There's no ice cream in the freezer at the Reider's Chevy Chase household, the family's fast food outings are limited to about once a month and brown-bag school lunches generally consist of turkey or lowfat yogurt.
Connie and Jeffrey Reider are not just responsible parents concerned about establishing healthful eating habits for their children. Jeffrey Reider has high blood cholesterol -- and so do his 6- and 9-year-old daughters.
The Reider children are representative of an increasing number of youngsters over the age of 2 who are having their blood cholesterol levels checked -- either routinely or because they have been identified as a high risk due to family history of high cholesterol or premature coronary heart disease. And what physicians are finding are children as young as 3 and 4 who have cholesterol levels well above the norm for their ages.
Mounting research on adults has shown that lowering elevated blood cholesterol can reduce the risk of coronary artery disease. But there are no studies that have tracked children with high cholesterol at age 10, for instance, through to their incidence of heart disease by age 50.
Nevertheless, early signs of cardiovascular disease were found in children in a 10-year, ongoing study in Bogalusa, La., and before that, autopsies performed on U.S. combat casualties in Korea and Vietnam revealed the presence of atherosclerotic lesions in the coronary arteries of 70 percent of the young men. In addition, because cholesterol levels rise normally with age as well, hypercholesterolemic children are likely to remain at risk as they get older.
"There is compelling evidence that atherosclerosis has its roots in early life," wrote Dr. Sidney Blumenthal, former senior consultant to the vice president of Columbia University, in the proceedings from a videoconference held last March on the prevention of artherosclerosis in childhood.
Yet not all physicians agree that screening should be required for all children (many agree that children whose parents have high cholesterol or familial histories of coronary heart disease should have their cholesterol checked, yet some do not even screen those), nor is there a consensus on the rigidity of dietary treatment for children at moderate risk.
According to Dr. Karen Kuehl, a pediatric cardiologist at Children's Hospital, there are two groups of children with family histories of hypercholesterolemia, stroke, hypertension or premature coronary heart disease for whom intervention is recommended. Moderate risk children have cholesterol levels between 170 and 185 milligrams per deciliter of blood. High risk children have cholesterol levels above 185 milligrams, according to Kuehl.
Connie Reider said she had several reactions after finding out through her pediatrician that her children had cholesterol levels over 200 milligrams. At first, it was "absolutely excruciating" to discover that something waswrong with her daughters, Reider said, but that she later decided that the most important thing was to teach them good eating habits.
And in doing so, the Reiders learned that the key to a cholesterol-lowering diet is cutting down on foods high in saturated fats, not just foods -- such as egg yolks -- that contain cholesterol.
The marketplace made that transition difficult. "All sorts of foods that we thought were okay, weren't," said Connie Reider, such as those with labels claiming "contains no cholesterol" but made, perhaps, with palm or coconut oils, two highly saturated vegetable fats.
But beyond learning about saturated fats, parents who discover that their child or children have high cholesterol are presented with some unique problems.
On the one hand, establishing healthful eating habits to prevent disease is what health experts have been recommending for the entire population -- and childhood is probably the best time to set those patterns into place.
On the other hand, imposing specific restrictions on a child who may be a picky eater, goes to birthday parties, is bombarded with fast food advertising and who shows no manifestations of disease may be a tough hurdle, both practically and psychologically.
(In fact, the National Heart, Lung and Blood Institute recently solicited applications for grants to establish clinics across the country. The clinics would study the effects of dietary intervention on hypercholesterolemic children, with an emphasis on the behavioral aspects.)
At any age, "getting kids to eat fish and chicken over hot dogs and hamburgers" is difficult, said Ann Litt, a local registered dietitian in private practice who counsels children with high cholesterol.
The challenge then becomes establishing a healthful eating regimen for the whole family that neither singles out the hypercholesterolemic child nor makes him feel as if he were sick.
It is crucial to make the child and the parent understand that the child does not have heart disease, said Dr. Peter Kwiterovich, professor of pediatrics and medicine at John Hopkins University. Kuehl said she emphasizes that the dietary changes are to promote long-term health and designed to make him grow up to be "a very old man."
Connie Reider said she has communicated the problem to her children by telling them that "everyone has something they have to watch," whether it's having allergies or being overweight.
Often it is difficult, too, if only one child in the family has the problem. Karen Caputo, whose 5-year-old son Alexander has high cholesterol, said she had more trouble dealing with her 7 1/2-year-old daughter, who does not. Caputo said she at first felt guilty about depriving her, but tackled it by saying, "In our house, we just don't buy that high-fat food ."
Yet parents must learn how to create an atmosphere in which the hypercholesterolemic child does not feel deprived.
Debbie Litt (no relation to dietitian Ann Litt), whose two daughters have high cholesterol, said that she tries not to make her children aware of what they can't eat, a technique that Caputo follows for Alexander. Caputo said she stresses the positive rather than the negative, telling him that the foods he can eat are good for him.
Instead of telling her daughters to stop eating a food because it's "against your diets," Litt said, she'll tone it down with a common parental warning such as "you've had enough of that."
Other parents tackle the deprivation problem by allowing treats in moderation, knowing that being too restrictive may backfire.
"When we're at home, we're good, when we're out, we're out," said Connie Reider.
Caputo said she'll let Alexander have chocolates for Easter or Christmas -- but just less of them. He gets more excited about "the idea" of eating candy than the desire to actually stuff himself with it, she said.
Or, parents will trade off treats laden with saturated fat for treats that are high in sugar.
In a perfect world, it would be great for kids to eat oat bran (a powdery cereal that has been shown to lower cholesterol levels) on top of a healthful whole-grain cereal, said Mary Dickie, an area registered dietitian who counsels children with high cholesterol. But the reality, she said, is that it just doesn't happen.
So if the child won't eat the healthful cereal, Dickie said, she will recommend that parents allow their children to sprinkle oat bran on top of a "junky" sugary cereal if that's the only way the child will eat the oat bran.
Caputo said that Alexander eats a dish of oat bran for breakfast six days a week -- sprinkled with a favorite, miniature marshmallows. She also allows him to eat sugary fruit rollups. Because, Caputo said, she'd rather have Alexander "get rotten teeth" than "a bad heart."
Litt said that her children get excited about treats that they create themselves. A favorite concoction her daughters make is a "cereal" of popcorn splashed with skim milk mixed with cocoa. And last week, her eldest daughter made an "ice cream sandwich" by wedging a Weight Watchers pop between two pieces of whole-wheat bread.
In fact, it is crucial that the child have a lot of input into his diet. The approach is to make the child feel that the food choices are his, rather than a punishment, said Debbie Mattes-Kulig, a registered dietitian who works as a consultant for a pediatrics group in Burke.
Ron Goor, former coordinator of the National Heart, Lung and Blood Institute's cholesterol education program and now a consultant, is the father of two sons with high cholesterol. Goor and his wife, Nancy, have written a book -- to be published in January -- which is based on the premise of choice.
"Eater's Choice: A Food Lover's Guide to Lowering Cholesterol" enables the child or parent to allow some favorite saturated-fat foods into the diet by budgeting them within the American Heart Association's recommendations of no more than 10 percent of calories per day from saturated fat, Goor said. The child or adult gets to choose the foods they wish, so long as they don't exceed the saturated fat allowance.
While parents of an older child may find this system helpful, those with younger children not yet affected by such influences as peers have the advantage of more direct control of the diet. And therein lies the importance of an early framework.
Litt, who said she was shocked to find out her children had high cholesterol because their diets are already low in fat, explained that many of the changes she was instructed to make had already been part of the family's eating regime. Her daughters already don't like chicken skin, for instance, Litt said.
But those children who already have strong likes and dislikes may be maleable. A lot of parents think "that you can't teach an old dog new tricks," said Mattes-Kulig, but after about the age of 8, a child has the capability of understanding the benefits of good nutrition.
And like adults, children's tastes can be adapted. If her oldest daughter ever eats a hot dog or piece of fried chicken now, she thinks it's too greasy, Reider said.
Dietitians advising hypercholesterolemic children must also be sure that the child is consuming enough calories and calcium.
Mary Perkins, a registered dietitian who works with Kuehl at Children's Hospital, said she encourages complex carbohydrates, such as cereals, popcorn, breads and grains, to make up for calorie-laden high-fat foods. And she tries to get the children to eat lowfat yogurt, perhaps mixed with fruits and sprinkled with cinnamon, instead of whole milk.
Alex Goor, the Goor's 14-year-old son, who did a science project last year showing how his cholesterol levels would rise and fall depending on his diet, said he satisfies his ravenous appetite by eating turkey sandwiches for snacks -- sometimes five at a clip. Instead of the school lunch or a trip to a fast food restaurant, he also buys a turkey sub at a sub shop everyday.
*Aside from moderating his intake of cheese, eating a healthful, lowfat diet hasn't been hard, said Goor, adding that he thinks it's probably easier to make changes as a kid than as an adult. It's something he wants to do for himself, Goor said, not because of pressure from his parents.
Nevertheless, he likes to recall the Woody Allen movie "Sleeper," in which Allen awakens in the future, asking for wheat germ. The doctors confer. Wheat germ? Doesn't he know that high-fat foods are good for him? That, said Goor, is "my dream."
DEBBIE MATTES-KULIG'S OATMEAL BANANA COOKIES (Makes 30 cookies)
1/4 to 1/3 cup corn oil
2 cups uncooked oatmeal
1 teaspoon vanilla
Mash bananas in a large bowl and mix with other ingredients. Drop by the tablespoonful onto an ungreased cookie sheet. Bake at 350 degrees for 20 to 25 minutes.
AMERICAN HEART ASSOCIATION'S ORANGE FUN SICKLES (Fills 2 ice cube trays)
6 ounces orange juice concentrate
6 ounces water 1 cup plain lowfat yogurt
1 teaspoon vanilla
Blend all ingredients and pour into ice cube trays. Put a drinking straw (which has been cut in half or thirds) into each cube. Freeze several hours.
MARY DICKIE'S OAT BRAN MILKSHAKE (1 serving)
1 tablespoon cocoa powder
1/4 to 1/3 cup oat bran
1 cup skim milk
Combine all ingredients in a blender or food processor. Blend for 3 to 5 minutes, or until thick.
RON AND NANCY GOOR'S CHICKEN WITH GREEN BEANS (10 servings)
Nancy Goor says that there's no reason why children can't learn to like "real food." Her two sons love this Indonesian-style chicken dish, which will be included in the Goor's book "Eater's Choice: The Food Lovers' Guide to Lower Cholesterol."
3 tablespoons olive oil
6 boned chicken breast halves, skinned, cut into bite-sized pieces
8 cloves garlic, minced
1 tablespoon minced fresh ginger root
1 small onion, chopped
1 pound green beans, washed and cut into bite-sized pieces
Juice of 1 lime
1 tablespoon soy sauce mixed with 1 1/2 teaspoons dark molasses
2 teaspoons brown sugar
2 teaspoons turmeric
3/4 teaspoon salt
Up to 1/2 cup water
In a large skillet, heat 2 tablespoons of the oil. Saute' chicken until it turns white and is cooked through, about 2 minutes. Remove chicken.
In the same skillet, heat remaining tablespoon of oil. Saute' garlic, ginger and onion until soft, about 2 minutes. Add green beans and stir-fry until they turn bright green, about 4 minutes. Add lime juice, soy sauce, brown sugar, turmeric, salt and 2 tablespoons of water. Slowly add more water if necessary but sauce should not be watery. Heat until hot but not boiling.
Add chicken pieces and stir until completely covered with sauce. Serve over rice.
CENTER FOR SCIENCE IN THE PUBLIC INTEREST'S FLUFFY HUMMUS (Makes about 2 cups)
The Washington consumer group CSPI recommends this oil-modified hummus as a brown bag lunch, packed into whole-wheat pita along with shredded fresh vegetables such as green pepper, red cabbage and cucumber.
1/4 cup sesame seeds
15-ounce can chickpeas
1/4 cup lemon juice
2 cloves garlic, minced
3/4 teaspoon cumin
1/4 teaspoon salt
Cayenne pepper to taste
Roast the sesame seeds in a dry skillet until they begin to smell toasty. (Shield yourself with a pot lid when they begin to pop.) Set aside.
Drain the chickpeas in a colander and rinse. Combine all ingredients in a food processor and pulse on and off until well chopped. Then turn the machine on for 30 to 45 seconds, until light and fluffy. If the mixture is too thick, add water a tablespoon at a time until desired consistency is reached. Alternately, combine all ingredients in a blender, or mash together energetically in a mixing bowl.
From "Nutrition Action Healthletter"