PEDIATRICS Vol. 114 No. 6 December 2004, pp. 1534-1544 (doi:10.1542/peds.2004-0674)
Trends in Risk Factors for Cardiovascular Disease Among Children and Adolescents in the United States
From the Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Background. The increasing prevalence of obesity among children and adolescents in recent decades might have affected trends in obesity-associated risk factors for cardiovascular disease.
Participants and Methods. We used data for 12 665 children and adolescents, 2 to 17 years of age, from the Third National Health and Nutrition Examination Survey (1988–1994) and for 3611 children and adolescents from National Health and Nutrition Examination Survey 1999–2000.
Results. For participants 2 to 17 years of age, waist circumference increased 1.6 cm among male subjects and 2.4 cm among female subjects. Mean systolic blood pressure increased by 2.2 mm Hg among children and adolescents 8 to 17 years of age. There were significant decreases in concentrations of triglycerides (8.8 mg/dL) and glucose (2.5 mg/dL) among children and adolescents 12 to 17 years of age. Mean concentrations of total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and glycosylated hemoglobin were relatively unchanged. Some changes in means of risk factors varied according to age.
Conclusions. The temporal trends for risk factors among children and adolescents during the 1990s exhibited different patterns. The effects of the increasing prevalence of obesity on the cardiovascular health of children and adolescents remain unclear.
Key Words: blood pressure • epidemiology • glucose • lipids • obesity
Abbreviations: NHANES, National Health and Nutrition Examination Survey
During the past 2 decades, more children and adolescents in the United States have become obese.1 This ominous trend has caused great concern about the potential consequences for the health of children, both in childhood and in later years. For example, whereas type 2 diabetes mellitus was once relatively rare among children in the United States, this disease is occurring more frequently among youths.2 Obesity during childhood is also associated with increased risks of various diseases and death when these children reach their adult years.3 Given the strong associations between obesity and diabetes and, to a lesser degree, cardiovascular disease, the obesity epidemic among children poses a potentially serious challenge to the collective health of the US population.
Excess weight unfavorably affects several risk factors for cardiovascular disease.4 It is positively associated with blood pressure and concentrations of glucose, glycosylated hemoglobin, triglycerides, and low-density lipoprotein cholesterol. It is inversely associated with concentrations of high-density lipoprotein cholesterol. The effect of excess weight on total cholesterol concentrations is less predictable.
Given the links between excess weight and risk factors for cardiovascular disease, we postulated that the increase in obesity among youths in the United States might have adversely affected trends in risk factors for cardiovascular disease. Few studies of such trends have been conducted among children and adolescents in the United States.5–9 To examine this question, we used data from 2 national surveys to compare waist circumference, systolic blood pressure, and concentrations of total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, glucose, and glycosylated hemoglobin among US children and adolescents in 1988–1994 and 1999–2000.
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METHODS |
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Study Design
We used data from the Third National Health and Nutrition Examination Survey (NHANES), conducted from 1988 to 1994, and NHANES 1999–2000. The basic methods for the 2 surveys were similar. A complex sampling design allowed selection of representative samples of the US population. Participants were interviewed at home and were asked to attend a mobile examination center to complete additional questionnaires, provide biological specimens for analyses, and undergo various examinations. Details of the designs and methods for the 2 surveys are available elsewhere.10–12
Children were weighed and their heights were measured. Details of the anthropometric procedures have been published.1 Because body mass index among youths depends on age and gender, we calculated age- and gender-specific percentiles of body mass index by using the growth charts from the Centers for Disease Control and Prevention.13
We included the following risk factors for cardiovascular disease in our analyses: waist circumference, systolic blood pressure, and concentrations of total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, glucose, and glycosylated hemoglobin. All of these measures, however, were not recorded for all children. In Table 1, we provide information on the age ranges for which data were available from the 2 surveys.
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NHANES III
The waist circumference was measured to the nearest 0.1 cm with a steel measuring tape at the high point of the iliac crest, at minimal respiration. Three blood pressure readings were obtained in the mobile examination center. Participants were seated with the right arm (if usable) resting at the level of the heart. Blood pressure was measured with a mercury-gravity manometer. Child, adult, and large-arm cuff sizes were available. Lipid measurements were performed at the Johns Hopkins University Lipoprotein Analytical Laboratory. Total cholesterol concentrations were measured enzymatically. Serum triglyceride concentrations were measured enzymatically, after hydrolysis to glycerol, and high-density lipoprotein cholesterol concentrations were measured with an Hitachi 704 analyzer (Boehringer Mannheim Diagnostics, Indianapolis, IN), after precipitation of other lipoproteins with a heparin-manganese chloride mixture. Low-density lipoprotein cholesterol concentrations were calculated with the Friedewald formula. Plasma glucose concentrations were measured at the University of Missouri, with an enzymatic assay (Cobas Mira Chemistry System; Roche Diagnostic Systems, Montclair, NJ). Glycosylated hemoglobin concentrations were measured with ion-exchange high-performance liquid chromatography (Diamat automated high-performance liquid chromatography system, model 723; Bio-Rad Laboratories, Hercules, CA).
NHANES 1999–2000
The waist circumference was measured to the nearest 0.1 cm with a steel measuring tape at the high point of the iliac crest, at the end of normal expiration. Up to 4 blood pressure measurements were obtained for each participant in the mobile examination center. Participants were seated with the right arm (if usable) resting at the level of the heart. Blood pressure was measured with a mercury-gravity manometer. Child, adult, and large-arm cuff sizes were available. Lipid measurements were performed at the Johns Hopkins University Lipoprotein Analytical Laboratory. Total cholesterol concentrations were measured enzymatically. Serum triglyceride concentrations were measured enzymatically, and high-density lipoprotein cholesterol concentrations were measured with an Hitachi 717 analyzer (Boehringer Mannheim Diagnostics), after precipitation of other lipoproteins with a heparin-manganese chloride mixture. Low-density lipoprotein cholesterol concentrations were calculated with the Friedewald formula and were reported only for participants who attended the morning examination session and had fasted for >8.5 hours. Plasma glucose concentrations were measured at the University of Missouri, with an enzymatic assay (Cobas Mira Chemistry System; Roche Diagnostic Systems). Glycosylated hemoglobin concentrations were measured with Primus CLC330 and Primus CLC385 instruments (Primus Corp, Kansas City, MO), which measure glycosylated hemoglobin concentrations with boronate affinity high-performance liquid chromatography.
To maintain consistency between the 2 surveys, we used the average of the last 2 measurements of blood pressure for participants with 3 or 4 measurements, the last measurement for participants with only 2 measurements, and the only measurement for participants with 1 measurement to establish high blood pressure status. Waist circumference and total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, serum triglyceride, serum high-density lipoprotein cholesterol, and plasma glucose concentrations were measured similarly in the 2 surveys. Lipid measurements were traceable and were standardized to the reference methods of the Centers for Disease Control and Prevention through the Centers for Disease Control and Prevention/National Heart, Lung, and Blood Institute standardization program.
We limited our analyses to children and adolescents 2 to 17 years of age who attended a mobile examination center; analytes were measured for particular age groups. For analyses of systolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, and glycosylated hemoglobin, we used all participants. For analyses of low-density lipoprotein cholesterol, triglycerides, and glucose, we limited the analyses to participants who attended the morning examination and had fasted for 
8 hours. Because many physiologic and biochemical parameters are age dependent among youths, we present the results for each year of age. To test the statistical significance of the changes in the means of the risk factors for cardiovascular disease between the 2 surveys, we used the t test. The pooled SE for the difference in means was calculated by taking the square root of the sum of the squared SEs. We used SUDAAN (Research Triangle Institute, Research Triangle Park, NC) software for analyses, to account for the complex sampling design. Statistics were calculated with the use of the sampling weights; therefore, the estimates are representative of the civilian, noninstitutionalized, US population.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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There were 12 265 subjects 2 to 17 years of age who attended the mobile examination center in NHANES III and 3611 such subjects in NHANES 1999–2000. The correlation coefficients for correlations between percentiles of body mass index and risk factors for cardiovascular disease were similar for the 2 surveys (Table 2). The strongest correlations were noted between percentiles of body mass index and systolic blood pressure and between percentiles of body mass index and triglyceride concentrations. The correlation coefficients between percentiles of body mass index and total cholesterol, glucose, and glycosylated hemoglobin concentrations were small.
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Among children and adolescents 2 to 17 years of age, the mean waist circumference increased by 2 cm (Table 3). Although the mean waist circumference did increase for most age groups, many of the increases were not statistically significant. Among children and adolescents 8 to 17 years of age, the mean systolic blood pressure increased by 2.2 mm Hg. Increases were notable primarily among children 8 to 10 years of age. The mean concentrations of total cholesterol and high-density lipoprotein cholesterol among youths 4 to 17 years of age were almost the same in the 2 surveys, as were the mean concentrations of low-density lipoprotein cholesterol among youths 12 to 17 years of age. However, the mean concentration of triglycerides among youths 12 to 17 years of age in NHANES 1999–2000 was almost 10% lower than the mean in NHANES III. The mean concentration of glucose decreased by 3% but the mean concentration of glycosylated hemoglobin changed little. Additional results for male and female participants are presented in Tables 4 and 5.
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Increases in waist circumference were particularly evident among black and Mexican American male subjects 12 to 17 years of age and female subjects 12 to 17 years of age (Table 6). With the exception of white male subjects 12 to 17 years of age, increases in mean systolic blood pressure occurred for each gender, racial/ethnic, and age group. Few changes in mean concentrations of total cholesterol and high-density lipoprotein cholesterol occurred. Concentrations of total cholesterol and high-density lipoprotein cholesterol decreased by
5% among black male subjects 12 to 17 years of age. Among participants 12 to 17 years of age, decreases in concentrations of low-density lipoprotein cholesterol and triglycerides were noted for most gender and racial/ethnic groups, although only the decrease in low-density lipoprotein cholesterol concentrations among white female subjects was significant; the decrease in triglyceride concentrations was of borderline significance. Except for black male subjects, mean glucose concentrations were lower in NHANES 1999-2000 than in the previous survey. However, the decreases reached statistical significance only for white male subjects and Mexican American female subjects.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Our study offers the most current and comprehensive examination of trends in risk factors for cardiovascular disease among children and adolescents in the United States. Despite the significant increases in the prevalence of obesity among youths in the United States, we found few effects on the risk factor profiles for cardiovascular disease. We had anticipated that the increase in obesity would have resulted in increases in systolic blood pressure and concentrations of low-density lipoprotein cholesterol, triglycerides, and glucose and in a decrease in concentrations of high-density lipoprotein cholesterol. Although a significant increase in the mean systolic blood pressure did occur, the mean concentrations of total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and glycosylated hemoglobin were relatively unchanged. Unexpectedly, the mean concentrations of triglycerides and glucose decreased.
Other analyses of NHANES III and NHANES 1999–2000 data showed similar findings among adults. For example, obesity prevalence, mean waist circumference, and hypertension prevalence increased significantly.14–16 Small decreases in the mean concentration of total cholesterol occurred.17 However, the prevalence of diabetes mellitus was relatively unchanged.18 Mean concentrations of glycosylated hemoglobin also remained stable.19 Trends in other lipid concentrations were unclear.
Few trend studies of physiologic or biochemical risk factors for cardiovascular disease among youths in the United States have been conducted. Among children 7 to 9 years of age who participated in the Bogalusa Heart Study, high-density lipoprotein cholesterol concentrations increased by 6 to 13 mg/dL, systolic blood pressure decreased by 4 to 6 mm Hg among white boys, white girls, and black girls, diastolic blood pressure decreased by 1 to 2 mm Hg among white boys and girls but increased by 1 to 2 mm Hg among black children, and triglyceride concentrations increased by 8 to 36 mg/dL between 1981 and 1991.5 Among children and adolescents 12 to 17 years of age who participated in several national surveys, mean cholesterol concentrations decreased by 7 mg/dL between 1966–1970 and 1988–1994.6 Among children 10 to 14 years of age from Minneapolis, Minnesota, the age- and ethnicity-adjusted mean systolic blood pressure was 1.5 mm Hg higher among male subjects and 0.7 mm Hg higher among female subjects and the mean diastolic blood pressure was 1.7 mm Hg lower among male subjects and 2.0 mm Hg lower among female subjects in 1996 than in 1986.7 In the Princeton School Study, Ohio students in third and fifth grades exhibited increases in mean body mass index, total cholesterol concentrations, systolic blood pressure (2.4–4.9 mm Hg), and diastolic blood pressure (0.3–3.1 mm Hg) between 1973–1975 and 1989–1990.8 In contrast to all except 1 of the aforementioned studies, our analyses provide nationally representative information on trends in risk factors for cardiovascular disease during a critical period when the prevalence of overweight among children and adolescents increased greatly.
Diet and physical activity are important determinants of the risk factors for cardiovascular disease included in this study. Therefore, changes in these 2 lifestyle factors could have affected temporal trends in the risk factors. Changes in diet and physical activity among children and adolescents were reviewed recently by Eisenmann.9 On the basis of data from NHANES studies, mean energy intakes were 6758 kJ among children 2 to 5 years of age, 8553 kJ among children 6 to 11 years of age, and 9726 kJ among youths 12 to 19 years of age in 1971–1974.20 In 1976–1980, these means were 6353 kJ, 8213 kJ, and 9498 kJ, respectively. In 1988–1994, the mean energy intakes were 6498 kJ, 8265 kJ, and 10 127 kJ, respectively. For each age, gender, and racial/ethnic group, the mean energy intake was lower in 1976–1980 then in 1971–1974. The most pronounced increase in energy intake observed in 1988–1994 was for black female subjects 12 to 19 years of age (861 kJ). Decreases occurred in the age-adjusted mean intakes of energy from total fat (from 36–37% to 33–34%) and from saturated fat (from 14% to 12%) during the course of the 3 national surveys. However, data from the 1965 and 1977–1978 Nationwide Food Consumption Surveys and the 1989–1991 and 1994–1996 Continuing Survey of Food Intake by Individuals did not demonstrate increases in energy intake among participants 11 to 18 years of age.21 Mean energy intakes were 9.92 MJ in 1965, 8.78 MJ in 1977–1978, 8.77 MJ in 1989–1991, and 9.58 MJ in 1994–1996. Decreases in total fat and saturated fat, expressed as percentages of energy intake, did progressively decrease. The inconsistent findings between the 2 sets of studies indicate the difficulty of monitoring trends in energy intakes.
Information on temporal trends in physical activity levels among children and adolescents is scarce. Data from the Youth Risk Factor Surveillance System showed that, among US students in grades 9 through 12, 65.8% reported engaging in vigorous physical activity in 1993, 63.7% in 1995, 63.8% in 1997, 64.7% in 1999, and 62.6% in 2003.22–26 Indirect evidence of physical activity levels among high school students can be gleaned from the percentages of students who participated in physical education classes. The percentages of US students in grades 9 through 12 who reported daily attendance in physical education classes were 41.6% in 1991, 34.3% in 1993, 25.4% in 1995, 27.4% in 1997, 29.1% in 1999, and 28.4% in 2003.22–27 The amount of time spent in sedentary activities such as watching television, playing video games, or using a computer provides another measure of activity levels among children and adolescents. In 1997, parents of children and adolescents 2 to 17 years of age reported that their children watched television an average of 2.1 hours each day.28 By 2000, this value had increased to 2.45 hours.29 In 2000, children and adolescents spent, on average, 382 minutes each day watching television or videotapes, playing video games, using a computer, talking on the telephone, or reading. Therefore, the apparent slight decline in the percentage of high school students who reported participating in vigorous physical activity and the increase in the mean time spent watching television might have contributed to the increases in abdominal obesity and blood pressure that we noted in this study.
The inconsistent trends in the risk factors for cardiovascular disease are difficult to explain. The NHANES surveys are designed to make trend studies possible by using the same methods. There are inevitable differences, however; new machines may be used and reagents may change even if they are obtained from the same manufacturer. Nevertheless, strict quality control measures for laboratory analyses are maintained. Furthermore, the correlation coefficients for correlations between percentiles of body mass index and the risk factors for cardiovascular disease were very similar for the 2 surveys.
The exact lag period for changes in risk factors for cardiovascular disease after weight gain is not known, but weight loss studies clearly show rapid changes in many risk factors in fairly short times, certainly within 1 year. Therefore, any effects of weight increases on risk factors for cardiovascular disease should have manifested themselves during the 8- to 9-year interval between the 2 surveys. Few young participants were receiving glucose-lowering or cholesterol-lowering prescription medications, and any change in the use of prescription medications is unlikely to explain our results.
A few limitations of the study deserve comment. The sample size of NHANES 1999-2000 was inadequate for detailed trend studies according to gender and race/ethnicity. Also, not all variables were measured for all age groups. Future studies with more extensive data may be able to provide information on trends in risk factors for cardiovascular disease in these age groups that we were unable to explore. We are not aware of previously published information on the intraobserver and interobserver variability of assessments of the risk factors for cardiovascular disease included in our analyses. Therefore, the changes or lack thereof between the 2 surveys must be interpreted cautiously.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The obesity epidemic among US youths appears not to have had serious effects on their metabolic health, at least in terms of trends in various risk factors for cardiovascular disease; only systolic blood pressure was significantly increased. The reasons for this lack of deleterious effects are unclear. Our findings do not argue for complacency, however. Surveillance of trends in obesity and potential effects on risk factors for cardiovascular disease should continue. The high prevalence of obesity among US youths is of immense public health concern, because many obese youths will become obese adults,30 because the origins of many chronic diseases can be traced to childhood, because obesity-associated morbidity is occurring at earlier ages, and because obesity among youths is associated with increased morbidity and death in adulthood. Therefore, efforts to address increasing obesity among children and adolescents must be pursued vigorously.
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FOOTNOTES |
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Accepted May 28, 2004.
Address correspondence to Earl S. Ford, MD, MPH, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS K66, Atlanta, GA 30341. E-mail: eford{at}cdc.gov
No conflict of interest declared.
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PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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American Heart Association, S. S. Gidding, B. A. Dennison, L. L. Birch, S. R. Daniels, M. W. Gilman, A. H. Lichtenstein, K. T. Rattay, J. Steinberger, N. Stettler, et al. Dietary Recommendations for Children and Adolescents: A Guide for Practitioners Pediatrics, February 1, 2006; 117(2): 544 - 559. [Abstract] [Full Text] [PDF]
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Endorsed by the American Academy of Pediatrics, S. S. Gidding, B. A. Dennison, L. L. Birch, S. R. Daniels, M. W. Gilman, A. H. Lichtenstein, K. T. Rattay, J. Steinberger, N. Stettler, et al. Dietary Recommendations for Children and Adolescents: A Guide for Practitioners: Consensus Statement From the American Heart Association Circulation, September 27, 2005; 112(13): 2061 - 2075. [Abstract] [Full Text] [PDF]
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