 The strategy of preventing heart disease risk in childhood has been described as radical, but is the concept really so radical? What would be radical is to actually adopt this concept and actually do something about it. The alternative is to continue indefinitely to rely upon the late, incompletely effective, costly strategies for treating already established risk factors like high cholesterol levels that may have been causing progression of the disease their whole lives. A failure to diagnose and treat risk factors in youth may miss an opportunity to prevent the long-term consequences of heart disease, the lead in cause of disability and death in the United States for both men and women. We could prevent 90% of heart attacks. Such a claim would have seemed outrageous 50 years ago, but now we know stopping this epidemic is achievable. There's two ways we can do this. The first is the clinical medicine approach in which physicians identify kids at risk and vigorously advocate lifestyle changes or drug them. But this model can best be applied to only a few individuals. We've got 15-minute doctor visits. Preventive care isn't reimbursed. And interventions directed at individuals are often ineffective because they're not supported by the surrounding culture. To stop the disease process completely, one may have to go on an almost exclusively plant-based diet, something that hasn't been officially recommended for fear of discouraging the public. But our job as physicians is to tell the truth and let the public decide. That's why we need broad social and cultural changes that pervade the entire population to prevent atherosclerosis. The evidence justifies igniting a veritable social movement that eventually will be officially supported by the powers that be. The goal of eliminating 90% of coronary heart disease is feasible, but the cultural and societal changes necessary to achieve this goal won't be easy and they won't happen soon, but it's time to start. So maybe the newest Academy of Pediatrics approved guidelines for universal cholesterol screening of all children starting around age 9 might actually be too conservative. How about starting at age 2? That's when parents are generally engaged and vigilant about well-child checkups, and when there are additional opportunities for parent education about the importance of diet exercise and healthy lifestyle, not only for their kids, but for them as well, because atherosclerosis can start even before birth and depend on what our moms ate. Fatty streak formation occurs in human fetal arteries and is greatly worsened by how high the pregnant mother's cholesterol is. Arteries were obtained from spontaneous miscarriages and premature newborns who died within 12 hours of birth, right around the end of the second trimester. They looked at the arteries of fetuses from mothers with normal cholesterol levels and from pregnant moms with high cholesterol, and fetal arteries from mothers with high cholesterol contained dramatically greater lesions. This suggests not only that heart disease may start much earlier than we previously assumed, but that it depends on maternal cholesterol levels. So, atherosclerosis might not just start out as a nutritional disease of childhood, but a nutritional disease of pregnancy.