Efficacy and safety of lowering dietary intake of total fat, saturated fat, and cholesterol in children with elevated LDL cholesterol: the Dietary Intervention Study in Children

The Healthy Eating Assessment Tool (HEAT): A Simplified 10-Point Assessment of CHILD-2 Dietary Compliance for Children and Adolescents with Dyslipidemia

Traditional dietary assessment tools used to determine achievement of cholesterol-lowering dietary targets, defined in the Cardiovascular Health Integrated Lifestyle Diet (CHILD-2), are time intensive. We sought to determine the utility of the Healthy Eating Assessment Tool (HEAT), a simplified 10-point dietary assessment tool, in relation to meeting dietary cut points of the CHILD-2, as well as its association with markers of adiposity and lipid variables. We performed a 2-year single-center, prospective cross-sectional study of pediatric patients with dyslipidemia. HEAT score associations with meeting CHILD-2 fat targets were modest. Only patients with the highest HEAT scores (good 43%, excellent 64%) met the CHILD-2 cut point of <25% total fat calories (p = 0.03), with a non-significant trend for limiting the percentage of daily saturated fat to <8% (excellent 64%), and no association with cholesterol intake. There were more consistent associations with markers of adiposity (body mass index z-score r = -0.31, p = <0.01 and waist-to-height ratio r = -0.31, p = <0.01), and there was no independent association with lipid levels. While fat-restricted diets are safe, they are not particularly effective for treatment of dyslipidemia or for weight management alone. The HEAT may be a more useful and simplified way of assessing and tracking broader dietary goals in clinical practice.

Evaluation and Management of Lipids and Lipoproteins in Children and Adolescents

Cardiovascular disease (CVD) is the leading cause of mortality in the United States. Universal screening in all children aged 9 to 11 years and 17 to 21 years, and targeted screening in children with high-risk factors, can help in early identification and treatment of dyslipidemia during the youth, significantly reducing clinical CVD risk in adult life. Lifestyle modifications with heart-healthy diet and moderate-vigorous activity are fundamental in the management of pediatric dyslipidemia. Pharmacotherapy has been evolving in children, and statins, bile acid sequestrants, ezetimibe and PCSK9 inhibitors, fibrates, niacin, and omega-3 fish oils are available for use in pediatric population.

The effects of an 8-year individualised lifestyle intervention on food consumption and nutrient intake from childhood to adolescence: the PANIC Study

We aimed to investigate the effects of a long-term, individualised, family-based lifestyle intervention on food consumption and nutrient intake from childhood to adolescence. We conducted an 8-year diet and physical activity intervention study in a population sample of children aged 7–9 years at baseline in 2007–2009. We allocated the participants to the intervention group (n 306) and the control group (n 198). We assessed diet by 4-d food records at baseline, 2-year follow-up and 8-year follow-up. We analysed the data using linear mixed-effects models adjusted for age at baseline and sex. The consumption of vegetables and vegetable oil-based spreads (fat ≥60 %) increased in the intervention group but did not change in the control group (P < 0⋅001 for time×group interaction). The consumption of fruits and berries increased in the intervention group but decreased in the control group (P = 0⋅036). The consumption of high-fat cheese (P = 0⋅029), butter-based spreads (P = 0⋅001) and salty snacks (P = 0⋅028) increased less, and the consumption of low-fat cheese (P = 0⋅004) increased more in the intervention group than in the control group. Saturated fat intake (P = 0⋅001) increased less, and the intakes of dietary fibre (P = 0⋅003), vitamin D (P = 0⋅042) and vitamin E (P = 0⋅027) increased more in the intervention group than in the control group. The intakes of vitamin C (P < 0⋅001) and folate (P = 0⋅001) increased in the intervention group but decreased in the control group. To conclude, individualised, family-based lifestyle intervention altered food choices towards more recommended diet and resulted in enhanced diet quality from childhood to adolescence.

Identification of Factors Influencing Cholesterol Changes in Elementary-School Children: A Longitudinal Study

Changes in serum cholesterol levels during childhood may affect the risk of cardiovascular disease in adulthood. However, cholesterol level changes in Japanese children and adolescents and the factors that influence them have not been completely elucidated. This study aimed to determine whether cholesterol levels changed due to the effects of growth and identify factors. This cohort study included elementary-school children in the fourth grade (9−10-year-old) who underwent assessments of cholesterol levels and demographic and lifestyle characteristics. The participants were followed up in their first year of junior high school with the same laboratory, demographic, and lifestyle assessments. From the fourth year of elementary school to the first year of junior high school, children’s cholesterol levels decreased (p < 0.0001). Regarding bowel movements, cholesterol level reduction was significant in individuals with regular bowel movements but not significant in those with infrequent bowel movements. Weight was the factor that most strongly negatively predicted cholesterol level reduction (p < 0.001). The study demonstrated the significance of lifestyle factors for growth-related changes of total cholesterol levels and identified weight as the factor that most strongly influenced total cholesterol level changes. Guidance regarding lifestyle improvements should be imparted to children from the fourth grade of elementary school.

Prevention of atherosclerosis from childhood

Cardiovascular diseases caused by atherosclerosis do not typically manifest before middle age; however, the disease process begins early in life. Preclinical atherosclerosis can be quantified with imaging methods in healthy populations long before clinical manifestations present. Cohort studies have shown that childhood exposure to risk factors, such as dyslipidaemia, elevated blood pressure and tobacco smoking, are associated with adult preclinical atherosclerotic phenotypes. Importantly, these long-term effects are substantially reduced if the individual becomes free from the risk factor by adulthood. As participants in the cohorts continue to age and clinical end points accrue, the strongest evidence linking exposure to risk factors in early life with cardiovascular outcomes has begun to emerge. Although science has deciphered the natural course of atherosclerosis, discovered its causal risk factors and developed effective means to intervene, we are still faced with an ongoing global pandemic of atherosclerotic diseases. In general, atherosclerosis goes undetected for too long, and preventive measures, if initiated at all, are inadequate and/or come too late. In this Review, we give an overview of the available literature suggesting the importance of initiating the prevention of atherosclerosis in early life and provide a summary of the major paediatric programmes for the prevention of atherosclerotic disease. We also highlight the limitations of current knowledge and indicate areas for future research.

A Positive Association Between Dietary Intake of Higher Cow's Milk-Fat Percentage and Non-High-Density Lipoprotein Cholesterol in Young Children

OBJECTIVES

To determine the association between cow's milk-fat and non-high-density lipoprotein (non-HDL) cholesterol, a marker of cardiovascular disease (CVD) risk in young children, and whether this association is mediated by the typical volume of cow's milk consumed.

STUDY DESIGN

A longitudinal study in 2- to 8-year-old children (n = 2890) was conducted through The Applied Research Group for Kids (TARGet Kids!), a practice-based research network in Toronto, Canada. Generalized estimating equations were used to examine the relationship between parent-reported cow's milk-fat percentage intake and serum non-HDL cholesterol concentrations as well as having high non-HDL cholesterol (≥3.75 mmol/L [145 mg/dL]), adjusting for covariates including age, sex, body mass index z score, breastfeeding duration, mother's ethnicity, and parental history of CVD. Bootstrap resampling (10 000 repetitions) was used to assess whether typical volume consumed mediated the association between cow's milk-fat percentage and non-HDL cholesterol.

RESULTS

In total, 156 (5.4%) had high non-HDL cholesterol. Each percent increase in cow's milk-fat was associated with a 0.035 mmol/L (1.35 mg/dL) (P < .001) and 0.024 mmol/L (0.92 mg/dL) (P = .01) increase in non-HDL cholesterol, unadjusted and adjusted for covariates respectively. Cow's milk-fat percentage was not associated with greater odds of having high non-HDL cholesterol. Volume of cow's milk partially mediated the association between cow's milk-fat percentage and non-HDL cholesterol, accounting for 28% of the relationship (P < .001).

CONCLUSIONS

Consumption of higher-fat cow's milk was associated with a small increase in non-HDL cholesterol but not greater odds of having high non-HDL cholesterol. Further research is needed to assess this relationship with other CVD risk factors in young children.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01869530.

Sudden Cardiac Arrest in a Young Population: Not So Unpredictable

See Article by Allan et al

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.

Hypertriglyceridemia in Diabetes Mellitus: Implications for Pediatric Care

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). It is estimated that the risk of CVD in diabetes mellitus (DM) is 2 to 10 times higher than in the general population. Much of this increased risk is thought to be related to the development of an atherogenic lipid profile, in which hypertriglyceridemia is an essential component. Recent studies suggest that dyslipidemia may be present in children and adolescents with DM, particularly in T2DM and in association with poor control in T1DM. However, the role of hypertriglyceridemia in the development of future CVD in youth with DM is unclear, as data are scarce. In this review, we will evaluate the pathophysiology of atherogenic hypertriglyceridemia in DM, the evidence regarding an independent role of triglycerides in the development of CVD, and the treatment of hypertriglyceridemia in patients with DM, highlighting the potential relevance to children and the need for more data in children and adolescents to guide clinical practice.

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.

Health effects of saturated and trans-fatty acid intake in children and adolescents: Systematic review and meta-analysis

BACKGROUND

Elevated cholesterol has been linked to cardiovascular disease in adults and preclinical markers of atherosclerosis in children, thus reducing saturated (SFA) and trans-fatty acids (TFA) intake from an early age may help to reduce cholesterol and the risk of cardiovascular disease later in life. The aim of this review is to examine the evidence for health effects associated with reducing SFA and TFA intake in free-living children, adolescents and young adults between 2 to 19 years of age.

DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs) and prospective cohort studies. Study selection, assessment, validity, data extraction, and analysis were undertaken as specified by the Cochrane Collaboration and the GRADE working group. Data were pooled using inverse variance models with random effects.

DATA SOURCES

EMBASE; PubMed; Cochrane Central Register of Controlled Trials; LILACS; and WHO Clinical Trial Registry (up to July 2016).

ELIGIBILITY CRITERIA FOR SELECTING TRIALS

RCTs involving dietary interventions aiming to reduce SFA or TFA intakes and a control group, and cohort studies reporting the effects of SFA or TFA exposures, on outcomes including blood lipids; measures of growth; blood pressure; insulin resistance; and potential adverse effects. Minimum duration was 13 days for RCTs and one year for cohort studies. Trials of weight loss or confounded by additional medical or lifestyle interventions were excluded.

RESULTS

Compared with control diets, there was a highly statistically significant effect of reduced SFA intake on total cholesterol (mean difference (MD) -0.16 mmol/l, [95% confidence interval (CI): -0.25 to -0.07]), LDL cholesterol (MD -0.13 mmol/l [95% CI:-0.22 to -0.03]) and diastolic blood pressure (MD -1.45 mmol/l [95% CI:-2.34 to -0.56]). There were no significant effects on any other risk factors and no evidence of adverse effects.

CONCLUSIONS

Advice to reduce saturated fatty acids intake of children results in a significant reduction in total and LDL-cholesterol levels as well as diastolic blood pressure without evidence of adverse effects on growth and development. Dietary guidelines for children and adolescents should continue to recommend diets low in saturated fat.

Dietary Fats and Cardiovascular Disease: A Presidential Advisory From the American Heart Association

Cardiovascular disease (CVD) is the leading global cause of death, accounting for 17.3 million deaths per year. Preventive treatment that reduces CVD by even a small percentage can substantially reduce, nationally and globally, the number of people who develop CVD and the costs of caring for them. This American Heart Association presidential advisory on dietary fats and CVD reviews and discusses the scientific evidence, including the most recent studies, on the effects of dietary saturated fat intake and its replacement by other types of fats and carbohydrates on CVD. In summary, randomized controlled trials that lowered intake of dietary saturated fat and replaced it with polyunsaturated vegetable oil reduced CVD by ≈30%, similar to the reduction achieved by statin treatment. Prospective observational studies in many populations showed that lower intake of saturated fat coupled with higher intake of polyunsaturated and monounsaturated fat is associated with lower rates of CVD and of other major causes of death and all-cause mortality. In contrast, replacement of saturated fat with mostly refined carbohydrates and sugars is not associated with lower rates of CVD and did not reduce CVD in clinical trials. Replacement of saturated with unsaturated fats lowers low-density lipoprotein cholesterol, a cause of atherosclerosis, linking biological evidence with incidence of CVD in populations and in clinical trials. Taking into consideration the totality of the scientific evidence, satisfying rigorous criteria for causality, we conclude strongly that lowering intake of saturated fat and replacing it with unsaturated fats, especially polyunsaturated fats, will lower the incidence of CVD. This recommended shift from saturated to unsaturated fats should occur simultaneously in an overall healthful dietary pattern such as DASH (Dietary Approaches to Stop Hypertension) or the Mediterranean diet as emphasized by the 2013 American Heart Association/American College of Cardiology lifestyle guidelines and the 2015 to 2020 Dietary Guidelines for Americans.

The effects of a 2-year individualized and family-based lifestyle intervention on physical activity, sedentary behavior and diet in children

OBJECTIVE

To investigate the effects of a long-term, individualized and family-based lifestyle intervention on physical activity, sedentary behavior and diet quality in children.

METHODS

We carried out a 2-year intervention study in a population sample of 506 children aged 6-8years in Finland in 2007-2012. We allocated the participants at baseline in the intervention and control group. We assessed physical activity and sedentary behavior by questionnaires and diet by food records.

RESULTS

Total physical activity (+9min/d in intervention group vs. -5min/d in control group, p=0.001 for time*group interaction), unsupervised physical activity (+7min/d vs. -9min/d, p<0.001) and organized sports (+8min/d vs. +3min/d, p=0.001) increased in the intervention group but not in the control group. Using computer and playing video games increased less in the intervention group than in the control group (+9min/d vs. +19min/d, p=0.003). Consumption of vegetables (+12g/d vs. -12g/d, p=0.001), high-fat vegetable-oil based margarine (+10g/d vs. +3g/d, p<0.001) and low-fat milk (+69g/d vs. +11g/d, p=0.042) and intake of dietary fiber (+1.3g/d vs. +0.2g/d, p=0.023), vitamin C (+4.5mg/d vs. -7.2mg/d, p=0.042) and vitamin E (+1.4mg/d vs. +0.5mg/d, p=0.002) increased in the intervention group but not in the control group. Consumption of butter-based spreads increased in the control group but not in the intervention group (+2g/d vs. -1g/d, p=0.002).

CONCLUSIONS

Individualized and family-based lifestyle intervention increased physical activity, attenuated increase in sedentary behavior and enhanced diet quality in children.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01803776.

A randomized, double blind, placebo-controlled pilot trial of the safety and efficacy of atorvastatin in children with elevated low-density lipoprotein cholesterol (LDL-C) and type 1 diabetes

BACKGROUND

Children with type 1 diabetes (T1D) and elevated LDL-C have an increased risk for cardiovascular disease, a process that can begin in childhood.

OBJECTIVE

To assess the safety and efficacy of atorvastatin improving lipid profiles in children with T1D and elevated LDL-C.

SUBJECTS

Sixty children (31M/29F) with T1D, mean age: 15 ± 0.3 yr, mean diabetes duration: 6.8 ± 0.5 yr, HbA(1c) : 8.8 ± 0.2%, with mean LDL-C 124 ± 4.0mg/dl were recruited.

METHODS

After a 3-month run-in period, subjects were randomized double-blindly to atorvastatin or placebo for 6 months. Lipoprotein subfractions were measured by ion mobility and glucose control by HbA1C; continuous glucose monitors were worn quarterly.

RESULTS

After a run-in period, 42 subjects were randomized. There were decreases in total cholesterol (-21%), LDL-C (-32%), non-HDL-C (-31%) and apoB (-26%) in the atorvastatin group versus placebo (p < 0.001). Lipoprotein subparticles (LDL-large 1 and 2A, IDL-large and small, VLDL- medium and small) decreased with statins (p < 0.03 all). Insulin sensitivity scores remained constant in both groups and correlated inversely with apoB (r = -0.312 p = 0.039) and small LDL 3A (r = -0.404 p = 0.007). One subject had asymptomatic elevation of creatinine kinase which normalized after atorvastatin discontinuation.

CONCLUSIONS

Atorvastatin lowered LDL-C, apoB, and atherogenic lipoprotein subparticles in children with T1D and elevated LDL-C without worsening insulin resistance. The drug was well tolerated and safe. Long-term studies would provide better insight on the impact of these interventions in the development of cardiovascular disease in children with diabetes.

Provision of healthy school meals does not affect the metabolic syndrome score in 8-11-year-old children, but reduces cardiometabolic risk markers despite increasing waist circumference

An increasing number of children are exhibiting features of the metabolic syndrome (MetS) including abdominal fatness, hypertension, adverse lipid profile and insulin resistance. Healthy eating practices during school hours may improve the cardiometabolic profile, but there is a lack of evidence. In the present study, the effect of provision of school meals rich in fish, vegetables and fibre on a MetS score (primary outcome) and on individual cardiometabolic markers and body composition (secondary outcomes) was investigated in 834 Danish school children. The study was carried out as a cluster-randomised, controlled, non-blinded, cross-over trial at nine schools. Children aged 8-11 years received freshly prepared school lunch and snacks or usual packed lunch from home (control) each for 3 months. Dietary intake, physical activity, cardiometabolic markers and body composition were measured at baseline and after each dietary period. The school meals did not affect the MetS score (P= 1.00). However, it was found that mean arterial pressure was reduced by 0.4 (95% CI 0.0, 0.8) mmHg (P= 0.04), fasting total cholesterol concentrations by 0.05 (95% CI 0.02, 0.08) mmol/l (P= 0.001), HDL-cholesterol concentrations by 0.02 (95% CI 0.00, 0.03) mmol/l, TAG concentrations by 0.02 (95% CI 0.00, 0.04) mmol/l (both P< 0.05), and homeostasis model of assessment-insulin resistance by 0.10 (95% CI 0.04, 0.16) points (P= 0.001) compared with the control diet in the intention-to-treat analyses. Waist circumference increased 0.5 (95% CI 0.3, 0.7) cm (P< 0.001), but BMI z-score remained unaffected. Complete-case analyses and analyses adjusted for household educational level, pubertal status and physical activity confirmed the results. In conclusion, the school meals did not affect the MetS score in 8-11-year-olds, as small improvements in blood pressure, TAG concentrations and insulin resistance were counterbalanced by slight undesired effects on waist circumference and HDL-cholesterol concentrations.

Dietary intake in 6-year-old children from southern Poland: part 1--energy and macronutrient intakes

Background

The studies on dietary intake in Polish children are sparse and the information about dietary intake in 6-year-olds in Europe is limited. The published studies on dietary intake in children rarely provide information on the intake of animal protein, plant protein and water. The purpose of the study was to analyse energy and macronutrient intakes in 6-year-old children from southern Poland.

Methods

The studied population comprised 120 children, 64 girls and 56 boys. Energy and macronutrient intakes were estimated from a three-day food record. Weight and height were measured, and body mass index was calculated.

Results

Intakes of energy (kJ, kcal), plant protein (g), total fat (g), saturated fatty acids (g, % of energy, g/1000 kcal), monounsaturated fatty acids (g) and starch (g, % of energy, g/1000 kcal) were significantly higher in boys, while intakes of sucrose (% of energy, g/1000 kcal) and total water (g/1000 kcal) were significantly higher in girls. The children’s diets were characterised by excessive intake of total fat, saturated fatty acids, sucrose, and by inadequate intake of polyunsaturated fatty acids, available carbohydrates and starch.

Conclusions

The observed adverse characteristics of the children’s diets are similar to those observed in the diets of children in other European countries and show the need to work out a common educational programme to improve nutrition in young European children. It is also important to provide the lacking information about the intake of animal protein, plant protein and water in young children.

Risks and benefits of statin use in young people with type 1 diabetes

Cardiovascular disease (CVD) is the primary cause of mortality in patients with type 1 diabetes (T1D). Despite advances in the management of microvascular complications of T1D, there is a lack of similar progress in reduction of macrovascular complications. Dyslipidemia is one of the major contributory factors for macrovascular complications in T1D, but the literature suggests significant under-treatment of this risk factor in children and adolescents with diabetes. Statins have shown to be both effective and safe in young people with familial hypercholesterolemia and adults with diabetes mellitus, but the role for statins in children and adolescent with T1D remains unclear and controversial. In this review, we will summarize the risks and benefits of statin use in young people with T1D.

The impact of replacing regular- with reduced-fat dairy foods on children's wider food intake: secondary analysis of a cluster RCT

BACKGROUND/OBJECTIVES

The effect of changing one aspect of diet needs to be considered within the context of total diet. The study aim was to evaluate the changes in children's overall food intake following replacement of regular-fat with reduced-fat dairy foods.

SUBJECTS/METHODS

Secondary analysis of a cluster Randomized Controlled Trial where families were received parental behavioral nutrition education to change to reduced-fat dairy foods (intervention) or reduce screen time (comparison control). Food intake was assessed via multiple 24-h recalls at baseline, week 12 (end of the intervention) and week 24. Participants were parents and their children (4-13 years, N=145) who were regular-fat dairy food consumers. The intervention effect was based on mixed model analysis adjusted for covariates, and baseline food intake.

RESULTS

At week 24, total dairy servings per day were similar between groups and servings of reduced-fat dairy foods were higher in the intervention group (0.8 servings per day 95% confidence interval (CI) 0.5-1.1, P<0.0001). Fruit intake was higher in the intervention group (0.5 servings per day 95% CI 0.02-0.9, P=0.040), with no other statistically significant differences in food intake. In the intervention group, the contribution of core food groups to saturated fat intake was 45% at baseline and 31% at week 24, with 'extra foods' being the largest contributor to total energy (28%) and saturated fat (40%) intake at follow-up.

CONCLUSIONS

Changing children's dairy food choices to reduced-fat varieties did not adversely affect overall food intake. Replacing energy-dense foods with nutrient-rich foods should be the focus of interventions to lower in saturated fat.

Effects of 12-week oral supplementation of Ecklonia cava polyphenols on anthropometric and blood lipid parameters in overweight Korean individuals: a double-blind randomized clinical trial

The effects of 12-week supplementation with a polyphenol extract from Ecklonia cava (ECP) on anthropometry, serum biochemistry and hematology have been investigated. Ninety-seven overweight male and female adults (average age 40.5 ± 9.2 yr and body mass index (BMI) of 26.5 ± 1.6 kg/m²) were enrolled in a randomized, double-blind, placebo-controlled trial with parallel-group design. Subjects were randomly allocated into three groups designated as PC (placebo), LD (low-dose, 72 mg-ECP/day) and HD (high-dose, 144 mg-ECP/day). Both LD and HD groups showed significant decreases in BMI, body fat ratio, waist circumference, waist/hip ratio, total cholesterol, low-density lipoprotein (LDL) cholesterol, total cholesterol/high-density lipoprotein (HDL) cholesterol and atherogenic index (AI) after 12 weeks, as compared with the placebo group. The HD group also showed a significant increase in serum HDL cholesterol as compared with the placebo group. Only the HD group showed significant decreases in serum glucose and systolic blood pressure after 12 weeks. There was no significant adverse event related with ingestion of ECP, and serum biochemical and hematological parameters were maintained within normal range during the intervention period. In conclusion, these results demonstrated that ECP supplementation significantly contributed to lowering body fat and serum lipid parameters such as total and LDL cholesterols with dose dependence. Further studies using different populations, dosages or biological markers are highly recommended to better understand the physiological features of this polyphenol.

Childhood cholesterol disorders: the iceberg base or nondisease?

Pediatric cholesterol disorders are common, affecting 1 in 5 adolescents, although most are mild or moderate abnormalities. Because cholesterol values during childhood are moderately predictive of adult cholesterol levels, and are associated with atherosclerosis by pathology and by vascular testing, and because familial hyperlipidemias are associated with early cardiovascular events, cholesterol screening is recommended during childhood. Identified lipid abnormalities are an indication for lifestyle improvement and, in rare cases, pharmacotherapy. However, many gaps in the pediatric knowledge base remain about the benefits and risk, the optimal method for lipid screening, and about appropriate indications for pharmacotherapy.

Changing from regular-fat to low-fat dairy foods reduces saturated fat intake but not energy intake in 4-13-y-old children

BACKGROUND

Dairy foods are nutrient rich but also a source of saturated fat in the diets of children.

OBJECTIVE

We assessed effects on dietary intakes and health outcomes of changing dairy foods consumed by children from regular- to reduced-fat varieties.

DESIGN

This study was a 24-wk cluster randomized controlled trial in 93 families with 4-13-y-olds who were randomly allocated to parental education regarding changing to reduced-fat dairy foods (n = 76 children) or reducing screen time (n = 69 children). Study outcomes, which were measured at weeks 0, 12 (end of the intervention), and 24, included saturated fat, energy, and nutrient intakes; pentadecanoic acid and blood lipid concentrations; body mass index z score; and waist circumference. Multilevel analyses were used with adjustment for child- and family-level covariates.

RESULTS

There were no group differences in overall dairy intakes (-45 g dairy; 95% CI: -141, 51 g dairy; P = 0.356). Saturated fat intakes were 3.3 percentage points lower (P < 0.0001) in the intervention group at week 24 than in the comparison group. Pentadecanoic acid concentrations were lower at week 12 (0.03%; P = 0.012) but not at week 24. LDL-cholesterol concentrations were not different at week 12, but LDL-cholesterol concentration was 0.15 mmol/L lower in the intervention group at week 24 than in the comparison group (P = 0.037). There were no significant group differences in total energy or adiposity measures. Regular-fat dairy foods decreased from 88% to 14% of dairy intake in the intervention group. Calcium, magnesium, and carbohydrate (percentage of energy) intakes were higher in the intervention group than in the comparison group; retinol intakes were lower in the intervention group than in the comparison group; and overall vitamin A intakes were similar between groups.

CONCLUSION

Advice to parents to change to reduced-fat products was effective in reducing children's saturated fat intakes but did not alter energy intakes or measures of adiposity. This trial was registered in the Australia New Zealand Clinical Trials Registry as ACTRN12609000453280.

Fatty acid intakes of children and adolescents are not in line with the dietary intake recommendations for future cardiovascular health: a systematic review of dietary intake data from thirty countries

Fatty acid composition of the diet may influence cardiovascular risk from early childhood onwards. The objective of the present study was to perform a systematic review of dietary fat and fatty acid intakes in children and adolescents from different countries around the world and compare these with the population nutrient intake goals for prevention of chronic diseases as defined by the WHO (2003). Data on fat and fatty acid intake were mainly collected from national dietary surveys and from population studies all published during or after 1995. These were identified by searching PubMed, and through nutritionists at local Unilever offices in different countries. Fatty acid intake data from thirty countries mainly from developed countries were included. In twenty-eight of the thirty countries, mean SFA intakes were higher than the recommended maximum of 10 % energy, whereas in twenty-one out of thirty countries mean PUFA intakes were below recommended (6–10 % energy). More and better intake data are needed, in particular for developing regions of the world, and future research should determine the extent to which improvement of dietary fatty acid intake in childhood translates into lower CHD risk in later life. Despite these limitations, the available data clearly indicate that in the majority of the countries providing data on fatty acid intake, less than half of the children and adolescents meet the SFA and PUFA intake goals that are recommended for the prevention of chronic diseases.

The efficacy of adherence interventions for chronically ill children: a meta-analytic review

OBJECTIVES

To provide quantitative information about the overall effectiveness of adherence interventions to improve adherence and health outcomes for children with chronic illnesses. To evaluate statistically the potential moderators.

METHODS

A meta-analysis was performed on 71 adherence intervention studies.

RESULTS

Weighted-mean effect size (ES) across all the adherence outcomes for group design studies was in the medium range (mean d = 0.58) and for single-subject design studies was in the large range (mean d = 1.44). The weighted mean ES across all health outcome measures for studies using group designs was in the medium range (mean d = 0.40) and for studies using single-subject designs was in the large range (mean d = 0.74).

CONCLUSIONS

Adherence interventions for children with chronic illnesses effectively increase adherence and result in some positive health benefits. Intervention and methodological variables had significant impact on ESs. High levels of heterogeneity characterized the data.

Clinical review: behavioral interventions to prevent childhood obesity: a systematic review and metaanalyses of randomized trials

CONTEXT

The efficacy of lifestyle interventions to encourage healthy lifestyle behaviors to prevent pediatric obesity remains unclear.

OBJECTIVE

Our objective was to summarize evidence on the efficacy of interventions aimed at changing lifestyle behaviors (increased physical activity, decreased sedentary activity, increased healthy dietary habits, and decreased unhealthy dietary habits) to prevent obesity.

DATA SOURCES

Data sources included librarian-designed searches of nine electronic databases, references from included studies and reviews (from inception until February 2006), and content expert recommendations.

STUDY SELECTION

Eligible studies were randomized trials enrolling children and adolescents assessing the impact of interventions on both lifestyle behaviors and body mass index (BMI).

DATA EXTRACTION

Two reviewers independently abstracted data on methodological quality, study characteristics, intervention components, and treatment effects.

DATA ANALYSIS

We conducted random-effects metaanalyses, quantified inconsistency using I(2), and conducted planned subgroup analyses for each examined outcome.

DATA SYNTHESIS

Regarding target behaviors, the pooled effect size for physical activity (22 comparisons; n = 9891 participants) was 0.12 [95% confidence interval (CI) = 0.04-0.20; I(2) = 63%], for sedentary activity (14 comparisons; n = 3003) was -0.29, (CI = -0.35 to -0.22; I(2) = 0%), for healthy dietary habits (14 comparisons, n = 5468) was 0.00 (CI = -0.20; 0.20; I(2) = 83%), and for unhealthy dietary habits (23 comparisons, n = 9578) was -0.20 (CI = -0.31 to -0.09; I(2) = 34%). The effect of these interventions on BMI (43 comparisons, n = 32,003) was trivial (-0.02; CI = -0.06-0.02; I(2) = 17%) compared with control. Trials with interventions lasting more than 6 months (vs. shorter trials) and trials with postintervention outcomes (vs. in-treatment outcomes) yielded marginally larger effects.

CONCLUSION

Pediatric obesity prevention programs caused small changes in target behaviors and no significant effect on BMI compared with control. Trials evaluating promising interventions applied over a long period, using responsive outcomes, with longer measurement timeframes are urgently needed.

Approaches to dyslipidemia treatment in children and adolescents

Atherosclerosis represents a disease that begins in childhood, and alterations in lipid concentration play a fundamental role in the development of this condition. Children and adolescents with high cholesterol levels are more likely than their peers in the general population to present with dyslipidemia in adulthood. Precocious identification of dyslipidemias associated with premature cardiovascular disease is crucial during childhood to delay or prevent the atherosclerotic process. The National Cholesterol Education Program has established guidelines for the diagnosis and treatment of dyslipidemia during pediatric age. It has been suggested that a heart-healthy diet should begin at 2 years of age, and no adverse effects on psychological aspects, growth, pubertal development and nutritional status in children and adolescents limiting total and saturated fat intake have been demonstrated. Pharmacotherapy should be considered in children aged 10 years or older when low-density lipoprotein cholesterol concentrations remain very high despite dietary therapy, especially when multiple risk factors are present. The lipid-lowering drugs recommended for childhood and adolescence are resins and statins. The increasing use of statins is dependent on their effectiveness and safety. Ezetimibe, a selective cholesterol absorption inhibitor, may provide a similar cholesterol-lowering effect as that reached with statin treatment. This review provides an update on recent advances in the therapy of dyslipidemia, especially hypercholesterolemia, during pediatric age and adolescence.

Impact of increasing adiposity in hyperlipidemic children

Despite lifestyle management, children with high-risk hyperlipidemias may become overweight, and this may further adversely impact their lipid profile. Regression analysis was used to determine changes over time in adiposity and their association with lipid profiles and other risk factors for hyperlipidemic children followed in a lipid disorder clinic. 184 patients were included. Median age at presentation was 7 years (2-17 years), and median duration of follow-up was 9 years (5-20 years). Mean initial total cholesterol was 6.9+/-1.6 mmol/L, low-density lipoproteins were 5.2+/-1.7 mmol/L, high-density lipoproteins were 1.2 +/- 0.4 mmol/L, triglycerides were 1.1+/-0.8 mmol/L, and body mass index z score was +0.4+/-1.0. A significant increase in body mass index z score (+0.032/year, P< .001) was observed. There was an associated significant increase in total cholesterol and triglyceride levels and decrease in high-density lipoprotein levels over time. Worsening adiposity is prevalent in hyperlipidemic children and adversely affects their lipid profiles and cardiovascular risk.

Lifestyle factors, body mass index, and lipid profile in adolescents

OBJECTIVE AND METHODS

A model specifying body mass index (BMI) as mediating the relationship between lifestyle factors (aerobic fitness determined by peak oxygen consumption; physical activity by 7-day physical activity recall; diet by 24 hr dietary recall), and lipid profile were tested in a sample of 205 adolescents (73% boys), who were on average at risk of overweight, aerobically unfit, and from ethnic minority groups.

RESULTS

In this well-fitting model, consuming a diet low in fat and cholesterol, and being aerobically fit predicted lower BMI, which together resulted in increases in high-density lipoprotein cholesterol and decreases in triglycerides and low-density lipoprotein cholesterol. Being physically active, predicted greater aerobic fitness.

CONCLUSIONS

In addition to furthering understanding of the interrelationships among predisposing, major, and conditional coronary heart disease risk factors in adolescents, these data suggest that improving diet and aerobic fitness will reduce BMI and result in a better lipid profile.

Diet does not explain the high prevalence of dyslipidaemia in paediatric renal transplant recipients

Dyslipidaemia exists frequently after renal transplantation (RTx) and promotes atherosclerosis. In this study, we examined the association between daily intake of nutrients and serum lipids after paediatric RTx. We studied 45 children with acceptably functioning kidney grafts and adequately completed food records at a median age of 10.6 years (range 4.3-17.2 years), a median 5.2 years (range 1.0-11.0) after RTx, and 178 healthy controls at a median age of 9.0 years (range 3.2-18.7 years). Serum total cholesterol (TC), triglyceride, and apolipoprotein B concentrations were higher in the RTx patients than in the controls (P < 0.001), despite similar dietary intakes of saturated and polyunsaturated fats, and cholesterol. Both the RTx patients and controls ingested a low amount of polyunsaturated fats [mean (SD) percent of total calories (E%) 4.8 (1.3) and 4.6 (1.5), respectively] and an excessive amount of saturated fats [mean (SD) E% 14.4 (2.4) and 14.1 (2.8), respectively]. In multiple regression analyses, dietary fibre was negatively associated with serum TC concentration. The standard deviation score for body mass index was negatively associated with serum concentration of high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein diameter, and positively with serum triglyceride concentration. In addition, dietary total fat intake was positively associated with serum HDL-C. In conclusion, the higher prevalence of dyslipidaemia in our paediatric RTx patients than in the controls was not explained by the diet. However, the type of fat consumed implicates the counselling for a healthier dietary lifestyle, with an increase in the ingestion of polyunsaturated fats and a decrease in that of saturated fats.

Rational approach to the treatment for heterozygous familial hypercholesterolemia in childhood and adolescence: a review

Atherosclerosis represents a disease that begins in childhood and in which LDL cholesterol plays a pivotal role for the development of the pathology. Children and adolescents with high cholesterol levels are more likely than their peers to present cholesterol elevation as adults. The identification of genetic dyslipidemias associated with premature cardiovascular disease is crucial during childhood to delay or prevent the atherosclerotic process. Guidelines for the diagnosis and treatment of hypercholesterolemia during pediatric age are available from the National Cholesterol Education Program. A heart-healthy diet should begin at the age of 2 yr and a large number of studies have demonstrated no adverse effects on nutritional status, growth, pubertal development, and psychological aspects in children and adolescents limiting total and saturated fat intake. Pharmacotherapy should be considered in children over 10 yr of age when LDL cholesterol concentrations remain very high despite severe dietary therapy, especially when multiple risk factors are present. The only lipid-lowering drugs recommended up to now for childhood and adolescence are resins reported to be effective and well tolerated, although compliance is very poor because of unpalatability. The use of statins is increasing and seems to be effective and safe in children, even if studies enrolled a small number of patients and evaluated efficacy and safety for short-term periods. Recently, an interesting drug represented by ezetimibe has been found that may provide cholesterol-lowering additive to that reached with statin treatment. This review provides an update on recent advances in the diagnosis, therapy, and follow-up of familial hypercholesterolemia during pediatric age and adolescence.

Early Increase of Oxidative Stress and Soluble CD40L in Children With Hypercholesterolemia

OBJECTIVES

The aim of the study was to analyze the behavior of oxidative stress and its interplay with CD40L, a protein that is implicated in atherosclerosis, in hypercholesterolemic children.

BACKGROUND

Oxidative stress has been suggested to play a major role in premature atherosclerosis.

METHODS

Forty-one children with hypercholesterolemia (mean age 9.28 +/- 0.5 years) and 40 children with normocholesterolemia (mean age 9.02 +/- 0.69 years) were matched for gender and age. Within each group, children were classified as having or not having a family history of cardiovascular disease. Serum levels of 8-hydroxy-2'-deoxyguanosine (8-OHdG), a marker of oxidative stress, and plasma levels of soluble CD40L (sCD40L) were measured in each child. In a subgroup of children with high (n = 8) or normal (n = 8) levels of serum cholesterol, platelet p38 mitogen-activated protein (MAP) kinase phosphorylation, a protein involved in the activation of nicotinamide adenine dinucleotide phosphate oxidase, was determined.

RESULTS

Children with hypercholesterolemia had higher values of 8-OHdG and sCD40L compared with control subjects (0.55 +/- 0.06 ng/ml vs. 0.21 +/- 0.02 ng/ml, p < 0.001 and 0.55 +/- 0.04 ng/ml vs. 0.19 +/- 0.03 ng/ml, p < 0.001, respectively). A significant correlation between 8-OHdG and sCD40L was observed in children with high (r = 0.676, p < 0.001) or normal (r = 0.878, p < 0.001) levels of cholesterol. Children with a family history of cardiovascular disease tended to have higher values of 8-OHdG and sCD40L, but the difference was not significant. Analysis of platelet p38 MAP kinase showed that it was phosphorylated more in children with hypercholesterolemia compared with control subjects (36.8 +/- 5.8 AU vs. 8.0 +/- 4.5 AU, p < 0.001 respectively).

CONCLUSIONS

Children with hypercholesterolemia have an early increase of oxidative stress that may be responsible for up-regulation of CD40L and potentially predispose to premature atherosclerosis.

The effects of low-fat, high-carbohydrate diets on plasma lipoproteins, weight loss, and heart disease risk reduction

Although there is consensus about restriction of dietary saturated and trans fatty acids, cholesterol, and sugars, there is debate about what the optimal total fat and carbohydrate content of the diet should be for weight loss and coronary heart disease (CHD) risk reduction. The overall evidence that dietary composition plays an important role in determining caloric intake is limited. Three recent randomized trials have indicated that low-carbohydrate diets are more effective in promoting weight loss in overweight and obese subjects over 4 to 6 months, but not over 1 year. In our own randomized trial no such differences were noted, and compliance with extreme diets was limited. Moreover little attempt has been made to control for the type of carbohydrate used in the low-fat, high-carbohydrate arms of these trials. Available evidence suggests that restriction of sugars and carbohydrates having a high glycemic index would be preferable to total carbohydrate restriction, and that an increased intake of fiber and essential fats (especially omega-3 fatty acids) is also important for overall heart disease risk reduction.

Dietary recommendations for children and adolescents: a guide for practitioners

Since the American Heart Association last presented nutrition guidelines for children, significant changes have occurred in the prevalence of cardiovascular risk factors and nutrition behaviors in children. Overweight has increased, whereas saturated fat and cholesterol intake have decreased, at least as percentage of total caloric intake. Better understanding of children's cardiovascular risk status and current diet is available from national survey data. New research on the efficacy of diet intervention in children has been published. Also, increasing attention has been paid to the importance of nutrition early in life, including the fetal milieu. This scientific statement summarizes current available information on cardiovascular nutrition in children and makes recommendations for both primordial and primary prevention of cardiovascular disease beginning at a young age.

Dietary Recommendations for Children and Adolescents

Since the American Heart Association last presented nutrition guidelines for children, significant changes have occurred in the prevalence of cardiovascular risk factors and nutrition behaviors in children. Overweight has increased, whereas saturated fat and cholesterol intake have decreased, at least as percentage of total caloric intake. Better understanding of children’s cardiovascular risk status and current diet is available from national survey data. New research on the efficacy of diet intervention in children has been published. Also, increasing attention has been paid to the importance of nutrition early in life, including the fetal milieu. This scientific statement summarizes current available information on cardiovascular nutrition in children and makes recommendations for both primordial and primary prevention of cardiovascular disease beginning at a young age.

Number of days, number of subjects, and sources of variation in longitudinal intervention or crossover feeding trials with multiple days of measurement

Dietary studies are often conducted as longitudinal intervention or crossover trials using multiple days of measurement on each subject during each of several measurement periods, and determining the required numbers of days and subjects is important in designing these studies. Linear mixed statistical models were used to derive equations for precision, statistical power and sample size (number of days and number of subjects) and to obtain estimates of between-subject, period-to-period, and day-to-day variation needed to apply the equations. Two cohorts of an on-going exercise intervention study, and a crossover study of Olestra, each with 14 d of measurement/subject per period, were used to obtain estimates of variability for energy and macronutrient intake. Numerical examples illustrate how the equations for calculating the number of days or number of subjects are applied in typical situations, and sample SAS code is given. It was found that between-subject, period-to-period, and day-to-day variation all contributed significantly to the variation in energy and macronutrient intake. The ratio of period-to-period and day-to-day standard deviations controls the trade-off between the number of days and the number of subjects, and this remained relatively stable across studies and energy and macronutrient intake variables. The greatest gains in precision were seen over the first few measurement days. Greater precision and fewer required days were noted in the study (Olestra) that exerted greater control over the subjects and diets during the feeding protocol.

Antioxidant vitamins C and E improve endothelial function in children with hyperlipidemia: Endothelial Assessment of Risk from Lipids in Youth (EARLY) Trial

BACKGROUND

Hyperlipidemia is associated with endothelial dysfunction, an early event in atherosclerosis and predictor of risk for future coronary artery disease. Epidemiological studies suggest that increased dietary intake of antioxidants reduces the risk of coronary artery disease. The purpose of this study was to determine whether antioxidant vitamin therapy improves endothelial function and affects surrogate biomarkers for oxidative stress and inflammation in hyperlipidemic children.

METHODS AND RESULTS

In a randomized, double-blind, placebo-controlled trial, the effects of antioxidant vitamins C (500 mg/d) and E (400 IU/d) for 6 weeks and the National Cholesterol Education Program Step II (NCEP-II) diet for 6 months on endothelium-dependent flow-mediated dilation (FMD) of the brachial artery were examined in 15 children with familial hypercholesterolemia (FH) or the phenotype of familial combined hyperlipidemia (FCH). Antioxidant vitamin therapy improved FMD of the brachial artery compared with baseline (P<0.001) without an effect on biomarkers for oxidative stress (autoantibodies to epitopes of oxidized LDL, F2-isoprostanes, 8-hydroxy-2'-deoxyguanosine), inflammation (C-reactive protein), or levels of asymmetric dimethylarginine, an endogenous inhibitor of nitric oxide.

CONCLUSIONS

Antioxidant therapy with vitamins C and E restores endothelial function in hyperlipidemic children. Early detection and treatment of endothelial dysfunction in high-risk children may retard the progression of atherosclerosis.

Challenges in dyslipidemia

Dyslipidemia is recognized as a significant risk factor for atherosclerotic disease. There has been a great deal of progress in the detection and management of dyslipidemia, but challenges remain, including whether to treat children, adolescents, and the elderly. Challenges include convincing physicians who tend to manage an outpatient disease with a single therapy that the management of cardiovascular risk and disease often requires multiple therapies, describing how we can combine therapies to provide an additive benefit without adding side effects or increasing morbidity, and determining whether a patient with one or more cardiovascular risk factors but a normal lipid should receive lipid-lowering therapy. Finally, there is the challenge of the Human Genome Project and predictive medicine. How will genetic information be integrated into the practice of medicine for disease prevention and management?

Risk factors for cardiovascular disease in children on maintenance dialysis

Cardiovascular disease mortality is high in children on maintenance dialysis, accounting for about 25% of patient deaths. Cardiovascular-related mortality rates for children on dialysis are higher than for children with successful kidney transplants. Data on the long-term consequences of risk factors for cardiovascular disease are lacking for pediatric end-stage renal disease patients. This article reviews pediatric data pertaining to the following risk factors: anemia, hypertension, hyperlipidemia, left ventricular hypertrophy, abnormal calcium-phosphorus metabolism, and hyperhomocysteinemia. The potential relationship of end-stage renal disease to the etiology of several functional disorders of the cardiovascular system is discussed. Clinical studies are needed to assess the prevalence of cardiovascular disease and of cardiovascular disease risk factors in the pediatric end-stage renal disease population. Possible preventive and therapeutic guidelines need to be developed for at-risk children on maintenance dialysis.