Although the usefulness of cardiovascular disease risk prediction models has been demonstrated (eg, Framingham, SCORE), they first need to be adapted and calibrated for the target population. More comparable concepts (risk percentiles or vascular age) have also been proposed to reduce the possible disparities in individual risk estimates.1 Indeed, up to 20% of cardiovascular events occur in the absence of the main determinants of cardiovascular risk (hypertension, hyperlipidemia, smoking, and diabetes).2 Accordingly, new factors contributing to ideal cardiovascular health have been identified3 that underlie modifiable lifestyle factors, which would be “determinants of the determinants”. A considerable number of cardiovascular events could be prevented with prompter intervention, namely, in these previous or distal (lifestyle habits) determinants, because in preventive medicine, the early bird catches the worm.4,5 Lifestyle habits determine cardiovascular risk independently of the genetic risk category.6

The priority in cardiovascular prevention should be primordial prevention,7 which acts before risk factors develop by changing the behaviors determining them.8–10 Thus, in addition to traditional risk factors, various other habits appear to have vascular benefits: a short afternoon nap,11 little time watching television,12 a Mediterranean alcohol consumption pattern,13 spending more time with friends,14 or the number of hours working.15

Here, we longitudinally analyzed the combined impact of 10 indicators of healthy lifestyle habits on cardiovascular event risk.

The participants’ baseline characteristics by HLS score are shown in Table 2. Participants with a better HLS were younger (34.1 years), were more likely to be women (71.3%), and had a lower BMI (≤ 22) and lower proportion of risk factors (diabetes, hypertension, dyslipidemia, and prevalent CVD).

Participants were followed up for a median of 10.4 years. There were 140 incident cases of CVD (0.72%): 37 deaths from cardiovascular causes (26.4%), 64 nonfatal acute coronary syndromes (45.7%), and 39 nonfatal strokes (27.9%).

Participants with a better HLS (7-10 points) showed a significant and inverse association with risk of primary cardiovascular events vs the worst HLS category (0-3 points) (HR, 0.22; 95%CI, 0.11-0.46; linear trend P < .001) (Table 3).

The relationship between a better score on the healthy lifestyle index and lower risk of primary CVD is shown in Figure 2.

Figure 2.

Fewer incident cardiovascular events by number of healthy habits. 95%CI, 95% confidence interval; HR, hazard ratio.

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The score estimates of all healthy habit indicators were individually associated with a lower risk of cardiovascular events (Table 4). However, the greatest benefit in terms of a decreased risk of primary CVD was obtained using a combination of all lifestyle habits in the HLS score (Figure 3).

Figure 3.

Risk of incident cardiovascular events for each of the factors comprising the cardiovascular health score. 95%CI, 95% confidence interval; aHR, adjusted hazard ratio.

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As expected, participants with higher cumulative exposure to smoking (> 20 packets/y) had a higher risk of CVD than those who had never smoked (HR, 2.39; 95%CI, 1.41-4.04), and active smokers (HR, 2.74; 95%CI, 1.69-4.43) had higher risk than exsmokers (HR, 1.49; 95%CI, 0.92-2.42) vs those who had never smoked. There were no significant differences for each category for the time since smoking cessation.

Multiple sensitivity analyses were performed with the other possible confounding factors listed in the Methods section and, for all factors, the calculated estimates were maintained in the same direction as the estimates obtained in the main analyses.

A history of other CVDs (eg, atrial fibrillation, heart failure, pulmonary embolism) was associated with higher CVD risk and a healthier lifestyle. However, the only habit directly associated with a history of other CVDs was no binge drinking. There was no other significant association for the other factors used in the score. Thus, the possible confounding effect of history of other CVDs was probably not relevant in this study (Table 5).

There was no significant interaction between sex and working hours (≥ 40h/wk; P for interaction = .951).

This prospective cohort study found an inverse association between a HLS score and CVD risk. This score combines traditional indicators of lifestyle habits (never smoking, physical activity, Mediterranean diet, BMI ≤ 22, and moderate alcohol consumption) with other factors not typically included in cardiovascular risk scores (television exposure < 2h/d, no binge drinking, taking a short afternoon nap, meeting up with friends more than 1h/d, and working at least 40h/wk).

Not smoking, performing physical activity, and having a healthy diet pattern are habits proposed by the American Heart Association to improve cardiovascular health.22 However, other lifestyle factors can effectively prevent CVDs.2

Other studies23,24 have analyzed the combined impact of various lifestyle habits. New investigations have been performed to develop cardiovascular health scores that integrate novel lifestyle habits for primordial prevention. The results obtained in our younger cohort of both sexes agree with those of previous studies that were limited to an elderly population25 or women.26

The Mediterranean diet score proposed by Trichopoulou et al.20 included alcohol intake. However, it was considered a separate lifestyle element because other studies have shown an independent effect of both moderate and excessive alcohol consumption on survival.13 In another analysis of this cohort,12 there was a positive and independent association between time spent watching television and all-cause mortality. A previous study found that participants who took a brief afternoon nap (< 30min/d) had lower risk of obesity (HR, 0.67; 95%CI, 0.46-0.96) than those who did not.11 Another of the factors included in this index was a BMI ≤ 22, due to previous findings that the incidence of metabolic risk factors increases above this threshold.27 Hu et al.28 determined that the most important risk factor for type 2 diabetes mellitus is a high BMI and even that a BMI from 23.0 to 24.9 was associated with higher risk of type 2 diabetes mellitus. In addition, in an exhaustive study recently published by the Global Burden of Disease group, with a sample size exceeding 68 million participants, an elevated BMI (from 22) was associated with death.29 Prospective studies have analyzed the protective effect of social relationships,14 whose biological mechanism might be based on inflammatory markers30 and could impact other healthy habits such as physical activity.31 The association between working hours and CVD is more controversial.32 Various socioeconomic factors have been proposed to explain the association between working hours and mortality. O’Reilly and Rosato15 found that professionals/managers who worked more than 40h/wk had lower risk of death than those who worked less time. Although these results appear to agree with those of recent work,33 other studies found higher risk of coronary heart disease and stroke in people who work more hours.34,35 Careful interpretation of these results is required due to the risk of bias from healthy workers. The socio-occupational homogeneity of the SUN cohort, together with the control for multiple confounding factors, reduces this possibility but does not eliminate it.

The difference between the separate effect of each of the indicators of healthy habits, only some of which are significant, and the combined effect of several factors is that the whole is probably more than the sum of its parts. In addition, similar results (with no significance for some individual elements but significance for the sum) have previously been published in the assessment of combination diet and cardiovascular risk scores20 or in the effect of various lifestyle factors on mortality.26

Unsurprisingly, adherence to various lifestyle habits that are beneficial individually would have a greater synergistic effect than a single habit in particular. The number of healthy habits should increase if individuals are concerned about maintaining ideal cardiovascular health or are encouraged to do so.36 Our findings stress this combined impact of various indicators of comprehensive healthy lifestyle habits. Even without consideration of classic variables key to cardiovascular epidemiology such as blood pressure, cholesterol, triglycerides, and glucose, a HLS is strongly associated with a reduced risk of primary CVD. This message is probably easier to convey to the general population and provides them with better control of their own health, that is, adequate training to improve their health (empowerment), and helps them to enjoy some much needed freedom from their laboratory values. All this allows us to advance beyond the clinical environment and expand the health promotion viewpoints according to the population strategy of cardiovascular prevention.5

In this cohort of university graduates, a HLS score constructed with 10 simple variables was associated with risk of primary CVD. These results indicate the importance of promoting a comprehensive HLS to maintain cardiovascular health and permit rapid patient evaluation in clinical practice. Further cohort and intervention studies are required to analyze populations at high cardiovascular risk and with participants from other socioeconomic and educational levels to confirm the results and extrapolate them to the general population.

The SUN study has received funding from the Spanish Government-Instituto de Salud Carlos III and the European Regional Development Fund (RD 06/0045, CIBERObn, grants PI10/02658, PI10/02293, PI13/00615, PI14/01668, PI14/01798, PI14/1764, and G03/140), the Regional Government of Navarre (45/2011, 122/2014), and the University of Navarre.

None declared.