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Journal of the American College of Nutrition, Vol. 23, No. 2, 117-123 (2004)
Published by the American College of Nutrition

Original Research

Cardiovascular Risk Reduction in Preschool Children: The "Healthy Start" Project

Christine L. Williams, MD, MPH, Barbara A. Strobino, MPH, PhD, Marguerite Bollella, MD, RD and Jane Brotanek, MD, MPH

Columbia University, Institute of Human Nutrition and Department of Pediatrics, New York, New York

Address reprint requests to: Christine L. Williams, MD, MPH, Director, Children’s Cardiovascular Health Center, Columbia University, Institute of Human Nutrition, BHN 7-702, 3959 Broadway, Babies & Children’s Hospital of New York, New York, NY 10032. E-mail: chrisw320{at}aol.com


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 CONCLUSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Objective: To evaluate the impact of a multicomponent cardiovascular health intervention ("Healthy Start") which included a food service modification in a largely minority Head Start preschool population. The primary outcome measure was the change in serum cholesterol from the beginning to the end of the school year.

Methods: Nine Head Start centers in Upstate N.Y. were assigned to either food service modification or control conditions. In addition, half of the centers assigned to the food service modification received supplemental nutrition education (FS/NU —food service modification/nutritional education), while the remaining centers were provided with supplemental safety education materials (FS- food service modification only). The control preschool centers (CON) also received supplemental safety educational curricula for children but their food services remained unchanged. Children had serum cholesterol, as well as height and weight measured at the beginning and end of the school year. A generalized linear univariate procedure was used with percent change in total serum cholesterol as the outcome variable and intervention group as the primary independent variable.

Results: There was a significant decrease in total serum cholesterol among preschool children in food service intervention groups, (FS/NU and FS), compared to Controls (-6.0 versus -0.4 mg/dL). In addition to the significant difference in group means, children with elevated cholesterol at baseline were significantly more likely to have a cholesterol level in the normal range (<170mg/dL) at follow-up if they attended a preschool in the food service modification group. There was a 30% reduction in risk of elevated cholesterol in the latter compared to controls. Participation in the dietary intervention did not affect short-term growth.

Conclusions: A preschool heart health intervention, "Healthy Start," designed to reduce the total and saturated fat content of snacks and meals to recommended levels was effective in reducing serum cholesterol in the study population as a whole and specifically children ‘at risk’; i.e., those with initial elevated serum cholesterol.

Key words: intervention, preschool children, serum cholesterol, dietary fat


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 CONCLUSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Elevated blood cholesterol has been identified as a major risk factor for cardiovascular disease (CVD) in adults [1]. Studies have demonstrated the beginning of arteriosclerosis and associated risk factors in children and adolescents [2–7]. Additionally, cardiovascular disease risk factors have been shown to track from infancy through childhood [8] and from childhood through adolescence to adulthood [9–10]. Thus, it is important that preventive efforts are instituted early in childhood.

Interventions aimed at lowering the saturated fat content of the diet yield a decrease in total serum cholesterol in adults [11–13]. A decrease in total cholesterol of as little as 10% can result in a 30% reduction in the incidence of coronary heart disease in the adult population [14]. Although it is not known how such a decrease in children affects their cardiovascular disease (CVD) risk as adults, there is a modest association between dietary fat intake and serum lipids in school age and preschool children [15–17].

The results of a controlled multicomponent intervention on serum blood cholesterol in preschool children are reported below. The study was designed to promote heart healthy behaviors and decrease CVD risk factors in disadvantaged preschool children from upstate New York. The primary intervention was modification of the preschool food service to reduce the saturated fat content of meals and snacks. The study is notable because it deals with a very young population and because the dietary modification is not dependent on parental behavior modification. It was hypothesized that lowering the saturated fat content in a school menu that provides from one-third to two-thirds of a child’s total nutritional intake would significantly lower blood cholesterol levels. In addition, we sought to determine if this effect could be enhanced in children who received a supplemental nutrition educational curriculum that included lessons on healthy eating. Notwithstanding the young age of the children (2–5 yrs.), it is possible that nutrition education could influence a child’s food choices at home.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 CONCLUSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Nine Head Start preschools located north of New York City participated in the "Healthy Start" project. All of the Head Start Centers were similar in that they served predominantly minority children from families with incomes below the national poverty level. Preschools were assigned to one of three interventions: Food service and supplemental nutrition education (FS/NU); Food service only (FS); and Control (CON). Both the FS and CON schools received supplemental safety education. A detailed discussion of the protocol is provided elsewhere [18]. The food service staff of preschools assigned to the food service intervention (FS/NU and FS) was provided with a full day in-service training on the purchasing and preparation of heart healthy meals and snacks. This program, administered by registered dietitians on the Healthy Start staff, was designed with the objective of achieving a total fat intake of <= 30% of total energy, and a saturated fatty acid intake of <=10% of total energy. The program effectively lowered saturated fat intake in the intervention schools without compromising energy intake or nutritional content of the diet. A detailed report of the outcome of the food service intervention is provided elsewhere [19].

Teachers in the preschools assigned to the educational intervention (FS/NU) were provided with a skills-based, developmentally appropriate health curriculum which focused heavily on nutrition and other general health issues such as hygiene, body parts, etc. The teachers were trained and instructed in the use of the curriculum by the Healthy Start staff. The Control group had no modifications made to their food service. However, a curriculum component along with teacher training was provided to these schools similar to that provided to the FS/NU schools. The only difference was that this curriculum focused on safety and accident prevention and general health issues other than nutrition. Both nutrition and non-nutrition programs included a parent component which included "take home" papers describing activities that could be done at home to enhance the preschool learning experience. Parent meetings on health themes were also held 3–4 times during the year.

At the beginning of the program, in the fall of 1995, and at the end of the school year, in the spring of 1996, measurements of weight, height, and blood pressure were taken by the Healthy Start pediatric team and serum lipids were measured enzymatically using nonfasting finger stick samples analyzed with the Cholestech L*D*X* [20–21].

The intervention groups were compared with respect to sociodemographic and baseline physical characteristics to identify potentially confounding variables. Additionally, baseline total cholesterol was examined by age, gender, ethnicity and baseline body mass index (BMI). T-tests compared group means and chi-square statistics compared distributions for categorical data.

A generalized linear model (GLM) univariate procedure (SPSS) [22] was used to compare the percent change in cholesterol level from the beginning of the program to the end of the school year. The GLM procedure provides regression analysis and analysis of variance for one dependent variable (per cent change in total cholesterol) by factors and covariates. Intervention group was the primary factor of interest. Other potentially confounding variables were entered as factors (ethnicity, gender) or as covariates (BMI, age at baseline, and number of months between baseline and follow-up measures). Main effects models and 2-way interactions between intervention group and gender and ethnicity were evaluated. Additional analyses looked at total cholesterol defined categorically as: normal (<170 mg/dL), borderline high (170–199 mg/dL) or high (>=200 mg/dL) [23]. Data analyses were carried out by first comparing outcomes in the FS/NU and FS groups. Since no significant differences were found, FS/NU and FS groups were combined to evaluate the effect of the food service intervention on the outcome measure.

The difference in weight to height ratio between baseline and follow-up was examined using the generalized linear model, with age at baseline and time between measurements entered as covariates and with gender and ethnicity included as factors. The short-term effects of lowering dietary fat consumption on weight gain could be assessed with intervention group also entered as a factor in the model.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
CONCLUSION
 ACKNOWLEDGMENTS
 REFERENCES
 
There were 787 children enrolled in the Head Start program at baseline and participation rates at all of the centers were generally excellent (Table 1). There were no differences between the intervention groups in the proportion participating in the anthropometrics screening at baseline. Fewer children in the Control group had their cholesterol tested at baseline due to a higher parental refusal rate. However, there were no significant differences in gender, ethnicity, and age between those children whose parents consented and those whose parents refused. Follow-up screening and cholesterol testing in spring 1996 were carried out for 91% of eligible children. At that time, there were no significant differences in the frequency of participation between the groups, indicating no differential loss to follow-up.


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  		Table 1. Participation in the Healthy Start Program at Baseline (FALL 1995) and Follow-Up (SPRING 1996) by Intervention

 
Some demographic differences existed between the FS/NU, FS, and CON groups (Table 2). Significantly more African-American and White children were in the FS/NU and FS groups, respectively, compared to the CON group. The majority of the children in the control group were Hispanic. Despite ethnic differences, there were no significant differences in mean serum cholesterol levels at baseline between the groups (Table 2). Children in the FS group were slightly younger and smaller than children in the control group and less time lapsed between baseline and follow-up measurements for the Controls compared to the FS/NU and FS groups.


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  		Table 2. Characteristics of the Healthy Start Population by Study Group

 
Total cholesterol was looked at by demographic characteristics to determine if the differences observed between the groups could confound the results for this outcome (Table 3). Both the mean cholesterol level, and the proportion of children with borderline high cholesterol (170–199 mg/dL) or high cholesterol (>=200 mg/dL) did not differ significantly by age, gender, or ethnicity. Body mass index was categorized as normal, overweight, and obese; <85th, 85th–95th, and >95th %-tiles, respectively, based on age and gender according to the year 2000 CDC growth charts [24]. There were no differences in total cholesterol by BMI.


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  		Table 3. Total Cholesterol at Baseline and Potentially Confounding Factors in the Healthy Start Population

 
Although there were no differences in total cholesterol between the groups at baseline, there were significant differences associated with the intervention (Table 4). Provision of supplemental nutrition education to the FS/NU group did not result in additional cholesterol lowering above and beyond that achieved by the food service intervention alone. Therefore, the FS/NU and FS groups were combined in the general linear model. With gender, ethnicity, BMI, age at program entrance, and time between measures entered into the model, only intervention group was significantly associated with percent change in TC from baseline to follow-up. Two-way interactions by gender and race were non-significant indicating that the association was consistent within these factors. Overall, the FS modification group experienced a 6 mg/dL drop in serum cholesterol in contrast to a 0.4 mg/dL drop in the CON group. The mean percent change was -.025 and +.013, respectively.


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  		Table 4. Change in Total Cholesterol (TC) from Baseline to Follow-Up

 
The change in weight-to-height ratio was used as a measure of a child’s growth over the course of the intervention. This variable was significantly associated with gender, ethnicity, age at program entrance, and time between baseline and follow-up (Table 5). The main effect of the intervention was not significant indicating that, in the population as a whole, there was no effect of the food service modification on the gain in weight-to-height ratio. The interaction between intervention and ethnicity was significant. Although among White children the change in weight-to-height ratio was greater in the FS modification group than CON, a test of simple means effects in the model was not significant.


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  		Table 5. Change in Weight-to-Height Ratio from Baseline to Follow-U

 
In addition to determining the amount of change in serum cholesterol associated with the intervention, its effect on TC defined categorically (normal vs. high-normal or high) was also considered. The proportion of children with total cholesterol levels at 170 mg/dL or above was not significantly different between the food modification group and controls at baseline (Fig. 1). At follow-up, however, the food service intervention groups had significantly fewer children with an elevated cholesterol level than Controls. The frequency of cholesterol >=170 mg/dL declined 9.7% for the children in the food service modification groups. In contrast, the proportion of children with elevated cholesterol in the control group increased by 3.8%.



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  		Fig. 1. Frequency (%) of elevated cholesterol (>=170 mg/dL) pre- and post-intervention by group.

 
Participation in the food service intervention effectively reduced the risk of elevated serum cholesterol among children with serum cholesterol >=170 mg/dL at baseline (Table 6). The relative risk of elevated TC in the food service modification groups compared to controls was significantly less than 1.0; 0.69 (95% CI = 0.57, 0.85). Thus, in the subpopulation of children with elevated baseline serum cholesterol, the food service intervention reduced the risk of elevated cholesterol by approximately 30%.


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  		Table 6. Serum Cholesterol at Follow-Up among 221 Children with Elevated Cholesterol at Baseline by Intervention

 

   DISCUSSION
 
Cross-sectional studies have demonstrated that blood cholesterol levels in elementary school children and preschool children are influenced by fat consumption in the child’s diet [15–16]. Additionally, nutrition counseling has been shown to be effective in lowering blood cholesterol in clinical practices that specialize in the treatment of children with elevated cholesterol [25–26].

The results of childhood interventions designed to lower serum cholesterol level in a general population sample have varied, possibly as a function of the age group involved and the type and extent of the intervention. Several community and school based education interventions have focused on older children. The Finnish North Karelia youth project demonstrated an effect of the intervention among adolescents on serum cholesterol but this was a unique population with high baseline serum cholesterol levels and a baseline diet high in saturated fat [27]. Studies in U.S. populations include the "Know Your Body" (KYB) program [28] among New York elementary school children and the CATCH trial (Child and Adolescent Trial for Cardiovascular Health) [29] which included elementary school children from sites across the U.S. The KYB study found a small effect of the intervention on serum cholesterol, while the CATCH study found no demonstrable effect of the intervention.

There are several possible reasons why our study resulted in a significant reduction in serum cholesterol in contrast to the two U.S. studies referred to above. The preschool children in our study were much younger than children in the other intervention studies. They had far fewer food choices than elementary school children with respect to what was available to eat at meals and snacks. In addition, children in elementary school derive most of their calories from outside sources, eating only lunch at school. The preschool children in our study consumed a significant proportion of their total calories within the school setting. Also, because of their young age, they were less likely than elementary school children to get food and snacks for themselves outside of school. It is also possible that there may be variation by age as to the effect of lowering the saturated fat content of the diet, with younger children experiencing more of an impact. Finally, our food service intervention could have been more effective in changing the fat content of meals and snacks at school since we were dealing with small school populations with only one or two key food service personnel per school.

There have been several studies that have tested CVD interventions aimed at young children. Of particular note is the Finnish Special Turku Coronary Risk Factor (STRIP) Study [30] in which parents were counseled on child diet intake from the time the child was 7 months old. This cohort has now been followed more than 7 years. The STRIP intervention also significantly affected serum cholesterol levels in the children during the initial study period. In our investigation, there was a significant effect on short-term tracking in that children in the intervention group with a baseline elevated serum cholesterol had a 30% decreased risk of continued elevated cholesterol at follow-up compared to control children.

Our study did not demonstrate additional cholesterol lowering among preschool children who received supplemental nutrition education over and above that of the food service intervention. Since all the Head Start centers must, by law, provide nutrition education in the classroom, the added supplemental nutrition material we provided may not have been a large enough ‘dose’ to make a difference in the outcome. Alternatively, the absence of an incremental effect could simply reflect the young age of the child, or the limited amount of time that was allocated to the supplemental education program in the classroom. Perhaps a longer educational experience is needed in children of preschool age to produce a change in behavior that is carried beyond the classroom. It is also feasible that the effect of the educational program is relatively small compared to the impact of the major environmental intervention of the food service modification.

The intervention did not significantly affect the children’s growth in the short-term in our population. There were no consistent differences in pounds per inch gained between the groups. These findings are comparable to those of others who found no adverse effects of a reduced fat diet on growth and development [26, 31–32].


   CONCLUSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 CONCLUSION
ACKNOWLEDGMENTS
 REFERENCES
 
In summary, a preschool heart health intervention, "Healthy Start," designed to reduce the total and saturated fat content of snacks and meals to recommended levels of <30% and <10%, respectively, was evaluated with serum cholesterol level as the outcome of interest. At the end of the school year, children in the pre-schools where the food service was modified experienced a significant lowering of total serum cholesterol compared to children in control schools. Additionally, the frequency of borderline high or high cholesterol was significantly reduced in the food service intervention groups. These children are currently being followed to evaluate the long-term effects of the intervention.

Although the intervention described was relatively short term, extending over the course of a single school year, the results are encouraging in that a relatively simple intervention aimed at changing an important environmental component of school health (the food service) can result in a significant reduction in a major CVD risk factor in a young minority population.


   ACKNOWLEDGMENTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 CONCLUSION
 ACKNOWLEDGMENTS
REFERENCES
 
This research was funded by the National Heart Lung and Blood Institute, NIH, HL50321. We gratefully acknowledge the administrators, nurses, cooks, teachers, parents, and children in each of the Head Start Centers who participated in the Healthy Start project, and without whose enthusiastic support this project could not have been conducted. We also thank Doris Gabari for her able administrative assistance throughout the project.

Received February 20, 2003. Accepted September 10, 2003.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 CONCLUSION
 ACKNOWLEDGMENTS
 REFERENCES
 

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