Metabolic Syndrome: Criteria for Diagnosing in Children and Adolescents
Endocrinology & Metabolic Syndrome

Endocrinology & Metabolic Syndrome
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Review Article - (2013) Volume 2, Issue 3

Metabolic Syndrome: Criteria for Diagnosing in Children and Adolescents

Loreana Sanches Silveira1*, Camila Buonani2, Paula Alves Monteiro1, Bárbara De Moura Mello Antunes2 and Ismael F Freitas Júnior3
1Department of Physiotherapy UNESP, Presidente Prudente-SP, Brazil
2Department of Physical Education UNESP, Rio Claro-SP, Brazil
3Department of Physical Education UNESP, Presidente Prudente-SP, Brazil
*Corresponding Author: Loreana Sanches Silveira, Department of Physiotherapy UNESP, Presidente Prudente - SP, Brazil Email:


Metabolic Syndrome (MS) is defined as a group of risk factors related to insulin resistance and its highest prevalence is found in obese individuals. The first observations concerning MS occurred in the 1920s, contributing to a surge of new associations between hyperglycemia and obesity. As of 1979, there was a greater understanding of one of its components: insulin resistance. The prevalence of MS varies according to the diagnostic criterion used, mainly for children and adolescents among which its prevalence has increased considerably. The principle criteria used in diagnosing the pediatric population are the International Diabetes Federation (IDF), National Cholesterol Education Program and Adult Treatment Panel III (NCEP-ATP III), World Health Organization (WHO) and I Prevention Directive against Atherosclerosis in Infancy and Adolescence, and due to their differences, the prevalence of the syndrome varies according to the diagnostic criterion used. Nevertheless, many points should be taken into consideration in choosing a criterion, such as sample size, age, applicability, risk factors to be considered and available resources. In this context, efficiency and applicability are advantages in distinct criteria.

Keywords: Metabolic syndrome; Children; Adolescent


Currently, obesity is seen as an epidemic of global proportion [1] and is associated with the increase of risk for many diseases and premature death [2]. Its interaction with other systemic and metabolic diseases increases organic disturbances significantly [3]. Among the several pathologies which are associated with obesity, Metabolic Syndrome (MS) has attracted the attention of health specialists.

Recent studies revealed that population sets which contain a greater number of MS are those formed by obese individuals [3-5] and this metabolic disturbance is present in developed countries as well as developing countries, with a high rate of prevalence among the adult population e increasing prevalence in the pediatric population [6,7].

Historical Aspects and Definition

MS has been observed since the 19th Century, receiving several names down through the years [8]. The first observations related to the syndrome occurred in the 1920s [9]. In 1923, Swedish doctor Eskil Kylin observed the association between hyperglycemia, obesity and the uric acid in the joints, known as gout, in hypertensive individuals [10].

In 1965, Avogaro et al. [11] described the metabolic aspects of obesity and mentioned a syndrome called plurimetabolic [11]. However, since 1979 there was greater understanding concerning an important component of MS, which is the Insulin Resistance (IR) [12,13]. In 1980, MS was called Syndrome X by Reaven, and since the studies of Reaven and Hoffman the involvement of IR and hyperinsulinemia in hypertension [14,15] etiology was verified.

Reaven also discussed the relationship of IR to the concentration of Free Fatty Acids (FFA) and progressed in the hypothesis that IR was a central mechanism in MS [16]. Finally, in a classic article published on the subject in 1988, this author proposed that a collection of diverse risk factors, connected by a common link could compose the syndrome which was then called MS [17].

After clarifying the boundaries which characterize MS, he went on to define it as a collection of risk factors of metabolic origin that appears to be directly related to the development of atherosclerosis and cardiovascular disease [18-20]. Among these risk factors are unfavorable lipid profile, hypertension, elevated plasmatic glucose, pro-thrombotic states, proinflammatory [21] and obesity, mainly abdominal [22].


The prevalence of MS has increased drastically in the last years, transforming it into an event of global proportions, similar to the obesity proportions. As such, there is believed to be a connection between MS and obesity [21]. The confirmation of this suspicion may be exemplified in a study which says that approximately 60% of participants with moderate obese (BMI of approximately 35 kg/m2) presented MS, although less than 6% of normal-weight adults met the criteria for the metabolic syndrome, affirming that normal-weight population may also met the criteria for MS [23].

Evidences indicate between 20 and 30% of the adult population can be diagnosed with MS [21]. In the United States, the prevalence of overweight children and adolescents is 6.8% and obesity is 28.7% and in the pediatric population of Brazil, Ferreira (2007) revealed the prevalence of MS to be 17.3% in obese children aged 7 to 10.

The prevalence of MS varies depending on the diagnostic criteria used, since different health organizations develop different ways to diagnose MS, not counting other factors which can influence its rise, such as ethnicity and age [5,24]. A study performed on the American population, verified the prevalence of MS to be 22% in adults, 42% in individuals between 60 and 69 years [25], suggesting that age appears to have an influence on the development of MS.

According to a European study DECODE (Diabetes Epidemiology: Collaborative Analysis of Diagnostic Criteria in Europe) there is a significant increase in death by all causes and cardiovascular complications in individuals with MS [26]. Similar data has been presented in studies using the British, Scandinavian, and American population [27-30].

Current Criteria for Diagnosing Metabolic Syndrome

Criteria used for each one of the risk factors which characterize MS are referred to, mainly, in regards to their etiology, clinical importance of the diagnosis and physiopathological mechanisms involved in MS [31] and consequently there is no consensus in regards to MS diagnosis.

Due to this variety of diagnostic criteria, there are difficulties in establishing what the global prevalence of MS is. Each criteria takes into consideration different risk factors, our different reference values, and studies show that the same sample evaluated by different criteria can present a wide variation in regards to prevalence [32].

Grundy [21] in a review study collected the data regarding the prevalence of MS in populations in different regions in the world and used different criteria, showing the high prevalence of MS in the global population, and the difference in prevalence in the same populations when using different criteria.

The numbers presented by Grundy [21] can be observed in Table 1, in which is presented studies performed throughout Europe, in Table 2, studies in Asian populations and in Table 3, studies in Latin America.

Country Population Age(N) Criteria MS Prevalence
(% of the population)
Men Women Total
France Men and Women 35-64
NCEP 3,0 16,9 -
France Men 50-59
(10 592)
Germany Men and Women (4816 men and 2315 women) NCEP 23,5 17,6 -
Holland Adult men and women 50-75
Italy Men and Women 45-64
NCEP 24,1 23,1 22,2
Italy Men and Women 40-79
Italy Men and Women ≥19
NCEP 15,0 18,0 -
Italy Men and Women 65-84
NCEP 29,9* 55,2* -
Spain Men and Women 35-64
27,7 33,6 -
Portugal Men and Women 18-90
NCEP 19,1 21,0 23,9
Greece Men and Women Adults
Croatia Men and Women 18-88
NCEP - - 34,0
United Kingdom Men and Women 60-79
NCEP = US National Cholesterol Education Program - Adult Treatment Panel III; IDF = International Diabetes Federation;
WHO = World Health Organization. *Subgroup with diabetes, 64.9% of the men and 87.1% of the women have Metabolic Syndrome according to NCEP

Table 1: Metabolic Syndrome prevalence in Europe.

Country Population Age (N) Criteria MS Prevalence
(% of the population)
Men Women Total
India Men and Women 20-70
(26 001)
India Men and Women >20
NCEP 22,9 39,9 31,6
India Men and Women 20-75
NCEP - - 41,1
Thailand Men and Women ≥35
NCEP - - 18,0
Thailand Men and Women 20-70
NCEP 15,7 11,7 12,8
Singapore Men and Women adults
NCEP 14,1 12,3 -
China Men and Women 20-90
NCEP with BMI ≥ 25 Kg/m² 15,7 10,2 13,2
China Men and Women 18-66
- - 9,6
China Men and Women 25-64
NCEP modified for asians
China Men and Women 50-85
China Men and Women with DMT2 >30 (1039) NCEP
China Men and Women with DMT2 19-95
NCEP 23,9 12,8 16,8
Japan Men and Women 19-88 (8144) NCEP 19,0 7,0 -
Japan Men and Women 30-79 (6985) NCEP 30,2 10,3 -
Japan Men and Women >40
Three or more metabolic risk factors - - 14,9
NCEP = US National Cholesterol Education Program - Adult Treatment Panel III; IDF = International Diabetes Federation; WHO = World Health Organization: DMT2 = Diabetes Mellitus type 2; BMI = body mass index.

Table 2: Metabolic Syndrome Prevalence in Asia.

Country Population Age (N) Criteria MS Prevalence
(% of the population)
Men Women Total
Brazil Men and Women of Asian Origin 30-60 (721) NCEP modified for Asians - - 53
Brazil Men and Women of Asian Origin 40-79 (151) NCEP 36,9 38,8  
Brazil Adults (385) WHO 39,7 58,7  
Brazil Men and Women of Asian Origin (479) NCEP modified for Asians 49,8 43,0  
Brazil Girls being or not being overweight 12-19 (388) Three or more risk factors   Normal Weight 14%
Overweight 21,4%
Mexico Men and Women 20-69 (2158) NCEP
Venezuela Hispanic Men and Women ≥ 20 (3108) NCEP     35,3
NCEP = US National Cholesterol Education Program - Adult Treatment Panel III; IDF = International Diabetes Federation; WHO = World Health Organization.

Table 3: Metabolic Syndrome Prevalence in Latin America.

The situation is even more complex when dealing with children and adolescents, because of the lack of consensus about the MS diagnosis in infancy that could be accepted by the whole scientific community.

Different criteria currently used for the parameters related to metabolic syndrome were published in varied well-known organizations in the area of health. In 1999, the World Health Organization (WHO) published their definition of MS [11] and two years later the National Cholesterol Education Program and Adult Treatment Panel III (NCEP-ATP III) [33] in the United States also published their own criteria.

In Brazil, the 1st Brazilian Guidelines for Metabolic Syndrome Diagnosis and Treatment [34], published in 2004 by the Brazilian Hypertension Society based on the definition proposed by NCEP-ATP III [33]. The following year, the Brazilian Cardiology Society proposed the I Guideline for Prevention of Atherosclerosis in Infancy and Adolescence [35] thereby providing reference values of the same components present in former directives, regarding MS, but specific for children and adolescents.

Aiming to standardize the MS diagnostic criteria for children and adolescents, the International Diabetes Federation (IDF) [36] in 2007 also released a definition according to age groups, thus establishing values which could be used for anthropometric delineation, pressure and sanguinary biochemicals, to be applied to children and adolescents between 10 and 19 years [35]. Children under the age of 6 were excluded from definition, not having sufficient data for this age group. IDF does not recommend the diagnosis of MS in children under the age of ten, however it suggests monitoring the abdominal circumference and following the other risk factors in case there is family history with MS, Diabetes Mellitus type 2, dyslipidemia, heart disease, hypertension and/or obesity.

In this criteria, for youth between 10 and 16 years of age, the reference values are the same as proposed by adults, with the exception of waist circumference whose percentiles rather than absolute values have been used to compensate for varying degrees of development and ethnicity, being considered as having excess of central fat the ones who present a circumference greater than 90th percentile. It is important to clarify that for all the age groups, central obesity is an essential condition to diagnose MS, in other words, the diagnosis requires the presence of central obesity plus two or more of the other risk factors. The reason to the using of waist circumference as a central obesity measure in IDF criteria is the impractical determination of insulin resistance in clinical practice and its strong correlation with waist circumference. In the IDF criterion for adolescents older than 16, reference values developed for adults should be used [36].

Furthermore, recent studies has shown that obese children and adolescents, with higher intra-abdominal fat are more prone to develop MS and non alcoholic fatty liver disease than those with higher values of subcutaneous fat, independent of possible confounding variables. It may be explained by the endocrine function of the adipose tissue (adipokines production), causing inflammatory process and insulin resistance, especially visceral adipose tissue, which has particularities related to higher lipolysis and higher release of adipokines [37].

Among the cited criteria, the most used are that from WHO and that of NCEP-ATP III and some differences among them are observed. The definition from WHO requires evaluation of resistance to insulin or the alteration of the glucose metabolism. On the other hand, the definition from NCEP-ATP III does not require the measuring of resistance to insulin, facilitating its use in epidemiological studies [38].

Comparative studies, using various diagnostic criteria of the metabolic syndrome for children and adolescents confirms the difference in prevalence and verifies that the one connected with WHO was the one which resulted in greater prevalence and consequently the one recommended because of the emphasis on glycemic homeostasis [32,39].

The prevalence of the syndrome in Brazil in children and obese adolescents can reach between 23% [40] to 39.1% [41]. The importance of identifying the risk factors and the forms of control and the treatment of MS in infancy and adolescence is because its presence in this phase of life remains, many years in “silence”. Therefore, its identification can contribute to the prevention of chronic diseases and premature death. Currently, there already exist MS definitions for children and adolescents which use as one of the criteria the abdominal obesity [42,43].

In Table 4 there are presented the main parameters and their respective reference values which are applied to children and adolescents.

Risk Factors IDF [36] WHO [44] NCEP [33] I DPAIA [35]
Age 10 to <16 years   12 to 19 years  
MS Diagnosis Obesity plus 2 or more RF 3 or more RF 3 or more RF  
Obesity WC ≥ 90th percentile or adult cut-off if lower BMI>95th percentile WC ≥ 90th percentile BMI>85th percentile according to sex and age
Glycemic homeostasis Fasting glucose
≥ 5.6 mmol/L
(100 mg/dL) or
known Diabetes Mellitus type2
· Hyperinsulinemia
prepubertal >15 mU/L;(31)
(stage 1 Tanner)
pubertal>30 mU/L; (31)
(stages 2-4 Tanner)
Post-pubertal ≥ 20 mU/L
(stage 5 Tanner)
· Fasting glucose ≥ 6.1 mM/L · Glucose intolerance · Glucose at 120 min ≥ 7.8 mM/L
Fasting glucose
≥ 110 mg/dL
Plasma Insulin
>15 um/L
Elevated Arterial Pressure Systolic BP ≥ 130 mmHg
o r
Diastolic BP ≥ 85 mmHg
SBP>95th percentile for age, sex and stature NHBPEP [46] SBP/DBP ≥ 90th percentile for age and sex and stature NHBPEP [45] SBP and/or DBP in >90th and >95th percentiles
or always that BP >120/80 mmHg
Dyslipidemia · TG ≥1.7 mmol/L
(150 mg/dL)
· HDL <1.03 mmol/L
(40 mg/dL)
· TG >105 mg/dL for< 10 years >13 6mg/dL for ≥ 10 years
· HDL <35 mg/dL
· TC>95th percentile
· TG ≥110 mg/dL
· HDL ≤ 40 mg/dL
TC < 150 mg/dL
LDL <100 mg/dL
HDL ≥ 45 mg/dL
TG <100 mg/dL
MS = metabolic syndrome; RF = risk factors; IDF = International Diabetes Federation; WHO = World Health Organization; NCEP = National Cholesterol Education Program - Adult Treatment Panel III; I DPAIA = Guidelines for the Prevention of Atherosclerosis in Childhood and Adolescence, BMI = body mass index, WC = waist circumference, TC= total cholesterol; TG = triglycerides, HDL = high density lipoprotein, SBP = systolic blood pressure, DBP = diastolic blood pressure; mm Hg = millimeters of mercury; mg/dL = milligrams per deciliter; mM / L = millimoles per liter

Table 4: Diagnostic Criteria for Metabolic Syndrome adapted for children and adolescents proposed by IDF, WHO, NCEP and I DPAID.

Some authors also adapted definitions proposed for adults to be applied on children and adolescents (Table 5).

Cook et al. Arch Pediatr Adolesc Med, 2003; 157, 821-7 [46] de Ferranti
et al. Circulation, 2004; 110, 2494-7 [47]
Cruz and Goran J Clin Endocrinol Metab, 2004; 89, 108-13 [48] Weiss et al. N Engl J Med, 2004; 350, 2362-74 [49] Ford Diabetes Care, 2005; 28, 878-81 [50]
Presence of three or more criteria
Fasting glucose
≥ 110 mg/dL
Fasting glucose
≥ 110 mg/dL
Glucose intolerance (ADAcriteria) Glucose intolerance (ADAcriteria) Fasting glucose
≥ 110 mg/dL
WC> 90th percentile (specific for age and sex, NHANES III) WC>75th percentile (specific for age and sex, NHANES III) WC>90th percentile (specific for age and sex, NHANES III) BMI - Z Score ≥ 2 (specific for age and sex) WC>90th percentile (specific for sex, NHANES III)
TG ≥ 110 mg/dL (specific for age and sex, NCEP) TG
≥ 100 mg/dL
TG ≥ 90th percentile (specific for age and sex, NHANES III) TG ≤ 95th percentile (specific for age and sex, ethnicity, NCHS) TG ≥ 110 mg/dL (specific for age and sex, NCEP)
<40 mg/dL (specific for age, NCEP)
< 50 mg/dL
HDL ≤ 10th percentile (specific for age and sex, NHANES III) HDL ≤ 5th percentile (specific for age and sex, ethnicity, NCHS) HDL
< 40 mg/dL (specific for age, NCEP)
BP ≥ 90th percentile (specific for age, sex and height NHBPEP) [46] BP ≥ 90th percentile (specific for age, sex and height NHBPEP)[46] BP ≥ 90th percentile (specific for age, sex and height NHBPEP) [46] BP ≥ 95th percentile (specific for age, sex and height NHBPEP) [46] BP ≥ 90th percentile (specific for age, sex and height NHBPEP) [46]
WC = waist circumference; NHANES III = Third National Health and Nutrition Examination Survey; TG = triglycerides;
NCEP = US National Cholesterol Education Program; BP = blood pressure; ADA = American Diabetes Association;
BMI = body mass index; NHBPEP = National High Blood Pressure Education Program;
NCHS= National Center for Health Statistics; HDL = high density lipoprotein.

Table 5: Definitions for metabolic syndrome for children and adolescents adapted by various authors.


The prevalence of MS has increased in the whole world’s adult population and pediatric population, and defining its prevalence has been an arduous task, due to the lack of consensus of its diagnostic criteria. When dealing with the ease in relation to its applicability and sensitivity, the criteria from the International Diabetes Federation can be considered the most advantageous. However, considering the efficacy of the diagnosis, the criteria which most emphasizes the characteristics of glycemic homeostasis, and consequently the main risk factor of MS, resistance to insulin, is the criteria from the World Health Organization for taking into consideration the risk factors like fasting glucose, hyperinsulinemia and glucose intolerance.


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Citation: Silveira LS, Buonani C, Monteiro PA, Mello Antunes BM, Freitas Júnior IF (2013) Metabolic Syndrome: Criteria for Diagnosing in Children and Adolescents. Endocrinol Metab Synd 2:118.

Copyright: © 2013 Silveira LS, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.