Cardiovascular risk factors in children with obesity, hypertension and diabetes: lipoprotein(a) levels and body mass index correlate with family history of cardiovascular disease

Canadian Society of Clinical Chemists Harmonized Pediatric Lipid Reporting Recommendations for Clinical Laboratories

Detecting dyslipidemia early is important because atherosclerosis originates in childhood and early treatment can improve outcomes. In 2022, the Canadian Cardiovascular Society (CCS)/Canadian Pediatric Cardiology Association (CPCA) published a clinical practice update to detect, evaluate, and manage pediatric dyslipidemia. However, guidance on its translation into clinical laboratories is lacking. The Canadian Society of Clinical Chemists Working Group on Reference Interval Harmonization Lipid Team aims to assist guideline implementation and promote harmonized pediatric lipid reporting across Canada. The 2022 CCS/CPCA clinical practice update, 2011 National Heart, Lung, and Blood Institute integrated guidelines, and new data analysis (Canadian pediatric reference values from the Canadian Laboratory Initiative on Pediatric Reference Intervals [CALIPER] and retrospective patient data from large community laboratories) were incorporated to develop 5 key recommendations. These include recommendations to: (1) offer nonfasting and fasting lipid testing; (2) offer a lipid panel including total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), non-HDL-C, and triglycerides, with apolipoprotein B and lipoprotein(a) available as individually orderable tests; (3) flag total cholesterol, LDL-C, and non-HDL-C results ≥ 95th percentile, and HDL-C results < 10th percentile, as recommended by CCS/CPCA/National Heart, Lung, and Blood Institute and validated by CALIPER, and flag apolipoprotein B and nonfasting triglyceride results ≥ 95th percentile on the basis of CALIPER, and do not flag lipoprotein(a) results but mention the adult cutoff in the interpretive comments; (4) implement interpretive comments listed in the current report; and (5) implement the National Institutes of Health LDL-C equation. The Canadian Society of Clinical Chemists Working Group on Reference Interval Harmonization Lipid Team will support clinical laboratories to implement these recommendations using knowledge translation strategies. Harmonizing pediatric lipid reporting across Canadian clinical laboratories will optimize clinical decision-making and improve cardiovascular risk management in youth.

Lp(a) does not affect intima media thickness in hypercholesterolemic children -a retrospective cross sectional study

PURPOSE

Combined hyperlipidaemia results in premature atherosclerosis and a high burden of cardiovascular morbidity and mortality. Early identification of highly affected subjects within this population is of utmost importance to enable informed treatment decisions. The measurement of intima media thickness (IMT) is a readily available, non-invasive method to investigate evidence of early atherosclerosis. To assess the usefulness of this method in pediatric subjects with hypercholesterolemia, we here examined a possible interaction of LDL-C and Lp(a) on IMT.

METHODS

Blood lipids (Lp(a), LDL-cholesterol, total cholesterol, triglycerides, high density lipoprotein (HDL) -cholesterol, apolipoprotein A1, apolipoprotein B), anthropometric parameters (age, height, weight, body mass index (BMI)) and possibly existing early evidence of atherosclerotic lesions measured by intima media thickness (IMT zscore).as a surrogate parameter was examined retrospectively in 113 children and adolescents (aged 1-18 years) with elevated Lp(a) and/or LDL-cholesterol (Lp(a) > 30 mg/dL, LDL>130 mg/dL). Furthermore, we compared hsCRP levels between groups.

RESULTS

There were no significant differences in IMT Zscore or hsCRP between groups. Regression analysis did not reveal a statistically significant interaction between Lp(a) and LDL-C.

CONCLUSIONS

At the age of 6-18 years, we found no significant differences in early markers of atherosclerosis between subjects with high Lp(a)- and/or high LDL-cholesterol with no detectable synergistic effects between the two lipoproteins.

Lipid Biomarkers and Atherosclerosis-Old and New in Cardiovascular Risk in Childhood

Lipids are a complex group of molecules in the body, essential as structural, functional and metabolic components. When disbalanced, they are regarded as a cardiovascular risk factor, traditionally in cholesterol level evaluation. However, due to their complex nature, much research is still needed for a comprehensive understanding of their role in atherosclerosis, especially in the young. Several new lipid biomarkers are emerging, some already researched to a point, such as lipoproteins and apolipoproteins. Other lipid molecules are also being increasingly researched, including oxidized forms due to oxidative inflammation in atherosclerosis, and sphingolipids. For many, even those less new, the atherogenic potential is not clear and no clinical recommendations are in place to aid the clinician in using them in everyday clinical practice. Moreover, lipids' involvement in atherogenesis in children has yet to be elucidated. This review summarizes the current knowledge on lipids as biomarkers of cardiovascular risk in the paediatric population.

Low-density lipoprotein cholesterol goal attainment in patients with clinical evidence of familial hypercholesterolemia and elevated Lp(a)

BACKGROUND

Although potent lipid-lowering therapies are available, patients commonly fall short of recommended low-density lipoprotein cholesterol (LDL-C) levels. The aim of this study was to examine the relationship between familial hypercholesterolemia (FH) and elevated lipoprotein(a) [Lp(a)] and LDL-C goal attainment, as well as the prevalence and severity of coronary artery disease (CAD). Moreover, we characterized patients failing to meet recommended LDL-C goals.

METHODS

We performed a cross-sectional analysis in a cohort of patients undergoing cardiac catheterization. Clinical FH was determined by the Dutch Clinical Lipid Network Score, and Lp(a) ≥ 50 mg/dL (≈ 107 nmol/L) was considered elevated.

RESULTS

A total of 838 participants were included. Overall, the prevalence of CAD was 72%, and 62% received lipid-lowering treatment. The prevalence of clinical FH (probable and definite FH) was 4%, and 19% had elevated Lp(a) levels. With 35%, LDL-C goal attainment was generally poor. Among the participants with clinical FH, none reached their LDL-C target. Among patients with elevated Lp(a), LDL-C target achievement was only 28%. The prevalence and severity of CAD were higher in participants with clinical FH (86% prevalence) and elevated Lp(a) (80% prevalence).

CONCLUSION

Most participants failed to meet their individual LDL-C goals according to the ESC 2016 and 2019 guidelines. In particular, high-risk patients with clinical FH or elevated Lp(a) rarely met their target for LDL-C. The identification of these patients and more intense treatment approaches are crucial for the improvement of CAD primary and secondary prevention.

Risk factors for cardiovascular disease in a healthy young population: Family matters

Background

India faces an epidemic of cardiovascular disease (CVD). This study sought the effect of family history of CVD and/or its risk factors (CVD-risk) on the presence of risk factors for CVD, in a healthy young college population.

Methods

Blood pressure (BP), heart rate (HR), anthropometric variables, fasting blood sugar and lipid fractions were measured in two hundred healthy individuals (163 men and 37 women), aged 17-22 years. Data were analysed to elicit effect of CVD-risk on measured parameters.

Results

All but one subject, had family history of a CVD-risk. Men with family history of coronary heart disease had higher diastolic BP (79.24 ± 7.7 vs 75.99 ± 7.49 mmHg, p = 0.007) and triglycerides (118.66 ± 57.98 vs 85.82 ± 50.89 mg/dL, p < 0.0001) compared with those without similar family history. Men with family history of hypertension (HTN) had higher diastolic BP (78.75 ± 7.15 vs 75.84 ± 8.37 mmHg, p = 0.019) and low-density lipoprotein (86.24 ± 25.38 vs 78.21 ± 17.93 mg/dL, p = 0.019), as well as lower high-density lipoprotein (50.27 ± 8.4 vs 53.96 ± 10.38 mg/dL, p = 0.019). Women with family history of diabetes mellitus had lower high-density lipoproteins (49.89 ± 8.05 vs 59.53 ± 11.44, p = 0.006). Family history of dyslipidaemia was associated with significantly higher triglycerides (146.14 ± 46.19 vs 98.44 ± 56.19 mg/dL, p = 0.002) in men and in subjects across sex. HDL was contrarily higher, in women with family history of cerebrovascular accident/HTN and men with family history of coronary heart disease/HTN. The proportion of pre-HTN, overweight/obese, impaired fasting glucose and borderline high triglycerides was 88.3%, 36.8%, 11% and 38.7% in men and 64.9%, 37.8%, 18.9% and 48.7% in female subjects.

Conclusion

Young adults with a family history of CVD-risk already have an incomplete/atypical CVD risk profile.

Global, Regional, and National Death, and Disability-Adjusted Life-Years (DALYs) for Cardiovascular Disease in 2017 and Trends and Risk Analysis From 1990 to 2017 Using the Global Burden of Disease Study and Implications for Prevention

Background: Cardiovascular disease is the leading cause of death worldwide and a major barrier to sustainable human development. The objective of this study was to evaluate the global, sex, age, region, and country-related cardiovascular disease (CVD) burden, as well as the trends, risk factors, and implications for the prevention of CVD.

Methods: Detailed information from 1990 to 2017, including global, regional, and national rates of CVD, and 11 categories of mortality and disability-adjusted life years (DALYs) were collected from the Global Burden of Disease Study 2017. The time-dependent change in the trends of CVD burdens was evaluated by annual percentage change.

Results: More than 17 million people died from CVD in 2017, which was approximately two times as many as cancer, and increased nearly 50% compared with 1990. Ischemic heart disease and stroke accounted for 85% of the total age-standardized death rate (ASDR) of CVD. The ASDR and age-standardized DALYs rate (ASYR) of CVD were 1.5 times greater in men compared with women. People over the age of 50 were especially at risk for developing CVD, with the number of cases and deaths in this age group accounting for more than 90% of all age groups. CVD mortality was related to regional economic development and the social demographic index. In regions with a high economic income or socio-demographic index, there was a greater decline in the ASDR of CVD. The ASDR of CVD in high SDI regions decreased more than 50% from 1990 to 2017. Tobacco use, diets low in whole grains, diets high in sodium, and high systolic blood pressure were the important risk factors related to CVD mortality.

Conclusions: CVD remains a major cause of death and chronic disability in all regions of the world. Ischemic heart disease and stroke account for the majority of deaths related to CVD. Although the mortality rate for CVD has declined in recent years from a global perspective, the results of CVD data in 2017 suggest that the mortality and DALYs of CVD varied in different ages, sexes, and countries/regions around the world. Therefore, it is necessary to elucidate the specific characteristics of global CVD burden and establish more effective and targeted prevention strategies.

Cardiovascular Risk Factors in Children with Obesity, Preventive Diagnostics and Possible Interventions

The increasing burden of obesity plays an essential role in increased cardiovascular morbidity and mortality. The effects of obesity on the cardiovascular system have also been demonstrated in childhood, where prevention is even more important. Obesity is associated with hormonal changes and vascular dysfunction, which eventually lead to hypertension, hyperinsulinemia, chronic kidney disease, dyslipidemia and cardiac dysfunction—all associated with increased cardiovascular risk, leading to potential cardiovascular events in early adulthood. Several preventive strategies are being implemented to reduce the cardiovascular burden in children. This paper presents a comprehensive review of obesity-associated cardiovascular morbidity with the preventive diagnostic workup at our hospital and possible interventions in children.

Expert position statements: comparison of recommendations for the care of adults and youth with elevated lipoprotein(a)

PURPOSE OF REVIEW

Summarize recent recommendations on clinical management of adults and youth with elevated lipoprotein(a) [Lp(a)] who are at-risk of or affected by cardiovascular disease (CVD).

RECENT FINDINGS

There is ample evidence to support elevated Lp(a) levels, present in approximately 20% of the general population, as a causal, independent risk factor for CVD and its role as a significant risk enhancer. Several guidelines and position statements have been published to assist in the identification, treatment and follow-up of adults with elevated levels of Lp(a). There is growing interest in Lp(a) screening and strategies to improve health behaviors starting in youth, although published recommendations for this population are limited. In addition to the well established increased risk of myocardial infarction, stroke and valvular aortic stenosis, data from the coronavirus pandemic suggest adults with elevated Lp(a) may have a particularly high-risk of cardiovascular complications. Lp(a)-specific-lowering therapies are currently in development. Despite their inability to lower Lp(a), use of statins have been shown to improve outcomes in primary and secondary prevention.

SUMMARY

Considerable differences exist amongst published guidelines for adults on the use of Lp(a) in clinical practice, and recommendations for youth are limited. With increasing knowledge of Lp(a)'s role in CVD, including recent observations of COVID-19-related risk of cardiovascular complications, more harmonized and comprehensive guidelines for Lp(a) in clinical practice are required. This will facilitate clinical decision-making and help define best practices for identification and management of elevated Lp(a) in adults and youth.

Lipoprotein (a): Examination of Cardiovascular Risk in a Pediatric Referral Population

Atherosclerotic cardiovascular disease (CVD), a leading cause of death globally, has origins in childhood. Major risk factors include family history of premature CVD, dyslipidemia, diabetes mellitus, and hypertension. Lipoprotein (a) [Lp(a)], an inherited lipoprotein, is associated with premature CVD, but its impact on cardiovascular health during childhood is less understood. The objective of the study was to examine the relationship between Lp(a), family history of premature CVD, dyslipidemia, and vascular function and structure in a high-risk pediatric population. This is a single-center, cross-sectional study of 257 children referred to a preventive cardiology clinic. The independent variable, Lp(a), separated children into high-Lp(a) [Lp(a) ≥ 30 mg/dL] and normal-Lp(a) groups [Lp(a) < 30 mg/dL]. Dependent variables included family history of premature CVD; dyslipidemia, defined as low-density lipoprotein cholesterol > 130 mg/dL, high-density lipoprotein cholesterol (HDL-C) < 45 mg/dL, triglycerides (TG) > 100 mg/dL; and vascular changes suggesting early atherosclerosis, as measured by carotid-femoral pulse wave velocity (PWV) and carotid artery intima-media thickness (CIMT). Of the 257 children, 110 (42.8%) had high Lp(a) and 147 (57.2%) had normal Lp(a). There was a higher prevalence of African-American children in the high-Lp(a) group (19.3%) compared to the normal-Lp(a) group (2.1%) (p < 0.001). High Lp(a) was associated with positive family history of premature CVD (p = 0.03), higher-than-optimal HDL-C (p = 0.02), and lower TG (p < 0.001). There was no difference in PWV or CIMT between groups. High Lp(a) in children is associated with family history of premature CVD and is prevalent in African-American children. In children with high Lp(a), promotion of intensive lifestyle modifications is prudent to decrease premature CVD-related morbidity.

Household cardiovascular screening of high-risk families: a school-based study

BACKGROUND

A parental history of cardiovascular disease has a strong relationship with risk factor clusters in the offspring. This study was performed to identify major cardiovascular risk factors in middle school-aged children and their parents in both high and low-risk families.

DESIGN

A school-based, cross-sectional study.

METHODS

The middle schools of the 6th district of Tehran were divided randomly into two groups. A total of 169 high-risk children with their families were recruited from the first group and 105 low-risk children with their families were recruited from the second group of schools. Anthropometric and metabolic measurements were performed.

RESULTS

The means of the waist circumference and waist-to-hip ratio were significantly higher in high-risk fathers. The means of total and low-density lipoprotein (LDL) cholesterol were significantly higher in both parents and children of the high-risk group. The means of the fasting plasma glucose were significantly higher in fathers and offspring of high-risk families. More fathers in high-risk families were smokers. The prevalence of increased total cholesterol, LDL-cholesterol and hyperglycemia (> or = 100 mg/dl) were higher in high-risk parents and children. The prevalence of increased body mass index (> or = 25 kg/m for parents and 85th percentile for children) was higher in fathers and children of high-risk families.

CONCLUSIONS

Cardiovascular risk factors are more prevalent and clustered in high-risk families. The screening of high-risk families is essential to prevent the progression of atherosclerosis from childhood and reduce the burden of cardiovascular disease in adulthood.

Development of hypertension in overweight adolescents: a review

The upward trend in adolescent hypertension is widely attributed to the adolescent obesity epidemic. Secular trends in adolescent prehypertension and hypertension have risen in congruence with increasing trends in the prevalence of overweight and obesity. The correlation between body mass index and blood pressure in adolescence is moderate to strong in most studies and strongest in those classified as overweight or obese. The mechanisms relating to the development of hypertension in overweight adolescents are unclear; however, a number of nonmodifiable and modifiable factors have been implicated. Importantly, certain clinical and biochemical markers in overweight adolescents are indicative of high risk for hypertension, including family history of hypertension and hyperinsulinemia. These characteristics may prove useful in stratifying overweight adolescents as high or low risk of comorbid hypertension. The treatment of overweight and obesity related hypertension in this population focuses on two key modalities: lifestyle change and pharmacotherapy. These approaches focus almost exclusively on weight reduction; however, a number of emerging strategies target hypertension more specifically. Among adolescents with overt hypertension there are also several factors that indicate higher risk of concurrent subclinical disease, persistent adult hypertension, and adult cardiovascular disease. This group may benefit substantially from more aggressive pharmacological treatments. Limitations in the literature relate to the paucity of studies reporting specific effects for the adolescent age group of overweight and obese individuals. Nonetheless, intervention for adiposity-related hypertension in adolescence may partially mitigate some of the cardiovascular risk in adulthood.

The influence of familial predisposition to cardiovascular complications upon childhood obesity treatment

INTRODUCTION

The aim was to investigate whether a familial predisposition to obesity related cardiovascular complications was associated with the degree of obesity at baseline and/or changes in the degree of obesity during a multidisciplinary childhood obesity treatment program.

METHODS

The study included 1421 obese children (634 boys) with a median age of 11.5 years (range 3.1-17.9 years), enrolled in treatment for 0.04 to 5.90 years (median 1.3 years) at the Children's Obesity Clinic, Denmark. At baseline, weight and height were measured, body mass index (BMI) standard deviation score (SDS) calculated, and self-reported information on familial predisposition to obesity, hypertension, type 2 diabetes mellitus (T2DM), thromboembolic events, and dyslipidaemia were obtained. A familial predisposition included events in biological parents, siblings, grandparents, uncles, and aunts. The treatment outcomes were categorically analysed according to the prevalence of familial predispositions.

RESULTS

The median BMI SDS at enrollment was 3.2 in boys and 2.8 in girls. One-thousand-and-forty-one children had obesity in their family, 773 had hypertension, 551 had T2DM, 568 had thromboembolic events, and 583 had dyslipidaemia. Altogether, 733 had three or more predispositions. At baseline, familial T2DM was associated with a higher mean BMI SDS (p = 0.03), but no associations were found between the other predispositions and the children's degree of obesity. During treatment, girls with familial obesity lost more weight, compared to girls without familial obesity (p = 0.04). No other familial predispositions were associated with changes in BMI SDS during treatment.

CONCLUSION

Obese children with a familial predisposition to T2DM showed a significantly higher degree of obesity at baseline and girls with familial obesity responded better to treatment. Besides these findings, no other associations were found between the occurrence of familial predispositions and the degree of obesity or changes herein during multidisciplinary childhood obesity treatment.

The Impact of Familial Predisposition to Obesity and Cardiovascular Disease on Childhood Obesity

The prevalence of childhood obesity has reached alarming rates world-wide. The aetiology seems to be an interplay between genetic and environmental factors, and a surrogate measure of this complex interaction is suggested as familial predisposition. Familial predisposition to obesity and related cardiovascular disease (CVD) complications constitute the presence of obesity and/or obesity-related complications in primarily blood-related family members. The approaches of its measurement and applicability vary, and the evidence especially of its influence on obesity and obesity treatment in childhood is limited. Studies have linked a familial predisposition of obesity, CVD (hypertension, dyslipidaemia and thromboembolic events), and type 2 diabetes mellitus to BMI as well as other adiposity measures in children, suggesting degrees of familial aggregation of metabolic derangements. A pattern of predispositions arising from mothers, parents or grandparents as being most influential have been found, but further comprehensive studies are needed in order to specify the exact implications of familial predisposition. In the scope of childhood obesity this article reviews the current literature regarding familial predisposition to obesity and obesity-related complications, and how these familial predispositions may impact obesity in the offspring.

Overweight and obesity in children with congenital heart disease: combination of risks for the future?

Background

Children who have unhealthy lifestyles are predisposed to develop hypertension, dyslipidemia and other complications. The epidemic of obesity is also affecting children with congenital heart disease. The aim of this study is to estimate the prevalence of obesity and describe associated risk factors, including family history in children with congenital heart disease.

Methods

A cross-sectional study with 316 children and adolescents with congenital heart disease seen in an outpatient clinic of a reference hospital. Collected sociodemographic data included family history of chronic disease, dietary habits, laboratory tests (total cholesterol, HDL and LDL/cholesterol, triglycerides, fasting glucose, CRP, hematocrit and hemoglobin), and anthropometric assessment. Anthropometric data of the caregivers was self-reported.

Results

The prevalence of excess weight was 26.9%. Altered levels of total cholesterol were observed in 46.9%, of HDL in 32.7%, LDL in 23.6% and of triglycerides levels in 20.0%. A higher frequency of family history of obesity (42.6%; p = 0.001), dyslipidemia (48.1%; p = <0.001), diabetes (47.4%; p = 0.002), hypertension (39.2%; p = 0.006) and ischemic disease (43.7%; p = 0.023), as well as significantly higher values of triglycerides (p = 0.017), glycemia (p = 0.004) and C-reactive protein (p = 0.002) were observed among patients with excess weight.

Conclusion

The presence of modifiable risk factors and the variables associated to excess weight in this population was similar to that described in the literature for children without congenital disease. As these children already present the risks associated to heart disease, it is particularly important to promote a healthy lifestyle in this group.

Low birthweight and elevated levels of lipoprotein(a) in prepubertal children

AIM

To evaluate whether healthy prepubertal children with low birthweight (LBW) exhibited higher serum levels of lipoprotein(a) (Lp(a)) than did those with normal birthweight (NBW).

METHODS

A total of 350 healthy children aged 6 to 9 years and in Tanner stage 1 were enrolled in a community-based cross-sectional study. Family history of hypertension, diabetes or cardiovascular disease (CVD) in parents and grandparents; active smoking; a diagnosis of acute or chronic illness; and intake of vitamins or nutritional supplements were exclusion criteria. The cut-off point for Lp(a) was 0.79 μmol/L.

RESULTS

LBW was identified in 51 (14.6%) children. In total, 42 (12.0%) children had elevated Lp(a) levels, with 25 (49.0%) and 17 (5.7%) in the LBW and NBW groups, respectively (P < 0.0005). None of the children had adverse cardiovascular outcomes. Average body mass index (BMI) (17.1 ± 3.3 and 18.8 ± 3.9, P = 0.001), glucose levels (4.5 ± 0.5 and 4.8 ± 0.4 mmol/L, P = 0.007), insulin levels (67.4 ± 45.1 and 86.1 ± 54.9 pmol/L, P = 0.02), and Lp(a) levels (0.52 ± 0.21 and 1.40 ± 0.49 μmol/L, P < 0.0005) were higher in the children with LBW than in the children with NBW. A multivariate analysis adjusted by age, sex, raw BMI, BMI standard deviation score and insulin level showed a significant association between LBW and elevated levels of Lp(a) (odds ratio 8.02, 95% confidence interval 7.3-21.3; P < 0.0005).

CONCLUSIONS

LBW was shown to be strongly associated with elevated serum levels of Lp(a).

Association of lipid profile and waist circumference as cardiovascular risk factors for overweight and obesity among school children in Qatar

BACKGROUND

Childhood obesity is a national as well as worldwide problem. The aim of this study was to evaluate the association of overweight and obesity among Qatari children with lipid profile and waist circumference as adverse cardiovascular risk factors in children aged 6-11 years. International Obesity Task Force reference values were used to screen for overweight and obesity.

METHODS

A cross-sectional study in a randomly selected sample was conducted in 315 Qatari primary school students aged 6-11 years. Anthropometric measurements, including body weight, height, waist circumference, and body mass index were calculated for 151 girls and 164 boys. Weight categories were based on International Obesity Task Force reference values. Fasting blood glucose, total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglycerides were measured, and atherogenic index was calculated.

RESULTS

In total, 31.71% of boys and 32.78% of girls were overweight or obese. Overweight and obese children screened against International Obesity Task Force reference values had a significantly increased risk of high waist circumference (P < 0.0001), hypertriglyceridemia (P = 0.002), low HDL-C (P = 0.017), and atherogenic index (P = 0.021) compared with children who were not overweight or obese. The partial correlation coefficient for the cardiovascular risk marker of waist circumference indicated a positive significant association with total cholesterol (r = 0.465, P = 0.003), triglycerides (r = 0.563, P < 0.001), and LDL-C (r = 0.267, P = 0.003), and a significant negative association with HDL-C (r = -0.361, P = 0.004). Overweight and obesity significantly increase the odds ratios (ORs) and 95% confidence interval (CIs) of cardiovascular risk factors as follows: hypertriglyceridemia (OR 6.34, CI 2.49-13.44, P < 0.0001); LDL-C (OR 3.18, CI 1.04-9.75, P = 0.043); hypercholesterolemia (OR 1.88, CI 1.10-3.19, P = 0.020); and increased waist circumference (OR 1.40, CI 1.29-1.55, P = 0.022). Overweight and obesity significantly increased the risk of atherosclerosis (assessed by atherogenic index) by about two-fold (OR 1.83, 95% CI 1.06-3.15, P = 0.025).

CONCLUSION

Overweight and obese children screened by International Obesity Task Force reference values are at increased risk of cardiovascular disease in adulthood.

Fatores socioeconômicos, demográficos, nutricionais e de atividade física no controle glicêmico de adolescentes portadores de diabetes melito tipo 1

OBJETIVO: Identificar a associação de condições socioeconômicas, demográficas, nutricionais e de atividade física sobre o controle glicêmico de adolescentes portadores de DM1. SUJEITOS E MÉTODOS: Estudo transversal com 71 adolescentes com diagnóstico clínico de diabetes tipo 1. Foram obtidos dados socioeconômicos, demográficos e antropométricos. O controle glicêmico foi classificado pelo índice de hemoglobina glicada (A1C). Foram aplicados quatro recordatórios de 24 horas de consumo alimentar e de atividade física. RESULTADOS: A A1C foi inadequada para a maioria dos adolescentes. A menor escolaridade do cuidador influenciou para o controle glicêmico inadequado. Pacientes com menor dose de insulina apresentaram melhor controle glicêmico. A alimentação observada foi hipoglicídica e hiperlipídica. A maioria dos pacientes era sedentária. CONCLUSÃO: Fatores relacionados à educação, à insulina e à alimentação influenciaram no controle glicêmico.

Children with type 2 diabetes mellitus are at greater risk of macrovascular complications

BACKGROUND

Type 2 diabetes mellitus (DM) is a risk factor for macrovascular complications in adults. Recently young-onset type 2 DM has increased worldwide and the increase of macrovascular complications in the young is worrisome.

METHODS

Plasma values for plasminogen activator inhibitor-1 (PAI-1) as a marker for promotion, and adiponectin as a marker for inhibition of atherosclerosis, were compared in 33 patients with type 1 DM (16 boys, 17 girls; age 14.9 +/- 3.7 years, mean +/- standard deviation) with those of 43 patients with type 2 DM (15 boys, 28 girls; age 16.5 +/- 3.5 years).

RESULTS

The PAI-1 level was significantly higher (19.3 +/- 8.1 vs 32.9 +/- 17.2 ng/ml; P < 0.001) and the adiponectin level was significantly lower (10.1 +/- 3.8 vs 7.4 +/- 3.7 microg/ml; P < 0.005) in the type 2 DM group. In obese patients, the PAI-1 level was significantly higher (P < 0.005) and the adiponectin level was lower (P= 0.15) in the type 2 DM group. Also, in the non-obese subjects, the PAI-1 level was significantly higher (P < 0.05) and the adiponectin level was lower (P= 0.11) in the type 2 DM group.

CONCLUSIONS

Even in young patients, type 2 DM is a risk factor for macrovascular complications compared with type 1 DM.

Metabolic syndrome among prepubertal Brazilian schoolchildren

This was a two-stage cross-sectional study that assessed metabolic syndrome and associated factors among prepubertal schoolchildren. In the first stage, nutritional status, blood pressure, personal (low birth weight) and family antecedents for cardiovascular disease (CVD) were collected. In the second stage, schoolchildren with at least one of these criteria participated: obesity, personal or family history. Metabolic syndrome (MS) was defined by ATP III and WHO definitions. Among 929 (6-10 year old) schoolchildren, 27.7% presented with overweight/obesity, 12.2% hypertension, and personal (9.4%) and family (35.3%) antecedents. 205 children finished the second stage. The frequencies of MS-ATP and MS-WHO were 9.3% and 1.9%. Among the obese, MS was present in 25.8% (ATP) and 5.2% (WHO). Children with normal weight presented: low HDL (23.6%), hyperglycaemia (3.6%), HOMA-IR (0.9%) and MS-ATP (0.9%). In conclusion, overweight/obesity was associated with metabolic syndrome in schoolchildren. It was found that children with normal weight with personal and/or family antecedents presented with HOMA-IR and MS-ATP.

Vascular disease in paediatric type 2 diabetes: the state of the art

Type 2 diabetes is an emerging problem in the paediatric population. Paediatricians and paediatric endocrinologists are struggling with how to best assess, predict and treat cardiovascular risk factors in these patients. There is a notable lack of consensus in how to proceed, even among experts in the field. There are very limited data from quality trials in established paediatric type 2 diabetes. We address the available information regarding traditional and non-traditional indices of cardiovascular risk, including examination findings, biochemical markers and non-invasive imaging modalities. We discuss the utility and pitfalls of applying knowledge gained in adult medicine to the paediatric population. Potential treatment strategies are reviewed, including the currently available pharmaceutical options, with the acknowledgement that there are few drugs formally approved in the paediatric population.

Epidemiology of childhood type 2 diabetes and obesity

Over the last decade, it has become apparent that type 2 diabetes extends not only into the young adult population but is also found in adolescents and even, occasionally, in children. The limited data that are currently available present a rather uncertain picture, with a rather wide range of prevalences and incidences of type 2 diabetes in children and adolescents. Not surprisingly, the majority of the cases, and the highest prevalences, have been found among ethnic groups known to be at high risk of adult type 2 diabetes. Nevertheless, even in European populations, where the prevalence of type 2 diabetes remains very low among children and adolescents and certainly is considerably smaller than type 1 diabetes, there are several cases reported. The risk factors for type 2 diabetes in children and adolescents are, as expected, similar to those seen in adults, with obesity being almost always present. In utero exposure to hyperglycemia now appears to be an additional risk factor to having a family history of diabetes and suggests that better management of diabetes in pregnancy and prevention of gestational diabetes may reduce the risk of diabetes developing in the offspring.

Lipid profile, glucose homeostasis, blood pressure, and obesity-anthropometric markers in macrosomic offspring of nondiabetic mothers

OBJECTIVE

The study was to determine whether being the macrosomic offspring of a mother without detected glucose intolerance during pregnancy has an impact on lipid profile, glucose homeostasis, and blood pressure during childhood.

RESEARCH DESIGN AND METHODS

Plasma total, HDL, and LDL cholesterol; triglycerides; apolipoprotein (Apo) A-1, -B, and -E; lipoprotein (a); fasting glucose and insulin; homeostasis model assessment of insulin resistance (HOMA-IR) index; blood pressure; BMI; and detailed anthropometry were evaluated in 85 children aged 3-10 years old, born appropriate for gestational age (AGA; n = 48) and large for gestational age (LGA; n = 37) of healthy mothers.

RESULTS

At the time of the assessment, body weight, height, skinfold thickness, BMI, waist circumference, and blood pressure did not differ between the LGA and AGA groups with the exception of head circumference (P < 0.01). There were no significant differences in plasma total or LDL cholesterol; triglycerides; Apo A-1, -B, or -E; lipoprotein (a); Apo B-to-Apo A-1 ratio; or glucose levels between the groups. The LGA group had significantly higher HDL cholesterol levels (P < 0.01), fasting insulin levels (P < 0.01), and HOMA-IR index (P < 0.01) but lower values of the glucose-to-insulin ratio (P < 0.01) as compared with the AGA group.

CONCLUSIONS

Children born LGA of mothers without confirmed impaired glucose tolerance during pregnancy show higher insulin concentrations than AGAs.

Early atherosclerosis in childhood: Diagnostic approaches and therapeutic strategies

The long preclinical phase of atherosclerosis involves the interaction of genetic and environmental factors that modulate the progression of disease from early life. Injury to the endothelium is a critical step in atherosclerotic process. Conventional and novel risk factors for coronary artery disease operate from early in life. Noninvasive methods, using mostly ultrasound techniques, have enabled the assessment of early functional and structural arterial disease progression even from the first decade of life. These measures have been shown to be good surrogate markers for atherosclerotic disease progression and future clinical cardiovascular events. Lifestyle and dietary modifications as well as pharmacological interventions have beneficial effects in prevention and restoration of the early arterial changes.

Type 2 diabetes in children and youth

The number of children and youth diagnosed with type 2 diabetes has increased dramatically over the last decade. Much still needs to be learned about why this epidemic is occurring presently with regard to other environmental factors that might promote insulin resistance and beta-cell failure. The TODAY trial will help to determine the best treatment strategies to improve glycemia, reduce complications, and ameliorate insulin resistance and beta-cell failure. As type 2 diabetes emerges as a worldwide public health problem, improved care for affected youth must be coupled with a focus on prevention.

Soluble adhesion molecules (sICAM-1, sVCAM-1) and selectins (sE selectin, sP selectin, sL selectin) levels in children and adolescents with obesity, hypertension, and diabetes

The attachment of monocytes and lymphocytes to endothelial cells, which initiates atherosclerosis, arises under the influence of adhesion molecules. The preclinical phase of this disease lasts many decades, and this provides an opportunity for the presymptomatic detection of high-risk subjects. We evaluated levels of the adhesion molecules: sICAM-1 (soluble intercellular adhesion molecule 1), sVCAM-1 (soluble vascular adhesion molecule 1), sE selectin, sP selectin, and sL selectin in children with atherosclerosis risk factors (n = 123, mean age 15.1 years) (obese [n = 17], hypertensive [n = 25], obese with hypertension [n = 30], type 1 diabetic [n = 51]). Twenty-seven healthy children formed the control group, mean age 15.2 years. sICAM-1 was higher in the study group compared with control (314.1 +/- 61 vs 264.9 +/- 55 ng/mL, P < .01). The same was found for sVCAM-1 (513.7 +/- 187 vs 407.9 +/- 76 ng/mL, P < .05) and E selectin (86.04 +/- 33.6 vs 62.1 +/- 20.3 ng/mL, P < .01). sP-selectin and sL-selectin levels were not different compared with controls. E selectin correlated with body mass index (BMI; r = 0.18, P = .03), total cholesterol (r = 0.2, P = .016), and triglycerides (r = 0.22, P = .008). sICAM-1 correlated with BMI (r = 0.19, P = .019) and systolic blood pressure (r = 0.13, P = .045). In multiple linear regression analysis, sE selectin was found to be associated with triglycerides (R2 = 0.29, P = .045), sICAM-1 dependent on BMI (R2 = 0.58, P = .047), and sVCAM-1 dependent on total cholesterol (R2 = 0.51, P = .006). Elevated concentrations of sICAM-1, sVCAM-1, and E selectin were found in obese, hypertensive, and diabetic children. We conclude that endothelial activation appears in these children, and adhesion molecules are related to the earliest stages of atherosclerosis.

The effect of plasminogen activator inhibitor-1 gene 4G/5G polymorphism on glucose and lipid metabolisms in Turkish obese children

OBJECTIVE

Obesity is a metabolic disorder that is associated with increased plasminogen activator inhibitor-1 (PAI-1) concentration in the circulation. This increase is related to insulin resistance, dyslipidaemia and cardiovascular disease. Some studies have demonstrated a relationship between plasma PAI-1 concentrations and the 4G/5G gene polymorphism in the PAI-1 gene, while other studies have not. It is well known that plasma PAI-1 levels are increased in obesity; however, the relationship between the polymorphism and obesity remains unclear. In this study, we aimed to elucidate the effect of the PAI-1 4G/5G polymorphism on glucose and lipid metabolism parameters in Turkish obese children.

DESIGN AND PATIENTS

Ninety children with obesity (37 male, 53 female; mean age 11.1 +/- 3.4 years; range 5.8-17.6 years) were included in the study. The children were divided into three groups according to the PAI-1 promoter 4G/5G polymorphism (4G/4G, 4G/5G and 5G/5G). These groups were compared for age, body mass index (BMI), serum glucose, lipid and insulin levels, and homeostasis model assessment of insulin resistance (HOMA-IR) score.

RESULTS

The genotype distribution was 52% (47/90) 4G/4G, 25% (22/90) 4G/5G and 23% (21/90) 5G/5G. No statistically significant differences among genotype groups were found with respect to age, BMI, serum levels of glucose, lipid and insulin, and HOMA-IR score.

CONCLUSION

Although the frequency of the 4G/4G genotype was higher in subjects in the current study than in subjects reported in the literature, in our study group we observed no influence of the PAI-1 4G/4G polymorphism on lipid and glucose metabolism.

Effects of obesity on women's reproduction and complications during pregnancy

Obesity is increasing rapidly among women all over the world, and more women in fertile ages become overweight and obese. Among all other problems, women who are obese have higher rates of amenorrhoea and infertility. Obese women have a higher risk of complications during pregnancy such as hypertensive diagnoses and gestational diabetes, and delivery complications such as higher rates of caesarean sections and prolonged time of delivery. The aim of this article is to review the consequences of being obese during the reproductive life of a woman.