Pediatric prevention of adult cardiovascular disease: Promoting a healthy lifestyle and identifying at-risk children

INTRODUCTION — Although atherosclerotic cardiovascular disease (ASCVD) generally manifests in adulthood, the atherosclerotic process begins in childhood [1]. For most children, atherosclerotic vascular changes are minor and can be minimized or even prevented with adherence to a healthy lifestyle. However, in some children, the atherosclerotic process is accelerated because of the presence of identifiable risk factors (eg, obesity and hypertension) and/or specific diseases that are associated with premature ASCVD (eg, familial hypercholesterolemia and diabetes mellitus) (table 1) [1,2].

Primary prevention measures to minimize the risk of developing atherosclerosis in childhood will be reviewed here. In addition, the primary care assessment to identify the child at risk for premature atherosclerosis and, by extension, ASCVD will also be discussed. Risk factors for early atherosclerosis in childhood and the management of the child at risk for atherosclerosis are reviewed separately. (See "Overview of risk factors for development of atherosclerosis and early cardiovascular disease in childhood" and "Overview of the management of the child or adolescent at risk for atherosclerosis".)

CARDIOVASCULAR HEALTH PROMOTION — The two primary goals of cardiovascular health promotion in children are [1-3]:

●To prevent the development of risk factors associated with atherosclerosis (primordial prevention) with measures that focus on adherence to a healthy lifestyle

●To identify and manage children and adolescents at risk for early atherosclerosis based on the presence of established risk factors including obesity, hypertension, dyslipidemia, and insulin resistance (see "Overview of risk factors for development of atherosclerosis and early cardiovascular disease in childhood", section on 'Traditional ASCVD risk factors')

PROMOTING A HEART-HEALTHY LIFESTYLE

Overview — Prevention of atherosclerotic cardiovascular disease (ASCVD) risk factors should be addressed in the pediatric primary care office by promoting a healthy lifestyle for the individual child and on a population level through advocacy (eg, promoting tobacco smoke and nicotine avoidance, improving school lunch, encouraging smaller portion sizes, and increasing public awareness on healthy dietary choices). The rationale for these approaches is that an adult population with a lower burden of atherosclerosis, as a result of pediatric preventive care, will have a lower burden of CVD [1,3,4].

Pediatric routine health care supervision should promote and reinforce positive health behaviors, focusing on the following areas to reduce the risk of developing atherosclerosis [1,2]:

●Heart-healthy diet

●Physical activity

●Healthy sleep habits

●Avoiding tobacco and nicotine exposure

The construct of ideal cardiovascular health, well developed in the adult literature, has been adapted for children and adolescents and includes tobacco exposure, weight status (body mass index [BMI] (calculator 1 and calculator 2)), physical activity, nutrition (healthy diet score), cholesterol, fasting blood sugar, and blood pressure [3]. Ideal cardiovascular health in childhood and young adulthood has been associated with a lower prevalence of ASCVD risk factors in adulthood in several large longitudinal pediatric and young adult cohorts [5-8]. Increasing numbers of ideal cardiovascular health measures in youth were associated with a reduced risk of hypertension, metabolic syndrome, and dyslipidemia (ie, elevated low-density lipoprotein cholesterol) and decreased carotid artery and aortic intima-media thickness (IMT) in early adulthood [6].

Heart-healthy diet — Good nutrition, beginning at birth, has profound health benefits, including a potential to decrease the risk of ASCVD by preventing or ameliorating obesity, dyslipidemia, hypertension, and insulin resistance/diabetes mellitus. Several United States health organizations (the American Academy of Pediatrics, American Heart Association, American Dietetic Association, and United States Departments of Agriculture and Health and Human Services) have issued dietary guidelines for children and adolescents that are generally consistent with one another. These are summarized in the table (table 2) and are discussed in greater detail separately. (See "Dietary recommendations for toddlers and preschool and school-age children", section on 'General guidance'.)

Important aspects of a heart-healthy diet for infants, children, and adolescents include the following [1]:

●Breastfeeding – Exclusive breastfeeding for the first six months after birth and continued breastfeeding to at least 12 months of age is strongly supported by many governmental and medical professional organizations. Breastfeeding is linked to a decrease in the prevalence of future obesity and dyslipidemia, two important CVD risk factors. These issues and other benefits of breastfeeding are discussed separately. (See "Infant benefits of breastfeeding", section on 'Limited evidence for benefit'.)

●Fat intake – A specific limit for total fat intake to reduce ASCVD risk has not been established. Rather, we emphasize that fat intake should be primarily plant-based and consist of monosaturated and polyunsaturated fat. In the absence of a medical indication, fat intake should not be restricted during infancy.

•Monosaturated and polyunsaturated fat – The majority of fat intake should be composed of a combination of monosaturated and polyunsaturated fat (table 3).

•Saturated fat – We suggest limiting saturated fat to 7 to 10 percent of total calories and dietary cholesterol to <300 mg/day (table 3). Support for this recommendation is based on the Special Turku Coronary Risk Factor Intervention Project for Children (STRIP) trial that demonstrated modest improvements in fasting lipid profiles in infants whose parents received counseling regarding a low-saturated fat, low-cholesterol diet compared with those whose parents did not receive any dietary counseling [7,9-12]. At 14 and 19 years of age, the group that received repeated dietary counseling for a low-saturated fat diet had lower saturated fat intakes and serum low-density lipoprotein cholesterol than the control group [13,14]. As noted above, the intervention group was more likely to have ideal cardiovascular health metrics as compared with the control group, which correlated with a decreased aortic IMT and improved elasticity [6]. Importantly, there was no difference in neurodevelopmental outcomes, which effectively addressed an initial concern that a low-fat diet may adversely affect neurodevelopment. This diet primarily relied on fruit and vegetables, whole grains, low-fat and nonfat dairy products, beans, fish, and lean meat [15].

•Trans fats – Trans fats should be eliminated from the diet.

●Protein and carbohydrate intake – Approximately 15 to 20 percent of caloric intake should be derived from protein and 50 to 55 percent from carbohydrates, primarily in the form of whole grains.

●Other dietary measures – Other heart-healthy dietary advice for pediatric patients includes:

•Encourage the intake of dietary fiber in the form of naturally fiber-rich foods such as fruits, vegetables, and whole grains, as supported by longitudinal data following children into adolescence and young adults into middle adulthood [16,17].

•Reduce the intake of sugar-sweetened beverages and foods – In infants between 6 and 12 months of age, only 100 percent juice should be allowed and the intake should not exceed 4 ounces per day.

•In children ≥1 year old, if cow's milk is introduced, decisions regarding the milk's fat content should be based upon the child's growth, appetite, BMI, ASCVD risk factors, and intake of other sources of fat- and calorie-dense foods. The medical provider may decide that low-fat dairy is appropriate as early as 12 months. By two years of age, saturated fat should be limited to 8 to 10 percent of the daily caloric intake and milk should be provided as 1 percent fat or skim.

•A daily minimum intake of vitamin D supplementation (600 international units/day) is recommended for all children. (See "Vitamin D insufficiency and deficiency in children and adolescents", section on 'Recommended vitamin D intake'.)

For families with children with identified ASCVD risk factors, ongoing nutritional counseling by a registered dietician can help children adopt and sustain a diet that provides adequate nutrition and reduces ASCVD risk. A behavioral approach that engages the child and family has been shown to be the most effective method for achieving dietary change [1]. Dietary counseling should be tailored to each child and family based on diet patterns, social setting, and patient sensitivities, such as lactose intolerance and food allergy.

Physical activity — Routine physical activity should be encouraged throughout childhood. Regular physical activity is associated with decreased risk of atherosclerosis and ASCVD. However, the optimal type and level of physical activity are uncertain.

Based on the available data, we suggest the following age-based approach (table 4) [1,18]:

●All children >5 years of age should participate in moderate to vigorous activity for at least 60 minutes per day. The activity should be vigorous on at least three days of the week. Examples of moderate activity are brisk walking, hiking, and games that mostly involve throwing and catching (eg, baseball, softball, catch); examples of vigorous activity are running, biking, jumping rope, dancing, martial arts, and games involving running or chasing (eg, tag, soccer, basketball, flag football).

●For infants and preschool-aged children, parents should allow for unlimited active playtime in a safe and supportive environment.

●Limit leisure screen time to less than two hours per day in children. In children under two years of age, screen viewing should be entirely discouraged [19].

Evidence supporting these recommendations come from studies in adults demonstrating that daily vigorous activity decreases the risk of ASCVD and type 2 diabetes mellitus, reduces blood pressure, and improves fasting lipid profiles. These data are discussed in detail separately. (See "Exercise and fitness in the prevention of atherosclerotic cardiovascular disease".)

Although data of similar quality are limited in children, there are several reports demonstrating beneficial effects of physical activity on reducing the risk of atherosclerosis in children and adolescents.

●In the STRIP study, lower amounts of physical activity among adolescents (as determined by questionnaire) correlated with more subclinical atherosclerosis (ie, increased mean aortic IMT and decreased endothelial function as measured by flow-mediated dilation) [20,21]. Sedentary adolescents who increased their level of physical activity decreased the progression of IMT compared with adolescents who remained sedentary. In persistently active adolescents, the progression of IMT was attenuated compared with those who became sedentary. (See "Overview of risk factors for development of atherosclerosis and early cardiovascular disease in childhood", section on 'Evidence of subclinical atherosclerosis'.)

●In another report from the STRIP study, sedentary adolescents were at an increased risk for clustered metabolic risk factors compared with more physically active peers [22]. Physical activity was based on self-report, and the cluster risk factors were BMI, lipid profile, and blood pressure.

●In a report from the longitudinal Cardiovascular Risk in Young Finns study that recruited children from ages 3 to 18 years, low physical activity was associated with accelerated IMT progression over 27 years of follow-up [23].

●Data from the International Children's Accelerometry Database demonstrated that increasing time for moderate to vigorous activity was associated with better cardiometabolic risk factors regardless of the amount of sedentary time [24]. Higher mean time spent in moderate to vigorous activity correlated with reductions in mean waist circumference, systolic blood pressure, fasting insulin, and fasting triglycerides and increases in high-density lipoprotein cholesterol.

●In the Dietary Intervention Study in Childhood, higher self-reported levels of physical activity were associated with lower systolic blood pressure [25].

●Several small studies have shown that exercise programs that improve physical fitness resulted in a reduction of CVD risk factors including lowering BMI, blood pressure, and arterial stiffness and improving lipid profiles [26-29].

In addition, there is evidence that physical activity patterns established in childhood continue into adulthood [1].

Other benefits of physical activity in children are discussed separately. (See "Physical activity and strength training in children and adolescents: An overview", section on 'Physical activity'.)

Healthy sleep habits — In adults, abnormal sleep duration (both too little and too much) and sleep disordered breathing (eg, obstructive sleep apnea) have been linked to increased risk of ASCVD. These associations are discussed elsewhere. (See "Insufficient sleep: Definition, epidemiology, and adverse outcomes", section on 'Cardiovascular morbidity' and "Obstructive sleep apnea and cardiovascular disease in adults".)

There are fewer data establishing a link between sleep problems in childhood and risk of premature ASCVD. Nevertheless, we emphasize the importance of establishing healthy sleep habits (table 5A-B), including appropriate duration of sleep (figure 1), as part of a heart-healthy lifestyle. (See "Assessment of sleep disorders in children".)

Avoid tobacco and nicotine exposure — Pediatric health care clinicians should provide ongoing counseling on the benefits of a tobacco-free environment for the child and family. Patients and parents should be informed about the addictive and adverse health effects of smoking cigarettes and other nicotine exposures. The adverse effects include increased risk of ASCVD for themselves and for their children. (See "Secondhand smoke exposure: Effects in children" and "Prevention of smoking and vaping initiation in children and adolescents" and "Overview of smoking cessation management in adults" and "Cardiovascular effects of nicotine".)

IDENTIFYING CHILDREN AT RISK FOR CARDIOVASCULAR DISEASE

Rationale — Screening is a routine part of pediatric care and aims to identify conditions that, if untreated, increase risk of disease sequelae and for which there is an available cost-effective intervention. When deciding whether screening should be performed, the test's sensitivity and specificity, prevalence of the screened condition, cost of the screening test, and potential benefits and harms of screening and intervention must be considered. (See "Screening tests in children and adolescents", section on 'Overview'.)

Data are not available regarding whether and how to best assess individual risk for atherosclerotic cardiovascular disease (ASCVD) in pediatric practice. Because ASCVD occurs decades after childhood exposures and early atherosclerosis is generally asymptomatic, it is generally not feasible to conduct randomized controlled trials to assess the effectiveness of different pediatric screening practices. Thus, the United States Preventive Services Task Force found insufficient data to recommend for or against screening children for lipid or blood pressure abnormalities [30-34]. (See "Dyslipidemia in children and adolescents: Definition, screening, and diagnosis".)

By contrast, there are multiple large prospective population-based studies involving adults that assessed individual risk for cardiovascular events and are used to guide risk reduction strategies in adult patients (eg, Framingham or Reynolds Risk Score). This approach directly links risk factors to cardiovascular events and is discussed in greater detail separately. (See "Atherosclerotic cardiovascular disease risk assessment for primary prevention in adults: Our approach".)

Despite the paucity of evidence from randomized controlled trials in children, pediatric risk factors for accelerated atherosclerosis (and, by extension, ASCVD) have been identified through direct evidence from autopsy studies and indirect evidence using methods that detect vascular changes that have been associated with increased risk of CVD in adults (table 1). Screening for these risk factors is recommended by the American Academy of Pediatrics; American Heart Association; and National Heart, Lung, and Blood Institute. (See "Overview of risk factors for development of atherosclerosis and early cardiovascular disease in childhood".)

Long-term outcome data are not available to conclusively demonstrate that identification and treatment of risk factors in childhood will reduce the prevalence of clinical disease in adulthood. Although opinions differ widely, many experts (including the authors of this review) believe it is reasonable to assume, based on data from adult studies, that timely intervention to prevent (primordial prevention), decrease, and possibly eliminate ASCVD risk factor(s) in children will decelerate the atherosclerotic process (primary prevention) and prevent or delay the onset of clinical CVD [35-37]. (See "Overview of the management of the child or adolescent at risk for atherosclerosis".)

Risk factors and special conditions — In children, traditional cardiovascular risk factors and other specific conditions are associated with accelerated atherosclerosis and early ASCVD. These factors are summarized in the table (table 1) and are discussed in greater detail separately [1,2] (See "Overview of risk factors for development of atherosclerosis and early cardiovascular disease in childhood".)

Routine screening — During routine health supervision visits, screening is recommended by the American Academy of Pediatrics; American Heart Association; and National Heart, Lung, and Blood Institute to identify children with risk factors for early CVD.

Routine screening consists of the following:

●Assess tobacco smoke and nicotine exposure – Obtain history for smoke and inhaled nicotine exposure including both personal and secondhand smoke. Smoking prevention in children and adolescents is discussed in detail separately. (See "Prevention of smoking and vaping initiation in children and adolescents" and "Secondhand smoke exposure: Effects in children".)

●Review diet. (See 'Heart-healthy diet' above.)

●Review frequency and quality of physical activity. (See 'Physical activity' above.)

●Review sleep history – Sleep duration and quality is an emerging cardiovascular risk factor. Specifically, obstructive sleep apnea is a risk factor for CVD and is discussed separately. (See "Assessment of sleep disorders in children" and "Cardiovascular consequences of obstructive sleep apnea in children".)

●Review the family history for premature CVD – Premature CVD is defined as a heart attack, treated angina, interventions for coronary artery disease, sudden cardiac death, or stroke in a parent or sibling before age 55 (males) or 65 (females).

●Measure blood pressure – Age- and height-specific blood pressure percentiles should be determined using the tables for girls (table 6) or boys (table 7). Blood pressure screening in children is discussed in detail separately. (See "Definition and diagnosis of hypertension in children and adolescents", section on 'Screening of blood pressure'.)

●Measure weight and height and calculate body mass index (BMI) – BMI and BMI percentiles may be determined using linked calculators for girls (calculator 1) or boys (calculator 2). For children under two years of age, we recommend using weight-for-height percentiles. (See "Measurement of growth in children".)

●Perform lipid screening in all children and adolescents (algorithm 1A-B) – For children without risk factors, the first screening is performed at 9 to 11 years of age, with a second screening between 17 and 21 years of age. Earlier (starting as young as two years of age) and more frequent monitoring may be warranted in children with risk factors for early CVD. Pediatric lipid screening in children is discussed in detail separately. (See "Dyslipidemia in children and adolescents: Definition, screening, and diagnosis", section on 'Approach to screening'.)

●Perform screening for type 2 diabetes mellitus in at-risk children and adolescents, as summarized in the table (table 8) and discussed in detail separately. (See "Epidemiology, presentation, and diagnosis of type 2 diabetes mellitus in children and adolescents", section on 'Screening'.)

●Identify other conditions associated with accelerated atherosclerosis (table 1 and algorithm 2). (See 'Risk factors and special conditions' above.)

The severity of childhood atherosclerosis (and, by extension, the risk of CVD) increases as the number of CVD risk factors increases. Thus, it is important to consider all cardiovascular risk factors together in making management decisions (algorithm 2).

Management of children who are judged to be at increased risk for atherosclerosis includes nonpharmacologic and pharmacologic interventions, which are discussed in detail separately. (See "Overview of the management of the child or adolescent at risk for atherosclerosis" and "Dyslipidemia in children and adolescents: Management" and "Nonemergent treatment of hypertension in children and adolescents".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lipid disorders and atherosclerosis in children".)

SUMMARY AND RECOMMENDATIONS

●General approach – Pediatric prevention of adult atherosclerotic cardiovascular disease (ASCVD) includes:

•A heart-healthy lifestyle aimed at eliminating or reducing risk factors associated with atherosclerosis. (See 'Promoting a heart-healthy lifestyle' above.)

•Identifying children who have established risk factors for ASCVD (including hypertension, obesity, dyslipidemia, insulin resistance, or other high-risk conditions (algorithm 2 and table 1)) and providing timely intervention to reduce or possibly eliminate ASCVD risk. (See 'Identifying children at risk for cardiovascular disease' above.)

●Promoting a heart-healthy lifestyle – Routine care visits provide an opportunity for primary care providers to promote positive health behaviors to reduce the risk of developing early atherosclerosis. (See 'Promoting a heart-healthy lifestyle' above.)

Pediatric care providers should supply age-appropriate information and support to children and their families regarding all of the following:

•Nutrition, encouraging a diet low in saturated fat and refined carbohydrates; lacking trans fats; and rich in vegetables, fruits, and whole grains (table 2) (see 'Heart-healthy diet' above and "Dietary recommendations for toddlers and preschool and school-age children")

•Physical activity (table 4) (see 'Physical activity' above and "Exercise and fitness in the prevention of atherosclerotic cardiovascular disease")

•Healthy sleep habits (table 5A-B and figure 1) (see 'Healthy sleep habits' above and "Assessment of sleep disorders in children")

•Avoidance of tobacco and nicotine exposure (see 'Avoid tobacco and nicotine exposure' above and "Prevention of smoking and vaping initiation in children and adolescents")

●Routine screening – Screening for ASCVD risk during childhood includes the following (see 'Routine screening' above):

•Reviewing the child's diet (see "Dietary recommendations for toddlers and preschool and school-age children")

•Assessing the child's physical activity level (table 4) (see 'Physical activity' above)

•Assessing tobacco and nicotine use/exposure (see "Prevention of smoking and vaping initiation in children and adolescents" and "Secondhand smoke exposure: Effects in children")

•Reviewing the family history for premature ASCVD (see "Overview of risk factors for development of atherosclerosis and early cardiovascular disease in childhood", section on 'Family history')

•Measuring blood pressure (see "Definition and diagnosis of hypertension in children and adolescents", section on 'Screening of blood pressure')

•Measuring weight and height and calculate body mass index (BMI) (see "Measurement of growth in children")

•Lipid screening (algorithm 1A-B) (see "Dyslipidemia in children and adolescents: Definition, screening, and diagnosis", section on 'Rationale for lipid screening')

•Screening for type 2 diabetes mellitus in at-risk children (table 8) (see "Epidemiology, presentation, and diagnosis of type 2 diabetes mellitus in children and adolescents", section on 'Screening')

•Identifying other conditions associated with accelerated atherosclerosis (table 1 and algorithm 2)

ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges Jane Newburger, MD, MPH, and Michael Mendelson, MD, ScM, who contributed to an earlier version of this topic review.