The results of this cross-sectional analysis of modifiable cardiovascular risk factors in adults in Germany suggest that, for the vast majority of adults in Germany, there is a high prevention potential for all of the behavioural risk factors investigated in this study: daily smoking, insufficient fruit, vegetable and fish consumption, high alcohol intake, insufficient physical activity and overweight. Almost 85 % of adults aged 40–79 years have at least one of these risk factors, with 45 % having a combination of two or more risk factors.

Studies on CVD risk factors in different countries are often difficult to compare due to differences in the specific combinations and definitions of the risk factors that were assessed. In the United States adherence to five healthy behavioural factors (including fruit and vegetable consumption, regular exercise, healthy weight, alcohol consumption and smoking) in 40 to 74 year olds was as low as 8 % in 2006 and had decreased from 15 % in 1988 [14]. A recent analysis from Italy on six cardiovascular risk factors (smoking, low fruit/vegetable consumption, obesity/overweight, hypertension, dyslipidaemia and diabetes) found that 90 % of the study population had more than one and 84 % had between two and five risk factors [15].

For BP and TC, we report prevalences of elevated, i.e., uncontrolled values as measured in our study. These prevalences do not include controlled hypertension or controlled hypercholesterolemia. It is encouraging that the target BP (<140 mmHg systolic and < 90 mmHg diastolic) was reached by almost 80 % of the participants but this proportion may be lower among severely ill patient groups. For comparison, in the SHARE survey the more stringent targets of < 140/90 mmHg in general and < 130/80 mmHg for patients with co-morbidities or high CV risk were reached by less than 60 % of general practice patients and by less than half of patients treated by cardiologists/internists [16]. The joint ESC 2012 guideline targets for hyperlipidaemia are mainly based on low-density lipoprotein (LDL) levels. We used TC and non-HDL since fasting level LDL data were not available for a sufficient number of participants. However, TC and non-HDL are established markers for increased cardiovascular risk and are independent of fasting time [17, 18]. The TC targets were more often reached by the CHD or stroke group than by the group without CHD or stroke, which is similar to previous findings [19] and most likely reflects more intensive lipid-lowering therapy among people with prior CHD or stroke. However, almost 90 % of the CHD or stroke group exceeded the stringent non-HDL target.

Except for physical inactivity, prevalence of behavioural risk factors was higher among men. Other studies found similar results concerning physical activity [20], smoking [5, 21], BMI [15] and fruit and vegetable intake [15]. Possible reasons include gender-specific cultural norms relating to lifestyle [22] and gender-specific responses to lifestyle. Higher prevalences for most modifiable risk factors were found among the age group 60–79 years compared to the younger group. This indicates the need for preventive interventions at early life stages, because the risk of CVD increases with the duration of risk factor exposure [3].

The strengths of our study include the large nationwide sample of community-dwelling adults, the highly standardized measurements and the detailed questionnaires. The most important limitation is that severely ill and institutionalized men and women were mainly not included in the study which may have led to an underestimation of the risk factor proportions and to the rather low stroke and CHD prevalence. Equally important, the group without prior CHD or stroke includes individuals in all risk categories including high risk. It is a heterogeneous group which is not in the main focus of the paper. Therefore, the main finding is that uncontrolled risk factors are currently still highly prevalent both in the overall group (general population) and in the group with prior CHD or stroke, a clearly high-risk group likely to be aware of this high risk. A further limitation is the self-reported diagnosis of hypertension and dyslipidaemia which may have led to an underestimation of the prevalence of these diseases. However, information on prior diagnosis was used only to calculate awareness of elevated BP and elevated TC.

The risk factors in this analysis are all among the top risk factors contributing to the Global Burden of Disease both 1990 and 2010 [23]. It is never too late for improvements in behavioural risk factors, as illustrated by a 35 % reduction of CVD events in 4 years in adults aged 45 years and older who switched to a healthy lifestyle [2]. Clearly, to individuals and to treating physicians it may appear more intuitive to put effort into lifestyle changes and enrol in prevention interventions in high-risk situations [24] where the number-needed-to-treat to prevent an event is low. However, population benefits are larger if healthy lifestyles are adopted early on in order to prevent or delay hypertension, dyslipidaemia, obesity and chronic diseases [25, 26]. Action is required both at the health care system and societal level. Individuals may need treatment, but more often they need knowledge, motivation and accessible, convenient and attractive opportunities for improved lifestyle. For example, health education through mass media has been shown to be cost-effective to limit CVD [27]. The key to population-wide risk factor changes is clearly a combination of personal and non-personal interventions.