logging in or signing up ADOLESCENT PREVENTIVE CARDIOLOGY praveenks Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: Embed: Flash iPad Copy Does not support media & animations WordPress Embed Customize Embed URL: Copy Thumbnail: Copy The presentation is successfully added In Your Favorites. Views: 991 Category: Education License: All Rights Reserved Like it (0) Dislike it (0) Added: July 01, 2009 This Presentation is Public Favorites: 1 Presentation Description ADOLESCENT PREVENTIVE CARDIOLOGY, m. zulfikar ahamed professor & head, pediatric cardiology sath, gmc, thiruvananthapuram Comments Posting comment... By: vivek1978 (47 month(s) ago) sir when we can't see your slide ,what we will coment. sir one thing i want to know , if a patient of rheumatic fever has CHF and active carditis and also have infective endocarditis .sir is steroid use will flare the bacteremia? steroid use for rheumatic fever is rationale in this case. Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Welcome To T h i r u v a n a n t h a p u r a m : Welcome To T h i r u v a n a n t h a p u r a m Slide 3: ‘ David Bowman becomes the Star Child ’ 2001 : A Space Odyssey Slide 6: ADULT LIFESTYLE DISEASES & CVD ADOLESCENT ACCEL ADOLESCENT ORIGIN INTRAUTERINE ORIGIN LBW The Circle of Life ? ADOLESCENT PREVENTIVE CARDIOLOGY : ADOLESCENT PREVENTIVE CARDIOLOGY m. zulfikar ahamed professor & head, pediatric cardiology sath, gmc, thiruvananthapuram MAN : MAN Hunter - Gatherer Agriculture and Settlements Mechanical Industrial & Digital revolution ? Zoonoses Infections Malnutrition Lifestyle Diseases CVD CARDIOVASCULAR DISEASES : CARDIOVASCULAR DISEASES CVD Major Challenge In India INDIA IS ON FIRE !The Economist Feb 2007butA Bleak House with regard to disease issues WHY ? : INDIA IS ON FIRE !The Economist Feb 2007butA Bleak House with regard to disease issues WHY ? Slide 11: Pre transitional diseases Double jeopardy INDIA - DISEASE BURDEN Post transitional diseases Slide 12: Major causes of Deaths In India (2005) Source : WHO MORBIDITY IN INDIA : MORBIDITY IN INDIA Slide 14: CVD mortality will rise by 100 % by 2015 CVD will cause 35 – 40 % of all deaths by 2015 ( current - 27% ) CVD Mortality INDIA CVDCardiovascular Diseases : CVDCardiovascular Diseases “ REVERSAL OF SOCIAL GRADIENT ” Poor Rich CVD in Kerala : CVD in Kerala The Ungainly “Age” Factor Acute Coronary events in CCU, MCH ,Tvpm < 45 yr - 40 % ! CVD Risk Factors ?Four Apocalypse : CVD Risk Factors ?Four Apocalypse OBESITY HYPERTENSION DYSLIPIDEMIA DIABETES & Smoking Slide 19: MAJOR CVD RISK FACTORS ‘ METABOLIC SYNDROME ’ & SMOKING ATHEROSCLEROSIS CLUSTERING MAJOR CVD RISK FACTORSThe Deadly Quartet Kerala Experience - HAP : MAJOR CVD RISK FACTORSThe Deadly Quartet Kerala Experience - HAP Hypertension 27% - 41 % Diabetes 13.5 % - 21 % Smoking 21% Obesity & Overweight 33 % ? (5.3 / 28) Slide 21: CVD RISK FACTORS Our State and Our Nation[ ER, State Planning Board 2005] India Kerala Hypertension 589 1433 Diabetes 221 980 (Per lakh) CARDIOVASCULAR DISEASES : CARDIOVASCULAR DISEASES A R o a d to P e r d i t i o n ? Slide 23: ROAD MAP FOR Atherosclerosis in youngas a Concept Framingham study Korean war; Vietnam war Bogalusa study ; PDAY : Muscatine Childhood Onset Adult Diseases WHAT DO THESE STUDIES SAY ? : WHAT DO THESE STUDIES SAY ? Major CVD risk factors start operating from childhood Dyslipidemia and atherosclerotic changes start in young adults and adolescents BMI, BP, low HDL cholesterol and high LDL Chol at 15 years correlated with CAD in adulthood Slide 25: Will Today’s Child be Tomorrow's Cardiac Patient ? Obesity Hypertension Dyslipidemia Youth risk behavior Smoking ADULTHOOD Possibly Yes ! What can be Done ? : What can be Done ? Secondary prevention Primary Prevention Primordial Prevention Lifetime Prevention Intrauterine Prevention ? Slide 27: PREVENTIVE CARDIOLOGY and THE ADOLESCENT Catch Them Young ! Make Adolescents “Heart Smart”! CVD risk reduction from adolescence WHY ? Slide 28: SCENARIO 12 year old boy has occasional severe headache . O/E BP 150 / 70 mm Hg RUL High volume radials. weighs 37 kg . Ht. 146.5 cms What to do ? HYPERTENSION : HYPERTENSION Prevalence : 1 % Adult : 25 - 40 % Slide 30: What is Hypertension ? “ level of BP at which there is a doubling of long term CVD risk ” Only an arbitrary answer ! Slide 31: 140 mmHg SBP CVD risk _ _ _ _ _ 5 4 3 2 1 Slide 32: 85 – 90 mmHg DBP CVD risk _ _ _ _ _ 5 4 3 2 1 Slide 33: STAGING of BPJNC 7 Stage SBP DBP Action Optimal < 120 < 80 no Pre hypertension 120 –139 80- 89 recheck . LSM Hypertension Stage 1. 140 –159 90 –99 Confirm + Evaluate 2. 160 –179 100- 109 Evaluate . Refer 3. > 180 > 110 Evaluate – immediate refer Slide 34: HYPERTENSION IN CHILDREN Normal : < 90 th centile Pre Hypertension : 90 - 95th centile HBP : > 95th centile for age sex height Slide 35: HBP in CHILD / ADOLESCENT( for 50th centile Height) Age Girl Boy 1 105 / 60 102 / 60 6 110 / 75 115 / 75 12 125 / 80 125 / 80 17 130 / 85 135 / 85 (approximate) Slide 36: ADOLESCENT HYPERTENSION 10 - 15 yrs SBP > 130 DBP > 80 mm hg 15 - 20 yrs SBP > 135 DBP > 85 mm hg Slide 37: HYPERTENSION - Issues Detection / Screening Pre hypertension ‘ Tracking ’ ‘ Clustering ’ phenomenon Treatment of high blood pressure Slide 38: Routine BP recording in children beyond 3 years Routine BP screening in Adolescent - is it required ? Child / Adolescent with high BP - HYPERTENSION : LSM DRUGS Slide 39: HYPERTENSION Concept of Pre hypertension Philip T Dick Pre crime JNC VII 2003 HYPERTENSION Child onset ? : HYPERTENSION Child onset ? TRACKING : Adolescents who have high centiles of BP continue to have higher centiles in adulthood and are likely to develop hypertension in adulthood Slide 41: TRACKING in HTN Child Adol Young Adult Adult BP Centile HTN 80th 50th 25th Slide 42: < 5 yrs - BP > 110 / 70 mmHg 5 - 10 yrs - BP > 120 / 80 mmHg 15- 10 yrs - BP > 130 / 80 mmHg BP IN CHILDREN Evaluation Indicated if Slide 43: ADOLESCENT HYPERTENSION LSM DRUG THERAPY Specific Measures Slide 44: LIFESTYLE MODIFICATION 1. Diet Sodium restriction ( < 6 gm /day) Fall in SBP/ DBP 2. Dietary supplementation of Potassium 3. Weight reduction Slide 45: LIFESTYLE MODIFICATION 4. Exercise 5. Reduce Alcohol consumption 6. Stress management 7. Vegetarian diet 8. Fiber intake + Slide 46: LSM - Impact Modification SBP reduction Weight reduction 5 - 20 mm Hg Sodium restriction 2 - 8 mm Hg Exercise 4 - 10 mm Hg Alcohol redn 2 - 4 mm Hg DASH eating plan 8 - 14 mm Hg Slide 47: HTN - LSM Reduction in weight of 1 kg will SBP by 2 - 3 mmHg DBP by 1- 2 mmHg Slide 48: HTN - DRUGSWhich Drugs To Chose ? ACE Inhibitors Calcium Channel Blockers Angiotensin Receptor Antagonists B- Blockers + Diuretics ? Slide 49: HTN - Drugs . Dosage Captopril : 2- 4 mg / kg / day 3 divided doses Enalapril : 0.1 mgm/ kg / dose 2 doses Ramipril : 6 mgm / M2 once daily Slide 50: Nifedipine : 0.5 - 1.0 mgm / kg /day 3 divided doses Amlodipine : 0.1 - 0.5 mgm/ kg once / twice daily Losartan : 0.5 - 1.0 mgm / kg /day once daily Irbesartan : 4 -5 mgm/kg once daily Atenolol : 1 mgm / kg / day once daily Metoprolol : 1- 4 mgm/kg twice daily HTN - DRUG DOSAGE Slide 51: Calcium Channel Blockers ADOLESCENT GIRL DRUG THERAPY ACE inhibitors B-blockers Diuretics ARB Slide 52: A 13 yr old has a BP of 144 / 86 1. Is it Normal ? 2. If it is normal - how normal ? 3. If it is abnormal - a. What will you look for in the child ? b. Should we look at Parents ? c. What are the minimal investigations? d. If BP is without secondary cause what will you do ? e. Which drug will you use if the child has mildly impaired GTT ? Slide 53: 16 year old boy. Visit for “excess weight” Weight 64 kg .146 cm . BMI 29.2 Father is 51. Non diabetic. BP 140 / 90 .BMI 26.2 Mother is 48 . BP 120 / 80 . BMI 24.2 SCENARIO What to do ? OBESITY‘ The world is too fat ‘- The Economist : Starts in Childhood Adolescent ? “Fetal - Postnatal Origins” Why ? Physical Inactivity TV watching Change in Eating habits Urbanization - ‘Kerala Model’ OBESITY‘ The world is too fat ‘- The Economist Slide 56: BMI more than [ adult ] ( Wt / Ht2) WHAT IS OBESITY ? > 30 Overweight - 25 - 30 Cut off values for BMI for Overweight : Cut off values for BMI for Overweight Slide 58: Measured by OBESITY IN CHILD & ADOL BMI CDC centiles BMI IOTF values Waist circumference [ > 90th centile] Adult > 100 / 90 cms Children > 70 to 100 cms OBESITY in CHILDREN based on BMI (CDC,USA)< 5 th centile Underweight5 th to 85 th centile Normal85 th to 95 th centile Overweight> 95 th centile Obesity : OBESITY in CHILDREN based on BMI (CDC,USA)< 5 th centile Underweight5 th to 85 th centile Normal85 th to 95 th centile Overweight> 95 th centile Obesity OVERWEIGHT IOTF 2000YR BMI 5 1710 2015 23 18 25 : OVERWEIGHT IOTF 2000YR BMI 5 1710 2015 23 18 25 OBESITY IOTF 2000 YR BMI above 5 1910 2415 2818 30 : OBESITY IOTF 2000 YR BMI above 5 1910 2415 2818 30 Slide 62: OBESITY IN CHILDREN Obesity in Adult 20 - 30 % >10 yrs 15 – 20 % 5 – 10 yrs 10 % More in BOYS ASIANS Slide 65: EPIDEMIC OF OBESITY Little or no social difference Less developed countries are affected Slide 67: Socioeconomic difference is decreasing From 1995 to 2005 CHILDHOOD OBESITY in THE WEST / INDIA ? “Childhood obesity - Is the gap closing the wrong way ?” Journal of Public Health June 2008 Slide 68: South Atlantic Ocean South Pacific Ocean Indian Ocean Arctic Ocean Arctic Ocean North Pacific Ocean Patterns Of Overweight & Obesity Globally For Nationally Representative Samples (Percentage overweight + Obese) Slide 69: PREVALENCE OF OBESITY 3 times 16% 2 decades Slide 70: Endemic Epidemic < 5 % 1998 OBESITY / OVERWEIGHT INDIA < 10 - 20 % 2005 - 2007 Slide 71: OBESITY INDIA Place Year Age % Name Kochi 2003 5 -16 1.2 ICMR Kochi 2005 5 -16 1.89 ICMR Delhi 2002 10 -16 7.4 Kapil Punjab 2008 9 -15 11.1 Chatwal Ludhiana 2004 11 -17 2 -3% Mohan Slide 72: Obesity in Indian/ Kerala Children NMJ of India vol 20 no. 6, 2007 2003 24842 4.9 % 2005 20263 6.57 % [Age 5-16 yrs] Increasing Trend in Overweight Obesity trends in school children : Obesity trends in school children Slide 74: CVS Risks in Obese Children AIMS Study Abn Total Cholesterol 26 % Abn TG 27 % Low HDL 53 % Abn LDL 28 % IR 37 % HBP 59 % MS 39 % OBESITY Magnitude ? HAP data : OBESITY Magnitude ? HAP data Adult Obesity ( Tvpm) Rural - 6 % Urban -19 % Adolescent Obesity ? ISSUES Shouldn’t we quantify Adolescent Obesity ? Slide 76: ADOLESCENT OBESITY-Kerala INCLEN study 2003 Age group : 14 years ( Girls) Rural : None Urban : 8 -10% Slide 77: OBESITY CVD Dyslipidemia Hypertension LVH Atherosclerosis Obstructive Sleep Apnea Slide 78: OBESITY as An ‘OUTCOME’ of imbalance between calorie intake and expenditure An ‘ EXPOSURE’ Linked HBP, diabetes, heart disease etc.. Slide 79: The mismatch between calories consumed and calories needed has ‘reversed’ obesity in children Slide 80: High Caloric Intake Lowering of prices of basic food grains Greater variety of food choices Promotion and use of caloric dense foods Lower cost of certain animal food Slide 81: Low Caloric Expenditure Personal transportation Labor saving devices at home Reduced sports & physical activity TV viewing / Digital revolution Slide 82: OBESITY & CHILDHOOD ENVIRONMENT Diet content and quantum Physical Activity Psychosocial factors ‘passive over consumption’ of energy Sugar sweetened beverages Fast food Low calcium content ? Slide 83: ENVIRONMENT IN UTERO INFANCY CHILDHOOD Under nutrition - ‘Barker’ Over nutrition - IGDM - Breast feeding - Complementary feeding - Formula feeding Slide 84: HBW tracks obesity LBW BIRTH WEIGHT Post natal catch up growth OBESITY : OBESITY Beware of Obese Children Who were Thin at Birth Look for Co-Morbid Conditions Obesity Risk Increases with the Age of the Child : Obesity Risk Increases with the Age of the Child Obese at 6 years 50% risk of obesity at 35 yrs Obese at 10 years 70 - 80% risk Obesity is a pediatric disorder with adult consequences Source: Bray 2002, Dietz 1998a, Dietzs 1998b,Guo et al. 2002; Kvaavik et al. 2003; `Must 2003, Whitaker et al. 1997; Slide 87: Nutrition Transition Increased BMI OBESITY & CVD act ! act ! C V D Slide 88: BF FF ‘Early protein’ ROAD MAP FOR OBESITY High Calorie Food loss of Physical Activity TV & Computers Academic pursuits LBW NB INFANCY CHILD ADOLESCENT Slide 89: PREVENTIVE MEASURES Screening high risk individuals and weight reduction Primary prevention Slide 90: OBESITY may not ( Cochrane review) So Emphasis must be on PRIMARY PREVENTION Will screening & intervention work ? Slide 91: High Risk and Population Approaches Truncate high risk end of exposure distribution (e.g. organize an obesity clinic). Clinical approach to disease prevention. Reduce a little risk in most people (e.g. reduce fat a little in fast-food outlets). Lifestyle change combined with an environmental approach. Slide 92: Physical activity at home and school Discouraging advertising of high calorie foods Restrict TV / computers PRIMARY PREVENTION PRIMARY PREVENTION IN CHILDREN : Legislation ban advertisements targeted to children regulation of school canteen compulsory physical activity in school Community action school playgrounds encouragement of sports Parental action restrict TV PRIMARY PREVENTION IN CHILDREN Slide 94: CHILDHOOD OBESITYTreatment LSM Dietary restriction Weight Reduction Exercise Control Co-morbid Factors Drugs / Weight reducing agents Metformin ‘do not jumpstart medications’ Slide 95: TREATMENT OF OBESITY Active Weight Goals a. < 2 yr – Maintain baseline weight b. < 7 yr – Prolonged weight maintenance - weight loss ( if sec. complication) c. > 7 yr – Prolonged weight maintenance if sec. compln - Weight loss > 95 th centile…. A 48 yr old man gets admitted into CCU with AMI. He has mild Diabetes & mild Hypertension. His elder brother died of SCD at 54 : A 48 yr old man gets admitted into CCU with AMI. He has mild Diabetes & mild Hypertension. His elder brother died of SCD at 54 He has 16 yr old son 1. Will you evaluate the boy?2. If so why?3. What clinical findings will you look for?4. What investigations ?5. The boy has S . chol 223 mg/dl. What will you do? Slide 97: Onset of atherosclerosis What is normal / abnormal ? Preventive & treatment aspects DYSLIPIDEMIA -Issues DYSLIPIDEMIA Beginning of the Beginning : DYSLIPIDEMIA Beginning of the Beginning Fatty Streaks - 3 years * Plaques - Adolescence Slide 99: Atherosclerosis Starts in Adolescence Accelerates in Adult CVD Slide 100: CHOLESTEROL VALUES IN CHILDREN Acceptable < 170 < 110 mg /dl Borderline 170- 199 110 -129 High > 200 > 130 T. Chol LDL -Chol Slide 101: DYSLIPIDEMIA IN TRIVANDRUMA HAP Study ( IHJ 2000 ) Mean T. cholesterol 223 + 45 223 + 45 HDL cholesterol 50 + 11 57 + 13 LDL cholesterol 145 + 41 145 + 42 DYSLIPIDEMIA What To Do ? : DYSLIPIDEMIA What To Do ? ?? Screen all Adolescents ? Screen high risk Adolescents INTERVENE Family history CAD HBP Obesity Slide 103: ACCEPTABLE ACTION Health education Repeat values at 5.0 years Health advice AHA step I diet Repeat values at 1.0 yr BORDERLINE Slide 104: HIGH VALUES Look for secondary cause(s) Step I II diet < 30% calories from fat < 7% sat fat < 200 mg chol / day Drug ? Slide 105: DIET / DRUG < 2 yrs - No restriction ; No drugs 2- 5 yrs - AHA step I diet 5 – 8 yrs - AHA diet ; No drug ?? > 8 .0 yrs - AHA diet ; Drugs ? Slide 106: DIET / DRUG < 2 yrs - No restriction ; No drugs 2- 5 yrs - AHA step I diet 5 – 8 yrs - AHA diet ; No drug ?? > 8 .0 yrs - AHA diet ; Drugs ? Slide 107: For children above 2.0 yrs NCEP Guidelines DIET Saturated F Acids < 10 % total calories Total Fat < 30 % total calories PUFA > 10 % total calories < 300 mg cholesterol / day adequate fiber Slide 108: INDICATIONS FOR DRUG THERAPY 6 – 12 mo of diet therapy : LDL > 190 Family h/o early CVD : LDL > 160 >2 risk factors : LDL > 160 All above 8 years Obesity Smoking Hypertension Diabetes Inactivity DYSLIPIDEMIA Treatment : DYSLIPIDEMIA Treatment DRUGS : Bile acid binding resins Nicotinic acid S t a t i n s < 2 yrs - Statins - No 2 -10 yrs - Statins - Probably not > 10 yrs - Statins - Yes NO FAT RESTRICTION Below 2 yrs Slide 110: DRUGS USES Cholestyramine redn < 20% Niacin Redn < 30% Statins reduction T. chol LDL- chol VLDL TG 30% 40% 20% 10% Slide 111: STATINS IN CHILDREN AHA Task Force : Boys - > 10 yrs Girls - > Menarche or SMR -2 Slide 112: STATINS USED Pravastatin 5 - 20 mgm / day Lovastatin 10- 40 mgm / day Simvastatin 10 mg / day Atorvastatin 5- 10 mg / day Slide 113: STATINS IN CHILDREN > 8 years ? AAP Recommendations 2008 Pediatrics July 2008 Slide 114: ‘Younger the Better’ ? OR ‘Later but Greater’ ? STATINS IN CHILDREN Slide 115: A 12 year old boy is brought with excessive Tiredness . Clinically normal . Not obese . BP 130 /85 His FBS 188 PPBS 299 SCENARIO What to do ? Slide 116: DIABETES IN THE YOUNG Type I Type II (Insulin Resistance ) Risk status in young ? weight management exercise glycemic control additional risk factor mgt Slide 117: HYPERGLYCEMIA Fasting Glucose > 100 mg/dl ( ? 110 mg/dl) IGT ( 2 hr) > 140 mg/dl Measured by Slide 118: INSULIN RESISTANCE Fasting serum Insulin level IGT Measured by DIABETESThe Kerala Scenario : DIABETESThe Kerala Scenario Prevalence in Adult : 6.0 % Rural (HAP) 12 -14 % Urban Now 13-21 % Indian Average of 2.5 % Rural 6.0 % Urban DIABETES IN KERALA High Co-morbidity : DIABETES IN KERALA High Co-morbidity Obesity 43% Hypertension 32 % Dyslipidemia 27% DIABETES & ADOLESCENCE Is There a Link ? : DIABETES & ADOLESCENCE Is There a Link ? Probably has an Adolescent Origin Life style Changes Physical Inactivity Obesity Nutritional Transition Possible Fetal Origin ? Slide 123: Adol. Risk factors ‘ tracking’ ? Preventive aspects Legislation on Food products INSULIN RESISTANCE - Issues Slide 124: INTERVENTION IN RISK REDUCTION Prudent diet Avoid obesity Encourage Exercise Screening - ?? DYSGLYCEMIA : Slide 125: SCENARIO A 14 yr boy has a 46 yr old father with Diabetes and Hypertension on drugs , Mother who has IGT. Boy looks obese . Will you be interested in evaluating this boy ? If no - - Why ? If yes - - which investigations will you order ? What is syndrome X ? Slide 126: “ Clustering of risk factors for Diabetes and CVD that is frequently observed in patients who are overweight ” What is METABOLIC SYNDROME ? Slide 127: MS Obesity Insulin resistance Slide 128: METABOLIC SYNDROME Reaven 1988 Definitions: WHO NCEP IDF Slide 129: METABOLIC SYNDROME Circulation 2005 Abdominal Obesity High Blood pressure High Triglycerides Low HDL High FBS 3/5 MS What is it ? Slide 130: MS CVD RISK 3 fold Type 2 DM 3 – 5 fold Slide 131: METABOLIC SYNDROMEA Road To Perdition OBESITY INSULIN RESISTANCE CVD TG HTN TG HDL HTN HG Slide 132: METABOLIC SYNDROME inCHILDREN Can develop in Childhood, Adolescence Lack of uniformity in diagnosis Central role of Insulin resistance / Obesity Risk Factor for CVD Needs intervention (s) Slide 133: METABOLIC SYNDROME IN CHILDREN 3 / 5 of Obesity ( BMI / WC) Hypertension IGT / HG HDL- low TG - high Slide 134: MS CHILDHOOD ADULT 4 % 24 % Slide 135: Hyperglycemia Hypertension Obesity Low HDL High TG MS IN CHILDREN Components 1.5% 4.9% 9.8% 23.3% 23.4% Slide 136: Clustering Risk Factors in adults EVOLUTION OF MS in the YOUNG CVD risk factors in the young Clustering in the young MS in Young Slide 137: MS TREATMENT APPROACH Population Approach Individual LSM DRUGS Diet Exercise Behavior Slide 138: “Label of MS in obese children should not be a green signal for treatment with drugs” ? DRUGS : Anti hypertensives LIPID lowering agents Weight reducing drugs Metformin TREATING MS Slide 139: Controversial Risk prediction of CVD MS DOES NOT TAKE INTO ACCOUNT Age Total cholesterol LDL cholesterol Smoking CVD RISK FACTORS : CVD RISK FACTORS Screening in Children Need Feasibility Cost Benefit Inter- Effect vention OBESITY +++ +++ +++ ++ ++ HTN +++ +++ ++ ++ ++ DYSLIPIDEMIA ++ + + + ++ INSULIN + + + ++ ++ RESISTANCE selective Slide 141: A 17 yr old college student girl admitted with acute anterior wall MI. Post MI CAG shows 2 Vessel disease with aneurism on LAD & RCA . There is a history of measles like illness when the boy was 2 yrs old. Can you link these unrelated events together ? If so - what could be the etiology ? What are the potential problems of the disease ? How will you follow up ? Slide 142: KAWASAKI DISEASE - Future CAD ? Future CAD risk Why so ? Slide 143: Atherogenic lipid changes Mildly Elevated Total Cholesterol Mildly Elevated LDL- Cholesterol Mildly Elevated TG Mildly decreased HDL - Cholesterol in convalescing KD KD and Lipid AbnormalitiesAn Intriguing Finding? CAD ? Slide 144: LIPIDS & KD 160.0 170.3 205.2 105.9 114.3 144.0 24.1 32.2 33.3 167.0 181.2 232.0 Slide 145: From KD to Later CAD A possible Route Map KD Dyslipidemia HTN. Obesity Persistence ? Persistence CAL CAD Endothelial Dysfunction Slide 146: Age group - 16 - 20 Yr TEENAGE SMOKING - KERALAGYTS study - Cochin Number - 954 16.5 % SMOKE ! Slide 147: Teenage Smoking - Kerala & India 16.5% 4.5% 4.0% 7.1% 14.8% Slide 148: Is there a link ? MS is more in young smokers SMOKING & MS non exposed - 1.2 % smokers - 8.7 % MS Slide 149: SMOKING in KERALA < 1% 2% 20% Slide 150: INTERVENTION IN RISK REDUCTION Quantify the risk / prevalence Adolescent counseling 15 20 yr Legislation School Curriculum ? SMOKING : Vulnerable window Slide 151: AT 15 YRS Atherosclerosis is in smokers than non smoking children & adolescents W H Y ? Slide 152: Diet Saturated fat ; Cholesterol Caloric Control Sugar DIET & PRIMORDIAL PREVENTIONOF CVD in CHILDREN Slide 153: DISC study 1995 USA STRIP study 2007 Finland DIET STUDIES Slide 154: Continued breast feeding Fat < 30 – 35 % of Energy Sat Fat / Unsat Fat ratio 1: 2 Cholesterol < 200mg /day Skimmed milk > 1 year STRIPRCT 19900 – 14 yrs Slide 155: STRIPEffects Reduction in total cholesterol, LDL –Chol Same HDL No Difference in Growth BMI Puberty Menarche Slide 156: CVD RISK FACTORS Clustering Effect Life style changes Metabolic Decontrol Fetal Origin ? Genetic “The Onion Peel Effect” CVD Risk Factors The Multi layering Concept Slide 157: “The Fetal Origins of Adult Disease” Editorial BMJ 2001 R .Robinson “No longer just a hypothesis and may be critically important in South Asia” BARKER HYPOTHESIS : BARKER HYPOTHESIS Hertfordshire 1988 1911 - 1930 Birth Register 1980’s - ‘Present’ UK Birth Weight < 2500 gm CVD MORTALITY BARKER HYPOTHESIS : BARKER HYPOTHESIS Reduced Fetal Growth LBW CVD Morbidity / Mortality in Adult Slide 160: LBW ATHEROSCLEROSIS CVD Slide 161: Is it Hypothesis ? Or is it Speculative ? BARKER HYPOTHESIS Slide 162: PROOF OF HYPOTHESIS STUDY NUMBER PERIOD RESULT Mysore , India 517 1934-54 Higher CAD LBW Helsinki, Finland 4630 1934- 44 Higher CAD LBW Uppsala, Sweden 14611 1915- 29 Higher CAD LBW IN UTERO ORIGIN OF CAD : IN UTERO ORIGIN OF CAD Epidemiological Proof ? Direct LENINGRAD SEIGE STUDY DUTCH FAMINE STUDY DUTCH FAMINE STUDY : DUTCH FAMINE STUDY Dutch Famine 1944 - 45 Unique opportunity for testing intrauterine Factors concept Heart 2000 Number to Famine exp CAD prevalence No 3.2 Early Gestation 8.8 Mid Gestation 0.9 Late Gestation 3.1 Slide 165: DUTCH FAMINE STUDY 1943- 47 Cohort CAD prevalence N - 736 3.3 3.2 8.8 LENINGRAD SEIGE STUDY BMJ 19971941 - 44 Siege 872 daysCalorie intake protein0 LBW 18% : LENINGRAD SEIGE STUDY BMJ 19971941 - 44 Siege 872 daysCalorie intake protein0 LBW 18% 3 Groups In utero exposed Infancy exposure Not exposed Slide 167: No difference in present day prevalence of IGT Dyslipidemia Hypertension CVD morbidity LENINGRAD SEIGE STUDY BMJ 1997 FETAL ORIGINS OF ATHEROSCLEROSIS & CVD : FETAL ORIGINS OF ATHEROSCLEROSIS & CVD Past 10 yrs : Near unequivocal evidence favoring link between IUGR, LBW & CAD Next 10 yrs : ? Cellular and Molecular mechanisms for such phenomenon New strategy to reduce impact of CVD Slide 169: BARKER HYPOTHESIS Still a hypothesis PROGRAMMING ? What are the implications ? Preventability Life time prevention What can be Done ? : What can be Done ? Secondary prevention Primary Prevention Primordial Prevention Lifetime Prevention Intrauterine Prevention ? Slide 171: LBW CVD Risk Factors CVD Undernourished Girl Undernourished Mother Slide 172: ADULT LIFESTYLE DISEASES ADOLESCENT ACCEL ADOLESCENT ORIGIN INTRAUTERINE ORIGIN LBW The Circle of Life ? Slide 173: C I R C L E OF L I F E “MANY FACTORS OF GENDER INEQUALITY” : “MANY FACTORS OF GENDER INEQUALITY” Inaugural Lecture Radcliff Institute , Harvard , USA Amartya Sen & also in ‘ARGUMENTATIVE INDIAN’ SEVEN Types of Gender Inequality + FOUR New Investigational Phenomena The ‘Quartet’ of A Different Kind ? : The ‘Quartet’ of A Different Kind ? Undernourishment of Girls over Boys Undernourishment of Mothers Prevalence of LBW High Incidence of CVD Slide 176: “ Given the uniquely critical role of women in the reproductive process , it would be hard to imagine that deprivation to which women are subjected would not have some adverse impact on the lives of all - men as well as women - adults as well as children” Amartya Sen Slide 177: “The Extensive Penalties of Neglecting Women’s interests rebound, it appears, on Men with Vengeance” Amartya Sen Slide 178: Gene environment FETAL ORIGINS OF CVD maternal gene expression alter fetal environment maternal gestational environment fetal gene expression PROTECT THE ADOLESCENT GIRL ! Slide 179: LBW Malnourished child Malnourished Adolescent Girl CVD CAD risk factors – Obesity,HTN,Dysglycemia, Dyslipidemia Life style factors Malnourished Mother Gender inequality Slide 180: Malnourished Adolescent Girl Malnourished Mother LBW CVD RISK FACTORS CVD CDC Model – M Z Ahamed, M K C Nair, B George 2002 Malnourished Child Life style factors OBESE Slide 181: What have we done ? CDC / Ped Card A cohort of 800 neonates 1987 High risk group Significant LBW BMI, BP, Plasma Glucose / insulin Lipid profile, LV compliance, Carotid IMT 2004 -2005 www.pedheartsat.org : www.pedheartsat.org Please visit our Website ! Slide 183: THANK YOU . You have been very kind & patient. ! You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
ADOLESCENT PREVENTIVE CARDIOLOGY praveenks Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: Embed: Flash iPad Copy Does not support media & animations WordPress Embed Customize Embed URL: Copy Thumbnail: Copy The presentation is successfully added In Your Favorites. Views: 991 Category: Education License: All Rights Reserved Like it (0) Dislike it (0) Added: July 01, 2009 This Presentation is Public Favorites: 1 Presentation Description ADOLESCENT PREVENTIVE CARDIOLOGY, m. zulfikar ahamed professor & head, pediatric cardiology sath, gmc, thiruvananthapuram Comments Posting comment... By: vivek1978 (47 month(s) ago) sir when we can't see your slide ,what we will coment. sir one thing i want to know , if a patient of rheumatic fever has CHF and active carditis and also have infective endocarditis .sir is steroid use will flare the bacteremia? steroid use for rheumatic fever is rationale in this case. Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Welcome To T h i r u v a n a n t h a p u r a m : Welcome To T h i r u v a n a n t h a p u r a m Slide 3: ‘ David Bowman becomes the Star Child ’ 2001 : A Space Odyssey Slide 6: ADULT LIFESTYLE DISEASES & CVD ADOLESCENT ACCEL ADOLESCENT ORIGIN INTRAUTERINE ORIGIN LBW The Circle of Life ? ADOLESCENT PREVENTIVE CARDIOLOGY : ADOLESCENT PREVENTIVE CARDIOLOGY m. zulfikar ahamed professor & head, pediatric cardiology sath, gmc, thiruvananthapuram MAN : MAN Hunter - Gatherer Agriculture and Settlements Mechanical Industrial & Digital revolution ? Zoonoses Infections Malnutrition Lifestyle Diseases CVD CARDIOVASCULAR DISEASES : CARDIOVASCULAR DISEASES CVD Major Challenge In India INDIA IS ON FIRE !The Economist Feb 2007butA Bleak House with regard to disease issues WHY ? : INDIA IS ON FIRE !The Economist Feb 2007butA Bleak House with regard to disease issues WHY ? Slide 11: Pre transitional diseases Double jeopardy INDIA - DISEASE BURDEN Post transitional diseases Slide 12: Major causes of Deaths In India (2005) Source : WHO MORBIDITY IN INDIA : MORBIDITY IN INDIA Slide 14: CVD mortality will rise by 100 % by 2015 CVD will cause 35 – 40 % of all deaths by 2015 ( current - 27% ) CVD Mortality INDIA CVDCardiovascular Diseases : CVDCardiovascular Diseases “ REVERSAL OF SOCIAL GRADIENT ” Poor Rich CVD in Kerala : CVD in Kerala The Ungainly “Age” Factor Acute Coronary events in CCU, MCH ,Tvpm < 45 yr - 40 % ! CVD Risk Factors ?Four Apocalypse : CVD Risk Factors ?Four Apocalypse OBESITY HYPERTENSION DYSLIPIDEMIA DIABETES & Smoking Slide 19: MAJOR CVD RISK FACTORS ‘ METABOLIC SYNDROME ’ & SMOKING ATHEROSCLEROSIS CLUSTERING MAJOR CVD RISK FACTORSThe Deadly Quartet Kerala Experience - HAP : MAJOR CVD RISK FACTORSThe Deadly Quartet Kerala Experience - HAP Hypertension 27% - 41 % Diabetes 13.5 % - 21 % Smoking 21% Obesity & Overweight 33 % ? (5.3 / 28) Slide 21: CVD RISK FACTORS Our State and Our Nation[ ER, State Planning Board 2005] India Kerala Hypertension 589 1433 Diabetes 221 980 (Per lakh) CARDIOVASCULAR DISEASES : CARDIOVASCULAR DISEASES A R o a d to P e r d i t i o n ? Slide 23: ROAD MAP FOR Atherosclerosis in youngas a Concept Framingham study Korean war; Vietnam war Bogalusa study ; PDAY : Muscatine Childhood Onset Adult Diseases WHAT DO THESE STUDIES SAY ? : WHAT DO THESE STUDIES SAY ? Major CVD risk factors start operating from childhood Dyslipidemia and atherosclerotic changes start in young adults and adolescents BMI, BP, low HDL cholesterol and high LDL Chol at 15 years correlated with CAD in adulthood Slide 25: Will Today’s Child be Tomorrow's Cardiac Patient ? Obesity Hypertension Dyslipidemia Youth risk behavior Smoking ADULTHOOD Possibly Yes ! What can be Done ? : What can be Done ? Secondary prevention Primary Prevention Primordial Prevention Lifetime Prevention Intrauterine Prevention ? Slide 27: PREVENTIVE CARDIOLOGY and THE ADOLESCENT Catch Them Young ! Make Adolescents “Heart Smart”! CVD risk reduction from adolescence WHY ? Slide 28: SCENARIO 12 year old boy has occasional severe headache . O/E BP 150 / 70 mm Hg RUL High volume radials. weighs 37 kg . Ht. 146.5 cms What to do ? HYPERTENSION : HYPERTENSION Prevalence : 1 % Adult : 25 - 40 % Slide 30: What is Hypertension ? “ level of BP at which there is a doubling of long term CVD risk ” Only an arbitrary answer ! Slide 31: 140 mmHg SBP CVD risk _ _ _ _ _ 5 4 3 2 1 Slide 32: 85 – 90 mmHg DBP CVD risk _ _ _ _ _ 5 4 3 2 1 Slide 33: STAGING of BPJNC 7 Stage SBP DBP Action Optimal < 120 < 80 no Pre hypertension 120 –139 80- 89 recheck . LSM Hypertension Stage 1. 140 –159 90 –99 Confirm + Evaluate 2. 160 –179 100- 109 Evaluate . Refer 3. > 180 > 110 Evaluate – immediate refer Slide 34: HYPERTENSION IN CHILDREN Normal : < 90 th centile Pre Hypertension : 90 - 95th centile HBP : > 95th centile for age sex height Slide 35: HBP in CHILD / ADOLESCENT( for 50th centile Height) Age Girl Boy 1 105 / 60 102 / 60 6 110 / 75 115 / 75 12 125 / 80 125 / 80 17 130 / 85 135 / 85 (approximate) Slide 36: ADOLESCENT HYPERTENSION 10 - 15 yrs SBP > 130 DBP > 80 mm hg 15 - 20 yrs SBP > 135 DBP > 85 mm hg Slide 37: HYPERTENSION - Issues Detection / Screening Pre hypertension ‘ Tracking ’ ‘ Clustering ’ phenomenon Treatment of high blood pressure Slide 38: Routine BP recording in children beyond 3 years Routine BP screening in Adolescent - is it required ? Child / Adolescent with high BP - HYPERTENSION : LSM DRUGS Slide 39: HYPERTENSION Concept of Pre hypertension Philip T Dick Pre crime JNC VII 2003 HYPERTENSION Child onset ? : HYPERTENSION Child onset ? TRACKING : Adolescents who have high centiles of BP continue to have higher centiles in adulthood and are likely to develop hypertension in adulthood Slide 41: TRACKING in HTN Child Adol Young Adult Adult BP Centile HTN 80th 50th 25th Slide 42: < 5 yrs - BP > 110 / 70 mmHg 5 - 10 yrs - BP > 120 / 80 mmHg 15- 10 yrs - BP > 130 / 80 mmHg BP IN CHILDREN Evaluation Indicated if Slide 43: ADOLESCENT HYPERTENSION LSM DRUG THERAPY Specific Measures Slide 44: LIFESTYLE MODIFICATION 1. Diet Sodium restriction ( < 6 gm /day) Fall in SBP/ DBP 2. Dietary supplementation of Potassium 3. Weight reduction Slide 45: LIFESTYLE MODIFICATION 4. Exercise 5. Reduce Alcohol consumption 6. Stress management 7. Vegetarian diet 8. Fiber intake + Slide 46: LSM - Impact Modification SBP reduction Weight reduction 5 - 20 mm Hg Sodium restriction 2 - 8 mm Hg Exercise 4 - 10 mm Hg Alcohol redn 2 - 4 mm Hg DASH eating plan 8 - 14 mm Hg Slide 47: HTN - LSM Reduction in weight of 1 kg will SBP by 2 - 3 mmHg DBP by 1- 2 mmHg Slide 48: HTN - DRUGSWhich Drugs To Chose ? ACE Inhibitors Calcium Channel Blockers Angiotensin Receptor Antagonists B- Blockers + Diuretics ? Slide 49: HTN - Drugs . Dosage Captopril : 2- 4 mg / kg / day 3 divided doses Enalapril : 0.1 mgm/ kg / dose 2 doses Ramipril : 6 mgm / M2 once daily Slide 50: Nifedipine : 0.5 - 1.0 mgm / kg /day 3 divided doses Amlodipine : 0.1 - 0.5 mgm/ kg once / twice daily Losartan : 0.5 - 1.0 mgm / kg /day once daily Irbesartan : 4 -5 mgm/kg once daily Atenolol : 1 mgm / kg / day once daily Metoprolol : 1- 4 mgm/kg twice daily HTN - DRUG DOSAGE Slide 51: Calcium Channel Blockers ADOLESCENT GIRL DRUG THERAPY ACE inhibitors B-blockers Diuretics ARB Slide 52: A 13 yr old has a BP of 144 / 86 1. Is it Normal ? 2. If it is normal - how normal ? 3. If it is abnormal - a. What will you look for in the child ? b. Should we look at Parents ? c. What are the minimal investigations? d. If BP is without secondary cause what will you do ? e. Which drug will you use if the child has mildly impaired GTT ? Slide 53: 16 year old boy. Visit for “excess weight” Weight 64 kg .146 cm . BMI 29.2 Father is 51. Non diabetic. BP 140 / 90 .BMI 26.2 Mother is 48 . BP 120 / 80 . BMI 24.2 SCENARIO What to do ? OBESITY‘ The world is too fat ‘- The Economist : Starts in Childhood Adolescent ? “Fetal - Postnatal Origins” Why ? Physical Inactivity TV watching Change in Eating habits Urbanization - ‘Kerala Model’ OBESITY‘ The world is too fat ‘- The Economist Slide 56: BMI more than [ adult ] ( Wt / Ht2) WHAT IS OBESITY ? > 30 Overweight - 25 - 30 Cut off values for BMI for Overweight : Cut off values for BMI for Overweight Slide 58: Measured by OBESITY IN CHILD & ADOL BMI CDC centiles BMI IOTF values Waist circumference [ > 90th centile] Adult > 100 / 90 cms Children > 70 to 100 cms OBESITY in CHILDREN based on BMI (CDC,USA)< 5 th centile Underweight5 th to 85 th centile Normal85 th to 95 th centile Overweight> 95 th centile Obesity : OBESITY in CHILDREN based on BMI (CDC,USA)< 5 th centile Underweight5 th to 85 th centile Normal85 th to 95 th centile Overweight> 95 th centile Obesity OVERWEIGHT IOTF 2000YR BMI 5 1710 2015 23 18 25 : OVERWEIGHT IOTF 2000YR BMI 5 1710 2015 23 18 25 OBESITY IOTF 2000 YR BMI above 5 1910 2415 2818 30 : OBESITY IOTF 2000 YR BMI above 5 1910 2415 2818 30 Slide 62: OBESITY IN CHILDREN Obesity in Adult 20 - 30 % >10 yrs 15 – 20 % 5 – 10 yrs 10 % More in BOYS ASIANS Slide 65: EPIDEMIC OF OBESITY Little or no social difference Less developed countries are affected Slide 67: Socioeconomic difference is decreasing From 1995 to 2005 CHILDHOOD OBESITY in THE WEST / INDIA ? “Childhood obesity - Is the gap closing the wrong way ?” Journal of Public Health June 2008 Slide 68: South Atlantic Ocean South Pacific Ocean Indian Ocean Arctic Ocean Arctic Ocean North Pacific Ocean Patterns Of Overweight & Obesity Globally For Nationally Representative Samples (Percentage overweight + Obese) Slide 69: PREVALENCE OF OBESITY 3 times 16% 2 decades Slide 70: Endemic Epidemic < 5 % 1998 OBESITY / OVERWEIGHT INDIA < 10 - 20 % 2005 - 2007 Slide 71: OBESITY INDIA Place Year Age % Name Kochi 2003 5 -16 1.2 ICMR Kochi 2005 5 -16 1.89 ICMR Delhi 2002 10 -16 7.4 Kapil Punjab 2008 9 -15 11.1 Chatwal Ludhiana 2004 11 -17 2 -3% Mohan Slide 72: Obesity in Indian/ Kerala Children NMJ of India vol 20 no. 6, 2007 2003 24842 4.9 % 2005 20263 6.57 % [Age 5-16 yrs] Increasing Trend in Overweight Obesity trends in school children : Obesity trends in school children Slide 74: CVS Risks in Obese Children AIMS Study Abn Total Cholesterol 26 % Abn TG 27 % Low HDL 53 % Abn LDL 28 % IR 37 % HBP 59 % MS 39 % OBESITY Magnitude ? HAP data : OBESITY Magnitude ? HAP data Adult Obesity ( Tvpm) Rural - 6 % Urban -19 % Adolescent Obesity ? ISSUES Shouldn’t we quantify Adolescent Obesity ? Slide 76: ADOLESCENT OBESITY-Kerala INCLEN study 2003 Age group : 14 years ( Girls) Rural : None Urban : 8 -10% Slide 77: OBESITY CVD Dyslipidemia Hypertension LVH Atherosclerosis Obstructive Sleep Apnea Slide 78: OBESITY as An ‘OUTCOME’ of imbalance between calorie intake and expenditure An ‘ EXPOSURE’ Linked HBP, diabetes, heart disease etc.. Slide 79: The mismatch between calories consumed and calories needed has ‘reversed’ obesity in children Slide 80: High Caloric Intake Lowering of prices of basic food grains Greater variety of food choices Promotion and use of caloric dense foods Lower cost of certain animal food Slide 81: Low Caloric Expenditure Personal transportation Labor saving devices at home Reduced sports & physical activity TV viewing / Digital revolution Slide 82: OBESITY & CHILDHOOD ENVIRONMENT Diet content and quantum Physical Activity Psychosocial factors ‘passive over consumption’ of energy Sugar sweetened beverages Fast food Low calcium content ? Slide 83: ENVIRONMENT IN UTERO INFANCY CHILDHOOD Under nutrition - ‘Barker’ Over nutrition - IGDM - Breast feeding - Complementary feeding - Formula feeding Slide 84: HBW tracks obesity LBW BIRTH WEIGHT Post natal catch up growth OBESITY : OBESITY Beware of Obese Children Who were Thin at Birth Look for Co-Morbid Conditions Obesity Risk Increases with the Age of the Child : Obesity Risk Increases with the Age of the Child Obese at 6 years 50% risk of obesity at 35 yrs Obese at 10 years 70 - 80% risk Obesity is a pediatric disorder with adult consequences Source: Bray 2002, Dietz 1998a, Dietzs 1998b,Guo et al. 2002; Kvaavik et al. 2003; `Must 2003, Whitaker et al. 1997; Slide 87: Nutrition Transition Increased BMI OBESITY & CVD act ! act ! C V D Slide 88: BF FF ‘Early protein’ ROAD MAP FOR OBESITY High Calorie Food loss of Physical Activity TV & Computers Academic pursuits LBW NB INFANCY CHILD ADOLESCENT Slide 89: PREVENTIVE MEASURES Screening high risk individuals and weight reduction Primary prevention Slide 90: OBESITY may not ( Cochrane review) So Emphasis must be on PRIMARY PREVENTION Will screening & intervention work ? Slide 91: High Risk and Population Approaches Truncate high risk end of exposure distribution (e.g. organize an obesity clinic). Clinical approach to disease prevention. Reduce a little risk in most people (e.g. reduce fat a little in fast-food outlets). Lifestyle change combined with an environmental approach. Slide 92: Physical activity at home and school Discouraging advertising of high calorie foods Restrict TV / computers PRIMARY PREVENTION PRIMARY PREVENTION IN CHILDREN : Legislation ban advertisements targeted to children regulation of school canteen compulsory physical activity in school Community action school playgrounds encouragement of sports Parental action restrict TV PRIMARY PREVENTION IN CHILDREN Slide 94: CHILDHOOD OBESITYTreatment LSM Dietary restriction Weight Reduction Exercise Control Co-morbid Factors Drugs / Weight reducing agents Metformin ‘do not jumpstart medications’ Slide 95: TREATMENT OF OBESITY Active Weight Goals a. < 2 yr – Maintain baseline weight b. < 7 yr – Prolonged weight maintenance - weight loss ( if sec. complication) c. > 7 yr – Prolonged weight maintenance if sec. compln - Weight loss > 95 th centile…. A 48 yr old man gets admitted into CCU with AMI. He has mild Diabetes & mild Hypertension. His elder brother died of SCD at 54 : A 48 yr old man gets admitted into CCU with AMI. He has mild Diabetes & mild Hypertension. His elder brother died of SCD at 54 He has 16 yr old son 1. Will you evaluate the boy?2. If so why?3. What clinical findings will you look for?4. What investigations ?5. The boy has S . chol 223 mg/dl. What will you do? Slide 97: Onset of atherosclerosis What is normal / abnormal ? Preventive & treatment aspects DYSLIPIDEMIA -Issues DYSLIPIDEMIA Beginning of the Beginning : DYSLIPIDEMIA Beginning of the Beginning Fatty Streaks - 3 years * Plaques - Adolescence Slide 99: Atherosclerosis Starts in Adolescence Accelerates in Adult CVD Slide 100: CHOLESTEROL VALUES IN CHILDREN Acceptable < 170 < 110 mg /dl Borderline 170- 199 110 -129 High > 200 > 130 T. Chol LDL -Chol Slide 101: DYSLIPIDEMIA IN TRIVANDRUMA HAP Study ( IHJ 2000 ) Mean T. cholesterol 223 + 45 223 + 45 HDL cholesterol 50 + 11 57 + 13 LDL cholesterol 145 + 41 145 + 42 DYSLIPIDEMIA What To Do ? : DYSLIPIDEMIA What To Do ? ?? Screen all Adolescents ? Screen high risk Adolescents INTERVENE Family history CAD HBP Obesity Slide 103: ACCEPTABLE ACTION Health education Repeat values at 5.0 years Health advice AHA step I diet Repeat values at 1.0 yr BORDERLINE Slide 104: HIGH VALUES Look for secondary cause(s) Step I II diet < 30% calories from fat < 7% sat fat < 200 mg chol / day Drug ? Slide 105: DIET / DRUG < 2 yrs - No restriction ; No drugs 2- 5 yrs - AHA step I diet 5 – 8 yrs - AHA diet ; No drug ?? > 8 .0 yrs - AHA diet ; Drugs ? Slide 106: DIET / DRUG < 2 yrs - No restriction ; No drugs 2- 5 yrs - AHA step I diet 5 – 8 yrs - AHA diet ; No drug ?? > 8 .0 yrs - AHA diet ; Drugs ? Slide 107: For children above 2.0 yrs NCEP Guidelines DIET Saturated F Acids < 10 % total calories Total Fat < 30 % total calories PUFA > 10 % total calories < 300 mg cholesterol / day adequate fiber Slide 108: INDICATIONS FOR DRUG THERAPY 6 – 12 mo of diet therapy : LDL > 190 Family h/o early CVD : LDL > 160 >2 risk factors : LDL > 160 All above 8 years Obesity Smoking Hypertension Diabetes Inactivity DYSLIPIDEMIA Treatment : DYSLIPIDEMIA Treatment DRUGS : Bile acid binding resins Nicotinic acid S t a t i n s < 2 yrs - Statins - No 2 -10 yrs - Statins - Probably not > 10 yrs - Statins - Yes NO FAT RESTRICTION Below 2 yrs Slide 110: DRUGS USES Cholestyramine redn < 20% Niacin Redn < 30% Statins reduction T. chol LDL- chol VLDL TG 30% 40% 20% 10% Slide 111: STATINS IN CHILDREN AHA Task Force : Boys - > 10 yrs Girls - > Menarche or SMR -2 Slide 112: STATINS USED Pravastatin 5 - 20 mgm / day Lovastatin 10- 40 mgm / day Simvastatin 10 mg / day Atorvastatin 5- 10 mg / day Slide 113: STATINS IN CHILDREN > 8 years ? AAP Recommendations 2008 Pediatrics July 2008 Slide 114: ‘Younger the Better’ ? OR ‘Later but Greater’ ? STATINS IN CHILDREN Slide 115: A 12 year old boy is brought with excessive Tiredness . Clinically normal . Not obese . BP 130 /85 His FBS 188 PPBS 299 SCENARIO What to do ? Slide 116: DIABETES IN THE YOUNG Type I Type II (Insulin Resistance ) Risk status in young ? weight management exercise glycemic control additional risk factor mgt Slide 117: HYPERGLYCEMIA Fasting Glucose > 100 mg/dl ( ? 110 mg/dl) IGT ( 2 hr) > 140 mg/dl Measured by Slide 118: INSULIN RESISTANCE Fasting serum Insulin level IGT Measured by DIABETESThe Kerala Scenario : DIABETESThe Kerala Scenario Prevalence in Adult : 6.0 % Rural (HAP) 12 -14 % Urban Now 13-21 % Indian Average of 2.5 % Rural 6.0 % Urban DIABETES IN KERALA High Co-morbidity : DIABETES IN KERALA High Co-morbidity Obesity 43% Hypertension 32 % Dyslipidemia 27% DIABETES & ADOLESCENCE Is There a Link ? : DIABETES & ADOLESCENCE Is There a Link ? Probably has an Adolescent Origin Life style Changes Physical Inactivity Obesity Nutritional Transition Possible Fetal Origin ? Slide 123: Adol. Risk factors ‘ tracking’ ? Preventive aspects Legislation on Food products INSULIN RESISTANCE - Issues Slide 124: INTERVENTION IN RISK REDUCTION Prudent diet Avoid obesity Encourage Exercise Screening - ?? DYSGLYCEMIA : Slide 125: SCENARIO A 14 yr boy has a 46 yr old father with Diabetes and Hypertension on drugs , Mother who has IGT. Boy looks obese . Will you be interested in evaluating this boy ? If no - - Why ? If yes - - which investigations will you order ? What is syndrome X ? Slide 126: “ Clustering of risk factors for Diabetes and CVD that is frequently observed in patients who are overweight ” What is METABOLIC SYNDROME ? Slide 127: MS Obesity Insulin resistance Slide 128: METABOLIC SYNDROME Reaven 1988 Definitions: WHO NCEP IDF Slide 129: METABOLIC SYNDROME Circulation 2005 Abdominal Obesity High Blood pressure High Triglycerides Low HDL High FBS 3/5 MS What is it ? Slide 130: MS CVD RISK 3 fold Type 2 DM 3 – 5 fold Slide 131: METABOLIC SYNDROMEA Road To Perdition OBESITY INSULIN RESISTANCE CVD TG HTN TG HDL HTN HG Slide 132: METABOLIC SYNDROME inCHILDREN Can develop in Childhood, Adolescence Lack of uniformity in diagnosis Central role of Insulin resistance / Obesity Risk Factor for CVD Needs intervention (s) Slide 133: METABOLIC SYNDROME IN CHILDREN 3 / 5 of Obesity ( BMI / WC) Hypertension IGT / HG HDL- low TG - high Slide 134: MS CHILDHOOD ADULT 4 % 24 % Slide 135: Hyperglycemia Hypertension Obesity Low HDL High TG MS IN CHILDREN Components 1.5% 4.9% 9.8% 23.3% 23.4% Slide 136: Clustering Risk Factors in adults EVOLUTION OF MS in the YOUNG CVD risk factors in the young Clustering in the young MS in Young Slide 137: MS TREATMENT APPROACH Population Approach Individual LSM DRUGS Diet Exercise Behavior Slide 138: “Label of MS in obese children should not be a green signal for treatment with drugs” ? DRUGS : Anti hypertensives LIPID lowering agents Weight reducing drugs Metformin TREATING MS Slide 139: Controversial Risk prediction of CVD MS DOES NOT TAKE INTO ACCOUNT Age Total cholesterol LDL cholesterol Smoking CVD RISK FACTORS : CVD RISK FACTORS Screening in Children Need Feasibility Cost Benefit Inter- Effect vention OBESITY +++ +++ +++ ++ ++ HTN +++ +++ ++ ++ ++ DYSLIPIDEMIA ++ + + + ++ INSULIN + + + ++ ++ RESISTANCE selective Slide 141: A 17 yr old college student girl admitted with acute anterior wall MI. Post MI CAG shows 2 Vessel disease with aneurism on LAD & RCA . There is a history of measles like illness when the boy was 2 yrs old. Can you link these unrelated events together ? If so - what could be the etiology ? What are the potential problems of the disease ? How will you follow up ? Slide 142: KAWASAKI DISEASE - Future CAD ? Future CAD risk Why so ? Slide 143: Atherogenic lipid changes Mildly Elevated Total Cholesterol Mildly Elevated LDL- Cholesterol Mildly Elevated TG Mildly decreased HDL - Cholesterol in convalescing KD KD and Lipid AbnormalitiesAn Intriguing Finding? CAD ? Slide 144: LIPIDS & KD 160.0 170.3 205.2 105.9 114.3 144.0 24.1 32.2 33.3 167.0 181.2 232.0 Slide 145: From KD to Later CAD A possible Route Map KD Dyslipidemia HTN. Obesity Persistence ? Persistence CAL CAD Endothelial Dysfunction Slide 146: Age group - 16 - 20 Yr TEENAGE SMOKING - KERALAGYTS study - Cochin Number - 954 16.5 % SMOKE ! Slide 147: Teenage Smoking - Kerala & India 16.5% 4.5% 4.0% 7.1% 14.8% Slide 148: Is there a link ? MS is more in young smokers SMOKING & MS non exposed - 1.2 % smokers - 8.7 % MS Slide 149: SMOKING in KERALA < 1% 2% 20% Slide 150: INTERVENTION IN RISK REDUCTION Quantify the risk / prevalence Adolescent counseling 15 20 yr Legislation School Curriculum ? SMOKING : Vulnerable window Slide 151: AT 15 YRS Atherosclerosis is in smokers than non smoking children & adolescents W H Y ? Slide 152: Diet Saturated fat ; Cholesterol Caloric Control Sugar DIET & PRIMORDIAL PREVENTIONOF CVD in CHILDREN Slide 153: DISC study 1995 USA STRIP study 2007 Finland DIET STUDIES Slide 154: Continued breast feeding Fat < 30 – 35 % of Energy Sat Fat / Unsat Fat ratio 1: 2 Cholesterol < 200mg /day Skimmed milk > 1 year STRIPRCT 19900 – 14 yrs Slide 155: STRIPEffects Reduction in total cholesterol, LDL –Chol Same HDL No Difference in Growth BMI Puberty Menarche Slide 156: CVD RISK FACTORS Clustering Effect Life style changes Metabolic Decontrol Fetal Origin ? Genetic “The Onion Peel Effect” CVD Risk Factors The Multi layering Concept Slide 157: “The Fetal Origins of Adult Disease” Editorial BMJ 2001 R .Robinson “No longer just a hypothesis and may be critically important in South Asia” BARKER HYPOTHESIS : BARKER HYPOTHESIS Hertfordshire 1988 1911 - 1930 Birth Register 1980’s - ‘Present’ UK Birth Weight < 2500 gm CVD MORTALITY BARKER HYPOTHESIS : BARKER HYPOTHESIS Reduced Fetal Growth LBW CVD Morbidity / Mortality in Adult Slide 160: LBW ATHEROSCLEROSIS CVD Slide 161: Is it Hypothesis ? Or is it Speculative ? BARKER HYPOTHESIS Slide 162: PROOF OF HYPOTHESIS STUDY NUMBER PERIOD RESULT Mysore , India 517 1934-54 Higher CAD LBW Helsinki, Finland 4630 1934- 44 Higher CAD LBW Uppsala, Sweden 14611 1915- 29 Higher CAD LBW IN UTERO ORIGIN OF CAD : IN UTERO ORIGIN OF CAD Epidemiological Proof ? Direct LENINGRAD SEIGE STUDY DUTCH FAMINE STUDY DUTCH FAMINE STUDY : DUTCH FAMINE STUDY Dutch Famine 1944 - 45 Unique opportunity for testing intrauterine Factors concept Heart 2000 Number to Famine exp CAD prevalence No 3.2 Early Gestation 8.8 Mid Gestation 0.9 Late Gestation 3.1 Slide 165: DUTCH FAMINE STUDY 1943- 47 Cohort CAD prevalence N - 736 3.3 3.2 8.8 LENINGRAD SEIGE STUDY BMJ 19971941 - 44 Siege 872 daysCalorie intake protein0 LBW 18% : LENINGRAD SEIGE STUDY BMJ 19971941 - 44 Siege 872 daysCalorie intake protein0 LBW 18% 3 Groups In utero exposed Infancy exposure Not exposed Slide 167: No difference in present day prevalence of IGT Dyslipidemia Hypertension CVD morbidity LENINGRAD SEIGE STUDY BMJ 1997 FETAL ORIGINS OF ATHEROSCLEROSIS & CVD : FETAL ORIGINS OF ATHEROSCLEROSIS & CVD Past 10 yrs : Near unequivocal evidence favoring link between IUGR, LBW & CAD Next 10 yrs : ? Cellular and Molecular mechanisms for such phenomenon New strategy to reduce impact of CVD Slide 169: BARKER HYPOTHESIS Still a hypothesis PROGRAMMING ? What are the implications ? Preventability Life time prevention What can be Done ? : What can be Done ? Secondary prevention Primary Prevention Primordial Prevention Lifetime Prevention Intrauterine Prevention ? Slide 171: LBW CVD Risk Factors CVD Undernourished Girl Undernourished Mother Slide 172: ADULT LIFESTYLE DISEASES ADOLESCENT ACCEL ADOLESCENT ORIGIN INTRAUTERINE ORIGIN LBW The Circle of Life ? Slide 173: C I R C L E OF L I F E “MANY FACTORS OF GENDER INEQUALITY” : “MANY FACTORS OF GENDER INEQUALITY” Inaugural Lecture Radcliff Institute , Harvard , USA Amartya Sen & also in ‘ARGUMENTATIVE INDIAN’ SEVEN Types of Gender Inequality + FOUR New Investigational Phenomena The ‘Quartet’ of A Different Kind ? : The ‘Quartet’ of A Different Kind ? Undernourishment of Girls over Boys Undernourishment of Mothers Prevalence of LBW High Incidence of CVD Slide 176: “ Given the uniquely critical role of women in the reproductive process , it would be hard to imagine that deprivation to which women are subjected would not have some adverse impact on the lives of all - men as well as women - adults as well as children” Amartya Sen Slide 177: “The Extensive Penalties of Neglecting Women’s interests rebound, it appears, on Men with Vengeance” Amartya Sen Slide 178: Gene environment FETAL ORIGINS OF CVD maternal gene expression alter fetal environment maternal gestational environment fetal gene expression PROTECT THE ADOLESCENT GIRL ! Slide 179: LBW Malnourished child Malnourished Adolescent Girl CVD CAD risk factors – Obesity,HTN,Dysglycemia, Dyslipidemia Life style factors Malnourished Mother Gender inequality Slide 180: Malnourished Adolescent Girl Malnourished Mother LBW CVD RISK FACTORS CVD CDC Model – M Z Ahamed, M K C Nair, B George 2002 Malnourished Child Life style factors OBESE Slide 181: What have we done ? CDC / Ped Card A cohort of 800 neonates 1987 High risk group Significant LBW BMI, BP, Plasma Glucose / insulin Lipid profile, LV compliance, Carotid IMT 2004 -2005 www.pedheartsat.org : www.pedheartsat.org Please visit our Website ! Slide 183: THANK YOU . You have been very kind & patient. !