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Nutrition interventions for youth with dyslipidemia: a National Lipid Association clinical perspective

Open AccessPublished:September 10, 2022DOI:https://doi.org/10.1016/j.jacl.2022.07.011

      Highlights

      • Atherosclerosis begins at an early age and is influenced by lifestyle behaviors.
      • Nutrition interventions can delay onset or prevent occurrence of CVD-related events.
      • A healthy lifestyle enhances the benefit of lipid-lowering medications in youth.
      • Data supporting use of dietary supplements in youth with dyslipidemia are limited.
      • Lifestyle changes are best achieved with a multidisciplinary, family-based approach.

      Abstract

      A heart-healthy lifestyle, beginning at an early age and sustained throughout life, may reduce risk for cardiovascular disease in youth. Among youth with moderate to severe dyslipidemia and/or those with familial hypercholesterolemia, lipid-lowering medications are often needed for primary prevention of cardiovascular disease. However, lifestyle interventions are a foundation for youth with dyslipidemia, as well as those without dyslipidemia. There are limited data supporting the use of dietary supplements in youth with dyslipidemia at this time. A family-centered approach and the support of a multi-disciplinary healthcare team, which includes a registered dietitian nutritionist to provide nutrition counseling, provides the best opportunity for primary prevention and improved outcomes. While there are numerous guidelines that address the general nutritional needs of youth, few address the unique needs of those with dyslipidemia. The goal of this National Lipid Association Clinical Perspective is to provide guidance for healthcare professionals caring for youth with disorders of lipid and lipoprotein metabolism, including nutritional guidance that complements the use of lipid lowering medications.

      Keywords

      This NLA clinical perspective will address the following key clinical questions

      • 1.
        Why are targeted nutritional interventions for youth necessary and is there evidence that they improve outcomes? How do the needs of youth with dyslipidemia differ from those of their peers? (Sections II and III)
      • 2.
        Are there specific nutritional interventions for youth with dyslipidemia caused by a genetic variant? Acquired causes of dyslipidemia? (Section IV)
      • 3.
        Does being under- or overweight alter the nutritional management of youth with dyslipidemia? (Section V)
      • 4.
        Is there a role for use of dietary supplements in the management of youth with dyslipidemia? If so, is there evidence to support their safety and efficacy? (Section VI)
      • 5.
        What are the psychosocial implications of dyslipidemia in youth and the need for adherence to a heart-healthy lifestyle, including proper nutrition? Is there evidence that altering dietary intake early in life may be harmful? (Section VII)

      Introduction

      It is well known that atherosclerosis begins in childhood and accelerates by age 20.
      • Skinner A.C.
      • Perrin E.M.
      • Moss L.A.
      • Skelton J.A.
      Cardiometabolic risks and severity of obesity in children and young adults.
      Lifestyle interventions, including a heart-healthy dietary pattern, daily moderate-to-vigerous physical activity, maintaining a healthy body weight, and avoiding tobacco use, are the cornerstone of cardiovascular disease (CVD) risk reduction in youth with acquired and genetic dyslipidemia.
      Expert panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: national Heart, Lung, and Blood Institute.
      U.S. Department of Agriculture and U.S.
      Department of Health and Human Services.
      • Jacobson T.A.
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      • Orringer C.E.
      • et al.
      National Lipid Association recommendations for patient-centered management of dyslipidemia: part 2.
      When adopted early and sustained over a lifetime, heart-healthy lifestyle habits are critical in maintaining overall health and reducing risk of premature CVD and CVD-related events. Acceptable and elevated levels of blood lipids in youth are shown in Table 1. Several professional guidelines address the nutritional needs of youth but few provide detailed recommendations, particularly for those with disorders of lipid and lipoprotein metabolism. This National Lipid Association (NLA) Clinical Perspective provides practical recommendations for healthcare professionals for nutrition interventions for youth with a variety of both acquired and genetic lipid/lipoprotein disorders. A summary of nutrition interventions for youth by lipid/lipoprotein disorder is provided in Table 2.
      Table 1Acceptable and elevated levels of blood lipids in youth <18 years of age
      Expert panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: national Heart, Lung, and Blood Institute.
      .
      TestAcceptableBorderlineaHigh
      95th.
      TC<170170–199≥200
      LDL-C<110110–129≥130
      TG

      0–9 yrs

      10–19 yrs


      <75

      <90


      75–99

      90–129


      ≥100

      ≥130
      AcceptableBorderline lowLow
      10th.
      HDL-C>4540–45<40
      *All values are listed in mg/dL
      Abbreviations: TC=total cholesterol; LDL-C=low-density lipoprotein cholesterol; TG=triglyercides; HDL-C=high-density lipoprotein cholesterol
      Percentiles: a75th.
      b 95th.
      c 10th.
      Table 2Summary of nutrition interventions for youth by disorder.
      Lipid DisorderNutrition Intervention
      Familial Hypercholesterolemia (FH)
      • FH is a common genetic disorder characterized by moderate-to-severe elevations of LDL-C that increase the likelihood of premature CHD.
      • While LLM is generally required to reduce LDL-C and non-HDL-C, nutrition interventions to reduce SFA to <7% daily caloric intake, avoidance of TFA, <200 mg/day of dietary cholesterol, and increased dietary soluble fiber provides additional benefits. Supplements, such as soluble fiber or plant sterols, may also be beneficial.
      • All diet modifications should exist in the context of an age-appropriate dietary pattern, with adequate calorie and macro- and micronutrient intake to promote normal growth and development.
      Familial Combined Hyperlipidemia (FCHL)
      • FCHL is a common metabolic disorder characterized by: (a) elevated levels of Apo B that may present as either mixed hyperlipidemia, isolated hypercholesterolemia, HTG, or as normal serum lipid levels with an elevated level of Apo B; (b) intra-individual and intra-familial variability of the lipid phenotype; (c) an increased risk of premature CHD; and (d) a polygenic inheritance.
      • Nutrition interventions are similar to those for FH, with additional recommendations for TG lowering, such as reduction in foods containing simple carbohydrates and sugar sweetened beverages, as needed.
      Elevated Lipoprotein(a) [Lp(a)]
      • Serum Lp(a) reaches adult levels by school age and remains relatively constant into adulthood.
      • Elevated Lp(a) is recognized as a causal, independent risk factor for premature CVD.
      • While nutrition interventions do not significantly lower Lp(a), a lifelong heart-healthy lifestyle is helpful in minimizing additional CVD risk factors.
      Sitosterolemia
      • Hyperabsorption and decreased biliary excretion of cholesterol and non-cholesterol sterols leads to accumulation of serum sterols, such as campesterol and sitosterol.
      • Effective nutrition intervention includes:
        • Dietary restriction of cholesterol and plant-based non-cholesterol sterols.
        • Limiting intake or avoidance of shellfish (e.g., clams, scallops, oysters) and plant foods that are high in fat (e.g. vegetable oils, olives, margarine, nuts, seeds, avocados, and chocolate).
        • Fruits, vegetables, and refined cereal products (not whole grain) may be used.
      • Margarines/spreads and other sterol- or stanol-fortified products are contraindicated.
      Cerebrotendinous Xanthomatosis (CTX)
      • CTX, characterized by impaired bile acid synthesis, leads to accumulation of cholestanol and cholesterol in many tissues, including the brain.
      • The treatment of choice for CTX is oral chenodeoxycholic acid therapy, although it is currently not approved by the FDA for this indication.
      • A dietary pattern low in cholestanol (egg yolks, meat, fish/shell fish and poultry, and high fat dairy), especially when implemented at a young age, may also be helpful.
      Lysosomal Acid Lipase Deficiency (LAL-D)
      • LAL-D is a rare autosomal recessive disease, the manifestations of which include a clinical continuum from infancy through adulthood.
      • The infantile form generally presents with severe failure to thrive, may require a low-fat, amino acid-based formula and, in the absence of timely enzyme replacement, is most often fatal.
      • Patients with childhood/adult-onset LAL-D may benefit from a dietary pattern with <25–30% daily caloric intake from fat and <200 mg dietary cholesterol daily. Fat-soluble vitamin supplementation may also be helpful in those who have malabsorption and malnutrition.
      • Enzyme replacement therapy with sebelipase alfa is recommended for the treatment of LAL-D.
      • Nutrition intervention is an important supportive measure to medical intervention and not a primary therapy to promote changes in lipid levels.
      HypobetalipoproteinemiasAbetalipoproteinemia (ABL) Homozygous ABL
      • A rare, inherited, autosomal-recessive disorder resulting from a microsomal triglyceride transfer protein deficiency characterized by the absence, or near absence, of LDL-C.
      • Disruption of cellular fat transport causes symptoms of fat malabsorption (steatorrhea, diarrhea) and failure to thrive, which often present in infancy or early childhood.
      • Dietary fat, cholesterol, and fat-soluble vitamins, such as A, E, D, and K, are poorly absorbed, leading to deficiencies.
      • A low-fat diet (20–30% daily caloric intake), adequate intake of EFAs (2–4% daily caloric intake) with supplementation as needed, and vitamin supplementation, are critical in nutritional management. These interventions are most effective when started at a young age,
      • Prognosis is variable, but early diagnosis and strict adherence to treatment can improve neurological function and halt disease progression
      •   
      Patients with heterozygous ABL usually have normal lipids.

      Hypobetalipoproteinemia (HBL)

      Homozygous HBL
      • A rare, inherited, autosomal co-dominant disorder resulting from mutations in both alleles of the APOB; characterized by the absence, or near absence, of LDL-C.
      • Disruption of cellular fat transport causes symptoms of fat malabsorption (steatorrhea, diarrhea) and failure to thrive, which often present in infancy or early childhood.
      • Dietary fat, cholesterol, and fat-soluble vitamins such as A, E, D, and K are poorly absorbed, leading to deficiencies.
      • A low-fat diet (20–30% daily caloric intake), adequate intake of EFAs (2–4% daily caloric intake) with supplementation as needed, and vitamin supplementation, are critical in management. These interventions are most effective when started at a young age,
      • Prognosis is variable, but early diagnosis and strict adherence to treatment can improve neurological function and halt disease progression
      •   
      Patients with heterozygous HBL typically have half-normal levels of Apo B-containing lipoproteins. Some may be at-risk of steatohepatitis.
      Familial Chylomicronemia Syndrome (FCS) and Multifactorial Chylomicronemia Syndrome (MCS)
      • Individuals with FCS have impaired or absent LPL activity caused by a monogenic variant; MCS, which is 50–100 times more common, occurs in individuals with co-existence of genetic and secondary causes.
      • Both FCS and MCS lead to severe elevations in TG (>1000 mg/dL).
      • The mainstay of treatment is a specialized dietary pattern:
        • Very-low-fat <15–20 g per day (<10%–15% of total daily caloric intake) while meeting EFA needs (2–4% daily caloric intake).
        • MCT oil to increase overall caloric intake and balance macronutrients in the dietary pattern, as needed.
        • Emphasis on complex carbohydrate foods (e.g., oatmeal, brown rice, quinoa, beans) while limiting simple and refined carbohydrate foods.
        • Avoidance of alcohol.
        • Fat-soluble vitamin and mineral supplementation, as needed.
      Familial Hypertriglyceridemia (FHTG)
      • FHTG may be present in youth, typically in those with overweight or obesity and/or insulin resistance.
      • A low-fat diet (<30% calories from fat), limited intake of foods and beverages with added sugars, and the addition of complex carbohydrate foods and dietary sources of O3FAs is helpful in lowering TGs.
      • Promotion of a healthy weight is especially helpful in youth with overweight or obesity and/or insulin resistance.
      Acquired Hypertriglyceridemia (HTG)
      • Acquired HTG is closely associated with adverse lifestyle behaviors.
      • Nutrition intervention with lifestyle behaviors designed to achieve and maintain healthy body weight are the primary treatments for acquired HTG.
      • For youth with mild- to moderate-HTG, emphasis on vegetables, fruits, and lean protein intake with reduced intake of refind carbohydrate foods and foods/beverages with added sugar can be effective.
      • For youth with severe HTG (fasting TGs >1000 mg/dL), fat intake should be decreased to <10–15% of total daily caloric intake (<15–20 g per day) with avoidance of simple carbohydrates, such as foods and beverages with added sugars and 100% fruit juice.
      Abbreviations: FH=familial hypercholesterolemia; LDL-C=low density lipoprotein cholesterol; CHD=coronary heart disease; LLM=lipid-lowering medication; non-HDL-C= non high density lipoprotein cholesterol; SFA=saturated fatty acids; TFA=trans fatty acids; FCHL=familial combined hyperlipidemia; Apo B=apolipoprotein B; HTG=hypertriglyceridemia; CVD=cardiovascular disease; TG=triglycerides; Lp(a)=lipoprotein(a); CTX=cerebrotendinous xanthomatosis; FDA=Food and Drug Administration; LAL-D=lysosomal acid lipase deficiency; ABL=abetalipoproteinemia; EFA=essential fatty acids; HBL=hypobetalipoproteinemia; FCS=familial chylomicronemia syndrome; LPL=lipoprotein lipase; MCS=multifactorial chylomicronemia syndrome; MCT=medium chain triglyceride; FHTG=familial hypertriglyceridemia; O3FAs=omega-3 fatty acids.

      Implementation and efficacy of nutrition interventions

      Nutrition interventions in youth with dyslipidemia provide short- and long-term benefits without adverse effects on growth or maturation.
      • Niinikoski H.
      • Lagstrom H.
      • Jokinen E.
      • et al.
      Impact of repeated dietary counseling between infancy and 14 years of age on dietary intakes and serum lipids and lipoproteins: the STRIP study.
      • Dorgan J.F.
      • Liu L.
      • Barton B.A.
      • et al.
      Adolescent diet and metabolic syndrome in young women: results of the Dietary Intervention Study in Children (DISC) follow-up study.
      • Torvik K.
      • Narverud I.
      • Ottestad I.
      • et al.
      Dietary counseling is associated with an improved lipid profile in children with familial hypercholesterolemia.
      • Nupponen M.
      • Pahkala K.
      • Juonala M.
      • et al.
      Metabolic syndrome from adolescence to early adulthood – effect of infancy-onset dietary counseling of low saturated fat: the Special Turku Coronary Risk Factor Intervention Project (STRIP).
      • Rask-Nissila L.
      • Jokinen E.
      • Terho P.
      • et al.
      Neurological development of 5-year-old children receiving a low-saturated fat, low-cholesterol diet since infancy: a randomized controlled trial.
      Recent guidelines, including the Dietary Guidelines for Americans (DGAs), outline a variety of heart-healthy dietary patterns, including the Mediterranean diet, Dietary Approaches to Stop Hypertension (DASH), Healthy US-style diet, and vegetarian-style dietary patterns.
      U.S. Department of Agriculture and U.S.
      Department of Health and Human Services.
      counseling by a registered dietitian nutritionist (RDN) is strongly recommended to help youth and their families successfully alter dietary intake to meet nutritional needs, provide ongoing support, and encourage long-term adherence to healthy nutrition habits.
      Expert panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: national Heart, Lung, and Blood Institute.
      ,
      • Jacobson T.A.
      • Maki K.C.
      • Orringer C.E.
      • et al.
      National Lipid Association recommendations for patient-centered management of dyslipidemia: part 2.
      ,
      • Sikand G.
      • Cole R.E.
      • Handu D.
      • et al.
      Clinical and cost benefits of medical nutrition therapy by registered dietitian nutritionists for management of dyslipidemia: a systematic review and meta-analysis.
      A shared decision-making model of family-centered care is critical which, ideally, includes the child. Nutrition interventions include detailed recommendations for dietary changes based upon age- and gender-specific nutrient needs, dietary patterns, cultural norms, the family's food preferences, as well as food allergies or sensitivities.
      Expert panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: national Heart, Lung, and Blood Institute.
      Assessing willingness to change, identifying potential barriers, including food cost and access, and setting realistic goals are also fundamental for successful nutrition changes.
      • Arnett D.K.
      • Blumenthal R.S.
      • Albert M.A.
      • et al.
      2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

      Components of a heart-healthy lifestyle

      Saturated and unsaturated fatty acids

      Saturated fatty acids (SFAs) have a substantial effect on plasma lipids.
      • Jump D.B.
      Dietary polyunsaturated fatty acids and regulation of gene transcription.
      • Fernandez M.L.
      • West K.L.
      Mechanisms by which dietary fatty acids modulate plasma lipids.
      • Sacks
      • et al.
      Dietary fats and cardiovascular disease: a Presidential advisory from the American Heart Association.
      Table 3 illustrates the SFA content of several common foods. In the United States (U.S.), the leading sources of SFA for youth 1 year of age and older include sandwiches (e.g., breakfast sandwiches, hamburgers, and tacos), and desserts and sweet snacks (e.g., ice cream and brownies).
      U.S. Department of Agriculture and U.S.
      Department of Health and Human Services.
      Table 3Saturated fat content in select foods

      U.S. Department of Agriculture Fooddata Central. [online] Available at: < https://fdc.nal.usda.gov/ >[Accessed 20 May 2021].

      .
      Food (serving size)SFA (g/serving)
      Lentils (1 cup, boiled)0.1
      Skim milk (1 cup)0.1
      Boneless, skinless chicken breast (3 oz, cooked)0.9
      Salmon, wild Atlantic (3 oz, cooked)1.1
      Low-fat yogurt, plain (6 oz)1.7
      Olive oil (1 Tbsp)1.9
      Sirloin steak (3 oz, lean only, cooked)1.9
      Egg (1 large, scrambled)2.0
      Ground beef (93% lean/7% fat) (3 oz, cooked)3.3
      Whole milk yogurt, plain (6 oz)3.6
      Field Roast® plant-based burger (Field Burger™) (one)4.0
      Whole milk (1 cup)4.5
      Ground beef (80% lean/20% fat) (3 oz, cooked)5.6
      Cheddar cheese (1 oz)6.0
      Palm oil (2 Tbsp)6.7
      Beyond Meat® plant-based burger (Classic Cookout™) (one)7.0
      Butter (1 Tbsp)7.3
      Bacon (3 oz, cooked)11.7
      Coconut oil (1 Tbsp)11.8
      Abbreviation: SFA=saturated fatty acid.
      While there are subtle differences in the effect on levels of LDL-C by different types of SFAs, it is more helpful to discuss their effects as a class.
      • Siri-Tarino P.W.
      • Sun Q.
      • Hu F.B.
      • et al.
      Saturated fatty acids and risk of coronary heart disease: modulation by replacement nutrients.
      For youth older than 2 years with dyslipidemia, the recommended intake of SFA is <7% of daily caloric intake (approximately 8–20 g/day, depending on the child's caloric needs).
      Expert panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: national Heart, Lung, and Blood Institute.
      ,
      • Jacobson T.A.
      • Maki K.C.
      • Orringer C.E.
      • et al.
      National Lipid Association recommendations for patient-centered management of dyslipidemia: part 2.
      Use of plant-based, minimally processed foods can help to reduce SFA intake and assist with lowering total cholesterol (TC) and LDL-C.
      • Melina V.
      • Craig W.
      • Levin S.
      Position of the Academy of Nutrition and Dietetics: vegetarian Diets.
      It is important to note that coconut oil, while plant-based, is high in SFAs and is not recommended as part of a heart-healthy diet.
      • Lichtenstein
      • et al.
      2021 Dietary guidance to improve cardiovascular health: a scientific statement from the American Heart Association.
      Replacing foods rich in SFAs with foods rich in unsaturated fatty acids (UFAs) lowers TC and LDL-C by increasing the number of LDL receptors (LDLR) and increasing LDL clearance from the plasma.
      • Fernandez M.L.
      • West K.L.
      Mechanisms by which dietary fatty acids modulate plasma lipids.
      ,
      • Siri-Tarino P.W.
      • Sun Q.
      • Hu F.B.
      • et al.
      Saturated fatty acids and risk of coronary heart disease: modulation by replacement nutrients.
      Patients should be encouraged to replace foods rich in SFAs with plant- and marine-based foods rich in monounsaturated fatty acids (MUFAs) and polyunsaturated fatty acids (PUFAs).
      • Jacobson T.A.
      • Maki K.C.
      • Orringer C.E.
      • et al.
      National Lipid Association recommendations for patient-centered management of dyslipidemia: part 2.
      ,
      • Arnett D.K.
      • Blumenthal R.S.
      • Albert M.A.
      • et al.
      2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
      ,
      • Kris-Etherton P.M.
      • Krauss R.M.
      Public health guidelines should recommend reducing saturated fat consumption as much as possible: YES.
      • Krauss R.M.
      • Kris-Etherton P.M.
      Public health guidelines should recommend reducing saturated fat consumption as much as possible: debate Consensus.
      (Table 4)
      Table 4Unsaturated fat content in select foods
      • Sacks
      • et al.
      Dietary fats and cardiovascular disease: a Presidential advisory from the American Heart Association.
      .
      Food (serving size)PUFAs (g/serving)MUFAs (g/serving)Total UFAs (g/serving)
      Nuts, average all varieties (1 oz)6.26.312.5
      Canola oil (1 Tbsp)4.18.212.3
      Peanuts, roasted (1 oz)4.47.011.4
      Olive oil (1 Tbsp)1.49.811.2
      Seeds, average all varieties (1 oz)7.03.910.9
      Avocado (1/2 medium)1.26.77.9
      Nut or seed butter, any variety (1 Tbsp)2.14.76.8
      Granola (1/4 cup)3.32.35.6
      Hummus (2 Tbsp)1.01.12.1
      Abbreviations: PUFA=polyunsaturated fatty acid; MUFA=monounsaturated fatty acid; UFA=unsaturated fatty acid.

      Trans fatty acids

      Elimination of dietary artificial trans fatty acids (TFAs) is important in reducing health risks, especially in patients with dyslipidemia. Replacement of SFAs and UFAs with TFAs increases LDL-C, triglycerides (TGs), apolipoprotein B (Apo B), and lipoprotein(a) [Lp(a)] and decreases high-density lipoprotein cholesterol (HDL-C).
      • Mozaffarin D.
      • Clarke R.
      Quantitative effects on cardiovascular risk factors and coronary heart disease risk of replacing partially hydrogenated vegetable oils with other fats and oils.
      Consumption of TFAs increases risk of atherosclerosis, although the mechanism(s) are incompletely understood.
      • Sacks
      • et al.
      Dietary fats and cardiovascular disease: a Presidential advisory from the American Heart Association.
      While legislation has eliminated most dietary sources of artificial TFAs in the U.S., families should be taught to read nutrition facts labels and encouraged to avoid products that contain “partially hydrogenated” oils, which indicates the food contains articial TFAs.

      Dietary cholesterol

      Evidence supporting reduction in CVD risk by limiting dietary cholesterol is the subject of ongoing debate. In 2015, the NLA recommended a dietary pattern containing reduced amounts of cholesterol (<200 mg/day) to decrease LDL-C and non-HDL-C, especially for persons at high risk for CVD or with diabetes.
      • Jacobson T.A.
      • Maki K.C.
      • Orringer C.E.
      • et al.
      National Lipid Association recommendations for patient-centered management of dyslipidemia: part 2.
      Reducing consumption of dietary cholesterol was included in recent recommendations from the American College of Cardiology and the American Heart Association, as well as the 2020–2025 DGAs.
      U.S. Department of Agriculture and U.S.
      Department of Health and Human Services.
      ,
      • Arnett D.K.
      • Blumenthal R.S.
      • Albert M.A.
      • et al.
      2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
      ,
      • Carson J.S.
      • Lichtenstein A.H.
      • Anderson C.A.M.
      • et al.
      Dietary cholesterol and cardiovascular risk: a science advisory from the American Heart Association.
      Heart-healthy dietary patterns are typically low in dietary cholesterol because they are low in animal products rich in SFA, which may also be high in dietary cholesterol. Choosing plant-based protein sources also limits cholesterol intake.
      • Sikand G.
      • Severson T.
      Top 10 dietary strategies for atherosclerotic cardiovascular risk reduction.
      Table 5 illustrates the cholesterol content of select foods.
      Table 5Cholesterol content of select foods15.
      Food (serving size)Cholesterol (mg/serving)
      Cheddar cheese (1 oz)30
      Butter (1 Tbsp)31
      Boneless, skinless chicken breast (3 oz, cooked)42
      Sirloin steak (3 oz, lean only, cooked)49
      Salmon, wild Atlantic (3oz, cooked)60
      Ground beef (80% lean/20% fat) (3 oz, cooked)76
      Ground beef (93% lean, 7% fat) (3 oz, cooked)76
      Bacon (3 oz, cooked)94
      Egg yolk (17 g)184

      Dietary soluble fiber

      Viscous soluble fiber, which is not absorbed by the intestine, binds cholesterol and facilitates its excretion. For all individuals older than 2 years of age, the DGAs recommends a total daily fiber intake of 14 g per 1000 calories.
      U.S. Department of Agriculture and U.S.
      Department of Health and Human Services.
      For youth with dyslipidemia, soluble fiber should account for at least 6 g/day for those 2–12 years old and 12 g/day or more for those older than 12 years of age.
      Expert panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: national Heart, Lung, and Blood Institute.
      U.S. Department of Agriculture and U.S.
      Department of Health and Human Services.
      • Jacobson T.A.
      • Maki K.C.
      • Orringer C.E.
      • et al.
      National Lipid Association recommendations for patient-centered management of dyslipidemia: part 2.
      Foods high in soluble fiber are shown in Table 6. Youth with inadequate dietary intake may benefit from soluble fiber supplementation.
      Table 6Fiber content of select foods15.
      Food (serving size)Soluble fiber (g/serving)Total dietary fiber (g/serving)
      Flaxseed (1/2 cup)6.912.8
      Kidney beans (1 cup, cooked)5.711.4
      Vegetarian baked beans (1 cup)4.812.6
      Avocado (1/2)3.49.2
      Fresh asparagus (1 cup, cooked)3.45.6
      Fresh broccoli (1 cup, cooked)2.34.6
      Pear (1 medium)2.24.0
      Fresh beets (1 cup, cooked)2.03.4
      Oats, rolled, uncooked (1/2 cup)24
      Pistachios (1/2 cup)1.76.9
      Fresh green beans (1 cup, cooked)1.63.7
      Kale (1 cup, cooked)1.42.6
      High-fiber whole wheat bread (1 slice)1.33.0
      Apple (one medium)1.03.7

      Dietary omega-3 fatty acids

      The impact of omega-3 fatty acids (O3FAs) on lipid levels and CVD risk reduction has been extensively investigated in adults; however, less is known of the benefits and potential side effects in youth. While there is debate on the benefit of dietary supplement O3FA, it is important to note that consumption of foods rich in O3FAs, particularly docosahexaenoic acid (DHA), is important for cerebral development and retinal function in young children, and is recommended as part of an overall heart-healthy dietary pattern.
      U.S. Department of Agriculture and U.S.
      Department of Health and Human Services.
      ,
      • Vannice G.
      • Rasmussen H.
      • Droke E.
      • et al.
      Position of the Academy of Nutrition and Dietetics: dietary fatty acids for healthy adults.
      While there are several O3FAs available in foods, most of the research has focused on the plant-derived alpha-linolenic acid (ALA) and the marine-derived O3FAs eicosapentaenoic acid (EPA) and DHA. Plant sources of ALA include chia seeds, walnuts, and soybean, flaxseed, and canola oils. Foods rich in EPA and DHA include fatty/oily fish (herring, fresh water trout, salmon, and sardines), seaweed, algae, fortified foods, and cod liver oil.
      Ods.od.nih.gov
      Office of Dietary Supplements - Omega-3 Fatty Acids.
      Recommended daily intake for EPA and DHA has not been specified in youth.
      U.S. Department of Agriculture and U.S.
      Department of Health and Human Services.
      However, the U.S. Food and Drug Administration (FDA) provides guidance on seafood serving sizes for individuals 2 years of age and older, as well as guidance on fish varieties low in mercury.
      U.S. Food and Drug Administration
      Advice About Eating Fish.
      (Table 7) Two servings of low-mercury fish per week is recommended, with serving sizes based on an individual's age. Fish that contain high levels of mercury, such as king mackerel, orange roughy, and swordfish, should be avoided by most individuals.
      U.S. Food and Drug Administration
      Advice About Eating Fish.
      Mozaffarian and Rimm reviewed studies that indicated a 36% lower risk of CVD death and 17% reduction in total mortality in adults who consumed 1–2 servings of fish per week, and noted 250 mg of EPA and DHA daily appears to be sufficient for primary prevention of coronary heart disease mortality.
      • Mozaffarian D.
      • Rimm E.B.
      Fish intake, contaminants, and human health: evaluating the risks and the benefits.
      Similar evidence is not available for youth. Guidance on use of O3FA supplementation in youth is discussed in section VI.
      Table 7Recommended fish serving sizes by age
      U.S. Food and Drug Administration
      Advice About Eating Fish.
      .
      AgeServing size*
      2–3 years1 oz
      4–7 years2 oz
      8–10 years3 oz
      ≥11 years4 oz
      *2 servings per week recommended.

      Refined carbohydrates and sugar-sweetened beverages

      Current guidelines recommend replacing simple, refined carbohydrate foods with complex carbohydrate foods while limiting added sugar to <10% of daily caloric intake.
      Expert panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: national Heart, Lung, and Blood Institute.
      U.S. Department of Agriculture and U.S.
      Department of Health and Human Services.
      ,
      • Lichtenstein
      • et al.
      2021 Dietary guidance to improve cardiovascular health: a scientific statement from the American Heart Association.
      Individuals should limit the consumption of beverages high in sugar, including soda, flavored milk, sweet tea, and other sweetened drinks, as well as 100% fruit juice. In adults, consumption of ≥1 sugary beverage/day was associated with high TGs and low HDL-C.
      • Haslam D.E.
      • Peloso G.M.
      • Herman M.A.
      • et al.
      Beverage consumption and longitudinal changes in lipoprotein concentrations and incident dyslipidemia in US adults: the Framingham Heart Study.
      Similarly, consumption of sugar-sweetened beverages in youth has been associated with development of obesity.
      • Ludwig D.S.
      • Peterson K.E.
      • Gortmaker S.L.
      Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis.
      • Malik V.S.
      • Pan A.
      • Willett W.C.
      • et al.
      Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis.

      Physical activity

      Although the focus of this NLA Clinical Perspective is nutrition interventions, one of the foundations of a heart-healthy lifestyle is physical activity, which is discussed briefly. Physical activity lowers the risk for early death, coronary heart disease (CHD), stroke, hypertension (HTN), an abnormal lipid profile, metabolic syndrome, and type 2 diabetes (T2D).
      • Volker A.
      • Axel L.
      Impact of exercise training on cardiovascular disease and risk.
      Physical activity also assists in achieving and maintaining a healthy body weight and lowers serum lipid levels in youth.
      • Opina A.D.
      • Cephus C.
      • Wang Y.
      • et al.
      The effects of lifestyle changes on serum lipid levels in children in a real life setting.
      At least 60 min of moderate-to-vigerous physical activity daily is recommended for all youth, including aerobic and bone- and muscle-strengthening activities.
      Expert panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: national Heart, Lung, and Blood Institute.
      U.S. Department of Agriculture and U.S.
      Department of Health and Human Services.

      Special considerations

      Underweight youth

      For youth with lipid disorders other than severe HTG who are underweight (BMI <5th percentile for age and gender), nutrient-dense, calorie-dense, high-fat foods rich in UFAs can provide additional calories for weight gain while remaining within guidelines for lipid lowering as previously outlined. Nuts, nut butters, seeds, avocados, and oils may be included in the dietary pattern; nutritional shakes that are low in SFAs, low in added sugars, and adequate in fiber may also be appropriate (Table 11). Increased caloric intake from foods rich in SFAs, such as fatty and processed meats (hot dogs, bacon, sausage, and pepperoni), full-fat dairy (whole milk, regular cheese, and full-fat yogurt), and butter and coconut oil, increases LDL-C and should be avoided in underweight youth with dyslipidemia.
      Table 11Sources of calorie-dense foods for underweight youth with lipid disorders15.
      Food (with serving size)Calories (per serving)UFA (g/serving)SFA (g/serving)
      PUFAMUFA
      Nuts, average all varieties (1 oz)1736.26.32.3
      Peanuts, roasted (1 oz)1664.47.02.0
      Salmon and other oily fish (3 oz)1602.12.71.3
      Seeds, average all varieties (1 oz)1587.03.91.9
      Granola (1/4 cup)1493.32.31.4
      Canola oil (1 Tbsp)1244.18.21.0
      Olive oil (1 Tbsp)1191.49.81.9
      Avocado (1/2 medium)1131.26.71.4
      Chia seeds (2 Tbsp)11261.60.75
      Dried fruit, average all varieties (1/4 cup)108000
      Nut or seed butter, any variety (1 Tbsp)972.14.71.3
      Ground flaxseed (2 Tbsp)75410.5
      Hummus (2 Tbsp)461.01.10.4
      Calorie-dense foods low in SFAs and TFAs may be added to an individual's usual dietary pattern. For example, adding a trans-fat free, oil-based butter alternative to a bowl of oatmeal adds calories and UFAs without affecting the flavor/texture. Some cholesterol-lowering spreads and other food products that contain plant sterols should be avoided in youth with suspected or known sitosterolemia.
      • Connor W.E.
      • Lin D.S.
      • Pappu A.S.
      • et al.
      Dietary sitostanol and campestanol: accumulation in the blood of humans with sitosterolemia and xanthomatosis and in rat tissues.
      Other calorie-dense items rich in UFAs, such as avocado, nuts, nut butters, and flaxseed, can also be incorporated into an individual's usual food intake. For youth with severe HTG, MCT oil can be utilized to provide additional calories to the dietary pattern (refer to discussion of MCT oil above).
      • Williams L.
      • Rhodes K.S.
      • Karmally W.
      • et al.
      Familial chylomicronemia syndrome: bringing to life dietary recommendations throughout the life span.
      An RDN can develop an individualized plan for youth who are underweight to assist with weight gain while adhering to the recommended nutrition plan for the individual's dyslipidemia diagnosis and needs.

      Youth with overweight or obesity

      Youth with overweight or obesity are at elevated risk for cardiometabolic diseases, and an estimated 39% of youth with obesity also demonstrate lipid abnormalities.
      • DeBoer M.D.
      Assessing and managing the metabolic syndrome in children and adolescents.
      • Kit B.K.
      • Kuklina E.
      • Carroll M.D.
      • et al.
      Prevalence of and trends in dyslipidemia and blood pressure among US children and adolescents, 1999-2012.
      Similar to adults, the most common pattern of dyslipidemia in youth with overweight or obesity is characterized by elevated TGs, decreased HDL-C, and increased levels of small, dense LDL. Levels of LDL-C measured on routine lipid panels are generally normal or mildly elevated in youth with overweight or obesity.
      • Magge S.N.
      • Goodman E.
      • Armstrong S.C.
      The metabolic syndrome in children and adolescents: shifting the focus to cardiometabolic risk factor clustering.
      Other comorbid conditions are common, and include insulin resistance, T2D, NAFLD, polycystic ovary syndrome, obstructive sleep apnea, and mental health disorders.
      • Magge S.N.
      • Goodman E.
      • Armstrong S.C.
      The metabolic syndrome in children and adolescents: shifting the focus to cardiometabolic risk factor clustering.
      BMI percentiles and z-scores are tools that are readily available and easy to use as a measure to determine if a child meets criteria for overweight or obesity. Youth with BMI at or above the 85th percentile for age and sex can benefit from a comprehensive pediatric weight management program, if available. It is important to note that programs may have varying referral criteria. In all age categories, short- and long-term decreases in BMI are more likely to be achieved in the context of a multi-component, family-centered weight management intervention that included nutrition counseling by an RDN, physical activity, and behavioral components managed by a psychologist or mental health provider.
      ANDEAL.org
      Pediatric Weight Management (PWM) Guideline.
      ,
      • Hoelscher D.M.
      • Brann L.S.
      • O'Brien S.
      • et al.
      Prevention of pediatric overweight and obesity: position of the Academy of Nutrition and Dietetics based on an umbrella review of systematic reviews.
      A staged approach to weight management has previously been outlined by the American Academy of Pediatrics (AAP) (Table 12).
      • Spear B.A.
      • Barlow S.E.
      • Ervin C.
      • et al.
      Recommendations for Treatment of Child and Adolescent Overweight and Obesity.
      Table 12Suggested staged approach to weight management for children and adolescents
      • Spear B.A.
      • Barlow S.E.
      • Ervin C.
      • et al.
      Recommendations for Treatment of Child and Adolescent Overweight and Obesity.
      .
      Stage 1: Prevention Plus
      ComponentsImplementation Details
      • ≥5 vegetables and fruits
      • ≤2 h of recreational screen time (none if <2y of age)
      • No TV in child's bedroom
      • ≥60 min of physical activity (may need to be gradual progression toward this goal)
      • Involve entire family and consider cultural differences
      • Primary care office-based
      • Administered by trained office support: physician, PNP, PA, RN
      • Schedule follow-up frequency tailored to family
      • Advance to stage 2 if no improvement in BMI status after 3–6 months, if congruent with family's readiness to change
      Stage 2: Structured Weight Management
      ComponentsImplementation Details
      • Reduced-calorie eating plan
      • Increased structure of daily meals and snacks
      • ≤60 min of recreational screen time
      • ≥60 min of physical activity
      • Implement monitoring of screen time, physical activity, etc.
      • Perform medical screening
      • Primary care office-based
      • Administered by RDN, physician, PNP with training in assessment and counseling
      • Support from referrals
      • Monthly follow-up visits
      • Advance to stage 3 if no improvement in BMI status after 3–6 months, if congruent with family's readiness to change
      Stage 3: Comprehensive Multidisciplinary Intervention
      ComponentsImplementation Details
      • More frequent contact
      • More structured monitoring, goal-setting, feedback
      • More behavioral strategies used with more formal monitoring and feedback.
      • Components include:
      • parental involvement for children <12 years old (decrease as adolescents age)
      • assessment of diet, physical activity, weight (body fat) before treatment and at specified intervals
      • behavioral program including food monitoring, short-term nutrition and activity goal setting and contingency management
      • parent/caregiver training to improve home food and activity environments
      • structured dietary and physical activity interventions that improve dietary quality and result in negative energy balance
      • Multidisciplinary team (behavioral counselor, RDN, exercise specialist) or RDN and behavioral specialist paired with an outside physical activity program if a multidisciplinary team unavailable
      • Structured physical activity
      • Weekly follow-up for 8–12 weeks, then monthly. Advance to stage 4 if no improvement in BMI, if congruent to family's readiness to change.
      Stage 4: Tertiary Care
      ComponentsImplementation Details
      All components of Stage 3, but also:
      • Consider obesity treatment medication
      • Consider bariatric surgery
      • Consider meal replacements
      • Ongoing behavior change
      • Pediatric weight management center
      • Multidisciplinary team with expertise in childhood obesity, including physician, behavioral counselor, RDN and exercise specialist
      • Clinical or research protocol
      Abbreviations: PNP=Pediatric Nurse Practitioner; PA=physician assistant; RN=registered nurse; RDN=registered dietitian nutritionist.
      Although some behavioral and pharmacotherapy studies report modest success, additional research into accessibility and efficacy for treating obesity in children and adolescents is limited.
      • Styne D.M.
      • Arslanian S.A.
      • Connor E.L.
      • et al.
      Pediatric obesity—Assessment, treatment and prevention: an endocrine society clinical practice guideline.
      The FDA has approved a select number of weight loss medications, and bariatric surgery can also be considered for youth who meet published criteria and who have been unsuccessful achieving satisfactory weight loss with lifestyle modification.
      • Styne D.M.
      • Arslanian S.A.
      • Connor E.L.
      • et al.
      Pediatric obesity—Assessment, treatment and prevention: an endocrine society clinical practice guideline.
      • Fox C.K.
      • Gross A.C.
      • Bomberg E.M.
      • et al.
      Severe obesity in the pediatric population: current concepts in clinical care.
      The 2017 Endocrine Society Clinical Practice Guideline recommends that adolescents undergoing lifestyle therapy, medication regimens, or bariatric surgery for obesity need cohesive planning to help them effectively transition to adult care, with continued monitoring, support, and intervention.
      • Styne D.M.
      • Arslanian S.A.
      • Connor E.L.
      • et al.
      Pediatric obesity—Assessment, treatment and prevention: an endocrine society clinical practice guideline.
      Further study is needed of the genetic and biological factors that increase the risk of weight gain and influence the response to therapeutic interventions in youth.
      • Styne D.M.
      • Arslanian S.A.
      • Connor E.L.
      • et al.
      Pediatric obesity—Assessment, treatment and prevention: an endocrine society clinical practice guideline.
      Encouragement and ongoing support for youth by the primary care provider that focuses on early intervention is essential.
      • Spear B.A.
      • Barlow S.E.
      • Ervin C.
      • et al.
      Recommendations for Treatment of Child and Adolescent Overweight and Obesity.
      • Styne D.M.
      • Arslanian S.A.
      • Connor E.L.
      • et al.
      Pediatric obesity—Assessment, treatment and prevention: an endocrine society clinical practice guideline.
      ,
      • Barlow S.E.
      Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.
      Extensive recommendations for weight management in youth are beyond the scope of this review. A brief discussion on weight in youth is provided in Section VII.

      Eating disorders

      Alterations in the levels of blood lipids have been reported in individuals with eating disorders, such as anorexia nervosa and bulimia. However, there are limited data in youth on the extent, mechanism, and normalization of dyslipidemia with weight restoration. In adults with eating disorders, the results of studies have been inconsistent; for example, both increased and decreased lipid concentrations have been reported in anorexia nervosa compared with healthy controls.
      • Feillet F.
      • Feillet-Coudray C.
      • Bard J.M.
      • et al.
      Plasma cholesterol and endogenous cholesterol synthesis during refeeding in anorexia nervosa.
      • Haluzík M.
      • Kábrt J.
      • Nedvídková J.
      • et al.
      Relationship of serum leptin levels and selected nutritional parameters in patients with protein-caloric malnutrition.
      • Haluzík M.
      • Papezová M.
      • Nedvídková J.
      • et al.
      Serum leptin levels in patients with anorexia nervosa before and after partial refeeding, relationships to serum lipids and biochemical nutritional parameters.
      • Shih P.B.
      • Yang J.
      • Morisseau C.
      • et al.
      Dysregulation of soluble epoxide hydrolase and lipidomic profiles in anorexia nervosa.
      Recently, Hussain et al. conducted a systematic literature review and meta-analysis that demonstrated aggregate evidence for elevated lipid concentrations in acutely ill anorexia nervosa patients compared with healthy controls, some of which persisted after partial weight restoration.
      • Hussain A.A.
      • Hübel C.
      • Hindborg M.
      • et al.
      Increased lipid and lipoprotein concentrations in anorexia nervosa: a systematic review and meta-analysis.
      The authors suggested that this finding could signal an underlying adaptation or dysregulation not fully reversed by weight restoration. Although concentrations differed between subjects with anorexia and healthy controls, most lipid levels remained within the reference range and meta-analyses were limited by the number of available studies.
      A detailed discussion on nutrition interventions for eating disorders is beyond the scope of this paper. Screening for and treatment of eating disorders are discussed in Section VII.

      Dietary supplements

      A limited number of dietary supplements are included in national guidelines for youth and discussed in this section. With all patients, it is important to inquire about use of dietary supplements, including herbal products, and provide appropriate guidance. Parents and caregivers should be informed that some dietary supplements may have harmful side effects, particularly if started at a young age and taken for a prolonged period of time. Dietary supplements should also be discussed with the medical care team, which ideally includes a pharmacist, to ensure that no drug-drug interactions exist for dietary supplements and any prescribed medications used by patients.

      Plant sterols and stanols

      Research findings demonstrate that plant sterols and stanols lower LDL-C in youth who have been unable to achieve their lipid-lowering goals with dietary modification alone.
      Expert panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: national Heart, Lung, and Blood Institute.
      ,
      • Ribas S.A.
      • Sichieri R.
      • Moreira A.S.B.
      • et al.
      Phytosterol-enriched milk lowers LDL-cholesterol levels in Brazilian children and adolescents: double-blind, cross-over trial.
      • Guardamagna O.
      • Abello F.
      • Baracco V.
      • et al.
      Primary hyperlipidemias in children: effect of plant sterol supplementation on plasma lipids and markers of cholesterol synthesis and absorption.
      • Garoufi A.
      • Vorre S.
      • Soldatou A.
      • et al.
      Plant sterols-enriched diet decreases small, dense LDL-cholesterol levels in children with hypercholesterolemia: a prospective study.
      For those 2 years of age and older, a dose of 2 g/day is recommended as a replacement for usual dietary fat sources.
      Expert panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: national Heart, Lung, and Blood Institute.
      Results of limited studies in youth 4.5–16 years of age have demonstrated 6–10% lowering of TC, LDL-C, and apo B in individuals with hypercholesterolemia or FH, and up to a 15% lowering of similar parameters in individuals with FCHL.
      • Guardamagna O.
      • Abello F.
      • Baracco V.
      • et al.
      Primary hyperlipidemias in children: effect of plant sterol supplementation on plasma lipids and markers of cholesterol synthesis and absorption.
      • Garoufi A.
      • Vorre S.
      • Soldatou A.
      • et al.
      Plant sterols-enriched diet decreases small, dense LDL-cholesterol levels in children with hypercholesterolemia: a prospective study.
      Plant sterols and stanols in fortified food, such as margarines, capsules, or chewable supplements, appear to be more effective when administered throughout the day and with meals, rather than as a single dose.
      • Ras R.T.
      • Geleijnse J.M.
      • Trautwein E.A.
      LDL-cholesterol-lowering effect of plant sterols and stanols across different dose ranges: a meta-analysis of randomised controlled studies.
      • Demonty I.
      • Ras R.D.
      • van der Knaap H.C.M.
      • et al.
      Continuous dose-response relationship of the LDL-cholesterol-lowering effect of phytosterol intake.
      While studies have demonstrated lipid-lowering and general safety, there is insufficient evidence in youth of long-term CV risk reduction.
      • Jacobson T.A.
      • Maki K.C.
      • Orringer C.E.
      • et al.
      National Lipid Association recommendations for patient-centered management of dyslipidemia: part 2.
      Plant sterols and stanols supplements are contraindicated in youth with sitosterolemia.
      • Jacobson T.A.
      • Maki K.C.
      • Orringer C.E.
      • et al.
      National Lipid Association recommendations for patient-centered management of dyslipidemia: part 2.
      ,
      • Jones P.J.K.
      • Shamloo M.
      • MacKay D.S.
      • et al.
      Progress and perspectives in plant sterol and plant stanol research.

      Soluble fiber

      While soluble fiber intake from food sources is imperative, supplemental soluble fiber may be beneficial to glucose tolerance and assist in lowering atherogenic lipid levels.
      Expert panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: national Heart, Lung, and Blood Institute.
      Viscous soluble fiber has been shown to be effective in reducing TC, LDL-C, and non-HDL-C.
      • Jacobson T.A.
      • Maki K.C.
      • Orringer C.E.
      • et al.
      National Lipid Association recommendations for patient-centered management of dyslipidemia: part 2.
      ,
      • Ribas S.A.
      • Cunha D.B.
      • Sichieri R.
      • et al.
      Effects of psyllium on LDL-cholesterol concentrations in Brazilian children and adolescents: a randomized, placebo-controlled, parallel clinical trial.
      • Guardamagna O.
      • Abello F.
      • Cagliero P.
      • et al.
      Could dyslipidemic children benefit from glucomannan intake?.
      • Vi Thanh Ho H.
      • Jovanovski E.
      • Zurbau A.
      • et al.
      A systematic review and meta-analysis of randomized controlled trials of the effect of konjac glucomannan, a viscous soluble fiber, on LDL cholesterol and the new lipid targets non-HDL cholesterol and apolipoprotein B.
      The recommend dose for youth is currently 6 g/day for those 2-12 years of age, and 12 g/day for those ≥12 years of age.
      Expert panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: national Heart, Lung, and Blood Institute.
      Studies with a range of soluble fiber doses and sources in youth 2–18 years of age have demonstrated up to a 23% lowering of TC and LDL-C.
      • Kwiterovich P.O.
      The Role of Fiber in the Treatment of Hypercholesterolemia in Children and Adolescents.
      • de Bock M.
      • Derraik J.G.B.
      • Brennan C.M.
      • et al.
      Psyllium supplementation in adolescents improves fat distribution and lipid profile: a randomized, participant-blinded, placebo-controlled, crossover trial.
      Soluble fiber supplements come in a variety of preparations, including powders, gummies, capsules, and fortified food products. To be effective, the gel-forming properties of a fiber supplement should remain intact throughout manufacturing and processing.
      • Jacobson T.A.
      • Maki K.C.
      • Orringer C.E.
      • et al.
      National Lipid Association recommendations for patient-centered management of dyslipidemia: part 2.
      Ample fluid intake should be encouraged to reduce the risk of intestinal blockage or constipation.
      • Jacobson T.A.
      • Maki K.C.
      • Orringer C.E.
      • et al.
      National Lipid Association recommendations for patient-centered management of dyslipidemia: part 2.
      Powdered supplements should be consumed with an 8 oz glass of water to reduce choking risk and may not be appropriate for those with swallowing dysfunction. Additional research is needed to support recommendations for dosing, long-term safety, and efficacy of fiber supplementation in the pediatric population to treat dyslipidemia.

      Omega-3 fatty acids (O3FAs)

      While numerous studies have investigated the effects of O3FA supplementation on dyslipidemia in adults, clinical trials in youth are limited and the results are inconclusive.

      Kris-Etherton P.M., Richter C.K., Bowen K.J., et al. Recent clinical trials shed new light on the cardiovascular benefits of omega-3 fatty acids. Methodist Debakey Cardiovascular J. 2019;15(3):171–178. doi: 10.14797/mdcj-15-3-171.

      • Miller M.L.
      • Wright C.C.
      • Browne B.
      Lipid-lowering medications for children and adolescents.
      • Valaiyapathi B.
      • Sunil B.
      • Ashraf A.P.
      Approach to hypertriglyceridemia in the pediatric population.
      A pediatric trial comparing high-dose, prescription O3FA supplementation (3.4 g EPA+DHA/day) to placebo demonstrated no statistically significant TG lowering, while two similar trials in youth (one using 500–1000 mg non-prescription fish oil daily and one using 4 g prescription omega-3 ethyl esters daily) demonstrated slight, though not statistically significant, decreases in TG.
      • de Ferranti S.D.
      • Milliren C.E.
      • Denhoff E.R.
      • et al.
      Using high-dose omega-3 fatty acid supplements to lower triglyceride levels in 10- to 19-year-olds.
      • Chahal N.
      • Manlhiot C.
      • Wong H.
      • et al.
      Effectiveness of omega-3 polysaturated fatty acids (fish oil) supplementation for treating hypertriglyceridemia in children and adolescents.
      • Gidding S.S.
      • Prosper C.
      • Hossain J.
      • et al.
      A double-blind randomized trial of fish oil to lower triglycerides and improve cardiometabolic risk in adolescents.
      Trials in youth younger than 8 years of age are lacking. Thus, while O3FAs are sometimes used in clinical practice to lower TG in youth, additional research is needed to help determine dosing recommendations, long-term efficacy, and safety of these supplements.
      If O3FA supplementation is used, prescription formulations are recommended, as dietary supplement preparations are not regulated by the FDA, may have an inaccurate representation of EPA and DHA content, and may contain significant amounts of cholesterol and SFAs or oxidized FAs.
      • Virani S.S.
      • Morris P.B.
      • Agarwala A.
      • et al.
      2021 ACC Expert Consensus Decision Pathway on the Management of ASCVD Risk Reduction in Patients with Persistent Hypertriglyceridemia.
      ,
      • Fialkow J.
      Omega-3 fatty acid formulations in cardiovascular disease: dietary supplements are not substitutes for prescription products.

      Coenzyme Q10 (CoQ10)

      While CoQ10 has been studied in adult populations, limited research exists that support the use of CoQ10 in the pediatric population. CoQ10 is often used, without proof of benefit, to help ameliorate statin-associated muscle symptoms in adults; however, such symptoms are rare in youth taking statins.
      • Qu H.
      • Guo M.
      • Chai H.
      • et al.
      Effects of coenzyme Q10 on statin-induced myopathy: an updated meta-analysis of randomized controlled trials.
      One small, short-term study of adolescents with FH treated with rosuvastatin reported a decrease in CoQ10 levels in peripheral blood mononuclear (PBM) cells, but without a decrease in adenosine triphosphate synthesis. The authors recommended the need for additional long-term studies to determine the effects of CoQ10 supplements on youth treated with statins.
      • Avis H.J.
      • Hargreaves I.P.
      • Ruiter J.P.N.
      • et al.
      Rosuvastatin lowers coenzyme Q10 levels, but not mitochondrial adenosine triphosphate synthesis, in children with familial hypercholesterolemia.
      Others have reported that PBM cell or plasma levels of CoQ10 may have little correlation with levels in myocytes or mitochondrial function in myocytes. Thus, there is insufficient evidence that the use of CoQ10 in youth treated with LLM either prevents or decreases statin-related myopathies.

      Psychosocial aspects of nutrition counseling in youth

      Discussions on weight

      Discussion about modifying a child's weight and recommendations for behavioral changes should be approached in a non-stigmatizing way by emphasizing modifiable lifestyle behaviors rather than weight modification. Weight stigmatization has been associated with maladaptive eating behaviors and decreased physical activity.
      • Puhl R.
      • Suh Y.
      Health Consequences of Weight Stigma: implications for Obesity Prevention and Treatment.
      • Vartanian L.R.
      • Porter A.M.
      Weight stigma and eating behavior: a review of the literature.
      • Nolan L.J.
      • Eshleman A.
      Paved with good intentions: paradoxical eating responses to weight stigma.
      Clinicians should attempt to mitigate peer, family, and clinician weight-related stigma by utilizing the AAP practice recommendations to guide interactions with youth, choice of mental health screening tools, clinical documentation, and decisions about how to structure the clinical environment
      • Pont S.J.
      • Puhl R.
      • Cook S.R.
      • Slusser W.
      Stigma Experienced by Children and Adolescents With Obesity.
      (Table 13).
      Table 13AAP recommendations to mitigate weight stigmatization in clinical practice
      • Pont S.J.
      • Puhl R.
      • Cook S.R.
      • Slusser W.
      Stigma Experienced by Children and Adolescents With Obesity.
      .
      • 1.
        Role Modeling. Demonstrate and model behavior that is supportive and non-stigmatizing to children and their families. Avoid placing blame and judgment solely on individuals with excess weight. Recognize and acknowledge the many contributors to obesity (i.e., genetic, socioeconomic, environment, family and cultural traditions, individual choices).
      • 2.
        Language and Word Choice. When referring to patients, use people first language, which places the person before the medical condition (i.e., child with obesity). Use neutral words like “weight” or “body mass index” over words that may be more emotionally laden (i.e., “obese,” “extremely obese,” “fat”)
      • 3.
        Clinical Documentation. Convey information about weight in a sensitive and supportive manner by using neutral words, such as “unhealthy weight” and “very unhealthy weight,” when speaking to families and when documenting in the medical record.
      • 4.
        Behavior Change Counseling. Use a collaborative, patient-centered approach, such as motivational interviewing, to encourage families to make healthy and sustainable behavioral changes.
      • 5.
        Clinical Environment. Provide a non-stigmatizing clinic space for children and their families by creating a setting that accommodates patients of varying body sizes.
      • 6.
        Behavioral Health Screening. Assess for psychosocial comorbidities associated with negative exposures associated with obesity (i.e., bullying, poor school performance, low self-esteem, depression, anxiety).

      Efficacy of family-based interventions

      Dietary choices and habits of youth are often made within the context of the family. As such, parent or caregiver involvement is critical to successful implementation and sustained healthful lifestyle changes for youth.
      • Golan M.
      • Crow S.
      Parents are key players in the prevention and treatment of weight-related problems.
      Family-based interventions have been shown to be efficacious by encouraging behavior changes in both the child and parent through teaching the parent behavioral skills.
      • Epstein L.H.
      • Paluch R.A.
      • Roemmich J.N.
      • et al.
      Family-based obesity treatment, then and now: twenty-five years of pediatric obesity treatment.
      A meta-analysis found that the greater the parent involvement, the better the treatment effects.
      • Kitzmann K.M.
      • Dalton W.T.
      • Stanley C.M.
      • et al.
      Lifestyle interventions for youth who are overweight: a meta-analytic review.
      Clinicians are encouraged to utilize cognitive behavioral interventions to encourage family-level behavioral changes
      • Barlow S.E.
      Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.
      (Table 14).
      Table 14Cognitive behavioral techniques to assist with family lifestyle behavior modification
      • Barlow S.E.
      Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.
      .
      • 1.
        Set concrete and achievable goals with families.
      • 2.
        Encourage families to keep track of progress toward their goals.
      • 3.
        Encourage families to reward their child for achieving behavioral goals (as opposed to rewarding weight change). Reinforcers could include verbal praise or non-food related privileges.
      • 4.
        Help families to be aware of their progress, even if their execution is imperfect. Encourage them to focus on their successes and not their failures.

      Disordered eating

      Youth with a history of overweight/obesity and individuals on restricted or weight-loss diets are at greater risk for developing an eating disorder.
      • Sim L.A.
      • Lebow J.
      • Billings M.
      Eating disorders in adolescents with a history of obesity.
      • Lebow J.
      • Sim L.A.
      • Kransdorf L.N.
      Prevalence of a history of overweight and obesity in adolescents with restrictive eating disorders.
      • West C.E.
      • Goldschmidt A.B.
      • Mason S.M.
      • et al.
      Differences in risk factors for binge eating by socioeconomic status in a community-based sample of adolescents: findings from Project EAT.
      • Cena H.
      • Stanford F.C.
      • Ochner L.
      • et al.
      Association of a history of childhood-onset obesity and dieting with eating disorders.
      While weight-related counseling is unlikely to lead to significant eating disordered-behaviors, it is important to mitigate risk when providing dietary counseling
      • Bravender T.
      • Lyna P.
      • Coffman C.J.
      • et al.
      Physician Weight-Related Counseling Is Unrelated to Extreme Weight Loss Behaviors Among Overweight and Obese Adolescents.
      • Neumark-Sztainer D.
      Preventing obesity and eating disorders in adolescents: what can health care providers do?.
      (Table 15). Since youth with eating disorders often have a normal or elevated BMI, identification of eating disorders can be more challenging.
      • Lebow J.
      • Sim L.A.
      • Kransdorf L.N.
      Prevalence of a history of overweight and obesity in adolescents with restrictive eating disorders.
      ,
      • Swenne I.
      Influence of premorbid BMI on clinical characteristics at presentation of adolescent girls with eating disorders.
      Clinicians should inquire about use of weight-control behaviors and screen youth for eating disorders
      • Lock J.
      • La Via M.C
      Practice parameter for the assessment and treatment of children and adolescents with eating disorders.
      • Morgan J.F.
      • Reid F.
      • Lacey J.H.
      The SCOFF questionnaire: assessment of a new screening tool for eating disorders.
      Table 16 illustrates an example of a screening tool for eating disorders. If an eating disorder is suspected or confirmed in youth, referral for a multi-disciplinary team approach with specialized and intensive treatment is indicated, including a psychotherapist, pediatrician, and dietitian.
      • Lock J.
      • La Via M.C
      Practice parameter for the assessment and treatment of children and adolescents with eating disorders.
      Table 15Recommendations to prevent obesity and eating disorders in adolescents
      • Golden N.H.
      • Schneider M.
      • Wood C.
      Committee on nutrition, committee on adolescence – section on obesity. Preventing obesity and eating disorders in adolescents.
      .
      • 1.
        Inform adolescents that dieting and unhealthy weight control behaviors may be counterproductive. Instead, encourage positive eating and physical behaviors that can be maintained on a regular basis.
      • 2.
        Do not use body dissatisfaction as a motivator for change. Instead, help teens care for their bodies so that they will want to nurture them through healthy eating, activity, and positive self-talk.
      • 3.
        Encourage families to have regular and enjoyable family meals.
      • 4.
        Encourage families to avoid weight talk: Talk less about weight and do more to help teens achieve a weight that is healthy for them.
      • 5.
        Assume overweight teens have experienced weight mistreatment and address this with teens and their families.
      Table 16SCOFF Questionnaire: Eating Disorder Assessment Tool
      • Morgan J.F.
      • Reid F.
      • Lacey J.H.
      The SCOFF questionnaire: assessment of a new screening tool for eating disorders.
      .
      • 1.
        Do you make yourself Sick because you feel uncomfortably full?
      • 2.
        Do you worry you have lost Control over how much you eat?
      • 3.
        Have you recently lost more than One stone (i.e., 14 pounds) in a 3-month period?
      • 4.
        Do you believe yourself to be Fata when others say you are too thin?
      • 5.
        Would you say that Food dominates your life?
      One point for every “yes”; a score ≥ 2 indicates a likely case of anorexia nervosa or bulimia
      a Consider using alternative language that may be considered less stigmatizing (i.e., too big)

      Additional psychosocial considerations

      The family's ability to understand and implement recommendations for lifestyle behavioral changes that affect dyslipidemia in youth are affected by modifiable and non-modifiable individual, family, community, and healthcare system-level factors.
      • Modi A.C.
      • Pai A.L.
      • Hommel K.A.
      • et al.
      Pediatric self-management: a framework for research, practice, and policy.
      It is important to be aware of the patient's psychosocial state when counseling families regarding the need for interventions. Interventions should be patient-centered and developmentally appropriate (i.e., considering the ages and cognitive abilities of both the child and family members) and sensitive to cultural differences. There is no universal agreement as to when youth can be considered competent to make decisions, as contextual factors (i.e., brain development maturity, personality, situational factors) significantly influence decisions.
      • Grootens-Wiegers P.
      • Hein I.M.
      • van den Broek J.M.
      • et al.
      Medical decision-making in children and adolescents: developmental and neuroscientific aspects.
      Clinicians are encouraged to utilize strategies for shared decision-making with a patient and their family that have been published previously.
      • Sawyer K.
      • Rosenberg A.R.
      How should adolescent health decision-making authority be shared?.
      A clear explanation of disease processes with the parents and the patient is important to ensure both have an accurate understanding. Knowledge gaps can be assessed and addressed by encouraging parents and youth to utilize the teach back method, sharing information previously learned.
      • Tamura-Lis W.
      Teach-Back for quality education and patient safety.
      Children and adolescents may present with mental health concerns, which can create barriers for successful implementation of lifestyle changes.
      • Leon G.
      • de Klerk E.
      • Ho J.
      • et al.
      Prevalence of comorbid conditions pre-existing and diagnosed at a tertiary care pediatric weight management clinic.
      • Ghandour R.M.
      • Sherman L.J.
      • Vladutiu C.J.
      • et al.
      Prevalence and treatment of depression, anxiety, and conduct problems in US children.
      • Danielson M.L.
      • Bitsko R.H.
      • Ghandour R.M.
      • et al.
      Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents.
      • Mojtabai R.
      • Olfson M.
      • Han B.
      National trends in the prevalence and treatment of depression in adolescents and young adults.
      • Mauro M.
      • Taylor V.
      • Wharton S.
      • et al.
      Barriers to obesity treatment.
      Some youth may require counseling and/or treatment with medications, including antipsychotics, many of which have been associated with weight gain and unhealthy metabolic profiles.
      • Correll C.U.
      • Manu P.
      • Olshanskiy V.
      • et al.
      Cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents.
      Additionally, families may struggle with food insecurity, imposing a barrier to adherence with treatment recommendations.
      • Alisha C.-.J.
      • Rabbitt M.P.
      • Gregory C.A.
      • et al.
      Household Food Security in the United States in 2016.
      • Morales M.E.
      • Berkowitz S.A.
      The relationship between food insecurity, dietary patterns, and obesity.
      Ideally, care should be provided within the context of a multidisciplinary team, with clinicians who can address concomitant mental health and social barriers. When this is not possible, it is important to screen for comorbid psychosocial risk factors, and seek out collaborative, specialist care clinicians.
      • Richardson L.P.
      • McCauley E.
      • Grossman D.C.
      • et al.
      Evaluation of the patient health questionnaire-9 item for detecting major depression among adolescents.
      • Mossman S.A.
      • Luft M.J.
      • Schroeder H.K.
      • et al.
      The generalized anxiety disorder 7-item scale in adolescents with generalized anxiety disorder: signal detection and validation.
      • Hager E.R.
      • Quigg A.M.
      • Black M.M.
      • et al.
      Development and validity of a 2-item screen to identify families at risk for food insecurity.

      Conclusion

      Atherosclerosis, the origin of CVD, begins at a very early age and is significantly influenced by lifestyle behaviors. When started at an early age and maintained over a lifetime, nutrition interventions and other heart-healthy lifestyle behaviors can delay the onset or prevent the occurrence of CVD-related events. Even in those who require LLM, lifestyle interventions provide additional benefits and enhance lipid-lowering. Changes in lifestyle habits are best achieved with a multidisciplinary, family-based approach. Referral to an RDN knowledgeable about the needs of youth with lipid disorders is recommended to help youth and their families successfully meet nutritional needs, provide ongoing nutritional support, and encourage long-term adherence. Referral to a social worker and/or a mental health professional is recommended to resolve treatment barriers.

      Credit authorship contribution statement

      LW, JC, SLL, and DPW contributed to the initial draft of the article. All authors contributed to the concept, design, revision, and approval of the article.

      Conflicts of interest

      Disclosures for CMBS during the prior 24 months include a speaker honorarium from Cardiometabolic Congress. ALP received consulting fees paid to institution from Novartis during the prior 24 months. DPW received consulting fees from Alexion during the prior 24 months. LW, JB, JC, CK, SLL, ASS, GS, and ALW have no relevant disclosures.

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