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Background/aims: Efficient and effective participant recruitment is key for successful clinical research. Adolescent and emerging adult recruitment into clinical trials can be particularly challenging, especially when targeting underrepresented groups. This study aimed to determine the most successful recruitment strategies from those employed during a pediatric trial testing the efficacy of a behavioral intervention on adiposity and cardiovascular disease risk., Methods: We determined the effectiveness, cost, and diversity of the final research population by each recruitment method utilized in the EMPower trial, a randomized clinical trial designed to test the effect of a technology-delivered behavioral Healthy Lifestyle intervention on adiposity, blood pressure, and left ventricular mass among adolescents and emerging adults with overweight or obesity. Effectiveness was determined by respondent yield (RY; number of respondents/number contacted), scheduled yield (SY; number scheduled for a baseline visit/number of respondents), enrollment yield (EY; number enrolled/number of respondents), and retention (number completed/number enrolled). Cost-effectiveness of each recruitment method was calculated and demographics of participants recruited via each method was determined., Results: A minimum of 109,314 adolescents and emerging adults were contacted by at least one recruitment method (clinic, web-based, postal mailing, electronic medical record (EMR) messaging) leading to 429 respondents. The most successful strategies in terms of RY were clinic-based recruitment (n = 47, 61% RY), community web-postings (n = 109, 5.33% RY), and EMR messaging (n = 163, 0.99% RY); however, website, postal mailings, and EMR recruitment led to more successful SY and EY. Postal mailings were the most costly strategy to employ (US$3261/completed participant) with EMR messaging the second most costly (US$69/completed participant). Community web-postings were free of charge. Clinic-based recruitment did not add additional costs, per se, but did require a substantial amount of personnel time (63.6 h/completed participant). Final cohort diversity primarily came from postal mailings (57% Black) and EMR messages (50% female)., Conclusion: Electronic medical record messaging and web-based recruitment were highly successful and cost-effective strategies in a pediatric clinical trial targeting adolescents and emerging adults, but was less successful in recruiting a diverse cohort. Clinic recruitment and postal mailings, despite being costly and time-consuming, were the strategies that enrolled a greater proportion of underrepresented groups. While online forms of trial recruitment are growing in popularity, clinic-based recruitment and non-web-based strategies may be required to ensure participant diversity and representation. more...

Background/aims: Obesity is a known risk factor for cardiovascular disease and contributes to the development and progression of kidney disease. However, the specific influence of obesity on outcomes in primary glomerular disease has not been well characterized., Methods: In this prospective cohort study, data were from 541 participants enrolled in the Nephrotic Syndrome Study Network (NEPTUNE), between 2010 and 2019, at 23 sites across North America. Blood pressure, lipids, and kidney disease outcomes including complete proteinuria remission, kidney failure, and chronic kidney disease progression were evaluated. Data were analyzed using linear and logistic regression with generalized estimating equations and time-varying Cox regression with Kaplan-Meier plots., Results: The prevalence of obesity at baseline was 43.3% (N = 156) in adults and 37.6% (N = 68) in children. In adults, obesity was longitudinally associated with higher systolic BP (β = 6.49, 95% CI: 2.41, 10.56, p = 0.002), dyslipidemia (OR = 1.74, 95% CI: 1.30, 2.32, p < 0.001), triglycerides (β = 41.92, 95% CI: 17.12, 66.71, p = 0.001), and lower HDL (β = -6.92, 95% CI: -9.32, -4.51, p < 0.001). In children, obesity over time was associated with higher systolic BP index (β = 0.04, 95% CI: 0.02, 0.06, p < 0.001) and hypertension (OR = 1.43, 95% CI: 1.04, 1.98, p = 0.03). In both adults and children, obesity was associated with a significantly lower hazard of achieving complete remission of proteinuria (adult HR = 0.80, 95% CI: 0.69, 0.88, p < 0.001; pediatric HR = 0.72, 95% CI: 0.61, 0.84, p < 0.001)., Conclusion: Obesity was associated with higher cardiovascular risk and less proteinuria remission from nephrotic syndrome in adults and children with proteinuric glomerulopathies. Weight-loss strategies may forestall cardiovascular disease and progressive kidney function decline in this high-risk patient group., (© 2021 S. Karger AG, Basel.) more...

The American Heart Association defines mood disorders (MDO) as a tier-II cardiovascular disease risk factor in children. Cross-sectional analysis of overweight/obese children referred to an obesity hypertension clinic revealed 37% had a MDO (defined by clinical diagnosis or Patient Health Questionnaire-9/-A score ≥10), 55% had confirmed hypertension, and 75% left ventricular hypertrophy (LVH). Children with MDOs were older, had greater measures of adiposity, and had a greater prevalence of hypertension (78%) than those without MDOs (42%; P = .04). Hypertensive children were 2.8 times more likely to have a MDO than those without (52% vs 18%; P = .02). Multivariable logistic regression revealed a statistically significant independent association of MDOs with hypertension (Odds Ratio [OR] 6.3, P = .048), but not LVH (LVMI ≥ 51 g/m 2.7 ; OR 1.13, P = .88). Overall, the prevalence of MDOs in this group of overweight/obese children with elevated blood pressure was well above national averages, suggesting that at-risk youth, particularly those with confirmed hypertension, should be regularly screened for MDOs., (©2018 Wiley Periodicals, Inc.) more...

Left ventricular hypertrophy (LVH) is prevalent among hypertensive children; however, blood pressure (BP) does not predict its presence. The authors conducted a 1-year prospective cohort study to examine the hypothesis that obesity-related risk factors are associated with left ventricular mass index (LVMI) in hypertensive children, and the association between adiposity and LVMI is mediated by BP-dependent and -independent pathways. A total of 49 hypertensive children were enrolled: 51% were overweight/obese and 41% had LVH at baseline. Children overweight/obese at baseline and follow-up had a greater LVMI increase than those of healthy weight at each visit: mean change of 6.4 g/m(2.7) vs 0.95 g/m(2.7) . Baseline body mass index z score was independently associated with LVMI change (β=4.08, 1.54-6.61; P=.002). Only pulse pressure and serum aldosterone partially mediated this relationship. Hypertensive youth manifest multiple cardiovascular disease risk factors that worsen over time despite treatment. Of these, adiposity is most associated with LVH and increasing LVMI., (© 2015 Wiley Periodicals, Inc.) more...

Both obesity and hypertension have increased substantially among children over the last several decades. At the same time, mounting evidence has pointed to the role of these and other cardiovascular disease risk factors on the development of end organ damage such as left ventricular hypertrophy in children. While traditionally thought to occur in response to an increased afterload as in systemic hypertension, evidence demonstrates that obesity is associated with left ventricular hypertrophy independent of blood pressure. Both hemodynamic and non-hemodynamic factors contribute to the pathogenesis of obesity-related left ventricular remodeling. However, more contemporary research suggests that adiposity and blood pressure have a greater effect on left ventricular geometry when present together than when present alone. Normalization of left ventricular mass in obese hypertensive individuals requires achievement of both normotension and weight loss. Additional strategies are needed to promote the cardiovascular health of children, with greater emphasis placed on obesity prevention. more...

Background: Uric acid (UA) is associated with high blood pressure in adolescents and with left ventricular hypertrophy (LVH) and cardiovascular disease (CVD) in adults. We sought to determine if UA is independently associated with CVD risk factors and left ventricular mass (LVM) over time in hypertensive youth., Methods: This was a 1-year prospective observational study of hypertensive children aged 3-19 years. Cross-sectional and longitudinal associations of serum UA with CVD risk factors and LVM were explored., Results: Of the 49 children who completed both the baseline and 12-month assessments, at baseline the mean age was 13.8 years and mean UA was 5.5 mg/dL; 24% had elevated UA, 51% were overweight/obese and 39% had LVH. Measures of adiposity, low high-density lipoprotein cholesterol, high-sensitivity C-reactive protein, LVM and LVH were all significantly associated with elevated UA at baseline, but not with change over time. Each 1 mg/dL increase in baseline UA was associated with a 2.5 g/m(2.7) increase in the LVM index at follow-up (95% confidence interval 0.64, 4.39; p = 0.01); after adjustment for age, sex, race, body mass index z-score, change in UA, time, blood pressure and medication use, this association was no longer significant., Conclusions: Hypertensive children with elevated UA have a higher prevalence of obesity-related CVD risk factors. Among hypertensive children, UA may be a marker of adiposity and not an independent CVD risk factor. more...

The overall prevalence of hypertension in childhood is 2% to 5%, and the leading type of childhood hypertension is primary hypertension, especially in adolescence. As in adults, the leading risk factors for children with primary hypertension are excess adiposity and suboptimal lifestyles; however, environmental stress, low birth weight, and genetic factors may also be important. Hypertensive children are highly likely to become hypertensive adults and to have measurable target organ injury, particularly left ventricular hypertrophy and vascular stiffening. Ambulatory and home blood pressure monitoring may facilitate diagnosis. Primordial prevention of hypertension through public health implementation of healthier diet and increased physical activity will reduce the prevalence of primary hypertension, and evidence-based treatment guidelines should be implemented when hypertension is diagnosed. Further research to optimize recognition and diagnosis and clinical trials to better define outcomes of treatment are needed. [ABSTRACT FROM AUTHOR] more...

Objective: Diabetes and prediabetes are growing concerns among US youth. Fasting glucose (FG) and HbA1c are standard diabetes screening tests, but HbA1c may be unreliable in some settings and fasting is burdensome in children. Glycated albumin (GA) is a non-fasting test that was recently cleared for clinical use in the United States, but studies in youth without diabetes are limited. Research Design and Methods: We conducted a cross-sectional analysis in 6826 youth without diabetes aged 8--19 years in the 1999--2004 National Health and Nutrition Examination Survey. We evaluated the associations of GA with HbA1c, FG, and cardiometabolic risk factors. Results: GA was poorly correlated with HbA1c (ρ = 0.074) and FG (ρ = -0.047) and was negatively associated with body mass index (BMI) and cardiometabolic risk factors. Compared to youth in the highest tertile of GA (≥13.5%), those in the lowest GA tertile (<12.4%) had a higher prevalence of obesity (29.9% vs. 7.6%), low high-density lipoprotein cholesterol (29.7% vs. 16.5%), and hypertensive blood pressure (4.0% vs. 2.7%). These inverse associations persisted after adjustment for age, sex, race/ethnicity, serum albumin, and C-reactive protein. Conclusions: GA was poorly correlated with traditional markers of hyperglycemia in youth without diabetes. Counterintuitively, there was a negative association between GA and BMI. Among youth without diabetes, GA does not identify youth at high cardiometabolic risk, and it does not appear to be an appropriate biomarker for screening of hyperglycemia. [ABSTRACT FROM AUTHOR] more...

Background: Development of clinical risk factors linked to metabolic syndrome (MetS) in adolescence is associated with higher incidence of atherosclerotic cardiovascular events in adulthood. Given the increasing burden of obesity and MetS in African-American (AA) youth, there is a need to establish the relation of MetS with modifiable risk factors such as diet quality, because these data may enhance preventative and treatment approaches.Objectives: The purpose of this study was to assess diet quality, measured by the Alternative Healthy Eating Index 2010 (AHEI-2010) and the Dietary Approaches to Stop Hypertension (DASH) pattern score, in AA adolescents and youth (aged 12-21 y) from the NHANES, and to investigate the association of diet quality with MetS and its components.Methods: This study is a cross-sectional analysis of NHANES data from the 2005-2016 cycles (n = 2459). Survey-weighted logistic regression models were used to assess the association of diet quality with the prevalence of MetS and individual cardiometabolic components [overweight/obesity, hypertensive blood pressure (BP), impaired fasting glucose, low HDL cholesterol, hypertriglyceridemia].Results: The mean ± SD AHEI-2010 score was 38.9 ± 9.7 and DASH pattern score was 21.8 ± 4.4, which is equivalent to 35% adherence to recommendations to achieve an optimal diet quality and 45% adherence to the DASH-style dietary pattern, respectively. Compared with those within the lowest quartile of DASH pattern score, individuals in the fourth quartile group had 0.63 (95% CI: 0.41, 0.97) times the odds of having hypertensive BP. Among individuals with complete clinical measures (n = 1007), individuals within the highest-quartile AHEI-2010 group had 0.25 (95% CI: 0.06, 0.99) times the odds of having MetS compared with those within the lowest quartile.Conclusions: Diet quality in US AA youth is low. Higher DASH pattern scores were associated with lower odds of hypertensive BP and higher AHEI-2010 scores were associated with lower odds of MetS. [ABSTRACT FROM AUTHOR] more...

Despite recognition that hypertension is associated with childhood obesity, data suggest that high blood pressure (BP) is infrequently diagnosed in children. This study sought to examine provider communication with overweight school-age children regarding BP measurements that were high at well-child visits. Cross-sectional mixed-methods analysis of audio-recorded communication from well-child visits with overweight 6–12-year-olds. Data from the subset of children with elevated BPs were used for this study. Three BP measures obtained at the audio-recorded visit were averaged, paired with historical BPs stored in the health record, and compared to contemporary/Fourth-Report thresholds to determine if children had elevated/hypertensive BPs only at the audio-recorded visit or met hypertension-diagnostic criteria (hypertension-level BP ≥3 separate visits). Two reviewers used visit transcripts to categorize communication about BP as " absent ," " unclear ," or " direct." Provider use of a billing diagnosis for elevated BP/hypertension in visits with direct -BP-communication was explored. In 36 of 126 (29%) visit-audio-recordings, children had elevated/hypertensive BPs. Thirty-three of the 36 eligible (92%) had intelligible audio-recordings. Of these, 9 (25%) were overweight and 24 (75%) had obesity. Seventeen (52%) had elevated BPs, and 16 (48%) hypertensive BPs. Ten (30%) met criteria for hypertension diagnosis. BP communication was absent in 20 visits (61%), unclear in 8 (24%), and direct in 5 visits (15%). Billing diagnoses for elevated BP/hypertension were entered at 4 of 5 (80%) visits with direct -BP communication. Most overweight children with elevated BPs did not receive communication that BP is high at well-child visits. Relevant billing diagnoses may indicate direct- BP communication. [ABSTRACT FROM AUTHOR] more...

Obesity is a potent cardiovascular disease (CVD) risk factor and is associated with left ventricular hypertrophy (LVH). Obstructive sleep apnea (OSA) is common among individuals with obesity and is also associated with CVD risk. The authors sought to determine the association of OSA, a modifiable CVD risk factor, with LVH among overweight/obese youth with elevated blood pressure (EBP). This was a cross-sectional analysis of the baseline visit of 61 consecutive overweight/obese children with history of EBP who were evaluated in a pediatric obesity hypertension clinic. OSA was defined via sleep study or validated questionnaire. Children with and without OSA were compared using Fisher's exact tests, Student's t tests, and Wilcoxon rank sum test. Multivariable logistic regression evaluated the association between OSA and LVH. In this cohort, 71.7% of the children had LVH. Children with OSA were more likely to have LVH (85.7% vs 59.4%, P = 0.047). OSA was associated with 4.11 times greater odds of LVH (95% CI 1.15, 14.65; P = 0.030), remaining significant after adjustment for age, sex, race, and BMI z-score (after adjustment for hypertension, P = 0.051). A severe obstructive apnea-hypopnea index (AHI >10) was associated with 14 times greater odds of LVH (95% CI 1.14, 172.64, P = 0.039). OSA was significantly associated with LVH among overweight/obese youth with EBP, even after adjustment for age, sex, race, and BMI z-score. Those with the most severe OSA (AHI >10) had the greatest risk for LVH. Future studies exploring the impact of OSA treatment on CVD risk in children are needed. [ABSTRACT FROM AUTHOR] more...

The article presents the authors' comments on the study, titled "Impact of lipid measurements in youth in addition to conventional clinic-based risk factors on predicting preclinical atherosclerosis in adulthood: International Childhood Cardiovascular Cohort Consortium," by J. Koskinen and colleagues, in the current issue. The authors comment that the findings underscore obesity, hypertension, and dyslipidemia as key risk factors in childhood of high carotid intima media thickness (cIMT). more...

OBJECTIVE: Race is a known risk factor for hypertension and cardiovascular disease in adults and influences blood pressure (BP) in children. We sought to determine if there are differences in clinical, laboratory, or echocardiographic characteristics among children with primary hypertension from different racial groups. PATIENTS AND METHODS: Study participants were 184 children aged 3 to 20 years with a diagnosis of primary hypertension who were examined at 1 of 3 participating centers at the time of initial evaluation of elevated BP. Black children were categorized as African American (AA) and nonblack children as non-AA. Comparisons were made for the entire group and after stratification according to age (<13 or ⩾13 years). RESULTS: Overall, children categorized as AA had a higher prevalence of overweight/obesity and left ventricular hypertrophy and had higher plasma renin activity than children who were categorized as non-AA. After age stratification, these differences remained only in the children younger than 13 years old; there were no differences in these findings among children aged 13 years or older. AA children who were aged 13 years or older, however, had higher BPs for both casual and ambulatory measurements. Specifically, they had higher casual diastolic BP, higher 24-hour diastolic BP, higher daytime systolic and diastolic BP, and higher BP loads at night and over a 24-hour period compared with non-AA children who were aged 13 years or older. CONCLUSIONS: These data indicate that black children with primary hypertension may be at increased cardiovascular risk compared with nonblack children with primary hypertension. However, the high prevalence of overweight/obesity and left ventricular hypertrophy in all youth with primary hypertension demonstrates the need for greater preventive and therapeutic efforts aimed at reducing cardiovascular risk in this vulnerable population. [ABSTRACT FROM AUTHOR] more...

Brady TM, Parekh RS. Metabolic syndrome: signs and symptoms running together. Pediatr Transplantation 2010: 14: 6–9. © 2010 John Wiley & Sons A/S. Children with kidney disease are at increased risk of having several comorbidities such as obesity, dyslipidemia, hypertension, and impaired glucose tolerance, and patients with a constellation of these symptoms are considered to have the MS. Children with kidney disease, and ESRD in particular, are at increased CV risk, as are patients with the MS. To determine the impact MS has on a particularly vulnerable population of children, those who have received a kidney transplant, Wilson et al. explored the prevalence of MS and the association of MS with cardiac abnormalities among this subset of children. They found an overall high prevalence of MS among pediatric transplant recipients and that the risk of left ventricular hypertrophy was higher among children with MS after renal transplant compared to those without MS. Review of the most common definitions of MS and also the clinical implications are discussed. While there is no doubt that children with kidney disease have a high prevalence of CV risk factors and that these children are at risk for CV events early in life, whether the sum of the parts of MS confers increased risk over what is seen with individual risk factors that often run together remains to be seen. [ABSTRACT FROM AUTHOR] more...

Summary: The prevalence of pediatric hypertension (HTN) has increased over the past several decades, bringing with it increased numbers of children with hypertensive sequelae such as left ventricular hypertrophy as well as greater numbers of hypertensive adults. This growing public health concern calls for vigilant screening, diagnosis, evaluation, and treatment of HTN in children. Although primary HTN has become more common in childhood and adolescence, it still should be considered a diagnosis of exclusion. As such, a diagnostic work-up should be conducted to rule out secondary causes of HTN for any child with a confirmed diagnosis of HTN. Important secondary causes of pediatric HTN include renal parenchymal, renovascular, and endocrine etiologies, and secondary HTN becomes more likely the younger the child is and the more severe the blood pressure elevation is at diagnosis. In addition, several genetic disorders have been identified in which one aberrant gene results in severe HTN, often early in life. All hypertensive children, regardless of the cause of their HTN, should be prescribed therapeutic lifestyle changes, and children with symptomatic, secondary, or severe HTN; HTN resistant to lifestyle changes; or children with evidence of end-organ damage also should be prescribed antihypertensive medications. [ABSTRACT FROM AUTHOR] more...

Introduction: High blood pressure (BP) in children is under recognized by pediatric providers. Our aim was to describe and determine factors associated with provider communication of high BP during visits with a child with an elevated BP. Hypothesis: Few providers will communicate that BP is high. Methods: Cross-sectional analysis of video/audio-recorded well-child visits of 6–12-year-olds with overweight/obesity recruited from academic and private clinics (2014–15). Elevated BP and hypertension (HTN) were identified by applying contemporary pediatric HTN thresholds to EHR-stored BP data. Systolic BP (SBP) exceeding the adult threshold of ≥120 mmHg also was determined. Recorded visits were transcribed/analyzed. Two independent reviewers used transcript data to identify BP communication and establish communication themes. Chi-square was used to test if SBP elevation ≥120 mmHg is associated with communication of high BP in children. Results: A child had an elevated BP at 34 of 100 visits; 30 were valid recordings with 23 providers. Of these encounters, mean age was 8.7 years (y); 37% were overweight, 63%, obese; 37%, Black, and 47%, Latino. At the visit, 53% had elevated BPs (of which, 38% met diagnostic criteria for elevated BP and 0% for HTN); 47% had HTN-level BPs (29% met criteria for elevated BP and 43% for HTN); 37% had SBP ≥120 mmHg. Major themes for how pediatricians communicate about BP included: direct, unclear, minimize and absent. Communication of high BP was direct in 17% of visits, unclear, 17%, minimize, 13%, and absent, 67%. Exemplifying direct communication, a pediatrician said, ' Your BP's a little bit high [avg. SBP 134]. 120 is the highest we want for her age [11 y].' An example of 'unclear' was, ' The biggest reason I worry about this [obesity] is you can start having adult problems like high BP ,' (8 y, BP 115/76, 93%). A quote illustrating 'minimize' was, ' BP is a bit high. He's just nervous ,' (8 y, BP 114/75, 91%). Exceeding the adult elevated-BP threshold was associated with direct communication, which occurred in 80% of visits with SBP ≥120, vs. 20% with <120 (P =.047). Conclusions: During well-child visits, most overweight children with high BP receive no communication that BP is high. Of those who do, communication commonly is unclear or dismissive, and more likely when SBP exceeds the adult high-BP threshold. [ABSTRACT FROM AUTHOR] more...