Thursday, May 16, 2013

Ask the Expert

Q: What is the risk for heart disease in adults with Down syndrome who do not have congenital heart problems (i.e., birth defects of the heart) and, specifically, atherosclerosis (hardening of the arteries)?

A: Adult patients having Down syndrome but no evidence of congenital heart disease are at the same risk for eventual development of atherosclerotic cardiovascular disease (coronary artery disease, stroke, peripheral artery disease, and aortic aneurysms) as compared to individuals who do not have Down syndrome.  Risk factors for the development of coronary artery disease and stroke include: 
(1) family history of early heard attacks or strokes,
(2) hyperlipidemia,
(3) hypertension,
(4) smoking,
(5) diabetes,
(6) obesity, and
(7) sedentary life style. 
The American Academy of Pediatrics (Pediatrics, July, 2008, Vol 122, No 1: 198-208) recommends a screening fasting lipid panel in all children by age 10 years, and as early as 2 years of age if there is a positive family of early atherosclerotic disease.  Atherosclerosis is a nutritional disease of childhood and decreasing the incidence of coronary artery disease in mid- and late-life necessitates establishing healthy habits in nutrition and lifestyle early in life.  (Berenson, et al; “Atherosclerosis: A Nutritional Disease of Childhood”, American Journal of Cardiology, 1998; 82:22T-29T)  The Muscatine, Iowa Study (Clarke, et al; “Changes in ponderosity and blood pressure in childhood: the Muscatine Study”; American Journal of Epidemiology, 1986; Vol 124, No 2, 124:195-206) confirmed that obese children have more significant hypertension and hyperlipidemia.  Longitudinal studies indicate that obesity acquired in childhood is predictive of worsened adult obesity and the development of coronary artery disease.  If children become overweight before age 8 years, obesity in adulthood is likely to be more severe.  Overweight children and adolescents may experience other health conditions associated with increased weight, which include asthma, liver damage, sleep apnea, and type 2 diabetes.  Obesity also puts children at long-term higher risk for other debilitating chronic conditions such as stroke; breast, colon, and kidney cancer; musculoskeletal disorders; and gall bladder disease.  The fundamental cause of obesity is a greater imbalance between energy intake (overeating) and energy expenditure (lack of exercise).

We must, therefore, encourage our children with Down syndrome to exercise more and decrease caloric intake to avoid obesity as a cause of developing atherosclerotic heart disease.  We need to treat the development of hypertension or hyperlipidemia aggressively.  If these patients develop insulin insensitivity (type 2 diabetes), this also needs to be aggressively managed.  A significant number of patients with Down syndrome may also have low thyroid levels (hypothyroidism) which may accentuate their tiring easily and obesity.  Blood tests are indicated to make certain that thyroid function in maintained normal.

Randall L. Caldwell, M.D.

Thursday, May 9, 2013

Ask the Expert: Body Mass Index

Q: We just had my son’s 4-year old check-up and his BMI is above the 95%ile. What does BMI mean and what can we do to help him with his weight?

A: BMI stands for Body Mass Index. It is a number that shows body weight adjusted for height. Children’s body proportions change as they mature, so BMI for children is gender and age-specific. Children with BMI at the 85-95 percentile are considered at risk for overweight or obesity, while children at or above the 95 percentile (heavier body proportions than 95% of kids the same age and gender) are considered overweight. Children and adults with DS are at higher risk of obesity, but there are many things you can do to help. If your child currently drinks whole or 2% milk, change to skim milk. Encourage your child to drink water when thirsty, rather than juice, soda or sweetened fruit drinks. Limit fast food – it tends to be high in fat & calories. Encourage healthy snacks, like fresh fruits and vegetables, or fat free yogurt, and limit the amount of “junk food” in the house. Model healthy eating behavior yourself. Limit TV watching and encourage opportunities for physical activity. Finally, although you may be tempted to put your little guy on a “diet” – don’t do it! Offer healthy food choices at regular meals and snack times. Let him eat what he wants. Limiting portions other than dessert or intake tends to backfire and kids will often overeat later when they get the chance.

Maria Stanley, M.D.
Ann Whitehill Down Syndrome Program
Riley Hospital for Children
Assistant Professor of Clinical Pediatrics
Indiana University School of Medicine