Clinically meaningful combined improvements of sleep, physical activity, and nutrition (SPAN) in relation to major adverse cardiovascular events

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ABSTRACT Background Sleep, physical activity, and nutrition (SPAN) are major modifiable risk factors for cardiovascular disease, yet the minimum and optimal combined improvements for prevention remain unknown. We examined the multi-behaviour associations of SPAN with risk of major adverse cardiovascular events (MACE) and its subtypes (myocardial infarction (MI), heart failure (HF), and stroke). Methods This prospective cohort analysis included 53,242 participants from the UK Biobank (median age: 63.0 years; 56.8% male) who wore activity trackers for 7 days and self-reported dietary data. Wearable-measured sleep (hours/day) and moderate to vigorous physical activity (MVPA; mins/day) were calculated using a machine learning-based algorithm. A 10-item diet quality score (DQS) assessed intake of vegetables, fruits, whole grains and refined grains, unprocessed and processed meats, fish, dairy, vegetable oils, and sugary beverages. Cox proportional hazards models were used to estimate hazard ratios (HR) for MACE risk across 27 joint tertile combinations of SPAN behaviours. We examined dose-response associations of SPAN with MACE using a composite score (from 0-100 points). Results Over the 8.0-year median follow-up time, 2,034 MACE events occurred, including 932 myocardial infarctions, 584 strokes, and 518 HF events. Compared to the combined SPAN referent group (lowest tertiles for all three), the optimal SPAN combination involving high sleep duration (8.0-9.4 hours/day), high MVPA (42-104 mins/day), and a DQS between 32.5 and 50.0 was associated with an HR of 0.43 (95%CI: 0.30, 0.62). Compared to the minimum SPAN score of 17.8, a median SPAN score of 52.8 was associated with a 41% lower risk of MACE (HR: 0.59; 0.49, 0.70). The median SPAN score corresponded to an HR of 0.53 (0.38, 0.75) for HF, 0.65 (0.50, 0.84) for MI, and 0.52 (0.38, 0.71) for stroke. A theoretical minimum combined improvement of an additional 11 min/day of sleep, 4.5 min/day MVPA, and 3 DQS (1/4 cup of vegetables per day) were associated with 10% lower MACE risk (HR: 0.90; 0.88, 0.94). Conclusions Modest theoretical improvements across SPAN behaviours were associated with clinically meaningful reductions in MACE and its subtypes. These findings support multi-behavioural CVD prevention trials testing the effectiveness of small improvements across multiple behaviours.

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