Primordial Prevention Of Chronic Disease

by Matt Gillman, MD, SM

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When you hear the word primordial, does it bring to mind 1) a primeval ooze or 2) the ability to keep babies healthy for a lifetime? If you are interested in #2, read on... 

Often we hear the term primary prevention. In the realm of heart attacks and strokes—leading causes of death in the US and now around the world—primary prevention usually means treating risk factors like high cholesterol and high blood pressure to lower the risk of getting or dying of those diseases. 

But what about preventing the emergence of cardiovascular risk factors in the first place? Virtually all babies are born with ideal cardiovascular health. They don’t smoke. They don’t have high cholesterol or blood pressure. They are not obese, and they don’t have diabetes.  They are prepared to eat well and get adequate physical activity. Primordial prevention aims to keep it that way.

Underlying heart disease and many strokes, kidney disorders, and other vascular diseases is atherosclerosis. This is a long term process that starts in youth and is related to higher risk factor levels. It progresses from innocuous enough fatty streaks in our arteries to larger plaques. Ultimately, this process may culminate in a completely occluded artery, causing a heart, brain, kidney, or leg “attack.” 

Because this process begins in youth, early intervention is potentially the best way to prevent these health consequences. But how? One approach is exemplified by STRIP, a wonderful long-term study with perhaps not the best acronym. During infancy, the investigators of the Finnish Special Turku Coronary Risk Factor Intervention Project for Children randomly allocated over 1000 infants to an individualized dietary intervention v. routine care and advice. They followed up with participants at least twice yearly until the age of 20 years. The families in the intervention group received repeated counseling to replace saturated fat with unsaturated fat, to consume more fruits, vegetables, and whole grains, and less salt, and to moderate portion sizes. At 8 years of age they began counseling to avoid smoking.

In adolescence, STRIP investigators were able to follow up about half of the original babies. At the age of 15-20 years, participants who got the dietary intervention since infancy had lower rates of the metabolic syndrome, a precursor to type 2 diabetes and cardiovascular disease, than the controls.  Also, the intervention group as a whole were closer to the ideal cardiovascular health status with which they were born.

Conducting a long-term primordial prevention trial like STRIP is a tour de force.  Another is PROBIT in which OPP faculty and colleagues from Belarus, Canada, and the UK showed that breastfeeding promotion does not benefit cardiovascular risk factors. But these are only two such studies, and there aren’t many more in existence.  We surely need additional studies like these to tell us what to do--and how to do it--for successful primordial prevention.