The Cardiovascular Impact of the Pediatric Obesity Epidemic: Is the Worst Yet to Come?
2011; Elsevier BV; Volume: 158; Issue: 5 Linguagem: Inglês
10.1016/j.jpeds.2010.12.013
ISSN1097-6833
Autores Tópico(s)Cardiovascular Disease and Adiposity
ResumoSee related article, p 709The prevalence of overweight and obesity in children and adolescents has increased substantially in the past several decades, with current estimates indicating that 31.9% of children and adolescents (2-19 years of age) in the United States are overweight and 17.1% are obese.1Ogden C.L. Carroll M.D. Flegal K.M. High body mass index for age among US children and adolescents, 2003-2006.JAMA. 2008; 299: 2401-2405Crossref PubMed Scopus (1454) Google Scholar, 2Hedley A.A. Ogden C.L. Johnson C.L. Carroll M.D. Curtin L.R. Flegal K.M. Prevalence of overweight and obesity among US children, adolescents and adults, 1999-2002.JAMA. 2004; 291: 2847-2850Crossref PubMed Scopus (3539) Google Scholar Recognized as a major risk factor for cardiovascular disease (CVD) in adulthood, obesity present in childhood and adolescence is associated with established risk factors for CVD and accelerated atherosclerotic processes, including elevated blood pressure, dyslipidemia, metabolic syndrome, and type 2 diabetes mellitus.3Freedman D.S. Mei Z. Srinivasan S.R. Berenson G.S. Dietz W.H. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study.J Pediatr. 2007; 150: 12-17Abstract Full Text Full Text PDF PubMed Scopus (1060) Google Scholar, 4Daniels S.R. The consequences of childhood overweight and obesity.Future Child. 2006; 16: 47-67Crossref PubMed Scopus (615) Google Scholar, 5Weiss R. Dziura J. Bergent T.S. Tamborlane W.V. Taksali S.E. Yeckel C.W. et al.Obesity and the metabolic syndrome in children and adolescents.N Engl J Med. 2004; 350: 2362-2374Crossref PubMed Scopus (2627) Google Scholar, 6Pinhas-Hamiel O. Dolan L.M. Daniels S.R. Standiford D. Khoury P.R. Zeitler P. Increased incidence of non-insulin dependent diabetes mellitus among adolescents.J Pediatr. 1996; 128: 608-615Abstract Full Text PDF PubMed Scopus (939) Google Scholar Obesity in childhood and adolescence has also been associated with adverse changes in cardiac geometry, including increased left ventricular mass (LVM).7Urbina E.M. Gidding S.S. Bao W. Pickoff A.S. Berdusis K. Berenson G.S. Effect of body size, ponderosity, and blood pressure on left ventricular growth in children and young adults in the Bogalusa Heart Study.Circulation. 1995; 91: 2400-2406Crossref PubMed Scopus (213) Google Scholar, 8Li X. Li S. Ulusoy E. Chen W. Srinivasan S.R. Berenson G.S. Childhood adiposity as a predictor of cardiac mass in adulthood: the Bogalusa Heart Study.Circulation. 2004; 110: 3488-3492Crossref PubMed Scopus (163) Google Scholar Observations from the Bogalusa Heart Study,7Urbina E.M. Gidding S.S. Bao W. Pickoff A.S. Berdusis K. Berenson G.S. Effect of body size, ponderosity, and blood pressure on left ventricular growth in children and young adults in the Bogalusa Heart Study.Circulation. 1995; 91: 2400-2406Crossref PubMed Scopus (213) Google Scholar for example, have shown that change in weight (and blood pressure) during childhood is predictive of excess LVM in children and young adults and also have illustrated that obesity beginning in childhood is a consistent predictor of LVM in young adults.8Li X. Li S. Ulusoy E. Chen W. Srinivasan S.R. Berenson G.S. Childhood adiposity as a predictor of cardiac mass in adulthood: the Bogalusa Heart Study.Circulation. 2004; 110: 3488-3492Crossref PubMed Scopus (163) Google Scholar In this community-based, bi-racial (29% African-American) sample of 467 young adults (20-38 years of age) who had 6 assessments of cardiovascular risk factors from childhood to adulthood, adiposity (body mass index [BMI]) in childhood, adiposity and systolic blood pressure in adulthood, and the cumulative burden of adiposity and systolic blood pressure from childhood to adulthood were significant predictors of LVM (obtained with two-dimensional M-mode echocardiography) in adulthood.8Li X. Li S. Ulusoy E. Chen W. Srinivasan S.R. Berenson G.S. Childhood adiposity as a predictor of cardiac mass in adulthood: the Bogalusa Heart Study.Circulation. 2004; 110: 3488-3492Crossref PubMed Scopus (163) Google Scholar Increased LVM/left ventricular hypertrophy is a recognized independent predictor of cardiovascular morbidity and mortality.9Koren M.J. Devereux R.B. Casale P.N. Savage D.D. Laragh J.H. Relation of left ventricular mass and geometry to morbidity and mortality in uncomplicated essential hypertension.Ann Intern Med. 1991; 114: 345-352Crossref PubMed Scopus (2160) Google Scholar, 10Levy D. Garrison R.J. Savage D.D. Kannel W.B. Casteli W.P. Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study.N Engl J Med. 1990; 322: 1561-1566Crossref PubMed Scopus (4808) Google ScholarSubstantial evidence has accumulated in the past several decades linking obesity in childhood with a number of cardiovascular-related co-morbidities, including adverse changes in major risk factors for CVD and adverse changes in cardiac structure and function. In this issue of The Journal, Crowley et al11Crowley D.I. Khoury P.R. Urbina E.M. Ippisch H.M. Kimball T.R. Cardiovascular impact of pediatric obesity epidemic: higher left ventricular mass related to higher body mass index.J Pediatr. 2011; 158: 709-714Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar add to the evidence supporting the urgent need for prevention and management of obesity early in the life course. A major aim of their innovative study was to examine secular changes in BMI and LVM in today's healthy children compared with children from a generation ago. Considering the increase in prevalence of obesity in children and youth in the United States and the known positive association of obesity and LVM, Crowley et al hypothesized that indexed LVM would be higher in the current generation of children and youth and that this increased indexed LVM would be partially attributable to the increase in obesity (as measured with BMI) in the past two decades.11Crowley D.I. Khoury P.R. Urbina E.M. Ippisch H.M. Kimball T.R. Cardiovascular impact of pediatric obesity epidemic: higher left ventricular mass related to higher body mass index.J Pediatr. 2011; 158: 709-714Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar The sample consisted of 700 healthy patients 2 to 19 year of age who underwent echocardiography at a major academic medical center from 1986 to 1989 (n = 350; 60% male; 82% white) and in 2008 (n = 350; age- and sex-matched with 1986-1989 participants). Participants at both time points were healthy; patients were excluded when they had any heart disease or systemic disease that would impact cardiac structure, cardiac function, or both. Obesity (BMI <40 kg/m2) was not an exclusion criterion, however, because effects of obesity on cardiac geometry was viewed as the primary outcome.Particularly noteworthy results of this study include the observation that children today (2008) have significantly higher indexed LVM than their counterparts a generation ago (current: 32.7 ± 7.8 g/m2.7; earlier: 31.5 ± 8.1 g/m2.7) and that this increase is partially attributable to the increase in BMI. Crowley et al showed that the average weight in the current (2008) study group (41.3 ± 25.2 kg) was approximately 5 kg higher than in the earlier generation (36.5 ± 20.1 kg), with the average weight percentile 11% higher and the average BMI 1.8 kg/m2 higher in the current (2008) group. In stepwise regression analyses, era (current; earlier) was not a significant contributor to indexed LVM; BMI z-score, however, was a determinant of indexed LVM at both points, as was younger age, male sex, and African-American race. In addition, changes demonstrated in left ventricular dimensions in the current era translate to an average indexed LVM that is 1.2 kg/m2.7 higher and an average indexed LVM z-score that is 0.23 points higher than in the earlier era. As Crowley and co-authors note, in the absence of obesity and other adverse conditions, the average indexed LVM should be stable with time.11Crowley D.I. Khoury P.R. Urbina E.M. Ippisch H.M. Kimball T.R. Cardiovascular impact of pediatric obesity epidemic: higher left ventricular mass related to higher body mass index.J Pediatr. 2011; 158: 709-714Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar In adults, a common indexed LVM threshold value of 51 gm/m2.7 confers a substantial (4-fold) risk for cardiovascular events.12deSimone G. Devereux R.B. Daniels S.R. Koren M.J. Meyer R.A. Laragh J.H. Effect of growth on variability of left ventricular mass: assessment of allometric signals in adults and children and their capacity to predict cardiovascular risk.J Am Coll Cardiol. 1995; 25: 1056-1062Abstract Full Text PDF PubMed Scopus (772) Google Scholar Although such cut point data are not available for children and adolescents, it has been suggested that LVM, similar to other risk factors, be viewed and treated as a continuous variable because cardiovascular events do occur incrementally in relation to LVM.13Verdecchia P. Carini G. Circo A. Dovellini E. Giovannini E. Lombardo M. et al.Left ventricular mass and cardiovascular morbidity in essential hypertension: the MAVI study.J Am Coll Cardiol. 2001; 38: 1829-1835Abstract Full Text Full Text PDF PubMed Scopus (294) Google ScholarMethodological limitations notwithstanding, the results of this study add to the growing body of knowledge about the adverse cardiovascular impact of the pediatric obesity epidemic on today's children and support the urgent need for multilevel approaches to reversing the trend and evidence-based recommendations designed to inform and guide cardiac screening and follow-up in children and youth.14Hayman L.L. Meininger J.C. Daniels S.R. McCrindle B.W. Helden L. Ross J. et al.Primary prevention of cardiovascular disease in nursing practice: focus on children and youth.Circulation. 2007; 116: 344-357Crossref PubMed Scopus (127) Google Scholar See related article, p 709The prevalence of overweight and obesity in children and adolescents has increased substantially in the past several decades, with current estimates indicating that 31.9% of children and adolescents (2-19 years of age) in the United States are overweight and 17.1% are obese.1Ogden C.L. Carroll M.D. Flegal K.M. High body mass index for age among US children and adolescents, 2003-2006.JAMA. 2008; 299: 2401-2405Crossref PubMed Scopus (1454) Google Scholar, 2Hedley A.A. Ogden C.L. Johnson C.L. Carroll M.D. Curtin L.R. Flegal K.M. Prevalence of overweight and obesity among US children, adolescents and adults, 1999-2002.JAMA. 2004; 291: 2847-2850Crossref PubMed Scopus (3539) Google Scholar Recognized as a major risk factor for cardiovascular disease (CVD) in adulthood, obesity present in childhood and adolescence is associated with established risk factors for CVD and accelerated atherosclerotic processes, including elevated blood pressure, dyslipidemia, metabolic syndrome, and type 2 diabetes mellitus.3Freedman D.S. Mei Z. Srinivasan S.R. Berenson G.S. Dietz W.H. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study.J Pediatr. 2007; 150: 12-17Abstract Full Text Full Text PDF PubMed Scopus (1060) Google Scholar, 4Daniels S.R. The consequences of childhood overweight and obesity.Future Child. 2006; 16: 47-67Crossref PubMed Scopus (615) Google Scholar, 5Weiss R. Dziura J. Bergent T.S. Tamborlane W.V. Taksali S.E. Yeckel C.W. et al.Obesity and the metabolic syndrome in children and adolescents.N Engl J Med. 2004; 350: 2362-2374Crossref PubMed Scopus (2627) Google Scholar, 6Pinhas-Hamiel O. Dolan L.M. Daniels S.R. Standiford D. Khoury P.R. Zeitler P. Increased incidence of non-insulin dependent diabetes mellitus among adolescents.J Pediatr. 1996; 128: 608-615Abstract Full Text PDF PubMed Scopus (939) Google Scholar Obesity in childhood and adolescence has also been associated with adverse changes in cardiac geometry, including increased left ventricular mass (LVM).7Urbina E.M. Gidding S.S. Bao W. Pickoff A.S. Berdusis K. Berenson G.S. Effect of body size, ponderosity, and blood pressure on left ventricular growth in children and young adults in the Bogalusa Heart Study.Circulation. 1995; 91: 2400-2406Crossref PubMed Scopus (213) Google Scholar, 8Li X. Li S. Ulusoy E. Chen W. Srinivasan S.R. Berenson G.S. Childhood adiposity as a predictor of cardiac mass in adulthood: the Bogalusa Heart Study.Circulation. 2004; 110: 3488-3492Crossref PubMed Scopus (163) Google Scholar Observations from the Bogalusa Heart Study,7Urbina E.M. Gidding S.S. Bao W. Pickoff A.S. Berdusis K. Berenson G.S. Effect of body size, ponderosity, and blood pressure on left ventricular growth in children and young adults in the Bogalusa Heart Study.Circulation. 1995; 91: 2400-2406Crossref PubMed Scopus (213) Google Scholar for example, have shown that change in weight (and blood pressure) during childhood is predictive of excess LVM in children and young adults and also have illustrated that obesity beginning in childhood is a consistent predictor of LVM in young adults.8Li X. Li S. Ulusoy E. Chen W. Srinivasan S.R. Berenson G.S. Childhood adiposity as a predictor of cardiac mass in adulthood: the Bogalusa Heart Study.Circulation. 2004; 110: 3488-3492Crossref PubMed Scopus (163) Google Scholar In this community-based, bi-racial (29% African-American) sample of 467 young adults (20-38 years of age) who had 6 assessments of cardiovascular risk factors from childhood to adulthood, adiposity (body mass index [BMI]) in childhood, adiposity and systolic blood pressure in adulthood, and the cumulative burden of adiposity and systolic blood pressure from childhood to adulthood were significant predictors of LVM (obtained with two-dimensional M-mode echocardiography) in adulthood.8Li X. Li S. Ulusoy E. Chen W. Srinivasan S.R. Berenson G.S. Childhood adiposity as a predictor of cardiac mass in adulthood: the Bogalusa Heart Study.Circulation. 2004; 110: 3488-3492Crossref PubMed Scopus (163) Google Scholar Increased LVM/left ventricular hypertrophy is a recognized independent predictor of cardiovascular morbidity and mortality.9Koren M.J. Devereux R.B. Casale P.N. Savage D.D. Laragh J.H. Relation of left ventricular mass and geometry to morbidity and mortality in uncomplicated essential hypertension.Ann Intern Med. 1991; 114: 345-352Crossref PubMed Scopus (2160) Google Scholar, 10Levy D. Garrison R.J. Savage D.D. Kannel W.B. Casteli W.P. Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study.N Engl J Med. 1990; 322: 1561-1566Crossref PubMed Scopus (4808) Google Scholar See related article, p 709 See related article, p 709 Substantial evidence has accumulated in the past several decades linking obesity in childhood with a number of cardiovascular-related co-morbidities, including adverse changes in major risk factors for CVD and adverse changes in cardiac structure and function. In this issue of The Journal, Crowley et al11Crowley D.I. Khoury P.R. Urbina E.M. Ippisch H.M. Kimball T.R. Cardiovascular impact of pediatric obesity epidemic: higher left ventricular mass related to higher body mass index.J Pediatr. 2011; 158: 709-714Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar add to the evidence supporting the urgent need for prevention and management of obesity early in the life course. A major aim of their innovative study was to examine secular changes in BMI and LVM in today's healthy children compared with children from a generation ago. Considering the increase in prevalence of obesity in children and youth in the United States and the known positive association of obesity and LVM, Crowley et al hypothesized that indexed LVM would be higher in the current generation of children and youth and that this increased indexed LVM would be partially attributable to the increase in obesity (as measured with BMI) in the past two decades.11Crowley D.I. Khoury P.R. Urbina E.M. Ippisch H.M. Kimball T.R. Cardiovascular impact of pediatric obesity epidemic: higher left ventricular mass related to higher body mass index.J Pediatr. 2011; 158: 709-714Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar The sample consisted of 700 healthy patients 2 to 19 year of age who underwent echocardiography at a major academic medical center from 1986 to 1989 (n = 350; 60% male; 82% white) and in 2008 (n = 350; age- and sex-matched with 1986-1989 participants). Participants at both time points were healthy; patients were excluded when they had any heart disease or systemic disease that would impact cardiac structure, cardiac function, or both. Obesity (BMI <40 kg/m2) was not an exclusion criterion, however, because effects of obesity on cardiac geometry was viewed as the primary outcome. Particularly noteworthy results of this study include the observation that children today (2008) have significantly higher indexed LVM than their counterparts a generation ago (current: 32.7 ± 7.8 g/m2.7; earlier: 31.5 ± 8.1 g/m2.7) and that this increase is partially attributable to the increase in BMI. Crowley et al showed that the average weight in the current (2008) study group (41.3 ± 25.2 kg) was approximately 5 kg higher than in the earlier generation (36.5 ± 20.1 kg), with the average weight percentile 11% higher and the average BMI 1.8 kg/m2 higher in the current (2008) group. In stepwise regression analyses, era (current; earlier) was not a significant contributor to indexed LVM; BMI z-score, however, was a determinant of indexed LVM at both points, as was younger age, male sex, and African-American race. In addition, changes demonstrated in left ventricular dimensions in the current era translate to an average indexed LVM that is 1.2 kg/m2.7 higher and an average indexed LVM z-score that is 0.23 points higher than in the earlier era. As Crowley and co-authors note, in the absence of obesity and other adverse conditions, the average indexed LVM should be stable with time.11Crowley D.I. Khoury P.R. Urbina E.M. Ippisch H.M. Kimball T.R. Cardiovascular impact of pediatric obesity epidemic: higher left ventricular mass related to higher body mass index.J Pediatr. 2011; 158: 709-714Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar In adults, a common indexed LVM threshold value of 51 gm/m2.7 confers a substantial (4-fold) risk for cardiovascular events.12deSimone G. Devereux R.B. Daniels S.R. Koren M.J. Meyer R.A. Laragh J.H. Effect of growth on variability of left ventricular mass: assessment of allometric signals in adults and children and their capacity to predict cardiovascular risk.J Am Coll Cardiol. 1995; 25: 1056-1062Abstract Full Text PDF PubMed Scopus (772) Google Scholar Although such cut point data are not available for children and adolescents, it has been suggested that LVM, similar to other risk factors, be viewed and treated as a continuous variable because cardiovascular events do occur incrementally in relation to LVM.13Verdecchia P. Carini G. Circo A. Dovellini E. Giovannini E. Lombardo M. et al.Left ventricular mass and cardiovascular morbidity in essential hypertension: the MAVI study.J Am Coll Cardiol. 2001; 38: 1829-1835Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar Methodological limitations notwithstanding, the results of this study add to the growing body of knowledge about the adverse cardiovascular impact of the pediatric obesity epidemic on today's children and support the urgent need for multilevel approaches to reversing the trend and evidence-based recommendations designed to inform and guide cardiac screening and follow-up in children and youth.14Hayman L.L. Meininger J.C. Daniels S.R. McCrindle B.W. Helden L. Ross J. et al.Primary prevention of cardiovascular disease in nursing practice: focus on children and youth.Circulation. 2007; 116: 344-357Crossref PubMed Scopus (127) Google Scholar Cardiovascular Impact of the Pediatric Obesity Epidemic: Higher Left Ventricular Mass is Related to Higher Body Mass IndexThe Journal of PediatricsVol. 158Issue 5PreviewTo compare secular changes in body mass index (BMI) and left ventricular mass (LVM) in today's children versus children of a generation earlier. Full-Text PDF
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