March 2012 Issue

Protect Young Hearts — Here’s What RDs Must Know About the New Cholesterol Screening Guidelines
By Sari Harrar
Today’s Dietitian
Vol. 14 No. 3 P. 12

Groundbreaking new guidelines written in late 2011 by an expert panel sponsored by the National Heart, Lung, and Blood Institute are requiring all children between the ages of 9 and 11 to get cholesterol screenings, a test once reserved only for kids and teens at high risk of heart disease.1

As family doctors and pediatricians across the nation begin widespread screenings of young patients, RDs can expect to counsel more families coping with a long-overlooked heart truth, says Karen Ansel, MS, RD, CDN, a spokesperson for the Academy of Nutrition and Dietetics (the Academy). “Children’s heart health is not on most parents’ radar screens, but it should be,” says Ansel, a Long Island, New York-based RD and coauthor of Healthy in a Hurry: Simple, Wholesome Recipes for Every Meal of the Day. “Even though heart disease may not be apparent until middle or old age, it develops over a lifetime. What children eat and do now has a definite impact.”

The new guidelines are endorsed by the American Academy of Pediatrics (AAP) and “strongly recommend” that doctors refer children and teens with high cholesterol—and their families—to an RD for medical nutrition therapy.

RDs can play a vital role in reversing this serious heart disease risk factor, says Bethany Thayer, MS, RD, director of Wellness Programs & Strategies at the Henry Ford Health System’s Center for Health Promotion and Disease Prevention in Detroit and a spokesperson for the Academy. “Very few kids will ever be prescribed cholesterol-lowering drugs,” she says. “The first line of prevention for all families and all kids includes healthful eating, daily activity, and helping kids achieve or maintain a healthful weight. RDs are the healthcare professionals who can help parents and caregivers adapt these strategies to work in their own lives.”

A Better Safety Net
Why screen all children when heart attacks almost never happen during the wonder years? Research shows that 10% of kids and teens have elevated total cholesterol, according to a Centers for Disease Control and Prevention analysis of National Health and Nutrition Examination Survey data by Ford and colleagues, published in the March 3, 2009, issue of Circulation. High cholesterol jump-starts the buildup of plaque in the arteries of children’s hearts as early as age 10.2

“One reason the guidelines have changed is that medical imaging has allowed researchers to measure atherosclerosis in the arteries of kids with high cholesterol, demonstrating that the damage begins early,” Thayer says. “This adds cholesterol to other important measures we use to evaluate heart health, which include blood pressure checks, body weight, and asking about family history, diet, and exercise.”

The danger is growing. Poor food choices and too little physical activity are fueling the childhood obesity epidemic as well as rising rates of high cholesterol, high blood pressure, and high blood sugar, say Northwestern University researchers who reviewed the health profiles of 5,447 teens and preteens for a study presented at the American Heart Association’s 2011 Scientific Sessions. Their conclusion: Today’s young people will face fatal heart disease earlier in adulthood than any previous generation.

The AAP’s previous guidelines called on doctors to check cholesterol levels only in children and teens with heart disease risks such as obesity, high blood pressure, diabetes, or a family history of early heart disease or those whose family histories were unknown. But these criteria may be missing up to 50% of kids with dyslipidemia, according to a 2007 US Preventive Services Task Force report published in Pediatrics.

Not all heart-health experts agree that cholesterol screening in kids is necessary given that the best protection for nearly everyone is a healthier lifestyle.3 But, Ansel notes, knowing that children have high cholesterol can help their families make additional adjustments, such as reducing the amount of saturated fat and dietary cholesterol they consume. “If a child is diagnosed with high cholesterol, parents don’t need to panic,” she says. “Choosing more plant-based fats and fewer animal fats can substantially help lower saturated fat and cholesterol and make a difference.”

Tips for Counseling Kids
To help families and their children with high cholesterol bring their numbers into a healthful range, follow these seven strategies:

1. Aim for five servings of produce daily. Most kids and teens don’t get enough fiber.4,5 “Aim for five servings a day,” Thayer says. Fruits and vegetables aren’t just filling; they help with weight control. Produce that contains soluble fiber, such as apples, oranges, pears, strawberries, cucumbers, celery, and carrots, also help lower cholesterol by forming a gel in the intestines that traps cholesterol-rich bile acids and removes them from the body with waste products, she says.

2. Nix the sugary drinks and encourage low-fat or fat-free milk or water instead. Up to 30% of some teens’ daily calories come from sugar-sweetened soda and other drinks.6 This raises the risk of obesity, which increases the odds of kids developing high cholesterol, according to the AAP report. Milk contains calcium, potassium, and magnesium, which help control blood pressure and lower the risk of diabetes—both potent heart disease risk factors. “[Suggest kids] aim for 2 to 4 cups of milk per day,” Thayer says.

3. Go for whole grains. “Oatmeal and barley contain soluble fiber that helps sweep cholesterol from the body,” Ansel says. The AAP recommends breakfast cereals enriched with the soluble fiber psyllium at a “dose” of 6 g/day for kids younger than age 13 and 12 g/day for teens.

4. Balance the fat. Kids with high cholesterol don’t need a low-fat diet. The AAP recommends they get 25% to 30% of their daily calories from fat while keeping saturated fat to a low 7% of daily calories and limiting dietary cholesterol to 200 mg/day. Counsel families to avoid artery-clogging trans fats. “[Have them] choose more plant-based fats such as avocados, nuts, canola oil, olive oil, and fewer animal fats, such as butter, red meat, cream cheese, and full-fat cheese,” Ansel suggests.

5. Aim for one hour a day of exercise—and no more than two hours of screen time. “Kids need plenty of physical activity plus everyday movement to stay healthy and avoid overweight,” Thayer says. “We encourage families to limit computer, video games, and TV to two hours per day maximum.”

6. Focus on healthful living instead of weight loss. “Most children who are overweight can grow into their weight through a healthful diet and exercise—weighing and measuring or trying to restrict food can backfire,” Thayer warns. “RDs should work closely with a family and the child’s doctor about weight goals.”

7. Suggest families get healthier together. “Singling out a child can embarrass or shame them,” Thayer says. “When a child has high cholesterol, it’s smart for the whole family to adopt a healthier lifestyle. Kids learn from what their parents do. And often parents come back to me thrilled because their own cholesterol numbers have improved, too. Everybody wins.”

— Sari Harrar is an award-winning freelance writer specializing in health, medicine, and science.


1. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128 Suppl 5:S213-256.

2. Haney EM, Huffman LH, Bougatsos C, Freeman M, Steiner RD, Nelson HD. Screening and treatment for lipid disorders in children and adolescents. Systematic evidence review for the US Preventive Services Task Force. Pediatrics. 2007;120(1):e189-e214.

3. O’Riordan M. Prevention: NHBLI-appointed expert panel recommends universal cholesterol screening for kids. website. Updated November 13, 2011.

4. Mean intake of dietary fiber & percentage contribution of various foods among US female children & adolescents, by age, NHANES 2005-06. National Cancer Institute website.

5. Mean intake of dietary fiber & percentage contribution of various foods among US male children & adolescents, by age, NHANES 2005–06. National Cancer Institute website.

6. Carlson JJ, Eisenmann JC, Norman GJ, Ortiz KA, Young PC. Dietary fiber and nutrient density are inversely associated with the metabolic syndrome in US adolescents. J Am Diet Assoc. 2011;111(11):1688-1695.