In a provocative article published last year in the Canadian Medical Association Journal, Dr. David L. Sackett stated that preventive medicine is arrogant.
He supports his thesis with three statements:
- Preventive medicine is aggressively assertive, pursuing symptomless individuals and telling them what they must do to remain healthy.
- Preventive medicine is presumptuous, confident that the interventions it supports will, on average, do more good than harm to those who accept and adhere to them.
- Preventive medicine is overbearing, attacking those who question the value of its recommendations.
Shall we then assume that when the American Academy of Pediatrics and the Canadian Paediatric Society made it clear the promotion of lifelong physical activity would be on their list of top priorities, they were arrogant? Not at all. In fact, according to a landmark publication in its official journal, The American Heart Association (AHA) put forth the first-ever scientific statement on preventing Atherosclerotic Heart Disease Beginning in Childhood. (Circulation, March 25, 2003. www.circulationaha.org.)
Although the Association has provided doctors and patients with previous statements (in 1996 and an updated version in 2002), these statements only referred to adults. Now for the first time ever, we are given data and well-researched references indicating that paediatricians can prevent heart attacks – or even cause them by not talking to families and ‘forgetting’ or deliberately ignoring data that tells them they should address these issues at every routine check-up.
Atherosclerotic heart disease remains the leading cause of both death and disability in North America, as well as in many parts of the planet. Its onset is early – in childhood – to be exact. Autopsies performed on children and young adults, often after unexpected deaths such as those due to homicides and automobile accidents, have shown the presence of almost plugged-up vessels. This early finding often correlates with established risk factors such as high cholesterol levels, elevated blood pressure, an increased body mass index and cigarette smoking.
The well-respected Bogalusa study confirms when a child is monitored prospectively from age 4 to as many as 35 years later, those with risk factors identified during adolescence, and even early childhood, are similar to a time-bomb just waiting to go off. It is not a question of whether they will end up with obstructed blood vessels; it is a question of when they will feel chest pains or, unfortunately, find out that a cardiac arrest is the first sign of heart trouble.
The current epidemic of obese children, many as young as preschool age, combined with a family history of atheroscleotic heart disease and inactivity, will cost society dearly. And to prevent this potential catastrophe is anything but arrogant or controversial.
Three activities are particularly important to discuss, starting as early as possible: dietary habits, physical activity and the use of tobacco. The data supporting such interventions are well summarized in the AHA's position statement.
Six broad categories are detailed and referenced in the March edition of Circulation: Pathological Evidence for Risk Factor Impact in the Young; Prevalence of Obesity and Type 2 Diabetes Mellitus; Tracking of Risk Factors from Childhood into Adult Life; Acquisition of Risk Behaviours in Childhood; Intervention Trials; and Pediatric Consensus Statements.
Are these highly necessary interventions, when started in childhood (done now with the belief heart attacks can be prevented later in life) considered safe for children? Fortunately, the answer is a confident yes. The Dietary Intervention Study in Children (DISC) demonstrated the safety and efficiency of a low-fat diet in children with hypercholesterolemia. Skill-training programs in smoking prevention in adolescents have been shown to be successful. Increasing physical activity levels in children by using elementary school-based programs also change the prevalence of childhood obesity
Meanwhile, if some doctors dither over the AHA's recommendations (unbelievably, some confused Cassandra’s exist – ones who are fearful of causing eating disorders or labelling children at too early an age) average parents can initiate some interventions on their own steam.
My advice is simple: parents should know their own cholesterol and blood pressure. If it is high and there is also a history of early heart attacks and strokes, a child over two years of age should get a cholesterol and triglyceride level done; parents must read more about healthy nutrition (the consumption of lower fat after two years of age, a variety of fruits, vegetables, whole grains, fish, legumes, poultry, lean meat, limited intake of salt, less than 6 g per day and reducing sugar consumption drastically); avoid exposure of the child to second-hand smoke and limit sedentary time by making physical activity fun. For more ideas on the specifics of these suggestions see www.paguide.com
Existing evidence indicates primary prevention of atherosclerotic disease should begin in childhood. It is not too early but it should be done with professional input and preferably by all doctors and nurses who encounter children. Unfortunately, some doctors see themselves as too important or busy to talk prevention and they erroneously see it as the task best done by a community health nurse. However, with new data from the AHA, this is about to change as more paediatricians discover they can prevent heart attacks.
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An informed parent is ... an empowered parent.