Author + information
- ↵∗Address for correspondence:
Dr. Keith C. Ferdinand, Tulane University School of Medicine, 1430 Tulane Avenue, #8548, New Orleans, Louisiana 70112.
The superior doctor prevents sickness. The mediocre doctor attends to impending sickness. The inferior doctor treats actual sickness.
—Chinese proverb (1)
An impressive decades-long reduction in U.S. cardiovascular disease (CVD) mortality has been documented, fueled by rapid progress in both prevention and treatment, including avoidance of cigarette smoking, high blood pressure treatment and control, lowered cholesterol levels with widespread statin use, and advances in coronary artery disease interventions (2). While approximately 47% of the CVD mortality decline has been attributable to evidence-based medical and surgical treatments, reductions in major risk factors contributed about 44% (2). Unfortunately, the gains in CVD mortality have recently plateaued and even increased in some subgroups, in consideration of persistently high and disparate CVD risk factors related to race/ethnicity, geography, and socioeconomic status (2).
Hence, the looming CVD mortality reversal may be fueled by suboptimal primordial prevention (healthy lifestyle and behavioral choices) with more prevalent obesity, including in children, and increases in hypertension and diabetes (2). Especially in blacks, hypertension is the most potent and prevalent CVD risk factor, and it is more frequently uncontrolled in racial/ethnic minorities, including not only blacks, but also Asian Americans and Hispanics (3).
Optimal cardiovascular health, defined as avoiding smoking, physical inactivity, obesity, poor diet, hypertension, high cholesterol, and diabetes, is associated with less incident heart failure and vascular disease (4). However, <1% of U.S. children meet all 7 criteria for ideal health (4). From 2009 to 2015, there was a steady rise from 24.9% to 41.7% in the time children spend sitting ≥3 h/day on computers for activities other than school work (e.g., video games or other computer games) (4). Strong national policies promoting primordial prevention may help children and families develop nutritious eating patterns, become active, and support healthier schools, child-care settings, and communities (Figure 1).
The 2018 State of Obesity report notes a U.S. childhood obesity rate of 18.5%, the highest rate ever documented, and rising as children get older: 13.9% of children age 2 to 5 years, 18.4% age 6 to 11 years, and 20.6% age 12 to 19 years have obesity (5). Unfortunately, disparities include a prevalence of 25.8% among Hispanic/Latino and 22% among black children, compared with non-Hispanic white (14.1%) and non-Hispanic Asian (11.0%) youth (5). Head Start, a comprehensive early childhood education program, prepares >1 million low-income children under the age of 5 years for school every year by providing education, health, and social services (5). Providing low-income children with nutritious meals may curtail obesity, as documented by the decline in obesity rates among 2- to 4-year-old children enrolled in WIC (the Special Supplemental Nutrition Program for Women, Infants and Children) (5).
The National School Lunch and School Breakfast Programs, offered to the 51% of U.S. children who qualify for free and reduced-price school meals, and school-based physical education may also be important pathways to reduce obesity (6). Considering that children may get one-third to one-half of their daily calories at school, in 2012 under the Healthy Hunger-Free Kids Act, the Obama administration established new standards to raise the overall nutritional requirements for school breakfast and lunch meals (6). Yet, to be determined are the effects of the recently mandated December 2018 reversal of these efforts: allowing flavored, low-fat milk, loosening weekly requirements for whole grains, and providing schools more time for gradual sodium reduction (6).
Moreover, to encourage physical activity, the 2018 U.S. Physical Activity Guidelines, for the first time, offers guidance for preschool children (ages 3 through 5 years), to move and engage in active play as well as in structured activities (7). To improve bone health and avoid excess fat in young children, the new guidelines target 3 h/day of activity (7).
In this issue of the Journal, the FAMILIA (Family-Based Approach in a Minority Community Integrating Systems-Biology for Promotion of Health) trial notes the potential benefit of early childhood healthy living promotion, specifically in an underserved community. This cluster-randomized controlled study involving Head Start preschools in Harlem, New York. Schools instilled healthy behaviors in relation to diet, physical activity, body/heart awareness, and emotion management compared with a standard curriculum (control). The primary outcome was change from baseline in the overall knowledge, attitudes, and habits (KAH) score in 562 preschool children ages 3 to 5 years (51% female, 54% Hispanic/Latino, and 37% African-American). Compared with the control group, the mean relative change from baseline in the overall KAH score was ∼2.2 fold higher in the intervention group (average absolute difference of 2.86 points; 95% confidence interval: 0.58 to 5.14; p = 0.014). However, indicating an unmet need, the improvements trended to less positive in the black children and those from the poorest families, with the largest benefits among 4-year-old children, boys, and Hispanic/Latino children, and among children from families with relatively higher self-reported annual household income (≥$25,000) and education level (high school or higher) (8).
Despite the positive results of the FAMILIA trial, continuous efforts are still needed to define the best approaches to healthy lifestyle interventions for preschool children, recognizing that definitive evidence of sustained results of similar programs remains limited (9). For instance, health care providers and others must serve as interventionists to also target parents for skill training and behavioral change in addition to general health and nutrition education for their children (9).
The suggestion that primordial CVD prevention should start in childhood is not new. The late Dr. Gerald Berenson was a prescient pioneer with his longitudinal study of CVD risk in children, the landmark BHS (Bogalusa Heart Study), which launched in 1972 in his Louisiana hometown and became the longest-running biracial health study in the world (10). The original BHS collected CVD risk factor data including blood pressure, height, weight, maturation, triceps skinfold thickness, lipids, and hemoglobin in 3,524 children (93% of the eligible population) (10). The reason CVD risk must be addressed in early childhood was profoundly demonstrated by Voors et al. (10): black children had significantly higher blood pressure levels than white children, starting before age 10 years, and childhood obesity was a strong determinant of blood pressure level. The BHS continues to yield important data; specifically, adiposity and elevated blood pressure are associated with left ventricular hypertrophy beginning in childhood (11).
Although the BHS generated thousands of peer-reviewed papers and encouraged worldwide preventive programs for very young children, Dr. Berenson was not satisfied with simply accumulating data, but actively sought to implement what he and his colleagues had reported (12). Recognizing that precursors of CVD begin at a young age, with many children already possessing 1 or more known risk factors (hypertension, obesity, and dyslipidemia) Berenson’s Heart Smart Program, established 3 decades ago for grades kindergarten through 6, encouraged the acquisition and maintenance of health-enhancing behaviors (12). Heart Smart promulgated nutritious eating habits; physical fitness and exercise; control of stress; and avoidance of smoking, alcohol, and drugs (12). Among others, he specifically promoted primordial prevention in a New Orleans Lower Ninth Ward elementary school, Joseph A. Hardin, destroyed by Hurricane Katrina in 2005, so black children in a disadvantaged urban environment could benefit from lessons learned from his rural biracial Bogalusa cohort (12). He considered Heart Smart to be a pathway for young children not only to better cardiometabolic health, but also to a more successful, drug-free, healthy adulthood (12).
The FAMILIA study represents an opportunity to identify best practices to potentially reduce obesity and CVD risk in children and youth, including children ages 0 to 6 years and subgroups where obesity prevention programs and their evidence of effectiveness remains limited (8). Childhood, including in the pre-school years, is a critical period for preventing obesity and CVD risk (8). Despite the need for evidence of long-term follow-up and sustainability, the FAMILIA trial is an important milestone for establishing healthy behaviors among preschoolers from a diverse and socioeconomically disadvantaged community (8). The time is now for primordial CVD prevention, which is even more critical in minorities and children from families with the lowest incomes and educational attainment (8).
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Dr. Ferdinand has served as a consultant for Quantum Genomics, Amgen, Sanofi, Novartis, Boehringer Ingelheim, and Janssen.
- 2019 American College of Cardiology Foundation
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