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American Journal of Clinical Nutrition, Vol. 69, No. 3, 516-523, March 1999
© 1999 American Society for Clinical Nutrition

Original Research Communications

Influence of dietary fat on the nutrient intake and growth of children from 1 to 5 y of age: the Special Turku Coronary Risk Factor Intervention Project1,2,3

Hanna Lagström, Ritva Seppänen, Eero Jokinen, Harri Niinikoski, Tapani Rönnemaa, Jorma Viikari and Olli Simell


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: Excessive decreases in fat intake in young children have been linked with low intakes of energy and nutrients and possible growth failure.

Objective: We valuated nutrient intakes and growth of healthy children with different fat intakes during the first 5 y of life.

Design: In the Special Turku Coronary Risk Factor Intervention Project (STRIP), 7-mo-old children were randomly assigned to an intervention aimed at reduced consumption of saturated fat and cholesterol (n = 540) or to a control group (n = 522). This analysis comprises data for children for whom >=6 of 8 possible 3–4-d food records were available (n = 730; 353 females). Children were divided according to fat intake pattern (percentage of energy) between the ages of 13 mo and 5 y into groups with continuously high fat intake (5% of children), increasing fat intake (5%), continuously low fat intake (5%), decreasing fat intake (5%), and average fat intake (80%). Children's energy and nutrient intakes and growth were then compared by analysis of variance.

Results: Fat intake at 13 mo of age was particularly low (21% of energy) in the increasing fat intake group and in the continuously low fat intake group (22% of energy at 13 mo; 26% of energy at 5 y). Growth of children in all 5 fat intake groups, however, was not significantly different throughout the study period. Intakes of vitamins and minerals, except of vitamin D, met recommended dietary allowances in all fat intake groups.

Conclusion: Nutrient intakes and growth were not significantly different in children whose fat intake patterns differed between 13 mo and 5 y of age.

Key Words: Energy intake • nutrient intake • fat intake • growth • preschool children • Special Turku Coronary Risk Factor Intervention Project


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Infants and young children have large energy requirements in relation to their body sizes. Very low dietary fat contents may result in low energy density and lead to a diet too bulky for infants and young children, whose stomachs have limited intake capacities. The supply of energy, fat-soluble vitamins, and several minerals may thus decline below a critical threshold and lead to clinical symptoms and failure to thrive (1–3), although some studies suggest that essential nutrients are obtained in adequate amounts when children consume low-fat diets (4–6). For reasons of safety, current recommendations assume that breast-fed and weaned infants consume well over 40% of energy as fat and that fat intake remains at 30–35% of energy until 2–3 y of age and then continues to decline and ideally stabilizes at {approx}30% of energy.

Studies have shown that in developed countries the diets of infants who consume solids in addition to breast milk or formula and of children aged 1–3 y can contain surprisingly small amounts of fat without any obvious deleterious effects on growth (7–12). In fact, diets with relative fat contents exceeding 40% of energy have been proposed to diminish the intake of some trace elements (4).

To evaluate the effect of dietary fat content on the intake of other nutrients and on growth, we studied food consumption and growth of children enrolled in a prospective, randomized trial. The trial aimed to decrease the exposure of children to known environmental atherosclerosis risk factors from 13 mo to 5 y of age.


   SUBJECTS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Design and subjects
The design of the Special Turku Coronary Risk Factor Intervention Project (STRIP) for children has been described (13, 14). Briefly, STRIP is a long-term, prospective, randomized atherosclerosis prevention trial. Families (n = 1054; 1062 infants) were recruited to the study at the child health center in Turku, Finland, when their children were 5 mo old; infants were first studied at 7 mo of age. Of the infants eligible, 56.5% were enrolled and randomly assigned to either an intervention group (n = 540) or a control group (n = 522) between March 1990 and June 1992. Twins (n = 8) were randomly assigned together for practical reasons. The project was approved by the Joint Ethics Committee of Turku University and the Turku University Central Hospital. Informed consent was obtained from all parents.

Counseling
The intervention families met with a pediatrician, a nutritionist, and a nurse at 1–3-mo intervals until the infants were 2 y old, and then twice each year. The intervention families were counseled to reduce their children's intake of saturated fat and cholesterol, but to supply adequate amounts of energy (10, 14). The purpose was not to reduce total fat intake before 13 mo of age, however. Later, reduced fat intake was proposed if a child's fat intake exceeded 35% of energy. The individualized counseling of the intervention families focused mainly on the children's diets and was based on previous eating habits of the children and their families. The principles of the recommended intervention diet were reviewed at each visit, practical food recommendations were given, and the diet was adjusted according to the child's age.

The control families met the same team twice yearly from the beginning of the trial. Dietary issues were discussed with the control families only in a general way according to the practice of the Finnish child health centers, and no detailed suggestions on the use of fat were given to the control families.

Breast-feeding was promoted for as long as the mothers felt it feasible. The mean (±SD) duration of breast-feeding (breast milk as the only milk source) was 5 ± 4 mo in the intervention and control groups. After children were weaned, the intervention families were advised to use nonfat milk as the milk source for children and to add 10–15 mL vegetable oil/d or 10 g soft margarine/d (2–3 teaspoons/d) to the food until the children were 2 y old to compensate for the fat missing from the recommended daily milk portion. The aim was to maintain fat intake at the same level as in children who consumed milk with 1.9% fat. Detailed suggestions were made to replace products containing large amounts of saturated fat with products containing mono- and polyunsaturated fats.

Supplementation with 400 µg (1000 IU) vitamin A (retinol equivalents) and 10 µg (400 IU) cholecalciferol (vitamin D3) was recommended for all children until 2 y of age.

Data collection and analyses
When the children were 7 mo old, the parents were taught how to record their children's food consumption; written instructions were also supplied of how to record exact descriptions of the amounts of all foods and drinks consumed. Food consumption was recorded at 8, 13, and 18 mo of age and thereafter at 6-mo intervals with 3-consecutive-day food records before 2 y of age and 4-consecutive-day food records thereafter. The record always included at least one weekend day. Each item of the records was reviewed by the nutritionist for completeness and accuracy during the follow-up visits. If needed, missing portion sizes, food descriptions, or food preparation methods were added after discussion with the parents.

Daily energy and nutrient intakes were calculated by using the MICRO-NUTRICA program developed at the Research Centre of the Social Insurance Institution in Turku, Finland. This program uses the Food and Nutrient Database of the Social Insurance Institution to calculate the content of 62 nutrients in commonly used foods and dishes in Finland. Nutrient compositions of the commonly used baby formulas and commercial infant foods were added to the database. Intake of nutrients from vitamin and mineral supplements was not included in the calculations. The program estimates intakes of energy and most nutrients, including fat, type of fat (saturated, monounsaturated, and polyunsaturated), and protein, reasonably well (15).

Measurement of growth
Weight (to the nearest 0.01 kg) was measured until 15 mo of age by using a baby scale (model 725; Seca, Hamburg, Germany) and thereafter (to the nearest 0.1 kg) with an electronic scale (model S10; Soehnle, Murrhardt, Germany). Length (to the nearest 1 mm) was measured horizontally by using a baby board (Bekvil; Paljerakenne, Helsinki) until 21 mo of age. Thereafter, standing height was measured (Harpenden Stadiometer; Holtain, Crymych, United Kingdom). Height, relative height (deviation of height in SD units from the mean height of healthy Finnish children of the same age and sex), weight, and relative weight (deviation of weight in percentages from the mean weight of healthy Finnish children of the same age and sex) were recorded (16).

Statistical analyses
Results are presented as means (±SDs) with P values. Heights, relative heights, weights, and relative weights at each age were normally distributed. In this study, nutrient intakes of the intervention and control children of both sexes were analyzed together. At 8 mo of age, when food consumption was recorded for the first time, 43% of infants were still receiving some breast milk. Because an accurate measurement of breast-milk consumption by such a large group of infants was not feasible and because all mothers weaned their infants fully before 13 mo of age, nutrient intake data of 13-mo-old children were used as the starting point in these analyses.

Children in STRIP with >=6 of 8 requested food records available were included in the analyses (n = 730; 353 females). Linear regression lines of relative fat intake (as a percentage of energy) versus the age of the child were formed by using all available data points between 13 mo and 5 y of age. The children were then divided in the following groups according to their fat intake pattern (expressed as % of energy) between the ages of 13 mo and 5 y:

  1. constantly high fat intake: the 5% of children with the consistently highest relative fat intake (mean fat intake between 13 mo and 5 y of age above the 95th percentile for fat intake);
  2. increasing fat intake: the 5% of children with the steepest increase in the relative fat intake regression line between 13 mo and 5 y of age;
  3. constantly low fat intake: the 5% of children with the consistently lowest relative low fat intake (mean fat intake between 13 mo and 5 y of age below the 5th percentile for fat intake);
  4. decreasing fat intake: the 5% of children with the steepest decline in relative fat intake; and
  5. average fat intake: the 80% of children with average relative fat intake.

Intervention and control children were evenly represented in the group with average fat intake (Table 1Go). More children in the constantly low fat intake group belonged to the intervention group and more children in the constantly high fat intake group belonged to the control group. The increasing and decreasing fat intake groups had similar numbers of intervention and control children. Energy intakes of the boys and girls differed, but intakes of individual nutrients by boys and girls were combined because they showed no significant differences at any ages studied.


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  		TABLE 1. Number of intervention and control children in the different fat intake groups
 
Next, nutrient intake and growth data (height and weight at 7, 13, and 18 mo and at 2, 2.5, 3, 3.5, 4, 4.5, and 5 y of age, as well as changes in these measures between the ages of 7 mo and 5 y) of the children belonging to the different fat intake groups were analyzed by one-way analysis of variance. The growth of boys and girls is thus shown separately. The statistical computation was performed by using the BMDP (version 1990; BMDP Statistical Software, Los Angeles) and SAS (version 6.08; SAS Institute Inc, Cary, NC) statistical program packages. Differences were considered significant at P < 0.05.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Energy intake, energy density, and growth
At 13 mo of age, the constantly high fat intake group had markedly higher energy intake than did the other children (P < 0.05; Table 2Go). By 3 y of age, significant differences in energy intake between the fat intake groups had disappeared, but children with constantly low fat intake and children with decreasing fat intake tended to have slightly lower energy intakes than children with average fat intake at all later time points studied. When intakes were corrected for body weight, relative energy intakes of children with constantly high fat intake were slightly higher than those of children with increasing (most significant P value = 0.008 at 13 mo), decreasing, constantly low (P = 0.003 at 13 mo), or average (P = 0.01 and P = 0.01 at 13 mo and 3 y) fat intake (Figure 1Go). Relative energy intakes of the fat intake groups differed most markedly at 13 mo. Interestingly, the heights and weights of the children in the 5 fat intake groups did not differ significantly at any ages studied. The children in all groups also grew equally during the follow-up period and growth velocity did not differ significantly according to fat intake (Tables 3 and 4GoGo).


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  		TABLE 2. Dietary energy density and daily energy and nutrient intakes of children in the different fat intake groups at 13 mo and 3 and 5 y of age1
 


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  		FIGURE 1. Relative energy intake of children with constantly high ({diamondsuit}- - -{diamondsuit}), increasing ({diamond}––––{diamond}), constantly low ({diamondsuit}. . . .{diamondsuit}), decreasing ({diamondsuit}– – –{diamondsuit}), or average ({star}––––{star}) fat intake between the ages of 13 mo and 5 y.

 

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  		TABLE 3. Heights and weights at 7 mo to 5 y of age and height gains and weight gains between 7 mo and 5 y of girls in the different fat intake groups1
 

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  		TABLE 4. Heights and weights at 7 mo to 5 y of age and height gains and weight gains between 7 mo and 5 y of boys in the different fat intake groups1
 
There were large differences in the energy density of the ingested food (kJ/g or kcal/g) between the fat intake groups at all ages (Table 2Go). Only occasionally were energy density values below the approximate energy density values of milks given to infants [breast milk or formula, both of which have an energy density of {approx}2.80 kJ/g (0.67 kcal/g)]. The mean energy density in the diet of the children with average fat intake increased from 2.83 kJ/g at 13 mo of age rather linearly to 3.71 kJ/g at 5 y. The mean energy density in the diet of children with constantly low fat intake was consistently below that of children with average fat intake (P = 0.006, P < 0.001, and P < 0.001 at 13 mo, 3 y, and 5 y of age, respectively), whereas the energy density in the diet of children with constantly high fat intake was consistently higher than that of children with average fat intake (P < 0.001 at each age point).

Intakes of fat, protein, and carbohydrate
The mean fat intake of children in the average fat intake group was low at 13 mo of age, but increased steadily with age and reached 32.1 ± 2.3% of energy by 5 y (Table 2Go). Fat intakes of children in the constantly low fat intake group and the increasing fat intake group at 13 mo were clearly below Nordic and other current recommendations (17). In the decreasing fat intake group, mean fat intake decreased from 34.3 ± 6.4% of energy at 13 mo of age to 27.4 ± 4.6% of energy at 5 y of age (Figure 2Go). The intake of essential fatty acids met current recommendations in all fat intake groups at all ages studied (data not shown).



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  		FIGURE 2. Relative fat intake of children with constantly high ({diamondsuit}- - -{diamondsuit}), increasing ({diamond}––––{diamond}), constantly low ({diamondsuit}. . . .{diamondsuit}), decreasing ({diamondsuit}– – –{diamondsuit}), or average ({star}––––{star}) fat intake between the ages of 13 mo and 5 y.

 
Children in the constantly low fat intake group received proportionally more protein at 13 mo of age than did the other children (P = 0.01 for the difference between children in the constantly low fat intake group and children in the increasing fat intake group). Differences in protein intake between the other fat intake groups were small and disappeared by 5 y of age (Table 2Go). At all ages studied, mean protein intake was <20% of energy in all fat intake groups.

Constantly high fat intake was associated with a low intake of carbohydrates at all ages (Table 2Go). Children in the increasing fat intake group consumed more carbohydrate than did children in the other fat intake groups at 13 mo of age (P < 0.001 when compared with the group with average fat intake). Clearly, changes in carbohydrate intake always almost fully compensated for the changes in energy intake induced by changes in fat consumption (Figure 3Go).



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  		FIGURE 3. Relation between fat and carbohydrate intakes and between fat and sucrose intakes in children with constantly high, increasing, constantly low, decreasing, or average fat intake between the ages of 13 mo and 5 y. The solid squares indicate the mean intake values and the vertical bars the SDs.

 
Intake of sucrose
The mean sucrose intake of children in the different fat intake groups was well below 10% of energy at 13 mo of age and changed only slightly between 13 mo and 5 y. Surprisingly, at all ages, children with constantly low or constantly high fat intake consumed relative amounts of sucrose that were almost equal to amounts consumed by children in the average fat intake group. However, sucrose intake of children in the decreasing fat intake group increased to 12.6 ± 5.3% of energy by 5 y of age (P = 0.02 when compared with children in the average fat intake group; Figure 3Go).

Intake of fiber
Children in the decreasing fat intake group consumed less fiber than did children in the other fat intake groups at 13 mo of age (P < 0.01, P = 0.27, P < 0.01, and P < 0.01 when compared with the increasing, constantly high, constantly low, and average fat intake groups, respectively). Children in the constantly low fat intake group consumed markedly more fiber than did other children at and after 3 y of age because they consumed more vegetables, fruit, and berries (data not shown).

Intake of vitamins and minerals
Intakes of vitamins and minerals varied only slightly in the different fat intake groups and exceeded recommended dietary allowances, except that intakes of vitamin D were low. Intakes of vitamin E depended on the age and fat intake group of the child (Table 5Go). Vitamin E intakes were slightly below recommended values in children with increasing, constantly low, or average fat intake at 13 mo, whereas intakes of children with constantly high or decreasing fat intake met the recommendations at that age. The differences in vitamin E intake were caused mainly by differences in consumption of margarine and oil (data not shown). Recommended intakes of vitamin A were reached by children in all fat intake groups at all ages, and there were no significant differences among groups. Children with constantly low fat intake consumed markedly more vitamin C at all ages (103 ± 46 mg/d at 5 y of age) than did children in the other fat intake groups (from 64 ± 42 to 82 ± 53 mg/d; P < 0.04).


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  		TABLE 5. Daily intakes of selected nutrients of children in the different fat intake groups at 13 mo and 3 and 5 y of age1
 
Calcium intake of children with decreasing fat intake was significantly lower than that of children with average fat intake at 13 mo of age (P < 0.05). On the other hand, children with low fat intake consumed more calcium than did children with average fat intake at 3 y of age (P < 0.05). Iron intakes were not significantly different among groups and were below the recommendations at 13 mo. Recommended intakes were later reached by all groups. Intakes of zinc were well within recommendations in all fat intake groups at all ages.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Low intake of dietary fat at a young age may lead to inadequate intakes of energy and some nutrients and reduce growth. The present study suggests, however, that the true connections between intakes of fat, intakes of other nutrients, and growth are loose during the early years of life. The growth of children with different fat intake patterns between the ages of 13 mo and 5 y was well within the range of healthy Finnish children (16, 18), and children in all fat intake groups showed similar growth. The current intake recommendations were met in all 5 fat intake groups for all nutrients except vitamin D at all ages studied and iron at 13 mo of age. Furthermore, intakes of the nutrients listed in Table 5Go were close in all 5 fat intake groups.

It is commonly believed that infants and young children receiving diets low in fat fail to obtain sufficient amounts of energy because of the bulkiness of the meals. In Nordic and other European countries and in North America, this belief has led to a recommendation that the energy density of diets of 1–3-y-old children exceed 2.80 kJ/g (0.67 kcal/g), which is the mean energy density in breast milk and currently used formulas (19). In our study, the mean energy density of the true diets was slightly <2.80 kJ/g at 13 mo of age in children with increasing fat intake and children with constantly low fat intake, but all values at later time points exceeded the recommendation, implying that current diets with low fat contents are not excessively bulky. The average intake of energy by children in the different fat intake groups was well within the range of currently recommended energy allowances and similar to that reported previously for children in Finland (4, 6) and other Western countries (1, 20, 21).

The fat intakes of children in the different fat intake groups were clearly below the recommended 35–40% of energy before 2 y of age (10, 14). In children with average fat intake, fat consumption increased from 27% of energy at 13 mo to 32% of energy at 5 y, whereas consumption increased from only 22% of energy to only 26% of energy in children with constantly low fat intake during the same age period. However, even children in the constantly low fat intake group grew as well as children with the highest fat intake. Current recommendations are still based on the belief that fat intake slowly decreases from {approx}50% of energy during the breast-feeding period to 30–35% of energy at preschool age (11). In real life, introduction of solid weaning foods markedly decreases dietary fat content (11), so that fat intake is usually slightly <30% of energy at 7–8 mo of age, decreases to as low as 26% of energy during the early months of the second year of life, and then increases slowly (4, 10, 11, 13, 19, 22). Interestingly, the growth rate of children with low fat intake in this and several other recent studies was similar to that of children with average fat intake (5, 9, 11, 12).

Another common hypothesis is that low fat intake is accompanied by increased sucrose intake in infants and young children. In the Bogalusa Heart Study, children who received <30% of their energy requirements as fat consumed more carbohydrate, mainly sucrose, than did children who ate high-fat foods (23). In our study, however, children received almost equal amounts of sucrose at and after 13 mo of age irrespective of the fat intake group to which they belonged. Sucrose intake exceeded 10% of energy only in children with decreasing fat intake at 5 y of age. In 8–12-y-old Norwegian children, decreased fat intake was associated with increased sugar intake, but also with increased nutrient density (24).

Some studies suggest that intakes of vitamins A and D as well as zinc and iron by preschool-aged children consuming <30% of total energy as fat may be deficient (1–3), but other studies reported no association between low-fat diets and low intakes of any essential nutrients (4, 6, 25, 26). In fact, high-fat diets (>40% of energy) are probably more likely to lead to decreased intake of several trace elements (4, 6). In an Australian study, the energy and nutrient intakes of children aged 3 mo to 8 y showed no significant differences according to the relative amount of fat in diet (5); in the present trial, intakes of vitamins, minerals, and trace elements in the 5 fat intake groups were quite similar. The current recommended dietary allowances were met for all vitamins and minerals with the exception of vitamin D and iron, intakes of which were low in all groups. Daily supplementation with 10 µg cholecalciferol is thus strongly recommended for Finnish children until 2 y of age, and wintertime supplementation is recommended up to 6 y of age. Despite the low iron intakes, no evidence of iron deficiency was observed in 3–4-y-old children in STRIP (27).

We conclude that energy and nutrient intakes and growth were not significantly different in groups of children with different fat intake patterns between 13 mo and 5 y of age. Even the diets of children in the extreme fat intake groups provided adequate amounts of energy and essential nutrients for normal growth, implying that Western diets with fat intakes of slightly <30% of energy are a valid option in healthy children between the ages of 13 mo and 5 y.


   ACKNOWLEDGMENTS
 
We thank Soile Kotilainen for excellent analysis of the food records and Markku Vuorinen for help in data handling and statistical analyses.


   FOOTNOTES
 
1 From the Cardiorespiratory Research Unit and the Departments of Pediatrics and Medicine, University of Turku, Turku, Finland; the Research and Development Centre of the Social Insurance Institution, Turku, Finland; and the Hospital for Children and Adolescents, University of Helsinki.

2 Supported by grants from the Ministry of Social Affairs and Health; the Yrjö Jahnsson Foundation; the Finnish Cultural Fund; the Mannerheim League for Child Welfare; the Finnish Cardiac Research Foundation; the Foundation for Pediatric Research, Finland; the Academy of Finland; the Juho Vainio Foundation; the Signe and Ane Gyllenberg Foundation; the Turku University Foundation; Chymos Ltd; the Raisio Group; and Van den Bergh Foods Company.

3 Address reprint requests to H Lagström, Cardiorespiratory Research Unit, University of Turku, Kiinamyllynkatu 10, FIN-20520 Turku, Finland. E-mail: hanna.lagstrom{at}utu.fi.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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Received for publication March 9, 1998. Accepted for publication July 30, 1998.




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D. M Bier, R. M Lauer, and O. Simell
Summary
Am. J. Clinical Nutrition, November 1, 2000; 72 (5): 1410S - 1413S.
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