As Americans — including even young children — continue to get fatter, their risk for heart disease is climbing too. So a panel of experts now is recommending that all kids have their cholesterol checked at least once between ages 9 and 11 and again between 17 and 21.
Although children typically don’t have heart attacks and strokes, evidence has been mounting for years that the roots of those diseases begin early in life, and the rising rates of obesity have only fueled the risk.
That means doctors should start looking for signs of future heart disease in all kids, said the authors of a report sponsored by the federal government that is the first comprehensive guide on heart risk management in children.
Such guidelines already exist to address heart disease risk in adults, but until now there has been none outlining what works best for children.
Developed by the National Heart, Lung and Blood Institute and endorsed by the American Academy of Pediatrics, the guidelines were welcomed by heart specialists and pediatricians, who said they were long overdue.
“It’s a major step forward,” said Dr. Alan Lewis, a pediatric cardiologist at Children’s Hospital Los Angeles who was not involved in crafting the report.
The guidelines were several years in the making, said panel chairman Dr. Stephen R. Daniels, pediatrician-in-chief at Children’s Hospital Colorado. Its recommendations, published Friday in the journal Pediatrics, are based on studies on all aspects of childhood risk factors for heart disease, carefully graded on the strength of the evidence, he said. Earlier guidelines for child heart health focused on solitary risk factors, such as high blood pressure or weight.
“Heart disease is the No. 1 cause of death in our society,” Daniels added. “We know the process that leads to those deaths begins in childhood. We also know that people who are able to maintain a low risk through childhood and early adulthood have a lower risk.
“If they can reach age 50 with low-risk status, they are very unlikely to have heart disease. That is the payoff here,” he said.
The report was developed to address the predicted upswing in heart disease rates caused by the obesity epidemic, said Dr. Elaine M. Urbina, director of preventive cardiology at Cincinnati Children’s Hospital Medical Center, who was a member of the panel.
About one-third of American children are overweight or obese, nearly triple the rate in 1963, according to the American Heart Assn. Approximately 17% of kids ages 2 to 19 — 12.5 million — are obese.
“This document focuses on the fact that this generation may be the first to have a shorter life expectancy than their parents,” Urbina said.
The recommendation to screen all children for high cholesterol is a departure from previous guidelines, in place since 1992, which called for screening only in children with a family history of heart disease or high cholesterol.
But the old guidelines were problematic, Lewis said.
“Approximately half of the children who would warrant at least dietary — if not medical — management would be missed,” he said. “That’s an unacceptable amount.”
Implementing universal cholesterol screening for children should have a sizable ripple effect, experts predicted.
“This doesn’t mean we are going to recommend medications for everyone,” Urbina said. But both doctors and parents may feel a greater sense of urgency to improve kids’ diet and exercise patterns if cholesterol numbers are above normal, she said.
“Having a specific number that you can tell a parent is abnormal is a good teaching tool and motivational tool,” she said.
Urbina added that it’s not enough to simply target cholesterol screenings toward kids who are overweight. Even normal-weight children can have high cholesterol. And not all overweight children have high cholesterol.
It’s not known how many U.S. children have abnormal cholesterol. However, more than 28% of children who are overweight may have metabolic syndrome, a cluster of risk factors that include high blood pressure and high cholesterol, according to a 2004 study.
The cholesterol test will not require fasting, the way it’s done in adult testing, Daniels said. The screening would involve either a blood draw or even just a finger prick in the doctor’s office, from which all blood fats except HDL cholesterol, the “good” kind, would be quantified.
If that first test suggests abnormal cholesterol levels, a fasting cholesterol test would be recommended.
In addition to the cholesterol recommendation, the report details many other ways in which the heart risk of a child should be monitored and managed from the earliest years, laying out a detailed road map for pediatricians and other health practitioners who treat children.
It begins with the advice that all babies should be exclusively breast-fed for the first six months of life — and that they should be fed a diet low in saturated fat beginning at age 1.
Children who score in the 85th to 95th percentile on weight-for-height charts (meaning their weight is higher than 85% of children their height) should receive counseling on diet and exercise because they are at higher risk for heart disease. Those recommendations should be “vigorously reinforced in these children,” the panel said.
The guidelines recommend several types of diets low in saturated fat depending on a child’s weight and whether he or she has high blood pressure or high cholesterol. Special tactics such as low-glycemic or low-carbohydrate diets have not been evaluated in children and therefore aren’t recommended.
The whole family needs to be included in revamped eating habits in cases in which heart disease risks are present, Daniels said.
The report also details how to advise kids and families on weight, physical activity and exposure to tobacco.
“Parents should anticipate their pediatrician asking more questions about their lifestyle and monitoring their children’s cardiovascular risk factors,” Urbina said. “We need to really impart the importance of a healthy diet and exercise for everybody — even if they are lean.”