In the JournalsPerspective

Severe obesity worsens cardiometabolic risk factors in children, young adults

Children and young adults with severe obesity were more likely to have cardiometabolic risk factors such as low HDL, high BP, high triglycerides and high HbA1c levels in a study published in The New England Journal of Medicine.

The association was most pronounced in young men and boys, according to the researchers.

They analyzed 8,579 children or young adults aged 3 to 19 years with overweight or obesity (BMI ≥ 85th percentile; 52% boys or young men; 53.7% white) included in the National Health and Nutrition Examination Survey between 1999 and 2012.

The researchers stratified participants based on severity of obesity — overweight (46.9%), class I obesity (36.4%), class II obesity (11.9%) or class III obesity (4.8%) — and analyzed the relationship between severity of obesity and the following cardiometabolic risk factors: total cholesterol, HDL, LDL, triglycerides, systolic BP, diastolic BP, HbA1c and glucose.

Asheley C. Skinner, PhD, and colleagues found that average values for the following variables were higher (or lower, in the case of HDL) for those with more severe obesity: total cholesterol (P < .001), HDL (P < .001), triglycerides (P < .001), systolic BP (P < .001), diastolic BP (P = .004), HbA1c (P < .001) and glucose (P = .003), and that the values were higher (or lower, in the case of HDL) for men than for women.

When Skinner, from the departments of pediatrics and health policy and management, University of North Carolina, Chapel Hill, and colleagues adjusted for age, race/ethnicity and sex, they found that greater severity of obesity conferred higher risk for the following variables:

  • low HDL (RR for class III obesity vs. class I obesity = 1.89; 95% CI, 1.35-2.66);
  • high triglycerides (RR for class III obesity vs. class I obesity = 1.63; 95% CI, 1.08-2.47);
  • high systolic BP (RR for class III obesity vs. class I obesity = 2.24; 95% CI, 1.42-3.54);
  • high diastolic BP (RR for class III obesity vs. class I obesity = 4.57; 95% CI, 1.88-11.06); and
  • high HbA1c (RR for class III obesity vs. class I obesity = 2.59; 95% CI, 1.55-4.34).

“A high prevalence of abnormal values for certain variables among children and young adults with class II or class III obesity may provide important information beyond that identified with standard obesity classifications, especially for boys and young men,” Skinner and colleagues wrote. “Determination of the severity of obesity can help identify children and young adults who are at the greatest risk for the negative health effects associated with obesity.” – by Erik Swain

Disclosure: One researcher reports receiving personal fees from Nestle.

Children and young adults with severe obesity were more likely to have cardiometabolic risk factors such as low HDL, high BP, high triglycerides and high HbA1c levels in a study published in The New England Journal of Medicine.

The association was most pronounced in young men and boys, according to the researchers.

They analyzed 8,579 children or young adults aged 3 to 19 years with overweight or obesity (BMI ≥ 85th percentile; 52% boys or young men; 53.7% white) included in the National Health and Nutrition Examination Survey between 1999 and 2012.

The researchers stratified participants based on severity of obesity — overweight (46.9%), class I obesity (36.4%), class II obesity (11.9%) or class III obesity (4.8%) — and analyzed the relationship between severity of obesity and the following cardiometabolic risk factors: total cholesterol, HDL, LDL, triglycerides, systolic BP, diastolic BP, HbA1c and glucose.

Asheley C. Skinner, PhD, and colleagues found that average values for the following variables were higher (or lower, in the case of HDL) for those with more severe obesity: total cholesterol (P < .001), HDL (P < .001), triglycerides (P < .001), systolic BP (P < .001), diastolic BP (P = .004), HbA1c (P < .001) and glucose (P = .003), and that the values were higher (or lower, in the case of HDL) for men than for women.

When Skinner, from the departments of pediatrics and health policy and management, University of North Carolina, Chapel Hill, and colleagues adjusted for age, race/ethnicity and sex, they found that greater severity of obesity conferred higher risk for the following variables:

  • low HDL (RR for class III obesity vs. class I obesity = 1.89; 95% CI, 1.35-2.66);
  • high triglycerides (RR for class III obesity vs. class I obesity = 1.63; 95% CI, 1.08-2.47);
  • high systolic BP (RR for class III obesity vs. class I obesity = 2.24; 95% CI, 1.42-3.54);
  • high diastolic BP (RR for class III obesity vs. class I obesity = 4.57; 95% CI, 1.88-11.06); and
  • high HbA1c (RR for class III obesity vs. class I obesity = 2.59; 95% CI, 1.55-4.34).

“A high prevalence of abnormal values for certain variables among children and young adults with class II or class III obesity may provide important information beyond that identified with standard obesity classifications, especially for boys and young men,” Skinner and colleagues wrote. “Determination of the severity of obesity can help identify children and young adults who are at the greatest risk for the negative health effects associated with obesity.” – by Erik Swain

Disclosure: One researcher reports receiving personal fees from Nestle.

    Perspective

    We have known for some time in both children and adults that obesity has an adverse impact on risk for CVD. This report adds a focus on severe obesity, and it shows that some risk factors are more severely impacted by more severe obesity. These findings emphasize that we should be more aggressive about preventing obesity in the first place, but they also indicate that, even for children and adolescents with milder degrees of obesity, there may still be a benefit from preventing further abnormal weight gain.  

    In terms of thinking about how to deal with the specific risk factors, the best approach is to prevent obesity or to improve BMI via improved diet and physical activity. However, health care providers should still think about treating the individual risk factors (such as high BP) when they develop. For patients with severe obesity and increased risk factors, particularly if they have type 2 diabetes, diet and activity may not be effective enough to improve BMI or the risk factors. These are patients in adolescence where bariatric surgery may be considered as a therapeutic option. 

    There is an issue with elevated lipids that should be mentioned here. These results emphasize that the lipid abnormalities seen with obesity are high triglycerides and low HDL. There are not good pharmaceutical approaches to those lipid abnormalities. They should be treated with lifestyle management. LDL is not impacted by obesity to a great extent, and does not increase systematically with increasing severity of obesity. This should put to rest the concern that has been expressed in the press that the increasing prevalence and severity of obesity would lead to an increased use of statins to lower LDL. 

    The management as patients with obesity enter adulthood should not really change. The focus should be on improvement of diet and activity and management of risk factors when they develop.

    • Stephen Daniels, MD, PhD
    • Pediatrician-in-Chief, Children's Hospital Colorado, Aurora Chairman, Department of Pediatrics, University of Colorado School of Medicine

    Disclosures: Daniels reports no relevant financial disclosures.