In 2011, the National Heart, Lung, and Blood Institute recommended universal cholesterol screening for adolescents and young adults ages 17–21 years. This recommendation is endorsed by the American Academy of Pediatrics and is meant to detect abnormal cholesterol levels that could lead to problems many years in the future, like heart attacks and strokes. The recommendation is predicated on the premise that teens will actually want to do something about an abnormal result — like change their diet or exercise habits or take a cholesterol-lowering medication. But will they?
As clinicians and researchers in the Division of Adolescent and Young Adult Medicine and the Department of Cardiology’s Preventive Cardiology Program, we sought to answer this question by going straight to the source — teens and young adults between the ages of 17-21 years. As part of a Patient Centered Outcomes Research Institute award, we teamed up with a variety of stakeholders who care about heart health and cholesterol screening in youth — teens, parents, pediatricians, nurse practitioners and researchers in the field. Working with this panel of stakeholders, we devised a set of hypothetical cholesterol-screening scenarios and presented them to 37 youth at different levels of risk for cholesterol problems, as well as 35 parents of youth in this age range. We asked them how they would feel if they or their child received a very high, moderately high or reassuring cholesterol test and then explored their thoughts and feelings further in an in-depth interview. Our results were recently published in the Journal of Adolescent Health.
Long term vs. short term lenses
Not surprisingly, youth and parents felt the very-high cholesterol and moderately-high cholesterol results would lead them to feel like they or their child were in less than “perfect” health. We did not see any significant differences in how youth vs. parents — or those at different levels of risk for cholesterol problems based on their own personal history — rated the hypothetical results on a numerical scale. However, the interviews revealed a much more interesting story.
Many parents expressed concerns that youth would not take the very-high cholesterol result seriously, either due to the competing demands of young adulthood or due to a sense of invincibility. However, the vast majority of youth felt knowing they might have a heart attack as early as 40 years of age greatly impacted their sense of health. They expressed fear, anxiety and worry about this hypothetical result and related their concerns to what they hoped to be doing with their lives at that age (such as parenting or working). Most youth said receiving a very-high cholesterol result would motivate them to take action in some way, typically by improving their dietary choices or starting/intensifying their exercise routine.
There was a wider range of responses to the moderately-high cholesterol scenario, which was described as indicating risk of a heart attack by age 70 years. Most youth conceded that this result would impact them less than the very-high result, rationalizing that 70 was close to the average life expectancy in the U.S. and/or was when people were expected to have heart attacks anyway. Parents were pretty skeptical that young people would have much of a reaction to a predicted event 50 years in the future. Youth and parents both felt that teens might initiate behavior change but have difficulty sustaining it or procrastinate until they were much older and closer to the age at predicted cardiovascular disease events.
So what do we do with this information? It is clear that the actions teens take now — dietary choices, exercise, weight management and smoking – impact their risk for heart attack and stroke many years in the future. Our results imply that when teens receive information indicating risk is more imminent, they may be motivated to do something about it.
But how do we convince teens in the moderate-risk group to stay heart healthy for the next 50 years? That is the next puzzle for me and my colleagues.
Holly Gooding, MD, MSc graduated from the UC Berkeley School of Public Health and UC San Francisco School of Medicine before completing her residency in Internal Medicine at Brigham and Women’s Hospital and her fellowship in Adolescent Medicine at Boston Children’s. She is the principal investigator of an NIH-funded study examining maintenance of cardiovascular health across the life course with her mentor and collaborator Sarah deFerranti, MD, MPH.
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