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All Children Should Have Their Cholesterol Checked Between Ages 9 and 11

Coronary artery disease does not magically appear. The disease begins “during early childhood and progress[es] unrecognized for several decades to its often final and unexpected endpoint of chest pain, disability, or premature death.”

As I discuss in my video Should All Children Have Their Cholesterol Checked?, “we need to remind ourselves that atherosclerosis begins in childhood as fatty streaks” in the arteries, which “are the precursors of the advanced lesions that ultimately” kill us. By the time we’re in our 20s, 20 percent of the inner surface of the artery coming off the heart is covered in fatty streaks, as you can see at 0:58 in my video. Fifty years ago, pathologists began raising the question of whether heart disease is best handled by cardiologists or by pediatricians.

“By their 30s, many young adults already have advanced coronary atherosclerosis,” so, in reality, intervention during our 30s and beyond “is actually secondary prevention, because advanced atherosclerosis is likely already present.” Indeed, intervention is just trying to mediate the ravages of the disease rather than prevent the disease itself.

What’s more, we are exporting the problem around the world. A study of young, thin, apparently healthy individuals found 97 percent of their collected arteries had atherosclerosis, which you can see at 4:52 in my video. So, even in developing countries like Brazil, where they’ve acquired our eating habits, we’re seeing an epidemic of heart disease and sudden death.

“Moreover, the risk factors that correlate with the extent of such early lesions are the same risk factors that correlate with myocardial infarction [or, heart attacks] later in life.” In other words, it’s the same disease but in the early stages. So, pathologists, the ones doing the autopsies on all these young people and seeing all this coronary artery disease, “began urging many years ago that preventive measures should be instituted earlier in life.”

We’ve known that fatty streaks exist in young children for more than a century, but it wasn’t until 1994 that a task force convened by the government came up with a “radical” idea: “The strategic key, and the greatest opportunity in preventing [cardiovascular disease] CVD, is to prevent the development of CVD risk in the first place.”

In my video Heart Disease Starts in Childhood, I noted that fatty streaks, the first stage of atherosclerosis, were found in the arteries of nearly 100 percent of kids by age ten who were raised on the standard American diet. In recognition of this fact, the latest Academy of Pediatrics’ recommendation is for all kids to get their cholesterol tested starting between the ages of 9 and 11.

Of course, this has drug companies salivating at the thought of slipping statins into Happy Meals, but “long-term drug intervention is costly and may be associated with adverse effects.” So, the conversation is about lifestyle modification.

In my video How Many Meet the Simple Seven?, I revealed the breathtaking statistic that only about 1 in 2,000 U.S. adults met the seven American Heart Association criteria for a heart-healthy lifestyle. What about American teenagers? Of the 4,673 adolescents aged 12 to 19 who were studied, zero made the cut. Not one teen “exhibited ideal levels of all 7 cardiovascular health behaviors and health factors.”

Most teen boys and girls don’t smoke, and most aren’t overweight. What was the main sticking point? Almost no one ate a healthy diet. Indeed, less than 1 percent of young men and women met a minimum of healthy diet criteria.

This sorry state of affairs is what’s behind a “controversial valuation that the current generation of US children and adolescents may be one of the first generations to be less healthy and have shorter life expectancy than their parents.”

If you think atherosclerosis by age ten is bad, check out my video Heart Disease May Start in the Womb.

Adverse effects with cholesterol-lowering drugs? See Statin Muscle Toxicity. I don’t think most people realize—doctors and patients alike—realize how relatively ineffective these drugs are. Watch, for example, The Actual Benefit of Diet vs. Drugs.

Cholesterol can do more than just build up and block off our arteries. In fact, Cholesterol Crystals May Tear Through Our Artery Lining.

What’s the Optimal Cholesterol Level? Does Cholesterol Size Matter? Watch the videos to find out.

Let’s take a step back, though. What about all the “cholesterol skeptics”? Check out How Do We Know That Cholesterol Causes Heart Disease?.

In health,
Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:


Michael Greger M.D., FACLM

Michael Greger, M.D. FACLM, is a physician, New York Times bestselling author, and internationally recognized professional speaker on a number of important public health issues. Dr. Greger has lectured at the Conference on World Affairs, the National Institutes of Health, and the International Bird Flu Summit, testified before Congress, appeared on The Dr. Oz Show and The Colbert Report, and was invited as an expert witness in defense of Oprah Winfrey at the infamous "meat defamation" trial.

49 responses to “All Children Should Have Their Cholesterol Checked Between Ages 9 and 11

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  1. Instead of wasting time checking cholesterol, let’s put the energy into eating healthy. In the produce department of our grocery store, they started offering free fruit for kids–a cute little shelf loaded with oranges and bananas. Good idea! We need lots more stuff like that.

    1. I agree. Have they asked how these kinds of tests could mess with kids’ minds and contribute to mental health issues? More dysmorphia for kids already down on their bodies. Just throw the junk from the kitchen cabinet and get some vegetables in their diet.

      1. Many–probably most–people need evidence that children have early atherosclerosis in order to even consider changing their eating habits, especially of the young, asymptomatic and apparently healthy children.

        The suspicion that cardiovascular disease was not limited to the older among us grew during the Korean war, when autopsies on young people grew, and so many were found to have early heart disease.

        We mustn’t deprive ourselves of tools that help to eliminate disease, especially with so many politicians trying to limit traditional medical care.

    2. Julie;

      Some cholesterol issues are hereditary, just ask me. We’ve been vegan for 10 years, and I am having to take meds to keep my LDL down, and yup, I had a “heart event” due to the high LDL.

    1. Barb,

      I looked at the page of the AHA healthy eating suggestions; I wonder what is meant by “plant-based protein,” as different from the whole plant foods listed that precede it: “ vegetables, fruits, whole grains, beans, legumes, nuts?” And what is meant by “lean animal protein?”

      I also wonder why they include animal products in their list of foods to enjoy? Why not in the list to limit?

      I’m so glad that soon after his heart attack (after vegetarian eating for several years), my brother saw a billboard advertising a program, which included classes on what to eat, and how to shop for it and cook it. The eating plan was whole plant foods, no animal products, no added oils, sugar, and salt. He has done amazingly well. And this is one of the few community based programs that has been shown to be effective in improving overall health, including heart health.

      1. “I also wonder why they include animal products in their list of foods to enjoy? Why not in the list to limit?”

        Because if the public ate a WFPB diet everyone at the AHA would be out of work. As would almost all cardiologists and 90% of the rest of the health care/disease management industry. I’ve never heard any of these plant based doctors say that the SAD causes less than 80-90% of US health care costs. Not to mention the animal products industry and the immense amount of farmland devoted to growing animal feed. It would destroy the economy and probably send us into another great depression.

        1. Blair, Regarding your paragraph with “It would destroy the economy and probably send us into another great depression.”.

          I kinda agree that it would cause a major readjustment in the economy. But similar adjustments have happened many times in the past. For example, when the automobile was invented, the buggy whip makers all went out of business! But tire makers popped up to take their place. And even today, computers and AI are replacing many jobs, so the employees have to be re-trained. As long as we, as a society, let the system move slowly, everything works out well in the end.

          That’s the beauty of a free-market system. It has built in feed-back loops ( the “invisible hand” of Adam Smith, supply-demand, etc.), so the economy “evolves”, similar to organisms evolving to a new environment.

    1. Adrienne

      There are all sorts of claims out there and some of them are even published in the professional literature..

      Blood cholesterol levels are undoubtedly a key risk factor heart disease,

      In terms of the cholesterol found in eggs, meat dairy etc, the current scientific understanding is that trans fatty acids may well be even more unhealthy for us than dietary cholesterol. However, we’ve known for decades that dietary cholesterol raises blood cholesterol:and thus increases risk for heart disease

      ‘When modest amounts of
      cholesterol are added to the daily diet, the major predictor of
      change in serum cholesterol is baseline dietary cholesterol. Thus,
      when one or two eggs are added to a diet that is typical for the
      average American (containing 400 mg/d), little change would
      be expected. This is precisely the study design of a number of
      outpatient studies in which there is little or no control of the
      diet, either before or after addition of eggs

      Serum cholesterol concentration is clearly increased by added
      dietary cholesterol but the magnitude of predicted change is
      modulated by baseline dietary cholesterol. The greatest response
      is expected when baseline dietary cholesterol is near zero, while
      little, if any, measurable change would be expected once baseline
      dietary cholesterol was > 400-500’

      Unfortunately, the egg industry and others have used this knowledge to fund scores of studies which show that feeding additional cholesterol to average Americans has little or no effect on their blood cholesterol levels. Therefore, they claim, dietary cholesterol is harmless. In fact, all it shows is that most Americans are already eating unhealthily large amounts of dietary cholesterol.

      You may find it helpful to review the other videos on cholesterol on this site

  2. Dr J, I can’t answer for the AHA but the plant protein category mystified me too, orher than it would be clearer to the general public. Non-wfpb people generally think in terms of protein, carbs, fats, and the first question I am asked is, what do you do for protein? Protein shakes, plant derived or otherwise are consistently hot sellers here.

    Re the inclusion of animal proteins…. it is consistent with my cardiologist’s view (all my doctors agree) here as well. A Mediterranean-style diet, is an evidence based diet that includes 2 portions of fish per week, and is recommended for heart patients (as well as others seeking healthy lifestyle).

    1. Barb,

      The problem is that they didn’t say a few times a week.

      And that means it will just be put on a list and it will more likely be eaten 2 or 3 times per day.

      1. I watched the man who made the documentary about fish-eating and he started eating fish 3 meals per day thinking that was the heart-healthiest possible diet and he was disappointed at his lab results at the end of the year.

        He had no concept other than “fish is good” and he was determined to have “great” results by eating it every meal.

        1. As someone who has received health education since early primary grades, I can not fathom that the usa has not incorporated health and nutrition topics throughout primary and high school grades. Maybe they do, and people conveniently forget while they sit with the motor running in the drive through… IDK
          I know that I have put more research and more effort into feeding my pet hamster than what some people do their kids around here. Sad fact. There are kids enrolled in the breakfast program, and the lunch program, and at home… nothing, or a bowl of white rice. It makes me angry tbh.

          1. Barb,

            There was a health class in school, but it was just a few classes and it wasn’t anything interesting or hands on.

            The guidelines use to be, eat a little bit from every single food group, including meat, fish, dairy, eggs, butter, and then they advised to add in any other categories you can think of.

            That evolved over the years to there is a plate now and that is better, but television really pushed the health benefit of chicken and milk and all sorts of things and still debates whether things like butter is healthy.

            Meaning, you would have gotten 15 minutes of a picture of food guidelines in school and then come home and watch hours of television proclaiming the opposite and advertising things like junk food and cooking shows where the protein is always a meat and you want a protein every meal, so 15 minutes of “eat a little of everything” almost backfires when you are going to be going home and have every advertiser in America try to get you to include their food as part of the “everything” in your diet.

            1. Something must have made you interested in nutrition so young and you learned how to research and learned that information was out there and how to find it.

              Most of the people around me don’t research anything at all.

              I was talking to a man who worked for the telephone company and I showed him the petri dishes from Dr. Annie’s site for washing machines and he now will research things that he had never thought about researching. I could see his eyes do the math and he will get a sanitizing washer and dryer. He already said it.

              He also told me to tell him how the steam cleaner is.

              The thing is, that “word of mouth” way of information spreading IS how information flows in America. More than any other way.

              1. What I see is that people have more of a concept of “going to college” for how they learn educational things and nutrition would fall in that category.

                Google and YouTube don’t offer them the same topics it offers me.

                1. In my family, electrician and plumbing, air conditioning and heating and manufacturing and carpentry and hunting and fishing and other topics would be spread word of mouth around the kitchen and living room. Baking and sewing and cleaning products and things like castor oil and cleaning door handles and washing hands and gargling with salt water to prevent cold and flu and Benjamin Moore versus Behr or Valspar would be talked about.

                  I think everything I learned, I learned through conversation.

                  But it isn’t laziness. I listened to the idiet woman in Chef AJ’s conference and she talked about willpower being sapped by having to make too many decisions and what I know is that I have intensely focused on learning about health and nutrition now, but it is ONLY because of the results of doctors like Dr. Ornish and Dr. Barnard and the studies where eating foods could turn things around.

                  Good for you, bad for you, eat a little of everything is much easier to handle mentally and not having to think about food leaves room for topics like work or time for building friendships or spiritual pursuits.

                  There is only so much time in the day and mentally it takes so much work to learn this. If I had started as a young person, it would have been learned when I had all of the time in the world to focus on it so I could have learned it well.

                  The people around me don’t know how to even start learning it yet and they don’t know that it is worth learning. They don’t believe it works.

          2. Barb,
            Where did you go to school? Somewhere outside the U.S.?
            The schools I attended never gave nutritional advice that I recall, and with a graduate degree, I’ve had plenty of education.
            Further, I worked in schools, and none of them gave nutritional information to their students.

      2. The Mediterranean Sea is one of the most polluted bodies of water on the planet. Perhaps the idea of “healthy fish” came before the oceans were so polluted. Fish are one of the most unhealthy things that a person could eat. They absorb mercury, plastics and all the toxins that we throw into the oceans of the world.

        Anyone who says eating fish twice a week, has lost my vote of confidence!

        It’s a great idea to bring education to children and their families via having them more aware of their cholesterol levels at a younger age. I’m so tired of people who feel things like this will hurt kids egos too much. They will adjust accordingly and many will change their diets. Those that can’t adjust generally have parents who over-protect them from reality. The need for a new approach is clearly shown in the obesity crisis in kids today! Being responsible for it at a younger age is an awesome idea. What you don’t know can hurt you!

  3. I agree with Julie that it all starts with healthy eating habits. That includes both educating our children and surrounding them with good examples – making sure that we ourselves are good examples for them also. The “standard American diet “ does not have to be the standard. Yes, it takes a lot of work to build healthy eating habits, but being proactive about your health and the health of your children is always worth it.

  4. People still don’t suspect, let alone realize, their diets are poor. Sure, they’ll joke about it, but not seriously entertain they aren’t the healthiest people in the World, since their US diets are filling, entertaining, socially acceptable, or follow some tradition that they think assures them of decent health. It’s not true, but they are convinced this is so. Evidence in a public form, like the blood tests presented to the athletes in the movie The Game Changers would be helpful to start them questioning. They aren’t dumb, just creatures of habit and imitation. They can become interested if the data is clearly visually presented in a way it’s not plausibly deniable.

    1. Robert,

      You are right.

      They need to learn it in a way that they find interesting so they can learn it and remember it.

      They need to learn that there are sites like this one on the internet.

      There are sites that are way more “scholarly” to learn from, but only highly educated people can use those. It has to be presented simply enough and entertaining enough.

  5. “Not one teen ‘exhibited ideal levels of all 7 cardiovascular health behaviors and health factors.’”

    As much of a pain-in-the-neck I have been with over-posting, there will be a future audience who will be so much worse than I am.

    That is just reality.

    By then though, maybe there will be so many more videos that at least the science might be simpler to understand.

  6. I am 62. My generation ate a lot of red meat, chicken, fish and pork. At the time in Brazil, a vegetarian diet was rare and a temporary situation until one recovered from whatever disease required a ban on dairy or meat.

    When soft margarine (transfat) was introduced advertised as being healthier than butter (and less expensive) we all turned to margarine. Some regions in the country cooked everything with lard (pork fat). When we first got our cholesterol checked (at age 21 or older), I do not remember any of my friends having cholesterol close to 200. It was 180 and lower. Obviously, we did not eat junk food, excepting cookies, sliced bread and the occasional burger. All the meals and most school snacks were made at home. We walked to school. And we were out playing on the streets, bicycling, and exercising twice a week at school. Weekends on the beach, in the parks. I suppose kids burnt all the lard they ate, then.

    I believe eating meat as a child is not as problematic as the “preparation”. There must be something really nasty about the ingredients in ready-to-eat food. And kids sitting on their behinds the whole day. God forbid nowadays kids will walk to the nearest corner from their house.

    1. Carolina,

      That sentence is interesting.

      “….a vegetarian diet was rare and a temporary situation until one recovered from whatever disease required a ban on dairy or meat.”

      The problem is that statistically, meat is a big part of the problem for many diseases. Processed food is also a big part of the problem.

      We are gambling with children’s lives.

      And we are giving them habits that they may never figure out how to break free from.

  7. Does anyone know if Dr. G ever commented on coronary artery calcium scoring – CAC test? February is heart month and the price is discounted.

    1. Greg, don’t know Dr. Greger’s take on Ca artery score. But you will be exposed to radiation. Speaking to doctors here, some don’t pay much attention to it. You can have a low score and unstable plaques with low calcium content.
      This article explains some of that. Scroll down to the paragraph past the chart that begins with “The message here”
      Bottom line, if you have no clinical symptoms, no risk factors the Ca score test will confirm low probability.
      If you have risk factors, symptoms, even with a score of zero, you can still have a coronary event.
      Personally I don’t see much value in this test, and don’t like radiation unless absolutely necessary.

    1. That is a great idea Deb… specially if it had an interactive component to it where kids could ” build a lunch box” for example, or put together a dinner plate for a dinner with their friends. Dr Greger would be great at putting something like this together.

    2. This IS a great idea!
      Is there a moderator there who is “listening” and passing along this idea to Dr. Greger? He would be EXCELLENT for this!!!

  8. If you think that hypercholesterolemia is only related to poor diet, then you are missing a few points. I would refer you to the research of Dr. Broda Barnes, and that of Dr. Mark Starr; the latter writes about the link between cholesterol / atherosclerosis and hypothyroidism in his book Hypothyroidism Type 2:

    ● Dr. Horsley: greatly accelerated atherosclerosis (hardening of the arteries) occurred after removal of thyroid glands in all of the animals (tested). (p. 29)

    ● Hypothyroidism causes damage to the linings of our arteries, the end result being atherosclerosis. (p. 152)

    ● Pathological studies confirm the sequence of events that occur in atherosclerosis. Tissue damage of the arterial lining occurs first, followed by an accumulation of fat on the lining. The accumulation of cholesterol appears later as the plaque (scar) is formed. The appearance of cholesterol is part of the healing process, not the cause of the damage. (p. 161)

    ● autopsy studies from 1969 showed evidence of atherosclerosis in ALL of the children by age three, whether they were from third world countries or modernized nations.18 (p. 29)

    ● during the first half of the 20th century, elevated cholesterol was considered one of the hallmarks of hypothyroidism. (p. 10)

    ● Normal metabolism of cholesterol is often impaired by the compromised liver function that may result from hypothyroidism. (p. 159)

    ● One of the mechanisms by which thyroid hormone decreases the plasma cholesterol concentration is to increase significantly the rate of cholesterol secretion in the bile and consequent loss in the feces. (p. 251)

    ● administering thyroid hormone to (these) animals halted the progression of atherosclerosis. (p. 29)

    ● After thyroid therapy, over half of the patients’ total cholesterol dropped 25 to 200 points. (p. 10)

    ● Historically, high cholesterol was a red flag for hypothyroidism. (p. 159)

    If you think that your doctor will be able to diagnose hypothyroidism by TSH or Free T3 levels, then you’ve missed the point of the book.

    Both Dr. Barnes and Dr. Starr propose that Hypothyroidism is epidemic and affects 25-30% of society including children.

    1. Barnes’ views on the prevalence of hypothyroidism were never widely accepted by the medical community and run counter to its current understanding of thyroid function, but they have been embraced by some elements of the alternative medicine community’

      Dr Starr is another favourite of the alternative health community. He is a homeopath.

      Conventional studies seem to show that overt and subclinical hyperthyroidism affect up to 15% of older people.

      1. Please judge Dr. Starr based on his research – read his book. He references research done by Doctors Hertoghe, Zondek, Virchow, Sonkin, etc.

        Regarding Dr. Barnes, may I refer you to an article appearing in the Journal of Family Practice. J Fam Pract. 2005 August;54(8):1-2

        “Barnes first suggested, because of observed high rates of hypometabolism, that resistance to thyroid hormone must be fairly common. That same year, the famous Albright guessed the same thing for the same reason given by Barnes. In 1981 Kaplan finally reported the biological parameters of a prototypical case. Since then, textbooks in endocrinology and thyroid disease in particular make routine reference to thyroid hormone resistance. While the emphasis in these texts is upon genetic lesions, acquired lesions are also suggested.”

        “Our research group has given doses far in excess of those given to the Kaplan patient, ranging up to 1350 μg of liothyronine (T3) (T4 equivalence 5400 μg) on multiple occasions without thyrotoxic effects. This is prima facie evidence that we have learned to accurately recognize partial peripheral resistance to thyroid hormone, for the consequences of this dosing would otherwise be catastrophic.”

        The Triiodothyronine (T3) content of Natural Desiccated Thyroid Tablet (Armour) is 12 ug. Neither you nor I would survive a dose of 1350 ug of T3, however some patients require an elevated dose. Peripheral Resistance to Thyroid Hormone (Hypothyroidism Type 2) is real. It has been observed in Hypercholesterolemia and Atherosclerotic Cardiovascular Disease (Dr. Barnes), and in Fibromyalgia (Dr. Garrison).

        To add to the importance of T3 activity, let me add the following statement:
        “The low-T3 syndrome is common, with an incidence of up to 75% in hospitalized patients”.
        Source: Nat Clin Pract Endocrinol Metab. 2008 March ; 4(3): 148–155.

        Hence up to 3 out of 4 patients in the hospital have either low levels of T3, elevated reverse-T3, or impaired Thyroid Hormone Receptors. Elevated Estrogen levels and BPA are TH Receptor antagonists. The end result is the same – hypometabolic tissues and organs, as determined by Dr. Barnes.
        Physiol Rev. 82: 923–944, 2002; 10.1152
        J Clin Endocrinol Metab, November 2002, 87(11):5185–5190

        Does 75% constitute an epidemic ?

  9. Dear Dr. Gregor,

    Thank you so much for this article!! I have familial hypercholesterolemia, which leads to total cholesterol in the 300s and heart attacks in one’s late 30s to early 40s without treatment. This condition is not uncommon (maybe 1 in 200 people) but is not on the radar of most primary care physicians and pediatricians.

    The earlier this condition is detected the longer people survive. The recommendation is that children with one copy of the gene for familial hypercholesterolemia start treatment around age 11-12 and children with two copies of the gene around age 7 (or they have heart attacks in their late teens and early 20s due to total cholesterol levels around 600!)

    Due to my diagnosis, I had all my family members tested, and, thank God, my kids have normal cholesterol levels. It is so simple to test for, all pediatricians should be informed about these guidelines. Thank you for getting the word out!!

  10. Dear Dr. Greger,

    My sister in law has just been diagnosed with heart disease. She noticed that she had heart pain, or chest pain, when running for a bus. She’s very overweight. She had no problem doing the treadmill stress test. She also had some pain after walking a couple miles carrying a very heavy back pack. She is able to do water aerobics without problems. The doctors at Kaiser are recommending angiogram and angioplasty if they find 75% blockage during the angiogram. My reading of the medical literature says stents don’t actually improve outcomes in stable people, and they have risks and downsides. I assume she qualifies as stable since she only has angina after rigorous exercise. She was already vegan and she is now holding to a strictly whole food plant based diet. Gone are oils, nuts, seeds, avocados, sugar and salt. Following Esselstein. She’s inclined to skip the angiogram and stent but, of course, none of us want her to die of a heart attack that could have been prevented by a stent.

    I have her medical report which I would share with you or your staff but I am not pasting into a public document.

    She needs to let the doctors know very soon if she’s not going to go through with the angiogram/angioplasty procedure. Any thoughts would be much appreciated.

    Thank you

  11. Keith,

    I’m sorry to hear about your sisters in laws condition.

    Has she considered an ultrasound evaluation of her carotid/aortic and femoral arteries ? As a non-invasive testing it might be an alternative consideration. Clearly not the same as the proposed procedures however, it might be enough information to keep the motivation at a high level and be useful as an ongoing method of keeping track of her progress.

    Please have her consult with her healthcare providers and discuss the diet and US evaluation along with other options that might be an acceptable method of avoiding the angio approach.

    And…. give her accolades with the great work in changing her diet. She should see the increased distance she can walk and her weight loss as the diet changes her physiology.

    Dr. Alan Kadish moderator for Dr. Greger

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