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The case for testing children for high cholesterol
By Aisha Dow
It’s a health issue usually associated with middle and older age. Testing for it typically doesn’t begin until Australians reach their 40s.
But are we getting it wrong when it comes to high cholesterol?
Unhealthier food is often cheaper and easier for families.Credit: Istock
A new study has reignited a debate about whether there needs to be a radical shift in approach that would see children screened for bad forms of the waxy substance, which over time can cause the build-up of fatty deposits in blood vessels.
“We should at least be having the conversation about tackling elevated ‘bad’ cholesterol much earlier in life,” said Associate Professor Costan Magnussen, an epidemiologist at Melbourne’s Baker Heart and Diabetes Institute and one of the authors of the study.
“It may mean that we need to be more prescriptive about lifestyle interventions and increase awareness about this issue in childhood, adolescence and young adulthood, before it leads to a heart attack or stroke in later life.”
Risk factors for high cholesterol include a diet high in unhealthy fats (such as deep-fried takeaway foods, fatty meats and ice-cream), a lack of exercise, and smoking. It can also be inherited and begin early in life, even in childhood.
“It’s usually a combination of inherited factors and [people’s] environment, particularly nutrition, because families don’t just share genes, they share meals,” explained Professor Garry Jennings, the Heart Foundation’s chief medical officer.
Jennings, a cardiologist, said high cholesterol was often seen more in disadvantaged communities because “some of the worst foods are also some of the cheapest and most readily available”.
While experts now agree that early intervention is important when it comes to bad cholesterol, there are differing opinions on what that involves. In 2011, the American Academy of Pediatrics and the National Heart, Lung, and Blood Institute endorsed cholesterol screening for all American children, with a first test between nine and 11 years.
One of the reasons for this was to identify cases of familial hypercholesterolemia, an inherited condition linked to extremely high levels of bad cholesterol. The genetic disorder can cause heart attacks at an early age, but can also benefit from statins (cholesterol-lowering drugs).
Fast foods can be high in unhealthy fats and lead to high cholesterol.Credit: Istock
However, the child-screening recommendation has remained controversial.
The new study by Magnussen and other researchers at the Baker Institute found that when high levels of bad cholesterol were resolved by adulthood, there was a similar risk of cardiovascular disease to those who never had high levels. The research involved 5121 American and Finnish children in six studies between 1970 and 2019.
Magnussen, the study’s senior author, said these results, published in the Journal of the American Medical Association, could bolster the case for testing in children.
“Children with high cholesterol levels often grow into adults with high cholesterol levels,” he said. “So opportunities to intervene earlier and upset that tracking could have an impact here.”
Still, opposition to much earlier, widespread testing – beyond those at known risk of familial hypercholesterolemia – remains among key groups, despite some praising the latest research.
The Heart Foundation’s guidelines recommend cardiovascular disease risk assessment, including cholesterol testing, from the age of 45, and younger for select at-risk groups, including those with diabetes.
Rather than added testing in childhood, Jennings said it would be more beneficial to tackle the root causes of high cholesterol, such as making more fresh food available to families, tackling vaping and smoking, and improving walkability.
He said there could also be some unintended consequences of universal childhood cholesterol screening, such as people assuming they don’t have to worry following a positive result when they were very young.
The Royal Australian College of General Practitioners similarly cautioned against any changes to the screening approach for children, with vice-president Associate Professor Michael Clements noting that universal cholesterol testing in children would represent a monumental shift that would require strong evidence of a benefit.
He was also concerned that it could put stress on parents trying to manage fussy eaters or result in children being placed unnecessarily on medications like statins.
“In cases where there is familial hypercholesterolemia in children … there probably is a good argument for medication,” said Clements.
“For all of our other children, we’d be recommending adherence to good lifestyle choices, but we recommend that anyway. So whether we know the child has high cholesterol or doesn’t, we absolutely recommend high-vegetable diets, moderate carbohydrate intake and good exercise.”
Dietitians Australia’s vice-president, Dr Fiona Willer, advised against focusing on a single number such as weight or cholesterol. She said that a healthy overall diet – with a variety of different fruits, vegetables and grains, light on saturated fat and meat – would also be good for the heart.
“If you’ve only got a pretty fixed budget for food, try to buy different things week-on-week in the fruit and veg section,” Willer advised.
“Different types of green veg, different types of orange veg. Eating that rainbow means that over time, everyone in the family is exposed to the variety of nutrients.”
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