Primordial Prevention – What Does It Mean?
In 1978, Strasser suggested that prevention of cardiovascular disease (CVD) should go beyond the concept of primary prevention. He coined the term ‘primordial prevention’ to denote activities that prevented the penetration of risk factors into the population1 by intervening to stop the appearance of the risk factors. The 3rd International Heart Health Conference held in 1998 in Singapore focused attention on “preventing the risk to heart health, from womb to tomb”, meaning that cardiovascular risk prevention had to be encouraged throughout the life span.2 Primordial prevention has important implications in the relationship between socioeconomic circumstances and adult risk factors. A life-course approach to primordial prevention means ensuring the availability of cheap healthy food and promoting desirable eating habits in school-age children in order to ensure they develop into adults aged 30 years with favourable risk profiles who can control their lipid levels without the need for statin drugs. However, school-based programmes of physical education and sport have been reduced due to financial pressures, which may contribute to later sedentary behaviour and obesity. Children who grow up in an environment with few opportunities to smoke will be less likely to adopt this behaviour – another risk factor for CVD – in adult life. Policy actions that influence structural characteristics of the environment, such as food patterns, physical activity, smoking and alcohol availability, may have important consequences in the future. Therefore, primordial and primary prevention suggest different targets for intervention. Primordial prevention prevents the appearance of the mediating risk factors in the population, focusing on aspects of social organisation and aiming to modify the conditions that generate and structure the unequal distribution of health-damaging exposures, susceptibilities and health-protective resources among the population. In contrast, primary prevention alters the levels of mediating risk factors after they appear in the population, focusing on individuals or groups of individuals and aiming to modify at the individual level the behavioural, psychosocial and biological mediators that lead to an increased risk of CVD.3
Epidemiological Evidence of Primordial Prevention
The Pathobiologic Determinants of Atherosclerosis in Youth4 study and the Bogalusa Heart study5 demonstrated that traditional risk factors such as high body mass index, high blood pressure and dyslipidaemia are strongly associated with the presence of and extent of arterial lesions. More recently, the Special Turku Coronary Risk Factor Intervention Project6 was able to provide important information on diet throughout childhood and its role in the primordial prevention of atherosclerosis.
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- Labarthe DR, Preventing the risk to heart health, from womb to tomb, CVD Prevention, 1998;1:259–65.
- Lynch JW, Socioeconomic factors in the behavioral and psychosocial epidemiology of cardiovascular disease. In: Schneiderman N, Gentry J, da Silva JM, et al. (eds), Integrating Behavioral and Social Sciences With Public Health, Washington, DC: American Psychological Association, 1999.
- Relationship of atherosclerosis in young men to serum lipoprotein cholesterol concentrations and smoking: a preliminary report from the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group, JAMA, 1990;264:3018–24.
- Newman WP, Freedman DS, Voors AW, et al., Relation of serum lipoprotein levels and systolic blood pressure to early atherosclerosis: The Bogalusa Heart Study, N Engl J Med, 1986;3124:138–44.
- Niinikoski H, Lagstrom H, Jokinen E, et al., Impact of repeated dietary counseling between infancy and 14 years of age on dietary intakes and serum lipids and lipoproteins: the STRIP study, Circulation, 2007;116:1032–40.
- Lambert J, Agostoni C, Elmadfa I, et al., Dietary intake and nutritional status of children and adolescents in Europe, Br J Nutr, 2004;92(Suppl. 2);S147–S211.
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- MacMahon S, Peto R, Cutler J, et al., Blood pressure, stroke and coronary heart disease. Part I, prolonged differences in blood pressure: prospective observational studies corrected for the regression diluition bias, Lancet, 1990;335:765–74.
- Blood Pressure Lowering Treatment Trailists’ Collaboration, Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials, Lancet, 2003;362:1527–35.
- MacMahon S, Peto R, Cutler J, et al., Blood pressure, stroke and coronary heart disease. Part II, prolonged differences in blood pressure: prospective observational studies corrected for the regression diluition bias, Lancet, 1990;335:765–74.
- Murray CJ, Lopez AD, Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study, Lancet, 1997;349:1436–42.
- National Heart Lung and Blood Institute, Reflections on hypertension control rates, Arch Intern Med, 2002;162:131–2.
- Wolf-Maier K, Cooper RS, Banegas JR, et al., Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States, JAMA, 2003;289(18):2363–9.
- Wilson PWF, D’Agostino RB, Sullivan L, et al., Overweight and Obesity as Determinants of Cardiovascular Risk. The Framingham experience, Arch Intern Med, 2002;162:1867–72.
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- Applel LJ, Moore TJ, Obarzanek E, et al., A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group, N Engl J Med, 1997;336:1117–24.
- Appel LJ, SacksFM, Carey VJ, et al., OmniHeart Collaborative Research Group, The effects of protein , monounsaturated fat, and carbohydrate intake on blood pressure and serum lipids: results of the OmniHeart randomized trial, JAMA, 2005;294:2455–64.
- US Dept of Health and Human Services, Public Health Service, NIH, NHLBI, The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure - Complete Report, Bethesda: NIH/NHLBI Publication No. 04-5230.
- US Dept of Health and Human Services, Public Health Service, NIH, NHLBI, Implementing recommendations for dietary salt reduction: Where are we? Where are we going? How do we get there?, Bethesda: NIH/NHLBI Publication No. 55-728N.
- Vollmer WM, Sacks FM, Svetkey LP, New insights into the effects on blood pressure of diets low in salt and high in fruits and vegetables and low-fat dairy products, Curr Control Trials Cardiovascular Med, 2001;2:71–4.