Cholesterol in Childhood
Committee on Nutrition
ABSTRACT. This updated statement
reviews the scientific justification for the recommendations of dietary changes
in all healthy children (a population approach) and a strategy to identify and
treat children who are at highest risk for the development of accelerated
atherosclerosis in early adult life (an individualized approach). Although the
precise fraction of risk for future coronary heart disease conveyed by elevated
cholesterol levels in childhood is unknown, clear epidemiologic and
experimental evidence indicates that the risk is significant. Diet changes that
lower fat, saturated fat, and cholesterol intake in children and adolescents
can be applied safely and acceptably, resulting in improved plasma lipid
profiles that, if carried into adult life, have the potential to reduce
atherosclerotic vascular disease.
ABBREVIATIONS. LDL, low-density lipoprotein;
HDL, high-density lipoprotein.
Although
the focus of this statement by the Committee on Nutrition is on cholesterol
levels in children, other risk factors for atherosclerosis originate in
childhood and should be addressed with equal attention. Specifically, smoking
should be discouraged, hypertension should be identified and treated, obesity
should be avoided and reduced, regular exercise should be encouraged, and
diabetes mellitus should be identified and treated.1
This
statement, for the most part, is in concert with statements of other experts
and expert panels, including the National Cholesterol Education Program, the
American Heart Association's Council on Cardiovascular Disease in the Young and
Committee on Nutrition, the US Department of Agriculture and the US Department
of Health and Human Services Dietary Guidelines for Americans, the US Surgeon
General, the National Research Council, and the National Cancer Institute.
DIET AND ATHEROSCLEROSIS
Studies in animals have demonstrated that high
blood cholesterol levels promote atherosclerosis.2-4 Atherosclerosis
develops in many species fed diets that raise the total and low-density
lipoprotein (LDL)-cholesterol levels. Vascular fatty
streaks and fibrous plaques develop in adolescent nonhuman primates fed diets
high in saturated fatty acids and cholesterol.5,6
In monkeys with severe atherosclerosis, regression of the process occurs when
the blood cholesterol level is lowered with diet and drugs. 2,7,8
In
adults, the major nutritional determinant of differences in serum cholesterol
levels between countries appears to be the proportion of saturated fat in the
diet.9-11 This also is observed in
childhood populations.11-13 Total blood cholesterol levels in
children vary geographically. In countries such as the Philippines, Italy, and
Ghana, saturated fat constitutes approximately <10% dietary intake,
and the serum cholesterol level in boys 8 to 9 years of age is generally below
160 mg/dL.13-15 In boys from countries such as the Netherlands,
Finland, and the United States, the saturated fat intake varies from 13.5% to
17.7% of energy intake, and serum cholesterol levels are generally >160 mg/dL. Although blood cholesterol levels are lowest in
countries in which nutrition is not optimal and growth is delayed, there are
many industrialized countries in which children have lower cholesterol levels
than children in the United States and in which normal growth is maintained (eg, Portugal, Israel, and Italy). A range of serum
cholesterol levels is found in industrialized countries, with the
CLINICAL
TRIALS
Clinical
trials in adult populations have shown that lowering cholesterol levels reduces
coronary risk.2,24-26 Aggregate analysis of many clinical trials
shows that lowering cholesterol levels by diet or drugs and by primary or
secondary prevention reduces fatal and nonfatal myocardial infarction.27
Initially, some controversy occurred about the effectiveness of lowering
cholesterol levels because a number of trials did not find a significant
reduction in total mortality after treatment to lower the cholesterol level.2
These findings have been clarified recently by several studies with large
samples of subjects and of long duration showing a decrease not only in the
incidence of coronary heart disease but also in mortality from all causes.28,29
In
addition, the Dietary Intervention Study in Children, a recent study of the
safety and efficacy of lower fat diets in pubertal children, was reported by a
collaborative multicenter group. In this study of 663
children 8 to 10 years of age who were followed for 3 years, an intervention
group receiving a diet with 28% of calories from total fat, ~10% of calories
from saturated fat, and 95 mg per day of cholesterol was compared with a group
that consumed 33% to 34% of calories as total fat, 12.7% of calories as
saturated fat, and 112 mg per day of cholesterol. There were no differences in
height, weight, or serum ferritin levels in the two
groups, and the intervention group had significant, but modestly lower, levels
of LDL-cholesterol levels and maintained psychologic
well-being.30
SIGNIFICANCE
OF BLOOD CHOLESTEROL LEVELS IN CHILDREN AND ADOLESCENTS
High
blood cholesterol levels clearly play a role in the development of premature
coronary heart disease in adults. This has been established by many laboratory,
clinical, pathological, and epidemiologic studies. It has also been shown that
lowering blood cholesterol levels in adults results in
a significant lowering of coronary heart disease rates and mortality. Because
no long-term studies of the relationship of blood cholesterol levels measured
in childhood to coronary heart disease in later life have been conducted, the
relationship of childhood cholesterol levels to the atherosclerotic process
must be inferred from less direct evidence.
These
lines of evidence are summarized as follows:
1. Compared with their
counterparts in many other countries, US children and adolescents have higher
blood cholesterol levels and higher intakes of saturated fatty acids and
cholesterol, and US adults have higher rates of coronary heart disease
morbidity and mortality.[13,15]
2. Autopsy studies demonstrate
that early coronary atherosclerosis or precursors of atherosclerosis often
begin in childhood and adolescence and are related to high serum total
cholesterol levels, LDL-cholesterol plus very low-density
lipoprotein-cholesterol levels, and low high-density lipoprotein levels.
3. Children and adolescents
with elevated serum cholesterol levels, particularly LDL-cholesterol levels,
often come from families in which there is a high incidence of coronary heart
disease in the adult relatives.32,33
4. A strong familial
aggregation of total, LDL-, and HDL-cholesterol levels exists in children and
parents.34,35 Familial aggregation of blood cholesterol levels
results because of shared environments and genetic factors.36 The
monogenetic factors that cause high cholesterol levels include familial
hypercholesterolemia and familial-combined hypercholesterolemia. Polygenic
disorders that result from the expression of a number of genes, each with a
small but additional effect, combined with environmental contributions such as
a diet high in saturated fat and cholesterol are likely the most frequent
causes of high cholesterol levels during childhood.37,38
5. Children and adolescents
with high cholesterol levels are more likely than the general population to
have high levels as adults.39-45 However, a substantial number of
children with high cholesterol levels become adults with desirable cholesterol
levels without intervention.46
STRATEGIES TO LOWER
CHOLESTEROL LEVELS IN CHILDREN AND ADOLESCENTS
To
lower blood cholesterol levels in children and adolescents, two complementary
approaches are recommended: a population approach and an individualized
approach.
The Population Approach
The population approach is designed as the primary
means for preventing coronary heart disease. It aims to lower the average level
of blood cholesterol in all children and adolescents through population-wide
changes in nutrient intake and eating patterns. These recommendations are
directed to groups that influence the eating patterns of children and
adolescents, including schools, health professionals, government agencies, the
food industry, and the mass media. The advantage of this approach is that even
a small reduction of the mean total and LDL-cholesterol levels in children and
adolescents, if carried into adult life, could decrease substantially the
incidence of coronary heart disease.
The
US Department of Agriculture 1987 to 1988 Food Consumption Survey indicated
that children and adolescents consume 35% to 36% of calories from total fat;
14% from saturated fat, and 193 to 296 mg per day of cholesterol.47,48
More recent US population-based data from the National Health and Nutrition
Examination Survey III for persons 2 to 19 years of age indicate that mean
intakes of total fat and saturated fat are 34% and 12%, respectively, and the
mean cholesterol intake is ~270 mg per day.49
Nutrient Recommendations *(See 4/98 Errata)
No restriction of fat or cholesterol is recommended
for infants <2 years when rapid growth and development require high energy
intakes. A precise percentage of dietary intake from
fat that supports normal growth and development while maximally reducing
atherosclerosis risk is unknown. Therefore, a range of appropriate values,
averaged over several days for a child or adolescent, is recommended based on
the scientific information available. Because concerns have been expressed that
some parents and their children may overinterpret the
need to restrict their fat intakes, a lower limit of fat intake is suggested by
this Committee. The Committee recognizes that children 2 to 5 years of age are
selective in their food choices. After 2 years of age, children and adolescents
should gradually adopt a diet that, by ~5 years of age, contains <30%
of calories and <20% from fat. As they begin to consume fewer
calories from fat, children should replace these calories by eating more grain
products, fruits, vegetables, low-fat milk products or other calcium-rich
foods, beans, lean meat, poultry, fish, or other protein-rich foods. These
recommendations are for average intakes over several days, so that if foods
high in total fat, saturated fat, and cholesterol are eaten, they can be
compensated for by eating less of these nutrients at other times. Because no
single food item provides all the essential nutrients in the amounts needed,
choosing a wide variety of food from all the food groups will ensure an
adequate diet.
Specific
nutrient recommendations are as follows: 1) nutritional adequacy should be
achieved by eating a wide variety of foods; and 2) caloric intake should be
adequate to support growth and development and to reach or maintain desirable
body weight. For a child or adolescent (2 to 18 years of age), the following
pattern of nutrient intake is recommended: 1) saturated fatty acids <10% of
total calories; 2) total fat over several days of <30% of total
calories and no less than 20% of total calories; and 3) dietary cholesterol
<300 mg per day.
Because
saturated fatty acids raise blood cholesterol levels,50 a major emphasis should
be placed on reducing saturated fat intake to <10% of calories. A
sufficiently low saturated fat intake can be achieved with a total fat intake
of ~30% of calories from fat. A lower fat intake is usually not necessary and,
for some children and adolescents, may make it difficult to provide enough
calories and minerals for optimal growth and development.
THE INDIVIDUALIZED APPROACH
The individualized approach to lowering cholesterol
levels calls on the cooperative effort of health care professionals to identify
and treat children and adolescents at highest risk of having high blood
cholesterol levels as adults and increased risk of coronary heart disease.
Selective Screening
Figures 1 and 2 present the algorithms for
selective screening.
Children
and adolescents who have a family history of premature cardiovascular disease
or have at least one parent with a high blood cholesterol level are at
increased risk of having high blood cholesterol levels as adults and increased
risk of coronary heart disease and, therefore, are recommended for selective
screening in the context of regular health care. This focus is supported by
strong evidence of familial aggregation of coronary heart disease, high blood
cholesterol levels, and other risk factors.
The
following are specific recommendations for selective screening of children and
adolescents in the context of their continuing health care.
1. Screen children and
adolescents whose parents or grandparents, at <55 years of age,
underwent diagnostic coronary arteriography and were
found to have coronary atherosclerosis. This includes those who have undergone
balloon angioplasty or coronary artery bypass surgery.
2. Screen children and
adolescents whose parents or grandparents, at <55 years of age, had a
documented myocardial infarction, angina pectoris, peripheral vascular disease,
cerebrovascular disease, or sudden cardiac death.
3. Screen the offspring of a
parent with an elevated blood cholesterol level (240 mg/dL
or higher).
4. For children and
adolescents whose parental history is unobtainable, particularly for those with
other risk factors, physicians may choose to measure cholesterol levels to
identify those in need of nutritional and medical advice.
Optional cholesterol
testing by practicing physicians may be appropriate for children who are judged
to be at higher risk for coronary heart disease independent of family history
(Table 1). For example, adolescents who smoke, consume excessive amounts of
saturated fats and cholesterol, or are overweight may also be tested at the
discretion of their physician. For parents who do not know their cholesterol
levels, pediatricians should strongly encourage them to have their levels
measured.
What Should Be Measured
The focus of the individualized approach is to
detect and treat the child or adolescent with hypercholesterolemia whose
elevated LDL-cholesterol level is likely to indicate increased risk in
adulthood. The screening protocol varies according to the reason for testing.
This protocol is suggested to limit the need for more sophisticated analyses.
If screening is performed because a parent has a cholesterol
higher than 240 mg/dL, the initial test should be a
measurement of total cholesterol. If the child's level is higher than 200 mg/dL, a fasting lipoprotein analysis should be obtained to
measure HDL-cholesterol and LDL-cholesterol levels. If the total cholesterol is
borderline (170 to 199 mg/dL), a second measurement
should be obtained and averaged with the first result. If the average is
borderline or high, a fasting lipoprotein analysis should be obtained.
If
the patient is being tested because of a documented family history of premature
cardiovascular disease, the initial test should be a lipoprotein analysis that
requires a 12-hour fast to obtain accurate triglyceride levels, which are
necessary for the computation of LDL-cholesterol levels. The acceptable
borderline and high levels for total and LDL-cholesterol are given in Table 2
Management Because there is
considerable variability in some children, once a lipoprotein analysis is
obtained, it should be repeated so that an average LDL-cholesterol level can be
calculated. The average LDL-cholesterol level determines the steps for risk
assessment and treatment. Follow-up of the averaged LDL-cholesterol
determinations is as follows:
1. Acceptable LDL-cholesterol
level (<110 mg/dL) — Provide education on the
eating pattern recommended for all children and adolescents and on other risk
factors; repeat lipoprotein analysis in 5 years.
2. Borderline LDL-cholesterol
(110 to 129 mg/dL) - Provide advice about risk
factors for cardiovascular disease; initiate the American Heart Association
Step-One diet and other risk factor intervention; reevaluate in 1 year.
3. High LDL-cholesterol (>130
mg/dL) — Examine for secondary causes (thyroid,
liver, and renal disorders) and familial disorders, screen all family members,
initiate Step-One diet, followed by the Step-Two diet, if necessary.
Step-One and Step-Two Diets
The Step-One diet calls for
the same nutrient intake recommended for the population approach to lower
cholesterol levels, ie, <30% and no less
than 20% of calories from total fat; <10% of total calories from saturated
fat; <10% of calories from polyunsaturated fat; and no more than 300
mg per day of cholesterol. What makes the diet therapeutic is prescription in a
medical setting with monitoring and follow-up by a health professional. If
careful adherence to this diet for at least 3 months does not result in a lower
LDL-cholesterol level to the acceptable range, the Step-Two diet should be
prescribed. Often children who have been determined to have high
LDL-cholesterol levels have instituted a diet similar to the Step-One diet and
require counseling to adopt the Step-Two diet.[51]
The
Step-Two diet requires detailed assessment of current eating patterns and
instruction by a physician, registered dietitian, registered nurse,
nutritionist, or other appropriately trained health professional. It aims to
induce an eating pattern that includes no more than 30% and no less than 20% of
calories from total fat; <7% of total calories from saturated fat; <10%
of calories from polyunsaturated fat; and no more than 200 mg per day of
cholesterol. This eating pattern requires careful planning to ensure adequacy
of nutrients, vitamins, and minerals, and often requires the services of a
registered dietitian or other qualified nutrition professional.
Drug
Therapy
Drug therapy should be considered only for children >10 years of age after
an adequate trial of diet therapy (for 6 to 12 months) and whose
LDL-cholesterol level remains >190 mg/dL or
whose LDL-cholesterol level remains >160 mg/dL
and there is a family history of premature cardiovascular disease (<55
years of age) or two or more other risk factors (Table 1) are present in
the child or adolescent after vigorous attempts have been made to control these
risk factors.
The
recommended drugs for the treatment of hypercholesterolemia and high
LDL-cholesterol levels in children are the bile acid sequestrants
cholestyramine and colestipol,
which bind bile acids in the intestinal lumen. They have documented efficacy,
relative freedom from adverse effects, and are apparently safe when
administered to children. Other pharmacologic agents are not recommended for
routine use in children and adolescents except in consultation with a lipid
specialist.
CONCLUSION
To
promote lower cholesterol levels in all healthy children (2 to 18 years of age)
in the
1. Saturated fatty acids
<10% of total calories.
2. Total fat over several days
of no more than 30% of total calories and no less than 20% of total calories.
*(See 4/98 Errata)
3. Dietary cholesterol <300
mg per day.
Pediatricians should
identify children at highest risk for the development of accelerated
atherosclerosis by screening cholesterol levels in children who have a parental
or grandparental history ( <55 years of age) of a documented
myocardial infarction, angina pectoris, peripheral vascular disease, cerebrovascular disease, or sudden cardiac death, or a
parent with a high blood cholesterol level ( >240 mg/dL). In addition, for children and adolescents whose
parental history is unobtainable, particularly those with other risk factors,
physicians may measure cholesterol levels to determine those in need of
nutritional and medical advice.
A
precise percentage of dietary intake from fat that
supports normal growth and development while maximally reducing atherosclerosis
risk is unknown. Therefore, a range of appropriate values, averaged over
several days for a child or adolescent, is recommended based on the scientific
information available.
TABLE
1 Other
Risk Factors That Contribute to Earlier Onset of
Coronary Heart Disease
|
Family history of
premature coronary heart disease, cerebrovascular
disease, or occlusive peripheral vascular disease (definite onset before the
age of 55 years in siblings, parent, or sibling of parent) |
|
Cigarette smoking |
|
Elevated blood pressure |
|
Low HDL-cholesterol
concentration (<35 mg/dL) |
|
Severe obesity (<
95th precentile weight for height) |
|
Diabetes mellitus |
|
Physical inactivity |
TABLE
2.
Classification of Total and LDL-Cholesterol Levels in Children and Adolescents From Families With Hypercholesterolemia or Premature
Cardiovascular Disease
|
Category |
Total Cholesterol (mg/dL) |
LDL-Cholesterol (mg/dL) |
|
Acceptable |
<170 |
<110 |
|
Borderline |
170-199 |
110-129 |
|
High |
200 |
130 |
|
Fig 1 Risk assessment.
Positive family history is defined as a history of premature (<55 years of
age) cardiovascular disease in a parent or grandparent (from the National
Cholesterol Education Program52). |
|
|
|
Fig 2 Classification,
education, and follow-up based on low-density lipoprotein-cholesterol (from
the National Cholesterol Education Program52). HDL indicates high-density
lipoprotein; LDL, low-density lipoprotein. |
|
|
COMMITTEE ON
NUTRITION, 1996 TO 1997
William J. Klish, MD, Chair
Susan S. Baker, MD
William J. Cochran, MD
Carlos A. Flores, MD
Michael K. Georgieff, MD
Marc S. Jacobson, MD
Alan Lake, MD
LIAISON
REPRESENTATIVES
Donna Blum
US Department of Agriculture
Suzanne S. Harris, PhD
International Life Sciences Institute
Van S. Hubbard, MD
National Institute of Diabetes & Digestive & Kidney Diseases
Ephraim Levin, MD
National Institute of Child Health & Human Development
Ann Prendergast, RD, MPH
Maternal & Child Health Bureau
Alice E. Smith, MS, RD
American Dietetic Association Elizabeth
Yetley, PhD
Food and Drug Administration
AAP SECTION
LIAISON
Ronald M. Lauer, MD
Section on Cardiology
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ERRATA (April 1998)
It has been brought to our attention that two errors occurred in the policy
statement entitled "Cholesterol in Childhood," which appeared in the
January 1998 issue of Pediatrics (pages 141-174). On page 142, in the section
on "Nutrient Recommendations," the sixth sentence should read as
follows:
After 2 years of age, children and adolescents should gradually adopt a diet
that, by ~5 years of age,
contains no more than 30% (not <30%) of calories and no less than 20% (not
<20%) from fat.
On page 143, in the second full paragraph, 2) should read as follows:
2) total fat over several days of no more than 30% (not <30%) of total
calories and not less than 20% of
total calories;
Pediatrics Volume 101,
Number
The
recommendations in this statement do not indicate an exclusive course of
treatment or serve as a standard of medical care. Variations, taking into
account individual circumstances, may be appropriate.
© Copyright 1998
No part of this statement may be reproduced in any form or by any means without
prior written permission from the