Heart Disease Prevention

Radical changes in expert advice for paediatricians to take heart disease prevention seriously in childhood

Issue No:
Child Health Monitor, Volume 3, Issue 7
July 2002

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Background:

Coronary heart disease remains the leading cause of death in developed countries such as Australia, the USA and the UK. Over the past 40 years we have accumulated convincing evidence linking certain "cardiovascular risk factors" with later heart disease and strokes. These risk factors work by accelerating the process of atherosclerosis (hardening of the arteries), whereby low-grade inflammation in the walls of blood vessels, allied to the accumulation of cholesterol, leads to thickening of the blood vessel wall causing a reduction and later blockage of blood flow through that blood vessel. In the heart this causes angina and later myocardial infarcts (heart attacks). In the brain, atherosclerosis results in cerebrovascular accidents (stroke). The known cardiovascular risk factors in adults include smoking, diabetes, obesity, hypertension, high blood lipid (cholesterol) levels, and a family history of heart disease.

While we are clear about which risk factors in adult life accelerate heart disease, we know less about the importance of these issues in childhood. We know that atherosclerosis is a process that begins in childhood and progresses gradually throughout life, even in healthy individuals. The known adult risk factors accelerate the process dramatically in adult life, but the question remains about how much we can do in childhood and adolescence to reduce the progression of atherosclerosis. Evidence is mounting from excellent research which shows that the same adult risk factors are linked with faster development of atherosclerosis in childhood. So interest in promoting cardiovascular health in childhood, particularly given the epidemic of obesity over the last 10 years, is increasing.

This interest in childhood cardiovascular health has largely remained in the research or policy arenas, and guidance for the individual paediatrician or parent is largely lacking. The issues of when to intervene and by how much, remain largely unanswered.

To answer this, the expert Committee on Atherosclerosis, Hypertension, and Obesity in the Young (AHOY) of the Council on Cardiovascular Disease in the Young of the American Heart Association, put together these detailed recommendations published this month. Their goal was to provide strategies for promoting cardiovascular health that can be integrated into the comprehensive paediatric care of children.

Findings:

The following is a summary of the recommendations from the expert panel for both parents and practising paediatricians:

Physical exercise
Main recommendations: All children over two years of age should participate in at least 30 minutes of moderate physical activity most days of the week, and preferably every day.

Recommendations for paediatricians to give to parents regarding exercise:

1. Consideration of exercise should be undertaken with all children and young people seen.
   
   
2. Advise parents to include planned activities instead of food as part of the family's reward system for positive accomplishments.
   
   
3. Advise parents to establish time limits for sedentary activities and encourage a daily time for physical activity.
   
   
4. All children should do PE or Games: Do not include or exclude a child from activities because of physical or mental limitations. Tailor suggestions for exercise to the child's physical ability.
   
   
5. Encourage participation in pick-up games, non-competitive activities, and organised sports. Emphasise sports that can be enjoyed throughout life, participation in summer camp, and school physical education programs.
   
   
6. Teach parents the importance of being role models for active lifestyles and providing children with opportunities for increased physical activity.
   
   

Obesity
Main recommendation: All children, adolescents, and their families can benefit from counselling to prevent excess weight gain and obesity e.g. strategies on how to eat a healthy diet and be more physically active.

Recommendations for parents:

• Aim for a diet low in saturated fat and cholesterol that includes five or more daily servings of vegetables and fruits and 6 to 11 servings of whole-grain and other complex-carbohydrate foods.
  
• It may be helpful for parents and children to visualize a "healthy plate" of which half is filled with salad and vegetables, one fourth with starch (potatoes, rice, etc), and one fourth with a protein source (meat, poultry, fish, soy, etc).
• Children should do the regular exercise outlined above, and also be encouraged to integrate more physical activity into their lifestyle, such as walking or biking to school instead of driving, taking stairs instead of elevators, and helping with active chores inside and outside of the house.
• Parents should help their children reduce excessive time spent on sedentary behaviours such as watching television and videotapes, playing on a computer, listening to music, and talking on the phone.

Elements of successful obesity treatment programs include the following (for paediatricians):

1. beginning treatment before adolescence, if possible
   
   
2. willingness on the part of both child and family to participate
   
   
3. education of families about the medical complications of obesity
   
   
4. involvement of the entire family and other caregivers in the treatment
   
   
5. promotion of long-term permanent changes in behaviour patterns instead of rapid weight loss
   
   
6. emphasis on small and gradual behaviour change goals
   
   
7. inclusion of activities to help families monitor their eating and physical activity behaviours
   
   
8. clinical empathy and encouragement rather than criticism and penalties.
   
   

The expert committee also noted that no currently available obesity drugs have been shown to be either safe or effective for children, and that obesity drugs should only be prescribed for children by a paediatric obesity specialist.

Insulin resistance & type II diabetes
The syndrome of obesity, high insulin levels, high blood pressure and high blood lipids (cholesterol and triglycerides) is called the insulin resistance syndrome or the Metabolic syndrome (also known as syndrome X). It is strongly linked with later cardiovascular disease and diabetes.

Recommendations for paediatricians:

1. Children known to be at risk for developing the syndrome of insulin resistance (a pre-diabetic state) or type II diabetes are those with severe obesity, those with a strong family history of type II diabetes, those from black or Asian backgrounds, or those with hypertension and raised cholesterol levels as well as obesity.
   
   
2. In obese children, Paediatricians should periodically measure fasting blood sugar, blood cholesterol and triglycerides, and blood pressure to aid early detection of the insulin resistance syndrome.
   
   
3. Children identified as having the syndrome, should be treated by specialists in paediatric diabetes or obesity.
   
   

High blood pressure
Recommendations for paediatricians:

1. Blood pressure should be measured routinely at every clinic visit on all children over the age of three years.
   
   
2. Blood pressure tables based on sex, age, and height should be used to interpret and track blood pressure measurements. It is not sufficient just to judge it to be normal or high without consulting tables.
   
   
3. If the blood pressure exceeds the 95th percentile from the tables (defined as hypertension), the measurement should be repeated at a subsequent visit. If resting blood pressure equals or exceeds the 95th percentile on three separate occasions, the diagnosis of hypertension should be made and an appropriate evaluation undertaken.
   
   
4. Severely high blood pressure should be treated by a specialist.
   
   

Blood cholesterol
Recommendations for parents:

The following strategy should be followed for all children over two years of age, with the goal of setting eating patterns in childhood that will provide the best possible adult cholesterol levels.

• Saturated fatty acids should provide <10% of total calories.
• Total fat should provide an average of no more than 30% and no less than 20% of total calories.
• Polyunsaturated fatty acids should provide up to 10% of total calories.
• Less than 300 mg of cholesterol should be consumed per day.
• Children should consume five or more daily servings of vegetables and fruits.
• Children should consume six to eleven daily servings of whole-grain and other grain foods.
• Children should consume adequate amounts of dietary fibre.

Recommendations for paediatricians:

1. cholesterol levels should be monitored in children of families where
   • there is a family history of high cholesterol in parents or siblings
   • family members (up to two generations) have developed heart disease below 55 years of age
   • there are other cardiovascular risk factors - e.g. high blood pressure or obesity
   • the child is taking drugs linked with high cholesterol eg, retinoic acid, oral contraceptives, or anticonvulsants
   • the child has a disease such as diabetes mellitus or nephrotic syndrome (both linked with high cholesterol)
     
     
2. A single cholesterol level does not indicate high cholesterol and multiple measures should be taken.
   
   
3. Cholesterol and triglyceride levels should generally be measured after a 12-hour fast (the child can drink water). A simple total cholesterol level is insufficient as it may miss isolated low high-density lipoprotein (HDL) cholesterol.
   
   

Comments:

While we score Expert Panel Conclusions themselves as low on the evidence scale, it is important to remember that these conclusions are the collected opinions of experts their field, based upon the best available evidence.

These conclusions should shake up the treatment of obesity, blood pressure and cholesterol in children by the average paediatrician. Most obese children do not have their cholesterol or blood pressure measured, and most paediatricians think very little about cardiovascular profiling of obese children. These recommendations show that paediatricians should be doing a lot more, a lot sooner, and a lot more robustly, to combat the rising tide of obesity and increased cardiovascular risk in our children.

Reference:

Williams et al. Cardiovascular Health in Childhood: A Statement for Health Professionals From the Committee on Atherosclerosis, Hypertension, and Obesity in the Young (AHOY) of the Council on Cardiovascular Disease in the Young, American Heart Association Circulation. July 2002;106:143.

Reproduced with permission of ChildHealthMonitor.org, which translates pediatric journal articles into everyday language providing comprehensive information on research breakthroughs ranging from general nutrition to rare diseases. A great resource for busy Pediatricians and also for parents who want to learn how best to care for their children's medical and parenting problems.