Life's Simple 7 and Nonalcoholic Fatty Liver Disease: The Multiethnic Study of Atherosclerosis

Published:December 04, 2020DOI:



      The American Heart Association (AHA) has defined Life's Simple 7 (LS7) as a measure of overall cardiovascular health . Nonalcoholic fatty liver disease (NAFLD) has been involved as a risk factor for cardiovascular disease. We evaluated the association between LS7 and NAFLD.


      We evaluated participants form the Multi-Ethnic Study of Atherosclerosis (MESA) cohort. Cardiovascular health score was calculated from the Life's Simple 7 metrics. A score of 0-8 was considered inadequate, 9-10 average, and 11-14 optimal. NAFLD was defined using noncontrast cardiac computed tomography (CT) and a liver/spleen attenuation ratio (L/S) < 1. Multivariable regression were performed to evaluate the association.


      Our cross-sectional analysis of 3901 participants showed 19% (n = 747) had optimal cardiovascular health, 33% (n = 1270) had average, and 48% (n = 1884) had inadequate. White participants were most likely to have an optimal score (51%, n = 378), whereas African American participants had the lowest proportion with optimal scores (16%, n = 120; P < 0.001). The overall prevalence of NAFLD was 18% with a distribution of 7%, 14%, and 25% in the optimal, average, and inadequate score categories, respectively (P < 0.001). Adjusted for risk factors, average and optimal health categories had lower odds of NAFLD compared to those with inadequate scores: odds ratio for average, 0.44 (95% confidence interval 0.36-0.54); optimal, odds ratio 0.19 (95% confidence interval 0.14-0.26). This association was similar across gender, race and age groups.


      A more favorable cardiovascular health score was associated with a lower prevalence of NAFLD. This study may suggest a potential of Life's Simple 7 in the prevention of liver disease.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Unger E
        • Diez-Roux AV
        • Lloyd-Jones DM
        • et al.
        Association of neighborhood characteristics with cardiovascular health in the Multi-Ethnic Study of Atherosclerosis.
        Circ Cardiovasc Qual Outcomes. 2014; 7: 524-531
        • Lloyd-Jones DM
        • Hong Y
        • Labarthe D
        • et al.
        American Heart Association Strategic Planning Task Force and Statistics Committee. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic impact goal through 2020 and beyond.
        Circulation. 2010; 121: 586-613
        • Conroy RM
        • Pyörälä K
        • Fitzgerald AP
        • et al.
        Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project.
        Eur Heart J. 2003; 24: 987-1003
        • Bambs C
        • Kip KE
        • Dinga A
        • et al.
        Low prevalence of “ideal cardiovascular health” in a community-based population: the heart strategies concentrating on risk evaluation (Heart SCORE) study.
        Circulation. 2011; 123: 850-857
        • Folsom AR
        • Yatsuya H
        • Nettleton JA
        • et al.
        Community prevalence of ideal cardiovascular health, by the American Heart Association definition, and relationship with cardiovascular disease incidence.
        J Am Coll Cardiol. 2011; 57: 1690-1696
        • Shay CM
        • Ning H
        • Allen NB
        • et al.
        Status of cardiovascular health in US adults: prevalence estimates from the National Health and Nutrition Examination Surveys (NHANES) 2003-2008.
        Circulation. 2012; 125: 45-56
        • Chalasani N
        • Younossi Z
        • Lavine JE
        • et al.
        The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American Gastroenterological Association, American Association for the Study of Liver Diseases, and American College of Gastroenterology.
        Gastroenterology. 2012; 142: 1592-1609
        • Marchesini G
        • Marzocchi R
        • Agostini F
        • et al.
        Nonalcoholic fatty liver disease and the metabolic syndrome.
        Curr Opin Lipidol. 2005; 16: 421-427
        • Targher G
        • Bertolini L
        • Padovani R
        • et al.
        Prevalence of nonalcoholic fatty liver disease and its association with cardiovascular disease among type 2 diabetic patients.
        Diabetes Care. 2007; 30: 1212-1218
        • Adams LA
        • Angulo P.
        Recent concepts in non-alcoholic fatty liver disease.
        Diabet Med. 2005; 22: 1129-1133
        • Targher G
        • Bertolini L
        • Poli F
        • et al.
        Nonalcoholic fatty liver disease and risk of future cardiovascular events among type 2 diabetic patients.
        Diabetes. 2005; 54: 3541-3546
        • Targher G
        Relationship between high-sensitivity C-reactive protein levels and liver histology in subjects with non-alcoholic fatty liver disease.
        J Hepatol. 2006; 45 (author reply 881-882): 879-881
        • Zeb I
        • Li D
        • Budoff MJ
        • et al.
        Non-alcoholic fatty liver disease and incident cardiac events: The Multi-Ethnic Study of Atherosclerosis.
        J Am Coll Cardiol. 2016 Apr 26; 67: 1965-1966
        • Alexander KS
        • Zakai NA
        • Lidofsky SD
        • et al.
        Non-alcoholic fatty liver disease, liver biomarkers and stroke risk: The Reasons for Geographic and Racial Differences in Stroke cohort.
        PLoS One. 2018; 13e0194153
        • Joseph JJ
        • Echouffo-Tcheugui JB
        • Carnethon MR
        • et al.
        The association of ideal cardiovascular health with incident type 2 diabetes mellitus: The Multi-Ethnic Study of Atherosclerosis.
        Diabetologia. 2016; 59: 1893-1903
        • Kulshreshtha A
        • Vaccarino V
        • Judd SE
        • et al.
        Life's Simple 7 and risk of incident stroke: the reasons for geographic and racial differences in stroke study.
        Stroke. 2013; 44: 1909-1914
        • Thacker EL
        • Gillett SR
        • Wadley VG
        • et al.
        The American Heart Association Life's Simple 7 and incident cognitive impairment: The REasons for Geographic And Racial Differences in Stroke (REGARDS) study.
        J Am Heart Assoc. 2014; 3e000635
        • Bild DE
        • Bluemke DA
        • Burke GL
        • et al.
        Multi-ethnic study of atherosclerosis: objectives and design.
        Am J Epidemiol. 2002; 156: 871-881
        • Tota-Maharaj R
        • Blaha MJ
        • Zeb I
        • et al.
        Ethnic and sex differences in fatty liver on cardiac computed tomography: the multi-ethnic study of atherosclerosis.
        Mayo Clin Proc. 2014; 89: 493-503
        • Kodama Y
        • Ng CS
        • Wu TT
        • et al.
        Comparison of CT methods for determining the fat content of the liver.
        AJR Am J Roentgenol. 2007; 188: 1307-1312
        • Grundy SM
        • Cleeman JI
        • Daniels SR
        • et al.
        Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute scientific statement: Executive Summary.
        Crit Pathw Cardiol. 2005; 4: 198-203
        • Sung K-C
        • Wild SH
        • Kwag HJ
        • Byrne CD
        Fatty liver, insulin resistance, and features of metabolic syndrome: relationships with coronary artery calcium in 10,153 people.
        Diabetes Care. 2012; 35: 2359-2364
        • Xing A
        • Ji C
        • Shi J
        • et al.
        Relationship between ideal cardiovascular behaviors/factors and the prevalence of nonalcoholic fatty liver disease.
        Zhonghua Liu Xing Bing Xue Za Zhi. 2015; 36: 40-44
        • Liu H
        • Yao Y
        • Wang Y
        • et al.
        Ideal cardiovascular health metrics and the risk of nonalcoholic fatty liver disease: a cross-sectional study in Northern China.
        Liver Int. 2019; 39: 950-955
        • Wang L
        • Li M
        • Zhao Z
        • et al.
        Ideal cardiovascular health is inversely associated with nonalcoholic fatty liver disease: a prospective analysis.
        Am J Med. 2018; 131: 1515.e1-1515.e10
        • Zhu S
        • Shi J
        • Ji C
        • et al.
        Association of the ideal cardiovascular behaviors and factors with the incidence of nonalcoholic fatty liver disease: a prospective study.
        Eur J Gastroenterol Hepatol. 2018; 30: 578-582
        • Mazidi M
        • Katsiki N
        • Mikhailidis DP
        • et al.
        Ideal cardiovascular health associated with fatty liver: results from a multi-ethnic survey.
        Atherosclerosis. 2019; 284: 129-135
        • Fang N
        • Jiang M
        • Fan Y
        Ideal cardiovascular health metrics and risk of cardiovascular disease or mortality: a meta-analysis.
        Int J Cardiol. 2016; 214: 279-283
        • Gardener H
        • Wright CB
        • Dong C
        • et al.
        Ideal cardiovascular health and cognitive aging in the northern Manhattan study.
        J Am Heart Assoc. 2016; 4e002731
        • Devulapalli S
        • Shoirah H
        • Dhamoon MS
        Ideal cardiovascular health metrics are associated with disability independently of vascular conditions.
        PLoS One. 2016; 11e0150282
        • Liu J
        • Musani SK
        • Bidulescu A
        • et al.
        Fatty liver, abdominal adipose tissue and atherosclerotic calcification in African Americans: the Jackson Heart Study.
        Atherosclerosis. 2012; 224: 521-525
        • Ozturk K
        • Uygun A
        • Guler AK
        • et al.
        Nonalcoholic fatty liver disease is an independent risk factor for atherosclerosis in young adult men.
        Atherosclerosis. 2015; 240: 380-386
        • Oni ET
        • Agatston AS
        • Blaha MJ
        • et al.
        A systematic review: burden and severity of subclinical cardiovascular disease among those with nonalcoholic fatty liver; should we care?.
        Atherosclerosis. 2013; 230: 258-267
        • Bhatia LS
        • Curzen NP
        • Calder PC
        • Byrne CD
        Non-alcoholic fatty liver disease: a new and important cardiovascular risk factor?.
        Eur Heart J. 2012; 33: 1190-1200
        • Sookoian S
        • Pirola CJ.
        Non-alcoholic fatty liver disease is strongly associated with carotid atherosclerosis: a systematic review.
        J Hepatol. 2008; 49: 600-607
        • Reeder SB
        • Cruite I
        • Hamilton G
        • Sirlin CB
        Quantitative assessment of liver fat with magnetic resonance imaging and spectroscopy.
        J Magn Reson Imaging. 2011; 34: 729-749
        • Oni ET
        • Kalathiya R
        • Aneni EC
        • et al.
        Relation of physical activity to prevalence of nonalcoholic Fatty liver disease independent of cardiometabolic risk.
        Am J Cardiol. 2015; 115: 34-39
        • Graciani A
        • García-Esquinas E
        • López-García E
        • et al.
        Ideal cardiovascular health and risk of frailty in older adults.
        Circ Cardiovasc Qual Outcomes. 2016; 9: 239-245