Cholesterol Management in Children

HOW THE PREVALENCE OF OVERWEIGHT CHILDREN IS IMPACTING THEIR HEALTHS.

You are listening to ReachMD, the channel for medical professionals.

Hi, this is Dr. Anne Goldberg, President of the National Lipid Association and I would like to welcome you to Lipid Luminations hosted by Dr. Larry Kaskel presented by the National Lipid Association.

Childhood obesity is growing exponentially; the number of overweight children has increased by 45% since 1984. With me today is Dr. Don P. Wilson, a pediatric endocrinologist and chair of pediatrics at Texas A&M Health Science Center College of Medicine to discuss how the prevalence of overweight children is impacting their health.

DR. LARRY KASKEL:

Dr. Wilson, welcome to the show.

DR. DON P. WILSON:

Thank you.

DR. LARRY KASKEL:

I would like to start by just having you answer, is measuring obesity in children different than in adults.

DR. DON P. WILSON:

Somewhat, we are dealing with a population that is growing and maturing, so we have to adjust our thinking a little bit in terms of that dynamic so most of the time we present information relative to a percentile rather than absolute number you know and in the adult world, we use BMIs commonly 13 above, 14 above for morbid obesity, but in children we usually have to refer to a chart that is gender specific and age specific.

DR. LARRY KASKEL:

So, it seems that our genes have not changed that much and obviously our environment has. Is it safe to say that if our grandparents would not recognize the ingredients on a food product, we should probably not consider it food and not give it to our kids?

DR. DON P. WILSON:

Well, it is a complex question in terms of what causing or what is fueling this environment. A simple answer to your question is that you have a genetic propensity to have obesity or obesity-related complications like cardiovascular disease or diabetes; you can always make a bad situation worse. You can make it worse by becoming sedentary, you can make it worse by having a very poor diet. Unfortunately, if your look around our current environment that is pretty much what we have surrounded ourselves with, things that make our lives easier, that decrease physical exertion and then most of our foods are very high in content with sugar or fats.

DR. LARRY KASKEL:

So, you are in the trenches obviously, you are seeing this daily, are you overwhelmed and how do you even begin to make an impact.

DR. DON P. WILSON:

Yeah, pretty much you know, that is one of difficult task with trying to encourage our primary care colleagues to bring this topic up during relatively brief encounters with children checkups or well-child checkups because it takes a lot of time and energy to try to motivate people and the vast majority of people we see, the entire family needs to be involved in that because most of them are all involved to some degree, but they also, the kids need the encouragement of the parents. The parents need to be good role models for children.

DR. LARRY KASKEL:

So, what can a primary care provider do in that 3 minutes he has to focus at the end of the visit. What can he say to get through to the parents when the parents are obviously not caring about their weights?

DR. DON P. WILSON:

To their benefit and credit, I don’t think they can solve your obesity problem in their offices. I think there are probably 3 categories of children that I see commonly in my practice and that is the children who are relatively young, at present time are not yet born and the opportunity is there for prevention. If you go to the other extreme, we know the data in terms of tracking it. If you look at the children who are currently obese, the vast majority of those kids are going to be obese and they are going to have the same risk factors as an adolescent as they do now. So, I am not conceding that group, but I am saying it is going to be a much harder task to get those kids turned around and the middle group is the one that I think deserves the time and attention because there is an opportunity to get those kids refocused. It is going to take more than just the exam room discussion, it is going to take a community to get involved, community activities, community education, and to some degree there may have to be legislation as you have already seen.

DR. LARRY KASKEL:

Dr. Wislon, what kind of blood work are you seeing regularly in obese kids that is shocking to you.

DR. DON P. WILSON:

For the last may be 10 year or so, we have actually taken a little bit more aggressive approach to screening children. You may now the current recommendations have to do, at least the historic recommendations had to with listening to family histories and assessing risk and so forth, but it became apparent to us from just the children referred to our Endocrine Clinic, all these kids who have BMIs over 95 percentile really needed to be screened. So, it is not uncommon that you see a cholesterol level that are in the 200s, occasionally 300s, but certainly at the 200 levels and then the thing I think primary care physicians need to understand is that the most common thing you are going to see in that adolescent obese group is going to be high triglycerides and low HDL. What that is not telling you is that the HDL has been altered, and so has the LDL, so the chemists talk about small dense LDL particles. It means that they are more iatrogenic, so we called that take your finding where you have high triglycerides and low HDL, iatrogenic dyslipidemia. It is a good handle because it is telling you that pathologically that is going to play out over time but we cannot ignore that because we always sort of say well that is just related to the child's weight. If we can get them to lose weight, then that will improve, but that may or may not be true because the weight loss thing is a real problem.

DR. LARRY KASKEL:

If you take that patient with that triad that you discussed and you put them on a virtually carbohydrate-free diet, will you see those numbers correct without putting them on any sort of lipid medicines.

DR. DON P. WILSON:

There is a good chance actually where you see significant improvement, now whether they entirely go away or not, I do not know because I think you have do a little more global assessment, for example, familial hypercholesterolemia. It is very common. So, it is likely in my mind that you are going to have somebody who has got both familial hypercholesterolemia i.e. reduced LDL receptors plus obesity or they may actually be prediabetic or have a family history predisposition to diabetes. So, I think it is not a simple answer, but the answer is it significantly will improve. The other thing as you start looking at these kids, you find a fair number of them have altered liver function studies, you could do any kind of imaging study, you will find a lot of these kids have fatty livers and so forth. There is kind of a snowball effect here after a while. But the disappointing part is that, what you said was true. Lifestyle intervention is absolutely the best thing to do and the most effective and safe thing to do that has been demonstrated many, many times. The problem is that we have not been able to effectively implement that within a degree of success.

If you have just turned in, you are listening to Lipid Luminations on ReachMD XM-157, the channel for medical professionals. I am Dr. Larry Kaskel and my guest today is Dr. Don P. Wilson. He is the chair of pediatrics at Texas A & M Health Science Center College of Medicine and we are talking about the dangers of childhood obesity.

DR. LARRY KASKEL

Dr. Wilson, what are the current guidelines for lipids and do you think they need to be changed or revised or they just happen.

DR. DON P. WILSON:

Well actually this just happened because those guidelines were initiated with the infant guidelines back in 1994. We saw a lot of things that changed since that time. For example, new data now suggests that there should be more emphasis on the negative effects of things like excess intakes of saturated fatty acids, transfats, cholesterol. That information on children was really available many years ago. Also, what you learn is that the excess intake of carbohydrates, so if we focus or have <_____> focus on decreasing fat in diet, they almost always replace that by carbohydrate. We call that carbohydrate often gets stored as fat, and so this is kind of a vicious cycle there and then more recent data suggests that there is need to probably step back and look at the efficacy that certainly will examine the safety of lipid-lowering medications in children. The older guidelines suggest that there was a very targeted population and we still believe that where kids have FIH for example, those started at age 10 and above, now we know that. It is relatively safe to do that in kids 8 years in age and older, but we broaden the definition now from what you said to include kids that are other risk categories, for example those who are clearly overweight or obese, kids who have prediabetes or metabolic syndrome, kids who may need to be treated with HIV drugs that increase lipid levels somehow post transplantations, etc.

DR. LARRY KASKEL:

Well you know back to the prescribing of medication for someone who is 8 year's old, I find in my practice when I give any medication, I am kind of enabling that patient to really not make any changes because they believe that they have a false sense of security, somehow that this medicine is sufficient and will decrease their risk of future events.

DR. DON P. WILSON:

That is a very good statement because some of our colleagues basically say the same thing, they don’t want to make it easy or sort of let them off the hook so to speak to do the right thing which is lifestyle interventions that help your lifestyles, so that needs to be ongoing, but despite our efforts, you know, the obesity thing has kind of gotten away from us over the last 15 or 20 years, so we need better strategies to do that, but I said earlier, we need to help to do that from the community and from the federal government or anybody else than can jump into it.

DR. LARRY KASKEL:

Well, what would you like the government to do? How do you think that they could help the problem?

DR. DON P. WILSON:

You know they have started that effort by first of all legislating that you have to have food labels that tell people what they are eating. Those food labels need to be truthful, so as they start acquainting that up and then making people aware of transfats for instance <_____> some <_____> that you need to get transfats out of the food, in the state of Texas for example, we have had major initiatives as have other states where they have had a mandate if you will that nutritional value at school…