Growth until 3 years of age in a prospective, randomized trial of a diet with reduced saturated fat and cholesterol

Effects of total fat intake on bodyweight in children

BACKGROUND

As part of efforts to prevent childhood overweight and obesity, we need to understand the relationship between total fat intake and body fatness in generally healthy children.

OBJECTIVES

To assess the effects and associations of total fat intake on measures of weight and body fatness in children and young people not aiming to lose weight.

SEARCH METHODS

For this update we revised the previous search strategy and ran it over all years in the Cochrane Library, MEDLINE (Ovid), MEDLINE (PubMed), and Embase (Ovid) (current to 23 May 2017). No language and publication status limits were applied. We searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov for ongoing and unpublished studies (5 June 2017).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children aged 24 months to 18 years, with or without risk factors for cardiovascular disease, randomised to a lower fat (30% or less of total energy (TE)) versus usual or moderate-fat diet (greater than 30%TE), without the intention to reduce weight, and assessed a measure of weight or body fatness after at least six months. We included prospective cohort studies if they related baseline total fat intake to weight or body fatness at least 12 months later.

DATA COLLECTION AND ANALYSIS

We extracted data on participants, interventions or exposures, controls and outcomes, and trial or cohort quality characteristics, as well as data on potential effect modifiers, and assessed risk of bias for all included studies. We extracted body weight and blood lipid levels outcomes at six months, six to 12 months, one to two years, two to five years and more than five years for RCTs; and for cohort studies, at baseline to one year, one to two years, two to five years, five to 10 years and more than 10 years. We planned to perform random-effects meta-analyses with relevant subgrouping, and sensitivity and funnel plot analyses where data allowed.

MAIN RESULTS

We included 24 studies comprising three parallel-group RCTs (n = 1054 randomised) and 21 prospective analytical cohort studies (about 25,059 children completed). Twenty-three studies were conducted in high-income countries. No meta-analyses were possible, since only one RCT reported the same outcome at each time point range for all outcomes, and cohort studies were too heterogeneous to combine.Effects of dietary counselling to reduce total fat intake from RCTsTwo studies recruited children aged between 4 and 11 years and a third recruited children aged 12 to 13 years. Interventions were combinations of individual and group counselling, and education sessions in clinics, schools and homes, delivered by dieticians, nutritionists, behaviourists or trained, supervised teachers. Concerns about imprecision and poor reporting limited our confidence in our findings. In addition, the inclusion of hypercholesteraemic children in two trials raised concerns about applicability.One study of dietary counselling to lower total fat intake found that the intervention may make little or no difference to weight compared with usual diet at 12 months (mean difference (MD) -0.50 kg, 95% confidence interval (CI) -1.78 to 0.78; n = 620; low-quality evidence) and at three years (MD -0.60 kg, 95% CI -2.39 to 1.19; n = 612; low-quality evidence). Education delivered as a classroom curriculum probably decreased BMI in children at 17 months (MD -1.5 kg/m2, 95% CI -2.45 to -0.55; 1 RCT; n = 191; moderate-quality evidence). The effects were smaller at longer term follow-up (five years: MD 0 kg/m2, 95% CI -0.63 to 0.63; n = 541; seven years; MD -0.10 kg/m2, 95% CI -0.75 to 0.55; n = 576; low-quality evidence).Dietary counselling probably slightly reduced total cholesterol at 12 months compared to controls (MD -0.15 mmol/L, 95% CI -0.24 to -0.06; 1 RCT; n = 618; moderate-quality evidence), but may make little or no difference over longer time periods. Dietary counselling probably slightly decreased low-density lipoprotein (LDL) cholesterol at 12 months (MD -0.12 mmol/L, 95% CI -0.20 to -0.04; 1 RCT; n = 618, moderate-quality evidence) and at five years (MD -0.09, 95% CI -0.17 to -0.01; 1 RCT; n = 623; moderate-quality evidence), compared to controls. Dietary counselling probably made little or no difference to HDL-C at 12 months (MD -0.03 mmol/L, 95% CI -0.08 to 0.02; 1 RCT; n = 618; moderate-quality evidence), and at five years (MD -0.01 mmol/L, 95% CI -0.06 to 0.04; 1 RCT; n = 522; moderate-quality evidence). Likewise, counselling probably made little or no difference to triglycerides in children at 12 months (MD -0.01 mmol/L, 95% CI -0.08 to 0.06; 1 RCT; n = 618; moderate-quality evidence). Lower versus usual or modified fat intake may make little or no difference to height at seven years (MD -0.60 cm, 95% CI -2.06 to 0.86; 1 RCT; n = 577; low-quality evidence).Associations between total fat intake, weight and body fatness from cohort studiesOver half the cohort analyses that reported on primary outcomes suggested that as total fat intake increases, body fatness measures may move in the same direction. However, heterogeneous methods and reporting across cohort studies, and predominantly very low-quality evidence, made it difficult to draw firm conclusions and true relationships may be substantially different.

AUTHORS' CONCLUSIONS

We were unable to reach firm conclusions. Limited evidence from three trials that randomised children to dietary counselling or education to lower total fat intake (30% or less TE) versus usual or modified fat intake, but with no intention to reduce weight, showed small reductions in body mass index, total- and LDL-cholesterol at some time points with lower fat intake compared to controls. There were no consistent effects on weight, high-density lipoprotein (HDL) cholesterol or height. Associations in cohort studies that related total fat intake to later measures of body fatness in children were inconsistent and the quality of this evidence was mostly very low. Most studies were conducted in high-income countries, and may not be applicable in low- and middle-income settings. High-quality, longer-term studies are needed, that include low- and middle-income settings to look at both possible benefits and harms.

Effects of total fat intake on bodyweight in children

BACKGROUND

As part of efforts to prevent childhood overweight and obesity, we need to understand the relationship between total fat intake and body fatness in generally healthy children.

OBJECTIVES

To assess the effects of total fat intake on measures of weight and body fatness in children and young people not aiming to lose weight.

SEARCH METHODS

For this update we revised the previous search strategy and ran it over all years in the Cochrane Library, MEDLINE (Ovid), MEDLINE (PubMed), and Embase (Ovid) (current to 23 May 2017). No language and publication status limits were applied. We searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov for ongoing and unpublished studies (5 June 2017).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children aged 24 months to 18 years, with or without risk factors for cardiovascular disease, randomised to a lower fat (30% or less of total energy (TE)) versus usual or moderate-fat diet (greater than 30%TE), without the intention to reduce weight, and assessed a measure of weight or body fatness after at least six months. We included prospective analytical cohort studies in these children if they related baseline total fat intake to weight or body fatness at least 12 months later. We duplicated inclusion decisions and resolved disagreement by discussion with other authors.

DATA COLLECTION AND ANALYSIS

We extracted data on participants, interventions or exposures, controls and outcomes, and trial or cohort quality characteristics, as well as data on potential effect modifiers, and assessed risk of bias for all included studies. We extracted outcome data using the following time point ranges, when available: RCTs: baseline to six months, six to 12 months, one to two years, two to five years and more than five years; cohort studies: baseline to one year, one to two years, two to five years, five to 10 years and more than 10 years. We planned to perform random-effects meta-analyses with relevant subgrouping, and sensitivity and funnel plot analyses where data allowed.

MAIN RESULTS

We included 24 studies comprising three parallel-group RCTs (n = 1054 randomised) and 21 prospective analytical cohort studies (about 25,059 children completed). Twenty-three were conducted in high-income countries. No meta-analyses were possible, since only one RCT reported the same outcome at each time point range for all outcomes, and cohort studies were too heterogeneous.For the RCTs, concerns about imprecision and poor reporting limited our confidence in our findings. In addition, the inclusion of hypercholesteraemic children in two trials raised concerns about applicability. Lower versus usual or modified total fat intake may have made little or no difference to weight over a six- to twelve month period (mean difference (MD) -0.50 kg, 95% confidence interval (CI) -1.78 to 0.78; 1 RCT; n = 620; low-quality evidence), nor a two- to five-year period (MD -0.60 kg, 95% CI -2.39 to 1.19; 1 RCT; n = 612; low-quality evidence). Compared to controls, lower total fat intake (30% or less TE) probably decreased BMI in children over a one- to two-year period (MD -1.5 kg/m2, 95% CI -2.45 to -0.55; 1 RCT; n = 191; moderate-quality evidence), with no other differences evident across the other time points (two to five years: MD 0.00 kg/m2, 95% CI -0.63 to 0.63; 1 RCT; n = 541; greater than five years; MD -0.10 kg/m2, 95% CI -0.75 to 0.55; 1 RCT; n = 576; low-quality evidence). Lower fat intake probably slightly reduced total cholesterol over six to 12 months compared to controls (MD -0.15 mmol/L, 95% CI -0.24 to -0.06; 1 RCT; n = 618; moderate-quality evidence), but may make little or no difference over longer time periods. Lower fat intake probably slightly decreased low-density lipoprotein (LDL) cholesterol over six to 12 months (MD -0.12 mmol/L, 95% CI -0.20 to -0.04; 1 RCT; n = 618, moderate-quality evidence) and over two to five years (MD -0.09, 95% CI -0.17 to -0.01; 1 RCT; n = 623; moderate-quality evidence), compared to controls. However, lower total fat intake probably made little or no difference to HDL-C over a six- to 12-month period (MD -0.03 mmol/L, 95% CI -0.08 to 0.02; 1 RCT; n = 618; moderate-quality evidence), nor a two- to five-year period (MD -0.01 mmol/L, 95% CI -0.06 to 0.04; 1 RCT; n = 522; moderate-quality evidence). Likewise, lower total fat intake probably made little or no difference to triglycerides in children over a six- to 12-month period (MD -0.01 mmol/L, 95% CI -0.08 to 0.06; 1 RCT; n = 618; moderate-quality evidence). Lower versus usual or modified fat intake may make little or no difference to height over more than five years (MD -0.60 cm, 95% CI -2.06 to 0.86; 1 RCT; n = 577; low-quality evidence).Over half the cohort analyses that reported on primary outcomes suggested that as total fat intake increases, body fatness measures may move in the same direction. However, heterogeneous methods and reporting across cohort studies, and predominantly very low-quality evidence, made it difficult to draw firm conclusions and true relationships may be substantially different.

AUTHORS' CONCLUSIONS

We were unable to reach firm conclusions. Limited evidence from three trials that randomised children to a lower total fat intake (30% or less TE) versus usual or modified fat intake, but with no intention to reduce weight, showed small reductions in body mass index, total- and LDL-cholesterol at some time points with lower fat intake compared to controls, and no consistent differences in effects on weight, high-density lipoprotein (HDL) cholesterol or height. Associations in cohort studies that related total fat intake to later measures of body fatness in children were inconsistent and the quality of this evidence was mostly very low. Twenty-three out of 24 included studies were conducted in high-income countries, and may not be applicable in low- and middle-income settings. High-quality, longer-term studies are needed, that include low- and middle-income settings and look at both possible benefits and risks.

The Role of the Pediatrician in Primary Prevention of Obesity

The adoption of healthful lifestyles by individuals and families can result in a reduction in many chronic diseases and conditions of which obesity is the most prevalent. Obesity prevention, in addition to treatment, is an important public health priority. This clinical report describes the rationale for pediatricians to be an integral part of the obesity-prevention effort. In addition, the 2012 Institute of Medicine report "Accelerating Progress in Obesity Prevention" includes health care providers as a crucial component of successful weight control. Research on obesity prevention in the pediatric care setting as well as evidence-informed practical approaches and targets for prevention are reviewed. Pediatricians should use a longitudinal, developmentally appropriate life-course approach to help identify children early on the path to obesity and base prevention efforts on family dynamics and reduction in high-risk dietary and activity behaviors. They should promote a diet free of sugar-sweetened beverages, of fewer foods with high caloric density, and of increased intake of fruits and vegetables. It is also important to promote a lifestyle with reduced sedentary behavior and with 60 minutes of daily moderate to vigorous physical activity. This report also identifies important gaps in evidence that need to be filled by future research.

Complementary Feeding: Critical Considerations to Optimize Growth, Nutrition, and Feeding Behavior

This review focuses on complementary feeding (CF) in westernized settings where primary health concerns are risk of obesity and micronutrient inadequacy. The current evidence is reviewed for: (1) when CF should be introduced, (2) what foods (nutrients and food types) should be prioritized and avoided, and (3) how the infant should be fed. Special attention is paid to the underlying physiological differences between breast- and formula-fed infants that often result in distinctly different nutritional and health risks. This difference is particularly acute in the case of micronutrient inadequacy, specifically iron and zinc, but is also relevant to optimal energy and macronutrient intakes. Emphasis is placed on the complex interplay among infants' early dietary exposures; relatively high energy and nutrient requirements; rapid physical, social and emotional development; and the feeding environment-all of which interact to impact health outcomes. This complexity needs to be considered at both individual and population levels and in both clinical and research settings.

Breast-feeding and cardiovascular risk factors and outcomes in later life: evidence from epidemiological studies

This paper considers the body of observational evidence examining the association of being breast-fed to cardiovascular risk factors and outcomes in later life, and whether any potentially advantageous findings are causal. Early cardiovascular consequences/correlates of breast-feeding, compared to being formula fed, include markedly higher levels of total blood cholesterol, lower levels of pre-prandial blood glucose and insulin and lower levels of adiposity. However, a key issue is whether these early differences at a period of rapid development programme/influence cardiovascular risk factors and outcomes in later life. Evidence of long-term effects of early feeding, largely from observational studies, has shown that those breast-fed have lower levels of blood total cholesterol, lower risk of type-2 diabetes and marginally lower levels of adiposity and blood pressure in adult life. There is no strong evidence to suggest effects of early feeding on adult levels of blood glucose, blood insulin and CHD outcomes, although further data are needed. However, the influence of confounding factors, such as maternal body size, maternal smoking and socio-demographic factors, and exclusivity of early feeding on these potentially beneficial associations needs to be considered before inferring any causal effects. Moreover, fewer studies have examined whether duration of exclusive breast-feeding has a graded influence on these risk factors and outcomes; such data would help further in deciding upon causal associations. While strong observational evidence suggests nutritional programming of adult cholesterol levels, associations with other markers of cardiometabolic risk and their consequences in later life need to be confirmed in well-conducted observational and experimental studies.

Toddlers get slimmer while adolescents get fatter--BMI distribution in five birth cohorts from four decades in Finland

AIM

To investigate the trends in the size of Finnish children in five birth cohorts from four decades.

METHODS

This is a retrospective longitudinal growth pattern study on children representing five birth cohorts: 1974, 1981, 1991, 1995 and 2001 from the city of Tampere and three rural municipalities. Growth data were collected from birth to 15 years of age, except in birth cohorts 1995 and 2001 until 12 and 5 years. Body mass index (BMI, kg/m²) was calculated. Pearson's chi-square test was used in analysis.

RESULTS

The 50th percentile of BMI at birth varied between the 1970's and 2000's (boys: p<0.001, girls: p=0.02), with increase seen in girls. The 50th BMI percentile remained unchanged in 6-month-aged boys, whereas in girls, it varied inconsistent (p=0.04). At 1 and 2 years of age, the 15th, 50th, 85th and 95th BMI percentiles decreased (p=0.26 to <0.001). The 50th BMI percentile remained fairly constant at 5 and 7 years of age. In 12- and 15-year-old boys, the 50th, 85th and 95th percentiles of BMI showed a marked increase (p=0.01 to <0.001). In 12-year-old girls, only the 85th BMI percentile increased (p=0.03).

CONCLUSIONS

During the last three decades, Finnish toddlers have become markedly slimmer. Concurrently, an opposite change has taken place in adolescent boys.

High sucrose intake is associated with poor quality of diet and growth between 13 months and 9 years of age: the special Turku Coronary Risk Factor Intervention Project

BACKGROUND

Previous studies have suggested that interventions to lower dietary fat content and improved fat quality lead to a compensatory increase in sucrose content.

OBJECTIVE

The purpose of this work was to determine what associations exist between sucrose intake and intake of nutrients, intake of specific foods, and growth in children aged 13 months to 9 years of age in the prospective, randomized Special Turku Coronary Risk Factor Intervention Project.

SUBJECTS AND METHODS

Nutrient intake and food consumption were evaluated annually at ages 13 months through 9 years by using food records. Altogether, 543 children were divided into 3 groups according to mean sucrose intake: constantly high sucrose intake (highest 10%), constantly low sucrose intake (lowest 10%), and average sucrose intake (80%). Absolute and relative weights and heights were recorded at 7, 13, and 24 months of age and annually thereafter until 9 years old.

RESULTS

The high sucrose-intake group exceeded the recommended sucrose intake (<10% of energy intake, World Health Organization) already at the age of 2 years. Energy and total fat intake did not differ between the sucrose-intake groups. Children with low and average sucrose intake consumed more protein and had a better dietary fat quality than children with high sucrose intake. They also tended to receive more vitamin E, niacin, calcium, iron, zinc, and dietary fiber than children who consumed a high sucrose diet. Children in the low sucrose-intake group consumed more grains, vegetables, and dairy products than the other children. Sugar intake had no direct association with obesity, but weight, height, and BMI of children differed between the sucrose-intake groups between 7 months and 9 years of age.

CONCLUSIONS

In children aged 13 months to 9 years, long-term low sucrose intake is associated with better nutrient intake and growth than high sucrose intake.

Therapeutic Lifestyle Changes and Pharmaceutical Care in the Treatment of Dyslipidemias in Adults

OBJECTIVE

To review each therapeutic lifestyle change (TLC) component listed in the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) cholesterol guidelines and discuss how the guidelines can be used by pharmacists in the treatment of patients with dyslipidemias.

DATA SOURCES

Published guidelines and abstracts identified through PubMed (May 1987-March 2004), Medline (January 1966-March 2004), using the search terms cholesterol, hypercholesterolemia, dyslipidemia, hyperlipidemia, diet, saturated fats, unsaturated fats, trans-fatty acids, overweight, obese, exercise, physical activity, program adherence, and guidelines; as well as the NCEP ATP III guidelines, the 2004 ATP III update, National Heart, Lung, and Blood Institute Obesity Guidelines, and Dietary Guidelines for Americans 2005.

STUDY SELECTION

Performed manually by author.

DATA EXTRACTION

Performed manually by author.

DATA SYNTHESIS

TLC components are recommended in the NCEP ATP III guidelines for treatment of patients with dyslipidemias independent of medication use. Dietary modifications are the primary focus of TLC therapy. Saturated fat intake should be limited to less than 7% of total caloric intake and trans-fatty acid intake should be low for patients with dyslipidemias. Persons who are overweight or obese with dyslipidemias should reduce body weight through a combination of physical activity, total calorie reduction, and behavior therapy modifications.

CONCLUSION

Pharmacists, given the proper training, can be effective at offering preventive pharmaceutical care for decreasing high blood cholesterol and the risk for coronary heart disease through patient counseling on TLC components as well as drug therapy in patients with dyslipidemias.

Risk factors for coronary heart disease in children and young adults

This review covers two ongoing studies in Finland: the Cardiovascular Risk in Young Finns study, which started in 1978, and the Special Turku Coronary Risk Factor Intervention Project for Children (STRIP), which started in 1989. In the cross-sectional Cardiovascular Risk in Young Finns study, cardiovascular risk factors were first assessed in 1980 in 3596 children and adolescents covering ages between 3 and 18 y at 3-y intervals. The latest follow-up examination was performed in 2001, when risk factors and early markers of atherosclerosis in carotid and brachial arteries were examined in 2264 subjects from the original cohorts, now covering ages from 24 to 39 y. The results clearly show that an individual's coronary heart disease (CHD) risk factor profile is regulated by early lifestyle-related factors and that exposure to risk factors in childhood induces changes in arteries that contribute to the development of atherosclerosis in adulthood. In the STRIP study, 1062 infants were randomized into an intervention group (n = 540; low-saturated-fat, low-cholesterol diet) or a control group (n = 522) at 7 mo of age. Fat, saturated fat and cholesterol intakes have been lower, while the polyunsaturated to saturated fat ratio has been higher in the intervention children than in the control children throughout the ongoing trial. During the first 7 y of life, serum cholesterol concentration was 0.2-0.3 mmol/l lower in the intervention boys than in the control boys, but the difference was negligible in girls. Neurological development of the intervention children at age 5 y was at least as good as that of the control children. Counselling had no effect on children's growth.

Position of the American Dietetic Association: Dietary guidance for healthy children ages 2 to 11 years

It is the position of the American Dietetic Association that children ages 2 to 11 years should achieve optimal physical and cognitive development, attain a healthy weight, enjoy food, and reduce the risk of chronic disease through appropriate eating habits and participation in regular physical activity. The health status of American children has generally improved over the past three decades. However, the number of children who are overweight has more than doubled among 2- to 5-year-old children and more than tripled among 6- to 11-year-old children, which has major health consequences. This increase in childhood overweight has broadened the focus of dietary guidance to address children's over consumption of energy-dense, nutrient-poor foods and beverages and physical activity patterns. Health promotion will help reduce diet-related risks of chronic degenerative diseases, such as cardiovascular disease, type 2 diabetes, cancer, obesity, and osteoporosis. This position paper reviews what US children are eating and explores trends in food and nutrient intakes as well as the impact of school meals on children's diets. Dietary recommendations and guidelines and the benefits of physical activity are also discussed. The roles of parents and caregivers in influencing the development of healthy eating behaviors are highlighted. The American Dietetic Association works with other allied health and food industry professionals to translate dietary recommendations and guidelines into achievable, healthful messages. Specific recommendations to improve the nutritional well-being of children are provided for dietetics professionals, parents, and caregivers.

Clinical practice guidelines for managing dyslipidemias in kidney transplant patients: a report from the Managing Dyslipidemias in Chronic Kidney Disease Work Group of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative

The incidence of cardiovascular disease (CVD) is very high in patients with chronic kidney (CKD) disease and in kidney transplant recipients. Indeed, available evidence for these patients suggests that the 10-year cumulative risk of coronary heart disease is at least 20%, or roughly equivalent to the risk seen in patients with previous CVD. Recently, the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (K/DOQI) published guidelines for the diagnosis and treatment of dyslipidemias in patients with CKD, including transplant patients. It was the conclusion of this Work Group that the National Cholesterol Education Program Guidelines are generally applicable to patients with CKD, but that there are significant differences in the approach and treatment of dyslipidemias in patients with CKD compared with the general population. In the present document we present the guidelines generated by this workgroup as they apply to kidney transplant recipients. Evidence from the general population indicates that treatment of dyslipidemias reduces CVD, and evidence in kidney transplant patients suggests that judicious treatment can be safe and effective in improving dyslipidemias. Dyslipidemias are very common in CKD and in transplant patients. However, until recently there have been no adequately powered, randomized, controlled trials examining the effects of dyslipidemia treatment on CVD in patients with CKD. Since completion of the K/DOQI guidelines on dyslipidemia in CKD, the results of the Assessment of Lescol in Renal Transplantation (ALERT) Study have been presented and published. Based on information from randomized trials conducted in the general population and the single study conducted in kidney transplant patients, these guidelines, which are a modified version of the K/DOQI dyslipidemia guidelines, were developed to aid clinicians in the management of dyslipidemias in kidney transplant patients. These guidelines are divided into four sections. The first section (Introduction) provides the rationale for the guidelines, and describes the target population, scope, intended users, and methods. The second section presents guidelines on the assessment of dyslipidemias (guidelines 1-3), while the third section offers guidelines for the treatment of dyslipidemias (guidelines 4-5). The key guideline statements are supported mainly by data from studies in the general population, but there is an urgent need for additional studies in CKD and in transplant patients. Therefore, the last section outlines recommendations for research.

A summary of results of the Dietary Intervention Study in Children (DISC): lessons learned

Prevention of cardiovascular disease must begin in childhood, preferably before risk factors develop. Elevated low-density lipoprotein cholesterol levels in children are likely to track over time and become high-risk levels in adults. The Dietary Intervention Study in Children (DISC) was a multicenter, collaborative randomized trial in pre-adolescent children designed to test the efficacy and safety of a dietary intervention to lower saturated fat and cholesterol intake among growing children with elevated low-density lipoprotein cholesterol. Numerous DISC results, which include findings on lipids-lipoproteins, genetics, and nutrient adequacy, as well as descriptions of the behavioral intervention strategies, have been reported. A summary of practical findings and their potential clinical applications have not previously been published. Highlights of key lessons learned from DISC and translational applications of potential interest to nurses and other health care providers are presented.

Therapeutic lifestyle change and Adult Treatment Panel III: evidence then and now

The Third Report of the National Cholesterol Education Program's Adult Treatment Panel (ATP III) has an extensive section on nonpharmacologic therapy for those with abnormal blood lipids. ATP III focused on the high-saturated fat atherogenic diet, obesity, and sedentary lifestyle and recommended a program of therapeutic lifestyle change (TLC). This review discusses several issues, including 1) why ATP III changed from the Step I and Step II diets to TLC; 2) the benefits of keeping trans fatty acid intake low and the addition of viscous fiber and plant stanol/sterol esters to reduce low-density lipoprotein cholesterol beyond that seen with the Step II diet; 3) the de-emphasis on total fat and a sharper focus on the kinds of fat ingested in the new guidelines; 4) the endorsement of regular physical activity and weight loss as important first steps in reversing the unwanted metabolic effects of the metabolic syndrome; and 5) the emphasis of health-promoting aspects of the diet that include, among other things, fish and omega-3 fatty acids. At all stages of TLC, ATP III encourages the referral to registered dietitians or other qualified nutritionists for medical nutrition therapy. TLC and the ATP III guidelines should provide guidance to practitioners who wish to get low-density lipoprotein cholesterol to goal (whether or not drugs are used), prevent or treat the metabolic syndrome, and improve the overall health of the patient.

Should pediatric patients with hyperlipidemia receive drug therapy?

Hyperlipidemia is now established as a major risk factor for causation of coronary heart disease (CHD) in adults; however, there is much debate on the level of coronary risk at which lipid-lowering drugs should be used. These issues of possible harm or lack of benefit from long-term use of lipid-lowering therapy, and cost effectiveness, are also pertinent in the pediatric setting. Evidence from several countries indicates that children have an increasing prevalence of obesity, hyperlipidemia and type 2 diabetes mellitus. Children who have high serum lipids 'track' these increased levels into adulthood. In some countries there is a trend to screen children for hypercholesterolemia. Family history itself is a poor discriminator in determining which children need to be screened and treated. Estimation of apolipoprotein B and/or apolipoprotein E genotype can improve prediction. Measuring high density lipoprotein cholesterol also helps, but obesity appears to be the best marker for screening children at high risk. These considerations should not cloud the need for case finding and treatment of children with genetic disorders. Low fat diets have been shown to be well tolerated and effective in children; however, there are no major long-term studies demonstrating harm or benefit in those on lipid-lowering drugs. Nevertheless, concerns regarding the psychological effect and the theoretical metabolic effects of long-term lipid lowering remain. Lipid-lowering drugs should be generally restricted to children with genetic disorders of lipid metabolism. Children with diabetes mellitus, hypertension or nonlipid-related inherited disorders leading to premature CHD in adults should be treated with diet, and with lipid-lowering drugs when they reach adulthood. Children with secondary hyperlipidemia should be assessed individually. A number of drugs and nutriceuticals are available for use in children, but only a few drugs are licensed for use in children.

Nutrient requirements for preterm infant formulas

Achieving appropriate growth and nutrient accretion of preterm and low birth weight (LBW) infants is often difficult during hospitalization because of metabolic and gastrointestinal immaturity and other complicating medical conditions. Advances in the care of preterm-LBW infants, including improved nutrition, have reduced mortality rates for these infants from 9.6 to 6.2% from 1983 to 1997. The Food and Drug Administration (FDA) has responsibility for ensuring the safety and nutritional quality of infant formulas based on current scientific knowledge. Consequently, under FDA contract, an ad hoc Expert Panel was convened by the Life Sciences Research Office of the American Society for Nutritional Sciences to make recommendations for the nutrient content of formulas for preterm-LBW infants based on current scientific knowledge and expert opinion. Recommendations were developed from different criteria than that used for recommendations for term infant formula. To ensure nutrient adequacy, the Panel considered intrauterine accretion rate, organ development, factorial estimates of requirements, nutrient interactions and supplemental feeding studies. Consideration was also given to long-term developmental outcome. Some recommendations were based on current use in domestic preterm formula. Included were recommendations for nutrients not required in formula for term infants such as lactose and arginine. Recommendations, examples, and sample calculations were based on a 1000 g preterm infant consuming 120 kcal/kg and 150 mL/d of an 810 kcal/L formula. A summary of recommendations for energy and 45 nutrient components of enteral formulas for preterm-LBW infants are presented. Recommendations for five nutrient:nutrient ratios are also presented. In addition, critical areas for future research on the nutritional requirements specific for preterm-LBW infants are identified.

Dietary patterns and nutrient intakes of 7-year-old children taking part in an atherosclerosis prevention project in Finland

OBJECTIVE

To evaluate the dietary patterns of 7-year-old children participating in an atherosclerosis prevention project and the relationship of those dietary patterns to nutrient intakes and serum cholesterol values.

DESIGN

In the randomized, prospective Special Turku Coronary Risk Factor Intervention Project (STRIP) 1,062 children were randomly assigned to an intervention group (n=540; low-saturated fat, low-cholesterol diet) or to a control group (n=522; unrestricted diet) at 7 months of age.

SUBJECTS/SETTINGS

The intervention families received, at 6-month intervals, individualized counseling that focused on the known environmental atherosclerosis risk factors and aimed at reducing children's saturated fat and cholesterol intake. Nutrition counseling was targeted at the child but, because of the young age of the children, was given to the parents. When children were 7 years old, food and nutrient intakes of 307 intervention and 323 control children were studied using 4-day food records.

STATISTICAL ANALYSES PERFORMED

K-means cluster analysis was used to classify children into 4 groups on the basis of similarity of food intake. Differences in nutrient intakes and serum lipid concentrations between children in the 4 food intake clusters were evaluated using Tukey's multiple comparison test.

RESULTS

Intervention children dominated the bread, skim milk, and margarine cluster and the cereals, rice, and pasta cluster whereas the 1.5%-fat milk and butter cluster included mainly control children. Saturated fat intake was nearest to the recommendations, that is 11.7% and 11.9% of energy, in the bread, skim milk, and margarine cluster and the cereals, rice, and pasta cluster, respectively. Children in the bread, skim milk, and margarine cluster had 20% to 27% higher fiber intakes (P<.001) whereas children in the sugar and sweets cluster had markedly higher sugar intakes than children in other clusters (P<.001). Serum cholesterol concentrations were lower in those clusters with high dietary ratios of polyunsaturated to saturated fat.

CONCLUSION

Detailed and repeated dietary counseling of parents, starting when children are aged 7 months, that aims at decreasing children's exposure to known nutrition risk factors for coronary heart disease modifies children's food patterns and nutrient intakes toward expected values.

Dietary fat intakes in infants and primary school children in Germany

We report dietary fat intake data in groups of infants and children in Germany. A group of 148 healthy infants was followed prospectively from birth through the first year of life. After birth, 78.9% of infants were breast-fed; 50% were breast-fed at 3 mo and 9. 8% were breast-fed at 12 mo. Infant formula was given to 22% of infants after birth, 53% at 3 mo, and 58% at 12 mo. Complementary foods were consumed by 16% of infants at 3 mo, 97% at 6 mo, and 98-100% at 7-12 mo. In non-breast-fed infants, mean dietary fat intakes were 44.8%, 42.9%, 37.4%, and 35.7% of energy intake at the ages of 1, 4, 6, and 12 mo, respectively. Calculated energy and nutrient intakes were within recommended ranges and weight gain was normal. Therefore, we see no compelling reason to actively modify total fat intakes at this age. In 158 primary school children aged 6-11 y, 7-d checklist protocols showed 41% of energy intake as fat with approximately 50% as saturated fat. Because German children of this age are experiencing increasing rates of obesity and high serum cholesterol concentrations, a stepwise reduction of total fat and saturated fat intakes in primary school children appears desirable to improve long-term health.

Prospective, randomized, infancy-onset trial of the effects of a low-saturated-fat, low-cholesterol diet on serum lipids and lipoproteins before school age: The Special Turku Coronary Risk Factor Intervention Project (STRIP)

BACKGROUND

We showed previously that repeated dietary counseling during the first 3 years of life reduces the concentration of serum nonfasting cholesterol. We have now extended the study to children 5 years of age and analyzed fasting blood samples, enabling LDL cholesterol calculations for the first time.

METHODS AND RESULTS

Families of 7-month-old infants (n=1062) were randomized to a control group (n=522) or an intervention group (n=540) that received individualized dietary counseling with the aims of a fat intake of 30% to 35% of daily energy, a saturated/monounsaturated/polyunsaturated fatty acid ratio of 1:1:1, and a cholesterol intake of <200 mg/d. Nutrient intakes were studied biannually, nonfasting serum lipid values were studied annually, and fasting values were studied at 5 years of age. The intervention children always had lower intakes of saturated fat and cholesterol than the control children. The intervention boys had 0.39 mmol/L (P:<0.0001) lower mean serum cholesterol values than the control boys between 13 and 60 months of age, but among girls, the difference was of marginal significance (0.15 mmol/L, P:=0.052). Five-year-old intervention boys had 9% lower mean serum LDL cholesterol concentrations than the control boys (P:=0.0002; 95% CI, -0.39 to -0.12 mmol/L), whereas no difference was observed in girls. In both sexes, serum triglyceride concentrations were similar in the 2 groups.

CONCLUSIONS

The restriction of saturated fat and cholesterol intake by repeated, individualized dietary counseling since infancy resulted in lower serum total and LDL cholesterol concentrations at 5 years of age. However, the effect was significant only in boys.

Changing eating and physical activity patterns of US children

The number of US children who are overweight has more than doubled over the last decade. This change has broadened the focus of dietary guidance for children to address nutrient overconsumption and physical activity patterns. Total fat consumption expressed as a percentage of energy intake has decreased among US children. However, this decrease is largely the result of increased total energy intake in the form of carbohydrates and not necessarily due to decreased fat consumption. The majority of children aged 5-17 years are not meeting recommendations for Ca intakes. Much of this deficit is attributed to changing beverage consumption patterns, characterized by declining milk intakes and substantial increases in soft-drink consumption. On average, US children are not eating the recommended amounts of fruits and vegetables. US adolescents become less active as they get older, and one-quarter of all US children watch > or = 4 h television each day, which is positively associated with increased BMI and skinfold thickness. There is an urgent need in the USA for effective prevention strategies aimed at helping children grow up with healthful eating and physical activity habits to achieve optimal health.

Growth and nutrition of Hong Kong children aged 0-7 years

OBJECTIVE

To study the early dietary practices in relation to growth of Hong Kong children from birth to 7 years.

METHODOLOGY

One hundred and seventy-three full-term Hong Kong Chinese babies were recruited at birth and were followed up for anthropometric measurements using standardized methods and dietary assessment using a combination of dietary history, 24 h recall and food frequency. At 7 years, 125 children remained in the study.

RESULTS

Mean (SD) birthweight was 3.3 (0.38) kg for boys and 3.1 (0.38) kg for girls. Mean (SD) weight at 7 years was 22.4 (4.2) kg for boys and 21.1 (3.7) kg for girls, and mean (SD) height was 120.3 (4.8) cm for boys and 119.8 (5.1) cm for girls. Hong Kong children were lighter and shorter than Australian children and the National Centre for Health Statistics (NCHS) references, but the magnitude is less than one standard deviation score. Mean weight and height of Hong Kong children were lower compared to Caucasian and Beijing children, with more obvious differences between 1 and 5 years. At 1 year, mean (SD) daily energy intake was 98 (24) kcal/kg/day for boys and 100 (26) kcal/kg/day for girls. By 7 years, it decreased to 82 (18) kcal/kg/day for boys and 73 (22) kcal/kg/day for girls. Between 2 to 4 years of age the energy intake of studied children were slightly lower than the Australian and Finnish children, but the protein intake was higher. Percentage of fat contributing to total daily energy intake was lower throughout at a level of 30%. Such differences in diet reflect a lower consumption of milk fat, higher consumption of meat and lower level of physical activity in Hong Kong children. Intakes of calcium, iron and vitamin C all reached 60% or above of US recommended daily allowance.

CONCLUSIONS

The smaller body build of Chinese compared to Caucasians cannot be explained by dietary differences. The diet of Hong Kong children is changing to one which is more Westernized with a higher consumption of animal products.

Macronutrient and energy intakes in young children fed milk products containing different quantities and qualities of fat and protein

BACKGROUND

Milk is the major source of protein and saturated fats in the diet after infancy. In the present study, the effects of different fat and protein quantity as well as fat quality in milk and dairy products on nutrient intake and growth in young children were determined.

METHODS

Thirty-eight healthy children were randomly assigned to one of four feeding groups at 12 months of age: 1) Low-fat milk (1.0 g fat/dl, 3.3 g protein/dl); 2) standard-fat milk (3.5 g fat/dl, 3.3 g protein/dl); 3) partially vegetable fat and protein-reduced milk (3.5 g fat/dl, 50% vegetable; 2.2 g protein/dl); and 4) full-vegetable-fat milk (3.5 g fat/dl, 100% vegetable; 3.0 g protein/dl). Nutrient intake and growth were measured at 12, 15, and 18 months.

RESULTS

The protein intake was significantly reduced with the protein-reduced milks. The intake of saturated fat was significantly lower with low-fat milk (11% of energy) or milks containing vegetable fat (13%) than in standard-fat milk (19.6%). However, the total fat intake was below 30% of energy in low-fat milk, whereas the total fat intake remained more than 30% in the other groups. Energy intake and growth were similar in all groups.

CONCLUSIONS

A modified milk with reduced protein content for young children results in protein intakes closer to recommendations. A modified milk with either 50% or 100% vegetable fat and dairy products with low milk fat and high vegetable fat content results in intakes of total and saturated fats closer to international recommendations, compared with standard or low-fat milk and dairy products.

Influence of dietary fat on the nutrient intake and growth of children from 1 to 5 y of age: the Special Turku Coronary Risk Factor Intervention Project

BACKGROUND

Excessive decreases in fat intake in young children have been linked with low intakes of energy and nutrients and possible growth failure.

OBJECTIVE

We evaluated nutrient intakes and growth of healthy children with different fat intakes during the first 5 y of life.

DESIGN

In the Special Turku Coronary Risk Factor Intervention Project (STRIP), 7-mo-old children were randomly assigned to an intervention aimed at reduced consumption of saturated fat and cholesterol (n = 540) or to a control group (n = 522). This analysis comprises data for children for whom > or = 6 of 8 possible 3-4-d food records were available (n = 730; 353 females). Children were divided according to fat intake pattern (percentage of energy) between the ages of 13 mo and 5 y into groups with continuously high fat intake (5% of children), increasing fat intake (5%), continuously low fat intake (5%), decreasing fat intake (5%), and average fat intake (80%). Children's energy and nutrient intakes and growth were then compared by analysis of variance.

RESULTS

Fat intake at 13 mo of age was particularly low (21% of energy) in the increasing fat intake group and in the continuously low fat intake group (22% of energy at 13 mo; 26% of energy at 5 y). Growth of children in all 5 fat intake groups, however, was not significantly different throughout the study period. Intakes of vitamins and minerals, except of vitamin D, met recommended dietary allowances in all fat intake groups.

CONCLUSION

Nutrient intakes and growth were not significantly different in children whose fat intake patterns differed between 13 mo and 5 y of age.

Cardiovascular disease risk factors in young children in the STRIP baby project

Introducing nutritional principles of preventive cardiology to the care of young children may improve permanently adherence to a low-saturated-fat, low-cholesterol diet later in life. This approach has not been readily adapted because of worries of the possible effects of such a diet on the growth and development of children. In the STRIP baby project, 1062 infants were randomized at 7 months of age into an intervention group (n = 540) or a control group (n = 522). The counselling of the intervention children aimed at a fat intake of 30% of energy after the age of 1 year and to a 1:1:1 ratio in saturated:monounsaturated:polyunsaturated fat intake. Dietary intake, growth and serum lipid concentrations were monitored in the children regularly through the first years of life. The intake of total fat, saturated fat and cholesterol were lower and the intake of polyunsaturated fat and the ratio of polyunsaturated to saturated fat (P/S) in the diet were higher in the intervention children than in the controls. During the first 3 years of the trial, the serum cholesterol concentration was 3-6% lower in the intervention children than in the controls (95% CI for the mean difference between groups from -0.27 to-0.12 mmol/L). No differences in the growth of the children were observed between the groups. We conclude that repeated individualized counselling aiming at reduced consumption of saturated fat combined with regular follow-up is effective and does not restrict the growth of children.

The role of dietary polyunsaturated fatty acids during the first 2 years of life

The early dietary supply of long-chain polyunsaturated fatty acids (LCPUFA) might contribute to the higher developmental scores of children breast-fed as infants. Preterm infants' improved visual acuity and neurodevelopmental performance correlate with dietary supplementation of LCPUFA in amounts similar to those that breast-fed infants receive and studies of term infants report similar effects with LCPUFA supplementation. Whether term infants may benefit from LCPUFA-unsupplemented formulas with higher amounts of alpha-linolenic acid (n - 3 LCPUFA precursor) is controversial. With the onset of weaning, the question of the exact quantity and quality of which dietary lipids to give for prevention purposes is still open. Early dietary intervention studies of weaned children under 2 years are in progress in populations at high risk for early cardiovascular disorders. Preliminary results indicate that these interventions, while preventing an age-dependent increase in blood lipid levels, are safe for growth, but the balance of all the macronutrients should be carefully considered before general recommendations can be made.

Dietary fat consumption and health

Dietary Guidelines have emerged over the past 30 years recommending that Americans limit their consumption of total fat and saturated fat as one way to reduce the risk of a range of chronic diseases. However, a low-fat diet is not a no-fat diet. Dietary fat clearly serves a number of essential functions. For example, maternal energy deficiency, possible exacerbated by very low-fat intakes (< 15% of energy), is one key determinant in the etiology of low birth weight. The debate continues over recommendations for limiting total fat and saturated fatty acid intake in children. Recent evidence indicates that diets with adequate energy providing less than 30% of energy from fat are sufficient to promote normal growth and normal sexual maturation. More attention needs to be devoted to the effect of dietary fat reduction on the nutrient density of children's diets. The association between dietary fat and CHD has been extensively studied. Diets high in saturated fatty acids and trans fatty acids increase LDL cholesterol levels, and in turn, the risk of heart disease. The relationship between high-carbohydrate/low-fat diets and CHD is more ambiguous because high-carbohydrate diets induce dyslipidemia in certain individuals. Obesity among adults and children is now of epidemic proportions in the United States. High-fat diets leading to excessive energy intakes are strongly linked to the increasing obesity in the United States. However, the prevalence of obesity has increased during the same time period that dietary fat intake (both in absolute terms and as a percentage of total dietary energy) has decreased. These trends suggest that a concomitant decrease in total dietary energy and modifications of other lifestyle factors, such as physical activity, also need to be emphasized. Obesity is also an independent risk factor for the development of diabetes. The current availability of fat-modified foods offers the potential for dietary fat reduction and treatment of the comorbidities associated with diabetes. However, to date, few studies have documented the effectiveness of fat-modified foods as part of a weight loss regimen or in reduction in CHD risks among individuals with diabetes mellitus. The association between total dietary fat and cancer is still under debate. While there is some evidence demonstrating associations between dietary fat intake and cancers of the breast, prostate, and colon, there are serious methodologic issues, including the difficulty in differentiating the effects of dietary fat independent of total energy intake. Reported total fat and saturated fatty acid intakes as a percentage of total energy have been declining over the past 30 years in the United States. Despite this encouraging trend, the majority of individuals--regardless of age--do not report consuming a diet that meets the levels of fat and saturated fatty acids recommended by the Dietary Guidelines for Americans. On a relative basis, saturated fat intake has gone down less than has total fat intake. Individuals of all ages who report consuming a diet with < or = 30% of energy from fat consistently have lower energy intakes. Given the increasing rates of obesity in the United States at an earlier and earlier age, dietary fat reduction may be an effective part of an overall strategy to balance energy consumption with energy needs. In each of the age/gender groups reporting consumption of < or = 30% of energy from fat and less than 10% of energy from saturated fatty acids, fat-modified foods play a more important role in their diets than for people who are consuming higher levels of fat and saturated fat. The data are clear than fat-modified foods make a more significant contribution to diets of consumers with low-fat intakes. While one cannot argue cause and effect from the results presented, the patterns of fat-modified foods/low-fat intakes are consistent. The focus on overall diet quality is often lost in the national obsession with lowering fat inta

Regulation of growth of 7- to 36-month-old children by energy and fat intake in the prospective, randomized STRIP baby trial

OBJECTIVE

To study the fat and energy intakes of children between 7 and 36 months of age with different growth patterns.

METHODS

In the Special Turku coronary Risk factor Intervention Project for Babies, children were randomized to intervention (n = 540) and control groups (n = 522) at age 7 months. The intervention was aimed at replacing part of the saturated fat intake with monounsaturated and polyunsaturated fat to reduce children's exposure to high serum cholesterol values. The control children consumed a free diet. Children followed for >2 years (n = 848) were included in the analysis. Five groups of children representing different extreme growth patterns during the first 3 years of life were formed, and their energy and fat intakes were analyzed. Relative weight was defined as deviation of weight in percentages from the mean weight of healthy children of same height and sex, and relative height as deviation of height in SD units from the mean height of healthy children of same age and sex.

RESULTS

Relative fat intakes (as percent of energy intake) were similar in children showing highly different height gain patterns. The thin (mean relative weight </= 5%) children consumed more fat (mean, 30% energy [ E%] [SD 7] at 13 months and 33 [4] E% at 24 months) than children with normal growth (27 [5] E% at 13 months and 31 [5] E% at 24 months). The energy intake of the tall (mean relative height >/= 95%) and the obese (mean relative weight >/= 95%) were highest, but weight-based energy intake of the tall (at 2 years, 82 [13] kcal/kg) and the obese (79 [17] kcal/kg) were lower than that of children with normal growth (89 [16] kcal/kg). The thin children consumed relatively more energy than the children with normal growth (at 2 years, 94 [13] kcal/kg and 89 [16] kcal/kg, respectively). Parental height and body mass index and the child's absolute and relative energy intakes predicted the best children's growth patterns. Children with consistently low fat intake grew equally to the children with higher fat intake.

CONCLUSIONS

Moderate supervised restriction of fat intake to values 25 to 30 E% is compatible with normal growth.