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Samenvatting
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In het project, ProCOR (Prediction Of Child CardiOmetabolic Risk) is onderzocht of dynamische predictie-instrumenten kunnen worden ontwikkeld voor toepassing binnen de Jeugdgezondheidszorg om overgewicht, (pre-)hypertensie en/of een afwijkend lipidenprofiel op latere leeftijd te voorspellen. Deze instrumenten zijn bedoeld voor kinderen van 0-6 jaar oud; kinderen in deze leeftijdsrange zijn immers extra gevoelig voor het ontwikkelen van overgewicht en comorbiditeit, en ook is op deze jonge leeftijd de kans om dit risico te keren nog aanzienlijk. Eerst zijn predictiemodellen ontwikkeld op basis van data van het Generation R en het PIAMA-cohort. Het predictiemodel Overgewicht is extern gevalideerd en heeft goed vooorspellende eigenschappen. De resultaten van het project zijn toegepast in een virtuele pilot. Er is een stakeholdersgroep samengesteld met leden vanuit diverse relevante geledingen, zoals de AJN, V&VN, NCJ, NVK, NHG, zorgverzekeraars en ouders. Deze stakeholdersgroep is 3 keer bieen geweest om te adviseren over voortgang, risicocommunicatie, implementatie en om relevante input te leveren.

Resultaten
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De belangrijkste resultaten van het project betreft

1. het vaststellen welke methoden kunnen worden gebruikt om dynamische predictiemodellen te ontwikkelen; dynamische predictiemodellen zijn modellen die op elke leeftijd (binnen een bepaalde range) kunnen worden toegepast;

2. het ontwikkelen van predictiemodellen, namelijk

* het predictiemodel overgewicht voor 0-6-jarigen in het PIAMA cohort: het blijkt dat dit model goede voorspellende eigenschappen bezit. Ook na toepassing van het model in andere data, het Generation R cohort, blijft het model goed voorspellen;

* predictiemodellen (diagnostisch en voorspellend) voor 0-6-jarigen van hoge bloeddruk en afwijkende lipidengehaltes in het Generation R cohort;

* de ontwikkeling van predictietools voor overgewicht en hoge bloeddruk (op basis van deze modellen) die toepasbaar zijn binnen de JGZ

3. Een kwalitatieve evaluatie van deze tools door JGZ- professionals in een virtuele pilot met aanbevelingen voor toepasbaarheid in de Jeugdgezondheidszorg.

Samenvatting van de aanvraag

Samenvatting
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RELEVANCE

Longitudinal studies show that overweight and related cardiometabolic risk factors, especially (pre-)hypertension and a low HDL cholesterol (HDL-C), in childhood are strongly associated with adult atherosclerosis (AA) and coronary heart diseases (CHD). Importantly, overweight, (pre-)hypertension and a low HDL-C, are highly prevalent in childhood and strongly track into adulthood, while both are usually asymptomatic.

 

Long term results of secondary prevention of overweight and cardiometabolic risk, are disappointing, due to the difficulty to change lifestyle and the tendency to lapse into old habits. Therefore, primary prevention is preferred. Moreover, the IOTF cut-offs of BMI, used as a screening tool for overweight in infancy in order to offer secondary prevention, have a weak relationship with adult overweight and cardiometabolic risk.

Currently, primary prevention of overweight is offered to the entire population, regardless of individuals’ risk profiles. This universal approach is promising, but still many children - especially from a low socioeconomic position - become overweight, calling for an additional targeted approach.

 

In recent cohort studies, two prototypes of evidence-based screening tools that predict future overweight have been developed with a fairly high sensitivity and specificity. These prototypes, based on the presence of predictors at birth (PIAMA cohort) and BMI changes in infancy(Terneuzen cohort), make targeted primary prevention of overweight feasible. This TOP proposal aims to combine, refine and validate these prototypes resulting into high quality evidence-based screening tools.

 

Predictors that can be assessed from birth onwards, such as parents’ BMI, birth weight, and BMI changes before age 6 are highly predictive of future overweight and cardiometabolic risk. Our proposal aims at identifying individual children at high risk before age 6 in order to offer targeted primary prevention. Therefore, innovative screening tools on the basis of repeated risk assessments are required to effectively identify children between birth and age 6 at high risk for future overweight and cardiometabolic risk.

In addition, we develop screening tools to identify children who already have signs of cardiometabolic risk such as (pre-)hypertension and a low HDL-C (or a high total-to-HDL-C ratio). These tools offer the opportunity to treat these cardiometabolic risk factors and thus prevent AA and CHD.

 

Our AIMS are:

1. to develop evidence-based screening tools on the basis of repeated risk assessments in order to identify:

a. children aged 0-6 years at high risk of developing overweight, (pre-)hypertension and/or a low HDL-C (or high total-to-HDL-C ratio)

b. children with cardiometabolic risk factors during the regular health checks at age 5-6 and 10 years;

2. to conduct a process evaluation of the pilot implementation of both screening tools in the Dutch Child Health Care, in combination with respectively

a. the currently applied Dutch Child Health Care Overweight Prevention Protocol as targeted primary prevention, and

b. offering further diagnostics and – if needed – interventions by the Child Health Care, general practitioner or paediatrician (measurements of blood pressure, blood tests).

 

See figure 1 for a visualized concept of the study.

 

METHODS

The screening tools will be developed on the basis of dynamic risk prediction models using data on relevant predictors, such as parents’ BMI, passive smoking, and BMI changes during growth. The screening tools will be used to update the risk estimations every time the child is seen by the Child Health Care.

Outcome variables of the prediction models are (abdominal) overweight and obesity, (pre-)hypertension, and high non-HDL-C (or a low total-to-HDL-C ratio) at age 10-15.

 

The dynamic prediction models will be developed and externally validated within the Generation R (n=7893) and PIAMA (n=3963) cohorts, including diverse ethnicities.

Advanced statistical modelling will be applied, such as Generalised Estimation Equations and restricted cubic spline functions.

Specific demands on the cut-offs (based on sensitivity, specificity, Positive and Negative Predictive Value), as well as the implementation and evaluation of the screening tools will be prepared from the start of the project in close cooperation with all relevant stakeholders.

 

This project will yield recommendations for adjustments within the Child Health Care practice, e.g. with respect to risk estimation and medical decision making, and for future research on the effects of the screening tools combined with follow-up actions.

 

The development of these screening tools will offer an innovative improvement of the prevention of overweight and related cardiometabolic risk. This new approach can be perfectly embedded within the Dutch Child Health Care system with a reach of more than 90% of all children, its database currently being digitized nationwide.

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