1. Cardiovascular Health and Risk Reduction in Children and Adolescents
                          
Don P. Wilson, M.D., FNLA
Fellow, American Board of Clinical Lipidology
Pediatric Endocrinology
Cook Children’s Medical Center
Fort Worth, Texas

2. Overview Atherosclerosis begins in childhood.
Risk factors for the development of atherosclerosis can be identified in childhood.
Development and progression of atherosclerosis clearly relates to the number and intensity of CV risk factors, beginning in childhood.
Risk factors track from childhood into adult life.
Interventions exist for management of identified risk factors.

3. Lipid Screening Guidelines For Children and Adolescents
Year
 Organization
NCEP
AAP
NHLBI
Target Population
Targeted:
Family History
Family History and Obesity
Universal Screening
First Screen
> 2 yrs of age
Not specified
Age 9-11
Subsequent Screen
Age 17-21
First-line Treatment
Diet change
Diet counseling*
Weight loss if overweight
Target LDL-c (mg/dL)
<130 (minimal) <110 (ideal)
<160 (initial)
<130 (or lower) with other risk factors
<130 (minimal)
<110 (ideal)
Criteria for initiating lipid lowering medication
Age ≥ 10 years
LDL ≥ 190 despite 6m-1y diet therapy
Age ≥ 8 years
LDL-C ≥ 190 or ≥ 160 if family history or 2+ risk factor (+) or ≥ 130 if diabetic
Age ≥ 10, persistent LDL≥ 190, ≥ 160 if family history (+) or 1+ risk factor; Age < 10 years, only special cases**
*Referral to a registered dietitian for family medical nutrition therapy for daily nutritional intake of <30% calories from fat (<=7% saturated fat, ~10% monounsaturated fat, no trans-fat); <200 mg of cholesterol/day.
**Severe primary hyperlipidemia (homozygous familial hypercholesterolemia, primary hypertriglyceridemia with TG ≥500 mg/dL), a high-risk condition or evident cardiovascular disease; all under the care of a lipid specialist.
1992
2008
2011

4. Assist primary pediatric care providers in the prevention of:
In 2006, the National Heart, Lung and Blood Institute (NHLBI) convened a panel of experts to develop comprehensive evidence-based guidelines addressing the known risk factors for CVD.
Goal:
Assist primary pediatric care
providers in the prevention of:
Risk factor development – primordial prevention.
Future CVD by effective management of identified risk factors – primary prevention.
The full report is available at:

5. Risk Evaluation for Achieving Cardiovascular Health The REACH Clinic
Pediatric Endocrinology and Diabetes
Cook Children’s Medical Center
Fort Worth, Texas

6. Risk Evaluation for Achieving Cardiovascular Health
Purpose:
To assess co-morbid conditions and promote heart healthy lifestyles through a multidisciplinary, structured program of health education, treatment and prevention aimed at improving the physical and emotional wellbeing of children (< 18 yrs. of age).

7. Comprehensive Screening – Treatment*
Early Intervention – Reversal of Disease**
Prevention
Heart Healthy Lifestyle becoming the “norm”
* Diabetes, Hypertension, OSA, Bone/Joint Disease, Steatohepatitis and Dyslipidemia
** Pre-diabetes, Pre-hypertension, Steatosis and Microalbuminuria

8. Academic Partners Cook Children’s R.E.A.C.H. Clinic
Service GI
Pulmonary
Cardiology
Orthopedics
Endocrine
Renal
Mental Health
Community Partners
Cook Children’s
R.E.A.C.H. Clinic
Community
resources

9. R.E.A.C.H. Clinic Pediatric Endocrinologist
R.E.A.C.H. Clinic Coordinator
Research Coordinator
Endocrine Nurses
Nutritionists
Psychologists
Social Services
Exercise Psychologist
Education Resources

10. Goals Not Met Refer to Endocrine
Community Based Program for the Prevention of Premature Cardiovascular Disease in Youth
PCP
Initial Workup
BMI
+ 2 CVDRFs
+ FH Diabetes
Low Risk
TLC
Follow
Moderate Risk
Treat
Goals Not Met Refer to Endocrine
Education
F/up with PCP
Treat & Follow
High Risk
Goals Met Follow
Refer To
REACH
REACH Evaluation
Initiate Rx
Co-Manage with PCP
TLC = Therapeutic Lifestyle Counseling

11. REACH Referral and Follow-up
PCP Initial Evaluation
and
*Diagnostic
Workup
Ordered
Risk Stratification
Low
Risk
F/up with PCP
Moderate
Targeted Health Education
REACH F/up 1 year
High
Targeted
Health
Education
Initial Nutrition F/up
Then REACH Clinic
q 4 mos.
REACH Referral
H&P
Review of Dx Evaluation
Assessments:
Psychosocial
Nutrition
Fitness
4 month follow-up
with the PCP
8 month follow-up with the PCP
Rx Plan
*Diagnostic Workup to be completed prior to being seen in the REACH Clinic.

12. It’s never too early to stop a heart attack !
We all have choices…
C igarette Smoking
H ypertension
O besity
I nsulin resistance
C holesterol (low HDL-c)
E xercise (lack of)