ACCEL | Growing evidence suggests that the negative health behaviors of childhood may persist through adulthood, increasing the risk of coronary heart disease (CHD) and other chronic diseases. Indeed, we have an increasing number of children who already have numerous cardiovascular disease (CVD) risk factors and may be more likely to experience premature ischemic heart disease than their parents. Therefore, school and community programs that promote regular physical activity may offer an opportunity for primary prevention and reduce the burden of chronic diseases associated with sedentary lifestyle and obesity.

Investigators recently reported the results of a public-private preschool program to promote the adoption of healthy diets and active lifestyles.¹ They used a cluster design to randomly assign 14 preschool facilities in Bogotá, Colombia, to a 5-month educational and playful intervention (seven preschool facilities) or to usual curriculum (seven preschool facilities). A total of 1,216 children aged 3-5 years, 928 parents, and 135 teachers participated.

Children in the interventional group received classroom educational and playful activities during 5 months, which included Sesame Workshop Healthy Habits storybooks, posters, videos, games, and songs (1 hour daily); a "Healthy family day" workshop (1 hour); and weekly health notes. (Formerly known as the Children's Television Workshop, Sesame Workshop is the nonprofit organization behind Sesame Street.)

Parents participated in three workshops and weekly notes containing positive health messages about nutrition and active lifestyles to share with their children. Teachers also participated in three centralized training sessions, plus personalized working sessions with a research supervisor (2 hours every 15 days), and received a teacher's guide. Meanwhile, the control preschool facilities continued with their usual preschool curriculum.

The study used an evaluation process whereby the evaluators were not aware of the status of the preschool facilities.

HEALTH KNOWLEDGE, HEALTHY HABITS

At baseline, the children had similar proportions to national (Colombian) statistics compiled in a 2010 survey: 2.55% of the study children were obese and 19.85% were overweight. After the intervention period, the proportion of children within healthy norms based on age and size increased in both intervened and control groups but favored the intervention group. Although the differences were not statistically significant, the authors said the results are encouraging and raise the hypothesis that maintaining some elements of the interventional strategy in the educational community over a longer period might produce larger changes.

After adjusting for sex and age of children, intervention group, socioeconomic status, age of parents, and age and educational level of teachers, children receiving the intervention showed significant changes in knowledge, attitudes, and physical activity habits.

Results in the interventional cohort were maintained or improved after 1 year. As part of a requirement of a local institutional review board, the preschool facilities comprising the control group were provided with a similar intervention after the initial 5-month study ended. The results for the control group after intervention were comparable to those of the initial study group.

Investigators have now published 36-month follow-up data,² although follow-up was challenging. At the start of the study, participants were distributed throughout 14 preschool facilities in one Bogotá community, but because of the high migration rate within the country due to social and economic hardships, the study population transitioned to 305 schools in 12 localities of Bogotá after 36 months. Still, follow-up was similar at both 18 and 36 months. The total number evaluated at 18 months was 596 children and 435 parents versus 36-month totals of 598 children and 475 parents.

At baseline, 62.1% of the study children were eutrophic and this percentage increased to 75.0% after 36 months of follow-up. Overall, after 36 months, the school-based intervention maintained a positive change, mainly in children's knowledge and attitudes, and lesser effect in their parents. Specifically:

• In children: increased mean knowledge, attitudes, and habits (all p < 0.001)
• In parents: scores improved for both knowledge and attitude (p < 0.001 for both)
• Nutritional status: children saw an improvement (p < 0.0001)

Importantly, physical activity improved after 36 months of follow-up. For children 3 years of age at study entry, the change in the knowledge score overtime was more significant than older peers. This supports the idea that major lifestyle changes can be obtained with programs that begin at an early age.

According to the study's principal investigator, Valentin Fuster, MD, PhD, "As a result of our successful pilot intervention in Colombia, the program has also been implemented in Spain, where we have expanded our reach to 20,000 more children." Dr. Fuster, director of Mount Sinai Heart at The Mount Sinai Hospital in New York City, said, "Additional countries are now joining in the implementation of this vital childhood intervention allowing for increased education about the benefits of a heart-healthy lifestyle to better protect our world's tiniest hearts."

REFERENCES

1. Céspedes J, Briceño G, Farkouh ME, et al. Am J Med. 2013;126:1122-6.
2. Céspedes J, Briceño G, Farkouh ME, et al. Am J Med. 2013;126:27-35.e3.

Keywords: CardioSource WorldNews Interventions

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