Prevalence of ideal cardiovascular health in European adolescents: The HELENA study

doi:10.1016/j.ijcard.2017.03.022

International Journal of Cardiology

Volume 240, 1 August 2017, Pages 428-432

https://doi.org/10.1016/j.ijcard.2017.03.022 Get rights and content

Abstract

Background

The ideal cardiovascular health (iCVH) construct consists of 4 health behaviours and 3 health factors and is strongly related to later cardiovascular disease. However, the prevalence of iCVH in European adolescents is currently unknown.

Methods

The Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) study is a cross-sectional, multicentre study conducted in 9 European countries during 2006–2007 and included 3528 adolescents (1683 boys and 1845 girls) between 12.5 and 17.5 years of age. Status (ideal vs. non-ideal) for the health behaviours (smoking status, body mass index, physical activity and diet) and health factors (total cholesterol, blood pressure and fasting glucose) were determined.

Results

Overall, the prevalence of ideal health behaviours was low; non-smoking (60.9% ideal), body mass index (76.8%), physical activity (62.1%), and diet (1.7%). The prevalence of ideal health factors was; total cholesterol (65.8%), blood pressure (62.0%) and plasma glucose (88.8%).

Conclusions

The low prevalence of iCVH behaviours, especially diet and physical activity, identified in European adolescents is likely to influence later cardiovascular health which strongly motivates efforts to increase ideal health behaviours in this population.

Introduction

Cardiovascular disease is a leading cause of death worldwide [1], [2]. In 2010, the American Heart Association (AHA) presented a new construct, ideal cardiovascular health (iCVH), which incorporated health behaviours and traditional cardiovascular risk factors to assess cardiovascular health [3]. iCVH was defined as the simultaneous presence of 7 ideal components, consisting of 4 health behaviours (non-smoking status and ideal body mass index (BMI), physical activity and diet) and 3 health factors (ideal total cholesterol, blood pressure and fasting glucose). Cut-offs to define ideal status were provided for children and adults [3].

Numerous studies have used the iCVH construct and reported that a higher number of iCVH components are related to better health [4]. For instance, iCVH components in adulthood have been related to lower morbidity and mortality from cardiovascular diseases [5], [6] as well as all-cause mortality [5], [6]. The importance of having an iCVH early in life has been pointed out previously [4], [7], [8], [9]. In adolescents, a higher number of iCVH components were associated with higher levels of cardiorespiratory fitness [9], an important marker of health [10], [11], and with aortic elasticity [8]. Laitinen et al. [7] found a strong association between adolescent and adult iCVH and also reported that each number of additional iCVH component in adolescence was associated with a 34% lower risk of hypertension and metabolic syndrome 21 years later. Taken together, these findings indicate that iCVH, already in adolescence, is of great importance not only for present but also for future health.

Although previous studies have provided important knowledge regarding cardiovascular risk factors in various adolescent populations [12], [13], [14], there is a great lack of data of the prevalence of iCVH in contemporary European adolescents. This data could contribute to the development of effective prevention programs, counselling, and public health policies.

Therefore, data obtained within the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) study provide an excellent opportunity to study the iCVH of European adolescents. The HELENA study was designed to provide reliable data on nutrition and health-related variables in a relatively large sample of European adolescents from 9 different countries and includes the components of the iCVH construct [9]. Thus, in this study we examined the prevalence of iCVH and its components in European adolescents.

Section snippets

Study participants

Detailed information regarding sampling procedures and study methods in the HELENA study has been published previously [15], [16], [17]. Since randomized sampling of the entire European adolescent population was not feasible, the HELENA study investigated 10 European cities in countries all across Europe. As described previously [16], countries were chosen according to their socioeconomic status, cultural reference and geographical locations of Europe (north, south, central, east, west). Hence,

Results

Fig. 1 shows the prevalence of the individual iCVH components for all adolescents, and detailed estimates and results stratified by sex and age are presented in Table 1. Most adolescents had ideal plasma glucose (88.8%) whereas only 1.7% had ideal status for the diet component. As shown in Table 2, few adolescents also had ideal status for the individual ideal dietary indicators. More than half of the adolescents had ideal status for non-smoking (60.9%), BMI (76.8%), physical activity (62.1%),

Discussion

This study reports the iCVH of contemporary European adolescents from the HELENA study. Overall, the prevalence of iCVH behaviours was low. For instance, 62.1% of participants had ideal physical activity levels and only 1.7% had an ideal diet.

Funding

The HELENA project was supported by the European Community Sixth RTD Framework Programme (contract FOOD-CT-2005-007034). The data for this study was gathered under the aegis of the HELENA project, and further analysis was additionally supported by the Spanish Ministry of Economy and Competitiveness (grants RYC-2010-05957 and RYC-2011-09011), the Spanish Ministry of Health: Maternal, Child Health and Development Network (grant RD16/0022), the Fondo Europeo de Desarrollo Regional (MICINN-FEDER)

Conflict of interest

The authors report no relationships that could be construed as a conflict of interest.

Acknowledgements

We thank the adolescents who participated in the study and their parents and teachers for their collaboration. We also acknowledge the members involved in fieldwork for their efforts.

HELENA study group members are attached as supplementary material. Author responsibilities were as follows: PH and JRR conceived and designed the current study; LGM, FBO, IL, IH, VER, YM, KW, JD, MGG, LAM, MJC, and JRR designed the research and acquired the data. PH, HH and JRR drafted the manuscript which was

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In addition, poor CVH in adolescence is associated with diverse deleterious effects such as higher inflammatory indices [11], lower handgrip strength [12], alterations in liver enzymes with increased levels of alanine aminotransferase and gamma-glutamyl transpeptidase [13], reduced muscle function [14], and increased body adiposity [15]. Most of studies about ideal CVH among adolescents were carried out with US, European, and Asian populations [4–7,11,13–22]. Only three studies found were conducted in South America, one with Colombian adolescents [12] and two with Brazilian adolescents [9,10] assessing cardiovascular health using ideal CVH.
We assessed the Ideal Cardiovascular Health (CVH) in Brazilian adolescents according to demographics and socioeconomic characteristics.
This is a cross-sectional study with data from the Study of Cardiovascular Risks in Adolescents (ERICA), with a nationwide representative sample of 36,956 Brazilian adolescents, aged 12–17 years, enrolled in public and private schools. The CVH metrics considered were body mass index (BMI), physical activity, smoking, healthy diet score, blood pressure, fasting plasma glucose, and total cholesterol. The demographics and socioeconomic characteristics analyzed were sex, age, race/skin color, and type of school attended. The study design was considered, and the significant difference determined by the non-overlapping of 95% Confidence Interval. The mean ideal CVH score was 4.0, higher for females, adolescents aged 15–17 years, and students from private schools. The prevalence of ideal fasting plasma glucose was 96%, of non-smoking 95.6%, of ideal blood pressure 75.5%, of ideal BMI 73.2%, of ideal total cholesterol 55.4%, of ideal physical activity 45.2%, and only 0.5% had an ideal diet. The prevalence of ideal CVH metrics varied according to demographics and socioeconomic characteristics.
Females, older adolescents, and students who attended private school had a better CVH. Demographics and socioeconomic characteristics were associated with CVH metrics. The low ideal proportions found for diet and physical activity are of concern and reinforce the need for food and nutritional educational actions designed to promote healthy behaviors in adolescence to prevent the development of cardiovascular diseases.
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To describe the prevalence of fish consumption and its association with cardiovascular risk factors and healthy behavior in Brazilian adolescents.
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Prevalence of fish consumption in the 7 days prior to the interview was 28.6% (95%CI 26.9-30.3), significantly higher among male adolescents (p = 0.0049), Asian descendants (p = 0.0270), private and rural school students (p < 0.001), and who resided in the Northern region (p < 0.001). A positive association between fish consumption and healthy behavior (breakfast consumption: OR=1.16; 95%CI 1.10-1.22; meals with family members: lunch: OR = 1.07; 95%CI 1.01-1.13; dinner: OR = 1.13; 95%CI 1.04-1.23; physical activity: OR = 1.14; 95%CI 1.02-1.28) and an inverse association with hypertriglyceridemia (OR = 0.84; 95%CI 0.73–0.98) remained significant even after adjustment for possible confounding factors.
This study demonstrated that fish consumption was associated with lower cardiovascular risk and may represent a marker of a healthy lifestyle in Brazilian adolescents.
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Ideal CVH is rare in adults, and poorer CVH is associated with incident CVD events and risk indicators such as arterial stiffness.21–25 Ideal CVH is also uncommon in childhood, and the prevalence of high childhood CVH may be decreasing.26–33 CVH is highest at birth and declines by adulthood, but dramatically worsening CVH is often evident even in early childhood.
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387 healthy adolescents (mean age 17.1 ± 1.4 years) attending the “G. Donatelli” High School in Terni, Italy, were evaluated. ICH was assessed through clinical evaluation, laboratory measures and interviewer-administered questionnaires. Cf-PWV was measured by arterial tonometry (SphygmoCor). For each ICH metric, a score of 2 was assigned for ideal levels, 1 for intermediate, and 0 for poor.
All subjects showed at least one ICH metric, whereas none showed all ICH 7 metrics. The average number of ICH metrics was 4.3 ± 1.1. The highest rates were observed for fasting blood glucose (98%), whereas an ideal healthy diet was achieved only by 8% of subjects. The Cf-PWV was inversely and linearly associated with the sum of ICH metrics (p = 0.03) and the ICH score (p < 0.01). At the multivariate analysis, the association between ICH score and cf-PWV remained significant after adjustment for age, sex, heart rate, mean arterial pressure and other confounders (p = 0.04).
ICH is relatively uncommon among Italian adolescents and inversely related to cf-PWV. Our results showed a detrimental association between CV unhealthy factors and behaviors with increased aortic stiffness, which starts developing at an early stage of the lifespan.
Cardiovascular health behaviors and associations of sex, age, and education in adolescents - Results from the EVA Tyrol study
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In line with previous evaluations in adolescents in Europe, USA and China, in our cohort, the prevalence of ideal CVH behaviors was generally low with 78.3% of study participants in an ideal BMI range, 42.5% with ideal physical activity and 70.4% being non-smokers [9,21–23]. The adolescents of similar age participating in the Healthy Lifestyle in Europe by Nutrition in Adolescence cross-sectional study in 10 larger European cities showed comparable results in terms of ideal BMI levels (76.8%), yet higher levels of ideal physical activity (62.1%), and a lower prevalence of non-smokers (60.9%) and of ideal diet (1.7%) [24]. The difference to our cohort might in part be explained that 61.2% of our cohort reside in rural areas.
Ideal cardiovascular health (CVH) behaviors in adolescents are defined by body mass index (BMI), diet, physical activity and smoking, and are directly associated with better health in later life. To further improve health prevention programs we investigated the prevalence of these behaviors in a cohort of healthy adolescents and focused on the associations with sex, age, and education.
The Early Vascular Aging Tyrol study is a cross-sectional study assessing 14- to 19-year-old pupils and apprentices in Western Austria and South Tyrol. Between May 2015 and July 2018 2047 adolescents (43.6% males, mean age 16.4 years) with complete data for all 4 health behaviors were included. The prevalence of ideal body mass index (BMI) was 78.3%, of ideal physical activity 42.5%, of non-smoking 70.4% and of ideal diet 8.1%. Females showed a higher smoking prevalence and a lower physical activity, but better dietary habits than males. Older adolescents of both sexes had lower prevalence of ideal smoking and diet. Apprentices and pupils of vocational schools had a higher BMI and a less favorable diet compared to secondary academic school students. Smoking prevalence was highest in apprentices. Non-ideal BMI was independently associated with smoking.
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Rationale and design of the school-based SI! Program to face obesity and promote health among Spanish adolescents: A cluster-randomized controlled trial
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Unhealthy habits in adolescents are increasing at an alarming rate. The school offers a promising environment in which to implement effective preventive strategies to improve adolescents' lifestyle behaviors. The SI! Program is a multilevel multicomponent school-based health-promotion intervention aimed at all stages of compulsory education in Spain. We present the study design of the SI! Program for Secondary Schools, targeting adolescents aged 12 to 16 years.
The main goal of this study is to evaluate the impact of the SI! Program educational intervention on adolescent lifestyle behaviors and health parameters.
The study was designed as a cluster-randomized controlled intervention trial and enrolled 1326 adolescents from 24 public secondary schools in Spain, together with their parents/caregivers. Schools and their students were randomly assigned to the intervention group (the SI! curriculum-based educational program over 2 or 4 academic years) or to the control group (usual curriculum). The primary endpoint will be the change from baseline at 2-year and 4-year follow-up in the composite Ideal Cardiovascular Health (ICH) score, consisting of four health behaviors (body mass index, dietary habits, physical activity, and smoking) and three health factors (blood pressure, total cholesterol, and glucose). Secondary endpoints will include 2-year and 4-year changes from baseline in ICH score subcomponents, the Fuster-BEWAT health scale, adiposity markers (waist circumference and body composition), polyphenol and carotenoid intake, and emotion management.
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¹: This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

²: This author acquired the data, critically revised the manuscript for key intellectual content and approved the final manuscript.

³: HELENA study group members are attached as supplementary material.

View full text

Prevalence of ideal cardiovascular health in European adolescents: The HELENA study

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Study participants

Results

Discussion

Funding

Conflict of interest

Acknowledgements

Prog. Cardiovasc. Dis.

Int. J. Cardiol.

Lancet Diabetes Endocrinol.

Int. J. Cardiol.

J. Am. Coll. Cardiol.

Maturitas

Executive summary: heart disease and stroke statistics—2013 update: a report from the American Heart Association

Circulation

Cardiovascular disease in Europe 2014: epidemiological update

Eur. Heart J.

Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic impact goal through 2020 and beyond

Circulation

Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults

JAMA

Ideal cardiovascular health in childhood and cardiometabolic outcomes in adulthood: the Cardiovascular Risk in Young Finns Study

Circulation.

Ideal cardiovascular health in adolescence: effect of lifestyle intervention and association with vascular intima-media thickness and elasticity (the Special Turku Coronary Risk Factor Intervention Project for Children [STRIP] study)

Circulation

Cardiorespiratory fitness and ideal cardiovascular health in European adolescents

Heart

Physical fitness in childhood and adolescence: a powerful marker of health

Int. J. Obes. (Lond)

Predictive validity of health-related fitness in youth: a systematic review

Br. J. Sports Med.