6. PREVENTION OF NUTRITION RELATED DISORDERS IN LATER LIFE
Try these questions (detailed answers at the bottom):
Q1. Which of the following is not recommended for prevention of Coronary Heart Disease?
A. Limiting fat intake at 1 year of age
B. Limiting fat intake at 2 years of age
C. Limiting fat intake at 5 years of age
D. Limiting fat intake in adolescence
Q2. True or false. Having a low cholesterol provides sufficient reassurance against Coronary Heart Disease (CHD) later in life.
And these techniques:
Take a careful diet history of your partner in class. Give each other a review and critique of what could be done to reduce risk for CHD.
Introduction
A final concern for consideration in these Nutrition Notes is somewhat new to pediatric nutrition, which is the subject of the prevention of the degenerative diseases of later life by appropriate nutrition in childhood. The topic is broad, overwhelming really. These comments on coronary heart disease (CHD)as an element of the [Dys]Metabolic Syndrome -- insulin resistance, hypertension and coronary heart disease -- can be applied through out all of the clinical cases presented in Part IV of the Teacher's Guide.
When should one attempt to prevent CHD. It is certain that cholesterol levels at the point where there is arterial damage have some influence on the occurrence of coronary occlusion. It is also clear that fatty streaks appear in the aortas of children on high fat diets by 10 years of age or so. Such lesions however, are not seen in coronary arteries until much later. What is not clear is whether dietary control in childhood will influence what happens in later life, except in those unusual families where there is a genetic defect producing hypercholesterolemia.
There remain differences of opinion on the importance of monitoring cholesterol levels in all children. Part of the reason lies in the fact that this measurement is a very crude surrogate for what one really wants to know. The other part of the objection is that having measured it, it is not clear (except in families with genetic defect) that anything beyond the already recommended diet is of any value. In another decade, and perhaps sooner, our tools will be better and our course of action more clearly delineated.
Moreover, the narrow focus on hypercholesterolemia as the one cause for coronary heart disease is no longer acceptable. For example, a body of evidence is accumulating that increases in homocysteine levels secondary to inadequate pyridoxine and folic acid in the diet may be of equal importance. On the other hand, iron sufficiency later in life may increase risk for CHD because iron stored as ferritin is an oxidizing agent.
As we move into the 21st century, the power of nutrition in utero and the first years of life to affect risk for the various components of the [Dys]Metabolic Syndrome becomes more apparent. The worst combination with respect to risk is inadequate in-utero nutrition followed by an over compensation during the first months post partum.
These comments are an invitation to gather information and remain informed before making recommendations that you will regret.
Screening children for CHD
The Committee on Nutrition of the American Academy of Pediatrics recommends a "population strategy" for screening children for their risk of coronary heart disease (CHD). In this, a cholesterol level is measured on children with a positive family history for CHD. All families are given the same advice for a prudent diet and life style. Neither mass screening (all children have serum cholesterol measured) nor no screening (all families receive advice, only) are recommended.
CAPTION: No screenings are conducted before two years of age. From two years to adolescence, the population strategy described above is applied. At adolescence and beyond, cholesterol testing is suggested for everyone.
Recommendations
For the general population it seems sensible to keep active and maintain a lean body weight. Eat a diet containing less fat than the current average American diet. In particular, the saturated fat component should be lower than is current and most agree that 10% of calories should be the upper limit for this dietary constituent. There is also general agreement that 30% of calories as fat is satisfactory for providing energy while not promoting a high cholesterol level. Thus, there is general agreement on advising a "prudent diet" for all Americans, adult and children over two years of age or so (see Sections 2d and 3c).
The answers
A1. The answer is A. We are cautious about limiting fat intake below 2 years of age. This age is expected to reduce, but a better approach would be to insure availability and use of nutritious food by preventing food insecurity and promoting nutrition education (See Part 3 Sections 1 and 6). The recommendation to hold off recommending a low fat diet until 2 years of age may be changed. Finish studies suggest that limitation at 18 months of age would be safe.
A2. The answer is False. CHD is a multifaceted outcome that is affected by multiple mediators and moderators. Many dietary changes are appropriate including maintaining body weight, physical fitness and stress reduction. These do not, however, remove risk from inborn metabolic precursors to CHD.
And technique
The pairs may come up with many healthy suggestions. They will also address issues such as engaging the patient, establishing empathy, and using interviewing techniques that also inform.
