The Coronary Artery Risk Detection in Appalachian Communities (CARDIAC) Project: An 18 Year Review

2.1. Comprehensive Health Screening Procedures

For schools in all consenting counties that have agreed to participate, the following assessments and procedures are used with all consented 5th grade students:

2.2. Reporting

Between 4 to 6 weeks after screening, a parent of each screened child receives a health report including screening values by mail. The report includes the health findings and health behavior change recommendations based on screening results. The CARDIAC Hotline fields phone calls from parents with questions about the health report and recommendations. Parents are also encouraged to access a dedicated social media site with educational messaging and a communications component. Results and recommendations are also shared with the primary care physician if authorized by the parent/guardian on the consent form, as well as school nurses for appropriate follow-up and recording. A personal phone call is made to each parent and parent-identified physician if the child's results show triglycerides are >500, glucose is >125, systolic blood pressure is > 175, and LDL cholesterol is > 190. In addition, the parents of participating children receive a voucher to get their fasting lipid profile measured at no cost at a commercial reference laboratory. The CARDIAC Project identifies and refers for treatment children and relatives with familial hypercholesterolemia (FH). To date, the CARDIAC Project has identified over 600 5^th grade children who have highly probable genetic dyslipidemia, which, if treated, has the greatest potential to decrease heart disease in West Virginia.

2.3. Children's Screening Results

The CARDIAC Project has screened 98,970 fifth graders, 20,003 kindergarteners, 91,516 second graders, 5,897 eighth graders, and 8,709 ninth graders. For the fifth graders who are under active consent, participation rates have ranged anywhere from 26-49% of eligible students. For those grades using the passive consent process (kindergarten and second grade) participation rates have ranged from 73-82% of eligible students. A summary of the children's screening results since the project inception is provided in Table 2. West Virginia children's BMI averages for 5th graders reveal that 18.7% are overweight (at or above 85th percentile), and 28.4% are obese (at or above 95^th percentile). Examining BMI cumulative results across grades and years, children who were overweight and obese (at or above 85^th percentile) progressively increased from kindergarten (33.9%), to 2^nd grade (37.7%) to 5^th grade (47.1 %).

2.4. Overview of Analysis of 5^th Grade Children's Results

As only 5th grade children had blood pressure and blood lipid measurement, in addition to BMI and AN screening, their results are presented in Table 2 and summarized as follows:

Nearly a quarter (23.2%) of children screened were identified as having hypertension, and 25.0% showed abnormal lipid values (LDL >130 and HDL <40). The most common lipid abnormality was low HDL values, which is highly correlated with obesity and lack of physical activity. A subset of children with AN (n=1579) had insulin resistance (IR) measured [Homeostatic Model Assessment for Insulin Resistance (HOMA-IR index)], with positive results in 60.9%. CARDIAC data revealed that obesity negatively affects all other risk factors assessed, and that those that are classified as severely obese have the highest prevalence of risk factors compatible with the metabolic syndrome [8].

2.5. Parents Screening Results

With their child's results, parents/guardians are given a voucher to take to a local certified laboratory to get their own lipid panels completed as part of the CARDIAC Project. To date, 5,416 parents (for 4,612 unique children) were screened (1.3% of fathers and 4.4% of mothers) between 1999 and 2016. Of those screened, 56.9% had abnormal lipids, defined as either a low HDL or a high total cholesterol. A closer look at the results stratified by gender revealed that most of the parents participating were females (N = 4,075 female, N = 1,341 male). Participating male parents/guardians had greater prevalence of dyslipidemia than their female counterparts; 41.2% of males versus 17.2% of participating females had low HDL (< 40); and similarly, 28.9% of females had LDL ≥ 130 and 8.1% had LDL ≥ 160, while 41.3% of males had LDL ≥ 130 and 14% had LDL ≥ 160. A CARDIAC study of parent participation in screening found that parents who chose to participate in the free screening opportunity tended to be more educated, more aware of family history CV risk factors, and less likely to smoke. Furthermore, the study did not find that parents were more likely to participate if their child's screening results found them at risk, nor did results show that a biased sample of parents who have extreme cardiovascular risk factor were the ones who chose to participate [9].

3.1. Micro-level Interventions

At the micro level of individual interventions, the screening process itself provided the initial strategy to intervene with children and their parents. Educational materials were sent to families prior to screening consent, educational sessions were provided for children in the school setting, and follow-up information with health behavior change recommendations was sent to parents with screening results. Currently, those practices have been updated, and involve parent-identified primary care physicians (PCPs) to be included in screening results and follow-up. Other modes of communication with parents have been established, including website pages, and targeted parent educational messaging through dedicated social media outlets (cardiacwv.org).

Initially, the first population-based interventions targeting individual change in children focused on using school-based strategies to reach the student population. In 2002, an online instructional module for fifth-grade students, Healthy Hearts 4 Kids, was offered to all 5^th grade teachers and their students in WV schools to be used as a supplement to the school health curriculum. A similar module was developed soon thereafter targeting middle school students, Take Charge! Be Healthy (takechargebehealthy.org). [12] In 2008, a multidisciplinary team of health professionals, healthcare providers, and researchers developed Camp NEW (Nutrition, Exercise, and Weight Management) You to target those children identified as at-risk through the CARDIAC screening (campnewyou.org). Three cohorts participated in the yearlong program (2008-2011), where children attended a two-week residential summer camp and three follow-up weekends during the year. The program included parent education sessions and group and individual counseling sessions, along with physical activity and dietary intake monitoring.

The Project's physician-led interventions include The Preventive Cardiology Clinics for Children and Adolescents (i.e. Lipid Clinics). The Lipid Clinics are offered through West Virginia University School of Medicine, Department of Pediatrics, and are available in five locations geographically distributed across the state. Housed in available hospital or clinic space in cooperation with other medical centers, they provide consultative services for children and their parents who have severe dyslipidemia. The clinic team is comprised of pediatric cardiologists and nutrition counselors. Exercise physiologists and genetic counselors are available for consultation as needed.

Of particular interest are children and their families who have been identified with a diagnosis of possible or probable familial hypercholesterolemia (FH). As an autosomal dominant disorder, it confers a twenty-fold increased probability of coronary heart disease as compared to the normal population and is inherited from one or rarely both parents. FH is one of the most common genetic diseases affecting the cardiovascular system, and affects approximately 1 in 270 individuals. It is estimated that less than 10% of those with the disease have been diagnosed. Data from the CARDIAC Project screenings identify and contact parents of children with LDL-C levels > 160 mg/dl. They are provided educational materials about FH, cascade screening options, and follow-up with physicians in the Lipid Clinics. Parents of children with LDL-C > 190mg/dL, or elevated fasting blood sugars, receive a personal phone call from CARDIAC physician staff strongly urging repeat laboratory test and evaluation. See a description of all Micro-level interventions in Table 3.

3.2. Meso-level Interventions

CARDIAC community level interventions at the Meso Level began with the development of West Virginia on the Move (WVOM), a national initiative supported first by the National Governor's Association. This initiative brought together major stakeholders to focus on physical activity as a primary risk factor in disease prevention, and to promote increased physical activity opportunities for and participation of all citizens of our state. The WVOM Schools on the Move Program became one of the first initiatives to award schools, through a competitive process, funding to provide those opportunities in the school setting. Another school-based intervention developed by the CARDIAC Project team is an online teacher resource, Active Academics (AA) (activeacadem-ics.org) [13]. AA is designed to help classroom teachers integrate more physical activity into the classroom environment, and throughout the school day. To date, AA has 4850 registered users. Two large district-wide school initiatives have been implemented to promote Comprehensive School Physical Activity. Both three-year initiatives focus on improving children's physical activity participation, and therefore, improved BMI [14, 15]. The Greenbrier CHOICES Project also included a clinical component for pediatric obesity treatment and intervention at school-based health centers and local pediatrician offices. See a description of all Meso-level interventions in Table 3.

3.3. Macro-level Interventions

Current literature supports the need for more investment in macro level interventional strategies in order to have a more profound impact on the obesogenic environment [16] The CARDIAC Project's impact on policy and practice within WV and beyond is attributed to the comprehensive focus on chronic disease prevention, the scope of the project, and its ongoing success and influence. CARDIAC Team members have contributed to a number of macro-level actions that have affected policy and systems change to potentially affect whole populations. The most impact to date has been on school-related policy change. Additionally, the implementation and evaluation of the WV Physical Activity Plan is still underway, but has the potential to be a robust public health initiative for behavior change that can potentially affect chronic disease morbidity and mortality in WV [17]. Periodic consultation with the governor's office, legislative leadership, and state agencies has led to substantive discussion and actions related to health policy. Although there are fewer macro-level interventions identified, developing and influencing policy is a complex process with multiple levels of capacity building, multidisciplinary interaction and cooperation, and investment of time. The ongoing interventions noted in this section are being implemented and evaluated, and are proving to be sustainable. See a description of all Macro-level interventions in Table 3.

4.1. Improvements in Health Outcomes

State and national organizations often look at CARDIAC project data to determine whether obesity trends are improving. In 2014, a CARDIAC publication documented decreases in LDL cholesterol [18]; however, these improvements did not extend to improvements in BMI. An updated figure is presented to show these trends including CARDIAC years 15 and 16 (Fig. 1). The article notes that these decreasing LDL (but not obesity) trends are reflected in other USA datasets as well [19].

Open in a separate window

Fig. (1)

Trends in LDL Cholesterol Decreases Over 12 Years.

4.2. Relationships Between Obesity and Cholesterol in 5^th Grade Childres

Many CARDIAC research endeavors have focussed on the relationship between obesity and associated co-morbidities. It is interesting to note that the prevalence of hypercholesterolemia doubles in the presence of obesity, from approximately 6% among normal weight children to about 12% when weight is above normal, for an odds ratio of 2.0. However, elevation in LDL-C associated with obesity is generally mild (LDL-C < 140 mg/dL). Nearly nine out of ten overweight or obese children do not have hypercholesterolemia. And notably, cholesterol risk, particularly with LDL and total cholesterol, does not continue to increase as weight status increases. This suggests that the major determinant of blood cholesterol level is genetic, with much less influence due to environmental factors. It should be noted that LDL particle size has become a part of evaluation of metabolic syndrome but metabolic syndrome is without definition in children. Particle size measurement was not common in 1998 at the start of the CARDIAC Project and has been beyond the scope of available funds for CARDIAC.

By way of contrast, co-morbidities associated with the metabolic syndrome progressively worsen as weight status increases. This includes hypertension, low HDL-C, high triglycerides, and AN. The relative validity of AN as a surrogate for insulin resistance is shown by finding an elevated HOMA > 3.0 in 60.9 % of children with this marker. Among morbidly obese children approximately one-third have clinical evidence of pre-diabetes [20] (Table 4).

4.3. Genetic Hypercholesterolemia

Between 1998 and 2015 60,404 5^th grade children had lipid profile measurement. An LDL-C > 160 mg/dL suggests a genetic etiology, such as familial hypercholesterolemia (FH). The prevalence of moderately severe hypercholesterolemia among this cohort is as follows:

An LDL level above 175 mg/dL approximates recently published data suggesting the presence of FH in 1/270 children [21]. To clarify, the cutpoint of 175 mg/dL was arbitrarily selected as the half-way point between an LDL of 160 at which one would consider the possibility of FH when there is a strong family history of premature heart disease; and an LDL of 190 mg/dL, the point at which there is significant likelihood of FH. One cannot be more definitive than this arbitrary cutpoint since genetic testing for FH is extremely limited in the U.S. When genetic testing is done a positive mutation is found variously between 60-80% of the time. Diagnosis at this time is primarily based on phenotypic criteria.

4.4. Changing Clinical and Health Policy

In 2010, CARDIAC data revealed that selective screening practices based on a family history of premature heart disease and significant dyslipidemia excludes a large percentage of students who have likely genetically high cholesterol (3). This finding has been cited as part of the debate as to whether universal pediatric lipid screening was justified [22-24]. Universal cholesterol screening is now recommended for all children between 9 and 11 years of age [25], a recommendation facilitated by CARDIAC's school-based screening method for the detection of familial hypercholesterolemia.

5.1. Engagement at the Individual/Family Level

Engagement at the individual and family level is the most significant influence that physicians have in positive health change. Screening, diagnosis, treatment, and intervention are all practices that contribute to improved health of their patients.

We wish to acknowledge the participation of many hundreds of health science students who assisted with the conduct of the CARDIAC Project since its inception in 1998. We are grateful for an outstanding group of Area Coordinators who interact most positively with school nurses to schedule and prepare for school-based screenings. Volunteer phlebotomists generously give of their time and expertise performing blood draws. And finally, coordination of the Project by Ms. Paula Nicholson, and data entry by Ms. Emily Polak have successfully guided surveillance of over 200,000 subjects. Many individuals and partners have participated in a wide variety of interventional strategies, without whom CARDIAC's focus on a healthier West Virginia would not have been possible.