Kids' arteries: Lifestyle changes can do wonders

At first blush, the new guidelines on cholesterol control in children were shocking. Statins, one of the most frequently prescribed drugs for adults worldwide, could be prescribed for some children as young as 8, according to recommendations released last week by the American Academy of Pediatrics.

But the vast majority of children will never in their pre-pubescence or teens pop a pill to lower cholesterol. Nor will their parents want them to. "I hear it every time I see parents," says Dr. Alan Lewis, a pediatric cardiologist and director of the lipid clinic at Childrens Hospital Los Angeles. " 'I don't want my kid taking a pill.' "

For most children, the new guidelines will simply serve to alert parents that their kids could be accumulating plaque in their arteries that will set them on a road to early heart attacks or strokes. "My own practice and the new guidelines emphasize the importance of lifestyle as the approach to lowering the risk of cardiovascular disease," Lewis says.

Whether you're a kid or a grown-up, here's how to adopt that lifestyle. Children ages 2 to 10 who test in the acceptable range (total cholesterol less than 170 milligrams per deciliter of blood) should simply keep up the good work.

Those who test in the borderline range (total cholesterol 170 to 199) need to make some changes in what they eat and how much they exercise. (For adults, total cholesterol of less than 200 is desirable; 200 to 239 is borderline high; above 240 is high, carrying with it twice the risk of heart disease as a level below 200.)

It's children who test at elevated levels, above 200, who bump into the controversial recommendation of taking a statin as part of their preventive therapy. Even then, "you should always start with lifestyle modifications," says Dr. Stephen R. Daniels, chairman of the department of pediatrics at the University of Colorado School of Medicine in Denver and lead author of the guidelines.

For starters, dietary fat intake should be lowered to less than 30 percent of calories, with saturated fat, found in meat and whole-milk dairy products, less than 10 percent of calories and no more than 200 milligrams of cholesterol a day.

If that doesn't do the trick, Lewis says, cut saturated fat to 7 percent of calories, keeping total fat below 27 percent. Trans-fatty acids should be all but eliminated, with the recommendation at less than 1 percent of calories. (The American Heart Association recommends that all adults keep dietary fat below 30 percent of daily calories, with no more than 7 percent of daily calories from saturated fat, and less than 1 percent from trans fats.) Kids as young as one year, according to the new guidelines, can cut out whole milk and start drinking reduced fat milk. The biggest influence on blood cholesterol is the mix of fats in the diet. Saturated fat, found mostly in animal products but also in coconut and palm oils, increases blood cholesterol levels the most.

Fiber, in the form of whole grains, fruits and vegetables, can lower cholesterol. It binds bile and blood cholesterol to form waste, which the body eliminates. If a fiber supplement is used, the guidelines suggest a dose of the child's age plus 5 grams a day, up to a dose of 20 grams a day at age 15. Long-standing government recommendations suggest that young kids 2 to 3 should get 3 ounces of grains a day, building up to 7 ounces by age 14 to 18. A slice of whole-grain bread, one-half cup of cooked brown rice and one-half cup of cooked oatmeal add up to about 3 ounces. Fruits and vegetables also contain fiber, and young children should get a cup of each, building up to 2 cups of fruit and 3 cups of vegetables for kids 14 and older.

The new guidelines recommend exercise in general, though without a recommended amount.

Exercise in adults has been shown primarily to increase levels of HDL, the protective cholesterol, though it has little effect on lowering LDL. But exercise can also lead to weight loss, and weight loss has been proven to lower total cholesterol in adults.

Children with less than ideal cholesterol levels could need up to six months of lifestyle changes before results are seen.

One study of children 8 to 11, published in the May 10, 1995, Journal of the American Medical Association., found that those who kept their total fat calories to 28 percent and saturated fat to 8 percent of calories dropped levels of LDL cholesterol by an average of 15 points over three years, compared to those in a control group who ate their normal diet.

For children whose cholesterol is mildly or moderately high, the reduction could get them into the normal range. The National Institutes of Health-sponsored study, the Dietary Intervention in Children Study, also found that after three years, children who were in the group that received aggressive nutrition education consumed 67 percent of their calories from heart-healthy foods, compared to 57 percent in the group that received no counseling.

Studies of adults have shown that bad cholesterol can be lowered by 5 percent to as much as 20 percent by lifestyle changes, including quitting smoking.

Losing excess weight, which requires lowering calories and fat consumption and increasing exercise, is the most successful strategy for lowering cholesterol. "Before starting a statin, try losing 20 pounds," says Dr. David Becker, cardiologist at the University of Pennsylvania Health System.

"In most kids, you'd want to work on this for three to six months before you go to a more aggressive treatment," Daniels says. If during that time physicians see evidence of improvement in lower cholesterol numbers and lost weight, the lifestyle treatment could continue without adding a drug.

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