3. Introduction
The metabolic syndrome in adults definition of the metabolic syndrome
has been defined as a cluster of in adults. 2 The intention was to
the most dangerous risk factors for rationalize the existing multiple
cardiovascular disease and type 2 definitions of the syndrome and to
diabetes, which include abdominal have a single, universally accepted
obesity, high cholesterol, high blood diagnostic tool that is easy to use in
pressure, diabetes (if not yet present) clinical practice and that does not rely
and raised fasting plasma glucose.2 upon measurements only available in
research settings. Additionally, the use
Already, a quarter of the world’s adult of a single unified definition makes
population has metabolic syndrome it possible to estimate the global
and this condition is appearing with prevalence of metabolic syndrome
increasing frequency in children and and make valid comparisons between
adolescents, due to the growing countries.
obesity epidemic within this young
population.3-4-5 People with metabolic To date, no unified definition exists
syndrome are two to three times as to assess risk or outcomes in children
likely to have a heart attack or stroke and adolescents, and existing adult-
and five times as likely to develop type 2 based definitions of the metabolic
diabetes compared with people syndrome were not felt appropriate
without the syndrome.2 Both diabetes to address the problem in this age
and cardiovascular disease cause death group. The intention of this consensus
and disability. Almost four million definition of metabolic syndrome in
deaths every year are a consequence children and adolescents is similar
of diabetes-related causes, and with to the definition in adults: to obtain
diabetes set to increase and reach 380 a universally accepted tool which is
million people within a generation, easy to use for the early diagnosis of
the death toll can only rise. metabolic syndrome, in order to take
preventive measures before the child
In 2005, the International Diabetes or adolescent develops diabetes or
Federation (IDF) published its cardiovascular disease.
5. Global burden of obesity
In 2004, the World Health Organization adolescents 6 to 18 years old more than
(WHO) estimated that approximately tripled from 4% in the mid 1970s to over
22 million children under the age 13% in the late 1990s.16
of five years were overweight or
obese.14 According to a report from Obesity in early life is of particular con-
the International Obesity Task Force cern due to its associated health conse-
(IOTF), at least 10% of school-aged quences and its influence on young peo-
children between five and 17 years are ple’s psychosocial development. Obesity
overweight or obese, representing a is also difficult and costly to cure, and
total of 155 million children. Around 30- previously obese people experience
45 million within that figure are classified tremendous challenges to maintain a
as obese, accounting for 2-3% of the healthy body weight. Additionally, a
world’s children aged 5-17.15 And the number of studies have shown that over-
situation is getting worse. In weight and obesity in child-
the United States, for example, “ his is
T hood and adolescence tend
the rate of overweight and the first to persist into young adult-
obesity among children and hood. Approximately one
adolescents aged 6 to 18
generation half of overweight adoles-
years increased to more than where cents and over one third of
25% in the 1990s from 15% in children overweight children remain
the 1970s.16 may die obese as adults. Childhood
obesity also confers long-
Such increases are not re-
before their term effects on mortality
stricted to developed coun- parents.” and morbidity.16
Paul Zimmet
tries; they are quickly reaching
many low- and middle-income countries. Each of these children is at increased
Globally, it is estimated that 17 of the 22 risk of developing metabolic syndrome
million children under five live in major and subsequently progressing to type 2
economically developing countries.17 diabetes and cardiovascular disease in
In China for example, the rate of over- later life. Early identification of children
weight and obesity observed in a study at risk and preventive action are there-
of urban schoolchildren increased from fore very important. Unless action is
almost 8% in 1991 to more than 12% six taken, diabetes experts agree that this
years later.16 In Brazil, the rate of over- is the first generation where children
weight and obesity among children and may die before their parents.
7. The new IDF definition of metabolic The wide variety of cut-off points
syndrome in children and adolescents used highlighted the need for a sin-
is inspired, in part, by the IDF world- gle definition that would use a con-
wide definition of metabolic syndrome sistent set of criteria, which would be
in adults.2 It builds on previous studies easily measurable, with age-specific
that used modified adult criteria to in- and sex-specific cut-off points.
vestigate its prevalence in children and
adolescents (see table 1). 4-18-19-20-21
Table 1: range of the published metabolic syndrome definitions in
A
pediatrics
de Ferranti et Cruz et al. Weiss et al. Ford et al.
Cook et al. Arch
al. Circulation, J Clin Endocrinol N Engl J Med, Diabetes Care,
Pediatr Adolesc Med,
2004; 110, Metab, 2004; 2004; 350, 2005; 28, 878-
2003; 157, 821-7 4
2494-721 89, 108-1322 2362-743 8144
Three or more of the following
Fasting glucose
Fasting Impaired Impaired
≥110 mg/dL
Fasting glucose glucose glucose glucose
1 ≥110 mg/dL ≥6.1 mmol/L tolerance (ADA tolerance (ADA
(additional
analysis with
(≥110 mg/dL) criterion) criterion)
≥100 mg/dL)
WC ≥90th WC ≥90th
WC ≥90th
percentile percentile BMI –Z score
WC 75 th
percentile
2 (age- and
percentile
(age-, sex- and ≥2.0 (age- and
(sex-specific,
sex-specific, race-specific, sex-specific)
NHANES III)
NHANES III) NHANES III)
Triglycerides Triglycerides
Triglycerides Triglycerides
Triglycerides ≥90th percentile 95th percentile
≥110 mg/dL ≥110 mg/dL
3 (age-specific,
≥1.1 mmol/L (age- and (age-, sex- and
(age-specific,
(≥100 mg/dL) sex-specific, race-specific,
NCEP) NCEP)
NHANES III) NGHS)
HDL-C ≤10th HDL-C 5th
HDL-C ≤40 HDL-C 1.3 HDL-C ≤40
percentile (age- percentile (age-,
4 mg/dL (all ages/ mmol/L
and sex-specific, sex- and race-
mg/dL (all ages/
sexes, NCEP) (50 mg/dL) sexes, NCEP)
NHANES III) specific, NGHS)
Blood pressure Blood pressure Blood pressure Blood pressure
≥90th percentile 90th percentile 95th percentile ≥90th percentile
Blood pressure
5 (age-, sex- and
90th percentile
(age-, sex- and (age-, sex- and (age-, sex- and
height-specific, height-specific, height-specific, height-specific,
NHBPEP) NHBPEP) NHBPEP) NHBPEP)
8. R
ationale for
the new definition
The new definition is simple and easy impact on fat distribution and on both
to apply in clinical practice. Similarly to insulin sensitivity and secretion.26
the adult criteria, waist measurement
is the main component because it is Therefore, single cut-off points can-
an independent predictor of insulin not be used to define abnormalities in
resistance, lipid levels, and blood pres- children. Percentiles, rather than abso-
sure.19-23 Moreover, in young people lute values of waist circumference have
who are obese and have similar body- been used to compensate for variation
mass index (BMI), insulin sensitivity in child development and ethnic origin.
is lower in those with high amounts So for example, values above the 90th,
of visceral adipose tissue and high 95th or 97th percentile for gender and
waist/hip ratio than in those with low age are used. Although there has not
amounts.24-25 been universal agreement as to which
level to use for the criteria for the met-
However, transposing the single defi- abolic syndrome, several studies,2,3,18
nition for adults to children is prob- have used the 90th percentile as a cut-
lematic. off for waist circumference. Children
with a waist circumference higher than
Although one single definition, albeit the 90th percentile are more likely to
with gender and ethnicity specific cut- have multiple cardiovascular disease
off points, is suitable for use in the at- risk factors than are those with a waist
risk adult population, transposing it to circumference below this level.27-28-29
children and adolescents is problemat- IDF has chosen to use the 90th percen-
ic. Blood pressure, lipid levels as well as tile as a cut-off for waist circumference,
body size and proportions change with which will be reassessed when more
age and development. Puberty has an outcome data become available.
10. For children age 10 years or older, except that waist circumference
metabolic syndrome can be diagnosed percentiles are recommended and
with abdominal obesity and the one (rather than a sex-specific) cut-off
presence of two or more other clinical is used for HDL-cholesterol levels.
features (ie elevated triglycerides, low
HDL-cholesterol, high blood pressure, For children older than 16 years, the
increased plasma glucose). In the IDF adult criteria can be used. Further
absence of contemporary definitive research is needed to identify opti-
data, the criteria adhere to the absolute mum criteria for the definition of the
values in the IDF adult definition, syndrome.
Table 2: he IDF consensus definition of metabolic syndrome in children and
T
adolescents
Glucose
Age group Obesity* Blood
Triglycerides HDL-C (mmol/L) or
(years) (WC) pressure
known T2DM
Metabolic syndrome cannot be diagnosed, but further
≥90th measurements should be made if there is a family history of
6–10 percentile metabolic syndrome, T2DM, dyslipidemia, cardiovascular
disease, hypertension and/or obesity.
≥5.6 mmol/L
(100 mg/dL)
10–16 ≥90th
Systolic ≥130/
percentile or ≥1.7 mmol/L 1.03 mmol/L (If ≥5.6
Metabolic adult cut-off if (≥150 mg/dL) (40 mg/dL)
diastolic ≥85
mmol/L [or
syndrome mm Hg
lower known T2DM]
recommend
an OGTT)
Use existing IDF criteria for adults, ie:
Central obesity (defined as waist circumference ≥ 94cm for Europid men and
≥ 80cm for Europid women, with ethnicity specific values for other groups*)
16+ plus any two of the following four factors:
• raised triglycerides: ≥ 1.7mmol/L
Metabolic
• educed HDL-cholesterol: 1.03mmol/L (40 mg/dL) in males and 1.29mmol/L
r
syndrome (50 mg/dL) in females, or specific treatment for these lipid abnormalities
•
raised blood pressure: systolic BP ≥130 or diastolic BP ≥85mm Hg, or
treatment of previously diagnosed hypertension
• mpaired fasting glycemia (IFG): fasting plasma glucose (FPG) ≥5.6 mmol/L
i
(≥100 mg/dL), or previously diagnosed type 2 diabetes
WC: waist circumference; HDL-C: high-density lipoprotein cholesterol; T2DM: type 2 diabetes mellitus; OGTT: oral
glucose tolerance test.
*The IDF Consensus group recognises that there are ethnic, gender and age differences but research is still needed
on outcomes to establish risk.
10
11. R
ecommendations for
prevention / treatment
“Early detection followed by treatment is
vital to halt the progression of the metabolic
syndrome and safeguard the future health
of children and adolescents.”
Sir George Alberti
IDF recommends that prevention and vascular disease and type 2 diabetes
primary management for the meta- mellitus.
bolic syndrome is a healthy lifestyle.
This includes: IDF hopes that the present booklet
m
oderate calorie restriction (to may also be used as a tool to make
achieve a 5–10 per cent loss of body governments and society more aware
weight in the first year) of the problems associated with obes-
m
oderate increase in physical activity ity and the likelihood of progression
change in dietary composition.
to metabolic syndrome in children and
adolescents. The anticipated outcome
Pharmacotherapy can be included is that it will encourage governments
if its safety has been clearly demon- to create environments that allow for
strated. lifestyle changes. This will require a
coordinated approach across all sec-
Early detection and treatment is likely tors including health, education, sports
to reduce morbidity and mortality in and agriculture, but it is the only way to
adulthood and help keep to a mini- curb the future burden of type 2 diabe-
mum the global burden of cardio- tes and cardiovascular disease.
11
13. Recommendations
for future research
Although it has been demonstrated 3. actor analysis in children and ado-
F
in adults that the clustering of three lescents to establish grouping of
or more components of the metabolic metabolic characteristics such as
syndrome significantly increases the risk adiposity, dyslipidemia, hyperin-
for cardiovascular disease and the new sulinemia, hypoadiponectinemia and
onset of diabetes, few, if any, outcome insulin resistance
data in children exist. The IDF criteria 4. nvestigation of how obesity in children
I
for metabolic syndrome in children and should be better defined, eg weight/
adolescents may change in future as height, waist circumference, etc
more outcome data become available. 5. evelopment of ethnic specific age
D
IDF has identified areas where more re- and sex normal ranges for waist cir-
search is currently needed in order to cumference, ideally based on healthy
identify optimal criteria for defining risk values
of future metabolic syndrome, diabetes 6. thnic specific studies of waist cir-
E
and cardiovascular disease beginning cumference versus visceral fat based
in this age group. on imaging
7. tudies of adiponectin, leptin, etc in
S
Key recommendations from IDF for children and adolescents as predictors
future research include the following: of metabolic syndrome in adulthood.
1. mproved understanding of the rela-
I 8. nitiation of long-term studies of
I
tion between body fat and its distri- cohorts of children of different ethnic
bution in children and adolescents origin into adulthood to define the
2. nvestigation of whether early growth
I natural history and effectiveness of
patterns predict future adiposity and interventions, particularly those re-
other features of the syndrome; and lating to lifestyle.
whether low birth weight predicts fu-
ture metabolic syndrome, diabetes
and cardiovascular disease
13
14. C
onclusion
The intention of the IDF consensus previously indicated, waist circumfer-
group was primarily to suppress the ence percentiles are recommended
confusion that could arise from the for use until outcome data from stud-
multiple interpretations of the meta- ies in children and adolescents indi-
bolic syndrome in children and ado- cate otherwise.
lescents. The aim of the definition is to
provide a simple, universally accepted Early detection followed by treatment is
tool, which is easy to apply in clinical needed in order to prevent further health
settings for the early detection and complications such as cardiovascular
treatment of metabolic syndrome. disease and diabetes in later life.
Lifestyle intervention is recommended
In the absence of definitive research and pharmacotherapy can be envisaged
findings at this time, the proposed IDF if its safety has been demonstrated.
definition of the metabolic syndrome Early detection and treatment are likely
in children and adolescents (Table 2) to reduce morbidity and mortality in
adheres to the absolute values pre- adulthood as well as minimise the global
sented in the adult definition with the socio-economic burden of cardiovascular
exception of waist circumference. As disease and type 2 diabetes.
14
15. Frequently Asked
Questions
Why is obesity a “sine qua non”? simple measure of waist circumfer-
In adults, insulin resistance and abdo- ence. Waist circumference is known to
minal obesity are considered to be correlate more strongly with visceral
significant causative factors in the adipose tissue (VAT) than BMI in adults
development of the metabolic syn- and its correlation has also been re-
drome.30,31-32 The link between obesity, cently demonstrated in children.36
insulin resistance and the risk of devel-
oping the metabolic syndrome has also Additionally, obesity is recognized
been described in children. However, to be an independent risk factor for
the measurement of insulin resistance the development of cardiovascular
is not practical for clinical use, whereas disease in adults,37 and a number of
measurement of abdominal adiposity studies (eg Bogalusa Heart study,38
(fat) can be easily assessed using the Muscatine study,39 NHANES III3) have
15
16. demonstrated a similar link between adolescents of various ethnic groups
childhood obesity and elevated car- (see annex 1).
diovascular risk in later life.
Why was the 90th percentile
Waist circumference in children is an chosen as a cut-off point for waist
independent predictor of insulin re- circumference?
sistance, lipid levels and blood pres- Several studies have shown that chil-
sure - all components of metabolic dren with a waist circumference 90th
syndrome.24,25,40,41 Moreover, in obese percentile are more likely to have mul-
youth with similar BMI, insulin sensitiv- tiple risk factors than those with a waist
ity is lower in those with high visceral circumference below this level.26-28
adipose tissue and high waist/hip ra- Several other studies attempting to
tio. 24,25 It is also recognized that insulin estimate the prevalence of metabolic
sensitivity decreases and insulin levels syndrome in children and adolescents
increase with increasing waist circum- have already used the 90th percentile
ference percentiles.42 as a cut-off point for waist circumfer-
ence.3,4,44 The IDF workshop has there-
In conclusion, these data, combined fore chosen to use the 90th percentile
with the unequivocal evidence of the based on this existing evidence. The
dangers of abdominal obesity in adult- group aims to reassess criteria and
hood, support the use of abdominal cut-off points in five years’ time, and
obesity as the “sine qua non” for the modify the definition, if necessary,
diagnosis of metabolic syndrome in based on new outcome data.
children and adolescents.
How can percentile charts for the
waist circumference measurement
be obtained?
To date some studies exist that show
the waist circumference percentile
regression values in some countries.
Fernandez JR, Redden D, Pietrobelli A
et al43 for example have produced
tables showing waist circumference
percentiles in nationally representa-
tive samples of American children and
16
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23
24. International Diabetes Federation (IDF)
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