16. Implications of The Guidelines For Public Policy, Reimbursement, Medical Education, and Research

These Guidelines for the reduction of risk of cardiovascular (CV) disease (CVD) in children and adolescents provide an important, up-to-date, evidence-based framework for implementation in primary care offices and in specialty referral programs for higher risk patients. We anticipate that clinical implementation will result in the improvement of CV health in children and adolescents, but the Expert Panel recognizes that releasing clinical guidelines will not be sufficient to optimize CV health in children. From the standpoint of population health, most CV events occur in individuals with moderate risk rather than in those with extreme risk; therefore, physician-based, high-risk targeted approaches will not be sufficient to control the CVD epidemic. Environmental factors strongly influence risk. The home environment, built environment, food industry, media, advertising, tax structure, schools, and cultural differences all influence the adoption and maintenance of behaviors related to CV health. Insufficient numbers of registered dietitians and other health care providers, such as physician assistants and nurses with training in pediatrics, inadequate resources for the comprehensive management of obesity, and inadequate reimbursement for preventive services will all hamper efforts by health care providers to implement guidelines in the clinical setting.

A public policy agenda is needed to support these clinical care recommendations. Cardiovascular health promotion and low risk of CVD should be normative in society. Public health policies should include (1) support for improved availability and affordability of fruits and vegetables, whole-grain foods, and low-fat dairy products; (2) restriction of food advertisements of unhealthy foods aimed at children; (3) support of a healthier built environment, including aspects that promote family activity and diminish sedentary time; (4) increased taxes on and increased cost of tobacco products; and (5) support of clean indoor air legislation. In schools, health behaviors should be taught routinely, and the food and physical activity environments should be consistent with recommended health behaviors. Examples include routine availability of high-quality fruits and vegetables, restricted availability of competitive energy-dense and high-salt foods, inclusion of 60 minutes of moderate-to-vigorous physical activity in every school day, and inclusion of education in the fundamentals of nutrition and food preparation in high school curricula.

Marked ethnic and socioeconomic disparities in the risk of CVD begin in childhood and progress through adolescence into adulthood. This fact places a priority on the prevention of these disparities early in life. Public policymakers should better understand and address these ethnic and socioeconomic disparities. Cultural diversity must be better understood as it relates to both CV health and risk. Culturally competent approaches that incorporate healthy behaviors from low-risk populations and limit adverse behaviors from high-risk populations must be developed and implemented. Of particular importance is improvement in educational opportunities for disadvantaged youths, since better education is strongly associated with better health behaviors. Simply translating the messages contained in these Guidelines into various languages will not be sufficient to accomplish this important task.

These Guidelines also have implications for education in medical schools, nursing schools, training programs for registered dietitians, and other relevant health education programs. To achieve a high level of adoption and adherence by families to dietary and physical activity recommendations, a higher skill level in behavioral management and access to skilled dietary counseling will be needed by providers. Without improved medical education concerning effective interventions, successful implementation of these evidence-based Guidelines is likely to be limited. Given the strong evidence that dietary change has been most effectively accomplished with counseling by registered dietitians, efforts are needed to increase the supply of these skilled professionals.

There are many areas in these Guidelines where more and different types of evidence than currently exist would help in the development of future guidelines. Evidence gaps identified in these Guidelines must be addressed, which will require support from Government funding agencies, industry, and other research support agencies. True promotion of CV health from childhood into adulthood will require the cooperation of all those involved in public policy development, public education, and the training of health care providers. Additional information on evidence-based public health approaches can be found in The Guide to Community Preventive Services, which is coordinated by the Centers for Disease Control and Prevention (http://www.thecommunityguide.org/index.html).

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