Family-Based Approaches to Cardiovascular Health Promotion

The effects of adverse and positive experiences on cardiovascular health in Australian children

BACKGROUND

Limited evidence suggests that positive experiences in childhood may promote cardiovascular health, providing additional opportunities for prevention and early intervention. This study aimed to examine the effects of adverse and positive experiences on cardiovascular health in late childhood.

METHODS

Data sources: Longitudinal Study of Australian Children (N = 1874).

EXPOSURES

Adverse and positive experiences assessed repeatedly (age 0-11 years).

OUTCOMES

Cardiovascular health (high versus low or moderate) quantified by four health behaviors (diet, physical activity, cigarette smoking, and sleep) and four health factors (body mass index, non-high-density lipoprotein, blood pressure, and blood glucose) (age 11-12 years) as per the American Heart Association's Life's Essential 8 metrics.

ANALYSES

Separate generalized linear models with log-Poisson links were used to estimate the effects of adverse and positive experiences on cardiovascular health, adjusting for confounders.

RESULTS

Children exposed to multiple adverse experiences (≥ 2) were less likely to have high cardiovascular health (RR = 0.82, 95% CI = 0.67 to 1.02) than those not exposed. Children exposed to multiple positive experiences (≥ 2) were more likely to have high cardiovascular health (RR = 1.14, 95% CI = 0.94 to 1.38) than those not exposed. Stratified analyses suggested that exposure to multiple positive experiences might buffer the detrimental effects of multiple adverse experiences on cardiovascular health.

CONCLUSIONS

Both adverse and positive experiences were found to be modestly associated with cardiovascular health in Australian children. Future research and practice should not only consider addressing childhood adversity but also use a strengths-based approach to promoting positive experiences to improve cardiovascular health.

Effectiveness of community-based hypertension management on hypertension in the urban slums of Haiti: A mixed methods study

Hypertension is a leading contributor to mortality in low-middle income countries including Haiti, yet only 13% achieve blood pressure (BP) control. We evaluated the effectiveness of a community-based hypertension management program delivered by community health workers (CHWs) and physicians among 100 adults with uncontrolled hypertension from the Haiti Cardiovascular Disease Cohort. The 12-month intervention included: community follow-up visits with CHWs (1 month if BP uncontrolled ≥140/90, 3 months otherwise) for BP measurement, lifestyle counseling, medication delivery, and dose adjustments. Primary outcome was mean change in systolic BP from enrollment to 12 months. Secondary outcomes were mean change in diastolic BP, BP control, acceptability, feasibility, and adverse events. We compared outcomes to 100 age, sex, and baseline BP matched controls with standard of care: clinic follow-up visits with physicians every 3 months. We also conducted qualitative interviews with participants and providers. Among 200 adults, median age was 59 years, 59% were female. Baseline mean BP was 154/89 mmHg intervention versus 153/88 mmHg control. At 12 months, the difference in SBP change between groups was -12.8 mmHg (95%CI -6.9, -18.7) and for DBP -7.1 mmHg (95%CI -3.3, -11.0). BP control increased from 0% to 58.1% in intervention, and 28.4% in control group. Four participants reported mild adverse events. In mixed methods analysis, we found community-based delivery addressed multiple participant barriers to care, and task-shifting with strong teamwork enhanced medication adherence. Community-based hypertension management using task-shifting with CHWs and community-based care was acceptable, and effective in reducing SBP, DBP, and increasing BP control.

Effect of Time-Varying Exposure to School-Based Health Promotion on Adiposity in Childhood

BACKGROUND

The results of most school-based health promotion initiatives are inconclusive.

OBJECTIVES

This trial assessed the effect of time-varying exposures to a multicomponent school-based health promotion intervention (SI! Program) on adiposity markers.

METHODS

A total of 48 schools in Madrid (Spain) were cluster randomized to receive the SI! Program through elementary education grades 1 to 6 (E1-6, 12 schools, 459 children), 1 to 3 (E1-3, 12 schools, 513 children), or 4 to 6 (E4-6, 12 schools, 419 children) or to receive the standard curriculum (control, 12 schools, 379 children). The primary endpoint was the between-group difference at 3- and 6-year follow-up in the change from baseline in adiposity markers and the overall knowledge-attitudes-habits (KAH) score.

RESULTS

At 3-year follow-up, children who had the intervention showed significantly lower increases than the control group in z-scores for body mass index (BMI), waist-to-height ratio (WHtR), and waist circumference (WC) (zBMI: -0.09; 95% CI: -0.16 to -0.03; P = 0.003; zWC and zWHtR: -0.19; 95% CI: -0.28 to -0.10; P < 0.001). At 6-year follow-up, the beneficial trend in zWC and zWHtR was maintained in the E1-6 and E1-3 groups: difference zWC control vs E1-6 (-0.19; 95% CI: -0.36 to -0.03; P = 0.020), control vs E1-3 (-0.22; 95% CI: -0.38 to -0.06; P = 0.009); difference zWHtR control vs E1-6 (-0.24; 95% CI: -0.41 to -0.06; P = 0.009), and control vs E1-3 (-0.29; 95% CI: -0.47 to -0.11; P = 0.001). No significant between-group differences were found in the change of overall KAH score.

CONCLUSIONS

Early elementary school interventions may be more effective than later interventions on abdominal adiposity. Further research should assess the sustainability effects of school-based health promotion programs.

Comparison of Cardiovascular Health Between Parents and Non-Parents in NHANES 2011-2018

BACKGROUND AND OBJECTIVES

We compared cardiovascular health for parents and non-parents using the American Heart Association's Life's Essential 8 (LE8).

METHODS

This cross-sectional cohort analyzed 2011-2018 NHANES participants aged 20 to 54. The exposure was parenting, defined as living with a child. Logistic regression assessed whether parenting was associated with odds of ideal LE8 total or sub-scores. Regression adjusted for age, sex, race and ethnicity, educational attainment, marital status, and income. Subgroups included female sex, male sex, income <150% federal poverty levels, and parents of younger children.

RESULTS

6847 participants represented a weighted population of 79 120 285 (57% parents). Parenting was not associated with adjusted odds of ideal total LE8 (OR 0.91, 95% CI 0.76-1.09). Parenting was associated with decreased odds of ideal body mass index (BMI) (OR 0.81, 95% CI 0.72-0.91) and increased odds of smoking avoidance (OR 1.22, 95% CI 1.09-1.38). Associations varied by subgroup. Only the subgroup with lower incomes demonstrated reduced odds of ideal total LE8 for parents (OR 0.58, 95% CI 0.41-0.82).

CONCLUSIONS

Parents and non-parents differed in smoking and BMI, though not in LE8 total. Families with low incomes may particularly benefit from dual generation cardiovascular risk reduction.

FirstStep2Health: A cluster randomised trial to promote healthy behaviours and prevent obesity amongst low-income preschoolers

OBJECTIVE

To evaluate the preliminary effects of a theory-based, multi-component intervention on improving healthy lifestyle behaviours and preventing obesity amongst low-income preschoolers.

METHODS

A cluster randomised controlled trial was conducted at 10 daycare centres. The 16-week FirstStep2Health intervention, grounded in the Actor-Partner Interdependence Model and the Social Cognitive Theory, included five components: a Facebook-based parent programme, three virtual parent meetings, three weekly motivational text messages, parent-child learning via weekly child letters and daycare centre-based child programme.

RESULTS

A total of 95 preschoolers (53 intervention and 42 control) participated. Preschoolers' mean age was 49.27 months, with 57.9% being female, 12.6% being Hispanic and 40% being African American. The intervention significantly decreased intervention preschoolers' fat intake (B = -33.76, p = 0.047) and % body fat (B = -1.18, p = 0.036) compared to the control. During year 2, there were significant intervention effects on increasing skin carotenoids (B = 87.06, p = 0.035). Although not statistically significant, the intervention showed positive effects on increasing preschoolers' fruit/vegetable intake; and decreasing screen time, body mass index z-score and proportion of overweight/obesity.

CONCLUSIONS

Even with some potential limitations (small sample size, measurement concerns and confounding with Coronavirus Disease 2019 pandemic), the study's results support the preliminary efficacy of the FirstStep2Health intervention in preventing obesity amongst low-income racially diverse preschoolers.

A Mother-Child Dyadic Approach to Evaluating Subclinical Cardiovascular Disease in Young Children: A Feasibility Study

BACKGROUND

Cardiovascular (CV) risk factors can be transmitted from mothers to their children. However, it is challenging to measure and identify subclinical CV risk in young children using traditional CV risk methods and metrics.

OBJECTIVE

The purpose of this study was to determine the feasibility of recruiting mother-child dyads and measuring arterial stiffness (pulse wave velocity, augmentation index/pressure), blood pressure (BP), BP circadian pattern, specifically nocturnal BP dipping, and CV health metrics in mothers and in children aged 1 to 5 years.

METHODS

All BP and arterial stiffness measures were obtained using the noninvasive automated oscillometric Mobil-O-Graph device. Also measured were blood cholesterol level; glucose level; body mass index (BMI); and smoking, diet, and physical activity history. Descriptive statistics were used for assessing recruitment feasibility and Pearson correlations for mother-child associations.

RESULTS

Thirty-five mother-child dyads completed the protocol. Recruitment reach was 89% and retention rate was 80%. Mothers were 34.3 ± 5.4 years old with a mean systolic BP (SBP) of 114.6 ± 9.5 mm Hg and BMI of 26.0 ± 6.5. Children were 3 ± 1.4 years old with a mean SBP of 103.3 ± 9.4 mm Hg and BMI z -scores of -0.3 ± 1.5. Arterial stiffness parameters were within normal ranges for mothers and children. Twenty-three percent of mothers did not exhibit nocturnal dipping (<10% decrease between day and nighttime SBP). Maternal SBP was positively correlated with child BMI z -scores ( r = 0.42, P = .022) as well as mother-child augmentation pressure ( r = 0.51, P = .010).

CONCLUSIONS

Our findings support using a mother-child approach and novel noninvasive approaches to assess and target CV risk in mothers and their young children.

The Role of the Pediatrician in the Promotion of Healthy, Active Living

Few children and adolescents meet federal nutrition or physical activity recommendations, and many experience poor or inadequate sleep and negative health effects from screen use and social media. These lifestyle factors exacerbate physical and mental health risks for children and adolescents. This clinical report provides guidance to help pediatricians address the nutritional, physical activity, sleep, media and screen use, and social-emotional factors that affect child and adolescent health and wellness. The recommendations in this clinical report aim to promote health and wellness practices for infants, children, and adolescents across several domains of influence, including the individual, interpersonal, institutional, community, and public policy levels.

Parent-Offspring Associations of Ideal Cardiovascular Health Metrics: Findings From the 2014 to 2021 Korea National Health and Nutrition Examination Survey

BACKGROUND

Studies have reported the strength of cardiovascular health (CVH) metrics in parent-offspring relationships. This study aimed to describe the sex-specific associations between CVH in parents and adult offspring.

METHODS AND RESULTS

This study was conducted on the Korea National Health and Nutrition Examination Survey data set, which analyzed trios of mother-father-child, with the child's age from 20 to 39 years. To use the nature of sampling design, survey weighting was applied to all our analyses. Ideal CVH was defined as a cluster of at least 5 ideal individual CVH metrics. We examined the association between parents and their adult offspring regarding clustering CVH and individual CVH metrics through odds ratios and 95% CIs using multiple logistic regression with standard errors adjusted for within-family clustering. The study included 1267 married couples comprising 748 sons and 819 daughters. After adjusting for household income and offspring's sex, age, education, and alcohol consumption, an offspring with either parent attaining a nonideal CVH was 3.52 times more likely to have nonideal CVH. Fathers' nonideal CVH was significantly positively associated with the daughters' nonideal CVH. Maternal nonideal CVH was significantly positively associated with the son's nonideal CVH. When analyzing individual CVH metrics, ideal status in fathers or mothers reduced the likelihood of their offspring having a nonideal status.

CONCLUSIONS

This cross-sectional study showed positive and differential associations of CVH and its components between parents' and offsprings' nonideal status. Our hypothesis-generating results suggest the relevance of using CVH as a composite indicator in family-centered approaches and heart-health interventions.

Psychosocial and environmental risk factors of obesity and hypertension in children and adolescents-a literature overview

Childhood obesity has become a worldwide epidemic in the 21st century. Its treatment is challenging and often ineffective, among others due to complex, often not obvious causes. Awareness of the existence and meaning of psychosocial and environmental risk factors seems to be an essential element in the prevention and treatment of obesity and its complications, especially arterial hypertension. In this review, we will discuss the role of that risk factors linking obesity and increased cardiovascular disorders including the role of nutritional factors (including the role of unhealthy diet, inadequate hydration), unhealthy behaviors (e.g. smoking, alcohol and drugs, sedentary behavior, low physical activity, disrupted circadian rhythms, sleep disorders, screen exposure), unfavorable social factors (such as dysfunctional family, bullying, chronic stress, mood disorders, depression, urbanization, noise, and environmental pollution), and finally differences in cardiovascular risk in girls and boys.

Geographical and sociodemographic disparities in fruit and vegetables consumption among adults in Burkina Faso: baseline results from the 2013 WHO STEPS survey

BACKGROUND

Evidence on sociodemographic determinants and spatial variations in the fruit and/or vegetable (FV) consumption was reported. This study aimed to explore geographical and sociodemographic disparities in the level of FV consumption among adults in Burkina Faso, using the national baseline data.

METHODS

This was a cross-sectional secondary study of primary data obtained by the 2013 (September to October) World Health Organization Stepwise Approach to Surveillance survey conducted in Burkina Faso. The participants were 4402 women and men aged 25-64 years and living in all 13 Burkinabè Regions. Descriptive and analytical analyses were performed using Student's t test, ANOVA, the chi-square test, Fisher's exact test and logistic regressions.

RESULTS

The prevalence of a typical daily consumption of at least three servings was 4.1% (95% CI: 3.6-4.8) for fruits and 6.6% (95% CI: 5.9-7.3) for vegetables. The national prevalence of adequate FV intake was 5.1% (95% CI: 4.4-5.8), and for two Regions ("Centre-Ouest" and "Nord") the pooled prevalence was 22.4%, while in the other eleven Regions its was significantly lower, 2.4% (p = 0.0001). Using quartiles derived from the national level of consumption, each of these two Regions had a higher proportion (about 50%) of their participants in the fourth quartile (the higher level). The associated sociodemographic factors with the adequate intake were being rural residents (aOR = 1.7, p = 0.011) and women (aOR = 1.3; p = 0.03).

CONCLUSION

Except for the Regions of "Centre-Ouest" and "Nord" of Burkina Faso, the prevalence of adequate consumption of FV was very low in its other eleven Regions. Measures to increase consumption in urban people are urgent while women should be the key actor in the family-based approaches implementation and the nutrition education promoting FV consumption.

Association Between a First-Degree Family History and Self-Reported Personal History of Obesity, Diabetes, and Heart and Blood Conditions: Results From the All of Us Research Program

Background Family history reflects the complex interplay of genetic susceptibility and shared environmental exposures and is an important risk factor for obesity, diabetes, and heart and blood conditions (ODHB). However, the overlap in family history associations between various ODHBs has not been quantified. Methods and Results We assessed the association between a self-reported family history of ODHBs and their risk in the adult population (age ≥20 years) of the AoU (All of Us) Research Program, a longitudinal cohort study of diverse participants across the United States. We conducted a family history-wide association study to systematically assess the association of a first-degree family history of 15 ODHBs in AoU. We performed stratified analyses based on racial and ethnic categories, education, household income and gender minority status, and quantified associations by type of affected relatives. Of 125 430 participants, 76.8% reported a first-degree family history of any ODHB, most commonly hypertension (n=64 982, 51.8%), high cholesterol (49 753, 39.7%), and heart attack (29 618, 23.6%). We use the FamWAS method to estimate 225 familial associations among 15 ODHBs. The results include overlapping associations between family history of different types of cardiometabolic conditions (such as type 2 diabetes and coronary artery disease), and their risk factors (obesity, hypertension), where adults with a family history of 1 ODHB exhibited 1.1 to 5.6 times (1.5, on average) the odds of having a different ODHB. Conclusions Our findings inform the utility of family history data as a risk assessment and screening tool for the prevention of ODHBs and to provide additional insights into shared risk factors and pathogenic mechanisms.

Declined prevalence, improved awareness and control of hypertension are associated with spousal educational attainment: A mega-data study

Cardiovascular diseases, including hypertension, have posed a serious threat to human health in recent decades. Family-centered health promotion and disease control for the management of hypertension is gaining attention. In this study, we assessed the association between spousal educational attainment (SEA) and hypertension prevalence, awareness, and control, intending to provide new directions for family health care. A total of 71 211 191 reproductive-aged participants from the National Free NFPCP during 2013-2019 were included in the current study. Inverse probability weighting (IPW) via propensity models were used to adjust for the imbalance by SEA. Both multivariable-adjusted ORs and inverse-probability-weighted ORs were used to assess the association between SEA and the prevalence, awareness, and control of hypertension. ORs of prevalence, awareness, and control of hypertension with SEA stratified by sex, age, and residency type were also reported. Compared with participants with SEA of compulsory education, the inverse-probability-weighted ORs for hypertension were 0.97 (0.96-0.97), 0.99 (0.98-1.00), and 0.91 (0.88-0.93) for participants with SEA of senior high, college, and postgraduate, respectively. The corresponding ORs for hypertension awareness were 1.12 (1.10-1.13), 1.15 (1.13-1.16), and 1.38 (1.34-1.41). The increment of hypertension control associated with SEA was only identified in urban areas. Modification analyses revealed that urban participants were observed to have more healthy benefits associated with SEA; additional decreased prevalent hypertension and increased hypertension awareness associated with SEA were observed in wives and husbands respectively. Thus, SEA was associated with decreased prevalent hypertension and increased awareness and control of hypertension. Our findings call for increased participation of spouses in family-centered healthcare, with consideration of modified effects by gender, age, and residency type, to improve chronic disease prevention and control including hypertension.

Preventative interventions that target cardiovascular dysfunction in children and young people: a systematic review of their effectiveness and an investigation of sexual dimorphism

Given that cardiovascular diseases remain a primary cause of mortality and morbidity, there is a need to consider preventative strategies to improve vascular function from early in life. The aims of this study were therefore to investigate which interventions may improve endothelial function, intima media thickness and arterial stiffness in children and young people and to assess whether these interventions differ in boys and girls. A systematic literature search of Science Direct, Pubmed, Google Scholar and the Cochrane Library by two independent reviewers was performed to source articles. Inclusion criteria were any studies including any child ≤18 years of age receiving an intervention, which measured vascular function other than blood pressure. Exclusion criteria were studies assessing children with chronic medical conditions. A total of 72 studies were identified, which met the inclusion criteria. A measurable change in outcome was more likely to be reported in studies investigating endothelial function (p = 0.03). Interventions which improved vascular function included physical activity and dietary programmes. Under 10% of studies considered sex differences. In conclusion, school-based physical activity interventions are most likely to result in improvements in vascular function. Endothelial function may be the first variable of vascular function to change secondary to an intervention. Standardisation of reporting of differences between the sexes is essential to be able to ensure interventions are equally effective for boys and girls.

Details of Cancer Education Programs for Adolescents and Young Adults and Their Effectiveness: A Scoping Review

The purpose of this review was to establish what cancer education programs have been carried out aimed at adolescents and young adults (AYAs) and what outcomes they achieved. The databases used were MEDLINE, CINAHL, and Web of Science, and the search period was set as 2011-2020. The extracted literature was evaluated for quality using the Joanna Briggs Institute's critical appraisal tools. The subjects of the analysis were 29 studies: 10 randomized controlled trials and 19 quasi-experimental designs. Regarding the varieties of cancers found in the data, in descending order, 10 documents looked at cervical cancer, 9 looked at cancer in general, and 4 looked at breast cancer. Most studies focused on AYAs exclusively, with just three studies involving their parents simultaneously. Many studies used lecture-based intervention, with information technology-based interventions using websites and cell phones. Topics included in the program were cancer epidemiology, cancer risk factors, cancer warning signs and symptoms, prevention methods, and screening methods. After the intervention, all studies showed statistically significant improvements in at least one outcome measure, which included knowledge and awareness of cancer, health beliefs, and intent to take preventive action, demonstrating a basis for educational intervention. Educating AYAs about cancer at a time when their ways of life are becoming more concrete can be expected to have a positive impact on cancer preventing behaviors in adulthood, increase their parents' awareness of cancer, and have a positive impact on behavior around screening.

A Heart-Healthy Diet for Cardiovascular Disease Prevention: Where Are We Now?

Purpose of Review

The relationship between cardiovascular health and diet is evolving. Lifestyle modifications including diet changes are the primary approach in managing cardiometabolic risk factors. Thus, understanding different diets and their impact on cardiovascular health is important in guiding primary and secondary prevention of cardiovascular disease (CVD). Yet, there are many barriers and limitations to adopting a heart healthy diet.

Recent Findings

Diets rich in fruits, vegetables, legumes, whole grains, and lean protein sources, with minimization/avoidance of processed foods, trans-fats, and sugar sweetened beverages, are recommended by prevention guidelines. The Mediterranean, DASH, and plant-based diets have all proven cardioprotective in varying degrees and are endorsed by professional healthcare societies, while other emerging diets such as the ketogenic diet and intermittent fasting require more long-term study. The effects of diet on the gut microbiome and on cardiovascular health have opened a new path for precision medicine to improve cardiometabolic risk factors. The effects of certain dietary metabolites, such as trimethylamine N-oxide, on cardiometabolic risk factors, along with the changes in the gut microbiome diversity and gene pathways in relation to CVD management, are being explored.

Summary

In this review, we provide a comprehensive up-to-date overview on established and emerging diets in cardiovascular health. We discuss the effectiveness of various diets and most importantly the approaches to nutritional counseling where traditional and non-traditional approaches are being practiced, helping patients adopt heart healthy diets. We address the limitations to adopting a heart healthy diet regarding food insecurity, poor access, and socioeconomic burden. Lastly, we discuss the need for a multidisciplinary team-based approach, including the role of a nutrition specialist, in implementing culturally-tailored dietary recommendations. Understanding the limitations and finding ways to overcome the barriers in implementing heart-healthy diets will take us miles in the path to CVD prevention and management.

Association of Parental Cardiovascular Health With Disability-Adjusted Life Years in the Offspring: Results From the Framingham Heart Study

BACKGROUND

Disability-adjusted life years (DALYs) are used to evaluate the relative burden of diseases in populations to help set prevention or treatment priorities. The impact of parental cardiovascular health (CVH) on healthy life years lost from cardiovascular disease (CVD) in adult offspring is unknown. We compared parent-offspring CVD DALYs trends over the life course and examined the association of parental CVH with offspring CVD DALYs.

METHODS

Using data from the Framingham Heart Study, 4814 offspring-mother-father trios were matched for age at selected baseline exams. CVH score was computed from the number of CVH metrics attained at recommended levels: poor (0-2), intermediate (3-4), and ideal (5-7). CVD DALYs were defined as the sum of years of life lost and years lived with CVD. Age-sex-standardized life expectancy and disability weights were derived from the actuarial life tables and Global Burden of Disease study, respectively. Multivariable-adjusted linear regression was used to investigate the association of parental CVH with offspring CVD DALYs.

RESULTS

Over an equal 47-year follow-up, parents lost nearly twice the number of CVD DALYs compared to their offspring (23 234 versus 12 217). However, age-adjusted CVD DALYs were higher at younger ages and similar along the life course for parents and offspring. One-unit increase in parental CVH was associated with 5 healthy life months saved in offspring. Offspring of mothers with ideal versus poor CVH had 3 healthy life years saved (β=-3.0 DALYs [95% CI, -5.6 to -0.3]). No statistically significant association was found between paternal CVH categories and offspring CVD DALYs.

CONCLUSIONS

Higher maternal and paternal CVH were associated with increased healthy life years in offspring; however, the association was strongest between mothers and offspring. Investment in CVH promotion along the life course has the potential to reduce the burden of CVD in the current and future generation of adults.

Individual and family predictors of ultra-processed food consumption in Spanish children. The SENDO project

BRACKGROUND

Ultra-processed food (UPF) consumption is increasing exponentially, becoming a matter of concern for Public Health, given its adverse health effects.

OBJECTIVE

To identify individual and family factors predicting UPF consumption in childhood.

DESIGN

The SENDO project is an ongoing prospective dynamic cohort of Spanish children. In this study, we used baseline information of participants recruited between January 2015 and June 2021. Dietary information was collected with a validated semi-quantitative FFQ, and food items were classified using the NOVA classification. Individual and family factors associated with UPF consumption (p< 0.20) in univariate analyses were introduced in a model of generalized estimating equations (GEE) which accounted for intra-cluster correlations between siblings.

SETTING

The SENDO proyect (Spain), 2015-2021.

PARTICIPANTS

Spanish children are recruited at the age of 4-5 years and followed yearly through online questionnaires completed by parents.

RESULTS

In this sample of 806 participants (49% girls; mean age 5 years [SD: 0.90]), the mean UPF consumption was 37.64 % of total energy intake (sd: 9.59). Large family size and longer exposure to screens predicted higher consumption of UPF. On the other hand, better knowledge of children's dietary recommendations, healthy dietary attitudes towards child's eating habits and longer breastfeeding were associated with lower consumption of UPF. All these factors accounted for approximately 16% of the variability on the consumption of UPF in childhood.

CONCLUSION

Since most of the factors identified in this study are modifiable, they should be considered in public health strategies aimed at promoting heathy dietary habits in early life.

Association of family history of cardiometabolic diseases (CMDs) and individual health behaviours: Analysis of CARRS study from South Asia

Objectives

Family history is considered as an important predictor of cardiovascular diseases (CVDs) and diabetes. Available research findings suggest that family history of chronic diseases is associated with perceived risk of disease and adoption of healthy behaviours. We examined the association between family history of cardio-metabolic diseases (CMDs) and healthy behaviours among adults without self-reported CMDs.

Methods

Cross-sectional data of 12,484 adults, without self-reported CMDs, from the baseline survey of Centre for cArdiometabolic Risk Reduction in South-Asia (CARRS) cohort study were analysed.

Results

Family history was positively associated with non-smoking and high fruits & vegetables consumption in the age group of 45–64 years and moderate to high physical activity in the age group ≥65 years after adjusting for sex, education, wealth index, city and body mass index.

Conclusions

Understanding perceived risks and cultural or psychological factors related to family history through ethnographic studies may deepen understanding of these associations.

Relationship Between Family Functioning and Medication Adherence in Chinese Patients With Mechanical Heart Valve Replacement: A Moderated Mediation Model

Background: Medication adherence is crucial for patients with mechanical heart valve replacement. Although families functioning is positively associated with medication adherence, little is known about the underlying mechanisms. Objective: To test whether family functioning affects medication adherence through illness perceptions and whether this mediating effect was moderated by medication literacy. Methods: 319 patients after mechanical heart valve replacement were included in this cross-sectional study from June 2021 to October 2021. Data regarding family functioning, illness perceptions, medication adherence, and medication literacy were collected through questionnaires. The moderated mediation model was examined by Hayes's PROCESS macro, based on the bootstrapping method. Results: The results revealed illness perceptions partially mediated the association of family functioning on medication adherence [β = 0.08, 95% confidence intervals: (0.04, 0.12)], and this effect was stronger for patients with low medication literacy than those with high literacy [β = -0.36, 95% CI: (-0.50, -0.22)]. Furthermore, the relationship between family functioning and medication adherence was only significant in patients with low medication literacy [β = 0.36, 95% CI: (0.23, 0.50)]. Conclusion: The mediating effect of illness perceptions between family functioning and medication adherence was moderated by medication literacy. Efforts to improve medication adherence by targeting at improving family functioning may be more effective when considering illness perceptions, especially for patients with limited medication literacy.

Assessing Cardiometabolic Health Risk Among U.S. Children Living in Grandparent-Headed Households

PURPOSE

We evaluated children's cardiometabolic health (CMH) risk indicators and adverse childhood experiences (ACEs) stratified by family structure type (grandparent-headed, two-parent headed, and single-parent headed households). Separately, we assessed whether family structure type and number of ACEs were independently associated with the CMH risk indicators.

DESIGN AND METHODS

Utilizing data from the 2017-2018 National Survey of Children's Health, we evaluated five CMH risk indicators (obesity, physical activity, secondhand smoke exposure, sleep, and sports participation). We used multivariable logistic regressions to assess the association of CMH risk indicators with family structure type and ACEs. We controlled for sex, age, race/ethnicity, health insurance, household poverty level, and overall health status.

RESULTS

Among children aged 10-17 years (n = 24,885), we found the number of ACEs differed by family structure type (P < 0.001) and was independently associated with obesity, secondhand smoke exposure, sleep, and sports participation. Adjusting for all covariates except ACEs, family structure type was significantly associated with children's CMH risk; but after controlling for ACEs that association was attenuated - except for sleep (less adequate sleep in grandparent-headed households) and exposure to secondhand smoke (less exposure in single-parent headed households).

CONCLUSIONS

ACEs were highest among children living in grandparent-headed households and independently associated with a majority of the CMH risk indicators. Findings suggest that children living in grandparent-headed households may be at elevated risk for poor CMH, potentially due to higher risk for ACEs.

PRACTICE IMPLICATIONS

It is recommended to consider ACEs and family structure type when assessing CMH risk in children.

Evaluation of health-related knowledge, attitudes, and behaviors of undergraduate students by cardiovascular risk factors

AIM

To determine the presence of cardiovascular (CV) risk (CVR) factors in university students and evaluate how these factors are affected from the knowledge, attitudes, and habits of the individuals regarding healthy lifestyle.

BACKGROUND

Starting from early ages, lifestyle habits such as lack of physical activity, unhealthy eating, and inappropriate drug use increase CV and metabolic risks of individuals.

METHODS

In April-May 2018, sociodemographic characteristics of 770 undergraduate students, in addition to their knowledge, attitudes, and habits regarding their nutrition and physical activity status were obtained through face-to-face questionnaires. CVR factors were determined according to blood pressure, blood glucose, total cholesterol levels, and anthropometric measurements. Collected data were compared by CVR factor presence (CV[+] or CV[-]) in students.

FINDINGS

The mean age of the participants was 22.3 ± 2.6 years. 59.6% were female and 71.5% were students of non-health sciences. In total, 274 individuals (35.9%) belonged to CV(+) group (mean risk number: 1.3 ± 0.5) with higher frequency in males (42.1% versus 31.6%, P < 0.05). The most common CVR factors were smoking (20.6%), high total cholesterol (7.5%), and hypertension/high blood pressure (6.0%). 15.5% of the participants regularly used at least one drug/non-pharmaceutical product. 11.3% complied the Mediterranean diet well. 21.9% of CV(+) stated consuming fast food at lunch compared to 14.3% of CV(-) (P < 0.05). 44.6% stated exercising below the CV-protective level.

CONCLUSIONS

This study showed one-third of university students was at CVR, independent of their sociodemographic characteristics. Furthermore, the students appear to perform below expectations in terms of nutrition and physical activity. Extensive additional measures are needed to encourage young individuals for healthy nutritional and physical activity habits.

Efficacy of a family-based cardiovascular risk reduction intervention in individuals with a family history of premature coronary heart disease in India (PROLIFIC): an open-label, single-centre, cluster randomised controlled trial

BACKGROUND

Coronary heart disease, a leading cause of death globally, is amenable to lifestyle interventions. The family environment can affect the ability or willingness of individuals to make lifestyle changes. We aimed to investigate the efficacy of a targeted family-based intervention for reduction of total cardiovascular risk in individuals with a family history of premature coronary heart disease.

METHODS

We did an open-label, cluster randomised controlled trial (PROLIFIC) in the families (first-degree relatives and spouses, older than age 18 years) of individuals with coronary heart disease who had been diagnosed before age 55 years. Patients with coronary heart disease diagnosed within the past year were selected from a tertiary care speciality hospital that provides care for patients from Kerala, India. Family members of selected patients who were bedridden or terminally ill, and individuals with a history of established cardiovascular heart disease and stroke were excluded, as were families with fewer than two eligible family members. Simple randomisation with computer-generated random numbers was used to randomly assign families to intervention and usual care groups (1:1). Participants in the intervention group received a comprehensive package of interventions facilitated by non-physician health workers, consisting of: screening for cardiovascular risk factors; structured lifestyle interventions; linkage to a primary health-care facility for individuals with established chronic disease risk factors or conditions; and active follow-up for adherence. The usual care group received one-time counselling and annual screening for risk factors. We obtained data on lifestyle, clinical, and biochemical characteristics at baseline and annually during the 2-year follow-up. The primary outcome was achievement or maintenance of any three of the following: blood pressure lower than 140/90 mm Hg, fasting plasma glucose lower than 110 mg/dL, low-density lipoprotein cholesterol lower than 100 mg/dL, and abstinence from tobacco. The primary outcome was analysed in all participants available for follow-up at the relevant timepoint. This trial is registered with Clinicaltrials.gov, NCT02771873.

FINDINGS

From Jan 1, 2015, to April 30, 2017, 980 patients with coronary heart disease were assessed for eligibility and 230 were excluded primarily due to lack of evidence of coronary artery disease (n=199), or a diagnosis of coronary heart disease more than 1 year previously (n=29). Of the 750 remaining families, 368 (with 825 participants) were assigned to the intervention group and 382 (with 846 participants) were assigned to the usual care group. At the 2-year follow-up, data from 803 (97%) of 825 participants in the intervention group and 819 (97%) of 846 participants in the usual care group were available. Of the 1671 participants, 1111 (66·5%) were women, and 560 (33·5%) were men. The mean age of the study population was 40·8 years (SD 14·2). At the 2-year follow-up, the primary outcome was achieved by 514 (64%) of 803 participants in the intervention group and 379 (46%) of 819 in the usual care group. After adjustment for clustering and baseline risk factors, the odds of achieving the primary outcome at the 2-year timepoint was two times higher in the intervention group than in the usual care group (odds ratio 2·2, 95% CI 1·7-2·7; p<0·0001).

INTERPRETATION

The reduction of total cardiovascular risk observed after the intervention could have a substantial public health impact by preventing future cardiovascular events.

FUNDING

The Wellcome Trust and Department of Biotechnology, Government of India, and India Alliance.

Communication approaches to enhance patient motivation and adherence in cardiovascular disease prevention

Preventive cardiology visits have traditionally focused on educating patients about disease risk factors and the need to avoid and manage them through lifestyle changes and medications. However, long-term patient adherence to the recommended interventions remains a key unmet need. In this review we discuss the rationale and potential benefits of a paradigm shift in the clinician-patient encounter, from focusing on education to explicitly discussing key drivers of individual motivation. This includes the emotional, psychological, and economic mindset that patients bring to their health decisions. Five communication approaches are proposed that progress clinician-patient preventive cardiology conversations, from provision of information to addressing values and priorities such as common health concerns, love for the family, desire of social recognition, financial stressors, and desire to receive personalized advice. Although further research is needed, these approaches may facilitate developing deeper, more effective bonds with patients, enhance adherence to recommendations and ultimately, improve cardiovascular outcomes.

Protecting Families: A Qualitative Study on the Implementation of Protective Measures to Prevent COVID-19 Transmission

BACKGROUND: Health protocol compliance among family members can help curb the spread of COVID-19. However, not all families or family members can easily navigate the changes brought about by the pandemic; hence, minimizing virus transmission remains a challenge. AIM: Therefore, observing how families implement health protocols in daily life will reveal the challenges and opportunities, and inform public health policies. METHODS: We conducted a qualitative study by collecting data through phone interviews from November 2020 to February 2021. Eighteen families with a total of 30 individuals participated in this study. The interview data were transcribed verbatim and analyzed using thematic analysis. RESULTS: The analysis shows that participants were actively involved in implementing protective measures to prevent transmission among their family members. Five themes emerged from the data, namely fundamental concerns, restraints and constraints, pandemic roles, compromises, and intergenerational attitudes. The themes described the families’ lives during the pandemic, their efforts in protecting family members, and the dynamic within the families related to the implementation of COVID-19 protective measures. CONCLUSION: This study indicates that families could play a key role in both protecting and compromising the health of their family members. Families respond to the health crisis actively, but at times increase the risk to virus exposure because they have to continue going about their daily lives.

Malnutrition, Family Support, and Possible Sarcopenia in Patients Undergoing Transcatheter Aortic Valve Implantation

Background

Possible sarcopenia, aortic valve stenosis, and malnutrition are important issues that afflict older adults.

Objective

The aims of this study were to compare the differences in nutritional status and family support in older adults with possible sarcopenia and those without sarcopenia after undergoing transcatheter aortic valve implantation (TAVI) and to identify the predictors of malnutrition and demonstrate changes in heart function over time after undergoing TAVI.

Methods

A case-control design was conducted. Possible sarcopenia was identified by measuring calf circumference, grip strength, and gait speed. The Mini Nutritional Assessment-Short Form and numerical family support rating scale were used to collect data. Left ventricular ejection fraction and New York Heart Association (NYHA) functional class were assessed at 5 time points to evaluate heart function.

Results

Eighty-one participants were categorized into those without sarcopenia (34) and those with possible sarcopenia (47). Logistic linear regression showed albumin and possible sarcopenia to be predictors of malnutrition (odds ratio, 5.5; 95% confidence interval, 1.02–30.19). Family support was associated with nutrition status (P = .019). For patient heart function, the results of NYHA functional class and left ventricular ejection fraction improved over time after TAVI. The improvement in NYHA functional class at T2 was significantly different between the 2 groups compared with that at T0.

Conclusions

The nutrition level was higher among participants without sarcopenia than those with possible sarcopenia. Approximately 90% of the participants indicated that they had high family support. Demographic factors and albumin levels could be used to evaluate risk of malnutrition. Patients without possible sarcopenia showed greater improvement in NYHA class.

Impact of Peer-Led Cancer Education Program on Knowledge, Health Beliefs, Practice, and Self-Esteem Among Pairs of Nepalese High-School Students and Their Knowledge-Sharing Partners

Raising cancer awareness among adolescents can increase their confidence in identifying cancer symptoms and develop healthy habits. This study tested the effectiveness of cancer education based on a new model among high schoolers. A non-randomized control group pre-post-test design study was conducted among 313 pairs of adolescent students and their knowledge-sharing partners in Lalitpur, Nepal. A baseline test was conducted before the education program, and it was followed up at two weeks and three months. Results were measured using a chi-square test, binary logistic regression, and a two-way repeated-measures ANOVA. There was a significant interaction effect of intervention and time on students' knowledge, beliefs, self-esteem, and practice, along with a change in some scores of knowledge-sharing partners. Joint assignment supported the idea of diffusion of information within the family and in the neighborhood. The peer group discussion could encourage active learning and help students to participate visibly in problem-solving and reflecting more sustainably. Time constraints, lack of human resources, and support groups, might limit this program's usage; however, preparing guidelines, and connecting communities, organizations, hospitals, volunteer health workers, and survivors can help make it more sustainable and approachable.

Swāsthya, an integrated chronic condition management programme for families of patients with hypertension and diabetes mellitus: a study protocol for a randomised controlled trial

Background

Kerala is known as the diabetes mellitus (DM) and hypertension (HTN) capital of the world, thus compelling health professionals to model strategies, addressing their social, behavioural, and cognitive risk factors and eliminating various barriers to management. This paper describes the protocol of our study that aims to examine the effectiveness and sustainability of an integrated care model for the management of chronic conditions and their risk factors through a family-based intervention. The proposed care model targets to modify systems and processes that predispose to chronic conditions by enhancing social cohesion and social networks, preventing lifestyle risks, developing iterative cognitive interventions, and engaging the family into customised treatment adherence strategies navigated by community health social workers (CHSWs).

Methods

A cluster randomised controlled trial (RCT) in selected participants will be conducted involving additional assessments prior to the baseline assessment. The assessment will identify and categorise patients into four risk groups, namely behavioural, social, cognitive, and multiple, based on dominant risks identified. Eligible participants will be randomly allocated (at a ratio of 1:1) into the intervention or control arm. The intervention arm will receive social, behavioural, and cognitive or multiple interventions corresponding to the identified risk groups, whereas the control arm will receive general intervention. Both the groups will be followed up at 6 months and 12 months post baseline to measure outcomes. The primary outcome will be the control of HTN and DM, and secondary outcomes include decreased depression and anxiety and improved functioning, social cohesion, and social network linkages. The sustainability and scalability of this intervention will be assessed through cost effectiveness, acceptability, and user friendliness of the integrated approach by performing a qualitative evaluation.

Discussion

This RCT will inform the potential paradigm shift from a medical model of chronic condition management to a multidimensional, multisystem, and multidisciplinary convergence model navigated by CHSWs. Such a model is not currently considered in the management of chronic conditions in Kerala.

Trial registration

Trial has been prospectively registered on Clinical Trial Registry of India- CTRI/2020/12/029474 on 1st December 2020.

Inequalities in morbidity in South Africa: A family perspective

South Africa is struggling to achieve sustainable development targets as the country faces a quadruple burden of diseases. Concerted efforts to realise good health for all people require evidence-based targeted interventions. This study aimed to investigate the relationship between living arrangements and self-reported ill-health among adults aged 15 years and older in South Africa. Analyses were based on a sample of 49,962 individuals drawn from the 2017 South African General Household Survey, using a multivariate regression technique to assess the distribution and predictors of ill-health. Composite indices of disease burdens were created using several related morbidities in each disease category. The findings confirm that health outcomes in South Africa vary by living arrangements of individuals, their socioeconomic status, and by the level of urbanisation or residence. It was found that women who are black, younger and less-educated, irrespective of their living arrangement, are particularly vulnerable to illhealth. Policy implications are discussed.

The Correlation Between Parental Perceptions and Readiness to Change with Participation in a Pediatric Obesity Program Serving a Predominantly Black Urban Community: A Retrospective Cohort Study

BACKGROUND

This study assessed whether maternal BMI and perceptions about weight and reported level of readiness to change was correlated with compliance to a pediatric lifestyle modification program targeting a hard-to-reach urban population with a high prevalence of severe obesity.

METHODS

The Parental Readiness Questionnaire (PRQ) was administered to the child's mother at program entry. The PRQ consisted of forty-seven multiple-choice and 10-point Likert scale questions regarding family demographics, exercise and eating habits, attitudes about health, body image, and weight, and the desire to improve nutrition and physical activity. Analysis was performed on PRQs of participants to compare parental perceptions and readiness for change with compliance to program requirements. Analysis was conducted on 596 questionnaires and compliance was categorized into three groups based on attendance to follow-up visits.

RESULTS

Significant differences were found between short-term and long-term follow-up groups in regards to parental perception of one's health as well as the health, weight, and body image of their child. Differences were found in perceptions of one's own weight and body image as well as the health of one's self and child between the group with a maternal BMI < 35 and the group with a maternal BMI ≥ 35. A lower maternal BMI was associated with a better perception of one's own weight, body image, and health, as well as the health of the child.

CONCLUSION

Positive parental perceptions on weight were correlated with improved compliance to a pediatric lifestyle modification program.

Hygiene and Eating Healthy Habits and Practices in Spanish Families with Children Aged 6 to 14

During childhood and pre-adolescence, the family environment is key to initiating and consolidating healthy styles in children through a balanced diet and basic hygiene habits. This study analyses hygiene, nutrition and health practices in Spanish families with children between 6 and 14 years of age according to the type of family (nuclear, single-parent or reconstituted) and the quantity, age and gender of the children. A representative Spanish national sample of 1103 Spanish parents, 270 fathers and 833 mothers, with children aged 6 to 14, is analysed. The study is descriptive, using statistical techniques with classic indicators (means, percentages). The results show that nuclear families manifest healthier habits, in general, and consider the consumption of pastries, ultra-processed food and excessive amounts of salt to be harmful. Furthermore, this family typology develops healthy and hygienic habits, such as brushing teeth daily, sleeping at least 8 h a day, drinking a glass of milk a day, eating fish more than once a week and eating fast food sporadically. They are also concerned about their children’s annual medical check-ups (paediatrician and dentist). It is concluded that the family type is related to the hygiene and feeding habits of the children.

Family History for Cardio-Metabolic Diseases: A Predictor of Major Adverse Cardiovascular Events in Men With Erectile Dysfunction

BACKGROUND

Family history (FH) of cardiovascular (CV) disease is a known CV risk factor. However, it is rarely considered for CV risk stratification. Furthermore, FH for metabolic diseases is generally overlooked.

AIM

To evaluate, in a population of men with erectile dysfunction (ED), whether FH for cardio-metabolic diseases could provide insights into metabolic and sexual features and predict the occurrence of forthcoming major adverse CV events (MACE).

METHODS

A consecutive series of 4,693 individuals (aged 51.3 ± 13.3 years) attending an Andrology outpatient clinic for ED was studied. A subset of these (n = 1,595) was evaluated retrospectively for MACE occurrence.

OUTCOMES

Several metabolic and sexual function-related parameters were studied. For the retrospective study, information on an incident MACE was collected over a mean follow-up of 4.2 ± 2.5 years.

RESULTS

A greater number of cardio-metabolic FH factors were associated with a worse metabolic profile, including higher waist circumference, triglycerides, glucose, glycosylated hemoglobin, and diastolic blood pressure, as well as lower high-density lipoprotein cholesterol. An increased number of FH factors were associated with worse erectile function (odds ratio = 1.14[1.07;1.23], P < .0001), impaired penile dynamic peak systolic velocity, and lower testosterone levels. In the retrospective study, a positive cardiometabolic FH was associated with a significantly higher incidence of MACEs, even after adjusting for age and comorbidities (hazard ratio = 1.51[1.06-2.16], P = .023). Interestingly, when dividing the sample into high- and low-risk categories according to several CV risk factors (age, previous MACEs, high-density lipoprotein cholesterol, and comorbidities), FH was confirmed as a predictor of incident MACE only among the low-risk individuals.

CLINICAL IMPLICATIONS

Investigating FH for cardio-metabolic diseases is a quick and easy task that could help clinicians in identifying, among individuals with ED, those who deserve careful evaluation of CV and metabolic risk factors. Moreover, considering FH for CV risk stratification could predict MACEs in individuals who, according to conventional CV risk factors, would be erroneously considered at low risk.

STRENGTHS & LIMITATIONS

The large sample size and the systematic collection of MACEs through an administrative database, with no risk of loss at follow-up, represent strengths. The use of administrative database for MACE collection may lead to some misclassifications. The specific population of the study limits the generalizability of the results.

CONCLUSION

FH is simple and inexpensive information that should be part of the CV risk assessment in all men with ED because it helps in the identification of those who need lifestyle and risk factor modifications and whose risk would otherwise be overlooked. Rastrelli G, Yannas D, Mucci B, et al. Family History for Cardio-Metabolic Diseases: A Predictor of Major Adverse Cardiovascular Events in Men With Erectile Dysfunction. J Sex Med 2020;17:2370-2381.

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.

Perceived facilitators and barriers of enrolment, participation and adherence to a family based structured lifestyle modification interventions in Kerala, India: A qualitative study

Background: The objective of the study was to describe participants’ and providers’ perspectives of barriers and facilitators of enrolment, participation and adherence to a structured lifestyle modification (SLM) interventions as part of the PROLIFIC trial in Kerala, India.

Methods: Family members who had been enrolled for 12-months or more in a family-based cardiovascular risk reduction intervention study (PROLIFIC Trial) were purposively sampled and interviewed using a semi-structured guide. The non-physician health workers (NPHWs) delivering the intervention were also interviewed or included in focus groups (FGDs). Thematic analysis was used for data analysis.

Results: In total, 56 in-depth interviews and three FGDs were conducted. The descriptive themes emerged were categorised as (a) motivation for enrolment and engagement in the SLM interventions, (b) facilitators of adherence, and (c) reasons for non-adherence. A prior knowledge of familial cardiovascular risk, preventive nature of the programme, and a reputed organisation conducting the intervention study were appealing to the participants. Simple suggestions of healthier alternatives based on existing dietary practices, involvement of the whole family, and the free annual blood tests amplified the adherence. Participants highlighted regular monitoring of risk factors and provision of home-based care by NPHWs as facilitators for adherence. Furthermore, external motivation by NPHWs in setting and tracking short terms goals were perceived as enablers of adherence. Nonetheless, home makers expressed difficulty in dealing with varied food choices of family members. Young adults in the programme noted that dietary changes were affected by eating out as they wanted to fit in with peers.

Conclusions: The findings suggest that a family-based, trained healthcare worker led SLM interventions are desirable and feasible in Kerala. Increasing the number of visits by NPHWs, regular monitoring and tracking of lifestyle goals, and targeting young adults and children for dietary changes may further improve adherence to SLM interventions.

Parent-child cooking meal together may relate to parental concerns about the diets of their toddlers and preschoolers: a cross-sectional analysis in Japan

BACKGROUND

Parents often have concerns about the food habits of their young children. Cooking is a frequent behavior related to dietary activities at home. We hypothesized that "a parent cooking meals together with young children might alleviate dietary concerns." The aim of this study was to identify the relationship between parental cooking practices (e.g., cooking meals together with the child) and diet-related concerns.

METHODS

Data were extracted from the "National nutrition survey on preschool children" conducted among nation-wide households with toddlers and preschoolers in 2015 by the Ministry of Health, Labour and Welfare of Japan. Parents were classified into two groups comprising those who cooked meals together with their children and those who did not. The following variables were compared: taking too much time to eat (slow eaters), "picky" eating (eating only certain foods), inconsistent food intake (eating too much or too little), playing with food/utensils while eating, preferring sweetened beverages and snacks over meals, eating too fast to chew well, not swallowing food, disinterested in eating, and spitting out food. The associations between parent-child cooking meals together and the concerns pertaining to the child's dietary habits and food intake were analyzed and compared between the two groups.

RESULTS

The concerns of "picky eating" and "playing with food/utensils while eating" were lower, while "eating too much" was higher in the parent-cooking together group. The intake frequency of fish, soybeans/soy products, vegetables, and milk among children were higher in the "cooking together" group than among those in the "not cooking together" group. Children in the "cooking together" group consumed a significantly greater variety of foods than those in the "not cooking together" group.

CONCLUSIONS

Cooking a meal together with a child may be related to the parent's lower concerns about the dietary habits of the child, including "picky eating" and "playing with food/utensils while eating," but may also be related to the higher concerns of "eating too much."

Atherosclerosis

Atherosclerosis, the formation of fibrofatty lesions in the artery wall, causes much morbidity and mortality worldwide, including most myocardial infarctions and many strokes, as well as disabling peripheral artery disease. Development of atherosclerotic lesions probably requires low-density lipoprotein, a particle that carries cholesterol through the blood. Other risk factors for atherosclerosis and its thrombotic complications include hypertension, cigarette smoking and diabetes mellitus. Increasing evidence also points to a role of the immune system, as emerging risk factors include inflammation and clonal haematopoiesis. Studies of the cell and molecular biology of atherogenesis have provided considerable insight into the mechanisms that link all these risk factors to atheroma development and the clinical manifestations of this disease. An array of diagnostic techniques, both invasive (such as selective coronary arteriography) and noninvasive (such as blood biomarkers, stress testing, CT and nuclear scanning), permit assessment of cardiovascular disease risk and targeting of therapies. An expanding armamentarium of therapies that can modify risk factors and confer clinical benefit is available; however, we face considerable challenge in providing equitable access to these treatments and in maximizing adherence. Yet, the clinical application of the fruits of research has advanced preventive strategies, enhanced clinical outcomes in affected individuals, and improved their quality of life. Rapidly accelerating knowledge and continued research promise to provide further progress in combating this common chronic disease.

How To Identify Familial Premature Myocardial Infarction: Comparing Approaches To Identify Familial Hypercholesterolemia

CONTEXT

How best to identify families with premature myocardial infarction is unclear.

OBJECTIVE

We compared approaches to identify familial premature myocardial infarction in the general population using different familial hypercholesterolemia (FH) criteria and low-density lipoprotein (LDL) cholesterol cut-points.

DESIGN AND SETTING

Clinical and mutation criteria for FH and LDL cholesterol cut-points were applied for identification of familial premature myocardial infarction in 106,732 individuals from the Copenhagen General Population Study.

RESULTS

FH criteria identified 898 (13%) cases with familial premature myocardial infarction, leaving 5856 (87%) cases undetected. The ORs for familial premature myocardial infarction, compared with the respective remainder groups, were 4.7 (95% CI, 3.7 to 6.0) for clinical FH by Dutch Lipid Clinic Network criteria, 4.4 (4.0 to 4.7) for Simon Broome criteria, 2.1 (95% CI, 1.7 to 3.6) for Make Early Diagnosis to Prevent Early Death criteria, 2.1 (95% CI, 1.4 to 3.3) for FH mutation, and 1.4 (95% CI, 1.3 to1.6) for LDL cholesterol ≥5 mmol/L (193 mg/dL). For these risk groups, the sensitivity (true positive rate) for identification of familial premature myocardial infarction were 1.3%, 13%, 1.6%, 0.9%, and 7.1%, respectively. Compared with universal screening of a similar fraction of the population, the relative increase in sensitivity for these risk groups was 3.8-fold [fraction of population examined: 0.3%, 3.3-fold (4%), 2.0-fold (0.8%), 2.0-fold (0.4%), and 1.4-fold (5.3%), respectively].

CONCLUSION

Criteria for FH identify a small fraction of individuals with familial premature myocardial infarction in the general population. Actively identifying families with premature myocardial infarction would be of potential preventive importance, and this study provides data that could be used to choose the best method for such family identification.

Family Dynamics in Sleep Health and Hypertension

PURPOSE OF REVIEW

Present a conceptual model and review the recent literature on family dynamics, sleep, and hypertension.

RECENT FINDINGS

Family dynamics predict hypertension and hypertension risk, in part, due to shared health behaviors. Sleep health behaviors (sleep duration, quality, and efficiency) predict hypertension risk in children and youth and are emerging as a family-level health behavior. Importantly, both family dynamics and sleep are modifiable. Family members influence one another's sleep through their physical presence and through psychological and emotional mechanisms. Family members' sleep patterns may also be coregulated. Negative family dynamics are associated with poor sleep health and predict greater cardiovascular risk. Sleep health behaviors in the family context may also interact with family dynamics to dampen or exacerbate hypertension risk factors in children and youth. This review proposes that promoting sleep health in a family context could be one way to reduce long-term hypertension risk.

Dementia: Paradigm shifting into high gear

Redressing the rising threat of dementia demands not only an increase, but a diversification of efforts. We need new approaches, trials, and partners. We cannot afford to continue to only round up the usual suspects, β amyloid, and tau and try to stop them with a single drug "silver bullet". Dementia of late onset is not a disease, but an amalgam of interactive pathologies on the shifting background of aging, requiring multimodal targeting. Cerebrovascular diseases coexist and coact with all major neurodegenerative pathologies, increasing two-fold the likelihood that they will manifest clinically. Cerebrovascular diseases need to be controlled, to give antidegenerative drugs a chance to succeed. This calls for new types of trials and designs. Stroke doubles the chances of developing dementia and decreases in stroke incidence correlate with decreases in dementia. Ninety percent of strokes are potentially preventable and so are a proportion of dementias. The stroke and dementia communities need to partner and complement the search for silver bullets with the golden opportunity of doing something now.

Rationale and design of the SI! Program for health promotion in elementary students aged 6 to 11 years: A cluster randomized trial

Unhealthy habits in children are increasing at an alarming rate. The school provides a promising setting for effective preventive strategies to improve children's lifestyle behaviors. The SI! Program is a multilevel multicomponent school-based educational intervention aimed at all stages of compulsory education in Spain. Here, we present the design of the SI! Program for Elementary School cluster-randomized controlled trial, targeting children aged 6 to 11 years. This trial aims to study the impact of different timings and intensities of exposure to SI! Program activities on elementary school children and their immediate environment (parents/caregivers, teachers, and school). The trial includes 1770 children from 48 public elementary schools in Madrid (Spain), together with their parents and teachers. Schools and their children were randomly assigned to the intervention group (the SI! curriculum-based educational program over 3 or 6 academic years) or to the control group (standard curriculum). The primary outcomes are the change from baseline at 3-year and 6-year follow-up in children's scores for knowledge, attitudes, and habits (KAH) and health factors (blood pressure, height, weight, waist circumference, and skinfold thickness). Secondary outcomes include 3-year and 6-year changes from baseline in lifestyle questionnaire scores for parents/caregivers and teachers, and in the school environment questionnaire. The overarching goal of the SI! Program is to provide an effective and sustainable health promotion program for the adoption of healthy behaviors in children. The present trial will address the impact and the optimal timing and duration of this educational intervention in the elementary school setting.

Barriers from Multiple Perspectives Towards Physical Activity, Sedentary Behaviour, Physical Activity and Dietary Habits When Living in Low Socio-Economic Areas in Europe. The Feel4Diabetes Study

This study investigated barriers towards health behaviours (physical activity, limiting sedentary behaviour and healthy dietary habits) experienced by young European families living in vulnerable areas, from multiple perspectives (parents, teachers, local community workers). Focus groups were conducted in six European countries (Belgium, Bulgaria, Finland, Hungary, Greece and Spain). In each country, three focus groups were conducted with parents, one with teachers and one with local community workers. Data were analysed using a deductive framework approach with a manifest content analysis using the software NVivo. The present study identified barriers on four levels (individual, interpersonal, organisational and macro level) of a socio-ecological model of health behaviour. From parents’ perspectives, both general barriers (e.g., financial limitations and lack of time) and country-specific barriers (e.g., organisational difficulties and inappropriate work environment) were identified. Additional barriers (e.g., lack of parental knowledge and lack of parental skills) were provided by other stakeholders (i.e., teachers and local community workers). The results of this study demonstrate the additional value of including multiple perspectives when developing a lifestyle intervention aiming to prevent type 2 diabetes in vulnerable groups. Future lifestyle interventions are recommended to include multiple components (family, school, and community) and could be implemented across European countries if country-specific adaptations are allowed.

Children Present a Window of Opportunity for Promoting Health: JACC Review Topic of the Week

Cardiovascular disease is the leading cause of death and disability in the world, largely because of risk factors modifiable by changes in behavior. There is evolving evidence that our behavior as adults has its roots in the environment that we live in from early childhood. Early sustained multicomponent educational programs focused on health promotion in children may represent a window of opportunity to potentially prevent disease in adulthood. The integration of school-based, family-based, and community-based strategies, along with the support of public policies, are likely necessary for the success of these programs. In this review, the authors describe the future of promoting health. Specifically: 1) reasons why children should be a focus for health promotion (alarming trends of risk factors, association between unhealthy factors and subclinical disease, and cost-effectiveness); 2) strategies for health promotion in children (school-based, family-based, and community-based approaches) along with legislative efforts; and 3) research gaps are discussed.

Family involvement in rehabilitation: Coronary artery disease-patients' perspectives

AIMS AND OBJECTIVES

To describe coronary artery disease patients' perceptions of family involvement in rehabilitation and the connection between background factors and family involvement.

BACKGROUND

Coronary artery disease patients' hospital stays can be very concise. Family members can support rehabilitation, but many challenges can emerge. There is a need to nurture patients and family members in an individual way and to recognise their concerns. More accurate patient education should be available for patients and their family members.

DESIGN

This study is a descriptive cross-sectional study.

METHODS

Data were collected from patients with coronary artery disease at least 6 weeks after discharge from hospital (n = 169) with a postal questionnaire. The Family Involvement in Rehabilitation (FIRE) scale measures family members' promotion of patients' rehabilitation and issues encumbering rehabilitation in family. The data have been analysed with statistical methods. Both parametric and nonparametric tests were used to evaluate group differences.

RESULTS

Patients with coronary artery disease perceived that family promotes their rehabilitation significantly. Respondents also perceived challenges at home. Family relations before hospitalisation were related to all subareas of family promoting rehabilitation and one subarea of issues encumbering rehabilitation in family. Patients with symptoms at rest also had more encumbrance on their rehabilitation. Patients who had undergone coronary artery bypass surgery perceived more challenges than percutaneous coronary intervention (PCI) patients in many subareas of issues encumbering rehabilitation in family.

CONCLUSIONS

Family relations prior to illness and the rigour of heart symptoms are significantly relevant to challenges that can occur between patient and their family members.

RELEVANCE TO CLINICAL PRACTICE

Healthcare staff need to pay attention to coronary artery disease patients' individual situation, and patient education should be more family-centred. In the future, it would be noteworthy to collect more data from family members of patients with coronary artery disease and to find out their perceptions of family involvement.

Thyroid hormone analogs for the treatment of dyslipidemia: past, present, and future

OBJECTIVE

Treatment of dyslipidemia is a major burden for public health. Thyroid hormone regulates lipid metabolism by binding the thyroid hormone receptor (TR), but the use of thyroid hormone to treat dyslipidemia is not indicated due to its deleterious effects on heart, bone, and muscle. Thyroid hormone analogs have been conceived to selectively activate TR in the liver, thus reducing potential side-effects.

METHODS

The authors searched the PubMed database to review TR and the action of thyromimetics in vitro and in animal models. Then, all double-blind, placebo controlled trials that analyzed the use of thyroid hormone analog for the treatment of dyslipidemia in humans were included. Finally, the ongoing research on the use of TR agonists was searched, searching the US National Institutes of Health Registry and the WHO International Clinical Trial Registry Platform (ICTRP).

RESULTS

Thyromimetics were tested in humans for the treatment of dyslipidemia, as a single therapeutic agent or as an add-on therapy to the traditional lipid-lowering drugs. In most trials, thyromimetics lowered total cholesterol, low-density lipoprotein cholesterol, and triglycerides, but their use has been associated with adverse side-effects, both in pre-clinical studies and in humans.

CONCLUSIONS

The use of thyromimetics for the treatment of dyslipidemia is not presently recommended. Future possible clinical applications might include their use to promote weight reduction. Thyromimetics might also represent an interesting alternative, both for the treatment of non-alcoholic steatohepatitis, and type 2 diabetes due to their positive effects on insulin sensitivity. Finally, additional experimental and clinical studies are needed for a better comprehension of the effect(s) of a long-term therapy.

Editor-in-Chief's Top Picks From 2016: Part One

Each week, I record audio summaries for every article in JACC, as well as an issue summary. While this process has been incredibly time-consuming, I have become quite familiar with every paper that we publish. Thus, I personally select papers (both original investigations and review articles) from 15 distinct specialties each year for your review. In addition to my personal choices, I have included manuscripts that have been the most accessed or downloaded on our websites, as well as those selected by the JACC Editorial Board members. In order to present the full breadth of this important research in a consumable fashion, we will present these manuscripts in this issue of JACC. Part One includes the sections: Basic & Translational Research, Cardiac Failure, Cardiomyopathies/Myocardial & Pericardial Diseases, Congenital Heart Disease, Coronary Disease & Interventions, and CVD Prevention & Health Promotion (1-74). Part Two will include the sections: CV Medicine & Society, Hypertension, Imaging, Metabolic & Lipid Disorders, Rhythm Disorders, Valvular Heart Disease, and Vascular Medicine.