School-Based Cardiovascular Health Promotion Programs: Evidence and Implementation Strategies for Preventing Early-Onset Heart Disease

Childhood and adolescence represent critical periods for establishing cardiovascular health behaviors and preventing early atherosclerotic changes that manifest as clinical disease in adulthood. School-based cardiovascular health promotion programs offer unique opportunities to reach large populations of children during formative developmental stages, establishing healthy behaviors before risk factors become entrenched. This narrative review examines evidence for school-based interventions targeting primary prevention of cardiovascular disease through modification of diet, physical activity, tobacco use, and knowledge about cardiovascular health. Globally, childhood obesity has tripled since 1975, with over 340 million children and adolescents aged 5-19 years classified as overweight or obese. Simultaneously, hypertension, dyslipidemia, and insulin resistance increasingly affect pediatric populations, tracking into adulthood and predicting future cardiovascular events. School-based programs demonstrate effectiveness in improving dietary quality, increasing physical activity, preventing tobacco initiation, and enhancing cardiovascular health knowledge. However, sustainability, scalability, and translation of behavior change into measurable reductions in cardiovascular risk factors remain challenging. Successful programs incorporate multicomponent interventions addressing individual, interpersonal, environmental, and policy levels; engage families and communities; modify school nutrition and physical education environments; and maintain adequate duration and intensity. Implementation barriers include competing academic priorities, limited resources, inadequate teacher training, and resistance to environmental changes. This review synthesizes evidence on effective program components, examines implementation challenges, and proposes strategies for integrating cardiovascular health promotion into educational systems. Achieving population-level cardiovascular disease prevention requires sustained investment in school-based health promotion as part of comprehensive life-course approaches.