Measures against Pediatric Metabolic Syndrome

Article information

J Korean Med Assoc. 2010;53(5):392-406

Publication date (electronic) : 2010 December 17

doi : https://doi.org/10.5124/jkma.2010.53.5.392

Young Ah Lee, MD , Choong Ho Shin, MD , Jung Sub Lim, MD

Department of Pediatrics, Seoul National University College of Medicine

Department of Pediatrics, Korea Cancer Center Hospital

Corresponding author : Choong Ho Shin E - mail : chshinpd@snu.ac.kr

Abstract

The incidence of metabolic syndrome (MS) has increased significantly worldwide including Korea over the past decade. Recent studies have shown that the MS develops during childhood and is highly prevalent among overweight children and adolescents. Thus, it is important for physicians to be acquainted with the definition, diagnostic criteria, epidemiology, and pathophysiology of MS for early identification and management of the MS in children and adolescents, which would be helpful to decrease the burden of type 2 diabetes and cardiovascular disease in adults. The aim of this review is to provide adequate guidelines for screening and managing strategies on MS based on recent findings. Proper and effective control of MS needs close cooperation among patients, physician, family members, school, society, and government, and it should be based on a thorough evaluation of medical system on obesity and MS.

Keywords: Metabolic syndrome; Child; Adolescent; Primary Health Care; Obesity; Insulin resistance; Mass screening

Table 1.

Definition of the risk group and metabolic syndrome in children and adolescents

Table 2.

Screening recommendation for risk factors of metabolic syndrome

Table 3.

Life style recommendation for preventing or improving the metabolic syndrome

References

1. Huang PL. A comprehensive definition for metabolic syndrome. Dis Model Mech 2009;2:231–237.

2. Hong YM, Song YW, Kim HS, Park HS, Min JH, Jung JW, Kim NS, Noh CI. Metabolic syndrome in the overweight and obese adolescents and the impact of obesity on the cardiovascular system. Korean J Pediatr 2009;52:1109–1118.

3. Chen W, Srinivasan SR, Li S, Xu J, Berenson GS. Clustering of longterm trends in metabolic syndrome variables from childhood to adulthood in Blacks and Whites: the Bogalusa Heart Study. Am J Epidemiol 2007;166:527–533.

4. Chen W, Srinivasan SR, Li S, Xu J, Berenson GS. Metabolic syndrome variables at low levels in childhood are beneficially associated with adulthood cardiovascular risk: the Bogalusa Heart Study. Diabetes Care 2005;28:126–131.

5. Oh K, Jang MJ, Lee NY, Moon JS, Lee CG, Yoo MH, Kim YT. Prevalence and trends in obesity among Korean children and adolescents in 1997 and 2005. Korean J Pediatr 2008;51:950–955.

6. DeFronzo RA, Ferrannini E. Insulin resistance. A multifaceted syndrome responsible for NIDDM, obesity, hypertension, dyslipidemia, and atherosclerotic cardiovascular disease. Diabetes Care 1991;14:173–194.

7. Eckel RH, Grundy SM, Zimmet PZ. The metabolic syndrome. Lancet 2005;365:1415–1428.

8. Beltrand J, Lévy-Marchal C. Pathophysiology of insulin resistance in subjects born small for gestational age. Best Pract Res Clin Endocrinol Metab 2008;22:503–515.

9. Saenger P, Czernichow P, Hughes I, Reiter EO. Small for gestational age: short stature and beyond. Endocr Rev 2007;28:219–251.

10. Park HK, Kim MJ, Kim YH, Jung JA, Yang S, Hwang IT, Lee HR, Kim JS. The prevalence of metabolic syndrome in children and adolescents born small for gestational age. J Korean Soc Pediatr Endocrinol 2007;12:55–62.

11. Srinivasan SR, Myers L, Berenson GS. Predictability of childhood adiposity and insulin for developing insulin resistance syndrome (syndrome X) in young adulthood: the Bogalusa Heart Study. Diabetes 2002;51:204–209.

12. Sinaiko AR, Donahue RP, Jacobs DR Jr, Prineas RJ. Relation of weight and rate of increase in weight during childhood and adolescence to body size, blood pressure, fasting insulin, and lipids in young adults. The Minneapolis Children? s Blood Pressure Study. Circulation 1999;99:1471–1476.

13. Muniyappa R, Iantorno M, Quon MJ. An integrated view of insulin resistance and endothelial dysfunction. Endocrinol Metab Clin North Am 2008;37:685–711.

14. Yamauchi T, Kadowaki T. Physiological and pathophysiological roles of adiponectin and adiponectin receptors in the integrated regulation of metabolic and cardiovascular diseases. Int J Obes (Lond) 2008;32(S7):S13–18.

15. Park MY, Ahn SA, Cho WK, Cho KS, Park SH, Hahn SH, Jung MH, Suh BK. Serum leptin, adiponectin and resistin levels in obese children and their correlations with insulin resistance. Korean J Pediatr 2009;52:766–771.

16. Evans JL, Goldfine ID, Maddux BA, Grodsky GM. Are oxidative stress-activated signaling pathways mediators of insulin resistance and beta-cell dysfunction? Diabetes 2003;52:1–8.

17. Johnson RJ, Perez-Pozo SE, Sautin YY, Manitius J, Sanchez-Lozada LG, Feig DI, Shafiu M, Segal M, Glassock RJ, Shimada M, Roncal C, Nakagawa T. Hypothesis: could excessive fructose intake and uric acid cause type 2 diabetes? Endocr Rev 2009;30:96–116.

18. Vos MB, Kimmons JE, Gillespie C, Welsh J, Blanck HM. Dietary fructose consumption among US children and adults: the Third National Health and Nutrition Examination Survey. Medscape J Med 2008;10:160.

19. Johnson RJ, Segal MS, Sautin Y, Nakagawa T, Feig DI, Kang DH, Gersch MS, Benner S, Sánchez-Lozada LG. Potential role of sugar (fructose) in the epidemic of hypertension, obesity and the metabolic syndrome, diabetes, kidney disease, and cardiovascular disease. Am J Clin Nutr 2007;86:899–906.

20. Stanhope KL, Schwarz JM, Keim NL, Griffen SC, Bremer AA, Graham JL, Hatcher B, Cox CL, Dyachenko A, Zhang W, McGahan JP, Seibert A, Krauss RM, Chiu S, Schaefer EJ, Ai M, Otokozawa S, Nakajima K, Nakano T, Beysen C, Hellerstein MK, Berglund L, Havel PJ. Consuming fructose-sweetened, not glucose-sweetened, beverages increases visceral adiposity and lipids and decreases insulin sensitivity in overweight/obese humans. J Clin Invest 2009;119:1322–1334.

21. Wei Y, Pagliassotti MJ. Hepatospecific effects of fructose on c-jun NH2-terminal kinase: implications for hepatic insulin resistance. Am J Physiol Endocrinol Metab 2004;287:E926–933.

22. Dong XC, Copps KD, Guo S, Li Y, Kollipara R, DePinho RA, White MF. Inactivation of hepatic Foxo1 by insulin signaling is required for adaptive nutrient homeostasis and endocrine growth regulation. Cell Metab 2008;8:65–76.

23. Lindqvist A, Baelemans A, Erlanson-Albertsson C. Effects of sucrose, glucose and fructose on peripheral and central appetite signals. Regul Pept 2008;150:26–32.

24. Sundaram SS, Zeitler P, Nadeau K. The metabolic syndrome and nonalcoholic fatty liver disease in children. Curr Opin Pediatr 2009;21:529–535.

25. Manco M, Marcellini M, Devito R, Comparcola D, Sartorelli MR, Nobili V. Metabolic syndrome and liver histology in paediatric non-alcoholic steatohepatitis. Int J Obes (Lond) 2008;32:381–387.

26. Schindhelm RK, Dekker JM, Nijpels G, Bouter LM, Stehouwer CD, Heine RJ, Diamant M. Alanine aminotransferase predicts coronary heart disease events: a 10-year followup of the Hoorn Study. Atherosclerosis 2007;191:391–396.

27. Goessling W, Massaro JM, Vasan RS, D? Agostino RB Sr, Ellison RC, Fox CS. Aminotransferase levels and 20-year risk of metabolic syndrome, diabetes, and cardiovascular disease. Gastroenterology 2008;135:1935–1944.

28. Zimmet P, Alberti KG, Kaufman F, Tajima N, Silink M, Arslanian S, Wong G, Bennett P, Shaw J, Caprio S. IDF Consensus Group. The metabolic syndrome in children and adolescents-an IDF consensus report. Pediatr Diabetes 2007;8:299–306.

29. Steinberger J, Daniels SR, Eckel RH, Hayman L, Lustig RH, McCrindle B, Mietus-Snyder ML. American Heart Association Atherosclerosis, Hypertension, and Obesity in the Young Committee of the Council on Cardiovascular Disease in the Young; Council on Cardiovascular Nursing; and Council on Nutrition, Physical Activity, and Metabolism. Progress and challenges in metabolic syndrome in children and adolescents: a scientific statement from the American Heart Association Atherosclerosis, Hypertension, and Obesity in the Young Committee of the Council on Cardiovascular Disease in the Young; Council on Cardiovascular Nursing; and Council on Nutrition, Physical Activity, and Metabolism. Circulation 2009;119:628–647.

30. Ford ES, Li C. Defining the metabolic syndrome in children and adolescents: will the real definition please stand up? J Pediatr 2008;152:160–164.

31. Cook S, Weitzman M, Auinger P, Nguyen M, Dietz WH. Prevalence of a metabolic syndrome phenotype in adolescents: findings from the third National Health and Nutrition Examination Survey, 1988-1994. Arch Pediatr Adolesc Med 2003;15:821–827.

32. Tailor AM, Peeters PH, Norat T, Vineis P, Romaguera D. An update on the prevalence of the metabolic syndrome in children and adolescents Int J Pediatr Obes 2009 [Epub ahead of print].

33. Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med 1998;15:539–553.

34. Park MJ, Boston BA, Oh M, Jee SH. Prevalence and trends of metabolic syndrome among Korean adolescents: from the Korean NHANES survey, 1998-2005. J Pediatr 2009;155:529–534.

35. Kong AP, Ko GT, Ozaki R, Wong GW, Tong PC, Chan JC. Metabolic syndrome by the new IDF criteria in Hong Kong Chinese adolescents and its prediction by using body mass index. Acta Paediatr 2008;97:1738–1742.

36. Park J, Hilmers DC, Mendoza JA, Stuff JE, Liu Y, Nicklas TA. Prevalence of metabolic syndrome and obesity in adolescents aged 12 to 19 years: comparison between the United States and Korea. J Korean Med Sci 2010;25:75–82.

37. Berenson GS, Srinivasan SR, Bao W, Newman WP 3rd, Tracy RE, Wattigney WA. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. The Bogalusa Heart Study. N Engl J Med 1998;338:1650–1656.

38. McGill HC Jr, McMahan CA, Herderick EE, Zieske AW, Malcom GT, Tracy RE, Strong JP. Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. Obesity accelerates the progression of coronary atherosclerosis in young men. Circulation 2002;105:2712–2718.

39. Mattsson N, Rönnemaa T, Juonala M, Viikari JS, Raitakari OT. Childhood predictors of the metabolic syndrome in adulthood. The Cardiovascular Risk in Young Finns Study. Ann Med 2008;40:542–552.

40. Morrison JA, Friedman LA, Wang P, Glueck CJ. Metabolic syndrome in childhood predicts adult metabolic syndrome and type 2 diabetes mellitus 25 to 30 years later. J Pediatr 2008;152:201–206.

41. Morrison JA, Friedman LA, Gray-McGuire C. Metabolic syndrome in childhood predicts adult cardiovascular disease 25 years later: the Princeton Lipid Research Clinics Follow-up Study. Pediatrics 2007;120:340–345.

42. McGill HC Jr, McMahan CA, Zieske AW, Malcom GT, Tracy RE, Strong JP. Effects of nonlipid risk factors on atherosclerosis in youth with a favorable lipoprotein profile. Circulation 2001;103:1546–1550.

43. Davis PH, Dawson JD, Riley WA, Lauer RM. Carotid intimal-medial thickness is related to cardiovascular risk factors measured from childhood through middle age: The Muscatine Study. Circulation 2001;104:2815–2819.

44. US Preventive Services Task Force. Screening and interventions for overweight in children and adolescents: recommendation statement. Pediatrics 2005;116:205–209.

45. US Preventive Services Task Force. Barton M. Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement. Pediatrics 2010;125:361–367.

46. US Preventive Services Task Force. Screening for lipid disorders in children: US Preventive Services Task Force recommendation statement. Pediatrics 2007;120:e215–219.

47. National Screening Committee policy-familial hypercholesterolaemia (hyperlipidaemia) screening (children) Available from: http://www.library.nhs.uk/screening/ViewResource.aspx?resID=60325&tabID=288&catID=1968.

48. Daniels SR, Greer FR. Committee on Nutrition. Lipid screening and cardiovascular health in childhood. Pediatrics 2008;122:198–208.

49. Kwiterovich PO Jr. Recognition and management of dyslipidemia in children and adolescents. J Clin Endocrinol Metab 2008;93:4200–4209.

50. Shaw JE, Zimmet PZ, de Courten M, Dowse GK, Chitson P, Gareeboo H, Hemraj F, Fareed D, Tuomilehto J, Alberti KG. Impaired fasting glucose or impaired glucose tolerance. What best predicts future diabetes in Mauritius? Diabetes Care 1999;22:399–402.

51. Nathan DM, Davidson MB, DeFronzo RA, Heine RJ, Henry RR, Pratley R, Zinman B. American Diabetes Association. Impaired fasting glucose and impaired glucose tolerance: implications for care. Diabetes Care 2007;30:753–759.

52. Weiss R, Taksali SE, Tamborlane WV, Burgert TS, Savoye M, Caprio S. Predictors of changes in glucose tolerance status in obese youth. Diabetes Care 2005;28:902–909.

53. Levitan EB, Song Y, Ford ES, Liu S. Is nondiabetic hyperglycemia a risk factor for cardiovascular disease? A metaanalysis of prospective studies. Arch Intern Med 2004;164:2147–2155.

54. Waugh N, Scotland G, McNamee P, Gillett M, Brennan A, Goyder E, Williams R, John A. Screening for type 2 diabetes: literature review and economic modelling. Health Technol Assess 2007;11:iii–iv. ix-xi, 1-125.

55. Orozco LJ, Buchleitner AM, Gimenez-Perez G, Roquél Figuls M, Richter B, Mauricio D. Exercise or exercise and diet for preventing type 2 diabetes mellitus. Cochrane Database Syst Rev 2008;3:CD003054.

56. Li G, Zhang P, Wang J, Gregg EW, Yang W, Gong Q, Li H, Li H, Jiang Y, An Y, Shuai Y, Zhang B, Zhang J, Thompson TJ, Gerzoff RB, Roglic G, Hu Y, Bennett PH. The longterm effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year followup study. Lancet 2008;371:1783–1789.

57. Diabetes Prevention Program Research Group. Knowler WC, Fowler SE, Hamman RF, Christophi CA, Hoffman HJ, Bren-neman AT, Brown-Friday JO, Goldberg R, Venditti E, Nathan DM. 10-year followup of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet 2009;374:1677–1686.

58. Lilly M, Godwin M. Treating prediabetes with metformin: systematic review and metaanalysis. Can Fam Physician 2009;55:363–369.

59. U.S. Preventive Services Task Force. Screening for type 2 diabetes mellitus in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;148:846–854.

60. Krebs NF, Himes JH, Jacobson D, Nicklas TA, Guilday P, Styne D. Assessment of child and adolescent overweight and obesity. Pediatrics 2007;120(Suppl 4):S193–228.

61. August GP, Caprio S, Fennoy I, Freemark M, Kaufman FR, Lustig RH, Silverstein JH, Speiser PW, Styne DM, Montori VM. Endocrine Society. Prevention and treatment of pediatric obesity: an endocrine society clinical practice guideline based on expert opinion. J Clin Endocrinol Metab 2008;93:4576–4599.

62. American Diabetes Association. Standards of medical care in diabetes-2010. Diabetes Care 2010;33(S1):S11–61.

63. Park HS, Han JH, Choi KM, Kim SM. Relation between elevated serum alanine aminotransferase and metabolic syndrome in Korean adolescents. Am J Clin Nutr 2005;82:1046–1051.

64. Pacifico L, Cantisani V, Ricci P, Osborn JF, Schiavo E, Anania C, Ferrara E, Dvisic G, Chiesa C. Nonalcoholic fatty liver disease and carotid atherosclerosis in children. Pediatr Res 2008;63:423–427.

65. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 2000;320:1240–1243.

66. Dam-Larsen S, Franzmann M, Andersen IB, Christoffersen P, Jensen LB, S⊘rensen TI, Becker U, Bendtsen F. Long term prognosis of fatty liver: risk of chronic liver disease and death. Gut 2004;53:750–755.

67. Tock L, Prado WL, Caranti DA, Cristofalo DM, Lederman H, Fisberg M, Siqueira KO, Stella SG, Antunes HK, Cintra IP, Tufik S, de Mello MT, Dâmaso AR. Nonalcoholic fatty liver disease decrease in obese adolescents after multidisciplinary therapy. Eur J Gastroenterol Hepatol 2006;18:1241–1245.

68. Nobili V, Manco M, Ciampalini P, Alisi A, Devito R, Bugianesi E, Marcellini M, Marchesini G. Metformin use in children with nonalcoholic fatty liver disease: an open-label, 24-month, observational pilot study. Clin Ther 2008;30:1168–1176.

69. Nobili V, Manco M, Devito R, Di Ciommo V, Comparcola D, Sartorelli MR, Piemonte F, Marcellini M, Angulo P. Lifestyle intervention and antioxidant therapy in children with nonalcoholic fatty liver disease: a randomized, controlled trial. Hepatology 2008;48:119–128.

70. Nobili V, Manco M, Devito R, Ciampalini P, Piemonte F, Marcellini M. Effect of vitamin E on aminotransferase levels and insulin resistance in children with non-alcoholic fatty liver disease. Aliment Pharmacol Ther 2006;24:1553–1561.

71. Cruz ML, Goran MI. The metabolic syndrome in children and adolescents. Curr Diab Rep 2004;4:53–62.

72. Nemet D, Barkan S, Epstein Y, Friedland O, Kowen G. Eliakim A Short-and longterm beneficial effects of a combined dietary-behavioral-physical activity intervention for the treatment of childhood obesity. Pediatrics 2005;115:e443–449.

73. Casazza K, Dulin-Keita A, Gower BA, Fernandez JR. Differential influence of diet and physical activity on components of metabolic syndrome in a multiethnic sample of children. J Am Diet Assoc 2009;109:236–244.

74. Ventura AK, Loken E, Birch LL. Risk profiles for metabolic syndrome in a nonclinical sample of adolescent girls. Pediatrics 2006;118:2434–2442.

75. Oh JH, Kwak IK, Yang S, Hwang IT, Jung JA, Lee HR. A Study of the relationship between childhood obesity and beverage intake. Kor J Pediatr 2003;46:1061–1066.

76. Klein-Platat C, Drai J, Oujaa M, Schlienger JL, Simon C. Plasma fatty acid composition is associated with the metabolic syndrome and low-grade inflammation in overweight adolescents. Am J Clin Nutr 2005;82:1178–1184.

77. Gidding SS, Dennison BA, Birch LL, Daniels SR, Gillman MW, Lichtenstein AH, Rattay KT, Steinberger J, Stettler N, Van Horn L. American Heart Association; American Academy of Pediatrics. Dietary recommendations for children and adolescents: a guide for practitioners: consensus statement from the American Heart Association. Circulation 2005;112:2061–2075.

78. Steffen LM, Jacobs DR Jr, Murtaugh MA, Moran A, Steinberger J, Hong CP, Sinaiko AR. Whole grain intake is associated with lower body mass and greater insulin sensitivity among adolescents. Am J Epidemiol 2003;158:243–250.

79. Ventura EE, Davis JN, Alexander KE, Shaibi GQ, Lee W, Byrd-Williams CE, Toledo-Corral CM, Lane CJ, Kelly LA, Wei-gensberg MJ, Goran MI. Dietary intake and the metabolic syndrome in overweight Latino children. J Am Diet Assoc 2008;108:1355–1359.

80. Barlow SE. Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007;120(S4):S164–192.

81. Kamath CC, Vickers KS, Ehrlich A, McGovern L, Johnson J, Singhal V, Paulo R, Hettinger A, Erwin PJ, Montori VM. Clinical review: behavioral interventions to prevent childhood obesity: a systematic review and metaanalyses of randomized trials. J Clin Endocrinol Metab 2008;93:4606–4615.

82. McGovern L, Johnson JN, Paulo R, Hettinger A, Singhal V, Kamath C, Erwin PJ, Montori VM. Clinical review: treatment of pediatric obesity: a systematic review and metaanalysis of randomized trials. J Clin Endocrinol Metab 2008;93:4600–4605.

83. Schmitz KH, Jacobs DR Jr, Hong CP, Steinberger J, Moran A, Sinaiko AR. Association of physical activity with insulin sensitivity in children. Int J Obes Relat Metab Disord 2002;26:1310–1316.

84. Kelly AS, Wetzsteon RJ, Kaiser DR, Steinberger J, Bank AJ, Dengel DR. Inflammation, insulin, and endothelial function in overweight children and adolescents: the role of exercise. J Pediatr 2004;145:731–736.

85. Torrance B, McGuire KA, Lewanczuk R, McGavock J. Overweight, physical activity and high blood pressure in children: a review of the literature. Vasc Health Risk Manag 2007;3:139–149.

86. Kavey RE, Allada V, Daniels SR, Hayman LL, McCrindle BW, Newburger JW, Parekh RS, Steinberger J. American Heart Association Expert Panel on Population and Prevention Science. American Heart Association Council on Cardiovascular Disease in the Young. American Heart Association Council on Epidemiology and Prevention. American Heart Association Council on Nutrition, Physical Activity and Metabolism; American Heart Association Council on High Blood Pressure Research. American Heart Association Council on Cardiovascular Nursing. American Heart Association Council on the Kidney in Heart Disease. Interdisciplinary Working Group on Quality of Care and Outcomes Research. Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation 2006;114:2710–2738.

87. Weiss R. Impaired glucose tolerance and risk factors for progression to type 2 diabetes in youth. Pediatr Diabetes 2007;8(S9):70–75.

88. Kavey RE, Daniels SR, Lauer RM, Atkins DL, Hayman LL, Taubert K. American Heart Association. American Heart Association guidelines for primary prevention of atherosclerotic cardiovascular disease beginning in childhood. Circulation 2003;107:1562–1566.

89. McCrindle BW, Urbina EM, Dennison BA, Jacobson MS, Steinberger J, Rocchini AP, Hayman LL, Daniels SR. American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee; American Heart Association Council of Cardiovascular Disease in the Young; American Heart Association Council on Cardiovascular Nursing. Drug therapy of high-risk lipid abnormalities in children and adolescents: a scientific statement from the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee, Council of Cardiovascular Disease in the Young, with the Council on Cardiovascular Nursing. Circulation 2007;115:1948–1967.

90. American Diabetes Association. Management of dyslipidemia in children and adolescents with diabetes. Diabetes Care 2003;26:2194–2197.

91. Lurbe E, Cifkova R, Cruickshank JK, Dillon MJ, Ferreira I, Invitti C, Kuznetsova T, Laurent S, Mancia G, Morales-Olivas F, Rascher W, Redon J, Schaefer F, Seeman T, Stergiou G. Management of high blood pressure in children and adolescents: recommendations of the European Society of Hypertension. J Hypertens 2009;27:1719–1742.

92. Khan LK, Sobush K, Keener D, Goodman K, Lowry A, Kakietek J, Zaro S. Centers for Disease Control and Prevention. Recommended community strategies and measurements to prevent obesity in the United States. MMWR Recomm Rep 2009;58:1–26.

93. Dobbins M, De Corby K, Robeson P, Husson H, Tirilis D. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6-18. Cochrane Database Syst Rev 2009;1:CD007651.

94. Gonzalez-Suarez C, Worley A, Grimmer-Somers K, Dones V. School-based interventions on childhood obesity: a metaanalysis. Am J Prev Med 2009;37:418–427.

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Table 1.

Definition of the risk group and metabolic syndrome in children and adolescents

	International Diabetes Federation			modified NCEP-ATP III
	6~9.9^∗ (yrs)	10~15.9 (yrs)	above 16 (yrs)	modified NCEP-ATP III
Obesity (WC)	≥ 90th percentile	≥ 90th percentile or adult cutoff if lower	≥ 90 cm (Asian male) ≥ 80 cm (Asian female)	≥ 90th percentile (age, gender, ethnicity specific)
TG (mg/dL)		≥ 150	≥ 150 or Thx for high TG	≥ 110
HDL-C (mg/dl)		< 40	< 40 (male) or < 50 (female) or Tx for low HDL	< 40
BP (mmHg)		SBP ≥ 130 or DBP ≥ 85	SBP ≥ 130 or DBP ≥ 85 or Tx for hypertension	≥ 90th percentile (age, gender, height specific)
FPG (mg/dL)		FPG ≥ 100^†or known T2DM	FPG ≥ 100^†or known T2DM	≥ 110
Diagnosis		central obesity plus 2 or more of 4 factors	3 or more of 5 factors

^∗

Metabolic syndrome can't be diagnosed, but further measurements should be made if there is a family history of metabolic syndrome, T2DM, dyslipidemia, cardiovascular disease, hypertension and/or obesity

^†

For clinical purposes, but not for diagnosing the Metabolic syndrome, if FPG 100~125 mg/dL and not known to have diabetes, an oral glucose tolerance test should be performed

Abbreviations: WC, waist circumference; TG, triglycerides; Tx, treatment; HDL-C, HDL-cholesterol; SBP, systolic blood pressure; DBP, diastoilic blood pressure; FPG, fasting plasma glucose; T2DM, type 2 diabetes mellitus

Table 2.

Screening recommendation for risk factors of metabolic syndrome

	National screening		Societies' recommendation
	USPSTF	NSC	AAP	Other
BMI	Grade B^∗ (45)		Routinely	Routinely
Fasting lipid	Grade I^†(46)	no report	BMI ≥ 85 percentile (48, 60) or
profile		recommend only in FHC (47)	one or more risks (48) - FH of hypertension, early CVD, strokes - unknown family history - hypertension - cigarette smoking - diabetes mellitus
Fasting plasma glucose	no report	no report	BMI ≥ 95 percentile (60) or BMI 85~94 percentile with one or more risks^‡ (60) - FH of hypertension, early CVD, strokes - hypertension - hyperlipidem	BMI > 85 percentile with two more risks (62) - FH of T2DM in 1st-or 2nd-degree relative - ethnicity like Asian American - AN, hyperthension, dyslipidemia, PCOS, SGA - maternal diabetes or GDM during child's gestation
AST/ALT	no reported	no reported	BMI ≥ 95 percentile (60) or BMI 85~94 percentile with one or more risks^‡ (60)

^∗

Grade B: The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial

^†

Grade I: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined

^‡

Suggested risk factors are identical for screening of fasting plasma glucose and AST/ALT Abbreviations : USPSTF, U.S. Preventive Services Task Force; NSC, National Screening Committee; AAP, American Academy of Pediatrics; FHC, familial hyperchole-sterolemia; FH, family history; CVD, cardiovascular deaths; AST, aspartate aminotransferase; ALT, alanine aminotransferase; PCOS, polycystic ovary syndrome; AN, acanthosis nigricans

Recommendation	Reference
Balance dietary calories with physical activity to maintain normal growth	77
Encourage high fiber intake like vegetables and fruits Encourage whole grain intake	79 78
Eat polyunsaturated fatty acids^∗ rather than food enriched saturated fat and trans fatty acids	76
Reduce the sugar-sweetened beverages and foods	77
Reduce time spent in sedentary activities^† to 1~2 h per day	80
Encourage at least 60 minutes of moderate to vigorous physical activity daily	81, 85