William A. Neal, M.D.
	Professor of Pediatrics James H. Walker Chair of Pediatric Cardiology
	HSC PO Box 9214 Morgantown, WV 26506-9214	Email: wneal@hsc.wvu.edu Phone: 304-293-2416 Fax: 304-293-1409

Coronary Artery Risk Detection in Appalachian Communities (CARDIAC):

The Coronary Artery Risk Detection in Appalachian Communities (CARDIAC) Project has been designed to address the unacceptably high morbidity and mortality from cardiovascular disease in West Virginia.

Background:

West Virginia is the second most rural state in the nation, with two-thirds of its 1.8 million people living in communities of less than 2,500 population. Family incomes are among the lowest in the nation with 24% of West Virginia families having incomes of less than 100% of the federal poverty level (1990-92). Only three other states and the District of Columbia had a higher percentage of their population below the FPL. The citizens of West Virginia have significantly more heart disease, malignant neoplasms, cerebrovascular disease, and chronic obstructive pulmonary disease than people of other states and have significantly higher Years of Potential Life Lost (YPLL) due to disease. The age-adjusted rate of death due to heart disease was 21% higher than the national average in 1995. Compared to other states, West Virginia currently has the highest rate of obesity, the third highest rate of self-reported hypertension, and the fifth highest rate of cigarette smoking.

Preliminary Research:

In the 1998-99 school year, three rural counties were randomly selected to participate in the pilot phase of a study to examine the effectiveness of universal blood cholesterol screening of pre-pubertal children in rural Appalachia in identifying children and their parents at risk of developing premature coronary heart disease (CHD). Health science students obtained family history (FH) of coronary artery disease; physical activity; dietary and anxiety profiles; non-fasting finger stick blood cholesterol (FSTC); a seated, resting systolic and 5th phase diastolic blood pressure; and anthropometric measures from 349 5th graders (mean age 10.9 years). A fasting lipid profile (FLP) was subsequently obtained in 34 children who had a positive FSTC (>170mg/dl) and 37 of their parents. A subset of 15 parents also participated in focus group interviews to assess their perception of the CARDIAC Project. The results of anthropometric measurements were compared to an ethnically similar age-matched sample of 173 children in the Fels Longitudinal Study in southwestern Ohio.

Conclusions of Pilot Phase:

1. Pre-adolescents in rural Appalachian counties are at elevated risk for coronary heart disease (CHD).
2. Universal blood cholesterol screening in this high-risk environment has greater sensitivity than selective screening based upon positive family history of cardiovascular disease.
3. Blood cholesterol screening of school children is an effective means of identifying parents at risk of developing premature CHD.
4. Blood cholesterol screening does not produce significant anxiety among school age children.
5. Universal blood cholesterol screening was well received by parents.

Present and Future Status of CARDIAC Project:

In the 10 years since its inception, The CARDIAC Project has expanded to include all 55 counties in West Virginia and provides free, school-based measurement of body mass index (BMI), blood pressure, fasting lipid profile, and a hyperinsulinemia marker know as Acanthosis Nigricans (AN) on approximately 50,000 5^th & 9^th grade students.  CARDIAC has also expanded and is doing BMI screening among additional cohorts of kindergarten and second grade students.  To date, more than 18,000 kinder and 9,000 second grade students have been screened.  Comprehensive chronic disease risk factor assessment unique to West Virginia's children is especially useful in predicting the consequences of weight status.

While many states are developing Body Mass Index (BMI) assessment programs for their children, WV is the first and only state to provide a comprehensive cardiovascular screening program for its children through The CARDIAC Project.  The additional blood pressure and lipid profile information collected through The CARDIAC Project has been sought for by other states as a means of understanding the role of BMI in cardiovascular disease development.  As a result, WV, Arkansas, and Michigan are collaborating to explore the developing childhood obesity trends.

Utilization of the innovative RHEP program as the platform upon which our most promising young students gain firsthand experience learning disease prevention and health promotion at the community level, coupled with a health conscious public school system, provide a unique opportunity to close the ever widening gap between CHD mortality in West Virginia and the nation as a whole. Successful accomplishment of this objective in West Virginia would serve as a model for the rest of Appalachia.

CARIDAC PROJECT  -  MISSION STATEMENT

To provide sustainable comprehensive risk factor identification, education, awareness and advocacy to engage and empower West Virginia children, families and communities to embrace a culture of wellness.

Specific Aims:

1. Establish the first statewide cardiovascular disease community intervention project in the nation by the year 2003.
2. Decrease the age-adjusted rate of death due to heart disease in West Virginia to the national average by the year 2010.
3. Improve the ability of health science students to counsel families about prevention of cardiovascular disease.
4. Improve the knowledge, attitudes, and behaviors of pre-pubertal school children regarding cardiovascular disease risk factors by utilizing interactive computer technology.

Selected Publications:

• Neal WA, Demerath E, Gonzales E, Spangler E, Minor EV, Stollings R, Islam S: Coronary Artery Risk Detection in Appalachian Communities (CARDIAC): Preliminary Findings.  WV Medical Journal 2001, 97:102-105.
• Muratova VN, Islam SS, Demerath EW, Minor VE, Neal WA: Cholesterol Screening in Children and Their Parents.  Preventive Medicine, 2001; 33:1-6.
• Gonzales EN, Marshall JA, Heimendinger J, Crane LA, Neal WA: Home and eating environments are associated with saturated fat intake in children in rural West Virginia.  J Am Diet Assoc, 2002;102:657-663.
• Muratova VN, Demerath EW, Spangler E, Ogershok P, Elliott E, Minor VE, Neal WA.  The relation of obesity to cardiovascular risk factors among children: the Coronary Artery Risk Detection in Appalachian Communities (CARDIAC) Project.  WV Med J, 2002 Nov-Dec; 98(6):263-7.
• Neal WA.  Editorial: Obesity and overweight: A public health epidemic.  WV Med J, 2002 Nov-Dec; 98(6):244.
• Demerath E, Muratova VN, Spangler E, Li J, Minor VE, Neal WA: School-based obesity screening in rural Appalachia.  Preventive Medicine, 2003; 37:1-8.
• Kelley C, Krummel D, Gonzales EN, Neal WA, Fitch CW.  Dietary intake of children at high risk for cardiovascular disease.  J Am Diet Assoc 2004; 104:222-225.
• Neal, W:  West Virginia Heart, Attack.  West Virginia Executive Health Care Magazine, July/August 2005.
• Cottrell L, Spangler-Murphy E, Minor V, Downes A, Nicholson P, Neal W:  Findings from a Kindergarten Cardiovascular Risk Surveillance Study:  CARDIAC-Kinder.  American Journal of Health Behavior, 29(6), 595-606
• Elliott E, Neal W, Palmer S, Aukerman M. (2005). Healthy Hearts for Kids: Is the Internet a viable tool for teaching health behaviors to children? Medicine and Science in Sports and Exercise
• Neal, W:  West Virginia Heart, Attack.  West Virginia Executive Health Care Magazine, July/August 2005.
• Deskins S, Harris CV, Bradlyn AS, Cottrell L, Coffman JW, Olexa J, Neal W.  Preventive care in appalachia: use of the theory of planned behavior to identify barriers to participation in cholesterol screenings among West Virginians. J Rural Health. 2006 Fall;22(4):367-74.
• Elliott, E., Cottrell, L., Murphy, E., Ward, A., & Neal, W. Healthy Hearts 4 Kids:  3-year results of a web-based health intervention in elementary schools. Obesity.  (October 2006), Supplement.
• Rhodes LA, Gustafson RA, Phillips JP, Cottrell L, Castillo W, Siu BL, Neal WA. The adult with congenital heart disease.  W V Med J. 2006 Jan-Feb;102(1):310-3. Review.
• Cottrell, L., Minor, V., Murphy, E., Ward, A., Elliot, E., Tillis, G. & Neal, W.  Comparisons of parent cardiovascular knowledge, attitudes, and behaviors based on screening and perceived child risks. Journal of Community Health Nursing, 24 (2).
• Rye JA, Thompkins NO, Eck R, Neal WA (2008).  Promoting youth physical activity and healthy weight through schools.  WV Med J, 2008 Mar-Apr; 104(2):12-15.
• Farris RP, Pearson T, Fogg T, Bryant L, Peters K, Keyserling T, Fitzpatrick A, Neal W.  Building capacity for heart disease and stroke prevention research:  the cardiovascular health intervention research   and translation network.  Health Promot Pract. 2008 July;9(3):220-7.
• Harris CV, Neal WA.  Assessing BMI in West Virginia Schools:  Parent Perspectives and the Influence of Context.  Pediatrics, In press 2008.
• Khanna R, Kavookjian J, Scott V, Kamal K, Miller L, Neal W.  Using the Theory of Reasoned Action to Determine Physicians' Intention to Measure Body Mass Index in Children and Adolescents. Research in Social & Administrative Pharmacy. 2008