Adjusted estimated population attributable fractions for cardiovascular disease (CVD) mortality were as follows¹: 40.6% (95% confidence interval [CI], 24.5%–54.6%) for high blood pressure; 13.7% (95% CI, 4.8%–22.3%) for smoking; 13.2% (95% CI, 3.5%–29.2%) for poor diet; 11.9% (95% CI, 1.3%–22.3%) for insufficient physical activity; and 8.8% (95% CI, 2.1%–15.4%) for abnormal blood glucose levels.

Although significant progress has been made over the past 4 decades, in 2012, among Americans ≥18 years of age, 20.5% of men and 15.9% of women continued to be cigarette smokers. In 2011, 18.1% of students in grades 9 through 12 reported current cigarette use.

The percentage of the nonsmoking population with exposure to secondhand smoke (as measured by serum cotinine levels ≥0.05 ng/mL) declined from 52.5% in 1999 to 2000 to 40.1% in 2007 to 2008. More than half of children 3 to 11 years of age (53.6%) and almost half of those 12 to 19 years of age (46.5%) had detectable levels, compared with just over a third of adults 20 years of age and older (36.7%).

The proportion of youth (≤18 years of age) who report engaging in no regular physical activity is high, and the proportion increases with age.

In 2011, among adolescents in grades 9 through 12, 17.7% of girls and 10.0% of boys reported that they had not engaged in ≥60 minutes of moderate to vigorous physical activity (defined as any activity that increased heart rate or breathing rate) at least once in the previous 7 days, despite recommendations that children engage in such activity 7 days per week.

In 2012, 29.9% of adults reported engaging in no aerobic leisure-time physical activity.

In 2009 to 2010, <1% of Americans met at least 4 of 5 healthy dietary goals. Among adults aged ≥20 years, only 12.3% met recommended goals for fruits and vegetables; 18.3% met goals for fish; 0.6% met goals for sodium; 51.9% met goals for sugar-sweetened beverages; and 7.3% met goals for whole grains. These proportions were even lower in children, with only 29.4% of adolescents aged 12 to 19 years meeting goals for low sugar-sweetened beverage intake.

The estimated prevalence of overweight and obesity in US adults (≥20 years of age) is 154.7 million, which represented 68.2% of this group in 2010. Nearly 35% of US adults are obese (body mass index ≥30 kg/m²). Men and women of all race/ethnic groups in the population are affected by the epidemic of overweight and obesity.

Among children 2 to 19 years of age, 31.8% are overweight and obese (which represents 23.9 million children) and 16.9% are obese (12.7 million children). Mexican American boys and girls and African American girls are disproportionately affected. From 1971–1974 to 2007–2010, the prevalence of obesity in children 6 to 11 years of age has increased from 4.0% to 18.8%.

Obesity (body mass index ≥30 kg/m²) is associated with marked excess mortality in the US population. Even more notable is the excess morbidity associated with overweight and obesity in terms of risk factor development and incidence of diabetes mellitus, CVD end points (including coronary heart disease, stroke, and heart failure), and numerous other health conditions, including asthma, cancer, end-stage renal disease, degenerative joint disease, and many others.

An estimated 31.9 million adults ≥20 years of age have total serum cholesterol levels ≥240 mg/dL, with a prevalence of 13.8%.

Based on 2007 to 2010 data, 33.0% of US adults ≥20 years of age have hypertension. This represents ≈78 million US adults with hypertension. The prevalence of hypertension is similar for men and women. African American adults have among the highest prevalence of hypertension (44%) in the world.

Among hypertensive Americans, ≈82% are aware of their condition and 75% are using antihypertensive medication, but only 53% of those with documented hypertension have their condition controlled to target levels.

In 2010, an estimated 19.7 million Americans had diagnosed diabetes mellitus, representing 8.3% of the adult population. An additional 8.2 million had undiagnosed diabetes mellitus, and 38.2% had prediabetes, with abnormal fasting glucose levels. African Americans, Mexican Americans, Hispanic/Latino individuals, and other ethnic minorities bear a strikingly disproportionate burden of diabetes mellitus in the United States.

The prevalence of diabetes mellitus is increasing dramatically over time, in parallel with the increases in prevalence of overweight and obesity.

The 2010 overall rate of death attributable to CVD was 235.5 per 100 000. The rates were 278.4 per 100 000 for white males, 369.2 per 100 000 for black males, 192.2 per 100 000 for white females, and 260.5 per 100 000 for black females.

From 2000 to 2010, death rates attributable to CVD declined 31.0%. In the same 10-year period, the actual number of CVD deaths per year declined by 16.7%. Yet in 2010, CVD (I00–I99; Q20–Q28) still accounted for 31.9% (787 650) of all 2 468 435 deaths, or ≈1 of every 3 deaths in the United States.

On the basis of 2010 death rate data, >2150 Americans die of CVD each day, an average of 1 death every 40 seconds. About 150 000 Americans who died of CVD in 2010 were <65 years of age. In 2010, 34% of deaths attributable to CVD occurred before the age of 75 years, which is before the current average life expectancy of 78.7 years.

Coronary heart disease alone caused ≈1 of every 6 deaths in the United States in 2010. In 2010, 379 559 Americans died of CHD. Each year, an estimated ≈620 000 Americans have a new coronary attack (defined as first hospitalized myocardial infarction or coronary heart disease death) and ≈295 000 have a recurrent attack. It is estimated that an additional 150 000 silent first myocardial infarctions occur each year. Approximately every 34 seconds, 1 American has a coronary event, and approximately every 1 minute 23 seconds, an American will die of one.

From 2000 to 2010, the relative rate of stroke death fell by 35.8% and the actual number of stroke deaths declined by 22.8%. Yet each year, ≈795 000 people continue to experience a new or recurrent stroke (ischemic or hemorrhagic). Approximately 610 000 of these are first events and 185 000 are recurrent stroke events. In 2010, stroke caused ≈1 of every 19 deaths in the United States. On average, every 40 seconds, someone in the United States has a stroke, and someone dies of one approximately every 4 minutes.

The decline in stroke mortality over the past decades, a major improvement in population health observed for both sexes and all race and age groups, has resulted from reduced stroke incidence and lower case fatality rates. The significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. The hypertension control efforts initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality, with lower blood pressure distributions in the population. Control of diabetes mellitus and high cholesterol and smoking cessation programs, particularly in combination with hypertension treatment, also appear to have contributed to the decline in stroke mortality.²

In 2010, 1 in 9 death certificates (279 098 deaths) in the United States mentioned heart failure. Heart failure was the underlying cause in 57 757 of those deaths in 2010. The number of any-mention deaths attributable to heart failure was approximately as high in 1995 (287 000) as it was in 2010 (279 000). Additionally, hospital discharges for heart failure remained stable from 2000 to 2010, with first-listed discharges of 1 008 000 and 1 023 000, respectively.

The total number of inpatient cardiovascular operations and procedures increased 28%, from 5 939 000 in 2000 to 7 588 000 in 2010 (National Heart, Lung, and Blood Institute computation based on National Center for Health Statistics annual data).

The total direct and indirect cost of CVD and stroke in the United States for 2010 is estimated to be $315.4 billion. This figure includes health expenditures (direct costs, which include the cost of physicians and other professionals, hospital services, prescribed medications, home health care, and other medical durables) and lost productivity that results from premature mortality (indirect costs).

By comparison, in 2008, the estimated cost of all cancer and benign neoplasms was $201.5 billion ($77.4 billion in direct costs, and $124 billion in mortality indirect costs). CVD costs more than any other diagnostic group.

Alan S. Go, MD

Melanie B. Turner, MPH

On behalf of the American Heart Association Statistics

Committee and Stroke Statistics Subcommittee

The most up-to-date data on national prevalence of ideal, intermediate, and poor levels of each of the 7 cardiovascular health metrics are shown for adolescents and teens 12 to 19 years of age (Chart 2-1) and for adults ≥20 years of age (Chart 2-2).

For most metrics, the prevalence of ideal levels of health behaviors and health factors is higher in US children than in US adults. Major exceptions are diet and PA, for which prevalence of ideal levels in children is similar to (for PA) or worse (for diet) than in adults.

Among children (Chart 2-1), the prevalence (unadjusted) of ideal levels of cardiovascular health behaviors and factors currently varies from <1% for the healthy diet pattern (ie, <1 in 100 US children meets at least 4 of the 5 dietary components) to >80% for the smoking, BP, and fasting glucose metrics.

Among US adults (Chart 2-2), the age-standardized prevalence of ideal levels of cardiovascular health behaviors and factors currently varies from 0.5% for having at least 4 of 5 components of the healthy diet pattern to up to 76% for never having smoked or being a former smoker who has quit for >12 months.

Age-standardized and age-specific prevalence estimates for ideal cardiovascular health and for ideal levels of each of its components are shown for 2007 to 2008 (baseline) and 2009 to 2010 in Table 2-2.

Chart 2-3 displays the prevalence estimates for the population of US children (12–19 years of age) meeting different numbers of criteria for ideal cardiovascular health (out of 7 possible) in 2009 to 2010.

Charts 2-4 and 2-5 display the age-standardized prevalence estimates of US adults meeting different numbers of criteria for ideal cardiovascular health (out of 7 possible) in 2009 to 2010, overall and stratified by age, sex, and race.

Chart 2-6 displays the age-standardized percentages of US adults and percentages of children who have ≥5 of the metrics (out of 7 possible) at ideal levels.

Chart 2-7 displays the age-standardized percentages of US adults meeting different numbers of criteria for both poor and ideal cardiovascular health. Meeting the AHA 2020 Strategic Impact Goals is predicated on reducing the relative percentage of those with poor levels while increasing the relative percentage of those with ideal levels for each of the 7 metrics.

Using data from the BRFSS, Fang and colleagues² estimated the prevalence of ideal cardiovascular health by state, which ranged from 1.2% (Oklahoma) to 6.9% (District of Columbia). Southern states tended to have higher rates of poor cardiovascular health, lower rates of ideal cardiovascular health, and lower mean cardiovascular health scores than New England and Western states (Chart 2-8).

The prevalence of poor health behaviors and health factors and their awareness, treatment, and control are displayed in Table 2-3 separately for those with and without self-reported CVD.

The trends over the past decade in each of the 7 cardiovascular health metrics (for diet, trends from 2005–2006 to 2009–2010) are shown in Chart 2-9 (for children 12–19 years of age) and Chart 2-10 (for adults ≥20 years of age).

On the basis of NHANES data from 1988 to 2008, if current trends continue, estimated cardiovascular health is projected to improve by 6% between 2010 and 2020, short of the AHA’s goal of 20% improvement (Chart 2-11).³ On the basis of current trends among individual metrics, anticipated declines in prevalence of smoking, high cholesterol, and high BP (in men) would be offset by substantial increases in the prevalence of obesity and DM and small changes in ideal dietary patterns or PA.³

On the basis of these projections in cardiovascular health factors and behaviors, CHD deaths are projected to decrease by 30% between 2010 and 2020 because of projected improvements in total cholesterol, SBP, smoking and PA (≈167 000 fewer deaths), offset by increases in DM and BMI (≈24 000 more deaths).⁴

In 2010, the age-standardized death rate attributable to all CVD was 236.6 per 100 000 (includes congenital CVD [ICD-10 I00-I99, Q20-Q28]; Chart 2-12), down 8.8% from 259.4 per 100 000 in 2007 (baseline data for the 2020 Impact Goals on CVD and stroke mortality).⁵

Data from NHANES 2009 to 2010 reveal that overall, 7.2% of Americans self-reported having some type of CVD (Table 2-3), including 3.2% with CHD, 2.7% with stroke, and 2.0% with CHF (some individuals reported >1 condition).

Bambs et al,⁶ Folsom et al,⁷ and Dong et al⁸ have all described the low prevalence (<1%) of ideal cardiovascular health, defined as being in the ideal category of all 7 AHA metrics in the Heart Strategies Concentrating on Risk Evaluation, ARIC, and NOMAS cohorts, respectively.

In ARIC and NOMAS, a stepwise inverse association was present between the number of ideal health metrics and incident CVD events (including CHD death, nonfatal MI, stroke, and HF) during 20 and 11 years of follow-up, respectively.^7,8 For ARIC participants with 0, 1, 2, 3, 4, 5, 6, and 7 metrics at ideal levels, the age-, sex-, and race-adjusted rates of incident CVD incidence were 3.21, 2.19, 1.60, 1.20, 0.86, 0.64, 0.39, and 0 per 100 person-years, respectively.⁷ Findings were similar in the Aerobics Center Longitudinal Study, in which individuals with 6 to 7 ideal metrics had a 63% lower risk of CVD death (HR [95% CI], 0.37 [0.15, 0.95]) compared with individuals with 0 to 2 ideal metrics.⁹

A similar stepwise association was present between the number of ideal cardiovascular health metrics and risk of all-cause mortality, CVD mortality, and ischemic HD mortality after 14.5 years of follow-up based on NHANES 1988 to 2006 data.¹⁰ The HRs for individuals with 6 or 7 ideal health metrics compared with individuals with 0 ideal health metrics were 0.49 (95% CI, 0.33–0.74) for all-cause mortality, 0.24 (95% CI, 0.13–0.47) for CVD mortality, and 0.30 (95% CI, 0.13–0.68) for ischemic HD mortality.¹⁰ Ford et al¹¹ demonstrated similar relationships.

The adjusted population attributable fractions for CVD mortality were as follows¹⁰:

The adjusted population attributable fractions for ischemic HD mortality were as follows¹⁰:

Data from the Cardiovascular Lifetime Risk Pooling Project indicate that adults with all-optimal risk factor levels (similar to having ideal cardiovascular health factor levels of cholesterol, blood sugar, and BP, as well as nonsmoking status) have substantially longer overall and CVD-free survival than those who have poor levels of ≥1 of these cardiovascular health factor metrics. For example, at an index age of 45 years, men with optimal risk factor profiles lived on average 14 years longer free of all CVD events, and ≈12 years longer overall, than individuals with ≥2 risk factors.¹²

Importantly, in many of these analyses, ideal health behaviors and ideal health factors were each independently associated with lower CVD risk in a stepwise fashion (Chart 2-13). Thus, across any levels of health behaviors, health factors were still associated with incident CVD, and across any levels of health factors, health behaviors were still associated with incident CVD.

Interestingly, based on NHANES 1999 to 2002, only modest intercorrelations are present between different cardiovascular health metrics. For example, these ranged from a correlation of −0.12 between PA and HbA_1c to a correlation of 0.29 between BMI and HbA_1c. Thus, although the 7 AHA cardiovascular health metrics appear modestly interrelated, substantial independent variation in each exists, and each is independently related to cardiovascular outcomes.¹¹

The AHA metrics may also be related to risk of noncardiovascular conditions. Rasmussen-Torvik et al¹³ demonstrated a graded, inverse association between ideal cardiovascular health and cancer incidence, with 51% lower risk among individuals with 6 or 7 ideal cardiovascular health metrics than among those with 0 ideal metrics. These results were only partially attenuated (25% lower risk) when smoking was removed from the sum of metrics. In contrast, Artero et al⁹ did not find a significant association between ideal cardiovascular health and death attributable to cancer in the Aerobics Center Longitudinal Study. The AHA cardiovascular health metrics have also been cross-sectionally associated with lower prevalence of depressive symptoms in the REGARDS cohort.¹⁴

Recent analyses from the US Burden of Disease Collaborators demonstrated that each of the 7 health factors and behaviors causes substantial mortality and morbidity in the United States. The top risk factor related to overall disease burden was suboptimal diet, followed by tobacco smoking, high BMI, HBP, high fasting plasma glucose, and physical inactivity.^14a

Taken together, these data continue to demonstrate both the tremendous relevance of the AHA 2020 Impact Goals for cardiovascular health and the substantial progress that will be needed to achieve these goals over the next decade.

A range of complementary strategies and approaches can lead to improvements in cardiovascular health. These include each of the following:

Such approaches can focus on both (1) improving cardiovascular health among those who currently have less than optimal levels and (2) preserving cardiovascular health among those who currently have ideal levels (in particular, children, adolescents, and young adults) as they age.

The metrics with the greatest potential for improvement are health behaviors, including diet quality, PA, and body weight. However, each of the cardiovascular health metrics can be improved and deserves major focus.

Continued emphasis is also needed on the treatment of acute CVD events and secondary prevention through treatment and control of health behaviors and risk factors.

For each cardiovascular health metric, modest shifts in the population distribution toward improved health would produce relatively large increases in the proportion of Americans in both ideal and intermediate categories. For example, on the basis of NHANES 2009 to 2010, the current prevalence of ideal levels of BP among US adults is 44.3%. To achieve the 2020 goals, a 20% relative improvement would require an increase in this proportion to 53.1% by 2020 (44.3% × 1.20). On the basis of NHANES data, a reduction in population mean BP of just 2 mm Hg would result in 56.1% of US adults having ideal levels of BP, which represents a 26.8% relative improvement in this metric (Table 2-7). Larger population reductions in BP would lead to even larger numbers of people with ideal levels. Such small reductions in population BP could result from small health behavior changes at a population level, such as increased PA, increased fruit and vegetable consumption, decreased sodium intake, decreased adiposity, or some combination of these and other lifestyle changes, with resulting substantial projected decreases in CVD rates in US adults.¹⁵

The AHA has a broad range of policy initiatives to improve cardiovascular health and meet the 2020 Strategic Impact Goals (Table 2-8). Future Statistical Updates will update these initiatives and track progress toward the 2020 Impact Goals.

In 2011:

Data from 2002 to 2004 suggest that ≈1 in 5 nonsmokers 12 to 17 years of age is likely to start smoking. Youths in the Mexican subpopulations were significantly more susceptible (28.8%) to start smoking than those in non-Hispanic white (20.8%), non-Hispanic black (23.0%), Cuban (16.4%), Asian Indian (15.4%), Chinese (15.3%), and Vietnamese (13.8%) subpopulations. There was no significant difference in susceptibility to start smoking between boys and girls in any of the major populations or subpopulations (NSDUH).¹¹

There is a sharp increase in CVD risk with low levels of exposure to cigarette smoke, including secondhand smoke, and a less rapid further increase in risk as the number of cigarettes per day increases.

A meta-analysis comparing pooled data of ≈2.4 million smokers and nonsmokers found the RR ratio of smokers to nonsmokers for developing CHD was 25% higher in women than in men (95% CI, 1.12–1.39).¹³

Current smokers have a 2 to 4 times increased risk of stroke compared with nonsmokers or those who have quit for >10 years.^14,15

Recent analysis has found that tobacco exposure is a top risk factor for disability in the United States, second only to dietary risks.¹⁶

Worldwide, tobacco smoking (including secondhand smoke) was 1 of the top 3 leading risk factors for disease in 2010.¹⁷

In 2005, tobacco smoking was the cause of ≈467 000 adult deaths (19.1%) in the United States. Approximately one third of these deaths were related to CVD.¹⁸

During 2000 to 2004, ≈49 000 (11.1%) of cigarette smoking–related deaths were attributable to secondhand smoke.¹⁹

Each year from 2000 to 2004, smoking caused 3.1 million years of potential life lost for males and 2.0 million years for females, excluding deaths attributable to smoking-attributable residential fires and adult deaths attributable to secondhand smoke.¹⁹

From 2000 to 2004, smoking during pregnancy resulted in an estimated 776 infant deaths annually.¹⁷

During 2000 to 2004, cigarette smoking resulted in an estimated 269 655 deaths annually among males and 173 940 deaths annually among females.¹⁹

On average, male smokers die 13.2 years earlier than male nonsmokers, and female smokers die 14.5 years earlier than female nonsmokers.¹

In 2010, tobacco smoking was the second-leading risk factor for deaths in the United States, after dietary risks.¹⁶

Overall mortality among US smokers is 3 times higher than that for never-smokers.²⁰

Worldwide, tobacco smoking (including secondhand smoke) was estimated to contribute to 6.2 million deaths in 2010.¹⁷

Smoking cessation reduces the risk of cardiovascular morbidity and mortality for smokers with and without CHD.

Smokers who quit smoking at 25 to 34 years of age gained 10 years of life compared with those who continued to smoke. Those aged 35 to 44 years gained 9 years and those aged 45 to 54 years gained 6 years of life, on average, compared with those who continued to smoke.²⁰

In 2010, 48.3% of adult current smokers ≥18 years of age who had a health checkup during the preceding year reported that they had been advised to quit. Smokers between 18 and 24 (31%) and 24 to 44 (44%) years of age were less likely to be advised to quit than those at older ages (57%; NHIS).²¹

Cessation medications (including sustained-release bupropion, varenicline, and nicotine gum, lozenge, nasal spray, and patch) are effective for helping smokers quit.²²

In addition to medications, smoke-free policies, increases in tobacco prices, cessation advice from healthcare professionals, and quitlines and other counseling have contributed to smoking cessation.²¹

In 2010, 52.4% of adult smokers reported trying to quit smoking in the past year; 6.2% reported they recently quit smoking. Of those who tried to quit smoking, 30.0% used cessation medications.²¹

To help combat the global problem of tobacco exposure, in 2003 the WHO adopted the Framework Convention on Tobacco Control treaty. The WHO Framework Convention on Tobacco Control contains a set of universal standards to limit tobacco supply and demand worldwide. These standards include the use of tax policies to reduce tobacco consumption, a ban on the indoor use of tobacco products, implementation of educational programs about the dangers of tobacco use, and restrictions of the sale of tobacco products to international travelers. Since it came into force in 2005, >175 countries have ratified the WHO Framework Convention on Tobacco Control.²³

Data from a 2006 report of the US Surgeon General on the consequences of involuntary exposure to tobacco smoke¹² indicate the following:

In 2008, data from 11 states showed that the majority of people surveyed in each state reported having smoke-free home rules, ranging from 68.8% in West Virginia to 85.6% in Arizona (BRFSS).²⁴

As of December 31, 2010, 25 states and the District of Columbia had laws that prohibited smoking in indoor areas of worksites, restaurants, and bars; no states had such laws in 2000. As of December 31, 2010, an additional 10 states had laws that prohibited smoking in 1 or 2 but not all 3 venues.²⁵

In 2012, 30 of the 50 largest US cities prohibited indoor smoking in private workplaces, either through state or local ordinances.²⁶

Pooled data from 17 studies in North America, Europe, and Australasia suggest that smoke-free legislation can reduce the incidence of acute coronary events by 10%.²⁷

The percentage of the US nonsmoking population with serum cotinine ≥0.05 ng/mL declined from 52.5% in 1999 to 2000 to 40.1% in 2007 to 2008, with declines occurring for both children and adults. During 2007 to 2008, the percentage of nonsmokers with detectable serum cotinine was 53.6% for those 3 to 11 years of age, 46.5% for those 12 to 19 years of age, and 36.7% for those ≥20 years of age. The percentage was also higher for non-Hispanic blacks (55.9%) than for non-Hispanic whites (40.1%) and Mexican Americans (28.5%; NHANES).²⁸

Direct medical costs ($96 billion) and lost productivity costs ($97 billion) associated with smoking totaled an estimated $193 billion per year between 2000 and 2004.¹⁸

In 2008, $9.94 billion was spent on marketing cigarettes in the United States.²⁹

Cigarette prices have increased 283% between the early 1980s and 2011, which contributed to decreased sales from ≈30 million packs sold in 1982 to ≈14 million packs sold in 2011.²⁹

Physical inactivity is responsible for 12.2% of the global burden of MI after accounting for other CVD risk factors such as cigarette smoking, DM, hypertension, abdominal obesity, lipid profile, no alcohol intake, and psychosocial factors.²⁴

In a meta-analysis of longitudinal studies among women, RRs of incident CHD were 0.83 (95% CI, 0.69–0.99), 0.77 (95% CI, 0.64–0.92), 0.72 (95% CI, 0.59–0.87), and 0.57 (95% CI, 0.41–0.79) across increasing quintiles of PA compared with the lowest quintile.²⁵

A 2003 meta-analysis of 23 studies on the association of PA with stroke indicated that compared with low levels of activity, high (RR, 0.79; 95% CI, 0.69–0.91) and moderate (RR, 0.91; 95% CI, 0.80–1.05) levels of activity were inversely associated with the likelihood of developing total stroke (ischemic and hemorrhagic).²⁶

With television watching as a sedentary activity, 2 hours of television per day is associated with an RR for type 2 DM of 1.20 (95% CI, 1.14–1.27), an RR for fatal or nonfatal CVD of 1.15 (95% CI, 1.06–1.23), and an RR for all-cause mortality of 1.13 (95% CI, 1.07–1.18). The risk for all-cause mortality further increases with >3 hours of television daily.²⁷

Longitudinal studies commonly report a graded, inverse association of PA amount and duration (ie, dose) with incident CHD and stroke.²⁸

The PA guidelines for adults cite evidence that ≈150 minutes per week of moderate-intensity aerobic activity, compared with none, can reduce the risk of CVD.²⁹

Adherence to PA guidelines for both aerobic and muscle-strengthening activities is associated with 27% lower all-cause mortality among adults without existing chronic conditions such as DM, cancer, MI, angina, CVD, stroke, or respiratory diseases and with 46% lower mortality among people with chronic comorbidities.²⁹

In the Health Professionals Follow-Up Study, for every 3-hour-per-week increase in vigorous-intensity activity, the multivariate RR of MI was 0.78 (95% CI, 0.61–0.98) for men. This 22% reduction of risk can be explained in part by beneficial effects of PA on HDL cholesterol, vitamin D, apolipoprotein B, and HbA_1c.³⁰

In a 20-year study of older male veterans, an inverse, graded, and independent association between impaired exercise capacity and all-cause mortality risk was found. For each increase of 1 metabolic equivalent tasks in exercise capacity, mortality risk was 12% lower (HR, 0.88; 95% CI, 0.86–0.90). Unfit individuals who improved their fitness status had a 35% lower mortality risk (HR, 0.65; 95% CI, 0.46–0.93) than those who remained unfit.³¹

PA improves inflammatory markers in people with existing stable CHD. After a 6-week training session, CRP levels declined by 23.7% (P<0.001), and plasma vascular cell adhesion molecule-1 levels declined by 10.23% (P<0.05); there was no difference in leukocyte count or levels of intercellular adhesion molecule-1.³²

In a randomized trial of patients with PAD, supervised treadmill exercise training and lower-extremity resistance training were each associated with significant improvements in functional performance and quality of life compared with a usual-care control group. Exercise training was additionally associated with improved brachial artery FMD, whereas resistance training was associated with better stair-climbing ability versus control.³³

On the basis of a meta-analysis of 34 randomized controlled trials, exercise-based cardiac rehabilitation after MI was associated with lower rates of reinfarction, cardiac mortality, and overall mortality.³⁴

The benefit of intense exercise training for cardiac rehabilitation in people with HF was tested in a trial of 27 patients with stable, medically treated HF. Intense activity (an aerobic interval-training program 3 times per week for 12 weeks) was associated with a significant 35% improvement in left ventricular EF and decreases in pro-brain natriuretic peptide (40%), left ventricular end-diastolic volume (18%), and left ventricular end-systolic volume (25%) compared with control and endurance-training groups.³⁵

Exercise training in patients with HF with preserved EF was associated with improved exercise capacity and favorable changes in diastolic function.³⁶

The economic consequences of physical inactivity are substantial. In a summary of WHO data sources, the economic costs of physical inactivity were estimated to account for 1.5% to 3.0% of total direct healthcare expenditures in developed countries such as the United States.³⁷

Interventions and community strategies to increase physical activity have been shown to be cost-effective in terms of reducing medical costs³⁸:

In 1999 to 2004, only 19.4% of hypertensive US adults were following a DASH-type diet (based on intake of fiber, magnesium, calcium, sodium, potassium, protein, total fat, saturated fat, and cholesterol). This represented a decrease from 26.7% of hypertensive US adults in 1988 to 1994.³⁸

Among older US adults (≥60 years of age) in 1999 to 2002, 72% met guidelines for dietary cholesterol intake, but only between 18% and 32% met guidelines for the HEI food groups (meats, dairy, fruits, vegetables, and grains). On the basis of the HEI score, only 17% of older US adults consumed a good-quality diet. Higher HEI scores were seen in white adults and individuals with greater education; lower HEI scores were seen in black adults and smokers.³⁹

Approximately half of US adults in 2007 to 2010 used ≥1 dietary supplement, with the most common supplement being multivitamin-multimineral products (32% of men and women reporting use).⁴⁰ It has been shown that most supplements are taken daily and for ≥2 years.⁴¹ Supplement use is associated with older age, higher education, greater PA, moderate alcohol consumption, lower BMI, abstinence from smoking, having health insurance, and white race.^40,41 Previous research also suggests that supplement users have higher intakes of most vitamins and minerals from their food choices alone than nonusers.^42,43 The primary reasons US adults in 2007 to 2010 reported for using dietary supplements were to “improve overall health” (45%) and to “maintain health” (33%).⁴⁰

One third (32%) of US children (birth to 18 years of age) used dietary supplements in 1999 to 2002, with the highest use (48.5%) occurring among 4- to 8-year-olds. The most common supplements were multivitamins and multiminerals (58% of supplement users). The primary nutrients supplemented (either by multivitamins or individual vitamins) included vitamin C (29% of US children), vitamin A (26%), vitamin D (26%), calcium (21%), and iron (19%). Supplement use was associated with higher family income, a smoke-free home environment, lower child BMI, and less screen time (television, video games, or computers).⁴⁴

In a 2005 to 2006 telephone survey of US adults, 41.3% were making or had made in the past a serious weight-loss attempt. Of these, one third (33.9%) had used a dietary supplement for weight loss, with such use being more common in women (44.9%) than in men (19.8%) and in blacks (48.7%) or Hispanics (41.6%) than in whites (31.2%); in those with high school education or less (38.4%) than in those with some college or more (31.1%); and in those with household income <$40 000 per year (41.8%) than in those with higher incomes (30.3%).⁴⁵

Multiple trials of most dietary supplements, including folate, vitamin C, and vitamin E, have generally shown no significant benefits for CVD risk, and even potential for harm.³⁶ For example, a multicenter randomized trial in patients with diabetic nephropathy found that B vitamin supplementation (folic acid 2.5 mg/d, vitamin B₆ 25 mg/d, and vitamin B₁₂ 1 mg/d) decreased GFR and increased risk of MI and stroke compared with placebo.⁴⁶

Fish oil supplements at doses of 1 to 2 g/d have shown CVD benefits in 2 large randomized, open-label trials and 1 large randomized, placebo-controlled trial (GISSI-Prevenzione, Japan Eicosapentaenoic Acid Lipid Intervention Study, and GISSI-HF),^47–49 but several other trials of fish oil have not shown significant effects on CVD risk.⁵⁰ A meta-analysis of all randomized controlled clinical trials demonstrated a significant reduction for cardiac mortality but no statistically significant effects on other CVD end points.⁵¹

The proportion of total US food expenditures for meals outside the home, as a share of total food dollars, increased from 27% in 1961 to 40% in 1981 to 49% in 2011.⁶⁶

The proportion of sales of meals and snacks from fast-food restaurants compared with total meals and snacks away from home increased from 5% in 1958 to 29% in 1982 to 36% in 2011.¹²¹

As a proportion of income, food has become less expensive over time in the United States. As a share of personal disposable income, average (mean) total food expenditures by families and individuals have decreased from 22.3% (1949) to 18.1% (1961) to 14.9% (1981) to 11.3% (2011). For any given year, the share of disposable income spent on food is inversely proportional to absolute income. The share increases as absolute income levels decline.¹²¹

Among 153 forms of fruits and vegetables priced with 2008 Nielsen Homescan data, price and calorie per portion of 20 fruits and vegetables were compared with 20 common snack foods such as cookies, chips, pastries, and crackers. Average price per portion of fruits and vegetables was 31 cents with an average of 57 calories per portion, compared with 33 cents and 183 calories per portion for snack foods.¹²¹

An overview of the costs of various strategies for primary prevention of CVD determined that the estimated costs per year of life gained were between $9800 and $18 000 for statin therapy, ≈$1500 for nurse screening and lifestyle advice, $500 to $1250 for smoking cessation, and $20 to $900 for population-based healthy eating.¹²²

Each year, >$33 billion in medical costs and $9 billion in lost productivity resulting from HD, cancer, stroke, and DM are attributed to poor nutrition.^123–126

Two separate cost-effectiveness analyses estimated that population reductions in dietary salt would not only be cost-effective but actually cost-saving.^127,128 In 1 analysis, a 1.2-g/d reduction in dietary sodium was projected to reduce US annual cases of incident CHD by 60 000 to 120 000, stroke by 32 000 to 66 000, and total mortality by 44 000 to 92 000.¹²⁸ If accomplished through a regulatory intervention, estimated savings in healthcare costs would be $10 to $24 billion annually.¹²⁸ Such an intervention would be more cost-effective than using medications to lower BP in all people with hypertension.