ABC | Volume 113, Nº4, October 2019

Updated Updated Cardiovascular Prevention Guideline of the Brazilian Society Of Cardiology – 2019 Arq Bras Cardiol. 2019; 113(4):787-891 3. Age-appropriate caloric intake, taking into account their basal metabolic rate, as well as growth and exercise needs, except in children with special conditions, or inadequate growth and body composition. 4. Offer the child the most varied and colorful food possible, respecting the proportionality between protein (10 to 20% of total daily caloric volume), fat (30 to 40%) and carbohydrates (30 to 50%) in each age, provided there are not any risk factors that require different proportions. 5. Encourage the daily intake of fruits and vegetables by offering this type of food at every meal. The child should eat the equivalent of his age + 5 in grams of fiber. 6. Avoid sugar (ideally less than 5% of total daily calories), coffee, canned goods,fried foods, soft drinks, candies, snacks and other treats throughout development, these foods should be banned in infants. Replace, whenever possible, processed and ultra-processed foods with fresh or minimally processed foods, regardless of age and body composition. 7. Use salt sparingly. Children’s food must have a less spice and salt than an adult’s; 1.2 to 1.5 g/day of salt for children up to preschool age and up to 2 g/day in school children and adolescents. 8. Associate proteins of animal and vegetal origin, eat whole grains and vegetables at least 5 times a week, in the ratio of 3:1. Animal proteins should be of varied origins, encouraging the consumption of fish. 9. Frequent water intake throughout the day, limiting the intake of juices, even if natural and without added sugar: Ideally, only provide juices from 1 year of age, and at most 120 mL, 180 mL and 240 mL, for infants, preschoolers and schoolchildren, respectively. 10. Offer high nutritional value fats, such as nuts (nuts, almonds, walnuts, among others) and vegetable oils, as long as they are safe (avoid fresh nuts in children under 3 years due to the risk of aspiration) and according to age-appropriate amount. Avoid the intake of trans fats as much as possible. For children with dyslipidemia, fat intake should be limited to about 25-30% of their total daily calories, while maintaining a proportion of < 7 to 10% saturated fat and 20% mono and polyunsaturated fat, similar to recommendations for adults. The addition of sugar should be avoided and the intake of omega-3 in the form of fish rich in these fatty acids ideally 2 or 3 times a week should be encouraged. Follow-up with a nutritionist or nutrologist is recommended when there is a risk of malnutrition or impaired growth and development. 565 (Recommendation Level IIa, evidence level A). For children with SAH, the DASH diet should be used, as in adults, which includes increasing the proportion of fresh foods, especially fruits and vegetables, and reducing salt intake. 566 (Recommendation Level IIa, level of evidence B). Control of the food environment is of utmost importance in childhood and adolescence, especially the school environment, which should be protected by public policies that encourage the supply of foods with high nutritional value and restrict ultra-processed, high-calorie or high-density foods with added sugar and trans fats. 567 (Recommendation Level I, level of evidence C). 11.3. Physical Activity in Childhood and Adolescence Physical activity is considered an independent protective factor in the primary prevention of coronary artery disease since childhood, because of its effect on modulating traditional risk factors and promoting normal endothelial function. Higher levels of physical activity are associated with improved bone health, nutritional status, cardiometabolic health, cognitive function, and reduced risk of depression. 568 Intervention programs to increase physical activity in children are associated with improved blood pressure and lipid profile. 569 Physical activity is considered any body movement that results in energy expenditure. Physical exercise consists of planned, structured and repetitive physical activity. In Brazil, the prevalence of physical inactivity was assessed in a sample of 74,589 adolescents in the Study of Cardiovascular Risks in Adolescents (ERICA). The prevalence of leisure-time physical inactivity reached 54.3%, being especially worrying in female adolescents (70.7%). More than a quarter of adolescents reported no leisure-time physical activity. 570 The discussion about childhood physical activity has two important aspects for cardiovascular prevention. The first is the tracking phenomenon described above, highlighting the importance of establishing healthy habits at a time when the child is developing, which is much easier to intervene than after the sedentary lifestyle has been established and excessive screen time (more than 2 hours/day). The second aspect is the accumulation of risk or protective factors over the course of life, which can determine different levels of risk over many years of exposure. Regarding these concepts, in 2016, the American Heart Association published the Cardiovascular Health Promotion in Children document: Challenges and Opportunities for 2020 and Beyond The Scientific Statement From the American Heart Association, stating that maintaining optimal CV health from birth to young adulthood is critical part of reducing CVD disease in adulthood. 571 The physical activity level considered ideal for children and adolescents aged 6 to 17 years is 60 minutes or more per day of intense to vigorous aerobic activity. The document also recommends performing muscle strength activity and muscle-strengthening and bone-loading1 at least three times a week (Recommendation Level IIa, Evidence Level B). 568,571 Preschoolers (3-5 years old) should remain active throughout the day to encourage growth, development and to acquire a repertoire of motor skills. Caregivers should aim to achieve a total of at least 3 active hours per day, diversifying from mild to vigorous intensities (Recommendation Level IIa, level of evidence B). Although there is no consensus on the amount of activity or exercise needed to treat CV risk factors such as dyslipidemia, hypertension or obesity in childhood, it is known that even without effective control of their CV risk, physical activity is one of the most important pillars in the prevention of 854