Eur J Pediatr (2010) 169:935–940
DOI 10.1007/s00431-010-1143-5
ORIGINAL PAPER
Prevalence of metabolic syndrome in a Portuguese obese
adolescent population according to three different definitions
Hugo Braga-Tavares & Helena Fonseca
Received: 28 October 2009 / Accepted: 12 January 2010 / Published online: 23 February 2010
# Springer-Verlag 2010
Abstract In order to determine the prevalence of metabolic
syndrome (MS) in a Portuguese pediatric overweight
population according to three different sets of criteria, 237
overweight and obese adolescents were evaluated at
engagement in a specific multidisciplinary program. Two
of the used definitions were based on the National
Cholesterol Education Program (ATPIII) guidelines modi-
fied for pediatric age and were proposed by Cook et al.
(Arch Pediatr Adolesc Med 157(8):821–827, 2003) and de
Ferranti et al. (Circulation 110(16):2494–2497, 2004). The
third definition used resulted from a consensus of the
International Diabetes Federation (IDF 2005). All of them
include five components: waist circumference, blood
pressure, high-density lipoprotein cholesterol, triglycerides,
and fasting glucose values, with different cut-off points. Of
the studied sample, 53% were girls, median age 13.4 years,
89% classified as obese, and the remaining as overweight.
MS prevalence was 15.6%, 34.9%, and 8.9% according to
Cook’s, de Ferranti's, and IDF definitions, respectively. No
adolescent fulfilled the five MS criteria, and only three
(1.2%), 15 (6%), and 13 (5.1%) had no criteria at all, ac-
cording to the three definitions used. Waist circumference
was the most prevalent component (89.5%, 98.7%, and
93.2%), and high fasting glucose the least (1.3% for the two
first and 2.5% according to the IDF definition). A signifi-
H. Braga-Tavares : H. Fonseca
Obesity Outpatient Clinic, Department of Pediatrics,
Centro Hospitalar Lisboa Norte, EPE—Hospital de Santa Maria,
Lisboa, Portugal
H. Braga-Tavares (*)
Rua Óscar da Silva 1295, 1° ESQ,
4450-760 Leça Palmeira, Portugal
e-mail: hugotavaresmd@gmail.com
cant correlation between increased body mass index and
MS was found, using the two first definitions (Cook et al.
p<0.05; de Ferranti et al. p<0.01), but not when using the
third one. Considerable prevalence differences were found
using three different MS criteria. It is urgent to establish a
consensus on MS definition to allow early identification of
adolescents at risk and the development of prospective
studies to define what cut-offs are the best indicators of
future morbidity.
Keywords Metabolic syndrome . Prevalence . Adolescents .
Obesity
Introduction
Metabolic syndrome (MS) is defined as a cluster of five
metabolic risk factors, including central obesity (evaluated
by waist circumference (WC)), arterial hypertension,
altered glucose metabolism, low high-density lipoprotein
(HDL) cholesterol, and hypertriglyceridemia [28].
Although the syndrome was originally described more
than 40 years ago, there is still no consensus regarding
the cut-off of the different components in the pediatric
population.
The two more widely accepted adult definitions were set
by the Third Report of the National Cholesterol Education
Program (NCEP) Expert Panel on Detection, Evaluation,
and Treatment of High Blood Cholesterol in Adults (Adult
Treatment Panel III [ATP III]) [28] and by the World Health
Organization [38]. Also, in 2005, the International Diabetes
Federation (IDF) published a definition for the syndrome
[2].
A recent review found more than 40 different pediatric
MS definitions, most of them adaptations of the modified
936
version of NCEP/ATP III [14]. Three of these definitions
have been used in large pediatric series and are summarized
in Table 1. However, they have different cut-off points for
some of the components that define the MS [2, 8, 11]. The
use of these different definitions has lead to significant
discrepancies on overall MS prevalence and also impairs
comparisons across studies [6].
MS is not evenly distributed in the pediatric population
with a higher prevalence across obese children and
adolescents, regardless of the definition used, as demon-
strated in large US series and also European population [4,
7, 8, 16, 17, 22, 37]. Although largely influenced by genetic
and environmental factors [19], published data showed that
obesity is the most predominant correlate of cardiometa-
bolic risk, especially in the presence of central obesity [15].
Therefore, it is not surprising that the raising prevalence of
MS in line with the dramatic obesity increase among
children and adolescents [1, 20, 23, 29, 30]. Furthermore,
as obesity is steadily starting at an earlier age and with
increasing severity, it is expected that MS occurs earlier and
earlier [8–11, 32, 34, 37].
Among adults, the MS is associated with an increased
risk of type 2 diabetes early onset and cardiovascular
disease [3, 5, 17, 21, 28], which may lead to an increased
cardiovascular mortality [17]. An increased risk of as much
as two to three times of having a heart attack or stroke and
five times of developing type 2 diabetes compared with
those without MS has been reported [3].
So far, there is scarce information regarding the impact
of childhood MS in health later in life. This is in part
related to the absence of a consensus definition that would
allow clear inclusion criteria for long-term prospective
studies. Nevertheless, there seems to be an increased risk of
Table 1 Definitions of metabolic syndrome in children and adolescents
Cook et al. (2003) [5]a
HDL-C ≤40 mg/dL
Triglycerides ≥110 mg/dL
Waist circumference ≥90th percentile
(age- and sex-specific)
Blood pressure ≥90th percentile
(age-, sex-, and height-specific)
Fasting glucose ≥110 mg/dL
IDF International Diabetes Federation, SBP systolic blood pressure, DBP diastolic blood pressure, T2DM type 2 diabetes mellitus, OGTT oral
glucose tolerance test
a
For all definitions, a total of three criteria must be present (In IDF's definition, WC must be one of the criteria)
b
For 16 years and older, the adult definition is used: HDL-C<40/50 mg/dL (males/females, respectively) or specific treatment for these lipid
abnormalities, triglycerides>150 mg/dL, WC≥94 cm for Europid men and ≥80 cm for Europid women, with ethnicity specific values for other
groups; blood pressure: SBP≥130 mmHg or DBP≥85 mmHg or treatment of previously diagnosed arterial hypertension; fasting glucose:
≥100 mg/dL or previously diagnosed T2DM
Eur J Pediatr (2010) 169:935–940
adult cardiovascular disease in children diagnosed with MS
[25, 26] and an increasing evidence that early detection and
intervention targeted at weight management and treatment
of the specific metabolic risk factors should have a
significant impact on future adult health [9, 31].
This study wants to evaluate the prevalence of MS and
of its components in a Portuguese adolescent obese popu-
lation according to three of the currently used definitions.
By comparing the definitions, we try to assess the impact of
different cut-off points used in the MS prevalence found.
Methods
Study population
A sample of 237 adolescents aged 10–20 years were
assessed at the moment of engagement in an Obesity
Management Program specifically designed for overweight
and obese adolescents in a central hospital outpatient clinic.
Variables assessment
Demographic data and anthropometric variables were
obtained at entrance. The three sets of MS definition
criteria used were derived from the NCEP/ATP III guide-
lines modified for pediatric age. They differ in HDL-C,
triglycerides, and WC cut-offs (Table 1).
In all the definitions, a total of three or more of the five
criteria are required to establish the diagnosis of MS. In
IDF's definition, WC must be one of the criteria.
Blood pressure was measured with an automatic digital
blood pressure monitor, with an adjustable arm cuff
de Ferranti et al. (2004) [6]a IDF consensus definition
(10–16years oldb; 2005) [2]a
<50 mg/dL <40 mg/dL
(<45 in boys 15–19 years)
≥100 mg/dL ≥150 mg/dL
>75th percentile ≥90th percentile
(age- and gender-specific) (or adult cut-off if lower)
>90th percentile SBP≥130 mmHg; DBP≥85 mmHg
(age-, sex-, and height-specific)
≥110 mg/dL ≥100 mg/dL (if ≥100 mg/dL or known
T2DM recommend OGTT)
Eur J Pediatr (2010) 169:935–940
according to arm size. Adolescents were seated with their
right arm resting at the level of the heart. The average of
three blood measurements was obtained and registered,
according to the American Hypertension Association [27].
The diagnosis of hypertension was established in the
presence of either a systolic or diastolic blood pressure
higher than 90th percentile (P90) according to age, gender,
and height percentile.
WC was measured with a steel measuring tape at the
highest point of the iliac crest at the end of a normal
expiration, to the nearest 0.1 cm. The reference charts
used for this parameter were derived from Fernandez
et al. [12].
Weight was assessed with adolescents wearing minimal
clothing using an electronic scale previously calibrated.
Height was measured in a conventional stadiometer.
According to the Centers for Disease Control and Preven-
tion growth charts, adolescents with a ≥85th and <95th
percentile of body mass index for age and gender were
classified as overweight. Those with <85th and ≥95th
percentile were, respectively, classified as normal weight
and obese.
All blood evaluations were performed at least after an
8-h fasting period. Glucose was determined by the oxidize
method, triglycerides with a colorimetric method after
enzymatic hydrolysis with lipases techniques, and HDL/
low-density lipoprotein cholesterol by the elimination of
chylomicron. All biochemical essays were performed in the
same certified laboratory.
Statistical analysis
SPSS for windows (version 17.0) was used for all the
statistical data analysis. χ2 test for proportions were also
calculated for cross-tabulation of discrete variables.
The study was approved by the Ethics Committee of our
Institution, and patient consent to participate in the study
was obtained on entering the Obesity Management Program.
Results
A total of 237 adolescents enrolled the program, 127 of
which were girls, median age 13.4 years (minimum 10 and
maximum 20 years old). One hundred and ninety were aged
between 10 and 15 years old (97 boys and 112 girls); 47
were between 15 and 20 years old (14 boys and 33 girls).
Table 2 summarizes the distribution of the sample
according to the different demographic variables.
The gender distribution was similar in the younger
group. However, there was a significantly higher propor-
tion of girls compared to boys in the older age group (χ2 =
6.8; p<0.01).
937
Table 2 Distribution of the studied population according to demo-
graphic variables
Male Female Total
Age (years) 10–14 97 93 190 (80.1%)
15–20 14 33 47 (19.9%)
Total 111 (47%) 126 (53%) 237
Body mass ≥P85 and <P95 13 13 26 (11%)
index ≥P95 98 113 211 (89%)
Race Caucasian 97 110 207 (87%)
Black 14 16 30 (13%)
Age (years): median, 13.4; minimum, 10; and maximum, 20
There was a clear higher prevalence of obesity (89% of
the studied population), which was expected as the
adolescents were enrolled in an Obesity Management
Program. There was no significant difference in obesity
prevalence when comparing the two genders.
The majority of the patients (207, 87%) were Caucasian,
the remaining 30 being Black (13%). All Caucasian
adolescents evaluated were of Portuguese ancestry. The
Black population, although most of them born and raised in
Portugal, had a genetic and cultural African background,
namely, from the ex-Portuguese African colonies.
MS was diagnosed in 15.6%, 35%, and 8.9%, respec-
tively, according to the different set of criteria used (Table 3).
The most and less prevalent criteria were increased WC
(89.5%, 98.7%, and 93.2%, respectively, according to Cook
et al., de Ferranti et al., and IDF definitions) and high
fasting glucose (1.3% for the two first and 2.5% according
to the IDF definition). No adolescent fulfilled the five MS
criteria; and only 15 (6.3% using Cook et al. definition), 3
(1.3%, using de Ferranti et al. definition), and 12 (5.1%
using IDF definition) reached no criteria at all. When
comparing the two genders, no significant differences in the
prevalence of MS or in its individual components were
found.
Although most of the adolescents were obese, they had a
significant higher MS prevalence when compared to the
overweight ones, using the two ATP III-derived definitions
(Cook et al., χ2 =5.6, p<0.05; de Ferranti et al., χ2 =10.2,
p<0.01), but not when using the IDF definition.
Comparing the de Ferranti's with the other two defini-
tions (Table 1), the main differences concern HDL-C,
triglycerides, and WC cut-off values, which are substan-
tially more restrictive in this definition, leading to a higher
prevalence of these components and of MS (Table 3).
The IDF definition has broader cut-off values for
triglycerides and blood pressure when compared to Cook
et al. definition (Table 1), which is reflected once again on
the prevalence of the individual components and MS as
well (Table 3).
938 Eur J Pediatr (2010) 169:935–940

Table 3 Prevalence of metabolic syndrome and of its components in Discussion

the total group of 237 subjects according to the three different
definitions used
Almost all adolescents had an increased WC, and as much
Cook et al. Ferranti et al. IDF as 50% had a low HLD-C. Hypertension was highly preva-
(2003) [5] (2004) [6] (2005) [2] lent with almost 40% of the studied population having high
Components (%)a
blood pressure values. Comparing our results with a similar
Spanish study that used Cook et al. definition, we found a
HDL-C 19.8 51.1 17.3
lower prevalence of low HDL-C (19.8% vs 27%), a higher
Triglycerides 18.6 23.6 8
prevalence of hypertension (38.8% vs 23%), and a similar
Waist circumference 89.5 98.7 93.2
prevalence of hypertriglyceridemia (18.6% vs 16%) [24].
Blood pressure 38.8 38.8 19.4
In our population, only between 1% and 6% had none of
Fasting glucose 1.3 1.3 2.5
the five metabolic risk factors, meaning that the large
Metabolic syndrome (%)b
majority remain a target for specific intervention. Compar-
Yes 15.6 35 8.9
ing to the NHANES III results, where 89% of overweight
Number of
components (%)
adolescents had at least one of the components [8], we
0 6.3 1.3 5.1
found a higher prevalence of adolescents with at least one
1 38.0 26.2 60.3
of metabolic risk factors. In a European obese children
study [6], only 6.3–8.8% was free from any risk factor,
2 40.1 37.6 25.7
which is more in line with our results.
3 12.7 27.8 6.8
Using any of the three definitions, 25–40% had two of
4 3.0 7.2 2.1
the components of MS and, therefore, are at the edge of
5 0.0 0.0 0.0
fulfilling the criteria for this syndrome.
a
For the cut-off values of the different components according to the MS was more prevalent among obese when compared to
three definitions used, please see Table 1 overweight adolescents, using the two MS definitions
b
The definition of metabolic syndrome comprises the presence of derived from the ATP III which is in line with the literature
three or more components; for the International Diabetes Federation [8, 10, 35].
definition, an altered waist circumference must be one of the criteria
According to the recent report issued from the Portu-
guese Obesity Task Force, adolescent obesity prevalence is
In summary, the main differences in MS prevalence were increasing with one out of three adolescents being either
secondary to the different HDL-C, triglycerides, and blood overweight or obese [Galvão-Teles et al. (2009) ONOCOP—
pressure cut-off values. Estudo da Prevalência da Obesidade Infantil e dos Adoles-
We found a higher prevalence of high blood pressure centes em Portugal Continental]. We are not aware of any
(χ2 =12.6, p<0.001 with the first two definitions; χ2 =4.85, national study tracking the MS components/prevalence
p<0.05 using IDF definition), increased WC (Cook et al., χ2 = from adolescence to adulthood, but comparable with what
55.0, p<0.01; de Ferranti et al., χ2 =23.6, p<0.01; IDF, χ2 = happens in most western countries, cardiovascular diseases
34.2, p<0.01), and lower HDL-C values (Cook et al., are the leading cause of mortality among adults in
χ2 =4.9, p<0.05; de Ferranti et al., χ2 =10.1, p<0.01; IDF, Portugal.
χ2 =3.9, p<0.05) among obese when compared to over- Considering that, as previously stated, obesity is the
weight adolescents. most well established risk factor for MS and both are
We found an association of low HDL-C values and associated with cardiovascular diseases, these data on
hypertriglyceridemia, independently of the used definition national adolescent obesity and MS prevalence are dramatic
(Cook et al., χ2 =6.9, p<0.01; de Ferranti et al., χ2 =10.1, p< and should lead to an urgent and appropriate response.
0.01; IDF, χ2 =8.8, p<0.01). This association is recognized Using IDF definition, we were able to find a signifi-
as being a strong predictor of cardiovascular events. cantly higher prevalence of MS in older adolescents, which
When comparing the two age groups, we found a higher has also been previously described in the literature [33].
prevalence of high blood pressure (χ2 =5.0, p<0.05, using We could not find an association between MS and
the ATP III-derived definitions; χ2 =13.7, p<0.01, accord- central obesity (evaluated by the WC) as previously
ing to IDF definition) and high WC (χ2 =4.1, p<0.05, using published [16], probably because almost all adolescents in
de Ferranti et al. definition) among the 10–14-year-old our sample had an increased WC.
adolescent population. A higher number of MS components We found no differences in MS prevalence across
were present, and a higher MS prevalence was found in the gender. Literature shows conflicting data on this topic with
older group, in line with previously published data, when some pointing to a male predominance [8], while others
using IDF definition (χ2 =11.1, p<0.01). were no able to show this trend [10].
Eur J Pediatr (2010) 169:935–940
It has been described a higher prevalence of MS among
Caucasians when compared to the Black adult [13] and
adolescent [9] US population. We could not confirm these
findings in our sample maybe because only 13% of the
studied population was non-Caucasian.
To our knowledge, these are the first results on the
prevalence of MS among Portuguese obese adolescents,
and data are quite consistent with international data, both in
the US [7, 8] and in European [4, 24, 36].
Although MS was highly prevalent among the studied
population independently of the definitions used, consider-
able prevalence differences were found associated with the
different cut-off points. This high discrepancy has already
been described in previous studies [6, 7, 14].
There are some particularities regarding MS in the
pediatric population that should be addressed when trying
to reach a consensus definition.
Some of the components are influenced by age, gender,
and height, and a fixed cut-off is not acceptable as it is the
case among adults. Adolescents are submitted to the burden
of pubertal growth, which may influence blood pressure,
insulin resistance, body fat, and the lipid profiles [18]. The
prevalence of some of the metabolic risk factors may
physiologically vary throughout puberty, making it difficult to
choose a specific valid cut-off point [18]. This instability of
MS components in adolescence also made some authors
question the clinical interest of diagnosing it in children [35].
At present, there are no specific guidelines for the
screening and management of MS in pediatric patients. It is
known that individually, each of the metabolic components
of the MS are associated with type 2 diabetes and coronary
vascular disease and should be sought and be a focus of a
specific intervention. Also, as these metabolic components
are frequently associated, the finding of one of them should
lead to investigate the presence of others [18].
It has been shown that lifestyle intervention in obese
children and adolescent decreases MS prevalence [12].
Interventions should involve families and start as early as
possible, since MS is already diagnosed at early stages of
adolescence. It should target every adolescent with meta-
bolic risk factors, independently of its total number,
because each one of them is associated with an increased
risk of early cardiovascular events and type 2 diabetes
onset.
It is urgent to find a consensus on the cut-off points of
the different components that define MS, to stratify the risk
for future morbidity and identify those adolescents at high
risk in order to submit them to a more intensive lifestyle/
behavior intervention. Furthermore, a consensus definition
is crucial to perform prevalence/incidence studies, to assess
long-term medical outcomes and monitor the impact of
lifestyle changes and eventual pharmacological intervention
on MS prevalence [14].
939
Effective adolescent obesity and its co-morbidity man-
agement are of utmost importance; however, the main
efforts should remain focused on prevention.
Conflict of interests There was no funding involved in the current
study. There is also no conflict of interest.
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