Shifts in Lifestyle Behavior Combinations and Cardiovascular Risk: Data from 20 Years of Follow-up (2002–2022)

Context: Specific combinations of a healthy and an unhealthy factor are widely understudied. Aims: The aim of this study was to assess shifts in lifestyle factors (smoking, physical activity, diet quality, and body weight), and their combinations, between 2002 and 2012, in relation to the 20-year cardiovascular disease (CVD) risk. Setting and Design: Prospective cohort study in Greece. Subjects and Methods: The sample was participants from the 20-year follow-up of the ATTICA study (2002–2022), who were initially free of CVD ( n = 1988). CVD was assessed in 2006, 2012, and 2022 according to the World Health Organization- International Classification of Diseases, 10 th revision. Statistical Analysis Used: Multi-adjusted Cox proportional hazards models, focused on participants who ameliorated their lifestyle habits in 2012 compared to those who maintained unhealthy lifestyle habits during the whole 2002–2012 period. Results: Improving smoking habits (quitting vs. always smoking) was associated with a 58% reduced CVD risk. Improving physical activity (starting physical activity vs. remaining inactive) was associated with 64% reduced CVD risk; this risk was modified based on other habits. Specifically, starting physical activity was associated with a 69% and a 76% reduced CVD risk in participants who maintained a low diet quality, and those who maintained an increased weight, respectively. Improvements in diet quality or body weight status were not linked to CVD risk. Conclusions: Smoking cessation and physical activity initiation should be encouraged even later in life to reduce CVD risk. Healthy dietary behaviors and a normal body weight should be introduced as early in life as possible.