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 Prevention
Can Start Young, Studies Suggest; but How?
by Linda Villarosa, December 2, 2003, New York Times
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As parents and
doctors struggle with an epidemic of childhood obesity in
America, Anne Youngquist worries about a subtler menace that may
not threaten her three children for decades: heart disease.
About eight years ago, after learning that her husband, Rod,
suffered from elevated cholesterol, she started having their
children's cholesterol checked, too. Bryce, at 16 their oldest
child, went on a low dose of cholesterol-lowering statin drugs
three years ago. Alyssa, 14, has also gone on statins.
Eight-year-old Brady is not on medication, but he, too, joins
the family in a diet low in fat; to the Youngquists 2 percent
milk tastes like heavy cream.
"The danger of heart disease is so great that we try and do
everything right," said Ms. Youngquist, 48, a marriage and
family therapist near San Luis Obispo, Calif.
Obesity is so common among America's children that 15 percent
are considered overweight. But Ms. Youngquist, like a growing
number of pediatricians and cardiologists, are looking beyond
just obesity to heart disease, the nation's No. 1 killer of
adults. They argue that more studies are showing that the
ingredients for a future heart attack, including obesity, are
present in the young and that preventive measures should start
at an early age. But even as the evidence mounts, the debates
continue over how to test for heart disease risk and how and
when to treat it.
"The knowledge base began building 50 years ago, and now the
evidence is coming through and converging that the same risk
factors that are associated with coronary heart disease in
adults begin in childhood," said Dr. Henry C. McGill Jr., a
senior scientist emeritus at the Southwest Foundation for
Biomedical Research in San Antonio.
"If we focus too exclusively on obesity, other risk factors like
high cholesterol, hypertension, smoking and inactivity are going
to make an end run," Dr. McGill said. "This means that we have
to redirect our efforts to changing lifestyle in childhood."
Other experts worry that testing children for heart disease risk
could unfairly stigmatize children as "diseased." They also
believe that focusing too narrowly on high cholesterol, which,
in most cases, will not lead to heart disease for decades,
ignores the real dangers of childhood, including car accidents,
unintentional injury, homicide and suicide.
"By screening healthy children who are unlikely to get coronary
heart disease for at least a half century, you are singling them
out and labeling them, which could cause psychological
consequences that are not trivial," said Dr. Stephen B. Hulley,
the chairman of epidemiology and biostatistics at the University
of California at San Francisco.
Two studies that appeared last month in The Journal of the
American Medical Association found that the heart disease risk
factors — drummed into the minds of adults for 20 years — are
also present in children. The studies reported that warning
signals like high blood pressure and elevated cholesterol could
predict atherosclerosis, or hardening of the arteries.
Unpublished results of a third study, presented three weeks ago
at the meeting of the American Heart Association in Orlando,
found that levels of smoking, cholesterol, blood pressure and
obesity in 5,000 young adults age 18 to 30 predicted
calcification of the coronary arteries as they approached middle
age, 15 years later. And finally, another study presented at the
association's meeting noted that research involving more than
2,000 children ages 8 to 17 in rural North Carolina found that
59 percent had at least 1 of 6 risk factors for future heart
disease and that 28 percent had 2 or more.
"At this point, we have the scientific knowledge, which if
incorporated into our society, we could prevent 95 percent of
precocious heart disease," said Dr. McGill, who wrote the
editorial that accompanied the two JAMA studies. He has studied
heart disease risk factors in children for some 50 years. "And
now we know that we can start that prevention process in
childhood."
In the largest of the two studies, researchers at the University
of Turku in Finland measured heart disease risk factors —
cholesterol, blood pressure, weight and smoking — in 2,229
children and adolescents in 1980 and then repeated the same
tests two decades later. In the later testing, they also used
ultrasounds to measure thickening of the carotid artery in the
neck. They found that the risk factors measured at ages 12 to 18
were associated with thickness of the carotid artery later in
life.
In the second study, Tulane University researchers looked at the
heart disease risk factors of hundreds of residents of Bogalusa,
La., beginning in 1973. They found that increased artery
thickness could be predicted in adults ages 25 to 37 based on
risk factors measured an average of 22 years before. The
researchers were surprised to learn that childhood cholesterol
measurements predicted future artery thickness, as well as those
taken later in the adult years.
"The oldest of the children are now reaching 45, and we've seen
these trends coming," said Dr. Gerald S. Berenson, the principal
investigator of the Bogalusa Heart Study and a professor of
medicine, pediatrics and biochemistry at Tulane. "The kids in
the study are now about 12 pounds heavier, their diets have
changed, and there is less activity. The message of this study
is that adult heart disease begins in childhood, and lifestyle
changes have to begin then, too."
Experts do not agree on ways to solve the problem. In his JAMA
editorial, Dr. McGill says that the evidence of heart disease
risk factors in children and adolescents is so strong that "it
may be time to reconsider the age at which measurement of
cholesterol levels should begin."
National Cholesterol Education Program guidelines recommend
testing for those age 20 and older every five years, and the
American Academy of Pediatrics advises testing children when
there is a family history of heart disease under age 55 or when
a parent has a total cholesterol over 240 milligrams per
deciliter.
Dr. Berenson said he would push for screening all schoolchildren
for blood pressure, total cholesterol and body mass index, a
ratio of weight to height. "It should be routine for children,"
he said. "I'm aggressive about prevention, so you have to know
and document risk factors."
But Dr. Hulley of U.C.S.F. argues that testing individual
children is unnecessary. "It seems that the most sensible
approach is not screening children but rather recommending
healthy lifestyles for all children," he said.
He is even more wary about using drugs to control cholesterol in
children. The class of medication known as statins has been
found to be highly effective in lowering blood cholesterol in
adults. Last year, the Food and Drug Administration approved two
statins, atorvastatin and lovastatin, marketed as Lipitor and
Mevacor, for use in children.
"Except for the very rare exceptions of children with severe
familial high cholesterol, it is not prudent to treat children
with drugs based on a lab test," Dr. Hulley said. "Children
don't get heart attacks, and it's exceedingly rare among young
adults. Statins work very well when begun in middle age, and the
only appropriate time to use drugs is when you are approaching
the age when you become at risk for the disease."
Dr. Daniel Bernstein, the pediatric cardiologist who treats the
Youngquist children, says he uses the medication only
cautiously. He put Bryce on statins only after a cholesterol
test revealed a reading close to 300.
Referring to the low density lipoprotein, or bad cholesterol, he
said, "There are very few children with L.D.L. levels that
warrant a statin."
Dr. Bernstein, who is also the director of the Children's Heart
Center at the Lucile Packard Children's Hospital at Stanford,
said diet and exercise should be enough for most children. "But
if you've got one whose cholesterol is very high," he added,
"you have to treat it."
Anne Youngquist says she is grateful to have the option of
treatment, but she sometimes worries about the safety of the
medication nonetheless. "The biggest concern is the liver, and I
worry about that because parents worry about everything," she
says.
Two years ago, a statin called cerivastatin was withdrawn from
the market after 31 deaths were linked to a rare muscular
disorder, a complication of the drug. "But I would worry much
more about heart damage," Ms. Youngquist said. "You choose the
lesser of the evils."
Around the country, communities are looking for large-scale ways
to teach children heart-healthy habits, particularly in school.
Schmalz Elementary just outside Houston — and about 1,000 other
schools in Texas and other parts of the country — have
instituted a program called the "Coordinated Approach to Child
Health" or Catch, which emphasizes the importance of nutrition
and exercise. At Schmalz, an alliance of parents, teachers,
staff members, food service workers and community partners
teaches children and their families about good health through
classroom and after-school activities.
"In the fourth-grade curriculum, we teach the kids the
difference between `go,' `slow' and `whoa' foods," said Lisa
Bunting, a Schmalz Elementary physical education teacher. "Go
are highly nutritious, fresh with lots of vitamins and
minerals," Ms. Bunting said. "Whoa are foods that are high in
fat, sugar and salt, and slow are in between. The point is to
get the kids to look at their lunch tray or food from home and
evaluate their meal. We teach them that if you're eating too
many whoa foods, over your lifetime you are more prone to
problems like heart disease. And if you aren't getting enough
physical activity, you're in double trouble."
Ms. Bunting says she has seen a big difference in the children
since the school began the program last year. "I didn't expect
to have so much positive student participation and response,"
she said. "The kids come to me in the morning and describe how
they looked at a food label last night and showed it to their
parents. Now the moms are saying things like, `Hey, thanks,
Wednesday, was my double Whataburger night and now we can't go
there anymore.' "
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