The Cholesterol Conundrum

Imagine this: A camera pans across a modern playground. Groups of children, ages ranging from just-walking toddlers to busy 6, 7, and 8s, are happily engaged in play against a backdrop of  shiny, new equipment. We zoom in on several boys and girls flying down one of those long, twisting slides. They’re laughing and happy, caught up in their race. The camera follows one boy, maybe 7 or 8 years old. He’s adorable, with a head of light brown curls and a crooked smile. He’s the perfect mix of innocent with just a touch of mischief. We fall in love. As we watch, the voice-over begins:

Meet Josh. Josh is in Mrs. Teisher’s 3rd grade class at Canyon Ridge Elementary. He’s the best pitcher on his Little League team and just got a B+ on his spelling test. He would have gotten an A, but he spelled mermaid with -ade on the end and left out the second n in spinning. Josh’s mom works at the library downtown on Mondays, Wednesdays and Fridays. His dad travels a lot providing tech support for a nationwide hospital chain. His  sister, Nola, is 6. She’s not allowed to go in his room uninvited, but yesterday he caught her playing with his Batman action figures. No one knows it yet, but Josh has high cholesterol. His dad did, too, before he started taking Lipitase. Josh’s Grandpa suffered a serious heart attack when he was just 49. That was years before cholesterol-lowering medicines were available. Lucky for Josh, his pediatrician is about to recommend screening for elevated cholesterol levels. Then the family will have the information they need to decide if Lipitase is the right choice for Josh, too. Like father, like son.

The ad goes on to describe the warnings on the label and the possible side effects of cholesterol-lowering drugs, or statins, in children. At the end it adds this disclaimer: A healthy diet low in fat and increased physical activity are first line treatment for an elevated lipid profile in children. But if this approach doesn’t provide adequate control for YOUR child, consider Lipitase.

If you think this scenario is gross exaggeration or satire, think again. The American Academy of Pediatrics recently issued guidelines for the management of elevated cholesterol in children that make ads like this a real possibility. The guidelines take a more cautious approach, but will that get lost as the pharmaceutical companies target this huge new market?

The AAP report offers the following advice:

•A healthy diet rich in fruits, vegetables, and whole grains, plus daily physical activity for all children.

•Low fat dairy products for all children over 2 years of age and overweight children from 12-24 months.

•Screening at age 2 for all children with a family history of elevated cholesterol or early heart disease.

•Screening for all children with unknown family history OR overweight, elevated blood pressure, or diabetes.

•Weight management for children who are overweight with elevated blood pressure or lipid levels.

Consider cholesterol lowering medication for children age 8 or older with LDL (low density lipoproteins – the bad guys) greater than 190 OR  LDL greater than 160 and a family history of early heart disease OR LDL greater than 130 with diabetes or elevated blood pressure.

When the report was released the phrase that immediately came to mind was “First, do no harm”. This is the most memorable line in the Hippocratic Oath. It’s the one you hear on the first day of medical school, and the last. Funny, I don’t recall hearing it much in between. But how do you square “First, do no harm”  with the idea of putting children as young as eight on medicine that has never been tested on developing bodies and that they will likely need every day for the rest of their lives?

Cholesterol is a fatty substance produced by the liver that is used to build cell walls and form some chemicals and tissues in the body. Foods that contain animal fat are another source of cholesterol, but your liver makes plenty on its own. The two main types of cholesterol, LDL (low-density lipoprotein) and HDL (high-density lipoprotein) play different roles. In this case, “low” is bad and “high” is good. If there is too much LDL in the blood, it can be laid down on the linings of arteries that lead to the heart and brain, forming plaque and blocking blood flow.  HDL helps to carry this excess cholesterol away from the arteries and back to the liver, where it’s processed and recycled. High levels of LDL cholesterol have been shown to increase the risk of heart disease in adults. High HDL, on the other hand, can reduce this risk by mopping up some of the sticky stuff and removing it.

Cholesterol-lowering medications — statins — work by reducing the amount of LDL produced by the liver and raising the level of HDL. They may slow the progression of plaque build-up in the arteries, and work best when combined with a low-fat diet and regular exercise. They have not been shown definitively to prolong life in patients with elevated cholesterol. The question is, how does this information help us decide on the best treatment for children at risk?

We know there are three major factors that contribute to high cholesterol levels in adults and children:

•A  family history (particularly parents and grandparents) of elevated cholesterol and/or early heart disease.

•A diet high in saturated and trans fats, sugars, and processed foods.

•Obesity related to poor diet, too many calories, and lack of exercise.

While you can’t choose your parents and not much can be done to modify your family medical history, the other factors can be managed with behavioral and life style changes. It’s not easy to change eating habits, particularly in children who love sweet treats and are choosy about unfamiliar foods. It’s our job as parents to provide lots of fruits and veggies and make foods that look good, taste good, and are good for you.

Exercise is just as important as diet. It’s a well-worn cliché to say that our kids spend too much time in front of a video screen, and too little outside being active, and it’s true. We need to unplug them. Regular exercise burns calories at an impressive rate. A half hour of active play for your kiddo, riding a bike, playing soccer, or running relay races in the back yard can burn 200 calories or more … that’s a small bag of M&Ms!

It also leads to higher levels of (good) HDL, which in turn lowers (bad) LDL. Physical activity is a win-win, and it’s fun and free with no unwanted side effects.

Statin medicines, on the other hand, come with a long list of warnings. Possible side effects include headache, nausea and vomiting, skin rash, mood swings, memory problems, nerve damage, muscle breakdown, kidney damage, liver damage, and of course, rarely death. These drugs, with trade names like Lipitor, Crestor, and Zocor, have been on the market for about twenty years. They have been successful in lowering cholesteral levels in adults, but have never been tested in children. A ten year old child who starts one of these medicines today will likely be taking them for the next sixty years or more. Do we have any idea what happens when you take these drugs for that long? Do we have any idea how the young, developing body responds? What are the risks, known and unknown?

And so, I say, first do no harm. Without a doubt, there is the rare child for whom the risk of early death from heart disease due to heredity is significantly greater than the risk of the drugs. That child needs medicine. For the rest of our kids, we can’t afford to fall for the ease of taking a pill. We must step up and make the hard choices. Eat differently, lose the weight, get active. Talk the talk and walk the walk.

I don’t want to see that TV commercial.

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Rachel Zahn, MD is a pediatrician turned health writer who had three kids during medical school and pediatric training—crazy, huh?

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