The strategy of trying to prevent heart disease risk in childhood has been described as radical, but is the concept really so radical? What truly would be radical would be to adopt this concept and actually do something about our #1 killer epidemic. “The alternative is to continue indefinitely to rely upon the late and incompletely effective strategies, with their recognized costs, for detecting and treating already established risk factors” like high cholesterol levels that may have been causing progression of the disease their whole lives. As I discuss in my video, “a failure to diagnose and treat risk factors in youth may miss an opportunity to prevent the long-term consequences of [heart] disease,” the leading cause of disability and death in the United States.
We could prevent 90 percent of heart attacks. Such a claim would have seemed outrageous 50 years ago, but now we know stopping this epidemic is achievable. There are two ways we can do this. The first is the clinical medicine approach, in which physicians identify kids at risk and vigorously advocate lifestyle changes or drug them. However, “[t]his model can, at best, be applied to only a few individuals, because physician effort is limited”—we have 15-minute doctor visits—“preventive care is not reimbursed, and interventions directed toward individuals are often ineffective because they are not supported by the surrounding culture.” To stop the disease process completely, one may have to go to an almost exclusively plant-based diet, something that hasn’t been officially recommended for fear of “discouraging” the public. But our job as physicians is to tell the truth and let the public decide.
That’s why, to prevent atherosclerosis, we need broad social and cultural changes that pervade the entire population. The evidence justifies igniting a veritable social movement that eventually will be supported officially by the powers that be. “The goal of eliminating 90% of [coronary heart disease] is feasible,” but the “cultural and societal changes necessary to achieve this goal won’t be easy, and they won’t happen soon, but it’s time to start.”
So, it may be that the newest Academy of Pediatrics-approved guidelines for universal cholesterol screening of all children, starting around age nine, might actually be too conservative. How about starting at age two? That’s “when parents are generally engaged and vigilant about well-child checkups and when there are additional opportunities for provider-parent education about the importance of diet, exercise, and a healthy lifestyle,” not only for their kids but for themselves as well, because atherosclerosis can start even before birth and depend on what our moms ate.
Fatty streak formation occurs in human fetal arteries and is worsened greatly by how high the pregnant mother’s cholesterol is. In one study, arteries were obtained from spontaneous miscarriages and premature newborns who died within 12 hours of birth around the end of the second trimester. They looked at the arteries of fetuses from mothers with normal cholesterol levels and from pregnant moms with high cholesterol, and fetal arteries from mothers with high cholesterol contained significantly greater lesions.
This suggests not only that heart disease may start much earlier than we had previously assumed, but that it also depends on maternal cholesterol levels. So, atherosclerosis might not just start out as a nutritional disease of childhood, but also as a nutritional disease of pregnancy.