Published online December 1, 2006
PEDIATRICS Vol. 118 No. 6 December 2006, pp. e1789-e1797 (doi:10.1542/peds.2006-0680)
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ARTICLE

Screening Children to Identify Families at Increased Risk for Cardiovascular Disease

Evelyn Cohen Reis, MDa, Kevin E. Kip, PhDb, Oscar C. Marroquin, MDc, Marin Kiesau, MDa, Lee Hipps, Jr, BAd, Ronald E. Peters, EdDe and Steven E. Reis, MDc

a Department of Pediatrics
c Cardiovascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
b Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
d Urban League of Pittsburgh, Pittsburgh, Pennsylvania
e Department of Urban Ministry, Pittsburgh Theological Seminary, Pittsburgh, Pennsylvania


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVES. Atherosclerotic cardiovascular disease is the leading cause of death in the United States. Atherosclerosis begins early in life; however, children and young and middle-aged adults are not universally screened for the presence of modifiable cardiovascular disease risk factors. The purpose of this study was to investigate whether cardiovascular disease risk-factor assessment in children can identify families who are at increased risk for cardiovascular disease.

PARTICIPANTS AND METHODS. Family Strategies Concentrating on Risk Evaluation is a community-based participatory research study designed to stratify cardiovascular disease risk in a cohort of children and their parents. Eligible families, consisting of ≥1 child and ≥1 biological parent, are recruited through community and faith-based educational and screening programs. In a single, fasted study visit, participants undergo assessment of cardiovascular disease risk factors: obesity, hypertension, dyslipidemia, and metabolic syndrome. Associations of cardiovascular disease risk factors between children and their parents were assessed.

RESULTS. Data were analyzed from 94 families: 108 parents (mean age: 38.5 ± 7.5 years), 141 children (mean age: 10.5 ± 3.4 years), and 170 child-parent pairs. Child-parent association was strong for many risk factors: BMI, waist circumference, systolic blood pressure, triglycerides, and total cholesterol. Several discrete-defined risk factors in children were found to be significant predictors of the presence of the same risk factors in their parents. Parents of children with hypertension, obesity, or hypertriglyceridemia had 15 times, 6 times, or 5 times increased odds, respectively, of having the same risk factors.

CONCLUSIONS. Identification of several clinically apparent and silent cardiovascular disease risk factors in children predicts elevated cardiovascular disease risk in their parents. Because children access primary care more frequently than adults, children can potentially serve as the index case to identify families at increased risk for cardiovascular disease.

Key Words: cardiovascular disease • risk factors • screening

Abbreviations: CVD—cardiovascular disease • Family SCORE—Family Strategies Concentrating on Risk Evaluation • HDL—high-density lipoprotein • NCEP—National Cholesterol Education Program • LDL—low-density lipoprotein • OR—odds ratio • CI—confidence interval

Atherosclerotic cardiovascular disease (CVD) is the leading cause of death in the United States.1 Atherosclerosis begins in childhood and young adulthood.2–5 The likelihood of developing CVD increases with the presence of risk factors, including hypertension, dyslipidemia, obesity, and metabolic abnormalities. The recent, dramatic rise in pediatric obesity is associated with increasing prevalences of these risk factors.6–11 Reduction of CVD risk factors in children and adults can reverse subclinical atherosclerosis and decrease CVD risk.12–15 However, despite these observations and established clinical practice guidelines,15–18 children and young and middle-aged adults are not universally screened for the presence of modifiable CVD risk factors.19,20

Adults are more likely to receive preventive services, such as CVD risk-factor assessment, if they have established primary care and health insurance.19–24 Young and middle-aged adults are less likely than older adults to receive preventive care.25 In contrast, most children receive regular primary care,26 which typically occurs in the company of a parent. Given the known associations of many CVD risk factors between children and their parents27–30 and the lack of universal CVD risk screening among young and middle-aged adults, we postulated that child-parent visits to pediatric health care providers may provide an opportunity to simultaneously stratify both children and their parents for CVD risk. The present study investigates the hypothesis that assessment of CVD risk factors in children can identify families who are at increased risk for CVD.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Study Design
The Family Strategies Concentrating on Risk Evaluation (Family SCORE) study is a community-based participatory research study31 that is designed to stratify CVD risk in a cohort of children and their parents. Participants are recruited through community and faith-based educational and screening programs that were designed and implemented by a collaborative effort among the University of Pittsburgh, Urban League of Pittsburgh, and the Pittsburgh Theological Seminary. Family SCORE was approved by the Human Research Committee of the Children's Hospital of Pittsburgh and the University of Pittsburgh Institutional Review Board.

Study Participants
Eligible families consist of ≥1 child (aged 5–17 years) and ≥1 biological parent (aged 18–75 years). Participants' age, ethnicity, and race are identified by parents. Child(ren) or parent(s) who are pregnant or have diagnosed cancer or connective tissue diseases are excluded. Data analyzed for this report were collected from families enrolled from October 4, 2003, through June 1, 2005.

Assessment of CVD Risk Factors
In a single study visit, which follows a minimum 8-hour fast, children and parents undergo fingerstick blood measurement of total and high-density lipoprotein (HDL) cholesterol, triglycerides, and glucose using a Cholestech LDX analyzer (Cholestech Corporation, Hayward, CA). This device has been certified by the Cholesterol Reference Method Laboratory Network to meet the National Cholesterol Education Program (NCEP) performance criteria for accuracy and precision.32 Low-density lipoprotein (LDL) cholesterol is calculated using the Friedewald equation.33 Participants also undergo measurement of height, weight, waist circumference, and blood pressure. Waist circumference is measured at the level of the umbilicus. Blood pressure is measured twice using a standard clinical technique, allowing participants to rest 15–30 minutes between measurements. BMI (kilograms per meter squared) is calculated by the quotient of weight and height squared.

Child Risk-Factor Definitions
Obesity
Based on Centers for Disease Control and Prevention definitions, children are classified as being overweight/obese if their BMI is ≥95th percentile and at risk for overweight if their BMI is 85th to 94th percentile for age and gender.34 Waist circumference >85th percentile for age and gender based on National Center for Health Statistics data are defined as abnormally large.35

Blood Pressure
Childhood hypertension is defined as systolic blood pressure and/or diastolic blood pressure >95th percentile for age, gender, and height or use of antihypertensive medication.18 Childhood prehypertension is defined as systolic blood pressure and/or diastolic blood pressure in the 90th to 95th percentile for age, gender, and height or systolic blood pressure ≥120 mmHg and/or diastolic blood pressure ≥80 mmHg.18

Dyslipidemia
Abnormal fasting lipoprotein levels are defined as triglycerides ≥110 mg/dL,36 HDL ≤40 mg/dL,36 and LDL ≥110 mg/dL.17

Hyperglycemia
Abnormal fasting blood glucose is defined as ≥110 mg/dL.37

Metabolic Syndrome
Classification of the metabolic syndrome requires the presence of ≥3 of 5 metabolic factors (abnormally large waist circumference, hypertension, hypertriglyceridemia, low HDL cholesterol, and hyperglycemia).

Adult Risk-Factor Definitions
Obesity
In adults, overweight is defined as BMI 25 to <30 kg/m2, and obesity is defined as BMI ≥30 kg/m2.38

Blood Pressure
Prehypertension is defined as systolic blood pressure 120–139 mmHg or diastolic blood pressure 80–89 mmHg.15 Hypertension is defined by systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg.15 Subjects who are being treated with antihypertensive medications are classified as hypertensive.

Dyslipidemia
Abnormal lipid levels are defined as triglycerides ≥150 mg/dL, HDL <40 mg/dL in males and <50 mg/dL in females, and LDL >130 mg/dL.16

Hyperglycemia
Abnormal fasting blood glucose is defined as ≥110 mg/dL.16

Metabolic Syndrome
Metabolic syndrome requires the presence of ≥3 of 5 metabolic abnormalities: waist circumference >88 cm in females, >102 cm in males; triglycerides ≥150 mg/dL; HDL cholesterol < 50 mg/dL in females, <40 mg/dL in males; systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥85 mmHg or antihypertensive drug therapy; and fasting glucose ≥110 mg/dL or history of diabetes.16

Statistical Analyses
Demographic and risk-factor characteristics among children and parents were described by means, SDs, medians, and ranges for continuous variables (depending on distributional properties) and percentages for categorical variables. Pearson and Spearman correlation coefficients were calculated to assess the degree of child-parent association in continuously distributed metabolic risk factors. Because some families had >1 child in the analysis and/or child pairs with both the biological mother and father, generalized estimating equations based on the normal distribution and identity link39,40 were used to generate adjusted P values that accounted for correlation among multiple within-family observations, as well as to adjust for age of the child and parent age, gender, and race. This model parallels the conventional linear regression model. Similarly, for metabolic risk factors categorized as discrete variables, including the metabolic syndrome, generalized estimating equations based on the binomial distribution and logit link39,40 were used to estimate adjusted odds ratios (ORs) for child-parent association while accounting for correlation among multiple within-family observations. This model parallels the conventional logistic regression model. Analyses were also stratified by parent race, parent gender, BMI of child, and children with 1 vs 2 parents in the analysis to explore the possibility of differential child-parent association in metabolic abnormalities. These subgroup analyses, based on relatively small sample sizes, yielded consistent results with the full cohort and, thus, are not reported herein. All of the analyses were conducted with SAS 8.2 (SAS Institute, Cary, NC), with 2-sided P values <.05 considered to be statistically significant.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Study Population
The study population consisted of 94 families that had between 1 and 5 child-parent pairs. This included 76 mother-only families (108 children), 4 father-only families (4 children), and 14 mother and father families (29 children). Thus, there were 108 parents and 141 children evaluated overall, with a total of 170 child-parent pairs in the analysis (29 children were paired with both their biological mother and father in the analysis). The number of children evaluated per family represents only those in which risk-factor assessment was completed, rather than the actual size of the family unit.

Characteristics of Children
The mean age of the 141 children was 10.5 ± 3.4 years; 69% were black, and 40% were girls (Table 1). Boys were on average 1.2 years older than girls. Mean BMI was 22.1 ± 6.3 kg/m2 with 52% of children classified as either at risk for overweight (BMI 85th to 94th percentile) or obese (BMI ≥95th percentile). Blood pressure measurements resulted in the classification of prehypertension and hypertension in 15% and 6% of the children, respectively. Mean triglycerides and HDL and LDL cholesterol levels were 80 ± 50, 49 ± 15, and 95 ± 26 mg/dL, respectively. Mean fasting glucose was 85 ± 13 mg/dL. On average, children had 0.9 risk factors (median: 1; range: 0–5) of the metabolic syndrome, with abnormally large waist circumference (33%) and low HDL cholesterol (27%) being the most prevalent factors and hyperglycemia being the least prevalent risk factor; only 3% of all of the children had abnormal fasting glucose levels. Fifty-one percent of children had ≥1 metabolic abnormality, and 8% of children met criteria for the metabolic syndrome. The prevalence of risk factors of the metabolic syndrome, including elevated triglycerides and low HDL cholesterol levels, was modestly higher among boys (data not shown.) By race (data not shown), black children were less likely than white children to have abnormally large waist circumference (26% vs 50%), high triglycerides (10% vs 27%), and LDL cholesterol levels (19% vs 37%), as well as low HDL cholesterol levels (23% vs 39%), thereby having a markedly lower number of metabolic abnormalities (mean: 0.7; median: 0; range: 0–3 vs mean: 1.3; median: 1; range = 0–5) and prevalence of the metabolic syndrome (5% vs 14%).


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  		TABLE 1 Subject Characteristics

 
Characteristics of Parents
The mean age of the 108 parents was 38.5 ± 7.5 years; 60% were black, and 83% were women (Table 1). Mean BMI was 32.6 ± 9.8 kg/m2 with 57% of parents classified as obese. Blood pressure measurements resulted in the classification of prehypertension and hypertension in 29% and 22% of the parents, respectively. Of note, among the 84 parents (78% of all parents) with no previous history of hypertension, 41% were identified with prehypertension or hypertension. Mean triglycerides and HDL and LDL cholesterol levels were 116 ± 73, 49 ± 13, and 103 ± 30 mg/dL, respectively. Abnormal triglycerides and HDL and LDL levels were identified in 20%, 50%, and 15% of parents, respectively. Of the 92 parents (85% of all parents) who had no previous history of dyslipidemia, 17%, 49%, and 13% were identified as having abnormally high triglycerides, low HDL, and high LDL levels, respectively. Mean fasting glucose level was 99 ± 33 mg/dL; 19% of all of the parents had hyperglycemia. A total of 101 (94%) of the parents had no previous history of diabetes. Of these parents, 14% met criteria for hyperglycemia, and 5% were diagnosed with diabetes. On average, parents had 1.8 (median: 2; range: 0–5) factors of the metabolic syndrome, with abnormally large waist circumference (59%) being the most prevalent, and abnormal fasting glucose (19%) being the least prevalent. Eighty-two percent had ≥1 metabolic abnormality, and 28% of all parents were classified as having the metabolic syndrome. Overall, female parents (data not shown) were younger (37 ± 7 years) than male parents (44 ± 6 years), more often black (66% vs 33%), had higher BMI (mean BMI: 33.3 vs 29.4), and more likely to have elevated fasting glucose (21% vs 11%). Conversely, female parents were less likely to have elevated blood pressure (23% vs 56%), triglycerides (16% vs 44%), and LDL cholesterol >130 mg/dL (9% vs 50%). By race (data not shown), black parents were, on average, 4.3 years younger than white parents (36.8 vs 41.1) and more often women (91% vs 73%), whereas they were less likely to have abnormal triglycerides (12% vs 32%), HDL cholesterol (45% vs 58%), and LDL cholesterol (11% vs 22%). Black parents had fewer average metabolic abnormalities (1.7; median: 2; range: 0–4 vs 2.0; median: 2; range: 0–5) and lower prevalence of the metabolic syndrome than white parents (22% vs 39%).

Child-Parent Correlations of CVD Risk Factors (Continuous Variables)
Significant child-parent correlations were observed for many CVD risk factors when these factors were analyzed as continuous variables. Strong correlations were observed for BMI (r = 0.35; P < .0001), waist circumference (r = 0.39; P < .0001), systolic blood pressure (r = 0.34; P = .0006), triglycerides (rs = 0.39; P < .0001), and total cholesterol (r = 0.30; P < .0001). Statistically significant correlations were also observed for diastolic blood pressure (r = 0.24; P = .01) and HDL cholesterol (r = 0.25; P = .01), whereas fasting glucose levels were unrelated between children and their parents (r = 0.03; P = .93).

Child-Parent Correlations of CVD Risk Factors (Discrete Variables)
Several discrete-defined CVD risk factors in children were found to be significant predictors of the presence of the same risk factors in their parents (Table 2). Parents of children who were obese were at ~6 times higher odds of being obese than parents of children who were not obese (adjusted OR: 5.97; 95% confidence interval [CI]: 2.50–14.24; P < .0001). Similarly, parents of children who had abnormally large waist circumferences were themselves at ~6 times higher odds of having abdominal adiposity (adjusted OR: 5.65; 95% CI: 2.30–13.89; P = .0002) than parents whose children had normal waist circumferences. Although only 12 children had hypertension defined by blood pressure ≥95th percentile, this condition, when present, conferred an ~15-times higher odds of hypertension among parents (adjusted OR: 14.70; 95% CI: 3.02–71.56; P = .0009). Elevated triglycerides in children conferred an approximate fivefold-increased odds among parents (adjusted OR: 4.89; 95% CI: 2.10–11.37; P = .0002). In contrast, elevated fasting glucose in children was not statistically associated with hyperglycemia in parents. However, there was a strong trend observed for the presence of the metabolic syndrome in children predicting the presence of metabolic syndrome in their parents (adjusted OR: 3.28; 95% CI: 0.91–11.90; P = .07).


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  		TABLE 2 ORs of Risk Factors in Parents Based on Child Status (N = 170)

 
Analyses were performed to determine the proportion of children and their parents who were similarly affected and at risk for CVD risk factors. The positive predictive value of the presence of risk factors in children appears evident for both clinically apparent and clinically "silent" risk factors (Table 2). Among obese children, ~80% of their parents were obese. Among children with hypertension, 75% of their parents also had hypertension. Among children with elevated triglycerides or low HDL levels, approximately half of their parents had these risk factors. Moreover, among children with the metabolic syndrome, nearly two thirds of their parents shared this condition.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Successful prevention of CVD depends on early identification and modification of CVD risk factors, such as hypertension and dyslipidemia. Because atherosclerosis begins early in life and remains occult for many years, screening for modifiable CVD risk factors should be performed universally in children and young- and middle-aged adults.17 However, many adults are not screened for CVD risk factors, often because of lack of established primary care and/or health insurance.19 Children, who are more likely than adults to receive regular primary care, do not routinely undergo comprehensive CVD risk-factor assessment, including measurement of serum lipoproteins. Our study demonstrates that risk-factor assessment in children can identify both children and their parents who are at increased CVD risk.

In 1987, investigators from the Bogalusa Heart Study41 reported that a small cohort of children with elevated blood pressure had parents with a higher than expected prevalence of hypertension, hypercholesterolemia, and overweight. Based on this pilot study, the authors suggested that, through "reverse" screening, identifying child probands with elevated blood pressure could predict multiple CVD risk factors in their parents.

Our results from a larger sample of children with and without risk factors indicate that measurements of BMI, waist circumference, blood pressure, triglycerides, and total and HDL cholesterol levels correlate between children and their parents. Furthermore, we found that several "silent," as well as clinically apparent, CVD risk factors in children are strong predictors of these risk factors in their parents. First, we found that parents of obese children were at 6 times higher odds of being obese than parents of nonobese children. The association of child and parent weight status has been reported previously42 and is typically apparent to clinicians. More importantly, we also demonstrated that the presence of 2 silent CVD risk factors, hypertension and hypertriglyceridemia, in children is highly predictive of the presence of these risk factors in their parents. Specifically, parents of children with hypertension were at ~15-times higher odds of having hypertension than parents of children without hypertension. Parents of children with elevated triglycerides had fivefold higher odds of having this CVD risk factor than parents of children with normal triglyceride levels. We also found a strong trend for the presence of metabolic syndrome in children predicting metabolic syndrome in their parents.

The finding that hypertension in children strongly predicts hypertension in their parents has great significance and potential for clinical application. Hypertension is known as the "silent killer," because affected individuals are asymptomatic until blood pressure reaches a critical level or until sequelae present. Untreated hypertension is associated with increased risk for myocardial infarction, congestive heart failure, stroke, and end-stage renal disease. Early identification and treatment of hypertension can reduce the risk of CVD sequelae.12,15,43 However, adults with hypertension are frequently unaware of their diagnosis, particularly adults who lack established primary care and/or health insurance.1,15,20,44

Our study finding that children's hypertension predicts parents' hypertension reinforces the need for universal blood pressure screening of children by pediatricians and other professionals. In health care settings, children undergo routine blood pressure measurement annually beginning at 3 years old in accordance with clinical practice guidelines.17,18 Blood pressure measurement can also be performed in children by professionals other than primary care providers, such as school nurses, coaches, and trainers. Routine blood pressure measurement in schools could be added to current state-based initiatives to measure and report BMI of all students to parents. Therefore, our finding that child hypertension is highly predictive of parental hypertension suggests that universal blood pressure screening of children may provide a feasible approach to identifying undiagnosed hypertension in their young and middle-aged parents.

Our results also indicate that hypertriglyceridemia in children is a strong independent predictor of hypertriglyceridemia in their parents. Hypertriglyceridemia, like hypertension, is a clinically silent CVD risk factor45,46 and can be effectively lowered by dietary modification, exercise, and pharmacologic therapy. Therefore, measurement of triglyceride levels in children may identify both high-risk children and parents who may benefit from intervention. Use of our study technique of measuring triglycerides by fingerstick blood sampling, in place of traditional venipuncture, would be feasible in pediatric primary care and other ambulatory settings.

Our finding of an association between obesity in children and parents has been reported previously.42 However, it is important to note that child-parent association in weight status does not account for our other findings. Specifically, child-parent correlations in risk factors noted for the entire study cohort were consistently observed in subgroup analyses, including by BMI of the child. Therefore, the implications of our results apply to both obese and nonobese children and parents.

Clinical encounters in the current health care system focus solely on the individuals who present for care. This focus limits the delivery of available preventive health care measures, because many young and middle-aged adults do not seek primary care services. Adults who are uninsured are more likely to be medically disadvantaged by this lack of access to preventive care. Nearly 20 years ago, Johnson et al41 suggested that through "reverse" screening, identifying child probands with CVD risk factors may identify high-risk adults. However, for the past 2 decades, this premise has not been evaluated further nor adopted in clinical practice. Our study, with a larger and more representative sample, provides additional evidence to support the screening of children for CVD risk factors to identify their high-risk parents. This approach expands the traditional view of family history by including consideration of children's risk factors, as well as those of older family members. Identification of CVD risk factors (eg, hypertension and hypertriglyceridemia) in children by pediatricians should prompt a recommendation for their parent(s) to consult a primary care physician (eg, internist) for CVD risk-factor assessment, diagnosis, and treatment. Future studies should investigate the public health impact of stratifying families' CVD risk based on screening children for CVD risk factors.

Generalizability of our study findings is limited by 2 factors. First, a local sample was recruited from a single geographic area. However, our study benefited from adherence to the tenets of community-based participatory research,31 which allowed robust recruitment from the minority community. Close collaboration among the academic health center and community and faith leaders resulted in onsite enrollment in multiple, diverse neighborhoods. This approach resulted in a cohort with minority representation that was fivefold that of the general local population. Second, only 1 parent per child was required to participate. Less than one quarter of the children had both parents enrolled, and the majority of parents were women. Based on this study design, which facilitated enrollment of minority families, we were unable to assess the relative contribution of child risk-factor status on both parents simultaneously. If child CVD risk factors are present, both parents should undergo CVD risk-factor assessment.

Another limitation is our definition of metabolic syndrome to identify insulin resistance in children. Although the NCEP Adult Treatment Panel III guidelines provide a standard clinical definition for the metabolic syndrome in adults,16 the definition in children has not yet been standardized.36,37,47 However, our findings support further studies of the predictive value of the metabolic syndrome in children, which should consider using the homeostasis model assessment of insulin resistance or glucose tolerance tests to more accurately define insulin resistance in both children and their parents. In addition, our study measured lipids from a fasting fingerstick blood sample using a Cholestech LDX analyzer. Although this device has been certified by the Cholesterol Reference Method Laboratory Network to meet the NCEP performance criteria for accuracy and precision,32 potential suboptimal accuracy and precision of the fingerstick method of measuring lipids may have resulted in a systematic underestimation of true child-parent associations among lipid levels. Therefore, it is conceivable that child-parent associations of lipid levels may be stronger than those reported in this study.

Finally, we chose risk-factor cutoff points based on current pediatric clinical definitions. We recognize that, in terms of risk prediction, there may be better cutoff points in children for use in identifying adults with CVD risk factors. Future research in this area may identify these optimal cutoff points and also assess a broader spectrum of racial/ethnic groups.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
Our study findings indicate that the identification of several clinically apparent and silent CVD risk factors in children predicts increased CVD risk in their parents. Specifically, parents of obese children were at 6 times higher odds of being obese than parents of nonobese children. Parents of children with hypertension were at ~15 times higher odds of having hypertension than parents of children without hypertension. Parents of children with elevated triglycerides were at fivefold higher odds of having hypertriglyceridemia than parents of children with normal triglyceride levels. Because children access primary care more frequently than adults, they can serve as the index case for increased CVD risk for their families. Given the long lead time between the detection of risk factors and the onset of clinical CVD, universal CVD risk-factor screening of children would provide ample opportunity for intervention in children and their young and middle-aged parents, with potential for great individual and public health benefit.


   ACKNOWLEDGMENTS
 
We acknowledge support from the Excellence in Partnerships for Community Outreach and Research on Disparities in Health and Training Project at the Center for Minority Health, Graduate School of Public Health, University of Pittsburgh, National Institutes of Health/National Center on Minority Health and Health Disparities grant P60 MD-000-207-03. The development of the community-based participatory research network that was used in this study was funded in part by the Pennsylvania Department of Health contract ME-02-384. The department specifically disclaims responsibility for any analyses, interpretations, or conclusions.

Family SCORE investigators and staff were: University of Pittsburgh: Department of Pediatrics: Evelyn C. Reis, MD (principal investigator), Marin Kiesau, MD, and Deborah Moss, MD; Department of Epidemiology: Kevin E. Kip, PhD; Cardiovascular Institute: Oscar C. Marroquin, MD, Steven E. Reis, MD, Amy Beto, RN, BSN, Rebecca Chambers, BS, Patti Chioda, Mary Catherine Coast, RN, BSN, Jowanda Green, Louise Martin, RN, BSN, Lee Ann McDowell, Rosalyn Rapsinski, BS, MA, and Pamela White, RN, BSN; Center for Minority Health: Stephen Thomas, PhD, Pittsburgh Theological Seminary: Rev Dr Ronald E. Peters, Rev Sherry Brooks, and Rev Sharon Washington; and Urban League of Pittsburgh: Lee Hipps Jr, and Mavis Burks.


   FOOTNOTES
 
Accepted Jul 11, 2006.

Address correspondence to Evelyn C. Reis, MD, Children's Hospital of Pittsburgh, General Academic Pediatrics, 3705 Fifth Ave, Pittsburgh, PA 15213. E-mail: evelyn.reis{at}chp.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.

An abstract of these findings was presented at the annual Pediatric Academic Societies meeting; May 14, 2005; Washington, DC.


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 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
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S. Cook and S. S. Gidding
Modifying Cardiovascular Risk in Adolescent Obesity
Circulation, May 1, 2007; 115(17): 2251 - 2253.
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