Pediatric Annals

Special Issue Article 

Preserving Optimal Cardiovascular Health in Children

Amanda M. Perak, MD, MS; Irwin Benuck, MD, PhD

Abstract

The origins of cardiovascular disease are at the beginning of life, and national guidelines recommend evaluation for cardiovascular risk factors such as obesity and hypertension as part of general pediatric care. In this review, a simple plan is proposed for clear and consistent monitoring and messaging throughout childhood, based on the American Heart Association's “cardiovascular health” construct. A framework is provided for age-appropriate scoring of the cardiovascular health components, including diet, physical activity and screen time, sleep, smoking exposure, body mass index, blood pressure, cholesterol, and glucose. Guidance is provided for evidence-based, efficient intervention by pediatric clinicians to preserve or restore cardiovascular health. Finally, anticipated near-term advances in pediatric cardiovascular health promotion are previewed. [Pediatr Ann. 2018;47(12):e479–e486.]

Abstract

The origins of cardiovascular disease are at the beginning of life, and national guidelines recommend evaluation for cardiovascular risk factors such as obesity and hypertension as part of general pediatric care. In this review, a simple plan is proposed for clear and consistent monitoring and messaging throughout childhood, based on the American Heart Association's “cardiovascular health” construct. A framework is provided for age-appropriate scoring of the cardiovascular health components, including diet, physical activity and screen time, sleep, smoking exposure, body mass index, blood pressure, cholesterol, and glucose. Guidance is provided for evidence-based, efficient intervention by pediatric clinicians to preserve or restore cardiovascular health. Finally, anticipated near-term advances in pediatric cardiovascular health promotion are previewed. [Pediatr Ann. 2018;47(12):e479–e486.]

Cardiovascular disease (CVD) is the leading cause of death in the United States.1 The origins of CVD are clearly at the beginning of life, as autopsy studies have shown that atherosclerosis is already present in childhood.2 Therefore, it is within the domain of pediatric clinicians to support families in setting their children on a course that will help them avoid CVD and maximize their healthy longevity. Furthermore, given that 33% of US youth age 2 to 19 years are overweight or obese,1 traditional CVD risk factors (eg, dietary intake and blood pressure) are unavoidable topics in pediatric primary care, as they are contributors to and consequences of excess weight.

Guidelines from the American Academy of Pediatrics (AAP),3 National Heart, Lung, and Blood Institute (NHLBI),2 US Department of Health and Human Services,4 US Preventive Services Task Force,5 and other national groups provide guidance on evaluating individual CVD risk factors such as obesity during the pediatric health care visit. However, assembling these guidelines into a simple plan for consistent CVD risk factor monitoring and optimization throughout childhood may represent a sizable challenge for the busy practitioner.

The American Heart Association (AHA)-defined concept of “cardiovascular health” (CVH), provides a simple platform for clear and consistent CVD risk factor measurement, monitoring, and messaging across the lifecourse.6,7 This article defines CVH, suggests a practical CVH tool for use in routine primary care, offers recommendations for how to intervene on CVH, and highlights emerging developments in CVH that are expected to affect pediatric care in the near future.

What is CVH?

CVH is a broader, more positive construct than just the absence of disease.6 The AHA defines CVH through health behaviors and health factors known as “Life's Simple 7.” These are diet, physical activity, smoking, body mass index (BMI), blood pressure, blood cholesterol, and blood glucose.6,7 For a given person, each CVH metric can be categorized as ideal, intermediate, or poor based on thresholds from national guidelines, and a score can be calculated to summarize overall CVH (Table 1). The special status of “ideal CVH” refers to optimal levels of all seven health behaviors and factors simultaneously.1

Suggested Cardiovascular Health Metric Scoring for the General Pediatric Clinician

Table 1.

Suggested Cardiovascular Health Metric Scoring for the General Pediatric Clinician

A large body of evidence supports the relevance of CVH as a clinical target in adults and children. Better CVH in adulthood is associated with not only markedly better CVD-free survival, but also a variety of noncardiovascular benefits, including lower rates of cancer and other chronic diseases of aging, longer overall longevity and healthy longevity (compression of morbidity), better cognitive function, less depression and superior quality of life, and reduced health care costs.1,6 Better CVH in childhood is associated with better CVH in adulthood8 as well as lower risks of subclinical CVD, such as coronary artery calcification,9 adverse cardiac structure and function,10 high-risk carotid intima-media thickness,8,9 and high-risk carotid distensibility.9 Moreover, childhood intervention can improve CVH and vascular function in adulthood. In the Special Turku Coronary Risk Intervention Project for Children study,11 repeated dietary counseling starting in infancy led to better CVH in adolescence, and better CVH was associated with better aortic elasticity and 44% lower risk of high aortic intima-media thickness.

On a population level, the current status of CVH in US youth is far from ideal, but it is better than in US adults (Figure 1). At the youngest ages, only a subset of CVH metrics are available in nationally representative data from the National Health and Nutrition Examination Surveys (NHANES). At age 2 to 5 years, about 75% of US children have ideal BMI (the only CVH metric measured in NHANES at that age).12 At age 8 to 11 years, just 39% of children have 3 of the 4 measured metrics (diet, BMI, cholesterol, and blood pressure) at ideal levels, whereas essentially none have all 4 metrics at ideal levels.12 For US adolescents age 12 to 19 years, 41% have at least 5 of the 7 metrics at ideal levels, but <1% have all 7 metrics at ideal levels.1 In adults, just 17% have at least 5 of 7 metrics at ideal levels.1 Thus, CVH is generally the highest early in life and then declines with age. Comparing the 7 metrics, ideal status is lowest for diet in both children and adults, followed by physical activity and BMI, then cholesterol (Figure 1).1,12

Status of CVH in children, adolescents, and adults in the United States. The proportions of people with metrics categorized as ideal (green), intermediate (yellow), or poor (red) are shown by the bars and overlaid numbers, based on population-weighted NHANES data1,12 from the indicated years. (A) This panel shows CVH in children age 2 to 11 years. Diet is shown for age 5 to 11 years, BMI for age 2 to 11 years, blood pressure for age 8 to 11 years, and total cholesterol for age 6 to 11 years. (B) This panel shows CVH in adolescents age 12 to 19 years. (C, D) These panels show CVH in younger and older adults, respectively. The data show that the prevalence of ideal CVH metrics is generally highest at the youngest ages and declines across the lifecourse. Asterisk indicates that in the child age groups the available data vary by metric. BMI, body mass index; CVH, cardiovascular health; NHANES, National Health and Nutrition Examination Survey.

Figure 1.

Status of CVH in children, adolescents, and adults in the United States. The proportions of people with metrics categorized as ideal (green), intermediate (yellow), or poor (red) are shown by the bars and overlaid numbers, based on population-weighted NHANES data1,12 from the indicated years. (A) This panel shows CVH in children age 2 to 11 years. Diet is shown for age 5 to 11 years, BMI for age 2 to 11 years, blood pressure for age 8 to 11 years, and total cholesterol for age 6 to 11 years. (B) This panel shows CVH in adolescents age 12 to 19 years. (C, D) These panels show CVH in younger and older adults, respectively. The data show that the prevalence of ideal CVH metrics is generally highest at the youngest ages and declines across the lifecourse. Asterisk indicates that in the child age groups the available data vary by metric. BMI, body mass index; CVH, cardiovascular health; NHANES, National Health and Nutrition Examination Survey.

How Should Pediatric Clinicians Assess CVH?

Routine assessment of CVH can easily be incorporated in all well-child visits across childhood and adolescence. This provides an opportunity for clear and consistent messaging to children and families, while addressing national guidelines for health monitoring. CVH also offers a unique advantage for addressing the prevalent risk factors of overweight and obesity. CVH assessment replaces a singular focus on weight, which is not directly modifiable and can be a source of embarrassment and distress that contributes to disordered eating.13 CVH instead emphasizes directly modifiable behaviors (eg, diet and physical activity) that contribute to excess weight and also to other adverse health outcomes. It also highlights tangible consequences (eg, dyslipidemia and hypertension) to increase understanding and motivation for families to make lifestyle changes.

Table 1 offers a suggested template for practical assessment and scoring of CVH factors across childhood and adolescence. For a given child, each of the CVH factors can be categorized as ideal, intermediate, or poor, and a total CVH score can be calculated. From the prenatal consultation through adolescence, each visit can include an assessment and brief discussion of CVH. Prenatally, the CVH assessment and discussion will focus primarily on family lifestyle habits (and heritable CVD risk factors). For example, the family's diet quality and exercise habits can be scored and discussed using the same metric definitions as for the child. As the child grows, more of his or her own CVH metrics are measured and become the focus. By age 9 to 11 years (after universal cholesterol screening2,14), the child's own measurements are available for all but fasting glucose (which is only measured in children with certain risk factors15), and glucose can be omitted from the score but discussed as an important outcome of CVH behaviors. Thus, across the spectrum of ages, the CVH metrics and messaging are consistent, which reinforces education for the family and simplifies assessment and counseling for the practitioner.

In the authors' opinion, this consistent messaging is the key to CVH's utility in general practice, and the pediatric clinician should worry less about precise categorization for health behavior metric levels where this is less straightforward (as opposed to health factors such as BMI, blood pressure, cholesterol, and glucose, where clear thresholds are established for ideal, intermediate, and poor). Taking diet as an example, the pediatric clinician might focus effort on becoming familiar with the Dietary Approaches to Stop Hypertension (DASH) pattern, as outlined in the NHLBI Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children,2 or the Dietary Guidelines for Americans pattern,16 which is nearly identical to DASH. The child's dietary pattern can be assessed qualitatively as ideal (essentially meeting all DASH goals), intermediate, or poor based on information about each meal and snack of a typical day. In the authors' practice, families are often given a printout of either a customized Dietary Guidelines for Americans MyPlate plan16,17 or the DASH table with a range of calorie levels circled based on an estimate of the child's needs (using the NHLBI guideline2) to provide a framework for counseling. However, precise serving sizes and numbers are not generally calculated and compared against the tables to assess the diet. Thus, CVH is used as a messaging tool—an opportunity to evaluate the diet qualitatively—and precise scoring is, therefore, less important.

With this in mind, Table 1 is based on the AHA's definition of CVH but also includes modifications aimed at increasing the utility of the CVH construct in pediatric practice. The AHA defined CVH to be not only evidence-based but also measurable in the population using NHANES data;6,7 therefore, some important metrics could not be included in the initial “Life's Simple 7” (but updates are expected). Thus, in Table 1, sleep has been added as an eighth CVH metric. A solid body of evidence supports the association between sleep patterns and health in childhood18 and adulthood,19 and it is possible that sleep may eventually be added to the CVH metrics to make an “Essential Eight.” Additionally, in Table 1, some of the AHA definitions of CVH metric categories are expanded to be more inclusive in ways particularly relevant to children. For example, the physical activity metric is expanded to address leisure screen time,20,21 the cholesterol metric is expanded beyond total cholesterol to include its components (low- and high-density lipoprotein cholesterol and triglycerides),2 and the smoking metric is expanded to include secondhand smoke.22

The following is an example of how to create a CVH score using Table 1. A 4-year-old eats fruits or vegetables at every meal and snack, drinks no sugar-sweetened beverages, rarely eats processed or fast food (sodium), but eats refined grains (not whole) and no fish (intermediate diet = 1 point); the child watches 2 hours per day of television and plays actively for more than 60 minutes/day (intermediate activity = 1 point), sleeps 12 hours/night (ideal sleep = 2 points), is not exposed to secondhand smoke (ideal = 2 points), has a BMI at the 70th percentile (ideal = 2 points), blood pressure at the 50th/60th percentiles (ideal = 2 points), and has not had cholesterol or glucose checked. The child has 10 of a possible 12 points on the 6 metrics scored, for a score of 83%, and therefore has high CVH. Counseling could focus on changing to whole grains, serving low-mercury fish twice per week, decreasing screen time, and continuing with other healthy habits.

A second example is a 15-year-old who has fruit once per day but no vegetables, a can of soda daily, fast food weekly, eats refined grains, and no fish (poor diet = 0 points); the adolescent watches 1 hour per day of television and has sports practice more than 60 minutes per day 5 days per week but no weekend exercise (intermediate activity = 1 point), sleeps 7.5 hours per night (intermediate sleep = 1 point), does not smoke but lives with a smoker (intermediate = 1 point), has a BMI at the 99th percentile (poor = 0 points), blood pressure of 125/77 mm Hg (intermediate = 1 point), total cholesterol of 172 mg/dL, low-density lipoprotein cholesterol of 105 mg/dL, high-density lipoprotein cholesterol of 32 mg/dL, and triglycerides of 173 mg/dL (poor [based on triglycerides and HDL-C] = 0 points), and fasting plasma glucose of 95 mg/dL (ideal = 2 points). The adolescent has 6 of a possible 16 points on the 8 metrics scored, for a score of 38%, and thus has low CVH. Intensive counseling is merited, and the adolescent may require referral to a lifestyle program (in addition to further evaluation of elevated blood pressure).

CVH behaviors (ie, diet, physical activity, sleep, and smoking exposure) can be incorporated into paper surveys that families can complete in the waiting room of the pediatric office. This can increase efficiency, facilitate subsequent discussion between the pediatric clinician and family, and reinforce the importance of these behaviors throughout childhood.

How Can a Pediatric Clinician Intervene on CVH?

Each metric provides an opportunity not only to assess the child's own risk and family history and environment, but also to offer intervention recommendations and/or anticipatory guidance. Even brief motivational interviewing by pediatric clinicians can positively impact behaviors, and the AAP has published free resources on the motivational interviewing technique, including the mobile app “Change Talk.”23,24 Most primary care counseling will be focused on the four CVH behaviors (ie, diet, physical activity, sleep, and smoking exposure), whereas children with poor levels of CVH factors (BMI, blood pressure, cholesterol, and glucose) may sometimes require referral for intensive management, as described below.

Diet

Based on population-level estimates (Figure 1), essentially every US child needs improvement in his or her dietary quality. Although assessment and counseling about dietary intake is nothing new for the pediatric clinician (eg, breast-milk vs formula, ensuring adequate vitamin D and calcium intake), recent guidelines have shifted the focus away from nutrients in favor of overall dietary patterns, given the synergistic and cumulative health effects of the totality of diet and the need for easier translation for patients.16,25 The DASH dietary pattern is recommended by the NHLBI guidelines for children2 and is essentially identical to the “healthy US-style” pattern recommended for children by the 2015 Dietary Guidelines for Americans.16,26 These patterns emphasize adequate intakes of fruits, vegetables, whole grains, nuts, seeds, legumes, and low-fat dairy, and restricted intake of added sugars (practically, the AHA recommends <25 g/d of added sugars for all children and adolescents).27 Fish, unprocessed meats, and unsaturated oils are also part of the healthy dietary patterns, whereas saturated fats are limited, and processed foods (high in sodium) and refined grains are discouraged. Both the NHLBI guidelines2 and Dietary Guidelines for Americans16 ( choosemyplate.gov/children17) offer resources to help with dietary counseling. For example, the “plate” method of eating ensures that half of every meal and snack consists of vegetables and fruits, which are preferably consumed before the rest of the meal and are also drawn on for “seconds” if hunger persists. The other half of the plate consists of age-appropriate portions of whole grains and lean proteins. Families can be encouraged to use this simple method when eating and to read labels when shopping, particularly for added sugars in children's cereals and snacks. These patterns and recommendations are applicable across ages, including in adulthood, and thus are highly relevant to entire families. Of course, at the youngest ages (0–24 months), the focus should be on encouraging breast-feeding (and healthy maternal diet) and age-appropriate introduction of the healthy dietary pattern.2 The pediatric clinician might focus effort on becoming familiar with the DASH or healthy US-style diet pattern and consider including questions about relevant food groups on patient surveys that can be completed in the waiting room.

Physical Activity

Children and adolescents should get at least 60 minutes per day (or at least 3 hours per day for children age 3 to 5 years) of moderate to vigorous intensity aerobic exercise.4 Practically, this level of exercise is expected to result in heavy breathing and sweating, and it can be useful to clarify this with older children and adolescents. Additionally, children should include muscle- and bone-strengthening exercise at least 3 days per week each. As active play, physical education classes, and school sports are not universally available, the pediatric clinician should keep in mind a few age-appropriate exercise options that require minimal new resources. For example, dancing (vigorously) is something many children enjoy and can easily do at home with no equipment, jumping rope requires minimal equipment and space, and active video games are a good option for children who already have consoles. Older children and adolescents may enjoy aerobic and body-weight resistance exercise videos, of which many are freely available online (eg, 7-minute workout apps). Park districts, Boys and Girls Clubs of America, and YMCA centers offer options for group fitness. Independent of physical activity, sedentary time is another important contributor to health,4,21 and in children screen time is the most relevant sedentary time. In fact, simply having a television in the bedroom is associated with higher risk of obesity,21 and removing that television may be a good first step for families with poor screen-time habits. Adherence to screen time limits (Table 1) also frees up needed time for exercise and sleep, particularly in older children with extracurricular activities and homework. Families can be counseled about exercise and screen time concurrently as two important contributors to activity levels.

Sleep

Parental concern about sleep may be weighted toward infancy and toddlerhood, but sleep is critical for health at all ages. Recommendations regarding appropriate amounts of sleep for children have been made by the American Academy of Sleep Medicine and endorsed by the AAP,28 and they are shown in Table 1. Pediatric clinicians can encourage healthy sleep habits first by educating families about recommended amounts of sleep, which may be surprising to some. Practically, regular routines are key. Daytime routines should include plenty of physical exercise, and bedtime routines should ensure that all screens are off at least 1 hour before bedtime.29 Pediatric clinicians can also help families recognize when their older children and adolescents are overscheduled and need to reprioritize to allow healthy sleep habits.

Smoking Exposure

Although the prevalence of tobacco smoking has decreased among both youth and adults over the past decade, it remains the largest preventable cause of death in the US, and nearly 10% of those deaths are attributed to secondhand smoke exposure.1 Secondhand smoke exposure is of particular relevance in childhood, with approximately 1 in 3 US children exposed.22 Additionally, e-cigarette use is increasing among adults and youth in the US,1 and the limited data available suggest that both firsthand and secondhand e-cigarette exposure may have detrimental effects on CVH. E-cigarette use may also initiate nicotine addiction, serve as a gateway to cigarette smoking, and reverse the gains in “de-normalizing” smoking behavior that have been made by anti-tobacco campaigns in recent decades.30 Pediatric clinicians can help promote a smoke-free environment and lifestyle by reinforcing a strong anti-smoking message for both children and parents at every visit. It is recommended that pediatric health care practices be established as a resource for smoking cessation, including provision of quit line numbers, links to community cessation resources, and information about pharmacotherapy for cessation.2,22

BMI, Blood Pressure, Cholesterol, and Glucose

For each of these health factors, significant disturbances may necessitate referral for more dedicated, time-intensive behavioral and pharmacologic management. Still, the pediatric clinician retains an important role in consistently reinforcing lifestyle messaging about the four CVH behaviors described above and reminding children and families about their critical importance for the CVH factors. National guidelines outline the diagnosis and management strategies for each of these CVH factors, including recommendations on when to refer.2,15,31–33

What New Information about CVH Can Pediatric Health Care Clinicians Expect in Coming Years?

It is expected that the AHA definition of CVH for children will be expanded and refined significantly over the next several years.7 The AHA has recently funded a Strategically Focused Children's Research Network, which includes several projects designed to improve the assessment of CVH from the beginning of life. CVH may be expanded to include new metrics (eg, sleep, completely novel components such as neurocognitive function), existing metrics may be modified to improve their relevance to children (eg, formally incorporating secondhand smoke exposure in the smoking metric, including specific guidance for pregnant women aimed at breaking intergenerational cycles of poor CVH), and scales may be made more granular to accommodate repeated evaluation in children (for whom small changes may be more relevant). Additionally, for the first time, the forthcoming 2020 Dietary Guidelines for Americans will address diet in pregnant women and in children age 0 to 24 months,34 and this may influence future CVH definitions and provide valuable resources for pediatric clinicians regarding CVH-promoting infant dietary exposures and caregiver feeding practices.

Conclusion

The CVH construct provides a simple, universal method for consistent health messaging across the lifecourse. Given the decline in ideal CVH metrics with age, and the known extensive health benefits of maintaining ideal CVH metrics, pediatric clinicians can play a critical role in improving population CVH and preventing morbidity and mortality from CVD.

References

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Suggested Cardiovascular Health Metric Scoring for the General Pediatric Clinician

Metric Ideal = 2 Points Intermediate = 1 Point Poor = 0 Points
Diet Assessed qualitatively against the DASH or the Dietary Guidelines for Americans pattern. Alternatively, particular focus can be given to 5 components: adequate intakes of (1) fruits and vegetables, (2) fiber-rich whole grains, and (3) fish, and limited intakes of (4) sugar-sweetened beverages and (5) sodium, all scaled for caloric intake
4–5 components met 2–3 components met 0–1 components met
Physical activity Combinations of adequate activity and limited leisure screen time, by age: Age 0–2 y: active play; no screen time Age 3–5 y: ≥3 hours per day of activity, <1 hour per day of screen time Age ≥6 y: ≥60 minutes per day of moderate-to-vigorous activity, <2 hours per day of screen time Activity >0 minutes per day but below ideal goal; or leisure screen time above ideal limits No appropriate physical activity (eg, no moderate-vigorous intensity activity for children age ≥6 years)
Sleep Total per 24 hours:   Age 4–12 months: 12–16 hours   Age 1–2 y: 11–14 hours   Age 3–5 y: 10–13 hours   Age 6–12 y: 9–12 hours   Age 13–18 y: 8–10 hours 1 hour or less outside the ideal range More than 1 hour outside the ideal range, or other significant sleep disturbance (eg, short night sleep and requiring daytime naps in an older child or adolescent)
Smoking Never smoked whole cigarette and no secondhand smoke exposure Secondhand smoke exposure and/or remotely tried smoking Tried smoking in the prior 30 days
Body mass index <85th percentile 85th–95th percentile >95th percentile
Blood pressure Age 0 to <13 y: SBP and DBP <90th percentile Age ≥13 y: <120/<80 mm Hg Age 0 to <13 y: SBP or DBP 90–95th percentile Age ≥13 y: 120 to <130/<80 mm Hg Age 0 to <13 y: SBP or DBP >95th percentile Age ≥13 y: SBP >130 or DBP >80 mm Hg
Cholesterol Total cholesterol <170 mg/dL Non-HDL cholesterol <120 mg/dL HDL cholesterol >45 mg/dL LDL cholesterol <110 mg/dL Triglycerides <75 mg/dL (age 0–9 y) or <90 mg/dL (age 10–19 y) Total cholesterol 170–199 mg/dL Non-HDL cholesterol 120–144 mg/dL HDL cholesterol 40–45 mg/dL LDL cholesterol 110–129 mg/dL Triglycerides 75–99 (age 0–9 y) or 90–129 mg/dL (age 10–19 y) Total cholesterol ≥200 mg/dL Non-HDL cholesterol ≥145 mg/dL HDL cholesterol ≤40 mg/dL LDL cholesterol ≥130 mg/dL Triglycerides ≥100 (age 0–9 y) or ≥130 mg/dL (age 10–19 y)
Glucose Fasting plasma glucose <100 mg/dL, HgbA1C <5.7% Fasting plasma glucose 100–125 mg/dL, HgbA1C 5.7%–6.4% Fasting plasma glucose ≥126 mg/dL or HgbA1C ≥6.5%
Total CVH Score Possible total score varies according to number of measured metrics available (eg, glucose not measured routinely). Suggest dividing sum of earned points by sum of possible points and calculating percent score
Ideal CVH 100% High CVH 75%–<100% Moderate CVH 50%–<75% Low CVH 0%–<50%
Authors

Amanda M. Perak, MD, MS, is an Assistant Professor, Departments of Pediatrics (Division of Cardiology) and Preventive Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine. Irwin Benuck, MD, PhD, is a Professor, Department of Pediatrics, and Chief of the Division of Community-Based Primary Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine.

Address correspondence to Amanda M. Perak, MD, MS, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL 60611; email: amanda.marma@northwestern.edu.

Grants: The work of A.M.P. was supported by a National Institutes of Health training grant (T32HL069771), a Pediatric Physician-Scientist Research Award from the Department of Pediatrics at Northwestern University Feinberg School of Medicine, and an American Heart Association Strategically Focused Children's Research Network grant (17SFRN33700242).

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/19382359-20181115-01

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