Evangelists and Snails

TO THE EDITOR:

As staff to the U.S. Preventive Services Task Force [1], we second Dr. Davidoff's observations on “evangelists” and “snails” [2]. We also note a related factor in the cholesterol debate: Proponents of screening point to the potential benefits to an individual patient under ideal circumstances (that is, efficacy), whereas evidence-based panels such as the U.S. Preventive Services Task Force, the American College of Physicians, and the Canadian Task Force on the Periodic Health Examination require proof of important net benefits in the real world (that is, effectiveness). Thus, the substantial cholesterol reductions obtained with specialized interventions in selected patients must be contrasted with the small average reductions (0% to 3%) obtained with diet counseling in primary care populations [1]. Although estimates of average or net benefits may not always be optimal for individual decisions with specific patients, they are the most appropriate basis for recommendations for the general population. The U.S. Preventive Services Task Force strongly endorses the principle that a recommendation for routinely screening healthy, asymptomatic persons should be based on convincing evidence that the clinical benefits justify the inconvenience, costs, and potential downstream consequences of screening and intervention. Although measuring a single cholesterol level may be relatively simple and inexpensive, it is neither easy nor inexpensive to fully implement the National Cholesterol Education Program's guidelines in practice. Unfortunately, the feasibility and cost-effectiveness of these guidelines are only now being tested in the primary care setting [3].

One need not deny the central role of lipids in atherosclerosis or the goal of lowering cholesterol levels in a population to question the effectiveness of universal cholesterol screening for young adults. Prevention efforts in young persons should emphasize the importance of a diet with low saturated fat intake and high intake of fruits and vegetables, regular exercise, and avoiding smoking [1]. Because all of these factors have important benefits independent of their effects on serum lipids, they need to be promoted regularly for all young persons, not simply those identified by screening. Contrary to Dr. LaRosa's assertion [4], little evidence suggests that cholesterol screening improves the effectiveness of routine dietary advice [5].

Dr. LaRosa's strong criticism of the College's guidelines strikes us as counterproductive, given the substantial international consensus on the most important steps for lowering cholesterol to prevent heart disease: 1) Promote effective primary prevention through clinician advice and public education; 2) screen for and treat high cholesterol levels in asymptomatic adults who are otherwise at increased risk because of age, family history, or other risk factors; and 3) aggressively treat high cholesterol levels in all patients who have clinical vascular disease. Because we have a long way to go in meeting even these objectives, we should emphasize them rather than the debate surrounding the incremental benefit of universal screening in young adults and others at low risk.

• Copyright ©2004 by the American College of Physicians