America’s Obesity Epidemic & The Correlation With Adulthood Cvd
America’s Childhood Obesity Epidemic & the Correlation to Adulthood CVD THR Harris Methodist HEB Hospital Laura Halleck, Intern Texas Woman’s University
Defining Obesity• Overweight is medically defined as >26% body fat• Obese is medically defined as >30% body fat• CDC Texas Counties Data• CDC Texas Surveillance Data
National Obesity Trends according to the National Health and Nutrition Examination Survey (NHANES)
Obesity & hypertension are known to track into adulthood when they begin in childhood. New evidence also shows that elevated lipids play a role as well.If these risk factors are not modified in childhood they could consequently turn into an adult at high risk for cardiovascular events.
Editorial: The New Pediatric Cardiology Paradigm: Prevention & Evidence (March 2012) Victoria Vetter, MD, MPH Pediatric Cardiology at The Children’s Hospital Philadelphia, Pennsylvania• Randomized controlled trials have been uncommon because results are often so complex. Pathobiological Determinant of Atherosclerosis in Youth (PDAY) & National Health and Nutrition Examination Survey (NHANES) have research that supports that obesity is a growing epidemic and there is a need for more research on this topic.• There is a need for pediatric cardiologists to adopt adult cardiology & a pediatric oncology investigative method of obtaining evidence by enrolling all patients in perspective trials.• Research will help us better understand the extent of neurocognitive impairments in children to help support early intervention to maximize potential & decrease negative impact.
According to NHLBI• Atherosclerosis at a young age was first identified in Korean and Vietnam War casualties. Two major contemporary studies evaluated the extent of atherosclerosis in children, adolescents and young adults who died accidentally.1. Bogalusa study measured CV risk factors (lipids, blood pressure, body mass index and tobacco use) as part of a comprehensive school-based epidemiologic study in a biracial community. Strong correlations were shown between the presence and intensity of risk factors and the extent and severity of atherosclerosis.• In the PDAY study, risk factors and surrogate measures of risk factors were measured post mortem in 15- to 34-year olds dying accidentally of external causes. Strong relationships were demonstrated between atherosclerotic severity and extent, and age, non HDL cholesterol, HDL cholesterol, hypertension (determined by renal artery thickness), tobacco use (thiocyanate concentration), diabetes mellitus(DM), and (in men), obesity. There was a striking increase in both severity and extent as age and the number of risk factors increased. By contrast, absence of risk factors was shown to be associated with a virtual absence of advanced atherosclerotic lesions, even in the oldest subjects in the study.
Research attempts for Children (NHLBI)• The most direct means of establishing evidence for active CVD prevention beginning at a young age would be to randomize young individuals with defined risks to treatment of CV risk factors or to no treatment and follow both groups over sufficient time to determine if CV events are prevented without undue increase in morbidity arising from treatment.• This direct approach is appealing because atherosclerosis prevention would begin at the earliest stage of the disease process, therefore maximizing benefits.• Unfortunately, this approach is as unachievable as it is attractive primarily because such studies are extremely expensive and would be several decades in duration, a time period in which changes in environment and medical practice would diminish the relevance of the results. The recognition that evidence from this direct pathway is unlikely to be achieved.
Studies showed that…• In adolescents with marked elevation of LDL-cholesterol due to genetically inherited high cholesterol, abnormal levels of coronary calcium, increased Carotid Intima-Media Thickness (CIMT) and impaired endothelial function have been demonstrated.• Children with hypertension have been shown to have increased CIMT and increased left ventricular mass.• Children with type 1 diabetes have significantly abnormal endothelial function and, in some studies, increased CIMT.• Children and young adults with a family history of myocardial infarction have increased CIMT, higher prevalence of coronary calcium, and endothelial dysfunction.• Endothelial dysfunction (the inability of arteries & arterioles to dilate fully in response to a stimulus) has been demonstrated by ultrasound and plethysmography in association with cigarette smoking (passive and active) and obesity. In obese children, improvement in endothelial function occurs with regular exercise!! Wahoo!• Left ventricular hypertrophy at levels associated with excess mortality in adults has been demonstrated in children with severe obesity.
Main CVD Risk Factors for Adults Nutrition & Diet Physical Activity Use of Tobacco The development of hypertension, obesity, metabolic syndrome, & diabetes Proven Relationships of risk factors measured in youth to atherosclerosis in adulthood– specifically : Dislipidemia (Elevated LDL cholesterol & low HDL cholesterol) Obesity Hypertension Tobacco use DiabetesIn many of these studies, risk factors measured in childhood and adolescence were better predictors of the severity of adult atherosclerosis than were risk factors measured at the time of the subclinical atherosclerosis study.This is directly correlated with the occurrence of coronary heart disease in adulthood, with an estimate that more than 100,000 excess cases of CVD will occur in the next 25 years related to current levels of adolescent obesity.
According to NHLBI…Childhood cholesterol and blood pressureCorrelation coefficients in the range of 0.4 have been reported consistently across many studies, correlating these measures in children 5 to 10 years of age with results 20 to 30 years later. Thesedata suggest that having cholesterolor blood pressure levels in the upperportion of the pediatric distribution makes having these as adult risk factors likely but not certain. Those who develop obesity have beenshown to be more likely to develop hypertension or dyslipidemia as adults.
Physical Fitness & Tobacco• Tracking data on physical fitness from childhood to adulthood are more limited. Physical activity levels do track but not as strongly as other risk factors.• By its addictive nature, tobacco use persists into adulthood though approximately 50% of those who have ever smoked eventually quit.
Diabetes Mellitus • Type I diabetes mellitus is a lifelong condition. • The insulin resistance of type II DM can be alleviated by exercise, weight loss, and bariatric surgery, but the long term outcome of type II DM diagnosed in childhood is not known. • As above, risk factor clusters such as those seen with obesity and the metabolic syndrome have been shown to track more strongly from childhood into adulthood.
Obesity tracks more strongly than any other risk factor from childhood into adulthood Among many reports demonstrating this, one of the most recent is a report from the Bogalusa study where more than 2,000 children were followed from initial evaluation at 5 to 14 yrs of age to adult follow-up at a mean age of 27 years. Based on BMI percentiles derived from the study population, 84% of those with a BMI in the 95th to 99th percentile as children were obese as adults and all of those with a BMI > 99th percentile This is dangerous because were obese in adulthood. Increased obesity is typically associated correlation is seen with increasing age with several other types of risk at which the elevated BMI occurs. factors as well.
NHLBI Concluded:• Atherosclerosis, the pathologic basis for clinical CVD, originates in childhood.• Risk factors for the development of atherosclerosis can be identified in childhood• Development and progression of atherosclerosis clearly relates to the number and intensity of CV risk factors, beginning in childhood• Risk factors track from childhood into adult life, obesity having the strongest influence• Interventions exist for management of identified risk factors WHERE DO WE GO FROM HERE?7. prevent the development of risk factors (primordial prevention; population strategy)8. recognize and manage those children and adolescents at increased risk due to the presence of identified risk factors (primary prevention) *It is well established that a population that enters adulthood with lower risk will have less atherosclerosis and will collectively have lower CVD rates! AKA “Prevention”* Cross sectional research in children has shown differences by race and ethnicity, and by geography for prevalence of CV risk factors; these differences are often partially explained by differences in socioeconomic status. No group within the United States is without a significant prevalence of risk.
InterventionPediatric care providers – pediatricians,family practitioners, nurses, nursepractitioners, physician assistants, registereddietitians - are ideally positioned to reinforceCV health behaviors as part of routine care. • Education • Lifestyle modifications • Medications when necessary
Management of hyperlipidemia in pediatrics Review: Stephen R. Daniels March 2012• Population approach: focuses on improving the diet and lifestyle of all children & adolescents. – Improvements of diet & increasing moderate to vigorous activity. – Diet rich in fruits & vegetables, low-fat dairy products, whole grains, fish, & meats with lower-saturated fat content. – Diet should include enough calories to support growth & development but avoid excess calories that lead to developmental obesity.• High-risk approach: focuses on identification of children & adolescents with dyslipidemia through screening & instituting appropriate treatment. – Quite often leads to controversy – Children & adolescents were to be screened on the presence of premature CVD (prior to age 55) in parents or grandparents, the presence of dyslipidemia (total cholesterol >240mg/dl) in parents or grandparents, or if the child had other risk factors present such as hypertension, diabetes or obesity
Population ApproachWhat’s currently recommended? Food Groups 1-3 years 4-18 years Total Fat 30-40% Daily Intake (DI) 25-35% DI Protein 5-20% 15-20% DI Carbohydrates 45-65% 50-55% DI Saturated Fats <10% <10% DI Cholesterol <300 mg per day <300 mg per day •Data from the Special Turku Coronary Risk Factor Intervention Project (STRIP) for babies supported the concept that a diet similar to these recommendations is associated with no adverse affects on growth, development, and neurocognitive function. •This type of diet was associated with 1. Lower LDL cholesterol in boys 2. Decreased obesity in girls
High-Risk ApproachIn 1992, The National Cholesterol Education Program (NCEP) recommended a staged approach to screening (the presence of premature CVD (prior to age 55) in parents or grandparents, the presence of dyslipidemia (total cholesterol >240mg/dl) in parents or grandparents, or if the child had other risk factors present such as hypertension, diabetes or obesity) – If there was insufficient data regarding family history, the screening was at the discretion of the primary care provider – Screening usually performed with a fasting lipid profile, but can be done with a nonfasting blood sample – Found that use of family history to determine the need for measurement of a fasting lipid profile missed many children with mild dyslipidemia and failed to detect a substantial number who likely had genetic dyslipidemia who might require more aggressive treatment, this consistent with other screening strategies that would miss 30-60% of children and adolescents with high cholesterol levels
High Risk Approach Continued• The National Lipid Association (NLA) has recently (2008) recommended universal screening for children aged 9-10 years with either a fasting or nonfasting lipid profile• The primary target of cholesterol screening is to identify young patients with genetic dyslipidemias because familial high cholesterol is a common problem occurring in every 1 in 500 individuals & is clearly associated with an increased lifetime risk of CVD which has been shown to decrease with proper treatment.• This is such a huge issue because dislipidemias are quite frequently accompanied with or by obesity. LDL Cholesterol Values and Risk Factors Supporting Pharmacologic treatment for Children aged 10 & Older Risk Factor Status LDL-C Cut Point No Other Risk Factors >190 mg/dl Other Risk Factors Present (obesity, >160 mg/dl hypertension, smoking or positive family history of premature CVD Diabetes >130 mg/dl
LDL Cholesterol Values and Risk Factors Supporting Pharmacologic treatment for Children aged 10 & Older Risk Factor Status LDL-C Cut Point No Other Risk Factors >190 mg/dl Other Risk Factors Present (obesity, >160 mg/dl hypertension, smoking or positive family history of premature CVD Diabetes >130 mg/dl1. If nonfasting HDL cholesterol measurements are abnormal, it should be followed by a fasting lipid profile.3. If values are borderline range then more aggressive approach to population lifestyle recommendations should be implemented.**Familial high cholesterol manifests with high LDL cholesterol while other lipid & lipoprotein concentrations are normal. A secondary form of dyslipidemia is called “Atherogenic Dyslipidemia”, it is associated with obesity, & is characterized by high triglycerides and low HDL cholesterol. It is often found in conjunction with increased insulin resistance and other components of metabolic syndrome, including increased abdominal deposition of fat.**
Reducing BMI, lowering LDL Cholesterol in Children• Safely making changes in lowering saturated fat intake, reduce intake of sweetened beverages and increased fruit and vegetable consumption for children (recommended 5g Dietary Approaches to lower LDL-C of fiber a day for young children and up to 14g in Total Calories per day (TC) of fiber for age 9 years and older). Total Fat <30% of TC• Vigorous physical activity has had most effect Saturated Fat <7% of TC on increasing HDL cholesterol in children, Trans Fat <1% of TC includes decreased overall calorie consumption in obese and overweight Cholesterol <200 mg/day children.• It has been shown that a 5-10% decrease in excess weight can have an important beneficial effect on CVD risk factors related to obesity.
Childhood Obesity in the Headlines Several cases say parents “fail to provide ‘necessary’ care” Columbia Journal of Law & Social Problems Summer 2001• This increase in childhood and adolescent obesity & its severity has been accompanied by an increase in the prevalence of comorbidities of obesity – some of which were seen previously only in adulthood-including type II diabetes, sleep apnea, asthma, nonalcoholic fatty liver disease, hypertension & atherosclerosis, & psychological problems such as depression.• Because of the severity of pediatric obesity throughout the country, courts legislatures have been increasingly faced with the question of whether and when state intervention is appropriate. Defining the limits of appropriate involvement has become a more pressing inquiry.There are four main factors for analysis:2.The severity of the child’s illnesses associated with obesity3.The degree to which medical treatment can mitigate the resulting adverse healthaffects4.An assessment of the child’s complete physical and mental health picture5.When the just answer remains unclear, the child’s risk of remaining obese as anadult
Texas is one of 8 states that has “recognized morbid obesity as an issue warranting state intervention into the family unit”. In examining the line between justifiable state intervention and state violation of parental rights in cases of potential medical neglect due to obesity, commentators have considered the useful distinction between life-saving, life-prolonging, and life- enhancing treatment.• Up to 45% of children recently diagnosed with DM have type II DM, “once virtually unrecognized in adolescence” • Overweight boys 3.1x & girls 1.8x more likely to get asthma • 46% of obese children and adolescents show evidence of abnormal sleep during sleep studies, & 27% have “moderate to severe” sleep abnormalities• Obstructive Sleep Apnea (OSA) is associated with learning disabilities and memory defects, thus negatively impacting academic performance • As much as 50% of obese children may have fat deposits in their livers, 80% of obese teenagers undergoing bariatric surgery has non-alcoholic fatty liver disease• 50-80% of children diagnosed with Blount’s disease (bowing of the tibia) are obese • Obese children and adolescents are more likely to experience depression and low- self esteem than their non-obese peers. • There is a relationship between body size & blood pressure in children.
Controversy• Regarding the use of ECG for screening to identify conditions associated with sudden cardiac death. Non Invasive look at CVD: Over the last decade, non-invasive measures of sub-clinical atherosclerosis have developed: – coronary calcium on electron beam computed tomography (EBCT) imaging – increased medial thickness in the carotid artery assessed with ultrasound (CIMT), – endothelial dysfunction (reduced arterial dilation) with brachial ultrasound imaging – increased left ventricular mass with cardiac ultrasound (These measures have been assessed in young individuals with severe abnormalities of individual risk factors and can be symptomatic or asymptomatic)• Possible screening of child with high lipid levels – Screening recommended based on genetic risk factors – Dyslipidemia – fasting or nonfasting blood tests
Non Invasive look at CVDOver the last decade, non-invasive measures of sub-clinical atherosclerosis have developed:• coronary calcium on electron beam computed tomography (EBCT) imaging• increased medial thickness in the carotid artery assessed with ultrasound (CIMT),• endothelial dysfunction (reduced arterial dilation) with brachial ultrasound imaging• increased left ventricular mass with cardiac ultrasound• Dyslipidemia – fasting or nonfasting blood tests These measures have been assessed in young individuals with severe abnormalities of individual risk factors and are often symptomatic.
Cardiac EffectsIncreased Risk of :•High Blood Pressure•Atherosclerosis•Left Ventricular Hypertrophy•High CholesterolThere is a relationship between body size & blood pressure in children. Abnormal blood lipids occur(s) frequently among obese children.Cardiac effects of childhood obesity are perhaps the most challenging comorbities of the condition to address through state interventionbecause the generally manifest in negative health consequences later in life and often do not pose immediate harm to minors.
How would you approach it?• Lack of education? http://www.letsmove.gov/• Does it start with parental habits? – Heritability of adiposity may then be an important factor contributing to increase in body fatness” and/or “the cultural transmission of learned ‘obesogenic’ behaviors passed from parents to kids – The odd ratios for obesity associated with maternal obesity were slightly higher than those associated with paternal obesity – Conflicting evidence exists to whether a predisposition to obesity is manifested as a low resting energy expenditure (thermogenesis/basal metabolic rate) in childhood – Puberty still not quite understood » Some have found that REE did decrease from early to mid stages of puberty » Bandini found no differences among prepubertal children, but pubertal children with lean parents had lower REE than those who had at least one overweight parent
In Conclusion…Keys to Prevention• Education (Parental & Children)• Screening• Appropriate treatment for patients with early indicators of CVD, especially those who are obese• Improvements in Habits – Diet – Exercise
Resources• Strode, P., Knapp, K., Ngai, J. (2006) California Food Guide Life Cycle: 1 to 3 Year Olds• Kimm, S. (2003) Nature versus nurture in childhood obesity: a familiar old conundrum. American Journal of Clinical Nutrition 78:1051-2.• Vetter, V. (2012) Editorial: the new pediatric cardiology paradign: prevention and evidence. Pediatric Cardiology Division, The children’s hospital Philadelphia. Current Opinion in Caridology, 27:67-69. www.co-cardiology.com• Daniels, S. (2012) Management of hyperlipidemia in pediatrics. Children’s Hospital Aurora, Colorado. Current Opinion in Cardiology, 27:92-97. www.co-cardiology.com• National Center for Chronic Disease Prevention and Health Promotion: – National Diabetes Fact Sheet 2011 – Physical Activity Guide: http://www.cdc.gov/physicalactivity/everyone/guidelines/children.html CDC Texas Counties Data & CDC Texas Surveillance Data• National Heart, Lung, and Blood Institute: – Pediatric Guidelines: http://www.nhlbi.nih.gov/guidelines/cvd_ped/ Lady Obama’s “Let’s Move” Program: http://www.letsmove.gov/