NATIONAL

FORUM
Bindler
HEART
etPROJECT
/ al.
January
ACADEMIES
/ NORTHWEST
2000
OFPEDIATRIC
PRACTICE

Interventions to Decrease
Cardiovascular Risk Factors in Children:
The Northwest Pediatric Heart Project
RUTH M. BINDLER

CRAIG LAMMERS

The Heart Institute of Spokane

Washington State University

Northwest Behavioral Health Services

ROBERT A. SHORT

Provo and Associates

MARK PROVO

Washington State University

WENDY REPOVICH

SHERYL K. COONEY

Eastern Washington University

The Heart Institute of Spokane

ANNE SCHWARTZ
Eastern Washington University

PAUL DOMITOR
HRAIR GARABEDIAN

NANCY M. VAN COTT

Northwest Pediatric Cardiology

North Park Racquet Club

RONDA HAIN
CRYSTAL JOHNSON
Deaconess Hospital Diabetes Education Center

Objective: The Northwest Pediatric Heart Project tested the

hypotheses that a cardiovascular risk reduction program
involving children and their parents would improve lipid and
lipoprotein levels, physical activity, and other physical
measurements.
Data Sources: Questionnaires related to physical activity,
diet, and Type A behavior and measurement of body size,
fitness level, blood pressure, and lipids/lipoproteins.
Setting: The Heart Institute of Spokane, Washington.
Participants: Thirty-nine children from 8 to 11 years of age
with a family history of early cardiovascular disease,
abnormal lipid/lipoprotein levels, and at least one other risk
factor for cardiovascular disease.
Interventions: Classes on physical activity, diet, and family
interactions for 21 children in the experimental group and
their parents during a 1-year period.
Main Outcome Measures: This article reports serum lipids/
lipoproteins, VO2 peak, blood pressure, and body size.
Results: Significant decreases in total cholesterol (TC) and
low-density lipoprotein-cholesterol (LDL-C) were observed
for both experimental and control groups. Improvement
occurred in fitness levels, with only 31% average or above at
the beginning of the study but 57% at that level by the end.

Significant relationships were found between childrens weight

percentiles, blood pressure, and high-density lipoproteincholesterol. Fitness classification was related to weight
percentile, body mass index, and triglyceride.
Ruth M. Bindler, M.S., R.N.C., is the Northwest Pediatric Heart project
director at The Heart Institute of Spokane and an associate professor at
Washington State University, College of Nursing; Robert A. Short, Ph.D., is
a research associate at Washington State University; Sheryl K. Cooney, B.S,
M.T.(ASCP), is a senior research technologist at the Heart Institute of Spokane; Paul Domitor, Ph.D., is a clinical psychologist; Hrair Garabedian,
M.D., is a physician at Northwest Pediatric Cardiology; Ronda Hain, M.S.,
is a mental health consultant; Crystal Johnson, M.S., R.D., is a dietitian at
Deaconess Hospital Diabetes Education Center; Craig Lammers, Ph.D., is
a clinical psychologist at Northwest Behavioral Health Services; Mark
Provo, C.S.W., is a social worker for Provo and Associates; Wendy Repovich, Ph.D., is the director of the Exercise Science and Health Promotion
and Wellness Program at Eastern Washington University; Anne Schwartz,
M.S., is an assessment analyst and associate professor at Eastern Washington University; Nancy M. Van Cott, AAFA, ESA PT, is a fitness instructor for
North Park Racquet Club.

AUTHORS NOTE: The authors gratefully acknowledge the support of The

Heart Institute of Spokane, Joanne Howard, Ph.D., Chris Howland, Ph.D.,
and the following grantors: Hanley Augustus family, Goodale & Barbieri
Companies, Johnston-Hansten Foundation, Manulife Foundation, SeaFirst
Foundation, and Wasmer Foundation.

NATIONAL ACADEMIES OF PRACTICE FORUM, Vol. 2, No. 1, January 2000 43-48

2000 Sage Publications, Inc.

43

44

NATIONAL ACADEMIES OF PRACTICE FORUM / January 2000

Conclusions: Cardiovascular events in the family are strong

motivators for members of the family to improve health.
Education is effective in lowering risk factors for cardiovascular disease, with even small changes in lifestyle being
associated with significant changes in TC, LDL-C, and VO2
peak.

lthough there has been improvement in rates of

morbidity and mortality due to cardiovascular disease
in the United States during the past decade, cardiovascular
disease still remains the primary cause of death and a major
health care concern. Of all deaths in the United States, 41%
are due to cardiovascular disease, with 1,100,000 heart
attacks and 370,000 deaths annually. Nearly 60 million
adults in this country, about one in four, have cardiovascular
disease (American Heart Association, 1998).
Coronary artery disease is a primary type of cardiovascular disease and is caused by coronary atherosclerosis, a slow,
progressive process characterized by plaque formation in the
intima of the aorta and coronary arteries. Although clinical
consequences of atherosclerosis are not often seen before
persons are in their middle or older years, the development of
the arterial lesions of atherosclerosis begins in childhood.
The earliest grossly visible lesion associated with atherosclerosis is the fatty streak, which has been found in the aortas of
children as young as 3 years of age (McGill, 1997).
Several risk factors in adults have been identified that
relate to coronary artery disease. There is increasing evidence that these factors are influential in children as well.
The major nonmodifiable risk factors for coronary artery disease are family history, age, male gender, and race. Major
modifiable factors include obesity, hypertension, hypercholesterolemia, physical inactivity, smoking, and stress. Large
studies in the United States, such as the Bogalusa Study,
Muscatine Study, and Pathological Determinants of Atherosclerosis in Youth Study (PDAY) have identified relationships between childhood lipid and lipoprotein levels and
presence and degree of arterial fatty streaks and fibrous
plaques. Childhood lipid and lipoprotein levels are directly
influenced by type and amount of dietary fat intake (National
Cholesterol Education Program, 1991).
Obesity prevalence is increasing among youth in the
United States and is a growing health concern. One in five
adolescents is now overweight (Troiano & Flegal, 1998).
Obesity in childhood is related to the extent of atherosclerosis in children and young adults (McGill et al., 1995). Childhood obesity is also related to being overweight in adulthood
and can thus contribute to all health problems associated with
being overweight. Increasing body mass index (BMI), a calculation based on height and weight (kg/m2), is also associated

with an increase in both systolic and diastolic blood pressure.

Physical inactivity or a sedentary lifestyle is linked to
250,000 deaths annually in the United States (National Center for Chronic Disease Prevention and Health Promotion,
1996; U.S. Department of Health and Human Services,
1995). In children, low-level physical activity is related to
high systolic and diastolic blood pressure, high triglyceride,
and low high-density lipoprotein-cholesterol (HDL-C) levels
(Al-Hazzaa, Sulaiman, Al-Matar, & Al-Mobiareek, 1994).
Stress, and particularly the response to stress known as
Type A Behavior Pattern (TABP), is an independent risk factor for coronary heart disease. TABP has been identified in
children as young as 5 years of age, when they exhibit characteristics such as achievement striving, impatience, anger,
time urgency, and competitiveness (Jemerin & Boyce,
1990). Smoking is another potent risk factor for cardiovascular disease. Greatest experimentation with and initiation of
cigarette smoking occur in the sixth through eighth grades
(11 to 14 years of age). In children and adolescents, smoking
is related to low-density lipoprotein-cholesterol (LDL-C),
very low-density lipoprotein-cholesterol (VLDL-C), amount
of fatty streaks, and raised lesions in the aorta and arteries
and inversely related to high-density lipoprotein-cholesterol
(HDL-C), or the helpful cholesterol (McGill, McMahon,
Oalman, & Strong, 1997).
The Northwest Pediatric Heart Project (NWP) was
designed to test the hypotheses that a cardiovascular risk
reduction program involving children and their parents
would improve lipid and lipoprotein levels, eating behavior,
physical activity, anger management, family cohesion, and
social behaviors associated with lifestyle behavior changes.
Targeted participants were children with a family member
with early cardiovascular disease, demonstrated elevated lipids and/or lipoproteins, and one other risk factor. This article
reports findings related to lipid and lipoprotein levels, physical activity, and other physical measurements.

METHOD
Sample
NWP was a prospective cohort study conducted between
1996 and 1997 at The Heart Institute of Spokane with 40
children from 8 to 11 years of age who had family histories of
early cardiovascular disease and who demonstrated abnormal lipid and/or lipoprotein levels and at least one other risk
factor for cardiovascular disease. Early cardiovascular disease in the family was defined as a parent or grandparent
who, at 55 years of age or less, suffered myocardial infarction, angina pectoris, peripheral vascular disease, or sudden
cardiac death; had coronary atherosclerosis confirmed by

Bindler et al. / NORTHWEST PEDIATRIC HEART PROJECT

arteriography; or had total cholesterol (TC) of 240 mg/dL or
higher (National Cholesterol Education Program, 1991). The
criterion of hyperlipidemia was met by two tests of lipid
and/lipoproteins from 1 to 2 weeks apart at the beginning of
the study. Children met this criterion if their TC and/or
LDL-C were above the 80th percentile for age and gender.
These hypercholesterolemic children then proceeded with
additional data gathering to establish if another risk factor
was present.
The project was planned by an interdisciplinary group of
experts from the physical and behavioral sciences. The team
included a nurse educator as project director, health statistician, nutritionists, exercise physiologist, fitness instructor,
physician, clinical psychologists, therapists, and laboratory
specialists. A total of 223 children with positive family histories of early cardiovascular disease were screened for lipid
levels and other risk factors. The study accepted 47 children
who met study criteria. The protocol was approved by the
Institutional Review Boards of Spokane, Washington, and of
Washington State University, and all parents provided
informed consent, whereas all children gave informed assent.
During the 1-year course of time, 7 children withdrew and 1
additional child who had a diagnosis of familial hypercholesterolemia was excluded from the study, so final analysis was
completed on 39. The children and their families were
recruited from health care offices, health-related community
events, and by school flyers.

Theoretical Model
An adaptation of Ewarts social problem-solving model
of health behavior change was the theoretical model used in
the study (Ewart, 1990). Ewarts performance model is based
on social learning theory, research on problem solving,
social interaction theory, and behavior exchange theories of
family functioning. Key concepts include self-efficacy (the
individuals belief that he or she is capable of performing
actions for a given result), outcome expectancy (expectation
that a given health behavior will produce the desired outcome), motivation, self-evaluation, and problem solving.
Social and family support are viewed as essential to behavior
change in this model.

Design and Data Collection

Several questionnaires were administered and physical
measurements completed at the beginning of the study and
repeated at 3, 6, and 12 months (see Table 1). Family record
of early cardiovascular disease was established by history.
To ensure accuracy of data, the project director met with each
child and parent(s) to explain all questionnaires. Food

TABLE 1

45

Study Variables and Testing Instruments

Variable
Diet
Physical activity
Type A behavior
Blood pressure
Body size

Self-efficacy

Value

Self-evaluation
Problem-solving

Family interaction
Smoking
Family history
Total cholesterol, LDL-C,
HDL-C, triglycerides

Testing Instrument
Eating Pattern Assessment Tool
4-day food diary
Canadian Aerobic Fitness Test
(used to calculate VO2 peak)
Matthews Youth Test for Health
Blood pressure measurement
Height
Weight
Skinfold
Body Mass Index
Eating Behavior Confidence Survey
Physical Activity Confidence Survey
Type A Behavior Confidence Survey
ValueEating Behavior
ValuePhysical Activity
ValueType A Behavior
Self-Perception Profile
Eating Behavior Knowledge Test
Physical Activity Knowledge Test
Type A Behavior Knowledge Test
Family Environment Scale
Smoking Habits Questionnaire
Coronary Risk Profile
Laboratory serum analysis

Note: LDL-C = low-density lipoprotein-cholesterol, HDL-C = highdensity lipoprotein-cholesterol.

models, measurement techniques, a videotape prepared by

the study nutritionist, and a practice session were used to
teach families how to keep 4-day diet records. The Eating
Pattern Assessment Tool (EPAT) used in the study is a food
frequency questionnaire designed to assess the overall intake
of dietary fat and cholesterol and to assess the frequency with
which a person eats foods within each food grouping (Peters
et al., 1994).
Physical measurements were obtained in uniform and recommended ways. All study personnel involved in height,
weight, skinfold, exercise, and blood pressure measurement
were fully trained and evaluated for reliability of technique.
All blood draws were completed by a licensed phlebotomist
after the children had fasted for at least 12 hours. TC,
HDL-C, and triglyceride were measured by the Beckman CX
5Delta analyzer, and LDL-C was calculated by using the
Friedewald equation, [TCHDL-C]triglycerides/5, within
24 hours of blood draw. VO2 peak was calculated from pulse
rates during the Canadian Aerobic Fitness Test. Values were
placed on grids for age and gender, and children were classified as average, above average, or below average for VO2
peak.
Classes were conducted weekly for children in the experimental group and their parents at the Heart Institute for 6
weeks, then at weeks 8, 10, and 12, and finally once a month
at months 4, 5, 6, 8, 10, and 12. There was a total of 15

46

NATIONAL ACADEMIES OF PRACTICE FORUM / January 2000

sessions, with most material presented at the beginning and

later classes focusing on problems incurred with maintaining
new health behaviors, methods to cope with lapses, and
reemphasis of information previously provided. For each
class session, children and parents attended different meetings on diet and attended physical activity and family interaction classes together. In addition, 13 children had been
identified on the Matthews Youth Test for Health as having
TABP. The seven children with TABP in the experimental
group attended classes on stress and anger management,
while their parents attended classes on working with the
child with TABP. All classes were conducted by experts in
their fields such as dietitians for nutrition classes, exercise
physiologist and fitness teacher for physical activity, and
clinical psycho- logists and therapists for family communication and TABP.

Statistical Analysis
Statistical analyses were carried out using the Statistical
Package for the Social Sciences (SPSS). To assess the influence of the intervention on each dependent variable, a
repeated measures analysis of covariance was conducted
with the null hypothesis that the occasion by group interactions would indicate no relationship between change over
time and group membership. The analysis also allowed testing the null hypothesis that there was no change over time
regardless of group. Other analyses included testing relationships between specific variables using a Pearsons productmoment correlation coefficient and, in the case of nominal
variables, a chi-square.

RESULTS
Forty children completed all phases of the study; 1 child
was eliminated due to a diagnosis of familial hypercholesterolemia. Subsequent data analysis occurred on 39 children,
19 girls and 20 boys. Average age of the children at the
beginning of the study was 10 years, 3 months. Of the population, 89% was European American, a statistic reflective of
the study location. Parents were married in 27 of the families
reporting this item (73%) and were not married or divorced
in 10 (27%). Parental education levels reflected great variability, with all educational levels represented. Incomes also
reflected a great deal of variability, from less than $10,000 to
more than $100,000.
At the beginning of the study, the mean weight was in the
74th percentile and the mean height was in the 62nd percentile (see Table 2).
Average BMI was 21. Blood pressure was 110/69. The
groups did not show significant differences in these beginning measurements.

The mean TC for all children at the study beginning was

203 mg/dL, LDL-C was 135 mg/dL, triglercides were
88 mg/dL, and HDL-C was 48 mg/dL. There were no significant differences in values between experimental and control
groups, except for LDL-C. A steady downward trend in TC
and LDL-C occurred in both groups during the study. The
decrease for TC was significant at 6 months and 1 year (p =
.003 and p = .000) and for LDL-C was significant at 1 year
(p = .001) (see Table 2). Triglycerides did not display significant changes, whereas HDL-C was significantly lower at 6
months but increased by 1 year.
The Canadian Aerobic Fitness Test showed that at the
beginning of the study, 7 (18%) children were above average
for VO2 when considering age and gender, 5 (13%) were
average, and 27 (69%) were below average. By 1 year, an
improvement in VO2 peak was seen with 15 (39%) above
average, 7 (18%) average, and 17 (44%) below average.
Children reported intake of 2142 kcal (101% of recommended daily allowance [RDA]) during baseline and 1775
kcal at the end of 1 year (82% of RDA). They reported 30%
of calories from fat and 10% from saturated fat at both times.
The score on the EPAT-I that measures intake of high fat and
cholesterol food was 26 at the beginning of the study and
24.13 at the end. The change for the experimental group was
significant. The EPAT-II score, which measures intake of
low-fat foods, increased from 27.26 to 29 during the study.
Significant relationships were found between childrens
weight percentiles and both their blood pressure and HDL-C
throughout the study, and between 12-month triglyceride and
fitness classification. Children who were heavier tended to
have higher systolic and diastolic blood pressures and lower
HDL-C levels. Similar findings were evident with BMI (see
Table 3). Total cholesterol and LDL-C were related, as
would be expected. HDL-C and triglyceride levels showed
significant inverse relationships. Fitness classification was
related to weight percentile, BMI, and triglyceride at 12
months. That is, at the end of 1 year, children who demonstrated greater fitness were more likely to have a lower
weight percentile, lower BMI, and lower triglyceride.

CONCLUSIONS
The improvement in lipid and VO2 maximum levels for
both control and experimental groups was an unexpected
finding. Several parents in the control group stated that due to
a recent heart attack in the family, the whole family had
decided to improve their health. When they were assigned to
the control group, some took other classes or obtained readings to assist the family in making lifestyle changes. This
suggested that a recent cardiovascular event in the family is a
strong motivator to family members to improve health.

Bindler et al. / NORTHWEST PEDIATRIC HEART PROJECT

TABLE 2

47

Physical Measurement at Beginning of Study, 6 Months, and 12 Months

Experimental (n = 21)
Month
Total cholesterol mg/dL
LDL mg/dL
HDL mg/dL
Triglycerides mg/dL
CAFT
Greater than average
Average
Less than average
Weight (%)
Height (%)
BMI
Systolic blood pressure
Diastolic blood pressure

Control (n = 18)
6
191
132
44
80

Total (N = 39)

0
207
140
49
91

6
194
131
40
117

12
187
125
41
109

0
198
128
48
83

12
183
119
45
93

4 (19%)
3 (14%)
14 (67%)
81
62
23
110
71

10 (48%)
0 (0%)
11 (52%)
78
62
23
109
70

9 (43%)
3 (14%)
9 (43%)
75
57
24
109
75

3 (17%)
6 (33%)
6 (33%)
2 (11%)
4 (22%)
4 (22%)
13 (72%)
8 (44%)
8 (44%)
66
63
60
61
59
48
20
21
22
109
106
107
66
66
71

0
203
135
48
88

6
193
131
42
100

12
185
122
43
101

7 (18%) 16 (41%) 15(39%)

5 (13%)
4 (10%)
7 (18%)
27 (69%) 19 (49%) 17 (44%)
74
71
68
62
61
53
21
22
23
110
108
108
69
68
73

Note: LDL = low-density lipoprotein; HDL = high-density lipoprotein; CAFT = Canadian Aerobic Fitness Test; BMI = body mass index.

Health care providers should inquire about children in the

family of an individual with a cardiac event or hypercholesterolemia and make recommendations for risk factor screening and intervention when appropriate. Although it has been
recommended that cardiologists refer children of adult
patients with early cardiovascular disease to a source of continuing health care for cholesterol screening and follow-up
(National Cholesterol Education Program, 1991), most families in this study stated this had not occurred. In addition, the
variability in education and income levels suggests that family cardiovascular disease is a potent motivator for change
among families with diverse characteristics.
This study supports the findings of other researchers that
education is effective in lowering risk factors for cardiovascular disease. Families expressed that they made small
changes based on the classes, such as changing to lower fat
dairy products and exercising at least two times weekly. It is
notable that even these small changes led to significant
results in terms of total cholesterol, LDL-C, and VO2 peak
for the children. The changes also were maintained over a
1-year period, and indeed there were additional improvements between the 6- and 12-month measuring points. This
suggests that interventions with young children can be effective in lowering risk factors for a period greater than 1 year.
Parental and family support were important for the children
and provided motivation for lifestyle changes.
The integration of many experts into the NWP was an
unusual and beneficial approach. Each expert brought a
unique perspective helpful to the study, both during the
design phase when evaluative methods were chosen and during the intervention phase, when classes were offered on topics of cardiovascular health. Challenges of working with
such a diverse group included identification of convenient
meeting times and locations and coming to agreement on a
theoretical model that would consider the frameworks of

various specialties. The effort was worthwhile however, as

the multiple perspectives contributed much to the project,
and families appreciated contact with many experts to
answer their questions and provide useful information.
As has been found in previous studies of children, cardiovascular disease risk factors cluster within individuals. Correlations of weight and BMI with blood pressure and HDL-C
suggest that when one risk factor is identified in a child, further screening should be performed. Measures commonly
obtained during child health care visits, such as height,
weight, and blood pressure, should be analyzed carefully.
Height and weight should be used to calculate BMI and grids
from the Centers for Disease Control and Prevention and the
National Center for Health Statistics (http://www.cdc.gov/
nchswww) should be consulted to identify the childs BMI
percentile. Evaluation of physical activity level should be
included in health care visits, either by short history or questionnaire. The child with more than one risk factor or who
has a family member with early cardiovascular disease
should have a blood draw for lipid and lipoprotein analysis.
The correlations observed at 12 months in the NWP also suggest that for children who are more fit, fitness level relates to
HDL-C and triglyceride levels.
This study was limited by its small sample size and the
lack of cultural diversity. Additional studies that include
more children of different ages, diverse cultural groups, and
various teaching approaches will be useful.
Cardiovascular disease should be viewed on a continuum
with interventions to lower risks possible at many points.
Childhood may be an especially appropriate time to offer
interventions because lifestyle changes can be influential
over a period of many years, thereby maximizing their benefits. Moreover, a cardiovascular event or condition in a family member is a key point for intervention to lower risk in all
of the family members.

48

NATIONAL ACADEMIES OF PRACTICE FORUM / January 2000

TABLE 3

Correlates of Physical Measurement

Systolic
Blood Pressure
Weight
Baseline
12 months
BMI
Baseline
12 months
Fitness
Baseline
12 mos
Total cholesterol
Baseline
12 months
LDL
Baseline
12 months
HDL
Baseline
12 months
Triglycerides
Baseline
12 months

Diastolic
Blood Pressure

Total
Cholesterol

LDL

HDL

Triglycerides

Fitness

.49**
.65**

.34*
.39*

.13
.02

.10
.02

.41*
.35*

.27
.32*

.11
.41**

.57**
.70**

.46**
.50**

.01
.11

.08
.07

.42**
.51**

.32*
.40*

.15
.39*

.05
.05

.24
.28

.06
.34*

1.0
1.0

.03
.02

.21
.27

.04
.09

1.0
1.0

.33*
.11

.10
.05

.05
.05

1.0
1.0

.62**
.68**

.24
.28

.62**
.68**

1.0
1.0

.03
.15

.17
.09

.04
.09

.02
.05

.16
.29

1.0
1.0

.03
.13

.07
.30

.59**
.90**

.59**
.90**

.38*
.44**

.29
.18

.03
.02

.33*
.11

.36*
.26

.00
.23

.21
.27

.10
.05

.06
.34*

Note: BMI = body mass index; LDL = low-density lipoprotein; HDL = high-density lipoprotein.
*correlation is significant at .05 level (2-tailed test).
**correlation is significant at .01 level (2-tailed test).

REFERENCES

Al-Hazzaa, H. M., Sulaiman, M. A., Al-Matar, A. J. & AlMobaireek, K. F. (1994). Cardiorespiratory fitness, physical
activity patterns and coronary risk factors in preadolescent boys.
, , 267-272.
American Heart Association. (1998).
. Dallas, TX: Author.
Ewart, C. K. (1990). A social problem-solving approach to behavior
change in coronary heart disease. In S. A. Shumaker, E. B.
Schron, & J. K. Ockene (Eds.),
pp. 153-190. New York: Springer.
Jemerin, J. M., & Boyce, W. T. (1990). Psychobiological differences in childhood stress response: Cardiovascular markers of
vulnerability.
, (3),
140-150.
McGill, H. C. (1997). Childhood nutrition and adult cardiovascular
disease.
, (Suppl.), S2-S11.
McGill, H. C., McMahon, C. A., Malcolm, G. T., Oalman, M. C.,
Strong, J. P. & the Pathological Determinants of Atherosclerosis
in Youth (PDAY) Research Group. (1995). Relation of glycohemoglobin and adiposity to atherosclerosis in youth.
, , 431-440.
International Journal of Sports Medicine

15

1999 heart and stroke statisti-

cal update

The handbook of health behavior

change

Developmental and Behavioral Pediatrics 11

Nutrition Reviews

55

Arterioscle-

rosis, Thrombosis, and Vascular Biology

15

McGill, H. C., McMahon, A., Oalman, M. C. & Strong, J. P. (1997).

Effects of serum lipoproteins and smoking on atherosclerosis in
young men and women.
, , 95-106.
National Center for Chronic Disease Prevention and Health Promotion. (1996).
. Atlanta, GA: U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention.
National Cholesterol Education Program. (1991).

Arteriosclerosis, Thrombosis, and Vas-

cular Biology

17

Physical activity and health: A report of the Sur-

geon General

Report of the

expert panel on blood cholesterol levels in children and adoles-

. Washington, DC: Department of Health and Human

Services.
Peters, J. R., Quiter, E. S., Brekke, M. L., Admire, J., Brekke, M. J.,
Mullis, R., & Hunninghake, D. B. (1990). The Eating Pattern
Assessment Tool: A simple instrument for assessing dietary fat
and cholesterol intake.
, , 1008-1013.
Troiano, R. P., & Flegal, K. M. (1998). Overweight children and
adolescents: Description, epidemiology, and demographics.
, , 497-504.
U.S. Department of Health and Human Services. (1995).
. Washington, DC: Author.
cents

Journal of the American Dietetic Asso-

ciation

94

Pediatrics

101

Healthy

people 2000:

Midcourse review and 1995 revisions