Should Kids Worry
About Cholesterol?

Brandon Kaufman has high cholesterol, so he has switched to whole wheat bread, broccoli instead of french fries, grilled chicken instead of fried, and considers pizza a once-a-week indulgence.

Brandon is 10 years old.

Worrying about cholesterol has long been a preoccupation of middle-age men and, as concern over heart disease grows, an increasing number of adult women. But new research, suggesting that the seeds of heart disease and stroke germinate in childhood and adolescence, is raising a question many parents never considered before. Should kids get their cholesterol levels checked?

Two studies published in this week's edition of the Journal of the American Medical Association found that high levels of so-called bad cholesterol in childhood predict a dangerous thickening of artery walls in adulthood, an early sign of problems that can lead to heart disease and stroke, the No. 1 and No. 3 causes of death in the U.S.

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"This provides the first really strong evidence that early teenage cholesterol is important," says Henry McGill Jr., senior scientist emeritus at the Southwest Foundation for Biomedical Research, who wrote an editorial accompanying the studies.

Though some pediatricians have long advocated cholesterol screening for their young patients, most consider heart disease and stroke adult afflictions. Pediatricians traditionally have been more concerned with immediate problems in kids -- such as congenital heart defects and asthma -- as well as preventing childhood diseases through vaccinations.

The American Academy of Pediatrics recommends cholesterol screening only for kids who have a family history of early heart disease, who have a parent with high cholesterol or those for whom parents' medical histories aren't known. The academy leaves it up to a doctor's discretion whether screening is needed for other higher-risk adolescents, such as those who smoke, are overweight or eat a lot of foods high in saturated fat. Consequently, most people don't get their cholesterol checked until they reach adulthood.

But for some experts in the field, the new studies are the most convincing evidence yet that parents should foster heart-healthy diets in kids and that pediatricians should consider adding a cholesterol test to an adolescent's physical. The larger of the two studies suggests that cholesterol levels in adolescents matter more than in very young children.

The American Heart Association provides standards for cholesterol levels in kids. The group says the acceptable total cholesterol level for people age two to 19 is below 170 mg/dL. Any number over 200 mg/dL is considered high. Those thresholds are lower than the heart association's guidelines for adults -- acceptable: less than 200 mg/dL; high risk: over 240 mg/dL -- because kids' cholesterol is naturally lower.

One of the new studies looked at 486 people, now age 25 to 37, in the town of Bogalusa, La., beginning in the 1970s. Researchers initially recorded their risk factors, then used ultrasound to measure the walls of each adult participant's carotid artery, a major artery in the neck that supplies blood to the brain. Thickening of this artery is considered a marker of early atherosclerosis, the buildup of artery-clogging plaque that can lead to heart disease and stroke. The study found that children and adolescents in the highest quartile for LDL, or bad cholesterol, had a 42% greater chance of developing a thickening of their carotid artery walls in adulthood than those in the lower three quartiles. Those with a body-mass index in the highest quartile had a 25% greater chance.

HOLD THE FRIES The American Heart Association's standards for cholesterol levels in youths aged two to 19. Category Total (mg/dL) LDL (mg/dL) Acceptable Less than 170 Less than 110 Borderline 170 to 199 110 to 129 High 200 or greater 130 or greater Note: HDL levels should be greater than or equal to 35 mg/dL and triglycerides should be less than or equal to 150 mg/dL

The second study was much larger, looking at 2,229 Finnish adults who had previously been checked between age three to 18 and then re-examined 21 years later. Researchers found that in 12- to 18-year-olds, high levels of bad cholesterol (as well as high systolic blood pressure, body-mass index and cigarette smoking) were directly related to the thickening of the carotid artery walls later in life. The researchers found less of a connection in younger kids.

Despite such findings, some doctors think cholesterol screening is unnecessary for kids. The question, says Thomas Newman, a critic of the idea, is what to do with the results. Low-fat diets for kids with high cholesterol levels have shown minuscule effects, says Dr. Newman, a professor of epidemiology and biostatistics at the University of California San Francisco School of Medicine.

While cholesterol-lowering drugs, such as Lipitor, are some of the top-selling medicines world-wide, many pediatricians say they would be reluctant to put children and adolescents on them if diet didn't work.

Dr. Newman points to one of the largest studies of dietary intervention in kids with high cholesterol. In it, he says, several hundred kids each had 27 to 31 visits with nutritionists, behaviorists and health educators, along with a monthly telephone followup for over three years. Despite the intensive effort, the difference in bad cholesterol levels between kids who got all the attention and those in the control groups was only 3.2 mg/dL on average, Dr. Newman noted in a 2000 commentary in the journal Pediatrics. Parents and doctors "would be much better off focusing attention on preventing smoking and obesity rather than focusing on cholesterol levels," he says.

But Marc Jacobson, director of the Center for Atherosclerosis Prevention at Schneider Children's Hospital in New Hyde Park, N.Y., says he has seen many children reduce high cholesterol through changes in diet and exercise. He has helped bring 10-year-old Brandon Kaufman's total cholesterol levels down to 216 mg/dL from 248 mg/dL in March 2002.

Many doctors agree that parents should limit kids' intake of saturated and trans fats regardless of cholesterol levels. The American Academy of Pediatrics recommends kids age two to 18 consume less than 10% of their total calories from saturated fat. (No limit on fat or cholesterol is recommended for children under age two because of rapid growth and development.) Kids who limit the amount of foods high in saturated fat, such as french fries, pizza and ice cream, still grow normally, studies have shown.

The debate over routine screening also concerns the cost of such tests and whether the results may provoke unnecessary concern in parents and kids, says Nancy Krebs, who heads up the American Academy of Pediatrics' nutrition committee. "But also we know that if you just screen children who have a positive family history you're going to miss quite a few who have elevated lipid levels," she says.

It's not clear whether insurers will pay for a cholesterol test if a child has no risk factors. Quest Diagnostics, the nation's largest diagnostic testing firm, charges individuals $75 in the New York metro area for a lipid panel, which includes total cholesterol, a breakdown of good and bad cholesterol levels and triglycerides. Insurers typically negotiate discount rates.

Write to Patricia Callahan at patricia.callahan@wsj.com

Updated November 5, 2003