Does My Kid’s High Cholesterol Need a Diet?
Putting the evidence about dietary changes and restriction dangers into (your) context.
Disclaimer: You’re reading this column because you value my input as a journalist who reports on these issues and therefore has a lot of informed opinions. I’m not a healthcare provider, and these responses are not meant to substitute for medical or therapeutic advice.
Q: At a recent annual well visit, my 13 year-old's pediatrician ran a blood test and determined that my daughter's cholesterol is elevated. The pediatrician's advice was:
"For elevated cholesterol, I would like her to eliminate trans fats from diet (think doughnuts, fried foods, anything that says "partially hydrogenated"), she should limit her intake of cholesterol (animal fats, eggs, butter, cheese) and simple carbs: bread, pasta, rice, potatoes, anything with sugar in the first three ingredients. Half of what she eats should be fruits and veggies. Limit all sweetened drinks. This includes 100% juice, sodas, flavored water."
I'd love your advice about how to approach this with my daughter in a way that doesn’t feel restrictive and diet culture-y. I am in a larger body and my daughter is in a smaller body, so giving advice about diet and nutrition feels especially fraught for me. And clearly, some parts of this advice (i.e. eat more fruits and vegetables) are easier to get behind than others.
Do I discuss the test results candidly with her or just try to subtly encourage her to make "healthier" choices? My first attempt was to suggest a family fruit and vegetable challenge and it didn't go over so well (lots of questions like, "Why doesn't juice count as a fruit?"). This comes after I've spent the last few years telling my kids all foods are good foods and working hard to reprogram my diet culture mindset. Any advice about how to avoid screwing this up would be appreciated!
If I could wave a wand and make one sweeping change in the way most doctors (pediatricians included) talk about food and bodies with patients, it would be: Stop prescribing restriction without context. Some of what your doctor suggested is evidence-based and some of it isn’t, and we’re going to walk through those specifics in a minute. But the big picture problem here is that doctors are taught to make blanket statements about diet (“cut out X to achieve Y health outcome”) without first asking how a patient already eats, whether making this change is remotely accessible, affordable or doable for them, and whether cutting out food groups might increase a patient’s risk for other health issues—namely disordered eating.
And to be clear: Everyone is at risk for disordered eating (even when it’s “medically necessary”), because diet culture. But 13-year-old girls are especially vulnerable to this because of their age (eating disorders tend to onset during adolescence) and gender socialization experiences. Yet when a health issue commonly associated with diet crops up, doctors tend to get tunnel vision about managing that one issue as if those other risks don’t exist. There’s a kind of trench warfare mentality that takes over— “perfect biomarkers at any cost”— which is rooted in our larger cultural misconceptions about childhood ob*sity even when the patient in question is thin. But health is not a single issue voter. Your daughter’s cholesterol does not exist in a void. And her context matters.
One piece of context that feels especially important here: The United States Preventive Services Task Force (one of the organizations that develops guidelines around when doctors should screen for what) does not recommend cholesterol screenings for kids under age 21.1 “This is because a lot of the data we have on the health consequences of high cholesterol for children are observational and look at adult health outcomes,” explains Andrea Westby, MD, a family medicine physician with the University of Minnesota Medical School. Lots of pediatricians track cholesterol starting between the ages of 9 and 11 anyway, because the American Academy of Pediatrics does recommend it. But even if your doctor does test, Dr. Westby advises against doing anything drastic based on one high test result: “A lot can influence test results, like whether the child fasted beforehand, their sleep and stress level,” she says. “I would want to know that levels are consistently high before recommending any treatment.”
And here’s another key piece of context: One common explanation for high cholesterol in kids—especially if high cholesterol runs in your family— is a genetic disorder called familial hypercholesterolemia (FH), which tends to onset at a young age and will impact 1 in 250 people during their lifetime. “[FH] needs to be treated with medications and is unlikely to respond adequately to lifestyle changes,” says Dr. Westby. She also considers whether kids are on any medications or supplements that could impact lipid metabolism, and evaluates them for other cardiovascular disease risk factors, like sleep, stress, activity level, experiences of trauma, and exposure to pollution. If one of those underlying issues is a potential driver of your daughter’s cholesterol levels, then it might make more sense to support her in navigating that, rather than rushing to make a bunch of diet changes right off the bat.
Another common cause of high cholesterol levels is not eating enough food. If you have any concerns that your daughter is already dieting or otherwise not eating enough, you should ask your pediatrician to screen her for an eating disorder (or refer you to the right support). Adding more food rules to a kid who is already restricting is only going to exacerbate every issue.
You should also know that while your pediatrician is following treatment guidelines endorsed by the AAP and other major medical organizations, the research on whether dietary changes do in fact successfully lower cholesterol is mixed. “The net benefit of dietary changes for elevated cholesterol levels is not consistently shown across larger studies,” says Dr. Westby. “The best results I saw were a reduction of 3 to 6 mg/dL, which is not likely to be clinically significant. And the reduction wasn’t particularly long lasting.” Dr. Westby doesn’t push diet changes for kids with high cholesterol because she’s not convinced by the data that the benefits outweigh the risks. “Lifestyle management doesn’t always succeed in achieving health goals, even when someone follows the plan ‘perfectly,’” she notes. “Is the potential of lowering cholesterol levels by 3 to 6 points enough of a change to balance out the risks? I can’t answer that for an individual, but I think it’s information we don’t always give when we push lifestyle changes first.”
Amelia Sherry, MPH, RD, a dietitian in private practice in New York, says she has seen patients improve with dietary changes, though again, only if it’s the kind of high cholesterol that will respond to diet — so not caused by FH, medication, anorexia, and so on. Ans she never suggests specific diet tweaks unless she’s sure the family she’s working with has a good foundation in place first. “If there’s a lot of chaos or emotions around food, or the parents or kids are already struggling with significant fears and restrictions around food, then I would not start with dietary changes,” says Amelia, who is also the author of Diet-Proof Your Daughter. “It’s almost impossible to follow a medically necessary diet without a positive relationship with food in place first.”
In evaluating what’s best for you and your daughter, you might want to ask your pediatrician to frame their goals for your daughter’s cholesterol in net benefit terms: “If we make these changes to her diet, what magnitude of change in cholesterol levels can we expect? How long can we expect that change to last? And how are we balancing the benefit of that change against any increase in stress or disordered eating that might result from following this diet?”
OK, But Should We Cut Out Any Foods?
Now let’s talk about which, if any, of your pediatrician’s food rules, might be useful if you’ve confirmed that your daughter’s cholesterol would in fact benefit from dietary changes. I asked Amelia to run down that list with me. Keep in mind that she’s a dietitian but not your child’s dietitian, so she’s evaluating these as general statements, not making treatment recommendations to you (or anyone else reading this!).
As discussed above, there are a lot of good reasons not to cut out foods even when there is some evidence showing a relationship between certain food groups and cholesterol. Your daughter’s mental health matters. Your mental health matters. Comfort and pleasure still matter. None of us can or should make every decision of the day based purely on what benefits our long-term health most.