Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Full Report

Introduction

The Expert Panel's goal was development of comprehensive evidence-based guidelines addressing all of the major CV risk factors to assist pediatric care providers—pediatricians, family practitioners, nurses and nurse practitioners, physician assistants, and registered dietitians—in both the promotion of CV health and the identification and management of specific risk factors from infancy to young adulthood. An initial assessment indicated that an innovative approach would be needed to develop a comprehensive integrated product for the following reasons:

  • A focus on CV risk reduction in children and adolescents addresses a disease process—atherosclerosis—in which the clinical end point of manifest cardiovascular disease (CVD) occurs much later in life. Therefore, the recommendations would need to address two different goals: the prevention of risk factor development—primordial prevention—and the prevention of future CVD by effective management of identified risk factors—primary prevention.
  • Most systematic evidence reviews address one or, at most, a small number of finite questions addressing the impact of specific interventions on specific health outcomes. A rigorous literature search and review process involving explicit inclusion and exclusion criteria often results in only a handful of in-scope articles for inclusion in the review. These reviews seek direct, rigorous evidence of the causal effect of an intervention on the designated outcomes or indirect evidence in the form of a chain of causal evidence through surrogate or other intermediate outcomes linking the interventions to the outcomes of interest. Often, in-scope evidence is limited to randomized controlled trials (RCTs), systematic reviews, and meta-analyses published over a defined time period. There is a defined format for abstracting studies, grading the evidence, and presenting the results. The level of evidence leads to the conclusions and recommendations.
  • Because of the scope of the effort by the Expert Panel, this evidence review needed to address a broader array of questions concerning the development, progression, and management of multiple CV risk factors extending from before birth to 21 years of age, including studies with followup into later adulthood—a scope and breadth that had known gaps in the evidence base. In part, this task required assembling and appraising the body of evidence pertaining to the role of single risk factors and risk factor combinations in childhood in the development and progression of atherosclerosis from childhood and adolescence to adulthood. Rather than relying solely on RCTs, much of the evidence for guidelines in youth is available from epidemiologic observational studies, which must be included in the review. In addition, this review required critical appraisal of the body of evidence that addresses the impact of managing risk factors in childhood on the development and progression of atherosclerosis. Finally, because of known gaps in the evidence base relating risk factors and risk reduction in childhood to clinical events in adulthood, the review had to include the available evidence justifying the evaluation and treatment of risk factors in childhood. The process of identifying, assembling, and organizing the evidence was extensive; the review process was complex; and conclusions could be developed only by interpretation of the body of evidence. Thus, there was explicit Expert Panel involvement throughout the evidence review process.

State of the Science: Cardiovascular Risk Factors and the Development of Atherosclerosis in Childhood

This section presents the results of a critical review of the evidence that atherosclerosis begins in childhood and that this process, from its earliest phases, is related to the presence and intensity of known cardiovascular (CV) disease (CVD) risk factors (see Table 2–1). As described in Section I. Introduction, the literature search for these Guidelines addressed 14 critical questions (I. Introduction, Table 1–1). Of these, the first nine pertain to evidence that atherosclerosis begins in childhood and that early atherosclerosis is associated with the presence and intensity of identified risk factors; it is this evidence that is reviewed here. A conceptual model for CVD prevention by pediatric care providers beginning in childhood was developed based on the evidence review.

Screening for Cardiovascular Risk Factors

Reducing lifetime risk for cardiovascular (CV) disease (CVD) is the principle that underlies all CVD prevention strategies, including those beginning in childhood. Especially important is the prevention of CVD events occurring relatively early in life (e.g., before ages 50–60 years). In these Guidelines, the Expert Panel highlights two complementary prevention strategies: (1) primordial prevention, which seeks to prevent the development of risk factors in all children and (2) primary prevention, a high-risk strategy aimed at reducing risk in children with dyslipidemia, hypertension, obesity, diabetes mellitus, or other identified factors associated with accelerated development of atherosclerotic CVD. In contrast with primordial prevention, primary prevention requires knowledge of risk factor levels through the screening of individuals. This section focuses on the principles of screening within the context of the need for practical clinical recommendations even in the presence of insufficient evidence.

Family History of Early Atherosclerotic Cardiovascular Disease

INTRODUCTION

This section of the Guidelines provides recommendations to pediatric care providers on obtaining and using family histories for early cardiovascular (CV) disease (CVD) in managing CV health in their patients. The section begins with background information on the role of a positive family history of early atherosclerotic disease in evaluating risk for future heart disease. The evidence review and the development process for the Guidelines are outlined in Section I. Introduction and are described in detail in Appendix A. Methodology. As described, the evidence review augments a standard systematic review, where findings from the studies reviewed constitute the basis for recommendations, with each study described in detail. This evidence review combines a systematic review with an Expert Panel consensus process that incorporates and grades the quality of all relevant data based on preidentified criteria. Because of the large volume of included studies and the diverse nature of the evidence, the Expert Panel also provides a critical overview of the studies reviewed for each risk factor, highlighting those that, in its judgment, provide the most important information. Detailed information from every study has been extracted into the evidence tables, which will be available at http://www.nhlbi.nih.gov/health-pro/guidelines/current/cardiovascular-health-pediatric-guidelines/index.htm. The conclusions of the evidence review are summarized and graded, and the section ends with the Expert Panel's age-specific family history recommendations. Where evidence is inadequate, recommendations reflect a consensus of the Expert Panel. References are listed sequentially at the end of the section, with references from the evidence review identified by unique PubMed identifier (PMID) numbers in bold text. Additional references do not include the PMID number.

Nutrition and Diet

INTRODUCTION

This section of the Guidelines provides recommendations to pediatric care providers on nutrition and diet for the promotion of cardiovascular (CV) health for their pediatric patients and families. The section begins with important background information on nutrition and diet from the 2010 Dietary Guidelines for Americans (2010 DGA) for healthypeople, including healthy children.[1] This is followed by the Expert Panel's summary of the evidence it reviewed relative to nutrition and diet for children, which collectively provides a rationale for initiating prevention efforts early in life. The evidence review and development processes for these Guidelines are described in detail in Section I. Introduction and in Appendix A. Methodology. More than the standard systematic review where findings from the included studies constitute the only basis for recommendations, these Guidelines combine the findings from a systematic review of the evidence with the Expert Panel's consensus process. The quality of all relevant data is incorporated and graded based on preidentified criteria. Because of the large number of included studies and the diverse nature of the evidence, the Expert Panel also provides a critical overview of the studies reviewed for this section, highlighting those that, in its judgment, provide the most important information. Detailed information from each study has been extracted into the evidence tables, which will be available at http://www.nhlbi.nih.gov/health-pro/guidelines/current/cardiovascular-health-pediatric-guidelines/index.htm. The conclusions of the Expert Panel's review of the evidence are then summarized and graded, followed by age-based recommendations for nutrition and diet in Table 5–2. Evidence-Based Dietary Recommendations for Patients of Pediatric Care Providers: Cardiovascular Health Integrated Lifestyle Diet (CHILD 1). The Expert Panel accepts the 2010 DGA as containing appropriate recommendations for diet and nutrition in children 2 years and older. The recommendations in these Guidelines are intended for pediatric care providers to use with their patients to address CV risk reduction. Where evidence is inadequate, recommendations are based on a consensus of the Expert Panel. The recommendations therefore represent the best available evidence when that exists and expert consensus opinion when it does not. References are listed sequentially at the end of the section. References from the evidence review are identified by a unique PubMed identifier (PMID), which appears in bold font. Additional references do not include the PMID number. There is obvious overlap with the nutrition information contained in other sections of these Guidelines; additional specific dietary information relative to lipids, blood pressure (BP), and obesity is located in Section VIII. High Blood Pressure, Section IX. Lipids and Lipoproteins, andSection X. Overweight and Obesity.

Physical Activity

INTRODUCTION

This section of the Guidelines provides recommendations to pediatric care providers on physical activity relative to cardiovascular (CV) health in children and adolescents. The section begins with background information on the association between physical activity levels and cardiovascular disease. This is followed by the Expert Panel's summary of the evidence review of the association between physical activity and sedentary behavior and CV risk factors and the randomized controlled trials (RCTs) addressing behavior change relative to both physical activity and sedentary time. The evidence review and the Guidelines development processes are outlined in Section I. Introduction and are described in detail in Appendix A. Methodology. As described, the evidence review augments a standard systematic review where the findings from the studies reviewed constitute the only basis for recommendations, with each study described in detail. This evidence review combines a systematic review with an Expert Panel consensus process that incorporates and grades the quality of all relevant data based on preidentified criteria. Because of the large volume of included studies and the diverse nature of the evidence, the Expert Panel also provides a critical overview of the studies reviewed for each risk factor, highlighting those that, in its judgment, provide the most important information. Detailed information from each study has been extracted into the evidence tables and will be available at http://www.nhlbi.nih.gov/health-pro/guidelines/current/cardiovascular-health-pediatric-guidelines/index.htm. The conclusions of the Expert Panel's review of the evidence are summarized and graded, and the section ends with age-specific recommendations. Where evidence is inadequate, recommendations are a consensus of the Expert Panel. References are listed sequentially at the end of the section, with references from the evidence review identified by unique PubMed identifier (PMID) numbers in bold text. Additional references do not include the PMID number.

Tobacco Exposure

INTRODUCTION

This section of the Guidelines provides recommendations to pediatric care providers on limiting tobacco exposure in their child and adolescent patients. The section begins with background information on the importance of tobacco dependence as a risk factor for cardiovascular disease (CVD). This is followed by the Expert Panel's summary of the evidence review relative to tobacco exposure. The evidence review and the development process for the Guidelines are outlined in Section I. Introduction and are described in detail in Appendix A. Methodology. As described, the evidence review augments a standard systematic review where the findings from the studies reviewed constitute the only basis for recommendations with each study described in detail. This evidence review combines a systematic review with an Expert Panel consensus process that incorporates and grades the quality of all relevant data based on preidentified criteria. Because of the large volume of included studies and the diverse nature of the evidence, the Expert Panel also provides a critical overview of the studies reviewed for each risk factor, highlighting those that, in its judgment, provide the most important information. Detailed information from each study has been extracted into the evidence tables. The complete evidence tables will be available online at http://www.nhlbi.nih.gov/health-pro/guidelines/current/cardiovascular-health-pediatric-guidelines/index.htm. The conclusions of the Expert Panel's review of the evidence are then summarized and graded, and the section ends with age-based recommendations to prevent tobacco exposure. References are listed sequentially at the end of the section, with references from the evidence review identified by unique PubMed identifier (PMID) numbers in bold text. Additional references do not include the PMID number.

High Blood Pressure

INTRODUCTION

This section of the Guidelines provides recommendations to pediatric care providers on the evaluation and treatment of high blood pressure (BP) in their child and adolescent patients. Because a recent National Heart, Lung, and Blood Institute (NHLBI) task force report addresses this subject,[1] this section differs from the rest of the sections in the Guidelines in that the evidence review was limited to the past 6 years, as described below. The results of this limited evidence review are summarized by the Expert Panel in this section, with detailed information from each study extracted into the evidence tables, which will be available at http://www.nhlbi.nih.gov/health-pro/guidelines/current/cardiovascular-health-pediatric-guidelines/index.htm. The conclusions of the Expert Panel's review of the evidence are summarized, and the section ends with age-specific recommendations for BP measurement and diagnosis and treatment of hypertension.

Lipids and Lipoproteins

INTRODUCTION

This section of the Guidelines provides recommendations to pediatric care providers on lipid management in their patients. The section begins with background information about the association between dyslipidemia and atherosclerosis and the changing clinical picture of dyslipidemia in childhood. This is followed by the Expert Panel's written synopses of the evidence review relative to lipids in five subsections:

  1. Relationship between dyslipidemia and atherosclerosis
  2. Lipid and lipoprotein assessment in childhood and adolescence
  3. Overview of the dyslipidemias
  4. Dietary treatment of dyslipidemias
  5. Pharmacologic treatment of dyslipidemias

This evidence review and the development process for the Guidelines are outlined in Section I. Introduction and are described in detail in Appendix A. Methodology. As described, the evidence review here augments a standard systematic review where the findings from the studies reviewed constitute the only basis for recommendations with each study described in detail. This evidence review combines a systematic review with an Expert Panel consensus process that incorporates and grades the quality of all relevant data based on preidentified criteria. Because of the large volume constituted by the included studies and the diverse nature of the evidence, the Expert Panel also provides a critical overview of the studies reviewed for each of the five subsections, highlighting those that in its judgment provide the most important information. Detailed information from each study has been extracted into the evidence tables, which will be available at http://www.nhlbi.nih.gov/health-pro/guidelines/current/cardiovascular-health-pediatric-guidelines/index.htm. The conclusions of the Expert Panel's review of the evidence are summarized and graded at the end of each subsection, followed by age-specific recommendations. Where evidence is inadequate, recommendations are a consensus of the Expert Panel. References are listed sequentially at the end of this section, with references from the evidence review identified by unique PubMed identifier (PMID) numbers in bold text. Additional references do not include the PMID number.

Overweight and Obesity

INTRODUCTION

This section of the Guidelines provides recommendations to pediatric care providers on management of overweight and obesity in their patients. The section begins with background information on the current prevalence of overweight and obesity in childhood and the association between childhood overweight and obesity and cardiovascular (CV) risk factors. This is followed by a subsection addressing the identification of overweight and obesity and then individual subsections on the prevention and treatment of overweight and obesity in childhood, with the Expert Panel's summaries of the evidence reviews in each of these areas. The evidence review and the development process for the Guidelines are outlined in Section I. Introduction and are described in detail in the Appendix. Methodology. This evidence review combines a systematic review with an Expert Panel consensus process that incorporates and grades the quality of all relevant data based on preidentified criteria. Because of the large volume of included studies and the diverse nature of the evidence, the Expert Panel also provides a critical overview of the studies reviewed for each risk factor, highlighting those that in its judgment provide the most important information. Detailed information from each study has been extracted into the evidence tables, which will be available at http://www.nhlbi.nih.gov/health-pro/guidelines/current/cardiovascular-health-pediatric-guidelines/index.htm. Each subsection ends with the conclusions of the review, grading of the evidence, and age-specific recommendations for the evaluation, prevention, and treatment of overweight and obesity in pediatric practice. Where evidence is inadequate, recommendations are a consensus of the Expert Panel. References are listed sequentially at the end of the section, with references from the evidence review identified by unique PubMed identifiers (PMID) in bold text. Additional references do not include the PMID number.

Diabetes Mellitus and Other Conditions Predisposing to the Development of Accelerated Atherosclerosis

INTRODUCTION

This section of the Guidelines provides recommendations for pediatric care providers on managing cardiovascular (CV) risk factors in children and adolescents with diabetes mellitus and other conditions that predispose them to accelerated atherosclerosis. The evidence review did not address management of hyperglycemia, and this is not addressed in the recommendations. The section begins with background information on the importance of diabetes as a risk factor for CV disease (CVD). This is followed by the Expert Panel's summary of the evidence review relative to diabetes, separated for type 1 and type 2 diabetes mellitus, and then by a subsection on other predisposing conditions. The evidence review and the development process for the Guidelines are outlined in the Section I. Introduction and are described in detail in Appendix A. Methodology. As described, the evidence review augments a standard systematic review, where the findings from the studies reviewed constitute the only basis for recommendations, with each study described in detail. This evidence review combines a systematic review with an Expert Panel consensus process that incorporates and grades the quality of all relevant evidence based on preidentified criteria. Because of the diverse nature of the evidence, the Expert Panel provides a critical overview of the studies reviewed for each risk factor. Detailed information from each study has been extracted into the evidence tables, which will be available at http://www.nhlbi.nih.gov/health-pro/guidelines/current/cardiovascular-health-pediatric-guidelines/index.htm. Following its review of the limited available evidence for this subject, the Expert Panel elected to employ expert opinion by expanding on the recommendations of the 2006 guidelines from the American Heart Association (AHA),[1] which addressed CV risk management in high-risk pediatric patients, including those with diabetes. This approach is described in detail in this section, relative to the management of other conditions predisposing to the development of accelerated atherosclerosis. References are listed sequentially at the end of the section, with references from the evidence review identified by unique PubMed identifier (PMID) number in bold text. Additional references do not include the PMID number.

Risk Factor Clustering and the Metabolic Syndrome

INTRODUCTION

This section of the Guidelines provides recommendations to pediatric care providers on an approach to the metabolic syndrome in children and adolescents. The evidence review and the development process for the Guidelines are outlined in Section I. Introduction and are described in detail in Appendix A. Methodology. This section begins with background information on the prevalence of the risk factor cluster known as the metabolic syndrome. This is followed by the Expert Panel's summary of the evidence review on the metabolic syndrome cluster and its recommendations for management in pediatric practice. The complete evidence tables will be available at http://www.nhlbi.nih.gov/health-pro/guidelines/current/cardiovascular-health-pediatric-guidelines/index.htm. Because of the paucity of the evidence, recommendations are a consensus of the Expert Panel. References are listed sequentially at the end of the section, with references from the evidence review identified by unique PubMed identifier (PMID) number in bold text. Additional references do not include the PMID number.

Perinatal Factors

INTRODUCTION

This section of the Guidelines provides recommendations to pediatric care providers on management of perinatal factors that predispose children to accelerated atherosclerosis. The section begins with background information on the role of pediatric care providers in perinatal risk exposure and the decision to focus on maternal smoking cessation. This is followed by the Expert Panel's summary of the evidence review. The evidence review and the development process for the Guidelines are outlined in Section I. Introduction and are described in detail in Appendix A. Methodology. As described, the evidence review augments a standard systematic review, whereby the findings from the studies reviewed constitute the only basis for recommendations, with each study described in detail. This evidence review combines a systematic review with an Expert Panel consensus process that incorporates and grades the quality of all relevant data based on preidentified criteria. Because of the large volume of the included studies and the diverse nature of the evidence, the Expert Panel also provides a critical overview of the studies for each risk factor, highlighting those that, in its view, provide the most important information. Detailed information from each study has been extracted into the evidence tables, which will be available at http://www.nhlbi.nih.gov/health-pro/guidelines/current/cardiovascular-health-pediatric-guidelines/index.htm. This section ends with the conclusions of the review, grading of the evidence, and the recommendations. Where evidence is inadequate, the recommendations are the consensus opinion of the Expert Panel. References are listed sequentially at the end of the section, with references from the evidence review identified by unique PubMed identifier (PMID) number in bold text. Additional references do not include the PMID number.

Inflammatory Markers

Because inflammation is an important part of the atherosclerotic process in adults, it was included as an independent risk factor for the evidence review, with specific inflammatory markers identified as outcome measures, as outlined in Appendix A. Methodology. No systematic reviews, meta-analyses, or randomized controlled trials (RCTs) that addressed inflammation in children or adolescents were identified. A small number of RCTs and observational studies included measurement of selected inflammatory markers, and these were reviewed. The Expert Panel concluded that the available evidence was not sufficient either to make any statement regarding the role of inflammation in atherosclerosis, as assessed by measurement of inflammatory markers in childhood, or to include any recommendation regarding measurement of inflammatory markers in the pediatric age group.

Integrated Cardiovascular Health Schedule*

Risk factor

Age
Birth–12 m

Age
1–4 y

Age
5–9 y

Age
9–11 y

Age
12–17 y

Age
18–21 y

Family history (FHx) of early CVD

 

At age 3 y, evaluate FHx for early CVD: parents, grandparents, aunts/uncles, M –55 y, F – 65 y. Review with parents, refer prn.
(+) FHx identifies children for intensive CV RF attention.

Update at each nonurgent health encounter.

Reevaluate FHx for early CVD in parents, grandparents, aunts/uncles,
M – 55 y, and
F – 65 y.

Update at each nonurgent health encounter.

Repeat FHx evaluation with patient.

Tobacco exposure

Advise smoke-free home; offer smoking cessation assistance or referral to parents.

Continue active antismoking advice with parents. Offer smoking cessation assistance and referral as needed.

Begin active antismoking advice with child.

Assess smoking status of child.
Active antismoking counseling or referral as needed.

Continue active antismoking counseling with patient. Offer smoking cessation assistance or referral as needed.

Reinforce strong antismoking message.
Offer smoking cessation assistance or referral as needed.

Nutrition/diet

Support breastfeeding as optimal to age 12 m if possible. Add formula if breastfeeding decreases or stops before age 12 m.

Age 12–24 m, may change to cow's milk with % fat per family and pediatric care provider.
After age 2 y, fat-free milk for all; juice –4 oz/d; transition to CHILD 1* Diet by age 2 y.

Reinforce CHILD 1* diet messages.

Reinforce CHILD 1* diet messages as needed.

Obtain diet information from child and use to reinforce healthy diet and limitations and provide counseling as needed.

Review healthy diet with patient.

Growth, overweight/
obesity

Review FHx for obesity – Discuss wt for ht tracking, growth chart, healthy diet.

Chart ht/wt/BMI à classify wt by BMI from age 2 y; review with parent.

Chart ht/wt/BMI and review with parent.
BMI – 85th %ile, crossing %iles, intensify diet/activity focus x 6 m. If no change – RD referral, manage per obesity algorithms.
BMI– 95th %ile, manage per obesity algorithms.

Chart ht/wt/BMI and review with parent and child.
BMI – 85th %ile, crossing %iles, intensify diet/activity focus x 6 m. If no change – RD referral, manage per obesity algorithms.
BMI – 95th %ile, manage per obesity algorithms.

Chart ht/wt/BMI and review with child and parent.
BMI – 85th %ile, crossing %iles, intensify diet/activity focus x 6 m. If no change – RD referral, manage per obesity algorithms.
BMI – 95th %ile, manage per obesity algorithms.

Review ht/wt/BMI and norms for health with patient.
BMI – 85th %ile, crossing %iles, intensify diet/activity focus x 6 m. If no change – RD referral, manage per obesity algorithms.
BMI – 95th %ile, manage per obesity algorithms.

Lipids

No routine lipid screening.

Obtain fasting lipid profile only if FHx (+), parent with dyslipidemia, any other RFs (+), or high-risk condition.

Obtain fasting lipid profile only if FHx (+), parent with dyslipidemia, any other RFs (+), or high-risk condition.

Obtain universal lipid screen with nonfasting non-HDL = TC – HDL, or fasting lipid profile – Manage per lipid algorithms as needed.

Obtain fasting lipid profile if FHx (+), parent with dyslipidemia, any other RFs (+), or high-risk condition; manage per lipid algorithms as needed.

Measure nonfasting non-HDL-C or fasting lipid profile in all x 1 – Review with patient; manage with lipid algorithms/ATP as needed.

Blood pressure

Measure BP in infants with renal/urologic/ cardiac diagnosis or Hx of neonatal ICU.

Measure annual BP in all from age 3 y; chart for age/gender/ht %ile and review with parent.

Check BP annually and chart for age/gender/ht – Review with parent; work up and/or manage per BP algorithm as needed.

Check BP annually and chart for age/gender/ht – Review with parent, work up and/or manage per BP algorithm as needed.

Check BP annually and chart for age/gender/ht – Review with
adolescent and parent, work up and/or manage per BP algorithm as needed.

Measure BP – Review with patient. Evaluate and treat as per JNC 7 guidelines.

Physical activity

Encourage parents to model routine activity. No screen time before age 2 y.

Encourage active play; limit sedentary/ screen time to – 2 h/d. No TV in bedroom.

Recommend MVPA – 1h/d; limit screen/sedentary time to – 2 h/d.

Obtain activity Hx from child à recommend MVPA – 1 h/y; screen/sedentary time – 2 h/d.

Use activity Hx with adolescent to reinforce MVPA – 1 h/d, leisure screen time – 2 h/d.

Discuss lifelong activity, sedentary time limits with patient.

Diabetes

 

 

 

Measure fasting glucose per ADA guidelines, refer to endocrinologist as needed.

Measure fasting glucose per ADA guidelines, refer to endocrinologist as needed.

Obtain fasting glucose if indicated, refer to endocrinologist as needed.

* The Full and Summary Report of the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents also may be found on the NHLBI Web site: http://www.nhlbi.nih.gov/

Implications of The Guidelines For Public Policy, Reimbursement, Medical Education, and Research

These Guidelines for the reduction of risk of cardiovascular (CV) disease (CVD) in children and adolescents provide an important, up-to-date, evidence-based framework for implementation in primary care offices and in specialty referral programs for higher risk patients. We anticipate that clinical implementation will result in the improvement of CV health in children and adolescents, but the Expert Panel recognizes that releasing clinical guidelines will not be sufficient to optimize CV health in children. From the standpoint of population health, most CV events occur in individuals with moderate risk rather than in those with extreme risk; therefore, physician-based, high-risk targeted approaches will not be sufficient to control the CVD epidemic. Environmental factors strongly influence risk. The home environment, built environment, food industry, media, advertising, tax structure, schools, and cultural differences all influence the adoption and maintenance of behaviors related to CV health. Insufficient numbers of registered dietitians and other health care providers, such as physician assistants and nurses with training in pediatrics, inadequate resources for the comprehensive management of obesity, and inadequate reimbursement for preventive services will all hamper efforts by health care providers to implement guidelines in the clinical setting.

Appendix A. Methodology

I. Background

For more than 35 years, the National Heart, Lung, and Blood Institute (NHLBI) has supported the development of clinical guidelines related to reducing cardiovascular (CV) risk. In October 2006, NHLBI Director Elizabeth Nabel, M.D., appointed an Expert Panel to develop an integrated clinical guideline addressing the known pediatric risk factors for the development of atherosclerosis to be used by pediatric care providers in caring for their patients. The goal of the guideline was to make it possible for the known CV risk factors to be identified and managed as part of routine pediatric care. The Expert Panel was chaired by Stephen R. Daniels, M.D., Ph.D., and included representatives from the medical specialties of pediatrics, family medicine, internal medicine, nutrition, epidemiology, and nursing—from both academic medicine and private practice. Previous NHLBI-facilitated CV risk-reduction guidelines for hypertension and cholesterol in children and adolescents were developed by expert panel consensus based on a traditional literature review and dealt with a single clinical topic. These guidelines differed in that a formal systematic review (SR) of the evidence initiated the process of recommendation development.