Analytical cross-sectional study. Data were obtained from the Life Stages Food and Nutrition Surveillance Survey (VIANEV) during 2017–2018. The VIANEV survey was implemented and supervised by the National Center for Food and Nutrition (CENAN) of Peru (8). To ensure the quality and transparency of our study, we adhered to the STROBE guidelines (Strengthening the Reporting of Observational Studies in Epidemiology) (9).

The technical report on VIANEV is found elsewhere (8). In summary, it collected information from three distinct domains: Metropolitan Lima, the capital of Peru, and other urban and rural areas. Data was collected through a stratified, multistage, and probabilistic sampling process, independent in each domain. The sample selection was in two stages. In the first stage, clusters of primary sampling units were randomly selected. In the second stage, households were randomly selected within these clusters, including adults aged 18–59. This sampling process allowed for inferences at the national level in urban, rural, and Metropolitan Lima areas.

Specific exclusion criteria were applied to the present work. Those without the variables that make up the cardiovascular health state were excluded.

The American Heart Association (AHA) has established seven metrics to define ICVH, Life's Simple 7. These metrics include blood pressure levels, total cholesterol (TC) glucose, smoking status, body mass index (BMI), physical activity levels, and dietary intake. Each of these metrics is evaluated and classified into one of three categories: ICVH, intermediate cardiovascular health (ICVHint), or poor cardiovascular health (ICVHdef). ICVH is defined as having 5–7 metrics in its optimal state, ICVHint is described as having 3–4 metrics in its optimal state, and ICVHdef is defined as having 0–2 metrics in its optimal state. The variable was categorized as poor/moderate vs. ideal for regression analysis (10).

In this study, ICVH was defined as follows: 1.

Blood Pressure: An ideal health state was considered if the individual had no history of high blood pressure and their systolic/diastolic blood pressure was <120/80 mm Hg.

Several factors were explored in this work as potential correlates of ICVH, including an individual's biological sex, age groups ranging from 18 to 29 up to 50 to 59 years old, relationship status of single or partnered, highest level of education completed of primary through secondary to high school, natural region of residence of Metropolitan Lima, elsewhere along the coast, the Mountain Range, or jungle, whether residence was located in an urban or rural area, socioeconomic classification of poor or not poor, and altitude of place of residence ranging from 0 to 1,499 meters up to 1,500 meters or higher.

According to existing literature, each of these covariables was selected because of its potential to influence cardiovascular health. The VIANEV report (8) reviews how each variable was measured.

The fasting status was verified through participant self-report during the survey interview, following VIANEV protocol guidelines. While glycated hemoglobin (HbA1c) would provide a more comprehensive assessment of glycemic control over time, this parameter was unavailable in the VIANEV survey. Similarly, the original survey did not collect data on secondhand smoke exposure or environmental smoke from cooking and heating sources.

Data analysis was performed using R software, version 4.0.5. Absolute and relative frequencies were used to describe the data. A bivariate analysis was conducted to evaluate the factors associated with cardiovascular health status, separated by sex; the Chi-square test was used. Adjusted prevalence ratios (aPR) and their 95% confidence intervals (CI 95%) were calculated. For this, generalized linear models were used, assuming a Poisson distribution and using logarithmic link functions. A bar graph was also created to visualize the distribution of each component of ideal ICVH globally, according to sex and region of residence.

It should be noted that all analyses were executed considering the complexity of the sample design. This means that stratification, clustering, and sample weights were assessed in all statistical calculations.

This work was carried out using the VIANEV survey datasets, which are freely and publicly accessible online (https://www.datosabiertos.gob.pe/dataset/estado-nutricional-en-adultos-de-18-59-a%C3%B1os-per%C3%BA-2017-%E2%80%93-2018). All personal identifiers were removed from these datasets before publication, thus ensuring the privacy and anonymity of the study participants.

Since this study analyzes existing and completely anonymous data, it was not considered necessary to submit it to an ethics committee review. This stance aligns with ethical guidelines for health research, which state that analyses of existing public datasets that do not contain identifiable information do not require honest review. Nevertheless, all necessary measures were taken to ensure that the analysis was conducted ethically and that the rights and dignity of the original study participants were respected.

The prevalence of intermediate ICVH was presented in almost half of those evaluated, while approximately one-tenth had a poor level. The overall levels between men and women were not statistically significant. These results are consistent, on the one hand, and contrast with other recent studies that have examined the prevalence of ICVH in different populations.

For example, a study conducted in the general middle-aged population in Sweden found that only 18.2% of the population reached the ideal state of ICVH. In comparison, 51.9% were classified as intermediate status, a level very similar to ours (3). Meanwhile, Gupta et al. (12) found that under half of their sample (43.1%) had ideal ICVH. Conversely, research conducted in China found shallow values of ideal ICVH (15.7% for men and 6.8% for women). In the study by Ghimire et al. (13), conducted in Nepal, there was a difference of almost ten percentage points in ideal ICVH between both sexes.

Specifically, if we focus on studies in Latin America, the research by Machado et al. (14) and Avecedo et al. found that only 7.8% and 14.3% had ideal ICVH. In Peru, Benziger et al. (7) found that only 10.5% of the evaluated Peruvians had ideal ICVH, unlike our research, in which it was three times more. The discrepancies of the latter may lie in the work of Bezinger et al. (7), who evaluated the population of four cities in the country. In contrast, in the present work, a national database was used.

The differences in ICVH prevalence between different populations may be due to various factors, according to an article by Peters et al. (15). It has been recommended that the patterns over time in cardiovascular danger elements may change between genders, which could account for a few of the distinctions that have been noticed. The researchers' findings revealed that whereas females saw body mass index increase more noticeably relative to males throughout the same timeframe, total cholesterol experienced a diminution more markedly for males in contrast to females. Similarly, Lu and colleagues examined this topic in another investigation. Found that although hypertension is more common in the United States, blood pressure levels are higher in China, which changes ICVH values (16).

Investigations into the connection between advancing age and cardiovascular wellness have revealed that with time, an individual's cardiac and vascular fitness will inevitably fade without preventative measures. The Framingham study discovered that the frequency of cardiovascular danger elements like hypertension, diabetes, obesity, and dyslipidemia amplified substantially right after a person's half-century birthday (17). The findings revealed that as one age, researchers uncovered links between amplified arterial stiffness, thickened inner linings of the carotid arteries, and exacerbated systolic blood pressure (18). The male-female ratio for coronary disease also reverses with age, being higher in young males but later higher in elderly females (19). These studies underline that advanced age, particularly after 65, is significantly associated with an increase in the prevalence of various types of ICVH. This effect seems more pronounced in young men but balances in advanced ages. In turn, it is vital to highlight that, in our work, the decrease in the prevalence of ideal ICVH with age was more pronounced in men than in women. Based on these findings, it is tentatively proposed that the cardiovascular system in males may prove more vulnerable to the deteriorative impacts of advancing years than in females. While further exploration could help validate this proposed explanation, more evidence is required before the hypothesis can be considered corroborated. A 2018 investigation suggested that the dissimilarities between male and female endothelial performances could be pivotal for vascular well-being and the all-encompassing peril of cardiovascular illnesses throughout one's lifetime (20).

Recent studies have explored the potential variances between sexes in terms of how marital status may impact achieving an optimum level of cardiovascular well-being. The work of Manfredini et al. (21), a large-scale investigation of over 21,000 individuals across the United States, revealed that married women or those in long-term partnerships were more inclined to attain ideal cardiovascular risk factors, including appropriate blood pressure levels when juxtaposed against their unmarried, divorced, or widowed associates. A further investigation conducted by the research team of Wang and colleagues was also published (22) found that participants with a higher score of ideal cardiovascular health metrics had a lower risk of having suboptimal health status. The findings from these investigations indicate that relationship status may considerably influence cardiovascular well-being, especially among females (23). While further exploration could provide deeper insight into how this association works and the extent to which additional determinants, like lifestyle choices or consistency of care, may also impact it, the whole nature of such a link remains uncertain.

An intriguing finding in our study was the decrease in cardiovascular risk factors with age in both men and women, which appears to contrast with traditional cardiovascular epidemiology literature. Several mechanisms might explain this unexpected pattern in the Peruvian context. First, this could reflect a survival effect, where individuals with better cardiovascular health are more likely to survive in older age groups. Second, our cross-sectional design captures different birth cohorts simultaneously—younger generations may have adopted more contemporary lifestyle habits (increased sedentary behavior, processed food consumption, and stress levels) that negatively impact cardiovascular health. Third, older adults in Peru might maintain more traditional lifestyle patterns, including higher consumption of conventional foods and more physical activity in daily life, particularly in non-urban areas. Fourth, there might be increased health awareness and better health-seeking behaviors among older adults with more frequent contact with healthcare services. Additionally, the higher prevalence of risk factors in younger adults could signal a concerning trend that warrants public health attention, as it may predict a higher burden of cardiovascular disease in future decades. These findings highlight the importance of early preventive interventions targeting younger age groups in Peru.

Our manuscript found that the likelihood of having an ideal ICVH decreases as the educational level increases. This finding echoes conclusions previously explored in earlier studies examining this same subject matter. A substantial part of the academic level differences seen in cardiovascular and all-cause mortality between Finnish men and women was discovered by the study from Finland to stem from variations in health behaviors such as engagement in smoking, the consumption of vegetables, and physical activity participation (24). Likewise, research in China observed that the pathways of cardiovascular wellness ratings over time were connected to succeeding chances of cardiovascular illness (25). Similarly, a study in Italy found that the burden of cardiovascular diseases and their risk factors remained high and required continuous appropriate action at the community and individual levels (26). Finally, a study in Turkey found a possible association between an adverse lipid profile, specific dietary patterns, and a higher level of parental education among school children (27). These results underscore the importance of education on maintaining cardiovascular health.

It was found that the natural region in which women live has a significant association with their ICVH. Specifically, females living on the coast (apart from the Lima metropolis), in the mountains, or in the jungle are less likely to have ideal ICVH vs. those living in the Lima metropolis. These findings are consistent with literature suggesting that geographical location may impact cardiovascular health. For instance, the systematic work examining the effects of exposure to environmental noise on hypertension, blood pressure, and ischemic heart diseases found that the results and exposure patterns may depend on gender as determined by the various social, economic, and cultural factors within society (28). While the natural region did not correlate with ICVH in the male participants of our research, other considerations remained unclear and warranted further exploration. While this finding indicates other drives may carry more weight in shaping men's internal cranial volumes or the association between geography and brain size proves more intricate for males, the relationship demands further scrutiny to unravel potentially nuanced influences.

Our findings revealed that females inhabiting elevations no less than 1,500 meters demonstrated an 82% higher probability of possessing ICVH than those from zero to 1,499 meters above sea level. Indeed, the finding that altitude may confer cardiovascular benefits corroborates prior work, implying such a protective impact, and represents an exciting development aligning with extant literature on this topic (29). Researchers in Austria discovered residence at moderate elevations appears increasingly protective against mortality from assorted causes, notably cardiovascular diseases. At the same time, a separate expedition to Everest found nearly half the hikers had pre-existing orthopedic or cardiovascular conditions (30). Preventive measures and education about altitude sickness deserve special attention.

Though the findings offer valuable perspective, one must consider various qualifiers when evaluating their full import. First, the study's cross-sectional nature cannot establish causal relationships between associated factors and ideal cardiovascular health status. Consequently, one should view the outcomes as interrelated factors rather than decisive causes, as correlation does not necessarily imply causation. While adjustments have been made for multiple influences in our examinations, the potential for some skewness remains as not all pertinent influences may have been adequately accounted for or quantified entirely due to restricted data. While certain constraints remain, our findings offer meaningful insight into the occurrence and correlates of ideal heart wellness in Peruvians, as characterized by established health indicators.

Additionally, some methodological constraints should be noted. First, fasting glucose measurements relied on self-reported fasting status, which could introduce recall bias. While HbA1c might provide a more reliable assessment of glycemic status, these data were unavailable in the VIANEV survey. Furthermore, the study did not account for secondhand smoke exposure or environmental smoke from cooking and heating sources, which could potentially impact cardiovascular health, particularly in rural areas where traditional cooking methods are common. Future studies in Peru should consider incorporating these important environmental exposures to provide a more comprehensive assessment of cardiovascular risk factors.