IPM Take
Cardiovascular prevention has traditionally been built around the middle-aged patient.
The arteries may not be waiting that long.
In this cohort, only about one in five young adults had no identifiable cardiovascular-kidney-metabolic risk factors. The rest already had excess or dysfunctional adiposity, metabolic abnormalities, kidney-related risk or evidence of subclinical cardiovascular disease. More advanced CKM stages were also associated with thicker carotid artery walls.
The study should not be turned into a claim that 80% of all American 20-somethings have early cardiovascular disease. The cohort intentionally included many participants from disadvantaged social backgrounds and is not nationally representative.
But that limitation may make the policy message more important, not less.
If cardiovascular risk is already biologically visible in communities exposed to disadvantage by the early 20s, prevention cannot begin with a lecture about lifestyle at age 50.
It has to begin upstream.
Executive Summary
Researchers analysed 1,283 participants in the Future of Families-Cardiovascular Health Among Young Adults study, or FF-CHAYA. Participants had been followed from birth and were approximately 23 years old when assessed.
Only 20.7% were classified as CKM stage 0, meaning no identified CKM risk factors. Another 40.2% were in stage 1, 36.2% in stage 2 and 2.8% in stage 3. None were in stage 4, which represents established clinical cardiovascular disease.
Cardiovascular health also deteriorated across CKM stages. Average Life’s Essential 8 scores were 77.6 at stage 0, 70.0 at stage 1, 63.8 at stage 2 and 64.4 at stage 3. Higher CKM stages were associated with greater carotid intima-media thickness, an imaging marker of early arterial injury.
The findings arrive only months after the first AHA/ACC clinical guideline for CKM syndrome recommended CKM staging across both youth and adulthood and called for earlier, integrated assessment of cardiovascular, kidney and metabolic risk.
One important gap remains: the PREVENT cardiovascular risk equations used in the new CKM framework were developed for people aged 30 to 79, so they cannot simply be applied to this younger population.
Why it matters
- HTA bodies: The study is not an HTA event, but it strengthens the evidence base for earlier cardiovascular risk detection and integrated CKM prevention rather than waiting for individual diseases to emerge.
- Payers: Earlier identification means earlier spending on prevention, monitoring and risk-factor treatment. The alternative is continuing to finance cardiovascular care only after obesity, hypertension, diabetes and kidney disease have become established.
- Industry / innovation partners: Risk assessment tools designed around middle age leave a gap in younger adults. There is room for validated diagnostics, digital tools and prevention models that can identify meaningful lifetime risk without medicalising normal young people.
Twenty-three is not an age most people associate with cardiovascular disease.
That may be part of the problem.
A new U.S. study suggests that by the time many young adults reach their early 20s, cardiovascular, kidney and metabolic risk may already be accumulating, and in some cases leaving measurable traces in the arteries.
Researchers analysed 1,283 participants from FF-CHAYA, an ancillary study of the Future of Families and Child Wellbeing Study, which began by enrolling mother-child pairs in 20 large U.S. cities between 1998 and 2000.
At the young-adult examination, the mean age was 22.9 years.
Only 20.7% were classified as CKM stage 0.
Forty percent were already at stage 1, defined largely by excess or dysfunctional adiposity. Another 36.2% were at stage 2, where metabolic risk factors or kidney disease enter the picture. A smaller 2.8% were at stage 3, which includes subclinical cardiovascular disease or very high cardiovascular or kidney risk.
The arteries tracked with the risk score
The finding would be less compelling if CKM staging merely rearranged familiar risk factors into new categories.
But carotid imaging suggested that the categories were detecting something biologically meaningful.
Compared with stage 0, participants at stages 1 to 3 had significantly greater mean-maximum carotid intima-media thickness. The reported differences were approximately 0.014 mm at stage 1, 0.020 mm at stage 2 and 0.100 mm at stage 3.
Carotid wall thickness is not a heart attack.
It is a marker of early arterial injury.
That distinction matters, but so does the age at which the signal appeared.
The participants were barely into adulthood.
Cardiovascular health worsened as CKM stage increased
The researchers also compared CKM staging with the American Heart Association’s Life’s Essential 8 framework, which measures diet, physical activity, nicotine exposure, sleep, BMI, blood glucose, lipids and blood pressure.
The average overall score declined from 77.6 in stage 0 to around 64 in stages 2 and 3.
Interestingly, the clearest differences were seen in physiological measures such as BMI, glucose, cholesterol and blood pressure. Self-reported behaviours such as diet, activity and sleep did not show the same clear gradient.
The authors suggested that self-reported behaviour may lack sensitivity and that behavioural exposures may take longer to translate into detectable arterial injury.
That is a useful warning against interpreting the study as another argument that young adults simply need to “make better choices.”
This cohort was not a cross-section of America
FF-CHAYA was specifically designed to study social determinants of cardiovascular health.
The original cohort oversampled births to unmarried mothers and includes substantial representation from groups exposed to social and economic disadvantage. In the present analysis, about 52% of participants identified as Black and 27% as Hispanic, and more than half had a history of parental incarceration.
The researchers explicitly caution that the findings may not generalise to all U.S. young adults.
But describing the population matters for another reason.
Cardiovascular risk does not develop in a vacuum.
Food insecurity, housing instability, financial strain and access to preventive care can shape metabolic and cardiovascular health long before someone receives a diagnosis. The 2026 CKM guideline now explicitly recommends screening for social factors such as food insecurity, unstable housing and financial strain as part of the broader prevention framework.
That moves CKM prevention into uncomfortable political territory.
We can tell a 22-year-old to eat better, sleep more and exercise.
We also have to ask what kind of environment makes those behaviours possible.
The new guideline says screen early. The risk calculator still starts at 30.
The timing of the study is important.
In June 2026, the AHA, ACC, American Diabetes Association and American Society of Nephrology published the first comprehensive clinical guideline for CKM syndrome.
It recommends CKM staging in both youth and adults. For stage 0 adults, lipids, glycemia and kidney function should be assessed at least every five years. At stage 1, assessment increases to every two to three years, and at stage 2 these measures generally move to annual monitoring.
But one of the guideline’s main cardiovascular risk tools, PREVENT, is validated for adults aged 30 to 79.
The people in this study were too young.
That leaves an important gap between identifying early CKM abnormalities and accurately quantifying what those abnormalities mean for long-term cardiovascular events.
Longitudinal follow-up will be essential.
Still, waiting for perfect lifetime-risk prediction cannot become an excuse for waiting until disease is obvious.
When arterial injury is already measurable in the early 20s, cardiovascular prevention at 50 is not early prevention.
It is damage control.
