The Future of Promoting Health: Should Childhood Education Be the Priority Focus?

Educational Objectives

After completing the activity, the clinician will be better able to describe a strategy for sustaining health throughout a lifetime, including the clinical strategy for 3 broad time periods in life.

Summary

Interviewer: Alfred A. Bove, MD, PhD, MACC

Take-home Messages:

• A multilevel, multicomponent, school-based program can positively affect knowledge, attitudes, and behavior related to healthy lifestyles in preschool children.
• Program SI! (or Salud Integral [“comprehensive health”]) is a groundbreaking public health program that has already transformed the delivery and study of high-impact, cost-effective interventions at the community level.
• At every age range, there are specific scientific/physiopathological backgrounds and educational/behavioral tools available to best intervene.

Investigators, led by Valentin Fuster, MD, PhD, have proposed a strategy for sustaining health throughout a lifetime, which involves a stratified approach at 3 different age ranges in the life of an individual. There is evidence that such a tripartite division could be most effective in promoting cardiovascular health or preventing the progression of disease, even among those at highest risk for cardiovascular events.

The evidence suggests there is an optimal time to motivate behavior in favor of health. This time is probably earlier than you think. As Dr. Fuster explained in one of his JACC Editor’s pages, “Indeed, there is evolving evidence that our behavior as adults has its roots in the environment that we live in from age 3 to 5 years. Furthermore, unhealthy diets begin to influence cardiovascular disease markers early in life, and conditions such as dyslipidemia, high blood pressure, impaired glucose tolerance, as well as obesity and metabolic syndrome, may become rooted as early as 3 to 5 years of age, increasing the risk of development of atherosclerosis in adolescence and early adulthood.”¹

In recent years, several new health care delivery models have been proposed by policy makers or politicians, including personalized medicine, precision medicine, the patient-centered medical home, and accountable care organizations. Yet, Dr. Fuster noted in JACC, “those of us who are actually entrusted to keep people healthy need to start approaching the population with a stratified health strategy.”

If health promotion and education start very early, when is the second big opportunity for stratified health? The evidence suggests that the age range of 25 to 50 years appears to be the right time to evaluate subclinical disease. (To think of it another way, this would be the period to initiate primary prevention. For primordial prevention — that is, the prevention of risk factors — that should occur from birth to age 25.)

And the third opportunity? That would be secondary prevention among individuals aged ≥ 50 years. This is the period when cardiovascular disease has often begun to manifest itself symptomatically or by an adverse event. However, Dr. Fuster emphasizes not to concentrate on the heart to the exclusion of the rest of the vasculature and, in particular — don’t forget the brain.

Degenerative brain disease is intimately linked to the vasculature and overall burden of atherosclerosis. Specifically, Dr. Fuster notes, the heart–degenerative brain disease axis is perceptible across a very broad spectrum of disease, from macrovascular large-vessel coronary, carotid, or ilio-femoral diseases leading to myocardial infarction or stroke, to microvascular small vessel changes causing dementia.

Thus, he wrote, “We must make a transition from primarily considering the coronary vessels to looking at the entire individual in terms of systemic cardiovascular disease, which includes the neurovascular region.”

At the Beginning

Given the data, what are the logistics of targeting kids 3 to 5 years of age? During these ages, education can include such topics as how the body and heart work, healthy food habits, physical activity, and emotional habits to avoid addictions. In the SI! Program for Cardiovascular Health Promotion in Early Childhood, for example, the intervention was designed to be applied at all preschool levels in 24 schools in Madrid, Spain, and included 2,062 children age 3 to 5 years.²

The goal was to promote cardiovascular health among children using their proximal environment (school, teachers, and families). Children were therefore exposed to the SI! Program for 1, 2, or 3 years, depending on their starting grade. Dr. Fuster and colleagues demonstrated that improvement was initially demonstrated during the first year of intervention and this program translated into a beneficial effect on adiposity, with maximal effect when started at the earliest age and maintained over 3 years.³

In an editorial comment accompanying the results published in JACC, Muthiah Vaduganathan, MD, MPH, Atheendar Venkataramani, MD, PhD, and Deepak L. Bhatt, MD (all of Brigham and Women’s or Massachusetts General Hospital, Boston), wrote, “Program SI!, standing for Salud Integral (or comprehensive health), is a groundbreaking public health program that has already transformed the delivery and study of high-impact, cost-effective interventions at the community level.” Furthermore, as improvements in cardiovascular disease (CVD) mortality plateau in the United States and the burden of CVD and its risk factors grow worldwide, new approaches targeting multiple levels of disease epidemiology need to be forged. Based on the evidence, the earlier the better for targeting community health.

Barrier Busting

There might be a few barriers to successfully implementing a health program for kids this age and their caregivers — and Dr. Fuster and his team have identified many of them. Fortunately, they also have identified actions to successfully address these barriers.

The 7 identified themes they reported at AHA.15 are:

• knowledge regarding social determinants of chronic diseases
• knowledge and perceptions regarding childhood obesity
• impact of stress on health
• impact of media and advertising on health choices
• perception regarding researchers
• incentives for healthy behaviors and choices
• cultural and social sensitivity
• Using this knowledge, they have now designed FAMILIA (Family-Based Approach in a Minority Community Integrating Systems-Biology for Promotion of Health).4 Ground zero for this study: Harlem, New York.

They will also be evaluating the effect of disparities on children’s health outcomes following a health promotion educational intervention in preschool children, focusing on variables such as:

• impact of socioeconomic differences at the family level
• factors that impact the teachers’ efficacy in implementing the educational intervention and health outcomes in children
• effect of school environment in implementing the educational intervention and health outcomes in children.

For this prospective educational intervention project, Dr. Fuster’s team will be involving public preschools in all 5 boroughs of New York City. Children between 3 and 5 years of age will receive their evidence-based health promotion educational curriculum for 5 months, followed by 24 months of follow-up.

Readings

1. Fuster V. Stratified approach to health: integration of science and education at the right time for each individual. J Am Coll Cardiol 2015;66:1627-9. www.onlinejacc.org/content/66/14/1627

2. Peñalvo JL, Sotos-Prieto M, Santos-Beneit G, et al. The Program Sl! intervention for enhancing a healthy lifestyle in preschoolers: first results from a cluster randomized trial. BMC Public Health 2013;13:1208. doi: 10.1186/1471-2458-13-1208

3. Peñalvo JL, Santos-Beneit G, Sotos-Prieto M, et al. The SI! program for cardiovascular health promotion in early childhood: a cluster-randomized trial. J Am Coll Cardiol 2015;66:1525-34. www.onlinejacc.org/content/66/14/1525

4. Bansilal S, Vedanthan R, Kovacic JC, et al. Rationale and design of Family-Based Approach in a Minority Community Integrating Systems-Biology for Promotion of Health (FAMILIA). Am Heart J 2017;187:170-81.

Disclosures

Valentin Fuster, MD, PhD, MACC
This author has nothing to disclose.

Interviewer: Alfred A. Bove, MD, PhD, MACC
World Health Networks, Inc (C); Merck & Co Inc (G,C); Insight Telehealth Systems Inc (C,E)

Acknowledgements

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

AC500719

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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