Preventing future CVD in childhood


Moving beyond intervention for diet and exercise, a new study out of Spain shows that incorporating health knowledge at the preschool level may help improve long-term cardiovascular health.

Health promotion in the early years can have a profound effect on long term health-even at the preschool level, according to a new study published in the Journal of the American College of Cardiology.

"This study suggests pediatricians could play an enormous role in educating children about cardiovascular risk factors, modifying their behavior, and ultimately reducing their future cardiovascular risk,” says Deepak L Bhatt, MD, MPH, executive director of interventional cardiovascular programs at Brigham and Women's Hospital and professor of medicine at Harvard Medical School, who authored commentary on the study.

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The study outlines a research program performed involving more than 2000 children spread across 24 public schools in Madrid, Spain. The SI! Program utilized a 1-, 2-, and 3-year intervention plans for children aged 3 to 5 years with schools, teachers, and families reinforcing cardiovascular health promotion through classroom activities and take-home materials on healthy diets, exercise, and education about the human body.

Adoption of unhealthy behavior habits begin early in life, and have a fast and lasting impact on long term cardiovascular health. According to the study authors, research has shown evidence that cardiovascular disease markers for conditions such as dyslipidemia, hypertension, obesity, and metabolic syndrome can set in at as early as 3 years of age.

“Early childhood is a unique opportunity to implement preventive strategies tackling lifestyle,” according to the study authors. “For very young children, school may be the most appropriate choice for a behavioral intervention, as it constitutes the most reliable means of effective transfer of knowledge and appropriate educational strategies. In the best-case scenario, the school-based intervention will also encompass the children’s families to create a supportive environment and enhance its effect.”

Traditionally, school-based interventions have focused on diet and physical activity, but few have incorporated behavioral components such as prosocial behaviors, according to the report.

“Incorporating the promotion of positive social interactions through improved management of emotions has been proposed as a way of preventing the initiation of addictions, such as smoking or alcohol consumption,” the study authors write. “Preventive strategies addressing the social context of children could increase the efficiency of the intervention, acting as a complementary and cohesive factor against the development of unhealthy behaviors.”

Three separate program structures were used for the study, targeting children of different ages using different program lengths.

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Three-year-old students were placed in a 3-year intervention program; 4-year-olds in a 2-year program; and 5-year-olds in a 1-year program. The children in the study groups were assessed by pediatric psychologists at the start and completion of the program on their knowledge and attitudes toward health. Researchers found that students in the 3-year SI! Program received the most benefit, and that program students overall scored higher than their peers who were not in the program on their health knowledge.

First-year students in the 3-year program scored 5.5% higher on their health status and knowledge than their peers; second-year students scored 7.7% higher; and third-year students scored 4.9% higher, according to the report, with researchers crediting the spike in year 2 to a greater emphasis on the physical activity component of the program.

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Four-year-olds participating in the 2-year program displayed assessment levels 4.3% and 5.9% higher in the first and second year, respectively, than their peers not in the SI! Program, according to the report. In the 5-year-old program using just 1 year of interventions, although physical activity assessment scores improved significantly, but researchers found no improvement in the diet or behavioral knowledge components of the program.

Researchers say the scores also were influenced by the level of the education the students’ parents had attained, as well as income levels. Study authors note that the children who scored the highest had parents with higher incomes who had at least completed high school. Parental age had no impact on the students’ outcomes, according to the report, but students who were of European descent scored highest.

In addition to increased knowledge, the study notes that the students in the SI! Program were healthier than their peers, with a 1.1% prevalence of obesity among program students compared to 1.3% among control group students. The percentage of overweight children in the program group was 7%, compared to 7.4% in the control group, and researchers noted that the most positive physical benefits of the program were observed in a group of students that participated in the program for the entire three-year duration. Program participation lasting less than 2 years had no impact on levels of body fat, according to the report.

Unlike some community- or school-based programs that focus on just 1 or 2 aspects of health, the SI! Program focuses on instilling lifestyle behaviors that can be applied to physical activity, diet, and an understanding of human physiology, according to the study authors.

The program also incorporated assessments and involvement from pediatricians, along with families, schools systems, and teachers. Teachers who helped facilitate the program received training, and had access to online intervention resources. They also communicated with other teachers participating in the program to share their experiences and observations, according to the report.

NEXT: Looking toward the long term effects


Additionally, the study authors note that research into the long term effects of the program is ongoing. The children involved in the initial study will be followed throughout elementary school to track long term success of the interventions, according to the report, and a new study has been started to evaluate similar interventions in the 6- to 12-year age group.

The study authors conclude that, given the high success rates in improved knowledge among students that participated in the 3-year SI! Program, wider, long-term adoption of such interventions would have a significant positive effect on cardiovascular health promotion.

In an additional commentary published on the report, Muthiah Vaduganathan, MD, MPH; Atheendar S. Venkataramani, MD, PhD; and Deepak L Bhatt, MD MPH, write that the SI! Program is innovative in its use of a structured protocol and evaluative framework that are often lacking in community-based public health programs. Behavior modulation drives the program, as well as a push to drive the early formation of healthy preferences in the children enrolled in the program.

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“Interventions targeted during a development period in childhood when preferences are formed may have powerful influences on behaviors later in life,” the authors write in their commentary. “This preference building may be reinforced through peer support in this school-based intervention.”

The commentary authors further state that the interventions used in the “groundbreaking” program may help positively influence the long-term programming of metabolic health and other health behaviors.

“It may not only be the cardiovascular health information itself that is helpful, but also the cognitive stimulation from and exposure to positive adult role models, which in turn influences personality traits such as delayed gratification and impulse control that are critical for health behavior and habit formation later in life,” the commentary authors write. “This pioneering study represents an important step in exploring the intersection of child development, cardiovascular health promotion, and primordial prevention.” 

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