4/28/2014 COMMENTARIES

http://www.athero.org/commentaries/comm697.asp 1/2
COMMENTARIES
Childhood Overweight, Obesity, and Metabolic Syndrome in Developing Countries
Roya Kelishadi, M.D., Associate Professor of Pediatrics, Head, Preventive Pediatric Cardiology Department, Isfahan Cardiovascular Research Center (WHO-
Collaborating Center), Isfahan University of Medical Sciences, Isfahan, Iran
Please address correspondence to:
Roya Kelishadi, M.D.
Associate Professor of Pediatrics
Head, Preventive Pediatric Cardiology Department,
Isfahan Cardiovascular Research Center (WHO-Collaborating Center)
Isfahan University of Medical Sciences
P.O. Box 81465-1148
Isfahan, Iran
Tel: +98 311 33771-8
Fax: +98 311 3373435
E-mail: kroya@aap.net , kelishadi@med.mui.ac.ir
The potential increase in chronic disease is escalating much more rapidly in low- and middle-income than high-income countries. According to the World Health
organization (WHO) estimates, by the year 2020, chronic diseases will account for approximately three-quarters of all death in the developing world [1]. Obesity is
a major risk factor for chronic diseases and plays a central role in the metabolic syndrome (MetS), and as a result, an increased risk of atherosclerotic
cardiovascular diseases.
Low- and middle-income nations face the double burden of having both malnourished and overnourished populations, with most overweight and obese
children being concentrated in urban areas. Genetic predisposition or early-life adverse events may contribute to the insulin resistance and adverse body fat-
patterning seen in the MetS and its related complications notably in non-European populations [2]. In developing countries, the rapid progress of urbanization and
demographic trends is associated with a cluster of non-communicable diseases and unhealthy lifestyles described as the lifestyle syndrome or the New World
syndrome. This is suggested as one of the most important etiologies for the very high rates of obesity and its consequent morbidity and mortality in developing
nations. In addition, in such communities, childhood obesity is still considered a sign of healthiness and high social class; and this emerging problem has been
largely ignored in health strategies of these countries which in turn is likely to create an enormous socioeconomic and public health burden for poorer nations in the
near future [3]. Hence, it is reasonable to increase our knowledge about the prevalence of these disorders in developing countries that are still grappling with the
public health effects of malnutrition and micronutrient deficiencies.
This review was carried out through an electronic search of the literature from 1950-2007, and data from surveys on the prevalence of overweight, obesity, and the MetS among children living in developing countries are compared in different regions. Epidemiological Reviews 2007 [
Overweight/Obesity
CHILDREN AT PRE-SCHOOL AGE
An estimated 22 million children under five are estimated to be at-risk of overweight and or overweight worldwide. Malnutrition and obesity coexist in many developing nations. While
These findings highlight that concurrent overweight or obesity and stunting is an important public health issue in low- and middle-income countries
beginning in early childhood. Maternal undernutrition, with intra-uterine growth retardation, compromised lactation, and infant feeding lead to stunting in early life.
This pattern is usually followed by overfeeding of stunted children with diets of low nutritional quality, characterized by energy-dense foods of low and little food
component density and diversity, which in turn would lead to rapid weight gain later in childhood. This growth pattern may lead to a disproportionately high fat
mass accompanied with central fat deposition and its consequences. It is therefore necessary to implement vigorous efforts to optimize infantile and childhood
growth, and to modify prenatal and perinatal determinants of adverse adult health outcomes.
CHILDREN AND ADOLESCENTS AGED 6-18 YEARS
In developing countries, the prevalence of overweight/obesity in older children is reported to be much higher than in preschoolers. However, considering the large
differences existing in socio-cultural context of these countries, and the rapid epidemiologic transition, the extent of childhood overweight largely differs across
countries. The highest prevalence of childhood overweight was found in Eastern Europe and the Middle East, whereas India and Sri Lanka had the lowest
prevalence. The highest prevalence reported from Eastern Europe is reported from Bosnia with a prevalence of 48.35% among boys and 30.77% among girls aged
13-14 years [7]. In the Middle-East, the highest prevalence of obesity is reported from Bahrain, being 21% in males and 35% in females aged 12-17 years [8],
followed by Kuwait, where the overall prevalence of overweight and obesity is reported 30.0% and 14.7%, respectively among males; and 31.8% and 13.1%,
respectively among females, aged 10-14 years [9]. In general, the prevalence of childhood obesity in Iran (overweight present in 8.8% and obesity in 4.5% of 6-18
year olds) is much lower than Arab countries in the region, which is suggested to be due to both genetic and lifestyle differences between Iranian and Arab
nations.
The comparison between different countries is provided in Figure1.
PEDI A TRI C META BOLI C SYNDROME
Experience is very limited about the prevalence of the MetS in children and adolescents living in developing countries. Most of these studies used definitions based
on the ATP III criteria, but with different cutoff values for each component. In Turkey 2.2% of adolescents are reported to have MetS, with nearly 10 times more
common among overweight and obese adolescents (21%) [10]. A study in the capital city of Iran reported a prevalence of 10.1% for the MetS in adolescents aged
10-19 years (10.3% in boys and 9.9% in girls) [11]. In the first national study in a non-Western population conducted in a large national-representative sample,
that included not only adolescents, but also children as young as 6 years, 14.1% of the children and adolescents studied had metabolic syndrome [12]. The
prevalence of the MetS among Korean adolescents aged 12-19 years [13]. In studies conducted among children and adults in Iran and Turkey, the most frequent
components of the metabolic syndrome were high TG and low HDL-C [14-15]. This can reflect an ethnic predisposition to this type of dyslipidemia in this region.
A complex interaction of genetic, environmental, and behavioral factors is suggested as the underlying cause of the metabolic syndrome. The only report
regarding the association of lifestyle factors and the MetS in the pediatric population of developing countries showed that the risk of the MetS rose with the
consumption of solid hydrogenated fat and white-flour bread. The frequency of consumption of sweets, fast foods and carbohydrates [16], as well as low levels of
physical activity [17] increased this risk, whereas the frequency of consumption of fruits and vegetable, as well as dairy products decreased this risk [16].
Birth weight reflects the pattern of intrauterine growth, and being born either large or small for gestational age (LGA, SGA) might have long-term impacts on chronic diseases in adulthood [18]. The only population-based study in developing countries showed that in boys, the history of being born LGA, and in girls, that of SGA increased the risk of having the metabolic syndrome [16].
Childhood socioeconomic status can affect adult health. As an indicator of socioeconomic status, education level is reported to be negatively correlated
with the relative risk of the MetS in children [16]. The lower education level of parents seems to be associated with the adoption of harmful habits, such as
unhealthy diet and physical inactivity among family members. In addition, a positive family history for chronic diseases is found to be related to the MetS [16].
Hence encouraging physical activity and healthy dietary habits such as increasing the fiber intake, reducing the consumption of junk foods and saturated fat, as well as increasing physical activity starting in childhood may have important
Conclusion
This review on the findings of studies in developing countries provide alarming evidence-based data for health professionals and policy makers about the
considerable prevalence of childhood overweight and its metabolic consequences in countries still grappling with the public health effects of malnutrition and
micronutrient deficiencies. Strategies aimed at reducing caloric intake, increasing caloric expenditure through regular exercise early and aggressively are necessary
to meet the challenges they impose. Establishment of a uniform and universally acceptable set of criteria for overweight, obesity, and the metabolic syndrome in
children and adolescents need to be defined for this emerging public health concern.
The limited number of comparable nationally representative data from developing countries in the current literature emphasizes on the importance of
4/28/2014 COMMENTARIES
http://www.athero.org/commentaries/comm697.asp 2/2
monitoring of the time-trends in child obesity in different countries in order to provide useful insights for evidence-based health promotion programs in various
communities, as well as for prevention and control of the growing epidemic of childhood obesity in an action-oriented manner.
Ref erences
1. WHO. Global strategy for non-communicable disease prevention and control (Draft). Geneva: World Health Organization, 1997 WHO/NCD/GS/97.1
2. Onat A , Ceyhan K, Basar O, et al. Metabolic syndrome: major impact on coronary risk in a population with low cholesterol levels-a prospective and cross-sectional evaluation. A therosclerosis
2002;165(2):285-92.
3. Freedman DS, Khan LK, Dietz WH, et al. Relationship of childhood obesity to coronary heart disease risk factors in adulthood: the Bogalusa Heart Study. Pediatrics 2001;100:712-18.
4. Martorell R, Kettel Khan L, Hughes ML, Grummer-Strawn LM. Overweight and obesity in preschool children from developing countries. I nt J Obes Relat Metab Disord 2000;24(8):959-67.
5. Onis M, Blossner M. Prevalence and trends of Overweight among preschool children in developing countries. A m J Clin Nutr 2000;72:1032-39.
6. Khor GL. Update on the prevalence of malnutrition among children in A sia. Nepal Med Coll J 2003;5(2):113-22.
7. Jusupovic F, Beslagic Z, Hadzihalilovic J, Osmic M, Dropic V . Trends in diet and nutritional status in elementary school children in the Tuzla Canton. Med A rh 2004;58(1 Suppl 1):53-56.
8. A l-Sendi A M,Shetty P, Musaiger A O. Prevalence of overweight and obesity among Bahraini adolescents: a comparison between three different sets of criteria. Eur J Clin Nutr 2003;57(3):471-74.
9. A l-I sa A N. Body mass index, overweight and obesity among Kuwaiti intermediate school adolescents aged 10-14 years. Eur J Clin Nutr 2004;58(9):1273-77.
10. A girbasli M, Cakir S, Ozme S, et al. Metabolic syndrome in Turkish children and adolescents. Metabolism 2006;55(8):1002-6
11. Esmaillzadeh A , Mirmiran P, A zadbakht L, et al. High prevalence of the metabolic syndrome in I ranian adolescents. Obesity (Silver Spring) 2006;14(3):377-82.
12. Kelishadi R, A rdalan G, Gheiratmand R, et al. Pediatric metabolic syndrome and associated anthropometric indices: CA SPI A N Study. A cta Paediatrica 2006;95:1625-34.
13. Kim HM, Park J, Kim HS, Kim DH. Prevalence of the metabolic syndrome in Korean adolescents aged 12-19 years from the Korean National Health and Nutrition Examination Survey 1998 and 2001. Diabetes
Res Clin Pract 2007 Jan;75(1):111-4. Epub 2006 Jun 5.
14. Uzunlulu M, Oguz A , Tinazli M,et al. Relationship between low levels of high-density lipoprotein cholesterol and metabolic syndrome in Turkish patients. A cta Cardiol 2005;60:532-36.
15. Kelishadi R, Gheiratmand R, A rdalan G, et al. A ssociation of anthropometric indices with cardiovascular disease risk factors among children and adolescents: CA SPI A N Study. I nt J Cardiol 2007;117:340-48.
16. Kelishadi R, Gouya MM, A deli K, et al. Factors associated with the metabolic syndrome in a national sample of youths: CA SPI A N Study. Nutr Metab Cardiovasc Dis (in press)
17. Kelishadi R, Razaghi EM, Gheiratmand R, et al. A ssociation of physical activity and the metabolic syndrome in children and adolescents: CA SPI A N Study. Horm Res 2006 11;67:46-52.
18. Miles HL, Hofman PL, Cutfield WS. Fetal origins of adult disease: a paediatric perspective. Rev Endocr Metab Disord 2005;6:261-68.

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