Cholesterol as a risk factor for early atherosclerosis: the Bogalusa Heart Study

Preventing cardiovascular heart disease: Promising nutraceutical and non-nutraceutical treatments for cholesterol management

Hypercholesterolemia is one of the major risk factors for the development of cardiovascular disease. Atherosclerosis resulting from hypercholesterolemia causes many serious cardiovascular diseases. Statins are generally accepted as a treatment of choice for lowering low-density lipoprotein (LDL) cholesterol, which reduces coronary heart disease morbidity and mortality. Since statin use can be associated with muscle problems and other adverse symptoms, non-adherence and discontinuation of statin therapy often leads to inadequate control of plasma cholesterol levels and increased cardiovascular risk. Moreover, there is compelling evidence on the presence of still considerable residual cardiovascular risk in statin-treated patients. Ezetimibe improves cholesterol-lowering efficacy and provides mild additional cardiovascular protection when combined with statin treatment. Despite a favorable safety profile compared to statins, ezetimibe-induced cholesterol-lowering is modest when used alone. Hence, there is a critical need to identity additional effective hypolipidemic agents that can be used either in combination with statins, or alone, if statins are not tolerated. Thus, hypolipidemic agents such as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, apolipoprotein B-100 antisense oligonucleotides, cholesteryl ester transfer protein (CETP) inhibitors, and microsomal triglyceride transfer protein (MTTP) inhibitors, as well as yeast polysaccharides (beta-glucans and mannans) and compounds derived from natural sources (nutraceuticals) such as glucomannans, plant sterols, berberine, and red yeast rice are being used. In this review, we will discuss hypercholesterolemia, its impact on the development of cardiovascular disease (CVD), and the use of yeast polysaccharides, various nutraceuticals, and several therapeutic agents not derived from 'natural' sources, to treat hypercholesterolemia.

Sustained Benefit Over Four-Year Follow-Up of Michigan's Project Healthy Schools

OBJECTIVES

We determined the sustainability of effects of a school-based intervention to improve health behaviors and cardiovascular risk factors among middle school children.

METHODS

We administered a questionnaire and health screenings to 5 schools in Ann Arbor and 2 schools in Ypsilanti, Michigan. We assessed demographics, physiological factors, diet, physical activity, and sedentary behaviors from 1126 students who received a health curriculum (Project Healthy Schools) in the fall of sixth grade in 2005, 2006, and 2007. We administered the questionnaire and screening again in the spring and each subsequent spring through ninth grade to all available, consenting students.

RESULTS

In the 4 years following the school-based intervention, total cholesterol, low-density lipoprotein cholesterol, and triglycerides improved, and for most years systolic and diastolic blood pressure improved. Serum glucose and body mass index did not change. Physical activity increased and sedentary behaviors diminished.

CONCLUSIONS

Project Healthy Schools is associated with sustainable improvements in both cardiovascular parameters and healthy behaviors.

Variability of lipid and lipoprotein concentrations during puberty in Brazilian boys

BACKGROUND

Evaluation of lipid profile in children and adolescents is important for early diagnosis of dyslipidemias. Physiological changes might be observed in the concentration of the lipid profile components, according to the stage of sexual maturation.

OBJECTIVE

To evaluate the variation in lipid and lipoprotein concentrations in boys during puberty.

METHODS

The sample consisted of 570 male adolescents with ages between 10 and 17 years. Weight, height, and body mass index (BMI) were assessed. Total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and triglyceride (TG) were determined by the enzymatic method, and low-density lipoprotein cholesterol (LDL-C) was calculated. Puberty was classified according to Tanner references. The percentile criterion was adopted for the distribution and identification of lipoprotein levels. The analysis of variance and description tests with p<0.05 was applied.

RESULTS

Participants had similar BMI z-score and physical activity habits in all groups. A significant reduction in TC and HDL-C concentrations between the start and end of puberty was observed. LDL-C levels rose during stage 3 of development, decreasing at the end of the pubertal process. TG levels did not change significantly with pubertal status.

CONCLUSION

Lipid and lipoprotein concentrations tend to undergo changes during puberty in boys. The use of percentile values can be very useful to track variations in lipid and lipoprotein levels during the maturation process.

Blood lipids in children: age-related patterns and association with body-fat indices: Project HeartBeat!

BACKGROUND

Longitudinal data on the normal development of blood lipids and its relationships with body fatness in children and adolescents are limited. Objectives of the current analysis were to estimate trajectories related to age for four blood lipid components and to examine the impact of change in body fatness on blood lipid levels, comparing estimated effects among adiposity indices, in children and adolescents.

METHODS

Three cohorts, with a total of 678 children (49.1% female, 79.9% nonblack) initially aged 8, 11, and 14 years, were followed at 4-month intervals (1991-1995). Total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglyceride levels were determined in blood samples taken following fasting. Body fatness was measured by five adiposity indices-BMI; percent body fat (PBF); abdominal circumference; and the sums of six and of two skinfold thicknesses. Trajectories of change in blood lipid levels from ages 8 to 18 years were estimated by gender and race. The impact of change in body fatness on lipid levels was evaluated for each index, adjusting for gender, race, and age.

RESULTS

All lipid components varied significantly with age. Total cholesterol decreased by approximately 19 mg/dL from ages 9 to 16 years in girls and more steeply from ages 10 to 17 years in boys. LDL-C decreased monotonically, more steeply in boys than in girls. It was higher among nonblacks than among blacks. HDL-C increased monotonically in girls, mainly from ages 14 to 18 years, but fluctuated sharply among boys. Levels of HDL-C were higher among blacks than among nonblacks. The levels of triglycerides increased from ages 8 to 12 years among girls and, almost linearly, from ages 8 to 18 years among boys. The levels of triglycerides were higher among nonblacks than among blacks. Increase in body fatness was significantly associated with increases in total cholesterol, LDL-C, and triglyceride levels. Significant interactions between the adiposity indices (except for BMI) and gender indicated smaller impacts of change in body fatness on total cholesterol and LDL-C in girls than in boys. The estimated impact on triglycerides was weaker among blacks than among nonblacks, except for PBF. Change in body fatness was negatively associated with HDL-C. The results remained essentially unchanged after adjustments for energy intake, physical activity, and sexual maturation.

CONCLUSIONS

Patterns of change with age in blood lipid components vary significantly among gender and racial groups. Increase in body fatness among children is consistently associated with adverse change in blood lipids. Evaluation of blood lipid level should take into account variation by age, gender, and race. Intervention through body-fat control should help prevent adverse lipid levels in children and adolescents.

Lipid screening in children and adolescents

Despite enormous advances in research supporting lipid screening among adults, there are critical research gaps in our understanding of the potential benefit and harm of routine screening of young children and adults. Although clear clinical opportunities exist to test and treat individual children from high risk backgrounds, building the case for systematically screening all children as part of a comprehensive cardiovascular disease prevention program requires more convincing evidence that this type of screening will yield true net positive clinical and public health outcomes. This should not prevent the pediatric community from aggressive promotion of healthy lifestyles, both in the office and through effective public policy.

High-sensitivity C-reactive protein in children at risk for coronary artery disease

AIM

To determine the value of high-sensitivity C-reactive protein (hs-CRP) in predicting risk factors for coronary heart disease (CHD) in children.

METHODS

We measured hs-CRP levels in 51 children (11.79 +/- 3.14 years) with risk factors for CHD (hypercholesterolemia, hypertension, obesity, low HDL cholesterol and familial history of CHD). The results were compared with 26 children (12.98 +/- 2.59 years) without any risk factors.

RESULTS

The children with risk factors had significantly higher serum levels of hs-CRP compared to the control group (3.33 +/- 4.58 vs. 0.92 +/- 1.90 mg/L, respectively, p < 0.01). CRP concentrations significantly increased in children with three or more risk factors. Hs-CRP levels correlated to body mass index (r = 0.411, p = 0.003), diastolic blood pressure (r = 0.323, p = 0.021), fibrinogen (r = 0.447 and p = 0.004) and HDL cholesterol levels (r =-0.461 and p = 0.001). Cutoff value for CRP was 1.04 mg/L with 58% sensitivity and 92% specificity.

CONCLUSION

Serum hs-CRP level is a useful marker in screening the children who are under the risk of CHD in adulthood. Early identification of the children with risk factors and intervention for obesity, harmful habits and life style in childhood might decrease the incidence of coronary heart disease in adulthood.

Screening and treatment for lipid disorders in children and adolescents: systematic evidence review for the US Preventive Services Task Force

OBJECTIVE

This was a systematic evidence review for the US Preventive Services Task Force, intended to synthesize the published evidence regarding the effectiveness of selecting, testing, and managing children and adolescents with dyslipidemia in the course of routine primary care.

METHODS

Literature searches were performed to identify published articles that addressed 10 key questions. The review focused on screening relevant to primary care of children without previously identified dyslipidemias, but included treatment trials of children with dyslipidemia because some drugs have only been tested in that population.

RESULTS

Normal values for lipids for children and adolescents are defined according to population levels (percentiles). Age, gender, and racial differences and temporal trends may alter these statistical cut points. Approximately 40% to 55% of children with elevated total cholesterol and low-density lipoprotein levels will continue to have elevated lipid levels on follow-up. Current screening recommendations based on family history will fail to detect substantial numbers (30%-60%) of children with elevated lipid levels. Drug treatment for dyslipidemia in children has been studied and shown to be effective only for suspected or proven familial monogenic dyslipidemias. Intensive dietary counseling and follow-up can result in improvements in lipid levels, but these results have not been sustained after the cessation of the intervention. The few trials of exercise are of fair-to-poor quality and show little or no improvements in lipid levels for children without monogenic dyslipidemias. Although reported adverse effects were not serious, studies were generally small and not of sufficient duration to determine long-term effects of either short or extended use.

CONCLUSIONS

Several key issues about screening and treatment of dyslipidemia in children and adolescents could not be addressed because of lack of studies, including effectiveness of screening on adult coronary heart disease or lipid outcomes, optimal ages and intervals for screening children, or effects of treatment of childhood lipid levels on adult coronary heart disease outcomes.

Effect of dietary supplementation with glucomannan on plasma total cholesterol and low density lipoprotein cholesterol in hypercholesterolemic children

AIM

This paper evaluates the effect of the adjunct of the hydrosoluble fiber glucomannan to a Step-One-Diet in 40 plasma hypercholesterolemic children, during a randomized controlled trial, to reduce plasma cholesterol.

METHODS

All the subjects recruited underwent an 8-week run in diet period; a Step-One-Diet was prescribed. After that, they were randomly allocated to one of two groups: Step-One-Diet only (control), and Step-One-Diet plus glucomannan in gelatine capsules. After another 8 weeks of treatment, the results were compared within and between the two groups.

RESULTS

Glucomannan treated group showed decreased values in plasma total cholesterol (TC) and low density lipoprotein cholesterol (LDL-C) vs. control group after 8 weeks of treatment. The percentage decrease showed a statistically significant difference between sex groups. Decreases were observed in favor of female vs. male children in TC (24% vs. 9%) and LDL-C (30% vs. 9%).

CONCLUSIONS

These results suggest that glucomannan may represent a rationale adjunct to diet therapy in primary prevention in high risk hypercholesterolemic children.