Cholesterol Screening in Obese and HighRisk Children

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Cholesterol Screening in Obese and High-Risk
Children

• Ziad S. Rafii, M.D., FAAP
• Clinical Associate, Department of Pediatrics
• American University Medical Center
• Beirut, Lebanon
• Director, Childrens Medical Services
• Tripoli, Lebanon

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Hypercholesterolemia in Children Why Should We
Screen?

• May lead to atherosclerosis and premature
• coronary artery disease
• Usually tracks into adult life
• May usher unsuspected hypercholesterolemia
• in their parents

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Hypercholesterolemia in Children What Are the
Risks?

• Moll et al (Circulation 1983 67(1)127-34)
  screened 3666 school
• children and 850 of their relatives
• The children's cholesterol levels clustered
  with those of their relatives
• Mortality due to CHD increased by 2.5 times in
  grandfathers of
• children with high-cholesterol
• The prevalence of CHD in all the grandfathers
  was associated with
• an index child's total cholesterol

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Hypercholesterolemia in Children What Are the
Risks?

• The Muscatine Study (Pediatrics 1988
  82(3)309-18) involving 2,446
• subjects initially examined at 8 to 18 years of
  age were reexamined
• as young adults
• Elevated levels of cholesterol during
  childhood were associated with
• elevation in adult life
• Obesity acquired in adolescence, oral
  contraceptive use, and
• cigarette smoking had deleterious effects on
  adult cholesterol levels
• and lipoprotein fractions

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Premature Coronary Heart Disease What Are the
Risks for the Offspring?

• OGrady MJ, et al. Pediatr Cardiol. 2007 Dec 17
  (Epub) measured LDL cholesterol in 97 children
  (8-18 years) in whom one parent had a history of
  premature ischemic heart disease (lt55 years)
• 8.5 of the children had high LDL-C
• 20.7 had borderline high LDL-C
• Screening for hypercholesterolemia in these
  at-risk children and adolescents is prudent and
  dietary advice must be offered

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Abnormal Cholesterol Values What is the Role of
obesity?

• Obese children develop hypercholesterolemia
  more than
• 3 times than non-obese children
• Obesity is associated with high levels of LDL,
  VLDL, and
• triglycerides with low level of HDL which
  places them at
• greater cardiovascular risk

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Abnormal Cholesterol Values What is the Role of
obesity?

• Washino K et al. (Pediatr Int. 1999
  41(3)260-5) measured lipid profile and body fat
  in 1289 children
• The probability of an Atherogenic Index (AI)
  score of 3 or more was significantly
  higher in children with an estimated 23-25
  body fat than in those with body fat less than
  17.
• When body fat was greater than 29, the odds
  ratio for AI score gt3 was 11-fold higher
  than those with body fat less than 17.

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Abnormal Cholesterol Values What is the Role of
obesity?

• Yan H, et al. (Beijing Da Xue Xue Bao. 2007
  39(6)591-4) explored the significance of family
  history and obesity in the development of
  dyslipidemia gt 19,000 in children

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Abnormal Cholesterol Values What is the Role of
obesity?

• Posadas-Sanchez R, et al. (Metabolism 2007
  56(12)1666-72) evaluated the role of obesity and
  waist circumference in 1846 adolescents (mean
  13.2 years)
• Obese children had the highest prevalence of
  low HDL and high TSC, LDL, and TG
• Waist circumference was negatively associated
  with HDL and positively associated with LDL
  and TG levels

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Abnormal Cholesterol Values What is the Role of
obesity?

• Cuestas-Montañés E, et al. (An Pediatr (Barc).
  2007 7(1)44-50) assesed the importance
  of waist circumference in identifying
  certain cardiovascular risk factors in 230
  children 2-9 years old
• There were no significant differences in lipid
  profiles between obese
• and non-obese children
• Larger waist circumference was associated with
  a greater risk of
• elevated values of total serum cholesterol,
  triglycerides, and
• hypertension

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Hypercholesterolemia in Children What Values
Are Normal?

• Normal cholesterol values are age, sex, and
  ethnic-dependent
• World wide mean TSC levels in children 3.47-
  5.54 mmol/L
• Arab children have similar mean TSC values as
  American
• children (3.8 - 4.0 mmol/L)
• Desirable target value is set at lt 4.4 mmol/L
  by the National Cholesterol Educational
  Program (NCEP) in the USA

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Hypercholesterolemia in Children Who should be
screened?

• Overweight and at risk for overweight children
• Family history of hypercholesterolemia/dyslipide
  mia
• Family history of premature coronary artery
  disease
• Family history of hypertension and type II
  diabetes
• Poor dietary habits
• Physical inactivity

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Hypercholesterolemia in Children AAP Policy
Statement (1998 2006)

• Although the precise fraction of risk for future
  coronary heart disease conveyed by elevated
  cholesterol levels in childhood is unknown, clear
  epidemiologic and experimental evidence
  indicates that the risk is significant. Diet
  changes that lower fat, saturated fat, and
  cholesterol intake in children and adolescents
  can be applied safely and acceptably, resulting
  in improved plasma lipid profiles that, if
  carried into adult life, have have the potential
  to reduce atherosclerotic vascular disease
  
• AAP,
  Committee on Nutrition. Pediatrics 1998 101
  141-147

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Cholesterol Values in Arab Children

• Rafii Z, et al. 1994
• Establishing reference total serum cholesterol
  values
• in Saudi children
• Alsaeid M, et al. 1998
• Serum lipoprotein (a) concentrations among Arab
  Children a hospital-based study in Kuwait
• Al-Hazmi M, Warsy A. 2001
• Prevalence of serum lipid abnormalities in Saudi
  children

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Cholesterol Values in Arab ChildrenSummary of
Studies Results

• Around 25 of Arab children have a higher than
  the desirable target TSC value of 4.4 mmol/L
  as set by the NCEP
• Around 5 10 of Arab children may be at risk
  for CHD

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Take Home Message

• ? Early detection of dyslipidemia and prevention
  of atherosclerosis
• should begin in childhood
• ? Obesity may contribute to increased cholesterol
  levels and
• dyslipidemia
• ? Cholesterol screening should be performed for
  all obese and
• high-risk children
• ? Universal cholesterol screening for all
  school-age children
• should also be considered

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