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March 1995, Vol 149, No. 3 >
Article | March 1995

Problems With the Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents FREE

Thomas B. Newman, MD, MPH; Alan M. Garber, MD, PhD; Neil A. Holtzman, MD, MPH; Stephen B. Hulley, MD, MPH
Arch Pediatr Adolesc Med. 1995;149(3):241-247. doi:10.1001/archpedi.1995.02170150021003.
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An Expert Panel convened by the National Cholesterol Education Program has recommended selective screening and treatment of children for high blood cholesterol levels, based on family history of cardiovascular disease or high blood cholesterol. This recommendation is problematic for several reasons. First, the recommended diets are likely to cause only a slight decrease in low-density lipoprotein cholesterol levels, the projected benefits of which will be offset by a similar decrease in high-density lipoprotein cholesterol levels. Lack of efficacy of the recommended diets could lead to use of more restrictive diets or to cholesterol lowering drugs. Second, even under optimistic assumptions, beneficial effects of cholesterol intervention will be small and delayed for many decades. As a result, childhood cholesterol-lowering efforts will not be cost-effective. Third, the Expert Panel's recommendations do not address important gender differences. Girls have higher average cholesterol levels than boys. They will therefore qualify for more dietary and drug treatment despite their lower age-adjusted risk of heart disease and the lack of association between cholesterol levels and cardiovascular mortality in women. Finally, recent evidence from randomized trials, cohort studies, and animal experiments suggests that cholesterol lowering may have serious adverse effects. This evidence was not discussed in the Expert Panel's report. Given current evidence, any screening and treatment of children for high blood cholesterol levels is, at best, premature.

(Arch Pediatr Adolesc Med. 1995;149:241-247)

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Newman TB, Browner WS, Hulley SB.  The case against childhood cholesterol screening . JAMA . 1990;;264:3039-3043.
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Holtzman NA.  The great god cholesterol . Pediatrics . 1991;;87:943-945.
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Gillman M, Lannon C.  Screening for hypercholesterolemia in children: the missing links . Ann Epidemiol . 1991;;1:559-565.
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Newman TB, Browner WS, Hulley SB.  Childhood cholesterol screening: contraindicated . JAMA . 1992;;267:100-101.
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Hulley SB, Newman TB.  Position statement: cholesterol screening in children is not indicated, even with positive family history . JAm Coll Nutr . 1992;;11S:20S-22S.
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Hoekelman RA.  Cholesterol mania . Pediatr Ann . 1992;;21:215-216.
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Frame PS.  Screening and management of cholesterol levels in children and adolescents . J Am Board Fam Pract . 1993;;6:582-587.
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Hulley SB, Newman TB, Grady D, Garber AM, Baron RB, Browner WS.  Should we be measuring blood cholesterol in young adults? JAMA . 1993;;269:1416-1419.
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Toronto Working Group on Cholesterol Policy.  Asymptomatic hypercholesterolemia: a clinical policy review . J Clin Epidemiol . 1990;:43:1028-1121.
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Ehnholm C, Huttunen JK, Pietinen P, et al.  Effect of diet on serum lipoproteins in a population with a high risk of coronary heart disease . N Engl J Med . 1982;;307:850-855.
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Schaefer EJ, Levy RI, Ernst ND, Van Sant FD, Brewer H Jr.  The effects of low cholesterol, high polyunsaturated fat, and low fat diets on plasma lipid and lipoprotein cholesterol levels in normal and hypercholesterolemic subjects . Am J J Clin Nutr . 1981;;34:1758-1763.
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Lifshitz F, Moses N.  Growth failure: a complication of dietary treatment of hypercholesterolemia . AJDC . 1989;;143:537-542.
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Ducobu J, Brasseur D, Chaudron JM, et al.  Simvastatin use in children . Lancet . 1992;;339: 1488.
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Mold JW, Stein HF.  The cascade effect in the clinical care of patients . N Engl J Med . 1986;; 314:512-514.
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Taylor WC, Pass TM, Shepard DS, Komaroff AL.  Cholesterol reduction and life expectancy . Ann Intern Med . 1987;;106:605-614.
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Garber AM, Wagner JL.  Practice guidelines and cholesterol policy . Health Aff (Millwood) . 1991;; 10:52-66.
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Goldman L, Weinstein MC, Goldman PA, Williams LW.  Cost-effectiveness of HMG-CoA reductase inhibition for primary and secondary prevention of coronary heart disease . JAMA . 1991;; 265:1145-1151.
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Lipid Research Clinics Program.  The Lipid Research Clinics Coronary Primary Prevention Trial results, II: the relationship of reduction in incidence of coronary heart disease to cholesterol lowering . JAMA . 1984;;251:365-374.
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Jacobs D, Blackburn H, Higgins M, et al.  Report of the Conference on Low Blood Cholesterol: mortality associations . Circulation . 1992;;86:1046-1060.
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Hulley SB, Walsh JM, Newman TB.  Health policy on blood cholesterol: time to change directions . Circulation . 1992;;86:1026-1029.
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American Academy of Pediatrics Committee on Nutrition.  Indications for cholesterol testing in children . Pediatrics . 1989;;83:141-142.
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Figures

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Interactive Graphics

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

References

1 +
Strong WB.  You are a preventive cardiologist: the scope of pediatric preventive cardiology . AJDC . 1989;:143:1145.
2 +
Garcia RE, Moodie DS.  Routine cholesterol surveillance in childhood . Pediatrics . 1989;;84:751-755.
3 +
Wynder E.  An American Health Foundation monograph: coronary artery disease prevention: cholesterol, a pediatric perspective . Prev Med . 1989;; 18:323-409.
4 +
Cresanta JL, Burke GL, Downey AM, Freedman DS, Berenson GS.  Prevention of atherosclerosis in childhood . Pediatr Clin North Am . 1986;;33: 835-858.
5 +
Holtzman NA.  Hyperlipidemia screening: a search for heffalumps? Pediatrics . 1979;:64:270-271.
6 +
Holtzman NA.  Hyperlipidemia screening and Semmelweis re-visited . Pediatrics . 1980;;66:838-839.
7 +
Newman TB, Browner WS, Hulley SB.  The case against childhood cholesterol screening . JAMA . 1990;;264:3039-3043.
8 +
Holtzman NA.  The great god cholesterol . Pediatrics . 1991;;87:943-945.
9 +
Gillman M, Lannon C.  Screening for hypercholesterolemia in children: the missing links . Ann Epidemiol . 1991;;1:559-565.
10 +
Newman TB, Browner WS, Hulley SB.  Childhood cholesterol screening: contraindicated . JAMA . 1992;;267:100-101.
11 +
Hulley SB, Newman TB.  Position statement: cholesterol screening in children is not indicated, even with positive family history . JAm Coll Nutr . 1992;;11S:20S-22S.
12 +
Hoekelman RA.  Cholesterol mania . Pediatr Ann . 1992;;21:215-216.
13 +
Frame PS.  Screening and management of cholesterol levels in children and adolescents . J Am Board Fam Pract . 1993;;6:582-587.
14 +
Hulley SB, Newman TB, Grady D, Garber AM, Baron RB, Browner WS.  Should we be measuring blood cholesterol in young adults? JAMA . 1993;;269:1416-1419.
15 +
Toronto Working Group on Cholesterol Policy.  Asymptomatic hypercholesterolemia: a clinical policy review . J Clin Epidemiol . 1990;:43:1028-1121.
16 +
Davey Smith G, Song F, Sheldon T.  Cholesterol lowering and mortality: the importance of considering initial level of risk . BMJ . 1993;;306:1367-1373.
17 +
Sox H.  Screening for lipid disorders under health system reform . N Engl J Med . 1993;;328:1269-1271.
18 +
Canadian Task Force on the Periodic Health Examination.  Periodic health examination, 1993 update, II: lowering the blood total cholesterol level to prevent coronary heart disease . Can Med Assoc J . 1993;;148:521-538.
19 +
National Cholesterol Education Program.  Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents . Pediatrics . 1992;;89:515-584.
20 +
American Academy of Pediatrics Committee on Nutrition.  Statement on cholesterol . Pediatrics . 1992;;90:469-473.
21 +
Arneson T, Luepker R, Pirie P, Sinaiko A.  Cholesterol screening by primary care pediatricians: a study of attitudes and practices in the Minneapolis–St Paul metropolitan area . Pediatrics . 1992;;89:502-505.
22 +
Puska P, Vartiainen E, Pallonen U, et al.  The North Karelia Youth Project: evaluation of 2 years of intervention on health behavior and CVD risk factors among 13- to 15-year-old children . Prev Med . 1982;;11:550-570.
23 +
Walter HJ, Hofman A, Vaughan RD, Wynder EL.  Modification of risk factors for coronary heart disease: 5-year results of a school-based intervention trial . N Engl J Med . 1988;;318:1093-1100.
24 +
Ramsay LE, Yeo WW, Jackson PR.  Dietary reduction of serum cholesterol concentration: time to think again . BMJ . 1991;;303:953-957.
25 +
Hunninghake DB, Stein EA, Dujovne CA, et al.  The efficacy of intensive dietary therapy alone or combined with lovastatin in outpatients with hypercholesterolemia . N Engl J Med . 1993;;328: 1213-1219.
26 +
Ornish D, Brown SE, Scherwitz LW, et al.  Can lifestyle changes reverse coronary heart disease?: the Lifestyle Heart Trial . Lancet . 1990;; 336:129-133.
27 +
Hjermann I, Velve Byre K, Holme I, Leren P.  Effect of diet and smoking intervention on the incidence of coronary heart disease: report from the Oslo Study Group of a randomised trial in healthy men . Lancet . 1981;;2:1303-1310.
28 +
Henkin Y, Garber DW, Osterlund LC, Darnell BE.  Saturated fats, cholesterol, and dietary compliance . Arch Intern Med . 1992;;152:1167-1174.
29 +
Orchard TJ, Donahue RP, Kuller LH, Hodge PN, Drash AL.  Cholesterol screening in childhood: does it predict adult hypercholesterolemia? the Beaver County experience . J Pediatr . 1983;;103: 687-691.
30 +
Mensink RP, Katan MB.  Effect of dietary fatty acids on serum lipids and lipoproteins: a metaanalysis of 27 trials . Arterioscler Thromb . 1992;; 12:911-919.
31 +
Ehnholm C, Huttunen JK, Pietinen P, et al.  Effect of diet on serum lipoproteins in a population with a high risk of coronary heart disease . N Engl J Med . 1982;;307:850-855.
32 +
Schaefer EJ, Levy RI, Ernst ND, Van Sant FD, Brewer H Jr.  The effects of low cholesterol, high polyunsaturated fat, and low fat diets on plasma lipid and lipoprotein cholesterol levels in normal and hypercholesterolemic subjects . Am J J Clin Nutr . 1981;;34:1758-1763.
33 +
Nicklas TA, Webber LS, Koschak M, Berenson GS.  Nutrient adequacy of low fat intakes for children: the Bogalusa Heart Study . Pediatrics . 1992;; 89:221-228.
34 +
Lifshitz F.  Children on adult diets: is it harmful? is it healthful? J Am Coll Nutr . 1992;;11:84S-90S.
35 +
Lifshitz F, Moses N.  Growth failure: a complication of dietary treatment of hypercholesterolemia . AJDC . 1989;;143:537-542.
36 +
Stelmach WJ, Rush DR, Brucker PC, et al.  Diet and exercise and gemfibrozil therapy for the management of dyslipidemia: a CEN study: clinical experience network . J Fam Pract . 1993;;36:401-408.
37 +
Cholesterol and Kids: A Family Affair . Bethesda, Md: Citizens for Public Action on Blood Pressure and Cholesterol Inc; 1991;.
38 +
Cholesterol in Children and Adolescents: A Physician's Handbook . Bethesda, Md: Citizens for Public Action on Blood Pressure and Cholesterol Inc; 1991;.
39 +
Liacouras CA, Coates PM, Gallagher PR, Cortner JA.  Use of cholestyramine in the treatment of children with familial combined hyperlipidemia . J Pediatr . 1993;;122:477-482.
40 +
Ducobu J, Brasseur D, Chaudron JM, et al.  Simvastatin use in children . Lancet . 1992;;339: 1488.
41 +
Mold JW, Stein HF.  The cascade effect in the clinical care of patients . N Engl J Med . 1986;; 314:512-514.
42 +
Taylor WC, Pass TM, Shepard DS, Komaroff AL.  Cholesterol reduction and life expectancy . Ann Intern Med . 1987;;106:605-614.
43 +
Garber AM, Wagner JL.  Practice guidelines and cholesterol policy . Health Aff (Millwood) . 1991;; 10:52-66.
44 +
Goldman L, Weinstein MC, Goldman PA, Williams LW.  Cost-effectiveness of HMG-CoA reductase inhibition for primary and secondary prevention of coronary heart disease . JAMA . 1991;; 265:1145-1151.
45 +
Lipid Research Clinics Program.  The Lipid Research Clinics Coronary Primary Prevention Trial results, II: the relationship of reduction in incidence of coronary heart disease to cholesterol lowering . JAMA . 1984;;251:365-374.
46 +
Jacobs D, Blackburn H, Higgins M, et al.  Report of the Conference on Low Blood Cholesterol: mortality associations . Circulation . 1992;;86:1046-1060.
47 +
Hulley SB, Walsh JM, Newman TB.  Health policy on blood cholesterol: time to change directions . Circulation . 1992;;86:1026-1029.
48 +
 Lowering blood cholesterol to prevent heart disease . JAMA . 1985;;253:2080-2086.
49 +
American Academy of Pediatrics Committee on Nutrition.  Indications for cholesterol testing in children . Pediatrics . 1989;;83:141-142.
50 +
 Erratum : Pediatrics . 1989;:83:678.
51 +
Mason RP, Herbette LG, Silverman DI.  Can altering serum cholesterol affect neurologic function? J Mol Cell Cardiol . 1991;;23:1339-1342.
52 +
McMurchie EJ, Patten GS.  Dietary cholesterol influences cardiac beta-adrenergic receptor adenylate cyclase activity in the marmoset monkey by changes in membrane cholesterol status . Biochim Biophys Acta . 1988;;942:324-332.
53 +
Clandinin MT, Field CJ, Hargreaves K, Morson L, Zsigmond E.  Role of diet fat in subcellular structure and function . Can J Physiol Pharmacol . 1985;; 63:546-556.
54 +
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55 +
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