Cholesterol and Children

Most parents never know their children’s cholesterol levels. Some should. This is not part of routine blood testing done for children during well baby checks or regular exams by children’s health care providers. In fact, the government’s expert panel says that routine screening is not needed for all children and might lead to unnecessary drug treatment because nearly half of children who have high blood cholesterol are likely to have almost normal levels as adults. However, children meeting the following criteria are at risk and should be screened: 

• If a parent or grandparent had coronary heart disease when aged 55 years or younger
  
  

• If a parent has a blood cholesterol level 240 mg/dL or above (About 90% of children with high cholesterol have a parent who also has high cholesterol.)

• If lipid abnormalities are in the family history

• If a child has a medical condition that predisposes to coronary heart disease, such as severe obesity, physical inactivity, smoking, diabetes, elevated blood pressure, renal disease, and low thyroid activity

• If family history is unknown

 Three factors are linked to cholesterol levels, and all are related to family issues:

• Heredity – whether the child inherited a tendency to have high blood cholesterol
  
  
• Diet – whether the child is eating a diet high in fat that leads to high blood cholesterol and heart risk
  
  
• Obesity – whether the child is seriously overweight and at risk not only for coronary heart disease but also diabetes

Children with high blood cholesterol levels can benefit from reducing the amount of fat, saturated fat, and cholesterol in their diets without adversely affecting their normal development, according to results from a long-term study funded by the National Heart, Lung, and Blood Institute (NHLBI).

In the Dietary Intervention Study in Children (DISC), children who adopted a recommended low-fat, low-cholesterol diet decreased their intake of total fat, saturated fat, and cholesterol within the first year of the study and maintained lower levels for several more years. These dietary modifications did not alter the children's growth, nutritional status, or sexual maturation throughout the 7-year study. Furthermore, the diet helped the children significantly decrease their blood levels of low-density lipoprotein (LDL) – the "bad" cholesterol – for up to 3 years.

Most children are already building plaque in their arteries. Atherosclerotic or fatty tissue is the material that causes blockage and leads to coronary heart disease. By age 20 years, plaque is present in about 15-20% of the population. Those most likely to have this plaque build up have coronary heart disease risk factors:  high cholesterol, smoking, obesity, and high blood pressure.
 
Children and adolescents with high cholesterol levels are more likely to continue to have high levels as adults, according to the American Academy of Pediatrics. But many of these children can grow into adulthood with cholesterol levels under control with simple lifestyle changes.

Because 90% of parents whose children have high cholesterol have high levels themselves, and because diet and exercise monitored by a parent are so important in lowering cholesterol levels, treatment is a family affair.

• Do not scare your child. Present the facts about high cholesterol in an age-appropriate way. Ask your health care provider for advice. Discuss ways to help your child improve his or her health. Do not present it as treatment for a “disease.”

• Plan family meals and monitor what your child eats. Pay special attention to cholesterol and fats in foods.

• Plan family activities that involve exercise, such as walks, hikes, games, and organized sports.

• Have your child’s cholesterol levels retested after 3 months of changes in diet.

• Talk with your child’s health care provider about the use of medication. It is usually only considered for children older than 10 years, and ONLY after changes in diet and exercise have been tried.

The American Academy of Pediatrics recommends dietary steps to lower cholesterol as follows:

• Children younger than 2 years should not be restricted from foods containing fat or cholesterol. Their rapid growth and development require high-energy intakes from food. 
  
  
• Children aged 2-5 years through 18 years should gradually adopt a diet that contains no less than 20% and no more than 30% of calories from fat. Less than 10% of total calories should come from saturated fat. Children should eat no more than 300 mg per day of cholesterol (when it is present in foods). As children eat fewer calories from fat, they should replace those calories by eating more grain products, fruits, vegetables, low-fat milk and other calcium-rich foods, beans, lean meat, poultry, fish, or other protein-rich foods. Children should be given a wide range of foods to make sure they get all the nutrients they need from a variety of foods.

This Step-One diet should be followed for at least 3 months. If cholesterol testing at that time does not show LDL cholesterol in an acceptable range, your health care provider may recommend a more restrictive Step-Two diet. 

The Step-Two diet requires detailed assessment of current eating patterns. Sometimes counseling with a health care provider or registered dietitian helps the family adjust. This Step-Two diet restricts saturated fats to less than 7% of total calories from fat and no more than 200 mg per day of cholesterol in food. This eating pattern requires careful planning to make sure your child is getting the right balance of nutrients, vitamins, and minerals. 

Changes in diet that lower fat, particularly saturated fat, and cholesterol levels, combined with regular exercise and avoidance of smoking, have been shown to improve high cholesterol and LDL levels in children and teens. The good news is that if these changes are carried into adult life, they may reduce your child’s risk for coronary heart disease.

If you help your child reduce total cholesterol levels and LDL, you can greatly lower the risk for coronary heart disease.

Heart-Healthy Eating

Read food labels for essential information. Labels can tell you how many calories are in a food item per serving and how large a serving is. You can also find out how much fat is in a serving and how much of that fat is from saturated fats (the ones to avoid). 

• Emphasize foods from 5 areas: fruit, vegetables, whole grains such as cereals and breads, beans, and fish. These are low in cholesterol (and will contribute to lowering your child’s blood cholesterol).
  
  
• Try lean meat such as skinless chicken breast. Trim off all fat you can see on any meats.
  
  
• Choose low-fat dairy products such as skim milk or low-fat yogurt. 
  
  
• Avoid fats in cooking. Grill or bake. Do not fry. 
  
  
• In healthy weight children, reduce intake of soft drinks, fruit drinks, and low-fat snacks. Avoid these products in overweight children. These provide empty calories and no nutrients.
  
  
• Reduce intake of foods high in cholesterol. Cholesterol is found in dairy products (choose skim milk and fat-free dairy products), meat, poultry, fish, and shellfish such as shrimp. Especially avoid organ meats such as liver. Eggs are one example of a food that has an easy cholesterol-free solution. Substitute egg whites or cholesterol-free “egg beaters.” Try these in recipes that call for eggs.
  
  
• Use liquid or tub margarines instead of butter. They are lower in saturated fat. 
  
  
• Avoid trans fats. These are a type of saturated fat usually found in cookies, crackers, baked goods, and hard margarines. You will be able to see how much trans fat is in a product because this information will soon be on food labels, as mandated by the FDA. Until then, read the list of ingredients. Avoid the food if among the ingredients is hydrogenated oils (these are trans fats). Use soft margarines instead.
  
  
• Switch your child’s snacks away from cookies and crackers to fruits, raw vegetables such as baby carrots, and plain unsalted popcorn or pretzels. The best snacks are apple slices with natural peanut butter, orange sections, fruit stirred into nonfat yogurt, juice bars, sherbet, lite or nonfat popcorn, low-fat pita chips, and low-fat bagel chips.
  
  
• Pack a healthy lunch for your child to take to school. For school lunches, pack low-fat or fat-free lunchmeat sandwiches made with whole-grain bread. Low-fat cheese can be added. 
  
  
• Vending machines can be a dilemma. Help you child choose the lower fat versions of chips or pretzels or avoid machines entirely. Avoid using soda machines.
  
  
• Kids are kids, and you will have trouble denying fun foods at birthday parties and school events. High-fat foods such as hot dogs, ice cream, fries, and pizza can still be part of your child’s diet when balanced with other healthful foods the same day and during the rest of the week.
  
  
• Use breakfast as a time to select high-fiber foods such as cereals (with skim or 1% milk) and whole-grain breads for toast. Fruit such as an apple will have more fiber than apple juice, so opt for the fruit and not the juice.

Exercise

Regular aerobic exercise, such as biking, running, walking, and swimming, will help raise HDL levels and lower your child’s risk for coronary heart disease in combination with dietary changes. Exercise combined with a healthy diet definitely helps prevent obesity. See if your child is interested in team sports. Lobby for recess activities and physical education classes in your schools.

|Web Links|

American Academy of Family Physicians, Cholesterol: Diet Tips for Children with High Cholesterol 

American Academy of Pediatrics, Cholesterol in Childhood

American Heart Association, Cholesterol in Children 
 
Extension Service, U.S. Department of Agriculture, Washington, D.C., North Central Regional Extension Publication 431, March 1995, Cholesterol Guidelines for Children 
 
National Heart, Lung, and Blood Institute, National Cholesterol Education Program 
 
Nemours Foundation, Cholesterol and Your Child

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Author: William Winter, MD, Professor, Departments of Pathology and Laboratory Medicine and Pediatrics, University of Florida College of Medicine.

Coauthor(s): Desmond Schatz, MD, Professor, Medical Director of Diabetes Center, Department of Pediatrics, Division of Endocrinology, University of Florida.

Editors: Alan D Forker, MD, Program Director of Cardiovascular Fellowship, Professor of Medicine, Department of Internal Medicine, University of Missouri at Kansas City School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Michael E Zevitz, MD, Clinical Assistant Professor, Department of Medicine, Rosalind Franklin University of Medicine and Science, Chicago.