Treatment of metabolic syndrome in children

Complex treatment of metabolic syndrome includes lifestyle changes, treatment of obesity, carbohydrate metabolism disorders, arterial hypertension, and dyslipidemia.

Lifestyle changes are the basis for successful treatment of this syndrome. The doctor's goal is to form a stable motivation in the patient aimed at long-term compliance with recommendations on nutrition, physical activity, and medication. The focus on success allows the patient to more easily endure the hardships that lifestyle changes require, which include: normalization of the regimen, diet; optimization of physical activity; psychotherapy; problem-based learning and self-control.

Normalization of the diet includes moderate restriction of the daily energy value (however, it is not recommended to be below 1200 kcal!). The reduction of the energy value of the diet occurs due to the restriction of carbohydrates and fats of animal origin (lard, butter, fatty meats, etc.), and the consumption of vegetable fats should be increased to 50% of the total amount of fats.

It is necessary to limit the "carbohydrate" level to 150 g per day. When making a diet, it is necessary to take into account the glycemic index of products. The less the product "ability" to increase the level of glucose in the blood, the more favorable its effect on the insular apparatus and the lower the risk of additional utilization of glucose in fat depots, and products with a high glycemic index increase this risk. However, it should be taken into account that in obese patients, almost all carbohydrate-containing products cause a greater increase in glucose levels than in people with normal weight.

The amount of protein in diets should be at least 0.9-1.0 g/kg of normal body weight. It is not recommended to consume less than 60 g of protein per day. Protein products (meat, fish, cottage cheese) should be included in your diet daily. Limit table salt (up to 5 g per day) and water (up to 1.5 l per day). It is necessary to use fasting days.

Physical activity is rightfully second only to nutrition in its importance in preventing and treating excess body weight. Walking, team sports, swimming, cycling, skiing and skating, including rollerblading, are good for training the cardiovascular system. You can and should move always and everywhere: while sitting in the bathroom, watching TV, on the bus, at your desk at school. You need to walk, run, swim, ride a bike, do exercises, do shaping, etc. It is important to remember that physical activity without diets is ineffective.

In recent years, program-targeted training of children with various chronic pathologies has taken a worthy place in the comprehensive approach to the treatment of these diseases and the prevention of their exacerbations. For children suffering from chronic pathology and their parents, it is very important not only to know as much as possible about this disease, but also to be able to control its course, possessing certain practical skills, using self-control tools. Lifestyle changes are necessary not only for the child, but also for his parents. The overwhelming percentage of adult patients are overweight since childhood, which emphasizes the need to begin problem-targeted training from the school period - before the appearance of serious complications of this chronic disease. Obesity cannot be cured without the knowledge of the sick child. It cannot be cured without active cooperation and mutual understanding between the doctor, the patient and his parents. In problem-targeted training of children and adolescents, in terms of increasing their motivation to reduce body weight and adhere to the principles of self-control, it is important to carry out differentiated psychological correction. In children with obesity and metabolic syndrome who have undergone problem-based learning, compared to children who have not undergone it, better anthropometric parameters (reliable decrease in BMI) are noted in dynamics (after 6 months), a tendency towards normalization of the identified metabolic shifts (lipidogram, IRI, HOMA-R) is recorded, and ultimately their quality of life indicators improve. Taking into account the research results, the optimal period for repeating the course of problem-based learning for children with obesity and metabolic syndrome can be considered a time period from 6 to 12 months. It is in this range that a tendency towards a decrease in motivation and exactingness in relation to the implementation of the basic principles of non-drug therapy (rational nutrition and physical activity) is noted against the background of the still-preserving self-monitoring regime for the dynamics of anthropometric and laboratory indicators.

Drug treatment of obesity

• Agents that influence eating behavior and improve diet tolerance (centrally acting drugs):
  • anorectics (central catecholamine agonists) - amfepramone, chlorphentermine (desopimone), mazindol, phenylpropanolamine (trimex), etc. are not used in pediatrics due to side effects;
  • dietary regulators: dexfenfluramine (isolipan) is not used due to its negative effect on the heart valve apparatus; fluoxetine (prozac) is better known as an antidepressant, a positive effect is not always achieved; sibutramine (meridia) is an inhibitor of the reuptake of norepinephrine and serotonin in brain structures (can be used in adolescents).
• Drugs that reduce insulin resistance and hyperinsulinemia, reducing the absorption of nutrients from the gastrointestinal tract (peripheral drugs):
  • Metformin (Glucophage, Siofor) belongs to the biguanide group, it increases tissue sensitivity to insulin, suppresses fat oxidation, has a hypotensive effect; it is currently widely used for metabolic syndrome, including without impaired glucose tolerance; it can be used in the absence of contraindications in school-age children (from 10 years old) and adolescents;
  • acarbose (Glucobay) inhibits the absorption of monosaccharides from the intestine;
  • Orlistat (Xenical) is an inhibitor of pancreatic and intestinal lipase; it can be used in children and adolescents with complicated forms of obesity.
• Drugs of peripheral and central action:
  • thermogenic sympathomimetics;
  • growth hormone;
  • androgens;
  • hormone replacement therapy drugs or progestogen-estrogen drugs.

Drug treatment of obesity is prescribed by a doctor for strict medical indications after examining the child and specifying the severity of metabolic and clinical disorders. In children and adolescents, the drug of choice for the treatment of obesity is metformin (approved for use from the age of 10). Currently, positive data have been obtained in the course of multicenter randomized placebo-controlled studies on the effectiveness of treating obesity in adolescents (over 12-13 years old) with sibutramine and orlistat.

Treatment of arterial hypertension and dyslipidemia

Non-drug treatment of arterial hypertension and dyslipidemia includes:

• keeping a diary;
• teaching sick children and adolescents;
• diet, change in eating habits;
• physical exercise.

It should be remembered that in order to improve the clinical status of patients with obesity and arterial hypertension, it is not necessary to reduce body weight to ideal values; it is sufficient to reduce it by only 5-10% of the initial value.

Drug treatment should be prescribed only by a doctor (pediatrician or endocrinologist) and carried out under his supervision.

There are four stages in the treatment of arterial hypertension in children and adolescents with obesity.

• Stage I: weight loss by 10-15% of the initial weight over 3-6 months while adhering to the principles of rational nutrition and limiting table salt.
• Stage II: if there is no positive effect from non-drug measures in the treatment of stage I arterial hypertension (without damage to target organs), labile arterial hypertension (according to 24-hour blood pressure monitoring) for 6 months, pharmacotherapy is recommended. In case of stage II arterial hypertension (with signs of damage to target organs), as well as stable arterial hypertension (according to 24-hour blood pressure monitoring), drug therapy is prescribed immediately.
• Stage III: drug monotherapy - ACE inhibitors (enalapril (renitec, berlipril)); selective beta-blockers [nebivolol (nebilet), etc. If the hypotensive effect is insufficient - increase the dose of the drug or replace it. If the hypotensive effect is insufficient - combination therapy.
• Stage IV: combination treatment - ACE inhibitors and diuretics [indapamide (arifon)]; selective beta-blockers and ACE inhibitors.

Angiotensin II receptor antagonists (irbesartan) are also promising in the treatment of arterial hypertension in metabolic syndrome.