Cardiovascular Health and Risk Reduction in Children and Adolescents                            Don P. Wilson, M.D., FNLA Fellow, American Board of Clinical Lipidology Pediatric Endocrinology Cook Children’s Medical Center Fort Worth, Texas

Overview Atherosclerosis begins in childhood. Risk factors for the development of atherosclerosis can be identified in childhood. Development and progression of atherosclerosis clearly relates to the number and intensity of CV risk factors, beginning in childhood. Risk factors track from childhood into adult life. Interventions exist for management of identified risk factors.

Lipid Screening Guidelines For Children and Adolescents Year  Organization NCEP AAP NHLBI Target Population Targeted: Family History Family History and Obesity Universal Screening First Screen > 2 yrs of age Not specified Age 9-11 Subsequent Screen Age 17-21 First-line Treatment Diet change Diet counseling* Weight loss if overweight Target LDL-c (mg/dL) <130 (minimal) <110 (ideal) <160 (initial) <130 (or lower) with other risk factors <130 (minimal) <110 (ideal) Criteria for initiating lipid lowering medication Age ≥ 10 years LDL ≥ 190 despite 6m-1y diet therapy Age ≥ 8 years LDL-C ≥ 190 or ≥ 160 if family history or 2+ risk factor (+) or ≥ 130 if diabetic Age ≥ 10, persistent LDL≥ 190, ≥ 160 if family history (+) or 1+ risk factor; Age < 10 years, only special cases** *Referral to a registered dietitian for family medical nutrition therapy for daily nutritional intake of <30% calories from fat (<=7% saturated fat, ~10% monounsaturated fat, no trans-fat); <200 mg of cholesterol/day. **Severe primary hyperlipidemia (homozygous familial hypercholesterolemia, primary hypertriglyceridemia with TG ≥500 mg/dL), a high-risk condition or evident cardiovascular disease; all under the care of a lipid specialist. 1992 2008 2011

Assist primary pediatric care providers in the prevention of: In 2006, the National Heart, Lung and Blood Institute (NHLBI) convened a panel of experts to develop comprehensive evidence-based guidelines addressing the known risk factors for CVD. Goal: Assist primary pediatric care providers in the prevention of: Risk factor development – primordial prevention. Future CVD by effective management of identified risk factors – primary prevention. The full report is available at: http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm

Risk Evaluation for Achieving Cardiovascular Health The REACH Clinic Pediatric Endocrinology and Diabetes Cook Children’s Medical Center Fort Worth, Texas

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

Comprehensive Screening – Treatment* Early Intervention – Reversal of Disease** Prevention Heart Healthy Lifestyle becoming the “norm” * Diabetes, Hypertension, OSA, Bone/Joint Disease, Steatohepatitis and Dyslipidemia ** Pre-diabetes, Pre-hypertension, Steatosis and Microalbuminuria

Academic Partners Cook Children’s R.E.A.C.H. Clinic Service GI Pulmonary Cardiology Orthopedics Endocrine Renal Mental Health Community Partners Cook Children’s R.E.A.C.H. Clinic Community resources

R.E.A.C.H. Clinic Pediatric Endocrinologist R.E.A.C.H. Clinic Coordinator Research Coordinator Endocrine Nurses Nutritionists Psychologists Social Services Exercise Psychologist Education Resources

Goals Not Met Refer to Endocrine Community Based Program for the Prevention of Premature Cardiovascular Disease in Youth PCP Initial Workup BMI + 2 CVDRFs + FH Diabetes Low Risk TLC Follow Moderate Risk Treat Goals Not Met Refer to Endocrine Education F/up with PCP Treat & Follow High Risk Goals Met Follow Refer To REACH REACH Evaluation Initiate Rx Co-Manage with PCP TLC = Therapeutic Lifestyle Counseling

REACH Referral and Follow-up PCP Initial Evaluation and *Diagnostic Workup Ordered Risk Stratification Low Risk F/up with PCP Moderate Targeted Health Education REACH F/up 1 year High Targeted Health Education Initial Nutrition F/up Then REACH Clinic q 4 mos. REACH Referral H&P Review of Dx Evaluation Assessments: Psychosocial Nutrition Fitness 4 month follow-up with the PCP 8 month follow-up with the PCP Rx Plan *Diagnostic Workup to be completed prior to being seen in the REACH Clinic.

It’s never too early to stop a heart attack ! We all have choices… C igarette Smoking H ypertension O besity I nsulin resistance C holesterol (low HDL-c) E xercise (lack of)