Cardiovascular disease is the leading cause of death in the United States, accounting for nearly 900,000 deaths in 2019 (Tsao et al., 2022). In 2010, the American Heart Association (AHA) introduced “Life’s Simple 7” to promote cardiovascular health (CVH) based on seven healthy behaviors and factors (Lloyd-Jones et al., 2010; Sacco, 2011). Ideal CVH reflected having at least 6 of the following: being of normal body weight, consuming a healthy diet, regular physical activity, not smoking; and having normal blood pressure, blood cholesterol, and blood glucose. A meta-analysis of prospective cohort studies identified that achieving ideal CVH was associated with a lower risk of both all-cause mortality and cardiovascular mortality (Fang et al., 2016). Since its introduction, multiple studies have looked at this concept including a systematic review and meta-analysis that highlighted an overall low level of ideal CVH (3.3%; range: 0.5%–15%) across all 21 studies reflecting the need for national efforts at population and individual levels (Jankovic et al., 2021).

Adverse childhood events (ACEs) are preventable, potentially traumatic experiences that occur in childhood (0–17 years of age) such as neglect and experiencing or witnessing violence. Also included are a child’s environment that can undermine their sense of safety and stability such as growing up in a household with substance use, mental health problems, or instability due to parental separation or incarceration. The original study from the Kaiser Permanente Health Maintenance Organization in the mid-1990’s identified consistent associations between reports of multiple ACEs and early causes of death (Felitti et al., 1998). Studies have also associated ACEs with risk factors for the leading causes of deaths including smoking, drug use, excess alcohol intake, obesity, hypertension, and diabetes (Bellis et al., 2019; Hughes et al., 2017; Merrick et al., 2019; Remigio-Baker et al., 2017; Vasquez et al., 2019). The objective of this study was to determine associations between ACEs and less than ideal CVH.

Data from the 2019 Behavioral Risk Factor Surveillance System (BRFSS) were analyzed. This telephone survey, using both landline and cell phone numbers, interviews adults aged 18 years or older in the civilian, non-institutionalized Unitedf States population. The survey includes a core component, optional modules, and state-added questions. The optional module on ACEs was implemented by 20 states in 2019 (Alabama, Delaware, Florida, Indiana, Iowa, Kansas, Michigan, Mississippi, Missouri, New Mexico, New York, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, Tennessee, Virginia, West Virginia, and Wisconsin). Using the American Association of Public Opinion Research response rate (e.g., number of respondents who completed the survey as a proportion of all eligible and likely-eligible people),(The American Association for Public Opinion Research (The American Association for Public Opinion Research, 2016)) the median rate among states that included the ACEs module was 51% and ranged from 37% to 61%. Relative to other surveys, data from BRFSS have acceptable reliability and validity for several chronic disease risk factors and conditions (Pierannunzi et al., 2013). Additional information is available online at https://www.cdc.gov/brfss/index.html. The number of respondents completing the ACEs module varied by state, ranging from 4040 to 16,101 with a median of 7032. There were 95,941 respondents with information on CVH status with 9357 (9.8%) of these excluded due to missing or unknown information on the ACEs module resulting in 86,584 adults. An additional 295 adults were excluded due to missing information on education group or health care coverage in the generalized logit analysis, resulting in a final sample 86,289 adults. This secondary analyses of de-identified publicly available data (https://www.cdc.gov/brfss/annual_data/annual_data.htm) in which participants provided informed consent does not constitute human subjects research is considered exempt from Institutional Review Board.

By age, 35.6% of the population were 18–44 years, 37.7% were 45–64, and 21.2% were 65–79. Just over half were female (51.1%; Table 1). By race/ethnicity, 72.6% of the population was comprised of White adults, 12.5% were Black adults, 8.8% were Hispanic adults, and 2.4% were Asian adults. By education level, 9.7% of the population had less than a high school education, and about 30% each had a high school degree or equivalent, some college, or were a college graduate. Not having health care coverage occurred in 8.0% of the adult population.

There was wide variation in the components of ACEs with 5.4% of respondents reporting being forced to have sex compared to 28.7% reporting verbal abuse and 28.1% reporting parents were divorced (Fig. 1). Overall, 37.0% reported 0, 22.5% reported 1, 12.7% reported 2, 8.5% reported 3, and 19.3% reported ≥4 ACEs (Table 1).

The components of CVH status ranged from 12.0% of adults reporting a healthy diet to 86.2% reporting no diabetes (Fig. 2). Overall, 16.7% reported poor CVH, 72.4% reported intermediate CVH, and 10.9% reported ideal CVH (Table 2). Estimates of CVH status (poor:15.5%–18.5%; intermediate:71.7%–72.7%; and ideal:8.8%–12.2%) varied by number of ACEs (Table 2).

In the poor vs. ideal CVH portion of the generalized logit model, after adjusting for age, sex, race/ethnicity, education group, and health care coverage, those with 1 (AOR = 1.27;95% Confidence Interval [CI]:1.11–1.46), 2 (AOR = 1.63;95% CI:1.36–1.96), 3 (AOR = 2.01;95% CI: 1.66–2.44), and ≥4 (AOR =2.47;95% CI:2.11–2.89) ACEs were more likely to have poor CVH compared to those who reported 0 ACEs (Table 3, Fig. 3). Additionally, in the adjusted model, those aged 45–64 years of age were (AOR = 7.24; 95% CI:6.26–8.38), those aged 65–79 years were (AOR = 13.02; 95% CI:11.22–15.12), and those ≥80 years of age were (AOR = 8.54; 95% CI:6.87–10.62) were all more likely to have poor CVH compared to those aged 18–44 years. Males were 1.84 (95% CI:1.66–2.05) times more likely than females to have poor CVH. Black adults were 1.91 (95% CI:1.55–2.36) times more likely to have poor CVH compared to White adults. Compared to those who were college graduates, those with less than a high school education (AOR = 9.36; 95% CI:6.90–12.69), a high school degree or equivalent (AOR = 4.06; 95% CI:(3.53–4.67), and some college (AOR = 2.76; 95%CI:2.43–3.13 were all more likely to have poor CVH.

In the intermediate vs. ideal CVH portion of the generalized logit model, after adjusting for age, sex, race/ethnicity, education group, and health care coverage, those with 2 (AOR = 1.28;95% CI:1.08–1.51), 3 (AOR = 1.48;95% CI: 1.25–1.75), and ≥ 4 (AOR = 1.59;95% CI:1.38–1.83) ACEs were more likely to have intermediate CVH compared to those who reported 0 ACEs (Table 3, Fig. 3). Additionally, in the adjusted model, those aged 45–64 years (AOR = 1.67; 95% CI:1.50–1.87), 65–79 years (AOR = 2.26; 95% CI:2.02–2.54), and ≥ 80 years (AOR = 2.00; 95% CI:1.67–2.39) were all more likely to have intermediate CVH compared to those aged 18–44 years. Males were 1.70 (95% CI:1.55–1.88) times more likely than females to have intermediate CVH. Black adults were 1.35 (95% CI:1.10–1.64) times more likely to have intermediate CVH compared to White adults. Compared to those who were college graduates, those with less than a high school education (AOR = 2.73; 95% CI:2.03–3.67), a high school degree or equivalent (AOR = 1.80; 95% CI:(1.59–2.03), and some college (AOR = 1.55; 95%CI:1.39–1.72) were all more likely to have intermediate CVH.

The introduction of a composite measure of CVH was released more than a decade ago by the AHA. National initiatives, such as the Department of Health and Human Services Healthy People program, have aligned and promoted its use through programmatic and policy initiatives. However, continued progress in achieving population-level ideal health is needed, as demonstrated in findings from this study, where an estimated 8 in 9 adults had less than ideal CVH. This study demonstrated associations between adverse childhood experiences and their potential health implications in adulthood. Continued efforts to promote positive experiences during childhood, resiliency, and supportive structures among those that experience adversity may help improve overall CVH across the lifespan.

The focus of our study was to evaluate the association between ACEs and CVH. A 2019 CDC Vital Signs Report estimated the proportion of adult health problems attributable to ACEs using 2015–2017 BRFSS data. That report highlighted that 39.0% of the population reported not experiencing ACEs and 15.6% reported at least 4 ACEs, which was similar to our estimates of 37.0% and 19.3%, respectively (Merrick et al., 2019). Additionally, that study showed reporting ≥4 ACEs accounted for a disproportionate share across every negative health and socioeconomic outcome measured. As ACEs score increased, the association with adverse outcomes became more pronounced across a range of behaviors and diseases including smoking, alcohol consumption, depression, heart disease, cancer, kidney disease, and stroke. This similar pattern with increasing number of ACEs associated with worse CVH was seen in our study. Our study also showed those reporting ≥4 ACEs had the highest burdens of less than ideal CVH with poor CVH (2.5 times) and intermediate CVH (1.6 times) compared to ideal CVH. Additionally, ACEs are associated with earlier onset of chronic disease in young adulthood which could potentially lead to poor CVH, supports the need for prevention of ACEs and anticipatory guidance on chronic disease prevention early in the lifecourse (Sonu et al., 2019).

Limited data are available on ACEs and CVH status; however, one prior study did describe early trauma experiences and CVH, highlighting some modifying factors. For example, early trauma, including general trauma, emotional abuse and sexual abuse, was associated with worse CVH among low but not higher income Black adults (Islam et al., 2021). Positive neighborhood characteristics, like social cohesion and activity with neighbors, have also been associated with better CVH among Black adults (Islam et al., 2020). Social cohesion and activity with neighbors may be representative of neighborhoods with higher incomes and more resiliency. Another study demonstrated the importance of early identification and prevention of ACEs, as one ACE was strongly and independently associated with diabetes, hypertension, and high cholesterol among adults under 40 years of age (Kreatsoulas et al., 2019). Additionally, other measures such as neighborhood resiliency and social support may potentially limit the negative impact of ACEs on individuals.

Although this study focused on adult CVH status, non-ideal CVH status has been documented in young children and adolescents (Yang et al., 2014). For example, less than half of children 12–19 years of age in the US had 5 or more ideal CVH components based on 2005–2010 data (Shay et al., 2013). Lack of improvement in ideal CVH among children and adolescents suggest the importance of interventions to prevent the deleterious effects later in life (Arteaga and Gillman, 2020). The National Heart Lung and Blood Institute has also called for efforts to evaluate, in a multi-dimensional manner, the impact of social determinants of health and their contribution to disparities in cardiovascular disease. These efforts may include circumstances that make children vulnerable to poor health early in life, including interventional studies that demonstrate a reduction in adverse outcomes across the life-course (Suglia et al., 2020). The CDC has programs and initiatives that include preventing exposure to ACEs in early childhood or adolescence as well as aiding adults to address the long-term health impact of childhood experiences (https://www.cdc.gov/violenceprevention/aces/preventingace-datatoaction.html). The CDC also promotes specific strategies to prevent ACEs through opportunities with states to leverage the best available evidence to prevent and respond to ACEs. Some of these strategies include strengthening economic supports for families, promoting social norms that protect against violence and adversity, ensuring a strong start for children, enhancing skills to help parents and youths handle stress and manage emotions, and interventions to lessen immediate and long term harms among those who experience ACEs (https://www.cdc.gov/violenceprevention/aces/index.html). There are a couple of CDC programs that are more specific to cardiovascular health that could potentially complement the general approach to prevent ACEs and improve health across the life course. For example, the Million Hearts^® initiative and the Well-Integrated Screening and Evaluation for WOMen Across the Nation (WISEWOMAN) program both promote CVH through multiple avenues. Million Hearts^®, co-led by CDC and the Centers for Medicare & Medicaid Services, aims to prevent 1 million heart attacks and strokes over 5 years through implementation of evidence-based strategies to improve cardiovascular health (https://millionhearts.hhs.gov/index.html). The priority areas include building healthy communities, optimizing care, and focusing on health equity. These priorities are addressed through convening health care and public health champions; facilitating impactful collaboration and resource sharing; promoting implementation of evidence-based strategies to prevent cardiovascular disease, and addressing health inequities through specific policies, processes, and practices. WISEWOMAN provides low-income, uninsured and under-insured women ages 40–64 years with heart disease and stroke risk factor screenings and services that promote healthy behaviors (https://www.cdc.gov/wisewoman/about.htm). These programs could be complemented by strategies promoting the prevention of ACEs, potentially improving ideal CVH in younger and older age groups through promotion of healthy behaviors and reduction of adversity.

In this study, we primarily explored the associations between ACEs and CVH, but there were also significant associations among the socio-demographic characteristics analyzed such as age, sex, race/ethnicity, and education group. There were differences in magnitude between the two outcomes with generally higher associations by magnitude among those reporting poor CVH compared to those reporting intermediate CVH for these socio-demographic characteristics. They likely play an important role that should be considered in developing initiatives or programs to improve CVH. Of these age and education group had the largest magnitude differences among their response levels. Those experiencing 4 or more ACEs are more likely to have lower educational attainment, be unemployed, and have no insurance (Merrick et al., 2019). Our study demonstrated that Black race was associated with a higher likelihood for both poor and intermediate CVH. Additionally, Black adults report experiencing 4 or more ACEs more than White adults (Merrick et al., 2019). These findings highlight the complexity of the intersection among cultural factors such as race/ethnicity, other social and structural determinants of health, and factors such as ACEs. There is a need to better understand these differences as well as accounting for both individual and larger societal interactions such as barriers influencing health outcomes are needed to describe, understand, and support improved health for individuals and populations.

Limitations of this study include the use of self-reported data. Responses may be subject to social desirability bias, such as under-reporting smoking while over-reporting adequate physical activity, normal weight, and a healthy diet. Responses on childhood experiences asked of adults is also subject to the potential of recall bias and also may be subject to societal changes over time. The cross-sectional data prevents analysis the cumulative effect of health behaviors over time and limits the ability to establish a causal relationship between ACEs and CVH later in life. The AHA published an update to the “Life’s Simple 7” in 2022, which modified some of the individual metrics and expanded the number of components in the composite metric to eight (i.e., addition of adequate sleep), coining the new metric as “Life’s Essential 8” (Lloyd-Jones et al., 2022). Unfortunately, the level of detail needed to refine the existing measures, and the assessment of sleep, is not available in the 2019 BRFSS. In addition, the small sample sizes within subgroups may limit the detection of significant associations among various race/ethnic groups (e.g., Hispanic sub-ethnicities, Hispanic in combination with various race groups, Asian subgroups, Native American/Alaskan Native, Native Hawaiian or Other Pacific Islander subgroups, and those that report more than one race). Additionally, there were limited variables available in the data to evaluate key drivers of social determinants of health to better understand the structural and societal factors that impact ACEs and ideal CVH. The inclusion of reliable and validated metrics in future surveys could inform interventions that address health inequities.

Awareness of the impact of ACEs is growing, and numerous public health and clinical efforts to address them are underway, including many at the state level which aim to prevent ACEs from occurring, promote positive childhood experiences, and promote trauma-informed systems of care that can mitigate the consequences of ACEs when they have already occurred (Haldar et al., 2021). More research is needed on ACEs screening including assessments of referral and response protocols to trauma-informed systems of care. This further understanding could potentially align with efforts to promote healthy behaviors, promote early screening, and promote prevention and management of health outcomes that could potentially improve CVH. For example, early guidance and health promotion throughout the life course would likely benefit the adoption of ideal health behaviors including among those who report having experienced ACEs.

In this study, an estimated 1 in 6 adults report poor CVH, the majority (78.5%) of adults report intermediate CVH, and just 1 in 9 report ideal CVH, and. At least one ACE was reported in nearly two-thirds of adults and about 1 in 5 reported ≥4 ACEs. This study demonstrates the disproportionate burden for those reporting ≥4 ACEs having both poor and intermediate CVH. Preventing and mitigating the harms of ACEs and addressing barriers to ideal CVH, particularly social and structural determinants, may improve health across the life course.