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Overrestriction of Dietary Fat Intake Before Formal Nutritional Counseling in Children With Hyperlipidemia
Abha Kaistha, MD;
Richard J. Deckelbaum, MD;
Thomas J. Starc, MD;
Sarah C. Couch, PhD, RD
Arch Pediatr Adolesc Med. 2001;155:1225-1230.
ABSTRACT
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Objective To assess the nutritional adequacy of the diets of children with hyperlipidemia
following medically unsupervised low-fat diets compared with children receiving
unrestricted diets.
Design Case comparison study.
Patients and Other Participants Forty-six children were referred to the Children's Cardiovascular Health
Center, Columbia–Presbyterian Medical Center, New York, NY, for treatment
of hyperlipidemia who had achieved the Step I diet recommendations for total
fat before formal nutritional counseling (mean age ± SE, 9.7 ±
0.3 years; sex distribution, 24 boys [53%]; ethnicity, 26 Latinos [57%] and
20 whites [43 %]; body mass index ± SE, 22.4 ± 0.7 kg/m2), and 34 healthy children participating in well-child visits at a
local pediatric practice (mean age ± SE, 10.2 ± 0.4 years; sex
distribution, 18 boys [54%]; ethnicity, 19 Latinos [57%] and 15 whites [43%];
body mass index ± SE, 22.5 ± 1.1 kg/m2).
Main Outcome Measures Three-day food records were analyzed by a registered dietitian using
the Minnesota Nutrient Data System. Outcome measures were intakes of calories,
total and saturated fats, carbohydrate, protein, essential fatty acids, fat-soluble
vitamins, folate, vitamin C, calcium, iron, and zinc.
Results The percentage of calories from fat and saturated fat was significantly
lower in the hyperlipidemic population (mean ± SE, hyperlipidemic vs
control subjects: total fat, 22.7% ± 0.7% vs 34.5% ± 0.6%, P<.001; saturated fat, 7.9% ± 0.3% vs 12.9% ± 0.4%, P<.001). The caloric intake in controls was 17% higher than in patients
with hyperlipidemia. Ninety percent of the decrease in calories in the hyperlipidemic
group could be accounted for by the decrease in total fat intake. After adjusting
for calories, no significant difference was noted between the groups for any
of the vitamins and minerals mentioned earlier.
Conclusion Our findings suggest that before formal nutritional counseling, overzealous
dietary fat restriction can occur in children with hypercholesterolemia.
INTRODUCTION
THERE IS strong evidence to suggest that blood cholesterol levels, specifically
low-density lipoprotein cholesterol (LDL-C) concentrations, in children play
an integral role in the development and progression of coronary heart disease
in later life.1, 2, 3, 4
Dietary modification of fat, saturated fat, and cholesterol intake have been
shown to decrease elevated LDL-C concentrations in children,5, 6, 7
and many professional organizations have made recommendations to decrease
dietary sources of these nutrients in both pediatric and adult populations.
The Expert Panel on Blood Cholesterol Levels in Children and Adolescents of
the National Cholesterol Education Program (NCEP) and the American Heart Association
have recommended that children consume a diet containing 30% or less of calories
from total fat, less than 10% of calories from saturated fat, and less than
300 mg/d of cholesterol.8 For those with severe
hypercholesterolemia (persistent LDL-C >130 mg/dL [3.36 mmol/L]), a further
reduction in saturated fat (<7% of calories) and cholesterol (<200 mg/d)
has been advised.
While the NCEP and American Heart Association dietary guidelines have
been shown to lower LDL-C levels in children with hyperlipidemia and promote
optimal growth and development when medically supervised,9
case reports have suggested that parent-imposed low-fat diets in the absence
of nutritional counseling may have a negative effect on growth and development.10 This finding is of concern given the recent increase
in the number of children being screened and diagnosed as having high blood
cholesterol levels.11 Often between the point
of diagnosis of hyperlipidemia and the receipt of formal nutritional counseling,
many parents are left to their own devices, or provided with minimal guidance
from pediatricians regarding the appropriate approach to take when initiating
a cholesterol-lowering diet. Although parents can successfully achieve the
NCEP guidelines for fat and cholesterol reduction in their children's diets
without formal nutritional counseling,12, 13
we question whether the caloric and micronutrient levels of these self-imposed
cholesterol-lowering diets may be compromised. Many foods containing high
amounts of total and saturated fats and cholesterol also contain significant
quantities of calories, zinc, calcium, iron, and fat-soluble vitamins. These
foods, and consequently these important nutrients, may be unnecessarily restricted
in an attempt to implement a low-fat diet. The absence of nutritional counseling
in implementing dietary recommendations may influence the nutrient adequacy
of the resulting meal plans.
This research evaluated the nutritional quality of low-fat diets imposed
by parents of children with hypercholesterolemia before receipt of formal
nutritional counseling. We hypothesized that parent-prescribed cholesterol-lowering
diets would be less nutritionally adequate than unrestricted diets of children
without diagnosed hyperlipidemia.
SUBJECTS AND METHODS
Children with hyperlipidemia were selected from patients referred between
April 1, 1996, and December 31, 1997, to the Children's Cardiovascular Health
Center (CCHC) at Columbia–Presbyterian Medical Center, New York, NY.
The CCHC is a referral program for the diagnosis and treatment of hypercholesterolemia
and other dyslipidemias present in childhood. Children from the tristate area
(ie, Connecticut, New York, and New Jersey), deemed at risk of atherosclerosis
by their pediatrician, are usually referred to the CCHC after the initial
diagnosis of hyperlipidemia is made. At the first visit to the CCHC, a detailed
medical history, physical examination, fasting lipid profile results, and
consent to participate in the program are obtained by the CCHC cardiologist.
Additionally, children are given a 3-day food record by a registered dietitian
with detailed instructions for its completion. This food record is collected
before or at the second visit (approximately 6 weeks from the initial visit).
No formal nutritional counseling is provided to families until the second
visit to the CCHC.
One hundred three children between 2 and 18 years were referred to the
CCHC between April 1, 1996, and December 31, 1997. Of these, 78 children returned
a completed 3-day food record before or at the second visit to the CCHC. Forty-six
of these children were found (through dietary analysis as described below)
to be meeting current NCEP Step I diet recommendations for total fat ( 30%
of calories). These children were considered subjects in this study. No child
included in these analyses had fasting triglyceride levels higher than 400
mg/dL (5.52 mmol/L) (n = 3 subjects) or homozygous LDL-C receptor deficiency
(n = 1 subject). The study population had mean (±SE) total cholesterol,
LDL-C, high-density lipoprotein cholesterol (HDL-C), and total triglyceride
levels that were not statistically significantly different (by t test) from those of all new CCHC patients (study group vs new CCHC
patients: total cholesterol, 229.88 ± 7.74 mg/dL [5.94 ± 0.20
mmol/L] vs 217.49 ± 7.35 mg/dL [5.62 ± 0.19 mmol/L]; LDL-C,
166.80 ± 8.51 mg/dL [4.31 ± 0.22 mmol/L] vs 155.96 ±
7.35 mg/dL [4.03 ± 0.20 mmol/L]; HDL-C, 40.25 ± 1.55 mg/dL [1.04
± 0.04 mmol/L] vs 39.47 ± 1.55 mg/dL [1.02 ± 0.04 mmol/L];
and total triglycerides, 113.28 ± 9.74 mg/dL [1.28 ± 0.11 mmol/L]
vs 110.63 ± 7/97 mg/dL [1.25 ± 0.09 mmol/L]).
Controls were recruited from local pediatric practices in the vicinity
of the Columbia–Presbyterian Medical Center. Children were invited to
participate as controls if their parents stated that they were healthy on
the day of recruitment, were free of chronic illness, and were not following
a modified or restricted diet at the time of the study. All parents signed
informed consent forms before their child participated in the study. The study
was approved by the Columbia–Presbyterian Medical Center institutional
review board.
A registered dietitian or trained research assistant instructed children
and parents on how to complete a 3-day food record. Children were asked to
complete 3 days of food records, including 2 weekdays and 1 weekend day. Children
and parents were trained in estimating portion sizes using common household
measuring utensils. Detailed written instructions with pictures of standard
serving sizes were provided on the food record form to improve self-reporting
of portion sizes and food descriptions. Parents of children 8 years or younger
were asked to complete the food record form with the help of the child. Children
older than 8 years were asked to complete the record with the help of the
parent. No dietary counseling or guidance was given to children or parents
at the time of diet-monitoring instruction. Completed diet records were mailed
or personally delivered to the CCHC. If clarification was needed on amounts
or descriptions of food, children and parents were called or questioned in
person by the CCHC registered dietitian.
Anthropometric data on all children were obtained at the time of diet-monitoring
instruction. Children's Cardiovascular Health Center and pediatric clinic
patients were measured for height (in centimeters) using a rigid stadiometer,
and for weight (in kilograms) using a triple-beam balance scale. Body mass
index (BMI) was calculated from these measures as the weight, in kilograms,
divided by height, in meters squared.
The Minnesota Nutrition Data System software (Version 2.7), developed
by the Nutrition Coordinating Center at the University of Minnesota, Minneapolis,
was used to analyze the food record forms. Multivitamin supplements were included
in the analyses to assess total micronutrient intake. Nutrients analyzed were
calories; total, saturated, polyunsaturated, and monounsaturated fats; linoleic
acid; cholesterol; carbohydrate (including total sugars and starch); dietary
fiber; protein; fat-soluble vitamins; folate; vitamin C; calcium; iron; and
zinc. Macronutrients were expressed as the percentage of total calories. Cholesterol
was expressed as milligrams consumed per day. Calories were expressed in absolute
amounts and as the percentage of the 1989 recommended dietary allowances (RDAs)
based on age and sex.14 Folate, vitamin C,
vitamin D, vitamin E, calcium, vitamin A, zinc, and iron intake were expressed
in absolute amounts and as a percentage of the dietary reference intakes (DRIs)
based on age and sex.15, 16, 17
Statistical analyses were completed using the Statistical Analyses System
program (SAS Institute Inc, Cary, NC). t Tests were
preformed to determine differences between groups for demographic and nutrient
intake data. Analysis of covariance was used to compare group means for nutrient
intake after adjusting for caloric intake. The  2 procedure
was used to compare the observed vs expected frequency of children within
each group for race and sex and for those who were below 75% of the RDA/DRI
for caloric and micronutrient intake.
RESULTS
Subject characteristics are given in Table 1. Groups matched closely for age, racial makeup, sex distribution,
and BMI. No significant differences were noted between groups for these demographic
variables.
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Table 1. Characteristics of the 80 Subjects Studied
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Caloric and macronutrient intakes, with the exception of protein, were
different between the groups (Table 2).
The children with hyperlipidemia had a lower mean caloric intake. Additionally,
the percentage of total calories from fat, saturated fat, polyunsaturated
fat, and monounsaturated fat were significantly lower for the group with hyperlipidemia
compared with the controls. On average, children with hyperlipidemia consumed
well below the NCEP Step I diet, while the controls consumed above these guidelines.
Cholesterol intake was lower in the group with hyperlipidemia vs the controls;
mean intakes of both groups were below NCEP recommendations. Although the
percentage of calories consumed as linoleic acid was lower for the children
with hyperlipidemia vs the controls, the mean intake of this essential fatty
acid in both groups was within the range recommended by the National Research
Council, Food and Nutrition Board.14
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Table 2. Caloric and Macronutrient Intake*
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In contrast to fat intake, carbohydrates made up a higher percentage
of the total calories in the group with hyperlipidemia vs the controls (Table 2). However, a greater proportion
of the total calories in the diets of the children with hyperlipidemia vs
controls was derived from the total amount of sugars consumed. Notably, a
large proportion of the total carbohydrate was derived from total sugars in
both groups (children with hyperlipidemia vs controls, mean ± SE: 46.8
± 2.1 vs 47.7 ± 3.0 percentage of total carbohydrate). No differences
were noted between the groups for dietary fiber or protein intake.
The mean intakes of the micronutrients are listed in Table 3. The group with hyperlipidemia had lower intakes of zinc
and vitamin E compared with controls. Additionally, a trend toward lower iron
intake (P = .06) was noted among the children with
hyperlipidemia. After micronutrient means were adjusted for total caloric
intake, no differences were noted between the groups for any of the vitamins
or minerals studied.
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Table 3. Micronutrient Intake*
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Figure 1 shows caloric and
micronutrient intake expressed as a percentage of the RDA/DRI. Mean intake
of vitamin E and calories were below 75% of the RDA in the group with hyperlipidemia,
and were significantly lower than in controls. Mean intake of zinc was lower
in the group with hyperlipidemia vs the controls, but above 75% of the RDA
for both groups. Although not significantly different, the mean intake of
calcium was below 75% of the adequate intake recommendation in both groups.
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Figure 1. Caloric and micronutrient intake
expressed as the percentage of the recommended dietary allowance/dietary reference
intake (RDA/DRI). Asterisks indicate statistically significant differences
between the groups for calories, zinc, and vitamin E, P<.05.
Vitamin C values were excluded from this figure so that comparisons of micronutrient
intakes below 100% of the RDA/DRI could be highlighted. Mean (SE bars) vitamin
C values (expressed as percentage of the RDA/DRI) for children with hyperlipidemia
vs controls are 302.1% ± 39.3% vs 294.6% ± 37.6%.
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Figure 2 demonstrates the
percentage of children in each group that were below 75% of the RDA/DRI for
caloric and micronutrient intake. Of concern, many children in both groups
did not meet the RDA for folate, vitamin E, and calories and the adequate
intake for calcium. A greater proportion of children with hyperlipidemia compared
with controls did not meet 75% of the RDA for vitamin E and calories.
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Figure 2. Percentage of children consuming
less than 75% of the recommended dietary allowance/dietary reference intake
(RDA/DRI) for calories and micronutrients. Asterisks indicates statistically
significant differences between the groups for caloric and vitamin E intake, P<.05.
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In this study vitamin and mineral supplements were included in the dietary
analysis to obtain information on the total micronutrient intake of the children
studied. Dietary supplements reported being consumed were all at or below
100% of the RDAs/DRIs for the vitamins and minerals of interest in this study.
To determine whether supplement use mattered for meeting micronutrient recommendations,
children taking vitamin and mineral supplements were compared (by 2 test) with those not taking supplements for the number of children
meeting at least 75% of recommended micronutrient intake levels. A greater
frequency of children with hyperlipidemia who were supplement users (n = 9)
vs nonsupplement users (n = 37) met the RDA for vitamin E (P<.05). No differences were noted among the hyperlipidemic supplement
users vs nonsupplement users for the number of children meeting at least 75%
of the RDA/DRI for folate, vitamin C, vitamin D, vitamin A, zinc, iron, or
calcium. Similar findings were observed for the control group.
COMMENT
The NCEP's Step I diet has been advocated for the entire American population
older than 2 years to prevent blood cholesterol levels from becoming elevated.
Additionally, the diet has been recommended as a cholesterol-lowering therapy
for children and adults with high blood cholesterol levels. As part of the
Step I diet guidelines for children, the NCEP recommends that adequate calories
be provided to support growth and development.8
The findings from this study suggest that, without formal nutritional counseling,
parents of children with hypercholesterolemia may inadvertently overrestrict
calories in their children's diet by attempting to eliminate obvious sources
of dietary fat. We found that children with hypercholesterolemia before nutritional
intervention had significantly lower mean caloric intakes compared with children
without hyperlipidemia. Further, 90% of the decrease in caloric intake could
be accounted for by a decrease in total fat intake. Both caloric intake and
total, saturated, polyunsaturated, and monounsaturated dietary fat intake
of the children with hypercholesterolemia were well below established recommendations.8 Although the length of time between the diagnosis
of hypercholesterolemia and formal nutritional counseling was not reported
in this study, other clinics have reported that the average duration from
the time of diagnosis of hypercholesterolemia in a pediatric population to
receipt of formal nutritional counseling ranged from 3 to 20 months.18, 19 Importantly, several reports citing
failure to thrive and malnutrition as consequences of a low-fat diet have
been documented among children who delayed receiving formal nutritional intervention
after the diagnosis of hypercholesterolemia.18, 19, 20
It is clear that in these cases parental imposition of a low-fat diet went
beyond the present guidelines recommending 30% of calories from fat and adequate
calories to support growth. Our data corroborate these case reports suggesting
the propensity of some parents to overly restrict calories in an attempt to
limit fat in the diets of their children to lower high blood cholesterol concentrations.
Overrestriction of dietary fat can have a negative effect on the overall
nutritional quality of children's diets. We found that children following
a parent-prescribed low-fat diet consumed significantly more total sugars
than children receiving unrestricted diets. Mean intake of total sugars was
29% of total calories, which is substantially higher than established recommendations
for dietary sugar.21 Data from the Bogalusa
Heart Study13 demonstrated that as the amount
of carbohydrates in the diets of children increased, intake of candy, desserts,
and nondairy beverages increased as well. It is apparent from the findings
in this study and others that some parents attempting to restrict fat in their
children's diets by increasing carbohydrates may inadvertently be promoting
increased intake of nonnutrient-dense foods.
In this study, dietary intakes of zinc and vitamin E were significantly
lower in the diets of children with hypercholesterolemia vs those receiving
unrestricted diets and, for vitamin E, substantially lower than recommended
levels. While taking a micronutrient supplement (at levels at or below the
RDAs/DRIs) seemed to be beneficial in terms of enabling some children to meet
vitamin E recommendations while following a low-fat diet, nutritional authorities
suggest food sources as the preferred means of obtaining adequate levels of
nutrients for healthy individuals with average requirements.22
Many of the children with hypercholesterolemia in this study consumed low-fat
and low-cholesterol diets by reducing their intakes of foods such as obvious
fats and oils, milk, dairy products, meat, and eggs (data not shown). These
dietary modifications may explain why dietary vitamin E and zinc levels were
affected. Additionally, we found that after adjusting for differences in calories,
no differences were noted between the groups for vitamin or mineral intake.
This finding suggests that caloric differences between the groups were primarily
responsible for differences in vitamin and mineral intake, and further supports
the notion that parents of children with hyperlipidemia must be counseled
to avoid unnecessary caloric restriction in their children's diets when encouraging
consumption of low-fat diets. Studies in which children have been provided
with formal nutritional education to lower intakes of calories from fat and
saturated fat showed that the dietary recommendations could be achieved without
any untoward effects on intakes of vitamins or minerals.23, 24
The results of this study are based on the 3-day dietary record. Despite
providing detailed instructions and training to children and parents regarding
the recording of food intake in the dietary records, the accuracy of the records
can be questioned. The very act of recording food intake may inadvertently
result in modified dietary intake, simply by making a subject more aware of
what and how much he or she is eating. Although the records of individual
participants may occasionally deviate from the true intake, group averages
of such records are much more reliable, especially if the average of several
days is considered.25
While evidence from carefully controlled intervention trials9, 26 has demonstrated that fat-restricted
diets are safe for children, there are clinical reports (as mentioned previously)
of children who have grown poorly while following unsupervised low-fat diets.18, 19 The distinction between these studies
and outcomes is in the care with which the diet is administered. Pediatricians
who diagnose hypercholesterolemia should be aware that making a suggestion
to parents to begin restricting their child's dietary fat before a visit with
a nutritional professional may lead to overzealous restriction of both dietary
fat and calories. This may have adverse effects on the nutritional status,
growth, and development of the child. Additionally, recent research in nutritional
behavior suggests that "stringent" parental control over child-feeding behavior
(eg, restricting high-fat foods) can potentiate preferences for high-fat,
calorie-dense foods in children.27 Given the
potential for untoward effects of unsupervised very low-fat/low-calorie diets
on growth and development and potentially long-term eating behavior, parents
of children with newly diagnosed hypercholesterolemia should be strongly encouraged
to seek immediate guidance from a registered dietitian after receiving the
diagnosis. Registered dietitians are trained to appropriately assist children
and their families in translating dietary recommendations into practice.
AUTHOR INFORMATION
Accepted for publication June 14, 2001.
What This Study Adds
While the NCEP and American Heart Association dietary guidelines have
been shown to lower LDL-C levels in children with hyperlipidemia and promote
optimal growth and development when medically supervised, case reports have
suggested that parent-imposed low-fat diets in the absence of formal nutritional
counseling may have a negative effect on growth and development. Before formal
nutritional counseling, overzealous fat and/or caloric restriction can occur
in children with hypercholesterolemia. Parents of children with newly diagnosed
hypercholesterolemia should be strongly encouraged to seek immediate guidance
from a registered dietitian after receiving the diagnosis.
From the Department of Pediatrics (Drs Kaistha, Deckelbaum, Starc,
and Couch) and the Institute of Human Nutrition (Drs Deckelbaum, Starc, and
Couch), Columbia–Presbyterian Medical Center, New York, NY. Dr Couch
is now with the Department of Health Sciences, Program in Dietetics and Nutrition
Science, University of Cincinnati Medical Center, Cincinnati, Ohio.
Corresponding author: Sarah C. Couch, PhD, RD, Department of Health
Sciences, Program in Dietetics and Nutrition Science, University of Cincinnati
Medical Center, 364 French Bldg E, Cincinnati, OH 45221-0394 (e-mail: couchsc{at}email.uc.edu). Reprints: Richard J. Deckelbaum, MD, Institute
of Human Nutrition, Columbia–Presbyterian Medical Center, PH 15E, 630
W 168th St, New York, NY 10032.
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