Childhood Behavioral Interventions May Promote Adult Cardiovascular Health

Childhood represents a unique time to instill heart-healthy behaviors, especially given emerging evidence that adult behaviors may be rooted in the environment individuals grow up in, according to a review published in the Journal of the American College of Cardiology.

Researchers explored the rationale behind focusing on children for health promotion, strategies for said health promotion (eg, school-, family-, and community-based approaches, and public policy), and gaps in research.

They pointed out that <1% of children in the United States have ideal dietary habits, and only ~50% of adolescents obtain the recommended amount of daily physical activity.

Furthermore, high total cholesterol levels are present in ~8% of children, and ~20% of high school students use tobacco products. However, if these behaviors are modified by or before adulthood, many individuals can substantially lower their risk for adverse cardiovascular events.

In terms of school-based initiatives, the researchers noted that effective interventions should use a “multilevel multicomponent educational approach.” The SI! Program (Salud Integral) is 1 such example, which has been studied in preschool-aged children. Its methodology seeks to empower the individual to adopt a healthy lifestyle via the implementation of multilevel (child, teacher, family, and school) and multicomponent (diet, physical activity, body and heart awareness, and emotional management) approaches.

Several study results demonstrated that Knowledge to Attitudes to Habits scores improved as a result of implementing this program. The SI! Program methodology is currently being investigated in older children (aged 6-11 years) and in adolescents (aged 12-16 years) across 2 clinical trials (ClinicalTrials.gov identifiers: NCT02428634 and NCT03504059).

Family-based programs that target childhood obesity, along with community-based programs to improve nutrition and physical activity and prevent smoking, have demonstrated positive outcomes. However, the researchers noted there is some inconsistency in the evidence.

There was no significant change in body mass index in the recent Growing Right Onto Wellness trial (ClinicalTrials.gov identifier: NCT01316653), for example. This finding may confirm previous meta-analysis results that found treatment of obesity and overweight in the form of diet, physical activity, and behavioral interventions may be beneficial only in achieving small, short-term reductions in body mass index. In addition, these interventions may be more effective the earlier in life they are initiated.

Comprehensive legislation that supports accessibility to healthy choices has been shown to increase the sale and consumption of healthier foods. Likewise, taxation on unhealthy foods and beverages, along with tobacco, has yielded reductions in sales of these products. The researchers suggested that these tax revenues could be reinvested in other healthy promotion programs to make them even more successful.

The implementation of school food environment policies helped to increase fruit and vegetable consumption by ~0.3 servings per day and reduced sugar-sweetened beverage and unhealthy snack intake by ~0.2 servings per day, according to a recent meta-analysis. If these policies were instituted nationwide, it is estimated that ~22,000 cardiometabolic disease-related deaths would be avoided per year. 

Limiting the marketing of foods and drinks that do not meet nutrition standards to children is another focus of public policy. Advertising across online and social media should be included.

Although health promotion programs in children may be beneficial, the authors stressed that certain gaps need to be addressed. First, interventions should start earlier in life and continue throughout childhood, using the multicomponent, multilevel approach with the support of the local community and legislation. In addition, adverse socioeconomic status should be accounted for, as it may trigger emotional issues that can lead to unhealthy habits. This is particularly important because underserved children are predisposed to high rates of disease.

Ultimately, more data on long-term outcomes and large-scale implementations of these kinds of interventions are necessary. “Longitudinal data directly linking unhealthy behaviors in children and [cardiovascular] outcomes in adults [are] scare, and needs more investigations,” the authors wrote. “Collaborative efforts are likely to yield unique insights on the independent effects of childhood levels of [cardiovascular] risk factors on subsequent disease occurrence.”

Reference

Fernandez-Jimenez R, Al-Kazaz M, Jaslow R, Carvajal I, Fuster V. Children: a window of opportunity for promoting health [published online December 6, 2018]. J Am Coll Cardiol. doi: pending