Heart disease is often thought of as a problem of adulthood, something that develops after decades of poor diet, stress or inactivity. But doctors say the groundwork for cardiovascular disease can begin much earlier during childhood, and long before symptoms ever appear.
Dr. Pinar Gumus Balikcioglu, a pediatric endocrinologist with Duke Health, said that identifying children at higher risk of cardiovascular disease and screening them for high cholesterol can help reduce long-term risk.
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“The earlier you identify a child has high cholesterol levels, the earlier you can start the intervention,” Balikcioglu said.
That’s the idea behind a new Pediatric Lipid Disorders Clinic that Balikcioglu oversees at Duke Children’s Hospital in Durham. The clinic specializes in diagnosing and treating children with high cholesterol and other lipid disorders, with the goal of preventing heart disease before it ever has a chance to take hold.
For six-year-old Adela Smith, the focus on prevention has already become part of her life, even though she looks like a picture of health. She races her dad on the playground, climbs to the top of the rock wall at her sports gym, and proudly talks about winning her kindergarten long jump competition.
“She is a happy, healthy, wonderful kid,” her father, Nick Smith, said.
You’d never guess by looking at her, but Adela has high cholesterol. Her family makes trips every six months to see Dr. Balikcioglu for routine blood work.
Her parents say they first learned about Adela’s high cholesterol after talking with her primary care doctor about family history. Based on that risk, Adela’s pediatrician recommended cholesterol screening when she was just three years old.
“It’s not something you even think about with a three-year-old,” her mother, Liz Smith, said. “Will she have heart disease in her 30s? Despite the family history, it was never mentioned growing up to me or my brother, so learning about that made a big difference.”
Balikcioglu shared that reaction is common.
“As pediatricians, our major goal is to prevent the disease process,” she said. “What we would like for our children is to deliver those children into adulthood as healthy as possible.”
Cardiovascular disease remains the leading cause of death and disability in the United States, and high cholesterol is one of its most significant risk factors. While heart attacks and strokes may not occur until later in life, Balikcioglu says the underlying damage often begins decades earlier.
“Atherosclerosis — the little plaque that develops in the veins or coronary arteries — does not just happen overnight,” she said. “Research shows these plaques start to form in childhood and progress over time.”
According to the American Academy of Pediatrics, all children should have their cholesterol checked at least twice: once between ages 9 and 11, and again between 17 and 21. Balikcioglu stated the reasoning behind the ranges is due to when cholesterol levels naturally peak during development, increasing the chances that abnormal levels would be detected on a test. The AAP said children with certain risk factors, such as family history, may need to be screened much earlier.
“For children with a family history of high cholesterol or cardiovascular disease, screening can start as young as two years old,” Balikcioglu said.
The physician explained that cumulative exposure is what makes high cholesterol dangerous. The longer a person’s body is exposed to high levels of LDL, or “bad” cholesterol, the higher their lifetime risk of developing cardiovascular disease.
For families worried about what early screening involves, Balikcioglu says the process is simpler than many expect. Initial cholesterol testing typically requires just a single blood draw, and children do not need to fast beforehand.
“I know how painful it can be for a two-year-old to skip breakfast,” she said. “But they don’t need to be fasting for the cholesterol measurement.”
When Adela was asked whether rock climbing or getting a blood test was harder, she quickly replied, “Rock climbing,” adding, “I never cry.”
A genetic condition called familial hypercholesterolemia affects about one in 250 children and causes dangerously high cholesterol levels from birth.
“It’s genetic and not something you did or the food or diet,” Balikcioglu said. “You are born with it.”
In addition to genetic cases, other risk factors like obesity, prediabetes, diabetes, and hypertension can also raise cholesterol levels in children. When those factors are considered together, as many as one in five children may be at increased risk.
“It’s common,” Balikcioglu said. “Every day when you go into clinic, you will see a child with high cholesterol levels.”
What makes the condition especially dangerous is that it is often missed for decades until it is too late.
“Hypercholesterolemia does not present with any signs or symptoms,” Balikcioglu said. “If you are not screened, you will not know about it until maybe later in life when you develop a cardiovascular event — and it’s too late.”
The new Duke clinic takes a team-based approach to care, bringing together specialists in genetics, cardiology, nutrition, and research through the Duke Molecular Physiology Institute. The goal is to understand why a specific child has high cholesterol and tailor treatment accordingly.
“Every day we are combining our resources to understand the root cause of why that specific child has high cholesterol levels,” Balikcioglu said. “Once you understand it better, you can prevent it from happening.”The physician told WRAL her ultimate goal is to cure the chronic condition.
For the Smith family, that early knowledge has helped provide peace of mind.
“You don’t always know what might be happening inside,” Nick Smith said. “Now that we do know, we’re better equipped to take care of it.”
Liz Smith added, “I feel a lot better as a parent knowing that we can do what we can now to help her as she grows. You want to do everything you can to give them a long, healthy life.”
Balikcioglu hopes the new clinic encourages both pediatricians and parents to take cholesterol screening seriously, especially when there’s a known family history.
“High cholesterol is not only a disease for adulthood,” she said. “If we intervene early, we can prevent premature cardiovascular disease and premature death.”