Cholesterol Screening and Treatment Practices and Preferences: A Survey of United States Pediatricians

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Quality Improvement Intervention for Universal Lipid Screening in Children Aged 9 to 11 Years

We performed a quality improvement intervention to increase universal lipid screening in well-child visits (age 9 to 11 years): 12-month preintervention; phase 1 (8 months) with provider education, group monthly chart review with feedback, and electronic health record cues to order lipids; and phase 2 (16 months) with electronic health record cues and examination room phlebotomy. Outcomes were compared with clinics having no intervention. In phase 1, immediate treatment effect on the regression line for provider behavior (proportion of visits with lipids ordered) showed 34% increase in intervention and 7% decrease in comparison clinics; patient behavior (phlebotomy completed) showed 19% increase in intervention and 5% decrease in comparison clinics. At the beginning of phase 2, the intervention clinic had average 44% orders entered and 33% phlebotomy completed per well-child visit, and these proportions were maintained. Provider education and chart review with feedback were associated with the greatest gains in outcomes.

Screening and Referral for Low-Income Families' Social Determinants of Health by US Pediatricians

OBJECTIVE

To measure the frequency US pediatricians report screening and referring for social needs and identify pediatrician and practice-level predictors for screening and referral.

METHODS

Data were from the American Academy of Pediatrics Periodic Survey for October 2014 to March 2015 with a response rate of 46.6% (732/1570). Respondents reported on: 1) routine screening of low-income families for social needs, 2) attitudes toward screening, and 3) referral of low-income families for community resources. Results were analyzed by pediatrician and practice characteristics.

RESULTS

Although most pediatricians (61.6%) thought that screening is important, fewer (39.9%) reported that screening is feasible or felt prepared addressing families' social needs (20.2%). The topics that pediatricians reported routinely asking low-income families about at visits (defined as ≥50% visits) were need for childcare (41.5%) and transportation barriers (28.4%). Pediatricians were less likely to report asking about housing (18.7%), food (18.6%), and utilities/heating (14.0%) insecurity. In multivariable analyses, pediatricians were more likely to report both that they screen and refer when they reported having more patients in financial hardship and having someone in the practice with the responsibility to connect low-income families to community services. Pediatricians who endorsed the importance of screening and who reported being prepared were also more likely to screen/refer.

CONCLUSIONS

A minority of pediatricians report routinely screening for social needs. Pediatricians were more likely to report that they screen and refer if they had positive attitudes toward the importance of screening, felt prepared, and had support staff to assist families in need.

Routine Cholesterol Tests and Subsequent Change in BMI Among Overweight and Obese Children

INTRODUCTION

In 2011, the National Heart, Lung and Blood Institute and American Academy of Pediatrics concluded that both familial and obesity-associated dyslipidemias increase cardiovascular risk and recommended universal cholesterol testing at ages 9 to 11. It remains unknown whether testing influences body mass index (BMI) trajectory, a key modifiable cardiovascular outcome.

METHODS

This quasi-experimental-matched cohort includes children aged 9 to 11 years completing well visits in a diverse primary care network from 2012 to 2014. Participants had baseline BMI ≥85th% and no prior cholesterol testing. Propensity score matching identified untested children similar to tested children on weight measures, practice site, sex, age, race, ethnicity, insurance, and well visit frequency. Change in BMI z-score was assessed over 18 months. Regression adjusted for residual confounding following matching. Data were analyzed in 2018.

RESULTS

Matching improved balance between tested and untested children for all characteristics. The matched cohort of 1808 children was predominantly non-Latino black (48%) or non-Latino white (33%), and Medicaid insured (39%). Baseline BMI z-score was 1.88 for tested and 1.84 for untested children. Of tested children, 25% had cholesterol levels above the 2011 guideline's "acceptable" range. Two children received cholesterol lowering medications. Adjusted analysis found no difference in change in BMI z-score between tested and untested children (0.02, 95% confidence interval -0.01, 0.04).

CONCLUSIONS

Individual risk assessment in the form of cholesterol testing is not associated with change in BMI trajectory among overweight and obese children. Though testing may identify familial hypercholesterolemia, results suggest testing does not change BMI trajectory, a key strategy to reduce cardiovascular risk.

US Pediatrician Practices and Attitudes Concerning Childhood Obesity: 2006 and 2017

OBJECTIVE

To compare primary care pediatricians' practices and attitudes regarding obesity assessment, prevention, and treatment in children 2 years and older in 2006 and 2017.

STUDY DESIGN

National, random samples of American Academy of Pediatrics members were surveyed in 2006, 2010, and 2017 on practices and attitudes regarding overweight and obesity (analytic n = 655, 592, and 558, respectively). Using logistic regression models (controlling for pediatrician and practice characteristics), we examined survey year with predicted values (PVs), including body mass index (BMI) assessment across 2006, 2010, and 2017 and practices and attitudes in 2006 and 2017.

RESULTS

Pediatrician respondents in 2017 were significantly more likely than in 2006 and 2010 to report calculating and plotting BMI at every well-child visit, with 96% of 2017 pediatricians reporting they do this. Compared with 2006, in 2017 pediatricians were more likely to discuss family behaviors related to screen time, sugar-sweetened beverages, and eating meals together, P < .001 for all. There were no observed differences in frequency of discussions on parental role modeling of nutrition and activity-related behaviors, roles in food selection, and frequency of eating fast foods or eating out. Pediatricians in 2017 were more likely to agree BMI adds new information relevant to medical care (PV = 69.8% and 78.1%), they have support staff for screening (PV = 45.3% and 60.5%), and there are effective means of treating obesity (PV = 36.3% and 56.2%), P < .001 for all.

CONCLUSIONS

Results from cross-sectional surveys in 2006 and 2017 suggest nationwide, practicing pediatricians have increased discussions with families on several behaviors and their awareness and practices around obesity care.

Pediatric heterozygous familial hypercholesterolemia patients have locally increased aortic pulse wave velocity and wall thickness at the aortic root

Familial hypercholesterolemia (FH) is an autosomal dominant disorder that affects 1 in 250 people. Aortic stiffness, measured by pulse wave velocity (PWV), is an independent predictor for cardiovascular events. Young FH patients are a unique group with early vessel wall disease that may serve to elucidate the determinants of aortic stiffness. We hypothesized that young FH patients would have early changes in aortic stiffness compared to healthy, age- and sex-matched reference values. Thirty-three FH patients ( ≥ 7 years age; mean age 14.6 ± 3.3 years; 26/33 on statin therapy) underwent cardiac MRI. PWV was determined using propagation of flow waveform from aortic arch phase contrast images. Distensibility and aortic wall thickness (AWT) were measured at the ascending, proximal descending, and diaphragmatic aorta. Ventricular volumes and left ventricular (LV) myocardial mass were measured from 2D cine images. These parameters were compared to age- and sex-matched reference values. FH patients had significantly higher PWV (4.5 ± 0.8 vs. 3.5 ± 0.3 m/s; p < 0.001), aortic distensibility, and ascending aortic wall thickness (1.37 ± 0.18 vs. 1.30 ± 0.02 mm; p < 0.05) compared to reference. There was no difference in aortic area or descending aortic wall thickness between groups. Young FH patients had aortic changes with increased aortic pulse wave velocity in the setting of increased aortic distensibility, accompanied by increased thickness of the ascending aortic wall. Presence of these early findings in young patients despite the majority being on statin therapy support enhanced screening and aggressive treatment of familial hypercholesterolemia to prevent potential future cardiovascular events.

Characteristics of Children Referred to a Lipid Clinic Before and After the Universal Screening Guidelines

In 2011, universal lipid screening was recommended for children aged 9 to 11 years; the impact of this recommendation on the lipid clinic setting is unknown. We examined the rate of primary and secondary dyslipidemia diagnoses in a lipid clinic before (2010-2011) and after (2012-2015) the guideline recommendation. We conducted a retrospective study of new clinic patients aged 0 to 20 years seen between April 2010 and April 2015. Chi-square testing was applied. The 345 subjects were 58% males; 48% ≥13 years; 56% Hispanic; and 59% obese. There was no difference in the rate of dyslipidemia diagnoses between periods (before: primary 23%, secondary 73%, no dyslipidemia 4% vs after: 22%, 72%, 6%, respectively; P = .616). There was no significant difference between periods in subject demographics for the total sample, but among those with primary dyslipidemia, pre- to post-guideline percentage of subjects with public insurance decreased (71% to 39%; P = .006). Additional strategies to increase identification of children with dyslipidemia are needed.

Trends in Levels of Lipids and Apolipoprotein B in US Youths Aged 6 to 19 Years, 1999-2016

Importance

Favorable trends occurred in the lipid levels of US youths through 2010, but these trends may be altered by ongoing changes in the food supply, obesity prevalence, and other factors.

Objective

To analyze trends in levels of lipids and apolipoprotein B in US youths during 18 years from 1999 through 2016.

Design, Setting, and Participants

Serial cross-sectional analysis of US population-weighted data for youths aged 6 to 19 years from the National Health and Nutrition Examination Surveys for 1999 through 2016. Linear temporal trends were analyzed using multivariable regression models with regression coefficients (β) reported as change per 1 year.

Exposures

Survey year; examined periods spanned 10 to 18 years based on data availability.

Main Outcomes and Measures

Age- and race/ethnicity-adjusted mean levels of high-density lipoprotein (HDL), non-HDL, and total cholesterol. Among fasting adolescents (aged 12-19 years), mean levels of low-density lipoprotein cholesterol, geometric mean levels of triglycerides, and mean levels of apolipoprotein B. Prevalence of ideal and adverse (vs borderline) levels of lipids and apolipoprotein B per pediatric lipid guidelines.

Results

In total, 26 047 youths were included (weighted mean age, 12.4 years; female, 51%). Among all youths, the adjusted mean total cholesterol level declined from 164 mg/dL (95% CI, 161 to 167 mg/dL) in 1999-2000 to 155 mg/dL (95% CI, 154 to 157 mg/dL) in 2015-2016 (β for linear trend, -0.6 mg/dL [95% CI, -0.7 to -0.4 mg/dL] per year). Adjusted mean HDL cholesterol level increased from 52.5 mg/dL (95% CI, 51.7 to 53.3 mg/dL) in 2007-2008 to 55.0 mg/dL (95% CI, 53.8 to 56.3 mg/dL) in 2015-2016 (β, 0.2 mg/dL [95% CI, 0.1 to 0.4 mg/dL] per year) and non-HDL cholesterol decreased from 108 mg/dL (95% CI, 106 to 110 mg/dL) to 100 mg/dL (95% CI, 99 to 102 mg/dL) during the same years (β, -0.9 mg/dL [95% CI, -1.2 to -0.6 mg/dL] per year). Among fasting adolescents, geometric mean levels of triglycerides declined from 78 mg/dL (95% CI, 74 to 82 mg/dL) in 1999-2000 to 63 mg/dL (95% CI, 58 to 68 mg/dL) in 2013-2014 (log-transformed β, -0.015 [95% CI, -0.020 to -0.010] per year), mean levels of low-density lipoprotein cholesterol declined from 92 mg/dL (95% CI, 89 to 95 mg/dL) to 86 mg/dL (95% CI, 83 to 90 mg/dL) during the same years (β, -0.4 mg/dL [95% CI, -0.7 to -0.2 mg/dL] per year), and mean levels of apolipoprotein B declined from 70 mg/dL (95% CI, 68 to 72 mg/dL) in 2005-2006 to 67 mg/dL (95% CI, 65 to 70 mg/dL) in 2013-2014 (β, -0.4 mg/dL [95% CI, -0.7 to -0.04 mg/dL] per year). Favorable trends were generally also observed in the prevalence of ideal and adverse levels. By the end of the study period, 51.4% (95% CI, 48.5% to 54.2%) of all youths had ideal levels for HDL, non-HDL, and total cholesterol; among adolescents, 46.8% (95% CI, 40.9% to 52.6%) had ideal levels for all lipids and apolipoprotein B, whereas 15.2% (95% CI, 13.1% to 17.3%) of children aged 6 to 11 years and 25.2% (95% CI, 22.2% to 28.2%) of adolescents aged 12 to 19 years had at least 1 adverse level.

Conclusions and Relevance

Between 1999 and 2016, favorable trends were observed in levels of lipids and apolipoprotein B in US youths aged 6 to 19 years.

Factors Affecting Pediatric Dyslipidemia Screening and Treatment

Identification and management of dyslipidemia in childhood can reduce future cardiovascular risk. We performed a retrospective cohort study of children ages 2 to 18 years during 2009 to 2013 to evaluate factors that affect screening and treatment of pediatric dyslipidemia related to 2011 National Heart, Lung, and Blood Institute (NHLBI) guidelines. Logistic regression analysis determined the impact of NHLBI-identified factors on odds of being screened, elevated low-density lipoprotein cholesterol (LDL-C), and receiving pharmacotherapy. A total of 1 736 032 children were included; 113 780 (6.6%) were screened for dyslipidemia. Screening in 9 to 11 year olds increased from 2009 to 2012. Of children screened, 18 801 (16.5%) had elevated LDL-C; 425 (2.3%) were treated pharmacologically. Parental dyslipidemia, diabetes mellitus, chronic kidney disease, Kawasaki disease, human immunodeficiency virus infection, nephrotic syndrome, liver, thyroid, and other endocrine disorders increased odds of screening. Older age, nephrotic syndrome, chronic kidney disease, diabetes mellitus, and hypertension increased odds of having elevated LDL-C and receiving treatment. Pediatric dyslipidemia screening rates remain low.

A Pilot Study of School-Based Comprehensive Cardiovascular Screening in Middle School Children

Although recommended, most children are not routinely screened for lipid abnormalities and diabetes. We report a pilot of universal screening for diabetes, lipid abnormalities, and hypertension in the middle-school setting. Of 45 children screened, 34.8% had lipid or hemoglobin A1c abnormalities and 2 had hemoglobin A1c values in the diabetes range.

HIV and cART-Associated Dyslipidemia Among HIV-Infected Children

BACKGROUND

Persistent dyslipidemia in children is associated with risks of cardiovascular accidents and poor combination antiretroviral therapy (cART) outcome. We report on the first evaluation of prevalence and associations with dyslipidemia due to HIV and cART among HIV-infected Ethiopian children.

METHODS

105 cART naïve and 215 treatment experienced HIV-infected children were enrolled from nine HIV centers. Demographic and clinical data, lipid profile, cART type, adherence to and duration on cART were recorded. Total, low density (LDLc) and high density (HDLc) cholesterol values >200 mg/dL, >130 mg/dL, <40 mg/dL, respectively; and/or, triglyceride values >150 mg/dL defined cases of dyslipidemia. Prevalence and predictors of dyslipidemia were compared between the two groups.

RESULTS

prevalence of dyslipidemia was significantly higher among cART experienced (70.2%) than treatment naïve (58.1%) children (p = 0.03). Prevalence of low HDLc (40.2% versus 23.4%, p = 0.006) and hypertriglyceridemia (47.2% versus 35.8%, p = 0.02) was higher among cART experienced than naïve children. There was no difference in total hypercholesterolemia and high LDLc levels. Nutrition state was associated with dyslipidemia among cART naïve children (p = 0.01).

CONCLUSION

high prevalence of cART-associated dyslipidemia, particularly low HDLc and hypertriglyceridemia was observed among treatment experienced HIV-infected children. The findings underscore the need for regular follow up of children on cART for lipid abnormalities.

An Electrochemical Cholesterol Biosensor Based on A CdTe/CdSe/ZnSe Quantum Dots-Poly (Propylene Imine) Dendrimer Nanocomposite Immobilisation Layer

We report the preparation of poly (propylene imine) dendrimer (PPI) and CdTe/CdSe/ZnSe quantum dots (QDs) as a suitable platform for the development of an enzyme-based electrochemical cholesterol biosensor with enhanced analytical performance. The mercaptopropionic acid (MPA)-capped CdTe/CdSe/ZnSe QDs was synthesized in an aqueous phase and characterized using photoluminescence (PL) spectroscopy, ultraviolet-visible (UV-Vis) spectroscopy, transmission electron microscopy (TEM), X-ray power diffraction (XRD), energy dispersive X-ray (EDX) spectroscopy. The absorption and emission maxima of the QDs red shifted as the reaction time and shell growth increased, indicating the formation of CdTe/CdSe/ZnSe QDs. PPI was electrodeposited on a glassy carbon electrode followed by the deposition (by deep coating) attachment of the QDs onto the PPI dendrimer modified electrode using 1-Ethyl-3-(3-dimethylaminopropyl)-carbodiimide hydrochloride (EDC), and N-hydroxysuccinimide (NHS) as a coupling agent. The biosensor was prepared by incubating the PPI/QDs modified electrode into a solution of cholesterol oxidase (ChOx) for 6 h. The modified electrodes were characterized by voltammetry and impedance spectroscopy. Since efficient electron transfer process between the enzyme cholesterol oxidase (ChOx) and the PPI/QDs-modified electrode was achieved, the cholesterol biosensor (GCE/PPI/QDs/ChOx) was able to detect cholesterol in the range 0.1⁻10 mM with a detection limit (LOD) of 0.075 mM and sensitivity of 111.16 μA mM-1 cm-2. The biosensor was stable for over a month and had greater selectivity towards the cholesterol molecule.

Effectiveness of early identification and electronic interventions for teens with risk factors for the development of heart disease and diabetes: Phase II findings

BACKGROUND AND PURPOSE

Serum and physical risk factors for the development of heart disease and diabetes are detectable long before adulthood. The purpose of this two-part study was to assess the prevalence and associations of these risk factors in teens and determine the effectiveness of a customizable two-part electronic education program on minimizing identified risks.

METHODS

Data were collected from teens (n = 168) from two high schools (one urban and one rural) in the mid-Atlantic region. After baseline data were collected, the two-part electronic education program was initiated. Serum and physical risk factors were rechecked at 12-week intervals, and results were analyzed.

CONCLUSIONS

Significant serum and physical risk factor associations were identified and remained present among teens over the course of the study. High-density lipoproteins showed significant, steady improvement. Low-density lipoproteins were positively associated with body mass index, diastolic blood pressure, and thyroid-stimulating hormone level.

IMPLICATIONS FOR PRACTICE

Although serum and physical risk factors are identifiable in teens, routine screening of this age group and younger is not an established standard of care. Health care providers need effective, innovative methods to counteract these risks. Through increased awareness of the presence of risk factors in young patients, advanced nurse practitioners may implement earlier interventions to counteract these risks.

Parent-child genetic testing for familial hypercholesterolaemia in an Australian context

AIM

The aim of this study was to evaluate the clinical outcome of parent-child testing for familial hypercholesterolaemia (FH) employing genetic testing and the likely additional cost of treating each child.

METHODS

Parent-child testing for gene variants causative of FH was carried out according to Australian guidelines. The number of new cases detected, the low-density lipoprotein (LDL)-cholesterol that best predicted a mutation and the proportional reduction in LDL-cholesterol following statin treatment was evaluated. Treatment costs were calculated as the cost per mmol/L reduction in LDL-cholesterol.

RESULTS

A total of 126 adult patients, known to have a pathogenic mutation causative of FH, and their children were studied. From 244 children identified, 148 (60.7%) were genetically screened; 84 children were identified as mutative positive (M+) and 64 as mutative negative. Six of the M+ children were already on statin treatment; 40 were subsequently treated with low-dose statins, with LDL-cholesterol falling significantly by 38% (P < 0.001). The estimated cost per mmol/L reduction of LDL-cholesterol of a child receiving statins from ages 10 to 18 years is AU$1361, which can potentially be cost-effective. An LDL-cholesterol threshold of 3.5 mmol/L had a sensitivity of 92.8% and specificity of 96.6% for the detection of a mutation.

CONCLUSION

Genetic testing of children of affected parents with FH is an effective means of detecting new cases of FH. Cascade testing can enable early statin therapy with significant reductions in LDL-cholesterol concentration.

Management of Hypertension and High Low-Density Lipoprotein in Pediatric Type 1 Diabetes

OBJECTIVE

To evaluate hypertension and hyperlipidemia management patterns in youth with type 1 diabetes and to assess perceived effectiveness of management strategies and barriers to management.

STUDY DESIGN

An electronic survey, including clinical scenarios, fielded to pediatric providers (members of the American Diabetes Association Diabetes in Youth Interest Group, Pediatric Endocrine Society, or T1D Exchange).

RESULTS

Respondents (N = 207, 86% MDs, 68% female) were practicing clinicians for youth with type 1 diabetes. As an initial recommendation, the overwhelming majority of respondents (83%-99%) endorsed lifestyle and nonmedical recommendations (eg, improve glycemic control) for hypertension and hyperlipidemia. Yet, few (6%-17%) reported these recommendations as effective. Many respondents (57%) reported referring to another specialist for hypertension, whereas few (8%) reported referring to another specialist for hyperlipidemia management. Approximately one-fifth (21%) of respondents never initiate antihypertensive medications, whereas only 8% never initiate lipid-lowering medication. Among prescribers, the majority of respondents only started antihypertensive or lipid-lowering medications after persistent elevations and in the setting of either ineffective lifestyle or nonmedical interventions or additional cardiovascular risk factors. More than two-thirds of respondents endorsed medications as often effective for hypertension and hyperlipidemia (68% and 69%, respectively).

CONCLUSIONS

Pediatric diabetes providers commonly defer prescribing antihypertensive and lipid-lowering medications until nonmedication interventions have been ineffective. Most providers describe medications, but not lifestyle interventions, as often effective. Efforts to align clinical practice with clinical guidelines are needed.

A national survey of primary care physicians: Perceptions and practices of low-dose CT lung cancer screening

Soon after the National Lung Screening Trial, organizations began to endorse low-dose computed tomography (LCDT) screening for lung cancer in high-risk patients. Concerns about the risks versus benefits of screening, as well as the logistics of identifying and referring eligible patients, remained among physicians. This study aimed to examine primary care physicians' knowledge, attitudes, referral practices, and associated barriers regarding LDCT screening. We administered a national survey of primary care physicians in the United States between September 2016 and April 2017. Physicians received up to 3 mailings, 1 follow-up email, and received varying incentives to complete the survey. Overall, 293 physicians participated, for a response rate of 13%. We used weighted descriptive statistics to characterize participants and their responses. Over half of the respondents correctly reported that the US Preventive Services Task Force recommends LDCT screening for high-risk patients. Screening recommendations for patients not meeting high-risk criteria varied. Although 75% agreed that the benefits of LDCT screening outweigh the risks, fewer agreed that there is substantial evidence that screening reduces mortality (50%). The most commonly reported barriers to ordering screening included prior authorization requirements (57%), lack of insurance coverage (53%), and coverage denials (31%). The most frequently cited barrier to conducting LDCT screening shared decision making was patients' competing health priorities (42%). Given the impact of physician recommendations on cancer screening utilization, further understanding of physicians' LDCT screening attitudes and shared decision-making practices is needed. Clinical practice and policy changes are also needed to engage more patients in screening discussions.

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Most physicians had five or less lung cancer screening referrals in the past year

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Recommendation strategies varied, but often aligned with USPSTF or NCCN guidelines

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Physicians were uncertain about the efficacy and cost-effectiveness of screening

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Insurance coverage and costs were commonly cited as barriers to screening referral

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A common barrier to performing SDM was patients' competing health priorities

Temporal trends in lipid testing among children and adolescents: A population based study

Unfavorable lipid levels during childhood are associated with subsequent development of atherosclerotic cardiovascular disease. The American Academy of Pediatrics and National Heart, Lung and Blood Institute in 2011 recommended universal lipid screening for children between ages 9–11 years and between ages 17–21 years. The objective of the study was to determine temporal trends in lipid testing among children and young adults in a mid-western population. The Rochester Epidemiology Project database was used to identify lipid testing in ages 2–21 years (n = 51,176) in the Olmsted County population from January 1, 2008 through December 31, 2014. Generalized estimating equations with Poisson distribution were used to test for temporal trends in lipid testing across the age groups. There was modest increase in lipid testing in children in the age groups, 9–11 years and 17–21 years (1.5% in 2008 to 2.2% in 2014, P < 0.001 and 4.4% in 2008 to 4.6% in 2014, P = 0.02, respectively). There was a significant decrease in proportion of 17–21 year olds with elevated total cholesterol (16.2% in 2008 to 11.6% in 2014; P = 0.01) and non-high density lipoprotein cholesterol (22.6% in 2008 to 12.6% in 2014; P < 0.001). In this population-based study, rates of lipid testing increased minimally only in the last six years. Further longitudinal studies are warranted to improve guideline dissemination and address attitudes, practices and barriers to lipid testing in children and young adults.

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In 2011, universal lipid screening was recommended for children and young adults.

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We investigated temporal trends in lipid testing in a mid-western community.

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There was only a minimal increase in rates of lipid testing.

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There is need for improve guideline dissemination and implementation.

An enquiry based on a standardised questionnaire into knowledge, awareness and preferences concerning the care of familial hypercholesterolaemia among primary care physicians in the Asia-Pacific region: the "Ten Countries Study"

OBJECTIVE

To determine physicians' knowledge, awareness and preferences regarding the care of familial hypercholesterolaemia (FH) in the Asia-Pacific region.

SETTING

A formal questionnaire was anonymously completed by physicians from different countries/regions in the Asia-Pacific. The survey sought responses relating to general familiarity, awareness of management guidelines, identification (clinical characteristics and lipid profile), prevalence and inheritance, extent of elevation in risk of cardiovascular disease (CVD) and practice on screening and treatment.

PARTICIPANTS

Practising community physicians from Australia, Japan, Malaysia, South Korea, Philippines, Hong Kong, China, Vietnam and Taiwan were recruited to complete the questionnaire, with the UK as the international benchmark.

PRIMARY OUTCOME

An assessment and comparison of the knowledge, awareness and preferences of FH among physicians in 10 different countries/regions.

RESULTS

1078 physicians completed the questionnaire from the Asia-Pacific region; only 34% considered themselves to be familiar with FH. 72% correctly described FH and 65% identified the typical lipid profile, with a higher proportion of physicians from Japan and China selecting the correct FH definition and lipid profile compared with those from Vietnam and Philippines. However, less than half of the physician were aware of national or international management guidelines; this was significantly worse than physicians from the UK (35% vs 61%, p<0.001). Knowledge of prevalence (24%), inheritability (41%) and CVD risk (9%) of FH were also suboptimal. The majority of the physicians considered laboratory interpretative commenting as being useful (81%) and statin therapy as an appropriate cholesterol-lowering therapy (89%) for FH management.

CONCLUSIONS

The study identified important gaps, which are readily addressable, in the awareness and knowledge of FH among physicians in the region. Implementation of country-specific guidelines and extensive work in FH education and awareness programmes are imperative to improve the care of FH in the region.

Knowns and unknowns in the care of pediatric familial hypercholesterolemia

Familial hypercholesterolemia (FH) is a common genetic disorder that causes elevated LDL cholesterol levels from birth. Untreated FH accelerates atherosclerosis and predisposes individuals to premature coronary artery disease (CAD) in adulthood. Mendelian randomization studies have demonstrated that LDL cholesterol has both a causal and cumulative effect on the risk of CAD. This supports clinical recommendations that children with FH commence pharmacological treatment from the age of 8 to 10 years, to reduce the burden of hypercholesterolemia. Worldwide, the majority of children with FH remain undiagnosed. Recent evidence suggests that the frequency of FH is at least 1 in 250 and this constitutes a public health issue. We review and identify the knowns and unknowns concerning the detection and management of pediatric FH that impact on the developing model of care for this condition.

The Role of Lipid and Lipoprotein Metabolism in Non-Alcoholic Fatty Liver Disease

Due to the epidemic of obesity across the world, nonalcoholic fatty liver disease (NAFLD) has become one of the most prevalent chronic liver disorders in children and adolescents. NAFLD comprises a spectrum of fat-associated liver conditions that can result in end-stage liver disease and the need for liver transplantation. Simple steatosis, or fatty liver, occurs early in NAFLD and may progress to nonalcoholic steatohepatitis, fibrosis and cirrhosis with increased risk of hepatocellular carcinoma. The mechanism of the liver injury in NAFLD is currently thought to be a “multiple-hit process” where the first “hit” is an increase in liver fat, followed by multiple additional factors that trigger the inflammatory activity. At the onset of disease, NAFLD is characterized by hepatic triglyceride accumulation and insulin resistance. Liver fat accumulation is associated with increased lipotoxicity from high levels of free fatty acids, free cholesterol and other lipid metabolites. As a consequence, mitochondrial dysfunction with oxidative stress and production of reactive oxygen species and endoplasmic reticulum stress-associated mechanisms, are activated. The present review focuses on the relationship between intra-cellular lipid accumulation and insulin resistance, as well as on lipid and lipoprotein metabolism in NAFLD.