Childhood Risk Factors Predict Later CVD Risk

CVD risk factors that are present in childhood can be strong predictors of cardiac events later in life, new data suggest.

The study of children from three countries who were followed for nearly 24 years into adulthood found that the body mass index (BMI) in the teen years and younger plays nearly as important a role as adult BMI in predicting risk of fatal or nonfatal CVD events. Other risk factors, including LDL cholesterol, total cholesterol, triglycerides, systolic BP, and smoking also were predictive of later risk, although the associations were not as strong as they were for BMI.

“The results are based on individuals who have lived in the period where programs for risk factor reduction in adulthood, such as sophisticated antihypertensive agents and statins, have been available,” the investigators write in JAMA Network Open. “Yet, still they have retained a much higher risk for adult CVD than their peers who had lower risk factor levels in childhood.”

Eugene Yang, MD (University of Washington, Bellevue), who was not involved in the study, told TCTMD that the findings highlight the need to put more efforts into primordial prevention.

“We need to increase the level of education at much earlier ages on adopting healthy lifestyle habits, because . . . these things impact other risk factors, including total cholesterol, LDL-C, and systolic blood pressure,” he said.

While some efforts have tried to address healthy habits in schools, Yang said parents need to take note of studies like this one and understand the seriousness of unhealthy weight, cholesterol, and BP in their children.

“It's going to require a paradigm shift, in my opinion,” Yang added. “Even though this is just one study, it really reinforces what we already believe, which is that we need to attack these problems maybe at the federal level through policies related to changes in how we organize schools, and [in] what importance needs to be placed on physical activity and nutrition.”

Tracking Into Adulthood in Three Countries

Investigators led by Noora Kartiosuo, MS (University of Turku, Finland), analyzed data on 10,634 participants (58% female; 10% Black) from the US, Finland, and Australia who were enrolled as part of the International Childhood Cardiovascular Cohort (i3C) consortium between the 1970s and the 1990s, when they were between 3 and 19 years of age (mean age 13 years).

All participants had at least one clinic visit in both childhood and adulthood, with follow-up for CVD events after age 25 (mean follow-up age 32 years). The clinic visits assessed height, weight, BMI, systolic BP, total cholesterol, LDL, triglycerides, and tobacco smoking.

Over the follow-up period, 521 participants had a fatal or nonfatal CVD event at a mean age of 49.2 years. BMI in childhood had both a direct impact on later CVD (RR 1.18; 95% CI 1.05-1.34) as well as an indirect impact (RR 1.19; 95% CI 1.09-1.29), as did LDL cholesterol (RR 1.16; 95% CI 1.01-1.34 and RR 1.11; 95% CI 1.05-1.17).

For the other continuous risk factors, indirect pathways contributed more than direct pathways for triglycerides (RR 1.17; 95% CI 1.12-1.21), total cholesterol (RR 1.14; 95% CI 1.08-1.19), and systolic BP (RR 1.15; 95% CI 1.10-1.19). Smoking at a young age contributed to later CVD risk, but only if it was continued in adulthood.

We need to increase the level of education at much earlier ages on adopting healthy lifestyle habits. Eugene Yang

Overall, a combined risk score that consisted of LDL cholesterol, total cholesterol, triglycerides, systolic BP, smoking, and BMI was more important than any single risk factor alone in predicting the direct or indirect impact on future CVD risk.

When considering that the participants of the study spent one-third of their lives in childhood, the researchers say the findings support the pathogenesis of CVD via early exposure to adverse health conditions.

“Once risk factors are established at a high level in childhood, reducing them effectively is difficult,” Kartiosuo and colleagues write. “Although efforts to reduce risk factors in adulthood remain important, efforts to achieve optimal success in preventing both the direct and indirect effects we observed may need to commence in childhood.”

To accomplish that, they say a desirable balance of lifestyle and clinical interventions at each life stage should now be a priority.

To TCTMD, Yang noted that while the study is large and well conducted, it lacks detail on the racial and ethnic backgrounds of the participants, making it difficult to know how generalizable it is with regard to impact of the various risk factors.

That aside, he said the study has implications regarding cholesterol screening in children. In their 2016 report, the United States Preventive Services Task Force (USPSTF) concluded that there are not enough data to justify routine cholesterol screening in asymptomatic children and adolescents.

Yang said the i3C data may be the push the USPSTF needs to consider recommending a one-time childhood screen as a preventive measure and the push that parents need to understand the very real harm of long-term exposure to elevated BP and cholesterol.

“We're not going to change everybody, but maybe this provides more ammunition for parents to say . . . maybe we are going to be much more careful about trying to give children the freedom to eat and do the things they want to, but at the same time also provide them with some better understanding of how nutrition is important, how physical activity is important, and optimizing weight is important,” he added.