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Introduction: Early-life determinants of middle-age cardiovascular health are poorly understood. This study examines associations of BMI and physical fitness in male adolescents with cardiovascular health measured by the Life's Essential 8 score in middle age.

Methods: A population-based cohort study linked BMI and physical fitness from the Swedish Military Conscription Register (men conscripted from 1972 to 1987) to cardiovascular health from the Swedish CArdioPulmonary bioImage Study (2013–2018). In 2025, a total of 8,930 men (mean age, 18.3 years) were analyzed after 38.2 years of follow-up.

Physical fitness included cardiorespiratory fitness (maximal cycle-ergometer test) and muscular strength (isometric dynamometry of knee extension, elbow flexion, and handgrip). Cardiovascular health was evaluated using the American Heart Association's Life's Essential 8 score (0–100 points; poor health: <60). Associations were assessed using linear and binomial logistic regressions and restricted cubic splines.

Results: BMI and cardiorespiratory fitness exhibited J-shaped and linear associations, respectively, with cardiovascular health. Compared with normal weight (BMI: 18.5–24.9 kg/m2), AORs of having poor cardiovascular health for overweight (BMI: 25.0–29.9 kg/m2) and obesity (BMI ≥30 kg/m2) were 2.42 (95% CI=2.00, 2.92) and 5.38 (95% CI=2.99, 9.70). No statistically significant associations were observed between muscular strength and cardiovascular health.

Conclusions: Obesity and low levels of cardiorespiratory fitness in male adolescents were associated with lower cardiovascular health in middle age, after nearly 4 decades of follow-up. Although further studies are needed, the promotion of a healthy body weight and cardiorespiratory fitness in youth may be of importance for later cardiovascular health.