Screening College Students for Hypercholesterolemia Harris C. Faigel, MD
Abstract. Selective screening for children and mass screening for adults are the two strategies for detecting hypercholesterolemia and identifying individuals at risk for early heart attacks that have been recommended by the American Academy of Pediatrics and the American Medical Association. The interval
marking the end of childhood and the beginning of adulthood is a time of transition without an unwavering demarcation line. It is a time when many adult disorders that demand attention and detection begin. Because of the close relationship of elevated cholesterol levels in youth to subsequent cardiovascular disease, a small liberal arts university began mandatory mass cholesterol screening for all full- or part-time students who matriculated in September 1977. More than thirty 18- and 19-year-old first-year students with unknown hypercholesterolemia were detected each year. The mean cost per case identified is estimated to have been $212. The author concluded that mass screening of students entering college can identify, at a reasonable cost, students who have high levels of cholesterol. Key Words. cholesterol, lipids, mandatory testing therosclerotic coronary artery disease is the leading cause of death in the United States.' Of hyperlipidemia, hypertension, and cigarette smoking, the three principal risk factors in this disorder, hyperlipidemia is the most prevalent in children and adolescents.' It is well known that elevated lipid levels in youth continue into adulthood,'" and that fatty streaks in the vessels of young children advance to fibrous plaques at puberty and to atheromata in a d ~ l t h o o dEarly . ~ detection of the condition is important because autopsies of men in their late teens and early twenties who were killed in battle in Korea and Vietnam revealed the presence of atherosclerotic The American Heart Association and the American Academy of Pediatrics Committee on Nutrition have limited their recommendation regarding testing for hyperlipidemia to selective screening only of children with a family history of hyperlipidemia or early heart attack
before age 50.7*8 On the other hand, the American Medical Association urges routine screening before a person is 21 years and the United States Public Health Service goal for the year 2000 is to have 75% of all 18-year-olds tested and aware of their cholesterol levels.'o Mass screenings have been opposed as unethical, expensive, and uneconomical, and testing has been criticized as ~nreliable.~," Cholesterol, however, is the most easily detectable risk factor in adolescents and young adults, making identification imperative." Selective screening programs have also been criticized. Although a family history is helpful in choosing whom to test in a selective screening it is not sufficiently sensitive for use with adolescents and young adults. Too many college students have parents who are still less than 50 years old, who have never had a coronary artery problem, and who are not yet old enough to have had a heart attack. Too many college students have parents who have never been tested for cholesterol. Faced with the evidence that (1) cholesterol is one of the prime culprits in coronary artery disease; (2) changes in arterial walls that lead to atherosclerosis may begin before the college years; (3) the reliability of cholesterol levels tracking into adulthood and correlating with risk of early disease; (4) the unreliability and insensitivity of a family history; ( 5 ) the importance of starting treatment as early as possible to prevent disease; and (6) the ease of determining cholesterol, the medical staff of the Brandeis University Health Services carefully considered the alternatives and chose to require routine cholesterol testing of all entering students. Although information was gathered on undergraduate and graduate students alike, this study focuses solely on the first-year undergraduate population because of the wide disparity in ages of newly matriculating graduate students. This article reports on the results of that examination. METHOD
Hamk C. Faigel is director of the student health service at Brandeis University in Waltham, Massachusetts.
272
Beginning with the classes matriculating in September 1977, every newly enrolled student in the university was JACH
SCREENING FOR HYPERCHOLESTEROLEMIA
required to submit the results of a cholesterol test to the student health service as part of the prematriculation medical examination required by the university in order to be allowed to register for classes. Every examination record submitted that lacked any of the required data was rejected and returned for completion. With the help of the university registrar, we achieved a compliance level of 100%. Students were permitted to enroll in the university, but none could complete registration for classes until they had been approved by the health service. Approval was withheld if any medical data, including cholesterol readings, were incomplete. We made no attempt to distinguish between plasma or serum, fasting or nonfasting levels on preregistration data, nor did we specify which would be required. No follow-up by the personal physician was requested, and no other lipid values were required. The mean cholesterol level for each entering class was calculated, and data were broken down for men and women. All students whose reported cholesterol exceeded 200 mg/dL (approximately the 95th percentile) were called to the health service, and a complete serum lipid profile was obtained in all who agreed (the rest were referred to their personal physician). The profile included fasting levels of total serum cholesterol, high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), and triglycerides. RESULTS
The age range for entering first-year undergraduates was 17 to 21 years (mean 18.2). Between September 1977 and June 1989, we collected data on 9,938 students, equally divided between men and women. In 1977, the mean cholesterol level of the entering freshman class was 176 f 15 mg/dL. The level in the men was 174 k 15 mg/dL, in the women 177 k 17 mg/dL. By 1987, these levels had fallen to 168 k 16 mg/dL in the men, 170 f 19 mg/dL in the women, and 170 f 16 mg/dL overall. The level of cholesterol needing further study was set at 200 mg/dL, based on the 95th percentile in our 1977/78 data. Abnormal lipid values were defined as those in which there was an elevation of the total fasting cholesterol above 200 mg/dL, LDL cholesterol above 160 mg/dL, or triglycerides above 180 mg/dL, or very low levels of HDL cholesterol (below 30 mg/dL). A ratio of cholesterol to HDL cholesterol greater than 5 was considered evidence of an increased risk of early atherosclerosis.’* We interviewed 873 students (467 women and 406 men) whose cholesterol exceeded 200 mg/dL and urged them to have lipid profile tests performed. Of these, 427 (229 women and 198 men) had fasting lipid profile determinations done at the university, and 344 (181 women and 163 men) were found to have abnormal levels of cholesterol, LDL, or triglycerides as defined above. Four hundred forty-six students (238 women and 208 men) chose to have further testing performed by their personal physicians at home. Data for their examinaVOL 40, MAY 1992
tions are incomplete and therefore are not included in this report (see Figure 1). Only 43 of 344 students with abnormal lipid profiles met the American Academy of Pediatrics criteria and had a family history of heart disease, coronary artery disease, or stroke before age 50. However, 206 more had a family history of such disorders after age 50 but before age 60. At a price of $6 per test, the average price at the reference laboratory used by the student health service during the period under study, we estimate that the 9,938 cholesterol screenings cost a total of $59,628. Recall letters to each of the 873 who had high screening levels cost $5 each to prepare and send. The 427 lipid profiles we performed at $21 each cost students or their insurance carriers $8,%7. The estimated total cost for cholesterol surveillance over the 12 years of this program was $72,960. Cost per hyperlipidemic student identified in the student health service was therefore $212. DISCUSSION
The decision about when to screen for the presence of the major reversible factors contributing to coronary artery disease should be made carefully and should be based on data properly derived from clinical study.The National Cholesterol Education Program Expert Panel7 offers rational guidelines for screening based on scientific data.l3*l4 The American Academy of Pediatrics recommends screening children only when there is a family history of heart disease before age 50,7 whereas the American Medical Association recommends screening every adult before the age of 21.13The dilemma these opposing recommendations create for college health services is that entering first-year students are both children and adults, depending on the definition one chooses to use, and neither association’s recommendation fits. The true issue is physiological maturity, and persons in late adolescence are physiologically mature. Cholesterol abnormalities in childhood track through adolescence into adulthood, reliably predicting the risk of atherosclerosis because individuals remain in the same quartile throughout their lifetimes. Thus, the quandary with regard to cholesterol is not whether to test, but when to test and how, and whether to make it optional or mandatory. The choices are whether to use selective screening at age 18, as the American Academy of Pediatrics recommends, then follow with mass screening of older students at 20, according to the advice of the American Medical Association; to do mass screening at age 18; to urge students to have voluntary testing and make it easily accessible but not mandatory; or to ignore the problem and leave it to others after the students graduate. Long” points out that routine annual health screenings encourage health promotion and the awareness of measures that can prevent illness, but it is important to know what benefits might accrue and what the costs 273
COLLEGE HEALTH
FIGURE 1 Results of Mass Screening College Students for Hyperlipidemia, 1977-1989
467 women Normal: 9,065
>200 mgJ& 873
406 men
Declined testing: 446
Normal: 83
229 women
Retested at student health service:427
Abnormal: 344
{
198 men
181 women
163 men Note: Abnormal was defmed as total fasting cholesterol > 200 mg/l ; ,DLcholesterol mg/dL; or triglycerides > 180 mg/dL; or HDL cholesterol < 30 mg/dL.
may be.16Marcus et al” have shown that teaching teenagers about high risks to health can change behaviors, and Williams’* reported that health-risk reduction in childhood is effective in promoting health in adults. Manchester et all9 report that the cost of finding one college student with hypercholesterolemia was $624 when done as part of a selective program, but only $121 per case as part of a mass screening program. We found that, at $212,it was more costly than Manchester had reported for us to find each student in mass screening because we were not able to follow every case with further testing when students chose to seek additional care elsewhere. Garcia and Moodie” recommend that every child older than 3 years have a cholesterol test. Cresanta et al,4 concerned over the fatty streaks seen by age 3, recommend annual cholesterol testing by age 5 . Kuske and Feldman recommend routine testing in all adults.” We believe that the onset of the process that leads to atherosclerosis begins at or near puberty, and this creates an imperative to begin preventive measures as early in life as p o s ~ i b l e . ~ Brown’s , ~ * ~ ’ data indicating that aggressive therapy can limit the progression of atherosclerosis, can lead to the regression of some lesions, and can reduce the frequency of cardiovascular occlusions c o n f m the importance of early detection and therapy.”” The medical staff of this student health service adopted a mandatory testing policy in 1977 for all students entering the university. We then called in every student whose entrance cholesterol exceeded 200 mg/dL to arrange further testing. The medical staff adopted this policy because we be274
> 160
lieved that our obligation for preventive medical care included detecting and treating the hyperlipidemias. The university already required a prematriculation medical examination, including measurement of hemoglobin, analysis of urine, and documented immunization against contagious diseases, in order to be permitted to register in the university. We concluded that there was sufficient research data to believe that some matriculants already had early atheroscler~sis,~~~ that recommendations for screening had been made by national and international organizations for nearly a decade, that preventive care needed to begin early in order to affect health in adulthood,” and that only mandatory mass screening could effect that. Furthermore, the staff believed then and now that failure to apply this knowledge was an unacceptable breach of our responsibility to our patients, that such knowledge made it incumbent upon us to detect and treat any condition, whether anemia, renal dysfunction, or hypercholesterolemia. Mandatory testing was and has been an extension of our obligation to provide preventive healthcare since the inception of the service 30 years earlier. Among 9,938matriculants, 873 (8.8%) reported cholesterol levels greater than 200 mg/dL. Although only 427 chose to have further testing at the university, 344 (80.8%) of those had abnormal lipid profiles. If abnormalities occurred with equal frequency in those who chose to be tested at home, then 705 (7.1%) of all matriculants would be expected to have had abnormal lipid profiles. We believe that this program is good value for the money and the effort expended. We have alerted 344 JACH
SCREENING FOR HYFERCHOLESTEROLEMiYl
people who might not have known about their hyperlipidemia and have enabled them to institute treatment that may extend their lives. Their appreciation buffers the complaints of those who think the economic or ethical costs of testing are too high. CONCLUSIONS We conclude that mass screening of all first-year college students is efficient, effective, and economical in detecting those students who would benefit from cholesterol reduction, one of the modifiable risks in coronary artery disease. Recognizing that we are a minority voice, we urge enforced mandatory cholesterol screening of every student matriculating at a college or university. There must be proper follow-up and care of all whose levels are abnormal. We suggest that permission to complete registration for classes is an acceptable and manageable hurdle that allows students to matriculate but ensures fullest cooperation. REFERENCES
1. Thom TJ, Kannel WB. Downward trend in cardiovascular mortality. Ann Rev Med. 1981;32427-434. 2. NIH Consensus Conference. Lowering blood cholesterol to prevent heart disease. JAMA. 1985;253:2080-2086. 3. Coates TJ, Perry C, Lden J, Slinkard LA. Heart healthy eating and exercise: Introducing and maintaining changes in health behaviors. A m JPublic Health. 1981;71:15-23. 4. Cresanta JL, Burke GL, Downey AM, Freedman DS, Berenson GS. Prevention of atherosclerosis in childhood. Pediatr CIin North Am. 1986;33:835-858. 5. Enos WF, Beyer JC, Holmes A. Pathogenesis of coronary diseases in American soldiers killed in Korea. JAMA. 1955;158~912-914. 6. Strong JP. Coronary atherosclerosis in soldiers: A clue to the natural history of atherosclerosis in the young. JAMA. 1986;256:2863-2866. 7. Committee on Nutrition. Indications for cholesterol testing in children. Pediatrics. 1989;83:141-142. 8. Walter HJ, Hoffman A. Socioeconomic status, ethnic origin and risk factors for coronary heart disease in children. Am Heart J. 1987;113:812-815. 9. Resnicow K, Morley-Kotchen J, Wynder E. Plasma cholesterol levels in 6,588children in the United States: Results of the Know Your Body screening in five states. Pediatrics. 1989;84:%9-976. 10. Public Health Service. Promoting health/preventing disease: Year 2ooo objectives for the nation (draft). Washington, DC: US Department of Health and Human Services; 1989. 11. Current Status of Blood Cholesterol Measurements in Clinical Laboratories in the United States: A Report From the Standardization Panel of the National Cholesterol Program. NIH Publication 88-2928,National Heart and Lung Institute; 1988. 12. Grundy SM. Recommendations for the treatment of hyperlipidemia in adults. Arteriosclerosk. 1984;4:445A-468A. 13. The Expert Panel. Report of the National Cholesterol Education Program Expert Panel on detection, evaluation and
VOL 40, MAY 7992
treatment of high blood cholesterol in adults. Arch Int Med. 1988;148:36-39. 14. Olson RE. Mass intervention vs screening and selective intervention for the prevention of coronary artery disease. JAMA . 1986;255:2204-2207. 15. Long JJ. Routine screening tests for the adolescent. Prim Care. 1987;14:41-47. 16. Kuske TT,Feldman EB. Hyperlipoproteinemia, atherosclerosis risk and dietary management. Arch Intern Med. 1987; 147~357-360. 17. Marcus AC, Wheeler RC, Cullen JW,Crane LA. Quasi-experimental evaluation of the Los Angeles Know Your Body program: Knowledge, beliefs and self-reported behaviors. Prev Med. 1987;16803-815. 18. Williams CL. Nutrition intervention and health risk reduction in childhood: Creating healthy adults. Pediatrician. 1983-1985;12:47-101. 19. Manchester R, McDuffie C, Diamond E. Screening for hypercholesterolemia in college students. J A m Coll Health. 1989;37:149-153. 20. Garcia RF, Moodie DS. Routine cholesterol surveillance in childhood. Pediatrics. 1989;84:751-755. 21. Leaf A, Ryan TJ. Prevention of coronary artery disease: A medical imperative. New Eng J Med. 1990;323: 14161419. 22. Brown G, Albers JJ, Fisher LD, et al. Regression of coronary artery disease as a result of intensive lipid-lowering therapy of men with high levels of apolipoprotein-B. New Eng JMed. 1990,323:1289-1298. 23. Loscalzo J. Regression of coronary atherosclerosis. New Eng JMed. 1990;323:1337-1339. CAREER OPPORTUNITY
SUNY-Geneseo Physician/Nledical Director Will over see a 5,300-enrollment student health center. Inpatient and outpatient clinics, 24-hour service. Position includes
rn clinical-practice rn shared administration responsibilities rn full-time commensurate salary rn malpractice coverage rn excellent state benefits Send cuniculum vitae to:
Joyce A. Hance Student Health Center State University College Geneseo, NY 14454 (716) 245-5736 New York State licensure required Applications accepted until position is filled. Women and minorities are encouraged to apply
AAlEOE
275
Abstract. Selective screening for children and mass screening for adults are the two strategies for detecting hypercholesterolemia and identifying individuals at risk for early heart attacks that have been recommended by the American Academy of Pediatrics and the American Medical Association. The interval
marking the end of childhood and the beginning of adulthood is a time of transition without an unwavering demarcation line. It is a time when many adult disorders that demand attention and detection begin. Because of the close relationship of elevated cholesterol levels in youth to subsequent cardiovascular disease, a small liberal arts university began mandatory mass cholesterol screening for all full- or part-time students who matriculated in September 1977. More than thirty 18- and 19-year-old first-year students with unknown hypercholesterolemia were detected each year. The mean cost per case identified is estimated to have been $212. The author concluded that mass screening of students entering college can identify, at a reasonable cost, students who have high levels of cholesterol. Key Words. cholesterol, lipids, mandatory testing therosclerotic coronary artery disease is the leading cause of death in the United States.' Of hyperlipidemia, hypertension, and cigarette smoking, the three principal risk factors in this disorder, hyperlipidemia is the most prevalent in children and adolescents.' It is well known that elevated lipid levels in youth continue into adulthood,'" and that fatty streaks in the vessels of young children advance to fibrous plaques at puberty and to atheromata in a d ~ l t h o o dEarly . ~ detection of the condition is important because autopsies of men in their late teens and early twenties who were killed in battle in Korea and Vietnam revealed the presence of atherosclerotic The American Heart Association and the American Academy of Pediatrics Committee on Nutrition have limited their recommendation regarding testing for hyperlipidemia to selective screening only of children with a family history of hyperlipidemia or early heart attack
before age 50.7*8 On the other hand, the American Medical Association urges routine screening before a person is 21 years and the United States Public Health Service goal for the year 2000 is to have 75% of all 18-year-olds tested and aware of their cholesterol levels.'o Mass screenings have been opposed as unethical, expensive, and uneconomical, and testing has been criticized as ~nreliable.~," Cholesterol, however, is the most easily detectable risk factor in adolescents and young adults, making identification imperative." Selective screening programs have also been criticized. Although a family history is helpful in choosing whom to test in a selective screening it is not sufficiently sensitive for use with adolescents and young adults. Too many college students have parents who are still less than 50 years old, who have never had a coronary artery problem, and who are not yet old enough to have had a heart attack. Too many college students have parents who have never been tested for cholesterol. Faced with the evidence that (1) cholesterol is one of the prime culprits in coronary artery disease; (2) changes in arterial walls that lead to atherosclerosis may begin before the college years; (3) the reliability of cholesterol levels tracking into adulthood and correlating with risk of early disease; (4) the unreliability and insensitivity of a family history; ( 5 ) the importance of starting treatment as early as possible to prevent disease; and (6) the ease of determining cholesterol, the medical staff of the Brandeis University Health Services carefully considered the alternatives and chose to require routine cholesterol testing of all entering students. Although information was gathered on undergraduate and graduate students alike, this study focuses solely on the first-year undergraduate population because of the wide disparity in ages of newly matriculating graduate students. This article reports on the results of that examination. METHOD
Hamk C. Faigel is director of the student health service at Brandeis University in Waltham, Massachusetts.
272
Beginning with the classes matriculating in September 1977, every newly enrolled student in the university was JACH
SCREENING FOR HYPERCHOLESTEROLEMIA
required to submit the results of a cholesterol test to the student health service as part of the prematriculation medical examination required by the university in order to be allowed to register for classes. Every examination record submitted that lacked any of the required data was rejected and returned for completion. With the help of the university registrar, we achieved a compliance level of 100%. Students were permitted to enroll in the university, but none could complete registration for classes until they had been approved by the health service. Approval was withheld if any medical data, including cholesterol readings, were incomplete. We made no attempt to distinguish between plasma or serum, fasting or nonfasting levels on preregistration data, nor did we specify which would be required. No follow-up by the personal physician was requested, and no other lipid values were required. The mean cholesterol level for each entering class was calculated, and data were broken down for men and women. All students whose reported cholesterol exceeded 200 mg/dL (approximately the 95th percentile) were called to the health service, and a complete serum lipid profile was obtained in all who agreed (the rest were referred to their personal physician). The profile included fasting levels of total serum cholesterol, high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), and triglycerides. RESULTS
The age range for entering first-year undergraduates was 17 to 21 years (mean 18.2). Between September 1977 and June 1989, we collected data on 9,938 students, equally divided between men and women. In 1977, the mean cholesterol level of the entering freshman class was 176 f 15 mg/dL. The level in the men was 174 k 15 mg/dL, in the women 177 k 17 mg/dL. By 1987, these levels had fallen to 168 k 16 mg/dL in the men, 170 f 19 mg/dL in the women, and 170 f 16 mg/dL overall. The level of cholesterol needing further study was set at 200 mg/dL, based on the 95th percentile in our 1977/78 data. Abnormal lipid values were defined as those in which there was an elevation of the total fasting cholesterol above 200 mg/dL, LDL cholesterol above 160 mg/dL, or triglycerides above 180 mg/dL, or very low levels of HDL cholesterol (below 30 mg/dL). A ratio of cholesterol to HDL cholesterol greater than 5 was considered evidence of an increased risk of early atherosclerosis.’* We interviewed 873 students (467 women and 406 men) whose cholesterol exceeded 200 mg/dL and urged them to have lipid profile tests performed. Of these, 427 (229 women and 198 men) had fasting lipid profile determinations done at the university, and 344 (181 women and 163 men) were found to have abnormal levels of cholesterol, LDL, or triglycerides as defined above. Four hundred forty-six students (238 women and 208 men) chose to have further testing performed by their personal physicians at home. Data for their examinaVOL 40, MAY 1992
tions are incomplete and therefore are not included in this report (see Figure 1). Only 43 of 344 students with abnormal lipid profiles met the American Academy of Pediatrics criteria and had a family history of heart disease, coronary artery disease, or stroke before age 50. However, 206 more had a family history of such disorders after age 50 but before age 60. At a price of $6 per test, the average price at the reference laboratory used by the student health service during the period under study, we estimate that the 9,938 cholesterol screenings cost a total of $59,628. Recall letters to each of the 873 who had high screening levels cost $5 each to prepare and send. The 427 lipid profiles we performed at $21 each cost students or their insurance carriers $8,%7. The estimated total cost for cholesterol surveillance over the 12 years of this program was $72,960. Cost per hyperlipidemic student identified in the student health service was therefore $212. DISCUSSION
The decision about when to screen for the presence of the major reversible factors contributing to coronary artery disease should be made carefully and should be based on data properly derived from clinical study.The National Cholesterol Education Program Expert Panel7 offers rational guidelines for screening based on scientific data.l3*l4 The American Academy of Pediatrics recommends screening children only when there is a family history of heart disease before age 50,7 whereas the American Medical Association recommends screening every adult before the age of 21.13The dilemma these opposing recommendations create for college health services is that entering first-year students are both children and adults, depending on the definition one chooses to use, and neither association’s recommendation fits. The true issue is physiological maturity, and persons in late adolescence are physiologically mature. Cholesterol abnormalities in childhood track through adolescence into adulthood, reliably predicting the risk of atherosclerosis because individuals remain in the same quartile throughout their lifetimes. Thus, the quandary with regard to cholesterol is not whether to test, but when to test and how, and whether to make it optional or mandatory. The choices are whether to use selective screening at age 18, as the American Academy of Pediatrics recommends, then follow with mass screening of older students at 20, according to the advice of the American Medical Association; to do mass screening at age 18; to urge students to have voluntary testing and make it easily accessible but not mandatory; or to ignore the problem and leave it to others after the students graduate. Long” points out that routine annual health screenings encourage health promotion and the awareness of measures that can prevent illness, but it is important to know what benefits might accrue and what the costs 273
COLLEGE HEALTH
FIGURE 1 Results of Mass Screening College Students for Hyperlipidemia, 1977-1989
467 women Normal: 9,065
>200 mgJ& 873
406 men
Declined testing: 446
Normal: 83
229 women
Retested at student health service:427
Abnormal: 344
{
198 men
181 women
163 men Note: Abnormal was defmed as total fasting cholesterol > 200 mg/l ; ,DLcholesterol mg/dL; or triglycerides > 180 mg/dL; or HDL cholesterol < 30 mg/dL.
may be.16Marcus et al” have shown that teaching teenagers about high risks to health can change behaviors, and Williams’* reported that health-risk reduction in childhood is effective in promoting health in adults. Manchester et all9 report that the cost of finding one college student with hypercholesterolemia was $624 when done as part of a selective program, but only $121 per case as part of a mass screening program. We found that, at $212,it was more costly than Manchester had reported for us to find each student in mass screening because we were not able to follow every case with further testing when students chose to seek additional care elsewhere. Garcia and Moodie” recommend that every child older than 3 years have a cholesterol test. Cresanta et al,4 concerned over the fatty streaks seen by age 3, recommend annual cholesterol testing by age 5 . Kuske and Feldman recommend routine testing in all adults.” We believe that the onset of the process that leads to atherosclerosis begins at or near puberty, and this creates an imperative to begin preventive measures as early in life as p o s ~ i b l e . ~ Brown’s , ~ * ~ ’ data indicating that aggressive therapy can limit the progression of atherosclerosis, can lead to the regression of some lesions, and can reduce the frequency of cardiovascular occlusions c o n f m the importance of early detection and therapy.”” The medical staff of this student health service adopted a mandatory testing policy in 1977 for all students entering the university. We then called in every student whose entrance cholesterol exceeded 200 mg/dL to arrange further testing. The medical staff adopted this policy because we be274
> 160
lieved that our obligation for preventive medical care included detecting and treating the hyperlipidemias. The university already required a prematriculation medical examination, including measurement of hemoglobin, analysis of urine, and documented immunization against contagious diseases, in order to be permitted to register in the university. We concluded that there was sufficient research data to believe that some matriculants already had early atheroscler~sis,~~~ that recommendations for screening had been made by national and international organizations for nearly a decade, that preventive care needed to begin early in order to affect health in adulthood,” and that only mandatory mass screening could effect that. Furthermore, the staff believed then and now that failure to apply this knowledge was an unacceptable breach of our responsibility to our patients, that such knowledge made it incumbent upon us to detect and treat any condition, whether anemia, renal dysfunction, or hypercholesterolemia. Mandatory testing was and has been an extension of our obligation to provide preventive healthcare since the inception of the service 30 years earlier. Among 9,938matriculants, 873 (8.8%) reported cholesterol levels greater than 200 mg/dL. Although only 427 chose to have further testing at the university, 344 (80.8%) of those had abnormal lipid profiles. If abnormalities occurred with equal frequency in those who chose to be tested at home, then 705 (7.1%) of all matriculants would be expected to have had abnormal lipid profiles. We believe that this program is good value for the money and the effort expended. We have alerted 344 JACH
SCREENING FOR HYFERCHOLESTEROLEMiYl
people who might not have known about their hyperlipidemia and have enabled them to institute treatment that may extend their lives. Their appreciation buffers the complaints of those who think the economic or ethical costs of testing are too high. CONCLUSIONS We conclude that mass screening of all first-year college students is efficient, effective, and economical in detecting those students who would benefit from cholesterol reduction, one of the modifiable risks in coronary artery disease. Recognizing that we are a minority voice, we urge enforced mandatory cholesterol screening of every student matriculating at a college or university. There must be proper follow-up and care of all whose levels are abnormal. We suggest that permission to complete registration for classes is an acceptable and manageable hurdle that allows students to matriculate but ensures fullest cooperation. REFERENCES
1. Thom TJ, Kannel WB. Downward trend in cardiovascular mortality. Ann Rev Med. 1981;32427-434. 2. NIH Consensus Conference. Lowering blood cholesterol to prevent heart disease. JAMA. 1985;253:2080-2086. 3. Coates TJ, Perry C, Lden J, Slinkard LA. Heart healthy eating and exercise: Introducing and maintaining changes in health behaviors. A m JPublic Health. 1981;71:15-23. 4. Cresanta JL, Burke GL, Downey AM, Freedman DS, Berenson GS. Prevention of atherosclerosis in childhood. Pediatr CIin North Am. 1986;33:835-858. 5. Enos WF, Beyer JC, Holmes A. Pathogenesis of coronary diseases in American soldiers killed in Korea. JAMA. 1955;158~912-914. 6. Strong JP. Coronary atherosclerosis in soldiers: A clue to the natural history of atherosclerosis in the young. JAMA. 1986;256:2863-2866. 7. Committee on Nutrition. Indications for cholesterol testing in children. Pediatrics. 1989;83:141-142. 8. Walter HJ, Hoffman A. Socioeconomic status, ethnic origin and risk factors for coronary heart disease in children. Am Heart J. 1987;113:812-815. 9. Resnicow K, Morley-Kotchen J, Wynder E. Plasma cholesterol levels in 6,588children in the United States: Results of the Know Your Body screening in five states. Pediatrics. 1989;84:%9-976. 10. Public Health Service. Promoting health/preventing disease: Year 2ooo objectives for the nation (draft). Washington, DC: US Department of Health and Human Services; 1989. 11. Current Status of Blood Cholesterol Measurements in Clinical Laboratories in the United States: A Report From the Standardization Panel of the National Cholesterol Program. NIH Publication 88-2928,National Heart and Lung Institute; 1988. 12. Grundy SM. Recommendations for the treatment of hyperlipidemia in adults. Arteriosclerosk. 1984;4:445A-468A. 13. The Expert Panel. Report of the National Cholesterol Education Program Expert Panel on detection, evaluation and
VOL 40, MAY 7992
treatment of high blood cholesterol in adults. Arch Int Med. 1988;148:36-39. 14. Olson RE. Mass intervention vs screening and selective intervention for the prevention of coronary artery disease. JAMA . 1986;255:2204-2207. 15. Long JJ. Routine screening tests for the adolescent. Prim Care. 1987;14:41-47. 16. Kuske TT,Feldman EB. Hyperlipoproteinemia, atherosclerosis risk and dietary management. Arch Intern Med. 1987; 147~357-360. 17. Marcus AC, Wheeler RC, Cullen JW,Crane LA. Quasi-experimental evaluation of the Los Angeles Know Your Body program: Knowledge, beliefs and self-reported behaviors. Prev Med. 1987;16803-815. 18. Williams CL. Nutrition intervention and health risk reduction in childhood: Creating healthy adults. Pediatrician. 1983-1985;12:47-101. 19. Manchester R, McDuffie C, Diamond E. Screening for hypercholesterolemia in college students. J A m Coll Health. 1989;37:149-153. 20. Garcia RF, Moodie DS. Routine cholesterol surveillance in childhood. Pediatrics. 1989;84:751-755. 21. Leaf A, Ryan TJ. Prevention of coronary artery disease: A medical imperative. New Eng J Med. 1990;323: 14161419. 22. Brown G, Albers JJ, Fisher LD, et al. Regression of coronary artery disease as a result of intensive lipid-lowering therapy of men with high levels of apolipoprotein-B. New Eng JMed. 1990,323:1289-1298. 23. Loscalzo J. Regression of coronary atherosclerosis. New Eng JMed. 1990;323:1337-1339. CAREER OPPORTUNITY
SUNY-Geneseo Physician/Nledical Director Will over see a 5,300-enrollment student health center. Inpatient and outpatient clinics, 24-hour service. Position includes
rn clinical-practice rn shared administration responsibilities rn full-time commensurate salary rn malpractice coverage rn excellent state benefits Send cuniculum vitae to:
Joyce A. Hance Student Health Center State University College Geneseo, NY 14454 (716) 245-5736 New York State licensure required Applications accepted until position is filled. Women and minorities are encouraged to apply
AAlEOE
275
