Many teenagers enter adulthood with significant risk factors for cardiovascular disease, and the transition from adolescence to adulthood is a key time to address these risk factors and reduce the risk of developing future cardiovascular disease, according to a new American Heart Association scientific statement published today in the Journal of the American Heart Association.

According to the scientific statement, "Cardiovascular Health in the Transition from Adolescence to Emerging Adulthood," emerging adulthood is the period between age 18 and the mid- to late-twenties, when the brain and decision-making ability are still maturing to adult levels. Greater independence and many changes in life circumstances are occurring simultaneously during this time.

"Emerging adulthood is a time of significant planning, often centered around career development and forming close personal relationships. This pivotal phase is also an ideal time to establish health practices that support lifelong heart health," said Chair of the scientific statement writing group Jewel Scott, Ph.D., R.N., FNP-C, an assistant professor of biobehavioral health and nursing science in the College of Nursing at the University of South Carolina in Columbia, South Carolina.

The scientific statement reviews many of the individual and social challenges to protecting heart health in emerging adults, and it identifies types of interventions that may help.

Transitions in health care and lifestyle changes

In childhood and adolescence, there are typically standard occasions to see health care professionals, such as scheduled vaccinations and school or sports check-ups. These visits provide an opportunity to measure weight and blood pressure and check cholesterol and blood sugar levels. They can also open the door to a discussion about maintaining heart health and addressing any concerns before a risk factor is apparent.

"In the transition from high school to young adulthood, the built-in checkpoints fall off, and young adults may not reengage with care until after they've developed a heart disease risk factor," said Scott.

Life's Essential 8, the American Heart Association's key measures for improving and maintaining cardiovascular health, include several health behaviors (such as eating a healthy diet and getting enough physical activity) that may worsen in emerging adulthood. This period of life usually brings greater responsibilities along with a loss of structures that were in place during adolescence. Becoming more sedentary is common, as is gaining weight.

"Lots of youth who were very active in high school become less active once the recreational sport or team sport they loved goes away. How to cook is not often taught in high school these days, and we know that people who have more cooking skills are more likely to prepare food at home -- and meals at home tend to have less sodium and to be more balanced than meals at fast food or sit-down restaurants," said Scott.

Responsibilities related to school, work, commuting and parenting may also make it difficult for young adults to get sufficient sleep, another important factor for optimal heart health.

While, historically, young people often started smoking tobacco in middle school and high school, the percentage of people who started using tobacco between 18 and 23 years of age doubled between 2002 to 2018, with electronic cigarettes as the most frequently used product. The authors emphasise that more research is needed to learn about the long-term cardiovascular effects of vaping.

Barriers to health care access

The ability to pay for health care may also become a challenge during the transition from adolescence to adulthood. Emerging adults make up the largest group of the 27 million uninsured adults in the United States. In some states without expanded Medicaid access, individuals can lose their Medicaid coverage when they turn 19. If their parents are insured through the Affordable Care Act, emerging adults age out of coverage after age 26.

While college health services can be important in providing care, 40% of all college students attend two-year community colleges. These students are less likely to have access to health care, which is often not available at community colleges. Young adults pursuing a trade pathway or apprenticeship are also less likely to have health insurance coverage.

To improve health care access for emerging adults, the statement suggests supporting policies that expand insurance access across the lifespan and eliminate gaps in coverage. However, the statement points out that barriers to obtaining health care go beyond insurance status, since health care utilisation is less than 40% among insured emerging adults. Barriers may include a lack of knowledge of health care services, past negative experiences with care or other issues, such as long wait times and poorly coordinated care.

Other social determinants of health

Social determinants of health have a significant impact on cardiovascular health outcomes during emerging adulthood. Factors such as education, neighborhood environment and economic stability play a crucial role in mediating health inequities:

"We highlight some of the populations that need extra effort or attention tailored to their unique circumstances, such as those moving out of the foster care system and others who have barriers engaging with the health care system. One size may seem to fit all, however, it doesn't usually work," said Scott.

Opportunities for engagement

When young adults visit their health care professionals, there may be missed opportunities to discuss how to protect heart health.

"Clinicians have limited time with each patient. We may see their blood pressure is a little high, but we don't address it because they came in with an ear infection or sprained ankle or something else that needs immediate attention. We may miss the opportunity to let them know that they are in the elevated blood pressure range and ways they can take action. We need to have these conversations and make sure that heart health is at the front of their minds," said Scott.

Health care engagement also provides an important opportunity to address cardiovascular health before pregnancy, since suboptimal cardiovascular health increases the risk of adverse pregnancy outcomes, such as gestational diabetes, preeclampsia and pre-term birth. Adverse pregnancy outcomes are strongly associated with poorer cardiovascular health later in life.

The statement also suggests leveraging telehealth and mobile technology to increase health care use among emerging adults. With young adults increasingly living in a digital world, there is a need to explore how social media can be harnessed to deliver tailored cardiovascular prevention messages and track whether they are effective in resulting in behavioral changes.

In addition, researchers, clinicians and the public health community are encouraged to think about other avenues for reaching emerging adults, such as community colleges and universities, the military and veterans administration, and industries such as hospitality that employ a disproportionate number of young adults.

This scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association Prevention Science Committee of the Council on Epidemiology and Prevention and the Council on Cardiovascular and Stroke Nursing; the Council on Lifelong Congenital Heart Disease and Heart Health in the Young; and the Council on Lifestyle and Cardiometabolic Health. American Heart Association scientific statements promote greater awareness about cardiovascular diseases and stroke issues and help facilitate informed health care decisions.

Scientific statements outline what is currently known about a topic and what areas need additional research. While scientific statements inform the development of guidelines, they do not make treatment recommendations. American Heart Association guidelines provide the Association's official clinical practice recommendations.