Hypercholesterolemia

Familial hypercholesterolemia (FH) is associated with an increased risk of premature atherosclerosis and coronary artery disease (CAD). Consensus panels recommend that prevention of CAD should be initiated in childhood. Statins are the newest class of lipid-lowering drugs. However, treatment with statins has not been evaluated for long-term safety in patients younger than 18 years of age. Therefore, a dietary approach is most important in the treatment of children with FH. The recommended diet is based on a restriction of total and saturated fat. Saturated fat should be replaced by unsaturated fat; thus, butter should be replaced by a spread rich in unsaturated fats. In addition to supplying favorable fatty acids, vegetable oil spread may be a good source of plant sterols or phytosterols, which have been shown to reduce serum cholesterol levels.

Since there are little to no studies on the effect of plant sterol esters (SEs) in spread on blood cholesterol concentrations, carotenoids, fat-soluble vitamins and physiologic variables in young children with FH, new research is needed. A recent study in the American Journal of Clinical Nutrition estimated the potency of a SE-enriched spread, to reduce plasma concentrations of LDL cholesterol in children with FH and investigated the influence of SE-enriched spread on carotenoids and fat-soluble vitamins in serum and other physiologic variables in these children.

Thirty-eight children with FH participated in this double-blind crossover study comprising two 8-week interventions. First, a run-in period of three weeks checked compliance and standardized the spread intake. At the start of the first intervention period, the subjects were randomly assigned to eat 20 g SE-enriched spread or control spread per day for eight weeks and were switched to the other spread in the second intervention period. A physical examination and a history of disease were undertaken on day 1. Blood samples were drawn for plasma lipids at baseline and on day 1 and 56 of each intervention period. Weights were also checked at these intervals. The subjects and their families received some dietary instruction and were encouraged to make additional changes and to follow the dietary advice during the entire study.

The children consumed 90.9% of the control spread and 91.7% of the SE spread, which corresponds to a daily intake of 18 and 18.2 g of the control and SE spreads, respectively. Plasma LDL-cholesterol concentrations decreased by 10.2% during the SE period compared with the control period. Total cholesterol and apolipoprotein B concentrations were reduced by 7.4% during the SE period. No changes were observed in HDL cholesterol, triacylglycerol, or apolipoprotein A-I. Serum concentration of lipid-adjusted retinol and a-tocopherol concentrations increased by 15.6% and 7.1%, respectively. Food diaries showed that the children consumed the recommended American Heart Association Step 1 diet during both intervention periods.

A daily intake of 1.6 g of sterol esters induces an additional reduction in LDL-cholesterol concentrations in children with FH consuming a recommended diet. Besides the beneficial effects mentioned above, a reduction of 8.1% in serum lycopene was observed. The authors state that this small decrease is of minor biological and clinical importance. When plant sterol supplements are introduced as part of a lipid-lowering diet in children with FH, an increased intake of fruit and vegetables is recommended to compensate for a possible decrease in serum lycopene. The results show that a SE-enriched spread may be an effective and safe tool in the treatment of serum cholesterol in children with FH.

Agot L Amundsen, Leiv Ose, Marit S Nenseter, and Fady Y Ntanios, Plant Sterol Ester-Enriched Spread Lowers Plasma Total and LDL Cholesterol in Children with Familial Hypercholesterolemia, Am J Clin Nutr 76: 338-344 (July), 2002) [Address reprint requests to AL Amundsen, Institute for Nutrition Research, University of Oslo, PO Box 1046, Blindern, N-0316 Oslo, Norway. E-mail: a.l.amundsen@basalmed.uio.no]

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