Associations of modifiable lifestyle behaviors with cardiovascular–kidney–metabolic syndrome across risk categories: Findings from a U.S. national survey

BACKGROUND: Poor cardiovascular-kidney-metabolic (CKM) health is highly prevalent and strongly associated with premature mortality. Although healthy lifestyle behaviors are linked to cardiovascular, renal, and metabolic outcomes, evidence on their associations with CKM syndrome risk categories, particularly by sex, remains limited. OBJECTIVES: To examine the associations of five modifiable lifestyle behaviors with CKM syndrome risk categories in a nationally representative U.S. sample and to explore potential sex-specific patterns. METHODS: We conducted a cross-sectional analysis of 9447 adults from the 2007-2018 National Health and Nutrition Examination Survey. CKM stages (0-4) were grouped into low-, moderate-, and high-risk categories. Physical activity, diet quality, smoking status, sleep duration, and alcohol intake were assessed using standardized questionnaires. Weighted logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs) for moderate- and high-risk CKM; a 0-5 lifestyle score assessed dose-response; sex-stratified and sensitivity analyses were performed. RESULTS: Physical inactivity, current smoking, short or long sleep, and nondrinking (vs light drinking) were associated with higher odds of moderate- or high-risk CKM. Poor diet quality was associated with moderate- but not high-risk CKM. Higher lifestyle scores showed an inverse dose-response pattern, and several associations varied by sex. CONCLUSION: In this nationally representative cross-sectional study, modifiable lifestyle behaviors were strongly associated with CKM syndrome risk categories, with important sex-specific patterns. These findings support incorporating lifestyle information into CKM risk stratification and motivate future longitudinal and interventional studies.