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A Primer on Non-HDL Cholesterol Screening for Children

By Amy Reed, MS, RD, CSP, LD

Several decades ago it was rare for a child or adolescent to be diagnosed with high cholesterol. But just as the prevalence of childhood obesity has climbed over many years so have lipid levels among our youth.

To continue to head off heart disease at the pass in this population, guidelines had to be established and reexamined to improve outcomes. Current guidelines for screening children for elevated cholesterol include testing between the ages of 9 and 11—earlier if they’re at high risk—and again between the ages of 17 and 19. These recommendations were made by the National Heart Lung and Blood Institute and endorsed by the American Academy of Pediatrics.1,2 Children and adolescents with diabetes, hypertension, or BMI >85th percentile are at high risk of elevated cholesterol, as are those who have a first degree relative with history of dyslipidemia (total cholesterol >240 mg/dL) and a strong family history of premature CVD, such as stroke or heart attack at a young age (before age 55 in men and 65 in women).

The reason cholesterol screening between the ages of 12 and 16 isn’t recommended is because of the effects puberty has on lipid levels. Studies have shown that cholesterol levels are low at birth and increase to a peak level between the ages of 9 and 10 and then start to decline. As a child’s height increases, LDL cholesterol (LDL-C) decreases.3 The Bogalusa Heart Study looked at this in adolescent males and saw a decrease in LDL-C and HDL cholesterol (HDL-C) as height increased.4 This could be due to hormonal changes, specifically growth hormone. When children go through growth hormone treatment, for example, researchers have observed that height increases and LDL-C levels decrease.5

Diagnosis
Many pediatricians diagnose high cholesterol with a finger stick in children who aren’t fasting. This in-office test provides information needed to calculate the non-HDL cholesterol level (total cholesterol - HDL = non-HDL cholesterol). The non-HDL cholesterol as opposed to total cholesterol is what’s recommended as a measurement for high cholesterol in children and adolescents because it elicits a combined measure of all apo-B containing lipoproteins. The apo-B containing lipoproteins include very low-density lipoprotein (VLDL), intermediate density lipoprotein (IDL), and LDL, all of which are atherogenic. Another reason non-HDL cholesterol screening is recommended is because total cholesterol (TC) and HDL can be measured accurately in a nonfasting patient.1

Interpreting Non-HDL Cholesterol

  • A desirable reading is <120 mg/dL non-HDL cholesterol; 120-144 mg/dL non-HDL cholesterol requires a repeat test in a few weeks, and >145 mg/dL non-HDL cholesterol requires a complete fasting lipid profile.1
  • If nonfasting total cholesterol is the only data available, a value >200 mg/dL indicates a need for a fasting lipid panel.1

Interventions to Lower Cholesterol

  • Encourage clients to include plant-based proteins in meals such as cooked beans (eg, black beans, kidney beans, navy beans, pinto beans, or garbanzo beans), lentils, tofu, tempeh, seitan, nuts, and nut butters. Pulses such as beans and lentils are low in saturated fat, and nuts and nut butters are good sources of polyunsaturated and monounsaturated fats.6 While there’s currently no recommended number of servings of plant-based proteins children should get in their daily diet, unless they’re vegetarian or vegan, MyPlate recommends consuming 1/2 to 1 1/2 cups (depending on age and gender) per week of pulses (eg, beans, lentils, peas). A recommended serving of plant-based proteins for school-age children or teenagers is 1/2 cup beans, 2 oz tofu, or 2 tablespoons nut butter. The American Heart Association’s (AHA) dietary recommendations for healthy children support these guidelines. The AHA guidelines recommend children consume foods low in saturated and trans fats and high in polyunsaturated and monounsaturated fats. Families can begin to include plant-based proteins in place of animal-based proteins at least three times per week and increase amounts as children tolerate them. The following are suggestions on how clients can incorporate more plant-based proteins:
    • decrease the amount of meat in soups and stews and replace it with beans;
    • blend beans and add them to brownie, cookie, and muffin recipes;
    • dip fruits in nut butter;
    • add tofu to pasta dishes; and
    • top oatmeal with nuts.
  • Recommend clients eat fish. If they don’t eat fish one to two times per week, as recommended by the 2015–2020 Dietary Guidelines for Americans, suggest they take omega-3 supplements. The goal is for children to consume the recommended adequate intakes of omega-3 fatty acids. These requirements are different for boys and girls. For boys aged 9 to 13, 1.2 g of alpha-linolenic acid (ALA) per day is considered adequate; for those aged 14 to 18, 1.6 g of ALA per day is deemed adequate. For girls aged 9 to 13, 1 g per day is sufficient, and for those aged 14 to 18, 1.1 g per day is appropriate.7 These numbers only refer to the short-chain omega-3 fatty acid ALA, as this is essential. There have been no intake recommendations set for the long-chain omega-3s EPA and DHA in this age group.8 Common foods high in omega-3s include salmon, shrimp, flaxseeds, walnuts, soybeans, and chia seeds.9
  • Discuss use of sterols and stanols in the diet. Sterols and stanols naturally occur in small amounts in plants and have cholesterol-lowering properties, which is why they’re added to foods. Sterols and stanols commonly are added to margarines and orange juice. They’re also available in supplements. It’s recommended that people with high cholesterol consume 2 g of sterols or stanols per day. Short-term studies haven’t found any harmful effects of sterol or stanol supplementation in children, and dietary intake is recommended for them as a supportive action of managing elevated LDL.10 Some foods with naturally high sources of sterols and stanols include sesame oil, pistachio nuts, and sesame seeds. If a family is interested in supplements, create a plan for sterol or stanol supplementation based on their intake from food.1,10
  • Increase activity and decrease screen time. In general, children and teens should aim for at least 60 minutes of moderate to vigorous activity per day. It’s recommended that children and teens get no more than two hours of screen time and the screen time shouldn’t replace physical activity or sleep.
  • Decrease consumption of added sugars from soda, candy, and baked goods. The AHA recommends children consume no more than 25 g added sugars per day (this is about 6 teaspoons).11 This doesn’t include natural sugar from milk, fruits, vegetables, and grains. An example of 25 g added sugars is the amount found in one pack of fruit snacks and one small packet of mini muffins. The World Health Organization established guidelines for added sugars based on percentage of calories, recommending that intake should be less than 10% of total calories. This will allow for greater intake of added sugars in children requiring more daily calories. Overall, dietitians must educate families on how to decrease their intake of added sugars by eating nutrient-dense foods that contain fewer amounts.12
  • Boost fiber intake by increasing the amount of whole grains in the child’s diet. The Department of Health and Human Services and National Heart, Lung, and Blood Institute Expert Panel’s recommendations for fiber intake for young children are the child’s age plus 5 g fiber (eg, a child aged 8 + 5 g = 13 g fiber); for older children, it’s 14 g fiber per 1,000 calories. This can be accomplished by replacing refined grains and cereal with foods like oatmeal, popcorn, whole grain pastas, and whole grain breads.1
  • Increase fruit and vegetable consumption by incorporating them in breakfast, lunch, dinner, and snack recipes. This will help improve overall nutrient quality of the diet.1
  • Educate families on appropriate fat consumption. The Expert Panel recommends that no more than 30% of calories should come from fat and only 7% to 10% of those calories should come from saturated fat. The remainder of the fat calories should come from monounsaturated and polyunsaturated fat. Since many children and adolescents aren’t preparing food, parents will need to learn about incorporating healthful fats like olive oil in cooking, and decreasing consumption of saturated fats like butter and trans fats that are found in many commercial baked goods.1

Counseling Strategies

  • Review the lipid panel. As mentioned, the expert recommendation is to use a child’s non-HDL cholesterol to determine if he or she is at risk or needs intervention. However, if the total cholesterol is the only number available or the RD realizes the non-HDL doesn’t meet the stated criteria, it will be important to discuss the findings with the referring pediatrician.
  • Minimize discussion of good and bad foods, as this can lead to disordered eating behaviors, food fears, and poor body image. Children diagnosed with high cholesterol may be entering a time of life in which they may be self-conscious about their appearance and what they eat, so RDs shouldn’t use fear-based food education when counseling them. It’s best to focus on what they can add to their diet and not what must be removed.

Tell clients these nutrition changes are good for the entire family no matter their children’s lipid profile or weight.

— Amy Reed, MS, RD, CSP, LD, has specialized in pediatric nutrition for 20 years. She practices in Cincinnati, Ohio, where she works for a pediatric private practice and runs her own private practice and consulting business, Amy Reed Nutrition, LLC. As part of her business, she manages a blog at www.amyreednutrition.com. She’s an active member of the Pediatric Nutrition Practice Group of the Academy of Nutrition and Dietetics, where she serves as chair of member support.

 

References
1. US Department of Health and Human Services and National Heart, Lung, and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. Bethesda, MD: National Institute of Health; October 2012. NIH publication number 12-7486.

2. Smith AJ, Turner EL, Kinra S. Universal cholesterol screening in childhood: a systematic review. Acad Pediatr. 2016;16(8):716-725.

3. Fujita Y, Kouda K, Nakamura H, Iki M. Inverse association between height increase and LDL cholesterol during puberty: a 3-year follow-up study in the Fukuroi City. Am J Hum Biol. 2016;28(3):330-334.

4. Chiang Y, Srinivasan SR, Webber LS, Berenson GS. Relationship between change in height and changes in serum lipid and lipoprotein levels in adolescent males: the Bogalusa Heart Study. J Clin Epidemiol. 1989;42(5):409-415.

5. Demarco S, Marcovecchio ML, Caniglia D, De Leonibus C, Chiarelli F, Mohn A. Circulating asymmetric dimethylarginine and lipid profile in pre-pubertal children with growth hormone deficiency: effect of 12-month growth hormone replacement therapy. Growth Horm IGF Res. 2014;24(5):216-220.

6. Dietary recommendations for healthy children. The American Heart Association website. https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/dietary-recommendations-for-healthy-children. Updated on April 16, 2018. Accessed on December 12, 2018.

7. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients). Washington, DC: National Academy Press; 2005.

8. Omega-3 fatty acids: fact sheet for health professionals. National Institutes of Health website. https://ods.od.nih.gov/factsheets/Omega3FattyAcids-HealthProfessional/. Updated November 21, 2018. Accessed December 12, 2018.

9. Do kids need omega 3 fats. American Academy of Nutrition and Dietetics website. https://www.eatright.org/food/vitamins-and-supplements/types-of-vitamins-and-nutrients/do-kids-need-omega-3-fats. Published May 13, 2015. Accessed December 12, 2018.

10. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(Suppl 5):S213-S256.

11. Jenco M. AHA: limit children’s sugar consumption to 6 teaspoons per day. American Academy of Pediatrics website. http://www.aappublications.org/news/2016/08/23/Sugar082316. Published August 23, 2016. Accessed December 13, 2018.

12. World Health Organization. Guideline: sugars intake for adults and children. http://apps.who.int/iris/bitstream/handle/10665/149782/9789241549028_eng.pdf;
jsessionid=9F7BB3D17B1A46ADD9582D14682E688B?sequence=1. Published 2015. Accessed December 13, 2018.