Along with the increase in the frequency of obesity, we’re experiencing an increase in the incidence of prediabetes. As the incidence of diabesity rises, so does the risk for complications. While in cardiology we emphasize the cardiovascular risk associated with chronic metabolic derangements, leading to coronary and peripheral vascular disease, nephropathy and retinopathy, there is also significant disability and death from noncardiac complications.

Patients may have prediabetes that is asymptomatic for many years. If they do not receive a periodic checkup, they will live in a high-risk state with no knowledge of their risk – until a catastrophic event like a stroke or myocardial infarction introduces them to the world of cardiac disease. Yet, there is clear evidence that the majority of individuals are aware of their overweight and obese state, but do not follow a behavior pattern that would move them toward lower cardiovascular risk.

Awareness doesn’t seem to be the issue. Most adults will readily admit they are overweight or obese, and often express a desire to lose weight. But one only needs to observe a shopping mall, for example, to realize that getting the population to an ideal weight is a formidable task. In our practice, we are consumed by the need to provide care for patients with overt disease, much of which is a consequence of lifelong exposure to the metabolic disorders that accompany overweight and obesity, hyperlipidemia, diabetes and hypertension.

Once identified, as health care providers, we need to address methods for health education and risk reduction for these patients. Health care providers are usually well versed in the methods to assess cardiovascular risk and to propose methods for improving risk. Attention to blood lipids, blood pressure, proper diet, exercise and weight loss are a standard litany recited repeatedly in cardiology practice, even by those not directly involved in the patient’s care.

Yet, the obesity epidemic and its metabolic derangements go on. There are medications to reduce cardiovascular risk, by treating hypertension, prediabetes and diabetes and by treating hyperlipidemia with statins, ezetimibe and the new PCSK9 inhibitors. However, there is no medication that will replace the metabolic benefits of exercise or that will accomplish a long-term and permanent reduction in weight to ideal levels. Safe long-term medications to lower weight have been elusive. Some demonstrate short-term results, but body weight returns to pretreatment levels when the medication is stopped. Others have side effects that prevent long-term use.

Even if we correct the effects of the abnormal metabolic state with medications, and ignore exercise and weight loss as part of a long-term health strategy, it is likely that a chronic state of obesity and deconditioning would have other effects that have not yet emerged.

For many adults, achieving ideal cardiovascular health may be an elusive task. Some data suggest that the vascular changes that are precursors of cardiovascular disease are already present in most adults. Advocates of primordial prevention suggest that the best way to accomplish ideal cardiovascular health is to start with children with key lifestyle behaviors: a diet that minimizes cardiovascular risk, adherence to a program of daily exercise, and education on minimizing high-risk behaviors such as cigarette smoking, alcohol and drug abuse.

Since ideal cardiovascular health is best accomplished at an early age – when positive health behaviors can be instilled as a lifelong behavior – the efforts at prevention need to first be brought to the adult population who must be committed to educating the children on maintaining healthy behaviors as they grow older.

We must address the need for education of adults about cardiovascular health and the need for programs that can improve cardiovascular health in adults to minimize risk in the next generation. So, we return to prediabetes, which is the beginning of the progression from ideal cardiovascular health in young children to increasing weight, metabolic syndrome, continuing to increase in weight and ultimately reaching overt cardiovascular disease.

The slide in adults from prediabetes to metabolic syndrome and ultimately clinically evident cardiovascular disease is best prevented by primordial prevention in childhood. Where do we go to implement such programs for prevention? Schools are a logical place to start.

Organized health programs in grade school that include daily exercise structured by the school to encourage participation would help to achieve the exercise goals and encourage students to maintain an active lifestyle. Despite knowing the value of such programs, incorporating organized exercise programs in grade school programs is not done consistently.

We also need to consider improving health in children who live in underserved areas who are less likely to participate in programs to improve health because of a lack of resources. It’s clear the best way to improve cardiovascular health is to start with children.

Keywords: ACC Publications, Cardiology Magazine, Blood Pressure, Prediabetic State, Lipids, Risk Factors, Pediatric Obesity, Obesity, Hypertension, Risk Reduction Behavior, Myocardial Infarction, Stroke, Hyperlipidemias

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