What About Fat Kids With Low Cholesterol?

Today the American Academy of Pediatrics issued new guidelines that call for cholesterol screening in children as early as age 2 and no later than age 10. According to the guidelines, treatment with cholesterol-lowering statins should be considered for children as young as 8 with certain risk factors. I don't know enough about the risks and benefits of statins in children to say whether this is a good idea or not, and it sounds like research on the question is meager. But I was struck by the way the New York Times story about the guidelines conflates cholesterol levels with weight:

Proponents [of the guidelines] say there is growing evidence that the first signs of heart disease show up in childhood, and with 30 percent of the nation's children overweight or obese, many doctors fear that a rash of early heart attacks and diabetes is on the horizon as these children grow up....

Previously, the academy had said cholesterol drugs should be considered in children older than 10 if they fail to lose weight after a 6- to 12-month effort.

Shouldn't the decision to treat a patient for high cholesterol hinge on how high his cholesterol is, as opposed to how much he weighs? Even if there's a correlation between weight and cholesterol, doesn't it make sense to focus on the risk factor that's the target of the treatment, instead of simply assuming that all fat kids have high cholesterol and that failing to lose weight is the same as failing to reduce cholesterol?

Another, apparently related puzzle: By way of justification for more-aggressive use of statins in  children, Jatinder Bhatia, a neonatologist who serves on the committee that revised the guidelines, says, "We are in an epidemic." But between 1988 and 2000, according to the guidelines, "triglyceride concentrations [measured by the National Health and Nutrition Examination Survey] decreased approximately 8.8 mg/dL in adolescents aged 12 to 17 years, and total cholesterol, LDL, and HDL concentrations remained relatively stable." Furthermore, a comparison of NHANES data from 1988-1994 with data from 1966-70 found "a decrease in mean total cholesterol concentration of approximately 7 mg/dL" among 4-to-19-year-olds. Evidently, then, Bhatia is not talking about an "epidemic" of high cholesterol levels. Probably he means an "epidemic" of obesity (although recent data indicate that the upward weight trend in children and teenagers seen in the '80s and '90s has leveled off in the last decade or so).

This slippery switching between cholesterol and weight disguises the paucity of evidence that extra weight per se is unhealthy. NHANES data indicate that people in the "overweight" (but not obese) category actually have lower mortality rates than people in the "healthy"/"normal" category. Even for the BMIs that are correlated with shorter life spans, it's not clear how much people should worry about fatness, as opposed to the poor diet and sedentary lifestyle associated with it. This is especially true in the case of heart disease. "As near as I can tell," Barry Glassner reports in his 2007 book The Gospel of Food, "not a single published study demonstrates that heart disease among the overweight and moderately obese results from their heft rather than from other factors that contribute to both obesity and heart disease." Other critics of the conventional wisdom about weight, including Paul CamposEric Oliver, and Gina Kolata, make similar points.

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  • B||

    I don't know enough about the risks and benefits of statins in children to say whether this is a good idea or not,

    Neither do the pediatricians.

    Herein lies the problem.

  • Balloon Maker||

    Considering the risks of statins to adults which have been ignored by MDs (i.e. interruption of steroid hormone production, CoQ10 synthesis, bile salt synthesis, and vit D production), I'd say the risks to children will be studied... never. But hot damn, will they sell a lot of statins, which is really what matters.

  • B||

    To be fair, the actual paper doesn't seem to make the same conflation between weight and cholesterol:

    "Drug therapy should be considered only for children >10 years of age after an adequate trial of diet therapy (for 6 to 12 months) and whose LDL-cholesterol level remains >= 190 mg/dL or whose LDL-cholesterol level remains >= 160 mg/dL and there is a family history of premature cardiovascular disease ..."

    In other words, the aim of the diet therapy is reduction of cholesterol, not weight loss per se.

    But yeah, I still have a problem with giving drugs that muck about with some seriously fundamental aspects of cellular metabolism to juveniles...

  • ||

    Has there ever been a study that clearly shows a coronary benefit from statins?

    Last I paid attention, statins were proven to reduce cholesterol levels but that (artificially reduced) lowering was not yet tied to decreased risk of coronary disease or heart attack.

    Anybody with an update would be greatly appreciated.

  • ||

    This slippery switching between cholesterol and weight disguises the paucity of evidence that extra weight per se is unhealthy.



    Read Malcolm Kendrick "The Great Cholesterol Con" and you will learn that it has NOT been demonstrated that high cholesterol is per se unhealthy. Very interesting and well-documented writing. Funny, too, in parts.

  • ||

    Just imagine, if you cut out the McDonalds and other JUNK Food, and add a little exercise (Yes that means limiting Internet and video game time) they might not be FAT at all! What a concept!

    www.FireMe.To/udi

  • ||

    Shouldn't the decision to treat a patient for high cholesterol hinge on how high his cholesterol is, as opposed to how much he weighs?

    Or even more to the point, shouldn't the informed decision be made by the patients and their parents? Giving full credit to the points made above, can anyone seriously make the argument that the state will never step in and do this by force? Anyone who categorizes non-contagious weight conditions as an "epidemic" should be nowhere near policy.

  • ||

    That is a very good logical post that makes valid points. What Mr. Sullum fails to understand is that people must have someone to pick on and ostracize. Not that many people smoke anymore. Most gun owners don't live in cities and you can't pick them out of a crowd. Condemning minorities went out with Nixon and is just not allowed anymore. Picking on white men is just so well 80s. Drugs are an addiction and sickness. What is someone to do? Pick on fat people. They are perfect. They are everywhere. You can always spot them in a crowd. They have no laws to protect them. It is perfectly legal and in many places desirable to act like a complete nattering jackass to fat people. You can take away their health care. You can deny them jobs. You can pick on their kids.

    Why anyone should let things like "facts" and "science" get in the way of that is beyond me. Further all of your so called "science" is just patriarchal thinking funded by big food.

  • Eric S.||

    My triglycerides are high because I quit smoking and now eat too much candy. :-)

  • ||

    Last I paid attention, statins were proven to reduce cholesterol levels but that (artificially reduced) lowering was not yet tied to decreased risk of coronary disease or heart attack.

    That was the impression I was under as well.

  • ||

    John,

    I think picking on fat people has gone on for a long time. It's just a matter of junk science now being available to support old prejudices.

  • Marcvs||

    As Balloon Maker mentioned, there are a number of serious known risks with statin use in adults (I know because I'm on Zocor), which, while rare, are serious enough that you don't want to hand these out to every child that happens to have cholesterol that's a little out of wack. Things such as myositis, myopathy, and rhabdomyolysis which can quickly lead to kidney failure (and death) are rare, but still very real possible outcomes. I'm not flat out against children getting statins, but it needs to be much better tested and done on a case-by-case assessment of risk.

  • Erica||

    I think lifestyle should be examined first, especially when we're talking about children. Are these circumstances where the children are eating lots of fast food, not getting enough exercise, etc. or is truly genetics? If the former plays a part (which it will in most cases) there are -imo- better ways to tackle this problem.

  • bubba||

    "Placebo-controlled clinical trials have shown that atorvastatin is beneficial in patients with myocardial ischemia, established coronary artery disease, hypertension and 3 other cardiovascular risk factors (e.g. left-ventricular hypertrophy, type 2 diabetes, smoking), and in diabetes, but not in patients with calcific aortic stenosis. "

    http://www.ncbi.nlm.nih.gov/pubmed/18473965?ordinalpos=11&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum


    "During 3-year follow-up, comparison of atorvastatin treatment with usual care demonstrated a relative risk reduction (RRR) of the primary end point (all vascular events) of 54% in women (hazard ratio [HR] 0.46, 95% confidence interval [CI] 0.24-0.87, p=0.003) and of 50% in men (HR 0.50, 95% CI 0.32-0.70, p

  • bubba||

    http://www.ncbi.nlm.nih.gov/pubmed/18430270?ordinalpos=15&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

    During 3-year follow-up, comparison of atorvastatin treatment with usual care demonstrated a relative risk reduction (RRR) of the primary end point (all vascular events) of 54% in women (hazard ratio [HR] 0.46, 95% confidence interval [CI] 0.24-0.87, p=0.003) and of 50% in men (HR 0.50, 95% CI 0.32-0.70, p

  • bubba||

    "The fall in LDL-C levels played the key role in end point reduction in both sexes. "

    Damn HTML formatting. Sorry for the multiple posts.

  • bubba||

    And here is a review of the pediatric science.

    Free link: http://circ.ahajournals.org/cgi/content/full/115/14/1948
    Drug Therapy of High-Risk Lipid Abnormalities in Children and Adolescents

  • ||

    Minor side effects are common and major side effects do happen and studies in children are practically non-existent. So the rush to statins is a bit scary.
    Meanwhile, all this talk of "lifestyle changes" may be useful in other ways but may not be much use in reducing cholesterol. I am a practicing pediatric endocrinologist and I cannot remember the last patient whose cholesterol budged 10% on "lifestyle changes".
    Statins HAVE been shown to reduce coronary events in adults and they do so in such short time that their anti-inflammatory effects may have more to do with it than the lowering of cholesterol per se. That benefit may not be as relevant in kids, who are decades away from their first heart attack (in most cases).
    Obesity and cholesterol are NOT that closely correlated and neither is a "fatty diet" or even a "high cholesterol diet". It seems you can blame your parents (and maybe other unknown factors) more than your diet for your cholesterol level.
    even if one accepts all the scare talk about obesity and mildly elevated cholesterol (marked elevation is another matter altogether), one still has to factor in groupthink and the role of pharma marketing in pushing these new guidelines.

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