Cardiovascular Health in the Transition From Adolescence to Emerging Adulthood: A Scientific Statement From the American Heart Association

Abstract

Cardiovascular disease remains a leading cause of death in the United States, with an alarming rise in the proportion of young adults experiencing cardiovascular events. Many adolescents enter adulthood with significant cardiovascular disease risk factors. This scientific statement addresses the critical need for cardiovascular health promotion during emerging adulthood, a transitional stage between the ages of 18 and 25 or 29 years of age. We discuss the significance of social determinants of health and the interplay between individual‐level risk factors and developmental changes, including shifts in substance use, social connections, and emotional well‐being. We conclude by outlining strategies for optimizing cardiovascular health promotion and disease prevention, underscoring the importance of primordial prevention, early intervention, and tailored approaches to address the unique needs of emerging adults. Addressing these multifaceted factors is crucial for mitigating the burden of cardiovascular disease risk factors among emerging adults and promoting long‐term cardiovascular well‐being.

Cardiovascular disease (CVD) is the leading cause of death in the United States, and alarmingly, an increasing proportion of young adults have experienced acute myocardial infarctions and ischemic stroke, often related to risk factors that begin early in life. ¹ , ² For some, cardiovascular health (CVH) can be good in childhood and early adolescence and tends to worsen in late adolescence to early adulthood, necessitating aggressive prevention and timely treatment of risk factors. ³ , ⁴

Emerging adulthood, defined as 18 to 25  years of age and sometimes up to 29  years of age, is a critical time for gaining independence and the skills necessary to make decisions in every area of life, including health‐related decisions (Table 1). ⁶ , ⁸ , ⁹

Table 1.

Key Definitions

Term	Age range, y	Notes on the definition
Adolescent	12–21	American Academy of Pediatrics definition, with ages 18–21 y defined as late adolescence 5
Emerging adult	18–25 (or 29)	Described by J. J. Arnett in 2000 in response to shifting trends of when adolescents transition to independence. Also supported by neurobiological evidence showing the continued maturation in decision‐making and brain development reaches adult levels closer to age 30 y 5 , 6
Young adult	18–44	The cutoff age of young adulthood varies widely. Age 44 y is often used but may extend up to age 55 y on the basis of commonly used cutoffs for premature CVD 7

Emerging adulthood represents one of the most diverse life stages, which includes establishing a career path, forming social and intimate connections, exploring identity and values, and transitioning from dependence to independence. ⁹ Emerging adulthood is also a period of continued growth in neurodevelopmental capacities such as future orientation and goal‐directedness. ⁵ , ⁹ Many youth enter adulthood with significant CVD risk factors, and emerging adulthood presents a critical opportunity to engage them in health promotion and disease prevention in developmentally appropriate ways. In this scientific statement, we highlight psychosocial, behavioral, and physiologic considerations for CVH in emerging adults and describe opportunities for interventions tailored to the developmental and psychosocial risk factors most relevant to promoting CVH in emerging adulthood.

CVD Risk Factors and Emerging Adulthood

Population‐Level CVD Risk Factors

In addition to worsening CVH, emerging adults are particularly susceptible to the impact of social factors on their CVH. Because they are often transitioning from being supported by parents and guardians to greater financial and social independence, social determinants of health (SDOHs) may play a greater role in their health outcomes.

SDOHs are summarized as the conditions we are born into; where we grow, play, and work; and the larger structural and social systems that determine these conditions. Indeed, SDOHs provide an essential context for understanding CVH trajectories and mediate inequities in CVD outcomes. ¹⁰ , ¹¹ , ¹² Figure 1 depicts considerations for SDOHs and CVH in the transition into adulthood in the 5 domains of the Centers for Disease Control and Prevention's SDOH framework: health care access and quality, neighborhood and built environment, education access and quality, economic stability, and social and community context. ¹⁰ Factors such as lack of insurance coverage and limited health care access are significant barriers to achieving desired health outcomes. ¹³ Emerging adults make up the largest group of the 27  million uninsured adults in the United States; 14.9%, 19 to 25  years; and 13.9%, 26 to 34  years. ¹⁴ The Affordable Care Act extended dependent coverage through age 26 years, allowing emerging adults greater time to obtain their own insurance coverage. ¹⁵ However, the extension benefits emerging adults only if their parents have insurance coverage. Most states expanded Medicaid access under the Affordable Care Act, providing insurance coverage to many low‐income emerging adults, but as of 2021, another 1.8  million young adults (aged 19–34  years) could potentially have coverage if the remaining states expanded access. (Note: Since 2020, 4 states have expanded Medicaid. ¹⁴ ) For emerging adults without insurance coverage, obtaining insurance coverage is associated with a greater likelihood of blood pressure control, particularly among adults who reside within high‐deprivation communities. ¹⁵ , ¹⁶ Although the Affordable Care Act allowed for greater access to preventive care, recent proposed changes to Medicaid coverage may negatively impact preventive care and the CVH of emerging adults. ¹⁵ , ¹⁶ , ¹⁷

Figure 1. Social determinants of cardiovascular health in emerging adulthood.

ACEs indicates adverse childhood experiences; CVD, cardiovascular disease; and IPV, intimate partner violence.

Neighborhood‐level deprivation, early exposure to segregated neighborhoods, unfavorable environmental factors, and even unfavorable neighborhood perception are associated with CVH and subclinical CVD. ¹⁸ , ¹⁹ In the CARDIA (Coronary Artery Risk Development in Young Adults) study, neighborhood residential segregation in emerging adulthood accounted for 32% of the racial difference in premature CVD among women. ¹⁸ Emerging research suggests that emerging adults in underresourced neighborhoods have an attenuated nocturnal blood pressure dip. ²⁰ Emerging adults who reside within segregated neighborhoods may experience poorer CVH, beginning at younger ages, compared with those who reside within more diverse communities. ¹⁸ , ¹⁹ , ²⁰

Although educational attainment is an individual‐level social risk factor, neighborhood and community factors, policies, and social forces also influence it. ²¹ , ²² School contexts, quality of education received, available health resources, and other dimensions of education are associated with health outcomes such as depression and self‐rated health, but CVH is underexplored. ²¹ , ²² , ²³ , ²⁴ However, simulation modeling has demonstrated the potential for school quality to reduce racial inequities in obesity, partly through social network effects. ²⁵ Educational attainment is also strongly correlated with CVH, and while limited, data suggest that emerging adults who attain a 4‐year or advanced degree have a 3 to 5 times higher likelihood of good CVH (defined as having 5 of 7 CVH metrics) compared with high school graduates. ²⁶ Unfortunately, the boost in CVH associated with education is not universal. At age 31  years, Black college graduates from financially disadvantaged backgrounds have a 33% higher risk of metabolic syndrome than Black college graduates from advantaged backgrounds, ²⁷ suggesting the profound impact of early‐life adversities and the need for comprehensive approaches to address CVH.

In the United States, 40% of all college students attend 2‐year college, ²⁸ but unfortunately, attaining a 2‐year degree is not associated with the CVH benefits of attaining a 4‐year degree. Compared with students at 4‐year universities, community college students are more likely to have high social needs (eg, food insecurity) and are less likely to have access to health care. ²⁹ , ³⁰ Data regarding the CVH of the >3  million “disconnected youth” who are in neither educational nor employment institutions ³¹ or those who follow other postsecondary pathways, such as vocational schooling and apprenticeships, are extremely limited.

The transition from adolescence to emerging adulthood also comes with increased awareness of social conditions and hierarchies and potentially increased exposure to racism, sexism, and other forms of discrimination. Although many studies investigate interpersonal experiences of racism, most experiences of racism have an institutional component, and existing measures may not fully capture these experiences. ³² It should be acknowledged that structural forces, such as racism, are part of the historical and social context that continues to drive inequities in health care access and the quality of care provided, a vexing problem that plagues health care systems and hinders health promotion and disease prevention efforts. ³³

Individual‐Level CVD Risk Factors

Pooled data from 5 cohort studies estimated age 17 years as a significant inflection point when CVH scores decline. ³ In the CARDIA study, two‐thirds of participants had low or moderate CVH (based on Life's Simple 7) at enrollment in 1985 to 1986 when they were aged 18 to 30  years, ³⁴ and on the basis of national trends, the proportion of emerging adults with moderate or worse CVH is higher now, especially among certain racial and ethnic populations. ³⁵ , ³⁶ Cardiovascular‐kidney‐metabolic (CKM) syndrome is a framework for describing the bidirectional relationship between kidney–cardiovascular disease and metabolic disease. The CKM framework can be applied to all ages, including emerging adults, and progresses from stage 0, no CKM risk factors, to stage 4, clinical CVD. ³⁷ According to a recent analysis of National Health and Nutrition Examination Survey data, stage 0 CKM was present in only 17% of adults aged 20 to 44  years, and that number drops to 7% and 13% for Mexican American young adults and Black young adults, respectively. ³⁸ Currently, there is no consensus on when to begin screening for CKM, but prevention is critical, and once concern for elevated blood pressure, hyperlipidemia, or other risk factors arises, evidence‐based management is essential for the prevention of CVD and multiorgan dysfunction.

Pivotal pathobiological and prospective studies highlight the prognostic implications of elevated low‐density lipoprotein cholesterol early in life with a greater risk of death from coronary heart disease and all causes. ³⁹ , ⁴⁰ In the CARDIA study, the cumulative exposure to low‐density lipoprotein cholesterol beginning in young adulthood (aged 18–30  years) through 15 to 20  years follow‐up was associated with subclinical coronary calcium. ⁴⁰ Diabetes prevalence has increased with the rising prevalence of obesity. ³⁶ , ⁴¹ The body's ability to regulate blood glucose levels declines with age, with the largest decline between ages 17 and 39  years, ⁴² which has been associated with increased risk of CVD. Excess adiposity, low levels of physical activity, and poor dietary habits also adversely impact glucose regulation, leading to a higher risk of impaired glucose metabolism during the transition from adolescence to young adulthood. ⁴² Alignment of pediatric and adult diagnostic and management criteria and enhanced prevention efforts could support improved outcomes across each of these risk factors (Table 2). ⁴³ , ⁴⁴ , ⁴⁹

Table 2.

Summary of Suggested Risk Factor Screening

Risk factor	Adolescents	Adult	Estimated prevalence
Hypertension	Percentile based until age 13  y; age ≥13  y follows the adult criteria	≥130/80  mm  Hg (office blood pressure)	18–39  y 22.4% 45
Obesity	Percentile based	Body mass index: ≥30  kg/m2	18–24  y 19.5% 46
Hyperlipidemia	Routine screening is recommended between 9–11 and 17–21  y of age	Serum cholesterol ≥240  mg/dL; low‐density lipoprotein cholesterol ≥190  mg/dL	20–39  y 7.5% 47
Diabetes	Hemoglobin A1c ≥6.5% or fasting plasma glucose ≥126  mg/dL; 2‐h plasma glucose during oral glucose tolerance test; random plasma glucose ≥200  mg/dL	Hemoglobin A1c ≥6.5% or fasting plasma glucose ≥126  mg/dL; 2‐h plasma glucose during oral glucose tolerance test; ≥200  mg/dL; random plasma glucose ≥200  mg/dL	18–44  y 4.8%*, 48

^*Prevalence reported among 18‐ to 44‐year‐olds.

Lifestyle Factors and Emerging Adulthood

Emerging adulthood is a high‐risk period for undesired weight gain, due to life changes, such as moving away from their childhood home, gaining financial independence, and new responsibilities. The prevalence of young adults with a body mass index of ≥30 is 21%, ⁴⁶ and it is currently estimated that 57% of children aged 2 to 19  years will have obesity by the age of 35  years. ⁵⁰ Convenience foods contribute to degeneration in cooking skills and, when combined with aggressive marketing of less nutritious foods to young adults, may lead to altered dietary decision‐making and shifts in dietary patterns toward more unhealthful foods. ⁵¹ , ⁵²

The increase in obesity with age can also be partly attributed to increases in sedentary behavior and concomitant declines in physical activity and overall diet quality. More than half (55%) of adolescents report not being physically active for at least 60  minutes most days of the week, with the least active groups being female (64%) and Asian youth, Hispanic youth, and Black youth (59%–65%). ⁵³ Physical activity levels shift somewhat during young adulthood, although data are inconsistent depending on social context. Some studies note increasing physical activity during the transition to emerging adulthood, while others suggest the opposite. ⁵⁴ , ⁵⁵ Declines in physical activity and related increases in weight gain may be due to decreases in active transportation (eg, biking, walking) and sports participation, with concomitant increases in sedentary behaviors. Both of these areas are opportune for future intervention. ⁵⁶ , ⁵⁷

Sleep is the newest essential behavior for optimal CVH. ⁵⁸ The amount of sleep an individual needs slowly decreases over time, resulting in adolescents (aged 13–18  years) being recommended to sleep between 8 and 10  hours to adults at least 7  hours. Due to the higher sleep needs during the adolescent period, 1 in 2 adolescents are classified as obtaining insufficient sleep, ⁵⁹ and there are known racial and ethnic disparities documenting poorer sleep among African American youth and Hispanic youth compared with White youth. ⁶⁰ Insufficient sleep during adolescence has been associated with higher CVD risk including greater adiposity, blood pressure, cholesterol, insulin resistance, inflammation, and metabolic syndrome during adolescence as well as later in life. ⁶¹

Developmental Considerations for Emerging Adult CVH

Alcohol, Tobacco, and Substance Use

Historically, the initiation of tobacco use has occurred in middle and high school, but data from the National Survey on Drug Use and Health shows that initiating tobacco use between ages 18 and 23  years has doubled from 20.6% in 2002 to 42.6% in 2018. ⁶² Electronic cigarettes have become the most common type of tobacco product used since 2014, and subsequent increases in use through 2018 have negated prior gains in overall use of tobacco products. ⁶³ The vascular effects of electronic cigarettes appear similar to more traditional forms of tobacco products, specifically combustible cigarettes, ⁶⁴ but long‐term cardiovascular effects are less established. ⁶⁴ , ⁶⁵ A tailored approach to prevent the escalation of tobacco and substance use among early initiators may be warranted, including addressing the underlying need, such as mood management or emotional regulation, but there is also a need for rigorous testing of tobacco cessation interventions tailored for emerging adults. ⁶⁶ Quitline interventions, texting, and web‐based interventions have shown promise for tobacco cessation at 6  months after intervention or reducing cigarette use, but the use of pharmacotherapy‐supported cessation interventions with emerging adults has been understudied. ⁶⁶

A growing body of evidence suggests the benefits of brief universal interventions to decrease alcohol, cannabis, and other substance use disorders among emerging adults. A large‐scale intervention involving family‐focused and school‐based interventions across sixth and seventh grades delivered in 28 public school districts in 2 states found significant relative reductions across all types of substances (from 16.1% to 51.8% for past‐year marijuana use and past‐year methamphetamine use, respectively), as well as slower growth in substance use in the intervention group at both 4.5‐ and 14‐year follow‐ups. ⁶⁷ , ⁶⁸ The potential of these interventions may be especially important given emerging data demonstrating dose–response relationships between certain substances and cardiovascular events. An analysis of data from the Behavior Risk Factor Surveillance Survey (2016–2017) identified a dose–response relationship between marijuana use and stroke among emerging and young adults aged 18 to 44  years. ⁶⁹ Results indicated that marijuana use in the past 30  days versus no use was associated with 1.8‐fold higher odds of stroke; moreover, adults who reported frequent use (>10  days/month), relative to nonusers, demonstrated 2.4‐fold increased odds of stroke. ⁶⁹ Ultimately, more data are needed to refine associations between substances such as marijuana with cardiovascular events, as well as to determine potential health intervention–related targets.

Preconception, Pregnancy, and Parenting

In 2022, the average age at first birth was 27.4 years, a record high for the United States. ⁷⁰ The rising age at first birth and concurrent decline in the teen birth rate create a significant window of opportunity to intervene on preconception CVH. ⁷⁰ , ⁷¹ The CVH of women is declining; between 1994 and 2014, <1 in 10 pregnant women had high CVH. ³⁴ Suboptimal CVH is a notable precursor to adverse pregnancy outcomes. ⁷¹ , ⁷² Moreover, the fact that 85% of pregnancy‐capable people will give birth during their reproductive years, a documented increase in adverse pregnancy outcomes (eg, 33% increase in gestational diabetes from 2011 to 2017, 102% increase in hypertensive disorders in pregnancy from 2009 to 2017), ⁷³ , ⁷⁴ and the strong association between adverse pregnancy outcomes and future CVH suggest that preconception and interconception health must be prioritized during adolescence and emerging adulthood. Three American Heart Association (AHA)‐commissioned scientific statements are available for an in‐depth review of the evidence on pregnancy outcomes and CVH, pathophysiological mechanisms, and the need for interventions across the life course to disrupt the intergenerational transmission of poor cardiovascular health (“Adverse Pregnancy Outcomes and Cardiovascular Disease Risk: Unique Opportunities for Cardiovascular Disease Prevention in Women,” “Optimizing Prepregnancy Cardiovascular Health to Improve Outcomes in Pregnant and Postpartum Individuals and Offspring,” and “Opportunities in the Postpartum Period to Reduce Cardiovascular Disease Risk After Adverse Pregnancy Outcomes”). ⁷¹ , ⁷⁵ , ⁷⁶

Social Connectedness, Support, and Emotional Well‐Being

Beginning in adolescence and continuing into emerging adulthood, peer relationships, including friendships and intimate relationships, gain centrality in the lives of youths. ⁶ , ⁸ However, relatively little research focuses on social isolation, loneliness, and CVH at this stage of adulthood. Similarly, few intervention studies have explored how to use adolescent and young adult peer relationships and social networks to promote behavioral change, such as tobacco cessation or physical activity. ⁷⁷

Trauma exposure, including adverse childhood experiences as well as sexual and intimate partner violence, is associated with greater CVD risk in adulthood (odds ratio [OR], 1.36 [95% CI, 1.27–1.46]; and OR, 1.25 [95% CI, 1.11–1.40], respectively). ⁷⁸ , ⁷⁹ Forty percent of intimate partner violence victims report first exposure before the age of 25  years. ⁸⁰ Social support may be particularly important for emerging adults with trauma histories. Among college women with lifetime sexual assault history, greater perceived social support from friends was associated with lower posttraumatic stress disorder symptoms 1 month later. However, this association was weakened among women who also reported using substances to cope, which may be encouraged in some social networks. ⁸¹

Interventions targeting emotion regulation among emerging adults may have benefits on heart‐healthy behavior, although existing research predominantly involves small college samples. College students participating in a 9‐week pilot mindfulness program reported improved physical and mental health; notably, improvements in physical health were due to improved sleep (not physical activity or diet). ⁸² In another pilot randomized controlled trial, college smokers who were randomized to cognitive behavioral therapy (versus nutrition focused program) reduced smoking intensity by 50% and maintained reductions at 3 and 6 months after intervention, although there were no differences between intervention groups at follow‐up time points. ⁸³ Among a sample of 150 emerging adults with overweight or obesity and serious mental illness (eg, schizophrenia, bipolar disorder), ⁸⁴ both group‐based lifestyle intervention and mobile health coaching led to improvements in CVD outcomes over 12  months, including weight loss and improved cardiorespiratory fitness, although no differences emerged between groups. Finally, middle‐aged adults with trauma histories who also reported stronger emotion regulation skills (reappraisal versus suppression) demonstrated lower systemic inflammation, indicating emotion regulation as a potential intervention target in emerging adulthood. ⁸⁵ , ⁸⁶ Emotion regulation skills may help improve cardiovascular outcomes. Moreover, they may be feasible to deliver via mobile health interventions, which could be more scalable than in‐person or group‐based formats.

Social Media and Digital Health Literacy

Nearly all teens report using social media, and the frequency of use increases as they enter adulthood. ⁸⁷ Social media is unlikely to decrease in relevance, despite the evidence that suggests too much time on social media negatively impacts physical and emotional health. ⁸⁸ , ⁸⁹ , ⁹⁰ There are opportunities to leverage an activity that is already part of daily routines as a tool for intervention delivery. A recent systematic review found that interactive social media interventions may significantly increase physical activity and fruit and vegetable intake, but study outcomes are mixed. ⁹¹ Social media interventions can face the same challenge as other interventions; participation and engagement with the content decrease significantly over time, and difficulties measuring engagement (eg, more passive engagement such as viewing content but not liking or leaving a comment). ⁹² , ⁹³ When social media was included as 1 component of multicomponent interventions, the acceptability of the social media component was sometimes lower than other components, such as text and email. ⁹² One explanation might be that behavioral change can be a sensitive topic for emerging adults, who are already intensely aware of peers' opinions, and participation in a behavioral change intervention may be socially undesirable. ⁹⁴ The EARLY (Early Adult Reduction of Weight Through Lifestyle Intervention) consortium consisted of 7 weight‐related clinical trials for young adults lasting 24  months each, with all interventions including a technology element such as texting, social media, and smartphone apps. ⁹⁵ Despite the incorporation of technology and the wide use of social media among young adults, the results were variable, challenging the notion that technology alone is the ultimate solution for reaching young adults and effecting behavioral change. Another consideration is the rapid increase in social media platforms. Most published social media interventions use Facebook or an investigator‐developed platform, but Facebook is used the least by emerging adults, with newer platforms being more popular (eg, TikTok, Instagram). ⁸⁷ The rapidly growing technology and introduction of new platforms will challenge interventions seeking to use social media as a delivery strategy, but social media may be a channel for public health messaging given its widespread use and accessibility.

Nearly 100% of teens use the Internet daily, and 46% report almost constant use of the Internet, up from 24% in 2014. ⁸⁷ Emerging adults, specifically Generation Z (born late 1990s–early 2000s), are more likely to seek health information online than other generations. ⁹⁶ Health professionals and educators alike are charged with beginning digital health literacy conversations with youth and emerging adults, such as evaluating website credibility and analyzing media messages and advertisements for mis‐ and disinformation. ⁹⁷

Optimizing CVH Promotion and Disease Prevention

Achieving the AHA goal of healthier, longer lives requires concerted efforts at health promotion and disease prevention in all stages of life. Focusing on health versus the traditional disease‐focused model is essential for preserving CVH for the entirety of a person's life span, particularly during the transition from adolescence to adulthood. Primordial prevention to avert the development of CVD risk factors will require policy and population‐level interventions (Figure 2). Examples of population‐level interventions include media campaigns, health policy, and environmental supports (eg, tobacco‐free buildings). These types of interventions were used successfully to reduce cigarette use among young people and increased social engagement about rejecting tobacco and may be needed now to address contemporary issues related to noncombustible tobacco use (eg, vaping) and other risks, such as dietary behaviors. ⁹⁸ , ⁹⁹

Figure 2. Optimizing CVH promotion and disease prevention.

ASCVD indicates atherosclerotic cardiovascular disease; CVD, cardiovascular disease; and CVH, cardiovascular health.

Policy

Shifting behavioral norms, for example, around increasing physical activity, reducing tobacco use, and improving access to healthy, affordable foods is complex but will be most effective when interventions are directed at multiple levels. Changes in public policy include evidence‐based approaches to reduce commercial tobacco use and nicotine addiction, including increasing tobacco excise taxes, removing flavored tobacco products from the marketplace, increasing the sales age to 21  years, and restricting tobacco retail outlets around youth‐serving institutions. ¹⁰⁰ , ¹⁰¹ For physical activity, policy and systems change approaches might include active living infrastructure in communities (eg, bike lanes, sidewalks), increasing access to free or low‐cost adult sports programs through municipal parks and recreation, or funding to support physical activity and fitness programs at community colleges, an approach that could also decrease stress while improving physical and mental health. ³⁰ Access to healthy foods would include healthy school meals for all as a strategy to acclimate the palates of children and adolescents to the rich flavors of unprocessed foods, warnings on sugar‐sweetened beverages, ¹⁰² and adequate funding for the Supplemental Nutrition Assistance Program and the Special Supplemental Nutrition Program for Women, Infants, and Children. Private public initiatives could include addressing the commercial determinants of health, including shelf placement and promotion of healthy foods in retail outlets, increasing delivery and availability of healthy foods into underresourced communities, and mobile food trucks or other healthy retail options in rural or underresourced communities. ¹⁰⁰ , ¹⁰¹

Programs should have the ability to be implemented quickly and at a low cost, using strategies that promote long‐term sustainability with community input and address structural inequities. ¹⁰¹ , ¹⁰³ Too many programs and research protocols conducted in clinical settings have constrained inclusion/exclusion criteria to improve study outcomes but likely exclude people who need these programs the most. This research and program implementation needs to be multidisciplinary and include implementation scientists, those with lived experience, and other expertise to ensure the program results can be disseminated back to the populations that need them the most. ¹⁰⁴

CVD Prevention

Primary prevention seeks to intervene before disease onset in developmentally appropriate ways (Table 3). Although recent findings from a school‐based CVH promotion intervention were disappointing, the potential for population‐level improvements is worth further attempts to incorporate school‐based interventions as part of broader ecologic approaches that include policy change. ¹⁰⁶ Studies also suggest that interventions focused on improving food and nutrition literacy combined with enhancing cooking skills during the transition to adulthood are valuable and may have long‐term benefits for nutrition. ¹⁰⁷ Many adolescents and emerging adults may be unaware that unhealthy weight control behaviors such as dieting promote cycles of weight loss and weight regain. ¹⁰⁸ , ¹⁰⁹ Expectation management for body shape and size, self‐acceptance of diverse body shapes, emphasis on diet quality, and discouraging restrictive weight control behaviors are important interventions.

Table 3.

Social and Developmental Considerations for Lifestyle Behavior Change of Emerging Adults

Lifestyle factor	Social and developmental factors	Examples of potential barrier
Diet	Life‐stage considerations	Body dissatisfaction, unhealthy weight control behaviors, cooking skills, commercial marketing, peer influences, weight gain related to transition to independence/university, food‐based coping
	Social risk factors	Food insecurity, access to nutritious foods, financial resources available for food
Physical activity	Life‐stage considerations	Decrease in active transportation such as walking or biking, decreased sports participation, increased sedentary behavior, parenting responsibilities
	Social risk factors	Time constraints related to work, school, neighborhood crime
Tobacco use	Life‐stage considerations	Experimentation, peer influence, electronic cigarettes, vaping, hookah, emotional health, and traumatic stress exposures
	Social risk factor	Health care access for cessation support, regional and geographic norms related to tobacco use
Sleep	Life‐stage considerations	Change in chronobiology (later bedtimes), emotional health and traumatic stress exposures, parenting responsibilities
	Social risk factor	Work or school schedule, noise

Adapted with permission from Kris‐Etherton et al. ¹⁰⁵ © Copyright 2021 the American Heart Association, Inc.

Parents significantly influence the dietary and physical activity behaviors of adolescents and emerging adults. Their modeling of weight maintenance behaviors and feeding practices (eg, pressure to eat, food restriction) is consistently associated with their child's risk of overweight, obesity, and unhealthy weight control behaviors as an adolescent and into adulthood. ¹¹⁰ , ¹¹¹ Practically, parents typically grocery shop and prepare meals, so efforts at increasing their “dietary literacy” could improve weight and other CVH metrics. For example, the Special Turku Coronary Risk Factor Intervention Project evaluated the long‐term effects of diet counseling delivered to families and children beginning in infancy until age 20  years. ¹¹² At the age of 26  years, the Special Turku Coronary Risk Factor Intervention Project led to superior cholesterol and glucose control. In addition to parental and family involvement, support from peers, colleagues, and significant others also influence diet and physical activity behaviors. ¹¹³ Finally, evidence suggests that fluctuations in physical activity influence weight maintenance; thus, it is critical to develop a better understanding of the specific factors influencing these fluctuations in emerging adulthood. ⁵⁷

Health‐related technologies have also been proposed as a potentially useful method for improving access to health information, both to track lifestyle behaviors and motivations and to track weight, blood glucose, and blood pressure. ¹¹⁴ Applications such as MyFitnessPal, CalorieKing, Fitbit, MySugr, Glucose Buddy, and Lose It! have been prescribed by physicians. ¹¹⁵ However, data regarding the usability and effectiveness of these applications, independent of clinician input, have been questioned, and there are economic disparities in access to wearable health devices. ¹¹⁶ , ¹¹⁷ Moreover, as mentioned above, the EARLY trials incorporated technology with varying degrees of success, raising questions about its utility for this population. ⁹⁵ However, today's emerging adults have been immersed in the Internet throughout their lives, and these technologies could ultimately serve as a valuable tool to enhance the health care infrastructure. ¹¹⁸ Additionally, few avenues or platforms are more ubiquitous for reaching emerging adults than social media. Future research may engage dissemination and implementation science to explore innovative methods to harness the power of social media for health communication. For example, some research suggests that social media influencers can have a positive impact on the physical activity motivations of their followers, and during the COVID‐19 pandemic, the potential of social media influencers as health communicators was evident. ¹¹⁹ , ¹²⁰ In addition, researchers, clinicians, and the public health community will need to think creatively about other avenues for reaching emerging adults, such as minority‐serving institutions (eg, historically Black colleges and universities), ¹²¹ the military and Veterans Affairs, and industries that employ a disproportionate number of emerging adults such as hospitality.

By identifying and addressing CVD risk factors early in the life span, primary prevention of CVD risk factor development has been associated with reduced CVD in mid and later adulthood. ³⁴ However, screening best practices for these risk factors (Table 2) may differ according to pediatric versus adult guidelines, ⁴³ , ⁴⁹ and some organizations, such as the US Preventive Services Task Force, find that there is insufficient evidence to support routine screening of asymptomatic individuals for hypertension and hyperlipidemia. ¹²² , ¹²³ Another challenge is the lack of representation of emerging adults in clinical trials focused on CVD prevention, an important priority for future research. ¹²⁴ , ¹²⁵ Of note, recent findings from behavioral clinical trials involving emerging and young adults are mixed but promising. A recent superiority trial in young adults (aged 18–39  years) found little support for aerobic exercise interventions improving blood pressure control 52  weeks after intervention, but there were cerebrovascular benefits. ¹²⁶ , ¹²⁷ In the MyHEART (My Hypertension Education and Reaching Target) trial, telephone coaching plus ambulatory blood pressure monitoring was not superior to usual care, albeit both resulted in a 4.2‐mm Hg reduction 6  months after intervention, ¹²⁸ and the REACH (Richmond Emerging Adults Choose Health) trial, a behavioral weight loss program adapted for emerging adults (aged 18–25  years) produced a 3‐kg weight loss at 6  months after intervention but no significant differences between groups with the motivational enhancements, ¹²⁹ and other trials are underway. ¹³⁰ , ¹³¹ Also, lessons distilled from the 7 EARLY interventions, which consisted of 17 treatment arms using multiple approaches such as goals and planning, feedback and monitoring, and social support, but provided little information on which components may be the most important, are an essential step for further research on optimizing behavioral interventions and adaptive designs. ⁴ , ¹³² Recruitment of emerging adults into clinical trials also merits consideration. Web‐based recruitment via social media and private messaging through medical charts has successfully recruited this age group and is cost effective, but there has been limited success in using such approaches for retaining and engaging participants within the trials, another area of opportunity and innovation. ¹³³

Risk Stratification for CVD During the Transitional Period

Because incidence rates for CVD events increase with each additional risk factor, ¹³⁴ composite CVH scores are a better predictor of long‐term CVD risk than an individual risk factor. ¹³⁵ Current primary prevention guidelines recommend estimating the lifetime or 30‐year risk for atherosclerotic CVD for young adults aged 20 to 39  years. ¹³⁶ The pooled cohort risk equations, developed by the AHA and the American College of Cardiology, provide an age, sex, and race‐specific estimation of lifetime atherosclerotic CVD risk for individuals aged ≥20 years. ¹³⁷ The AHA Predicting Risk of CVD Events is a sex‐specific, race‐free, risk equation that provides 10‐ and 30‐year estimates for CVD beginning at age 30  years. ¹³⁸ , ¹³⁹ The predictive ability of this calculator is enhanced compared with other risk stratification tools by the addition of cardiovascular–kidney–metabolic factors (eg, urine albumin‐to‐creatinine ratio), hemoglobin A_1c, and the zip code–level social deprivation index. ¹³⁸ , ¹³⁹ In addition, there are many atherosclerotic CVD risk enhancers, including a family history of premature atherosclerotic CVD, persistently elevated low‐density lipoprotein cholesterol ≥160  mg/dL, chronic kidney disease, metabolic syndrome, inflammatory diseases such as rheumatoid arthritis, and conditions such as preeclampsia and premature menopause, which should be considered when prescribing lipid‐lowering therapy. ⁴⁴ Young adults with low short‐term risk but high long‐term risk have not been thoroughly evaluated in lipid lowering trials, despite data suggesting this may be an important population to target with preventive therapies. ¹⁴⁰

Transition From Pediatric to Adult Care

Early detection of risk factors and connecting youth with health care services is paramount. Among insured emerging adults, health care usage is <40%, indicating that barriers to health care access are more complex than insurance status. ¹⁵ Innovative approaches are needed, such as collaborations with community health centers, college health, employer‐based programs, and creative use of technology, to reach emerging adults. A systematic review of barriers to health care access for adolescents and young adults identified a lack of knowledge of health care services, negative past experiences with care, and many organizational‐ and policy‐level factors (eg, long wait times, poor care coordination); in contrast, youth‐centered, web‐based technologies and place‐based care (college, employer) may help facilitate care. ¹⁴¹

The transition period represents a particularly vulnerable time for individuals with chronic disease and those at greatest risk for developing chronic disease. Best practices for transition from pediatric/adolescent practice to adult care recommend transition of care between the ages of 18 and 21  years. In a study of 60 233 adolescents, individuals were found to transition care later than recommended, and a gap of >1 year was noted between pediatric and adult primary care. ¹⁴² The adjusted mean age at the time of transfer was 21.8  years for all office visits (eg, acute care, chronic disease management) and 23.1  years for preventive visits.

Considering the transition from pediatric to adult care, a study of young adults with familial hypercholesterolemia and their parents identified several key challenges during this transition, including recognizing oneself as a decision‐maker, prioritizing treatment for a chronic condition with limited external symptoms, managing social implications of their condition, and finding credible resources and guidance. ¹⁴³ Health care practices jointly staffed by pediatric and adult clinicians, as well as enhanced after‐hours support, are examples of interventions that may ease the transition. ¹⁴⁴ More broadly, supporting the transition to adulthood should be expanded to help eligible emerging adults understand how to sign up for Supplemental Nutrition Assistance Program benefits, navigate insurance coverage issues, and other life skills that some of the most vulnerable youth may need. For example, a community advisory board guided the development of a health insurance and financial toolkit for emerging adults with type 1 diabetes. ¹⁴⁵ These types of supports are needed for other populations, such as the 23 000 emerging adults who age out of foster care each year or the 4.4  million disconnected youth (Figure 3). ¹⁴⁶

Figure 3. Summary of current knowledge, priority populations, and future research directions.

CVD indicates cardiovascular disease; CVH, cardiovascular health; and LGBTQ+, lesbian, gay, bisexual, transgender, queer, or questioning, and other identities. *National Foster Youth Institute. ^{146 †}Conway D 2020, US Census Bureau. ^{147 ‡}Osterman et al 2022, National Vital Statistics Report. ^{148 §}Curtin and Xu 2022, National Center for Health Statistics. ^{149 ‖}Williams Institute, UCLA. ^{150 ¶}National Equity Atlas. ¹⁵¹

Conclusions

Efforts to reduce the burden of CVD risk factors in emerging adults have the promise of positively impacting CVD risk. Comprehensive approaches focused on population‐level interventions and individual‐level health behavior change, including addressing psychosocial stressors, are needed during the critical transitional period between adolescence and emerging adulthood. Strategic, tailored health promotion and disease prevention in emerging adulthood can prepare them for a healthier, more fulfilled middle age and beyond. A focus on the CVH of the youngest adults aligns with the AHA's commitment to health equity and CVH for all.

Disclosures

Writing Group Disclosures

Writing group member	Employment	Research grant	Other research support	Speakers’ bureau/honoraria	Expert witness	Ownership interest	Consultant/advisory board	Other
Jewel Scott	University of South Carolina	National Institutes of Health (Mentored researcher on an NIH Diversity/Administrative supplement ‐ R01NR020127‐03S1)†	None	None	None	None	None	None
Anandita Agarwala	Baylor Scott and White Heart Hospital	None	None	None	None	None	None	None
Carissa M. Baker‐Smith	Center for Cardiovascular Research and Innovation, Nemours Cardiac Center, Nemours Children's Health, Sidney Kimmel Medical College of Thomas Jefferson University Cardiac Center	NIH/NIGMS (research funding)†	PCORI (Advisory Board: Pediatric Renovascular Hypertension for PCORI)*	None	None	None	Medscape*	Nemours Children's Health (director of Pediatric Preventive Cardiology)†
Matthew J. Feinstein	Northwestern University Medicine	NIH (project grants [eg, R01])†; AHA (Strategically Focused Research Network Center and project grants)†	None	None	None	None	Abbott Laboratories†	None
Karen Jakubowski	University of Pittsburgh	NIH (Early Career Award [K23HL159293])†; NCATS (UL1TR001857)†	None	None	None	None	None	None
Jill Kaar	University of Colorado Anshutz Medical Campus	None	None	None	None	None	None	None
Niyati Parekh	New York University School of Global Public Health	None	None	None	None	None	None	None
Kershaw V. Patel	Houston Methodist DeBakey Heart and Vascular Center	NIH NHLBI R21HL169708 (research support from grant as co‐investigator)†	None	None	None	None	Novo Nordisk*	None
Janna Stephens	University of Illinois Chicago, College of Nursing	None	None	None	None	None	None	None

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $5000 or more during any 12‐month period, or 5% or more of the person's gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $5000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.

^*Modest.

^†Significant.

Reviewer Disclosures

Reviewer	Employment	Research grant	Other research support	Speakers' bureau/honoraria	Expert witness	Ownership interest	Consultant/advisory board	Other
Yamnia I. Cortes	University of Iowa	None	None	None	None	None	None	None
Holly C. Gooding	Emory University School of Medicine	None	None	None	None	None	None	None
Melissa Laska	University of Minnesota	None	None	None	None	None	None	None
Ruth‐Alma N. Turkson‐Ocran	Beth Israel Deaconess Medical Center/Harvard Medical School	None	None	None	None	None	None	None

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $5000 or more during any 12‐month period, or 5% or more of the person's gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $5000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.