New cholesterol screening guidelines for children: CU Med School connection

It's never fun to get stuck with needles, and for little kids the justification for getting jabbed can be hard to comprehend.  So kids may not be too thrilled about the new recommendations for cholesterol screening for children.  Last November, a panel sponsored by the National Heart Lung and Blood Institute, and chaired by CU Med School's Dr. Stephen Daniels, announced new screening guidelines.  The biggest change: the panel believe all children should be screened between age 9 and 10, not just children with a family history of heart disease.

I consult with kids and their parents, when a screening test shows the child has elevated cholesterol, but those are typically children from families with a history of heart disease.  Pediatricians want to get a handle on risk factors early.  So these new guidelines got my attention, and I went right to the source for more information.

Last week I interviewed Dr. Daniels about these new recommendations.  First I asked him about the objections from some prominent pediatricians, who say we don't need yet another mandatory and costly medical test that only finds a tiny number of potential problems.   He noted that the NHLBI panel discussed these issues at length.  But ultimately, they felt it's important to identify kids with hypercholesteremia.  About 1 in 500 people can have a genetic variation that puts them at risk for early-onset cardiovascular disease, in the 30 to 50 year age range.  The family history screening approach didn't work very well, so a universal screening program is the better approach.

The test is done with a simple finger-stick, and the child does not need to be fasting.  The test will measure non-HDL cholesterol.  This is different from the typical cholesterol test for adults which focuses on LDL as the "bad" cholesterol.  It's calculated by subtracting HDL ("good" cholesterol) from Total Cholesterol.  According to some panel members, it's a better measure of atherogenic particles than LDL.  If the non-HDL cholesterol is above 145, the doctor should order a more thorough lipid screening.

Medical data shows that cholesterol values for 9-10 year old kids reflects their long range adult values.  So the guidelines suggest that the screening be done at that age.  Cholesterol levels change at puberty, so testing before then is important.  Should younger children be tested?  Daniels thinks it's only appropriate if there's a strong family history of heart disease, or if the child has other risk factors, such as hypertension or diabetes.  

What about the obesity effect on cholesterol.  Dr. Daniels answered:

"It's confusing to a lot of people, and it's important.  It's not uncommon for me to have parents being very surprised to have a child with high LDL cholesterol and they're not overweight.   LDL cholesterol is driven by genetics and diet.  Obesity has biggest impact on causing triglycerides to go up and HDL to go down.  Obesity has a very minor effect on LDL cholesterol."

He pointed out that when an obese child loses weight, triglycerides improve and HDL typically goes up, resulting in some improvement in total cholesterol.  But LDL usually doesn't change much.

For kids with total non-HDL cholesterol above 145, the first step in treatment is lifestyle changes.  Not just for the child, but for the whole family.  Improved diet and exercise can have a really big impact if implemented properly.  But what if lifestyle changes don't help, or if the family doesn't comply?  Do you put a child on a statin drug?  Dr. Daniels says an adolescent may reach a time when he or she has gotten as much as possible out of lifestyle, and the doctor has to initiate a discussion about medication.  If LDL is elevated, that child likely has a genetic component that will not be affected by lifestyle changes.  He notes that the decision to medicate is based on LDL levels, not on non-HDL cholesterol, and "less than 1% of kids would qualify for that discussion about medication."

We ended our interview with a summary of the steps in the new guidelines:

1. Screen 9-10 year olds for non-HDL cholesterol, using a finger stick, non-fasting test.
2. If total non-HDL cholesterol is above 145, do fasting lipid profile.  This gives the doctor a chance to confirm the high value.
3. If triglyceride is high and HDL is low, the child likely has a weight issue.  Focus should be diet and physical activity, with weight normalization.  As Daniels notes, "a lot of people miss the concept that for triglycerides, sugars and simple carbs may be as important as fats, and overall calories."
4. If LDL is elevated, intervention needs to focus on saturated fat intake and other dietary factors that impact cholesterol level.

NHLBI is working on some helpful tools for physicians, such as iPhone apps and a pocket guide, to help with implementation of these new guidelines.  Those should become available sometime this year.