1. Check the Lipid Profile? Why? Douglas W. Teske, MD The Heart Center Nationwide Children’s Hospital Douglas W. Teske, MD The Heart Center Nationwide Children’s Hospital

2. Objectives 1.To state the recommendations to obtain lipid profiles in children and adolescents 2.To discuss the approach to an abnormal lipid profile 3.To determine when to initiate a lipid lowering medication 1.To state the recommendations to obtain lipid profiles in children and adolescents 2.To discuss the approach to an abnormal lipid profile 3.To determine when to initiate a lipid lowering medication

3. Heart Healthy Lifestyle Normal weight for height Appropriate diet for level of physical activity Daily exercise No smoking or use of other tobacco products Normal weight for height Appropriate diet for level of physical activity Daily exercise No smoking or use of other tobacco products

4. Epidemic of Childhood Obesity Concerns: - type 2 diabetes mellitus - systemic hypertension - risk of CVD in young adults - cigarette smoking/use of OTPs - oral contraceptives Concerns: - type 2 diabetes mellitus - systemic hypertension - risk of CVD in young adults - cigarette smoking/use of OTPs - oral contraceptives

5. Body Mass Index BMI Obesity (kg/M2) Classification Underweight <18.5 Normal 18.5-24.9 Overweight 25.0-29.9 Obesity 30.0-34.9 I 35.0-39.9 II Extreme obesity >40.0III BMI Obesity (kg/M2) Classification Underweight <18.5 Normal 18.5-24.9 Overweight 25.0-29.9 Obesity 30.0-34.9 I 35.0-39.9 II Extreme obesity >40.0III

6. Metabolic Syndrome in Adults Waist circumference men >102 cm/>40 in female >88 cm/>35 in Triglyceride >150 mg/dL HDL-C men <40 mg/dL female <50 mg/dL Blood pressure >130/>85 mmHg Fasting blood sugar >100 mg/dL Waist circumference men >102 cm/>40 in female >88 cm/>35 in Triglyceride >150 mg/dL HDL-C men <40 mg/dL female <50 mg/dL Blood pressure >130/>85 mmHg Fasting blood sugar >100 mg/dL

7. Metabolic Syndrome in Pediatrics No accepted definition Concerns with increases in obesity, prediabetes mellitus, and type 2 diabetes mellitus Concerns with autopsy findings of fatty streaks and fibrous plaques in adolescents Treatment: lower the BMI with lifestyle changes in diet and physical activity No accepted definition Concerns with increases in obesity, prediabetes mellitus, and type 2 diabetes mellitus Concerns with autopsy findings of fatty streaks and fibrous plaques in adolescents Treatment: lower the BMI with lifestyle changes in diet and physical activity

8. Concern for the Present and Future Increasing number of obese children and adolescents Increasing number of inactive children and adolescents Inability to significantly lower the number of children and adolescents who smoke and use other tobacco products Increasing number of obese children and adolescents Increasing number of inactive children and adolescents Inability to significantly lower the number of children and adolescents who smoke and use other tobacco products

9. Childhood Risk Factors for Adult CVD Obesity Sedentary lifestyle Cigarette smoking/use of OTPs Hypertension Hyperlipidemia –high LDL-C –low HDL-C Obesity Sedentary lifestyle Cigarette smoking/use of OTPs Hypertension Hyperlipidemia –high LDL-C –low HDL-C

10. Lipid Screening American Academy of Pediatrics: –First screening after 2 y/o but no later than 10 y/o –Should be a fasting lipid profile –Obtained in context of a well-child and health maintenance visit –If normal range valves, retest in 3 to 5 years American Academy of Pediatrics: –First screening after 2 y/o but no later than 10 y/o –Should be a fasting lipid profile –Obtained in context of a well-child and health maintenance visit –If normal range valves, retest in 3 to 5 years

11. AAP: Universal Screening Approach First time recommendation for universal screening for pediatric patients No data to support that a specific level of a childhood cholesterol will predict the risk of adult CVD No data on lack of identification and treatment of children with a high lipid level will lead to an increased risk of CVD development First time recommendation for universal screening for pediatric patients No data to support that a specific level of a childhood cholesterol will predict the risk of adult CVD No data on lack of identification and treatment of children with a high lipid level will lead to an increased risk of CVD development

12. Universal Pediatric Approach A family problem which requires changes in the behavior of the whole family: –Improve the diet –Increase daily activities –Improve family lifestyle –Improve the school lunch –Join community activities –Stop family use of tobacco products A family problem which requires changes in the behavior of the whole family: –Improve the diet –Increase daily activities –Improve family lifestyle –Improve the school lunch –Join community activities –Stop family use of tobacco products

13. Healthful Eating Behaviors Eat meals and snacks at regular times Avoid calorie-dense snacks At the dinner table, focus on conversation and not just the food Plate the food Don’t eat in front of the TV Eat slowly Eat a healthy breakfast Limit fast-food meals to once a week Eat meals and snacks at regular times Avoid calorie-dense snacks At the dinner table, focus on conversation and not just the food Plate the food Don’t eat in front of the TV Eat slowly Eat a healthy breakfast Limit fast-food meals to once a week

14. Personal Recommendations Ages 2 to 8/10 years old –heart healthy lifestyle recommendations –be aggressive in patients with diabetes, renal disease, congenital or acquired heart disease, collagen vascular disease, cancer survivors Ages 8 to 10 years old –fasting lipid profile –consider dietitian, exercise physiologist, psychologist Ages 2 to 8/10 years old –heart healthy lifestyle recommendations –be aggressive in patients with diabetes, renal disease, congenital or acquired heart disease, collagen vascular disease, cancer survivors Ages 8 to 10 years old –fasting lipid profile –consider dietitian, exercise physiologist, psychologist

15. Personal Recommendations Normal profile and no need for ensuing intervention: –repeat the FLP when 16-18 years old Abnormal profile and a need for intervention: –repeat the FLP in 1-2 years Again abnormal in males: increase the intervention or consider a medication Again abnormal in females: increase the intervention and consider a medication after a repeat profile after 6 months of regular menses or the use of an oral contraceptive Normal profile and no need for ensuing intervention: –repeat the FLP when 16-18 years old Abnormal profile and a need for intervention: –repeat the FLP in 1-2 years Again abnormal in males: increase the intervention or consider a medication Again abnormal in females: increase the intervention and consider a medication after a repeat profile after 6 months of regular menses or the use of an oral contraceptive

16. Fasting Lipid Profile Normal lipid levels the same for 2-18 y/o Concentrations in mg/dL TC LDL-C HDL-C TG acceptable 40 (M) >50 (F) borderline 170-199 100-129 elevated >200 >130 >110 Normal lipid levels the same for 2-18 y/o Concentrations in mg/dL TC LDL-C HDL-C TG acceptable 40 (M) >50 (F) borderline 170-199 100-129 elevated >200 >130 >110

17. Fasting Lipid Profile Intention to treat if LDL-C level: – >130 mg/dL with diabetes – >160 mg/dL with a positive family history parent/grandparent with an early cardiac event parent/grandparent with a TC >240 mg/dL unknown family history – >190 mg/dL with a negative family history Intention to treat if LDL-C level: – >130 mg/dL with diabetes – >160 mg/dL with a positive family history parent/grandparent with an early cardiac event parent/grandparent with a TC >240 mg/dL unknown family history – >190 mg/dL with a negative family history

18. Abnormal Lipid Profile Evaluate for secondary causes –exogenous – drugs or obesity –endocrine and metabolic – hypothyroidism and diabetes –storage diseases –obstructive liver diseases –chronic renal disease Evaluate for secondary causes –exogenous – drugs or obesity –endocrine and metabolic – hypothyroidism and diabetes –storage diseases –obstructive liver diseases –chronic renal disease

19. Screening Laboratory Studies Liver –ALT, AST, CK, PT/INR Kidney –BUN, Cr, UA Thyroid –T-4 total, TSH Heme –CBC with differential and platelets Liver –ALT, AST, CK, PT/INR Kidney –BUN, Cr, UA Thyroid –T-4 total, TSH Heme –CBC with differential and platelets

20. Medication Discussion Need for compliance with long-term medicine use Understanding that there is no evidence that pharmacologic treatment at a younger age will decrease morbidity and mortality from a CV event Understanding that there is no evidence that it is safe and cost effective to treat for decades individuals with an elevated cholesterol level Concern with labeling adolescents with a “disease” Treatment could exacerbate the prevalence of eating disorders Need for compliance with long-term medicine use Understanding that there is no evidence that pharmacologic treatment at a younger age will decrease morbidity and mortality from a CV event Understanding that there is no evidence that it is safe and cost effective to treat for decades individuals with an elevated cholesterol level Concern with labeling adolescents with a “disease” Treatment could exacerbate the prevalence of eating disorders

21. Pharmacotherapeutic Agents Bile acid sequestrant –Cholestyramine Niacin Statins –Pravastatin, Lovastatin, Simvastatin, Atorvastatin Cholesterol absorption inhibitor Fibrate Bile acid sequestrant –Cholestyramine Niacin Statins –Pravastatin, Lovastatin, Simvastatin, Atorvastatin Cholesterol absorption inhibitor Fibrate

22. Statin Therapy Use the statin of your choice at 10 mg/day taken at bedtime Add a morning multivitamin with vitamin K Emphasize an adequate daily calcium intake Repeat the FLP in 2 months and adjust the statin dose With a stable statin dose, repeat the FLP every 6-12 months with yearly liver studies Use the statin of your choice at 10 mg/day taken at bedtime Add a morning multivitamin with vitamin K Emphasize an adequate daily calcium intake Repeat the FLP in 2 months and adjust the statin dose With a stable statin dose, repeat the FLP every 6-12 months with yearly liver studies

23. Case Study #1 FemaleAge 8 years –Wt51.5 kg (>97%) –Ht132 cm (50-75%) –BMI29.3 kg/M2 –BP112/72 mmHg –TG281 mg/dL –TC224 mg/dL –HDL-C 35 mg/dL –LDL-C133 mg/dL FemaleAge 8 years –Wt51.5 kg (>97%) –Ht132 cm (50-75%) –BMI29.3 kg/M2 –BP112/72 mmHg –TG281 mg/dL –TC224 mg/dL –HDL-C 35 mg/dL –LDL-C133 mg/dL

24. Case Study #2 Male11 years old –Wt51.2 kg (95%) –Ht142.5 cm (~50%) –BMI25.2 kg/M2 –BP106/64 mmHg –TG 58 mg/dL –TC208 mg/dL –HDL-C 56 mg/dL –LDL-C141 mg/dL Male11 years old –Wt51.2 kg (95%) –Ht142.5 cm (~50%) –BMI25.2 kg/M2 –BP106/64 mmHg –TG 58 mg/dL –TC208 mg/dL –HDL-C 56 mg/dL –LDL-C141 mg/dL

25. Case Study #2 Male11 years old16 years old –Wt51.2 kg (95%)56.8 kg (50%) –Ht142.5 cm (~50%)168.2 cm (~50%) –BMI25.2 kg/M220.1 kg/M2 –BP106/64 mmHg116/70 mmHg –TG 58 mg/dL 44 mg/dL –TC208 mg/dL160 mg/dL –HDL-C 56 mg/dL 50 mg/dL –LDL-C141 mg/dL101 mg/dL Male11 years old16 years old –Wt51.2 kg (95%)56.8 kg (50%) –Ht142.5 cm (~50%)168.2 cm (~50%) –BMI25.2 kg/M220.1 kg/M2 –BP106/64 mmHg116/70 mmHg –TG 58 mg/dL 44 mg/dL –TC208 mg/dL160 mg/dL –HDL-C 56 mg/dL 50 mg/dL –LDL-C141 mg/dL101 mg/dL

26. Case Study #3 Male14 years old –Wt99.4 kg (>97%) –Ht165.6 (~50%) –BMI36.2 kg/M2 –BP124/58 mmHg –TG199 mg/dL –TC228 mg/dL –HDL-C 33 mg/dL –LDL-C155 mg/dL Male14 years old –Wt99.4 kg (>97%) –Ht165.6 (~50%) –BMI36.2 kg/M2 –BP124/58 mmHg –TG199 mg/dL –TC228 mg/dL –HDL-C 33 mg/dL –LDL-C155 mg/dL

27. Case Study #3 Male14 years old15 years old –Wt99.4 kg (>97%) –Ht165.6 cm (~50%) –BMI36.2 kg/M2 –BP124/58 mmHg –TG199 mg/dL266 mg/dL –TC228 mg/dL230 mg/dL –HDL-C 33 mg/dL 33 mg/dL –LDL-C155 mg/dL144 mg/dL Male14 years old15 years old –Wt99.4 kg (>97%) –Ht165.6 cm (~50%) –BMI36.2 kg/M2 –BP124/58 mmHg –TG199 mg/dL266 mg/dL –TC228 mg/dL230 mg/dL –HDL-C 33 mg/dL 33 mg/dL –LDL-C155 mg/dL144 mg/dL

28. Case Study #4 Male11 years old –Wt68.3 kg (>>97%) –Ht160 cm (>97%) –BMI26.7 kg/M2 –BP136/86 mmHg –TG366 mg/dL –TC248 mg/dL –HDL-C 40 mg/dL –LDL-C134 mg/dL Male11 years old –Wt68.3 kg (>>97%) –Ht160 cm (>97%) –BMI26.7 kg/M2 –BP136/86 mmHg –TG366 mg/dL –TC248 mg/dL –HDL-C 40 mg/dL –LDL-C134 mg/dL

29. Case Study #4 Male11 years old 17 years old –Wt68.3 kg (>>97%) 122.1 kg (>>97%) –Ht160 cm (>97%) 186.5 cm (>95%) –BMI26.7 kg/M2 35.1 kg/M2 –BP136/86 mmHg 142/88 mmHg –TG366 mg/dL 453 mg/dL –TC248 mg/dL270 mg/dL –HDL-C 40 mg/dL 38 mg/dL –LDL-C134 mg/dL Male11 years old 17 years old –Wt68.3 kg (>>97%) 122.1 kg (>>97%) –Ht160 cm (>97%) 186.5 cm (>95%) –BMI26.7 kg/M2 35.1 kg/M2 –BP136/86 mmHg 142/88 mmHg –TG366 mg/dL 453 mg/dL –TC248 mg/dL270 mg/dL –HDL-C 40 mg/dL 38 mg/dL –LDL-C134 mg/dL

30. Case Study #5 Male15 years old –Wt107.5 kg (>97%) –Ht178.9 cm (90%) –BMI33.6 kg/M2 –BP142/94 mmHg –TG312 mg/dL –TC333 mg/dL –HDL-C 20 mg/dL –LDL-C243 mg/dL Male15 years old –Wt107.5 kg (>97%) –Ht178.9 cm (90%) –BMI33.6 kg/M2 –BP142/94 mmHg –TG312 mg/dL –TC333 mg/dL –HDL-C 20 mg/dL –LDL-C243 mg/dL

31. Case Study #5 Male15 years old16 years old –Wt107.5 kg (>97%)81.1 kg (~90%) –Ht178.9 cm (90%)180.3 cm (~90%) –BMI33.6 kg/M224.9 kg/M2 –BP142/94 mmHg120/72 mmHg –TG312 mg/dl 88 mg/dL –TC333 mg/dL290 mg/dL –HDL-C 20 mg/dL 39 mg/dL –LDL-C243 mg/dL233 mg/dL Male15 years old16 years old –Wt107.5 kg (>97%)81.1 kg (~90%) –Ht178.9 cm (90%)180.3 cm (~90%) –BMI33.6 kg/M224.9 kg/M2 –BP142/94 mmHg120/72 mmHg –TG312 mg/dl 88 mg/dL –TC333 mg/dL290 mg/dL –HDL-C 20 mg/dL 39 mg/dL –LDL-C243 mg/dL233 mg/dL

32. Case Study #6 Male13 years old –Wt46.8 kg (25%) –Ht163.8 cm (25-50%) –BMI17.4 kg/M2 –BP96/64 mmHg –TG105 mg/dL –TC347 mg/dL –HDL-C 46 mg/dL –LDL-C280 mg/dL Male13 years old –Wt46.8 kg (25%) –Ht163.8 cm (25-50%) –BMI17.4 kg/M2 –BP96/64 mmHg –TG105 mg/dL –TC347 mg/dL –HDL-C 46 mg/dL –LDL-C280 mg/dL

33. Case Study #6 Male13 years old15 years old –Wt46.8 kg (25%) –Ht163.8 cm (25-50%) –BMI17.4 kg/M2 –BP96/64 mmHg –TG105 mg/dL48 mg/dL –TC347 mg/dL179 mg/dL –HDL-C 46 mg/dL 44 mg/dL –LDL-C280 mg/dL125 mg/dL Male13 years old15 years old –Wt46.8 kg (25%) –Ht163.8 cm (25-50%) –BMI17.4 kg/M2 –BP96/64 mmHg –TG105 mg/dL48 mg/dL –TC347 mg/dL179 mg/dL –HDL-C 46 mg/dL 44 mg/dL –LDL-C280 mg/dL125 mg/dL

34. Case Study #7 Female13 years old –Wt58.6 kg (75%) –Ht159 cm (50%) –BMI23.2 kg/M2 –BP122/70 mmHg –TG 65 mg/dL –TC274 mg/dL –HDL-C 39 mg/dL –LDL-C222 mg/dL Female13 years old –Wt58.6 kg (75%) –Ht159 cm (50%) –BMI23.2 kg/M2 –BP122/70 mmHg –TG 65 mg/dL –TC274 mg/dL –HDL-C 39 mg/dL –LDL-C222 mg/dL

35. Case Study #7 Female13 years old 16 years old –Wt58.6 kg (75%) 60.4 kg (50-75%) –Ht159 cm (50%) 160.5 cm (25-50%) –BMI23.2 kg/M2 23.4 kg/M2 –BP122/70 mmHg 104/64 mmHg –TG 65 mg/dL 83 mg/dL –TC274 mg/dL 203 mg/dL –HDL-C 39 mg/dL 37 mg/dL –LDL-C222 mg/dL 149 mg/dL Female13 years old 16 years old –Wt58.6 kg (75%) 60.4 kg (50-75%) –Ht159 cm (50%) 160.5 cm (25-50%) –BMI23.2 kg/M2 23.4 kg/M2 –BP122/70 mmHg 104/64 mmHg –TG 65 mg/dL 83 mg/dL –TC274 mg/dL 203 mg/dL –HDL-C 39 mg/dL 37 mg/dL –LDL-C222 mg/dL 149 mg/dL

36. 10 Ways to Help Children Develop Healthy Habits 10. Be an advocate for healthier children 9. Make a game of reading food labels 8. Make dinnertime a family time 7. Find new ways to celebrate good behavior 6. Set specific goals and realistic limits 5. Be supportive 4. Customize physical activities 3. Limit TV, video games, iPod time, and computer time 2. Get the whole family involved 1. Be a positive role model 10. Be an advocate for healthier children 9. Make a game of reading food labels 8. Make dinnertime a family time 7. Find new ways to celebrate good behavior 6. Set specific goals and realistic limits 5. Be supportive 4. Customize physical activities 3. Limit TV, video games, iPod time, and computer time 2. Get the whole family involved 1. Be a positive role model