Reducing dietary intake of fat and cholesterol in children

National trends in the management of cardiovascular disease risk factors in children: second NHLBI survey of primary care physicians

BACKGROUND

The evidence that atherosclerosis begins during adolescence has led to the belief that primary prevention of cardiovascular disease (CHD) should commence in childhood. Although several national guidelines have been issued for the detection and treatment of CHD risk factors in children, concerns continue to be expressed regarding what constitutes appropriate measures and when to institute such measures in children. A 1988 national survey of primary care physicians revealed variation in the management of CHD risk factors in children by physician categories, which suggested the underlying quandary among physicians regarding CHD risk factors in children.

OBJECTIVE

To assess current clinical management of pediatric CHD risk factors in the primary care setting and also to evaluate time trends between the current and 1988 surveys.

METHODS

A 25-minute telephone survey was conducted with 1036 of eligible physicians (ie, >20 hours per week direct patient care including at least five pediatric patient contacts) selected from a national probability sample in three practice categories (family practitioners, pediatricians, and general practitioners). The questionnaire assessed the current practice of these physicians in the primary care setting regarding cholesterol and blood pressure (BP) screening and treatment, both nonpharmacologic and pharmacologic, and physician attitude and knowledge.

RESULTS

Cholesterol screening in children was performed by 75.7% of all physicians. Nonscreening was highest among general practitioners (38%) and lowest among pediatricians (12%). BP was measured by almost all physicians. The majority of physicians (71%) prescribed diet as the first cholesterol-lowering step, but approximately 16% also used pharmacologic therapy. Cholesterol synthesis inhibitors and bile acid sequestrants were the drugs used most commonly. Approximately 25% of physicians have used drugs in children to treat high BP. Diuretics and beta-blockers were used most frequently. More than one fourth of the physicians had some concern about identifying and treating children for CHD risk factors. There was slightly less cholesterol measurement in 1995 compared with 1988, and no notable increase in the knowledge regarding major CHD risk factors.

CONCLUSION

The results of the second National Heart, Lung, and Blood Institute survey of primary care physicians suggest that additional inroads need to be made in the dissemination of the national guidelines for the management of CHD risk factors in children, including appropriate use of pharmacologic agents.

A rational approach to treating hypercholesterolaemia in children. Weighing the risks and benefits

Because atherosclerosis is a continuous process throughout life, expert panels have suggested guidelines to reduce the risk of cardiovascular disease, starting from childhood. The guidelines focus on population-based measures and on treating hypercholesterolaemia in individual children. Low-fat diets in children have been widely debated. There is little evidence that growth is stunted or that nutritional deficiencies arise if the energy that is lost by limiting fat intake is substituted with other nutrients. Dietary fibre, plant sterols and fish oils have been used to modify lipid levels in children; however, the efficacy of these dietary adjuncts is limited. Bile acid-binding resins are the only approved drugs to lower cholesterol levels in children and appear to be well tolerated. However, compliance with resins is low because of unpalatability, so low dosages are preferred and vitamin supplementation is prudent. Data on HMG CoA reductase inhibitors and fibrates are insufficient to recommend these drugs at present. Drug treatment should be restricted to children who are at exceptionally high risk of disease, usually those with genetic dyslipidaemias.