This presentation was required for my internship at THR HEB hospital. It was presented to the fitness center staff on Friday, April 13, 2012.

1. America’s Childhood Obesity Epidemic
& the Correlation to Adulthood CVD
THR Harris Methodist HEB Hospital
Laura Halleck, Intern
Texas Woman’s University

2. 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

3. National Obesity Trends according to the National
Health and Nutrition Examination Survey
(NHANES)

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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
Diabetes
In 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.

10. According to NHLBI…
Childhood cholesterol and blood pressure
Correlation 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. These
data suggest that having cholesterol
or blood pressure levels in the upper
portion of the pediatric distribution
makes having these as adult risk
factors likely but not certain. Those
who develop obesity have been
shown to be more likely to develop
hypertension or dyslipidemia as
adults.

11. 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.

12. 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.

13. 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.

14. 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.

15. Intervention
Pediatric care providers – pediatricians,
family practitioners, nurses, nurse
practitioners, physician assistants, registered
dietitians - are ideally positioned to reinforce
CV health behaviors as part of routine care.
• Education
• Lifestyle modifications
• Medications when
necessary

16. 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

17. Population Approach
What’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

18. High-Risk Approach
In 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

19. 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

20. 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
1. 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.**

21. 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.

22. 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 obesity
3.The degree to which medical treatment can mitigate the resulting adverse health
affects
4.An assessment of the child’s complete physical and mental health picture
5.When the just answer remains unclear, the child’s risk of remaining obese as an
adult

23. 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.

24. 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

25. 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
• 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.

26. Cardiac Effects
Increased Risk of :
•High Blood Pressure
•Atherosclerosis
•Left Ventricular Hypertrophy
•High Cholesterol
There 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 intervention
because the generally manifest in negative health consequences later in
life and often do not pose immediate harm to minors.

27. 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

28. 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

29. 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/