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RESEARCH

erspectives in Practice

ietary Intake of Children at High Risk forardiovascular Disease

OLLEEN KELLEY, MS, RD; DEBRA KRUMMEL, PhD, RD; ELIZABETH N. GONZALES, MSPH, RD; WILLIAM A. NEAL, MD;

INDY W. FITCH, PhD, RD

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BSTRACTardiovascular disease and obesity begin in childhood,nd dietary interventions to prevent them should be ini-iated then. We hypothesized that children who were atigh risk for cardiovascular disease based on family his-ory would have diets that were different than those ofhildren from low-risk families. Two hundred ninety-even children were screened for family history of earlyardiovascular disease; had height, weight, and finger-tick total cholesterol measured; and filled out food fre-uency questionnaires. Sixty-eight (23%) children weret risk for cardiovascular disease. Cholesterol was signif-cantly higher compared with those not at risk (4.71�0.93

mol/L vs 4.35�0.92 mmol/L, P�.005). Intakes of en-rgy, fat, fiber, and cholesterol were similar betweenroups. Children at high risk for cardiovascular diseaseere no more likely to meet guidelines for heart-healthyiets than were children at low risk. Families need guid-nce to change dietary patterns to prevent future disease.Am Diet Assoc. 2004;104:222-225.

he American Heart Association has issued guide-lines to prevent cardiovascular disease beginning inchildhood (1). Among its recommendations is the

ecommendation to limit foods high in saturated fats andholesterol. West Virginia consistently exceeds the na-ional average for cardiovascular disease and obesity (2).

survey of West Virginia adults revealed that fewer than

. Kelley is a clinical dietitian at Providence Hospital inashington, DC; at the time of the study, she was a

raduate student at West Virginia University, Morgan-own, WV; D. Krummel is an associate professor in theepartment of Community Medicine and W. Neal is arofessor in the Department of Pediatrics, Robert C.yrd Health Sciences Center, Morgantown, WV; E. N.onzales is aprivate nutrition consultant in Kentfield,A; and C. W. Fitch is an assistant professor in theVU Davis College of Agriculture, Forestry and Con-

umer Sciences, Morgantown, WV.Address correspondence to: Cindy W. Fitch, PhD, RD,

ssistant Professor, Human Nutrition and Foods, Westirginia University, PO Box 6124, 702 Allen Hall,vansdale Campus, Morgantown, WV 26506-6124.E-mail: cfitch@wvu.eduCopyright © 2004 by the American Dietetic

ssociation.0002-8223/04/10402-0009$30.00/0

adoi: 10.1016/j.jada.2003.11.014

22 Journal of THE AMERICAN DIETETIC ASSOCIATION

alf met the recommendation for percentage of calories asat or saturated fat (3). Approximately, 40% consumeddequate amounts of calcium or vitamin C, and 20%onsumed adequate amounts of folate or vitamin E. Theseietary behaviors are associated with an increased risk ofhronic disease and contribute to the high rate of cardio-ascular disease in West Virginia. Yet, cardiovascularisease begins in childhood (4), and dietary patterns thatre formed during childhood persist throughout adoles-ence (5) and into adulthood. Dietary interventions torevent obesity and chronic diseases should be targetedo children.

Families with a history of cardiovascular disease maye more aware of dietary guidelines, so their childrenay have diets that are lower in fat and higher in other

utrients. The objective of this study was to compare theutrient intake of children who are at risk for cardiovas-ular disease based on family history with those who areot at risk.

ETHODShis study was conducted as a part of the Coronaryrtery Risk Detection in Appalachian Communities

CARDIAC) Project, a collaborative effort between Westirginia University and the West Virginia Rural Healthducation Partnership. It was designed to evaluate theffectiveness of universal blood cholesterol screening ofreadolescent children in Appalachia. During the 1998-999 school year, three counties participated in the pilothase. Packets were sent to the parents of all fifth gradehildren in the schools (n�781) explaining the CARDIACroject and study procedures. Each packet contained aonsent form for the parent, an assent form for the child,nd a short questionnaire on history of early cardiovas-ular disease, heart disease, diabetes, hypertension, andtroke among parents and grandparents. Children werencluded in the study if they assented to the proceduresnd their parents signed an informed consent (n�347).he Institutional Review Board for the Protection of Hu-an Subjects at West Virginia University approved the

tudy.Dietary intake was measured using the Youth Adoles-

ent Questionnaire (6), a self-administered, 151-item foodrequency questionnaire (FFQ) that has been previouslyalidated in young people aged 9 to 18 years (7). Studentsere shown an instructional video that illustrated por-

ion sizes and examples of foods that were contained inhe questionnaire. A facilitator from the CARDIACroject was present to administer the questionnaire and

nswer any questions. The questionnaires were scanned

© 2004 by the American Dietetic Association

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t the Channing Laboratory in Boston, and intake of eachutrient was calculated.After filling out the FFQ, students were taken to a

eparate room in which they were weighed on an elec-ronic scale (Seca Model 770, Seca Corp., Hanover, MD),heir height was measured using a portable stadiometerIrwin Shorr, Olney, MD), and body mass index (BMI)as calculated. Seated, resting blood pressure was mea-

ured in triplicate using a standard sphygmomanometernd appropriate cuff size. Nonfasting, finger-stick totalholesterol was measured using portable CHOLESTECHDX analyzers (Perigon, Chicago, IL). The coefficient ofariation for total cholesterol was 3.2. A health sciencestudent, school nurse, or physician performed all proce-ures. Children with a total cholesterol of �4.4 mmol/LTo convert mmol/L cholesterol to mg/dL, multiplymol/L by 38.7. To convert mg/dL cholesterol to mmol/L,ultiply by 0.26. Cholesterol of 5.00 mmol/L�193 mg/

L.) and their parents were offered the opportunity tobtain a fasting lipid profile as a part of the study. Thirty-our children took advantage of that opportunity.

Children were categorized as being at risk for cardio-ascular disease based on the National Cholesterol Edu-ation Program (NCEP) risk factors of family history ofarly (�55 years of age) cardiovascular disease or hyper-holesterolemia in a parent (8). Nutrient intakes weredjusted for energy intake. Mean intake for each nutrientas compared between students who met NCEP risk

riteria and those who did not using the Student’s t test.he proportion of children in each group whose intake ofutrients met recommendations issued by the Americaneart Association (8,9) and Institute of Medicine (10) was

ompared using �2 analysis. Statistical analyses wereone using the Statistical Analysis System for Windows,ersion 8 (The SAS Institute, Cary, NC, 1999-2000).

ESULTSata from the CARDIAC study have been reported pre-iously (11-13). Questionnaires were completed by 327tudents. Those who had given consent but did not com-lete questionnaires were absent from school or had

Table 1. Characteristics of children who meet NCEPa criteria for risk

BMIb, blood pressure, and nutrient intakeAt-risk (mean�S

BMI 20.5�4Systolic blood pressure (mm Hg) 112�9Diastolic blood pressure (mm Hg) 70�8Energy kcal 2,419�1% Energy as fat 31.9�4% Energy as saturated fat 11.9�2% Energy as monounsaturated fat 11.9�1% Energy as polyunsaturated fat 5.6�1Cholesterol (mg) 272�1Dietary fiber (g) 19�1

aNCEP�National Cholesterol Education Program.bBMI�body mass index.cSD�standard deviation.dNS�not significant.

oved from the area at the time of the study. One child d

as unable to complete the questionnaires because ofeading difficulties. Six records were eliminated becausef errors in student identification numbers. That left 321FQ for analysis. Of those, dietary records with energy

ntake less than 500 kcal (n�3) or greater than 5,000 kcaln�21) were omitted from the analysis for a final numberf 297 diet records.

Dietary interventions to preventobesity and chronic diseases shouldbe targeted to children.

The participants were white, and 157 (53%) were fe-ale. Average age was 10.8�0.6 years for boys and

0.6�0.7 years for girls. Sixty-eight (23%) children weret risk for CVD based on NCEP guidelines. Mean non-asting cholesterol was significantly greater in the at-riskroup compared with the not-at-risk group (4.71�0.93mol/L vs 4.35�0.92 mmol/L, P�.005). There were no

ifferences in BMI or blood pressure between groups (Ta-le 1). Twenty-five students (37%) in the at-risk groupnd 91 (40%) in the low-risk group had BMI greater thanhe 85th percentile. Of the 34 children who had fastingipid profiles, mean LDL was 3.34�0.58 mmol/L, andyslipidemia was diagnosed in 21 (62%).There were no differences between groups in intake ofacronutrients, fiber, cholesterol, or percentage of calo-

ies as fat (Table 1). Percentages of calories as fat andaturated fat were higher than recommended for bothroups. Mean intakes of vitamins and minerals met cur-ent recommendations and were not different betweenroups (Table 2). There was no difference between groupsn the proportion of children who met intake recommen-ations.

ISCUSSIONhildren’s dietary intake has an impact on their futureisk for obesity, cardiovascular disease, and other chronic

pared with those not at risk

8) Not-at-risk (N�229)mean�SD Significance

21.0�4.8 NSd

110�9.8 NS69�8.0 NS

2,293�1,015 NS32.2�5.1 NS11.9�2.4 NS12.0�2.0 NS5.9�1.3 NS244�125 NS

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iseases. Average intakes of total fat and saturated fat as

Journal of THE AMERICAN DIETETIC ASSOCIATION 223

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percentage of energy were similar to that reported for 6-o 11-year-old children in the Third National Health andutrition Examination Survey (NHANES III) (14)

33.7%�0.23% and 12.5%�0.12%, respectively, forHANES III). However, energy intake was notablyigher in this study (2,419 kcal for at-risk and 2,293 forot-at-risk) compared with NHANES III data (1,971�28cal). This may reflect to some extent the different meth-dology. NHANES III data were collected using a singleultiple-pass, 24-hour recall, and data for this studyere collected by FFQ, which tends to overestimate en-rgy intake (7). Energy needs for children in this ageroup (10 to 11 years) are highly variable and depend onhysical maturation and activity levels. Nevertheless,verage energy intake for this group of children was highnd may be contributing to the high rate of obesity that iseen in West Virginia.

Children at risk for cardiovasculardisease based on family history didnot have a lower fat intake than thosewithout known risk factors.

The average dietary intake of cholesterol was accept-ble, and 71% of all children took in less than 300 mgholesterol per day. However, average intakes of fat andaturated fat exceeded recommendations, and mean totalat intake was more than 80 grams per day. Children atisk for cardiovascular disease based on family historyid not have a lower fat intake than those without known

Table 2. Intake guidelines and number of children who met theguideline

Nutrient

Guideline orrecommendation(Referencenumber)

Number (%)of childrenmeetingguideline(N�297)

n %

% kcal as fat �30% (8) 95 32% kcal as saturated fat �10% (8) 58 20Cholesterol �300 mg (8) 210 71Dietary fiber 15 g (age in

years�5) (9)147 50

Thiamin 0.9 mg (10) 248 83Riboflavin 0.9 mg (10) 287 97Niacin 12 mg (10) 232 78Vitamin B-6 1.0 mg (10) 238 80Folate 300 �g (10) 123 41Vitamin B-12 1.8 �g (10) 282 95Vitamin C 45 mg (10) 265 89Vitamin A 600 �g (10) 289 97Vitamin D 5 �g (10) 204 69Vitamin E 11 mg (10) 45 15Calcium 1,300 mg (10) 117 39Iron 8 mg (10) 238 80Zinc 8 mg (10) 195 66

isk factors. Families with a known history of early car-

24 February 2004 Volume 104 Number 2

iovascular disease have not made appropriate dietaryhanges. It is critical that health professionals addressealthy dietary patterns during childhood because theabits that are established at this time are likely to track

nto adulthood (5).Most children were meeting intake recommendations

or vitamins and minerals except for folate, calcium, anditamin E. Forty-one percent met recommendations forolate intake, 39% for calcium intake, and only 15% foritamin E intake. This is similar to intake reported inest Virginia adults (3). Calcium has been linked to

ecreased risk for obesity and hypertension (15); folateay lower the risk for cardiovascular disease by lowering

omocysteine concentration (16); and vitamin E is a po-ent antioxidant that may help prevent heart disease17).

Although the dietary patterns of these children appearo be adequate in most vitamins and minerals, there areotable exceptions that may have implications for chronicisease prevention. Intakes of fat and saturated fat as aercentage of energy are still greater than recommended,nd total energy intake is high. Overall, these dietaryatterns are consistent with an increased risk for obesitynd cardiovascular disease and likely contribute to theigh incidence of both in West Virginia.

ONCLUSIONS

Children need to change dietary patterns to preventfuture cardiovascular disease.Children from families with a high risk of cardiovascu-lar disease need targeted lifestyle intervention to lowertheir risk.Health care professionals must promote the benefits ofhealthy dietary patterns to children and their families.It is critical that public health research address behav-ior modification in children.

his study was funded in part by grants to W. A. Nealrom Stanley Hostler, Esq., The Claude Worthingtonenedum Foundation, and the West Virginia Ruralealth Education Partnerships (RHEP).

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