Comparison of ultrasonographic and anthropometric methods to assess body fat in childhood obesity

Effects of resistance training on heat shock response (HSR), HSP70 expression, oxidative stress, inflammation, and metabolism in middle-aged people

Resistance training (RT) can increase the heat shock response (HSR) in the elderly. As middle-aged subjects already suffer physiological declines related to aging, it is hypothesized that RT may increase the HSR in these people. To assess the effects of resistance training on heat shock response, intra and extracellular HSP70, oxidative stress, inflammation, body composition, and metabolism in middle-aged subjects. Sixteen volunteers (40 - 59 years) were allocated to two groups: the trained group (n = 7), which performed 12 weeks of RT; and the physically inactive-control group (n = 9), which did not perform any type of exercise. The RT program consisted of 9 whole-body exercises (using standard gym equipment) and functional exercises, carried out 3 times/week. Before and after the intervention, body composition, muscle mass, strength, functional capacity, and blood sample measurements (lipid profile, glucose, insulin, oxidative damage, TNF-α, the HSR, HSP70 expression in leukocytes, and HSP72 in plasma) were performed. The HSR analysis demonstrated that this response is maintained at normal levels in middle-aged people and that RT did not cause any improvement. Also, RT increases muscle mass, strength, and functional capacity. Despite no additional changes of RT on the antioxidant defenses (catalase, glutathione peroxidase, and reductase) or inflammation, lipid peroxidation was diminished by RT (group x time interaction, p = 0.009), indicating that other antioxidant defenses may be improved after RT. HSR is preserved in middle-aged subjects without metabolic complications. In addition, RT reduces lipid peroxidation and can retard muscle mass and strength loss related to the aging process.

The Potential for Using Sonography to Measure Abdominal Adiposity in Children

The accumulation of abdominal adiposity has been associated with many risk factors in adults and children. Currently, body mass index (BMI) percentiles, computed tomography (CT), and dual X-ray absorptiometry (DXA) are widely used to evaluate body fat but are not widely acceptable for measuring visceral and subcutaneous adiposity. The aim of this study was to evaluate abdominal adiposity in children by the use of diagnostic medical sonography (DMS). Fifty-eight third graders were recruited for a 10-week interventional study. This cohort received baseline body composition and anthropometric measures, including height, weight, calculated BMI percentiles, blood pressure, bioelectric impedance, and DMS. The resulting data analysis provided a set of descriptive statistics. DMS may be a reliable, practical, and cost-effective method for measuring visceral and subcutaneous adiposity across varied body compositions of children.

Ultrasound measurements of subcutaneous adipose tissue thickness show sexual dimorphism in children of three to five years of age

Aim

A standard approach to measure subcutaneous adipose tissue (SAT) using ultrasound has proved successful in adults, but has not been studied in children. This study addressed that gap in children aged three to five years.

Methods

In autumn 2016, 24 preschools in Southwest Germany, recruited via mail, agreed to take part in this study and 274 children (51.4% boys) with a mean age of 4.6 ± 0.7 years participated in measurements of SAT and anthropometry. Differences in measurements were explored between the sexes and anthropometric predictors of mean SAT thickness were identified. Intra‐observer reliability for ultrasound measurements of SAT was also assessed.

Results

The mean SAT thickness showed significant differences between the boys and girls (5.3 ± 2.0 and 6.3 ± 2.0 mm, respectively, p < 0.01). The children's body mass, height and sex explained 66% of the variance in the mean SAT thickness, as SAT was larger with a higher body mass, a smaller stature and in girls. Intra‐observer reliability resulted in an intra‐class correlation coefficient of 0.994 (p < 0.01) with a 95% confidence interval of 0.983–0.998.

Conclusion

Subcutaneous adipose tissue thickness differed between boys and girls with a mean age of 4.6 years. Intra‐observer reliability was excellent. This standardised approach enabled high‐precision measurements of SAT in a paediatric population.

THE USE OF ULTRASONOGRAPHY TO EVALUATE MUSCLE THICKNESS AND SUBCUTANEOUS FAT IN CHILDREN AND ADOLESCENTS WITH CYSTIC FIBROSIS

Objective:

To compare muscle thickness and subcutaneous fat in cystic fibrosis (CF) patients and healthy controls using ultrasonography (US), and to correlate US findings with nutritional, clinical and functional variables.

Methods:

Patients aged 6 to 18 years old with a diagnosis of CF and healthy controls were included. Participants underwent anthropometric measurements, an ultrasonographic evaluation of muscle thickness and subcutaneous fat in the triceps, quadriceps, and gastrocnemius regions, and skinfold thickness measurements. Body fat percentage was estimated using skinfold measurement. Subjects with CF also underwent a pulmonary function assessment using spirometry.

Results:

We studied 39 CF patients and 45 controls. Alower body mass index was observed in CF patients (p=0.011). Body composition and muscle thickness were similar between the groups. Only calf (p=0.023) circumference and femur diameter (p<0.001) were lower in CF patients. Although there were no significant between-group differences in the comparison of US measurements of subcutaneous fat, CF patients exhibited decreased skinfold thickness in the triceps (p=0.031) and quadriceps (p=0.019). Moreover, there were weak and moderate correlations of US quadricep thickness with forced vital capacity (FVC) and lean mass, respectively. Moderate correlations of the triceps, quadriceps and gastrocnemius between US subcutaneous fat and skinfold measurements were found.

Conclusions:

Patients with CF presented a reduction in subcutaneous fat content. Muscle thickness correlated with FVC and nutritional parameters. In addition, US findings correlated positively with skinfold measurements.

Assessing subcutaneous adipose tissue by simple and portable field instruments: Skinfolds versus A-mode ultrasound measurements

Purpose

This study compared subcutaneous adipose tissue (SAT) measurements using a skinfold caliper and Renco Lean-Meater Series 12 A-mode portable ultrasound scanner (A-US). It aimed to assess their inter- and intra-rater reliability and measure the agreement between both methods.

Methods

Eighty-four volunteers of different fitness levels were divided into three groups by Ʃ6 skinfolds: G1 ≤ 55 mm (n = 33 males); G2 > 55 mm (n = 32 males); G3 = 98.0 ± 52.3 mm (n = 19 females). Triceps, subscapular, biceps, iliac crest, supraspinal, abdominal, front thigh and medial calf were assessed by ultrasound and skinfolds. Two technicians for both tools performed triplicate measures. Intraclass correlation (ICC), technical error of measurement (TEM) and coefficients of variation (CVs) were applied for test-retest and inter-rater reliability. Non-Parametric statistics were used in order to establish possible statistical differences and correlation between skinfolds thickness and uncompressed subcutaneous adipose tissue thickness from ultrasound. The amount of agreement between both methods was assessed with Lin’s coefficient and a scatterplot of all site locations. A Bland-Altman plot was constructed to establish limits of agreement between groups and regression analysis was employed to assess the ability of skinfolds to explain the variance of ultrasound.

Results

Test-retest ICC for skinfolds and ultrasound were higher than 0.989 and 0.793, respectively. Inter-rater ICC for skinfolds was 0.999 with a 95% CI of 0.995 to 0.999 and for ultrasound was 0.755 with a much larger 95% CI of 0.622 to 0.841. TEMs (> 8.50%) and CVs (> 6.72%) compromised ultrasound reliability. Statistical differences were found in most of the analysed anatomical sites (p < 0.001) except in biceps G2 (Z = -1.150, p = 0.25) and G3 (Z = -1.309, p = 0.19). Good correlations (r > 0.7, p ≤ 0.05) were reported at almost all anatomical sites and groups except for biceps (G1: Rho = 0.26, p = 0.140) and abdominal (G2: Rho = -0.16, p = 0.38; G3: Rho = 0.43, p = 0.068). Lin’s concordance correlation coefficient registered low values of agreement between skinfolds and A-mode ultrasound (ranged from—0.009–0.646). The scatterplot and the estimated regression line drawn through the midst of all anatomical sites of the whole sample had a slope of 0.51 and R² adjusted = 0.62 was obtained. The combined analysis between the Bland-Altman plot and the linear regression showed that specifically in the G2 and G3 groups, as the SAT increases the differences between skinfolds and ultrasounds measurements also increases.

Conclusions

The Renco Lean-Meater ultrasound is not interchangeable with skinfold measures. Its utility is questionable, particularly for assessing SAT in active adult populations. Its poor test-retest and inter-rater reliability as well as the lack of agreement when compared to the skinfolds would exclude the free use of the A-mode ultrasound scanner in its hypothetical replacing of the classical calipers.

Ultrasound as a method to evaluate the distribution of abdominal fat in obese prepubertal children and the relationship between abdominal fat and metabolic alterations

Abstract

Visceral fat thickness and its associations with pubertal and metabolic parameters among girls with precocious puberty

PURPOSE

This study aimed to investigate associations of central obesity with sexual maturation and metabolic parameters in Korean girls with precocious puberty.

METHODS

This retrospective study evaluated data from 72 girls under 8 years of age with a chief complaint of early breast development. The patients were categorized as central precocious puberty (CPP) subjects or non-CPP subjects based on their gonadotropin-releasing hormone stimulation test results. Visceral fat thickness (VFT) was measured using ultrasonography and defined as the distance from the linea alba to the aorta. Patient anthropometric, metabolic, and hormonal parameters were also evaluated.

RESULTS

Increased VFT was correlated with an earlier onset of thelarche among all study subjects (r=-0.307, P=0.034). Overweight CPP subjects showed higher insulin resistance than normal weight CPP subjects. Insulin resistance was not significantly different between overweight and normal weight non-CPP subjects. VFT was not significantly different between CPP and non-CPP subjects (2.22±0.79 cm vs. 2.74±1.47 cm, P=0.169). However, overweight and obese CPP subjects (body mass index percentile&gt;85%) had lower VFT than non-CPP obese subjects.

CONCLUSION

Central obesity, defined using ultrasonography-measured VFT, might be associated with early pubertal development in Korean girls. However, VFT was not higher in CPP than non-CPP patients and was not significantly correlated with insulin resistance. Further longitudinal studies with a larger cohort are needed.

Genetic contribution to waist-to-hip ratio in Mexican children and adolescents based on 12 loci validated in European adults

BACKGROUND/OBJECTIVES

The prevalence of abdominal obesity in Mexican children has risen dramatically in the past decade. Genome-wide association studies (GWAS) for waist-to-hip ratio (WHR) performed predominantly in European descent adult  populations have identified multiple single-nucleotide polymorphisms (SNPs) with larger effects in women. The contribution of these SNPs to WHR in non-European children is unknown.

SUBJECTS/METHODS

Mexican children and adolescents (N = 1421, 5-17 years) were recruited in Mexico City. Twelve GWAS SNPs were genotyped using TaqMan Open Array and analyzed individually and as a gene score (GS).

RESULTS

Mexican boys and girls displayed 2.81 ± 0.29 and 3.10 ± 0.31 WHR standard deviations higher than children and adolescents from the United States. WHR was positively associated with TG (β = 0.733 ± 0.190, P = 1.1 × 10^-4) and LDL-C (β = 0.491 ± 0.203, P = 1.6 × 10^-2), and negatively associated with HDL-C (β = -0.652 ± 0.195, P = 8.0 × 10^-4), independently of body mass index. The effect allele frequency (EAF) of 8 of 12 (67%) SNPs differed significantly (P < 4.17 × 10^-3) in Mexican children and European adults, with no evidence of effect allele enrichment in both populations (4 depleted and 4 enriched; binomial test, P = 1). Ten out of 12 SNPs (83.3%) had effects that were directionally consistent with those reported in GWAS (P = 0.04). HOXC13 rs1443512 displayed the best fit when modeled recessively, and was significantly associated with WHR under a recessive mode of inheritance (β = 0.140 ± 0.06, P = 2.3 × 10^-2). Significant interactions with sex were also observed for HOXC13 rs1443512 and the GS on WHR (P = 2.2 × 10^-2 and 1.2 × 10^-2, respectively). HOXC13 rs1443512 (β = 0.022 ± 0.012, P = 4.7 × 10^-2) and the GS (β = 0.007 ± 0.003, P = 7.0 × 10^-3) were significantly associated with WHR in girls only.

CONCLUSIONS

This study demonstrates that Mexican children are at high risk for abdominal obesity and detrimental lipid profiles. Our data support a partial transferability of sex-specific European GWAS WHR association signals in children and adolescents from the admixed Mexican population.

Risperidone and Cardiometabolic Risk in Children and Adolescents: Clinical and Instrumental Issues

PURPOSE/BACKGROUND

Although second-generation antipsychotics are used to treat and manage symptoms for several psychiatric disorders, data about their adverse effects in developmental age are limited. The aim of this prospective observational study was to verify the cardiovascular and metabolic risk in a sample of antipsychotic-naive children/adolescent patients starting risperidone therapy.

METHODS

Twenty-two patients, younger than 18 years, were recruited. The assessment included anthropometric data, cardiovascular parameters, blood tests, and ultrasonographic abdominal study.

RESULTS

After an average follow-up period of 7.6 months, statistically significant increases in mean values of waist circumference, body mass index (BMI), BMI percentile, BMI z score, total cholesterol, and prolactin were found. Other cardiometabolic parameters showed an upward trend in time. Subjects in pubertal/postpubertal stage and female patients were more susceptible to developing cardiometabolic changes. Moreover, significant correlations between changes in anthropometric and several metabolic parameters were found. A tendency to change in constitution of the liver parenchyma and distribution of the abdominal fat mass with ultrasonographic abdominal study was also evident.

CONCLUSIONS

In our sample, several metabolic parameters showed a sensitivity to risperidone treatment. Because most of these parameters are age dependent, metabolic syndrome criteria used for adults were inappropriate in children and adolescents. Periodic clinical and instrumental evaluations and guidelines for monitoring of any metabolic, laboratory, and instrumental complications are necessary in the perspective of even long-time second-generation antipsychotics treatment in children and adolescents.

Relationship between visceral obesity and plasma fibrinogen in obese children

BACKGROUND

The prevalence of obesity in children and adolescents has increased significantly worldwide with an alarming rise of its co-morbidities. The excess of visceral adipose tissue is associated with hypertension, prothrombotic and pro-inflammatory states. Our aim was to find a possible association between visceral obesity and plasma fibrinogen, as one of the cardiovascular risk factors, in obese children.

METHODS

Forty-three obese children and 40 non-obese controls were studied regarding their history, complete physical examination, anthropometric assessment, body composition analysis, ultrasonographic measurement of visceral adipose tissue and subcutaneous fat as well as laboratory measurement of plasma fibrinogen.

RESULTS

Our study revealed significant higher levels of fibrinogen in obese children than controls (14.5+5.1 and 2.9+0.52 mg/mL, respectively) with p-value <0.01. Moreover, the obese group had statistically significant difference in visceral fat (5.96+0.77 cm) and subcutaneous fat (2.66+0.70 cm) than controls (2.45+0.65 and 0.70+0.18 mg/mL, respectively) with p-value <0.01. In addition, fibrinogen had significant positive correlation with body mass index (r=0.327), waist/hip ratio (r=0.394), fat percentage (r=0.301), visceral adipose tissue (r=0.323) and subcutaneous fat (r=0.301).

CONCLUSIONS

There was highly significant increase in the fibrinogen level, visceral and subcutaneous abdominal fat in the obese group with insignificant sex differences. Fibrinogen had a significant positive correlation with the different adiposity markers, blood pressure, visceral and subcutaneous fat. Visceral adipose tissue is a stronger predictor for cardiovascular risk compared to subcutaneous fat.

Indices of Central and Peripheral Obesity; Anthropometric Measurements and Laboratory Parameters of Metabolic Syndrome and Thyroid Function

BACKGROUND

Metabolic syndrome (MetS) and obesity are serious health problems in the World, including Turkey. Contemporary studies have suggested a meaningful association between insulin resistance (IR), MetS parameters, and thyroid function tests.

AIMS

We aimed to elucidate the impact of fat distribution on the anthropometric and laboratory parameters, especially indices of MetS, IR and thyroid function, in obese women.

STUDY DESIGN

Cross-sectional study.

METHODS

Anthropometric measurements of all participants and biochemical tests in their serum samples were performed.

RESULTS

Weight, waist circumference (WC), body mass index (BMI), and other parameters of fat distribution were significantly increased in all obese compared to control subjects; but there was no significant difference between central and peripheral obese groups. The central obese group had significantly higher insulin levels, components of MetS, the ratio free triiodothyronine (fT3) to free thyroxin fT4, and fT4 than those of peripheral obese and control groups.

CONCLUSION

Elevated triglyceride, glucose and insulin levels may be associated with increased IR, which in turn is related to MetS. Body fat composition may affect thyroid tests in the obese; the changes in fT3/fT4 could be the consequence of fat distribution.

Sonographic assessment of abdominal fat distribution during the first year of infancy

BACKGROUND

Longitudinal data regarding the fat distribution in the early postnatal period is sparse.

METHODS

We performed ultrasonography (US) as a noninvasive approach to investigate the development of abdominal subcutaneous (SC) and preperitoneal (PP) fat depots in infants ≤1 y and compared longitudinal US data with skinfold thickness (SFT) measurements and anthropometry in 162 healthy children at 6 wk, 4 mo, and 1 y postpartum.

RESULTS

US was found to be a reproducible method for the quantification of abdominal SC and PP adipose tissue (AT) in this age group. Thickness of SC fat layers significantly increased from 6 wk to 4 mo and decreased at 1 y postpartum, whereas PP fat layers continuously increased. Girls had a significantly higher SC fat mass compared to boys, while there was no sex-specific difference in PP fat thickness. SC fat layer was strongly correlated with SFT measurements, while PP fat tissue was only weakly correlated with anthropometric measures.

CONCLUSION

US is a feasible and reproducible method for the quantification of abdominal fat mass in infants ≤1 y of age. PP and SC fat depots develop differentially during the first year of life.

Sonographically measured suprailiac adipose tissue is a useful predictor of non-alcoholic fatty liver disease in obese children and adolescents

OBJECTIVE

The objective of the present study was to identify ultrasonographic and anthropometric parameters that are highly associated with the presence of non-alcoholic fatty liver disease (NAFLD) in overweight children and adolescents.

METHODS

A total of 447 overweight children and adolescents (body mass index, 32.4 ± 5.2 kg m(-2) ; mean age, 14.2 ± 1.9 years; range 10.1-20.3 years) were analysed. Subjects underwent ultrasound examination of the liver as well as ultrasonographic measurement of the amount of adipose tissue overlying the biceps brachii and triceps brachii muscles, and of subscapular, suprailiac and abdominal subcutaneous adipose tissue and intra-abdominal depth. Anthropometric parameters such as body mass index, waist and hip circumference were documented.

RESULTS

The prevalence of NAFLD was 27.1%; it was significantly associated with the above-cited anthropometric parameters (P < 0.001). Ultrasonographic findings identified a significant association between NAFLD and the amount of subscapular, suprailiac and abdominal subcutaneous adipose tissue (P < 0.001) as well as between NAFLD and intra-abdominal depth (P < 0.001). Stepwise logistic regression analysis showed only intra-abdominal depth for both gender and the deposit of subcutaneous suprailiac adipose tissue in females to be independent predictors of NAFLD.

CONCLUSIONS

In overweight children and adolescents, we identified intra-abdominal depth for both gender and the ultrasonographically easily determined subcutaneous suprailiac adipose tissue in females as independent predictor of NAFLD.

Systematic review to identify and appraise outcome measures used to evaluate childhood obesity treatment interventions (CoOR): evidence of purpose, application, validity, reliability and sensitivity

BACKGROUND

Lack of uniformity in outcome measures used in evaluations of childhood obesity treatment interventions can impede the ability to assess effectiveness and limits comparisons across trials.

OBJECTIVE

To identify and appraise outcome measures to produce a framework of recommended measures for use in evaluations of childhood obesity treatment interventions.

DATA SOURCES

Eleven electronic databases were searched between August and December 2011, including MEDLINE; MEDLINE In-Process and Other Non-Indexed Citations; EMBASE; PsycINFO; Health Management Information Consortium (HMIC); Allied and Complementary Medicine Database (AMED); Global Health, Maternity and Infant Care (all Ovid); Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost); Science Citation Index (SCI) [Web of Science (WoS)]; and The Cochrane Library (Wiley) - from the date of inception, with no language restrictions. This was supported by review of relevant grey literature and trial databases.

REVIEW METHODS

Two searches were conducted to identify (1) outcome measures and corresponding citations used in published childhood obesity treatment evaluations and (2) manuscripts describing the development and/or evaluation of the outcome measures used in the childhood intervention obesity evaluations. Search 1 search strategy (review of trials) was modelled on elements of a review by Luttikhuis et al. (Oude Luttikhuis H, Baur L, Jansen H, Shrewsbury VA, O'Malley C, Stolk RP, et al. Interventions for treating obesity in children. Cochrane Database Syst Rev 2009;1:CD001872). Search 2 strategy (methodology papers) was built on Terwee et al.'s search filter (Terwee CB, Jansma EP, Riphagen II, de Vet HCW. Development of a methodological PubMed search filter for finding studies on measurement properties of measurement instruments. Qual Life Res 2009;18:1115-23). Eligible papers were appraised for quality initially by the internal project team. This was followed by an external appraisal by expert collaborators in order to agree which outcome measures should be recommended for the Childhood obesity Outcomes Review (CoOR) outcome measures framework.

RESULTS

Three hundred and seventy-nine manuscripts describing 180 outcome measures met eligibility criteria. Appraisal of these resulted in the recommendation of 36 measures for the CoOR outcome measures framework. Recommended primary outcome measures were body mass index (BMI) and dual-energy X-ray absorptiometry (DXA). Experts did not advocate any self-reported measures where objective measurement was possible (e.g. physical activity). Physiological outcomes hold potential to be primary outcomes, as they are indicators of cardiovascular health, but without evidence of what constitutes a minimally importance difference they have remained as secondary outcomes (although the corresponding lack of evidence for BMI and DXA is acknowledged). No preference-based quality-of-life measures were identified that would enable economic evaluation via calculation of quality-adjusted life-years. Few measures reported evaluating responsiveness.

LIMITATIONS

Proposed recommended measures are fit for use as outcome measures within studies that evaluate childhood obesity treatment evaluations specifically. These may or may not be suitable for other study designs, and some excluded measures may be more suitable in other study designs.

CONCLUSIONS

The CoOR outcome measures framework provides clear guidance of recommended primary and secondary outcome measures. This will enhance comparability between treatment evaluations and ensure that appropriate measures are being used. Where possible, future work should focus on modification and evaluation of existing measures rather than development of tools de nova. In addition, it is recommended that a similar outcome measures framework is produced to support evaluation of adult obesity programmes.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The Relation between Visceral and Subcutaneous Fat to Bone Mass among Egyptian Children and Adolescents

BACKGROUND: The relation between fat distribution and bone mass is still being debated in children and adolescents.AIM: To verify the influence of both visceral and subcutaneous fat on bone mass among Egyptian children and adolescents.SUBJECTS AND METHODS: The study involved 78 (38 boys and 40 girls) individuals from children (42) and adolescents (36), aged 8-17 years. They were divided into 2 age groups: children group (20 boys and 22 girls) aged 8-12 years and adolescent group (18 boys and 18 girls) aged 13-17 years. Anthropometric measurements, visceral and subcutaneous fat (measured by ultrasound), body composition, BMD and BMC (Measured by DXA), were attempted.RESULTS: Among children, significant positive correlations between visceral fat; in males; and subcutaneous fat; in females; with total BMC, BMD and its Z-score were revealed. After exclusion of age effect, the association between visceral fat in females with total BMD and its Z-score and lumbar BMD-Z-score became significant.  For adolescents, no correlation was observed between either visceral or subcutaneous fat with any parameter of bone mass.CONCLUSIONS: Visceral and subcutaneous fat had significant positive association with bone mass in children; males and females respectively. On the contrary such association disappeared during adolescence.

Validity of parentally reported versus measured weight, length and waist in 7- to 9-year-old children for use in follow-up studies

The aim of this prospective cohort study was to assess the validity of parentally reported anthropometric data compared to measured data in 7- to 9-year-old Flemish children especially for use in follow-up studies. The subjects were 116 Flemish children of a birth cohort recruited in the first Flemish Environment and Health Study (2002-2003). Data about anthropometric measures (waist circumference (WC), weight and length) were obtained by a postal parentally reported questionnaire and during a home visit. Our study showed that parents tend to overreport their child's WC and underreport the BMI, especially in children with large WC and high BMI. The median difference between measured and parentally reported WC was 1.6% of the median measured WC; for BMI, the median difference was 2.8% of the median measured BMI. Both for WC and BMI, we observed a good agreement between parentally reported values and measured values to classify children in the highest 10 and 20% of the study population. When classifying the children in 'overweight' and 'not overweight', there were less misclassifications when parentally reported WC was used compared to parentally reported BMI.

CONCLUSIONS

Although there is a high agreement between parentally reported and measured WC, the parentally reported data must be used with reserve. Moreover, this study is the first to suggest that WC is a better indicator compared to BMI when parentally reported values are used to classify children.

Methodologies to assess paediatric adiposity

INTRODUCTION

Childhood obesity is associated with increased risk of adult obesity, cardiovascular disease, diabetes and cancer. Appropriate techniques for assessment of childhood adiposity are required to identify children at risk. The aim of this review was to examine core clinical measurements and more technical tools to assess paediatric adiposity.

METHODS

The online databases PubMed, CINALH and EMBASE were searched and the abstracts identified were reviewed to determine appropriate studies. Their reference lists were also searched to identify further eligible studies. Publications were included if they described childhood measurement techniques or involved validation.

RESULTS AND DISCUSSION

There are many body composition assessment tools available, none of which are direct. Each technique has limitations and a combination of methods may be used. The main clinical techniques are weight, height, body mass index (BMI) and circumferences which provide sufficient information to enable classification of overweight or obesity when growth centile charts and ratios are employed. Further investigation depends on resources available and examiner skill. Skinfold thicknesses are cost-effective but require technical training and only measure subcutaneous fat. Dual energy X-ray absorptiometry (DEXA), air displacement plethysmography (ADP), magnetic resonance imaging (MRI) and computed tomography (CT) are more costly and intensive, requiring the child to remain still for longer periods. DEXA and ADP are capable of accurately measuring adiposity but are unable to distinguish between fat depots. MRI and CT can distinguish intra-abdominal from subcutaneous adiposity and are considered gold standards, but CT is unsuitable for adiposity measurement in children due to high levels of radiation exposure. Ultrasound is a promising technique capable of measuring intra-abdominal adiposity in children but requires further validation.

CONCLUSION

The core clinical measurements of weight, height, BMI and circumferences are sufficient to enable diagnosis of paediatric overweight and obesity while more technical tools provide further insight.

Obesity and body size perceptions in a Spanish Roma population

BACKGROUND

Roma people are particularly vulnerable to developing overweight and obesity. Self-perception of body image may influence the prevalence of obesity in this ethnic minority.

AIM

The objectives of this study are to estimate the prevalence of obesity, to analyse body size perceptions and preferences and to assess the relationship between body size perceptions and obesity in the Roma population.

SUBJECTS AND METHODS

The analyses were carried out on 372 men, women and children from the Roma population residing in the Greater Bilbao region (Basque Country, Spain). In adults, a standard figural scale was used to analyse body size perceptions and preferences in this ethnic minority.

RESULTS

Overall 51.7% of adult and 24.4% of minor Roma individuals were obese. Both Roma men and women had inaccurate self-perceptions of their body size. Significant differences on body size perceptions were detected based on age, sex, nutritional status and socioeconomic characteristics.

CONCLUSION

This Roma population presents one of the highest rates of obesity worldwide. Although a certain awareness of the correct weight status was appreciated, the inability of Roma individuals to see themselves as overweight or obese may be a significant factor on the high prevalence of obesity in this population.

Ultrasound as a tool to assess body fat

Ultrasound has been used effectively to assess body fat for nearly 5 decades, yet this method is not known as well as many other body composition techniques. The purpose of this review is to explain the technical principles of the ultrasound method, explain the procedures for taking a measurement and interpreting the results, evaluate the reliability and validity of this method for measuring subcutaneous and visceral adipose tissue, highlight the advantages and limitations of ultrasound relative to other body composition methods, consider its utility to clinical populations, and introduce new body composition-specific ultrasound technology. The focus of this review is adipose, although various tissue thicknesses (e.g., muscle and bone) can be measured with ultrasound. Being a portable imaging device that is capable of making fast regional estimates of body composition, ultrasound is an attractive assessment tool in instances when other methods are limited. Furthermore, much of the research suggests that it is reliable, reproducible, and accurate. The biggest limitations appear to be a lack of standardization for the measurement technique and results that are highly dependent on operator proficiency. New ultrasound devices and accompanying software designed specifically for the purpose of body composition assessment might help to minimize these limitations.

Accuracy of anthropometric measurements in estimating fat mass in individuals with 21-hydroxylase deficiency

OBJECTIVE

The use of anthropometric measurements to estimate the percentage of body fat (%BF) is easy and inexpensive. However, the accuracy of these methods in patients with 21-hydroxylase deficiency (21OHD) has not been explored. The objective of this study was to evaluate the accuracy of skinfold-based models, body mass index (BMI), and waist circumference (WC) in estimations of %BF using dual-energy X-ray absorptiometry (DXA) as the reference method in individuals with 21OHD.

METHODS

Fifty-four 21OHD patients (32 women and 22 men), aged 7 to 20 y, were recruited for the study. DXA was used to determine %BF; four predictive skinfold equations, BMI, and WC were assessed for accuracy in determining %BF.

RESULTS

All predictive skinfold equations were highly associated (R, range: 0.82-0.89) with DXA %BF values. In women, BMI and WC showed moderate correlations (R = 0.69 for both BMI and WC) with DXA values. In contrast, among men there was a low explanatory power for BMI (13%) and WC (4%) and high errors (BMI, 6.9%; WC, 7.4%). All predictive equations significantly underestimated %BF (range of differences, -4.1 to -8.9) compared with DXA (women, 31.3 ± 6.1; men, 24.4 ± 7.3), and large limits of agreement were observed (range, -15.3 to 1.7 and -15.5 to 4.2 for women and men, respectively).

CONCLUSION

In children and adolescents with 21OHD, %BF as estimated by skinfold measurements was associated more strongly with DXA-assessed %BF than both BMI and WC. However, still, the skinfold-based assessment underestimated DXA %BF and showed moderate agreement.

Body fat location and cardiovascular disease risk factors in overweight female adolescents and eutrophic female adolescents with a high percentage of body fat

BACKGROUND

Excessive body fat, mainly abdominal fat, is associated with higher cardiovascular risk. However, a fat localisation measurement that would be more indicative of risk in adolescents has not yet been established.

OBJECTIVE

This study was conducted in order to evaluate the correlation between body fat location measurements and cardiovascular disease risk factors in female adolescents.

MATERIALS AND METHODS

A total of 113 girls - 38 eutrophic according to their body mass index but with a high percentage of body fat, 40 eutrophic with adequate body fat, and 35 with excessive weight - were evaluated using 15 anthropometrical measurements and 10 cardiovascular risk factors.

RESULTS

The central skinfold was the best measurement for predicting variables such as glycaemia and high-density lipoprotein; waist circumference for insulin and homeostasis model assessment; coronal diameter for total cholesterol and low-density lipoprotein; sagittal abdominal diameter for triglycerides and leptin; hip circumference for blood pressure; and the central/peripheral skinfold ratio for homocysteine. The correlation between the measurements and the number of risk factors showed that waist circumference and the waist/stature ratio produced the best results.

CONCLUSIONS

The results suggest that the body fat distribution in adolescents is relevant in the development of cardiovascular risk factors. Simple measurements such as waist circumference and the waist/stature ratio were the best predictors of a risk of disease and they should therefore be associated with the body mass index in clinical practice in order to identify those adolescents at higher risk.

Validation of ultrasound estimates of visceral fat in black South African adolescents

Accurate quantification of visceral adipose tissue (VAT) is needed to understand ethnic variations and their implications for metabolic disease risk. The use of reference methods such as computed tomography (CT) and magnetic resonance imaging (MRI) is limited in large epidemiological studies. Surrogate measures such as anthropometry and dual-energy X-ray absorptiometry (DXA) do not differentiate between VAT and subcutaneous abdominal adipose tissue (SCAT). Ultrasound provides a validated estimate of VAT and SCAT in white populations. This study aimed to validate the use of ultrasound-based assessment of VAT in black South African adolescents. One hundred healthy adolescents (boys = 48, girls = 52) aged 18-19 years participating in the birth to twenty cohort study had VAT and SCAT measured by single slice MRI at L4. These MRI "criterion measures" were related to ultrasound VAT and SCAT thickness, anthropometry (BMI, waist and hip circumferences), and DXA android region fat. Ultrasound VAT thickness showed the strongest correlations with MRI VAT (Spearman's correlation coefficients: r = 0.72 and r = 0.64; in boys and girls, respectively), and substantially improved the estimation of MRI VAT compared to anthropometry and DXA alone; in regression models the addition of ultrasound VAT thickness to models containing BMI, waist, and DXA android fat improved the explained variance in VAT from 39% to 60% in boys, and from 31% to 52% in girls. In conclusion, ultrasound substantially increased the precision of estimating VAT beyond anthropometry and DXA alone. Black South African adolescents have relatively little VAT compared to elderly whites, and we therefore provide new ultrasound-based prediction equations for VAT specific to this group.

Design and results of the pretest of the IDEFICS study

BACKGROUND

During the preparatory phase of the baseline survey of the IDEFICS (Identification and prevention of dietary- and lifestyle-induced health effects in children and infants) study, standardised survey procedures including instruments, examinations, methods, biological sampling and software tools were developed and pretested for their feasibility, robustness and acceptability.

METHODS

A pretest was conducted of full survey procedures in 119 children aged 2-9 years in nine European survey centres (N(per centre)=4-27, mean 13.22). Novel techniques such as ultrasound measurements to assess subcutaneous fat and bone health, heart rate monitors combined with accelerometers and sensory taste perception tests were used.

RESULTS

Biological sampling, physical examinations, sensory taste perception tests, parental questionnaire and medical interview required only minor amendments, whereas physical fitness tests required major adaptations. Callipers for skinfold measurements were favoured over ultrasonography, as the latter showed only a low-to-modest agreement with calliper measurements (correlation coefficients of r=-0.22 and r=0.67 for all children). The combination of accelerometers with heart rate monitors was feasible in school children only. Implementation of the computer-based 24-h dietary recall required a complex and intensive developmental stage. It was combined with the assessment of school meals, which was changed after the pretest from portion weighing to the more feasible observation of the consumed portion size per child. The inclusion of heel ultrasonometry as an indicator of bone stiffness was the most important amendment after the pretest.

DISCUSSION

Feasibility and acceptability of all procedures had to be balanced against their scientific value. Extensive pretesting, training and subsequent refinement of the methods were necessary to assess the feasibility of all instruments and procedures in routine fieldwork and to exchange or modify procedures that would otherwise give invalid or misleading results.

Overweight and waist circumference among Norwegian 11-year-olds and associations with reported parental overweight and waist circumference: The HEIA study

Aims: The aim of this paper is to investigate anthropometric characteristics in 11-year-old Norwegian by gender and parental education, and to study associations between adolescents’ overweight and waist circumference (WC) and maternal and paternal overweight and WC. Methods: A total of 1483 adolescents, 1156 mothers, and 1016 fathers participated in the baseline survey of the HEalth In Adolescents (HEIA) study (September 2007). Anthropometric measures of the adolescents were assessed by project staff according to standard procedures. Self-reported data about pubertal status were collected through questionnaires. Parental education and anthropometric measures of parents were collected by self-report. Results: The prevalence of overweight (including obesity) determined by the cut-offs for body mass index (BMI) suggested by the International Obesity Task Force was 14.6% among girls and 13.6% among boys. The highest prevalence of overweight was observed among adolescents with parents who had less than 12 years of education (18.8%). Overweight and WC in girls was strongly associated with maternal overweight and WC. For boys, overweight and WC was strongly associated with both maternal and paternal overweight and WC. Conclusions: There was a social gradient in anthropometric characteristics and overweight rates among Norwegian 11-year-old adolescents. Maternal overweight and WC was associated with overweight and WC in girls and boys, while paternal overweight and WC were associated with overweight and WC in boys. The results indicate that mothers are key persons in prevention of overweight among adolescents, despite gender. Fathers are important as role models for their sons. Targeting parental overweight/ obesity could be a strategy in future interventions.

Waist circumference and mesenteric fat in neonates: negative correlation

OBJECTIVE

To measure mesenteric fat thickness with ultrasound scan in neonates and to assess the correlation with waist circumference.

METHODS

Ninety five healthy newborns had the maximum thickness of mesenteric leaves measured by ultrasound examinations of abdomen with an Envisor scanner (Philips Ultrasound, Bothell, Wash) and a L12-5 transducer (Philips Ultrasound). The correlation between the thickness of mesenteric leaves with abdominal waist was calculated.

RESULTS

Maximum thickness of mesenteric leaves ranged from 0.24 to 1.00 mm (x = 0.57 ± 0.17) . There was a significant negative correlation between abdominal waist (AW) and mesenteric fat thickness (r = -0.384; p < 0.001).

CONCLUSIONS

Mesenteric fat thickness in newborns is inversely associated with waist circumference. Higher visceral adiposity in neonates may be a protective mechanism from intrauterine growth restriction however this could persist into adulthood life.

Relationship of body mass index to percent body fat and waist circumference among schoolchildren in Japan--the influence of gender and obesity: a population-based cross-sectional study

Background

Although the correlation coefficient between body mass index (BMI) and percent body fat (%BF) or waist circumference (WC) has been reported, studies conducted among population-based schoolchildren to date have been limited in Japan, where %BF and WC are not usually measured in annual health examinations at elementary schools or junior high schools. The aim of the present study was to investigate the relationship of BMI to %BF and WC and to examine the influence of gender and obesity on these relationships among Japanese schoolchildren.

Methods

Subjects included 3,750 schoolchildren from the fourth and seventh grade in Ina-town, Saitama Prefecture, Japan between 2004 and 2008. Information about subject's age, sex, height, weight, %BF, and WC was collected from annual physical examinations. %BF was measured with a bipedal biometrical impedance analysis device. Obesity was defined by the following two criteria: the obese definition of the Centers for Disease Control and Prevention, and the definition of obesity for Japanese children. Pearson's correlation coefficients between BMI and %BF or WC were calculated separately for sex.

Results

Among fourth graders, the correlation coefficients between BMI and %BF were 0.74 for boys and 0.97 for girls, whereas those between BMI and WC were 0.94 for boys and 0.90 for girls. Similar results were observed in the analysis of seventh graders. The correlation coefficient between BMI and %BF varied by physique (obese or non-obese), with weaker correlations among the obese regardless of the definition of obesity; most correlation coefficients among obese boys were less than 0.5, whereas most correlations among obese girls were more than 0.7. On the other hand, the correlation coefficients between BMI and WC were more than 0.8 among boys and almost all coefficients were more than 0.7 among girls, regardless of physique.

Conclusions

BMI was positively correlated with %BF and WC among Japanese schoolchildren. The correlations could be influenced by obesity as well as by gender. Accordingly, it is essential to consider gender and obesity when using BMI as a surrogate for %BF and WC for epidemiological use.

Sensibilidade e especificidade de diferentes critérios de classificação do excesso de peso em escolares de João Pessoa, Paraíba, Brasil

OBJETIVO: Descrever a proporção de excesso de peso usando diferentes critérios de classificação do índice de massa corporal e avaliar valores de sensibilidade, especificidade e concordância entre os critérios. MÉTODOS: A população incluiu 1.570 estudantes, de 7 a 12 anos de idade, da cidade de João Pessoa (PB), 2005. O excesso de peso foi classificado conforme os critérios da World Health Organization, da International Obesity Task Force e por outros autores. O percentual de gordura foi estimado a partir das dobras cutâneas e utilizado como critério de referência (masculino: >25%; feminino: >30%). RESULTADOS: A proporção de excesso de peso diferiu entre os critérios, sendo menor com a utilização dos critérios da World Health Organization e maior segundo o critério de autores brasileiros (p<0,05). Os critérios de classificação do índice de massa corporal apresentaram boa sensibilidade (83-97%), exceto o critério da World Health Organization (masculino=65% e feminino=48%). A especificidade foi elevada em todos os valores críticos analisados (85-98%). O índiceKappademonstrou boa concordância entre as propostas (Kappa >0,60), com discreto aumento no critério da IOTF (Kappa=0,72) e menor concordância para a proposta da World Health Organization (Kappa=0,63). CONCLUSÃO: Os critérios analisados foram sensíveis para diagnosticar o excesso de peso, com menor sensibilidade ao ser adotada a proposta da World Health Organization. Houve elevada especificidade e boa concordância em todas as propostas, entretanto, os valores para os sexos e as idades oscilaram menos no critério da International Obesity Task Force. Portanto, os resultados sugerem que o critério da International Obesity Task Force mostrou-se mais adequado para confirmar a presença de excesso de peso em populações com características similares às deste estudo.

Abdominal fat in children measured by ultrasound and computed tomography

The prevalence of childhood obesity is increasing rapidly. Visceral fat plays an important role in the pathogenesis of metabolic and cardiovascular diseases. Currently, computed tomography (CT) is broadly seen as the most accurate method of determining the amount of visceral fat. The main objective was to examine whether measures of abdominal visceral fat can be determined by ultrasound in children and whether CT can be replaced by ultrasound for this purpose. To assess whether preperitoneal fat thickness and area are good approximations of visceral fat at the umbilical level, we first retrospectively examined 47 CT scans of nonobese children (body mass index <30kg/m(2); median age 7.9 y [95% range 1.2 to 16.2]). Correlation coefficients between visceral and preperitoneal fat thickness and area were 0.58 (p<0.001) and 0.76 (p<0.001), respectively. Then, to assess how preperitoneal and subcutaneous fat thicknesses and areas measured by ultrasound compare with these parameters in CT, we examined 34 nonobese children (median age 9.5 [95% range 0.3 to 17.0]) by ultrasound and CT. Ultrasound measurements of preperitoneal and subcutaneous fat were correlated with CT measurements, with correlation coefficients ranging from 0.75-0.97 (all p<0.001). Systematic differences of up to 24.0cm(2) for preperitoneal fat area (95% confidence interval -29.9 to 77.9cm(2)) were observed when analyzing the results described by the Bland-Altman method. Our findings suggest that preperitoneal fat can be used as an approximation for visceral fat in children and that measuring abdominal fat with ultrasound in children is a valid method for epidemiological and clinical studies. However, the exact agreement between the ultrasound and CT scan was limited, which indicates that ultrasound should be used carefully for obtaining exact fat distribution measurements in individual children.

Correlação e concordância entre indicadores de obesidade central e índice de massa corporal em adolescentes

OBJETIVO: Analisar o desempenho de indicadores de obesidade central por correlação e concordância com índice de massa corporal para avaliação nutricional em adolescentes segundo sexo e idade. MÉTODOS: Estudo seccional do tipo censo incluindo 635 adolescentes, de 10 a 19 anos (342 do sexo masculino e 293 do feminino), realizado em escola pública da cidade do Rio de Janeiro. Variáveis do estudo: índice de massa corporal (IMC), circunferências de cintura e abdômen, razões cintura-quadril e cintura/altura, estado nutricional, sexo e idade. Desenvolveram-se análise univariada e bivariada controlada por estratificação. RESULTADOS: As circunferências de cintura e abdômen correlacionaram-se positiva e significativamente (p < 0,05) com o IMC em ambos os sexos, faixa etária e estado nutricional, enquanto a correlação de razão cintura/altura foi influenciada por sexo e estado nutricional. Para razão cintura/quadril, a variação do sentido da correlação foi influenciada ainda por idade. As circunferências de cintura e abdômen foram dependentes da variação dos valores de IMC em todos os grupos com elevados R² (0,66 a 0,80) e ² positivo, o que não ocorreu para razões cintura/quadril e cintura/altura. Somente a circunferência de cintura apresentou agregamento moderado com o IMC (Índice Kappa de 0,41 a 0,57) em todos os estratos, enquanto nos demais indicadores o agregamento variou de relativo a moderado. CONCLUSÕES: Dentre os indicadores de obesidade central analisados, as circunferências de cintura e abdômen apresentaram os melhores desempenhos, destacando-se a circunferência de cintura como mais apropriada para uso complementar ao IMC na avaliação nutricional de adolescentes.

Sonographic assessment of abdominal fat distribution in infancy

There is growing evidence that not only the total amount of fat, but also the distribution of body fat determines risks for metabolic and cardiovascular disease. Developmental studies on factors influencing body fat distribution have been hampered by a lack of appropriate techniques for measuring intraabdominal fat in early life. Sonography, which is an established method for assessing abdominal fat distribution in adults, has not yet been evaluated in infants. To adapt the sonographic measurement of abdominal fat distribution to infants and study its reliability. The Generation R study, a population-based prospective cohort study. We included 212 one- and 227 two-year old Dutch infants in the present analysis. Sixty-two infants underwent replicate measurements to assess reproducibility. We developed a standardized protocol to measure the thickness of (1) subcutaneous and (2) preperitoneal fat in the upper abdomen of infants. To this end we defined infancy specific measurement areas to quantify fat thickness. Reproducibility of fat measurements was good to excellent with intraclass correlation coefficients of 0.93–0.97 for intra-observer agreement and of 0.89–0.95 for inter-observer agreement. We observed a pronounced increase in preperitoneal fat thickness in the second year of life while subcutaneous fat thickness increased only slightly, resulting in an altered body fat distribution. Gender did not significantly influence fat distribution in the first two years of life. Our age specific protocol for the sonographic measurement of central subcutaneous and preperitoneal fat is a reproducible method that can be instrumental for investigating fat distribution in early life.

Relationships between cardiovascular risk profile, ultrasonographic measurement of intra-abdominal adipose tissue, and waist circumference in obese children

BACKGROUND & AIMS

Ultrasonographic measurements have been proposed to assess intra-abdominal adipose tissue. The aim of this study was to compare the relationship between waist circumference (WC), ultrasonographic measurements of intra-abdominal adipose tissue (UMA), and cardiovascular risk factors (CRF).

METHODS

We determined blood pressure (BP), fasting HDL-cholesterol, LDL-cholesterol, triglycerides, glucose, insulin resistance index HOMA, 2 h glucose in oral glucose tolerance test (oGTT), weight status (SDS-BMI), WC, and UMA in 89 obese children. Furthermore, we analyzed the changes of CRF, SDS-BMI, WC, and UMA in 29 obese children participating in a one-year lifestyle intervention.

RESULTS

In stepwise multivariable regression analysis, waist circumference was significantly associated to LDL-cholesterol, triglycerides, HOMA, and systolic blood pressure (adjusted variance (AV) 0.05-0.17). SDS-BMI was significantly related to triglycerides, HDL-cholesterol, 2 h glucose in oGTT, and diastolic blood pressure (AV 0.12-0.15), while UMA was related significantly to HOMA (AV 0.04). The obese children participating in a lifestyle intervention significantly reduced their overweight, which was associated with a significant improvement of most CRF and a reduction of WC and UMA. Changes of WC were significantly correlated to changes of HDL-cholesterol (r=-0.45), HOMA (r=0.37), glucose tolerance (r=0.59), systolic BP (r=0.60), and diastolic BP (r=0.43), while change of SDS-BMI and UMA were not significantly related to any CRF.

CONCLUSIONS

Compared to UMA, WC was stronger related to CRF in obese children. Therefore, the simple measurement of WC seems preferable as an indirect marker of CRF.

Young adult obese subjects with and without insulin resistance: what is the role of chronic inflammation and how to weigh it non-invasively?

BACKGROUND

Obesity is a leading risk factor for metabolic syndrome whose further expression is non-alcoholic fatty liver disease. Metabolic syndrome is associated with a proinflammatory state that contributes to insulin resistance. Finally, a "metabolically benign obesity" that is not accompanied by insulin resistance has recently been postulated to exist.

AIM

To find whether any inflammation markers were independently associated with the presence of insulin resistance, evaluating specific anthropometric, ultrasonographic and laboratory parameters in a population of young adult obese subjects.

METHODS

Of forty two young individuals, divided into two groups (with or without insulin resistance), were studied serum C-reactive protein and fibrinogen as indexes of chronic pro-inflammatory status. Body mass index, waist circumference and metabolic syndrome presence were assessed as part of the metabolic evaluation. Ultrasonography weighted visceral and subcutaneous abdominal fat thickness, spleen size as longitudinal diameter and liver hyperechogenicity.

RESULTS AND DISCUSSION

Serum C-reactive protein and fibrinogen as well as spleen longitudinal diameter were significantly increased in the obese young with insulin resistance compared to non-insulin resistance group. Insulin resistance was significantly associated with hepatic steatosis score at sonography (r = 0.33, P = 0.03), spleen longitudinal diameter (r = 0.35, P = 0.02) and C-reactive protein (r = 0.38, P = 0.01), but not with body mass index, visceral or subcutaneous abdominal adipose tissue, waist circumference and fibrinogen (P = 0.18, 0.46, 0.33, 0.37 and 0.4, respectively). Steatosis score at sonography was well associated with spleen volume (rho = 0.40, P = 0.01) and C-reactive protein levels (rho = 0.49, P = 0.002). Metabolic syndrome was much more frequent in obese patients with insulin resistance. These findings show that in young adults the only abdominal adiposity without insulin resistance, plays a scarce role in determining hepatic steatosis as well as metabolic syndrome.

CONCLUSION

Increases in spleen size and CRP levels represent a reliable tool in diagnosing insulin resistance.