Donald M. Lloyd-Jones, MD

Nearly 80% of young adults in a new study were classified in an early or intermediate stage of cardiovascular-kidney-metabolic (CKM) health, with excess adiposity emerging as the leading driver. The findings, published in Circulation: Population Health and Outcomes, suggest the seeds of atherosclerosis may be sown far earlier than previously appreciated.

"Even though heart attacks and strokes most often affect us in our 40s, 50s, 60s, actually the thing that is leading up to those heart attacks really starts to get rolling in our 20s," Donald Lloyd-Jones, MD, MS, said in an interview with HCPLive.

4 Out of 5 Young Adults Show Early Cardiovascular-Kidney-Metabolic Risk

Lloyd-Jones is an American Heart Association volunteer, a cardiologist at Boston Medical Center, professor of medicine at Boston University's Chobanian & Avedisian School of Medicine, director of the Framingham Center for Population and Prevention Science, and principal investigator of the Framingham Heart Study.

Why Young Adulthood Is a Blind Spot in Cardiovascular Prevention

Findings from prior research suggest traditional risk factors, including elevated cholesterol, elevated blood pressure, diabetes, and smoking, are associated with arterial damage in older adults. That damage, measurable by carotid ultrasound, is an indicator of greater risk for myocardial infarction and stroke. Previous research also shows levels of these risk factors in childhood, even within the normal range, are associated with greater plaque buildup later in life.

To address this gap in research, few studies have quantified this kind of arterial injury specifically in young adults, a period Lloyd-Jones and colleagues believe is critical to understanding who is on a fast track toward cardiovascular disease.

"Young adulthood, we think, is a time when atherosclerosis or plaques are really starting to get going," Lloyd-Jones said.

The CKM construct itself reflects this cardiovascular-kidney interconnection: stage 2 CKM is defined by the presence of either metabolic risk factors or kidney risk factors, and stage 3 by subclinical cardiovascular disease or advanced kidney disease, meaning kidney function is embedded in the staging system alongside traditional cardiometabolic measures rather than considered separately.

Investigators analyzed data from 1283 participants (mean age, 22.9 years; 54.4% women) in the Future of Families–Cardiovascular Health Among Young Adults (FF-CHAYA) study, an ancillary study of the Future of Families and Child Well-Being Study that Lloyd-Jones helps lead. The cohort included oversampling of participants from disadvantaged backgrounds, including unmarried mothers and those living below the poverty line.

Participants underwent carotid ultrasonography to assess early arterial injury and were classified using the American Heart Association's CKM staging construct, which ranges from stage 0 (no risk factors) to stage 4 (clinical cardiovascular disease); this analysis excluded stage 4, given its focus on primary prevention. Cardiovascular health was also quantified using Life's Essential 8 (LE8) scores, a composite of 8 metrics including diet, physical activity, sleep, nicotine exposure, body mass index, blood glycemia, blood lipids, and blood pressure.

Only 1 in 5 Young Adults Had Optimal Cardiovascular Health

Investigators found 20.7% of participants were classified as stage 0 CKM, with no CKM risk factors. The remaining 79.3% were classified in stage 1 or higher: 40.2% in stage 1 (excess or dysfunctional adiposity), 36.2% in stage 2 (metabolic or kidney risk factors), and 2.8% in stage 3 (subclinical cardiovascular disease or advanced kidney disease).

"Only about 20% of these young adults...seemed to be in kind of optimal health," Lloyd-Jones said. "Eighty percent of them were in stage 1 or higher cardiovascular kidney metabolic health."

More advanced CKM stage was associated with significantly lower LE8 scores, from 77.6 in stage 0 to 70.0 in stage 1, 63.8 in stage 2, and 64.4 in stage 3 (P < .001). Notably, this decline was driven by physiological measures, including body mass index, blood lipids, blood pressure, and glycemia, rather than self-reported health behaviors; scores for diet, physical activity, sleep, and nicotine exposure did not differ significantly across CKM stages.

Kidney-related measures also tracked with CKM stage. Mean estimated glomerular filtration rate declined across stages, from 117.7 mL/min/1.73 m² in stage 0 to 111.5 mL/min/1.73 m² in stage 3, and mean creatinine was highest in stage 3 (1.4 mg/dL) relative to earlier stages (0.8 mg/dL). Investigators noted that while variation in glycemia and kidney function was less pronounced than variation in adiposity, blood pressure, and lipids in this young cohort, early kidney involvement was still detectable well before clinical disease.

"That early weight gain is really a key driver of the whole process that leads people to developing either heart or kidney problems over lifetimes," Lloyd-Jones said.

Arterial Injury Was Already Detectable in Participants' Early 20s

More advanced CKM stage was also associated with significantly greater carotid intima-medial thickness (cIMT), an early marker of atherosclerosis. Compared with stage 0, mean-maximum cIMT was 0.014 mm greater in stage 1 (95% CI, 0.005-0.020), 0.020 mm greater in stage 2 (95% CI, 0.017-0.035), and 0.100 mm greater in stage 3 (95% CI, 0.085-0.128).

Although these differences are small in absolute terms, investigators noted prior research has linked even modest cIMT differences to significantly greater risk of myocardial infarction and stroke in older adults, associations they suggest may be amplified in a younger population.

What These Findings Mean for Physicians Seeing Patients in Their 20s

"In your early 20s is actually a really really important time to be connected with the healthcare system, to have a healthcare practitioner, to make plans," Lloyd-Jones said.

Lloyd-Jones noted that in most cases, risk factors identified in a patient's 20s can be addressed through lifestyle change alone, including improved eating patterns and more regular physical activity, potentially restoring health rather than simply preserving it. He said medication is rarely necessary in this age group unless risk factors are already significantly elevated, underscoring the importance of knowing key numbers, including cholesterol, blood pressure, and blood glucose trends, earlier rather than later.

"Things may already be getting started that could affect them either shortening their lifespan or really degrading their health for the long term," Lloyd-Jones said.

Krishnan V, Ning H, Notterman DA, et al. Association between cardiovascular-kidney-metabolic health and early arterial injury in young adults in the United States: the Future of Families–Cardiovascular Health Among Young Adults Study. 

. 2026;19:e013042. doi:10.1161/CIRCOUTCOMES.125.013042

Ndumele CE, Rangaswami J, Chow SL, et al; American Heart Association. Cardiovascular-kidney-metabolic health: a presidential advisory from the American Heart Association. 

. 2023;148:1606-1635. doi:10.1161/CIR.0000000000001184

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Carotid ultrasound data reveal early arterial injury even at earlier CKM stages, says Donald Lloyd-Jones, MD, MS

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