All Children Should Have Their Cholesterol Checked Between Ages 9 and 11

Coronary artery disease does not magically appear. The disease begins “during early childhood and progress[es] unrecognized for several decades to its often final and unexpected endpoint of chest pain, disability, or premature death.”

As I discuss in my video Should All Children Have Their Cholesterol Checked?, “we need to remind ourselves that atherosclerosis begins in childhood as fatty streaks” in the arteries, which “are the precursors of the advanced lesions that ultimately” kill us. By the time we’re in our 20s, 20 percent of the inner surface of the artery coming off the heart is covered in fatty streaks, as you can see at 0:58 in my video. Fifty years ago, pathologists began raising the question of whether heart disease is best handled by cardiologists or by pediatricians.

“By their 30s, many young adults already have advanced coronary atherosclerosis,” so, in reality, intervention during our 30s and beyond “is actually secondary prevention, because advanced atherosclerosis is likely already present.” Indeed, intervention is just trying to mediate the ravages of the disease rather than prevent the disease itself.

What’s more, we are exporting the problem around the world. A study of young, thin, apparently healthy individuals found 97 percent of their collected arteries had atherosclerosis, which you can see at 4:52 in my video. So, even in developing countries like Brazil, where they’ve acquired our eating habits, we’re seeing an epidemic of heart disease and sudden death.

“Moreover, the risk factors that correlate with the extent of such early lesions are the same risk factors that correlate with myocardial infarction [or, heart attacks] later in life.” In other words, it’s the same disease but in the early stages. So, pathologists, the ones doing the autopsies on all these young people and seeing all this coronary artery disease, “began urging many years ago that preventive measures should be instituted earlier in life.”

We’ve known that fatty streaks exist in young children for more than a century, but it wasn’t until 1994 that a task force convened by the government came up with a “radical” idea: “The strategic key, and the greatest opportunity in preventing [cardiovascular disease] CVD, is to prevent the development of CVD risk in the first place.”

In my video Heart Disease Starts in Childhood, I noted that fatty streaks, the first stage of atherosclerosis, were found in the arteries of nearly 100 percent of kids by age ten who were raised on the standard American diet. In recognition of this fact, the latest Academy of Pediatrics’ recommendation is for all kids to get their cholesterol tested starting between the ages of 9 and 11.

Of course, this has drug companies salivating at the thought of slipping statins into Happy Meals, but “long-term drug intervention is costly and may be associated with adverse effects.” So, the conversation is about lifestyle modification.

In my video How Many Meet the Simple Seven?, I revealed the breathtaking statistic that only about 1 in 2,000 U.S. adults met the seven American Heart Association criteria for a heart-healthy lifestyle. What about American teenagers? Of the 4,673 adolescents aged 12 to 19 who were studied, zero made the cut. Not one teen “exhibited ideal levels of all 7 cardiovascular health behaviors and health factors.”

Most teen boys and girls don’t smoke, and most aren’t overweight. What was the main sticking point? Almost no one ate a healthy diet. Indeed, less than 1 percent of young men and women met a minimum of healthy diet criteria.

This sorry state of affairs is what’s behind a “controversial valuation that the current generation of US children and adolescents may be one of the first generations to be less healthy and have shorter life expectancy than their parents.”


If you think atherosclerosis by age ten is bad, check out my video Heart Disease May Start in the Womb.

Adverse effects with cholesterol-lowering drugs? See Statin Muscle Toxicity. I don’t think most people realize—doctors and patients alike—realize how relatively ineffective these drugs are. Watch, for example, The Actual Benefit of Diet vs. Drugs.

Cholesterol can do more than just build up and block off our arteries. In fact, Cholesterol Crystals May Tear Through Our Artery Lining.

What’s the Optimal Cholesterol Level? Does Cholesterol Size Matter? Watch the videos to find out.

Let’s take a step back, though. What about all the “cholesterol skeptics”? Check out How Do We Know That Cholesterol Causes Heart Disease?.

In health,
Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:

Why Drinking Diet Soda Makes You Crave Sugar

Recommendations on limiting sugar consumption vary around the world, with guidelines ranging from “[l]imit sweet desserts to one every other day” to “[k]eep sugar consumption to 4 or less occasions per day.” In the United States, the American Heart Association is leading the charge, “proposing dramatic reductions in the consumption of soft drinks and other sweetened products” and recommending fewer than about 5 percent of calories a day from added sugars, which may not even allow for a single can of soda.

Why is the American Heart Association so concerned about sugar? “Overconsumption of added sugars has long been associated with an increased risk of cardiovascular disease,” meaning heart disease and strokes. We used to think added sugars were just a marker for an unhealthy diet. At fast-food restaurants, for example, people may be more likely to order a cheeseburger with their super-sized soda than a salad. However, the new thinking is that the added sugars in processed foods and drinks may be independent risk factors in and of themselves. Indeed, worse than just empty calories, they may be actively disease-promoting calories, which I discuss in my video Does Diet Soda Increase Stroke Risk as Much as Regular Soda?.

At 1:14 in my video, you can see a chart of how much added sugar the American public is consuming. The data show that only about 1 percent meet the American Heart Association recommendation to keep added sugar intake down to 5 or 6 percent of daily caloric intake. Most people are up around 15 percent, which is where cardiovascular disease risk starts to take off. There is a doubling of risk at about 25 percent of calories and a quadrupling of risk for those getting one-third of their daily caloric intake from added sugar.

Two hundred years ago, we ate an estimated 7 pounds of sugar annually. Today, we may consume dozens of pounds of sugar a year. We’re hardwired to like sweet foods because we evolved surrounded by fruit, not Froot Loops, but this adaptation is “terribly misused and abused” today, “hijacked” by the food industry for our pleasure and their profits. “Why are we consuming so much sugar despite knowing too much can harm us?” Yes, it may have an addictive quality and there’s the hardwiring, but the processed food industry isn’t helping. Seventy five percent of packaged foods and beverages in the United States contain added sweeteners, mostly coming from sugar-sweetened beverages like soda, which are thought responsible for more than a 100,000 deaths worldwide and millions of years of healthy life lost. Given this, can we just switch to diet sodas? By choosing diet drinks, can’t we get that sweet taste we crave without any of the downsides? Unfortunately, studies indicate that “[r]outine consumption of diet soft drinks is linked to increases in the same risks that many seek to avoid by using artificial sweeteners—namely type 2 diabetes, metabolic syndrome heart disease, and stroke.” At 3:15 in my video, you can see data showing the increased risks of cardiovascular disease associated with regular soft drinks and also diet soda. They aren’t that dissimilar.

“In other words, the belief that artificially sweetened diet beverages reduce long-term health risks is not supported by scientific evidence, and instead, scientific data indicate that diet soft drink consumption may contribute to the very health risks people have been seeking to avoid.” But, why? It makes sense that drinking all that sugar in a regular soft drink might increase stroke risk, due to the extra inflammation and triglycerides, but why does a can of diet soda appear to increase stroke risk the same amount? It’s possible that the caramel coloring in brown sodas like colas plays a role, but another possibility is that “artificial sweeteners may increase the desire for sugar-sweetened, energy-dense beverages/foods.”

The problem with artificial sweeteners “is that a disconnect ultimately develops between the amount of sweetness the brain tastes and how much glucose [blood sugar] ends up coming to the brain.” The brain feels cheated and “figures you have to eat more and more and more sweetness in order to get any calories out of it.” So, “[a]s a consequence, at the end of the day, your brain says, ‘OK, at some point I need some glucose [blood sugar] here.’ And then you eat an entire cake, because nobody can hold out in the end.”

If people are given Sprite, Sprite Zero (a zero-calorie soda), or unsweetened, carbonated, lemon-lime water, but aren’t told which drink they’re getting or what the study is about, when they’re later offered a choice of M&M’s, spring water, or sugar-free gum, who do you think picks the M&M’s? Those who drank the artificially sweetened soda were nearly three times more likely to take the candy than those who consumed either the sugar-sweetened or unsweetened drinks. So, it wasn’t a matter of sweet versus non-sweet or calories versus no-calories. There’s something about non-caloric sweeteners that somehow tricks the brain.

The researchers did another study in which everyone was given Oreos and were then asked how satisfied the cookies made them feel. Once again, those who drank the artificially sweetened Sprite Zero reported feeling less satisfied than those who drank the regular Sprite or the sparkling water. “These results are consistent with recent [brain imaging] studies demonstrating that regular consumption of [artificial sweeteners] can alter the neural pathways responsible for the hedonic [or pleasure] response to food.”

Indeed, “[t]he only way really to prevent this problem—to break the addiction—is to go completely cold turkey and go off all sweeteners—artificial as well as fructose [table sugar and high fructose corn syrup]. Eventually, the brain resets itself and you don’t crave it as much.”

We’ve always assumed the “[c]onsumption of both sugar and artificial sweeteners may be changing our palates or taste preferences over time, increasing our desire for sweet foods. Unfortunately, the data on this [were] lacking”…until now. Twenty people agreed to cut out all added sugars and artificial sweeteners for two weeks. Afterwards, 95 percent “found that sweet foods and drinks tasted sweeter or too sweet” and “said moving forward they would use less or even no sugar.” What’s more, most stopped craving sugar within the first week—after only six days. This suggests a two-week sugar challenge, or even a one-week challenge, may “help to reset taste preferences and make consuming less or no sugar easier.” Perhaps we should be recommending it to our patients. “Eating fewer processed foods and choosing more real, whole, and plant-based foods make it easy to consume less sugar.”


Speaking of stroke, did you see my Chocolate and Stroke Risk video?

For more on added sugars, see:

You may also be interested in my videos on artificial and low-calorie sweeteners:

In health,
Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:

How to Lower Your Sodium Intake

Reduction of salt consumption by just 15 percent could save the lives of millions. If we cut our salt intake by half a teaspoon a day, which is achievable simply by avoiding salty foods and not adding salt to our food, we might prevent 22 percent of stroke deaths and 16 percent of fatal heart attacks—potentially helping more than if we were able to successfully treat people with blood pressure pills. As I discuss in my video Salt of the Earth: Sodium and Plant-Based Diets, an intervention in our kitchens may be more powerful than interventions in our pharmacies. One little dietary tweak could help more than billions of dollars worth of drugs.

What would that mean in the United States? Tens of thousands of lives saved every year. On a public-health scale, this simple step “could be as beneficial as interventions aimed at smoking cessation, weight reduction, and the use of drug therapy for people with hypertension or hypercholesterolemia,” that is, giving people medications to lower blood pressure and cholesterol. And, that’s not even getting people down to the target. 

A study I profile in my video shows 3.8 grams per day as the recommended upper limit of salt intake for African-Americans, those with hypertension, and adults over 40. For all other adults the maximum is 5.8 daily grams, an upper limit that is exceeded by most Americans over the age of 3. Processed foods have so much added salt that even if we avoid the saltiest foods and don’t add our own salt, salt levels would go down yet still exceed the recommended upper limit. Even that change, however, might save up to nearly a hundred thousand American lives every year.

“Given that approximately 75% of dietary salt comes from processed foods, the individual approach is probably impractical.” So what is our best course of action? We need to get food companies to stop killing so many people. The good news is “several U.S. manufacturers are reducing the salt content of certain foods,” but the bad news is that “other manufacturers are increasing the salt levels in their products. For example, the addition of salt to poultry, meats, and fish appears to be occurring on a massive scale.”

The number-one source of sodium for kids and teens is pizza and, for adults over 51, bread. Between the ages of 20 and 50, however, the greatest contribution of sodium to the diet is not canned soups, pretzels, or potato chips, but chicken, due to all the salt and other additives that are injected into the meat.

This is one of the reasons that, in general, animal foods contain higher amounts of sodium than plant foods. Given the sources of sodium, complying with recommendations for salt reduction would in part “require large deviations from current eating behaviors.” More specifically, we’re talking about a sharp increase in vegetables, fruits, beans, and whole grains, and lower intakes of meats and refined grain products. Indeed, “[a]s might be expected, reducing the allowed amount of sodium led to a precipitous drop” in meat consumption for men and women of all ages. It’s no wonder why there’s so much industry pressure to confuse people about sodium.

The U.S. Dietary Guidelines recommend getting under 2,300 milligrams of sodium a day, while the American Heart Association recommends no more than 1,500 mg/day. How do vegetarians do compared with nonvegetarians? Well, nonvegetarians get nearly 3,500 mg/day, the equivalent of about a teaspoon and a half of table salt. Vegetarians did better, but, at around 3,000 mg/day, came in at double the American Heart Association limit.

In Europe, it looks like vegetarians do even better, slipping under the U.S. Dietary Guidelines’ 2,300 mg cut-off, but it appears the only dietary group that nails the American Heart Association recommendation are vegans—that is, those eating the most plant-based of diets.


This is part of my extended series on sodium, which includes:

If you’re already cutting out processed foods and still not reaching your blood pressure goals, see:

In health,
Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live, year-in-review presentations: