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EDITORIAL
Primary prevention of cardiovascular disease begins in
childhood
Clara A Vázquez-Antona*.
K eywords: Cardiovascular risk of atherosclerosis. Primary prevention. Infancy. K ey words :
Atherosclerotic cardiovascular diseases. Primary prevention. Childhood (Arch Cardiol Mex
2007; 77: 7-10).
ardiovascular diseases are the third
leading cause of death in patients under 15
years of age. Cardiovascular disease is the
third leading cause of death in patients
under 15 years of age.
However, an unhealthy lifestyle (poor diet,
smoking and lack of exercise) is increasingly
responsible for an alarming increase in car-
diovascular problems in childhood and
adolescence.
Coronary heart disease is the leading cause of
mortality in several countries of the world,
including Mexico. It is responsible for one
million deaths per year. Since 1980, heart
disease has been the leading cause of general
mortality in Mexico, with 68,677 deaths in
1998, representing 15.4% of all deaths; more
than half of these cases (62.4%) corresponded
to ischemic heart disease.1
In the last two decades, risk factors that
accelerate the process of atherosclerosis in
adults have been identified. There are data
showing that atherosclerosis begins in
childhood and develops silently for decades
before clinical events such as myocardial
infarction or cerebral vascular disease occur.2-4
It has been shown that risk factors that occur in
childhood are predictive of adult risk, and that
edig raph
exposure to cardiovascular risk factors in the
early stages of life can be predictive of adult
risk.
changes in the arteries that contribute to the
development of atherosclerosis,5,6 so it is
important to promote a healthy lifestyle at this
stage to prevent adult cardiovascular disease.
The objective is to provide strategies that
promote cardiovascular health and that can be
integrated into pediatric care in areas such as
physical activity, obesity, arterial hypertension,
high cholesterol and smoking.
Obesity is currently considered a worldwide
health problem. Recent data indicate a
dramatic increase in obesity and overweight in
children and adolescents.7,8 In the United
States, 33% of adults are obese, and from 1976
to date, childhood obesity has increased from
20% to 27%, but specifically in children
between 6 and 11 years of age, overweight
increases up to 54%.9 In Mexico there is a high
prevalence of overweight and obesity; in adults
it is estimated that 23% are obese and 38.4%
are overweight and in school-age children the
prevalence is 19.5%, one in five children is
overweight or obese.10,11
Although obesity is not considered a disease in
itself, its importance lies in the fact that it
ic.c om
increases the risk of developing chronic
noncommunicable diseases that can lead to the
development of chronic diseases.
Vol. 77 Number 1/January-March 2007:7-
10
 medigraphic Artemenilsínaea
* Pediatric Cardiologist, Echocardiography Department. Ignacio Chávez National Institute of Cardiology, Mexico.

Correspondence: Dr. Clara Andrea Vázquez Antona. Echocardiography Department, Instituto Nacional de Cardiología "Ignacio Chávez"
(INCICH, Juan Badiano No. 1. Col. Sección XVI, Tlalpan 14080, Mexico City).
Telephone: (52) 5573- 2911 ext. 1212 Fax: (52) 5573-0994. E-mail: cvazquezant@yahoo.com.mx

Received: December 4, 2006

Accepted: December 20, 2006

www.archcardiolmex.org.mx
8 CA Vázquez-Antona
are a major cause of morbidity and mortality,
representing a high cost to society. These
diseases include arterial hypertension, adverse
lipid profiles, type II diabetes and early
atherosclerotic lesions, as well as morbidity
associated with adult obesity.12 It is known
that 50% of children who are overweight will
also be overweight in adulthood; if obesity
occurs in children between 10 and 18 years of
age, the risk increases to 80%.
E sencially all children, adolescents and their
families benefit from advice to prevent
overweight and obesity. T he advice should
include strategies on how to have a healthy
diet and more physical activity. In a world with
ideal nutrition, the recommended diet for
children should promote health, support
growth and prevent risks of disease. Total fat
intake should contribute to the formation of
essential fatty acids, fat-soluble vitamins and
the production of energy needed to support
sustained growth, but not with excess
cholesterol, saturated fats and fatty acids that
raise low-density lipoproteins and cholesterol.
Data provided by the National Nutrition Survey
in 199913 showed that the consumption
pattern of the Mexican population is
characterized by an abundant intake of foods
of ani- mal origin, with a high proportion of
lipids and an excessive energy load, low intake
of dietary vegetables, fruits and fiber. The high
consumption of cholesterol in all
socioeconomic strata is striking.
The progressive increase in adipose tissue in
children is related to a decrease in physical
activity rather than to an increase in energy
intake. Sedentary lifestyles, most often
associated with prolonged television viewing,
lead to a decrease in energy expenditure. It has
been observed that children spend more time
watching television than doing homework,
together with the use of computers and video
edig raph
games. This tendency of children toward physical
inactivity is related to the urbanization process,
since they have fewer possibilities to develop
outdoor activities for reasons of physical space,
traffic, time spent moving from one place to
another, con- tamination, and sometimes
insecurity.
I ncreased physical activity has been associated
with increased life expectancy and
www.archcardiolmex.org.mx
decrease in cardiovascular risk.14,15 Physical
activity programs should be appropriate for
each child, depending on his or her age, sex,
level of sexual maturity, and physical and
intellectual capacities. Daily activities such as
walking, bicycling, using stairs and school gyms,
limiting time for watching television or using
computers or video games, promoting team
play and school exercise to a minimum of half
an hour of intense exercise daily for children
over 2 years of age, and taking time for family
recreational activities should be encouraged.
Regular exercise decreases the risk of
cardiovascular disease, increases energy
expenditure which aids in weight control, and
gives a sense of general well-being by
decreasing stress. T he importance of promoting
physical exercise and sports activities during
childhood lies in the fact that it is at this stage
that individuals' healthy behaviors and
attitudes are patterned.
Other cardiovascular risk factors that are also
associated with obesity are arterial
hypertension and hyperlipidemia.
High blood pressure accelerates the
development of coronary artery disease and
contributes significantly to the pathogenesis of
stroke, heart failure and renal failure. In
addition, children with systemic hypertension
and obesity are at increased risk of left
ventricular hypertrophy;16 it is believed that the
presence of left ventricular hypertrophy at an
early age may increase the risk of
cardiovascular complications later in life.
Hypertension does not cause symptoms, so it
should be detected during pediatric screening
with routine blood pressure measurement in
subjects over 3 years of age, to identify
patients at risk.17,18 One piece of advice, which
it is prudent to give, is to insist on the
moderate use of salt in the child's diet.
Children generally consume much more salt
than required, which favors the development
ic.c om
of arterial hypertension in salt-sensitive
individuals.
On the other hand, it has been shown that high
cholesterol levels in children and adolescents
increase atherosclerotic lesions in coronary
arteries and other arteries3,4 Because the
atherosclerotic process precedes the clinical
manifestations by years, timely detection
should be performed to reduce the risks in
adults. The following strategies are
recommended as general strategies
Primary prevention of cardiovascular disease in childhood
In addition, individual strategies are
recommended to identify children at high risk
of cardiovascular disease and high cholesterol
levels.19 In children at high risk, specific
strategies are recommended especially when
there is a family history, such as cardiovascular
disease in relatives under 55 years of age, or
parents, grandparents and uncles with a family
history of hypercholesterolemia and children
with other cardiovascular risk factors.
Acceptable total cholesterol and LDL levels for
children aged 2 to 19 years are < 170 mg/dL
and < 110 mg/dL, respectively, borderline
levels of 170-199 mg/dL and 110-129 mg/dL,
and high levels > 200 mg/dL and > 130 mg/dL
LD. Two determinations should be performed
before decisions are made.20
Low HDL levels have been correlated with
cardiovascular disease in adults. HDL levels < 35
mg/dL are also a risk factor in childhood. The
relationship of elevated triglycerides in children
with adult cardiovascular disease is not yet
known; however, triglyceride levels > 200
mg/dL are associated with obesity that
responds to dietary management with
decreased consumption of simple sugars and
fats and increased consumption of omega-3
fatty acids. T riglyceride levels > 500 mg/dL
suggest genetic alterations of triglyceride
metabolism. In general, all children with LDL
levels >130 mg/dL should be followed up.19
Smoking contributes to the development of
arteriosclerosis due to the activity of nicotine
and carbon monoxide. It is the greatest health
problem today, causing a significant number of
deaths. It has been reported, worldwide, that
about 60% of smokers have started to use
tobacco.
References
I-
edig raph
1. OL A IS G. ROJA S R , BA R QUER A S , S HA MA H T , A GU
L A R C , C R A V IOT O P, ET A L : National Health Survey
2000. Volume 2. Adult health. C uernavaca
Morelos; Mexico. National Institute of Public
Health. 2003.
2. PA UC IULL O P, L A NNUZZ I A , SA RT OR IO R , IR A C E C , C
OV ETT I G, DI C OST A NZ O A , ET A L : Increased inti- ma-
media thickness of the common carotid artery in
9
from the age of 13, and more than 90% before
the age of 13.
20. The latest studies carried out in our country
indicate that 27.7% of the population between
12 and 65 years of age is smokers, that is,
almost 3 out of every 10 Mexicans.21 T he age
group with the highest prevalence of smoking is
18 to 29 years old. About 10% of adolescents in
the general population are smokers, in a ratio
of 3 males for every female.22,23 For this reason,
an effective prevention program involving
pediatricians, parents, and authorities is
required, since it is the only avoidable
cardiovascular risk factor.24-26 In infants and
preschoolers the intervention is in parents or
relatives who smoke at home. I n
schoolchildren, it is important to prevent
contact with cigarettes "the experience of
smoking", especially in children finishing
primary school, and information about the
negative effects of smoking should be
reinforced. It is in adolescence when there is
the greatest risk of starting the tobacco habit,
even though they recognize the harmful effects
of smoking, however, they visualize them as
something remote and irrelevant, so
prevention methods should show more the
immediate consequences, such as having bad
breath, the effects of nicotine on the fingers
and teeth, on the heart with the increase in
heart rate and blood pressure, even if it is only
one cigarette, and that this will be repeated
with each cigarette.27 It is necessary to
establish a comprehensive strategy that
includes research, prevention, legislation,
education, treatment and rehabilitation.28
Awareness should be created in children and
adolescents so that in future stages they can
maintain a healthy heart and thus have a better
quality of life. Harmful lifestyles should be
avoided by teaching them to maintain a healthy
diet, promote exercise and avoid tobacco use.
hypercholesterolemic children. A
rterioscl T hromb 1994; 14:
1075,1079.
Vol. 77 Number 1/January-March 2007:7-
10
 3. R A IT A K A R I OT , J OUNA L A M , K A HONE N M , T A IT O- NEN L , L A IT
INEN T , MÄ K Y -TOR KK ON, ET A L : C ardio-.
ic.com
vascular Risk F actors in C hildhood and C arotid Artery Intima-
10 Media Thickness in Adulthood. JA MA 2003; 290: 2277-2283. CA Vázquez-Antona
4. B E R E NSON G, SR INIV A SA N S, B A O W, NE WMA N III.
W, TR A C Y R , WA TT IGNE Y W: Association Between Multiple C
ardiovascular Risk F actors and Athe- rosclerosis in C hildren and
young Adults. N E ngl J Med 1998; 338: 1650-1656.

www.archcardiolmex.org.mx
10
5. B ER E NSON GS, WA TT IGNE Y W, T R A C Y R , NE WMA N
III E , SR INIV A SA N SR W EBBER R , ET A L : Atheroscle-.
rosis of the Aorta and C oronary Arteries and C
ar- diovascular Risk F actors in Persons Aged 6 to
30 Years and Studied at Necropsy (The Bogalusa
Heart Study). A m J C ardiol 1992; 70: 851-858.
6. JA RV ISA L O MJ, JA RTT I L , NA NT O-SA L ONEN K , I RJA L A
K , R ONNE MAA T , H A RT IA L A JJ, ET A L : Increased
aortic intima-media thickness: a marker of
precli- nical atherosclerosis in high-risk children.
C ir- culation 2001; 104: 2943-2947.
7. G ONZÁ L E Z -V ILL A L PA NDO C , S TER N M: Obesity.
as a cardiovascular risk factor in Mexico. A study
in an open population. Rev Invest C lin 1993; 45:
13-21.
8. T OUSSA INT MG: Patterns of diet and physical
activity in the pathogenesis of obesity in urban
schoolchildren. B ol Med Hosp Infant Mex 2000;
57(1): 650-662.
9. SA B IN MA , C R OWNE E C , SHIE L D JPH: The progno-.
sis in childhood obesity. C urr Pediatr 2004; 14:
110-114.
10. H ERNÁ NDEZ B, C UEV A S-NA SU L , S HA MA H T , MONTE- RR
UB IO E , R A MÍRE Z -S IL V A C , GA R C ÍA -F ERE GR INO R
, Profes- sionals F rom the C ommittee on
ET A L : F actors associated with overweight and
obesity in Mexican school-age children: results
from the 1999 National Nutrition Survey. Salud
Pública Mex 2003; 45: 1-8.
11. R IV ERA DJ, L EV Y T : Presentation of results of the
1999 National Nutrition Survey. Nutritional
status of children and women in Mexico. Salud
Pú- blica Mex 2002; 44: 188-189.
12. G IDDING S, L E IBE L R , D A NIE L S S, R OSE NB A UM M,
V A N HOR N L , MA R X G: Understanding Obesity in
Youth A statement for Healthcare Professionals
F rom the C ommittee on Atherosclerosis and Hy-
pertension in the Young of the C ouncil on C
ardio- vascular Disease in the Young and the
Nutrition C ommittee, American Heart
Association. C ircula- tion 1996; 94: 3383-3387.
13. SE PÚL V E D A A J , R IV ER A D J : E ncuesta Nacional
de Nutrición 1999. C uernavaca Morelos;
Mexico. C entro de Investigación en Nutrición y
S a- lud. National Institute of Public Health.
2003: 12-13.
14. C A L ZA DA R , L ORE DO-A B DA L Á A : C onclusions of
the national consensus meeting on prevention,
diagnosis, and treatment of obesity in
children
Mex and adolescents. B ol Med Hosp Infant
2002; 59: 517-524.
edigraphic.
15. K REB S N, B A K ER R , GREER F, HEY MA N M, JA K SIC T ,
L IFSHITZ F: A merican A cademy of Pediatrics:
Pre- vention of Pediatric Overweight and
Obesity. Pe- diatrics 2003; 112: 424-428.
www.archcardiolmex.org.mx
CA Vázquez-Antona
16. HA NE V OL D C , WA LL ER J, D A NIE L S S, PORT A M N,
SOR OF J: The effects of obesity, gender, and ethnic
group on the left ventricular hypertrophy and
geo- metry in hypertensive children: a
collaborative stu- dy of the International
Pediatric Hypertension Association. Pediatrics
2004; 113: 328-233.
17. National High B lood Pressure E ducation Program
Working Group on High B lood Pressure in C hil-
dren and A dolescents: The F ourth Report on
the Diagnosis, Evaluation, and Treatment of
High Blood Pressure in C hildren and
Adolescents. Pe- diatrics 2004; 114: 555-576.
18. V E L A S QU E Z -JON E S L : Arterial hypertension and
obesity. B ol Med H osp Infant Mex 1990; 47:
139-141.
19. K A V E Y R-E, D A NIEL S S, L A UER R M, A T K INS D, H A -
Y MA N L , TA U B ER T K : American Heart Association
Guidelines for Primary Prevention of Atheroscle-
rotic C ardiovascular Disease Beginning in C hild-
hood. J Pediatr 2003; 142(4): 368-372.
20. W ILL IA MS C , H A Y MA N L , DA NIE L S S, R OB INSON T ,
STE INBER GER J, PA R IDON S, ET A L : C ardiovascular
Health in C hildhood statement for Health
Atherosclerosis, Hypertension, and Obesity in the
Young (AHOY) of the C ouncil on C ardiovascular
Disease in the Young, American Heart
Association. C irculation 2002; 106: 1143-160.
21. B EL SA SSO G: Smoking in Mexico. Boletín es- pecial
de tabaquismo. C ONA DIC /SSA . Progra- ma
contra el tabaquismo 1992-1994. Mexico 1994.
22. 2002 National Survey of A dictions: Tobacco,
alcohol and other drugs. C ONA DIC /SSA .
Mexico 2002: 9-14.
http://www.conculta.com.mx/interio-
res/99_pdfs/15_others_pdf/ena.pdf.
23. A ZA MA R MJ, ORT ÍN-L E ÓN MC , BA RR IOS-A L V A RE Z
Y , A ZA MA R -A RIZ MENDI RA : Tobacco Addiction in
Minors in the City of Xalapa, Ver. Universi- dad V
eracruzana http://www.insp.mx/salvia/9830/
sal98301.html
24. T A PIA C R : Prevention and control of the global
tobacco epidemic: a comprehensive strategy.
Public Health Mex 2000; 42: 6-7.
25. S TE IN R , H A DD OC K C K , O'B Y R NE K , H Y MOWIT Z
N, SC HWA B S: The Pediatrician's in Reducing To-
bacco Exposure in Children. Pediatrics 2000;
106: 1-17.
26. DE MIC HE LL I A , I ZA GUIRRE -A V IL A R : Tobacco and
ta-.
baquismo in the history of Mexico and Europe. R
ev
613.
cIonvmest C lin 2005; 57: 608-
27. L A NIA DO-L A B OR ÍN R , MOL GAA R D C , E L DER J: E fec-.
tivity of a tobacco prevention program in
Mexican schoolchildren. Salud Pública Mex
1993; 35: 403-408.