Most of us think of cholesterol problems as an adult issue. However, for a number of reasons, cholesterol can be a health problem for kids as well. As more and more kids struggle with the challenges of being overweight or even obese, doctors have noticed that some of these kids have high cholesterol levels. There are also children who have inherited a tendency to slightly elevated cholesterol levels and rarely children have inherited diseases that cause very high cholesterol levels. For this reason, in 2011 the United States Preventive Services Task Force together with the National Heart, Lung and Blood Institute recommended that pediatricians begin testing the cholesterol levels of kids first at about age 9-10 years and again at about 17-21 years. This testing is in addition to the testing we were already doing on groups of children that had risk factors for high cholesterol and heart disease. These high-risk groups get tested every at least every 5 years. This article is intended to address the many questions parents have about who needs this testing, when it should be performed, why, how to interpret the results and how to manage high cholesterol.

Who needs testing and when?

Kids with the following issues are considered more likely than other children to have high cholesterol. For this reason, these kids should be tested beginning at age 2 years or whenever these issues are identified. Even if the testing is normal, it should be repeated every 5 years as long as the risk factors persist. 

High risk conditions

  • Children with a sibling, parent, grandparent or aunt or uncle with early heart disease or early high cholesterol. Early is defined as before age 55 years in men and before age 65 years in women. 
  • Known total cholesterol level > 240
  • Smoker
  • High blood pressure
  • Elevated body mass index (BMI)
  • Diagnosis of some chronic diseases including: diabetes, chronic kidney disease, Kawasaki disease, childhood cancer, some congenital heart diseases, juvenile rheumatoid arthritis, inflammatory bowel disease

Everybody else needs to be tested at age 9-10 years and again at age 17-21 years. 

Why do we test kids?

Kids are very unlikely to suffer a heart attack, stroke or other disease that we typically associate with elevated cholesterol levels. So why do we do this screening test? There are two main reasons. First, screening may identify a few kids with extremely high cholesterol levels. These kids likely inherit the tendency to have these very high levels from their families. They are at very high risk for cardiovascular disease at younger ages than typically seen in the US. By identifying these kids early, we can intervene with some lifestyle changes, specialty care and perhaps medications to reduce their risk of heart disease and stroke. Second, screening can also identify kids whose cholesterol levels are abnormal but probably not high enough to require medication any time soon. We want to work with these kids to improve their nutrition and exercise choices and to monitor their cholesterol levels every year or two. If the levels do not respond to diet and exercise changes or the levels continue to climb, they may benefit from the care of specialists and may even start medications. Before these recommendations went into effect, healthy adults without risk factors may not have had their cholesterol levels checked until age 35 years for men and 45 years for women. By that age, high cholesterol, poor diet and inadequate exercise may have already led to early heart disease. 

How to interpret your child’s test results

children-with-high-cholesterolIf your cholesterol screening test is performed in our office, your provider will discuss the results with you before you leave. If your test is performed at an outside lab, our nurses may discuss it with you by phone when the results are available.
Cholesterol testing usually includes values for total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL) and triglycerides. 
It is important to understand that non-fasting tests, although they are a good, quick, in-office assessment, are not as accurate as fasting tests. If your initial non-fasting screening test is abnormal, you may be instructed to follow up with a fasting test at a later date. In particular, although triglyceride levels are included in our in-office testing, they are difficult to interpret if the patient was not fasting. For this reason, your provider may choose to focus only on the cholesterol values.

Abnormal cholesterol levels:

  • Total cholesterol>200
  • LDL > 130
  • HDL < 40
  • Non-HDL total cholesterol (Total cholesterol minus HDL) > 145

So your child’s cholesterol level is abnormal; what’s next?

Unless your child’s level is remarkably high and requires referral to a specialist, your regular pediatric provider will manage this aspect of your child’s health. In almost all cases, the first steps are:

  • Improving the quality of the food your child eats
  • Increasing the amount and consistency of the exercise your child performs
  • Balancing calorie intake and calorie expenditure to achieve or maintain a healthy body mass index
  • Repeat testing to confirm and monitor your child’s cholesterol levels

Dietary changes

There is some controversy among experts about the degree that diet choices impact our cholesterol. However, most experts agree that the following steps can be beneficial for general health and might specifically improve cholesterol levels and reduce the risk for heart disease and stroke later in life.

  • Reduce or eliminate your intake of saturated fat. This is the fat found in animal products like red meat, fatty cuts of chicken and pork and lard as well as in shortening, butter, cream, whole milk, palm oil, coconut oil, and margarine. 
  • Avoid trans fats. These are usually found in processed foods like prepackaged cakes and cookies. Nutrition labels list the amount of trans fat in these foods. Aim for zero!
  • Consume moderate amounts of healthy fats. These are the fats found in fish, nuts and vegetables like olives. Use oil-based dressings instead of those with butter, stick margarine, or cream cheese. Drink fat-free (skim) or low-fat (1%) milk instead of reduced-fat (2%) or whole milk. Buy lean cuts of meat instead of fatty meats or choose these foods less often. Try low-fat plain yogurt instead of cream or sour cream.

Get moving!

lower-cholesterol-by-excersizingChildren need a lot of exercise. Aim for 30-60 minutes of vigorous activity every day. Young children usually get their exercise through play. The best way to encourage this kind of exercise is to restrict their access to TV, movies, video/computer games and other electronic devices to less than 2 hours daily. If your child needs to get more exercise, consider restricting screen time to less than 1 hour daily.

A healthy BMI

If your child has a body mass index that is greater than 85% percentile as compared to his/her peers, improving this measure might help reduce the total and/or “bad” cholesterol. You provider will alert you if your child falls into this category. We do not recommend “putting kids on diets.” However, following the above recommendations for reducing saturated fats, increasing healthy fats and increasing exercise are a step toward improved BMI. Additional improvement can results from eliminating all beverages other than low-fat milk or water, increasing intake of fruits and vegetables and limiting number and size of servings of proteins, grains, dairy and sweets. 

Bottom line

Cholesterol levels are one aspect of your child’s health but we believe they are important. The medical community continues to learn more about the interaction between cholesterol levels, diet, exercise, inherited traits, and cardiovascular health. This information represents our best advice about cholesterol at this time. As always, we look forward to partnering with you and your child to achieve their best health.