Nutrition and Children
A Statement for Healthcare Professionals From the Nutrition Committee, American Heart Association
The American Heart Association, the National Cholesterol Education Program (NCEP), and the Food and Drug Administration advocate “heart-healthy” diets for adults. The major goal of such diets is to restrict the total intake of fats, especially saturated fat and cholesterol, which have the potential to raise plasma levels of low density lipoprotein (LDL) cholesterol, a major risk factor for developing coronary artery disease. The AHA Step I diet recommends (1) that calories consumed as fat not exceed 30% of total calories consumed per day, (2) that calories consumed as saturated fat equal no more than 8% to 10% of total calories consumed per day, and (3) that total cholesterol intake be less than 300 mg/d. Although it is well established that the Step I diet is safe and beneficial for adults, some controversy surrounds the benefits and safety of this type of diet for children. For example, because the clinical manifestations of atherosclerosis usually do not develop until well into adulthood, it has been argued that institution of the AHA Step I diet in childhood is of little benefit and may even be hazardous by inducing nutritional deficiencies compromising growth and development. The Nutrition Committee has reviewed the evidence concerning the safety and efficacy of the AHA Step I diet in children. The Step I diet can be safely recommended for the majority of children and will ultimately result in a lower frequency of coronary artery disease in the general population.
Studies of the early stages of atherosclerosis in children and young adults began in the 1950s and have consistently shown the presence of arterial deposits of fats and early plaques at young ages.1 Recently the most systemic and rigorous test of the hypothesis that atherosclerosis begins in childhood and is influenced by risk factors for adult coronary artery disease was undertaken. The Pathological Determinants of Atherosclerosis in Youth (PDAY) study examined over 1500 persons aged 15 to 34 years, most of whom died from accidental or traumatic causes, for evidence of arterial lesions and risk factors such as smoking, hyperlipidemia, and diabetes.2 The extent of fatty and fibrous arterial lesions increased with age. The risk factor most closely associated with arterial lesions was the LDL serum cholesterol concentration measured postmortem. Smoking, adiposity, glycohemoglobin,3 and hypertension (as indicated by renal vascular lesions4 ) also were closely associated with arterial lesions, particularly advanced plaques. These early results provide compelling data that starting a heart-healthy diet before adulthood reduces the prevalence of obesity and elevations in serum cholesterol levels and blood pressure that commonly occur in adults, thereby retarding the rate of progression of atherosclerosis and delaying the onset of clinical coronary artery disease.
The major safety issue that has been considered is whether a heart-healthy diet will support the special needs of childhood, growth and development.
Because growth and development in early childhood occur in the context of a milk-based diet naturally high in saturated fat and cholesterol, the AHA Step I diet is not proposed for children less than 2 years old.
In children older than 2 years, the safety of a diet with a total fat intake in the range of 30% has been amply shown in both survey and prospective studies. In the Third National Health and Nutrition Examination Survey (NHANES III), the decrease in the average level of fat intake from the second survey in children aged 3 to 19 years did not result in an increased prevalence of poor growth or weight gain.5 Another survey found no difference in intake of specific micronutrients between children whose fat intake was 28% to 30% of total calories and children consuming higher-fat diets.6 In a prospective study (Dietary Intervention Study in Children [DISC]) involving more than 600 children aged 8 to 10 years with elevated LDL-cholesterol levels, the subjects consumed one of two diets: a diet designed to provide 28% of calories as fat, 10% as saturated fat, and 95 mg cholesterol per day, and the subjects’ “usual” diet containing 33% to 34% of calories as fat, 13% as saturated fat, and 112 mg cholesterol per day, respectively. There were no differences between the two groups in any variables tested (height, weight, micronutrients, or psychological well-being) except for a small but significant reduction of LDL cholesterol in the group consuming less dietary fat.7
Another source of concern has been that the dietary recommendations are population based and that persons who are overly zealous about diet or those already eating a heart-healthy diet may drastically reduce their intake of foods with a fat content containing essential fatty acids, vitamins, and other specific nutrients. For this reason, the Nutrition Committee does not recommend consumption of diets with very low total fat intake and has established a limit of no less than 15% total fat intake for adults. The American Academy of Pediatrics recommends a total fat intake of no less than 20% in children older than 2 years.8 In the 15% to 20% range of fat intake, there should be no deficiencies of fat-associated nutritional factors, such as vitamins A, D, and E and long-chain polyunsaturated essential fatty acids.
Rigorous and ongoing research shows that atherosclerosis begins in children and the extent of early arterial involvement is strongly associated with LDL-cholesterol levels. When started in childhood, diets restricted in components that elevate LDL cholesterol (saturated fat and cholesterol) have the long-term potential to decrease the frequency of coronary artery disease and the extent of clinical disease later in adulthood.
Recent surveys of childhood nutritional intake have shown averages of 33% to 35% of total food energy intake coming from fat, with 12% to 13% of calories from saturated fat.5 Despite improvements compared with intake patterns of previous decades, both of these values are higher than those of the AHA Step I diet (no more than 30% and 10% of total calories, respectively). However, the elevations are relatively modest, so that often only minor changes in food selection and dietary habits are necessary to achieve the recommended goals. After the age of 2, when the diet becomes progressively more varied and includes foods prepared both in and out of the home, a gradual transition to a heart-healthy diet can be accomplished by replacing foods rich in fat with grains, fruits, lean meat, and other foods low in fat and high in complex carbohydrates and protein.
The Nutrition Committee strongly believes that the AHA Step I Diet supports normal growth and development in children older than 2 years so that limiting the amount of fat and cholesterol consumed should be a family concern, not just something parents do for themselves.
“Nutrition and Children” was approved by the American Heart Association Science Advisory and Coordinating Committee in December 1996.
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- Copyright © 1997 by American Heart Association
Kleinman RE, Finberg LF, Klish WJ, Lauer RM. Dietary guidelines for children. J Nutr.. 1996;126:1028S-1030S.
McGill HC Jr, McMahan CA, Malcom GT, Oalmann MC, Strong JP. Relation of glycohemoglobin and adiposity to atherosclerosis in youth: Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. Arterioscler Thromb Vasc Biol.. 1995;15:431-440.
McGill HC Jr, Strong JP, Tracy RE, McMahan CA, Oalmann MC. Relation of a postmortem renal index of hypertension to atherosclerosis in youth: Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. Arterioscler Thromb Vasc Biol.. 1995;15:2222-2228.
McPherson RS, Nichaman MZ, Kohl HW, Reed DB, Labarthe DR. Intake and food sources of dietary fat among school children in The Woodlands, Texas. Pediatrics.. 1990;86:520-526.
Lauer RM, et al. Cholesterol in childhood. Elk Grove, Ill: American Academy of Pediatrics. Statement. In press.