ANALELE UNIVERSITII DUNREA DE JOS GALAI MEDICIN FASCICULA XVII, nr.

1, 2012

ORIGINAL STUDY OBESITY AND CARDIOMETABOLIC RISKS IN CHILDREN AND ADOLESCENTS

Bianca Ioana Chesaru, Michaela Dobre, Dana Tutunaru, Aurel Nechita
Faculty of Medicine and Pharmacy, "Dunarea de Jos" University of Galati dr_chesaru@yahoo.com

ABSTRACT
Pediatric obesity is a worldwide public health problem. Obesity is still the core aspect of insulin resistance and seems to be the physiopathological link, common to metabolic syndrome (MS), cardiovascular disease and diabetes. The metabolic syndrome has been recently described in children. However, a standard criterion has not been established for its diagnosis. The selection of obese children and adolescents or those with cardiometabolic risk factors at an early stage of life entails a signification that ca nt be neglected. Increased BMI, altered glucose homeostasis, and high blood pressure in childhood are associated with a high risk of developing obesity, diabetes, hypertension, and coronary artery disease in adulthood. KEYWORDS: obesity, metabolic syndrome, high blood pressure, dyslipidemia, disglycemia, children

1. Introduction
Nowadays, obesity is among the most serious global health problems. In the last years, its incidence raised among children and adolescents, meeting the increasing frequency and side effects of it. In 2007, the WHO estimated that 22 million children under 5 years of age were overweight around the world, more than 75% of them living in low- or middle-income countries [1]. Based on criteria set by the Center of Diseases Control (CDC) and using data from 21 European countries, International Obesity Task Force (IOTF) highlighted obesity as a percentage between 10-36 % in children around the age of 10 years [2]. In 2006, EU Members States, over 20,000 children had, in addition to obesity, diabetes mellitus type 2, more

than 400,000 impaired oral glucose tolerance and over a million of them, three or more components of MS [3]. The metabolic syndrome, also called insulin resistance syndrome, is a complex of interrelated risk factors for cardiovascular disease and diabetes. These factors include dysglycemia, raised blood pressure, dyslipidemia and obesity (particularly central

adiposity) [4]. In pediatrics, the concept of MS, although recently admitted, is a reality. Although there is still no standardized and universally accepted definition in pediatric age, because of the

cardiometabolic risk factors at an early age, with consequences in adult life, such a research has

increased in children [5]. Readiness to identify each component of MS in childhood would allow preventing permanent damage and chronic diseases

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later in life [6]. The underlying pathophysiology of the metabolic syndrome is not adequately understood. In the background of genetic predisposition, insulin resistance considered and to secondary be the hyperinsulinemia central factors is in

Subjects were evaluated for anthropometry, blood pressure and biochemical cardiovascular risk factors. The following data were collected: degree, gender, age, weight, height, body mass index (BMI) and blood pressure. Additionally, a fasting blood sample was obtained for lipids and glucose

pathophysiology of the metabolic syndrome and dysglycemia. The development of insulin resistance is one of the important consequences of obesity. In MS, dyslipidemia has been characterized by hypertriglyceridemia, low levels of HDL-cholesterol (HDL-C) and an increased presence of small, dense low-density lipoprotein-cholesterol (LDL-C) [7]. Increased blood pressure in childhood is the most powerful predictor of hypertension in adulthood but its significance in children, in the context of the metabolic syndrome, is yet unknown. It seems that hyperinsulinemia secondary to insulin resistance leads to increased renal retention of sodium and increased sympathetic activity, which causes

quantification. Percentiles were calculated according to American standards for weight, height and BMI [10]. Patients were classified as obese (BMI greater than 95th BMI percentile) according to the US Centers for Disease Control and Prevention (CDC) criteria [11]. Subjects blood pressure were evaluated taking into consideration the sex, height and agespecific charts [12]. MS was defined using the criteria proposed (IDF) by in International 2005, Diabetes and

Federation

modified

supplemented in 2007 and 2009, adapted to study the child taking into account the percentiles for age and sex [4]. Metabolic syndrome was defined by the presence of at least three of the following criteria: fasting triglyceride over 150 mg/dL; HDL-C up to 50 mg/dL for girls and 40 mg/dL for boys, fasting glucose over 100 mg/dL, waist circumference greater than 90th percentile for age and gender and blood pressure above 95th percentile.

elevation of blood pressure [8]. Other associated factors, such as hypertension, dyslipidemia and subclinical inflammation, are more likely to be the consequences of insulin resistance rather than play any substantive role in the pathophysiology of the metabolic syndrome in children [9].

2. Materials and Methods 3. Results

The aim of the present prospective study was to explore how obesity is related to the presence of high blood pressure, raised concentration of The study lot comprised 74 boys and 65 girls, sex ratio 1.13 (male/female), aged between 6 and 18 years (12.52 3.76). Of these, 102 were from urban and 37 from rural area. (figure 1). Obesity was present in a proportion of 48% in age group 6-12 years and 52% in the age group 13-18 years. Of the 139 obese patients, 122 had waist circumference greater than 90th percentile. Table I shows the characteristics of the study participants. Average systolic blood pressures (SBP) were between 120 and 140 mmHg in 50 investigated patients and surpassed

triglycerides and serum glucose and the frequency of metabolic risk factors in a group of obese children and adolescents. The study group consisted of 139 obese children and adolescents under care at Sf. Ioan Clinical Emergency Childrens Hospital of Galati between 2009 and 2011. Written informed consent was obtained from parents or guardians of all consecutive obese children who were offered the study.

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140 mmHg in 31 patients. Average diastolic blood pressures (DBP) were below 80 mmHg in 85 patients and above this value in the remaining 54. In the study group, 57 patients were diagnosed with high blood pressure (HT) (27 girls and 30 boys) and 21 patients, with arterial prehypertension (preHT) (9 girls and 12 boys). The remaining 61 patients were normotensive (Figure 2).

had elevated triglyceride levels: 17 with moderately high (150-200 mg/dL) and 9 with very high triglyceride levels (above 200 mg/dL). Lipid balances revealed 28 boys with HDL-C lower than 40 mg/dL, 44 girls with HDL-C lower than 50 mg/dL and 13 patients with a LDL-C level above 130 mg/dL. In terms of glycemic profile, 29 patients had impaired fasting glucose (greater than 126 mg/dL), the rest falling to normal. The presence of MS was detected

urban rural 0 25 50 75 100 125

Girls Boys

in 56 patients. The frequency of cardiometabolic risk factors in obese children is presented in Table II and Figure 3. Table II. Associated risk factors for MS in study lot
Risk factors no risk factor 1 risk factor 2 risk factors 3 risk factors 4 risk factors 5 risk factors Total Subjects 5 36 42 39 16 1 139 % 3% 26% 30% 28% 12% 2% 100% Cummulative % 59%

Figure 1. Lot distribution by subjects sex and residence Table 1. Descriptive statistic for investigated parameters
Variable Age (years) Height (m) Weight (kg) BMI SBP (mmHg) DBP (mmHg) Chol (mg/dL) LDL-C (mg/dL) HDL-C (mg/dL) VLDL-C (mg/dL) TGL (mg/dL) Gly jeun (mg/dL) Mean 12,52 1,55 69,20 27,67 124,38 76,12 165,92 97,20 46,84 22,03 110,30 89,58 Min 6 1 25 18,9 90 55 104 44 27 7 37 56 Max 18 1,83 111 36,9 166 103 265 194 93 65 324 142 SD. 3,76 0,17 22,46 4,20 15,82 8,45 29,22 26,36 12,43 10,83 53,24 16,24

41% 100%

Figure 3. Cardiometabolic risks between patients

4. Discussion
44% 15% 41% HT preHT
normal BP

Childhood obesity is frequently associated with cardiovascular and metabolic disturbances [13]. We found a high prevalence of MS in obese children (41%) which is similar to data from other European

Figure 2. Blood pressure status between patients Analyzing patients serum lipid profile, it can be concluded that 14 subjects had elevated total cholesterol levels (above 200 mg/dL) and 26 subjects

countries [14,15]. However, when considering the diverse definitions applied, large differences are noticed [14,15,16]. In terms of frequency of MS according to sex, there were no important differences

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between boys (49%) and girls (51%). We found 134 (96%) cases in obese group had one, two or more cardiometabolic risk factors. From the evaluated children, 88% presented abdominal obesity. The second most frequent cardiometabolic risk factor was the decreased HDL-C (56% of subjects), followed by arterial hypertension (41% of subjects). Only 19% of the investigated patients presented elevated

adulthood since lifestyle modifications and weight loss may lead to favorable changes in risk factors.

References
1. WHO. Childhood overweight and obesity. [online]; Accessed on 01.04.2012; URL: http://www.who.int/ dietphysicalactivity/childhood/en/. 2. Lobstein T, Frelut M.L.. Prevalence of overweith among children in Europe. Obes Rev 2003;(4):195-200. 3. Lobstein T, Jackson-Leach R. Estimated burden of paediatric obesity and co-morbidities in Europe. Part 2. Numbers of children with indicators of obesity-related disease. Int J Pediatr Obes 2006; 1(1):33-41. 4. Alberti K.G.M.M., Eckel R.H., Grundy S.M., Zimmet, P.Z., Cleeman J.I., Donato K.A., Fruchart J.-C., James W.P.T., Loria C.M., Smith S.C. Harmonizing the metabolic syndrome: A Joint Interim Statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation 2009;(120):1640-1645. 5. Duncan G.E., Li S.M., Zhou X.H. Prevalence and trends of a metabolic syndrome phenotype among U.S. Adolescents, 1999 2000. Diabetes Care 2004;27:243843. 6. Jessup A, Harrell J.S. The metabolic syndrome: look for it in children and adolescents, too! Clin Diabetes. 2005;23:26-32. 7. Misra A., Khurana, L., Vikram, N.K., Goel, A., Wasir, J.S. Metabolic syndrome in children: current issues and South Asian perspective Nutrition 2007;23:895910. 8. Antic V., Dulloo A., Montani J.P. Multiple mechanisms involved in obesity-induced hypertension. Heart Lung Circ 2003;12:84 93. 9. Caprio S. Definitions and pathophysiology of the metabolic syndrome in obese children and adolescents. Int J Obes 2005; 29(suppl 2):S24 5. 10. ***CDC Growth Charts: United States. [online] Accessed on 01.05.2012. URL: http://www.cdc.gov/ growthcharts/ zscore.htm. 11. Kuczmarski R.J., Ogden C.L., Grummer-Strawn L.M., Flegal K.M., Guo S.S., Wei R, Mei Z, Curtin L.R., Roche A.F., Johnson C.L.: CDC growth charts: United States. Adv Data 2000, 314:1-28. 12. ***National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents: The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 2004, 114:555-576. 13. Saland J.M. Update on the metabolic syndrome in children. Curr Opin Pediatr 2007, 19:183-191. 14. Reinehr T., de Sousa G., Toschke A.M., Andler W. Comparison of metabolic syndrome prevalence using eight different definitions: a critical approach. Arch Dis Child 2007;92:1067-1072. 15. Bokor S, Frelut M.L, Vania A, Hadjiathanasiou C.G., Anastasakou M., Malecka-Tendera E., Matusik P., Molnar D. Prevalence of metabolic syndrome in European obese children. Int J Pediatr Obes 2008, 3:3-8. 16. Nechita A., Dobre M., Matei M, Investigation of high blood pressure as a predisposition for metabolic syndrome in children, Analele Universitii Dunrea de jos Galai, Medicina, Fascicula XVII, nr.2, 2010;131-135. 17. Reinehr T, Andler W, Denzer C, Siegried W, Mayer H, Wabitsch M. Cardiovascular risk factors in overweight German children and adolescents: relation to gender, age and degree of overweight. Nutr Metab Cardiovasc Dis 2005;15:181e187. 18. Yoshinaga M, Tanaka S, Shimago A, Sameshima K, Nishi J, Nomura Y, Kawano Y., Hashiguchi J., Ichiki T., Shimizu S. Metabolic syndrome in overweight and obese Japanese children. Obes Res 2005;13:1135e1140. 19. Cruz M.L., Goran M.I.: The metabolic syndrome in children andadolescents. Curr Diab Rep 2004, 4:53-62.

triglyceridemia. In a German survey of overweight children 4to 18 years of age, 37% had high blood pressure and 20% had increased triglycerides [17]. In 6 to 8 year old Japanese schoolchildren, the frequencies of risk factors among the overweight and obese were abdominal obesity (91.5%) and high triglyceride levels (31.0%) [18]. Fasting glucose levels were high in 21% patients, which reflect the range of abnormalities of glucose homeostasis associated with childhood obesity. Indeed, excess weight in children and adolescents may serve to accelerate the onset of diabetes mellitus 2 in childhood [19].

5. Conclusions
Our study showed a significant prevalence of MS and its cardiometabolic complications in obese children and adolescents. Abdominal obesity was present in all children and the frequency of HBP was high. The importance of early identification of obese children, those with increased risk of developing MS, diabetes mellitus type 2 and cardiovascular diseases in adulthood, cannot be neglected. Thus, a consensual pediatric definition of MS is needed in order to better compare studies and populations and for proper screening, evaluation and treatment of children at risk or with MS. The prevention and treatment of obesity in childhood are urgently required in reducing the risk for cardiovascular disease and diabetes in

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