Family matters: rethinking cardiovascular health promotion through a household lens

This invited commentary refers to ‘Parental influence on adolescents’ cardiovascular health: insights from household data in the Korea National Health and Nutrition Examination Survey’ by Y.J. Lee and S.Y. Hwang. https://doi.org/10.1093/eurjcn/zvaf049. Cardiovascular disease (CVD) risk assessment in adolescents is gaining increasing attention due to the early onset of risk factors that persist into adulthood. The presence of two or more risk factors during adolescence predicts the likelihood of cardiovascular events occurring within the next 10 years. Therefore, it is vital to evaluate CVD risk factors during adolescence, with particular attention to their simultaneous relationships.1 Our conceptualization of health continues to evolve as we recognize the intricate connections between genetic predisposition, developmental context and interactions with the environment.2 Lee et al.3 examined both the direct and indirect pathways through which parental factors—particularly physical activity, cardiovascular health, dietary habits, and socioeconomic status—affect adolescent CVD risk using path analysis. The findings indicated significant direct effects of parental physical activity on adolescent physical activity, of parental CVD risk on adolescent CVD risk, and of parental dietary habits on adolescent dietary habits. No other indirect or direct pathways reached statistical significance. This two-way dynamic illustrates that CVD risk is passed down not only through genetics but also through shared behaviours and social environments, reinforcing the need for prevention efforts that address the family as a whole. By drawing from a nationally representative dataset and employing robust path analysis, the authors make a significant contribution to our understanding of how parental health and behaviours can shape adolescent health trajectories. The study’s inclusion of dual-parent provides a comprehensive view of familial influence on adolescent health outcomes, especially that previous studies have only focused on maternal influence. These findings contribute important insights to previous studies demonstrating how health behaviours are transmitted within families.4 Parents’ own dietary behaviours serve as a model for their children. For instance, parents who consume a variety of fruits and vegetables and maintain healthy eating habits are more likely to use positive reinforcement feeding practices, which in turn encourage similar behaviours in their children.5 Additionally, the home food environment, showing availability of various food options as well as parental involvement in meal planning and preparation, plays crucial roles in shaping children’s dietary habits.6 By confirming this direct correlation, the study adds to a growing consensus that interventions to improve adolescent health must account for family influences. Both maternal and paternal influences were found to be significant, challenging the tendency to focus on one parent over the other in adolescent health interventions. The data were derived from a secondary analysis of information collected between 2015 and 2019, before the onset of the COVID-19 pandemic. This context is important, as lifestyle behaviours shifted significantly since then. Pre-COVID, there was growing awareness of healthy living, with observed declines in smoking and greater engagement in physical activity. However, during the pandemic, increased sedentary behaviour, mental health challenges, disrupted medical follow-ups and poorer glycaemic control re-emerged as risk factors.7 Post-pandemic, the rise of digital health technologies, including mobile applications and artificial intelligence driven health tools, transformed how individuals track and manage their cardiovascular health.8 These shifts should be considered in future studies to reflect contemporary influences on adolescent and family health behaviours. While the path diagram was simplified, it is important to acknowledge that the topic of adolescent CVD risk is complex and multi-faceted, with several key variables omitted. The study thoughtfully examined parental influence; however, it did not account for the significant role of peers and broader social environments in shaping adolescents’ lifestyle behaviours—factors that are critical when assessing CVD risk.9 Another relevant element to be considered within the model is a family history of premature CVD, a well-established, non-modifiable risk factor that captures both genetic predisposition and shared environmental exposures.10 Additionally, psychosocial influences such as chronic stress and poor sleep quality were not considered, despite strong evidence from the American Heart Association highlighting their impact on cardiometabolic health.11,12 Incorporating these dimensions—peer influence, family history, and psychosocial factors—would support a more comprehensive understanding of adolescent CVD risk and contribute to the development of more holistic and effective prevention strategies. Future research should consider longitudinal designs to explore causality and further investigate how additional factors—such as economic hardship, digital media use, and psychosocial health—mediate these familial health patterns.13 Integrating qualitative perspectives could enhance our understanding of the ‘how’ and ‘why’ behind these associations. Moreover, the observed lack of a direct relationship between adolescent diet/physical activity and CVD risk may suggest a high correlation between these variables. Therefore, a serial pathway, rather than a parallel one, might be more appropriate. However, clarifying the theoretical sequence of variables remains critical for accurate modelling.14 This study offers important insights into how parental behaviours influence adolescent cardiovascular health. Its dual-parent focus and emphasis on modifiable lifestyle factors strengthen the case for family-centred interventions. As non-communicable diseases and lifestyle-related risks rise in Korea and globally, the study’s methodology provides a replicable model for culturally tailored public health strategies that reflect diverse family structures and sociocultural norms. To enhance understanding of adolescent cardiovascular risk, future research should include non-modifiable factors (like genetics and family history), improve risk assessment beyond body mass index, and address contemporary influences such as the post-COVID health landscape and digital health trends.15 A multi-layered prevention approach—engaging schools, families, and healthcare systems—is essential for reducing CVD risk from adolescence into adulthood. This study calls for a paradigm shift: from individual-focused models to household-informed strategies. For the cardiovascular nursing community, it presents both a challenge and an opportunity to advocate for and implement family-based care as the foundation of cardiovascular health promotion. T.A. (Tamar Avedissian): Conceptualization [lead], Writing—original draft [lead], Writing—review & editing [lead], K.O. (Krystel Ouaijan): Conceptualization [equal], Writing—original draft [equal], Writing—review & editing [equal], and A.M. (Angela Massouh): Conceptualization [equal], Writing—original draft [equal], Writing—review & editing [equal]. All authors have read and approved the final manuscript. All authors have declared that no funding or financial support was received from any organization for the submitted work. No data used in preparation of the manuscript.