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Hypercholesterolemia

Cardiovascular disease is the leading cause of morbidity and death in the United States. While this has traditionally been known as an adult-onset issue, the recent obesity epidemic (and increased risk of type 2 diabetes mellitus and hypertension) have brought this to the forefront of pediatrics as well. With many physicians now tackling hypercholesterolemia in school-age children and younger, an understanding of the risk of atherosclerosis in children and its prevention is paramount to healthy development.

As a result, the American Academy of Pediatrics (AAP) has recently updated their guidelines on cholesterol in childhood (Daniels et al, Pediatrics, 2008). Traditionally, risk factors for cardiovascular disease in adults have included elevated levels of low-density lipoprotein (LDL), decreased levels of high-density lipoprotein (HDL), elevated blood pressure, type 1 or 2 diabetes mellitus, cigarette smoking, and obesity. Research has shown that many of these may be present at a young age, and as a result, identification and prevention of risk factor progression has become paramount in the last several years.

One of the most important questions relates to the timing of cholesterol screening – when should children get tested? According to current AAP guidelines, children and adolescents should be screened with a fasting lipid profile if any of the following risk factors are present:

  1. A positive family history of dyslipidemia or premature (<55 years of age for men and < 65 years for women) cardiovascular disease or dyslipidemia.
  2. Obesity (BMI > 95th percentile).
  3. Hypertension (blood pressure > 95th percentile).
  4. A history of cigarette smoking.
  5. A history of diabetes mellitus.

For these individuals, the first screening should occur after age 2, but no later than age 10. If values are normal, repeat testing should be done at 3-5 year intervals. Importantly, new guidelines also use percentile values for children and adolescents to identify abnormal cholesterol levels, rather than using one cutoff value for all ages.

Non-pharmacologic treatment of hypercholesterolemia involves a multidisciplinary approach. Success often requires a family-wide change in eating and exercise habits. The therapeutic lifestyle changes (TLC) diet focuses on the following:

  1. No more than 25-35% of the day’s total calories from fat.
  2. No more than <7% of the day’s total calories from saturated fat.
  3. Less than 200 mg of dietary cholesterol per day.
  4. Sodium intake < 2400 mg/day.
  5. Just enough calories to achieve or maintain a healthy weight.

More information on this diet can be found at www.nhlbi.nih.gov, where tailored dietary strategies can be individually formulated.

Drug intervention for hypercholesterolemia is usually reserved for individuals who persist with high values despite diet, exercise, and weight control. Additionally, recent data indicates safe pharmacologic options exist starting around 8 years of age (possibly younger with dramatically high values). Multiple pharmacologic approaches exist, including bile acid-binding resins, statin drugs (3-hydroxy-3-methyl-glutaryl coenzyme A reductase inhibitors), cholesterol-absorption inhibitors, and fibrates. Careful consultation with your physician will aid in choosing the proper medication tailored to each person’s needs.