Hypercholesterolemia Among Children: When Is It High, and When Is It Really High?

Stephen Cook
Circulation. 2009;119:1075-1077
doi: 10.1161/CIRCULATIONAHA.108.837666
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Editorial
Hypercholesterolemia Among Children
When Is It High, and When Is It Really High?
Stephen Cook, MD, MPH

he rate of childhood obesity has at least tripled over the

past 3 decades and has raised significant concerns about
the cardiovascular health of Americas youth.1 Some fear that
as a result of the obesity epidemic, a wave of debilitating
chronic conditions will afflict Americas youth. We do not
yet know when, or even if, the wave of cardiovascular risk
factors, such as hypercholesterolemia and type 2 diabetes,
will crash into the health of our countrys young adults.
Perhaps the real question is the impact of childhood obesity,
and the accompanying risk factors, on the health of Americans in their 30s and 40s.

Article p 1108
The American Academy of Pediatrics Committee on Nutrition released new guidelines on the screening and treatment
of high cholesterol in children and adolescents.2 The guidelines were an update from 1998 and were intended to define
both a broad population approach and a targeted individual
approach. The popular media focused on the message that
statins could now be prescribed to obese children as young as
8 years of age, and they missed the message about
population-based prevention through lifestyle changes in
nutrition and physical activity. The concern for families and
providers would be that any obese youth with elevated
cholesterol would now need to start a medication that their
grandparents also use.
The public health and epidemiology community has recently provided data on the trends of a number of cardiovascular risk factors in youth. There needs to be more clarity in
regard to the current health status of Americas children.
There are significant differences in the rates of teens with an
abnormal risk factor, such as impaired fasting glucose 100
mg/dL, and a clear clinical condition, such as type 2 diabetes
mellitus. Previous data showed that the US prevalence of type
2 diabetes in the early 1990s was only 0.4% of US adolescents, and impaired fasting glucose (110 to 125 mg/dL)
affected only 1.7%.3 When the American Diabetes Association changed the criteria for elevated fasting glucose from
110 mg/dL to 100 mg/dL, it was found that impaired fasting
glucose affected 7% of adolescents in 1999 2000.4 This has
not been an isolated finding. A study of a large cohort of
The opinions expressed in this article are not necessarily those of the
editors or of the American Heart Association.
From the Department of Pediatrics, University of Rochester Medical
Center, and Golisano Childrens Hospital at Strong, Rochester, NY.
Correspondence to Dr Stephen Cook, MD, MPH, 601 Elmwood Ave, Box
777, Rochester, NY 14642. E-mail stephen_cook@urmc.rochester.edu
(Circulation. 2009;119:1075-1077.)
2009 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.108.837666

mostly overweight eighth graders from across the United

States showed that 40% had a fasting glucose 100 mg/dL.5
The SEARCH for Diabetes in Youth study confirmed that
type 2 diabetes, once virtually unknown in the young, is
likely to represent one third to one half of all new cases of
diabetes among US adolescents.6 Although specialty clinics
first showed a dramatic rise in referrals for type 2 diabetes,7
more recent national data still show type 2 diabetes to be a
rare condition (0.5%).6,8 These findings highlight the prevalence of the precursors for serious disease in todays
adolescents, but full-fledged disease is still a rare event in
teens.9
This difference is apparent in the article by Ford et al in the
present issue of Circulation.10 They reported the rate of
elevated cholesterol and high cholesterol requiring pharmacotherapy among US adolescents. Key features of this study
are that it is both nationally representative and current (ie,
reported during the current obesity epidemic) and is not from
a single pediatric lipid specialty clinic. Their first finding was
that only 0.8% of US teens had a low-density lipoprotein
(LDL) cholesterol level above the threshold for pharmacotherapy to be considered. This group included youth with an
LDL cholesterol level 190 mg/dL, those with LDL 160
mg/dL with risk factors (obesity, hypertension, smoking, or
family history of premature cardiovascular disease), and
those with diabetes mellitus and LDL 130 mg/dL. They
also found that less than half of those meeting criteria for
pharmacotherapy had an LDL 190 mg/dL, a rate consistent
with a familial form of hypercholesterolemia. The second
point of this article was that elevated cholesterol, defined by
cutoffs from the Lipid Research Clinics Prevalence Study and
the National Cholesterol Education Program, was found to
affect only 9% to 10% of US teens. This difference, 10%
compared with 1%, is similar to the rates of impaired
fasting glucose compared with actual levels of type 2 diabetes. These findings should enlighten the pediatric health
community to the fact that, despite all the attention given to
the recent cholesterol screening guidelines from the American Academy of Pediatrics, they will encounter few children
or teens in need of medication to treat severe hyperlipidemia
in their primary care practices.
We need to consider the trends of cardiovascular risk
factors on a population level. On a population level, some risk
factors in children have been stable during the pediatric
obesity epidemic, and some seem to be decreasing.11 US data
show that mean levels of total, LDL, and high-density
lipoprotein cholesterol have remained unchanged from the
early 1990s to 2000. During this time, body mass index, waist
circumference, and blood pressure have increased. The rate of
smoking and second-hand smoke exposure is decreasing.12,13

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1076

Circulation

March 3, 2009

The rate of high school seniors who smoke has also decreased
by nearly 30% from 1980 to 2006.14 It seems that public
health efforts may be paying off in terms of the reduction of
some cardiovascular risk factors.
Certain environmental and population efforts are likely
linked to these improvements. The amount of saturated fat in
the US food supply remained fairly stable up until 2000 but
has increased since then.14 Although some national data have
shown a decrease in the percentage of calories from fat in the
US diet, the absolute amount of fat also increased in parallel
with an increase in total calories.15 Novel efforts have now
begun to decrease trans fat availability and intake to help
reduce the risk for cardiovascular disease. In addition to
efforts to improve the diet of the US population, efforts to
reduce smoke exposure need continued vigilance. There has
been somewhat of a leveling off in the decline of tobacco use
among adolescents of late.13
The low prevalence of serious conditions such as familial
hypercholesterolemia and type 2 diabetes mellitus in youth
provides some reassurance about the immediate or imminent
cardiovascular health of US teens, but the high prevalence of
the precursors of cardiovascular disease in this group puts in
doubt the health of these same individuals in their third,
fourth, or fifth decades of life. Longitudinal studies of adults
who were obese with cardiovascular risk factors 20 to 30
years ago suggest a growing likelihood of premature cardiovascular sequelae that may be starting in todays children in
this obesity epidemic.16,17 US mortality data among adults has
shown a concerning trend in recent years. Coronary heart
disease mortality, which had been dropping steadily over 20
years, has leveled off for women aged 35 to 45 years and has
increased among men aged 35 to 45 years.18 This finding
raises questions and concerns that, although tobacco use has
decreased, a slight rise among young adults may be a signal
whereby the rise in childhood obesity, as well as the accompanying risk factors, may begin to have an impact on the
health of Americas adults.
The roles of the primary and specialty pediatricians are
clearly changing but should be directed toward community,
family, and behavioral approaches to improve the current and
future health status of America. The protective effect of exercise
and fitness has a role in determining the course of this disease
process. In October 2008, the Department of Health and
Human Services released the Physical Activity Guidelines for
all Americans as a national policy for this country. The
American Academy of Pediatrics lipid guidelines state that
changes in diet and other lifestyle factors are key for the
population approach. Behavioral counseling for diet and
exercise is also the first-line treatment for the targeted,
individual approach. Behavioral techniques for discussing
nutrition and exercise changes with families are both feasible
and accepted by families.19
Behavioral and lifestyle treatment modalities are currently
moving toward more strong support by the medical community. The Healthcare Effectiveness Data and Information Set
measures for 2009 will now include body mass index tracking
and counseling for diet and physical activity at all annual
visits for children aged 2 years.20 Pediatricians do not need
enroll in continuing medical education events on the use of

statins and angiotensin-converting enzyme inhibitors in their

adolescent patients. They would be better served to seek
training in behavioral approaches to motivate families to
adopt healthy dietary patterns and prescribe exercise as a
medicine to be taken daily. A reversal of this trend is not
likely to come solely from behavioral approaches in the
clinical setting.
The urgent issues we need to address are the importance of
implementing preventive strategies versus continued observation of these abnormal risk factors. These are questions to
be addressed and supported by the continued tracking of
health status and risk factors on both regional and national
levels. The issue of prevention also needs to be supported on
local and global levels. It would be ideal if this article by Ford
et al received the attention of the general pediatric audience
that the cholesterol guidelines received. The pediatric clinical
community is in a unique position to meet with the entire
family to discuss and apply prevention guidelines. Pediatric
providers can advocate for continued and increased efforts to
reduce the effects of tobacco smoke on youth. They can push
for community efforts to support active outdoor play and to
preserve and expand activity time during the school day,
either as recess or physical education. They can call for
improved dietary standards in childcare facilities and schools,
advocate limitations on vending options in schools, and
endorse limits on advertising to children. Pediatricians can
also be a strong voice for the health of todays children and
the future of America.

Sources of Funding
Dr Cook is supported by National Institutes of Health Career
Development grant K23 HL08694-01A1.

Disclosures
Dr Cook has received a speakers honorarium from the American
Dairy Council.

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KEY WORDS: Editorials diagnosis epidemiology hypercholesterolemia

obesity pediatrics

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