Back in November 2011, a panel of experts assembled by the National Heart, Lung and Blood Institute (NHLBI) in the US published recommendations regarding cholesterol screening in children. The panel recommended that all children aged 9-11 should be screened, and that more targeted testing (in those deemed to be at high risk) should be used in 2-8 year-olds and 12-16 year olds. These recommendations risk making millions of American children into patients with their diagnosis of ‘dyslipidemia’ (disordered blood fat levels). Many may end up on cholesterol-reducing medication, of course, which is not without risk. And what evidence is there that this strategy will reap dividends in the long term?
The problems inherent in the NHLBI panel recommendations were made plain this week in an on-line article penned by three doctor-researchers at the University of California in San Francisco which appeared on-line in the journal Pediatrics . In the piece, the authors draw our attention to the fact that the guidelines are simply a matter of opinion, albeit supposedly ‘expert’ opinion. The fact of the matter is that there has been no proper study which assesses the benefits (or otherwise) of screening children or the recommendations that may come out of this screening.
Not only this, but there has been simply no effort to quantify the costs of such an endeavour. So, in addition to not knowing whether the proposed strategy would even work, we have no idea what it would cost and are therefore unable to determine if it offers value for money (and if that money might be better spent elsewhere).
The authors of the article also draw our attention to the fact that there were significant financial conflicts of interest to be found in the NHLBI panel. The website sciencedaily.com reports here that:
The authors [of the article] note that the panel chair and all members who drafted the lipid screening recommendations disclosed an “extensive assortment of financial relationships with companies making lipid lowering drugs and lipid testing instruments.” Some of those relevant relationships include paid consultancies or advisory board memberships with pharmaceuticals that produce cholesterol-lowering drugs such as Merck, Pfizer, Astra Zeneca, Bristol-Myers Squibb, Roche and Sankyo.
“The panel states that they reviewed and graded the evidence objectively,” said Newman [Thomas Newman – one of the authors of the article]. “But a recent Institute of Medicine report recommends that experts with conflicts of interest either be excluded from guideline panels, or, if their expertise is considered essential, should have non-voting, non-leadership, minority roles.”
Evidence is needed to estimate health benefits, risks and costs of these proposed interventions, and experts without conflicts of interest are needed to help synthesize it, according to Newman. He said that “these recommendations fall so far short of this ideal that we hope they will trigger a re-examination of the process by which they were produced.”
Pediatrics also published on-line this week a rebuttal to this article co-written by several of the panel members, including its chairman Dr Stephen Daniels . Here Dr Daniels (who has worked as a consultant or advisory board member for several cholesterol drug manufacturers including Abbott Laboratories, Merck and Schering-Plough) is quoted as saying that he feels industry ties did not influence the debate among panel members. He can say what he likes, but common sense suggests otherwise, as does the distinct lack of rigour in the panel’s recommendations.
In the linked article, the NHLBI’s acting director and the person who convened the panel, Dr Susan Shurin, tells us that there are few qualified specialists which have no industry relationships. This perhaps goes to show just how the effective the industry can be in sewing up an area and ensuring it gets the ‘expert’ opinion it wants.
“We got the best people in the country to do this,” Dr Shurin is quoted as saying. What a shame the ‘best people’ come with so many of conflicts of interest attached, and that their recommendations are set to convert millions of kids into patients despite there being simply no good evidence that this will benefit them or society in general.
1. Newman TB, et al. Overly Aggressive New Guidelines for Lipid Screening in Children: Evidence of a Broken Process. Pediatrics Published online July 23, 2012(
2. McCrindle BW, et al. Guidelines for Lipid Screening in Children and Adolescents: Bringing Evidence to the Debate. Pediatrics Published online July 23, 2012