Pediatric Research Update: Childhood Obesity and Cardiovascular Risk

Each month, the OMA Pediatric Committee reviews a pediatric-focused obesity research update to help keep you up to date about the latest findings. This month’s update explores the critical link between childhood obesity and cardiovascular disease, highlighting early markers of vascular aging, social determinants of health, and the latest treatment approaches. Discover key insights into how childhood experiences, systemic factors, and innovative interventions can shape long-term heart health in youth.

Article Summary

This article reveals crucial insights into childhood obesity as major risk factor for heart disease, highlighting hidden dangers and essential strategies every parent and caregiver should know.

Read Full Article

Article Review

This paper focuses on the current research around childhood obesity and CVD, including the most up-to-date information on the public health implications. The article discusses the role of childhood experiences, social factors and other systemic determinants of obesity and cardiometabolic diseases. In addition, the article reviews how the new screening and treatment approaches affect disease prevention and management.

A major component of the article is the graphical abstract that depicts the link between social institutions, childhood adversity, mental health and cardiometabolic disease. This offers a holistic view of the interrelated factors that are contributing to the increasing incidence of pediatric obesity and its consequences on long-term health.

Childhood Obesity and Early Vascular Aging

One of the main topics of the article is how childhood obesity leads to vascular aging. Visceral adiposity is mentioned as a major contributor because it is associated with inflammatory components and ectopic fat deposition. Youth with obesity often have premature markers of vascular aging, including increased carotid intima-media thickness and arterial stiffness. These changes lead to the faster development of atherosclerotic cardiovascular disease (ASCVD) from an early age, which in turn increases the long-term cardiovascular risk. These early markers of vascular deterioration are important and should be recognized to come up with strategies of preventing CVD in the youth.

The article also discusses the social determinants of health in relation to childhood obesity and CVD. The two main areas of concern are food insecurity and adverse childhood experiences (ACEs). Food insecurity is a public health problem that affects approximately 10% of U.S. households, impacting youths with type 1 and type 2 diabetes, those from low-income backgrounds, uninsured families, or families with lower parental education. While, some studies present inconsistent associations between food insecurity and cardiovascular risk; nevertheless, the American Academy of Pediatrics (AAP) and the American Heart Association (AHA) acknowledge the complex and lifetime cardiometabolic risks of food insecurity. These factors underscore the necessity of systemic interventions to guarantee equal access to nutritious food and healthcare services. ACEs are forms of childhood trauma and chronic stress that affect the CVD risk in three main ways: behaviors (e.g. poor diet, physical inactivity, smoking, and inadequate sleep), physiological effects (e.g. systemic inflammation, and hormonal alterations), mental health disorders, and substance abuse. Although the relationship between ACEs and ASCVD is strong, the evidence is primarily based on observational studies. Further work is needed to establish causality and to identify interventions through which the cycle of adversity and poor health can be broken.

Current Treatment Strategies for Childhood Obesity and ASCVD Risk Reduction

The article also reviews the current strategies for the treatment of childhood obesity and the management of ASCVD risk. Lifestyle changes, with or without pharmacological management, are the cornerstone of therapy and are recommended in the guidelines. However there is decreased effect especially for the underserved and minority youth who face barriers to health care, healthy foods, and structured physical activity. Intermittent fasting has been proposed as a dietary approach to manage ASCVD in adults with obesity, but is not recommended for children and adolescents due to the lack of data and potential problems. Nevertheless, new and innovative lifestyle interventions such as the personalized nutrition counselling, culinary medicine, the produce prescription programs, and the mobile health applications suggest potential positive intervention effect to support healthy lifestyles in this population.

Pharmacological and Surgical Treatment

Over the last ten years, there has been a great improvement in the pharmacological and surgical management of pediatric obesity and type 2 diabetes. Liraglutide was approved by the FDA in December 2020 as a pediatric anti-obesity medication, showing small weight loss and enhancement of metabolic and glycemic parameters. Phentermine/topiramate was approved for the chronic management of obesity in children in 2022; it resulted in a 4–8% BMI decrease over 54 weeks. Semaglutide has also presented encouraging results in adolescent clinical trials, with a BMI decrease of 16.1% in 68 weeks. However, there are still many questions regarding the long-term weight loss and the effects on ASCVD. Although not included in this article, liraglutide may now be under consideration for approval for children as young as six years and older, and other medications such as Tirzepatide are being studied for pediatric use. These new pharmacological options are additional to the management of obesity in children and adolescents, but their long-term efficacy and safety have yet to be established in this population. Metabolic and bariatric surgery (MBS) has over 20 years safety and effectiveness data to treatment of severe pediatric obesity. The Teen-LABS study and other similar longitudinal analyses have established that there is substantial improvement in the cardiovascular risk factors after surgery. The most frequent MBS among the adolescents in the United States is vertical sleeve gastrectomy (VSG) and major medical organizations support MBS for severe pediatric obesity. Despite the effectiveness, MBS is not accessible to many patients due to the medical, socio-economic, barriers along with poor reimbursement for care, thus there is a need to increase access for eligible patients.

Research Gaps and Future Directions

Despite much progress, research opportunities in pediatric obesity management remain. One major problem is calculating the long-term cardiovascular consequences from childhood metabolic risk factors. More longitudinal research is needed to establish how early metabolic changes lead to ASCVD in adulthood and to come up with evidence-based treatment guidelines for youth. Current pediatric dyslipidemia guidelines are based on adult ASCVD outcome trials, and there is limited data on whether treating moderate dyslipidemia in youth with obesity and diabetes reduces ASCVD-related morbidity and mortality. Also, the ideal levels of LDL and total cholesterol for children are yet to be well defined as they are based on expert opinion rather than actual data. Future work should also include the identification of reliable markers of early stage ASCVD and vascular aging, as well as the socio-ecological factors that contribute to ASCVD risk in youths. Another emerging field of study is the relationship between childhood obesity, cardiovascular disease risk, and gut microbial dysbiosis through the mechanism of TMAO metabolites. Although initial findings suggest a connection, it is still unknown whether these pathways are causal or correlational. Further research is required to establish the feasibility of manipulating the gut microbiota as a potential approach to preventing obesity-associated cardiovascular risk.

Conclusion

The article highlights the multifactorial association of childhood obesity, social determinants of health and cardiovascular disease risk. Although lifestyle changes are the cornerstone of pediatric obesity management, new pharmacological and surgical interventions are available to help manage obesity and prevent ASCVD. Nevertheless, there are barriers to care that linger, especially for vulnerable youth, which calls for policy-level interventions to address these issues. Future studies should address the following: improving treatment recommendations, measuring biomarkers for early vascular aging, and new approaches such as modulation of the gut microbiota. Thus, the gaps to be filled will be crucial for the formulation of more efficient ways of tackling pediatric obesity and its consequences on the cardiovascular system.