Comment
and community mobilisation was possible for the Mitanin programme, but there were no community-level balines or controls in t he programme design t o measure outcomes, and suffi cient sample sizes were neither easy nor aff ordable. At this stage, outcomes can be assd only by u of indicators in independent surveys of national health and demographics. The surveys show that the rural infant mortality in Chhattisgarh decread from 85 deaths per 1000 livebirths in 2002 to 65 deaths per 1000 livebirths in 2005,5 which is much the same as the national rural infant mortality rate (64 deaths per 1000 livebirths). However, estimation of the preci contribution of the Mitanin programme to this decrea is diffi cult.
Much of the improvement in child survival in C hhattisgarh undoubtedly relates to better health-eking behaviour and child-care practices. The initiation of breastfeeding in the first 2 h after birth incread from 24% of livebirths to 71% of livebirths,6 and the u of oral rehydration salts in the management of diarrhoea in children younger than 3 years incread by 12% in the 2 weeks before the survey.7 The two interventions substantially affect child survival,8 and were highly mon i t ored and eff ective Mitanin interventions. Other re c orded improvements include total immunisation and ante n atal care, to which Mitanins would have lent support.7
C ommunity participation and the empowerment of women cau change.9 The many Mitanins who have since entered elected offi ce in local governance bodies, and the successful Mitanin-led community actions against deforestation, for curing of tribal liveli h oods,10 for early childhood-care facilities,11 or against alcohol-ism and corruption are testimonies to the so-called unintend e d positive outcomes. However, as the pro-gramme grows, the actions will po new problems for the sus t ainability of large-scale C HW programmes, and might again lay bare the tensions between the diff erent expec t ations and descriptions of the CHW.12 Thiagarajan Sundararaman
State Health Resource Centre, Kalibadi, Raipur 492001, India sundararaman.
I thank Mekhala Krishnamurthy and Samir Garg for their comments. I declare that I have no confl ict of interest.
神经内科心得体会1 Haines A, Saunders D, Lehmann U, et al. Achieving child survival goals:
potential contribution of community health workers. Lancet 2007;
published online March 6. DOI:10.1016/S0140-6736(07)60325-0.
2 Department of Public Health and Family Welfare, Government of
Chhattisgarh. Annual administrative report 2002–2003. Raipur:
Department of Public Health and Family Welfare, 2003: 47.
3 State Health Resource Center. Mitanin programme—conceptual issues and
operational guidelines. September, 2003: www.shsrc/pdf/Mitani n%20Programme%20Conceptual%20Issues%20and%20Operational%20G uidelin.pdf (accesd Feb 27, 2007).
4 Walt G, Perera M, Heggenhougen K. Are large-scale volunteer community
health worker programs feasible? The ca of Sri Lanka. Soc Sci Med 1989;
29: 599–608.
5 Registrar General, India. Vital statistics: sample registration system (SRS)
bulletins. April, 2006: susindia/vs/srs/bulletins/index.形容云彩的词语
html (accesd Feb 27, 2007).
6 UNICEF and Mode Services Pvt Ltd. Coverage evaluation survey 2005, all
India: a report. New Delhi: UNICEF, 2006: 90.
重枣7 National Family Health Survey, India. Key fi ndings from NFHS-3. 2006:
www.nfh sindia/factsheet.html (accesd Feb 27, 2007).
8 Jones G, Steketee R, Black R, for the Bellagio Child Survival Group. How
many child deaths can we prevent this year? Lancet 2003; 362: 65–71.
9 Manandhar DS, Osrin D, Shrestha BP, et al. Eff ect of a participatory
intervention with women’s groups on birth outcomes in Nepal:奥数题100道及答案
cluster-randomid controlled trial. Lancet 2004; 364: 970–79.
10 Kohli K. Two crore trees and livelihoods of thousands at stake.
Infochange Features May, 2006: www.infochangeindia.
org/features362.jsp (accesd Jan 24, 2007).
11 Garg S. Grassroots mobilisation for children’s nutritional rights.
Econ Polit Wkly Aug 26, 2006: 3694.
12 Werner D. The village health worker—lackey or liberator? Palo Alto:
Hesperian Foundation, 1977.
The metabolic syndrome in adults is defi ned as a cluster of risk factors for cardiovascular dia and type 2 diabetes mellitus, which include abdominal obesity, dyslipid-aemia, gluco intolerance, and hypertension.1,2 In 2005, the International Diabetes Federation (IDF) published its definition of the metabolic syndrome in adults.2 However, to date no unifi ed defi nition exists to asss risk or outcomes in children and adolescents.
Early identification of children who are at risk of developing the syndrome, type 2 diabetes mellitus, and cardiovascular dia in later life is important. Circumstances in utero and in early childhood predispo a child to disorders such as obesity, dysglycaemia, and the metabolic syndrome.3–5 Furthermore, urbanisation, unhealthy diet, and dentary lifestyle are major contrib-utors to such dis
orders.1 Obesity is associated with incread risk of cardiovascular dia, which may persist from childhood and adolescence into young adulthood.4,6 A clinically accessible diagnostic tool is needed to identify the metabolic syndrome in young people
The metabolic syndrome in children and adolescents
Comment
globally. This need prompted the IDF to develop a new
个人车辆转让协议
simple definition. C onsistent with criteria for adults,2
this defi nition is a starting point that can be changed
as information emerges. The new IDF defi nition for the
metabolic syndrome in young people builds on previous
studies that ud modifi ed adult criteria to investigate
prevalence in children and adolescents (panel).6–10
Thus a study of adolescents that ud modifi ed Adult
Treatment Panel III (ATP III) criteria identifi ed 12% with
metabolic syndrome.10 In tho aged 12–19 years in the
National Health And Nutrition Examination Survey III,6
which ud modified ATP-III criteria, about 10% had
the syndrome. A recent study11 suggested a new t of
criteria with age-specifi c and x-specifi c cutoff s, which
underlined the need for a consistent defi nition.
Many variables are ud to defi ne obesity in children.
However, waist circumference in children, consistent
with the situation in adults, is an independent predictor
of insulin resistance, lipid levels, and blood pressure.7,12
More o ver, in young people who are obe and have
similar body-mass index, insulin nsitivity is lower in
tho with high amounts of visceral adipo tissue than in tho with low amounts.12 Therefore waist measure-ment is included in the new defi nition. Percentiles, rather than absolute values, of waist circumference have been ud in the new defi nition to compensate for variation in child development and ethnic origin. Data for percentiles of waist circumference that are specifi c to ethnic origin are becoming increasingly available.13 C hildren who have a waist circumference higher than the 90th percentile are more likely to have multiple risk factors for cardiovascular dia than are tho with lower waist circumference.14 Several studies6,7,15 have ud the 90th percentile as a cutoff for waist circumference. The data, and the unequivocal evidence for the dangers of abdominal obesity in adults, lend support to its u as the main and esntial component of the new defi nition for diagnosis of the metabolic syndrome in children and adolescents. The IDF has chon to u the 90th percentile as a cutoff for waist circumference, which will be reassd when more data are available. The new IDF definition is divided according to age-groups becau of developme
ntal challenges prented by age-related differences in children and adolescents: age 6 years to younger than 10 years; age 10 years to younger than 16 years; and 16 years or older. Children who are younger than 6 years were excluded from the defi nition becau of insuffi cient data for this age-group. We suggest that the metabolic syndrome should not be diagnod in children younger than age 10 years, but that a strong message for weight reduction should be delivered for tho with abdominal obesity. For children aged 10 years or older, metabolic syndrome can be diagnod by abdominal obesity and the prence of two or more other clinical features (ie, elevated triglycerides, low HDL-cholesterol, high blood pressure, or incread plasma gluco). Whereas one defi nition, albeit with cutoff s specifi c for x and ethnic origin, is suitable for u in at-risk adults,2 u of one definition in children and adolescents is problematic. Blood pressure, lipid levels, insulin nsitivity, and anthropometric variables change with age and pubertal development. However, in the abnce of contemporary definitive data, the criteria adhere to the absolute values in the IDF adult defi nition, except that waist circumference percentiles are recommended and one (rather than a x-specifi c) cutoff is ud for HDL. For children older than 16 years, the IDF adult criteria can be ud. Further rearch is needed to identify optimum criteria for defi nition of the syndrome.
Key recommendations from the IDF for future rearch include: understanding of the relation betwee
n body fat and its distribution in children and adolescents; Panel: IDF defi nition of at-risk group and of metabolic syndrome in children and adolescents
Age 6 to <10 years
• Obesity ≥90th percentile as assd by waist
circumference
石锅拌饭怎么做• Metabolic syndrome cannot be diagnod, but further measurements should be made if family history of
metabolic syndrome, type 2 diabetes mellitus,
dyslipidaemia, cardiovascular dia, hypertension,
or obesity
小数点的移动
Age 10 to <16 years
• Obesity ≥90th percentile (or adult cutoff if lower) as assd by waist circumference
• Triglycerides ≥1·7 mmol/L
• HDL-cholesterol <1·03 mmol/L
• Blood pressure ≥130 mm Hg systolic or ≥85 mm Hg diastolic
• Gluco ≥5·6 mmol/L (oral gluco tolerance test
recommended) or known type 2 diabetes mellitus
Age >16 years
• U existing IDF criteria for adults2
Comment
investigation of whether early growth patterns predict future adiposity and other features of the syndrome; and initiation of long-term studies of cohorts of children of diff erent ethnic origin into adulthood to defi ne the natural history and eff ectiveness of interventions, especially tho relating to lifestyle.
The IDF aimed to develop a simple easy-to-apply clinical definition. Early detection followed by treat-ment—particularly lifestyle intervention—is vital to halt the progression of the metabolic syndrome in children and adolescents. Such action should reduce morbidity and mortality in adulthood and help keep to a minimum the global burden of cardiovascular dia and type 2 diabetes mellitus. Governments and society must be made more aware of the problems associated with obesity and the likelihood of progression to the metabolic syndrome in children and adolescents.
Paul Zimmet, *George Alberti, Francine Kaufman,
Naoko Tajima, Martin Silink, Silva Arslanian, Gary Wong, Peter Bennett, Jonathan Shaw, Sonia Caprio, on behalf of
the International Diabetes Federation Task Force on Epidemiology and Prevention of Diabetes
International Diabetes Institute, Melbourne, Vic, Australia (PZ); Imperial College, London, UK, and Department of Endocrinology and Metabolic Medicine, St Mary’s Hospital, London W2 1NY, UK (GA); Children’s Hospital, Los Angeles, CA, USA (FK); Jikei University School of Medicine, Tokyo, Japan (NT); Westmead Hospital, Sydney, NSW, Australia (MS); Children’s Hospital, Pittsburg, PA, USA (SA); Prince of Wales Hospital, Hong Kong (GW); Phoenix Epidemiology and Clinical Rearch
Branch, NIDDK, Phoenix, AZ, USA (PB); International Diabetes Institute, Melbourne, Vic, Australia (JS); Yale University School of Medicine, New Haven, CT, USA (SC)
*George.alberti@ncl.ac.uk The IDF Connsus workshop was convened by GAand PZ on behalf of the IDF Task Force on Epidemiology and Prevention of Diabetes, and was sponsored by an unrestricted educational grant from Sanofi -Aventis. The funding covered the cost of travel and accommodation for the meeting. The company was not reprented at the meeting, and had no involvement in the writing of this Comment. Except for GW and MS, we declare consultancy, speaker fees, and/or rearch support from relevant drug companies; FK is a shareholder in Diabetes Prevention Services.
1 Eckel RH, Grundy SM, Zimmet PZ. The metabolic syndrome. Lancet 2005;
365: 1415–28.
2 Alberti KGMM, Zimmet PZ, Shaw JE. The metabolic syndrome—a new
world-wide defi nition from the International Diabetes Federation
Connsus. Lancet 2005; 366: 1059–62.
3 Alberti G, Zimmet P, Shaw J, Bloomgarden Z, Kaufman F, Silink M. Type 2
diabetes in the young: the evolving epidemic: the international diabetes
federation connsus workshop. Diabetes Care 2004; 27: 1798–811.
4 Burke V, Beilin LJ, Simmer K, et al. Predictors of body mass index
and associations with cardiovascular risk factors in Australian children:
a prospective cohort study. Int J Obes 2005; 29: 15–23.
5 Singh R, Shaw J, Zimmet P. Epidemiology of childhood type 2 diabetes in
the developing world. Pediatric Diabetes 2004; 5: 154–68.
6 Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syndrome among
别人骑马我骑驴US adults: fi ndings from the third National Health and Nutrition
Examination Survey. JAMA 2002; 287: 356–59.
7 Lee S, Bacha F, Arslanian SA. Waist circumference, blood pressure, and lipid
components of the metabolic syndrome. J Pediatr 2006; 149: 809–16.
8 Cook S, Weitzman M, Auinger P, Nguyen M, Dietz WH. Prevalence of a
metabolic syndrome phenotype in adolescents: fi ndings from the third
National Health and Nutrition Examination Survey, 1988–1994.
Arch Pediatr Adolesc Med 2003; 157: 821–27.
9 de Ferranti SD, Gauvreau K, Ludwig DS, Newfeld EJ, Newburger JW, Rifai N.
Prevalence of the metabolic syndrome in American adolescents: fi ndings from the third national health and nutrition examination survey.
Circulation 2004; 110: 2494–97.
10 Gungor N, Bacha F, Saad R, Janosky J, Arslanian SA. The metabolic
syndrome in healthy children using in-vivo insulin nsitivity
measurement. Pediatr Res 2004; 55: 145 (abstr).
11 Joliff e CJ, Jansn I. Development of age-specifi c metabolic syndrome
criteria that are linked to the Adult Treatment Panel III and International
Diabetes Federation Criteria. J Am Coll Cardiol 2007; 49: 891–98.
12 Bacha F, Saad R, Gungor N, Arslanian SA. Are obesity-related metabolic risk
factors modulated by the degree of insulin resistance in adolescents?
Diabetes Care 2006; 29: 1599–604.
13 Fernandez JR, Redden DT, Pietrobelli A, Allison DB. Waist circumference
percentiles in nationally reprentative samples of African-American,
European-American, and Mexican-American children and adolescents.
J Pediatr 2004; 145: 439–44.
14 Maff eis C, Pietrobelli A, Grezzani A, Provera S, Tato L. Waist circumference and
cardiovascular risk factors in prepubertal children. Obes Res 2001; 9: 179–87.
15 Lee S, Bacha F, Arslanian SA. Waist circumference, blood pressure, and lipid
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