Prevention may include diet changes, physical activity changes and in some instances drugs for high blood pressure and high cholesterol for children at high risk.
The "American Heart Association Guidelines for Primary Prevention of Atherosclerotic Cardiovascular Disease Beginning in Childhood" is the first comprehensive set of guidelines that addresses prevention beginning in childhood. A working group from the American Heart Association's Council for Cardiovascular Disease in the Young wrote the guidelines.
"There is now quite a large body of evidence documenting pathologic and physiologic changes when hypertension, high cholesterol and diabetes are present in childhood. Because the process of heart disease begins then, prevention should hold the most promise when it is initiated in children," says lead author Rae-Ellen W. Kavey, M.D., chair of cardiology at Children's Memorial Hospital, Northwestern University - Feinberg School of Medicine in Chicago.
"The paper builds on specific guidelines to address all the risk factors that we have identified in adults and how to approach each of those beginning in childhood," she says.
Evidence that much of cardiovascular disease is preventable led to developing guidelines for adults. However, those guidelines don't address prevention in children. The accumulation of strong evidence pointing to the importance of known risk factors for atherosclerosis in children and young adults led the American Heart Association to develop recent scientific statements and these guidelines for primary prevention in children.
"These guidelines present a conservative approach in an easy-to-use format identifying risk factors in childhood and safely modifying those identified without harm to the growing child," the authors write.
The guidelines address three areas. The first identifies "health promotion goals" for all children. It recommends that physicians assess diet, tobacco use and physical activity level at every visit. Pediatricians should educate parents to restrict high-fat foods after age 2 and limit salt and sugar intake. Sedentary time should be reduced, such as limiting children to no more than two hours of television a day.
The second area identifies children and adolescents at high risk for cardiovascular disease by assessing the factors mentioned above plus measuring height, weight, body mass index (BMI) and blood pressure. Physicians should also make regular updates to family medical history and test cholesterol levels in high-risk children. This section identifies those children who should have specific testing and provides normal data to allow physicians to interpret results.
The third area focuses on intervention for children with identified risks. For children and adolescents with abnormal cholesterol, this includes dietary changes to reduce low-density lipoprotein (LDL) - the so-called "bad cholesterol" - and considering cholesterol-lowering drugs for those with a strong family history of premature cardiovascular disease.
For children with blood pressure above the 95th percentile for their age, gender and height, the guidelines suggest restricting sodium (salt), and emphasizing weight control. Possible causes for persistent elevated blood pressure such as renal disease should be investigated, and some children may neeed blood pressure-lowering drugs.
The statement recommends diet and increased physical activity for overweight and obese children. The guidelines suggest that weight management be directed at all overweight family members.
Other intervention recommendations call for referring tobacco-users (parents and children) to smoking cessation resources and for controlling type 1 and type 2 diabetes in youth.
"Pediatricians are well prepared to carry out these recommendations," Kavey says. "They should be routinely looking at body weight, charting blood pressure and asking about physical activity in all kids, and specifically measuring cholesterol levels in select children. All those things should be part of routine pediatric care. Hopefully, these guidelines will make that process easier."
Co-authors are Stephen R. Daniels, M.D., Ph.D.; Ronald M. Lauer, M.D.; Dianne L. Atkins, M.D.; Laura L. Hayman, Ph.D., R.N.; and Kathryn Taubert, Ph.D.
The guidelines will be published in the March 25 print issue of Circulation: Journal of the American Heart Association.
Editor's Note: For the past 24 years, the American Heart Association has made a priority of physical education and teaching the benefits of living a heart-healthy lifestyle to school children. In association with American Alliance for Health, Physical Education, Recreation and Dance (AAHPERD), Jump Rope For Heart and Hoops For Heart teach more than 5 million elementary and middle school students each year the value of incorporating physical activity and living a heart-healthy lifestyle at a young age. For more information, contact Elaine Speer at 214-706-1538, elaines@heart.org or visit americanheart.org.
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