The Importance of Identifying Risk Factors in Childhood and Adolescence

Ana Paula Marte Chacra About the author

Keywords
Dyslipidemias; Obesity; Overweight; Adolescent; Cholesterol LDL-C; Triglycerides; Risk Factors; Atherosclerosis

The study "Dyslipidemia in Adolescents Seen in a University Hospital in the city of Rio de Janeiro/Brazil: Prevalence and Association" showed a high prevalence of obesity (53%) followed by overweight (25.2%) in adolescents. The obese group had a predominance of low HDL-c besides the positive association of body mass index (BMI) and abdominal circumference with triglyceride values.11 Vizentin NP, Cardoso PMS, Maia CAG, Alves IP, Aranha GL, Giannini DT. Dyslipidemia in adolescents seen in a university hospital in the city of Rio de Janeiro/Brazil: prevalence and association. Arq Bras Cardiol. 2019; 112(2):147-151 These date are fundamental and warn of the importance of early assessment of risk factors.

Elevated triglycerides and low HDL-c are strongly linked to obesity, especially in youth22 Elmaoğulları S, Tepe D, Uçaktürk SA, Karaca Kara F, Demirel F. Prevalence of dyslipidemia and associated factors in obese children and adolescents. J Clin Res Pediatr Endocrinol. 2015;7(3):228-34. and early exposure to that unfavourable metabolic profile will contribute to a higher cardiovascular risk.33 Skinner AC, Perrin EM, Moss LA, Skelton JA. Cardiometabolic risks and severity of obesity in children and young adult. N Engl J Med. 2015;373(4):1307-17.

Evidences have shown that atherosclerosis begins in childhood and it is associated with early presence of established risk factors for cardiovascular disease. The progression of atherosclerotic process depends on the time of exposure beyond the interaction between conventional, genetics and environmental risk factors.44 Berenson GS, Wattigney WA, Tracy RE, Newman WP 3rd,et al. Atherosclerosis of the aorta and coronary arteries and cardiovascular risk factors in persons aged 6 to 30 years and studied at necropsy (The Bogalusa Heart Study). Am J Cardiol. 1992; 70(9):851-8.,55 Wissler RW. USA Multicenter Study of the pathobiology of atherosclerosis in youth. Ann N Y Acad Sci. 1991;623:26-39.

Despite the early onset of atherogenesis, children and adolescents do not develop clinic manifestations of coronary heart disease, since cardiovascular outcomes depend on prolonged exposure to risk factors. Even so, few longitudinal studies have linked childhood risk factors to adult cardiovascular disease.

Twig et al.66 Twig G, Yaniv G, Levine H, Leiba A, Goldberger N, Derazne E, et al. Body-mass index in 2.3 million adolescents and cardiovascular death in adulthood. N Engl J Med. 2016;374(25):2430-40. demonstrated association between higher BMI during adolescence with increased cardiovascular mortality in adulthood throughout 40 years of follow-up.66 Twig G, Yaniv G, Levine H, Leiba A, Goldberger N, Derazne E, et al. Body-mass index in 2.3 million adolescents and cardiovascular death in adulthood. N Engl J Med. 2016;374(25):2430-40. Increased in BMI and triglyceride level was predictive of cardiovascular event in young adulthood, whereas LDL-c levels did not.77 Morrison JA, Glueck CJ, Horn PS, Yeramanemi S, Wang P. Pediatric triglycerides predict cardiovascular disease events in the fourth to fifth decade of life. Metabolism. 2009;58(9):1277-84.

Measurements of carotid intima-media thickness (cIMT) by non-invasive imaging techniques provide a surrogate endpoint to assess early atherosclerosis.88 Lorenz MW, Markus HS, Bots ML, Rosvall M, Sitzer M. Prediction of clinical cardiovascular events with carotid intima-media thickness: a systematic review and meta-analysis. Circulation. 2007;115(4):459-67. Studies have shown that childhood clustering of risk factors are predictive of adult cIMT.99 Li S, Chen W, Srinivesan SR, Bond MG, Tang R, Urbina EM, et al. Childhood cardiovascular risk factors and carotid vascular changes in adulthood: the Bogalusa Heart Study. JAMA. 2003;290(17):2271-6.

In the study “International Childhood Cardiovascular Cohort (i3C)", Koskinen et al.1010 Koskinen J, Juonala M, Dwyer T, Venn A, Thomson R, Bazzano L, et al. Impact of lipid measurements in youth in addition to conventional clinic-based risk factors on predicting preclinical atherosclerosis in adulthood: International Childhood Cardiovascular Cohort Consortium. Circulation. 2018;137(12):1246-55. demonstrated that obesity, hypertension, and dyslipidemia were predictors of high cIMT in adults.1010 Koskinen J, Juonala M, Dwyer T, Venn A, Thomson R, Bazzano L, et al. Impact of lipid measurements in youth in addition to conventional clinic-based risk factors on predicting preclinical atherosclerosis in adulthood: International Childhood Cardiovascular Cohort Consortium. Circulation. 2018;137(12):1246-55. They found that obesity in children was the most prevalent risk factor associated with high cIMT in adult, increasing the risk by 3.7 times.1010 Koskinen J, Juonala M, Dwyer T, Venn A, Thomson R, Bazzano L, et al. Impact of lipid measurements in youth in addition to conventional clinic-based risk factors on predicting preclinical atherosclerosis in adulthood: International Childhood Cardiovascular Cohort Consortium. Circulation. 2018;137(12):1246-55. Using risk prediction models, when it added the lipid profile to obesity and hypertension, there was a modest improvement in the risk discrimination for increased cIMT in adulthood (area under the curve increased from 0.698-0.717). It may be due to a weak relationship between LDL-c levels and obesity since obesity interferes minimally with LDL-c levels1010 Koskinen J, Juonala M, Dwyer T, Venn A, Thomson R, Bazzano L, et al. Impact of lipid measurements in youth in addition to conventional clinic-based risk factors on predicting preclinical atherosclerosis in adulthood: International Childhood Cardiovascular Cohort Consortium. Circulation. 2018;137(12):1246-55. except where obesity-related metabolic changes unmask an underlying genetic dyslipidemia. In the present cross-sectional study11 Vizentin NP, Cardoso PMS, Maia CAG, Alves IP, Aranha GL, Giannini DT. Dyslipidemia in adolescents seen in a university hospital in the city of Rio de Janeiro/Brazil: prevalence and association. Arq Bras Cardiol. 2019; 112(2):147-151 obesity seems to be the driver of the lipid changes as prevalence of low HDL-c and association of abdominal adiposity with triglycerides levels, without changes in LDL-c values.11 Vizentin NP, Cardoso PMS, Maia CAG, Alves IP, Aranha GL, Giannini DT. Dyslipidemia in adolescents seen in a university hospital in the city of Rio de Janeiro/Brazil: prevalence and association. Arq Bras Cardiol. 2019; 112(2):147-151 Despite these findings, high LDL-c is a well-established risk factor for atherosclerosis as observed in familial hypercholesterolemia, and early detection allows the initiation of pharmacological therapy even in the children.1111 Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(Suppl 5):S213-S256.

The present study reinforces that current obesity is a growing epidemic.11 Vizentin NP, Cardoso PMS, Maia CAG, Alves IP, Aranha GL, Giannini DT. Dyslipidemia in adolescents seen in a university hospital in the city of Rio de Janeiro/Brazil: prevalence and association. Arq Bras Cardiol. 2019; 112(2):147-151 The Universal screening would allow for earlier diagnosis and intervention for children with dyslipidemia secondary to lifestyle or genetic factors.1212 Kwiterovich PO, Gidding SS. Universal screening of cholesterol in children. Clin Cardiol. 2012;35(11):662-4.

  • Short Editorial related to the article: Dyslipidemia in Adolescents Seen in a University Hospital in the city of Rio de Janeiro/Brazil: Prevalence and Association

References

  • 1
    Vizentin NP, Cardoso PMS, Maia CAG, Alves IP, Aranha GL, Giannini DT. Dyslipidemia in adolescents seen in a university hospital in the city of Rio de Janeiro/Brazil: prevalence and association. Arq Bras Cardiol. 2019; 112(2):147-151
  • 2
    Elmaoğulları S, Tepe D, Uçaktürk SA, Karaca Kara F, Demirel F. Prevalence of dyslipidemia and associated factors in obese children and adolescents. J Clin Res Pediatr Endocrinol. 2015;7(3):228-34.
  • 3
    Skinner AC, Perrin EM, Moss LA, Skelton JA. Cardiometabolic risks and severity of obesity in children and young adult. N Engl J Med. 2015;373(4):1307-17.
  • 4
    Berenson GS, Wattigney WA, Tracy RE, Newman WP 3rd,et al. Atherosclerosis of the aorta and coronary arteries and cardiovascular risk factors in persons aged 6 to 30 years and studied at necropsy (The Bogalusa Heart Study). Am J Cardiol. 1992; 70(9):851-8.
  • 5
    Wissler RW. USA Multicenter Study of the pathobiology of atherosclerosis in youth. Ann N Y Acad Sci. 1991;623:26-39.
  • 6
    Twig G, Yaniv G, Levine H, Leiba A, Goldberger N, Derazne E, et al. Body-mass index in 2.3 million adolescents and cardiovascular death in adulthood. N Engl J Med. 2016;374(25):2430-40.
  • 7
    Morrison JA, Glueck CJ, Horn PS, Yeramanemi S, Wang P. Pediatric triglycerides predict cardiovascular disease events in the fourth to fifth decade of life. Metabolism. 2009;58(9):1277-84.
  • 8
    Lorenz MW, Markus HS, Bots ML, Rosvall M, Sitzer M. Prediction of clinical cardiovascular events with carotid intima-media thickness: a systematic review and meta-analysis. Circulation. 2007;115(4):459-67.
  • 9
    Li S, Chen W, Srinivesan SR, Bond MG, Tang R, Urbina EM, et al. Childhood cardiovascular risk factors and carotid vascular changes in adulthood: the Bogalusa Heart Study. JAMA. 2003;290(17):2271-6.
  • 10
    Koskinen J, Juonala M, Dwyer T, Venn A, Thomson R, Bazzano L, et al. Impact of lipid measurements in youth in addition to conventional clinic-based risk factors on predicting preclinical atherosclerosis in adulthood: International Childhood Cardiovascular Cohort Consortium. Circulation. 2018;137(12):1246-55.
  • 11
    Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(Suppl 5):S213-S256.
  • 12
    Kwiterovich PO, Gidding SS. Universal screening of cholesterol in children. Clin Cardiol. 2012;35(11):662-4.

Publication Dates

  • Publication in this collection
    Feb 2019
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