Atherogenesis in children: implications for the prevention of atherosclerosis

Although it is frequently stated that "atherosclerosis begins in childhood," it is not so frequently stated that only the first stage of atherosclerosis--the innocuous, highly reversible fatty streak--occurs in childhood. The more harmful second stage of atherosclerosis, the atheromatous plaque, does not appear until after puberty in boys and much later in girls. The purpose of this review is to emphasize the natural history of atherosclerosis, particularly as it pertains to children, and to consider its implications for the prevention of atherosclerosis. Present evidence supports the view that intervening in childhood (2-15 years) with low-fat, low-cholesterol diets or even worse, lipid-lowering drugs, to prevent plaque formation in adulthood is wasted effort. Furthermore, the data show that children respond more poorly to lipid-lowering diets than do adults, and that the emphasis on low-fat diets for children leads some parents to overdo the guidelines and unwittingly push their children into malnutrition. The program adopted by Health Canada on the advice of pediatricians in that country to taper fat intake from 40% of energy at 2 years of age to 30% of energy at the conclusion of linear growth (late adolescence) is a step forward.