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Cholesterol Checkups, Not Just for Adults

Columnist: Sal Iaquinta, M.D.
August, 2018 Issue

Sal Iaquinta, M.D.
All articles by columnist

When it comes to watching cholesterol levels, we think of it as an adult concern, not a childhood issue. However, one in five teenagers have abnormal cholesterol levels. A normal level should be under 170 mg/dL. About 40 percent of obese teenagers have abnormal cholesterol. When studies say “abnormal cholesterol levels,” this means total cholesterol level could be normal, but low-density lipoprotein—also known as LDL could be too high. The LDL should be less than 130 mg/dL. This situation still counts as abnormal and it should. LDL is what damages the lining of blood vessels and allows for fatty build up inside a vessel.

The American Academy of Pediatrics recommends children get their first cholesterol level check around age 10 and then again between 17 and 21. This is drastically younger than the old recommendation to first check at age 20. It’s a sign of the times—cholesterol levels are primarily determined by diet, weight and exercise. The change in screening time was made because prevention and early intervention can reduce the risk of future heart disease.

The first step in controlling cholesterol levels is exercise and diet. Cardiovascular exercise (at least a half hour a day), along with eliminating fast food and processed food from your diet will have a significant impact. The rationale for the popular Paleo diets stems from research on ice age ancestors. Ten thousand years ago, people ate nuts, fruits, vegetables, and truly free-range meat. This was a low fat, low cholesterol diet. They didn’t have atherosclerosis and their cholesterol levels were about one-fourth of what the average adult is today. (I stay in shape just out of fear that I’ll be trapped in a glacier and analyzed by scientists 10,000 years from now.)

For some people, the added exercise along with eating tubers and squirrel won’t be enough and medication will be recommended. The newest classes of drugs to combat high cholesterol are called PCSK9 inhibitors. The PCSK9 protein degrades LDL receptors, which prevents liver cells from taking up LDL cholesterol from the bloodstream and metabolizing it. This is one example of how your body can work against you.

The latest form of this drug is Inclisiran, which blocks the body’s ability to make the PCSK9 protein, thereby increasing the number of LDL receptors on liver cells. Like its predecessor, it’s an injection, but it only has to be given every four to six months, rather than monthly. Inclisiran and the other inhibitors are expensive with costs up to $15,000 per year.

These drugs are highly effective and can cut LDL levels in half. In one study, they reduced the risk of heart attack by 27 percent in high-risk patients. Really low levels of cholesterol can even reverse the build up of plaque in arteries.

Before you fire off an email to your doctor saying you want the Ferrari of cholesterol-lowering medication, it’s important to know these drugs are available only for specific conditions, such as people with a familial genetic defect that causes high cholesterol. Of all the children with high cholesterol, about 2 percent fall into this familial category and can present as early as two years old.

Most people are fine by adjusting their diet and exercise to manage cholesterol levels. But if that isn't enough, they can take a “statin.” These drugs are also effective, can be taken in pill form, and are far more affordable. Statins are also “miracle” drugs. Studies demonstrate they lower LDL and when taken by people with normal LDL, they still improve survival. This affirms that lower is better for LDL and it also makes us question whether the “normal range” should be even lower.

The real miracle would be if we could change the way we produce food—whether it’s in the kitchen, or at the factory. We’re moving in that direction. I recently tried the “Impossible Burger,” food science’s newest all-vegetable burger. Its meaty flavor arises from the plant-based source of heme, the same protein in muscle, but without an animal and its trans fats and cholesterol involved in the process. This burger is the only veggie burger that earns the “burger” name; the others are vegetable discs. Obviously, we could all eat a plant-based diet and be much healthier for it, but it’s more fun if we can eat foods that taste as satisfying as the unhealthy foods we love, without the need for drugs to curtail the damage. Until scientists make these dreams come true, we have to continue watching what we feed our families because kids don’t know better. We have to lead the way.

Salvatore Iaquinta, M.D., is a head-and-neck surgeon at Kaiser Permanente. He is also the author of
The Year They Tried to Kill Me.




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