Case Study: Universal Screening and Obesity-related Dyslipidemia

A 12-year-old male presents to the Lipid Heart Clinic for evaluation of mixed dyslipidemia. The patient had his lipids first checked at age 10 as part of universal screening. At that time, his triglycerides (TG) were elevated to 231 mg/dL. He was told to “work on his diet.” The labs were not rechecked until 2 years later. Mom notes he had a significant weight gain over the past 2 years. Family history is unremarkable for early heart disease or hypertriglyceridemia. The patient’s diet consists of: for breakfast, high-sugar cereal or frozen French toast and chocolate milk; for lunch, turkey sandwich with cheese on white bread, chips, and iced tea or juice; for snack, cookies or pudding; for dinner, a lean meat, mashed potatoes or pasta, a vegetable, and juice; for dessert, occasional ice cream. He does not participate in sports, but has gym class daily and rides his bicycle in the summer. His sedentary time is 2 to 4 hours daily.

On physical exam, his height is at the 57^th percentile, weight at the 97^th percentile, and BMI at the 98^st percentile, placing him in the obese category. His blood pressure is 107/64 and his pulse is 89 bpm. Notable examination findings include faint abdominal striae and acanthosis nigricans behind his neck. The remainder of the examination is normal. His fasting lipid panel revealed (in mg/dL): total cholesterol (TC) 238, HDL-C 39, LDL-C N/A, TG 449, and non-HDL-C (TC minus HDL-C) 199.

Universal screening

The most recent guidelines for screening children and adolescents for dyslipidemia were released in 2011. The biggest change was the recommendation for universal screening once between the ages of 9 and 11 years and, if no issues, again between 17 and 21 years (Kavey). Universal screening can be performed using either a non-fasting lipid profile (non-FLP), where TC and HDL-C are obtained and non-HDL-C is calculated, or a fasting lipid profile (FLP) can be obtained. If there are abnormalities on the non-FLP (see Tables 1 and 2), then the average of 2 FLPs should be used to determine if further treatment is necessary. However, if there are abnormalities on the initial FLP (see Tables 1 and 2), then a repeat FLP should be performed 2 weeks to 3 months later, and the results of the both tests averaged.

Lipid screening guidelines

< 2 Years

No screening

2–8 Years

No routine screening
Screening if:
Family history of early heart disease
Parent has TC > 240
Family history is unknown
High risk condition (see risk factors below)
Laboratory tests to obtain: FLP × 2*

9–11

Universal screening
If non–HDL-C > 145 or HDL-C < 40
Laboratory tests to obtain: Non-FLP, then obtain FLP × 2*

If LDL-C > 130 or non–HDL-C > 145 or
HDL-C < 40 or
TG > 100 (age < 10 yrs) or > 130 (age > 10 yr )
Laboratory tests to obtain: FLP, then obtain Repeat FLP*

12–16

No routine screening
Screening if:
New knowledge of CVD risk, same as 2–8 yrs
Laboratory tests to obtain: FLP × 2*

17–21

Universal Screening

17–19

If non–HDL-C > 145 or HDL-C < 40
Laboratory tests to obtain: Non-FLP, then obtain FLP × 2*

If LDL-C > 130 or non–HDL-C > 145 or
HDL-C < 40 or
TG > 100 (age < 10 yrs) or > 130 (age > 10 yrs)
Laboratory tests to obtain: FLP, then obtain repeat FLP*

17–21

If non–HDL-C > 190 or HDL-C < 40
Laboratory tests to obtain: Non-FLP, then obtain FLP × 2*

If LDL-C > 160 or non–HDL-C > 190 or
HDL-C < 40 or TG > 150
Laboratory tests to obtain: FLP, then obtain repeat FLP*

CVD, cardiovascular disease; FLP, fasting lipid profile; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; TC, total cholesterol; TG, triglycerides.

*Second lipid profile should be obtained 2 weeks to 3 months after the first lipid profile obtained.

Values are measured in milligrams per deciliter.

Selective screening should still occur between the ages of 2 and 8 years and/or 12 and 16 years if certain risk conditions are present.

• Hypertension receiving drug therapy    
• Cigarette smoking
• Severe obesity (BMI ≥ 97th percentile)
• Diabetes (type I and type 2)
• Chronic/end-stage kidney disease/post-renal transplant
• Postorthotopic heart transplantation
• Kawasaki disease, currently with aneurysm

• Hypertension (blood pressure > 95th percentile for gender and age) not requiring drug therapy
• Obesity (BMI ≥ 95th percentile, but < 97th percentile)
• HDL-C < 40 mg/dL
• Kawasaki disease with regressed aneurysm
• Chronic inflammatory disease
• HIV infection
• Nephrotic syndrome

BMI, body mass index; CVD, cardiovascular disease; HDL-C, high-density lipoprotein cholesterol.

Adapted from Kavey RE, Simons-Morton DG, de Jesus JM, suppl eds. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report. Pediatrics 2011;128:S213-S256.

Obesity and dyslipidemia

Obesity-related dyslipidemia is characterized by high TGs, low HDL-C, and mild-moderately elevated LDL-C and non-HDL-C levels. This form of dyslipidemia generally improves with focused dietary changes, weight loss or weight stabilization, and aerobic exercise. A complete dietary history is imperative, with the emphasis not only what the child eats, but also what the child drinks throughout the day. Simple carbohydrates should be replaced with complex ones. Sugar-sweetened beverages, including 100% fruit juice, should be eliminated from the diet. Children should be encouraged to increase fish intake, focusing on fish that are low in mercury and high in omega-3 fatty acids. Other lifestyle changes should also be encouraged, including weight management, decreasing sedentary time to less than 2 hours daily, and increasing physical activity with a goal of at least 1 hour daily of moderate to vigorous activity. An FLP should be repeated 3 to 6 months after diet and lifestyle changes. If a repeat FLP continues to show elevated TGs or non–HDL-C for age (see Table 1), then a more restrictive diet is necessary. These children should be considered for referral to Lipid Heart Clinic, where they will also meet with a registered dietitian.

Patient follow-up

Six months later, the patient returned to clinic. He stopped drinking sugar-sweetened beverages, changed to skim milk from 2% milk, and increased his vegetable intake. He had joined the soccer team and also lost 15 pounds. His most recent lipid panel had almost entirely normalized and showed (in mg/dL): TC 170, HDL-C 40, LDL-C 102, TG 139, non-HDL-C 130.

References and suggested readings

Kavey RE, et al. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report. Pediatrics. 2011;128:S213-S256.

Gidding SS, Dennison BA, Birch LL, et al. Dietary recommendations for children and adolescents. A guide for practitioners. Consensus statement from the American Heart Association. Endorsed by the American Academy of Pediatrics. Circulation. 2005;112:2061-2075.