the american heart association s ( aha s ) strategic planning task force and statistical committee recently implemented 2020 impact goals for cardiovascular health promotion called life s simple 7 ( 1 ) . these goals are based on the current understanding of modifiable risk factors for cardiovascular disease ( cvd ) and provide up - to - date goals for optimal cardiovascular health .
the goals comprise four health behaviors and three health factors : a physically active lifestyle ; healthy diet ; healthy bmi ; avoiding smoking ; and lower blood pressure , fasting glucose , and total cholesterol ( 1 ) .
current aha guidelines recommend achieving the seven goals to maintain optimal cardiovascular health . to date , several studies have examined the association of achievement of these goals with risk of cvd and other cvd - related end points , including kidney disease , depression , and mortality ( 25 ) . however , no published studies have examined the association of the goals with incident diabetes , which is associated with high cvd risk ( 6 ) .
the overarching goals of life s simple 7 are to improve the cardiovascular health profiles of all americans and reduce deaths from cvd by 20% by 2020 ( 1 ) .
moreover , the life s simple 7 strategic plan highlights racial disparities in cardiovascular health in the u.s . and emphasizes the importance of promoting life s simple 7 in minority populations . although diabetes is a leading risk factor for cvd and mortality for all americans , the burden of diabetes in american indian ( ai ) communities is particularly troubling ( 7 ) .
ais are 2.5 times more likely to have diabetes than non - hispanic whites of similar age ( 8) . in the strong heart family study ( shfs ) , the prevalence of diabetes among ais ( median age 37 years ) was 31% in 2009 . additionally , as in other ethnic groups , obesity , physical inactivity , poor diet , and smoking are common in ai communities ( 9,10 ) .
previous studies in primarily white populations have shown that a low - risk cardiometabolic health profile , including regular physical activity , a healthy diet , abstinence from smoking , moderate alcohol use , and a healthy bmi , is associated with a lower risk of diabetes ( 1113 )
. however , many of these behaviors are largely culturally determined ( 14,15 ) , and the generalizability of the findings to other ethnic groups with high rates of obesity and diabetes remains unclear .
thus we examined the combined effect of a low - risk health profile on diabetes risk among ais , a population with high rates of diabetes and cvd .
the purpose of this analysis was to examine the associations of low - risk health behaviors and factors , as defined using the life s simple 7 goals , with incident type 2 diabetes among ais who participated in the shfs .
the shfs offers a unique opportunity to assess the relationship of the life s simple 7 goals with incident diabetes because of its large size and availability of rigorously collected risk factors and outcome measures .
the shfs is a population - based longitudinal study of the genetic , metabolic , and behavioral risk factors for cvd in 13 ai communities in arizona , north dakota , south dakota , and oklahoma .
both exams included a standardized personal interview , physical examination , medication review , laboratory testing , and a 1-week pedometer log for ascertaining physical activity levels .
the institutional review boards from each indian health service region and all 13 communities approved the study , and written informed consent was obtained from all participants at each exam .
there were 2,458 shfs participants who did not have diabetes at the baseline examination in 20012003 and had a follow - up examination in 20072009 .
we excluded those with a history of myocardial infarction , stroke , or heart failure or who were currently pregnant ( n = 115 ) at baseline , because these conditions may influence other health behaviors , such as diet or physical activity .
participants missing baseline glucose measures , family information , physical activity data , smoking information , or bmi measures or who were < 18 or 75 years old were also excluded ( n = 472 ) . finally , participants with missing or implausible dietary measures , as previously defined ( 10 ) , were excluded ( n = 232 ) . in total , 1,639 persons comprised the study population .
shfs participants excluded from the analytic sample due to loss to follow - up or missing data were less likely to be female ( 54 vs. 63% ) but otherwise similar to those included in the analytic sample .
a low - risk score was defined using established criteria for physical activity , diet , smoking , bmi , cholesterol , blood pressure , and fasting glucose .
specifically , we categorized participants based on 1 ) physical activity ( ideal [ accumulated 10,000 + steps / day ] , intermediate [ accumulated 3,50010,000 steps / day ] , poor [ accumulated < 3,500 steps / day ] ) , 2 ) diet ( ideal [ achieved 45 dietary components ] , intermediate [ achieved 23 dietary components ] , poor [ achieved 01 dietary component ] ) , 3 ) bmi ( ideal [ < 25 kg / m ] , intermediate [ 25 to < 30 kg / m ] , poor [ 30 + kg / m ] ) , 4 ) smoking ( ideal [ never or quit > 12 months ] , intermediate [ former 12 months ] , poor [ current ] ) , 5 ) cholesterol ( ideal [ < 200 mg / dl without medication ] , intermediate [ 200239 mg / dl or treated to < 200 mg / dl ] , poor [ 240 mg / dl ] ) , 6 ) blood pressure ( ideal [ < 120/<80 mmhg , without medication ] , intermediate [ systolic blood pressure ( sbp ) 120139 mmhg or diastolic blood pressure ( dbp ) 8089 mmhg or treated to < 120/<80 mmhg ] , poor [ sbp 140 mmhg or dbp 90 mmhg ] ) , and 7 ) fasting glucose ( ideal [ < 100 mg / dl , without medication ] , intermediate [ 100125 mg / dl or treated to < 100 mg / dl ] , poor [ not applicable by design since participants with diabetes at baseline were excluded from analyses ] ) . aside from the physical activity metric , the above classifications are taken directly from the life s simple 7 impact goals ( 1 ) .
the life s simple 7 goals classify physical activity levels based on total activity time ( minutes per day ) , but in the shfs , physical activity was assessed with pedometers ( steps per day ) . as several studies suggest that individuals who accumulate at least 10,000 steps per day have a decreased risk of obesity and hypertension and better glucose tolerance and lipid profiles compared with individuals who accumulate fewer steps per day ( 2024 ) , accumulation of 10,000 + steps per day was considered an ideal level of activity .
we created a composite metric of low - risk cardiovascular health status based on achievement of  ideal  status for each of the individual health metrics . although the life s simple 7 only consider individuals who achieve 
status for all 7 health metrics as  low risk ,  we chose categorization of 01 , 23 , and 4 + for the composite to most closely represent the distribution of below average , average , and above average goal achievement in the shfs population and to be consistent with the three - tiered classification scheme for the individual health metrics .
incident diabetes was defined using 2003 american diabetes association criteria , including use of insulin or oral antidiabetes medication or with a fasting plasma glucose level 126 mg / dl at the second exam . because type 1 diabetes is rare in ai populations and all shfs participants
were at least 18 years of age at baseline , we assumed that all new occurrences of diabetes were type 2 . to account for potential correlation between members of the same family within the data , generalized estimating equations with an independence
working correlation structure and sandwich ses were used to examine whether achievement of 01 , 23 , or 4 + goals was associated with diabetes risk ( 25 ) .
additionally , we examined whether achievement of the health behavior goals ( 01 vs. 2 + ) , health factor goals ( 01 vs. 2 + ) , or individual health behavior or health factor goals ( poor vs. intermediate or ideal ) influenced diabetes risk .
odds ratios ( ors ; 95% ci ) were calculated comparing participants who achieved 23 or 4 + goals ( or 2 + goals for the health behaviors or health factors analyses ) , using those who achieved 01 goals as the referent group . for the analyses of the individual goals , ors ( 95% ci ) were calculated comparing participants who achieved  intermediate  or  ideal  status , using those with 
all models were adjusted for a priori confounders , including age , sex , site , education , and family history of diabetes .
because the associations of goal achievement with diabetes risk may differ by sex or age , we examined the interaction of each goal ( and the combined goals ) with sex and age on risk of diabetes .
wald s tests were used to evaluate the statistical significance of the multiplicative interaction term in each model .
as the association of the life s simple 7 goals and diabetes risk may differ among older versus younger individuals , we stratified the analyses at the median age in sensitivity analyses .
all statistical analyses were conducted using stata version 9.0 ( stata corp . , college station , tx ) .
a low - risk score was defined using established criteria for physical activity , diet , smoking , bmi , cholesterol , blood pressure , and fasting glucose .
specifically , we categorized participants based on 1 ) physical activity ( ideal [ accumulated 10,000 + steps / day ] , intermediate [ accumulated 3,50010,000 steps / day ] , poor [ accumulated < 3,500 steps / day ] ) , 2 ) diet ( ideal [ achieved 45 dietary components ] , intermediate [ achieved 23 dietary components ] , poor [ achieved 01 dietary component ] ) , 3 ) bmi ( ideal [ < 25 kg / m ] , intermediate [ 25 to < 30 kg / m ] , poor [ 30 + kg / m ] ) , 4 ) smoking ( ideal [ never or quit > 12 months ] , intermediate [ former 12 months ] , poor [ current ] ) , 5 ) cholesterol ( ideal [ < 200 mg / dl without medication ] , intermediate [ 200239 mg / dl or treated to < 200 mg / dl ] , poor [ 240 mg / dl ] ) , 6 ) blood pressure ( ideal [ < 120/<80 mmhg , without medication ] , intermediate [ systolic blood pressure ( sbp ) 120139 mmhg or diastolic blood pressure ( dbp ) 8089 mmhg or treated to < 120/<80 mmhg ] , poor [ sbp 140 mmhg or dbp 90 mmhg ] ) , and 7 ) fasting glucose ( ideal [ < 100 mg / dl , without medication ] , intermediate [ 100125 mg / dl or treated to < 100 mg / dl ] , poor [ not applicable by design since participants with diabetes at baseline were excluded from analyses ] ) . aside from the physical activity metric , the above classifications are taken directly from the life s simple 7 impact goals ( 1 ) .
the life s simple 7 goals classify physical activity levels based on total activity time ( minutes per day ) , but in the shfs , physical activity was assessed with pedometers ( steps per day ) .
as several studies suggest that individuals who accumulate at least 10,000 steps per day have a decreased risk of obesity and hypertension and better glucose tolerance and lipid profiles compared with individuals who accumulate fewer steps per day ( 2024 ) , accumulation of 10,000 + steps per day was considered an ideal level of activity .
we created a composite metric of low - risk cardiovascular health status based on achievement of  ideal  status for each of the individual health metrics . although the life s simple 7 only consider individuals who achieve 
status for all 7 health metrics as  low risk ,  we chose categorization of 01 , 23 , and 4 + for the composite to most closely represent the distribution of below average , average , and above average goal achievement in the shfs population and to be consistent with the three - tiered classification scheme for the individual health metrics .
incident diabetes was defined using 2003 american diabetes association criteria , including use of insulin or oral antidiabetes medication or with a fasting plasma glucose level 126 mg / dl at the second exam . because type 1 diabetes is rare in ai populations and all shfs participants
were at least 18 years of age at baseline , we assumed that all new occurrences of diabetes were type 2 . to account for potential correlation between members of the same family within the data , generalized estimating equations with an independence working correlation structure and sandwich ses were used to examine whether achievement of 01 , 23 , or 4 + goals was associated with diabetes risk ( 25 ) .
additionally , we examined whether achievement of the health behavior goals ( 01 vs. 2 + ) , health factor goals ( 01 vs. 2 + ) , or individual health behavior or health factor goals ( poor vs. intermediate or ideal ) influenced diabetes risk .
odds ratios ( ors ; 95% ci ) were calculated comparing participants who achieved 23 or 4 + goals ( or 2 + goals for the health behaviors or health factors analyses ) , using those who achieved 01 goals as the referent group .
for the analyses of the individual goals , ors ( 95% ci ) were calculated comparing participants who achieved  intermediate  or  ideal  status , using those with 
all models were adjusted for a priori confounders , including age , sex , site , education , and family history of diabetes .
because the associations of goal achievement with diabetes risk may differ by sex or age , we examined the interaction of each goal ( and the combined goals ) with sex and age on risk of diabetes .
wald s tests were used to evaluate the statistical significance of the multiplicative interaction term in each model . as the association of the life s simple 7 goals and
diabetes risk may differ among older versus younger individuals , we stratified the analyses at the median age in sensitivity analyses .
all statistical analyses were conducted using stata version 9.0 ( stata corp . , college station , tx ) .
of the 1,639 shfs participants who comprised the analytic cohort , 63% were women , and the mean age at the baseline examination was 38 years .
there were 71% of participants with cholesterol levels < 200 mg / dl without medication and 40% of participants with blood pressure less than < 120/80 without medication at the baseline exam .
additionally , 57% of study participants were classified as never smokers or quit at least 12 months ago .
there were 18% of participants with bmi < 25 and 12% of study participants who accumulated 10,000 + steps per day .
no study participants achieved 4 + dietary guidelines based on the life s simple 7 dietary criteria . in total
, 25% of participants achieved 4 + of the 7 life s simple 7 goals and 16% of participants achieved only 01 goals .
achievement of each life s simple 7 goal was only modestly correlated with diabetes ; the spearman correlation coefficient for achievement of the fasting glucose goal and diabetes was 0.33 , while the correlation coefficients of all other individual goals with diabetes were small ( less than 0.15 in absolute values [ data not shown ] ) .
distribution of low - risk health metrics among 1,639 shfs participants aged 1874 years free of cvd and diabetes * 92% of shfs participants met 01 dietary goal , and 8% of participants met 2 dietary goals .
whole - grain intake was estimated from a food frequency questionnaire using the criterion that whole grains contain 1.1 g fiber per 10 g carbohydrate . during a mean follow - up of 5 years ( range 48 years ) ,
the ors of diabetes according to the number of low - risk health metrics the participants achieved at baseline are shown in table 2 . compared with participants who achieved 01 goals , participants who achieved 23 goals or 4 + goals had a lower risk of diabetes , with or = 0.40 ( 95% ci 0.290.56 ) and or = 0.11 ( 0.050.21 ) , respectively .
the lower risk of diabetes was attributable to both health behaviors ( or comparing participants who achieved 2 + to 01 health behavior goals = 0.54 [ 95% ci 0.320.92 ] ) and health factors ( or comparing participants who achieved 2 + to 01 health factor goals = 0.26 ( 95% ci 0.190.37 ] ) .
ors of diabetes according to number of low - risk health metrics achieved among 1,639 shfs participants aged 1874 years total low - risk health metrics achieved , number of low - risk health metrics achieved , and number of low - risk health factors achieved represent independent regression models .
model includes age , sex , site , education ( years ) , and family history of diabetes .
includes all life s simple 7 goals , including achievement of physical activity , diet , bmi , smoking , total cholesterol , fasting glucose , and blood pressure goals .
 includes only health behavior goals , including achievement of physical activity , diet , smoking , and bmi goals .
includes only health factor goals , including achievement of total cholesterol , fasting glucose , and blood pressure goals . in general , participants were more likely to achieve the health factor goals than the health behavior goals .
more than 70% of study participants achieved the fasting glucose and total cholesterol goals , while less than 20% achieved the bmi , physical activity , or dietary goals .
the ors of diabetes comparing levels of the individual health metrics are shown in table 3 .
lower bmi was associated with lower odds of developing diabetes . comparing the ideal category ( bmi < 25
kg / m ) to the poor category ( bmi 30 + kg / m ) , the or was 0.12 ( 95% ci 0.050.30 ) .
in addition , higher levels of physical activity and lower levels of blood pressure were associated with lower odds of diabetes .
contrasting the intermediate or ideal activity categories with the poor category for accumulated steps per day , the ors for diabetes were 0.73 ( 95% ci 0.520.98 ) and 0.65 ( 95% ci 0.381.11 ) , respectively . for blood pressure , compared with participants with poor blood pressure ( sbp 140 mmhg or dbp 90 mmhg ) , participants with ideal blood pressure ( < 120/<80 mmhg without medication ) had a lower odds of developing diabetes ( or = 0.42 [ 95% ci 0.260.69 ] ) . because the outcome of interest for this analysis was incident diabetes , participants with poor levels of fasting glucose at baseline ( 126 mg / dl ) were excluded by design . however , compared with participants with intermediate fasting glucose ( 100125 mg / dl ) , participants with ideal fasting glucose ( < 100 mg / dl ) had a lower odds of developing diabetes : or = 0.14 ( 95% ci 0.100.20 ) .
we found no association of diet , smoking , or total cholesterol with diabetes risk ( table 3 ) .
ors of diabetes according to life s simple 7 metrics among 1,639 shfs participants aged 1874 years each health behavior or factor represents an independent regression model .
each adjusted model includes age , sex , site , education ( years ) , and family history of diabetes . in secondary analyses ,
modeling the life s simple 7 risk score linearly ( 07 goals achieved ) did not materially alter reported ors ( data not shown ) .
there were also no statistically significant interactions of each health metric with sex when assessing risk of diabetes ( data not shown ) . in sensitivity analyses , omitting fasting glucose from the combined health metrics and the health factors analyses slightly attenuated reported ors , while omitting bmi from the health behaviors analysis largely attenuated the observed association ( data not shown ) .
associations of the life s simple 7 goals with diabetes incidence were similar in analyses stratified by median age ( data not shown ) .
participants who achieved at least two of the life s simple 7 goals had a lower risk of diabetes than participants who met one or none of these criteria .
this effect was graded across the metrics where participants achieving 23 or 4 + goals had a 60% and 89% lower risk of diabetes when compared with participants who only achieved 01 goals . when the health behaviors and health factors were examined separately ,
however , the association of health factors with diabetes was largely explained by differences in baseline fasting glucose .
although no participants achieved all seven goals , goal achievement was similar to that in other cohort studies and the national health and nutrition examination survey ( 25,2629 ) .
the health factors goals were more likely to be achieved than the health behaviors goals , and the dietary goal was the least likely to be achieved . developing strategies to encourage the american population to achieve optimal diet , physical activity , and
more research is needed to better understand if the current life s simple 7 health behavior thresholds represent realistic health targets for the american population at large or if promoting less aggressive ( or incremental ) changes in health behaviors better stimulates behavioral change ( 31 ) . to our knowledge , this is the first study that has examined the association of low - risk health behaviors and factors with incident diabetes using life s simple 7 goals .
the results of these analyses are comparable with two published observational studies that have examined the association of lifestyle factors and incident diabetes in other populations using different criteria . in the nurse s health study and the cardiovascular health study , participants with a healthy lifestyle  including physically active nonsmokers with low / moderate alcohol use and diets high in fiber and the ratio of polyunsaturated to saturated fat , and low in trans fat and glycemic load  had a 89% lower risk of developing diabetes when compared with less healthy study participants ( 11,12 ) .
our results complement these studies and suggest that a healthier lifestyle and low - risk health factors are associated with a lower risk of diabetes among ais . in the present analyses ,
dietary factors were not associated with diabetes risk . because 92% of the cohort achieved 2 of the core dietary goals and only 210 participants developed diabetes during follow - up , we had limited ability to adequately assess this relationship . because we had no participants who met the criteria for ideal diet , and diet quality is a major determinant of diabetes risk ( 32,33 ) , our results are likely an underestimation of the association of achievement of the life s simple 7 criteria and incidence of diabetes .
however , as smoking in this population often involves intermittent smoking and rarely exceeds 10 cigarettes per day , we had limited ability to evaluate this association .
strengths of this study include detailed information on health behaviors and factors for all study participants and 48 years of follow - up . additionally , this is the only large multitribal longitudinal study of chronic disease among ais .
although ais have a particularly high burden of obesity and diabetes , the risk factors for diabetes are similar across ethnic groups , and we expect these findings to be generalizable to other populations with similar risk profiles
although physical activity was assessed using an objective measurement tool , shfs participants may have altered physical activity patterns during the days that the pedometer was worn .
physical activity , diet , smoking , bmi , fasting glucose , total cholesterol , and blood pressure may also be associated with other unmeasured behaviors , such as access to medical care , compliance with medical advice , and other unmeasured elements of behavior that likely influence diabetes risk .
the life s simple 7 criteria comprise a crude additive scoring method based on achievement of 07 of the health behavior and factor goals ; however , the magnitude of the association of each individual health behavior or metabolic factor is not the same , and the life s simple 7 scoring may oversimplify the association of the goals with diabetes risk ( 27 )
. finally , the life s simple 7 criteria were designed as a broad public health metric to promote cardiovascular health and prevent deaths from cvd . although there is overlap between risk factors for cvd and diabetes ( e.g. , physical inactivity , diet , bmi , smoking , and fasting glucose ) , dyslipidemia and hypertension are more closely related to cvd than diabetes .
the results of this study suggest that achievement of as few as two or three of the life s simple 7 goals is associated with a lower risk of diabetes in ais , an underserved group with a high risk of cardiometabolic diseases .
this study adds to the growing body of evidence demonstrating the health benefits of achieving healthy lifestyle goals as summarized in the aha life s simple 7 and specifically suggests the potential impact of achievement of a modest number of these goals on metabolic health .
 objectivethe american heart association s recommendations for optimal health , summarized in life s simple 7 , have been associated with reduced risk of cardiovascular disease ( cvd)-related end points , but no studies have examined the association of these goals with incident type 2 diabetes , which is associated with high risk for cvd . the purpose of this analysis was to examine the associations of life s simple 7 goals with incident diabetes among american indians , a population at high risk of cardiometabolic diseases.research design and methodsstrong heart family study participants without diabetes ( n = 1,639 ) at baseline and who participated in a follow - up examination were included in the analysis . 
 risk scores ranging from 0 to 7 were created using physical activity , diet , bmi , smoking , blood pressure , fasting glucose , and cholesterol metrics in accordance with life s simple 7 goals . 
 diabetes was defined using 2003 american diabetes association criteria , including use of insulin or oral antidiabetes medication or a follow - up fasting plasma glucose level 126 mg / dl . 
 generalized estimating equations were used to examine the association of risk scores with incident diabetes.resultsduring a mean 5-year follow - up ( range 48 years ) , we identified 210 cases of incident type 2 diabetes . compared with participants who achieved 01 goals , those who achieved 23 or 4 + goals had lower odds of diabetes , with odds ratios = 0.40 ( 95% ci 0.290.56 ) and 0.11 ( 95% ci 0.050.21 ) , respectively.conclusionsthe adoption of as few as two or three life s simple 7 goals is associated with a lower risk of diabetes . 
Introduction
Research Design and Methods
Classification of Low Risk
Diabetes
Results
Conclusions