Screening for High Cholesterol and Other Lipid Disorders
in Children Has Serious Implications for Adult Health

Increasingly strong evidence indicates that the presence of cardiovascular disease (CVD) risk factors in childhood is associated with the premature development of CVD events among young and middle-aged adults. Prominent among these risk factors are overweight and obesity, high blood pressure, smoking, and lipid disorders including high cholesterol and high triglycerides.

What are lipid disorders and what causes them?
High blood levels of cholesterol and triglycerides are the main types of lipid disorder. High cholesterol generally refers to having a high levels of low-density lipoprotein cholesterol (LDL-C; “bad” cholesterol) or elevated non–HDL-C levels. The other major form of cholesterol, high-density lipoprotein cholesterol (HDL-C) is not associated with increased CVD and may be protective when LDL-C is high.

Lipid disorders (dyslipidemias) in both children and adults increase the risk of plaque buildup inside blood vessels (atherosclerosis), and when the blood vessels of the heart or brain are affected, it can lead to atherosclerotic cardiovascular disease (ASCVD), especially heart attacks and strokes.

High cholesterol in children can be due to both genetic and lifestyle factors including a diet high in saturated fat, sugar and refined carbohydrates, being overweight or obese, and lack of exercise. High cholesterol in children is not rare. A recent study found that 30 percent of the children studied fell into the category of high or borderline high triglycerides and 40 percent had either high or borderline high cholesterol.

An uncommon cause of high cholesterol is the genetic disease heterozygous familial hypercholesterolemia (FH) that causes very high cholesterol levels in children. It affects approximately 1 in every 250-350 children and a total ofabout 1.3 million individuals in the U.S. FH often does not cause symptoms in children and adolescents. FH affects approximately one in every 250-350 children and a total of 1.3 million individuals in the US.

Triglycerides are the commonest form of fat. They come from foods, especially butter, oils, and other fats you eat. Triglycerides both circulate in your blood and are stored in fat cells when the calories from any source (fat, sugar, or protein) that you eat are not immediately needed for energy. High blood triglyceride levels are very common–up to one in four adults are affected.

Some people may have a higher risk of high blood triglycerides, for example:

• People who live with HIV

• People with a gene that prevents the body from breaking down lipids and causes high triglyceride levels in families (familial hypertriglyceridemia) 

• People of South Asian ancestry (for example, people from Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka) who live in the U.S.

High triglyceride levels may be caused by any of these: 

• Diabetes
• Lack of exercise
• Eating a lot of foods high in simple carbohydrates, saturated-fat and sugar
• Excessive intake of alcohol
• Hypothyroidism
• Kidney disease
• Liver disease
• Obesity
• Some medicines

Screening for Lipid Disorders in Children and Adolescents Pros and Cons
According to the US Preventive Services Task Force (USPSTF), the evidence on screening children and adolescents for lipid disorders is still unclear and there is not enough data to show that treatment during childhood benefits cardiovascular health in adulthood.
 The cons of screening also include the potential side effects from medications used to treat high cholesterol (such as effects on the liver or muscles). However, there is not much data on the importance of these side effects in children.

The pros of screening are increasingly suggested by recent studies that indicates that the finding and early treatment of high blood lipids with lifestyle changes or medications lowers LDL-C levels in children and the risk of adult ASCVDs. Since high lipids are asymptomatic a blood test to measure to measure levels of LDL-C, HDL-C, and triglycerides is needed for detection.

Detection of familial hypercholesterolemia (FH) by screening is clearly desirable. FH is generally asymptomatic in childhood and rarely associated with ASCVD in the first 2 decades of life. But if left untreated, FH is strongly associated with early ASCVD due to prolonged exposure to markedly elevated LDL-C and a 2 to 4 times increase in cardiovascular disease and death in adulthood. When FH is treated in childhood, most of the risk of ASCVD is eliminated. Without screening the average age of FH diagnosis in the US is 50 years, often after the onset of ASCVD.

Lipid Testing Recommendations by Age
Stanford Medicine suggests:

• Under age 2. Lipid testing is not advised.
• Ages 2 to 8. Testing is advised if your child has other risk factors for heart disease. These include diabetes, high blood pressure, obesity, exposure to cigarette smoke, or a family history of these. Other risk factors include family history of early coronary artery disease or lipid disorder, kidney disease, or other chronic inflammatory diseases.
• Ages 9 to 11. Testing is advised. This can be done with either a fasting or non-fasting lipid profile.
• Ages 12 to 16. Testing is not advised. This is because of changing lipid levels during puberty. But testing is advised if your child has risk factors as noted above.
• Ages 17 to 21. Testing is advised. This is because lipid levels are more stable after puberty.

Understanding Test Results
A full lipid profile should include LDL-C, HDL-C, triglycerides, and total cholesterol. In general, healthy levels are:

• LDL-C of less than 130 mg/dL, ideal is 70 mg/dL or lower
• HDL-C of greater than 60 mg/dL
• In one study of high cholesterol in childhood, the cutoff for elevated non–HDL-C levels was 120mg/dL or greater and 145 mg/dL or greater for dyslipidemia.

Some children and teens (ages 2 to 19) have families with high cholesterol or early heart disease. In these cases, the National Heart Lung and Blood Institute advises these levels for cholesterol:

Triglycerides are considered high when a fasting blood triglyceride level is regularly 150 milligrams mg/dL or higher. Triglyceride levels usually fall into the following categories:

• Healthy: Below 150 milligrams per deciliter (mg/dL) for adults; lower than 90 mg/dL for children and teens (ages 10-19)
• Borderline high: Between 150 and 199 mg/dL
• High: Between 200 and 499 mg/dL
• Very high: Above 500 mg/dL

Treatment Options for High Cholesterol and High Triglycerides in a Child or Teen
Fortunately, most children and teens with abnormal lipids will not need medicine. A healthy diet, weight loss, and more physical activity may bring a child's blood lipid levels to normal.
What children (and adults) should do is maintain a normal weight; adopt a diet low in added sugar and saturated fat, and high in natural unrefined whole plant-based foods, (fruits, vegetables, legumes, soy and whole grains); get enough sleep and physical activity; manage stress; and avoid high risk behaviors like abuse of drugs, alcohol and tobacco.
And if medical treatment is needed the medications that are used are usually inexpensive and cause few side effects.
You should share any concerns you have about cholesterol or heart health with your child’s doctor, and they can take the best course of action for your child.

References:
US Preventive Services Task Force.  Screening for lipid disorders in children and adolescents: US Preventive Services Task Force recommendation statement.   JAMA. 2023;330(3):253-260. doi:10.1001/jama.2023.11330
Wu F, Jacobs DR, Daniels SR, et al. Non–High-Density Lipoprotein Cholesterol Levels From Childhood to Adulthood and Cardiovascular Disease Events. JAMA. Published online April 12, 2024. doi:10.1001/jama.2024.4819
Jacobs DR Jr, Woo JG, Sinaiko AR, et al. Childhood cardiovascular risk factors and adult cardiovascular events. April 4, 2022, N Engl J Med 2022;386:1877-1888. DOI: 10.1056/NEJMoa2109191
US Preventive Services Task Force. Screening for lipid disorders in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA. July 18, 2023. doi:10.1001/jama.2023.11330.
High Blood Triglycerides. National Institutes for Health. https://www.nhlbi.nih.gov/health/high-blood-triglycerides
Speidel J J. The Building Blocks of Health: How to Optimize Wellness with a Lifestyle Checklist. Amazon.com 

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