The West Virginia CARDIAC (Coronary Artery Risk Detection in Appalachian Communities) Project was initiated to identify and address the nation-leading adult heart disease, insulin resistance, diabetes, and obesity in school children in WV. School children are screened for cardiometabolic risk factors that will lead to adult heart disease. Parents, schools, and the children receive intervention to promote cardiovascular health with a special focus on recognizing, treating, and preventing obesity. Children in fifth grade were screened for Body Mass Index (BMI), blood pressure, and fasted lipids. Over time, BMI assessments were added for kindergarten and second-grade cohorts. Two hundred thousand children have been screened over 25 years. The WV birth rate has varied from 22,000 to 17,000 per year over that time frame. Each year, approximately 40% of state fifth graders were screened. Forty-three percent of fifth-grade sample are either overweight or obese in WV, including inversion of the obese (24%) to overweight (19%) ratio in WV compared with other states. Over 15 years of lipid testing, 632 persons with LDL-C over 160 mg/dl were identified. This is the childhood LDL-C level that gives a strong likelihood of familial hypercholesterolemia (FH) and represents 1% of those screened, rather than the usual rate of 1 in 250 or 0.4% prevalence. WV data indicated that only ½ to 2/3 of children with LDL-C over 130 mg /dl were identified by family history and prompted the 2012 American Academy of Pediatrics recommendation for universal screening. Family engagement to improve cardiovascular health includes direct education to children, support for school health education through the Active WV program, return of screening results to parents and to parent-identified providers, education, and policy formation at state and federal levels. Research efforts stemming from WV CARDIAC have included the creation of virtual longitudinal cohorts to allow natural history studies and follow-up of the detection of FH. A WV familial comparison of LDL-C and triglyceride levels has been accomplished in siblings who are matched with probabilistic linkage. Finally, several investigations have studied factors that determine participation in screening, the rural trends in cardiometabolic risk factors (CMRFs), and factors that drive families to improve CMRFs.