Eighty-eight school children and their parents who had been counselled regarding appropriate dietary and activity patterns aimed at reducing serum cholesterol were followed-up 21 months later to determine changes in dietary and activity patterns and in serum lipid levels. The decline in serum total cholesterol ranged from 8 to 14% in the different age and sex groups (P \u3c 0.05 to P \u3c 0.001). Serum triglycerides did not change significantly. Cholesterol intake decreased 36% and 54% in 10-14 year old boys and girls respectively (P \u3e 0.001). The activity level increased significantly in both the 5-9 year and 10-14 year olds (P \u3c 0.05 to P \u3c 0.005). These results show that nutrition education can bring about a change in dietary and activity patterns, resulting in a decline in serum cholesterol levels

Badruddin, S H

Khursheed, M

Molla, A

Vaz, S

English

eCommons@AKU

eCommons@AKUSection of Internal Medicine Department of MedicineNovember 1993The impact of nutritional counselling on serumlipids, dietary and physical activity patterns ofschool childrenS H. BadruddinAga Khan UniversityA MollaM KhursheedS VazAga Khan UniversityFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_med_intern_medRecommended CitationBadruddin, S. H., Molla, A., Khursheed, M., Vaz, S. (1993). The impact of nutritional counselling on serum lipids, dietary and physicalactivity patterns of school children. Journal of Pakistan Medical Association, 43(11), 235-237.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_med_intern_med/101The Impact of Nutritional Counselling on Serum Lipids,Dietaryand Physical Activity Patterns of School ChildrenPages with reference to book, From 235 To 237 Salma Halai Badruddin ( Departments of Medicine, The Aga Khan University Medical Center, Karachi. ) Ayesha Molla, Mohammed Khursheed ( Department of Pathology, The Aga Khan University Medical Centre, Karachi. ) Sandra Vaz ( School of Nursing, The Aga Khan University Medical Center, Karachi. ) Abstract Eighty-eight school children and their parents who had been counselled regarding appropriate dietaryand activity patterns aimed at reducing serum cholesterol were followed-up 21 months later todetermine changes in dietary and activity patterns and in serum lipid levels. The decline in serum totalcholesterol ranged from 8 to 14% in the different age and sex groups (P <0.05 to P <0.001). Serumtriglycerides did not change significantly. Cholesterol intake decreased 36% and 54% in 10-14 year oldboys and girls respectively (P >0.001 ). The activity level increased significantly in both the 5-9 yearand 10-14 year olds (P <0.05 to P <0.005). These results show that nutrition education can bring abouta change in dietary and activity patterns, resulting in a decline in serum cholesterol levels (JPMA43:235, 1993).Introduction Our earlier studies on school Children have shown that 58% of children from well to do families1, haveserum cholesterol levels above 4.4 mmol/L (170 mg/dl), a level at which it is recommended thatchildren be counselled regarding diet and exercise to lower serum cholesterol levels.Hypercholesterolemia is a known risk factor for coronary heart disease2 and it has been reported thatchildren whose serum cholesterol levels are high tend in general to have high levels as adults3,4.Positive cross-sectional associations between various indices of obesity with serum total cholesterol(TC), triglycerides (TG) and low-density lipoprotein cholesterol (LDL-C) in both adult and childrenhave been reported and high density lipoprotein cholesterol (HDL-C) has been shown to be inverselyassociated with obesity5-7. Prospective studies in adults and adolescence have indicated that increasesin obesity are positively associated with increases in levels of TC, TG and LDL-C8-10. Torland andGillam11 have reported an association between the level of physical activity and serum lipids values inchildren. Higher levels of physical activity were correlated with lower TG levels and higher HDL-C toTC ratios. Similarly TC and TG levels tended to be lower or HDL-C levels higher in children fromschools where they were strongly encouraged to exercise12. The present study was undertaken to assessthe effectiveness of the counselling given to the children and parents in bringing about changes indietary and activity pattern which would result in a decrease in serum cholesterol levels.Subjects and Methods 87 children (41 males, 46 females) who were identified as having serum cholesterol levels > 4.4mmol/L (> 170 mg/dl) and were counselled regarding needed changes in dietary and activity patternswere followed up 21 months after the initial blood test that identified them as hypercholesterolemic.BiochemistryAll subjects fasted overnight for 12-14 hours before blood collection in the morning. About 5 ml ofblood was collected in neutral tubes, centrifuged and stored at 4°C. Cholesterol and’ triglycerides wereestimated by enzymatic methods13,14 using a Beckman ASTRA autoanalyzer. HDL and LDLcholesterol were estimated using the Boehringer kit following the methods of Burnstein et al andLopes-Vireila et al15,16.Nutritional AssessmentHeights and weights were recorded at the time of drawing blood and a detailed interview conducted bytrained nutritionists regarding food intake and activity patterns. Cholesterol intake was calculated usingfood composition tables17,18.The children were classified according to the number of physical activity periods of 30 minutes eachper week as follows:Sedentary                   <3Moderately active      3-5Active                         >5CounsellingEight children of the same age and sex were invited with their parents to attend a counselling session.At the beginning of the session each parent child pair was informed of the child’s weight status relativeto the height. The focus of the counselling session was on how to meet the nutritional needs of thechildren by diets that were low in total fat, cholesterol and simple sugars and high in complexcarbohydrates and fiber. The total quantity of food required by the children in a day was displayed. Thechildrens need for physical activity and how this could be incorporated into the daily routine wereexplored in depth. The whole session was very interactive with parents and children raising questionsand concerns. After the joint session, the nutritionists met with each parent-child pair and evaluated thechild’s individual needs regarding appropriate body weight, food likes and dislikes and activitypatterns. The strengths and weaknesses of the child’s usual dietary pattern as obtained from the dietaryinterview were pointed out and ways to improve the diets were discussed. The aim of theindividualized counselling was to help the parents and child to formulate an action plan which wasacceptable to both and in keeping with the scientific guidelines for meeting nutritional needs andlowering cholesterol levels. The parents were followed-up by at least one pjione call 12 weeks after thecounselling to remind them to monitor their child’s serum lipid levels, diet and activity and to addressany questions or queries the parents may have.Statistical AnalysisPaired students "t" test was used to test for differences in values for mean serum cholesterol andtriglycerides and cholesterol intake before and after counselling. Chi-square with Yates correction wasused to test for significance in changes in activity levels.Results Serum total cholesterol and triglyceride levels before and after counselling are shown in Table I.There was a significant decrease in the serum cholesterol levels in all four groups ranging from 8% inthe 5-8 year old girls to 14.1% in the 10-14 year old girls. The mean TG values ranged from 0.96mmol/L for the 5-9 year old boys to 1.28 mmol/L for the 5-9 year old girls. There was no significantchange in the serum TG values after counselling. The maximal change was observed in the 5-9 yearold’ boys whose TG values decreased 14.6% from 0.96 to 0.82 The mean LDL-C ranged from 2.7mmol/L in the 5-9 year old boys to 3.1 mmol in the 5-9 year old girls. The mean HDL-C level was 1.5mmol/L in the 5-9 year old boys, the other three groups all had mean HDL-C level of 1.2 mmol/L.LDL-C and HDL-C levels were not determined prior to counselling, therefore, no- comparative resultsare available. The cholesterol intake decreased in all four groups but the change was significant only inthe 10-14 year olds (Table II).The major change in food intake was a decreased consumption of eggs, milk and cheese. The 10-14year old girls decreased their mean milk intake from 1.5 glasses/day to 1.0 glass/day, their egg intakedecreased from about 4/week to! 1/week and the frequency of cheese intake decreased from 3.5/weekto 1.5/week. Most children ate organ meats 1-3 times/month, after counselling the frequency of intakedeclined to less than once a month. More striking changes were seen in the activity levels especially forthe boys, but for all age and sex groups there was a significant increase in the percentage of childrenclassified as active. All the children had gained weight in the 21 months since the time their weight wasrecorded in 1988 but relative to their height 50.5% had decreased their body weight, 10% remained thesame and 39.5% had a higher relative body weight.Discussion Although the serum TC decreased considerably in all four groups, the LDL-C levels were still at orabove the 75th percentile of values of North American children except for the 10-14 year old girls. TheHDL-C levels tended to be low with only the 5-9 year old boys having values above the 50thpercentile; the other three groups had HDL-C values that were at or below the 25th percentile of valuesfor North American children of comparable age and sex19. The percent decrease in serum TC is evenmore remarkable when one considers the fact that an increase in TC levels of 0.16 to 0.41 mmol/L isreported to occur during childhood20. However, the absence of a control group in our study makes itdifficult to attribute these changes to the counselling given. The possibility exists that just theawareness that the child’s serum cholesterol level was high might have brought about changes in foodintake and activity which in turn resulted in a decrease in serum cholesterol levels. We feel however,that this is unlikely on the basis of our qualitative observation during the counselling sessions. Thosechildren who were >5% above expected weight for height were often perceived by their parents, asbeing underweight or normal, therefore, they would be unlikely to curtail caloric dense foods.Secondly, there was a great deal of resistance, especially by parents of the younger children torecommendations to decrease intake of foods such as eggs, cheese and where necessary, milk. Thesewere generally classified by parents as “good foods and essential for growing children. It was only afterconsiderable reassurance from the nutritionist (SHB) that the parents agreed to consider decreasingtheir child’s intake of such foods. Nonetheless, the results show that this decrease was much moremarked in the older age groups who made their food choices relatively independently of their parents ascompared to younger age groups who were still influenced by parental control over food intake. Parentswere much more receptive to the idea of increasing their childrens physical activity and this is reflectedin the significant increase in physical activity observed in these children. Becque et al have shown thatexercise in addition to moderate dietary restriction can result in a reduction in the serum lipids in obeseadolescents21. Similarly, Tamir and co-worker have reported that a health education programme inschool resulted in a decrease in TC and BMI and increase in HDL in children age 7-9 years22. TheWorld Health Organization has projected that in another 10 years there will be more deaths fromcardiovascular diseases in the developing countries, than - from a number of infectious diseasecombined including diarrhoeal disease, schistosomiasis, tuberculosis, malaria, measles and whoopingcough23. The results of this study show that risk factors for heart disease are modifiable during theschool ages and health programmes designed to inculcate healthy lifestyles in school age children mayhelp to avert the epidemic of heart disease that threatens to engulf us.Acknowledgement The authors wish to thank the children and administration of the Karachi Grammer School as well asthe parents for their co-operation in the study. We also wish to acknowledge the assistance of Mr.Sulaiman Gilani in the preparation of the manuscript.References 1. Badruddin, S.H., Khurshid, M., Molla, A. etst Factorsassociated with elevated serum cholesterollevels in well-to-do Pakistani school children. I Trop. Med. Hyg., 1991;94:123-29.2. National cholesterol Education Programme. Report of expert panel on blood cholesterol levels inchildren and adolescents. Pedistrics, (Suppl. 3, Part 2), 1992;89:525- 84.3. Lauer, R.M. and Clark, W.R. Use of cholesterol measurements in childhoodfor the prediction ofadulthypercholesterolemia. TheMuscatine study. JAMA., 1990;264:3034-38.4. Orchard, Ti., Donahue, R.P., Kuller, LI-I. et al. cholesterol screening in childhood: does it predictadult hypercholesterolemia? The Beaver county experience. 3. Pedistr., 1983;103:687-91.5. Frerichs, R.P., Webber, US., Srinivasan, SR. et al. Relation of serum lipids and lipoprotein to obesityand sexual maturity inwhite and black children. Am.J. Epidemiot, 1987;125:186-96.6. Freedman, D.S., Srinivaaan, S.R., Shear, CL et at. Correlates of HDL cholesterol and apolipoproteinA-I levels in children: The Bogaluss Heart Study. Arteriosclerosis, 1987;7:354-60.7. Aristimuno, 0.0., Foster, TA., Voors, A.W. et al. Influence of persistent obesity in children oncardiovascular risk factors: The Bogslusa Heart Study. circulation, 1984;69:895-904.8. Freedman, D.S., Burke, G.L, Harsha, D.W. et at. Relationship of changes in obesity to serum lipidand lipoprotein changes in childhood and adolescence. JAMA., 1985;254:515-20.9. Noppa, H. Body weight change in relation to incidence of iachemic heart disease and change in riskfactors for ischemicheart disease. Ami. Epidemiol., 1980;111:693-704.10. Khoury, PMorrison, J.A. and Mellies, M. Weight change since age I8years in 30 to 55 year oldwhites and blacks: associations with lipid values, lipoprotein levels and blood pressure. JAMA.,1983;250:3179-87.11. Torland, W.G. andOillam, T.B. comparison of serum lipids between babituallyhigh and low activepre-adoleacent males. Med. Sci. Sports. Exerc., 1981;13:316-21.12. Yathamoto, A., Horibe, H., Sawada, S. et al. Serum lipid levels in elementatyand junior highachoolchildren and theirrelationahip to relativeweight. Prey. Med., 1988;17:93 108.13. Allian, CC, Poon, US., chan, CS.G. et at. Enzymatic determination of total serum cholesterol din.chem., 1974;20:470-75.14. Bucolo, 0. and David, H. Quantitativedetermination of serum triglycerides by the uaeof enzymes.Clin. Chem., 1973;19:476-82.15. Burnstein, M. Rapid method of isolation of lipoprotein from human serum by precipitation withpoly-anions. J. Lipid Res., 1970,11:583-95.16. Lopes-Virella, M.F. cholesterol determination in high density lipoprotein separated by threedifferentmetbods. din. chem., 1977;23:282-84.17. Gopalan, c., Rama Sastri, B.V. and Balasubramanian, s.c. Nutritive value of Indian foods. NationalInstitute of Nutrition. Indian Coun. Med. Res. Hyderabad, India, 1985.18. Pennington, J.T.A> and church, H.N. Food valuesof portions commonly used. 14th ed.Philadelphia, J.B. Lippincott Co., 1984.19. Lipid Research clinics, Population Studies, Data Book Vol 1.The prevalence study, Washington DC.Department of Health and Human Services. Public Health Service. National Institute of Health,Publication Number 80-1527, 1980; pp. 28-81.20. Berenson, 0.5. and Epstein, F.H. Conference on blood lipids in children: optimal levels for earlyprevention of coronaty artery disease. Prev. Med., 1983;12:725-902.21. Becque, M.D., Katch, V.L., Rocchini, A.P. et al Coronary risk incidence of obese adolescents:reduction by exercise plus diet intervention. Pediatrics, 1988;81:605-12.22. Tamir, D., Feurstein,A., Brunner, S. etal. Primary preventionofcardiovasculardiseases in childhood;changes in serum total cholesterol, high density lipoprotein and bodymass index after 2 years ofintervention in Jerusalem school children aged 7-9 years. Prey. Med., 1990;19:22-30.23. World Health Organization. Heart beat: the rhythm of health. CH- 1211, Geneva 27, Switzerland,WHO., 1992.

The impact of nutritional counselling on serum lipids, dietary and physical activity patterns of school children

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The impact of nutritional counselling on serum lipids, dietary and physical activity patterns of school children

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