 Dietary Fats in Children: The American Perspective . . . page 1 W. J. Klish, M.D. Professor of Pediatrics Baylor College of Medicine AAP Statements on Dietary Fat and Cholesterol: Historic Perspective The Committee On Nutrition of the American Academy of Pediatrics (CON/AAP) issued its first policy statement regarding dietary fat and cholesterol in 1986. This was a vague statement which suggested lowering the intake of fat and cholesterol in children, but did not specify to what level. In 1989, a statement was issued which suggested indications for testing serum cholesterol levels in children and adolescents but did not advocate universal screening or the routine use of the fingerstick methods for screening of serum cholesterol. Finally, in 1992, a comprehensive "Statement on Cholesterol" was published which recommended that all American children over the age of two years ingest an average daily intake of 30% of total calories from fat, less than 10% of total calories from saturated fatty acids and less than 300 mg cholesterol per day. This statement generated a fair amount of controversy. It was felt by some to be overly restrictive, and if followed by an overly zealous parent, growth faltering could result. Others challenged the concept that atherosclerosis had its roots in childhood. Some individuals were concerned that labelling a child with hypercholesterolemia could have a psychological impact on the child. The final argument against this 1992 position statement by the American Academy of Pediatrics was directed at the concept of subjecting the entire population of American children to a diet that would only benefit some. The Current AAP Statement on Cholesterol in Childhood As a result of these criticisms, the American Academy of Pediatrics revised its 1992 statement on Cholesterol in Childhood which was published in January 1998(1). Since the 1992 statement more data were published which CON-AAP felt strengthened its position in this area. The 1998 statement contained more background material and was much more specific than the 1992 statement. It also made a couple of concessions from the previous statement. While CON-AAP continues to recommend fat restriction starting at age two, it concedes that the target of 30% of energy from fat should be gradually introduced until age five since preschool eaters tend to be picky eaters. A lower limit of 20% of the calories was placed on fat restriction to prevent the overzealous use of these diets. While the focus of the statement was on cholesterol levels in children, other risk factors for atherosclerosis were addressed. Specifically, smoking should be discouraged; hypertension should be identified and treated; obesity should be avoided and reduced; regular exercise should be encouraged; and diabetes mellitus should be identified and treated. Lowering High Blood Cholesterol: A Population Approach To lower blood cholesterol levels in children and adolescents two complimentary approaches were recommended: a population approach and an individualized approach. Population Approach was designed as the principal means for preventing coronary heart disease. It aims to lower the average level of blood cholesterol in all children and adolescents through population-wide changes in nutrient intake and eating patterns. These recommendations are directed to groups that influence the eating patterns of children and adolescents, including schools, health professionals, government agencies, the food industry and the mass media. The advantage of this approach is that even a small reduction in mean total and LDL-cholesterol levels in children and adolescents, if carried into adult life, could substantially decrease the incidence of coronary heart disease. No recommendations are made for children under two years of age when dietary preferences and feeding practices should include greater fat intakes for the caloric density needed for sufficient energy intake. After two years of age, children should gradually adopt a diet that, by about five years of age, contains no more than 30% or no less than 20% of calories from fat. Saturated fatty acids should represent less than 10% of total calories and dietary cholesterol should total less than 300 mg/day. As they begin to consume fewer calories from fat, children should replace these calories by eating more grain products, vegetables and fruits, low fat milk products or other calcium - rich foods, and protein - rich foods, such as beans, lean meat, poultry and fish. Saturated fatty acids specifically raise blood cholesterol, therefore emphasis was directed at reducing saturated fat intake. A sufficiently low saturated fat intake can be achieved, primarily by moderation in animal-based foods, when the total fat intake is about 30% of calories from fat. A lower fat intake is usually not necessary. Lowering High Blood Cholesterol: An Individualized Approach The Individualized Approach to cholesterol lowering called upon the cooperative effort of health care professionals to identify and treat children and adolescents at highest risk of having high blood cholesterol and coronary heart disease (CHD) as adults. Risk factors which contribute to earlier onset of coronary heart disease include:
The following specific recommendations for selective screening of children and adolescents in the context of their continuing health care are :
Optional cholesterol testing by practicing physicians may be appropriate in certain children who are judged to be at higher risk for coronary heart disease independent of family history. For example, adolescents who smoke or consume excessive amounts of saturated fats and cholesterol and who are overweight may also deserve testing at the discretion of their physician. For parents who do not know their cholesterol levels, pediatricians should arrange that their levels be measured. The focus of the individualized approach is to detect and treat the hypercholesterolemic child or adolescent whose elevated LDL-cholesterol level is likely to signify increased risk in adulthood. The screening protocol varies according to the reason for testing. This protocol is suggested to limit the greater expense of lipoprotein analyses. If screening is being done because a parent has a blood cholesterol in excess of 240 mg/dL, (6.2 mmol/L) the initial test should be a measurement of total cholesterol. If the child's level is high (over 200 mg/dL, 5.2 mmol/L), a lipoprotein analysis should be carried out to measure HDL-cholesterol and LDL-cholesterol levels. If the total cholesterol is borderline (170-199 mg/dL, 4.4-5.2 mmol/L), a second measurement of total cholesterol should be taken and averaged with the first. If the average is borderline or high, a lipoprotein analysis should be carried out. If the patient is being tested because of a documented family history of premature cardiovascular disease, the initial test should be a lipoprotein analysis which requires a 12-hour fast. |
