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Check the Lipid Profile? Why?

Check the Lipid Profile? Why?. Douglas W. Teske, MD The Heart Center Nationwide Children’s Hospital. Objectives. 1.To state the recommendations to obtain lipid profiles in children and adolescents 2.To discuss the approach to an abnormal lipid profile

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Check the Lipid Profile? Why?

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  1. Check the Lipid Profile? Why? Douglas W. Teske, MD The Heart Center Nationwide Children’s Hospital

  2. Objectives 1.To state the recommendations to obtain lipid profiles in children and adolescents 2.To discuss the approach to an abnormal lipid profile 3.To determine when to initiate a lipid lowering medication

  3. Heart Healthy Lifestyle • Normal weight for height • Appropriate diet for level of physical activity • Daily exercise • No smoking or use of other tobacco products

  4. Epidemic of Childhood Obesity Concerns: - type 2 diabetes mellitus - systemic hypertension - risk of CVD in young adults - cigarette smoking/use of OTPs - oral contraceptives

  5. Body Mass Index BMI Obesity (kg/M2) Classification Underweight <18.5 Normal 18.5-24.9 Overweight 25.0-29.9 Obesity 30.0-34.9 I 35.0-39.9 II Extreme obesity >40.0 III

  6. Metabolic Syndrome in Adults Waist circumference men >102 cm/>40 in female >88 cm/>35 in Triglyceride >150 mg/dL HDL-C men <40 mg/dL female <50 mg/dL Blood pressure >130/>85 mmHg Fasting blood sugar >100 mg/dL

  7. Metabolic Syndrome in Pediatrics • No accepted definition • Concerns with increases in obesity, prediabetes mellitus, and type 2 diabetes mellitus • Concerns with autopsy findings of fatty streaks and fibrous plaques in adolescents • Treatment: lower the BMI with lifestyle changes in diet and physical activity

  8. Concern for the Present and Future • Increasing number of obese children and adolescents • Increasing number of inactive children and adolescents • Inability to significantly lower the number of children and adolescents who smoke and use other tobacco products

  9. Childhood Risk Factors for Adult CVD • Obesity • Sedentary lifestyle • Cigarette smoking/use of OTPs • Hypertension • Hyperlipidemia • high LDL-C • low HDL-C

  10. Lipid Screening • American Academy of Pediatrics: • First screening after 2 y/o but no later than 10 y/o • Should be a fasting lipid profile • Obtained in context of a well-child and health maintenance visit • If normal range valves, retest in 3 to 5 years

  11. AAP: Universal Screening Approach • First time recommendation for universal screening for pediatric patients • No data to support that a specific level of a childhood cholesterol will predict the risk of adult CVD • No data on lack of identification and treatment of children with a high lipid level will lead to an increased risk of CVD development

  12. Universal Pediatric Approach • A family problem which requires changes in the behavior of the whole family: • Improve the diet • Increase daily activities • Improve family lifestyle • Improve the school lunch • Join community activities • Stop family use of tobacco products

  13. Healthful Eating Behaviors • Eat meals and snacks at regular times • Avoid calorie-dense snacks • At the dinner table, focus on conversation and not just the food • Plate the food • Don’t eat in front of the TV • Eat slowly • Eat a healthy breakfast • Limit fast-food meals to once a week

  14. Personal Recommendations • Ages 2 to 8/10 years old • heart healthy lifestyle recommendations • be aggressive in patients with diabetes, renal disease, congenital or acquired heart disease, collagen vascular disease, cancer survivors • Ages 8 to 10 years old • fasting lipid profile • consider dietitian, exercise physiologist, psychologist

  15. Personal Recommendations • Normal profile and no need for ensuing intervention: • repeat the FLP when 16-18 years old • Abnormal profile and a need for intervention: • repeat the FLP in 1-2 years • Again abnormal in males: increase the intervention or consider a medication • Again abnormal in females: increase the intervention and consider a medication after a repeat profile after 6 months of regular menses or the use of an oral contraceptive

  16. Fasting Lipid Profile • Normal lipid levels the same for 2-18 y/o • Concentrations in mg/dL TC LDL-C HDL-C TG acceptable <170 <100 >40 (M) >50 (F) borderline 170-199 100-129 elevated >200 >130 >110

  17. Fasting Lipid Profile • Intention to treat if LDL-C level: • >130 mg/dL with diabetes • >160 mg/dL with a positive family history • parent/grandparent with an early cardiac event • parent/grandparent with a TC >240 mg/dL • unknown family history • >190 mg/dL with a negative family history

  18. Abnormal Lipid Profile • Evaluate for secondary causes • exogenous – drugs or obesity • endocrine and metabolic – hypothyroidism and diabetes • storage diseases • obstructive liver diseases • chronic renal disease

  19. Screening Laboratory Studies • Liver • ALT, AST, CK, PT/INR • Kidney • BUN, Cr, UA • Thyroid • T-4 total, TSH • Heme • CBC with differential and platelets

  20. Medication Discussion • Need for compliance with long-term medicine use • Understanding that there is no evidence that pharmacologic treatment at a younger age will decrease morbidity and mortality from a CV event • Understanding that there is no evidence that it is safe and cost effective to treat for decades individuals with an elevated cholesterol level • Concern with labeling adolescents with a “disease” • Treatment could exacerbate the prevalence of eating disorders

  21. Pharmacotherapeutic Agents • Bile acid sequestrant • Cholestyramine • Niacin • Statins • Pravastatin, Lovastatin, Simvastatin, Atorvastatin • Cholesterol absorption inhibitor • Fibrate

  22. Statin Therapy • Use the statin of your choice at 10 mg/day taken at bedtime • Add a morning multivitamin with vitamin K • Emphasize an adequate daily calcium intake • Repeat the FLP in 2 months and adjust the statin dose • With a stable statin dose, repeat the FLP every 6-12 months with yearly liver studies

  23. Case Study #1 • Female Age 8 years • Wt 51.5 kg (>97%) • Ht 132 cm (50-75%) • BMI 29.3 kg/M2 • BP 112/72 mmHg • TG 281 mg/dL • TC 224 mg/dL • HDL-C 35 mg/dL • LDL-C 133 mg/dL

  24. Case Study #2 • Male 11 years old • Wt 51.2 kg (95%) • Ht 142.5 cm (~50%) • BMI 25.2 kg/M2 • BP 106/64 mmHg • TG 58 mg/dL • TC 208 mg/dL • HDL-C 56 mg/dL • LDL-C 141 mg/dL

  25. Case Study #2 • Male 11 years old 16 years old • Wt 51.2 kg (95%) 56.8 kg (50%) • Ht 142.5 cm (~50%) 168.2 cm (~50%) • BMI 25.2 kg/M2 20.1 kg/M2 • BP 106/64 mmHg 116/70 mmHg • TG 58 mg/dL 44 mg/dL • TC 208 mg/dL 160 mg/dL • HDL-C 56 mg/dL 50 mg/dL • LDL-C 141 mg/dL 101 mg/dL

  26. Case Study #3 • Male 14 years old • Wt 99.4 kg (>97%) • Ht 165.6 (~50%) • BMI 36.2 kg/M2 • BP 124/58 mmHg • TG 199 mg/dL • TC 228 mg/dL • HDL-C 33 mg/dL • LDL-C 155 mg/dL

  27. Case Study #3 • Male 14 years old 15 years old • Wt 99.4 kg (>97%) • Ht 165.6 cm (~50%) • BMI 36.2 kg/M2 • BP 124/58 mmHg • TG 199 mg/dL 266 mg/dL • TC 228 mg/dL 230 mg/dL • HDL-C 33 mg/dL 33 mg/dL • LDL-C 155 mg/dL 144 mg/dL

  28. Case Study #4 • Male 11 years old • Wt 68.3 kg (>>97%) • Ht 160 cm (>97%) • BMI 26.7 kg/M2 • BP 136/86 mmHg • TG 366 mg/dL • TC 248 mg/dL • HDL-C 40 mg/dL • LDL-C 134 mg/dL

  29. Case Study #4 • Male 11 years old 17 years old • Wt 68.3 kg (>>97%) 122.1 kg (>>97%) • Ht 160 cm (>97%) 186.5 cm (>95%) • BMI 26.7 kg/M2 35.1 kg/M2 • BP 136/86 mmHg 142/88 mmHg • TG 366 mg/dL 453 mg/dL • TC 248 mg/dL 270 mg/dL • HDL-C 40 mg/dL 38 mg/dL • LDL-C 134 mg/dL

  30. Case Study #5 • Male 15 years old • Wt 107.5 kg (>97%) • Ht 178.9 cm (90%) • BMI 33.6 kg/M2 • BP 142/94 mmHg • TG 312 mg/dL • TC 333 mg/dL • HDL-C 20 mg/dL • LDL-C 243 mg/dL

  31. Case Study #5 • Male 15 years old 16 years old • Wt 107.5 kg (>97%) 81.1 kg (~90%) • Ht 178.9 cm (90%) 180.3 cm (~90%) • BMI 33.6 kg/M2 24.9 kg/M2 • BP 142/94 mmHg 120/72 mmHg • TG 312 mg/dl 88 mg/dL • TC 333 mg/dL 290 mg/dL • HDL-C 20 mg/dL 39 mg/dL • LDL-C 243 mg/dL 233 mg/dL

  32. Case Study #6 • Male 13 years old • Wt 46.8 kg (25%) • Ht 163.8 cm (25-50%) • BMI 17.4 kg/M2 • BP 96/64 mmHg • TG 105 mg/dL • TC 347 mg/dL • HDL-C 46 mg/dL • LDL-C 280 mg/dL

  33. Case Study #6 • Male 13 years old 15 years old • Wt 46.8 kg (25%) • Ht 163.8 cm (25-50%) • BMI 17.4 kg/M2 • BP 96/64 mmHg • TG 105 mg/dL 48 mg/dL • TC 347 mg/dL 179 mg/dL • HDL-C 46 mg/dL 44 mg/dL • LDL-C 280 mg/dL 125 mg/dL

  34. Case Study #7 • Female 13 years old • Wt 58.6 kg (75%) • Ht 159 cm (50%) • BMI 23.2 kg/M2 • BP 122/70 mmHg • TG 65 mg/dL • TC 274 mg/dL • HDL-C 39 mg/dL • LDL-C 222 mg/dL

  35. Case Study #7 • Female 13 years old 16 years old • Wt 58.6 kg (75%) 60.4 kg (50-75%) • Ht 159 cm (50%) 160.5 cm (25-50%) • BMI 23.2 kg/M2 23.4 kg/M2 • BP 122/70 mmHg 104/64 mmHg • TG 65 mg/dL 83 mg/dL • TC 274 mg/dL 203 mg/dL • HDL-C 39 mg/dL 37 mg/dL • LDL-C 222 mg/dL 149 mg/dL

  36. 10 Ways to Help Children Develop Healthy Habits 10. Be an advocate for healthier children 9. Make a game of reading food labels 8. Make dinnertime a family time 7. Find new ways to celebrate good behavior 6. Set specific goals and realistic limits 5. Be supportive 4. Customize physical activities 3. Limit TV, video games, iPod time, and computer time 2. Get the whole family involved 1. Be a positive role model

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