Tuesday, November 15, 2011

Why Cholesterol Screening for Kids is the Wrong Idea

If your ears are tuned to the health-o-sphere, I'm guessing you've heard that America's National Institute of Health's NHLBI has recommended screening children starting at age 9 for hyperlipidemia, and doing so by means of a blood test.

While I won't debate the gravity of the rising tide of childhood hyperlipidemia, diabetes, obesity, hypertension, etc., I really do scratch my head about their recommendations.

Firstly I don't believe in ordering blood tests where there's a low likelihood of clinically relevant consequent intervention. What I mean is, doctors shouldn't order tests unless the results have a clear cut, reproducible and clinically effective response.  So what type of response will there be?  Obviously it won't be the kids intervening themselves as it doesn't matter what you tell a 9 year old about their cholesterol, they're 9 years old! Does anyone really think a 9 year old has the necessary insight to react rationally to an elevated serum cholesterol? The problem is, neither do adults. In fact we as a profession seem to be almost wholly incapable of inspiring lifelong change even in supposedly insightful adults with elevated cholesterol.  I wonder therefore why we think we're so good at it so as to ask a child to endure a screening blood test at age 9.

Secondly, even if we could affect lasting change, are the recommendations provided proven to be a clinically reproducible, useful and efficacious dietary pattern?

Well, from what I can gather, fancy expert panel or not, they seem to have simply regurgitated the same low-fat message that recent years have pretty much proven to be non-helpful in preventing cardiovascular problems in adults. And despite regurgitating old, proven to be ineffective with adults advice, what's perhaps more shocking is what they didn't recommend. From what I read there's not one word about whole-food cooking, and not one word about the processed food environment in which these kids are drowning.

I find that absolutely astonishing. Much ado was made about how we have to work with best available evidence in terms of testing 9 year olds rather than wait for the clinical trials. How about the best available evidence that from a dietary perspective society's nutritional fracture is the loss of the ability, desire, time, and/or motivation to regularly transform raw ingredients into meals? Where's the advice to actually cook from scratch? To minimize all meals out and not just "fast" food? To stay away from boxes? Instead all I see is the DASH diet, a call to avoid eggs (good grief), and a call to avoid full fat milk.

Lastly, do we really need 9 year olds to endure a blood test to know that they're on an unhealthy path, and moreover and more importantly, are high cholesterol, sugar or blood pressure really the barometers of dangerous dietary or lifestyle dysfunctions?  Does that mean that kids who eat atrocious diets and live unhealthy lifestyles but don't have signs of traditionally adult diseases are safe?

Whether they've got elevated cholesterol, sugar or blood pressure or not, how about we teach doctors to take detailed eating and lifestyle histories from every kid, at every annual visit?

What sort of history?

Well for starters, how about questions like:
  • How many meals out a week (including cafeterias, take out and restaurants)?
  • Who, if anyone, is cooking?
  • How much juice?
  • How many sweetened beverages?
  • What are their patterns of eating like?
  • Do they struggle with any disordered eating?
  • What are their usual meals for breakfast, lunches, dinners or snacks?
  • How often do they exercise (and what do they enjoy doing)?
  • What does their parental healthy living role modeling look like?
  • How many hours of screen time?
  • What time do they go to sleep?
  • How is their body image?
  • How is their self-esteem?
In medical school I was taught that over 90% of diagnoses can be made on the basis of history alone. Rather than recommending a blood test, how about recommending physicians take lifestyle histories and that way, instead of just focusing on those kids who are unfortunate and predisposed enough to be developing "adult" style chronic diseases at a frighteningly young age, we can focus on all kids, including those whose youth might still be protecting them against an awful lifestyle.  Don't those kids need help too?

My view from the trenches for those folks in their ivory towers?

We don't need a blood test from a 9 year old to know if a kid needs help, and looking at the actual recommendations these experts have put forth, I think it's pretty clear they need some help too.

So my two cents addition to this expert report (and I'll keep it short and sweet)?
  1. Lifestyle history from all kids starting at birth (obviously with parental input until the kids are old enough to answer for themselves).
  2. As a family: Cook.  From scratch.  More often than not. (oh, and mixing things from packages together isn't actual cooking).
  3. Live the lives you want your children to live.

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  1. I'm certainly not qualified to assess whether most or any 9 yr old children should/need be screened for high cholesterol, but that issue aside, any child who has an annual physical usually "endures" a blood test (for routine things like CBC, etc.), doesn't he/she? The actual blood draw (for whatever tests are to be performed) shouldn't be portrayed as some kind of risky or traumatic event.

  2. First, a disclosure: my 18-year-old daughter has heterozygous familial hypercholesterolemia (FH) (a genetic disease that causes very high LDL ("bad") cholesterol).

    I don't think we need to screen all 9-year-olds but I would support screening all kids at, say, age 16, preferably after a discussion with the patient and the parent. The reason is that FH is severely underdiagnosed and can have very serious consequences if not treated early. FH occurs in 1/500 people (it is more common in certain populations such as Quebec and Afrikaners in South Africa due to a founder effect).

    Why not just test kids who have a parent with high cholesterol or family history of premature heart disease? This has been shown not to work very well. Too many people don't know their family history, don't know their cholesterol levels, or both. There are also people who are carriers of an FH mutation, which means they can pass it on to their children, but for unknown reasons their LDL is within the normal range or only slightly elevated.

    FH can cause heart attacks as early as ones 30s and 40s, especially in people who have other cardiac risk factors. The main treatment is statins.

    Why not just screen people at age 18 or 20? Because many people that age don't have a primary care physician and don't go to a doctor regularly. At least that is the case in the U.S. So you would miss too many people that way. I have met people who weren't diagnosed until their mid-30s and already have coronary artery disease.

  3. Anonymous6:55 am

    I don't have a blood test routinely during my physicals, and children DEFINITELY don't.

    It seems like a waste of money and time to do it for no reason.

  4. In the US, most primary care physicians/pediatricians do routine blood and urine screening annually for their patients...for adults, they look at CBC, blood glucose, cholesterol of course. Children are screened for lead levels, I'm sure. In any case, a blood draw is not any sort of thing to be portrayed as something a patient "endures"...

  5. There is value in having baseline data at a young age so future test results can be interpreted more effectively. But I am thinking like a scientist and not as a bean counter.

  6. I couldn't agree with this post more. Very well put! As a dietitian, do you know how many kids I've seen (after they've seen their physician) who are overweight and their doctor says they're "fine?" Or...switches them to skim milk when the real problem is drinking 6 + cups of milk a day and eating fast food for most meals? What we should be doing is more nutrition education/intervention! Not another test, drug, or the like!

  7. Anonymous2:45 pm

    Full disclosure -- I'm a Canadian family doctor. I'm in complete agreement with Dr. Freedman that this is ridiculous; the emphasis needs to be on correcting our broken food system, not on screening for the problems it causes. Though maybe screening might raise awareness.

    @Norma -- there is no evidence for "routine" blood tests in children. That might be practiced in the US, where more medicine is often seen as better medicine, but it certainly isn't in Canada.

    @healthyapron -- at least kids are being referred to you. It's unrealistic to expect physicians to be able to do your job.

    @sanevoter -- not necessarily. Normal levels change throughout life so the number you get at age 9 might not be comparable to the number you get at, say, 30.

    @weightymatters -- do you have time to do a full lifestyle screening at every well child exam? I certainly don't, though I do ask pointed questions about diet and exercise and screen time. But if I ran through your list every time (especially if I wanted to discuss the answers), I wouldn't have time to see the other people needing my help. That's a systemic problem, but there it is. Maybe we need to come up with a screening form a la the Rourkes. Do you need a project?

  8. Hi Anonymous MD, thanks for the comment and questions.

    Annual physicals would be a logical place to ask those questions. I'd think of them as more of a screening tool, where if you're not happy with any of the answers, that triggers a return visit for a specifically booked health counseling session (or two) to review barriers to change and for suggestions.

    Me though, I don't see kids anymore. I'm exclusively seeing adults and working on nutrition and weight with my interdisciplinary team (MDs, RDs, trainers and clinical psychologist).

    Regarding new projects - while it does sound like a worthwhile one, I'm currently working on another project for family MDs with Memorial University on in-office management....maybe when that one's done!


  9. I definitely agree with your argument that nutritional advice should reflect the latest findings and not be the same outdated nonsense they've been giving us since the 80's or earlier. I can't believe it's still standard for doctors to tell people not to eat too many eggs.

    The only advantage I can think of for the blood tests, is finding our your child has high cholesterol might be enough to shock some parents into providing healthier food for their child. These are obviously people who either don't know or don't care that they're eating poorly and providing poor nutrition for their children, so they might need something more than a well meaning lecture from a doctor to make them see that their choices have a quantifiable negative impact on their children's health.

    That said, I'm still not sure that's enough of a justification for subjecting children to this.