The metabolic  syndrome  in children

 MBBS(Ceylon), DCH(Ceylon), DCH(England), MD(Paediatrics), FRCP(Edinburgh), FRCP(London), FRCPCH(United Kingdom), FSLCPaed, FCCP, FCGP(Sri Lanka) Consultant Paediatrician

The origin of the phrase "Metabolic Syndrome" dates back to at least the late 1950s. However, it came into common usage in the late 1970s to describe various associations of risk factors with diabetes that had been noted as early as the 1920s. The Marseilles physician Dr. Jean Vague in 1947 observed that upper body obesity appeared to predispose to diabetes, atherosclerosis, gout and calculi. In 1977, Haller used the term "metabolic syndrome" for associations of obesity, diabetes mellitus, elevated blood lipids or fat, increased blood uric acid levels and fat deposition in the liver, in describing the additive effects of risk factors on atherosclerosis. In 1977 and 1978, Gerald B. Phillips developed the concept that risk factors for heart attacks concur to form a "constellation of abnormalities" such as elevated levels of blood sugar, cholesterol, other blood fats and blood pressure. He suggested that there must be an underlying linking factor, the identification of which could lead to the prevention of cardiovascular disease. The terms "metabolic syndrome," "insulin resistance syndrome," and "syndrome X" are now used specifically to define a collection of abnormalities that is associated with increased risk for the development of type 2 diabetes mellitus and atherosclerotic vascular disease such as heart attacks and strokes. The word metabolism refers to all the chemical processes in the human body that lead to the production of energy and maintenance of growth. There are many metabolic diseases which occur when hormones and other chemicals in the body fail to interact properly. These are quite different to the Metabolic Syndrome. The latter refers to a cluster of risk factors that put adults and children on the road to heart disease, strokes and type 2 diabetes.

The metabolic syndrome is an exceedingly important phenomenon in children as it threatens the health of the future generations. Children with the metabolic syndrome have at least three of four risk factors. These are excessive belly fat, high blood pressure, abnormal levels of blood fats lipids or fats including cholesterol and triglycerides and high blood sugar. It might surprise a lot of the readers to note that children can have these problems as many people associate these features as those of adults and older people. This is not so anymore. Mostly due to the rising obesity epidemic in young people, children and teenagers are getting these conditions and they are getting them earlier than ever before. Some estimates say that in the Western countries, nearly 1 in 10 teenagers and over a third of obese teens have the metabolic syndrome. This is something parents should know about, especially because they can take certain definitive steps to lessen their children’s chances of developing metabolic syndrome or the risk factors that lead to it.

Central adiposity or fatness is a key feature of the syndrome, reflecting the fact that the syndrome’s prevalence is driven by the strong relationship between waist circumference and increasing adiposity. Physical inactivity is a predictor of later cardiac events and related mortality. Many components of metabolic syndrome are associated with a sedentary lifestyle. International Diabetes Federation, consensus worldwide definition of the metabolic syndrome is central obesity defined as a high waist circumference above ethnic specific values and any two of the following :-

* Raised triglycerides or "blood fats" in the blood.

* Reduced HDL or "good"cholesterol

* Raised blood pressure

* Raised fasting plasma glucose or "blood sugar".

The exact mechanisms of the complex pathways of metabolic syndrome are not yet completely known. These seem to be extremely complex and have been only partially elucidated. Some of the more important associated factors are :-

1. weight

2. genetics

3. age

4. sedentary lifestyle

Because it is a precursor to heart disease and type 2 diabetes, metabolic syndrome is brought on by the same problems that cause those very same diseases. In that sense, having a diet that is high in calories and low in nutrients and consuming lots of fast food and sweetened beverages can put children at considerable risk. Playing video games for most of the day or sitting in front of the computer and not getting enough or for that matter, any exercise also can increase a child’s chance of developing factors like obesity and other related problems. The risk of developing the condition appears to be highest around puberty. That may be because body fat, blood pressure and lipids are all affected by the hormones that bring about the many changes of puberty. Children who have a family history of heart disease or diabetes are at greater risk for metabolic syndrome. However, as with many things in life, the lifestyle habits a child adopts can push things in one direction or another. So those who are active, fit, and eat a lot of fruits and vegetables may drastically decrease their chances of developing metabolic syndrome, even if a close relative already has it.

Metabolic syndrome itself often has no noticeable symptoms early on. But when its risk factors are left to snowball for too long, major changes may start to develop in the body. Some of these include :-

* Arteriosclerosis where cholesterol and fats harden and begins to build up in the walls of arteries, causing blockages that can lead to high blood pressure, heart attack, and stroke.

* Poor kidney function with these organs becoming less able to filter toxins out of the blood, which can also increase the risk of high blood pressure, heart attack, or stroke.

* Insulin resistance which occurs when the body’s cells do not respond to insulin which is the hormone that helps to regulate sugar in the blood.

* Polycystic ovarian syndrome which is thought to be related to insulin resistance. This disorder involves the release of extra male hormones by the ovaries, which can lead to abnormal menstrual bleeding, excessive hair growth, acne, and fertility problems.

* Acanthosis nigricans, a skin disorder that causes thick, dark or blackish, velvet-like patches of skin around the neck, armpits, groin, between the fingers and toes, or on the elbows and knees.

Primary care providers must be aware that, as in adults, risk factors for heart disease and type 2 diabetes may cluster in children and adolescents. That is, children who have one risk factor are likely to have others as well, especially if they are overweight. Early identification of children at risk will be crucial to the prevention of chronic disease during childhood and in later life.

If a child is diagnosed with metabolic syndrome, it does not necessarily mean that he or she will develop heart disease or diabetes, but the chances are increased, especially if the risk factors involved are not improved or eliminated. For some of them, a lifestyle change may be enough to reduce the risk for serious disease. The current recommendations are :-

* To try and drop excess weight. Even a moderate amount of weight loss can translate to big improvements in blood pressure, blood lipid levels and the body’s ability to use insulin.

* To engage in more physical activity and exercise. By taking just one of those hours spent in front of a screen each day and spending it on something that gets the blood flowing, a child can dramatically improve his or her blood pressure, cholesterol, and sensitivity to the effects of insulin.

* Eating sensibly. A child who learns to see food as fuel and not emotional compensation can start to make better choices at mealtime. For example, selecting complex instead of simple carbohydrates such as whole-grain instead of white bread, and brown rice instead of white rice, increasing fibre intake with more beans, fruits, and vegetables, choosing "healthy" fats like palm oil and nuts and avoiding too many empty calories from fizzy drinks and sweets.

When lifestyle changes are not sufficient, it may be necessary to prescribe medications to treat individual risk factors. Some may need medications for high blood pressure, cholesterol and to reduce insulin resistance

Puberty presents a unique challenge to insulin-glucose balancing mechanisms. During puberty, insulin resistance is increased and insulin sensitivity is reduced in both non-diabetic and diabetic children. This insulin resistance is normally compensated for by increased insulin secretion. Body fat, blood pressure, and lipids are all affected by puberty. The percentage of body fat increases strikingly in females through adolescence, but changes in body fat in males is not consistent. Blood pressure also rises with pubertal stage independent of age, particularly in girls. Lipids vary by pubertal stage in youth. For example, total cholesterol drops in mid-puberty and begins rising toward adult levels at the end of puberty. In addition, the changes in body fat, blood pressure and lipid profiles during puberty may be influenced by the decrease in physical activity and changes in eating habits that are commonly seen during adolescence. Thus, puberty is a crucial time for the development of the metabolic syndrome, and yet it is a difficult time during which to identify it.

Various strategies have been proposed to prevent the development of the metabolic syndrome. These include increased physical activity and a healthy, reduced calorie diet. There are many studies that support the value of a healthy lifestyle. Recommendations for dietary intake in children and adolescents include consumption of at least five fruits and vegetables a day, increased consumption of whole grains, avoidance of sweets, sodas, and other empty-calorie foods and a dietary fat content of no more than 30% of total calories per day. Unfortunately, many studies confirm that the current diet of adolescents is poor, right round the globe. Experts provide comprehensive summaries of strategies for helping families of overweight children and stress the need for health professionals to assess the parents’ and adolescents’ readiness to participate in lifestyle changes or treatment. The strategies include suggestions for helping parents develop parenting skills that promote healthy eating behaviours in children and ideas for increasing physical activity for children and families, such as walking to school or decreasing time spent watching television. The best approach to decreasing the incidence of metabolic syndrome in children is prevention. Primary care providers can encourage children, adolescents, and their parents to adopt lifestyle changes such as healthier diets, increased physical activity, and decreased sedentary activities.

As parents, most people know that life is full of cause-and-effect scenarios: If one does not go to work, then one cannot pay the bills. If one ignores the abnormal sound the car is making, then one could end up on the side of the road with engine trouble. Unfortunately, this concept is often a little harder for children to grasp. They tend to live in the present and do not think too much about long-term consequences. Usually this works out just fine because the parents are there to offer support and when necessary, provide a safety net. However, when it comes to kids’ health, there are some long-term consequences the parents may not even realize what they are up against. One of the best examples of this is this condition called the metabolic syndrome.

At present, the metabolic syndrome is found in a very significant proportion of children and adolescents in population-based studies. Quite unfortunately, even in Sri Lanka, this seems to be the case. This presents a serious threat to the current and future health of our youth. The metabolic syndrome and its many consequences, including heart problems and diabetes, will continue to increase unless we can find ways to prevent obesity and the metabolic syndrome in childhood and adolescence. We must be diligent in screening for and identifying children and adolescents with metabolic syndrome and supporting and encouraging them and their families through healthy lifestyle changes. Primary care providers can join other health care providers in developing and testing primary prevention strategies that will change the environment to provide access to safe places where our children can be active and play and to promote an atmosphere conducive to making healthier food choices.

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Treating Risk Factors

If your child is diagnosed with metabolic syndrome, it does not necessarily mean that he or she will develop heart disease or diabetes, but the chances are increased — especially if the risk factors involved aren’t improved or eliminated.

For some kids, a lifestyle change may be enough to reduce the risk for serious disease. A doctor may recommend:

* Dropping excess pounds. If your child is overweight, even a moderate amount of weight loss can translate to big improvements in blood pressure, blood lipid levels, and the body’s ability to use insulin.

* Getting more exercise. By taking just one of those hours spent in front of a screen each day and spending it on something that gets the blood flowing, your child can dramatically improve his or her blood pressure, cholesterol, and sensitivity to the effects of insulin.

* Eating mindfully. A child who learns to see food as fuel and not emotional compensation can start to make better choices at mealtime — for example, selecting complex instead of simple carbs (such as whole-grain instead of white bread, and brown rice instead of white); increasing fiber intake with more beans, fruits, and vegetables; choosing "healthy" fats like olive oil and nuts; and avoiding too many empty calories from soda and sweets.

* Fiber supplements. If your child might not be getting enough fiber through food, a fiber supplement may provide an added boost to help reduce the amount of LDL cholesterol in the blood.

* Not smoking. No surprise here — it’s just about the worst thing people can do to their heart and lungs. Either alone or in combination with metabolic syndrome risk factors, smoking greatly increases your child’s risk for developing heart disease.

When lifestyle changes aren’t enough, a child may be prescribed medications to treat individual risk factors. So, kids with high blood pressure might be put on antihypertension drugs. Others with high LDL cholesterol might be prescribed statins or other lipid-lowering drugs. Children with high blood sugar, who are on the brink of developing diabetes, may be given medication to decrease insulin resistance.

Although weight-loss drugs that are helpful to adults are still investigational in children, some kids who are morbidly obese (double or more the healthy weight for kids their sex, age, and height) might benefit from these medications.

While bariatric surgery for weight loss is not yet approved by the U.S. Food and Drug Administration (FDA) in kids, some teens with morbid obesity or those who are obese and have developed heart disease or diabetes may be candidates for the procedure.

Changing Course

Here’s a great thing kids can learn about cause-and-effect: they have the power to positively influence many health outcomes. Eating right and staying active are two ways they can help ensure a healthier tomorrow.

Of course, it’s easier for kids to make better choices if they see their parents doing the same. So make a plan to help your entire family choose a new, healthier direction. After all, getting a late start on the right path beats staying on the wrong one.

KEY POINTS

= Metabolic syndrome is a condition during childhood and adolescence that increases the risks for major adult diseases like heart problems, diabetes and strokes

= The association with poor eating habits, obesity and inactivity are well established.

= Children who are obese need to be screened early for the other associated problems.

= Life style changes need to be made to mitigate the problem.

= Some may need specific drug therapy

Courtesy - The Island