Trends in Levels of Lipids and Apolipoprotein B in US Youths Aged 6 to 19 Years, 1999-2016

Amanda M Perak; Hongyan Ning; Brian K Kit; Sarah D de Ferranti; Linda V Van Horn; John T Wilkins; Donald M Lloyd-Jones

doi:10.1001/jama.2019.4984

. 2019 May 21;321(19):1895–1905. doi: 10.1001/jama.2019.4984

Trends in Levels of Lipids and Apolipoprotein B in US Youths Aged 6 to 19 Years, 1999-2016

Amanda M Perak ^1,^2,^✉, Hongyan Ning ¹, Brian K Kit ³, Sarah D de Ferranti ⁴, Linda V Van Horn ¹, John T Wilkins ^1,⁵, Donald M Lloyd-Jones ^1,⁵

¹Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois

²Division of Cardiology, Department of Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois

³National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland

⁴Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts

⁵Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois

^✉

Corresponding Author: Amanda M. Perak, MD, MS, Department of Preventive Medicine, Northwestern University, 680 N Lake Shore Dr, Ste 1400, Chicago, IL 60611 (amarma@luriechildrens.org).

Accepted for Publication: April 3, 2019.

Author Contributions: Drs Perak and Ning had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.

Concept and design: Perak, de Ferranti, Van Horn, Lloyd-Jones.

Acquisition, analysis, or interpretation of data: Perak, Ning, Kit, Van Horn, Wilkins, Lloyd-Jones.

Drafting of the manuscript: Perak, Lloyd-Jones.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Ning.

Obtained funding: Perak.

Administrative, technical, or material support: Van Horn.

Supervision: Van Horn, Wilkins, Lloyd-Jones.

Conflict of Interest Disclosures: Dr Wilkins reported receiving consulting fees from NGM Biopharmaceuticals. No other disclosures were reported.

Funding/Support: Dr Perak’s work was supported in part by training grant T32 HL069771 from the National Institutes of Health, a pediatric physician-scientist research award from the Department of Pediatrics, Northwestern University Feinberg School of Medicine, and career development award K23 HL145101 from the National Heart, Lung, and Blood Institute. Dr Wilkins’s work was supported in part by career development award K23 HL33601 from the National Heart, Lung, and Blood Institute. Under intra-agency agreement A-HL-17-001, the National Heart, Lung, and Blood Institute and the National Institutes of Health provided funding for select measures described in this article.

Role of the Funder/Sponsor: The National Institutes of Health had a role in the review and approval of the manuscript; however, the National Institutes of Health and other funding organizations had no role in design and conduct of the analysis; collection, management, analysis, and interpretation of the data; preparation of the manuscript; or the decision to submit the manuscript for publication.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute, the National Institutes of Health, or the US Department of Health and Human Services.

^✉

Corresponding author.

PMCID: PMC6537842 PMID: 31112258

Key Points

Question

What are the recent trends in serum levels of lipids and apolipoprotein B in US youths aged 6 to 19 years?

Findings

In this serial cross-sectional analysis of nationally representative data from 26 047 youths during the period 1999-2000 to 2015-2016, decreasing linear trends were observed in mean levels of total cholesterol (from 164 mg/dL to 155 mg/dL), non–high-density lipoprotein cholesterol (from 108 mg/dL to 100 mg/dL), low-density lipoprotein cholesterol (from 92 mg/dL to 86 mg/dL), triglycerides (from 78 mg/dL to 63 mg/dL), and apolipoprotein B (from 70 mg/dL to 67 mg/dL), and increasing linear trends were observed in mean levels of high-density lipoprotein cholesterol (from 52.5 mg/dL to 55.0 mg/dL).

Meaning

Lipids and apolipoprotein B changed favorably in US youths during recent years.

Abstract

Importance

Favorable trends occurred in the lipid levels of US youths through 2010, but these trends may be altered by ongoing changes in the food supply, obesity prevalence, and other factors.

Objective

To analyze trends in levels of lipids and apolipoprotein B in US youths during 18 years from 1999 through 2016.

Design, Setting, and Participants

Serial cross-sectional analysis of US population–weighted data for youths aged 6 to 19 years from the National Health and Nutrition Examination Surveys for 1999 through 2016. Linear temporal trends were analyzed using multivariable regression models with regression coefficients (β) reported as change per 1 year.

Exposures

Survey year; examined periods spanned 10 to 18 years based on data availability.

Main Outcomes and Measures

Age- and race/ethnicity-adjusted mean levels of high-density lipoprotein (HDL), non-HDL, and total cholesterol. Among fasting adolescents (aged 12-19 years), mean levels of low-density lipoprotein cholesterol, geometric mean levels of triglycerides, and mean levels of apolipoprotein B. Prevalence of ideal and adverse (vs borderline) levels of lipids and apolipoprotein B per pediatric lipid guidelines.

Results

In total, 26 047 youths were included (weighted mean age, 12.4 years; female, 51%). Among all youths, the adjusted mean total cholesterol level declined from 164 mg/dL (95% CI, 161 to 167 mg/dL) in 1999-2000 to 155 mg/dL (95% CI, 154 to 157 mg/dL) in 2015-2016 (β for linear trend, −0.6 mg/dL [95% CI, −0.7 to −0.4 mg/dL] per year). Adjusted mean HDL cholesterol level increased from 52.5 mg/dL (95% CI, 51.7 to 53.3 mg/dL) in 2007-2008 to 55.0 mg/dL (95% CI, 53.8 to 56.3 mg/dL) in 2015-2016 (β, 0.2 mg/dL [95% CI, 0.1 to 0.4 mg/dL] per year) and non-HDL cholesterol decreased from 108 mg/dL (95% CI, 106 to 110 mg/dL) to 100 mg/dL (95% CI, 99 to 102 mg/dL) during the same years (β, −0.9 mg/dL [95% CI, −1.2 to −0.6 mg/dL] per year). Among fasting adolescents, geometric mean levels of triglycerides declined from 78 mg/dL (95% CI, 74 to 82 mg/dL) in 1999-2000 to 63 mg/dL (95% CI, 58 to 68 mg/dL) in 2013-2014 (log-transformed β, −0.015 [95% CI, −0.020 to −0.010] per year), mean levels of low-density lipoprotein cholesterol declined from 92 mg/dL (95% CI, 89 to 95 mg/dL) to 86 mg/dL (95% CI, 83 to 90 mg/dL) during the same years (β, −0.4 mg/dL [95% CI, −0.7 to −0.2 mg/dL] per year), and mean levels of apolipoprotein B declined from 70 mg/dL (95% CI, 68 to 72 mg/dL) in 2005-2006 to 67 mg/dL (95% CI, 65 to 70 mg/dL) in 2013-2014 (β, −0.4 mg/dL [95% CI, −0.7 to −0.04 mg/dL] per year). Favorable trends were generally also observed in the prevalence of ideal and adverse levels. By the end of the study period, 51.4% (95% CI, 48.5% to 54.2%) of all youths had ideal levels for HDL, non-HDL, and total cholesterol; among adolescents, 46.8% (95% CI, 40.9% to 52.6%) had ideal levels for all lipids and apolipoprotein B, whereas 15.2% (95% CI, 13.1% to 17.3%) of children aged 6 to 11 years and 25.2% (95% CI, 22.2% to 28.2%) of adolescents aged 12 to 19 years had at least 1 adverse level.

Conclusions and Relevance

Between 1999 and 2016, favorable trends were observed in levels of lipids and apolipoprotein B in US youths aged 6 to 19 years.

This national survey study uses National Health and Nutrition Examination Survey data from 1999-2016 to characterize trends in levels of lipids and apolipoprotein B in US youths aged 6 to 19 years.

Introduction

Optimal lipid levels are 1 of 7 critical factors that define ideal cardiovascular health during childhood according to the American Heart Association.^1,2 Conversely, nonoptimal childhood levels of lipids (including total cholesterol,³ high-density lipoprotein [HDL] cholesterol,^4,5 non-HDL cholesterol,^6,7 low-density lipoprotein [LDL] cholesterol,^3,7 and triglycerides^3,5) are associated with concurrent presence and extent of early atherosclerotic lesions at autopsy, and with later subclinical atherosclerosis by imaging. In addition, childhood apolipoprotein B levels, indicating total atherogenic lipoprotein particle concentration (independent of the cholesterol content within those particles, which can vary), may predict adult subclinical atherosclerosis even more strongly than cholesterol levels.⁸

Data on lipid levels for US youths can therefore provide insight into current and future cardiovascular health, as well as highlight pediatric dyslipidemia–related resource needs⁹ and inform public health efforts.¹⁰ In prior analyses of lipid levels in US youths, favorable trends were observed for mean levels of all lipid types (total cholesterol, HDL cholesterol, non-HDL cholesterol, triglycerides, and LDL cholesterol) from 1988-1994 to 2007-2010¹¹; nevertheless, 20% of youths had adverse levels for at least 1 lipid in 2011-2012.¹² Trends in the prevalence of ideal levels of lipids and apolipoprotein B in US youths have not been described.

The objective of the present study was to analyze trends in serum lipids and apolipoprotein B during up to 18 years from 1999-2000 to 2015-2016 in US youths aged 6 to 19 years.

Methods

Study Design

We used data from the National Health and Nutrition Examination Survey (NHANES), which uses a complex, multistage probability sampling design to select a representative sample of the civilian noninstitutionalized US population.¹³ NHANES combines in-home interviews with mobile examinations and laboratory tests, including HDL and total cholesterol in youths aged 6 to 19 years and fasting triglycerides and apolipoprotein B in a subset of adolescents aged 12 to 19 years. Written informed consent, assent, or both was obtained from all participants.

We included youths aged 6 to 19 years who attended an examination during any NHANES cycle from 1999-2000 to 2015-2016; the overall examination response rate was 81% (range, 65%-86% across cycles).¹⁴ We analyzed all available data, excluding individuals from particular analyses if relevant variables were missing. The analyses were designed to maintain sample sizes of 200 or greater whenever possible. The Northwestern University institutional review board waived the need for review because the research did not involve human participants.

Survey Years

We accessed data from 1999-2000 through 2015-2016 to include all 9 continuous NHANES data cycles (vs earlier intermittent cycles). We included all available NHANES cycles for total cholesterol (1999-2016), triglycerides and LDL cholesterol (1999-2014), and apolipoprotein B (2005-2014). For HDL and non-HDL cholesterol, we included data from 2007-2016 only because NHANES documentation indicates that differing assay methods and laboratories before 2007 caused bias within the HDL cholesterol values.¹⁵

Demographics

We analyzed data for the following age categories: 6 to 8 years, 9 to 11 years, 12 to 15 years, and 16 to 19 years. These age categories were constructed because lipid levels change with maturation; however, pubertal staging was unavailable. To preserve sample size, in some of the analyses we categorized children as being aged 6 to 11 years, adolescents as aged 12 to 19 years, and the combined ages sample (aged 6-19 years) included all youths. Per the NHANES protocol, race and ethnicity were self- or parent-reported from provided categories and coded as Mexican, other Hispanic, non-Hispanic white, non-Hispanic black, or other race; and starting in 2011, non-Hispanic Asian became a separate category from other race. To maintain consistency across NHANES years, the race/ethnicity adjustment variable combined non-Hispanic Asian with other race.

Body Mass Index Categories

Body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared and used NHANES-collected standardized height and weight measurements. The 2000 US Centers for Disease Control and Prevention sex-specific BMI-for-age growth charts for youths aged 2 to 20 years were used to categorize BMI as underweight (<5th percentile), normal weight (≥5th to <85th percentile), overweight (≥85th to <95th percentile), or obese (≥95th percentile).

Laboratory Measurements

For most youths, blood was drawn in the nonfasting state. The subset (45%-50%) of adolescents aged 12 to 19 years who attended a morning examination were requested to fast; self-reported fasting times of 8.5 to 24 hours were required for the measurement of triglycerides and apolipoprotein B (otherwise, values were set as missing).

Venous blood samples were frozen and shipped to standardized laboratories. There were changes made in the use of laboratory equipment during the NHANES cycles; however, NHANES uses the US Centers for Disease Control and Prevention’s Lipid Standardization Program to ensure accuracy and precision of measurements between laboratories and over time. Across included NHANES cycles, levels of total cholesterol and triglycerides were directly measured using enzymatic assays, and levels of HDL cholesterol and apolipoprotein B were directly measured using immunoassays.

A correction factor was applied to apolipoprotein B levels from 2005-2006 that was recommended by NHANES to account for cycle-specific laboratory and equipment differences. Level of non-HDL cholesterol was calculated as the difference between HDL and total cholesterol. Level of LDL cholesterol was calculated using the Friedewald equation¹⁶ for serum samples with triglyceride values of 400 mg/dL or less and set as missing for samples with triglyceride values greater than 400 mg/dL.

Classification of Lipids and Apolipoprotein B

Levels of lipids and apolipoprotein B were classified as ideal, borderline, or adverse according to the most recent pediatric lipid guidelines.¹⁷ Cut points for ideal and adverse, respectively, were as follows: less than 170 mg/dL and 200 mg/dL or greater for total cholesterol, greater than 45 mg/dL and less than 40 mg/dL for HDL cholesterol, less than 120 mg/dL and 145 mg/dL or greater for non-HDL cholesterol, less than 90 mg/dL and 130 mg/dL or greater for triglycerides, less than 110 mg/dL and 130 mg/dL or greater for LDL cholesterol, and less than 90 mg/dL and 110 mg/dL or greater for apolipoprotein B.

Apolipoprotein B levels also were classified as concordant or discordant with cholesterol levels using a published method.¹⁸ Linear regression of apolipoprotein B on non-HDL cholesterol (or LDL cholesterol, secondarily) was performed for the entire sample (2007-2014), and the difference between each individual’s observed and regression-predicted apolipoprotein B levels (ie, [observed apolipoprotein B] − [regression-predicted apolipoprotein B]) was calculated as the individual’s residual value.

Residual values of −5 to 5 mg/dL identified concordance. More negative residual values identified discordance with low apolipoprotein B level (favorable profile). More positive residual values identified discordance with high apolipoprotein B level (unfavorable profile), which is a pattern that has been associated with the presence of small, dense LDL particles and elevated cardiovascular disease risk.⁸

Statistical Analysis

Survey procedures in SAS version 9.3 (SAS Institute Inc) were used to account for the complex NHANES design. We applied survey weights to generate US population–level estimates. We calculated means (geometric means for triglycerides, given its skewed distribution) and proportions of youths with ideal and adverse levels and apolipoprotein B and cholesterol concordance or discordance for each survey period, using multivariable linear regression models to adjust for changes in population structure over time.

For the primary analyses, the means and proportions were calculated by sex and age strata, adjusting for continuous age and race/ethnicity. In the secondary analyses, the means and proportions were calculated by race/ethnicity strata adjusting for age and by BMI strata adjusting for age and race/ethnicity. Data for strata with inadequate sample sizes¹³ (other Hispanic, other race, underweight) were not analyzed. The decision to stratify was made a priori based on previously reported differences in lipid levels among these subgroups^11,12 (ie, interaction analyses were not performed).

For the analyses of temporal trends, each 2-year NHANES cycle constituted a period; however, when the sample sizes were inadequate,¹³ the NHANES cycles were combined into 2 equal periods and simple change was analyzed. We tested for linear temporal trends using age- and sex-specific multivariable regression models adjusting for age and race/ethnicity, and fitting each NHANES cycle as an ordinal variable scaled as a 2-year interval so that regression coefficients (β) could be reported per 1 year. Trends for triglyceride levels were tested using log-transformed values because of the skewed distribution for triglycerides.

In the secondary analyses, we tested for trends in race/ethnicity and BMI strata. In a sensitivity analysis, we repeated our primary trend analyses, treating 2-year NHANES cycle as a categorical variable with the earliest cycle as the referent, and using orthogonal-contrast matrices to test for linear or quadratic trends. The results from the analyses using this method were similar overall to our primary analyses and are not presented. For all analyses, hypotheses were tested using an α level of .05 based on a 2-tailed test, with no adjustment for multiple comparisons. Because this increased the potential for type I error, we considered the secondary (subgroup) analyses to be exploratory.

To address missing data, we calculated the number and proportion of examined youths in each cycle with any missing data for levels of lipids or apolipoprotein B. We then compared demographics and BMI between youths with and without missing values. To further assess the effects of missing data, we used the SAS SURVEYIMPUTE procedure to impute missing levels for total cholesterol, which was the lipid with the highest proportion of missing data (up to 23% for some age groups and NHANES cycles). The resulting estimates were essentially identical and the conclusions were unchanged; therefore, reported estimates are from the analyses excluding missing data, consistent with prior reports of lipid levels in US youths and adults.^11,12,19

Results

Analytic Sample

A total of 26 047 youths aged 6 to 19 years participated in an NHANES examination from 1999 to 2016 and were eligible for inclusion (weighted mean age, 12.4 years; female, 51%). Sample sizes and characteristics varied between cycles according to sampling strategy (eg, intentional oversampling of adolescents in 1999-2006 and of non-Hispanic Asians in 2011-2016; eTable 1 in the Supplement).

Across NHANES cycles, 17% to 25% of children (aged 6-11 years) and 10% to 12% of adolescents (aged 12-19 years) were missing data on HDL or total cholesterol, and 15% to 19% of adolescents eligible for the analyses of triglycerides, LDL cholesterol, and apolipoprotein B were missing data for at least 1 of these measurements. Compared with youths with complete data, youths with missing data tended to be younger, were less often Mexican, and had lower BMI percentiles for some cycles, but sex distribution was similar (eTable 2 in the Supplement).

Adjusted Trends in Mean Levels of Lipids and Apolipoprotein B

Table 1 and the Figure show age- and race/ethnicity-adjusted mean levels and trends for levels of lipids and apolipoprotein B. In all youths (aged 6-19 years), total cholesterol level decreased linearly during the 18-year period from 164 mg/dL (95% CI, 161 to 167 mg/dL) in 1999-2000 to 155 mg/dL (95% CI, 154 to 157 mg/dL) in 2015-2016 (β, −0.6 mg/dL [95% CI, −0.7 to −0.4 mg/dL] per year). The contributions to total cholesterol made by HDL and non-HDL cholesterol were in opposite directions, but both were favorable from the standpoint of risk for atherosclerosis. The adjusted mean HDL cholesterol level increased from 52.5 mg/dL (95% CI, 51.7 to 53.3 mg/dL) in 2007-2008 to 55.0 mg/dL (95% CI, 53.8 to 56.3 mg/dL) in 2015-2016 (β, 0.2 mg/dL [95% CI, 0.1 to 0.4 mg/dL] per year). The adjusted mean non-HDL cholesterol level decreased from 108 mg/dL (95% CI, 106 to 110 mg/dL) in 2007-2008 to 100 mg/dL (95% CI, 99 to 102 mg/dL) in 2015-2016 (β, −0.9 mg/dL [95% CI, −1.2 to −0.6 mg/dL] per year).

Table 1. Age- and Race/Ethnicity-Adjusted Trends in Mean Levels of Lipids and Apolipoprotein B in US Youths Aged 6 to 19 Years, 1999-2016.

	Total Cholesterol, Mean Level (95% CI), mg/dL^a		β (95% CI), mg/dL/y	HDL Cholesterol, Mean Level (95% CI), mg/dL^a		β (95% CI), mg/dL/y	Non-HDL Cholesterol, Mean Level (95% CI), mg/dL^a		β (95% CI), mg/dL/y
	1999-2000	2015-2016	β (95% CI), mg/dL/y	2007-2008	2015-2016	β (95% CI), mg/dL/y	2007-2008	2015-2016	β (95% CI), mg/dL/y
All youths	164 (161 to 167)	155 (154 to 157)	−0.6 (−0.7 to −0.4)	52.5 (51.7 to 53.3)	55.0 (53.8 to 56.3)	0.2 (0.1 to 0.4)	108 (106 to 110)	100 (99 to 102)	−0.9 (−1.2 to −0.6)
Males	162 (158 to 165)	155 (153 to 157)	−0.6 (−0.7 to −0.4)	52.1 (51.0 to 53.2)	54.8 (53.5 to 56.1)	0.3 (0.1 to 0.4)	107 (104 to 110)	100 (98 to 102)	−0.9 (−1.3 to −0.5)
Age group, y
6-8	162 (158 to 166)	158 (155 to 160)	−0.4 (−0.7 to −0.2)	55.9 (54.0 to 57.7)	60.2 (58.2 to 62.2)	0.4 (0.1 to 0.7)	107 (102 to 111)	97 (95 to 100)	−1.1 (−1.7 to −0.5)
9-11	171 (163 to 178)	160 (156 to 163)	−0.7 (−1.0 to −0.3)	54.1 (52.4 to 55.7)	57.6 (55.3 to 60.0)	0.4 (0.1 to 0.7)	112 (107 to 116)	103 (99 to 106)	−1.2 (−1.8 to −0.6)
12-15	159 (155 to 163)	152 (148 to 155)	−0.7 (−1.0 to −0.4)	50.2 (48.3 to 52.2)	52.6 (50.1 to 55.1)	0.1 (−0.3 to 0.5)	103 (97 to 108)	99 (95 to 102)	−0.5 (−1.2 to 0.2)
16-19	158 (152 to 165)	154 (151 to 157)	−0.4 (−0.7 to −0.1)	48.3 (46.7 to 49.9)	49.8 (47.8 to 51.8)	0.2 (−0.1 to 0.5)	111 (106 to 115)	104 (100 to 108)	−1.1 (−1.8 to −0.4)
Females	166 (163 to 169)	156 (153 to 158)	−0.6 (−0.8 to −0.4)	53.0 (52.0 to 54.0)	55.4 (54.0 to 56.8)	0.2 (0.04 to 0.4)	109 (106 to 112)	101 (99 to 102)	−0.9 (−1.2 to −0.5)
Age group, y
6-8	174 (166 to 182)	158 (154 to 161)	−0.9 (−1.2 to −0.5)	52.2 (50.0 to 54.4)	55.5 (53.3 to 57.8)	0.4 (0.1 to 0.8)	113 (109 to 117)	103 (100 to 106)	−1.1 (−1.6 to −0.5)
9-11	170 (164 to 176)	156 (153 to 160)	−0.8 (−1.1 to −0.5)	51.4 (49.4 to 53.5)	56.5 (54.1 to 58.8)	0.5 (0.2 to 0.9)	112 (106 to 118)	100 (96 to 103)	−1.3 (−2.1 to −0.6)
12-15	160 (155 to 165)	151 (148 to 154)	−0.5 (−0.7 to −0.2)	51.7 (50.1 to 53.4)	54.2 (52.0 to 56.4)	0.3 (−0.05 to 0.6)	106 (102 to 109)	97 (95 to 100)	−0.9 (−1.4 to −0.3)
16-19	163 (159 to 166)	159 (155 to 164)	−0.3 (−0.6 to −0.1)	56.0 (54.2 to 57.8)	56.0 (54.2 to 57.8)	−0.1 (−0.4 to 0.2)	108 (103 to 112)	104 (99 to 108)	−0.3 (−1.0 to 0.3)
	Triglycerides, Geometric Mean Level (95% CI), mg/dL^a^,^b		β (95% CI)^c	Low-Density Lipoprotein Cholesterol, Mean Level (95% CI), mg/dL^a		β (95% CI), mg/dL/y	Apolipoprotein B, Mean Level (95% CI), mg/dL^a		β (95% CI), mg/dL/y
	1999-2000	2013-2014	β (95% CI)^c	1999-2000	2013-2014	β (95% CI), mg/dL/y	2005-2006	2013-2014	β (95% CI), mg/dL/y
All adolescents	78 (74 to 82)	63 (58 to 68)	−0.015 (−0.020 to −0.010)	92 (89 to 95)	86 (83 to 90)	−0.4 (−0.7 to −0.2)	70 (68 to 72)	67 (65 to 70)	−0.4 (−0.7 to −0.04)
Age group, y
12-15	79 (74 to 85)	61 (55 to 69)	−0.018 (−0.024 to −0.011)	91 (88 to 95)	85 (80 to 89)	−0.5 (−0.9 to −0.2)	68 (65 to 70)	66 (63 to 69)	−0.3 (−0.7 to 0.2)
16-19	76 (71 to 81)	64 (59 to 70)	−0.013 (−0.019 to −0.006)	92 (88 to 97)	88 (83 to 92)	−0.4 (−0.7 to −0.02)	72 (69 to 75)	69 (65 to 72)	−0.5 (−1.0 to 0.04)
Males	77 (71 to 83)	64 (57 to 71)	−0.015 (−0.022 to −0.008)	93 (89 to 97)	83 (78 to 87)	−0.7 (−1.0 to −0.3)	68 (66 to 71)	66 (62 to 69)	−0.4 (−0.8 to 0.1)
Females	79 (74 to 85)	62 (57 to 67)	−0.016 (−0.022 to −0.010)	91 (88 to 94)	90 (86 to 95)	−0.2 (−0.5 to 0.1)	72 (68 to 75)	69 (66 to 72)	−0.4 (−0.9 to 0.1)

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SI conversion factors: To convert high-density lipoprotein (HDL), low-density lipoprotein (LDL), non-HDL, and total cholesterol to mmol/L, divide by 38.6; triglycerides to mmol/L, divide by 88.6.

^{^a}

All estimates are based on population-weighted data from the National Health and Nutrition Examination Survey. The unweighted sample size ranges for each lipid and survey cycle are as follows: total cholesterol in 1999-2000, the minimum was 184 (females aged 6-8 years) and maximum was 2930 (all youths); HDL and non-HDL cholesterol in 2007-2008, minimum of 239 (females aged 6-8 years) and maximum of 2055 (all youths); HDL, non-HDL, and total cholesterol in 2015-2016, minimum of 243 (males aged 9-11 years) and maximum of 2099 (all youths); triglycerides in 1999-2000, minimum of 429 (adolescents aged 16-19 years) and maximum of 904 (all adolescents); LDL cholesterol in 1999-2000, minimum of 424 (adolescents aged 16-19 years) and maximum of 892 (all adolescents); apolipoprotein B in 2005-2006, minimum of 413 (female adolescents) and maximum of 851 (all adolescents); triglycerides and apolipoprotein B in 2013-2014, minimum of 256 (male adolescents) and maximum of 532 (all adolescents); and LDL cholesterol in 2013-2014, minimum of 255 (male adolescents) and maximum of 531 (all adolescents).

^{^b}

The data are geometric means due to the skewed distribution.

^{^c}

The regression coefficient was tested. The data are presented as log-transformed units per year.

Among adolescents, the decline in non-HDL cholesterol level was accounted for by declines in both levels of triglycerides and LDL cholesterol. The adjusted geometric mean for triglycerides declined from 78 mg/dL (95% CI, 74 to 82 mg/dL) in 1999-2000 to 63 mg/dL (95% CI, 58 to 68 mg/dL) in 2013-2014, a mean decrease of 1.5% per year (log-transformed β, −0.015 [95% CI, −0.020 to −0.010] per year). The adjusted mean LDL cholesterol level declined from 92 mg/dL (95% CI, 89 to 95 mg/dL) in 1999-2000 to 86 mg/dL (95% CI, 83 to 90 mg/dL) in 2013-2014 (β, −0.4 mg/dL [95% CI, −0.7 to −0.2 mg/dL] per year). The adjusted mean apolipoprotein B level declined from 70 mg/dL (95% CI, 68 to 72 mg/dL) in 2005-2006 to 67 mg/dL (95% CI, 65 to 70 mg/dL) in 2013-2014 (β, −0.4 mg/dL [95% CI, −0.7 to −0.04 mg/dL] per year).

In sex- and age-specific analyses, favorable total cholesterol trends were statistically significant in all subgroups (Table 1 and the Figure). The temporal trends for non-HDL cholesterol level reached statistical significance in both sexes, in children (aged 6-8 years and aged 9-11 years), and in some adolescent subgroups. The temporal trends for HDL cholesterol level reached statistical significance in both sexes and in both age groups of children. The temporal trends for triglyceride level were statistically significant in all subgroups of adolescents, whereas the temporal trends for LDL cholesterol level reached statistical significance in both age subgroups and in males. The temporal trends for apolipoprotein B level did not reach statistical significance in any subgroup.

Adjusted Trends in the Prevalence of Ideal Levels of Lipids and Apolipoprotein B

The age- and race/ethnicity-adjusted trends in the prevalence of ideal levels of lipids and apolipoprotein B appear in Table 2 and Table 3. Among youths overall, the prevalence of ideal levels of HDL, non-HDL, and total cholesterol each increased linearly over time. Among adolescents, the prevalence of ideal levels of triglycerides and LDL cholesterol also increased linearly, whereas the prevalence of ideal levels of apolipoprotein B remained high without statistically significant change. In age- and sex-specific analyses, temporal trends varied in statistical significance for HDL cholesterol level (significant only in females aged 6-11 years), non-HDL cholesterol level (no clear pattern), and LDL cholesterol level (significant only in 12- to 15-year-olds and males). Otherwise, temporal trends were statistically significant among all subgroups for levels of total cholesterol and triglycerides and among no subgroups for levels of apolipoprotein B.

Table 2. Age- and Race/Ethnicity-Adjusted Trends in the Prevalence of Ideal Levels of Lipids and Apolipoprotein B in US Youths Aged 6 to 19 Years, 1999-2016.

	Proportion With Ideal Level of Total Cholesterol, % (95% CI)^a		β (95% CI), %/y	Proportion With Ideal Level of HDL Cholesterol, % (95% CI)^a		β (95% CI), %/y	Proportion With Ideal Level of Non-HDL Cholesterol, % (95% CI)^a		β (95% CI), %/y
	1999-2000	2015-2016	β (95% CI), %/y	2007-2008	2015-2016	β (95% CI), %/y	2007-2008	2015-2016	β (95% CI), %/y
All youths	61.3 (58.0 to 64.6)	71.4 (69.0 to 73.8)	0.8 (0.6 to 0.9)	68.2 (65.6 to 70.9)	75.4 (72.1 to 78.7)	0.7 (0.2 to 1.1)	69.6 (66.5 to 72.7)	77.9 (75.5 to 80.3)	1.0 (0.5 to 1.4)
Age group, y
6-8	58.2 (52.8 to 63.5)	70.2 (64.8 to 75.5)	0.8 (0.4 to 1.2)	75.4 (69.6 to 81.2)	83.2 (79.0 to 87.4)	1.0 (0.2 to 1.8)	73.0 (66.5 to 79.5)	80.0 (76.5 to 83.6)	0.6 (−0.2 to 1.4)
9-11	50.9 (41.6 to 60.3)	68.7 (63.1 to 74.2)	1.1 (0.6 to 1.5)	69.8 (65.4 to 74.1)	78.8 (74.8 to 82.9)	0.9 (0.2 to 1.6)	61.2 (55.7 to 66.7)	78.8 (74.9 to 82.7)	1.9 (1.1 to 2.7)
12-15	64.8 (59.6 to 70.0)	74.2 (69.8 to 78.6)	0.8 (0.5 to 1.1)	64.5 (59.8 to 69.2)	71.9 (65.8 to 77.9)	0.5 (−0.3 to 1.4)	72.9 (67.1 to 78.8)	78.2 (74.3 to 82.0)	0.6 (−0.2 to 1.4)
16-19	66.2 (61.4 to 71.0)	70.4 (65.9 to 75.0)	0.5 (0.2 to 0.7)	63.4 (58.8 to 68.0)	69.2 (64.3 to 74.1)	0.4 (−0.3 to 1.2)	68.1 (64.4 to 71.9)	73.7 (68.6 to 78.8)	0.9 (0.2 to 1.6)
Males	64.2 (60.5 to 67.9)	71.7 (69.0 to 74.4)	0.7 (0.5 to 0.9)	66.9 (62.9 to 70.9)	73.5 (69.5 to 77.4)	0.6 (−0.1 to 1.2)	70.9 (67.1 to 74.7)	76.6 (73.2 to 79.9)	0.8 (0.2 to 1.3)
Age group, y
6-11	59.1 (53.5 to 64.7)	68.5 (64.4 to 72.5)	0.7 (0.4 to 1.1)	78.2 (74.7 to 81.6)	83.8 (80.0 to 88.1)	0.6 (−0.02 to 1.2)	69.9 (64.5 to 75.3)	78.7 (75.7 to 81.6)	0.9 (0.2 to 1.6)
12-19	67.3 (63.4 to 71.1)	73.9 (69.4 to 78.4)	0.7 (0.4 to 0.9)	56.5 (51.1 to 62.0)	63.8 (58.5 to 69.1)	0.6 (−0.3 to 1.5)	71.1 (66.2 to 76.1)	74.2 (69.4 to 78.9)	0.6 (−0.1 to 1.3)
Females	58.3 (54.3 to 62.4)	71.2 (67.9 to 74.5)	0.8 (0.6 to 1.1)	69.6 (66.5 to 72.7)	77.5 (73.9 to 81.1)	0.8 (0.2 to 1.3)	68.2 (63.2 to 73.2)	79.5 (76.1 to 82.9)	1.2 (0.5 to 1.8)
Age group, y
6-11	50.7 (43.6 to 57.8)	70.8 (65.0 to 76.6)	1.2 (0.7 to 1.6)	67.3 (61.3 to 73.3)	78.7 (75.1 to 82.2)	1.4 (0.6 to 2.2)	64.3 (56.9 to 71.7)	80.7 (75.8 to 85.5)	1.6 (0.7 to 2.6)
12-19	63.5 (57.9 to 69.1)	71.4 (68.2 to 74.6)	0.6 (0.4 to 0.9)	71.6 (68.0 to 75.2)	77.2 (72.4 to 82.0)	0.3 (−0.4 to 1.0)	70.4 (64.9 to 76.0)	78.3 (74.3 to 82.3)	0.9 (0.1 to 1.6)
	Proportion With Ideal Level of Triglycerides, % (95% CI)^a		β (95% CI), %/y	Proportion With Ideal Level of LDL Cholesterol, % (95% CI)^a		β (95% CI), %/y	Proportion With Ideal Level of Apolipoprotein B, % (95% CI)^a		β (95% CI), %/y
	1999-2000	2013-2014	β (95% CI), %/y	1999-2000	2013-2014	β (95% CI), %/y	2005-2006	2013-2014	β (95% CI), %/y
All adolescents	63.4 (59.5 to 67.2)	76.7 (70.8 to 82.5)	1.0 (0.6 to 1.4)	77.9 (72.8 to 83.1)	84.1 (79.8 to 88.4)	0.5 (0.2 to 0.8)	85.8 (81.3 to 90.4)	87.9 (84.8 to 91.0)	0.3 (−0.3 to 0.9)
Age group, y
12-15	62.3 (55.5 to 69.1)	78.2 (70.6 to 85.8)	1.2 (0.7 to 1.7)	78.7 (72.9 to 84.4)	83.0 (77.1 to 88.9)	0.5 (0.1 to 1.0)	87.6 (83.0 to 92.2)	88.1 (83.5 to 92.6)	0.01 (−0.8 to 0.8)
16-19	65.1 (58.8 to 71.5)	75.6 (68.1 to 83.1)	0.8 (0.2 to 1.3)	77.6 (71.2 to 84.0)	85.7 (80.3 to 91.0)	0.5 (−0.02 to 1.0)	84.3 (78.6 to 90.0)	88.0 (82.9 to 93.1)	0.6 (−0.3 to 1.5)
Males	64.1 (58.6 to 69.6)	73.7 (66.3 to 81.2)	0.8 (0.2 to 1.4)	76.6 (69.5 to 83.7)	87.2 (80.9 to 93.4)	0.7 (0.2 to 1.1)	87.1 (82.3 to 91.9)	90.3 (85.1 to 95.5)	0.2 (−0.5 to 1.0)
Females	62.9 (57.2 to 68.7)	79.3 (72.7 to 85.9)	1.2 (0.7 to 1.7)	79.3 (73.5 to 85.0)	81.0 (75.7 to 86.2)	0.4 (−0.1 to 0.8)	84.5 (77.6 to 91.5)	85.5 (80.8 to 90.2)	0.4 (−0.6 to 1.3)

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^{^a}

The following ideal levels were defined by the 2011 National Heart, Lung, and Blood Institute Expert Panel Guidelines: total cholesterol, less than 170 mg/dL; high-density lipoprotein (HDL) cholesterol, greater than 45 mg/dL; non-HDL cholesterol, less than 120 mg/dL; triglycerides, less than 90 mg/dL; low-density lipoprotein (LDL) cholesterol, less than 110 mg/dL; and apolipoprotein B, less than 90 mg/dL.²⁰ All estimates are based on population-weighted data from the National Health and Nutrition Examination Survey. The unweighted sample size ranges for each lipid and survey cycle are as follows: total cholesterol in 1999-2000, the minimum was 411 (females aged 6-11 years) and the maximum was 2930 (all youths); HDL and non-HDL cholesterol in 2007-2008, minimum of 481 (females aged 6-8 years) and maximum of 2055 (all youths); HDL, non-HDL, and total cholesterol in 2015-2016, minimum of 493 (males aged 6-11 years) and maximum of 2099 (all youths); triglycerides in 1999-2000, minimum of 429 (adolescents aged 16-19 years) and maximum of 904 (all adolescents); LDL cholesterol in 1999-2000, minimum of 424 (adolescents aged 16-19 years) and maximum of 892 (all adolescents); apolipoprotein B in 2005-2006, minimum of 413 (female adolescents) and maximum of 851 (all adolescents); triglycerides and apolipoprotein B in 2013-2014, minimum of 256 (male adolescents) and maximum of 532 (all adolescents); and LDL cholesterol in 2013-2014, minimum of 255 (male adolescents) and maximum of 531 (all adolescents).

Table 3. Age- and Race/Ethnicity-Adjusted Trends in the Prevalence of Ideal Levels of Lipids and Apolipoprotein B in US Youths Aged 6 to 19 Years, 1999-2016.

	Proportion With Ideal Levels of HDL, Non-HDL, and Total Cholesterol, % (95% CI)^a		β (95% CI), %/y	Proportion With Ideal Levels of All Lipids and Apolipoprotein B, % (95% CI)^a^,^b		β (95% CI), %/y
	2007-2008	2015-2016	β (95% CI), %/y	2007-2008	2013-2014	β (95% CI), %/y
All youths	42.1 (39.6 to 44.7)	51.4 (48.5 to 54.2)	1.1 (0.6 to 1.5)
Age group, y
6-11	41.0 (37.0 to 45.0)	53.9 (49.7 to 58.0)	1.4 (0.8 to 2.1)
12-19	42.3 (38.8 to 45.8)	49.0 (45.2 to 52.9)	0.8 (0.2 to 1.3)	39.6 (33.7 to 45.4)	46.8 (40.9 to 52.6)	1.0 (−0.2 to 2.3)

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^{^a}

^{^b}

All lipids includes triglycerides and HDL, LDL, non-HDL, and total cholesterol.

Among all youths, the proportions with all ideal levels of HDL, non-HDL, and total cholesterol increased by a mean of 1.1% (95% CI, 0.6% to 1.5%) per year up to 51.4% (95% CI, 48.5% to 54.2%) in 2015-2016. Among adolescents, the proportion with ideal levels of all lipids and apolipoprotein B was 39.6% (95% CI, 33.7% to 45.4%) in 2007-2008 and 46.8% (95% CI, 40.9% to 52.6%) in 2013-2014, but the linear trend did not reach statistical significance (β, 1.0% [95% CI, −0.2% to 2.3%] per year).

Adjusted Changes in the Prevalence of Adverse Levels of Lipids and Apolipoprotein B

The age- and race/ethnicity-adjusted changes in the prevalence of adverse levels of lipids and apolipoprotein B from earlier to later periods appear in Table 4. Among all youths, the prevalence of adverse levels decreased significantly for non-HDL and total cholesterol, whereas the difference did not reach statistical significance for HDL cholesterol. Among adolescents, the prevalence of adverse levels decreased significantly for triglycerides but nonsignificantly for LDL cholesterol and apolipoprotein B.

Table 4. Age- and Race/Ethnicity-Adjusted Changes in the Prevalence of Adverse Levels of Lipids and Apolipoprotein B in US Youths Aged 6 to 19 Years, 1999-2016.

	Proportion With Adverse Level of Total Cholesterol, % (95% CI)^a		P Value^b	Proportion With Adverse Level of HDL Cholesterol, % (95% CI)^a		P Value^b	Proportion With Adverse Level of Non-HDL Cholesterol, % (95% CI)^a		P Value^b
	1999-2006	2009-2016	P Value^b	2007-2010	2013-2016	P Value^b	2007-2010	2013-2016	P Value^b
All youths	10.3 (9.2-11.4)	7.1 (6.4-7.8)	<.001	14.0 (12.7-15.4)	12.1 (10.4-13.7)	.06	9.2 (7.8-10.5)	6.4 (5.6-7.3)	.002
	Proportion With Adverse Level of Triglycerides, % (95% CI)^a		P Value^b	Proportion With Adverse Level of LDL Cholesterol, % (95% CI)^a		P Value^b	Proportion With Adverse Level of Apolipoprotein B, % (95% CI)^a		P Value^b
	1999-2006	2007-2014	P Value^b	1999-2006	2007-2014	P Value^b	2005-2008	2011-2014	P Value^b
Adolescents aged 12-19 y	15.3 (13.3-17.2)	10.2 (8.3-12.1)	<.001	7.7 (6.0-9.4)	6.4 (4.9-7.8)	.19	3.6 (2.2-5.1)	2.4 (1.1-3.7)	.20
	Proportion With ≥1 Adverse Level of HDL, Non-HDL, or Total Cholesterol, % (95% CI)^a		P Value^b	Proportion With Adverse Level of Any Lipid or Apolipoprotein B, % (95% CI)^a^,^c		P Value^b
	2007-2010	2013-2016	P Value^b	2007-2010	2011-2014	P Value^b
All youths	23.1 (21.5-24.7)	19.2 (17.6-20.8)	.002
Age group, y
6-11	22.2 (19.8-24.6)	15.2 (13.1-17.3)	<.001
12-19	23.7 (21.6-25.8)	21.8 (19.6-24.0)	.27	25.4 (22.5-28.3)	25.2 (22.2-28.2)	.92

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^{^a}

The adverse levels were defined by the 2011 National Heart, Lung, and Blood Institute Expert Panel Guidelines: total cholesterol, 200 mg/dL or greater; high-density lipoprotein (HDL) cholesterol, less than 40 mg/dL; non-HDL cholesterol, 145 mg/dL or greater; triglycerides, 130 mg/dL or greater; low-density lipoprotein (LDL) cholesterol, 130 mg/dL or greater; and apolipoprotein B, 110 mg/dL or greater.²⁰ All estimates are based on population-weighted data from the National Health and Nutrition Examination Survey. The unweighted sample sizes or the sample size ranges for each lipid and survey cycle are as follows: total cholesterol, 11 716 in 1999-2006 and 10 661 in 2009-2016; HDL and non-HDL cholesterol in 2007-2010, 4205; HDL cholesterol in 2013-2016, 6457; non-HDL cholesterol in 2013-2016, 6456; triglycerides, 3587 in 1999-2006 and 2045 in 2007-2014; LDL cholesterol, 3564 in 1999-2006 and 2042 in 2007-2014; apolipoprotein B, 1290 in 2005-2008 and 1049 in 2011-2014; HDL, non-HDL, and total cholesterol, minimum of 1958 (youths aged 6-11 years) and maximum of 4205 (all youths) in 2007-2010 and minimum of 2041 (youths aged 6-11 years) and maximum of 4381 (all youths) in 2013-2016; and all lipids and apolipoprotein B, minimum of 997 in 2007-2010 and maximum of 1048 in 2011-2014.

^{^b}

Compares the proportions between the periods.

^{^c}

Any lipid includes triglycerides and HDL, non-HDL, LDL, and total cholesterol.

The proportion of youths with at least 1 adverse level of HDL, non-HDL, or total cholesterol decreased significantly for all youths from 23.1% to 19.2% (P = .002) and for children from 22.2% to 15.2% (P < .001), but not for adolescents (from 23.7% to 21.8%; P = .27). The proportion of adolescents with at least 1 adverse level of total cholesterol, HDL cholesterol, non-HDL cholesterol, triglycerides, LDL cholesterol, or apolipoprotein B did not significantly change from 25.4% to 25.2% (P = .92).

Adjusted Changes in the Prevalence of Apolipoprotein B Concordance and Discordance With Types of Cholesterol

The age- and race/ethnicity-adjusted changes in the prevalence of apolipoprotein B concordance and discordance with non-HDL and LDL cholesterol from earlier to later periods appear in eTable 3 in the Supplement. Among all adolescents, no significant changes were detected. The decreases in discordance with a high level of apolipoprotein B for a given level of non-HDL or LDL cholesterol (unfavorable profile) reached statistical significance in a few subgroups (eg, vs non-HDL cholesterol in 16- to 19-year-olds; P = .04), but sample sizes were limited.

Secondary Analyses: Race/Ethnicity- and BMI-Stratified Trends

The adjusted trends for levels of lipids and apolipoprotein B by race/ethnicity and BMI category appear in eTables 4-6 in the Supplement. In these exploratory analyses, temporal trends in mean levels and in the prevalence of ideal and adverse levels were generally directionally consistent across racial/ethnic groups and BMI categories, but variable in magnitude and in whether statistical significance was reached.

Discussion

Between 1999 and 2016, favorable temporal trends were observed in mean levels and in the distribution of ideal and adverse levels of HDL, non-HDL, and total cholesterol among youths aged 6 to 19 years. Among adolescents, favorable trends were observed for levels of triglycerides, LDL cholesterol, and apolipoprotein B. Despite these favorable trends, it was estimated at the end of the study period that 47% to 51% of US youths had all lipids at ideal levels and 19% to 25% had at least 1 adverse level. In the exploratory subgroup analyses, trends for levels of lipids and apolipoprotein B were generally directionally consistent across racial/ethnic groups and BMI categories.

In the context of published analyses,^11,12 these results demonstrate a continuation of the favorable trends in mean lipid levels and prevalence of adverse lipid levels in US youths from 1988-1994 to 2007-2010. The findings also align with those from a report showing favorable lipid trends in US adults from 1999 to 2014.¹⁹ Given evidence that lipid levels track from youth to adulthood,^20,21 these findings warrant some optimism about the future of atherosclerotic cardiovascular disease related to dyslipidemia. For example, the 13-mg/dL reduction in mean total cholesterol level among US adults from 1980 to 2000 was estimated to have resulted in the prevention or postponement of 82 830 deaths from coronary heart disease.²² In the present analysis, mean total cholesterol level among US youths declined by 9 mg/dL from 1999 to 2016.

Nevertheless, at the end of the study period, the proportion of youths with adverse levels of lipids or apolipoprotein B remained substantial (19%-25%), and the proportion with all ideal levels of lipids and apolipoprotein B was relatively low (47%-51%). An ideal cholesterol level constitutes 1 of 7 factors that define “ideal cardiovascular health,” a construct introduced by the American Heart Association with its 2020 strategic impact goal.^1,2 This positive construct emphasizes primordial prevention (ie, prevention of the development of risk factors proximal to disease) as a populationwide strategy of particular relevance to youths. Ideal cardiovascular health is associated with lower prevalence and extent of subclinical atherosclerosis in youths^23,24 and lower incidence of cardiovascular disease, cancer, and all-cause mortality in adults.^25,26 The current findings provide a baseline for efforts to increase the prevalence of ideal lipid levels in youths.

To our knowledge, this study is also the first to analyze population-level apolipoprotein B trends in US youths. During the atherosclerotic disease process, retention of apolipoprotein B–containing particles within the arterial wall is a fundamental step that is driven in large part by apolipoprotein B–containing particle concentration.⁸ Particle concentration can be measured by serum apolipoprotein B level because apolipoprotein B has a 1:1 relationship with its lipoprotein particles. Because lipoprotein particles may carry average, high, or low amounts of cholesterol, apolipoprotein B levels may be discordant with non-HDL or LDL cholesterol levels (measured by weight, not particle number) in a given individual.

Although the optimal clinical use of apolipoprotein B is not yet clear, apolipoprotein B levels have been shown to be superior to traditional lipid levels for predicting atherosclerosis and cardiovascular disease events,^18,27 particularly in younger adults with discordance between levels of apolipoprotein B (or particle number) and LDL cholesterol. Discordance is most common among individuals with obesity, the obesity-associated dyslipidemia of high triglycerides and low HDL cholesterol, and dysglycemia.²⁸ In this context, the favorable trend in mean apolipoprotein B levels and the absence of an unfavorable trend in discordance with high apolipoprotein B levels observed in this study were unexpected, given known increases in childhood obesity²⁹ and type 2 diabetes³⁰ prevalence over a similar period. Similarly, it was unexpected that levels of triglycerides improved so substantially in light of the obesity trends.

It will be important to understand the reasons for the favorable lipid trends observed in this study to both acknowledge public health successes and plan future efforts. A wide variety of factors has been associated with lipid and apolipoprotein B levels, such as diet,³¹ physical activity,³² smoking,³³ body size,³⁴ pubertal stage,³⁵ medications,³⁶ and glycemia.³⁷ Among US youths, some of these factors may be improving (eg, decreased trans fats in the food supply¹⁰), others are worsening (eg, BMI³⁸), and others may be changing in unknown ways.

The strengths of this study include generalizability because of its use of nationally representative data and the comprehensiveness of the lipid and apolipoprotein B assessment using both continuous and categorical measures.

Limitations

This study also has several limitations. First, blood was drawn in the nonfasting state for adolescents (aged 12-19 years) who attended afternoon or evening examinations as well as all children (aged 6-11 years). This would not have affected the measurement accuracy of HDL, non-HDL, or total cholesterol^17,39; conversely, fasting was required for the measurement of triglycerides, LDL cholesterol (calculated using triglycerides), and apolipoprotein B; therefore, the sample size was limited. Second, the study periods for HDL and non-HDL cholesterol and apolipoprotein B were truncated due to potential bias or data unavailability during certain NHANES cycles. For HDL and non-HDL cholesterol, prior analyses of lipid levels from 1988-1994 to 2007-2010¹¹ provide some continuity with the present analyses of lipids from 2007-2008 to 2015-2016.

Third, because of the positive bias in HDL cholesterol for 1999-2006,¹⁵ LDL cholesterol levels for 1999-2006 may have been reciprocally negatively biased through the use of the Friedewald equation; however, such an effect would have biased the favorable trend results toward the null. Fourth, because LDL cholesterol level was considered missing for samples with triglyceride levels greater than 400 mg/dL, population LDL cholesterol levels may have been underestimated if samples with triglyceride levels greater than 400 mg/dL also had elevated LDL cholesterol levels; however, exclusion of LDL cholesterol data for this reason occurred for less than 1% of eligible samples. Fifth, youths using lipid-lowering medications were not excluded; however, this was rare (self-reported by 1 participant aged 16-19 years in 2013-2014 and 1 in 2015-2016).

Sixth, subgroup analyses must be interpreted with caution due to limitations in power related to sample sizes and risk of false-positive results related to multiple testing. Formal interaction testing was not performed due to concerns about type II errors, and any comparisons are exploratory and qualitative. Seventh, despite its importance for lipid profiles in youths, pubertal staging was unavailable, and even short age intervals are not perfect proxies for development. Eighth, pregnant youths were not excluded because pregnancy status was unavailable in the public use data set for individuals younger than 20 years; however, the proportion of girls younger than 20 years who were pregnant was less than 1% per NHANES documentation.⁴⁰

Conclusions

Between 1999 and 2016, favorable trends were observed in levels of lipids and apolipoprotein B in US youths aged 6 to 19 years.

Supplement.

eTable 1. Maximal Sample Sizes, by Survey Cycle: National Health and Nutrition Examination Survey, 1999-2016

eTable 2. Characteristics of Examined Youth with Complete Versus Any Missing Data for Lipids and Apolipoprotein B, by Survey Cycle: National Health and Nutrition Examination Survey, 1999-2016

eTable 3. Age- and Race/Ethnicity-Adjusted Changes in the Prevalence of Apolipoprotein B Concordance and Discordance with Non-HDL Cholesterol and LDL Cholesterol Over Time in US Youth Ages 12 to 19 Years, 2007-2014

eTable 4. Age-Adjusted Trends in Mean Levels of Lipids and Apolipoprotein B Over Time by Race/Ethnicity and BMI Category in US Youth Ages 6 to 19 Years, 1999-2016

eTable 5. Age-Adjusted Changes in the Prevalence of Ideal Levels of Lipids and Apolipoprotein B Over Time by Race/Ethnicity and BMI Category in US Youth Ages 6 to 19 Years, 1999-2016

eTable 6. Age-Adjusted Changes in the Prevalence of Adverse Levels of Lipids and Apolipoprotein B Over Time by Race/Ethnicity and BMI Category in US Youth Ages 6 to 19 Years, 1999-2016

eReferences

Click here for additional data file.^{(170.7KB, pdf)}

References

1.Lloyd-Jones DM, Hong Y, Labarthe D, et al. . Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic impact goal through 2020 and beyond. Circulation. 2010;121(4):586-613. doi: 10.1161/CIRCULATIONAHA.109.192703 [DOI] [PubMed] [Google Scholar]
2.Steinberger J, Daniels SR, Hagberg N, et al. . Cardiovascular health promotion in children: challenges and opportunities for 2020 and beyond: a scientific statement from the American Heart Association. Circulation. 2016;134(12):e236-e255. doi: 10.1161/CIR.0000000000000441 [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Berenson GS, Srinivasan SR, Bao W, et al. . Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults: the Bogalusa Heart Study. N Engl J Med. 1998;338(23):1650-1656. doi: 10.1056/NEJM199806043382302 [DOI] [PubMed] [Google Scholar]
4.McGill HC Jr, McMahan CA, Malcom GT, et al. . Effects of serum lipoproteins and smoking on atherosclerosis in young men and women. Arterioscler Thromb Vasc Biol. 1997;17(1):95-106. doi: 10.1161/01.ATV.17.1.95 [DOI] [PubMed] [Google Scholar]
5.Pacifico L, Bonci E, Andreoli G, et al. . Association of serum triglyceride-to-HDL cholesterol ratio with carotid artery intima-media thickness, insulin resistance and nonalcoholic fatty liver disease in children and adolescents. Nutr Metab Cardiovasc Dis. 2014;24(7):737-743. doi: 10.1016/j.numecd.2014.01.010 [DOI] [PubMed] [Google Scholar]
6.McGill HC Jr, McMahan CA, Zieske AW, et al. ; Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group . Associations of coronary heart disease risk factors with the intermediate lesion of atherosclerosis in youth. Arterioscler Thromb Vasc Biol. 2000;20(8):1998-2004. doi: 10.1161/01.ATV.20.8.1998 [DOI] [PubMed] [Google Scholar]
7.Frontini MG, Srinivasan SR, Xu J, et al. . Usefulness of childhood non-high density lipoprotein cholesterol levels versus other lipoprotein measures in predicting adult subclinical atherosclerosis. Pediatrics. 2008;121(5):924-929. doi: 10.1542/peds.2007-1472 [DOI] [PubMed] [Google Scholar]
8.Gidding SS, Sniderman A. Improving recognition of cardiovascular risk in children. J Pediatr. 2014;164(2):228-230. doi: 10.1016/j.jpeds.2013.09.050 [DOI] [PubMed] [Google Scholar]
9.de Ferranti SD, Rodday AM, Parsons SK, et al. . Cholesterol screening and treatment practices and preferences: a survey of United States pediatricians. J Pediatr. 2017;185:99-105.e2, e102. doi: 10.1016/j.jpeds.2016.12.078 [DOI] [PubMed] [Google Scholar]
10.US Food and Drug Administration Final determination regarding partially hydrogenated oils. Fed Regist. 2015;80:34650-34670. [PubMed] [Google Scholar]
11.Kit BK, Carroll MD, Lacher DA, et al. . Trends in serum lipids among US youths aged 6 to 19 years, 1988-2010. JAMA. 2012;308(6):591-600. doi: 10.1001/jama.2012.9136 [DOI] [PMC free article] [PubMed] [Google Scholar]
12.Kit BK, Kuklina E, Carroll MD, et al. . Prevalence of and trends in dyslipidemia and blood pressure among US children and adolescents, 1999-2012. JAMA Pediatr. 2015;169(3):272-279. doi: 10.1001/jamapediatrics.2014.3216 [DOI] [PMC free article] [PubMed] [Google Scholar]
13.Johnson CL, Paulose-Ram R, Ogden CL, et al. National Health and Nutrition Examination Survey: analytic guidelines, 1999-2010. https://www.cdc.gov/nchs/data/series/sr_02/sr02_161.pdf. Accessed March 19, 2019. [PubMed]
14.National Center for Health Statistics NHANES response rates and population totals. https://wwwn.cdc.gov/nchs/nhanes/ResponseRates.aspx. Accessed February 24, 2019.
15.National Center for Health Statistics NHANES 2005-2006 data documentation, codebook, and frequencies: cholesterol-HDL. https://wwwn.cdc.gov/Nchs/Nhanes/2005-2006/HDL_D.htm. Accessed September 4, 2018.
16.Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem. 1972;18(6):499-502. [PubMed] [Google Scholar]
17.National Heart, Lung and Blood Institute Expert panel on integrated guidelines for cardiovascular health and risk reduction in children: full report. https://www.nhlbi.nih.gov/health-topics/integrated-guidelines-for-cardiovascular-health-and-risk-reduction-in-children-and-adolescents. Accessed April 12, 2019. [DOI] [PMC free article] [PubMed]
18.Pencina MJ, D’Agostino RB, Zdrojewski T, et al. . Apolipoprotein B improves risk assessment of future coronary heart disease in the Framingham Heart Study beyond LDL-C and non-HDL-C. Eur J Prev Cardiol. 2015;22(10):1321-1327. doi: 10.1177/2047487315569411 [DOI] [PubMed] [Google Scholar]
19.Rosinger A, Carroll MD, Lacher D, Ogden C. Trends in total cholesterol, triglycerides, and low-density lipoprotein in US adults, 1999-2014. JAMA Cardiol. 2017;2(3):339-341. doi: 10.1001/jamacardio.2016.4396 [DOI] [PMC free article] [PubMed] [Google Scholar]
20.Bao W, Srinivasan SR, Wattigney WA, et al. . Usefulness of childhood low-density lipoprotein cholesterol level in predicting adult dyslipidemia and other cardiovascular risks. Arch Intern Med. 1996;156(12):1315-1320. doi: 10.1001/archinte.1996.00440110083011 [DOI] [PubMed] [Google Scholar]
21.Magnussen CG, Raitakari OT, Thomson R, et al. . Utility of currently recommended pediatric dyslipidemia classifications in predicting dyslipidemia in adulthood. Circulation. 2008;117(1):32-42. doi: 10.1161/CIRCULATIONAHA.107.718981 [DOI] [PubMed] [Google Scholar]
22.Ford ES, Ajani UA, Croft JB, et al. . Explaining the decrease in US deaths from coronary disease, 1980-2000. N Engl J Med. 2007;356(23):2388-2398. doi: 10.1056/NEJMsa053935 [DOI] [PubMed] [Google Scholar]
23.Pahkala K, Hietalampi H, Laitinen TT, et al. . Ideal cardiovascular health in adolescence. Circulation. 2013;127(21):2088-2096. doi: 10.1161/CIRCULATIONAHA.112.000761 [DOI] [PubMed] [Google Scholar]
24.Laitinen TT, Pahkala K, Magnussen CG, et al. . Ideal cardiovascular health in childhood and cardiometabolic outcomes in adulthood. Circulation. 2012;125(16):1971-1978. doi: 10.1161/CIRCULATIONAHA.111.073585 [DOI] [PubMed] [Google Scholar]
25.Yang Q, Cogswell ME, Flanders WD, et al. . Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults. JAMA. 2012;307(12):1273-1283. doi: 10.1001/jama.2012.339 [DOI] [PMC free article] [PubMed] [Google Scholar]
26.Younus A, Aneni EC, Spatz ES, et al. . A systematic review of the prevalence and outcomes of ideal cardiovascular health in US and non-US populations. Mayo Clin Proc. 2016;91(5):649-670. doi: 10.1016/j.mayocp.2016.01.019 [DOI] [PubMed] [Google Scholar]
27.Wilkins JT, Li RC, Sniderman A, Chan C, Lloyd-Jones DM. Discordance between apolipoprotein B and LDL-cholesterol in young adults predicts coronary artery calcification: the CARDIA study. J Am Coll Cardiol. 2016;67(2):193-201. doi: 10.1016/j.jacc.2015.10.055 [DOI] [PMC free article] [PubMed] [Google Scholar]
28.Mietus-Snyder M, Drews KL, Otvos JD, et al. ; HEALTHY Study Group . Low-density lipoprotein cholesterol versus particle number in middle school children. J Pediatr. 2013;163(2):355-362. doi: 10.1016/j.jpeds.2013.01.012 [DOI] [PMC free article] [PubMed] [Google Scholar]
29.Ogden CL, Carroll MD, Lawman HG, et al. . Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA. 2016;315(21):2292-2299. doi: 10.1001/jama.2016.6361 [DOI] [PMC free article] [PubMed] [Google Scholar]
30.Dabelea D, Mayer-Davis EJ, Saydah S, et al. . Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA. 2014;311(17):1778-1786. doi: 10.1001/jama.2014.3201 [DOI] [PMC free article] [PubMed] [Google Scholar]
31.Hooper L, Martin N, Abdelhamid A, Davey Smith G. Reduction in saturated fat intake for cardiovascular disease. Cochrane Database Syst Rev. 2015;6(6):CD011737. [DOI] [PubMed] [Google Scholar]
32.Kraus WE, Houmard JA, Duscha BD, et al. . Effects of the amount and intensity of exercise on plasma lipoproteins. N Engl J Med. 2002;347(19):1483-1492. doi: 10.1056/NEJMoa020194 [DOI] [PubMed] [Google Scholar]
33.Craig WY, Palomaki GE, Haddow JE. Cigarette smoking and serum lipid and lipoprotein concentrations. BMJ. 1989;298(6676):784-788. doi: 10.1136/bmj.298.6676.784 [DOI] [PMC free article] [PubMed] [Google Scholar]
34.Friedemann C, Heneghan C, Mahtani K, et al. . Cardiovascular disease risk in healthy children and its association with body mass index. BMJ. 2012;345:e4759. doi: 10.1136/bmj.e4759 [DOI] [PMC free article] [PubMed] [Google Scholar]
35.Eissa MA, Mihalopoulos NL, Holubkov R, et al. . Changes in fasting lipids during puberty. J Pediatr. 2016;170:199-205. doi: 10.1016/j.jpeds.2015.11.018 [DOI] [PMC free article] [PubMed] [Google Scholar]
36.Vuorio A, Kuoppala J, Kovanen PT, et al. . Statins for children with familial hypercholesterolemia. Cochrane Database Syst Rev. 2017;7:CD006401. [DOI] [PMC free article] [PubMed] [Google Scholar]
37.Mooradian AD. Dyslipidemia in type 2 diabetes mellitus. Nat Clin Pract Endocrinol Metab. 2009;5(3):150-159. [DOI] [PubMed] [Google Scholar]
38.Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA. 2012;307(5):483-490. doi: 10.1001/jama.2012.40 [DOI] [PMC free article] [PubMed] [Google Scholar]
39.Grundy SM, Stone NJ, Bailey AL, et al. . 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol [published online November 10, 2018]. Circulation. doi: 10.1161/CIR.0000000000000625 [DOI] [Google Scholar]
40.National Center for Health Statistics National Health and Nutrition Examination Survey 2015-2016 data documentation, codebook, and frequencies: demographic variables and sample weights (DEMO_I). https://wwwn.cdc.gov/Nchs/Nhanes/2015-2016/DEMO_i.htm#Analytic_Notes. Accessed March 19, 2019.

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement.

eTable 1. Maximal Sample Sizes, by Survey Cycle: National Health and Nutrition Examination Survey, 1999-2016

eTable 2. Characteristics of Examined Youth with Complete Versus Any Missing Data for Lipids and Apolipoprotein B, by Survey Cycle: National Health and Nutrition Examination Survey, 1999-2016

eTable 4. Age-Adjusted Trends in Mean Levels of Lipids and Apolipoprotein B Over Time by Race/Ethnicity and BMI Category in US Youth Ages 6 to 19 Years, 1999-2016

eTable 5. Age-Adjusted Changes in the Prevalence of Ideal Levels of Lipids and Apolipoprotein B Over Time by Race/Ethnicity and BMI Category in US Youth Ages 6 to 19 Years, 1999-2016

eTable 6. Age-Adjusted Changes in the Prevalence of Adverse Levels of Lipids and Apolipoprotein B Over Time by Race/Ethnicity and BMI Category in US Youth Ages 6 to 19 Years, 1999-2016

eReferences

Click here for additional data file.^{(170.7KB, pdf)}

[joi190042r1] 1.Lloyd-Jones DM, Hong Y, Labarthe D, et al. . Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic impact goal through 2020 and beyond. Circulation. 2010;121(4):586-613. doi: 10.1161/CIRCULATIONAHA.109.192703 [DOI] [PubMed] [Google Scholar]

[joi190042r2] 2.Steinberger J, Daniels SR, Hagberg N, et al. . Cardiovascular health promotion in children: challenges and opportunities for 2020 and beyond: a scientific statement from the American Heart Association. Circulation. 2016;134(12):e236-e255. doi: 10.1161/CIR.0000000000000441 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi190042r3] 3.Berenson GS, Srinivasan SR, Bao W, et al. . Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults: the Bogalusa Heart Study. N Engl J Med. 1998;338(23):1650-1656. doi: 10.1056/NEJM199806043382302 [DOI] [PubMed] [Google Scholar]

[joi190042r4] 4.McGill HC Jr, McMahan CA, Malcom GT, et al. . Effects of serum lipoproteins and smoking on atherosclerosis in young men and women. Arterioscler Thromb Vasc Biol. 1997;17(1):95-106. doi: 10.1161/01.ATV.17.1.95 [DOI] [PubMed] [Google Scholar]

[joi190042r5] 5.Pacifico L, Bonci E, Andreoli G, et al. . Association of serum triglyceride-to-HDL cholesterol ratio with carotid artery intima-media thickness, insulin resistance and nonalcoholic fatty liver disease in children and adolescents. Nutr Metab Cardiovasc Dis. 2014;24(7):737-743. doi: 10.1016/j.numecd.2014.01.010 [DOI] [PubMed] [Google Scholar]

[joi190042r6] 6.McGill HC Jr, McMahan CA, Zieske AW, et al. ; Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group . Associations of coronary heart disease risk factors with the intermediate lesion of atherosclerosis in youth. Arterioscler Thromb Vasc Biol. 2000;20(8):1998-2004. doi: 10.1161/01.ATV.20.8.1998 [DOI] [PubMed] [Google Scholar]

[joi190042r7] 7.Frontini MG, Srinivasan SR, Xu J, et al. . Usefulness of childhood non-high density lipoprotein cholesterol levels versus other lipoprotein measures in predicting adult subclinical atherosclerosis. Pediatrics. 2008;121(5):924-929. doi: 10.1542/peds.2007-1472 [DOI] [PubMed] [Google Scholar]

[joi190042r8] 8.Gidding SS, Sniderman A. Improving recognition of cardiovascular risk in children. J Pediatr. 2014;164(2):228-230. doi: 10.1016/j.jpeds.2013.09.050 [DOI] [PubMed] [Google Scholar]

[joi190042r9] 9.de Ferranti SD, Rodday AM, Parsons SK, et al. . Cholesterol screening and treatment practices and preferences: a survey of United States pediatricians. J Pediatr. 2017;185:99-105.e2, e102. doi: 10.1016/j.jpeds.2016.12.078 [DOI] [PubMed] [Google Scholar]

[joi190042r10] 10.US Food and Drug Administration Final determination regarding partially hydrogenated oils. Fed Regist. 2015;80:34650-34670. [PubMed] [Google Scholar]

[joi190042r11] 11.Kit BK, Carroll MD, Lacher DA, et al. . Trends in serum lipids among US youths aged 6 to 19 years, 1988-2010. JAMA. 2012;308(6):591-600. doi: 10.1001/jama.2012.9136 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi190042r12] 12.Kit BK, Kuklina E, Carroll MD, et al. . Prevalence of and trends in dyslipidemia and blood pressure among US children and adolescents, 1999-2012. JAMA Pediatr. 2015;169(3):272-279. doi: 10.1001/jamapediatrics.2014.3216 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi190042r13] 13.Johnson CL, Paulose-Ram R, Ogden CL, et al. National Health and Nutrition Examination Survey: analytic guidelines, 1999-2010. https://www.cdc.gov/nchs/data/series/sr_02/sr02_161.pdf. Accessed March 19, 2019. [PubMed]

[joi190042r14] 14.National Center for Health Statistics NHANES response rates and population totals. https://wwwn.cdc.gov/nchs/nhanes/ResponseRates.aspx. Accessed February 24, 2019.

[joi190042r15] 15.National Center for Health Statistics NHANES 2005-2006 data documentation, codebook, and frequencies: cholesterol-HDL. https://wwwn.cdc.gov/Nchs/Nhanes/2005-2006/HDL_D.htm. Accessed September 4, 2018.

[joi190042r16] 16.Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem. 1972;18(6):499-502. [PubMed] [Google Scholar]

[joi190042r17] 17.National Heart, Lung and Blood Institute Expert panel on integrated guidelines for cardiovascular health and risk reduction in children: full report. https://www.nhlbi.nih.gov/health-topics/integrated-guidelines-for-cardiovascular-health-and-risk-reduction-in-children-and-adolescents. Accessed April 12, 2019. [DOI] [PMC free article] [PubMed]

[joi190042r18] 18.Pencina MJ, D’Agostino RB, Zdrojewski T, et al. . Apolipoprotein B improves risk assessment of future coronary heart disease in the Framingham Heart Study beyond LDL-C and non-HDL-C. Eur J Prev Cardiol. 2015;22(10):1321-1327. doi: 10.1177/2047487315569411 [DOI] [PubMed] [Google Scholar]

[joi190042r19] 19.Rosinger A, Carroll MD, Lacher D, Ogden C. Trends in total cholesterol, triglycerides, and low-density lipoprotein in US adults, 1999-2014. JAMA Cardiol. 2017;2(3):339-341. doi: 10.1001/jamacardio.2016.4396 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi190042r20] 20.Bao W, Srinivasan SR, Wattigney WA, et al. . Usefulness of childhood low-density lipoprotein cholesterol level in predicting adult dyslipidemia and other cardiovascular risks. Arch Intern Med. 1996;156(12):1315-1320. doi: 10.1001/archinte.1996.00440110083011 [DOI] [PubMed] [Google Scholar]

[joi190042r21] 21.Magnussen CG, Raitakari OT, Thomson R, et al. . Utility of currently recommended pediatric dyslipidemia classifications in predicting dyslipidemia in adulthood. Circulation. 2008;117(1):32-42. doi: 10.1161/CIRCULATIONAHA.107.718981 [DOI] [PubMed] [Google Scholar]

[joi190042r22] 22.Ford ES, Ajani UA, Croft JB, et al. . Explaining the decrease in US deaths from coronary disease, 1980-2000. N Engl J Med. 2007;356(23):2388-2398. doi: 10.1056/NEJMsa053935 [DOI] [PubMed] [Google Scholar]

[joi190042r23] 23.Pahkala K, Hietalampi H, Laitinen TT, et al. . Ideal cardiovascular health in adolescence. Circulation. 2013;127(21):2088-2096. doi: 10.1161/CIRCULATIONAHA.112.000761 [DOI] [PubMed] [Google Scholar]

[joi190042r24] 24.Laitinen TT, Pahkala K, Magnussen CG, et al. . Ideal cardiovascular health in childhood and cardiometabolic outcomes in adulthood. Circulation. 2012;125(16):1971-1978. doi: 10.1161/CIRCULATIONAHA.111.073585 [DOI] [PubMed] [Google Scholar]

[joi190042r25] 25.Yang Q, Cogswell ME, Flanders WD, et al. . Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults. JAMA. 2012;307(12):1273-1283. doi: 10.1001/jama.2012.339 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi190042r26] 26.Younus A, Aneni EC, Spatz ES, et al. . A systematic review of the prevalence and outcomes of ideal cardiovascular health in US and non-US populations. Mayo Clin Proc. 2016;91(5):649-670. doi: 10.1016/j.mayocp.2016.01.019 [DOI] [PubMed] [Google Scholar]

[joi190042r27] 27.Wilkins JT, Li RC, Sniderman A, Chan C, Lloyd-Jones DM. Discordance between apolipoprotein B and LDL-cholesterol in young adults predicts coronary artery calcification: the CARDIA study. J Am Coll Cardiol. 2016;67(2):193-201. doi: 10.1016/j.jacc.2015.10.055 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi190042r28] 28.Mietus-Snyder M, Drews KL, Otvos JD, et al. ; HEALTHY Study Group . Low-density lipoprotein cholesterol versus particle number in middle school children. J Pediatr. 2013;163(2):355-362. doi: 10.1016/j.jpeds.2013.01.012 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi190042r29] 29.Ogden CL, Carroll MD, Lawman HG, et al. . Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA. 2016;315(21):2292-2299. doi: 10.1001/jama.2016.6361 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi190042r30] 30.Dabelea D, Mayer-Davis EJ, Saydah S, et al. . Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA. 2014;311(17):1778-1786. doi: 10.1001/jama.2014.3201 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi190042r31] 31.Hooper L, Martin N, Abdelhamid A, Davey Smith G. Reduction in saturated fat intake for cardiovascular disease. Cochrane Database Syst Rev. 2015;6(6):CD011737. [DOI] [PubMed] [Google Scholar]

[joi190042r32] 32.Kraus WE, Houmard JA, Duscha BD, et al. . Effects of the amount and intensity of exercise on plasma lipoproteins. N Engl J Med. 2002;347(19):1483-1492. doi: 10.1056/NEJMoa020194 [DOI] [PubMed] [Google Scholar]

[joi190042r33] 33.Craig WY, Palomaki GE, Haddow JE. Cigarette smoking and serum lipid and lipoprotein concentrations. BMJ. 1989;298(6676):784-788. doi: 10.1136/bmj.298.6676.784 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi190042r34] 34.Friedemann C, Heneghan C, Mahtani K, et al. . Cardiovascular disease risk in healthy children and its association with body mass index. BMJ. 2012;345:e4759. doi: 10.1136/bmj.e4759 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi190042r35] 35.Eissa MA, Mihalopoulos NL, Holubkov R, et al. . Changes in fasting lipids during puberty. J Pediatr. 2016;170:199-205. doi: 10.1016/j.jpeds.2015.11.018 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi190042r36] 36.Vuorio A, Kuoppala J, Kovanen PT, et al. . Statins for children with familial hypercholesterolemia. Cochrane Database Syst Rev. 2017;7:CD006401. [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi190042r37] 37.Mooradian AD. Dyslipidemia in type 2 diabetes mellitus. Nat Clin Pract Endocrinol Metab. 2009;5(3):150-159. [DOI] [PubMed] [Google Scholar]

[joi190042r38] 38.Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA. 2012;307(5):483-490. doi: 10.1001/jama.2012.40 [DOI] [PMC free article] [PubMed] [Google Scholar]

[joi190042r39] 39.Grundy SM, Stone NJ, Bailey AL, et al. . 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol [published online November 10, 2018]. Circulation. doi: 10.1161/CIR.0000000000000625 [DOI] [Google Scholar]

[joi190042r40] 40.National Center for Health Statistics National Health and Nutrition Examination Survey 2015-2016 data documentation, codebook, and frequencies: demographic variables and sample weights (DEMO_I). https://wwwn.cdc.gov/Nchs/Nhanes/2015-2016/DEMO_i.htm#Analytic_Notes. Accessed March 19, 2019.

PERMALINK

Trends in Levels of Lipids and Apolipoprotein B in US Youths Aged 6 to 19 Years, 1999-2016

Amanda M Perak, MD, MS

Hongyan Ning, MD, MS

Brian K Kit, MD, MPH

Sarah D de Ferranti, MD, MPH

Linda V Van Horn, PhD, RD

John T Wilkins, MD, MS

Donald M Lloyd-Jones, MD, ScM

Key Points

Question

Findings

Meaning

Abstract

Importance

Objective

Design, Setting, and Participants

Exposures

Main Outcomes and Measures

Results

Conclusions and Relevance

Introduction

Methods

Study Design

Survey Years

Demographics

Body Mass Index Categories

Laboratory Measurements

Classification of Lipids and Apolipoprotein B

Statistical Analysis

Results

Analytic Sample

Adjusted Trends in Mean Levels of Lipids and Apolipoprotein B

Table 1. Age- and Race/Ethnicity-Adjusted Trends in Mean Levels of Lipids and Apolipoprotein B in US Youths Aged 6 to 19 Years, 1999-2016.

Figure. Age- and Race/Ethnicity-Adjusted Trends in Mean Levels of Lipids and Apolipoprotein B in US Youths Aged 6 to 19 Years, 1999-2016.

Adjusted Trends in the Prevalence of Ideal Levels of Lipids and Apolipoprotein B

Table 2. Age- and Race/Ethnicity-Adjusted Trends in the Prevalence of Ideal Levels of Lipids and Apolipoprotein B in US Youths Aged 6 to 19 Years, 1999-2016.

Table 3. Age- and Race/Ethnicity-Adjusted Trends in the Prevalence of Ideal Levels of Lipids and Apolipoprotein B in US Youths Aged 6 to 19 Years, 1999-2016.

Adjusted Changes in the Prevalence of Adverse Levels of Lipids and Apolipoprotein B

Table 4. Age- and Race/Ethnicity-Adjusted Changes in the Prevalence of Adverse Levels of Lipids and Apolipoprotein B in US Youths Aged 6 to 19 Years, 1999-2016.

Adjusted Changes in the Prevalence of Apolipoprotein B Concordance and Discordance With Types of Cholesterol

Secondary Analyses: Race/Ethnicity- and BMI-Stratified Trends

Discussion

Limitations

Conclusions

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

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Links to NCBI Databases