The Instituto de Salud Carlos III-Fondo de Investigacion Sanitaria (PI19/01704) and the European Regional Development Fund/European Social Fund ("A way to make Europe"/"Investing in your future"), the Fundació la Marató de TV3 (369/C/2016), the ‘la Caixa’ Foundation (LCF/PR/CE16/10700001 and LCF/PR/MS19/12220001), the Ministerio de Ciencia e Innovación (AGL2016–75329-R), the Generalitat de Catalunya, and the SHE Foundation. The CNIC is supported by the Instituto de Salud Carlos III (ISCIII), the Ministerio de Ciencia e Innovación, and the Pro CNIC Foundation and is a Severo Ochoa Center of Excellence (SEV-2015-0505).S

Bodega, Patricia

Carvajal, Isabel

de Cos-Gandoy, Amaya

de Miguel, Mercedes

Domènech, Mónica

Estruch, Ramón

Fernandez-Jimenez, Rodrigo

Fernández-Alvira, Juan Miguel

Fuster, Valentin

Ibañez, Borja

Lamuela-Raventós, Rosa Maria

Laveriano-Santos, Emily P

Rodríguez, Carla

Santos-Beneit, Gloria

Storniolo, Carolina

Tresserra-Rimbau, Anna

European Journal of Preventive Cardiology

English

Ibáñez, Borja

REPISALUD

.............................................................................Prevalence and correlates of cardiovascularhealth among early adolescents enrolled in theSI! Program in Spain: a cross-sectional analysisRodrigo Fernandez-Jimenez 1,2,3*, Gloria Santos-Beneit1,4,Amaya de Cos-Gandoy1,4, Juan Miguel Fernández-Alvira1,Anna Tresserra-Rimbau5,6, Carolina Storniolo5,6, Mónica Domènech5,7,Emily P. Laveriano-Santos6, Patricia Bodega1,4, Mercedes de Miguel1,4,Carla Rodrı́guez4, Isabel Carvajal4, Borja Iba~nez1,3,8, Ramón Estruch5,7,Rosa Maria Lamuela-Raventós5,6, and Valentin Fuster 1,9†1Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; 2Hospital Universitario Clinico San Carlos, Madrid, Spain; 3Centro de Investigación Biomédica EnRed en enfermedades CardioVasculares (CIBERCV), Madrid, Spain; 4Foundation for Science, Health and Education (SHE), Barcelona, Spain; 5Centro de Investigación Biomédicaen Red Fisiopatologı́a de la Obesidad y la Nutrición (CIBEROBN), Institute of Health Carlos III, Madrid, Spain; 6Department of Nutrition, Food Science and Gastronomy, Schoolof Pharmacy and Food Sciences, XaRTA, INSA, University of Barcelona, Barcelona, Spain; 7Department of Internal Medicine, Hospital Clı́nic, Institut d’Investigacions BiomèdiquesAugust Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain; 8Department of Cardiology, IIS-Fundación Jiménez Dı́az Hospital, Madrid, Spain; and 9Division ofCardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USAReceived 18 June 2020; revised 14 September 2020; editorial decision 22 September 2020; accepted 2 October 2020The American Heart Association (AHA) recommends the assess-ment of cardiovascular health (CVH) through the assessment ofhealth behaviours [smoking status, body mass index (BMI), physicalactivity, and diet] in addition to traditional cardiovascular risk factors(blood pressure, total cholesterol, and glucose measurements).1Numerous studies have demonstrated an inverse association be-tween the number of ideal CVH factors and the incidence of adverseoutcomes in adults.2 Recent studies have emphasized the importanceof having a good CVH profile early in life.3 Adolescence is a criticalperiod for the initiation of unhealthy habits. With the aim of instillingsustained healthy behaviours in adolescents, we recently launchedthe SI! Program for Secondary School trial (NCT03504059), whichenrolled 24 secondary public schools in Madrid and Barcelona,Spain.4 We conducted a cross-sectional analysis at enrolment of ado-lescents’ CVH and their correlates with different socioeconomiccharacteristics. Details about the recruitment of schools and adoles-cents can be found elsewhere.4Adolescents’ CVH metrics were assessed using medical devicesand questionnaires guided by a team of nutritionists and nurses aspreviously described.4 Parents/caregivers completed an online surveywith questions related to sociodemographic parameters. We usedthe AHA measures of ideal CVH in children and adolescents.1For each of the seven CVH metrics, a value of 1 was assigned whenthe criterion was met (ideal metric) and a value of 0 when it was notmet. Scores thus ranged from 0 to 7, with a higher score indicating abetter CVH profile. A poor CVH score was defined as <_3 ideal met-rics, an intermediate score as 4 or 5 ideal health metrics, and an idealscore as 6 or 7 ideal health metrics. All adolescents with valid data forat least 5 of the 7 individual metrics were included in the analysis. Forparticipants with one (n = 9, 0.7%) or two (n = 45, 3.4%) missing met-rics, the missing metrics were assigned a score calculated as the aver-age of the remaining metrics for the individual concerned. Twoparticipants had more than two individual metrics missing, and wereexcluded from the analysis. For subgroup analyses of socioeconomiccorrelates, missing values on variables used to create subgroupswere not imputed; instead, the pairwise deletion was performed.Crude prevalence of categorized overall CVH (poor, intermediate,ideal), together with their 95% confidence intervals (CI), were calcu-lated using the Wilson approximation. Prevalence ratio (PR) pointestimates (and their 95% CIs) of categorized overall CVH were calcu-lated with generalized models using a Poisson distribution with a loglink and robust error variance. Mixed-effects linear regression modelswere used to assess adjusted between-group differences for theoverall CVH as a continuous variable (range 0–7). Stratified modelswere built according to sociodemographic variables of interest. In alladjusted models, fixed effects were age and sex, whereas region(Madrid or Barcelona) and schools within each region were handledas random effects. Crude models included only random effects.This analysis included 1324 adolescents (641 girls, 683 boys) outof 1326 enrolled in the trial, with a mean age of 12.0 (SD 0.5) years.* Corresponding authors. Tel: (þ34) 91 453 12 00, Fax: (þ34) 91 453 12 65; Email: rfernandez@cnic.es (R.F.-J.);† Tel: (þ34) 91 453 12 00, Fax: (þ34) 91 453 12 65; Email: vfuster@cnic.es (V.F.)Published on behalf of the European Society of Cardiology. All rights reserved. VC The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.European Journal of Preventive Cardiology RESEARCH LETTERdoi:10.1093/eurjpc/zwaa096Downloaded from https://academic.oup.com/eurjpc/advance-article/doi/10.1093/eurjpc/zwaa096/5957241 by guest on 09 November 2020................................................................................The mean overall CVH score (range 0–7) was 4.3 points (95% CI4.3–4.4). The lowest scoring individual component was dietary habits,with just 0.6% (95% CI 0.3–1.2) of adolescents meeting ideal recom-mendations (Figure 1A). Smoking habits scored the highest, with92.3% (95% CI 90.7–93.6) of adolescents reporting never havingsmoked. The overall prevalence of overweight and obesity was17.6% (95% CI 15.7–19.8) and 10.0% (95% CI 8.5–11.7), respectively.According to the number of ideal CVH components, most adoles-cents were classified as having an intermediate (n = 889, 67.2%) orpoor (n = 289, 21.8%) overall CVH. Only 1 adolescent (0.1%) hadseven ideal CVH components.Overall CVH scores were better among female adolescentsthan males [4.5 points (95% CI 4.4–4.5 vs. 4.2 points (95% CI4.1–4.3)]. Similarly, adolescents from high-income families scoredbetter than those from low-income families [4.5 points (95% CI4.4–4.6) vs. 4.2 points (95% CI 4.1–4.3)], as did those whoseparents had a higher educational level vs. those with the lowesteducational level [4.5 points (95% CI 4.4–4.5) vs. 4.2 points (95%CI 4.1–4.4)] and those from a non-migrant background vs. thosefrom a migrant background [4.4 points (95% CI 4.3–4.4) vs. 4.2points (95% CI 4.1–4.3)]. Similar adjusted trends were observedfor the analysis of overall CVH score as a continuous variable(range 0–7 points, Figure 1B) or as a categorical variable (poor,intermediate, and ideal, Table 1).Comprehensive data on contemporary CVH in early adolescentsin Europe are scarce.5 Our study represents one of the largestsamples of contemporaneous early adolescents examined forCVH and sociodemographic correlates to date in Spain. Becauseprior studies included children of a variety of ages,6 our results aredifficult to contextualize. Nevertheless, in agreement with priordata, dietary habits scored the lowest among all health metricsexamined. On the other hand, non-smoking scored the highest;however, the proportion of young adolescents (8%) whoreported already having tried smoking is not negligible. Althoughwe found better CVH profiles in girls than in boys, the evidence forgender differences in CVH scores is conflicting. In line with previ-ous data,7 we found that parental education and household incomeshowed a direct association with overall CVH. Furthermore, ado-lescents from a migrant background had a lower overall CVH andmight represent a particularly vulnerable population. Early promo-tion of CVH is considered a global priority.8 The SI! Programfor Secondary School is part of a multidimensional educationalintervention with the overarching goal of promoting lifelong CVHby instilling healthy behaviours from early childhood in a variety ofsocioeconomic settings.9,10Some limitations warrant consideration. Because of the cross-sectional nature of the analysis, our study demonstrates associationsbut not causation. The schools and participant adolescents wererecruited with a non-probabilistic sampling method; therefore,the population analysed might not be representative of the overalladolescent population in Spain. Nevertheless, the mean overallparticipation rate of individuals from enrolled schools was53% andFigure 1 (A) Prevalence of poor, intermediate, and ideal individual cardiovascular health components. Stacked bars represent the percentageof adolescents enrolled in the SI! Program with poor (red), intermediate (orange), or ideal (green) individual cardiovascular health componentsdefined according to American Heart Association criteria. Adolescents who reported never having smoked a whole cigarette were categorizedas having an ideal smoking status; all other individuals were classified as having a poor smoking status. Age- and sex-adjusted BMI percentiles werecalculated according to Centers for Disease Control standards, with ideal, intermediate, and poor BMI defined as <85th percentile, 85–95th percent-ile, and >95th percentile, respectively. Ideal physical activity was defined as >_60 min/day moderate-to-vigorous activity, intermediate activity as anyactivity <60 min/day, and poor physical activity as no physical activity. Adolescents who met all four healthy diet criteria (consumption of fruits andvegetables >_4.5 servings/day, fish >_2 servings/week, fibre-rich whole grains >_ 1 servings/day, and sugar-sweetened beverages <_1 L/week) were classi-fied as having an ideal diet, whereas those meeting 2–3 or only 0–1 of the criteria were classified as having an intermediate or poor diet, respectively.Blood pressure (BP) percentiles and stages were calculated according to blood pressure reference data from the American Academy of Pediatricswith ideal, intermediate, and poor BP defined as <90th percentile, 90–95th percentile, and >95th percentile, respectively. Ideal total cholesterol (TC)was TC <170 mg/dL, intermediate TC 170–199 mg/dL, and poor TC >_200 mg/dL. Ideal fasting blood glucose was <100 mg/dL, intermediate glucose100–125 mg/dL, and poor glucose >_126 mg/dL. (B) Differences in overall cardiovascular health across sociodemographic variables of interest.Forest plots represent crude (red) and adjusted (blue) mean differences and 95% confidence intervals in overall cardiovascular health as a continuousvariable (range 0–7 points). The X-axis is in linear scale.2 R. Fernandez-Jimenez et al.Downloaded from https://academic.oup.com/eurjpc/advance-article/doi/10.1093/eurjpc/zwaa096/5957241 by guest on 09 November 2020............................................................................did not significantly differed by region. Finally, the prevalence of idealglucose levels may have been underestimated because some adoles-cents were likely assessed in non-fasting conditions, thus reducing theoverall CVH score.In conclusion, most early adolescents enrolled in the SI! Programfor Secondary School trial in Spain had a poor or intermediate CVH,with just 11% of them demonstrating ideal CVH (6 or 7 ideal CVHcomponents). The lowest scoring individual component was dietaryhabits, with only 0.6% of adolescents meeting ideal recommenda-tions. Self-reported family low-income status, low parental education,and migrant condition were associated with worse adolescent CVH.Health promotion interventions should be implemented at youngages, with a particular focus on dietary habits and low socioeconomicsettings.FundingThe Instituto de Salud Carlos III-Fondo de Investigacion Sanitaria (PI19/01704) and the European Regional Development Fund/European SocialFund ("A way to make Europe"/"Investing in your future"), the Fundació laMarató de TV3 (369/C/2016), the ‘la Caixa’ Foundation (LCF/PR/CE16/10700001 and LCF/PR/MS19/12220001), the Ministerio de Ciencia eInnovación (AGL2016–75329-R), the Generalitat de Catalunya, and theSHE Foundation. The CNIC is supported by the Instituto de Salud CarlosIII (ISCIII), the Ministerio de Ciencia e Innovación, and the Pro CNICFoundation and is a Severo Ochoa Center of Excellence (SEV-2015-0505).Conflict of interest: The authors declare no relationship with industryor other relevant entities that might pose a conflict of interest in connec-tion with this article.AcknowledgementsThe authors thank the SHE Foundation (intellectual owner of the SI!Program) and its partners. We also thank Vanesa Carral, Xavi Òrrit,and Domingo Haro for their contribution to the study design andthe coordination, development, and implementation of the educa-tional program and all personnel who performed measurements inadolescents at participating schools. A.T.-R. was supported by theMinisterio de Ciencia e Innovación through a Juan de la Cierva-forma-ción contract. We especially thank all adolescents and their families,teachers, and schools participating in the study. Simon Bartlett(CNIC) provided English editing.References1. Steinberger J, Daniels SR, Hagberg N, Isasi CR, Kelly AS, Lloyd-Jones D, Pate RR,Pratt C, Shay CM, Towbin JA, Urbina E, Van Horn LV, Zachariah JP.Cardiovascular health promotion in children: challenges and opportunities for2020 and beyond: a scientific statement from the American Heart Association.Circulation 2016;134:e236–55.2. Fang N, Jiang M, Fan Y. Ideal cardiovascular health metrics and risk of cardiovas-cular disease or mortality: a meta-analysis. Int J Cardiol 2016;214:279–283.3. Meirhaeghe A, Montaye M, Biasch K, Huo Yung Kai S, Moitry M, Amouyel P,Ferrières J, Dallongeville J. Coronary heart disease incidence still decreased be-tween 2006 and 2014 in France, except in young age groups: results from theFrench MONICA registries. Eur J Prev Cardiol 2020;27:1178–1186............................................................................................. ....................................................................................................................................................................................................................................................................Table 1 Prevalence of overall cardiovascular health and prevalence ratios according to different sociodemographiccharacteristicsn (%) Prevalence of overall cardiovascular health (95% CI) Prevalence ratio (95% CI)Poor 3 idealcomponentsIntermediate 4–5 idealcomponentsIdeal 6–7 idealcomponentsCrude AdjustedAll 1,324 (100) 21.8 (16.7–24.1) 67.2 (64.6–69.6) 11.0 (9.5–12.8) — —SexMale 683 (51.6) 25.5 (22.4–28.9) 65.6 (62.0–69.1) 8.9 (7.0–11.3) Ref. Ref.Female 641 (48.4) 17.9 (15.2–21.1) 68.8 (65.1–72.3) 13.3 (10.9–16.1) 1.14 (1.07–1.22) 1.13 (1.11–1.15)Household incomeLow 406 (33.1) 25.9 (21.8–30.3) 65.0 (60.3–69.5) 9.1 (6.7–12.3) Ref. Ref.Average 380 (31.0) 24.0 (19.9–28.5) 65.5 (60.6–70.1) 10.5 (7.8–14.0) 1.04 (0.95–1.14) 1.03 (1.03–1.04)High 440 (35.9) 14.3 (11.4–17.9) 71.4 (67.0–75.4) 14.3 (11.4–17.9) 1.20 (1.10–1.30) 1.17 (1.14–1.20)Parental educationLess than secondary school 215 (17.1) 26.1 (20.6–32.3) 65.1 (58.5–71.2) 8.8 (5.7–13.4) Ref. Ref.Secondary or professionalschool528 (41.9) 22.9 (19.5–26.7) 68.4 (64.3–72.2) 8.7 (6.6–11.4) 1.04 (0.93–1.15) 1.03 (0.98–1.09)University degrees 518 (41.1) 17.8 (14.7–21.3) 67.8 (63.6–71.6) 14.5 (11.7–17.8) 1.17 (1.05–1.30) 1.14 (1.10–1.17)Parents born in SpainYes 849 (68.0) 19.6 (17.0–22.4) 68.3 (65.1–71.4) 12.1 (10.1–14.5) Ref. Ref.No 399 (32.0) 24.3 (20.4–28.8) 66.7 (61.9–71.1) 9.0 (6.6–12.2) 0.92 (0.85–0.99) 0.92 (0.80–1.07)Prevalence ratios of having overall healthier categorized cardiovascular health were calculated from generalized models using a Poisson distribution with a log link and robusterror variance. Stratified models were built according to the different sociodemographic variables of interest. Adjusted models included age and sex as fixed effects and region(Madrid or Barcelona) and schools within each region as random effects. Crude models included only random effects. Parental educational level was categorized according tothe International Standard Classification of Education (ISCED): Low (families with no studies or only primary studies; 0–1 ISCED score), medium (secondary studies and profes-sional training; 2–4 ISCED score), and high (university studies; 5–6 ISCED score). This analysis considered the parent/caregiver with the highest education level. Socioeconomicstatus (SES) was defined according to the most recently published Spanish average annual household income at the time of baseline data collection (2016, e26 730). Householdincome was classified into three categories: low (below the average), average (around the average), and high (above the average). A migrant background was assumed if at leastone of parent/caregiver was born outside Spain.Ideal cardiovascular health among Spanish adolescents 3Downloaded from https://academic.oup.com/eurjpc/advance-article/doi/10.1093/eurjpc/zwaa096/5957241 by guest on 09 November 2020................................4. Fernandez-Jimenez R, Santos-Beneit G, Tresserra-Rimbau A, Bodega P, de MiguelM, de Cos-Gandoy A, Rodrı́guez C, Carral V, Orrit X, Haro D, Carvajal I, Iba~nezB, Storniolo C, Domènech M, Estruch R, Fernández-Alvira JM, Lamuela-RaventósRM, Fuster V. Rationale and design of the school-based SI! Program to face obes-ity and promote health among Spanish adolescents: a cluster-randomized con-trolled trial. Am Heart J 2019;215:27–40.5. Kalra R, Parcha V, Patel N, et al. Increased awareness, inadequate treatment, andpoor control of cardiovascular risk factors in American young adults: 2005-2016.Eur J Prev Cardiol 2020.6. Henriksson P, Henriksson H, Gracia-Marco L, Labayen I, Ortega FB, HuybrechtsI, Espa~na-Romero V, Manios Y, Widhalm K, Dallongeville J, González-Gross M,Marcos A, Moreno LA, Castillo MJ, Ruiz JR. Prevalence of ideal cardiovascularhealth in European adolescents: The HELENA study. Int J Cardiol 2017;240:428–432.7. Garrido-Miguel M, Cavero-Redondo I, Álvarez-Bueno C, Rodrı́guez-Artalejo F,Moreno LA, Ruiz JR, Ahrens W, Martı́nez-Vizcaı́no V. Prevalence and trends ofoverweight and obesity in European children from 1999 to 2016: a systematicreview and meta-analysis. JAMA Pediatr 2019;173:e192430.8. Fernandez-Jimenez R, Al-Kazaz M, Jaslow R, Carvajal I, Fuster V. Children presenta window of opportunity for promoting health: JACC review topic of the week.J Am Coll Cardiol 2018;72:3310–3319.9. Fernandez-Jimenez R, Jaslow R, Bansilal S, Santana M, Diaz-Munoz R, Latina J,Soto AV, Vedanthan R, Al-Kazaz M, Giannarelli C, Kovacic JC, Bagiella E,Kasarskis A, Fayad ZA, Hajjar RJ, Fuster V. Child health promotion in under-served communities: the FAMILIA trial. J Am Coll Cardiol 2019;73:2011–2021.10. Fernandez-Jimenez R, Briceno G, Cespedes J, et al. Sustainability of and adher-ence to preschool health promotion among children 9 to 13 years old. J Am CollCardiol 2020;75:1565–1578.4 R. Fernandez-Jimenez et al.Downloaded from https://academic.oup.com/eurjpc/advance-article/doi/10.1093/eurjpc/zwaa096/5957241 by guest on 09 November 2020

Prevalence and correlates of cardiovascular health among early adolescents enrolled in the SI! Program in Spain: a cross-sectional analysis.

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Prevalence and correlates of cardiovascular health among early adolescents enrolled in the SI! Program in Spain: a cross-sectional analysis.

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