Cardiovascular Risk Begins in Childhood A Time for Action Gerald S. Berenson, MD
eart disease is the major cause of death worldwide. Pediatric cardiovascular epidemiologic studies over the past 4 decades have clearly shown that precursors of coronary artery disease, hypertension, and type 2 diabetes all originate in childhood. Further, cardiovascular risk factors, evidence of subclinical, asymptomatic cardiovascular lesions, can be diagnosed early in life. What is also evident is that the developmental occurrence of heart disease represents both genetic and environmental determinants. Factors such as obesity and tobacco smoke are preventable, while family history can be dealt with only by understanding and controlling risk factors. The autopsy findings in The Bogalusa Heart Study and Pathobiological Determinants of Atherosclerosis in Youth showed a strong relationship of vascular disease to traditional cardiovascular risk factors. These observations provided irrefutable evidence of the importance of cardiovascular diseases and associated risk factors beginning in youth. The autopsy findings of a very high prevalence of coronary artery lesions in soldiers in the Korean and Vietnam wars gave credence to the occurrence of early onset of heart disease broadly in Westernized populations. Geoffrey Rose1 has defined this phenomenon elegantly and with foresight as “sick individuals and sick populations.” Although recommendations to address childhood risk factors have been made for 30 years, such recommendations have remained insufficiently implemented in clinical and public health practices. The current epidemic of obesity and its consequences are the best evidence of our failure. The papers in this supplement to the American Journal of Preventive Medicine,2–15 based on Project HeartBeat! have the important message of the need and how to address the cardiovascular health of children. Current recommended guidelines and implementations for medical care are stated to be “evidence-based.” This compilation of research on children and adolescents provides the evidence base for action. A Time for Action from the WHO, with the book’s senior author, Darwin Labarthe, set the stage to show the urgent need to From Tulane University Schools of Medicine and Pediatrics, New Orleans, Louisiana Address correspondence and reprint requests to: Gerald S. Berenson, MD, Tulane University, 1430 Tulane Avenue, Room 2140, New Orleans LA 70112. E-mail: [email protected]
begin prevention worldwide of the primordial onset of risk factors in childhood.16 The lag in action since that recommendation in 1990 illustrates the difficulty of putting the cardiovascular health of children as a top priority by governments, including that of the U.S. Although a number of long-term studies of cardiovascular risk factors in children such as The Bogalusa Heart Study, Muscatine, Princeton, Finnish Youth Study, and others have been conducted, the design of Project HeartBeat! is unique. It provides measurements at 4-month intervals over the age span of childhood, adolescence, and beginning young adulthood. An excellent example of repeated measurements over a short period of time shows how the maximum growth spurt occurring at puberty can be documented. Growth of height peaks in girls at 12.5 years and 13.5 years for boys, while adult stature is reached at 15 years for girls and 18 years for boys. Obviously such changes reflect dynamic metabolic and hormonal effects on cardiovascular risk factors. Project HeartBeat!’s research emphasizes the need to evaluate the normality of risk factors for a given age or state of growth rather than by rigid cut-points as recommended by a task force guideline. These observations amplify race and gender contrasts, which reflect on the life-long burden of risk factors and eventual clinical disease occurring with race and sexual dimorphisms. The intake of a high-fat diet and lack of activity among youth shown in this study are clear targets for change. The marked decrease of total cholesterol and low-density lipoprotein cholesterol and especially highdensity lipoprotein cholesterol during adolescence are noted. These changes precede the marked increase of total and low-density lipoprotein cholesterol found in adults. With such changes, it becomes apparent that body size, lean body mass, and body fatness are determinants of risk factors as we measure them. This is especially so of blood cholesterols and systolic blood pressure, and to some extent on cardiac size. Thus, Project HeartBeat! provides evidence of the importance of gender, race/ethnicity, and sexual development on dynamic changes of risk factors interacting with environmental/behavioral influences, for example, nutrition and physical activity. Project HeartBeat! reinforces recommendations to prevent and modulate the development of risk factors during childhood. Controlling weight gain of children
Am J Prev Med 2009;37(1S) © 2009 Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
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through improved nutrition and physical activity becomes the main direction for prevention. Considerations of screening of children for risk factors needs to be based on understanding the nature of their change as well as their predictability of adult risk and the burden on disease. Importantly, Project HeartBeat! provides the evidence of the urgency of achieving a public health policy to begin the prevention of adult heart diseases in childhood. These investigators are to be thanked and commended for providing such information. No financial disclosures were reported by the author of this paper.
References 1. Rose G. Sick individuals and sick populations. Int J Epidemiol 1985; 14:32– 8. 2. Harrist RB, Dai S. Analytic methods in Project HeartBeat! Am J Prev Med 2009;37(1S):S17–S24. 3. Dai S, Fulton JE, Harrist RB, Grunbaum JA, Steffen LM, Labarthe DR. Blood lipids in children: age-related patterns and association with body-fat indices: Project HeartBeat! Am J Prev Med 2009;37(1S):S56 –S64. 4. Fulton JE, Dai S, Grunbaum JA, Boerwinkle E, Labarthe DR. Effects of apolipoprotein E genotype on blood cholesterol in adolescent girls. Am J Prev Med 2009;37(1S):S78 –S85. 5. Dai S, Harrist RB, Rosenthal GL, Labarthe DR. Effects of body size and body fatness on left ventricular mass in children and adolescents: Project HeartBeat! Am J Prev Med 2009;37(1S):S97–S104.
6. Eissa MA, Wen E, Mihalopoulos NL, Grunbaum JA, Labarthe DR. Evaluation of AAP guidelines for cholesterol screening in youth: Project HeartBeat! Am J Prev Med 2009;37(1S):S71–S77. 7. Labarthe DR, Dai S, Day RS, Fulton JE, Grunbaum JA. Findings from Project HeartBeat!: their importance for CVD prevention. Am J Prev Med 2009;37(1S):S105–S115. 8. Day RS, Fulton JE, Dai S, Mihalopoulos NL, Barradas DT. Nutrient intake, physical activity, and CVD risk factors in children: Project HeartBeat! Am J Prev Med 2009;37(1S):S25–S33. 9. Steffen LM, Dai S, Fulton JE, Labarthe DR. Overweight in children and adolescents associated with TV viewing and parental weight: Project HeartBeat! Am J Prev Med 2009;37(1S):S50 –S55. 10. Fulton JE, Dai S, Steffen LM, Grunbaum JA, Shah SM, Labarthe DR. Physical activity, energy intake, sedentary behavior, and adiposity in youth. Am J Prev Med 2009;37(1S):S40 –S49. 11. Altwaijri YA, Day RS, Harrist RB, Dwyer JT, Ausman LM, Labarthe DR. Sexual maturation affects diet– blood total cholesterol association in children: Project HeartBeat! Am J Prev Med 2009;37(1S):S65–S70. 12. Labarthe DR, Dai S, Fulton JE, Harrist RB, Shah SM, Eissa MA. Systolic and fourth- and fifth-phase diastolic blood pressure from ages 8 to 18 years: Project HeartBeat! Am J Prev Med 2009;37(1S):S86 –S96. 13. Eissa MA, Dai S, Mihalopoulos NL, Day RS, Harrist RB, Labarthe DR. Trajectories of fat mass index, fat free–mass index, and waist circumference in children: Project HeartBeat! Am J Prev Med 2009;37(1S): S34 –S39. 14. Labarthe DR, Dai S, Harrist RB. Blood lipids, blood pressure, and BMI in childhood and adolescence: background to Project HeartBeat! Am J Prev Med 2009;37(1S):S56 –S64. 15. Labarthe DR, Dai S, Day RS, et al. Project HeartBeat!: concept, development, and design. Am J Prev Med 2009;37(1S):S9 –S16. 16. WHO Expert Committee. Prevention in childhood and youth of adult cardiovascular diseases: time for action. Geneva: World Health Organization; 1990. Technical Report Series 792.
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