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Childhood Obesity Brings Heavy Heart Disease Burden in Adulthood
By Crystal Phend , Staff Writer, MedPage Today
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine.
COPENHAGEN, Dec. 5 -- Overweight and obesity in childhood and adolescence substantially increase
future risk of heart attack and other cardiac events, researchers found, confirming fears that the most
serious consequences of the obesity epidemic are yet to come.
Action Points

Explain to interested parents and patients that overweight and obesity in childhood have been
shown to have serious long-term health consequences.

Inform parents and patients that previous studies have found that childhood overweight and
obesity have an impact on adult health regardless of adult body mass index (BMI).
Boys overweight by 11.2 kg (25 lb) at age 13 had a 33% higher risk of coronary heart disease events in
adulthood than those at a normal weight at that age, according to a large longitudinal cohort study in the
Dec. 6 issue of the New England Journal of Medicine.
This elevated risk for children at the 88th versus the 41st BMI percentile-for-age was similar among girls,
reported Jennifer L. Baker, Ph.D., of the Institute of Preventive Medicine in Copenhagen, and colleagues.
Previous studies have linked childhood obesity to risk factors for heart disease, but studies looking at
heart disease outcomes have been generally too small to complete the chain of events, they said.
These findings may have important implications as childhood obesity spreads worldwide, they said.
If current trends continue, heart disease prevalence may increase 5% to 16% over the next 25 years as
today's obese adolescents age, according to an accompanying analysis by Kirsten Bibbins-Domingo,
Ph.D., M.D., of the University of California at San Francisco, and colleagues.
"The childhood obesity epidemic has gotten a lot of attention, but the full impact of the epidemic is many
years in the future," commented David S. Ludwig, M.D., Ph.D., of Children's Hospital in Boston and
Harvard.
His accompanying perspective article suggested that the findings show the "shape of things to come."
The epidemic began in the 1970s with increasing obesity rates among children, he said, and has now
progressed to a second phase in which serious weight-related problems, including type 2 diabetes, are
emerging.
But it may take many years to reach the third phase of the epidemic "in which the medical complications
of obesity lead to life-threatening disease," he said, as illustrated in the studies.
Dr. Baker's group studied 276,835 people born from 1930 to 1977 for whom body mass index data was
available in the Copenhagen School Health Records Register. Such data were available because annual
health examinations at public or private schools are mandatory there.
The records were linked to 10,235 coronary heart disease events among men and 4,318 among women
in the National Cause of Death Register and the National Hospital Discharge Register during 46 years of
follow-up. Most events were nonfatal (8,392 and 3,637, respectively).
The researchers found that every one-unit increase in BMI z score at each age from seven to 13 was
associated with elevated risk of coronary heart disease events in adulthood.
For boys, the elevated risk was significant at age seven for both fatal events (adjusted hazard ratio: 1.10,
95% confidence interval: 1.06 to 1.15) and nonfatal events (adjusted HR: 1.05, 95% CI: 1.03 to 1.08).
Risk increased with age to hazard ratios of 1.24 and 1.17, respectively, at age 13.
For girls, the elevated risk became significant at age eight for fatal events (adjusted HR: 1.08, 95% CI:
1.01 to 1.17) and at age 10 for nonfatal events (adjusted HR: 1.06, 95% CI: 1.02 to 1.10). It likewise
increased through age 13 to hazard ratios of 1.23 and 1.11, respectively.
Increasing risk with age may have reflected the increasing weight gain required for a one-unit increase in
BMI z score, which about doubled from 1.96 to 2.17 kg at age seven to 5.60 to 6.30 kg at age 13.
"Increases in BMI z scores at these later ages could reflect a greater accumulation of fat, in particular
intra-abdominal fat, which increases the risk of coronary heart disease," the researchers speculated,
"aside from the fact that body size in late childhood is more proximal in time to adult body size."
Furthermore, the findings did not support a threshold approach to risk for children, they said, such as a
BMI threshold at the 85th or 95th percentile on growth charts.
Although the researchers cautioned that they did not have data on adult BMI, they noted that a previous
study showed that adolescent BMI had an effect on adult heart disease independent of adult body size.
The public health consequences are likely to be substantial, according to the study by Dr.
Bibbins-Domingo's group.
Based on the prevalence of overweight adolescents in 2000, the projected prevalence of obesity at age
35 was 30% to 37% among men compared with the current 25% and 34% to 44% among women
compared with the current 32%.
When combined with the known effects of obesity on cardiovascular risk factors, the projected effect of
increased obesity on cardiovascular outcomes included:

An excess total number of coronary heart disease events of 10% in 2020 rising to 14% in 2035
(absolute excess events 550 and 33,000, respectively).

An excess coronary heart disease incidence of 15% by 2035 (40,000 events).

An excess of 59 deaths from coronary heart disease in 2020 (9% excess) rising to 3,600 in 2035
(13% excess).
These projections 25 and more years into the future
must be interpreted with great caution, they
acknowledged.
However, "the obesity epidemic is a looming crisis
that requires action before all the scientific
evidence is in," Dr. Ludwig concluded. "Simple
solutions are available, and with a comprehensive national strategy, we may be able to implement them
without great sacrifice."
Dr. Baker's study was supported by grants from the National Institute of Diabetes and Digestive and
Kidney Diseases and the Danish Heart Foundation and by the Danish National Science Foundation. Dr.
Baker and co-authors reported no conflicts of interest.
Dr. Bibbins-Domingo's study was supported by a grant from the Flight Attendants Medical Research
Institute, a grant from the Swanson Family Fund to the University of California at San Francisco, and
grants from the Robert Wood Johnson Foundation and the National Heart, Lung, and Blood Institute.
Dr. Ludwig provided no information on conflicts of interest.
Primary source: New England Journal of Medicine
Source reference:
Bibbins-Domingo K, et al "Adolescent overweight and future adult coronary heart disease" N Engl J Med
2007; 357: 2371-9.
Additional source: New England Journal of Medicine
Source reference:
Baker JL, et al "Childhood body-mass index and the risk of coronary heart disease in adulthood" N Engl J
Med 2007; 357: 2329-37.
Additional source: New England Journal of Medicine
Source reference:
Ludwig DS, "Childhood obesity -- the shape of things to come" N Engl J Med 2007; 357: 2325-27.
Related Article(s):

TV Watching Linked to Childhood Hypertension

Weight Loss Maintenance for Kids Benefits from Extended Intervention
Bubble Bursts for Childhood Obesity Prevention Program
Cardiorespiratory Fitness Outdoes BMI as Mortality Predictor
By Judith Groch , Senior Writer, MedPage Today
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San
Francisco
COLUMBIA, S.C., Dec. 4 -- Fitness level, not body fat, may be a stronger predictor of longevity for older
adults, according to investigators here.
During a mean 12-year follow-up of those older than 60, low cardiorespiratory fitness at baseline was a
significant predictor of all-cause mortality independent of overall or abdominal adiposity, Xuemei Sui,
M.D., of the University of South Carolina, and colleagues, reported in the Dec. 5 issue of the Journal of
the American Medical Association.
They found that fit individuals who were obese (those with a BMI of 30.0 to 34.9, abdominal obesity, or an
excessive percent of body fat) had a lower risk of all-cause mortality than did unfit, normal-weight, or lean
individuals.
Action Points

Explain to interested patients that among older individuals, fitness (brisk walking at least 30
minutes or more on most days) was a major predictor of longer life, even if the person was
overweight.
Death rates for those with higher fitness were often less than half the rates for those who were unfit, per
stratum of adiposity, they added.
Prospective studies provide convincing evidence that obesity and physical inactivity each can produce
excess mortality in middle-age patients. However, there had been little data for whether this is also true
for older adults, Dr. Sui said.
So to examine the independent and joint associations among fitness, adiposity, and mortality in men and
women 60 or older, the researchers studied a cohort of 2,603 participants (mean age 64.4, 20% women)
enrolled in the Aerobics Center Longitudinal Study who completed a baseline health examination a some
point from 1979 through 2001.
Fitness was measured by a maximal exercise test, and adiposity was assessed by BMI, waist
circumference, and percent body fat.
Low fitness was defined as the lowest fifth of the sex-specific distribution of maximum duration on an
exercise treadmill.
The distributions of BMI, waist circumference, and percent body fat were grouped for analysis according
to clinical guidelines.
All-cause mortality through Dec. 31, 2003 included 450 deaths during a mean follow-up of 12 years and
31,236 person-years of exposure. Those who died were older, had lower fitness levels, and had more
cardiovascular risk factors than survivors.
Members of the higher fitness groups were for the most part less likely to have risk factors for
cardiovascular disease, such as hypertension, diabetes, or high cholesterol levels. However, the
researchers found no significant differences in adiposity measures.
Fit participants had lower death rates than unfit participants within each stratum of adiposity -- overweight,
waist circumference, and percent body fat, for example -- except for two of the obesity groups.
In most instances, death rates for those with higher fitness were less than half the rates for those who
were unfit, the researchers said.
Fitness had a strong inverse association with mortality, and this pattern was changed little by adjustment
for adiposity or fat distribution. Thus, the researchers said, their primary finding is that both fitness and
BMI were strong and independent predictors of all-cause mortality.
Significantly, upon analyzing the combination of fitness and BMI, they found that higher levels of fitness
were inversely related to all-cause mortality in both normal weight and overweight BMI subgroups.
These individuals included those with a normal waist circumference and those with abdominal obesity,
and those with a normal percentage of body fat and those with an excessive percentage of body fat.
These data, they wrote, suggest that fitness levels in older individuals influence the association of obesity
with mortality.
In reviewing the findings, the researchers reported that death rates per 1,000 person-years, adjusted for
age, sex, and examination year were:
13.9, 13.3, 18.3, and 31.8 across BMI groups of 18.5-24.9, 25.0-29.9, 30.0-34.9, and ≥35.0, respectively
(P=0.01 for trend);
13.3 and 18.2 for normal and high waist circumference (≥88 cm in women; ≥102 cm in men) (P=0.004);
13.7 and 14.6 for normal and high percent body fat ( ≥30% in women; ≥25% in men) (P=0.51);
32.6, 16.6, 12.8, 12.3, and 8.1 across incremental fifths of fitness (P=<0.001 for trend).
The association between waist circumference and mortality persisted after further adjustment for
smoking, baseline health status, and BMI (P=0.02) but not after additional adjustment for fitness
(P=0.86).
Fitness predicted mortality risk after further adjustment for smoking, baseline health, and either BMI,
waist circumference, or percent body fat (P<0.001 for trend).
Study limitations included a focus on individuals who were primarily white and well-educated, had middle
to upper socioeconomic status, and were physically able to complete a maximal exercise test. Thus the
results may not apply to other groups, they said.
Adequate information about diet was lacking, and because of the limited number of women who
participated in the study, the groups were combined, with adjustment made for sex.
In addition, the study focused primarily on all-cause mortality because of the relatively small number of
cause-specific deaths. However, some exploratory cause-specific analyses were done suggesting that
cardiovascular disease and cancer accounted for 74% of all the deaths.
These data provide further evidence regarding the complex long-term relationship among fitness, body
size, and survival. It may be possible to reduce all-cause death rates among older adults, including those
who are obese, by promoting regular physical activity, such as brisk walking for 30 minutes or more on
most days of the week, which would help most individuals enjoy longer life in better health, the
researchers said.
The Aerobics Center Longitudinal Study was supported by National Institutes of Health grants.
Dr. Sui reported no financial conflicts.
Book royalties, honoraria, research grants, and lecture fees for co-authors included those from Human
Kinetics, Jenny Craig, Magellan Health Services, Matria Health Care, BodyMedia, and the University of
North Texas. Some of these fees were donated to the South Carolina Educational Foundation or to other
nonprofit groups.
Primary source: Journal of the American Medical Association
Source reference:
Sui X, et al "Cardiorespiratory fitness and adiposity as mortality predictors in older adults" JAMA 2007;
298: 2507-2516.
Related Article(s):

Cardiovascular Benefits of Exercise Depend Little on Weight Loss

A Little Brisk Walking Gives Benefits to the Sedentary
Heart-healthy diet: 7 steps to
prevent heart disease
Although you might know eating certain foods can increase your heart disease
risk, it's often tough to change your eating habits. Whether you have years of
unhealthy eating under your belt or you simply want to fine-tune your diet, here
are seven heart-healthy diet tips. Once you know which foods to eat more of
and which foods to limit, you'll be on your way toward a heart-healthy diet.
1. Limit unhealthy fats and cholesterol.
Of the possible changes, limiting how much saturated and trans fat you eat is
the most important step you can take to reduce your blood cholesterol and
lower your risk of coronary artery disease. A high blood cholesterol level can
lead to a buildup of plaques in your arteries, called atherosclerosis, which can
increase your risk of heart attack and stroke.
The American Heart Association offers these guidelines for how much
fat and cholesterol to include in a heart-healthy diet:
Type of fat
Recommendation
Saturated fat
Less than 7 percent of your total daily
calories
Trans fat
Less than 1 percent of your total daily
calories
Cholesterol
Less than 300 milligrams a day for
healthy adults; less than 200
milligrams a day for adults with high
levels of low-density lipoprotein (LDL),
or "bad," cholesterol or those who are
taking cholesterol-lowering medication
The best way to reduce saturated and trans fats in your diet is to limit the
amount of solid fats — butter, margarine and shortening — you add to food
when cooking and serving. Use low-fat substitutions when possible for a
heart-healthy diet. For example, top your baked potato with salsa or low-fat
yogurt rather than butter, or use low-sugar fruit spread on your toast instead of
margarine. You may also want to check the food labels of some cookies,
crackers and chips. Many of these snacks — even those labeled "reduced fat"
— may be made with oils containing trans fats. One clue that a food has some
trans fat in it is the phrase "partially hydrogenated" in the ingredient list.
When you do use fats, choose monounsaturated fats, such as olive oil or
canola oil. Polyunsaturated fats, found in nuts and seeds, also are good
choices for a heart-healthy diet. When used in place of saturated fat,
monounsaturated and polyunsaturated fats may help lower your total blood
cholesterol. But moderation is essential. All types of fat are high in calories.
If you're not sure which fats or oils to use when cooking or baking, use
this guide:
Choose
Avoid






Olive oil
Canola oil
Margarine labeled "trans
fat-free"
Cholesterol-lowering
margarine, such as Benecol,
Promise activ or Smart Balance







Butter
Lard
Bacon
Gravy
Cream sauce
Nondairy creamers
Hydrogenated margarine and
shortening
Cocoa butter, found in
chocolate
Coconut, palm, cottonseed and
palm-kernel oils
2. Choose low-fat protein sources.
Lean meat, poultry and fish, low-fat dairy products and egg whites or egg
substitutes are some of your best sources of protein. But be careful to choose
lower fat options, such as skim milk rather than whole milk and skinless
chicken breasts rather than fried chicken patties.
Fish is another good alternative to high-fat meats. Some types of fish — such
as cod, tuna and halibut generally have less total fat, saturated fat and
cholesterol than do meat and poultry. And certain types of fish are heart
healthy because they're rich in omega-3 fatty acids, which can lower blood fats
called triglycerides and may reduce your risk of sudden cardiac death. You'll
find the highest amounts of omega-3 fatty acids in cold-water fish, such as
salmon, mackerel and herring. Other sources are flaxseed, walnuts, soybeans
and canola oil.
Legumes — beans, peas and lentils — also are good sources of protein and
contain less fat and no cholesterol, making them good substitutes for meat.
Substituting soy protein for animal protein — for example, a soy burger for a
hamburger — will reduce your fat and cholesterol intake.
To help you decide which high-protein foods are best, use this guide:
Choose








Skim or low-fat (1 percent) milk
Fat-free or low-fat dairy
products, such as yogurt and
cheese
Egg whites or egg substitutes
Fish, especially fatty,
cold-water fish, such as salmon
Skinless poultry
Legumes
Soybeans and soy products, for
example, soy burgers
Lean ground meats
Avoid









Full-fat milk and other dairy
products
Organ meats, such as liver
Egg yolks
Fatty and marbled meats
Spareribs
Cold cuts
Frankfurters, hot dogs and
sausages
Bacon
Fried, breaded or canned
meats
3. Eat more vegetables and fruits.
Vegetables and fruits are good sources of vitamins and minerals; they are low
in calories and rich in dietary fiber. A diet high in soluble fiber, the kind found in
fruits and vegetables, can help lower your cholesterol and reduce your risk of
heart disease. Vegetables and fruits also contain substances found in plants
that may help prevent cardiovascular disease. Eating more fruits and
vegetables may help you eat less high-fat foods, such as meat, cheese and
snack foods.
Featuring vegetables and fruits in your diet may not be as difficult as you might
think. Keep carrots, cauliflower and broccoli washed and cut in your
refrigerator for quick snacks. Keep apples, bananas, grapes or peaches in a
bowl in your kitchen so that you'll remember to eat them. Choose recipes that
have vegetables or fruits as the main ingredient, such as vegetable stir-fry or
fresh fruit mixed into salads. Even frozen or canned fruits and vegetables are
good choices, provided they don't have lots of added sodium or sugar. Don't
smother vegetables in butter, dressings, creamy sauces or other high-fat
garnishes.
This guide can help you sort out which fruits and vegetables offer the
most health benefits:
Choose



Fresh or frozen vegetables and
fruits
Low-sodium canned vegetables
Canned fruit packed in juice or
water
Avoid




Coconut
Vegetables with creamy sauces
Fried or breaded vegetables
Canned fruit packed in heavy
syrup
4. Select whole grains.
Whole grains are good sources of fiber and other nutrients. Whole grains are
also a source of vitamins and minerals, such as thiamin, riboflavin, niacin,
vitamin E, magnesium, phosphorus, selenium, zinc and iron. Various nutrients
found in whole grains play a role in regulating blood pressure and heart health.
You can increase the amount of whole grains in a heart-healthy diet by making
simple substitutions. For example, choose breads made from 100 percent
whole grain instead of those with refined white flour, whole-wheat pasta over
regular pasta and brown rice instead of white rice. Select high-fiber cereals for
breakfast, such as bran flakes, oats, or shredded wheat, instead of
sugar-sweetened cereals, muffins or doughnuts. And select whole-wheat flour
rather than white flour for baking at home.
Another easy way to add whole grains to your diet is ground flaxseed.
Flaxseeds are small brown seeds that are high in fiber and omega-3 fatty acids,
which can lower your total blood cholesterol. You can easily grind the seeds in
a coffee grinder or food processor and add them to your diet by stirring a
teaspoon of them into yogurt, applesauce or hot cereal.
Use this guide to help you choose cereals, breads, rice or pasta:
Choose


Whole-wheat flour
Whole-grain bread, preferably
100 percent whole-wheat or
Avoid



Muffins
Frozen waffles
Corn bread





100 percent whole-grain bread
High-fiber cereal with 5 or more
grams of fiber per serving
Brown rice
Whole-grain pasta
Oatmeal (steel-cut or regular)
Ground flaxseed










Doughnuts
Biscuits
Quick breads
Granola bars
Cakes
Pies
Egg noodles
Buttered popcorn
High-fat snack crackers
Potato chips
5. Reduce the salt in your food.
Eating a lot of salt can contribute to high blood pressure, a risk factor for
cardiovascular disease. Reducing the salt in your food is an important part of a
heart-healthy diet. The American Heart Association recommends that healthy
adults eat less than 2,300 milligrams of sodium a day (about a teaspoon).
You might think the best way to cut back on salt is to stop reaching for the
shaker. True, but don't forget about the processed foods. Although reducing
the amount of salt you add to food at the table or while cooking is a good first
step, much of the salt you eat comes from canned or processed foods, like
soups and frozen dinners. Eating fresh foods and making your own soups and
stews can reduce the amount of salt you eat. If you like the convenience of
canned soups and prepared meals, look for ones with reduced sodium. Some
brands offer the same soups or meals you already eat with as much as 40
percent less sodium.
Another way to reduce the amount of salt you eat is to choose your
condiments carefully. Reduced-sodium ketchups and soy sauces are available.
Instead of regular table salt, reach for a salt substitute or other herbs and
spices that can flavor your food. If using a salt substitute or reduced-sodium
condiment, it is still important to use it sparingly. The amount of salt, although
reduced, adds up quickly.
Use this guide to help you choose lower salt alternatives:
Choose



Herbs and spices
Salt substitutes
Reduced-salt canned soups or
prepared meals
Avoid


Table salt
Canned soups and prepared
foods, like frozen dinners

Reduced-salt versions of
condiments, such as
reduced-salt soy sauce

Soy sauce
6. Practice moderation.
In addition to knowing which foods to eat, you'll also need to know how much
you should eat. Overloading your plate, taking seconds and eating until you
feel stuffed can lead to eating more calories, fat and cholesterol than you
should. Portions served in restaurants are often more than anyone needs.
Keep track of the number of servings you eat — and use proper serving sizes
— to help control your portions.
A serving size is a specific amount of food, defined by common measurements
such as cups, ounces or pieces. For example, one serving of pasta is 1/2 cup,
or about the size of an ice cream scoop. A serving of meat, fish or chicken is 2
to 3 ounces, or about the size and thickness of a deck of cards. Judging
serving size is a learned skill. You may need to use measuring cups and
spoons or a scale until you're comfortable with your judgment.
A heart-healthy diet is also about balance. A simple rule of thumb is to
remember to keep your portion size for meat, poultry and fish about the size of
a deck of cards. This makes room on your plate for servings of vegetables,
fruits and whole grains.
Allow yourself an indulgence every now and then. Don't let it turn into an
excuse for giving up on your healthy-eating plan. If overindulgence is the
exception, rather than the rule, you'll balance things out over the long term.
What's important is that you eat healthy foods most of the time.
7. Plan ahead: Creating daily menus.
You know what foods to feature in your heart-healthy diet and which ones to
limit. Now it's time to put your plans into action.
Create daily menus using the six strategies listed above. When selecting foods
for each meal and snack, emphasize vegetables, fruits and whole grains.
Choose lean protein sources and limit high-fat and salty foods. Watch your
portion sizes and add variety to your menu choices. For example, if you have
grilled salmon one evening, try a black bean burger the next night. This helps
ensure that you'll get all of the nutrients your body needs. Variety also makes
your meals and snacks more interesting.
Incorporate these seven tips into your life, and you'll continue to find that
heart-healthy eating is both doable and enjoyable. With planning and a few
simple substitutions, you can eat with your heart in mind.
By Mayo Clinic Staff
Mar 20, 2008
© 1998-2008 Mayo Foundation for Medical Education and Research (MFMER).
All rights reserved. A single copy of these materials may be reprinted for
noncommercial personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com,"
"EmbodyHealth," "Reliable tools for healthier lives," "Enhance your life," and
Make a DASH for healthier eating
DASH — do you know of it?
It's an eating plan focused on lowering your sodium (salt) intake. The other key
components include eating foods low in fat, saturated fat, cholesterol, and high
fiber foods — fruits, vegetables, and whole grain products. Lean protein
sources such as lean red meat, poultry, and fish are recommended. Nuts and
seeds are also included. Nutrients of particular interest are potassium,
magnesium, and calcium.
DASH — Dietary Approaches to Stop Hypertension — was introduced in 1997
following extensive research funded by the National Heart, Lung, and Blood
Institute with additional support by the National Center for Research
Resources and the Office of Research on Minority Health, all units of the
National Institutes of Health. The result was convincing evidence that the
DASH eating plan can prevent or help control blood pressure.
Within the last month the "Archives of Internal Medicine" released a report
stating that people with high blood pressure (hypertension) are not
implementing dietary practices to improve their health. Rather their diets tend
to be higher in fat and low in fiber.
One must wonder why more people aren't giving DASH a try when there is
strong evidence that what you eat can prevent adverse outcomes associated
with high blood pressure such as stroke, heart, or kidney damage. Could it be
that most people are unaware of it? Is it the fact that dietary changes are a
challenge to adhere to? Or is it easier to take a pill?
Most of us consume far too much sodium. Share the word about DASH, we
can all eat healthier. As always, your thoughts and comments are welcome.
To your health,