When my daughter turned four and her pediatrician suggested we test her cholesterol level, I waited for the punchline. There wasn’t one. Although my husband doesn’t have any genetic or lifestyle risk factors for heart disease, he does have borderline high cholesterol. Because our child could inherit a lousy lipid profile we agreed to test her. I’m relieved to say at the ripe old age of four, she passed. This all seemed absurd until I realized it’s a good idea for kids and their parents to know their medical destiny as early as possible so they can try to avoid future health disasters.
It seems the AAP agrees.
On July 7th the American Academy of Pediatrics (AAP) announced their policy statement regarding Lipid Screening and Cardiovascular Health in Childhood. In summary their guidelines are:
> All children older than 2 should follow the Dietary Guidelines for Americans. Children 12 months to 2 years for whom obesity is a concern should drink reduced-fat milk.
> Children between ages 2 and 10 should undergo cholesterol screening if they have any of the following risk factors: are overweight, have diabetes, have high blood pressure, or there’s a family history of high cholesterol or early cardiovascular disease.
> Children and adolescents with high LDL and higher risk for heart disease should be individually counseled on nutrition, changes in diet and increased physical activity.
> Overweight or obese patients with high triglycerides or low HDL should improve diet and increase physical activity.
> Consider drug therapy in patients age 8 or older with an LDL level of 190 mg/dL or greater, if there are no other risk factors. The initial goal of therapy is to lower LDL cholesterol to less than 160 mg/dL, but a lower target may be needed if the patient has other risk factors.
The AAP had me at “early cholesterol screening and individually counsel on nutrition, changes in diet and increased physical activity.” They lost me at “consider drug therapy in patients age 8 or older with an LDL of 190 or greater.”
At first glance, this guideline seems well-directed. With almost 14 million children, 24 percent of the U.S. population ages 2 to 17 obese, and an additional 8.6 at risk for obesity, parents lifestyle choices have officially leached into their children’s long term health prognosis.
Unfortunately the U.S isn’t very good at looking long term when it comes to preventative medicine and health management. Doing so would likely mean less money in the pockets of health insurance and pharmaceutical companies. Dr. John Abramson, clinical instructor at Harvard Medical School and author of the book “Overdosed America” suggests, “Recommendations like these (AAP’s) need to set off an alarm bell that our approach to health care is being dominated by commercial interests.”
Although the health care community isn’t very proactive, they are exceptional crisis managers and with Type 2 Diabetes levels surging in adults and children; we now have an epidemic on our hands. Dr. Jennifer Li, A Duke University children’s heart specialist notes that 15 years ago the majority of her patients with cholesterol issues had an inherited form of cholesterol disease, not connected to obesity, “but now they’re really outnumbered” by overweight kids with cholesterol problems and high blood pressure.
The question is, how do we attack the crisis?
Perhaps popping a pill in lieu of playing hard on the playground or eating an apple is simply the American Way and I’m being too hard on our pharmaceutical-pushing community. Yet from strictly a cost / benefit analysis, the unknown risks to children who take statins long-term could feasibly outweigh the presumed (and also unknown) gains.
Dr. John LaRosa who studies statins, told CBS News correspondent Nancy Cordes “We have very little evidence that it does any good to start lowering cholesterol with drugs in children to prevent something that might not happen for 20 or 30 years down the line.” What we do know are the reported side effects of statins in adults which can include depression, muscle weakness, pain, and potential liver damage and stomach cancer. In other words, giving high risk kids statins to prevent an unknown cardiac event is still largely a crapshoot, and perhaps one we don’t want to take with our youngest, and most vulnerable populous.
“In adults, we don’t jump to medical treatment if the 10-year risk of a cardiac event is low. Using this same measure of absolute risk, I’d step back from these guidelines and be cautious of recommending early medical treatment in an 8-year-old, whose 10-year risk is extremely low, regardless of other risk factors,” said Dr. Laurence Sperling, director of preventive cardiology and an associate professor of medicine at Emory.
Although the medication guideline is strictly for children 8 and older who don’t respond to lifestyle changes and who have a strong family history of heart disease, it seems we’re headed down a slippery slope of avoidance.
We’re smack dab in the middle of societal denial about we need to do to halt obesity and the associated diseases. The hard facts are we live in a culture where healthy foods are more expensive than those loaded with high-fructose corn syrup, salt and fat, flavors we’ve grown to crave. In addition, physical activity has become either a last-chance-to-live prescription for people at risk for disease or a compulsion for the fitness crowd, rather than an expected human practice like brushing your teeth or looking both ways before you cross.
The only way to attack a burgeoning problem like obesity, heart disease, high blood pressure and Type 2 Diabetes is to face the root causes that can be changed, rather than to give up and offer one more pharmaceutical band-aid because it’s easier than changing how we think; how we eat; how we live.
But trying to change a way of life can feel futile within a growing culture of convenience.
I sometimes shake a finger at myself when I bring my daughter with me to the YMCA to “get her moving” on the treadmill. Even though Y equipment has attached TVs and headphones, I still have to beg her to come. As an only child my ten year old reminds me that playing outside by herself is “no fun” although when my husband and I were younger we managed it for hours, even if our siblings or friends weren’t around. When our parents sent us to the yard this was an expected part of our day, not an act of coercion or a planned event. I’m acutely aware of the dangers lurking around every dark corner, but safe havens exist in our own backyards, during what’s left of school PE and recess programs, and through organized sports.
Enter Wii to the rescue. This hot new virtual reality toy has become the “new active family play time.” I refuse to believe however, that the joystick feels anything like the wind in my hair or the itchy grass on my back, so to my ten year old’s disgust, I won’t buy one.
I also know that spending hours in the kitchen whipping up healthy, low cost meals is no longer a part of our daily existence. As a lazy chef, I spend as little time as possible in the kitchen, but an extraordinary amount of time finding “fast foods” that are easy, affordable and nutritious. I balance my healthy compulsion with just enough junk food to satiate my family’s need for fried, fatty and sugary. Nothing will ever replace the taste of Twizzlers, fries, pizza and soda, and quite frankly, nothing ever should.
However each family chooses to move towards a healthier lifestyle to pass on a legacy of good habits to their kids, something’s gotta give, and it’s not in my opinion, bringing cardiac pharmaceuticals to the younger market.
Although not everyone agrees giving statins to high risk children is a good idea, I suspect most understand that genetics can trump even the most disciplined lifestyle. Dr. Martin Siegfried, a Gainesville Florida cardiologist notes, “If it’s a genetic problem, the child probably will have to be on medication for a lifetime. But if it’s caused by something that can be improved, such as obesity, they may not need medication long-term.”
“Medication long-term” could be debated depending on how you feel about nutraceuticals, which is food or naturally occurring food supplements thought to have a beneficial effect on human health. I happen to think that although the natural approach isn’t without risk; nature blows the pharmaceutical competition out of the water. With supplements, diet, exercise and bi-annual cholesterol screenings, my husband now has his lipids well under control.
His other option wasn’t looking so good.
Seven years ago a nurse called to explain that in addition to maintaining a low cholesterol diet, my husband’s doctor wanted him to take the statin Baycol. No one never discussed potential side effects or why with a total cholesterol level of only 225, he needed the medication. Drug therapy had long since turned into a “liability waiver” of sorts for doctors, as well as a comforting sign for patients that they got their full money’s worth.
The first day my husband started taking Baycol he felt sick. His whole body ached; he was nauseous and he felt like his blood pressure was skyrocketing. After the third dose he stopped taking it. Months later the FDA pulled Baycol from the market after 31 people died from rhabdomyolysis, an acute condition in which muscle is destroyed and released into the bloodstream. Symptoms include muscle pain, weakness, fever, dark urine, nausea, and vomiting. That weekend my husband’s body told him something wasn’t right, and his brain, thank God, listened. Something tells me that statins and children shouldn’t mix.
I can accept that our daughter might some day draw a genetically pre-disposed high cholesterol card. What I can’t accept is that our medical community and their patients seem to promote medication as an organic part of health management, rather than what it sometimes is, a declaration that we’ve lost control of our lifestyle, and the results are seeping into our kid’s livelihood.
In all fairness however, plenty of adults do their very best to lower their kids and their own cholesterol levels and they still need to take medication. I cannot “lifestyle” my way out of my pituitary disorder, instead I take natural hormone replacement therapy. Medications serve a real purpose when nature and genetics let us down.
But giving cholesterol lowering drugs to children at high risk with the notion that this protocol will stave off future heart disease, seems to me, like feeding the machine of pharmaceutical reliance. Over time the only health management solution our children will ever know will come in the form of little pills in plastic amber bottles. Likely they’ll learn to adapt to the medicine’s many side effects that are often worse than the impending condition. They’ll accept the down side to drug therapy as inherent to the human condition. Yet side effects are not in any way natural, they’re a sign our body is protesting.
My generation will sadly be the first to outlive their children. Thousands of adolescents across the country will one day wake up after years of playing video games and eating buckets of fast food and suddenly feel worse than the adults in the next room. These are the ones I worry about, our healthy-by-choice generation who follow their parents’ lead, who are being led down the path of diabetes, high blood pressure and heart disease by those older and presumably, wiser.
The time to shift our paradigm about the kinds of food we eat and how we take care of ourselves is now, long before the cost of living a healthy life pales in comparison to mounting medical bills, long before type 2 diabetes becomes the disease of the century, long before before our cemeteries fill with mothers and fathers sobbing over of the graves of their dead children, leaving them to wonder: why the young were the very first to go.
AAP Issues New Guidelines On Cholesterol Screening. American Academy of Pediatrics. AAP Policy Statement. July 7, 2008. http://www.aap.org/new/july08lipidscreening.htm
“Cholesterol Drugs For Kids Recommended.” CBS/AP News Online. July 7, 2008. http://www.cbsnews.com/stories/2008/07/07/health/main4235922.shtml
Gilbert, Debbie. “Local Docs Like Cholesterol Tests, Not Cholesterol Drugs, For Kids.” Gainsesvilletimes.com. July 13, 2008.http://www.gainesvilletimes.com/news/archive/7077/
Lee, Jung Eun. “Cholesterol Drugs For Kids Debated.” The Atlanta Journal-Constitution.
July 13, 2008.http://www.ajc.com/metro/content/printedition/2008/07/13/childstatins.html
Preboth, Monica, “Baycol Pulled from the Market – For Fatal Rhabdomyolisis Side Effects.” American Academy of Family Physicians. American Family Physician. Sept 15, 2001. http://www.aafp.org/afp/20010901/newsletter.html