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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">It is a popular misconception that myocardial infarction and stroke are acute events that strike suddenly and unexpectedly in middle aged and elderly adults&#46; Yet the Bogalusa&#44; Muscatine&#44; Young Finns&#44; and PDAY studies clearly demonstrate that atherosclerosis is a chronic&#44; progressive disease that begins in childhood&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> Identification of high-risk children and institution of preventive measures at an early age are therefore imperative&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Critical determinants of atherosclerosis in adolescence and adulthood include obesity&#44; hyperlipidemia&#44; hypertension&#44; glucose intolerance&#44; smoking&#44; sedentary activity&#44; and a family history of early cardiovascular disease and stroke&#46; The earliest structural lesions of atherosclerosis&#44; fatty streaks&#44; can be detected even in young children&#46; Accumulation of lipid-laden macrophages&#44; monocytes&#44; and T cells is followed by platelet aggregation&#44; vascular smooth muscle cell proliferation&#44; and the formation of a lesion capped by smooth muscle and collagen known as a fibrous plaque&#46; But prior to the emergence of fatty streaks and plaques there are changes in endothelial function manifest as heightened permeability to lipoproteins&#44; up-regulation of leukocyte adhesion molecules&#44; and translocation of leukocytes into the arterial wall&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a> These are associated with functional changes in micro- and macro-vascular compliance and reactivity that are associated&#44; at least in adults&#44; with mortality from cardiovascular disease&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">As assessed by reductions in flow-mediated dilation of the brachial artery and flow-mediated hyperemia of peripheral vessels&#44; endothelial dysfunction has been demonstrated in children and adolescents with obesity and insulin resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> Poorly understood&#44; however&#44; are the roles of diet and physical activity in the control of vascular function in obese and lean young people&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The study by Penha et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> examined the relationship between physical activity in prepubertal children and vascular function as measured by venous occlusion plethysmography&#46; This method assesses changes in limb volume following venous occlusion&#46; An acute increase in limb volume during venous outflow obstruction reflects arterial blood inflow&#44; which depends on the capacity of the major arterial conduit vessels to overcome resistance of small arterioles&#59; an inadequate rise in limb volume during venous occlusion reflects higher resistance&#44; or lower vasodilatory capacity&#44; of small resistance vessels&#46; Thus&#44; the technique is an indirect measure of the vasoreactivity of the microcirculation&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The authors found a reduced hyperemic response to venous occlusion in overweight and obese children&#44; in association with measures of adiposity &#40;&#37; body fat and hyperleptinemia&#41;&#46; Interestingly&#44; there was no relationship between arterial vascular reactivity and physical fitness or habitual physical activity&#44; as assessed by questionnaire and a speed-shuttle endurance run&#46; Run performance did correlate negatively with body fat and waist circumference&#59; whether a decrease in physical fitness is a cause or consequence &#40;or both&#41; of adiposity is currently unclear&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The authors did not explore the mechanisms by which obesity reduces microvascular reactivity in prepubertal children&#46; A defect in vascular relaxation may signify a deficit of nitrous oxide &#40;NO&#41; generation by vascular endothelial cells or an impaired response of vascular smooth muscle cells to NO or other endogenous vasodilatory substances&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;7</span></a> Endothelial synthesis of NO is controlled in part by insulin and various other hormones and cytokines&#46; In lean subjects&#44; insulin promotes vasodilatation by increasing the expression of NO synthase &#40;eNOS&#41; in endothelial cells&#59; this action is mediated by <span class="elsevierStyleItalic">tyrosine</span> phosphorylation of insulin receptor substrates 1 and 2 and activation of phosphoinositide 3-kinase &#40;PI-3 kinase&#41; and Akt&#46; In obesity and other states associated with insulin resistance&#44; <span class="elsevierStyleItalic">serine</span> phosphorylation of insulin receptor substrates inhibits activation of PI-3 kinase and Akt and impedes NO generation&#59; under these conditions&#44; insulin promotes <span class="elsevierStyleItalic">vasoconstriction</span> through mitogen-activated protein kinase &#40;MAPK&#41;-mediated induction of endothelin-1&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;7</span></a> The overweight subjects in this study were insulin resistant&#44; as determined by hypoadiponectinemia and increases in HOMA-IR and the ratio of triglycerides to HDL&#46; Nevertheless&#44; the hyperemic response did not correlate with measures of insulin sensitivity&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In parallel with its effects on insulin sensitivity&#44; obesity can impair endothelial function through visceral and perivascular fat accretion and vascular inflammation&#58; obesity-induced hypertrophy of visceral and perivascular white adipocytes is accompanied by free fatty acidemia&#44; macrophage infiltration&#44; and generation of inflammatory cytokines and reactive oxygen species&#46; In concert&#44; these promote tissue inflammation&#44; reduce vascular NO availability&#44; and inhibit the smooth muscle cell vasodilatory response to NO&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#8211;8</span></a> Other factors contributing to loss of vascular compliance in obesity include activation of the sympathetic nervous system by hyperleptinemia&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#8211;8</span></a> induction of renin-angiotensin-aldosterone activity via heightened white adipocyte angiotensinogen production&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#8211;9</span></a> and loss of capillary perfusion associated with hypoadiponectinemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#8211;10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">What is the significance of endothelial dysfunction in overweight and obese children&#63; Loss of endothelial vasodilatation likely contributes to hypertension&#44; a common co-morbidity in obese subjects&#44; and to the development of obesity-related glomerulosclerosis&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> Of equal or more concern&#44; experimental evidence suggests that endothelial dysfunction might limit cerebral blood flow and predispose to cognitive dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The relationship between endothelial dysfunction in prepubertal children and adult cardiovascular disease is less clear&#46; No studies to date clearly demonstrate that prepubertal endothelial dysfunction predisposes to myocardial infarction or stroke&#46; On the other hand&#44; obesity during childhood and adolescence increases the risks for coronary artery disease if excess fat deposition persists into adulthood&#46; A large &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;3 million&#41;&#44; longitudinal study<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> of Israeli adolescents found that obesity at mean age 17&#46;3 years was associated with a 4&#46;9-fold increase in the risk of coronary artery disease and a 4&#46;1-fold increase in cardiovascular deaths by ages 47&#8211;57 years&#46; Lower &#40;but statistically significant&#41; risks of future acute coronary events &#40;10&#37; increase for every 1-unit increase in BMIz&#41; were noted in a study of 7&#8211;13-year-old Danish children&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> Finally&#44; a meta-analysis<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> showed that a 1-SD increase in BMI in childhood and adolescence &#40;ages 7&#8211;18 years&#41; predicts a 14&#8211;30&#37; increase in the risk of adult coronary heart disease&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Nevertheless&#44; the association of carotid intimal thickening with childhood obesity was abolished after adjustment for adult obesity in the Bogalusa&#44; Muscatine and Young Finns studies&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> Moreover&#44; cardiovascular mortality was not increased in adult Swedes who were obese in childhood but not during adolescence or adult life&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> Thus&#44; endothelial dysfunction in children and obesity-related risks for cardiovascular morbidity and mortality are potentially reversible&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">What measures might be taken to reverse the endothelial dysfunction in obese children&#63; Weight loss is known to promote NO generation&#44; and a combination of diet and aerobic exercise training improves <span class="elsevierStyleItalic">macro</span>-vascular endothelial function in obese children in as little as 6&#8211;8 weeks<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">15&#44;16</span></a>&#59; more prolonged interventions may be needed to improve <span class="elsevierStyleItalic">micro</span>-vascular endothelial function&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> It is thought that surges in limb blood flow during bouts of physical activity may facilitate a rise in endothelial NO production and&#47;or activity&#46; Both aerobic and resistance training are effective<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a>&#59; however&#44; the benefits of exercise on vascular function appear to be lost if training ceases&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Dietary and exercise counseling may not suffice for subjects with more severe metabolic dysfunction&#59; in such cases&#44; the addition of a pharmacologic agent may prove salutary&#46; For example&#44; an emerging literature suggests that metformin can enhance endothelial function in adults with severe insulin resistance&#44; type 2 diabetes mellitus&#44; and the polycystic ovary syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> The drug may therefore provide cardiovascular as well as glycemic benefits to adolescents with prediabetes or overt glucose intolerance&#46; Angiotensin-converting enzyme &#40;ACE&#41; inhibitors and angiotensin II receptor blockers &#40;ARBs&#41; improve endothelial-dependent vasodilation in adults with renal disease<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">9&#44;20</span></a> and may be useful in obese children and adolescents with hypertension and&#47;or microalbuminuria&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Critical gaps remain in our understanding of the development and pathogenesis of vascular dysfunction and atherogenesis in children&#46; Long-term studies of dietary and exercise interventions in overweight and obese subjects will enhance our ability to prevent long-term vascular complications and increase quality of life&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The author declares no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Freemark M&#46; Endothelial dysfunction and cardiovascular disease in childhood obesity&#46; J Pediatr &#40;Rio J&#41;&#46; 2019&#59;95&#58;503&#8211;5&#46;</p>"
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Editorial
Endothelial dysfunction and cardiovascular disease in childhood obesity
Disfunção endotelial e doença cardiovascular na obesidade infantil
Michael Freemark
Duke University Medical Center, Pediatric Endocrinology and Diabetes, Durham, United States
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">It is a popular misconception that myocardial infarction and stroke are acute events that strike suddenly and unexpectedly in middle aged and elderly adults&#46; Yet the Bogalusa&#44; Muscatine&#44; Young Finns&#44; and PDAY studies clearly demonstrate that atherosclerosis is a chronic&#44; progressive disease that begins in childhood&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> Identification of high-risk children and institution of preventive measures at an early age are therefore imperative&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Critical determinants of atherosclerosis in adolescence and adulthood include obesity&#44; hyperlipidemia&#44; hypertension&#44; glucose intolerance&#44; smoking&#44; sedentary activity&#44; and a family history of early cardiovascular disease and stroke&#46; The earliest structural lesions of atherosclerosis&#44; fatty streaks&#44; can be detected even in young children&#46; Accumulation of lipid-laden macrophages&#44; monocytes&#44; and T cells is followed by platelet aggregation&#44; vascular smooth muscle cell proliferation&#44; and the formation of a lesion capped by smooth muscle and collagen known as a fibrous plaque&#46; But prior to the emergence of fatty streaks and plaques there are changes in endothelial function manifest as heightened permeability to lipoproteins&#44; up-regulation of leukocyte adhesion molecules&#44; and translocation of leukocytes into the arterial wall&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a> These are associated with functional changes in micro- and macro-vascular compliance and reactivity that are associated&#44; at least in adults&#44; with mortality from cardiovascular disease&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">As assessed by reductions in flow-mediated dilation of the brachial artery and flow-mediated hyperemia of peripheral vessels&#44; endothelial dysfunction has been demonstrated in children and adolescents with obesity and insulin resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> Poorly understood&#44; however&#44; are the roles of diet and physical activity in the control of vascular function in obese and lean young people&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The study by Penha et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> examined the relationship between physical activity in prepubertal children and vascular function as measured by venous occlusion plethysmography&#46; This method assesses changes in limb volume following venous occlusion&#46; An acute increase in limb volume during venous outflow obstruction reflects arterial blood inflow&#44; which depends on the capacity of the major arterial conduit vessels to overcome resistance of small arterioles&#59; an inadequate rise in limb volume during venous occlusion reflects higher resistance&#44; or lower vasodilatory capacity&#44; of small resistance vessels&#46; Thus&#44; the technique is an indirect measure of the vasoreactivity of the microcirculation&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The authors found a reduced hyperemic response to venous occlusion in overweight and obese children&#44; in association with measures of adiposity &#40;&#37; body fat and hyperleptinemia&#41;&#46; Interestingly&#44; there was no relationship between arterial vascular reactivity and physical fitness or habitual physical activity&#44; as assessed by questionnaire and a speed-shuttle endurance run&#46; Run performance did correlate negatively with body fat and waist circumference&#59; whether a decrease in physical fitness is a cause or consequence &#40;or both&#41; of adiposity is currently unclear&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The authors did not explore the mechanisms by which obesity reduces microvascular reactivity in prepubertal children&#46; A defect in vascular relaxation may signify a deficit of nitrous oxide &#40;NO&#41; generation by vascular endothelial cells or an impaired response of vascular smooth muscle cells to NO or other endogenous vasodilatory substances&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;7</span></a> Endothelial synthesis of NO is controlled in part by insulin and various other hormones and cytokines&#46; In lean subjects&#44; insulin promotes vasodilatation by increasing the expression of NO synthase &#40;eNOS&#41; in endothelial cells&#59; this action is mediated by <span class="elsevierStyleItalic">tyrosine</span> phosphorylation of insulin receptor substrates 1 and 2 and activation of phosphoinositide 3-kinase &#40;PI-3 kinase&#41; and Akt&#46; In obesity and other states associated with insulin resistance&#44; <span class="elsevierStyleItalic">serine</span> phosphorylation of insulin receptor substrates inhibits activation of PI-3 kinase and Akt and impedes NO generation&#59; under these conditions&#44; insulin promotes <span class="elsevierStyleItalic">vasoconstriction</span> through mitogen-activated protein kinase &#40;MAPK&#41;-mediated induction of endothelin-1&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#44;7</span></a> The overweight subjects in this study were insulin resistant&#44; as determined by hypoadiponectinemia and increases in HOMA-IR and the ratio of triglycerides to HDL&#46; Nevertheless&#44; the hyperemic response did not correlate with measures of insulin sensitivity&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In parallel with its effects on insulin sensitivity&#44; obesity can impair endothelial function through visceral and perivascular fat accretion and vascular inflammation&#58; obesity-induced hypertrophy of visceral and perivascular white adipocytes is accompanied by free fatty acidemia&#44; macrophage infiltration&#44; and generation of inflammatory cytokines and reactive oxygen species&#46; In concert&#44; these promote tissue inflammation&#44; reduce vascular NO availability&#44; and inhibit the smooth muscle cell vasodilatory response to NO&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#8211;8</span></a> Other factors contributing to loss of vascular compliance in obesity include activation of the sympathetic nervous system by hyperleptinemia&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#8211;8</span></a> induction of renin-angiotensin-aldosterone activity via heightened white adipocyte angiotensinogen production&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#8211;9</span></a> and loss of capillary perfusion associated with hypoadiponectinemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6&#8211;10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">What is the significance of endothelial dysfunction in overweight and obese children&#63; Loss of endothelial vasodilatation likely contributes to hypertension&#44; a common co-morbidity in obese subjects&#44; and to the development of obesity-related glomerulosclerosis&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> Of equal or more concern&#44; experimental evidence suggests that endothelial dysfunction might limit cerebral blood flow and predispose to cognitive dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The relationship between endothelial dysfunction in prepubertal children and adult cardiovascular disease is less clear&#46; No studies to date clearly demonstrate that prepubertal endothelial dysfunction predisposes to myocardial infarction or stroke&#46; On the other hand&#44; obesity during childhood and adolescence increases the risks for coronary artery disease if excess fat deposition persists into adulthood&#46; A large &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;3 million&#41;&#44; longitudinal study<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> of Israeli adolescents found that obesity at mean age 17&#46;3 years was associated with a 4&#46;9-fold increase in the risk of coronary artery disease and a 4&#46;1-fold increase in cardiovascular deaths by ages 47&#8211;57 years&#46; Lower &#40;but statistically significant&#41; risks of future acute coronary events &#40;10&#37; increase for every 1-unit increase in BMIz&#41; were noted in a study of 7&#8211;13-year-old Danish children&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> Finally&#44; a meta-analysis<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> showed that a 1-SD increase in BMI in childhood and adolescence &#40;ages 7&#8211;18 years&#41; predicts a 14&#8211;30&#37; increase in the risk of adult coronary heart disease&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Nevertheless&#44; the association of carotid intimal thickening with childhood obesity was abolished after adjustment for adult obesity in the Bogalusa&#44; Muscatine and Young Finns studies&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> Moreover&#44; cardiovascular mortality was not increased in adult Swedes who were obese in childhood but not during adolescence or adult life&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> Thus&#44; endothelial dysfunction in children and obesity-related risks for cardiovascular morbidity and mortality are potentially reversible&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">What measures might be taken to reverse the endothelial dysfunction in obese children&#63; Weight loss is known to promote NO generation&#44; and a combination of diet and aerobic exercise training improves <span class="elsevierStyleItalic">macro</span>-vascular endothelial function in obese children in as little as 6&#8211;8 weeks<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">15&#44;16</span></a>&#59; more prolonged interventions may be needed to improve <span class="elsevierStyleItalic">micro</span>-vascular endothelial function&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> It is thought that surges in limb blood flow during bouts of physical activity may facilitate a rise in endothelial NO production and&#47;or activity&#46; Both aerobic and resistance training are effective<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a>&#59; however&#44; the benefits of exercise on vascular function appear to be lost if training ceases&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Dietary and exercise counseling may not suffice for subjects with more severe metabolic dysfunction&#59; in such cases&#44; the addition of a pharmacologic agent may prove salutary&#46; For example&#44; an emerging literature suggests that metformin can enhance endothelial function in adults with severe insulin resistance&#44; type 2 diabetes mellitus&#44; and the polycystic ovary syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> The drug may therefore provide cardiovascular as well as glycemic benefits to adolescents with prediabetes or overt glucose intolerance&#46; Angiotensin-converting enzyme &#40;ACE&#41; inhibitors and angiotensin II receptor blockers &#40;ARBs&#41; improve endothelial-dependent vasodilation in adults with renal disease<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">9&#44;20</span></a> and may be useful in obese children and adolescents with hypertension and&#47;or microalbuminuria&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Critical gaps remain in our understanding of the development and pathogenesis of vascular dysfunction and atherogenesis in children&#46; Long-term studies of dietary and exercise interventions in overweight and obese subjects will enhance our ability to prevent long-term vascular complications and increase quality of life&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The author declares no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Freemark M&#46; Endothelial dysfunction and cardiovascular disease in childhood obesity&#46; J Pediatr &#40;Rio J&#41;&#46; 2019&#59;95&#58;503&#8211;5&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0025">See paper by Penha et al&#46; in pages 531&#8211;7&#46;</p>"
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