Implementing a health promotion program for children is a complex endeavor. In this review, we outline the key lessons learned over 10 years of experience in implementing the SI! Program (Salud ...Integral-Comprehensive Health) for cardiovascular health promotion in preschool settings in 3 countries: Colombia (Bogotá), Spain (Madrid), and the United States (Harlem, New York). By matching rigorous efficacy studies with implementation science, we can help bridge the divide between science and educational practice. Achieving sustained lifestyle changes in preschool children through health promotion programs is likely to require the integration of several factors: 1) multidisciplinary teams; 2) multidimensional educational programs; 3) multilevel interventions; 4) local program coordination and community engagement; and 5) scientific evaluation through randomized controlled trials. Implementation of effective health promotion interventions early in life may induce long-lasting healthy behaviors that could help to curb the cardiovascular disease epidemic.
A low intake of fruits and vegetables (F&Vs) is a major risk factor for cardiovascular disease (CVD) in the United States. Both mass media campaigns (MMCs) and economic incentives may increase F&V ...consumption. Few data exist on their comparative effectiveness.
We estimated CVD mortality reductions potentially achievable by price reductions and MMC interventions targeting F&V intake in the US population.
We developed a US IMPACT Food Policy Model to compare 3 policies targeting F&V intake across US adults from 2015 to 2030: national MMCs and national F&V price reductions of 10% and 30%. We accounted for differences in baseline diets, CVD rates, MMC coverage, MMC duration, and declining effects over time. Outcomes included cumulative CVD (coronary heart disease and stroke) deaths prevented or postponed and life-years gained (LYGs) over the study period, stratified by age, sex, and race.
A 1-y MMC in 2015 would increase the average national F&V consumption by 7% for 1 y and prevent ∼18,600 CVD deaths (95% CI: 17,600, 19,500), gaining ∼280,100 LYGs by 2030. With a 15-y MMC, increased F&V consumption would be sustained, yielding a 3-fold larger reduction (56,100; 95% CI: 52,400, 57,700) in CVD deaths. In comparison, a 10% decrease in F&V prices would increase F&V consumption by ∼14%. This would prevent ∼153,300 deaths (95% CI: 146,400, 159,200), gaining ∼2.51 million LYGs. For a 30% price decrease, resulting in a 42% increase in F&V consumption, corresponding values would be 451,900 CVD deaths prevented or postponed (95% CI: 433,100, 467,500) and 7.3 million LYGs gained. Effects were similar by sex, with a smaller proportional effect and larger absolute effects at older ages. A 1-y MMC would be 35% less effective in preventing CVD deaths in non-Hispanic blacks than in whites. In comparison, price-reduction policies would have equitable proportional effects.
Both national MMCs and price-reduction policies could reduce US CVD mortality, with price reduction being more powerful and sustainable.
Adherence to evidence-based cardiovascular (CV) medications after an acute myocardial infarction (MI) is low after the first 6 months. The use of fixed-dose combinations (FDC) has been shown to ...improve treatment adherence and risk factor control. However, no previous randomized trial has analyzed the impact of a polypill strategy on adherence in post-MI patients.
The cross-sectional FOCUS (Fixed-Dose Combination Drug for Secondary Cardiovascular Prevention) study (Phase 1) aimed to elucidate factors that interfere with appropriate adherence to CV medications for secondary prevention after an acute MI. Additionally, 695 patients from Phase 1 were randomized into a controlled trial (Phase 2) to test the effect of a polypill (containing aspirin 100 mg, simvastatin 40 mg, and ramipril 2.5, 5, or 10 mg) compared with the 3 drugs given separately on adherence, blood pressure, and low-density lipoprotein cholesterol, as well as safety and tolerability over a period of 9 months of follow-up.
In Phase 1, a 5-country cohort of 2,118 patients was analyzed. Patients were randomized to either the polypill or 3 drugs separately for Phase 2. Primary endpoint was adherence to the treatment measured at the final visit by the self-reported Morisky-Green questionnaire (MAQ) and pill count (patients had to meet both criteria for adherence at the in-person visit to be considered adherent).
In Phase 1, overall CV medication adherence, defined as an MAQ score of 20, was 45.5%. In a multivariable regression model, the risk of being nonadherent (MAQ <20) was associated with younger age, depression, being on a complex medication regimen, poorer health insurance coverage, and a lower level of social support, with consistent findings across countries. In Phase 2, the polypill group showed improved adherence compared with the group receiving separate medications after 9 months of follow-up: 50.8% versus 41% (p = 0.019; intention-to-treat population) and 65.7% versus 55.7% (p = 0.012; per protocol population) when using the primary endpoint, attending the final visit with MAQ = 20 and high pill count (80% to 110%) combined, to assess adherence. Adherence also was higher in the FDC group when measured by MAQ alone (68% vs. 59%, p = 0.049). No treatment difference was found at follow-up in mean systolic blood pressure (129.6 mm Hg vs. 128.6 mm Hg), mean low-density lipoprotein cholesterol levels (89.9 mg/dl vs. 91.7 mg/dl), serious adverse events (23 vs. 21), or death (1, 0.3% in each group).
For secondary prevention following acute MI, younger age, depression, and a complex drug treatment plan are associated with lower medication adherence. Meanwhile, adherence is increased in patients with higher insurance coverage levels and social support. Compared with the 3 drugs given separately, the use of a polypill strategy met the primary endpoint for adherence for secondary prevention following an acute MI. (Fixed Dose Combination Drug Polypill for Secondary Cardiovascular Prevention FOCUS; NCT01321255).
To assess the agreement between self-reported and parent-reported dietary and physical activity habits in children; and to evaluate the socio-economic determinants of healthier habits (Mediterranean ...diet and physical activity) among children.
Cross-sectional analysis of children recruited to a cluster-randomized controlled trial (Program SI!). Information about children's and parents' dietary and physical activity habits was obtained through validated questionnaires (Program SI! questionnaires, Kidmed, Krece Plus and Predimed scores).
Twenty-four schools in Madrid, Spain.
Children (n 2062) aged 3-5 years and their parents (n 1949).
There was positive agreement between parental- and self-reporting for three of the six children's habits examined. Parents' dietary and physical activity patterns were associated with those of their children. The main determinants of higher scores in children were higher parental age, the mother's scores, Spanish origin and higher awareness of human health (P<0·005). Children from parents with a low educational level had lower odds for scoring positively on items such as using olive oil (OR=0·23; 95 % CI 0·13, 0·41) and not skipping breakfast (OR=0·36; 95 % CI 0·23, 0·55), but higher odds for meeting the recommendations for consuming pulses (OR=1·71; 95 % CI 1·14, 2·55). Other habits being influenced by parental socio-economic status included the consumption of vegetables, fish, nuts, avoidance of fast food, and consumption of bakery products for breakfast.
Children's habits may be influenced by their parents' health awareness and other socio-economic characteristics. These findings suggest that intervention strategies, even in very young children, should also target parents in order to achieve maximum success.
The workplace offers a unique opportunity for effective health promotion. We aimed to comprehensively study the effectiveness of multicomponent worksite wellness programmes for improving diet and ...cardiometabolic risk factors.
We did a systematic literature review and meta-analysis, following PRISMA guidelines. We searched PubMed-MEDLINE, Embase, the Cochrane Library, Web of Science, and Education Resources Information Center, from Jan 1, 1990, to June 30, 2020, for studies with controlled evaluation designs that assessed multicomponent workplace wellness programmes. Investigators independently appraised the evidence and extracted the data. Outcomes were dietary factors, anthropometric measures, and cardiometabolic risk factors. Pooled effects were calculated by inverse-variance random-effects meta-analysis. Potential sources of heterogeneity and study biases were evaluated.
From 10 169 abstracts reviewed, 121 studies (82 68% randomised controlled trials and 39 32% quasi-experimental interventions) met the eligibility criteria. Most studies were done in North America (57 47%), and Europe, Australia, or New Zealand (36 30%). The median number of participants was 413·0 (IQR 124·0–904·0), and median duration of intervention was 9·0 months (4·5–18·0). Workplace wellness programmes improved fruit and vegetable consumption (0·27 servings per day 95% CI 0·16 to 0·37), fruit consumption (0·20 servings per day 0·11 to 0·28), body-mass index (–0·22 kg/m2 –0·28 to –0·17), waist circumference (–1·47 cm –1·96 to –0·98), systolic blood pressure (–2·03 mm Hg –3·16 to –0·89), and LDL cholesterol (–5·18 mg/dL –7·83 to –2·53), and to a lesser extent improved total fat intake (–1·18% of daily energy intake –1·78 to –0·58), saturated fat intake (–0·70% of daily energy –1·22 to –0·18), bodyweight (–0·92 kg –1·11 to –0·72), diastolic blood pressure (–1·11 mm Hg –1·78 to –0·44), fasting blood glucose (–1·81 mg/dL –3·33 to –0·28), HDL cholesterol (1·11 mg/dL 0·48 to 1·74), and triglycerides (–5·38 mg/dL –9·18 to –1·59). No significant benefits were observed for intake of vegetables (0·03 servings per day 95% CI –0·04 to 0·10), fibre (0·26 g per day –0·15 to 0·67), polyunsaturated fat (–0·23% of daily energy –0·59 to 0·13), or for body fat (–0·80% –1·80 to 0·21), waist-to-hip ratio (–0·00 ratio –0·01 to 0·00), or lean mass (1·01 kg –0·82 to 2·83). Heterogeneity values ranged from 46·9% to 91·5%. Between-study differences in outcomes were not significantly explained by study design, location, population, or similar factors in heterogeneity analyses.
Workplace wellness programmes are associated with improvements in specific dietary, anthropometric, and cardiometabolic risk indicators. The heterogeneity identified in study designs and results should be considered when using these programmes as strategies to improve cardiometabolic health.
National Heart, Lung, and Blood Institute.
Unhealthy lifestyles contribute to the development of cardiovascular risk factors, whose incidence is increasing among children and adolescents. The Program SI! is a long-term, multi-target ...behavioral intervention to promote healthy lifestyle habits in children through the school environment. The objective of the study is to evaluate the efficacy of this intervention in its first phase, preschoolers.
Cluster-randomized controlled trial in public schools in the city of Madrid, Spain. A total 24 schools, including 2062 children (3-5 years), 1949 families, and 125 teachers participated in the study. Schools were assigned to their usual school curriculum or to engage in an additional multi-component intervention (Program SI!). The primary outcome of this trial is 1-school year changes from baseline in scores for children's knowledge, attitudes and habits (KAH). Secondary outcomes are 1-school year changes from baseline in scores for knowledge, attitudes, and habits among parents, teachers, and the school environment.
After 1-school year, our results indicate that the Program SI! intervention increases children's KAH scores, both overall (3.45, 95% CI, 1.84-5.05) and component-specific (Diet: 0.93, 95% CI, 0.12-1.75; Physical activity: 1.93, 95% CI, 1.17-2.69; Human body: 0.65, 95% CI, 0.07-1.24) score.
The Program SI! is demonstrated as an effective and feasible strategy for increasing knowledge and improving lifestyle attitudes and habits among very young children.
NCT01579708, Evaluation of the Program SI! for Preschool Education: A School-Based Randomized Controlled Trial (Preschool-SI!).
This study aimed to report mortality, risk factors, and burden of diseases in Spain. The Global Burden of Disease, Injuries, and Risk Factors 2019 estimates the burden due to 369 diseases, injuries, ...and impairments and 87 risk factors and risk factor combinations. Here, we detail the updated Spain 1990-2019 burden of disease estimates and project certain metrics up to 2030. In 2019, leading causes of death were ischaemic heart disease, stroke, chronic obstructive pulmonary disease, Alzheimer's disease, and lung cancer. Main causes of disability adjusted life years (DALYs) were ischaemic heart disease, diabetes, lung cancer, low back pain, and stroke. Leading DALYs risk factors included smoking, high body mass index, and high fasting plasma glucose. Spain scored 74/100 among all health-related Sustainable Development Goals (SDGs) indicators, ranking 20 of 195 countries and territories. We forecasted that by 2030, Spain would outpace Japan, the United States, and the European Union. Behavioural risk factors, such as smoking and poor diet, and environmental factors added a significant burden to the Spanish population's health in 2019. Monitoring these trends, particularly in light of COVID-19, is essential to prioritise interventions that will reduce the future burden of disease to meet population health and SDG commitments.
Daily habits, including the number and quality of eating occasions, are potential targets for primary prevention strategies with large health impacts. Skipping breakfast is considered a frequent and ...unhealthy habit associated with an increased cardiovascular (CV) risk.
The study sought to explore the association between different breakfast patterns and CV risk factors and the presence, distribution, and extension of subclinical atherosclerosis.
Cross-sectional analysis was performed within the PESA (Progression of Early Subclinical Atherosclerosis) study, a prospective cohort of asymptomatic (free of CV events at baseline) adults 40 to 54 years of age. Lifestyle and multivascular imaging data along with clinical covariates were collected from 4,052 participants. Multivariate logistic regression models were used in the analysis.
Three patterns of breakfast consumption were studied: high-energy breakfast, when contributing to >20% of total daily energy intake (27% of the population); low-energy breakfast, when contributing between 5% and 20% of total daily energy intake (70% of the population); and skipping breakfast, when consuming <5% of total daily energy (3% of the population). Independent of the presence of traditional and dietary CV risk factors, and compared with high-energy breakfast, habitual skipping breakfast was associated with a higher prevalence of noncoronary (odds ratio: 1.55; 95% confidence interval: 0.97 to 2.46) and generalized (odds ratio: 2.57; 95% confidence interval: 1.54 to 4.31) atherosclerosis.
Skipping breakfast is associated with an increased odds of prevalent noncoronary and generalized atherosclerosis independently of the presence of conventional CV risk factors. (Progression of Early Subclinical Atherosclerosis PESA; NCT01410318).
The specific association of olive oil consumption with coronary heart disease (CHD) or stroke has not been totally established.
Objective: to examine whether olive oil consumption is associated with ...subclinical atherosclerosis, the risk of total cardiovascular disease (CVD), CHD, and stroke.
Three cohorts were included: AWHS (2318 men), SUN Project (18,266 men and women), and EPIC-Spain (39,393 men and women). Olive oil consumption was measured at baseline using validated questionnaires.
In the AWHS, 747 participants had a positive coronary artery calcium score (CACS>0), and the OR (95% CI) was 0.89 (0.72, 1.10) in those with virgin olive oil consumption ≥30 g/day (v. <10 g/day). In the SUN Project (follow-up 10.8 years) 261 total CVD cases occurred, and the HR was 0.57 (0.34, 0.96) for consumptions ≥30 g/day (v. <10 g/day). In the EPIC-Spain (follow-up 22.8 years) 1300 CHD cases and 938 stroke cases occurred; the HRs for stroke according, 0 to <10 (ref), 10 to <20, 20 to <30, and ≥30 g/day of olive oil consumption, were 0.84 (0.70, 1.02), 0.80 (0.66, 0.96), 0.89 (0.74, 1.07). A weaker association was observed for CHD. The association was stronger among those consuming virgin olive oil, instead of common (refined).
Olive oil is associated with lower risk of CVD and stroke. The maximum benefit could be obtained with a consumption between 20 and 30 g/day. The association could be stronger for virgin olive oil and might operate from the early stages of the disease.
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