The New Phase of the Prevention Pyramid–the Primordial Prevention

You are what your mother eats: launch a new generation into a lifetime of ideal cardiovascular health

––#AHA21 Recap from presidential lecture by Dr. Don Lloyd-Jones, AHA President

My PhD research was focused on maternal nutrition and epigenetics. When I started graduate school, the field of epigenetics just started to make some splash in the scientific community. As a new graduate student, I have a plethora of questions. What is epigenetics? Why should I care to study it? How does that have anything to do with nutrition? You are what your mother ate. The food your mother had during pregnancy and lactation can forever change your health through epigenetic regulation (without changes in your genetic makeup). This became my passion, to understand how maternal nutrition affects offspring and how to promote healthy life from the beginning of everything.

At 2021 scientific sessions of American Heart Association (AHA), Dr. Don Lloyd-Jones gave an inspirational speech about the next phase of the Prevention Pyramid–the Primordial Prevention (Fig.1). The previous Prevention Pyramid contains three segments which were chronically progressed: Tertiary Prevention,

Secondary Prevention, and Primary Prevention. With the development of medical devices and acute therapy, the Tertiary Prevention helped in-hospital mortality rate drop from more than 30% to less than 5%. The Secondary Prevention applies discharge therapies and significantly reduces the recurrent incidences of cardiovascular diseases (CVD) events. The current strategy to fight CVD is through reducing incidences via targeting risk factors, called the Primary Prevention. Starting from the Framingham Heart Study, many important risk factors of CVD such as age, blood cholesterol level, blood pressure, smoking status have been identified. The previous Prevention pyramid made a big success in terms of CVD prevention until 2011. Then the progress curve starts to show stagnation, partly because of obesity epidemics sequelae and widening social-economics disparities.

With the help of pioneer research from Dr. Jeremiah Stamler from Northwestern University, modern CVD studies start to shift focus to study healthy people for low risk factor identification. AHA developed criteria, “Life’s simple 7TM” , defining ideal cardiovascular health (CVH): stop smoking, eat better, get active, lose weight, manage blood pressure, control cholesterol, and reduce blood sugar1. High CVH is associate with better CVD events prevention, the CVH trajectories from childhood are set as early as the 3rd grade2. Current research showed that women with ideal maternal gestational CVH is 8+ times more likely to have offspring with ideal CVH 10 years later3. The importance of Primordial Prevention is unignorable. From the latest discoveries of epigenetics studies, results suggest that not only mother’s CVH can affect babies’ CVH, father’s CVH could potentially possess certain influences as well4.

“No man is an island”, as John Donne wrote. Social determinants of health can affect 80% to 90% of a person’s risk factors (Fig. 2). To promote a better CVH for the whole community, AHA relentlessly aims to drive a more equitable health impact to the society. “Let’s do this for all the children in our life”, as Dr. Lloyd-Jones concluded, AHA is dedicating funding for more research studies to guide us towards an exciting phase of CVD prevention, the Primordial Prevention in the foreseeable future.


  1. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, Greenlund K, Daniels S, Nichol G, Tomaselli GF, Arnett DK, Fonarow GC, Ho PM, Lauer MS, Masoudi FA, et al. Defining and Setting National Goals for Cardiovascular Health Promotion and Disease Reduction. Circulation. 2010;121(4):586–613.
  2. Allen NB, Krefman AE, Labarthe D, Greenland P, Juonala M, Kähönen M, Lehtimäki T, Day RS, Bazzano LA, Van Horn L V, Liu L, Alonso CF, Webber LS, Pahkala K, Laitinen TT, et al. Cardiovascular Health Trajectories From Childhood Through Middle Age and Their Association With Subclinical Atherosclerosis. JAMA Cardiology. 2020;5(5):557–566.
  3. Perak AM, Lancki N, Kuang A, Labarthe DR, Allen NB, Shah SH, Lowe LP, Grobman WA, Lawrence JM, Lloyd-Jones DM, Lowe Jr WL, Scholtens DM, Group HF-USCR. Associations of Maternal Cardiovascular Health in Pregnancy With Offspring Cardiovascular Health in Early Adolescence. JAMA. 2021;325(7):658–668.
  4. Hughes V. Epigenetics: The sins of the father. Nature. 2014;507(7490):22–24.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”