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

Check the Lipid Profile? Why?

Check the Lipid Profile? Why?

Douglas W. Teske, MDThe Heart Center

Nationwide Children’s Hospital

Douglas W. Teske, MDThe Heart Center

Nationwide Children’s Hospital

ObjectivesObjectives

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

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

Heart Healthy LifestyleHeart Healthy Lifestyle

• Normal weight for height • Appropriate diet for level of physical

activity• Daily exercise• No smoking or use of other tobacco

products

• Normal weight for height • Appropriate diet for level of physical

activity• Daily exercise• No smoking or use of other tobacco

products

Epidemic of Childhood ObesityEpidemic of Childhood Obesity

Concerns:- type 2 diabetes mellitus

- systemic hypertension- risk of CVD in young adults

- cigarette smoking/use of OTPs- oral contraceptives

Concerns:- type 2 diabetes mellitus

- systemic hypertension- risk of CVD in young adults

- cigarette smoking/use of OTPs- oral contraceptives

Body Mass IndexBody Mass Index

BMI Obesity (kg/M2)

ClassificationUnderweight <18.5Normal 18.5-24.9Overweight 25.0-29.9Obesity 30.0-34.9 I

35.0-39.9 IIExtreme obesity >40.0 III

BMI Obesity (kg/M2)

ClassificationUnderweight <18.5Normal 18.5-24.9Overweight 25.0-29.9Obesity 30.0-34.9 I

35.0-39.9 IIExtreme obesity >40.0 III

Metabolic Syndrome in AdultsMetabolic Syndrome in Adults

Waist circumference men >102 cm/>40 in

female >88 cm/>35 inTriglyceride >150 mg/dLHDL-C men <40 mg/dL female <50 mg/dLBlood pressure >130/>85 mmHgFasting blood sugar >100 mg/dL

Waist circumference men >102 cm/>40 in

female >88 cm/>35 inTriglyceride >150 mg/dLHDL-C men <40 mg/dL female <50 mg/dLBlood pressure >130/>85 mmHgFasting blood sugar >100 mg/dL

Metabolic Syndrome in Pediatrics

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

• 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

Concern for the Present and Future

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

• 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

Childhood Risk Factors for Adult CVD

Childhood Risk Factors for Adult CVD

• Obesity• Sedentary lifestyle• Cigarette smoking/use of OTPs• Hypertension• Hyperlipidemia

– high LDL-C– low HDL-C

• Obesity• Sedentary lifestyle• Cigarette smoking/use of OTPs• Hypertension• Hyperlipidemia

– high LDL-C– low HDL-C

Lipid ScreeningLipid 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

• 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

AAP: Universal Screening Approach

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

• 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

Universal Pediatric ApproachUniversal 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

• 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

Healthful Eating BehaviorsHealthful 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

• 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

Personal RecommendationsPersonal 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

• 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

Personal RecommendationsPersonal 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

• 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

Fasting Lipid ProfileFasting 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

• 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

Fasting Lipid ProfileFasting 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

• 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

Abnormal Lipid ProfileAbnormal Lipid Profile

• Evaluate for secondary causes– exogenous – drugs or obesity– endocrine and metabolic –

hypothyroidism and diabetes– storage diseases– obstructive liver diseases– chronic renal disease

• Evaluate for secondary causes– exogenous – drugs or obesity– endocrine and metabolic –

hypothyroidism and diabetes– storage diseases– obstructive liver diseases– chronic renal disease

Screening Laboratory StudiesScreening Laboratory Studies

• Liver– ALT, AST, CK, PT/INR

• Kidney– BUN, Cr, UA

• Thyroid– T-4 total, TSH

• Heme– CBC with differential and platelets

• Liver– ALT, AST, CK, PT/INR

• Kidney– BUN, Cr, UA

• Thyroid– T-4 total, TSH

• Heme– CBC with differential and platelets

Medication DiscussionMedication 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

• 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

Pharmacotherapeutic AgentsPharmacotherapeutic Agents

• Bile acid sequestrant– Cholestyramine

• Niacin• Statins

– Pravastatin, Lovastatin, Simvastatin, Atorvastatin

• Cholesterol absorption inhibitor• Fibrate

• Bile acid sequestrant– Cholestyramine

• Niacin• Statins

– Pravastatin, Lovastatin, Simvastatin, Atorvastatin

• Cholesterol absorption inhibitor• Fibrate

Statin TherapyStatin 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

• 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

Case Study #1Case 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

• Female Age 8 years

– Wt 51.5 kg (>97%)– Ht 132 cm (50-75%)– BMI 29.3 kg/M2– BP 112/72 mmHg



• Male 11 years old

– Wt 51.2 kg (95%)– Ht 142.5 cm (~50%)– BMI 25.2 kg/M2– BP 106/64 mmHg



– Wt 51.2 kg (95%)– Ht 142.5 cm (~50%)– BMI 25.2 kg/M2– BP 106/64 mmHg



• 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


– 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




– Wt 99.4 kg (>97%)– Ht 165.6 (~50%)– BMI 36.2 kg/M2– BP 124/58 mmHg



– Wt 99.4 kg (>97%)– Ht 165.6 (~50%)– BMI 36.2 kg/M2– BP 124/58 mmHg




– Wt 99.4 kg (>97%)– Ht 165.6 cm (~50%)– BMI 36.2 kg/M2– BP 124/58 mmHg



– Wt 99.4 kg (>97%)– Ht 165.6 cm (~50%)– BMI 36.2 kg/M2– BP 124/58 mmHg




– Wt 68.3 kg (>>97%)– Ht 160 cm (>97%)– BMI 26.7 kg/M2– BP 136/86 mmHg



– Wt 68.3 kg (>>97%)– Ht 160 cm (>97%)– BMI 26.7 kg/M2– BP 136/86 mmHg




– 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


– 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



– Wt 107.5 kg (>97%)– Ht 178.9 cm (90%)– BMI 33.6 kg/M2– BP 142/94 mmHg



– Wt 107.5 kg (>97%)– Ht 178.9 cm (90%)– BMI 33.6 kg/M2– BP 142/94 mmHg




– 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


– 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



– Wt 46.8 kg (25%)– Ht 163.8 cm (25-50%)– BMI 17.4 kg/M2– BP 96/64 mmHg






• Female 13 years old

– Wt 58.6 kg (75%)– Ht 159 cm (50%)– BMI 23.2 kg/M2– BP 122/70 mmHg


• Female 13 years old

– Wt 58.6 kg (75%)– Ht 159 cm (50%)– BMI 23.2 kg/M2– BP 122/70 mmHg



• 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


• 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


10 Ways to Help Children Develop Healthy Habits

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

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

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

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