AHA Revamps Life’s Simple 7, Adding Sleep to Create ‘Essential 8’

After 12 years, Life’s Simple 7 from the American Heart Association (AHA)—used to assess an individual’s cardiovascular health status—has been reworked. Notably, sleep has been added as an eighth health metric, resulting in a change to the tool’s name to Life’s Essential 8.

Life’s Simple 7 was first defined in 2010, with cardiovascular health classified as poor, intermediate, or ideal according to how individuals scored on seven metrics: dietary quality, physical activity, exposure to cigarette smoking, body mass index (BMI), fasting blood glucose, total cholesterol, and blood pressure.

“We felt like it was really important for people to have something positive to strive for, and what’s more important or positive than health?” said AHA President Donald Lloyd-Jones, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), lead author of the 2010 document and chair of the writing group behind the new presidential advisory announcing the update, published Wednesday in Circulation. “We wanted to say that health is more than just the absence of disease and that there are characteristics that people can modify to make sure that they improve their health.”

The new score does really give us a much more granular look at people. Donald Lloyd-Jones

Over the last 12 years, more than 2,500 scientific papers have cited Life’s Simple 7, showing that “it’s really a pretty darn good way to think about what your long-term health outcomes are likely to be,” Lloyd-Jones told TCTMD.

Even so, “we also learned that it’s not perfect,” he added. “There were ways we could refine the scoring to better represent the full spectrum of health for the population and for people.”

The authors made several major changes, supported by evidence that was included in two prior AHA documents, a 2017 presidential advisory defining optimal brain health and a 2021 scientific statement addressing psychological health, well-being, and the mind-heart-body connection:

• The tool can be used in children as young as 2.
• Scoring is on a 100-point scale, with higher scores indicating better cardiovascular health. That makes it easier for people to see progress with small changes to their lifestyle or health factors.
• Sleep is one of the eight key metrics. The optimal amount of sleep each night is 7 to 9 hours for adults and 8 to 16 hours (depending on age) for children and teens. 
• The method for assessing diet quality has changed, focusing on the Dietary Approaches to Stop Hypertension (DASH) eating pattern for population-level assessments and the Mediterranean Eating Pattern for Americans (MEPA) at the individual level and reflecting a broader range of healthy and unhealthy eating patterns.
• The cigarette-smoking measure has been changed to nicotine exposure to account for use of e-cigarettes and vaping devices, as well as contact with secondhand smoke.
• The preferred lipid measure has been changed from total cholesterol to non-HDL cholesterol, which incorporates multiple atherogenic lipoprotein fractions and can be measured in a nonfasting state.
• The blood sugar metric has been expanded to include both fasting blood glucose and hemoglobin A1c.
• The eight essential metrics have been split into two main areas—health behaviors (diet, physical activity, nicotine exposure, and sleep) and health factors (BMI, cholesterol, blood sugar, and blood pressure).

No modifications have been made to how physical activity, BMI, and blood pressure are measured.

Other factors were considered for inclusion, such as stress, mental health, and social determinants of health, although it was determined that further research is necessary before incorporating them. Nonetheless, “the foundational contexts of social determinants of health and psychological health were addressed as crucial factors in optimizing and preserving cardiovascular health,” Lloyd-Jones et al write.

Individuals can calculate their cardiovascular health score using the online My Life Check tool. Users receive a score of up to 100 points based on the average of scores for each component. Cardiovascular health is low if the score is below 50, moderate if the score is between 50 and 79, and high if the score is 80 or more.

The concept of Life’s Simple 7 had good buy-in at the public health and research levels, with lower penetration at the clinical level, Lloyd-Jones said. This was part of the rationale for revamping it.

One of the important ways Life’s Essential 8 can be used at the patient level is in discussing risks with people younger than 40, both children and young adults, Lloyd-Jones said. This is a particularly crucial time to talk about lifestyle choices and cardiovascular health, but there hadn’t really been a comprehensive way to do that, he added. Life’s Essential 8, then, provides a method to get young people to “work for positive change rather than just thinking about risk for a stroke, which is hard to get a child or a young adult to focus on. If we talk about their health, that resonates more. And so I think this is a really powerful tool especially in those age groups, although it works at all ages.”

How Is the US Doing?

To get an updated idea of how the US population is faring when it comes to cardiovascular health, Lloyd-Jones and his colleagues—in a separate paper in Circulation—applied the new criteria of Life’s Essential 8 to data from the National Health and Nutrition Examination Survey for 2013 to 2018. The analysis included 23,409 participants ages 2 to 79, representing 201.7 million adults and 74.4 million children and teens.

Overall, the mean cardiovascular health score based on all eight metrics was 64.7 among adults. For children and teens, the mean overall score was based on the three metrics that could be applied down to age 2 (diet, physical activity, and BMI); it came out to 65.5.

Average scores among adults were particularly low for diet (36.0), physical activity (51.6), and BMI (57.5), although there were large differences in the various metrics across groups defined by age, sex, and race/ethnicity.

In children and teens, the diet score was low overall (mean 40.6) and declined from 61.1 among children ages 2 to 5 to just 28.5 among those ages 12 to 19. Mean physical activity and BMI scores were 75.1 and 81.1, respectively.

“The new score does really give us a much more granular look at people and where they are in the full spectrum of cardiovascular health because of the way it’s designed differently than the original score,” Lloyd-Jones said.

“What’s also clear is as a population, we have some work to do to improve our cardiovascular health,” he added, noting that the mean score of around 65 “is clearly suboptimal if we want to have good long-term health outcomes.”

To highlight what could be gained by helping individuals improve their cardiovascular health, Lloyd-Jones pointed to a study published earlier this year in Circulation that calculated the impact of both genetic susceptibility to heart disease and CV health status according to Life’s Simple 7 on lifetime risk of coronary heart disease. Among those with high genetic risk, ideal CV health was associated with roughly 16 more years free of coronary heart disease and 12 more years of life compared with poor CV health.

“It really did seem like you could trump bad genes by focusing on good cardiovascular health, and for me, that’s a very optimistic and promising message that we can give people,” Lloyd-Jones said.