ABC | Volume 113, Nº4, October 2019

Updated Updated Cardiovascular Prevention Guideline of the Brazilian Society Of Cardiology – 2019 Arq Bras Cardiol. 2019; 113(4):787-891 atherosclerosis, with improvement of endothelial function and even regression of intimal thickening, markers of subclinical atherosclerosis. 571,572 (Recommendation Level IIa, level of evidence B). Current evidence for adults shows that total activity volume is more important than the duration of each individual session. 573 Recommendations for all age groups emphasize increasing overall physical activity (moving more) and reducing sedentary activity (avoiding long sitting periods) whenever possible. For children, this means encouraging outdoor play whenever possible, activities with different levels of intensity, such as walking the dog, storing toys, walking to school, among others. It also means, from a public policy point of view, ensuring safe spaces for children and adolescents to play sports or jogging, an urban layout that encourages walking or cycling, and the structure and availability of qualified physical exercise teachers, schools and other community locations such as parks and gyms. 568,573 (Recommendation Level I, level of evidence C). 11.4. Smoking in children and Adolescence About 18.5% of Brazilian adolescents have tried cigarette smoking. Smoking increases CV risk in childhood, even when it is passive: low birth weight, higher risk of childhood obesity; it also determines endothelial dysfunction as early as childhood, in addition to all pulmonary neurological risks. 574,575 Childhood is the most important phase for smoking prevention, as about 90% of people start smoking by age 18. In addition, it is an ideal moment for parental smoking cessation, as they may change their habits if the harmful effects of secondhand smoke are shown to their children. This intervention should occur in different environments, 2 of which may be directly addressed by the physician: 576 (Recommendation level I, level of evidence C). At the pediatrician clinic: 1. Ask about your child’s passive exposure to smoking during childcare consultations and in consultations regarding potentially smoking-related illnesses. Ask about caregiver and environment smoking, electronic cigarettes and cannabis use. 2. Include smoking prevention in your childcare agenda. Clarification about the harms of smoking in consultations from 5 years of age. For teens, talk about the effects on appearance, sports performance and costs. Discuss electronic cigarette. 3. Recommend treatment for caregivers who smoke. Refer to specialized smoking cessation services. 4. Offer treatment to adolescent smokers users who want to quit smoking. Moderate or severe adolescent users may benefit from drug treatment. Periodic follow-up should occur due to the high chance of relapse. 5. Closely assess the risk of psychiatric symptoms during treatment. Suicidal ideation and suicide may occur, which must be monitored and treated. 6. Do not recommend the use of electronic cigarettes. The harmful effects are similar. 7. If second-hand smoke cannot be eliminated, agree on measures that minimize exposure. In medical schools: At all levels of teaching and learning and for all health professionals, smoking cessation training should be provided. The prevention of active and passive smoking, as well as forms of intervention in smoking cessation should be part of the curriculum of pediatric and family medicine residency programs, due to the great importance of abuse in the general population. (Recommendation Level I, level of evidence C). 11.5. Obesity in Childhood and Adolescence Between 1975 and 2016 the prevalence of obesity between 5 and 19 years increased on average from 0.7% to 5.6% in girls and from 0.8% to 7.8% in boys in all geographic regions of the world. The study estimated that in 2016 there were 50 million obese girls and 74 million obese boys worldwide. 577 In Brazil, the 2015 National School Health Survey identified a prevalence of overweight and obesity in 23.3 % and 8.5% in students from 13 to 17 years old, respectively. 578 11.5.1. Diagnosis BMI is used as the standard measure of overweight and obesity in children from two years of age, 579 using World Health Organization reference curves. (https://www.who . int/childgrowth/standards/bmi_for_age/en/). Overweight is defined as between the 85 th and 94 th BMI percentile; obesity above the 95 th percentile; severe obesity, when BMI is greater than or equal to 120% of the 95th percentile or BMI equal to or above 35 kg/m 2 . (Recommendation Level IIa, level of evidence C). 11.5.2. Consequences Childhood obesity is associated with dyslipidemia (high triglyceride levels and low HDL-cholesterol), hypertension, hyperglycemia, hyperinsulinemia, inflammation and oxidative stress, favoring the evolution of fatty striae in the aorta and coronary arteries, as well as other atherosclerotic lesions. 580 About 50% of obese children aged 6 years and one obese parent will have obesity in adulthood; 80% of obese adolescents in this condition, will be an obese adult. 580 11.5.3. Etiology It is the result of the interaction between genetic factors and environmental factors; sedentary lifestyle and excessive calorie consumption, the focus of treatment strategies, are among the latter. 580,581 The secondary causes of childhood obesity are described in Chart 11.1. 11.5.4. Treatment The therapeutic approach for overweight in children and adolescents should be multiple and gradual, with progressive evaluation of the results obtained and involve better diet quality, reduced calorie intake, increased physical activity and meal replacements. Pharmacotherapy (Orlistat is currently the only one approved for use in adolescents) and bariatric 855