Tales of the "Fountain of Youth" are sprinkled throughout history, documenting an enduring quest for extended youthfulness. Medical research has resumed that search to extend life and reduce morbidity and mortality. In recent decades, this has been a tremendously successful endeavor. Global average life expectancy has had the fastest rate of increase since the 1960s, increasing by 5.5 years between 2000 and 2016.¹ In the US, although concerning trends were recently observed between 2015 and 2018,² the trend reversed in 2019 and now life expectancy is rising in the US again.³

As the average life expectancy in the world continues to increase, our attention now pivots to how to extend life free of disease. Chronic disease directly impacts quality of life, results in morbidity and disability, and represents an enormous burden to the US health system. Ninety percent of the nation's $3.5 trillion in annual health care expenditures are devoted to treat chronic conditions.⁴

Heart disease and stroke not only kill the most Americans each year, but also cost the health care system $199 billion per year, with $131 billion in lost productivity.⁴ Therefore, it becomes important not only to extend life but also to find ways to protect life from disease. Efforts to reduce the chronic disease burden are paying off. Since the 1980s, individuals 65 years and older in the US have experienced an increase in the proportion of life free of disability.⁵ But, are all US communities benefiting equally from these improvements?

A growing body of evidence suggests that a person's race, socioeconomic status (SES) and zip code have a large impact on their life expectancy.⁶ Data from NYU Langone Health's City Health Dashboard showed that individuals living in fifty-six US cities can expect to live 20 years less than their fellow citizens from nearby wealthier neighborhoods. This disparity is as high as 30 years in Chicago.⁶ Racial minority groups and those living in poverty in the US also suffer a larger burden of disease.

Despite a lower prevalence of metabolic syndrome, Blacks suffer disproportionally higher cardiovascular disease and type 2 diabetes rates and related complications compared to White counterparts.⁷ The causes of these disparities are multifactorial and include lower educational attainment, poor health literacy, limited health insurance and access to care, accessibility to healthy foods and green space, housing conditions, exposure to pollution, violence, segregation, and racism.

Adhering to a healthy lifestyle is a powerful determinant of a person's cardiovascular health and life expectancy. Li and colleagues have recently provided further supporting evidence to this important notion.

Using self-reported questionnaires collected from the Nurses' Health Study (1980-2014) and Health Professions Follow-up Study (1986-2014), the authors demonstrated that among mostly White health professionals, a healthy lifestyle (never smoking, body mass index 18.5–24.9, moderate to vigorous physical activity ≥30 minutes/day, moderate alcohol intake [women: 5-15g/day; men 5-30g/day], and a high diet quality score [upper 40%]) is associated with an increased total life expectancy and life free of cancer, cardiovascular disease, and type 2 diabetes.⁸ This was approximately 7.5 years in men and 10 years in women compared with participants with a healthy lifestyle. An important limitation was that the study population consisted of mostly White health professionals who have adopted relatively healthy behaviors. Therefore, results may not be fully generalizable to other populations.

This adds to a large body of literature on the benefits of a healthy lifestyle, and provides further, updated support to the recent 2019 Primary Prevention of Cardiovascular Disease guideline recommendations from both the American College of Cardiology/American Heart Association as well as from the European Society of Cardiology/European Atherosclerosis Society.^9,10 However, it is critical to consider that "modifiable" lifestyle factors may be harder to modify for certain communities.

Why is this? The individual-patient approach to healthy lifestyle counseling for cardiovascular prevention focuses on informing (and eventually improving) individual patient's choices. This approach is central to personalized preventive medicine, and strongly supported by both American and European guidelines.^9,10 A key assumption of this paradigm is that patients are able to choose their habits—i.e., their diet or amount of leisure daily physical activity. However, this may not hold true in many cases, particularly among people facing adverse socioeconomic circumstances.

For example, while wealthier persons may attend preventive health checkups more often, individuals with limited or no health insurance will have fewer encounters with primary care or cardiovascular prevention specialists—limiting their exposure to healthy lifestyle advice. Also, while wealthier families are able to afford more expensive, healthy foods such as fresh fruits, fish, or nuts, this may not be as realistic for those facing more constrained budgets.

Similarly, while individuals with higher income will often live in walkable neighborhoods where they can exercise outdoors, or afford expensive fitness centers, low-income persons will typically live in less safe areas, and have access to fewer, affordable fitness choices. Thus, under the individual-level paradigm for lifestyle change, SES features can become key to determining a person's likelihood to eventually succeed, which may unintentionally exacerbate prevailing health disparities.

These trends have been seen in a number of studies. For instance, in a prospective study evaluating the impact of living in a food desert (as defined by poor access to healthy foods and low area income) on adverse cardiovascular outcomes,¹¹ Kelli and colleagues followed 4944 patients who had undergone cardiac catheterization, for a median of 3.2 years. The authors found that those living in food deserts had a 44% higher risk of incident myocardial infarction (MI), after adjustment for patient demographics and traditional risk factors, than those who did not. Moreover, when food access and low income were assessed simultaneously, only low area income remained independently associated with a higher risk of MI and death/MI, stressing the role of low income is a key upwards cardiovascular health determinant; thus, a higher income can counteract intermediate factors such as poor access to healthy foods. Moreover, patients living in food deserts were more likely to be Black (31% vs 20% among those living in non-food dessert areas), highlighting the complex interplay between socioeconomic factors and race.

These reasons stress the need for complementing individual-level interventions with structural approaches, with a particular focus on low-resource and diverse communities. Investing in evidence-based, quality public health interventions is an effective means of extending life, reducing disease burden, curbing healthcare costs, and addressing health disparities. There are numerous examples of successful public health interventions that improve health outcomes by targeting smoking, diets and physical activity.¹² Interventions also exist, such as those utilizing community-based health workers that are cost-effective and improve health outcomes in low-income and racial and ethnic minority communities.¹³

A meta-analysis showed that the median return on investment for public health interventions was 14.3 to 1 and median cost-benefit ratio was 8.3.¹⁴ Recognizing this, the Centers for Disease Control and Prevention (CDC) has laid out ten recommendations for a public health action plan to prevent heart disease and stroke.¹⁵ These support policies to assure effective public health action and evaluation; develop interventions within all groups, especially those most at risk; strengthen public health agencies; create training, consultation, and technical support services; improve data collection and monitoring; create information exchanges; and work with global partners.¹⁵

Of concern is that our public health infrastructure has been weakening in recent years, with public health spending on the decline.¹⁶ This undermines prevention efforts especially in the most vulnerable communities. The Affordable Care Act originally set aside $15 billion for public health funding, but various laws, federal spending cuts, and fund diversions have reduced this funding significantly.^16,17

The CDC's funding to prevent chronic diseases in 2019 was less than in 2013 after adjusting for inflation.¹⁷ Similar cuts were seen in many state and local health departments.¹⁷ Currently, many state public health agencies are spending less than 3% of their budgets on chronic disease prevention programs.¹⁵

In this context, the Institute of Medicine expert panel concluded that public health agencies are markedly underfunded.¹⁶ For example, the CDC's State Physical Activity and Nutrition (SPAN) initiative only has enough funding in 2019 to support programs in 16 states.¹⁷ Funding diversions have also reduced spending on health disparity projects such as the Racial and Ethnic Approaches to Community Health (REACH) program aimed to reduce health disparities in chronic disease and related risk factors.¹⁷ The Affordable Care Act allotted additional monies for public health initiatives; it developed CDC Community Transformation Grants to implement, evaluate and disseminate evidence-based community preventive health activities that were culturally and linguistically appropriate.¹⁸ However, this program was discontinued in 2014.

As of 2020, cardiovascular clinical practice guidelines in the US and Europe now inform the most personalized individual-level primary prevention ever. However, additional efforts are needed to curb the current cardiovascular epidemic, particularly in low-income persons and communities. As a key next step, policymakers should re-appropriate funds back to federal, state, and local public health agencies and can use the CDC's public health action plan as a framework for how to utilize these funds.

Detailed guidance on multi-level interventions for the prevention of CVD in rural and low-income communities is also included in two recent statements released by the American Heart Association.^19,20 The authors state that "support of biomedical and health services research should be a national priority, and inflation-adjusted funding for the National Institutes of Health, CDC, and other agencies must be maintained and expanded".²⁰

Through funding and supporting a public health infrastructure, we can meet the Healthy People 2030 goals of healthy equity, reducing disparities, and improving health of all US population groups. Studies such as Li et al. should persuade policy makers that it is worthwhile to invest in public health initiatives that support and facilitate healthy lifestyles, providing opportunities for all individuals to benefit from an improved life expectancy free of disease. For this to happen, it is critical that these initiates address the social determinants of health and the barriers that make it challenging for our most vulnerable to live their healthiest life.

References

1. Life expectancy. Global health observatory data. (World Health Organization website). Available at: https://www.who.int/gho/mortality_burden_disease/life_tables/situation_trends_text/en/. Accessed February 10, 2020.
2. Table 4. Life expectancy at birth, at age 65, and at age 75, by sex, race, and Hispanic origin: United States, selected years 1900-2017. (CDC website). Available at: https://www.cdc.gov/nchs/data/hus/2018/004.pdf. Accessed February 10, 2020.
3. U.S. Life Expectancy 1950-2020. (Macrotrends website). Available at: https://www.macrotrends.net/countries/USA/united-states/life-expectancy. Accessed February 10, 2020.
4. Health and economic costs of chronic disease. National Center for Chronic Disease Prevention and Health Promotion. (CDC website). Available at: https://www.cdc.gov/chronicdisease/about/costs/index.htm. Accessed February 10, 2020.
5. Crimmins EM, Zhang Y, Saito Y. Trends over 4 decades in disability-free life expectancy in the United States. Am J Public Health 2016;106:1287–93.
6. Ducharme, Jamie & Wolfson, E. Your ZIP code might determine how long you live – and the difference could be decades. TIME. (2019). Available at: https://time.com/5608268/zip-code-health/ . Accessed February 10, 2020.
7. Osei K, Gaillard T. Disparities in cardiovascular disease and type 2 diabetes risk factors in Blacks and Whites: dissecting racial paradox of metabolic syndrome. Front Endocrinol (Lausanne) 2017;8:204.
8. Li Y, Schoufour J, Wang DD, et al. Healthy lifestyle and life expectancy free of cancer, cardiovascular disease, and type 2 diabetes: prospective cohort study. BMJ 2020;368:l6669.
9. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019;140:e596–e646.
10. Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J 2020;41:1–88.
11. Kelli HM, Kim JH, Samman Tahhan A, et al. Living in food deserts and adverse cardiovascular outcomes in patients with cardiovascular disease. J Am Heart Assoc 2019;8:e010694.
12. Our Impact. National Center for Chronic Disease Prevention and Health Promotion. (CDC website). Available at: https://www.cdc.gov/chronicdisease/programs-impact/impacts.htm . Accessed February 10, 2020.
13. Kim K, Choi JS, Choi E, et al. Effects of community-based health worker interventions to improve chronic disease management and care among vulnerable populations: a systematic review. Am J Public Health 2016;106:e3–e28.
14. Masters R, Anwar E, Collins B, Cookson R, Capewell S. Return on investment of public health interventions: a systematic review. J Epidemiol Community Health 2017;71:827–34.
15. Executive Summary. Public Health Action Plan to Prevent Heart Disease and Stroke. (CDC website). Available at: https://www.cdc.gov/dhdsp/action_plan/pdfs/action_plan_2of7.pdf. Accessed February 10, 2020.
16. Himmelstein DU, Woolhandler S. Public Health's Falling Share of US Health Spending. Am J Public Health 2016;106:56–57.
17. McKillop M, Illakkuvan V. The impact of chronic underfunding on America's public health system: trends, risks, and recommendations, 2019. (Trust for America's Health (TFAH) website). (2019). Available at: https://www.tfah.org/wp-content/uploads/2019/04/TFAH-2019-PublicHealthFunding-06.pdf . Accessed February 10, 2020.
18. Community transformation grants (2011-2014). (CDC website). Available at: https://www.cdc.gov/nccdphp/dch/programs/communitytransformation/index.htm Accessed February 10, 2020.
19. Harrington RA, Califf RM, Balamurugan A, et al. Call to Action: Rural Health: A Presidential Advisory from the American Heart Association and American Stroke Association. Circulation 2020. Available online at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000753
20. Warner JJ, Benjamin IJ, Churchwell K, et al. Advancing Healthcare Reform: The American Heart Association's 2020 Statement of Principles for Adequate, Accessible, and Affordable Health Care: A Presidential Advisory from the American Heart Association. Circulation 2020 [published online ahead of print].

Clinical Topics: Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, Diet, Exercise

Keywords: Life Expectancy, Body Mass Index, Follow-Up Studies, American Heart Association, Self Report, Metabolic Syndrome, Cardiovascular Diseases, Quality of Life, Health Literacy, Minority Groups, Health Expenditures, Diabetes Mellitus, Type 2, Health Behavior, Chronic Disease, Diet, Social Class, Primary Prevention, Insurance, Health, Habits, Atherosclerosis, Stroke, Counseling, Neoplasms, Health Occupations, Biomedical Research, Exercise, Socioeconomic Factors, Health Services Accessibility, Heart Diseases, Leisure Activities, Longitudinal Studies, Epidemiologic Studies, Dyslipidemias

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