Cholesterol testing in children and adolescents: useful or unreliable?

The other week a coaching client of mine told me about a recent cholesterol test ordered by the child’s pediatrician. Its results were mixed, some numbers fell into “normal” ranges, and others didn’t. Of particular concern for the family was the slightly elevated total cholesterol and non-HDL cholesterol. High cholesterol ran in the family. The father has had high cholesterol for years.

The mother was direct, asking what to think of the results in the context of the father’s elevated numbers, and how to translate the test results into lifestyle changes. The child was scared, hiding their face in a pillow trying to hold back tears. “I don’t want dad to die,” they said, after I asked why they were hiding.

It didn’t take long for the child to draw the obvious connection: my dad has high cholesterol; the doctor said high cholesterol is bad for your health, which means you’ll die earlier; so my dad is going to die soon. They then pictured themselves in the same sequence of events.

****

This was a difficult conversation. Not only did I have to empathize and relate, I had to convey a sense of optimism – that one blood test isn’t destiny.

After the meeting, though, I found myself thinking about why the family was in this situation to begin with. Should a cholesterol test (when I say cholesterol test I mean a standard lipid panel) be recommended for children and adolescents in the first place? Is a cholesterol test reliable in children and adolescents? Even if it is, do the results change the prescribed treatment, which in many cases for this age group is a combination of lifestyle changes?

So I dug into the research.

The most significant research I found came from a 1990 paper of cholesterol testing reliability in children and adolescent, which described the results of the Bugalusa Heart Study from the early 1980’s. The study examined total cholesterol as a predictive screening tool for almost 3,000 children ages 5 to 17 years from Bugalusa, Louisiana (which includes the same age group I primarily work with for health coaching). In essence, is total cholesterol a meaningful biomarker to use to assess elevated LDL cholesterol?

Despite the appeal of a low-cost screening tool, like measuring total cholesterol, the study found it wasn’t reliable at all. At the 95th percentile total cholesterol cut-off point, less than half of individuals with elevated LDL cholesterol were detected, and about 50% of these were false positives. When this cut-off was lowered to the 75th percentile, false positive results increased to over 80%.

The researchers concluded,

“its poor test characteristics make serum total cholesterol measurement inefficient as a screening tool for detecting elevated levels of low-density lipoprotein cholesterol in children and adolescents.”

These findings and others with conflicting results have since prompted the US Preventive Services Task Force to issue updated recommendations on lipid screening in children and adolescents.

Hot off the presses, published last month,

“The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents 20 years or younger.”

They reason that,

“Most children with elevated lipid levels of a multifactorial origin will not progress to a clinically important lipid disorder or develop premature cardiovascular disease and are therefore subject to overdiagnosis.”

It goes on to say, and back to one of my original points about treatment options,

“The adverse effects of long-term use of lipid-lowering pharmacotherapy and lifestyle modification (including diet and physical activity) have not been adequately studied.”

So to sum up, cholesterol testing in children and adolescents seems too unreliable to effectively screen for subsequent health risks, and is prone to over-diagnosis. As such, there is a considerable possibility to inflict psychological harm, like a mother and child obsessively worrying about “abnormal” test results even when the test may not be reliable in the first place. Worse, there is the potential to prescribe lipid-lowering medications when they aren’t needed, and in the face of limited evidence that such interventions are safe and effective.

Regardless of clinical guidelines, clinical practice is separate issue. Off-label prescribing persists, and strong financial interests operate behind the scenes within healthcare. Changing clinical practice takes time and changes in norms, not just guidelines.

So the real question is: will these new USPSTF guidelines make a difference? Cholesterol testing among children and adolescents is happening in many healthcare systems across the country. Will clinical practice change?

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