Don P. Wilson, M.D., FNLADon P. Wilson, M.D., FNLAFellow, American Board of Clinical LipidologyFellow, American Board of Clinical Lipidology

Pediatric EndocrinologyPediatric EndocrinologyCook Children’s Medical CenterCook Children’s Medical Center

Fort Worth, TexasFort Worth, Texas

Cardiovascular Health and Cardiovascular Health and Risk Reduction in Children Risk Reduction in Children and Adolescentsand Adolescents

Overview Overview

• Atherosclerosis begins in childhood.Atherosclerosis begins in childhood.

• Risk factors for the development of Risk factors for the development of atherosclerosis can be identified in childhood.atherosclerosis can be identified in childhood.

• Development and progression of atherosclerosis Development and progression of atherosclerosis clearly relates to the number and intensity of CV clearly relates to the number and intensity of CV risk factors, beginning in childhood.risk factors, beginning in childhood.

• Risk factors track from childhood into adult life.Risk factors track from childhood into adult life.

• Interventions exist for management of identified Interventions exist for management of identified risk factors. risk factors.

Lipid Screening Guidelines For Children and AdolescentsYear

Organization NCEP AAP NHLBI

Target PopulationTargeted: Family History

Targeted: Family History and Obesity

Universal Screening

First Screen > 2 yrs of age Not specified Age 9-11

Subsequent Screen Not specified Not specified Age 17-21

First-line Treatment Diet change Diet change

Diet counseling* Weight loss if overweight

Target LDL-c (mg/dL)

<130 (minimal) <110 (ideal)

<160 (initial)<130 (or lower) with other risk factors

<130 (minimal)<110 (ideal)

Criteria for initiating lipid lowering medication

Age ≥ 10 yearsLDL ≥ 190 despite 6m-1y diet therapy

Age ≥ 8 years LDL-C ≥ 190 or ≥ 160 if family history or 2+ risk factor (+) or ≥ 130 if diabetic

Age ≥ 10, persistent LDL≥ 190, ≥ 160 if family history (+) or 1+ risk factor; Age < 10 years, only special cases**

*Referral to a registered dietitian for family medical nutrition therapy for daily nutritional intake of <30% calories from fat (<=7% saturated fat, ~10% monounsaturated fat, no trans-fat); <200 mg of cholesterol/day.

**Severe primary hyperlipidemia (homozygous familial hypercholesterolemia, primary hypertriglyceridemia with TG ≥500 mg/dL), a high-risk condition or evident cardiovascular disease; all under the care of a lipid specialist.

19921992 20082008

In 2006, the National Heart, Lung and Blood Institute In 2006, the National Heart, Lung and Blood Institute (NHLBI) convened a panel of experts to develop (NHLBI) convened a panel of experts to develop comprehensive evidence-based comprehensive evidence-based guidelines addressing the known guidelines addressing the known risk factors for CVD. risk factors for CVD.

Goal:Goal:

Assist primary pediatric care Assist primary pediatric care

providers in the prevention of:providers in the prevention of:• Risk factor development – Risk factor development – primordial primordial

preventionprevention..• Future CVD by effective management of Future CVD by effective management of

identified risk factors – identified risk factors – primary preventionprimary prevention. .

The full report is available at: The full report is available at: http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm

RRisk isk EEvaluation for valuation for AAchieving chieving CCardiovascular ardiovascular HHealthealth

The REACH ClinicThe REACH ClinicPediatric Endocrinology and DiabetesPediatric Endocrinology and Diabetes

Cook Children’s Medical CenterCook Children’s Medical Center

Fort Worth, TexasFort Worth, Texas

RRisk isk EEvaluation for valuation for AAchieving chieving CCardiovascular ardiovascular HHealthealth

Purpose:Purpose:To assess co-morbid conditions and promote To assess co-morbid conditions and promote heart healthy lifestyles through a heart healthy lifestyles through a multidisciplinary, structured program of multidisciplinary, structured program of health education, treatment and prevention health education, treatment and prevention aimed at improving the physical and aimed at improving the physical and emotional wellbeing of children (< 18 yrs. of emotional wellbeing of children (< 18 yrs. of age).age).

Comprehensive Screening – Treatment* Comprehensive Screening – Treatment*

Early Intervention – Reversal of Disease**Early Intervention – Reversal of Disease**

PreventionPrevention

Heart Healthy Lifestyle becoming the “norm”Heart Healthy Lifestyle becoming the “norm”* Diabetes, Hypertension, OSA, Bone/Joint Disease, Steatohepatitis and Dyslipidemia * Diabetes, Hypertension, OSA, Bone/Joint Disease, Steatohepatitis and Dyslipidemia ** Pre-diabetes, Pre-hypertension, Steatosis and Microalbuminuria** Pre-diabetes, Pre-hypertension, Steatosis and Microalbuminuria

Community Partners

Cook Children’sR.E.A.C.H. Clinic

Academic PartnersService

GI

Pulmonary

Cardiology

Orthopedics

Endocrine

Renal

Mental HealthCommunityresources

R.E.A.C.H. Clinic

Pediatric Endocrinologist

R.E.A.C.H. Clinic Coordinator

Research Coordinator

Endocrine Nurses

Nutritionists

Psychologists

Social Services

Exercise Psychologist

Education Resources

Community Based Program for the Prevention of Community Based Program for the Prevention of Premature Cardiovascular Disease in YouthPremature Cardiovascular Disease in Youth

TLC = Therapeutic Lifestyle CounselingTLC = Therapeutic Lifestyle Counseling

REACH Referral and Follow-upREACH Referral and Follow-up

**Diagnostic Workup to be completed prior Diagnostic Workup to be completed prior to being seen in the REACH Clinic.to being seen in the REACH Clinic.

Rx PlanRx Plan

It’s never too early to It’s never too early to stop a heart attack !stop a heart attack !

We all have choices…

CC igarette Smoking HH ypertension OO besity II nsulin resistance CC holesterol (low HDL-c) EE xercise (lack of)