Published online before print February 16, 2009, doi: 10.1161/CIRCULATIONAHA.108.816769
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
(Circulation. 2009;119:1108-1115.)
© 2009 American Heart Association, Inc.
Pediatric Cardiology |
Concentrations of Low-Density Lipoprotein Cholesterol and Total Cholesterol Among Children and Adolescents in the United States
From the Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Ga.
Correspondence to Earl Ford, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS K66, Atlanta, GA 30341. E-mail eford{at}cdc.gov
Received August 22, 2008; accepted November 24, 2008.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Background— Recently, the American Academy of Pediatrics updated guidance on lipid screening in childhood. Our objective was to examine recent distributions in concentrations of total cholesterol and low-density lipoprotein cholesterol among US children and adolescents and to estimate the prevalence of adolescents who are potentially eligible for pharmacological treatment for elevated concentrations of low-density lipoprotein cholesterol.
Methods and Results— We used data from the National Health and Nutrition Examination Survey 1999 to 2006 for participants 6 to 17 years of age. The mean concentration for low-density lipoprotein cholesterol for participants 12 to 17 years of age was 90.2 mg/dL (n=2724), and the mean concentration of total cholesterol among participants 6 to 17 years of age was 163.0 mg/dL (n=9868). Depending on the cut points used, an elevated concentration of low-density lipoprotein cholesterol was noted for 5.2% to 6.6% of participants and an elevated concentration of total cholesterol for 9.6% to 10.7%. Approximately 0.8% of adolescents 12 to 17 years of age were potentially eligible for pharmacological treatment for elevated concentrations of low-density lipoprotein cholesterol.
Conclusion— Given current guidelines, only a small percentage of US adolescents may need pharmacological treatment for elevated concentrations of low-density lipoprotein cholesterol.
Key Words: cholesterol • epidemiology • lipids • pediatrics • prevention
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
The roots of coronary heart disease herald back to childhood. Autopsy studies have demonstrated the presence of early lesions of coronary heart disease in the heart vessels of children and adolescents.1 Furthermore, the presence of these changes correlated with known risk factors for cardiovascular disease, including concentrations of low-density lipoprotein cholesterol and total cholesterol.2,3 In addition, concentrations of low-density lipoprotein cholesterol predict subclinical atherosclerosis as determined by carotid intima-media thickness in adults.4,5 In recognition of the role of dyslipidemia in the early genesis of coronary heart disease, the American Academy of Pediatrics (AAP) recently released a report on lipid screening in childhood.6
Editorial p 1075
Clinical Perspective p 1115
In that report, thresholds for defining hypercholesterolemia and elevated low-density lipoprotein cholesterol were summarized. One set of values were derived from a report from the National Cholesterol Education Program (NCEP) in 1992. Another set of values were derived from data from the Lipid Research Clinics Prevalence Study. Previous publications have provided important information about lipid concentrations in children and adolescents.7–14 However, much of that information is >10 years old. Therefore, our objective was to provide updated information about concentrations of low-density lipoprotein cholesterol and total cholesterol in children and adolescents in the United States.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
We used data from the National Health and Nutrition Examination Survey (NHANES) 1999 to 2006. During each consecutive 2-year cycle from 1999 through 2006, a national sample was recruited using a multistage, stratified sampling design. The surveys were designed to produce results representative of the civilian, noninstitutionalized US population. Participants were interviewed at home and were invited to attend a mobile examination center, where they were asked to complete additional questionnaires, undergo various examinations, and provide a blood sample. The surveys received human subject approval. Parental permission to allow a child to participate in the survey was obtained, as well as assent from children and adolescents 7 to 17 years of age. Participants
18 years of age were asked to sign an informed consent form. Details about the survey may be found elsewhere.15
Measurements of concentrations of total serum cholesterol were conducted for participants 3 years of age for NHANES 1999 to 2004 and for participants 6 years of age for NHANES 2005 to 2006. For analyses involving concentrations of total cholesterol, we included all participants who had a measurement regardless of fasting status. Measurements of fasting serum concentrations of low-density lipoprotein cholesterol were calculated with the Friedewald equation for participants 12 years of age who attended the morning examination if their concentrations of triglycerides were <400 mg/dL.
Detailed descriptions about blood collection and processing are provided in the NHANES Laboratory/Medical Technologists Procedures Manual. Specimens were stored at –20°C and shipped weekly to the Lipoprotein Analytical Laboratory at Johns Hopkins University Hospital. This laboratory participates in the Lipid Standardization Program of the Centers for Disease Control and Prevention. From 1999 through 2005, serum cholesterol was measured enzymatically on a Hitachi 717 Analyzer (Roche Diagnostics, Indianapolis, Ind) with commercial reagents. In 2006, serum cholesterol was measured enzymatically on a Hitachi 912 Analyzer. We used the 2 approaches presented in the AAP guidelines to define elevated concentrations of low-density lipoprotein cholesterol and total cholesterol: (1) cut points from guidelines of the NCEP in 199216 and (2) cut points derived from data from the Lipid Research Clinics Pediatric Prevalence Study.6 The cut points based on the NECP guidelines are 200 mg/dL for total cholesterol and 130 mg/dL for low-density lipoprotein cholesterol. The cut points for abnormal concentrations of total cholesterol based on the 95th percentile in the Lipid Research Clinics Prevalence Study are 201 mg/dL for boys 10 to 14 years of age, 191 mg/dL for boys 15 to 19 years of age, 205 mg/dL for girls 10 to 14 years of age, and 208 mg/dL for girls 15 to 19 years of age. The cut points for low-density lipoprotein cholesterol are 133, 130, 136, and 137 mg/dL for the 4 groups, respectively.
During 1999 to 2002, concentrations of high-density lipoprotein cholesterol were measured by both the heparin-manganese precipitation method and the direct immunoassay method. A change in the method for measuring concentrations of high-density lipoprotein cholesterol took place in 2003 when, from then on, concentrations of high-density lipoprotein cholesterol were measured only with the direct immunoassay method.17 Concurrent with this change in methods, measurements of concentrations of high-density lipoprotein cholesterol were higher for the period of 2003 to 2006 than for the period of 1999 to 2002. Because concentrations of low-density lipoprotein cholesterol were calculated, the upward bias in concentrations of high-density lipoprotein cholesterol may have resulted in a slight lowering of the calculated values for low-density lipoprotein cholesterol for the period of 2003 to 2006 compared with the period of 1999 to 2002.
Using the approach presented in the AAP report, we estimated the percentage of adolescents 12 to 17 years of age whose elevated concentration of low-density lipoprotein cholesterol potentially qualified them for pharmacological treatment.6 The AAP uses 3 thresholds for elevated concentrations of low-density lipoprotein cholesterol to determine the need for pharmacological management of the dyslipidemia. If a patient does not have a risk factor (obesity, hypertension, cigarette smoking, family history of premature cardiovascular disease, or diabetes mellitus), pharmacological management can be considered when concentrations of low-density lipoprotein cholesterol exceed 190 mg/dL. In the presence of risk factors (obesity, hypertension, cigarette smoking, or family history of premature cardiovascular disease), pharmacological management can be considered when concentrations of low-density lipoprotein cholesterol exceed 160 mg/dL. In the presence of diabetes mellitus, pharmacological management can be considered when concentrations of low-density lipoprotein cholesterol equal or exceed 130 mg/dL.
Obesity was defined as a body mass index 95th percentile determined from the 2000 Centers for Disease Control and Prevention Growth Charts.18 The recommendations of the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents were used to define hypertension.19 Concentrations of cotinine were used to establish smoking status. A concentration >10 ng/mL was considered smoking.20 Participants who had a fasting plasma concentration of glucose 126 mg/dL or reported using insulin or oral hypoglycemic agents were classified as having diabetes. Demographic covariates included in the analyses were age, sex, race, or ethnicity (white, black, Mexican American, other).
The main analyses include data from NHANES 1999 to 2006. Generally, analyses involving low-density lipoprotein cholesterol were limited to participants 12 to 17 years of age and analyses involving total cholesterol to those 6 to 17 years of age. In addition, we analyzed data for NHANES 1999 to 2004 to provide estimates of mean concentrations of total cholesterol for participants as young as 3 years of age and as old as 19 years of age and to make comparisons with previously published information concerning concentrations of total cholesterol and low-density lipoprotein cholesterol from NHANES III (1988 to 1994). We calculated means and percentages with elevated concentrations of lipids. For race- or ethnic-specific estimates, we present results for only the 3 major groups (whites, blacks, Mexican Americans). Differences in proportions and means were tested with 
2 tests and t tests, respectively. Multiple linear regression analysis was conducted to examine the statistical significance of the effects of age, gender, and ethnicity on concentrations of lipids. Log-binomial regression analysis was used to examine the effects of age, gender, and ethnicity on the prevalence of elevated concentrations of lipids. In regression models, age was treated a continuous variable for analyses involving participants 12 to 17 years of age and was dichotomized for analyses involving participants 6 to 17 years of age (6 to 11 and 12 to 17 years of age). Software for the Statistical Analysis of Correlated Data (SUDAAN) was used for the analyses to account for the complex sampling design.
The authors had full access to and take full responsibility for the integrity of the data. All authors have read and agree to the manuscript as written.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Of the 7180 participants 12 to 17 years of age who participated in NHANES 1999 to 2006, 2778 were part of the fasting subsample. Values of low-density lipoprotein cholesterol were available for 2724 of them. Participants with a value for low-density lipoprotein cholesterol were 0.7 years younger (P=0.048). However, no significant differences in the percentage of participants who were male or white were present. Of the 11714 participants 6 to 17 years of age who attended the mobile examination center, 9868 had a value for total cholesterol. Participants with a value for total cholesterol were 1.3 years older (P<0.001). However, no significant differences in the percentage of participants who were male or white were present.
The mean concentration of low-density lipoprotein cholesterol among adolescents 12 to 17 years of age was 90.2 mg/dL (Table 1). The results of a multiple linear regression model that included age, gender, ethnicity, and survey cycle showed that none of the demographic variables were significant predictors of concentrations of low-density lipoprotein cholesterol.
|
The mean concentration of total cholesterol among children and adolescents 6 to 17 years of age was 163.0 mg/dL. Results from the multiple linear regression analysis indicated that concentrations of total cholesterol were 6.2 mg/dL lower among participants 12 to 17 years of age than among those 6 to 11 years of age (P<0.001) and 3.6 mg/dL higher among girls than boys (P<0.001). Furthermore, concentrations of total cholesterol were 2.6 mg/dL higher among blacks than whites (P=0.006) and 1.9 mg/dL lower among Mexican Americans than whites (P=0.022). Mean concentrations of total cholesterol plotted by individual year of age for boys and girls participating in NHANES 1999 to 2004 suggest that the higher concentrations among girls start to emerge around 14 years of age (Figure).
|
Percentiles for the concentrations of low-density lipoprotein cholesterol by demographic variables are shown in Table 2, and percentiles for adolescents with a body mass index <85th percentile are shown in Table 3. Among participants with a body mass index <85th percentile, the median concentration of low-density lipoprotein cholesterol was 
3 mg/dL lower than the median for all participants.
|
|
When Lipid Research Clinics Prevalence Study cut points were used, 5.2% of adolescents 12 to 17 years of age had an elevated concentration of low-density lipoprotein cholesterol, and 10.7% of participants 6 to 17 years of age had hypercholesterolemia (Table 4). The results of the log-binomial analysis that included age, gender, ethnicity, and survey cycle showed no significant effects of the demographic variables on elevated concentrations of low-density lipoprotein cholesterol.
|
Compared with participants 6 to 11 years of age, participants 12 to 17 years of age had a lower prevalence of hypercholesterolemia (P<0.001). The prevalence of hypercholesterolemia was higher among boys than girls (P=0.009) and higher among blacks than whites (P=0.026).
The use of the NCEP cut points resulted in a somewhat higher prevalence of elevated concentrations of low-density lipoprotein cholesterol but a slightly lower prevalence of hypercholesterolemia (Table 5). Whereas the analyses based on the Lipid Research Clinics Prevalence Study cut points resulted in a higher prevalence of elevated concentrations of total cholesterol for boys than girls, the analyses based on the NCEP cut points yielded the opposite pattern. No statistically significant age, gender, or ethnic differences in the prevalence of elevated concentrations of low-density lipoprotein cholesterol were found.
|
With respect to hypercholesterolemia, participants 12 to 17 years of age had a lower prevalence (P=0.024) than those 6 to 11 years of age. Blacks had a higher prevalence than whites (P=0.016). No statistically significant differences were noted between boys and girls.
Using the recommendations for pharmacological treatment of elevated concentrations of low-density lipoprotein cholesterol issued by the AAP, we found that 0.8% of adolescents 12 to 17 years of age were eligible for treatment. Because of the small magnitude of these percentages, detailed analyses for possible determinants were not feasible. Of the 26 adolescents who qualified for pharmacological treatment, 11 had a concentration >190 mg/dL (4 also had at least 1 risk factor, and 1 participant had a risk factor and diabetes), and 15 had at least 1 risk factor and a concentration >160 mg/dL. Only 1 participant 16 years of age reported using a cholesterol-lowering medication, in this case cholestyramine.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
The recent lipid screening recommendations issued by the AAP have drawn new attention to the importance of healthy lipid concentrations in children and adolescents. Our analysis of recent national data from the United States indicates that, depending on the cut points used, 5.2% to 6.6% of adolescents 12 to 17 years of age had elevated concentrations of low-density lipoprotein cholesterol. Furthermore, 0.8% of such adolescents would qualify for lipid-lowering treatment based on the AAP guidelines.
Although the difference in age groups limits the possible comparisons, the 50th, 75th, 90th, and 95th percentiles for low-density lipoprotein cholesterol from the Lipid Research Clinic Pediatric Prevalence Study for adolescents 15 to 19 years of age were 93, 109, 123, and 130 mg/dL, respectively, for boys and 93, 110, 129, and 137 mg/dL, respectively, for girls. In comparison, the percentiles calculated with NHANES 1999 to 2006 data for boys 15 to 19 years of age were 88, 106, 124, and 138 mg/dL, respectively, and those for girls 15 to 19 years of age were 92, 109, 127, and 137 mg/dL, respectively. Thus, the percentiles for girls are in close agreement between the 2 sets of data, whereas those for boys differ somewhat. Limiting the analysis to those who were not overweight or obese reduced the NHANES medians by a few milligrams per deciliter. NHANES data have demonstrated clear decreases in concentrations of total cholesterol among adolescents 12 to 17 years of age in the United States from 1966 to 1970 to 1988 to 1994.13 During this same period, marked increases in childhood obesity occurred in the United States. An unfavorable effect of obesity on concentrations of lipids in children has been demonstrated.21 Beside the possible effects of temporal trends, differences in characteristics of the study populations and laboratory methods further complicate comparisons between the 2 sets of data.
Several major studies, including the Muscatine Study, Lipid Research Clinics Prevalence Study, Bogalusa Heart Study, and NHANES, have provided important information about concentrations of lipids in children and adolescents in the United States.7–14 These studies have yielded important information about age, gender, and ethnic differences in concentrations of lipids. In addition, critical insights into the tracking of concentrations of lipids have been gleaned from these studies.22–24 Data from NHANES III (1988 to 1994) provided some of the most detailed information about concentrations of lipids in children and adolescents in the United States.13 The authors provided means and various percentiles of lipid distributions but did not provide estimates of the prevalence of elevated concentrations of lipids. The 90th percentile for participants 4 to 19 years of age in that survey was 200 mg/dL, which is the same as in NHANES 1999 to 2004. Consistent with the findings from NHANES III, we also observed that concentrations of total cholesterol peaked around 8 to 10 years of age. No age-related differences in concentrations of total cholesterol were reported from the Muscatine Study.7 In NHANES III, concentrations of total cholesterol were higher in female than male participants.13 In addition, gender differences have been noted in other studies such as the Lipid Research Clinics Prevalence Study and the Child and Adolescent Trial for Cardiovascular Health11–13,25 but not in other studies.7,9
Our results showing that concentrations of total cholesterol were higher among black children and adolescents than white children and adolescents are consistent with the results from previous studies.8,13,25 In NHANES III, concentrations of total cholesterol were 6 mg/dL higher among black children and adolescents 4 to 19 years of age than white children and adolescents.13 Part of the higher concentrations of total cholesterol among blacks is attributable to the higher unadjusted mean concentrations of high-density lipoprotein cholesterol among blacks (56.1 mg/dL) than among whites (50.9 mg/dL) in NHANES 1999 to 2006.
Compared with results from NHANES III, concentrations of total cholesterol among children and adolescents 4 to 19 years of age were 1 mg/dL lower in NHANES 1999 to 2004 (NHANES III, 165 mg/dL [SE, 0.6 mg/dL]13; NHANES 1999 to 2004, 164 mg/dL [SE, 0.6 mg/dL]). For those 12 to 17 years of age, mean concentrations of total cholesterol were 160 mg/dL (SE, 1.1 mg/dL) in NHANES III and 161 mg/dL (SE, 0.7 mg/dL) in NHANES 1999 to 2004. Assuming that laboratory methods for determining concentrations of total cholesterol were reasonably consistent for the surveys,26 it appears that little change in mean concentrations of total cholesterol took place over a period of 10 to 11 years. This stands in contrast to the 7-mg/dL decline that occurred among adolescents 12 to 17 years of age from 1966 to 1970 to 1988 to 1994.
For participants 12 to 19 years of age, mean concentrations of low-density lipoprotein cholesterol were 95 mg/dL (SE, 1.6 mg/dL) in NHANES III13 and 94 mg/dL (SE, 0.8 mg/dL) in NHANES 1999 to 2004. For boys 12 to 19 years of age, mean concentrations were 91 mg/dL (SE, 2.1 mg/dL) in NHANES III and 94 mg/dL (SE, 1.3 mg/dL) in NHANES 1999 to 2004. For girls 12 to 19 years of age, mean concentrations were 99 mg/dL (SE, 2.4 mg/dL) in NHANES III and 93 mg/dL (SE, 1.0 mg/dL) in NHANES 1999 to 2004. Thus, little change in mean concentrations of low-density lipoprotein cholesterol occurred during the period covered by 2 surveys, although the data suggest that concentrations increased in boys and decreased in girls.
Because information about a family history of cardiovascular disease was not collected for participants <20 years of age, we were unable to estimate precisely the prevalence of children and adolescents who were potentially eligible for pharmacological treatment. Although our estimate of 0.8% is an underestimate as a result, it is not likely to be substantially higher. In addition, larger sample sizes would have allowed more detailed analyses of lipid concentrations by combinations of demographic variables.
About 5.2% to 6.6% of adolescents 12 to 17 years of age had elevated concentrations of low-density lipoprotein cholesterol, and 9.6% to 10.7% of children and adolescents 6 to 17 years of age had elevated concentrations of total cholesterol. An estimated 0.8% of children and adolescents 12 to 17 years of age qualified for pharmacological treatment to lower concentrations of low-density lipoprotein cholesterol. According to population projections for the US population in 2008, 25 million people were 12 to 17 years of age. Thus, a percentage of 0.8% of adolescents who might be eligible for pharmacological treatment would represent 200 000 adolescents 12 to 17 years of age. NHANES data from 1999 to 2006 provide an updated picture of the state of affairs regarding concentrations of low-density lipoprotein cholesterol and total cholesterol in children and adolescents in the United States and the size of the potential pool of children and adolescents who may be eligible for pharmacological treatment for elevated concentrations of low-density lipoprotein cholesterol.
|
Acknowledgments |
|---|
Disclosures
None.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
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, Malcom GT, Oalmann MC, Strong JP. Effects of serum lipoproteins and smoking on atherosclerosis in young men and women: the PDAY Research Group: Pathobiological Determinants of Atherosclerosis in Youth. Arterioscler Thromb Vasc Biol. 1997; 17: 95–106.
3. Berenson GS, Srinivasan SR, Bao W, Newman WP III, Tracy RE, Wattigney WA. 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.
4. Raitakari OT, Juonala M, Kahonen M, Taittonen L, Laitinen T, Maki-Torkko N, Jarvisalo MJ, Uhari M, Jokinen E, Ronnemaa T, Akerblom HK, Viikari JS. Cardiovascular risk factors in childhood and carotid artery intima-media thickness in adulthood: the Cardiovascular Risk in Young Finns Study. JAMA. 2003; 290: 2277–2283.
5. Frontini MG, Srinivasan SR, Xu J, Tang R, Bond MG, Berenson GS. Usefulness of childhood non-high density lipoprotein cholesterol levels versus other lipoprotein measures in predicting adult subclinical atherosclerosis: the Bogalusa Heart Study. Pediatrics. 2008; 121: 924–929.
6. Daniels SR, Greer FR. Lipid screening and cardiovascular health in childhood. Pediatrics. 2008; 122: 198–208.
7. Lauer RM, Connor WE, Leaverton PE, Reiter MA, Clarke WR. Coronary heart disease risk factors in school children: the Muscatine study. J Pediatr. 1975; 86: 697–706.[CrossRef][Medline] [Order article via Infotrieve]
8. Frerichs RR, Srinivasan SR, Webber LS, Berenson GR. Serum cholesterol and triglyceride levels in 3,446 children from a biracial community: the Bogalusa Heart Study. Circulation. 1976; 54: 302–309.
9. Srinivasan SR, Frerichs RR, Webber LS, Berenson GS. Serum lipoprotein profile in children from a biracial community: the Bogalusa Heart Study. Circulation. 1976; 54: 309–318.
10. Morrison JA, Degroot I, Kelly KA, Edwards BK, Mellies MJ, Tillett S, Khoury P, Glueck CJ. High and low density lipoprotein cholesterol levels in hypercholesterolemic school children. Lipids. 1979; 14: 99–104.[CrossRef][Medline] [Order article via Infotrieve]
11. Plasma lipid distributions in selected North American populations: the Lipid Research Clinics Program Prevalence Study: the Lipid Research Clinics Program Epidemiology Committee. Circulation. 1979; 60: 427–439.
12. Tamir I, Heiss G, Glueck CJ, Christensen B, Kwiterovich P, Rifkind BM. Lipid and lipoprotein distributions in white children ages 6–19 yr: the Lipid Research Clinics Program Prevalence Study. J Chronic Dis. 1981; 34: 27–39.[CrossRef][Medline] [Order article via Infotrieve]
13. Hickman TB, Briefel RR, Carroll MD, Rifkind BM, Cleeman JI, Maurer KR, Johnson CL. Distributions and trends of serum lipid levels among United States children and adolescents ages 4–19 years: data from the Third National Health and Nutrition Examination Survey. Prev Med. 1998; 27: 879–890.[CrossRef][Medline] [Order article via Infotrieve]
14. Ford ES, Mokdad AH, Ajani UA. Trends in risk factors for cardiovascular disease among children and adolescents in the United States. Pediatrics. 2004; 114: 1534–1544.
15. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey. Available at: http://www.cdc.gov/nchs/about/major/nhanes/datalink.htm.
16. American Academy of Pediatrics. National Cholesterol Education Program: report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Pediatrics. 1992; 89: 525–584.
17. Centers for Disease Control and Prevention. MEC laboratory component: total cholesterol and HDL-cholesterol: survey years: 2003 to 2004. Available at: http://www.cdc.gov/nchs/data/nhanes/nhanes_03_04/l13_c.pdf. Accessed July 16, 2008.
18. Centers for Disease Control and Prevention. 2000 CDC growth charts: United States. Available at: http://www.cdc.gov/GROWTHCHARTS/. Accessed July 15, 2008.
19. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004; 114: 555–576.
20. Pirkle JL, Bernert JT, Caudill SP, Sosnoff CS, Pechacek TF. Trends in the exposure of nonsmokers in the U.S. population to secondhand smoke: 1988–2002. Environ Health Perspect. 2006; 114: 853–858.[Medline] [Order article via Infotrieve]
21. Gidding SS, Bao W, Srinivasan SR, Berenson GS. Effects of secular trends in obesity on coronary risk factors in children: the Bogalusa Heart Study. J Pediatr. 1995; 127: 868–874.[CrossRef][Medline] [Order article via Infotrieve]
22. Freedman DS, Srinivasan SR, Cresanta JL, Webber LS, Berenson GS. Cardiovascular risk factors from birth to 7 years of age: the Bogalusa Heart Study: serum lipids and lipoproteins. Pediatrics. 1987; 80: 789–796.
23. Webber LS, Srinivasan SR, Wattigney WA, Berenson GS. Tracking of serum lipids and lipoproteins from childhood to adulthood: the Bogalusa Heart Study. Am J Epidemiol. 1991; 133: 884–899.
24. Kelder SH, Osganian SK, Feldman HA, Webber LS, Parcel GS, Leupker RV, Wu MC, Nader PR. Tracking of physical and physiological risk variables among ethnic subgroups from third to eighth grade: the Child and Adolescent Trial for Cardiovascular Health cohort study. Prev Med. 2002; 34: 324–333.[CrossRef][Medline] [Order article via Infotrieve]
25. Webber LS, Osganian V, Luepker RV, Feldman HA, Stone EJ, Elder JP, Perry CL, Nader PR, Parcel GS, Broyles SL. Cardiovascular risk factors among third grade children in four regions of the United States: the CATCH Study: Child and Adolescent Trial for Cardiovascular Health. Am J Epidemiol. 1995; 141: 428–439.
26. Carroll MD, Lacher DA, Sorlie PD, Cleeman JI, Gordon DJ, Wolz M, Grundy SM, Johnson CL. Trends in serum lipids and lipoproteins of adults, 1960–2002. JAMA. 2005; 294: 1773–1781.
|
Footnotes |
|---|
The findings and conclusions in this article are those of the authors and do not represent the official position of the Centers for Disease Control and Prevention.
Related Article:
Circulation 2009 119: 1067-1068.
This article has been cited by other articles:
 |
|
 |
|
  S. Cook Hypercholesterolemia Among Children: When Is It High, and When Is It Really High? Circulation, March 3, 2009; 119(8): 1075 - 1077. [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||