Metabolism and Risk – The Lancet Child & Adolescent Health

Metabolic epidemics have been developing for decades. They have not created sudden, disruptive effects, but their prevalence is vast, they pose risks to cardiovascular health and premature death, and multiple interventions have been advocated, yet they remain epidemic.

Attention has focused on the epidemics of childhood obesity and diabetes, but given the underlying pathophysiology of type 2 diabetes and obesity, a broader view might be helpful. What we now call the metabolic syndrome has changed in name and conceptualization over the last half century, but it is essentially a collection of metabolic abnormalities. Today, its central component is often considered to be impaired glucose metabolism, with other key components being abdominal obesity, high blood pressure and disturbed lipid metabolism. Although debate continues over how many factors to include and how they should be measured (e.g. waist circumference, fasting blood sugar and high triglyceride levels), the group makes perfect sense as that set of risk factors for cardiovascular disease and type 2 diabetes; it is a risk marker for health threats later in life. In a new systematic review and modeling analysis, Jean Jacques Noubiap and colleagues estimated that the global prevalence of metabolic syndrome in 2020 was almost 3% in children aged 6 to 12 years and almost 5% in adolescents aged 13 to 18, which equates to approximately 26 million children and 36 million adolescents.
Health threats, however, are more imminent than many realize. Most patients with metabolic syndrome have type 2 diabetes, due to low fasting blood sugar, and in 2019 more than 16,000 deaths in people under 25 are thought to be due to diabetes. The importance of increasing access to affordable health care is evident, as diabetes mortality was higher in low-income countries and was inversely related to universal health care coverage. Diabetes mortality has decreased since 1990, mainly from type 1 diabetes, due to better access to care and better treatment (eg insulin pumps). But the incidence of type 2 diabetes has increased, and the decline in deaths from type 2 diabetes since 1990 has been small. Rising rates of type 2 diabetes in young people pose new challenges to health systems; adolescents with type 2 diabetes have a higher overall risk of complications during adolescence than with type 1 diabetes, including kidney disease, retinopathy, poor pregnancy outcomes and depressive symptoms.

The complications of diabetes and the risk of cardiovascular disease make it important to put the metabolic syndrome at the forefront of thinking about the health of young people. Some question the clinical value of diagnosing the metabolic syndrome, but tracking its prevalence and setting specific national targets will be helpful in assessing changes in current and potential health. Metabolic health could provide a useful focal point for policies and interventions. In turn, these interventions must focus on one of the components of the metabolic syndrome: obesity.

In addition to addressing its consequences, a new conceptual approach to type 2 diabetes emphasizes obesity as a key upstream driver. Up to 61 million children and adolescents were obese in 2020. Despite the heterogeneity of type 2 diabetes and the fact that pathology rather than the amount of fatty tissue can lead to complications, sustained weight loss is likely to help most people with type 2 diabetes. This is especially the case for adiposity-associated phenotypes, which younger people are more likely to have. A new review proposes a 15% body weight loss as a goal for this group, to reduce adipose tissue pathology and improve their metabolic milieu, with the aim of preventing diabetes for people with prediabetes and in remission or reduction for those already diagnosed with type 2 diabetes.

Unlike epidemics caused by infectious diseases, such as COVID-19, metabolic epidemics have no single identifiable cause against which to direct measures. They have multiple risk factors and single-component interventions are not effective. The rise in obesity, type 2 diabetes and metabolic syndrome has been accompanied by the growing dominance of sedentary activities in the lives of young people and changing food environments in which highly processed foods and beverages , nutrient-poor and energy-rich have become more available, accessible and desirable, linked to pervasive commercialization and economic growth. It has been established that interventions need to be multifaceted, multisectoral and appropriate to age and cultural and geographical context, but we are not on track to achieve the necessary gains. Metabolic health is at the heart of human health and well-being, and efforts to take care of it must be made with zeal.

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