Physicians' Academy for Cardiovascular Education

Improving health lifestyle in middle age lowers atherosclerosis risk

Literature - Spring B et al., Circulation. 2014 - Circulation. 2014 Jul 1;130(1):10-7


Healthy Lifestyle Change and Subclinical Atherosclerosis in Young Adults: Coronary Artery Risk Development in Young Adults (CARDIA) Study

Spring B, Moller AC, Colangelo LA, et al.

Circulation. 2014 Jul 1;130(1):10-7


A large body of epidemiological evidence shows an association between the sustained presence of healthy lifestyle factors and reduced risk of myocardial infarction and CHD mortality [1-4]. Behavioural Risk Factor Surveillance data show, however, that only 5% of adults meet heart-healthy standards for all of the healthy behaviours, namely physical activity, fruit and vegetable consumption and non-smoking [5].
Most people have at least one unhealthy behaviour when reaching young adulthood, thus it is important to know whether lifestyle changes in adulthood still affect cardiovascular health.
Therefore, data from the Coronary Artery Risk Development in Young Adults (CARDIA) study [6] were used to determine whether health behaviour changes earlier in adulthood are associated with the burden and extent of subclinical atherosclerosis (coronary artery calcium: CAC and carotid intima media thickness: cIMT) in middle age. Baseline characteristics were obtained when participants were 18-30 years old. Data obtained 20 years later were analysed. A healthy lifestyle factor (HLF) score was used that summed the number of different healthy behaviours, ranging from 0 to 5, where 5 is the most favourable situation.

Main results

  • After correction for multiple common CV risk factors, a change in HLF was associated with significantly altered odds of having CAC at year 20 (OR: 0.85, 95%: 0.77-0.94). A decrease in HLF over the 20 years was associated with higher prevalence and greater odds of CAC.
  • To assess whether HLF change has a uniform linear effect for both healthy and unhealthy lifestyle changes, positive and negative changes were entered as independent variables. Each additional healthy HLF change lowered the odds of detectable CAC (OR: 0.85, 95%CI: 0.74-0.98), while each unhealthy HLF change increased the odds of CAC (OR: 1.17, 95%CI: 1.02-1.33).
  • In the model considering number of healthy and unhealthy HFLs, showed that healthy HFL change predicted significantly lower cIMT at year 20, on 2 out of 3 indicators (common carotid IMT: β=-0.005, P=0.12, carotid bulb IMT: β=-0.024, P=0.001, internal carotid IMT, β=-0.015, P<0.01). Negative HLF change on the other hand predicted significantly higher carotid IMT at year 20 on all 3 indicators (common carotid IMT, β=0.009, P=0.001; carotid bulb IMT, β=0.020, P<0.01; internal carotid IMT, β=0.012, P<0.05).
  • When considering the top 80% of individual HLFs, maintaining non-smoking and maintaining a nonoverweight body weight predicted reduced odds of CAC>0 and IMT at year 20. Baseline and change in physical activity and alcohol intake were not significantly associated with CAC or IMT.


Change in HLFs from young adulthood to middle age is associated with the presence and extent of subclinical atherosclerosis , measured after 20 years of follow-up. This association was irrespective of demographics, baseline number of HLFs and medication. The effects associated with healthy lifestyle change were nearly identical in magnitude to those associated with unhealthy change.
These findings suggests that, even after a person reaches young adulthood and independent of the health lifestyle at this stage, improving lifestyle can still lower the odds of coronary atherosclerosis. Conversely, quitting healthy behaviour may increase risk, thus continued promotion of a healthy lifestyle is needed.
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