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.