Cardiovascular consequences of paediatric obesity: Will there be a future epidemic of premature cardiovascular disease?

There can be no doubt that there is a worldwide epidemic of overweight and obese children; despite an increasing amount of attention directed at the issue, the problem is worsening. Canadian statistics suggest that the prevalence of overweight is rising faster in youth than in adults (1,2). This trend may represent a more global phenomenon (3). There is also no doubt that the causes of the problem are complex and multifactorial. No single intervention can be expected to reverse these trends, and the role and impact of health care providers remains unclear. While there are important personal and societal costs, the health care system is already starting to feel the burden, even among children. Hampl et al (4) examined health care utilization and expenditures using an administrative database, and noted greater health care expenditures for obese youth, without the recognition by health care providers that the youth were obese. Paediatric health care providers may routinely listen for heart murmurs and meticulously plot height and weight percentiles, but may still not recognize or initiate discussion and intervention regarding a child's increasing adiposity or recognize the fact that children today are probably more than 500 times more likely to die from atherosclerotic cardiovascular disease than from congenital cardiac malformations during their lifetime. The body of evidence from which the epidemic of childhood obesity can be predicted to translate into a future epidemic of premature cardiovascular disease is great and compelling. Increasing adiposity in children is accompanied by metabolic derangements that manifest as a cluster of cardiovascular risk factors (5). While there is debate as to the underlying mechanisms, there is an increasing risk of insulin resistance and type 2 diabetes, hypertension and lipid abnormalities. Lipid abnormalities include a triad of lower high-density lipoprotein (HDL) cholesterol, higher triglycerides and the presence of more atherogenic small dense low-density lipoprotein (LDL) cholesterol particles. From large-scale, longitudinal epidemiological studies, such as the Bogalusa Heart Study (6), there is strong evidence that childhood obesity is associated with a greater prevalence of cardiovascular risk factors, a problem that tracks into adulthood. For children with a body mass index (BMI) above the 95th percentile, the majority will have at least one cardiovascular risk factor (6). It has been shown that most overweight youth become obese adults, and that this persistence of obesity is associated with a worsening of cardiovascular risk factors (7). A more recent study has suggested that children with a BMI at or above the 99th percentile are at the greatest risk, with 59% having at least two cardiovascular risk factors and 88% going on to have a BMI in adulthood of at least 35 kg/m2 (8). Autopsy evidence of early atherosclerotic lesions, such as fatty streaks and fibrous plaques, can be identified, quantified and related to cardiovascular risk factors in youth. In the Bogalusa Heart Study, risk factors were quantified in serial cross-sectional assessments and related to findings at autopsy. They showed progressive involvement with age, direct linear relationships with usual cardiovascular risk factors (with BMI being a constant correlate), and geometric acceleration with an increasing number of risk factors, such as that seen in the setting of the metabolic syndrome (9,10). A second major study, the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study (11), examined aortic and coronary artery pathology, and related these to risk factors assessed from anthropomorphic measurements, and blood and renal tissue derived at the time of autopsy. PDAY showed findings that were similar to the Bogalusa Heart Study, but noted that the greatest acceleration occurred in men with a BMI greater than 30 kg/m2 and with more pronounced abdominal or visceral fat distribution (12). These studies provide strong pathological evidence that the atherosclerotic process is active in youth and is greatly accelerated in the setting of obesity and the associated clustering of cardiovascular risk factors. Several noninvasively determined markers of early atherosclerosis have been applied in the research setting for the paediatric population as validated measures of vascular health, including assessment of arterial reactivity, conductance properties, intima-media thickness and calcification. The Bogalusa Heart Study has noted associations of paediatric obesity and associated risk factors with increased carotid intima-media thickness (13–15) and impaired brachial artery distensibility using ultrasound (16). The Muscatine study (17–20), another paediatric population-based study, showed associations between increasing BMI and increasing coronary artery calcification using electron beam computed tomography, as well as increasing carotid intima-media thickness. Other studies (21–23) using ultrasound in overweight children have shown impaired arterial reactivity, indicating the presence of endothelial dysfunction. These studies provide strong evidence in vivo that the atherosclerotic process is accelerated in overweight and obese youth. Given the complexity and pervasiveness of factors contributing to childhood obesity, no single intervention is likely to have a significant, or often measurable, impact on the problem. Nonetheless, there is some evidence that vascular health can be improved in children through healthy lifestyle or specific risk factor interventions. Two clinical trials in obese children have shown improvements in arterial reactivity with primarily aerobic exercise interventions, without concomitant changes in measures of adiposity but with improvements in distribution toward less visceral or abdominal fat (24–26). A further clinical trial of an exercise program showed improvement in cardiovascular risk factors and atherosclerosis markers associated with improvements in adiposity (27). An exercise intervention has also been shown to improve psychopathology associated with obesity in adolescents (28). Likewise, interventions aimed at reducing sedentary behaviours have been shown to be effective in improving weight indices (29), and the inclusion of a family component to interventions may be important (30). Dietary interventions play an important role, although studies have shown varying and inconsistent results because of the complexity of this intervention (31). However, lipid-lowering drug therapy is rarely indicated for obesity-related lipid abnormalities in children, and evidence appears to be increasing that it is possible to reduce cardiovascular risk factors and halt or reverse the acceleration of the atherosclerotic process through effective interventions. There is strong evidence that an epidemic of childhood obesity has led to a significant increase in the prevalence of cardiovascular risk factors and an acceleration of the atherosclerotic process, which, if unchecked, will lead to an epidemic of premature cardiovascular disease. There is a strong imperative for the development and implementation of evidence-based strategies aimed at the prevention and treatment of obesity in youth. While the solution must be multifactorial and multidimensional in nature, there is much that paediatric health care providers can contribute to reverse what is a dire prediction for the future. Be a personal role model for healthy weight and a healthy lifestyle (32). Familiarize yourself with information and recommendations from several evidence-based reviews (33–36). Include assessment and discussion of healthy lifestyle recommendations as part of provision of clinical care, particularly as part of routine health care maintenance and anticipatory guidance. Serially calculate and plot BMI on standardized charts , identifying children above the 85th percentile as overweight and above the 95th percentile as obese, and share these findings with families (37). Alternatively, pay attention to widening discrepancies between height and weight percentiles. For overweight children, additional assessment of waist circumference may be indicated and related to published normal values (38,39). Some particularly muscular children may have high BMI but lower levels of adiposity as indicated by lower waist circumference, whereas overweight children with a greater waist circumference and, hence, a more visceral fat distribution may be at greater risk for metabolic abnormalities. Particularly for obese children, assessments and interventions for obesity-related morbidities are indicated, including hypertension, dyslipidemia, fatty liver, insulin resistance and type 2 diabetes, and orthopedic and psychological issues. Become familiar with and apply motivational interviewing techniques (40). Help families to set multiple small goals and monitor progress. Provide expert advice, encouragement and monitoring. Have at hand an array of patient resource materials to disseminate or recommend. These may be handouts addressing specific issues or goals, compendiums of Internet-based resources or books with healthy lifestyle programs (41). Direct families to Health Canada's Physical Activity Guides for Children and Youth . Identify, recommend and use outside resources, such as overweight programs, nutritionists, fitness specialists, and fitness facilities or community groups with activity or healthy lifestyle programs. Develop and implement curricula within training programs regarding paediatric obesity and its management (42). Advocate for policy and environmental change to promote healthy lifestyles for children and youth.

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