Dietary fat intakes in infants and primary school children in Germany

¹ From the Department of Pediatrics, Ludwig-Maximilians-University of Munich, Germany, and Frauenklinik, Klinikum Ingolstadt, Germany.

² Presented at the symposium Fat Intake During Childhood, held in Houston, June 8–9, 1998.

³ Supported in part by Bayerisches Staatsministerium für Arbeit und Sozialordnung, Familie, Frauen und Gesundheit, München, Germany.

⁴ Address correspondence to B Koletzko, Division of Metabolic Disorders and Nutrition, University of Munich, Kinderklinik and Kinderpoliklinik, Dr von Haunersches Kinderspital, Lindwurmstrasse 4, D-80337 München, Germany. E-mail: berthold.koletzko{at}kk-i.med.uni-muenchen.de.

ABSTRACT  
We report dietary fat intake data in groups of infants and children in Germany. A group of 148 healthy infants was followed prospectively from birth through the first year of life. After birth, 78.9% of infants were breast-fed; 50% were breast-fed at 3 mo and 9.8% were breast-fed at 12 mo. Infant formula was given to 22% of infants after birth, 53% at 3 mo, and 58% at 12 mo. Complementary foods were consumed by 16% of infants at 3 mo, 97% at 6 mo, and 98–100% at 7–12 mo. In non-breast-fed infants, mean dietary fat intakes were 44.8%, 42.9%, 37.4%, and 35.7% of energy intake at the ages of 1, 4, 6, and 12 mo, respectively. Calculated energy and nutrient intakes were within recommended ranges and weight gain was normal. Therefore, we see no compelling reason to actively modify total fat intakes at this age. In 158 primary school children aged 6–11 y, 7-d checklist protocols showed 41% of energy intake as fat with 50% as saturated fat. Because German children of this age are experiencing increasing rates of obesity and high serum cholesterol concentrations, a stepwise reduction of total fat and saturated fat intakes in primary school children appears desirable to improve long-term health.

Key Words: Diet • fat intake • lipids • saturated fat • coronary heart disease • infants • children • Germany

INTRODUCTION  
The desirable ranges of the amounts and the composition of dietary lipid intake during childhood are the subject of ongoing discussions, and recent recommendations on these questions vary (1–7) (Table 1). The dietary lipid supply is of importance for early growth because lipids are the predominant dietary energy source for infants and young children. Lipids provide 40–55% of energy in human milk and in modern infant formulas (8). The provision of dietary lipids in amounts at least meeting the needs for tissue storage and obligate fat oxidation is considered advantageous because de novo synthesis of lipids from other substrates, eg, carbohydrates, appears to be limited (9). In contrast to proteins and carbohydrates, lipids can store energy in the body in almost unlimited amounts with a much higher energy deposition per gram of tissue than can be achieved with glycogen or protein. Lipid depots in the body provide energy reserves for periods of reduced dietary intakes that may occur during diseases, eg, infections and diarrhea, or under poor living conditions during times of food shortages. Lipids greatly influence the palatability of foods and modulate their texture, flavor, and aroma. Hence, the quantity and quality of fats in foods may have a direct impact on food consumption.

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TABLE 1. Recommended fat intakes by various scientific bodies for infants and young children¹  
In children and adolescents, high habitual intakes of dietary fat are associated with a higher prevalence of obesity (10, 11). High dietary intakes of saturated and of trans unsaturated fatty acids increase plasma total and LDL-cholesterol concentrations and, even at a young age, may enhance vascular lipid deposition and the occurrence of early vascular lesions (12–14). Therefore, low dietary intakes of saturated and trans fatty acids are recommended for healthy children and adolescents to reduce the long-term risk of heart disease (6). Some have also advocated lowering dietary fat intakes in infancy (15, 16). Any considerations on modulating dietary fat and nutrient intakes of childhood populations need to relate to current intakes of foods and nutrients. Here we report data on dietary fat intakes in infants and children in Germany.

SUBJECTS AND METHODS  
Data on dietary intakes in infancy were obtained in infants enrolled at birth and followed prospectively through the first year of life in the city of Ingolstadt, Bavaria, Germany. All parents of apparently healthy infants born between November and December 1995 at the Department of Obstetrics, Klinikum Ingolstadt, were invited to participate in the study. Mothers and if available, fathers, were visited in the maternity hospital in the first days after birth by one coauthor. The nature of the study was explained orally and with a written information sheet, and informed verbal consent for participation was obtained. Infants with apparent congenital malformation or disease, including those who required intravenous feeding or medical treatment as inpatients after birth, were excluded from participation. Because the study population was also intended to serve as a reference group for an ongoing study investigating the potential influence of cultural and ethnic background on infant feeding habits, we excluded infants with a non-German parent. Mothers of participating infants were subjected to a standardized personal interview by one coauthor in the first week after birth, in which medical history, sociodemographic data, knowledge, and motivation with respect to infant feeding as well as feeding practices after birth were investigated. Questionnaires on details of infant feeding were mailed to the families at 1, 4, 6, and 12 mo after birth and then were evaluated. Twenty-four-hour dietary protocols were also completed by the parents at home to obtain information on dietary intakes of the infants at the ages of 1, 4, 6, and 12 mo. Human milk intake was not determined precisely; therefore, data on dietary nutrient intakes presented here are derived from a subsample of infants who were not breast-fed at the time of the dietary protocol.

To obtain data on dietary intakes of primary school children, we approached a primary school in a mixed lower to middle class residential area in the city of Munich, Bavaria, Germany, which was attended by 170 pupils aged 6–11 y distributed in 8 school classes. After obtaining formal permission from the supervising government office, we discussed the aims and character of the study with the school principal, all teachers, and representatives of the parents' association, who agreed to participate in the project. In November 1995, parents of all pupils were contacted by a letter distributed by the teachers to the children, which explained the nature of the study and requested parental consent. The letter also included a retrospective checklist protocol over a 7-d period, which was to be completed by the parents together with their children. The form contained detailed instructions for completing the checklist protocol and a list of 52 food items. Checklist protocols were based on given serving sizes for the foods, adapted for children of this age group. Parents were asked to note the number of servings that their children had consumed over 7 d. Because the primary aim of this data collection was to obtain data on fat consumption, food items were chosen to estimate the intake of fat as well as saturated and unsaturated fatty acids as precisely as possible. Therefore, dairy products, meats, and sweets with different fat contents were included, and a distinction was made between different oils, eg, vegetable oil rich in polyunsaturated fatty acids and olive oil rich in monounsaturated fatty acids. Mean daily food intake in grams was calculated from the number of servings and the serving sizes.

The study protocols were reviewed and approved by the Ethical Committee, Medical Faculty, Ludwig-Maximilians-University of Munich, Germany. Energy and nutrient intakes were calculated from dietary records of both the infants and the schoolchildren with the program PRODI VERSION 4.4 EXPERT (Prodi, Stuttgart, Germany) using the nutrient data bank Bundeslebensmittelschlüssel II.2. Data analysis was performed with the SPSS (Version 6.1.3; SPSS, Munich, Germany).

RESULTS  
Of the parents of the 170 infants meeting the study entry criteria, parents of 148 infants (87%) participated in the prospective study on infant feeding. Maternal age at childbirth was 29.6 ± 3.6 y ( During the first week of life, 78.9% of the study population was breast-fed (Figure 1). At 3 mo, 50% of the sample was still breast-fed. Partial breast-feeding with additional feeding of formula or solid foods remained fairly constant at 32.6%, 29.4%, and 33.6%, respectively, at the ages of 1, 4, and 6 mo. At the end of the first year, 9.8% of the infants were still breast-fed, but none were breast-fed exclusively at that time. Infant formula was consumed by 22% of infants in the first week after birth, by 53% at age 3 mo, by 59% at 6 mo, by 64% at 8 mo, and by 58% at 12 mo. Of the total study population, 78% of infants were fed formula at some time point during the first year of life. Beikost (ie, solid and liquid complementary food other than breast milk or infant formula) was consumed by 16% of the population at 3 mo, 97% at 6 mo, and 98–100% between 7 and 12 mo (Figure 1). Evolution of body weights and nutrient intakes calculated from dietary protocols of the subsample of infants not receiving human milk is shown in Table 2.

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FIGURE 1.. Prevalence of feeding human milk, formula, and Beikost (complementary solid and liquid foods other than breast milk or infant formula) in 148 German infants followed prospectively from birth to age 12 mo.

 

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TABLE 2. Body weights and macronutrient intakes of a subsample of non-breast-fed infants during the first year of life  
In the study of primary school children, completed and evaluative dietary records were obtained from 158 children (86 boys and 72 girls) out of the total 170 pupils attending the school (92.9%). The age ranged from 6 to 11 y, with 46 pupils in grade 1, 40 pupils in grade 2, 38 pupils in grade 3, and 34 pupils in grade 4. On average, the children consumed >300 g/d of milk and dairy products (Table 3). The intake of full-fat milk and yogurt (containing 3.5% fat) was 3 times higher than the intake of low-fat milk and yogurt (containing 1.5% fat). Consumption of meat and poultry products was 80 g/d and high-fat sausages were consumed twice as much as low-fat sausages. Egg consumption was not high, with an average 1.3 eggs eaten/wk. One-third of the average 60 g/d of bread consumed was contributed by whole-grain products. The average intake of butter was 2 times higher than the consumption of vegetable oil margarine. The participating children ate 50 g/d of sweets and cookies, again with a preference for high-fat products.

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TABLE 3. Consumption of food products in a group of 158 primary school children aged 6–11 years in Munich  
Calculated energy and nutrient intakes of the 158 pupils are presented in Table 4. Fat contributed an average 41% of energy intake, whereas the mean contributions of protein and carbohydrates were 15% and 44% of energy, respectively. About one-half of the total fat intake was comprised by saturated fatty acids (20% of energy intake).

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TABLE 4. Energy and nutrient intakes of 158 primary school children aged 6–11 y in Munich¹  

DISCUSSION  
The infant population studied achieved intakes of energy, macronutrients, vitamins, minerals, and trace elements, eg, calcium and iron, similar to population reference intakes as defined by the German Society for Nutrition (17). Mean fat intakes contributed 45% of total energy at the end of the first month, which is similar to the contribution of fat to energy in human milk (18). The proportion of energy provided by fat decreased to 35% of energy intake at the end of the first year. The contribution of lipids to dietary energy tends to decrease with the introduction of Beikost (complementary foods) because these foods usually tend to be rich in carbohydrates and lower in fat than human milk or infant formula (19). The observed infant population showed normal birth weights and a normal weight gain during the first year of life, which matches reference percentile values for central European children (20). Obviously, the dietary supply allowed for an adequate weight gain.

Compared with the infant population at age 1 y, the primary school children studied had a clearly higher dietary fat intake of 41 ± 3.5% of energy intake ( ± SE) and as much as half of the intake was composed of saturated fatty acids. Reliable data on intakes of trans fatty acid intakes could not be calculated because an accurate database on trans fatty acid contents of local foods is not available. A previous study performed from 1985 to 1991 in children and adolescents aged 1–18 y in the city of Dortmund in northern Germany showed a similar fat intake of 39% of energy as found in our cohort (21). Thus, the high fat intakes we observed do not appear to be limited to the specific population or geographic region we studied but seem to be typical for German children. The main source of the intake of total and saturated fat was the preferential use of milk products, meats, and sweets with a high content of discretionary fat and of butter as visible fat. The fat intake in our childhood population is clearly higher than the 35% of energy as fat observed between 1989 and 1991 in children aged 2–19 y in the United States ( The high fat intake that we observed appears to be associated with the high obesity rate of 12% that we found in a larger sample of 2500 primary school children of this age group (6–11 y) from the Munich area who were participating in a preventive health study at the same time (Dokoupil et al, unpublished observations, 1999). Studies in adult populations and in children and adolescents showed that the prevalence of obesity increases with the proportion of dietary energy derived from fat (10, 11, 23–26). In view of the current increase in the prevalence of obesity in children and adolescents in this country, measures to achieve a stepwise reduction of total fat intake of children in Germany appear desirable.

Coronary heart disease is a major cause of mortality and morbidity in Europe and atherosclerotic lesions start to develop at an early age (6, 27). An important risk indicator related to dietary composition is the plasma cholesterol concentration (12). In the larger group of children aged 6–11 y participating in our previously cited preventive health study in Munich, we also measured very high mean values for total cholesterol of 175 mg/dL (4.53 mmol/L) (Dokoupil et al, unpublished observations, 1999). These cholesterol values are markedly higher than the mean values of 160 mg/dL (4.14 mmol/L) found in children of similar age groups in the United States (28) or in Israel (29).

The major dietary factor modulating serum cholesterol concentrations is the dietary intake of saturated fats (8). Serum total cholesterol values of 7–9-y old boys from 6 countries were correlated with average dietary intakes of saturated fatty acids; 24% of the intercountry differences in cholesterol values were considered to be due to the variation in saturated fatty acid intake (30, 31). Cholesterol values of Finnish boys with a saturated fatty acid intake of >17% of energy were 19% higher than those of Italian boys with a low intake of saturated fatty acids (<11% of energy intake). In a study of children with primary genetic hypercholesterolemia, modification of the habitual dietary intake by repeated counseling aimed primarily at the reduction of saturated fatty acid intake reduced total and LDL cholesterol by 15–20 mg/dL (32). Preventive strategies in healthy children aimed at the promotion of a healthy diet and lifestyle, which includes a limited intake of saturated fats, appears prudent (6, 33). Following this concept, the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition has recommended that children from the age of 2–3 y and adolescents should aim at a saturated fatty acid intake of <8–12% of energy intake (6). Average intake of cis polyunsaturated fatty acids was recommended not to exceed >6–10% of energy, whereas the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition saw no reason to advise strict limitations of the intakes of total fat or monounsaturated fatty acids for physically active children with normal body weights (Table 5). There is no need to limit the consumption of cis monounsaturated fatty acids or oils containing predominantly cis monounsaturated fatty acids, eg, olive and rapeseed oils, in children with normal body weights because monounsaturated fatty acids do not raise LDL cholesterol (4). However, under the current conditions and dietary habits in central Europe, one practical strategy to achieve a saturated fatty acid intake of 8–12% of energy intake is a limitation of total fat intake to <30–35% of energy (6).

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TABLE 5. Recommended dietary intakes of the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition for children aged >2–3 y and for adolescents¹  
Public health efforts in adult populations often emphasize the importance of limiting the dietary intake of saturated and total fats for preventing cardiovascular disease, obesity, type II diabetes, and certain forms of cancer. Young families are a segment of the population that appear particularly receptive to such public health messages. Although these messages are usually not aimed at infants and young children, parents may project the message into the diets of their infants. In an English study in which a group of 1004 women with infants were interviewed, 87.5% of the mothers felt that a low dietary fat intake was important or very important for their infants, and 82.9% stated they sometimes or always avoided giving fat and fatty foods to their children (34). Relatively low fat intakes were observed in several populations of infants, reaching average values as low as 28–30% of energy at 6–12 mo of age (28–31), with 10% of infants at lipid intakes that were 22% of energy intake (35). The question was raised whether such low fat intakes during infancy are safe (35–37).

Chronic, nonspecific diarrhea (eg, toddlers' diarrhea, pea and carrot diarrhea) was proposed as a potential adverse effect of low-fat diets in young children. Chronic, nonspecific diarrhea is considered a motility disorder and may improve after an increase in fat intake, which slows gastric emptying and small-intestinal motility (38).

Foods with a low fat content tend to have a low energy density (19) and concerns were raised that a low fat intake during infancy with a low energy density may have adverse effects on growth (35, 39). Indeed, adverse effects of low-fat diets on weight gain and longitudinal growth in young children were described in some reports (40, 41). A certain proportion of fat in the diet appears to be of value for supporting growth because the biological energy value of dietary long-chain triacylglycerol (38 kJ/g) is 2.25-fold higher than that of carbohydrates and protein. The biological energy value of lipids for growing infants and young children, ie, in the capacity to generate ATP and deposit tissue during growth, may differ even more from nonlipid energy. During the first 6 mo of life of a healthy full-term infant, lipids contribute 35% to weight gain or 90% of the energy retained in newly formed tissue (42). Although infants have the metabolic ability to synthesize lipids for tissue deposition de novo from carbohydrates or proteins, the capacity of this endogenous synthesis appears to be limited (43); moreover, it would result only in nonessential fatty acids with an unfavorable tissue composition. Endogenous lipid synthesis requires an increased energy intake because a substantial amount of the energy from dietary carbohydrates and proteins is lost in an energetically futile use of ATP for the synthesis of molecules for storage as metabolic fuel (eg, glycogen, protein) or tissue components (44). For example, the synthesis of fat from glucose requires 25% of the glucose energy invested for the cost of synthesis, whereas the synthesis of fat from fat requires only 1–4% of the energy invested (45). The extent of energy loss in vivo is difficult to determine, but a higher thermogenic effect of dietary carbohydrates and proteins compared with long-chain lipids is well known (23, 46). Studies supplying isoenergetic diets with different fat contents actually found a high body weight and fat gain and a low energy expenditure with the high-fat diets (23, 47, 48).

Niinikoski et al and Lagstrom et al (15, 16, 49) evaluated the effects of modifying fat intake from the seventh month of life onward by providing dietary counseling aimed at reducing dietary saturated fat intake, on the basis of the assumption that such an early intervention might be beneficial for risk reduction of later heart disease. A total of 1062 infants were recruited in Turku, Finland, and randomly assigned to either an intervention group with intensive diet education or a control group with standard care. Dietary fat intakes were low in both groups at 8 mo (intervention: 29% of energy; control: 28.8% of energy; NS) and slightly different between intervention and control groups at 13 mo (intervention: 26.2% of energy; control: 27.9% of energy; P < 0.0001), whereas the ratio of unsaturated to saturated fats was significantly higher in the intervention group at 13 mo. Heights, weights, and weights relative to heights, as well as head circumference, were normal for local growth charts and did not differ between groups up to the age of 36 mo. Thus, in this carefully supervised group of infants and young children from an affluent society, a change in the quality of fat combined with a slight reduction of fat and energy intakes did not impair growth. It is conceivable that this might have been achieved by adaptive mechanisms, eg, a change in physical activity. Whether or not a similar fat intake is safe in less affluent populations stressed by high rates of infection or diarrhea is not known.

The main argument presented for a restricted total lipid intake in young children is that it might be beneficial for the prevention of cardiovascular disease at a later age. However, beneficial effects on lipoprotein metabolism are only expected from a reduction of saturated and trans monounsaturated fats, but not of total lipids (8). Moreover, there is no evidence that a restricted total lipid intake in infancy has a long-term preventive effect. In fact, epidemiologic studies in a population born in the 1920s raised the possibility that poor growth during the first year of life, which in populations is associated with a low dietary energy density and low fat intake, may even increase the risk of cardiovascular mortality later in life (50) (Figure 2). At this time, there is no firm scientific basis to favor low total fat intakes during the first years of life if body weight is normal. Because growth rate and energy requirements per kg body weight decrease rapidly with increasing age, it appears prudent to aim at a stepwise reduction in fat intake to 30–35% of dietary energy beginning at the age of 2–3 y.

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FIGURE 2.. Standardized mortality ratios for coronary heart disease <65 y of age show a statistically significant inverse relation with weight at age 1 y in 10141 men born between 1911 and 1930. These data question whether low-fat diets during infancy, which tend to be associated with low dietary energy densities, are of long-term benefit for prevention of later heart disease. Data from reference 50.

ACKNOWLEDGMENTS  
We gratefully acknowledge the helpful support of the children; the parents; the staff of the obstretical unit, Klinikum Ingolstadt; and the teachers involved in the studies reported here.

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