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Racial trends, body shape clues of risk
They may be young now, but many kids could be well on the road to developing heart disease. Researchers say well-recognized risk factors in adults are appearing in racially based patterns in children. Overall, those who are studying the details say too many kids are smoking. Kids are too fat. And diseases such as diabetes are getting a foothold.
But what do all those facts mean to clinicians who take care of CHF patients today — most of whom are well into adulthood? Start working with pediatricians, says Stephen R. Daniels, MD, PhD, a pediatrician and epidemiologist at the University of Cincinnati College of Medicine and Children’s Hospital Medical Center.
"Physicians who take care of adults with hypertension or heart disease can alert the doctors treating their younger relatives," he says. That way, doctors are getting a jump on a child’s family history of risk factors for developing heart disease. "If you tweak at both ends, hopefully the message will get out."
Increases in left-ventricular mass, hypertension, and unhealthy cholesterol levels all can be developing in pediatric cases. "It’s clear these bodily processes can start early," he says.
Daniels says there are many different types of interventions doctors can put into place for kids to help them avoid developing heart disease later in life:
1. Check the patient’s blood cholesterol.
If it is too high, kids can be put on medication to keep it under control. And after a child is 3, blood pressure should be checked on a regular basis.
"Pediatricians tend to feel less comfortable treating children with cholesterol medication or for high blood pressure," he says. "When they have severe problems, they can send the child to a specialist." The University of Cincinnati has a pediatric drug therapy clinic that specializes in this kind of care.
2. During an office visit, get a sense of where fat is being distributed on the child’s body.
Boys and girls follow the apple-and-pear-shape models, just like adults. It’s really a spectrum, Daniels says. Most boys put fat on around their middle, while girls put on weight around the hips and thighs. But it is possible to see girls with central fat and boys take on the pear shape.
Daniel’s recent study, published in the February issue of Circulation, reported fat distribution is a better indicator of cardiovascular risk than percent body fat.
His team X-rayed 127 children 9 to 17 with dual-energy X-ray absorptiometry, took fasting lipid and lipoprotein levels and blood pressure, and assessed left-ventricular mass. He found that central fat distribution can be a predictor of triglycerides, high-density lipoprotein (HDL) cholesterol, systolic blood pressure, and left-ventricular mass.
Left unattended over time, Daniels says, these conditions can go on to cause heart disease.
"One question that comes up is Do we know how to alter fat distribution — can you turn an apple into a pear?’" he says. "We don’t know how to do that. Which factors influence the deposition of fat? There’s a lot of research we need to do."
But there are a lot of basic interventions that can be done right now, adds Marilyn A. Winkleby, PhD, MPH, from the Center for Research and Disease Prevention at Stanford University School of Medicine in Palo Alto, CA. Those interventions focus mostly on giving kids some thoughtful direction in how to start making good choices about the food to eat and the habits to develop.
What’s needed, Winkleby says, is to help youngsters understand what heart-healthy activity means and to get them thinking about how to lower their cardiovascular risks. Kids need help because it’s too easy to get off track.
"Go to any park, and what’s your choice at the snack bar?" she asks. The answer usually is junk food such as soda, chips, and ice cream. Stop in for lunch at any public school, and you will see fast-food options.
And kids in urban areas may not have facilities available to them to get some exercise. Playgrounds can be crime scenes, and sports pavilions are often so crowded it’s hard to get regular access.
"What it comes down to is how committed do you want to be to eliminate heart disease?" Winkleby asks. "Are we going to make an environment where kids can grow up and find support to have a healthy lifestyle? As a society we can make a difference."
Her recent study of black, white, and Mexican children and young adults showed different ethnic groups had varying risk factors that all can lead to heart disease. The report, the Third National Health and Nutrition Examination Survey, 1988-1994, used 89 mobile examination centers to collect information about 2,769 black, 2,854 Mexican-American, and 2,063 non-Hispanic whites ages 6 to 24.
Here are some trends Winkleby and her team found:
After assessing the data, the team determined kids need interventions to help control their weight, beginning early in childhood — especially black and Mexican-American girls. Black and Mexican-American girls and boys also need help to prevent Type 2 diabetes.
Winkleby says kids need guidance from people who can make the right suggestions on how to take better care of themselves. "Physicians are very influential," she says. "Kids love their pediatrician." That relationship provides a good atmosphere to start talking to kids about these issues, or get a nurse or other caregiver to help:
"Doctors should be asking where their patients work," she says. Many teens have jobs after school and on weekends, and very often it’s at a fast-food restaurant. That tends to be where they eat one or two meals a day, which adds up to thousands of daily calories, and a great deal of it is fat.
"Kids don’t know how many calories to get or how to know about limiting fat," she says. "It’s awareness of these things that kids need and physicians can certainly help with that."
At medical meetings, Winkleby often shows advertising targeted to young urban white males to illustrate how tobacco companies know the market is there.
Billboards of tough, smoking T-shirted young men being admired by seductive young women poised on a fire escape are difficult images to compete with — especially when most of their peers, parents, and grandparents probably smoke as well. Doctors can help break the allure of smoking by being good counselors.
Be especially careful that black girls are not on their way to developing them. Guide patients with the diseases toward keeping them under control.
"It’s not very jazzy," Winkleby says, "but these are powerful messages."
1. Winkleby MA, et al. Ethnic variation in cardiovascular disease risk factors among children and young adults. JAMA 1999; 281(11):1,006-1,013.
2. Daniels SR, et al. Association of body fat distribution and cardiovascular risk factors in children and adolescents. Circulation 1999; 99:541-545.