Preveive Meine Repos 6 (2017) 27-32 Contents lists avaible at ScionceDirect Preventive Medicine Reports ELSEVIER Journal homepage: http:i/e Reports vier comipmedr Metabolic syndrome's risk factors and its association with nutritional status in schoolchildren Fabiana Costa Teixeira **, Flavia Erika Felix Pereira, Avany Fernandes Pereira °, Beatriz Goncalves Ribeiro“ + Prana Ps Crag Niro de Nu UFR Laborato rere de Pei mes do Ere, UY Camps Maco ra ° Prana PCr om Alimentoa,Npo eSals, Ueno sda oo dono UES akan tra de equa om iri opr UF Comps Mao hf Cs de Nun Unveridde era oi dea, rat * Po Cs de Nar Laburacioigads de Psu em Cnc opr UF Comps Maca, Sl Recent fo 2 amy 2917 ‘lable eine 8 eraty The metabolic risk actors (RF) tothe agnosis of metabalic syndrome (MS) have been evidenced a ea 39, Inclang cilren, The aim of he presen study was to deni the prevalence of RF tothe diagnosis of Mets and itsasaciton with ntrtional status of schookhikren fom to VOyears old. Acros-sectonal tudy wasted ‘tin 505 students of municipal schools in Maca, Braz, conducted rom 2013 9 2014 The RF evaluated were blood pressure (mim He), rlycerides (minal), HDL-choesteol (no) fasting glucose (ramol} and waist ‘Sraumferece (cm). A fastone RF was present in 1% (n= 208) ofthe sample. By nutitional tats here was = fisher peas of Fn overeioesescnlchlren compared tose i oral eight exeptin Stu éone the contrat of HDL The prevalence oon, oan thee RF (MeiS) wore 307% (n= 175) 21.08 WS seat {m= 0) and 52% (n= 27) respec. Two RF were oe presen overweight (2028952 196, 390) rc Sn obese (tt 58 9541314521) compared fo nota! weight elien 13589520139, 173}. Tre a nu itore RF wee mre quent among ces (25 254170, 35) maton ooverwegt (248 952102 8) and nal weet crn (038 9SNL0 17), The datas high revalnce oF an ationship wh be mud of body weight ences Terfree enicaion a early eament of tes ough tininic tere Me and reed ean: 12017 The thors ubished by Ese in Thisisan open acess article unde the CCBY-NC-NDcese itp. fcatvecommonsorgfitensesiy- nd 1. Introduction Ther sno consensus forthe dlagnoss of Metin cilzen (Corte Metabolic syndrome (MetS) can be defined asthe co-occurrence of metabolic risk factors (RF) that contributes tothe development of car- diovascular disease (CVD) and type 2 diabetes mellitus (DM2) (Albert ‘tal, 2009), The RF, a insulin resistance (IR), hypertension (HAS), y= perelvcemis, hypertriglycerdemia, low high density lipoprotein choes- terol concentration (HDI-<) and excess waist circumference (WC), have been identified at earlier ages, including children (Agirbasi etal, 2018), Iyperersion, HDL, high density poproteim cholesterol ceaceazation: To, trainer BF, lo presse: dy mando: Ww ceferens SE * Comesponding autor at: Laborato lnegrado de Pesquisa em Sade e Sociedade Universidade Feea earl UF. Compas Mass, hi Ni, $9 cans ot ‘Palade tastier (EC Tee} perealetgacrn (EE Perera} anvergmurcaouipbr (AE Peer) nbekegncaleseOgmalom (He Ren) naps on/10 S016) pede 301702802 and Nobili, 2015; D‘Adamo et al, 2011; Petgher et al, 2010). Some criteria have been suggested and differentiated for RF as ther cutoffs (Ford ana Li, 2008). However, regardless ofthe eritri, commonly itis required at least three RF for the diagnosis of MetS in children (O'Adamn et al, 2011), Whea RF is present during childhood, it tend to persist through adolescence and adulthood (Magnussen etal. 2014); thus ithas been suggested thatthe focus of research in children be in the RF of MetS regardless ofits diagnosis (D'Adamo ct al, 2011; Faienza etal, 2016; Kassiet al, 2011; Sinaiko, 2015), The RF in children are more common in the obese population (Abrams and Levit kata, 2011; de et al. 2003), which increased signif. ‘cantly in recent years, representing a serious public health problem in Brazil and worldwide (IBGE, 2010; Cupra et al, 2013; Marie etal 2014). Although studies to evaluate the nutsitonal status, bload pres- sure (BP), lipid profile and blood glucose levels in the juvenile group are growing (Kuschnir etal, 2016; Onzuz and Demir, 2015; Strufaldi etal, 2009; Wee etal, 2011), they are not so frequent in children espe- cialy in developing countries (Gupta et al,2013), Early identifieation of the presence of RF predictors of MetS enables the planning and imple- ‘mentation of programs for the prevention of CVD and DMD. in 221133557 2017 The Authors Published by Elsevier Ine This a open aces ate unde the CCBY-NCND lense (hp teavecomsnonsrgcenssy-ne-ndi40)8 Trea Prose Meer 6 (2017) 27-22 adulthood, Thus, the aim ofthis stady sto identify the prevalence of RF to MetS and its association with nutritional stats in schoolchildren from 6 to 10 yeats ol in the city of Macae, Bazi, 2. Methods 2.1, Study design and sample population ‘This investigation was 2 cross-sectional study conducted from March 2013 to November 2014 in schoolchildren (6-19 years) fom public schools in the city of Macae, located in the state of Rio de Janeiro, Brazil, with 1219.8 kn of area and about 217,000 inhab- itants thas the petroleum as main economic activity, being the low social class prevalent among schoolchildren of municipal schools. The city is divided into $ administrative sectors, with $2 schools and 10,247 schoolchildren (6-10 years). For the reference popula- tion, by logistical issues, it was selected one school of ezch sector, to- taling 1553 schoolchildren, who were invited to participate. A simple dora sample size was carried based on the national prevalence of ‘obesity in the study age group (142%) (IBGE, 2010), 95%CI, maxi- mum error 2.5% and the population (1553). The final sample size ‘was 502 schoolehildren, ‘The exclusion criteria were: children whe had physical impair- ‘ment that prevented the evaluations, wth diabetes mellitus and/or hypothyroidism and/or use of medications that could interfere in ‘the results, OF the 1553 schoolchildren, one was exclude due to ‘dwarfism, Were not authorized for biochemical examination 936 schoolchildren. The total of children evaluated in all parameters ‘was 505 (Fig. 1), 22, Data collection Data were collected in schools under the supervision af responsi- ble research including: body weight, height, WC, BP and biochemical L oa | 05221 males 26 en ig 1. Fw chartof the study sample cre ag 6-10 years Naa, rl, 2013/14 ‘examination, Te team that carried out the collection was properly trained, 23, Anthropometry Body weight and height were measured in duplicate according to the technique proposed by Lohman etal. (1988), through electronic and portable scale Tanita® platform (linois, USA) with capacity of up to 150 kg and range of 50g and anthropometer Height Exataw® (Minas Gerais, Brazil) with 20.1 cm, The children were evaluated with light clothing without shoes and without headdress. The value ofthe average ‘ofthe two measurements was used to calculate body mass index (BMI) in kg/m’. The schoolchildren were classified in four categories: under- ‘welght, normal weight, overweight and obese by 2-score as the criteria proposed by WHO (2007). ‘Waist circumference (cm) was measured atthe midpoint between the last rib and the upper edge of the iliac fest as recommended by ‘WHO (2014) in duplicate and the average of the measurementswasca- culated, It was considered excess abdominal fat WC value above the ‘0th percentile according to sex and age (Maffes et al, 2001), obtained from the sample data that consists of all schoolchiléren who had WC measured (Dias etal, 201 24. Blood pressure The procedures for measuring BP of the schoolchildren were based on the guidelines of the Brazilian Society of Cardiology (SBC, 2005), without having done exercise for an hour before the procedure and after § min of rest, sitting, reclining in chair and legs ‘unerossed, It used validated digital equipment OMRON HEM-705 (cP (G-Tech International- Republican of Korea) and the cuffs ‘were adequate to arm size. The measurements were performed in éuplicate and with an interval of 2 min between them. To classify the PA was considered the average value of the measures. The cuto point used were the suggested by the Brazilian Society of Cardiology (high BP 295 percentile for age, sex and height percentile for age) ($8, 2008), 2, Biochemical measurements Avenous blood sample was collected overnight past 12h, To make sure about fasting it was sent tothe children's parents a reminder the day before the procedure, It was also requested a signed confirmation of fasting state ofeach chi delivered atthe time of biochemical analy- sis. Approximately 10 mL blood sample was collected and centrifuged for 5 min. Then, the samples were placed in coolers and transported ‘within a maximum of 2h tothe laboratory where they were frozen for later analysis. They were analyzed by enzymatic colorimetric meth- (od, kit LABTESTB: Glucose (mmol), HDL-c (mmol) and triglveerides (16) (mmol) For classification, were use the cutoff points suggested by the Bra- zillan Society of Cardiology (SBC, 2005): HDL-c (<1.16 mmol/l), TG (21.13 mmol) and fasting glucose was use to reference the Brazilian Society Diabetes (SBD, 2016) of >5.55 mmol/l. The diagnosis of Mets ‘was based on the concurrent presence of three or more of RF cited as citeria proposed by the NCEP-ATPII (Grundy etal, 2004) with cutof points adapted forthe child population 26, Ethical aspects The study was approved by the Research Ethics Committe of the University Veiga de Almeida (Number: 875333) and authorized by the ‘Municipal Department of Education ofthe cty of Macae Ro de Janeiro and the direction ofeach participating school, Parents or guardians in- terested in their children’s participation inthe study signed the freeTrea / Prose Miner 2017 27-22 2 and informed consent, At the end ofthe investigation, participants re- ‘ceived individual results oftheir assessments 27, Statistical analysis The mean and standard deviation were calculated for continuous variables and frequencies of categorical variables and their respective 195% confidence interval (95%C1) Quantitative variables were compared by sex using a Student's t-test for independent samples. For the associ- ation between RF and nutritional status and gender, Chi-square and Fisher's Exat tests were used. p value <005 for statistical significance ‘was considered fr all analysis. Data analysis was performed using the Statistical Program forthe Socal Sciences, version 21.0 (SPSS, Chicago, i) 3. Results The sample included 505 schoolchildren, 221 (43.8%) boys and 284 (56.2%) gies. Anthropometric, B and biochemical data are presented in Table 1. There was no gender difference in any ofthe parameters evaluated, ‘Amongihe schoolchildren, 14 (2.8%), 312 (61.8%), 85 (168%) and 94 (186%) had underweight, normal weight, overweight and obesity, re- spectively, At least one RF included in the diagnosis of MetS was present in 308 (61%) children. The prevalences of RFin the total sample accord ingto sex and nutritional status are shown in Table 2. The underweigh schoolchildren were excluded from the analysis for nutritional status ‘due tothe reduced number of RF in this group. Hypertrglyceridemia was the most prevalent RF, observed in 283% (= 148) ofthe sample. The low HDL-<, more prevalent in males than in females, wasthe only RF that showed a significant difference between, Sexes (p = 0.03), and was not associated with nutritional status (p = (043). For other BF in schoolchildren, overweight andjar obesity had higher prevalence rates compared to normal weight (p < 005) (Table 2} ‘There were 175 (34.7%), 105 (21,08) and 27 (53%) schoolchildren ‘ith one, two and three or mare RE (MetS), respectively, without dffer- lence between the sexes, According to the nutritional satus, there was no significative difference between the prevalence of one RF (p = (0.085) and significative diference was observed between 2,3 orm RE (p< 000%) (Table 2) ‘Toe concomitant presence of two RF was higher in overweight cil- ‘dren and obese children compared to those with normal weight Three ‘or mare RF (MetS) were moze prevalent among obese in relation to ‘overweight and normal weight (Fig.2) aber (sos) (eae (es 2 ‘ge Gea) Teri 79210 7x10 040 Ce) tess asa eea3s Om0 wetem) bi9i91 Gigaea Gisa0s On Cheemia (mmol) 4732079 475209 478082 O51 Tetmmolt) Oa i047 Gap 204s Osrzode O15 SePiemis) 107283 1057 281 én Deo(mm ie) 673077 S227 on 4 (Body Nass den) WC ast creer) 6 (ulyeees) HDL HDL ces ‘er BP sy Blood presize).BP(@asolc bed pestze) Inthe present study conducted in Brazian children, at least one RF {or MetS was identified in more than half ofthe sample, Ie was shown ‘that obese children have the highest prevalence of WC, and high [BP in relation to normal weight, as well 2s WC and high BP relative to ‘overweight. The concomitant presence of two RE was higher in over- ‘weight/obesty children, and three or more among obeses. Therefore, this study demonstrates the association of nutritional status of children withthe RFthat contributes to Met. Studies in difleent countries also demonstrate the occurrence of BF for CVD and DMB2 in children, especially among the overwreight/obese ‘ones (Adair etal, 2014; Freedman etal, 2007; Folst-Schumacher et al, 2009; "Allemand etal, 2008; Kuschnir etal, 2016; Rosin et al. 2015; Seki et al, 200%; Van Vliet etal, 2009). In children born after ‘the 2000s, obesity was abserved tobe three times prevalent as com- pared to those ofthe same age born inthe 80's (Gupta, 2015; Marie et al, 2014), Despite being stabilize in some countries, the prevalence of obesity remains high (Dietz and Economos, 2015; Ogden et al 2016). In Brazil, the ast national survey data showed overweightobes {y in 33.5% of children aged 5 to 9 years of age. Obesity was present in 16% ofthe girls and 11.8% ofthe boys (IBGE, 2010), igh BMI in child hood is related to metabolic changes, including changes inthe lpi pro- file, BP elevation and insulin resistance (Abrams etal, 2011; Han eta. 2010; Freedman etal, 1999). In this sense, the high prevalence of over~ ‘weight/abesity observed inthis study may explain, in part the frequen- cy of Fin the sample, Associated with the occurrence of obesity or overweight diagnosed by BMI itwas shown the prevalence about 60% of excess WC among ‘obese, which was compatible with other national studies such as ‘those conducted by Ricco etal. (2010) and Preto et al. (2015) who ob- setved, respectively, 50% and 84,7&excess WC among obese ehilden, ln study conducted in Turkey in about 4000 schoolchildren, excess WC ‘was also observed in those with high BMI (inane, 2014). Although its nota consensus in children, it has been shown that excess abdominal fat, estimated by WC, is beter predictor of metabolic alterations com- pared with BMI (MeCarthy, 2006), that can indicate the impact of the istribution of body fat in the cardiovascular risk (Goran and Gower, 1999; Spolidoro etal, 2013) There is no universal cutoff point for WC associated to cardiometabolic RF, butit has been suggested that children ‘with a WC > 80th percentile are at higher risk of having multiple cardio- ‘metabolic RF than those with lower WC percentiles (Maffels et al 2001). Considering the lack of such reference curves in Brazile cassi- Sication of risk in this study was WC > 90th percentile according to values ofits sample, Despite the difficulty in comparing with other stud- Jes, the results showed excess of cental adiposity, with posible reper- cussions onthe heath of these children. -Hypertriglyceridemia and low HDL-< were the most common abnor- ‘mal biochemical parameters a5 observed by Tavares etal (2010) in a systematic review of MetS in Brazilian children and adolescents Rosiniet al, (2015) also identified a high prevalence ofthese RFbetween Brazilian schoolchildren 6-14 years old. The process of atherosclerosis ‘may begin in childhood (Amaiz et al. 2013; Magnussen etal, 2014) and is associated with changes in lipid profile, including the rise of low-density cholesterol and T (Berenson etal, 1998), andthe low con- centration of HDL-c, wich is also included in Met's diagnosis (Ford and 1K, 2008). In 2 26-year cohort study with 770 schoolchildren from 5 yeats old, Morrison etal. (2012b) observed that children with perss- {ent hypertriglyeeridemia from childhood to adulthood had a higher prevalence of CVD compared to those without this RE ‘According tothe nutitonal status, there was no difference in prev= lence in low HDL concentration, corroborating to Perera el, (2009) in a Brazilian study. Moreover, hypertriglyceridemia was higher in ‘obese than normal weight children, as reported by Seki etal (2001) and Inanc (2014) in Brazilian and Turkish schoolchildren respectively Data from large longitudinal studies such asthe Bogalusa Heart Studyx0 Pe Tate Preven Mi Report 6 2017) 27-32 able? Prove of metabo isk ator or table syndrome scaking apne nd ins as ia len aged 6-10 es, Macs ea 2013/14 a Se ro we 2m nce tel ss sxc Wate Female Nomalweait —Ovewaat Obs (wn zy tm 284) pale n= 312) (ees) Gent) pale Raktactr acess WC fm) secs) e027) s0cins) as 103) 102) 5695) <0001 yperiicerdemia 48283) 0271) 8308) ass 75 (240) wa = ear) <0 waesss aS Bete? iaueon2 dots? aes Lon OL t3@e3) G2) aa) 751240) aaGns) 26075) a ign 068) 39075) aanss) ast 23193) w6cs8) 3793) «oom wis eas sen02 ba-n30 sieae7 254400 yperaeemia an is) Aas) 08 70) Busy iat) or Nmber ok fctore ‘ik aor mea G7) aaa a 11588) sagsss) 254245) ass 2 rk tacoe osieis) 3025) 5197) 2033) pasa) 394415) 45,000 children of different ethnic groups and identified increased risk of high BP as increased BMI, regardless of sex, ace or age. In a systematic review of HAS in Brazllan schoolchildren aged 6 fo 10 years, Pereira et al. (2015) showed higher prevalence in ‘overweightéobese children and highlighted the association between mu- ‘wtional status and che BP values. However, o consolidate the diagnosis ‘ofHAS in children itis necessary thatthe BP average i above the cuto established in at least three days (SBC, 2005). In this sense, the results shouldbe interpreted only asa risk. Nevertheless, the high prevalence ofthis RF in the study group is relevant, cansidering that BP values can be elevated since their childhood and it can also be related to arte- ‘al stiffness and HAS in adults (i etal, 2004; SBC, 2005) The insulin resistance (IR), other RF associated with Mets results in hyperglycemia, what is a Fisk for the development of DM2 (junior RF ORF Sor #RF Number of risk factors ‘snormalweght overweight obesity Eu tn) pelos ecm nema wee Wp oy manatee e001 ey nee ig 2 Prevalence (of numbe fiat or dane of metalic some by nuttional status ince ar 6-10 years Maza, rz 200314eT etal/Peeve Men Report 6 2017) 27-32 n Montenegro etal, 2013).The IR during cilchood and adolescence cor- responds toa cardiovascular RF independent of the DM2 development and is associated with the increased rate of cardiovascular events in adults (Steinberger et al, 2009). Hyperglycemia, parameter used in the study to evaluate the glucose metabolism, was preseat in 8.7% ‘ofthe sample, and it has been also the less frequent RF in other invest- gations (Seki etal, 2001; Weiss et al, 2004). However, the prevalence of hyperglycemia among overweight/obese children was twice higher ‘compated to normal weight, showing the association between excess ‘weight and changes in glucose metabolism (Dias et al, 2014; Han et al, 2010; Morrison eta, 20128}. Except forthe reduced HDL-« concentration, more in boys than in irl, there was no difference inthe presence of RF to sex. Seki eta (2001) ina study of Brazilian schoolchléren and Paula et al (2015) in Pediatric patients in clinical nutrition have not identified differences in RF to sex. However, ina systematic review conducted by Friend et al. (2013) the RF of MetS were more present among boys compared to airls. The early age range of the schoolchildren in this study suggests that most have not entered puberty, a period in which the differences between the sexes are more evident, possibly with greater impact on the evaluated parameters (SBC, 2005}, Three or more RF were seen in 5.2% of the sample, higher than that ‘observed by Seki et al, (2001) in Brazilian schoolchildren aged 6 to ‘years of age (3:28). However, the prevalence was lose to the average ‘of te most recent systematic review of MetS in children alsa identified by NCEP-ATPII adaprations (4.2%) (Friend etal, 2013). It must be em- phasized that, regardless ofthe Ms, the concomitant presence of RF ‘was present in approximately 26% of the schoolchildren. Loureiro eta (2015) identified in Chilean children and adolescents progressive in- ‘crease in caiovascular risk including inflammation of the endotheli- um, asthe presence of each RE. Barja et al. (2008) and Amnaiz etal (2013) complemented these findings by identifying the individual ca- rotid intima thickening in the co-occurrence of RF in children. The re- sults ofthis study indicated the presence of associated RF, which may promote physiological changes, independent of MetS'diagnosis (Berenson et al, 1998) ‘The presence of two RF was higher among overweight/obese chil- «dren compared to normal weight and three or more RF among obese ‘compared with others. The daca corroborate the literature and suggest that overweight/obesity and its magnitude may increase the risk of the association of RF, hence the presence of metabolic disorders (Griend etal, 2013; [Allemand et al, 2008; Rosni eal 2015), ‘There was no difference in having one RF by nutritional status. It shows that even those with adequate weight have already one RF. Be sides the excess weight, REsuch as high BP, hyperglycemia ow HDL-< may be associated with genetics, physical activity level, die, birth ‘weight, among others (Loureiro et al, 2015, Weiss et al, 2004). In this Sense, studies have also demonstrated RF in normal weight children (Seki et al, 2001; Dias et al, 2014), Noteworthy, the early treatment of metabolic RF and averweight/ ‘obesity does not imply a worse prognosis for CVD in adulthood when ‘compated to those who never had such complications (Magnussen et al, 2014), Moreover, the persistence ofthese RF into adultinood relates to the substantial increase cardiovascular risk (Magnussen et al, 2014). In this sense, once overweight/abesity o the presence of any of the RF of MeS is identified. immediate intervention strategies as nutri- tion education, regular physical exercise in addition to more active be- havior in daly activities are suggested, regardless of the diagnosis of MetS (Paienza et al, 2016; Magnussen et al, 2013; Owens and Gallowey, 2014) ‘Although previous studies have demonstrated the presence of RFin the pediatric population, the present study demonstrates in early ages not only the RF, but also the concomitant presence of two or more RF for MetS' and is association with nutritional satus, investigations that are scarce in Brail (Seki eta, 2001; Rsini etal, 2015). In this sense, itmay contribute tothe gap in the literature in developing countries, especially in Brazil However our findings should be interpreted consi¢- ering its limitations. Athough using cutoffs of different RF previously advocated for child population, they donot always represent consensus resulting in the lack of standardization between different studies. ‘Whereas the result of prevalence of RF depend, among others, on the values established by diferent researchers, the interpretation and com- parison ofthe occurrence of the different parameters become difficult (an Vliet etal, 2011). In alton, the parameters evaluated as RF are influenced by the behavior, genetics, ethnicity and may have more sig- nificance than others depending onthe population studied (Loureiro et Al, 2015). inthis sense, the data in ths specific group of children may nat represent other groups even if they are the same age and nationality and should not be extrapolated 5. Conclusions The data indicated high prevalence of RF of MetS among schoolchildten, mainly influenced by nutritional status. The potential ‘impact of excessive body weigh in the concomitant presence of RF and its magnitude in the presence of three or more RF observed in the study reinforce the importance of prevention and treatment of over- ‘Wielghtobesity in order to reduce the ikelnood of MetS and related is- cases in adults Financial support This work was supported by the Foundation of Research Suppor of the State of Rio de Janeiro (FAPER) number E-26/110,487/2010), Na- tional Counsel of Technological and Scientific Development (CNPQ number 19011), Conflict of interest None declare. ‘Authors’ contributions. Study concept and design: BGR Acquisition of data: FC, EPP. Anal- ysis and interpretation of data: BGR, AFP, FCT, FDP. Drafting ofthe ‘manuscript: CT, FPP, Critical revision ofthe manuscript: BGR, AFP. Funding acquisition: BGR. Study supervision: BC.R. All authors read and approved the fina version ofthis manuscript. Acknowledgments Te authors thank Professor Dr Roni Ragio (Postgraduate program in public health at the Federal University of Rio de Janeiro) for his assistance with statistical analysis, Dr. jackson de Souza Menezes and Dr. Anderson Morales for biochemical analysis. We also thank the ‘Municipality of Macae (Municipal Department of Education and the ‘Municipal Health Department) for permission to access the schools and technical support, respectively References ova, evi Kats, LE, 2011. Metabo ft oes aig ete in Tod Csr Opi Engin Dabs Oe 18, 23-27 ‘ese. Coronas P- Du Seal, 2014 Eergence of adometabole dese iki Chae chien nat Qe Rev. 1348-38 ‘Agia Tabi AM. Beeson, C5, 2016 Meo yaa: beng te ap om dhdised oaasood Caos thes 5430-56. ‘Aber, KEM El RH, lun, SM, a, 2009 aon the metabo sr “rome: 2 at intra statement of he nternatoal Dube Federation Task Force on Eidesiny ane Pevenson; Nationa Heat, Lng and Rod nse ‘menean Hes eso; Word ea ert nemaonl. Creston 120, Toate, ‘oni, Ba, S Villareal, 2013, Atrslerosi Sabin ¥Sindrome ‘MeaSeo Ea ies te Hesp. 28 (905) 1587-1385,2 FT etal Peeve Men Report 6 (2017) 27-32 aca, Acevedo, M. Arai Pt al, 2008, Macaores de ateroesterosstempraney “inde meta niin Re Me Cn 52250 ere. Srna, SR Bao, Wiel, 186 Aeaaton between mip a “ovarian tik fice nd aherwleros im elren snd youn sa The Aegan Her Sdy Eg | Med. 38 161056 ‘conte, CDA. Nobis 2015, Metooc nde pea popltion tie o hk uc om goss ceri? Cl Hep Sk ‘adsmo Sarah ap 201 Metabo snermespediis anceps eve ne eanzpls dena Pet Cn New frm 36 1241-1255 (eer). is Pangea J Rodan Siva, Patel eSutana MIL al, 2014 Metab yr ad aected ator ien a aetna Brasian muni i Wasp. 2, 885-872 at i ands C3, 215. gente coal of nt bey es ‘Reza MF Wag DOM, Babbek, Ca, 2016 The anges nk beeen ci ota wand pits oct abd tele ae ts ee For ES, UC 2008 Deft mabe sydre In cldsen a adlescents wl ‘he cal éeinson pee sand up| Peat, 100-104 ‘eed, DS. Dietz WH. Saas etl, 1969 The eso overwegh0 ca “dovasculr is urs aman chich and assets: the gas Heat Sty Fehrs 103 75-18 ‘rena, DS. Me Zsinasan SX. etal 207-Cardoascaar i ars and excess ‘post among overweht hen and aélescents he Boplsa Hea tay tet 150117 Pen Aig Tue 201. he pean of metabo syndrome in een: Syste othe care, Mea Sy eat Disord 11, 71-80 ‘cam omer iA 188 Rea been elt ees kn siden hd alee | Ch. Ne, 70, 3951585, ‘pia 0 2013 syprame X metabolic syneame for geoeratian 21 Why? Metab Se elt oe 1, 13-104 cpl Sh. Naya ea 0. Chord bes andthe metabo aynrame "in dcilping cone ina) Peds 81-10 ‘randy, Brews clean, eal, 2004 Deion of metab ere ort oltieNatanal esr ang ang ratte meri Het Aeoston Man Jes Lav, Kin $75,200, Childe ces" pris nd challenges ote-Sunache, | Ns H, Monge Rojas Re ly 208. Compares ofthe ‘neal dione sang seo roc and se Coe eh ‘atemund D. Wega Rese, Ta 208, Caos isk a 25008 Ee ‘ahovermeght crn at eased by a mulcenterdaabse Obesity (Siver Spey 5, 1672-1673 18 SEAS, 2010. eseuia de Oxamenos Files: 2006-2008, Axzopmetta€ ado Sutricana de Changs, Adolescents e Adios no HSH lta > ‘Mize do lansaeot, gamete ceo 30 ‘ate 2004 Metboe stone in schoachten Mardin Souh-aster of Tu ey. urs) Ne, 136-15. ‘olor Menenego, Mi, Ament, SL, Fort A, a, 2013. Diabetes Melis — {Casiteaco «Diagn Endod Cin 3, Gi o3h. as, Pando, Pata. etal, 2017 Meso sydrome: eins nd con ‘roverses AMC Med 91 Kustnin Mey doch KN Soka, Me al, 2016, ERICA: preva ‘insane cm ales brisinros Rev Side POD 0,378 Lohman, 1 eal, 158 fathrapemrire sane eeence mana. AN "ince nee 1S Chen Wr Seis SR ta 2004 Chitood lod presses preitor ofa- ‘en sess nyu als: the Bogalosa Hear Stag. person 4541546 are €, Coo. A Mare, A a2, Meabte eroe a nea “empresa seg sac with a pro-pismstany ndin resan Stn in peutic population Nerr Hoop 22 15121518 ‘Mec, 1D. 208 By testes incl a predictors fo the metab yntome fois tauren Poe Nae Sc 6 (04) 285-1, Matt C Pall A Geese Ave, 2001, Wt eum ab aoe ‘Magnussen CC. Smith Kunin M. 2013 When prevent caovasuar dase? ‘seat tps lens om ppective cos beginning in aloo. Ca Opi cei 28 s51-368, ‘Magne CC Si Jon M, 2014 What te long een cab stds hat "ez in dod have aught us about the tgs ef covonay beat disease. a cava is ep. 8,10, moc KML, Xi, Tanabe, Meal. 2012 Scening for sven in eve "eight you peeing or wel unageent Dabees Ce 38, PLL mors JA, Cluck C), Wor, Jeet, 2012 Rsk forse cxdovasct dese “ne tpesdaetes ean fom cleo to auttoe pre aul outcomes. ‘he onecen LC Follow-up Suey Int} Pee Eds 1 ari Ne Hein obnsn Me 2074 Gb ena ne natonl prevalence ‘of wcrp an obesty in cheren ané als ering 1960-2015 a ystemate Safer he lbs arden 9 ease ty 2013. aw 38470578, ‘oe! 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