High cholesterol in patients ages 20 or younger can be caused primarily by genetics (familial hypercholesterolemia) or by both genetic and environmental factors (multifactorial dyslipidemia). No matter the cause, however, the concern is that lipid disorders in childhood and adolescence convey a heightened risk for cardiovascular disease in adults.
On Aug. 9, the U.S. Preventive Services Task Force (USPSTF) published its final recommendation statement(www.uspreventiveservicestaskforce.org) on whether screening for lipid disorders in asymptomatic children and adolescents (i.e., those younger than 20) leads to a lower risk of cardiovascular disease events in adulthood, finding that there isn't enough evidence to determine the benefits or harms of screening in this age group -- an "I" recommendation.(www.uspreventiveservicestaskforce.org)
This final recommendation is consistent with and updates the USPSTF's 2015 draft recommendation statement and its 2007 final recommendation statement.
"By issuing an I statement, we are calling for more research to better understand the benefits and harms of screening and treatment of lipid disorders in children and teens and on the impact these interventions may have on their cardiovascular health as adults," said USPSTF Vice Chair David Grossman, M.D., M.P.H., in a news release.(www.uspreventiveservicestaskforce.org) "In the absence of evidence, health care professionals should continue to take each patient’s individual risks and circumstances in consideration and use their best judgment when deciding whether or not to screen."
- On Aug. 9, the U.S. Preventive Services Task Force (USPSTF) published its final recommendation statement and evidence reviews on screening for lipid disorders in children and adolescents.
- The task force found there isn't enough evidence to determine the benefits or harms of screening in this age group -- an "I" recommendation.
- This final recommendation is consistent with and updates the USPSTF's 2015 draft recommendation statement and its 2007 final recommendation statement on this topic.
The AAFP also released its own final recommendation that found insufficient evidence to recommend for or against routine screening for lipid disorders in children and adolescents.
A Look at the Evidence
Based on public comment on the draft research plan, the USPSTF commissioned two separate systematic evidence reviews to update its 2007 recommendation on screening for lipid disorders in these patients: one on screening for heterozygous familial hypercholesterolemia(www.uspreventiveservicestaskforce.org) and the other on screening for multifactorial dyslipidemia.(www.uspreventiveservicestaskforce.org)
According to a summary of the evidence(www.uspreventiveservicestaskforce.org) on screening for familial hypercholesterolemia, screening can detect the condition in children, and then lipid-lowering treatment during childhood can reduce lipid concentrations in the short term with little evidence of harm. No evidence exists, however, to demonstrate the effect screening children for this condition has on lipid concentrations or cardiovascular outcomes in adulthood or on the long-term benefits or harms of starting lipid-lowering treatment during childhood.
An evidence summary(www.uspreventiveservicestaskforce.org) on the effects of screening children and teens for multifactorial dyslipidemia revealed that this type of screening has not been evaluated in randomized clinical trials. However, the results of one observational study and nationally representative prevalence estimates showed that the simulated diagnostic yield (calculated as initial screening yield × positive predictive value from a study with confirmatory testing) of screening for elevated total cholesterol ranged between 4.8 percent and 12.3 percent. Percentages were higher among obese children, as well as among those at ages when total cholesterol normally peaks (i.e., 9-11 and 16-19 years).
On a related note, one good-quality randomized clinical trial found that intensive dietary counseling about maintaining a low-fat, low-cholesterol diet had a modest effect at one year from baseline on lipid levels in children ages 8 to 10 years with mild to moderate dyslipidemia.
The reviewers concluded that although no direct evidence was found to show the benefits or harms of childhood screening or treatment on adult outcomes, intensive dietary interventions appeared to be safe, yielding modest short-term benefit of uncertain clinical significance.
Homozygous familial hypercholesterolemia and secondary causes of dyslipidemia (e.g., diabetes, nephrotic syndrome or hypothyroidism) were outside the scope of this review.
Implications for Practice
"Despite this lack of evidence on lipid screening, the task force does recommend screening for obesity in children 6 years and older and referring them to intensive behavioral counseling on weight management," said former task force member Douglas Owens, M.D., M.S., in the news release. "Helping children improve their diet and physical activity may also improve their cardiovascular health, as well."
Family physicians can help these young patients avoid high cholesterol and its potential cardiovascular sequelae by recommending they eat a healthy diet, maintain a normal weight and engage in physical activity.
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