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. Um, happy to be talking with you today. Um, I always 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 and here we are. So I'm gonna actually, today's talk is going to be really practically focused looking at management guidelines and offering some practical tips. I have no relevant disclosures and we have really three main objectives. We really want to make sure that everyone is very clear about the ap guidelines for screening, be equipped with really some key 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, will 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 19 fifties 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 relation With cardiovascular disease. Um, in the 1970s, the medications available like cholesterol. Mean, 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 seemed to work quite well. And really key guidelines for adults happened in 2013 and in 2018, which really kind of uh, you know, has had an increased focus on looking at people in terms of risk categories. So, for the pediatric timeline that really begins in the early 90s, when there was research that started to say that actually there was evidence of artist real involvement years before actual development of cardiovascular disease. You know, some of those landmark studies, most, most pediatricians have heard of, um, you know, the Bogalusa heart study, which was a cohort study with school Children, some of whom died of external causes. And you know, that that was the study that people will sometimes refer to when they say, oh gosh, you know, we could see fatty streaks and Children as young as preschool or kindergarten age. Um, another related study of young adults who died of accidental causes showed that those who had higher levels of traditional risk factors, had higher evidence of coverage of the insides of their aorta and coronary arteries with those streaks and flax um, imaging studies, uh, you know, help you study live subjects and the Muscatine study actually looked specifically at intermediate thickness on a carotid artery and showed that, um, you know, in relatively young adults in their thirties and forties, that um you know, that higher evidence of plaque on the insides of their charity were correlated not only with the total cholesterol in their blood stream, but also historic childhood risk factors. Um and then looking at a large study of uh fin finish adults, cardiovascular risk factors in adolescents were predictive of later thickness in the carotid arteries on imaging and, you know, really very relevant for Children with familial hypercholesterolemia or single gene high cholesterol, which causes extremely high levels. Um There are a lot of parts of the world where uh cholesterol genes are concentrated. And so in the Netherlands, there a lot of people that have familial cholesterol hypercholesterolemia. Um and studies that have come out of the Netherlands um where they've compared a child followed for 10 years with FH who was on statin therapy and compared them to their lucky unaffected siblings showed that although at start, those kids had a, you know, jump start on that early fatty streaks on the insides of their charities 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 were 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 changes in the guideline recommendations for adults in the interim and key pieces that are important to know our 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 Children 2 to 8, targeted screening apply. So if there's a family history of cardiovascular disease, you do not need to wait until they're nine. Um if the parents high, you know, parents says that they have a total question of 2 40 or the child has any risk factors if they have obesity, if they have diabetes or necrotic 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 constitutes fasting, lipid profile or 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 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, universal's lipid screening is easier said than done and everyone gets that. Um And just um just even in large institutions with um a lot of practices in place to uh streamline processes like Kaiser even don't 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? A couple of reasons? Um Family history isn't always so reliable actually. Family history alone will miss over half of kids that have disability mia's um screen also because non HDL is useful as a correlative atherosclerosis. And also most kids will have a required pediatric office visit during that time period. And another interesting tidbit about why that ages 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 nine or 10, it's you know, it's going to be here. This this point up here, there's kind of a natural nadir 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 again, the recommendations include targeted screening if it was missed when they were 9-11. And in theory a universal screening again when people are 17. So this is a large diagram of the 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 1.30. Is it everyone 60 or is it everyone 90? 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 100 and 10, that is where the lab starts to tell me doctor, your patient's cholesterol is high because it is um you know 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 then they would be for Children 95th%ile. They'd be one of the five at the front of the line. And that helps them sort of say, Okay, well fair 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, especially for the families where their child has clear FH and their LDL is 250 it helps them really see, oh this is more than just a few points here. This is really off the charts, so to speak. And about 101 102 150 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%ile. And so this is what the guidelines uses the cut off for uh suggesting that it's worth going back and repeating and doing fasting. So um those numbers that you're gonna remember when 91 60 and 1 30 it really is is sort of a part of the numbers game is really working backwards from 1 90. You know all of this algorithm, a lot of the stuff that's here refers to this concept of extra risk factors. There are big, big time high level risk factors and their moderate level risk factors. And um generally speaking, if your LDL cholesterol is in the 1 30 to 1 60 range appropriate enough to say let's repeat it in six months. But actually remembering and realizing that you could see a 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. Ask about family history. You think about risk factors and conditions. A pretty high constellation of risk factors. Could believe it or not. Warren Staten in just this range 1 30 to 1 sixties say the patient has diabetes and they have another high level risk factor like a family history of 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 1 60 to 1 90 you can have them repeat it in a couple of 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 Lp little, maybe one 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 LP Little A. 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 a lifetime risk, not just risk that the person will have a heart attack in the next five years. L. P. L. A Little A. Is actually highly relevant. Um and so in this ballpark of 11,690, some people, some patients would even warrant a statin just because of the risk profile with one high level risk alone, such as having diabetes. Now, if you're patient has, you know, has been all of these and I apologize all of these buckets 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, he has been working on lifestyle optimization and their LDL is truly over 1 90 it is really hard to just eat your way with diet alone to this degree of the cell body mia from exogenous intake. I have seen it, 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 really um you're not doing them any favors by waiting on a stand for those people. So as an audience question uh your patients LDL is 1 32. This represents the value at the this is going to be automatic for everyone. 1 32 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 there are 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 242 104 199 range. Um you know, basically the upshot of the guidelines is really, that's a range where it's okay to consider fish oil, I will talk much more about that towards the end as well, I have a lot to a lot of opinions on that one. Um and actually if, you know, if they're trackless ride is over 100 or over 100 and 30 and a teenager, you know, that is sort of where you would say this is this is starting to be high and below that it's really effectively normal. So just just some some inkling about sort of the degree of change that you can see with lifestyle optimization. Let's just take this example patient, you know, they're triplets rights were in the two hundred's range, they had LDL consistently over the 95th percentile in the one thirties and the forties. 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 nine 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 change. And now on on average 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 the big 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 they have receptor mutations and their LDL receptor, for example, a PB 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 is 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 it is actually not not a classic pathogenic 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 results. Um and also some people with a kind of non classic version of a genetic mutation but in a classic jean. 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 and 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 difference, 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 school lunch program. Um guidelines are based off the recommendation is that no more than 25 to 30% of calories come from total fat, saturated fat is the main driver and the food 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 kind of extrapolate or really in triple it to say that that means any specific food should have more than 10% of its calories from saturated fat in terms of cholesterol itself. You know the this level guideline says that, 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 and the guilt is 100 and 80 mg. Um so for people who are heart attack survivors, who are at a stricter level of intake for cholesterol, Yes. You know that they will become, they will dig more into the details about that in general limitation. Dietary cholesterol intake is really not where the money is. The money is really more with saturated fats from processed meats from bacon, salami, hot dogs 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, okay, 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 a daily of a daily required daily value. Um ice cream is tends to be in the 40 to 50% range. This is 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 poly unsaturated mono unsaturated fat which 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 going to get some benefit from pulling out of the diet. And then another part of the story is what can we actually added to 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 to half a cup serving of broccoli has four g of fiber. There is actually research, it's good research that says four 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 to 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's a stricter recommendation of 7% of calories coming from saturated fat. I will say that this is just very hard to do, I will just be honest with you. And so um I think a lot of times um With patients I don't, 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 is 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, no more than 200 mg a day. Plant stana Lester. So for example, Benecol is a product um I can't believe it's not butter, 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, would require quite a lot of spoonfuls of that product from a tub or quite a lot of um capsules of cola stuff. 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 parallax is actually leaning into the fact that psyllium fiber, the major ingredient of Metamucil actually um is proven tablespoon a day. six g of fiber lowers LDL by about 7 to 10%. This is extremely useful actually. The patients that I probably the most have taking this, our little kids who will clearly end up on a statin, but they're younger than eight or people who are really at that borderline and they're trying everything. They have a kind of apologetics setup for high cholesterol. They're not a candidate for static, 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 the 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 poly and saturated and mono and saturated 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 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 four or five different types of statins. For the most part, I actually prefer to just use either pravastatin or atorvastatin 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 is what you can use as soon as you know when kids are as young as eight. Um 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, you must take it at night because they do have a short half life. Um and they're taking the thinking is it's more they're they're more effective when you take them at night because we think people produce more cholesterol at night so that's kind of the reason for that and they're cheap, They've been around for a long time. The lovastatin took forever to come off patent, but that is available when Children are over 10. Um, and that is a high potency statin and actually receive the statin can actually 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, its relatively more expensive. Actually, I need to update the slide actually, this has changed and now 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 appropriately, so parents are not eager to say sign my child up. I want them to take this stat and 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 or 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 five 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 and and frequently um we see responses in Children that are greater lowering than what you usually anticipate from studies and adults. In terms of what percentage lowering you get from what dose of statins. The side effects primarily the risk of rhabdomyolysis or myopathy. Zor 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 actually have had, what we thought in retrospect truly was a real a real 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 simvastatin is actually 40 mg. We don't generally go higher than 20 in pediatrics if we're not worrying, need to be with 20 mg of simvastatin. I will add another medicine like to me, which is a non statin. Um of course uh Most clinicians are aware, you know you need to avoid pregnancy if a patient is taking a statin because particularly early um early weeks of gestation on a statin, higher risk of having birth of birth defects. Um This is not in a category however where you are required to be monitoring with pregnancy testing. Um And uh the evidence thus far is actually truly mostly, you know, most the key studies are based on Children and teens with FH mata, genic familial hypercholesterolemia and not those with disability mia of obesity or apologetic, dislike anemia. 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 coast. I mean um you know, they haven't, 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 cholesterol to bile acids to kind of make up for that difference. In theory you they come with a lot of tolerance issues. Um I've actually had a child who had a biopsy confirmed diagnosis of her. She runs and she did fine on Costar mean um and just one point is that co star mean is okay for pregnant ladies. Um You know sometimes when patients who have extremely high cholesterol or starting a stat and then 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 you know can I you know what do I do Or the parent might ask about the kid. And actually you know sometimes for people with extremely high LDL actually um during management during pregnancy actually it's it's a reasonable option for pregnant women to be enclosed instead of their statin. So just a couple of patient examples does this patient have some little hypercholesterolemia? Well let's see see the LDL of 203 1 76. You might look at this and say oh my gosh ding ding ding this is over 1 90 this is it, this is it. But um you know like it is a journey. Some people, especially after the pandemic are coming out with a much higher 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 say oh well at one point had a. L. D. L. Down to 1 36. And oh gosh old records cash in 2012 2013 when they were younger their LDL was only 101 does this person have FH 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 a as low as 100 when they were younger. How about this one does this patient need to Afghanistan, you take a quick look, you look at these numbers and you say, oh LDL is only one in 58. Actually, this particular patient was one of those patients where because of family history um and the family history that you know grandma had a known Appleby mutation. They were always extremely careful since early childhood about their dietary intake. And so this is somebody where they actually had their their their diet optimized pretty much as much as humanly possible. And if they had any kind of a more typical american diet in any way, if they ever ate pizza or ever had any Gs, they probably really would clearly have been over 1 90. So you really have to interpret this with a grain of salt when you see a number to be like, well what is there, what are their habits like? And and you know, is it possible? This is just as low as they can go. Um So audience questions, Children should always only be started on private statins for LDL lowering, true or false, It's false. It's not necessarily wrong to start with private sound, 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 it all but actually obviously in lipid metabolism, you know, other things to keep keep in mind are there are genes and then there are genes. So for example, there are patients I've only had two that really following this category of the millennial kylo micro nemea syndrome where they might have a double loss of the lipoprotein, light based receptor or you know, this is a complete loss of function there, lipoprotein light based 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 most of your patients where they might have higher than average, right? You might sort of say, Oh gosh, this patient has a track right in the 400 range, right? Will be somebody where there is a genetic situation. Maybe they have a variant of one of the famous or 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, I I see plenty of these patients because people providers appropriately checking over over time and just seeing these numbers aren't really budging down to normal ranges, no matter what they do. But a lot of people file kind of in that middle, right? Because lipoprotein light based insulin resistance with extra weight gain um messes up like lipoprotein lipoprotein light based 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 build up of triglyceride rich VL Tl and other academics in your So this is sort of you know a lot of patients have kind of 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 lipoprotein processing along the way leads to build up on triglycerides and those other remnants those V. L. D. L. Ideal. So to translate that will say, okay well trackless Ride is a fat and blood. Our body makes not only from fats we eat because it's true fats we eat it will end up as reckless, right? But also from extra sugar and starch that we don't need. Some people have genes that make them wired to be sky high over five times normal. Even with a pretty decent diet. Um some people have a setup and most people are you know most people that they flag your attention. You're kind of noticing that they're in that 400 range frequently they have a set up in their genes, such as if they don't have a good diet, especially if they have extra weight, their levels of blossom, maybe 23 times normal. But honestly anybody, regardless of genes, regardless of extra setup, will have trouble is right that the blossoms up, that drifts upward over time with poor diet and no exercise. So dietary fat certainly increases triglycerides. You ingest kyla microns and you're fat and you're in food. And if they're not, you know, they get broken down but added sugars and refined starches drive up triglyceride levels because of V. LDL production in the liver. And this is where 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 per So as an example, right, sweet sweet beverages are probably the number one quick way to raise someone's tried, tried and also conversely to lower it, Say, for example, 100% fruit juice, the only permitted sweetened beverage. But even that shouldn't be more than four oz a day, which is hard to hit, right? That's what school lunches have in a carton. So those are small sized cartons, but the easier, easier messages 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 four g of T 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 you say look for the sugar and you divide it by four. 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 were aiming for drinks to have in eight ounces no more than 10 g of sugar. 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 H. And It just kind of highlighted uh you know how alarmingly many adolescents in the US consume 20-50 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 particular triglyceride. And in fact actually if you have um if you have about a vigorous activity there is suppression in postprandial triglyceride 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 a relationship between exercise and LDL cholesterol. Exercise is of course extremely important for overall heart health, endurance. Your heart is a muscle you needed 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 they're saying we're just going to exercise more exercise alone doesn't bring LDL down all that much unless it's exercise. That brings a reduction and extra weight. So like I said, even in the absence of weight loss, exercise will really peel down that trackless ride. But exercise well really not attack or not really trip away too much of the LDL unless it's exercise that helps somebody lose weight. Um This is just to remind me to 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 hyper triglyceride induced pancreatitis, There's really different mechanisms for why this would be 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 sledging and interestingly 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, 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's in that 1000 plus 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 this right? Over 1000, you know, they have a much higher risk. And so, you know, this is, you know, sorry, pretty much said most of this, it's really mostly people who are in 1000 in a higher range. Um the majority of acute pancreatitis is not from trackless, right associated, pancreatitis, but um in these kids, you know, where the this is the only reason that I end up visiting patients in the ICU is because of checklist, right? 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 2 to 4000 mg a day of omega three can help are not saying 2 to 4000 mg of fish oil because D. H. A. And E. P. A. R. The omega three 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 three in each 1000 mg capsule. That's just the size of the capsule and the rest. Other than the 300 mg of omega three is just fish fat gummies. 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 is 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, oh 252 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, I 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 three 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 204 to 500 range. And you really tried 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, okay, 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 pink otitis 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 four g a day of omega three is really impossible to get them to that dose with regular over the counter stuff Lavazza is the prescribe herbal pharmaceutical grade omega three which is never covered unless your patient has diabetes. But increasingly actually at the time I made these slides, the triple strength from CBS 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 as they will say pharmaceutical strength or they'll say triple strength. And just the thing to kind of tell yourself is actually we're looking for the actual Omega three, 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 before you go putting everyone on fish oil, see what they can do on their own first is really valuable. 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. But 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 is 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. Of course vibrates are the medication of choice, feta vibrate 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 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 fiber there on a fiber because primarily it's the Trackless Ride, that is the issue. So just things to remember if it's 100 to 200 repeat a panel next year, 200 to 499. And like to really frame it and 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 they were on top of things and then they slid off the wagon and then you never got the benefit of that check that. I bet you can bring this down to normal. Um You know, if there are over 500 you know, we need to see some serious effort and recheck in a three months to see whether omega three 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 do 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 mentioned that you have high cholesterol and high triglycerides and that you know just to just mention that and it just helps people make that connection. That that is a risk factor for their child. So let's say you did a lipid screening. Your new patient is 10. They had a lot 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 because 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 not fasting lipid screening 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 or 1 91 61 30 or 500 for triglycerides. And the number three recheck abnormal liberates in your patients in a few months. And 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're 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.