Atherogenic Vascular Damage in Obese Children Seen to Be ...

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Atherogenic Vascular Damage in Obese Children Seen to Be ...

    Atherogenic Vascular Damage in Obese Children Seen to Be Reversible

Reuters Health Information 2006. ? 2006 Reuters Ltd.

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    NEW YORK (Reuters Health) Dec 04 - Obese children are subject to atherosclerotic changes in their arteries, but investigators in Germany report decreased intima/media thickness (IMT) of the common carotid artery and reduced cardiovascular risk factors when obese children lose weight.

    As in adults, obesity in children is associated with an adverse cardiovascular risk profile, including increased thickness of the IMT of the common carotid artery. Dr. Thomas Reinehr and his associates investigated the reversibility of atherosclerotic changes with weight loss during childhood, and report their findings in the December issue of Pediatrics.

    Dr. Reinehr, a pediatrician at the University of Witten/Herdecke, and colleagues conducted a prospective study involving 56 obese children and 10 nonobese children, median age 9 years.

    The investigators express the degree of overweight as "a standard deviation score in body mass index" (SDS-BMI). Significant weight loss was defined as a decrease of at least 0.5 SDS-BMI. IMT was measured using B-mode ultrasound with a 14 mHz linear transducer.

    At baseline, mean SDS-BMI was 2.4 in the obese group and 0.7 in the normal weight children. IMT averaged 0.60 mm and 0.47 mm, respectively. Other cardiovascular risk factors were elevated as well in the obese group.

    The obese group then participated in a 1-year program of physical exercise, nutrition education, behavioral therapy, and psychotherapy. After 1 year, 24 obese children had reduced their weight significantly (mean SDS-BMI reduced from 2.4 to 1.7), while the remaining 32 did not (2.3 to 2.2).

    IMT was reduced in the group that lost weight (0.62 to 0.55 mm), "demonstrating the reversibility of this early atherogenic vascular damage," the researchers write. In contrast, IMT tended to progress in the subjects who had not lost weight (0.59 to 0.62 mm). Weight loss also engendered a healthier cardiovascular risk profile, including decreases in blood pressure, insulin, insulin resistance index and triglyceride levels, while HDL cholesterol levels increased significantly. Those who failed to lose weight had no

    significant change in blood pressure, or lipid profile, while their insulin levels and insulin resistance index increased significantly.

    In the final analysis, only change in SDS-BMI was significantly associated with changes in IMT, suggesting that "weight loss is the main determinant of changes in IMT," the authors indicate.

    In conclusion, Dr. Reinehr's group writes, "Intervention in obese children may prevent cardiovascular diseases in later life."

    Pediatrics 2006;118:2334-2340.

    Low-Fat Diet in Infancy May Improve Endothelial Function in 11-Year-Old Boys CME

    News Author: Laurie Barclay, MD

    CME Author: Désirée Lie, MD, MSEd

    Complete author affiliations and disclosures, and other CME information, are available at

    the end of this activity.

    Release Date: December 6, 2005; Reviewed and Renewed: December 6, 2006; Valid

    for credit through December 6, 2007

    Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)? for physicians;

    Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians

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    Dec. 6, 2005 Adopting a low-fat diet in 7-month-old infants is associated with improved endothelial function at age 11 years for boys, but not girls, according to the results of a randomized study reported in the Dec. 6 Rapid Access issue of Circulation.

    The effect may be mediated by a reduction in cholesterol.

    "Early childhood introduction of nutritional habits aimed at atherosclerosis prevention reduces children's serum total cholesterol concentration, but its effect on vascular endothelial function is unknown," write Olli T. Raitakari, MD, PhD, from the University of Turku in Finland, and colleagues from the Special Turku Coronary Risk Factor Intervention Project for Children (STRIP). "STRIP has demonstrated that a fat-modified diet (low in saturated fat) initiated in infancy and combined with repeated individualized dietary and lifestyle counseling lowers serum cholesterol concentration in children without adversely influencing growth or neurological development."

    Between 1990 and 1992, 1,062 healthy 7-month-old infants were randomized to intervention (low-saturated-fat diet) and control (unrestricted diet) groups. At age 11 years, 179 children from the intervention group and 190 from the control group had high-resolution ultrasound to measure endothelium-dependent (flow-mediated) and endothelium-independent (nitrate-mediated) vasodilatory responses of the brachial artery.

    In boys, but not in girls, the effect of intervention on endothelial function was significant (P = .0034 vs P = .69). In boys, the mean maximum endothelium-dependent dilation response was 9.62% ? 3.53% in the intervention group and 8.36% ? 3.85% in the control

    group. For girls, the corresponding figures were 8.84% ? 4.00% and 8.44% ? 3.60%, respectively. Intervention did not affect nitrate-mediated dilation.

    After adjustment for current serum total or low-density lipoprotein (LDL) cholesterol levels, the difference in endothelial function in boys remained significant. However, this became nonsignificant after adjustment for mean cholesterol measured at younger than 3 years (adjusted means, 9.46% [95% confidence interval [CI], 8.68% - 10.24%] vs 8.54% [95% CI, 7.75% - 9.32%]; P = .11).

    Study limitations include loss of a substantial number of children to follow-up and performance of ultrasound only in a subgroup of the initial study cohort. "A low-saturated-fat diet introduced in infancy and maintained during the first decade of life is associated with enhanced endothelial function in boys," the authors write. "The effect is explained in part by the diet-induced reduction in serum cholesterol concentration."

    The Academy of Finland; City of Turku; the Finnish Foundation for Pediatric Research; the Finnish Foundation of Cardiovascular Research; the Finnish Cultural Foundation; government grants for Turku University Hospital; Juho Vainio Foundation; the Mannerheim League for Child Welfare; Raisio Group Research Foundation; the Social Insurance Institution of Finland; the Turku University Foundation; the Van den Bergh Foods Company; the Yrjö Jahnsson Foundation; and the Sigrid Juselius Foundation supported this study. The authors have disclosed no relevant financial relationships. Circulation. Posted online Dec. 6, 2005.

    Learning Objectives for This Educational Activity

    Upon completion of this activity, participants will be able to:

    ; Describe the effect of a low-saturated-fat diet in the first 11 years of life on lipid

    levels in children.

    ; Describe the association between cholesterol-lowering and flow-mediated

    vasodilatory responses of the brachial artery in children.

    Clinical Context

    Hypercholesterolemia is associated with impaired endothelial function and accelerated atherogenesis in children and, according to the authors, a step II diet of the National Cholesterol Education Program diet can reduce cholesterol levels in children for a 6-month period without change in endothelial function in a previous study. The authors conducted a long-term study for 11 years to examine the effect of a low-saturated-fat diet on total and LDL cholesterol levels and endothelial function in children from the age of 7 months to investigate if cholesterol lowering in children affected endothelial function measured in the brachial artery.

    Study Highlights

    ; 540 children were randomized at the 5-month well-child visit to an intervention

    diet and 522 to a control diet from the age of 7 months.

    ; Intervention children received family dietary and lifestyle counseling biannually

    and 2 food-record examinations by a dietician a year.

    ; Control children received no dietary counseling and similar food-record


    ; The fat intake of the intervention group was approximately 30% vs a significantly

    higher fat intake in the control group (P < .001).

    ; Both parents of the intervention group and the children consumed less saturated

    fat than control groups.

    ; There was no effect of the intervention on early or later growth of the children. ; Weight, height, blood pressure, and Tanner staging were performed. ; Serum total, high-density lipoprotein and LDL cholesterol, and triglyceride levels

    were measured at 7 and 13 months and at 2, 3, 4, 5, 7, 9, 10, and 11 years. ; 93% of children received 8 or more measurements.

    ; Brachial artery ultrasounds were obtained on 369 children at 11 years. ; Ultrasound scans were analyzed by a blinded assessor.

    ; Flow velocity after induction by inflation of a cuff and after cuff deflation were


    ; Total dilatation response and dilatory response to 250-µg sublingual

    nitroglycerine were obtained.

    ; The intervention group had lower intake of saturated fat and a higher ratio of

    polyunsaturated to saturated fatty acid than the control children (P < .001).

    ; Boys in the intervention group had 0.23-mmol/L lower total serum cholesterol

    level (P = .035) and 0.26-mmol/L lower LDL cholesterol concentration (P = .009)

    vs the control group.

    ; There were no differences in total and LDL cholesterol level between intervention

    and control girls.

    ; At age 11 years, two thirds of children had ongoing puberty but none had

    completed puberty.

    ; Maximum flow-mediated dilation (P = .012) and the area under the dilation

    response vs. time curve (P = .004) were higher in the intervention than in the

    control boys.

    ; These values did not differ between intervention and control girls. ; Mean cholesterol values measured between ages 7 months and 2 years and

    between 3 and 5 years were significantly related to flow-mediated dilation. ; Mean cholesterol measured between age 7 and 11 years and current cholesterol

    levels were not significantly related to flow-mediated vasodilation in girls or boys. ; Total and LDL cholesterol levels had no association with nitrate-mediated dilation.

    Pearls for Practice

    ; A low-saturated-fat diet in children aged 7 months to 11 years is associated with

    lower levels of total and LDL cholesterol at 11 years.

    ; Lower total and LDL cholesterol levels measured up to age 5 years is associated

    with increased flow-mediated but not nitrate-mediated dilation in the brachial

    artery in children placed on a low-saturated-fat diet from age 7 months to 11


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    Target Audience

    This article is intended for primary care physicians, pediatricians, and other specialists who care for children at risk for hypercholesterolemia.


    The goal of this activity is to provide the latest medical news to physicians and other healthcare professionals in order to enhance patient care.

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    News Author

    Laurie Barclay, MD

    is a freelance reviewer and writer for Medscape.

    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships. Clinical Reviewer

    Gary Vogin, MD

    Senior Medical Editor, Medscape

    Disclosure: Gary Vogin, MD, has disclosed no relevant financial relationships. CME Author

    Desiree Lie, MD, MSEd

    Clinical Professor of Family Medicine; Director, Division of Faculty Development, University of California, Irvine School of Medicine, Irvine, California

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