Outlook: Newsletter of the Society of Behavorial Medicine

Fall 2022

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The American Heart Association Adds Sleep to the Cardiovascular Health Checklist: Implications for Behavioral Medicine

Caroline Doyle, PhD✉; Allison Gaffey, PhD✉; and Alyssa Vela, PhD✉; Cardiovascular Disease SIG


In 2010, the American Heart Association (AHA) developed the cardiovascular health checklist – also known as “Life’s Simple 7” - a novel quantification of the diverse factors that influence cardiovascular health.1 The checklist aimed to extend beyond cardiovascular disease to include factors related to health promotion and prevention across the lifespan. Components included diet, physical activity, nicotine exposure, body mass index, blood lipids, blood glucose, and blood pressure.1 In 2022, the AHA updated the metrics to include sleep, changing “Life’s Simple 7” to “Life’s Essential 8”. This new addition highlights an ever-increasing awareness of the connection between sleep and cardiac health. As well as being a useful research tool, this cardiovascular health checklist is a simple way for providers and patients to quantify contributors to heart health and discuss habits that might exacerbate risk for heart disease. Importantly, half of the “Essential 8” are modifiable health behaviors.2 The robust correlational evidence between sleep and cardiovascular disease (CVD) that has emerged in the past decade was essential to the addition of sleep to the “Essential 8.”3,4

From the ubiquity of wearable devices, to a seemingly endless stream of “sleep aids” and beyond, the sleep industry has boomed in the past decade,5 making the inclusion of sleep into the cardiovascular health checklist particularly timely. The popularity of commercial wearable devices that track sleep also indicates a desire among the public to learn more about their sleep health and bodily rhythms. Advances in such technology is likely to increase ease-of-use and accuracy of the devices. This also has implications for clinical practice, as behavioral medicine providers may be able to leverage technology to support interventions. For example, wearable devices can be used in treatment to help patients set and measure exercise or sleep goals, potentially reducing treatment barriers.

What might the change from “7” to “8” mean for behavioral medicine researchers? Dr. Michael Grandner, a sleep researcher and one of the authors of the “Essential 8,” said that the inclusion of sleep will give a big boost to sleep as a pillar of health, but that there is more work to be done. “We need more objective data, we need more precision in our predictive models, and most importantly, we need more interventions,” Dr. Grandner stated regarding the relationship between sleep and CVD outcomes. Indeed, those who study sleep and CVD, such as Dr Grandner, know that while there is a robust association at the population level, the causal evidence that improving sleep affects cardiovascular risk is minimal.2 Why might this be? One hypothesis is that sleep has an incremental and insidious effect on cardiovascular health over time that has historically been difficult to measure with objective measures like polysomnography and subjective measures like sleep diaries.6 To advance our understanding of the sleep-CVD connection, a few avenues warrant exploration. First, before wearable devices are used as standard research practice, they need to be validated for accuracy – work that has already begun.7,8 Second, behavioral medicine providers are in a unique position to learn from their clinical encounters about the potential utility of wearable devices for prevention and treatment of CVD risk factors, specifically the "Essential 8." These experiences can inform development of interventions to test the efficacy of wearables for health behavior change for those with, or at risk for, CVD. Third, more comprehensive longitudinal studies, as well as larger scale experimental studies, on the impact of sleep disruption, insufficient sleep, and poor-quality sleep, on markers of cardiovascular risk are needed to better establish this connection as a pathway to disease. "Life’s Essential 8" is one of many indicators of increased interest in the sleep-CVD relationship among providers and the public alike. Perhaps this increased awareness and ever-improving wearable technology will help us finally uncover the answers to our remaining questions about this mysterious relationship.

 

References

  1. Lloyd-Jones, D. M., Allen, N. B., Anderson, C., Black, T., Brewer, L. C., Foraker, R. E., Grandner, M. A., Lavretsky, H., Perak, A. M., Sharma, G., Rosamond, W., & American Heart Association (2022). Life's Essential 8: Updating and Enhancing the American Heart Association's Construct of Cardiovascular Health: A Presidential Advisory From the American Heart Association. Circulation, 146(5), e18–e43. https://doi.org/10.1161/CIR.0000000000001078
  2. AHA News, 2022: https://www.heart.org/en/news/2022/06/29/sleep-joins-revamped-list-of-heart-health-essentials
  3. Kwok, C. S., Kontopantelis, E., Kuligowski, G., Gray, M., Muhyaldeen, A., Gale, C. P., Peat, G. M., Cleator, J., Chew-Graham, C., Loke, Y. K., & Mamas, M. A. (2018). Self-Reported Sleep Duration and Quality and Cardiovascular Disease and Mortality: A Dose-Response Meta-Analysis. Journal of the American Heart Association, 7(15), e008552. https://doi.org/10.1161/JAHA.118.008552
  4. Pienaar, P. R., Kolbe-Alexander, T. L., van Mechelen, W., Boot, C., Roden, L. C., Lambert, E. V., & Rae, D. E. (2021). Associations Between Self-Reported Sleep Duration and Mortality in Employed Individuals: Systematic Review and Meta-Analysis. American journal of health promotion : AJHP, 35(6), 853–865. https://doi.org/10.1177/0890117121992288
  5. https://www.sleepassociation.org/blog-post/sleep-innovation-advances-and-the-rise-of-the-sleep-industry/
  6. Andrew, T. L., Rostaminia, S., Homayounfar, S. Z., & Ganesan, D. (2022). Perspective—Longitudinal Sleep Monitoring for All: Payoffs, Challenges and Outlook. ECS Sensors Plus, 1(1), 011602.
  7. Stucky, B., Clark, I., Azza, Y., Karlen, W., Achermann, P., Kleim, B., & Landolt, H. P. (2021). Validation of Fitbit Charge 2 Sleep and Heart Rate Estimates Against Polysomnographic Measures in Shift Workers: Naturalistic Study. Journal of medical Internet Research, 23(10), e26476. https://doi.org/10.2196/26476
  8. Hajj-Boutros, G., Landry-Duval, M. A., Comtois, A. S., Gouspillou, G., & Karelis, A. D. (2022). Wrist-worn devices for the measurement of heart rate and energy expenditure: A validation study for the Apple Watch 6, Polar Vantage V and Fitbit Sense. European Journal of Sport Science, 1–13. Advance online publication. https://doi.org/10.1080/17461391.2021.2023656