Endothelial Function in Healthy 11-Year-Old Children After Dietary Intervention With Onset in Infancy

The Influence of Dietary Counseling Over 20 Years on Tracking of Non-High-Density Lipoprotein Cholesterol from Infancy to Young Adulthood

This 26-year study found that non-high-density lipoprotein cholesterol (non-HDL-C) levels tracked from infancy to young adulthood suggesting early-life non-HDL-C could predict future levels. However, infancy-onset dietary counseling reduced the odds of maintaining at-risk non-HDL-C, highlighting the potential importance of early interventions in preventing cardiovascular risk associated with high pediatric non-HDL-C.

Preventative interventions that target cardiovascular dysfunction in children and young people: a systematic review of their effectiveness and an investigation of sexual dimorphism

Given that cardiovascular diseases remain a primary cause of mortality and morbidity, there is a need to consider preventative strategies to improve vascular function from early in life. The aims of this study were therefore to investigate which interventions may improve endothelial function, intima media thickness and arterial stiffness in children and young people and to assess whether these interventions differ in boys and girls. A systematic literature search of Science Direct, Pubmed, Google Scholar and the Cochrane Library by two independent reviewers was performed to source articles. Inclusion criteria were any studies including any child ≤18 years of age receiving an intervention, which measured vascular function other than blood pressure. Exclusion criteria were studies assessing children with chronic medical conditions. A total of 72 studies were identified, which met the inclusion criteria. A measurable change in outcome was more likely to be reported in studies investigating endothelial function (p = 0.03). Interventions which improved vascular function included physical activity and dietary programmes. Under 10% of studies considered sex differences. In conclusion, school-based physical activity interventions are most likely to result in improvements in vascular function. Endothelial function may be the first variable of vascular function to change secondary to an intervention. Standardisation of reporting of differences between the sexes is essential to be able to ensure interventions are equally effective for boys and girls.

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.

Achievement of the Targets of the 20-Year Infancy-Onset Dietary Intervention-Association with Metabolic Profile from Childhood to Adulthood

The Special Turku Coronary Risk Factor Intervention Project (STRIP) is a prospective infancy-onset randomized dietary intervention trial targeting dietary fat quality and cholesterol intake, and favoring consumption of vegetables, fruit, and whole-grains. Diet (food records) and circulating metabolites were studied at six time points between the ages of 9-19 years (n = 549-338). Dietary targets for this study were defined as (1) the ratio of saturated fat (SAFA) to monounsaturated and polyunsaturated fatty acids (MUFA + PUFA) < 1:2, (2) intake of SAFA < 10% of total energy intake, (3) fiber intake ≥ 80th age-specific percentile, and (4) sucrose intake ≤ 20th age-specific percentile. Metabolic biomarkers were quantified by high-throughput nuclear magnetic resonance metabolomics. Better adherence to the dietary targets, regardless of study group allocation, was assoiated with higher serum proportion of PUFAs, lower serum proportion of SAFAs, and a higher degree of unsaturation of fatty acids. Achieving ≥ 1 dietary target resulted in higher low-density lipoprotein (LDL) particle size, lower circulating LDL subclass lipid concentrations, and lower circulating lipid concentrations in medium and small high-density lipoprotein subclasses compared to meeting 0 targets. Attaining more dietary targets (≥2) was associated with a tendency to lower lipid concentrations of intermediate-density lipoprotein and very low-density lipoprotein subclasses. Thus, adherence to dietary targets is favorably associated with multiple circulating fatty acids and lipoprotein subclass lipid concentrations, indicative of better cardio-metabolic health.

Effects of Randomized Controlled Infancy-Onset Dietary Intervention on Leukocyte Telomere Length-The Special Turku Coronary Risk Factor Intervention Project (STRIP)

Reduced telomere length (TL) is a biological marker of aging. A high inter-individual variation in TL exists already in childhood, which is partly explained by genetics, but also by lifestyle factors. We examined the influence of a 20-year dietary/lifestyle intervention on TL attrition from childhood to early adulthood. The study comprised participants of the longitudinal randomized Special Turku Coronary Risk Factor Intervention Project (STRIP) conducted between 1990 and 2011. Healthy 7-month-old children were randomized to the intervention group (n = 540) receiving dietary counseling mainly focused on dietary fat quality and to the control group (n = 522). Leukocyte TL was measured using the Southern blot method from whole blood samples collected twice: at a mean age of 7.5 and 19.8 years (n = 232; intervention n = 108, control n = 124). Yearly TL attrition rate was calculated. The participants of the intervention group had slower yearly TL attrition rate compared to the controls (intervention: mean = −7.5 bp/year, SD = 24.4 vs. control: mean = −15.0 bp/year, SD = 30.3; age, sex and baseline TL adjusted β = 0.007, SE = 0.004, p = 0.040). The result became stronger after additional adjustments for dietary fat quality and fiber intake, serum lipid and insulin concentrations, systolic blood pressure, physical activity and smoking (β = 0.013, SE = 0.005, p = 0.009). A long-term intervention focused mainly on dietary fat quality may affect the yearly TL attrition rate in healthy children/adolescents.

Early-Life Nutrition Interventions and Associated Long-Term Cardiometabolic Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Early-life nutrition interventions can have lifelong cardiometabolic benefits. Most evidence on this topic is derived from observational studies. We evaluated the association of randomized controlled nutritional trials in early life and long-term cardiometabolic outcomes. Through literature search of PubMed, CABI Global Health, Embase, and Cochrane, with manual reference check and weekly alert from PubMed, we identified 8312 records, and included 53 records from 40 cohorts in 21 countries. The total number of participants was 33,551. Interventions were initiated as early as conception, and the longest until 7 y (except 1 study from infancy to 20 y). The cohorts were followed up for between 3 and 73 y. We identified 7 types of interventions (protein-energy supplements, long-chain PUFAs, single micronutrient, multiple micronutrients, infant and young child feeding, dietary counseling, and other) and 4 categories of cardiometabolic outcomes (biomarkers, cardiovascular, body size and composition, and subclinical/clinical outcomes). Most findings were null. Fasting glucose concentration was 0.04 mmol/L lower (95% CI: -0.05, -0.02 mmol/L; I2 = 0%) in the intervention groups than in the control groups (15 studies). BMI (kg/m2) was 0.20 higher (95% CI: 0.12, 0.28; I2 = 54%) in the intervention groups than control groups (14 studies). No significant effect was observed for total cholesterol (12 studies) or blood pressure (17 studies). Ongoing and personalized dietary counseling was associated with lower glucose and cholesterol, better endothelial function, and reduced risk of metabolic syndrome. The timing of intervention mattered, with earlier initiation conferring greater benefit (improved lipid profile and marginally lower glucose concentration) based on 2 studies. In sum, glucose concentration was lower following early-life nutrition interventions, but there is a risk of unintended consequences, including higher BMI. Maternal and child nutrition interventions must be evidence-based and tailored to each population to promote long-term cardiometabolic health.

Attainment of Targets of the 20-Year Infancy-Onset Dietary Intervention and Blood Pressure Across Childhood and Young Adulthood: The Special Turku Coronary Risk Factor Intervention Project (STRIP)

We examined whether success in achieving the key targets of an infancy-onset 20-year dietary intervention was associated with blood pressure (BP) from infancy to young adulthood. In the prospective randomized STRIP (Special Turku Coronary Risk Factor Intervention Project; n=877 children), dietary counseling was provided biannually based on the Nordic Nutrition Recommendations primarily to improve the quality of dietary fat in children's diets and secondarily to promote intake of vegetables, fruits, and whole grains. Dietary data and BP were accrued annually from the age of 13 months to 20 years. The dietary targets for fat quality were defined as the ratio of saturated fatty acids to monounsaturated and polyunsaturated fatty acids <1:2 and intake of saturated fatty acids <10 E%, dietary fiber intake in the top age-specific quintile, and dietary sucrose intake as being in the lowest age-specific quintile. Attaining a higher number of the dietary targets was associated with lower systolic BP (mean [SE] systolic BP, 107.3 [0.3], 107.6 [0.3], 106.8 [0.3], and 106.7 [0.5] mm Hg in participants meeting 0, 1, 2, and 3 to 4 targets, respectively; P=0.03) and diastolic BP (mean [SE] diastolic BP, 60.4 [0.2], 60.5 [0.2], 59.9 [0.2], and 59.9 [0.3] mm Hg; P=0.02). When the lowest age-specific quintile of dietary cholesterol was added as an additional target, the association with systolic BP remained significant (P=0.047), but the association with diastolic BP attenuated (P=0.13). Achieving the key targets of an infancy-onset 20-year dietary intervention, reflecting dietary guidelines, was favorably albeit modestly associated with systolic and diastolic BP from infancy to young adulthood. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT00223600.

Dietary Fats and Atherosclerosis From Childhood to Adulthood

BACKGROUND

The association of dietary fat distribution with markers of subclinical atherosclerosis during early life is unknown. We examined whether success in achieving the main target of an infancy-onset dietary intervention based on the distribution of dietary fat was associated with aortic and carotid intima-media thickness (IMT) and distensibility from childhood to young adulthood.

METHODS

In the prospective randomized controlled Special Turku Coronary Risk Factor Intervention Project trial, personalized dietary counseling was given biannually to healthy children from infancy to young adulthood. The counseling was based on Nordic Nutrition Recommendations, with the main aim of improving the distribution of dietary fat in children's diets. IMT and distensibility of the abdominal aorta and common carotid artery were measured repeatedly at ages 11 (n = 439), 13 (n = 499), 15 (n = 506), 17 (n = 477), and 19 years (n = 429). The targeted distribution of dietary fat was defined as a ratio of saturated fatty acids to monounsaturated and polyunsaturated fatty acids of <1:2 and as an intake of saturated fatty acids of <10% of energy intake. Participants who met ≥1 of these 2 criteria were defined to achieve the main intervention target.

RESULTS

Individuals who achieved the main intervention target had lower aortic IMT (age- and sex-adjusted mean difference 10.4 µm; 95% confidence interval: 0.3 to 20.5 µm) and better aortic distensibility (0.13% per 10 mm Hg; 95% confidence interval: 0.00% to 0.26% per10 mm Hg) compared with their peers who did not meet the target.

CONCLUSIONS

Achieving the main target of an infancy-onset dietary intervention, reflecting dietary guidelines, was favorably associated with aortic IMT and distensibility during the early life course. These data support the recommendation of favoring unsaturated fat to enhance arterial health.

Low-saturated-fat and low-cholesterol diet does not alter pubertal development and hormonal status in adolescents

Aim

The aim was to assess the influence of dietary counselling on the pubertal development and hormonal status in healthy adolescents.

Methods

We used a subcohort of 193 healthy boys (52%) and girls (48%) from the Special Turku Coronary Risk Factor Intervention Project. Participants were recruited by nurses at the well‐baby clinics in Turku Finland in 1990–1992 and randomised into intervention and control groups. Intervention children received low‐saturated fat and low‐cholesterol dietary counselling initiated at seven months of age. Participants were examined once a year with Tanner staging, anthropometric measurements and serial reproductive hormones from 10 to 19 years of age. In girls, postmenarcheal hormones were not analysed.

Results

Pubertal hormones in boys or girls did not differ between the intervention and control groups. However, we observed slight differences in pubertal progression by Tanner staging and in anthropometric parameters. The intervention boys progressed faster to G4 (p = 0.008), G5 (p = 0.008) and P5 (p = 0.03). The intervention boys were taller than control boys (p = 0.04), while weight and body mass index did not differ.

Conclusion

Dietary intervention did not affect pubertal hormonal status. This finding supports the safety of implemented counselling in respect to puberty.

Success in Achieving the Targets of the 20-Year Infancy-Onset Dietary Intervention: Association With Insulin Sensitivity and Serum Lipids

OBJECTIVE

We examined whether success in achieving the key targets of an infancy-onset 20-year dietary intervention associated with insulin sensitivity and serum lipids from early childhood to young adulthood.

RESEARCH DESIGN AND METHODS

The sample comprised 941 children participating in the prospective, randomized Special Turku Coronary Risk Factor Intervention Project (STRIP). Dietary counseling was given biannually based on the Nordic Nutrition Recommendations with the main aim to improve the quality of dietary fat in children's diets and the secondary aim to promote intake of vegetables, fruits, and whole-grain products. Food records and serum lipid profile were studied annually from 1 to 20 years of age, and HOMA of insulin resistance (HOMA-IR) was assessed between 7 and 20 years of age. Meeting the intervention targets for quality of dietary fat was defined as the ratio of saturated fatty acids (SAFA) to monounsaturated and polyunsaturated fatty acids (MUFA + PUFA) <1:2 and intake of SAFA <10% of total energy intake (E%). Meeting the target for intake of whole-grain products, fruits, and vegetables was indicated by a fiber intake ≥3 g/MJ.

RESULTS

Participants in the intervention group had a higher probability of meeting the targets of SAFA/(PUFA + MUFA) <1:2 (risk ratio [RR] 3.91 [95% CI 3.33-4.61]), intake of SAFA <10 E% (RR 3.33 [95% CI 2.99-3.96]), and intake of fiber >3 g/MJ (RR 1.37 [95% CI 1.04-1.80]). Participants who achieved more targets had lower HOMA-IR, lower concentrations of fasting serum glucose, insulin, LDL cholesterol, and non-HDL cholesterol, and a lower ratio of apolipoprotein (Apo) B/ApoA1 (P values all ≤0.003).

CONCLUSIONS

Achieving the key targets of an infancy-onset 20-year dietary intervention was associated with better insulin sensitivity and serum lipid profile throughout the early life course.

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.

Effect of Dietary Counseling on a Comprehensive Metabolic Profile from Childhood to Adulthood

OBJECTIVES

To study the effects of repeated, infancy-onset dietary counseling on a detailed metabolic profile. Effects of dietary saturated fat replacement on circulating concentrations of metabolic biomarkers still remain unknown.

STUDY DESIGN

The Special Turku Coronary Risk Factor Intervention Project (STRIP) study is a longitudinal, randomized atherosclerosis prevention trial in which repeated dietary counseling aimed at reducing the proportion of saturated fat intake. Nuclear magnetic resonance metabolomics quantified circulating metabolites from serum samples assessed at age 9 (n = 554), 11 (n = 553), 13 (n = 508), 15 (n = 517), 17 (n = 457), and 19 (n = 417) years.

RESULTS

The intervention reduced dietary intake of saturated fat (mean difference in daily percentage of total energy intake: -2.1 [95% CI -1.9 to -2.3]) and increased intake of polyunsaturated fat (0.6 [0.5-0.7]). The dietary counseling intervention led to greater serum proportions of polyunsaturated fatty acids (P < .001), with greater proportions of both circulating omega-3 (P = .02) and omega-6 (P < .001) fatty acids. The proportion of saturated fatty acids in serum was lower for both boys and girls in the intervention group (P < .001), whereas the serum proportion of monounsaturated fat was lower for boys in the intervention group only (P < .001). The intervention also reduced circulating intermediate-density lipoprotein and low-density lipoprotein lipid concentrations (P < .01). Dietary intervention effects on nonlipid biomarkers were minor except from greater concentrations of glutamine in the intervention group.

CONCLUSIONS

Repeated dietary counseling from infancy to early adulthood yielded favorable effects on multiple circulating fatty acids and lipoprotein subclass lipids, particularly in boys. These molecular effects substantiate the beneficial role of saturated fat replacement on the metabolic risk profile.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00223600.

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.

How effective are family-based and institutional nutrition interventions in improving children's diet and health? A systematic review

BACKGROUND

Effective strategies to improve dietary intake in young children are a priority to reduce the high prevalence of chronic non-communicable diseases in adulthood. This study aimed to assess the impact of family-based and school/preschool nutrition programs on the health of children aged 12 or younger, including the sustainability of these impacts and the relevance to socio-economic inequalities.

METHODS

A systematic review of literature published from 1980 to December 2014 was undertaken. Randomised controlled trials involving families with children aged up to 12 years in high income countries were included. The primary outcomes were dietary intake and health status. Results were presented in a narrative synthesis due to the heterogeneity of the interventions and outcomes.

RESULTS

The systematic search and assessment identified 39 eligible studies. 82% of these studies were set in school/preschools. Only one school study assessed the impact of involving parents systematically. The family-based programs which provided simple positive dietary advice to parents and regular follow-up reduced fat intake significantly. School and family-based studies, if designed and implemented well, increased F&V intake, particularly fruit. Effective school-based programs have incorporated role-models including peers, teachers and heroic figures, rewards and increased access to healthy foods. School nutrition programs in disadvantaged communities were as effective as programs in other communities.

CONCLUSIONS

Family and school nutrition programs can improve dietary intake, however evidence of the long-term sustainability of these impacts is limited. The modest overall impact of even these successful programs suggest complementary nutrition interventions are needed to build a supportive environment for healthy eating generally.

Beat-to-Beat Blood Pressure and Two-dimensional (axial and radial) Motion of the Carotid Artery Wall: Physiological Evaluation of Arterial Stiffness

The physiological relationship between local arterial displacement and blood pressure (BP) plays an integral role in assess- ment of the mechanical properties of arteries. In this study, we used more advanced methods to obtain reliable continuous BP and the displacement of the common carotid artery (CCA) simultaneously. We propose a novel evaluation method for arterial stiffness that relies on determining the physiological relationship between the axial and radial displacements of the CCA wall and beat-to-beat BP. Patients (total of 138) were divided into groups according to the following three criteria: essential hyper- tension (EH) and normotension, male and female, elderly and younger. The Pearson correlation test and canonical correlation analysis showed that the CCA indices were significantly correlated with BP indices (r = 0:787; p < 0:05). The slope of the CCA displacement/pressure curve showed a progressive reduction with increasing age and EH disease occurrence (EH: 0.496 vs. normotension: 0.822; age <= 60:0.585 vs. age > 60:0.783). Our method provides an explicit reference value and relationship for the manner in which the CCA wall responds to changes in BP. Short-term and continuous BP were significantly correlated with CCA displacement and exhibited a close inverse relationship with each subject's BP and EH, age, and systolic blood pressure.

Impact of Health Status and Lifestyle Modifications on Vascular Structure and Function in Children and Adolescents

Until recently cardiovascular disease is often thought of as a disease that manifests itself during middle age. Researchers and clinicians have begun to realize that the initial signs of cardiovascular disease begin early on in childhood with changes present in both vascular structure and function. This increased recognition has resulted in considerable effort to develop accurate and reliable methods to measure as well as track changes in vascular structure and function applicable to study this process in children and adolescents. Certain genetic abnormalities and chronic diseases, which present or emerge in childhood often result in meaningful changes to vascular structure and function, which aid in our understanding of the vascular disease process. In this review, we will discuss different methods of assessing vascular structure and function, the diseases in childhood associated with decrements and maladaptive changes in the vascular system, and whether modification of lifestyle (ie, weight loss, dietary and/or exercise changes) can affect vascular structure and function in children.

Psychological wellbeing in 20-year-old adults receiving repeated lifestyle counselling since infancy

AIM

This study examined whether there was an association between a repeated dietary and lifestyle intervention that began in infancy and participants' psychological wellbeing at the age of 20.

METHODS

We examined the psychological wellbeing of 457 young adults participating in the Special Turku Coronary Risk Factor Intervention Project (STRIP), a randomised controlled trial conducted in Finland between 1989 and 2011. We assessed potential differences in psychological wellbeing between the intervention and control groups by examining participants' satisfaction with life, how they rated their health, their experiences of stress and the consequences of experiencing stress and symptoms of depression at the age of 20. We also assessed socio-economic status during childhood as a potential confounding factor.

RESULTS

We found no association between the long-term dietary and lifestyle intervention and participants' psychological wellbeing in adulthood. Adjusting for sex and childhood socio-economic status did not affect the results and socio-economic status did not moderate the association between the intervention and psychological wellbeing.

CONCLUSION

Our findings showed no association between intensive dietary and lifestyle counselling that was initiated in infancy with psychological wellbeing in adulthood and the initiative did not appear to pose any psychological risks.

High lipoprotein(a) concentrations are associated with impaired endothelial function in children

OBJECTIVE

To examine the association between familial high lipoprotein(a), or Lp(a), concentrations and endothelial function in children participating in the Special Turku Coronary Risk Factor Intervention Project study.

STUDY DESIGN

Seven-month-old children (n = 1062) with their families were randomized to a risk intervention group or to a control group. The intervention group received individualized dietary counseling to reduce the total cholesterol concentration. Children's Lp(a) and lipid values were measured repeatedly. At age 11 years, children were recruited to an ultrasound study of the flow-mediated dilation (FMD) of the brachial artery. The association between relative peak FMD and Lp(a) concentration was examined in 198 control and 193 intervention group children by linear regression analyses adjusted for sex, total cholesterol concentration, and basal artery diameter. The analyses were made in both the control and intervention groups and in the familial risk children who had a parent with Lp(a) concentration greater than 250 mg/l.

RESULTS

Lp(a) concentrations were similar at age 11 years in the intervention and control groups. In all control children, FMD (%) associated inversely with Lp(a) concentration: (β [%/1000 mg/L] = -3.74, 95% CI [-6.43, -1.45]; P = .007) and in 68 familial risk children (β = -4.92, 95% CI [-8.18, -1.66]; P = .0037). In the intervention group the associations were lacking (P > .5), and FMD in the children with high Lp(a) concentrations (>500 mg/L, n = 12) had no attenuation (P = .027).

CONCLUSIONS

Familial high Lp(a) concentration is associated with attenuated endothelial function. This association may be mitigated by an early lifestyle intervention.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00223600.

Metabolic syndrome from adolescence to early adulthood: effect of infancy-onset dietary counseling of low saturated fat: the Special Turku Coronary Risk Factor Intervention Project (STRIP)

BACKGROUND

Adolescent metabolic syndrome (MetS) predicts type 2 diabetes mellitus and subclinical atherosclerosis in adulthood. Our aim was to establish the relationship between an infancy-onset dietary intervention and risk of having MetS between 15 and 20 years of age.

METHODS AND RESULTS

The Special Turku Coronary Risk Factor Intervention Project for Children (STRIP) study is a longitudinal, randomized atherosclerosis prevention trial in which repeated dietary counseling aiming at reducing intake of saturated fat took place from infancy to early adulthood. Participants who had complete data on the MetS components (waist circumference, blood pressure, triglycerides, glucose, high-density lipoprotein cholesterol) at 15 (n=512), 16 (n=485), 17 (n=475), 18 (n=459), 19 (n=439), and 20 (n=407) years of age were included in the study. Modified International Diabetes Foundation criteria with 80th/20th percentile cutoff points for the components were primarily applied in statistical analyses, and the results were replicated with the use of other pediatric MetS definitions. Between the ages of 15 and 20 years, the prevalence of MetS varied between 6.0% and 7.5% in participants in the intervention group and between 10% and 14% in the control group. The long-term relative risk of MetS was significantly lower in the intervention group (relative risk, 0.59; 95% confidence interval, 0.40-0.88; P=0.009). Of the individual MetS components, the intervention decreased risk of high blood pressure in both sexes (relative risk, 0.83; 95% confidence interval, 0.70-0.99) and high triglycerides in male subjects (relative risk, 0.71; 95% confidence interval, 0.52-0.98). A statistically nonsignificant reduction was seen in the risk of high waist circumference in the intervention individuals (relative risk, 0.78; 95% confidence interval, 0.59-1.03).

CONCLUSION

Repeated infancy-onset dietary intervention is effective in the prevention of MetS in adolescence.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT00223600.

The effect of dietary intervention on paraffin-stimulated saliva and dental health of children participating in a randomized controlled trial

OBJECTIVES

The aim was to study the impact of dietary intervention on the properties of paraffin-stimulated saliva, and on dental caries.

STUDY DESIGN

At 7 months of age 1062 infants (540 intervention; 522 controls) started in the prospective, randomized Special Turku Intervention Project (STRIP) aimed at restricting the child's saturated fat and cholesterol intake to prevent atherosclerosis of adult age (www.clinicaltrials.gov NCT 00223600). At 3 years of age, every fifth child was invited to an oral sub-study, and 148 (78 boys) children attended. At 6, 9, 12 and 16 years of age 135, 127, 114 and 88 children were restudied, respectively. Dietary intakes of carbohydrates, protein, saturated fat, calcium, phosphate, and fibre were regularly recorded using 4-day food records. Height and weight were regularly monitored. Paraffin-stimulated saliva samples were collected at 6, 9, 12 and 16 years of age, and analyzed for flow rate, buffer capacity, calcium, phosphate and proteins. Dental health was recorded and expressed as d3mft/D3MFT, and as time of caries onset.

RESULTS

Dietary intakes of calcium, phosphate and fibre, and salivary flow rate increased with time in both groups (p<0.001, GLM for repeated measures). Fibre intake and salivary flow rate were higher in the intervention than in the control group (p=0.042 and p=0.0394, respectively, GLM for repeated measures). There were no correlations between dietary intakes and salivary concentrations of calcium or phosphate. Children who did not have caries experience (d3mft/D3MFT=0) during the entire follow-up had higher salivary calcium than those who had caries already at 3 years of age. The association between salivary calcium and caries onset was significant up to 12 years of age. Toothbrushing frequency was statistically significantly associated with caries-onset at ages 6 (gamma statistic 0.457, p=0.046) and 12 years (gamma statistic 0.473, p=0.019).

CONCLUSIONS

The current long-term dietary intervention increased children's paraffin-stimulated salivary flow rate. The concentration of salivary calcium was directly correlated to dental health. Higher salivary flow rate in the intervention group is believed to be due to higher fibre intake in the intervention group.

Axial and radial waveforms in common carotid artery: an advanced method for studying arterial elastic properties in ultrasound imaging

Our objective was to develop a method for studying the biomechanics of the common carotid artery (CCA) by evaluating both radial and less known axial distension of the arterial wall. We developed software capable of tracking the movements of different arterial wall layers from ultrasound recordings of CCA, and we then calculated several indices of arterial stiffness. The wide spectrum of arterial stiffness indices defined from one measurement is a unique feature of our method. The motion-tracking algorithm is based on 2-D cross-correlation enhanced with luminance optimizations. The repeatability and reproducibility of the motion tracking were evaluated by performing 10-s ultrasound recordings of left CCA twice to 19 healthy volunteers (11 women, 8 men, age 41.3 ± 14.3 y). The method revealed a biphasic axial movement of the CCA and demonstrated that the indices of arterial stiffness defined from radial movement of carotid artery are reproducible (Cronbach's α, 0.59-0.97) as well as the indices from axial movement are reproducible (Cronbach's α, -0.68 to 0.93). The good reproducibility of the motion tracking is evidence that this method of studying arterial elastic properties is adequate for in vivo studies.

Early nutrition patterns and diseases of adulthood: a plausible link?

In the last decades several studies tested the hypothesis that at early development stages certain foods or nutrients, in specific amounts, fed during limited sensitive periods, may determine an endocrine metabolic asset leading to clinical alterations that take place decades later (early nutritional programming of long term health). Evidence is mounting for programming effects of infant feeding. Observational studies indicate that breast feeding, relative to formula feeding, reduces the risk for obesity at school age by about 20% even after adjustment for biological and sociodemographic confounders. Moreover, breastfeeding is constantly associated with increased neurodevelopmental scores up to early adulthood, while its outcome in terms of delayed decay of brain function is still unknown. Besides the environment surrounding breastfeeding, specific nutrients within human milk may play a direct role. With the introduction of solids the major changes in diet are represented by the sudden decrease of fat intake from 50 to 30% of total energy. A protein excess, commonly found throughout all European Countries, has been associated to a higher risk of adiposity in early childhood, as confirmed by first reports from a large European trial. The amount of fat does not seem to be associated with later adiposity, while its quality may affect blood lipoproteins, blood pressure and neurodevelopmental performance. Early intake of dietary fibers might also have beneficial effects. Epidemiologic data show that episodes of rapid growth (growth acceleration hypothesis), whichever the dietary habits, are associated with later unfavorable health conditions and should be prevented.

Role of fats in the first two years of life as related to later development of NCDs

AIMS

Compared to exclusive breastfeeding, the introduction of solids leads to a reduction of dietary fats. We explore the hypothesis that dietary fats consumed in the 6-24-month period might have later effects on non-communicable disorders and health.

DATA SYNTHESIS

We have considered studies on dietary fats as substrate for oxidation and energy production, effects on adiposity, blood lipoprotein levels and features of the metabolic syndrome, and the possible influences on brain development and function. Fat oxidation, despite a high initial dietary supply, is greatly suppressed and only gradually increases after birth. There is no evidence of any convincing association between fat intake during the 6-24-month period and later indices of adiposity. Fat quality may affect the blood lipoprotein picture at short-term through the first 12 months of life. In a large Finnish trial, a moderately restricted fat diet started at 7 months, with an increased unsaturated/saturated fat ratio, has shown favourable effects on serum cholesterol values, indices of insulin resistance and endothelial function especially in boys, and had no negative effects until the age of 18 years. The dietary supply of docosahexaenoic acid might affect brain development as well as some features of the metabolic syndrome.

CONCLUSIONS

In the 6-24-month period, the amount of fat intake does not show associations with later health conditions, and relatively high-fat diets do not seem to be harmful. Fat quality may have later effects on chronic-degenerative processes that need to be explored more in depth.

Left ventricular mass and geometry in adolescence: early childhood determinants

It is not known whether birth weight and early childhood growth are associated with the development of cardiac left ventricular mass (LVM) in healthy adolescents. Left ventricular growth and geometric remodeling may have long-term consequences on cardiovascular health later in life. We studied the determinants of LVM and patterns of geometric remodeling in adolescents with specific emphasis on birth size and growth in early childhood. Left ventricular measurements were obtained with echocardiography in 418 adolescents at the age of 15 years in a prospective atherosclerosis prevention study, Special Turku Coronary Risk Factor Intervention Project (STRIP). Birth weight (P=0.0004), current pulse pressure (P=0.013), physical activity level (P=0.0024), weight (P<0.0001), and male sex (P<0.001) had an independent direct association with LVM in adolescents explaining 47% of the variation. Growth in early childhood was not associated with LVM in adolescents. Birth weight (P=0.0066), current weight (P<0.0001), and physical activity level (P=0.0017) were directly associated with left ventricular posterior wall thickness. Current weight was also directly associated with septal thickness (P<0.0001). Boys had a thicker septum than girls (P=0.0092). Normal relative wall thickness and increased left ventricular mass index (eccentric remodeling) (P<0.0001), as well as increase in both variables (concentric, increased LVM) (P=0.0003), were associated with higher body mass index. Our results indicate that birth weight has a long-lasting impact on LVM and normal body weight is beneficial for cardiac structure in adolescents.

When and how to start prevention of atherosclerosis? Lessons from the Cardiovascular Risk in the Young Finns Study and the Special Turku Coronary Risk Factor Intervention Project

This review provides an up-to-date summary of findings from two ongoing population-based, prospective studies conducted in Finland: The Cardiovascular Risk in Young Finns Study, and the Special Turku Coronary Risk Factor Intervention Project (STRIP), which have contributed significantly to the scientific literature concerning the childhood origin of cardiovascular disease, and whether prevention efforts in adults can be expanded to young people. From the Young Finns Study, we summarize evidence demonstrating childhood risk factors to be associated with both risk factors and preclinical markers of atherosclerosis in adulthood, and from STRIP, we summarize evidence showing that supervised dietary counseling of a low saturated fat diet effectively decreases exposure to cardiovascular risk factors without affecting growth and development of healthy children and adolescents. The evidence available from these studies supports that the ability to prevent or delay the risk of premature atherosclerosis and its clinical sequelae later in life lies in maintaining a low lifetime risk by preventing the development of risk factors in early life.

Early determinants of obesity: genetic, epigenetic, and in utero influences

There is an emerging body of work indicating that genes, epigenetics, and the in utero environment can impact whether or not a child is obese. While certain genes have been identified that increase one's risk for becoming obese, other factors such as excess gestational weight gain, gestational diabetes mellitus, and smoking can also influence this risk. Understanding these influences can help to inform which behaviors and exposures should be targeted if we are to decrease the prevalence of obesity. By helping parents and young children change certain behaviors and exposures during critical time periods, we may be able to alter or modify one's genetic predisposition. However, further research is needed to determine which efforts are effective at decreasing the incidence of obesity and to develop new methods of prevention. In this paper, we will discuss how genes, epigenetics, and in utero influences affect the development of obesity. We will then discuss current efforts to alter these influences and suggest future directions for this work.

Ideal cardiovascular health in childhood and cardiometabolic outcomes in adulthood: the Cardiovascular Risk in Young Finns Study

BACKGROUND

The American Heart Association (AHA) defined a new concept, cardiovascular health, and determined metrics needed to monitor it over time as part of its 2020 Impact Goal definition. Ideal cardiovascular health is defined by the presence of both ideal health behaviors and ideal health factors. The applicability of this concept to a cohort of children and its relationship with cardiometabolic outcomes in adulthood has not been reported.

METHODS AND RESULTS

The sample comprised 856 participants aged 12 to 18 years (mean age 15.0 years) from the Cardiovascular Risk in Young Finns Study cohort. Participants were followed up for 21 years since baseline (1986) and had data available concerning health factors and behaviors in childhood and cardiometabolic outcomes in adulthood (2007). The number of ideal cardiovascular health metrics present in childhood was associated with reduced risk of hypertension (odds ratio [95% confidence interval] 0.66 [0.52-0.85], P<0.001), metabolic syndrome (0.66 [0.52-0.77], P<0.001), high low-density lipoprotein cholesterol (0.66 [0.52-0.85], P=0.001), and high-risk carotid artery intima-media thickness (0.75 [0.60-0.94], P=0.01) in adulthood. All analyses were age and sex adjusted, and the results were not altered after additional adjustment with socioeconomic status.

CONCLUSIONS

The number of ideal cardiovascular health metrics present in childhood predicts subsequent cardiometabolic health in adulthood. Our findings suggest that pursuit of ideal cardiovascular health in childhood is important to prevent cardiometabolic outcomes in adulthood.

Effect of repeated dietary counseling on serum lipoproteins from infancy to adulthood

BACKGROUND AND OBJECTIVE

As atherosclerosis is a lifelong process, prevention of exposure to its risk factors should start at an early age. Our aim was to study the influences of repeated low saturated fat dietary counseling on dietary intakes and lipoprotein measures from infancy to adulthood.

METHODS

Dietary intakes (food records) and serum lipid profile were studied annually from 7 months to 19 years of age in an atherosclerosis prevention study (Special Turku Coronary Risk Factor Intervention Project), comprising 540 children in the intervention group and 522 children in the control group. Serum total and high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG) were measured and used to estimate very low-density lipoprotein-TG, intermediate-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and HDL(2)-C, as well as apolipoproteins A-1 and B.

RESULTS

Compared with controls, the intervention children had a lower saturated fat intake (mean daily difference [95% confidence interval] between groups: -2.1 [-2.3, -1.9] percentage of total energy intake in boys; -1.9 [-2.1, -1.7] percentage of total energy intake in girls, both P < .001) and LDL-C concentration (difference [95% confidence interval] between groups: -0.18 [-0.26, -0.10] mmol/L, P < .001 in boys; -0.10 [-0.19, -0.01] mmol/L, P = .037 in girls), whereas HDL-C and apolipoprotein A-1 did not differ between the study groups. In boys, total cholesterol and intermediate-density lipoprotein cholesterol, very low-density lipoprotein-TG, apolipoprotein B, and TG concentrations were also lower in the intervention than in the control group, whereas no differences were found in girls.

CONCLUSIONS

Repeated dietary counseling is effective in decreasing saturated fat intake and serum LDL-C values from infancy until 19 years of age in both genders. In boys, significant intervention effects are evident in various lipoprotein measures, indicating a more favorable lipid profile in the counseling group.

A review of the evidence for the effects of total dietary fat, saturated, monounsaturated and n-6 polyunsaturated fatty acids on vascular function, endothelial progenitor cells and microparticles

Vascular dysfunction is recognised as an integrative marker of CVD. While dietary strategies aimed at reducing CVD risk include reductions in the intake of SFA, there are currently no clear guidelines on what should replace SFA. The purpose of this review was to assess the evidence for the effects of total dietary fat and individual fatty acids (SFA, MUFA and n-6 PUFA) on vascular function, cellular microparticles and endothelial progenitor cells. Medline was systematically searched from 1966 until November 2010. A total of fifty-nine peer-reviewed publications (covering fifty-six studies), which included five epidemiological, eighteen dietary intervention and thirty-three test meal studies, were identified. The findings from the epidemiological studies were inconclusive. The limited data available from dietary intervention studies suggested a beneficial effect of low-fat diets on vascular reactivity, which was strongest when the comparator diet was high in SFA, with a modest improvement in measures of vascular reactivity when high-fat, MUFA-rich diets were compared with SFA-rich diets. There was consistent evidence from the test meal studies that high-fat meals have a detrimental effect on postprandial vascular function. However, the evidence for the comparative effects of test meals rich in MUFA or n-6 PUFA with SFA on postprandial vascular function was limited and inconclusive. The lack of studies with comparable within-study dietary fatty acid targets, a variety of different study designs and different methods for determining vascular function all confound any clear conclusions on the impact of dietary fat and individual fatty acids on vascular function.

Association of Physical Activity With Vascular Endothelial Function and Intima-Media Thickness

Background—

Impairment of vascular endothelial function and increased intima-media thickness (IMT) are important early steps in atherogenesis. Longitudinal data on the effect of physical activity on endothelial function and IMT in healthy adolescents are lacking. We investigated prospectively the association of leisure-time physical activity with endothelial function (brachial artery flow-mediated dilatation; FMD) and aortic IMT in adolescents.

Methods and Results—

FMD and IMT were measured with ultrasonography at 13 (n=553), 15 (n=531), and 17 (n=494) years of age in adolescents participating in a longitudinal atherosclerosis prevention study (Special Turku Coronary Risk Factor Intervention Project for Children). Mean aortic IMT, maximum FMD, and total FMD response (area under the dilatation curve 40 to 180 seconds after hyperemia) were calculated. Leisure-time physical activity was assessed with a questionnaire, and metabolic equivalent (MET) hours per week of leisure-time physical activity were calculated by multiplying weekly mean exercise intensity, duration, and frequency. Leisure-time physical activity was directly associated with endothelial function ( P for maximum FMD=0.0021, P for total FMD response=0.0036) and inversely with IMT ( P =0.011) after adjustment for age, sex, body mass index, high-density lipoprotein/total cholesterol, systolic blood pressure, and C-reactive protein and regarding FMD brachial artery diameter. Sedentary adolescents who increased their leisure-time physical activity from <5 to >5 (IMT) or >30 (maximum FMD) MET h/wk between 13 and 17 years of age had an increased maximum FMD ( P =0.031) and decreased progression of IMT ( P =0.047) compared with adolescents who remained sedentary. IMT progression was attenuated in persistently active adolescents compared with those who became sedentary ( P =0.0072).

Conclusions—

Physical activity is favorably associated with endothelial function and IMT in adolescents. Importantly, a moderate increase in physical activity is related to decreased progression of IMT. A physically active lifestyle seems to prevent the development of subclinical atherosclerotic vascular changes in healthy adolescents.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00223600 (STRIP19902010).

Tracking of serum lipid levels, blood pressure, and body mass index from childhood to adulthood: the Cardiovascular Risk in Young Finns Study

OBJECTIVES

To examine tracking and predictiveness of childhood lipid levels, blood pressure, and body mass index for risk profile in adulthood and the best age to measure the childhood risk factor levels.

STUDY DESIGN

Study subjects were participants of the longitudinal Cardiovascular Risk in Young Finns Study, started in 1980 (age 3, 6, 9, 12, 15, and 18 years). A total of 2204 subjects participated to the 27-year follow-up in 2007 (age, 30 to 45 years).

RESULTS

In both sex groups and in all age groups, childhood risk factors were significantly correlated with levels in adulthood. The correlation coefficients for cholesterol levels and body mass index were 0.43 to 0.56 (P < .0001), and for blood pressure and triglyceride levels, they were 0.21 to 0.32 (P < .0001). To recognize children with abnormal adult levels, the National Cholesterol Education Program and the National High Blood Pressure Education Program cutoff points for lipid and blood pressure values and international cutoff points for overweight and obesity were used. Age seemed to affect associations. The best sensitivity and specificity rates were observed in 12- to 18-year-old subjects.

CONCLUSIONS

Childhood blood pressure, serum lipid levels, and body mass index correlate strongly with values measured in middle age. These associations seemed to be stronger with increased age at measurements.

Parental eating attitudes and indicators of healthy eating in a longitudinal randomized dietary intervention trial (the STRIP study)

OBJECTIVE

To examine the effects of child-oriented dietary intervention on parental eating attitudes and dietary behaviour.

DESIGN

In the prospective, randomized Special Turku Coronary Risk Factor Intervention Project for Children (the STRIP study), a cohort of Finnish families took part in a nutritional intervention trial focused on the quality of their children's fat intake since the age of 8 months. Health-related and hedonic eating attitudes of the parents were measured after 10 years of dietary intervention using a validated Health and Taste Attitude Scales (HTAS) questionnaire (n 660). Parents' eating behaviour was studied using a 1 d food record (n 491).

SETTING

Finland.

SUBJECTS

Mothers and fathers (n 660) of the STRIP children.

RESULTS

The parents of the intervention families had a higher level of interest in healthy eating compared with control parents. The interest in natural products or hedonic eating attitudes did not differ between the groups. The parents' general health interest was associated with low saturated fat intake, fruit and vegetable consumption, fibre intake and seeking pleasure in eating, but it was not associated with BMI. The intervention also improved the quality of dietary fat among parents with the lowest level of interest in healthy eating.

CONCLUSIONS

Parents' general health interest was associated with regular dietary counselling as well as with healthier food choice behaviour. However, the dietary intervention that focused especially on the quality of the child's fat intake also enhanced specific changes in the family's fat consumption without a high level of interest in healthy eating.

Effect of infancy-onset dietary intervention on salivary cholesterol of children: a randomized controlled trial

This study investigated salivary cholesterol of children from 6 to 16 years of age in response to dietary intervention. One thousand sixty-two infants started in the prospective, randomized project. At 3 years of age, every fifth child was invited into the study (n=178). Of these, 148 enrolled, and 86 completed the oral sub-study at 16 years of age. The intervention aimed at restricting the child's saturated fat and cholesterol intake. Control children received no special recommendations. Every third year, paraffin-stimulated saliva samples (10.0 mL) were collected for cholesterol assays. Nutrient intakes and serum total cholesterol concentrations were regularly followed up by means of 4-day food records and blood samples. Intake of saturated fatty acids (SAFA) was lower in the intervention than in the control group (p<0.001). Salivary cholesterol concentration increased from 1.9 (±1.1) µmol/L at 6 years of age to 16.0 (±9.0) µmol/L at 16 years of age. The increase was smaller in the intervention than in the control group (p<0.001). The ratios of salivary to serum cholesterol concentrations tended to be higher in boys than in girls (p=0.07). Thus, dietary intervention was reflected in children's salivary cholesterol values more sensitively than in serum cholesterol values. (clinicaltrials.gov NCT00223600).

Rationale and design of dal-VESSEL: a study to assess the safety and efficacy of dalcetrapib on endothelial function using brachial artery flow-mediated vasodilatation

OBJECTIVE

Dalcetrapib increases high-density lipoprotein cholesterol (HDL-C) levels through effects on cholesteryl ester transfer protein (CETP). As part of the dalcetrapib dal-HEART clinical trial programme, the efficacy and safety of dalcetrapib is assessed in coronary heart disease (CHD) patients in the dal-VESSEL study (ClinicalTrials.gov identifier: NCT00655538), the design and methods of which are presented here. RESEARCH DESIGN AND STUDY METHOD: Men and women with CHD or CHD risk equivalent, with HDL-C levels <50  mg/dL were recruited for a 36-week, double-blinded, placebo-controlled trial. After a pre-randomisation phase of up to 8 weeks, patients received dalcetrapib 600  mg/day or placebo in addition to their existing treatments. Brachial flow-mediated dilatation (FMD) measured by B-mode ultrasound represents endothelial function and is a validated marker for early atherosclerosis and cardiovascular disease risk.

MAIN OUTCOME MEASURES

The primary efficacy outcome is change from baseline in brachial FMD after 12 weeks. The primary safety endpoint is 24-hour ambulatory blood pressure monitoring (ABPM) assessed at week 4. Secondary endpoints include brachial FMD at 36 weeks, ABPM at 12 and 36 weeks, lipid profile, CETP mass and activity, and markers of inflammation, oxidation, and cardiovascular risk. Clinical endpoints are assessed as a composite endpoint for the dal-HEART Program.

CURRENT STATUS

In 19 European clinical centres, 476 subjects met inclusion criteria and have entered the study. In conclusion, the dal-VESSEL study is the largest multicentre trial with brachial FMD ever performed. The study assesses efficacy and safety of dalcetrapib on endothelial function, blood pressure, lipids, and clinical outcomes in CHD patients with below average HDL-C and will therefore provide vital information regarding its potential role in the preventative treatment of CHD risk.

Combined hyperlipidemia in patients with lysinuric protein intolerance

BACKGROUND AND AIMS

Lysinuric protein intolerance (LPI) is an autosomal recessive disorder characterized by defective transport of cationic amino acids lysine, arginine, and ornithine. Low plasma concentrations of arginine and ornithine lead to impaired urea cycle function and, subsequently, decreased protein tolerance. Patients often develop natural aversion to protein-rich foods, which may predispose them to nutritional problems. The objective of this retrospective study was to investigate lipid values and efficacy of lipid-lowering therapy in patients with LPI.

METHODS AND RESULTS

Serum total and high-density-lipoprotein (HDL)-cholesterol and triglyceride concentrations were analyzed in 39 Finnish LPI patients (14 males) aged 3-64 years. Dietary intakes were analyzed from food records. Mean [standard deviation (SD)] serum and HDL-cholesterol and triglyceride concentrations were 7.16 (2.13) mmol/l, 1.21 (0.58) mmol/l, and 4.0 (2.4) mmol/l, respectively. Patients with renal dysfunction had marginally higher total cholesterol and significantly higher triglyceride concentration than patients without renal impairment. Twenty-two patients were started on 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (atorvastatin or simvastatin). After 6 months, serum cholesterol and triglyceride concentrations had decreased by 32% (p < 0.001), whereas HDL-cholesterol had increased by 13% (p = 0.016).

CONCLUSION

Serum cholesterol and triglyceride values are markedly elevated in LPI patients. Although the mechanism of combined hyperlipidemia remains unknown and is not explained by fat consumption, hyperlipidemia is clearly progressive with age, suggesting that starting statin therapy early is probably beneficial. Statins are well-tolerated and efficacious in LPI.

Influence of age on associations between childhood risk factors and carotid intima-media thickness in adulthood: the Cardiovascular Risk in Young Finns Study, the Childhood Determinants of Adult Health Study, the Bogalusa Heart Study, and the Muscatine Study for the International Childhood Cardiovascular Cohort (i3C) Consortium

BACKGROUND

Atherosclerosis has its roots in childhood. Therefore, defining the age when childhood risk exposure begins to relate to adult atherosclerosis may have implications for pediatric cardiovascular disease prevention and provide insights about the early determinants of atherosclerosis development. The aim of this study was to investigate the influence of age on the associations between childhood risk factors and carotid artery intima-media thickness, a marker of subclinical atherosclerosis.

METHODS AND RESULTS

We used data for 4380 members of 4 prospective cohorts-Cardiovascular Risk in Young Finns Study (Finland), Childhood Determinants of Adult Health study (Australia), Bogalusa Heart Study (United States), and Muscatine Study (United States)-that have collected cardiovascular risk factor data from childhood (age 3 to 18 years) and performed intima-media thickness measurements in adulthood (age 20 to 45 years). The number of childhood risk factors (high [highest quintile] total cholesterol, triglycerides, blood pressure, and body mass index) was predictive of elevated intima-media thickness (highest decile) on the basis of risk factors measured at age 9 years (odds ratio [95% confidence interval] 1.37 [1.16 to 1.61], P=0.0003), 12 years (1.48 [1.28 to 1.72], P<0.0001), 15 years (1.56 [1.36 to 1.78], P<0.0001), and 18 years (1.57 [1.31 to 1.87], P<0.0001). The associations with risk factors measured at age 3 years (1.17 [0.80 to 1.71], P=0.42) and 6 years (1.20 [0.96 to 1.51], P=0.13) were weaker and nonsignificant.

CONCLUSIONS

Our analyses from 4 longitudinal cohorts showed that the strength of the associations between childhood risk factors and carotid intima-media thickness is dependent on childhood age. On the basis of these data, risk factor measurements obtained at or after 9 years of age are predictive of subclinical atherosclerosis in adulthood.

Parental and childhood overweight in sedentary and active adolescents

We studied whether the prevalence of overweight since age 2 years differed in sedentary and active adolescents (N=346). Further, we analyzed the energy intake of sedentary and active adolescents across 12 years. BMI was assessed annually since birth, energy intake since age 13 months and parents' BMI from the time their child was 7 months old in a longitudinal atherosclerosis prevention study. Data on physical activity were collected at age 13 years (N=560). Sedentary and Active groups were formed by upper and lower physical activity tertile cut-points. Girls Sedentary at 13 years were more often overweight than Active peers already since age 2 years (P=0.048). Activity habits were not associated with energy intake. Conversely, among boys, activity habits in adolescence were not associated with childhood overweight, while the energy intake of Active boys was higher than that of Sedentary boys (P=0.008). Parental overweight was not associated with the physical activity of children; however, Sedentary girls more often had an overweight mother than Active girls (P=0.021). In conclusion, overweight during early years of life is more common among girls who are Sedentary as adolescents than in Active peers. Overweight mothers more often have Sedentary daughters than normal-weight mothers. A healthy lifestyle right from early childhood requires active support.

Cardiovascular sex differences influencing microvascular exchange

The vital role of the cardiovascular (CV) system is maintenance of body functions via the matching of exchange to tissue metabolic demand. Sex-specific differences in the regulatory mechanisms of CV function and the metabolic requirements of men and women, respectively, have been identified and appreciated. This review focuses on sex differences of parameters influencing exchange at the point of union between blood and tissue, the microvasculature. Microvascular architecture, blood pressure (hydrostatic and oncotic), and vascular permeability, therefore, are discussed in the specific context of sex in health and disorders. It is notable that when sex differences exist, they are generally subtle but significant. In the aggregate, though, they can give rise to profoundly different phenotypes. The postulated mechanisms responsible for sex differences are attributed to genomics, epigenetics, and sex hormones. Depending on specific circumstances, the effect of the combined factors can range from insignificant to lethal. Identifying and understanding key signalling mechanisms bridging genomics/sex hormones and microvascular exchange properties within the scope of this review holds significant promise for sex-specific prevention and treatment of vascular barrier dysfunction.

Dietary fiber does not displace energy but is associated with decreased serum cholesterol concentrations in healthy children

BACKGROUND

Dietary fiber has health benefits, but fiber recommendations for children are controversial because fiber may displace energy.

OBJECTIVE

The objective was to longitudinally evaluate dietary fiber intake in children and to study associations between growth variables, serum cholesterol concentrations, and intakes of fiber, energy, and nutrients.

DESIGN

Altogether, 543 children from a prospective randomized atherosclerosis prevention trial (the Special Turku Coronary Risk factor Intervention Project; STRIP) participated in this study between the ages of 8 mo and 9 y. The intervention children (n = 264) were counseled to replace part of saturated fat with unsaturated fat. Nutrient intakes, weight, height, and serum total, HDL-, and LDL-cholesterol and triglyceride concentrations were analyzed. Children were divided into 3 groups according to mean dietary fiber intake in foods: low (lowest 10%), high (highest 10%), and average (middle 80%) fiber intakes.

RESULTS

Fiber intake associated positively with energy intake and inversely with fat intake. Children with a high fiber intake received more vitamins and minerals than did children in other groups. In longitudinal growth analyses, weights and heights were similar in all 3 fiber intake groups, and fiber intake (g/d) associated positively with weight gain between 8 mo and 2 y. Serum cholesterol concentrations decreased with increasing fiber intakes. Children in the intervention group had a higher fiber intake than did the control children during the entire follow-up period.

CONCLUSION

Fiber intake did not displace energy or disturb growth between 13 mo and 9 y of age. Serum cholesterol values correlated inversely with fiber intake, which indicated that part of the cholesterol-lowering intervention effect in the STRIP project may have been explained by dietary fiber.