Metabolic Syndrome
Metabolic Syndrome: Excerpt from The 5-Minute Pediatric Consult
George A. Datto, III, MD
Sandra Gibson Hassink, MD
Metabolic Syndrome - BASICS
Metabolic Syndrome - description
- A cluster of metabolic disorders that is the antecedent to cardiovascular disease and type 2 diabetes in adults.
- The presence of three or more of the following metabolic abnormalities is required to meet the diagnosis:
- Obesity:
- BMI >97% (BMI Z-score >2)
- Low HDL-cholesterol:
- Elevated triglycerides:
- Hypertension:
- Systolic and/or diastolic BP >95% for age and gender
- Impaired fasting blood sugar/impaired glucose tolerance:
- Fasting blood sugar >100 mg/dL
- 2-hour glucose tolerance test >140 mg/dL
Metabolic Syndrome - general prevention
Obesity prevention
Metabolic Syndrome - prevalence
- Uncommon in children of normal weight
- 30–50% of obese children meet criteria for the metabolic syndrome
- Rates increase with higher BMI
- Highest rates in Mexican Americans > whites > African Americans
- More prevalent in males than females
Metabolic Syndrome - risk factors
- Obesity
- Family history of cardiovascular disease
- Family history of type 2 diabetes mellitus
Metabolic Syndrome - genetics
Strong family history of early coronary heart disease and type 2 diabetes supports genetic component
Metabolic Syndrome - pathophysiology
- Visceral fat:
- Deposition of fat centrally which can be influenced by diet and genetics
- Adipocytes:
- Adipocytes produce proinflammatory mediators (adiponectin, resistin, and tumor necrosis factor alpha).
- Insulin resistance:
- Inflammatory mediators affect cell’s ability to respond to insulin.
Metabolic Syndrome - etiology
- Obesity
- Physical inactivity
- Insulin resistance
- Aging
- Genetics
Metabolic Syndrome - associated conditions
- Polycystic ovarian syndrome
- Nonalcoholic steatohepatitis (NASH)
- Sleep apnea
Metabolic Syndrome - DIAGNOSIS
Metabolic Syndrome - signs & symptoms
Obese patients with the metabolic syndrome usually lack any symptoms, but may complain of:
- Easy and rapid weight gain
- Excessive hunger
- Tiredness
- Headaches
- Darkening of neck and axillae (findings suggestive of acanthosis nigricans)
- Nocturia
Metabolic Syndrome - history
- Obesity trigger:
- Age at which weight gain started
- Family or patient stress
- Life events
- Parents’/Patient’s beliefs:
- Level of concern and motivation
- Self-assessed reasons for weight gain
- Previous attempts at weight control
- Family history:
- Early coronary heart disease and diabetes mellitus
- Lifestyles:
- Eating behavior
- Sugared beverage consumption
- Snacks: Frequency and content
- Eating structure
- Physical activity
- Hours of screen time
- Sports and activity participation
- Time outside
- Parenting skills
- Assessing the environment
- Ability to set boundaries
- Role modeling
- Anger management
- Hunger management
Metabolic Syndrome - physical exam
A complete physical should be done on all patients. Special attention should be paid to the following:
- Weight, height and BMI
- Waist circumference
- Blood pressure
- Acanthosis nigricans
- Abdominal striae
- Hepatomegaly
- Tanner stage
- Affect
Metabolic Syndrome - tests
Metabolic Syndrome - lab
Metabolic screening (fasting specimens) should be done on all obese patients:
- Lipid profile: cholesterol, HDL, and triglycerides
- Glucose
- Insulin level
- Hemoglobin A1c
- Liver function tests: ALT and AST
- Thyroid function tests—free T4 and TSH
- A 2-hour glucose tolerance test should be considered in patients with a fasting blood sugar >100 mg/dL or a hemoglobin A1c >6% to document either impaired glucose tolerance or type 2 diabetes.
- Abnormal lab tests should be repeated after a trial of weight management.
- Normal lab studies should be repeated yearly with significant weight gain.
Metabolic Syndrome - imaging
All patients with hypertension (BP >95th percentile × 3) should have an ECG to evaluate for left ventricular hypertrophy.
Metabolic Syndrome - differencial diagnosis
- Hereditary dyslipidemia
- Essential hypertension
- Hypertriglyceridemia
- Diabetes mellitus
- Secondary hypertension
Metabolic Syndrome - TREATMENT
Metabolic Syndrome - general measures
In the adults, lifestyle intervention has been more effective than Metformin in decreasing the incidence of diabetes mellitus in patients who have the metabolic syndrome.
Modest decreases in BMI by incorporating lifestyle interventions will decrease risk factors of the metabolic syndrome. Effective pediatric obesity management incorporates the following principals:
- Effective communication with patient and family:
- Nonblaming approach
- Be positive that change can occur
- Assessing family’s understanding of problem and readiness to make lifestyle change(s)
- Incorporate motivational interviewing to help families with their stage of change
- Identification of energy balance abnormalities
- Provide options for change
- Support families in planning and making lifestyle change
- Goal setting
- Parenting skills
- Controlling the environment
- Ongoing evaluation of treatment efficacy
Metabolic Syndrome - diet
Limiting intake of simple sugars has been shown to improve insulin resistance.
- Eliminate sugared beverages from the diet
- Increase amount of fruits, vegetables, whole grains, and protein in diet
- Portion control junk food
- Portion control carbohydrates
- Family eats healthy together
- Parents monitor child’s food intake
Metabolic Syndrome - activity
Increased physical activity has been shown to reduce insulin resistance and lower inflammatory markers associated with the metabolic syndrome.
- When possible add structured physical activity into daily routine.
- Incorporate both resistance and aerobic activities.
- Non-weight-bearing activities such as swimming and stationary bike riding may be easier for the morbidly obese deconditioned patient.
- Limit sedentary activity to no >2 hours per day.
- Home monitoring:
- Food and activity record logs may increase awareness and importance of healthy lifestyles.
- At home or in school, blood pressure monitoring may rule out white coat hypertension.
- Pre-prandial and 2-hour postprandial blood sugars are helpful in monitoring impairments in glucose metabolism.
- Preprandial blood sugar <100 mg/dL
- Postprandial blood sugar <140 mg/dL
Metabolic Syndrome - medication
- Medications may be appropriate in certain clinical situations to treat the components of the metabolic syndrome when lifestyle interventions fail to show clinical improvement.
- Dyslipidemia
- Statin therapy to treat hypercholesterolemia should be considered in adolescent patients with the following problems:
- LDL >190 mg/dl
- LDL >160 mg/dl with strong family history of early coronary artery disease (first-degree relatives with coronary artery disease less than 55)
- Patients with type 2 diabetes with dyslipidemia
- Atorvastatin: 10 mg PO daily to max of 40
- Treatment goal: LDL<130 mg/dl
- Side effects: Elevation of liver function tests
- Hypertension (see “Hypertension” chapter)
- Anti-hypertensive drug therapy should be considered in the following patients:
- Hypertensive patients with insufficient clinical response to lifestyle modification
- Patients with evidence of left ventricular hypertrophy on echocardiogram
- Patients with type 2 diabetes
- ACE inhibitors or angiotension-receptor blockers may have renal protective effects in diabetic patients
- Impaired fasting blood sugar/impaired glucose tolerance; Type 2 diabetes mellitus (see “Diabetes” chapter)
- Drug therapy should be considered in all patients with a fasting blood sugar >126 mg/dL or a hemoglobin A1c >7.0%.
Metabolic Syndrome - surgery
Gastric bypass surgery should be considered for morbidly obese adolescent patients (BMI >40) who have severe comorbid conditions, including the following:
- Diabetes mellitus
- Sleep apnea
- Disabling orthopedic complications
- NASH with fibrosis
Metabolic Syndrome - FOLLOW UP
Metabolic Syndrome - disposition
Metabolic Syndrome - issues for referral
Refer for components of the metabolic syndrome that do not improve with reductions in BMI or treatment of complications (i.e., dyslipidemia, hypertension, diabetes)
Metabolic Syndrome - prognosis
Improvement in the components of the metabolic syndrome depends on the ability to implement lifestyle changes and achieve modest weight loss.
Metabolic Syndrome - complications
- Short term:
- Increased risk of progression to Type 2 diabetes mellitus with weight gain
- Long term:
- Metabolic syndrome in adults increases risk of coronary heart disease
- 2–4 fold depending on population studied
- 3.5 fold increase in cardiovascular mortality
Metabolic Syndrome - patient monitoring
- Patients should be followed frequently, every 1–2 months, when they are implementing lifestyle changes.
- Therapy should be intensified (lifestyle and/or pharmacologic) if components of the metabolic syndrome are not clinically improving or worsening.
Metabolic Syndrome - bibliography
- De Ferranti SD, Gauvreau K, Ludwig DS, et al. Prevalence of the metabolic syndrome in American adolescents. Circulation. 2004;110:2494–2497.
- Knowler WC, Barret-Coonor E, Hamman RF, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or Metformin. N Engl J Med. 2002;246(6):393–403.
- Weiss R, Dziura J, Burquet TS, et al. Obesity and the metabolic syndrome in children and adolescents. N Engl J Med. 2004;350:2362–2374.
- National High Blood Pressure Working Group on High Blood Pressure in Children and Adoelscents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114:555–576.
- Gungor N, Hannon T, Libman I, et al. Type 2 diabetes in youth: The complete picture to date. Pedaitr Clin North Am. 2005;52(6):1579–1609.
Metabolic Syndrome - CODES
Metabolic Syndrome - icd9
- 272.4 Hyperlipidemia
- 277.7 Metabolic syndrome
- 278.0 Obesity
- 278.1 Morbid obesity
- 401.9 Hypertension
- 790.29 Impaired glucose tolerance
Metabolic Syndrome - FAQ
- Q: Why is it important to diagnose the metabolic syndrome in children?
- A: Making the diagnosis can help clinicians to educate patients and families that the metabolic syndrome is the antecedent to type 2 diabetes mellitus, and increases risk of premature cardiovascular disease.
- Q: What is the first-line therapy for the metabolic syndrome?
- A: Weight loss, as modest as 5% reductions in body mass index, can improve the components of the metabolic syndrome.
- Q: How early can the metabolic syndrome be diagnosed?
- A: Prepubertal children can be diagnosed with the metabolic syndrome.
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Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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