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Clinical Practice Guidelines: Cholesterol Tests for Children?

The American Academy of Family Physicians journal American Family Physician (AFP) has a feature called Journal Club that I’ve mentioned before.  Three physicians examine a published article, critique it, discuss whether to believe it or not, and put it into perspective. In the September 15 issue  the journal club analyzed an article that critiqued the process for developing clinical practice guidelines. It discussed how two reputable organizations, the United States Preventive Services Task Force (USPSTF) and the American Academy of Pediatrics (AAP) looked at the same evidence on lipid screening in children and came to completely different conclusions and recommendations.

The AAP recommends testing children ages 2-10 for hyperlipidemia if they have risk factors for cardiovascular disease or a positive family history. The USPSTF determined that there was insufficient evidence to recommend routine screening. How can a doctor decide which recommendation to follow?

What Are Clinical Practice Guidelines?

They are “cookbooks” developed for the convenience of doctors in practice. A group of experts asks a practical question (for instance, should we screen the general population for prostate cancer with a PSA test?) and does the dirty work, plowing through mountains of evidence so when a doctor in practice asks that question, a handy science-based answer will be available to him. There is a National Guideline Clearing House that has compiled 2476 of these guidelines, with as many as 20 guidelines on a single topic. They don’t provide any oversight of quality or of how the guidelines were developed. In general, guidelines from specialty groups tend to be methodologically less sound and to recommend a more aggressive strategy than guidelines from primary care organizations. I recently wrote about prostate cancer screening, where most groups now recommend against routine PSA testing but urologists strongly disagree.  Another problem is that published guidelines are not always current; they must be updated as new evidence comes in.

Comparison of the USPSTF and AAP Guideline Development Process

Why did the USPSTF and the AAP disagree? This table offers some clues:

Standard USPSTF AAP
Clear description of methods used to identify and analyze scientific data Yes No
Method of updated literature review that is referenced and outlined Yes No
Standard process for appraisal and grading the quality or sufficiency of the evidence Yes No
Conflicts of interest rigorously vetted Yes No
External peer and public review Yes No

The Journal Club participants felt the USPSTF process was “best in class,” and they chose to follow the more rigorous, more conservative, USPSTF recommendation over the AAP recommendation for childhood lipid screening.

Problems with the Process

All too often, there is no good clear-cut evidence to answer the question, so guidelines fall back on consensus recommendations from a group of experts. A review of American Heart Association/American College of Cardiology guidelines found that only 11% were based on multiple randomized trials or meta-analyses, and nearly half were based only on experts expressing their opinions.  Also, 56% of guidelines had an author who disclosed a conflict of interest.  Worse yet, 87% of guidelines had ties to the pharmaceutical industry.

In one documented case, a prominent nonprofit organization received $11 million dollars from a pharmaceutical company and then placed 6 members with ties to that company on a 9-person committee charged with determining the role of the company’s drug in a guideline.

Another problem is lack of transparency. Published guidelines seem to imply unanimity, but individual committee members may have disagreed. It would be helpful to know whether the vote was 9-0 or 5-4. And why.

Improving the Process

The Institute of Medicine (IOM) has proposed these 8 standards:

  1. Complete transparency
  2. Conflict-of-interest disclosure
  3. Multidisciplinary member composition
  4. Systematic literature review meeting IOM standards
  5. Clear and consistent rating and description of evidence
  6. Recommendations articulated in detail and in a standard form
  7. External review by the full spectrum of stakeholders
  8. Appropriate updating of guidelines

There is no requirement to follow these standards, and no way to enforce them. The American Cancer Society has said it will follow them. The WHO has also proposed its own rigorous 19-step process.

Conclusion

The Journal Club analysis concludes with a summary of key points, including:

  • There are no controlled trials demonstrating that lipid screening in children improves long-term health outcomes.
  • The level of evidence of clinical practice guidelines should be reviewed before widespread implementation.

I would add: Clinical practice guidelines are very useful and the USPSTF guidelines are the most trustworthy.

 

 

Posted in: Science and Medicine

Leave a Comment (44) ↓

44 thoughts on “Clinical Practice Guidelines: Cholesterol Tests for Children?

  1. windriven says:

    ” There are no controlled trials demonstrating that lipid screening in children improves long-term health outcomes.”

    Lipid screening is simple and inexpensive requiring nothing of the testee beyond a brief fast. Statin treatment of dyslipidemias is inexpensive, relatively safe and non-invasive.

    “Atherosclerosis begins in childhood, and these early lesions are related to cardiovascular risk factors, including non-high-density lipoprotein cholesterol (HDL-C).” (1)

    “Medium-term clinical trials of statin therapy for inherited dyslipidemias are safe and effective in lowering low-density lipoprotein cholesterol (LDL-C).” (1)

    “Early therapy has been associated with improvements in noninvasive measures of early atherosclerosis in children, which likely can be extrapolated to improved freedom from cardiovascular disease events over the lifespan, as has been observed in adults. ” (2)

    There may not be any controlled trials demonstrating that lipid screening in children improves long-term health outcomes but that is not the same as demonstrating that improvements don’t exist. Given the ease of screening, the low cost of therapy and the potential long term upside it is difficult for me to understand the USPSTF recommendation.

    It is one thing to acknowledge that good trials haven’t been done, quite another to advocate a broad policy based on that absence.

    (1) Universal Screening of Cholesterol in Children, Kwiterovich and Gidding, Clinical Cardiology 2012 Aug 28 [Epub ahead of print]

    (2) Familial Hypercholesterolemia in Children and Adolescents, McCrindle, Curr Opin Lipidol. 2012 Aug 21. [Epub ahead of print]

  2. Janet says:

    Is it justified to screen where a strong family history is present? Isn’t early intervention warranted in such cases?

    In spite of asking those questions, I think I now will wonder even more if my doctor recommendations are based on anything conclusive.

  3. cervantes says:

    Conflict of interest disclosure is greatly overrated as a corrective policy. If you believe that conflicts of interest can distort the outcome of the process — which they certainly can — then the right policy is to prohibit them. If disclosing them is supposed to fix things, then all it accomplishes is to make the guidelines worthless, because you have officially declared that they aren’t trustworthy. That is utterly feckless.

    Don’t tell me you can’t find people with appropriate expertise who don’t have a financial interest in the results of whatever the consensus guidelines or regulatory process may be. It’s just the academic medical culture that declares this person is so prestigious that they have to be on the panel, despite their COI; whereas there are plenty of perfectly smart, competent people who haven’t taken industry money and don’t make an income off of the procedures which are being judged.

  4. Note: I have no opinion on screening for lipids in children. Can any pediatricians comment on what you do if a child is born to a family that has a history of familial hypercholesterolemia?

    To play Devil’s advocate:

    Dr. Hall, you wrote:

    I would add: Clinical practice guidelines are very useful and the USPSTF guidelines are the most trustworthy.

    I completely agree with the first part of your statement. I, of course, understand that in the second part you are stating your opinion. Part of me wonders if you feel that the USPSTF guidelines are the most trustworthy because you used to be a military doctor, it gave you a great life, and a great career. You know, part of that subtle bias that we all seem to readily accept that doctors are susceptible to if they are given a clicky-top pen and a free lunch. I’m not saying that you are ignoring evidence, or that USPSTF guidelines suck, or anything negative in any way, but I do wonder if you trust them the most because of your history?

    I typically appreciate the science behind the USPSTF guidelines, and we all have our criticisms of recommendations made by many groups. But sometimes I can’t help but feel that USPSTF guidelines are made to try to save money. I know that usually money is said to not be a factor in their recommendations, but when they reduce the intervals of screening, it can mean that since this test is no longer recommended, they (the government… Medicaid) can get out of paying for the test. (And yes, I have an inherent distrust of the government, which is probably completely unfounded, but exists nonetheless.)

  5. cervantes says:

    Familial hypercholesterolemia is a specific hereditary disease. That’s unrelated to the question of population screening. Of course a child with a family history should be tested.

  6. windriven says:

    @cervantes

    “Don’t tell me you can’t find people with appropriate expertise who don’t have a financial interest in the results of whatever the consensus guidelines or regulatory process may be.”

    Many devices and all drugs have to go through a regulatory process with FDA that generally require studies. These studies are funded by the companies making the products. I’m not sure how a different funding system would function.

    But it would certainly be useful if all studies that might be submitted to FDA or for publication in a peer reviewed journal had to be listed in a publicly accessible database before the study began. This would give some insight into studies that had negative results but never see the light of day. The database might disclose objectives, methodology, principal investigators, funding, et cetera. And certainly any COIs should be disclosed in considerable detail.

  7. ^ Yeah, no joke. I’ll word my question better: Pediatricians, what do if a child is born to a family that has a history of familial hypercholesterolemia? If either of the parents has a known history, do you do genetic testing right away?

  8. Harriet Hall says:

    @SkepticalHealth,

    “if you feel that the USPSTF guidelines are the most trustworthy because you used to be a military doctor, it gave you a great life, and a great career. ”

    Why would you even suggest that when I presented a table showing the superior methodology of the USPSTF and the conclusion of the Journal Club authors that it was “best in class”? And when the military has no connection with the USPSTF?

    “USPSTF guidelines are made to try to save money”

    No, they’re not. The USPSTF is an independent body of experts in prevention and evidence-based medicine, working to improve the health of all Americans by making evidence-based recommendations about the effectiveness of clinical preventive services and health promotion. It does not consider cost-effectiveness. Its work does not require AHRQ or HHS approval.

    “I have an inherent distrust of the government”

    Your paranoia is showing. I distrust some of the things government does, but my distrust is not indiscriminate, and does not extend to the USPSTF.

  9. @HH,

    Why would you even suggest that when I presented a table showing the superior methodology of the USPSTF and the conclusion of the Journal Club authors that it was “best in class”?

    The table you presented had to do with a group of people comparing the evidence on lipid screening in children from two different agencies. How can you take that and make a broad recommendation that the USPSTF recommendations are the most trustworthy? If this broad recommendation was not your intention, it sure seems that way from the last sentence in your otherwise interesting article.

  10. cervantes says:

    Windriven — The FDA panels and the consensus guideline panels obviously don’t have to include any of the people who participated in the industry funded trials. I don’t take your point at all.

  11. Harriet Hall says:

    @SH,
    “The table you presented had to do with a group of people comparing the evidence on lipid screening in children from two different agencies.”

    No, it had to do with the methods the USPSTF uses to reach its conclusions, contrasted with the methods used by the AAP.

    “How can you take that and make a broad recommendation that the USPSTF recommendations are the most trustworthy? ”

    I am going by the data about methodology presented in the article and the many sources it cited, as well as by my observations throughout my career. I don’t know of any other group whose recommendations are more trustworthy. Do you? Can you cite an instance where the USPSTF was clearly wrong?

  12. ELloyd says:

    Hi, Dr. Hall.

    I simply want to post a short note her to apologize to you, in particular. I was not aware of who you were when I posted on Dr. Gorski’s colum, and again, I apologize. I do not have anything negative to say about you.

    This is my last post anywhere in these forums, and I will not be back to read any responses, but I do feel that you deserve more respect than I have shown you, and for that, I am truly sorry.

  13. windriven says:

    @cervantes

    Perhaps it was I who didn’t didn’t grasp yours. I reread your original post and see that it is not authors that concern you but rather regulators and guideline panelists. Of course there is some of the revolving door effect at FDA with professionals moving back and forth between government and industry roles but I don’t have authoritative information on how widespread that is. In any event I misread your original post so my comment was apropos of … nothing.

    (Rosanna Rosanna Danna voice) Never mind.

  14. mousethatroared says:

    @Harriet Hall – Initially I thought this was just going to be a rundown on new guidelines for screening in children. But I enjoyed that you turned that into a discussion of the process used to determine those guidelines and how a more transparent process with established criteria can lead to more trustworthy guidelines. Good angle.

    I was a bit confused by this statement though – “The AAP recommends testing children ages 2-10 for hyperlipidemia if they have risk factors for cardiovascular disease or a positive family history. The USPSTF determined that there was insufficient evidence to recommend routine screening.”

    It sounds like the AAP is recommending ‘testing’ based on risk factors, while that USPSTF’s recommendation are based on general ‘screening’ for ALL children of the determined age.

    ‘screening’ vs ‘testing’ are something that have thrown me off more than once.

    Am I correct in thinking that these two guidelines are not necessarily in opposition to one another?

  15. Harriet Hall says:

    @mousethatroared,

    The guidelines are in opposition. The AAP recommends testing children age 2-10 who have risk factors. The USPSTF does not recommend testing children, even for children with those risk factors. On the other hand, the USPSTF does not recommend AGAINST testing children for specific reasons like a suspected genetic disorder (familial hyperlipidemia). They leave the decision to test up to the clinician for individual cases rather than making across-the-board recommendations for all children in a specified group.

    Hope that clarifies things.

  16. mousethatroared says:

    Yes, It does. Thanks!

  17. BillyJoe says:

    Windriven,

    HH: ” There are no controlled trials demonstrating that lipid screening in children improves long-term health outcomes.”
    windriven: “Lipid screening is simple and inexpensive requiring nothing of the testee beyond a brief fast. Statin treatment of dyslipidemias is inexpensive, relatively safe and non-invasive.”

    If there are no controlled trials demonstrating that lipid screening in children improves long-term health outcomes, then lipid screening in children should not be done. Period. That it is inexpensive and simple is irrelevant.

    “Given the ease of screening, the low cost of therapy and the potential long term upside it is difficult for me to understand the USPSTF recommendation.”

    It is perfectly understandable. If there is no evidence of benefit, a screening test should not be implemented.

    “It is one thing to acknowledge that good trials haven’t been done, quite another to advocate a broad policy based on that absence.”

    Unless and until those trials ae done, the recommendations should stand.

  18. windriven says:

    Sorry Billy Joe, your argument amounts to a basket of nothing.

    There are many studies demonstrating that managing lipid levels improves long term health outcomes. The fact that none have apparently been done on a particular age cohort does not mean that one can’t extrapolate the benefit. It is probably true that no studies exist demonstrating that lipid screening in blue-eyed blondes improves long term health outcomes. Does that mean that blue-eyed blondes shouldn’t be screened?

    It is unrealistic to run RCTs on every phenotypic variant. Further, running RCTs on minors present unique difficulties. Should children and adolescents – humans with the longest span remaining and for whom early interventions may offer the greatest benefits – be deprived of every test and therapy for which an RCT hasn’t been run???

    And speaking of RCTs, is one RCT enough? Ioannidas might not think so. So where does it stop before Billy Joe is willing to pull the trigger?

    Following your argument to its logical conclusion, medicine today wouldn’t be much beyond trepanning.

  19. Harriet Hall says:

    @windriven,

    “The fact that none have apparently been done on a particular age cohort does not mean that one can’t extrapolate the benefit.”

    One “can” but perhaps one “shouldn’t.” Children are not just miniature adults; that’s why we have pediatricians. We need to test what the benefits are rather than just extrapolating and making educated guesses. We’d like to know how much actual difference it makes whether statins are started at age 2 or 10 or ? And we want to know whether lowering cholesterol levels in children (with or without statins) might carry significant harms, perhaps especially at the younger ages. Low cholesterol has been linked to a number of diseases, and statins have side effects even in adults. If we decide to lower cholesterol levels in children, we need to know what target level is optimum.

    IMHO the most reasonable course is to wait for the evidence; and meanwhile, to recommend a healthy diet, exercise, and obesity prevention for all children.

  20. windriven says:

    @Dr. Hall

    I appreciate the distinction between adults and peds. Children are not miniature adults but they have the same organ systems though those systems are still developing. I’ll say again – there are any number of tests and therapies that are used in pediatric medicine without the support of RCTs. Just for grins I scanned pubmed for pediatric use of coumadin/warfarin and found no RCTs but I know for a fact that coumadin has been used in pediatric patients (anecdotal reports can be found in Pubmed).

    Going back to my original comment, the starting point in contention is screening. Ordering lipids as part of routine blood work is a no-brainer. In all deference to you and Billy Joe, the cost is inconsequential. If lipids are within nominal levels, no harm, no foul. If not, I would expect the clinician to carefully examine family history for hypercholesterolemia and to develop a treatment plan starting, as you suggest, with diet and exercise with follow up and, if necessary, escalating to statins*. The link between managing lipids and improved long term health is clear (see the Bogalusa study as a starting point).

    RCTs are great and multiple, carefully structured RCTs are golden. But there aren’t enough research dollars to investigate every screen and every therapy in every patient population. So dots are connected and extrapolations are made. Clinical judgment matters.

    CAD is a major cause of morbidity and mortality in the US; it is expensive to treat and it erodes quality of life. Screening is cheap and atraumatic. Treatment can be as simple as managing diet and exercise. IMHO, not screening in pediatric populations where early capture may provide a lifetime of benefit is very hard to justify.

    *Yes, statins have side effects but they are rare and easily identified.

  21. Harriet Hall says:

    @windriven,

    We don’t have adequate evidence in this area. It’s an area where good science-based doctors can come to different conclusions based on their philosophies about risk, insurance, the precautionary principle, their experience with CVD, and other factors.

    Yes, there are a lot of things we do to treat children based only on adult studies. Studies in children are needed, and in their absence we resort to guesswork. That doesn’t mean we should add more untested things to what we are already doing.

    “Ordering lipids as part of routine blood work is a no-brainer.” But routine blood work is not ordered on healthy children. Neither blood nor urine tests are done routinely during the well baby or well child visit. Blood tests are not even routinely done on a child with a fever unless there are other signs of significant illness. It would be necessary to draw blood only for the purpose of checking lipids, and it is not exactly “atraumatic.” (Ask any child!)

    I can see how knowing about elevated cholesterol could encourage children and parents to follow preventive lifestyle changes. I can also see how it could alarm people and cause a great deal of worry and label a child as “sick.” An example is a friend’s 18 year old son whose cholesterol was tested (I don’t know why) and found to be very high. He is planning a career as an airline pilot and fears any health condition or requirement to take medication because it might put an end to his plans. Everyone was panicking until the test was repeated and found to be normal. But he’s still worried. Sure, he can alleviate that worry by following good preventive practices, but we should all be doing that anyway.

    The criteria for screening tests are:
    The condition should be an important health problem.
    There should be a treatment for the condition.
    Facilities for diagnosis and treatment should be available.
    There should be a latent stage of the disease.
    There should be a test or examination for the condition.
    The test should be acceptable to the population.
    The natural history of the disease should be adequately understood.
    There should be an agreed policy on whom to treat.
    The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole.
    Case-finding should be a continuous process, not just a “once and for all” project.

    It seems to me that cholesterol screening in children doesn’t meet all these criteria. I respect your right to disagree.

  22. Chris says:

    Dr. Hall:

    It would be necessary to draw blood only for the purpose of checking lipids, and it is not exactly “atraumatic.” (Ask any child!)

    Especially one who had to skip getting breakfast!

  23. In 2004, a double-blind, RCT on children 8-18 was done on children with familial hyperlipidemia. There were over 100 kids in each group. It followed them for 2 years. The conclusion was,

    “Two years of pravastatin therapy induced a significant regression of carotid atherosclerosis in children with familial hypercholesterolemia, with no adverse effects on growth, sexual maturation, hormone levels, or liver or muscle tissue.”
    JAMA. 2004 Jul 21;292(3):331-7

    I’d like to see follow-up data on these kids. Regression of early plaques in teens is likely very significant.

    Cochrane reviewed the evidence of statins for kids with familial hyperlipidemia. The conclusion reads,

    “Statin treatment is an efficient lipid-lowering therapy in children with familial hypercholesterolemia. It seems to be safe in the short term but long-term safety is unknown. Children treated with statins should be carefully followed up by their pediatricians. Large long-term randomized controlled trials are needed to establish the long-term safety of statins.”
    Cochrane Database Syst Rev. 2010 Jul 7;(7):CD006401

    We do not have long term data yet. This is likely because the idea of giving statins to kids is relatively new. The update to the Cochrane review in 10 years will be telling.

    In the meantime, it seems reasonable to screen kids as they enter the teen years if there is a relevant family history of early heart disease. Treatment is likely safe if monitored closely.

    In the general public, testing may have some use for opening a discussion between the doctor and the family about lifestyle and nutrition. However, that discussion should be taking place anyway.

  24. Harriet Hall says:

    @Skeptical Medicine,

    That study is very reassuring, but (1) it was in patients with familial hypercholesterolemia and (2) it measured a marker for CVD, intimal thickness, rather than showing the kind of clinical outcomes (POEMS, Patient Oriented Evidence that Matters) that only long followup can show: whether it resulted in fewer CV incidents or lower mortality. Long term studies in patients with elevated lipids not related to familial hyperlipidemia might have different results.

    I think your position, screening teens with positive family histories (and/or risk factors like obesity, diabetes, hypertension) and treating them cautiously, is an eminently reasonable approach while we await better evidence.

  25. windriven says:

    Thanks to you Dr. Hall and to SkepticalMedicine for helping me to refine my views on this issue.

  26. windriven says:

    @Chris

    I understand your feelings on this. But a hungry tummy and a needle stick don’t seem much of a price if it leads to a longer and healthier life for the child.

    We don’t have evidence of genetic predisposition to hypercholesterolemia in my family and my kids are pretty much grown now. I’m not sure whether or not I’d push for the screening if they were young. No risk factors to speak of. But the evidence in adults is so compelling that I might.

    You may recall another of Dr. Hall’s posts not long ago looked at statins; it engaged me because my primary care physician when I lived in New Orleans was one of the researchers on the Bogalusa Heart Study. He was a true believer and started me on lipitor despite having reasonable total cholesterol (~160) and passable ratio 5:1. I stopped the drug after I moved, largely because it took me several years to find a primary care physician I could live with. Though my numbers are still good I’m going to discuss resuming a statin regimen when I next see her, largely owing to research I did during discussions and compelling arguments mounted by some of the MD commenters.

    I come at this from the ounce of prevention vs. pound of cure perspective. Prevention (speaking now about adults) is inexpensive and non-invasive. Treatment of CAD is wildly expensive and often quite invasive to say nothing of truncated lives and diminished quality of life.

  27. BillyJoe says:

    Windriven,

    “Thanks to you Dr. Hall and to SkepticalMedicine for helping me to refine my views on this issue.”

    I hope they have.
    Just remember, it is not justified to do screening tests without evidence of clear benefit above risks.
    Otherwise what we have is quackery, something SBM strives hard against.
    Once the tests are being performed routinely without the necessary evidence, it is hard to stop once the evidence suggests they should not be done (eg PSA screening).

  28. windriven says:

    @Billy Joe

    “I hope they have.”

    Refining one’s views doesn’t necessarily mean changing one’s views. The link between controlling lipid levels and improved outcomes is so clear in adults that extrapolating that link to adolescents strikes me as reasonable absent evidence to the contrary. So while there is not evidence in the adolescent cohort there is ample evidence in the broader population of clear benefit above risk (someone is going to bleed out from a blood test?).

    In any event, it has been an interesting conversation.

  29. Janet says:

    “I think your position, screening teens with positive family histories (and/or risk factors like obesity, diabetes, hypertension) and treating them cautiously, is an eminently reasonable approach while we await better evidence.”

    Thank you HH for eventually answering my initial question toward the top of these comments. And thanks to SH and windriven for taking the conversation in a direction that brought clarity to a multi-faceted question.

    I love this blog.

  30. estockly says:

    I’m wondering if there is a danger of moving from Science Based Medicine and Evidence Based Medicine to “Guideline Based Medicine” and “Authority Based Medicine.”

    From what I’ve seen of this discussion (and others) physicians rely on guidelines and place their trust that the “Authorities” who develop the guidelines base them on the best science available.

    Which is quite understandable given the complexity of the human body and the science used to understand it. You can’t expect every doctor to be an expert in the science behind every condition and the guidelines are useful, if they are based on the best science available.

    The guidelines Dr. Hall referred to as the “best” are a good example. For Obesity they recommend referral to a dietician.

    That would be fine if the recommendations and guidelines followed by dietitians were based on the best science available. (I would argue they are not.)

    ES

  31. nybgrus says:

    Let’s not forget that the recent JUPITER statin follow up demonstrated a significant increase in diabetes from statin use. They determined that the long term CVD outcomes outweighed the negatives of the increased risk and incidence of diabetes. That is, of course, in the context of the background risk factors leading to statin use in adults. We simply do not have similar data in children to make an adequate risk: benefit analysis. You can’t possibly extrapolate the long term risk from diabetes versusCVD in otherwise healthy children lacking personal risk factors.

  32. nybgrus has a legitimate concern. The topic is safety in kids, but the JUPITER data was in adults. In the meantime, those teens at high risk still must be dealt with cautiously until better data is available.

    A close analysis of the data shows that the increased incidence of diabetes really only occurs in those at risk for diabetes in the first place. In other words, those people would likely be diagnosed with diabetes anyway at some point in the near future (in which case, they would need a statin). All subsets benefited from the statin with lower risk of cardiovascular events.

    Here is an exert from a good discussion on the adult data…(http://www.nlm.nih.gov/medlineplus/news/fullstory_128111.html)

    “”Among those with one or more major risk factors for diabetes, there were 134 fewer heart attacks, strokes and other major cardiovascular events among those who got the statin, but this came with the hazard of 54 new cases of diabetes being diagnosed. This group is already at high risk for getting diabetes, a group who are already considered candidates for statin therapy,” …

    Patients taking statins who were not at risk for diabetes had a 52 percent lower risk of developing heart disease and no increased risk of developing diabetes, the research team added.

    “Among those with no risk factors for diabetes, there were 86 fewer heart attacks, stroke and other major vascular events among those who got the statin as compared to placebo, with no new cases of diabetes at all. So, for this group, there was cardiovascular benefit with no diabetes risk”

  33. nybgrus says:

    Indeed you are correct SH. My concern though is how would this actually manifest in kids? I think it can be argued any way – they will be less likely to develop diabetes, they will be more likely, just as likely, will develop it later in life anyways… there is just no data to support any particular conclusion. And the lifetime risk of diabetes is the real issue – having diabetes (even well controlled) for 40 or 60 years is different than having it for 10 or 30 years. There is also the pragmatic issue – we can make sure kids are pretty compliant with meds until they are 18. Then what? I could envision a precipitous drop in compliance and consequently significantly worse outcomes. Will that happen? I can’t say, but the possibility is another reason for me to be cautious without evidence to back me up.

    I would agree that what we do know makes it reasonable to lean towards statin therapy being useful in this case, but we simply can’t say for certain. I tend to think that for screening programs we need to limit them to cases where the evidence is reasonably clear with a demonstrated benefit. Obviously kids with familial hypercholesterolemia and strong family histories of cholesterol abnormalities are exceptions. Screening those kids makes sense, but not universal screening, IMO.

  34. BillyJoe says:

    Nybgrus,

    I think you’ve mistaken SM for SH (or a typo?).

    “I tend to think that for screening programs we need to limit them to cases where the evidence is reasonably clear with a demonstrated benefit”

    I would put it stronger.
    There must be a demonstrated clear benefit above risk for a test to be used as a screening test.
    Because, once implemented, it becomes almost impossible to stop a screening test when the evidence eventually does come through and indicates that it is a waste of time, money, and manpower.

  35. nybgrus says:

    Good eye BJ. Yes, I was writing mobile sitting in the ER between patients and did indeed not realize it was SM (new guy? or have I been making this mistake for a while now? LOL) and not SH.

    In any event, I would tend to agree with you. As we have seen from the mammography screening debacle, even though there is still utility and the original rationale was solid, changes in treatment and diagnosis necessitated changes in screening modalities and yet hit a brick wall. I know of breast cancer surgeons who simply don’t care and think that recommending screening as before is still the way to go. Interestingly they don’t seem to have this issue when the new guidelines came out regarding axillary dissection. I think everyone – inluding physicians – underestimate the negative aspects of screening tests and over-hype the positive aspects.

  36. mousethatroared says:

    BillyJoe – Oh I’m glad you pointed that out. I was making the same mistake….far too many skeptical folks around here…I think I will change my name to CredulousMouse (anyone who thinks this is redundant hasn’t ever meet my mouse)

  37. mousethatroared says:

    Although, the the two Skepticals seem to have very similar concerns. A bit confusing.

  38. BillyJoe says:

    Michele,

    (Regarding “the mouse that roared”)

    My avatar on the JREF forums is a little mouse carrying a big pencil. It doesn’t quite mean “the mouse that roars”, but rather a person with no special talents who is going to give his opinion anyway. It arose because everyone else on the board seemed to be scientists of some description (this was in the early days, but things have deteriorated significantly since then), and I found that giving my plainly stated but relatively uneducated opinion led to some of those scientists correcting and educating me on things like relativity, quantum physics, and how to interpret clinical trials.

  39. mousethatroared says:

    BillyJoe – Yes, that’s the thing that reading a book or article about a topic lacks. A discussion with a knowledgable person gives you the opportunity to see if and/or where you’ve got it wrong. Sometimes it’s just more engaging to learn in a discussion.

    Sometime taking the risk of being corrected or glaringly wrong is intimidating. But I remember what my brother in law said when he was helping teach me to ski. “If you ain’t falling, you ain’t learning.”

    But, strangely enough my screen name was not intentionally a commentary of any approach or view that I have. I wanted to change my nym (for reasons unrelated to this board, really not trying to be a sock puppet*) and I have a mouse who looks like she is roaring when she yawns, tied to the old movie name, so that I’ll remember it. I suppose one could go on about subconscious influences, etc, like the art historians like to do with famous artists, but I’m always skeptical of that stuff.

    *as much as “sock puppet” makes me happy.

  40. BillyJoe says:

    Yes, I love it when I’m wrong and understand that I am wrong from what the other person has said, because then I’ve learnt something. I don’t even care if they heap abuse in the process because I can look past that to the lesson learnt.

  41. mousethatroared says:

    BillyJoe – Personally I’d rather not be abused. :) But then I seldom ski black diamonds and try quite hard to fall on my butt rather than my bad shoulder. This is why I don’t frequent some of the blogs where abusive comments are as common or more than reasoned ones.

  42. BillyJoe says:

    I think it helps if you think about the abuse are not saying anything about you, but about saying a great deal about the abuser. Also, I think it is amusing that someone will get so hot under the collar about someone they’ve never met except via the Internet. And (with the exception of Jeremiah, who tried to find out who I am and hinted at harming me and my family), I never get upset by anonymous people posting abuse on Internet forums. But, yes, I do prefer forums where views are exchanged instead if insults.

  43. mousethatroared says:

    My problem is that I sometimes find it more upsetting to think about what the abusive comments say about the commentor than I do to think about what those comments say about me.

  44. Children (and everyone else) need foods without artificial ingredients and toxins. I’d like to see that tried, and see how their cholesterol measures. Eating oatmeal for a month or so actually worked for me also. Red Yeast Rice I understand is a good possibility… I hope no one is thinking to start children on statin drugs…I certainly hope that’s not ‘on the table’…

    http://www.stopagingnow.com/products/hhealthyheart9?utm_source=san&utm_medium=special&utm_content=a&utm_campaigncontrol=6_30_12
    Experts agree that statins severely deplete levels of CoEnzyme Q10 (CoQ10), which is very dangerous for your heart as it needs CoQ10 for optimal performance. A Columbia University study found that within 30 days of statin therapy, your levels of CoQ10 can be decreased by half. Not only does CoQ10 help your heart, it boosts energy throughout your system and helps fight fatigue. In addition, CoQ10 helps to reduce muscle-related pain and weakness, which are major side effects of statin drugs.

    http://www.aniota.com/~jwhite/poison.html

    After taking a statin drug for just a few months I was stricken with the most horrific cramps. They seemed to lock up my entire body, leaving me almost screaming in pain. In comparison, ordinary muscle cramps were a walk in the park. The first thing my doctor said was to stop taking the statin drug. My cramps stopped immediately, and I thought that was the end of it.

    http://www.liveinthenow.com/article/new-study-finds-statin-drugs-accelerate-hardening-of-arteries?utm_source=san&utm_medium=newsflash&utm_content=a&utm_campaign=08_28_12abox

    Emerging research is showing that statins are not the wonder drugs they were once thought to be. Their effect wears off quickly if you stop taking them, they do little to raise good cholesterol and while they make your “numbers” look good, they actually do little to decrease cardiovascular related deaths. In fact, a recent study published in the British Medical Journal found that for every 10,000 people, there were only 271 fewer cases of heart disease, proving that statin drugs are less effective than once thought. At the same time, the study showed that there were many more side effects than expected, which has led to a growing number of people who are skeptical of statins.

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