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According to the National Center for Health Statistics’ 2008 report, 32 percent of children and teenagers ages 2 to 19 (about 23 million) are overweight or obese. At the same time, there’s been an increase in children with hypertension and hyperlipidemia. Here, Sarah D. de Ferranti, MD, MPH, director of the Preventive Cardiology Clinic at Children’s Hospital Boston, discusses the connections between the conditions and the steps clinicians can take to prevent and treat them.
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Start by asking, “Is this actually hypertension or just elevated blood pressure (BP)?” Measuring BP is tricky. Make sure you have the right size cuff and make clinical decisions based on an auscultated BP, not oscillometric or dynamat (which tend to overestimate the true BP). Confirm the elevated measurements. We usually recommend three BP measurements per visit over three visits to verify hypertension. If the patient has symptoms that might be related to elevated BP (frequent headaches or visual changes), evaluations need to move quickly.
Evaluate for other diseases that might lead to elevated BP. The most common is renal disease. Patients with hypertension need to have an electrolyte panel with blood urea nitrogen (BUN) and creatinine, a urinalysis and possibly a renal ultrasound. This depends on the patient’s age, the severity of the BP elevation and whether the patient is overweight. For overweight adolescents with mild BP elevations, I might hold off on the ultrasound unless I feel we need medication to lower the patient’s BP.
Recommend a nutritionist to make sure the patient isn’t getting too much salt and that he’s getting adequate amounts of fruits, vegetables and fiber. I recommend plenty of aerobic exercise for mild hypertension. If a patient is severely hypertensive, I don’t recommend vigorous exercise until the BP is controlled.
For mild BP without signs of related medical problems, stick with lifestyle change for at least six months or longer, if progress is being made. If the BP elevation is severe, medication should be considered. There’s no one single medicine that we recommend using first. For overweight patients with elevated BP who might be at risk for metabolic syndrome or diabetes, I tend to start with an ace inhibitor. If you use them, be sure you know the electrolytes, BUN and creatinine beforehand and repeat those values one to two weeks after starting medication to look for increasing creatinine or potassium. In evaluation for hypertension, you’ll also want an EKG to be sure there are no signs of left ventricular hypertrophy. We generally do an echocardiogram to look at the left ventricular mass when someone has clear stage 1 or 2 hypertension.
Many times, it’s connected to being overweight, although there are patients in whom that’s not the reason for either condition. Overweight patients tend to have a particular type of hyperlipidemia: They have low HDL and high triglycerides, and the LDL is less effective. Patients who have hypertension related to their extra weight usually show mild to moderate elevations in blood pressure, affecting systolic BP more the diastolic BP.
For nearly all patients, hyperlipidemia is asymptomatic, so you have to screen for it. Since it’s a risk factor for heart disease, screening is recommended after age 2. The most recent recommendation from the AAP is screening every three to five years with a fasting lipid profile if patients have a family history of hypercholesterolemia or early heart disease, or in kids who are at risk due to being overweight or have insulin resistance or hypertension.
That’s a subject of a lot of debate. A lipid profile is most useful when fasting, but a child who comes in the afternoon isn’t fasting. An alternative may be non-fasting testing using a total cholesterol and HDL, but you don’t catch the whole picture of hypertriglyceridemia, which frequently affects overweight kids. You also can’t test for diabetes with non-fasting screening, which is also relevant.
The first step is nearly always dietary modification with exercise. Eliminate certain types of foods depending on their lipid profile. If a child has an elevated LVL, eliminate trans fats. If she has a low HDL, increase her exercise and intake of monounsaturated fats. If a child has elevated triglycerides, she needs to limit refined starches and carbohydrates, switch to a more whole-grain diet and eliminate sugar-sweetened beverages, excess starches and desserts.
If you’re considering using medications, we’re happy to treat these patients because of the side effects they may cause. The decision to begin medication needs to be discussed with the family. For hypertension, there’s more urgency because of the risk of stroke or left ventricular hypertrophy during childhood. For anything above mild hypertension, we suggest obtaining the tests mentioned above, which are often easier for us to facilitate at Children’s. I’m interested in seeing hypertension patients early, in order to prevent them from getting left ventricular hypertrophy.
Dr. de Ferranti is currently accepting patients for her clinical study about the nutritional treatment of overweight adolescents with cardiovascular risk factors. Contact Erica Denhoff at 617-355-0485 or erica.denhoff@cardio.chboston.org for more information.
More information: childrenshospital.org/prevcardio
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