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Middle-aged adults engaging in unhealthy lifestyle behaviors are at higher risk of chronic diseases. However, little is known about the co-occurrence of these behaviors and their determinants. This cohort study examined the co-occurrence of unhealthy lifestyle behaviors (alcohol consumption, diet, physical inactivity, and smoking) in 30,154 middle-aged adults and their associations with sociodemographic factors, social support, and disease history. Alcohol use was measured by the AUDIT, diet by the MiniMeal-Q, and physical inactivity and smoking by single questions. Participants had a mean age of 58 years, with 51% being female. Of them, 14% had no unhealthy behaviors, 38% had one, 36% had two, 10% had three, and 2% had all four. The most common co-occurrence was between physical inactivity and poor diet (38%). Higher education decreased the likelihood of having three or four unhealthy behaviors, while financial difficulties, having no one around who appreciated one's efforts, and suffering of a lung disease increased it. In conclusion, middle-aged adults exhibit varying levels of unhealthy lifestyle behaviors. Higher education is linked to reduced engagement in multiple unhealthy behaviors, whereas financial strain, lower quality of social support, and lung disease increase the risk.