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Optimizing Cardiovascular Health Across the Life Course

Hayman, Laura L. PhD, RN, FAAN; Worel, Jane Nelson MSN, APRN-BC, APNP, FAHA

doi: 10.1097/JCN.0000000000000299
DEPARTMENTS: Progress in Prevention
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Laura L. Hayman, PhD, RN, FAANAssociate Vice-Provost for Research & Graduate Studies and Professor of Nursing, University of Massachusetts, Boston.

Jane Nelson Worel, MSN, APRN-BC, APNP, FAHA Nurse Practitioner, Phases, Primary HealthCare for Women, Madison, Wisconsin.

The authors have no conflicts of interest to disclose.

Correspondence Laura L. Hayman, PhD, RN, FAAN, University of Massachusetts, Boston, 100 Morrissey Blvd, Boston, MA 02125 (laura.hayman@umb.edu).

The American Heart Association (AHA) has prompted considerable national and global emphasis on the promotion of ideal cardiovascular health (ICVH) across the life course. The AHA’s 2010 document 1 focused on the 2020 strategic impact goal of improving the cardiovascular health of all Americans by 20% while simultaneously reducing deaths from cardiovascular diseases (CVDs) and stroke by 20% has stimulated considerable research, practice, public education, and policy-related initiatives focused on optimizing cardiovascular health across the life course.

The majority of children are born with ICVH as defined and operationalized by the 7 AHA metrics that include 4 health behaviors (smoking status, body mass index [BMI], physical activity, healthy diet score) and 3 health factors (total cholesterol, blood pressure, fasting plasma glucose).1 Population-based prevalence data, however, indicate unacceptably high prevalence of adverse levels of these health factors and behaviors in childhood.2 A recent report from the National Health and Nutrition Examination Surveys provided prevalence data for several ICVH metrics (total cholesterol, BMI, blood pressure, diet) for children aged 2 to 11 years.2 Of note and consistent with other reports, ideal healthy diet score was least prevalent in children (0.1%), whereas ideal levels of blood pressure were most prevalent (90.5%). Approximately 40% of children exhibited intermediate (170–199 mg/dL) or poor (>200 mg/dL) total cholesterol. Ideal BMI (<85th age- and sex-specific percentile) was less frequent in 6- to 11-year-old children than in children 2 to 5 years of age (67% vs 77%, respectively).2 Underscoring the importance of the life course approach are 3 decades of clinical and epidemiological research that provides convincing evidence: atherosclerosis begins early in life and is influenced and accelerated over time by potentially modifiable adverse health factors and behaviors.3 In addition, data indicate that individuals who maintain optimal levels of established risk factors for CVD through adult life have dramatically lower lifetime CVD risk and markedly longer survival than their adult counterparts who developed 1 or more risk factors earlier in life.4–6

Primordial prevention, highlighted in the AHA’s strategic plan and subsequent publications,7,8 places emphasis on preventing the development of adverse health factors and behaviors and also considers macrolevel strategies such as environmental and policy initiatives that enable development and maintenance of behaviors central to ICVH. Exemplifying the benefits of primordial prevention is evidence generated from several pediatric cohort studies that point to the importance of modifiable factors that have potential to promote the maintenance of ICVH beyond early life.9,10 Conducted in Finland, STRIP (Special Turku Coronary Risk Factor Intervention Project for Children) is a prospective, randomized trial designed to prevent atherosclerosis beginning in infancy.11,12 Families of 6-month-old infants were recruited from clinics in Turku, and infants were subsequently randomized to a dietary intervention (n = 540) or control (n = 522) group. The intervention group received individualized dietary and subsequently antismoking counseling at least biannually until 20 years of age. At follow-up, complete data on ICVH metrics were available at 15 (n = 394), 17 (n = 376), and 19 (n = 298) years of age.9 Adolescents in the control group had an increased risk of low ICVH (≤3 metrics) compared with the intervention adolescents; the number of ICVH metrics was inversely associated with aortic intima-media thickness (P < .0001) and directly associated with elasticity (P = .045). Of note, the risk of high intima-media thickness (>85th percentile) was substantially higher in adolescents with a low number of ICVH metrics (≤3) compared with those with a higher score (risk ratio = 1.78; 95% confidence interval, 1.31–2.43).9 Taken together, the results suggest that ICVH, as defined by AHA metrics, is beneficially associated with vascular health in adolescence and reaffirm the STRIP investigators’ clinical perspective supporting the relevance of targeting health factors and behaviors as part of primordial prevention efforts.9,11,12

A recent report from the Cardiovascular Risk in Young Finns Study, a multicenter follow-up study that included participants (n = 1089) who were 3 to 18 years of age at baseline, demonstrates the cumulative effect of psychosocial factors in youth on ICVH in adulthood.13 Conceptualized within a life course health framework that emphasizes importance of early-life psychosocial exposures on health status in adulthood,14 the investigators examined whether positive psychosocial factors (socioeconomic environment, emotional environment, life events, self-regulation, health behaviors, social adjustment) in youth predict AHA-defined ICVH in adulthood. Results indicated that a favorable socioeconomic environment (β = .12; P < .001) and participants’ self-regulatory behavior (β = .07; P = .004) were the strongest predictors of ICVH 27 years later in adulthood.13 Of note, individuals exhibiting favorable levels in all psychosocial factors in youth had the healthiest profiles in adulthood.13 Although findings may not be generalizable to diverse populations, they point to the importance of positive psychosocial factors as a component of primordial prevention efforts. Taken together and combined with other recent longitudinal studies,15,16 results support emerging interdisciplinary research initiatives focused on the integration of positive psychology and ICVH.17,18

The individual and societal benefits of maintaining ICVH have been demonstrated and acknowledged, respectively.7 Clearly, accumulated evidence indicates the need for both individual-level and population-based primordial prevention strategies to optimize ICVH across the life course of individuals from diverse racial and ethnic populations and socioeconomic backgrounds. Individual-level interventions could begin in utero with emphasis on maintaining ICVH in the offspring of pregnant women. Excess weight gain during pregnancy has been associated with higher risk of complications (ie, gestational diabetes) as well as offspring with a higher BMI and adverse levels of other CVD risk factors including elevated systolic blood pressure and lower cardioprotective high-density lipoprotein cholesterol.19 Specific evidence-based strategies for promoting ICVH through childhood and adolescence, as suggested in the 2011 Integrated Guidelines,20 focus on development and maintenance of behaviors central to cardiovascular health (ie, patterns of physical activity and dietary intake, smoke-free lifestyles, and environments), encourage family involvement and engagement, and consider child’s developmental stage, as well as family preferences and available resources.

Recognizing the importance of multilevel, contextual-environmental factors for optimizing cardiovascular health, particularly in vulnerable underserved populations, interventions and public health programmatic initiatives must also extend beyond the individual and family as units of intervention and target schools, work sites, and communities. A recent report from the Multi-ethnic Study of Atherosclerosis21 provides evidence reaffirming associations between neighborhood characteristics (ie, socioeconomic status, availability of healthy foods, and outlets for physical activity) and level of cardiovascular health. Evidence-based population strategies designed to promote ICVH across the life course have been defined22; however, implementation is much less than optimal and will require collaboration across local, state, and national levels.

Cardiovascular nurses functioning in healthcare and community-based settings are well positioned and prepared to implement evidence-based recommendations designed to optimize cardiovascular health across the life course of individuals and families from diverse and vulnerable populations. As recognized advocates for the health of the public, we must also participate in multilevel initiatives designed to allocate resources focused on primordial prevention and with the goal of promoting optimal life course cardiovascular health for all.

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