2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents

Increasing prevalence of hypertension (HTN) in children and adolescents has become a significant public health issue driving a considerable amount of research. Aspects discussed in this document include advances in the definition of HTN in 16 year or older, clinical significance of isolated systolic HTN in youth, the importance of out of office and central blood pressure measurement, new risk factors for HTN, methods to assess vascular phenotypes, clustering of cardiovascular risk factors and treatment strategies among others. The recommendations of the present document synthesize a considerable amount of scientific data and clinical experience and represent the best clinical wisdom upon which physicians, nurses and families should base their decisions. In addition, as they call attention to the burden of HTN in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, these guidelines should encourage public policy makers to develop a global effort to improve identification and treatment of high blood pressure among children and adolescents

Cardiac left ventricular mass and arterial stiffness from childhood to early adulthood - association with cardiometabolic risk factors : the Special Turku Coronary Risk Factor Intervention Project (STRIP)

Background: Cardiac left ventricular mass and arterial stiffness are subclinical markers of cardiovascular disease which are associated with cardiovascular disease and clinical events in adulthood. Aims: The aim of this thesis was to study left ventricular mass and arterial stiffness in childhood and their determinants in terms of cardiometabolic risk factors and ideal cardiovascular health. This thesis also aimed to investigate the effect of a dietary and lifestyle intervention on ideal cardiovascular health and subclinical markers of cardiovascular disease. Subjects and methods: This thesis is a part of the prospective, randomized Special Turku Coronary Risk Factor Intervention Project (STRIP) that has followed initially over 1,000 children for 27 years. Their cardiometabolic risk factors have been repeatedly measured from childhood to adulthood. Children in the intervention group (n=540) have received dietary and lifestyle counseling aimed at improving the quality of dietary fat. Subclinical markers of atherosclerotic cardiovascular disease were examined using noninvasive ultrasonic measurements of carotid and aortic distensibility, pulse wave velocity, carotid intima-media thickness and cardiac left ventricular mass. This study analyses the data of the children who participated in the arterial ultrasound evaluations from the age of 11 to 19 years (n=420–503), and in the cardiac ultrasound assessments from the age of 15 to 19 years (n= 394–420). Results: Cardiac left ventricular mass and arterial stiffness increased with increasing age from childhood to early adulthood. In boys, the arterial stiffness increased more than in girls. It was found that current pulse pressure, weight and physical activity along with birth weight were associated with left ventricular mass in adolescence; overall these factors explained nearly 50% of the variation in left ventricular mass. Childhood blood pressure, body mass index, LDL cholesterol concentration and insulin resistance were associated with arterial stiffness. The dietary and lifestyle intervention was associated with ideal cardiovascular health in adolescence, however, it had no effect on left ventricular mass or arterial stiffness. Conclusions: Marked age-related arterial stiffening is evident already in childhood, particularly in boys. Several cardiometabolic risk factors determine arterial stiffness and cardiac structure already at an early age. Although the dietary and lifestyle intervention promoted ideal cardiovascular health in adolescence, the intervention did not change the subclinical markers of cardiovascular disease at this early age.Sydämen vasemman kammion massa ja valtimoiden jäykistyminen lapsuudesta varhaiseen aikuisuuteen – yhteys kardiometabolisiin riskitekijöihin. Sepelvaltimotaudin Riskitekijöiden Interventioprojekti (STRIP) Tausta: Sydämen vasemman kammion massa ja valtimoiden jäykistyminen ovat valtimoterveyden varhaismarkkereita, jotka ovat yhteydessä sydän- ja verisuonisairauksien päätetapahtumiin aikuisiällä. Tavoite: Väitöskirjatutkimuksen tavoitteena oli tutkia vasemman kammion massaa ja valtimoiden jäykistymistä lapsuudessa, sekä selvittää niitä määrittäviä tekijöitä kardiometabolisten riskitekijöiden ja ihanteellisen sydänterveyden mittareiden avulla. Lisäksi tutkimuksen tavoitteena oli selvittää ravitsemus- ja elämäntapaneuvonnan yhteyttä ihanteelliseen sydänterveyteen ja valtimoterveyden varhaisiin muutoksiin. Menetelmät: Väitöskirjatutkimus on osa prospektiivista, satunnaistettua Sepelvaltimotaudin Riskitekijöiden Interventioprojekti (STRIP) -tutkimusta, jossa on seurattu 27 vuoden ajan alun perin yli 1000 lasta. Tutkittavien lasten sydän- ja verisuonisairauksien riskitekijät on mitattu toistuvasti lapsuudesta aikuisuuteen. Ateroskleroottisen sydän- ja verisuonitaudin varhaisia muutoksia tutkittiin mittaamalla ultraäänellä kaulavaltimon ja aortan distensibiliteetti, pulssiaallon etenemisnopeus, kaulavaltimon intima-median paksuus sekä sydämen vasemman kammion massa. Interventioryhmän lapset (n=540) ovat saaneet ravitsemus- ja elämäntapaneuvontaa, jonka päätavoitteena on ollut ruokavalion rasvan laatuun vaikuttaminen. Tässä työssä käytettiin niiden lasten tietoja, jotka osallistuivat valtimoiden ultraäänitutkimukseen 11– 19 vuoden iässä (n=420–503) ja sydämen ultraäänitutkimukseen 15–19 vuoden iässä (n=394–420). Tulokset: Sydämen vasemman kammion massa kasvoi ja valtimot jäykistyivät lapsuudesta varhaiseen aikuisuuteen. Pojilla valtimoiden jäykistyminen oli voimakkaampaa kuin tytöillä. Tutkimuksessa havaittiin, että pulssipaine, paino ja liikunta sekä syntymäpaino olivat yhteydessä vasemman kammion massaan nuoruudessa selittäen lähes 50 % variaatiosta. Lapsuudessa mitattu verenpaine, painoindeksi sekä seerumin LDL-kolesterolipitoisuus ja insuliiniresistenssi olivat yhteydessä valtimoiden jäykistymiseen lapsuudesta varhaiseen aikuisuuteen. Ravitsemus- ja elämäntapaneuvonta oli yhteydessä ihanteelliseen sydänterveyteen nuoruudessa, mutta sillä ei havaittu olevan yhteyttä valtimoiden jäykistymiseen tai vasemman kammion massaan Johtopäätökset: Valtimot jäykistyvät iän myötä jo lapsuudessa - erityisesti pojilla. Useat kardiometaboliset riskitekijät ovat yhteydessä valtimoiden jäykistymiseen ja sydämen rakenteeseen jo varhaisella iällä. Ravitsemus- ja elämäntapaneuvonnalla voidaan edistää ihanteellista sydänterveyttä nuoruudessa, vaikkakaan se ei ollut yhteydessä valtimotaudin varhaismarkkereihin näin varhaisella iällä

Trends in Nutritional Status and Dietary Behavior in School-Aged Children with Congenital Heart Defects

Background: Malnutrition and poor weight gain has been reported in infants with congenital heart defects (CHDs); however data in older children with CHDs are limited. In order to obtain representative data on the nutritional status, dietary behavior, and potential influencing factors in school-aged children with CHDs, we performed a nationwide online survey. Methods: Patients aged 6 to 17 years registered in the German National Register for CHDs were asked to participate in this study by completing the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) eating study questionnaire in order to assess their self-reported dietary habits. The use of the same questionnaire enabled a comparison with a representative subset of 4569 participants of the KiGGS study. Results: A total of 894 patients (mean age 12.5 ± 3.0 years; 47.2% female) were enrolled. Patients were allocated according to anatomic complexity into simple (23.8%), moderate (37.8%), and complex CHDs (38.4%). The consumption of sugar-containing food (p < 0.001) and fast food (p < 0.05) was significantly lower among the CHD patients than in the healthy children. Children with CHDs showed significantly lower body mass index (BMI) percentiles (p < 0.001) compared with their healthy peers, while children with complex and moderate CHDs had the lowest BMI. While in CHD patients, the BMI percentiles were not related to unhealthy food, there was a strong correlation with the CHD severity and number of previous interventions (p < 0.01). Conclusions: According to this nationwide survey, school-aged children with complex CHD are at risk of undernutrition, which is not due to dietary habits but to CHD severity and repeated surgery

Perinatal and early life factors and their relevance for cardiometabolic health in early adulthood

Das übergeordnete Ziel dieser Arbeit war die Gewinnung neuer Erkenntnisse über die Relevanz frühkindlicher Faktoren für die kardiometabolische Gesundheit im Erwachsenenalter. Anhand von Daten der DONALD-Studie wurde deren Bedeutung für (I) die Intima-Media-Dicke (IMT) der Halsschlagader im frühen Erwachsenenalter (II) Marker des kardiometabolischen Risikos im frühen Erwachsenenalter untersucht; III. ein systematisches Review adressierte den Zusammenhang zwischen mütterlichem Gewicht/BMI (pBMI) in der Schwangerschaft bzw. der Gewichtszunahme während der Schwangerschaft (GWG) und dem Blutdruck (BP) der Nachkommen. In Studie I (N=265) war ein höheres mütterliches Alter bei der Geburt des Kindes nur bei Frauen mit einer erhöhten IMT im Erwachsenenalter verbunden. Dieser Zusammenhang wurde nicht durch Adipositas oder Blutdruck im Erwachsenenalter vermittelt. In Studie II (N=348) führte ein höherer mütterlicher BMI in der frühen Schwangerschaft zu einem höheren Fettleberindex (FLI), hepatischem Steatose-Index (HSI), pro-inflammatorischem Score und einer niedrigeren Insulinsensitivität (HOMA2-%S) im Erwachsenenalter. Eine höhere GWG führte zu ähnlichen Ergebnissen. Diese Zusammenhänge wurden durch die Adipositas im Erwachsenenalter vermittelt. In Studie III konnte keine eindeutige Schlussfolgerung zum Zusammenhang zwischen pBMI oder GWG und dem Blutdruck der Nachkommen gezogen werden. Zusammenfassend zeigt diese Arbeit, dass frühe Lebensfaktoren wichtige Determinanten von Risikomarkern kardiometabolischer Erkrankungen im Erwachsenenalter sind. Eine gesunde Ernährung und ein gesundes Körpergewichts sollten vornehmlich in der Zeit vor und während der Schwangerschaft gefördert werden.Environmental factors acting during early life may be pertinent to adulthood disease etiology. The overall goal of this thesis was to provide new insights on the relevance of perinatal and early life factors to adulthood cardiometabolic health. Thus, three studies addressed early life factors and their relevance to (I) intima-media thickness (IMT) of the common carotid artery in early adulthood (II) markers of cardiometabolic risk in early adulthood; III. a systematic review assessed the association between maternal pregnancy weight/BMI (pBMI) or gestational weight gain (GWG) with offspring's blood pressure (BP) in later life. Data from DONALD study were used for study I+II. Maternal pregnancy weight, GWG, maternal age, birth weight and full breastfeeding were assessed at childs recruitment into the DONALD study with outcomes measured in early adulthood. In study I (N=265), advanced maternal age at child birth was associated with an increased IMT in adulthood among females only. This association was not mediated by offspring adiposity or BP. In study II (N=348), a higher early maternal pregnancy BMI resulted in a higher offspring fatty liver index (FLI), hepatic steatosis index (HSI), pro-inflammatory score and a lower insulin sensitivity (HOMA2-%S). Also a higher GWG resulted in similar results. These associations were mediated by offspring adult adiposity. In study III, no firm conclusion could be drawn on the association between pBMI or GWG with offspring BP. In conclusion, this thesis shows that early life factors are relevant determinants of risk markers of cardiometabolic diseases in adulthood. Public health strategies to promote healthy diet and weight during preconception and pregnancy and breastfeeding may be beneficial.by Juliana Nyasordzi ; 1. Gutachterin: Prof. Dr. Anette E. Buyken, Paderborn University, 2. Gutachter: Prof. Dr. Thomas Remer, University of BonnTag der Verteidigung: 27.10.2021Universität Paderborn, Dissertation, 202

Detection of metabolic syndrome features among childhood cancer survivors: A target to prevent disease

Along with the growing epidemic of obesity, the risk of atherosclerosis, cardiovascular disease morbidity, and mortality are increasing markedly. Several risk factors for cardiovascular disease, such as visceral obesity, glucose intolerance, arterial hypertension, and dyslipidemia commonly cluster together as a condition currently known as metabolic syndrome. Thus far, insulin resistance, and endothelial dysfunction are the primary events of the metabolic syndrome. Several groups have recommended clinical criteria for the diagnosis of metabolic syndrome in adults. Nonetheless, in what concerns children and adolescents, there are no unified definitions, and modified adult criteria have been suggested by many authors, despite major problems. Some pediatric disease states are at risk for premature cardiovascular disease, with clinical coronary events occurring very early in adult life. Survivors of specific pediatric cancer groups, particularly acute lymphocytic leukemia, central nervous system tumors, sarcomas, lymphomas, testicular cancer, and following bone marrow transplantation, may develop metabolic syndrome traits due to: hormonal deficiencies (growth hormone deficiency, thyroid dysfunction, and gonadal failure), drug or radiotherapy damage, endothelial impairment, physical inactivity, adipose tissue dysfunction, and/or drug-induced magnesium deficiency. In conclusion, some primary and secondary prevention remarks are proposed in order to reduce premature cardiovascular disease risk in this particular group of patients

Excess Adiposity in Youth: Subclinical Cardiovascular Disease and Future Implications

University of Minnesota Ph.D. dissertation.July 2017. Major: Epidemiology. Advisor: Alvaro Alonso. 1 computer file (PDF); v, 90 pages.Excess adiposity remains a serious public health threat; 33% of U.S. adolescents are classified as having overweight or obesity. Adolescent obesity is associated with a 3.5 times higher lifetime risk of cardiovascular disease (CVD) mortality, thus subclinical CVD phenotypes such as carotid intima-media thickness (cIMT) have become widely accepted as relevant to earlier stages of CVD in youth. In the first manuscript, we developed a risk prediction model that predicted cIMT in middle adulthood using relevant CVD risk factors in adolescence. Longitudinal associations were observed between most CVD risk factors in adolescence and increased cIMT in middle adulthood; our risk prediction model poorly predicted cIMT in middle adulthood based on discrimination and calibration metrics. In the second manuscript, we contrasted longitudinal data from two bi-racial cohort studies by examining the association between CVD risk factors and cIMT in two distinct periods of life. Higher body mass index was associated with an increased cIMT in the younger cohort. In the older cohort, no association was present between body mass index and cIMT; higher systolic blood pressure was associated with increased cIMT. The American Heart Association set 2020 Strategic Impact Goals that defined CVD risk factors to include in the concept of ideal cardiovascular health (ICH). In the final manuscript, we examined the prevalence of ICH by adiposity level in youth, including severe obesity. We then generated a continuous ICH sample z-score, and examined the distribution of the ICH sample z-score by adiposity level in youth. Children with overweight/obesity and severe obesity had lower ICH sample z-scores than those with normal weight. Taken together, these three projects provide insight into the relationship between excess adiposity and subclinical CVD and cardiovascular health in youth. In addition, this dissertation considers metrics that have the potential to address excess adiposity prevention efforts in youth

Cardiometabolic and Cardiovascular Complications of Obesity in Children

The rise in obesity in both children and adults has made obesity one of the biggest public health problems of this century. Obesity along with other factors such as hypertension, insulin resistance, dyslipidemia and diabetes mellitus are risk factors for the development of cardiovascular diseases. Overweight and/or obesity during childhood and its maintenance until adult life has been associated with early stages of cardiovascular disease. For this reason, the aim of this study is to revise the state of the art of cardiometabolic and cardiovascular complications related with overweight and/or obesity in children and adolescents. The first consequence of weight gain is an increase in adipose tissue, with different distribution depending on the sex. The excess of fat mass entails dysfunction of adipose tissue with an altered secretion of adipokines and instauration of a proinflammatory environment, which may derive in metabolic syndrome condition. The increase of adipose tissue along with an increase in sympathetic nervous system, triggers an increased left ventricular mass and with a reduced diastolic function. Therefore, obesity should be prevented from the early stages of life, in order to avoid obesity itself and the metabolic disturbances that could undermine quality of life further on

Perinatal and early life risk factors for cardiometabolic disease in young people

The Barker hypothesis and Developmental Origins of Health And Disease highlight the importance of the perinatal and early life stages for shaping health into adolescence and adulthood. Assessing the health of the vasculature in youth can be used to identify those at increased risk of adult cardiovascular disease. This thesis presents research investigating the association between exposure to risk factors during early life and early signs of cardiometabolic disease risk in young people by assessing aortic intima-media thickness (aIMT), pulse wave velocity (PWV) and heart rate variability (HRV). Two systematic reviews investigated early life risk factors and their association with altered vascular health during the first 1,000 days of life. In Chapter 2, outcomes from pregnancy including small for gestational age (SGA), intrauterine growth restriction, preeclampsia and large for gestational were associated with greater aIMT in youth compared with controls. Chapter 3 found limited evidence that youth exposed to maternal diabetes or born SGA have increased arterial stiffness (PWV) compared to controls. Chapter 4 showed that children aged two to five years of age exposed to intrauterine preeclampsia did not have altered vascular health (aIMT or PWV) compared to normotensive controls. Chapter 5 showed that youth with type 2 diabetes have a higher frequency of cardiovascular autonomic neuropathy (assessed by HRV) and present with higher rates of severe obesity and more vascular complications including hypertension, peripheral nerve abnormality and albuminuria, compared with youth with type 1 diabetes. The main findings of this thesis are that maternal factors and adverse early life exposures, particularly during pregnancy, may increase risk of CVD in later life. Targeting modifiable risk factors including diet, exercise and weight, in youth with early life exposures may be pertinent to reduce the future risk of cardiovascular disease

The effect of maternal exposure to alcohol and nicotine on pancreas and kidney size, aorta and carotid intima thickness and visceral fat in their children.

Doctor ScientiaeIn utero exposure to teratogens, increasing urbanization, rapid nutritional transition from poverty to affluence, adoption of a Western-style diet and physical inactivity have contributed to the growing obesity epidemic in the low-income countries. To investigate the associations between in utero exposure to alcohol and nicotine on the growth and development of children aged five years from a low-income setting. These effects will be observed in children aged five years as a reduced pancreas and kidney size, higher aorta and carotid intima thickness as well as higher visceral abdominal adiposity measurements