Obesity, Hypertension, and Dyslipidemia in Childhood Are Key Modifiable Antecedents of Adult Cardiovascular Disease

A Call to ActionArticle, see p 1246 C arotid intima media thickness (cIMT) measured via ultrasound correlates with the risk of future cardiovascular events, including myocardial infarction and death. 1 Thus, researchers use cIMT as an intermediate outcome to denote atherosclerosis in younger populations that would not have time to develop clinical cardiovascular end points.In this issue of Circulation, Koskinen and colleagues 2 use data from the International Childhood Cardiovascular Cohort (i3C) consortium to identify antecedents in childhood of high cIMT (>90th study-specific percentile) in adulthood.This rich dataset includes 23.4 years of longitudinal follow-up on 2893 twelve-to 18-year-old participants from 4 studies (Cardiovascular Risk in Young Finns, Childhood Determinants of Adult Health, Bogalusa Heart, and Insulin Studies) across 3 continents.The combined i3C data show childhood obesity, hypertension, and dyslipidemia in adolescence predict the presence of high cIMT in adulthood.In the analysis, obesity is the risk factor most strongly associated with high cIMT, increasing risk 3.7 (2.0-7.0)-fold.This makes sense because adolescent obesity is highly prevalent, challenging to treat, and strongly associated with obesity and premature mortality in adulthood (Figure ). 3 Prevalence of childhood overweight and obesity has nearly tripled in the United States since 1988, and rates worldwide have increased 10-fold.4 Short-term weight stabilization or loss is achievable with intensive family-based behavioral approaches, but disturbingly few adolescents with obesity (2%) achieve clinically meaningful treatment responses at 3 years.5 Of even greater concern is the cooccurrence of obesity-related comorbidities: >60% of adolescents with obesity have additional risk factors such as hypertension or dyslipidemia.These risk factors improve with lifestyle changes and pharmacological treatments.For this reason, pediatric guidelines for weight management, hypertension, and hyperlipidemia recommend treating obesity-related comorbidities with intensive lifestyle counseling, coupled with effective pharmacological therapies when indicated.6,7 Hypertension is strongly linked to obesity, with significant consequences for the heart and vasculature.6 Although prevalence of hypertension in US children overall is 3% to 5%, prevalence among children with obesity is much higher (up to 25%).6 As fat mass increases, so does total blood volume via central (eg, renin-angiotensin and sympathetic systems) and peripheral (eg, baroreceptors and autonomic dysregulation) mechanisms.8 The resultant increase in stroke volume, cardiac output, systemic vascular resistance, and afterload leads to elevated blood pressure, hypertension, increased left ventricular mass, and left ventricular concentric hypertrophy.8 Total blood volume and hypertension increase further in the presence of sleep apnea (present in 55% of adolescents undergoing bariatric surgery 6 ).Repeti-