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Circulation. 2004;110:2266-2275
doi: 10.1161/01.CIR.0000141117.85384.64
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(Circulation. 2004;110:2266-2275.)
© 2004 American Heart Association, Inc.

AHA Scientific Statement

Cardiovascular Health Promotion in the Schools

A Statement for Health and Education Professionals and Child Health Advocates From the Committee on Atherosclerosis, Hypertension, and Obesity in Youth (AHOY) of the Council on Cardiovascular Disease in the Young, American Heart Association

Laura L. Hayman, PhD, RN, Cochair; Christine L. Williams, MD, MPH, Cochair; Stephen R. Daniels, MD, PhD; Julia Steinberger, MD, MS; Steve Paridon, MD; Barbara A. Dennison, MD; Brian W. McCrindle, MD, MPH


Key Words: AHA Scientific Statements • pediatrics • prevention • public health • schools


*    Introduction
up arrowTop
 *Introduction
down arrowBackground and Rationale
 down arrowRecommendations
 down arrowDisclosure
 down arrowSuggested Reading
 down arrowReferences
 
Cardiovascular disease (CVD) is a major cause of morbidity and premature mortality in men and women in the United States, most of the industrialized world, and many developing countries.1 Primary prevention of CVD beginning in early childhood is supported by extensive evidence culled from epidemiological, clinical, and laboratory studies.2–16 Taken together, these data provided the impetus for the American Heart Association (AHA) Guidelines for Primary Prevention of Atherosclerotic Cardiovascular Disease Beginning in Childhood17 and support the need for population-based approaches to cardiovascular health promotion and risk reduction. Specifically, the population-based approach, which is aimed at modifying the food and physical activity environments of children, is an important concomitant to the high-risk approach because without the proper environment, the high-risk strategy cannot be optimally implemented. School health programs initiated in preschool and extending through high school have the potential to influence the cardiovascular health of the majority of US children and youth. Toward this goal, this statement is intended for health and education professionals, child health advocates, policymakers, and community leaders who are interested in optimizing the school environment as an integral part of population-based strategies designed to promote cardiovascular health for all US children and youth and reduce the risk and public health burden of CVD.


*    Background and Rationale
up arrowTop
 up arrowIntroduction
 *Background and Rationale
down arrowRecommendations
 down arrowDisclosure
 down arrowSuggested Reading
 down arrowReferences
 
Several lines of evidence underscore the importance of primary prevention of CVD beginning in childhood and the need for population-based approaches to cardiovascular health promotion and risk reduction. Autopsy studies (after the unexpected deaths of children and youth)2–5 document significant positive associations between established risk factors and the presence and extent of atherosclerotic lesions in the aorta and coronary arteries of children and youth. Specifically, data from the Bogalusa Heart Study3,4 and the Pathobiological Determinants of Atherosclerosis in Youth (PDAY)2,5 study link potentially modifiable risk factors, including atherogenic lipids and lipoproteins, systolic and diastolic blood pressures, obesity (body mass index [BMI]), and cigarette smoking, to the development and progression of atherosclerotic processes. Recent data from the Bogalusa Heart Study7 and Finland8 reaffirm the link between risk-factor exposures in childhood and adolescence and preclinical atherosclerosis in adulthood. In addition, longitudinal studies demonstrate the tracking (ie, maintenance of percentile rank over time) of risk factors and CVD-related health behaviors from childhood to young adulthood.10,11,18 Finally, the results of several randomized controlled trials conducted in clinical, home, and school settings demonstrate the feasibility, safety, and efficacy of modifying risk factors in children and youth.19–24

Epidemiological studies, including the Third National Nutrition Examination Survey (NHANES III), provide nationally representative data on the prevalence and trends of risk factors, including CVD-related health behaviors.12–16 Useful in informing and guiding public health strategies, these data support the need for more effective population-based approaches to cardiovascular health in children and youth. A particularly disturbing trend, observed in NHANES and other national surveys, is the dramatic increase in the prevalence of overweight and obesity in children and youth.13 Recent data (1999–2000) from NHANES indicate that 15.5% of 6- to 19-year-olds and 10.4% of 2- to 5-year-olds are overweight (BMI ≥95th age-specific percentile).14 The prevalence of overweight among non-Hispanic black (23.6%) and Mexican-American (23.4%) adolescents increased >10 percentage points between NHANES III (1988–1994) and the most recent survey (1999–2000).14 This trend is of particular concern because obesity clusters with other major CVD risk factors, including hypertension, dyslipidemia, and type 2 diabetes mellitus.15,25,26 The results of several recent clinical studies documented increases in the prevalence of obesity-induced diabetes mellitus in children and adolescents, particularly among minority youth.25,26 National surveys indicate that patterns of dietary intake and physical activity for the majority of children and youth are not meeting current recommendations. Dietary fat intake has decreased over the past 2 decades from 36.3% to 34% of total food energy intake (EI); however, saturated fat intake (12% to 13% of EI) exceeds current recommendations.27 Paralleling the NHANES prevalence and trend data for overweight, minority youth (black and Mexican American) have significantly higher saturated fat intakes than their white counterparts.12,27 National data on intake of 3-year-olds (surveyed in the 1995 Continuing Survey of Food Intakes by Individuals [CSFII]28) also suggest that preschool children are exceeding the recommendations for saturated fat intake. Recently, the US Department of Agriculture (USDA) compared the macronutrient and micronutrient contents of menus for young children who participated in the Child and Adult Care Food Program (CACFP) with nutrient standards.29 The Dietary Guidelines for Americans recommendations were used as the standard for percentage of energy from total fat and saturated fat.30 An analysis of CACFP menus from these preschool day care programs indicated that the total fat and saturated fat content of the children’s lunches exceeded the levels recommended in these guidelines.29 In addition, 2001 data from the national Youth Risk Behavior Surveillance (YRBS) indicated that almost 80% of schoolchildren do not consume the recommended 5 or more servings of fruits and vegetables per day.31

Physical activity data from the YRBS indicated that the proportion of students who attend physical education (PE) classes daily decreased from 41.6% in 1991 to 29.1% in 1999.31 Of the students who reported attending PE classes, only about one third reported that they actually exercise 20 minutes or more during PE class. In addition, daily attendance in PE classes and participation in recreational/leisure-time physical activity decreased substantially from grades 9 through 12. This pattern of change was more pronounced among girls. For example, in the 2001 YRBS survey the rate of participation by girls in sufficient vigorous physical activity was 67% in grade 9 and 45% in grade 12.31 Similarly, data from the longitudinal National Heart, Lung, and Blood Institute (NHLBI) Growth and Health Study indicated precipitous declines in leisure-time physical activity throughout adolescence among both black and white girls.32 By age 18 or 19, 56% of black girls and 31% of white girls reported no habitual recreational activity. Noteworthy predictors of declines in physical activity included lower levels of parental education, higher BMI, pregnancy (black girls only), and cigarette smoking (white girls only).32

Prevalence and trend data for cigarette smoking among US children and youth also provide cause for concern.12,31 In 2001, 28.5% of high school students were current cigarette smokers, compared with 27.5% in 1991.31 Data from NHANES III and the Centers for Disease Control and Prevention indicated racial/ethnic differences in the rates of smoking among high school students, particularly among girls; white girls smoke at higher rates than their black or Hispanic counterparts.12,31

Collectively, available evidence, including CVD risk factor prevalence and trend data, emphasizes the need for both individual/high-risk and population-based approaches to the primary prevention of CVD beginning in childhood. By definition, public health or population-based approaches are designed to shift the entire distribution of risk factors within the population to more desirable levels. The AHA’s Guide for Improving Cardiovascular Health at the Community Level33 outlines a comprehensive list of goals, strategies, and recommendations that exemplify the population-based approach. As such, they are intended for and are applicable on a community-wide basis, and they identify relevant community-based structures (including schools) as central and essential components of population-based strategies. The rationale for school-based heart health education and related preventive interventions is compelling. One third of the Year 2010 health objectives for the nation can be significantly influenced by school health programs, a fact that highlights the key role of schools in achieving national health objectives.34 Through schools, virtually all of our nation’s youth can be reached, and through youth, both parents and teachers may be reached as well. Schools provide many opportunities for shaping dietary and physical activity behaviors, which influence CVD risk factors such as blood lipids, blood pressure, and adiposity. School policies and health education initiatives also influence the adoption of cigarette smoking in youth, another major risk factor for CVD. School-based programs are unique in that they have the ability to provide and sustain stable and effective educational initiatives within existing institutional structures.

School-Based Cardiovascular Health Promotion/Risk Reduction Research
Since the late 1970s, numerous school-based health promotion interventions have been developed and tested: Some exclusively addressed heart health, and others addressed risk factors for CVD through a more comprehensive approach. Many of the earlier first-generation studies were primarily didactic and focused on positively influencing health knowledge, attitudes, and self-reported behavior. By the mid-1980s, school-based research focused on theoretically derived behavioral interventions and incorporated the assessment and measurement of physiological risk factors for CVD as primary end points/outcomes.35 The results of these second-generation trials (reviewed, critiqued, and synthesized by Resnicow and Robinson35) demonstrated the potential of school-based interventions for improving the CVD risk status of children and youth and informed the third generation of research that extended beyond the classroom, with interventions focused on the broader school environment, including food service, physical activity programs and facilities, and school policies that affect health-related behaviors. Extension into after-school and community programs and linkages with community agencies also were emphasized.

The Child and Adolescent Trial for Cardiovascular Health (CATCH) exemplifies the third generation of school-based research.21,36–39 Specifically, CATCH was the largest randomized controlled field trial designed to evaluate the effects of theoretically derived multicomponent (individual-, school-, and family-based) interventions on risk factors for CVD in elementary school children. Included in this multisite trial were 96 schools (56 intervention, 40 control) from 4 geographic areas (California, Louisiana, Minnesota, and Texas). The sample at baseline included third-grade students from ethnically diverse backgrounds. The CATCH intervention consisted of school-based (classroom curricula, food service, PE) and family-based (home curricula) components. Primary end points/outcomes at the school level were changes in the fat content of food service lunch offerings and the amount of moderate-to-vigorous physical activity (MVPA) in PE. At the individual-student level, serum cholesterol change was the primary end point; psychosocial factors, recall measures of eating and physical activity behaviors, and other physiological measures were secondary end points.21,36–38 Three-year outcomes indicated that CATCH interventions were able to modify the fat content of school lunches, increase MVPA, and improve eating and physical activity behaviors.21 Specifically, the total fat content of school lunch menus decreased significantly more in intervention schools (from 38.7% to 31.9%) than in control schools (from 38.9% to 36.2%). Similarly, the CATCH intervention decreased the saturated fat content of school lunch menus from 14.8% to 12.0%; that for control schools decreased from 15.1% to 13.7%. Concomitantly, the CATCH PE intervention resulted in a significant increase in the percentage of MVPA during PE class—from 37% to 52%—with students in the intervention schools also demonstrating greater energy expenditure than did their control school counterparts. No significant between-group (intervention–control school) differences in serum cholesterol or other physiological measures were observed.21 A follow-up of 73% (n=3714) of the CATCH cohort was conducted to assess differences maintained through the eighth grade in diet, physical activity, and related health indicators, including physiological measures of CVD risk.39 Intervention students maintained a higher self-reported daily MVPA than did controls; however, between-group differences declined over time (from 13.6 minutes in the fifth grade to 8.8 minutes in the eighth grade). The between-group differential in self-reported daily EI from fat was maintained. Consistent with 3-year outcomes,21 no significant between-group differences were observed in any of the physiological indicators of CVD risk, including serum cholesterol, blood pressure, and BMI.39

Collectively, the CATCH results and the data generated from other recent research support the potential role of schools (as defined in the AHA’s Guide for Improving Cardiovascular Health at the Community Level33) as key structures for population-based behavioral change interventions. Illustrating the importance of multicomponent interventions, including environmental and individual-level strategies, CATCH has been used as a model for guiding and informing other programs, including the Healthy Start project (discussed below) for preschoolers. Results from CATCH and other third-generation school-based studies suggest that effective behavioral change strategies with children and youth must extend beyond the individual level and target environments in which health behaviors develop and are influenced. The effectiveness of CATCH in altering eating and physical activity behaviors has been attributed in part to involving school environmental changes as intervention elements. Behavioral differences narrowed in magnitude but persisted for 3 years after intervention, pointing to the need for follow-up that reinforces interventions at both the school and individual levels.39 Recent results from CATCH-ON,40–42 which was designed to assess the sustainability of CATCH, reaffirm this need as they emphasize the school-level infrastructures and the school and environmental policies necessary to maintain CVD-related health behaviors, including the recommended levels of physical activity in PE classes and the macronutrient content of school lunch programs.40–42

Preschool Cardiovascular Health Promotion/Risk Reduction Research
Paralleling the third generation of school-based cardiovascular health–promotion/risk-reduction research was the emergence of preschool-based research and heart health education initiatives. Contemporary preschool heart health programs are based on the premise that for children to be able to take care of themselves, they need to know what to do to keep themselves healthy (knowledge), need to believe that healthy living is really important to them (good attitudes), and need the opportunity to practice good health behavior, not just talk about it (actions and behavior). The ultimate goal is to enable young children to make healthy lifestyle choices and develop good health behaviors in the first place, rather than learn bad habits that need to be undone later.43 Toward that goal and building on lessons learned from CATCH and other third-generation school-based studies, research and demonstration projects (completed and in progress) that target preschool populations illustrate the importance of efforts focused on the individual child and relevant preschool and social and environmental factors.44–49

Healthy Start, an example of a preschool-based demonstration and education research project, was initiated in the mid-1990s with funding from NHLBI-NIH (National Institutes of Health) and was modeled in part on CATCH.44–47 The project was designed to evaluate the impact of a multicomponent preschool cardiovascular health intervention, including the modification of meals and snacks served by the school food service, in a largely minority Head Start preschool population. Specific aims were reducing the total and saturated fat content of preschool meals and snacks, increasing nutrition knowledge, and reducing total serum cholesterol. Nine Head Start centers in upstate New York were assigned to either food service modification or control conditions. Half of the centers assigned to the food service modification also received supplemental nutrition education, whereas the remaining food service modification and the control centers were provided with supplemental safety education materials. Teacher-training workshops led by health education and nutrition specialists preceded all program activities. Children in each of the preschool centers were evaluated twice each year for 3 years, with semiannual measures taken of health knowledge and attitudes, dietary intake, growth patterns, body fatness, and blood cholesterol. Evaluation of the Healthy Start program showed that meals and snacks in the intervention preschools became more heart healthy. Specifically, the saturated fat content of preschool menus decreased from 12.5% to 8.0% EI in intervention schools, whereas the saturated fat content in the control schools decreased from 12.1% to 11.6%.44,45 Although several strategies were used to achieve this goal, reducing the fat content of milk and other dairy products, as suggested in the AHA’s recommendations, was commonly employed. In addition, children in the intervention preschools, as compared with controls, experienced greater improvement in nutrition and overall health knowledge scores.46 Noteworthy recent results indicate a significant decrease in total serum cholesterol among the Healthy Start children who participated in the food service intervention groups (–6.0 mg/dL) as compared with controls (–0.4 mg/dL).47 In addition, children with elevated cholesterol levels at baseline were significantly more likely to have cholesterol levels in the normal range (<170 mg/dL) at follow-up if they were assigned to a food service modification/intervention preschool.47

Taken together and combined with results from other early childhood health promotion initiatives,43,48,49 the above findings suggest that multicomponent preschool programs can be effective in promoting the adoption of heart-healthy behaviors and reducing risk factors for CVD. Similar to school-based programs and central to successful outcomes are theoretically derived developmentally appropriate interventions that address knowledge and behavioral skill training, provide participatory opportunities for children, and target dimensions of the preschool environment that extend beyond the classroom.

Summary and Future Directions
The collective results of school-based research support the recommendations outlined in the AHA’s Guide for Improving Cardiovascular Health at the Community Level33 that emphasized schools as important components of population-based cardiovascular health promotion and risk-reduction efforts. Specifically, the majority of school-based studies, including those summarized in the Table21,22,50–61 and reviewed by Resnicow and Robinson35 and Meininger,62 reported statistically significant effects on health knowledge, attitudes, and behavioral outcomes. Although on average the diet and physical activity changes reported in some studies may appear to be modest in magnitude, from a population perspective they translate into potentially sizable reductions in population-attributable CVD risk and must be interpreted within the context of population-wide strategies. Similarly, the results of school-based intervention research to date have showed a modest change in physiological indicators including serum cholesterol, blood pressure, and measures of adiposity. Critical reviews of CATCH and other school-based research that included physiological indicators as primary outcomes offer insight and provide direction for future school-based initiatives.63 Specifically, the characteristics of the intervention (eg, dose, duration, and methods of delivery), effects of pubertal maturation (eg, interindividual differences in physiological changes during puberty that bias the effects of intervention), and methodological limitations inherent in school-based designs (eg, differential selection, attrition) are important areas for consideration. To ensure the fidelity of the intervention, the quality and quantity of implementation, training, and support for providers are as essential as is ongoing process evaluation.64–66 Across well-controlled and well-conducted studies, differential results in physiological outcome indicators point to the need for researchers to pay more attention to developmental age, gender, culture, and sociodemographic factors. Taken together, these results indicate that the modification of risk factors for CVD in "real-world" school settings must be reinforced and complemented at multiple levels of intervention. Toward that goal, from a population perspective, broader public health interventions as suggested in the AHA’s Guide for Improving Cardiovascular Health at the Community Level are warranted.33 Partnerships between healthcare and educational professionals in collaboration with policymakers and community leaders will be required to actualize the school environment in promoting the cardiovascular health of all of our children and youth and reducing the risk and public health burden of CVD.


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  		Overview of School-Based Research


*    Recommendations
up arrowTop
 up arrowIntroduction
 up arrowBackground and Rationale
 *Recommendations
down arrowDisclosure
 down arrowSuggested Reading
 down arrowReferences
 
The AHA’s Council on Cardiovascular Disease in the Young (CVDY) supports the need for both high-risk and population-based approaches to cardiovascular health promotion and risk reduction beginning in early childhood. Consistent with the AHA’s Guide for Improving Cardiovascular Health at the Community Level, CVDY endorses the role of schools and school health programs as central and essential components of population-based strategies. To this end, goals and recommendations that are designed to optimize the school environment (including preschools and after-school programs) in promoting cardiovascular health for children and youth are listed below. Information that is relevant to these recommendations is included in the Guidelines and School Health Objectives portion of the Suggested Reading section.

Heart Health Education and Health Behaviors
Goals

Recommendations

School Policies
Goals

Recommendations

School and Community Linkages
Goal

Recommendation


*    Disclosure
up arrowTop
 up arrowIntroduction
 up arrowBackground and Rationale
 up arrowRecommendations
 *Disclosure
down arrowSuggested Reading
 down arrowReferences
 
Dr Laura L. Hayman reported no financial relationships to disclose. Dr Christine L. Williams reported no financial relationships to disclose. Dr Stephen R. Daniels reported no financial relationships to disclose. Dr Julia Steinberger reported serving as a consultant for American Phytotherapy Research Laboratory, Inc. Dr Steve Paridon reported no financial relationships to disclose. Dr Barbara A. Dennison reported no financial relationships to disclose. Dr Brian W. McCrindle reported no financial relationships to disclose. This represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit.


*    Suggested Reading
up arrowTop
 up arrowIntroduction
 up arrowBackground and Rationale
 up arrowRecommendations
 up arrowDisclosure
 *Suggested Reading
down arrowReferences
 
Guidelines and School Health Objectives

American Academy of Pediatrics Committee on School Health. Soft drinks in schools. Pediatrics. 2004;113:152–154.
Berenson GS, Harsha DW, Hunter SMcD, Johnson CC, Levy M, Little SD, Nicklas TA, Srinivasan SR, Virgilio SJ, Webber LS. Introduction of Comprehensive Health Promotion for Elementary Schools: The Health Ahead/Heart Smart Program. New York, NY: Vantage Press Inc; 1998.
Briggs M, Safaii S, Beall DL; American Dietetic Association; Society for Nutrition Education; American School Food Service Association. Position of the American Dietetic Association, Society for Nutrition Education, and American School Food Service Association—Nutrition services: an essential component of comprehensive school health programs. J Am Diet Assoc. 2003;103:505–514.
Burke LE, Fair J. Promoting prevention: skill sets and attributes of health care providers who deliver behavioral interventions. J Cardiovasc Nurs. 2003;18:256–266.
Chyun DA, Amend AM, Newlin K, Langerman S, Melkus GD. Coronary heart disease prevention and lifestyle interventions: cultural influences. J Cardiovasc Nurs. 2003;18:302–318.
Food and Nutrition Board. Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients). Washington, DC: The National Academies Press; 2002.
Guidelines for school and community programs to promote lifelong physical activity among young people. Centers for Disease Control and Prevention. MMWR Recomm Rep. 1997;46:1–36.
Guidelines for school health programs to promote lifelong healthy eating. Centers for Disease Control and Prevention. MMWR Recomm Rep. 1996;45:1–41.
Harrell JS, Pearce PF, Hayman LL. Fostering prevention in the pediatric population. J Cardiovasc Nurs. 2003;18:144–149.
Hayman LL, Reineke PR. Preventing coronary heart disease: the implementation of healthy lifestyle strategies for children and adolescents. J Cardiovasc Nurs. 2003;18:294–301.
Hazinski MF, Markenson D, Neish S, Gerardi M, Hootman J, Nichol G, Taras H, Hickey R, OConnor R, Potts J, et al. Response to cardiac arrest and selected life-threatening medical emergencies: the medical emergency response plan for schools: a statement for healthcare providers, policymakers, school administrators, and community leaders. Circulation. 2004;109:278–291.
Kavey RE, Daniels SR, Lauer RM, Atkins DL, Hayman LL, Taubert K, American Heart Association. American Heart Association guidelines for primary prevention of atherosclerotic cardiovascular disease beginning in childhood [published simultaneously in J Pediatr. 2003;142:368–372]. Circulation. 2003;107:1562–1566.
Krauss RM, Eckel RH, Howard B, Appel LJ, Daniels SR, Deckelbaum RJ, Erdman JW Jr, Kris-Etherton P, Goldberg IJ, Kotchen TA, et al. AHA Dietary Guidelines: revision 2000: a statement for healthcare professionals from the Nutrition Committee of the American Heart Association. Circulation. 2000;102:2284–2299.
Krebs NF, Jacobson MS; American Academy of Pediatrics Committee on Nutrition. Prevention of pediatric overweight and obesity. Pediatrics. 2003;112: 424–430.
Patrick K, Spear B, Holt K, Sofka D, eds. Bright Futures in Practice: Physical Activity. Arlington, Va: National Center for Education in Maternal and Child Health; 2001.
Physical fitness and activity in schools. American Academy of Pediatrics. Pediatrics. 2000;1156–1157.
Pyramid Communications. Healthy Schools for Healthy Kids. Princeton, NJ: Robert Wood Johnson Foundation; 2004.
US Department of Agriculture. The Food Guide Pyramid for Young Children 2 to 6 Years Old. Center for Nutrition Policy and Promotion. 2003. Available at: http://www.usda.gov/cnpp/KidsPyra/PyrBook.pdf. Accessed July 16, 2004.
Williams CL, Hayman LL, Daniels SR, Robinson TN, Steinberger J, Paridon S, Bazzarre T. Cardiovascular health in childhood: a statement for health professionals from the Committee on Atherosclerosis, Hypertension, and Obesity in the Young (AHOY) of the Council on Cardiovascular Disease in the Young, American Heart Association. Circulation. 2002;106:143–160.

School Health Education and Research

Arbeit ML, Johnson CC, Mott DS, Harsha DW, Nicklas TA, Webber LS, Berenson GS. The Heart Smart cardiovascular school health promotion: behavior correlates of risk factor change. Prev Med. 1992;21:18–32. Berenson GS, Arbeit ML, Hunter SM, Johnson CC, Nicklas TA. Cardiovascular health promotion for elementary school children. The Heart Smart Program. Ann N Y Acad Sci. 1991;623:299–313. Berenson GS. Prevention of heart disease beginning in childhood through comprehensive school health: the Heart Smart Program. Prev Med. 1993;22:507–512.
Berger S, Whitstone BN, Frisbee SJ, Miner JT, Dhala A, Pirrallo RG, Utech LM, Sachdeva RC. Cost-effectiveness of Project ADAM: a project to prevent sudden cardiac death in high school students. Pediatr Cardiol. January 28, 2004. DOI: 10.1007/s00246-003-0668-z. Available at: http://www.springerlink.com.
Bush PJ, Zuckerman AE, Taggart VS, Theiss PK, Peleg EO, Smith SA. Cardiovascular risk factor prevention in black school children: the "Know Your Body" evaluation project. Health Educ Q. 1989;16:215–227.
Bush PJ, Zuckerman AE, Theiss PK, Taggart VS, Horowitz C, Sheridan MJ, Walter HJ. Cardiovascular risk factor prevention in black schoolchildren: two-year results of the "Know Your Body" program. Am J Epidemiol. 1989;129:466–482.
Chomitz VR, Collins J, Kim J, Kramer E, McGowan R. Promoting healthy weight among elementary school children via a health report card approach. Arch Pediatr Adolesc Med. 2003;157:765–772.
Donnelly JE, Jacobsen DJ, Whately JE, Hill JO, Swift LL, Cherrington A, Polk B, Tran ZV, Reed G. Nutrition and physical activity program to attenuate obesity and promote physical and metabolic fitness in elementary school children. Obes Res. 1996;4:229–243.
Doshi A, Patrick K, Sallis JF, Calfas K. Evaluation of physical activity web sites for use of behavior change theories. Ann Behav Med. 2003;25:105–111.
Elder JP, Perry CL, Stone EJ, Johnson CC, Yang M, Edmundson EW, Smyth MH, Galati T, Feldman H, Cribb P, et al. Tobacco use measurement, prediction, and intervention in elementary schools in four states: the CATCH Study. Prev Med. 1996;25:486–494.
Ellison RC, Capper AL, Goldberg RJ, Witschi JC, Stare FJ. The environmental component: changing school food service to promote cardiovascular health. Health Educ Q. 1989;16:285–297.
Ellison RC, Capper AL, Stephenson WP, Goldberg RJ, Hosmer DW Jr, Humphrey KF, Ockene JK, Gamble WJ, Witschi JC, Stare FJ. Effects on blood pressure of a decrease in sodium use in institutional food preparation: the Exeter-Andover Project. J Clin Epidemiol. 1989;42:201–208.
Gortmaker SL, Peterson K, Wiecha J, Sobol AM, Dixit S, Fox MK, Laird N. Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health. Arch Pediatr Adolesc Med. 1999;153:409–418.
Harrell JS, Gansky SA, McMurray RG, Bangdiwala SI, Frauman AC, Bradley CB. School-based interventions improve heart health in children with multiple cardiovascular disease risk factors. Pediatrics. 1998;102:371–380.
Harrell JS, McMurray RG, Bangdiwala SI, Frauman AC, Gansky SA, Bradley CB. Effects of a school-based intervention to reduce cardiovascular disease risk factors in elementary-school children: the Cardiovascular Health in Children (CHIC) study. J Pediatr. 1996;128:797–805.
Johnson CC, Osganian SK, Budman SB, Lytle LA, Barrera EP, Bonura SR, Wu MC, Nader PR. CATCH: Family process evaluation in a multicenter trial. Health Educ Q. 1994;(suppl 2):S91–S106.
Killen JD, Telch MJ, Robinson TN, Maccoby N, Taylor CB, Farquhar JW. Cardiovascular disease risk reduction for tenth graders: a multiple-factor school-based approach. JAMA. 1988;260:1728–1733.
Killen JD, Robinson TN, Telch MJ, Saylor KE, Maron DJ, Rich T, Bryson S. The Stanford Adolescent Heart Health Program. Health Educ Q. 1989;16:263–283.
McMurray RG, Harrell JS, Bangdiwala SI, Bradley CB, Deng S, Levine A. A school-based intervention can reduce body fat and blood pressure in young adolescents. J Adolesc Health. 2002;31:125–132.
Nader PR, Sellers DE, Johnson CC, Perry CL, Stone EJ, Cook KC, Bebchuk J, Luepker RV. The effect of adult participation in a school-based family intervention to improve children’s diet and physical activity: the Child and Adolescent Trial for Cardiovascular Health. Prev Med. 1996;25:455–464.
Nicklas TA, Dwyer J, Mitchell P, Zive M, Montgomery D, Lytle L, Cutler J, Evans M, Cunningham A, Bachman K, et al. Impact of fat reduction on micronutrient density of children’s diets: the CATCH Study. Prev Med. 1996;25:478–485.
Parcel GS, Simons-Morton B, O’Hara NM, Baranowski T, Wilson B. School promotion of healthful diet and physical activity: impact on learning outcomes and self-reported behavior. Health Educ Q. 1989;16:181–199.
Pate RR, Freedson PS, Sallis JF, Taylor WC, Sirard J, Trost SG, Dowda M. Compliance with physical activity guidelines: prevalence in a population of children and youth. Ann Epidemiol. 2002;12:303–308.
Sallis JF, McKenzie TL, Alcaraz JE, Kolody B, Faucette N, Hovell MF. The effects of a 2-year physical education program (SPARK) on physical activity and fitness in elementary school students. Sports, Play and Active Recreation for Kids. Am J Public Health. 1997;87:1328–1334.
Sallis JF, McKenzie TL, Conway TL, Elder JP, Prochaska JJ, Brown M, Zive MM, Marshall SJ, Alcaraz JE. Environmental interventions for eating and physical activity: a randomized controlled trial in middle schools. Am J Prev Med. 2003;24:209–217.
Sallis JF, Owen N. Physical Activity and Behavioral Medicine. Thousand Oaks, Calif: Sage Publications; 1998.
Sallis JF, Owen N. Ecological models of health behavior. In: Glanz K, Lewis FM, Rimer BK, eds. Health Behavior and Health Education: Theory, Research and Practice. 3rd ed. San Francisco, Calif: Jossey-Bass; 2002:462–484.
School health resources. Available at: http://www.americanheart.org. American Heart Association, Dallas, Tex. Accessed spring 2004.
Simons-Morton BG, Parcel GS, Baranowski T, Forthofer R, O’Hara NM. Promoting physical activity and a healthful diet among children: results of a school-based intervention study. Am J Public Health. 1991;81:986–991.
Stone EJ, McKenzie TL, Welk GJ, Booth ML. Effects of physical activity interventions in youth: review and synthesis. Am J Prev Med. 1998;15:298–315.
Stone EJ, Osganian SK, McKinlay SM, Wu MC, Webber LS, Luepker RV, Perry CL, Parcel GS, Elder JP. Operational design and quality control in the CATCH Multicenter Trial. Prev Med. 1996;25:384–399.
Stone EJ, Perry CL, Luepker RV. Synthesis of cardiovascular behavioral research for youth health promotion. Health Educ Q. 1989;16:155–169.
Walter HJ, Hofman A, Vaughan RD, Wynder EL. Modification of risk factors for coronary heart disease: five-year results of a school-based intervention trial. N Engl J Med. 1988;318:1093–1100.
Webber LS, Osganian SK, Feldman HA, Wu M, McKenzie TL, Nichaman M, Lytle LA, Edmundson E, Cutler J, Nader PR, et al. Cardiovascular risk factors among children after a 2 1/2-year intervention: the CATCH Study. Prev Med. 1996;25:432–441.

Preschool Heart Health Education and Research

Bollella MC, Spark A, Boccia LA, Nicklas TA, Pittman BP, Williams CL. Nutrient intake of Head Start children: home vs. school. J Am Coll Nutr. 1999;18:108–114.
Dowda M, Pate RR, Trost SG, Almeida MJ, Sirard JR. Influences of preschool policies and practices on children’s physical activity. J Community Health. 2004;29:183–196.
Kohl HW III, Hobbs KE. Development of physical activity behaviors among children and adolescents. Pediatrics. 1998;101:549–554.
Nix ST, D’Agostino Ibanez C, Strobino BA, Williams CL. Developing a computer-assisted health knowledge quiz for preschool children. J Sch Health. 1999;69:9–11.
Spark A, Pfau J, Nicklas T, Williams CL. Reducing fat intake in preschool meals: description of the food service intervention component of Healthy Start. J Nutr Educ. 1998;30:170–177.
Stolley MR, Fitzgibbon ML, Dyer A, Van Horn L, KauferChristoffel K, Schiffer L. Hip-Hop to Health Jr., an obesity prevention program for minority preschool children: baseline characteristics of participants. Prev Med. 2003;36:320–329.
Williams CL, Spark A, Strobino BA, Bollella MC, D’Agostino CA, Brotanek J, Campanaro L, Pfau J, Squillace MM. Cardiovascular risk reduction in a preschool population: the Healthy Start Project. Prev Cardiol. 1998;2:45–55.
Williams CL, Strobino BA, Ibanez C, Liebmann-Smith J. What do preschool children think about cigarettes and smoking? Knowledge, attitudes and future smoking intentions: the Healthy Start Project. CVD Prevention. 2000;2:235–241.


*    Footnotes
 
The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on July 19, 2004. A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0299. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 410-528-4121, fax 410-528-4264, or e-mail kgray@lww.com. To make photocopies for personal or educational use, call the Copyright Clearance Center, 978-750-8400.


*    References
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 *References
 

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