Effect of quantitative and qualitative diet prescription on children behavior after diagnosis of heterozygous familial hypercholesterolemia

Cholesterol-Lowering Bioactive Foods and Nutraceuticals in Pediatrics: Clinical Evidence of Efficacy and Safety

Long-term exposure to even slightly elevated plasma cholesterol levels significantly increases the risk of developing cardiovascular disease. The latest evidence recommends an improvement in plasma lipid levels, even in children who are not affected by severe hypercholesterolemia. The risk-benefit profile of pharmacological treatments in pediatric patients with moderate dyslipidemia is uncertain, and several cholesterol-lowering nutraceuticals have been recently tested. In this context, the available randomized clinical trials are small, short-term and mainly tested different types of fibers, plant sterols/stanols, standardized extracts of red yeast rice, polyunsaturated fatty acids, soy derivatives, and some probiotics. In children with dyslipidemia, nutraceuticals can improve lipid profile in the context of an adequate, well-balanced diet combined with regular physical activity. Of course, they should not be considered an alternative to conventional lipid-lowering drugs when necessary.

Associations between dietary copper intake and hypertriglyceridemia among children and adolescents in the US

BACKGROUND AND AIMS

A relationship exists between dietary copper intake and hypertriglyceridemia in the United States (US). However, children and adolescents have there is limited research data for children and adolescents, who have not been thoroughly investigated. This study aimed to carefully evaluate this relationship.

METHODS AND RESULTS

This cross-sectional study included 3982 children and adolescents who participated in the US National Health and Nutrition Examination Survey 1999-2006. The outcome variable was hypertriglyceridemia, defined as a triglyceride (TG) concentration >150 mg/dL. Multivariate and binary logistic regression models were applied in this study. The median (Q1-Q3) copper intake and TG levels were 0.98 (0.71-1.32) mg/d and 72.00 (53.00-100.00) mg/dL, respectively. The smoothing curve showed an inverted L-shaped relationship between copper intake and the prevalence of hypertriglyceridemia in American children and adolescents. A binary logistic regression model was developed to evaluate the relationship between copper intake and the prevalence of hypertriglyceridemia, and the inflection point was 0.76 mg/d. The odds of developing hypertriglyceridemia significantly increased with increasing levels of copper intake (odds ratio (OR), 2.00; 95% confidence interval (CI): 1.39-2.86) in participants with copper intake >0.76 mg/d (P for log likelihood ratio test = 0.032). The association between high copper intake and increased hypertriglyceridemia risk was significantly stronger in participants with a high body mass index (BMI; ≥23 kg/m²) (OR: 2.09; 95% CI: 1.42-3.07) than in those with a low BMI (tertile 1-2) (p for interaction = 0.048). Moreover, the increase in copper intake in adolescents aged 13-18 years significantly increased the prevalence of hypertriglyceridemia (OR: 1.95; 95% CI: 1.38-2.76; p for interaction = 0.001).

CONCLUSION

Higher dietary copper intake increases the prevalence of hypertriglyceridemia, especially among US adolescents with a BMI ≥23 kg/m².

Correlation of cardiovascular risk predictors with overweight and obesity in patients with familial hypercholesterolemia

Purpose

We aimed to analyze the correlation between overweight and obesity-related indicators and cardiovascular risk predictors in patients with familial hypercholesterolemia (FH) and to evaluate their mutual predictive properties.

Methods

A total of 103 patients with FH included from 2004 to 2017 were retrospectively analyzed. Pearson correlation analysis and multiple linear regression analysis were used to assess the correlation between overweight and obesity-related indicators and cardiovascular risk predictors in FH patients. Subject operating characteristic (ROC) curve was used to analyze their reciprocal predictive performance.

Results

(1) Atherogenic index of plasma (AIP) (β = 0.020) and ApoB/ApoA1 Ratio (BAR) (β = 0.015) were independently correlated with body mass index (BMI) (P < 0.05); AIP (β = 1.176) was independently correlated with waist-to-hip ratio (WHR) (P < 0.01); AIP (β = 1.575), BAR (β = 0.661) and atherogenic coefficient (AC) (β = 0.427) were independently correlated with waist-to-height ratio (WHtR) (P < 0.05). (2) The area under the ROC (AUC) for overweight corresponding to AIP, BAR, and AC were 0.695 (95% CI = 0.593–0.797, P < 0.01), 0.660 (95% CI = 0.555–0.766, P < 0.01), and 0.632 (95% CI = 0.525–0.740, P < 0.05), respectively; and AUCs for central obesity corresponding to AIP, BAR and AC were 0.757 (95% CI = 0.656–0.857, P < 0.001), 0.654 (95% CI = 0.536–0.771, P < 0.05) and 0.651 (95% CI = 0.538–0.764, P < 0.05), respectively. The AUCs for moderate risk of AIP corresponding to BMI, WHR, and WHtR were 0.709 (95% CI = 0.608–0.811, P < 0.001), 0.773 (95% CI = 0.678–0.867, P < 0.001), 0.739 (95% CI = 0.641–0.836, P < 0.001), respectively, and BMI, WHR and WHtR corresponded to an AUC of 0.691 (95% CI = 0.585–0.797, P < 0.01), 0.734 (95% CI = 0.632–0.835, P < 0.001), and 0.706 (95% CI = 0.603–0.810, P < 0.01) for high risk of AIP, respectively.

Conclusion

AIP has independent positive linear correlation with indicators related to overweight and obesity in FH patients; AIP has good predictive performance for overweight and obesity in FH patients, and WHR has good performance for identifying moderate and high risk of AIP in FH patients.

Nutritional Treatment in a Cohort of Pediatric Patients with Familial Hypercholesterolaemia: Effect on Lipid Profile

Background and aims: Familial Hypercholesterolaemia (FH) is characterised by a genetic alteration in the transport and metabolism of cholesterol that leads to elevated levels of total cholesterol (CT) and low-density lipoprotein cholesterol (LDL-C) and early onset of atherosclerosis. According to the current guidelines, diet and promotion of healthy habits are first-line treatments. Little is known about the effectiveness of cholesterol-lowering diet and healthy lifestyle habits on plasma cholesterol and lipid profile in children and adolescents with FH. The aim of the study is to investigate the effect of the nutritional counseling on plasma lipid profile in FH children at the first step of treatment. Methods: 115 FH children (2−17 years) were included in the study; dietary habits were evaluated through a Food Frequency Questionnaire (FFQ) and blood samples for lipid profile were collected at the enrollment (T0) and six months later (T1). Results: the lipid profile at T0 and T1, expressed as mean ± standard deviation in mg/dL, was, respectively: total cholesterol 285.9 ± 51.1 and 276.6 ± 46.8 (paired test difference p value < 0.01), LDL-cholesterol 214.9 ± 47.7 and 206.4 ± 46.6 (p value < 0.01), HDL-cholesterol 52.9 ± 13 and 54.4 ± 11.5 (p value 0.07), triglycerides 87 ± 46.7 and 82.2 ± 38.4 (p value 0.4), non-HDL cholesterol 233 ± 51.4 and 222.2 ± 47.4 (p < 0.01). In the dietary habits (weekly portions) we observed an improvement (p ≤ 001) for fruit and vegetables, fish, pulses, whole foods, and a reduction (p < 0.01) for meat, sausages, cheese, junk foods consumption. Conclusions: In FH children we have highlighted an improvement of the plasma lipid profile and in healthy dietary habits after nutritional counseling.

Distinct causal effects of body fat distribution on cardiometabolic traits among children: Findings from the BCAMS study

BACKGROUND AND AIMS

Observational studies reveal that different body fat measures are associated with cardiometabolic disease with different effects. However, causality is not reflected by such observations. To explore and compare the causal relationships of general obesity (measured by body mass index (BMI)), adipose obesity (measured by fat mass percentage (FMP)) and central obesity (measured by waist-to-height ratio (WHtR)) with cardiometabolic traits among children.

METHODS AND RESULTS

We conducted one sample Mendelian randomization (MR) analysis in 3266 children from Beijing Children and Adolescents Metabolic Syndrome Study. Genetic instruments based on 28 SNPs were performed to explore and compare the causal associations of genetically BMI, FMP and WHtR with cardiometabolic traits. The genetic instruments were robustly correlated with observed BMI, FMP and WHtR. Each genetically 1-SD increment in BMI, FMP and WHtR were causally associated with increment in systolic blood pressure (SBP), diastolic blood pressure (DBP), log-transformed fasting plasma glucose (FPG), log-transformed HOMA-β, and decrease in log-transformed high-density lipoprotein cholesterol (HDL), respectively (all P < 0.05 after Bonferroni correction). The receiver operating characteristic curve indicated that BMI and FMP showed stronger effects on SBP, DBP, HOMA-β and HDL than WHtR (all P < 0.05). We also observed causal associations of BMI and FMP with log-transformed fasting insulin and HOMA-IR.

CONCLUSIONS

The MR analysis based on population-based cohort indicated a causal relationship of adiposity and body fat distribution with cardiometabolic traits. When compared with central obesity, general obesity and adipose obesity might own stronger effects on blood pressure and blood lipids among children.

Recent Advances on Familial Hypercholesterolemia in Children and Adolescents

Familial hypercholesterolemia is a common autosomal hereditary disorder characterized by elevated concentrations of low-density lipoprotein cholesterol and the development of premature atherosclerosis and cardiovascular disease. Early diagnosis, as well as prompt and aggressive treatment, are fundamental steps to prevent cardiovascular complications and a high rate of premature mortality in children and adolescents. Clinics and genetics are the two main aspects on which diagnosis is based. Widespread screening programs are a respectable option for the early detection of familial hypercholesterolemia. Different types of screening have been proposed so far; however, the optimal screening program has not yet been found. The treatment approach for both heterozygous and homozygous familial hypercholesterolemia in the pediatric population is multidisciplinary, including lifestyle modifications, standard lipid-lowering medications, and novel pharmacological agents. The latter show promising results, especially for patients who experience intolerance to other treatment or present with more severe conditions. Our purpose is to focus on the importance of the early detection of familial hypercholesterolemia, and to highlight the best therapeutic strategies, including the recent approaches based on current clinical evidence, that need to be adopted from the earliest stages of life.

Application of the Sampson equation to estimate LDL-C in children: Comparison with LDL direct measurement and Friedewald equation in the BLIP study

BACKGROUND AND AIMS

In epidemiological trials and in clinical practices, it is relevant to have affordable and reliable methods to measure the main lipid cardiovascular risk factors, and in particular low-density lipoprotein cholesterol (LDL-C) plasma level. In this context, we aimed to compare the reliability of the Friedewald's (LDL-Cf) and Sampson's (LDL-Cs) equations with the LDL-value dosed by a validated dosage method (LDL-Cd) in a large cohort of children.

METHODS AND RESULTS

We considered the lipid values of 145 infants, 278 preschoolers, 810 scholar children, and 1372 adolescents (Total N. 2605, 1291 males, 1314 females), with mean total cholesterol (TC) = 169.8 ± 39.7 mg/dL, HDL-Cholesterol = 50.8 ± 12.7 mg/dL, non HDL-Cholesterol = 118.9 ± 35.9 mg/dL, Triglycerides (TG) = 90.3 ± 77.9 mg/dL, LDL-Cd = 106.2 ± 29.9 mg/dL, LDL-Cf = 100.9 ± 33.8 mg/dL, and LDL-Cs = 102.2 ± 33.4 mg/dL. Comparing the distance to the LDL-Cd, Friedewald's equation mildly but significantly underestimated in infants (3.4 ± 5.3 mg/dL), preschoolers (1.5 ± 7.1 mg/dL). Children (1.2 ± 2.2 mg/dL) and adolescents (1.1 ± 5.9 mg/dL) compared to Sampson's equation (all comparisons, p < 0.001).

CONCLUSIONS

Our analysis, being carried out on a large population sample, shows that Sampson's equation is more reliable than Friedewald's one at each considered age class and even for extreme TG values.

Universal Cholesterol Screening among Pediatric Primary Care Providers within California and Minnesota: A Qualitative Assessment of Barriers and Facilitators

OBJECTIVE

To assess current pediatric cholesterol screening practices, and attitudes, among pediatric primary care providers (PCPs) via qualitative semistructured interviews designed to identify barriers and facilitators to universal cholesterol screening practices recommended by the National Heart Blood and Lung Institute and the American Academy of Pediatrics.

STUDY DESIGN

An online survey and subsequent 30-minute semistructured phone interview were completed with PCPs from regions in Northern California and Minnesota (survey n = 25, interview n = 12). Interviews were qualitatively analyzed using the consolidated framework for implementation research to categorize barriers, facilitators, and strategies to increase pediatric cholesterol screening among PCPs.

RESULTS

PCPs from California (n = 8) and Minnesota (n = 4) consistently identified cost of cholesterol screening, particularly the cost of time due to competing visit priorities, as a barrier. A supportive learning environment, feelings of self-efficacy, access to resources, and well-established clinical networks with specialists (eg, cardiologists) were facilitators to screening. The perceived level of endorsement behind cholesterol screening within the clinic, perceived validity of national guidelines, and ability to adapt guidelines to existing clinical workflow were notable differentiators between high vs low self-reported screen rates.

CONCLUSIONS

Findings of this study suggest that efforts to increase universal pediatric cholesterol screening will likely require the development of strategies to increase provider education about the long-term benefits of cholesterol screening (knowledge and beliefs), and ensuring providers feel supported and empowered when assessing/acting on the results of this screening (self-efficacy, engaging leaders, networks, and communication).

Dietary intake and lipid levels in Norwegian and Spanish children with familial hypercholesterolemia

BACKGROUND AND AIMS

Both the Nordic and Mediterranean diets claim to have a beneficial effect on lipid metabolism and cardiovascular prevention. The objective of this study was to compare diets consumed by children with FH at the time of diagnosis in Norway and Spain and to study their relationship with the lipid profile.

METHODS AND RESULTS

In this cross-sectional study, we appraised the dietary intake in children (4-18 years old) with (n = 114) and without FH (n = 145) from Norway and Spain. We compared Nordic and Mediterranean diet composition differences and determined the association between food groups and lipid profiles.

RESULTS

The Spanish FH group had a higher intake of total fats (mainly monounsaturated fatty acids (MUFAs)), cholesterol and fibre, but a lower intake of polyunsaturated fatty acids (PUFAs) compared to the Norwegian FH group. The Norwegian children consumed more rapeseed oil, low-fat margarine and whole grains and less olive oil, eggs, fatty fish, meat, legumes and nuts. In the Norwegian FH group, fat and MUFAs were directly correlated with total cholesterol, low-density lipoprotein cholesterol and apolipoprotein B and inversely correlated with high-density lipoprotein (HDL-C). In Spanish children with FH, the intake of fats (mainly MUFAs) was directly associated with HDL-C and apolipoprotein A1.

CONCLUSIONS

Despite a similar lipid phenotype, diets consumed by children with FH in Norway and Spain have significant differences at time of diagnosis. Nutrition advice should be more adapted to local intake patterns than on specific nutrient composition.

Vitamin D is not associated with body composition and metabolic profile among Brazilian children with 25-hydroxyvitamin D ≥ 75 nmol/L: A cross-sectional study

BACKGROUND AND AIMS

The association of vitamin D with cardiovascular disease risk factors among children remains inconclusive, and there is a lack of studies that evaluate children with optimal serum 25-hydroxyvitamin D [25(OH)D]. Thus, this study aimed to analyze the relationship between serum 25(OH)D and body composition and metabolic profile among Brazilian children with sufficient serum 25(OH)D.

METHODS AND RESULTS

A cross-sectional study was conducted with 88 Brazilian children aged 4-11 years. Self-reported race, physical activity, anthropometry (body mass and height), body composition (waist circumference, body fat percentage, fat free mass, triceps and subscapular skinfolds), biochemical profile [lipid fractions, fasting glucose and 25(OH)D] and blood pressure data were collected. No difference was found in sex, self-reported race, physical activity, age, anthropometry, body composition, biochemical parameters and blood pressure between children with 25(OH)D 75-99 and ≥ 100 nmol/L. In addition, there was no association between serum vitamin D and body composition and metabolic profile.

CONCLUSIONS

Serum 25(OH)D was not associated with body composition and metabolic profile among Brazilian children with sufficient serum 25(OH)D. Further studies among children with serum levels ≥ 75 nmol/L are needed to confirm this finding.

Randomized nutrient bar supplementation improves exercise-associated changes in plasma metabolome in adolescents and adult family members at cardiometabolic risk

BACKGROUND

Poor diets contribute to metabolic complications of obesity, insulin resistance and dyslipidemia. Metabolomic biomarkers may serve as early nutrition-sensitive health indicators. This family-based lifestyle change program compared metabolic outcomes in an intervention group (INT) that consumed 2 nutrient bars daily for 2-months and a control group (CONT).

METHODS

Overweight, predominantly minority and female adolescent (Teen)/parent adult caretaker (PAC) family units were recruited from a pediatric obesity clinic. CONT (8 Teen, 8 PAC) and INT (10 Teen, 10 PAC) groups randomized to nutrient bar supplementation attended weekly classes that included group nutrition counseling and supervised exercise. Pre-post physical and behavioral parameters, fasting traditional biomarkers, plasma sphingolipids and amino acid metabolites were measured.

RESULTS

In the full cohort, a baseline sphingolipid ceramide principal component composite score correlated with adiponectin, triglycerides, triglyceride-rich very low density lipoproteins, and atherogenic small low density lipoprotein (LDL) sublasses. Inverse associations were seen between a sphingomyelin composite score and C-reactive protein, a dihydroceramide composite score and diastolic blood pressure, and the final principal component that included glutathionone with fasting insulin and the homeostatic model of insulin resistance. In CONT, plasma ceramides, sphinganine, sphingosine and amino acid metabolites increased, presumably due to increased physical activity. Nutrient bar supplementation (INT) blunted this rise and significantly decreased ureagenic, aromatic and gluconeogenic amino acid metabolites. Metabolomic changes were positively correlated with improvements in clinical biomarkers of dyslipidemia.

CONCLUSION

Nutrient bar supplementation with increased physical activity in obese Teens and PAC elicits favorable metabolomic changes that correlate with improved dyslipidemia. The trial from which the analyses reported upon herein was part of a series of nutrient bar clinical trials registered at clinicaltrials.gov as NCT02239198.

Associations between body mass index trajectories in childhood and cardiovascular risk factors in adulthood

BACKGROUND AND AIMS

Children with a growth trajectory of overweight have higher levels of cardiovascular disease (CVD) risk factors than children with a normal-weight trajectory. However, less is known about how trajectories of body mass index (BMI) across the rest of the BMI spectrum relate to CVD risk factors and whether adult BMI affects these associations. Our aim was to examine associations between childhood BMI trajectories and adult CVD risk factors.

METHODS

We included 2466 individuals with childhood weights and heights (ages 6-14) from the Copenhagen School Health Records Register and adult CVD risk factors (ages 20-81) from the Copenhagen City Heart Study. Associations between childhood BMI trajectories identified by latent class modelling and CVD risk factors were examined using generalized linear regression analyses with and without adjustment for adult BMI. Normal-weight and overweight were defined by growth references from the Centers for Disease Control and Prevention.

RESULTS

We identified four childhood trajectories within the normal-weight spectrum and one trajectory of overweight. Compared to the trajectory with the lowest BMI level, several higher BMI trajectories were associated with worse circumference, HDL and glucose homeostasis in adulthood. The highest trajectory was additionally associated with higher total cholesterol and triglycerides. When adjusting for adult BMI, the higher BMI trajectories had lower waist circumference, blood pressure and triglycerides.

CONCLUSIONS

Trajectories of BMI within the normal-weight range and in the overweight range are associated with a worse CVD risk profile than in the lowest BMI trajectory, and these associations are modifiable by growth after childhood.

Lipid profile and left ventricular geometry pattern in obese children

Background

Left ventricular hypertrophy (LVH) is an important risk factor for cardiovascular and all-cause mortality. Previous studies reported conflicting results concerning the relationship between serum lipid levels and left ventricular geometry pattern. We sought to explore the relationship between standard serum lipid profile measures with left ventricular geometry pattern in obese children.

Patients and methods

In this cross-sectional study, a total of 70 obese children were examined. Fasting blood samples were taken to measure total cholesterol, low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), triglycerides (TGs), glucose, and insulin. Based on these values TG/HDL ratio, BMI and HOMA index were calculated. We also measured the average 24-h ambulatory systolic blood pressure (SBP) and two-dimensional (2/D) transthoracic echocardiography was performed to determine left ventricular mass index (LVMI) and relative wall thickness (RWT). Multiple regression analyses were conducted to explore relationships between study variables and the LVMI or RWT as outcome variables. The final model with LVMI included TG/HDL ratio, BMI, 24 h-average SBP, age and sex, while for the RWT we included BMI, insulin, age and sex.

Results

Our study included 70 children (65.71% boys and 34.29% girls) median age (14 years, IQR = 12–16)." We demonstrated independent and positive association of TG/HDL ratio, BMI and 24 h-average SBP with LVMI (effect = 3.65, SE = 1.32, p < 0.01; effect = 34.90, SE = 6.84, p < 0.01; effect = 0.32, SE = 0.12, p < 0.01, respectively). On the other hand, in model with RWT as outcome variable, only BMI and insulin were significantly linked (BMI: effect = 13.07, SE = 5.02, p = 0.01 Insulin: effect = 2.80, SE = 0.97).

Conclusion

Increased TG/HDL ratio in obese children is associated with the development of eccentric left ventricular hypertrophy while increased BMI and insulin were associated with concentric left ventricular hypertophy.

Efficacy of therapeutic lifestyle changes on lipid profiles assessed by NMR in children with familial and non-familial hypercholesterolemia

BACKGROUND AND AIMS

The first line of therapy in children with hypercholesterolaemia is therapeutic lifestyle changes (TLSC). The efficacy of lifestyle intervention in children with familial hypercholesterolaemia (FH), where LDL-C levels are genetically driven, deserves a focused study.

AIMS

To evaluate the impact of a lifestyle education program, focused on food patterns and physical activity, on lipid profiles assessed by nuclear magnetic resonance (NMR) in children with FH vs. non-FH.

METHODS

Phase 1 was a cross-sectional study of baseline characteristics, and phase 2 was a prospective TLSC intervention study. In total, the study included 238 children (4 to 18 years old; 47% girls) attending the lipid unit of our hospital due to high cholesterol levels. Eighty-five were diagnosed with FH (72% genetic positive), and 153 were diagnosed with non-Familial hypercholesterolaemia. A quantitative food frequency questionnaire (FFQ) including 137 items was used. Physical activity (PA) was assessed by the Minnesota questionnaire. The lipid profile was assessed using the 2D-1H-NMR (Liposcale test). A total of 127 children (81 in the FH group) participated in the prospective phase and were re-assessed after 1 year of the TLSC intervention, consisting of education on lifestyle changes delivered by a specialized nutritionist.

RESULTS

The FH and non-FH groups were similar in anthropometry and clinical data, except that those in the FH were slightly younger than those in the non-FH group. Both the FH and non-FH groups showed a similar diet composition characterized by a high absolute calorie intake and a high percentage of fat, mainly saturated fat. The PA was below the recommended level in both groups. After one year of TLSC, the percentage of total and saturated fats was reduced, and the amount of fiber increased significantly in both groups. The percentage of protein increased slightly. The number of children engaged in at least 1 hour/day of PA increased by 56% in the FH group and by 53% in the non-FH group, and both these increases were significant. The total and small-LDL particle numbers were reduced in both groups, although the absolute change was greater in the FH group than in the non-FH group.

CONCLUSIONS

Educational strategies to implement TLSC in children lead to empowerment, increased adherence, and overall metabolic improvement in children with high blood cholesterol, including those with FH.

Barriers to Early Diagnosis and Treatment of Familial Hypercholesterolemia: Current Perspectives on Improving Patient Care

Familial hypercholesterolemia (FH) is a frequent disorder associated with premature atherosclerotic cardiovascular disease. Different clinical diagnosis criteria are available, and cost of genetic testing has been reduced in the last years; however, most cases are not diagnosed worldwide. Patients with FH are at high cardiovascular risk and the risk can be reduced with lifelong lifestyle and pharmacological treatment. Statins and ezetimibe are available as generic drugs in most countries reducing the cost of treatment. However, the use of high-intensity statins combined with ezetimibe and PCSK9 inhibitors, if necessary, is low for different reasons that contribute to a high number of patients not reaching LDL-C targets according to guidelines. On the other hand, cardiovascular risk varies greatly in families with FH; therefore, risk stratification strategies including cardiovascular imaging is another element to consider for improving care and management of FH. There are numerous barriers depending on the awareness, knowledge, perception of risk, management and care of patients living with FH that impact in the diagnosis and treatment of the disorder. In this contemporary review, we analyze different barriers in the diagnosis and care of patients to improve patients’ care and prevention of atherosclerotic cardiovascular disease and describe recent advances and strategies to improve the gaps in the care of FH, including global collaboration and advocacy.

Safety of Prescribing Statins in Childhood Dyslipidemia

Hyperlipidemia is on the rise in pediatrics, leading to early coronary artery disease complications. Familial hypercholesterolemia is an important risk factor, with the homozygous subtype being more dangerous, yet less prevalent than the heterozygous subtype. Statins are shown to be an effective treatment in this population. This systematic review will emphasize the safety of such drug class in pediatrics, while taking into consideration the latest cholesterol guideline. Cochrane Library, Clinicaltrials.gov, and PubMed were reviewed systematically in June 2019 and rechecked in November 2019 for the past 5 years with keywords like child, safety, hyperlipidemia, and statins, which resulted in nine randomized clinical trials. In short, statins are shown to be intermediately effective—median decrease of low-density lipoprotein cholesterol was 32% achieving the target of < 160 mg/dL in 67% of patients—in lowering lipid levels yet preventing early complications. They are also considered safely tolerated in most cases, even when taken for extended periods, but still not evidently permissible for children below 8 years old, which was the average age of all participants in the trials. Statins should not be given generally for pediatrics of less than 8 years old, in contrast to what was mentioned in the American Heart Association guideline (0–19 age range), since there is no evidence supporting their safety within this age group.