Expert Panel on Integrated Guidelines for Cardiovascular ...

1 National Heart, Lung, and Blood Institute Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents FULL REPORT. National Heart, Lung, and Blood Institute Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents Full Report NIH Publication No. 12-7486. October 2012. Expert Panel Membership Stephen R. Daniels, , , Panel Chair Peter O. Kwiterovich, University of Colorado School of Medicine Johns Hopkins University School of Medicine Denver, CO Baltimore, MD. Irwin Benuck, , Patrick E. McBride, , Northwestern University Feinberg School University of Wisconsin School of Medicine and of Medicine Public Health Chicago, IL Madison, WI. Dimitri A. Christakis, , Brian W. McCrindle, , University of Washington The Hospital for Sick Children Seattle, WA Toronto, ON. Barbara A.

2 Dennison, Albert P. Rocchini, New York State Department of Health Mott Children's Hospital Albany, NY Ann Arbor, MI. Samuel S. Gidding, Elaine M. Urbina, Alfred I duPont Hospital for Children Cincinnati Children's Hospital Medical Center Wilmington, DE Cincinnati, OH. Matthew W. Gillman, , Linda V. Van Horn, , Harvard Pilgrim Health Care Northwestern University Feinberg School of Boston, MA Medicine Chicago, IL. Mary Margaret Gottesman, , , Ohio State University College of Nursing Reginald L. Washington, Columbus, OH Rocky Mountain Hospital for Children Denver, CO. ii Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents Full Report NHLBI Staff Rae-Ellen W. Kavey, , Panel Coordinator National Heart, Lung, and Blood Institute Bethesda, MD. Christopher J. O'Donnell, , National Heart, Lung, and Blood Institute Framingham, MA.

3 Karen A. Donato, National Heart, Lung, and Blood Institute Bethesda, MD. Robinson Fulwood, , National Heart, Lung, and Blood Institute Bethesda, MD. Janet M. de Jesus, , National Heart, Lung, and Blood Institute Bethesda, MD. Denise G. Simons-Morton, , , National Heart, Lung, and Blood Institute Bethesda, MD. Contractor Support The Lewin Group, Falls Church, VA. Clifford Goodman, , Christel M. Villarivera, Charlene Chen, Erin Karnes, Ayodola Anise, Expert Panel Membership iii Relationship/Conflict of Interest/Financial/. Other Disclosures Expert Panel members disclosed relevant financial Dr. McBride has served as a consultant or interests to each other prior to discussions. The advisory board member for Bristol-Myers Squibb following financial interests are reported in the and Merck. He has served on speakers bureaus for publication in the Journal of Pediatrics: Kos, Merck, and Pfizer.

4 He declared no relevant relationships since July 2007. Dr. Benuck, Dr. Christakis, Dr. Dennison, Dr. O'Donnell, Dr. Rocchini, and Dr. Washington have Dr. McCrindle has been a consultant for Abbott, declared no relevant relationships. Bristol-Myers Squibb, Daichii Sankyo, and Roche. He owns stock in CellAegis. He reports funding/. Dr. Daniels has served as a consultant for Abbott grant support for research from Astra Zeneca, Laboratories, Merck, and Schering-Plough. He has Sankyo, Merck, Schering-Plough, and the NIH. received funding/grant support for research from the NIH. Dr. Urbina reports funding/grant support for research from Merck, Schering-Plough, Sankyo, Dr. Gidding has served as a consultant for Merck and the NIH. and Schering-Plough. He has received funding/. grant support for research from GlaxoSmithKline. Dr. Van Horn has provided advice to Chartwells School Food Service.

5 She has received funding/. Dr. Gillman has given invited talks for Nestle grant support for research from General Mills Nutrition Institute and Danone. He has received and the NIH. funding /grant support for research from Mead Johnson, Sanofi-aventis, and the NIH. Dr. Gottesman has served on the Health Advisory Board, Child Development Council of Franklin County. She was a consultant to Early Head Start for Region 5B. She has written for iVillage and taught classes through Garrison Associates for the State of Ohio, Bureau of Early Intervention Services, and Help Me Grow program. She has received funding /grant support for research from the NIH. Dr. Kwiterovich has served as a consultant or advi- sory board member for Merck, Schering-Plough, Pfizer, Sankyo, LipoScience, and Astra Zeneca. He has served on speaker bureaus for Merck, Scher- ing-Plough, Pfizer, Sankyo, Kos, and Astra Zeneca.

6 He has received funding/grant support for research from Pfizer, Merck, GlaxoSmithKline, Sankyo, and Schering-Plough. iv Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents Full Report Contents Background .. vi 1. Introduction .. 1. 2. State of the Science: Cardiovascular Risk Factors and the Development of Atherosclerosis in Childhood .. 7. 3. Screening for Cardiovascular Risk Factors .. 22. 4. Family History of Early Atherosclerotic Cardiovascular Disease .. 28. 5. Nutrition and Diet .. 33. 6. Physical Activity .. 64. 7. Tobacco Exposure .. 71. 8. High Blood Pressure .. 78. 9. Lipids and Lipoproteins .. 94. 10. Overweight and Obesity .. 141. 11. Diabetes Mellitus and Other Conditions Predisposing to the Development of Accelerated Atherosclerosis .. 160. 12. Risk Factor Clustering and the Metabolic Syndrome.

7 168. 13. Perinatal Factors .. 173. 14. Inflammatory Markers .. 177. 15. Integrated Cardiovascular Health Schedule .. 178. 16. Implications of the Guidelines for Public Policy, Reimbursement, Medical Education, and Research .. 179. Appendix A. Methodology .. 181. Contents V. Background In 2005, based on recommendations from the clinical endpoint of manifest CVD is much experts convened in a national Thought Leaders later in life. Therefore, the recommendations Meeting, the National Heart, Lung, and Blood would need to address both the prevention of risk Institute (NHLBI), under the leadership of the factor development primordial prevention . Director Elizabeth G. Nabel, , endorsed a new and the prevention of future CVD by effective approach for guideline development. This new management of identified risk factors primary approach is characterized by a formal evidence prevention .

8 Review and an Integrated format with the major There have been no previous NHLBI-appointed Cardiovascular (CV) risk factors addressed Expert panels that addressed multiple risk factors simultaneously in a single guideline document. in children. Previous CV pediatric Guidelines Atherosclerotic Cardiovascular disease (CVD) have addressed cholesterol (National Cholesterol remains the leading cause of death among Education Program: Report of the Expert Panel North Americans. Although manifest disease in on Blood Cholesterol Levels in Children and childhood and adolescence is rare, risk factors and Adolescents (1992)) and blood pressure (The risk behaviors that accelerate the development Fourth Report on the Diagnosis, Evaluation, and of atherosclerosis begin in childhood, and there Treatment of High Blood Pressure in Children is increasing evidence that risk reduction delays and Adolescents (2004)).

9 The Expert Panel used progression toward clinical disease. To address this these reports as a framework for development health issue, the NHLBI appointed an Expert Panel of the Integrated format. A systematic review of to develop Cardiovascular (CV) health and risk the evidence was conducted to address a broad reduction Guidelines for pediatric care providers array of questions concerning the development, based on the new approach, using a formal progression, and management of multiple evidence review of this science with an Integrated CV risk factors extending from before birth to format addressing all the major CV risk factors 21 years of age. This review required assessing all simultaneously. This publication, Full Report of the the evidence pertaining to the role of risk factors Expert Panel on Integrated Guidelines for Pediatric in childhood on the development and progression Cardiovascular Health and Risk Reduction, is the of atherosclerosis from childhood and adolescence result of the Expert Panel 's work to adulthood, as well as the body of evidence that addresses the impact of managing risk factors in Chaired by Dr.

10 Stephen R. Daniels, the Expert childhood on the development and progression of Panel 's goal was development of evidence-based atherosclerosis. Based on the assembled evidence, Guidelines addressing all of the major risk factors the Expert Panel developed graded, age-specific to assist pediatric care providers pediatricians, recommendations that are Integrated across risk family practitioners, nurses and nurse factors and across age groups. practitioners, physician assistants, and registered dietitians in both the promotion of CV health In developing these comprehensive evidence- and the identification and management of specific based Guidelines addressing all of the major risk factors from infancy to young adulthood. The risk factors, the Panel has provided a practical Expert Panel determined that a focus on CV risk approach to both the optimization of CV health reduction in children and adolescents addresses and the management of identified risk factors a disease process atherosclerosis in which throughout childhood and adolescence, a time vi Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents Full Report when many health-behavior patterns develop and when risk reduction should have the greatest impact.