Subclinical Atherosclerosis in Young, Socioeconomically Vulnerable Hispanic and Non-Hispanic Black Adults.

BACKGROUND Non-Hispanic Black persons are at greater risk of cardiovascular (CV) events than other racial/ethnic groups; however, their differential vulnerability to early subclinical atherosclerosis is poorly understood. OBJECTIVES This work aims to study the impact of race/ethnicity on early subclinical atherosclerosis in young socioeconomically disadvantaged adults. METHODS Bilateral carotid and femoral 3-dimensional vascular ultrasound examinations were performed on 436 adults (parents/caregivers and staff) with a mean age of 38.0 ± 11.1 years, 82.3% female, 66% self-reported as Hispanic, 34% self-reported as non-Hispanic Black, and no history of CV disease recruited in the FAMILIA (Family-Based Approach in a Minority Community Integrating Systems-Biology for Promotion of Health) trial from 15 Head Start preschools in Harlem (neighborhood in New York, New York, USA). The 10-year Framingham CV risk score was calculated, and the relationship between race/ethnicity and the presence and extent of subclinical atherosclerosis was analyzed with multivariable logistic and linear regression models. RESULTS The mean 10-year Framingham CV risk was 4.0%, with no differences by racial/ethnic category. The overall prevalence of subclinical atherosclerosis was significantly higher in the non-Hispanic Black (12.9%) than in the Hispanic subpopulation (6.6%). After adjusting for 10-year Framingham CV risk score, body mass index, fruit and vegetable consumption, physical activity, and employment status, non-Hispanic Black individuals were more likely than Hispanic individuals to have subclinical atherosclerosis (OR: 3.45; 95% CI: 1.44-8.29; P = 0.006) and multiterritorial disease (P = 0.026). CONCLUSIONS After adjustment for classic CV risk, lifestyle, and socioeconomic factors, non-Hispanic Black younger adults seem more vulnerable to early subclinical atherosclerosis than their Hispanic peers, suggesting that the existence of emerging or undiscovered CV factors underlying the residual excess risk (Family-Based Approach in a Minority Community Integrating Systems-Biology for Promotion of Health [FAMILIA (Project 2)]; NCT02481401).This study was funded by the American Heart Association under grant No 14SFRN20490315 and the Stephen Gellman Children’s Outreach Program. Dr Fernandez-Jimenez is recipient of grant PI19/01704 funded by the Fondo de Investigación Sanitaria- Instituto de Salud Carlos III (ISCIII) and co-funded by the European Regional Development Fund/European Social Fund "A way to make Europe"/"Investing in your future." Dr Santos-Beneit is recipient of grant LCF/PR/MS19/ 12220001 funded by “la Caixa” Foundation (ID 100010434). The CNIC is supported by the ISCIII, the Ministerio de Ciencia e Innovación (MCIN) and the Pro CNIC Foundation, and is a Severo Ochoa Center of Excellence (grant CEX2020-001041-S funded by MICIN/AEI/10.13039/ 501100011033). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.S

Lessons Learned From 10 Years of Preschool Intervention for Health Promotion: JACC State-of-the-Art Review.

Implementing a health promotion program for children is a complex endeavor. In this review, we outline the key lessons learned over 10 years of experience in implementing the SI! Program (Salud Integral-Comprehensive Health) for cardiovascular health promotion in preschool settings in 3 countries: Colombia (Bogotá), Spain (Madrid), and the United States (Harlem, New York). By matching rigorous efficacy studies with implementation science, we can help bridge the divide between science and educational practice. Achieving sustained lifestyle changes in preschool children through health promotion programs is likely to require the integration of several factors: 1) multidisciplinary teams; 2) multidimensional educational programs; 3) multilevel interventions; 4) local program coordination and community engagement; and 5) scientific evaluation through randomized controlled trials. Implementation of effective health promotion interventions early in life may induce long-lasting healthy behaviors that could help to curb the cardiovascular disease epidemic.This work is supported by the SHE Foundation and “la Caixa” Foundation (LCF/CE16/10700001). The project in Colombia was funded by Santo Domingo Foundation; the study in the United States (FAMILIA) was funded by the American Heart Association (grant no. 14SFRN20490315); and the study in Spain (SI! Program) was funded by the SHE Foundation, the research grant FIS-PI11/ 01885 (Fondo de Investigación Sanitaria del Instituto de Salud Carlos III), and Fundació la Marató de TV3 (369/C/2016). Dr SantosBeneit is the recipient of grant LCF/PR/MS19/12220001 funded by “la Caixa” Foundation (ID 100010434). Dr Fernández-Jiménez is the recipient of grant PI19/01704 funded by the Fondo de Investigación Sanitaria–Instituto de Salud Carlos III and co-funded by the European Regional Development Fund/European Social Fund “A way to make Europe”/“Investing in your future.” The Centro Nacional de Investigaciones Cardiovasculares is supported by the Instituto de Salud Carlos III, the Ministerio de Ciencia e Innovación, and the Pro CNIC Foundation, and is a Severo Ochoa Center of Excellence (CEX2020-001041-S). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.S

Different Lifestyle Interventions in Adults From Underserved Communities: The FAMILIA Trial

BACKGROUND: The current trends of unhealthy lifestyle behaviors in underserved communities are disturbing. Thus, effective health promotion strategies constitute an unmet need. OBJECTIVES: The purpose of this study was to assess the impact of 2 different lifestyle interventions on parents/caregivers of children attending preschools in a socioeconomically disadvantaged community. METHODS: The FAMILIA (Family-Based Approach in a Minority Community Integrating Systems-Biology for Promotion of Health) study is a cluster-randomized trial involving 15 Head Start preschools in Harlem, New York. Schools, and their children's parents/caregivers, were randomized to receive either an "individual-focused" or "peer-to-peer-based" lifestyle intervention program for 12 months or control. The primary outcome was the change from baseline to 12 months in a composite health score related to blood pressure, exercise, weight, alimentation, and tobacco (Fuster-BEWAT Score [FBS]), ranging from 0 to 15 (ideal health = 15). To assess the sustainability of the intervention, this study evaluated the change of FBS at 24 months. Main pre-specified secondary outcomes included changes in FBS subcomponents and the effect of the knowledge of presence of atherosclerosis as assessed by bilateral carotid/femoral vascular ultrasound. Mixed-effects models were used to test for intervention effects. RESULTS: A total of 635 parents/caregivers were enrolled: mean age 38 ± 11 years, 83% women, 57% Hispanic/Latino, 31% African American, and a baseline FBS of 9.3 ± 2.4 points. The mean within-group change in FBS from baseline to 12 months was ∼0.20 points in all groups, with no overall between-group differences. However, high-adherence participants to the intervention exhibited a greater change in FBS than their low-adherence counterparts: 0.30 points (95% confidence interval: 0.03 to 0.57; p = 0.027) versus 0.00 points (95% confidence interval: -0.43 to 0.43; p = 1.0), respectively. Furthermore, the knowledge by the participant of the presence of atherosclerosis significantly boosted the intervention effects. Similar results were sustained at 24 months. CONCLUSIONS: Although overall significant differences were not observed between intervention and control groups, the FAMILIA trial highlights that high adherence rates to lifestyle interventions may improve health outcomes. It also suggests a potential contributory role of the presentation of atherosclerosis pictures, providing helpful information to improve future lifestyle interventions in adults.AGENCIA FINANCIADORA: The American Heart Association, under grant No 14SFRN20490315, funded this study. R.F-J is a recipient of funding from the European Union Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 707642. The CNIC is supported by the Instituto de Salud Carlos III (ISCIII), the Ministerio de Ciencia, Innovación y Universidades (MCNU) and the Pro CNIC Foundation, and is a Severo Ochoa Center of Excellence (SEV-2015-0505).S

Children Present a Window of Opportunity for Promoting Health: JACC Review Topic of the Week

Cardiovascular disease is the leading cause of death and disability in the world, largely because of risk factors modifiable by changes in behavior. There is evolving evidence that our behavior as adults has its roots in the environment that we live in from early childhood. Early sustained multicomponent educational programs focused on health promotion in children may represent a window of opportunity to potentially prevent disease in adulthood. The integration of school-based, family-based, and community-based strategies, along with the support of public policies, are likely necessary for the success of these programs. In this review, the authors describe the future of promoting health. Specifically: 1) reasons why children should be a focus for health promotion (alarming trends of risk factors, association between unhealthy factors and subclinical disease, and cost-effectiveness); 2) strategies for health promotion in children (school-based, family-based, and community-based approaches) along with legislative efforts; and 3) research gaps are discussed.The FAMILIA (Family-Based Approach in a Minority Community Integrating Systems-Biology for Promotion of Health) study is funded by the American Heart Association under grant No 14SFRN20490315. The CNIC is supported by the Ministerio de Ciencia, Innovación y Universidades, and the Pro CNIC Foundation, and is a Severo Ochoa Center of Excellence (SEV-2015-0505). Dr. Fernandez-Jimenez has received funding from the European Union Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 707642S

Reproducibility of Three-Dimensional Vascular Ultrasound for the Detection and Quantification of Early Atherosclerosis: A FAMILIA Substudy

American Heart Association Scientific Sessions 2018. Chicago, USA. November 10-12, 2018.Introduction: Three-dimensional vascular ultrasound (3DVUS) offers promise for cardiovascular risk stratification in the general population. However, 3DVUS reproducibility in early stages of atherosclerosis disease has not been well stablished. Objective: To determine 3DVUS agreement and reproducibility for plaque detection and focal atherosclerosis disease burden quantification in bilateral carotid and ileofemoral territories in adults enrolled in the “Family-Based Approach in a Minority Community Integrating Systems-Biology for Promotion of Health” (FAMILIA) study. Methods: A total of 772 vascular territories were studied by 3DVUS at baseline in a random sample of 193 adults, including parents/caregivers and staff, recruited in the FAMILIA study from 15 Head Start preschools in Harlem (New York). The acquired images were analyzed off-line using the Vascular Plaque Quantification tool in QLAB, by two independent experienced technicians. Prevalence-adjusted and bias-adjusted kappa (PABAK) coefficients were calculated to assess the intraobserver and interobserver agreement for plaque detection. For intraobserver and interobserver reproducibility analyses of focal atherosclerosis disease burden (plaque volume quantification), the intraclass correlation coefficient (ICC) and Bland-Altman plots were employed in all plaque-positive participants recruited in the FAMILIA trial (n = 46 adult participants). Results: Mean age of studied FAMILIA adult participants was 37.8±11.4 years, 85% female, 64% Hispanic/Latino, 26% Non-Hispanic Black. The overall prevalence of atherosclerosis was 8.3 %. Intraobserver and interobserver agreement was excellent for the detection of plaque (PABAK ranging from 0.97 to 1) and good for focal disease burden quantification (average ICC >0.85 in all cases). No significant intraobserver or interobserver bias was detected in Bland-Altman plots. Conclusion: 3DVUS shows excellent intraobserver and interobserver agreement and good reproducibility for the detection and quantification of focal disease in early stages of atherosclerosis. Thus, 3DVUS could be used as a tool for subclinical atherosclerosis screening and for promoting healthy habits in the general population

Ethnic Disparities in Metabolic Syndrome Among Caregivers of Preschool Children in a Community-Based Trial

American Heart Association Scientific Congress 2017. Anaheim, USA. November 11-15, 2017.Introduction: Obesity and dyslipidemia are increasingly prevalent, disproportionately affecting low-income families. We studied the presence of metabolic syndrome (MetS) by ethnicity among caregivers of preschool children in Harlem, New York. Methods: We analyzed 553 Hispanic and non-Hispanic black caregivers of children in Head Start preschools at their baseline assessment enrolling in a community-based lifestyle intervention. MetS was defined by at least 3 of the following: waist circumference >102/88 cm for men/women respectively, systolic/diastolic blood pressure ≥130/85 mm Hg, serum glucose > 100 mg/dL, triglycerides >150 mg/dL, or HDL < 40/50 mg/dL for men/women. Univariate logistic regression was used to determine significant predictors of MetS, and a multivariable logistic regression model was constructed to predict MetS among participants. Results: The mean age of participants was 37.5±11.3 years old. 34.4% Hispanic and 24.6% non-Hispanic black participants had MetS (p=0.015). This difference in the odds of MetS was primarily driven by a higher incidence of elevated triglycerides, elevated glucose, and low HDL in Hispanic participants, whereas hypertension was more common among black participants. Non-metabolic predictors of MetS in this population included age (OR 1.89 for every 10-year increase in age, p<0.0001, 95% CI: 1.58-2.26), education level (some college or more as compared to high school or less, OR 0.65, p=0.036, 95% CI 0.43-0.97), and Hispanic ethnicity as compared to non-Hispanic black (OR 1.64, p=0.021, 95% CI: 1.08-2.49). These predictors remained statistically significant after additionally adjusting for gender, household income, and tobacco use. Conclusions: Hispanic caregivers had significantly higher odds of MetS as compared to non-Hispanic black caregivers. The overall prevalence of MetS is high, demonstrating an alarming trend among low-income adults enrolled in an urban community-based trial.N

Child Health Promotion in Underserved Communities: Primary Results From the Cluster Randomized FAMILIA Trial

American Heart Association Scientific Sessions 2018. Chicago, USA. November 10-12, 2018.Introduction: Preschool-based interventions offer promise to instill healthy behaviors in children. However, its efficacy in underserved communities is not well established. Objective: To assess the impact of a preschool-based health promotion education intervention in an underserved community. Methods: We performed the cluster-randomized controlled “Family-Based Approach in a Minority Community Integrating Systems-Biology for Promotion of Health” (FAMILIA) trial involving 15 Head Start preschools in Harlem, New York. Schools and their children were 3:2 randomized to either receive the usual curriculum (control); or a 4-month educational intervention for a total of 50 hours to instill healthy behaviors in relation to diet, physical activity, understanding how the human body and heart work, and emotion management. The primary outcome was the change from baseline in the overall knowledge, attitudes, and habits (KAH) score of the child. As secondary outcomes, we evaluated the changes in KAH subcomponents and in the test of emotion comprehension. Linear mixed-effects models were used to test for intervention effects. Results: We enrolled 562 children 3 to 5 years old, 51% female, 54% Hispanic/Latino and 37% African-American. The mean % relative change from baseline in the overall KAH score was 5.5% and 11.8% in control and intervention groups, respectively. The average between-group absolute difference in overall KAH was 2.89 points (95% CI: 0.61 to 5.17; p = 0.013; Figure). Physical activity and understanding of the human body and heart components, and knowledge and attitudes domains, were the main drivers of the effect. Changes in emotion comprehension trended to favor intervened children as compared to controls. Conclusions: The FAMILIA trial demonstrates that a multidimensional school-based education intervention is an effective strategy for instilling healthy behaviors among preschoolers from a diverse and socially/economically disadvantaged community. As part of our long-term vision, we are conducting a long-term follow-up of the children to assess the sustainability of the intervention effects

Racial Disparities in Early Subclinical Atherosclerosis: Insights from the FAMILIA Study

American Heart Association Scientific Sessions 2018. Chicago, USA. November 10-12, 2018.Introduction: African-Americans are at a greater risk of cardiovascular (CV) events. Differential race vulnerability to early subclinical atherosclerosis disease is likely, and yet few studies have addressed this relationship. Objective: To study the impact of race on the presence of early subclinical atherosclerosis in adults enrolled in the “Family-Based Approach in a Minority Community Integrating Systems-Biology for Promotion of Health” (FAMILIA) study. Methods: A total of 431 adults, including parents/caregivers and staff, recruited in the FAMILIA study from 15 Head Start preschools in Harlem (New York) and with no previous history of CV disease, underwent bilateral carotid and femoral three-dimensional vascular ultrasound. The 10-year Framingham CV risk was calculated, and the relationship between race and the presence of subclinical atherosclerosis was analysed by using multivariate logistic regression models and receiver operating characteristic (ROC) curves. Results: Mean age of participants was 38.1±11.1 years, 83% female, 66% Hispanic/Latino, 34% non-Hispanic Black. Mean 10-year Framingham CV risk was 3.8% with no significant differences by race. The overall prevalence of subclinical atherosclerosis was 8.6%, and was significantly higher in non-Hispanic Blacks (12.2%) than in Hispanic/Latino participants (6.7%) [Figure 1A]. Adjusted by 10-year Framingham CV risk, non-Hispanic Blacks were more likely to have subclinical atherosclerosis than Hispanic/Latino (odds ratio = 2.18; 95% CI, 0.97 to 4.91; p = 0.06). The model including 10-year Framingham CV risk and race showed good discriminatory capacity for the prediction of subclinical CV disease with an area under the ROC curve of 0.89 (95% CI, 0.85 to 0.91) [Figure 1B]. Conclusion: For the same predicted CV risk, non-Hispanic Blacks seem more vulnerable to early subclinical atherosclerosis as compare to Hispanic/Latino, placing them at enhanced risk for clinical CV disease. These results may be important for the implementation of prevention programs in different populations

Social determinants of lifestyle and cardiovascular health in a minority community study for promotion of health

American College of Cardiology 67th Annual Scientific Session 2018. Orlando, USA. March 10-12, 2018