The American Heart Association (AHA) released a “pediatric-focused companion” to their previously published document, “Defining and Setting National Goals for Cardiovascular Health Promotion and Disease Reduction: The American Heart Association’s Strategic Impact Goal Through 2020 and Beyond.”

Julia Steinberger, MD, MS, FAHA, chair of the writing committee and professor and division director in pediatric cardiology at the University of Minnesota in Minneapolis, and colleagues sought to define ideal cardiovascular health in children and improve the cardiovascular health metric scores that currently categorize children as having “poor or intermediate cardiovascular health.”

“The principles detailed in the document reflect the American Heart Association’s new dynamic and proactive goal to promote cardiovascular health throughout the life course,” they wrote.


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Dr Steinberger and colleagues examined the AHA’s current recommendations on smoking, BMI, physical activity, diet, cholesterol, blood pressure, and fasting blood glucose. The specific recommendations include: abstaining from smoking, maintaining BMI <85th percentile, engaging in ≥60 minutes of moderate or vigorous physical activity per day, and consuming a diet with an emphasis on fruits, vegetables, fish, whole grains, low sodium, and few sugar-laden foods and drinks.

While these recommendations are helpful, the writing committee pointed out some limitations. For example, an increasing number of young people have tried electronic cigarettes, which were not previously listed as a primary cardiovascular health metric due to insufficient data at the time. In addition, while BMI is correlated with adiposity, it’s also not the most ideal measure of body fat percentage in children and adolescents.

Healthy dietary measures may also need adjustment as assessment “remains challenging in the absence of standardized, simple-to-use, age-appropriate, validated tools.”  The fact that many young people consume a lot of their food outside of their home environment makes it even more difficult to accurately assess their eating habits.

Upon closer inspection of the AHA’s blood lipids and total cholesterol goals (total cholesterol <170 mg/dL, blood pressure <90th percentile, and fasting plasma glucose level <100 mg/dL), the authors noted the wide age range of 6 to 19 years presents a problem. During puberty, for example, there is usually a 10% to 15% reduction in total cholesterol, regardless of diet and those mechanisms are not well-understood. There are also race and sex differences to consider after puberty. And while total cholesterol remains the “strongest predictor of cardiovascular outcomes in NHANES [National Health and Nutrition Examination Survey], the increasingly more prevalent detection of combined dyslipidemia that accompanies the development of an obesity pattern (high triglycerides/low high-density lipoprotein cholesterol) may represent an important risk factor.”

To begin refining these recommendations, the authors urged improved surveillance on cardiovascular health in children and adolescents, and emphasized that those health metrics should be followed from childhood through adulthood. They suggested taking advance of “big data” and analytics such as electronic health records to track health factors and behaviors, as well as wearable technologies to collect and study patient data.

“The use of cross-sectional population-based cut points for defining risk in childhood can contribute to significant risk misclassification later in life,” Dr Steinberger and colleagues wrote. “A new process by which cardiovascular health factors are identified independently of available data, with that process then driving decisions for NHANES and other population-based studies, would be an improvement.”

“Optimally, availability of longitudinal data on these factors would allow evaluation of the process of loss of cardiovascular health and connect that loss with later adverse cardiovascular health outcomes,” they concluded.

Reference

Steinberger J, Daniels SR, Hagberg N, et al; on behalf of the American Heart Association Atherosclerosis, Hypertension, and Obesity in the Young Committee of the Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Council on Epidemiology and Prevention; Council on Functional Genomics and Translational Biology; and Stroke Council. Cardiovascular health promotion in children: challenges and opportunities for 2020 and beyond. A scientific statement from the American Heart Association. Circulation. 2016;134. doi:10.1161/CIR.0000000000000441.