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DATE DUE DATE DUE DATE DUE fiat-fiend f ‘ " ’m‘ ‘ J 1/98 alumnus-p.14 PEDIATRICIANS' ATTITUDES AND PRACTICES CONCERNING THE TESTING OF SCHOOL-AGE CHILDREN FOR CHOLESTEROL By Jeanne LaCosse A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Educational Administration 1 997 ABSTRACT PEDIATRICIANS’ ATTITUDES AND PRACTICES CONCERNING THE TESTING OF SCHOOL-AGE CHILDREN FOR CHOLESTEROL By Jeanne LaCosse This study focused on current pediatricians’ attitudes and practices regarding Cholesterol screening and intervention for hypercholesterolemia. The study was undertaken to gather information that will be helpful to school administrators, educators, parents, and health professionals in the development and implementation of cardiovascular programs to be included in health curriculums. A mail survey of 54 pediatricians actively engaged in primary care in the Lansing, Michigan, area was conducted to assess their cholesterol-screening practices and hypercholesterolemia management. Thirty-nine pediatricians responded, for a response rate of 73%. it was found that 23.1% of the pediatricians screened all of their patients for cholesterol. Most of them indicated they would manage hypercholesterolemia patients themselves, nearly always through dietary means. Despite their support for screening, the pediatricians expressed Skepticism about the childhood cholesterol level as a predictor of cardiovascular disease and doubted their effectiveness in getting patients to adopt a cholesterol-reducing diet. Their definition of elevated total Jeanne LaCosse cholesterol level was consistent with published recommendations. The pediatricians expressed strong opposition to pediatric cholesterol screening in schools or in any setting other than Clinics and hospitals. It was found that pediatricians routinely did not test blood Cholesterol in all of their patients. but they did collect family history of premature myocardial infarction or hyperlipidemia. Pediatricians thought that childhood cholesterol levels are somewhat important indicators of the risk of developing cardiovascular disease in adulthood. Pediatricians had varied Opinions on whether all children should be Checked for cholesterol levels at some time during their Childhood, as well as whether only those children with a family history of premature myocardial infarction or hyperlipidemia Should have their cholesterol levels tested. Most respondents agreed that pediatricians should be doing more Cholesterol testing in their practices. They had varied opinions concerning at what age to test for serum Cholesterol for the first time. Most pediatricians would not measure cholesterol again ifit was not elevated initially. Pediatricians agreed that lipoprotein fractions should be measured if the total cholesterol level was elevated. Pediatricians would refer patients with elevated cholesterol levels to a medical specialist. Most opposed school-based cholesterol screening programs for Children. ACKNOWLEDGMENTS To my Chairperson, Dr. Louis G. Romano, for his advice, encouragement, patience, and positive guidance. To my doctoral committee, Dr. Keith Groty, Dr. Lois Bader, and Dr. Louis Hekhuis. To my husband, Tom, who knows how and when to give encouragement and suppon. To my friend, jeanne, for her continuous words of encouragement. To my typist, Sue Miller, for her assistance. TABLE OF CONTENTS LIST OF TABLES ............................................... vii Chapter I. THE PROBLEM ....................................... 1 Introduction to the Study ................................ 1 The Problem ......................................... 2 Purpose of the Study ................................... 3 Research Questions ................................... 4 Significance of the Study ................................ 6 Delimitations and Limitations of the Study .................. 7 Definition of Terms .................................... 7 Overview ........................................... 10 ll. REVIEW OF THE LITERATURE ......................... 11 Introduction ......................................... 1 1 Childhood Beginnings of Heart Disease ................... 11 Educational-Intervention Studies ........................ 15 Know Your Body School Health Program, 1984-1988 ...... 15 School-Based Intervention Study, 1988 ................. 15 School-Site Screening Intervention, 1989-1990 ........... 17 University of Michigan Study, 1985-1991 ................ 17 Pediatricians’ Perceptions of and Attitudes Toward Children and Cholesterol Screening .................... 20 Impact of Literature on the Study ........................ 25 Ill. DESIGN OF THE STUDY .............................. 27 Research Questions .................................. 27 The Study Setting .................................... 29 The Population ...................................... 30 The Instrument ...................................... 30 Data-Collection Procedures ............................ 31 IV. ANALYSIS OF THE DATA ............................. 33 Introduction ......................................... 33 Description of the Sample .............................. 33 Findings Pertaining to the Research Questions ............. 34 Research Question 1 ............................... 34 Research Question 2 ............................... 34 Research Question 3 ............................... 35 Research Question 4 ............................... 36 Research Question 5 ............................... 36 Research Question 6 ............................... 37 Research Question 7 ............................... 38 Research Question 8 ............................... 39 Research Question 9 ............................... 40 Research Question 10 .............................. 41 Research Question 11 .............................. 42 Research Question 12 .............................. 43 Research Question 13 .............................. 44 Research Question 14 .............................. 45 Research Question 15 .............................. 46 Research Question 16 .............................. 47 Research Question 17 .............................. 48 Summary ........................................... 49 V. SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS . . . 50 Introduction ......................................... 50 Summary ........................................... 50 Findings ............................................ 51 Conclusions ......................................... 54 Implications of the Study ............................... 56 Recommendations for Further Study ..................... 57 Reflections ......................................... 57 APPENDIX ........................ ~ ............................ 60 BIBLIOGRAPHY ................................................ 75 vi 10. 11. LIST OF TABLES Number of Pediatricians Who Recommend a Test of Blood Cholesterol for All of Their Patients ............................ 34 Number of Pediatricians Who Routinely Collect Family History of Premature Myocardial Infarction or Hyperlipidemia ................ 35 Pediatricians’ Ratings of the Importance of Childhood Cholesterol Levels as an Indicator of the Risk of Developing Cardiovascular Disease in Adulthood ....................................... 35 Respondents’ Level of Agreement With the Statement That All Children Should Have Their Cholesterol Level Checked at Some Time During Childhood ..................................... 36 Respondents’ Level of Agreement With the Statement That Only Children With a Family History of Premature Myocardial Infarction or Hyperlipidemia Should Have Their Cholesterol Level Tested ...... 37 Respondents’ Level of Agreement mm the Statement That Pedia- tricians Should Be Doing More Cholesterol Testing in Their Practice ............................................. 38 Age at Which Respondents Thought the First Serum Cholesterol Test Should Be Given ...................................... 39 Respondents Who Would or Would Not Routinely Measure Cholesterol Again If It Was Not Elevated Initially .................. 40 Level Above Which Pediatricians Would Consider an 8—Year-Old Boy’s Total Cholesterol to Be Elevated ......................... 41 Number of Times 3 Cholesterol Level Needs to Be Measured to Be Certain It Is Elevated .................................. 42 Respondents’ Recommendation That the Lipoprotein Fractions Be Measured If Total Cholesterol Is Elevated ....................... 42 vii 12. 13. 14. 15. 16. 17. 18. Level of LDL Cholesterol Respondents Would Consider Elevated for an 8-Year-Old Boy ...................................... 43 Respondents Who Would Routinely Refer a Patient WIth an Elevated Total Cholesterol Level to a Medical Specialist ............ 44 Whether Respondents Would Consider Medication for an 8-Year—Old Boy With an Elevated Total Cholesterol Level .................... 45 Total Cholesterol Level at Which Respondents Would Consider Medication for an 8-Year-Old Boy ............................. 46 Respondents’ Effectiveness at Reducing the Saturated-Fat Intake of Their Patients ........................................... 47 Respondents Who Favored or Opposed School-Based Cholesterol Screening Programs for Children .............................. 48 Respondents Who Favored Locations Other Than Schools for Cholesterol Screening Programs for Children .................... 48 viii CHAPTER I THE PROBLEM Mmduflimmnefludy In the United States today, one of the leading causes of death is cardiovascular disease. Despite success in reducing coronary heart disease deaths over the last 20 years, this disease is still responsible for more than 500,000 deaths annually. Approximately 20% of hospital discharges are for premature coronary heart patients age 50 and under (American Heart Association, 1990). It is now believed that the onset of heart disease occurs early in life. This is not a newly developed concept. In the late 19503, Holman, MCGill, Strong, and Geer (1958) concluded that the arteries of infants Show changes, such as fatty streaks, that may be precursors of clinically Significant lesions in later life. The mean serum cholesterol level of American children in adolescence is about 160 mg/dl. The recommended level is 140 mg/dl (American Academy of Pediatrics, 1986). Approximately 25% of American children ages 1 to 19 have cholesterol levels that exceed 170 mg/dl (American Academy of Pediatrics, 2 1986). There are some interesting facts about Children and Cholesterol. First, children with high cholesterol levels are more likely as adults to have high cholesterol levels. Second, American children who have high Cholesterol levels live in families where more adults have myocardial infarctions. Third, American children demonstrate higher serum Cholesterol levels than young people living in countries with a low incidence of cardiovascular heart disease (American Academy of Pediatrics, 1986). Even though there is strong evidence that the atherosclerosis process leading to cardiovascular disease begins in childhood, there is considerable controversy among pediatricians regarding Cholesterol screening of children for serum cholesterol levels. In the last several years, school health education has received increasing attention from educators and health professionals. This is due, in part, to a general increased national commitment to preventive rather than curative medicine. It is hoped that, in the future, health professionals, educators, and school administrators willworktogethertodevelop and implement cardiovascular programs for children. IheEmblem For school administrators and educators to adapt cardiovascular programs for children, they must have cooperation from health professionals, including 3 pediatricians. At present, there is a great deal of controversy among pediatricians concerning children and cholesterol. Some pediatricians have advocated almost no screening, others have taken a middle—Of-the-road attitude, and still others have suggested testing all Children over the age of two. i In 1985, anational studywas doneto assess pediatricians. This study did not yield Significant information (Nader, 1985). In 1992, a study was conducted at the University of Minnesota, involving pediatricians from the Minneapolis-St. Paul area (Ameson, Luepke, Pirie, & Sinaiko, 1992). In this study, the attitudes and practices of pediatricians regarding cholesterol and children were assessed. The researchers concluded that there are differences of opinion among pediatricians regarding Cholesterol screening and children. The primary concerns are whom to screen, at what age, and issues concerning the management of children with high cholesterol levels. The present study was intended to provide information that might improve efficiency in the development and implementation of cardiovascular programs for Children. Eumsuflhefitudx The researcher’s purpose in this study was to assess current pediatric attitudes and practices regarding Cholesterol screening and intervention for hypercholesterolemia in children. The study was undertaken to gather 4 information that will be helpful to school administrators, educators, and health professionals in the development and implementation of cardiovascular programs to be included in health curriculums. W The following questions were posed to guide the collection of data for this study: 1. Do pediatricians recommend a test of blood cholesterol for all of their patients? 2. Do pediatricians routinely collect family history of premature myocardial infarction or hyperlipidemia? 3. How important do pediatricians think-childhood cholesterol levels are as an indicator of the risk of developing cardiovascular disease In adulthood? 4. Do pediatricians think that all children Should have their Cholesterol level checked at some time during Childhood? 5. Do pediatricians think only Children with a family history of premature myocardial infarction or hyperlipidemia should have their cholesterol level tested? 6. Do pediatricians think that they should be doing more Cholesterol testing in their practices? 7. At what age should the first serum Cholesterol test be given? 5 8. In cases where cholesterol was not elevated, would pediatricians routinely measure it again? 9. Above what level would pediatricians consider an 8-year-old boy’s total cholesterol to be elevated? 10. How many times would a cholesterol level need to be measured by a pediatrician in order to be certain it was elevated? 1 1. If total cholesterol is elevated, would pediatricians recommend that the lipoprotein fractions be measured? 12. What level of LDL cholesterol would pediatricians consider elevated for an 8-year-old boy? 13. If total cholesterol is elevated, would pediatricians routinely refer this patient to a medical specialist? 14. Would pediatricians consider medication for an 8-year-old boy with an elevated total cholesterol level? If so, at what total cholesterol level would they consider medication? 15. How effective do pediatricians think they are in helping to reduce the saturated-fat intake of their patients? 16. Do pediatricians favor or oppose school-based cholesterol screening programs for Children? 6 17. Are there locations or settings other than schools where pediatricians would favor Cholesterol screening programs for children? 5' 'fi [II SI l Little research has been done on pediatricians’ perceptions of children and Cholesterol. Children who consume a typical American diet of high fat are more likely to have elevated cholesterol levels than are children in other areas of the world where heart disease is rare. Children with elevated Cholesterol levels should be identified. Ifthis is not done, they may never receive dietary counseling. Preventing the problem is better than treating it. Schools will be more likely to have effective health and lunch programs when pediatricians’ attitudes are known. Before educators and administrators can act intelligently in designing Children’s health programs and lunch programs, they should know what pediatricians’ attitudes and recommendations are, and they should work together in developing these programs. Determination of pediatricians’ attitudes on this subject will help educators and administrators judge how important screening and treating children’s Cholesterol will be. This study will provide scientific data On the effectiveness of childhood Cholesterol interventions and will provide background for pediatric recommendations. 7 D I' 'l l II' 'l l [II SI I 1. The sample was delimited to mid-Michigan pediatricians selected from a published list of Michigan pediatricians. Participation in the study was voluntary. Thus, the results might not reflect the views of all pediatricians. 2. A questionnaire developed at the University of Minnesota was used to collect the data. This questionnaire was used in a previous study of pediatricians and was considered acceptable for the purpose for which it was to be used. The validity Of this study depends on the degree of sincerity and frankness with which subjects responded to this instrument. 3. The motivation and honesty of the respondents may influence the results obtained. 4. The practice patterns were assessed by self-report; therefore, the screening practices described might differ from actual current practices. 5. Subjects’ attitudes may depend on factors not measured by the survey. 6. Subjects’ practices may depend on factors not measured by the survey. D [i 'l’ [I The following terms are defined in the context in which they are used in this study: 8 Anginapemfls: Pressing ortightening pain in the middle of the Chest due to a significant blockage in a coronary artery that deprives the heart muscle of needed oxygen. Adeflgsclemsis: A term used to cover a variety of diseases that lead to abnormal thickening and hardening of the walls of arteries. Athemsclemsis: A Chronic disease process in which there is gradual build-up of plaque on the inside walls of the arteries. Cholesterol: A white, waxy substance that does not dissolve in water. It is found only in animal cells, where it is used to make cell membranes and hormones. W: An artery that supplies blood with its nutrients and oxygen to the heart muscle. WW: Results from blockages of atherosclerosis in the arteries of the heart called the coronary arteries. W: The early form of atherosclerosis, at which time cholesterol and other materials from the blood are deposited in the lining of the arteries but the build-up has not begun to narrow the Opening of the artery. W: An intermediate form of atherosclerosis in which cholesterol and other materials from the blood are starting to narrow the opening of the artery but a significant amount of blockage has not yet occurred. 9 HighzdensityjimnmieinfliQL): Ablood lipoprotein that carries about 20% to 25% of the Cholesterol in blood. HDL is sometimes referred to as the "good Cholesterol" because high levels of HDL are associated with a lower risk of coronary heart disease and low levels with a higher risk. Hypemhplestemlemja; A high level of total cholesterol in the blood. Hyperlipidemia: A high level of cholesterol and triglyceride. Lipid: Any of various substances that are insoluble in water but will dissolve in solvents such as chloroform. Lipoprotein: Acomplex of proteins called apolopoproteins and lipids, such as cholesterol. Blood Iipoproteins are responsible for transporting lipids between various organs of the body. LMBDSMDQDLOIBIDJLDL): The major carrier of cholesterol in blood. A high level of LDL promotes atherosclerosis and coronary heart disease. Myocardialjnfamtim: The technical term for a heart attack. W: The major carrier of triglyceride in the blood of a fasting patient. VLDL is made primarily in the liver and contains about 65% of its weight as triglyceride. It also cOntainS cholesterol and phospholipid. 10 012mm This dissertation is divided into five chapters. Chapter I consisted of an introduction to the study, the problem and purpose of the study, limitations, and definitions of important terms. Pertinent literature is reviewed in Chapter II. The focus is on studies involving children and cholesterol, and pediatricians' attitudes and practices. The literature review includes documentation of data establishing the connection between elevated cholesterol level in childhood and its effect in later life. Chapter III contains a discussion of the methods, materials, and procedures used in the study. This includes the sampling, instrumentation, data collection, and method of analysis. The findings of the study are presented in Chapter IV. Chapter V includes a summary of the study, a summary of the results, conclusions, discussion of the implications, and recommendations for further research. CHAPTER II REVIEW OF THE LITERATURE Introduction The intention of this Chapter is to highlight the literature and research that served to influence this study. The review includes key points of the literature and their effect on the structuring of this study. The literature review is divided into three areas of studies: (a) childhood beginnings of heart disease, (b) educational interventions, and (c) pediatricians’ perceptions of and attitudes toward children and Cholesterol screening. Cl'lll IB .. [II III A study done by Enos, Holmes, and Beyer (1986) focused on 200 soldiers (ages 18 to 48) with an average age of 22.1 years. They evaluated the hearts of these soldiers killed in combat. The researchers concluded that: [Thirty-five] percent of the soldiers had coronary lesions which didn’t cause significant obstructions. Another 39 percent had narrowing of the coronary arteries ranging from 10 percent to 90 percent. In 3 percent, plaque deposits had completely closed one or more vessels. Only 23 percent of these soldiers had no visible signs of any coronary artery disease. (p. 2859) 11 12 Holman et al. (1958) conducted a study in New Orleans, Louisiana, to assess aortas from 526 autopsies of children and young adults between the ages of 1 and 40 years. They concluded that: Fatty streaks were demonstrated in the aortas of all children over the age of 3 years. The percentage of intimal surface covered with fatty streaks ‘ increased Slowly through the first decade of life, then more rapidly during adolescence (occurring sooner in blacks than in whites). Fibrous plaques in the aorta begin to appear significantly only in the fourth decade of life. Overall there was about a 15—year lag between the development of fatty streaks and fibrous plaques and in this case, whites had a greater extent of intimal surface involvement than blacks. (p. 209) Strong and MCGIII (1969) studied both coronary and aortic lesions of 4,747 children and young adults (ages 10 to 39). This study was part of the International Atherosclerosis Project. The subjects were both sexes from six different geographic and racial groups. The major findings were as follows: 1. Fatty streaks in the coronary arteries were before 10 years of age, quite frequent between 10 and 20 years, and nearly always present after 20. 2. Some fatty streaks became fibrous plaques, a transition that began in some cases before the age of 20 and increased quite rapidly in the following two decades. 3. Countries such as the United States, where fatty streaking was more extensive in childhood, had more advanced lesions of coronary atherosclerosis in middle age. These observations suggest that atherosclerosis begins in Childhood and slowly progresses through the adult years, leading to significant blockages in the arteries that result in heart attack, sudden death, angina pectoris, stroke, or poor Circulation. (p. 255) 13 Gerald Berenson (1992), a professor of cardiology at the Louisiana State University Medical School, conducted a study to assess the effects of diet and exercise on children in Bogalusa, Louisiana. By 1994, more than 14,000 children had been followed by the program. The major conclusions were as follows: Elevated cholesterol and LDL [low—density lipoprotein] levels could be found in children as young as 6 months of age, and . . . those with high levels usually maintained them. Autopsy studies, beginning in 1978 of children who had died suddenly of accidents and other causes of unexpected deaths showed that fatty streaks were found in the aortas of all Children over the age of three, and in coronary arteries of most of the children and young adults between the ages of 3 and 33 years of age. Many of these children and young adults had been followed in the study for years, and those with the highest known cholesterol levels had the most fatty deposits. This indicated a need for intervention during childhood. (p. 851) Laurer and Clarke (1990) examined the relationship between childhood and adult Cholesterol levels. Initially, they tested 2,446 Children at ages 8 to 18; later they retested them as young adults. The following results were obtained: 1 . The initial childhood blood cholesterol level wasthe major predictor of adulthood cholesterol level. 2. Of children with blood cholesterol levels initially found to be high, 43 percent were found to be high (greater than the 90th percentile) on a single measurement, at ages 20-30 years, 62 percent had levels greater than the 75th percentile and 81 percent had levels greater than the 50th percentile. 3. There was little risk of finding high adult levels (above the 90th percentile) when childhood levels were less than the 50th percentile. 14 4. Blood Cholesterol levels in childhood were also a predictor of adult LDL cholesterol levels and the ratio of LDL cholesterol to HDH Cholesterol, but not of adult HDH cholesterol levels. 5. LDL cholesterol and HDH cholesterol levels and the ratio of LDL cholesterol to HDH cholesterol were adversely affected by a number of acquired lifestyles or conditions, including obesity, smoking, and the use of oral contraceptives. 6. A family history of coronary heart disease was an important correlate of elevated blood cholesterol levels in both children and adults, indicating further than inherited factors play an important role in the control of blood cholesterol levels, even in children. (p.3035) The Beaver County Lipid Study (Donahue, 1985) was a nine-year follow- up investigation of young adults in Pennsylvania. The students were first evaluated as seventh-grade students. The tracking of these students indicated that "by age 22, 20% had cholesterol levels as high as 358” (p. 460). Stary (1989) examined the arteries of 422 individuals who died between birth and 29 years of age. He found that: Fatty deposits were found in the coronary arteries of Children by age 3 years. By age 12 nearly 70 percent of Children examined had fatty deposits. They all increased in size rapidly throughout the teens, and all young adults had them by age 21. (p. 23) Basil Rifkind, director ofthe Lipid Metabolism Atherogenesis Branch ofthe National Heart, Lung and Blood Institute, and Paula Einhorn wrote an editorial in 1993 that assessed a project organized in 1983 to study the natural progress 15 of cholesterol lesions in Children and young adults. They reported the following conclusions: Among the 1,532 autopsies studied, aortic cholesterol lesions were in all children between the ages of15-19. Half of these children had lesions in the coronary arteries. Since these deposits are known to develop over many years, the study concludes that childhood heart disease accelerates during the early years. (p. 373) El l' HI I' SI |' Schools are the major organizational sites for improving the health of children. Studies related to this idea are reviewed in the following paragraphs. WWW Between 1984 and 1988, 6,585 Children, ages 5 to 18, from 22 different schools were measured fortotal cholesterol levels (Resnicow, Morley-Kothchen, 8. Wynder, 1989). The researchers found that: The mean total cholesterol concentration was 166.4 mgldl. Total cholesterol was Significantly higher in girls (168 mgldl) than in boys (165 mgldl), although the sex differences were inconsistent across race/ ethnicity. The mean value for blacks, 173 mgldl, and Hispanics, 168 mgldl, was higher than for Asians, 165 mgldl, and whites, 163 mgldl. (p. 970) W A study was conducted to assess the effectiveness of an educational intervention designed to modify risk factors associated with coronary heart 16 disease among 3,388 children in 37 schools in two demographically dissimilar area in and around the New York City area (Walter, Hofman, Vaughn, 8 Wynder, 1988). Schools within each area were randomly assigned to either intervention or nonintervention groups. In schools targeted for intervention, children in the fourth through eighth grades were taught ateacher-delivered curriculum focusing on diet, physical activity, and cigarette smoking. Risk-factor levels were measured in all schools at baseline at four follow-up points. A total of 1,769 of the children qualified for analysis of the intervention effect. After five years, the results were as follows: The intervention program appeared to be associated with favorable trends in blood levels of total cholesterol among two demographically dissimilar populations of schoolchildren. In both populations, there were significant net increases in prevention-related knowledge. (p. 1095) At the beginning of the ninth grade, the prevalence of Cigarette smoking was still too low to permit detection of an effect on the number of subjects who started to smoke. The program appeared to have no effects on body mass, physical form, physical fitness, or blood pressure (p. 1095). In subjects in both groups of schools, blood levels of total cholesterol declined over the course of the investigation. This finding is consistent with previously reported age-associated trends in children. The decline in the levels was greater among subjects receiving intervention than among those not receiving it. 17 .SQhQQESflejEHBBflkELkflenflflflknLLUflfiklflflQ Four Michigan elementary schools received a risk-factor screening intervention twice during a one-year study, and four served as comparison sites (Resnicow, Cross, LaCosse, & Nichols, 1993). The study sample consisted of 1,166 children and their parents. The results of the study were as follows: Significant changes relevant health knowledge as well as attitudes regarding: nutrition, early detection of disease; and local school health programs relative to comparisons were observed. There was also a Significant decrease in students’ self-reported intake ofhigh-fat foods, and parents of Children who participated were more likely to report having had their cholesterol and blood pressure tested. The data suggest that school-based risk factor screening programs represent a potentially effective adjunctto traditional curricular approaches to disease prevention and health education as well as an alternative means of early detection. (p. 838) l!’ 'l [ll'l' Sll ISBS-IESI From 1985 to 1991, a total of 7,275 male and female youths, ages 1 to 19 years, from 18 Michigan school districts participated in a study conducted by the Department of Kinesiology at the University of Michigan (Kuntzleman, Reiff, Poore, Cumberworth, & Arends, 1992). All students were tested for Cholesterol levels. Data were grouped and analyzed by gender and age. It was found that: Males had mean cholesterol levels 7 mgldl higher than a similar population of US. youth. Females had mean cholesterol levels 6 mgldl higher than the US. population, which corresponds to an 8 percent theoretical increased risk for heart disease. Thirty-six percent of Michigan males tested had elevated cholesterols, while 43 percent of the Michigan 18 females had higher cholesterols compared to a national average of 25 percent. The study concluded that proactive strategies should be taken by state agencies for inclusion of health and fitness programs in the schools. Incentives need to be developed to reward schools that are successful in developing programs that lead to increased cardiovascular activity, maintenance of ideal body fat and consumption of low fat food. (p. 10) Educational intervention alone has achieved similar results. The American Heart Foundation Know Your Body (KYB) Study, 1979-1985, studied 1,105 children in fourth grade (Walter et al., 1988). Approximately half (eight schools) were given classroom instruction in diet, physical activities, and cigarette-smoking prevention—all related to coronary heart disease. The children’s parents received educational materials and attended seminar groups conducted by study personnel. The other half of the Children (seven schools) were not subjected to these activities. It was found that, after five years, the Children who had received the educational intervention had lower cholesterol levels than did the control group and had a surprising 73% reduction in the rate of initiation of cigarette smoking. The Johns Hopkins University School of Medicine conducted a nutritional- education program for 400 third- and fourth-grade Children in Baltimore, Maryland. The children were taught to make better food choices in fast-food restaurants, at snack time, and in the grocery store. Three years later, the study findings indicated that the subjects’ cholesterol levels were much lower than at 19 the start of the program. Dr. Kerry Stewart, who directed the program, said, "Kids don’t die from heart disease; they die from itwhen they are adults“ (p. 121 ). He said his goal was to establish good eating habits now to prevent heart disease later. Another bonus was that children taught their parents what they learned about nutrition. The Pawtucket Heart Health Program in Rhode Island works closely with 23 public and parochial schools (Attwood, 1988-89). It is an educational program designed to teach junior high school students about the healthful effects of reducing their dietary fat. In 1988-89, 105 students participated in a "cook-off" program and were given scores for creative low-fat meals. At the beginning of the program, 40% of the students had elevated serum cholesterol (over 170 mgldl). These children experienced a 10.7% drop in their cholesterol levels during the 12 weeks of the cook-off. Roland Chevalier, superintendent of schools in St. Martin Parish, Louisiana, convinced his school board to set up a task force to study and establish a comprehensive health-and-wellness plan (Attwood, 1988-89). The goal of the program in fall 1993 was to improve the nutritional standards for their school lunches by reducing fat, sodium, and cholesterol in the Children’s lunch choices. School administrators approved the establishment of one of the most unusual and progressive school lunch programs in the nation. 20 The American Heart Association estimated that, in 1993, 36% of American Children ages 19 and under had high blood Cholesterol levels—above 170 mgldl (American Heart Association, 1993). E II" ’E I' I5 IEII'II I l Cl'll ICI ll IS . The Division of Pediatric Cardiology began a preventive cardiology program in the Tidewater Virginia area in response to the American Academy of Pediatric Nutrition Committee’s recommendations on pediatric Cholesterol screening (Jennings 8 Leon, 1992). The program consisted of both public and physician educational programs, as well as the treatment of individual hyperlipidemic Children. A survey of 67 local pediatricians revealed that they had not followed the American Academy of Pediatricians’ directive for a ”family history“ approach to pediatric Cholesterol screening, with most pediatricians screening their patients for Cholesterol abnormalities. Davidson and Smith (1990) conducted a study on cholesterol screening of children during visits to the pediatrician’s office. According to'the study findings, elevated blood cholesterol level, a major risk for coronary heart disease in adults, has been associated with atherosclerosis in Children. Davidson and Smith said that 10% of North American children have blood cholesterol levels higher than the desirable levels for adults. The researchers concluded that 21 current guidelines recommend screening only in children who have a family history of hyperlipidemia or myocardial infarction at an early age; however, this method fails to identify most Children with hypercholesterolemia. They recommended that office-based Cholesterol screening is an effective means of identifying children for dietary assessment and counseling. In addition, it was recommended that referral for pharmacologic treatment be used if the preceding measures are insufficient. The National Heart, Lung, and Blood Institute Sponsored a national survey on primary care physicians and children’s blood Cholesterol (Kim, Payne, Lakato, Webber, 8 Greenblatt, 1992). Conclusions were as follows: 1. Sixty-two percent of primary care physicians of children believed that high levels of low-density lipoprotein cholesterol in childhood had a great effect on subsequent heart-disease risk. 2. Seventy-five percent believed that high blood pressure, smoking, and diabetes had similar effects. 3. Routine cholesterol screening in children under 10 years was infrequent, however, 72% of physicians screened high-risk children. The age at which screening was done varied; most pediatricians screened children younger than five years. 22 4. Twenty-six percent of the physicians prescribed low—saturated-fat diets for elevated cholesterol. 5. Twelve percent of the physicians prescribed lipid-lowering drugs. Factors that affected physicians’ treatment of hypercholesterolemia included physician specialty type, organization of practice. and the age distribution of the pediatric population. Controversy exists regarding cholesterol screening in childhood. As a result of his study, Schoen (1992) concluded that: 1. No long-term evidence has proven that lowering Childhood cholesterol levels prevents the development of coronary heart disease in aduflhood. 2. Questions remain as to the effectiveness and safety of lipid- lowering diets in children. Even if future research indicates that lipid-lowering diets are beneficial, children and their families may not be willing to comply with the prescribed regimen. 3. A more sensible way to prevent coronary heart disease in adults may be to promote a healthy lifestyle beginning in early childhood and including a balanced diet, weight control, and exercise. 23 Newman, Browner, and Hylley (1990) reviewed studies to determine the possible risks and benefits of screening children for Cholesterol. They concluded that: 1. Childhood cholesterol levels are not a good predictor of high cholesterol levels in young adulthood and will be a poor predictor of coronary heart disease later in life. 2. There is no evidence to predict that blood cholesterol levels can be lowered more easily in children than in adults. 3. There is no evidence that cholesterol reduction in childhood will be much more effective at preventing coronary heart disease than cholesterol reduction begun later in life. 4. Screening and intervention to lower blood cholesterol levels for millions of Children would be expensive, could lead to labeling and family conflicts, and may cause malnutrition and increased noncardiovascular mortality. 5. Because the benefits of Cholesterol screening are unlikely to exceed the above-mentioned risks, children should not be screened for high blood cholesterol levels. Griffin, Christoffel, Binns, and McGuire (1989) evaluated the efficacy of family-history factors as screening criteria for Childhood hypercholesterolemia. One thousand five Children from eight Office practices were randomly screened 24 for serum cholesterol. Family histories were obtained. Griffin et al. found that 274 children had total cholesterol levels greater than or equal to 175 mgldl, and 175 of these children returned for retesting after an overnight fast. A total of 88 children were found to have low-density lipoprotein-Cholesterol values greater than or equal to the 90th percentile for age and gender. It was concluded that if thorough identification of young children with elevated Cholesterol is desired, inclusive population screening rather than a family-history-based strategy would be the most effective approach. Four pediatricians screened 1,665 Children in 12 months, using a portable cholesterol analyzer (Goff et al., 1991). They concluded that office-based cholesterol screening in a pediatric practice was both practical and useful. Arneson, Luepker, Pirie, and Sinaiko (1992) conducted a study of 197 board-certified pediatricians (95% participation rate) in the Minneapolis-St. Paul metropolitan area. The subjects participated in a telephone survey to assess their cholesterol-screening practices and hypercholesterolemia management. Arneson et al. found that 90% of the subjects did some Cholesterol screening; 58% screened only children with a strong family history of coronary heart disease. Thirty-three percent screened all of their patients; however, 66% suggested universal pediatric screening. Most of the pediatricians who were 25 surveyed indicated that they would manage hypercholesterolemia themselves, usually through dietary means. Although the pediatricians in the Arneson et al. study had strong support for screening, they expressed skepticism about the significance of childhood cholesterol level as a predictor of adult cardiovascular disease and doubted their effectiveness in getting patients to adopt a cholesterol-reducing diet. Their definition of elevated total cholesterol level in childhood was consistent with published recommendations, but only 29% could define elevated LDL cholesterol level. The pediatricians expressed strong opposition to pediatric cholesterol screening in schools or in any setting other than Clinics and hospitals. Glueck(1991) recommended samplingtotalcholesterol,triglycerides, and HDL cholesterol in all children. lmnactCLLiteLatuLeeaneStudv Although the design of the study is detailed in Chapter III, it is helpful to acknowledge the influence of earlier studies. Only a few studies have been done on pediatricians’ attitudes and perceptions regarding Childhood cholesterol. However, other previous studies involving children and Cholesterol are of importance in understanding childhood cholesterol. First, the work done by Enos, Holmes, Beyers, Holman, and others has confirmed that heart disease begins in early Childhood. Second, the work done by the American Heart 26 Foundation and others has helped to focus the study on school intervention. Third, a limited number of studies done by the Division of Pediatric Cardiology in Tidewater, Virginia, the National Heart, Lung, and Blood Institute, and others have focused on pediatricians’ attitudes toward and perceptions of childhood cholesterol. The present study will add to the literature concerning how pediatricians feel about childhood cholesterol and school intervention. CHAPTER III DESIGN OF THE STUDY This study was designed to determine the attitudes and perceptions of pediatricians regarding childhood cholesterol intervention. The research was undertaken in an attempt to provide thorough, insightful, and useful answers to the research questions. This chapter contains the research questions and hypotheses, a discussion of the study setting, the study population, the Instrument used to collect the data, and the data-collection techniques. Besearchfiuestions The following research questions were posed to guide the collection of data for this study: 1. Do pediatricians recommend a test of blood cholesterol for all of their patients? 2. Do pediatricians routinely collect family history of premature myocardial infarction or hyperlipidemia? 27 28 3. How important do pediatricians think childhood cholesterol levels are as an indicator of the risk of developing cardiovascular disease in adulthood? 4. Do pediatricians think that all children should have their cholesterol Level checked at some time during childhood? 5. Do pediatricians think only children with a family history of premature myocardial infarction or hyperlipidemia should have their cholesterol level tested? 6. Do pediatricians think that they should be doing more cholesterol testing in their practices? 7. At what age should the first serum Cholesterol test be given? 8. In cases where cholesterol was not elevated, would pediatricians routinely measure it again? 9. Above what level would pediatricians consider an 8-year-old boy’s total cholesterol to be elevated? 10. How many times would a cholesterol level need to be measured by a pediatrician in order to be certain it was elevated? 1 1. If total cholesterol is elevated, would pediatricians recommend that the lipoprotein fractions be measured? 12. What level of LDL Cholesterol would pediatricians consider elevated for an 8-year-old boy? 29 13. If total cholesterol is elevated, would pediatricians routinely refer this patient to a medical specialist? 14. Would pediatricians consider medication for an 8-year-old boy with an elevated total cholesterol level? If so, at what total cholesterol level would they consider medication? 15. How effective do pediatricians think they are in helping to reduce the saturated-fat intake of their patients? 16. Do pediatricians favor or oppose school-based cholesterol screening programs for Children? 17. Are there locations or settings other than schools where pediatricians would favor Cholesterol screening programs for children? Wag The Lansing, Michigan, metropolitan area has a population of 440,000. The labor force is a mix of government, industry, education, and agriculture. A large percentage of people in Lansing are employed either by government or educational facilities (US. Bureau of the Census, 1990). Lansing is the capital of Michigan. It is the home of Michigan State University and abounds with cultural activities. 30 mm The survey population included all pediatricians in the metropolitan Lansing area. Demographic data were requested from the American Academy of Pediatrics, Sparrow Hospital, St. Lawrence Hospital, and lngham Capital Medical Center. These data included name, address, telephone number, certification, and hospital affiliation of the pediatricians. Of the original target population of 54 pediatricians, 39 returned usable responses (a response rate of 72%). Eleven pediatricians did not return the survey, and four returned uncompleted surveys, stating that they were not qualified to answer the questionnaire. From this point on, whenever the term ”sample” is used, it will refer to the 39 pediatricians who returned usable questionnaires. Of this sample, 68% were females and 31% were males. They ranged in age from 25 to 74 years. mm The instrument used to collect data for this study was developed at the University of Minnesota to study attitudes and practices of pediatricians in the Minneapolis-St. Paul metropolitan area. For this study, the following modifications were made: 31 1. The method used for data collection was Changed from a telephone interview to a mailed questionnaire. Because the participants were physicians, it was almost impossible to set up a time to conduct a telephone interview. 2. Because of the focus of this study, not all questions asked on the Minnesota survey were pertinent to this study. Therefore, some questions were deleted. This was accomplished through discussions with Dr. P. Pirie, who directed the Minnesota study. Dr. Pirie suggested questions to be retained and gave permission to use all or any part of the Minnesota questionnaire. The questionnaire was administered to an independent group of pediatricians from another area of Michigan to test for content, readability, flow, and validity. The field test was satisfactory, and the questionnaire was put into final form to be mailed out to the pediatricians in the metropolitan Lansing area. A copy of the questionnaire is included in the Appendix. Dammmemcedmes The data for this study were collected in the winter of 1995. Included in the mailing were a cover letter (see Appendix) explaining the purpose of the study and a retum-addressed, stamped envelope. The subjects were asked to return the questionnaires within three weeks. This was done to accommodate the pediatricians’ busy schedules. 32 Data from the completed questionnaires were entered onto a computer at Michigan State University. Statistical analysis was performed using the Statistical Package for the Social Sciences. CHAPTER IV ANALYSIS OF THE DATA Introduction The researcher’s purpose in this study was to determine the perceptions and practices of pediatricians regarding screening school-age children for cholesterol. The population comprised 54 Lansing-area pediatricians. Thirty-nine ofthe 54target pediatricians returned usable questionnaires. The basis of the instrument used in the study was a questionnaire developed and used by researchers at the University of Minnesota. The questionnaire consisted of open- and closed-ended questions. An analysis of the data and the findings resulting from this study are presented in this chapter. The sample is described first, and then findings pertaining to each of the research questions are presented. D . l' E II S l Ofthe 39 pediatricians who returned usable questionnaires, 70% were male and 30% were female. Five percent of the respondents were 25 to 34 years old, 51% were 35 to 44 years of age, 28% were 45 to 54, and 16% were between 55 and 74. Ninety-four percent of the respondents were certified in pediatrics. The average number of patients the respondents saw weekly was 100. 33 34 E'I'El"|l|B IDI' In this section, each research question is restated, followed by the findings for that question. Besearchfluestiond DO pediatricians recommend a test of blood cholesterol for all of their patients? As shown in Table 1, 23.1% of the pediatricians in the study routinely performed cholesterol screening. In contrast, 76.9% of the respondents said they did not test the blood choleSterol of all of their patients. Table 1: Number of pediatricians who recommend a test of blood cholesterol for all of their patients. Recommend Test Freq. % Yes 9 23.1 No 30 76.9 Total 39 100.0 W Do pediatricians routinely collect family history of premature myocardial infarction or hyperlipidemia? Of the 37 pediatricians responding to this question, 94.6% said they collected family history of premature myocardial infarction or hyperlipidemia (see Table 2). However, only 59% of them updated infOrmation through adolescence. 35 Table 2: Number of pediatricians who routinely collect family history of premature myocardial infarction or hyperlipidemia. Collect Family History Freq. % Yes 35 89.7 No 2 5.1 No response 2 5.1 Total 39 100.0 W How important do pediatricians think childhood cholesterol levels are as an indicator of the risk of developing cardiovascular disease in adulthood? When asked about childhood Cholesterol level as an indicator of risk for developing adult cardiovascular disease, 9 (23. 1 %) of the pediatricians in this study said it was very important, and 26 (66.7%) said it was somewhat important. Conversely, 2 (5.1%) of the respondents said it was not very important, and 2 (5.1%) said they did not know (see Table 3). Table 3: Pediatricians’ ratings‘of the importance of childhood cholesterol levels as an indicator of the risk of developing cardiovascular disease in aduflhood. Importance Freq. % Very important 9 23.1 Somewhat important 26 66.7 Not very important 2 5.1 Do not know 2 5.1 Total 39 100.0 36 Reseamfluestlonfi Do pediatricians think that all children should have their cholesterol level checked at some time during Childhood? Pediatricians were asked to indicate their level of agreement or disagreement with the statement that all children should have their cholesterol level checked at some time during Childhood (see Table 4). Of the 38 pediatricians responding to this item, 6 (15.8%) strongly agreed, 12 (30.8%) somewhat agreed, 14 (35.9%) somewhat disagreed, 5 (12.8%) strongly disagreed, and 1 (2.6%) did not know. One person did not respond to this item. Table 4: Respondents’ level of agreement with the statement that all children should have their Cholesterol level checked at some time during childhood. H Level of Agreement Freq. % Strongly agree 6 15.4 Somewhat agree 12 30.8 Somewhat disagree 14 35.9 Strongly disagree 5 12.8 Don’t know 1 2.6 No response 1 2.6 Total 39 100.0 W Do pediatricians think only children with a family history of premature myocardial infarction or hyperlipidemia should have their Cholesterol level tested? 37 Pediatricians were asked to rate their level of agreement or disagreement with the statement that only children with a family history of premature myocardial infarction or hyperlipidemia should have their Cholesterol level tested. As shown In Table 5, 6 (15.4%) of the respondents strongly agreed with this statement, and 17 (43.6%) somewhat agreed. On the other hand, 12 (30.8%) somewhat disagreed and 3 (7.7%) strongly disagreed. One person did not respond to this item. Table 5: Respondents’ level of agreement with the statement that only Children with afamily history of premature myocardial infarction or hyperlipidemia Should have their cholesterol level tested. Level of Agreement Freq. % Strongly agree 6 15.4 Somewhat agree 17 43.6 Somewhat disagree 12 30.8 Strongly disagree 3 7.7 No response 1 2.5 Total 39 100.0 Besearchfluestlonfi Do pediatricians think that they should be doing more cholesterol testing in their practices? Of the 39 pediatricians responding to this item, 9 (23.1%) strongly agreed that pediatricians should be doing more cholesterol testing In their practice. Twenty-one respondents (53.8%) somewhat agreed with this item, and 9 (23.1%) somewhat disagreed (see Table 6). 38 Table 6: Respondents’ level of agreement with the statement that pediatricians should be doing more cholesterol testing in their practice. ‘: - ———— Level of Agreement Freq. % “ Strongly agree 9 ' 23.1 i Somewhat agree 21 53.8 I Somewhat disagree 9 23.1 Total 39 100.0 I The pediatricians who answered negatively about more screening were given an opportunity to explain their answers. The most frequent responses were as follows: 1. Skepticism about the efficacy of interventions or pediatric cholesterol screening. 2. Skepticism about the correlation between childhood cholesterol levels and adult cardiovascular disease. 3. Poor cost-effectiveness. 4. Skepticism about the pain of testing. Beseardnfiuesflenl At what age should the first serum cholesterol test be given? Respondents were asked at what age they thought the first serum cholesterol test Should be given. As shown in Table 7, 6 (15.4%) of the respondents said the first serum cholesterol test should be given when a child is less than 2 years old, 7 39 (17.9%) thought it should be given at 2 to 5 years, 12 (30.8%) said 6 to 12 years, and 5 (12.8%) said over 12 years. Nine pediatricians (23.1%) did not respond to this question. Table 7: Age at which respondents thought the first serum cholesterol test should be given. Age of First Test Freq. % Less than 2 years 6 15.4 2-5 years 7 17.9 6-12 years 12 30.8 Over 12 years 5 12.8 No response 9 23.1 Total 39 100.0 W In cases where cholesterol was not elevated, would pediatricians routinely measure it again? Respondents were asked whether, in cases where cholesterol was not elevated, they would routinely measure it again. Of the 30 pediatricians responding to this question, 10 answered affirmatively and 20 responded negatively (see Table 8). 40 Table 8: Respondents who would or would not routinely measure cholesterol again if it was not elevated initially. Response Freq. % Yes 10 25.6 NO 20 51 .3 No response 9 23.1 Total 39 100.0 W009 Above what level would pediatricians consider an 8-year-old boy’s total cholesterol to be elevated? The pediatricians were asked specifically to define total cholesterol level in a healthy 8-year-old boy. The mean response was 185.857 (SD = 12.975), and the median was 190. The levels above which pediatricians said they would consider an 8-year-old boy’s total cholesterol to be elevated are Shown in Table 9. The majority of respondents (28 or 71.8%) said that 180 to 200 was the level at which they would consider an 8-year-old boy’s total Cholesterol to be elevated. 41 Table 9: Level above which pediatricians would consider an 8-year-old boy’s total cholesterol to be elevated. = Cholesterol Level Freq. % 150 1 2.6 160 1 2.6 170 3 7.7 175 1 2.6 180 1 1 28.2 190 8 20.5 200 9 23.1 210 1 2.6 No response 4 10.3 Total 39 100.0 mm How many times would a Cholesterol level need to be measured by a pediatrician in order to be certain it was elevated? Respondents were asked how many times they would need to measure a cholesterol level to be certain It was elevated. Results are shown in Table 10. Of the 39 pediatricians responding to this question, 4 (10.3%) said they would need to measure a cholesterol level once, 29 (74.4%) said twice, and 6 (15.4%) said three times. The mean was 2.05 (SD = .51). Table 10: Number of times a Cholesterol level needs to be measured to be certain it is elevated. Number of Times Freq. % Once 4 10.3 Twice 29 74.4 Three times 6 15.4 Total 39 100.0 Beseamluluesflnnil lf total Cholesterol is elevated, would pediatricians recommend that the lipoprotein fractions be measured? Respondents were asked whetherthey would recommend that the lipoprotein fractions be measured if the total cholesterol was elevated. Of the 39 pediatricians, 38 (97.4%) answered this item affirmatively (see Table 11). Only one (2.6%) would not recommend measuring the lipoprotein fractions. Table 1 1: Respondents’ recommendation that the lipoprotein fractions be measured if total cholesterol is elevated. E Recommendation Freq. % Yes 38 97.4 No 1 2.6 Total 39 100.0 43 Besearchfiuestiomz What level of LDL cholesterol would pediatricians consider elevated for an 8-year-old boy? Respondents were asked the level of LDL Cholesterol they would consider to be elevated for an 8-year-old boy. Their answers are shown in Table 12. Of the 17 respondents indicating a specific LDL cholesterol level, the majority (5 or 12.8%) said 130. Twenty-one respondents said they would refer to the laboratory or check lab standards, and one replied ”Don’t know.” The mean was 133.4 (SD = 20.6). Table 12: Level of LDL cholesterol respondents would consider elevated for an 8-year-old boy. LDL Cholesterol Level Freq. % 1 10 3 7.7 120 2 5.1 129 2 5.1 130 5 12.8 140 2 5.1 160 2 5.1 190 1 2.6 Refer to lab/check lab standards 21 53.9 Don’t know 1 2.6 Total 39 100.0 44 Reseamfluestionjfi If total cholesterol is elevated, would pediatricians routinely refer this patient to a medical specialist? As shown in Table 13, 8 (20.5%) respondents said that they would routinely refer a patient with an elevated total cholesterol level to a medical specialist, whereas 24 (61.5%) said it would depend on the level. Six (15.4%) pediatricians said they would not refer such a patient to a medical specialist, and one did not respond to this question. Most pediatricians tended to initiate management of elevated Cholesterol in their own patients. Table 13: Respondents who would routinely refer a patient with an elevated total cholesterol level to a medical specialist. Refer Patient Freq. % Yes, routinely 8 20.5 Depends on level 24 61.5 No 6 15.4 No response 1 2.6 Total 39 100.0 In an open-ended question about the management of an 8-year-old boy with an elevated cholesterol level, pediatricians made the following suggestions: (a) change in diet and lifestyle; (b) exercise; (C) maintain ideal weight; (d) counseling, (e) information, booklets, recipes; (1) educate family and Child; (9) possibly refer to specialist; and (h) possible medication. 45 Reseatchfiuestiom Would pediatricians consider medication for an 8-year-old boy with an elevated total cholesterol level? If so, at what total cholesterol level would they consider medication? As shown in Table 14, 3 (7.7%) of the pediatricians in this study said they never would consider medication for a 8-year-old boy with an elevated total cholesterol level. On the other hand, 34 (87.2%) said they would refer such a youngster for medication. Two individuals did not respond to this question. Table 14: Whether respondents would consider medication for an 8-year-old boy with an elevated total cholesterol level. Consider Medication? Freq. % Never would 3 7.7 Would refer for medication 34 87.2 No response 2 5.1 Total 39 100.0 Thirteen respondents indicated the total Cholesterol level at which they would consider medication for an 8-year-old boy. Of that number. 4 (10.3% of the sample) said that they would consider medication at a total cholesterol level of 300. 46 Table 15: Total cholesterol level at which respondents would consider medication for an 8-year-old boy. E Cholesterol Level Freq. % 220 2 5.1 225 2 5.1 250 3 7.7 280 1 2.6 300 4 10.3 350 1 2.6 No response 26 66.7 Total 39 100.0 Reseatchfluestienjfi How effective do pediatricians think they are in helping to reduce the saturated-fat intake of their patients? Just one (2.6%) of the respondents indicated being very effective in reducing patients’ saturated-fat intake. A majority of respondents (22 or 56.4%) thought they were somewhat effective in that regard, whereas 15 (38.5%) thought they were slightly effective. One individual did not respond to this question. 47 Table 16: Respondents’ effectiveness at reducing the saturated-fat intake of their patients. Effectiveness Freq. % ll Very effective 1 2.6 ll Somewhat effective 22 56.4 H Slightly effective 15 38.5 II No response 1 2.6 Total 39 100.0 mm Do pediatricians favor or oppose school-based cholesterol screening programs for Children? A majority of the pediatricians (20 or 51.3%) in this study voiced strong opposition to school-based cholesterol screening (see Table 17). The reasons respondents gave for their opposition included (a) poor screening machines and poor preparations, (b) inexperienced people, (c) possible false positives, and (d) no follow-up orintervention. Ten (25.6%) respondents favored school-based screening under some Circumstances. Only 4 (10.3%) favored such programs, and only if the school has the resources to provide intervention and follow-up. They also stated that all positive results should be sent to a pediatrician or family physician. Also, they thought that the schools could reach children who otherwise would not be reached. 48 Table 17: Respondents who favored or opposed school-based Cholesterol screening programs for children. Favor/Oppose Screening Freq. % Favor 4 10.3 Favor under some Circumstances 10 25.6 Oppose 20 51.3 Don’t know/no opinion 5 12.8 Total 39 100.0 Beseamhfluesjignjl Are there locations or settings other than schools where pediatricians would favor Cholesterol screening programs for children? Twenty-two respondents (56.4%) said there were no locations other than schools where they would favor having cholesterol screening programs for children (see Table 18). Five (12.8%) respondents said there were such locations, stating that the screenings should be done by a pediatrician, physician, Clinic, or hospital- sponsored health fair. Twelve pediatricians did not respond to this question. Table 18: Respondents who favored locations other than schools for cholesterol screening programs for children. Favor Other Location Freq. % Yes 5 12.8 No 22 56.4 No response 12 30.8 Total 39 100.0 49 Summary This Chapter contained the results of the data analyses performed in this study. Characteristics of the respondents were presented first. Then the results for each of the research questions were presented. Chapter V contains a summary of the study, major findings, conclusions drawn from the findings, implications, recommendations for further research, and the researcher’s reflections. CHAPTER V SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS 101mm Chapter V is divided into six main sections. A summary of the study is given first, followed by the major findings and conclusions drawn from the findings. Implications of the study are discussed next, and recommendations are given for future research. The chapter concludes with the writer’s reflections. Summary In this study, the researcher examined the perceptions and practices of pediatricians regarding screening school-age Children for Cholesterol. The study was undertaken to gather information that will be helpful to school administrators, educators, and health professionals in the development and implementation of cardiovascular programs to be included in health curriculums. Literature was reviewed on (a) childhood beginnings of heart disease, (b) educational interventions, and (C) pediatricians’ perceptions of and attitudes toward children and Cholesterol screening. Only a few studies have been done on 50 51 pediatricians’ attitudes and perceptions regarding childhood cholesterol. Past studies have confirmed that heart disease does begin in early Childhood and that school intervention can play an important part in prevention of heart disease. In this study, the researcher examined which Children should be tested for cholesterol levels, and at what age screening should be done. The researcher also examined how pediatricians evaluate and manage childhood cholesterol and who should screen children for Cholesterol. The survey population included 54 pediatricians in the Lansing, Michigan, area. The instrument used to collect data for this study was developed at the University of Minnesota to study attitudes and practices of pediatricians. The instrument was described in greater detail in Chapter III. The data were collected by means of a mailed questionnaire. Endings Ofthe pediatricians in this study, 23.1% routinely screened all of their patients for cholesterol. In addition, 15.4% of the pediatricians screened patients before age two. A history of premature myocardial infarction hyperlipidemia was routinely collected by 89.7% of the pediatricians, but only 33% of them updated that information through adolescence. Pediatricians were asked specifically to define elevated total cholesterol in a healthy 8-year-old boy. The mean response was 185.857 mgldl (SD = 12.975), and 52 the median response was 190 mgldl. Elevated cholesterol level was defined as 150 to 175 mgldl by 14% of the pediatricians, as 180 to 190 mgldl by 54%, and as greater than 200 mgldl by 18%. Ninety percent of the pediatricians recommended verification of an elevated Cholesterol level through a second measurement, and 97% answered that an elevated total cholesterol value warranted a measurement of lipoprotein fractions. The median response given for elevated lipoprotein was 133.412. The pediatricians tended to initiate management of elevated cholesterol levels in their own patients. Twenty percent referred to another medical specialist, and 61% said they would refer to a specialist only if cholesterol was "extremely high.“ In an open-ended question about the management of an 8-year-old boy with an elevated cholesterol level, pediatricians suggested (a) a Change in diet and lifestyle; (b) exercise; (c) maintenance of ideal weight; ((1) counseling; (e) information, booklets, Classes, and recipes; (f) education of both family and child; (9) possible reference to specialist; and/or (h) medication. There was a general reluctance among the pediatricians in the sample to start lipid-lowering drugs in children. A majority (87.2%) said they would consider medication, whereas 7.7% said they would never consider medication. Many pediatricians emphasized that failure with dietary intervention is a prerequisite to use of drugs. 53 Respondents were asked to assess the effectiveness of pediatricians in helping their patients reduce their saturated-fat intake. Only 2.6% responded that pediatricians are very effective. When asked about childhood Cholesterol level as an Indicator of risk for developing adult cardiovascular disease, 23.1% answered "very important,” and 66.7% said ”somewhat important.” Some of the pediatricians (46.6%) advocated screening all Children, whereas 15.4% believed only children with a strong family history of premature myocardial infarction or hyperlipidemia should be screened. Fifty-nine percent believed that pediatricians should be doing more screening. The pediatricians who answered negatively about more screening were asked to explain their response. Their answers included (a) skepticism about efficacy of interventions or pediatric cholesterol screening, (b) Skepticism about the correlation between childhood cholesterol levels and adult cardiovascular disease, (c) poor cost-effectiveness of screening, and (d) skepticism aboutthe pain involved in testing. Respondents who agreed that pediatricians should be doing more screening in their practices were asked why pediatricians are reluctant to do more screening. Answers included the following: (a) uncertainty about proper management once levels are Obtained, (b) cost, (c) skepticism about the efficacy of interventions or of pediatric cholesterol screening, (d) skepticism about the correlation between 54 childhood Cholesterol levels and adult cardiovascular disease, and (e) inconvenience and trauma Of getting a blood sample. Most pediatricians were opposed to school-based cholesterol screening. About 10% favored such programs, 25.6% said they supported them somewhat, and 51.3% were opposed. Those who favored school-based cholesterol testing thought that the results should be sent to a physician or a pediatrician, and that testing should be done only if the schools had the resources to provide intervention and counseling. Also, they thought that the schools could reach children who otherwise would not be reached. Pediatricians who opposed school-based screening did so because of (a) poor screening equipment and poor preparations, (b) nonqualified people doing the testing, (C) possible false positives, and ((1) lack of follow-ups or interventions. Conclusions The following conclusions were drawn from the study findings: 1. Pediatricians routinely do not test blood Cholesterol in all of their patients. 2. Pediatricians routinely collect family history of premature myocardial infarction or hyperlipidemia. 55 3. Pediatricians think that Childhood cholesterol levels are somewhat important as an indicator of the risk of developing cardiovascular disease in adunhood. 4. Pediatricians have varied opinions on whether or not all children should be checked for cholesterol levels at some time during their Childhood. 5. Pediatricians have varied opinions on whether or not only those children with a family history of premature myocardial infarction or hyperlipidemia should have their Cholesterol levels tested. 6. Most pediatricians agreed that pediatricians should be doing more Cholesterol testing in their practices. 7. Pediatricians had varied opinions concerning at what age to test for serum cholesterol for the first time (most thought 6 to 12 years). 8. Most pediatricians would not measure cholesterol again if it was not elevated initially. 9. Pediatricians had varied opinions concerning at which level they would consider an 8-year-old boy’s total Cholesterol to be elevated (180 was the most common response). 10. Most pediatricians thought that Cholesterol level should be measured twice to be certain that it was elevated. 56 11. Pediatricians agreed that lipoprotein fractions should be measured if the total cholesterol level was elevated. 12. The majority of pediatricians would refer to lab/check lab standards to consider elevated LDL Cholesterol for an 8-year-old boy. 13. Pediatricians would refer patients to a medical specialist according to elevated Cholesterol levels. 14. Pediatricians would consider medication for an 8—year-old boy with an elevated Cholesterol level. 15. Pediatricians thought they were somewhat effective at reducing the saturated-fat intake of their patients. 16. Most pediatricians opposed school-based Cholesterol screening programs for Children. Some pediatricians favored such programs under some circumstances. 17. Pediatricians preferred that Cholesterol screening be done by a pediatrician, physician, Clinic, or hospital-sponsored health fair. I I' I' [II SI | The findings identified deficiencies in the management of hypercholesterol- emia in Children and highlighted this as an important area for pediatric education. Much controversy in pediatrics exists concerning Childhood Cholesterol screening, in particular, who is to screen and at what age to begin screening. The study 57 findings imply that pediatricians. educators, and parents all have to obtain knowledge and work together for a better understanding of Children and cholesterol. Wyatt Because of the lack of research in this area, there is a vast field of studies that could be attempted in the area of Children and Cholesterol. Topics pertinent to the present study that it would be beneficial to investigate are as follows: 1. Conduct an intervention evaluation Of children with high Cholesterol. 2. Determine whether assessment of LDL and HDL Cholesterol, in addition to total Cholesterol, proves medically and cost effective. 3. Compare school-based interventions to physician-based interventions. 4. Evaluate pediatricians’ knowledge of children and Cholesterol. 5. Evaluate cardiologists’ perceptions and management of Childhood cholesterol screening. 6. Evaluate the differences in perceptions and management ofchildhood Cholesterol screening between rural and urban pediatricians. Reflections It is the researcher’s opinion that pediatricians lack knowledge in the area of Children and cholesterol screening. Pediatricians Should look at multiple channels of dissemination of information on this subject, such as a combination of general- 58 readership and specialty journals, self-help materials, workshops, and continuing medical education courses. Pediatricians have been reluctant to screen Children for Cholesterol, partly because of uncertainties about what is normal in children and partly because of fears that therapy could be harmful. Pediatricians are in a position to suggest a diet to promote healthy hearts in Children before adult dietary habits become fixed and more difficult to Change. Pediatricians can serve as resources to their communities in developing nutrition and CH0 risk-reduction programs. The goal of health education is to motivate society to adopt health behaviors that will reduce premature morbidity and mortality from preventable causes. This motivation can be effective only within the framework of educated pediatricians in this field and action-oriented school health programs, with a high degree of personal involvement and well-informed parents. Pediatricians can also work with the schools’ breakfast and lunch programs to encourage selection of foods that are both appealing and low in saturated fatty acids, total fat, and cholesterol. Understanding ofand use of food labels should also betaught 59 It is almost never too late—or too early—to begin making Changes in diet and lifestyle. Education in the area of Childhood cholesterol would benefit pediatricians, schools, and parents. An important message to pediatricians, schools, and parents Is that “a healthy body tomorrow begins with a healthy diet and lifestyle today.“ APPENDIX UNIVERSITY OF MINNESOTA Twin Cities Campus Division of Epidemiology Suite 300 . 1300 South Second Street 56,1001 ofPubltc Health Minneapolis. MN 55454-1015 612—624-1818 Fars612-624-0315 April 28, 1994 Ms. Jeanne LaCosse 6322 West Lake Drive Haslett, Michigan 48840 Dear Ms. LaCosse: As you requested, this letter will serve as written permission for you to use all or part of Pediatrician Survey (DCSS 0790) (enclosed) from the University of Minnesota Division of Epidemiology, in your research. That survey was developed by Tom Arneson, M.D., and myself, and was used to collect data for: Arneson, T., Luepker, R., Pirie, P., and Sinaiko, A., Cholesterol screening by primary care pediatricians: A study Of attitudes and practices in the Minneapolis — St. Paul metrOpolitan area. Pediatrics, 89(3):502-505, 1992. The above-mentioned paper should be referenced in any publication making use of our questionnaire. Sincerely, Phyllis L. Pirie, Ph.D. Associate Professor PLPzdg Enclosure 6O COLLEGE OF EDUCATION Department of iiacatlonal Administration Michigan State University 418 Erickson Hall East Lansrng, Michigan 48824-1034 1-517/355-4538 FAX: 1-517/363-6393 HALE Program 428 Erickson Hall 1-517/353-5187 II-12 Program 413 Erickson Hall 1-517/353-8480 Administrative Certification 402 Erickson Hall 1-517/‘353-5139 Michigan Cantor for Car & Tm M 230 Erickson Hall 1-517/353-4397 FAX: 5-517/353-6393 MSU is an affirmative-action. eater-0000mm IIISIIIUIiOn MICHIGAN STATE U N l V E R S l T Y Jeanne M. LaCosse 6322 W. Lake Dr. Haslett, Ml 48840 (517) 339-9265 Dear Dr. We are conducting a study concerning cardiovascular risk factors in childhood. The research will be used as part Of a Ph.D. dissertation at Michigan State University (Department of Educational Administration). We are requesting your participation in the study. The study will include a mail survey of Closed- and open-ended questions. You have the option to answer all or any of the questions asked, and all information will remain confidential. Your name and address will not be used in the study; subjects will be identified as Michigan pediatricians. We feel the study is important because previous research has indicated that coronary heart disease may begin in Childhood. Little is known about pediatricians’ attitudes regarding children and cholesterol. This study could provide information to pediatricians, educators, and parents. We have enclosed a stamped, addressed envelope for your participation response. If you choose to participate, we will contact your office to set up an interview time. The interview will take 10 to 15 minutes to complete. Sincerely, Jeanne LaCosse (Doctoral Student) Lou Romano, Ph.D. (Project Advisor) 62 PEDIATRICIAN SURVEY 1. What percentage of your patients are primary care? PERCENT 32 PERCENT IN PRIMARY CARE MUST BE AT LEAST 50%. OTHERWISE, TERMINATE INTERVIEW. 2. How many pediatric patients do you see in an average week? (UNDER AGE 18) PATIENTS lViISJST BE AT LEAST 25 PATIENTS. OTHERWISE, TERMINATE INTERVIEW. 3. And just to check my information. are you Board certified in Pediatrics? 1ElYEs 2DNO 38 IF NOT. TERMINATE INTERVIEW EPI/PED 001 (2-14) 7/90 Ver. 1 63 4. In your practice. do you routinely recommend a test of blood Cholesterol level for all your patients? 1l:lYEs . 5. ZELNO 6 GO TO Q. 14. PAGE 5 In a patient who comes to you as an infant and stays with you until late adolescence. at what age would you prefer to first test serum cholesterol level? (CHECK ONLY ONE) 1[___ILESS THAN 2 YEARS 21:12 - 5 YEARS 31:16 - 12 YEARS WRITE EXACT RESPONSE 4DOVER 12 YEARS 5|:lNO PREFERENCE to c In cases where the cholesterol was not elevated. would you routinely measure it again? IDYES . 7. At what age or ages would you do that? 2DNO III A. 42 j B I... GO TO Q. 8 GO TO Q. 8. NEXT PAGE NEXT PAGE EPl/PED 001 (3-14) 7/90 Ver. 1 64 8. Do you routinely collect family history of premature MI or hyperlipidemia? 1|:jYES . 2ClNO |I6 I GO TO Q. 22. PAGE 7 9. DO you use a printed form to collect family history for the patient’s medical record? IDYES . 10. Do you happen to recall if both premature MI and hyperlipidemia ZDNO are asked for specifically on the “7 form? ileEs. BOTH 2|:bNLY Ml SDONLY HYPERLIPIDEMIA 4DNEITHER sgDONT RECALL GO TO 9. 1 1 V 1 1. How frequently or at what ages is the family history updated? A. B. 12. Would you evaluate a child with a positive family history any differently than other children? IDYES . 13. In what way? 2DNO S 3 GO TO Q. 22. PAGE 7 GO TO Q. 22, PAGE 7 its 51 5h 56 $8 EPl/PED 001 (4-14) 7/90 Ver. 1 65 14. Do you routinely collect family history of premature MI or hyperlipidemia? IDYES . 15. Do you use a printed form to collect family history for the patient's medical record? ZDNO IDYES . 16. DO you happen to recall if both 6° premature MI and hyperlipidemia ZDNO are asked for specifically on the 5‘ form? 1DYES. BOTH 2DONLY MI SDONLY HYPERLIPIDEMIA AUNEITHER V GO TO Q. 22. SDDONT RECALL PAGE 7 s 2 ' GO TO Q. 17, NEXT PAGE GO TO Q. 17, NEXT PAGE EPI/PED 001 (5-14) 7/90 Ver. 1 66 updated? 17. How frequently or at what ages is the family history 1EjYES _, 2|:lNO 67 V GO TO Q. 22, NEXT PAGE 18. Do you routinely test blood cholesterol level in children with a family history in first degree relatives of premature M1 or hyperlipidemia? B. 19. In a patient who comes to you as an infant and stays until late adolescence. and who has a positive family history. at what age would you prefer to first test blood cholesterol level? (CHECK ONLY ONE) 1DYES __, 2[:INO 69 1E1LESS THAN 2 YEARS 2|:jz - 5 YEARS SDS - 12 YEARS WRITE EXACT RESPONSE 4DOVER 12 YEARS SDNO PREFERENCE 6 8 20. In cases where the cholesterol was not elevated. would you routinely measure it again? 21. At what age or ages would you do that? A. 70 e B. 72 GO TO Q. 22, GO TO Q. 22. NEXT PAGE NEXT PAGE 63 65 EPl/PED 001 (6-14) 7/90 Ver. 1 67 For the next few questions. please consider a healthy eight-year old boy. 22. 23. 24. 26. 27. Above what level would you consider his total cholesterol to be elevated? MG/DL OR PERCENTILE 7k 77 How many times would a cholesterol level need to be measured in order to be certain it is elevated? TIMES 79 If total cholesterol is elevated. would you recommend the lipoprotein fractions be measured? IDYES . 25. What level of LDL-cholesterol would you consider elevated in this eight-year old boy? 2l:lNo 8‘ MG/DL AND UP OR PERCENTILE 1 1mm as If the total cholesterol is elevated. would you routinely refer this patient to a medical specialist? 1DYES. ROUTINELY 2DDEPENDS ON LEVEL BDNO 88 And what advice would you give this patient? 89 91 93 EPI/PED 001 (7-14) 7/90 Ver. 1 68 28. At what total cholesterol level. if any. would you consider medication for this eight-year old boy? | MG/DL OR PERCENTILE 95 98 1E] NEVER WOULD 2DWOULD REFER FOR MEDICATIONS 100 29. How effective do you think pediatricians are likely to be in helping to reduce the saturated fat intake of their patients? Would you say they generally are likely to be very effective. somewhat effective. or only slightly effective? IDVERY EFFECTIVE 2DSOMEWHAT EFFECTIVE 3DSLICHTLY EFFECTIVE 4DDK 101 30. How important do you think childhood Cholesterol levels are as an indicator of the risk of developing cardiovascular disease in adulthood? Would you say they are very important. somewhat important. or not very important? 1DVERY IMPORTANT 2DSOMEWHAT IMPORTANT 3[:lNOT VERY IMPORTANT 4DDK 102 EPI/PED 001 (8-14) 7/90 Ver. 1 69 For each of the following. please indicate whether you strongly agree. somewhat agree. somewhat disagree. or strongly disagree. 31. Ideally. all children should have their cholesterol level checked at some time during childhood. IDSTRONGLY AGREE 2DSOMEWHAT AGREE SEISOMEWHAT DISAGREE 4DSTRONGLY DISAGREE SDDK 103 32. Only Children with a family history of premature M1 or hyperlipidemia should have their cholesterol level tested. 1[:]STRONGLY AGREE 2DSOMEWHAT AGREE SEISOMEWHAT DISAGREE 4E]STRONGLY DISAGREE 5DDK 10H EPI/PED 001 (914) 7/90 Ver. 1 33. Pediatricians should be doing more cholesterol screening in their practices. IDSTRONGLY AGREE 2DSOMEWHAT AGREE SDSOMEWHAT DISAGREE 4DSTRONGLY DISAGREE SEIDON'T KNOW I O 5 GO TO Q. 36. NEXT PAGE EPI/PED 001 (IO—l4) 7/90 Ver. 1 70 doing cholesterol screening? 34. What do you think keeps pediatricians from 106 108 110 '112 GO TO Q. 36. NEXT PAGE iiu Should not be doing more screening? $9.091? GO TO Q. 36. NEXT PAGE 35. In your opinion, why do you think physicians _l_ —|—l 116 116 12( 122 12I 71 87:11 129p 36. Do you favor or oppose school-based cholesterol screening programs for children? IUFAVOR . ZDFAVOR ONLY IN SOME CIRCUM- STANCES _, 3DOPPOSE _, 37. Why? GO TO Q. 40. BELOW 38. WHAT WOULD THAT BE? GO TO Q. 40. BELOW 39. Why is that? GO TO Q. 40. BELOW ‘4DDK/NO OPINION 126 40. Are there locations or settings, other than schools. where you would favor cholesterol screening programs for children? GO TO 9. 42. NEXT PAGE 127 130 132 13“ 136 13! 11H 1»: 41. Where is that? :1?— GO TO Q. 42. NEXT PAGE 1'0 EPI/PED 001 (ll-14) 7/90 Ver. 1 72 42. Have you ever attended a CME (Continuing Medical Education) course that included information about cholesterol testing and ways to effectively give guidance on diet? 1|:lYES _, 2DNO 151 V 43. 44. How long ago was that? IDLESS THAN OR EQUAL TO 2 YEARS AGO 2|:JGREATER THAN 2 YEARS AGO SDDK/DR 152 How likely would you be to attend another such course. if it were given in a Twin Cities location? Would you be very likely, somewhat likely. or not very likely to attend? IDVERY LIKELY TO ATTEND 2|]SOMEWHAT LIKELY TO ATTEND 3[___]NOT VERY LIKELY TO ATTEND 4l:]DK 153 GO TO Q. 46. NEXT PAGE 45. How likely would you be to attend such a course. if it were given in a Twin Cities location? Would you be very likely. somewhat likely. or not very likely to attend? IDVERY LIKELY TO ATTEND 2DSOMEWHAT LIKELY TO ATTEND 3DNOT VERY LIKELY TO ATTEND 4|'__'JDK 15H EPI/PED 001(12-14)7/90Vcr. 1 73 46. Where do you usually obtain information about cholesterol in childhood? Would you say you obtain information from a) journals? IDYES ZDNO 155 b) CME courses? IDYES 2EINO l 56 c) professional meetings? 1DYES ZDNQ 157 d) American Academy of Pediatrics? lDYES 2E1NO ‘58 e) consultations with colleagues? IDYES 2DNO l 59 0 Are there other sources of information you use? lDYES 2DNO 160 l SPECIFY: EPI/PED 001 (13-14) 7/90 Ver. 1 74 Finally. in order to help our staff interpret these results. I have just a few questions about you. 47. GENDER 48. 50. 51. IDMALE zljFEMALE 161 What is your age? :52 ASKQ. 49 YEARS IF WONT GIVE AGE. 49. Which age group are you in? In what year did you receive your Board Certification in Pediatrics? 19 165 IDNONE 167 IDGROUP HEALTH 168 IDMED CENTERS 169 IDPHP 170 IDSHARE 171 ICIBLUE PLUS 172 IDOTHER, SPECIFY: 173 Which HMO'S are you affiliated with? (CHECK ALL THAT APPLY) EPI/PED 001 (14-14) 7/90 Ver. 1 BIBLIOGRAPHY BIBLIOGRAPHY American Academy of Pediatrics. (1986). Prudentlifestyles for children: Dietary fat and cholesterol. Pediatrics, 18, 521. American Heart Association. (1990). fieafijagts. Dallas. TX: Author. Arneson, T.. Luepker, R.. Pirie. P.. & Sinaiko, A. (1992. March). Cholesterol screening by primary care pediatricians: A study of attitudes and practices in the Minneapolis-St. Paul metropolitan area. Eediairins. 89, 502-505. Berenson, G. (1992). Atherosclerosis of the aorta and cardiovascular risk factors in persons aged 6-30 years. WM 2.0. 851 -858. Davidson. D. M., & Smith, R. M. (1990, January-February). Cholesterol screening in children during office visits. Joumalpfliediatrictleaflnfiare, 1.1117. Donahue. P. (1985). Lipid and lipoproteins in a young adult population: The Beaver County lipid study. AmedsanJQumaLQLEpidelelm 122. 458- 467. Einhom, P. &Rifkind. B. (1993, April). Editorial. AmeflcanJQumaLQLQiseases QtClJlldhood. 141. 373-375. Enos, W. F. Holmes, R. G. & Beyer. J. (1986). Coronary disease among United States soldiers killed in action in Korea. JoumalpflheAmeucan MedicaLAssgciaiion. 25.6. 2859-2862 Glueck. C. (1991). Surveillance and management of children. Goff, D. C., Donker. G. A., Ragan. J. D., Jr., Adkins. A. T.. Killinger, R. P.. Caudill, J. W., Jr., 8. Labarthe, D. R. (1991, August). Cholesterol screening in pediatric practice. Eedjatrigs, 85. 250-258. 75 76 Griffin, T. C.. Christoffel, K. K., Binns, H. J., & McGuire, P. A. (1984, August). Family history evaluation as a predictive screen for childhood hypercho- Iesterolemia. Pediatric Practice Research Group. Pediatrics. 84. 365- 373. Holman, R. L., McGill. H. 0., Strong. J. P.. & Geer. J. C. (1958). The natural history of atherosclerosis: The early aortic lesions as seen in New Orleans. in the middle of the 20th century. W 9!. 34. 209-235. Jennings, R. B.. & Leon, S. P. (1992. February). Pediatric preventive cardiolo- gy: Experience in the Tidewater Virginia area. Wm 32, 39. 93. Kim. S. Y., Payne. G. H.. Lakato, S. E., Webber, L. 8.. & Greenblatt, J. (1992). Primary care physicians and children’s blood cholesterol. Kuntzleman, C. Reiff, G. Poore, E. Cumbenlvorth, 8.. &Arends. J. (1992). Noniastmgiloodiholesiemuflemmflmum. Ann Arbor: University of Michigan, Department of Movement Science. Laurer, R. M. 8. Clarke, W. R. (1990. December 19). Use of cholesterol measurements in childhood for the prediction of adult hypercholesterol- emia: The Muscatine study. JournaloijheAmeflcamMedicaLAssocia: lion. pp. 3034- 3038. . Nader, P. R. (1986, November). The role of the pediatrician in the prevention of coronary heart disease in childhood. Jananesefleandoumal. 21. 911- 922. Newman, T. B., Browner, W. 8.. &Hulley.S. B. (1990. December19). The case against childhood cholesterol screening. Wed Association. pp. 3039-3043. Resnicow, K., Cross, 0., LaCosse. J., & Nichols, P. (1993). Evaluation of a school-site cardiovascular risk factor screening intervention. ELElQDIIlLQ Medicine. 22. 838—856. Resnicow, K., Morley-Kothchen. J.. & Synder, E. (1989). Plasma cholesterol levels of 6,585 children in the United States: Results of the Know Your Body screening in five states. Pediatrics, 84: 969-976. Schoen, E. J. (1992. May). Childhood cholesterol screening. An alternative view. Americaniamflxflhxslcian. .45. 2179-2182. 77 Stary, H. C. (1989). Evolution and progression of atherosclerosis lesions in coronary arteries of children and young adults. Athemsdemsjs. 9. 1-32. Strong, J. P.. & McGill. H. C.. Jr. (1969). Pediatric aspects of atherosclerosis. 825.120.. 9. 251-265. Walter, H. Hofman, A. ,.Vaughan R. &Wynder. E. (1988). Modification of nsk factors for coronary heart disease. WWW 3.1.8. 1093- 1100.