Early Childhood Education and Midlife Ideal Cardiovascular Health in a Prospective Urban Cohort

This cohort study assesses whether preschool is associated with long-term cardiovascular health as measured by the American Heart Association’s Ideal Cardiovascular Health Index.

This supplementary material has been provided by the authors to give readers additional information about their work.

AHA Definitions and Justification
The American Heart Association (AHA) defines Ideal Cardiovascular Health (iCVH) as an index of seven positive metabolic and healthy lifestyle behaviors that are associated with longrun health and well-being: Healthy weight, no smoking, normal range blood glucose (low diabetes risk), total cholesterol and blood pressure, healthy diet, and moderate or vigorous physical activity.These iCVH metrics are described by AHA as "My Life Check-Life's Simple 7." study participants to score them on each of these metrics.Participants received a "1" on a metric if their response fell under the AHA's categorization as ideal and a "0" for intermediate or poor.However, as our data did not have the exact metrics of iCVH, close approximations were estimated (with assessment of different assumptions).Table S1 provides these operational definitions.Consistent with the original definition of iCVH, we defined each metric dichotomously as the presence or absence of ideal health, with the intermediate category scored as 0. Studies vary substantially in their definitions and scoring.Finally, we add the score across the seven metrics to compute an overall ideal index score (between 0 and 7).The mean and median value for the ideal AHA index score was four, with nearly 30% of participants having an index score of five or greater.
Prior research has found the iCVH indicators to be associated with lower levels of studies shows that iCVH metrics were associated with a lower risk of cardiovascular diseases and mortality.Hence, in this study, we focus our analysis on the total number of ideal indicators.One advantage of iCVH over the widely used Framingham Risk Score is that all metrics for the former are alterable for improving health and setting goals for increasing CVH in eTable 1 provides the iCVH definitions for the criterion indicators and the measures used in this study.Prevalence rates are provided along with the iCVH means for the participants meeting each criterion.The far-right columns show that the iCVH indicators were, as expected, positively associated with self-rated health (SRH) from the midlife interview and years of education by age 34.Notably, these associations are likely underestimated given the dichotomous measurement of the cardiovascular indicators.The survey measures were corroborated with in-person health For example, the correlation between in-person examination of BMI and survey report was .85(n = 268 participants).Supporting validity, iCVH moderately correlated with Framingham risk (r = -0.59),self-rated health (r = .25),and in-person exams at ages 37-39 (r = .67).The latter two values do not account for range restriction.
We used data from a self-reported survey on health outcomes (ages 35-37) completed by our Another meta-analysis of nine research

Inverse Propensity Score Weighting
As a follow-up to other studies, Inverse Propensity Score Weighting (IPW) was used to adjust for potential attrition bias.Nearly 30% of the original cohort did not complete the midlife survey on health outcomes that was used to score participants on various health metrics.IPW helps remove confounding by creating a pseudo-population in which attrition from the study sample is independent of the measured confounders (baseline attributes), making the follow-up sample closely resemble that of the original sample at the beginning of the study, and thereby The regression model included the following attrition weight variable: The predicted probabilities of sample recovery (SR; age 35-37 survey) were estimated by logistic regression (OLS regression also yields consistent estimates) with 31 input predictors hypothesized or known to be important.These included birth outcomes and demographics (BD), home environment (HE), program (PR), school, and neighborhood factors (SN).In the outcome regressions, this weight was applied such that individuals with higher weights were counted more heavily in program effect estimates (they have lower probabilities of responding to the adult survey).Those with lower weights were counted less.Analyses revealed that estimated program impacts were similar between IPW and non IPW models.

Alternative Estimates for AHA Index
Alternative models with different assumptions and definitions of ideal cardiovascular health were assessed to examine robustness of findings for the main model specification (Model 2).As shown in eTable 2, in all cases, the adjusted group differences maintained their significant associations.This included, for example, Model 4 in which BMI scores at/above 30 replaced the interview iCVH for cholesterol.This approach is consistent with the use of BMI as a stand-in for Alternative definitions and multiple imputation of iCVH scores also yielded similar findings.

Percent Reduction in Group Difference Associated with Educational Attainment
The share of Child-Parent Center (CPC) group differences, adjusted for baseline and IPW, explained by years of education at age 34 is shown in the Supplementary Figure .For the total sample, women and men, and residence in high poverty neighborhoods growing up (40%≥ of population below federal poverty line), education accounted for, on average, one third of the CPC-iCVH relation.Adding a second measure predictive of educational attainmentsocioemotional adjustment at age 9 (6-item scale)-further increased the percent reduction estimates.

CLS Background
The Chicago Longitudinal Study (CLS) follows a same-age cohort of low-income children (N = 1539, 93% African American, 7% Latino) born in 1979-1980 who participated in federaland state-funded early education programs beginning in preschool or kindergarten (1983)(1984)(1985)(1986) Participants grew up in high-poverty neighborhoods in central-city Chicago and participated in one of 20 CPCs in preschool and kindergarten (N = 989) or a matched comparison group from primarily randomly selected schools offering the usual early childhood services in the district (e.g., full-day kindergarten) as well as those entering CPCs in kindergarten (N = 550).Whereas 60% of CPC participants attended full-day kindergarten, all did in the comparison group.CPC participation could continue through 2nd or 3rd grade.Thus, the study assesses the benefits of the comprehensive CPC program with continuing services in the elementary grades compared to the usual early childhood services.
The key goals of the study are to: (1) assess the impacts of the CPC program on life-course development and well-being, (2) identify and better understand the pathways through which the effects of program lead to long-run health and well-being, and (3) investigate contributions of individual, family, school, and social environments from early childhood to midlife on health and As a prospective cohort design, participants have been followed throughout life and are currently between 43 and 44 years of age.Over the years, the CLS team has examined a wide range of predictors and outcomes that may be related to high-quality early childhood education, including parent involvement, social-emotional learning, educational attainment, employment and income, and criminal justice involvement, among others.Previous data has been collected at ages 10, 15 to 18, 18 to 24, and 26 to 28.The team has also employed various modes of data collection, including birth records, K-12 school records, parent and teacher report, participant The current phase of the study aims to understand the association between CPC preschool participation and well-being in midlife, including physical health, economic well-being, and 301 participants underwent an in-person health examination between ages 37 and 39.This study Two hundred and eighty-six participants (268) completed both the self-report survey by age 37 and a comprehensive in-person health exam at ages 37 to 39 (March 24, 2017 to December 21, 2019), whereby their BMI was also computed.The in-person exam occurred at the Department of Preventive Medicine Research Clinic, Northwestern University Feinberg School of Medicine in Chicago, Illinois.
We note that since our study was completed, the American Heart Association updated iCVH original measure remains strong, as no studies of early childhood education have assessed it.Follow up work will investigate the new, expanded measure.

CPC Program Description
The The CPC program aims to strengthen school achievement and overall well-being for preschool through elementary school-aged children from low-income families by way of educational enrichment, family support, health resources, and community outreach services.After 1 or 2 years of part day preschool, kindergarten through third grade services are provided.Key elements include collaborative leadership, effective learning experiences, aligned curriculum, parent involvement, professional development, and continuity and stability.

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eMethods.Definitions, Analysis, and Participants eTable Definitions for American Heart Associations' Ideal Cardiovascular Health (iCVH) and as Operationalized in the Chicago Longitudinal Study (CLS) eTable Alternative Models for CPC Preschool and Ideal Cardiovascular Health at Midlife eReferences.
in the Framingham Risk Score calculator.11 in the Chicago Public School District.strengthening inferences.
CPC program was established in 1967 through funding from Title I of the landmark Elementary and Secondary Education Act of 1965.Initially implemented in four sites in Chicago and later expanded to 25, the program originally served families in high-poverty neighborhoods In 2012, Arthur Reynolds at the University of Minnesota, along with participating districts, revised the CPC Program as a Under an Investing in Innovation Grant from the U.S. Department of Education, Human Capital Research Collaborative (HCRC) began an expansion of the CPC program in 2012 in four school districts, including St. Paul, Minnesota, and Chicago, Evanston, and Normal (McLean County) in Illinois.
telephone survey on health and well-being between ages 35 and 37. Further, a sub-sample of mental health.Nearly 1125 participants (73%) from the original sample completed a written and in-depth health exams for select participants.comprehensive school reform model to serve children in a broad variety of geographic and economic contexts.well-being.uses data on health outcomes obtained from these recent data collections.that were not reached by other early childhood programs.toinclude sleep quality, and is now called Life's Essential 8.The need for assessing the Continued research on the CPC preschool to 3 rd grade program (P-3) and its six core elements To promote holistic well-being, including physical health, CPCs have parent resource rooms and family programming supported collaboratively by a Parent Resource Teacher and School-Community Representative.Together, these members of the CPC leadership team conduct home visits, engage parents in the school, mobilize resources in the community, and provide referrals to health services.Parent workshops and training are a predominant element of the program, which frequently include child development, health literacy, nutrition, financial literacy, and personal development topics.Through these avenues of intervention, the CPC program is expected to promote healthy lifestyle choices and reduce cardiovascular risk over the life course.

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demonstrated effectiveness and scalability of the intervention. eTable

Metric AHA criterion for Ideal CLS measure, mean age 35 yrs. Evidence of Validity/Other % iCVH ideal mean r-value SRH Edu. Healthy Weight
Note. iCVH sample size = 1042.Prevalence rates are based on all available data for each indicator.AHA = American Heart Association.SRH = Self-rated health from age 37 interview.Edu.= Years of education by age 34 (7 to 22; May 2014).BMI = Body Mass Index 2. Alternative Models for CPC Preschool and Ideal Cardiovascular Health at Midlife