Prevention of Heart Disease Begins in Childhood
Heart disease is a major national health concern. It is the primary cause of mortality in the United States, claiming more American lives every year than the next five leading causes of death combined.
Although heart disease is typically diagnosed in adulthood, sadly, its roots often begin in childhood. Compelling research has shown that plaque begins building up in the walls of the arteries (known as arteriosclerosis) very early in life. In fact, fatty buildup has been identified in the hearts of children as young as five years old. Heart disease is the result of a lifelong process and, as such, intervention strategies to reduce risk should begin in childhood.
Research underscores the importance of adopting a healthy lifestyle as early in life as possible. Scientific evidence collected in the last thirty years has greatly informed our understanding of heart disease and its associated modifiable risk factors. The "evidenced-based" guidance dispensed by groups like the American Heart Association and the National Cholesterol Education Program is based largely on this research.
Much of the compelling historical data related to children and heart disease comes from epidemiological studies which follow a group of young subjects for a significant period of time (for example, childhood through adolescence through early adulthood) to observe which health factors contribute to the development heart disease. This type of research allows for a long follow-up period and the ability to "track" various health parameters throughout the years.
American Heart Association's Scientific Position on Cholesterol and Atherosclerosis in Children:
"There is compelling evidence that atherosclerosis (fatty deposits of plaque in artery walls) or its precursors begins in childhood and progresses slowly into adulthood. Then it often leads to coronary heart disease, the single largest cause of death in the United States… Children age 2 years and older should be encouraged to eat at least five servings of fruits and vegetables daily as well as a wide variety of other foods low in saturated fat and cholesterol. Doing this will them maintain normal blood cholesterol levels and promote cardiovascular health."
Note: Evaluate cholesterol levels after 2 years of age in children with family history of premature heart disease. (
Several landmark studies related to children, adolescents and heart disease are detailed below:
Bogalusa Heart Study: Perhaps the most well-known study to look specifically at the natural history and development of heart disease, researchers began collecting data on young subjects in Bogalusa, Louisiana in 1973. More than 16,000 subjects have been involved in this study, which has followed some participants from early life to age 40. Some of the key findings to come from this research include:
- Autopsy findings from young study participants who were killed in accidents provide concrete evidence that fatty buildup begins forming in the aorta in the first decade of life.
- Cholesterol levels (total and LDL) are predicative of the degree of arterial plaque.
- Children who are overweight are at an increased risk of becoming overweight adults. Excess weight tracks from childhood to adulthood, particularly from adolescence to adulthood.
- Obesity in children and adolescents associates with elevated cholesterol and elevated blood pressure and tracks from childhood to adulthood.
Muscatine Heart Study: Similar to Bogalusa, another long term, longitudinal study that contributed important information about the early origins of cardiovascular disease. This study, designed to examine risk factors for cardiovascular disease in school age children, began collecting data on children in a rural Iowa community in 1970. Information on weight, height, blood pressure, cholesterol and other risk factors has been collected from participants for nearly 40 years. Some observations from the study follow:
- A considerable number of school-age children have risk factors that are predictive of heart disease in adults, including: high blood pressure, high body mass index (BMI), high blood cholesterol.
- Children with high cholesterol are also more likely to have siblings and parents with high cholesterol.
- Children with the highest blood pressure levels are more likely to become adults with hypertension.
Cardiovascular Risk in Young Finns Study: A study involving five universities in Finland, the Young Finns research was initiated in 1980 to examine the affects of childhood lifestyle and biological factors on the risk of cardiovascular diseases in adulthood. In addition to traditional risk factor measurements (BMI, blood cholesterol, blood pressure), participants have been screened for structural changes to the heart via ultrasound examinations. Some notable findings from this research include:
By The Numbers: Heart Disease Risk and Kids
- According to national statistics, about 10 percent of adolescents aged 12 to 19 have high cholesterol - total cholesterol levels above 200 mg/dL (NHANES III [1988-94], CDC/NCHS)
- The well-known Bogalusa Heart Study found that overweight children between the ages of 5 and 17 were more than twice as likely to have high cholesterol levels as those of normal weight children.
- About 80 percent of people who use tobacco begin before age 18. Smoking tobacco increases blood pressure, decreases exercise tolerance and increases the tendency for blood to clot.
- 37.2 percent of high school students spend three or more hours a day watching TV.
- According to the Framingham Children's Study, by the end of adolescence, BMI was highest for those children who watched the most television during childhood.
- Socioeconomic status in childhood affects blood pressure measures later in life. More specifically, early socioeconomic disadvantage can have a negative impact on adult risk for hypertension.
- Young healthy adults with a family history of heart disease have increased carotid intima media thickness (CIMT), which is predictive of future cardiac events, like heart attack.
Framingham Children's Study: Initiated in 1985 as part of the Framingham Heart Study, this Massachusetts-based study examines factors that influence eating and exercise behaviors in children that affect future heart disease risk, including data on family and environmental factors. Among the most notable research findings to date:
- Children who ate four or more servings of fruits and vegetables had smaller yearly increases in systolic blood pressure
- Higher levels of activity in childhood correlated to lower levels of body fat in early adolescence
- Children whose parents modeled undesirable eating habits were more likely to be overweight
- By the end of adolescence, BMI was highest for those children who watched the most television during childhood and lowest for those who watched the least.
In addition to the observational research detailed above, there are many intervention studies that examine heart disease risk factors in youth. A few notable interventions that have helped to inform current preventive cardiology practices are detailed below:
The Special Turku Coronary Risk Factory Intervention Project (STRIP): This ongoing study aimed at primary prevention of heart disease provides supervised counseling to young Finnish children and their parents to encourage low saturated fat intake beginning in early childhood. Lessons from this research include the following:
- The prime target in counseling of young children and their parents should be a change in fat quality rather than fat quantity.
- Restriction of saturated fat from infancy until 15 years of age decreases childhood and adolescent blood pressure.
- The importance of childhood lifestyle counseling and primary prevention of hypertension should be emphasized, especially in those children with a family history of atherosclerosis.
CATCH (Child and Adolescent Trial for Cardiovascular Health): This school based intervention, which began in 1991, focused on three components to support healthful behaviors in children and encouraged cardiovascular health: environmental changes related to food consumption, physical activity and smoking policy in the school; classroom curriculum; and family and home-based education. Results from this study support the following:
- Changes in the school environment that encourage healthful behaviors can be maintained over time. Staff training is an important factor in achieving success.
- Students exposed to the intervention consumed less fat and participated in more physical activity outside of school.
- Changes in diet and physical activity were maintained three years post-intervention.