My husband was told by his family doctor that his cholesterol is too high. Given this new family history, I am concerned that my three teenage sons are at risk for having high cholesterol. I do not want to overreact by getting my sons' cholesterol checked at such young ages. How concerned should I be?
High cholesterol levels in children and adolescents are becoming more and more common in our obesogenic society as a result of childhood obesity and poor lifestyle choices. However, high cholesterol can also be inherited.
The incidence of familial hypercholesterolemia (FH) is approximately one in 500, making it more common than other conditions in which screening has become routine. If this condition is left untreated or never identified until later in life, it can lead to serious consequences. For example, adolescents who have FH have a 20% risk of a heart attack in their 20's; this risk increases to 75% by their 50's.
From autopsy studies and more recent sophisticated imaging studies, we know that the process of atherosclerosis (hardening of the arteries) begins very early in life. The initial changes in children's blood vessels may be subtle - stiffening of the vessels and early build up of cholesterol deposits. Over time the process may accelerate when a teen eats poorly: consuming foods high in saturated fats, processed foods, and foods high in sugars; avoiding fish consumption; and getting less than 5 to 10 servings of fruits and vegetables each day. Inactivity, obesity, and high blood pressure all accelerate the process and drive patients toward early cardiovascular disease.
The first guidelines for classifying lipid risk in children were released in 1992 (see www.nhlbi.nih.gov/guidelines/cholesterol/dskref.htm). Currently, there is no consensus among pediatricians about the best way to screen for high cholesterol. Some feel the best way to pick up and prevent trouble is to screen all patients at the regular annual check ups. Other clinicians feel this is too aggressive, even when the incidence of FH is one in 500.
The solution to this challenge is to see a physician who cares about prevention and spends the time needed to address the topic in detail. A strong family history of cardiovascular disease, high blood pressure, diabetes, and stroke will alert the doctor to pay extra attention to a patient's blood pressure and Body Mass Index (BMI is a value derived by dividing a patient's weight in kilograms by height in meters squared). It is ideal to keep a teenager's blood pressure below the 90th percentile and the BMI below the 85th percentile.
Screening for high lipids is best done when the patient fasts for about 12 hours. The blood test looks at total cholesterol and triglycerides as well as LDL and HDL cholesterols. If the patient has an overweight problem, it is wise to monitor the glucose, insulin, thyroid function, and liver enzymes.
When these tests identify an abnormality, it is important to do regular follow-up visits in order to set new goals based on patient co-operation. One of the best methods to change a teenager's behavior is a technique known as motivational interviewing. This
tool allows the teen to decide what he or she is able to do. The patient is not told in a paternalistic way what to do, but rather is guided by a skillful clinician to come up with his or her own ideas and solutions. This allows for more realistic goals which are customized to the patient's environment and personality. In this way, the odds for healthier changes increase dramatically.
Most lifestyle changes lead to at least a 15% reduction in the LDL cholesterol. A good way to distinguish LDL and HDL cholesterol is to remember the “L” in LDL stands for “lousy” cholesterol (the worst kind), whereas the “H” in HDL stands for "healthy" cholesterol (the good kind). Regular physical activity is one of the best ways to raise HDL.
If lifestyle changes fail to reduce high cholesterol after one to two years, some experts suggest the use of medications known as statins. These pharmaceutical agents slow down the synthesis of cholesterol by the liver. They are only used in patients who are at least 10 years old. Statins are not safe to use during pregnancy, therefore teenage girls with high lipids should be told not to get pregnant while on the treatment. Side-effects involve muscle tenderness, inflammation of muscles, and possible damage to the liver. Therefore, patients who take statins must get their liver function enzymes checked regularly.
Some patients prefer to avoid medication and to lower their cholesterol naturally. Foods high in fiber may be helpful (e.g., regular oatmeal, barley, oat bran, whole-grain breads, fruits, beans, peas, and vegetables). Soy products and nuts (e.g., almonds, pecans, walnuts, and hazelnuts) also help. More recently, there is an explosion of knowledge on the role of omega-3 fatty acids in lowering cholesterol and reducing inflammation (see www.DHAomega3.org). A dosage of 1-3 grams of combined DHA and EPA is considered safe for teens.
The National Cholesterol Education Program runs a great interactive patient education resource (see www.nhlbisupport.com/chd1/tlc_lifestyles.htm). On this site, one can learn more about eating healthier, shop at a virtual grocery store, visit a cyber café, learn how to read labels, and find out how high cholesterol can damage one's health over time.Given elevated lipids are becoming more common at a younger and younger age, new guidelines on the management of high cholesterol in childhood and adolescence are currently under development. They will be published by 2008.
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