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Release on “groundbreaking” pre-school heart health study underwhelms on outcomes

Teaching 3- to 5-year-olds about diet, exercise can also improve entire family’s health behavior

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IMAGE: Introducing healthy lifestyle behaviors to children in preschool improves their knowledge, attitude and habits toward healthy diet and exercise and can lead to reduced levels of body fat, according to… view more

Credit: Journal of the American College of Cardiology

Introducing healthy lifestyle behaviors to children in preschool improves their knowledge, attitude and habits toward healthy diet and exercise and can lead to reduced levels of body fat, according to a study published today in the Journal of the American College of Cardiology. Researchers predict early intervention in children will not only translate to a lifelong understanding of healthy habits but will also serve to encourage their parents to adopt healthier lifestyles.

Research has shown that unhealthy diets at a young age can contribute to cardiovascular disease later in life and that certain heart disease conditions can set in as early as 3 years old. Through the SI! Program, researchers in Madrid implemented a three-year healthy lifestyle intervention for 3 to 5 year olds that used their school, teachers and families to promote cardiovascular health through healthy diet, increased physical activity, understanding of the human body and managing emotions.

Over 2,000 children in 24 Madrid public schools were followed during the program and exposed to the lifestyle intervention for three years, two years or one year depending on their age when the program began. Intervention materials included classrooms materials, take-home activities to do with their families and activities organized within the school’s annual health fair. Students were assessed by pediatric psychologists at the start of the program and again annually for three years with a questionnaire to determine their knowledge, attitude and habits toward diet, physical activity and the human body.

“There is a need for a complete change in the timing of when we deliver care,” said Valentin Fuster, M.D., Ph.D., senior author of the paper. “Until now, the clinical community has focused on cardiovascular disease, which typically manifests in the later stages of life. Now, we need to focus our care in the opposite stage of life–we need start promoting health at the earliest years, as early as 3 to 5 years old, in order to prevent cardiovascular disease.”

Children in the intervention group scored 5.5 percent higher on their knowledge, attitude and habits score than students not receiving intervention after the first year, 7.7 percent higher after the second year and 4.9 percent higher after the third year. Overall scores were influenced by the level of parental education and income, with the highest impact seen in families with at least a high school education and higher income. There was no difference in score based on parental age, but a higher impact in score was seen for children whose parents were of European origin.

Body weight, height, waist circumference, skinfold thickness and BMI were also measured. The prevalence of obesity among children at the end of three years was 1.1 percent in the group receiving intervention compared to 1.3 percent in the control group. The total of overweight children was 7 percent in the intervention group and 7.4 percent in the control group. The largest positive changes in body fat were seen in the 3-year-old group that received three years of interventions. Interventions less than two years were not successful at reducing body fat.

In an accompanying editorial, Deepak L. Bhatt, M.D., M.P.H., executive director of interventional cardiovascular programs at Brigham and Women’s Hospital Heart and Vascular Center and professor of medicine at Harvard Medical School in Boston, said the program is groundbreaking, and follow-up studies to further pinpoint the exact mechanisms by which the program achieved positive effects on young children’s health will be vital for implementing the program in other areas and informing the design of future global programs.

“It may not only be the cardiovascular health information from the program that is helpful but also the cognitive stimulation from and exposure to positive adult role models, which in turn influence personality traits critical for health behavior and habits,” Bhatt said. “This pioneering study represents a very important step in exploring the intersection of child development, cardiovascular health promotion and primordial prevention. We eagerly await longitudinal follow-up, data from other age-groups, and outcomes related to families and schools from the SI! Program.”

The study and editorial are part of a comprehensive Population Health Promotion issue of the Journal of the American College of Cardiology focusing on issues that broadly impact public health and the prevention of cardiovascular disease and related conditions. Population health is a strategic priority of the American College of Cardiology, which recently brought together experts from around the world to address issues such as smoking and nutrition in the context of developing public health strategies for improving population health.

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The Journal of the American College of Cardiology, which publishes peer-reviewed research on all aspects of cardiovascular disease, is the most widely read cardiovascular journal worldwide. JACC is ranked No. 1 among cardiovascular journals worldwide for its scientific impact.

The American College of Cardiology is a 49,000-member medical society that is the professional home for the entire cardiovascular care team. The mission of the College is to transform cardiovascular care and to improve heart health. The ACC leads in the formation of health policy, standards and guidelines. The College operates national registries to measure and improve care, provides professional medical education, disseminates cardiovascular research and bestows credentials upon cardiovascular specialists who meet stringent qualifications. For more information, visit acc.org.

Early intervention improves preschoolers' heart healthy habits

Our Review Summary

LibraryA study in Madrid of 2,000 preschoolers compared those who received special education in heart-healthy living with those who didn’t – and showed a modest improvement for children who received the lessons. An editorial used the word “groundbreaking” for the study, but the numbers seemed quite modest. The release could have provided context to try to justify the excitement.

 

Why This Matters

Changing people’s habits is a vital part of reducing the chronic diseases, including obesity and heart disease, that are epidemic in industrial societies. If making health part of the preschool classroom can accomplish this, it would be big news. This news release overstates a study that is mostly showing a proof of principle and will require much follow-up and analysis before one can say the educational intervention made these children any healthier or produced a durable change in their habits.

Criteria

Does the news release adequately discuss the costs of the intervention?

Not Satisfactory

The news release does not talk at all about costs, and this three-year intervention including education for 3-5 year-old children sounds as if it could have had substantial cost.

Does the news release adequately quantify the benefits of the treatment/test/product/procedure?

Satisfactory

The release does quantify benefits – but it leaves readers a bit underwhelmed. The numerical differences shown are rather small for the conclusion that the release trumpets. We would have liked some context to justify the excitement about this study.

Children who received intervention scored 5.5 percent higher in “knowledge, attitude and habits” than the controls, after the first year. However, that difference lowered to just 4.9 percent after the third year of intervention. We suspect that quantifying the “knowledge” of a 4-year-old is tricky and perhaps a bit more subjective than a blood test or other study data.

Children who received the intervention had obesity rates of 1.1 percent in the group compared to 1.3 percent in the control group. The release should have explained why the authors believe the difference of only 2/10 of a percent qualified as “groundbreaking.”

In addition, we’d note that the release touts reductions in body fat, measured through skinfold measurements, as a positive outcome. But skinfold measurements are a questionable marker of body fat given not only risk of inter-, but intra-operator error in terms of landmarking the exact same skinfold location for repeated measurements.

Does the news release adequately explain/quantify the harms of the intervention?

Not Applicable

Because the interventions are largely educational and don’t include drugs or therapies, we’ll say that harms are unlikely. But is it theoretically possible that the intervention could have some unforeseen impact on these children that shows up years later? Fear of fat? Anorexia? We won’t penalize the release for not raising the issue, but saying something about downstream potential would have added depth and insight.

Does the news release seem to grasp the quality of the evidence?

Satisfactory

This study of 2,000 children appears to have a high quality of evidence in the study itself, and the release does a Satisfactory job of summarizing what the researchers did and what they found. But the news release could have gone further. It could have noted, for example, that schools were randomly assigned to participate or not in the intervention — and that this helps assure that the findings represent an isolated effect of the intervention itself rather that other factors that could have had an impact. There is similarly no discussion of potential limitations of the study, nor does the release give us any specifics as to what kinds of education and lifestyle interventions were offered to the children. As we said above, we wish the release had included some context by which to judge the small difference between study subjects and controls.

Does the news release commit disease-mongering?

Satisfactory

There is no disease mongering in this release.

Does the news release identify funding sources & disclose conflicts of interest?

Not Satisfactory

The release does not mention the funding sources for the study, which was supported by government and foundation grants. Although there are no obvious conflicts of interest here, we always ask that news releases provide funding information about studies so that readers and journalists have easy access to this information.

Does the news release compare the new approach with existing alternatives?

Not Applicable

The use of education for preschool-aged children to prevent cardiovascular disease appears novel, and we are not aware of a direct alternative “education” that exists. We’ll rule this one Not Applicable.

Does the news release establish the availability of the treatment/test/product/procedure?

Not Satisfactory

The release mentions that the intervention is part of the SI! program — but it doesn’t establish what that is or whether it’s something that the wider public has access to. One might presume that the program is used only in a research setting at present, but we don’t know that for sure, and the release should have made this clear.

Does the news release establish the true novelty of the approach?

Satisfactory

The release establishes the novelty of this prevention intervention with a quote: “There is a need for a complete change in the timing of when we deliver care,” said Valentin Fuster, M.D., Ph.D., senior author of the paper. “Until now, the clinical community has focused on cardiovascular disease, which typically manifests in the later stages of life. Now, we need to focus our care in the opposite stage of life–we need start promoting health at the earliest years, as early as 3 to 5 years old, in order to prevent cardiovascular disease.”

Does the news release include unjustifiable, sensational language, including in the quotes of researchers?

Not Satisfactory

The biggest claim is that the intervention “improves their [preschoolers] knowledge, attitude and habits toward healthy diet and exercise and can lead to reduced levels of body fat.” That claim is not unjustified, but rather the data seems to show the improvement is slight.

But we think it’s unjustified to predict that these results will “translate to a lifelong understanding of healthy habits” as the release claims. There’s no data at all to suggest that these changes would be sustained beyond the active intervention period.

We’re similarly concerned with a quote pulled from the accompanying editorial which states that there is a need to pinpoint the mechanisms through which the intervention “achieved positive effects on young children’s health.” We’re not at all sure that a slight increase in knowledge a very small reduction in bodyfat represent “positive effects on health.” Health encompasses much more than these things.

Total Score: 4 of 8 Satisfactory

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