A new study examined the combined effects of sleep, physical activity, and nutrition (collectively termed SPAN behaviours) on the risk of major adverse cardiovascular events (MACE), including myocardial infarction, stroke, and heart failure.
Cardiovascular disease remains a leading global cause of mortality, and lifestyle behaviours such as inadequate sleep, physical inactivity, and poor diet are key modifiable contributors. While previous research has largely evaluated these behaviours in isolation, this study assessed their joint and interacting effects using a comprehensive, multi-behavioural framework.
The researchers used data from 53,242 participants in the UK Biobank, with a median age of 63 years and 56.8% male. Participants were followed for a median of 8 years, during which 2,034 MACE events were recorded, including 932 myocardial infarctions, 584 strokes, and 518 cases of heart failure. Individuals with pre-existing major cardiovascular disease or early events during follow-up were excluded to minimise reverse causation.
Sleep and physical activity were objectively measured using wrist-worn accelerometers worn continuously for seven days, providing high-resolution data. Sleep duration was calculated using validated algorithms, while physical activity was quantified as time spent in moderate-to-vigorous physical activity (MVPA) using machine learning classification. Dietary intake was assessed at baseline using a food frequency questionnaire, from which a diet quality score (DQS) was derived, ranging from 0 to 100, with higher scores indicating healthier dietary patterns.
To evaluate combined lifestyle effects, participants were categorised into 27 groups based on tertiles (low, medium, high) of each SPAN behaviour. The study also examined dose–response relationships using a continuous composite SPAN score and assessed potential synergistic interactions between behaviours.
The findings demonstrated that all three behaviours contributed to cardiovascular risk, with physical activity having the strongest association, followed by sleep and diet. Compared with the least healthy combination, several intermediate combinations were associated with significantly lower MACE risk. For example, individuals with low MVPA but moderate sleep and diet had a 34% lower risk, while those with moderate levels across all three behaviours had a 36% lower risk. The lowest observed risk occurred in groups with high physical activity and sleep, although diet quality showed weaker and less consistent associations.
The study identified optimal behavioural ranges associated with the greatest reduction in cardiovascular risk. These included approximately 8.0–9.4 hours of sleep per day, 42–104 minutes of MVPA, and moderate diet quality scores. Individuals within these ranges experienced up to a 57% lower risk of MACE compared with those in the least favourable categories.
Dose–response analyses revealed an L-shaped relationship between both sleep and physical activity and cardiovascular outcomes, indicating diminishing returns at higher levels. In contrast, diet showed a weaker and non-significant association with MACE, likely due to measurement limitations. The study found no statistically significant synergistic interaction between SPAN behaviours, suggesting that while the effects are additive, they do not strongly amplify one another biologically.
A key contribution of this research was the identification of clinically meaningful, achievable behavioural changes. The authors demonstrated that even modest improvements, such as an additional 10 minutes of sleep per day, 5 minutes of MVPA, and a small increase in diet quality equivalent to roughly one-quarter cup of vegetables, were associated with a 10% reduction in MACE risk. Larger combined improvements yielded progressively greater reductions, highlighting the cumulative benefits of small lifestyle changes.
This study provides robust evidence that combined improvements in sleep, physical activity, and diet are associated with substantially lower cardiovascular risk. Even small, incremental changes across multiple behaviours can yield meaningful health benefits, while larger combined improvements offer even greater protection. These findings support the development of integrated, multi-behaviour lifestyle interventions aimed at preventing cardiovascular disease and reducing the burden of major adverse cardiovascular events.
Source: European Journal of Preventive Cardiology
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