Small combined lifestyle changes lower cardiovascular event risk, finds study

By Sasha Ellery BM BCh

Modest concurrent differences in sleep, moderate-to-vigorous physical activity and diet quality are associated with substantially lower risk of major adverse cardiovascular events (MACE), according to a prospective analysis published in the European Journal of Preventive Cardiology.

Researchers followed 53,242 participants (median age 63 years) over an eight-year period. Sleep duration and physical activity were measured using wrist accelerometers, and diet quality was assessed using a 10-item diet quality score. During follow up, 2034 MACE occurred, including 932 myocardial infarctions, 584 strokes and 518 heart failure events.

Professor Emmanuel Stamatakis, senior study author and Professor of Physical Activity, Lifestyle and Population Health at Monash University, Melbourne, said, ‘While sleep, physical activity and nutrition are each known to influence cardiovascular disease risk, they have traditionally been studied in isolation, despite being deeply interconnected in daily life. Poor sleep disrupts appetite regulation, physical activity improves sleep quality and diet affects energy levels for exercise.’

He told Medicine Today the researchers set out to examine, for the first time, how combined variations across all three behaviours related to the risk of MACE.

Compared with participants in the lowest tertiles for all three behaviours, those with the most favourable combined profile had a 57% lower risk of MACE. This profile comprised 8.0 to 9.4 hours of sleep per day, 42 to 104 minutes per day of moderate-to-vigorous physical activity and a dietary quality score of 32.5 to 50.0.

The researchers also reported that the combination of an additional 11 minutes of sleep per day, an additional 4.5 minutes more of moderate-to-vigorous physical activity and 3 extra diet quality score points (one-quarter cup of vegetables/day) was associated with a 10% lower risk of MACE.

‘Achieving the same risk reduction through sleep alone required an additional 30 minutes per night,’ Professor Stamatakis said. ‘Spreading modest changes across three behaviours substantially lowers the burden on any single one, making the goal far more achievable,’ he added.

‘Assuming causal relationships, the potential clinical significance seems to be substantial, based on these results, particularly for patients who find standard lifestyle guidelines daunting. Current recommendations typically call for 150 to 300 minutes of moderate-to-vigorous activity weekly, seven to eight hours of sleep nightly and broad dietary improvement, targets many patients regard as unachievable,’ he said.

Physical activity contributed most strongly to the overall association, followed by sleep then diet. No statistical synergistic interaction was observed between the three behaviours. The researchers noted the observational design, possible residual confounding and the use of self-reported diet data as limitations of the study.

These findings supported a multibehaviour approach in general practice, Professor Stamatakis explained.

‘Rather than prescribing major transformation in one area, GPs can encourage manageable, simultaneous improvements across all three domains. This approach is not only more achievable but likely more sustainable, as the behaviours are interdependent and improvements in one tend to support improvements in the others.’

Eur J Prev Cardiol 2026; 00: 1-15. https://doi.org/10.1093/eurjpc/zwag141.