Cardiovascular diseases (CVDs) encompass a range of conditions affecting the heart and blood vessels, including coronary artery disease and stroke, among others. These diseases remain the leading cause of mortality both in Europe1 and globally. Approximately 19 million individuals died of CVDs in 2020, constituting 32% of total global fatalities.2 Among these cases, 85% were attributed to heart attacks and strokes. While traditionally viewed as diseases of aging, there is growing evidence highlighting the impact of lifestyle factors on cardiovascular health,3 particularly among young adults.4

A recent publication by Castillo-García et al.5 in Revista Española de Cardiología offers a thorough epidemiological analysis of the incidence and prevalence of cardiovascular risk factors, as well as their correlation with lifestyle, among economically active individuals aged 18 to 30 years in Spain.

The results are based on a nationwide cohort of 78 421 Spanish young adults (36% female) aged 18 to 30 (27±2) years insured by an occupational risk prevention company.

The authors evaluated the incidence, prevalence, and association of lifestyle-related factors and cardiovascular risk factors. They analyzed 3 groups of variables that were measured by participants’ physicians at baseline and during yearly visits: a) demographic variables: age, sex, and socioeconomic status; b) lifestyle-related factors: weight (normal, overweight, or obesity), aerobic physical activity (active or inactive), self-reported sleep duration and quality (poor or good), smoking, and alcohol intake; and c) cardiovascular risk factors: prediabetes, diabetes, hypercholesterolemia, prehypertension, and hypertension.

Cardiovascular risk profile was defined as “healthy” when participants had none or 1 cardiovascular risk factor or “unhealthy” when they had 2 or more of these factors.

Prevalence was estimated based on the baseline measurements. Incidence was calculated based on follow-up, including participants with at least 2 examinations, from baseline to the last available assessment. Finally, the independent association between lifestyle and cardiovascular risk factors was analyzed based on a cross-sectional and a prospective analysis, using logistic regression. The analyses for each lifestyle factor and cardiovascular risk factors were adjusted by age, sex, socioeconomic status, calendar year, and the remaining factors.

At baseline, the authors found that 51% of the participants were physically inactive, 40% were overweight or obese, 36% were smokers, 23% had poor sleep, and 10% were alcohol consumers. A small fraction (3.5%) of the participants adhered to an optimal lifestyle (normal weight, being physically active, abstaining from drinking and smoking, and ensuring good sleep). Regarding cardiovascular risk factors: 10% had hypercholesterolemia, 15% had prehypertension/hypertension, and approximately 1% had prediabetes/diabetes. The prevalence of an “unhealthy” cardiovascular risk profile was considerable (18%).

In the prospective analysis, 44 776 participants showing a healthy cardiovascular risk profile at baseline were followed up for 2 to 5 (median 2) years. In most of the participants (98%), their cardiovascular risk profile was unchanged. The remainder (2%) of the participants transitioned to an unhealthy profile. The most frequent change was hypercholesterolemia (1.49%). Having all “healthy” lifestyle factors at baseline was shown to be correlated with a lower risk of shifting to an unhealthy cardiovascular risk profile (odds ratio [OR] reduction, 38%; 95% confidence interval [95%CI], −49% to −23%).

Regular physical activity was correlated with a lower odds of progressing to an unhealthy profile (OR reduction of 5%; 95%CI, −19% to −1%). Nevertheless, inactive, or sedentary lifestyles were especially prevalent at baseline. Young adults, often caught up in the hustle of work and social commitments, may neglect regular exercise.

Likewise, a normal weight also showed a lower odds of transitioning to an unhealthy profile (OR reduction of 39%; 95%CI, −49% to −30%). Overweight and obesity are usually the consequences of poor dietary patterns, characterized by high intake of processed foods, saturated fats, and sugary beverages. Dietary choices among young adults are often influenced by busy modern living conditions.4 Overweight and obesity are a cause for concern in Spain, particularly among individuals aged 19 years and older and start at a very early age (15.9% in the 3-8 years age bracket, and 11.6% in 9-18 year-olds).6

Although the remaining lifestyle factors were not associated with transitioning to an unhealthy profile, smoking was fairly prevalent among young adults, despite widespread awareness of its detrimental health effects. In this population, stressful work environments and peer influence may exacerbate tobacco dependence.7

Excessive alcohol consumption may also contribute to cardiomyopathy. Furthermore, alcohol consumption represents an additional source of calories leading to weight gain. Several studies have suggested that consuming moderate quantities of alcohol, particularly red wine, could be beneficial for cardiovascular health through various mechanisms, including changing lipid profile, insulin sensitivity and blood viscosity due to its antioxidant properties.8,9 Establishing a clear cause-and-effect relationship between alcohol consumption and cardiovascular health is challenging. In the case of red wine intake, other confounding factors must be considered. For instance, individuals who enjoy red wine may have higher incomes, which are often related to higher levels of education and a healthy diet. All this information may be misleading; for instance, it may be challenging to differentiate between moderate and excessive drinking, especially in young adults who may have a low perception of long-term negative outcomes, and a better tolerance to excessive drinking, including hangovers. Moreover, genetic epidemiology suggests that consuming any amount of alcohol is associated with increased cardiovascular risk.10

Sleep plays a crucial role in cardiovascular health, with inadequate sleep duration and quality linked to an increased risk of hypertension and obesity.11 The demanding schedules and lifestyle choices of young working adults often compromise their sleep patterns, leading to chronic sleep deprivation and disrupted circadian rhythms.

Another behavior not included in the study, yet relevant, is stress and psychosocial factors. The modern workplace can be a significant source of stress for young adults, impacting their cardiovascular health through several physiological and behavioral pathways. Chronic stress activates the sympathetic nervous system and hypothalamic-pituitary-adrenal axis,12 contributing to hypertension, inflammation, and dyslipidemia.13 Moreover, maladaptive coping mechanisms such as emotional eating and substance abuse may further exacerbate cardiovascular risk.

The study by Castillo-García et al.5 makes 2 relevant contributions. The first is that it provides a picture of both the lifestyle and cardiovascular risk profiles of Spanish young adults. The second is that an unhealthy cardiovascular risk profile is shown to be inversely associated with an optimal lifestyle. Even though the study did not aim to analyze the impact of cardiovascular risk factors on cardiovascular events, other studies have shown that a decline in lifestyle over time potentially results in a roughly one-third increase in the risk of both CVD occurrence and all-cause mortality.4

Preventive interventions and health promotion strategies addressing cardiovascular risk factors in working young adults are therefore crucial. They require a multifaceted approach encompassing individual, organizational, and societal levels. Workplace wellness programs, educational initiatives, and policy interventions can play pivotal roles in promoting healthier lifestyles and reducing the burden of CVDs in this population.14

Lifestyle factors strongly influence cardiovascular health outcomes in young working adults. By addressing modifiable risk factors such as physical inactivity, unhealthy diets, smoking, excessive alcohol consumption, stress, and sleep disturbances, major strides can be made in preventing CVDs and promoting overall well-being in this population. Collaboration among individuals, health care providers, employers, and policymakers is essential for implementing effective interventions and fostering a culture of cardiovascular health promotion in the workplace.15

To ensure a proper extrapolation of the findings of the study, it is important to address its limitations. First, lifestyle variables were collected using self-reported information. Self-reported data have been related to several reporting biases, including social-desirability bias and response-shift bias, both commonly seen in behavioral research.16 In addition, a short follow-up (median of 2 years) may introduce some bias toward an underestimation of the transition between lifestyle patterns and cardiovascular risk profile. Even so, the results obtained with these data are already worrisome.

In conclusion, the study by Castillo-García et al.5 shows that the prevalence of an unhealthy profile (ie, prediabetes/diabetes, prehypertension/hypertension, or hypercholesterolemia) is not uncommon in a Spanish cohort of economically active adults aged 18 to 30 years (18%). This profile is inversely associated with an optimal lifestyle (ie, normal weight, regular physical activity, no drinking/smoking, and good sleep), which was quite unusual (3.5% of the studied population). These findings are worrisome considering their potential impact on the incidence of CVD and premature mortality.