Promoting Cardiovascular Health in the Developing World A Critical Challenge to Achieve Global Health (2010) / Chapter Skim
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6 Cardiovascular Health Promotion Early in Life
6 Cardiovascular Health Promotion Early in Life
Pages 275-316
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From page 275... ...
This chapter describes the determinants of CVD that have origins early in life, followed by a discussion of the effects of childhood health promotion and prevention initiatives on later CVD risk. This chapter, consistent with the scope of this report as described in Chapter 1, focuses on the accumulation starting early in life of risk for coronary heart disease and stroke This is not intended to underemphasize the importance of treating and preventing congenital heart diseases and other cardiovascular diseases in childhood, including prevention and treatment of streptococcal infections to prevent rheumatic heart disease, which exacts a high toll on children in low and middle income countries and was discussed in more detail in Chapter 2.
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From page 276... ...
Second, those already working in child health globally should take chronic disease prevention into consideration where there are relatively feasible and evidence-based interventions available in order to achieve not only short-term child outcomes but also to promote lifelong health. Third, the impact of health promotion and health education in children on adult CVD outcomes as well as the effectiveness of active CVD prevention programs in early childhood, youth, and adolescence in low and middle income countries are areas to be emphasized for further intervention research.
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Maternal smoking during pregnancy has been linked to CVD-related risk factors. It has been consistently associated with increased childhood obesity independent of other risk factors (Oken et al., 2008)
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In another developing country cohort, a longitudinal study of more than 3,000 children in South Africa also found that the combination of low birth weight and rapid growth in childhood was associated with an increased risk of obesity and risk factors for type 2 diabetes (Crowther et al., 1998; Richter et al., 2007)
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On the other hand, several recent reviews and meta-analyses of studies examining early undernutrition found rapid weight gain between birth and age 2 years was associated with lower morbidity and mortality in low and middle income countries (Black et al., 2008; Victora et al., 2008)
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A large prospective cohort study from Denmark also found that higher BMI during childhood is associated with an increased risk of coronary heart disease (CHD) in adulthood and that the elevated risk associated with childhood obesity increases with the age of the child (Baker et al., 2007)
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Similar findings have been noted in studies conducted in other low and middle income countries (Agirbasli et al., 2006; Csabi et al., 2000; Kelishadi, 2007)
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Early CVD Pathology in Childhood Many of the risk factors described above have been shown to be related to surrogates for CVD pathophysiology that can already be observed in childhood, such as increased left ventricular mass, left ventricular systolic dysfunction, and higher arterial thickness in overweight children (Johnson et al., 1999; Laird and Fixler, 1981; Sorof et al., 2003)
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Hence, efforts for the prevention of CVD should begin right from childhood and adolescence when lifestyle habits are being formed, especially with respect to diet and physical activity, as well as during the prenatal period with respect to maternal nutrition and health. GLOBAL TRENDS IN MAJOR DETERMINANTS OF CVD RISK EARLY IN LIFE An understanding of the trends fueling the growing burden of childhood risk factors for chronic diseases is imperative if a reversal is to be brought about through public policy and programs.
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. Nearly 25 percent of them try their first cigarette before the age of 10 years, and 19 percent are susceptible to initiating smoking during the next year (Global Youth Tobacco Survey Collaborative Group, 2002)
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. In addition, since the study looked at a wide variety of potential risk factors, including violence-related intentional and unintentional injuries, mental health and wellness indicators, and nutrition and physical activity levels, it provided a more complete, well-rounded picture of adolescent risk behaviors, reinforcing the need to look more closely at the complex interactions that contribute to youth health status (Reddy et al., 2003)
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PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD FIGURE 6.2 Illustrative prevalence of overweight in boys.
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CARDIOVASCULAR HEALTH PROMOTION EARLY IN LIFE FIGURE 6.3 Illustrative prevalence of overweight in girls.
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. However, the most important determinants that have recently been widely studied are nutrition and physical activity transitions.
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. Although data on physical activity among children is generally sparse in developing countries, a 2002 national survey in South Africa found that 37.5 percent of school children in grades 8-11 were physically inactive, classified as not engaging in moderate or vigorous physical activity at least 3 or 5 days per week, respectively (Reddy et al., 2003)
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Marketing related to CVD risk factors is part of the broader social determinants underlying behavioral and lifestyle changes occurring among children and young adults that increase their risk for developing CVD later in life. Children and teenagers may be disproportionately vulnerable to the effects of marketing.
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. The food industry in the west, and now even in the developing world, relies heavily on marketing to promote global brands.
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Conclusion 6.1: Accumulation of cardiovascular risks begins early in life, and strong evidence supports the value of starting cardiovascular health promotion during pregnancy and early childhood and continu ing prevention efforts throughout the life course. Maternal and child health programs and other settings that already serve children in low and middle income countries offer an opportunity to provide care that takes into account not only shorter-term childhood outcomes but also long-term healthful behavior and reduction of chronic disease risk.
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. In addition to the Global School Health Initiative, the newly formed Mega Country Health Promotion Network has also included a school health component into its mission.
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Therefore, the effectiveness and implementation of such adaptation needs to be the subject of research so that the benefits of school-based smoking prevention can be evaluated objectively in low and middle income settings (Flay, 2009a)
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In recent times, many interventions have used schools as the vehicle of change because the school culture is seen as one that fosters and supports physical activity and health. Several school-based obesity prevention and health promotion programs have been successfully implemented and evaluated in high income countries, but published efforts from low and middle income countries are scarce.
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. Although evidence from low and middle income countries is scarce, there have been a few studies designed to encourage physical activity in middle income countries.
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Youth-Focused Policy Initiatives Tobacco Control There have been a number of initiatives both at the international and government levels to control the increasing use of tobacco products in both the developed and developing worlds. The World Health Organization's (WHO's)
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. However, despite the adoption of the FCTC, tobacco control programs in low and middle income countries have been limited in their implementation and variable in their success.
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Restricting Food Marketing There is a continued need for the international public health community, learning from the experience with the tobacco industry, to develop a sustained, global response to the aggressive marketing of potentially unhealthful food products, aimed pointedly at children and adolescents. Marketing restrictions, curtailing advertising of such products in children's television, and the banning of in-school marketing, accompanied by the promotion of healthful foods such as fruits and vegetables, are some examples of steps that can be and have been taken to this end.
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Progress at monitoring and enforcing these self-regulation mechanisms in low and middle income countries has been more inconsistent and ranges from almost no action in South Africa to the very responsive Indian Advertising Standards Council (Hawkes, 2007)
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Because habits related to diet and physical activity begin to be established at an early age, and because adolescents and young adults are particularly susceptible to experimenting with alcohol and tobacco use, targeting campaigns focused on these risk factors of younger age groups is a rational strategy (IOM, 2006)
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The success of one campaign doesn't necessarily translate into successful implementation in all other settings. The success of mass media campaigns is greatly contingent on the characteristics and requirements of the target population, and educational levels, socioeconomic backgrounds, and cultural backdrops go a long way in determining whether such a campaign will generate results in the desired direction.
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The group aims to connect young people from around the world, forming a global alliance of national, regional, and global partnerships that can collectively promote common causes. These include advocating for tobacco control, healthful diets, regular physical activity, environmental protection, gender equality, women's health, and reduction of alcohol and drug abuse (HRIDAY–SHAN, 2006)
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. At the global level, an electronic signature campaign on Global Health Promotion for Youth with a focus on tobacco control, initiated by Y4H members and endorsed by more than 225,000 youth and adults worldwide, was presented by Y4H members to the Secretary General of the United Nations (UN)
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CHALLENGES TO IMPLEMENTING YOUTH-BASED PROGRAMS IN LOW AND MIDDLE INCOME COUNTRIES Despite great progress in identifying increasing trends in the acquisition of risk early in life, data on the incidence and prevalence of CVD risk factors in youth remain very limited. More data is clearly needed to prioritize avenues for program implementation and intervention research, yet the best methods to pursue information specific to children and adolescents remain unclear.
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This coordination with the education sector is thus a critical component of the broader messages in this report supporting intersectoral and whole-of-government approaches to address CVD and related chronic diseases. CONCLUSION Accumulation of cardiovascular risk begins early in life, and evidence on rising rates of childhood obesity and youth smoking in low and middle income countries as well as emerging evidence on the effects of early nutrition on later cardiovascular health support the value of starting cardiovascular health promotion during pregnancy and early childhood and continuing prevention efforts throughout the life course.
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The available evidence on the impact of cardiovascular health promotion and CVD prevention initiatives in childhood and adolescence is limited and of variable quality, especially in low and middle income country settings. Approaches with some success on a small scale that have emerging potential for developing countries include education initiatives targeted to children, school-based programs, and programs targeted to take advantage of the potential for adolescents and young adults to serve as powerful advocates for change.
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2002. Childhood risk factors predict adult risk associated with subclinical cardiovascular disease.
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2009. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6-18.
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2001. Rela tionship of childhood obesity to coronary heart disease risk factors in adulthood: The Bogalusa Heart Study.
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2003. Childhood cardiovascular risk factors and carotid vascular changes in adulthood: The Bogalusa Heart Study.
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Health Promotion International 22(3)
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2008. Comparison of two school-based smoking prevention programs among South African high school stu dents: Results of a randomized trial.
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Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, U.S. Department of Health and Human Services, Public Health Service.
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WHO Mega Country Health Promotion Network.
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