Starting early to control all risk factors in order to prevent coronary heart disease

Elevated blood cholesterol level was the first major contributor to atherosclerosis to have its clinical manifestations established by controlled clinical trials. More specific lipid conditions (high LDL-C and low HDL-C) and nonlipid conditions (hypertension, smoking, obesity and diabetes mellitus) have also been established by clinical trials or extensive observational studies as contributors to atherosclerosis and its sequelae. Programs directed at adults to control these conditions, known as risk factors, have reduced the incidence of clinical disease. However, both autopsy and cohort studies have demonstrated that atherosclerosis begins in childhood, and its progression to clinically significant lesions is associated with all the risk factors, lipid and nonlipid, during the teenage and young adult years. Advanced plaques, vulnerable to changes that lead to rupture and thrombosis, are present in the coronary arteries of some individuals by the age of 40 years. These observations indicate that risk-factor prevention should begin in childhood. Furthermore, all risk factors are important and no risk factor can be safely ignored, regardless of the presence or absence of other risk factors. Promoting lifestyles in childhood that prevent all the risk factors offers the best long range prevention strategy for adult atherosclerotic disease.