Cardiovascular Health Promotion in Children: Challenges and Opportunities for 2020 and Beyond: A Scientific Statement From the American Heart Association

Psychometric Properties of the Healthy Lifestyle Beliefs Scale for Adolescents

INTRODUCTION

Healthy lifestyle behaviors are at the core of maintaining health. This study analyzed the psychometric properties of the 16-item healthy lifestyle beliefs (HLB) scale that measures a person's beliefs about their ability to live a healthy lifestyle.

METHOD

Descriptive statistics, exploratory factor analysis, confirmatory analysis, and measurement invariance were conducted for this study.

RESULTS

Cronbach alpha was 0.894. The Exploratory factor analysis scree plot identified two factors with eigenvalues greater than one. All factor loadings were greater than 0.40 and no items cross-loaded. A two-factor solution was retained for Confirmatory factor analysis. The measurement invariance results suggested that there was no gender difference in HLB regarding factor structure, factor loading, threshold, and residual variances.

DISCUSSION

The HLB scale was found to have adequate internal consistency and fit with the data. Findings show it is valid and acceptable for both boys and girls.

Positive psychological well‐being and cardiovascular disease: Exploring mechanistic and developmental pathways

Empirical research regarding the health benefits of positive psychological well‐being (e.g., positive emotions, life satisfaction, purpose in life, and optimism) has flourished in recent years, particularly with regard to cardiovascular disease. This paper reviews the state of evidence for well‐being's association with cardiovascular disease in both healthy individuals and those diagnosed with a disease. Prospective studies consistently indicate well‐being reduces cardiovascular events in healthy and, to a lesser extent, patient populations. Potential pathways that link well‐being with cardiovascular disease are discussed (including health behaviors, physiological processes, and stress buffering), although the existing evidence is mostly cross‐sectional which limits conclusions about directionality. Issues related to development across the lifespan are considered and childhood is identified as a crucial period for establishing healthy cardiovascular trajectories. Outstanding questions for future research are provided with recommendations to focus on well‐powered and prospective study designs with rigorous assessment of both well‐being and cardiovascular‐related outcomes.

Development of a Health Information Technology Tool for Behavior Change to Address Obesity and Prevent Chronic Disease Among Adolescents: Designing for Dissemination and Sustainment Using the ORBIT Model

Health information technology (HIT) has not been broadly adopted for use in outpatient healthcare settings to effectively address obesity in youth, especially among disadvantaged populations that face greater barriers to good health. A well-designed HIT tool can deliver behavior change recommendations and provide community resources to address this gap, and the Obesity-Related Behavioral Intervention Trials (ORBIT) model can guide its development and refinement. This article reports the application of the ORBIT model to (1) describe the characteristics and design of a novel HIT tool (the PREVENT tool) using behavioral theory, (2) illustrate the use of stakeholder-centered "designing for dissemination and sustainability" principles, and (3) discuss the practical implications and directions for future research. Two types of stakeholder engagement (customer discovery and user testing) were conducted with end users (outpatient healthcare teams). Customer discovery interviews (n = 20) informed PREVENT tool components and intervention targets by identifying (1) what healthcare teams (e.g., physicians, dietitians) identified as their most important "jobs to be done" in helping adolescents who are overweight/obese adopt healthy behaviors, (2) their most critical "pains" and "gains" related to overweight/obesity treatment, and (3) how they define success compared to competing alternatives. Interviews revealed the need for a tool to help healthcare teams efficiently deliver tailored, evidence-based behavior change recommendations, motivate patients, and follow-up with patients within the constraints of clinic schedules and workflows. The PREVENT tool was developed to meet these needs. It facilitates prevention discussions, delivers tailored, evidence-based recommendations for physical activity and food intake, includes an interactive map of community resources to support behavior change, and automates patient follow-up. Based on Self-Determination Theory, the PREVENT tool engages the patient to encourage competence and autonomy to motivate behavior change. The use of this intentional, user-centered design process should increase the likelihood of the intended outcomes (e.g., behavior change, weight stabilization/loss) and ultimately increase uptake, implementation success, and long-term results. After initial tool development, user-testing interviews (n = 13) were conducted using a think-aloud protocol that provided insight into users' (i.e., healthcare teams) cognitive processes, attitudes, and challenges when using the tool. Overall, the PREVENT tool was perceived to be useful, well-organized, and visually appealing.

The Cardiovascular Health Integrated Lifestyle Diet (CHILD) Lowers LDL-Cholesterol Levels in Brazilian Dyslipidemic Pediatric Patients

OBJECTIVE

To analyze the impact of the CHILD-2 diet on the lipid profile of Brazilian children and adolescents with dyslipidemia.

METHODS

This is a quasi-experimental study, where 149 participants (5-17 years) with mild-to-moderate hypercholesterolemia were divided into two groups (GI: low or normal weight; n = 58 and GII: overweight; n = 91). Both groups underwent the CHILD-2 diet, characterized by 25-30% total fat and less than 7% of low-saturated fat (SF) for 6 months. Changes from baseline in the lipid profile, including Total cholesterol (TC), LDL-C, triacylglycerols and glucose concentrations, dietary and anthropometric data were examined at 3 and 6 months. Longitudinal analyses were performed using linear mixed-effects models in SAS.

RESULTS

Serum LDL-C concentrations reduced over time compared with baseline (Δ = -5.1 mg/dL; p < 0.01), with no difference between groups (p = 0.35). TC concentrations decreased by -2.0 mg/dL (p < 0.01); but no difference was observed between groups. We found no significant changes in body mass index/age Z scores after a dietary intervention compared with baseline in both groups (p = 0.94).

CONCLUSION

Despite the modest reduction, our findings confirm that children with dyslipidemia can benefit from the CHILD-2 diet combined with a healthy lifestyle.

Ideal cardiovascular health at age 5-6 years and cardiometabolic outcomes in preadolescence

BACKGROUND

The American Heart Association (AHA) developed a definition of ideal cardiovascular health (ICH) based on the presence of both ideal health behaviours (diet, physical activity, weight status and smoking) and ideal health factors (glucose, total cholesterol and blood pressure levels). However, research of ICH in the paediatric population is scarce. We aimed to study ICH at age 5-6 years by extending the original ICH score with the health behaviours: sleep duration, screen time and prenatal smoke exposure, and to evaluate its association with cardiometabolic outcomes at age 11-12.

METHODS

A total of 1666 children aged 5-6 years were selected from the database of the ABCD-study, a prospective cohort study on the health and development of children born in Amsterdam, the Netherlands. Of these, 846 (50.8%) were boys and 1460 (87.6%) had a healthy weight. Data on self-reported health behaviours and health factors were used to calculate the ICH scores (original and extended) by adding the frequency of scoring 'healthy' on each indicator, based on international cut-offs. The children were followed up for 6 years and cardiometabolic outcomes (carotid intima-media thickness (CIMT), blood pressure, glucose and lipids) were measured. Associations between ICH (both original and extended) and cardiometabolic outcomes were examined using multivariable regression models.

RESULTS

At age 5-6 years, 11% scored poor (score 1-5), 56% intermediate (score 6-7) and 33% good (score 8-9) on extended ICH. Healthy diet and normal total cholesterol concentrations were the least prevalent. Neither the original nor the extended ICH scores were associated with CIMT at age 11-12. A higher score on the extended ICH was associated with lower total cholesterol (p for trend < 0.001), lower systolic (p for trend = 0.012) and diastolic blood pressure (p for trend = 0.011), and lower body mass index (BMI) (p < 0.001) at age 11-12. The original ICH score was associated with lower total cholesterol (p < 0.001) and BMI (p < 0.001) only.

CONCLUSION

Our findings suggest that extending the ICH score in young children with additional health behaviours improves prediction of some cardiometabolic outcomes, but not CIMT in preadolescence, compared to the original ICH score. We would recommend other researchers to incorporate objective measures of health behaviours and longer follow-up to find out whether associations persist into adulthood.

Durability of Changes in Biomarkers of Cardiometabolic Disease: 1-Year Family-Based Intervention in Children with Obesity

Background: The sustainability of health benefits in response to lifestyle-based interventions remains unclear in children with overweight and obesity, and cardiometabolic disease (CMD). We determined the changes in novel biomarkers of CMD in a 1-year family-based intervention (FBI) program, during 6-month active monitoring phase and at 12-month follow-up. Methods: Children with an age-adjusted body mass index (BMI) percentile ≥85 (N = 130; age 8-11 years) were recruited for a 1-year (6-month monitored and 6-month unmonitored) randomized controlled FBI program. Anthropometry and selected biomarkers of CMD were measured in 87 participants, randomly allocated to intervention (INT) and education-only (EDU) groups, at baseline, immediately after a 6-month active intervention or control period, and at 12-month unmonitored follow-up. Results: Samples from 87 participants (age 10.00 ± 0.11 years and Tanner stage ≤3) with obesity (BMI%ile = 97.45 ± 0.15) were available. Overall intervention effect (between groups), was observed for total (T) and high molecular weight (HMW) adiponectin, ratio of total to HMW adiponectin, fibrinogen, and interleukin (IL)-6 (P < 0.05 for all). However, between-group beneficial changes after adjusting for baseline levels were limited to BMI percentile, T and HMW adiponectin and their ratio, IL-6, and fibrinogen (P < 0.05 for all) mainly during the 6-month period of monitored intervention. Changes in traditional risk factors such as lipids and triglycerides were inconsistent. During the 6-month follow-up period, the changes in biomarkers leveled-off, except for T and HMW adiponectin, IL-6, and fibrinogen that continued to show benefits (P < 0.05) from the 6- to 12-month follow-up. Conclusions: The FBI program beneficially altered novel biomarkers of CMD during the monitored intervention phase in school-age children with obesity, but they mostly moved back toward baseline during the unmonitored follow-up phase. The changes in novel biomarkers of CMD appear to be more sensitive compared to the traditional risk factors. The study implies the need for refinements in lifestyle-based approaches in the preservation of cardiovascular health and calls for robust biomarkers to monitor the changes. The study was registered at ClinicalTrials.gov (NCT01146314).

The association between neighborhood quality, youth physical fitness, and modifiable cardiovascular disease risk factors

PURPOSE

Striking disparities persist in cardiovascular disease risk factors among minority youth. We examined the association between multiple indicators of neighborhood quality and minority youth fitness.

METHODS

The primary exposure was the Child Opportunity Index (COI), a measure comprised of indicators that facilitate healthy child development. Outcome data were drawn from the 2018-2019 Fit2Play Study (Miami-Dade County, FL). Hotspot analysis evaluated COI spatial clustering. Generalized linear mixed models examined cross-sectional COI-fitness associations.

RESULTS

The sample included 725 youth (53% Black, 43% Hispanic; 5-17 years). Significant neighborhood quality spatial clusters were identified (Gi*_z-score = -4.85 to 5.36). Adjusting for sociodemographics, walkability was associated with lower percentiles in body mass index (BMI) and diastolic blood pressure percentiles (DBP) (β = -5.25, 95% CI: -8.88, -1.62 and β = -3.95, 95% CI: -7.02, -0.89, respectively) for all, lower skinfold thickness (β = -4.83, 95% CI: -9.97, 0.31 and higher sit-ups (β = 1.67, 95% CI: -0.17, 3.50) among girls, and lower systolic blood pressure percentiles (SBP) (β = -4.75, 95% CI: -8.99, -0.52) among boys. Greenspace was associated with higher BMI (β = 6.17, 95% CI: 2.47, 9.87), SBP (β = 3.47, 95% CI: -0.05, 6.99), and DBP (β = 4.11, 95% CI: 1.08, 7.13).

CONCLUSIONS

COI indicators were positively associated with youth fitness. Disparities in youth cardiovascular disease risk may be modifiable through community interventions and built environment initiatives targeting select neighborhood factors.

Exercise Prescription to Foster Health and Well-Being: A Behavioral Approach to Transform Barriers into Opportunities

The current literature contains multiple examples of exercise interventions to foster health and to prevent/treat many chronic non-communicable diseases; stress and functional syndromes. On the other hand, sedentariness is increasing and to transform a sedentary subject into a regular exerciser is not only very difficult but considered by some unrealistic in current clinical practice. Ideally a physical activity intervention may be considered actually efficacious when it outgrows the research setting and becomes embedded in a system, ensuring maintenance and sustainability of its health benefits. Physicians need specific skills to improve patients' exercise habits. These range from traditional clinical competencies, to technical competencies to correctly prescribe exercise, to competencies in behavioral medicine to motivate the subject. From a behavioral and medical point of view, an exercise prescription may be considered correct only if the subject actually performs the prescribed exercise and this results in an improvement of physiological mechanisms such as endocrine, immunological and autonomic controls. Here we describe a model of intervention intended to nurture exercise prescription in everyday clinical setting. It aims to a tailored prescription, starts from the subject's assessment, continues defining clinical goals/possible limitations and ends when the subject is performing exercise obtaining results.

The Association of the Parent-Child Language Acculturation Gap with Obesity and Cardiometabolic Risk in Hispanic/Latino Youth: Results from the Hispanic Community Children's Health Study/Study of Latino Youth (SOL Youth)

BACKGROUND

Hispanic/Latino youth are disproportionately burdened by obesity and have a high prevalence of prediabetes and dyslipidemia. Differences in parent and child acculturation related to language use and preference (i.e., language acculturation) are associated with adverse cardiometabolic health behaviors, but no study has examined associations with cardiometabolic markers.

PURPOSE

To determine whether discordance in parent-child language acculturation (parent-child acculturation gap) was associated with poor youth cardiometabolic health.

METHODS

Hispanic/Latino 8-16-year-olds (n = 1,466) and parents from the Hispanic Community Children's Health Study/Study of Latino Youth (SOL Youth) were examined. Mean scores for the Brief ARSMA-II's Anglo (AOS) and Latino (LOS) Orientation Scales represented language acculturation. Cardiometabolic markers included youth body mass index (BMI) percentile, blood pressure percentiles, and dysglycemia and hyperlipidemia measures. Missing data were imputed. Survey-weighted multivariable linear regression examined the association of youth, parent, and youth × parent (the acculturation gap) AOS and LOS scores separately with each cardiometabolic marker.

RESULTS

Youth reported greater English and lower Spanish use than parents. Greater discordance in AOS scores was associated with elevated BMI percentile only (p-for-interaction < .01). The LOS acculturation gap was not associated with any outcome. Adjustment for acculturative stress, family functioning and closeness, parenting style, and youth's diet and physical activity did not alter findings. Removal of nonsignificant acculturation gaps did not indicate an association between individual youth or parent AOS or LOS scores and any cardiometabolic marker.

CONCLUSIONS

Discordance in Hispanic/Latino parent-child dyads' English use may relate to increased risk for childhood obesity. Future studies should identify mediators of this association.

Cardiovascular Health Trajectories From Childhood Through Middle Age and Their Association With Subclinical Atherosclerosis

Importance

Cross-sectional measures of cardiovascular health (CVH) have been associated with cardiovascular disease in older age, but little is known about longitudinal trajectories in CVH and their association with subclinical atherosclerosis in middle age.

Objectives

To model long-term patterns in CVH starting in childhood and to assess their association with subclinical atherosclerosis in middle age.

Design, Setting, and Participants

This cohort study used data from 5 prospective cardiovascular cohort studies from the United States and Finland from 1973 to 2015. A total of 9388 participants aged 8 to 55 years had at least 3 examinations and were eligible for this study. Statistical analysis was performed from December 1, 2015, to June 1, 2019.

Exposures

Clinical CVH factors (body mass index, total cholesterol level, blood pressure, and glucose level) were classified as ideal, intermediate, or poor, and were summed as a clinical CVH score. Group-based latent class modeling identified trajectories in this score over time.

Main Outcomes and Measures

Carotid intima-media thickness (cIMT) was measured for participants in 3 cohorts, and high cIMT was defined as a value at or above the 90th percentile. The association between CVH trajectory and cIMT was modeled using both linear and logistic regression adjusted for demographics, baseline health behaviors, and baseline (or proximal) CVH score.

Results

Among 9388 participants (5146 [55%] female; 6228 [66%] white; baseline mean [SD] age, 17.5 [7.5] years), 5 distinct trajectory groups were identified: high-late decline (1518 participants [16%]), high-moderate decline (2403 [26%]), high-early decline (3066 [32%]), intermediate-late decline (1475 [16%]), and intermediate-early decline (926 [10%]). The high-late decline group had significantly lower adjusted cIMT vs other trajectory groups (high-late decline: 0.64 mm [95% CI, 0.63-0.65 mm] vs intermediate-early decline: 0.72 mm [95% CI, 0.69-0.75 mm] when adjusted for demographics and baseline smoking, diet, and physical activity; P < .01). The intermediate-early declining group had higher odds of high cIMT (odds ratio, 2.4; 95% CI, 1.3-4.5) compared with the high-late decline group, even after adjustment for baseline or proximal CVH score.

Conclusions and Relevance

In this study, CVH declined from childhood into adulthood. Promoting and preserving ideal CVH from early life onward may be associated with reduced CVD risk later in life.

MILK Symposium review: The importance of milk and dairy foods in the diets of infants, adolescents, pregnant women, adults, and the elderly

The ongoing increase in life expectancy is not always accompanied by an increase in healthy life span. There is increasing evidence that dietary exposure in early life can substantially affect chronic disease risk in later life. Milk and dairy foods are important suppliers of a range of key nutrients, with some being particularly important at certain life stages. It is now recognized that milk protein can stimulate insulin-like growth factor-1 (IGF-1), essential for longitudinal bone growth and bone mass acquisition in young children, thus reducing the risk of stunting. Low milk consumption during adolescence, particularly by girls, may contribute to suboptimal intake of calcium, magnesium, iodine, and other important nutrients. Given the generally low vitamin D status of European populations, this may have already affected bone development, and any resulting reduced bone strength may become a big issue when the populations are much older. Suboptimal iodine status of many young women has already been reported together with several observational studies showing an association between suboptimal iodine status during pregnancy and reduced cognitive development in the offspring. There is now good evidence that consumption of milk and dairy foods does not lead to an increased risk of cardiovascular diseases and type 2 diabetes. Indeed, some negative associations are seen, notably between yogurt consumption and type 2 diabetes, which should be researched with urgency. Greater emphasis should be placed on reducing malnutrition in the elderly and on dietary approaches to reduce their loss of muscle mass, muscle functionality, and bone strength. Whey protein has been shown to be particularly effective for reducing muscle loss; this needs to be developed to provide simple dietary regimens for the elderly to follow. There is an ongoing, often too simplistic debate about the relative value of animal versus plant food sources for protein in particular. It is important that judgments on the replacement of dairy products with those from plants also include the evidence on relative functionality, which is not expressed in simple nutrient content (e.g., hypotensive and muscle synthesis stimulation effects). Only by considering such functionality will a true comparison be achieved.

Carotid Intima-Media Thickness in Healthy Children and Adolescents: Normative Data and Systematic Literature Review

Objectives: Early identification of children at risk of atherosclerosis is of paramount importance for implementing primary preventive measures addressing vascular health. Carotid intima-media thickness (cIMT) is a non-invasive biomarker of atherosclerosis. Semiautomatic radiofrequency-based software-guided technique quality intima-media thickness (RF-QIMT) was used to determine cIMT normative values in a healthy cohort of Caucasian children aged 6 to 18 years.

Study design: In a cross-sectional study, data on age, chronic illness, medication use, and pubertal status was acquired by a questioner. Anthropometric and blood pressure measurements were performed by standardized methods and trained medical personnel. cIMT of the right common carotid artery far wall (1 centimeter proximal to bifurcation) was determined using a multifrequency (3–13 MHz) electronic linear array transducer SL1543, a portable ultrasound device (MyLab Gamma Esaote, Genoa, Italy), and RF-QIMT software. A systematic review of the published normal cIMT in children was done using PRISMA methodology, and identified normative values were compared to those obtained in the presented study.

Results: 1137 non-obese normotensive children (males: n = 512; mean age 12.04 ± 3.52 years, females: n = 625, mean age 12.98 ± 3.83 years) were included. Gender-, age-, and height-specific mean cIMT percentile tables, percentile charts, and LMS tables for the RF-QIMT method were provided. They were comparable to the previously published data on mean cIMT gained by other validated ultrasound imaging techniques. cIMT increased with age, height, hip circumference, and BMI and was higher in males.

Conclusions: Gender-, age-, and height-specific normative cIMT values, using the semiautomatic software-guided RF-QIMT technique, in children aged 6 to 18 years were developed and validated in respect to the previously published pediatric normative cIMT data. It is suggested that the investigated method could be used for the estimation of atherosclerotic risk in children, especially in epidemiological studies.

Association of Vitamin D Status and Physical Activity with Lipid Profile in Korean Children and Adolescents: A Population-Based Study

Dyslipidemia is one of the important influencing factors of cardiovascular health in the youth, and thus, assessment of its etiology is important. We aimed to investigate the association of dyslipidemia with vitamin D and physical activity in Korean children and adolescents. Data of 3183 subjects aged 12–18 years in the Korea National Health and Nutrition Examination Survey were analyzed. Participants were divided into subgroups according to sex, body mass index, 25-hydroxyvitamin D levels, and lipid profile. The mean 25-hydroxyvitamin D level was 16.15 ng/mL, which was below normal. In total, 79.3% of the subjects had vitamin D deficiency. Females had lower vitamin D levels and a higher incidence of dyslipidemia compared to males. Vitamin D deficiency was significantly associated with high density lipoprotein cholesterol (HDL-C) levels. The low HDL-C group consisted of a higher proportion of subjects with vitamin D deficiency and low physical activity. This study suggests that vitamin D deficiency is prevalent in Korean children and adolescents. Vitamin D deficiency and low physical activity are related with low HDL-C levels. Maintaining sufficient vitamin D levels and physical activity may help prevent dyslipidemia.

Effects of a Community-Based Pilot Intervention on Home Food Availability among U.S. Households

The purpose of this study was to assess the effects of a pilot community-based behavioral intervention on the home food environment in U.S. households. Parents (21 females, 2 males; age = 36 ± 5.5 years; 78% Hispanic) of elementary school-aged children attended a 10-week dietary improvement behavioral intervention targeting an increase in fruit and vegetable consumption and a reduction in sugar intake. Home food availability of fruit, vegetables, and sugar-laden foods and beverages were assessed before and after the intervention using a modified version of the Home Food Inventory. Relative to baseline, the intervention resulted in significant increases in fruit availability (7.7 ± 3.2 items vs. 9.4 ± 3.1 items; p = 0.004) and low sugar cereal (2.3 ± 1.4 types vs. 2.7 ± 1.4 types; p = 0.033). There was a significant reduction in sugar-sweetened beverage availability (3.2 ± 1.9 types vs. 1.7 ± 1.3 types; p = 0.004). There was a significant increase in the number of households with accessible ready-to-eat vegetables and fruit, and a significant reduction in available prepared desserts, and candy (p < 0.01). There were no significant changes in the availability of vegetables and sugar-laden cereals. The current intervention resulted in positive changes in the home food environment. Further research to confirm these results in a randomized controlled trial is warranted.

Effects of short-term consumption of strawberry powder on select parameters of vascular health in adolescent males

Cardiovascular disease is a leading cause of death in the United States and much of the developed world, costing billions of dollars in lost work time, lower productivity and high health care expenditures. Research on foods and bioactive food components that have cardioprotective benefits may provide new insights as to how modest changes in one's diet may result in a reduced risk of vascular disease. In intervention trials, the consumption of strawberries, either fresh or freeze-dried, has been reported to improve select markers of cardiovascular health, including improved lipid profiles, microvascular function, and platelet reactivity. Consistent with the above, epidemiological studies suggest beneficial effects of strawberries on vascular function. Preliminary studies on the effects of freeze-dried strawberry powder on vascular health are reviewed in the current paper.

Preventing Premature Atherosclerotic Disease

PURPOSE OF REVIEW

Cardiovascular disease (CVD) can begin in youth. Prevention is essential to reducing the burden of CVD-related risk factors in childhood and disease development in adulthood. This review addresses the clinical scope of CVD prevention, including a review of conditions encountered, proposed diagnostic criteria, and management strategies. We also highlight the impact of the intrauterine environment on the development of CVD risk. Finally, we highlight the potential role of telehealth in the management of pediatric patients with risk factors for premature CVD.

RECENT FINDINGS

Growing evidence suggests that maternal obesity, diabetes, and preeclampsia may play an important role in the development of CVD risk among offspring contributing to the development of known traditional CVD risk factors among offspring. As the prevalence of CVD continues to rise, knowledge as well as appropriate diagnosis and management of primordial and traditional risk factors for CVD is needed. The diagnosis and management of CVD risk factors is a central role of the preventive pediatric cardiologist, but it is imperative that the general physician and other pediatric subspecialists be aware of these risk factors, diagnoses, and management strategies. Finally, telehealth may offer an additional method for providing preventive care, including screening and counseling of at risk children and adolescents for traditional risk factors and for providing education regarding risk factors in cases of long distance care and/or during periods of social distancing.

An Assessment of Turkish Adults' Knowledge Levels About Their Salt and Sugar Consumption, and Their Attitudes Toward Protecting Children from Excessive Salt and Sugar Consumption

PURPOSE

The study aimed to assess adults' knowledge levels about salt and sugar consumption and their attitudes toward protecting children from excessive consumption of them.

DESIGN AND METHODS

A cross-sectional, methodological, descriptive, and correlational study design was conducted. The study was carried out at a family health center and included 377 participants. The results were analyzed using descriptive statistics, reliability analysis and multiple regression.

RESULTS

The participants' knowledge scores accounted for 1.7% of their attitude scores. The participants' socio-demographic characteristics accounted for 13.9% of their knowledge scores, and the model was statistically significant (F = 7.453, p < 0.001). The participants' socio-demographic characteristics accounted for 11% of their attitude scores, and the model was statistically significant (F = 5.672, p < 0.001).

CONCLUSIONS

Children and adults should be protected from salt and sugar overconsumption, which is a risk factor for many diseases. Therefore, adults' knowledge levels about salt and sugar consumption and their attitudes toward protecting children from excessive consumption of them should be improved. It is also important to teach adults how to choose foods and beverages after checking their labels and how to be role models for children in this regard.

PRACTICE IMPLICATIONS

The study results will contribute to the planning of experimental studies to protect children from excessive salt and sugar consumption. In addition, the study results will provide an infrastructure for the preparation of training programs about salt and sugar consume according to the needs of different groups (older adults, young adults etc.).

Perspective: Childhood Obesity Requires New Strategies for Prevention

The prevalence of obesity among youth in the USA is currently >18% with projections that more than half of today's children will be obese as adults. The growth trajectory of children more likely to become obese is determined by weight in earliest childhood, and childhood body mass index (BMI) tracks through adolescence and adulthood. Childhood consequences of obesity include increased risk of asthma, type 2 diabetes mellitus, orthopedic disorders, and reduced academic performance. Health implications of obesity in adulthood include premature coronary artery disease, hypertension, type 2 diabetes, stroke, and certain cancers, contributing to the leading causes of adult mortality. Early childhood obesity is influenced by prenatal exposure to maternal obesity and environmental obesogens, and is associated with poverty, food insecurity, and poor nutritional quality. New strategies for primordial prevention of early childhood obesity require focusing attention on growth parameters during the first 2 y of life, with support for increasing the duration of breastfeeding, and improvements in dietary quality and availability, particularly the reduced consumption of added sugars. Reducing the prevalence of obesity among adolescent females and reducing exposure to environmental obesogens may reduce the prevalence of transgenerational obesity. The reduction of early childhood obesity could improve population health, quality of life, and longevity throughout the life course.

Machine Learning Models for Classifying Physical Activity in Free-Living Preschool Children

Machine learning (ML) activity classification models trained on laboratory-based activity trials exhibit low accuracy under free-living conditions. Training new models on free-living accelerometer data, reducing the number of prediction windows comprised of multiple activity types by using shorter windows, including temporal features such as standard deviation in lag and lead windows, and using multiple sensors may improve the classification accuracy under free-living conditions. The objective of this study was to evaluate the accuracy of Random Forest (RF) activity classification models for preschool-aged children trained on free-living accelerometer data. Thirty-one children (mean age = 4.0 ± 0.9 years) completed a 20 min free-play session while wearing an accelerometer on their right hip and non-dominant wrist. Video-based direct observation was used to categorize the children’s movement behaviors into five activity classes. The models were trained using prediction windows of 1, 5, 10, and 15 s, with and without temporal features. The models were evaluated using leave-one-subject-out-cross-validation. The F-scores improved as the window size increased from 1 to 15 s (62.6%–86.4%), with only minimal improvements beyond the 10 s windows. The inclusion of temporal features increased the accuracy, mainly for the wrist classification models, by an average of 6.2 percentage points. The hip and combined hip and wrist classification models provided comparable accuracy; however, both the models outperformed the models trained on wrist data by 7.9 to 8.2 percentage points. RF activity classification models trained with free-living accelerometer data provide accurate recognition of young children’s movement behaviors under real-world conditions.

Children's Consumption Patterns and Their Parent's Perception of a Healthy Diet

This study aims to examine children's fruit, vegetable, and added sugar consumption relative to the Dietary Guidelines for Americans and the American Heart Association's recommendations, as well as to compare children's reported consumption with parental perception of the child's overall diet quality. Data were drawn from 2 independent, cross sectional panels (2009-10 and 2014-15) of the New Jersey Child Health Study. The analytical sample included 2229 households located in five New Jersey cities. Daily consumption of fruit (cups), vegetables (cups), and added sugars (teaspoons) for all children (3-18 years old) were based on parent reports. Multivariate linear regression analyses estimated children's adjusted fruit, vegetable, and added sugar consumption across parents' perception categories (Disagree; Somewhat Agree; and Strongly Agree that their child eats healthy). Although only a small proportion of children meet recommendations, the majority of parents strongly agreed that their child ate healthy. Nonetheless, significant differences, in the expected direction, were observed in vegetable and fruit consumption (but not sugar) across parental perceptional categories for most age/sex groups. Dietary interventions tailored to parents should include specific quantity and serving-size information for fruit and vegetable recommendations, based on their child's age/sex, and highlight sources of added sugar and their sugar content.

Effects of 2 Methods of Combined Training on Cardiometabolic Risk Factors in Adolescents: A Randomized Controlled Trial

PURPOSE

To analyze the effects of 2 combined training methods on the cardiometabolic risk factors in adolescents.

METHODS

A total of 76 adolescents (16.1 [1.1] y, n = 44 female) were randomized into groups of moderate-intensity continuous training combined with resistance training (MICT + RT), high-intensity interval training combined with resistance training (HIIT + RT), or control. The training sessions were performed twice weekly for 12 weeks. The outcomes evaluated included body fat percentage, waist circumference, fasting blood glucose, fasting insulin, total cholesterol, triglycerides, low-density lipoprotein, high-density lipoprotein, glycated hemoglobin, insulin resistance index, blood pressure, peak oxygen consumption (VO2peak), and cardiometabolic risk Z score.

RESULTS

The intervention groups presented a significant reduction in the cardiometabolic risk Z score after 12 weeks of the combined exercise program. In relation to the cardiometabolic risk Z score between groups, the HIIT + RT group presented a significant intervention effect when compared with the control group (Cohen d = 0.23; P < .05). Significant intervention effects were found when comparing the MICT + RT and control groups for body fat percentage, high-density lipoprotein, and VO2peak. Between the HIIT + RT and control groups, significant intervention effects were found for body fat percentage, blood pressure, and VO2peak. There were not significant differences between the HIIT + RT and MICT + RT groups.

CONCLUSION

Twelve weeks of HIIT + RT and MICT + RT were effective in significantly reducing the cardiometabolic risk in these adolescents.

Prevention of Atherosclerotic Cardiovascular Disease in Childhood

PURPOSE OF REVIEW

Atherosclerotic-CVD processes begin early in life and are influenced over the life course by interaction of genetic and potential modifiable risk factors, behaviors, and environmental exposures. The purpose of this review is to highlight importance of primordial and primary prevention beginning early in the life course.

RECENT FINDINGS

Evidence-based guidelines and recommendations for primordial and primary prevention support importance of individual/clinical and population-based approaches to CVD prevention beginning early in life with goal of reducing the risk and burden of CVD. Substantial evidence supports the individual and societal benefits of prevention of CVD and promotion of optimal cardiovascular health beginning early in life and extending across the life course and the need for additional research to guide and inform practices and policies enabling optimal cardiovascular health for all.

Development and Psychometric Evaluation of the Cardiovascular Health Behavior Scale for Children

PURPOSE

The aim of this study was to develop a cardiovascular health behavior scale for children and to assess its psychometric properties.

DESIGN AND METHOD

A cross-sectional, methodological, descriptive, and correlational study design was conducted. The study sample consisted of 745 children between the ages of 10 to 15 years. The content validity of the scale was assessed by consulting 13 experts in pediatrics and cardiovascular health. Numbers, percentages, t-test, correlation analysis, Cronbach's α reliability coefficient and factor analysis were used for data analysis.

RESULTS

The Cronbach's alpha coefficient for the overall scale was 0.83, and the Cronbach's alpha values for the subscales were 0.70-0.79. The item-total score correlations ranged from 0.354 to 0.637 (p < .05). The exploratory factor analysis showed that the scale explained 54.65% of the total variance, and the factor loadings of items ranged from 0.48 to 0.84. The confirmatory factor analysis also showed that the factor loadings of the scale ranged from.30 to.83. GFI, NFI, NNFI, CFI were found to be >0.90, and RMSA was found to be <0.080.

CONCLUSION

All the statistical procedures performed in the validity and reliability stages of the study show that the scale is a valid, reliable measurement tool for the Turkish culture.

PRACTICE IMPLICATIONS

The scale can be used as a measurement tool in experimental studies about cardiovascular health and can easily be adapted for use in other societies because of its universal items regarding cardiovascular health and its user-friendly structure.

Pediatric Obesity, Hypertension, Lipids

PURPOSE OF REVIEW

The rise of the pediatric obesity pandemic over the past 40 years has sharpened focus on the management of obesity, hypertension and lipid abnormalities in children. Multiple studies demonstrate that these risk factors track from childhood into adulthood predisposing individuals to premature atherosclerotic cardiovascular disease and putting them at risk for early morbidity and mortality.

RECENT FINDINGS

Importantly, obesity, hypertension and lipid problems are individual risk factors that can occur independently. Multiple studies have shown that each risk factor causes target organ damage in children. Intensive and focused lifestyle modifications can improve a child's subclinical disease and decrease the risk for future morbidity.

SUMMARY

Childhood offers a unique opportunity at primordial and primary prevention of atherosclerotic cardiovascular disease. Clinicians must focus on targeting these highly prevalent conditions and applying lifestyle modification and then pharmacologic or surgical therapies as needed.

Weight Reduction Behaviors Among European Adolescents-Changes From 2001/2002 to 2017/2018

PURPOSE

The purpose of this study was to analyze changes in the prevalence of weight reduction behaviors (WRBs) among European adolescents from 26 countries between 2001/2002 and 2017/2018. The impact of the perception of body weight on WLB was also analyzed, with particular attention being paid to overestimation.

METHODS

The data of 639,194 European adolescents aged 11, 13, and 15 years who participated in the Health Behaviour in School-aged Children survey were analyzed. Age-standardized prevalence rates of WRB were estimated separately by survey round and gender for each country, using the overall 2017/2018 Health Behaviour in School-aged Children study population as the standard. Multivariate logistic regression analyses were used to assess WRB trends over time, adjusted for survey year, body mass index, body weight misperception, and family affluence and stratified by gender and age.

RESULTS

In the 26 countries examined, the overall age-adjusted prevalence rates of WRB were 10.2% among boys and 18.0% among girls. The prevalence of WRB was higher for girls, but in the more recent surveys, gender differences in WRB decreased. There was a significant increase in the percentage of WRB among boys in most countries. Among girls, most countries did not experience significant changes. Increases in body mass index and overestimation of body weight were significant factors increasing the risk of WRB in both genders.

CONCLUSIONS

The change in the prevalence of WRB by gender warrants greater attention from researchers and practitioners alike.

Recommendations for exercise and screening for safe athletic participation in hypertensive youth

Physical activity is an important component of ideal cardiovascular health. Current guidelines recommend that youth with hypertension participate in competitive sports once hypertensive target organ effects and risks have been assessed and that children with hypertension receive treatment to lower BP below stage 2 thresholds (e.g., < 140/90 mmHg or < 95th percentile + 12 mmHg) before participating in competitive sports. Despite these recommendations, pediatricians and pediatric subspecialists continue to struggle with how best to counsel their patients regarding appropriate forms of physical activity, the impact of exercise on blood pressure, and how best to screen for cardiovascular conditions that place youth at risk for sudden cardiac death. This review provides a summary of our current knowledge regarding the safety and utility of exercise in the management of high blood pressure in youth. We review determinants of blood pressure during exercise, the impact of blood pressure on cardiovascular health and structure, mechanisms for assessing cardiometabolic fitness (e.g., exercise stress test), contraindications to athletic participation, and how best to plan for athletic participation among hypertensive youth. Greater knowledge in these areas may offer clarity to providers faced with the challenge of prescribing exercise recommendations for hypertensive youth.

Multidisciplinary lifestyle intervention in children and adolescents - results of the project GRIT (Growth, Resilience, Insights, Thrive) pilot study

BACKGROUND

During childhood and adolescence leading behavioural risk factors for the development of cardiometabolic diseases include poor diet quality and sedentary lifestyle. The aim of this study was to determine the feasibility and effect of a real-world group-based multidisciplinary intervention on cardiorespiratory fitness, diet quality and self-concept in sedentary children and adolescents aged 9 to 15 years.

METHODS

Project GRIT (Growth, Resilience, Insights, Thrive) was a pilot single-arm intervention study. The 12-week intervention involved up to three outdoor High Intensity Interval Training (HIIT) running sessions per week, five healthy eating education or cooking demonstration sessions, and one mindful eating and Emotional Freedom Technique psychology session. Outcome measures at baseline and 12-week follow-up included maximal graded cardiorespiratory testing, the Australian Child and Adolescent Eating Survey, and Piers-Harris 2 children's self-concept scale. Paired samples t-test or Wilcoxon signed-rank test were used to compare baseline and follow-up outcome measures in study completers only.

RESULTS

Of the 38 recruited participants (median age 11.4 years, 53% male), 24 (63%) completed the 12-week intervention. Dropouts had significantly higher diet quality at baseline than completers. Completers attended a median 58 (IQR 55-75) % of the 33 exercise sessions, 60 (IQR 40-95) % of the dietary sessions, and 42% attended the psychology session. No serious adverse events were reported. Absolute VO₂peak at 12 weeks changed by 96.2 ± 239.4 mL/min (p = 0.06). As a percentage contribution to energy intake, participants increased their intake of healthy core foods by 6.0 ± 11.1% (p = 0.02) and reduced median intake of confectionary (- 2.0 [IQR 0.0-3.0] %, p = 0.003) and baked products (- 1.0 [IQR 0.0-5.0] %, p = 0.02). Participants significantly improved self-concept with an increase in average T-Score for the total scale by 2.8 ± 5.3 (p = 0.02) and the 'physical appearance and attributes' domain scale by median 4.0 [IQR 0.5-4.0] (p = 0.02).

CONCLUSIONS

The 12-week group-based multidisciplinary lifestyle intervention for children and adolescents improved diet quality and self-concept in study completers. Future practice and research should focus on providing sustainable multidisciplinary lifestyle interventions for children and adolescents aiming to improve long-term health and wellbeing.

TRIAL REGISTRATION

ANZCTR, ACTRN12618001249246. Registered 24 July 2019 - Retrospectively registered.

Sustainability of and Adherence to Preschool Health Promotion Among Children 9 to 13 Years Old

BACKGROUND

Long-term evaluations of child health promotion programs are required to assess their sustainability and the need for reintervention.

OBJECTIVES

This study sought to explore the long-term impact of a preschool health promotion intervention delivered in an urban low-income area of Colombia (phase 1) and to assess the effect of a new community-based intervention (phase 2).

METHODS

In phase 1, a cross-sectional analysis of knowledge, attitudes, and habits (KAH) toward a healthy lifestyle and ideal cardiovascular health (ICH) scores of 1,216 children 9 to 13 years old was performed. Of the total, 596 had previously received a preschool health promotion intervention at 3 to 5 years old, whereas the remaining 620 were not previously intervened (intervention-naive group). In phase 2, all children were cluster randomized 1:1 to receive either a 4-month educational intervention (the SI! Program) to instill healthy behaviors in community centers (24 clusters, 616 children) or to control (24 clusters, 600 children). Previously intervened and intervention-naive children were not mixed in the same cluster. The primary outcomes were the change from baseline in KAH and ICH scores. Intervention effects were tested for with linear mixed-effects models.

RESULTS

In phase 1, ∼85% of children had nonideal cardiovascular health, and those who previously received a preschool intervention showed a negligible residual effect compared with intervention-naive children. In phase 2, the between-group (control vs. intervention) differences in the change of the overall KAH and ICH scores were 0.92 points (95% confidence interval [CI]: -0.28 to 2.13; p = 0.133) and -0.20 points (95% CI: -0.43 to 0.03; p = 0.089), respectively. No booster effect was detected. However, a dose-response effect was observed, with maximal benefit in children attending >75% of the scheduled intervention; the difference in the change of KAH between the high- and low-adherence groups was 3.72 points (95% CI: 1.71 to 5.73; p < 0.001).

CONCLUSIONS

Although overall significant differences between the intervention and control groups were not observed, high adherence rates to health promotion interventions may improve effectiveness and outcomes in children. Reintervention strategies may be required at multiple stages to induce sustained health promotion effects (Salud Integral Colombia [SI! Colombia II]; NCT03119792).

Longitudinal associations between ultra-processed foods and blood lipids in childhood

Emerging evidence suggests that the consumption of ultra-processed foods (UPF) plays a role in the development of chronic diseases, but evidence of their influence in children is limited. Our objective was to study longitudinal trends of UPF intake and determine their impact on blood lipids in young children. The present study was a follow-up of a randomised field trial of children (n 308) from Porto Alegre, Brazil. Dietary intake was collected using two 24-h recalls at 3 and 6 years of age, and consumption of UPF was classified according to the NOVA system, a food classification based on the extent and purpose of industrial food processing. At age 6 years, blood tests were performed to measure lipid profile. Contribution of UPF to total energy intake increased by 10 % during the follow-up period, from 43·4 % at 3 years to 47·7 % at 6 years of age. Linear regression models showed that children in the highest tertile of UPF consumption at age 3 years had higher levels of total cholesterol (TC; β 0·22 mmol/l; 95 % CI 0·04, 0·39) and TAG at age 6 years (β 0·11 mmol/l, 95 % CI 0·01, 0·20) compared with those in the lowest tertile. A positive dose-response was observed for an absolute increment of 10 % of UPF on TC (β 0·07 mmol/l, 95 % CI 0·00, 0·14) and TAG (β 0·04 mmol/l, 95 % CI 0·01, 0·07). Based on our data, consumption of UPF increased significantly over time and was associated with higher blood lipid levels in children from a low-income community. Our findings highlight the need for effective strategies to minimise the consumption of UPF in early life.

Early characteristics of bone deficits in children with Fontan palliation

BACKGROUND

This is a cross-sectional study aiming to understand the early characteristics and background of bone health impairment in clinically well children with Fontan circulation.

METHODS

We enrolled 10 clinically well children with Fontan palliation (operated >5 years before study entrance, Tanner stage ≤3, age 12.1 ± 1.77 years, 7 males) and 11 healthy controls (age 12.0 ± 1.45 years, 9 males) at two children's hospitals. All patients underwent peripheral quantitative CT. For the Fontan group, we obtained clinical characteristics, NYHA class, cardiac index by MRI, dual x-ray absorptiometry, and biochemical studies. Linear regression was used to compare radius and tibia peripheral quantitative CT measures between Fontan patients and controls.

RESULTS

All Fontan patients were clinically well (NYHA class 1 or 2, cardiac index 4.85 ± 1.51 L/min/m2) and without significant comorbidities. Adjusted trabecular bone mineral density, cortical thickness, and bone strength index at the radius were significantly decreased in Fontan patients compared to controls with mean differences -30.13 mg/cm3 (p = 0.041), -0.31 mm (p = 0.043), and -6.65 mg2/mm4 (p = 0.036), respectively. No differences were found for tibial measures. In Fontan patients, the mean height-adjusted lumbar bone mineral density and total body less head z scores were -0.46 ± 1.1 and -0.63 ± 1.1, respectively, which are below the average, but within normal range for age and sex.

CONCLUSIONS

In a clinically well Fontan cohort, we found significant bone deficits by peripheral quantitative CT in the radius but not the tibia, suggesting non-weight-bearing bones may be more vulnerable to the unique haemodynamics of the Fontan circulation.

Cardiac structure and function in youth with type 2 diabetes in the iCARE cohort study: Cross-sectional associations with prenatal exposure to diabetes and metabolomic profiles

OBJECTIVE

This study aimed to determine the degree of left ventricular (LV) dysfunction and its determinants in adolescents with type 2 diabetes (T2D). We hypothesized that adolescents with T2D would display impaired LV diastolic function and that these cardiovascular complications would be exacerbated in youth exposed to maternal diabetes in utero.

METHODS

Left ventricular structure and function, carotid artery intima media thickness and strain, and serum metabolomic profiles were compared between adolescents with T2D (n = 121) and controls (n = 34). Sub-group analyses examined the role of exposure to maternal diabetes as a determinant of LV or carotid artery structure and function among adolescents with T2D.

RESULTS

Adolescents with T2D were 15.1 ± 2.5 years old, (65% female, 99% Indigenous), had lived with diabetes for 2.7 ± 2.2 years, had suboptimal glycemic control (HbA1c = 9.4 ± 2.6%) and 58% (n = 69) were exposed to diabetes in utero. Compared to controls, adolescents with T2D displayed lower LV diastolic filling (early diastole/atrial filling rate ratio [E/A] = 1.9 ± 0.6 vs 2.2 ± 0.6, P = 0.012), lower LV relaxation and carotid strain (0.12 ± 0.05 vs 0.17 ± 0.05, P = .03) and elevated levels of leucine, isoleucine and valine. Among adolescents with T2D, exposure to diabetes in utero was not associated with differences in LV diastolic filling, LV relaxation, carotid strain or branched chain amino acids.

CONCLUSIONS

Adolescents with T2D display LV diastolic dysfunction, carotid artery stiffness, and elevated levels of select branch chain amino acids; differences were not associated with exposure to maternal diabetes in utero.

Methods and rationale to assess the efficacy of a parenting intervention targeting diet improvement and substance use prevention among Latinx adolescents

Latinx adolescents are at higher risk for chronic diseases relative to adolescents of other ethnic groups, in part because of their lack of adherence to diet recommendations and their higher rates of substance use. Given the proximal influence of family factors during the developmental stage of adolescence, parenting interventions may be an effective way to promote healthy nutrition and substance use prevention simultaneously. This article describes the design and theoretical rationale of a study assessing the effects of Families Preparing the New Generation Plus (FPNG Plus), a 10-week culturally-tailored nutrition and substance use prevention parenting program, on diet and substance use outcomes among Latinx middle school students (6th-8th grade). The 3-arm cluster randomized controlled trial compares FPNG Plus (substance use prevention and healthy nutrition), FPNG (substance use prevention only), and a comparison condition (focusing on academic success) in 1494 parent-child dyads from 18 schools, randomized at the school level. Adolescents and parents will complete surveys pre- and post-intervention, and 16-weeks after program participation, regarding diet behaviors, substance use, and parenting practices. A random subsample of 126 dyads (42 from each program), will participate in additional data collection to assess the home food environment, detailed dietary intake (via two 24-h recalls), and provide biomarkers of cardiometabolic risk (blood pressure, total cholesterol and HbA1c). If successful, this study will provide evidence contributing to helping Latinx parents assist their adolescent children develop and maintain long-lasting positive lifestyle behaviors in order to prevent concurrent substance use and diet-related chronic diseases.

Pediatric Clinical Endpoint and Pharmacodynamic Biomarkers: Limitations and Opportunities

Medical research in children typically lags behind that of adult research in both quantity and quality. The conduct of rigorous clinical trials in children can raise ethical concerns because of children's status as a 'vulnerable' population. Moreover, carrying out studies in pediatrics also requires logistical considerations that rarely occur with adult clinical trials. Due to the relatively smaller number of pediatric studies to support evidence-based medicine, the practice of medicine in children is far more reliant upon expert opinion than in adult medicine. Children are at risk of not receiving the same level of benefits from precision medicine research, which has flourished with new technologies capable of generating large amounts of data quickly at an individual level. Although progress has been made in pediatric pharmacokinetics, which has led to safer and more effective dosing, gaps in knowledge still exists when it comes to characterization of pediatric disease and differences in pharmacodynamic response between children and adults. This review highlights three specific therapeutic areas where biomarker development can enhance precision medicine in children: asthma, type 2 diabetes mellitus, and pain. These 'case studies' are meant to update the reader on biomarkers used currently in the diagnosis and treatment of these conditions, and their shortcomings within a pediatric context. Current research on surrogate endpoints and pharmacodynamic biomarkers in the above therapeutic areas will also be described. These cases highlight the current lack in pediatric specific surrogate endpoints and pharmacodynamic biomarkers, as well as the research presently being conducted to address these deficiencies. We finally briefly highlight other therapeutic areas where further research in pediatric surrogate endpoints and pharmacodynamic biomarkers can be impactful to the care of children.

Adolescent Obesity: Diet Quality, Psychosocial Health, and Cardiometabolic Risk Factors

Obesity is a multifaceted chronic condition with several contributing causes, including biological risk factors, socioeconomic status, health literacy, and numerous environmental influences. Of particular concern are the increasing rates of obesity in children and adolescents, as rates of obesity in youth in the United States have tripled within the last three decades. Youth from historically disadvantaged backgrounds tend to have higher rates of obesity compared to other groups. Adolescents often do not meet intake recommendations for certain food groups and nutrients, which may contribute to a heightened risk of obesity. With obesity disproportionately affecting adolescents (ages 12–19 years), negative effects of excess adiposity may be particularly salient during this critical period of development. The presentation of chronic cardiometabolic disease symptoms typically observed in adults, such as hypertension, hyperglycemia, dyslipidemia, and inflammation, are becoming increasingly common in adolescents with obesity. Additionally, there is dynamic interplay between obesity and psychosocial health, as adolescents with obesity may have increased levels of stress, depressive symptoms, and reduced resilience. To reduce and prevent adolescent obesity, the implementation of theory-driven multicomponent school- and community-based interventions have been suggested. These interventions promote knowledge and self-efficacy for healthful practices that have the potential to progress to sustained behavior change.

Is there an association between family history of diabetes mellitus and long-term cardiovascular hospitalizations of offspring?

OBJECTIVE

Gestational diabetes mellitus (GDM) was previously found to be an independent risk factor for long-term cardiovascular morbidity of parturients and their offspring. The objective of this study was to investigate the association between family history of diabetes mellitus (DM) in non-diabetic mothers and long-term pediatric cardiovascular hospitalizations of their offspring.

STUDY DESIGN

In a hospital-based cohort study, the incidence of cardiovascular disorders was compared between offspring of non-diabetic mothers with and without a family history of DM. Cardiovascular hospitalizations were assessed up until 18years of age according to a predefined set of ICD-9 codes associated with hospitalization of offspring. Exclusion criteria included multiple gestations, mothers with pre-gestational or gestational diabetes, lack of prenatal care, and children with congenital malformations and chromosomal abnormalities. A Kaplan-Meier survival curve was used to compare cumulative hospitalizations incidence. A cox proportional hazards model was performed to control for confounders.

RESULTS

A total of 208,728 deliveries were included in the study. Of them, 17,040 (8.2%) offspring were born to non-diabetic mothers with a family history of DM. Significant differences in the rates of IVF, induction of labor, obesity, hypertensive disorders of pregnancy, smoking and birth weight were found between the two study groups. Total cardiovascular hospitalizations were comparable between the study groups (0.6% vs. 0.7%, p=0.416). The Kaplan-Meier survival curve exhibited no difference in the cumulative incidence of total cardiovascular hospitalizations of the offspring (log-rank test, p=0.271). A Cox regression model found that a family history of DM in non-diabetic mothers was not independently associated with long-term cardiovascular hospitalizations of the offspring after controlling for the following confounders: maternal age, birth weight, caesarian section and maternal hypertensive disorders (aHR=1.130, 95% CI 0.930-1.374, p=0.220).

CONCLUSION

A family history of DM in non-diabetic parturients, does not increase the risk for cardiovascular hospitalizations of their offspring.

Vascular Health of Children Conceived via In Vitro Fertilization

OBJECTIVE

To evaluate whether in vitro fertilization (IVF) has an effect on the cardiovascular health of offspring.

STUDY DESIGN

This was a cross-sectional pilot study. We performed vascular health assessment for 17 children aged 10-14 years who were conceived via IVF with autologous oocytes at Stanford University. Carotid artery ultrasound evaluated intima-media thickness and stiffness, carotid-femoral pulse wave velocity determined segmental arterial stiffness, and endothelial pulse amplitude testing assessed endothelial function. We compared IVF offspring with control adolescents assessed in the same laboratory, with all comparisons adjusted for age, sex, and race/ethnicity.

RESULTS

All participants had normal body mass index and blood pressure. Compared with controls, IVF children had thicker common carotid artery intima-media thickness (0.44 ± 0.03 mm vs 0.38 ± 0.03 mm; P < .01), higher elastic modulus (395.29 ± 185.33 mm Hg vs 242.79 ± 37.69 mm Hg; P = .01), higher βstiffness (2.65 ± 0.38 vs 2.28 ± 0.23; P < .01), and higher peak velocity (142.29 ± 31.62 cm/s vs 117.71 ± 32.69 cm/s; P = .04). The mean endothelial pulse amplitude testing reactive hyperemia index was not significantly different between IVF and controls. The mean pulse wave velocity was 4.69 ± 0.51 m/s compared with the controls 4.60 ± 0.57 m/s (P = .11), with 8 (47%) having abnormal values.

CONCLUSION

In an assessment of endothelial function and arterial properties of children conceived via IVF, we found that children conceived via IVF seem to have evidence of abnormal vascular health. Further studies with larger sample size and long-term follow-up are warranted.

Rationale and design of the school-based SI! Program to face obesity and promote health among Spanish adolescents: A cluster-randomized controlled trial

Unhealthy habits in adolescents are increasing at an alarming rate. The school offers a promising environment in which to implement effective preventive strategies to improve adolescents' lifestyle behaviors. The SI! Program is a multilevel multicomponent school-based health-promotion intervention aimed at all stages of compulsory education in Spain. We present the study design of the SI! Program for Secondary Schools, targeting adolescents aged 12 to 16 years.

AIM

The main goal of this study is to evaluate the impact of the SI! Program educational intervention on adolescent lifestyle behaviors and health parameters.

METHODS

The study was designed as a cluster-randomized controlled intervention trial and enrolled 1326 adolescents from 24 public secondary schools in Spain, together with their parents/caregivers. Schools and their students were randomly assigned to the intervention group (the SI! curriculum-based educational program over 2 or 4 academic years) or to the control group (usual curriculum). The primary endpoint will be the change from baseline at 2-year and 4-year follow-up in the composite Ideal Cardiovascular Health (ICH) score, consisting of four health behaviors (body mass index, dietary habits, physical activity, and smoking) and three health factors (blood pressure, total cholesterol, and glucose). Secondary endpoints will include 2-year and 4-year changes from baseline in ICH score subcomponents, the Fuster-BEWAT health scale, adiposity markers (waist circumference and body composition), polyphenol and carotenoid intake, and emotion management.

DISCUSSION

The overarching goal of the SI! Program is to instill healthy behaviors in children and adolescents that can be sustained into adulthood. The SI! Program for Secondary School is a comprehensive health-promotion intervention targeting 12-16-year-old adolescents and their immediate environment. The present study addresses the optimal timing and impact of the educational intervention on health in adolescence.

The Validity of Children's Fruit and Vegetable Intake Using Plasma Vitamins A, C, and E: The SAYCARE Study

Despite that fruits and vegetables are key elements for health promotion, there are limited studies validating their intake in children. We aimed to validate the SAYCARE (South American Youth/Child Cardiovascular and Environmental) Study Food Frequency Questionnaire (FFQ) and the combination of the FFQ frequency of intake with the 24 h-dietary-recall (24 h-DR) (mean of 3 days), for children's fruit and vegetable intake. The reference methods were plasma dosages of β-carotene, retinol, ascorbic acid, and α-tocopherol, which were collected in the school environment. It is a validity study in a subsample of 45 children aged 6-10 years participating in the SAYCARE Study, from São Paulo (Brazil). The FFQ was answered by the parents/guardians over the previous 3 months; the 24 h-DR was answered three times (two weekdays by nutritionists, one weekend day by parents/guardians). The mean fruit and vegetable intake (combined with frequency of intake) was calculated using the multiple source method (MSM). Multiple linear regression showed pooled correlation coefficients of 0.29 to 0.35 for the reported fruit and vegetable intake estimated by the FFQ and the MSM, respectively. The SAYCARE FFQ is an accurate and useful tool for ranking fruit and vegetable intake in children between 6-10 years from the SAYCARE Study.

Lifestyles and Cardiovascular Prevention in Childhood and Adolescence

Pathology studies demonstrated that coronary fatty streaks develop early in life and that even more advanced fibrous plaques are present in a proportion of adolescents. The presence and extent of atherosclerosis in children and adolescents can be correlated with the same risk factors present in adults; as well as, childhood levels of these risk factors predict adult cardiovascular diseases. Children are born with ideal cardiovascular health but, unfortunately, most of them develop over time modifiable behavioral risk factors. Achieving sustained lifestyle changes initiated too late in adults is difficult, and pharmacologic risk factor control cannot fully restore a low-risk state. Therefore, it seems eminently reasonable to initiate healthful lifestyle training as early in life, decreasing the prevalence of cardiovascular risk factors to retard atherogenic processes and reduce the future burden of cardiovascular diseases. Many guideline recommendations encourage universal adoption of healthier lifestyles, identification of children with cardiovascular risk factors, and their treatment using targeted lifestyle modification and, rarely, pharmacotherapy. Major gains will likely accrue from public health strategies targeting incorrect diet, physical activity, and cigarette smoking. Individualized strategies, however, will initially focus on the highest risk children such as those with familial hyperlipidaemia, diabetes, hypertension, and obesity. The primary purpose of this article is to provide a broad overview on the long-term cardiovascular effects of risk factors in children and youth and to outline various lines of evidence for the efficacy of primordial and primary prevention in young people, as well as recommendations for population- and individual-level strategies and evidence-based interventions.

Child Blood Pressure Profile in Bali, Indonesia

BACKGROUND:

Mortality and morbidity in an adult will be reduced by controlling hypertension from an early age. Uncontrolled blood pressure since children can contribute to diseases such as heart disease, organ damage, and decreased quality of life. As changes in lifestyle, it is estimated that hypertension in children will continue to increase. Until now, data regarding the profile of blood pressure in children in Indonesia is still lacking.

AIM:

The purpose of this study was to determine the prevalence of increased blood pressure and hypertension in children in Bali.

METHODS:

This study was a cross-sectional study. The sampling technique in this study was multistage random sampling, that is, from 9 regencies in Bali, the selection of 3 regencies to be sampled according to socio-economic stratification based on regional economic growth and regional per capita income in Bali Province.

RESULTS:

From 1257, samples examined the prevalence of increased blood pressure, and hypertension was 689 children (54.8%). From the age group, the prevalence of an increase in blood pressure and hypertension in the age group ≤ , 12 years was 47.3%, and in the age group > 12 years was 62.2%. Increased blood pressure in nutritional status including Obesity 51.4%, Nutrition More 52.9%, Good Nutrition 42.2%, Nutrition Less 43.9%, Malnutrition 50.0%. In families with a history of hypertension, the prevalence of increased blood pressure and hypertension in subjects was 60.3% and in families without a history of hypertension was 43.4%.

CONCLUSION:

It can be concluded that there is still a prevalence of hypertension in children in Bali. Health efforts are needed so that they can minimise the further health impact that might occur. It should also be noted that various factors can influence the prevalence of increased blood pressure and hypertension in children.