes. 2015;8:164–71.CrossRefPubMedGoogle Scholar
  23. 23.
    González HM, Tarraf W, Rodríguez CJ, Gallo LC, Sacco RL, Talavera GA, et al. Cardiovascular health among diverse Hispanics/Latinos: Hispanic Community Health Study/Study of Latinos (HCHS/SOL) results. Am Heart J. 2016;176:134–44.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Patterson F, Zhang G, Davey A, Tan Y, Ma GX. American Heart Association’s ideal cardiovascular health metrics in under-represented Asian Americans. J Community Health. 2016;41:1282–9.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Talegawkar SA, Jin Y, Kandula NR, Kanaya AM. Cardiovascular health metrics among South Asian adults in the United States: prevalence and associations with subclinical atherosclerosis. Prev Med. 2017;96:79–84.CrossRefPubMedGoogle Scholar
  26. 26.
    Janković S, Stojisavljevi D, Jankovi J, Eri M, Marinkovi J. Association of socioeconomic status measured by education, and cardiovascular health: a population-based cross-sectional study. BMJ Open. 2014;4:e005222.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Olsen GS, Holm A-SS, Jørgensen T, Borglykke A. Distribution of ideal cardiovascular health by educational levels from 1978 to 2006: a time trend study from the capital region of Denmark. Eur J Prev Cardiol 2014;21:1145–1152.Google Scholar
  28. 28.
    Savelieva K, Pulkki-Råback L, Jokela M, Kubzansky LD, Elovainio M, Mikkilä V, et al. Intergenerational transmission of socioeconomic position and ideal cardiovascular health: 32-year follow-up study. Health Psychol. 2017;36:270–9.CrossRefPubMedGoogle Scholar
  29. 29.
    Henriksson P, Henriksson H, Labayen I, Huybrechts I, Gracia-Marco L, Ortega FB, et al. Correlates of ideal cardiovascular health in European adolescents: the HELENA study. Nutr Metab Cardiovasc Dis. 2018;28:187–94.CrossRefPubMedGoogle Scholar
  30. 30.
    Veromaa V, Kautiainen H, Saxen U, Malmberg-Ceder K, Bergman E, Korhonen PE. Ideal cardiovascular health and psychosocial risk factors among Finnish female municipal workers. Scand J Public Health. 2017;45:50–6.CrossRefPubMedGoogle Scholar
  31. 31.
    Slopen N, Chen Y, Guida JL, Albert MA, Williams DR. Positive childhood experiences and ideal cardiovascular health in midlife: associations and mediators. Prev Med. 2017;97:72–9.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    • Boehm JK, Soo J, Chen Y, Zevon ES, Hernandez R, Lloyd-Jones D, et al. Psychological well-being’s link with cardiovascular health in older adults. Am J Prev Med. 2017;53:791–8. Analyses from the English Longitudinal Study of Ageing highlight the importance of psychological well-being on the progression of ideal cardiovascular health (including smoking status, diabetes, blood pressure, cholesterol, and BMI) in older adults. CrossRefPubMedGoogle Scholar
  33. 33.
    Pulkki-Råback L, Elovainio M, Hakulinen C, Lipsanen J, Hintsanen M, Jokela M, et al. Cumulative effect of psychosocial factors in youth on ideal cardiovascular health in adulthood: the cardiovascular risk in young Finns study. Circulation. 2015;131:245–53.CrossRefPubMedGoogle Scholar
  34. 34.
    Ellis BJ, Del Giudice M. Beyond allostatic load: rethinking the role of stress in regulating human development. Dev Psychopathol. 2014;26:1–20.CrossRefPubMedGoogle Scholar
  35. 35.
    Cabeza de Baca T, Wahl RA, Barnett MA, Figueredo AJ, Ellis BJ. Adversity, adaptive calibration, and health: The case of disadvantaged families. Adapt Hum Behav Physiol 2016;2:93–115.Google Scholar
  36. 36.
    Matthews KA, Boylan JM, Jakubowski KP, Cundiff JM, Lee L, Pardini DA, et al. Socioeconomic status and parenting during adolescence in relation to ideal cardiovascular health in Black and White men. Health Psychol. 2017;36:673–81.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Sood E, Gidding SS. Childhood psychosocial determinants of cardiovascular health. Curr Cardiovasc Risk Rep. 2016;10:20.CrossRefGoogle Scholar
  38. 38.
    Rosengren A, Hawken S, Ôunpuu S, Sliwa K, Zubaid M, Almahmeed WA, et al. Association of psychosocial risk factors with risk of acute myocardial infarction in 11 119 cases and 13 648 controls from 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364:953–62.CrossRefPubMedGoogle Scholar
  39. 39.
    Gaye B, Prugger C, Perier MC, Thomas F, Plichart M, Guibout C, et al. High level of depressive symptoms as a barrier to reach an ideal cardiovascular health. The Paris Prospective Study III Sci Rep 2016;6.Google Scholar
  40. 40.
    Li Z, Yang X, Wang A, Qiu J, Wang W, Song Q, et al. Association between ideal cardiovascular health metrics and depression in Chinese population: a cross-sectional study. Sci Rep [Internet]. 2015;5. Available from:
  41. 41.
    Loucks EB, Britton WB, Howe CJ, Eaton CB, Buka SL. Positive associations of dispositional mindfulness with cardiovascular health: the New England Family Study. Int J Behav Med. 2015;22:540–50.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Hernandez R, Kershaw KN, Siddique J, Boehm JK, Kubzansky LD, Diez-Roux A, et al. Optimism and cardiovascular health: Multi-Ethnic Study of Atherosclerosis (MESA). Health Behav Policy Rev. 2015;2:62–73.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Chomistek AK, Chiuve SE, Eliassen AH, Mukamal KJ, Willett WC, Rimm EB. Healthy lifestyle in the primordial prevention of cardiovascular disease among young women. J Am Coll Cardiol. 2015;65:43–51.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Pacor JM, Younus A, Malik R, Osondu CU, Aziz M, Ogunmoroti O, et al. Prevalence of ideal cardiovascular health metrics in children & adolescents: a systematic review. Prog Pediatr Cardiol. 2016;43:141–6.CrossRefGoogle Scholar
  45. 45.
    Aatola H, Hutri-Kahonen N, Juonala M, Laitinen TT, Pahkala K, Mikkila V, et al. Prospective relationship of change in ideal cardiovascular health status and arterial stiffness: the cardiovascular risk in young Finns study. J Am Heart Assoc. 2014;3:e000532.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Chang Y, Li Y, Guo X, Li T, Chen Y, Dai D, et al. The association of ideal cardiovascular health and left ventricle hypertrophy in rural population of northeast China: a cross-sectional observational study. Medicine (Baltimore). 2017;96:e6050.CrossRefGoogle Scholar
  47. 47.
    Olson NC, Cushman M, Judd SE, McClure LA, Lakoski SG, Folsom AR, et al. American Heart Association’s Life’s Simple 7 and risk of venous thromboembolism: the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. J Am Heart Assoc. 2015;4:e001494.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Kulshreshtha A, Goyal A, Veledar E, McClellan W, Judd S, Eufinger SC, et al. Association between ideal cardiovascular health and carotid intima-media thickness: a twin study. J Am Heart Assoc. 2014;3:e000282.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Hwang S-J, Onuma O, Massaro JM, Zhang X, Fu Y-P, Hoffmann U, et al. Maintenance of ideal cardiovascular health and coronary artery calcium progression in low-risk men and women in the Framingham Heart Study. Circ Cardiovasc Imaging. 2018;11:e006209.CrossRefPubMedGoogle Scholar
  50. 50.
    Guo L, Cheng L, He W, Ju Y, Zhao X. Ideal cardiovascular health and incidence of carotid plaque among middle-aged and elderly adults. J Stroke Cerebrovasc Dis. 2018;27:391–6.CrossRefPubMedGoogle Scholar
  51. 51.
    Gebreab SY, Manna ZG, Khan RJ, Riestra P, Xu R, Davis SK. Less than ideal cardiovascular health is associated with shorter leukocyte telomere length: the National Health and Nutrition Examination Surveys, 1999–2002. J Am Heart Assoc. 2017;6:e004105.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    •• Aneni EC, Crippa A, Osondu CU, Valero-Elizondo J, Younus A, Nasir K, et al. Estimates of mortality benefit from ideal cardiovascular health metrics: a dose response meta-analysis. J Am Heart Assoc. 2017;6:e006904. This meta-analysis documents the dose-response linear risk reduction in cardiovascular and all-cause mortality with the increase in ideal cardiovascular health components. CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Fang N, Jiang M, Fan Y. Ideal cardiovascular health metrics and risk of cardiovascular disease or mortality: a meta-analysis. Int J Cardiol. 2016;214:279–83.CrossRefPubMedGoogle Scholar
  54. 54.
    Guo L, Zhang S. Association between ideal cardiovascular health metrics and risk of cardiovascular events or mortality: a meta-analysis of prospective studies. Clin Cardiol. 2017;40:1339–46.CrossRefPubMedGoogle Scholar
  55. 55.
    Ogunmoroti O, Oni E, Michos ED, Spatz ES, Allen NB, Rana JS, et al. Life’s Simple 7 and incident heart failure: the multi-ethnic study of atherosclerosis. J Am Heart Assoc. 2017;6:e005180.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Dong C, Rundek T, Wright CB, Anwar Z, Elkind MSV, Sacco RL. Ideal cardiovascular health predicts lower risks of myocardial infarction, stroke, and vascular death across whites, blacks, and Hispanics: the northern Manhattan study. Circulation. 2012;125:2975–84.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Leung CW, Epel ES, Ritchie LD, Crawford PB, Is LBAFI. Inversely associated with diet quality of lower-income adults. J Acad Nutr Diet. 2014;114:1943–1953.e2.CrossRefPubMedGoogle Scholar
  58. 58.
    •• Leung C, Tester J, Laraia B. Household food insecurity and ideal cardiovascular health factors in US adults. JAMA Intern Med. 2017;177:730. Leung et al. find an association between food insecurity and decreased cardiovascular health in a U.S. sample. CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Saiz AM, Aul AM, Malecki KM, Bersch AJ, Bergmans RS, LeCaire TJ, et al. Food insecurity and cardiovascular health: findings from a statewide population health survey in Wisconsin. Prev Med. 2016;93:1–6.CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Cabeza de Baca T, Albert MA. Psychosocial stress, the unpredictability schema, and cardiovascular disease in women. under reviewGoogle Scholar
  61. 61.
    Slopen N, Kontos EZ, Ryff CD, Ayanian JZ, Albert MA, Williams DR. Psychosocial stress and cigarette smoking persistence, cessation, and relapse over 9–10 years: a prospective study of middle-aged adults in the United States. Cancer Causes Control. 2013;24:1849–63.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Torres OV, O’Dell LE. Stress is a principal factor that promotes tobacco use in females. Prog Neuro-Psychopharmacol Biol Psychiatry. 2016;65:260–8.CrossRefGoogle Scholar
  63. 63.
    Baek J, Sánchez BN, Berrocal VJ, Sanchez-Vaznaugh EV. Distributed lag models: examining associations between the built environment and health. Epidemiology. 2016;27:116–24.CrossRefPubMedPubMedCentralGoogle Scholar
  64. 64.
    Renalds A, Smith TH, Hale PJA. Systematic review of built environment and health. Fam Community Health. 2010;33:68–78.CrossRefPubMedGoogle Scholar
  65. 65.
    Unger E, Diez-Roux AV, Lloyd-Jones DM, Mujahid MS, Nettleton JA, Bertoni A, et al. Association of neighborhood characteristics with cardiovascular health in the multi-ethnic study of atherosclerosis. Circ Cardiovasc Qual Outcomes. 2014;7:524–31.CrossRefPubMedPubMedCentralGoogle Scholar
  66. 66.
    Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty N. Examining health care costs among MANNA clients and a comparison group. J Prim Care Community Health. 2013;4:311–7.CrossRefPubMedGoogle Scholar
  67. 67.
    Palar K, Napoles T, Hufstedler LL, Seligman H, Hecht FM, Madsen K, et al. Comprehensive and medically appropriate food support is associated with improved HIV and diabetes health. J Urban Health. 2017;94:87–99.CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Berkowitz SA, Terranova J, Hill C, Ajayi T, Linsky T, Tishler LW, et al. Meal delivery programs reduce the use of costly health care in dually eligible Medicare and Medicaid beneficiaries. Health Aff (Millwood). 2018;37:535–42.CrossRefGoogle Scholar
  69. 69.
    Serlachius A, Pulkki-Råback L, Elovainio M, Hintsanen M, Mikkilä V, Laitinen TT, et al. Is dispositional optimism or dispositional pessimism predictive of ideal cardiovascular health? The Young Finns Study Psychol Health. 2015;30:1221–39.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Tomás Cabeza de Baca
    • 1
    Email author
  • Eva M. Durazo
    • 2
  • Fatima Rodriguez
    • 3
  1. 1.Division of Cardiology, Department of MedicineUniversity of California, San FranciscoSan FranciscoUSA
  2. 2.Department of Epidemiology and BiostatisticsUniversity of California, San FranciscoSan FranciscoUSA
  3. 3.Division of Cardiovascular Medicine and Cardiovascular InstituteStanford University School of Medicine, Stanford UniversityStanfordUSA

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