This article was downloaded by: [Indiana University Libraries] On: 16 March 2015, At: 04:55 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
Cholesterol Screening—What Should We Be Doing? Ralph A. Manchester MD a
a b
University Health Service , USA
b
Department of Medicine , University of Rochester , Rochester, New York, USA Published online: 09 Jul 2010.
To cite this article: Ralph A. Manchester MD (1992) Cholesterol Screening—What Should We Be Doing?, Journal of American College Health, 40:6, 278-279, DOI: 10.1080/07448481.1992.9936293 To link to this article: http://dx.doi.org/10.1080/07448481.1992.9936293
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
EDITORUL Cholesterol ScreeningWhat Should We Be Doing?
Downloaded by [Indiana University Libraries] at 04:55 16 March 2015
Ralph A. Manchester, MD
C
ollege health professionals have a golden opportunity to promote prevention of a variety of chronic diseases, including certain cancers, coronary heart disease, substance abuse, and several infectious diseases, to name a few. Although disease prevention and health promotion certainly should be part of the scope of activities in a college health service,’ many questions remain concerning priorities and methods. The article by Dr Faige12 in this issue of JACH describes one institution’s approach to identifying students who have high blood cholesterol, one of the major reversible risk factors for coronary heart disease. Since 1977 this institution has had a policy that makes measurement of blood cholesterol a condition of enrollment for all entering students. Dr Faigel recommends “enforced mandatory cholesterol screening of every student matriculating at a college or university.” Let us examine this proposal more closely. The rationale for screening college students for coronary artery disease risk factors has been described previously in this j ~ u r n a l Screening .~ for any coronary artery disease risk factors can be done selectively (only on individuals who are thought to be at some increased risk) or universally; similarly, it can be mandatory or optional. Current guidelines from the National Cholesterol Education Program (NCEP)4 recommend selective screening for children aged 2 to 19 years (based on family history) and universal screening of adults aged 20 and above. The NCEP Expert Panels have not recommended mandatory screening under any circumstances. But because cholesterol screening seems like a good idea, why not use the power of the institution to force students to do it? Mandated compliance with diagnostic testing and medical treatment is fairly unusual in this country. In general,
Ralph A . Manchester b medical chief of the university health service and an assbtant professor in the Department of Medicine at the University of Rochester in Rochester, New York. 278
individuals are free to accept or decline most types of healthcare, with the area of contagious diseases the only exception for mentally competent people. Health evaluations done as a condition of participation in sports or to get a job or insurance policy are a different matter; no treatment is offered by the agency that requires the evaluation. Compliance with measures designed to control the spread of contagious diseases can be rationalized by invoking the need to protect the health of others. This argument, however, does not apply to coronary heart disease or to any of its risk factors. Some states have made seat belt use mandatory, but wearing a seat belt to decrease the number of deaths and severe injuries in motor vehicle accidents is quite different from testing to determine the presence of a risk factor. It seems that screening for high blood cholesterol does not meet the criteria we usually invoke when deciding to make a medical intervention mandatory. Several issues that are more specific to cholesterol testing and modification also make mandatory screening ill-advised. Perhaps the most important is the question of treatment. Cholesterol lowering requires a lifelong commitment by the individual at risk, who must follow an appropriate diet, exercise regimen, and (sometimes) drug treatment plan. Clearly, these steps cannot be mandated. How likely is it that the person who didn’t want to know his or her cholesterol level in the first place will decide to follow the treatment program? Other concerns include the lack of accuracy in some laboratory tests’ and lingering questions about cost-effectiveness of treatment.6 Ultimately, one must decide where to draw the line: Should Papanicolaou (Pap) testing for cervical cancer be mandatory? What about drug testing or testing for HIV infection? What should we be doing? As we’ and others have suggested, nonmandatory universal screening for high blood cholesterol and other coronary heart disease risk factors (family history, smoking, hypertension, obesity, diabetes, and possibly sedentary lifestyle) seems to be appropriate. But what is the optimal blood cholesterol cut-off point: 200 mg/dL? 180? Some other number? JACH
EDITORIAL: CHOLESTEROL SCREENING 2. Faigel HC. Screening college students for hypercholesterolemia. J A m Coil Health. 1992;40:272-275. 3. Manchester RA, Greenland P. Prevention of coronary atherosclerosis: The role of a college health service. J A m CON Heulth. 1987;35:261-266. 4. The Expert Panel. Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults. Arch Znt Med. 1988; 148:36-69. 5 . Dujovne CA, Harris WS. Variabilities in serum lipid measurements-Do they impede diagnosis and treatment of dyslipidemia? Arch Zht Med. 1990,1501583-1585. 6. Toronto Working Group. Efficiency considerations: The cost-effectiveness of treating asymptomatic hypercholesterolemia. J CIin Epidemiol. 1990;43: 1093-1101. 7. Manchester RA, McDuffie C, Diamond E. Screening for hypercholesterolemia in college students. J A m Coil Health.
Should HDL-cholesterol be measured as part of the initial screening test? Which intervention strategies are most effective in this young adult population? What is an appropriate level of resources to put into coronary heart disease prevention versus sexually transmitted disease prevention, substance abuse prevention, injury prevention, and prevention of other causes of premature death and disability? Can we answer all these questions in the next 5 to 10 years? REFERENCES 1. DeArmond MM, Bndwell MW, Cox JW, McCutcheon M, Beauregard RA, Charles KE, Heffern M-KR. College health toward the year 2OOO. J A m Coil Health. 1991;39:
1989;37: 149-153.
Downloaded by [Indiana University Libraries] at 04:55 16 March 2015
249-253.
The computer system for International Travel Advice
1M
What it is: A computer program which contains health information and U S . State Department Travel Advisories on over 200 countries
For these computers: IBM PC (MS-DOS 2.X) (and other compatibles) Available for Maclntosh What it does: 1. Produces reports for individual travelers to any number of countries; includes a summary statement of all preventive measures 2. Provides immediate access to all recommendations including CDC, WHO and U.S. State Department Travel Advisories
VOL 40, MAY 1992
Dept. B 93 Timber Drive Storrs, CT 06268 Voice/FAX: 203/487-0611 Is it current? The master program is updated daily as needed to reflect changes in world conditions; new diskettes can be mailed weekly or monthly as desired. Who is using Immunization Alert? physicians in primary care specialists in Infectious Diseases state and local health departments travel clinics group practices and HMO’s corporations whose employees must travel medical libraries
279
Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
Cholesterol Screening—What Should We Be Doing? Ralph A. Manchester MD a
a b
University Health Service , USA
b
Department of Medicine , University of Rochester , Rochester, New York, USA Published online: 09 Jul 2010.
To cite this article: Ralph A. Manchester MD (1992) Cholesterol Screening—What Should We Be Doing?, Journal of American College Health, 40:6, 278-279, DOI: 10.1080/07448481.1992.9936293 To link to this article: http://dx.doi.org/10.1080/07448481.1992.9936293
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
EDITORUL Cholesterol ScreeningWhat Should We Be Doing?
Downloaded by [Indiana University Libraries] at 04:55 16 March 2015
Ralph A. Manchester, MD
C
ollege health professionals have a golden opportunity to promote prevention of a variety of chronic diseases, including certain cancers, coronary heart disease, substance abuse, and several infectious diseases, to name a few. Although disease prevention and health promotion certainly should be part of the scope of activities in a college health service,’ many questions remain concerning priorities and methods. The article by Dr Faige12 in this issue of JACH describes one institution’s approach to identifying students who have high blood cholesterol, one of the major reversible risk factors for coronary heart disease. Since 1977 this institution has had a policy that makes measurement of blood cholesterol a condition of enrollment for all entering students. Dr Faigel recommends “enforced mandatory cholesterol screening of every student matriculating at a college or university.” Let us examine this proposal more closely. The rationale for screening college students for coronary artery disease risk factors has been described previously in this j ~ u r n a l Screening .~ for any coronary artery disease risk factors can be done selectively (only on individuals who are thought to be at some increased risk) or universally; similarly, it can be mandatory or optional. Current guidelines from the National Cholesterol Education Program (NCEP)4 recommend selective screening for children aged 2 to 19 years (based on family history) and universal screening of adults aged 20 and above. The NCEP Expert Panels have not recommended mandatory screening under any circumstances. But because cholesterol screening seems like a good idea, why not use the power of the institution to force students to do it? Mandated compliance with diagnostic testing and medical treatment is fairly unusual in this country. In general,
Ralph A . Manchester b medical chief of the university health service and an assbtant professor in the Department of Medicine at the University of Rochester in Rochester, New York. 278
individuals are free to accept or decline most types of healthcare, with the area of contagious diseases the only exception for mentally competent people. Health evaluations done as a condition of participation in sports or to get a job or insurance policy are a different matter; no treatment is offered by the agency that requires the evaluation. Compliance with measures designed to control the spread of contagious diseases can be rationalized by invoking the need to protect the health of others. This argument, however, does not apply to coronary heart disease or to any of its risk factors. Some states have made seat belt use mandatory, but wearing a seat belt to decrease the number of deaths and severe injuries in motor vehicle accidents is quite different from testing to determine the presence of a risk factor. It seems that screening for high blood cholesterol does not meet the criteria we usually invoke when deciding to make a medical intervention mandatory. Several issues that are more specific to cholesterol testing and modification also make mandatory screening ill-advised. Perhaps the most important is the question of treatment. Cholesterol lowering requires a lifelong commitment by the individual at risk, who must follow an appropriate diet, exercise regimen, and (sometimes) drug treatment plan. Clearly, these steps cannot be mandated. How likely is it that the person who didn’t want to know his or her cholesterol level in the first place will decide to follow the treatment program? Other concerns include the lack of accuracy in some laboratory tests’ and lingering questions about cost-effectiveness of treatment.6 Ultimately, one must decide where to draw the line: Should Papanicolaou (Pap) testing for cervical cancer be mandatory? What about drug testing or testing for HIV infection? What should we be doing? As we’ and others have suggested, nonmandatory universal screening for high blood cholesterol and other coronary heart disease risk factors (family history, smoking, hypertension, obesity, diabetes, and possibly sedentary lifestyle) seems to be appropriate. But what is the optimal blood cholesterol cut-off point: 200 mg/dL? 180? Some other number? JACH
EDITORIAL: CHOLESTEROL SCREENING 2. Faigel HC. Screening college students for hypercholesterolemia. J A m Coil Health. 1992;40:272-275. 3. Manchester RA, Greenland P. Prevention of coronary atherosclerosis: The role of a college health service. J A m CON Heulth. 1987;35:261-266. 4. The Expert Panel. Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults. Arch Znt Med. 1988; 148:36-69. 5 . Dujovne CA, Harris WS. Variabilities in serum lipid measurements-Do they impede diagnosis and treatment of dyslipidemia? Arch Zht Med. 1990,1501583-1585. 6. Toronto Working Group. Efficiency considerations: The cost-effectiveness of treating asymptomatic hypercholesterolemia. J CIin Epidemiol. 1990;43: 1093-1101. 7. Manchester RA, McDuffie C, Diamond E. Screening for hypercholesterolemia in college students. J A m Coil Health.
Should HDL-cholesterol be measured as part of the initial screening test? Which intervention strategies are most effective in this young adult population? What is an appropriate level of resources to put into coronary heart disease prevention versus sexually transmitted disease prevention, substance abuse prevention, injury prevention, and prevention of other causes of premature death and disability? Can we answer all these questions in the next 5 to 10 years? REFERENCES 1. DeArmond MM, Bndwell MW, Cox JW, McCutcheon M, Beauregard RA, Charles KE, Heffern M-KR. College health toward the year 2OOO. J A m Coil Health. 1991;39:
1989;37: 149-153.
Downloaded by [Indiana University Libraries] at 04:55 16 March 2015
249-253.
The computer system for International Travel Advice
1M
What it is: A computer program which contains health information and U S . State Department Travel Advisories on over 200 countries
For these computers: IBM PC (MS-DOS 2.X) (and other compatibles) Available for Maclntosh What it does: 1. Produces reports for individual travelers to any number of countries; includes a summary statement of all preventive measures 2. Provides immediate access to all recommendations including CDC, WHO and U.S. State Department Travel Advisories
VOL 40, MAY 1992
Dept. B 93 Timber Drive Storrs, CT 06268 Voice/FAX: 203/487-0611 Is it current? The master program is updated daily as needed to reflect changes in world conditions; new diskettes can be mailed weekly or monthly as desired. Who is using Immunization Alert? physicians in primary care specialists in Infectious Diseases state and local health departments travel clinics group practices and HMO’s corporations whose employees must travel medical libraries
279
