According to the American Heart Association (AHA), improvements in the current status of health among US children in the areas of body weight, diet, physical activity levels, and tobacco smoke exposure have the potential to decrease the future proportion of American adults affected by cardiovascular disease (CVD).1 As the leading cause of adult death in the United States,2 CVD affects approximately 1 of every 3 American adults and has an annual economic burden of more than $444 billion.3 Although myocardial infarction, stroke, and peripheral artery disease are medical conditions of adulthood, the processes leading up to these conditions begin at an early age.
Atherosclerotic lesions, including fatty streaks and fibrous plaques, begin to develop in childhood as lipids accumulate in response to nonmodifiable factors (family history, familial hypercholesterolemia, history of high-risk illness) and modifiable factors (excess body weight, hypertension, dyslipidemia, tobacco smoke exposure).4–6 Early studies, laboratory and autopsy data, and clinical evidence produced in landmark studies7–9 formed the foundation for the current understanding of how higher levels of risk in childhood influence the onset and severity of clinical CVD in adulthood.10 Evidence that is more recent suggested that slowing the progression of childhood atherosclerotic lesions through lifestyle modification can prevent or delay the development of CVD in adulthood, thereby extending life expectancy and improving quality of life.11
The AHA 2020 Impact Goals12 to improve the cardiovascular (CV) health of all Americans have prompted those interested in child health to develop, implement, and evaluate interventions that discourage the development of risk factors (primordial prevention) and those that promptly identify risk factors and act to reduce them (primary prevention). Prevention strategies based in pediatric primary care and led by advanced practice nurses (APNs) are appropriate first-line therapies to reduce the lifetime risk of CVD when they inform parents about the child’s health status and presence of CV risk factors, engage parents in learning about healthy lifestyle behaviors, and focus on health promotion through brief counseling reinforced over time in the areas of weight, nutrition, exercise, and tobacco smoke exposure.13–19 Consideration of these factors during the implementation of universal lipid screenings once for all 9- to 11-year-old children triggered the development of a pilot study designed to raise parental awareness of child health behaviors and CVD risk factors and to evaluate their intent to implement lifestyle changes that reduce modifiable risks and promote health. The pilot aimed to answer the question “During the 9- to 11-year-old well-child examination, does introducing a plan for healthy living that identifies the presence of modifiable child CVD risk factors have an effect on parental intent to encourage lifestyle behaviors that impact child cardiovascular health?”
Beckman et al20 suggest that theory-based health behavior change techniques show promise in the battle against childhood obesity and the early development of CVD risk. Midrange theory, specifically, is useful to the APN who wishes to promote positive outcomes, explain a person’s response to his/her condition, and more quickly align situations with effective interventions while reducing time and resources spent on irrelevant or unnecessary processes.21 With this in mind, the Integrated Theory of Health Behavior Change21 guided the project. Defined as a midrange descriptive theory, the Integrated Theory of Health Behavior Change assumes that desire and motivation are prerequisites to change and that change is enhanced, although not guaranteed, by the 3 constructs of fostering knowledge, social facilitation, and encouraging self-regulation, which lead to both proximal and distal outcomes. It was hypothesized that by educating parents about a simple plan for healthy living and identifying the presence of modifiable child CVD risk factors (increasing knowledge), the APN (social facilitator) would effectively motivate a significant percentage of parent participants to state an increased intent to encourage healthy lifestyle behaviors (self-regulation) in at least 1 area (proximal outcomes) to optimize the child’s health (distal outcome).
Risk Factors for Cardiovascular Disease
The AHA1 defines ideal CV health as the simultaneous presence of 7 health behaviors and health factors, including maintaining a body mass index (BMI) at less than the 85th percentile for age and gender; consuming a healthy diet; exercising regularly; having serum lipids, glucose, and blood pressure within normal ranges; and not smoking. Shay et al22 compared the AHA standards with National Health and Nutrition Examination Survey (NHANES) data from 2005 to 2010 and determined that none of the 4673 participants in the 6-year cross-sectional study (representing approximately 33 million nonpregnant, noninstitutionalized US adolescents) displayed ideal health in the 7 CV behaviors, and only 50% exhibited 5 or more.
The high prevalence of nonideal health behaviors and factors in US adolescents serve as a reminder of the need to intervene in childhood to prevent or slow the development of CVD in adulthood. Hong23 and Le et al24 agreed that atherosclerotic lesions in childhood increase at a rate that corresponds to the number and severity of risk factors. Although some risk factors cannot be changed, up to 80% of adult CVD may be preventable through optimal health behaviors started early in life.22 Health-promoting behaviors include consuming a balanced diet, engaging in regular physical activity, and avoiding exposure to tobacco smoke. Guiding children to develop patterns of these behaviors early in life is a prevention strategy that will lead to improvements in the prevalence of the modifiable risk factors of excess body weight, hypertension, dyslipidemia, and tobacco smoke exposure.
Excess Body Weight
The prevalence of childhood overweight and obesity steadily increased from the 1980s until 2007, when it began to level at 32% to 33% of 6- to 19-year-olds.25 The risk for the development of overweight or obesity is evaluated throughout childhood by plotting the BMI (BMI = weight in kilograms divided by height in meters squared) on age- and gender-specific charts. A BMI greater than the 85th percentile (overweight) or 95th percentile (obese) is associated with higher levels of serum cholesterol, higher blood pressures, and higher rates of prediabetes,26 all risk factors for the early development of CVD.27 In a systematic review of the literature, Singh et al28 reported an increased risk for overweight or obese youth to become overweight or obese adults, with the likelihood of persistence directly related to the extent of the BMI elevation. The American Academy of Pediatrics (AAP) estimated that up to 80% of obese children would develop into obese adults.29 Fontaine et al30 added that obese children may have life spans that are up to 13 years shorter than that of their average-weight peers. Despite these facts, research indicates that parents often do not consider excess body weight as problematic in their own children, nor do they consider excess body weight a health concern in childhood.31–35
Current estimates place the prevalence of hypertension in childhood at 3.2%, with another 15% of children in the prehypertensive stage when measured on age-, gender-, and height-specific charts as recommended by The National Heart, Lung, and Blood Institute (NHLBI).36,37 Falkner et al38 reported that, without intervention, 15% of prehypertensive children will convert to hypertensive within 4 years. Ingelfinger39 stated that for every 1 to 2–mm Hg increase in blood pressure, there is a 10% greater risk that hypertension will extend into adulthood, a risk factor that Hong23 stated accelerates the development of vascular stiffness, increased left ventricular mass, and atherosclerosis. Tracking blood pressure in pediatrics, however, can be a challenge because of inherent circadian variations, confounding effects of the “white coat” phenomenon, operator reliability, and vague or confusing parameters. In a large study of 14 187 children between 3 and 18 years of age, Hansen et al40 reported that only 26% of children and adolescents with 3 or more elevated blood pressure measurements during well-child visits had a diagnosis of hypertension or elevated blood pressure documented in the electronic medical record.
In a review of NHANES results between 1999 and 2008, May et al41 reported that at least 22% of US 12- to 19-year-olds had lipid levels above normal, with higher rates observed in adolescents who were overweight or obese. In the absence of an inherited disorder, serum lipid levels increase throughout childhood at a rate that corresponds to lifestyle behaviors (dietary intake of excessive fat and insufficient fiber, physical inactivity, and tobacco smoke exposure) before peaking at puberty, where they are considered to be predictive of adult atherosclerosis.4,42 Rarely do abnormal lipid levels produce symptoms in children, but up to 75% of children with abnormal levels grow into adults with dyslipidemia.43 As lipids accumulate, they influence health by forming fatty streaks and plaques within the blood vessels, leading to vessel narrowing, hypertension, and the development of thrombi capable of causing myocardial infarction, stroke, and peripheral vascular disease.11
Tobacco Smoke Exposure
According to the US Surgeon General, 22 million US children and adolescents are exposed to the toxins in tobacco smoke.44 Tobacco smoke exposure is a risk factor for CVD because it contributes to arterial inflammation, increased clotting tendencies, heart rate elevations, hypertension, hyperlipidemia, and suppression of the protective effect of high-density lipoprotein cholesterol (HDL-C).45 Although antismoking campaigns have been successful in reducing the prevalence of adult smokers from 24% in 2005 to 19% in 2011,46 the prevalence remains above the Healthy People 2020 goal of 12%.47 Evidence-based tobacco control initiatives to help smokers quit, prevent the initiation of tobacco use, and educate the public about the dangers of smoke exposure remain a national priority.
Recommendations for Childhood Cardiovascular Screenings
In 2008, the AAP outlined recommendations for primary care providers to evaluate CVD risk factors by having regular discussions throughout childhood and adolescence about family history of CVD, diet, physical activity, and tobacco smoke exposure.48 The AAP directs providers to obtain routine physical measurements of height, weight, and calculation of BMI at every well-child visit and blood pressure readings at least annually after age 3 years.48 In 2012, the AAP endorsed the recommendation of the NHLBI to add universal blood lipid level testing (fasting lipid panel or nonfasting non-HDL-C) to annual screenings once for all children between 9 and 11 years of age and again for those between 17 and 21 years of age.37,49 Previous recommendations were for “targeted” screenings based on family history of high cholesterol or premature death from CVD, unknown family history of CVD, or the identification of hypertension, diabetes, overweight/obesity, or cigarette smoking in the child.48 Although targeted screenings continue to be useful in the presence of identified risk factors, screenings based solely on these criteria fail to identify moderate dyslipidemias and genetic lipid disorders.49,50
Juonala and colleagues51 integrated the results of 4 large studies of childhood CV risk factors and their extension into adulthood (The Cardiovascular Risk in Young Finns Study, the Childhood Determinants of Adult Health Study, the Bogalusa Heart Study, and the Muscatine Study) to make recommendations regarding the optimal age for initiation of routine modifiable risk factor screenings. Their analysis revealed that the presence of modifiable risk factors before the age of 9 years had only a slight association with CV health 20 years later, whereas risk factors present after 9 years of age were significantly associated with the development of CVD in adulthood.
Reduction of Risk Factors for Cardiovascular Disease
Cardiovascular health promotion and reduction of identified modifiable risk factors for CVD depend on lifestyle choices. Hayman and colleagues52 recommended that intervention strategies promote achievement of appropriate weight, encourage healthy diet and regular exercise, and discourage tobacco smoke exposure. In children, these goals are more likely to be met when parents are motivated to encourage behavior changes in each area.14 Parental motivation has been shown to be positively influenced by healthcare providers when they provide the results of child screening tests along with lifestyle counseling, but research has revealed that these activities are not routinely implemented in primary care settings.53,54 To aid healthcare providers in providing a simple, consistent key message to inform and educate parents and families about activities that promote optimal weight and CV health, the AAP endorses the use of clinical guidelines focused on the “5210” plan.55 The 5210 plan was developed as a collaborative effort between the Maine Chapter of the AAP and the Maine Center for Public Health (www.letsgo.org) and encourages all children to eat 5 servings of fruits or vegetables per day, limit non-school-related “screen time” to less than 2 hours per day, engage in at least 1 hour of physical activity per day, and eliminate sugar-sweetened beverages in favor of more water and low-fat milk. The plan further recommends that healthcare providers specifically advise parents to discourage children and adolescents from cigarette smoking and eliminate tobacco smoke from places where children live, learn, and play. Parents not meeting the recommendations of the 5210 plan can be encouraged to set small, simple, and concrete goals for their families and to schedule regular follow-up visits to evaluate progress. Recommendations such as these are evidence based, safe for virtually all children, and effective in providing reinforcement for those already meeting the guidelines, as well as in promoting early intervention for those who are not.11,52,56,57
Increase Consumption of Fruits and Vegetables
A healthy diet in childhood consists of a portion-controlled variety of foods from the groups found in the Dietary Guideline for Americans,58 with a focus on plant-based foods as low-calorie sources of vitamins and fiber. A diet rich in fruits and vegetables causes a feeling of satiety that helps discourage unhealthy snacking behaviors and overindulgences in foods that are high in fat, salt, and sugar. Although a pattern of healthy eating leads to optimal body weight, blood pressure, and lipid levels, research has revealed that up to 90% of children older than 8 years do not consume the recommended amount of vegetables and up to 75% do not consume the recommended amounts of fruits.59
Limit Screen Time
The Family Nutrition and Physical Activity Survey reported that 25% of children today use computers more than 3 hours per day for non-school-related activities and 33% watch more than 3 hours of television per day, despite recommendations that screen time be limited to less than 2 hours per day.60 The AAP Council on Communications and Media stated that excessive engagement in screen time results in a reduction in physical activity and an increase in unhealthy eating because of snacking and exposure to marketing strategies that target children with the promotion of foods and beverages that are high in fat, salt, and sugar.61 The result is an increase in rates of obesity, hypertension, dyslipidemia, insulin resistance, and type 2 diabetes. Lambiase62 conducted a review of the literature and concluded that limits on sedentary behavior led to increases in physical activity and decreases in caloric intake, body fat, and BMI percentiles.
Encourage Physical Activity
The Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents recommend that children engage in at least 60 minutes of age-appropriate moderate to vigorous physical activity on most days to maintain optimal health and prevent the development of CV risk factors.37 Evidence supports the assumption that physical activity reduces adiposity, improves muscle strength, lowers blood pressure, improves lipid levels, and may even be more effective against obesity than dietary interventions are.63,64 Walker et al65 contributed that vigorous physical activity is associated with a reduction in CVD risk regardless of the participant’s BMI. Despite the overwhelming evidence in support of regular physical activity, The Family Nutrition and Physical Activity Survey found that only 16% of US children achieve the recommended daily amount of exercise.60
Eliminate Sugar-Sweetened Beverage Intake
Sugar-sweetened beverages are those that contain added caloric sweeteners. An average 20-oz soda contains 15 to 18 teaspoons (68–75 g) of sugar, which is equivalent to approximately 240 nonnutritive or “empty” calories.66 Consumption of these beverages by children has increased dramatically over the past 50 years and is associated with higher caloric intake, higher body weight, reduced intake of milk, and an increased risk of medical problems, including hypertension, dyslipidemia, metabolic disease, fatty liver disease, and dental caries.67,68 A recent analysis of NHANES data from 1999 to 2010 revealed that sugar-sweetened beverages account for 155 nonnutritive calories per day per average American youth and have displaced adequate milk consumption in many girls and boys.59,69 The reduction or elimination of sugar-sweetened beverages can lead to improvements in health by reducing caloric intake, promoting weight loss, and improving the associated comorbidities in children.
Eliminate Exposure to Tobacco Smoke
The US Surgeon General stated that there is no safe level of tobacco smoke exposure for children.44 The NHLBI guidelines have advised that children be kept away from all forms of tobacco smoke and that providers explicitly warn parents about the dangers of tobacco smoke exposure.37 The AAP has recommended that children be protected from the marketing of tobacco products, including advertising done through print and electronic media, product placement in television shows and movies, and via banner ads at sporting events.61
The study design for this pilot was quasi-experimental to begin to understand parental willingness to incorporate health behavior changes that promote CV health in children. This study targeted participants who were parents or guardians of 9- to 11-year-old children who presented for well-child care in a Midwest primary care clinic during April and May 2013. Participants completed informed consent and baseline questionnaires before an APN-led educational session about the child’s modifiable risk factors for CVD and the AAP-endorsed 5210 plan for healthy living. Participants completed postintervention questionnaires to evaluate the effectiveness of the educational sessions. The researcher compared baseline and postintervention responses to draw conclusions.
After institutional review board approval from The University of Alabama (IRB 13-OR-129-ME) and Heartland Regional Medical Center was obtained, the pilot study was conducted during the course of routine well-child checks in a pediatric and adult primary care clinic during April and May 2013. The setting was selected based on ease of access, support of administration, accessibility of subjects, and concurrent initiation of point-of-care lipid screenings for all 9- to 11-year-old children who presented to the clinic for well-child care.
A convenience sample of parents or legal guardians of 9- to 11-year-old patients assigned to the APN-investigator as primary care provider who were eligible for well-child care during April and May 2013 were contacted until the number of participants who made and kept appointments reached 26. According to Hertzog,70 a population sample size of 20 to 25 is adequate if the aim of a pilot study is to evaluate intervention efficacy in a single group where population effect size is moderate or larger. The study sample included male and female adult parents, grandparents, and legal guardians of male and female patients between the ages of 9 years 0 months and 11 years 11 months. Potential subjects were invited to participate regardless of socioeconomic class, educational level, race, nationality, or because of an assumption of CVD risk factor presence, as long as they were able to read and provide written responses to the questionnaires and were willing to commit to the additional time required to complete the study materials. Participants were excluded if they did not understood English in its spoken and written forms because the study instruments are currently only available in English. Participants were also excluded if they accompanied children without healthcare coverage or with healthcare coverage that did not reimburse the performance of the lipid screening test.
The intervention in the pilot was the presentation of the 5210 plan for healthy living and results of the child’s modifiable CVD risk factor screening using a brief educational session with the participant and child during the 9- to 11-year-old well-child examination. The APN used a verbal teaching format and a written summary sheet to present each participant with a 3-part outline. First, the participant received a 1- to 2-minute overview of the importance of the early detection of CVD risk factors and an explanation of the difference between nonmodifiable and modifiable risks. Second, the participant received a 2- to 3-minute introduction to the AAP-endorsed plan for healthy living in the 5210 format. Third, the participant was engaged in a 4- to 5-minute discussion while receiving the results of the child’s screening tests for the modifiable risk factors of excess body weight, hypertension, elevated non-HDL-C, and tobacco smoke exposure. The BMI and blood pressure results were written on the summary sheet and assessed according to whether they were above or below the 85th percentile (BMI) and 90th percentile (blood pressure) to indicate if the result constituted a CV risk factor. Non-HDL-C was written next to the optimal parameter of less than 120 mg/dL indicating “not a risk factor,” 120 to 144 mg/dL indicating “borderline risk,” and greater than 145 mg/dL indicating a risk factor for CVD. Tobacco smoke exposure was listed either as “no” or as a risk factor for CVD. At the bottom of the page, the identified risk factors were totaled and placed on a scale of 0 (no modifiable CVD risk factors identified) to 4 (most modifiable CVD risk factors identified). All results were explained and participants were free to ask questions or seek clarification at any time during the clinic visit.
The APN-researcher made telephone contact and scheduled appointments based on a query report from the electronic medical record identifying patients between the ages of 9 and 11 years who were eligible for well-child care. Informed consent was obtained from each participant at the time of the scheduled visit. Each participant completed a brief baseline questionnaire to evaluate perceptions and concerns about the child’s weight and heart health, subjective estimates of the child’s health behaviors (frequency of fruit and vegetable consumption, hours of non-school-related screen time, minutes of physical activity per day, and intake of sugar-sweetened beverages), and self-evaluations of the adequacy of each behavior at its current level. The participant observed as the child underwent a routine well-child evaluation, including the collection of a nonfasting capillary blood specimen for lipid screening using an in-office lipid analyzer. During the 10-minute period required for lipid analysis, the APN-researcher held the educational session with the parent and the child as outlined under the “Intervention” section. If the APN-researcher did not identify CV risk factors in the child, the participant and child were encouraged to maintain healthy habits and consider the 5210 plan to prevent the development of CVD. If CV risk factors were identified in the child, the clinical guidelines from the AAP55 were used to provide focused education designed to reduce or eliminate risk and to direct appropriate follow-up or referral appointments.
At the conclusion of the visit, the APN-researcher asked the participant to complete a 1-page postintervention questionnaire and then left the room. The questionnaire asked for a reassessment of the participant’s level of concern for the child’s weight and heart health and reevaluation of the adequacy of each health behavior at its current level. The questionnaire also asked how likely the parent was to encourage change in each area. The concluding item asked the participant to identify which 1 risk factor topic area (weight, blood pressure, lipid result, or other) encouraged the consideration of change. Each participant put both completed questionnaires in 1 envelope and handed it to the APN-researcher on departure. There were no other requirements of the participant.
The questionnaires were developed by adapting (with permission) 3 preexisting questionnaires. Questions from Parent Opinions About Weight, Nutrition, and Exercise71 were adapted to measure parent concern about child weight issues and health behaviors. Items from the Youth Risk Behavior Parent Survey72 were adapted to evaluate health behaviors. Modifications of items from Parents’ Views on Childhood Obesity13 allowed the researcher to evaluate the participant’s level of concern for the child’s weight and health habits. A panel of representatives from the fields of nutrition, exercise, psychology, and grammar and 1 parent representative outside the study population evaluated the face validity of the new instruments. Readability of the questionnaires was determined using Flesch Reading Ease73 and Flesch-Kincaid Grade Level73 scores, which were 73.3/5.9 and 82.6/4.2, respectively.
No identifying data or protected health information were gathered. Baseline and postintervention questionnaires were matched by number only and were kept apart from the signed consent forms in a locked cabinet. The APN-researcher was the sole data collector and had exclusive access to the study data. The well-child examination, measurements, test results, and educational sessions were documented in the electronic medical record but were not included in the data analysis. No survey information was collected from the child.
Questionnaire responses were analyzed using IBM Statistical Package for the Social Sciences 21.0 (2012; SPSS, Inc, Armonk, New York). Pearson correlations and Wilcoxon signed ranks tests were calculated to identify the relationships between preintervention and postintervention concern for the child’s future heart health and perceptions of adequacy of each health behavior in the 5210 plan. Descriptive statistics were used to describe the population and the participants’ perceptions of the children’s weights, to evaluate the parents’ likelihood of encouraging health behavior changes, and to identify the distribution of each risk factor category. One-way analysis of variance (ANOVA) was used to test for the effect of the child’s insurance, gender, and age on parental perception of adequacy of child’s current health behavior in each category. One-way ANOVA was also used to test for the effect of the child’s insurance, gender, and age on which factor or result most influenced the participant to consider encouraging changes.
Twenty-six adult participants completed both questionnaires, representing 12 male (46%) and 14 female (54%) children, of whom 17 (65%) were covered by Missouri Medicaid and 9 (35%) were covered by private insurance. Eleven participants (42%) responded that the children they were accompanying were aged 9 years, 4 (15%) responded that the children were aged 10 years, and 11 (42%) responded that the children were aged 11 years. Baseline questionnaires revealed that 15 participants (58%) considered their children to be at the right weight, whereas 11 (42%) considered their children either “a little overweight” or “very overweight.” There were no changes in weight estimates in the postintervention survey. Nine participants (35%) initially stated that they were not concerned about their children’s future heart health, 10 (38%) claimed to be “a little” concerned, and 7 (27%) claimed to be “concerned.” In the postintervention questionnaire, 7 participants (27%) had an increase in their level of concern for their children’s future heart health.
Preintervention and postintervention responses to items associated with health behaviors are summarized in Figure 1. Positive correlations were detected in preintervention and postintervention estimates of adequacy of each health behavior, including fruit and vegetable consumption (r = 0.793, P = .01), screen time (r = 0.686, P = .05), physical activity (r = 0.671, P = .01), and sugar-sweetened beverage intake (r = 0.621, P = .01), but Wilcoxon signed rank tests determined that significant change was present only in the areas of fruit and vegetable consumption (z = −1.732, P = .083) and physical activity (z = −2.00, P = .046). Postintervention increases in awareness of inadequate health behaviors in the areas of screen time and sugar-sweetened beverage intake were not significant (z = −1.00, P = .317; z = −1.342, P = .180, respectively). Responses to how likely the participants were to consider encouraging change in each of the 4 health behaviors are summarized in Figure 2. Figure 3 summarizes the distribution of postintervention responses to which 1 risk factor topic or result motivated the participant to consider encouraging change. Using ANOVA, no significant associations were found between child’s gender, healthcare coverage, or age on the parent’s awareness of adequacy or inadequacy of any health behavior or on which factor influenced the parent to consider encouraging health behavior change.
This pilot study used the AHA focus issue of optimizing CV health and the NHLBI recommendation for implementing lipid screenings in all 9- to 11-year-old children to test a 10-minute intervention designed to educate parents about healthy lifestyle choices and modifiable CVD risk factors to influence their willingness to encourage lifestyle changes. The approach incorporated the evidence-based primordial and primary prevention techniques endorsed by the AAP, was simple to implement, and produced responses indicating that parents had significant increases in their awareness of adequate fruit and vegetable intake and physical activity levels and were likely to consider encouraging health behavior change in these 2 areas plus the areas of screen time and sugar-sweetened beverage intake. The brief intervention achieved 92% to 100% positive responses for parental likelihood of encouraging changes in all areas of the health promotion plan.
Future study using the results of this pilot could emphasize limiting screen time and sugar-sweetened beverage intake to improve parental awareness of recommendations in these 2 areas. Secondary teaching modalities, such as a visual comparison between hours of screen time and CV fitness or a test tube filled with the amount of sugar in 1 can of soda, could be used without adding significant time to the intervention. It is possible that the areas of screen time and sugar-sweetened beverage intake were relatively resistant to change because of the current social environment. With the proliferation of entertainment technology, the use of social media, and the readily available access to stimulating material, both children and adults are engaging in screen time much more than recommended. In addition, parents with obligations outside of the home often see various devices as “safe” alternatives to unsupervised outdoor play, or as “educational.” Regarding excessive intake of sugar-sweetened beverages, clever marketing practices by the beverage industry have produced a generation of children who demand sugar-sweetened beverages and parents who not only indulge these demands but also have come to believe that certain sugar-sweetened sports drinks are necessary for the good health of their children. A unified effort from healthcare professionals, concerned citizens, government agencies, the media, and supporting organizations would be beneficial in the battle against such unhealthy influences. Community and statewide programs, such as Maine’s 5210 Let’s Go! (www.letsgo.org), are demonstrating significant improvements in parental awareness of positive lifestyle behaviors by using a consistent format to promote healthy eating and regular physical activity throughout childhood.
Risk factor responses in the pilot study approximated national prevalence estimates for excess body weight (38.5% vs national prevalence 32%–33%), hypertension (0 vs national prevalence 3.2%), dyslipidemia (23% vs national prevalence 23.3%), and “other”–tobacco smoke exposure (15% vs national prevalence between 8% and 20%). These results indicate that there was a diversity of concern in the small study population because the intervention did not highlight any 1 area over another. Failure to find significance in the influence of the child’s gender, insurance coverage, or age on the participants’ assessments of adequacy in each health behavior category, or on which factor was most influential, indicates that the intervention may have been well suited for all participants in the study group, regardless of these demographics.
The results of this study can be helpful to APNs interested in promoting CV health in children. Combining the 5210 plan with CVD risk factor identification during 9- to 11-year-old well-child visits is 1 innovative approach that may enhance parental likelihood of changing unhealthy behaviors to improve long-term CV health. In addition, APNs may consider incorporating the concepts of the plan as they advocate for good health throughout childhood. Areas where nursing professional could apply primordial and primary prevention techniques to promote CV health include the following:
- endorsing school policy changes in the areas of nutrition and physical education;
- promoting increases in the availability of healthy food and free drinking water;
- lobbying for funds to develop safe areas for active play; and
- campaigning for public policies that discourage behaviors considered to be contrary to the principles of good health (smoke-free communities, limits on advertising to children, or taxation of sugar-sweetened beverages).
There are several limitations to the pilot study. First, although the use of a quasi-experimental design provided the benefits of convenience, administrative ease, and low cost, the study lacked a control group, which led to some difficulty in interpreting the results. Second, the pilot study lacks generalizability because of its small sample size, inclusion of only English-speaking participants, and the use of participants from only 1 clinic. Also affecting generalizability is the short time frame in which the study was completed. Conducting the study in 2 spring months may have captured a skewed population of individuals seeking clearance for participation in school sports, thereby attracting a healthier group of children with more fitness-minded parents. Third, having the child’s primary care provider as the data collector may have falsely inflated the results of the study because participants may have felt coerced to participate or tried to please the researcher with their responses. Fourth, administering the posttest immediately after the intervention took advantage of the “freshness” of the information but did not adequately evaluate the extent to which participants retained or implemented the education they received. Finally, the use of new, untested instruments poses questions related to validity and reliability of results.
Future study into motivating parents to promote CV health in children could incorporate a more traditional experimental design with randomization of participants into intervention and control groups, selection of a more diverse population from multiple locations, use of a longer study period, and use of a research assistant to act as data collector. The survey tools in this pilot study would benefit from further development, including the addition of demographic questions and items related to the presence of nonmodifiable risk factors such as family history of CVD or personal history of high risk past illnesses. In addition, a postintervention item asking if any risk factors were identified in the child could be added to ascertain whether children with identified risks had parents who were more likely to encourage lifestyle changes. Delaying posttest administration to a future clinic visit, a mailed questionnaire, or a follow-up telephone call could be considered, but any of these options would almost certainly result in a significant loss of participation. Translation into other languages and the performance of psychometric testing on the questionnaires would advance their usefulness in future studies.
The problem of the early development of CVD risk factors is negatively affecting the nation’s health. This research supports previous studies that highlight the importance of engaging parents in the process of improving child weight, diet, physical activity, and level of tobacco smoke exposure to optimize long-term heart health. The pilot project used midrange nursing theory to streamline the movement of research directly into the development of interventions that attempted to raise parental concern and enhance motivation to participate in activities that prevent (primordial prevention) or reduce (primary prevention) the development of modifiable CVD risk factors. The project’s relevance lies in its incorporation of new evidence-based lipid screening guidelines into a 10-minute plan that highlights the APN’s skills as knowledge provider and social facilitator to outline recommendations for good health and identify modifiable CVD risk factors, which showed a positive effect on parental intent to encourage lifestyle changes. Further study is needed in this area and on other innovative CV health promotion techniques to advance the science of CVD prevention and risk reduction in children.
What’s New and Important
- The addition of universal lipid screening to 9- to 11-year-old well-child visits is an opportunity for APNs to engage in CVD prevention and risk reduction.
- Brief interventions outlining recommendations for good health and identifying child modifiable CVD risk factors may influence parents to promote lifestyle changes.
The authors thank Drs Corinne Ridens-Dale and Cynthia Brownfield, Heartland Pediatric and Adult Care, for their support and encouragement.
1. Go AS, Mozaffarian D, Roger VL, et al. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation. 2013; 127: e6–e245. doi: 10.1161/CIR.0b013e31828124ad.
3. Centers for Disease Control and Prevention
, National Center for Chronic Disease Prevention
and Health Promotion. Heart disease and stroke prevention
: addressing the nation’s leading killers at a glance, 2011. CDC Web site. 2010. Updated July 21, 2010. http://www.cdc.gov/chronicdisease/resources/publications/AAG/dhdsp.htm
. Accessed April 7, 2013.
4. Juonala M, Magnussen CG, Venn A, et al. Parental smoking in childhood and brachial artery flow-mediated dilatation in young adults: the Cardiovascular Risk in Young Finns study and the Childhood Determinants of Adult Health study. Arterioscler Thromb Vasc Biol. 2012; 32 (4): 1024–1031. doi: 10.1161/ATVBAHA.111.243261.
5. McBride PE, Kavey RW. Lipid screening and treatment recommendations for children and adolescents. Pediatr Ann. 2012; 41 (7): 1–10. doi: 10.3928/00904481-20120625-08.
6. Peinemann F, Moebus S, Dragano N, et al.; on behalf of the Heinz Nixdorf Recall Study Investigative Group. Second hand smoke exposure and coronary artery calcification among nonsmoking participants of a population-based cohort. Environ Health Perspect. 2011; 119 (11): 1556–1561. doi: 10.1289/ehp.1003347.
7. Berenson GS, Srinivasan SR, Bao W, Newman WP, Tracy RE, Wattigney WA. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. The Bogalusa Heart Study. N Engl J Med. 1998; 338 (23): 1650–1656. doi: 10.1161/CIRCULATIONAHA.107.184595.
8. Davis PH, Dawson JD, Riley WA, Lauer RM. Carotid intimal-medial thickness is related to cardiovascular risk factors measured from childhood through middle age: the Muscatine Study. Circulation. 2001; 104 (23): 2815–2819. doi: 10.1161/hc4601.099486.
9. McGill HC, McMahan CA, Malcom GT, Oalmann MC, Strong JPfor the PDAY Research Group. Effects of serum lipoproteins and smoking on atherosclerosis in young men and women. Arterioscler Thromb Vasc Biol. 1997; 17: 95–106. doi: 10.1161/01.ATV.17.1.95.
10. Shah AS, Dolan LM, Gao Z, Kimball TR, Urbina EM. Clustering of risk factors: a simple method of detecting cardiovascular disease
in youth. Pediatrics
. 2011; 127: e312–e318. doi: 10.1542/peds.2010-1125.
11. McGill HC, McMahan CA, Gidding SS. Preventing heart disease in the 21st century: implications of the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study. Circulation. 2008; 111: 1216–1227. doi: 10.1161/CIRCULATIONAHA.107.717033.
12. Lloyd-Jones DM, Hong Y, Labarthe D, et al.; on behalf of the American Heart Association Strategic Planning Task Force and Statistics Committee. Defining and setting national goals for cardiovascular health promotion and disease reduction. Circulation. 2010; 121: 586–613. doi: 0.1161/CIRCULATIONAHA.109.192703.
13. Rhee KE, DeLago CW, Arscott-Mills T, Mehta SD, Davis RK. Factors associated with parental readiness to make changes for overweight children. Pediatrics
. 2005; 116 (1): 94–101. doi: 10.1542/peds.2004-2479.
14. Moore LC, Harris CV, Bradlyn AS. Exploring the relationship between parental concern and the management of childhood obesity. Matern Child Health J. 2012; 16: 902–908. doi: 10.107/s10995-11-0813-x.
15. Vaczy E, Seaman B, Peterson-Sweeny K, Hondorf C. Passport to health: an innovative tool to enhance healthy lifestyle choices. J Pediatr Health Car. 2011; 25 (1): 31–37. doi: 10.1016/j.pedhc.2010.04.006.
16. West F, Sanders MR, Cleghorn GJ, Davies PSW. Randomised clinical trial of a family-based lifestyle intervention for childhood obesity involving parents as the exclusive agents of change. Behav Res Ther. 2010; 48 (12): 1170–1179. doi: 10.1016/j.brat.2010.08.008.
17. Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert Committee recommendations. Pediatrics
. 1998; 102 (3): E29. doi: 10.1542/peds.102.3.e29.
18. Barlow SE, The Expert Committee. Expert Committee recommendations regarding the prevention
, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics
. 2007; 120 (4): s164–s192. doi: 10.1542/peds.2007-2329C.
19. Kelishadi R, Malekahmadi M, Hashemipour M, et al. Can a trial of motivational lifestyle counseling be effective for controlling childhood obesity and the associated cardiometabolic risk factors? Pediatr Neonatol. 2012; 53 (2): 90–97. doi: 10.1016/j.pedneo.2012.01.005.
20. Beckman H, Hawley S, Bishop T. Application of theory-based health behavior change techniques to the prevention
of obesity in children. J Pediatr Nurs. 2006; 21 (4): 266–275. doi: 10.1016/j.pedn.2006.02.012.
21. Ryan P. Integrated theory of health behavior change. Clin Nurse Spec. 2009; 23 (3): 161–172. doi: 10.1097/NUR.0b013e3181a42373.
22. Shay CM, Ning H, Daniels SR, Rooks CR, Gidding SS, Lloyd-Jones DM. Status of cardiovascular health in US adolescence: prevalence estimates from the National Health and Nutrition Examination Surveys (NHANES) 2005–2010. Circulation. 2013; 127: 1369–1376. doi: 10.1161/CIRCULATIONAHA.113.001559.
23. Hong YM. Atherosclerotic cardiovascular disease
beginning in childhood. Korean Circ J. 2010; 40 (1): 1–9. doi: 10.4070/kcj.2010.40.1.1.
24. Le J, Zhang D, Menees S, Chen J, Raghuveer G. “Vascular age” is advanced in children with atherosclerosis-promoting risk factors. Circ Cardiovasc Imaging. 2010; 3: 8–14. doi: 10.1161/CIRCIMAGING.109.880070.
25. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in the United States, 2009–2010. NCHS Data Brief
. 2012;82. National Center for Health Statistics Web site. http://www.cdc.gov/nchs/data/databriefs/db82.pdf
. Accessed April 7, 2013.
26. Freedman DS, Mei Z, Srinivasan SR, Bergenson GS, Dietz WH. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. J Pediatr. 2007; 150 (1): 12–17. doi: 10.1016/j.peds.2006.08.042.
27. Kavey RW, Simons-Morton DG, deJesus JM. Expert panel on integrated guidelines for cardiovascular health and risk reduction in childhood and adolescents: summary report. Pediatrics
. 2011; 128 (S5): S1–S44. doi: 10.1542/peds. 2009-2107A.
28. Singh AS, Mulder C, Twisk JWR, van Mechelen W, Chinapaw JM. Tracking of childhood overweight into adulthood: a systematic review of the literature. Obes Rev. 2008; 9: 474–488. doi: 10.1111/j.1467-789X.2008.00475.x.
29. American Academy of Pediatrics
. Policy statement: prevention
of pediatric overweight and obesity. Pediatrics
. 2003; 112 (2): 424–430.
30. Fontaine KR, Redden DT, Wang C. Years of life lost to obesity. JAMA. 2010; 289 (2): 187–193. doi: 10.10001/jama.289.2.187.
31. DeLaO A, Jordan KC, Ortiz K, et al., Do parents accurately perceive their child’s weight status? J Pediatr Health Care. 2009; 23 (4): 216–221. doi:10.1016/j.pedhc.2007.12.014.
32. He M, Evans A. Are parents aware that their children are overweight or obese? Do they care? Can Fam Physician. 2007; 53: 1493–1499.
33. Jones AR, Parkinson KN, Drewett RF, Hyland RM, Pearce MS, Adamson AJ; Gateshead Millennium Study Core Team. Parental perceptions of weight status in children: the Gateshead Millennium Study. Int J Obesity. 2011; 35: 953–962. doi: 10.1038/ijo.2011.106.
34. Towns N, D’Auria J. Parental perceptions of their child’s overweight: an integrative review of the literature. J Pediatr Nurs. 2009; 24 (2): 115–130. doi: 10.1016/jpedn.2008.02.032.
35. Warschburger P, Kroeller K. Maternal perception of weight status and health risks associated with obesity in children. Pediatrics
. 2009; 124 (1): e60–e68. doi: 10.1542/peds.2008-1845.
36. McNiece K, Poffenbarger T, Turner J, Franco K, Sorof J, Portman R. Prevalence of hypertension and pre-hypertension among adolescents. J Pediatr. 2007; 150 (6): 640–644. doi: 10.1016/j.jpeds.2007.01.052.
37. National Institutes of Health. Summary report of the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. NIH Web site. http://www.nhlbi.nih.gov/guidelines/cvd_ped/
. Updated January, 2013. Accessed April 7, 2013.
38. Falkner B, Gidding SS, Portman R, Rosner B. Blood pressure variability and classification of prehypertension and hypertension in adolescence. Pediatrics
. 2008; 122 (2): 238–342. doi: 10.1542/peds.2007-2776.
39. Ingelfinger JR. Pediatric antecedents of adult cardiovascular disease
—awareness and intervention. N Engl J Med. 2004; 350: 2123–2126. doi: 10.1056/NEJMp048069.
40. Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children. JAMA. 2007; 298 (8): 874–879. doi: 10.1001/jama.298.8.874.
41. May AL, Kuklina EV, Yoon PW. Prevalence of cardiovascular disease
risk factors among US adolescents, 1999–2008. Pediatrics
. 2012; 129 (6): 1035–1041. doi: 10.1542/peds.2011-1082.
42. Cockrell-Skinner A, Steiner MJ, Chung AE, Perrin EM. Cholesterol curves to identify population norms by age and sex in healthy weight children. Clin Pediatr. 2012; 51 (3): 233–237. doi: 10.1177/0009922811430344.
43. Berenson GS, Srinivasan SR. Cardiovascular risk factors in youth with implications for aging: the Bogalusa Heart Study. Neurobiol Aging. 2005; 26: 303–307.
45. Campbell SC, Moffatt RJ, Stamford BA. Smoking and smoking cessation—the relationship between cardiovascular disease
and lipoprotein metabolism: a review. Atherosclerosis. 2008; 201: 225–235. doi: 10.1016/j.atherosclerosis.2008.04.046.
46. Morbidity and Mortality Weekly Reports. Current cigarette smoking among adults—United States, 2011. MMWR Morb Mortal Wkly Rep. 2012; 61 (44); 889–894.
49. deFerranti S, Washington RL. NHLBI guidelines on cholesterol in kids: what’s new and how does this change practice? AAP News. 2012; 33: 1. doi:10.1542/aapnews.2012332-1b.
50. Ritchie SK, Murphy EC-S, Ice C, et al. Universal versus targeted blood cholesterol screening among youth: the CARDIAC Project. Pediatrics
. 2010; 26: 260–265. doi: 10.1542/peds.2009-2546.
51. Juonala M, Magnussen CG, Venn A, et al. Influence of age on associations between childhood risk factors and carotid intima-media thickness in adulthood: the Cardiovascular Risk in Young Finns Study, the Childhood Determinants of Adult Health Study, the Bogalusa Heart Study, and the Muscatine Study for the International Childhood Cardiovascular Cohort (i3C) Consortium. Circulation. 2010; 122 (25): 2514–2520. doi:10.1161/CIRCULATIONAHA.110.966465.
52. Hayman LL, Meininger JC, Daniels SR, et al. Primary prevention
of cardiovascular disease
in nursing practice: focus on children and youth: a Scientific Statement From the American Heart Association Committee on Atherosclerosis, Hypertension, and Obesity in Youth of the Council on Cardiovascular Disease
in the Young, Council on Cardiovascular Nursing, Council on Epidemiology and Prevention
, and Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2007; 116: 344–357. doi: 10.1161/CIRCULATIONAHA.107.184595.
53. Kubik MY, Story M, Davey C, Dudovitz B, Zuehlke EU. Providing obesity prevention
counseling on children during a primary care clinic visit: results from a pilot study. J Am Diet Assoc. 2008; 108 (11): 1902–1906. doi: 10.1016/j.jada.2008.08.017.
54. Cook S, Weitzman M, Auinger P, Barlow SE. Screening and counseling associated with obesity diagnosis in a national survey of ambulatory pediatric visits. Pediatrics
. 2005; 116 (1): 112–116. doi: 10.1542/peds.2004-1517.
55. American Academy of Pediatrics
. Pediatric Obesity Decision Support Chart 5210 Clinical Guidelines. Elk Grove, IL: American Academy of Pediatrics
57. Morrison JA, Glueck CJ, Wang P. Childhood risk factors predict cardiovascular disease
, impaired fasting glucose plus type 2 diabetes mellitus, and high blood pressure 26 years later at a mean age of 38 years: the Princeton-Lipid Research Clinics follow-up study. Metabolism. 2012; 61 (4): 531–541. doi: 10.1016/j.metabol.2011.08.010.
58. US Department of Health and Human Services, Office of Disease Prevention
and Health Promotion. Dietary Guidelines for Americans. USDHHS Web site. Updated March 23, 2013. http://health.gov/59.dietaryguidelines/2010.asp
. Accessed April 7, 2013.
59. Ervin RB, Ogden CL. Trends in intake of energy and macronutrients in children and adolescents from 1999–2000 through 2009–2101. National Center for Health Statistics Data Brief
. CDC NCHS Web site. Updated February 21, 2013. http://www.cdc.gov/nchs/data/databriefs/db113.htm
. Accessed April 7, 2013.
60. American Dietetic Association Foundation. The state of family nutrition and physical activity. Are we making any progress? ADAF Web site. Updated 2013. http://www.eatright.org/foundation/fnpa/
. Accessed April 7, 2013.
61. Strasburger VCand the Council on Communications and Media. Children, adolescents, obesity, and the media. Pediatrics
. 2011; 128 (1): 201–208. doi: 10.1542/peds.2011-1066.
62. Lambiase M. Treating pediatric overweight through reductions in sedentary behavior: a review of the literature. J Pediatr Health Care. 2009; 23 (1): 29–36. doi: 10.1016/j.pedhc.2008.04.005.
63. Doyle-Baker PK, Venner AA, Lyone ME, Fung T. Impact of a combined diet and progressive exercise intervention for overweight and obese children. Appl Physiol Nutr Metab. 2011; 36: 515–525. doi: 10.1139/H11-042.
64. Guntin B. Diet vs. exercise for the prevention
of pediatric obesity: the role of exercise. Int J Obes. 2011; 35 (1): 29–32. doi: 10.1038/ijo.2010.140.
65. Walker DJ, MacIntosh A, Kozyrskyj A, Becker A, McGavock J. The associations between cardiovascular risk factors, physical activity, and arterial stiffness in youth. J Phys Act Health. 2013; 10 (2): 198–204.
68. Kosova EC, Auinger P, Bremer AA. The relationship between sugar-sweetened beverage intake and cardiometabolic markers in young children. J Acad Nutr Diet. 2013; 113: 219–227.
69. Kit BK, Fakhouri TH, Park S, Nielsen SJ, Ogden CL. Trends in sugar-sweetened beverage consumption among youth and adults in the United States: 1999–2010 [published online ahead of print May 15, 2013]. Am J Clin Nutr. doi: 10.3945/ajcn.112.057943.
70. Hertzog MA. Considerations in determining sample size for a pilot study. Res Nurs Health. 2008; 31: 180–191.
71. Jaballas E, Clark-Ott D, Clasen C, Stolfi A, Urban M. Parents’ perceptions of their children’s weight, eating habits, and physical activities at home and at school. J Pediatr Health Car. 2011; 25 (5): 294–301. doi: 10.1016/j.pedhc.2010.05.003.
72. Thorn JE, DeLellis N, Chandler JP, Boyd K. Parent and child self-reports of dietary behaviors, physical activity, and screen time. J Pediatr. 2012; 162 (3): 57–561. doi: 10.1016/j.jpeds.2012.08.031.