This practical guide for pediatricians clarifies when to start lipid screening in children; delineates risk factors and the lifelong value of preventive care for those with high LDL or triglycerides; and provides hard numbers to apply in assessing risk, retesting, and knowing when a patient has entered the pancreatitis “danger zone.” Included is guidance on counseling kids and parents on which lifestyle modifications truly pay off. Bonus: the lowdown on fish oils.
Thank you very much. I'm happy to be talking with you today. Um, yeah, I always, uh, think it's funny. I used to joke with people that I went into pediatrics because I didn't want to manage anyone's cholesterol. And, um, and here we are. So, uh, I'm gonna actually, today's talk is gonna be, uh, really practically focused, uh, looking at management guidelines and, and offering some practical tips. I have no relevant disclosures. And we have really 3 main objectives. We really wanna make sure that everyone's very clear about the AEP guidelines for screening, be equipped with really some key, uh, out of the box pieces of lifestyle counseling, and also be familiar with when a patient should be started on medication and or referred to lipid clinic. And as an outline, we'll be starting with some historical context, of course, covering the screening guidelines and really um focusing primarily on specifically LDL cholesterol, specifically on triglycerides, offering key nutrition points, and then just some information about therapies. Now, I, um, you know, I always like to kind of take a step back and say, you know, obviously everything that we do with kids, uh, it comes out of the context of what we've learned about adults, and the story for adults really starts from the 1950s, when we, you know, there were large studies that said, hey, you know, we've had this emerging radical idea that maybe high blood cholesterol might have a relationship. with cardiovascular disease. Um, in the 1970s, the medications available like cholestyramine, you know, helped people realize that lowering cholesterol reduced heart attacks. Statins emerged on the scene in the 1980s, and really there was an era, you know, for the next couple of decades of realizing experience that actually statins really seem to work quite well. And really key guidelines for adults happened in 2013 and in 2018, uh, which really kind of, uh, you know, had had an increased focus on, on looking at people in terms of risk categories. So for the pediatric timeline that really begins in the early 1990s, when there was research that started to say that actually there was evidence of our. involvement years before actual development of cardiovascular disease. You know, some of those landmark studies, uh, most, most pediatricians have heard of, uh, you know, the Bogalusa Heart study, which was a, um, a cohort study with schoolchildren, some of whom died of external causes, and, you know, the, that was the study that people will sometimes refer to when they say, Oh gosh, you know, we, we could see fatty streaks in children as young as um preschool or kindergarten age. Um, the, another related study of young adults who died of accidental causes showed that those who had higher levels of traditional risk factors, um, had higher evidence of coverage of the insides of their aorta and coronary arteries with those streaks and plaques. Um, imaging studies, uh, you know, help you study live subjects, and the muscatine study actually looked, you know, specifically at in the media thickness on a carotid artery and showed that, um, you know, in, in relatively young adults in their 30s and 40s, that, um, you know, that higher evidence of plaque on the insides of their carotids. were correlated not only with the total cholesterol in their bloodstream, but also historic childhood risk factors. Um, and then looking at a large study of, uh, Finn Finnish adults, uh, cardiovascular risk factors in adolescence were predictive of later thickness in the carotid arteries on imaging. And, you know, Really very relevant for uh children with uh familial hypercholesterolemia or single gene high high cholesterol, which causes extremely high levels. Um, there are a lot of um parts of the world where uh cholesterol genes are concentrated, and so in the Netherlands, there are a lot of people that have familial cholesterol hypercholesterolemia. Um, and, uh, studies that have come out of, uh, the Netherlands, um, where they've compared a child followed for 10 years, uh, with FH who was on statin therapy and compared them to their lucky unaffected siblings, showed that although at the start, those kids had a, you know, jump start on that early fatty streaks on the insides of their carotids and their arteries, um. Being on a statin for 10 years actually leveled the playing field, such that actually 10 years out, they were no worse than we are compared to their lucky sibling who was never on a statin and never had high cholesterol. So, the 2011 expert panel guidelines are really, honestly, what we still use in children 10 years later, despite the fact that there have been, you know, changes in the guideline recommendations for adults in the interim. And key pieces that are important to know are that actually targeted screening, which was previously, you know, in, in previous iterations, uh, screening focused primarily on just looking at people with risk. Children, uh, children 2 to 8, uh, targeted screening applies. So, There's a family history of cardiovascular disease, you do not need to wait until they're 9. if the parents' high, you know, if parents says that they have a total cholesterol of 240, or the child has any um risk factors, if they have obesity, if they have diabetes or nephrotic syndrome, they're all, you know, you can go ahead and check. Um, universal screening is for children 9 to 11, um, and, you know, it, it constitutes fasting lipid profile or a non-fasting followed up by fasting later if that non-HDL is high. We'll come back to these numbers in a second. And actually, uh, just stopping right there, actually. Um, this is not, this is a webinar and not a live audience, so there's no clickers and no one can raise their hand, but, uh, you know, I just like to kind of, you know, uh universal lipid screening is easier said than done. Uh, we, everyone gets that, um, and just, um, just even in, uh, large institutions with, um, a lot of, uh, practices in place to, uh, Streamline processes like Kaiser even don't, are, are nowhere even near 50%. So, you have company if you're not screening more than 10 or 25% of your patients. Um, you know, the goal is to increase and understanding, of course, that that's easier said than done. But why screen in this age group? Couple of reasons. Um, family history isn't always so reliable. Actually, family history alone will miss, um, over half of kids that have dyslipidemias. Um, screen also because non-HDL is useful as a correlate of atherosclerosis, and also most kids will have a required um pediatric office visit during that time period. And another interesting tidbit about why that age is handy is actually if you take a child and you check their cholesterol every year on their birthday, um, there is, you know, around when they're 9 or 10, it's, you know, you're it's gonna be here this this point up here. There's kind of a natural nature for most people in their mid-adolescence, and then around when they're 17, it'll kind of come back up again. And so 9 to 11 is a really good time to catch them. Um, uh, again, the recommendations, uh, include targeted screening if it was missed when they were 9 to 11, and in theory, uh, a universal screening again when people are 17. So, this is a large diagram of the um of the guidelines, and I just really want a few take home points here. I want people to just remember these numbers, right? These are really useful kind of benchmark numbers. Is the LDL over 130? Is it over 160, or is it over 190? So, this image I find helpful to kind of level set, and I actually use this and I share this with patients. Um, I will basically explain to them, well, if you get your cholesterol checked and that LDL is over 110, that is where the lab starts to tell me, doctor, your patient's cholesterol is high, because it is, um, you know, I basically say to them out of 100 people all lined up, they would be one of the 25 in the front of the line, that's the 75th percentile. If their LDL is over 130, uh, then they would be for children, 95th percentile, they'd be one of the five at the front of the line. And that helps them sort of say, OK, well, if they're at the 160 or higher mark, they are kind of that kid out of the 100, out of the usual group of 100 kids with the highest LDL. And that actually helps frame it up, um, especially for the, uh, families where their child has clear FH and their LDL is 250, and it helps them really see, oh, this is more than just a few points higher, this is really off the charts, so to speak, and about 101 in 100, 250 people will fall in that bucket, and most pediatricians have a panel of larger than 250 people. The non-HDL number of 145 is there because that actually corresponds to the 90th percentile, and so this is what the guidelines use as the cutoff for um uh suggesting that it's worth going back and repeating and doing fasting. So, um Those numbers that you're gonna remember 190, 160, and 130, um, it really is, is sort of a part of the numbers game is really working backwards from 190, um, you know, all of this algorithm, a lot of the stuff that's here refers to this concept of high extra risk factors. There are big, big time high level risk factors and there are moderate level risk factors, and, um, generally speaking, if Your LDL cholesterol is in the 130 to 160 range. It's appropriate enough to say, let's repeat it in 6 months, but actually remembering and realizing that you could see change in 4 to 6 weeks actually, and which is really very motivating for people to kind of know how soon could I see a change. You ask about family history, you think about risk factors and conditions, a pretty high constellation of risk factors could, believe it or not, warrant statin in just this range, 130 to 160. Say the patient has diabetes and they have another high level risk factor like a family history of um early cardiovascular disease. However, you'd be surprised how many people in this range can improve. If they are in that next rung up in that 160 to 190. You know, you can have them repeat it in a couple months, dig more into family history. These are patients where it absolutely makes sense to think a little bit harder about risk factors, um, and actually something called lipoprotein little A. Which is really not done that much in the adult world, because, um, you know, having a high LPA, maybe 1 out of 10 people around the globe has a high lipoprotein A, and, um, and it doesn't matter at all if their cholesterol is low, but the double whammy of having a high LPA and high cholesterol makes that individual at a much higher risk for having an early cardiovascular event compared to the next person. Um, so in the adult world, it doesn't really factor in that much into management algorithms. In pediatrics, where we are looking at lifetime risk, not just risk that the person will have a heart attack in the next 5 years, LPLA is actually highly relevant. Um, and so in this ballpark of 160, 190, some people, some patients were even born on a statin just because of their risk profile with one high level risk alone, such as having diabetes. Now, if your patient has, you know, has been, all of these, and I apologize, all of these uh buckets, uh, go with the assumption that you have already initiated some some efforts at lifestyle counseling, which we will, of course, talk about. Um, however, if some Somebody has been working on lifestyle optimization and their LDL is, is truly over 190. Uh, it is really hard to just eat your way with diet alone to this degree of dyslipidemia from exogenous intake. I have seen it. I, I continue to see it, but it's, it's quite hard to get there. Um, so, you know, generally speaking, if someone is at or above 109 for the LDL cholesterol, they're, they're really, um, you're not doing them any favors by waiting on a statin for those people. So as an audience question, uh, your patient's LDL is 132. This represents a value at the, this is gonna be automatic for everyone, 132 is gonna be the 95th percentile. Triglycerides, you zoom in on the algorithm regarding triglycerides, really relevant numbers are If they're in, well, if they're over 500, that's an automatic, um, completely reasonable to refer to lipid clinic at that point, assuming that this was a fasting level. Um, if they're in the 204 to 10499 range, um, you know, basically the, the upshot of the guidelines is really, that's a range where it's OK to consider fish oil. I will talk much more about that, uh, towards the end as well. I have a lot to, a lot of opinions on that one. and actually, if, you know, if their triglyceride is over 100 or over 130 in a teenager, you know, that is sort of where you, you would say, this is, this is starting to be high, and below that, it's really effectively normal. So just a, just some, some inkling about sort of the degree of change that you can see with lifestyle optimation. Let's just take this example, patient, you know, their triglycerides were uh in the 200s range, they had LDL consistently over the 95th percentile in the 130s and the 140s. Um, they reduced, this is a real person, they reduced frequency of eating out, they cut Starbucks drinks, and actually, um, you know, um. Uh, 9 months later, had actually a 17% reduction in LDL and they cut their triglycerides by, by about half. Triglycerides actually respond, um, dramatically and faster to lifestyle uh change, and now, on, on average, LDL lifestyle optimization can reduce your LDL kind of in the neighborhood of around up to 25%, depending on where you started. So with LDL cholesterol, um, you know, we could honestly spend hours just talking about lipid metabolism. I will spare you from that, of course. Just some main points are, of course, there's exogenous sources um from cholesterol slash fat from the diet. Uh, there are people for whom biologically, they just, uh, they have receptor mutations and their LDL receptor, for example, AOB mutations, such that they Just fundamentally since the day they were born, have had high levels of LDL cholesterol. Um, you know, sometimes I'll explain it to people as just your body just simply produces a lot more. Um, you know, some of the mutations, really the more proper way to think of it is really it's a garbage truck problem. They actually cannot recycle it and so it builds up. And there are people where they have clearly a genetic inheritance pattern, but um it is actually not a not a classic pathogenic uh mutation in the LDL receptor so much as something else. Uh, other receptors, other mutations not on our general list when we look for genetic, uh, results, um, and also some people with a kind of non-classic version of a genetic mutation, but in a classic gene. So to translate that to patients, I like to kind of use some sort of language that's a little bit easier to digest. So I will say to them, cholesterol in our blood comes in part from the food that we eat, but our bodies produce and recycle cholesterol. Most of the cholesterol in a tube of blood when you go to the lab is from what we produce. Sometimes I will tell people we are like red meat on two legs. Some people have a rare genetic problem where they just can't recycle the cholesterol, so it builds up. Lowering LDL earlier on makes a difference. Starting young really saves lives. Um, more people, however, have a different, have a different genetic setup, and it's really a setup for them, such as the LDL cholesterol can run high, higher than the next person, but it's manageable. And like I said a second ago, you know, on average, lifestyle can improve LDL by about up to 25%. Um, so the guidelines include, uh, you know, the sort of formally named child level one and child level two diets. Child one is really just a prudent dietary pattern. It's really how everyone should be eating, and this is kind of what, um, school lunch program, um, guidelines are based off. Uh, the recommendation is that no more than 25 to 30% of calories come from total fat. Saturated fat is the main driver in the Foods that your patients eat, which will contribute most directly to LDL cholesterol. Um, I like to kind of explain to people, not all fats are bad. Saturated fat in particular for that type of cholesterol is a real issue though. And so the overall recommendation is that for anybody, no more than 10% of total calories should come from saturated fat. And then we, we kind of extrapolate or really interpolate to say that that means any specific food shouldn't have more than 10% of its calories from saturated fat. In terms of cholesterol itself, you know, the, this level guideline says that there, you know, you shouldn't be consuming more than 300 mg of cholesterol a day. Um, I never ever have people label read for cholesterol, for what it's worth. But just to put it in perspective, an egg yolk is 180 mg. Um, so, for people who are heart attack survivors who are at a stricter level. of intake for cholesterol. Yes, you know, they, they will become, they will dig more into the details about that. In general, limiting dietary cholesterol intake is really not where the money is. The money is really more with saturated fats from processed meats, from bacon, salami, hotdogs, cheese, ice cream. Let's go over some things. So, like we said earlier, 10%. We're gonna, we're gonna look at this label here. We're gonna scoot to the right and we're gonna say, OK, so, a tablespoon of coconut oil, which was really trendy for quite some time. A tablespoon of it actually has 12 g of saturated fat, which translates to 58% of your um of, of a daily, of a daily uh Required with daily value. Um, ice cream tends to be in the 40 to 50% range. This is a Haagen-Dazs ice cream here with 10 g of saturated fat that clocks in at 50%. Here's something where the saturated fat for almonds here is 5%, and actually just, you know, noting that actually there is some saturated fat. There's, of course, no trans fat, but there is plenty of polyunsaturated monounsaturated fat, which you remind people, not all fats are bad. Fiber, um, you know, sometimes I'll tell people half the story is kind of identifying what somebody is eating that they're gonna get some benefit from pulling out of the diet. And then another part of the story is, what can we actually add into the diet that will help? So really, it's all about fiber, especially soluble fiber. Um, in theory, we're supposed to be eating in the neighborhood of 20 to 25 g a day, and just to frame that up, a half a cup serving of broccoli has 4 g of fiber. There is actually research, it's good research, that says 4 g a day of viscous soluble fiber, meaning water soluble or basically oatmeal fiber, can lower LDL by 6 to 10%. And so here, for example, you know, you can say Quaker Oats, when they claim that they're good for heart health, they're not lying, and it's the, it is the soluble fiber component that actually is helpful in terms of lowering cholesterol. It's actually why Cheerios makes their claim as well. So, the child 2, or the more advanced guidelines, or the stricter guidelines to say, it's really the shaving off even more. Um, this is where the, you still would say, no more than 25 to 30% of your total calories should come from fat, but then there is a stricter recommendation of 7% of calories coming from saturated fat. I will say that this is just very hard to do. I, I will just be honest with you. And so, um, I think a lot of times, um, Uh, with patients, uh, I don't, it, it gets confusing. I don't really tend to spend that much time making a distinction between saying that somebody is at the 10% versus someone who's at the 7% of calories and saturated fat. It's just all the same message, but that that line is stricter, and I will say to them, for example, patients who have survived heart attacks have very frequent counseling to make sure that they are in this very tight range, cholesterol number than 200 mg a day. Plants dental esters. So, for example, Benneol is a product, um, uh, I can't believe it's not butter. There, there's different kinds of things that come in a tub that are surprisingly actually beneficial. Um, a word of caution, though, uh, to, to get a true dose of plants dental esters that actually makes a difference, uh, would require quite a lot of spoonfuls of that product from a tub or A lot of um capsules of Colita. So I don't typically go there in most patients, but for what it's worth, it is something in the guidelines that is reasonable to know about. Something that I do lean on and actually I find quite helpful, especially in kids where They already, um, maybe tend to have constipation, for example, they're constantly on or off. MiraLax is actually leaning into the fact that psyllium fiber, or the major ingredient of Metamucil, actually, um, is proven, uh, you know, 1 tablespoon a day, 6 g of fiber, um, lowers LDL by about 7 to 10%. This is extremely useful, actually, the, the patients that I probably the most have taking this are little kids who will clearly end up on a statin, but they're younger than 8, or people who are really at that borderline and they're trying everything. They have a kind of a polygenic setup for high cholesterol. They're not a candidate for a statin, but we're just trying to do everything we can to shave off. So, I have some people who happily take this for years. So, a question. Food item in this mysterious nutrition facts label is not a good choice for someone looking to improve their high cholesterol because the total fat is higher than 10%. Is this true or false? And here's where all of you would click and say, this is false because it is saturated fat above or below 10% that we care about. And actually, this is, this is almonds. These are, they are low in saturated fat, full of very desirable polyunsaturated and monounsaturated fats. Medications. So statins, um, fundamentally, I always tell people statins are not an eraser. You do not give somebody statins to erase the extra, uh, goodies that they have had in their diet. The statins, the whole point is to turn the dial down and and reduce the amount of cholesterol that we produce. Um, so, You know, fundamentally, they block cholesterol production. There's also other back routes for how they help is basically the decreased synthesis internally, up regulates receptors, and then you get greater clearance. And so it's sort of another double, double effect of why they're effective. So, um, you know, there are 4 or 5 different types of statins. For the most part, I actually prefer to just use either pravastatin or rosuvastatin, primarily in pediatrics, we lean on these more because they are water soluble, so as opposed to say lipid soluble Lipitor or simvastatin, um, water-soluble medications are less likely to cross into the blood, cross over the blood-brain barrier. Um, pravastatin, uh, is what you can use as soon as, you know, when kids are as young as 8, and in general, they are a lower potency statin that you might get up to a 30% reduction in LDL. They are in that family of statins, so you must take it at night because they do have a short half-life, um, and they're, you know, you take it at night. The, the thinking is, it's more, they're, they're more effective when you take them at night because we, we think people produce more cholesterol at night. So it's kind of the reasoning for that. And they're cheap, they've been around for a long time. Rosuvastatin took forever to come off patent, um, but that is, uh, available when children are over 10. Um, and, uh, that is a high potency statin, and actually rosuvastatin can actually, uh, give you up into the ballpark of a 50% reduction in LDL. You can take it any time of day, whatever time is easier for people to remember to take. Um, it's relatively more expensive actually, but I, I need to update this slide. Actually, this has changed and now I, I very rarely struggle with insurances to get this covered. Um, this is a really, probably one of the most important points here in this slide, because many times, uh, appropriately so, parents are not eager to say, sign my child up, I want them to take this statin I've heard so many horrible things about. So, really key points is that in adult medicine, when you are worried that your patient might have a heart attack in the next couple of months before you see them next, you do not waste time. And it is very common for adults when you realize that they're high risk and they need to be on a statin, they go on the top dose of Lipitor. There are many parents that you talked to where they're like, I'm on 80 of atorvastatin, right? You don't waste time. In pediatrics, we have time. We are not worried that the child will have a heart attack in the next 5 years. We are in it for the long game. So, we start at the low dose, and we work up, and we see what we get, and we work up, and we see what we get, and we work up the dose and uh and, and frequently, um we see responses in children that are a greater lowering than what you usually anticipate from studies in adults in terms of what percentage lowering you get from what dose of statins. The side effects, primarily the risk of rhabdomyolysis or myopathies or statin-associated muscle symptoms are dose dependent. Um, I can really count on the fingers of one hand, maybe half of the other one in terms of how many children I've seen who We have had what we've thought in, in retrospect truly was a real, um, a real, uh, adverse reaction. Um, and it's, it's extremely rare. And, and to be honest, most of the time, it's a teenager who was lifting weights and a little aggressively so, and they just backed off and it was fine. But, um, the side, the side effects are just dependent and so by relationship to the first point, um, you know, when you're starting children on low doses, and we actually stop at half the dose. This is another point that should be in the slide. The maximum dose of atorva of, of rosuvastatin is actually 40 mg. We don't generally go higher than 20 in pediatrics. If we're not where we need to be with 20 mg of rosuvastatin, I will add another medicine like azetimibe, which is a non-statin. Um, of course, uh, most clinicians are aware, you know, you need to avoid pregnancy if a patient is, is taking a statin because, um, particularly early, um, early weeks of gestation on a statin, a higher risk of having birth, of birth defects. Um, this is not in a category, however, where you are required to be, uh, monitoring with pregnancy testing. Um, and, uh, The evidence thus far is actually truly, mostly, you know, most, the, the, the key studies are based on children and teens with FH, uh, monogenic familial hyper hypercholesterolemia, and not those with dyslipidemia of obesity or polygenic dyslipidemia. Um, there are other older medications that can still be used in young children. I actually have had quite a few patients actually that I have had them on cholestyramine. Um, you know, they have a, they work in a different manner. They bind bile acids in the intestine, um, and so basically, you, you poop bile acids in the stool and it increases conversion of cholesterol to bile acids to kind of make up for that difference. In theory, you, uh, they come with a lot of tolerance issues. Um, I've actually had a child who had a biopsy confirmed diagnosis of Hirschbung's and She did fine on cholestyramine. Um, and just one point is that cholestyramine is OK for pregnant ladies. Um, you know, sometimes when patients, um, who have extremely high cholesterol are started on a statin, then, and they get that they're not supposed to be pregnant while on their statin, and they'll ask, you know, what do I do when I want to have kids, or, well, you know, can I, you know, what do I do, or the parent might ask, not the kid. And actually, you know, sometimes for people with extremely high LDL actually um during uh Management during pregnancy, actually, it's, it's a reasonable option for pregnant women to be on cholestyramin instead of their statin. So, just a couple of patient examples. Does this patient have familial hypercholesterolemia? Well, let's see. See the LDL of 203, 176, you might look at this and say, oh my gosh, ding ding ding, this is over 190, this is it, this is it. But, um, you know, It is a journey. Some people, especially after the pandemic, are coming out with a much higher um degree of weight gain than they had in previous years. This particular patient, for example, let's see, we had, you know, if you go back in time and you see, oh, well, they at one point had an LDL down to 136. And oh gosh, old records, gosh, in 2012, 2013, when they were younger, their LDL was only 101. Does this person have FDH? Likely not, right? You know, generally speaking, if somebody is in that category where they, since the day they were born, have always been either producing or not recycling LDL. They generally have never been at as low as 100 when they were younger. How about this one? Does this patient need to be on a statin? You take a quick look, you look at these numbers, and you say, ah, LDL is only 158. Actually, this particular patient was one of those patients where because of family history, um, and the, the family history that, you know, grandma had a known APOB mutation, they were always extremely careful since early childhood about their dietary intake. And so this is somebody where they actually had their um their their diet. optimized pretty much as much as humanly possible. And uh if they had any kind of a more typical American diet in any way, if they ever ate pizza or ever had any cheese, they probably really would clearly have been over 190. So, you really have to interpret this with a grain of salt when you see a number to be like, well, what is their, what are their habits like? And, and, you know, is it possible this is just as low as they can go? Um, so audience question. Children should always only be started on pravastatins for LDL lowering. True or false? It's false. It's not necessarily wrong to start with pravastatin, but if they're over 10, and they clearly need more than 30% reduction, it's reasonable to start with higher potency already. So triglycerides, um, I haven't spoken about at all, but actually obviously in lipid metabolism. You know, uh, other things to keep in mind are, there are genes, and then there are genes. So, for example, there are patients, uh, I've only had two that really fall in this category of familial chelomicronemia syndrome, where they might have a double loss of the Lioprotein lipase receptor or, you know, this is a complete loss of function. Their lipoprotein lipase does not work at all. And these are people where their their triglyceride is pretty much, no matter what they eat, always in the 4 to 10,000 range if you catch them on a normal day. Most people, uh, if you, most of your patients where they might have higher than average, right? You might sort of say, oh gosh, this patient has a triglyceride in the 400 range, right? Will be somebody where there is a genetic situation, um, maybe they have a variant of one of the famous or uh pathogenic genes, or they just have another one that doesn't pop up in a genetic test, and we just don't know about it yet, right? But they're kind of in that basket. These are patients, you know, the, I, I see plenty of these patients because people are providers are properly checking over, over time and just seeing these numbers are, aren't really budging down to normal ranges no matter what they do. But a lot of people fall kind of in that middle, right? Cause lipoprotein lipase insulin resistance with extra weight gain and messes up lipoprotein lipoprotein lipoprotein lipase activity here and here and here, and you get the idea, right? There are insulin resistance decreases that enzyme activity and you end up with buildup of triglyceride rich VLTL and other atherogenic inner. And so this is sort of, you know, a lot of patients have kind of um uh have, have started to understand a little bit more, oh, you know, doctor, we're realizing that, you know, we've heard that it's not just about bacon, right? You know, of course, starches are important and this is exactly where that falls in, right? That insulin resistance and, and carbohydrate metabolism absolutely relates to all of this, particularly because that impaired Um, impaired, uh, lipoprotein processing along the way leads to buildup of triglycerides in those other remnants, those VLDL, IDL. So to translate that, we'll say, OK, well, triglyceride is a fat and blood our body makes, not only from fats we eat, cause it's true, fats we eat and will end up as triglycerides, but also from extra sugar and starch that we don't need. So some people have genes that make them wired to be sky high, over 5 times normal, even with a pretty decent diet. Um, some people have a setup, and most people are, you know, most people that you, you, they flag your attention, you're kind of noticing that they're in that 400 range frequently. They have a setup in their genes such as if they don't have a good diet, and especially if they have extra weight, their levels will blossom to maybe 2 or 3 times normal. But honestly, anybody, regardless of genes, regardless of extra setup, will have triglycerides that that blossoms up, that drifts upward over time with poor diet and no exercise. So dietary fat certainly increases tri triglycerides. You ingest caloricrons in your fat in your, in, in food, and if they're not, you know, they, they get broken down. But added sugars and refined starches drive up triglyceride levels because of VLDL production in the liver. And this is why I tell people, it's sort of like your liver, your body takes the extra sugar you didn't need and turns it into fat in your blood for another day. 100%, as an example, right? Sweet sweet beverages are probably the number one quick way to raise someone's triglycerides, and also conversely, to lower it. Say for example, 100% fruit juice is the only permitted sweetened beverage. But even that shouldn't be more than 4 ounces a day, which is hard to hit, right? That's what school lunches have in a carton, so those are small size cartons, but the easier easier message is just to say you don't need the juice. Um, so, for example, everything in this Denny's Grand Slam except for the black coffee will contribute to increased triglycerides. Um, some math that's helpful. So sometimes for the older kids, I'll say, hey, you know, like in math, when you have word problems, so every 4 g of tea of sugar is a teaspoon. And so you can kind of, you know, impress people, you're in the supermarket, you kind of do the math. And, and you say, look for the sugar, and you divide it by 4, and that tells you how many teaspoons of sugar there are in a serving of that thing, right? So, you know, drinks in general, we, we were aiming for drinks to have in 8 ounces, no more than 10 g of sugar. Um, American Heart Association recommends that added sugar shouldn't be more than 6 to 9 teaspoons a day, but this 16 ounce boba has 13 teaspoons, and actually this super small article you can't really see in that report from AHM. It just kind of highlighted, uh, you know, how alarmingly many adolescents in the US consume 20 to 50 teaspoons of sugar a day, so that consumption can be quite high. Level setting is really helpful. Um, exercise, even in the absence of weight loss, is very helpful for lowering triglycerides, in, in particular, triglycerides. And in fact, actually, if you have, um, if you have About a vigorous activity, there is suppression in postprandial triglycerides that is sustained for, you know, over a day, and actually, you know, that you can, they've done interesting studies where people hooked up to a treadmill and you're kind of sampling their triglycerides, and you can really watch that really powerful relationship between exercise and triglycerides. This is somewhat different from the relationship between exercise and LDL cholesterol. Uh, exercise is, of course, extremely important for overall heart health, endurance. Your heart is a muscle, you need it to work your whole life. Exercise is extremely important, but I think sometimes people have an unrealistic expectation. Sometimes these are the families where the child has an LDL of 200 and they're saying we're just gonna exercise more. Exercise alone doesn't bring LDL down all that much, unless it's exercise that brings a reduction in extra weight. So, like I said, even in the absence of weight loss, exercise will really peel down that triglyceride, but exercise. We really not attack or not really chip away too much of the LDL unless it's exercise that helps somebody lose weight. Um, this is just to remind me to, you know, mention that the reason that the guidelines, um, you know, for triglyceride, um, thresholds focus so much on 500 when someone's fasting is because of the risk of hypertriglyceridemia and induced pancreatitis. There's really different mechanisms for why this would be, uh, that, you know, if your triglyceride is 1000, it's not that it causes a heart attack, but the concern that could happen tomorrow for a child is that they could have pancreatitis. And so there's sort of oxidative stress factors, sludging. And interestingly, it, there, there are other factors that just make some people more prone to having a risk of pancreatitis than others. And so when I hear from a family that somebody in the, like, you know, somebody in a child's family had a history of pancreatitis, I am much more cautious with those kids in terms of making sure that their triglycerides are in a reasonable range. Um, you know, the guidelines will, will alert you to say that if, you know, triglycerides over 500, they're at risk for pancreatitis. To be honest, it doesn't really usually happen unless somebody is in that 1,000+ range. I think part of the reason that 500 is important is because, well, you're catching them when they're fasting and it's over 500. Imagine what it is right after they had lunch, right? Um, so, you know, the risk in the general population is low, you know, people with triglycerides over 1000, you know, they, they have a much higher risk, and so, you know, this is, you know, risk of, sorry, pretty much said most of this, it's really mostly people who are in the 1000 in a higher range. Um, the majority of acute pancreatitis is not from triglyceride associated pancreatitis, but, um, in these kids, you know, where the, the, I, this is the only reason that I end up visiting patients in the ICU is because of triglyceride associated pancreatitis. Um, so, notes about fish oil. Um, so, first of all, you have to make sure that we're talking about the, we're all talking about the same thing. So, the research studies and everything that show that 20 to 4000 mg a day of omega-3 can help. I'm not saying 200 to 4000 mg of fish oil, because DHA and EPA are the omega 3 or the active ingredient. And this Nature's Bounty is a pretty typical over the counter, usually what's on sale bottle, where most brands will have about 300 mg of omega-3 in each 1000 mg capsule. That's just the size of the capsule, and the rest other than the 300 mg of omega-3 is just fish fat. Gummies, there there's no such thing as a gummy that has any kind of meaningful amount. They really just have barely anything. Um, so, So if somebody has a borderline high triglyceride, will it hurt them to take omega-three? Of course not. And if you look in the, uh, you know, in the guidelines, they might say, 0, 250 to 2 g a day could be reasonable. I personally do not bother because I fundamentally feel that it sends a very confusing message because And this always makes sense to people when you change many things at the same time, you don't know what did the trick. And if you see a patient and you say, oh, your triglycerides are 300, and you say, exercise more and take omega 3, and they've done both, and they come back, they are convinced it was because they were taking capsules, and you don't let them actually see the benefit of What they could have done on their own. It's in the 2004 to 500 range, and you really tried. I, I, I, I, for a while, and actually, once I've kind of gone through a lot of the steps of kind of seeing how much lower can someone bring it down to, I will often sometimes come back to say, OK, we know we can get you where you need to be without it. We can, of course, also add these now, knowing that it is not the crutch, or this is not the only thing keeping you between. Being fine and in the hospital with pancreatitis or something like that. Now, if they're in the typically over 500 towards 1000 range, you can optimize them such that the maximum dose would be 4 g a day of omega-3. It is really impossible to get them to that dose with regular over the counter stuff. Lovaza is the prescribable pharmaceutical grade um omega-3, which is never covered unless your patient has diabetes. But increasingly, actually, at the time they made these slides, the triple strength from CVS was the only thing around. There really are actually a lot more products available on the market that are over the counter. They're usually the code words that they will use is they will say pharmaceutical strength or they'll say triple strength, and just the thing to kind of tell yourself is actually, we are looking for the actual omega 3, not just the size of the capsules. Um, this is tricky territory. I really don't prefer to go right here because I really find that that, um, before you go putting everyone on fish oil, see what they can do on their own first is really valuable. I, I think it's important to be very clear about what you're recommending because if you do start on fish oil, I want them to treat it like you mean it. I want you to be very anal, very picky with them, about what's the dose that they're taking, and monitor for improvement, just like any prescription medication, because half-hearted recommendation turns into half-hearted compliance. And this is sort of the case for so many people where somebody will say, take some fish oil, it's probably good, they'll take a bottle, and then they'll finish the bottle, and then they won't buy a second bottle, because, of course, there was never any. Feedback about whether it was helpful or whether it seemed to make a difference, and it was clear that they didn't need to take it, right? So, either, you know, usually I prefer to not actually have people on fish oil until we've really gone through the wringer quite a bit in terms of seeing what their own responses are. So, um, So If triglycerides are still extremely high despite good consistent effort, um, of course, fibrates are the medication of choice, uh, fenofibrate for children rather than, um, gemfibrozil. There's a lot of different mechanisms, actually, several mechanisms for why they're helpful, um, primarily because of basically increasing metabolism, um, of triglycerides, um, and also decreased production, right? Um, there's other side benefits there, you know, there's some lowering of LDL, but that's not why they're on a fibrate. They're on a fibrate because primarily it's the triglycerides that is the issue. So just things to remember. If it's 100 to 200, repeat a panel next year. 200 to 499, I'd like to really frame it at how many times normal. They're double normal, they're triple normal. Let's specifically focus on beverage, reduce carbohydrates, and let's Repeat the lipid panel in a couple of months, because if you wait a long time, a lot of times what happens is kids were behaving really, really good and they had it, they were on top of things, and then they slid off the wagon, and then you never got the benefit of that check. But I bet you can bring this down to normal, um, you know. If they're over 500, you know, we need to see some serious effort and recheck in 3 months to see whether omega-3 would be enough, um, or if we need something stronger. Um, and if it's over 1000, you know, I just, they need to know. I mean, they're in the danger zone, they could have pancreatitis tomorrow, they need to address this and I'm very clear with them. If you, there's lots of things that cause abdominal pain, um, but if you end up in the ER just mention that you have high cholesterol and high triglycerides and that, you know, just to, to just mention that and it just helps you to make that connection that that is a risk factor for their child. So, let's say you did a lipid screen and your new patient is 10, they had a triglyceride of 205, um, so you should recommend that they take fish oil and come back and recheck their lipids at next year's physical. True or false? So hopefully, many of you are just just cringing in your seats cause you're like, no, because they might be happy about the idea that you prescribed them something to fix their cholesterol, they will miss out on the ability to see the effective lifestyle change on their own with no supplements. Not to mention the fact that a year later, like I said, they'll be off it, and you'll never know if it made a difference anyways. Um, so changes you may wish to make in practice. Number one, of course, adhere to the guidelines, fasting or non-fasting lipid screen in all children 9 to 11. Familiarize yourself with cutoffs that should signal either referral or starting them on a medication. Those numbers you should be in your head are 190, 160, 130, or 500 for triglycerides. And then number 3, recheck abnormal lipids in your patients in a few months. And I, I love framing it this way. Give them the gift of feedback. I really feel like, um, that helps them have a goal and something they're trying to reach, and it helps you prevent burnout because you are actually really being able to sort of see how much can they do, how much can they do, rather than just say, I don't know, take fish oil, it's supposed to help. See you in a year. And here are some references, and that's it.
