An American Health Foundation monograph. Coronary artery disease prevention: cholesterol, a pediatric perspective

Supporting healthy eating among preschoolers: challenges for child care staff

PURPOSE

The child care setting can help preschoolers develop healthy eating habits. Establishing such habits may increase preschoolers' likelihood of carrying them into adulthood, which can decrease the risk of nutrition-related chronic diseases. Challenges in supporting preschoolers' healthy eating were investigated among child care staff.

METHODS

Three focus group interviews were conducted with 29 child care staff members. Audiotapes of the sessions were transcribed.

RESULTS

Several themes were identified from the analysis of the transcripts. An intrapersonal (individual) factor was children's picky eating. Interpersonal factors (interactions) included perceptions that parents do not encourage their children to eat in a healthy way, and that child care staff's use of practices were inconsistent with health professional recommendations. Physical environment factors included perceptions that healthy food was not accessible at child care centres and that children have unhealthy food at home.

CONCLUSIONS

Program planners and health professionals can develop and implement strategies to overcome some of the identified challenges to supporting preschoolers' healthy eating.

Short-term repeatability of a food frequency questionnaire in New Zealand children aged 1–14 y

OBJECTIVE

To evaluate the repeatability of a children's food frequency questionnaire (FFQ) by gender, ethnicity, and age group.

DESIGN

A 117-item FFQ asking about food intake patterns over the past 4 weeks was developed using food records from 428 children (204 boys and 224 girls) and the reproducibility on average 13 days apart was tested in 130 children (78 boys and 52 girls). Children were recruited using clustered probability sampling (n=103), and a convenience sample of 25 Maori children.

SETTING

Children aged 1-14 y from Auckland, Feilding and Shannon, New Zealand.

SUBJECTS

There were 71 Maori, 20 Pacific, and 39 Other children.

RESULTS

Spearman correlations between the two FFQs ranged from 0.50 for bread to 0.82 for fruit, with a median of 0.76 for spreads and nonmilk drinks, and Cronbach's coefficient alpha's ranged from 0.59 for bread to 0.92 for nonmilk drinks, with a median of 0.85 for mixed meat dishes. There were no significant differences between the two administrations, apart from reporting higher intakes of vegetables and snacks & sweets in the first FFQ. Correlation coefficients tended to be slightly higher in boys than in girls, and in Other ethnic groups compared to Maori and Pacific children. Correlations were slightly higher for the 1-4 y age group, intermediate in the 10-14 y age group, and lowest in the 5-9 y-old age group.

CONCLUSIONS

Overall, the FFQ described here shows similar or better repeatability in New Zealand children of all major ethnic groups compared to other child or adolescent FFQs.

Rapid westernization of children's blood cholesterol in 3 countries: evidence for nutrient-gene interactions?

The aim of this study was to examine potential factors that modify blood cholesterol among children in countries in which dietary and lifestyle habits are becoming westernized. Population data on serum total and lipoprotein cholesterol, anthropometric indexes, and dietary intake were reviewed and compared for children aged 1-18 y from Japan, Spain, and the United States. The data show that total serum cholesterol in Japanese and Spanish children recently exceeded the 75th percentile for US children, primarily reflecting LDL cholesterol, although both LDL and HDL cholesterol contributed. Adiposity indexes do not explain the trends observed. Total and saturated fat intakes increased substantially in both Japan and Spain but in Japan are still lower than intakes in the United States. The Hegsted equation was used to relate differences in serum cholesterol to dietary fat intake. Changes in total serum cholesterol followed established dietary correlations among children in Spain, but not in Japan. Serum cholesterol in Japanese children was predicted to be 0.20-0.32 mmol/L lower than in US children; actual concentrations were considerably higher. These results suggest that a rapid westernization of children's blood cholesterol concentrations has occurred in Japan and Spain. Changes in fat intake predict changes in blood cholesterol in Spain, but not in Japan. Differences in genetic response to diet in certain populations, such as the Japanese, may explain higher blood cholesterol concentrations with lower fat intakes compared with the United States.

Fruit juice consumption and the prevalence of obesity and short stature in german preschool children: results of the DONALD Study. Dortmund Nutritional and Anthropometrical Longitudinally Designed

BACKGROUND

In recent years, a possible association between excessive consumption of fruit juice (> or =12 fl oz per day) and short stature and/or obesity has been discussed. The association among the consumption of fruit juice, anthropometric indices, and the overall diet was examined during a 3-year period in a sample of healthy preschool children participating in the Dortmund Nutritional and Anthropometrical Longitudinally Designed (DONALD) Study.

METHODS

Two hundred five children were examined annually at the ages of 3, 4, and 5 years. Dietary intake was calculated from 3-day weighed diet records. Height was measured using a stadiometer. Weight was measured using an electronic scale.

RESULTS

Five children consumed excessive fruit juice continually in all three records, 10 children in two records, and 23 children in one record. None of the five children with repeatedly excessive fruit juice consumption was obese or short. Growth velocity, body mass index, and height standard deviation score were not correlated with fruit juice consumption. Consumption of fruit juice was inversely correlated with the consumption of all other beverages and the total consumption of all other food. The intake of protein, fat, and carbohydrates of children consuming excessive fruit juice was closer to the international dietary preventive guidelines than the intake of children consuming low amounts of fruit juice.

CONCLUSIONS

In the study sample, even repeatedly excessive fruit juice consumption had no influence on anthropometric indices. The results do not justify a general warning or a general promotion regarding high fruit juice consumption in preschool children's diets.

A primary intervention program (pilot study) for Mexican American children at risk for type 2 diabetes

Many chronic diseases that are leading causes of morbidity and mortality can be prevented or controlled by primary or secondary interventions. Type 2 diabetes with its complications constitutes a major health problem, especially among Mexican Americans. The purpose of this pilot study was to develop an age- and culturally appropriate primary intervention program for Mexican American children at risk of type 2 diabetes. The sample included 37 Mexican American children ages 7 to 12 years who had at least one parent or grandparent with type 2 diabetes. A health screen of physiologic risk factors, a nutritional assessment, and a diabetes knowledge test were administered before and after the program. The eight-session activity oriented educational program focused on nutrition, exercise, and diabetes knowledge. Due to small sample size and limited study time, changes in physiologic factors and diet were not analyzed for statistical significance. Analysis of individual factors showed a trend toward more normal values. Results of this pilot program indicated that health intervention projects may be effective in helping children at risk of type 2 diabetes adopt healthier lifestyles.

Healthy Start: a comprehensive health education program for preschool children

BACKGROUND

Healthy Start is a 3-year demonstration and education research project designed to evaluate the effectiveness of a multidimensional cardiovascular (CV) risk reduction intervention in preschool centers over a 3-year period of time.

METHODS

Two primary interventions are employed. The first is the preschool food service intervention program designed to reduce the total fat in preschool meals and snacks to less than 30% of calories and reduce the saturated fat to less than 10% of calories. The second major intervention is a comprehensive preschool health education curriculum, focused heavily on nutrition.

RESULTS

Effectiveness of the intervention will be determined through evaluation of changes in dietary intake of preschool children at school meals and snacks, especially with respect to intake of total and saturated fat. Evaluation of the education component will include assessment of program implementation by teachers, assessment of changes in nutrition knowledge by preschool children, and assessment of changes in home meals that children consume (total and saturated fat content). Blood cholesterol will be evaluated semiannually to evaluate changes that may be due to modification of dietary intake. Growth and body fatness will also be assessed.

CONCLUSIONS

While substantial efforts have targeted CV risk reduction and health education for elementary school children, similar efforts aimed at preschool children have been lacking. The rationale for beginning CV risk reduction programs for preschool children is based upon the premise that risk factors for heart disease are prevalent by 3 years of age and tend to track over time, most commonly hypercholesterolemia and obesity, both related to nutrition. Since the behavioral antecedents for nutritional risk factors begin to be established very early in life, it is important to develop and evaluate new educational initiatives such as Healthy Start, aimed at the primary prevention of cardiovascular risk factors in preschool children. The purpose of this publication is to describe the rationale and methods for the Healthy Start project.

The effect of changes in dietary fat on the food group and nutrient intake of 4- to 10-year-old children

OBJECTIVE

To determine how young children changed their overall diet when they changed their fat intake after 3 months of participating in a nutrition education demonstration study designed to lower low-density lipoprotein cholesterol and cardiovascular risk.

METHODS

Three 24-hour dietary recalls were collected from 303 4- to 10-year-old children at baseline and 3 months later. At both times, mean number of servings from food groups, grams of fat contributed from food groups, and intake of calories and nutrients were calculated and compared among quartiles of children formed according to change in their percent of calories from total fat after 3 months.

RESULTS

Children who reduced their percent of calories from total fat most (ie, by an average of 8.5%) after 3 months consumed fewer servings from meats, eggs, dairy, fats/oils, and breads but tended to increase their number of servings from lower-fat foods within those food groups, particularly from dairy foods. These children also increased their mean intake of fruits, vegetables, and desserts, and maintained average intakes of all nutrients (except vitamin D) in excess of two thirds of the respective recommended dietary allowance.

CONCLUSIONS

Young children who reduced their percent of calories from total fat in accordance with the current National Cholesterol Education Program recommendations accomplished this by reducing their overall intake of higher-fat foods, replacing higher-fat foods with lower-fat foods within several food groups, particularly within the dairy group (eg, drinking skim milk instead of whole milk) and by consuming more servings of fruits, vegetables, and very-low-fat desserts. These behaviors did not compromise their mean calorie or nutrient intakes, showing that it is possible for young children to lower their fat intake safely to reduce their risk of future heart disease.

Fitness, diet and coronary risk factors in a sample of southeastern U.S. children

The purpose of this study was to evaluate the relationship between physical fitness variables and nutrient intake to coronary risk factors (CRF) in a sample of children living in the Southeastern U.S. A total of 22 sixth-grade children of whom 10 were boys (mean age = 11.83 +/- 0.3) and 12 were girls (mean age 11.7 +/- 0.3) volunteered for this study. Results indicated that boys in comparison to girls weighed more (54.0 +/- 10.8 kg versus 42.1 +/- 8.0 kg; p < 0.05), had a higher body mass index (BMI) (23.6 +/- 2.7 versus 20.2 +/- 3.3; p < 0.05), a higher lean body mass (37.8 +/- 6.0 kg versus 30.7 +/- 3.8 kg; p < 0.01), and a higher systolic blood pressure (115.7 +/- 11.1 versus 106.4 +/- 8.1; p < .0001). There were, however, no significant gender differences in serum lipoproteins or nutrient intake. Stepwise multiple regression analyses indicated that physical fitness variables which included VO2max, one-mile run for time, grip strength, and leg strength could significantly predict resting diastolic blood pressure (DBP) (F = 3.06; p < 0.05) and percent body fat (F = 4.98; p < 0.01) in children. Analysis of food intake revealed that total and saturated fat, and carbohydrate intake could predict serum triglycerides (TG) (F = 5.18; p = 0.01) while total kilocalorie, fat, and carbohydrate intake could significantly predict percent body fat (F = 3.42; p < 0.03). These findings may be clinically relevant since both serum triglyceride levels and percent body fat were well above the 50th percentile according to U.S. norms. In summary, the present study showed that measurements of muscular strength in addition to aerobic fitness are associated with DBP and percent body fat in children. Furthermore, it is recommended that nutrient intake be used when evaluating CRF in children due to its ability to predict TG and percent body fat.

Effects of an obesity prevention program on the eating behavior of African American mothers and daughters

Cardiovascular disease (CVD) is the number one cause of death in the United States. Obesity is highly related to CVD risk, especially in African American women. This study explored the efficacy of a culturally specific obesity prevention program. Designed for low-income, inner-city African American girls and their mothers, the program addressed the importance of eating a low-fat, low-cholesterol diet and increasing activity. Mother-daughter dyads were randomly assigned to a 12-week treatment or an attention placebo group. Participants were assessed at pre- and posttreatment on dietary intake, including daily fat intake, daily saturated fat intake, percentage of daily calories from fat, and daily cholesterol intake. Results showed significant differences between the treatment and control mothers for daily saturated fat intake and percentage of calories from fat. Differences among treatment and control groups were also noted for the daughters on percentage of daily calories from fat. Implications of the findings for developing culturally specific health risk reduction programs are discussed.

Lipoprotein(a) in Korean children and a history of coronary or cerebral vascular events in their older family members

The purpose of this study was to determine the relationships between serum apolipoprotein concentration and family history of coronary or cerebral events in schoolchildren. In 269 primary schoolchildren aged 6-11 years (145 boys and 124 girls) we measured the blood concentrations of total cholesterol, apolipoproteins B and A-1, and lipoprotein(a), and questioned their parents about coronary or cerebral vascular events. Serum concentrations of apo B, A-1 and Lp(a) significantly increased with age. In children with serum cholesterol concentration > 5.18 mmol/L the concentrations of apo B, A-1, Lp(a) and apo B/apo A-1 ratio were significantly higher. The concentrations of total cholesterol, apo B, Lp(a), and apo B/apo A-1 ratio in the obese group (body weight 20% above the median body weight for age and height) differed significantly from those in the non-obese group. Serum concentrations of Lp(a) in the children who had positive family histories of coronary or cerebral events (geometric mean = 0.174 x/divided by 0.036g/L) and was significantly higher than that in the children with negative history (geometric mean = 0.086 x/divided by 0.36g/L). Family history was an independent and major contributor to high Lp(a). In evaluating children's lipid profiles, measurement of Lp(a) may help to identify children and their families at increased risk and this may facilitate the targeting of preventive measures.

Guidelines for school health programs to promote lifelong healthy eating

Healthy eating patterns in childhood and adolescence promote optimal childhood health, growth, and intellectual development; prevent immediate health problems, such as iron deficiency anemia, obesity, eating disorders, and dental caries; and may prevent long-term health problems, such as coronary heart disease, cancer, and stroke. School health programs can help children and adolescents attain full educational potential and good health by providing them with the skills, social support, and environmental reinforcement they need to adopt long-term, healthy eating behaviors. This report summarizes strategies most likely to be effective in promoting healthy eating among school-age youths and provides nutrition education guidelines for a comprehensive school health program. These guidelines are based on a review of research, theory, and current practice, and they were developed by CDC in collaboration with experts from universities and from national, federal, and voluntary agencies. The guidelines include recommendations on seven aspects of a school-based program to promote healthy eating: school policy on nutrition, a sequential, coordinated curriculum, appropriate instruction for students, integration of school food service and nutrition education, staff training, family and community involvement, and program evaluation.

Relation of total homocysteine and lipid levels in children to premature cardiovascular death in male relatives

We assessed the relative importance of lipid, apo B, lipoprotein(a) [Lp(a)], and total homocysteine (tHcy) levels in children in relation to premature cardiovascular disease in family members. Parents of 381 girls and 375 boys age 8-12 y completed family history questionnaires. Nonfasting serum lipid and lipoproteins and plasma tHcy and cysteine levels were measured in the children. Serum folate and vitamin B12 levels were determined in a random subsample of 23% of the children, who participated in a food frequency interview. Children whose parents reported hypercholesterolemia had higher total and non-HDL cholesterol and apo B levels than the rest, but these levels were not associated with cardiovascular disease. tHcy levels were similar in girls and boys. tHcy was higher in children whose father, grandfather, or uncle died at age < or = 55 y of myocardial infarction or sudden cardiac arrest (n = 42) than in control children [5.92 mumol/L (95% confidence interval [CI] of 5.47-6.36) versus 5.25 mumol/L (95% CI, 5.16-5.34)], also after adjustment for socioeconomic group. Intake and serum levels of vitamin B12 and folate were within recommended or reference ranges. In a stepwise multiple regression analysis, serum folate (negative correlation), plasma creatinine, and sugar intake as percent of dietary energy (positive correlations) were significantly associated with tHcy (multiple r = 0.44, adjusted r2 = 18%; 95% CI, 5-30%). Our data show that a modest elevation in tHcy in children was related to premature cardiovascular death in their male relatives and may partly account for the contribution of family history to risk of cardiovascular disease. tHcy may be modifiable through the diet, even in children with apparently adequate vitamin nutriture.

Cholesterol levels in children: to screen or not to screen

Universal screening and targeted screening are the two approaches used in pediatric practice to identify children with elevated cholesterol levels. This study reports total cholesterol levels in 415 2-year-old children and the relationship of these results to risk factors. Based on these data, universal screening for total cholesterol (TC) does not appear to be necessary. Targeted screening for TC may be the more practical method for identifying children with dangerously high TC elevations.

From the discovery of risk factors for coronary artery disease to the application of preventive measures

Hyperlipidemia and high blood pressure have clearly evolved as major risk factors for cardiovascular diseases. High fat intake, obesity, and cigarette smoking have been shown to be root causes of such risk. Ecologic correlations and case-control studies have provided evidence that hyperlipidemia and obesity certainly have their beginnings during childhood, and that the onset of cigarette smoking at a young age escalates the risk for coronary artery disease. Thus, preventive measures will have the greatest impact when applied at an early age. In fact, several fine comprehensive school health education programs (eg, Health Ahead/Heart Smart, Know Your Body) have demonstrated that behavior can be changed and that the risk factors for heart disease can be reduced. Such programs are most cost effective when they are multifactorial in nature and address health promotion on a broad scale. Therefore, comprehensive school health education programs should be a component of national health-care reform. The investment in early health education will pay off by deterring chronic diseases in adulthood and will thus contribute to a healthier nation.

Preventive cardiology and its potential influence on the early natural history of adult heart diseases: the Bogalusa Heart Study and the Heart Smart Program

Observations from pediatric epidemiology studies over the past 20 years document that atherosclerosis and essential hypertension begin in childhood. Evidence of coronary artery disease and hypertensive cardiovascular renal disease is found and relates strongly to clinical cardiovascular risk factors. Obesity, especially central obesity, and hyperinsulinemia are commonly found, and these cluster with other risk factors. Lifestyles, such as poor eating behavior and tobacco usage, also begin early and influence cardiovascular risk. The implication from these pediatric observations is that intervention should begin early to prevent unhealthy lifestyles and encourage adoption of healthy behaviors. Where adult heart diseases pervade the major part of the United States population and other industrialized cultures, various epidemiologic strategies of prevention are needed. A high-risk, clinical approach can be applied to individuals with heart disease or to individuals with underlying risk factors and their families. Primary and secondary prevention are both important and should be implemented by primary care physicians. A population approach is also needed because of the widespread occurrence of heart disease. A public health approach to prevention can occur through health education and health promotion programs. Physicians should play a role in encouraging prevention for the general population. The future direction of Preventive Cardiology for our nation rests on educating children to adopt and maintain healthy lifestyles. The Bogalusa Heart Study has made a major contribution in providing the background information for that direction.

Guidelines for screening, evaluating, and treating children with hypercholesterolemia

Hypercholesterolemia is the most frequently identified coronary heart disease risk factor in childhood, with 25% or more of children in the United States reported to have borderline high or high levels. This article provides a summary of current recommendations for cholesterol screening, evaluation, treatment, and follow-up in the pediatric office or clinic setting. Detection and treatment of pediatric dyslipidemia, however, is only one component of preventive cardiology and should be addressed in routine well child and adolescent care along with major efforts to prevent cigarette smoking, obesity, inactivity, and hypertension.

Soluble fiber enhances the hypocholesterolemic effect of the step I diet in childhood

BACKGROUND

Psyllium, a water-soluble fiber, has been shown to have a cholesterol-lowering effect in studies of adults. A small number of studies in children have produced variable results.

METHODS

A 12-week, randomized, single-blind, placebo-controlled, parallel clinical trial was conducted to test the effectiveness of psyllium in lowering total (TC) and low-density lipoprotein cholesterol (LDL-C) in 50 healthy 2 to 11 year old children. Children with two baseline LDL-C levels > or = 110 mg/dL were invited to participate in the trial, and were randomly assigned to follow a usual Step I (Control) diet of low dietary fat, saturated fat and cholesterol, or a Step I diet enriched with psyllium. Children consumed two 1-oz boxes of cereal per day, with each box of psyllium-enriched cereal containing 3.2 g of soluble fiber, and each box of placebo cereal containing less than 0.5 g of soluble fiber.

RESULTS

Greater reduction of total and LDL-cholesterol, and increase in HDL-cholesterol were noted after 12 weeks of the psyllium-enriched Step I diet compared to the Step I control diet. Total cholesterol decreased 21 mg/dL for the high fiber group compared with 11.5 mg/dL for the control group. LDL-C decreased 23 mg/dL for the high fiber group compared with 8.5 mg/dL for the control group. HDL-C increased 4 mg/dL for the high fiber group compared with 1 mg/dL for the controls. TC/HDL and LDL/HDL ratios decreased significantly more so for the high fiber group as well.

CONCLUSIONS

In this 12-week study, soluble fiber (psyllium) provided added benefit to the Step I diet in the treatment of hypercholesterolemia.

Health promotion in schools: policies and practices in Stockholm county, 1990

A survey was undertaken of the policies and practices concerning organisation and implementation of health education and health promotion in schools in 151 of the total 213 Local Educational Areas (LEAs) in Stockholm county in 1990. Health education was included in the workplan of 49% of the responding LEAs, while 39% of respondents had a local action programme or guidelines for health education. Topic areas taught to all pupils and considered most important included alcohol, drug abuse, smoking, sex education, bullying, nutrition and physical exercise. Most senior level schools (55-83%) had written policies concerning pupils using alcohol, drugs or smoking in school, and 68% of LEAs had restrictions on staff smoking in school. Continuing health education was desired by 87% of the respondents. A written programme/plan regarding health education was identified as an important indicator of interest and commitment in health education and health policy issues by the local school.

Cholesterol screening and family history of vascular disease

Hypercholesterolaemia is a major risk factor for the development of coronary heart disease (CHD). Early detection and management of hypercholesterolaemia could retard the atherosclerotic process. Given that CHD and hypercholesterolaemia cluster within families, a screening strategy based on a family history of vascular disease has been advocated. Serum total cholesterol concentrations were measured in a random stratified sample of 1012 children aged from 12-15 years old participating in a coronary risk factor surveillance study in Northern Ireland. Information about vascular disease in close family members was obtained by means of a questionnaire. The study population was divided into two groups according to total cholesterol values: (i) normal, < 5.2 mmol/l (n = 822) and (ii) raised, > or = 5.2 mmol/l (n = 190). A family history identified 63 out of 190 individuals with hypercholesterolaemia yielding a sensitivity of 33.2% and specificity of 71.5%. Our data indicated that a strategy whereby only children from high risk families are screened for hypercholesterolaemia is ineffective. While primary prevention emphasising a healthy diet for all is essential, the role of universal screening deserves further appraisal.

Should children or young adults be screened for serum lipid levels to prevent adult coronary heart disease? Experience from the Cardiovascular Risk in Young Finns study

Coronary heart disease (CHD) has its origin in childhood. High cholesterol levels measured in children and adolescents are indicative of concurrent atherosclerotic changes and probably predict adult coronary heart disease. We review here the relevance of screening children, adolescents or young adults for serum lipid levels in order to efficiently prevent premature adult coronary heart disease. Data is presented in the light of the large Cardiovascular Risk in Young Finns study and other studies. The authors do not recommend universal screening strategies because of (i) the limited predictive power of serum lipid levels on an individual level, (ii) the limited knowledge on the safety of interventive measures on the growing child, and (iii) the limited knowledge on the ethical aspects of screening (labelling). However, the importance of measuring serum lipids to detect familial dyslipidaemic disorders such as familial hypercholesterolaemia, is stressed. The selection of children or adolescents for serum lipid measurements should be made on the basis of family history of early CHD or dyslipidaemia.

Age and gender specific serum lipid and apolipoprotein fractiles of Finnish children and young adults. The Cardiovascular Risk in Young Finns Study

We present fractile data on serum lipids and apolipoproteins A-l and B for children and young adults from the cardiovascular risk in young Finns study cohort of 1986. The sample comprised 2370 fasting children and young adults (1114 males and 1256 females) aged 9, 12, 15, 18, 21 and 24 years. The determinations were performed in duplicate with standard methods. LDL-cholesterol values were calculated. The limits for clearly pathological values (exceeding the 97.5th percentile) irrespective of age and gender were 7.5 mmol/l, 5.0 mmol/l, 3.5 mmol/l and 1.4 g/l for serum total cholesterol, LDL-cholesterol, triglycerides and apolipoprotein B, respectively. Corresponding values (below the 2.5th percentile) for HDL-cholesterol, apolipoprotein A-l, HDL2- and HDL3-cholesterol were 0.80 mmol/l, 1.0 mg/l, 0.20 mmol/l and 0.70 mmol/l, respectively. Approximately 79%, 33% and 7% of males had serum total cholesterol values greater than 4.0 mmol, 5.0 mmol/l and 6.0 mmol/l, respectively. Corresponding percentages for females were 87%, 43% and 10%. However, age-related differences were marked. The prevalence of values, e.g. greater than 6 mmol/l according to age, ranged from 6 to 13% in females and from 3 to 12% in males, emphasizing the need for age-specific reference values. Additionally, postpubertal values for total and LDL-cholesterol tended to be slightly lower compared to prepubertal values, indicating that the reference values for adults do not apply to adolescents and young adults. The age-related changes in lipid levels were evident in each fractile and were especially accentuated in higher fractiles. Fluctuations with age were more pronounced in males than in females. These results are intended to be applied as reference values for diagnosing dyslipidemias.

Longitudinal tracking of adolescent smoking, physical activity, and food choice behaviors

OBJECTIVES

A major assumption underlying youth health promotion has been that physiological risk factors track from childhood into adulthood. However, few studies have systematically examined how behaviors change during adolescence. This paper describes longitudinal tracking of adolescent health behaviors in two Minnesota Heart Health Program communities.

METHODS

Beginning in sixth grade (1983), seven annual waves of behavioral measurements were taken from both communities (baseline n = 2376). Self-reported data included smoking behavior, physical activity, and food preferences.

RESULTS

A progressive increase in the change to weekly smoking status was observed across the smoking status categories. As students began to experiment with smoking, they were more likely to either begin to be or remain regular smokers. Tracking of physical activity and food choice variables was also apparent. In nearly all the follow-up periods, the students identified at baseline as measuring high remained high, and those measuring low remained low.

CONCLUSIONS

These results indicate that there is evidence of early consolidation and tracking of physical activity, food preference, and smoking behavior. The early consolidation of health behaviors implies that interventions should begin prior to sixth grade, before behavioral patterns are resistant to change. The smoking results suggest that students are experiencing difficulty quitting smoking; thus, youth smoking cessation interventions are warranted.

Increased intima-media thickness of the common carotid artery in hypercholesterolemic children

Common carotid intima-media thickness was measured by B-mode ultrasound imaging in 46 children (mean age, 7.4 years) with serum cholesterol > or = 6.4 mmol/L (mean, 8.25 mmol/L) and in 48 children (mean age, 6.4 years) with serum cholesterol < 6.4 mmol/L (mean, 4.60 mmol/L). Maximum thickness was significantly higher in hypercholesterolemic children than in control children (0.50 versus 0.47 mm, P = .007). Subgroup analysis showed that only in children > 6.2 years old (the median of all the children's ages) was maximum thickness significantly higher in hypercholesterolemic children than in control children (0.51 versus 0.48 mm, P = .014). The odds ratio (OR) of common carotid intima-media thickening (maximum thickness of the far wall higher than the 95th percentile of the control group, 0.51 mm) between patients and control subjects was statistically significant both in univariate analysis (OR, 6.39; 95% confidence interval, 1.19 to 32.3; P = .025) and after age (OR, 5.96; 95% confidence interval, 1.09 to 32.4; P = .039) and sex (OR, 7.54; 95% confidence interval, 1.38 to 41.2; P = .020) were controlled for. Children > 6 years old with serum cholesterol > or = 6.4 mmol/L show increased thickness of the common carotid intima-media.

Dietary sources of fats and cholesterol in US children aged 2 through 5 years

OBJECTIVES

This study of lipid intakes among preschool children (1) analyzed the contributions of 38 food groups to fat, saturated fat, and cholesterol intakes; (2) estimated the effects of food substitutions on intakes; and (3) examined demographic differences in food group intake and food group sources of these lipids.

METHODS

The sample consisted of 547 children, aged 2 to 5 years, from the US Department of Agriculture's 1985 and 1986 Continuing Surveys of Food Intakes by Individuals. Dietary information for 4 nonconsecutive days throughout a year was used. All foods were classified into groups and the lipids contributed from each group were computed.

RESULTS

Over 80% of the children consumed more total fat, saturated fats, and cholesterol than is recommended. The major source of total fat and saturated fats was whole milk; the major sources of dietary cholesterol were eggs and whole milk. Children's food consumption patterns differed by region of the country and race/ethnicity, providing opportunities to refine nutrition education interventions and evaluations.

CONCLUSIONS

By substituting lower-fat foods for the major sources of saturated fats, significant reductions in preschool children's intakes of saturated fats, fat, and dietary cholesterol could be achieved.

CATCH: classroom process evaluation in a multicenter trial

The purpose of this paper is to describe the process evaluation model for the classroom curricula of the Child and Adolescent Trial for Cardiovascular Health (CATCH) Project. The process evaluation plan specifically targets how much each curriculum was implemented, to what degree it was implemented as designed, and the barriers to implementation. Additionally, the rationale for each of the process evaluation measures and the instrument development process are presented. Data resulting from these measures will be essential in order to answer questions regarding the internal validity of the main outcomes of the project. Specific examples and sample results are provided from the CATCH third-grade classroom curriculum, which was implemented the first year of CATCH. A discussion also is presented of how the findings from a sample of these measures were used to gain additional insight on the salient features of the curriculum, and how those features may be related to student outcomes.

Individualized dietary counselling of families: serum cholesterol concentration and growth of children aged 7-13 months

We studied the effect of a change in dietary fat composition on serum total and high-density lipoprotein cholesterol and growth in healthy infants between 7 and 13 months of age. The intervention families (n = 22) received individualized dietary counselling when the infant was 7, 8 and 10 months of age. The intervention diet was designed to have a fat content of 35-45 E% of total energy intake in infants aged 7-12 months and 30-35 E% after 12 months of age. The ratio of saturated to monounsaturated to polyunsaturated fatty acids was designed to be 1:1:1. The children in the control group (n = 23) were given no specific advice on the fat composition of the diet. Intake of polyunsaturated fatty acids was significantly higher in the intervention group than in the controls (5.9 E% versus 3.6 E%, p < 0.05). Serum total cholesterol concentration decreased significantly in the intervention group during the study from 4.16 +/- 0.41 mmol/l to 3.86 +/- 0.48 mmol/l (p < 0.05). The infants of both groups grew like average Finnish children. Modification of dietary fat composition, as widely recommended for adults and older children to prevent coronary heart disease, decreases cholesterol values in infants without affecting their normal growth.

Disturbances of lipid metabolism in children with chronic renal failure

This review discusses the pathogenesis, clinical significance and current therapy of hyperlipoproteinaemia (HLP) in children with chronic renal failure. Uraemic dyslipidaemia, characterized by hypertriglyceridaemia and low high-density lipoprotein-cholesterol levels, is present in the majority patients with chronic renal failure. In addition, serum levels of total cholesterol, very low-density lipoprotein-cholesterol, low-density lipoportein-cholesterol and apolipoprotein B are frequently elevated. The pathophysiological mechanisms causing these disturbances are complex and mainly involve a diminished catabolism of triglyceride-rich lipoproteins. For unknown reasons and independent of other lipoproteins, serum levels of the highly atherogenic and thrombogenic lipoprotein(a) are also often elevated. HLP is an important factor in cardiovascular morbidity and mortality. In addition, dyslipidaemia may enhance progression of renal disease in patients with residual renal function. Therefore, treatment of HLP seems indicated in overtly hyperlipidaemic patients, but until there is more experience with lipid-lowering drugs in children, no safe recommendations for pharmacological treatment of HLP can be given. Dietary modifications can be recommended only to a limited extent.

Cholesterol levels and prevalence of hypercholesterolemia in Mexican children and teenagers

In Mexico, the incidence and prevalence of coronary heart disease has increased over the past three decades and has become the leading cause of death in some areas of the country. Hypercholesterolemia (HC) is a major risk factor for coronary atherosclerosis and most developed countries currently have public health strategies that attempt to reduce the level of cholesterol. In order to learn the mean total cholesterol values and the prevalence of HC, an epidemiologic survey was carried out in a representative population sample that included men and women aged 1 to 98 years, across the nation. In this report, we present the findings in children and teenagers of both sexes (n = 34369). Considering the country as a whole, the mean serum TC was 147 +/- 35 mg/dl, the prevalence of borderline hypercholesterolemia (TC between 170 and 199 mg/dl) was 14.7% and the prevalence of high risk hypercholesterolemia (TC > or = 200 mg/dl) was 6.7%. This cross sectional study demonstrated the existence of significant geographic differences in serum TC, with mean state values ranging from 133 mg/dl in the south to 164 mg/dl in the north. The prevalences of high risk hypercholesterolemia was as high as 18.2% in Baja California Norte and as low as 2.5% in the state of Morelos. These geographic differences in total cholesterol and prevalence of hypercholesterolemia were already present at one year of age and persisted throughout childhood and adolescence.

Breakfast consumption affects adequacy of total daily intake in children

Breakfast consumption patterns were assessed for 467 10-year-old children (59% white, 50% girls), who were interviewed in 1984-1985 or in 1987-1988. Consumption patterns were then related to mean daily nutrient intake patterns. More whites (56%) and more girls (46%) ate breakfast at home, whereas more blacks (58%) and more boys (49%) ate breakfast at school. Results indicated that 16% of all children skipped breakfast; the highest percentage was in black girls (24%). Breakfast consumption made a significant contribution to the child's mean daily nutrient intake. The average total energy intake was significantly lower for children who did not consume breakfast (mean = 1,821 kcal) and for children who consumed breakfast at home (mean = 2,098 kcal) compared with children who consumed breakfast at school (mean = 2,326 kcal). A similar pattern was noted for macronutrient contribution. Percentage of total energy from fat was lower in children who did not eat breakfast (34%) compared with those who did (37% to 39%), yet percentage of energy from carbohydrate was higher (53%) in children who did not eat breakfast. Children who skipped breakfast did not make up the differences in dietary intakes at other meals. A higher percentage of children who did not consume breakfast compared with those who ate breakfast did not meet two thirds of the Recommended Dietary Allowance for vitamins and minerals. These data confirm the importance of breakfast to overall dietary quality and adequacy in school-age children.

Dietary changes in Swedish adolescents

A school-based dietary survey, using seven-day records, was performed in two cohorts of Swedish adolescents; 14- and 17-year-olds. The study comprised 366 boys and 365 girls. When compared to previous studies in Sweden, a striking finding was a decrease in dietary fat intake and an increase in carbohydrate intake. However, the relative intake of saturated fat had not changed (15% of total energy). The dietary change was mainly due to an increased consumption of cereal products. There were no major differences in dietary habits or nutrient density of the food between the two age groups, or between boys and girls. The mean intakes of protein, fat and carbohydrate, expressed as a percentage of the total energy intake, were 15, 33 and 52%, respectively. The mean intakes of vitamins and minerals were low only for selenium. The boys had a high iron intake (1.5 and 1.7 times the recommended intake for 14- and 17-year-olds, respectively) while the mean iron intake for girls was 0.9 times the recommended dietary allowances in both age groups. The intake of dietary salt was higher in boys than in girls (7.7 g and 9.0 g per day in 14- and 17-year-old boys, respectively, and 5.8 g per day in both 14- and 17-year-old girls). In a long-term health perspective, this positive change in nutrient intake in adolescents may contribute to a reduction in the incidence of diet-related diseases in Sweden.(ABSTRACT TRUNCATED AT 250 WORDS)

Childhood origins of lifestyle-related risk factors for coronary heart disease in adulthood

Research over the past 40 years clearly points to childhood as a critical period when dietary and lifestyle patterns are initiated which have longterm implications for coronary heart disease risk in adult life. Smoking, high habitual dietary intake of total fat and saturated fat, low exercise level, and excessive alcohol consumption often occur in family aggregates. They are correlated with elevated serum cholesterol, obesity, and hypertension in children, as well as with a predisposition to premature death from coronary heart disease. Intervention studies in children and adolescents show, however, that these lifestyle-risk factors are controllable through education and dietary counselling of the affected individual and their family. Equally important are the emerging data in adults showing that vigorous longterm intervention involving reduction of dietary fat and work-related stress, increased exercise, and elimination of smoking all contribute to a significant improvement in coronary perfusion. Hence, effective dietary and lifestyle management of coronary heart disease can occur at early or later stages of the disease and needs better support from health authorities at the national and international level.

Monitoring the fat and cholesterol intake of children and adolescents

Nurse practitioners and other health care providers play vital roles in the health education of their clients. A health professional should be able to understand the interplay of diet, education, and exercise in a healthy existence. This article reviews the recommendations offered by the National Cholesterol Education Program (1991) on testing and managing cholesterol levels in children and adolescents. The program recommends a strategy combining two complementary approaches: a population approach and an individual approach. By evaluating these approaches, the timing and rationale for lowering fat and cholesterol are discussed and recommendations are made to health care providers about identifying children at risk. Health care providers should work to promote a physically conscious generation that is well-versed in health maintenance, to identify "high-risk" individuals, and to update their own knowledge of national recommendations for managing fat and cholesterol levels in their clients' diets.

Childhood prevention of essential hypertension

Childhood prevention of essential hypertension requires knowledge of alterable determinants of blood pressure in children; these include obesity and sodium intake and perhaps physical activity and intake of potassium and calcium. Altering these determinants may involve two general preventive strategies. The first is a population strategy, which attempts to lower blood pressure (or keep it from rising) among all children. Population strategies may require educating children to active participants in changing their behaviors (active approach) or may merely change their environment (passive approach). The second general strategy aims to focus on children at high risk of developing hypertension as adults. To determine the usefulness of this high-risk strategy, more information is needed about prediction of adult blood pressure from childhood values and about the efficacy of interventions to control blood pressure levels in high-risk children.

A three-year evaluation of the know your body program in inner-city schoolchildren

The impact of the Know Your Body (KYB) comprehensive school health education program was evaluated in a sample of first through sixth-grade students from New York City, using two analytic strategies: a longitudinal cohort and a "posttest only" cohort. In both cohorts, program impact was examined between condition (i.e., KYB vs. no-treatment comparison group) as well as within condition (i.e., low, moderate, and high student exposure). Students in the longitudinal cohort (n = 1,209) who were exposed to high implementation teachers had significantly (p < .05) lower total plasma cholesterol and systolic blood pressure at 3-year posttest than comparison students. Students in the posttest only cohort (n = 3,066) who had high implementation teachers showed significantly (p < .05) lower total plasma cholesterol, systolic blood pressure, self-reported intake of meat and desserts, as well as higher health knowledge and self-reported intake of "heart healthy" foods and vegetables than comparison students. In both cohorts, program effects for several outcome variables were linearly related to level of student exposure to the curriculum, suggesting a dose-response effect. While several methodologic limitations may have influenced study outcomes, these data nonetheless appear to confirm that the KYB program can have a significant positive impact on the knowledge, behavior, and selected risk factors of students in primary grades and that efforts to disseminate and evaluate school health education programs should include strategies to monitor and enhance teacher implementation.

A pilot study of the effect of cholesterol measurement on the eating patterns of adolescents

Epidemiologic research demonstrates that a diet high in total fat, saturated fat, and cholesterol is linked to elevated cholesterol levels and increased risk for heart disease in adults. It is thought that this relationship also holds true for children and adolescents. The literature shows strong support for combining instruction strategies with cardiovascular risk factor screening within the educational setting. Reasons cited include: enhancing the effectiveness of classroom curriculum in achieving health behavior modification; presenting a motivational component; providing important physiological feedback; and offering norm-creating potential. Teaching the adolescent the importance of controlling blood cholesterol through a low-fat diet can be difficult, but producing a change in behavior can be even more challenging. The purpose of this project was to determine whether or not incorporating a cholesterol measurement into instructional strategies would enhance learning. Project objectives included: 1) increasing students' knowledge of the health effects of a high blood cholesterol; and 2) promoting a change in dietary behaviors related to low-fat dietary choices.

Serum lipids and blood pressure in relation to age and sexual maturity

This study was designed to examine serum lipid profile and blood pressure in relation to age and sexual maturity. Written informed consent to participate was obtained from 42% of the eligible population of two Devon communities. The blood pressure of 343 boys and 336 girls, aged 11-16 years, was recorded and sufficient blood for analysis was obtained from 320 boys and 301 girls. Of these, sexual maturity of 221 boys and 209 girls was visually assessed using the indices developed by Tanner. In girls there was a significant (p less than 0.05) correlation between age and serum triglyceride level (r = 0.16) and in boys both serum cholesterol and HDL-cholesterol were significantly (p less than 0.01) and negatively correlated with age (r = -0.25 and -0.18 respectively). Girls had significantly higher (p less than 0.05) levels of HDL-cholesterol than boys but neither sex demonstrated significant changes (p greater than 0.05) in serum lipids or lipoproteins with sexual maturity. No significant differences (p greater than 0.05) were detected between the mean diastolic blood pressures of boys and girls but older boys had significantly higher (p less than 0.05) systolic blood pressures than similarly aged girls. Age was positively and significantly correlated (p less than 0.01) with blood pressure in both boys (systolic, r = 0.49; diastolic, r = 0.30) and girls (systolic, r = 0.28; diastolic, r = 0.29). More mature children were demonstrated to have both higher systolic and diastolic blood pressures than less mature children (p less than 0.05) but when allowance was made for school year group through analysis of co-variance the relationship for diastolic blood pressure in boys no longer remained significant. Blood pressures observed in this study do not raise general cause for concern but the data indicate that unfavourable serum lipid and lipoprotein profiles are common.

Achievable guidelines for food consumption to reach a balanced fat and nutrient intake in childhood and adolescence

In many highly industrialized countries a reduction in the high average intake of fat, especially saturated fatty acids and cholesterol, has been recommended for the prevention of cardiovascular diseases for the general population, including children. However, it has not yet been shown that such a diet is generally achievable in childhood and that it meets the Recommended Dietary Allowances (RDA) for essential nutrients. Based on results of a nutrition survey using a 3-day weighing method for 350 German children and adolescents (1-14 years of age), achievable dietary modifications have been proposed to improve the observed nutrient intake (percentages of energy intake from protein:fat/saturated fatty acids:carbohydrates 13:39/18:48%). Age-related average daily quantities are given for 11 main food groups (e.g., milk, lean meat, visible fats, grain products, vegetables). The main proposals for food consuption are: avoidance of fatty meat and fatty meat products, reduction of fatty foodstuffs commonly consumed with bread and of foodstuffs with a high sucrose content and an increase in whole grain cereal products, potatoes and vegetables. The food consumption proposals are compatible with the typical meal patterns of German children and adolescents. Nutrient content of the proposed diet is presented. The proportions of protein:fat/saturated fatty acids:carbohydrates are 13:35/12:52% of total energy intake. It is shown that the US RDA for most of the calculated minerals, trace elements and vitamins can be met by the proposed balanced mixed diet without using special dietary products or products with added nutrients.

Effects of developmental changes and early nutrition on cholesterol metabolism in infancy: a review

Plasma cholesterol levels usually range between 50 and 100 mg/dl at birth, with the cholesterol approximately equally distributed between low-density lipoprotein (LDL) and high-density lipoprotein (HDL). Plasma cholesterol increases rapidly over the first days after birth, predominantly due to an increase in cholesterol with LDL, irrespective of whether the infant is breast fed or fed with infant formulas. With continued feeding, plasma cholesterol becomes progressively, and significantly, higher in infants who are breast fed compared to those fed low-cholesterol, polyunsaturated fatty acid-rich infant formula. Studies in the developing young of other species have suggested that up-regulation of cholesterol synthesis, or turnover and excretion, at stages when these pathways are acquiring functional maturity may have lasting effects on cholesterol metabolism. The information available, however, indicates the diet-related differences in plasma cholesterol of the more mature human newborn are temporal in nature and probably not of significance to adult cardiovascular disease. Infants born early in the third trimester of gestation, however, are at risk for marked elevations in plasma cholesterol, with stimulation of endogenous cholesterol biosynthesis, as a result of the intravenous nutrition required to sustain life. Whether this has long-term consequences for this group of infants is unknown. There is presently no reason to advocate diet modification to alter the plasma cholesterol of normal infants under the age of 2 years.

Cardiovascular risk factors in schoolchildren

A total of 1470 students in Berlin, Germany, aged 7-22 years, were screened for cardiovascular risk factors such as hypercholesterolemia, hypertension, obesity, smoking habits, and a positive family history. Only 56% had no modifiable risk factor, but 16% showed total cholesterol (TC) levels greater than 200 mg/dl. One percent had severe and 11% had borderline hypertension. Also, 21% were overweight, and 27% of the adolescents greater than or equal to 15 years admitted to smoking regularly. In this paper we concentrate on cholesterol findings of this study, i.e., the dependence of TC on sex, age, weight, and the use of oral contraceptives. There was an age dependency in both sexes. In boys the lowest TC levels were found in the 12-17-year-olds, whereas the group under 10 had the highest ones. In the age group over 17, TC was higher than in the younger groups. The age dependency of the TC levels in girls was similar, but less pronounced. The minimum level was reached earlier, namely in the group 14-15 years old, rather than in the group 16-17. TC levels of girls compared to boys were significantly higher in the 12-13 and 16-17 age groups. Girls who use oral contraceptives had significantly higher TC levels. Obesity had no influence on TC. Our results support the demand for screening for cardiovascular risk factors in children.

Cardiovascular risk modification in the college student: knowledge, attitudes, and behaviors

STUDY OBJECTIVES

To study knowledge, attitudes, and behaviors regarding cardiovascular risk in college students, and to delineate preferred modes of gaining further information.

DESIGN

Cross-sectional survey.

SETTING

Four-year public liberal arts college.

PARTICIPANTS

1,503 students returning a questionnaire (response rate of 60.4%).

RESULTS

Over 91% of respondents knew hypertension was a major cardiovascular risk factor. In addition, 90% identified smoking, 86.7% identified cholesterol level, and 72% identified exercise as additional factors. Under 16% reported that they smoked cigarettes, but only 33.5% exercised regularly. Only 32.9% had had cholesterol levels checked, with 19.2% knowing their values. Over 94% named doctors and nurses as desired sources of further information, yet only 23% said doctors had previously discussed prevention of heart disease with them.

CONCLUSIONS

General knowledge of cardiac risk factors is high among college students, yet actual behavior does not necessarily reflect assimilation of these concepts. Students seek health information from traditional sources. Primary care physicians have a unique opportunity to address these issues, especially in the pre-college physical examination.