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Kumar K, Lodha R, Jat KR, Jain V, Kabra SK. Prevalence of Metabolic Abnormalities and their Association with Asthma Symptom Control in Children. Indian J Pediatr 2024; 91:434-440. [PMID: 37470958 DOI: 10.1007/s12098-023-04716-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/01/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVES To determine the prevalence of insulin resistance (IR), dyslipidemia and metabolic syndrome (MS) in children with asthma, aged 10 to 15 y, and to determine if these metabolic abnormalities showed an association with asthma symptom control and lung function. METHODS A cross-sectional study was conducted at a tertiary centre in north India. Consecutive children with physician diagnosed asthma were enrolled. Asthma symptom control over previous four weeks was assessed as per Global Initiative for Asthma (GINA) recommendations. Fasting plasma glucose, serum insulin and lipid levels were estimated. Homeostasis Model Assessment- Insulin Resistance (HOMA-IR) was used as a marker of IR. Spirometry was performed for assessing lung function. RESULTS Eighty-three children were enrolled. Median (IQR) age was 12.0 (11.0, 13.5) y and mean (SD) body mass index (BMI) Z score was -0.42 (1.0). Median (IQR) HOMA-IR was 1.65 (1.06, 2.39). Prevalence of IR was 42.3% (95% CI: 31.7-52.9%). Number of children with elevated triglycerides, total cholesterol, and low-density lipoprotein (LDL)-cholesterol was 4 (4.8%), 4 (4.8%) and 5 (6%), respectively. Sixty-seven (80.7%) children had low high-density lipoprotein (HDL)-cholesterol. Only one subject was found to have metabolic syndrome. Presence of IR and elevation in serum insulin and triglycerides were associated with poorer asthma control, independent of BMI. None of the metabolic parameters were associated with lung function, after adjusting for height. CONCLUSIONS Among children with asthma, aged 10 to 15 y, the prevalence of IR was 42.3% (95% CI: 31.7-52.9%). Elevated serum insulin, triglycerides, and presence of IR were associated with poorer asthma control, after adjusting for BMI.
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Affiliation(s)
- Ketan Kumar
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.
| | - Kana Ram Jat
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Vandana Jain
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sushil K Kabra
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Das G, Setlur K, Jana M, Ramakrishnan L, Jain V, Meena JP, Gupta AK, Dwivedi SN, Seth R. Serum Adipokines as Biomarkers for Surveillance of Metabolic Syndrome in Childhood Acute Lymphoblastic Leukemia Survivors in Low Middle-Income Countries. Nutr Cancer 2024; 76:262-270. [PMID: 38225859 DOI: 10.1080/01635581.2023.2301139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/26/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND Serum adipokines (leptin and adiponectin) are dysregulated before the onset of metabolic syndrome and hence may be useful biomarkers for screening of cardiometabolic late effects in childhood Acute Lymphoblastic Leukemia (cALL) survivors. METHODS We compared serum adipokine levels between 40 cALL survivors (aged 10-18 years, >2 years from treatment completion) with similar controls. A multivariable logistic regression analysis was then done to assess the association of metabolic syndrome in cALL survivors with variables including adipokines and other metabolic parameters, demographic and treatment details, and Dual-energy X-ray absorptiometry scan-derived variables. RESULTS Compared to controls, cALL survivors had a higher prevalence of metabolic syndrome (8/40 vs. 2/40, P = .044) and central obesity (11/40 vs. 4/40, P = 0.042). Median Serum Leptin (7.39 vs. 4.23 ng/ml, P = 0.207) levels and derived Leptin-Adiponectin Ratio (1.44 vs. 0.80, P = 0.598), were higher but not statistically different in our survivors compared to controls; Adiponectin levels were similar (6.07 vs. 5.01 µg/ml, P = 0.283). In the cALL survivors, overweight/obesity (odds ratio [OR] 21.9, P = 0.020) or higher Leptin levels (OR 1.11, P = 0.047), were independently associated with metabolic syndrome. CONCLUSIONS Serum Leptin, independently predictive of metabolic syndrome in our cALL survivors, may be tested in larger studies to assess its utility in surveillance and initiation of early preventive measures.
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Affiliation(s)
- Gargi Das
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences-New Delhi, India
| | - Kritika Setlur
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences-New Delhi, India
| | - Manisha Jana
- Department of Radiodiagnosis, All India Institute of Medical Sciences-New Delhi, India
| | - Lakshmy Ramakrishnan
- Department of Cardiac Biochemistry, All India Institute of Medical Sciences-New Delhi, India
| | - Vandana Jain
- Division of Pediatric Endocrinology, Department of Pediatrics, All India Institute of Medical Sciences-New Delhi, India
| | - Jagdish Prasad Meena
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences-New Delhi, India
| | - Aditya Kumar Gupta
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences-New Delhi, India
| | - Sada Nand Dwivedi
- Department of Biostatistics, All India Institute of Medical Sciences-New Delhi, India
| | - Rachna Seth
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences-New Delhi, India
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Amer OE, Sabico S, Khattak MNK, Alnaami AM, Aljohani NJ, Alfawaz H, AlHameidi A, Al-Daghri NM. Increasing Prevalence of Pediatric Metabolic Syndrome and Its Components among Arab Youth: A Time-Series Study from 2010-2019. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8121129. [PMID: 34943325 PMCID: PMC8700288 DOI: 10.3390/children8121129] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 11/28/2021] [Accepted: 11/30/2021] [Indexed: 01/19/2023]
Abstract
Background: Metabolic syndrome (MetS) is a cluster of cardiometabolic disorders, mostly studied in adults with certain ethnic groups, such as Arabs with higher predisposition and heritability. In this time-series study, we tried to determine the prevalence of MetS in the Arabic pediatric population from 2010–2019 to gauge the need to intervene in the younger population. Methods: A total of 7985 Saudi school children aged 12–18 coming from different sets of cohorts in different timepoints were included in this time-series studies (Year 2010, n = 2081, 877 boys and 1204 girls; Year 2015, n = 3360, 1625 boys and 1735 girls, Year 2019, n = 2544, 956 boys and 1588 girls). Anthropometrics were measured as well as fasting blood samples for the assessment of lipids and glucose. Screening for MetS was conducted using the pediatric definition obtained from the 2004 definition of de Ferranti et al. Results: In 2010, the prevalence of MetS was 11.8%, which increased sharply to 20.1% in 2015 and again in 2019 to 20.6%. Stratified according to sex, the increased prevalence of MetS was more evident in boys with only 7.8% in 2010 jumping to 25.3% in 2019. In girls, the increase in prevalence was modest with 14.8% in 2010 to 17.7% in 2019. In both boys and girls, the highest increase in prevalence among MetS components was observed to be low HDL-cholesterol, elevated triglycerides, and central obesity, respectively. Conclusions: The alarming increase in pediatric MetS among Arab children and adolescents over a short timespan have significant clinical and economic implications if not addressed immediately. Health policy makers should implement lifestyle interventions aimed at high-risk children or overweight youths.
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Affiliation(s)
- Osama E. Amer
- Biochemistry Department, King Saud University College of Science, Riyadh 11451, Saudi Arabia; (O.E.A.); (S.S.); (M.N.K.K.); (A.M.A.)
| | - Shaun Sabico
- Biochemistry Department, King Saud University College of Science, Riyadh 11451, Saudi Arabia; (O.E.A.); (S.S.); (M.N.K.K.); (A.M.A.)
| | - Malak N. K. Khattak
- Biochemistry Department, King Saud University College of Science, Riyadh 11451, Saudi Arabia; (O.E.A.); (S.S.); (M.N.K.K.); (A.M.A.)
| | - Abdullah M. Alnaami
- Biochemistry Department, King Saud University College of Science, Riyadh 11451, Saudi Arabia; (O.E.A.); (S.S.); (M.N.K.K.); (A.M.A.)
| | - Naji J. Aljohani
- Obesity, Endocrine and Metabolic Center, King Fahad Medical City, Riyadh 11525, Saudi Arabia;
| | - Hanan Alfawaz
- Department of Food Science and Nutrition, College of Food Science and Agriculture, King Saud University, Riyadh 11495, Saudi Arabia;
| | | | - Nasser M. Al-Daghri
- Biochemistry Department, King Saud University College of Science, Riyadh 11451, Saudi Arabia; (O.E.A.); (S.S.); (M.N.K.K.); (A.M.A.)
- Correspondence: ; Tel.: +96-61-1467-5939; Fax: +96-61-1467-5931
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Yudhani RD, Nugrahaningsih DAA, Sholikhah EN, Mustofa M. The Molecular Mechanisms of Hypoglycemic Properties and Safety Profiles of Swietenia Macrophylla Seeds Extract: A Review. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.6972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2022] Open
Abstract
BACKGROUND: Insulin resistance (IR) is known as the root cause of type 2 diabetes; hence, it is a substantial therapeutic target. Nowadays, studies have shifted the focus to natural ingredients that have been utilized as a traditional diabetes treatment, including Swietenia macrophylla. Accumulating evidence supports the hypoglycemic activities of S. macrophylla seeds extract, although its molecular mechanisms have yet to be well-established.
AIM: This review focuses on the hypoglycemic molecular mechanisms of S. macrophylla seeds extract and its safety profiles.
METHODS: An extensive search of the latest literature was conducted from four main databases (PubMed, Scopus, Science Direct, and Google Scholar) using several keywords: “swietenia macrophylla, seeds, and diabetes;” “swietenia macrophylla, seeds, and oxidative stress;” “swietenia macrophylla, seeds, and inflammation;” “swietenia macrophylla, seeds, and GLUT4;” and “swietenia macrophylla, seeds, and toxicities.”
RESULTS: The hypoglycemic activities occur through modulating several pathways associated with IR and T2D pathogenesis. The seeds extract of S. macrophylla modulates oxidative stress by decreasing malondialdehyde (MDA), oxidized low-density lipoprotein, and thiobarbituric acid-reactive substances while increasing antioxidant enzymes (superoxide dismutase, glutathione peroxidase, and catalase). Another propose mechanism is the modulating of the inflammatory pathway by attenuating nuclear factor kappa β, tumor necrosis factor α, inducible nitric oxide synthase, and cyclooxygenase 2. Some studies have shown that the extract can also control phosphatidylinositol-3-kinase/ Akt (PI3K/Akt) pathway by inducing glucose transporter 4, while suppressing phosphoenolpyruvate carboxykinase. Moreover, in vitro cytotoxicity and in vivo toxicity studies supported the safety profile of S. macrophylla seeds extract with the LD50 higher than 2000 mg/kg.
CONCLUSION: The potential of S. macrophylla seeds as antidiabetic candidate is supported by many studies that have documented their non-toxic and hypoglycemic effects, which involve several molecular pathways.
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Nirmal G, Thankamony P, Chellapam Sojamani G, Nair M, Rajeswari B, Varikkattu Rajendran P, Krishna K M J. Prevalence and Risk Factors for Metabolic Syndrome Among Childhood Acute Lymphoblastic Leukemia Survivors: Experience From South India. J Pediatr Hematol Oncol 2021; 43:e154-e158. [PMID: 32516199 DOI: 10.1097/mph.0000000000001856] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/12/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Improved survival of childhood acute lymphoblastic leukemia (ALL) has diverted attention to the long-term consequences of the treatment; metabolic abnormalities being one of the most important issues. METHODS Children diagnosed with ALL at age 14 years and younger at Regional Cancer Centre in South India who completed treatment and who were on follow-up for >2 years were enrolled in the study between April 1, 2018 and March 31, 2019. They were prospectively evaluated for the presence of metabolic syndrome (MS) and associated risk factors. RESULTS AND DISCUSSION A total of 277 survivors of pediatric ALL were recruited during the study period. MS was present in 8.3% (n=23) and 6% (n=13) survivors by National Cholesterol Education Programme Adult Treatment Panel III (NCEPATP III) and International Diabetes Federation (IDF) criteria, respectively. The prevalence of overweight and obesity in the survivors was 9% and 13%. The prevalence of increased waist circumference, low high-density lipoprotein cholesterol, elevated triglycerides, elevated fasting glucose, and increased blood pressure were 10.5%, 28.9%, 24.9%, 2.5%, and 9%, respectively. Overweight/obese survivors were at an increased risk for developing MS (odds ratio=17.66; 95% confidence interval=6.2-50.16, P=0.001). Survivors who received cranial radiotherapy were at an elevated risk for having low high-density lipoprotein cholesterol (P=0.001). CONCLUSIONS In our study, the prevalence of MS was higher in childhood ALL survivors, as compared with the general population. The study points to the need for regular screening of pediatric ALL survivors for early detection of MS, along with lifestyle modification in those with metabolic abnormalities, to curb the growing incidence of coronary artery disease.
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Affiliation(s)
| | | | | | | | | | | | - Jagathnath Krishna K M
- Cancer Epidemiology and Biostatistics, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
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Metabolic Syndrome: Prevalence and Risk Factors among Adolescent Female Intermediate and Secondary Students in Saudi Arabia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18042142. [PMID: 33671739 PMCID: PMC7926656 DOI: 10.3390/ijerph18042142] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/10/2021] [Accepted: 02/14/2021] [Indexed: 12/19/2022]
Abstract
Background: Metabolic syndrome (MS) has become one of the major challenges to public health worldwide due to its significant association with increased risk of developing type 2 diabetes and cardiovascular disease (CVD) among children and adolescents. Therefore, this study aims to determine the prevalence and risk factors of MS in Saudi adolescents. Methods: This cross-sectional study was conducted in two female National Guard schools (Um Kalthoom Intermediate School and Zainab Bint Jahsh Secondary School) in Jeddah, Saudi Arabia, between January 2018 and March 2018. Of the 808 female students, 172 (age range of 12–19 years) participated voluntarily, with consent from their guardian(s), fasted for at least 8 h prior to the study, and represent the final study sample. Male students were not included due to cultural constraints in conducting the study. Demographic data, physical measurement (blood pressure, weight, height, body mass index (BMI) and waist circumference (WC)), and biochemical measurement (fasting plasma glucose and triglycerides, high-density lipoprotein (HDL), and low-density lipoprotein) were obtained. The International Diabetes Federation (IDF) criteria was utilized in the diagnosis of MS. Results: Of the 172 female adolescents, 24 (13.75%) are overweight, 20 (11.63%) are obese, and 3 (1.74%) are underweight. High-fasting plasma glucose (n = 85, 49.41%) and high waist circumference (n = 74, 43.02%) were the most common risk factors of MS among female adolescents. The overall prevalence of MS was 7% (n = 12/172). MS is more common among those who are obese or among those with a BMI that falls at the ≥95th percentile (n = 6/20, 30.0%) (p < 0.05) as compared to those who are overweight with a BMI that falls within the 85th to <95th percentiles (n = 2/24, 8.33%). Interestingly, 3.20% of the sample (n = 4/125) with normal BMI were diagnosed with MS. Conclusions: Our study indicates that MS is common among obese and overweight female adolescents but is also present among those who are not obese or with normal BMI. Moreover, the prevalence of overweight, obese, and those with MS in this reference population are lower compared to the cities of Makkah and Riyadh; however, it varies widely around the world due to different criteria and cut-off values in the diagnosis of MS.
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Zhang L, Zhang Z, Wang B, Yuan Y, Sun L, Gao H, Fu L. Relative Children's Lipid Accumulation Product Is a Novel Indicator for Metabolic Syndrome. Front Endocrinol (Lausanne) 2021; 12:645825. [PMID: 34093432 PMCID: PMC8173219 DOI: 10.3389/fendo.2021.645825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 02/22/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The children's lipid accumulation product (CLAP) is associated with MS in Chinese children and adolescents. The aim of this study was to develop a more effective indicator, the relative children's lipid accumulation product (RCLAP) was evaluated for correlation with MS and the density of lipid accumulation. METHODS A stratified cluster sampling method was used to recruit 683 students aged 8-15 years in this study. The presence of MS was defined according to the NCEP-ATP III criteria. The participants' guardians signed informed consent before the medical examination. This study was approved by the Medical Ethics Committee of the Bengbu Medical College [(2015) No.003] and was conducted in accordance with the Declaration of Helsinki. RESULTS The overall prevalence of MS was 4.8% (male 6.6%, female 2.8%). After adjusting for sedentary activity time, relative children's lipid accumulation product per height (RCLAP-H) and relative children's lipid accumulation product per sitting height (RCLAP-SH) significantly increased the risk of MS in girls [OR (95% CI): 96.13 (11.11-831.97) and 96.13 (11.11-831.97), respectively]. After adjusting for ages and moderate-to-vigorous physical activity time, RCLAP-H, and RCLAP-SH significantly increased the risk of MS in boys [OR (95% CI): 171.75 (33.60-878.00) and 133.18 (27.65-641.39), respectively]. The AUCs of RCLAP-H and RCLAP-SH for predicting MS were 0.950, 0.948 in girls, and 0.952, 0.952 in boys, which were higher than BMI, WHtR, Tg/HDL-C, CLAP, and CLAP combining height, sitting height. CONCLUSIONS The RCLAP-H and RCLAP-SH were more effective indicators for predicting MS than BMI, WHtR, Tg/HDL-C, and CLAP in children and adolescents.
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Affiliation(s)
| | | | | | | | | | | | - Lianguo Fu
- *Correspondence: Lianguo Fu, ; Huaiquan Gao,
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Bitew ZW, Alemu A, Ayele EG, Tenaw Z, Alebel A, Worku T. Metabolic syndrome among children and adolescents in low and middle income countries: a systematic review and meta-analysis. Diabetol Metab Syndr 2020; 12:93. [PMID: 33117455 PMCID: PMC7590497 DOI: 10.1186/s13098-020-00601-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/19/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Metabolic syndrome (MetS) is a clustering of cardiovascular risk factors, which is rising in the low and middle income countries (LMICs). There are various studies with inconsistent findings that are inconclusive for policy makers and program planners. Thus, this systematic review and meta-analysis aimed at estimating the pooled prevalence of MetS and its components in LMICs. METHODS Electronic searches were conducted in international databases including PubMed, Web of Science, EMBASE (Elsevier), Scopus, CINAHL (EBSCOhost), Science direct (Elsevier), Food Science and Technology Abstracts (FSTA), Global Health and Medline, and other sources (World Cat, Google Scholar, and Google). The pooled estimates were computed in the random effect model. The pooled prevalence was computed using the three diagnostic methods (IDF, ATP III and de Ferranti). Publication bias was verified using funnel plot and Egger's regression test. Subgroup and sensitivity analysis were performed to identify the possible sources of heterogeneity among the included studies. RESULT In this study, 142,142 children and adolescents from 76 eligible articles were included to compute the pooled prevalence of MetS and its components in LMCIs. MeTs among overweight and obese population was computed from 20 articles with the pooled prevalence of 24.09%, 36.5%, and 56.32% in IDF, ATP III and de Ferranti criteria, respectively. Similarly, a total of 56 articles were eligible to compute the pooled prevalence of MetS in the general population of children and adolescents. Hence, Mets was found in 3.98% (IDF), 6.71% (ATP III) and 8.91% (de Ferranti) of study subjects. Regarding the components of MetS, abdominal obesity was the major component in overweight and obese population and low HDL-C was the most common component in the general population. This study also revealed that males were highly affected by MetS than females. CONCLUSION This study illustrates that MetS among children and adolescents is an emerging public health challenge in LMICs, where the prevalence of obesity is on the move. Preventive strategies such as community and school based intervention need to be designed. Promoting physical activities and healthy eating behaviors could avert this problem.
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Affiliation(s)
| | | | | | - Zelalem Tenaw
- College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Anmut Alebel
- College of Health Science, Debremarkose University, Debre Markos, Ethiopia
- Australian Centre for Public and Population Health Research, School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, NSW Australia
| | - Teshager Worku
- College of Health and Medical Sciences, School of Nursing and Midwifery, Haramaya University, Harar, Ethiopia
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Sharma R. Continuous Metabolic Syndrome Score in Children: How Useful is it? Indian J Pediatr 2019; 86:881-882. [PMID: 31378001 DOI: 10.1007/s12098-019-03047-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 07/23/2019] [Indexed: 01/03/2023]
Affiliation(s)
- Rajni Sharma
- Division of Pediatric Endocrinology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Sawant SP, Amin AS. Use of Continuous Metabolic Syndrome Score in Overweight and Obese Children. Indian J Pediatr 2019; 86:909-914. [PMID: 31300954 DOI: 10.1007/s12098-019-02994-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 05/22/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To assess the utility of continuous metabolic syndrome score (cMetS) for predicting metabolic syndrome (MS) and determine the cut-off values in overweight and obese children. METHODS This study was conducted among 104 children (7-14 y) attending obesity clinics of a tertiary care hospital in Mumbai, India. The cMetS was computed by standardizing the residuals of waist circumference (WC), mean arterial blood pressure (MAP), high density lipoprotein cholesterol (HDL-C), triglycerides (TG), and Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) by regressing them according to age and sex and aggregating them. The optimal cut-off of cMetS for predicting MS was determined by the receiver operation characteristic (ROC) curve analysis. RESULTS The cMetS increased significantly with increase in the number of MS risk factors. It was significantly high in children with MS than those without it (boys: 1.070 + 1.834 vs. -1.478 + 2.262; girls: 2.092 + 1.963 vs. -2.253 + 2.140; combined children group: 1.572 + 1.950 vs. -1.907+ 2.374; p < 0.001). The score predicted MS with high accuracy in girls; (AUC of 0.95, 95% CI: 0.90-1.00), moderate accuracy in boys (AUC of 0.79, 95% CI: 0.65-0.92) and in the combined group (AUC of 0.87, 95% CI 0.80-0.94) respectively. The cut-off of cMetS yielding maximal sensitivity and specificity for predicting the MS was -1.009 in boys (sensitivity 93% and specificity 62%); -0.652 in girls (sensitivity 96.4% and specificity 77%) and - 0.6881 in the combined group (sensitivity 91.2% and specificity 70.2%). CONCLUSIONS cMetS predicted MS with moderate to high accuracy. It had high sensitivity and specificity in predicting MS in overweight and obese children.
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Affiliation(s)
- Sangeeta P Sawant
- Department of Pediatrics, Bhabha Atomic Research Centre Hospital, Anushakti Nagar, Mumbai, Maharashtra, 400094, India.
| | - Alpa S Amin
- Department of Pediatrics, Bhabha Atomic Research Centre Hospital, Anushakti Nagar, Mumbai, Maharashtra, 400094, India
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Sharma V, Coleman S, Nixon J, Sharples L, Hamilton-Shield J, Rutter H, Bryant M. A systematic review and meta-analysis estimating the population prevalence of comorbidities in children and adolescents aged 5 to 18 years. Obes Rev 2019; 20:1341-1349. [PMID: 31342672 PMCID: PMC6851579 DOI: 10.1111/obr.12904] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 04/30/2019] [Accepted: 04/30/2019] [Indexed: 12/11/2022]
Abstract
Evidence for the health impact of obesity has largely focussed on adults. We estimated the population prevalence and prevalence ratio of obesity-associated comorbidities in children and adolescents aged 5 to 18 years. Five databases were searched from inception to 14 January 2018. Population-based observational studies reporting comorbidity prevalence by weight category (healthy weight/overweight/obese) in children and adolescents aged 5 to 18 years from any country were eligible. Comorbidity prevalence, stratified by weight category, was extracted and prevalence ratios (relative to healthy weight) estimated using random effects meta-analyses. Of 9183 abstracts, 52 eligible studies (1 553 683 participants) reported prevalence of eight comorbidities or risk markers including diabetes and nonalcoholic fatty liver disease (NAFLD). Evidence for psychological comorbidities was lacking. Meta-analyses suggested prevalence ratio for prediabetes (fasting glucose ≥ 100 mg/dL) for those with obesity relative to those of a healthy weight was 1.4 (95% confidence interval [CI], 1.2-1.6) and for NAFLD 26.1 (9.4-72.3). In the general population, children and adolescents with overweight/obesity have a higher prevalence of comorbidities relative to those of a healthy weight. This review provides clinicians with information when assessing children and researchers a foundation upon which to build a comprehensive dataset to understand the health consequences of childhood obesity.
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Affiliation(s)
- Vishal Sharma
- Clinical Effectiveness Team, Leeds and York Partnership NHS Foundation Trust, Leeds, UK
| | - Susanne Coleman
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jane Nixon
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Linda Sharples
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Harry Rutter
- Department of Social and Policy Sciences, University of Bath, Bath, UK
| | - Maria Bryant
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Khadilkar AV, Lohiya N, Mistry S, Chiplonkar S, Khadilkar V, Kajale N, Ekbote V, Vispute S, Mandlik R, Prasad H, Singh N, Agarwal S, Palande S, Ladkat D. Random Blood Glucose Concentrations and their Association with Body Mass Index in Indian School Children. Indian J Endocrinol Metab 2019; 23:529-535. [PMID: 31803592 PMCID: PMC6873251 DOI: 10.4103/ijem.ijem_536_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE AND AIMS Overweight/obese children are at risk of developing type 2 diabetes mellitus. Random glucose elevations provide early warning signs of glycemic dysregulation. To assess random blood glucose (RBG) concentrations and risk factors associated with prediabetes in children aged 3-18 years from six Indian regions. METHOD Multicenter, cross sectional, observational school-based study; multi-stage stratified random sampling was carried out. Height and weight measured; body mass index (BMI) was computed. RBG measured using a glucometer. National sample survey was used for dietary patterns. Data were analyzed using SPSS 25.0 for Windows. SETTING Study centers were from Maharashtra, Gujarat, Chhattisgarh, Assam, Tamil Nadu and Punjab from 40 selected schools. PARTICIPANT Children aged 3-18 years were measured. RESULTS Data on 14339 subjects (7413 boys) were analyzed. Prevalence of obesity was 5.8% and overweight-10.6%. Overall, 1% had low (<3 mmol/L), 93.7% in reference range (3.9-7.2 mmol/L) and 5.3% had elevated RBG (>7.2 mmol/L). With increasing mean BMI, there was increase in RBG concentrations. Children from Tamil Nadu were more likely to have RBG outside reference range compared to other regions (P < 0.05). Assam and Punjab had highest prevalence of RBG and BMI within reference range. Energy intake partly explained regional variations. Multivariate analysis showed male gender, urban residency, age >10 yrs (girls) and 13 yrs (boys), and overweight or obesity were predictive of prediabetes. CONCLUSION Increased prevalence of overweight, obesity and prediabetes in Indian children are a matter of concern. Regional differences suggest that strategies to prevent obesity and combat perturbations in blood sugar may have to be customized.
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Affiliation(s)
- Anuradha V. Khadilkar
- Department of Paediatric and Endocrine, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospitals, Pune, Maharashtra, India
| | - Nikhil Lohiya
- Department of Paediatric and Endocrine, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospitals, Pune, Maharashtra, India
| | - Sejal Mistry
- Department of Paediatric and Endocrine, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospitals, Pune, Maharashtra, India
| | - Shashi Chiplonkar
- Department of Paediatric and Endocrine, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospitals, Pune, Maharashtra, India
| | - Vaman Khadilkar
- Department of Paediatric and Endocrine, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospitals, Pune, Maharashtra, India
| | - Neha Kajale
- Department of Paediatric and Endocrine, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospitals, Pune, Maharashtra, India
| | - Veena Ekbote
- Department of Paediatric and Endocrine, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospitals, Pune, Maharashtra, India
| | - Smruti Vispute
- Department of Paediatric and Endocrine, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospitals, Pune, Maharashtra, India
| | - Rubina Mandlik
- Department of Paediatric and Endocrine, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospitals, Pune, Maharashtra, India
| | - Hemchand Prasad
- Department of Paediatric Endocrinology, Dr Mehta's Hospital Pvt Ltd, Chennai, Tamil Nadu, India
| | - Narendra Singh
- Department of Anthropology, Assam University, Diphu, Assam, India
| | - Sanwar Agarwal
- Department of Paediatric Endocrinology, Ekta Institute of Child Health, Raipur, India
| | - Sonal Palande
- Department of Paediatric and Endocrine, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospitals, Pune, Maharashtra, India
| | - Dipali Ladkat
- Department of Paediatric and Endocrine, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospitals, Pune, Maharashtra, India
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Prasad G, Bandesh K, Giri AK, Kauser Y, Chanda P, Parekatt V, Mathur S, Madhu SV, Venkatesh P, Bhansali A, Marwaha RK, Basu A, Tandon N, Bharadwaj D. Genome-Wide Association Study of Metabolic Syndrome Reveals Primary Genetic Variants at CETP Locus in Indians. Biomolecules 2019; 9:E321. [PMID: 31366177 PMCID: PMC6723498 DOI: 10.3390/biom9080321] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 07/26/2019] [Accepted: 07/30/2019] [Indexed: 12/11/2022] Open
Abstract
Indians, a rapidly growing population, constitute vast genetic heterogeneity to that of Western population; however they have become a sedentary population in past decades due to rapid urbanization ensuing in the amplified prevalence of metabolic syndrome (MetS). We performed a genome-wide association study (GWAS) of MetS in 10,093 Indian individuals (6,617 MetS and 3,476 controls) of Indo-European origin, that belong to our previous biorepository of The Indian Diabetes Consortium (INDICO). The study was conducted in two stages-discovery phase (N = 2,158) and replication phase (N = 7,935). We discovered two variants within/near the CETP gene-rs1800775 and rs3816117-associated with MetS at genome-wide significance level during replication phase in Indians. Additional CETP loci rs7205804, rs1532624, rs3764261, rs247617, and rs173539 also cropped up as modest signals in Indians. Haplotype association analysis revealed GCCCAGC as the strongest haplotype within the CETP locus constituting all seven CETP signals. In combined analysis, we perceived a novel and functionally relevant sub-GWAS significant locus-rs16890462 in the vicinity of SFRP1 gene. Overlaying gene regulatory data from ENCODE database revealed that single nucleotide polymorphism (SNP) rs16890462 resides in repressive chromatin in human subcutaneous adipose tissue as characterized by the enrichment of H3K27me3 and CTCF marks (repressive gene marks) and diminished H3K36me3 marks (activation gene marks). The variant displayed active DNA methylation marks in adipose tissue, suggesting its likely regulatory activity. Further, the variant also disrupts a potential binding site of a key transcription factor, NRF2, which is known for involvement in obesity and metabolic syndrome.
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Affiliation(s)
- Gauri Prasad
- Genomics and Molecular Medicine Unit, CSIR-Institute of Genomics and Integrative Biology, New Delhi 110025, India
- Academy of Scientific and Innovative Research, CSIR-Institute of Genomics and Integrative Biology Campus, New Delhi 110020, India
| | - Khushdeep Bandesh
- Genomics and Molecular Medicine Unit, CSIR-Institute of Genomics and Integrative Biology, New Delhi 110025, India
- Academy of Scientific and Innovative Research, CSIR-Institute of Genomics and Integrative Biology Campus, New Delhi 110020, India
| | - Anil K Giri
- Genomics and Molecular Medicine Unit, CSIR-Institute of Genomics and Integrative Biology, New Delhi 110025, India
- Academy of Scientific and Innovative Research, CSIR-Institute of Genomics and Integrative Biology Campus, New Delhi 110020, India
| | - Yasmeen Kauser
- Genomics and Molecular Medicine Unit, CSIR-Institute of Genomics and Integrative Biology, New Delhi 110025, India
- Academy of Scientific and Innovative Research, CSIR-Institute of Genomics and Integrative Biology Campus, New Delhi 110020, India
| | - Prakriti Chanda
- Systems Genomics Laboratory, School of Biotechnology, Jawaharlal Nehru University, New Delhi 110067, India
| | - Vaisak Parekatt
- Genomics and Molecular Medicine Unit, CSIR-Institute of Genomics and Integrative Biology, New Delhi 110025, India
| | - Sandeep Mathur
- Department of Endocrinology, S.M.S. Medical College, Jaipur, Rajasthan 302004, India
| | - Sri Venkata Madhu
- Division of Endocrinology, University College of Medical Sciences, New Delhi 110095, India
| | - Pradeep Venkatesh
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Anil Bhansali
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh 160012, India
| | - Raman K Marwaha
- Department of Endocrinology, International Life Sciences Institute, New Delhi 110024, India
| | - Analabha Basu
- National Institute of Bio Medical Genomics, Netaji Subhas Sanatorium (Tuberculosis Hospital), Kalyani 741251, West Bengal, India
| | - Nikhil Tandon
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi 110029, India.
| | - Dwaipayan Bharadwaj
- Academy of Scientific and Innovative Research, CSIR-Institute of Genomics and Integrative Biology Campus, New Delhi 110020, India.
- Systems Genomics Laboratory, School of Biotechnology, Jawaharlal Nehru University, New Delhi 110067, India.
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14
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Zhang Y, Hu J, Li Z, Li T, Chen M, Wu L, Liu W, Han H, Yao R, Fu L. A Novel Indicator Of Lipid Accumulation Product Associated With Metabolic Syndrome In Chinese Children And Adolescents. Diabetes Metab Syndr Obes 2019; 12:2075-2083. [PMID: 31632117 PMCID: PMC6791402 DOI: 10.2147/dmso.s221786] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/03/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The lipid accumulation product (LAP) is a powerful marker for predicting metabolic syndrome (MS) in adults. The present study aimed to propose a novel indicator, the children's lipid accumulation product (CLAP), and to assess its association with MS among Chinese children and adolescents. METHODS A total of 683 Chinese children aged 8-15 years were recruited using a stratified cluster sampling method in this cross-sectional study. The presence of MS was defined according to the NCEP-ATP III criteria. The effects of BMI, WHtR and the CLAP for predicting MS were compared using logistic regression models and receiver operating characteristic (ROC) curves. RESULTS The prevalence of MS was 5.1% (6.6% and 3.5% among boys and girls, respectively). Overall obesity (based on BMI), abdominal obesity (based on WHtR) and CLAP≥P75 were significantly associated with an increased risk of MS (ORs (95% CIs) were 143.79 (18.78-1101.22), 86.83 (27.19-277.27), 150.75 (20.11-1130.19), respectively). The area under the ROC curve (AUC) for the CLAP was higher than that for BMI and WHtR for predicting MS, with AUC (95% CI) values of 0.944 (0.913-0.975), 0.895 (0.864-0.927), and 0.928 (0.903-0.953), respectively. CONCLUSION The children's lipid accumulation product (CLAP) was an effective indicator associated with MS in Chinese children and adolescents and was better than BMI and WHtR for predicting MS.
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Affiliation(s)
- Yifei Zhang
- Department of Child and Adolescent Health, School of Public Health, Bengbu Medical College, Bengbu, People’s Republic of China
| | - Jingyao Hu
- Department of Child and Adolescent Health, School of Public Health, Bengbu Medical College, Bengbu, People’s Republic of China
| | - Zhiqiang Li
- Department of Child and Adolescent Health, School of Public Health, Bengbu Medical College, Bengbu, People’s Republic of China
| | - Ting Li
- Department of Child and Adolescent Health, School of Public Health, Bengbu Medical College, Bengbu, People’s Republic of China
| | - Manman Chen
- Department of Child and Adolescent Health, School of Public Health, Bengbu Medical College, Bengbu, People’s Republic of China
| | - Lu Wu
- Department of Child and Adolescent Health, School of Public Health, Bengbu Medical College, Bengbu, People’s Republic of China
| | - Wenmin Liu
- Department of Child and Adolescent Health, School of Public Health, Bengbu Medical College, Bengbu, People’s Republic of China
| | - Hui Han
- Department of Child and Adolescent Health, School of Public Health, Bengbu Medical College, Bengbu, People’s Republic of China
| | - Rongying Yao
- Department of Child and Adolescent Health, School of Public Health, Bengbu Medical College, Bengbu, People’s Republic of China
| | - Lianguo Fu
- Department of Child and Adolescent Health, School of Public Health, Bengbu Medical College, Bengbu, People’s Republic of China
- Correspondence: Lianguo Fu Department of Child and Adolescent Health, School of Public Health, Bengbu Medical College, 2600 East Sea Avenue, Bengbu233030, Anhui, People’s Republic of China. Tel +8613195529639Fax +86-5523175215 Email
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15
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Heshmat R, Hemati Z, Qorbani M, Nabizadeh Asl L, Motlagh ME, Ziaodini H, Taheri M, Ahadi Z, Shafiee G, Aminaei T, Hatami H, Kelishadi R. Metabolic syndrome and associated factors in Iranian children and adolescents: the CASPIAN-V study. J Cardiovasc Thorac Res 2018; 10:214-220. [PMID: 30680080 PMCID: PMC6335982 DOI: 10.15171/jcvtr.2018.37] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 11/16/2018] [Indexed: 12/15/2022] Open
Abstract
Introduction:Metabolic syndrome (MetS) is one of the common metabolic disorders seen in
children and adolescents. This study aims to assess the rate of the MetS and its associated factors in
a nationally-representative sample of Iranian pediatric age groups.
Methods: This nationwide cross- sectional study was designed in 2015 in 30 provinces of Iran.
Participants consisted of 4,200 school students, aged 7-18 years, studied in a national school-based
surveillance program (CASPIAN-V). Physical examination and laboratory tests were performed
using standard protocols. Blood samples were drawn from 3834 students for biochemical tests.
Results: The participation rate for blood sampling was 91.5%. MetS was significantly more
prevalent among students in urban than in rural areas (5.7% vs. 4.8%, P value < 0.01). MetS was
more prevalent in students with obese parents than in those with non-obese parents (6.4% vs.
4.5%, P value < 0.05). Significant association existed between moderate level of healthy nutritional
behaviors and MetS after controlling for potential confounders (odds ratio [OR]: 0.62, 95% CI:
0.40-0.98). Students with high unhealthy nutritional behaviors showed an increased risk of MetS in
crude (OR: 1.6, 95% CI: 1.05-2.44) and adjusted model (OR: 1.65, 95% CI: 1.05-2.63).
Conclusion: High rate of MetS and associated risk factors was observed in Iranian pediatric age
groups, with higher rates among boys. These findings provide useful information for effective
preventive strategies based on diet, exercise, and lifestyle modification rather than therapeutic
modalities.
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Affiliation(s)
- Ramin Heshmat
- Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Zeinab Hemati
- Pediatrics Department, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mostafa Qorbani
- Non-Communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran.,Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Laleh Nabizadeh Asl
- Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Department of Nutrition and Dietetics, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey
| | | | - Hasan Ziaodini
- Bureau of Health and Fitness, Ministry of Education and Training, Tehran, Iran
| | - Majzoubeh Taheri
- Office of Adolescents and School Health, Ministry of Health and Medical Education, Tehran, Iran
| | - Zeinab Ahadi
- Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Gita Shafiee
- Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Tahereh Aminaei
- Office of Adolescents and School Health, Ministry of Health and Medical Education, Tehran, Iran
| | - Hooman Hatami
- Student Research Committee, Alborz University of Medical Sciences, Karaj, Iran
| | - Roya Kelishadi
- Pediatrics Department, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
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16
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Zeitler P, Arslanian S, Fu J, Pinhas-Hamiel O, Reinehr T, Tandon N, Urakami T, Wong J, Maahs DM. ISPAD Clinical Practice Consensus Guidelines 2018: Type 2 diabetes mellitus in youth. Pediatr Diabetes 2018; 19 Suppl 27:28-46. [PMID: 29999228 DOI: 10.1111/pedi.12719] [Citation(s) in RCA: 139] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 05/24/2018] [Indexed: 02/06/2023] Open
Affiliation(s)
- Phillip Zeitler
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Silva Arslanian
- Children's Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Junfen Fu
- The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Orit Pinhas-Hamiel
- Edmond and Lily Safra Children's Hospital, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv, Israel
| | - Thomas Reinehr
- Vestische Children's Hospital, University of Witten/Herdecke, Witten, Germany
| | - Nikhil Tandon
- All India Institute of Medical Sciences, New Delhi, India
| | | | - Jencia Wong
- Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - David M Maahs
- Lucile Packard Children's Hospital, Stanford University, Stanford, California
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17
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Vikram NK. Cardiovascular and Metabolic Complications - Diagnosis and Management in Obese Children. Indian J Pediatr 2018; 85:535-545. [PMID: 29218646 DOI: 10.1007/s12098-017-2504-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 09/20/2017] [Indexed: 02/06/2023]
Abstract
The world at present is facing a burden of rising prevalence of obesity in children and adolescents. The developing countries are particularly facing the dual burden on under-nutrition and obesity. This is associated with appearance and clustering of cardiometabolic abnormalities at an early age with development of chronic complications early and possible decrease in life span of these children and adolescents. In adults this clustering has been termed as 'metabolic syndrome' with definitions that can be used universally. However, in children and adolescents there is no consensus on a uniform definition of metabolic syndrome that can be applicable across the age groups and various ethnicities. Further, as childhood is a period of growth and development, changes in body composition and insulin sensitivity that occur with puberty may influence the thresholds of components used to define metabolic syndrome. Children of South Asian ethnicity appear to be more predisposed to develop abnormalities of metabolic syndrome, possible due to their adverse body fat patterning and genetic influences. The definition of pediatric metabolic syndrome proposed by International Diabetes Federation is useful across different ethnicities. Presence of at least one component of metabolic syndrome should lead to detailed screening for other components and complications. A multimodality approach including therapeutic lifestyle changes targeted at the individual, family and community is essential for management. Pharmacotherapy for individual components may be required if initial management strategies fail to achieve the goals.
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Affiliation(s)
- Naval K Vikram
- Department of Medicine, Metabolic Research Group, All India Institute of Medical Sciences, New Delhi, 110029, India.
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18
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Gupta A, Sachdeva A, Mahajan N, Gupta A, Sareen N, Pandey RM, Ramakrishnan L, Sati HC, Sharma B, Sharma N, Kapil U. Prevalence of Pediatric Metabolic Syndrome and Associated Risk Factors among School-Age Children of 10-16 Years Living in District Shimla, Himachal Pradesh, India. Indian J Endocrinol Metab 2018; 22:373-378. [PMID: 30090730 PMCID: PMC6063189 DOI: 10.4103/ijem.ijem_251_17] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Recently, an increasing trend in the prevalence of pediatric metabolic syndrome (PMS) among school-age children has been documented in different parts of India. There is lack of data on the prevalence of PMS and its associated risk factors among school-age children living in district Shimla, Himachal Pradesh. Hence, to fill in the gap in the existing knowledge, the present study was conducted. METHODOLOGY A cross-sectional study was conducted during 2015-2016. Thirty clusters (schools) were identified from a list of all schools using population proportionate to size sampling methodology. From each school, 70 children in the age group of 10-16 years were selected. Data was collected on the sociodemographic characteristics, anthropometry, waist circumference, blood pressure, and physical activity. Fasting venous blood samples were collected for estimation of blood glucose, triglycerides, and high-density lipoprotein levels. RESULTS The prevalence of PMS using International Diabetes Federation classification was 3.3% and using modified-adult treatment panel classification criteria was 3.5%. Risk factors identified to be associated with PMS among school-age children were (i) male gender, (ii) high family monthly income, (iii) sedentary lifestyle, (iv) consumption of evening snack, (v) television/computer viewing, and (vi) motorized transportation for commuting to school. CONCLUSION The PMS prevalence was 3.3% in school-age children residing in District Shimla. There is a need to formulate interventions to prevent and correct metabolic syndrome among them for reducing early onset of cardiovascular disease during adulthood.
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Affiliation(s)
- Anmol Gupta
- Department of Community Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - Amit Sachdeva
- Department of Community Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - Narender Mahajan
- Department of Community Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - Aakriti Gupta
- Department of Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Neha Sareen
- Department of Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Ravindra Mohan Pandey
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Lakshmy Ramakrishnan
- Department of Biochemistry, All India Institute of Medical Sciences, New Delhi, India
| | - Hem Chandra Sati
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Brij Sharma
- Department of Gastroenterology, Indira Gandhi Medical College, Shimla, India
| | - Neetu Sharma
- Department of Physiology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - Umesh Kapil
- Department of Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
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19
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Nogueira-de-Almeida CA, de Mello ED. Different Criteria for the Definition of Insulin Resistance and Its Relation with Dyslipidemia in Overweight and Obese Children and Adolescents. Pediatr Gastroenterol Hepatol Nutr 2018; 21:59-67. [PMID: 29383306 PMCID: PMC5788952 DOI: 10.5223/pghn.2018.21.1.59] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 10/24/2017] [Accepted: 10/26/2017] [Indexed: 02/06/2023] Open
Abstract
PURPOSE to compare cut off points corrected for age and gender (COOP) with fixed cut off points (FCOP) for fasting plasma insulin and Homeostatic model assessment-insulin resistance (HOMA-IR) for the diagnosis of IR in obese children and adolescents and their correlation with dyslipidemia. METHODS A multicenter, cross-sectional study including 383 subjects aged 7 to 18 years, evaluating fasting blood glucose, plasma insulin, and lipid profile. Subjects with high insulin levels and/or HOMA-IR were considered as having IR, based on two defining criteria: FCOP or CCOP. The frequency of metabolic abnormalities, the presence of IR, and the presence of dyslipidemia in relation to FCOP or CCOP were analyzed using Fisher and Mann-Whitney exact tests. RESULTS Using HOMA-IR, IR was diagnosed in 155 (40.5%) and 215 (56.1%) patients and, using fasting insulin, 150 (39.2%) and 221 (57.7%), respectively applying FCOP and CCOP. The use of CCOP resulted in lower insulin and HOMA-IR values than FCOP. Dyslipidemia was not related to FCOP or CCOP. Blood glucose remained within normal limits in all patients with IR. There was no difference in the frequency of IR identified by plasma insulin or HOMA-IR, both for FCOP and CCOP. CONCLUSION The CCOP of plasma insulin or of HOMA-IR detected more cases of IR as compared to the FCOP, but were not associated with the frequency of dyslipidemia. As blood glucose has almost no fluctuation in this age group, even in the presence of IR, fasting plasma insulin detected the same cases of IR that would be detected by HOMA-IR.
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Affiliation(s)
| | - Elza Daniel de Mello
- Department of Pediatric, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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20
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Roy S, Ghosh JR. Hypertension in Asian Indian Children and Adolescents: A Systematic Review on the Prevalence and Associated Risk Factors. ACTA ACUST UNITED AC 2017. [DOI: 10.1080/09751270.2017.1336014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Swastika Roy
- Department of Anthropology, Visva-Bharati University, Santiniketan 731 235, West Bengal, India
| | - Jyoti Ratan Ghosh
- Department of Anthropology, Visva-Bharati University, Santiniketan 731 235, West Bengal, India
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21
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Kulshreshtha B, Arpita A, Rajesh PT, Sameek B, Dutta D, Neera S, Mohd M. Adolescent gynecomastia is associated with a high incidence of obesity, dysglycemia, and family background of diabetes mellitus. Indian J Endocrinol Metab 2017; 21:160-164. [PMID: 28217517 PMCID: PMC5240059 DOI: 10.4103/2230-8210.196022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Gynecomastia during adolescence is common though etiology is not clear. We studied the clinical and hormonal profile of adolescent patients with gynecomastia. METHODOLOGY Patients who had onset of breast development between age 10 and 20 years were included in this study. Their clinical profile, biochemical, and hormonal parameters were studied. RESULTS Of 94 patients with gynecomastia, 4 had hypogonadotropic hypogonadism, 4 had hypergonadotropic hypogonadism, and 1 had fibroadenosis, but in majority (90.4%), no apparent cause for breast enlargement was evident. In the idiopathic group, majority were obese (63%). Fourteen (16%) patients had impaired fasting glucose or impaired glucose tolerance. Another twenty patients had subtle abnormalities (high 1 h glucose or glucose peak at 2 h). Twenty-nine percent of lean and 38% of obese patients had mild abnormalities in glucose profile. Sixty percent of patients had family background of diabetes. Obese patients had lower testosterone as compared to lean patients; however, estradiol, luteinizing hormone, and follicle-stimulating hormone levels were similar in the two groups. CONCLUSION Gynecomastia during adolescence is associated with obesity, dysglycemia, and family background of diabetes mellitus.
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Affiliation(s)
| | - Arora Arpita
- Department of Endocrinology, PGIMER, Dr. RML Hospital, New Delhi, India
| | - Patnaik T. Rajesh
- Department of Endocrinology, PGIMER, Dr. RML Hospital, New Delhi, India
| | | | - Deep Dutta
- Department of Endocrinology, PGIMER, Dr. RML Hospital, New Delhi, India
| | - Sharma Neera
- Department of Biochemistry, PGIMER, Dr. RML Hospital, New Delhi, India
| | - Mohsin Mohd
- Department of Endocrinology, PGIMER, Dr. RML Hospital, New Delhi, India
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Kelishadi R, Hovsepian S, Djalalinia S, Jamshidi F, Qorbani M. A systematic review on the prevalence of metabolic syndrome in Iranian children and adolescents. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2016; 21:90. [PMID: 28163736 PMCID: PMC5244691 DOI: 10.4103/1735-1995.192506] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 05/18/2016] [Accepted: 06/23/2016] [Indexed: 01/19/2023]
Abstract
Background: Metabolic syndrome (MetS), a cluster of cardiovascular risk factors, is one of the most common metabolic disorders, which lead to many chronic diseases. The link between childhood MetS and occurrence of atherosclerosis and its sequels in adulthood is well documented. This study aims to systematically review the prevalence of MetS among Iranian children and adolescents. Materials and Methods: An electronic search was conducted on studies published from January 1990 to January 2015. The main international electronic data sources were PubMed and the NLM Gateway (for MEDLINE), Institute of Scientific Information (ISI), and SCOPUS. For Persian databases, we used domestic databases. We included all available population-based studies and national surveys conducted in the pediatric age group aged 3–21-year-old. Results: In this review, 2138 articles were identified (PubMed: 265; SCOPUS: 368; ISI: 465; Scientific Information Database: 189; IranMedex: 851; Irandoc: 46). After quality assessment, 13 qualified articles were evaluated. The number of total population and points of data were 24,772 and 125, respectively. Regarding the geographical distribution, we found 2 national, 6 provincial, and 5 district level points of data. The prevalence range of MetS among children was 1–22% using different definitions. Reported range of pediatric MetS defined by different criteria was as follows: National Cholesterol Education Program-Adult Treatment Panel III; 3–16%, International Diabetes Federation; 0–8%, American Heart Association; 4–9.5%, The National Health and Nutrition Examination Survey III; 1–18%, de Ferranti; 0–22%. Conclusion: MetS is a common metabolic disorder among Iranian children and adolescents, with increasing trends during the last decades. This finding provides baseline useful information for health policy makers to implement evidence based-health promotion for appropriate controlling of this growing health problem for the pediatric population.
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Affiliation(s)
- Roya Kelishadi
- Department of Pediatrics, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Silva Hovsepian
- Department of Pediatrics, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shirin Djalalinia
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Science Institute, Tehran University of Medical Sciences, Tehran, Iran; Development of Research and Technology Center, Tehran, Iran
| | - Fahimeh Jamshidi
- Department of Pediatrics, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mostafa Qorbani
- Department of Community Medicine, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran; Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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Evaluation of surrogate markers for insulin resistance for defining metabolic syndrome in urban Indian adolescents. Indian Pediatr 2015; 51:279-84. [PMID: 24825264 DOI: 10.1007/s13312-014-0401-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To compare parameters of insulin resistance, with special reference to McAuley index, in urban Indian adolescents, and to establish their cut-off values for defining metabolic syndrome. DESIGN Cross-sectional study. SETTING Schools located in four different geographical zones of Delhi, India. PARTICIPANTS 695 apparently healthy adolescents grouped as normal weight (298), overweight (205) and obese (192). OUTCOME MEASURES Cut-off point for indices of insulin resistance was assessed by fasting insulin, insulin glucose ratio, and other methods (HOMA model, QUICKI, McAuley index) to define metabolic syndrome. RESULTS The McAuley index increased progressively from normal weight to obese adolescents in both sexes. McAuley index was significantly lower in adolescents with metabolic syndrome (5.36 ± 1.28 vs. 7.05 ± 1.88; P<0.001). McAuley index had the highest area under curve of receiver operator characteristics [0.82 (0.02)] as compared to other indices of insulin resistance. McAuley index of 6.23 had the highest specificity (88%) with sensitivity of 63.3% for diagnosing metabolic syndrome, whereas insulin glucose ratio had the highest sensitivity (79.7%) but low (55.5%) specificity. McAuley index was negatively correlated with height (r= -0.257, P=<0.001), weight (r= -0.537, P=<0.001), body mass index (r= -0.579, P<0.001), waist circumference (r= -0.542, p<0.001), and waist hip ratio (r= -0.268, P<0.001). CONCLUSIONS Among various parameters of insulin resistance, McAuley index had the highest specificity, and insulin glucose ratio had the highest sensitivity in diagnosing metabolic syndrome in urban Indian adolescents.
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Pastucha D, Filipčíková R, Horáková D, Azeem K, Malinčíková J, Kocvrlich M. Evaluation of insulin resistance and metabolic syndrome in a group of obese Czech children. J Pediatr Endocrinol Metab 2014; 27:651-6. [PMID: 24566360 DOI: 10.1515/jpem-2013-0310] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Accepted: 01/29/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The study aimed to determine the incidence of metabolic syndrome (MS) in a group of Czech obese children, to evaluate the incidence of insulin resistance according to HOMA-IR in this group, and to consider the diagnostic value of HOMA-IR in early MS detection in obese children using the logistic regression models for analyzing the relations between HOMA IR and MS. SUBJECTS AND METHODS Anthropometric and laboratory examinations were performed in a group of 274 obese children aged 10-17 years. RESULTS MS was established in 102 subjects (37%). The presence of insulin resistance according to HOMA-IR >3.16 was ascertained in 53% of the subjects. HOMA-IR limit was exceeded by 70% in the MS (+) group and by 43% in children in the MS (-) (p<0.0001) category. CONCLUSION The relatively high incidence of insulin resistance in obese children without MS questions the prevailing diagnostic criteria of, perhaps, falsely excluding some cases of, MS.
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Shabir I, Ganie MA, Zargar MA, Bhat D, Mir MM, Jan A, Shah ZA, Jan V, Rasool R, Naqati A. Prevalence of metabolic syndrome in the family members of women with polycystic ovary syndrome from North India. Indian J Endocrinol Metab 2014; 18:364-9. [PMID: 24944933 PMCID: PMC4056137 DOI: 10.4103/2230-8210.131186] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is the most complex and common endocrine disorder of women in reproductive years. In addition to irregular menstrual cycles, chronic anovulation and hyperandrogenism, it has many metabolic manifestations such as obesity, hyperlipidemia, hyperinsulinemia, insulin resistance, dysglycemia, increased risk of cardiovascular disease or possibly endometrial cancer. Familial clustering of PCOS in consistence with the genetic susceptibility has been described. MATERIALS AND METHODS The present study assessed the clinical, biochemical and hormonal parameters including prevalence of metabolic syndrome by two different criteria in the first- degree relatives of patients with PCOS. RESULTS The average age of 37 index patients was 23 ± 3.6 years, with the mean age of menarche as 13.3 ± 1.2 years. The mean age and age of menarche in mothers (n = 22) was 48.8 ± 5.1 and 13 ± 1.3 years, respectively, whereas as it was 23.5 ± 4.7 and 13.3 ± 1.2 years in sisters (n = 22), respectively. Metabolic syndrome (MS) defined by International Diabetes Federation (IDF) criteria was present in 10 index patients, 1 brother, 4 sisters, 17 mothers and 15 fathers while as by Adult Treatment Panel III (ATP III) it was in 8 index patients, 5 sisters, 16 mothers and 11 fathers. CONCLUSION The presence of MS or related metabolic derangements is high in the family members of women with PCOS.
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Affiliation(s)
- Iram Shabir
- PhD Scholar, All India Institute of Medical Sciences, New Delhi, India
| | - Mohd Ashraf Ganie
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
| | - Mohd Afzal Zargar
- Department of Biochemistry, University of Kashmir, Srinagar, Jammu and Kashmir, India
| | - Dilafroz Bhat
- Department of Clinical Biochemistry, Sheri Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Mohd Muzzafar Mir
- Department of Clinical Biochemistry, Sheri Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Aleem Jan
- Department of Hematology, Sheri Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Zaffar Amin Shah
- Department of Immunology and Molecular Medicine, Sheri Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Vicar Jan
- Department of Cardiology, Sheri Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Riyaz Rasool
- Department of Radiodiagnosis, Sheri Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Andleeb Naqati
- Department of Biochemistry, University of Kashmir, Srinagar, Jammu and Kashmir, India
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Singh Y, Garg MK, Tandon N, Marwaha RK. A study of insulin resistance by HOMA-IR and its cut-off value to identify metabolic syndrome in urban Indian adolescents. J Clin Res Pediatr Endocrinol 2013; 5:245-51. [PMID: 24379034 PMCID: PMC3890224 DOI: 10.4274/jcrpe.1127] [Citation(s) in RCA: 129] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Insulin resistance (IR) and associated metabolic abnormalities are increasingly being reported in the adolescent population. Cut-off value of homeostasis model of assessment IR (HOMA-IR) as an indicator of metabolic syndrome (MS) in adolescents has not been established. This study aimed to investigate IR by HOMA-IR in urban Indian adolescents and to establish cut-off values of HOMA-IR for defining MS. METHODS A total of 691 apparently healthy adolescents (295 with normal body mass index (BMI), 205 overweight, and 199 obese) were included in this cross-sectional study. MS in adolescents was defined by International Diabetes Federation (IDF) and Adult Treatment Panel III (ATP III) criteria. IR was calculated using the HOMA model. RESULTS Mean height, waist circumference (WC), waist/hip ratio (WHR), waist/height ratio (WHtR), and blood pressure were significantly higher in boys as compared to girls. The HOMA-IR values increased progressively from normal weight to obese adolescents in both sexes. Mean HOMA-IR values increased progressively according to sexual maturity rating in both sexes. HOMA-IR value of 2.5 had a sensitivity of >70% and specificity of >60% for MS. This cut-off identified larger number of adolescents with MS in different BMI categories (19.7% in normal weight, 51.7% in overweight, and 77.0% in obese subjects) as compared to the use of IDF or ATP III criteria for diagnosing MS. Odds ratio for having IR (HOMA-IR of >2.5) was highest with WHtR (4.9, p p<0.0001) and WC (4.8, p p<0.0001), compared to WHR (3.3, p p<0.0001). CONCLUSIONS In Indian adolescents, HOMA-IR increased with sexual maturity and with progression from normal to obese. A HOMA-IR cut-off of 2.5 provided the maximum sensitivity and specificity in diagnosing MS in both genders as per ATP III and IDF criteria.
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Affiliation(s)
- Yashpal Singh
- International Life Sciences, Scientific Advisor (Projects), New Delhi, India. E-mail:
| | - MK Garg
- Command Hospital (Southern Command), Department of Endocrinology, Pune, India
| | - Nikhil Tandon
- All Indian Institute of Medical Sciences, Department of Endocrinology, New Delhi, India
| | - Raman Kumar Marwaha
- International Life Sciences, Scientific Advisor (Projects), New Delhi, India
,* Address for Correspondence: International Life Sciences, Scientific Advisor (Projects), New Delhi, India Phone: +91 9810296820 E-mail:
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Angurana SK, Angurana RS. Prevalence of metabolic syndrome in adolescents: Reason to worry. Indian J Endocrinol Metab 2013; 17:1135-1136. [PMID: 24381906 PMCID: PMC3872707 DOI: 10.4103/2230-8210.122656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Renu Suthar Angurana
- Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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