Enhancing the Cardiovascular Health Construct With a Psychological Health Metric for Predicting Mortality Risk.

Background: The American Heart Association's Life's Essential 8 (LE8) Presidential Advisory deemed psychological health foundational for cardiovascular health (CVH) but did not include it as a CVH metric. Objectives: The purpose of this study was to evaluate associations of a CVH construct enhanced with a ninth metric for psychological health based on readily administered depression screening with mortality risk in U.S. adults. Methods: Participants were 21,183 adults (mean age: 48y, 51% female, 11% Black, 15% Hispanic, 65% White) from the 2011 to 2018 National Health and Nutrition Examination Survey. The LE8 algorithm was used to assess CVH. Two enhanced CVH constructs that include a ninth psychological health metric based on depression screening using the Patient Health Questionnaires (PHQ-2 and PHQ-9) were computed. Multivariable Cox proportional hazards models compared all-cause and cause-specific mortality risk across CVH score tertiles and a priori defined categories (high: 80-100, moderate: 50-79, low: 0-49) in the overall sample and by sex and race and ethnicity. Results: There were 1,397 deaths (414 cardiovascular and 329 cancer deaths). High vs low CVH scores, enhanced with PHQ-2 and PHQ-9, were associated with 69% and 70% lower mortality risk, while a high vs low LE8 score was associated with 65% lower risk (p-trend<0.001). Higher LE8 and enhanced CVH scores predicted lower mortality risk in both sexes and in Black and White but not Hispanic adults and were also associated with lower cardiovascular and cancer mortality. Both enhanced CVH scores had excellent performance for predicting mortality, similar to the LE8 score (C-statistic = 0.843 vs 0.842, P < 0.001). Conclusions: A CVH construct enhanced with psychological health strongly predicts mortality. Inclusion of psychological health as a ninth CVH metric, with depression screening as a feasible proxy in clinical and public health settings, should be considered.

The role of social support in the relation between chronotype and mental health in a cohort of women from the American Heart Association Go Red for Women Strategically Focused Research Network.

Women are disproportionally affected by psychological distress and lack of social support and are more vulnerable to the negative impact of chronotype on mental health. This study evaluates cross-sectional associations between chronotype and mental health, while assessing the mediating role of social support among women from diverse racial/ethnic backgrounds. Women from the American Heart Association Go Red for Women Research Network were included (N = 506, mean age = 37 ± 15.7, 61% racial/ethnic minority). Chronotype, depression, perceived stress, health-related quality of life, and social support were assessed at baseline using validated self-reported questionnaires. Linear regression and causal mediation analyses were performed. Depression and negative emotionality were higher among women with evening vs. morning/intermediate chronotypes (all p < 0.05). Multivariable analyses adjusted for sociodemographic and clinical confounders showed associations between evening chronotype and higher depression (p = 0.004) and negative emotionality (p = 0.010). However, these associations were no longer significant after adjusting for social support (depression: p = 0.12; negative emotionality: p = 0.18). Social support significantly mediated 44.6% and 45.8% of the total effect of chronotype on depression and negative emotionality, respectively. Social support represents a potential mechanism underlying the associations between eveningness and poor mental health. Chronotype and social support should be considered in interventions for the promotion of mental health in women.

The effects of sustained mild sleep restriction on stress and distress among healthy adults: Findings from two randomized crossover studies.

OBJECTIVE/BACKGROUND: Experimental studies suggest that sleep loss affects psychological outcomes. However, most studies focus on acute severe in-laboratory sleep restriction, with limited ecological validity. This study examines the impact of sustained mild sleep restriction (SR) on stress and distress among healthy adults in a naturalistic home environment. PATIENTS/METHODS: We analyzed data from two randomized crossover studies. Individuals who regularly slept 7-9 h/night completed two 6-wk intervention phases separated by a 6-wk washout: habitual sleep (HS: maintenance of habitual bed and wake times) and SR (delayed bedtime by 1.5 h/night and maintenance of habitual wake time). Adherence to sleep duration requirements was verified with wrist actigraphy and daily sleep diaries during each intervention phase. Measures of perceived stress, subjective anxiety, subjective depression, rumination, and cortisol were collected at baseline and endpoint of each intervention phase. RESULTS: Sixty-two participants (age 36.4 ± 14.0 y, 85.5 % women, 63.3 % racial/ethnic minority) were included in our analyses. Mean total sleep time was 7.4 ± 0.4 h/night during HS and 6.2 ± 0.4 h/night during SR (p < 0.001). Higher perceived stress (3.6 ± 1.0, p = 0.0007) and subjective anxiety (1.1 ± 0.5, p = 0.039) were observed after SR compared to HS. No effect of sleep condition was observed on subjective depression, rumination, and cortisol. CONCLUSIONS: Our findings suggest that prolonged mildly insufficient sleep, similar to what commonly experienced in the real world, can lead to increased perceived stress and subjective anxiety in healthy adults. Addressing sleep loss, even if mild, should be a key component of interventions aimed at promoting mental health in the general population.

Chronic Insufficient Sleep in Women Impairs Insulin Sensitivity Independent of Adiposity Changes: Results of a Randomized Trial.

OBJECTIVE: Insufficient sleep is associated with type 2 diabetes, yet the causal impact of chronic insufficient sleep on glucose metabolism in women is unknown. We investigated whether prolonged mild sleep restriction (SR), resembling real-world short sleep, impairs glucose metabolism in women. RESEARCH DESIGN AND METHODS: Women (aged 20-75 years) without cardiometabolic diseases and with actigraphy-confirmed habitual total sleep time (TST) of 7-9 h/night were recruited to participate in this randomized, crossover study with two 6-week phases: maintenance of adequate sleep (AS) and 1.5 h/night SR. Outcomes included plasma glucose and insulin levels, HOMA of insulin resistance (HOMA-IR) values based on fasting blood samples, as well as total area under the curve for glucose and insulin, the Matsuda index, and the disposition index from an oral glucose tolerance test. RESULTS: Our sample included 38 women (n = 11 postmenopausal women). Values are reported with ±SEM. Linear models adjusted for baseline outcome values demonstrated that TST was reduced by 1.34 ± 0.04 h/night with SR versus AS (P < 0.0001). Fasting insulin (ß = 6.8 ± 2.8 pmol/L; P = 0.016) and HOMA-IR (ß = 0.30 ± 0.12; P = 0.016) values were increased with SR versus AS, with effects on HOMA-IR more pronounced in postmenopausal women compared with premenopausal women (ß = 0.45 ± 0.25 vs. ß = 0.27 ± 0.13, respectively; P for interaction = 0.042). Change in adiposity did not mediate the effects of SR on glucose metabolism or change results in the full sample when included as a covariate. CONCLUSIONS: Curtailing sleep duration to 6.2 h/night, reflecting the median sleep duration of U.S. adults with short sleep, for 6 weeks impairs insulin sensitivity, independent of adiposity. Findings highlight insufficient sleep as a modifiable risk factor for insulin resistance in women to be targeted in diabetes prevention efforts.

Psychosocial factors are associated with sleep disturbances and evening chronotype among women: A brief report from the American Heart Association Go Red for Women Strategically Focused Research Network.

OBJECTIVES: To evaluate associations between psychosocial factors and sleep characteristics commonly linked to cardiovascular disease risk among racially/ethnically diverse women. METHODS: Women from the AHA Go Red for Women cohort (N = 506, 61% racial/ethnic minority, 37 ± 16years) were assessed using self-reported questionnaires. Logistic regression models were adjusted for age, race, ethnicity, education, and insurance. RESULTS: Women with depression had ∼3-fold higher odds of short sleep (95%CI=1.69-4.61), 2-fold higher odds of poor sleep quality and obstructive sleep apnea risk (95%CI=1.42-3.70 and 1.34-4.24), 4-fold higher odds of insomnia (95%CI=2.42-6.59), and greater likelihood of having an evening chronotype (OR:2.62, 95%CI=1.41-4.89). Low social support was associated with insomnia (OR:1.79, 95%CI=1.18-2.71) and evening chronotype (OR:2.38, 95%CI=1.35-4.19). Caregiving was associated with short sleep (OR:1.73, 95%CI=1.08-2.77) and obstructive sleep apnea risk (OR:2.46, 95%CI=1.43-4.22). CONCLUSIONS: Depression, caregiver strain, and low social support are significantly associated with poor sleep and evening chronotype, highlighting a potential mechanism linking these psychosocial factors to cardiovascular disease risk.

Well-being therapy and sleep hygiene in a non-clinical population of adults reporting poor sleep quality and distress: A remote pilot randomized controlled study.

OBJECTIVES: This pilot randomized controlled study evaluates the feasibility and preliminary efficacy of a 7-week remote intervention combining well-being therapy and sleep hygiene to improve sleep and psychological outcomes among adults reporting poor sleep and distress. METHODS: Thirty-one participants (81% women, 40.2 ± 13.0 y, 48% racial/ethnic minority) were recruited from the community during the COVID-19 pandemic through online and local advertisement, and randomized to well-being therapy+sleep hygiene or sleep hygiene-only. Study outcomes were evaluated by self-reported questionnaires administered at baseline and post-intervention and a daily sleep diary. RESULTS: Compared to sleep hygiene-only, well-being therapy+sleep hygiene led to greater improvements in wake after sleep onset (time-by-group interaction: 3.6 ± 1.5 min, p = .017), personal growth (ß -3.0, 95%CI -5.2, -0.8, p = .01), and purpose in life (ß -3.5, 95%CI -6.1, -0.9, p = .009). Anxiety, perceived stress, sleep quality, and insomnia symptoms improved similarly in both groups (between-group differences, p > .05). Improvements in sleep quality, insomnia, and sleep duration were associated with reductions in multiple measures of psychological distress (all p < .05). CONCLUSIONS: These findings suggest that, in a non-clinical setting of individuals suffering from combined poor sleep and psychological distress, the addition of well-being therapy to sleep hygiene may provide additional benefits for sleep by promoting sleep continuity and well-being.

Obesity and Severity of Menopausal Symptoms: a Contemporary Review.

PURPOSE OF REVIEW: Vasomotor symptoms are frequently experienced by women during menopause and have been linked to obesity. Severity of menopausal symptoms is a distinct construct from presence of symptoms, and the relation between severity of symptoms and obesity is less established. The purpose of this brief narrative review was to summarize evidence from recent studies on associations between menopausal symptom severity and measures of obesity. RECENT FINDINGS: Sixteen articles were identified that specifically assessed and reported on the severity of menopausal symptoms in relation to measures of obesity including body mass index (BMI), waist circumference, and waist-to-hip ratio. Most studies to date show that greater BMI, waist size, and waist-to-hip ratio are associated with greater severity of menopausal symptoms. Given the large segment of women who will experience symptoms and that severity of symptoms influences treatment decisions, future studies are needed to determine how weight management efforts may reduce the severity of menopausal symptoms.

Paradoxical Effects of Prolonged Insufficient Sleep on Lipid Profile: A Pooled Analysis of 2 Randomized Trials.

Background Insufficient sleep is associated with increased cardiovascular disease risk, but causality is unclear. We investigated the impact of prolonged mild sleep restriction (SR) on lipid and inflammatory profiles. Methods and Results Seventy-eight participants (56 women [12 postmenopausal]; age, 34.3±12.5 years; body mass index, 25.8±3.5 kg/m2) with habitual sleep duration 7 to 9 h/night (adequate sleep [AS]) underwent two 6-week conditions in a randomized crossover design: AS versus SR (AS-1.5 h/night). Total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol, triglycerides, and inflammatory markers (CRP [C-reactive protein], interleukin 6, and tumor necrosis factor-α) were assessed. Linear models tested effects of SR on outcomes in the full sample and by sex+menopausal status (premenopausal versus postmenopausal women+men). In the full sample, SR increased high-density lipoprotein cholesterol compared with AS (ß=1.2±0.5 mg/dL; P=0.03). Sex+menopausal status influenced the effects of SR on change in total cholesterol (P-interaction=0.04), LDL-C (P-interaction=0.03), and interleukin 6 (P-interaction=0.07). Total cholesterol and LDL-C decreased in SR versus AS in premenopausal women (total cholesterol: ß=-4.2±1.9 mg/dL; P=0.03; LDL-C: ß=-6.3±2.0 mg/dL; P=0.002). Given paradoxical effects of SR on cholesterol concentrations, we explored associations between changes in inflammation and end point lipids under each condition. Increases in interleukin 6 and tumor necrosis factor-α during SR tended to relate to lower LDL-C in premenopausal women (interleukin 6: ß=-5.3±2.6 mg/dL; P=0.051; tumor necrosis factor-α: ß=-32.8±14.2 mg/dL; P=0.027). Conclusions Among healthy adults, prolonged insufficient sleep does not increase atherogenic lipids. However, increased inflammation in SR tends to predict lower LDL-C in premenopausal women, resembling the "lipid paradox" in which low cholesterol associates with increased cardiovascular disease risk in proinflammatory conditions. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02835261, NCT02960776.

Mild sleep restriction increases endothelial oxidative stress in female persons.

Sleep restriction is associated with increased cardiovascular risk, which is more pronounced in female than male persons. We reported recently first causal evidence that mild, prolonged sleep restriction mimicking "real-life" conditions impairs endothelial function, a key step in the development and progression of cardiovascular disease, in healthy female persons. However, the underlying mechanisms are unclear. In model organisms, sleep restriction increases oxidative stress and upregulates antioxidant response via induction of the antioxidant regulator nuclear factor (erythroid-derived 2)-like 2 (Nrf2). Here, we assessed directly endothelial cell oxidative stress and antioxidant responses in healthy female persons (n = 35) after 6 weeks of mild sleep restriction (1.5 h less than habitual sleep) using randomized crossover design. Sleep restriction markedly increased endothelial oxidative stress without upregulating antioxidant response. Using RNA-seq and a predicted protein-protein interaction database, we identified reduced expression of endothelial Defective in Cullin Neddylation-1 Domain Containing 3 (DCUN1D3), a protein that licenses Nrf2 antioxidant responses, as a mediator of impaired endothelial antioxidant response in sleep restriction. Thus, sleep restriction impairs clearance of endothelial oxidative stress that over time increases cardiovascular risk.Trial Registration: NCT02835261 .

Intuitive and mindful eating to improve physiological health parameters: a short narrative review of intervention studies.

OBJECTIVES: This brief narrative review aims to give an up-to-date overview of intuitive and mindful eating (I/ME) interventions with specific focus on cardiometabolic risk factors, including glucose, lipid profile, blood pressure and inflammatory markers. CONTENT: I/ME intervention studies in adults which measured at least one physiological parameter other than weight were identified from PubMed. The clinical trial/randomized controlled trial filters and publication dates 2001 through April 2021 with variations of the following keywords were applied: intuitive eating, mindful eating, weight neutral. Ten articles were identified. SUMMARY AND OUTLOOK: Of the 10 studies, seven showed I/ME interventions were more effective than control in at least one cardiometabolic outcome, two showed significant I/ME within-group improvements but no between-group differences, and one showed neither within-group nor between-group differences. Specifically, I/ME improved glucose levels among pregnant women with or without gestational diabetes, lipid profile among adults with overweight or obesity, blood pressure among participants with overweight and inflammatory markers among post-menopausal women with obesity. However, the positive impact of I/ME on each of these cardiometabolic parameters was not consistent across studies: of the six studies that examined glucose regulation, two demonstrated positive outcomes for I/ME group, whereas four found no effect compared to control. Three out of five studies had positive lipid effects, one out of five demonstrated systolic blood pressure (SBP) improvements and one of two showed improvements in inflammatory markers. Given these mixed results, more research is needed to understand the possible effectiveness of I/ME to improve cardiometabolic health.

Variable Eating Patterns: A Potential Novel Risk Factor for Systemic Inflammation in Women.

BACKGROUND: The timing and regularity of eating patterns could play a role in systemic inflammation, as circadian clocks responsible for daily rhythms of inflammatory signaling are entrained by food intake. PURPOSE: To evaluate associations of intra-weekly and weekday-weekend differences in eating timing patterns with high-sensitivity C-reactive protein (hsCRP). METHODS: A community-based sample of 103 U.S. women from the American Heart Association Go Red for Women Strategically Focused Research Network completed a meal-timing questionnaire and provided a blood sample for measurement of hsCRP. Differences in weekday versus weekend eating start time, eating end time, and nightly fasting duration were calculated as eating jetlag metrics. Intra-weekly variability in eating timing patterns was defined by the standard deviation (SD) of these variables. Multivariable linear regression models were used to evaluate cross-sectional associations of eating timing variability metrics with hsCRP. RESULTS: Each additional 30-min difference in weekday-weekend eating end time was related to 13% higher hsCRP (p = .023). Similarly, every 30-min increase in eating end time SD, reflecting greater variability in timing of last eating occasion, was associated with 29% higher hsCRP. Per 1-hr weekday-weekend difference in nightly fasting duration, there was a 45% elevation in hsCRP (p = .003). Every 30-min increase in nightly fasting duration SD, representing greater variability in span of the daily fasting/eating periods, was associated with 46% higher hsCRP. CONCLUSIONS: Variable eating timing patterns were associated with higher hsCRP. Intervention studies are needed to determine whether stabilizing the timing of eating occasions may represent a novel strategy to reduce chronic inflammation.

Redefining Cardiovascular Health to Include Sleep: Prospective Associations With Cardiovascular Disease in the MESA Sleep Study.

Background Although sufficient and healthy sleep is inversely associated with cardiovascular disease (CVD) and its risk factors, the American Heart Association's Life's Simple 7 (LS7), as a measure of cardiovascular health (CVH), did not include sleep. We evaluated an expanded measure of CVH that includes sleep as an eighth metric in relation to CVD risk. Methods and Results The analytic sample consisted of MESA (Multi-Ethnic Study of Atherosclerosis) Sleep Study participants who had complete data on sleep characteristics from overnight polysomnography, 7-day wrist actigraphy, validated questionnaires, and the outcome. We computed the LS7 score and 4 iterations of a new CVH score: score 1 included sleep duration, score 2 included sleep characteristics linked to CVD in the literature (sleep duration, insomnia, daytime sleepiness, and obstructive sleep apnea), scores 3 and 4 included sleep characteristics associated with CVD in MESA (score 3: sleep duration and efficiency, daytime sleepiness, and obstructive sleep apnea; score 4: score 3+sleep regularity). Multivariable-adjusted logistic and Cox proportional hazards models evaluated associations of the LS7 and CVH scores 1 to 4 with CVD prevalence and incidence. Among 1920 participants (mean age: 69±9 years; 54% female), there were 95 prevalent CVD events and 93 incident cases (mean follow-up, 4.4 years). Those in the highest versus lowest tertile of the LS7 score and CVH scores 1 to 4 had up to 80% lower odds of prevalent CVD. The LS7 score was not significantly associated with CVD incidence (hazard ratio, 0.62 [95% CI, 0.37-1.04]). Those in the highest versus lowest tertile of CVH score 1, which included sleep duration, and CVH score 4, which included multidimensional sleep health, had 43% and 47% lower incident CVD risk (hazard ratio, 0.57 [95% CI, 0.33-0.97]; and hazard ratio, 0.53 [95% CI, 0.32-0.89]), respectively. Conclusions CVH scores that include sleep health predicted CVD risk in older US adults. The incorporation of sleep as a CVH metric, akin to other health behaviors, may enhance CVD primordial and primary prevention efforts. Findings warrant confirmation in larger cohorts over longer follow-up.

Effects of Objective and Perceived Social Isolation on Cardiovascular and Brain Health: A Scientific Statement From the American Heart Association.

Background Social isolation, the relative absence of or infrequency of contact with different types of social relationships, and loneliness (perceived isolation) are associated with adverse health outcomes. Objective To review observational and intervention research that examines the impact of social isolation and loneliness on cardiovascular and brain health and discuss proposed mechanisms for observed associations. Methods We conducted a systematic scoping review of available research. We searched 4 databases, PubMed, PsycInfo, Cumulative Index of Nursing and Allied Health, and Scopus. Findings Evidence is most consistent for a direct association between social isolation, loneliness, and coronary heart disease and stroke mortality. However, data on the association between social isolation and loneliness with heart failure, dementia, and cognitive impairment are sparse and less robust. Few studies have empirically tested mediating pathways between social isolation, loneliness, and cardiovascular and brain health outcomes using appropriate methods for explanatory analyses. Notably, the effect estimates are small, and there may be unmeasured confounders of the associations. Research in groups that may be at higher risk or more vulnerable to the effects of social isolation is limited. We did not find any intervention studies that sought to reduce the adverse impact of social isolation or loneliness on cardiovascular or brain health outcomes. Conclusions Social isolation and loneliness are common and appear to be independent risk factors for worse cardiovascular and brain health; however, consistency of the associations varies by outcome. There is a need to develop, implement, and test interventions to improve cardiovascular and brain health for individuals who are socially isolated or lonely.

Adverse Changes in Body Composition During the Menopausal Transition and Relation to Cardiovascular Risk: A Contemporary Review.

The menopausal transition period in aging women is strongly associated with weight gain. Evidence shows that weight changes during menopause increases the risk of developing cardiovascular disease (CVD) in postmenopausal women. However, the potential mechanisms that cause weight gain and adverse changes to body composition specifically during the menopausal transition period remain to be elucidated. In this contemporary review, we examined recent evidence for adverse changes in body composition at midlife during the menopausal transition and the link to increased CVD risk and described factors that may contribute to these changes, including normal chronological aging, hormonal factors (decreased estrogen, etc.), behavioral factors (changes in diet, physical activity), or other emerging factors (e.g., sleep). This review focused on identifying factors that make the menopausal transition period a critical window for prevention of CVD. Future study is needed to decipher the extent to which hormonal changes, age-related factors, and behavioral factors interact with and contribute to increased CVD risk in women undergoing menopause. Understanding the causes of weight gain during the menopausal transition may help to inform strategies to mitigate adverse CVD outcomes for women transitioning through menopause.

Research Goes Red: Early Experience With a Participant-Centric Registry.

RATIONALE: Cardiovascular disease remains the leading cause of death in women. To address its determinants including persisting cardiovascular risk factors amplified by sex and race inequities, novel personalized approaches are needed grounded in the engagement of participants in research and prevention. OBJECTIVE: To report on a participant-centric and personalized dynamic registry designed to address persistent gaps in understanding and managing cardiovascular disease in women. METHODS AND RESULTS: The American Heart Association and Verily launched the Research Goes Red registry (RGR) in 2019, as an online research platform available to consenting individuals over the age of 18 years in the United States. RGR aims to bring participants and researchers together to expand knowledge by collecting data and providing an open-source longitudinal dynamic registry for conducting research studies. As of July 2021, 15 350 individuals have engaged with RGR. Mean age of participants was 48.0 48.0±0.2 years with a majority identifying as female and either non-Hispanic White (75.7%) or Black (10.5%). In addition to 6 targeted health surveys, RGR has deployed 2 American Heart Association-sponsored prospective clinical studies based on participants' areas of interest. The first study focuses on perimenopausal weight gain, developed in response to a health concerns survey. The second study is designed to test the use of social media campaigns to increase awareness and participation in cardiovascular disease research among underrepresented millennial women. CONCLUSIONS: RGR is a novel online participant-centric platform that has successfully engaged women and provided critical data on women's heart health to guide research. Priorities for the growth of RGR are centered on increasing reach and diversity of participants, and engaging researchers to work within their communities to leverage the platform to address knowledge gaps and improve women's health.