Pediatric Prevention of Atherosclerotic Cardiovascular Disease
Ronald M. Lauer, MD; Trudy L. Burns, MPH, PhD; Steven R. Daniels, MD, PhD; eds
378 pages. New York, NY: Oxford University Press; 2006. $69.95. ISBN: 9780195150650
Atherosclerotic cardiovascular disease is the most common cause of premature death in the United States. Although a great deal of interest and attention has been paid to the epidemiology and study of risk factors for atherosclerosis in adult populations, the risk factors for cardiovascular disease (eg, smoking, systemic hypertension, obesity, diabetes mellitus) can start during adolescence as well as in childhood, and the medical community must accept that heart disease does, in fact, begin at birth. Genetic predisposition occurs in virtually all disorders with phenotypic expression based on environmental factors. For the health of our nation, and for the health of the world, we need to turn our attention to preventing cardiovascular disease before adulthood, when atherosclerosis may no longer be amenable to therapy. This book has been written for physicians and all healthcare professionals who practice preventive cardiology in children, adolescents, and young adults. It is also useful for school nurses and school administrators, as well as for epidemiologists focusing on public health. However, for reasons that remain unclear, preventive medicine has never been given the attention it needs, particularly in children; far more studies focus on unraveling the pathobiology of specific diseases to understand what leads to the diseases and to develop therapeutic approaches to treat the diseases. However, prevention of disease, if possible, would be preferable. This book reviews cholesterol, blood pressure, body size, and tobacco use in childhood and adolescence—that is, risk factors for obesity, diabetes, coronary artery calcification, and increased carotid artery intimal–medial thickness. Given that all of these risk factors for atherosclerosis are interrelated, if we take obesity as an example of one significant risk factor, more than 65% of the adults in the United States are overweight, with more than 30% obese. Obesity begins in childhood, and it must be recognized and dealt with during childhood if we want to decrease these numbers in adulthood. More than 15% of children in the United States are overweight, with another 30% of children and adolescents considered at risk of becoming overweight. Overweight adolescents have a 70% chance of becoming overweight adults. This increases to 80% if one or both parents are overweight or obese. More than 30% of male and more than 25% of female students in high school report current tobacco use, and approximately 80% of people who have used tobacco begin before age 18; the most common age of initiation is 14 or 15 years. All of these risk factors begin in childhood.
In addition to genetic and environmental factors, gene–environment interaction effects also come into play in the development of atherosclerotic cardiovascular disease. Whether we are speaking about coronary heart disease, peripheral vascular disease, or stroke, the harbingers of these diseases all begin early in life. Unfortunately, when pediatricians and pediatric cardiologists are asked about heart disease in children, they think about congenital heart disease. And although congenital heart disease is associated with the highest mortality of any congenital defect, only 0.4% of deaths in the United States from cardiovascular diseases are caused by congenital cardiovascular defects, with 54% caused by coronary heart disease, 18% caused by stroke, 6% caused by congestive heart failure, and 5% attributable to high blood pressure. High cholesterol, high blood pressure, diabetes, obesity, and smoking are predictive of cardiovascular disease with increased morbidity and mortality. Although few studies have followed children with these risk factors into adulthood, studies are now examining the relationships between these risk factors in childhood and surrogate markers (eg, coronary artery calcification or carotid artery intimal–medial thickness) to predict cardiovascular risk for these children when they reach adulthood.
This book combines epidemiology and pathobiology. The epidemiology provides the basis for clinical practice recommendations with regard to screening and treating as well as counseling children and their parents on the consequences of obesity, smoking, diabetes, systemic hypertension, and high cholesterol. The most recent recommendations from the American Academy of Pediatrics, the American Heart Association, and the national high blood pressure education program, as well as the national cholesterol education program, are based on the results of the epidemiological studies. The book is divided into sections on a variety of topics: origins of cardiovascular disease; measures of the atherosclerotic process in children and young adults; cholesterol, blood pressure, obesity, and diabetes in childhood and adolescence; smoking prevention and cessation among youth; and promotion of health in the school setting. Whether a reader is drawn to a particular chapter or reads the entire book, this book emphasizes that atherosclerosis begins in childhood and that the risk factors for coronary heart disease are not only present in youth but also influence the development of atherosclerosis. This book should be mandatory for pediatricians in practice, nurses and nurse practitioners who work in pediatricians’ offices, and school nurses. Both the science and application of pediatric preventive cardiology are clearly and succinctly presented. Reading the entire book may be most useful, because of the book’s organization, but whether the reader is a pediatrician in private practice, a pediatric cardiologist in a tertiary medical center, or a school nurse, each will be able to easily find the data and answers to questions they may have on how to approach pediatric prevention of atherosclerotic cardiovascular disease in this well-written book.
Although controlled clinical trials have not demonstrated that risk-factor modification in children and adolescents reduces the probability of clinically manifest coronary heart disease and results in regression of coronary artery atherosclerosis (as has been demonstrated in adult populations), it may be necessary to draw conclusions on observational data in pediatrics, as long as this does not result in adverse effects, because all evidence to date demonstrates that decreasing the risks of diabetes, systemic hypertension, lung cancer, chronic obstructive pulmonary disease due to obesity, and tobacco use all decrease the risk of cardiovascular disease. It is hard enough to convince children and adolescents that their behavior during childhood will result in early death as adults. Children, particularly adolescents, have always (and probably always will) considered themselves invincible. The first step to decreasing cardiovascular disease in our children as they approach adulthood must begin by decreasing these risk factors that can begin in childhood. In busy pediatric practices and in schools with fewer available resources, it is more and more difficult to work with our children on good dietary habits, increasing physical activity, and avoiding smoking. But without this, we will not be successful in decreasing the incidence and prevalence of cardiovascular disease in adults. Our children are our future, and they deserve more time and attention to preventing cardiovascular disease.