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On July 7, the American Academy of Pediatrics issued a brand new set of cholesterol screening and treatment recommendations for children. It had last done so a decade ago, but now the country's kid doctors felt there was a "new urgency," "given the current epidemic of childhood obesity with the subsequent increasing risk of type 2 diabetes mellitus, hypertension, and cardiovascular disease in older children and adults."
The 23-page clinical report summarizing the recommendations stated that "pediatricians must initiate the lifelong approach to prevention of CVD in their patients." They acknowledged that "diet and physical activity are equally important [as genetics] in determining the course of the disease process," but basically went on to outline procedures for testing blood-fat levels in children and recommending treatment with cholesterol-lowering drugs for those over age 8 who were placed at risk because of obesity.
The response to the new guidelines has largely been a debate focusing on the wisdom of treating children long-term with drugs that have been tested only for the short term, and then only among those children with familial cholesterol problems.
Professionalized Activity
OK, it isn't always easy to change ingrained patterns of behavior—but we are talking here about kids, for whom a "lifelong approach" to anything has not necessarily been established. And about kids who—the report acknowledges this—are experiencing low levels of physical activity in part because schools have taken away play and recess. They're also experiencing less physical activity because outside of school, activity among youth has been considerably professionalized to the point that it is dominated by the youth leagues of organized sports. There are no longer those casual neighborhood gatherings called pick-up games that anyone could join, even the many kids who just aren't good enough or coordinated enough or interested enough to want to be on a highly scheduled team. And there's less physical activity because there are now many competing demands for kids' attention in the form of X-boxes and computer games, which, by themselves, are not the end of civilization as we know it but which can confine kids indoors unless the adults in the house set up some simple rules of engagement. Of course, many parents today are quite comfortable knowing their kids are indoors, away from the predations of the pedophiles they (mistakenly) believe are lurking around every corner.
A Medicalized Approach
Still, the ideal lifelong approach would be to teach good nutrition and facilitate physical activity. Who better than the nation's pediatricians going into the schools and making the case for an institutional approach to increased physical activity—more active play, more recess, more playground time in general. They could make a swell argument on the obesity issue alone. Then there's the whole body of evidence that breaks for physical activity during the day actually increase the ability of kids to concentrate in the classroom. Yes, it's sometimes hard for schools to grasp this, but in education as in architecture, sometimes less is more; taking a little time away from instruction to add more recess actually makes the class time much more efficient; kids learn better after recess. Not incidentally, I should also point out there are studies showing that vigorous physical activity in kids stimulates brain development, boosts levels of nerve growth factors in the cortex. Admittedly it's counterintuitive, but play seems to promote growth of the very brain centers that will allow children to focus their attention and learn.
Uh-Oh, There's Fun Involved
Do I have to mention that free play and physical activity (when there are more options than organized sports) are actually fun and often downright thrilling for kids? For some kids, notably boys, recess can be the single most positive thing about school. But for most kids, playing freely tends to have a highly reinforcing quality. Physical activity does all that—and probably much more that we'll be hearing about from research labs in the years ahead. But instead, the pediatricians have chosen to focus on giving kids pills—a medical solution to a much more complex issue.
The Debate
I am horrified that the debate has focused largely on the quality of the evidence for medication. "While some doctors applauded the idea," Tara Parker-Pope reported in the New York Times, "others were incredulous. In particular, these doctors called attention to a lack of evidence that the use of cholesterol-lowering drugs, called statins, in children would prevent heart attacks later in life."
Punitive but Remunerative
So the best "lifelong approach" to cardiovascular disease is to get kids on the pharmaceutical track early? This seems almost punitive to me. After all, the alternative is to push for a solution that directly targets the cause and that, by the way, kids might actually end up enjoying. Why push for physical activity when you can make short shrift of the problem by turning kids into pill poppers? Why promote a passive rather than a—literally and figuratively—active solution, when passivity is part of the problem? The irony is that pediatricians tend to be among the most humane physicians. But in this case they have chosen a solution that benefits only pharmaceutical manufacturers. I'm just astounded that everyone who cares about kids isn't up in arms over this set of recommendations and marching on the schools to get them to restore recess and build in more activity to the day. Or, at home, just pushing the kids out the door for a while. We do care about our kids, don't we? Don't we?
See you next month. And don't hesitate to post an informed comment on any of the blog entries any time.
