Posted 12 March 2026
Associate Professor Jock Campbell argues that cardiovascular disease prevention needs to start in childhood, because early education about risk factors can create lifelong habits, improve blood pressure and cholesterol control, and ultimately add 10-15 years of healthy living.
Recently, in The Age’s Good Weekend, journalist Amanda Hooton discussed how to find a healthy path through the perilous years of middle age. With particular reference to risk for midlife mortality, she advocated for better management of five modifiable risk factors: tobacco use, physical inactivity, poor diet, overweight and obesity, and alcohol use.
This article seeks to expand on Amanda’s advice with focus on elevated blood pressure and cholesterol levels, two major modifiable risk factors for cardiovascular disease, which encompasses heart and blood vessel disease, comprising coronary artery disease, heart attacks, heart failure and stroke. The prospect of 10-15 years of additional healthy living should motivate people to modify their risk, yet despite the availability of effective medication, on the whole we are failing to adequately manage elevated blood pressure and cholesterol levels.
A major obstacle to prevention of cardiovascular disease is our lack of awareness that it can start in childhood and affect everyone to different degrees. This lack of awareness can be largely attributed to a lack of adequate education about individual risk.
A childhood-targeted education program that instils a mindset for cardiovascular health early in life that continues throughout life, analogous to the SunSmart program for prevention of skin cancer, offers considerable potential to improve the control of cardiovascular disease risk and better prevent its consequences. Such a program, together with pharmacist support with medication, would likely result in more years of healthy living.
The Australian Institute of Health and Welfare reported cardiovascular disease in 2023 was the underlying cause of 16,922 deaths (9.2% of all deaths), contributed to 16,685 deaths attributed to dementia, and to more than half a million hospitalisations each year. Australians aged 40 years had an estimated lifetime risk for heart attack of 24.4% for males and 13.2% for females in 2018.
The Heart Foundation reports coronary heart disease kills more than twice as many Australian women as breast cancer, and the number of individuals with cardiovascular disease is predicted to nearly double between 2025 and 2050.
Cardiovascular disease can largely be prevented by optimising an individual’s cardiovascular disease risk factors. Compared with individuals with two or more risk factors for cardiovascular disease, those with optimal risk factors (optimal blood pressure and cholesterol levels, healthy weight, who do not smoke or have diabetes) live an additional 10 to 15 years free of cardiovascular disease from age 45 to 50 years, according to the Journal of the American Medical Association.
Elevated blood pressure is the most common risk factor for cardiovascular disease and is the leading cause of death and disability in Australia and worldwide. Elevated blood pressure was responsible for 42% of coronary heart disease, 39% of stroke, 37% of chronic kidney disease, and 31% of atrial fibrillation and flutter (abnormal heart rhythm) in Australia in 2018.
Blood pressure measurement provides two numbers: a higher number called systolic blood pressure (when the heart beats) and a lower number called diastolic blood pressure (between heart beats), with the units of blood pressure expressed as millimetres of mercury (mmHg). Population studies showed lower blood pressure was associated with improved cardiovascular health (living more years without cardiovascular disease), down to a systolic blood pressure of at least 115 mmHg. Lowering systolic blood pressure to less than 120 mmHg with blood pressure-lowering medication in people with elevated blood pressure provided protection from cardiovascular disease. Moreover, reduction of systolic blood pressure to less than 130 mmHg reduced dementia risk. American and Australian guidelines describe a healthy or ‘normal’ systolic blood pressure as less than 120 mmHg.
A blood total cholesterol level of 2.8 to 3.4 mmol/L represents minimal risk of cardiovascular disease. Reducing the level of low-density lipoprotein cholesterol (‘bad’ cholesterol) to less than 2 mmol/L with cholesterol-lowering medication reduced cardiovascular death and illness and also caused regression of coronary artery disease. Moreover, reduction of elevated low-density lipoprotein cholesterol levels to less than 1.8 mmol/L with cholesterol-lowering medication was associated with reduced dementia risk.
Despite the benefits of blood pressure- and cholesterol-lowering medication, management of elevated blood pressure and cholesterol levels in Australia is unsatisfactory, placing too many people at risk of premature illness and death. To respond to Amanda Hooton’s concern about midlife mortality, being healthy post 50 should not be “dumb luck”, but the norm.
The failure of Australians to adequately prevent cardiovascular disease can be attributed, at least in part, to a failure to control risk factors for cardiovascular disease, illustrated by the failure to adequately manage elevated blood pressure and cholesterol levels.
Addressing the risk of midlife mortality, Amanda asks: “is there anything we can do about it?…Why do we so reliably fail to do the things we know are good for us? …we continue to take risks with our health we would never countenance in other parts of our lives. Why?”
Management of tobacco use, alcohol use, physical activity, diet and weight challenges us because it requires behaviour modification. Control of elevated blood pressure and cholesterol levels should be less challenging because these risk factors are managed predominantly with medication prescribed by medical practitioners. Taking blood pressure or cholesterol medication need be no more of a challenge than taking any other regular medication each day, like the contraceptive pill. However, we’re failing to control these two risk factors.
According to the Australian Institute of Health and Welfare and the National Hypertension Taskforce of Australia, one third of adults have elevated blood pressure. For many, elevated blood pressure is not controlled, either because they are not aware their blood pressure is elevated, they were not taking blood pressure-lowering medication, or their blood pressure is not controlled by their medication.
The proportion with elevated blood pressure is much higher than these numbers suggest because they are based on a definition of high systolic blood pressure greater than 140 mmHg, whereas a healthy or ‘normal’ systolic blood pressure is less than 120 mmHg.
There is a similar lack of awareness of and failure to correct elevated cholesterol levels. One third of Australian adults have elevated cholesterol levels, and of those receiving cholesterol-lowering medication, most have cholesterol levels higher than optimal.
Our failure to adequately manage cardiovascular disease risk raises the question of how we can do better. In discussing modifiable risk factors, Amanda Hooton focussed her attention on actions that can be taken mid-life. However, cardiovascular disease starts in childhood and prevention should start in childhood.
Childhood and adolescence may appear to be free of cardiovascular disease, but it silently progresses until it manifests as illness or death later in life. Children with higher blood pressures at age 7 years are at greater risk of cardiovascular disease when they reach middle age.
Other cardiovascular disease risk factors in adolescence and young adulthood, including smoking, being overweight, and elevated cholesterol levels, are also associated with cardiovascular disease in midlife. For many people, their first heart attack occurs without warning, and adults younger than 40 years represent an increasing proportion of heart attacks. There is an urgent need to improve cardiovascular health and prevent cardiovascular disease, particularly in the young.
Each of us has a personal responsibility to our cardiovascular health and risk of cardiovascular disease. To fulfil this responsibility, Australians need education about cardiovascular health and disease, their own cardiovascular disease risk, ‘optimal’ targets for their risk factors, and the need to adhere to risk reduction strategies to achieve optimal risk factor control. Given the evolution of cardiovascular disease over a lifetime and the association of childhood risk factors with cardiovascular death and illness later in life, the challenge is to instil a mindset for cardiovascular health early in life that endures. One possible solution is a childhood-targeted education program, like the SunSmart program.
Part of the success of the SunSmart program was its education and empowerment of children, with advice in the 80s from ‘Sid the Seagull’, to instruct their parents to practice sun protection. The SunSmart program was estimated to have prevented 43,000 skin cancers between 1988 and 2011. It is important to note that the benefits of the SunSmart program were due not to medication (apart from sunscreen) but from behaviour change. Such behaviour change regarding sun protection may extend over generations, as parents who experienced the SunSmart program as children may be more likely to instruct their children in sun protection than parents who had not. The program provides a template for community-based childhood-targeted education about cardiovascular health that could empower children to instruct their parents about cardiovascular disease risk management.
Health education is part of the school curriculum. This curriculum can be expanded with instruction that educates students about optimal lifestyle for cardiovascular health. With guidance from a community nurse, students could learn how to measure blood pressure, and to measure cholesterol levels with a ‘point-of-care’ instrument. Students could measure their own and their classmates’ blood pressure and take the blood pressure monitor home to measure the blood pressure of family members (with attention to cuff size) and encourage family members to obtain measurement of their cholesterol level. They could carry out an assignment whereby they tabulate the cardiovascular disease risk of family members and discuss how their cardiovascular disease risk might be improved.
Rather than attempt to obtain precise measurement of cardiovascular disease risk parameters, the primary goal of such an activity would be to create an awareness and appreciation of cardiovascular health and its determinants. Discovery of cardiovascular disease risk parameters that are of concern could prompt evaluation by a general practitioner.
Educating and empowering children to implement strategies that address cardiovascular disease risk, including knowledge and control of their blood pressure and cholesterol levels, physical activity, a healthy diet, avoidance of overweight, moderation of alcohol intake, and never smoking, has potential to impact not only the lifetime cardiovascular disease risk of the child but also the cardiovascular disease risk of their families and the community.
Every child at the end of secondary school should know their blood pressure and cholesterol level, and they should encourage family members to know these levels as well.
The proposed program would present challenges to implementation and, as illustrated by the SunSmart program, would require the skills of a creative marketing agency. The SunSmart program was delivered to the community primarily through television advertisements. The program might also be delivered through television advertisements, although telemedicine and social media offer alternative means of delivery.
For cardiovascular health to become part of the school curriculum, teachers would need to be provided with the skills to implement the program, although teachers may be keen to participate because they may gain from the program with respect to their personal cardiovascular disease prevention. Additionally, participation of a community nurse in school-based education would require funding.
The Heart Research Institute recommends individuals older than 18 years of age have their blood pressure checked at least every two years, and annually for individuals older than 45 years of age. The Heart Research Institute also recommends individuals aged 45 years or older (35 years or older for Aboriginal or Torres Strait Islander peoples) have their cholesterol measured every 5 years, or every 12 months if they have elevated blood pressure, diabetes, heart disease, stroke, or kidney disease.
By contrast, the American National Heart, Lung and Blood Institute and the American Academy of Pediatrics recommend universal cholesterol screening for all children aged 9 to 11 years. Measurement of blood pressure and cholesterol levels in children can enable the identification of children at increased risk, which may be genetic, and medication commenced early to prevent cardiovascular disease.
Efforts to manage cardiovascular disease risk in the community could also be implemented through existing healthcare providers. Comparison of different approaches to management of elevated blood pressure in the community showed that pharmacists and community health workers were effective in the management of elevated blood pressure, and community healthcare provider-led management of elevated blood pressure was effective in reducing cardiovascular disease and death. Individuals could also be encouraged to measure their blood pressure at home with an automatic blood pressure monitor, or their pharmacist could provide this service.
Another possible approach is the provision of self-service kiosks for blood pressure measurement at retail stores. Blood pressure- and cholesterol-lowering medication could be initiated by a general practitioner, with supervision and continuation of prescription medication by a pharmacist. Pharmacist co-management has been shown to substantially improve management of elevated cholesterol levels in individuals requiring cholesterol-lowering medication.
Telemedicine and mobile-health technologies, operating synergistically with public-health education models, may similarly assist individuals in achieving cardiovascular disease risk factor control and prevention. A key benefit of empowering people to manage their blood pressure and cholesterol levels, with support from pharmacists and allied health professionals, is reduction in the burden of prevention on general practitioners.
Self-management of medication is well established, as illustrated by individuals with diabetes who adjust their insulin dose. Pharmacist support for self-management of blood pressure and cholesterol levels would be an extension of the role they already play in health promotion, as illustrated by their provision of vaccinations, resupply of oral contraception, and supply of an antibiotic for a urinary tract infection if appropriate.
Despite considerable understanding of risk factors for cardiovascular disease and how their control can prevent cardiovascular disease, current cardiovascular disease risk reduction strategies do not fulfil their potential. There is need for innovative strategies to address gaps in awareness and management of cardiovascular disease risk.
A childhood-targeted education program that instils a mindset for cardiovascular health early in life offers considerable potential to improve the control of cardiovascular disease risk and better prevent its consequences. This could help us find a healthy path through middle age and achieve more years of healthy living.
References:
This article is based on a manuscript published in the International Journal of Cardiology Cardiovascular Risk Prevention 2025;27:200553. doi: 10.1016/j.ijcrp.2025.200553 that provides references to the data described in this article.
