J Korean Med Assoc.  2010 May;53(5):392-406.

Measures against Pediatric Metabolic Syndrome

• Lee YA
• Shin CH
• Lim JS

Abstract

The incidence of metabolic syndrome (MS) has increased significantly worldwide including Korea over the past decade. Recent studies have shown that the MS develops during childhood and is highly prevalent among overweight children and adolescents. Thus, it is important for physicians to be acquainted with the definition, diagnostic criteria, epidemiology, and pathophysiology of MS for early identification and management of the MS in children and adolescents, which would be helpful to decrease the burden of type 2 diabetes and cardiovascular disease in adults. The aim of this review is to provide adequate guidelines for screening and managing strategies on MS based on recent findings. Proper and effective control of MS needs close cooperation among patients, physician, family members, school, society, and government, and it should be based on a thorough evaluation of medical system on obesity and MS.

Keyword

Metabolic syndrome; Child; Adolescent; Primary Health Care; Obesity; Insulin resistance; Mass screening

MeSH Terms

Adolescent
Adult
Cardiovascular Diseases
Child
Humans
Incidence
Insulin Resistance
Korea
Mass Screening
Obesity
Overweight
Physicians, Family
Primary Health Care

Reference

1. Huang PL. A comprehensive definition for metabolic syndrome. Dis Model Mech. 2009; 2:231–237.

2. Hong YM, Song YW, Kim HS, Park HS, Min JH, Jung JW, Kim NS, Noh CI. Metabolic syndrome in the overweight and obese adolescents and the impact of obesity on the cardiovascular system. Korean J Pediatr. 2009; 52:1109–1118.

3. Chen W, Srinivasan SR, Li S, Xu J, Berenson GS. Clustering of longterm trends in metabolic syndrome variables from childhood to adulthood in Blacks and Whites: the Bogalusa Heart Study. Am J Epidemiol. 2007; 166:527–533.

4. Chen W, Srinivasan SR, Li S, Xu J, Berenson GS. Metabolic syndrome variables at low levels in childhood are beneficially associated with adulthood cardiovascular risk: the Bogalusa Heart Study. Diabetes Care. 2005; 28:126–131.

5. Oh K, Jang MJ, Lee NY, Moon JS, Lee CG, Yoo MH, Kim YT. Prevalence and trends in obesity among Korean children and adolescents in 1997 and 2005. Korean J Pediatr. 2008; 51:950–955.

6. DeFronzo RA, Ferrannini E. Insulin resistance. A multifaceted syndrome responsible for NIDDM, obesity, hypertension, dyslipidemia, and atherosclerotic cardiovascular disease. Diabetes Care. 1991; 14:173–194.

7. Eckel RH, Grundy SM, Zimmet PZ. The metabolic syndrome. Lancet. 2005; 365:1415–1428.

8. Beltrand J, Lévy-Marchal C. Pathophysiology of insulin resistance in subjects born small for gestational age. Best Pract Res Clin Endocrinol Metab. 2008; 22:503–515.

9. Saenger P, Czernichow P, Hughes I, Reiter EO. Small for gestational age: short stature and beyond. Endocr Rev. 2007; 28:219–251.

10. Park HK, Kim MJ, Kim YH, Jung JA, Yang S, Hwang IT, Lee HR, Kim JS. The prevalence of metabolic syndrome in children and adolescents born small for gestational age. J Korean Soc Pediatr Endocrinol. 2007; 12:55–62.

11. Srinivasan SR, Myers L, Berenson GS. Predictability of childhood adiposity and insulin for developing insulin resistance syndrome (syndrome X) in young adulthood: the Bogalusa Heart Study. Diabetes. 2002; 51:204–209.

12. Sinaiko AR, Donahue RP, Jacobs DR Jr, Prineas RJ. Relation of weight and rate of increase in weight during childhood and adolescence to body size, blood pressure, fasting insulin, and lipids in young adults. The Minneapolis Children? s Blood Pressure Study. Circulation. 1999; 99:1471–1476.

13. Muniyappa R, Iantorno M, Quon MJ. An integrated view of insulin resistance and endothelial dysfunction. Endocrinol Metab Clin North Am. 2008; 37:685–711.

14. Yamauchi T, Kadowaki T. Physiological and pathophysiological roles of adiponectin and adiponectin receptors in the integrated regulation of metabolic and cardiovascular diseases. Int J Obes (Lond). 2008; 32(S7):S13–18.

15. Park MY, Ahn SA, Cho WK, Cho KS, Park SH, Hahn SH, Jung MH, Suh BK. Serum leptin, adiponectin and resistin levels in obese children and their correlations with insulin resistance. Korean J Pediatr. 2009; 52:766–771.

16. Evans JL, Goldfine ID, Maddux BA, Grodsky GM. Are oxidative stress-activated signaling pathways mediators of insulin resistance and beta-cell dysfunction? Diabetes. 2003; 52:1–8.

17. Johnson RJ, Perez-Pozo SE, Sautin YY, Manitius J, Sanchez-Lozada LG, Feig DI, Shafiu M, Segal M, Glassock RJ, Shimada M, Roncal C, Nakagawa T. Hypothesis: could excessive fructose intake and uric acid cause type 2 diabetes? Endocr Rev. 2009; 30:96–116.

18. Vos MB, Kimmons JE, Gillespie C, Welsh J, Blanck HM. Dietary fructose consumption among US children and adults: the Third National Health and Nutrition Examination Survey. Medscape J Med. 2008; 10:160.

19. Johnson RJ, Segal MS, Sautin Y, Nakagawa T, Feig DI, Kang DH, Gersch MS, Benner S, Sánchez-Lozada LG. Potential role of sugar (fructose) in the epidemic of hypertension, obesity and the metabolic syndrome, diabetes, kidney disease, and cardiovascular disease. Am J Clin Nutr. 2007; 86:899–906.

20. Stanhope KL, Schwarz JM, Keim NL, Griffen SC, Bremer AA, Graham JL, Hatcher B, Cox CL, Dyachenko A, Zhang W, McGahan JP, Seibert A, Krauss RM, Chiu S, Schaefer EJ, Ai M, Otokozawa S, Nakajima K, Nakano T, Beysen C, Hellerstein MK, Berglund L, Havel PJ. Consuming fructose-sweetened, not glucose-sweetened, beverages increases visceral adiposity and lipids and decreases insulin sensitivity in overweight/obese humans. J Clin Invest. 2009; 119:1322–1334.

21. Wei Y, Pagliassotti MJ. Hepatospecific effects of fructose on c-jun NH2-terminal kinase: implications for hepatic insulin resistance. Am J Physiol Endocrinol Metab. 2004; 287:E926–933.

22. Dong XC, Copps KD, Guo S, Li Y, Kollipara R, DePinho RA, White MF. Inactivation of hepatic Foxo1 by insulin signaling is required for adaptive nutrient homeostasis and endocrine growth regulation. Cell Metab. 2008; 8:65–76.

23. Lindqvist A, Baelemans A, Erlanson-Albertsson C. Effects of sucrose, glucose and fructose on peripheral and central appetite signals. Regul Pept. 2008; 150:26–32.

24. Sundaram SS, Zeitler P, Nadeau K. The metabolic syndrome and nonalcoholic fatty liver disease in children. Curr Opin Pediatr. 2009; 21:529–535.

25. Manco M, Marcellini M, Devito R, Comparcola D, Sartorelli MR, Nobili V. Metabolic syndrome and liver histology in paediatric non-alcoholic steatohepatitis. Int J Obes (Lond). 2008; 32:381–387.

26. Schindhelm RK, Dekker JM, Nijpels G, Bouter LM, Stehouwer CD, Heine RJ, Diamant M. Alanine aminotransferase predicts coronary heart disease events: a 10-year followup of the Hoorn Study. Atherosclerosis. 2007; 191:391–396.

27. Goessling W, Massaro JM, Vasan RS, D? Agostino RB Sr, Ellison RC, Fox CS. Aminotransferase levels and 20-year risk of metabolic syndrome, diabetes, and cardiovascular disease. Gastroenterology. 2008; 135:1935–1944.

28. Zimmet P, Alberti KG, Kaufman F, Tajima N, Silink M, Arslanian S, Wong G, Bennett P, Shaw J, Caprio S. IDF Consensus Group. The metabolic syndrome in children and adolescents-an IDF consensus report. Pediatr Diabetes. 2007; 8:299–306.

29. Steinberger J, Daniels SR, Eckel RH, Hayman L, Lustig RH, McCrindle B, Mietus-Snyder ML. American Heart Association Atherosclerosis, Hypertension, and Obesity in the Young Committee of the Council on Cardiovascular Disease in the Young; Council on Cardiovascular Nursing; and Council on Nutrition, Physical Activity, and Metabolism. Progress and challenges in metabolic syndrome in children and adolescents: a scientific statement from the American Heart Association Atherosclerosis, Hypertension, and Obesity in the Young Committee of the Council on Cardiovascular Disease in the Young; Council on Cardiovascular Nursing; and Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2009; 119:628–647.

30. Ford ES, Li C. Defining the metabolic syndrome in children and adolescents: will the real definition please stand up? J Pediatr. 2008; 152:160–164.

31. Cook S, Weitzman M, Auinger P, Nguyen M, Dietz WH. Prevalence of a metabolic syndrome phenotype in adolescents: findings from the third National Health and Nutrition Examination Survey, 1988-1994. Arch Pediatr Adolesc Med. 2003; 15:821–827.

32. Tailor AM, Peeters PH, Norat T, Vineis P, Romaguera D. An update on the prevalence of the metabolic syndrome in children and adolescents. Int J Pediatr Obes 2009 [Epub ahead of print].

33. Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med. 1998; 15:539–553.

34. Park MJ, Boston BA, Oh M, Jee SH. Prevalence and trends of metabolic syndrome among Korean adolescents: from the Korean NHANES survey, 1998-2005. J Pediatr. 2009; 155:529–534.

35. Kong AP, Ko GT, Ozaki R, Wong GW, Tong PC, Chan JC. Metabolic syndrome by the new IDF criteria in Hong Kong Chinese adolescents and its prediction by using body mass index. Acta Paediatr. 2008; 97:1738–1742.

36. Park J, Hilmers DC, Mendoza JA, Stuff JE, Liu Y, Nicklas TA. Prevalence of metabolic syndrome and obesity in adolescents aged 12 to 19 years: comparison between the United States and Korea. J Korean Med Sci. 2010; 25:75–82.

37. Berenson GS, Srinivasan SR, Bao W, Newman WP 3rd, Tracy RE, Wattigney WA. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. The Bogalusa Heart Study. N Engl J Med. 1998; 338:1650–1656.

38. McGill HC Jr, McMahan CA, Herderick EE, Zieske AW, Malcom GT, Tracy RE, Strong JP. Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. Obesity accelerates the progression of coronary atherosclerosis in young men. Circulation. 2002; 105:2712–2718.

39. Mattsson N, Rönnemaa T, Juonala M, Viikari JS, Raitakari OT. Childhood predictors of the metabolic syndrome in adulthood. The Cardiovascular Risk in Young Finns Study. Ann Med. 2008; 40:542–552.

40. Morrison JA, Friedman LA, Wang P, Glueck CJ. Metabolic syndrome in childhood predicts adult metabolic syndrome and type 2 diabetes mellitus 25 to 30 years later. J Pediatr. 2008; 152:201–206.

41. Morrison JA, Friedman LA, Gray-McGuire C. Metabolic syndrome in childhood predicts adult cardiovascular disease 25 years later: the Princeton Lipid Research Clinics Follow-up Study. Pediatrics. 2007; 120:340–345.

42. McGill HC Jr, McMahan CA, Zieske AW, Malcom GT, Tracy RE, Strong JP. Effects of nonlipid risk factors on atherosclerosis in youth with a favorable lipoprotein profile. Circulation. 2001; 103:1546–1550.

43. Davis PH, Dawson JD, Riley WA, Lauer RM. Carotid intimal-medial thickness is related to cardiovascular risk factors measured from childhood through middle age: The Muscatine Study. Circulation. 2001; 104:2815–2819.

44. US Preventive Services Task Force. Screening and interventions for overweight in children and adolescents: recommendation statement. Pediatrics. 2005; 116:205–209.

45. US Preventive Services Task Force. Barton M. Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement. Pediatrics. 2010; 125:361–367.

46. US Preventive Services Task Force. Screening for lipid disorders in children: US Preventive Services Task Force recommendation statement. Pediatrics. 2007; 120:e215–219.

47. National Screening Committee policy-familial hypercholesterolaemia (hyperlipidaemia) screening (children). Available from:. http://www.library.nhs.uk/screening/ViewResource.aspx?resID=60325&tabID=288&catID=1968.

48. Daniels SR, Greer FR. Committee on Nutrition. Lipid screening and cardiovascular health in childhood. Pediatrics. 2008; 122:198–208.

49. Kwiterovich PO Jr. Recognition and management of dyslipidemia in children and adolescents. J Clin Endocrinol Metab. 2008; 93:4200–4209.

50. Shaw JE, Zimmet PZ, de Courten M, Dowse GK, Chitson P, Gareeboo H, Hemraj F, Fareed D, Tuomilehto J, Alberti KG. Impaired fasting glucose or impaired glucose tolerance. What best predicts future diabetes in Mauritius? Diabetes Care. 1999; 22:399–402.

51. Nathan DM, Davidson MB, DeFronzo RA, Heine RJ, Henry RR, Pratley R, Zinman B. American Diabetes Association. Impaired fasting glucose and impaired glucose tolerance: implications for care. Diabetes Care. 2007; 30:753–759.

52. Weiss R, Taksali SE, Tamborlane WV, Burgert TS, Savoye M, Caprio S. Predictors of changes in glucose tolerance status in obese youth. Diabetes Care. 2005; 28:902–909.

53. Levitan EB, Song Y, Ford ES, Liu S. Is nondiabetic hyperglycemia a risk factor for cardiovascular disease? A metaanalysis of prospective studies. Arch Intern Med. 2004; 164:2147–2155.

54. Waugh N, Scotland G, McNamee P, Gillett M, Brennan A, Goyder E, Williams R, John A. Screening for type 2 diabetes: literature review and economic modelling. Health Technol Assess. 2007; 11:iii–iv. ix-xi, 1-125.

55. Orozco LJ, Buchleitner AM, Gimenez-Perez G, Roquél Figuls M, Richter B, Mauricio D. Exercise or exercise and diet for preventing type 2 diabetes mellitus. Cochrane Database Syst Rev. 2008; 3:CD003054.

56. Li G, Zhang P, Wang J, Gregg EW, Yang W, Gong Q, Li H, Li H, Jiang Y, An Y, Shuai Y, Zhang B, Zhang J, Thompson TJ, Gerzoff RB, Roglic G, Hu Y, Bennett PH. The longterm effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year followup study. Lancet. 2008; 371:1783–1789.

57. Diabetes Prevention Program Research Group. Knowler WC, Fowler SE, Hamman RF, Christophi CA, Hoffman HJ, Bren-neman AT, Brown-Friday JO, Goldberg R, Venditti E, Nathan DM. 10-year followup of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet. 2009; 374:1677–1686.

58. Lilly M, Godwin M. Treating prediabetes with metformin: systematic review and metaanalysis. Can Fam Physician. 2009; 55:363–369.

59. U.S. Preventive Services Task Force. Screening for type 2 diabetes mellitus in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008; 148:846–854.

60. Krebs NF, Himes JH, Jacobson D, Nicklas TA, Guilday P, Styne D. Assessment of child and adolescent overweight and obesity. Pediatrics. 2007; 120(Suppl 4):S193–228.

61. August GP, Caprio S, Fennoy I, Freemark M, Kaufman FR, Lustig RH, Silverstein JH, Speiser PW, Styne DM, Montori VM. Endocrine Society. Prevention and treatment of pediatric obesity: an endocrine society clinical practice guideline based on expert opinion. J Clin Endocrinol Metab. 2008; 93:4576–4599.

62. American Diabetes Association. Standards of medical care in diabetes-2010. Diabetes Care. 2010; 33(S1):S11–61.

63. Park HS, Han JH, Choi KM, Kim SM. Relation between elevated serum alanine aminotransferase and metabolic syndrome in Korean adolescents. Am J Clin Nutr. 2005; 82:1046–1051.

64. Pacifico L, Cantisani V, Ricci P, Osborn JF, Schiavo E, Anania C, Ferrara E, Dvisic G, Chiesa C. Nonalcoholic fatty liver disease and carotid atherosclerosis in children. Pediatr Res. 2008; 63:423–427.

65. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ. 2000; 320:1240–1243.

66. Dam-Larsen S, Franzmann M, Andersen IB, Christoffersen P, Jensen LB, S⊘rensen TI, Becker U, Bendtsen F. Long term prognosis of fatty liver: risk of chronic liver disease and death. Gut. 2004; 53:750–755.

67. Tock L, Prado WL, Caranti DA, Cristofalo DM, Lederman H, Fisberg M, Siqueira KO, Stella SG, Antunes HK, Cintra IP, Tufik S, de Mello MT, Dâmaso AR. Nonalcoholic fatty liver disease decrease in obese adolescents after multidisciplinary therapy. Eur J Gastroenterol Hepatol. 2006; 18:1241–1245.

68. Nobili V, Manco M, Ciampalini P, Alisi A, Devito R, Bugianesi E, Marcellini M, Marchesini G. Metformin use in children with nonalcoholic fatty liver disease: an open-label, 24-month, observational pilot study. Clin Ther. 2008; 30:1168–1176.

69. Nobili V, Manco M, Devito R, Di Ciommo V, Comparcola D, Sartorelli MR, Piemonte F, Marcellini M, Angulo P. Lifestyle intervention and antioxidant therapy in children with nonalcoholic fatty liver disease: a randomized, controlled trial. Hepatology. 2008; 48:119–128.

70. Nobili V, Manco M, Devito R, Ciampalini P, Piemonte F, Marcellini M. Effect of vitamin E on aminotransferase levels and insulin resistance in children with non-alcoholic fatty liver disease. Aliment Pharmacol Ther. 2006; 24:1553–1561.

71. Cruz ML, Goran MI. The metabolic syndrome in children and adolescents. Curr Diab Rep. 2004; 4:53–62.

72. Nemet D, Barkan S, Epstein Y, Friedland O, Kowen G. Eliakim A Short-and longterm beneficial effects of a combined dietary-behavioral-physical activity intervention for the treatment of childhood obesity. Pediatrics. 2005; 115:e443–449.

73. Casazza K, Dulin-Keita A, Gower BA, Fernandez JR. Differential influence of diet and physical activity on components of metabolic syndrome in a multiethnic sample of children. J Am Diet Assoc. 2009; 109:236–244.

74. Ventura AK, Loken E, Birch LL. Risk profiles for metabolic syndrome in a nonclinical sample of adolescent girls. Pediatrics. 2006; 118:2434–2442.

75. Oh JH, Kwak IK, Yang S, Hwang IT, Jung JA, Lee HR. A Study of the relationship between childhood obesity and beverage intake. Kor J Pediatr. 2003; 46:1061–1066.

76. Klein-Platat C, Drai J, Oujaa M, Schlienger JL, Simon C. Plasma fatty acid composition is associated with the metabolic syndrome and low-grade inflammation in overweight adolescents. Am J Clin Nutr. 2005; 82:1178–1184.

77. Gidding SS, Dennison BA, Birch LL, Daniels SR, Gillman MW, Lichtenstein AH, Rattay KT, Steinberger J, Stettler N, Van Horn L. American Heart Association; American Academy of Pediatrics. Dietary recommendations for children and adolescents: a guide for practitioners: consensus statement from the American Heart Association. Circulation. 2005; 112:2061–2075.

78. Steffen LM, Jacobs DR Jr, Murtaugh MA, Moran A, Steinberger J, Hong CP, Sinaiko AR. Whole grain intake is associated with lower body mass and greater insulin sensitivity among adolescents. Am J Epidemiol. 2003; 158:243–250.

79. Ventura EE, Davis JN, Alexander KE, Shaibi GQ, Lee W, Byrd-Williams CE, Toledo-Corral CM, Lane CJ, Kelly LA, Wei-gensberg MJ, Goran MI. Dietary intake and the metabolic syndrome in overweight Latino children. J Am Diet Assoc. 2008; 108:1355–1359.

80. Barlow SE. Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007; 120(S4):S164–192.

81. Kamath CC, Vickers KS, Ehrlich A, McGovern L, Johnson J, Singhal V, Paulo R, Hettinger A, Erwin PJ, Montori VM. Clinical review: behavioral interventions to prevent childhood obesity: a systematic review and metaanalyses of randomized trials. J Clin Endocrinol Metab. 2008; 93:4606–4615.

82. McGovern L, Johnson JN, Paulo R, Hettinger A, Singhal V, Kamath C, Erwin PJ, Montori VM. Clinical review: treatment of pediatric obesity: a systematic review and metaanalysis of randomized trials. J Clin Endocrinol Metab. 2008; 93:4600–4605.

83. Schmitz KH, Jacobs DR Jr, Hong CP, Steinberger J, Moran A, Sinaiko AR. Association of physical activity with insulin sensitivity in children. Int J Obes Relat Metab Disord. 2002; 26:1310–1316.

84. Kelly AS, Wetzsteon RJ, Kaiser DR, Steinberger J, Bank AJ, Dengel DR. Inflammation, insulin, and endothelial function in overweight children and adolescents: the role of exercise. J Pediatr. 2004; 145:731–736.

85. Torrance B, McGuire KA, Lewanczuk R, McGavock J. Overweight, physical activity and high blood pressure in children: a review of the literature. Vasc Health Risk Manag. 2007; 3:139–149.

86. Kavey RE, Allada V, Daniels SR, Hayman LL, McCrindle BW, Newburger JW, Parekh RS, Steinberger J. American Heart Association Expert Panel on Population and Prevention Science. American Heart Association Council on Cardiovascular Disease in the Young. American Heart Association Council on Epidemiology and Prevention. American Heart Association Council on Nutrition, Physical Activity and Metabolism; American Heart Association Council on High Blood Pressure Research. American Heart Association Council on Cardiovascular Nursing. American Heart Association Council on the Kidney in Heart Disease. Interdisciplinary Working Group on Quality of Care and Outcomes Research. Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. 2006; 114:2710–2738.

87. Weiss R. Impaired glucose tolerance and risk factors for progression to type 2 diabetes in youth. Pediatr Diabetes. 2007; 8(S9):70–75.

88. Kavey RE, Daniels SR, Lauer RM, Atkins DL, Hayman LL, Taubert K. American Heart Association. American Heart Association guidelines for primary prevention of atherosclerotic cardiovascular disease beginning in childhood. Circulation. 2003; 107:1562–1566.

89. McCrindle BW, Urbina EM, Dennison BA, Jacobson MS, Steinberger J, Rocchini AP, Hayman LL, Daniels SR. American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee; American Heart Association Council of Cardiovascular Disease in the Young; American Heart Association Council on Cardiovascular Nursing. Drug therapy of high-risk lipid abnormalities in children and adolescents: a scientific statement from the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee, Council of Cardiovascular Disease in the Young, with the Council on Cardiovascular Nursing. Circulation. 2007; 115:1948–1967.

90. American Diabetes Association. Management of dyslipidemia in children and adolescents with diabetes. Diabetes Care. 2003; 26:2194–2197.

91. Lurbe E, Cifkova R, Cruickshank JK, Dillon MJ, Ferreira I, Invitti C, Kuznetsova T, Laurent S, Mancia G, Morales-Olivas F, Rascher W, Redon J, Schaefer F, Seeman T, Stergiou G. Management of high blood pressure in children and adolescents: recommendations of the European Society of Hypertension. J Hypertens. 2009; 27:1719–1742.

92. Khan LK, Sobush K, Keener D, Goodman K, Lowry A, Kakietek J, Zaro S. Centers for Disease Control and Prevention. Recommended community strategies and measurements to prevent obesity in the United States. MMWR Recomm Rep. 2009; 58:1–26.

93. Dobbins M, De Corby K, Robeson P, Husson H, Tirilis D. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6-18. Cochrane Database Syst Rev. 2009; 1:CD007651.

94. Gonzalez-Suarez C, Worley A, Grimmer-Somers K, Dones V. School-based interventions on childhood obesity: a metaanalysis. Am J Prev Med. 2009; 37:418–427.