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Most recent posting below. See other blog postings in the column to the right.

Cholesterol in Kids

July 01, 2002

By Mark B. Levin, M.D. and Timothy J. Patrick-Miller, M.D., and Louis J. Tesoro, M.D.
The Pediatric Group, P.A., Princeton

This is the 37th article written in a series for Princeton Online

We are continually bombarded with information about the health hazards of obesity, inactivity and dietary fat indiscretions in the ypical American lifestyle. The resultant high blood cholesterol, and the greater risk of heart attacks as adults, is a concern for everyone. Many adults in this country are taking cholesterol- lowering drugs to reduce high blood cholesterol levels resulting from both genetic and environmental causes. But what does this mean for our children?

Heart attacks (also known as Myocardial Infarctions or M.I., for short) occur when insufficient blood and nutrients pass through the coronary arteries to the heart muscles. Certain fats can clog the coronary arteries, thereby increasing the risks for heart attacks. The same mechanism plays a role in strokes (also known as cerebro-vascular accidents, or CVAs, for short) when the arteries to the brain become clogged. Understanding the physiology of blood cholesterol will help explain the recommendations made by physicians, the NIH and the American Heart Association.

Eating cholesterol-laden foods does not directly raise the level of cholesterol in our blood. Rather the liver takes the digested nutrients and remanufactures (and repackages) the various forms of cholesterol. High density lipoproteins (HDL) are thought to inhibit the deposit of fat in the arteries. Low density lipoproteins (LDL) are thought to promote the deposit of fat in the arteries. Triglycerides (TG), a type of liver-manufactured fat that is not cholesterol at all, also promote fat deposits in arteries. How much of each type of cholesterol the liver makes depends on the types of digested nutrients it receives and on genetic programming. Studies of children and adults have shown that the amount of the different types of cholesterol in the blood can be influenced by diet and exercise.

We know that adults are supposed to watch their diets, but why children? Are they not using their fat intake to make new cells during growth? Why should we be concerned about the fat in their diets? When some children are the victims of accidental death, autopsies have demonstrated that fat is deposited in the large artery of the upper body (the aorta) by age 3 years and in the arteries of the heart (coronary arteries) by age 12 years. Although enough fat to cause a heart attack does not accumulate until adulthood, once it has accumulated, the disease is manifest. Waiting until symptoms appear before altering a persons lifestyle is inadvisable: many times the first symptom is an MI and nearly half of these MIs are fatal. For the future health of our children, therefore, our thrust must be to encourage a healthy lifestyle now while they are young and their hearts are healthy.

Which children are at greatest risk and would require aggressive screening and earlier intervention? Children who are overweight, who have a high fat or high calorie diet, who have a family history of early vascular disease (heart attacks and strokes) or those who have other predisposing conditions to high blood fats (such as hypothyroidism or diabetes) are prime targets for intervention. Since family histories are often incomplete or inaccurate (our parents often do not know or are unavailable to tell us what conditions they had), blood cholesterol testing is currently the only way of identifying the majority of high-risk children. To be effective, identification of high risk individuals should be accomplished early before much fat is deposited in the arteries -- preferably before bad habits are ingrained and advice on diet and activity falls on deaf ears. For these reasons, many pediatricians will screen children with a blood cholesterol test in early childhood. Repeat screening can be done if risk factors persist or if the initial screening yields an undesirable result. Screening total cholesterol can be performed in the non-fasting state as it is little influenced by recent food intake. The fasting lipid profile (the definitive test which determine the proportion of HDL, LDL and TG), is necessary for children only if the total cholesterol is high or other risk factors are present. The lipid profile must be done fasting because recent food intake influences both LDL and TG levels.

Once a high risk child is identified, appropriate interventions should be instituted. Since desirable levels vary with physical age and development, and intervention varies with blood fat levels, age and risk factors, decisions about your child should be individualized with your child's health care provider. Children who have appropriate weight for their height should be encouraged to maintain their proportions by maintaining the same volume of intake, but should be encouraged to alter the composition of their intake (dietary suggestions appear below). Children whose weight percentiles are in excess of their height percentiles, particularly if they lack muscularity, are thin-boned or are growing faster for weight than for height, should be placed on what the American Heart Association calls the "Step I diet". This diet describes the appropriate calorie intake for a child and the appropriate mix of protein, fat and carbohydrates in the diet. A pediatric nutritionist can provide valuable menu suggestions. If this fails to control a child's weight gain, a more stringent diet (the Step II diet) is recommended.

Along with dietary intervention, maintaining a high activity level is critical for lowering harmful LDL and TG levels, while increasing HDL levels. Recommended activities must be characterized by continuous activity for at least 20 minutes at least three times per week. Stop-start activities are not helpful in controlling blood fat levels. Children who are enrolled in some organized sports activity are far more likely to meet the activity requirements than those who are sent out to play or who get to it when they have time.

Finally, children with less than desirable levels of blood fat profiles who are prescribed intervention, must be followed with growth charts and periodic re-measurement of blood fats to ascertain the effectiveness of the intervention.

By teaching our children to adhere to a healthy lifestyle (appropriate exercise, rest, and healthy diet), we will not only be maximizing their chances of a long, healthy life, but we will also be teaching them the value of thinking about what they are doing to and with their body.

General Guidelines for Food Selection

Current recommendations for food group distribution include meats, dairy, sweets, fats and oils (unsaturated), breads and cereals, vegetables and fruits. In an average school age/young adult's healthy diet of 1800-2000 calories, about 30% of the calories (540-600 calories) should be from fat, but no more than 300 mg of this should be from cholesterol. The balance of the calories from fat should be from unsaturated fats (non-animal sources). 15% of the daily calorie requirement should come from 67-75 grams of protein (270-300 calories) and about 55% of the daily calories should come from 247-275 grams of carbohydrate (990-1100 calories).

The lists below describe which foods to avoid and those to seek in a cholesterol-conscious diet. The numbers in parentheses after each food indicates its approximate cholesterol content in mg in a 3 ½ ounce portion. Note that the content of saturated fat in these foods is not directly correlated with the cholesterol content. The more solid the fat, the higher the content in saturated fat*.

Minimize Foods High in Cholesterol (ie, foods of animal origin) and Saturated Fat* (also foods of animal origin, plus cocoa, coconut, palm oil and manufactured foods containing shortening):

Encourage Foods Low in Cholesterol (ie, vegetables, fruits and grains) and Low in Saturated Fat*:

* saturated fat means the available electrons in the carbon atoms in the fat are completely bound to hydrogen atoms. This makes the fat more solid. Liquid fats are termed "unsaturated" because their carbon atoms have available electrons not bound to hydrogen atoms. "Polyunsaturated" fats means that many carbon atoms in the fat structure are not saturated with hydrogen. It has recently been discovered that "trans" fat has more of an effect on cholesterol than "cis" fat. These terms refer to the structural configuration of the hydrogen atoms on the carbon. The FDA will soon require nutritional labeling to include trans fat content.

**lean cuts of meat: beef (round, sirloin, chuck,loin); veal (all trimmed cuts); pork (tenderloin, fresh leg, arm or picnic shoulder); lamb (leg, arm, loin)

Clues to Encouraging Healthy Eating Habits Without Making a Child Feel Punished:
Changing eating habits is never easy. If you focus on what your child can eat, rather than on what is forbidden, meals are more likely to be agreeable. Present the foods in a matter-of-fact fashion as part of your meal routine. Plan consistent meals and snacks -- it is healthier for a child to eat frequent small meals than infrequent large ones. This will also minimize hunger cravings. Make healthy choices away from home, too, in restaurants and on vacations. Consider sending lunch to school with your child, as prepared school lunches may be high in fat and salt. Minimize unnecessary eating by cutting down on food cues or reminders to eat. Pick things other than a promise of food (hugs, praise, educational toys) as a reward. Think of your child as a healthy person rather than as a sick patient with a high cholesterol. Involve your child in setting eating limits. Let you child know that healthy eating choices are not always possible. When slips happen, encourage him or her to quickly return to low-fat eating.

In addition to the information above and the resources listed below, there is a plethora of low-fat cook books with sample menus available at bookstores and on-line through the Internet. If you are having difficulty designing meals that your child will eat or if you have specific dietary restrictions (food allergies, vegetarianism, religious restrictions), contact your pediatrician for the name of a pediatric nutritionist.

Resources Organizations:

Dr. Mark B. Levin

Dr. Levin was a member of the staff at The Pediatric Group starting in 1977. He was an attending Pediatrician at the Medical Center at Princeton, Chairman, Department of Pediatrics, Medical Center at Princeton, 1984 to 1986, 1989 to 1992, and past President, Medical and Dental Staff, Medical Center at Princeton, 1987 to 1988. Dr. Levin served on numerous Departmental and hospital committees. He published original articles both while at Upstate Medical Center in Syracuse and at The Pediatric Group.Dr. Timothy Patrick-Miller Dr. Patrick-Miller has been a member of the staff at The Pediatric Group since 1985. Dr. Patrick-Miller has served on several Departmental and hospital committees. He has published original work while at The Pediatric Group. He and his wife enjoy travel. He also likes hiking, biking, gardening and reading.

Dr. Louis J. Tesoro

Dr. Tesoro has been a member of the staff at The Pediatric Group since 1988. Dr. Tesoro is Attending Pediatrician, Medical Center at Princeton, 1988 to present. He has served on several Departmental and hospital committees and was Chairman, Department of Pediatrics, Medical Center at Princeton from 1996 - 2000. He has lectured at the Universiy of Pennsylvania and has published original articles both while at The Children's Hospital of Philadelphia and at The Pediatric Group.

Moderated by Helen Rose.

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