Metabolic Syndrome in Childhood Predicts Adult Cardiovascular Disease 25

Years Later: The Princeton Lipid Research Clinics Follow-up Study

John A. Morrison, Lisa Aronson Friedman and Courtney Gray-McGuire
Pediatrics 2007;120;340
DOI: 10.1542/peds.2006-1699

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/120/2/340.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
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ARTICLE

Metabolic Syndrome in Childhood Predicts Adult

Cardiovascular Disease 25 Years Later: The Princeton
Lipid Research Clinics Follow-up Study
John A. Morrison, PhDa, Lisa Aronson Friedman, ScMb, Courtney Gray-McGuire, PhDc

aDivision of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; bMaryland Medical Research Institute, Baltimore, Maryland; cDepartment of

Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio

The authors have indicated they have no financial relationships relevant to this article to disclose.

ABSTRACT
OBJECTIVE. The goal was to assess the association of metabolic syndrome in childhood
with adult cardiovascular disease 25 years later.
www.pediatrics.org/cgi/doi/10.1542/
METHODS. Data from the National Heart, Lung, and Blood Institute Lipid Research peds.2006-1699
Clinics Princeton Prevalence Study (1973–1976) and the Princeton Follow-up doi:10.1542/peds.2006-1699
Study (2000 –2004) were used. BMI was used as the obesity measure in childhood, Key Words
cardiovascular disease, body weight,
because waist circumference was not measured in the Lipid Research Clinics study. metabolic syndrome
The adult cardiovascular disease status of participants and their parents was Abbreviations
obtained through participant report. A logistic analysis was used to predict adult CVD— cardiovascular disease
cardiovascular disease; pediatric metabolic syndrome, age at the Princeton Fol- LRC—Lipid Research Clinics
OR— odds ratio
low-up Study, gender, race, and parental history of cardiovascular disease were PFS—Princeton Follow-up Study
potential explanatory variables. HDL-C— high-density lipoprotein
cholesterol
RESULTS. Ages ranged from 6 to 19 years in the Lipid Research Clinics study and from CDC—Centers for Disease Control and
Prevention
30 to 48 years in the Princeton Follow-up Study. There were 17 cases of cardio-
Accepted for publication Mar 16, 2007
vascular disease in the analysis cohort in the Princeton Follow-up Study. Pediatric Address correspondence to John A. Morrison,
metabolic syndrome and age at follow-up assessment were significant predictors of PhD, OSB 4, Division of Cardiology, Children’s
Hospital Medical Center, 3333 Burnet Ave,
cardiovascular disease. Pediatric metabolic syndrome and changes in age-specific Cincinnati, OH 45229. E-mail: john.morrison@
BMI percentile from childhood to adulthood were significant predictors of adult cchmc.org
metabolic syndrome. PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright © 2007 by the
CONCLUSIONS. Evaluating children for metabolic syndrome could identify patients at American Academy of Pediatrics

increased risk of adult cardiovascular disease, making targeted interventions

possible.

340 MORRISON et al
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I N ADULTS, THE clustered presence of ⱖ3 cardiovascular
disease (CVD) risk factors from among elevated waist
circumference, blood pressure, triglyceride levels, and
glucose levels and low high-density lipoprotein choles-
terol (HDL-C) levels has been designated the “metabolic
syndrome.”1 Although labeling this collection of risk
factors as a syndrome is controversial,2,3 their com-
bined presence is associated with increased risk of future
CVD in adults.4–7 The cutoff values used in defining
abnormal levels1 are not extreme, generally falling near
the 80th to 85th percentiles for adult reference popula-
tions.8 Whether the clustered presence of these factors in
childhood predicts adult CVD is not known, although a
number of studies have reported that individual factors
track from childhood into young adulthood.9,10 More-
over, the Bogalusa Heart Study, which was initiated
before Kissebah et al11 identified central adiposity as a
predictor of diabetes mellitus and other metabolic disor-
ders, reported that persistent high insulin levels12 and
overweight, identified on the basis of BMI instead of
waist circumference,13 were associated with higher levels
of the factors in the metabolic syndrome later in life.
Those reports12,13 did not assess CVD. The longitudinal
nature of the data from the Lipid Research Clinics (LRC)
Princeton Prevalence Study and the Princeton Fol-
low-up Study (PFS) provides an opportunity to assess
the association between the metabolic syndrome in
childhood and adult CVD ⬃25 years later. We hypoth-
esized that the presence of the metabolic syndrome in
childhood would predict CVD in adulthood.
METHODS
Study Group
The PFS participants were drawn from the Cincinnati
clinic of the National Heart, Lung, and Blood Institute
LRC Prevalence Study, a multistage survey of lipid levels
in 10 communities in the United States and Canada that
was conducted in 1973 to 1978 to describe lipid level
distributions in free-living populations and their associ-
ations with other CVD risk factors. The Cincinnati clinic
conducted its prevalence study in the public and paro-
chial schools in the Princeton School District of Greater
Cincinnati, targeting students in grades 1 to 12.14,15
Briefly, the original student population was 73% white
and 27% black, 52% male and 48% female.14 Race was
self-declared as white or black. In addition, the parents
in a 50% sample of Princeton Prevalence Study house-
holds were recruited to the study. At an initial visit, total
cholesterol and triglyceride levels were measured, basic
demographic information was collected, and the rela-
tionships between participants and other participating
members of their households were established.14 Ap-
proximately 6 weeks later, randomly selected and hy-
perlipidemic visit 1 subjects were recalled, independent
of other family members, for a second screening, at
Downloaded from pediatrics.aappublications.org at Nyu Medical Center on October 12, 2014
which complete lipid profiles, blood chemistry values,
anthropometric data, blood pressure, and family history
of CVD were recorded.15 In 1976, the LRC Family Study
(visit 3) screened all consenting first-degree relatives of
selected visit 2 subjects with respect to lipid levels, an-
thropometric data, and blood chemistry values, to assess
familial correlations of lipid levels.16 The PFS, which was
conducted to evaluate long-term changes in familial lipid
correlations, recruited all visit 3 participants and visit 2
participants with ⱖ1 sibling or parent also at visit 2.17
The time between LRC study and PFS visits ranged be-
tween 22 and 31 years, depending on when the subjects
attended their LRC study and PFS visits. In the LRC
study, 84% of eligible students participated at the initial
LRC study visit and 91% of eligible students participated
at subsequent visits; participation rates did not differ
significantly between races.14–16
Clinical Measures
In both the LRC study and the PFS, data were collected
by using standard protocols.15–17 Height and weight were
measured with the subjects in light indoor clothing, with
shoes removed. In the LRC study, single measurements
of height and weight were made. In the PFS, 2 measure-
ments of height, weight, and waist circumference were
made, with a third measurement if the first 2 measure-
ments differed by more than a set amount. The means of
the 2 closest PFS measurements were used in analyses.
The BMI was used to characterize body habitus. In the
PFS, waist circumference was measured at the level of
the umbilicus, at the end of a normal expiration. In
the LRC study and PFS, blood pressure was measured on
the right arm with a standard sphygmomanometer,
after participants had been sitting for 5 minutes. Systolic
blood pressure and diastolic blood pressure were defined
with the appearance of sound (first Karotkoff phase) and
the disappearance of sound (fifth Karotkoff phase), re-
spectively. The mean of 2 readings was used for the LRC
study, and the mean of the second and third readings
was used for the PFS. In each study, fasting blood sam-
ples were drawn into Vacutainer tubes (Becton Dickin-
son and Co, Franklin Lakes, NJ) containing EDTA, kept
on wet ice (LRC study) or cold packs (PFS), and deliv-
ered to the laboratory within 3 hours for processing;
lipid profiles were measured in LRC/Centers for Disease
Control and Prevention (CDC)-standardized laborato-
ries. In the LRC study, glucose levels were measured
with an ABA-100 system by using the hexokinase meth-
od.18 In the PFS, glucose levels were measured with a
Dade Dimension Xpand system (Dade Behring Inc,
Deerfield, IL) by using the hexokinase/glucose-6-phos-
phate dehydrogenase method.19
Definitions of Metabolic Syndrome and CVD
Adult metabolic syndrome was defined by using Adult
Treatment Panel III criteria, as follows: waist circumfer-
PEDIATRICS Volume 120, Number 2, August 2007 341
ence of ⱖ88 cm (female subjects) or ⱖ102 cm (male
subjects), HDL-C levels of ⱕ50 mg/dL (female subjects)
or ⱕ40 mg/dL (male subjects), triglyceride levels of
ⱖ150 mg/dL, blood pressure of ⱖ130 mm Hg (systolic)
or ⱖ85 mm Hg (diastolic), and glucose levels of ⱖ110
mg/dL.1 CVD (myocardial infarction, coronary artery by-
pass graft, angioplasty, or stroke) in participants and
their parents was determined through report of the par-
ticipants at the time of the PFS. BMI was used to define
obesity in childhood, because waist circumference was
not measured in the LRC study. Pediatric standards were
used to define abnormal triglyceride levels, BMI, and
blood pressure, because pediatric distributions of these
factors differ markedly from adult distributions.20 Tri-
glyceride levels of ⱖ110 mg/dL were defined as elevated,
and BMI values at or above the age-specific 90th per-
centile, based on the CDC 2000 growth charts,21 were
defined as high. Systolic or diastolic blood pressure at or
above the age- and height-specific 90th percentile21 was
defined as elevated. HDL-C levels of ⱕ50 mg/dL (female
subjects) or ⱕ40 mg/dL (male subjects) were defined as
low.20 Glucose levels of ⱖ110 mg/dL were defined as
elevated.20
Statistical Methods
SAS 9.1.322 was used for all analyses. A logistic analysis
for clustered sample design was used to identify factors
related to CVD status (yes/no) at follow-up assessment,
taking into account sibling correlations. Age at PFS, gen-
der, race, parental CVD, and pediatric metabolic syn-
drome status were potential explanatory variables. Pre-
dictors with P values of ⬍.15 were retained in the model.
Because adult metabolic syndrome is associated with
significantly greater risk for CVD, we also determined
the risk of metabolic syndrome in adulthood associated
with its presence in childhood. To evaluate intervening
change in obesity as a predictor of CVD and adult met-
abolic syndrome, the change in the age-specific BMI
percentiles between the 2 studies was tested as a covari-
ate. The pediatric BMI percentiles in the LRC study were
taken from the CDC 2000 growth charts,21 and the adult
percentiles were taken from the compilation of National
TABLE 1 Summary Statistics for Princeton School Students in the LRC Study (1973–1976) and the PFS
(2000 –2004)
LRC Study (n ⫽ 771)
Mean
Age, y 12.9
BMI, kg/m2 19.8
Waist circumference, cm
Glucose level, mg/dL 85.5
HDL-C level, mg/dL 54.5
Triglyceride level, mg/dL 75.2
Systolic blood pressure, mm Hg 104.0
Diastolic blood pressure, mm Hg 62.3
342 MORRISON et al
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Health and Nutrition Examination Survey I and II data
by Frisancho.23 Finally, to evaluate elevated glucose lev-
els in childhood as predictors of metabolic syndrome and
CVD (separately), we tested the associations by using
LRC study glucose levels of ⱖ100 mg/dL and ⱖ110
mg/dL as cutoff values, with Fisher’s exact test.
RESULTS
The ethnic composition of the 771 members in the anal-
ysis cohort (28% black and 72% white) was similar to
that of the total school population in the LRC study
(27% black and 73% white); the proportion of female
subjects (55%) was greater. In the LRC study, the cohort
ranged in age from 5 years to 19 years, with a mean of
12.9 years (Table 1). The mean BMI for the students was
19.8 kg/m2; 18.2% of the students were at or above the
CDC 2000 age-specific 85th percentile (at risk of over-
weight), and 7.0% were at or above the 95th percentile
(overweight). The prevalence rates of abnormal BMI
(13.7%), blood pressure (11.9%), triglyceride levels
(12.3%), and HDL-C levels (13.0%) in the LRC study
were slightly higher than the 10% expected from the use
of age-adjusted 90th or 10th percentile cutoff values
(Table 2). The prevalence of abnormal glucose levels
(0.7%) was low, because the cutoff value was the same
as for adults (110 mg/dL). Thirty-one LRC study partic-
ipants (4.0%) had ⱖ3 abnormal factors and were classi-
fied as having metabolic syndrome. Of the 31 students
with the syndrome, 24 (77%) had BMI values above the
90th percentile and an additional 4 (13%) had BMI
values above the 85th percentile but below the 90th
percentile.
At follow-up assessment, the mean age of the cohort
was 38.4 years, the mean BMI was 28.6 kg/m2 (approx-
imately the 75th percentile of the National Health and
Nutrition Examination Survey I and II distribution), and
25.4% of the cohort had BMI values at or above the age-
and gender-specific 90th percentile (Table 1). Commen-
surate with the increase in BMI, the prevalence of low
HDL-C levels, elevated triglyceride levels, elevated blood
pressure, and elevated fasting glucose levels increased to
52.9%, 28.3%, 33.8%, and 6%, respectively. The prev-
PFS (n ⫽ 771)
SD Mean SD
3.4 38.4 3.6
4.3 28.6 6.8
96.9 16.6
8.1 90.7 27.1
12.3 45.6 14.6
38.1 135.2 133.4
12.7 119.9 14.9
12.1 79.0 11.0
 TABLE 2 Prevalence of Abnormal Metabolic Syndrome Factors,
Metabolic Syndrome, and CVD in Students in the LRC
Study (1973–1976) and the PFS (2000 –2004)
Factor
LRC Study
High BMI (⬎90th percentile)
Large waist circumference
High glucose level
Low HDL-C level
High triglyceride level
High blood pressure
Metabolic syndrome
CVD
In the LRC study, age-specific cutoff values were used; in the PFS, Adult Treatment Panel III
cutoff values for waist circumference, triglyceride levels, HDL-C levels, glucose levels, and blood
pressure were used.
alence of large waist circumferences was 49.1%, and
27.2% of the cohort had metabolic syndrome (Table 2).
The syndrome was associated strongly with increased
BMI; of the 210 cohort members with adult metabolic
syndrome, 200 (95%) were overweight or obese (BMI of
ⱖ25 kg/m2) and 151 (72%) were obese (BMI of ⱖ30
kg/m2). The overall tracking coefficient from childhood
to adulthood was 0.59, and 63% of participants at risk of
overweight in the LRC study were obese in the PFS. Of
31 LRC study subjects with pediatric metabolic syn-
drome, 21 (68%) had metabolic syndrome at follow-up
assessments (␹2 ⫽ 26.7; P ⬍ .0001). In a multivariate
analysis with age, gender, race, and pediatric metabolic
syndrome as potential explanatory variables, pediatric
syndrome status (odds ratio [OR]: 6.1; P ⬍ .0001) alone
was significant; female gender (OR: 0.8; P ⫽ .10) was not
significant at the P ⫽ .05 level. When the change in BMI
percentile between the studies was added to the model,
the factor was significant (OR: 1.024; P ⬍ .0001) but
female subjects had a P value of 0.22, which suggests
that part of the gender difference in the risk of adult
metabolic syndrome was attributable to less weight gain
among female subjects. For each increase in the age-
specific BMI percentile of 10 points, the risk of adult
metabolic syndrome increased 24%. Of the 10 subjects
with metabolic syndrome in the LRC study but not the
PFS, 2 had increases in BMI percentile (changes of ⫹4.9
and ⫹12.8), 7 had decreases in BMI percentile (range:
⫺31.5 to ⫺6.8), and 1 had no change.
There were 17 cases of CVD in the PFS analysis sam-
TABLE 3 ORs and 95% Confidence Intervals for Predictors of Adult Metabolic Syndrome and CVD at Follow-up Assessments (2000 –2004) for
Members of the Princeton LRC Cohort (1973–1976)
Predictor
OR
Pediatric metabolic syndrome 6.2
PFS age
Change in BMI percentile 1.02
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ple. The incidence of CVD during the intervening years
for the 31 patients with pediatric metabolic syndrome
was 19.4% (n ⫽ 6), compared with 1.5% for subjects
Prevalence, % without metabolic syndrome as children. In multivariate
logistic analyses, pediatric metabolic syndrome (OR:
PFS
14.7; P ⬍ .0001) and age (OR: 1.2; P ⫽ .03) were
13.7 25.4
49.1
significant predictors of CVD (Table 3), and gender, race,
0.7 6.0 and parental history of CVD were not (P ⬎ .2). When
13.0 52.9 change in BMI percentile was added to the final model,
12.3 28.3 the factor was not significant (P ⬎ .5). Finally, CVD at
11.9 33.8 follow-up assessment was not associated with glucose
4.0 27.2
0 2.2
levels of ⱖ100 or ⱖ110 mg/dL in childhood. Of 5 LRC
study subjects with glucose levels of ⱖ110 mg/dL, none
had CVD; of 29 with glucose levels of ⱖ100 mg/dL, 2
had CVD (P ⫽ .13).
DISCUSSION
The key finding in this follow-up study of former stu-
dents from the Princeton LRC School Study is that chil-
dren with the cluster of factors defined as pediatric met-
abolic syndrome were significantly more likely to have
CVD 25 years later as adults, compared with their peers.
The prevalence of the syndrome in the students as chil-
dren was 4%, similar to that reported by Cook et al.20
The finding that the syndrome in childhood predicts
later CVD agrees with the recent report of a significant
association between pediatric metabolic syndrome and
subclinical atherosclerosis (determined as carotid inti-
mal-medial thickness) in young adults with a mean age
of 32 years in the Bogalusa Heart Study.24 Similar find-
ings link combinations of these risk factors in childhood
to subsequent carotid intimal-medial thickness in young
adults.25,26 In the current study, the mean age (38.4
years) was 6 years older than that in the Bogalusa report,
and clinical disease was becoming more prevalent.
At follow-up assessments, the prevalence of the syn-
drome was 27.2%, reflecting the marked increase in
BMI and associated changes in obesity-related risk fac-
tors, a prevalence somewhat higher than that published
by Ford et al27 (based on National Health and Nutrition
Examination Survey III data from 10 years earlier).
Given the well-established relationship between the
constellation of adult risk factors identified as metabolic
syndrome and the risk of future CVD,1,4–7 it is important
to note that metabolic syndrome in adulthood was as-
sociated strongly with the presence of the syndrome in
Adult Metabolic Syndrome Adult CVD
95% Confidence Interval P OR 95% Confidence Interval P
2.8–13.8 ⬍.0001 14.6 4.8–45.3 ⬍.0001
1.2 1.02–1.4 .02
1.017–1.03 ⬍.0001
PEDIATRICS Volume 120, Number 2, August 2007 343
childhood (Table 3). Within this context, the change in
BMI percentile between studies was also highly associ-
ated with the development of metabolic syndrome; for
every increase (or decrease) in age-specific BMI percen-
tile of 10 points, the risk of metabolic syndrome in
adulthood increased (or decreased) 24%, which empha-
sizes the cost of greatly increasing weight in adult years
and the benefit of losing relative weight in adulthood if
one is overweight as a child or youth.
It is somewhat surprising that parental history of CVD
was not associated with CVD, because family history is
well established as a risk factor for CVD.1 The lack of an
association here could be attributable to the small num-
ber of CVD cases (n ⫽ 17) in the cohort at this point or
to the obesity explosion that has occurred in the past
quarter century, changing the prevalence of obesity-
related risk factors and potentially altering the factors
explaining early CVD.
As noted above, there is controversy regarding label-
ing this set of factors as a syndrome. Reaven,2 who was
largely responsible for focusing attention on insulin re-
sistance as a risk factor for CVD, has argued against the
label for 3 main reasons, that is, (1) it occurs only in
insulin-resistant persons, (2) it has no clinical or peda-
gogical utility, and (3) the emphasis must be on treating
the individual factors, because there is no treatment for
the syndrome itself. In his review of the issue, Goetz28
suggested that using the syndrome label might be tan-
tamount to having Big Pharma turn obesity into a dis-
ease and then seeking to develop a cure for it, but he
went on to write, “a diagnosis of metabolic syndrome
can get them off the couch in a way that a doctor
tut-tutting about their extra pounds cannot.”28 More-
over, treating the individual factors one at a time (with
prescribed drugs) may constitute a less-efficient, less-
effective approach to the problem than addressing the
underlying problem, which on a population basis is obe-
sity-related insulin resistance. The strong association of
the syndrome in childhood and adulthood with high
BMI highlights the role of obesity in the constellation of
factors, whatever it is labeled.
Limitations of the study include the use of participant
reports of CVD in the participants and their parents,
instead of hospital records. However, Murabito et al29
compared offspring reports of parental CVD history in
the Framingham Offspring Study with confirmed medi-
cal findings and reported that positive and negative his-
tory reports were reliably accurate for heart attack and
stroke. Furthermore, the authors reported no difference
in accuracy between male and female offspring. A sec-
ond limitation is the lack of insulin data. Insulin data
were collected for a subgroup as part of an ancillary
study, but only 3 of the 17 CVD cases had insulin values,
which precluded meaningful statistical analyses. A third
limitation is the use of casual fasting glucose levels in
344 MORRISON et al
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childhood, instead of oral glucose tolerance data, as po-
tential predictors of adult CVD.
The findings from this 25-year follow-up evaluation
of former students in the LRC Princeton Prevalence
Study, with and without pediatric metabolic syndrome
in childhood, stress the potential importance of preven-
tive actions for patients during the pediatric years and
into adulthood. The increased risk of adult disease asso-
ciated with the pediatric syndrome clearly identifies pa-
tients at risk, as well as the need for intervention. In
addition, the significant changes in the risk of the syn-
drome in middle age that are associated with changes in
BMI percentile rankings between the 2 studies under-
score the importance of weight management in early
and middle adult years.
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than a typical doctor’s visit and much lower than the emergency room. No
appointment necessary. Open daytime, evenings and weekends. Most take
insurance. . . . Thousands of free-standing primary care clinics have been
operating for years in malls and main streets around the country, often staffed
by physicians and many offering a broad range of health services. The retail
health clinics are creating a new model with more limited services at lower
prices and almost always staffed by nurses. The Convenient Care Association
estimates there are about 325 of these retail clinics operating nationwide
today. Seventy-six of them are in Wal-Marts in 12 states, but the company
announced last month it will expand to 400 clinics by the end of the decade
and 2000 in five to seven years. They will be run by outside firms, including
for-profit ventures like RediClinic as well as local and regional health plans
and hospitals. The industry is rapidly expanding. . . . Of all patients who have
visited the clinics, almost half went there for a vaccination, and one-third
received treatment for ear infections, colds, strep throat, skin rashes or sinus
infections. Ninety percent said they were satisfied with the care they received.
The nurses staffing the clinics are under physician supervision and follow
strict protocols to refer patients to physicians or emergency rooms if problems
are more serious. . . . The clinics are working to solve another problem that is
vexing Washington— creation of electronic medical records. Most retail clin-
ics create computerized patient records, with the goal of making the records
accessible throughout the chain. The records also can be emailed to a hospital
or to the patient’s regular doctor— or sent by fax if necessary.”
Turner G. Wall Street Journal. May 14, 2007
Noted by JFL, MD

PEDIATRICS Volume 120, Number 2, August 2007 345

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Metabolic Syndrome in Childhood Predicts Adult Cardiovascular Disease 25
Years Later: The Princeton Lipid Research Clinics Follow-up Study
John A. Morrison, Lisa Aronson Friedman and Courtney Gray-McGuire
Pediatrics 2007;120;340
DOI: 10.1542/peds.2006-1699
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