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Risk factors for cardiovascular disease in children with type I diabetes: Part II
Risk Factors For Cardiovascular Disease in Children With Type I Diabetes: Part U Terri H. Lipman, PhD, CRNP Laura L. Hayman, PhD, RN, FAAN Carolyn E. Fabian, MSN, RN, CRNP Diabetes is a major risk factor for premature morbidity and mortality caused by cardiovascular disease (CVD). In Part l of this two part series, physiologic risk factors for cardiovascular disease in children with diabetes were presented. In Part II lifestyle CVD risk factors in children with diabetes will be discussed. Dietary factors, smoking behavior, and activity level are the risk factors most amenable to intervention. Two case studies are included to show clinical application of the data presented.
Copyright 9 1997 by W.B. Saunders Company
p
ERSONS with diabetes are at increased risk for the development of cardiovascular disease. There is convincing evidence that primary prevention of Cardiovascular disease (CVD) must begin early in childhood, particularly in children with diabetes. Lifestyle risk factors are most amenable to intervention. Although data in children are incomplete and controversial, reducing dietary fat, cessation of smoking, and increasing activity level improve the risk factor profile. A review of the literature related to lifestyle CVD risk factors with implications for nurses working with children with diabetes will be presented.
LIFESTYLERISK FACTORS Diet Dietary factors are the most important environmental determinants of serum lipoproteins and atherogenic processes that advance the development of coronary artery disease. Hypercholesterolemia may be directly related to dietary intake behaviors that individuals learn in early childhood.
From the University of Pennsylvania, School of Nursing, Diabetes/Endocrinology, St. Christopher's Hospital for Children, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland OH, and Children's Hospital of Philadelphia, Philadelphia, PA 19104. Address reprint requests to Terri H. Lipman, Assistant Professor, University of Pennsylvania School of Nursing, Diabetes/ Endocrinology, St. Christopher's Hospital for Children, Philadelphia, PA 19134. Copyright 9 1997 by W.B. Saunders Company 0882 -5963/97/1206-0001 $3.00/0 318
These behaviors and food attitudes are further influenced by parents, peers, and the school setting. A diet high in saturated fats, cholesterol and simple sugars contributes to elevated cholesterol levels (National Cholesterol Education Program, 1991; Hallfrisch et al., 1985). Major sources of total and saturated fat intake in children as reported in the Bogalusa Heart Study include beef, milk, pork, and desserts (Frank et al., 1986). Recent national data from NHanes III indicate that U.S. children and adolescents are consuming 34% of their daily total calories from fat with saturated fats contributing 12% (McDowell et al., 1994; Lenfant & Ernst, 1994). These data, combined with other recent results (Thompson & Dennison, 1994), suggest some positive temporal trends in children's dietary intakes; however, additional progress is needed to meet population goals, reduce total cholesterol (TC) levels, and prevent premature CVD. Food patterns emphasizing fruits, vegetables, fiber, and grains high in complex carbohydrates are associated with healthy lipid levels. The NCEP ( 1991) and the American Heart Association's Committee on Atherosclerosis and Hypertension in Childhood (Strong et al., 1992) recommend as a first line of treatment for elevated cholesterol that children over age 2 limit their total fat intake to less than 30% of their total caloric intake and decrease their cholesterol to 100 mg per 1000 calories while receiving sufficient calories, protein, minerals, and vitamins. Thompson and Dennison (1994) suggest substituting lower fat foods as a major strategy for Journalof PediatricNursing,Vol 12, No 6 (December),1997
CVD IN DIABETIC CHILDREN
achieving these goals while maintaining growth processes. In persons with diabetes, as in persons without diabetes, a reduction in high dietary intakes of cholesterol-raising fatty acids is an important goal to reduce the risk of CVD (Franz et al., 1994). There is controversy regarding the percent of dietary calories that should be composed of fat. The American Diabetes Association recommends that dietary protein should contribute 10% to 20% of daily calories. Therefore 80% to 90% of calories remain to be distributed between dietary carbohydrate and fat. In an attempt to lower dietary saturated fat intake, diets consisting of less than 30% of calories from fat have been recommended. This approach would leave 60% of calories to be composed of carbohydrates. It has been shown that high carbohydrate low-fat diets may aggravate hypertriglyceridemia, and reduce HDL cholesterol (Coulston, Hollenbeck, Swislock & Reavan, 1989). Because of this controversy, the ADA recommendations state that less than 10% of daily calories should be from saturated fat, but that the percent of calories from carbohydrate and total fat should be based on nutritional assessment and treatment goals (1994). If elevated LDL cholesterol is a problem in a person with diabetes, the ADA (1994) recommends implementing the National Cholesterol Education Program Step II diet guidelines in which less than 7% of total calories are from saturated fat, less than 30% of the calories are from total fat and dietary cholesterol is less than 200 mg/day. There is also controversy related to the effect of fructose and fiber on cholesterol in persons with diabetes. Although the data are difficult to interpret in dietary fiber trials because body weight and calories have not been adequately controlled, there is evidence that chronic consumption of soluble fiber can marginally reduce blood total and LDL cholesterol in persons with diabetes (Nuttall, 1993). Conversely, fructose has been shown to increase total cholesterol and LDL cholesterol in patients with diabetes (Bantle, Swanson, Thomas & Laine, 1992). Because the effects of fiber and fructose on lipid levels in diabetes are minor, the recommendations are the same as for the general population. The ADA stresses that nutrition recommendations for children with diabetes should be individualized with the goal of maintaining health and a sense of normality. The dietary prescription must allow for normal growth and development (Franz, et al., 1994).
319
Smoking The excess risk for cardiovascular mortality in cigarette smokers can in part be attributed to an atherogenic lipid profile. Cigarette smoking stimulates norepinephrine release that raises free fatty acid levels, which enhance hepatic triglyceride and cholesterol synthesis (Craig, Palomaki, & Haddow, 1989). Cross-sectional studies show higher VLDL and low HDL levels among cigarette smokers (Voors et al., 1982). Few studies have examined the effect of smoking on the risk for CVD in persons with diabetes, which is crucial in view of the fact that the prevalence of smoking among people with diabetes is even higher than among people without diabetes, especially in Black and Hispanic men (Voors et al., 1982). In men with IDDM, cholesterol ester transfer protein (CETP) is increased. CETP is important in the distribution of cholesterol ester between lipoproteins and may be responsible for depositing cholesterol in the arterial wall. In one study, male smokers with IDDM also had significantly lower levels of HDL than men with IDDM who did not smoke (Dullaart et al., 1994). Persons with IDDM who smoke have atherogenic alterations comparable with those in the nondiabetic population. Nurses who work with adolescents with diabetes must be cognizant of the importance of obtaining a smoking history from the adolescent without a parent being present. Use of adolescent support groups may be effective in disseminating the message of the importance of not smoking.
Activity Studies have shown significant relationships between levels of physical activity and lipid and lipoprotein levels among adolescents (Linder & Durant, 1982). Higher levels of cardiovascular fitness and lower levels of obesity have been associated with more favorable serum lipid and lipoprotein levels in young children (Durant et al., 1993). Regular aerobic exercise has a beneficial effect on lipids by increasing HDL and decreasing total cholesterol, triglycerides and LDL cholesterol (Hofman & Walter, 1989). There are limited data on the effects of activity on lipids and lipoproteins in children with IDDM. Exercise has been shown to enhance muscle glucose uptake and augment insulin sensitivity (Bjorkman, 1986; Koivisto, Yki-Jarvinen & DeFronzo, 1986). In a study of 59 adolescents with IDDM, physical fitness correlated inversely with LDL (Austin, Waity, Janosky & Aslanian, 1993). Campaigne and others (1985) showed that an
320
UPMAN, HAYMAN, AND FABIAN
exercise program resulted in a significant decrease in LDL levels in children with IDDM. There was not an increase in HDL, although in adults with IDDM, exercise has been shown to increase levels of HDL (Wood & Haskell, 1979). Clearly, more studies are needed to further elucidate the effect of exercise on the lipid profile of children with diabetes. Various tools are available for the assessment of activity level (Pate, Long & Heath, 1994). Children with diabetes should be encouraged to participate in age-appropriate sports and other types of recreational physical activity. For the sedentary child who dislikes exercise, a walking program which includes the family should be initiated at the time of diagnosis of diabetes.
SUMMARY It has been shown that cardiovascular disease is more prevalent in persons with diabetes but much is still unknown. The effect of diabetes control on CVD risk is controversial. Research has indicated some similarities and some differences in the CVD risk factor profile of children with diabetes compared with the general population. For both diabetic and nondiabetic children, however, the data suggest adoption of a heart-healthy lifestyle early in life to prevent premature CVD. Interventions specific to CVD risk factors can be found in Table 1. In the next section, two case studies are presented to show the clinical application of information presented. Table 1. Nursing Interventionsfor Children with Diabetes Having Risk Factorsfor Cardiovascular Disease
CVDRiskFactors Diabetes
PositiveFamily History Hypertension Obesity High Fat Diet
Smoking Inactivity
ClinicalInterventions Cannot be eliminated Improve Diabetes Control Increase number of blood glucose levels Increase number of insulin injections Cannot be changed Decreasesodium in diet IncreaseActivity Decreasecaloric intake IncreaseActivity Heart healthy diet <7% calories from saturated fat <30% calories from total fat Increasedietary fiber Adolescent support group for smoking cessation Encourage sports Developwalking program Arrange group activities
CASE STUDY NO. 1 Dana is a 15-yem'-old white young woman with IDDM since age 8. Her father has hypercholesterolemia (240 mg/dL) controlled with diet. Her paternal grandfather had a myocardial infarction at age 62. There is no other family history of CVD. Dana's diabetes is in good control. She monitors her blood sugar twice a day and she takes two injections of mixed insulin each day. Her last glycosylated hemoglobin, which is a measure of diabetes control, was 9.2% (nl 5-8.5%). She has never smoked. Dana is very active--she plays softball in the summer and soccer in the winter, and follows a well-balanced low-fat diet. On physical examination, Dana's height is at the 50th percentile, her weight is at the 25th percentile. Her blood pressure is 114/68. Her pubertal development is Tanner IV. Her total cholesterol level is 172 mg/dL. What does Dana's history tell us? What is her CVD risk profile? What should the nursing interventions be? Dana has several risk factors for cardiovascular disease. She has a family history of CVD and she has type I diabetes. However, the remainder of her CVD risk factor profile is excellent. Her cholesterol and blood pressure are normal. She is not obese, she is active and does not smoke. She eats a low-fat diet and her diabetes is in good control. The plan of care for Dana would be to intervene with those risk factors that could be altered to improve her CVD risk factor profile. Dana's family history and diabetes risk factors cannot be altered. Her plan would include reinforcing the importance of Dana maintaining her heart healthy lifestyle (activity, low-fat diet, non-smoking, lean body mass). Her diabetes control, which is good, could be improved. The interventions would be to recommend increasing the number of blood glucose tests at home and possibly adding a third injection of insulin. Dana's healthy lifestyle coupled with improved diabetes control should be very helpful in preventing cardiovascular disease.
CASE STUDY NO. 2 Emily is a 12-year-old girl who was diagnosed recently with hypercholesterolemia by her pediatrician. An initial nonfasting total cholesterol of 238 mg/dL was reported 3 months ago and recently a fasting lipid profile reflected a total cholesterol of 240 mg/dL, HDL - 6 5 , LDL - 1 5 4 , and triglycerides-103. Her father's cholesterol was recently tested for the first time and he was found to have hypercholesterolemia TC - 265 mg/dl, LDL - 199,
CVD IN DIABETICCHILDREN
321
HDL - 4 2 , and triglycerides -90). Her mother and her siblings have normal lipid profiles. There is no other family history of CVD, hypercholesterolemia, hypertension, or diabetes. Emily is very active with softball and cheerleading at school. She tries to eat fairly balanced meals but she does not like the low-fat foods that are available and she feels pressure from peers to eat "fast foods." However, her mother is learning to buy and prepare low-fat meals for the family so Emily and her father can "eat better." Upon physical exam, Emily's weight and height are both in the 75th percentile for her age. Her blood pressure is 118/68, and her pubertal development is Tanner III. Emily has never smoked, she has tried to lose some weight over the past 2 years but has been unsuccessful in all of the attempts. 1. What does Emily's history show? 2. What is her CVD risk profile? 3. What are appropriate nursing interventions? Emily has several risk factors for cardiovascular disease including a family history of hyperlipidemia, hypercholesterolemia (TC >95th percentile for age and sex), excess weight/adiposity, and a typical high-fat American diet consisting of fast foods. Her blood pressure, patterns of physical activity, smoking behavior, and attempts at weight and dietary change are positive aspects of her total CVD profile. At Tanner III, Emily is experiencing the physiologic changes of puberty that are known to influence CVD risk factors including her lipid profile. Persistence at the 95th percentile for TC during this developmental transition suggests that Emily will need to monitor and manage this risk factor throughout her adult life. Fortunately, Emily's mother is attempting to help her regulate the most important environmental (modifiable) influ-
ence on blood cholesterol and weight, her dietary intake. Because developmental transitions can be critical points for behavioral change, professional, family, and peer support have the potential to influence positively her future cardiovascular health. Although specific nursing interventions would vary as a function of the setting in which the provider-consumer encounter occurs, a developmental profile approach to health promotion and risk reduction would be most effective across settings. Because Emily is physically and cognitively capable of managing her risk factor profile, interventions should aim to engage her actively in all phases of the plan of care. Targeting her weight problem through restrictions in dietary fat and total calories while concomitantly increasing energy expenditure through self-selected physical activity would be treatment hallmarks. Specifically, the plan would include the American Heart Association's Step I diet with sufficient calories for growth and developmental processes. Failure to reduce cholesterol levels within a 6 month time period may result in the Step II diet with additional reductions in dietary saturated fat. Empowering Emily for heart healthy self-care and supporting her physically active, smoke-free lifestyle promotes adherence and should be part of the plan of care across settings.
CONCLUSIONS Knowledge of physiologic lifestyle risk factors for cardiovascular disease is crucial for all nurses caring for children with diabetes. Each risk factor must be routinely assessed. Appropriate intervention or referral must be instituted in an attempt to decrease or eliminate cardiovascular disease in persons with diabetes.
REFERENCES American Diabetes Association. Position statement: Nutrition recommendations and principles for people with diabetes mellitus (1994). Diabetes Care, 17, 519-522. Austin, A., Waity, V., Janosky, J., & Aslanian, S. (1993). The relationship of physical fitness to lipid and lipoprotein (a) levels in adolescents with IDDM. Diabetes Care, 16, 421-425. Bantle, J.P., Swanson, J.E., Thomas, W., & Laine, D.C. (1992) Metabolic effects of dietary fructose in diabetic subjects. Diabetes Care, 15, 1468-1476. Bjorkman, O. (1986). Fuel metabolism during exercise in normal and diabetic men. Diabetes~Metabolism Reviews, 1, 319-357. Campaigne, B.N., Landt, M.J., Mellies, M.D., et al. (1985). The effects of physical training in blood lipid profiles in adolescents with IDDM. Physician and Sports Medicine, 13, 83-89. Coulston, A.M., Hollenbeck, C.B., Swislock, A.L.M., & Reavan, G.M. (1989). Persistence of hypertriglyceridemic effect
of low fat, high carbohydrate diets in IDDM patients. Diabetes Care. 1Z 94-101. Craig, W.Y., Palomaki, G.E., & Haddow, J.E. (1989). Cigarette smoking and serum lipid and lipoprotein concentrations: An analysis of published data. British Medical Journal, 298, 784-788. Dullaart, R.P.F., Groener, J.E.M., Pikkeschei, B.D., et al. (1994). Elevated cholesterol ester transfer protein activity in IDDM men who smoke. Diabetes Care, 17, 688-692. Durant, R.H., Baranowski, T., Rhodes, T., Gatin, B., Thompson, W.D., Carroll, R., Puhl, J., & Greaves, K.A. (1993). Association among serum lipid and lipoprotein concentrations and physical activity, physical fitness, and body composition in young children. Journal of Pediatrics, 123, 185-192. Frank, G., Webber, L,, et al. (1986). Data Book: Quantifying dietary intake of infants, children, and adolescents--the Bogalusa heart study, 1973-1983. From the Nutrition Core and Planning and Analysis Core Components of National Research
322 and Demo Cente~ Arteriosclerosis (NRDC-A), New Orleans, LA. Franz, M.J., Horton, E.S. Sr., Bantle, J.P., Beebe, C.A., Brunzell, J.D., Coulston, A.M., Henry, R.R., Hoogwef, B.L, & Stacpoole, P.W. (1994). Nutrition principles for the management of diabetes and related complications. Diabetes Care, 17, 490-518. Hallfrisch, J., West, S., Fisher, C., Reiser, S., Metz, W., Prather, E.S., & Canary, J.J. (1985). Modification of the US diet to effect changes in blood lipids and lipoprotein distribution. Atherosclerosis, 57, 179. Hofman, A. & Walter, H.J. (1989). The association between physical fitness and cardiovascular disease risk factor in children in a five year follow-up study. Journal of Epidemiology, 18, 830-835. Koivisto, V.A., Yki-Jarvinen, H. & DeFronzo, R.A. (1986). Physical training and insulin sensitivity. Diabetes Metabolism Reviews, 1, 445-481. Lenfant, C. & Ernst, N. (1994). Daily dietary fat and total food-energy intakes. Third National Health and Nutrition Examination Survey. Phase 1. 1988-1991. MMWR. 43: 116. Linder, C.W., & Durant, R.H. (1982). Exercise, serum lipids, and cardiovascular disease risk factors in children. Pediatric Clinics of North America, 29, 1341-1354. McDowell, M.A., Briefel, R.R., Alaimo, K., Bischof, A.M. et al. (1994). Energy and macronutrient intakes of persons ages 2 months and over in the United States: Third National Health and Nutrition Examination Survey, Phase 1, 1988-91. USDHHS,
UPMAN, HAYMAN, AND FABIAN PHS, Centers for Disease Control and Prevention (Advance Data No. 255, October 24, 1994). National Cholesterol Education Program. (1991). Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Bethesda, MD., National, Heart Lung and Blood Institute Information Center. (NIH Publication No. 91-2732). Nuttall, EQ. (1993). Dietary fiber in the management of diabetes. Diabetes, 42, 503-508. Pate, R.R., Long, B.J. & Heath, G. (1994). Descriptive epidemiology of physical activity in adolescents. Pediatric Exercise Science, 6(4), 434-447. Strong, W.B., Deckelbaum, R.J., Gidding, S.S., Kavey, R.E., Washington, R., Wilmore, J.H. & Perry, C.L. (1992). Integrated cardiovascular health promotion in childhood. A statement for health professionals from the subcommittee on atherosclerosis and hypertension in childhood of the council on cardiovascular disease in the young, American Heart Association. Circulation, 85, 1638-1650. Thompson, EE., & Dennison, B.A. (1994). Dietary sources of fats and cholesterol in children aged 2 through 5 years. American Journal of Public Health, 84, 799-806. Voors, A.W., Srinvasan, S.R., Hunter, S.M., Webber, L.S., Sklov, M.C. & Berenson, G.S. (1982). Smoking, oral contraceptives, and serum lipid and lipoprotein levels in youths of a total biracial community. Preventive Medicine, 11, 1-2. Wood, P.D. & Haskell, W.L. (1979). The effect of exercise on plasma high density lipoproteins. Lipids, 14, 417-427.
Copyright 9 1997 by W.B. Saunders Company
p
ERSONS with diabetes are at increased risk for the development of cardiovascular disease. There is convincing evidence that primary prevention of Cardiovascular disease (CVD) must begin early in childhood, particularly in children with diabetes. Lifestyle risk factors are most amenable to intervention. Although data in children are incomplete and controversial, reducing dietary fat, cessation of smoking, and increasing activity level improve the risk factor profile. A review of the literature related to lifestyle CVD risk factors with implications for nurses working with children with diabetes will be presented.
LIFESTYLERISK FACTORS Diet Dietary factors are the most important environmental determinants of serum lipoproteins and atherogenic processes that advance the development of coronary artery disease. Hypercholesterolemia may be directly related to dietary intake behaviors that individuals learn in early childhood.
From the University of Pennsylvania, School of Nursing, Diabetes/Endocrinology, St. Christopher's Hospital for Children, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland OH, and Children's Hospital of Philadelphia, Philadelphia, PA 19104. Address reprint requests to Terri H. Lipman, Assistant Professor, University of Pennsylvania School of Nursing, Diabetes/ Endocrinology, St. Christopher's Hospital for Children, Philadelphia, PA 19134. Copyright 9 1997 by W.B. Saunders Company 0882 -5963/97/1206-0001 $3.00/0 318
These behaviors and food attitudes are further influenced by parents, peers, and the school setting. A diet high in saturated fats, cholesterol and simple sugars contributes to elevated cholesterol levels (National Cholesterol Education Program, 1991; Hallfrisch et al., 1985). Major sources of total and saturated fat intake in children as reported in the Bogalusa Heart Study include beef, milk, pork, and desserts (Frank et al., 1986). Recent national data from NHanes III indicate that U.S. children and adolescents are consuming 34% of their daily total calories from fat with saturated fats contributing 12% (McDowell et al., 1994; Lenfant & Ernst, 1994). These data, combined with other recent results (Thompson & Dennison, 1994), suggest some positive temporal trends in children's dietary intakes; however, additional progress is needed to meet population goals, reduce total cholesterol (TC) levels, and prevent premature CVD. Food patterns emphasizing fruits, vegetables, fiber, and grains high in complex carbohydrates are associated with healthy lipid levels. The NCEP ( 1991) and the American Heart Association's Committee on Atherosclerosis and Hypertension in Childhood (Strong et al., 1992) recommend as a first line of treatment for elevated cholesterol that children over age 2 limit their total fat intake to less than 30% of their total caloric intake and decrease their cholesterol to 100 mg per 1000 calories while receiving sufficient calories, protein, minerals, and vitamins. Thompson and Dennison (1994) suggest substituting lower fat foods as a major strategy for Journalof PediatricNursing,Vol 12, No 6 (December),1997
CVD IN DIABETIC CHILDREN
achieving these goals while maintaining growth processes. In persons with diabetes, as in persons without diabetes, a reduction in high dietary intakes of cholesterol-raising fatty acids is an important goal to reduce the risk of CVD (Franz et al., 1994). There is controversy regarding the percent of dietary calories that should be composed of fat. The American Diabetes Association recommends that dietary protein should contribute 10% to 20% of daily calories. Therefore 80% to 90% of calories remain to be distributed between dietary carbohydrate and fat. In an attempt to lower dietary saturated fat intake, diets consisting of less than 30% of calories from fat have been recommended. This approach would leave 60% of calories to be composed of carbohydrates. It has been shown that high carbohydrate low-fat diets may aggravate hypertriglyceridemia, and reduce HDL cholesterol (Coulston, Hollenbeck, Swislock & Reavan, 1989). Because of this controversy, the ADA recommendations state that less than 10% of daily calories should be from saturated fat, but that the percent of calories from carbohydrate and total fat should be based on nutritional assessment and treatment goals (1994). If elevated LDL cholesterol is a problem in a person with diabetes, the ADA (1994) recommends implementing the National Cholesterol Education Program Step II diet guidelines in which less than 7% of total calories are from saturated fat, less than 30% of the calories are from total fat and dietary cholesterol is less than 200 mg/day. There is also controversy related to the effect of fructose and fiber on cholesterol in persons with diabetes. Although the data are difficult to interpret in dietary fiber trials because body weight and calories have not been adequately controlled, there is evidence that chronic consumption of soluble fiber can marginally reduce blood total and LDL cholesterol in persons with diabetes (Nuttall, 1993). Conversely, fructose has been shown to increase total cholesterol and LDL cholesterol in patients with diabetes (Bantle, Swanson, Thomas & Laine, 1992). Because the effects of fiber and fructose on lipid levels in diabetes are minor, the recommendations are the same as for the general population. The ADA stresses that nutrition recommendations for children with diabetes should be individualized with the goal of maintaining health and a sense of normality. The dietary prescription must allow for normal growth and development (Franz, et al., 1994).
319
Smoking The excess risk for cardiovascular mortality in cigarette smokers can in part be attributed to an atherogenic lipid profile. Cigarette smoking stimulates norepinephrine release that raises free fatty acid levels, which enhance hepatic triglyceride and cholesterol synthesis (Craig, Palomaki, & Haddow, 1989). Cross-sectional studies show higher VLDL and low HDL levels among cigarette smokers (Voors et al., 1982). Few studies have examined the effect of smoking on the risk for CVD in persons with diabetes, which is crucial in view of the fact that the prevalence of smoking among people with diabetes is even higher than among people without diabetes, especially in Black and Hispanic men (Voors et al., 1982). In men with IDDM, cholesterol ester transfer protein (CETP) is increased. CETP is important in the distribution of cholesterol ester between lipoproteins and may be responsible for depositing cholesterol in the arterial wall. In one study, male smokers with IDDM also had significantly lower levels of HDL than men with IDDM who did not smoke (Dullaart et al., 1994). Persons with IDDM who smoke have atherogenic alterations comparable with those in the nondiabetic population. Nurses who work with adolescents with diabetes must be cognizant of the importance of obtaining a smoking history from the adolescent without a parent being present. Use of adolescent support groups may be effective in disseminating the message of the importance of not smoking.
Activity Studies have shown significant relationships between levels of physical activity and lipid and lipoprotein levels among adolescents (Linder & Durant, 1982). Higher levels of cardiovascular fitness and lower levels of obesity have been associated with more favorable serum lipid and lipoprotein levels in young children (Durant et al., 1993). Regular aerobic exercise has a beneficial effect on lipids by increasing HDL and decreasing total cholesterol, triglycerides and LDL cholesterol (Hofman & Walter, 1989). There are limited data on the effects of activity on lipids and lipoproteins in children with IDDM. Exercise has been shown to enhance muscle glucose uptake and augment insulin sensitivity (Bjorkman, 1986; Koivisto, Yki-Jarvinen & DeFronzo, 1986). In a study of 59 adolescents with IDDM, physical fitness correlated inversely with LDL (Austin, Waity, Janosky & Aslanian, 1993). Campaigne and others (1985) showed that an
320
UPMAN, HAYMAN, AND FABIAN
exercise program resulted in a significant decrease in LDL levels in children with IDDM. There was not an increase in HDL, although in adults with IDDM, exercise has been shown to increase levels of HDL (Wood & Haskell, 1979). Clearly, more studies are needed to further elucidate the effect of exercise on the lipid profile of children with diabetes. Various tools are available for the assessment of activity level (Pate, Long & Heath, 1994). Children with diabetes should be encouraged to participate in age-appropriate sports and other types of recreational physical activity. For the sedentary child who dislikes exercise, a walking program which includes the family should be initiated at the time of diagnosis of diabetes.
SUMMARY It has been shown that cardiovascular disease is more prevalent in persons with diabetes but much is still unknown. The effect of diabetes control on CVD risk is controversial. Research has indicated some similarities and some differences in the CVD risk factor profile of children with diabetes compared with the general population. For both diabetic and nondiabetic children, however, the data suggest adoption of a heart-healthy lifestyle early in life to prevent premature CVD. Interventions specific to CVD risk factors can be found in Table 1. In the next section, two case studies are presented to show the clinical application of information presented. Table 1. Nursing Interventionsfor Children with Diabetes Having Risk Factorsfor Cardiovascular Disease
CVDRiskFactors Diabetes
PositiveFamily History Hypertension Obesity High Fat Diet
Smoking Inactivity
ClinicalInterventions Cannot be eliminated Improve Diabetes Control Increase number of blood glucose levels Increase number of insulin injections Cannot be changed Decreasesodium in diet IncreaseActivity Decreasecaloric intake IncreaseActivity Heart healthy diet <7% calories from saturated fat <30% calories from total fat Increasedietary fiber Adolescent support group for smoking cessation Encourage sports Developwalking program Arrange group activities
CASE STUDY NO. 1 Dana is a 15-yem'-old white young woman with IDDM since age 8. Her father has hypercholesterolemia (240 mg/dL) controlled with diet. Her paternal grandfather had a myocardial infarction at age 62. There is no other family history of CVD. Dana's diabetes is in good control. She monitors her blood sugar twice a day and she takes two injections of mixed insulin each day. Her last glycosylated hemoglobin, which is a measure of diabetes control, was 9.2% (nl 5-8.5%). She has never smoked. Dana is very active--she plays softball in the summer and soccer in the winter, and follows a well-balanced low-fat diet. On physical examination, Dana's height is at the 50th percentile, her weight is at the 25th percentile. Her blood pressure is 114/68. Her pubertal development is Tanner IV. Her total cholesterol level is 172 mg/dL. What does Dana's history tell us? What is her CVD risk profile? What should the nursing interventions be? Dana has several risk factors for cardiovascular disease. She has a family history of CVD and she has type I diabetes. However, the remainder of her CVD risk factor profile is excellent. Her cholesterol and blood pressure are normal. She is not obese, she is active and does not smoke. She eats a low-fat diet and her diabetes is in good control. The plan of care for Dana would be to intervene with those risk factors that could be altered to improve her CVD risk factor profile. Dana's family history and diabetes risk factors cannot be altered. Her plan would include reinforcing the importance of Dana maintaining her heart healthy lifestyle (activity, low-fat diet, non-smoking, lean body mass). Her diabetes control, which is good, could be improved. The interventions would be to recommend increasing the number of blood glucose tests at home and possibly adding a third injection of insulin. Dana's healthy lifestyle coupled with improved diabetes control should be very helpful in preventing cardiovascular disease.
CASE STUDY NO. 2 Emily is a 12-year-old girl who was diagnosed recently with hypercholesterolemia by her pediatrician. An initial nonfasting total cholesterol of 238 mg/dL was reported 3 months ago and recently a fasting lipid profile reflected a total cholesterol of 240 mg/dL, HDL - 6 5 , LDL - 1 5 4 , and triglycerides-103. Her father's cholesterol was recently tested for the first time and he was found to have hypercholesterolemia TC - 265 mg/dl, LDL - 199,
CVD IN DIABETICCHILDREN
321
HDL - 4 2 , and triglycerides -90). Her mother and her siblings have normal lipid profiles. There is no other family history of CVD, hypercholesterolemia, hypertension, or diabetes. Emily is very active with softball and cheerleading at school. She tries to eat fairly balanced meals but she does not like the low-fat foods that are available and she feels pressure from peers to eat "fast foods." However, her mother is learning to buy and prepare low-fat meals for the family so Emily and her father can "eat better." Upon physical exam, Emily's weight and height are both in the 75th percentile for her age. Her blood pressure is 118/68, and her pubertal development is Tanner III. Emily has never smoked, she has tried to lose some weight over the past 2 years but has been unsuccessful in all of the attempts. 1. What does Emily's history show? 2. What is her CVD risk profile? 3. What are appropriate nursing interventions? Emily has several risk factors for cardiovascular disease including a family history of hyperlipidemia, hypercholesterolemia (TC >95th percentile for age and sex), excess weight/adiposity, and a typical high-fat American diet consisting of fast foods. Her blood pressure, patterns of physical activity, smoking behavior, and attempts at weight and dietary change are positive aspects of her total CVD profile. At Tanner III, Emily is experiencing the physiologic changes of puberty that are known to influence CVD risk factors including her lipid profile. Persistence at the 95th percentile for TC during this developmental transition suggests that Emily will need to monitor and manage this risk factor throughout her adult life. Fortunately, Emily's mother is attempting to help her regulate the most important environmental (modifiable) influ-
ence on blood cholesterol and weight, her dietary intake. Because developmental transitions can be critical points for behavioral change, professional, family, and peer support have the potential to influence positively her future cardiovascular health. Although specific nursing interventions would vary as a function of the setting in which the provider-consumer encounter occurs, a developmental profile approach to health promotion and risk reduction would be most effective across settings. Because Emily is physically and cognitively capable of managing her risk factor profile, interventions should aim to engage her actively in all phases of the plan of care. Targeting her weight problem through restrictions in dietary fat and total calories while concomitantly increasing energy expenditure through self-selected physical activity would be treatment hallmarks. Specifically, the plan would include the American Heart Association's Step I diet with sufficient calories for growth and developmental processes. Failure to reduce cholesterol levels within a 6 month time period may result in the Step II diet with additional reductions in dietary saturated fat. Empowering Emily for heart healthy self-care and supporting her physically active, smoke-free lifestyle promotes adherence and should be part of the plan of care across settings.
CONCLUSIONS Knowledge of physiologic lifestyle risk factors for cardiovascular disease is crucial for all nurses caring for children with diabetes. Each risk factor must be routinely assessed. Appropriate intervention or referral must be instituted in an attempt to decrease or eliminate cardiovascular disease in persons with diabetes.
REFERENCES American Diabetes Association. Position statement: Nutrition recommendations and principles for people with diabetes mellitus (1994). Diabetes Care, 17, 519-522. Austin, A., Waity, V., Janosky, J., & Aslanian, S. (1993). The relationship of physical fitness to lipid and lipoprotein (a) levels in adolescents with IDDM. Diabetes Care, 16, 421-425. Bantle, J.P., Swanson, J.E., Thomas, W., & Laine, D.C. (1992) Metabolic effects of dietary fructose in diabetic subjects. Diabetes Care, 15, 1468-1476. Bjorkman, O. (1986). Fuel metabolism during exercise in normal and diabetic men. Diabetes~Metabolism Reviews, 1, 319-357. Campaigne, B.N., Landt, M.J., Mellies, M.D., et al. (1985). The effects of physical training in blood lipid profiles in adolescents with IDDM. Physician and Sports Medicine, 13, 83-89. Coulston, A.M., Hollenbeck, C.B., Swislock, A.L.M., & Reavan, G.M. (1989). Persistence of hypertriglyceridemic effect
of low fat, high carbohydrate diets in IDDM patients. Diabetes Care. 1Z 94-101. Craig, W.Y., Palomaki, G.E., & Haddow, J.E. (1989). Cigarette smoking and serum lipid and lipoprotein concentrations: An analysis of published data. British Medical Journal, 298, 784-788. Dullaart, R.P.F., Groener, J.E.M., Pikkeschei, B.D., et al. (1994). Elevated cholesterol ester transfer protein activity in IDDM men who smoke. Diabetes Care, 17, 688-692. Durant, R.H., Baranowski, T., Rhodes, T., Gatin, B., Thompson, W.D., Carroll, R., Puhl, J., & Greaves, K.A. (1993). Association among serum lipid and lipoprotein concentrations and physical activity, physical fitness, and body composition in young children. Journal of Pediatrics, 123, 185-192. Frank, G., Webber, L,, et al. (1986). Data Book: Quantifying dietary intake of infants, children, and adolescents--the Bogalusa heart study, 1973-1983. From the Nutrition Core and Planning and Analysis Core Components of National Research
322 and Demo Cente~ Arteriosclerosis (NRDC-A), New Orleans, LA. Franz, M.J., Horton, E.S. Sr., Bantle, J.P., Beebe, C.A., Brunzell, J.D., Coulston, A.M., Henry, R.R., Hoogwef, B.L, & Stacpoole, P.W. (1994). Nutrition principles for the management of diabetes and related complications. Diabetes Care, 17, 490-518. Hallfrisch, J., West, S., Fisher, C., Reiser, S., Metz, W., Prather, E.S., & Canary, J.J. (1985). Modification of the US diet to effect changes in blood lipids and lipoprotein distribution. Atherosclerosis, 57, 179. Hofman, A. & Walter, H.J. (1989). The association between physical fitness and cardiovascular disease risk factor in children in a five year follow-up study. Journal of Epidemiology, 18, 830-835. Koivisto, V.A., Yki-Jarvinen, H. & DeFronzo, R.A. (1986). Physical training and insulin sensitivity. Diabetes Metabolism Reviews, 1, 445-481. Lenfant, C. & Ernst, N. (1994). Daily dietary fat and total food-energy intakes. Third National Health and Nutrition Examination Survey. Phase 1. 1988-1991. MMWR. 43: 116. Linder, C.W., & Durant, R.H. (1982). Exercise, serum lipids, and cardiovascular disease risk factors in children. Pediatric Clinics of North America, 29, 1341-1354. McDowell, M.A., Briefel, R.R., Alaimo, K., Bischof, A.M. et al. (1994). Energy and macronutrient intakes of persons ages 2 months and over in the United States: Third National Health and Nutrition Examination Survey, Phase 1, 1988-91. USDHHS,
UPMAN, HAYMAN, AND FABIAN PHS, Centers for Disease Control and Prevention (Advance Data No. 255, October 24, 1994). National Cholesterol Education Program. (1991). Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Bethesda, MD., National, Heart Lung and Blood Institute Information Center. (NIH Publication No. 91-2732). Nuttall, EQ. (1993). Dietary fiber in the management of diabetes. Diabetes, 42, 503-508. Pate, R.R., Long, B.J. & Heath, G. (1994). Descriptive epidemiology of physical activity in adolescents. Pediatric Exercise Science, 6(4), 434-447. Strong, W.B., Deckelbaum, R.J., Gidding, S.S., Kavey, R.E., Washington, R., Wilmore, J.H. & Perry, C.L. (1992). Integrated cardiovascular health promotion in childhood. A statement for health professionals from the subcommittee on atherosclerosis and hypertension in childhood of the council on cardiovascular disease in the young, American Heart Association. Circulation, 85, 1638-1650. Thompson, EE., & Dennison, B.A. (1994). Dietary sources of fats and cholesterol in children aged 2 through 5 years. American Journal of Public Health, 84, 799-806. Voors, A.W., Srinvasan, S.R., Hunter, S.M., Webber, L.S., Sklov, M.C. & Berenson, G.S. (1982). Smoking, oral contraceptives, and serum lipid and lipoprotein levels in youths of a total biracial community. Preventive Medicine, 11, 1-2. Wood, P.D. & Haskell, W.L. (1979). The effect of exercise on plasma high density lipoproteins. Lipids, 14, 417-427.