Background: Cardiovascular health (CVH) and abdominal aortic calcification (AAC) are closely linked to cardiovascular disease (CVD) and related mortality. However, the relationship between CVH metrics via Life's Essential 8 (LE8) and AAC remains unexplored. Methods: The study analyzed data from the 2013–2014 National Health and Nutrition Examination Survey (NHANES) cohort, which included adults aged 40 or above. The research used the LE8 algorithm to evaluate CVH. Semi-quantitative AAC-24 scoring techniques were employed to assess AAC, categorized into no calcification, mild to moderate calcification, and severe calcification. Results: The primary analysis involved 2,478 participants. Following adjustments for multiple factors, the LE8 score exhibited a significant association with ACC risk (Mild-moderate ACC: 0.87, 95% CI: 0.81,0.93; Severe ACC: 0.77, 95% CI: 0.69,0.87, all P < 0.001), indicating an almost linear dose–response relationship. Compared to the low CVH group, the moderate CVH group showed lower odds ratios (OR) for mild-moderate and severe calcification (OR = 0.78, 95% CI: 0.61–0.99, P = 0.041; OR = 0.68, 95% CI: 0.46–0.99, P = 0.047, respectively). Moreover, the high CVH group demonstrated even lower ORs for mild-moderate and severe calcification (OR = 0.46, 95% CI: 0.31, 0.69, P < 0.001; OR = 0.29, 95% CI: 0.14, 0.59, P = 0.001, respectively). Interactions were found between chronic kidney disease (CKD) condition, history of CVD, marital status and CVH metrics to ACC. Participants without CKD exhibited a more pronounced negative association between the CVH metric and both mild-moderate and severe ACC. Those lacking a history of CVD, and never married/widowed/divorced/separated showed a stronger negative association between the CVH metric and severe ACC. Conclusions: The novel CVH metrics demonstrated an inverse correlation with the risk of AAC. These findings suggest that embracing improved CVH levels may assist in alleviating the burden of ACC.
Quanjun Liu and Hong Xiang contributed equally to this work.
Abdominal aortic calcification (AAC) refers to the accumulation of calcium deposits in the abdominal aorta, the largest artery in the abdominal cavity [[
In 2010, the American Heart Association (AHA) introduced Life's Simple 7 (LS7), a set of cardiovascular health (CVH) metrics encompassing seven key behavioral and health factors: healthy diet, physical activity, normal body mass index (BMI), no smoking, normal blood pressure, normal fasting glucose, and normal total cholesterol [[
Given the established correlation between LE8 and AAC with cardiovascular disease and cardiovascular death, we hypothesize that ideal CVH is associated with lower severity of AAC. Several lifestyle and clinical measures, such as a heart-healthy diet, physical activity, smoking status, sleep pattern, blood glucose, blood lipid, and blood pressure, have been associated with AAC risk [[
To explore the association of novel CVH metrics, and its components, with AAC, we first conducted an observational study utilizing data from the National Health and Nutrition Examination Survey (NHANES) cohort of 2013–2014.
This population-based, cross-sectional study was performed based on the NHANES project conducted by the National Center for Health Statistics at the Centers for Disease Control and Prevention (CDC) in the United States. The survey protocol received approval from the NCHS institutional review board, and all respondents provided written informed consent. All NHANES data utilized in this analysis are publicly available at https://
Graph: Fig. 1Screening flow of participants included in the research. Abbreviation: ACC, abdominal aortic calcification; CVH, cardiovascular health; eGFR, estimated glomerular filtration rate
The components of LE8 encompass diet, physical activity, nicotine exposure, sleep health, body mass index (BMI), blood lipids, blood glucose, and blood pressure (BP), categorized into health behaviors (diet, physical activity, nicotine exposure, sleep) and health factors (BMI, blood lipids, blood glucose, BP) [[
The Healthy Eating Index (HEI) 2015 was used to assess the diet metrics [[
Each participant's scan and phantom scan underwent analysis by the UCSF using standard radiologic techniques and study-specific NHANES protocols. AAC-24 scoring semi-quantitative techniques were employed for ACC assessment [[
Race/ethnicity (non-Hispanic (NH) white, NH black, Hispanic, other race) were categorized based on the survey design. To simplify the interpretation of results, education level was simplified into below high school (less than 11th grade), high school graduate or general educational development test (GED) (high school Grad/GED), and some college or above (AA degree or College or above). And marital status was divided into married or living with a partner, and never married/widowed/divorced/separated. The Poverty-Income Ratio (PIR) served as an index of income related to federally established poverty thresholds, accounting for economic inflation and family size. eGFR was calculated using the Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation [[
Categorical variables were presented as frequency (percentages) and compared using chi-square tests. Continuous variables followed a normal distribution and were presented as mean ± standard deviation (SD), analyzed via the Kruskal–Wallis H test.
Multivariable logistic regressions were employed to independently assess the association of novel CVH metrics with AAC, adjusting for potential demographic confounders (age (as a continuous variable), gender and race/ethnicity, poverty ratio (as a continuous variable), education levels, and marital status) using forward selection methods. Odds ratios (ORs) were calculated in an unadjusted model, age, gender and race/ethnicity-adjusted model (Model 1), and after adjustment for potential confounders, including age, gender, race/ethnicity, poverty ratio, education levels, and marital status (Model 2). Additionally, multifactorial logistic regression analysis was conducted to explore correlations between the components of CVH metrics and ACC, adjusting for the aforementioned factors and other constituents of CVH metrics.
The restricted cubic spline regression examined the potential nonlinear relationships between the LE8 score and ACC, with nonlinearity tested using the likelihood ratio test. Subsequently, stratification and interaction analyses were performed by gender, age, race, marital status, CKD condition, and history of CVD. All statistical analyses were conducted using IBM SPSS Statistics 27 and R software. A two-sided p-value < 0.05 was considered statistically significant.
The characteristics and CVH of participants across the three categories of total ACC score (no, mild-moderate, severe) are shown in Table 1. Notably, 70.4% of participants had no ACC, 20.6% had mild-moderate ACC, and 9.0% had severe ACC. Those with higher ACC scores were notably older, more likely to be NH white, and never married/widowed/divorced/separated (P < 0.05). Furthermore, individuals with a history of CVD, diabetes, stroke, and CKD were more likely to have higher ACC scores (all P values < 0.05). Concerning CVH, higher ACC score participants displayed lower LE8, physical activity, nicotine exposure, blood glucose, and blood pressure scores but higher BMI scores (all P values < 0.05). However, diet, sleep health, and blood lipid scores did not significantly differ among the three groups (P > 0.05).
Table 1 Characteristics and cardiovascular health assessment based on no, mild-moderate and severe abdominal aortic calcification
Characteristics Total No ACC Mild-moderate ACC Severe ACC 58.41 (11.86) 55.86 (10.89) 61.59 (11.79) 71.08 (9.19) < 0.001 < 0.001 40–49 708 (28.6) 597 (34.2) 104 (20.4) 7 (3.1) 50–59 630 (25.4) 493 (28.3) 116 (22.7) 21 (9.4) 60–69 618 (24.9) 428 (24.5) 140 (27.4) 50 (22.4) ≥ 70 522 (21.1) 226 (13.0) 151 (29.5) 145 (65.0) 1196 (48.3) 833 (47.8) 258 (50.5) 105 (47.1) 0.519 < 0.001 Non-Hispanic White 1153 (46.5) 745 (42.7) 261 (51.1) 147 (65.9) Non-Hispanic Black 481 (19.4) 366 (21.0) 88 (17.2) 27 (12.1) Hispanic 528 (21.3) 400 (22.9) 99 (19.4) 29 (13.0) Multiracial/othera 316 (12.8) 233 (13.4) 63 (12.3) 20 (9.0) 0.050 Below high school 518 (20.9) 355 (20.4) 104 (20.4) 59 (26.5) High school graduate or GED 556 (22.4) 374 (21.4) 128 (25.0) 54 (24.2) Some college or above 1404 (56.7) 1015 (58.2) 279 (54.6) 110 (49.3) 0.240 < 1.3 729 (29.4) 507 (29.1) 154 (30.1) 68 (30.5) 1.3–3.5 857 (34.6) 585 (33.5) 187 (36.6) 85 (38.1) > 3.5 892 (36.0) 652 (37.4) 170 (33.3) 70 (31.4) < 0.001 Married or living with partner 1576 (63.6) 1145 (65.7) 317 (62.0) 114 (51.1) Never married/Widowed/divorced/separated 902 (36.4) 599 (34.3) 194 (37.9) 109 (48.9) 55.83 (13.63) 56.03 (13.72) 55.36 (13.77) 55.39 (12.59) 0.669 698.29 (1263.22) 760.22 (1320.14) 622.92 (1213.80) 385.50 (769.53) < 0.001 6.89 (2.32) 6.85 (2.60) 6.89 (1.45) 7.25 (1.35) < 0.001 28.56 (5.66) 28.92 (5.94) 27.83 (5.03) 27.42 (4.29) < 0.001 141.28 (44.95) 142.27 (45.47) 142.93 (44.47) 129.73 (40.32) < 0.001 5.91 (1.16) 5.86 (1.18) 5.93 (0.99) 6.23 (1.30) < 0.001 126.95 (18.51) 125.09 (17.50) 129.78 (19.85) 134.99 (20.13) < 0.001 70.68 (12.43) 71.84 (11.83) 69.55 (13.19) 64.20 (12.99) < 0.001 84.48 (20.26) 87.42 (18.92) 81.43 (20.22) 68.45 (21.91) < 0.001 272 (11.0) 119 (6.8) 76 (14.9) 77 (34.5) < 0.001 129 (5.2) 53 (3.0) 32 (6.3) 44 (19.7) < 0.001 403 (16.3) 250 (14.3) 85 (16.6) 68 (30.5) < 0.001 107 (4.3) 53 (3.0) 28 (5.5) 26 (11.7) < 0.001 LE8 score 60.96 (15.02) 62.02 (15.39) 58.79 (14.22) 57.65 (12.72) < 0.001 Diet score 39.74 (31.31) 40.07 (31.52) 38.94 (31.19) 38.97 (30.00) 0.768 Physical activity score 44.00 (46.59) 46.59 (47.03) 37.36 (44.89) 38.88 (45.26) < 0.001 Nicotine exposure score 72.12 (37.85) 73.70 (37.51) 68.28 (39.01) 68.59 (37.17) < 0.001 Sleep health score 80.68 (25.51) 80.17 (25.59) 80.59 (26.27) 84.93 (22.68) 0.084 Body mass index score 61.39 (31.89) 59.56 (32.82) 64.77 (29.91 68.00 (27.27) < 0.001 Blood lipid score 61.68 (29.60) 62.22 (30.04) 59.45 (29.31) 62.51 (26.53) 0.159 Blood glucose score 70.21 (27.88) 72.19 (27.76) 67.96 (26.85) 59.82 (28.52) < 0.001 Blood pressure score 57.84 (34.16) 61.62 (33.39) 52.94 (34.71) 39.48 (31.45) < 0.001 < 0.001 Low (0–49) 560 (22.6) 372 (21.3) 134 (26.2) 54 (24.2) Moderate (50–79) 1608 (64.9) 1115 (63.9) 336 (65.8) 157 (70.4) High (80–100) 310 (12.5) 257 (14.7) 41 (8.0) 12 (5.4)
Data presented as mean (standard deviation, SD) for continuous and no. (%) values for categorical Abbreviations: ACC Abdominal aortic calcification, GED General educational development test, HEI Healthy eating index, PA Physical activity, BMI Body mass index, HDL High-density lipoprotein, HbA1c Hemoglobin A1c, SBP Systolic blood pressure, DBP Diastolic blood pressure, CKD Chronic kidney disease, eGFR Estimated glomerular filtration rate, LE8 Life's essential 8
The prevalence of mild-moderate ACC was 13.2%, while severe ACC was 3.9% among high CVH participants. This was significantly lower than moderate CVH participants, where mild-moderate ACC was 20.9%, severe ACC was 9.8%, and low CVH participants, where mild-moderate ACC was 26.2% and severe ACC was 24.2%.
Table 2 shows results from univariate and multivariate logistic regression analyses. Unadjusted univariate logistic regression model showed an association between every 10-point increase in LE8 score and reduced OR of mild-moderate ACC (OR = 0.87, 95% confidence interval (CI): 0.81, 0.93) and severe ACC (OR = 0.83, 95% CI: 0.75, 0.91). After adjustment for age, gender, and race/ethnicity, the association between LE8 score and severity of ACC persisted across model 1. In the fully adjusted model, the impact of LE8 score was still significant when adjusting for poverty ratio, education levels, and marital status (Mild-moderate ACC: 0.87, 95% CI: 0.81,0.93; Severe ACC: 0.77, 95% CI: 0.69,0.87, both P < 0.001). Moreover, moderate and high CVH groups exhibited lower ORs for mild-moderate and severe calcification compared to the low CVH group after adjustments for multiple factors (P < 0.05). Restricted cubic spline regression analysis did not reveal nonlinear relationships between LE8 score and mild-moderate or severe ACC risk after adjustment for multiple covariates (Fig. 2) (P for nonlinear = 0.200, P for nonlinear = 0.170, respectively). Moreover, the minimal threshold for the beneficial association was 61.25 points for mild-moderate ACC and severe ACC (estimated OR = 1). Beyond this LE8 total score threshold, the risk decreases rapidly.
Table 2 Association of the Life's Essential 8 scores with abdominal aortic calcification
Variables Mild–moderate AAC versus no AAC Severe AAC versus no AAC Per 10 points increase 0.87 (0.81,0.93) < 0.001 0.83 (0.75,0.91) < 0.001 LE8 score Low (0–49) 1 (Reference) - 1 (Reference) - Moderate (50–79) 0.84 (0.66,1.06) 0.132 0.97 (0.70,1.35) 0.857 High (80–100) 0.44 (0.30,0.65) < 0.001 0.32 (0.18,0.59) 0.001 Per 10 points increase 0.87 (0.81,0.93) < 0.001 0.77 (0.68,0.86) < 0.001 LE8 score Low (0–49) 1 (Reference) - 1 (Reference) - Moderate (50–79) 0.78 (0.61,0.99) 0.041 0.68 (0.46,0.99) 0.045 High (80–100) 0.46 (0.31,0.69) < 0.001 0.28 (0.14,0.58) 0.001 Per 10 points increase 0.87 (0.81,0.93) < 0.001 0.77 (0.69,0.87) < 0.001 LE8 score Low (0–49) 1 (Reference) - 1 (Reference) - Moderate (50–79) 0.78 (0.61,0.99) 0.041 0.68 (0.46,0.99) 0.047 High (80–100) 0.46 (0.31,0.69) < 0.001 0.29 (0.14,0.59) 0.001
Abbreviations: ACC Abdominal aortic calcification, OR Odds ratio, CI Confidence interval, LE8 Life's essential 8
Graph: Fig. 2Dose–response relationships between Life's Essential 8 score and mild-moderate (A) and severe (B) abdominal aortic calcification. Note: Odds ratio adjusted for age (as a continuous variable), gender, race, poverty ratio (as a continuous variable), education levels, and marital status. Abbreviation: OR, odds ratio; LE8, life's essential 8
Regarding the components of LE8, physical activity, nicotine exposure, and blood lipid scores negatively correlated with mild-moderate ACC in adjusted models (all P values < 0.05). Similarly, nicotine exposure, blood glucose, and blood lipid scores displayed negative correlations with severe ACC (all P values < 0.001). In contrast, the BMI score showed a significant positive correlation with both mild-moderate and severe ACC (Table S2).
In subgroup analysis, the association between LE8 score and ACC was not consistently significant across certain groups (Fig. 3). Specifically, the relationship between LE8 score and ACC lacked statistical significance among Hispanic participants, those with CKD condition, and participants with a history of CVD (P > 0.05). Similar insignificance was observed for mild-moderate ACC in NH Black and Other races (P > 0.05). Additionally, the association between LE8 score and severe ACC was not statistically significant in participants who were married or living with a partner (P > 0.05). Interaction testing indicated that gender, age, race, marital status, and history of CVD did not significantly impact the association between LE8 score and mild-moderate ACC (all P for interaction > 0.05). However, CKD condition significantly influenced this association (P for interaction < 0.05). The inverse association between LE8 score and mild-moderate ACC appeared stronger in populations without CKD condition (OR for per 10 scores increase, 0.86; 95% CI 0.80, 0.93). Moreover, significant interactions between LE8 score and marital status, CKD condition, and history of CVD were observed with severe ACC (P < 0.05 for interaction). The inverse association between LE8 score and severe ACC appeared stronger in participants who were never married/widowed/divorced/separated (OR for per 10 scores increase, 0.66; 95% CI 0.55, 0.81), those without CKD condition (OR for per 10 scores increase, 0.77; 95% CI 0.67, 0.88), and participants without a history of CVD (OR for per 10 scores increase, 0.78; 95% CI 0.67, 0.89).
Graph: Fig. 3Subgroup analysis of the association of the Life's Essential 8 score and the risk of mild-moderate (A) and severe (B) abdominal aortic calcification. Note: Logistical model adjusted for age (as a continuous variable), gender, race, poverty ratio (as a continuous variable), education levels, and marital status. * Status 1 indicates married or living with a partner, while status 2 indicates never married/widowed/divorced/separated. Abbreviation: OR, odds ratios; CI, confidence interval; NH, non-Hispanic; CKD, chronic kidney disease; CVD, cardiovascular disease
This study, conducted among US NHANES participants (2013–2014), affirmed our hypothesis that adults with higher levels of CVH metrics assessed by LE8 have a reduced risk of ACC. We observed a linear dose–response association between increased LE8 score and decreased ACC risk, with each 10-point rise in LE8 score associated with a 13% reduction in mild-to-moderate ACC and a 23% reduction in severe ACC.
Several previous studies have explored the connection between CVH and artery calcification. For instance, a cohort study of 65,494 adults found a correlation between higher cardiovascular health scores assessed by LF7 and a lower prevalence of coronary artery calcification [[
The prevalence of a high CVH score based on LE8 among US adults was found to be low, and this total CVH score is inversely correlated with all-cause and CVD-specific mortality [[
In our correlation analysis between LE8 components and AAC, nicotine exposure score, blood glucose score, and blood pressure scores emerged as primary contributors to arterial calcification. Smoking, extensively studied for its association with arterial calcification, was examined here through nicotine exposure assessed by LE8, encompassing both active smoking and secondhand smoke exposure [[
Our study noted that physical activity levels and blood lipid scores were only associated with mild-to-moderate calcification and not with severe calcification. While previous studies have explored the link between physical activity and arterial calcification, our findings did not show consistent results [[
Inconsistent with prior data, our study did not find an association between diet scores assessed by HEI-2015 and AAC, potentially due to scoring method variations [[
There are several strengths in this study. Our study was the first to explore the association of novel CVH metrics using LE8 and its components with AAC. Meanwhile, all the data we used were obtained from NHANES, which has a standardized data collection process to ensure data accuracy. Additionally, we explored the dose–response relationship between CVH and ACC, determining the minimum threshold for beneficial associations. However, we need to consider several potential limitations in our study. Firstly, although we controlled for several potential confounding factors, the cross-sectional design of our study limits establishing a causal relationship between CVH and AAC. Meanwhile, our findings distinctly indicate a correlation between better CVH and reduced ACC risk, laying the groundwork for further prospective research. Secondly, our analysis involved participants from a single nation, potentially limiting the generalizability of this study's conclusions to many countries worldwide. Lastly, many indicators of CVH in our study relied on self-reported questionnaires, possibly introducing measurement errors and recall biases.
The findings of this study underscore the importance of public education and health campaigns emphasizing CVH concepts to promote overall health and prevent cardiovascular diseases. Enhancing public awareness of CVH concepts can elevate health consciousness and encourage proactive measures. Further research will deepen our understanding of the mechanisms and associations between cardiovascular health and arterial calcification, offering strategies for future prevention and treatment.
This cross-sectional study demonstrated that the novel CVH metrics, evaluated using LE8, had an inverse association with the risk of AAC. Among the LE8 components, nicotine exposure, blood glucose, and blood pressure emerged as significant factors linked to ACC risk. These findings suggest a promising role for LE8 as a viable method to promote cardiovascular health. Additionally, these findings may support further large-scale prospective studies to clarify the precise causality of this relationship for preventing vascular calcification and CVD.
We are grateful to all participants and project teams in the NHANES study.
QL and HL conceived and designed the study. QL and HX organized the data, conducted the analyses, and drafted the manuscript. QL, HX, SC, HL, JZ, and JO reviewed and edited the manuscript. YC, PG, XZ, JF, and XZ contributed to data collection. Each author critically revised successive drafts of the paper and approved the final version.
This research was funded by the National Key R&D Program of China (2021YFC2500500), the National Natural Science Foundation of China (82270519, 81970252, 81870352), and the Natural Science Foundation of Hunan Province (2023JJ30838).
No datasets were generated or analysed during the current study.
NHANES is conducted by the Centers for Disease Control and Prevention (CDC) and NCHS. The NCHS Research Ethics Review Committee reviewed and approved the NHANES study protocol. All participants signed written informed consent.
All the authors have read and agreed to the published version of the manuscript.
The authors declare no competing interests.
Graph: Supplementary Material 1.
• AAC
- Abdominal aortic calcification
• AHA
- American Heart Association
• BMI
- Body mass index
• BP
- Blood pressure
• CVH
- Cardiovascular health
• CVD
- Cardiovascular disease
• CKD
- Chronic kidney disease
• CI
- Confidence interval
• DXA
- Dual-energy X-ray absorptiometry
• eGFR
- Estimated glomerular filtration rate
• GED
- General educational development test
• HEI
- Healthy eating index
• OR
- Odds ratio
• PIR
- Poverty-income ratio
• NH
- Non-Hispanic
• NHANES
- National Health and Nutrition Examination Survey
• LE8
- Life's essential 8
• LF7
- Life's simple 7
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