Kids at Risk

Heart disease, the top killer of Americans, doesn’t just magically appear in middle age. It’s rooted in the carefree days of youth.

Kids as young as 15 may already have arteries lined with plaque not usually seen until decades later, even though they don’t feel ill. Because coronary artery disease starts with silent and invisible changes, a child’s risk can easily slip the notice of parents--and doctors. For most kids, the first sign of a problem is chest pain, heart attack or sudden death in adulthood.

That doesn’t have to happen. As new research sheds light on how and when heart disease begins, the importance of evaluating all children and instilling healthy habits becomes increasingly clear. Some pediatricians, cardiologists and researchers even recommend routine blood cholesterol tests and, if necessary, intervention with drugs. They criticize current guidelines that call for testing only those with specific family histories as falling far short.

But all agree that America is missing an opportunity to derail the precursors of heart attack and stroke. Prevention in the young can go further, and at lower cost, they add, than treatment later on.

“This is all about risk reduction,” said Dr. Alan Lewis, a pediatric cardiologist at Childrens Hospital Los Angeles. “We can’t absolutely prevent disease, but we can reduce the risk.”

Coronary artery disease begins with innocuous, and common, streaks of fatty material in blood vessel walls. But over time, fat and cholesterol can accumulate, transforming into raised lesions, or plaques, that in turn lead to scarring in the artery wall. Eventually, plaques can block blood flow through the heart. Or pieces can break off and lodge in an artery, causing a heart attack or stroke.

“Our best long-term hope of prevention is to start with pediatric patients,” said Dr. Stephen R. Daniels, a pediatric cardiologist at the University of Cincinnati. Daniels says assessing kids’ risk at routine medical visits, though expensive, will cost less than treating the new epidemic of heart disease now planting its roots.

Researchers cannot precisely estimate the size of this epidemic. Although angiograms could help determine which children are at risk, that would involve making an incision in children’s groins, snaking a catheter through their hearts’ arteries and taking X-rays to see if the vessels are narrowing. Such invasive procedures would not be ethical.

But doctors have other clues about the number of children affected. They know that 1 in 500 people--about 145,000 kids younger than 18--has a form of inherited high cholesterol, called familial hyperlipidemia, that can send their cholesterol into the 300s and higher and raises their chances of suffering a heart attack or stroke in their teens and 20s. In addition, about 10% of kids, or almost 7 million youngsters, have total cholesterol over 190, which is considered high for a child. And there’s been an explosion of kids with Type 2 diabetes, which used to strike primarily in adulthood, and an epidemic of obesity--all of which drive coronary artery disease.

Other than genetics, most risk factors can be tackled with lifestyle changes. But as with adults, it’s hard to convince youngsters (and the parents who care for them) that resisting the siren song of fat and sugar, exercising regularly and shunning cigarettes will pay off down the road.

Some Children Establish

Healthy Lifestyle Early

Those kids who have heeded the message usually are ones who know they’ve inherited high cholesterol through a faulty gene. All too aware of the dangers of heart disease and how to manage their risk, these children have shown that screening and lifestyle changes can indeed work.

Rebeca Poore, a lean 10-year-old from La Crescenta, sticks with a regimen of good diet, exercise and medication.

Her father, Mark, 43, suffered a massive heart attack at 29 while mountain biking, and last year had his second major bypass operation. He inherited high cholesterol from his father, who suffered a heart attack and stroke by his late 50s.

Rebeca stuck for years with her prescribed Cholestid, a powdered cholesterol-lowering drug that’s mixed into juice or water and reviled by kids. “It tasted like sand. It was really gross,” she said. But “I really didn’t want to have surgery like my dad, so I decided I’d better take it.”

Now she takes Lipitor, a cholesterol-lowering statin. Such drugs are rarely prescribed for children because they’ve only been tested in adults and a few teenagers and no one knows what their long-term effects may be. But the drug has proved effective. Her total cholesterol has dropped from 369 to 209. Not complacent, Rebeca still brings a healthy lunch to school, indulges her sweet tooth with nonfat candies and has found lots of other dietary compromises. She even strips most of the cheese and pepperoni off her pizza and gives them to one of her friends.

Kids like Rebeca have offered insight about heart disease in the very young, but studies that have tracked groups of kids for years have taught researchers about how fatty buildups actually develop. And a pioneering study based on autopsies of more than 3,000 teen and young adult victims of accidental or violent deaths, age 15 to 34, found that about 15% to 20% of late teens had diseased arteries and that the number increased with age.

Among the most important findings from that autopsy study, which continues to yield new information, is that the risk factors that affect adult heart disease--obesity, high cholesterol levels, high blood pressure, smoking, diabetes and a family history of heart disease, apply in kids. In the study, the more risk factors someone had as a child, the more likely they were to have thick plaques inside their arteries, and the more rapidly heart disease had progressed. The study also found that elevated blood sugar was a powerful predictor of coronary plaques.

Together, such studies have shown that heart disease risk factors in children “are not just a curiosity, but are causing disease in the vascular system at least as early as the teenage years,” said Dr. Darwin Labarthe, associate director for cardiovascular health policy and research at the federal Centers for Disease Control and Prevention. Labarthe has been among those leading the drive for increased attention to kids’ heart health.

Lacking good, noninvasive methods of seeing inside kids’ arteries, investigators have been experimenting with techniques that give them an indirect view. Some are trying ultrasound tests to establish whether thickening of the carotid artery in the neck can be a good surrogate indication there’s buildup in the heart vessels. Others have been putting pressurized cuffs on kids’ arms and checking to see if blood vessels there are stiffening up, another sign of atherosclerosis. Though potentially promising, such methods aren’t ready for broad use.

Other techniques that show promise include checking for deposits of calcium in the coronary arteries; examining the major pumping chamber of the heart, the left ventricle, for enlargement, which can signify high blood pressure; and magnetic resonance imaging to monitor cardiac plaque.

But until such methods are further refined, researchers say, the best attack is aggressive prevention. And that will require sweeping cultural change.

Determining Who Will

Spearhead Prevention

First, the medical community must be educated about the problem. Medicine, for the most part, emphasizes treatment rather than prevention. And most pediatricians and family doctors long have seen cardiovascular disease as the domain of internists and cardiologists.

“We need to raise this consciousness among those who care for healthy children ... and make them the authorities,” said Dr. Roberta G. Williams, chairman of pediatrics at the Keck School of Medicine at USC in Los Angeles. “This is the stock in trade of pediatrics.”

Communities also must change, experts say. Kids today get less exercise, are at least 10 pounds heavier than their counterparts 30 years ago, and far exceed dietary recommendations for fat and cholesterol. Without an emphasis on heart health, that is unlikely to change, researchers say.

Several doctors hope that, as with smoking, policymakers will lead a national attack on heart disease, which costs an estimated $300 billion each year, including $100 billion for coronary artery disease, according to the American Heart Assn. One step in that direction is likely to be a National Action Plan for Cardiovascular Health, which Labarthe is working on at the CDC.

But ultimately, the message has to hit home with families.

“It’s got to start with the parents,” said Dr. Henry C. McGill, an emeritus professor at the University of Texas in San Antonio, who led the pioneering autopsy studies.

Parents need to see relevance for the kids they’re tucking into bed tonight--and for their kids’ playmates.

Because Eric Fiedler, 12, of Glendale, looks healthy, it takes a lot to persuade the other moms and dads at soccer practice not to ply him with high-fat snacks. Said his dad Bob, from whom he inherited high cholesterol: “They don’t understand because they don’t have the problem.”

Eric’s mother, Hilda, is disappointed that so many parents are uninformed about the risks that kids like her son face. “They say, ‘He’s just a kid, he’ll grow out of it.’ That kind of ignorance is really sad.”

Often, parents of young children haven’t had their own cholesterol checked, or haven’t developed symptoms themselves. Grandparents “may be young enough that they may not have much of a history, except in the worst cases,” Lewis said.

And because the American Academy of Pediatrics currently recommends cholesterol screening in children older than 2 years only when there are known risks, such as diabetes, obesity or hypertension, or a family history of early heart disease, many kids are overlooked, he says.

Lewis believes that every child should be tested before entering kindergarten.

Such broad testing remains controversial, but there’s no argument that relatively low-cost programs that reach out to parents, into the school cafeterias and physical education programs to reinforce healthy practices, can make a difference.

In Texas, for example, a school-based community program, sponsored by the National Heart, Lung and Blood Institute, improved kids’ diet and increased activity through physical education classes, Labarthe said.

“There is no inherent reason why a similar effort could not be successful on a nationwide basis,” he said.

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Keeping Young Arteries Healthy

Several risk factors in childhood have been linked to coronary artery disease, which can lead to eventual heart attack and stroke. These include:

* High cholesterol. Generally, concern begins with youngsters age 2 and up, when total cholesterol exceeds 170 and LDL cholesterol exceeds 110 to 130. Total cholesterol of 170 to 190 is considered borderline elevated, 190 to 200 is mildly elevated and over 200 is seriously elevated.

* High blood pressure. Thresholds, different from those of adults, vary by age.

* Family history. Having close relatives with a history of angina, heart attack, angioplasty or bypass surgery before age 55.

* Obesity.

* Smoking.

* Diabetes.