Get smart about metabolic syndrome!
Pediatricians must act to reverse metabolic syndrome in kids—by starting early and starting small.
As pediatricians we are all too aware of our nation’s struggle with childhood overweight and obesity. Approximately 1 of every 5 children that we see in the office every day is obese. Despite tremendous efforts to reverse this trend, it is clear we are in this battle for the long haul.
Although we need to continue to work hard and advocate loudly for early-childhood community-based prevention, we also must develop effective tools for screening and identifying those obese children who are at the highest risk of developing long-term health-related complications. These complications, if left unrecognized and untreated, will undoubtedly cause excess mortality in adulthood.
What is metabolic syndrome?
Metabolic syndrome is a major complication of childhood obesity. It is clearly present in a large proportion of our patients. Unfortunately, it continues to be underdiagnosed in pediatrics. When speaking with my colleagues about the condition, just saying the words “metabolic syndrome” often results in a long silent pause, followed by a series of questions about high-density lipoprotein (HDL), hypertension, how to document central obesity, and finally ends with a palpable sense of frustration. In order to move forward and improve our care of this high-risk population, we must first address where the challenges lie.
A major challenge is that there is still a lack of routine screening for the known complications of childhood obesity. Fortunately, with the help of electronic medical records we are doing a better job of recognizing children who are overweight and obese. The next step is to put systems in place that remind us to do routine screening of these children with accurately measured blood pressures, waist circumference measurements, and fasting blood work. Chronic care models like those used in other diseases such as asthma need to be more available for obesity and utilized.
Another challenge is the confusion around the very definition of metabolic syndrome. In the adult literature, different organizations have published different criteria for the diagnosis. The World Health Organization, International Diabetes Federation, National Cholesterol Education Program, and the American Association of Clinical Endocrinologists all use different definitions. Given that this used to be an exclusively adult disease, our pediatric definitions tend to be derived from these various guidelines.
A cluster of risk factors
This lack of a unifying definition is frustrating, to say the least. However, I would argue how you define metabolic syndrome is less important than the simple understanding that the greater number of cardiovascular risk factors that an obese child has, the more at risk they are for the development of early cardiovascular disease and type 2 diabetes. Any combination or clustering of these risk factors, including elevated blood pressure, elevating fasting glucose, low HDL, high triglycerides, and elevated waist circumference should increase our level of concern and prompt additional discussions with the patient and family about [the child’s] risk.
Finally, perhaps the greatest challenge is the pediatricians’ lack of self-efficacy to deliver obesity treatment. The “cure” for metabolic syndrome is to improve the child’s weight status, and pediatricians continue to face real barriers when it comes to this. These barriers include lack of training in motivational interviewing, lack of face-to-face time with their patients, lack of resources such as nutrition support, lack of appropriate payment from insurers, and family denial.
Start with small changes
[Because] it can be impossible to tackle all these barriers, pediatricians may often feel that any effort is futile. However, we have found that by focusing on slow but steady behavioral change, we can make a positive impact on a child’s body mass index and decrease [his/her] risk for chronic disease. I believe that even the smallest decline in a child’s weight velocity has the potential to prevent metabolic syndrome.
Fortunately, there are now multiple tools and resources that pediatricians can access and use with their obese patients. In 2007, Barlow et al published the Expert Committee Recommendations regarding prevention, assessment, and treatment of child and adolescent overweight and obesity.4 In 2015, the American Academy of Pediatrics Institute for Healthy Childhood Weight took these guidelines and enhanced them into a user-friendly algorithm. You can locate the algorithm at https://ihcw.aap.org. In addition, the site links to a very informative app titled Change Talk, meant to improve motivational interviewing skills.
The long-term health implications of childhood obesity and metabolic syndrome are real. As pediatricians we must persevere in our efforts to obtain the knowledge and skills needed to appropriately prevent, identify, and address metabolic syndrome. If we do, then, as with so many other seemingly insurmountable childhood diseases before, we will succeed for our patients.
1. Della Corte C, Alisi A, Nobili V. Metabolic syndrome in paediatric population: is it time to think back on diagnosis criteria? EMJ Hepatol. 2015;3(1):48-54.
2. Lee L, Sanders RA. Metabolic syndrome. Pediatr Rev. 2012;33(10):459-468.
3. Wittcop C, Conroy R. Metabolic syndrome in children and adolescents. Pediatri Rev. 2016;37(5):193-202.
4. Barlow SE; Expert Committee. Expert Committee Recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(suppl 4):S164-S192.