Association between changes in cardiovascular health and the risk of multimorbidity: community-based cohort studies in the UK and Finland

Abstract

Background: Better cardiovascular health is associated with lower risk of various chronic diseases, but its association with multimorbidity is poorly understood. We aimed to examine whether change in cardiovascular health is associated with multimorbidity risk.

Methods: The primary analysis was conducted in the Whitehall II multiwave prospective cohort study (UK) and the validation analysis in the Finnish Public Sector cohort study (Finland). Change in cardiovascular health was assessed using the American Heart Association Life's Simple 7 (LS7) and Life's Essential 8 (LE8) at baseline and re-assessments, using objective measures in Whitehall II and self-reports and pharmacy claims in the Finnish Public Sector cohort study, respectively. Multimorbidity was defined as the presence of two or more of 12 chronic diseases during follow-up. We estimated hazard ratios (HR) and 95% confidence intervals (CI) using Cox's proportional hazard models with age as time scale, adjusting for sex, education, occupation, marital status, and ethnicity.

Findings: In the primary analysis among 9715 participants, mean age was 44.8 (standard deviation 6.0) years and 67.6% participants were men at baseline. During the median follow-up of 31.4 (interquartile range 26.8-32.3) years, 2751 participants developed multimorbidity. The hazard of multimorbidity decreased by 8% (HR 0.92, 95% CI 0.88-0.96) per ideal LS7 metric increment over 5 years and by 14% (HR 0.86, 95% CI 0.80-0.93) per ten points increase in LE8 score over 10 years. These findings were replicated in the validation analysis among 75,377 participants in terms of 4-year change in cardiovascular health.

Interpretation: Improvement in cardiovascular health was associated with lower multimorbidity risk in two community-based cohort studies. Interventions improving cardiovascular health of the community may contribute to multimorbidity prevention.

Funding: None.

Keywords: Cardiovascular health; Chronic diseases; Cohort study; Multimorbidity; Prevention.

Fig. 1

Cumulative incidence curves for multimorbidity status by category of change in the number of ideal LS7 metrics. Part A shows incidence by 5-year change from baseline to 1991–1993 in the Whitehall II study population. Part B shows incidence by 4-year change from baseline to second evaluation in the Finnish Public Sector study population. Baseline examination took place in 1985–88 and re-assessment in 1991–1993 in the Whitehall II study with a follow-up of multimorbidity until 31 March 2019. Baseline evaluation took place in 2000–2002, 2004–2005, and 2008–2009 and re-assessment 4 years later in 2004–2005, 2008–2009, and 2012–2013 in the Finnish Public Sector study (open cohort) with a follow-up of multimorbidity until 31 December 2016. LS7 is without healthy diet metric in the Finnish Public Sector study. At baseline and re-assessments, poor (P), intermediate (I), and high (H) LS7 categories defined as 0–2, 3–4, and 5–7 ideal LS7 metrics in the Whitehall II study and as 0–2, 3–4, and 5–6 ideal LS7 metrics in the Finnish Public Sector study. Due to the small number of participants, we combined poor to intermediate or high LS7 category of change. H, high; I, intermediate; P, poor.

Fig. 2

Hazard ratios and 95% confidence intervals for associations of change in ideal LS7 metrics with multimorbidity status during follow-up. Part A shows associations of 5-year change from baseline to 1991–1993 in the Whitehall II study population. Part B shows associations of 4-year change from baseline to re-assessment in the Finnish Public Sector study population. Baseline examination took place in 1985–88 and re-assessment in 1991–1993 in the Whitehall II study with a follow-up of multimorbidity until 31 March 2019. Baseline evaluation took place in 2000–2002, 2004–2005, and 2008–2009 and re-assessment 4 years later in 2004–2005, 2008–2009, and 2012–2013 in the Finnish Public Sector study (open cohort) with a follow-up of multimorbidity until 31 December 2016. Hazard ratios and 95% confidence intervals from Cox's proportional hazards models with age as time scale and birth cohort strata, adjusted for sex, education, occupation, and marital status in the Finnish Public Sector study and additionally for ethnicity in the Whitehall II study. Hazard ratios per one ideal LS7 metric increase over time are additionally adjusted for baseline value. LS7 is without healthy diet metric in the Finnish Public Sector Study. At baseline and re-assessments, poor, intermediate, and high LS7 categories defined as 0–2, 3–4, and 5–7 ideal LS7 metrics in the Whitehall II study and as 0–2, 3–4, and 5–6 ideal LS7 metrics in the Finnish Public Sector study. Due to the small number of participants, we combined poor to intermediate or high LS7 category of change. CI, confidence interval; IR, incidence rate; HR, hazard ratio; MM, multimorbidity; PY, person-years.