Preventing Adolescent Metabolic Syndrome: A Lesson from Finland
September 1, 2015
By Donald J. Brown, ND
Managing Director, Natural Product Research Consultants, Seattle
Dr. Brown reports he is a retained consultant for Nature’s Way.
Synopsis: Adolescent metabolic syndrome predicts type 2 diabetes mellitus and subclinical atherosclerosis in adulthood. This Finish study found that repeated infancy-onset dietary intervention primarily aimed at reducing intake of saturated fat from infancy to early adulthood was effective in preventing adolescent metabolic syndrome.
Source: Nupponen M, et al. Metabolic syndrome from adolescences to early adulthood. Effect of infancy-onset dietary counseling of low saturated fat: The Special Turku Coronary Risk Factor Intervention Project (STRIP). Circulation 2015;131:605-613.
Summary Points
- Adolescent metabolic syndrome (MetS) increases the risk of type 2 diabetes and subclinical atherosclerosis in adulthood.
- The results of this study indicate that repeated dietary counseling beginning in infancy and extending to early adulthood significantly decreases the risk of adolescent MetS.
The Special Turku Coronary Risk Factor Intervention Project (STRIP) was designed to study the effect of dietary intervention that begins in infancy and continues until the age of 20 years. The focus is on atherosclerosis risk factors. A prospective, randomized, controlled trial, the STRIP study recruited families with 5-month-old infants at well baby clinics in Turku, Finland, between February 1990 and June 1992. At the age of 6 months, 1062 infants were randomly allocated to an intervention (n = 540) or a control group (n = 522). The intervention group received individual dietary counseling at least biannually until the age of 20 years. Parents received counseling for their child until age 7 years and, from then on, it was given directly to the child. The primary focus of the counseling was the replacement of saturated fat with unsaturated fat. Dietary counseling also included reduction of salt intake and the increased use of whole grains, fruits, and vegetables. A fixed diet was never ordered and the counseling was individualized with recent food records used to tailor dietary suggestions. The primary prevention of smoking was introduced at the age of 8 years and a physically active lifestyle was encouraged but not structured for the children. Children in the control group were seen at similar intervals and received only basic health education but not dietary counseling.
The study report is based only on those participants who were tested for metabolic syndrome (MetS) within a study visit between 15 and 20 years of age. Included in the definition of MetS were waist circumference, blood pressure, triglycerides, glucose, and HDL-C. Because there is no universally accepted definition of adolescent MetS, several criteria were applied including the modified International Diabetes Federation definition of MetS (80th/20th percentile cutoff points for each component) as well as the National Cholesterol Education Program definition and others. A total of 534 participants were included in the analysis at age 15 years. There were 127 participants lost to follow-up between ages 15 and 20 years, and this was higher in the intervention group compared to the control group (29% vs 19%; P = 0.008).
At 15 to 20 years of age, the prevalence of MetS varied between 6% and 7.5% in the intervention group and 10% and 13% in the control group. The intervention group had a 41% lower risk of MetS compared with the control group (relative risk [RR], 0.59; 95% confidence interval [CI], 0.40-0.88; P = 0.009). There were no study group-by-sex or study group-by-age interactions, indicating that the interaction effects were similar among females and males at different ages. On the individual MetS components, the intervention decreased risk of high blood pressure in both sexes (RR, 0.69; CI, 0.46-0.98; P = 0.039) and high triglycerides in male subjects (RR, 0.71; 95% CI, 0.52-0.98; P = 0.006). A study group-by-age interaction on glucose indicated that the effect of intervention was different by age. In pairwise comparisons, the risk for high glucose was lower in intervention participants only at 18 years of age (RR, 0.60; 95% CI, 0.38-0.96; P = 0.016). A statistically nonsignificant reduction in waist circumference was measured in the intervention group compared to the control group (RR, 0.78; 95% CI, 0.59-1.03; P = 0.09). The intervention was not associated with positive changes in HDL-C.
Commentary
What a study! This is a first of its kind — a longitudinal trial started in infancy to report the effect of repeated dietary intervention/counseling on the risk of adolescent MetS. The big picture ramifications extend to prevention of type 2 diabetes mellitus and cardiovascular disease in adulthood. Talk about preventive medicine! Or, as the investigators brilliantly state, “primordial prevention.”
These are not the first results to be reported from the STRIP study. Earlier analysis found a lower clustering of cardiometabolic risk factors in the intervention group compared with the control group in 5- to 15-year-old participants.1 Insulin sensitivity was also found improved in the intervention group.2 The blood pressure benefits found in this study were also found in the intervention group between the ages of 7 months and 15 years.3 The intervention group had on average 1 mmHg lower blood pressure than the control group.
Early life exposures, including diet, have significant ramifications for future health. Numerous studies have shown that environment and lifestyle (diet and exercise being two keys) are associated with not only childhood obesity and dyslipidemia but also with health outcomes in adulthood that include MetS, type 2 diabetes mellitus, dyslipidemia, hypertension, obesity, and subclinical atherosclerosis.4,5 In the Dietary Intervention Study for Children with hypercholesterolemic children, the benefits of a low-fat, high-fiber diet started in childhood on glycemic control were evident in adulthood.6
The major strengths of this study are the long follow-up period beginning early in life, the large number of repeatedly studied participants, and the use of well-established measures of MetS. A major shortcoming is the fact that the children in the STRIP study were all white. Also, with such a large dropout rate, an intention-to-treat analysis would have been useful. Hopefully, this remarkable design can be repeated in larger and more diverse populations in the future.
Finally, some good news reported in The New York Times on July 26.7 Reported by Margot Sanger-Katz, calories consumed in the United States appear to be dropping since they peaked in 2003. Interestingly, the drop in caloric intake appears to be occurring mainly for children. Is the federal government mandate to make school lunches healthier having an effect? One notable fact in the article is that Americans averaged about 40 gallons of full-calorie soda in 1998 and this has “dropped” to 30 gallons in 2014.
REFERENCES
- Hakanen M, et al. Dietary and lifestyle counseling reduces the clustering of overweight-related cardiometabolic risk factors in adolescents. Acta Pediatr 2010;99:888-895.
- Oranta O, et al. Infancy-onset dietary counseling of low-saturated fat diet improves insulin sensitivity in healthy adolescents 15-20 years of age: The Special Turku Coronary Risk Factor Intervention Study (STRIP). Circulation 2013;36:2952-2959.
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Nimikoshki H, et al. Blood pressure is lower in children and adolescents with a low-saturated fat diet since infancy: The Special Turku Coronary Risk Factor Intervention Study. Hypertension 2009;53:
918-924. - Magnussen CG, et al. The association of pediatric low- and high-density lipoprotein cholesterol dyslipidemia classifications and change in dyslipidemia status with carotid intima-media thickness in adulthood evidence from the Cardiovascular Rick in Young Finns Study, the Bogalusa Heart Study, and the CDAH (childhood Determinants of Adult Health) study. J Am Coll Cardiol 2009;53:860-869.
- Juonala M, et al. Childhood adiposity, adult adiposity, and cardiovascular risk factors. N Engl J Med 2011;365:1876-1885.
- Dorgan JF, et al. Adolescent diet and metabolic syndrome in young women: Results of the Dietary Intervention in Children (DISC) follow-up study. J Clin Endocrinol Metab 2011;96:E1999-E2008.
- Sanger-Katz M. America starts to push away from the plate. New York Times 2015; July 26. Available at: http://www.nytimes.com/2015/07/25/upshot/americans-are-finally-eating-less.html?ref=health&_r=0&abt=0002&abg=1.
Adolescent metabolic syndrome predicts type 2 diabetes mellitus and subclinical atherosclerosis in adulthood. This Finish study found that repeated infancy-onset dietary intervention primarily aimed at reducing intake of saturated fat from infancy to early adulthood was effective in preventing adolescent metabolic syndrome.
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