Carotid Intima-media Thickness In Adults Research Articles

Low serum adiponectin levels in childhood and adolescence predict increased intima-media thickness in adulthood. The Cardiovascular Risk in Young Finns Study

Introduction: Low adiponectin levels may predict the development of atherosclerosis. We examined the association of childhood adiponectin with preclinical carotid atherosclerosis that is defined as plaque and/or high (≥95th percentile) intima-media thickness (IMT) at the carotid bifurcation in adulthood.Methods: The Cardiovascular Risk in Young Finns Study is a cohort study on cardiovascular risk factors. We used risk factor data from the baseline study (1980) and ultrasound findings from the follow-ups (2001 and 2007). The study population included 1708 participants, aged 3–18 years at baseline.Results: In multivariate analysis, childhood adiponectin was inversely associated with preclinical carotid atherosclerosis: odds ratio 0.68, 95% confidence interval (CI) 0.53–0.86, p = .001, for 1-SD increase in childhood adiponectin after adjusting for childhood non-high-density lipoprotein cholesterol, body mass index, and blood pressure. When examining the incremental predictive ability, we observed that compared to an approach utilizing only conventional risk factors, the model additionally including adiponectin levels improved c-statistics area under curve from 0.733 (95% Cl 0.694–0.771) to 0.748 (95% Cl 0.710–0.786), p = .02.Conclusions: Childhood adiponectin levels improve the prediction of carotid atherosclerosis in adulthood over conventional risk factors. This supports the idea that low adiponectin levels may have a role in the development of preclinical atherosclerosis.Key messagesChildhood adiponectin levels improve the prediction of increased carotid intima-media thickness in adulthood over conventional cardiovascular risk factors.These results suggest that adiponectin levels measured in childhood may have a role in the atherosclerotic process.

Childhood Psychosocial Cumulative Risks and Carotid Intima-Media Thickness in Adulthood: The Cardiovascular Risk in Young Finns Study.

Adverse experiences in childhood may influence cardiovascular risk in adulthood. We examined the prospective associations between types of psychosocial adversity and having multiple adversities (e.g., cumulative risk) with carotid intima-media thickness (IMT) and its progression among young adults. Higher cumulative risk score in childhood was expected to be associated with higher IMT and its progression. Participants were 2265 men and women (age range, 24-39 years in 2001) from the ongoing Cardiovascular Risk in Young Finns study whose carotid IMTs were measured in 2001 and 2007. A cumulative psychosocial risk score, assessed at the study baseline in 1980, was derived from four separate aspects of the childhood environment that may impose risk (childhood stressful life events, parental health behavior family, socioeconomic status, and childhood emotional environment). The cumulative risk score was associated with higher IMT in 2007 (b = 0.004, standard error [SE] = 0.001, p < .001) and increased IMT progression from 2001 to 2007 (b = 0.003, SE = 0.001, p = .001). The associations were robust to adjustment for conventional cardiovascular risk factors in childhood and adulthood, including adulthood health behavior, adulthood socioeconomic status, and depressive symptoms. Among the individual childhood psychosocial risk categories, having more stressful life events was associated with higher IMT in 2001 (b = 0.007, SE = 0.003, p = .016) and poorer parental health behavior predicted higher IMT in 2007 (b = 0.004, SE = 0.002, p = .031) after adjustment for age, sex, and childhood cardiovascular risk factors. Early life psychosocial environment influences cardiovascular risk later in life, and considering cumulative childhood risk factors may be more informative than individual factors in predicting progression of preclinical atherosclerosis in adulthood.

Childhood 25-OH Vitamin D Levels and Carotid Intima-Media Thickness in Adulthood: The Cardiovascular Risk in Young Finns Study

Low vitamin D levels in adulthood have been associated with cardiovascular disease. To investigate if low vitamin D levels in childhood are related with increased carotid artery intima-media thickness (IMT) in adulthood. The analyses included 2148 subjects from the Cardiovascular Risk in Young Finns Study, aged 3-18 years at baseline (in 1980). Subjects were re-examined at age 30-45 years (in 2007). Childhood levels of 25-hydroxy-vitamin D were measured from stored serum in 2010. The carotid artery IMT from 2007 was used. When adjusted for age, sex, and childhood risk factors, continuous data of childhood 25-OH vitamin was inversely associated with adulthood carotid IMT levels among females (β ± SE -0.006 ± 0.003, P = 0.03), but not among males (0.001 ± 0.004, P = 0.88). Children with 25-OH vitamin D levels in the lowest quartile (<40 nmol/L) had significantly increased odds of having high-risk IMT (highest decile of common carotid or carotid bulb IMT or carotid plaque) as adults, in analyses adjusted for age, sex and either childhood risk factors (odds ratio 1.70 [95 % CI 1.15-2.31], P = 0.0007) or adult risk factors, including adult vitamin D levels (odds ratio 1.80 [1.30-2.48], P = 0.0004). In sex-specific analyses, these associations were significant both in females and males (P always <0.05). In sensitivity analyses, those with childhood vitamin D levels in the lowest quintile (<37 nmol/L), gave similar results to those using a quartile cut-point. Low 25-OH vitamin D levels in childhood were associated with increased carotid IMT in adulthood.

Association between fat amount of dairy products with pulse wave velocity and carotid intima-media thickness in adults.

BackgroundExamine the relation between consumption of low-fat vs. whole-fat dairy products with the carotid intima-media thickness and pulse wave velocity.FindingsMethods: Cross-sectional and multi-center study. A total of 265 subjects were selected by stratified random sampling. Measurements: Information about dairy products was assessed using a semi-quantitative food-frequency questionnaire. Carotid intima-media thickness (IMT) was measured by carotid ultrasonography. Pulse wave velocity (PWV) was measured using the SphygmoCor-System.ResultsSubjects (age 55.8 ± 12.2) had mean values of IMT 0.68 ± 0.10 mm and PWV 7.60 ± 2.0 m/sec. The relationship between PWV and IMT with whole-fat and low-fat dairy intake groups, adjusted for age, sex, energy intake and other confounders revealed lower values of PWV in subjects with a consumption higher than 125 g/day of low-fat dairy and in those who did not intake whole-fat dairy. In a risk-factor adjusted regression model, an increase in PWV of 0.109 m/sec (95% CI: 0.006 –0.213) was estimated for every 100 g/day increase in whole-fat dairy intake. Similarly, a decrease in PWV of 0.101 m/sec (95% CI: −0.178 –0.023) was estimated for every 100 g/day increase in low-fat dairy intake, (p = 0.038 and p = 0.011 respectively). While for every 100 g/day increase in low-fat dairy intake, the estimate decrease of IMT was 0.005 mm (95% CI: −0.010 –0.001), p = 0.011.ConclusionsPWV and IMT showed an inverse association with the intake of low-fat dairy and a positive association with the intake of whole-fat dairy, so the amount of fat in dairy products can play an important role in arterial stiffness and subclinical atherosclerosis.

Exposure to parental smoking in childhood or adolescence is associated with increased carotid intima-media thickness in young adults: evidence from the Cardiovascular Risk in Young Finns study and the Childhood Determinants of Adult Health Study

Recent evidence suggests that the exposure of children to their parents' smoking adversely effects endothelial function in adulthood. We investigated whether the association was also present with carotid intima-media thickness (IMT) up to 25 years later. The study comprised participants from the Cardiovascular Risk in Young Finns Study (YFS, n = 2401) and the Childhood Determinants of Adult Health (CDAH, n = 1375) study. Exposure to parental smoking (none, one, or both) was assessed at baseline by questionnaire. B-mode ultrasound of the carotid artery determined IMT in adulthood. Linear regression on a pooled dataset accounting for the hierarchical data and potential confounders including age, sex, parental education, participant smoking, education, and adult cardiovascular risk factors was conducted. Carotid IMT in adulthood was greater in those exposed to both parents smoking than in those whose parents did not smoke [adjusted marginal means: 0.647 mm ± 0.022 (mean ± SE) vs. 0.632 mm ± 0.021, P = 0.004]. Having both parents smoke was associated with vascular age 3.3 years greater at follow-up than having neither parent smoke. The effect was independent of participant smoking at baseline and follow-up and other confounders and was uniform across categories of age, sex, adult smoking status, and cohort. These results show the pervasive effect of exposure to parental smoking on children's vascular health up to 25 years later. There must be continued efforts to reduce smoking among adults to protect young people and to reduce the burden of cardiovascular disease across the population.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Improving Blood Pressure in Children Is Protective Over the Long Term

Improving Blood Pressure in Children Is Protective Over the Long Term

Relation of Childhood Obesity/Cardiometabolic Phenotypes to Adult Cardiometabolic Profile: The Bogalusa Heart Study

Not all obese adults have cardiometabolic abnormalities. It is unknown whether this is true in children and, if true, whether children who have metabolically healthy overweight/obesity (MHO) will also have favorable cardiometabolic profiles in adulthood. These aspects were examined in 1,098 individuals who participated as both children (aged 5-17 years) and adults (aged 24-43 years) in the Bogalusa Heart Study between 1997 and 2002 in Bogalusa, Louisiana. MHO was defined as being in the top body mass index quartile, while low density lipoprotein cholesterol, triglycerides, mean arterial pressure, and glucose were in the bottom 3 quartiles, and high density lipoprotein cholesterol was in the top 3 quartiles. Forty-six children (4.2%) had MHO, and they were more likely to retain MHO status in adulthood compared with children in other categories (P < 0.0001). Despite markedly increased obesity in childhood and in adulthood, these same MHO children and adults showed a cardiometabolic profile generally comparable to that of nonoverweight/obese children (P > 0.05 in most cases). Moreover, there was no difference in carotid intima-media thickness in adulthood between MHO children and nonoverweight/obese children. Further, carotid intima-media thickness in adulthood was lower in MHO children than in metabolically abnormal, overweight/obese children (P = 0.003). In conclusion, the MHO phenotype starts in childhood and continues into adulthood.

Influence of Age on Associations Between Childhood Risk Factors and Carotid Intima-Media Thickness in Adulthood

Background— Atherosclerosis has its roots in childhood. Therefore, defining the age when childhood risk exposure begins to relate to adult atherosclerosis may have implications for pediatric cardiovascular disease prevention and provide insights about the early determinants of atherosclerosis development. The aim of this study was to investigate the influence of age on the associations between childhood risk factors and carotid artery intima-media thickness, a marker of subclinical atherosclerosis. Methods and Results— We used data for 4380 members of 4 prospective cohorts—Cardiovascular Risk in Young Finns Study (Finland), Childhood Determinants of Adult Health study (Australia), Bogalusa Heart Study (United States), and Muscatine Study (United States)—that have collected cardiovascular risk factor data from childhood (age 3 to 18 years) and performed intima-media thickness measurements in adulthood (age 20 to 45 years). The number of childhood risk factors (high [highest quintile] total cholesterol, triglycerides, blood pressure, and body mass index) was predictive of elevated intima-media thickness (highest decile) on the basis of risk factors measured at age 9 years (odds ratio [95% confidence interval] 1.37 [1.16 to 1.61], P =0.0003), 12 years (1.48 [1.28 to 1.72], P &lt;0.0001), 15 years (1.56 [1.36 to 1.78], P &lt;0.0001), and 18 years (1.57 [1.31 to 1.87], P &lt;0.0001). The associations with risk factors measured at age 3 years (1.17 [0.80 to 1.71], P =0.42) and 6 years (1.20 [0.96 to 1.51], P =0.13) were weaker and nonsignificant. Conclusions— Our analyses from 4 longitudinal cohorts showed that the strength of the associations between childhood risk factors and carotid intima-media thickness is dependent on childhood age. On the basis of these data, risk factor measurements obtained at or after 9 years of age are predictive of subclinical atherosclerosis in adulthood.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Are We There Yet? Pediatric Screening for Inflammatory Biomarkers and Low Cardiorespiratory Fitness to Identify Youth at Increased Risk of Cardiovascular Disease

Are We There Yet? Pediatric Screening for Inflammatory Biomarkers and Low Cardiorespiratory Fitness to Identify Youth at Increased Risk of Cardiovascular Disease

Pulse Pressure in Youth and Carotid Intima-Media Thickness in Adulthood

Large pulse pressure associates with atherosclerosis, but it is unclear if it contributes to the development of atherosclerosis or if atherosclerosis leads to pulse pressure widening. We examined whether exposure to large pulse pressure in childhood predicts carotid artery intima-media thickness in adulthood. Carotid intima-media thickness was measured in 2146 adults in the Cardiovascular Risk in Young Finns Study. These subjects have blood pressure data available dating back to their childhood (baseline in 1980, ages 3 to 18 years). Baseline pulse pressure measured in adolescence was significantly related to carotid intima-media thickness measured in adulthood 21 years later (r=0.123, P<0.0001). The relation remained significant (P=0.0029) in models adjusted for age, sex, adolescent mean arterial pressure, adult systolic pressure, adult pulse pressure, body mass index, smoking, physical activity, and carotid artery diameter. Each 10 mm Hg increment in pulse pressure was associated with a 0.008-mm (95% CI, 0.003 to 0.013 mm) increase in carotid intima-media thickness. Exposure to wide pulse pressure in adolescence may induce changes that contribute to carotid artery intima-media thickening.

The Association of Pediatric Low- and High-Density Lipoprotein Cholesterol Dyslipidemia Classifications and Change in Dyslipidemia Status With Carotid Intima-Media Thickness in Adulthood: Evidence From the Cardiovascular Risk in Young Finns Study, the Bogalusa Heart Study, and the CDAH (Childhood Determinants of Adult Health) Study

This study was designed to determine which of the National Cholesterol Education Program or National Health and Nutrition Examination Survey low- and high-density lipoprotein cholesterol classifications of dyslipidemia status in adolescents is most effective at predicting high common carotid artery intima-media thickness (IMT) in adulthood. Two classifications of pediatric dyslipidemia status have been proposed. No study has assessed which of these is most effective for predicting adolescents who will develop preclinical atherosclerosis in adulthood. Three population-based, prospective cohort studies collected lipoprotein measurements on 1,711 adolescents age 12 to 18 years who were remeasured as young adults age 29 to 39 years. Lipoproteins in adolescence were classified according to National Cholesterol Education Program and National Health and Nutrition Examination Survey cut points, and high IMT in adulthood was defined as those at or above the age-, sex-, race-, and cohort-specific 90th percentile of IMT. Independent of the classification employed, adolescents with dyslipidemia were at significantly increased risk of having high IMT in adulthood (relative risks from 1.6 to 2.5). Differences in predictive capacity between both classifications were minimal. Overweight or obese adolescents with dyslipidemia had increased carotid IMT (males: 0.11 mm; females: 0.08 mm) in adulthood compared with those who did not have both risk factors. Adolescent dyslipidemia status was more strongly associated with high IMT in adulthood than change in dyslipidemia status. Pediatric dyslipidemia classifications perform equally in the prediction of adolescents who are at increased risk of high IMT in young adulthood. Our data suggest that dyslipidemia screening could be limited to overweight or obese adolescents.

Abstract 1186: Asymmetric Dimethylarginine and HDL-cholesterol Independently Affect Arterial Wall Thickness in the First Decade of Life

Introduction The pathological changes of early atherosclerosis (fatty streaks and fibrous plaques) may be observed in the young and can be reflected in vivo by the carotid intima-media thickness (CIMT), measured by ultrasound. CIMT is a reliable marker of subclincal atherosclerosis in adults and traditional cardiovascular risk factors present in childhood predict CIMT in adulthood. However, the determinants of CIMT in childhood are largely unknown. We assessed the influence of traditional cardiovascular risk factors and also asymmetric dimethylarginine (ADMA, an endogenous inhibitor of nitric oxide synthesis) on CIMT, in healthy 8-year old children. Methods 406 community-based children (age 8.0±0.1, 49% girls) had anthropometry, systolic and diastolic blood pressure (SBP, DBP) and mean left and right CIMT measured. A non-fasting blood sample was collected for HDL, non-HDL cholesterol, apolipoprotein B (apo B), high sensitivity CRP (hs-CRP) and ADMA (measured by ELISA). Correlates of CIMT were evaluated. Results Mean (± sd) values were CIMT 0.59±0.06 mm, HDL 1.46±0.37 mmol/L, non-HDL cholesterol 2.96±0.70 mmol/L, apo B 0.64±0.15 mmol/L, and ADMA 0.91±0.22 μmol/L; median hs-CRP was 0.3 mg/L (interquartile range 0.21 to 1.09 mg/L). On univariate analysis, CIMT was associated significantly with SBP (r=0.164, p&lt;0.001), DBP (r=0.105, p&lt;0.017), HDL (r= −0.142, p&lt;0.006) and ADMA (r=0.182, p&lt;0.001). Measures of body size, apo B and hs-CRP were not significantly related to CIMT. On multivariable analysis, HDL (β coefficient = −0.118, p&lt;0.035) and ADMA (β coefficient = 0.175, p&lt;0.002) were significant independent determinants of CIMT in a model adjusted for all measured risk factors and sex. Conclusions Lower HDL-cholesterol and higher levels of ADMA, an endogenous inhibitor of nitric oxide synthesis, are significantly associated with CIMT in childhood. These data may permit earlier cardiovascular risk stratification and suggest novel mechanisms whereby HDL and ADMA might be modulating atherogenesis at an earlier stage than previously envisaged.

Lifetime body mass index and later atherosclerosis risk in young adults: examining causal links using Mendelian randomization in the Cardiovascular Risk in Young Finns study

AimsMendelian randomization uses genetic variants related to environmentally modifiable risk factors in an attempt to improve causal inference from observational data. We examined the effect of lifetime body mass index (BMI) on adult carotid intima-media thickness (CIMT) and various atherosclerotic risk factors by using both Mendelian randomization and conventional analyses.Methods and resultsA total of 2230 individuals (1218 women), aged 3–18 at study induction, took part in clinical examinations in 1980, 1983, 1986, and, most recently, 2001 when they were aged 24–39. In these analyses we utilized the known relation between FTO polymorphism rs9939609 and BMI. The dose–response association between the number of A alleles in FTO and higher mean BMI from childhood to adulthood was confirmed, but no associations with potential confounding factors were observed. In standard regression models, lifetime BMI was associated with adult CIMT, lifetime systolic blood pressure, adult fasting glucose, and adult HOMA-index. When variation in FTO was used as an instrument for unconfounded BMI levels, similar or larger effects of lifetime BMI on all these phenotypes were found, although with wider confidence intervals.ConclusionMutually supportive results from Mendelian randomization and standard regression models strengthen the evidence of the effect of lifetime BMI on atherosclerosis risk in young adults.

Usefulness of Childhood Non–High Density Lipoprotein Cholesterol Levels Versus Other Lipoprotein Measures in Predicting Adult Subclinical Atherosclerosis: The Bogalusa Heart Study

This study sought to examine the usefulness of childhood non-high-density lipoprotein cholesterol level versus low-density lipoprotein cholesterol level, high-density lipoprotein cholesterol level, triglyceride level, apolipoprotein B level, apolipoprotein A-I level, total cholesterol/high-density lipoprotein cholesterol ratio, and apolipoprotein B/apolipoprotein A-I ratio in predicting adult excess carotid intima-media thickness, an indicator of subclinical atherosclerosis. This retrospective cohort study included 437 black and white subjects (70% white and 40% male) who participated in the Bogalusa Heart Study as children 5 to 17 years of age and as adults 16 to 19 years later. In analyses of each lipoprotein measure as a risk factor for predicting excess carotid intima-media thickness in adulthood, non-high-density lipoprotein cholesterol level, low-density lipoprotein cholesterol level, total cholesterol/high-density lipoprotein cholesterol ratio, apolipoprotein B level, and apolipoprotein B/apolipoprotein A-I ratio emerged as significant predictors, with respective odds ratios of 2.60, 2.95, 1.78, 1.44, and 1.69, after adjustment for childhood BMI, systolic blood pressure, other lipoprotein measures, and follow-up years; the odds ratios for high-density lipoprotein cholesterol, triglyceride, and apolipoprotein A-I levels were not significant. Regarding the discriminating value of different childhood lipoprotein measures in predicting excess carotid intima-media thickness in adulthood, analyses of the area under the receiver operating characteristic curve for each lipoprotein measure, adjusted for the aforementioned nonlipoprotein covariates, indicated that the value of 0.65 for the non-high-density lipoprotein cholesterol level was similar in magnitude to those for other lipoprotein measures, with values ranging from 0.62 to 0.66. CONCLUSIONS; Childhood non-high-density lipoprotein cholesterol levels are as good as other lipoprotein measures in predicting subclinical atherosclerosis in adulthood, which has practical implications for coronary artery disease risk assessment and intervention in pediatric populations.

Is the association between job strain and carotid intima-media thickness attributable to pre-employment environmental and dispositional factors? The Cardiovascular Risk in Young Finns Study

Objectives: Most previous studies of job strain and cardiovascular risk have been limited to adult data. It remains unclear whether this association might be explained by factors already present before...

Challenges of Existing Pediatric Dyslipidemia Guidelines

Existing guidelines for screening and managing lipoprotein abnormalities in children and adolescents are based on a consensus document published over 15 years ago by the National Cholesterol Education Program (NCEP) Expert Panel on Blood Cholesterol Levels in Children and Adolescents.1 This document was based on evidence that elevated levels of low-density lipoprotein (LDL) cholesterol are highly correlated with development of atherosclerotic cardiovascular disease (ASCVD) in adults and on pathological data suggesting that dyslipidemia in children and adolescents was associated with early arterial plaque development. The panel recommended 2 strategies to address abnormal lipoprotein levels in children: a population-based approach (dietary recommendations) and a targeted screening approach (selective screening based on family history of ASCVD and/or parental hypercholesterolemia). The guidelines recommended dietary and lifestyle interventions for children with elevated LDL cholesterol levels. They proposed that drug therapy only be considered when LDL cholesterol levels are ≥190 mg/dL or ≥160 mg/dL with concomitant ASCVD risk factors (≥2) or with a family history of ASCVD. Article p 32 Since the initial publication of the existing guidelines, many significant challenges have emerged that deserve attention. First, accumulating data suggest that the guidelines significantly underestimated the number of children who would be targeted for lipoprotein screening. Second, the guidelines do not account for variations in lipids due to race, gender, and pubertal status, all of which are known …

Race (black–white) and gender divergences in the relationship of childhood cardiovascular risk factors to carotid artery intima–media thickness in adulthood: The Bogalusa Heart Study

It has been established that childhood cardiovascular (CV) risk factors are predictive of adulthood vascular changes as measured by carotid intima–media thickness (IMT). However, whether this relationship is race- and gender-specific is not known. This aspect was examined in a black–white cohort of 868 adults (29% blacks, 42% males) aged 25–44 years who were examined at least twice in childhood for traditional CV risk factors with an average follow-up period of 26.4 years. The average value of the two earliest childhood measurements was used as the childhood value, standardized to age, race, and gender-specific z-score. Carotid IMT was measured by B-mode ultrasonography. The mean of the maximum carotid IMT readings of three right and three left far walls for common, bulb and internal segments was used. In univariate analysis, significant correlates of adulthood carotid IMT (standardized to age-, race- and gender-specific z-score) were, in the order of decreasing magnitude, triglyceride and LDL cholesterol in white males; systolic blood pressure, LDL cholesterol, and body mass index (BMI) in white females; systolic blood pressure in black males; BMI and systolic blood pressure in black females. In multivariate regression analysis, significant predictors of carotid IMT were triglycerides and LDL cholesterol in white males; systolic blood pressure and LDL cholesterol in white females; systolic blood pressure in black males; and BMI and LDL cholesterol in black females. In conclusion, the predictability of childhood CV risk factors for increased carotid IMT in adulthood varies by race and gender. The prevention implications of these findings need further investigation.

New Cholesterol Guidelines for Children?

For children and adolescents, comprehensive guidelines for the diagnosis and management of elevated cholesterol have been published once, by the National Cholesterol Education Program in 1992.1 Since then, substantial research on early atherosclerosis and in related clinical areas has been conducted; simultaneously, the obesity epidemic has added the metabolic syndrome and its related high-triglyceride/low–high-density lipoprotein (HDL) phenotype to the agenda of those interested in establishing a consensus approach to early cardiovascular disease prevention.2 Article p 1056 Before assuming that new knowledge and secular trends in risk factors demand substantial revision of cardiovascular health guidelines for children, we must first consider several valuable, often prescient aspects of the 1992 report. First is an emphasis on the importance of nutritional management over pharmacological management of elevated low-density lipoprotein (LDL) cholesterol, unless levels clearly associated with premature cardiovascular disease exist and children are sufficiently old that advanced atherosclerotic lesions may be presumed to be present. Two randomized trials of dietary intervention, the DISC (Dietary Intervention Study in Children) and STRIP (Special Turku coronary Risk factor Intervention Project for babies) studies, have shown that the diet recommended by the 1992 report is safe and mildly effective in lowering LDL cholesterol and thus can be implemented in population-based strategies of cardiovascular disease risk lowering.3,4 Furthermore, the PDAY (Pathobiological Determinants of Atherosclerosis in Youth) study has shown that advanced, irreversible atherosclerotic lesions (American Heart Association grades IV and V) are rarely present before 19 years of age and that the relationship of risk to atherosclerosis in late adolescence is with regard to reversible early lesion grades (American Heart Association grades I through III).5 A second and woefully underrecognized virtue of the 1992 report is the definition of risk strata for LDL cholesterol, with borderline values being 110 to 129 mg/dL and high …