As the first approach to stratified health is within the first 25 years of life, it is reasonable to assume that at that stage there is no significant cardiovascular disease yet in most individuals. We have learned that the optimal period of time to motivate behavior in favor of health is between the ages of three to five years. Indeed, there is evolving evidence that our behavior as adults has its roots in the environment that we grew up in from age three to five years. Furthermore, unhealthy diets begin to influence cardiovascular disease markers early in life. Conditions such as dyslipidemia, high blood pressure, impaired glucose tolerance, as well as obesity and metabolic syndrome may become rooted as early as three to five years of age, increasing the risk of development of atherosclerosis in adolescence and early adulthood.

During these ages, educational topics can include how the body and heart work, healthy food habits, physical activity and emotional habits to avoid addictions. In the SI! Program for Cardiovascular Health Promotion in Early Childhood, for example, intervention was designed to be applied at all preschool levels in 24 Madrid, Spain, schools for the purpose of promoting cardiovascular health among children using their proximal environment (school, teachers and families). Improvement was initially demonstrated during the first year of intervention. This program translated into a beneficial effect on adiposity, with maximal effect when started at the earliest age and maintained over three years. The results presented in the Madrid SI! Program align well with those obtained previously in a Colombian initiative. After intervention, Colombian preschoolers were followed-up for 36 months, sustaining the effect toward healthier behaviors and ultimately leading to a nationwide expansion of the program. The critical question will be answered when these children are 15 to 20 years of age. In other words, can intervention at age three to five years affect health behaviors when these children reach adulthood?

For the second opportunity for stratified health, the age range of 25 to 50 years appears to be the right time to evaluate subclinical disease, about which we have been learning a significant amount through noninvasive imaging techniques. In two recent bioimaging studies, we assessed approximately 10,000 asymptomatic adults >40 years of age using multimodality vascular imaging of the coronary arteries with electron-beam computed tomography for calcification and of the carotid arteries with 3-D ultrasound. We found that subclinical atherosclerosis was highly prevalent, detectable in both the coronary and carotid vascular territories (more recently also in the ilio-femoral region) in close to 60 percent of participants. Thus, we concluded that incorporating detection of subclinical atherosclerosis irrespective of anatomic territory, in addition to cardiovascular risk factors, would motivate patients to change their lifestyle. Through the use of advanced imaging technologies, we are now testing in such adult populations with manifested subclinical disease whether addressing risk factor profile through “group therapy” or an intensified and “around-the-clock” personalized approach is more beneficial in terms of changing lifestyle and preventing progression of the disease than the usual conventional means.

The third opportunity for stratified health is for individuals >50 years, when cardiovascular disease has often begun to manifest itself symptomatically or by an adverse event. It is of value to approach this population by taking into account the total body vasculatures, including the heart and the brain. It has been increasingly recognized that degenerative brain disease is intimately linked to the vasculature and overall burden of atherosclerosis disease. Specifically, the heart-degenerative brain disease axis is perceptible across a very broad spectrum of disease, from macrovascular large-vessel coronary, carotid or ilio-femoral diseases leading to myocardial infarction or stroke, to microvascular small vessel changes causing dementia. Thus, we must make a transition from primarily considering the coronary vessels to looking at the entire individual in terms of systemic cardiovascular disease, which includes the neurovascular region. Furthermore, in the elderly population with already manifested disease, two pharmacological challenges need to be addressed: Can adherence to medication be improved? Can medication be simplified such as with the use of a polypill?

In summary, at every age range, there are specific scientific/physiopathological backgrounds and educational/behavioral tools available to best intervene. Although there have been external pressures to make “medicine” more personalized or precision-based – terms that have yet to be clearly defined – those of us who are actually entrusted to keep people healthy need to start approaching the population with a stratified health strategy.

Fuster is director of Mount Sinai Heart; physician-in-chief of Mount Sinai Hospital; and editor-in-chief of the Journal of the American College of Cardiology.

He spoke on these approaches during ACC’s Population Health Policy retreat in July and received an award from the Population Health Policy and Health Promotion Committee at the retreat for his leadership in changing the landscape and improving patient health through the lifespan.

Blood Pressure (BP) and Diabetes:
Elevated BP may be associated with increased risk of diabetes, according to Connor A. Emdin, HBSc, et al. In a prospective analysis of 4.1 million patients without vascular disease or diabetes, 20 mmHg higher systolic BP was found to be associated with a 58 percent higher risk of diabetes, while a 10 mmHg higher diastolic BP was associated with a 52 percent higher risk. “These investigators offer an exceptionally rigorous evaluation of the relation between BP and incident diabetes,” states Donna K. Arnett, MSPH, PhD, in an accompanying editorial comment. “This study provides a strong rationale for continued research into the biological basis and pharmacological implications of the observed association.”

Smoking Cessation:
An analysis of medical costs associated with atherosclerotic lower extremity peripheral artery disease (PAD) found that health care costs in one year were $18,000 higher in smokers with PAD than non-smokers with the condition. Accordingly, smokers may be more likely to be hospitalized for leg events, heart attack and coronary heart disease related to atherosclerotic PAD than non-smokers with PAD. In an accompanying editorial, Geoffrey D. Barnes, MD, MSc, FACC, and Elizabeth Jackson, MD, MPH, FACC, note the study highlights the urgent need for smoking cessation among PAD patients and that getting patients to quit may improve care and save significant health dollars over the long term.

Impact of Childhood Stress:
A 45-year study of nearly 7,000 people born in a single week in Great Britain in 1958 found psychological distress in childhood – even when conditions improved in adulthood – may be associated with higher risk for cardiovascular disease and diabetes later in life. “This study supports growing evidence that psychological distress contributes to excess risk of cardiovascular and metabolic disease and that effects may be initiated relatively early in life,” says lead author Ashley Winning, ScD, MPH. “Early prevention and intervention strategies focused not only on the child but also on his or her social circumstances may be an effective way to reduce the long-lasting harmful effects of distress.” In an accompanying editorial comment, E. Alison Holman, PhD, FNP, explains that it may not be helpful for clinicians to focus on “managing” known cardiovascular disease risk factors like smoking, obesity, elevated cholesterol and lack of exercise without addressing underlying risk factors that affect patients.

Global Food Consumption:
More than 80 percent of cardiovascular disease deaths occur in low- and middle-income countries, but very little data on the impact of diet on cardiovascular disease exists from these countries. A state-of-the-art review summarizes the evidence relating food to cardiovascular disease and how the global food system contributes to dietary patterns that greatly increase the risks for populations with poor health. The authors identify what an optimal diet for reducing cardiovascular disease looks like – giving the traditional Mediterranean diet as an example – and suggest that it may be possible to recreate this diet in other regions using appropriate similar food replacements based on food availability and preferences.

Fructose and Cardiometabolic Health:
There is compelling evidence that drinking too many sugar-sweetened beverages, which contain added sugars in the form of high fructose corn syrup or sucrose, can lead to excess weight gain and a greater risk of developing type 2 diabetes and cardiovascular disease, according to a research letter by Vasanti S. Malik, ScD, and Frank B. Hu, MD, PhD. The study – the most comprehensive review of the evidence on the health effects of sugar-sweetened beverages to date – also takes a closer look at the unique role fructose may play in the development of these conditions.

Achieving Ideal Cardiovascular Health:
Promotion of a healthy diet and physical activity will likely help in achieving the ideal cardiovascular health goals set by the American Heart Association, according to a research letter from Adnan Younus, MD, et al. In a review of 18 studies related to cardiovascular health metrics, researchers found that diet metrics were suboptimal, while BP and body mass index (BMI) metrics reported less than 50 percent. Focusing efforts on promotion of healthy diet and exercise may indirectly influence BMI, BP and fasting glucose metrics, according to the authors.

Early Healthy Lifestyle Intervention:
Introducing healthy lifestyle behaviors to children in preschool may improve their knowledge, attitude and habits toward a healthy diet and exercise, and may lead to reduced levels of body fat, according to Valentin Fuster, MD, PhD, MACC, editor-in-chief of JACC, who was an author of the study. Through the SI! Program, researchers in Madrid implemented a three-year healthy lifestyle intervention for three to five 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. “We need to focus our care in the opposite stage of life – we need start promoting health at the earliest years … in order to prevent cardiovascular disease,” states Fuster. (See related article, above) In a related editorial comment, Deepak L. Bhatt, MD, MPH, FACC, et al., says 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.

Risk Factor Management:
Three cross-sectional surveys of EUROASPIRE show challenges in applying prevention guidelines in clinical practice for acute coronary artery disease patients, according to a research letter from Kornelia Kotseva, MD, PhD, et al. The results of the surveys show increases in obesity and diabetes amongst the patients, while the proportion of persistent smokers remained the same. “The life-saving treatments for acute coronary artery disease … must be matched by modern preventive cardiology programs combining a professional lifestyle intervention with effective risk factor control to reduce total cardiovascular risk,” states Kotseva.

Read the full JACC Population Health Promotion issue at OnlineJACC.org.

Reference

1. J Am Coll Cardiol. 2015;66(14).