Statin Drugs for 8 Year-Olds…….Really?
A month ago, the American Academy of Pediatrics (AAP)
published their latest guidelines for lipid screening
and cardiovascular health in childhood [Pub Med]. The
news media focused primarily on the pharmaceutical
recommendations which are recommended in certain
populations starting at age 8; and screening for
dyslipidemias in some patients starting at age 2. While
there is more to the recommendation than these two
bullet points, these updated recommendations are still
fraught with simplistic and outdated ideas.
We agree that dyslipidemias in children and adolescents
is a health concern. The combination of obesity,
sedentary living, poor diet and environmental factors is
driving a phenomenon of metabolic disorders decades
earlier in current populations than was typical 50 years
ago. Unfortunately, these recommendations incorporate
very little of the information gathered over the past
decades on managing these disorders. First and foremost,
the screening and target goals are based solely on
LDL-cholesterol levels (they mention metabolic syndrome
but since the cut-off points are for adults- no specific
recommendations are given). Their recommendation is “For
patients 8 years and older with an LDL concentration of
190 mg/dL (or 160 mg/dL with a family history of early
heart disease or 2 additional risk factors present or
130 mg/dL if diabetes mellitus is present),
pharmacologic intervention should be considered. The
initial goal is to lower LDL concentration to <160 mg/dL.
However, targets as low as 130 mg/dL or even 110 mg/dL
may be warranted when there is a strong family history
of CVD, especially with other risk factors including
obesity, diabetes mellitus, the metabolic syndrome, and
other higher-risk situations.”
The over-emphasis on LDL cholesterol as a single goal
for therapy will result in an over-reliance on statin
drug therapy; known for LDL-C lowering, which they
generally recommend over other pharmaceutical options
due to their belief in both the efficacy and safety of
statins (they generally do not recommend bile-acid
sequestering resins, nicotinic acid, or fibrates).
General recommendations are made for low HDL-C and high
triglycerides, but no mention of advanced lipid tests (ApoB,
ApoA, lipoprotein particle size or number), although
several of these have been shown to be more correlated
with later adult risk than LDL-C. While lifestyle
recommendations are given in the AAP document, they are
very general and include the usual restrictions in
saturated fats and cholesterol. Passing mention is made
of fiber and plant sterols but no mention of glycemic
impact (GI or GL) of foods, insulin-sensitizing diets or
the role of juice and sweetened beverages in their
connection with metabolic disorders.
We are in the midst of a huge metabolic crisis.
Regrettably, a large portion of the medical
establishment believes the only true savior is
pharmaceutical intervention. A comment made during the
recent conference on Integrated Biomarkers in
Cardiovascular Disease (Seattle, WA July 9-11) is
typical of this view. When asked during a case
presentation whether omega-3 fatty acids would be
helpful to reduce triglycerides in the patient being
discussed, the presenter responded “why would I use fish
oil when I can achieve the same results using
pharmacotherapy.” This individual, and many more with
the same medical view, are still at the helm of many
editorial boards, medical schools, and guidance
committees influencing thousands of physicians and
patients (see article below). Hopefully this trend can
slowly be reversed before they recommend statin drug
fortification in the municipal drinking water.
Related Links and Articles:
Dietary intake and the metabolic syndrome in overweight
latino children. J Am Diet Assoc. 2008
Aug;108(8):1355-9.
Sugar-Sweetened Beverages and Incidence of Type 2
Diabetes Mellitus in African American Women. Arch Intern
Med. 2008;168(14):1487-1492.
Plasma Vitamin C Level, Fruit and Vegetable Consumption,
and the Risk of New-Onset Type 2 Diabetes Mellitus Arch
Intern Med. 2008;168(14):1493-1499.
Childhood levels of serum apolipoproteins B and A-I
predict carotid intima-media thickness and brachial
endothelial function in adulthood: the cardiovascular
risk in young Finns study. J Am Coll Cardiol. 2008 Jul
22;52(4):293-9.
Fasting plasma insulin modulates lipid levels and
particle sizes in 2- to 3-year-old children. Obes Res.
2003 Jun;11(6):709-21.
The relative impact of a vegetable-rich diet on key
markers of health in a cohort of Australian adolescents.
Asia Pac J Clin Nutr. 2008;17(1):107-15.
Effect of a short-term diet and exercise intervention in
youth on atherosclerotic risk factors. Atherosclerosis.
2007 Mar;191(1):98-106.
|
