One-on-One with a Veteran Pediatric Lipid Specialist

Dr. Don P. Wilson, a Fellow of the National Lipid Association, began his career with the National Lipid Association (NLA) in 2006. Dr. Wilson received his medical degree from the University of Mississippi and completed his internship and pediatric residency training at Baylor College of Medicine in Houston. His fellowship training is in Pediatric Endocrinology, completed at the same institute.

Throughout his career in pediatric medicine, which spans more than 30 years, Dr. Wilson has published over 100 articles in peer-reviewed journals with an emphasis on childhood diabetes, CVD risk assessment and prevention, and genetically and acquired dyslipidemias. Below is an in-depth one-on-one interview with Dr. Wilson on his professional and personal experiences.

What made you become a member of the NLA initially?

Having devoted most of my career to childhood diabetes, I realized that one of the biggest threats to these children as they mature into adults is premature cardiovascular disease.  In addition to maintaining adequate glycemic control, the NLA has helped me understand the need for global risk factor assessment of all children, especially in those with diabetes. I have subsequently become very interested in genetic dyslipidemias, including familial hypercholesterolemia and mutations that cause severe hypertriglyceridemia (familial chylomicronemia syndrome).  It is exciting to realize that by identifying children with familial hypercholesterolemia, for example, premature cardiovascular disease and CVD-related events that commonly occur during adulthood can truly be prevented.

Having read your work advocating for the screening of genetic mutations in children and adolescents with dyslipidemia – how far are we in this pursuit and how much work in your opinion needs to be done both nationally and globally?

I think there is a case to be made for the benefits of identifying genetic mutations. For example, I have a young patient whose mother is a compound homozygous for familial hypercholesterolemia.  As expected, her daughter has a confirmed heterozygote mutation but age and sex appropriate LDL-C.  The daughter’s level of LDL-cholesterol is intriguing. What is the mechanism by which she is able to maintain an age/ sex appropriate level of LDL-C? Does she have, for example, a second “protective mutation”, such as a PCSK9 loss-of-function mutation? Is she at higher risk of premature CVD than peers with a comparable LDL-C?

Although, for purposes of clinical decision making, we have encouraged her to adopt a healthy lifestyle, we have not felt she would benefit from lipid lowering medication at this time.  We continue to follow her on a regular basis for preventive counseling and have discussed the potential of passing her FH gene onto her child in the future. Although the daughter’s LDL-C is age/sex appropriate, we don’t know if that will be true for her children, should one or more inherit her FH gene mutation.  This case helps to illustrate the value of using biomarkers (i.e. LDL-C) and genetic analysis in providing optimal clinical care and informative genetic counseling. The other area where I feel genetic testing would be helpful is in patients whose LDL-C is in the so called grey zone (130-189mg/dL) to assist with risk stratification and clinical decision making. While not ignoring important issues such as privacy and ethical concerns, in an ideal world, genetic screening would be cheaper and more readily available.  Clinicians need to be able to detect these mutations for better understanding, surveillance and treatment of these individuals along with lipid biomarkers and, when available, informative family histories. However, currently, these costs can be well over thousands of dollars, which is far too expensive for most of our patients.  If genetic testing is to be performed, it is imperative that counseling be available, ideally provided by a trained genetic counselor.

Given that children are prone to early onset of coronary artery disease (CAD) with genetic dyslipidemias, what would you advise young pediatricians to look out for?

Most general pediatricians and family physicians have limited knowledge about lipid-lowering therapies in children but play an invaluable role by encouraging healthy lifestyles and providing lipid screening. In the U.S., universal testing of all children is recommended, while cascade screening is more common worldwide, particularly in European countries.  Universal testing has the advantage of identifying FH in asymptomatic youth and young adults, creating opportunities for early intervention and reverse cholesterol screening of family members.  Currently there are many barriers to identifying a child with FH. For lipid lowering to be effective, by whatever means, individuals with FH must first be identified, ideally at an early age.

Pediatric healthcare providers most commonly encounter children who are obese and have high triglyceride and low levels of HDL-C.  Promotion of a heart-healthy lifestyle, including emphasis on avoidance of tobacco products, age-appropriate nutrition, and moderate-to-strenuous daily physical activity essential to health and well-being, should be offered to all children. In that regard it is encouraging to note that the absence of established risk factors at 50 years of age is associated with very low lifetime risk for CVD and markedly longer survival.  Few clinicians, however, would advocate use of lipid-lowering medications in children with lifestyle-related dyslipidemia.  In contrast, it is important to note that most children with familial hypercholesterolemia are generally of normal weight, active, and in good health.  While total and LDL cholesterol levels are elevated, the triglycerides and HDL-C in these children are usually normal.

To achieve our goal of reducing CVD-related morbidity and mortality, education starting in medical school and residency is needed to facilitate understanding of the role of CVD risk factors, including genetic dyslipidemias.  Although the optimum age to start routine screening is not known, currently 4 major U.S. organizations (NHLBI, AAP, NLA, and ACC/AHA) recommend initial screening at 10 years of age of all children without regard to state of health or family history.  Selective screening of those at risk can be performed at any time after 2 years of age.  We need to realize that treating dyslipidemia in children is a cornerstone in preventing premature CAD, which remains the no. 1 cause of death in the U.S.

In an attempt to harmonize recommendations for clinical practice to facilitate implementation in busy clinical practices, the NLA advocates initial screening at 10 years of age and every 5 years thereafter if normal. A summary of these recommendations can be found in the NLA’s 2016 Annual Summary of Clinical Lipidology- http://www.lipidjournal. com/issue/S1933-2874(16)X0008-6.

How has the NLA changed over the past 15 years?

The organization has always been focused on the application of science and research in clinical practice.  As such, the NLA continues to find ways of providing education to primary care physicians, dietitian nutritionists, pharmacists, and other healthcare professionals, as well as informative educational materials for patients and families.

What has been your favorite/most memorable moment as an NLA member?

I have enjoyed getting to know the members and developing a supportive network that has become invaluable in the care of my patients.  I also had the privilege of serving on the NLA committee whose work resulted in publication of the initial National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia: Parts 1 & 2. These comprehensive publications, which are updated yearly, provide clinicians with state of the art recommendations for clinical practice.  In addition to the scientific evidence detailing the role of lipids and lipoproteins in cardiovascular disease, I was very pleased that the NLA Leadership had the foresight to include recommendations that address the needs of a wide variety of special populations, such as children and adolescents, women, and the elderly.

Why have you remained a member for all of these years?

Although much is known about cardiovascular health and disease risk, there is still much to be learned.  The NLA continues to explore opportunities for better diagnostic testing, therapeutic interventions, and cost effective/informative monitoring of outcomes. I am very encouraged that, by focusing on early identification and appropriate intervention of individuals at risk, we can significantly reduce needless CVD-related morbidity and mortality in future generations.

What do you see as the benefits of an NLA membership?

Membership in the NLA provides a great opportunity for professional growth and development.  Especially for members who are still early in their career, the knowledge gained by participating as a member of the NLA will be invaluable in developing unique expertise in preventative cardiology to best serve the needs of the population and community.

Over the past 15 years, what moments stand out as turning points for the organization?

In addition to the educational programs offered by the NLA, there are at least 3 “turning points” that I feel have made a major impact on the organization and the clinical practice of lipidology.  The 1st is the NLA’s vision in creating the Journal of Clinical Lipidology, which has been highly successful and internationally well-received by both those in the scientific and clinical community.  Second is the creation of a certification program to recognize individuals who have unique training and expertise in lipidology.  And finally, the 3rd is the creation of the National Lipid Association’s Recommendations for Patient-Centered Management of Dyslipidemia: Parts 1 & 2 and the organization’s commitment to updating these recommendations.  In retrospect, all have proven to be pivotal events in the history of the NLA.

What is in store for the NLA in years to come?

As the organization continues to grow, I anticipate that there will be growing interest and participation in an expanding number of  “working groups” within the NLA, specifically targeting the education and clinical needs of those who primarily provide services to children and adolescents, women, the elderly, ethnic minorities, etc.  It would be my hope that the American Board of Clinical Lipidology will, sometime in the future, create a “sub-board” certification to recognize those who have special knowledge, skill and experience in these and other important areas.

How has being a member of the NLA helped you grow personally and professionally?

In addition to a wealth of knowledge gained through active participation in the NLA’s educational programs, professional contacts and friendships have been invaluable to me personally and professionally.

How have you used your NLA membership in everyday practice?

The knowledge and support provided by the NLA has allowed me to create a unique Lipid Clinic for children and adolescents in 3 locations – Baylor/ Scott & White in Central Texas, Phoenix Children’s Hospital in Arizona and, more recently, Cook Children’s Medical Center in Fort Worth.

What advice would you give to a new member of the organization?

Whenever possible, participate in regional and national NLA-sponsored scientific meetings, take advantage of the excellent education opportunities offered by the Lipid Academy and the Masters course, complete the self-assessment programs, and take an opportunity to get to know current members.

What is your advice to young professionals who are building their careers?

The best advice I can share with younger colleagues is to seek out the best training available to you. Second, whatever environment you are in, associate with well-trained, thoughtful colleagues and keep those connections strong.  Third, always look for ways of self-improvement, whether in your personal or professional life. Asking colleagues for advice and feedback, tracking data, and participating in quality improvement projects can help identify opportunities for improvement.

Always give back in the best way possible and strive to make sure patients and parents understand the child’s medical condition and treatment options. There are some simple tricks you learn in clinical practice. For example, with children I often ask them to repeat their understanding of what happened during their last clinic visit. Do they understand why they were being seen, what conclusions were reached about their condition, what recommendations were made and what the likely benefits of successful treatment are? It’s also important to address fears, concerns and barriers.  If the child does not understand the answers to one or more of these questions, I simply repeat what was said, looking for meaningful, age-appropriate examples to illustrate difficult concepts that will enhance the child’s understanding. Better yet, I often ask children to explain their diagnosis and treatment to medical students and residents rotating in our clinic. That way you get “two for two”! The children seem to really enjoy being part of the educational process, and I get a pretty good idea of what they know about their condition.

Where do you draw your strength from?

My faith and family have always been my main source of strength. For over 45 years my wife has been incredibly supportive and encouraging. Furthermore, the value, support, and joy that comes from working with well-trained, dedicated colleagues cannot be over emphasized. Finally, I would be remiss not to thank the many children and families who have taught me so much over the course of my career, and, in their individual ways, have touched me personally and enhanced my professional career.  Over my 30+ year career as a pediatrician, children have given me simple notes and drawings, treasured reminders of not only our professional relationship, but of lifelong friendships. I have a whole drawer of drawings and messages from my patients. When I am having a rough day, just reading notes from that drawer can really lift me up and help validate what I am doing.

What do you think are the possibilities for young NLA members to get involved in the society?

Besides taking advantage of many of the educational opportunities offered by the NLA, younger colleagues should consider becoming involved in one or more of the NLA’s working groups. For example, we have a Pediatric Atherosclerosis Prevention and Lipidology Group (PedAL) which is composed of a diverse group of healthcare professionals who provide care for children and adolescents with disorders of lipid and lipoprotein metabolism. PeDAL, a working committee within the National Lipid Association’s Practice Management Council, provides a network for discussion of a variety of topics, including recommendations for clinical practice, educational needs, opportunities for collaborative research and publication, and on-line case discussions. A formal meeting of PeDAL members is held once a year during the NLA’s annual scientific meeting. Currently PeDAL members are creating tear sheets that are pediatric-specific.

I would also encourage participation by submitting abstracts to NLA-sponsored regional and national meetings, manuscripts for the Journal of Clinical Lipidology and LipidSpin, and serving on a committee or work group.

What are some of your other hobbies outside work?

I am a fan of history. The past can tell us a lot about what we can expect in the future. I enjoy cartooning, something I have practiced over the years. My patients (and, importantly, my grandchildren!) seem to enjoy them. A brief note highlighted with a simple cartoon can be a source of encouragement for a child dealing with a chronic illness. In recent years I have aspired to learn music and enjoy playing the guitar.  In my younger days, I participated in distance running and played tennis quite regularly.

If you could meet anyone past or present and pick their brain who would it be?

There are a number of outstanding scientists and clinicians within the NLA, all of whom have been very gracious in sharing their knowledge and experience.  I have been particularly grateful for Dr. Virgil Brown’s mentorship.  His contributions to the field have provided us all with important scientific discovery and benchmarks for excellence in clinical practice. Dr. Brown is a great role model and friend.