Failure of current guidelines for cholesterol screening in urban African-American adolescents

The National Cholesterol Education Program (NCEP) and the American Academy of Pediatrics recommend selective screening to detect children and adolescents with hypercholesterolemia. We compared the effectiveness of these guidelines with other potential screening strategies in urban African-American adolescents.

Two hundred sixty African-American adolescents and young adults (192 females and 68 males; age range, 12 to 20 years) who were free from illnesses or medications that disrupt lipid metabolism were included in the study. Participants completed a questionnaire regarding their smoking habits, blood pressure, contraceptive pill use, and family history of early heart disease and high cholesterol and had their blood lipids, lipoproteins, and apolipoproteins measured (152 fasting and 108 nonfasting).

Nineteen percent of participants reported family histories of hypercholesterolemia; 26% reported family histories of premature heart disease; and 8% had family histories of both hypercholesterolemia and premature heart disease. Therefore, 37% of these participants would have been targeted for cholesterol screening, compared with the 25% predicted by the NCEP. Less than 50% of the participants with low-density lipoprotein cholesterol (LDL-C) levels greater than 110 or 130 mg/dL would have been detected by selective screening. Total cholesterol was superior as a screening test to apolipoprotein B in predicting LDL-C levels greater than 110 mg/dL (sensitivity, 92% vs 59%). However, total cholesterol minus high-density lipoprotein cholesterol showed better positive predictive value (100%) at LDL-C levels greater than 110 mg/dL than total cholesterol in the fasting (80%) and total groups (90%).

In this population, selective screening with total cholesterol, as recommended by the NCEP, has such poor sensitivity and positive predictive value that other options may be superior. As an alternative, we recommend the measurement of high-density lipoprotein cholesterol together with total cholesterol at the initial screening step in adolescents and universal screening for those older than 16 years to capture a greater proportion of young adults with increased LDL-C. Furthermore, we recommend using the less stringent treatment guidelines established by the Adult Treatment Panel II for premenopausal women and men younger than 35 years for older adolescents and young adults.