Because of a production error, the level of cholesterol considered high was misstated in an article last week. Children with a cholesterol level of 175 (not 75) are considered at increased risk of later heart trouble. (Published 8/4/87)
Just when it seemed that the controversy was finally over and most people had accepted the evidence linking dietary factors to heart attacks and strokes, a new controversy has arisen: What about the children?
Most medical scientists agree that many Americans would benefit by limiting their daily fat intake to 30 percent or less of calories, restricting the amount of saturated (animal) fat and increasing the amount of unsaturated (plant) fat so that they are consumed in approximately equal quantities, and limiting cholesterol intake to 300 milligrams a day or less.
Now, a panel of experts has suggested that all children over age 2 consume this fat-restricted diet. The experts base their recommendation on data showing that in most people who switch to such a diet, serum cholesterol levels will fall, thus reducing their risk for heart disease.
High levels of cholesterol lead to the deposit of this waxy material in our arteries. As these deposits build up, they progress from simple yellow or fatty streaks to raised rough plaques that can block the flow of blood to such vital organs as the heart and brain, causing a heart attack or stroke.
This process of plaque formation takes many years and can begin early in life. A very high proportion of U.S. soldiers killed in the Korean and Vietnam wars already had fatty streaks within some of their arteries. Thus, it would seem logical to begin a low-fat, low-cholesterol diet as early as possible. For this reason, the panel of scientists recommended beginning such a diet after age 2.
This recommendation caused major concern among pediatricians and was criticized by the Committee on Nutrition of the American Academy of Pediatrics. The criticism was based on a number of important considerations. First, all infants are normally exposed to a very high-fat diet. All mammalian milks, including human breast milk, supply 50 percent or more of their calories in the form of fat and are high in cholesterol. Second, a certain amount of fat is essential for adequate growth and development. Third, the brain, which is growing rapidly, is composed of large amounts of fat, which must be deposited during infancy and early childhood. And finally, we do not know the consequences of a low-fat, low-cholesterol diet in the developing child.
Thus, two competing needs have been identified. On one hand, we wish to lower the fat and cholesterol content of our diet as soon as possible to prevent future ill effects. On the other, we must provide enough fat during the growing years to ensure optimal growth and development.
When, then, is the best time to begin such a diet?
Unfortunately, we do not yet have the data to answer this question precisely. A decision must be made using the best judgment of people who are knowledgeable in the fields of nutrition and child health.
My feeling is that until we know more, only those children who are at risk for developing atherosclerosis later in life should limit fat. This includes children who have a family history of early heart attack or stroke, children whose parents have high levels of blood cholesterol (greater than 200), and of course children who themselves have high levels of serum cholesterol (the exact level will vary with age, but levels above 75 should be considered high, particularly in the younger age groups). In these high-risk children, it makes sense to lower the intake of fat and cholesterol soon after major brain growth has taken place, which is around age 5.
This implies, of course, that parents know their own risk and their child's risk. To find out, they must know their own and their child's serum cholesterol levels. This simple test requires only a finger stick, and I believe every child should have one before age 5.
Remember, I am not talking about drastic modifications. Cutting back on meats, particularly fatty meats, using skim or 2 percent fat milk, substituting vegetable oils for lard or butter in cooking, using soft margarine in spreads and limiting the intake of egg yolks to two or three a week is usually all that is needed.
Don't go overboard; growing children and adolescents need more fat than adults, and you certainly don't want to cause a deficiency.
Thus, my solution to this medical controversy is to focus on the individual child by determining in the best way available whether he or she is likely to benefit from a dietary change. If so, I would limit fat and cholesterol to the recommended amounts beginning at around age 5. I would not limit fat and cholesterol more than this in any child unless there were a compelling medical reason to do so.
Myron Winick, MD, is the Williams Professor of Nutrition at the College of Physicians and Surgeons, Columbia University, New York.