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(Circulation. 2003;107:1562.)
© 2003 American Heart Association, Inc.

AHA Scientific Statement

American Heart Association Guidelines for Primary Prevention of Atherosclerotic Cardiovascular Disease Beginning in Childhood

Rae-Ellen W. Kavey, MD; Stephen R. Daniels, MD, PhD; Ronald M. Lauer, MD; Dianne L. Atkins, MD; Laura L. Hayman, PhD, RN; Kathryn Taubert, PhD

Key Words: AHA Scientific Statements • pediatrics • atherosclerosis • cardiovascular diseases • prevention

	Introduction

Top Introduction Selected Readings by Subject

 
Atherosclerotic cardiovascular disease remains the leading cause of both death and disability in North America. Evidence that most cardiovascular disease is preventable led to development of the American Heart Association’s initial "Guide to the Primary Prevention of Cardiovascular Disease" in 1996 and the updated version in 2002. Those guidelines do not address prevention in children, a group for whom primary prevention should hold the most promise. Emergence of multiple lines of evidence with regard to the importance of known risk factors for atherosclerotic disease in children and young adults has provided the impetus to develop guidelines for primary prevention in this young population.

Pathological studies have shown that both the presence and extent of atherosclerotic lesions at autopsy after unexpected death of children and young adults correlate positively and significantly with established risk factors, namely low-density lipoprotein cholesterol, triglycerides, systolic and diastolic blood pressure, body mass index, and presence of cigarette smoking. Findings from the Bogalusa study indicate that as the number of cardiovascular risk factors increases, so does the pathological evidence for atherosclerosis in the aorta and coronary arteries beginning in early childhood. Electron beam computed tomography of coronary artery calcium and increased carotid artery intima-media thickness, an ultrasound measure of carotid artery atherosclerosis, have been evaluated in 29- to 39-year-olds monitored from 4 years of age. Significant risk predictors for coronary artery calcium were obesity and elevated blood pressure in childhood and increased body mass index and dyslipidemia as young adults. Multiple epidemiological studies have demonstrated a disturbing increase in the prevalence of obesity beginning in childhood, with at least 22% of 6- to 17-year-olds diagnosed as overweight. This is a cause for particular concern because of the strong association between obesity and hypertension, dyslipidemia, and type II diabetes mellitus beginning in childhood. Long-term follow-up studies have demonstrated tracking of obesity, hypercholesterolemia, and hypertension from childhood into adult life. There is now substantial scientific evidence documenting the acquisition of behaviors associated with risk factors in childhood; these include dietary habits, physical activity behaviors, and the use of tobacco. Finally, an increasing body of research now documents the safety and success of intervention to reduce risk factors in childhood. These studies include the Dietary Intervention Study in Children trial, which demonstrated the safety and efficacy of a low-fat diet in children with hypercholesterolemia; skill-training programs in smoking prevention in adolescents; the Child and Adolescent Trial for Cardiovascular Health Study, which increased physical activity levels in children by using elementary school-based programs; and other successful long-term family-based treatment programs for childhood obesity.

There has not been nor will likely ever be a controlled trial comparing the effect of risk reductions beginning in childhood on the subsequent development of atherosclerotic disease. The existing evidence indicates that primary prevention of atherosclerotic disease should begin in childhood. The following guidelines represent a practical approach to cardiovascular health promotion and identification and management of known risk factors for cardiovascular disease in children and young adults. These guidelines complement other American Heart Association guidelines and should be useful for primary care providers, specialists, and parents of children and adolescents. The writing group that developed this statement considered the National Cholesterol Education Program Pediatric Panel Report, the second Task Force report on the diagnosis and management of hypertension in childhood, the update of that task force report by the National High Blood Pressure Education Program, and multiple additional publications, which are included in the reading list. Two major primary prevention strategies for children and adolescents are outlined in the tables below: (1) Population guidelines are directed cardiovascular health promotion for the entire pediatric population, whereas (2) individual guidelines focus on the identification and management of children and adolescents at highest risk for atherosclerotic disease.

The population guidelines, which apply to all children and adolescents, are presented in Table 1. In this table, the goals are presented in the left column and the recommendations for achieving those goals are presented in the right. Table 2 presents general and risk factor-specific guidelines for identifying pediatric patients at high risk of future cardiovascular disease. Finally, Table 3 presents goals and recommendations to achieve the goals of reducing risks in children and adolescents identified at high risk of future cardiovascular disease.

View this table: [in this window] [in a new window]   TABLE 1. Guidelines for Cardiovascular Health Promotion in All Children and Adolescents

View this table: [in this window] [in a new window]   TABLE 2. Guidelines for Identification of Children and Adolescents at High Risk of CVD

View this table: [in this window] [in a new window]   TABLE 3. Guidelines for Cardiovascular Risk Reduction: Intervention for Children and Adolescents With Identified Risk

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 American Heart Association’s Council on Cardiovascular Disease in the Young has developed a cardiovascular health schedule that allows risk factor identification and modification within the framework of routine pediatric care, and this approach is highly recommended (Williams et al, reference 7 in section VI). These guidelines are complementary to the recommendations published by Williams et al. Risk reduction has been shown to delay the onset and modify the course of atherosclerotic disease in adults; with evidence for the extent and importance of identified risk factors in the young, the time for primary prevention beginning in childhood has come.

	Selected Readings by Subject

Top Introduction Selected Readings by Subject

 
I. Pathological Evidence for Risk Factor Impact in the Young

1. Relationship of atherosclerosis in young men to serum lipoprotein cholesterol concentrations and smoking: a preliminary report from the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. JAMA. 1990;264:3018–3024.
   
2. McGill HC Jr, McMahan CA, Zieske AW, et al. Effects of nonlipid risk factors on atherosclerosis in youth with a favorable lipoprotein profile. Circulation. 2001;103:1546–1550.
   
3. Newman WP 3rd, Freedman DS, Voors AW, et al. Relation of serum lipoprotein levels and systolic blood pressure to early atherosclerosis: the Bogalusa Heart Study. N Engl J Med. 1986;314:138–144.
   
4. Berenson GS, Srinivasan SR, Bao W, et al. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults: the Bogalusa Heart Study. N Engl J Med. 1998;338:1650–1656.
   
5. Mahoney LT, Burns TL, Stanford W, et al. Coronary risk factors measured in childhood and young adult life are associated with coronary artery calcification in young adults: the Muscatine Study. J Am Coll Cardiol. 1996;27:277–284.
   

II. Prevalence of Obesity/Type 2 Diabetes Mellitus

1. Luepker RV, Jacobs DR, Prineas RJ, et al. Secular trends of blood pressure and body size in a multi-ethnic adolescent population: 1986 to 1996. J Pediatr. 1999;134:668–674.
   
2. Morrison JA, James FW, Sprecher DL, et al. Sex and race differences in cardiovascular disease risk factor changes in schoolchildren, 1975–1990: the Princeton School Study. Am J Public Health. 1999;89:1708–1714.
   
3. Troiano RP, Flegal KM, Kuczmarski RJ, et al. Overweight prevalence and trends for children and adolescents: the National Health and Nutrition Examination Surveys, 1963 to 1991. Arch Pediatr Adolesc Med. 1995;149:1085–1091.
   
4. Pinhas-Hamiel O, Dolan LM, Daniels SR, et al. Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. J Pediatr. 1996;128(5 Pt 1):608–615.
   
5. Fagot-Campagna A, Pettitt DJ, Engelgau MM, et al. Type 2 diabetes among North American children and adolescents: an epidemiologic review and a public health perspective. J Pediatr. 2000;136:664–672.
   

III. Tracking of Risk Factors From Childhood Into Adult Life

1. Lauer RM, Lee J, Clarke WR. Factors affecting the relationship between childhood and adult cholesterol level: the Muscatine Study. Pediatrics. 1988;82:309–318.
   
2. Lauer RM, Clarke WR. Childhood risk factors for high adult blood pressure: the Muscatine Study. Pediatrics. 1989;84;633–641.
   
3. Whitaker RC, Wright JA, Pepe MS, et al. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;337:869–873.
   

IV. Acquisition of Risk Behaviors in Childhood

1. Oliveria SA, Ellison RC, Moore LL, et al. Parent-child relationships in nutrient intake: the Framingham Children’s Study. Am J Clin Nutr. 1992;56:593–598.
   
2. Feunekes GI, de Graaf C, Meyboom S, et al. Food choice and fat intake of adolescents and adults: associations of intakes within social networks. Prev Med. 1998;27(5 Pt 1):645–656.
   
3. Janz KF, Dawson JD, Mahoney LT. Tracking physical fitness and physical activity from childhood to adolescence: the Muscatine study. Med Sci Sports Exerc. 2000;32:1250–1257.
   
4. Powell KE, Dysinger W. Childhood participation in organized school sports and physical education as precursors of adult physical activity. Am J Prev Med. 1987;3:276–281.
   
5. Rojas NL, Killen JD, Haydel KF, et al. Nicotine dependence among adolescent smokers. Arch Pediatr Adolesc Med. 1998;152:151–156.
   

V. Intervention Trials

1. Obarzanek E, Kimm SY, Barton BA, et al. Long-term safety and efficacy of a cholesterol-lowering diet in children with elevated low-density lipoprotein cholesterol: seven-year results of the Dietary Intervention Study in Children (DISC). Pediatrics. 2001;107:256–264.
   
2. Flynn BS, Warden JK, Secker-Walker R. Cigarette smoking prevention: effects of mass media and school interventions targeted to gender and age groups. J Health Educ. 1995;26:545–551.
   
3. Luepker RV, Perry CL, McKinlay SM, et al. Outcomes of a field trial to improve children’s dietary patterns and physical activity: the Child and Adolescent Trial for Cardiovascular Health. CATCH collaborative group. JAMA. 1996;275:768–776.
   
4. Sallis JF, McKenzie TL, Alcaraz JE, et al. The effects of a 2-year physical education program (SPARK) on physical activity and fitness in elementary school students. Sports, Play and Active Recreation for Kids. Am J Public Health. 1997;87:1328–1334.
   

VI. Pediatric Consensus Statements

1. American Academy of Pediatrics. National Cholesterol Education Program: Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Pediatrics. 1992;89(3 Pt 2):525–584.
   
2. National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents. Update on the 1987 Task Force Report on High Blood Pressure in Children and Adolescents: a working group report from the National High Blood Pressure Education Program. Pediatrics. 1996;98(4 Pt 1):649–658.
   
3. Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert Committee recommendations. The Maternal and Child Health Bureau, Health Resources and Services Administration and the Department of Health and Human Services. Pediatrics. 1998;102:E29.
   
4. American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care. 2000;23:381–389.
   
5. American Academy of Pediatrics, Committee on Public Education. Media education. Pediatrics. 1999;104(2 Pt 1):341–343.
   
6. Cavill N, Biddle S, Sallis JF. Health enhancing physical activity for young people: statement of the United Kingdom expert consensus conference. Pediatr Exerc Sci. 2001;13:12–25.
   
7. Williams CL, Hayman LL, Daniels SR, et al. Cardiovascular health in childhood: a statement for health professionals from the Committee on Atherosclerosis, Hypertension, and Obesity in the Young (AHOY) of the Council on Cardiovascular Disease in the Young, American Heart Association. Circulation. 2002;106:143–160. [Erratum Circulation. 2002;106:1178.]
   

	Footnotes

 
The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement has been co-published in the April 2003 issue of The Journal of Pediatrics.

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on November 4, 2002. A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0248. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 410-528-4426, fax 410-528-4264, or e-mail klbradle@lww.com. To make photocopies for personal or educational use, call the Copyright Clearance Center, 978-750-8400.

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kavey, R.-E. W. Articles by Taubert, K. Search for Related Content PubMed PubMed Citation Articles by Kavey, R.-E. W. Articles by Taubert, K. Related Collections Primary prevention Pathophysiology Risk Factors