The first hurdle to clear is to identify who should be screened for hypercholesterolemia. Most practitioners agree on the American Heart Association’s recommendation of screening all children after two years of age who meet at least one of the following historical criteria:
Although this approach would be beneficial in detecting many children who are at high risk for adult cardiovascular disease, it could detect some children with elevated lipids that might spontaneously resolve without any aggressive lifestyle modifications or medical therapy. Conversely, many children who ultimate-y develop adult dyslipidemia may be missed when these criteria are used. The likelihood of correctly identifying more children at risk for hypercholesterolemia increases if we set the parents’ cholesterol level to 200 mg/dL instead of the previously suggested 240 mg/dL.
The alternative approach involves universal screening. Even though this approach undoubtedly would find more children with dyslipidemia, there are significant drawbacks. One problem involves the significant cost associated with screening all children. More important, if dyslipidemia is detected, the decision to treat is an even more onerous one.
Most practitioners who detect dyslipidemia in children with a strong family history believe that aggressive intervention is warranted to help prevent a similar fate. However, the universal screening approach might identify an individual with dys-lipidemia but with no family history of concern, thereby making the need to treat much less clear.
The timing of screening also is an important variable. Older children and adolescents normally have a physiological nadir in lipid levels that climbs into adulthood. Generally speaking, cholesterol levels are higher in preadolescents than in older adolescents. Therefore, the age at which children undergo screening has a definite impact on the decision to treat.
Health care professionals might choose not to prescribe medications for a preadolescent with a borderline high cholesterol level, knowing that the patient’s lipid profile might naturally improve in the upcoming adolescent years. Although health care providers might decide not to intervene, they must be cognizant of a possible rebound worsening of the lipid profile into early adulthood.
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Let us now assume that we identify the child with an elevated lipid profile via the targeted-screening approach and that we are now considering treatment. Certainly, few would disagree with recommending lifestyle changes; however, many practitioners hold little confidence in the ability of their patients to actually achieve target goals solely with lifestyle modifications. Many health care professionals say that diet and exercise “just don’t work.” This is a common misperception; in reality, however, lifestyle modification is highly effective—the real problem is that compliance with lifestyle changes is difficult to achieve.
Why is compliance so difficult for patients to achieve?
Shouldn’t the goal of a healthier body be enough motivation?
Noncompliance may be prevalent because of the following:
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