The Canadian Paediatric Society has issued a new position statement about the screening, diagnosis and management of cholesterol in children. Although the document covered many aspects of lipidology care, the main takeaway was a call for universal cholesterol screening for all kids between the ages of two and 10.
You might be tempted to scoff at such a recommendation, since cholesterol is often seen as a problem of old age. The slow steady buildup of fat in our blood and plaque in our arteries is often thought to be a consequence of our sloppy diet and slothful lifestyle. But in reality, genetics plays a considerable role in determining the level of cholesterol in your blood. And the problem with genetics is that they get locked in at conception. So even kids are at risk for high cholesterol.
Though we tend to think of cholesterol as divided between good and bad particles, the reality is more complex. Some aspects of cholesterol, like triglycerides, are highly dependent on what and when we last ate, whereas other aspects, like Lp(a), are coded in your genes and remain constant with little variation over your entire life.
So as surprising as it might be to hear, even children can have high cholesterol — and treating it early is what will prevent heart disease later in life.
Cholesterol disorders in children are rare, but more common than you think. One of the most common genetic cholesterol disorders — familial hypercholesterolemia — affects roughly one in 300 children. In Quebec, it’s nearly three times more common because of a biological phenomenon called the founder effect.
It’s estimated that over 80 per cent of Quebec’s population can trace their origins back to around 8,500 French settlers who came to New France between 1608 and 1759. Most of these settlers hailed from northwestern France and carried a rare genetic mutation on their cholesterol receptors. Over many generations, and thanks to a high birthrate, what was a rare mutation in France became much more common in New France.
The problem with genetic cholesterol syndromes is that there seems to be a collective uncertainty of how to deal with them. A 2017 survey of American pediatricians, found that less than half were aware of screening guidelines and almost two-thirds were not regularly screening their pediatric patients for high cholesterol. A more recent U.S. study of electronic health records found only 11 per cent of children between nine and 21 had a cholesterol test on file.
We are much worse in Canada. A 2020 Canadian survey found only three per cent of pediatricians were practising universal cholesterol screening of nine- to 11-year-olds. Screening rates were higher in older children or children with obesity, but the point of genetic screening is to catch problems early, even in children who appear healthy.
Perhaps more worryingly is that when asked in the survey how they would deal with a hypothetical child with severe persistent high cholesterol, two-thirds said they would refer the child to a dietitian or lipid specialist, but only seven per cent said they would start treatment themselves.
Although statins have become a lightning rod for misinformation and cholesterol denialism online, there is a wealth of data showing they are safe and effective to treat high cholesterol, even in children. A 2019 Cochrane review found nine studies showing effectiveness with no safety issues. Also, a 20-year follow-up study of children with familiar hypercholesterol found statin therapy slowed plaque progression and reduced cardiovascular events.
It may seem odd to worry about high cholesterol in kids, but genetically mediated cholesterol is more common than we realize. Unless you check for it, you will never find it. Unless you find it, you will never treat it. And if you don’t treat it, you won’t prevent the heart disease that’s coming down the road.
Christopher Labos is a Montreal physician. He’s the host of The Body of Evidence podcast and the author of Does Coffee Cause Cancer?
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