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Life's Essential 8™ - Children & Adolescents Program

"The earlier you start, the longer you benefit" - Cardiovascular Prevention Principle

Cardiovascular disease doesn't begin in middle age - it begins in childhood. Autopsy studies of children and adolescents who died from accidents reveal that atherosclerosis starts as early as age 3, with fatty streaks in coronary arteries visible by age 10, and fibrous plaques by the teenage years. The Bogalusa Heart Study definitively demonstrated that childhood risk factors (obesity, high cholesterol, elevated blood pressure) predict adult atherosclerosis and cardiovascular events.

Yet the opportunity is equally clear: healthy habits established in childhood track into adulthood. Children who eat well, stay active, and maintain healthy weight are far more likely to be healthy adults. Prevention is most effective - and most feasible - when started early, before unhealthy patterns become entrenched.

The stakes have never been higher: the childhood obesity epidemic has created a generation at unprecedented cardiovascular risk. In the United States, 19.7% of children and adolescents (ages 2-19) have obesity, triple the rate from 1980. Type 2 diabetes - once called "adult-onset" - now affects children and adolescents, with more aggressive progression than adult-onset disease. Hypertension affects 5-10% of youth, and dyslipidemia is increasingly common.

This program addresses the cardiovascular health crisis facing today's youth through comprehensive, family-centered, evidence-based prevention - giving children and families the knowledge, skills, and support to build healthy hearts for life.

Program Overview

Why Start in Childhood?

Principle Evidence Implication
Atherosclerosis begins early Pathobiological Determinants of Atherosclerosis in Youth (PDAY): Fatty streaks in aorta present in 50% by age 10-14, 85% by age 21-39
Coronary fatty streaks in 30% adolescents		 Prevention must begin in childhood, not wait until middle age when disease advanced
Risk factors track Bogalusa Heart Study: Children in highest quartile for risk factors (BMI, BP, cholesterol) have 2-3× ↑ subclinical atherosclerosis as adults (carotid IMT, coronary calcium) Childhood risk factors predict adult CVD - intervene early to change trajectory
Habits track Longitudinal studies: Diet quality, physical activity, sedentary behavior in childhood moderately correlate with adult behaviors (r=0.3-0.5) Establish healthy habits early (easier than changing established patterns later)
Intervention effective Meta-analyses: School-based interventions ↓ BMI 0.3-0.5 kg/m², improve diet quality, ↑ physical activity
Family-based programs ↓ childhood obesity 1-2 BMI units		 Prevention works - substantial impact on health trajectories
Childhood obesity → adult disease ~80% obese adolescents become obese adults
Childhood obesity → ↑ 2-3× adult CVD mortality even if lose weight by adulthood (legacy effect)		 Preventing childhood obesity = preventing adult CVD, diabetes, metabolic syndrome
Critical periods Adiposity rebound (age 4-6), puberty (age 10-14) = periods when interventions particularly impactful Target interventions to developmental windows of opportunity

Target Population

  • All children and adolescents (ages 2-18 years) - universal prevention
  • Special focus on high-risk groups:
    • Children with obesity (BMI ≥95th percentile for age/sex)
    • Children with family history of premature CVD (parent/sibling <55♂ or <65♀)
    • Children with diabetes (type 1 or type 2), hypertension, dyslipidemia
    • Children from low-income families, racial/ethnic minorities (disparities in obesity, access)
    • Children with sedentary lifestyles, poor diets, excessive screen time

Program Goals

Goal Strategies Outcomes
Primary Prevention Health education, family engagement, school-based programs, community partnerships All children achieve healthy Life's Essential 8™ scores
Prevent obesity, diabetes, HTN onset
Early Detection Universal screening (BMI, BP at well-child visits), selective lipid/glucose screening Identify high-risk children early
Intervene before complications
Treatment Family-based lifestyle intervention, multidisciplinary care, medications if indicated Reverse obesity, normalize BP/lipids/glucose
Prevent progression to adult disease
Health Equity Target underserved communities, culturally-tailored programs, reduce access barriers Eliminate disparities in childhood obesity, CVD risk factors
Systems Change Advocate for healthy school policies, built environment improvements, food access Create environments supporting healthy choices
Population-level impact

Program Structure - Tiered Approach

Tier Target Intervention Intensity
Tier 1:
Universal Prevention		 ALL children • School-based health education
• Community awareness campaigns
• Well-child visit counseling
• Parent education		 Low intensity
Broad reach
Tier 2:
Targeted Prevention		 At-risk children
(overweight, family history, borderline BP/lipids)		 • Group lifestyle programs
• School wellness programs
• Enhanced primary care counseling		 Moderate intensity
Group-based
Tier 3:
Clinical Treatment		 Children with obesity, HTN, dyslipidemia, diabetes • Intensive family-based behavioral intervention
• Multidisciplinary clinic
• Medications if indicated
• Bariatric surgery (extreme cases)		 High intensity
Individual/family

Life's Essential 8™ for Children & Adolescents

Metrics adapted for pediatric population - age-appropriate definitions and targets

1. Diet Quality

Age-Specific Recommendations

Age Group Key Recommendations Portions/Day
Toddlers
(1-3 years)		 • Whole milk (transition to low-fat at age 2 if growing well)
• Variety of fruits, vegetables (encourage exploration)
• Whole grains
• Limit juice (<4 oz/day), avoid added sugars		 1,000-1,400 kcal/day
1-1.5 cups fruit
1-1.5 cups vegetables
3 oz grains
Preschool
(4-5 years)		 • Low-fat dairy (1% or skim milk)
• 5 servings fruits/vegetables daily
• Limit sugary drinks, sweets
• Family meals (model healthy eating)		 1,200-1,600 kcal/day
1-2 cups fruit
1.5-2 cups vegetables
4-5 oz grains
School-Age
(6-11 years)		 • Balanced meals (MyPlate model: ½ plate fruits/vegetables, ¼ grains, ¼ protein)
• Whole grains >50%
• Lean proteins (fish 2×/week)
• Limit fast food, processed snacks
• Water as primary beverage		 1,400-2,200 kcal/day
1.5-2 cups fruit
2-3 cups vegetables
5-6 oz grains
4-5.5 oz protein
Adolescents
(12-18 years)		 • Similar to adults (Mediterranean/DASH patterns)
• Adequate calcium (1,300 mg/day - bone growth)
• Iron (girls - menstruation)
• Avoid energy drinks, excessive caffeine
• Address disordered eating if present		 1,600-3,200 kcal/day (varies by sex, activity)
2-2.5 cups fruit
2.5-4 cups vegetables
6-10 oz grains
5-7 oz protein

Special Considerations

Common Pediatric Dietary Issues:

  • Picky eating (toddlers/preschoolers):
    • Normal developmental phase - repeated exposure (10-15 times) often needed before acceptance
    • Strategies: Involve children in meal planning/preparation, make food fun (colorful plates), avoid pressure/bribes, model healthy eating, limit distractions (TV during meals)
    • Don't cater to preferences excessively (short-order cooking) - offer healthy options, child chooses how much to eat
  • Sugary beverages:
    • Major contributor to childhood obesity - 120-200 kcal/day from sugary drinks common
    • Eliminate: Soda, juice drinks, sports drinks (unless truly needed for athletics), energy drinks
    • Limit 100% juice: <4 oz/day age 1-3, <6 oz/day age 4-6, <8 oz/day age 7+
    • Promote: Water (primary), low-fat/skim milk
  • Fast food:
    • 1 in 3 children eats fast food daily - high calorie, low nutrient quality
    • Strategies: Limit to <1×/week, choose healthier options when unavoidable (grilled chicken, salads, fruit sides), avoid supersizing
  • School meals:
    • USDA standards improved (more fruits/vegetables, whole grains, ↓ sodium) but still challenges
    • If packing lunch: Follow MyPlate model, avoid processed foods, include water
  • Family meals:
    • Protective factor - children who eat family meals ≥5×/week have better diet quality, lower obesity risk, better academic/mental health outcomes
    • Prioritize even if busy - simple meals acceptable, focus on togetherness

Practical Counseling Tips

  • Traffic light approach (for families):
    • 🟢 Green foods: "Anytime foods" - fruits, vegetables, whole grains, lean proteins, water
    • 🟡 Yellow foods: "Sometimes foods" - refined grains, higher-fat proteins, 100% juice (limited portions)
    • 🔴 Red foods: "Once-in-a-while foods" - sweets, fried foods, soda (special occasions only)
    • Easy for children to understand, empowers choices
  • Involve children: Grocery shopping (choose vegetables), meal preparation (wash, mix, set table), gardening (grow vegetables) → ↑ willingness to try new foods
  • Positive framing: "Eating vegetables helps you grow strong" not "Eat vegetables or no dessert" (avoids food as reward/punishment)

2. Physical Activity

Recommendations by Age

Age Guideline Examples
Preschool
(3-5 years)		 • Active throughout day (no specific time)
• Variety of activities
• Limit sedentary time (no >1 hour sitting except sleep)		 • Running, jumping, climbing at playground
• Dancing, tumbling
• Swimming, tricycle
• Active play with peers/parents
Children
(6-17 years)		 ≥60 minutes/day moderate-to-vigorous activity
• Aerobic: Most of 60 min
• Muscle-strengthening: ≥3 days/week
• Bone-strengthening: ≥3 days/week		 Aerobic: Running, biking, swimming, active games (tag, soccer)
Muscle: Climbing, push-ups, resistance bands, weight training (adolescents)
Bone: Jumping, running, tennis, basketball

Current Reality & Barriers

Alarming statistics:

  • Only 24% of children 6-17 years meet 60 min/day guideline
  • Physical activity ↓ dramatically during adolescence (especially girls)
  • Average child/adolescent spends 7-8 hours/day sedentary (school, screen time)

Barriers:

  • Screen time epidemic: TV, video games, smartphones, tablets - highly sedentary, displaces active play
  • Reduced PE: Only 51% high schools require PE, time allocated decreased
  • Safety concerns: Parents fear letting children play outside unsupervised (traffic, crime) → indoor sedentary activities
  • Built environment: Lack of sidewalks, parks, safe play spaces in many neighborhoods
  • Structured schedules: Overscheduled with academics, lessons → little free play time
  • Parental modeling: Sedentary parents → sedentary children

Strategies to Increase Activity

Individual/Family Level:

  • Limit screen time:
    • AAP recommendations: <18 months: Avoid screens (except video chatting), 18-24 months: High-quality programming only with parent co-viewing, 2-5 years: <1 hour/day high-quality programming, ≥6 years: Consistent limits (interferes with sleep, activity, other healthy behaviors)
    • Practical: No screens during meals, 1 hour before bed, in bedrooms. Use parental controls. "Screen-free" zones/times.
  • Active transportation: Walk/bike to school if feasible (safe route), walk to nearby destinations
  • Family activities: Hikes, bike rides, sports, swimming on weekends - models activity, quality time
  • Organized sports: Team sports (soccer, basketball, baseball) - social, skill-building, consistent activity. BUT don't overschedule (burnout risk), ensure fun/noncompetitive for younger children.
  • Active play: Unstructured playtime outdoors - essential for development, creativity, activity
  • Make it fun: Children more likely to continue activities they enjoy - explore options (dance, martial arts, skateboarding, rock climbing, swimming) until find what child loves

School Level:

  • Quality daily PE: Restore PE requirements, ↑ time allocated, ensure moderate-to-vigorous intensity (not just standing around)
  • Recess: ≥20 min/day, encourage active play, provide equipment (balls, jump ropes)
  • Active classrooms: Activity breaks during lessons, standing desks, movement-based learning
  • After-school programs: Sports, active clubs, intramurals

Community Level:

  • Safe routes to school: Infrastructure improvements (sidewalks, crosswalks, crossing guards)
  • Parks and recreation: Accessible playgrounds, sports facilities, programs (subsidized for low-income)
  • Built environment: Walkable neighborhoods, bike lanes, urban planning prioritizing activity

3. Nicotine Exposure

Pediatric Concerns

Secondhand smoke:

  • ~40% of children exposed to secondhand smoke regularly (home, car, public places)
  • Health effects: ↑ Respiratory infections, asthma, SIDS, ear infections, AND ↑ atherosclerosis (endothelial dysfunction measurable in children exposed to secondhand smoke)
  • No safe level of secondhand smoke exposure

Youth tobacco use:

  • Cigarette smoking: ↓ Dramatically (5% high schoolers 2021 vs 36% in 1997) - success story
  • E-cigarette epidemic: 2 million middle/high school students current e-cigarette users (2022)
    • Highly addictive - nicotine impairs adolescent brain development (prefrontal cortex not fully developed until age 25)
    • Gateway to combustible cigarettes
    • Cardiovascular effects (endothelial dysfunction, ↑ BP, ↑ HR) even in adolescents
    • Targeted marketing to youth (flavors, social media, influencers)

Prevention Strategies

Parental actions:

  • Be smoke-free: #1 predictor of youth smoking = parental smoking. If parent smokes → child 3× more likely to smoke. Quit (or never start).
  • Smoke-free home and car: 100% - no exceptions. Protects children from secondhand smoke, denormalizes smoking.
  • Talk early and often: Start age 5-6 (before experimentation). Discuss harms (addiction, health), reasons people smoke (peer pressure, stress), how to refuse offers. Ongoing conversation, not one-time.
  • Monitor: Know friends, activities, social media. High supervision protective.
  • Set clear expectations: "Our family doesn't use tobacco/e-cigarettes" - establish norm.

School-based programs:

  • Evidence-based curricula (e.g., "Botvin LifeSkills Training") - teach refusal skills, correct misperceptions (most teens DON'T smoke), stress management
  • Tobacco-free campus policies (students, staff, visitors)
  • Enforcement of age restrictions (sales to minors)

Policy:

  • ↑ Tobacco taxes (↓ youth initiation)
  • Flavor bans (e-cigarettes - flavors appeal to youth)
  • Marketing restrictions (youth-oriented advertising)
  • Raising minimum age to 21 (Tobacco 21 laws - effective ↓ youth access)

Cessation for Youth Who Use Tobacco

  • Counseling: Motivational interviewing, cognitive-behavioral therapy (address triggers, coping strategies)
  • Pharmacotherapy: NRT, varenicline, bupropion approved age ≥12-18 (depending on medication). Less studied in adolescents than adults but can help if dependent.
  • Involve parents: Parental support ↑ quit success
  • Address comorbidities: Depression, ADHD, substance use common in adolescent smokers - treat holistically

4. Sleep Health

Sleep Recommendations by Age

Age Recommended Hours/24h Notes
Infants (4-12 months) 12-16 hours (including naps) Regular sleep schedule, safe sleep environment (back to sleep, firm surface, no loose bedding - SIDS prevention)
Toddlers (1-2 years) 11-14 hours (including naps) Consistent bedtime routine, transition from crib to bed age ~3
Preschool (3-5 years) 10-13 hours (naps less frequent) Behavioral sleep issues common (resistance, night wakings) - consistent routine, limit stimulation before bed
School-age (6-12 years) 9-12 hours Adequate sleep → better academic performance, behavior, emotional regulation
Teens (13-18 years) 8-10 hours Insufficient sleep epidemic (only 20-30% get adequate sleep) - biological phase delay + early school start times = chronic sleep debt

Current Sleep Crisis in Youth

Insufficient sleep widespread:

  • ~60% middle schoolers, 70% high schoolers get <8 hours/night (below recommended minimum)
  • Consequences: ↓ Academic performance, ↑ obesity (sleep deprivation → ↑ appetite, ↓ physical activity), ↑ depression/anxiety, ↑ risk-taking behaviors (drowsy driving), ↑ BP

Contributing factors:

  • Early school start times: Many high schools start 7-7:30am - conflicts with adolescent circadian rhythm (biological phase delay - teens naturally fall asleep later, wake later)
  • Academic pressure: Homework, extracurriculars → late nights
  • Screen time: Smartphones, tablets in bedroom → delayed bedtime, blue light suppresses melatonin, notifications disrupt sleep
  • Caffeine: Energy drinks, coffee common in teens → interferes with sleep
  • Social activities: Texting, gaming with friends late at night

Strategies to Improve Sleep

Family/Individual:

  • Consistent schedule: Same bedtime/wake time every day (including weekends) - regulates circadian rhythm
  • Adequate opportunity: Bedtime early enough to allow 9-10 hours sleep (teens) - if wake at 6am for school → asleep by 9pm
  • Bedtime routine: Wind-down activities (reading, bath, quiet time) - signals body to prepare for sleep
  • Sleep-friendly environment: Dark, quiet, cool (60-67°F), comfortable mattress/pillow
  • No screens 1 hour before bed: Blue light suppresses melatonin - use "night mode," stop using earlier, charge phones OUTSIDE bedroom
  • Limit caffeine: Avoid after 2pm (half-life 5-6 hours)
  • Physical activity: Regular exercise → better sleep (but not close to bedtime - stimulating)

School/Policy:

  • Later school start times: AAP, AMA, CDC recommend middle/high schools start ≥8:30am
    • Evidence: Schools that delayed start times → students sleep 30-60 min more/night, ↑ attendance, ↑ grades, ↓ car crashes, ↓ depression
    • Challenges: Transportation logistics, extracurriculars, parent work schedules - solvable but requires planning
  • Homework policies: Reasonable limits (10 min/grade level per night guideline), no homework over breaks
  • Health education: Teach students importance of sleep, sleep hygiene

Sleep Disorders

  • Obstructive sleep apnea (OSA): 1-5% children (↑ in obese)
    • Signs: Snoring, gasping, daytime sleepiness, behavioral problems, enuresis, morning headaches
    • Diagnosis: Polysomnography (sleep study)
    • Treatment: Adenotonsillectomy (if enlarged tonsils/adenoids - curative in 80%), CPAP (if surgery not option or residual OSA), weight loss (if obese)
    • Consequences if untreated: Neurocognitive impairment, behavioral problems, ↑ BP, failure to thrive
  • Insomnia: Difficulty falling/staying asleep
    • Treatment: Sleep hygiene, behavioral interventions (relaxation, CBT-I), address underlying anxiety/depression, medications rarely needed (melatonin sometimes used)

5. Body Mass Index (Weight)

Pediatric BMI Interpretation

BMI percentiles (age- and sex-specific) - NOT absolute BMI cutoffs

Category BMI Percentile LE8 Score Interpretation
Underweight <5th percentile Variable (evaluate for malnutrition, eating disorder) May indicate inadequate nutrition, chronic illness, or restrictive eating
Healthy Weight 5th-84th percentile 100 points Optimal
Overweight 85th-94th percentile 70 points At risk for obesity-related complications
Obesity ≥95th percentile 30 points Significantly ↑ risk metabolic complications, adult obesity
Severe Obesity ≥120% of 95th percentile
OR BMI ≥35		 0 points Very high risk complications, requires intensive treatment

Why percentiles (not absolute BMI)? Children growing, body composition changing - BMI varies by age/sex during development. Percentiles compare child to reference population same age/sex. Example: 10-year-old girl BMI 20 = 85th percentile (overweight); 16-year-old girl BMI 20 = 30th percentile (healthy).

Childhood Obesity Epidemic

Prevalence (US 2017-2020):

  • 19.7% children/adolescents (2-19 years) have obesity (vs 5% in 1970s - 4× increase)
  • 6.1% have severe obesity
  • Disparities: Hispanic 26.2%, Non-Hispanic Black 24.8%, Non-Hispanic White 16.6%, Non-Hispanic Asian 9.0%
  • Lower-income families disproportionately affected (limited access healthy food, safe activity spaces)

Consequences:

  • Immediate: Prediabetes/type 2 diabetes (1 in 4 obese adolescents have prediabetes), HTN, dyslipidemia, fatty liver disease, OSA, orthopedic problems, psychosocial issues (bullying, low self-esteem, depression)
  • Long-term: ~80% obese adolescents → obese adults, ↑ 2-3× adult CVD mortality (even if lose weight as adults - "legacy effect"), ↑ diabetes, metabolic syndrome, certain cancers
  • Economic: Annual medical costs of childhood obesity ~$14 billion (US)

Etiology - Multifactorial

Factor Contribution
Genetics Heritability 40-70% (polygenic - multiple genes each small effect)
Rare monogenic causes (MC4R, leptin deficiency) <5%
Syndromes (Prader-Willi) very rare
Dietary ↑ Calorie-dense, nutrient-poor foods (fast food, processed snacks, sugary drinks)
Larger portion sizes
↓ Home-cooked meals, family dinners
Physical Inactivity ↓ Active play, ↑ screen time (7-8 hours/day average)
↓ PE in schools, unsafe neighborhoods limit outdoor play
Sleep Insufficient sleep → ↑ appetite (↑ ghrelin, ↓ leptin), ↓ activity, ↑ sedentary snacking
Parental Parental obesity (modeling), feeding practices (pressure to eat, food as reward), lack of nutrition knowledge
Socioeconomic Food insecurity paradox (↑ calorie-dense cheap foods, ↓ fruits/vegetables), limited access to healthy foods ("food deserts"), unsafe neighborhoods, stress
Prenatal/Early Life Maternal obesity/GDM → ↑ offspring obesity risk, rapid infant weight gain → ↑ later obesity, breastfeeding protective (modest effect)
Medications Atypical antipsychotics, certain antidepressants, corticosteroids → weight gain

Treatment - Family-Based Behavioral Intervention

Gold standard for childhood obesity: Intensive, family-based, multicomponent lifestyle intervention

Components:

  • Dietary:
    • Calorie reduction (moderate - avoid extreme restriction, diets). Goal ↓ 250-500 kcal/day (or maintain intake while child grows → BMI gradually normalizes).
    • Traffic light approach (green/yellow/red foods)
    • Portion control, limit calorie-dense foods, eliminate sugary beverages
    • Family meals, model healthy eating
  • Physical activity:
    • ↑ To 60 min/day moderate-to-vigorous (or more if feasible)
    • ↓ Screen time to <2 hours/day recreational
    • Find activities child enjoys (adherence)
  • Behavioral:
    • Self-monitoring (food diary, activity log, daily weigh-ins for older children/teens)
    • Goal-setting (SMART goals - specific, achievable)
    • Stimulus control (don't keep junk food at home, plan meals, structured eating times)
    • Problem-solving (identify barriers, brainstorm solutions)
    • Positive reinforcement (praise efforts, non-food rewards)
    • Relapse prevention (normal to have setbacks, learn from them, recommit)
  • Parental involvement:
    • Essential - parents control home food environment, model behaviors, provide support
    • Parent training in behavior modification techniques
    • Address parent's own weight if obese (family-based approach benefits all)

Intensity:

  • AAP 2023 Guidelines: ≥26 contact hours over 3-12 months (e.g., weekly 1-hour sessions × 6 months)
  • Group or individual sessions (group = peer support, cost-effective)
  • Multidisciplinary team: Pediatrician, dietitian, exercise specialist, behavioral psychologist

Outcomes:

  • Meta-analyses: Intensive family-based programs → BMI reduction 1-2 units sustained 6-12 months (modest but clinically meaningful)
  • More effective in younger children (6-11) vs adolescents (12-18) - habits less entrenched, more parental influence

Pharmacotherapy (Adjunct to Lifestyle)

AAP 2023 update: Consider medications ≥12 years with obesity (BMI ≥95th percentile) IF lifestyle insufficient

Medication Age Mechanism Efficacy Side Effects
Semaglutide 2.4mg
(Wegovy)		 ≥12 years GLP-1 agonist
↓ Appetite, ↑ satiety		 STEP Teens trial: ↓ 16% BMI vs placebo at 68 weeks GI (nausea, vomiting - usually transient)
Injectable (weekly)
Expensive
Liraglutide 3.0mg
(Saxenda)		 ≥12 years GLP-1 agonist ↓ 5% BMI vs placebo GI, daily injection
Orlistat
(Xenical, Alli)		 ≥12 years Lipase inhibitor
Blocks fat absorption		 ↓ 3% BMI (modest) GI (oily stools, fecal urgency)
Requires low-fat diet
Less effective than GLP-1
Phentermine
(Short-term)		 ≥16 years Appetite suppressant
Sympathomimetic		 ↓ 5-10% weight (short-term) ↑ HR, ↑ BP, insomnia
Not for long-term use
Rarely used in pediatrics

Key points:

  • Medications = adjunct to lifestyle, not replacement
  • GLP-1 agonists (semaglutide, liraglutide) most effective - game-changers in pediatric obesity
  • Benefits: Substantial weight loss, improve metabolic parameters (BP, lipids, glucose)
  • Challenges: Cost ($$$$), insurance coverage limited, long-term safety data in adolescents still emerging, weight regain if stopped
  • Use in conjunction with intensive lifestyle program for best outcomes

Bariatric Surgery (Metabolic Surgery)

Consider if: Age ≥13 years + severe obesity (BMI ≥120% of 95th percentile or ≥35) + serious comorbidities (type 2 diabetes, severe OSA, NASH) AND failed comprehensive lifestyle + medications

Procedures:

  • Vertical sleeve gastrectomy (VSG): Most common in adolescents - remove 80% stomach → restrictive
  • Roux-en-Y gastric bypass (RYGB): More complex, more weight loss, more complications

Outcomes:

  • Teen-LABS study: Adolescents post-bariatric surgery → ↓ 27% BMI at 3 years (vs 3% non-surgical), diabetes remission 90%, HTN resolution 75%, dyslipidemia improvement 66%
  • Substantial, sustained weight loss + metabolic improvement

Risks:

  • Surgical complications (leak, bleeding, obstruction), nutritional deficiencies (iron, B12, calcium - requires lifelong supplementation), psychological issues (must address eating behaviors, body image), not reversible

Requirements:

  • Comprehensive evaluation (medical, nutritional, psychological), informed consent (adolescent + parents understand risks/benefits/lifelong commitment), specialized center (pediatric bariatric surgery expertise), multidisciplinary team, long-term follow-up

Controversy: Surgery in adolescents controversial (developing bodies, psychosocial maturity, permanent alteration) BUT for severe obesity with comorbidities, benefits may outweigh risks. Individualized decision.

6-8. Blood Pressure, Lipids, Glucose

Blood Pressure

Pediatric BP percentiles (age, sex, height-specific) - complex

Category Definition Management
Normal <90th percentile Recheck at next well-child visit
Elevated BP ≥90th to <95th percentile
OR 120/80-129/80 (adolescents)		 Lifestyle counseling (weight loss if overweight, diet, activity), recheck 6 months
Stage 1 HTN ≥95th percentile to <95th + 12 mmHg
OR 130/80-139/89 (adolescents)		 Confirm on 3 separate visits, evaluate for secondary causes if <6 years or severe, lifestyle intervention, consider medication if no improvement 3-6 months OR symptomatic/target organ damage
Stage 2 HTN ≥95th percentile + 12 mmHg
OR ≥140/90 (adolescents)		 Evaluate urgently (rule out secondary causes, assess target organ damage - LVH, retinopathy, kidney), lifestyle + medication (usually start treatment, don't wait)

Prevalence: 5-10% children/adolescents have elevated BP or HTN (mostly undiagnosed - BP often not checked or interpreted incorrectly in pediatrics)

Primary HTN (most common): Associated with obesity (60-70% obese children have HTN)

Secondary HTN: More common in children vs adults (especially <6 years) - renal disease (most common - CKD, renal artery stenosis), coarctation of aorta, endocrine (hyperthyroidism, Cushing's), medications (steroids, stimulants)

Management:

  • Lifestyle: Weight loss (if obese - most effective intervention), DASH diet, sodium <1,500 mg/day, exercise 60 min/day
  • Medications (if lifestyle insufficient or Stage 2/symptomatic): ACE-I (lisinopril), ARB (losartan), CCB (amlodipine), thiazide - same classes as adults, weight-based dosing
  • Goal: <90th percentile (or <130/80 if adolescent)

Lipids

Screening:

  • Universal screening: Once between age 9-11 years (before puberty - hormonal changes affect lipids during puberty, harder to interpret), repeat age 17-21
  • Selective screening (age 2-8 or 12-16): If family history premature CVD (<55♂ or <65♀ first-degree relative), parent with total cholesterol ≥240 mg/dL, child has obesity/diabetes/HTN
  • Non-fasting acceptable for screening (unless triglycerides very high >400 - fasting clarifies)

Interpretation (children/adolescents):

Lipid Acceptable Borderline High
Total cholesterol <170 mg/dL 170-199 ≥200
LDL-C <110 mg/dL 110-129 ≥130
Non-HDL-C <120 mg/dL 120-144 ≥145
HDL-C >45 mg/dL 40-45 <40 (low)
Triglycerides <75 mg/dL (0-9y)
<90 (10-19y)		 75-99 (0-9y)
90-129 (10-19y)		 ≥100 (0-9y)
≥130 (10-19y)

Management:

  • Lifestyle first: Therapeutic Lifestyle Changes (TLC) diet - similar to DASH, <7% saturated fat, plant sterols 2g/day if LDL high, increase physical activity, weight loss if obese
  • Medications (age ≥10 years):
    • Indications: LDL ≥190 mg/dL (or ≥160 + family history premature CVD or ≥2 risk factors), OR familial hypercholesterolemia
    • Statin: First-line - atorvastatin, rosuvastatin. Start low dose, titrate. Monitor liver enzymes, CK.
    • Goal: LDL <130 mg/dL (ideally <110)
    • Safety: Statins generally safe in children/adolescents (growth, puberty not affected). Long-term data still emerging.

Familial Hypercholesterolemia (FH):

  • Genetic disorder - defective LDL receptor → very high LDL from birth
  • Prevalence: 1 in 250 (heterozygous FH) - often undiagnosed
  • Clinical: LDL >190 mg/dL child, tendon xanthomas (not always present in children), family history early CVD
  • Diagnosis: Genetic testing (LDLR, APOB, PCSK9 mutations) confirms
  • Management: Aggressive - lifestyle + statin starting age 8-10 years (earlier than other dyslipidemia), goal LDL <130 (ideally <100), lifelong treatment, screen family members (cascade screening)
  • Prognosis: Without treatment, 50% men with FH have CVD by age 50, women by 60. WITH treatment started in childhood → near-normal life expectancy.

Glucose

Type 2 Diabetes in Youth - Alarming Trend

  • Once rare in children, now ≈5,000 new cases/year in US (vs 18,000 type 1 cases/year)
  • Parallels childhood obesity epidemic - 80% youth with type 2 diabetes have obesity
  • High-risk groups: Hispanic, African American, Native American, Asian American youth, family history diabetes
  • More aggressive than adult-onset: Faster β-cell decline, more difficult to control, earlier complications

Screening:

  • After age 10 years or at puberty onset (whichever earlier) IF:
    • Overweight (BMI ≥85th percentile) or obese (≥95th) PLUS ≥1 risk factor:
      • Family history diabetes (first or second degree relative)
      • High-risk race/ethnicity
      • Maternal gestational diabetes or diabetes during child's gestation
      • Signs insulin resistance (acanthosis nigricans, PCOS, HTN, dyslipidemia)
  • Test: Fasting glucose or HbA1c, repeat every 3 years if normal

Diagnosis: Same criteria as adults - fasting glucose ≥126 mg/dL, HbA1c ≥6.5%, or random glucose ≥200 + symptoms

Prediabetes in youth: Fasting glucose 100-125 mg/dL or HbA1c 5.7-6.4% - indicates high risk progression to diabetes, requires intensive lifestyle intervention

Management Type 2 Diabetes (Youth):

  • Lifestyle: Intensive family-based weight loss program, DASH diet, exercise 60 min/day, screen time limits
  • Metformin: First-line medication (approved age ≥10 years), start immediately at diagnosis (unlike adults where may try lifestyle alone first - youth diabetes more aggressive)
  • Insulin: If ketosis, HbA1c >8.5%, or metabolic decompensation at diagnosis (30-40% youth with type 2 diabetes present with DKA or HHS)
  • Other agents: Liraglutide approved age ≥10 years (GLP-1 - helps weight + glucose), other agents used off-label
  • Monitoring: HbA1c every 3 months, screen for complications (albuminuria, retinopathy, neuropathy) starting at diagnosis (earlier onset → longer exposure → earlier complications)
  • Goal: HbA1c <7% (individualize - avoid hypoglycemia)

Prevention: Same as obesity prevention (diet, activity, limit screen time, adequate sleep) - type 2 diabetes in youth is nearly always preventable.

Program Delivery Models

1. School-Based Programs

Rationale: Schools = ideal setting (children spend 6-8 hours/day, reach all socioeconomic groups, infrastructure exists)

Components:

  • Health education curriculum: Age-appropriate nutrition, physical activity, sleep hygiene taught in classrooms (integrate into science, health, PE classes)
  • Healthy cafeteria: USDA standards (more fruits/vegetables, whole grains, ↓ sodium), eliminate sugary beverages, offer appealing healthy options
  • Physical education: Daily quality PE (not just recreational - structured, moderate-to-vigorous intensity), trained PE teachers
  • Recess: ≥20 min/day, equipment provided, encourage active play
  • Active classrooms: Movement breaks during lessons, standing/stability ball desks, walk-and-talk activities
  • After-school programs: Sports, active clubs, homework club with healthy snacks
  • Wellness policies: Restrict unhealthy foods (parties, fundraisers), eliminate junk food vending machines, promote water consumption
  • Family engagement: Newsletters, workshops, homework involving families (e.g., "track your family's activity this week")

Evidence: School-based interventions (multicomponent, ≥1 year duration) → ↓ BMI 0.3-0.5 kg/m², improve diet quality, ↑ physical activity (modest individual-level effects but LARGE population impact)

2. Primary Care-Based (Clinical Programs)

Well-child visits = prevention opportunity

AAP Bright Futures Guidelines:

  • Universal: All children - BMI screening (annually age ≥2), BP screening (annually age ≥3), anticipatory guidance (nutrition, activity, sleep, screen time)
  • Targeted: High-risk children (obesity, elevated BP, family history) - more intensive counseling, labs (lipids, glucose), referrals

Brief counseling (5-10 minutes):

  • 5-2-1-0 message: ≥5 fruits/vegetables/day, ≤2 hours screen time/day, ≥1 hour physical activity/day, 0 sugary beverages
  • Assess readiness to change, set 1-2 SMART goals, provide written materials
  • Follow-up 1-3 months (adherence, progress, adjust)

Intensive programs (obesity treatment):

  • Referral to pediatric weight management program (if available) - multidisciplinary team, ≥26 contact hours
  • If not available - primary care can deliver structured program (e.g., "Traffic Light Diet" protocol), group visits (cost-effective, peer support)

3. Community-Based Programs

Examples:

  • Recreation programs: Community centers, YMCAs, parks & rec - subsidized sports leagues, swimming lessons, after-school programs for low-income youth
  • Summer camps: Day camps with activity, healthy meals (address "summer weight gain" phenomenon - children often gain more weight during summer than school year due to less structure)
  • Nutrition education: Cooking classes for families, farmers market tours, community gardens (hands-on learning, food access)
  • Faith-based programs: Churches, mosques, temples - wellness programs for families, culturally-tailored
  • Worksite wellness (parents): Healthy parents → healthy children. Support working parents (flexible schedules for family meals, lactation rooms, insurance coverage for weight management)

4. Digital/Technology-Based

Emerging modality - mobile apps, wearables, telemedicine

Advantages: Scalable, low-cost, accessible, engaging (gamification), real-time feedback

Examples:

  • Apps for self-monitoring (food, activity, sleep), goal-setting, education
  • Fitness trackers (Fitbit, Apple Watch) - step goals, challenges
  • Exergaming (active video games - Just Dance, Ring Fit Adventure) - more active than passive gaming (not substitute for outdoor play but better than sitting)
  • Telemedicine weight management - virtual group sessions, video counseling (↑ access, especially rural areas)

Limitations: Digital divide (not all families have smartphones/internet), screen time concerns (ironic - using screens to reduce screen time), limited evidence for long-term efficacy, sustainability

Enroll Your Child/School in Life's Essential 8™ for Kids

EPA Bienestar IA offers comprehensive cardiovascular prevention programs for children, adolescents, and families.

For Families:

  • ✅ Pediatric cardiovascular risk assessment
  • ✅ Family-based healthy lifestyle programs
  • ✅ Childhood obesity treatment (intensive multicomponent program)
  • ✅ Management of pediatric hypertension, dyslipidemia, diabetes
  • ✅ Nutrition counseling by registered dietitians
  • ✅ Exercise/activity planning
  • ✅ Behavioral support
  • ✅ Medication management (if indicated)
  • ✅ Coordinated care with pediatrician

For Schools:

  • ✅ Turnkey school-based wellness program implementation
  • ✅ Curriculum materials (age-appropriate, evidence-based)
  • ✅ Teacher training
  • ✅ Policy consultation (wellness policies, food services)
  • ✅ Family engagement strategies
  • ✅ Evaluation/outcome measurement

For Communities:

  • ✅ Community health screenings (BMI, BP)
  • ✅ Parent education workshops
  • ✅ Youth activity programs
  • ✅ Policy advocacy (healthy food access, safe play spaces, later school start times)
Enroll Your Child or School →

Contact: Dra Giovanna Sanguinetti Colón
Program Director, Pediatric Cardiovascular Prevention
EPA Bienestar IA
Email: info@epa-bienestar.com
Phone: [Contact number]

Invest in your child's heart health today - benefits last a lifetime.