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1 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 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 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 lowdensity 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 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, A single reprint is available by calling (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX Ask for reprint No To purchase additional reprints: up to 999 copies, call (US only) or fax ; 1000 or more copies, call , fax , or klbradle@lww.com. To make photocopies for personal or educational use, call the Copyright Clearance Center, (Circulation. 2003;107: ) 2003 American Heart Association, Inc. Circulation is available at DOI: /01.CIR E 1562
2 Kavey et al Primary Prevention in Childhood 1563 TABLE 1. Guidelines for Cardiovascular Health Promotion in All Children and Adolescents Health Promotion Goals Diet An overall healthy eating pattern Appropriate body weight Desirable lipid profile Desirable blood pressure Assess diet at every visit. Match energy intake with energy needs for normal growth and development. Make appropriate changes to maintain a healthy weight and achieve weight loss when indicated. Advocate consumption of a variety of fruits, vegetables, whole grains, dairy products, fish, legumes, poultry, and lean meat. Fat intake is unrestricted prior to 2 years of age. After age 2, limit foods high in saturated fats ( 10% of calories per day), cholesterol ( 300 mg per day), and trans-fatty acids. Limit salt intake to 6 g per day. Limit intake of sugar. Smoking No new initiation of cigarette smoking No exposure to environmental tobacco smoke Complete cessation for those who smoke Question tobacco use by parents at every visit. Question tobacco use by children at every visit starting at age 10. Provide clear, strong, informed, and personalized counseling against initiation of smoking. Advise avoidance of second-hand smoke at home, with friends, at school, or at work. Physical Activity Be physically active every day Reduce sedentary time (eg, television watching, computer, video games, or time on the phone) 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. 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 Assess physical activity at every visit. Advise young people to participate in at least 60 minutes of moderate to vigorous physical activity every day. Physical activity should be fun for children and adolescents. For adolescents, resistance training (10 to 15 repetitions at moderate intensity) can be combined with aerobic activity in an overall activity program. Sedentary time should be limited. For example, limit television time to at most 2 hours per day. 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 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: 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: 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: 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: 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:
3 1564 Circulation March 25, 2003 TABLE 2. Guidelines for Identification of Children and Adolescents at High Risk of CVD Assessment General Assessment Goals for Pediatric Care Providers Timed, targeted risk factor assessment Appropriate interpretation of results and communication to families Goals for Parents Recognition of risk factor significance for development of cardiovascular disease, especially family history Family history: Update regularly (parents, grandparents, aunts, and uncles) with regard to obesity, hypertension, dyslipidemia, diabetes, cigarette smoking, and cardiovascular disease before age 55 for men and age 65 for women. Height, weight, BMI: Assess at every examination. Blood pressure: Measure at every examination after age 3 years; chart for age/sex/height. Diet and physical activity: Assess at every visit. Cigarette smoking: Evaluate starting at 9 to 10 years of age. Specific Risk Assessment: Levels of Concern Lipids and Lipoprotein Total cholesterol 170 mg/dl is borderline; 200 mg/dl is elevated LDL-C 110 mg/dl is borderline; 130 mg/dl is elevated Triglycerides 150 mg/dl HDL-C 35 mg/dl Blood Pressure Systolic and diastolic blood pressure 90th percentile for age, sex, and height Perform targeted screening of fasting lipids in children 2 years of age with a family history of dyslipidemia or premature CVD. For children in whom family history is unknown and other risk factors are present, assess lipids and lipoproteins. If averaged results of 3 fasting lipid profiles are above cut points, refer to Table 3. Know appropriate blood pressure measurement techniques, including appropriate cuff size. Interpret blood pressure measurements on the basis of age, sex, and height. (Blood pressure percentiles are available at Body Size BMI 85th percentile is at risk of overweight; 95th percentile is overweight 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 J Pediatr. 1999;134: Morrison JA, James FW, Sprecher DL, et al. Sex and race differences in cardiovascular disease risk factor changes in schoolchildren, : the Princeton School Study. Am J Public Health. 1999;89: 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 Arch Pediatr Adolesc Med. 1995;149: 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): 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: 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: Lauer RM, Clarke WR. Childhood risk factors for high adult blood pressure: the Muscatine Study. Pediatrics. 1989;84; Whitaker RC, Wright JA, Pepe MS, et al. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;337: Body size should be charted by BMI. (Norms for BMI percentiles are available at The 95th percentile can be approximated by the age (in years) 13 for boys and the age (in years) 14 for girls after age 9 years. BMI indicates body mass index; CVD, cardiovascular disease; HDL-C, high-density lipoprotein cholesterol; and LDL-C, low-density lipoprotein cholesterol. 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: 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): 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: 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: Rojas NL, Killen JD, Haydel KF, et al. Nicotine dependence among adolescent smokers. Arch Pediatr Adolesc Med. 1998;152: 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: 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: 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:
4 Kavey et al Primary Prevention in Childhood 1565 TABLE 3. Guidelines for Cardiovascular Risk Reduction: Intervention for Children and Adolescents With Identified Risk Risk Intervention Blood Cholesterol Management LDL-C 160 mg/dl ( 130 mg/dl is even better) For patients with diabetes, LDL-C 100 mg/dl Other Lipids and Lipoprotein Fasting TG 150 mg/dl HDL-C 35 mg/dl Management of Blood Pressure Elevation Systolic and diastolic blood pressure 95th percentile for age, sex, and height Weight Management Achieve and maintain BMI 95th percentile for age and sex Diabetes Management Near normal fasting plasma glucose ( 120 mg/dl) Near normal HgA1 c ( 7%) (goals for fasting glucose and HgA1 c should take into consideration age and risk of hypoglycemia) Cigarette Smoking Cessation Complete cessation of smoking for children and parents who smoke TG indicates triglycerides. If LDL-C is above goals, initiate additional therapeutic lifestyle changes, including diet ( 7% of calories from saturated fat; 200 mg cholesterol per day), in conjunction with a trained dietitian. Consider LDL-lowering dietary options (increase soluble fiber by using age in years plus 5 to 10 g up to age 15, when the total remains at 25 g per day) in conjunction with a trained dietitian. Emphasize weight management and increased physical activity. If LDL-C is persistently above goals, evaluate for secondary causes (thyroid-stimulating hormone, liver function tests, renal function tests, urinalysis). Consider pharmacological therapy for individuals with LDL 190 mg/dl with no other risk factors for CVD; or 160 mg/dl with other risk factors present (blood pressure elevation, diabetes, obesity, strong family history of premature CVD). Bile acid binding resins or statins are usual first-line agents. Pharmacological intervention for dyslipidemia should be accomplished in collaboration with a physician experienced in treatment of disorders of cholesterol in pediatric patients. Elevated fasting TG and reduced HDL-C are often seen in the context of overweight with insulin resistance. Therapeutic lifestyle change should include weight management with appropriate energy intake and expenditure. Decrease intake of simple sugars. If fasting TG are persistently elevated, evaluate for secondary causes such as diabetes, thyroid disease, renal disease, and alcohol abuse. No pharmacological interventions are recommended in children for isolated elevation of fasting TG unless this is very marked (treatment may be initiated at TG 400 mg/dl to protect against postprandial TG of 1000 mg/dl or greater, which may be associated with an increased risk of pancreatitis). Promote achievement of appropriate weight. Reduce sodium in the diet. Emphasize increased consumption of fruits and vegetables. If blood pressure is persistently above the 95th percentile, consider possible secondary causes (eg, renal disease, coarctation of the aorta). Consider pharmacological therapy for individuals above the 95th percentile if lifestyle modification brings no improvement and there is evidence of target organ changes (left ventricular hypertrophy, microalbuminuria, retinal vascular abnormalities). Start blood pressure medication individualized to other patient requirements and characteristics (ie, age, race, need for drugs with specific benefits). Pharmacological management of hypertension should be accomplished in collaboration with a physician experienced in pediatric hypertension. For children who are at risk of overweight ( 85th percentile) or obesity ( 95th percentile), a weight management program should be initiated with appropriate energy balance achieved through changes in diet and physical activity. For children of normal height, a secondary cause of obesity is unlikely. Weight management should be directed at all family members who are overweight, using a family-centered, behavioral management approach. Weight management should be done in collaboration with a trained dietitian. Management of type 1 and type 2 diabetes in children and adolescents should be accomplished in collaboration with a pediatric endocrinologist. For type 2 diabetes, the first step is weight management with improved diet and exercise. Because of risk for accelerated vascular disease, other risk factors (eg, blood pressure, lipid abnormalities) should be treated more aggressively in patients with diabetes. Advise every tobacco user (parents and children) to quit and be prepared to provide assistance with this (counseling/referral to develop a plan for quitting using available community resources to help with smoking cessation).
5 1566 Circulation March 25, 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: 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): 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): 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:E American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care. 2000;23: American Academy of Pediatrics, Committee on Public Education. Media education. Pediatrics. 1999;104(2 Pt 1): 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: 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: [Erratum Circulation. 2002;106:1178.] KEY WORDS: AHA Scientific Statements pediatrics atherosclerosis cardiovascular diseases prevention
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