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Trans fat intake in children: risks and recommendations.

Despite long-standing concern Labour consumption of saturated fat, trans fat has only recently reached mainstream news and garnered concern from American health care providers. Trans fat, also known as trans fatty acid (TFA) or partially hydrogenated oil, has been a staple in processed foods for many years. Potential health effects of trans fat consumption include coronary heart disease, diabetes mellitus, inflammation, and alterations in lipoproteins. Ongoing research suggests that trans fat may be more detrimental to one's health than saturated fat. Although the major negative health effects of trans fat intake are seen later in life, dietary preferences and eating habits are formed in early childhood, necessitating early intervention to prevent future health problems. Increased understanding among health care professionals about the negative consequences of a diet high in TFAs will assist them in sharing this information with patients for behavior change.

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What Are Trans Fatty Acids?

Trans fatty acids are created from vegetable oils through the process of hydrogenation. In this process, alpha linoleic acid (ALA) is converted to stearic acid, oleic acid, or elaidic acid (Schaefer, 2002) by adding hydrogen atoms to unsaturated double bonds of ALA in either the cis (same side) or trans (opposite side) position to the existing double bond. When hydrogen is added in the trans position, the bond is straighter and more closely resembles a saturated double bond (Baic, 2007). Figure 1 illustrates the chemical structures of saturated fat, cisunsaturated fatty acids, and transfatty acids (Norris, 2007). The straighter trans bond is not as flexible, creating a less fluid structure when incorporated into the phospholipid membrane. An unsaturated fatty acid needs to contain only one trans double bond to be considered a TFA (Lichtenstein, 2000). Hydrogenation allows manufacturers to produce food that has a longer shelf life, enhanced taste, and better texture without the use of large amounts of saturated fat (Baic, 2007). Hydrogenation has been in use since the early 20th century, with increased use during the middle 20th century as the food industry moved away from the use of saturated fats (Eckel, Borra, Lichtenstein, & Piazza, 2007). Use of hydrogenated oils has declined recently as consumers and the food industry have become aware of the negative health effects of consuming trans fat (Baic, 2007).

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Where Are Trans Fatty Acids Found?

Trans fatty acids are found in many ready-made foods at grocery stores and in many items at fast-food restaurants. Vegetable shortening and margarine are composed primarily of hydrogenated oils. Thus, any food product that contains shortening or margarine is likely to contain TFA, including cookies, crackers, snack bars, cereals, fried foods, and other baked goods (Eckel et al., 2007). Commercially prepared foods, such as French flies and onion rings, contain trans fat when cooked in hydrogenated oils (Zaloga, Harvey, Stillwell, & Siddiqui, 2006). Commercial frying oils are partially hydrogenated to prevent deterioration by oxidative processes that limit ability to reuse the oil. The presence of TFA also raises the temperature to which the oil can be heated without degradation (Eckel et al., 2007). Despite long-standing concern regarding trans fat, use of hydrogenated oils continued because it was believed that the benefits of reducing saturated fat in the diet were more important than the risks of consuming trans fat (Lichtenstein, 2000).

Low levels of trans fats are found naturally in some animal products, such as cow's milk, lamb, and beef. The trans fat found in these animal sources is produced by the bacteria residing in the stomach of ruminant animals, such as cows (Baic, 2007). Due to the presence of naturally occurring TFA, it would not be possible to completely eliminate trans fat from the average diet. However, it is possible to significantly reduce con sumption of trans fat by eliminating the use of hydrogenated oils in food preparation and consuming fewer processed foods. Altering the diet to consume lower levels of trans fat could reduce the risk of diet-related health conditions, such as hypercholesterolemia and cardiovascular disease (Eckel et al., 2007).

Effect of Trans Fat Consumption on Health

Lipoproteins

Several studies have documented the effects of trans fat consumption on both cholesterol levels and cholesterol molecule composition. Schaefer (2002) reported that the presence in the diet of elaidic acid, which contains trans double bonds, is associated with increased low-density lipoprotein (LDL) levels and decreased high-density lipoprotein (HDL) levels. Lichtenstein (2000) and Mauger et al. (2003) found a dose-dependent relationship between consumption of trans fat and increased levels of LDL in the blood. This relationship suggests that consuming greater amounts of trans fat increases one's risk for conditions associated with high LDL cholesterol levels.

It is estimated that Americans consume approximately 4% to 12% of their daily fat intake in the form of TFA. This corresponds to approximately 13 grams of TFA (Zaloga et al., 2006). Although consumption of saturated fat raises both LDL and HDL cholesterol levels, leaving the ratio of total cholesterol to HDL cholesterol relatively stable, trans fat has been shown to have either no effect on HDL cholesterol levels (Eckel et al., 2007) or to lower HDL cholesterol levels (Lichtenstein, 2000). The resulting higher ratio of total cholesterol to HDL cholesterol is a significant risk factor for cardiovascular disease (Harvey et al., 2007). An additional risk factor for the development of cardiovascular disease, lipoprotein (a), has also been shown to increase with increased TFA consumption (Schaefer, 2002). In addition, Mauger et al. (2000) showed that as the proportion of trans fat in the diet increased, the size of LDL particles decreased, resulting in greater atherogenic risk.

Inflammation

Consumption of TFA has been linked with increased markers of inflammation in multiple studies. Harvey et al. (2007) found that the presence of TFA in endothelial cells increased the activation level of the cells, a phenomenon that can contribute to the development of atherosclerotic disease. Chronic activation is thought to encourage development of atherosclerosis, and altered cell function is thought to prevent the collateral vessel growth necessary to compensate for occlusion due to atherosclerosis.

Mozaffarian et al. (2004) suggest that the incorporation of TFA into endothelial cell membranes may be related to heightened levels of inflammation. Lopez-Garcia et al. (2004) found that increased TFA consumption was associated with increased plasma levels of several biomarkers of inflammation, including C-reactive protein (CRP). Previous studies have shown elevated levels of CRP to be an independent predictor of cardiovascular events (Lichtenstein et al., 2003). The findings of these studies suggest an explanation for epidemiological observations that consumption of trans fats confers a greater risk of developing cardiovascular disease than would be expected based solely on the changes in blood lipids.

Diabetes Mellitus

Preliminary evidence suggests a relationship between consumption of TFA and risk of type 2 diabetes mellitus. Salmeron et al. (2001) followed a cohort of women for 10 years, with results suggesting that replacement of TFA with polyunsaturated fatty acids conferred a 40% lower risk of developing type 2 diabetes mellitus. In addition, a 2% increase in TFA consumption was associated with increased risk of developing type 2 diabetes mellitus in sedentary, obese women.

Coronary Heart Disease

Several large studies have confirmed the relationship between consumption of TFA and the development of coronary heart disease (CHD). The Nurses Health Study found that women with the lowest intake of trans fat and the highest intake of polyunsaturated fat had the lowest risk of CHD. These results prompted recommendations that dietary saturated and trans fat be replaced with monounsaturated and polyunsaturated fats (Hu et al., 1997). The Seven Countries Study found that higher intake of trans fat was associated with increased serum cholesterol levels and increased mortality due to CHD (Kromhout et al., 1995). The relationship between consumption of TFA, unfavorable cholesterol levels, and chronic systemic inflammation suggests that reducing intake of TFA could modify these risk factors and potentially decrease risk of developing cardiovascular disease.

Trans Fat Consumption in Infants and Children

Animal models are used to test hypotheses before carrying out studies in humans, especially in vulnerable populations, such as infants and children. In pregnant rats and rat pups, Larque, Zamora, and Gil (2001) confirmed that trans fatty acids cross the placenta and are incorporated into fetal rat tissue. In their study of adult rats, Albuquerque et al. (2006) found that fetal and early postnatal nutrition affects the development of dietary control mechanisms, potentially creating life-long alterations in this system. Altered appetite signaling mechanisms were seen in adult rats fed a diet enriched in trans fat from fetal development to adulthood.

Researchers are beginning to take notice of these results, but little work in infants and children has been reported. Human studies have confirmed that trans fatty acids are transported across the placenta and that the percentages of trans fatty acids in maternal and infant plasma lipid profiles are similar (Houwelingen & Hornstra, 1994; Innis, 2006; Koletzko & Muller, 1990). Innis (2006) reported that maternal plasma levels of alpha linoleic acid (ALA) and linoleic acid (LA) are positively correlated with the corresponding levels in infant plasma and umbilical cord samples. Increased TFA levels in the maternal plasma profile are associated with decreased levels of ALA and LA. This may be detrimental to fetal growth because ALA and LA are desaturated to form arachadonic acid (AA) and docosahexanoic acid (DHA), each of which is necessary for fetal growth, neural development, and possibly postnatal development (Elias & Innis, 2001). An inverse relationship between fetal plasma TFA levels and fetal growth has been demonstrated in some studies (Innis & King, 1999), with increased circulating TFA levels corresponding to decreased birth weight (Innis, 2007a).

High levels of TFA in the maternal diet continue to affect the breast-fed infant because the level of TFA in human breast milk is correlated with maternal intake (Innis & King, 1999). Infants breast-fed by mothers with a high-TFA, low-LA intake are exposed to potential adverse effects, including risk of inflammatory and immune conditions due to incorporation of atypical fatty acids into cellular membranes and low intake of essential fatty acids (Innis, 2007b). Infants with low plasma levels of DHA may suffer long-term problems in both cognitive and behavioral development (Innis, 2007b).

Why Early Intervention?

Although the adverse effects of atherosclerosis are not seen until adult life, the process that causes these effects begins in childhood (Chen, Srinivasan, Li, Xu, & Berenson, 2007; Myers, Coughlin, Webber, Srinivasan, & Berenson, 1995; Srinivasan, Frontini, Xu, Berenson, 2006). Longitudinal studies, including the Bogalusa Heart Study, have demonstrated that clusters of risk factors associated with metabolic syndrome, such as elevated systolic blood pressure, elevated cholesterol, and obesity, may appear during childhood (Chen et al., 2007; Myers et al., 1995; Srinivasan et al., 2006). Given that these risk factors are associated with cardiovascular disease in adults (Chen et al., 2007) and that consumption of trans fat has been linked to unfavorable cholesterol levels (Schaefer, 2002), coronary heart disease (Hu et al., 1997; Kromhout, et al., 1995), and other conditions (Harvey et al., 2007; Lopez-Garcia et al., 2004; Mozaffarian et al., 2004; Salmeron et al., 2001), education and intervention must begin early in life.

According to the 2002 Feeding Infants and Toddlers Study (FITS), meal and snack patterns begin to emerge around age 7 to 8 months and are established by age 9 to 11 months (Ziegler, Briefel, Ponza, Novak, & Hendricks, 2006). Ziegler et al. (2006) found that compared to 1977 data, children age 2 to 5 years old are now eating more between-meal snacks, totaling approximately 100 additional calories per day. These snacks tend to be of lower nutritional value than foods eaten during meals. Children who eat lunch or snacks at home consume significantly less trans fat than when lunch or snacks are consumed away from home. This correlates with a greater intake of fried foods, such as chicken nuggets and French fries, when snacks and meals are consumed away from the home.

Spruijt-Metz, Lindquist, Birch, Fisher, and Goran (2002) reported that food intake preferences and patterns develop early in life and are greatly influenced by maternal child-feeding practices. Therefore, parents of young children, toddlers, and/or infants are prime targets for dietary interventions to reduce trans fat intake. Parents can be encouraged to provide healthier food options in the home and to make better choices outside the home. Tucker, Irwin, He, Bouck, and Pollett (2006) found that parents of preschool-aged children want nutrition education for themselves and their children to enable them to make healthier food choices.

Current Programs to Reduce Dietary Fat Intake In Children

The High Five, Low Fat (H5LF) program provides parental education to increase knowledge and involvement in the child's physical growth and development. Parent educators trained in child development provided teaching through at-home visits and group meetings. Initial success of this program is thought to arise from the high level of community involvement in the H5LF program (Haire-Joshu et al., 2003).

The Special Turku Coronary Risk Factor Intervention Project for Children (STRIP) study has provided valuable information about long-term dietary interventions to reduce risk factors for atherosclerosis (Kaitosaari et al., 2006). In this study, parents and children in the intervention group received biannual individualized counseling from a physician and a dietitian on maintaining a diet low in saturated fats. Control children received only the standard health education offered at well-baby clinics. Children in the intervention group consumed less total and saturated fat, and showed lower levels of insulin resistance at 9 years of age. The results of this study suggest that establishing healthy eating and lifestyle habits could prevent development of insulin resistance and/or atherosclerosis in later life.

Golan and Crow (2004) followed children for several years to determine the success of either child-only or parent-only dietary counseling. Counseling centered on altering the home environment to improve health, rather than focusing on a child's weight as the reason for change. At the end of the intervention, researchers found that children in the parent-only group had a significantly higher percentage weight reduction (14.6%) compared to children in the child-only group (8.43%). At 7 years post-intervention, 60% of the children in the parents-only group were non-obese, compared to just 31% of the children in the child-only group. This clearly demonstrates the importance of including and preferably targeting parents in interventions to improve dietary habits of children. Parents were empowered to provide healthful foods and guide the choices made for family meals, providing a healthful model for children to learn eating behaviors. However, it must be remembered that providing information and improving knowledge of healthy behaviors does not guarantee that a child or an adult will choose to engage in these behaviors (Weepie & McCarthy, 2002).

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Proposed Educational Intervention

Given the research available about the negative health effects of trans fat consumption and the success of strategies currently in use to encourage changes in dietary habits, it is proposed that educational content regarding trans fatty acids be developed and included in programs aimed at parents and children. Preferably, parents would receive initial counseling at prenatal visits and reinforcement throughout well-baby/well-child visits, early preschool, and other interactions with the health care community. Interventions that involve continued education and reinforcement have shown the greatest success in changing dietary behaviors and reducing cardiovascular risk factors (Golan & Crow, 2004; Haire-Joshu et al., 2003; Kaitosaari et al., 2006).

Supplemental written information in conjunction with dietary counseling could assist parents in making healthier choices on their own. The information should include basic facts on trans fat, as discussed in this article. Figure 2 provides a model brochure for this information, including a brief discussion of why changes must begin in early childhood and examples of foods that contain trans fat contrasted with healthier alternatives. The foods list should include snack and meal foods purchased at grocery stores, as well as items from popular fast-food establishments. Including fast-food items is important because the proportion of meals and snacks eaten at these establishments has increased over the past 30 years, especially for children of preschool age (Ziegler et al., 2006).

As reported by Tucker et al. (2006), parents want to make better choices but are not sure of the best choices to make, with convenience often a factor in food choices. A portable list of "good" snack and meal foods to purchase at the store could ease decision making for parents and reduce the time needed to determine which foods are healthy and which are not. Determining the amount of trans fat in a food item by reading the ingredients list can be time-consuming and difficult. Foods often claim to have 0 grams of trans fat, but partially hydrogenated oil may still be found in the ingredients list. This is because the U.S. Food and Drug Administration (FDA) allows a manufacturer to list 0 grams on the Nutrition Facts label for any ingredient that is less than 0.5 grams per serving (FDA, 2003). Although the per serving amount of trans fat in an item may be low, if one consumes more than the recommended serving, or a combination of foods with this level of trans fat, one can easily reach high levels of daily trans fat intake. Therefore, it is important that parents know how to read both the nutrition label and the ingredients list when selecting food items (see Figure 2).

When choosing a framework for both content and presentation, one must consider characteristics of the target audience, such as literacy/education, socioeconomic status/resource availability, dietary norms/preferences, and the importance placed on a healthy lifestyle. Tailoring interventions to the literacy level of the target audience and using audiovisual approaches when necessary has proven effective in past research (Eyler, Haire-Joshu, Brownson & Nanney, 2004). It is important to use a family-centered approach tailored to the family's beliefs, practices, and life skills, aimed at empowering parent and child, when attempting to change behaviors to benefit child health (Gance-Cleveland, 2007). Interventions must also account for the availability and affordability of foods encouraged by the dietary program.

Parents should be encouraged to choose food items with lower saturated fat and trans fat content, and to consider a diet that contains fewer processed items. A diet containing more "whole" foods and fewer refined foods would necessarily contain less trans fat because most dietary trans fat is found in baked goods, snack foods, and fast foods (Eckel et al., 2007; Zaloga et al., 2006).

Programs aimed at reducing saturated fat intake have had success by providing counseling on the effects of saturated fat and how to make healthier food choices. These programs emphasize decreasing saturated fat intake while increasing fruit and vegetable intakes (Haire-Joshu et al., 2003). Educational materials could include simple information, such as eating trans fat raises "bad" cholesterol, puts one at greater risk of heart disease, and changes the way the cells in your body act, putting one at greater risk of developing type 2 diabetes mellitus. Prenatal patients should be informed that trans fats cross the placenta and are found in breast milk. Reducing trans fat intake during pregnancy and breast-feeding is healthy for the mother and her baby (Decsi, Burus, Molnar, Minda, & Veitl, 2001; Houwelingen & Hornstra, 1994; Innis, 2006; Koletzko & Muller, 1990). Parents should be taught that what they eat and what they feed their children in the first few years will shape the child's food choices for the rest of his or her life. Most importantly, parents should be educated and empowered to make healthy food choices, rather than just be told to avoid trans fat.

This education intervention is likely to be most successful when added to an educational framework aimed at reducing saturated fat intake. Because saturated and trans fats both have negative health effects, decreasing consumption of trans fat should not be achieved at the expense of increasing consumption of saturated fat or vice versa. Sustained changes from childhood through adulthood are necessary to continue to control risk factors and prevent development of conditions such as atherosclerosis, coronary heart disease, and diabetes mellitus.

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Ziegler, R, Briefel, R., Ponza, M., Novak, T., & Hendricks, K. (2006). Nutrient intakes and food patterns of toddlers' lunches and snacks: Influence of location. Journal of the American Dietetic Association, 106(1, Suppl. 1), $135-$148.

Lindsay R. Bauer, BSN, RN, is a Staff

Nurse, The University of North Carolina

Hospitals, Chapel Hill, NC.

Julee Waldrop, MS, RN, FNP, PNP, is an

Associate Professor of Nursing and

Pediatrics, The University of North Carolina

at Chapel Hill, Chapel Hill, NC.

Statement of Disclosure: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education article.
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Title Annotation:Continuing Nursing Education Series
Author:Bauer, Lindsay R.; Waldrop, Julee
Publication:Pediatric Nursing
Geographic Code:1USA
Date:Nov 1, 2009
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