European Journal of Cardiovascular Medicine

Cardiovascular diseases (CVDs) remain the leading cause of morbidity and mortality worldwide, accounting for an estimated 17.9 million deaths annually, which represents nearly 32% of all global deaths [1]. While the clinical manifestations of CVDs typically appear in adulthood, there is compelling evidence that the roots of cardiovascular risk are often established much earlier, even during childhood and adolescence [2]. The growing burden of CVDs, particularly in low- and middle-income countries, underscores the importance of primordial and primary prevention strategies aimed at mitigating modifiable risk factors from a young age [3]. Among these risk factors, unhealthy diet, physical inactivity, obesity, tobacco use, and hypertension are increasingly prevalent among children and adolescents, largely driven by urbanization, changing lifestyles, and socio-cultural influences [4].

Several large-scale epidemiological studies, including the Bogalusa Heart Study, have shown that atherosclerotic changes begin in childhood and are directly related to the presence of traditional risk factors such as elevated blood pressure, dyslipidemia, and obesity [5]. These findings highlight the critical need for early identification and intervention to curb the progression of subclinical cardiovascular disease. Alarmingly, data from various parts of the world reveal a rising trend in overweight and obesity among school-aged children, a phenomenon once largely confined to high-income nations but now pervasive across low- and middle-income settings as well [6]. In India, recent surveys indicate that the prevalence of overweight and obesity among school children ranges between 10–30%, depending on geographic location and socio-economic strata [7].

Beyond the physiological risk factors, the knowledge, attitudes, and behaviors of children concerning cardiovascular health play a pivotal role in shaping future risk profiles. Knowledge gaps and misconceptions about healthy diet, physical activity, and tobacco hazards are widespread among school children, often perpetuated by inadequate health education both at home and in school curricula [8]. Studies have shown that children who are better informed about cardiovascular risk factors are more likely to adopt healthier lifestyles, suggesting that targeted health education could have significant long-term benefits [9]. However, despite the growing recognition of this need, there remains a paucity of comprehensive data on the actual level of knowledge among school children, particularly in rapidly urbanizing countries undergoing nutritional and epidemiological transitions.

The school setting offers a unique and strategic platform for health promotion, given that children spend a significant portion of their formative years within these institutions. School-based interventions—ranging from curriculum integration to physical activity programs and healthy canteen policies—have demonstrated varying degrees of success in improving awareness and modifying risk behaviours. Moreover, the involvement of teachers and parents as role models and facilitators of health behaviour change has been emphasized as an integral part of sustainable intervention strategies. Recognizing the dynamic nature of adolescence—a period characterized by experimentation and the establishment of lifelong habits—early and consistent health education becomes particularly vital.

Study Design: Prospective cross-sectional observational study with a mixed-methods design.

Study Period: From January 2024 to December 2024.

Study Area: Singur Anandanagar (A Rural area of West Bengal)

Study Population: School children aged 10–16 years.

Sample Size: Total of 250 students were included in the study.

Sampling Technique: Stratified random sampling to ensure representation from different age groups, gender, and rural schools.

Inclusion Criteria:

• Children aged 10–16 years
• Both males and females
• Those who gave assent and whose parents provided written informed consent

Exclusion Criteria:

• Children with known chronic systemic illnesses
• Children unwilling to participate

Study Procedure:

Data were collected using three structured instruments. The first instrument assessed cardiovascular risk factors and comprised three sections: (i) demographic details, including age, sex, and class; (ii) lifestyle-related risk factors, such as physical inactivity, dietary habits, smoking, and tobacco use; and (iii) clinical parameters, including measurements of weight, height, body mass index (BMI), and blood pressure.

The second instrument evaluated knowledge related to cardiovascular disease and included questions on the definition of the disease, associated risk factors, and preventive strategies. Each correct answer was awarded one point, while incorrect or no responses were scored as zero. The maximum possible score was 22. Scores were categorized as follows:

• <11 – Inadequate knowledge (i.e. less than 50% correct responses)
• 12–16 – Moderately adequate knowledge (i.e. 50–75% correct responses)
• >17 – Adequate knowledge (i.e. more than 75% correct responses)

The third instrument collected socio-biographic information from parents, including total monthly family income, educational and occupational status of both parents, and family history of cardiovascular disease. Initially developed in English, all tools were translated into Hindi for better comprehension.

Data collection was conducted between June and December 2012. Parents were asked to complete their section at home and return it the following day along with signed consent forms. Demographic information and clinical measurements were obtained directly from the students. Weight was measured using a calibrated digital weighing scale (Dr. Morepen Weight & Watch, model MS-8604; capacity: 0–150 kg; least count: 0.1 kg), and height was recorded using a non-elastic measuring tape with a least count of 0.1 cm. Blood pressure was assessed using a digital sphygmomanometer (CITIZEN, model CH432 new; least count: 1 mmHg). All instruments were calibrated by the Central Workshop of the Institute to ensure accuracy.

Students identified as being at risk for obesity or hypertension were reported to the school authorities. An educational module was subsequently provided to promote awareness and preventive practices. All data collection and assessments were conducted by a single trained investigator.

Cardiovascular risk factors were defined using standardized criteria. Obesity was assessed through BMI, with overweight classified as BMI >85th percentile and obesity as >95th percentile based on WHO BMI-for-age charts. Blood pressure classification followed the Fourth Report (2004), with thresholds adjusted for age, sex, and height percentiles to define normal, prehypertension, and stages I and II hypertension. Physical activity and dietary intake over the past seven days were self-reported using researcher-developed tools. A positive family history included cardiovascular events in first- and second-degree relatives before age 55 in men and 65 in women. Data analysis was performed using STATA version 11.1, with associations evaluated using paired Chi-square and Fisher's exact tests, considering p < 0.05 as statistically significant.

Statistical Analysis: -

For statistical analysis, data were initially entered into a Microsoft Excel spreadsheet and then analyzed using SPSS (version 27.0; SPSS Inc., Chicago, IL, USA) and GraphPad Prism (version 5). Numerical variables were summarized using means and standard deviations, while Data were entered into Excel and analyzed using SPSS and GraphPad Prism. Numerical variables were summarized using means and standard deviations, while categorical variables were described with counts and percentages. Two-sample t-tests were used to compare independent groups, while paired t-tests accounted for correlations in paired data. Chi-square tests (including Fisher’s exact test for small sample sizes) were used for categorical data comparisons. P-values ≤ 0.05 were considered statistically significant.

Table 1: Demographic Profile of School Children and Statistical Significance of Group Differences

Table 2: Comparison of BMI and Blood Pressure Categories by Sex

Table 3: Comparison of Physical Activity and Sedentary Behaviour by Sex

Table 4: Frequency of Consumption of Desirable Food Items among School Children and Associated Statistical Significance

Table 5: Knowledge Regarding Risk Factors and Preventive Strategies of Heart Disease — Comparison by Sex

Table 6: Knowledge of Preventive Actions — Comparison by Sex

Table 7: Knowledge of Heart-Healthy Diet — Comparison by Sex

Table: 8. Logistic Regression Analysis of the Factors Associated with BMI and Blood Pressure (N = 250)

Figure 1: Bar chart illustrating how often school children consume desirable food items, with statistically significant differences highlighted across groups

Figure 2: Bar chart showing differences in awareness of heart-healthy dietary practices between males and females

Figure: 3. Knowledge score regarding cardiovascular risk factor among school children

Figure: 4. Bar chart showing that most patients had normal BMI and blood pressure, with fewer cases of overweight/obesity and hypertension

The mean age of the study participants was 12.7 ± 1.2 years, ranging from 11 to 15 years, and this distribution was statistically significant (p = 0.031). The study population consisted of 130 boys (52%) and 120 girls (48%), with no significant difference by sex (p = 0.457). Class-wise, the highest proportion of students were in 6th standard (36%), followed by 7th (32.8%) and 8th (31.2%), showing a statistically significant association (p = 0.019). Monthly family income was significantly associated with the variables studied (p = 0.005), with 34% of families earning ₹5,001–10,000 and 24% earning ≤ ₹5,000. Regarding parental education, 32% of fathers had completed secondary education, and 30% had only primary-level education (p = 0.021). Among mothers, 36% had primary education and 28% were illiterate, with this distribution also being significant (p = 0.033). The majority of fathers were farmers (38%), followed by daily laborers (32%) (p = 0.041). Most mothers were homemakers (72%), although this variable did not reach statistical significance (p = 0.069).

In this study involving 250 schoolchildren (130 boys and 120 girls), the majority were found to be within the non-overweight/non-obese BMI category, with a significantly higher proportion among girls (83.3%) compared to boys (73.1%) (p = 0.048). Overweight and obesity were more prevalent among boys (19.2% and 7.7%, respectively) than girls (12.5% and 4.2%). In terms of blood pressure, a higher percentage of girls (75.0%) had normal blood pressure compared to boys (63.1%), which was also statistically significant (p = 0.034). Prehypertension and both stages of hypertension were slightly more common in boys than girls.

In this analysis of physical activity and sedentary behavior among 250 schoolchildren, notable gender differences were observed. A significantly higher proportion of girls (23.3%) reported no physical activity in the past week compared to boys (15.4%) (p = 0.041), while boys were more likely to engage in daily physical activity (7 days/week: 19.2% vs. 10.0%). Similarly, participation in stretching or strengthening exercises was lower among girls, with 56.7% reporting no such activity compared to 42.3% of boys (p = 0.022). In terms of sedentary time, girls tended to spend more time in sedentary activities, with 33.3% reporting 5–6 hours per day compared to 26.9% of boys. The difference in sedentary behavior was statistically significant (p = 0.037).

The dietary habits of the study participants revealed suboptimal consumption of desirable food items, with statistically significant differences observed across categories. Fruit intake was limited in many children, with only 16% consuming fruits daily, while 14% reported rarely or never consuming them (p = 0.026). Vegetable consumption was somewhat better, with 32% consuming vegetables daily, though 8% reported almost never eating them (p = 0.013). Milk products were consumed daily by 24% of participants, while 16% reported almost no intake (p = 0.041). Notably, nut consumption was the lowest among all categories, with 40% reporting never or almost never eating nuts and only 10% consuming them daily (p = 0.018).

A significantly higher proportion of girls than boys knew that heart diseases can occur in children (79.2% vs. 65.4%, p = 0.014) and that family history increases heart disease risk (83.3% vs. 73.1%, p = 0.049). More girls correctly identified that exercise does not cause heart disease (87.5% vs. 76.9%, p = 0.031), and that obesity (95.8% vs. 84.6%, p = 0.006), fast food (87.5% vs. 76.9%, p = 0.030), and stress (83.3% vs. 69.2%, p = 0.015) are contributory factors. Additionally, awareness of smoking as a cause (95.8% vs. 88.5%, p = 0.042) and the role of fruits and vegetables in prevention (91.7% vs. 76.9%, p = 0.003) was higher among girls. Furthermore, more girls believed that heart disease is preventable (87.5% vs. 73.1%, p = 0.008) and that preventive measures should start in childhood (91.7% vs. 76.9%, p = 0.004). While the knowledge gap was not significant regarding gender being a risk factor (p = 0.072)

A significantly higher proportion of girls (83.3%) than boys (73.1%) recognized maintaining normal body weight as a preventive measure (p = 0.048). Although more girls correctly identified other preventive strategies—such as limiting screen time to less than 2 hours per day (79.2% vs. 69.2%) and the incorrect belief that exercising less than 1 hour daily is sufficient (75.0% vs. 65.4%)—the differences in these items were not statistically significant (p > 0.05). High awareness was observed in both groups regarding the importance of avoiding smoking and tobacco use, with over 84% agreement in both genders, and no significant gender difference.

The evaluation of dietary knowledge among 250 students revealed that girls demonstrated significantly better awareness of healthy dietary practices compared to boys. A higher percentage of girls correctly identified the importance of consuming more fruits and vegetables (95.8% vs. 80.8%, p = 0.001) and reducing intake of fried foods (87.5% vs. 73.1%, p = 0.006) and cold drinks (83.3% vs. 69.2%, p = 0.011). However, misconceptions were also more prevalent among girls, with a higher proportion incorrectly believing that a diet with more salt (87.5% vs. 69.2%, p = 0.001) and more sweets (79.2% vs. 65.4%, p = 0.021) is beneficial.

Logistic regression analysis revealed several factors significantly associated with Body Mass Index (BMI) and blood pressure among the participants. In the univariate analysis for BMI, adolescents aged 13–18 years had lower odds of being overweight or obese compared to those aged 9–12 years (OR = 0.55; 95% CI: 0.33–0.90; p = 0.017), although this association lost significance in the adjusted model (p = 0.565). Students from private schools showed higher odds of being overweight or obese than those from government schools (OR = 1.87; 95% CI: 1.14–3.07; p = 0.013), but the association was not significant after adjustment (p = 0.091). Notably, participants from households with monthly incomes ≥ ₹80,000 were significantly more likely to be overweight or obese compared to those with income ≤ ₹10,000 (adjusted OR = 2.47; 95% CI: 1.01–6.03; p = 0.049). No significant associations were observed with sex, class, family history, or knowledge level.

Regarding blood pressure, adolescents aged 13–18 years had higher odds of elevated blood pressure compared to younger children in univariate analysis (OR = 1.91; 95% CI: 1.12–3.27; p = 0.017), though this was not statistically significant in the adjusted model (p = 0.146). Private school students were more likely to have high blood pressure than government school students (adjusted OR = 1.85; 95% CI: 1.01–3.38; p = 0.046). Additionally, students from class 8 showed borderline higher odds (adjusted OR = 2.06; 95% CI: 0.98–4.33; p = 0.058). High family income (≥ ₹80,000) was associated with increased odds of hypertension in univariate analysis (p = 0.029), though this was not statistically significant after adjustment (p = 0.074). Importantly, overweight and obese individuals had significantly higher odds of elevated blood pressure (adjusted OR = 2.45; 95% CI: 1.30–4.61; p = 0.005). No significant associations were noted with sex, family history, or knowledge levels in the multivariable analysis.

We observed that the mean age of the students was 12.7 ± 1.2 years, indicating a well-represented adolescent group, with a statistically significant distribution. The sex distribution was nearly equal, with no significant difference between boys and girls, suggesting an unbiased sample. Class-wise distribution revealed a significant variation, with a slight predominance of students in 6th standard, reflecting mid-level schooling engagement in the area. Socioeconomic factors such as monthly family income and parental education levels demonstrated notable associations. Most families had a monthly income between ₹5,001–10,000, and a large proportion of fathers had attained secondary education, while mothers predominantly had primary-level education. The majority of fathers were engaged in farming, which was statistically significant (p<0.05), whereas mothers were largely homemakers, though this was not statistically significant. These findings are consistent with those reported by Kumar et al., who found a similar age distribution and male-to-female ratio in a rural adolescent cohort in Uttar Pradesh, India, emphasizing the representativeness of such populations in school-based health studies [9].

We observed significant gender-based differences in the distribution of BMI and blood pressure categories among school children. Among boys (n=130), a lower proportion were non-overweight/non-obese (73.1%) compared to girls (83.3%), while overweight (19.2% vs. 12.5%) and obesity (7.7% vs. 4.2%) were more prevalent among boys. This difference in BMI distribution was statistically significant (p=0.048), indicating a higher burden of excess weight among boys. Blood pressure assessment further revealed that boys had a lower proportion of normal readings (63.1%) than girls (75.0%) and a higher prevalence of elevated blood pressure, including prehypertension and hypertension stages. Specifically, Stage 1 and Stage 2 hypertension were more common in boys (11.5% and 6.2%) compared to girls (8.3% and 4.2%), and this gender disparity also reached statistical significance (p=0.034).These findings are consistent with earlier studies. Bhargava et al. found a positive association between BMI and blood pressure, particularly among male adolescents, highlighting the role of body weight in blood pressure regulation [10].

We observed statistically significant gender differences in physical activity patterns, exercise habits, and sedentary behavior among the students. Boys (n=130) were generally more active, with 25 (19.2%) reporting daily physical activity of ≥1 hour, compared to only 12 girls (10.0%) among 120 participants. Conversely, a higher proportion of girls (23.3%) reported no physical activity during the past week, compared to 15.4% of boys—a difference that was statistically significant (p=0.041). Similar disparities were seen in engagement with stretching and strengthening exercises (p=0.022); 42.3% of boys and 56.7% of girls did not engage in any such activities, while more boys participated in these exercises for 1–2 days or ≥3 days per week. Sedentary behavior was also higher among girls. A significantly larger number of girls (16.7%) than boys (11.5%) reported 7–8 hours of sedentary activity per day, while 33.3% of girls and 26.9% of boys reported 5–6 hours (p=0.037).These findings are in agreement with. Saha et al. found that sedentary behavior, especially screen time and inactivity, was more prevalent among adolescent girls, linked to sociocultural and environmental constraints [11].

We observed significant variation in the consumption patterns of key nutritious foods—fruits, vegetables, milk products, and nuts—among school-aged participants. Only 40 students (16.0%) reported consuming fruits daily, while a majority consumed them occasionally: 100 (40.0%) once or twice a week, 75 (30.0%) on most days, and 35 (14.0%) rarely. This distribution was statistically significant (p=0.026). Vegetable intake was relatively better, with 80 students (32.0%) consuming vegetables daily and 90 (36.0%) on most days, though a concerning 20 students (8.0%) reported minimal intake (p=0.013). Milk product consumption was more evenly distributed, with 60 (24.0%) consuming them daily and 80 (32.0%) once or twice weekly; however, 40 (16.0%) rarely consumed them (p=0.041). Nut intake was notably the lowest among the food groups, with only 25 students (10.0%) consuming them daily, and a large proportion—100 students (40.0%)—almost never consuming them (p=0.018).These findings indicate suboptimal dietary patterns, particularly regarding nutrient-rich foods essential for adolescent growth and development. Similar trends were reported by, Mehta et al. found a significant gap between recommended and actual dietary practices in school-aged children, emphasizing the role of targeted nutritional interventions [12].

We observed notable gender differences in cardiovascular health knowledge, with several parameters showing statistically significant variation between boys and girls. Awareness that heart diseases can affect children was significantly higher among girls (79.2%) compared to boys (65.4%) (p=0.014). While a greater proportion of boys (69.2%) than girls (58.3%) believed that males are more susceptible to heart disease, the difference was not statistically significant (p=0.072). Girls demonstrated significantly better awareness regarding family history as a risk factor (83.3% vs. 73.1%, p=0.049) and the link between obesity and heart disease (95.8% vs. 84.6%, p=0.006).A concerning misconception was that exercise causes heart disease—believed by 76.9% of boys and 87.5% of girls (p=0.031). Similarly, a high proportion of both boys (76.9%) and girls (91.7%) incorrectly thought that increased consumption of fruits and vegetables could lead to heart disease (p=0.003), highlighting major gaps in nutritional understanding. Awareness of smoking as a cardiovascular risk factor was high overall but significantly higher among girls (95.8%) than boys (88.5%) (p=0.042). Girls also had greater awareness regarding the role of stress (83.3% vs. 69.2%, p=0.015) and fast food consumption (87.5% vs. 76.9%, p=0.030) in heart disease. Furthermore, girls were more likely to understand the preventability of heart disease (87.5% vs. 73.1%, p=0.008) and the importance of initiating preventive measures during childhood (91.7% vs. 76.9%, p=0.004).These results indicate that while girls demonstrated better overall knowledge, both genders showed significant misconceptions, particularly around diet and physical activity. Similar gender-based knowledge disparities have been reported in other Indian and international studies. Tandon et al. found that additionally, emphasized the role of school-based education in correcting such misconceptions, particularly around nutrition and physical activity [13].

We observed that awareness regarding preventive measures for heart disease varied between boys and girls, with certain differences reaching statistical significance. A significantly higher proportion of girls (83.3%) than boys (73.1%) were aware that maintaining normal body weight is a key preventive strategy (p=0.048). However, misconceptions about the adequacy of physical activity were prevalent in both groups. A majority of students—85 boys (65.4%) and 90 girls (75.0%)—incorrectly believed that exercising for less than one hour per day is sufficient to prevent heart disease. While this gender difference was not statistically significant (p=0.098), it highlights a critical gap in understanding physical activity guidelines. Similarly, awareness about limiting screen time to under two hours daily was marginally higher among girls (79.2%) compared to boys (69.2%), though this difference also did not reach statistical significance (p=0.079). On a positive note, awareness about the importance of avoiding smoking and tobacco use was high among both sexes. A total of 115 boys (88.5%) and 110 girls (91.7%) acknowledged smoking as a risk factor (p=0.415), and 110 boys (84.6%) and 105 girls (87.5%) were aware of the risks of tobacco use (p=0.530).In a national survey, Rathi et al. emphasized the importance of integrating structured heart health education in school curricula to correct misconceptions and improve preventive behaviors [14].

The majority of participants (65%) demonstrated an adequate level of knowledge with scores greater than 17. A smaller proportion (25%) were classified as moderately adequate with scores ranging from 12 to 16, while only 10% had inadequate responses with scores below 11. This distribution indicates a generally satisfactory level of understanding among respondents.

We observed significant gender-based differences in dietary knowledge related to heart health among school students. A notably higher proportion of girls (95.8%) than boys (80.8%) correctly identified that increased consumption of fruits and vegetables is beneficial, a difference that was statistically significant (p=0.001). However, a concerning misconception was prevalent among both sexes regarding salt intake: 90 boys (69.2%) and 105 girls (87.5%) incorrectly believed that consuming more salt is healthy, with this misconception being significantly more common among girls (p=0.001).Regarding awareness of fried food consumption, a higher proportion of girls (87.5%) than boys (73.1%) correctly recognized the importance of reducing intake (p=0.006). However, knowledge about the adverse effects of sweets was lacking—65.4% of boys and 79.2% of girls incorrectly believed that more sweets are healthy, with this misconception being significantly more common among girls (p=0.021). Awareness regarding the harms of cold drink consumption was better, with 83.3% of girls and 69.2% of boys acknowledging its unhealthiness (p=0.011). Similar trends were observed by Chopra et al. who reported better overall dietary knowledge among girls but highlighted persistent misconceptions regarding processed foods and sugar intake [15].

We concluded that highlights a significant prevalence of cardiovascular risk factors among school children in rural West Bengal, with gender-based differences in BMI, blood pressure, physical activity, and dietary habits. Girls demonstrated better awareness regarding cardiovascular health and prevention, though both genders exhibited notable misconceptions—especially regarding the role of fruits, vegetables, salt, and physical activity. Socioeconomic factors like parental education and income were significantly associated with risk profiles. These findings underscore the urgent need for school-based health education programs that address both lifestyle modifications and misconceptions to promote early cardiovascular risk reduction in the adolescent population.

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