Getting an early start

in check

Getting an early start

General assumption is that only adults face cholesterol problems. But the truth is even kids and adolescents face this problem. And controlling high cholesterol in early adulthood reduces the risk of heart attack and stroke later in life. In a majority of cases, high cholesterol can be managed with diet, physical exercise and weight control. Drug therapy is needed only when cholesterol levels are very high.

At high risk

Lately, it has been recognised that the first cholesterol check should be performed in childhood rather than adulthood. There are two reasons for this. One, some children have genetically determined, severely elevated cholesterol levels that predispose them to heart attacks in their 30s or 40s, rather than in 50s or 60s. In such children, effective cholesterol reduction may be desirable from childhood onwards. Second, obesity and type 2 diabetes mellitus due to lifestyle-related factors are increasingly being associated with cholesterol level elevation in children and adolescents. Postponing treatment of severely elevated cholesterol until middle age or late adulthood in both situations may be too late.  

High cholesterol, per se, does not produce any symptoms. It can only be detected by a blood test. Therefore, it is recommended that everybody should have cholesterol testing on attainment of adulthood. In actual practice, cholesterol is often measured for the first time only when a person manifests symptoms of heart disease. 

Till 2011, cholesterol screening in children and adolescents had been directed to those at increased risk, i.e., children above two years with a close relative having a coronary heart disease, or a parent having very high cholesterol levels (>240 mg/dl). Use of family history as the main reason for screening may miss out children with high cholesterol, largely because parents themselves may not know their own cholesterol. 

Therefore, it is now recommended that all children should be screened for cholesterol between ages 9 and 11, and once again between 17 and 21 years. The rationale for choosing these age groups for universal screening is that cholesterol levels change throughout childhood. Cholesterol estimation may also be indicated in other age groups when a child or adolescent is found to have elevated blood pressure, blood glucose, or excessive weight.

In all children with abnormal cholesterol levels, an evaluation for a cause is necessary. Causes may be one or more of four Ds: diet, disease, drugs and dysmetabolism. Elucidation of common causes requires assessment of liver, kidney and thyroid function, as well as blood glucose estimation. Severe elevation of cholesterol is likely to be genetic in origin. The most common genetic disorder of cholesterol is familial combined hypercholesterolemia (FCH), found in 1 in 200, followed by heterozygous familial hypercholesterolemia (HeFH) in 1 in 500. In the latter, blood cholesterol levels are far beyond normal may be found as young as two years.

Nearly 50% of males and 25% of females with this disorder develop angina or heart attack before 50 years of age. Homozygous familial hypercholesterolemia (HoFH) is much rarer (1 in a million), but associated with even higher cholesterol levels and propensity to develop heart attack in childhood or early adulthood.

The treatment

The mainstay of treatment of abnormally high cholesterol levels in children and adolescents is diet and physical activity. Emphasis is on low-fat unflavoured milk as the main beverage, a high-fibre diet rich in fruits, vegetables and whole grains, and limitation of sugar-sweetened beverages and animal, hydrogenated fats. 

Drug treatment is not encouraged due to concerns about potential effects on growth and development though studies have indicated that this fear may be unfounded. When cholesterol levels are very high and presumed to be genetic, children above 8-10 years of age may benefit from statin drug therapy, but the dosing should be conservative, ensuring the minimum effective dose. Routine health monitoring during dietary and drug treatment should include assessment of growth and development. Liver functions should be monitored annually.

Since cholesterol treatment is a life-long affair, the female adolescent should be made aware that statin use should be withdrawn while planning pregnancy after marriage as statin use during pregnancy may cause birth defects. Bile acid sequestrants and ezetimibe are also approved for children who do not achieve effective cholesterol reduction with statins alone. Both inhibit dietary cholesterol absorption from the intestine.  
 
Cholesterol reduction should be considered at a young age to reduce the risk of premature heart attacks. While the primary treatment for treating high cholesterol in children is diet and physical activity, drug therapy may be indicated for those older than 10 years with more severe and particularly genetic forms as well as those who are unable to adopt healthy lifestyles.

4Ds of Cholesterol Abnormalities

Diet
High saturated fat & calorie, excessive carbohydrate, excessive alcohol intake, anorexia nervosa

Disease

Cardiac: Kawasaki disease, heart transplantation,
congenital heart disease
Hepatic: Intrahepatic cholestasis, chronic liver disease, primary biliary cirrhosis,
hepatitis, biliary atresia,
Alagille syndrome   
Renal: Chronic renal failure, nephrotic syndrome,
hemolytic-uremic syndrome

Drugs

Oral estrogens, progestins and contraceptives, anabolic steroids, corticosteroids, thiazide diuretics, B-blockers, bile acid-binding resins glucocorticoids, protease inhibitors 
Dysmetabolism
Diabetes type 1 and type 2, obesity, insulin resistance, acute intermittent porphyria, hypopituitarism, lipodystrophy
 
(Dr Peeyush is the head, department of preventive cardiology, and Dr Ashok is the chairman, cardiac sciences, Fortis-Escorts Heart Institute, New Delhi.)

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