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Background There is little information about how diet quality evolves in early childhood, whether children exhibit varying diet quality trajectories, or which components of diet quality should be targeted for intervention. Objective The goal of this study was to identify and evaluate trajectories of dietary quality in young children. Design This was a secondary analysis of an observational, longitudinal cohort study of non-Hispanic African American or White children and their parents from racially concordant households with 4 years of follow-up (up to 13 study visits). Data on mother, infant feeding, and body mass index were assessed at baseline. Diet was evaluated using 3-day diaries at each visit. Participants/setting Of 372 children enrolled, 349 children had at least 3 study visits with dietary data for this analysis. Participants were enrolled at age 3 years between March 2001 and August 2002 in Cincinnati, OH. Final study visits were conducted between February 2005 and June 2006. Main outcome measure The main outcome measure was the total Healthy Eating Index 2005 (HEI-2005) score and HEI-2005 component scores. Statistical analyses Diet quality trajectories were modeled using group-based modeling techniques. Results The total HEI-2005 score was low at age 3 years (mean ± standard error = 55.1 ± 0.4 of maximum 100 points) and remained stable to age 7 years (mean ± standard error = 54.0 ± 0.6; P = 0.08 for trend). Five HEI-2005 trajectory groups were identified, of which 1 declined and 1 improved over time. HEI-2005 component scores, except milk intake and meat/beans scores, differed significantly (all, P ≤ 0.02) among trajectory groups at age 3 years, and most differences were maintained at age 7 years. Total vegetables, dark green and orange vegetables and legumes, and whole grains component scores were low for all trajectory groups. Whole fruit; total fruit; saturated fat; and calories from solid fats, alcoholic beverages, and added sugars (SoFAAS) were highly variable among trajectory groups. Children in the lowest diet quality trajectory group were less likely to be breastfed and more likely to have been regular consumers of soft drinks (e.g., powdered drink mixes, sport drinks, or soda pop) before age 3 years. Conclusions Young childhood diet quality was low at age 3 years and remained stable to age 7 years. Improving intake of vegetables and whole grains is needed for all children. Focused attention regarding increasing fruit intake and reducing SoFAAS may be needed for families at increased risk for low overall diet quality.

Changes in left ventricular structure and function have been previously described in children with obstructive sleep apnea (OSA). We aimed to determine if these structural and functional cardiac changes are reversible after treatment of OSA with adenotonsillectomy. Children aged 5 to 13 years with OSA and matched healthy controls were recruited. Adenotonsillectomy occurred within 1 month after diagnosis. Echocardiography and polysomnography were repeated postoperatively. Linear mixed models were fitted to echocardiography measures at baseline and follow-up to assess the effect of OSA on cardiac structure and function. These adjusted for age, gender, race, body mass index, systolic, and diastolic blood pressure. The study sample included 373 children, 199 with OSA and 174 healthy controls. In the control group, 114 children completed the study and 112 completed the study in the OSA group. Children with OSA had reduced diastolic function, lower systolic function, and greater left ventricular mass index at baseline compared with healthy controls (all p < 0.05). Measures of active relaxation, elastic recoil and lengthening of the left ventricle impacted overall diastolic function; each of these worsened with increasing OSA severity. Postoperatively, diastolic function improved in children with OSA compared with controls. There were not significant changes in LV mass index or geometry. In conclusion, children with OSA have impaired left ventricular relaxation during diastole indicating early stage diastolic dysfunction. Adenotonsillectomy for OSA signficantly improved diastolic function. Left ventricular remodeling did not change with improvement of OSA.

Purpose of review To summarize types of dyslipidemia frequently encountered during childhood and adolescence, with a focus on screening, diagnosis, and management. Recent findings It is important that screening for atherosclerotic cardiovascular disease (ASCVD) begin in childhood. Genetic testing allows for increased awareness of dyslipidemia and more targeted intervention. Pharmacologic treatment of pediatric dyslipidemias has a good safety profile and can reduce adult ASCVD risk. Summary Much of what is known about pediatric dyslipidemia has been extrapolated from adult data, but recently, there have been increasing investigations within the pediatric population to better guide diagnosis and management of these disorders.

OBJECTIVE To examine childhood BMI, fasting glucose, and insulin in relation to incident adult type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS We used data from the International Childhood Cardiovascular Cohort (i3C) Consortium. Data included childhood (age 3–19 years) measurements obtained during the 1970s–1990s; a health questionnaire, including self-report of adult T2DM (occurrence age, medication use) obtained at mean age 40 years; and a medical diagnosis registry (Finland). RESULTS The sample included 6,738 participants. Of these, 436 (6.5%) reported onset of T2DM between ages 20 and 59 (mean 40.8) years, and 86% of them reported use of a confirmed antidiabetic medication. BMI and glucose (age and sex standardized) were associated with incident T2DM after adjustment for cohort, country, sex, race, age, and calendar year of measurement. Increasing levels of childhood BMI and glucose were related to an incrementally increased risk of T2DM beginning at age 30 years, beginning at cut points CONCLUSIONS Childhood BMI and glucose are predictors of adult T2DM at levels previously considered to be within the normal range. These easy-to-apply measurements are appealing from a clinical perspective. Fasting insulin has the potential to be an additional predictor.

Introduction: To identify longitudinal sleep trajectories in early childhood and examine the influence of sleep duration on obesity risk via BMI percentile (BMIp). Methods: Sleep, physical activity, and television viewing were measured in a cohort of 301 children, starting in 2001–2002, when children were 3 years and followed them through age 6. Nighttime sleep, daytime naps, and sleep duration were calculated. A series of latent growth curve models were used to estimate predictors of rate of change in sleep duration and BMIp overtime. A parallel process latent growth model examined the longitudinal relationship between sleep duration and BMIp simultaneously. Results: Most children (>80%) slept >10 hours per night across ages 3 to 6 years, despite the majority of children (>66%) having bedtimes after 9 pm. Sleep duration decreased on average by 0.22 (95% CI 0.20–0.24) hours each year of age (p

As part of the National Children's Study (NCS) comprehensive and longitudinal assessment of the health status of the whole child, scientific teams were convened to recommend assessment measures for the NCS. This manuscript documents the work of three scientific teams who focused on the motor, sensory, or the physical health aspects of this assessment. Each domain team offered a value proposition for the importance of their domain to the health outcomes of the developing infant and child. Constructs within each domain were identified and measures of these constructs proposed. Where available extant assessments were identified. Those constructs that were in need of revised or new assessment instruments were identified and described. Recommendations also were made for the age when the assessments should take place.

Background In high-income countries, cancer is the leading cause of death among middle-aged adults. Prospective data on the effects of childhood risk exposures on subsequent cancer mortality are scarce. Methods We examined whether childhood body mass index (BMI), blood pressure, glucose and lipid levels were associated with adult cancer mortality, using data from 21,012 children enrolled aged 3–19 years in seven prospective cohort studies from the U.S., Australia, and Finland that have followed participants from childhood into adulthood. Cancer mortality (cancer as a primary or secondary cause of death) was captured using registries. Results 354 cancer deaths occurred over the follow-up. In age-, sex, and cohort-adjusted analyses, childhood BMI (Hazard ratio [HR], 1.13; 95% confidence interval [CI] 1.03–1.24 per 1-SD increase) and childhood glucose (HR 1.22; 95%CI 1.01–1.47 per 1-SD increase), were associated with subsequent cancer mortality. In a multivariable analysis adjusted for age, sex, cohort, and childhood measures of fasting glucose, total cholesterol, triglycerides, and systolic blood pressure, childhood BMI remained as an independent predictor of subsequent cancer mortality (HR, 1.24; 95%CI, 1.03–1.49). The association of childhood BMI and subsequent cancer mortality persisted after adjustment for adulthood BMI (HR for childhood BMI, 1.35; 95%CI 1.12–1.63). Conclusions Higher childhood BMI was independently associated with increased overall cancer mortality.

Objective: To evaluate the impact of the 2017 American Academy of Pediatrics hypertension Clinical Practice Guideline (CPG), compared with the previous guideline (“Fourth Report”), on the frequency of hypertensive blood pressure (BP) measurements in childhood and associations with hypertension in adulthood using data from the International Childhood Cardiovascular Cohort Consortium. Study design: Childhood BPs were categorized in normal, prehypertensive/elevated, and hypertensive (stage 1 and 2) ranges using the Fourth Report and the CPG. Participants were contacted in adulthood to assess self-reported hypertension. The associations between childhood hypertensive range BPs and self-reported adult hypertension were evaluated. Results: Data were available for 34 014 youth (10.4 ± 3.1 years, 50.6% female) with 92 751 BP assessments. Compared with the Fourth Report, the CPG increased hypertensive readings from 7.6% to 13.5% and from 1.3% to 2.5% for stage 1 and 2 hypertensive range, respectively (P < .0001). Of 12 761 adults (48.8 ± 7.9 years, 43% male), 3839 (30.1%) had self-reported hypertension. The sensitivity for predicting adult hypertension among those with hypertensive range BPs at any point in childhood, as defined by the Fourth Report and the CPG, respectively, was 13.4% and 22.4% (specificity 92.3% and 85.9%, P < .001), with no significant impact on positive and negative predictive values. Associations with self-reported adult hypertension were similar and weak (c-statistic range 0.61-0.68) for hypertensive range BPs as defined by the Fourth Report and CPG. Conclusions: The CPG significantly increased the prevalence of childhood BPs in hypertensive ranges and improved the sensitivity, without an overall strengthened association, of predicting self-reported adult hypertension.

In 1997, Soergel et al 1 published the first set of normative values for ambulatory blood pressure monitoring (ABPM) in children. Since then, the clinical utility of ABPM has increased dramatically, and now, ABPM is accepted as the standard method to confirm the diagnosis of hypertension in children. Despite significant progress in the field of pediatric ABPM, many important questions remain unanswered. One of the most controversial issues is how to define ambulatory hypertension in children. The purpose of this review is to discuss the limitations of the current pediatric ABPM classification scheme and to provide the justification and rationale for a new classification.

Background Atherosclerosis develops silently for decades before adult cardiovascular disease (aCVD) occurs. There is currently no evidence directly linking childhood risk factors to aCVD outcomes. Methods i3C is an international consortium of 7 cohorts involving 40,709 participants enrolled between 1970-95 in childhood (age 3-19) who underwent measurement for BMI, SBP, total cholesterol, and triglycerides, and smoking (the last mostly in adolescence). Participants were followed by direct contact and review of medical records or death registry ascertainment through adulthood in 2014-19. 20,560 participants were found and interviewed or had died in the approximately 40 years since enrollment; 738 had a CVD event, confirmed by medical record review (n = 449) or death certificate ICD code (n = 289). Results Estimated hazard ratios (HRs) for childhood risk factors and their confidence intervals are displayed in the table below. The CIs excluded 1.0 for all these variables in the univariable analysis and, although the HRs were reduced in multivariable analysis which included all of these risk factors, the CIs still excluded 1.0. Conclusion Exposure to CVD risk factors in youth predicts adult CVD with implications for primordial CVD prevention. Key messages Intervention to reduce CVD risk factors in childhood is likely to reduce risk of adult CVD

Background and Objectives: Adult class II/III obesity (BMI ≥ 35 kg/m2) has significant adverse health outcomes. Early prevention and treatment are critical, but prospective childhood risk estimates are lacking. This study aimed to define the prospective risk of adult class II/III obesity, using childhood BMI. Methods: Children ages 3–19 years enrolled in cohorts of The International Childhood Cardiovascular Cohort (i3C) Consortium with measured BMI assessments in childhood and adulthood were included. Prospective risk of adult class II/III obesity was modeled based on childhood age, sex, race and BMI. Results: 12 142 individuals (44% male, 85% white) were assessed at median age 14 [Interquartile range, IQR: 11, 16] and 33 [28, 39] years. Class II/III adult obesity developed in 6% of children with normal weight; 29% of children with overweight; 56% of children with obesity; and 80% of children with severe obesity. However, 38% of the 1 440 adults with class II/III obesity (553/1440) were normal weight as children. Prospective risk of adult class II/III obesity varied by age, sex and race within childhood weight status classifications, and is notably higher for girls, black participants, and those in the United States. The risk of class II/III obesity increased with older adult age. Conclusions: Children with obesity or severe obesity have a substantial risk of adult class II/III obesity, and observed prospective risk estimates are now presented by age, sex, race and childhood BMI. Clinical monitoring of children’s BMI for adult class II/III obesity risk may be especially important for females and black Americans., Table of Contents Summary This study developed prospective risk estimates of adult class II/III obesity using childhood BMI, childhood age, sex and race, using longitudinal international data.

Blood pressure (BP) tracking (maintaining a BP percentile) across life is not well defined but is important in predicting which children will become hypertensive adults. We computed BP tracking in subjects with BP measured in childhood and adulthood and performed logistic regression to determine the ability of childhood BP to predict adult hypertension (N=5035, 46.7 years, 74.2% white, 17.7% black; 39.6% male). Prevalence of hypertension was 29%. Correlations between systolic BP for child and adolescent were r =0.48; for adolescent and young adult were r =0.40, and for child and young adult were r =0.24 (all P P P 2

OBJECTIVE: To examine the associations of in utero exposure to maternal diabetes with surrogate measures of offspring pubertal timing (age at peak height velocity [APHV]) and speed of pubertal growth (peak height velocity [PHV]). STUDY DESIGN: Data from 77 exposed and 340 unexposed youth followed from age 2 to 19 years (51% non-Hispanic white, 50% females) were analyzed using the Exploring Perinatal Outcomes among Children study, a historical prospective cohort. Maternal diabetes status was collected from obstetric records, and child heights from 2 years to current age from pediatric records. Other covariates were collected during research visits. The Superimposition by Translation and Rotation method, using height measurements (4-52 per participant), modeled APHV and PHV. Accelerated failure time analyses were used to test whether exposure to maternal diabetes was associated with younger APHV and faster PHV. RESULTS: Adjusting for child’s sex and race/ethnicity, median APHV was reached ~3 months earlier in youth exposed to maternal diabetes compared with unexposed youth (P < .03). Youth exposed to maternal diabetes had a faster PHV than unexposed youth: exposed females had 10.5% greater median PHV compared with unexposed females and exposed males had a 4.0% greater median PHV compared with unexposed males (p

Childhood blood pressure (BP) levels predict adult subclinical atherosclerosis. However, the best childhood BP component for prediction has not been determined. This study comprised 5925 participants aged 3 to 18 years from 6 cohorts who were followed into adulthood (mean follow-up 25.8±6.2 years). Childhood BP was measured by using a standard mercury sphygmomanometer in all cohorts. Study-specific carotid intima-media thickness ≥90th percentile was used to define subclinical atherosclerosis. Per SD change in the predictor, childhood systolic BP (SBP; age- and sex-adjusted odds ratio [95% CI], 1.24 [1.13–1.37]), mean arterial pressure (1.10 [1.07–1.13]), and pulse pressure (1.15 [1.05–1.27]) were associated with increased adulthood intima-media thickness. In age- and sex-adjusted analyses, area under the receiver operating characteristic curves for SBP ( C value [95% CI], 0.677 [0.657–0.704]) showed significantly improved prediction compared with diastolic BP (0.669 [0.646–0.693], P =0.006) or mean arterial pressure (0.674 [0.653–0.699], P =0.01). Pulse pressure provided a C value that was not different from SBP (0.676 [0.653–0.699], P =0.16). Combining different BP components did not improve prediction over SBP measurement alone. Based on the associations with adult carotid intima-media thickness, cut points for elevated SBP were 105 mm Hg for 3- to 6-year-old boys, 108 mm Hg for 3- to 6-year-old girls, 108 mm Hg for 7- to 12-year-old boys, 106 mm Hg for 7- to 12-year-old girls, 123 mm Hg for 13- to 18-year-old boys, and 115 mm Hg for 13- to 18-year-old girls. Our analyses suggest that several childhood BP measurement components are related to adulthood carotid intima-media thickness. Of these, SBP provided the best predictive ability.

Ambulatory blood pressure (BP) monitoring is the accepted standard to confirm the diagnosis of hypertension. Although adult guidelines use absolute BP cut points to define ambulatory hypertension, current pediatric guidelines define it based on sex- and height-specific 95th percentiles and BP loads. To examine the association of different ambulatory BP parameters with hypertensive target organ injury, we compared adult and pediatric cut points and assessed the utility of BP load as a predictor of left ventricular hypertrophy (LVH) in 327 adolescents who were ≥13 years of age. Logistic regression was used to assess association of different ambulatory BP parameters with LVH. Sensitivity and specificity of different ambulatory BP cut points as predictors of LVH were also calculated. Sixty-eight (20.8%) participants had LVH. In the analysis comparing adult and pediatric criteria for ambulatory hypertension to predict LVH, adult cut points had better sensitivity-specificity balances than the pediatric 95th percentiles. Although the adult cut point for sleep systolic BP (110 mm Hg) was the optimal predictor of LVH, lower cut points for wake systolic BP (125 mm Hg) and 24-hour systolic BP (120 mm Hg) were better predictors of LVH than adult cut points. In a separate analysis, mean systolic BP, but not BP load, was significantly associated with LVH. We conclude that a single static cut point using an absolute ambulatory systolic BP value is comparable to sex-and height-based systolic BP percentiles in predicting LVH and that BP load does not provide any additional (to mean systolic BP) value to predict LVH in adolescents.

This randomized control trial assessed the post-intervention and 18-month follow-up effects of a 6-month dietary approaches to stop hypertension (DASH)-focused behavioral nutrition intervention, initiated in clinic with subsequent telephone and mail contact, on blood pressure (BP) and endothelial function in adolescents with elevated BP. Adolescents (n=159) 11 to 18 years of age with newly diagnosed elevated BP or stage 1 hypertension treated at a hospital-based clinic were randomized. DASH participants received a take-home manual plus 2 face-to-face counseling sessions at baseline and 3 months with a dietitian regarding the DASH diet, 6 monthly mailings, and 8 weekly and then 7 biweekly telephone calls focused on behavioral strategies to promote DASH adherence. Routine care participants received nutrition counseling with a dietitian consistent with pediatric guidelines established by the National High Blood Pressure Education Program. Outcomes, measured pre- and post-intervention and at 18-months follow-up, included change in BP, change in brachial artery flow-mediated dilation, and change in DASH score based on 3-day diet recalls. Adolescents in DASH versus routine care had a greater improvement in systolic BP (–2.7 mm Hg, P = 0.03, –0.3 z-score, P =0.03), flow-mediated dilation (2.5%, P =0.05), and DASH score (13.3 points, P P =0.03) and DASH score (7.4 points, P =0.01) to 18 months. The DASH intervention proved more effective than routine care in initial systolic BP improvement and longer term improvement in endothelial function and diet quality in adolescents with elevated BP and hypertension. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT00585832.

Hypertension is associated with cardiovascular events in adults. Subclinical changes to left ventricular strain and diastolic function have been found before development of decreased left ventricular ejection fraction and cardiovascular events. Our objective was to study effects of blood pressure (BP) on ventricular function in youth across the BP spectrum. Vital signs and labs were obtained in 346 participants aged 11 to 19 years who had BP categorized as low-risk (N=144; systolic BP P ≤0.05). The E/e′ ratio was higher in the high-risk group versus the low-risk and mid-risk groups, and the e′/a′ ratio was lower in the high-risk versus the low-risk group (both P ≤0.05). BP and adiposity were statistically significant determinants of left ventricular systolic and diastolic function. Subclinical changes in left ventricular systolic and diastolic function can be detected even at BP levels below the hypertensive range as currently defined.

Background Despite declining US adolescent smoking prevalence from 40% among 12th graders in 1995 to around 10% in 2018, adolescent smoking is still a significant problem. Using the International Childhood Cardiovascular Cohort (i3C) Consortium, which includes 7 international cohorts recruited in childhood and followed into adulthood, the present study was designed to confirm the important relation between adolescent smoking and daily adult smoking and present new data on adult smoking into the forties and comparison of smoking in the United States, Finland, and Australia. Methods and Results Childhood smoking experience during ages 6 to 19 in the 1970s and 1980s was classifiable in 6687 i3C participants who also provided smoking status in their twenties and forties through 2011–2018. Prevalence of daily smoking in their twenties was directly related to degree of smoking during adolescence and inversely related to the age at which that smoking experience occurred ( P trend, P trend, US , Finnish, and Australian participants. Conclusions These long‐term follow‐up data show that smoking intensity increased throughout adolescence. Prevalence of adult smoking and cessation by the forties were both correlated with levels of childhood smoking intensity. These data lend support to preventive strategies designed to reduce, delay, or eliminate any youth access to cigarettes.

BACKGROUND: Elevated non–high-density lipoprotein cholesterol (HDL-C) levels are used to identify children at increased cardiovascular risk, but the use of non–HDL-C in childhood to predict atherosclerosis is unclear. We examined whether the National Heart, Lung, and Blood Institute classification of youth non–HDL-C status predicts high common carotid artery intima-media thickness in adulthood. METHODS: We analyzed data from 4 prospective cohorts among 4582 children aged 3 to 19 years who were remeasured as adults (mean follow-up of 26 years). Non–HDL-C status in youth and adulthood was classified according to cut points of the National Heart, Lung, and Blood Institute and the National Cholesterol Education Program Adult Treatment Panel III. High carotid intima-media thickness (cIMT) in adulthood was defined as at or above the study visit-, age-, sex-, race-, and cohort-specific 90th percentile of intima-media thickness. RESULTS: In a log-binomial regression analysis adjusted with age at baseline, sex, cohort, length of follow-up, baseline BMI, and systolic blood pressure, children with dyslipidemic non–HDL-C were at increased risk of high cIMT in adulthood (relative risk [RR], 1.29; 95% confidence interval [CI], 1.07–1.55). Compared with the persistent normal group, the persistent dyslipidemia group (RR, 1.80; 95% CI, 1.37–2.37) and incident dyslipidemia (normal to dyslipidemia) groups (RR, 1.45; 95% CI, 1.07–1.96) had increased risk of high cIMT in adulthood, but the risk was attenuated for the resolution (dyslipidemia to normal) group (RR, 1.17; 95% CI, 0.97–1.41). CONCLUSIONS: Dyslipidemic non–HDL-C levels predict youth at risk for developing high cIMT in adulthood. Those who resolve their non–HDL-C dyslipidemia by adulthood have normalized risk of developing high cIMT in adulthood.

Introduction: Adolescence is a period of increased independence in lifestyle choices, as well as shifts in cardiometabolic risk factors. Understanding how stability or change in BMI status may be superimposed on risk factor changes will enable focused attention on girls whose risk factors are likely to deteriorate during adolescence. Methods: Girls were enrolled at age 10 into the NHLBI Growth and Health Study (NGHS) at 3 centers (n=2379) and assessed annually to age 19. Ideal cardiovascular risk factors (smoking, dietary sodium, dietary saturated fat, BMI, blood pressure (BP), total cholesterol (TC) and glucose), and related risk factors (HDL and LDL cholesterol, and triglycerides (TG)) were assessed. Trajectories of adherence to ideal risk factor definitions were evaluated using group-based modeling, with risk factor trajectories layered over BMI trajectories in change-over-change analysis. Results: Four trajectories of BMI across adolescence were: ideal (51%), deteriorating (14%), improving (11%) and poor (25%). Two to 4 trajectories were identified for other risk factors, with similar trajectory shapes (e.g., ideal, improving, deteriorating and poor). Ideal smoking prevalence only deteriorated, with trajectories differing by timing of smoking uptake (early, middle or late adolescence). Most adolescent girls had poor adherence to diet metrics throughout adolescence, with diet intake trajectories improving somewhat at different ages (early or later adolescence) in a small percent of participants. Stable poor or ideal BMI trajectories were associated primarily with stable risk factor trajectories (poor or ideal, respectively), for LDL, HDL, TG, BP (all p=0.0001). The poor BMI trajectory was also associated with late adolescent deteriorating glucose (p=0.0001) and TC trajectories (p=0.02). Changing BMI trajectories, either improving or deteriorating, can unmask the sensitivity of risk factors to change in BMI status. The improving BMI trajectory was more likely to be in the later-improving saturated fat (p=0.003), improving HDL (p=0.0002) and moderate-improving TG trajectories (p=0.01) and less likely to be in the low-deteriorating BP trajectory (p=0.04) compared to the deteriorating BMI trajectory. Smoking trajectories did not differ by BMI trajectory. Conclusions: Stable poor BMI is associated with poor, but not with deteriorating cardiometabolic risk profiles during adolescence, suggesting these changes must have occurred before age 10. Decreasing ideal TC and glucose appear to be late adolescent responses to persistently poor BMI. However, improving BMI status during adolescence is associated with improving dietary saturated fat intake and blood lipid profiles, while deteriorating BMI is associated with deteriorating BP and lipids. Thus, specific ideal health factors may be differentially sensitive to BMI changes in adolescent girls.

Introduction: Although childhood obesity is related to incident adult type 2 diabetes (T2DM), whether other childhood risk factors relate to T2DM is not clear and no childhood risk score has been established to help with prediction of T2DM. Methods: We examined childhood risk factors in The International Childhood Cardiovascular Cohort (i3C) Consortium with a goal of developing a risk score for predicting adult T2DM. The pooled datasets included childhood measurements during the 1970s to 1990s. Participants were re-contacted at mean age 40 yr and completed a health questionnaire including self-report of adult T2DM (occurrence age, medication use). Results: N = 4,425 i3C participants with measurements during ages 3-19 yr. 225 (5.1%) reported onset of T2DM between ages 20-55 (mean 38.4) years (82% reported use of a valid antidiabetic medication). After stepwise regression, age-sex standardized deviates (mean of all repeated measures during ages 3-19 yr) of body mass index (BMI), glucose and ln(insulin) were associated with incident T2DM; the unadjusted risk curves visibly steepened at about 0.75 standard deviates (Figure, top panel). In multivariable models, BMI, glucose and ln(insulin) in a single model were associated with adult T2DM after adjustment for sex, race, cohort, and individual mean childhood age and calendar year. Prediction of incident T2DM was directly related to the number of the three risk factors with levels above +0.75 standard deviates (0: 3.2% (96/2966), 1: 6.2% (63/1,012), 2: 14.3% (56/392), 3:18.2% (10/55); the corresponding adjusted HR (95%CI) for the counts were 1 (reference), 1.8 (1.3, 2.4), 4.7 (3.3, 6.5), and 6.7 (3.5, 13.1), respectively). The +0.75 standard deviates in natural units are given in the Figure (bottom panel), e.g. about 92 mg/dL for glucose at age 12-14. Conclusion: The study suggests that a childhood risk score composed of BMI, glucose and insulin is a strong predictor of adult T2DM. Provisionally suggested cutpoints are lower than currently defined normal.

Cardiovascular disease remains the leading cause of death worldwide. Although there is little direct evidence that ties the presence of risk factors in childhood with adult cardiovascular disease, there are multiple indirect lines of evidence that, when synthesized, make a strong case for maintaining cardiovascular health through childhood and adolescence as well as screening for and treating risk factors when they develop to diminish lifetime risk. This review summarizes these lines of evidence and asserts that it is imperative that primordial and primary cardiovascular risk reduction begins early.

Ambulatory blood pressure (BP) monitoring provides a more precise measure of BP status than clinic BP and is currently recommended in the evaluation of high BP in children and adolescents. However, ambulatory BP monitoring may not always be available. Our aim was to determine the clinic BP percentile most likely to predict ambulatory hypertension. We evaluated clinic and ambulatory BP in 247 adolescents (median age, 15.7 years; 63% white; 54% male). Clinic BP percentile (based on the fourth report and the 2017 American Academy of Pediatrics clinical practice guidelines) and ambulatory BP status (normal versus hypertension) were determined by age-, sex-, and height-specific cut points. Sensitivity and specificity of different clinic BP percentiles and cutoffs to predict ambulatory hypertension were calculated. Forty (16%) and 67 (27%) patients had systolic hypertension based on the fourth report and the 2017 guidelines, respectively, whereas 38 (15%) had wake ambulatory systolic hypertension. The prevalence of ambulatory wake systolic hypertension increased across clinic systolic BP percentiles, from 3% when clinic systolic BP was

Background: Data suggest that the prediction of adult cardiovascular disease using a model comprised entirely of adult nonlaboratory-based risk factors is equivalent to an approach that additionally incorporates adult lipid measures. We assessed and compared the utility of a risk model based solely on nonlaboratory risk factors in adolescence versus a lipid model based on nonlaboratory risk factors plus lipids for predicting high-risk carotid intima-media thickness (cIMT) in adulthood. Methods: The study comprised 2893 participants 12 to 18 years of age from 4 longitudinal cohort studies from the United States (Bogalusa Heart Study and the Insulin Study), Australia (Childhood Determinants of Adult Health Study), and Finland (The Cardiovascular Risk in Young Finns Study) and followed into adulthood when cIMT was measured (mean follow-up, 23.4 years). Overweight status was defined according to the Cole classification. Hypertension was defined according to the Fourth Report on High Blood Pressure in Children and Adolescents from the National High Blood Pressure Education Program. High-risk plasma lipid levels were defined according to the National Cholesterol Education Program Expert Panel on Cholesterol Levels in Children. High cIMT was defined as a study-specific value ≥90th percentile. Age and sex were included in each model. Results: In univariate models, all risk factors except for borderline high and high triglycerides in adolescence were associated with high cIMT in adulthood. In multivariable models (relative risk [95% confidence interval]), male sex (2.7 [2.0–2.6]), prehypertension (1.4 [1.0–1.9]), hypertension (1.9 [1.3–2.9]), overweight (2.0 [1.4–2.9]), obesity (3.7 [2.0–7.0]), borderline high low-density lipoprotein cholesterol (1.6 [1.2–2.2]), high low-density lipoprotein cholesterol (1.6 [1.1–2.1]), and borderline low high-density lipoprotein cholesterol (1.4 [1.0–1.8]) remained significant predictors of high cIMT ( P P =0.02). Conclusions: Nonlaboratory-based risk factors and lipids measured in adolescence independently predicted preclinical atherosclerosis in young adulthood. The addition of lipid measurements to traditional clinic-based risk factor assessment provided a statistically significant but clinically modest improvement on adolescent prediction of high cIMT in adulthood.

The prevalence of obesity, measured by body mass index, has risen to unacceptable levels in both men and women in the United States and worldwide with resultant hazardous health implications. Genetic, environmental, and behavioral factors influence the development of obesity, and both the general public and health professionals stigmatize those who suffer from the disease. Obesity is associated with and contributes to a shortened life span, type 2 diabetes mellitus, cardiovascular disease, some cancers, kidney disease, obstructive sleep apnea, gout, osteoarthritis, and hepatobiliary disease, among others. Weight loss reduces all of these diseases in a dose-related manner—the more weight lost, the better the outcome. The phenotype of “medically healthy obesity” appears to be a transient state that progresses over time to an unhealthy phenotype, especially in children and adolescents. Weight loss is best achieved by reducing energy intake and increasing energy expenditure. Programs that are effective for weight loss include peer-reviewed and approved lifestyle modification programs, diets, commercial weight-loss programs, exercise programs, medications, and surgery. Over-the-counter herbal preparations that some patients use to treat obesity have limited, if any, data documenting their efficacy or safety, and there are few regulatory requirements. Weight regain is expected in all patients, especially when treatment is discontinued. When making treatment decisions, clinicians should consider body fat distribution and individual health risks in addition to body mass index.

Severe obesity in adolescents is increasing and few effective treatments exist. Bariatric surgery is one option, but the extent to which surgery influences cardiovascular risk factors over time in youth is not clear. We hypothesized that Roux-en Y gastric bypass (RYGB) would be associated with sustained improvements in lipids over time (5 years).Youth who underwent RYGB from 2001 to 2007 were recruited for the Follow-up of Adolescent Bariatric Surgery-5+ (FABS-5+) in 2011-2014. Baseline body mass index (BMI) and lipids were abstracted from medical records. Follow-up data were obtained at a research visit. Analyses included paired t-tests to assess changes in BMI and lipids over time. General linear models were used to evaluate predictors of high-density lipoprotein (HDL) and non-HDL-cholesterol at follow-up. A non-operative group was recruited for comparison.Surgical participants (n=58) were a mean±s.d. age of 17±2 years at baseline and 25±2 years at long-term follow-up. Eighty-six percent were Caucasian and 64% were female. At long-term follow-up BMI decreased by 29% and all lipids (except total cholesterol) significantly improved (P0.01). Female sex was a significant predictor of non-HDL-cholesterol level at 1 year, while change in BMI from 1 year to long-term follow-up was a significant predictor of non-HDL-cholesterol and HDL-cholesterol during the same interval (P0.05). In the non-operative group, BMI increased by 8% and lipid parameters were unchanged.This is the longest and most complete follow-up of youth following RYGB. Weight loss maintenance over time was significantly associated with improvements in lipid profile over 5 years.

Summary Background Little is known about the long-term outcomes of bariatric surgery for severe adolescent obesity, raising questions about the durability of early responses to surgery. We aimed to analyse long-term (>5 years) outcomes of Roux-en-Y gastric bypass in a cohort of young adults who had undergone the operation during adolescence, in the Follow-up of Adolescent Bariatric Surgery at 5 Plus Years (FABS-5+) extension study. Methods A cohort of young people aged 13–21 years underwent Roux-en-Y gastric bypass for clinically severe obesity at a paediatric academic medical centre in the USA. We did a prospective follow-up analysis of these patients' outcomes 5–12 years after surgery. Outcomes assessed included BMI, comorbidities, micronutrient status, safety, and other risks. The FABS study is registered with ClinicalTrials.gov, number NCT00776776. Findings Between May, 2001, and February, 2007, 74 young people underwent Roux-en-Y gastric bypass in the FABS study. Of these, 58 individuals were eligible for the FABS-5+ study, could be located, and agreed to follow-up assessment. At baseline, the mean age of the cohort was 17·1 years (SD 1·7) and mean BMI was 58·5 kg/m 2 (10·5). At mean follow-up of 8·0 years (SD 1·6; range 5·4–12·5), the mean age of the cohort was 25·1 years (2·4) and mean BMI was 41·7 kg/m 2 (12·0; mean change in BMI −29·2% [13·7]). From baseline to long-term follow-up, significant declines were recorded in the prevalence of elevated blood pressure (27/57 [47%] vs 9/55 [16%]; p=0·001), dyslipidaemia (48/56 [86%] vs 21/55 [38%]; p vs 1/55 [2%]; p=0·03). At follow-up, 25 (46%) of 58 patients had mild anaemia (ie, not requiring intervention), 22 (45%) had hyperparathyroidism, and eight (16%) had low amounts of vitamin B12 (ie, below the normal cutpoint). Interpretation Roux-en-Y gastric bypass surgery resulted in substantial and durable bodyweight reduction and cardiometabolic benefits for young adults. Long-term health maintenance after Roux-en-Y gastric bypass should focus on adherence to dietary supplements and screening and management of micronutrient deficiencies. Funding Ethicon Endosurgery, National Center for Advancing Translational Sciences (US National Institutes of Health).

Nonalcoholic fatty liver disease (NAFLD) is a highly prevalent chronic liver disease that occurs in the setting of insulin resistance and increased adiposity. It has rapidly evolved into the most common liver disease seen in the pediatric population and is a management challenge for general pediatric practitioners, subspecialists, and for health systems. In this guideline, the expert committee on NAFLD reviewed and summarized the available literature, formulating recommendations to guide screening and clinical care of children with NAFLD.

Background: Preliminary studies suggest that offspring to mothers living near oil and natural gas (O&G) well sites are at higher risk of congenital heart defects (CHDs). Objectives: Our objective was to address the limitations of previous studies in a new and more robust evaluation of the relationship between maternal proximity to O&G well site activities and births with CHDs. Methods: We employed a nested case-control study of 3324 infants born in Colorado between 2005 and 2011. 187, 179, 132, and 38 singleton births with an aortic artery and valve (AAVD), pulmonary artery and valve (PAVD), conotruncal (CTD), or tricuspid valve (TVD) defect, respectively, were frequency matched 1:5 to controls on sex, maternal smoking, and race and ethnicity yielding 2860 controls. We estimated monthly intensities of O&G activity at maternal residences from three months prior to conception through the second gestational month with our intensity adjusted inverse distance weighted model. We used logistic regression models adjusted for O&G facilities other than wells, intensity of air pollution sources not associated with O&G activities, maternal age and socioeconomic status index, and infant sex and parity, to evaluate associations between CHDs and O&G activity intensity groups (low, medium, and high). Results: Overall, CHDs were 1.4 (1.0, 2.0) and 1.7 (1.1, 2.6) times more likely than controls in the medium and high intensity groups, respectively, compared to the low intensity group. PAVDs were 1.7 (0.93, 3.0) and 2.5 (1.1, 5.3) times more likely in the medium and high intensity groups for mothers with an address found in the second gestational month. In rural areas, AAVDs, CTDs, and TVDs were 1.8 (0.97, 3.3) and 2.6 (1.1, 6.1); 2.1 (0.96, 4.5) and 4.0 (1.4, 12); and 3.4 (0.95, 12) and 4.6 (0.81, 26) times more likely than controls in the medium and high intensity groups. Conclusions: This study provides further evidence of a positive association between maternal proximity to O&G well site activities and several types of CHDs, particularly in rural areas. Keywords: Congenital heart defects, Birth outcomes, Oil and natural gas development, Case control study, Environmental exposure, Hydraulic fracturing

Background: Data are limited regarding the association of cumulative burden and trajectory of body mass index (BMI) from early life with adult lipid disorders. Methods: The study cohort consisted of 5195 adults who had BMI repeatedly measured 4 to 21 times from childhood and had blood lipid measurements of low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG) and information on lipid-lowering medications in the last adult survey. The area under the curve (AUC) was calculated as a measure of long-term burden (total AUC) and trends (incremental AUC) of BMI. Results: Participants with dyslipidemia, high LDL-C, low HDL-C and high TG had consistently and significantly higher BMI levels from childhood to adulthood compared to those with normal lipid levels. After adjusting for age, race, sex, and cohort, increased risk of adult dyslipidemia was significantly associated with higher values of childhood BMI, adulthood BMI, total AUC and incremental AUC, with odds ratio (95% confidence interval) = 1.22 (1.15&ndash, 1.29), 1.85 (1.74&ndash, 1.97), 1.61 (1.52&ndash, 1.71), and 1.59 (1.50&ndash, 1.69), respectively, and p &lt, 0.001 for all. The association patterns were similar in most race&ndash, sex subgroups. Conclusions: Adults with dyslipidemia versus normal lipid levels have consistently higher levels and distinct life-course trajectories of BMI, suggesting that the impact of excessive body weight on dyslipidemia originates in early life.

Background: Historically, cutoff points for childhood and adolescent overweight and obesity have been based on population-specific percentiles derived from cross-sectional data. To obtain cutoff points that might better predict overweight and obesity in young adulthood, we examined the association between childhood body-mass index (BMI) and young adulthood BMI status in a longitudinal cohort. Methods: In this study, we used data from the International Childhood Cardiovascular Cohort (i3C) Consortium (which included seven childhood cohorts from the USA, Australia, and Finland) to establish childhood overweight and obesity cutoff points that best predict BMI status at the age of 18 years. We included 3779 children who were followed up from 1970 onwards, and had at least one childhood BMI measurement between ages 6 years and 17 years and a BMI measurement specifically at age 18 years. We used logistic regression to assess the association between BMI in childhood and young adulthood obesity. We used the area under the receiver operating characteristic curve (AUROC) to assess the ability of fitted models to discriminate between different BMI status groups in young adulthood. The cutoff points were then compared with those defined by the International Obesity Task Force (IOTF), which used cross-sectional data, and tested for sensitivity and specificity in a separate, independent, longitudinal sample (from the Special Turku Coronary Risk Factor Intervention Project [STRIP] study) with BMI measurements available from both childhood and adulthood. Findings: The cutoff points derived from the longitudinal i3C Consortium data were lower than the IOTF cutoff points. Consequently, a larger proportion of participants in the STRIP study was classified as overweight or obese when using the i3C cutoff points than when using the IOTF cutoff points. Especially for obesity, i3C cutoff points were significantly better at identifying those who would become obese later in life. In the independent sample, the AUROC values for overweight ranged from 0·75 (95% CI 0·70–0·80) to 0·88 (0·84–0·93) for the i3C cutoff points, and the corresponding values for the IOTF cutoff points ranged from 0·69 (0·62–0·75) to 0·87 (0·82–0·92). For obesity, the AUROC values ranged from 0·84 (0·75–0·93) to 0·90 (0·82–0·98) for the i3C cutoff points and 0·57 (0·49–0·66) to 0·76 (0·65–0·88) for IOTF cutoff points. Interpretation: The childhood BMI cutoff points obtained from the i3C Consortium longitudinal data can better predict risk of overweight and obesity in young adulthood than can standards that are currently used based on cross-sectional data. Such cutoff points should help to more accurately identify children at risk of adult overweight or obesity.