Overview

In a world with the convenience of fast food restaurants found on nearly every street corner, it is no wonder that the health of the public is of growing concern (Richardson, Boone-Heinonen, Popkin, & Gordon-Larsen, 2011). According to Statistics Canada nearly one third of Canadian children aged 5-17 years old can be identified as being overweight or obese when looking at body mass index (BMI) data (Roberts, Shields, de Groh, Aziz, & Gilbert, 2012). The percentage of the population who fall into this category only increases with age. Over 50% of Canadian adults are considered overweight or obese (Statistics Canada, 2014) and approximately one in five Canadian adults meet the criteria for having the metabolic syndrome (Riediger and Clara, 2011). While the metabolic syndrome is less common in paediatric cases than it is in adults, it is still seen quite frequently amongst North American children (Gerald, Anderson, Johnson, Hoff, & Trimm, 1993; Hadjiyannakis, 2005).

Diagnosis

Movement Experiences for Children
KIN 366
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Instructor:	Dr. Shannon S.D. Bredin
Email:	shannon.bredin@ubc.ca
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Important Course Pages
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Diagnosis in Adults

The metabolic syndrome is a collection of interrelated risk factors for type 2 diabetes mellitus as well as cardiovascular disease (Alberti et al., 2009). An individual is diagnosed with the metabolic syndrome if they are found to have three of five different screening variables: increased waist circumference, dyslipidemia (broken down into high levels of circulating triglycerides and lowered levels of high-density lipoproteins), elevated fasting blood-glucose levels, and hypertension (Alberti et al., 2009).

Specifics of Screening Variables

A patient is diagnosed with the metabolic syndrome if they meet three of the following five screening variables, published by Alberti et al. (2009).

1. Elevated waist circumference of 102cm in males; 88cm in females

2. Elevated triglycerides of ≥150 mg/dL (1.7 mmol/L)

Alternative indicator is the current presence of drug treatment for elevated triglycerides

3. Reduced high-density lipoprotein cholesterol (HDL-C) of <40 mg/dL (1.0 mmol/L) in males; <50 mg/dL (1.3 mmol/L) in females

Alternative indicator is the current presence of drug treatment for reduced HDL-C

4. Elevated blood pressure of systolic ≥130 and/or diastolic ≥85 mmHg

Alternative indicator is the current presence of antihypertensive drug treatment in a patient with a history of hypertension

5. Elevated fasting glucose of ≥100 mg/dL

Alternative indicator is the current presence of drug treatment for elevated glucose

Diagnosis in Children

While the metabolic syndrome is more commonly found in adult populations, it is also of great concern for children of all ages (Gerald, Anderson, Johnson, Hoff, & Trimm, 1993; Hadjiyannakis, 2005). Obesity is highly linked to the metabolic syndrome in children. Nearly one third of obese children meet the criteria for having this disease and 90% meet at least one of the five criteria used for diagnosing the metabolic syndrome (Hadjiyannakis, 2005). The same criteria that are generally used for adults are used in the diagnosis of childhood metabolic syndrome. However, no standard measures have yet been established for the paediatric cases (Lee, Bacha, Gungor, & Arslanian, 2008). While there is no unified definition of this syndrome, the use of different published definitions all lead to the production of very similar results (Lee et al., 2008).

Who is at Risk?

While any child has the potential to develop the metabolic syndrome, there are certain social, physiological, as well as lifestyle characteristics that have been identified as additional risk factors.

Social Factors

Children living in low-income and/or low-education families, as well as those living in single parent homes show a greater incidence of childhood obesity and development of the metabolic syndrome (Gerald et al., 1993; Siahpush & Kogan, 2010).

Physiological Factors

Paediatric obesity is the greatest predictor of childhood metabolic syndrome (Hadjiyannakis, 2005). As well as obesity, cardiovascular fitness has also proven to be a significant predictor of increased metabolic risk (Rizzo et al., 2007). Higher frequencies of childhood metabolic syndrome have also been linked to birth size and intrauterine exposure to diabetes (Boney, Verma, Tcker, & Vohr, 2005). An increased prevalence of the metabolic syndrome has been observed amongst large-for-gestational-age children who were born to mothers with gestational diabetes (Boney et al., 2005).

Lifestyle Factors

High levels of TV viewing and low levels physical activity have both been independently linked with increased metabolic risk (Ekelund et al., 2006). Many different researchers around the globe have observed a strong inverse relationship between physical activity levels and metabolic risk (Ekelund et al., 2006; Brage et al., 2004; Rizzo et al., 2007). This relationship is seen independently of all other social, physiological, or lifestyle factors (Brage et al., 2004). High levels of TV viewing have also been independently linked to increased risk of developing childhood metabolic syndrome (Ekelund et al., 2006). It is believed that this is more due to poor eating habits and snacking that frequently accompany TV viewing than due to reduced time for physical activity (Ekelund et al., 2006).

Future Health Concerns

Individuals who were obese and/or had the metabolic syndrome as children are at an increased risk of developing or continuing to have the metabolic syndrome in adulthood (Vanhala, Vanhala, Kumpusalo, Halonen, & Takala, 1998). The presence of the metabolic syndrome throughout childhood has also proven to be a significant predictor of the development of type 2 diabetes as well as cardiovascular disease later on in life (Morrison, Friedman, Wang, & Glueck, 2008; Morrison, Friedman, & Gray-McGuire, 2007). Knowing this correlation could allow practitioners to identify patients who exhibit signs of increased risk for the development of these diseases (Morrison et al., 2007). Targeting patients with childhood metabolic syndrome while they are still young and implementing early interventions could have positive effects on their health throughout their entire lives (Morrison et al., 2007).

Treatment with Lifestyle Interventions

A study performed by Monzavi et al. (2006) found significant improvements in the presence of risk factors for childhood metabolic syndrome as well as insulin resistance in overweight youth (aged 8-16years) who participated in a 12week, family-centred lifestyle intervention program. Throughout the 12 weeks the families attended weekly sessions that were offered free of charge. During the first half of these sessions, the children participated in a 45-minute exercise program aimed at promoting moderate to vigorous cardiovascular physical activity. During this time, the parents attended an education session where there learned about co-morbidities of obesity, such as type 2 diabetes and hyperlipidemia – increased fats or lipids in the blood (Monzavi et al., 2006). The second half of the session was made up of a family-centred nutrition lesson, which was attended by the children and parents alike. Topics covered in this session included the food pyramid, how to reduce fat intake, tools for improving the quality of snacking, tips for portion control, and strategies for eating outside of the house.

At the end of the 12week intervention, the participants showed a significant decrease in nearly all risk factors associated with the metabolic syndrome. Decreases in BMI, systolic blood pressure, total cholesterol as well as LDL cholesterol, and triglyceride levels were all observed (Monzavi et al., 2006).

Recommendations for Parents

Physical Activity

Increase frequency of physical activity of children
Replace sedentary activities (such as TV viewing and video games) with active play as frequently as possible
Active play is defined as any play activities that result in enough physical excursions to lead to sweating and/or heaving breathing (Anderson, Economos, & Must, 2008)
Some examples of active play outlined by Kids at Play (2009):

Indoor activities – dancing to action songs, making an obstacle course, hide and seek, bowling in the hallway using recyclable products, musical chairs, etc.
Outdoor activities – throwing a ball in bucks of varying distance, catching and throwing games, going to the local park, running and stopping game (e.g. red light/green light), etc.

Lifestyle

Restrict screen time allowance
Monitor eating habits and snacking – especially during TV viewing
Bring children for regular check-ups with general practitioner or paediatrician. If signs of obesity or the metabolic syndrome are seen in children at any age, appropriate lifestyle changes should be made right away in order to best improve the health of the children at risk.

References

Alberti, K G. M. M., Eckel, R. H., Grundy, S. M., Zimmet, P. Z., Cleeman, J. I., Donato, K. A., . . . Smith, S.C. (2009). Harmonizing the metabolic syndrome: A joint interim statement of the international diabetes federation task force on epidemiology and prevention; national heart, lung, and blood institute; American heart association; world heart federation; international atherosclerosis society; and international association for the study of obesity. Circulation, 120(16), 1640.

Anderson, S. E., Economos, C. D., & Must, A. (2008). Active play and screen time in US children aged 4 to 11 years in relation to sociodemographic and weight status characteristics: a nationally representative cross-sectional analysis. BMC Public health, 8(1), 366.

Boney, C. M., Verma, A., Tucker, R., & Vohr, B. R. (2005). Metabolic syndrome in childhood: association with birth weight, maternal obesity, and gestational diabetes mellitus. Pediatrics, 115(3), e290-e296.

Brage, S., Wedderkopp, N., Ekelund, U., Franks, P. W., Wareham, N. J., Andersen, L. B., & Froberg, K. (2004). Features of the Metabolic Syndrome Are Associated With Objectively Measured Physical Activity and Fitness in Danish Children The European Youth Heart Study (EYHS). Diabetes care, 27(9), 2141-2148.

Ekelund, U., Brage, S., Froberg, K., Harro, M., Anderssen, S. A., Sardinha, L. B., ... & Andersen, L. B. (2006). TV viewing and physical activity are independently associated with metabolic risk in children: the European Youth Heart Study. PLoS medicine, 3(12), e488.

Gerald, L. B., Anderson, A., Johnson, G. D., Hoff, C., & Trimm, R. F. (1994). Social class, social support and obesity risk in children. Child: Care, Health and Development, 20(3), 145-163. doi:10.1111/j.1365-2214.1994.tb00377.x

Hadjiyannakis, S. (2005). The metabolic syndrome in children and adolescents. Paediatrics & Child Health, 10(1), 41-47.

Kids at Play. (2009). active play every day. Factsheet No: 3. Retrieved from http://health.act.gov.au/c/health?a=dlglobres&globres=1264819712

Lee, S., Bacha, F., Gungor, N., & Arslanian, S. (2008). Comparison of different definitions of pediatric metabolic syndrome: relation to abdominal adiposity, insulin resistance, adiponectin, and inflammatory biomarkers. The Journal of pediatrics, 152(2), 177-184.

Monzavi, R., Dreimane, D., Geffner, M. E., Braun, S., Conrad, B., Klier, M., & Kaufman, F. R. (2006). Improvement in risk factors for metabolic syndrome and insulin resistance in overweight youth who are treated with lifestyle intervention.Pediatrics, 117(6), e1111-e1118.

Morrison, J. A., Friedman, L. A., & Gray-McGuire, C. (2007). Metabolic syndrome in childhood predicts adult cardiovascular disease 25 years later: the Princeton Lipid Research Clinics Follow-up Study. Pediatrics, 120(2), 340-345.

Morrison, J. A., Friedman, L. A., Wang, P., & Glueck, C. J. (2008). Metabolic syndrome in childhood predicts adult metabolic syndrome and type 2 diabetes mellitus 25 to 30 years later. The Journal of pediatrics, 152(2), 201-206.

Richardson, A. S., Boone-Heinonen, J., Popkin, B. M., & Gordon-Larsen, P. (2011). Neighborhood fast food restaurants and fast food consumption: A national study. BMC Public Health, 11(1), 543-543. doi:10.1186/1471-2458-11-543

Riediger, N. D., & Clara, I. (2011). Prevalence of metabolic syndrome in the Canadian adult population. CMAJ : Canadian Medical Association Journal, 183(15), E1127-e1134. doi:10.1503/cmaj.110070

Rizzo, N. S., Ruiz, J. R., Hurtig-Wennlöf, A., Ortega, F. B., & Sjöström, M. (2007). Relationship of physical activity, fitness, and fatness with clustered metabolic risk in children and adolescents: the European youth heart study. The Journal of pediatrics, 150(4), 388-394.

Roberts, K.C., Shields, M., de Groh, M., Aziz, A., Gilbert, J. (2012). Overweight and obesity in children and adolescents: Results from the 2009 to 2011 Canadian Health Measures Survey. Statistics Canada. Retrieved from http://www.statcan.gc.ca/pub/82-003-x/2012003/article/11706-eng.htm

Singh, G. K., Siahpush, M., & Kogan, M. D. (2010). Rising social inequalities in US childhood obesity, 2003–2007. Annals of epidemiology, 20(1), 40-52.

Statistics Canada. (2014). Body mass index, overweight or obese, self-reported, adult, by sex, provinces and territories (Percent). Retrieved from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/health82b-eng.htm

Vanhala, M., Vanhala, P., Kumpusalo, E., Halonen, P., & Takala, J. (1998). Relation between obesity from childhood to adulthood and the metabolic syndrome: population based study. Bmj, 317(7154), 319-320.