Lipid screening and cardiovascular health in childhood

Screening for diabetes in asymptomatic children: A simple and efficient method

BACKGROUND/PURPOSE

Type 2 diabetes has become an important cause of diabetes in children. Since most children with type 2 diabetes are asymptomatic, a screening method is needed. However, physicians are required in the screening methods recommended by professional associations. We aimed to develop a simple and efficient screening method for children with diabetes.

METHODS

A nationwide survey was conducted, which included 2,270,496 seventh-grade students. Students with two abnormal results in sequential urinalyses were given a fasting blood test. Three screening methods were developed.

RESULTS

Among the screening methods, method C is simple, and can be performed by parents, teachers, or school nurses. It suggests children with two abnormal results in sequential urinalyses and who are overweight or have a family history of diabetes receive blood tests. As a result, 0.10% of boys and 0.16% of girls were recommended to receive blood tests, and 7.0% of boys and 6.7% of girls receiving blood tests were diagnosed diabetes. On average, 15,002 boys and 9056 girls had to be screened to find one child with diabetes. The cost per 1000 children by method C was 2466.84 US dollars.

CONCLUSION

Urinalysis screening followed by evaluation of risk factors is a simple and efficient way to identify children with diabetes in schools.

Metabolic profile, cardiovascular risk factors and health-related quality of life in children, adolescents and young adults with congenital adrenal hyperplasia

Background The present study was designed to evaluate the metabolic profile, cardiovascular risk factors and quality of life in children with congenital adrenal hyperplasia (CAH) and compare it with age- and sex-matched controls. Methods Fifty-two patients aged 3-21 years with classic CAH due to 21-hydroxylase deficiency were included in the study. Metabolic profiling was done for 36 cases and compared with 28 healthy age- and sex-matched controls. Quality of life was assessed in all 52 children and their parents using a validated Pediatric Quality of Life Inventory (PedsQL) questionnaire and was compared with normative data from the same population. Results The median age was 12 years with 14 (27%) males and 38 (73%) females. Out of the total 52 patients, 35 (67%) had salt wasting and 17 (33%) had simple virilising CAH. The median height standard deviation score (SDS) of cases was similar to that of controls (-0.72 vs. -0.64, p = 0.57) and 81% of females had normal pubertal status indicating a good control of the disease. Weight SDS, body mass index (BMI) SDS, mean diastolic blood pressure and insulin resistance were significantly higher in cases when compared to controls (0.31 vs. -0.3; 0.96 vs. 0.17; 67.8 ± 10.49 vs. 61 ± 8.49 and 2.1 vs. 0.95, respectively). The quality of life was significantly reduced in all domains as per parents' perspective, whereas the children reported reduced quality of social and school functioning. There was no significant correlation between quality of life and metabolic parameters. Conclusions Children with CAH despite a reasonably good control of the disease have a higher cardiovascular risk and reduced quality of life when compared to healthy controls.

Association of lipid profile and BMI Z-score in southern Iranian children and adolescents

Background Heart disease has been the leading cause of death for decades in the US population. Dyslipidemia is the most important risk factor for cardiovascular disease (CVD), and it often starts during childhood. Methods This cross-sectional study was performed in a growth assessment clinic in the city of Shiraz to determine the relation between body mass index (BMI) and dyslipidemia among children and teenagers aged 2-18 years. Nine hundred and eighty-nine children including 422 boys and 567 girls were selected. Results Adjusted for age and gender, total cholesterol (TC) (r = 0.172, p = 0.000), low-density lipoprotein cholesterol (LDL-c) (r = 0.176, p = 0.000), non-high-density lipoprotein cholesterol (non-HDL-c) (r = 0.227, p = 0.000) and triglycerides (TG) (r = 0.253, p = 0.000) showed a significant positive correlation with BMI Z-score, and HDL-c showed a significant negative correlation with BMI Z-score (r = -0.131, p = 0.000). Adjusted for age and gender, overweight and obese children were 1.882 times more likely to have high TC levels (p = 0.009), 2.236 times more likely to have high non-HDL-c levels (p = 0.000) and 3.176 times more likely to have high TG levels (p = 0.000) in comparison with children who had a healthy weight. Obese children had the highest percentage of isolated TG dyslipidemia (23.1%) and underweight children had the highest percentage of isolated HDL dyslipidemia (15.6%). Conclusions There is a strong link between atherosclerotic cardiovascular disease (ASCVD) and the level of blood lipids and between blood lipids and BMI Z-score. The first step in preventing ASCVD is the reduction of blood lipids, preventing weight gain and loss of extra weight.

Age-specific and sex-specific reference intervals for non-fasting lipids and apolipoproteins in 7260 healthy Chinese children and adolescents measured with an Olympus AU5400 analyser: a cross-sectional study

AIMS

Ethnic, demographic, lifestyle, genetic and environmental factors influence lipids and apolipoproteins. The aim of this study was to establish age-specific and gender-specific reference intervals for non-fasting lipids and apolipoproteins in healthy Chinese children and adolescents.

METHODS

This study followed the Clinical and Laboratory Standards Institute EP28-A3c guidelines. Non-fasting samples were collected from 7260 healthy Chinese children and adolescents, and they were analysed using the Olympus AU5400 analyser for: triglycerides, total cholesterol (TC), high-density lipoprotein cholesterol, low-density lipoprotein cholesterol (LDL-C), apolipoprotein A1 and apolipoprotein B (ApoB). The age-related and gender-related reference intervals were partitioned using the Harris-Boyd method. The non-parametric method was used to establish the lower limit (2.5th percentile) and the upper limit (97.5th percentile) for the reference intervals. The 90% CIs for the lower and upper limits were also calculated.

RESULTS

Based on the Harris-Boyd method, gender partitions were required for TC, LDL-C and ApoB. Age differences were observed for all analytes. Paediatric reference intervals were established for non-fasting lipids and apolipoproteins based on a large population of healthy children and adolescents.

CONCLUSIONS

Previously used reference intervals did not take age and gender into account. These age-specific and gender-specific reference intervals established in this study may contribute to improved management and assessment of paediatric diseases.

A Comparison of the Impact of Two Methods of Nutrition-Behavioral Intervention on Selected Auxological and Biochemical Parameters in Obese Prepubertal Children-Crossover Preliminary Study

Obese children are exposed to short and long-term health consequences, such as dyslipidemia, hypertension and diabetes mellitus. For these reasons, the prevention and treatment of obesity in the pediatric population is a challenge for health care professionals. The aim of this study was to evaluate whether an intensive intervention based on diet and physical activity has a better impact on the auxological and biochemical parameters than standard care (intervention). The study included 20 children (six boys, 14 girls), of the mean age 8.9 (SD 1.4) before puberty. The participants were randomly assigned to two groups: Group I (starting treatment with intensive intervention), and II (starting treatment with standard intervention). After three months, the groups were switched. The comparison of the two interventions in the study group indicates a better effectiveness of intensive intervention in the improvement of anthropometric parameters and majority of biochemical ones (except for insulin concentration, HOMA IR index and LDL cholesterol). As the result of intensive intervention, the mean % of weight-to-height excess and hip circumference decreased significantly (p < 0.005). Our results confirm that complex intervention based on systematic control visits, including personalized dietitian counselling and physician care, during the weight reduction process is more effective than a one-off standard visit.

Assessing and Managing the Metabolic Syndrome in Children and Adolescents

The metabolic syndrome (MetS) is a group of cardiovascular risk factors that are associated with insulin resistance and are driven by underlying factors, including visceral obesity, systemic inflammation, and cellular dysfunction. These risks increasingly begin in childhood and adolescence and are associated with a high likelihood of future chronic disease in adulthood. Efforts should be made at both recognition of this metabolic risk, screening for potential associated Type 2 diabetes, and targeting affected individuals for appropriate treatment with an emphasis on lifestyle modification. Effective interventions have been linked to reductions in MetS-and in adults, reductions in the severity of MetS have been linked to reduced diabetes and cardiovascular disease.

Associations between anthropometric indicators in early life and low-grade inflammation, insulin resistance and lipid profile in adolescence

BACKGROUND AND AIMS

The long-term relations between excessive adiposity in early childhood and unfavourable cardiometabolic profiles in later ages are not yet completely understood. We aimed to assess the associations between birth weight (BW) and BMI from 6 months to 6 years of age, with biomarkers indicative of low-grade inflammation, insulin resistance and lipid profiles in adolescence.

METHODS AND RESULTS

Retrospective school-based study with 415 Portuguese adolescents (220 girls), mean age of 14.08 ± 1.6 years old. Anthropometric data from birth to 6 years old was extracted from individual child health book records. Actual weight and height were measured and BMI calculated. Participants were classified at each time point as normal weight or overweight according to WHO reference values. Biomarkers were obtained from venous blood samples. Linear regressions were used to explore the associations between the biomarkers and early life anthropometric indicators. From 2 years onwards, BMI associated positively with the inflammatory score and HOMA-IR in adolescence. Children who were overweight/obese from 2 to 6 years of age presented significantly higher inflammatory score and HOMA-IR later in adolescence. TC/HDL ratio was also positively associated with BMI from the age of 5 years onwards. The associations between BMI and cardiometabolic outcomes remained positive in adolescence, with overweight adolescents presenting a higher inflammatory score, HOMA-IR and TC/HDL than normal weight adolescents.

CONCLUSION

A high BMI from an early age was consistently associated with worse inflammatory and lipid profiles and insulin resistance in adolescence. No associations were found between BW and the same studied outcomes.

Metabolic Changes in Children that Received Chemotherapy

Cancer treatments are associated with short and long-effects. Epidemiological reports have revealed clinical features of metabolic syndrome (MS), obesity or overweight in young cancer survivors. The aim of the study was to examine the prevalence of unhealthy weight status and risk factors associated with MS related to chemotherapy. We study 52 pediatric cancer patients and analyze cholesterol, triglycerides, glycosylated hemoglobin, body mass index, waist circumference (WC), FINDRISC test. All the parameters were analyzed according to the percentile corresponding to sex and age of each child. The data show an important modification in weight, body mass index, and WC as in triglycerides, and cholesterol that could be associated with the development of MS. The variance analysis showed that the WC, triglycerides, and cholesterol are statistically correlated in our population. A follow-up for MS in children cancer survivor should be considered necessary.

[Own and Parental Predictors of Hypertriglyceridemia in Children of Persons with Early Ischemic Heart Disease]

AIM

to elucidate predictors of high level of basal triglycerides (TG) in blood of children of persons with early (onset: men ≤55, women ≤60 years) ischemic heart disease (EIHD).

MATERIALS AND METHODS

We examined 316 families: patients (probands) (n=295; 77.9 % after MI) with EIHD, their spouses (n=219; 83.1 % women) and native children of probands (n=413; 55.7 % men) aged 5-38 years. In children aged 5-17 and 18-38 years proband's spouse was mother in 88 and 77 % of cases, respectively. Hypertriglyceridemia in children (HTG) was defined in persons aged 5-17 years as ≥90 percentile (Lipid Research Clinics), ≥18 years - ≥1.7 mmol / l or HTG drug treatment. Predictors of HTG were selected by binary logistical regression with adjustment for age, sex and drugs.

RESULTS

HTG was found in 31 / 158 children aged 5-17 years. Its independent predictors were systolic arterial pressure (odds ratio [OR] of top [&gt;108] vs. two bottom [≤108 mm Hg] tertiles 3.85, 95 % confidence interval [CI] 1.38-10.7, р=0.010), heart rate (HR, OR of top [&gt;78] vs. two bottom [≤78 bpm] tertiles 2.94, 95 % CI 1.20-7.23, р=0.019), and high density lipoprotein cholesterol (HDL-C, OR 0.35, 95 % CI 0.13-0.94; р=0.038) of their children; HR (OR of top [&gt;72] vs. two bottom [≤72 bpm] tertiles 3.56, 95 % CI 1.38-9.11, р=0.008), low density lipoprotein cholesterol (OR 2.49, 95 % CI 1.12-5.52, p=0.025]), and type 2 diabetes (OR 25.9, 95 % CI 1.01-665.3; p=0.049) of the parent - proband's consort. HTG was found in 35 / 255 children aged 18-38 years and was associated with own age (OR 1.10, 95 % CI 1.02-1.19, р=0.012) and male sex (OR 6.21, 95 % CI 2.45-15.8; р=0.000). HTG was independently associated with body mass index (OR top [&gt;25.4] vs. two bottom [≤25.4 kg / m2] tertiles 4.94, 95 % CI 2.13-11.4, р=0.000); basal glycemia (OR top [5.1] vs. two bottom [≤5.1 mmol / l] tertiles 2.52, 95 % CI 1.17-5.43, р=0.019); HDL-C (OR 0.17, CI 0.04-0.81, 0.027); alcohol consumption (OR consuming more than once vs. once a week and less 2.27, 95 % CI 1.02-5.02, p=0.044) of these children; HDL-C (OR 0.19, 95 CI 0.04-0.94; p=0.041) of the proband-parent.

CONCLUSIONS

HTG in children aged 5-38 years with parental early IHD was independently associated mainly with own characteristics, forming components of metabolic syndrome. Attention should be paid to the dominance of maternal transmission in children and adolescents (age group 5-17 years).

Prevalence of, and biochemical and anthropometric risk factors for, dyslipidemia in children and adolescents aged 7 to 18 years in China: A cross-sectional study

OBJECTIVE

This study aimed to investigate the prevalence of dyslipidemia and its risk factors in children and adolescents aged 7 to 18 years in China.

METHODS

A cross-sectional study was conducted from November, 2013 to July, 2014. A total of 2283 children and adolescents from urban and rural areas in Hainan (South China) and Shaanxi Provinces (Northwest China) were selected using multi-stage stratified cluster sampling method. Each participant underwent anthropometric and serum biochemical tests which included serum lipids and hepatitis B virus surface antigen (HBsAg).

RESULTS

The overall prevalence of high total cholesterol (TC), high triglyceride (TG), high low-density lipoprotein cholesterol (LDL-C), low high-density lipoprotein cholesterol (HDL-C), hyperlipidemia and dyslipidemia were 6.5%, 7.5%, 5.2%, 9.1%, 14.3%, and 20.6%, respectively. After standardization by age, girls had higher prevalence of high TC (8.2%), high LDL-C (6.6%), and hyperlipidemia (16.4%), but lower prevalence of low HDL-C (8.21%) than boys (4.2%, 3.4%, 11.9%, and 11.3%, respectively). The risk of dyslipidemia increased with age (OR = 1.067, 95% CI: 1.030-1.106). Boys had a decreased risk of dyslipidemia (OR = 0.798, 95% CI: 0.640-0.994). The restricted cubic spline revealed a linear relationship between BMI and the risk of dyslipidemia (P < .001). Subjects who were HBsAg positive had higher risk of dyslipidemia (OR = 1.550, 95% CI: 1.050-2.287) compared with those who were HBsAg negative.

CONCLUSIONS

Our study highlights the high prevalence of dyslipidemia in youth in China, and is the first study to reveal a positive association between positive status for HBsAg and abnormal lipid levels in children and adolescents.

Uric acid is linked to cardiometabolic risk factors in overweight and obese youths

OBJECTIVE

Observational studies have indicated that high levels of serum uric acid are associated with the risk of cardiovascular disease. The aim of the present study is to investigate the association of uric acid with individual cardiometabolic risk factors, as well as their degree of clustering, in overweight and moderate obese youth.

METHODS

Three hundred and thirty-three Caucasians of both sexes (149 women), from 5-18 years of age from those who underwent an assessment of overweight/obesity. Anthropometric parameters, office and 24-h blood pressure measurements and metabolic profile, including HDL-cholesterol, triglycerides, insulin, HOMA index and uric acid were assessed.

RESULTS

Uric acid was significantly higher in boys than in girls. A positive significant association between uric acid, and office, daytime and night-time SBP, insulin and triglycerides was observed. When boys and girls were grouped by sex-specific uric acid tertiles, a progressive increment was observed in BMI, BMI z-score and waist circumference as well as fasting insulin and HOMA index. In boys, this was also present in office and ambulatory SBP. Likewise, the number of abnormal metabolic risk factors also increases with the uric acid values and the higher the number of metabolic components the higher the uric acid values. Moreover, in a multiple regression analysis, uric acid was significantly related with male sex, waist circumference, both office and night-time SBP and birth weight.

CONCLUSION

The present study found a positive association between uric acid and blood pressure, insulin and triglycerides. As uric acid levels increase there is a relevant clustering of metabolic risk factors, whereas elevated blood pressure is the risk factor less frequently present. Further studies need to assess the mechanistic link between uric acid and the cardiometabolic risk factors.

Cow milk does not affect adiposity in growing piglets as a model for children

The effect of milk consumption on childhood obesity is unclear and a direct demonstration of an association is needed. In the present study, we used piglets as a model for prepubertal children to determine the effect of milk on adipose tissue. Two studies were conducted: study 1 with 5-wk-old male piglets (n = 8) and study 2 with 8- to 9-wk-old male piglets (n = 12). The piglets were fed a normal growing diet and randomly assigned to receive daily either 750 mL of whole cow milk or an isocaloric maltodextrin solution (control). For approximately 12 wk, body weight, feed intake, and subcutaneous back fat thickness were determined ultrasonographically and recorded. At euthanasia, back and neck fat thicknesses were measured and samples of back fat were collected for adipose histology. In study 1, but not study 2, piglets receiving milk grew more and ate more compared with control. In study 1, both back fat and neck fat thickness were greater in the milk-fed piglets and they had a higher frequency of small adipocytes and a lower frequency of intermediate and large adipocytes compared with controls. In study 2, control pigs had a significantly greater frequency of intermediate adipocytes but the milk-fed piglets tended to have a higher frequency of the largest adipocytes. In conclusion, milk has no apparent causal or consistent effect on adipose tissue in growing piglets.

Universal screening program for lipid disorders in 2-10 years old Lebanese children: A new approach

Introduction

Dyslipidemia has been recognized as a risk factor for cardiovascular diseases. Studies have showed that the development of atherosclerotic lesions begins in childhood and progresses throughout life. While the prevalence of dyslipidemia in adults has been reported to be 10 times higher in Lebanon compared to Western countries, data on the prevalence of dyslipidemic children in Lebanon is lacking.

Objectives

This study was conducted to assess the benefit of a protocol for universal screening for lipid disorders in Lebanese children aged between two and ten years old.

Materials and methods

A total of four hundred children aged 2–10 years old (51.5% boys) were included in the study. The subjects were recruited from private pediatric clinics after parental consent. Fasting total cholesterol (TC), triglycerides (TG), low density lipoprotein (LDL), high density lipoprotein (HDL) levels were measured and non-HDL cholesterol was calculated. The values were categorized according to 2011 Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents.

Results

The overall prevalence of high TC (≥200 mg/dL), high non-HDL-C (≥145 mg/dL), high LDL (≥130 mg/dL), high TG (≥100 mg/dL) and low HDL (<40 mg/dL) was respectively 19.5%, 23%, 19%, 31.8% and 20%. The overall frequency of dyslipidemia was 51.7%. In a bivariate analysis, dyslipidemia in children was associated with a BMI ≥95th percentile and parents having TC > 240 mg/dL with a P value respectively of .006 and .0001. Furthermore, high TG was independently associated with a BMI ≥95th percentile (P = .0001). Children with parents having TC > 240 mg/dL was significantly correlated with high TC, high non-HDL-C and high LDL (P = .0001 for all variables). Finally, according to the Pediatric Dyslipidemia Screening Guidelines from the 2011 Expert Panel, 62.3% of dyslipidemic children had at least 1 risk factor that qualified them for screening while 37.7% of them didn't have any risk factor.

Conclusions

It is preferable to review the latest pediatric dyslipidemia screening guidelines by performing a universal screening program since a third of our dyslipidemic Lebanese children will be missed.

Healthy Body Weights With Corticosteroid-free Immunosuppression Is the Best Predictor of Cardiovascular Health in Children After Liver Transplantation

INTRODUCTION

Cardiometabolic dysregulation (CMD) influences morbidity and mortality risk in adults post-liver transplantation (LTx). CMD is reported in 10% to 25% of pediatric LTx recipients, but no information regarding the longitudinal expression of CMD is available. The study objective was to examine the longitudinal expression of CMD and associations with body composition and growth in children post-LTx.

METHODS

A retrospective review was conducted in youth (34 F/30 M) who underwent LTx between 1994 and 2015 at the Stollery Children's Hospital. Primary outcomes included serum markers of CMD (insulin, glucose, hemoglobin A1C [A1C], homeostasis model assessment for insulin resistance [abnormal >3], lipid panel triglycerides, total cholesterol, high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol) and systolic/diastolic blood pressure (BP: absolute/z scores).

RESULTS

Mean (±SD) age, weight z, height z, body mass index z was 9.7 ± 3.4 years (3.5-17.9), 0.26 ± 1.03, 0.017 ± 1.2, and 0.41 ± 1.05, respectively. The majority of children had percentage fat mass, percentage fat-free mass within normal reference ranges. Systolic/diastolic BP was within healthy references ranges in 83.1% and 93.5% of children, respectively. Serum insulin (83.4%) and high-density lipoprotein-cholesterol (43.9%) concentrations were low, with abnormal findings of other laboratory markers found in <5% of participants. Abnormal findings for metabolic parameters were independent of weight z, body mass index z, fat mass, and corticosteroids but were positively related to child's age (>9.7 years) and fat-free mass (total, arms). Insulin levels decreased significantly in the first 4 years post-LTx, but no changes in lipid panel, A1C and glucose were noted over 10 years.

CONCLUSIONS

Pediatric LTx recipients with healthy body weights and corticosteroid-free immunosuppression have a low expression of CMD over 10 years.

Comparing the validity of continuous metabolic syndrome risk scores for predicting pediatric metabolic syndrome: the CASPIAN-V study

Background The aim of this study was to compare the validity of various approaches to pediatric continuous metabolic syndrome (cMetS) scores including siMS scores (2 waist/height + fasting blood glucose [FBG]/5.6 + triglycerides [TG]/1.7 + systolic blood pressure [BP]/130 + high-density lipoprotein [HDL]/1.02), Z-scores, principal component analysis (PCA) and confirmatory factor analysis (CFA) for predicting metabolic syndrome (MetS). Methods This nationwide cross-sectional study was conducted on 4200 Iranian children and adolescents aged 7-18 years. The cMetS was computed using data on HDL, cholesterol, TGs, FBG, mean arterial pressure (MAP) and waist circumference (WC). The areas under the receiver operating characteristic curves (AUCs) were used to compare the performances of different cMetS scores. Results Data of 3843 participants (52.4% boys) were available for the current study. The mean (standard deviation [SD]) age was 12.6 (3) and 12.3 (3.1) years for boys and girls, respectively. The differences in AUC values of cMetS scores were significant based on the Delong method. The AUCs (95% confidence interval [CI]) were for Z-scores, 0.94 (0.93, 0.95); first PCA, 0.91 (0.89, 0.93); sum PCA, 0.90 (0.88, 0.92), CFA, 0.79 (0.76, 0.3) and also for siMS scores 1 to 3 as 0.93 (0.91, 0.94), 0.92 (0.90, 0.93), and 0.91 (0.90, 0.93), respectively. Conclusions The results of our study indicated that the validity of all approaches for cMetS scores for predicting MetS was high. Given that the siMS scores are simple and practical, it might be used in clinical and research practice.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY GUIDELINES FOR MANAGEMENT OF DYSLIPIDEMIA AND PREVENTION OF CARDIOVASCULAR DISEASE

OBJECTIVE

The development of these guidelines is mandated by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs).

METHODS

Recommendations are based on diligent reviews of the clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols.

RESULTS

The Executive Summary of this document contains 87 recommendations of which 45 are Grade A (51.7%), 18 are Grade B (20.7%), 15 are Grade C (17.2%), and 9 (10.3%) are Grade D. These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world medical care. The evidence base presented in the subsequent Appendix provides relevant supporting information for Executive Summary Recommendations. This update contains 695 citations of which 203 (29.2 %) are EL 1 (strong), 137 (19.7%) are EL 2 (intermediate), 119 (17.1%) are EL 3 (weak), and 236 (34.0%) are EL 4 (no clinical evidence).

CONCLUSION

This CPG is a practical tool that endocrinologists, other health care professionals, health-related organizations, and regulatory bodies can use to reduce the risks and consequences of dyslipidemia. It provides guidance on screening, risk assessment, and treatment recommendations for a range of individuals with various lipid disorders. The recommendations emphasize the importance of treating low-density lipoprotein cholesterol (LDL-C) in some individuals to lower goals than previously endorsed and support the measurement of coronary artery calcium scores and inflammatory markers to help stratify risk. Special consideration is given to individuals with diabetes, familial hypercholesterolemia, women, and youth with dyslipidemia. Both clinical and cost-effectiveness data are provided to support treatment decisions.

ABBREVIATIONS

4S = Scandinavian Simvastatin Survival Study A1C = glycated hemoglobin AACE = American Association of Clinical Endocrinologists AAP = American Academy of Pediatrics ACC = American College of Cardiology ACE = American College of Endocrinology ACS = acute coronary syndrome ADMIT = Arterial Disease Multiple Intervention Trial ADVENT = Assessment of Diabetes Control and Evaluation of the Efficacy of Niaspan Trial AFCAPS/TexCAPS = Air Force/Texas Coronary Atherosclerosis Prevention Study AHA = American Heart Association AHRQ = Agency for Healthcare Research and Quality AIM-HIGH = Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides trial ASCVD = atherosclerotic cardiovascular disease ATP = Adult Treatment Panel apo = apolipoprotein BEL = best evidence level BIP = Bezafibrate Infarction Prevention trial BMI = body mass index CABG = coronary artery bypass graft CAC = coronary artery calcification CARDS = Collaborative Atorvastatin Diabetes Study CDP = Coronary Drug Project trial CI = confidence interval CIMT = carotid intimal media thickness CKD = chronic kidney disease CPG(s) = clinical practice guideline(s) CRP = C-reactive protein CTT = Cholesterol Treatment Trialists CV = cerebrovascular CVA = cerebrovascular accident EL = evidence level FH = familial hypercholesterolemia FIELD = Secondary Endpoints from the Fenofibrate Intervention and Event Lowering in Diabetes trial FOURIER = Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects With Elevated Risk trial HATS = HDL-Atherosclerosis Treatment Study HDL-C = high-density lipoprotein cholesterol HeFH = heterozygous familial hypercholesterolemia HHS = Helsinki Heart Study HIV = human immunodeficiency virus HoFH = homozygous familial hypercholesterolemia HPS = Heart Protection Study HPS2-THRIVE = Treatment of HDL to Reduce the Incidence of Vascular Events trial HR = hazard ratio HRT = hormone replacement therapy hsCRP = high-sensitivity CRP IMPROVE-IT = Improved Reduction of Outcomes: Vytorin Efficacy International Trial IRAS = Insulin Resistance Atherosclerosis Study JUPITER = Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin LDL-C = low-density lipoprotein cholesterol Lp-PLA2 = lipoprotein-associated phospholipase A2 MACE = major cardiovascular events MESA = Multi-Ethnic Study of Atherosclerosis MetS = metabolic syndrome MI = myocardial infarction MRFIT = Multiple Risk Factor Intervention Trial NCEP = National Cholesterol Education Program NHLBI = National Heart, Lung, and Blood Institute PCOS = polycystic ovary syndrome PCSK9 = proprotein convertase subtilisin/kexin type 9 Post CABG = Post Coronary Artery Bypass Graft trial PROSPER = Prospective Study of Pravastatin in the Elderly at Risk trial QALY = quality-adjusted life-year ROC = receiver-operator characteristic SOC = standard of care SHARP = Study of Heart and Renal Protection T1DM = type 1 diabetes mellitus T2DM = type 2 diabetes mellitus TG = triglycerides TNT = Treating to New Targets trial VA-HIT = Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial VLDL-C = very low-density lipoprotein cholesterol WHI = Women's Health Initiative.

Body fat indicators perform better than body mass index in identifying abnormal lipid profiles in boys but not in girls

BACKGROUND

BMI as a body weight indicator, may inadequately represent the biological effect of body fat on lipid profiles. This study aims to assess whether body fat indicators were superior to BMI for recognizing children with dyslipidemia.

METHODS

A nationwide cross-sectional study involving 8944 pediatric participants aged 6-18 years. Measures of fat mass index (FMI), fat mass percentage (FMP), BMI, and four lipid profiles were obtained.

RESULTS

Among boys, the standard multi-linear regression coefficients of FMI for TC, LDL-C, and TG were higher than those of BMI (P < 0.01), but not for HDL-C. Also, the prevalence ratios and area under curves (AUCs) of excess fat classified by FMI for specific abnormal lipid profiles (except for HDL-C) were greater than overweight classified by BMI. The AUCs for detecting children with abnormal TC, LDL-C, and TG of FMI-based excess fat were 3.9%, 5.6%, and 2.8% higher than those of BMI-based overweight, respectively, all P < 0.01. Among girls, the associations of BMI with lipid profiles were substantially similar to FMI. All these results were almost identical when FMP was used instead of FMI.

CONCLUSIONS

DXA measured body fat performs better than BMI in identifying abnormal lipid profiles in boys but not in girls.

Prenatal Metal Concentrations and Childhood Cardiometabolic Risk Using Bayesian Kernel Machine Regression to Assess Mixture and Interaction Effects

BACKGROUND

Trace metal concentrations may affect cardiometabolic risk, but the role of prenatal exposure is unclear. We examined (1) the relation between blood metal concentrations during pregnancy and child cardiometabolic risk factors; (2) overall effects of metals mixture (essential vs. nonessential); and (3) interactions between metals.

METHODS

We measured 11 metals in maternal second-trimester whole blood in a prospective birth cohort in Mexico City. In children 4-6 years old, we measured body mass index (BMI), percent body fat, and blood pressure (N = 609); and plasma hemoglobin A1C (HbA1c), non-high-density lipoprotein (HDL) cholesterol, triglycerides, leptin, and adiponectin (N = 411). We constructed cardiometabolic component scores using age- and sex-adjusted z scores and averaged five scores to create a global risk score. We estimated linear associations of each metal with individual z scores and used Bayesian Kernel Machine Regression to assess metal mixtures and interactions.

RESULTS

Higher total metals were associated with lower HbA1c, leptin, and systolic blood pressure, and with higher adiponectin and non-HDL cholesterol. We observed no interactions between metals. Higher selenium was associated with lower triglycerides in linear (β = -1.01 z score units per 1 unit ln(Se), 95% CI = -1.84, -0.18) and Bayesian Kernel Machine Regression models. Manganese was associated with decreased HbA1c in linear models (β = -0.32 and 95% CI = -0.61, -0.03). Antimony and arsenic were associated with lower leptin in Bayesian Kernel Machine Regression models. Essential metals were more strongly associated with cardiometabolic risk than were nonessential metals.

CONCLUSIONS

Low essential metals during pregnancy were associated with increased cardiometabolic risk factors in childhood.

Cardiometabolic health in Turner syndrome

Individuals with Turner syndrome (TS) have a higher morbidity and mortality compared to the general population. Diabetes and cardiovascular disease are the major contributors to this burden. Precursors to diabetes and cardiovascular disease make up what is known as metabolic syndrome, including abdominal obesity, hypertension, dyslipidemia, and elevated fasting glucose. These features of poor cardiometabolic health are also prevalent among women with TS. Youth with TS also exhibit many of these features, indicating that the pathogenesis of these cardiometabolic conditions may begin early in life. The etiology of the increased risk of cardiometabolic conditions in TS is likely multifactorial, involving genetics, epigenetics, hypogonadism, medical comorbidities, medications, and lifestyle. Counseling for the increased risk of cardiometabolic diseases as well as efforts to prevent or lower this risk should be routinely provided in the care of all patients with TS. Clinical practice guidelines are now available to guide screening and treatment of cardiometabolic conditions in girls and women with TS.

Psoriasis and metabolic and cardiovascular comorbidities in children: A systematic review

INTRODUCTION

Psoriasis is associated with a higher risk of cardiovascular and/or metabolic comorbidity in adults, but discordant data have been reported in children.

OBJECTIVE

To evaluate the frequency of metabolic and cardiovascular comorbidity in children with psoriasis and to establish whether age at onset of psoriasis correlates with metabolic and cardiovascular comorbidity in adulthood.

MATERIAL AND METHODS

We conducted a systematic review on MEDLINE, using PubMed and Ovid. The search was limited to children (<18 years). The following key words were used: "psoriasis" with "children or childhood or adolescent" and "obesity" or "hypertension" or "diabetes" or "dyslipidemia" or "cardiovascular risk factor" or "myocardial infarction" or "stroke" or "coronaropathy" or "comorbidity". The reference lists of the articles retrieved were checked for additional relevant studies.

RESULTS

A total of 377 potential citations were analyzed. After removing duplicate articles and reviewing eligibility in titles and abstracts, 16 articles remained. The studies analyzed revealed significantly higher risk of overweight and obesity in children with psoriasis, despite the numerous definitions used. Four studies reported higher risk of abdominal obesity in children with psoriasis. Data on hypertension, diabetes, dyslipidemia, metabolic syndrome, and major cardiovascular events suggested there was no higher risk of these comorbidities in children with psoriasis. Two studies suggested that age at onset of psoriasis did not increase the frequency of comorbidity in adulthood.

CONCLUSION

This systematic review suggests that psoriasis in children is not associated with metabolic and cardiovascular comorbidities, except overweight and obesity, for which higher prevalence is clearly demonstrated in the literature.

Review shows that lipid disorders are associated with endothelial but not renal dysfunction in children

AIM

We undertook this review to assess the effects of lipid metabolism abnormalities on endothelial and renal function in children.

METHODS

A search of relevant literature published in English from January 1988 to May 2018 was performed, and this included randomised controlled trials, observational cohort studies, systematic reviews and case reports.

RESULTS

The search process identified 2324 relevant studies and 29 were finally included. Noninvasive ultrasound markers of endothelial dysfunction, such as flow-mediated dilation and carotid intima-media thickness, were impaired in children with dyslipidaemia. Dietary interventions and statin therapy reversed the effects of dyslipidaemia on endothelial function in children. Most data from adult studies failed to prove a causative relationship between dyslipidaemia and renal disease progression or a beneficial effect of lipid-lowering treatment on renal outcomes. The limited paediatric data did not indicate dyslipidaemia as an independent risk factor for renal dysfunction, which was mainly estimated by cystatin C levels or proteinuria. Therefore, further investigation is needed to clarify a potential relationship.

CONCLUSION

In view of limited available paediatric evidence, dyslipidaemia may be adversely associated with endothelial function. However, the association between lipid metabolism disorders and renal function in childhood needs to be further investigated.

Obesity and Cardiometabolic Risk Factors in Children and Young Adults With Non-classical 21-Hydroxylase Deficiency

Introduction: Classical congenital adrenal hyperplasia is associated with an increased risk of obesity and cardiometabolic disease. The aim of the study was to determine if this is also true for non-classical congenital adrenal hyperplasia (NCCAH). Methods: A retrospective, cross-sectional, single-center study design was used. Data were collected on 114 patients (92 female) with NCCAH diagnosed during childhood/adolescence at a tertiary medical center. Patients were classified by treatment status at the last clinic visit. Outcome measures were assessed at diagnosis and the last clinic visit: weight status, body composition, blood pressure, lipid profile, and glucose metabolism. The prevalence of overweight/obesity was compared to the parental prevalence, and for patients aged 11-20 years, to the Israeli National Survey. Results: Mean age was 7.9 ± 4.2 years at diagnosis and 17.1 ± 6.9 years at the last follow-up. At the last clinic visit, 76 patients were under treatment with glucocorticoids, 27 were off-treatment (previously treated), and 11 had never been treated. The rate of obesity (11.4%) was similar to the parental rates, and the rate of overweight was significantly lower. In patients 11-20 years old, rates of obesity or obesity + overweight were similar to the general Israeli population (11.4 vs. 15.1%, P = 0.24 and 34.2 vs. 41.6% P = 0.18, respectively). No significant difference was found between glucocorticoid-treated and off-treatment patients in any of the metabolic or anthropometric parameters evaluated, except for a lower mean fat mass (% of body weight) in off-treatment patients (23.0 ± 7.7% vs. 27.8 ± 6.8%, P = 0.06). Systolic hypertension was found in 12.2% of NCCAH patients either treated or untreated. Conclusion: NCCAH diagnosed in childhood, whether treated or untreated, does not pose an increased risk of overweight, obesity, or metabolic derangements in adolescence and early adulthood.

A Novel Indicator Of Lipid Accumulation Product Associated With Metabolic Syndrome In Chinese Children And Adolescents

BACKGROUND

The lipid accumulation product (LAP) is a powerful marker for predicting metabolic syndrome (MS) in adults. The present study aimed to propose a novel indicator, the children's lipid accumulation product (CLAP), and to assess its association with MS among Chinese children and adolescents.

METHODS

A total of 683 Chinese children aged 8-15 years were recruited using a stratified cluster sampling method in this cross-sectional study. The presence of MS was defined according to the NCEP-ATP III criteria. The effects of BMI, WHtR and the CLAP for predicting MS were compared using logistic regression models and receiver operating characteristic (ROC) curves.

RESULTS

The prevalence of MS was 5.1% (6.6% and 3.5% among boys and girls, respectively). Overall obesity (based on BMI), abdominal obesity (based on WHtR) and CLAP≥P75 were significantly associated with an increased risk of MS (ORs (95% CIs) were 143.79 (18.78-1101.22), 86.83 (27.19-277.27), 150.75 (20.11-1130.19), respectively). The area under the ROC curve (AUC) for the CLAP was higher than that for BMI and WHtR for predicting MS, with AUC (95% CI) values of 0.944 (0.913-0.975), 0.895 (0.864-0.927), and 0.928 (0.903-0.953), respectively.

CONCLUSION

The children's lipid accumulation product (CLAP) was an effective indicator associated with MS in Chinese children and adolescents and was better than BMI and WHtR for predicting MS.

13. Children and Adolescents: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Serum Uric Acid Levels as an Indicator for Metabolically Unhealthy Obesity in Children and Adolescents

BACKGROUND

Metabolically healthy obesity (MHO) refers to those individuals who do not show cardiometabolic abnormalities. Our aim was to identify potential clinical and metabolic indicators that may help to distinguish between metabolically healthy and unhealthy individuals amongst overweight and obese children and adolescents.

METHODS

The study involved 246 overweight/obese and 212 normal-weight individuals enrolled in the LIFE Child study, aged between 6 and 18 years. Overweight/obese individuals without cardiovascular risk factors (fasting serum lipids, blood pressure, and glucose) were classified as MHO. Individuals meeting 1 or more criteria of cardiovascular risk factors were classified as metabolically unhealthy obesity (MUO).

RESULTS

Among the 246 overweight/obese individuals, 173 (70%) were MHO and 73 (30%) were MUO. The MHO individuals were younger, more likely to be male, and had lower BMI SDS. In the logistic regression models, uric acid (UA) SDS (OR 1.61, 95% CI 1.1-2.6, p = 0.004), waist circumference SDS (OR 2.50, 95% CI 1.2-6.4, p = 0.017), and C-peptide (OR 4.05, 95% CI 3.5-91, p = 0.003) were significant indicators of MUO.

CONCLUSION

Our results suggest that nearly one-third of overweight/obese children are already identified as MUO. Serum levels of UA can be used as an indicator of unhealthy obesity in youth, where lower levels of UA indicate a lower risk and higher levels suggest a higher risk of MUO. We note that the relevance of identifying potential indicators remains the first most important step in future clinical research.

Decreasing the Cholesterol Burden in Heterozygous Familial Hypercholesterolemia Children by Dietary Plant Stanol Esters

This review covers the current knowledge about plant stanol esters as a dietary treatment option for heterozygous familial hypercholesterolemia (he-FH) children. The current estimation of the prevalence of he-FH is about one out of 200–250 persons. In this autosomal dominant disease, the concentration of plasma low-density lipoprotein cholesterol (LDL-C) is strongly elevated since birth. Quantitative coronary angiography among he-FH patients has revealed that stenosing atherosclerotic plaques start to develop in he-FH males in their twenties and in he-FH females in their thirties, and that the magnitude of the plaque burden predicts future coronary events. The cumulative exposure of coronary arteries to the lifelong LDL-C elevation can be estimated by calculating the LDL-C burden (LDL-C level × years), and it can also be used to demonstrate the usefulness of dietary stanol ester treatment. Thus, when compared with untreated he-FH patients, the LDL-C burden of using statin from the age of 10 is 15% less, and if he-FH patients starts to use dietary stanol from six years onwards and a combination of statin and dietary stanol from 10 years onwards, the LDL-C burden is 21% less compared to non-treated he-FH patients. We consider dietary stanol treatment of he-FH children as a part of the LDL-C-lowering treatment package as safe and cost-effective, and particularly applicable for the family-centered care of the entire he-FH families.

Exercise Capacity Assessment by the Modified Shuttle Walk Test and its Correlation with Biochemical Parameters in Obese Children and Adolescents

OBJECTIVES

To evaluate exercise capacity of obese children and adolescents compared with normal-weight individuals and to investigate possible correlations with blood biochemical parameters.

METHODS

In this study, children and adolescents between 6 and 18 y were included and divided into control (eutrophic) and obese groups according to body mass index (BMI). Data were collected regarding demographic, anthropometric, waist circumference and exercise capacity through the Modified Shuttle Walk Test (MSWT). In the obese group, biochemical parameters in the blood (total cholesterol, HDL, LDL, triglycerides and glucose) were evaluated, and a physical activity questionnaire was applied.

RESULTS

Seventy seven participants were included; 27 in the control group and 50 obese. There was no significant difference between the two groups regarding sample characteristics, except for body weight, BMI and waist circumference. Most obese children presented results of biochemical tests within the desirable limit, though none were considered active. There was a significant exercise capacity reduction (p < 0.001) in the obese group compared to control subjects. Positive correlations were identified for the MSWT with age and height, and a negative correlation with BMI. However, there were no correlations with the biochemical parameters analyzed.

CONCLUSIONS

Obese children and adolescents have reduced exercise capacity when compared to normal individuals. The MSWT performance seems to have a negative association with BMI, but is not correlated with blood biochemical parameters.

Changes in socio-economic status and lipoproteins in Chilean adolescents: a 16-year longitudinal study

OBJECTIVE

The present longitudinal study assessed whether changes in socio-economic status (SES) from infancy to adolescence were associated with plasma lipoprotein concentrations in adolescence, of which low HDL-cholesterol (HDL-C) and high LDL-cholesterol (LDL-C), TAG and total cholesterol (TC) concentrations are associated with higher cardiovascular risk.

DESIGN

SES, assessed using the modified Graffar Index, was calculated at 1, 5, 10 and 16 years. Principal components factor analysis with varimax rotation extracted two orthogonal SES factors, termed 'environmental capital' and 'social capital'. Generalized linear models were used to analyse associations between environmental and social capital at 1 and 16 years and outcomes (HDL-C, LDL-C, TAG, TC) at 16 years, as well as changes in environmental and social capital from 1-5, 5-10, 10-16 and 1-16 years, and outcomes at 16 years.

SETTING

Santiago, Chile.ParticipantsWe evaluated 665 participants from the Santiago Longitudinal Study enrolled at infancy in Fe-deficiency anaemia studies and examined every 5 years to age 16 years.

RESULTS

Social capital in infancy was associated with higher HDL-C in adolescence. Environmental capital in adolescence was associated with higher LDL-C and TC during adolescence. Changing environmental capital from 1-16 years was associated with higher LDL-C. Changing environmental capital from 1-5 and 1-16 years was associated with higher TC.

CONCLUSIONS

Improvements in environmental capital throughout childhood were associated with less healthy LDL-C and TC concentrations in adolescence. We found no evidence of associations between changing environmental capital and HDL-C or TAG, or changing social capital and HDL-C, LDL-C, TAG or TC.

Effective sociodemographic and clinical factors in weight loss in childhood obesity

Aim

Obesity is a more common and important health problem in childhood. We aimed to determine sociodemographic and clinical factors contributing weight loss.

Material and Methods

Medical records of 120 obese patients (6-18 years old) applied at least twice for follow-up between 2012 (January)-2016 (September) were reviewed. Age, gender, socioeconomic status, family obesity, comorbidities, medications, operations, exercise frequency, screen time, physical examination findings and biochemical/hormone values [thyroid hormone, fasting insulin/glucose, cholesterol levels, Homeostasis model assesment insulin resistance (HOMA-IR), oral glucose tolerance test results (if applied) were recorded. Patients with a difference between the initial and last body mass index standart deviation higher than -0.2 were defined as "the good losing weight" group; the rest as "the poorly losing weight" group. The SPSS 22.0 program was used for analyzes.

Results

Puberty stage showed a significant difference (p=0,019); 65% of patients in the poorly losing weight group but 54% of other group were at stage 4-5. The initial body mass index standart deviation and exercise frequency were higher in the good losing weight group, the last measured body mass index standart deviation was lower (p=0). In the other group, baseline HOMA-IR was higher (p=0.037); there were more metformin-initiated patients but the difference was not significant.

Conclusion

We observed that exercise frequency was higher in cases with good weight loss; therefore, we consider that increasing physical activity is an important step. Other crucial outcomes are that the initial body mass index standart deviation is higher while HOMA-IR is lower in those cases and that puberty stage is higher in poorly weight losing patients.

Impact of gaining or maintaining excessive weight in infancy on markers of metabolic homeostasis in young children: A longitudinal study in Chilean children

Childhood obesity in Chile is one of the highest in the world. The objective of this study was to assess the impact of excessive weight gained or maintained over a 3-year period, on markers of metabolic homeostasis in young children. This is a longitudinal study which includes 243 children followed from 4 to 7 years. We assessed BMI, body fat percentage, waist circumference (WC), waist-hip ratio (WHR), waist-height (WH) and trunk fat as well as the following metabolic parameters: glucose, insulin, triglycerides, total cholesterol, LDL, HDL and metabolic risk score. Kruskal- Wallis was used to assess differences in metabolic markers by nutritional status and logistic regression to determine the effect of maintaining or gaining excess weight over the 3-year period, compared with children who maintained a normal weight. Children who were obese at both ages compared with those who were normal weight, had a significantly higher WC, serum concentrations of total fat, total cholesterol, triglycerides, LDL cholesterol and metabolic risk score (P < 0.05). Children who were overweight or obese at 4 and 7 years, had a greater risk of having a high WC (OR: 3.37; P = 0.03), total cholesterol (OR: 4.17; P < 0.003), triglycerides (OR: 1.96; P = 0.04); thus a higher metabolic risk score (OR: 3.21; P = 0.003). Excess weight maintained over time in early childhood, significantly increases the risk of having higher serum biomarkers of cardiovascular risk, which in turn determines the magnitude of cardiovascular and metabolic risks later in life.

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A Chilean cohort study followed from 4 to 7 years showed that the prevalence of overweight/obese increased from 32 to 35%.

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23% of children remained overweight/obese at both ages.

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13% of children changed from normal to overweight.

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Excess weight maintained over time increases disruption of metabolic homeostasis.

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Cardiovascular parameters may determine the magnitude of cardiovascular risks.

Lifestyle Medicine: The Health Promoting Power of Daily Habits and Practices

There is no longer any serious doubt that daily habits and actions profoundly affect both short-term and long-term health and quality of life. This concept is supported by literally thousands of research articles and incorporated in multiple evidence-based guidelines for the prevention and/or treatment of chronic metabolic diseases. The study of how habits and actions affect both prevention and treatment of diseases has coalesced around the concept of "lifestyle medicine." The purpose of this review is to provide an up-to-date summary of many of the modalities fundamental to lifestyle medicine, including physical activity, proper nutrition, weight management, and cigarette smoking cessation. This review will also focus specifically on how these modalities are employed both in the prevention and treatment of chronic diseases including coronary heart disease, diabetes, obesity, and cancer. The review concludes with a Call to Action challenging the medical community to embrace the modalities of lifestyle medicine in the daily practice of medicine.

Serum ferritin level as an early indicator of metabolic dysregulation in young obese adults - a cross-sectional study

The aim of this study was to investigate the relationship between serum ferritin level and antioxidative status and metabolic dysregulation in young adult obese population. This cross-sectional study included 300 subjects of either sex, grouped as obese and non-obese subjects. The body mass index, total iron binding capacity, fasting blood glucose, superoxide dismutase activity, and levels of serum ferritin, iron, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglyceride, glutathione, and vitamin C were estimated. Analysis showed a significant alteration in all the parameters in obese adults. The correlation of ferritin level and body mass index showed a positive correlation (r = -0.81, p < 0.001, respectively) with levels of fasting blood glucose, superoxide dismutase, total cholesterol, low-density lipoprotein cholesterol, and triglyceride in obese individuals, whereas an insignificant correlation with vitamin C and glutathione level was observed in obese individuals. The significant positive correlation of ferritin level with the metabolic parameters and some antioxidative parameters in obese individuals signifies the development of metabolic disorders. Therefore, estimation of serum ferritin level will be an important early indicator for the risk of developing metabolic disorders in young adults.

Triglyceride to high density lipoprotein cholesterol ratio among adolescents is associated with adult hypertension: the Kangwha study

Background

The triglyceride to high density lipoprotein cholesterol (TG/HDL-C) ratio associated with hypertension in adults. However, whether the TG/HDL-C ratio in adolescents predicts future hypertension remains unclear. Here, we evaluated the prospective association between the TG/HDL-C ratio in adolescents and hypertension in early adulthood.

Methods

The Kangwha Study is an ongoing prospective cohort study that has tracked the blood pressure of first grade elementary school students since 1986. We followed up 272 participants who completed health examinations at the age of 16 and 35 years. We excluded 27 participants with adolescent hypertension, defined as those whose blood pressures were above the age- and sex-specific 95th percentiles of the Korean population, and finally analysed 245 participants. We defined high and low TG/HDL-C ratio groups according to the age- and sex-specific 75th percentile of the TG/HDL-C ratio (1.04 for boys and 0.81 for girls) of the Korean population. Adult hypertension was defined by a systolic/diastolic blood pressure ≥ 140/90 mmHg or by taking antihypertensive medication at the age of 35 years. Logistic regression analysis was performed to evaluate the association between adolescent TG/HDL-C ratio and adult hypertension after adjusting for age at follow-up, sex, baseline systolic blood pressure, waist circumference, and total cholesterol and fasting glucose levels.

Results

During the 20-year follow-up, 11 (18.3%) individuals developed hypertension in the high TG/HDL-C ratio group and 10 (5.4%) individuals developed hypertension in the low TG/HDL-C ratio group. The adjusted odds ratio for incident hypertension in the high TG/HDL-C ratio group, compared with the low TG/HDL-C ratio group, was 3.40 (95% confidence interval 1.24–9.31).

Conclusions

High TG/HDL-C ratio in adolescence is associated with hypertension in early adulthood.

Electronic supplementary material

The online version of this article (10.1186/s12944-018-0861-y) contains supplementary material, which is available to authorized users.

Metabolically healthy and metabolically unhealthy obese children both have increased carotid intima-media thickness: a case control study

BACKGROUND

The cardiovascular disease risk was assessed in metabolically healthy obese (MHO) children, obese children with metabolic disorders (MUO), and to a control group of normal-weight children using carotid intima-media thickness (CIMT).

METHODS

Participants were 204 obese children (114 M, 90 F), including 162 MUO (74 M, 88 F) and 42 MHO (24 M, 18 F), and 99 gender- and age-matched controls (45 M, 54 F). Glucose, triglycerides, total cholesterol, high-density and low-density lipoprotein cholesterol, and other serum values were determined in peripheral blood. Anthropometric parameters, blood pressure, and a carotid Doppler ultrasound scan were also acquired. The mean CIMT of obese subjects and controls was compared by analysis of variance. Abnormality of even one of the metabolic parameters assessed involved assignation to the MUO group. Mean CIMT was compared in MHO and MUO children.

RESULTS

Mean CIMT in control children was 402.97 ± 53.18 μm (left carotid artery) and 377.85 ± 52.47 μm (right carotid artery). In MHO and MUO patients CIMT was respectively 453.29 ± 62.04 and 460.17 ± 92.22 μm (left carotid artery) and 446.36 ± 49.21 and 456.30 ± 85.7 μm (right carotid artery). The mean CIMT was not significantly different in MUO and MHO children, whereas it showed a significant difference between both groups of obese children and controls (p < 0.01).

CONCLUSION

CIMT was significantly greater in obese patients, also in those without metabolic alterations, than in normal-weight children. Obesity is therefore an important risk factor for cardiovascular disease in itself, also in the absence of metabolic abnormalities.

Beverage Consumption Patterns among Infants and Young Children (0⁻47.9 Months): Data from the Feeding Infants and Toddlers Study, 2016

(1) Background: Data about early life beverage intake patterns is sparse. We describe beverage patterns among infants and young children from the Feeding Infants and Toddlers Study (FITS) 2016. (2) Methods: FITS 2016 is a cross-sectional survey of U.S. parents/caregivers of children 0⁻47.9 months (n = 3235). Food and beverage intakes were collected by 24-h dietary recalls to describe beverage consumption patterns including: a) prevalence of consumption, per capita and per consumer intake, b) contribution to intake of calories and key nutrients, and c) prevalence according to eating occasions. (3) Results: Breast milk and infant formula were commonly consumed among <12-month-olds. Among 12⁻23.9-month-olds, the most commonly consumed beverage was whole milk (67% consuming), followed by 100% juice (50% consuming). Plain drinking water was consumed by 70% of 12⁻23.9-month-olds and 78% of 24⁻47.9-month-olds. Among 12⁻47.9-month-olds, milks provided more energy and key nutrients than all other beverages. Across eating occasions, sugar-sweetened beverage (SSB) consumption, especially in the form of fruit-flavored drinks, was higher among 24⁻47.9 compared to 12⁻23.9-month-olds. Only 23⁻32% of ≥12-month-olds consumed milk or water at lunch or dinner. (4) Conclusions: Opportunities exist to improve beverage patterns. Future interventions may benefit from focusing on timely introduction of age-appropriate beverages and reducing consumption of SSBs.

The Pattern of Complementary Foods in American Infants and Children Aged 0⁻5 Years Old-A Cross-Sectional Analysis of Data from the NHANES 2011⁻2014

Proper nutrition early in life can influence children’s present and future health. While several authoritative sources provide eating/food recommendations, only a few studies have assessed whether these recommendations are followed. The goal of this paper was to examine food and nutrient intakes on any given day during infancy and early childhood among various ethnicities. Twenty-four-hour dietary recall data of 0–5 years-old children (n = 2431) from the National Health and Nutrition Examination Survey (NHANES) 2011–2014 was used to estimate intakes of nutrients and food groups and prevalence of inadequate intake. Data was analyzed separately for various age groups and ethnicities, and differences in means by age and or race/ethnicity were determined by t-tests with p < 0.05 as significant. The results indicate that intakes of all food groups were expectedly low at 0–11 months, increased with age, and were influenced by race/ethnicity. Mixed dish consumption, which also increased with age, made substantial contributions to children’s food group intakes. However, there was a substantial percentage of the population among all age and race/ethnic groups who did not consume the recommended amounts for each food group and had inadequate intakes of key nutrients, such as calcium, vitamin D, and vitamin E. Non-Hispanic black children consumed less dairy and more protein foods, and a significantly greater proportion of these children had inadequate intakes of calcium and vitamin D compared to their peers. In conclusion, the results from this study suggest that a substantial population of American infants and children from 0 to five years of age did not meet food group recommendations and had inadequate intakes of key nutrients such as calcium, vitamin D, and vitamin E from foods.

Anthropometric features as predictors of atherogenic dyslipidemia and cardiovascular risk in a large population of school-aged children

BACKGROUND

Autopsy studies reveal that atherosclerosis lesions can be found as early as two years of age. To slow the development of this early pathology, obesity and dyslipidemia prevention should start from childhood making it urgent to explore new ways to evaluate dyslipidemia risk in children that can be applied widely, such as the non-invasive anthropometric evaluation.

OBJECTIVE

Assess the metabolic profile of a pediatric population at a specific age to describe the association between anthropometric and biochemical cardiovascular disease risk factors; and evaluate selected anthropometric variables as potential predictors for dyslipidemic cardiovascular risk.

DESIGN AND METHODS

Anthropometric features, bioimpedance parameters and fasting clinical profile were assessed in Lisbon and the Tagus Valley region pre-pubertal nine-year-old children (n = 1.496) from 2009-2013 in a descriptive, cross-sectional study. Anthropometric variables predictive power was evaluated through regression analysis.

RESULTS

At least one abnormal lipid parameter was found in 65% of "normal weight", 73% of "overweight" and 81% of "obese" children according to the International Obesity Task Force (IOTF) standards. Dyslipidemia was present in 67.8% of children. Waist-hip ratio (WHR) explained 0.4% of total cholesterol (TC) variance. Waist circumference (WC) explained 2.8% of apolipoprotein (APO) A1 variance. Waist-circumference-to-height-ratio (WHtR) explained 2.7%, 2.8% and 1.9% of low-density lipoprotein cholesterol (LDL-c), APO B, and N_HDL-c variance, respectively. Children with abnormally high WHR levels had an increase in risk of 4.49, 3.40 and 5.30 times, respectively, for developing cardiovascular disease risk factors measured as high-risk levels of TC, LDL-c and non-HDL-c (N_HDL-c) (p<0.05). Only 29.9% of "normal weight" children had no anthropometric, bioimpedance or biochemical parameters associated with CV risk.

CONCLUSION

A large proportion of school age children have at least one lipid profile abnormality. BMI, zBMI, calf circumference (CC), hip circumference (HC), WC, and WHR are directly associated with dyslipidemia, whereas HC and calf circumference (CC) adjusted to WC, and mid-upper arm circumference (MUAC), are all inversely associated with dyslipidemia. Selected anthropometric variables are likely to help predict increased odds of having CV risk factors.

Retrospective Review of Comorbid Conditions in a Multidisciplinary Pediatric Weight Management Clinic

A retrospective medical chart review was conducted of patients enrolled in the Fit for Healthy Weight Clinic (Fit Clinic). At initial evaluation, comorbidities were identified by the patient and pediatrician. The number of comorbidities increased with age among patients. In reviewing the differences among the number of identified comorbidities among grade school age and adolescent patients, increases of 30% were observed in gastrointestinal-associated, 23% in psychiatric, 18% in endocrine, 16% in cardiovascular, and 14% in respiratory comorbidities. Fit Clinic patients already manifest many known obesity-related comorbidities as evidenced in identified conditions and abnormal laboratory values. The elevated blood pressures, blood glucose, and cholesterol levels raise concern for the future development of coronary artery disease and type 2 diabetes mellitus. With an average of five obesity-related comorbidities, Fit Clinic patients already have more comorbidities than what is evidenced in large US population-based studies, demonstrating that solely addressing body mass index is not sufficient.

Cholesterol screening and statin use in children: a literature review

Atherosclerosis begins in childhood. Fatty streaks, the earliest precursor of atherosclerotic lesions, have been found in the coronary arteries of children of 2 years of age. Hypercholesterolaemia is a risk factor for coronary artery disease. Hypercholesterolaemia can be either primary, when it is characteristic of the main disease, or secondary when it occurs as a result of either a disease process or drug treatment. Given the risk of vascular disease, including myocardial infarction (MI), cerebrovascular accidents (CVA, also known as strokes), peripheral vascular disease (PVD) and ruptured aortic aneurysm, which may follow atherosclerosis, it is important to prevent or slow the early development of atherosclerotic lesions. This prevention necessitates the control of key risk factors such hypercholesterolaemia, dyslipidaemia, hypertension etc. However, at what point this prevention ought to occur, and in what form, is uncertain. Using pharmacological primary prevention for hypercholesterolaemia in the paediatric population is controversial. In an adult patient, hypercholesterolaemia warrants the initiation of a statin. Statins, also known as hydroxymethylglutaryl co-enzyme A inhibitors (or HMG-CoA inhibitors) act by altering cholesterol metabolism. In the paediatric population, the clinical course of vascular disease and the effect of altering this clinical course are less certain. This article reviews the published literature on hypercholesterolaemia in children and the use of statins as a treatment for dyslipidaemia in children. The US National Cholesterol Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents 2012 guidelines (NCEP guidelines) regarding the recognition and treatment of childhood dyslipidaemia are reviewed.

Prevalence of cardiometabolic risk factors in a nationally representative sample of Iranian children and adolescents: the CASPIAN-V Study

Introduction: This study presents the prevalence of cardiometabolic risk factors in a nationally representative sample of Iranian children and adolescents. Methods: This multi-centric study was conducted in 2015 among 4200 students aged 7-18 years. They were selected by multistage cluster sampling from 30 provinces of Iran. Anthropometric indices, biochemical and clinical parameters were measured. Results: The mean of weight, height, waist circumference (WC), systolic blood pressure (SBP), diastolic blood pressure (DBP), and fasting blood glucose (FBG) was higher in boys than in girls (P < 0.05). The mean of triglyceride (TG), total cholesterol (TC) and low-density lipoprotein (LDL) levels were higher in girls than in boys (P < 0.05). The mean of weight, height, WC, SBP, DBP, alanine transaminase (ALT) and body mass index (BMI) was higher in urban than in rural residents (P < 0.05). Overall, 16.1%, 9.4% and 11.4% were underweight, overweight and obese. Abdominal obesity was documented in 21.6% of boys and 20.5% of girls. Low HDL-C was the most prevalent abnormality of lipid profile (29.5%) followed by high serum TGs (27.7%). Low HDL-C was more prevalent in boys than in girls (32.7% vs. 26%, respectively, P < 0.05). Prevalence of obesity and overweight were higher in girls than in boys (P < 0.05). The prevalence of obesity and overweight, abdominal obesity, and low HDL-C were higher in urban than in rural residents (P < 0.05). Conclusion: We found considerably high prevalence of some cardiometabolic risk factors including overweight and obesity, low HDL-C and hypertriglyceridemia in Iranian children and adolescents. The current findings underscore the necessity of intensifying health interventions for primordial and primary prevention of non-communicable diseases from early life.

Familial Hypercholesterolemia: Cascade Screening in Children and Relatives of the Affected

OBJECTIVE

Familial Hypercholesterolemia (FH) is an inherited disorder of lipid metabolism characterized by very high low density lipoprotein (LDL) cholesterol since birth, resulting in premature atherosclerosis and coronary artery disease (CAD). Cascade screening of children and family members of proven FH individuals can identify more subjects who have high LDL cholesterol or the family mutation and appropriate intervention can reduce their risk of atherosclerosis and prevent its complications.

METHODS

Cascade screening by molecular testing, was carried out in 133 family members, comprising 24 children, of 31 probands with FH having a pathogenic mutation in LDLR/ApoB gene. Lipid profiles were obtained in 44 family members including 11 children.

RESULTS

Of 133 family members tested, 88 (66.1%) were identified to carry the family mutation. Twelve of these were children below 18 y of age and 76 were adults. CAD was present in 15 (11.2%) family members and 63(47.4%) family members, including nine children, were already on Lipid Lowering Therapy.

CONCLUSIONS

Cascade screening led to identification of 88 new cases, with a pathogenic mutation, who were at a very high risk of developing premature CAD. The authors identified 12 children with family specific mutation, out of which 9 were initiated on low dose statin therapy. Four homozygous children were treated with high dose statins because of substantially increased risk of CAD. Cascade screening, therefore, proved to be a successful initiative towards primary prevention of CAD in India.

Intima-media thickness at different arterial segments in pediatric type 1 diabetes patients and its relationship with advanced glycation end products

BACKGROUND

Patients with type 1 diabetes mellitus (T1DM) are at risk for premature atherosclerosis (AS), which has its origin in childhood. Carotid intima-media thickness (IMT) is an established surrogate marker for subclinical AS in adults. The first macroscopically detectable AS changes, however, begin in the abdominal aorta. Advanced glycation end products (AGE) predict microvascular complications in diabetes.

OBJECTIVES

To assess the sensitivity for early macrovascular changes of brachial, femoral, and aortic IMT compared to conventional carotid IMT in pediatric T1DM patients ; and the relationship of IMT with AGE.

METHODS

Using high-resolution external ultrasound, carotid, brachial, femoral, and aortic IMT were prospectively analyzed in children and adolescents with established T1DM and in controls (Ctrls). AGE were estimated by skin intrinsic fluorescence (SIF). Other established cardiovascular risk factors were excluded.

RESULTS

Seventy-six subjects (T1DM = 38; Ctrls = 38) with a mean age of 13.1 ± 4.0 years (6-19, median 13) qualified for analysis. Carotid, brachial, femoral, and aortic IMT analyses were feasible in 100%, 74%, 84%, and 92% of subjects, respectively. Aortic and femoral IMT were increased in T1DM patients (0.60 ± 0.11 vs 0.52 ± 0.10 mm, P < .001; and 0.41 ± 0.07 vs 0.36 ± 0.07 mm, P < .01, respectively) while carotid and brachial IMT were not. AGE levels were elevated in T1DM patients and correlated with aortic IMT only. The influence of AGE on aIMT did not remain significant after adjusting for T1DM and age in our small population.

CONCLUSION

We found aortic IMT-and to a lesser degree femoral IMT-to be more sensitive than carotid and brachial IMT for detecting early macrovascular changes in pediatric T1DM patients.

Is there a gender-specific association between asthma and carotid intima media thickness in Swiss adolescents?

Respiratory diseases are associated with increased cardiovascular risk in adults, but little is known on the early impact on the vasculature in youth. The SAPALDIA Youth study, the offspring study of the Swiss Study on Air Pollution and Lung and Heart Disease In Adults (SAPALDIA), investigated the association between physician-diagnosed asthma status and common carotid artery intima media thickness (CIMT). Offspring underwent standardized clinical protocols and provided information on early life factors, health, and lifestyle. The association between per subject averages of CIMT and asthma was estimated using mixed linear regression analyses adjusting for main confounders, testing for interaction with gender and age. Of 257 offspring (mean age 15 years, 53% female), 11.5% reported doctor-diagnosed asthma (male 17%, female 7%). Mean CIMT was significantly different by gender (male 0.53 mm (± 0.045), female 0.50 mm (± 0.048); p < 0.001). Interaction was highly significant by gender (p = 0.001) with significantly increased CIMT in asthmatic vs. non-asthmatics boys (difference 0.023 mm, 95% CI 0.003; 0.043), as compared to girls.

CONCLUSION

Our study suggests an increased risk for early vascular change in adolescent asthmatic boys. Whereas the small number of girls limits the interpretation, the result necessitates further research into sex-specific atherosclerotic burden related to respiratory health in adolescence. What is Known: • Evidence points to a significant impact of adult respiratory disease on cardiovascular health indicators as well as on endpoints. • Inflammation is a key pathway in vascular change across the life course. What is New: • We observe an adverse association between physician-diagnosed asthma and carotid intima media thickness in adolescent boys. • Albeit a limited number of asthmatic girls, we hypothesize the gender typical timing of asthma or a higher male cardiovascular vulnerability as possible explanations for the gender-specific results.

Selected risk factors for atherosclerosis in children and their parents with positive family history of premature cardiovascular diseases: a prospective study

Background

The aim of the study was to evaluate serum parameters of lipid metabolism, homocysteine, soluble adhesion molecules and common carotid artery wall thickness in children from families with early symptoms of atherosclerosis.

Methods

The first stage included 137 pairs of mothers and newborns, and the second 18 children from the same group (age 18-30 months) and their parents (age 21-46 years) with a history of premature coronary artery disease (CAD), as well as 12 age- and sex-matched controls.

Results

During the first stage, inverse correlations were found between birthweight, cord blood concentrations of triglycerides (TG), VLDL cholesterol and apolipoprotein B (Apo B). Serum concentrations of total cholesterol (TC), apolipoprotein A1 (Apo A1), LDL and HDL cholesterol and were significantly higher in female than in male newborns. During the second stage, children from families with a history for premature CAD were shown to present with significantly higher serum concentrations of TG, VLDL cholesterol and lipoprotein A (Lp(a)) than the controls. Furthermore, their TC correlated positively with vascular cell adhesion molecule-1 (Rs=0.717, p<0.05) and intracellular adhesion molecule-1 (sICAM-1) levels (Rs=0.833, p<0.05). Moreover, positive correlations were found between maternal carotid intima media thickness (IMT) and TC (Rs=0.831, p<0.01), as well as between paternal IMT and Apo B (Rs=0.692, p<0.05), TG and sICAM-1 (Rs=0.912, p<0.01), TG and sE-selectin (Rs=0.678, p<0.05).

Conclusions

Serum Lp(a) may serve as a maker of cardiovascular risk in children and adolescents.