Lifestyle in Heart Health and Disease

book.

Part I

Overview and Mechanisms

Chapter 1

Cardiovascular Diseases, Obesity, and Lifestyle Changes

John Kwagyan; Otelio S. Randall    Howard University College of Medicine, Washington, DC, United States

Abstract

Cardiovascular disease remains the leading cause of death in the United States, accounting for about one in four deaths with coronary heart disease (CHD) being responsible for over a third of a million deaths per year. While physical inactivity has been reported as a leading cause of cardiovascular disease in the United States, only about 20% of adults meet the minimum aerobic physical activity guidelines. This coupled with the consumption of high-caloric and dense fatty diets and sugary juices and soda has resulted in increase in obesity and related metabolic syndrome and ardent risk factors of heart diseases. In this chapter, we provide an overview of obesity and associated conditions and examined the cross-sectional distribution and correlates of major cardiovascular disease risk factors. In addition, we report the effect of preventive measures including physical activity and low-salt, low-fat diet on coronary heart disease risk reduction in a high-risk population.

Keywords

Blood pressure; Cardiovascular disease; Lifestyle changes; Metabolic syndrome; Obesity; Physical activity

Obesity and Cardiovascular Diseases

Subjectively, obesity is defined as excess weight or excess body fat. Objectively, obesity is defined by a body mass index, BMI ≥ 30 kg/m². Globally, more than 1.5 billion persons are overweight, and the prevalence of obesity has doubled since 1980 [1]. Current reports on the prevalence in the United States estimate that 35.5% of adult men and 35.8% of adult women are obese [2]. Disparities in prevalence among race have been noted with rates higher among minority populations. For the African American population, the age-adjusted rates are 49.5% compared with 39.1% in Hispanics and 34.3% in Caucasians [2]. In recent years, there has been a rise in obesity-specific cardiovascular disease (CVD) morbidity and mortality [3,4]. There is also the concern of dramatic increase of the prevalence and magnitude of obesity in children and adolescent [5,6]. Obesity has been linked with major cardiovascular disease risk factors including hypertension, diabetes mellitus, and dyslipidemia [7–10].

A report by Fontaine et al. [11] indicated a marked reduction in life expectancy due to obesity with significant differences observed between races. In the study, it was reported that the maximum years of life lost for the young adult obese African American man was estimated to be 20 years compared with 13 years for Caucasians. In another study, Fontaine et al. [12] reported the impact of obesity on the health-related quality of life and indicated more impairment in obese persons when compared with the general population. The pattern of the results indicated that, as weight increases, the quality of life related to the physical domains becomes adversely affected. In the general population, the prevalence of these risk factors increases progressively with increasing BMI [7,13–15]. Randall et al. [15] reported a major finding in a cohort of obese African Americans that suggests a threshold of between 30 and 35 kg/m² for maximal appearance of CVD risk factors, after adjusting for age and sex. The implication of the results from the study is that preventive measures need to be implemented before reaching the threshold BMI, and there is the need to curtail the incidence of risk factors sooner rather than later. Fig. 1 provides a conceptual pathway for the development of various CV outcomes including diabetes, myocardial infarction, congestive heart failure, left ventricular hypertrophy, and stroke. The pathway clearly suggests the autonomous influence of obesity in the development of these risk factors and associated CV outcomes.

Fig. 1 Risk factors affecting the developmental pathway to major cardiovascular disease events. Source: Ethnicity & Disease © 2015. (Kwagyan et al.). Published by ISHIB. Printed with permission. All rights reserved.

Coexistence of obesity related cardiovascular disease risk factors including hypertension, diabetes, and dyslipidemia is termed the metabolic syndrome [16–19]. Clinically, the metabolic syndrome is described according to the Third National Cholesterol Education Program Adult Treatment Panel (NCEP ATP III) when at least three of the following five features are present: abdominal obesity reflected by a large waistline and characterized with waist circumference > 102 cm (40.2 in.) in men and > 88 cm (34.6 in) in women, low high-density lipoprotein (HDL) cholesterol level defined as HDL < 40 mg/dL in men or < 50 mg/dL in women, high serum triglycerides (TG) defined as TG ≥ 150 mg/dL, high blood pressure (BP) defined as ≥ 130/85 mmHg, and high fasting serum glucose (BS) defined as ≥ 110 mg/dL. The metabolic syndrome, an important marker for atherosclerosis—hardening and narrowing of the arteries—including premature coronary artery disease and cardiovascular mortality affects about 25%–35% of the US adults [18–20], and the age-specific rates increased rapidly. A person's risk for heart disease, diabetes, and stroke increases with the number of metabolic syndrome risk factors, and the risk of having metabolic syndrome is closely linked to obesity and a lack of physical activity. There is the report that, in the future, metabolic syndrome may overtake smoking as the leading risk factor for heart disease (https://www.nhlbi.nih.gov/health/health-topics/topics/ms). The prevalence in 50-year-old persons was > 30% and that in persons aged 60 years and above was 40%. Epidemiological studies [18] show a highest prevalence of the metabolic syndrome in Hispanics and lower in Caucasian and in African Americans. Haffner and Heinrich [20] explained that the lower prevalence of the metabolic syndrome among African Americans may be explained by the two separate lipid criteria defined by the NCEP (high triglycerides and low HDL cholesterol), which offset the higher rates of hypertension and glucose intolerance observed in this ethnic group. Among the African Americans, the metabolic syndrome has been linked with increased insulin levels, elevated blood pressure, dyslipidemia, and endothelial dysfunction [16–18]. In a sample of adolescents, the prevalence of the metabolic syndrome was estimated at 6.8% among overweight adolescents and 28.7% among obese adolescents [20]. Cherqaoui et al. [21] recently noted in a two-factorial analysis that even in the so-called metabolically healthy but obese, the state of the phenotype appears to be only transient. The finding of increased risk of death or cardiovascular events for obese individuals suggests that gaining excess weight is associated with risk that may accumulate over time, even before metabolic and cardiovascular signs become apparent in laboratory tests.

Coronary Heart Disease

Heart disease remains the leading cause of death in the United States [22,23] and worldwide. Overall, heart disease accounts for about one in four deaths. Coronary heart disease (CHD) affects 15.5 million Americans with a prevalence of 6.2% and is responsible for one in seven deaths in the United States [2]. For the African American and Hispanic, however, the morbidity and mortality rate is disproportionally high [22,23]. From 2006 to 2010, the age-adjusted prevalence of coronary heart disease (CHD) in the United States declined overall [23] from 6.7% to 6.0%. However, while declines from 2006 to 2010 were observed across all racial/ethnic groups, the prevalence among Blacks rose in the same period. For Whites, the rates declined from 6.4% to 5.8% and for Hispanics from 6.9% to 6.1%. Among Blacks, the rate increases marginally [23] from 6.4% to 6.5%. It is reported that genetics, environment, lifestyle, and access to health care are the major contributing factors to the negative outcomes seen in African Americans [24]. Coronary heart disease is a multifactorial disease, and a measure of the overall disease risk is necessary and has been derived from the Framingham Heart Study [22], a prospective epidemiological study of cardiovascular diseases. Elevated blood pressure and lipid levels are known to be associated with an increasing risk of cardiovascular disease (CVD) and are part of the Framingham score algorithm.

High serum cholesterol is a known risk factor and a treatment target in primary and secondary prevention of CHD. Results from the MESA study [25] observed that in a cohort free of CHD, there was no significant difference in the prevalence of dyslipidemia among African Americans, Hispanics, and Caucasians. The report showed that African Americans and the Hispanic group were 30% less likely than Caucasians to have their dyslipidemia under control. When these metrics were adjusted for socioeconomic status and health care access, there was attenuation of the disparity, implying that biological differences alone were not responsible for the differences in control.

Hypertension or high blood pressure is a common disease in which blood flows through the blood vessels (arteries) at higher than normal pressures. It is the major risk factor for atherosclerosis and by far the leading risk factor for the development of CVD and the leading cause of death and disability [26–28].

Over time, consistently high blood pressure weakens and damages the blood vessels, which can lead to severe clinical complications including but not limited to the development of heart failure, heart attack, chronic kidney disease, cognitive changes, eye damage, and stroke, to list a few (NHLBI site). The prevalence and incidence of hypertension and hypertension-related complications are reported to be disproportionately higher among African Americans than other ethnicities [29,30]. This has been linked with low social economic status, the lack of access to health care, and a higher noncompliance with prescribed medication usage.

Biophysical Properties of the Arterial System

While high blood pressure is a major risk factor for cardiovascular events, the role of pulse pressure, an independent predictor of arterial stiffness, is modestly emphasized. Pulse pressure, a marker of the biophysical properties of the arterial system, has been demonstrated in observational and longitudinal studies to show a direct association with carotid atherosclerosis [31,32], left ventricular mass [31], white matter lesions [33], and heart failure [34]. A report by Randall et al. [35] discussed the effect of intensive blood pressure control on cardiovascular remodeling in hypertensive patients with nephrosclerosis and showed that, after covariate adjustment, a higher pulse pressure is associated with increased risk of CV outcome (relative risk = 1.28 and CI = 1.11–1.47) and development of LVH (relative risk = 1.26 and CI = 1.04–1.54). Although an association between increased BMI and elevated blood pressure has been established [36,37], limited data exist on the relationship between BMI and PP. Martin and colleagues [38] examined the relationship between BMI and PP in older adults with isolated systolic hypertension and reported PP to increase with BMI values greater than 30 kg/m², while pulse pressure decreased with increasing BMI values less than or equal to 30 kg/m². Randall et al. [39] and Kwagyan et al. [40] showed a closer significant correlation between pulse pressure and BMI than between systolic blood pressure and BMI. These studies further reported that diet and exercise program averaging 10% reductions in BMI, translated into a significant improvement in pulse pressure, stroke volume, a measure of the amount of blood the heart pumps per beat, and arterial compliance, the ratio of stroke volume to pulse pressure. In a recent study, Kwagyan et al. [40] showed in multivariate models in obese African Americans that pulse pressure is associated positively with increasing BMI (P < .01), systolic blood pressure (P = .01), diabetes mellitus (P = .04), and age above 50 years (P = .01) and negatively with heart rate (P = .04). There was also a strong correlation between pulse pressure and systolic blood pressure (r = 0.67 and P < .01) and no correlation between pulse pressure and diastolic blood pressure (r = 0.02 and P = .83). In multiple regression analysis, pulse pressure correlated positively with systolic blood pressure (P < .01) and BMI (P < .01) and negatively with heart rate (P = .02). Fig. 2 shows the relationship of pulse pressure with number of metabolic syndrome components.

Fig. 2 Relationships of pulse pressure (PP mmHg) to number of metabolic syndrome components.

As expected, the figure depicts a positive relationship between the number of components and pulse pressure. The results indicate that CVD risk factors including hypertension, dyslipidemia, and diabetes that are also features of the components of the metabolic syndrome constellation impact negatively on arterial vascular properties, as reflected in increased pulse pressure, suggesting that the metabolic syndrome is detrimental to vascular health.

Distribution and Correlates of Major CVD Risk Factors in Obese African Americans

Randall et al. [41] examined the distribution and correlates of major CVD risk factors in 515 obese African Americans, with average age ± SD was 48.3 ± 9.9 years and BMI of these individuals was 42.9 ± 6.8 kg/m² (see Table 1). Of these individuals, 27% had dyslipidemia, 56.9% had hypertension, and 24.1% had diabetes mellitus. These rates are higher than those found in the African American population by the third NHANES survey. The study noted that, after adjusting for age and sex, there were no significant differences in the prevalence rates of these risk factors according to increasing BMI, suggesting a threshold of between 30 and 34.99 kg/m² for maximal appearance of these risk factors. Ninety-nine percent met the metabolic syndrome criteria for waist circumference, 40% met the criteria for BP, and 37% for HDL. Thirty-nine percent had exactly two features of the metabolic syndrome, and 36% were diagnosed with it. The proportion of participants who met the MS criteria for HDL and those diagnosed with it increases significantly across BMI categories. In particular, a logistic regression analysis showed that in these obese individuals, a 5 kg/m² rise in BMI increased the risk of the MS by 44%.

Table 1

Data are percent.

Ambulatory Blood Pressure Monitoring

Several studies support the prognostic significance of 24 h ambulatory blood pressure monitoring [24–32]. This offers a convenient means of obtaining a large number of repeated BP measurements on each subject and thereby increases the statistical power of detecting significant hemodynamic changes. The diurnal variation of ABP provides a measure of the percentage of BP readings that are elevated, the extent of BP fall during sleep, and thus the overall BP load. Although a nocturnal fall in BP is usual, various groups of individuals including Blacks, diabetics, and subjects who have developed left ventricular hypertrophy (LVH) or renal damage have been noted to have little or no nocturnal fall [24,42–44]. Both observational and longitudinal studies alike have shown that target organ damage accompanying hypertension is closely related to 24 h ABP. Individuals with a lack of a significant nocturnal fall in BP has been linked to more serious target organ damage and higher incidence of cardiovascular complications than those with a nocturnal fall [45–48]. Kwagyan et al. [49] reported in a cohort of obese African Americans that 44% were nondippers in any BP component, with dipping defined as those who exhibit a reduction in average BP by at least 10% from the day to night. The proportions of dippers in SBP were 17%, DBP 54%, and MBP 40%. Ninety-nine percent of SBP dippers were also DBP dippers. Consistent with other studies, the report showed that increasing BMI correlated negatively with DBP dipping (P = .01). Systolic BP dipping correlated positively with HTN (P = .02) and HR (P = .06) and negatively with DM (P = .02). The higher percentage of nondipping in these obese African Americans is alarming. A lifestyle change in these obese populations is necessary to improve dipping status and CV health. Evaluation of nocturnal fall in DBP may be of clinical relevance, and more research is needed to establish its prognostic value. The high rate of nondipping in this obese population reinforces the need to reduce BMI and improve hemodynamic and lipid profiles through therapeutic lifestyle changes. This is likely to shift nondippers to dipper status and reduce the potential risk for target organ damage.

Diet and Physical Activity Intervention

The modifiable environmental factors that have been clearly shown to correlate with blood pressure levels and CVD risk are salt intake, physical activity, and excess body weight [39]. A key element of prevention is therefore to identify those individuals most likely to have cardiovascular events and intervention strategies for reduction of associated risk factors. Preventive measures, such as physical activity and nutritious low-salt and low-fat diets, particularly diets low in cholesterol and saturated fats, have been investigated and established to reduce the risk of hypertension and CHD. Kwagyan et al. [49] examined the effect of participating in a diet-exercise program on cardiovascular risk factors and CHD risk prediction among obese African Americans. Variables included in the estimate of CHD risk prediction were age, systolic BP, diastolic BP, total cholesterol, HDL, cigarette smoking, and diabetes. Table 2 showed the average percent changes in anthropometric, hemodynamic, and lipid measures after 6-month diet and exercise intervention from the study.

Table 2

Source: Ethnicity & Disease © 2015. (Kwagyan et al.). Published by ISHIB. Printed with permission. All rights reserved.

The results show an 11% decrease in BMI, an 8% decrease in LDL, and a 10% increase in HDL. The LDL/HDL ratio decreased from 2.3 to 2.1, while the total cholesterol/HDL ratio decreased from 4.4 to 3.4. The initial 10-year CHD risk, as per the Framingham risk calculator, was 6% in women and 16% in men. The 10-year CHD risk prediction decreased on average from 6% to 4% for women and 16% to 13% for men. This was accomplished by the improvements in BMI (kg/m²), waist circumference, blood pressure, LDL, and HDL. The results clearly highlight the importance of continuous and persistence adherence to lifestyle changes to risk reduction and cardiovascular health (see Fig. 1). Implementing similar programs that are culturally sensitive across minority groups could significantly improve cardiovascular health and CHD risk for an at-risk population at lower costs than long-term pharmacological treatment.

Conclusion

In cardiovascular research, the primary objective is to identify and attempt to prevent or reduce the onset of risk factors that are predictive of cardiovascular disease morbidity and mortality. Obesity, and the related condition, the metabolic syndrome, are noted to be risk factors for the development of CVD [50]. The prevalence of the major CVD risk factors is disproportionately higher among minority populations, in general and particularly among obese individuals. Obesity is a multifactorial condition, with some individuals suffering from an endocrine disease or from genetic propensity. Many individuals, however, have developed the condition from poor eating habits and less or no physical activity and have become an epidemic in minority populations. Management of obesity, metabolic syndrome, and CVD risks consists primarily of modification or reversal of the root causes and direct therapy of the risk factors. Moreover, the high prevalence and increasing incidence of obesity, the metabolic syndrome, and associated cardiovascular risk factors in adults and children emphasize the need to focus on obesity reduction in this population. There is the report that, in the future, metabolic syndrome may overtake smoking as the leading risk factor for heart disease (NHLBI site).

The first strategy involves weight reduction and increased physical activity, both of which can improve all components of the CHD risk profile and components of the metabolic syndrome. Lifestyle changes are the most important target for decreasing these risk factors. As we have discussed and others have shown that this can be achieved through a successful diet and exercise program and likely at less cost in the long-term than through pharmacological means [39,40]. Education and awareness are of the utmost importance in ensuring success with the diet an exercise program [51]. Understanding why they are overweight, the consequences of excess weight and the associated deliberating complications should be emphasized in educational programs.

In conclusion, we emphasize that with the rise in prevalence and incidence of obesity and associated conditions worldwide and particularly the high onset of the obesity and the metabolic syndrome among children and the adolescent, earlier intervention through lifestyle modification to stop this epidemic will have potential benefit to the society now and the future. This includes regularly engaging in physical activity; consumption of low-salt, low-fat diet; consumption of fruits and vegetables; and refraining from high sugary foods and drinks. Other healthy lifestyle changes include managing stress, having a good night sleep, quitting smoking, and adhering to prescription medication.

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Further Reading

[1] Masuo K., Mikami H., Ogahara T., Tuck M.L. Weight gain-induced blood pressure elevation. Hypertension. 2000;35:1135–1140.

Chapter 2

Public Knowledge of Cardiovascular Risk Numbers: Contextual Factors Affecting Knowledge and Health Behavior, and the Impact of Public Health Campaigns

Jeffrey L. Kibler; Mindy Ma; Jacquelyn Hrzich; Roberta A. Roas    College of Psychology, Nova Southeastern University, Fort Lauderdale, FL, United States

Abstract

Cardiovascular disease (CVD) is the leading cause of mortality globally. A critical component of American Heart Association (AHA) efforts to reduce cardiovascular morbidity, and mortality involves enhancing the public's knowledge and management of modifiable risk factors. Studies have been mixed with regard to the knowledge of personal and target levels in the general community for key cardiovascular indicators. The present chapter is a review of the recent literature (2005–17) on adults' knowledge/awareness for personal and target levels of four key cardiovascular metrics identified by AHA (blood pressure, lipids, body mass, and glucose) and relationships of knowledge to health behaviors. We also address some of the potential determinants of knowledge that have been suggested (i.e., race/ethnicity and level of risk). In addition, we review the current literature on the effectiveness of interventions for enhancing knowledge/awareness.

Keywords

Knowledge; Cardiovascular; Risks; Health behavior; Health beliefs; Public health; Intervention

Introduction

Cardiovascular disease (CVD) is the leading cause of mortality globally, accounting for 31% of all deaths in 2013 [1]. In the United States, although the CVD mortality rate has declined in the past few decades, it remains the leading cause of death, with a rate of approximately 800,000 per year in 2013 [1,2]. Despite the considerable progress made in the prevention, detection, and management of CVD, heart disease and stroke remain important health concerns impacting 84.6 million Americans [1,3]. The annual expenditure in CVD-related direct and indirect costs total more than $316.6 billion [1]. Although genetics and demographic characteristics may predispose individuals to CVD, a significant proportion of the variance may be attributable to social, cultural, economic, and behavioral factors [4,5].

The relationships between lifestyle and CVD risks have been well established [6–8]. Recognizing the importance of enhancing the public's knowledge and management of modifiable risk factors, the American Heart Association (AHA) has developed a strategic plan to improve heart health by 20% and CVD-related mortality by 20% for all Americans by 2020 [6]. The AHA's 2020 impact goals aim to target all stages of prevention throughout the life span by promoting core factors that define ideal cardiovascular health. Known as the seven metrics [6], ideal cardiovascular health consists of the presence of four favorable cardiovascular health factors (normal blood pressure (BP), cholesterol/lipid levels, body mass index (BMI), and glucose level) and three health behaviors (healthy diet, physical activity, and abstention from smoking).

Conceptual Significance of the Health Belief Model

The health belief model (HBM) is a theoretical framework that has been widely used to predict whether individuals are likely to engage in risk reduction/disease prevention [9]. This model provides for a contextual understanding of variables that impact behaviors related to cardiovascular health. According to this model, motivations to initiate and maintain health-protecting behaviors are influenced by perception variables, which include beliefs surrounding personal susceptibility to disease, seriousness of the disease, benefits of taking action, and barriers to behavioral change. The greater the perceived risk, the greater the likelihood that individuals will change their behaviors to decrease risk. In a study that examined knowledge of heart disease in women [10], the perceptions of susceptibility and seriousness of heart disease, knowledge of risk factors, and general health motivation accounted for 76% of the variance in cardiovascular preventive behaviors. An intervention study aimed at increasing the knowledge of risks associated with uncontrolled diabetes, personal susceptibility to the disorder, and beliefs about the benefits of adherence to treatment revealed a significant decrease in fasting blood glucose in the treatment group relative to the control group [11]. These findings suggest knowledge and individual perceptions identified by the HBM are associated with the seven key CVD metrics highlighted in the AHA recommendations [6].

Research has addressed ways in which knowledge of personal and target levels of health indicators may interact with HBM variables [12,13] to predict engagement in preventive behaviors [14]. In order to be aware of personal risks, individuals must possess knowledge of their own and target levels of the CVD risk factors [12]. For example, knowledge of target BP levels has been associated with improvements in diet [15] and rates of BP control [16]. Additionally, increased physical activity was observed among women with awareness of optimal blood glucose levels [15].

Additional factors, such as race/ethnicity, age, and level of education, may influence knowledge and perceptions according to the HBM. Health-related perceptions vary across ethnic and racial groups and appear to be influenced by internal and external stimuli. African Americans and Hispanic Americans are less likely to perceive themselves as obese compared with Caucasian Americans [17,18]. Cultural factors related to race/ethnicity may play an important role in determining body image and weight parameters that are desirable and acceptable. Relative to Caucasian women, obese African American women are more likely to report their weight as normal and to overestimate their height and underestimate their weight [18]. This leads to inaccurate estimates of BMI and distorted perceptions of susceptibility to disorders that are comorbid with obesity, such as diabetes and cardiovascular disease [18]. Obesity rates are higher, and trends reflect a faster rise in obesity, among African American and Hispanic populations; thus, greater health disparities in comorbid illnesses may emerge than are observed currently if effective preventative efforts are not initiated [17,19]. With regard to education, a study with African American women revealed a positive relationship between years of education and likelihood of perceiving heart disease as a serious health risk [20]. Further, women 50 years of age and older were more likely than their younger counterparts to list heart disease as a serious health threat [20].

Purpose of the Present Chapter

In the present chapter, we review the recent literature on adults' knowledge for personal and target levels of four key cardiovascular variables (BP, lipids, BMI, and glucose) and relationships of knowledge to health behaviors; searches of PsycInfo and Medline were utilized to identify relevant studies from the past 12 years (2005–17). We address some of the potential determinants of knowledge that have been suggested (i.e., race/ethnicity and level of risk). The current literature on the effectiveness of community interventions is then presented. Finally, we present our conclusions and future directions for each of these areas of research.

Knowledge of Target Numbers and Personal Levels for CVD Risk Indicators

The research on knowledge and awareness of key cardiovascular indicators has largely focused on four variables (BP, lipid levels, BMI, and glucose levels), and AHA has identified these variables as key elements of national public health initiatives [6]. The AHA recommendations incorporate an ideal health perspective, articulating that in order to meet the definition of ideal cardiovascular health, an individual would achieve the ideal levels for each of these four factors, along with maintaining a healthy diet, engaging in physical activity, and abstaining from smoking.

Blood Pressure

High BP has been recognized as a major independent modifiable risk factor for cardiovascular health [21]. It can be argued that knowledge of healthy/optimal BP levels, along with awareness of one's own personal BP levels, is one of the first important steps in preventing hypertension in the community. Although awareness of hypertension as a risk factor for CVD is relatively high, with estimates from 66% to 84% of individuals being aware [22,23], research on knowledge of actual cutoffs for normal and clinically high BP reflects variability in estimates of awareness. The levels of awareness/knowledge of healthy BP levels reported in the studies reviewed here ranged widely, from 37% observed by Mochari et al. [24] to 91% reported by Wright-Nunes et al. [25], but a cluster of estimates was observed around 50% [15,26–29]. A methodological consideration in interpreting the results from these studies is that the definition of an optimal BP is defined slightly differently across studies. It is notable that the Wright-Nunes et al. study of 401 patients with chronic kidney disease [25] defined the accurate optimal BP as less than 130 systolic and 80 diastolic. In a study of 449 pharmacy patients [30], only 40% of participants reported that a healthy BP is in the range less than 140/90; only 35% of the participants who reported healthy BP readings in this range (13% of the total sample) identified a BP under 120/80 as the optimal range. Relative to awareness of healthy BP levels, fewer studies assessed awareness of one's own BP, but the available estimates reflected a similarly wide range from 42% observed by Slark et al. [28] to 82% reported by Chun et al. [31]. These estimates were more evenly distributed across this range with no apparent cluster of awareness levels across studies. In terms of accuracy in categorically estimating hypertension status, Huerta et al. [32] reported data from a large representative community sample in Spain (N = 1556) that indicated underestimation of hypertension status; only 20% of participants reported hypertension, whereas measured BP data reflected that 35% of participants would meet the criteria for hypertension.

Most of the studies on BP awareness/knowledge did not assess whether race or ethnic group differences were a demographic variable that accounted for variability in rates. However, a few studies that examined demographics did identify significant differences by race/ethnicity [12,15,24]. Ma and Ma [12] reported significantly greater awareness of target and personal BP levels for Caucasians relative to African Americans. In another study [24], Caucasians were more likely than Hispanics to know healthy BP levels; no significant group differences were observed for African Americans in this study. The Mosca et al. study [15] revealed significantly greater awareness of optimal BP levels for Caucasians relative to both African American and Hispanic participants. In all, these studies reflect racial/ethnic group differences, with minority groups tending to report lower levels of awareness for BP.

A subset of the studies examining awareness of BP also examined relationships of awareness to health behaviors/outcomes [12,15,27]. In the Ma and Ma study [12], awareness of personal BP levels was associated with physical activity, and awareness of both personal and optimal levels was associated with healthier diet for Caucasians only (this relationship was not observed for African Americans). Mosca et al. [15] also reported that awareness of healthy BP levels was associated with improvements in diet, and the effect in this study was not affected by racial/ethnic group. In a study by Prugger et al. [27], the lack of awareness of optimal BP levels was associated with more obesity and higher cholesterol. In general, these studies support the notion that awareness of BP levels is related to healthier behaviors/outcomes. There is not yet sufficient information to evaluate whether there is racial/ethnic group moderation of these relationships.

Lipids

Awareness of healthy/optimal lipid levels and one's own personal lipid levels is generally lower than the awareness for BP. This is likely due in large part to the added complexity of having different types of lipid readings (i.e., total cholesterol (TC), low-density lipoprotein (LDL) levels, high-density lipoprotein (HDL) levels, and triglycerides). The range of awareness/knowledge of healthy lipid levels for the studies reviewed here ranged from 4% awareness of TC among a large sample of Korean women [33] to 50% overall awareness of healthy TC for a sample of Caucasian and African American men and women in the Southern United States [12]. However, there were only a limited number of studies that reported on awareness of healthy lipid levels [12,15,26,29,33], and the findings clustered around 40%–50% awareness for TC. The two studies that reported awareness of healthy LDL and HDL [15,34] showed lower levels of knowledge for these indexes (2%–37%).

There were a greater number of studies that reported awareness of participants' own lipid levels, and these results ranged more widely than the awareness for healthy levels. In the Choi study [33] of Korean women, 5% awareness of participant's own personal TC was observed, whereas in a very large study of women who work as health professionals [35], 84% of participants reported their own TC level. In all, these findings for personal lipid levels did not produce a clear cluster, with six studies reporting personal TC awareness on the low end (5%–29%) and five others observing levels on the high end (43%–84%). As with awareness of healthy lipid levels, the available data [34–36] suggest that awareness of personal levels of LDL and HDL tend to be lower overall (7%–28%) compared with awareness for TC. Studies generally support the accuracy of participants' knowledge of their own lipid level numbers, but their interpretation of these numbers may not be consistent with clinical guidelines; Huerta et al. [32] observed that participants significantly underestimated hyperlipidemia as defined by elevated TC or triglycerides, and Huang et al. [35] observed an underestimate of hyperlipidemia by 6% based on TC. Also, those being treated for CVD or who are identified as being high risk do not necessarily have better awareness. The Cheng et al. [34] study indicated that a greater number of risk factors and/or history of CVD did not predict better awareness.

Several studies examined whether race/ethnicity was associated with knowledge/awareness of lipid levels. In a large study of 467 inner-city men and women, Kaplan et al. [37] observed that Caucasians had significantly greater awareness of personal TC level (25%) than African American (5%) and Hispanic participants (14%). Likewise, in a large sample of 1008 women, Mosca et al. [15] found that Caucasian participants had significantly greater awareness of healthy LDL and HDL levels compared with African American and Hispanic participants. Ma and Ma [12] also reported significantly greater awareness of both personal TC and healthy TC among Caucasians relative to African American participants. In the Mochari et al. [24] study, Caucasians were significantly more likely to know healthy HDL levels than Hispanics. In another study [34], Caucasians displayed significantly greater awareness of personal TC levels than a group of unspecified nonwhite participants. There were two studies, however, that did not observe race/ethnic differences with respect to awareness of lipid levels [29,35]. Although these studies are mixed overall, in terms of observing significant race/ethnic differences, the majority of studies do reflect group differences. Moreover, there is a clear pattern identified in these studies, with Caucasians demonstrating greater awareness. This reinforces the need for additional research on the mechanisms underlying awareness/the lack of awareness and better programs to enhance awareness of lipid levels for minority groups.

A few of the studies investigating lipid awareness examined whether this knowledge is associated with health behaviors/outcomes. In the large study of 39,876 female health professionals, Huang et al. [35] observed a significant association of personal lipid level awareness with less obesity, more physical activity, and lower smoking prevalence. In the Ma and Ma [12] study of Caucasian and African American men and women, awareness of healthy TC levels was only associated with healthier diet among Caucasian participants. However, in a large study of 1008 women, Mosca et al. [15] did not observe significant associations between awareness of healthy LDL/HDL levels and physical activity or diet. This pool of studies is too limited to draw firm conclusions, but it is interesting to note that the lack of findings in the Mosca et al. [15] study involved relationships with LDL and HDL. Although speculative without further research, these preliminary results suggest the possibility that knowledge/awareness of LDL and HDL translate less easily into health behaviors due to the more limited understanding of these indexes in the general community.

Body Mass/Obesity

The evaluation of knowledge/awareness of body weight-related information has been conducted using two general constructs: (1) the awareness of specific BMI levels and (2) the awareness of weight status/category (i.e., normal, overweight, and obese). With regard to BMI study, participants' awareness of their own level has been found to range widely, from 8% [38] to 66% [39]. However, most studies have observed low levels of awareness for personal BMI, with a cluster of studies reporting estimates from 8% to 18% [12,38,40,41]. A similar pattern was observed for knowledge/awareness of the healthy/clinical cutoffs for BMI; knowledge of accurate BMI cutoffs ranged from 8% in a study of 657 obese British men and women [41] to 62% in a study of 53 renal transplant recipients [39]. As with awareness of personal BMI, these estimates for knowledge of BMI cutoffs tended to be low, with several studies observing rates in the 8%–22% range