The metabolic syndrome: A growing problem for the pediatrician

Abstract

The increased prevalence of obesity in the pediatric population has been associated with an increase in the metabolic syndrome, a constellation of findings associated with increased risk of cardiovascular disease and Type 2 diabetes. Both the National Cholesterol Education Program Adult Treatment Panel III (NCEP) and the World Health Organization (WHO) criteria for metabolic syndrome predict cardiovascular disease in adults. In this issue of The Journal, Goodman et al clearly demonstrate that these criteria identify different populations. Only the WHO criteria require evidence of insulin resistance or abnormality in carbohydrate metabolism. Goodman et al indicate that only 63% of the patients in the NHANES III database had hyperinsulinemia, yet application of the WHO guidelines classified approximately twice as many children as having metabolic syndrome compared to the NCEP guidelines. Which factors in the constellation of signs and symptoms are most important predictors of risk? Which definition of metabolic syndrome is most helpful for tracking future cardiovascular disease? These questions are unanswered. By the time children have insulin resistance, they already have vascular inflammation. The earlier we, as practicing pediatricians, identify these patients, the greater the chance of reversing or slowing the progression of the vascular abnormalities that are the precursors to atherosclerosis. How do we accomplish this? Waist circumference is associated with insulin resistance, and has been shown to predict cardiovascular disease and visceral fat better than BMI in adults. Using NHANES III data, Fernandez et al has developed tables published in this issue of The Journal in which waist circumference is stratified according to gender, race and age (2-18 years). This provides important normative data for practitioners to use to stratify risk in their patients. Those children who have waist circumferences on the 75th and 90th percentile for age, sex, and race are at increased risk for the co-morbidities of hypertension, dyslipidemia, and diabetes. They should be monitored and treated aggressively with diet and exercise, and potentially with medication if diet and exercise alone fail to improve these risk factors. As Louis Pasteur said in 1884, “Whenever thinking about a disease, I rather think of ways of preventing it than curing it.” We must do whatever we can to stem the tide of increasing numbers of children with Type 2 diabetes and likely early cardiovascular disease.