Preventive Medicine Column

Dr. David L. Katz

The American Stroke Association’s International Stroke Conference 2011 was held a week ago in Los Angeles.  Among the many important research findings reported was this bit of profoundly disquieting news: strokes are occurring with increasing frequency in people under age 35.  Worse still, a marked increase in the rate of stroke was noted in children ages 5 to 14.

That this is a trend in modern epidemiology is both tragedy and travesty.  The researchers readily acknowledge they don’t know for sure why stroke rates, declining in adults over age 50, are rising in children and young adults.  The study in question, by investigators at the CDC, was simply a review of hospitalization records between 1994 and 2007.  The analysis was designed to show what, but not why.

But that does not preclude some educated guesses, by the researchers themselves and the rest of us.  The decline in strokes in older adults is almost certainly due to better treatment of hypertension, the leading cause of stroke, and to a lesser extent the modification of other risk factors for cardiovascular disease, such as lipid-lowering with statin drugs.  Such vulnerabilities are routinely being sought, found, and modified in adults known to be in the at-risk group.

But of course, stroke and ischemic heart disease are not expected in the pediatric age group.  Historically, there has been no cause to look systematically for risk factors of vascular disease in this population, let alone apply the use of antihypertensives and statin drugs to avert calamity.

It is nothing short of calamity that it has come to this.  The researchers’ best guess, and mine, is that the migration of stroke down the age curve is being propelled by epidemic obesity and diabetes and rising rates of hypertension in our children.  We can choose to be shocked by the advent of stroke in children, but it was, in fact, predictable.

Predictions need not be about what comes true.  Grim predictions can motivate preventive responses so the adversities they foretell never materialize.  Forewarned can be forearmed.

I have, for years, been predicting heart disease as a routine, pediatric condition- in the hope it would never come true.

The logic behind my rather lonely rants on this topic has been quite straightforward.  When 16, 17, and 18 year-olds have already had what used to be called “adult onset” diabetes, and is now euphemistically called “type 2” for a decade or more, shouldn’t we expect to start seeing them show up in emergency rooms with angina pectoris and myocardial infarction?  I have long thought we should.  And regrettably, I have had incremental indications over time that my predictions were coming true.

When I first started making a fuss about this years ago, my audiences were dubious, and uncertain of my reasoning.  More recently, they have seemed less stunned, more convinced, and deeply concerned.  Now, they are starting to provide evidence to prove me right.  This is a very unhappy trend.  And frankly, while I was warning against the advent of angina as an adolescent rite of passage alongside acne, even I didn’t envision strokes in children under age 10.

Which brings us back to the new research findings.  We don’t know with certainty the causes of a rising rate of stroke in our children.  But with the stakes this high, do we really want to wait for more data?  The best way to predict the future is to create it, and I would very much like to predict a future in which the only stroke my children and grandchildren need worry about is the stroke of a dissatisfied teacher’s red pen.

Modern trends in chronic disease constitute a crisis.  A crisis is a dangerous opportunity, because recognition of danger inspires will for change.

We can change our ways, and protect the health of our children and grandchildren – by becoming a society that honors feet and forks as master levers of medical destiny, rather than relying so heavily on stethoscopes, scalpels, and statins in the aftermath of disaster.  By doing all that is required to make eating well and being active lie along the path of least resistance.

The list of interventions to get us there is long, but not complicated.  Every policy at odds with these goals is a public enemy- and a potential threat to a child, quite possibly one you love.  Vote accordingly.

In defense of our children, we should act- even as we await data to verify likely causes.   We should not attribute deplorable trends in epidemiology to unkind strokes of fate.  The fate in question is almost certainly in our own hands.  The bell curve of chronic disease is tolling ever more loudly for us all.  It is past time to answer the alarm with the urgency it warrants.




Dr. David L. Katz;