11:21 AM

492 - Increasing Health Span, Sleep Apnea Evidence?, Beyond Empathy

Take 3 – Practical Practice Pointers©

From the Literature

1)  Life’s Essential 8, Cardiovascular Health, and Health Span


The concept of cardiovascular health (CVH) was proposed by the American Heart Association (AHA) in 2010 and is composed of both lifestyle factors and biological metrics. The original algorithm for evaluating CVH was the Life’s Simple 7 (LS7) score, consisting of measures for diet, physical activity, tobacco/nicotine exposure, body mass index, non–high-density lipoprotein cholesterol, blood glucose, and blood pressure. 

In 2022, the AHA published the new algorithm for evaluating CVH, the Life’s Essential 8 (LE8) score, on the basis of feedback on the LS7 score and new evidence. (Take 3 July 8, 2022).  The components of Life’s Essential 8 include:

·         Healthy Diet:  Encourages the DASH diet components for population measure and the Mediterranean Eating Pattern for Americans (MEPA) for individuals. 

·         Regular Physical Activity:  Measured by the total number of minutes of moderate (>150 minutes/week) or vigorous (>75 minutes/week) physical activity/week.

·         Limiting Nicotine Exposure: Includes all inhaled nicotine-delivery systems and exposure to second-hand smoke.

·         Healthy Sleep:  Measured by average hours of sleep/night with target 7-9 hours.

·         Healthy Weight:  BMI of 18.5–24.9 is target. 

·         Healthy Lipids:  Non-HDL cholesterol (Total cholesterol minus HDL cholesterol) with target of < 130.

·         Healthy Blood Glucose:  Use of fasting blood sugar (FBS) or hemoglobin A1C.  Target is < 100 or < 5.7.

·         Healthy Blood Pressure:  Target measure is < 120/80.

Previous studies have shown that having a higher CVH level was not only associated with a lower risk of CVD, but also associated with lower risks of other diseases, such as diabetes, cancer, and dementia, as well as risk of all-cause mortality.  Currently, studies assessing the relations between CVH defined by LE8 and overall health are lacking.

This cohort study included 135,199 adults in the United Kingdom Biobank study who were initially free of major chronic disease and had complete data on LE8 metrics.  The CVH level was evaluated at baseline and categorized into low (LE8 score <50), moderate (LE8 score ≥50 but <80), and high (LE8 score ≥80) levels.  The primary outcome was the life expectancy free of 4 major chronic diseases (CVD, diabetes, cancer, and dementia).

The authors found that men with moderate or high CVH levels lived on average 4.0 (95% CI, 3.4-4.5) or 6.9 (95% CI, 6.1-7.7) longer years free of chronic disease, respectively, at age 50 years, compared with men with low CVH levels. The corresponding longer years lived free of disease for women were 6.3 (95% CI, 5.6-7.0) or 9.4 (95% CI, 8.5-10.2).  For participants with high CVH level, there was not a statistically significant difference in disease-free life expectancy between participants with low and other socioeconomic status.

The authors concluded that a high Cardiovascular Health Level, evaluated by the LE8 score, is strongly associated with longer life expectancy, especially life expectancy free of major chronic diseases (“health span”) in both men and women.  These findings support the improvement in population health by promoting high CVH levels, which may also narrow health disparities associated with socioeconomic status.

Mark’s Comments:

To be able to increase life span AND health span substantially by attending to a defined number of metrics seems a real bargain!  Many of the metrics are in direct control of an individual and the others can be modified/addressed by lifestyle intervention and, in the case of blood sugar and blood pressure, with the assistance of an assortment of readily available/affordable medications.  Now the challenge is how do we begin to change the quite unhealthy dominant culture?  My experience as of late has been by modeling it ourselves and then being willing to engage in the conversation, over and over … and over again, while also supporting public policy that allows a healthy lifestyle to be accessible, affordable, and preferable for those across the socioeconomic spectrum.

If you’d like to determine your present cardiovascular health based on the Essential 8, see the link at the 2nd reference below.  I was please that I “scored” in the high health range and am looking to address those areas that could improve through ongoing lifestyle changes.  Now to determine what best to do with those additional 6.9 years!


·         Wang X, et al.  Association of Cardiovascular Health With Life Expectancy Free of Cardiovascular Disease, Diabetes, Cancer, and Dementia in UK Adults.  JAMA Intern Med. February 27, 2023;183(4):340-349. Link

·         American Heart Association “My Life Check” Cardiovascular Health Assessment (Register for Free):  Link

From the Agency for Healthcare Research and Quality (AHRQ)

2)  Sleep Apnea Diagnosis and Treatment – Inadequate Evidence


Obstructive sleep apnea (OSA) is increasingly common (estimate vary from 2 to 20% of the population) – linked as it is to the obesity epidemic – and I certainly am aware of patients that have concerning and sometimes dangerous symptoms from this condition. We are ordering lots of sleep studies these days as potential explanations for chronic lower extremity edema, fatigue, hypertension, and headaches.

A technology assessment from AHRQ reviews the research behind the diagnosis and treatment of OSA. There were four major topics covered in the review: 1) sleep apnea definitions and diagnoses, 2) continuous positive airway pressure (CPAP) as a treatment for OSA, and 3) CPAP vs. other methods to treat OSA, and 4) adverse events related to therapy for OSA.

Fifty-two studies looked at the terms and definitions of sleep apnea and found extensive variation in their use, even despite using national guidelines for definitions. Cutoff levels for diagnosis and staging of OSA were not used in a standard manner in studies.

For the evaluation of CPAP therapy vs. none, there were14 randomized controlled trials and 17 non-randomized studies. All these studies had at least moderate risk of bias.

The RCTs alone did not demonstrate an improvement with CPAP in overall (effect size (ES) 0.89, 95% CI 0.66 to 1.21) or cardiovascular (CV) mortality (ES 0.99, 95% CI 0.64 to 1.53). But when non-randomized studies were added (which had a high risk of bias), the effect sizes became significant, especially when the analyses selected for patients adherent to the CPAP. Multiple other analyses on individual CV outcomes, traffic and home accidents, and cognitive and psychiatric outcomes all suffered from imprecise estimates of effect (due to small sample sizes and/or few studies), conflicting results (e.g., for hypertension), and the same pattern of achieving statistically significant differences only when the lower-quality, non-randomized studies were included.

For the evaluations of CPAP vs. other therapies for OSA, there were few studies and no statistically significant differences found. For adverse events related to CPAP therapy, there was little systematic evidence, but review of Food & Drug Administration adverse event reporting found dental, respiratory, nose and throat, eye, and gastrointestinal event reports consistent with improper use of the equipment, inadequate humidification, and device malfunction.

The review also looked at surrogate measures of improvement in OSA, such as change in apnea-hypopnea index scores, sleepiness scales, etc. There was insufficient evidence found that changes in these scores was related to patient-oriented outcomes.

The review authors emphasize that the evidence for these questions is either of low quality, imprecise, or inconsistent. They note that there is not a convincing argument of lack of effect but call for (and explain) the kinds of research needed to arrive at better guidance about OSA and CPAP.

John’s Comments:

It’s a bit unsettling to consider the relatively shaky evidence base that our management of OSA rests on. How should we practice while waiting for better quality evidence? I think reserving OSA workups for those who are significantly symptomatic (e.g., by symptom scale), or who have clinical findings that suggest sleep apnea (poorly controlled hypertension and obesity, significant lower extremity edema, etc.) is prudent. Emphasizing CPAP therapy for moderate-severe OSA and encouraging adherence are suggested by the existing data as reasonable management choices.


·         Balk EM, Adam GP, Cao W, et al. Long-Term Health Outcomes in Obstructive Sleep Apnea: A Systematic Review of Comparative Studies Evaluating Positive Airway Pressure and the Validity of Breathing Measures as Surrogate    Outcomes. Agency for Healthcare Research and Quality; 2022:182. Link

From PeerRxMed ( www.PeerRxMed.org )

Is It Really Empathy That We’re After? 


"I got it wrong.  I do not think it is possible to learn to recognize emotion in other people …. There is no merit in trying to walk in someone else's shoes.  Let them tell their own story ... and believe them."   Brene Brown, PhD

It’s not often that someone who is very prominent in the human development movement (or any other space) is candid about their ongoing evolution of thought, and in particular using the phrase, “I was wrong.”  Therefore, when I heard Brene Brown, whose work I greatly admire, share the statement above on a 2021 podcast interview with, of all people, Oprah, I took notice and hit pause. 

Her words struck a chord with me.  It seems as if “showing more empathy” has become a very trendy solution to some of our profession’s many woes, from diminishing burnout to improving our patient satisfaction scores.  And this has not felt right to me.  My struggle is not whether we can experience emotional resonance with another person.  It is rather whether it is possible to truly understand another person's feelings in a situation from their point of view.  In other words, whether the statement “I know how you feel” can never be accurate.  Brene Brown went on to explain that her epiphany came about when she realized that whenever she believed she “knew” what another was feeling, she was more likely projecting her experience and context onto theirs.

Indeed, when I consider my personal experience with emotions as well as my work in an emotional-laden profession for many years, the act of trying to simplify the complex myriad of emotions one experiences in the setting of distress into a few words or descriptors seems simplistic and even a bit naïve.  It didn’t take too much research to realize that there is much more nuance (and disagreement) about the science of understanding ours and other’s emotions than one would come to believe when they are encouraged to “just show more empathy.” 

For example, according to psychologists Daniel Goleman (of Emotional Intelligence fame) and Paul Ekman (a legend in psychology circles), there are 3 types of empathy:  cognitive (I know what you are feeling), emotional (I feel what you are feeling), and compassionate (it appears you are suffering, and I want to help).  In contrast, psychologist and leadership development expert Rasmus Hougaard (The Potential Project) insists that compassion and empathy are very different, are processed in different parts of the brain, and that because of their important differences, compassion is the destination we should be striving for.  

The antidote for this confusion?  Brene Brown says we should “let them tell their own story … and believe them.”  Which has led me to conclude that any process that has me concerned about naming what a person is feeling becomes a distraction from my ability to be present with them.  Perhaps that time is better invested in understanding that they are feeling, that those emotions are impacting them negatively (causing suffering), and that we are therefore moved to help them without feeling the need to become enmeshed in their emotions.  In other words, that our calling as healthcare professionals is to be a caring presence and to help initiate a healing process for our patients – to not “empathize with” as much as want to “walk with” them.  To show them compassion ….

But, of course, I could be wrong.  What do you think?  If you’ve struggled with this as well, I’d love to hear from you.


Mark and John

Carilion Clinic Department of Family and Community Medicine

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Email: mhgreenawald@carilionclinic.org