Using the New “Life’s Essential 8” Metrics to Evaluate Trends in Cardiovascular Health Among US Adults From 2005 to 2018: Analysis of Serial Cross-sectional Studies

**Background:** Cardiovascular disease (CVD) remains a major public health burden in the United States. The American Heart Association (AHA) introduced the Life's Essential 8 (LE8) metrics in 2022 to address limitations of the earlier Life's Simple 7 (LS7), adding sleep health, expanding diet assessment, and using continuous scoring (0-100) for each component. Understanding secular trends in cardiovascular health (CVH) using these updated metrics is crucial for guiding public health policy.

**Methods:** This study analyzed data from 7 cycles of the National Health and Nutrition Examination Survey (NHANES) from 2005-2006 to 2017-2018. A total of 21,667 adults aged 20-79 years were included after exclusions (pregnant/breastfeeding women, those with CVD history, missing data). The LE8 score comprises 4 behavioral factors (diet, physical activity, nicotine exposure, sleep health) and 4 health factors (BMI, blood lipids, blood glucose, blood pressure), each scored 0-100. The overall CVH score is the mean of all 8 components. Age-standardized mean scores and 95% confidence intervals were calculated using direct standardization to the 2018 US population. Linear regression was used to test trends over time, adjusting for demographic variables. Survey weights were applied to ensure national representativeness.

**Key Results:** The age-standardized overall CVH score did not change significantly from 2005-2006 to 2017-2018 (65.5, 95% CI 63.9-67.1 to 65.0, 95% CI 62.8-67.1; P for trend=.82). Among individual components, three improved: nicotine exposure (64.7 to 71.9; P<.001), sleep health (83.7 to 84.1; P=.006), and blood lipids (61.6 to 67.0; P<.001). Two worsened: BMI (63.4 to 56.2; P<.001) and blood glucose (83.9 to 77.4; P<.001). Three remained stable: diet (41.0 to 41.5; P=.94), physical activity (57.5 to 53.0; P=.26), and blood pressure (68.4 to 68.6; P=.35). Subgroup analyses showed significant worsening of overall CVH in older adults (65-79 years; P=.02), Hispanic (P=.02), and non-Hispanic White individuals (P=.007). By 2018, higher CVH scores were observed in females (66.9 vs. 63.0 for males), younger adults (20-39 years: 69.8), non-Hispanic White (65.9) and Asian/Other (66.4) groups, those with college education (73.1 vs. 57.1 for <high school), married individuals (66.3 vs. 60.4 for unmarried), and those with high income (68.3 vs. 59.0 for low income). The proportion of adults with high CVH (≥80 points) remained around 20%, intermediate (50-79) about 65%, and low (<50) about 15% across all survey cycles.

**Clinical Implications:** The lack of improvement in overall CVH over 13 years, despite gains in smoking cessation, sleep, and lipid management, underscores the need for intensified public health efforts targeting rising obesity and diabetes. The persistently low diet and physical activity scores (often below 60) indicate that lifestyle interventions remain a critical priority. The widening or persistent disparities by race/ethnicity, education, and income highlight the importance of addressing social determinants of health. The worsening BMI and blood glucose trends are particularly concerning given their strong links to CVD and may explain the recent deceleration in CVD mortality decline. Clinicians should use the LE8 framework to assess and counsel patients on all 8 metrics, with special attention to weight management and glycemic control. Population-level strategies, such as food policy changes, built environment improvements, and equitable access to preventive care, are needed to reverse these trends.