With a continuing obesity epidemic among kids and teens, some pediatricians are turning to tools that, in the past, have been used mostly to help adults.
Dr. Carlos Lerner relies on a graph – with columns of "hamburgers" – to illustrate how often doctors check their patients' BMI (or body mass index, a ratio of weight to height).
"Residents often tell me they think a child is not overweight, and I ask them to actually calculate BMI and plot it on the charts we have," he says. "And they're surprised to see the kids are technically overweight even though visually they might look normal because really being overweight is the norm."
Lerner says about one-third of the teenagers seen at the UCLA pediatrics clinic are overweight. And so are lots of younger children. Being overweight puts these kids at risk for a host of related problems – everything from diabetes to premature heart disease and high cholesterol. Doctors at UCLA are increasingly aware of that potential. Says Lerner: "Cholesterol wasn't on our radar screen until fairly recently as a commonly obtained test and now it's become a fairly common screening test in pediatrics."
Cholesterol levels are routinely taken for kids who have a family history of heart disease or diabetes. But now, Lerner says, cholesterol levels are also taken when kids are overweight or obese.
And, as with adults, doctors get concerned if overall cholesterol levels top 200.
They should be concerned, says cardiologist Gregg Fonarow, who runs UCLA's heart disease prevention program.
"We really now have definitive evidence that heart disease can begin early in children and adolescents," he says. "There's evidence that cholesterol buildup in arteries, the precursor for heart attacks occurring, can be seen in children with risk factors, and there is evidence now that it progresses over time and ultimately can result in premature heart disease in these individuals."
Fonarow points to studies of children who died prematurely of other causes. Autopsies show early lesions or fatty streaks in their arteries. "You can actually see on autopsies this fatty area on the artery wall that normally should not be there," he says. "Those lesions progress and become the full-blown plaques that rupture and cause heart attacks."
Fonarow says that for many of the adult patients he sees in cardiac rehab, heart disease likely started as early as childhood or adolescence.
For kids who are diagnosed with high cholesterol, the first line of defense, says Lerner, is the same as it is for adults: diet and exercise. The problem, he says, is that today's efforts to help kids lose weight and lower cholesterol just aren't good enough.
"Programs should contain several elements, not just the pediatrician but a multidisciplinary approach that includes an exercise physiologist, a mental health professional and a nutritionist," he says. "Any weight loss program for kids has to be intensive so the family and the child get support several times a week for at least six months."
Lerner and colleagues at UCLA work with what they have – talking to parents during yearly well child visits, trying hard to convince them and their kids to change their diet (eat less fatty fried and fast foods), and to get out and exercise more. But if that fails and, after six months or so, cholesterol levels are still high, Lerner considers medication – the same type of statins to lower cholesterol that are prescribed to adults. The problem, he says, is that there are no long-term studies showing these medications are safe if taken for years and years.
"If we're diagnosing a 10-year-old with high cholesterol, does that mean they're taking medications for 60 to 70 years?" he asks. "We don't have the kind of information we need to say this is valuable and safe. This is unchartered territory, really."
Lerner says large clinical trials that follow kids for a long time, for 20 – even 30 – years, are needed to make sure these cholesterol-lowering medications are safe and even needed to be taken permanently.