Cardiovascular disease (CVD) is a major cause of morbidity and mortality in women and men in the United States and globally.1 It is well established that atherosclerotic CVD processes begin early in life and are influenced over the life course by the interaction of genetic and potentially modifiable risk factors, patterns of health-related lifestyle behaviors, and environmental exposures and contexts. Relatedly, the benefits of maintaining ideal cardiovascular health across the life course are well established.2 Central to cardiovascular health in childhood is the adoption and maintenance of healthy lifestyle behaviors with the aim of preventing the emergence of risk factors for CVD. During the past several decades, evidence-based guidelines for promoting cardiovascular health and preventing future risk for CVD in childhood have been issued by the American Heart Association3; the National Heart, Lung, and Blood Institute (NHLBI)4; and the American Academy of Pediatrics (AAP).5 As underscored in the integrated guidelines issued by NHLBI,4 the rationale for development and dissemination was based on (1) accumulated evidence documenting early life origins of atherosclerotic CVD processes, (2) existence of methods for identifying and measuring risk factors in childhood, (3) evidence demonstrating that development and progression of atherosclerosis is related to the number and intensity of CVD risk factors beginning in childhood, (4) longitudinal research indicating that risk factors (ie, obesity) track from childhood into adult life, and (5) existence of interventions for the management of identified CVD risk factors.4 Particularly noteworthy and highlighted in all the guidelines is emphasis on healthy lifestyle behaviors as the cornerstone of cardiovascular health promotion and risk reduction.3–5

Designed for implementation by pediatric healthcare professionals, recent clinical practice guidelines issued by the AAP focuses on obesity, a major risk factor for CVD in children and adolescents.5 Indeed, the prevalence and secular trends of childhood obesity do not augur well for their cardiovascular health later in the life course. Defined as body mass index ≥ 95th age-sex–specific percentile, data indicate that 14.7 million children and adolescents (aged 2–19 years) are obese with differences by age, race/ethnicity, and sociodemographics and social determinants of health.6 Recent data (from the National Health and Nutrition Examination Surveys) indicate that, among all children and adolescents (aged 2–19 years), obesity prevalence increased with age (12.7% for those aged 2–5 years, 20.7% for those aged 6–11 years, and 22.2% for 12- to 19-year-olds). The prevalence of obesity among children and adolescents was 17.6% and 15.4% for non-Hispanic White, 18.8% and 30.8% for non-Hispanic Black, 13.1% and 5.2% for non-Hispanic Asian, and 29.3% and 23.0% for Hispanic boys and girls, respectively.6 Although this population-based data predate the COVID-19 pandemic, the differences in prevalence of obesity in children and adolescents by race/ethnicity have been observed consistently.7 Relatedly, data generated from clinical and population-based studies demonstrate the impact of sociodemographic factors on weight status and health behaviors including patterns of physical activity and dietary intake.7 Obesity has been shown to disproportionally affect lower income and minority adult and pediatric populations, with data indicating an increased prevalence of this chronic condition due to the COVID-19 pandemic.8

The AAP guidelines,5 like those issued by the American Heart Association3 and NHLBI,4 endorse the importance of developing and maintaining healthy patterns of lifestyle behaviors that are known to influence energy balance and weight status. Recognizing the impact of social determinants of health-on-health behaviors and health across the life course, the AAP calls substantial attention to the importance of healthcare providers' assessments of factors and contexts that extend beyond the level of the individual child and clearly affect the acquisition of healthy patterns of lifestyle behaviors.5 Viewed within a social determinants of health perspective, it is well established that disparities exist in access to safe and appropriate outlets for physical activity and availability and resources essential for heart-healthy dietary intake. The AAP clinical guideline for evaluation and management of obesity in childhood details the effects of adverse social determinants on weight status in childhood.5 As such, healthcare providers are encouraged to be knowledgeable about underlying environmental and social determinants that pose risk for obesity in children and their respective families as well as considering the genetic and biological factors that contribute to this chronic condition. Relatedly, in clinical encounters with children with obesity and their respective families, healthcare providers are advised to inform them about the complexities of childhood obesity and to recognize risk factors in their environments and behaviors, to honor cultural preferences, and to institute changes independently as well as with the guidance of trusted and well-trained advocates—such as pediatricians, nurses, and other primary healthcare providers. The AAP also recommends emphasis placed on the goals of treatment including improved weight status and reduction or elimination of obesity-related comorbidities.5

Recommendations offered by the AAP for obesity treatment are comprehensive and include (1) providing intensive health behavior and lifestyle treatment; (2) evaluating and monitoring child or adolescent for obesity-related medical and psychological comorbidities; (3) identifying and addressing social drivers of health; (4) using nonstigmatizing approaches that honor unique individual qualities of child and family; (5) using motivational interviewing that addresses nutrition, physical activity, and health behavior change with evidence-based targets for weight reduction and health promotion; (6) setting collaborative treatment goals not limited to body mass index stabilization or reduction—including goals that reflect improvement or resolution of comorbidities, quality of life, and self-image; and (7) tailoring treatment to the ongoing and changing needs of the individual child or adolescent, and the family and community context.5 Noteworthy is that the AAP guideline recommends integrating weight management components and strategies across appropriate disciplines, which can include intensive health behavior and lifestyle treatment with pharmacotherapy, and metabolic and bariatric surgery if needed.5

Clearly, the prevalence and trends of obesity in children and adolescents in the United States do not bode well for their cardiovascular health and pose major challenges for healthcare providers and systems of care.8 Obesity is associated with other cardiovascular-related comorbidities in childhood and adolescence including (but not limited to) dyslipidemia, hypertension, elevated blood pressure, adverse changes in vascular structure and function, left ventricular hypertrophy, metabolic syndrome, and type 2 diabetes.9

Although the AAP guideline offers a comprehensive and evidence-based approach to evaluation and treatment of childhood obesity, the optimal approach is to prevent its development in the first place.2 A challenge and opportunity for optimizing cardiovascular health for all US children and adolescents is to advocate for multilevel policies that will enable primordial prevention and ensure equal access to environments and resources central to development and maintenance of patterns of health behaviors known to impact weight status and cardiovascular health of all children and youth.8

1. Martin SS, Aday AW, Almarzooq ZI, et al. 2024 Heart and stroke statistics: a report of US and global data from the American Heart Association. Circulation. 2024;149:e000–e000. doi:10.1161/CIR. 0000000000001209. 2. Lloyd-Jones DM, Allen NB, Anderson CAM, et al. Life's Essential 8: updating and enhancing the American Heart Association's construct of cardiovascular health: a presidential advisory from the American Heart Association. Circulation. 2022;146(5):e18–e14. 3. Kavey RE, Daniels SR, Lauer RM, et al. American Heart Association guidelines for primary prevention of atherosclerotic cardiovascular disease beginning in childhood. Circulation. 2003;107:1562–1566. 4. National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(suppl 5):S213–S256. 5. Hampl SE, Hassink SG, Skinner AG, et al. Clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. Pediatrics. 2023;151(2):e2022060640. 6. Centers for Disease Control and Prevention. Prevalence of childhood obesity in the United States. https://www.cdc.gov/obesity/data/childhood.html. Accessed January 24, 2024. 7. Bleich SN, Ard JD. COVID-19 and structuralism racism: understanding the past and identifying solutions for the future. Cell Metab. 2021;33(2):234–241. 8. Trust for America's Health. State of obesity 2023: better policies for healthier America. https://www.tfah.org/report-details/state-of-obesity-2023. Accessed January 24, 2024 9. Daniels SR, Arnett DK, Eckel RH, et al. Overweight in children and adolescents: pathophysiology, consequences, prevention and treatment. Circulation. 2005;222:1999–2012.