Introduction

Over 800,000 people in the United States (U.S.) annually succumb to complications attributed to cardiovascular disease (CVD) [1••]. Although CVD rates have steadily decreased over time, CVD still accounts for $329.7 billion in direct and indirect economic costs [1••]. Moreover, research indicates that CVD rates vary between different groups residing in the U.S., with higher rates among racial/ethnic minorities and low-income families [1••]. Importantly, CVD is largely preventable through lifestyle modifications and risk factor control. As such, the American Heart Association (AHA) has created the AHA 2020 Strategic Goals [2••] to address these disparities and ultimately reduce both CVD morbidity and mortality in the U.S. by 20% in the year 2020 [2••]. Upon the creation of the AHA 2020 Strategic Goals, a major question arose: How would the AHA and researchers track annual progress? In response, the AHA created cardiovascular health (CVH), a standard measure and trackable index to assess progress towards the 2020 Strategic Goals.

The development of the CVH index to monitor population-level trends in disease risk was primarily informed by the concept of primordial prevention [2••, 3], which reorients researchers and policy-makers to focus on the prevention of risk factors as a means of disease prevention. By shifting the focus to modifying major behavioral and health risk factors, prevention of CVD should follow. The CVH index, a score based on attainment of seven modifiable risk factors, can be used to monitor individual- and population-level health trajectories in progression of CVD risk.

While the significance of social and psychological characteristics were acknowledged as profound forces in the etiology of CVH, they were ultimately not included in the creation of the CVH index [2••]. As such, this paper takes a social epidemiological approach [4]—in which we examine psychosocial determinants that may enhance or undermine individual- and population-level CVH, such as social capital and inequality factors and personal relationships [5]. Cardiovascular morbidity and mortality disproportionately affects disadvantaged groups in the U.S., particularly racial/ethnic minorities and lower-income individuals. As a result, there is likely a social gradient of health such that psychosocial, behavioral, and environmental factors have a profound impact on health through their influence on health behaviors and life experiences [6,7,8].

Similarly, Puterman and Epel [9] have put forth the concept of multi-system resiliency to organize and integrate major psychosocial and behavioral factors that promote healthy aging across the lifespan, including social connections, psychological resources, and health-maintaining behaviors (see Table 1 for a summary of this literature). Maintaining these three factors of healthy aging may dampen the inimical effect of stress over the lifetime and cultivate good health and longevity. Meanwhile, an absence of these three factors could accelerate aging, chronic disease, and somatic deterioration. While research on multi-system resiliency typically aggregates the three factors together to create a composite of health-enhancing factors, currently no research exists examining the association of multi-system resiliency on ideal CVH. Because of this, we examine each of the components of multi-system resiliency individually.

Table 1 Brief summary of psychosocial factors and ideal cardiovascular health (in alphabetical order)
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Figure 1 presents a conceptual schematic that visually illustrates the organization of the paper. Thus, we begin the review by defining the CVH index, and next, we examine sociodemographic factors (sex, race/ethnicity, and socioeconomic status) to identify vulnerable populations that may be most at risk for poor CVH. We then consider psychosocial and behavioral health-enhancing components (e.g., high-quality social connections and positive psychological resources) that may enhance CVH. Finally, we briefly review the association of CVH with intermediate and hard endpoints of CVD. We conclude by briefly discussing the importance of context and examining each of these factors within ecological models.

Fig. 1
figure 1

Conceptual schemata of the proposed pathways between sociodemographic factors, multi-system resiliency, ideal cardiovascular health, and cardiovascular endpoints

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Cardiovascular Health

The AHA’s CVH index was created to track empirically validated and modifiable indicators, including four lifestyle behaviors (smoking behavior, body mass index, physical activity, and healthy dietary factors) and three health factors (total cholesterol, blood pressure, and glucose), known as Life’s Simple 7 ([2••]; see Table 2 for a complete description of CVH and its components).

Table 2 Criteria and components of ideal cardiovascular health
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Individually, each of the components is categorized into three different levels of CVH: ideal, intermediate, and poor, based on evidence-based cut-points. For instance, an individual who has never smoked or quit smoking over a year ago is categorized as ideal; a former smoker who quit less than a year ago is classified as intermediate; and a current smoker is categorized as poor on the smoking behavior metric.

Summed together, Life’s Simple 7 creates an overall CVH score which can be categorized into ideal, intermediate, and poor categories [2••, 10], or examined as a continuous variable. Ideal CVH is defined by the AHA as the absence of CVD and the presence of ideal CVH on all seven components.

Sociodemographic Factors

Sex Differences

Adults in the U.S. have CVH profiles that predominately fail to meet the Simple 7 criteria for “ideal” CVH, with 17% of individuals achieving an ideal CVH profile on five or more components [1••]. When disaggregated by sex, prevalence of five or more ideal CVH components is higher in U.S. women (21%) compared to men (13%) [1••]. Cross-sectional studies from China and Spain similarly find that a majority of adults fail to meet all seven components of ideal CVH, but women had higher proportions of ideal and intermediate CVH [11, 12].

Using the National Health Survey in the Republic of Srpska, Bosnia, and Herzegovina, Jankovic et al. [13] observed that younger women aged 18–39 years had three times the odds of attaining ideal CVH compared to men in the same age group. While they observed that middle-aged women aged 40–64 years had 2.25 times the odds of ideal CVH compared to men, there was no difference by sex for adults age 65 and over. Similarly, a cross-sectional study of middle-aged and older adults in France found that women had four times the odds of ideal CVH and two times the odds of having intermediate CVH compared to men [14•]. When testing interactions, the authors observed less of a sex difference in CVH with increasing socioeconomic deprivation and more of a sex difference in CVH with increasing levels of education. While this study could not determine why there were such drastic sex differences, in particular for ideal CVH, the authors hypothesize that women interact with the health care system more often than men throughout their life course, offering opportunities for health education and prevention [15].

Race/Ethnicity

Disparities in CVH by race/ethnicity follow similar patterns as to the racial/ethnic disparities for CVD: non-Hispanic whites (whites) have better CVH, followed by Latinos, and African Americans tend to have the poorest CVH [16,17,18,19]. Little research is available for the U.S. Asian population and its subgroups. When available, Asians, as a collective group, have higher levels of ideal CVH compared to whites [19]. It is important to note that, like Latinos, there is much heterogeneity (i.e., within-group differences) that may differentially impact CVH.

In a recent study using the National Health and Nutrition Examination Survey (NHANES), Brown et al. [18] found that less than 40% of whites, 25% of Mexican Americans, and 15% of African Americans in the U.S. have optimal CVH, demonstrating a clear disparity in ideal CVH. While disparities have decreased over time, this was attributed to a decline in the optimal CVH of whites and not an improvement in CVH for the other groups [18]. Another NHANES study found that the racial/ethnic disparities were even more pronounced by sex [20]. Black women had consistently worse CVH profiles compared to white women at each survey time-point. Mexican American women had worse CVH compared to white women for most survey time-points, yet racial/ethnic differences were smaller and mostly non-significant in men [20].

African Americans have been found to have the lowest scores of ideal CVH. Findings from the Jackson Heart Study demonstrated that neither sex met all seven ideal CVH factors, and 0.3% of men and 0.6% of women met six ideal CVH components [21]. Additionally, the number of ideal CVH components attained in this population decreased with age. Especially low scores were attributed to poor diet, physical activity, and body mass index (BMI) among all adults. Among a study of children up to age 11 using NHANES data, Ning et al. found that black boys and girls had the lowest prevalence of ideal CVH components, with similar levels for white and Mexican American boys and higher attainment of ideal CVH among Mexican American and white girls [22].

While research has found that Latinos exhibit poorer overall CVH compared to whites, there is much more to be understood according to Latino ethnic subgroup. Fewer than 1% of Latinos met all seven ideal CVH components and 6% met six, according to data from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) [23]. Poorer CVH profiles were observed in older adults and males [23]. Lower CVH scores were attributed to poor diet and body weight profiles. There were also significant differences by Latino subgroups living in the U.S.; South Americans had the best CVH scores, followed by Mexicans, Cubans, and Puerto Ricans.

There is limited research on the attainment of ideal CVH among Asians in the U.S., although they generally have better CVD outcomes compared to other racial/ethnic groups. A community sample of Vietnamese, Chinese, and Korean Asians produced the poorest CVH component scores for physical activity, diet, and glucose levels, with 65% of participants classified as overweight/obese using the Asian BMI criteria [24]. Korean-origin adults had the poorest CVH profile across the different measured components [24]. Additionally, Asian immigrants with a longer duration of residence in the U.S. had lower CVH as compared to those who had newly immigrated [24]. A study of South Asians from the Indian sub-continent found that no participants had all seven ideal CVH components, with 4.7% achieving six components [25]. In particular, this population of South Asians failed to meet ideal profiles for diet, blood pressure, and cholesterol [25].

Accordingly, there is much variation by ethnic subgroups for the U.S. Asian and Latino populations of which we are only beginning to uncover. By the limited availability of research, there is much more work to be done to understand the disparities in ideal CVH by race/ethnicity.

Socioeconomic Status

Individuals with low education levels and low income are at greater risk of poor CVH [1••, 17]. Specifically, low-income adults have an inverse linear relationship with ideal CVH; adults with a low family income (below federal poverty level) had 70% lower odds of reaching five to seven ideal CVH components compared to adults with a high family income [17]. Adults with less than 12 years of education had 78% lower odds of meeting five to seven ideal CVH components compared to those with 12 years of education or greater. Similar findings for education were observed in a study in the Republic of Srpska, Bosnia, and Herzegovina [26]. A longitudinal study in Denmark found that over time, education became an important modifier for women in particular, with the difference in ideal CVH increasing by 500% between the highest- and lowest-educated women [27].

Evidence suggests that socioeconomic status in childhood may influence CVH trajectories in adulthood. A Finnish cohort with a 32-year follow-up found that, when traditional risk factors were accounted for, parental socioeconomic status predicted offspring CVH. Additional analyses found that socioeconomic status in adulthood mediated the association, but childhood socioeconomic position was still a predictor for CVH [28]. Similarly, adolescents who had a more educated mother (defined by the authors as higher secondary education or higher education university degree) obtained higher levels of CVH when compared to adolescents with mothers of lower education [29].

Multi-system Resiliency

Social Connections

A body of work exists documenting the health-enhancing effects of high-quality social connections on indices of health. To our knowledge, limited work has been documented on the effect of social connections on CVH. A cross-sectional study of female municipal workers from Finland found that social isolation (i.e., the lack of social connection) was most prevalent in women with two or fewer ideal CVH components, followed by those with three to four and five to seven, respectively, at ideal levels; accounting for age and educational attainment attenuated this association (p = .06) [30]. In the Midlife in the U.S. (MIDUS) survey, social support (partner, family, and friends) was associated with greater levels of ideal CVH (B = 0.34), even when accounting for other psychosocial and demographic factors [31].

Psychological Resources

An English longitudinal study on older adults found that greater psychological well-being, an aggregated psychological resource variable including control, autonomy, pleasure, and self-realization, was associated with favorable CVH across three time-points measured over approximately 10 years [32•]. Interestingly, there was no interaction between time and well-being, suggesting that well-being was not contingent on rate of change; however, favorable CVH in older adults appeared to be temporally stable.

Research on Finnish children (mean age = 10.2) found evidence to suggest that favorable childhood psychosocial composite measures of socioeconomic status, household quality, and self-regulatory and adjustment assessments, predicted better adult CVH over 25 years later [33]. In the MIDUS survey, recalled positive childhood experiences were associated with higher levels of CVH, even when controlling for age, sex, race, and other psychosocial factors [31]. Additional analyses demonstrated that the association between positive childhood experiences and ideal CVH was fully mediated by adult educational attainment, depression, and social support, suggesting that nurturing and predictable early childhood experiences may orient individuals toward prioritizing time, resources, and effort toward greater increased psychological resources, health-maintenance, and high-quality social connections [9, 34, 35]. The impact of parental quality may be especially important to the CVH of racial/ethnic minorities [36]. Additional research suggests that early childhood factors which promote the development of psychological resources in adulthood, including family emotional climate and self-control, can positively impact ideal CVH in adulthood (reviewed and discussed in [37]).

Depression, a major psychosocial risk factor previously implicated in the progression of CVD risk [38], was found to diminish the likelihood of attaining intermediate CVH by 30% and ideal CVH by 44% [39]. Other work continues to support that depression may be an important risk factor for diminished CVH [30, 31, 40], while dispositional mindfulness and optimism have both been correlated with better CVH [41, 42].

Health-Maintaining Behaviors

A prospective study utilizing the Nurses’ Health Study II found that young women who maintained a healthy lifestyle had a 92% lower risk of CHD and a 66% lower risk of CVD when compared to women with no healthy lifestyle factors. Furthermore, women with one or more clinical CVD risk factor (such as hypertension or diabetes) and one healthy lifestyle factor had a lower risk of CHD compared to women with no healthy lifestyle factors, with a risk decreasing in a dose-response fashion as the number of healthy lifestyle factors increased. This demonstrates that following a healthy lifestyle in young adulthood can serve as a preventive measure for CVD risk later in life [43].

CVH research examining the importance of health-maintaining behaviors has focused on the emergence of healthy habits early in the lifespan, identifying diet and physical activity as important childhood and adolescent CVH behaviors to consider [22, 44]. For instance, children between the ages of 5 and 11 failed to achieve an ideal diet (prevalence of four or five ideal diet components: 0.03% boys; 0.05% girls), with the majority of children falling into the poor diet category (one or fewer ideal diet components; 85.5% boys; 83.1% girls) [22]. Similarly, European adolescents who watched television for two or more hours a day—a potential proxy for inactive lifestyle behaviors—had lower ideal CVH scores than adolescents who watched two or fewer hours of television daily [29].

CVD Endpoints and Cardiovascular Health

CVH denotes an emergent construct of cardiovascular risk factors that are derived from a series of behavioral/lifestyle and biological domains. The composite measure was designed to monitor the annual progression of population-level CVH to ensure that the 2020 Strategic Goals put forth by the AHA were being met. As with any construct, it is important to examine convergent and predictive validity of a measure (i.e., does CVH predict other cardiovascular endpoints?). Here, we briefly summarize an emerging body of research that examines the association between CVH and intermediate endpoints (anatomic/pathophysiological) and hard endpoints (CVD events).

Intermediate Endpoints

Ideal CVH and 21-year positive change in ideal CVH have been identified as predictors of decreased pulse wave velocity [45]. There was a gradient effect observed between the number of ideal CVH components and concentric and eccentric left ventricle hypertrophy (LVH): fewer ideal CVH components were associated with an increased prevalence of LVH [46]. There was additionally a substantial risk of concentric LVH (OR 5.90; 95% CI 2.77, 12.55) and eccentric LVH (OR 3.24; 95% CI 2.36, 4.47) abnormalities in individuals with poor CVH, compared to intermediate-ideal CVH [46]. Higher levels of ideal CVH have also been associated with a lower risk of venous thromboembolism [47], carotid intima-media thickness [48], and incident coronary artery calcification [49] and with an 8% decrease in incident carotid plaque [50]. Ideal CVH is also associated with novel biological markers such as telomere length. When compared to ideal CVH, intermediate (B = − 2.37; 95% CI − 4.41, − 0.33) and poor (B = − 3.41; 95% CI − 5.97, − 0.84) CVH were associated with a significant shortening of telomere length, even when controlling for sociodemographic factors and C-reactive protein [51].

Hard Endpoints

Meta-analytic data of six studies (N = 142,137) found a 19% reduction in CVD-related death (HRpooled 0.81, 95% CI 0.75, 0.87) and an 11% reduction in all-cause mortality with the presence of each additional ideal CVH component (HRpooled 0.89, 95% CI 0.86, 0.93) [52••]. Other meta-analytic studies have also found decreased risk of CVD and stroke events, and CVD death with greater presence of ideal CVH [53, 54]. Multi-Ethnic Study of Atherosclerosis data revealed that heart failure risk decreases with increasing CVH [55] The association between ideal CVH and lower risk of CVD has been documented across diverse racial/ethnic groups [55, 56].

Heart of the Matter: Addressing Ecological Forces—an Example of Food Insecurity

Although a large body of literature exists to suggest the importance of health-maintaining behaviors in fostering CVH, the environment in which an individual resides may particularly influence health-maintaining behaviors. For instance, an emerging body of research is examining the impact of food insecurity on CVH. Food insecurity is defined as inconsistent and unpredictable access to and consumption of nutritionally dense food and has been linked to poor diet quality in economically disadvantaged individuals [57].

Consistent with that finding, data from NHANES demonstrated that a greater perception of food insecurity dose-dependently decreased the odds of obtaining ideal CVH [58••]. A large Wisconsin sample also found an association between greater food insecurity and poorer CVH [59]. Among both sexes, food insecurity was negatively associated with ideal smoking behavior [58••], suggesting that stressful life circumstances which include instances of food-related anxiety may orient behavior toward reward-seeking or self-medicating [60], such as consumption of nicotine products [61, 62]. Taken together, the results suggest that food insecurity may be a proxy for resource-disadvantaged communities with built environments that preclude high-quality diets and/or physical activity [63, 64], which in turn influences CVH [65].

Therefore, identifying communities with food insecurity may serve as a marker for needing assistance in maintaining CVH, particularly in early childhood. As such, public health and policy initiatives informed by a social epidemiological framework could improve CVH in communities with food insecurity by targeting social and ecological factors beginning in early childhood that bolster social connections and reduce psychosocial stressors and resource inequalities. Stronger neighborhood ties would theoretically increase the quality of social relationships, but may also perpetuate neighborhood pride and political engagement which in turn would improve the quality of the built environment (e.g., safer neighborhoods, increased park space, and access to grocery stores with nutritious food choices).

Additionally, interventions could target household and parenting quality by eliminating family-level burden through food assistance programs, by financial and budgeting counseling, and by increasing psychological resources. California Food is Medicine Coalition (www.calfimc.org) is a statewide pilot program which provides nutrition assistance to low-income patients recovering from congestive heart failure. CALFIMC is an example of a medically and ecologically informed public health intervention that seeks to eliminate chronic health burden by addressing patient nutrition needs. Past research examining this paradigm in other patients with chronic disease have shown an improvement in healthcare costs, hospital readmissions, and psychosocial health outcomes [66,67,68]. As such, through non-clinical public health approaches to improving the health of diverse communities, we could move from treating disease to promoting ideal CVH.

Conclusions

Achievement of ideal CVH through the promotion of healthy lifestyle habits is a national priority. Although much work has documented the importance of these factors (normal blood pressure, normal cholesterol levels, healthy body weight, normal glucose levels, not smoking, eating healthy, and exercising regularly) in reducing adverse cardiovascular endpoints, limited literature exists on the role of social factors in promoting CVH. This review summarized that attainment of CVH may be particularly challenging for men, racial/ethnic minorities, and those of low socioeconomic status. We then described the importance of a constellation of positive life factors, which include maintenance of high-quality relationships, promotion of psychological functioning, and pursuit of an active lifestyle—known collectively as multi-system resiliency—in promoting CVH. Future research, clinical interventions, and public health policies should incorporate an ecological-informed framework that can mitigate sociodemographic vulnerabilities while integrating health-enhancing factors to promote CVH.