RAY SUAREZ: More than 1 out of 3 American children is considered overweight or obese. Doctors have been considering the best ways to fight what many now call an obesity epidemic.
The most influential pediatricians’ group has released its strongest guidelines yet to tackle the problem. The American Academy of Pediatrics recommends “cholesterol screenings for children who are 2 years or older, if they have a family history of cardiac disease or have one of several other risk factors; greater use of cholesterol-lowering drugs, such as statins, for a select group of kids who are eight or older at risk; and lifestyle and diet changes, even among the youngest children.”
For more, I’m joined by Dr. Sarah Clauss, a pediatric cardiologist who works with obese children and those with heart problems at Children’s National Medical Center in Washington, D.C.
And if you go to the pediatrician routinely with your child, how do you know whether your kid is one who should get this second look, this extra screening?
DR. SARAH CLAUSS, Pediatric Cardiologist: Some of the risk factors that you need to look for or ask for as a pediatrician or a cardiologist are, first, is there a family history of heart disease, especially premature heart disease in men younger than 55 and women younger than 65? Sometimes the parents don’t know, so that would also be a reasonable approach to screen the children at that point.
Is the child overweight or obese? Is there a history in the child of hypertension or diabetes? Those children need to have screening for high cholesterol.
Identifying problems early
RAY SUAREZ: What this report does is push down the age range where we start asking a lot of these questions. Is that basically it?
DR. SARAH CLAUSS: It just emphasizes and restates in these guidelines that it's important to ask, and it's important to ask it early, because the earlier that we find out about it and identify it in the children, the earlier we can start treating, and so it really underscores that this is a problem in kids. And the earlier we can really start treating it, the better off we'll be in the long run.
RAY SUAREZ: Now, these are normally problems we associate with middle age. Are they presenting now in large numbers of children?
DR. SARAH CLAUSS: The cholesterol is presenting in large number in children. Children are not going to have myocardial infarctions or strokes, but they will their precursors to that.
So that the plaques and the abnormalities that lead up to those big events start in childhood, and so if you can prevent having high cholesterol, you can possibly change the future events as an adult.
RAY SUAREZ: So not the diseases themselves, but a sign of who's going to have that trouble later in life?
DR. SARAH CLAUSS: Right, correct, so the precursors of the disease, so the plaque formations and the thickening of the arteries starts as a child.
RAY SUAREZ: How do you make the decisions about using cholesterol-lowering drugs?
DR. SARAH CLAUSS: Right now, there are guidelines that were published in 1992 and these more recent guidelines, so first to suggest who should get screened, and then there's a specific LDL, or the bad cholesterol type values, that lead us to treat or not treat.
First of all, anyone that comes in with an abnormal LDL cholesterol gets recommendations and treatment, in terms of what they should be eating and the lifestyle modifications that they need to have, and then a sub-select group of those children get treated with medication.
RAY SUAREZ: So, first, you try to modify diet and physical activity and try all of that and, only if that doesn't work, resort to the drugs?
DR. SARAH CLAUSS: Correct. Correct. So the first line of treatment is diet and exercise. Typically, the diet component is undertaken with a nutritionist so that we make sure that the kids receive the nutrients they should, while having a diet low in fats and carbohydrates. And then, if their LDL values are still extremely high, then we start the medications.
Data show statins safe for children
RAY SUAREZ: How do you make the judgment over whether it's better to wait until these changes take effect or whether it's more important to get these numbers down using the drugs?
DR. SARAH CLAUSS: We typically know that diet and lifestyle modifications can take up to six weeks to work, so we'll give that a try first. And we try to make sure that the patients really do make an effort to change their diet and to increase their activity.
If it still doesn't work and their LDL value is greater than 160 milligrams per deciliter, and they have a family history or they have obesity or other risk factors, hypertension, diabetes, we will start medications.
If there's no family history, no risk factors, we let the LDL at this point be 190 milligrams per deciliter before we start medication.
RAY SUAREZ: Is there enough data so that we know how these drugs work in children's bodies?
DR. SARAH CLAUSS: We have data on the statins showing that there is no short-term effect, in terms of their growth velocity or puberty development. Also, there doesn't seem to be any increased risk or difference in the way kids respond, in terms of abnormal liver function tests or muscle enzymes.
So the data suggests that it's very safe to use and efficacious. Certainly there is no long-term data, so the kids that we're starting on medications now at age 10 presumably are going to be on cholesterol-lowering medications over a lifetime.
We don't have that data, but we have the short-term data to show that it is safe.
RAY SUAREZ: Well, do children's bodies metabolize drugs differently from the way adults do?
DR. SARAH CLAUSS: Typically, children's medications are dosed in how many kilograms or how much they weigh. But in the statin drugs, we typically use the low-end dose of what is recommended for adults, and then we can go up from there if we need.
Changes in pediatrics
RAY SUAREZ: Now, what's changed about American life that you're suddenly seeing this large number of kids who need this kind of treatment?
DR. SARAH CLAUSS: Up until now, most of the kids that have been treated have had genetic difficulties, so they have an abnormal lipid metabolism, and so they've needed the medication.
The thing that's different now is that more and more children are obese and overweight, have high blood pressure, insulin resistance, so a combination of things that make them more at risk for having cardiovascular disease as adults.
RAY SUAREZ: Now, these are, in some cases, tests that weren't recommended, even a few years ago, until young people were 20 years old or pushing 20 years old. Now we're talking about 2-year-olds, 6-year-olds, 8-year-olds.
Does this add to the cost profile? Does it add to the way we're going to start treating children in this country?
DR. SARAH CLAUSS: I think testing children earlier won't add to the cost overall. In fact, it will help, because we're going to be able to identify, and treat, and hopefully prevent adult-onset-type disease and hopefully safe money in health care down the road.
RAY SUAREZ: And does it change the job of a pediatrician? I know that pediatricians talk with parents a lot about what very young children eat, but then, after that, maybe talk a little less about diet.
DR. SARAH CLAUSS: The pediatricians have a hard job to do. They have to talk about a lot in a short encounter. And so they do need to be more vigilant about screening children, who not only have a family history, but now have obesity or are just overweight, have high blood pressure.
And so they'll probably add that to their encounter, and it'll make it longer, but then they can refer those patients to us for more specialized treatment.
Diet, exercise have biggest impact
RAY SUAREZ: And as a clinician in this area, what will you want to see in the next two years, four years, six years to help you know whether this was the right set of moves to make right now?
DR. SARAH CLAUSS: I'd like to see us win in the battle of overweight and obesity and see more kids be healthier, have a better lifestyle, eat healthier meals, and show that, in terms of their cholesterol profiles, having a low LDL or bad cholesterol, having a high HDL or good cholesterol, having normal triglycerides.
So I think these encounters will let us really teach kids about being healthy and have an impact down the road.
RAY SUAREZ: So you could do more with lifestyle control and not have to resort to the drugs in many of these cases?
DR. SARAH CLAUSS: Absolutely. In most of the cases that is a lifestyle and diet discussion. I find that a lot of kids rely on eating breakfast and lunch in school, which is a problem. And most kids rely on school for all their physical activity for the day.
Some kids have P.E. class once a week. You need to have at least 60 minutes of exercise five times a week. Most kids don't do that.
And so, while it seems like it's not a lot, you really have to talk to people about making it a homework assignment. It needs to be something they do every day. Otherwise, they don't. They find themselves doing homework or watching television.
RAY SUAREZ: Sarah Clauss, Dr. Clauss, thanks a lot.
DR. SARAH CLAUSS: Thank you. Nice to be here.