US Task Force Reviews Lipid Screening For Children and Adolscents

MedicalResearch.com Interview with:

Paula Lozano, MD MPH Associate Medical Director, Research and Translation Group Health Physicians SENIOR INVESTIGATOR Group Health Research Institute Metropolitan Park East Seattle, WA 98101

Dr. Paula Lozano

Paula Lozano, MD MPH
Associate Medical Director, Research and Translation
Group Health Physicians
Senior Investigator
Group Health Research Institute
Metropolitan Park East
Seattle, WA 98101

MedicalResearch.com: What is the background for this study?

Response: This wasn’t a study, but rather a study of studies, to support the US Preventive Services Task Force in updating its previous recommendation of

I: insufficient to assess the balance of benefits and harms. We conducted two systematic evidence reviews of screening children and adolescents:

1. for familial hypercholesterolemia (FH, a genetic disorder that interferes with the body’s ability to metabolize cholesterol and can result in early coronary heart disease); and

2. for multifactorial dyslipidemia—which we defined as elevated LDL cholesterol or total cholesterol, not caused by familial hypercholesterolemia. LDL and total cholesterol were of interest because they are considered atherogenic.

One of the challenges of lipid screening in youth is that blood levels of these atherogenic lipids are known to fluctuate during the course of childhood and adolescence. It’s sort of a W-shaped curve, with a peak at age 9-11 years. So for a given child, the definition of what’s an elevated LDL or total cholesterol level will change with age. Also, two-thirds of kids identified as having high cholesterol through universal screening would not go on to have high cholesterol as adults.

MedicalResearch.com: What should readers take away from your report?
Response:
• Very few screening studies met our inclusion criteria, so evidence is quite limited.
• For both  familial hypercholesterolemia and multifactorial dyslipidemia, we found no direct evidence of an effect of screening asymptomatic populations on intermediate or long-term health outcomes.
• In children and adolescent with known FH, we found good evidence of effectiveness of statins to reduce total cholesterol and LDL cholesterol, in studies up to two years’ duration. (Effectiveness of diet and lifestyle interventions is limited in these youth.)
• There is some evidence that statins are well-tolerated in youth with  familial hypercholesterolemia. They have few harms in short-term (up to two years), but long-term effects and harms are unknown.
• We found no direct evidence that treating children and adolescents with FH reduces incidence of heart disease or stroke during adulthood.
• In youth with multifactorial dyslipidemia, dietary intervention showed a small, impact on LDL and total cholesterol in the short term, and no long-term benefit.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Response: More research is needed in this area.
It would be valuable to have more randomized trials on the effectiveness and harms of screening for dyslipidemia in children and adolescents. We also need longer-term treatment trials in youth with FH, as well as randomized trials to inform the decision about at what age to start treatment for FH.

MedicalResearch.com: Is there anything else you would like to add?

Response: Some clinicians and medical scientists may be confused about the way that these kinds of systematic reviews are conducted in support of the US Preventive Services Task Force. Our team of researchers is part of an Evidence-based Practice Center (EPC) called Kaiser Permanente Research Affiliates EPC, which includes researchers from Kaiser Permanente, Group Health and Health Partners. We review all of the relevant studies on a particular topic, and then compile evidence reviews for the Task Force.

An important feature of EPC reviews is that we base our work on an analytic framework with defined key questions and we use a set of commonly-agreed on scientific methods that are part of the standard EPC protocol. The goal of this EPC methodology is to avoid bias in interpreting the evidence base and to ensure that the results of the systematic reviews are applicable, valid and meaningful for the general population of children and adolescents in the US. Members of the Task Force then use the EPC’s review to make recommendations about clinical practice guidelines.

It’s important to know that our EPC researchers are independent of the Task Force. In this interview, I can speak to our evidence reviews, but not specifically about the Task Force recommendations. That said, it might be of interest to know that in a recent JAMA editorial (commenting on a different USPSTF recommendation:

http://jama.jamanetwork.com/article.aspx?articleid=2536607),

Drs. Tsao and Weinstock called on the scientific community to view the I designation “not…as an indictment but rather an invitation to the public health, medical, and scientific communities to galvanize and to work together in executing well-designed but feasible studies so future recommendations can be of greater public health benefit.”

I think that’s a great call to action for all of us.
You can learn more about work of the Task Force here:
http://www.ahrq.gov/research/findings/evidence-based-reports/overview/index.html

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